Finals

Leucopenia

- chemo - HIV infection - leukaemia - sepsis - radiaction exposure - iatrogenic/accidental

Neutrophilia

- stress - infection - gout - RhA - thyroiditis - trauma - pregnancy

Signs of acute angle closure glaucoma

1. Mid-dilated pupil (oval) 2. Conjunctival injection 3. Lid edema 4. Corneal edema 5. Elevated IOP 60-80mmHg

Causes of Back Pain

15-30 - postural, mechanical, prolapsed disk, trauma, fracture, AnkSpon, pregnancy 30-50 - postural, prolapsed disk, spondyloarthropathies, discitis, degenerative joint disease 50+ postural, degenerative, paget's malignancy, osteoporotic collapse, myeloma

alpha-Thalassaemia

4 alpha-globulin genes, each on Ch16 - AR mutation SEAsian origin Presentations A-T major - all 4: hydrops faetalis - mid trimester oedema and ascites, fatal in utero/shortly after delivery - needs in utero transfusion HbH disease - 3 chains deleted, moderate hypochromic microcytic anaemia with splenomegaly - occasionally transfusion dependent HbH - tetrameric beta chains - seen precipitated as Heinz bodies a-T trait - asx with mild/absent aneamia, hypochromic and microcytic aneamia (confusion with IDA) - can be 1 or 2 deletions (more sx with 2) - 2 deletions can be cis (asian) or trans (african) Sx - Major: severe anaemia and jaundice from 3-6m, FtT, extramedullary haemopoiesis - BM expansion (maxillary overgrowht, skull bossing, later HSM) Minor : hypochronic, disproportionately microcytic anaemia, usually asx, raised HbA2 Rx - maintain Hb >100 - chronic iron overload (cardiac failure, liver cirrhosis, diabetes, infertility) Iron chelation therapy from 2-3y BMT curative - HLA-matched sibling best

TOAST Criteria

5 Classes of ischaemic stroke 1 - Large artery - atherosclerosis, CT/MRI, duplex shows >50% occlusion/stensois in precerebral arteries 2 - Cardioembolic - ECG/TOE confirms high/medium risk of cardio-embolic source 3 - Small vessel disease - lacunar, not large vessel/cardioembolic disease 4 - other aetiolgoy 5 - undetermined aetiology

NHL presentation

70% B cell, 30% T cell RFs - 55-60 peak, caucasian, hx viral infection - EBV, HHV8, HTLV1, pesticides, solvents, hx chemo/RT, immunodeficiencies, autoimmune (SLE, sjogren's, coeliac), h pylori (MALT) High grade - fast progression, good response - DLBCL, burkitt, mantle Low grade - slow progressing, rarely curative - follicular, marginal zone/MALToma, hairy cell Sx - lymphadenopathy, hepatosplenomegaly, testicular swelling, B sx, extranodal disease more common - gastric, bone marrow, lungs, skin, CNS - nerve palsies Ix - raised LDH, paraproteinaemia, AIH, HIV, ESR, uric acid (high grade), IgG/M - B cell

Vascular territories

Anterior cerebral - motor and sensory lower limb, voluntary control micturition, corpus callosum Middle cerebral (large area - malignant oedema) - upper limb and face, vision - homhemi>quad, if proximal/dominant - global aphasia, if non-dominant - neglect, tactile/visual extinction, anosognosia Posterior cerebral - inferior parietal, lateral parietal, occipital - homhemi macular sparing Cerebellar - DANISH Basilar - pons - bilateral sx, distal - cortical blindness, thalamic, midbrain; proximal - pontine artery - locked-in syndrome Lenticulostriate - pure motor strokes

Leukaemia

Acute - blasts; chronic - cytes Acute - mutations prevent differentiation, produce immature blast cells AML - myeloid ALL - lymphoid

Causes pancytopenia

Acute leukaemia - lymphoblastic/myeloid aplastic anaemia BMF - myelofibrosis, aplasia Drugs - chemo/metho, A-HTN, abx - linezolid and chloramphenicol, antipsychotics Viruses - EBV, CMV, HIV, TB with bone marrow involvement Malignancy spread to bone marrow Severe nutritional deficiency B12/folate

Stroke rx

Admit to stroke unit <4.5 hrs - IV alteplase <6 hrs - thrombectomy Optimise physiology, surveillance, prevention cx/early intervention, nutrition support, rehabilitation Secondary prevention - aetiology - antithrombotic, BP control, lipid control, glycaemic contril, CEA, lifestyle Left atrial appendage closure in AF

AML

Adults - elderly Causes - idio, myeloproliferative/dysplastic syndromes which convert, radiation/carcinongen exposure, previous chemo Assoc - DS, neurofibromatosis, fanconi anaemia Sx - BMF - pallor, lethargy, weakness, infections, ulcers, bleeding, purpura, epistaxis, mennorhagia, mucosal bleeding, petechiae, HSM, bone pain, B sx Extramedullary - gum infiltration, skin infiltration, CNS Ix - FBC, urate high, clotting - DIC, blood film - blast cells, auer rods (AML7), BMA&T, IP/CTG/CTC Dx - 20% of cell in blood/BM sample are (myeloid) blasts

SCR Rx

All vaccines and pneumococcal Daily folic acid (high cell turnover) Avoidance crisis triggers Treat crises - good analgesia, good hydration, abx if infection, O2 if low sats, exchange transfusion for acute chest syndrome, stroke and priapism Chronic problems - hydroxyurea increases HbF - protects against further crises - severe refractory - bone marrow transplant

Warm AIHA

Antibody (usually IgG) causes haemolysis at body temp, tends to occur in extravascular sites - e.g. spleen Causes - autoimmune disease e.g. SLE (mixed cold and warm), neoplasia - lymphoma, CLL, drugs - methyldopa Rx - folic acid, steroids, rituximab, IVIg, treat cause Transfusion problematic - autoantibodies react even if ABO compatible, sent off to reference laboratory Evan's syndrome - AIHA with ITP

ROSIER score

Assessment of stroke - must first exclude hypo -1 for LOC/seizure +1 for - asymmetric facial, arm or leg weakness, speech disturbance, visual field defect

Leucocytosis

CLL Infection - chronic, Tb, viral (measles, mumps, EBV, rubella, whooping cough; toxoplasmosis, brucellosis

Major ABO Incompatibility

Can cause fatal massive haemolysis Sx - rapidly developing pyrexia at onset, dyspnoea, chest tightness, intense headache, severe loin pain, hypotension - acute oligouria (ATN), DIC with spontaneous bruising and haemorrhage, later jaundice Ix - hyperbilirubinaemia, positive Coomb's test - new antibody Rx - resuscitate, call senior help, oliguria - osmotic diuresis with mannitol and loop diuretic

cephalosporins

Ceft, cephalexin, cefuroxime etc cell wall synthesis - allosteric penicillin binding protein inhibition better for g-neg, less for g-pos

ALL

Children - 80% B cell precursors peak incidence 2-5y, M>F Sx - BMF (may occur very rapidly) - anaemia, neutropenia, thrombocytopenia, fever, lymphadenopathy, HSM, anorexia, back and joint pain - BM infiltration CNS involvement more common Males - testicles T cell - mediastinal nodal mass and PlEf Ix - WCC may be raised, blasts raised; BMA and trefine - dx; lumbar puncture for CNS infiltration, immunophenotyping, cytochemistry, cytogenetics - philadelphia Types - common ALL - pre-B, Tcell and Bcell

fluoroquinolones

Cipro, levo, ofloxacin nucleic acid synthesis - topoisomerase II ligase (DNA fragmantation) IC bacteria g-neg and typical c.diff association

ITP

Commonest cause of TCpenia in childhood - immune mediated, younger - congenital causes Sx - tends to present mroe acutely than with adults; often 1-2w after a viral illness - petechiae, purpura - dx of exclusion Rx - only treat if evidence of major bleeding (majority don't need - oral pred or IVIg; transfuse only if life-threatening bleeding - avoid trauma Prognosis - generally self-limiting over 1-2w Cx - prolonged severe can lead to ICH Chronic ITP - 6m post-dx remains low (20%) - long-steroids not needed, supportive mx, remission or stabilisation (asx) usually within 3y - screen for SLE - may predate development of autoantibodies - children w/ sig bleeding need specialist care - may need splenctomy

Cryoprecipitate

Concentration of FFP Generally used for fibrinogen contains VIII, vWBF, fibrinogen, factor XIII, fibronectin Fibrinogen deficient in DIC and liver disease

Causes hyposplenism

Congenital - rare; heterotaxy syndrom,e isolated congenital asplenia, polysplenia Acquired - splenectomy, hypersplenism - spherocytosis/elliptocytosis, malignancy, treatment for disease e.g. ITP, thalassaemia; disease process damaging - SCD

TIA

Consider causes - hypercoaguable states, glucose, vasculidities, carotid thrombus, AF Rx - treatment dose aspirin (300mg) UNLESS - bleeding disorder, on AC, already taking, known allergy - <7/7 - ax w/in 24 hours - >7/7 - ax w/in 1/52 - >1 TIA - consider admission (crescendo) Further - antithrombotic - clopidogrel ongoing (aspirin and DHP if can't tolerate) - ix CEA - >70% - rx risk factors, lifestyle advice

FFP

Contains all of the clotting factors AB positive is universal donor - must not have any anti-A/B antibodies Given for high PT/Ptt, coagulopathy deficiency of clotting factors - raised PTT/APTT

Metronidazole

DNA synthesis anaerobes+++ - c.diff amoebae, giargia, trichoma - bacterial vaginosis

Managing low back pain

Encourage self management Stay active and exercise Analgesia - NSAIDs - PPI if >45 (sciatica = neuropathic) Others - group exercise program, manual therapy - manipulation, mobilisation or massage, RF denervation, epidural injections of local anaesthetic/steroid for acute and severe sciatica

macrolides

Erythro, clari, azithro protein synthesis - peptidyltransferse (peptide bond - 50s) good distribution - IC mild g-pos

NHL subtypes

Follicular - low grade, B cell - chornic incurable with relapse remitting course - grade 1/2 indolent, 3 aggressive, may transform to CLL Burkitt's - 2 forms, endemic african variety affects maxilla/mandible, assoc with c-myc translocation and EBV infeciton; sporadic causes ileocaecal lymphomas, assoc with HIV; see starry sky, treated with rasburicase Gastric MALT lymphoma - strong h.pylori assoc, low grade responds to eradication, paraproteinaemia

Stroke mimics

G1 - identifiable on brain imaging - BPPV, Transient global amnesia, migraine with aura, focal seizures, functional syndrome Stereotyping indicates alternative pathology generally except with: - capsular warning syndrome: recurrent events over minutes-hours shows fluctuation symptoms without complete resolution - intracranial stenosis: affected areas disproportionately hypoperfused with systemic insult (e.g. postural hypotension)

classifying ligament injuries

Grade 1 - local tenderness, no abnormal movement - NSAIDs, support and mobilisation Grade 2 - slightly abnormal movement, protect joint, elevante, middle of range movement Grade 3 - abnormal joint movement, refer to ortho

SCD presentations

HbS - beta-globulin point mutation from glutamine to valine - sticky hydrophobic pocket when deoxygenated, causes polymerisation and 'sickling'; exacerbated by low oxygen, dehydration, and cold SCA - homozygous SCD - HbS and HbC - no normal HbA Sickle beta-Thalassaemia - HbS and beta-thalassaemia - similar sx to SCD SCTrait - HbS and one normal - 40% abnormal, asx but can pass on Sx - Anaemia - moderate ongoing, acute may be triggered by infection (parvo) - Infection - encapsulated organisms - hyopsplenism (esp early childhood) - Crises - vaso-occlusive pain: late infancy - dactylitis, bones of limbs and spine, cerebral, pulmonary, perthe's; precipitated by cold, dehydration, excessive exercise, stress, hypoxia, infarction - Sequenstration crises - acute anaemia, sudden splenic enlargement - Priapism - treat promptly with exchange tranfusion - Splenomegaly - young children

Igs

IgG - 75% - opsonisation in circulation IgA - 15% - localised protection on mucous membranes IgM - 10% - pentamer, first response to infection, antigen presentation IgD - 1% - activates B cells IgE - 0.1% - mediates T1 hypersensitivity reactions - binds Fc receptors on mast cells and basophils - provides immunity to parasites

CML rx

Imatinib first line - TK inhibitor - very high response rate SEs - GI upset, myalgia, headache, rash Poor response - other TKi targetting BCR:ABL Severely hypercellular - Hydroxyurea and IFa to reduce cell burden - renal function (high risk TLS) and fertility ASCT

Thrombocythaemia causes

Inflammation Infection Bleeding IDA

assessing back pain

Keele Start - >3w if not resolve refer for physical therapy - >=4 and not resolved in 4w then refer

Stroke Patterns

Lateral medullary syndrome - posterior inferior cerebellar - Wallenberg's syndrome - ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy, contralateral limb sensory loss Weber's syndrome - ipsilateral III palsy, contralateral weakness

Febrile non-haemolytic transfusion reactions

Leucocyte incompatibility - rare now leucocyte depleted - Temp rise >1 degree during administration indicates this - stop for 30 mins and give antipyretics Seen with multi-transfused or multiparous women

indications for MRI in back pain

Lumbar XR not routinely offered MRI only offered where this would change management - malignancy, infection, fracture, cauda equina or ankspon suspected young - <25, exclude AnkSpon Elderly - vertebral collapse/malignancy Hx of trauma

Classification AML

M0 - undiff M1 - no maturation M2 - granulocytic maturation M3 - acute promyelocytic M4 - granulocytic and monocytic maturation M5 - monocytic M6 - erythroleukaemia M7 - megakaryoblastic

carbapenems

Meropenem cell wall synthesis - penicillin binding protein broad spectrum - anaerobes and g-neg poor bio-availability

Causes anaemia

Microcytic - IDA, thalassaemia, chronic disease Normocytic - myelodysplasia, recent bleed, chronic disease (classic) Macrocytic - B12/folate, hydrocycarbdemide, myelodysplastic syndromes, liver disease, chronic alcohol use

Causes splenomegaly

Mild (palpable below costal margin) - inflammatory conditions: sarcoid, lupus, amyloid, RhA (felty's), haem - thalassamia, SCD, AIH, portal hypertension; acute infections - viral, bacterial Moderate (costal margin - umbilicus) - Massive (crosses umbilicus and midline/iliac crest) - myeloproliferative disorders: myelofibrosis, chronic myeloid leukaemia, lymphoma; malaria, HIV, malignancy, Gaucher's syndrome, viral leishmaniasis

MGUS

Monoclonal gammopathy of undetermined significance Asx, <10% monoclonal plasma cells in BM IgG/A - progress to MM IgM progress to NHL/WM

CLL

Monoclonal proliferation of well-differentiated lymphocytes - 99% B cell - most common leukaemia in adults Usually over 50 Sx - often asx incidental finding, BMF - bleeding, infections, other cancers (hypogammaglobinaemia causes immunodef), more common LMPY, HSM, extramedullary infiltration - skin, GI, CNS, lungs, kidney, bone Classified by mutation of Ig heavy chain variable region Ix - blood film - smear cells Flow cytometry, cytology, cytogenetic, cytochemistry - show clonal B cells BMA - ^small lymphs Staging A - no anaemia or thrombocytopenia, <3 lymphoid areas enlarged B - no A/T, >3 areas enlarged C - A or T Assoc - warm AIH in 10-15% patients Richter's transformation - high grade lymphoma, poorly differentiated large cell

CML

Myeloid cells - neutrophils, eosinophils and basophils, or precursors Sx - anaemia, Bsx, marked splenomegaly, spectrum of myeloid cells in blood Cx - blast transformation - AML>ALL 4:1 RFs - M>>F, median age 65, Radiation, Philadelphia chromosome - translocation c22-9, BCR:ABL on c22, abnormal TK protein

Essential thrombocythaemia

Myeloproliferative disorder - Megakaryocyte proliferation - overproduction of plts Ix - plt count >600 - >1000 definitive JAK2 mutation in 50% Venous and arterial thrombi and haemorrhage can be seen, haemorrhage also Characteristic sx - burning in hands Rx - hydroxyurea widely used to reduce platelet count, IFa in younger patients; low dose aspirin to reduce thrombotic risk

Polycythaemia vera

Myeloproliferative disorder - increased RBC volume, overproduction of neuts and plts may be seen JAK2 mutation in 95% of patients - primary proliferative polycythaemia 2dry causes - RCC (EPO), COPD (hypoO2), HCC (EPO productive) Peak 50s Sx - hyperviscosity prominent, post bath pruritis - mast cell degranulation, HSM - splenomegaly prominent (RBC destruction), plethora, HTN, gout - uric acid, thrombotic events - retinal thrombosis Rx - aspirin - TE risk; venesection 1st line, cytoreductive - hydroxyurea (risk leukaemia), phosphorus-32 therapy - radioactive phosphate - collects in bone marrow Prognosis - TEEvents major cause mortality/morbidity, 5-15% progress to myelofibrosis 5-15% progress to acute leukaemia

Myelofibrosis

Myeloproliferative disorder - myeloid cell overproduction - abnormal megakarocytes release plateled-derived GF which stimulates fibroblasts Sx - often asx (30%) fatigue from anaemia, splenomegaly prominent, 60% hepatomegaly, prutitis, Bsx Secondary causes - 30% PCV, ET Ix - anaemia, early leucocytosis, and thrombocytosis, later pancytopenia, dacrocytes - tear drop shaped RBCs BM biopsy needed to show fibrosis - dry tap

Paediatric IDA

Neonatal - <140 1-12m - <100 1-12 <110 Infants have high iron needs - deficiency likely - need vit C rich foods Sx - fatigue, pallor (conjunctiva, tongue, palmar creases), pica, changes in behaviour/intellectual function Rx - supplementation - sytron, niferex, should rise by 10g/L

Lymphadenopathy causes

Perihilar - sarcoidosis, Tb, fungus, silicosis, berylliosis, EAA Infective - EBV, HIV, bacterial infection, rubella, toxoplasmosis, CMV, roseola infantum Autoimmune - SLE, RhA Graft V Host Drugs - phenytoin, allopurinol, isoniazid

MDS

Pre-leukaemic - neoplastic disorder of haemopoietic stem cells More common with increasing age Sx - BMF - fatigue, SOB, easily beleds, infections RFs - previous chemo or RT, chemical exposure - tobacco, pesticides and benzene Rx - supportive - EPO, abx Chemo can be curative ASCT

Transfusion associated circulatory overload

Rare in healthy adults - CVS conditions with large volumes/fast (more speed) - sx appear within 6 hrs RFs - young <3 and old >60, renal disease, high volumes, fast, cardiac disease, amiodarone and aspirin use, recent surgery Rx - diuretics, oxygen therapy

Stroke cx

Recurrence Complications of immobility rICP - MO, hydroceph, haemorrhagic trans Infections Mood/cognitive problems Post stroke fatigeu PSPain Spasticity, contractures Secondary epilepsy

HKL presentation

Reed-Sternberg B cell - owl eyes RFs - EBV infection hx, FHx, HIV Peaks 30s and 70s Non-tender cervical, axillary, inguinal lymphadenopathy Pruritis, cough, Pel Ebsteins fever (cyclical), haemoptysis, dyspnoea, pain following alcohol B sx - earlier in HK - weight loss, fever, night sweats Hepatosplenomegaly may be seen Ix - LDH raised, normocytic anaemia, eosinophilia Classification - nodular sclerosing HL - 70%, good prognosis, female, associated lacunar cells - mixed cellularity - 25% - good prognosis, EBV, high numbers of RS cells - lymphocyte-rich - 5%, best prognosis - lymphocyte-depleted - rare, worst prognosis

management GORD

Review medication and lifestyle alternations PPI 1m trial Test for H.pylori if no response H2Antag/domperidone if no response 2ww referral for endoscopy if any of - chronic bleed, weight loss, dysphagia, vomiting, mass, age>55 (stop NSAIDs and PPI/H2A Routine referral - previous ulcer, surgery, NSAIDs, high risk for gastric cancer, anxiety

Headache red flags

S: systemic features N: Neuro deficits O: older than 50 yo O: Sudden and maximal P: progression of HA, pattern of HA also Fever and worsening with purpura/meningism Recent head injury Associated with postural change, sneezing, cough or exercise Change in personality Atypical aura

AML emergencies

Severe anaemia Infection - neutropenic sepsis Severe bleeding Hyperviscosity syndrome - leucostasis TLS - high risk

SCD LT cx

Short stature Delayed puberty Cognitive problems - strokes and subtle vascular damage Adenotonsilar Hyp - OSA can trigger crises Cardiac enlargement - chronic anaemia Heart failure - uncorrected anaemia Renal dysfunction - may exacerbate enuresis (unable to concnetrate) Pigment gallstones Leg ulcers Psychosocial problems - education

Types of headaches

Sinus - tender over sinuses Cluster - eye pain, autonomic sx Tension - band, stress and low mood Migraine - aura, visual disturbance, triggers Trigeminal neuralgia - stabbing pain in CNV distribution Glaucoma - red eye with halos Medication overuse rICP - worse on waking, sneezing, cushing's triad Cervicogenic headache

HKL rx

Staging - Ann Arbour I - single LN region II - 2+ regions on the same side of the diaphragm III - 2+ regions on both sides IV - extra nodal sites A - no add sx, B - b sx, E - extranodal primary Rx Early - I&II no PPFs - RT alone, <30% fail to cure - chemo - ABVD Advanced - III&VI required chemo with RT for bulky disease/palliation - ABVD regimen of choice; targeted - anti-CD30 PPFs - advanced stage, >45y, Hb <105, lymphs <600/8%, male, albumi <40g, WBC>15000, poor response to chemo, early relapse Prognosis - early stage cure rate 90%, advanced curable in 80%, elderly less LT - secondary malignancy, breast cancer, cardiac disease, lung damage, sterility, endocrine dysfunction

NHL rx

Staging - ann arbour (PET for mets) Rx - watchful waiting, flu/PNCL vaccine, abx proph for neutropenia (co-tri for PCP), allopurinol for TLS, acyclovir for herpes, chemo - ritux, chlorambucil, cyclophos, steroids alongside in first few days/weeks ASCT - last resort May convert to high grade DLCBL Cx - bone marrow infiltration, mets, SVCO, spinal cord compression, SEs of chemo

AML rx

Supportive care RE pancytopenia Chemo - induction (<5% blast cells in marrow), consolidation - may take months but maintenance rarely needed ASCT if refractory <24y - young adult service PPFs >60 at presentation (less tolerance of chemo), >20% blasts after 1st round, chromosome defect 5 or 7 80-90% complete remission in adults, children 5YS 50%

All rx

Supportive care RE pancytopenia Chemo - induction - vincristine, pred, asparaginase; maintenence (2-3y) - metho and mercaptupurine (clo-tri for PCP) - intrathecal and systemic Cranial RT if high risk Protect renal function - hyperhydration and allopurinol Allogenic SCT if poor prognostic factors Relapse - high dose chemo, total body irradiation and bone marrow transplantation PPFs - age <2 / >10 (biggest) - adults incurable - WBC >20 at dx - Tor b cell markers - non-caucasian - male Children - curable, induction and maintenance for 2-2.5y, ASCT for relapse/PPFs, detect minimal residual disease, LT effects - endocrine, secondary leukaemia, cardiotoxicity Adults - remission common, 16-25 cure rate 75%; >60 low - QoL, allogenic SCT in first remission increases LTS, if Ph positive - imatinib adjunct

MM

Sx - bone pain (back and chest), infections, may be asx BMF - infiltration Renal failure - Ig light chains form obstructive casts Hypercalcaemia Amyloidosis Types - Waldenstrom's macroglobulinaemia - indolent lymphoma with IgM secretion - hyperviscosity, 1% risk progression per year - MGUS - raised paraprotein with no other criteria - Monoclonal gammopathy - assoc with lymphoma, malignancy and CTDs but also common in healthy people RFs - >60, afro-carribean Ix - lytic lesions (bone scans not effective), clonality - light chain variant kappa/lamda Rx - zolendronic acid, palliative - pain relief, control sx and reduce complications Induction - if candidate for ASCT, or course of chemo if not, likely to relapse may need repeat ASCT 3m follow up Annual flu vaccines, Ig replacement

Transfusion-associated allergic reaction

Sx - fever, pruritis, skin rashes, angio-oedema Rarely anaphylaxis Mild - stop/slow for 30 mins and give antihistamines Ix cause - Consider latex allergy

CLL Rx

Sx control and prolong life (not curative) Manage when sx present, or if rapid progression, advanced presentation Chemo - fludarabine, cyclophosphamide, rituximab - FCR Steroids for pancytopenia or AIH/thrombocytopenia Poor responders - anti-CD53 alemtuzumab/ibrutinib RT for palliation Splenectomy - painful or autoimmune cytopenia IVIg - hypogammaglobinaemia If younger - aggressive rx with ASCT if poor prognostic factors such as 17p deletion PPFs Age, poor response, atypical morphology, diffuse BM infiltration, high lymphocytosis, short lymphocyte doubling time (<12m), immunophenotype and cytogenetic markers

OCSP

TACS - MCA occlusion, will see hemiparesis, cortical dysfunction and homonymous hemianopia PACS - usually MCA branch, usually embolic, isolated higher cortical dysfunction LACS - lacunar - lenticulostriate branches, brainstem or pure WM tract; pure motor/sensory/sensorimotor stroke, ataxia, dysarthria POCS - vertebral, cerebellar or PCA vessels, isolated hemianopia, brainstem, or cerebellar syndromes

Cold AIHA

Usually IgM - haemolysis at 4 deg C, compliment mediated - intravascular Features include sx of reynauds and acrocyanosis Less responsive to steroids Causes - neoplasm - lymphoma; infections - myc, EBV

beta-Thalassaemia

Variety of mutations affecting 2 copies of beta-chains of Hb - AR mutation - globulin chains precipitate in RBC membrane - cell death in bone marrow, premature removal in spleen (Heinz bodies) - gamma-chain synthesis continues beyond neonatal period - HbF - Delta-chain production increases HbA2 Mutation gene 11 Target cells seen - relative increased cell mass - Hb gathers in centre and round peiphery Seen in Indian, mediterranean and middle eastern ethnicities Presentations b-T major - most severe, no HbA b-T intermedia - mutations allow a small amount of HbA, or large amount of HbF - milder, varied presentation Sx - Major: severe anaemia and jaundice from 3-6m, FtT, extramedullary haemopoiesis - BM expansion (maxillary overgrowht, skull bossing, later HSM) Minor : hypochronic, disproportionately microcytic anaemia, usually asx, raised HbA2 Prognosis - fatal without regular transfusions, with good compliance can live to 40s, with mixed death in early adulthood due to iron overload Rx - maintain Hb >100 - chronic iron overload (cardiac failure, liver cirrhosis, diabetes, infertility) Iron chelation therapy from 2-3y BMT curative - HLA-matched sibling best

Stroke Chameleons

Venous infarcts - gradual onset with seizures Small cortical strokes - peripheral nerve lesions Limb-shaking TIA - presents as seizure Occipital infarcts - presents with confusion Stroke amnestic syndromes Stroke mimicking vestibular dysfunction

tetracyclines

doxycyline - penicillin allergy, atypical pathogens e.g. chlamydia

Antiphospholipid Syndrome

acquired autoimmune hypercoagulopathy disorder - recurrent venous or arterial thrombosis - often presents as recurrent fetal loss and thrombocytopenia, also may see pulmonary hypertension, pre-eclampsia - persistently elevated levels of antibodies directed against membrane anionic phospholipids Commonly secondary to lupus - livedo reticularis, or other AIDs, lymphoproliferative disorders Rx - warfarin INR 2-3 for 6m - recurrent VTE - lifelong VTE on proph - 3-4 ATE - 2-3 lifelong

Rx of conjunctivitis

acute usually self-limiting - bathe regularly with boiled water, simple hyiene measures if not resolving in 3-5 days, topical chloramphenicol QDS for 5D

gram negative

amoxicillin co-amoxiclav carbapenems cephalosporins aminoglycosides - gentamycin ciprofloxacin polymixins

causative organisms of UTI

e.coli >70% proteus spp pseudomonas spp streptococci staphylococci

cephalosporins

ceftriaxone (meningitis/gonorrhoea)

polymixins

cell membrane function - bind to LPS (amphipathic detergent action) g-neg

beta lactams

cell wall synthesis - penicillins - cephalosporins - carbapenems

glycopeptides

cell wall synthesis - bind peptidoglycans to prevent cross-linkage Vancomycin g-pos no oral bio-availability (c.diff)

penicillins

cell wall synthesis - competitive inhibition penicillin binding protein g-pos - mainly strep

fluoroquinolones

ciprofloxacin (g-neg and atypical)

macrolides

clarithrymycin erythromycin azithromycin (chlamydia)

anaerobes

co-amoxiclav carbapenems metronidazole

complications of URTIs

exacerbation of asthma/COPD secondary infection - bronchitis, pneumonia, conjunctivitis, OM, sinusitis, tonsilitis acute bronchitis

staph

flucloxacillin

rx for UTI

increased fluid intake potassium citrate solution abx - trimethoprim 3D for uncomplicated, 7D for complicated 7D cefalexin/cipro, nitro second line prophylaxis - tri or nitro Pregnant - tri contra, nitro unless near term then amox

Signs of conjunctivitis

inflammation Redness in the white of the eye or inner eyelid Increased amount of tears sticking of eyelids on waking enlarged papillae under upper eyelid pre-auricular lymph node enlargement

complications of LRTI

pleural effusion - reactive, empyema lung abscess septicaemia/sepsis metastatic infections respiratory failure jaundice

rifampicin

nucleic acid synthesis - RNA polymerase

strep

penicillin

penicillins

penicillin (strep) flucloxacillin (staph) amoxicillin (g-neg) co-amoxiclav (anaerobes)

gram-positive

penicillins carbapenems cephalosporins glycopeptides - vancomycin tetracyclines - doxycyline marcolides

aminoglycosides

protein synthesis (30s) gentamycin - irreversible g-neg active in blood and urine

tetracyclines

protein synthesis - binds aatRNA in ribosome (30s) broad spectrum g-pos in penicillin allergy

PTCC

prothrombin complex concentrate - used for anticoagulation reversal where severe bleeding/ICH

indications for MC&S

resolved UTI recurrent male catheterised child pregnant suspicion pyelo haematuria

treat bronchitis

systemically unwell serious complication comorbidities cough and >65 + 2 of/>80 + 1 of - hospital admission in last year - diabetes - CCF - on oral steroids

Neutropenia

transient - viral illness (may last months), bacterial infection, chemo persistent - viral (EBV, HIV, hepatitis), autoimmune - SLE/RhA, anaemia, radiation, benign ethnic neutropenia, many drugs, haem - myelodysplasia, leukaemia, lymphoma, myeloma, B12/folate deficiency Mild <1.5; moderate <1; severe <0.5 if pyrexial - send to hospital

glycopeptides

vancomycin - IV/oral for c.diff