RENAL, ENDOCRINOLOGY , HAEMATOLOGY, MICROBIOLOGY, RESPIRATORY, ENT, RHEUMATOLOGY, Orthopedics, Dermatology, Ophthalmology, GASTROENETEROLOGY FINALS

Thyroid cancers: list 1B

4 types -Papillary: -follicular- -Medullary ANAPLASTIC

Ix and Rx ORBITAL CELLULITIS

5. Ix -CT orbit and sinus w/ contrast -LP -bloods : WCC , cultures, CRP, lactate 6. Rx *ADULT* admit IV abx empirical ( Taz , clindamycin, iv cipro *KIDS* ADMIT iv co-amoxiclav (allergy; iv cefuroxime & metronidazole -incision and drainage

ORAL APHTHOUS ULCERS 1B

"canker sores"; small, painful, round ulcers in the oral mucosa of unknown cause -common in women -MAJOR or minor -minor: small, oval and heal w/o scarring in 1-2 wks -major: irreg edges, deeper and large, can take up to 6 weeks to heal and can leave scarring CAUSES Diseases having oral aphthous ulcerations Crohn's disease/ulcerative colitis. Behçet's syndrome. Celiac disease/nontopical sprue: Malabsorption/Glutensensitive enteropathy. Food hypersensitivity: Nuts (walnuts, hazelnuts, Brazil nuts), spices, tomatoes, and chocolate. HIV. Nutritional: Hematinic and other deficiency states such as vitamin B12, folic acid and iron. Sweet's syndrome: Acute febrile neutrophilic dermatosis. Periodic fever, aphthous stomatitis, pharyngitis and adenitis syndrome. Drug-induced aphthous-type oral ulcerations Non-steroidal anti-inflammatory drugs Beta-blockers Potassium channel blockers. AEx: FHx, Females, poor diet, underlying med cond, Haematinic (iron, folic acid, or vitamin B12) deficiencies features : oral ulcers, afebrile Ix: haematinics , FBC Rx mouth rinse containing steroid dexaethasone oral suspensions of tetracycline chemically cauterizing Nutritional supp (folic acid, B-6, B-12, zinc) he treatment of these painful ulcers include: Fluocinonide topical application six times a day. Dexamethasone swishes (0.5 mg in 5 ml elixir TDS). Lidocaine 10% spray

What is hyperopia?

"far-sighted" Eye too short. Light is focused behind retina.

What is amblyopia?

"lazy eye" When the vision in one of the eyes is reduced because the eye and the brain are not working together properly. The eye itself looks normal, but it is not being used normally because the brain is favoring the other eye

What is myopia?

"near sighted" Eye is too long. Light is targeted too far in front of retina.

What is leukocoria?

"white pupil" Can be c/b: -cataract -tumor (retinoblastoma) -retinal detachment -vitreous hemorrhage -retinopathy of prematurity -toxocariasis (larvae in eye) -Coats disease (abnormal development in the blood vessels behind the retina of the eye)

acute of hypersensitive pneumonitis

(4-6 h after exposure) dyspnea, cough, fever, chills, malaise (lasting 18-24 h) CXR: diffuse infiltrates type III (immune complex) reaction

CHRONIC MYELOID LEUKAEMIA 1B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

(Myeloproliferative disorder /myelodysplasia) - Proliferation of immature granulocytes- eosinophils, basophils and neutrophils. 20-45s, 60s. >10% chronic,> 20% blast phase. accelerated phase with added mutations. Ph in 95%. -erythroid, platelet and myeloid cells at different stages of proliferaion 1. malignant proliferation of *immature granulocytes (neutrophil, basophil, or eosinophil. )* a. common in >60 peaks at 25-45 >F. - PH chromosome ( BCR-ABL1) present in 95% Aex: ionising radiation, immune suppression, benzene, pesticides features: a. asymptomatic, initially, anaemia, , FATIGUE b. B symptoms ( night sweats, fever, weight loss) hepatosplenomegaly --> MASSIVE SPLENOMEGALY c. bleeding (gums, retinal, epistaxis), gout, infection d. LUQ pain e. priaprism Blast phase: fatal, blasts >20% in BM (20-40%) accelerated: additional mutations, increased symptoms Ix 1. FBC: ⬆ WBC, anaemia,⬆ platetes or normal , ⬆ uric acid 2. Blood film : ⬆ WBCs 3. LDH and urate ⬆ 4. BM : >10% blasts in chronic and >20% in accelerated Rx: Tyrosine kinase inhibitors - Imatinib, nilotinib, ponatinib

Tinea Corporis & Faciae 1A

(classic "ringworm") 1. Fungal infection of the body or face, Trichophyton rubrum most common cause 2. acute sudden Annular lesions with central depression and outer active border (more inflamed n red) . -can acutely present as itchy inflamed red patches 5. Ix skin biopsy, microscopy and skin culture 6. treatment i. Anitifungal Creams for mild to moderate cases (terbinafine 1%, econazole 1%, miconazoleetc.) ii. Oral antifungals for extensive or resistant cases and for facial tinea (griseofulvin, intraconazole, fluconazole, terbinafine) Questions to ask -Diabetic- like glucose -immunosupression ?

Associated Features of Atopic Dermatitis Atopic Pleats

(dennie-morgan infraorbital fold) may be seen in some atopic children, once thought to be a reliable sign of atopy

mixed resp and metabolic acidosis

* ↓ pH * ↑CO2 * ↓HCO3- * Potential causes include: * Cardiac arrest * Multi-organ failure

Rubella 1A

*German Measles* Mild, self-limiting virus caused by rubella virus , RNA S&S: - * MACULOPAPULAR RASH begins on FACE AND NECK* THEN generalised maculopapular rash - conjunctivitis, and arthralgias or arthritis, pharyngitis. Tender swollen postauricular, and posterior cervical nodes is characteristic. red pinpoint lesions occur on the soft palate. (asymptomatic for 7 days) Pregnancy: spontaneous abortion, stillbirth, congenital defects, sensorineural heaimng loss, cataracts, cardiac defets, retinopathy Ix: ELISA IgM ab, FBC Rx: supportive in post natal, pregnant refer to consultant ( Ig IM), notifiable dz

Pemphigus Erythematosus (senear Usher Syndrome )

+ positive ANA , variant of Pemphigus Foliaceous and thought to be cross over with LUPUS

Kartagener's syndrome

- (also known as primary ciliary dyskinesia) -defect in mucociliary function lungs ➡️ immotile cilia -results in recurrent infection ➡️bronchiectasis -mucus cannot be clear in lungs -results in recurrent infection ➡️bronchiectasis -chronic cough with yellow sputum sometimes haemoptysis -chronic cough with yellow sputum sometimes haemoptysis

management of pleural effusion

- *Ultrasound-guided thoracentesis above the rib, mid-scapular line, 1-2rib* spaces below the upper fluid level (21G needle and 50ml syringe) ( therapeutic only if symptomatic, infective etc..) - Talc pleurodesis - Pleurectomy -furosemide in CHF -empirical IV abx ( amoxicillin/clavulanate:+ metronidazole)

Chronic retension 1B

- -An insidious, painless increased in bladder capacity over 1.5L --may be low pressure (normal creatinine and absence of hydronephrosis on ultrasound) or high pressure (raised creatinine which falls post-catheterization, usually with hydronephrosis on ultrasound). -Leads to overflow urinary incontinence -Abdominal mass -Frequent UTIs - Renal failure in bilateral obstructive uropathy -hydronephrosis and renal impairment

Rx hyperkalaemia

- 10ml of 10% calcium gluconate IV over 5 minutes(for cardio-protection, stabilises the myocardial membrane) - 10 units of IV act-rapid in 50ml of 50% dextroseover 15 minutes (pushes potassium into cells) - 10mg of nebulised salbutamol (pushes potassium into cells) Calciumresonium with lactulose for less severe

What is a Zenker diverticulum ( pharyngeal pouch)

- A cervical outpouching of the oesophagus through the cricopharyngeal muscle. A posterior, false diverticulum. Ix -Barium swallow will show out-pouchings

WHAT IS HYPERKALAEMIA 1A

- A potassium of >5.5mmol/L (mild/moderate) - Severe is >6.5mmol/L

What is an anal fissure and Aex ?

- A tear of the skin of the anal canal due to - Constipation - Crohn's disease - Anorectal infections e.g. TB, HIV - Haematological cancer

What is a pinguecula?

- A yellowish, slightly raised thickening of the conjunctiva on the sclera, close to the edge of the cornea. - Non-cancerous bumps on the eyeball and typically occur on top of the middle part of the sclera — the part that's between your eyelids and therefore is exposed to the sun.

Assessment of AKI and Rx

- ABCDE approach - assess volume status (BP, JVP,skin turgor, capillary refill, pulse, catheter, mucous membranes, sunken eyes, crackles,RR, heart sounds, cyanosis, saturations, oedema) - Electrolytes to check for hyperkalaemia - ECG to check for life-threatening changes due tohyperkalaemia - History - check for risk factors, renal disease,fluid intake/losses, chemotherapy, drugs, rashes, joint pain, coughing,haemoptysis etc. - Examination: § Palpable bladder - urinary retention orobstruction § Palpable kidneys - polycystic kidneys § Abdominal or pelvic mass § Renal bruits - Assess volume status and aim to maintainEuvolaemia via IV fluid therapy - Stop nephrotoxins - NSAIDs, ACE inhibitors,gentamicin, amphotericin, metformin - Monitor in ITU - observations, urine output viacatheter, U&Es, fluid balance, weigh - Nutritional support - NG tube, parenteral

Coal Worker's Pneumoconiosis 2B

- AKA black lung disease" - due to LT exposure to coal dust simple Pathophysiology- coal dust builds up in bronchioles,. accumulation of macrophages in a alveoli to mop up coal dust and remove it via mucolciliary thing --> tcausing immune response -> damage lung tissue. macrophages engulf dust but they get overwhelmed due to too much dust and build up and the immune response damages lng tissu features; increases SOB but ooften aysmptomatic Complicated pneumoconiosis, also known as progressive massive fibrosis (PMF). same pathology as aboove but with aggregation of the fibrotic nodules to form larger lesions 2-10cm diameter. features: cough, productive of mucoid or blackened sputum, and breathlessness, particularly on exertion, and may, in time, lead to the development of cor pulmonale CXR: upper lung zone fibrosis - spiro: reduced FEV1 ( maybe normal) and FVC FVC/FEV1 increased

DEFINE AKI AND ITS STAGES 1A

- AKI is a rapid reduction in kidney function over hours to days - Involves rising urea and creatinine - Failure to maintain fluid balance, electrolyte and acid-base homeostasis - A rise in creatinine >26.5umol/L over 48hours - A rise in creatinine >1.5x the baseline for 7 days - A urine output of <0.5ml/kg/hr for >6 consecutive hours - IN CHILDREN - 25% or more fall in eGFR over 7days stage 1- 1.5.1.9 increase in creatinine or <.5ml/kg.hr output stage 2 2-2.9 <.5mL/kg/r for 12 rs stage 3 creatining 3x baseline or <.5mL/kg/r for 24 hrs/ anuria 12rs S&S

Ix in SBO

- AXR: Dilated small bowel loops, air-fluid levels, plicae circularis, central location - CT : bowel dilation and decompresiion distally - bloods: creatinine, u&es, lactate (late sign),, WBC (necrosis) , low Hb (bleeding)

what is diarrhoea?

- Abnormal faecal discharge characterised by frequent and/or fluid stool. - Result of disease in small intestine. Involves increased fluid and electrolyte loss.

CHOLESTEATOMA

- Abnormal growth of squamous epithelium in the middle ear and mastoid - usually due to chronic CSOM -congenital or acquired -features: hearing loss, fullness, smelly dx -signs: retraction of pocket in TM , keratin debris, TM perf, malodorous otorrhoea, hearing loss, ear pain complications -ossicular erosion -inner ear erosion, labyrinthitis -mastoiditis, petrosis -facial paralysis -meningitis

complicated UTI

- Abnormal renal or genitourinary tract - Voiding difficulty - Urinary obstruction - Impaired renal function - Impaired immunity - Infection with a virulent organism e.g. staph A -males

Dermatological complications in diabetes

- Acanthosis nigricans - Necrobiosis lipoidica - Ulceration - Infections

WHAT IS DIABETIC KETOACIDOSIS 1B

- Acute complication of T1DM due to a metabolic switch to lipolysis for generation of ATP ➡ excess FFA➡ converted to ketone bodies results in Ketones , metabolic and lactic acidosis , Hyperkalaemia , osmotic diuresis due to glycosyuria -metabolic acidosis with high anion gap

WHAT CONDITIONS ARE ASSOCIATED WITH DIABETES

- Addison's disease - Hypoparathyroidism - Vitiligo - Hypogonadism - Pernicious anaemia - Rheumatoid arthritis

gastric carcinoma 1B

- Adenocarcinoma MC cause of cancer worldwide - more common in men >50 Aex: Diet with lots of nitrates and salt and low in vegies, H.pylori and chronic gastritis. -genetic, familial 3/4 S&S early stages: may be absent progressive: anorexia, dyspepsia, Weight loss Abdominal pain/ epigastric, weight loss, GI bleed (REDFLAGS) constipation anemia N/V -enlarged virchow's nodes (Troisier's sign) and migratory thrombophlebitis (Trousseau's sign) are rare but classic signs Ix gastroscopy- signet cells Rx Surgical resection, however most patients present with late-stage incurable disease with 5 year survival <10%

Emergency ibd treatment

- Admission, NBM - IV fluids and IV steroids - - Ciclosporin or infliximab rescue therapy ( uc)

female pattern hair loss 1B

- Associated with elevated levels of the serum adrenal androgen dehydroepiandrosterone sulfate -occurs in women with adrogenic alopecia - characterised by diffuse thinning of hair on the scalp due to increased hair shedding or a reduction in hair volume -50-100 hairs lost per day -baldness begins with receding frontal hairline that progresses to a bald patch on top of the head Rx minoxidil (0.25 mg daily) and spironolactone (25 mg daily) combination 6 months to see effects

SIGNS AND SYMPTOMS OF AKI

- Asymptomatic f - reduced urine output -pulmonary and peripheral oedema -arrhythmias (secondary to changes in potassium and acid-base balance) features of uraemia (for example, pericarditis or encephalopathy)

Sepsis six/ BUFALO

- BLOOD CULTURES - URINE OUTPUT - FLUIDS -ABX - LACTATE -OXYGEN

SEBORRHOEIC KERATOSIS

- Benign plaques (3-20mm) - greasy, "stuck on" appearance. -elderly but may begin in 30-40s - particularly in sun exposed areas - *NOT associated with sebum or sebaious glands and not restricted to sebacious areas as in Seb dermatittis* Rx reassurance

What is ulcerative colitis?

- Chronic inflammatory disease affecting the colon - Begins in the rectum and then extends proximally to affect the entire colon in a continuous inflammation with eventual backwash ileitis - More common in men, 15-25 years of age - Typical presentation is that of bloody diarrhoea

Causes of CN VI Palsy?

- Congenital - birth trauma, hydrocephalus, CP - Acquired - ischemia (DM/HTN), trauma, elevated ICP (downward displacement of brainstem), tumor, viral infection, MS, stroke, infiltrative, idiopathic

rx anal fissure

- Correction of constipation - Local anaesthesia - Topical nitroglycerin or diltiazem cream - Botulinum toxin injection - Sphincterotomy

HIP PAIN: PUBIC RAMI FRACTURE

- DIRECT TRAUma , usually motobikr "open book fracture -heal on their own if minor -cause permenant disability -if extensive unstable , needs surgery Complications - blood loss due to rupture of pelvic blood vessels

-CXR of pleural effusion

- Dense white shadow with a concave upper edge (meniscus sign) - Blunted costophrenic and cardiophrenic angles - Can result in total white-out and mediastinal - *tracheal deviation TO OPPOSITE SIDE* - Often causes an obscured hemidiaphragm

Diabeticneuropathy

- Due to increased oxidative stress and glycosylation of nerve proteins - Leads to demyelination and nerve damage - Also associated with impaired blood supply via the vasa nervorum

extrinsic allergic alveolitis (2B)

- EAA is a hypersensitivity pneumonitis occurring in response to inhaled allergens. - Can be type 3 or 4 hypersensitivity (NOT IgE mediated) - Involves a mononuclear infiltration, non-caseating granulomas formation and healing with fibrosis - due to repeated inhalation of organic dust, usually in a specific occupational setting triggering inflamation Types - Farmer'slung - Bird breeder's lung - Bagassosis(mouldy molasses) - Chemical worker's lung - Byssinosis - Cheese worker's lung - Prawn washer's lung chronic presentation insidious onset dyspnea, cough, malaise, anorexia, weight loss S&S -Acutely:Breathlessness, dry cough, and systemic symptoms (fever, chills, arthralgia, myalgia, headache) occur 4-12h after exposure to antigen. crackles and squeaks on auscultation, fever; wheeze OE leading to a misdiagnosis of asthma Chronic: progressive SOBOE , Fever, fatigue, fine end respiratory crackles , haemoptysis, clubbinf Ix PFTs: progressively restrictive CXR: predominantly upper lobe reticulonodular pattern type IV (cell mediated, delayed hypersensitivity) reaction (s • in both acute and chronic reactions, serum precipitins may be detectable (neither sensitive nor specific) HRCT: Diffuse centrilobular nodules, ground-glass change, mosaic attenuation from air trapping, may be honeycombing and traction bronchiectasis (may mimic appearance of UIP, although upper lobe predominance is typical in HP) Rx -predinosolone especially in short-term no effective treatment in LT -avoid contact with allegerns

INVESTIGATIONS FOR IBS 1A

- FBC - Stool studies - Coeliac screen - Abdominal X-ray - Colonoscopywht - Hydrogen breath test - Faecal calprotectin - ESR, CRP ( exclude inflammatory conditions)

Ix for IBD

- FBC - anaemia, raised WCC, low iron, low B12, low folate, thrombocytopenia - Raised ESR and CRP - Raised faecal calprotectin (leucocyte degradation product) - Positive anti-saccharomyces cerevisiae antibody (ASCA) - LFTs - may show liver disease or hypoalbuminaemia due to protein-losing enteropathy - Blood culture - stool studies ( ccalprotectin) - Plain X-ray - CD (obstruction, toxic megacolon, sacroiliitis, abscesses, bowel wall oedema) and UC (- Lead pipe appearance of colon due to ulcerative colitis, Complete loss of haustral markings, Smooth-walled, cylindrical segment of colon, Thumb-printing due to mucosal oedema ) - CT - bowel wall thickening, abscesses, strictures, fistulae, peri-colic fat stranding, Comb and fat halo signs - Barium enema or follow-through - mucosal oedema, ulceration, narrowing and strictures throughout the bowel

Dx and Rx Colon cancer

- FBC - iron deficiency anaemia - LFTs - metastasis - U&Es - ureteric compression - Positive carcinoma embryonic antigen (CEA) -1st line colonoscopy w/ biopsy gold standard other options - Barium enema reveals a classic apple-core appearance of a malignant stricture - CT colonography - CT abdomen - narrowed lumen and wall thickening - PET-CT and MRI for staging Stanging Duke's staging system: A and B have good prognosis, 2/3 of patients present with Duke's C or D which is advanced disease with poor prognosis Rx Surgical resection. Duke's C and D will need adjuvant chemotherapy.

complications of AKI

- Hyperkalaemia - Pulmonary oedema due to fluid overload - Metabolic acidosis due to reduced synthesis ofbicarbonate - this leads to hyperkalaemia by exchanging H+ for K+ ions - Uraemic pericarditis - Uraemic effusion

complications of sleep apnoea

- Hypertension - MI - Stroke - Arrhythmias - Due to nocturnal sympathetic surges, blood pressure fluctuations leading to reactive oxygen specie formation, inflammation and CVD

SEA URCHIN STING

- IMMEDIATELY PAINFUL puncture wound can become infected -Immerse the affected area in hot water ( as hot as can be tolerate ) for 30-90 mins Remove any spines you can with tweezers The pedicellariae can be shave off with a razor blade/scalpel if present Scrub the wound with soap and water and then leave it open, apply antibiotic cream 3 times a day if any remnants still left in Monitor closely for infection

Rx of metabolic acidosis

- IV sodium bicarbonate - 50ml of 8.4% bicarbonate

1B pathology of AKI

- Impaired renal perfusion leads to activation ofRAAS which causes vasoconstriction of the efferent arteriole and dilatation ofthe afferent arteriole - This eventually leads to acute tubular necrosis,microvascular endothelial injury and tubular ischaemia - Obstructive uropathy causes increasedintra-tubular pressure which is back-transmitted and causes parenchymal atrophyand ischaemia with inflammation, free-radical production and TGF-beta activity

Treatment for IBS 1A

- Lifestyle - relaxation, stress relief, avoid caffeine, avoid lactose, increase fibre, probiotics - Laxatives for constipation NOT LACTULOSE - Anti-diarrhoeals for diarrhoea- Loperamide is 1st line - Anti-spasmodics for pain - hyoscyamine, peppermint oil, mebeverine ( 1st line) - 2nd line : LOW DOSE TCA : amytriptylline - SSRIs - CBT - Hypnotherapy - Low dose amitriptyline

Rx for chrons and UC

- Low-residue diet - Avoid lactose -Remission induction - Steroids - prednisolone, swallowed budesonide, hydrocortisone - Biologics - infliximab, adalimumab, natalizumab - Polymeric, elemental or semi-elemental diets for 6-8 weeks Symptoms - Anti-diarrhoeals - Analgesia - Replacement of ADEK, vitamin D, calcium, B12, iron, folate - Antibiotics for infections Maintenance therapy - Azathioprine or mercaptopurine (check TPMT thiopurine methyltransferase levels) (CD) - - Topical and oral 5-ASA ( UC) - Methotrexate - Biologics - Long-term enteral nutrition Surgical therapy - Ileocaecal or ileal resection - Resection of localised disease - Colectomy - Perianal surgery - Stricturoplasty

features of polymyositis 2B

- Proximal muscle weakness - Dysphagia - Dysphonia - Respiratory failure due to respiratory muscle damage - Systemic features - fatigue, malaise, weight loss, fever - Cardiac failure - Sjogren's syndrome

Near drowning 1A

- RESIRATORY IMPAIREMENT FROM a maculopapular, pruritic rash develops in around 99% of patients who take ampicillin/amoxicillin whilst they have infectious mononucleosis - Fresh water can --> Hypervol, lyte distrubance, hemolysis physiology After an initial gasp, with possible aspiration, or a period of breath holding, apnoea eventually exceeds breaking point and stimulates hyperventilation, causing aspiration and a variable degree of laryngospasm. This leads to hypoxia and resultant acidosis with the patient eventually losing consciousness and developing cardiac arrest. Rx 1. Resus- ABCDE 2. intubation if unconscious 3. oxygen -4. Treat hypothermia, hypoglycaemia, seizures, hypovolaemia and hypotension, if they occur.

Hepatitis C virus

- RNA -Transmission: Bodily fluids transmission/ blood bourne -blood bourne, sexually transmited - s/sx: fever, N&V, anorexia, malaise, and jaundice but may be asymptomatic. - can develop into chronic, 80% become chronic.Rarely leads to liver failure. -cirrhosis and HCC rare -Ix: Antibody to HCV (anti-HCV) and HCV RNA Rx: supportive Chronic : Typically two direct-acting antivirals ie. harvoni or viekara pak or one plus ribavarin.

Hepatitis C virus 1B

- RNA -blood bourne, sexually transmited - s/sx: fever, N&V, anorexia, malaise, and jaundice but may be asymptomatic. - can develop into chronic -cirrhosis and HCC rare -Ix: Antibody to HCV (anti-HCV) and HCV RNA Rx: supportive

Polymyositis and dermatomyositis Ix 2B

- Raised ESR and CRP - Raised creatine kinase, LDH, adolase, AST and ALT - Positive anti-JO-1 and anti-MI-2 antibodies - Electromyogram - Muscle or skin biopsy

complications of varices

- Rupture --> GI bleed bleed may be facilitated by coagulopathies due - to liver damage - encephalopathy--> common in px with GI bleeding - spontaneous bacterial peritonitis and other conditions common

Simple laceration 1A

- SUPERFICIAL, REQUIRING ONE LAYER CLOSURE -may just need cleaing ( saline chlorhexadine) -normal dressing

When do you NOT patch a corneal abrasion?

- SUSPICIOUS OF PERFORATION - CONCERNED ABOUT FOLLOW-UP - SUSPICIOUS OF INFECTION *also, do not give topical anaesthetics, they prevent healing

Polymyositis and dermatomyositis rx 2B

- Steroids - Methotrexate - Azathioprine - Cyclophosphamide - Physiotherapy and exercises - SALT for speech and language

Tendinopathy & Bursitis Treatment

- Systemic analgesics, ice or heat applications, or local injection of an anesthetic and a corticosteroid to reduce inflammation - Bursitis: Aspiration to drain excess fluid -Physical therapy

ROTATOR CUFF TEAR Definition Features Investigations

- Tear in tendons of rotator cuff - common in elderly due to degeneration -results in pain and weakness of shoulder, exacerbated by overhead activity --> often misdiagnosed as subacromial impigmenet - difficult abduction - Normal passive movements - Ix: MRI

acute severe asthma

- Unable to complete full sentences - RR>25 - HR>110 - PEFR33-50% predicted

Granulomatosis with polyangiitis (Wegener)

- Vasculitis, cANCA -Upper respiratory tract: perforation of nasal septum, chronic sinusitis, otitis media, mastoiditis, bloody discharge -Lower respiratory tract: hemoptysis, cough, dyspnea. -Renal: hematuria, red cell casts. - joints: mild to full blown arthritis - affects eyes too

Developmental Hip Dysplasia 1B paeds

- abnormal development of hip resulting in dysplasia and subluxation/dislocation of hip - most common orthopedic disorder in newborns tests: Positive Ortolani sign = definitive "clunk" with hip mov't as femoral head reduces into acetabulum, barlow's test, galeazzi sign. Ix: xray 1st line USS, X-ray after 4-6mos Sx = asymmetric skin folds (non-specific), shortened leg, decr ROM, gluteal muscle atrophy affected side

What is diverticulitis

- acute Inflammation and micro-perforation of a diverticula secondary to fecalith impaction -fever, leucocytosis, occult blood in stool

Aex of gastritis /duodenitis

- alochol - reduce gastric mucosal blood flow --> loss of mucosal protective barrier -h.pylori : stimulates gastrin production, causes the greatest hyperacidity and duo- denal ulceration -NSAIDS inhibit prostaglandin production ( prostaglandings inhibit HCO3 secretion and increase mucus protection

Elbow dislocation

- anterior capsule and collateral ligaments disrupted - due to : elbow hyperextension via FOOSH or valgus/supination stress during elbow flexion - usually the radius and ulna are dislocated together, or the radius head dislocates and the ulna remains ("Monteggia") -80% are posterior/posterolateral, anterior are rare and usually devastating ss: elbow pain, swelling, flexion contracture, +/- ulnar + radial pulses Ix: x-ray assess NVS before resuction: brachial artery, median and ulnar nerves (can become entrapped during manipulation) Rx: reduction under sedation, long-arm splint, operation , RORIF complcations: stiffness (loss of extension), intra-articular loose body, neurovascular injury (ulnar nerve, median nerve, brachial artery), radial head fracture • recurrent instability uncommon

PERNICIOUS ANAEMIA 1A

- autoimmune atrophic gastritis --> destruction of parietal cellss--> no intrinsic factor --> reduced ileal Vit B12 absorption - results in megaloblastic/ macrocytic anaemia -more common in females -Associated with autoimmune thyroid disease, Addison's disease and vitiligo -features: glossitis, angular stomatotis, pallor, parasthesia, anaemia, soboe uncommon: petechiae, ataxia, decreasd vibration sense, cognitive impairement Ix: FBC: low Hb, low Hct, high MCV blood smear : megalocytes /HYPERSEGMENTED NEUTROPHILS serum B12 Rx: 1. IV cynacbalamin or hydroxocobalamin 2. neurologist referral 3HAem referral

Vitiligo 1B

- autoimmune disease characterised by symmetrical localised loss of skin pigmentation characterized by milk-white patches (leukoderma) -spontaneous remission can occur - due to destruction of melanocytes -can be drug induced -common in india aex: metastatic melanoma, drugs immune checkpoin inhibitors, diabtes, thyroid dz, addisons, SLE, RA, psoriasis, kobner phenomenon ( site of injury ) Rx - Sunblock - Topical steroids - Phototherapy - Tacrolimus

Bullous Pemphigoid 1B

- autoimmune skin condition , SUB-EPIDERMAL TENSE BULLAE - seen intact - IgE and IgG against DEJ - seen in elderly, severely itchy, affects everywhere but pemphigus more linked to oral mucosa -*Lasts months to years w/o tx* -oral cavity may be affected Increased Eosinophils in blister Ix: biopsy of C3 and IgE Tx:ultra otenet steroids clobetasol , Abx, pain relief, PO steroids, antihistamines

Types of gallstones

- cholesterol (yellow appearance, contains cholesterol and calcium salts, mostly due to increased fat diet) - pigmented (black in appearance, contains bilirubin, bile salts, proteins) --> due to haemolysis, cirrhosis, chrons - mixed -Brown : commonly form due to infections mainly with bacteria --> strictures,PSC, surgery, bacterial infections - bacteria release enzymes (mucin) which interact with calcium bilirubinate and choesterol

MYELODYSPLASTIC SYNDROME 1B

- clonal disorders characterised by ineffective haematopoiesis and peripheral cytopenia due to increased apoptosis --> MACROCYTIC NORMOBLASTIC - tend to evolve to acute myeloblastic leukaemia. - peak incidence 70 2. RF: prior cancer therapy ((chlorambucil, cyclophosphamide, melphalan, benzene, familial/genetic Features: Pancytopaenia Anaemia: SOB, pallor, palpitations, fatigue Neutropaenia: infections fever Thrombocytopaenia symptoms: petechiae, ecchymosis, bleeding gums, epitaxis, hepatosplenomegaly Ix: 1. FBC: macrocytic/normochromic anaemia ± neutropenia ± thrombocytopenia ± neutrophilia ± monocytosis ± thrombocytosis 2. blood film: various things 3. U&E, LFTs, ECG and CXR: to assess co-morbidity. 4. iron studies serum ferritin, vitamin B12 and RBC folate: usually normal levels; ferritin may be elevated in RARS. 5. BM aspirate 6. cytogenetics

Intraabdominal abscess 1B

- collection of pus or infected material in the peritoneal cavity - can be intra-retro peritoneal or visceral - due to infection of organ (s) in the cavity - common 2ry to perforations, appendicitis, diverticulitis, surgical procedues - commonly due to E.coli infection S&S: malaise, fever, abdominal pain, +/- N&V, diarrhoes, severe obstipation Exam: tender abdo, +/- rebound tenderness , palpable mass Ix: CT, FBC , U&Es, lactate, ESR, CRP, culture , LFTs, Rx: empiric IV abx (ertapenem, moxifloxacin, cefuroxime) and metronidazole

humerus fracture (proximal ) 1B

- common in young -FOOSH from standing features: proximal tenderness, deformity with severe fracture, swelling , painful ROM, bruising, Ix: axillary nerve function, Xrays, CT scan complications : AVN, nerve palsy (45% _ typically axillary nerve), malunion, post-traumatic arthritis

euchian tube

- connects the middle ear with the nasopharynx at the back of the nasal cavity. - permits aeration of the middle ear and if it is obstructed fluid may accumulate in the middle ear causing deafness.

With a fracture there may be the following damages

- damage to muscles - tearing of blood and lymph vessels - damage to periosteum and blood vessels in the cortex and marrow. - damage to nerves

calcific tendonitis / Acute tendinitis 1B

- depositis of calcium in supraspinatus tendon --> sudden onset of sever shoulder pain - Aex unknown -common in women 40-60 - visible on X-ray -Rx: analgesia, steroid injection, needle aspiration, lavage, open drainage

2B glomerulonephritis

- diseases in which there is inflammation of the glomerular capillaries and glomerular BM and nephrons results in haematuria and some protein in urine - OFTEN follows streptococcal infection -common in kids -includes membranous GN, minimal change disease, focal and segmental glomerulosclerosis, immunoglobulin A nephropathy -mostly immune mediated - GN is a common cause of end stage renal failure -The main consequences are haematuria, hypertension,proteinuria, haematuria and AKI, HTN and oedema , low gfr, rbcs, casts - can be primary diseases or secondary to other causes : SLE, resp and GI infections , drugs, malignancy -diagnosed by renal biopsy -treated with transplant or dialysis

olecranon #

- due to trauma to posterior aspect of elbow or FOOSH -s&s: localised pain, palpable defect +/- loss of active extension due to avulsion of triceps tendon IX: xray -Rx: nondisplace: cast , displaced: ORIF and ROM

alcohol related liver disease 1B

- excessive alcohol intake results n fatty liver (90%), alchol hepatitis, cirrhosis and HCC - usually after 8 years - there is reduced exportation of fa from liver due to hepatic fatty acid oxidationand lipoprotein production decrease.

features of alcoholic liver disease

- fatty liver: asymptomatic, splenomegaly ( smooth non-tender) -hepatitis: fatigue, fever, jaundice, RUQ pain, hepatomegaly, hepatic bruit -cirrhosis: small liver, asympomatic if compesated

genu varum

- femoratibial angular deformity resulting in bow legged. caused by a tight posterior hip capsule - common in toddlers resolves spontaneously by 18mo - if persistent suspect Blount dz or rickets -blount dz is growth disturbance of the medial aspect of the proximal tibial growth plate; genu varum and tibial torsion may occur. Rx: night splint or osteotomy if severe.

Erythema nodosum is characterized by

- inflammatory skin condition characterised by raised tender subcutaneous bilateral lesions (red bumps) on anterior surfaces of lower legs - common in women 20-30-40s -Aex: URTI, sarcoidosis, TB, pregnancy, COCP, drugs, IBD

Psoriasis, def, features, Aex, types 1A

- inflammatory skin condition characterised by well-demarcated scaly plaques on erythematous bases, silvery scales, prominent skin lines and pruritus - common in females, onset 16-22 and 55-60 -Aex: Isomorphic Koebner's Phenomenon, Lithium, Beta blockers, antimalarials, systemic steroids , infection, smokingm alcohol Histology: Absent granular layer, Polymorphonuclear abscesses, Elongated and clubbed rete ridges, Neutrophil and lymphocyte infiltrate Clinical Types: 1. Psoriasis Vulgaris/chronic plaque psoriasis 2. Gutatte psoriasis 3. Pustular psoriassis of the palms and soles 4.Pustular psoriasis of the digit 5. Generalized pustular psoriasis 6. Erythrodermic Psoriasis 7. Inverse Psoriasis 8. Nail Psoriasis

septic hip/ Arthritis Paeds ( everything) 1A

- intra-articula infection of the hip - usually Group B( s.aureus, salmonella)) strep or Hib, or Neisseria gonorrhoeae in adolescents - surgical emergency -through haematogenous seeding - extension of osteomyletis ss: acute onset of hip pain, fever, rigor, limp, refusal to bear weight , swelling, effusion, tender warm. hip rests in a position of flexion, abduction, and external rotation (FABER) limited ROM Ix: X-ray, USS, MRI, hip aspiration, cultures, LP Rx: ABx, Urgent operation with emperic IV abx,( oxacillin, gentamicin) surgical drainage, splining Complications : destruction of femur head due to chondrolytic effect of pus

ACUTE LOSS OF VISION - PAINLESS 1B

- loss of vision which develops in a few minute sto a few days AEx -Vascular occlusions of the retina (central retinal artery occlusion, central retinal vein occlusion) -Ischemic optic neuropathy (often in patients with temporal arteritis) -optic neuritis -Vitreous hemorrhage (caused by diabetic retinopathy or trauma) Trauma -retinal detachment -papillitis -acute congetsive glaucoma -cortical lesiona - trauma, vascular -Acute corneal hydrops as in keratoconus -Photo-ophthalmia—Eclipse and snow blindness, exposure to bright arc or flash light LESS COMMON -Anterior uveitis(usually causes eye pain severe enough to trigger evaluation before vision is lost) -Aggressive retinitis -Drugs -(eg, methanol, salicylates, ergot alkaloids, quinine) - tumour

LEUKOPAENIA 1B

- low WBC < 4000 - characterised by reduced number of neutrophils, although a reduced number of lymphocytes, monocytes, eosinophils, or basophils may also contribute -NEutropaenia low neutrophil <1500 and <1200 in blacks - lymphhocttopaenia

Neutropaenia 1B

- low neutrophils <1.5 moderate <.05-1.0L severe <0.5 - risk of severe bacterial and fungal infections increases -asymptomatic, signs of infections fever common infections affected with neutropaenia -cellulitis -furunculosis -pneumonia -septicimia -Skin infections: by S.aurus

Insect bites and stings

- may present with papular urticaria ( clusters of irritable urticated papules) -may have pale centre, erythematous, urticarial, papular, vesicular, eczematoid or granulomatous. -Bees, wasps, ants: bullae, swelling, erythematous wheal, systemic anaphylaxos inc urticaria, angioedema, bronchospasm and hypotension. Rx: adrenaline .5ml 1:1000, IV antihistamines, oxygen, venom , steroids Malaria (Anopheles mosquitoes) West Nile fever and Dengue fever (Aedes mosquito) Chikungunya fever (Aedes mosquito) Viral encephalitis (Cu lex mosquito) Filariasis (Culex mosquito) Tularemia (deer fly and black fly) Cat-scratch disease (cat fleas) Plague (fleas) Leishmaniasis and bartonellosis (sandflies, fleas and lice) Onchocerciasis (black fly) Trypanosomiasis (kissing bugs, tsetse fly)

COPD LTOT CRITERIA

- measurements of pO2 < 7.3 kPa -OR Po2 >7.3 and - polycythaemia =oedema -pulmonary htn

Juvenile RA / juvenile idiopathic RA 2B

- most common arthropathy in children - arthritis before age of 16 in 1 or more joints for at least 6 wks -chracterised by swelling or effusion, increased warmth, and/or painful limited movement with or without tenderness 7 sub-types - Systemic arthritis (fever, salmon pink urticarial rash when warm, oligo & polyarhtritis, - Serositis - pericarditis, pleuritis, peritonitis, silent effusion, myocarditis, cardiomegaly and failure ) - Oligoarthritis ( common in females, silent ant uveitis., asymetrical involvement of knees, elbows, writs, overgrowth) - RF-positive polyarthritis ( chronic, symmetrical, inflammatory, polyarthritis in 5> joints, common in girls, more aggressive than adult RA, early morning stiffness, worse with inactivity. fever hepatosplenomegaly, adenopathy, pericarditis etc..) - RF-negative polyarthritis (30% IJA, fever, rash, symetrical joint involvement, swelling, stiffness, limited mobility, muscle wasting) - Psoriatic arthritis ( after psoriasis, asymetrical arthropathy- knees, ankles and small joints, nail involvement) - Enthesitis-related ( juvenile ankylosing spondylits, inflammatory spinal pain, sacroilic joint pain) - Undifferentiated

POLYCYTHAEMIA RUBRA VERA 1B

- myeloproliferative neoplasm. *erythrocytosis, leukocytosis, thrombocytosis, Jak 2 mutation* -PH chromosome negative myeloproliferative neoplasm of the bone marrow characterised by erythrocytosis and often thrombocytosis, leukocytosis, and splenomegaly - JAK2 mutation in 95% -more common in men >70 - classically: intense itching which usually occurs after exposure to hot water or hot and humid weather -hyperviscosity -pruritus, typically after a hot bath splenomegaly haemorrhage (secondary to abnormal platelet function) plethoric appearance hypertension in a third of patient Secondary causes: - COPD - altitude - obstructive sleep apnoea - excessive erythropoietin: cerebellar haemangioma, hypernephroma, hepatoma, uterine fibroids Ix - Raised HCT, raised Hb, raised red cells, raised platelets, raised , wcc - JAK2 positive - Raised WCC, platelets -• Serum erythropoietin (sEPO): included in initial work-up; usually ⬇ but can be n in PV JAK2 mutation is the only thing that CONFIRMS PRV Rx -venesection aspirin

Whats the criteria for a transudate effusuin and what are the causes

- occurs due to hydrostatic/osmotic pressure changes · Low protein content · Due to extravasation down pressure gradients · <30g/L protein · <200u/L LDH Fluid to serum LDH ratio <0.6 causes - Cardiac failure (most common- bilateral ) - Cirrhosis - Ascites - Nephrotic syndrome - Constrictive pericarditis - Hypothyroidism -Meig's syndrome (ovarian tumour (fibroma), ascites and right-sided pleural effusion)

Bisphosphonates side effects

- oesophageal reactions: oesophagitis, oesophageal ulcers (especially alendronate) - osteonecrosis of the jaw - increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate - acute phase response: fever, myalgia and arthralgia may occur following administration - hypocalcaemia: due to reduced calcium efflux from bone. Usually clinically unimportant stop bisphosphonates at 5 years if following: patient is < 75-years-old femoral neck T-score of > -2.5 low risk according to FRAX/NOGG

Subacromial Tendonitis and Bursitis

- painful arc -shoulder pain worse on abduction -reduced abduction between 90-120 degrees -due to trauma or chronic impingement

WEEVER FISH STING

- peirce skin and leaves venom - short-term paralysis and numbness - excruciating pain for 2 hrs - wash with hot water as hot as can tolerate 20-30 mins-. thermolabile toxin -remove spines

THROMBOCYTOPAENIA 2B

- plate;ets <150 - due either to decreased bone marrow production of platelets or to increased destruction or sequestration of platelets from the circulation (or both) -featureS: Purpura, easy bruising and prolonged post-traumatic bleeding Bone marrow production issues - Marrow failure: aplastic anaemia -Marrow infiltration: leukaemias, myelodysplasia, myeloma, myelofibrosis (- 'tear-drop' poikilocytes on BF), lymphoma, metastatic carcinoma. -Marrow suppression: cytotoxic drugs and radiotherapy, other drugs (e.g. chloramphenicol). - Selective megakaryocytic: ethanol, drugs (phenylbutazone, co-trimoxazole; penicillamine), chemicals, viral infection (e.g. HIV, parvovirus). - Nutritional deficiency: megaloblastic anaemia INCREASED DESTRUCION OF PLATELETS -ITP - SLE, CLL, lymphoma -drugs DIC, TTP/HUS Ix - Hx: drugs, illness, virus - Exam: infection, lymphoadenopathy , hepatisplenomegally ??? - blood film -BM exam

What is diverticulosis

- presence Many diverticula, the most common cause of acute lower GI bleeding in patients >40 years of age -most in sigmoid colon -cause of GI bleed/ bowel obstruction

Myeloma Hypercalcaemia

- primary factor: due primarily to increased osteoclastic bone resorption caused by local cytokines (e.g. IL-1, tumour necrosis factor) released by the myeloma cells - much less common contributing factors: impaired renal function, increased renal tubular calcium reabsorption and elevated PTH-rP levels

Non-invasive ventilation (NIV) in COPD exacerbation

- provides positive pressure breaths for patients with spontaneous breathing. - Patients with a pH in the range of 7.25-7.35 achieve the most benefit Indications for NIV - COPD with respiratory acidosis pH 7.25-7.35* -type II respiratory failure secondary to chest wall deformity -neuromuscular disease or obstructive sleep apnoea -cardiogenic pulmonary oedema unresponsive to CPAP weaning from tracheal intubation

venous ulcers

- proximal to the medial malleolus, irregular shape, shallow, mild to moderate pain, normal pedal pulses, increased edema, normal skin temp, flaky, dry skin, leg elevation lessens pain Ix- ABPI R/O PVD ( normal .8-1.2 Rx compression bandagess

NASAL SEPTAL HAEMATOMA NOM

- result of nasal trauma - Features: pain , rhinorrhoea, bilateral red swelling arising from nasal septum , feels boggy whereas septum feels firm Rx- refer to ENT urgently , surgical drainage and abx if untreated can result in necrosis -> saddle nose deformity

Jaundice causes 1B

- results from accumulation of bilirubin in bloodstream nd subsequent deposition in the skin, sclera, and mucous membranes. -bilirubin normal range (0.2-1.2mg/dL) Pre-hepatic - red blood cell destruction Intrahepatic - failure of the liver to remove and conjugate bilirubin Post-hepatic - obstruction of bile flow

Re-feeding syndrome 1A

- sudden shifts in electrolytes after re-introduction of food after malnourishment -characterised by rapid reductions in phosphate, potassium, and magnesium, water dysregulation, and altered glucose metabolism, and can lead to fatal cardiac complications. -follows: malnourishment, fastng, extreme dieting, starvation , anaroxia, alcoholism - calorie intake should be increased gradually -close monitoring of electrolytes inc. phosphate, glucose, weight and fluid ( daily) -dietitian input needed signs: hypophosphataemia, congestive heart failure, and mental status change., oedema transiently.

Shoulder instability/ dislocation 2B

- there is separation of the humerus from the glenoid of the scapula at the glenohumeral joint - anterior and posterior -95% anterior -anterior : Abducted arm is externally rotated/hyperextended, or blow to posterior shoulder Posterioir : caused by force applied along the axis of the arm, shoulder is adducted. Internally rotated and flexed associated with (1) Hill-Sachs lesion: indentation of humeral head after impaction on glenoid rim; o (2) Bankart lesion: avulsion of capsule when shoulder dislocates occurs in 85% of all anterior dislocations X-ray: light bulb sign, incogruency of humeral head and outline of the glenoid mercedez-benz sign Nerve damage axillary nerve rnay be damaged. therefore check sensation and contraction over lateral deltoid: for musculocutaneous nerve, check sensation of lateral forearm and contraction of biceps

complex lacerations 1B

- think about tendons and underlying anatomy - disinfectant / sterile technique - analgesia +/- anasthesia - lidocaine - prophylactic abx - tetanus IG - suture require more than layered closure and may require reconstructive surgery

ACOUSTIC NEUROMA 1B

- tinnitus, Vestibular Schwannoma - benign tumour in internal auditory meatus (usually uniltareal -bilateral in familial neurofi bromatosis type 2 (NF2) V rare -compresses on trigeminal nerve in the CP angle as it enlarges causing loss of corneal sensation - facial nerve palsy FEATURES progressive hearing loss and imbalance 2. raised intracranial pressure 3. Associated facial nerve palsy (due to compression within the internal acoustic meatus) 4. Absent corneal reflex due to CN V (trigeminal nerve) palsy - other features of deficit - compression as the cochlear nerve leaves the internal acoustic meatus 5. café-au-lait skin lesions, and multiple intracranial lesions Ix: MRI, audiogram, poor speech, vestibular tests Rx surgery

FOLLICULAR THYROID CARCINOMA 1B

- tumor of the follicular cells of the thyroid gland. It is a slowly growing, painless, cold nodule. 10%, common in elderly in regions of iodine deff. lung and bone mets

Oesophageal neoplasm 1B

- two common types - adenocarcinoma and squamos cell carcinoma -adenocarcinoma risk increasing in UK -SCC occurs in upper 2/3 oesophagus risk factors include alcohol, smoking.:achalasia, smoking, hot liquids, -adenocarcinoma more linked to bO , occurs in lower 1/3 of oesophagus, risks: bO, smoking, obesiy, GORD 3/4 S&S 1. voice hoarseness, progressive dysphagia, weight loss, coughing after swallowing Ix Ix: Barium swallow, gastroscopy with biopsy, CT for staging, Rx: Chemoradiation and surgical resection are first-line. Poor prognosis.

Oesophageal neoplasia

- two common types - adenocarcinoma and squamos cell carcinoma -adenocarcinoma risk increasing in UK MOST COMMON TYPE OF OESOPHAGEAL CA -SCC occurs in upper 2/3 oesophagus risk factors include alcohol, smoking.:achalasia, smoking, hot liquids, -adenocarcinoma more linked to bO , occurs in lower 1/3 of oesophagus, risks: bBO, smoking, obesiy, GORD

arterial ulcers 1B

- ulcers of the foot and toes, webbed spaces due to arterial insufficiency , more often atherosclerosis - ulcers result from acute or chronic ischaemia and/or atheroembolisation of fibrin, platelet and cholesterol debris from a distal source into small vessels of the skin. features: nocturnal pain, hairlessness, chronic ischaemia, pale skin, absent pulses, nail dystropy, waslting of calf muscles,, decreased skin temperature, thin and shiny tissue, hair loss, yellow nails. leg elevation increases pain. ix: check pulses, check sensation, ABPI 0.5 and 0.8 abnormal (1 normal) <.5 revascularisation -RF: vasculitis, chilblains, Raynaud's phenomenon, disseminated intravascular coagulation (DIC), cryoglobulinaemia, hyperviscosity syndrom

Ulnar Nerve Entrapment

- ulnar nerve can become trapped in teh *cubital tunnel* posteromedial to elbow joint -results in numbness and wasting on the ulnar one and 1/2 fingers Secondary to compression of the *ulnar nerve at the wrist* tunnel of guyon between pissiform and hook of hamate -common in cyclists - affects hypothenar and interosseous muscles -can cause clawing of fingers esp in low lesion - movements of bending hand up/down or side to side at the wrist

Rodent bite or rodent urine and saliva

- usually rats - common in children <5 - Infections Streptobacillus moniliformis Spirillum minus Salmonella spp. Rx fever penicillin hospital in fever, swolen nodes etc...

Roseola Infantum (Exanthem Subitum) 1A

- widespread rash accompanied by systemic symptoms inc. fever, malaise and headache -usually viral -ae: vzv, measles, rubella , roseola ( HPV 6B) A. aka: 6th disease, exanthem subitum B. Etiology: Human Herpes virus 6, type A & B C. Clinical findings: 1. Incubation period 12 days 2. Prodrome of high fever (103-106F), otherwise relatively asymptomatic 3. Rash develops after fever breaks D. Treatment: treat fever, as this is common cause of febrile seizures

OTOTOXIC DRUGS

-*Aminoglycosides*: Gentamicin, streptomycin, trobamycin, (Neomycin ) - furosemide - NSAIDS and Aspirin -Quinine

MEDULLARY THYROID CANCER 1B

-4% thyroid cancers - neuroendocrine tumor of parafollicular C cells of thyroid produce calcitonin and present as solitary thyroid nodules in 70-95% patients. -can also secrete prostaglandins, ACTH, serotonin, kallikrein, or bradykinin Rx total thyroidectomy followed by radioiodine (I-131) to kill residual cells yearly thyroglobulin levels to detect early recurrent disease

CN IV Palsy

-75% congenital -Acquired: Trauma, ischemic, stroke, tumor, MS, inflammatory/infiltrative , meningitis, vasculitis , cavernous -CN IV has longest intracranial course - susceptible to damage during head trauma Features - vertical diplopia worse on downgaze -• Ipsilateral hypertropia/phoria worse on downgaze or on ipsilateral head tilt

de Quervain's Tenosynovitis 1B

-: inflammation in 1st extensor compartment (APL and EPB) common cause of radial wrist pain - >F , Age: 30-50 - synovitis of tendon sheath of abductor pollicis longis and extensor pollicis brevis due Overuse to *repetitive gripping* - s/s: painful fusiform/ along radial aspect of wrist swelling aggravated by twisting of wrist , pain on thumb flexion. -tender over radial styloid process, , painful abduction of thumb against resistenace O/E: pain localised to 1st extensor compartment -test: finkelstein test Ix: clinical dx rX: analgesia, steroid injection, splintage, surgical decompression Finkelstein's test: with the thumb is flexed across the palm of the hand, pain is reproduced by movement of the wrist into flexion and ulnar deviation

LICHEN PLANUS 1B

-A chronic and recurrent inflammatory dermatosis characterized by flat-topped, violaceous, shiny, pruritic papules, and milky white papules in the mouth. - Lesions can coalesce into plaques Grouped, linear (isomorphic phenomenon), annular, or disseminatedscattered discrete lesions Wrists (flexor), lumbar region, eyelids, shins (thicker, hyperkeratotic lesions), scalp, and glans penis Mucous Membranes 40% to 60% of individuals with LP (more milky white in appearance) --> causes lacy white streaks, plaques and ulceration with PAIN when in the mucosa as opposed to itching 2. The 5 P's of Lichen planus are Pruritic, Planar, Purple, Polyangular, Papules 3. 30 to 60 years, Females > males, 10% family history Etiology: Drugs may induce a lichen planus like eruption (gold, antimalarials, penicillamine) Prognosis: 1. LP usually persists for months, but in some cases, for years Treatment: 1. Topical and intralesional corticosteroids : 2. Oral prednisolone, retinoids (acitretin or etretinate), cyclosporine,PUVA

What is the optic disc?

-A region at the back of eye continuous with the retina -Is the collection point of the nerve fiber layer as it exits the eye: - where the nerve fiber layer becomes the optic nerve -where the central retinal artery enters the retina -where the central retinal vein exits the retina - Has a normal slight depression called the physiologic cup - Is round or slightly ovoid - Is about 1.5 millimeters in diameter - Is called the blind spot

Sturge-Weber syndrome

-A vascular malformation or port-wine stain over the face that involves the cutaneous distribution of the ophthalmic division of the trigeminal nerve - leptomeningeal vascular malformation, cerebral calcification, seizures • A high incidence of mental retardation and ipsilateral ocular complications - glaucoma - choroidal hemangioma ("tomato catsup fundus")

Ventral hernia

-A weakness in the abdominal wall, usually resulting in protrusion of abdominal viscera against the peritoneum and abdominal fascia. -anywhere on abdomen -can become strangulated - cmmmon in elderly -can be asymptomatic Rx: lap repair, open surgery

SUBACUTE THYROIDITIS (DE QUERVAIN )

-AKA subacute thyroiditis - thyroiditis is Inflammation of the thyroid gland often leads to a transient thyrotoxicosis followed by hypothyroidism - granulomatous thyroiditis, *Painful goitre*, hyperthyroidism symptoms common POST-INFECTIOUS -caused by viral infection or post viral infection : including *mumps, coxsackie, influenza, adenoviruses, and echoviruses* -damages follicular cells--> released of stored t3/4 -does not increase synthesis -lasts 2-6 wks hyper, then euthyroid then -followed by hypothyroidism then euthyroidism Ix TSH ⬇ T4 ⬆⬆⬆⬆⬆ ESR ⬆⬆ DECREASED UPTATE GLOBALLY ON THYROID SCAN Rx: self-limiting, no treatment, NSAIDs, steroids in severe cases. globally reduced uptake on iodine-131 scan

OTITIS EXTERNA 1A

-AKA swimmer's ear -Inflamm of Ext Aud canal common in swimmers -*could cause CFS infections* - Immune deficient peeps/diabetes can get necrotizing/ malignant OE : is unremitting pain w/ NSAIDs, otorrhoea, fever or malaise, paralysed facial nerve, osteomyelitis of temp bone.--> pseudomonas aeruginosa or staph aureus. Rx Ciproflaxin *Chronic*: occurs every 2-3 wks, pruritus, atrophic and scaly epidermal lining, AEx: 1. Pseudomonas, 2. S.aureus, 3. Strep . Fungal ( candida, aspergillus , mechanical Q-tips, headphones, Features: Otalgia , pruritis, purulent discharge (otorrhea), pain on pinna/tragus, *conductive hearing loss* Ix: 1. otoscopy: erythema of external auditory meatus, scaling and otorrhoea 2. ear culture Rx: 1. otowick 2. Topical abx: otomize 3. Hydrocortisone and paracetamol for severe dz 4.Abx ONLY IF cellulitis beyond external ear canal, wick cannot be inserted, diabetes and immunocompromised , se;f-care advice 5. IV abx cipro for necrotising or Refer to ENT surgeon --> can spread to bone and CNS CHRONIC 1. Fungal : Treat with a topical antifungal : Clotrimazole 1% solution, Acetic acid 2% spray (unlicensed use), Clioquinol and a corticosteroid (for example Locorten-Vioform®).

Erysipelas ( 1B in both matrices) St. Anthony's fire

-Acute cellulitis of the DERMAL CT and LYMPHATICS involvement -Aex: Strep or stap -characterised by Tense, hot, uniformly elevated, shining patch with irregular outline - sharply defined and raised border.. -Prodromal Symptoms: Malaise, chills, fever, +/- anorexia and vomiting. starts off as one spot Tx: -Strep - phenoxymethylpenicillin -Staph - flucloxacillin IV abx if systemic upset

Diagnosis of acute pancreatitis 1A

-Amylase -Lipase ( more sensitive) -Abdo U/S or CT may show an enlarged pancreas with stranding, abscess, haemorrhage, necrosis or pseudocyst - FBC, U&E, LFT - Raised WCC - Raised HCT - predicts necrosis, important monitoring test - ABGs - Raised CRP - Clotting profile - Serum lactate - raised due to necrosis - Glucose - CXR - pleural effusion - AXR - sentinel loop sign - US - inflammation, stranding, fluid - CT - irregular, enlarged, non-homogeneous pancreas, fat-stranding - MRCP and ERCP - stones, enlargement, ERCP can perform sphincter manometry

sickle cell TRAIT

-Asymptomatic carriers have one abnormal bS gene and one normal b gene -NO CLINICAL features - Occasional renal papillary necrosis, haematuria and inability to concentrate the urine in adults.

Goodpasture's disease (Anti-glomerular basement membrane disease) -features -treatment

-Auto-antibodies against type 4 collagen in the lung causes pulmonary haemorrhage - The same antibodies in the kidneys cause renal nephritis and bleeding, depoisit IgG in basememnt membrane - common in young males - Presents with nephritic syndrome, haematuria and AKI -Fever, haemoptysis, nausea Ix: renal function tests, Biopsy with immunofluorescence reveals IgG deposition along the basement membrane, anti-GBM, ANCA Rx -Plasmapheresis -Steroids -Cytotoxic drugs e.g. cyclophosphamide

Alopecia areata

-Autoimmune hair loss with antibodies against hair follicles -Leads to patches of baldness -Broken exclamation mark hairs are seen at the edges of bald areas -Associated with nail pitting -Totalis - whole head -Universalis - entire body -RX --> topical steroids

RETINOBLASTOMA 2B

-Autosomal dominant condition (or acquired) with loss of the PRB tumour suppressor gene on chromosome 17 Features: -Presents with leucocoria (white pupillary reflex instead of red) in children aged under 2 - due to pale, elevated tumour at the posterior pole of the eye -May also experience a squint, painful red eye -Most common ocular neoplasm in children Ix: - Fundoscopy: Whitish-pink mass protrudes from the retina into the vitreous cavity - orbital USS - orbital CT ot MRI Treatment: - Enucleation of the eye - Cryotherapy - Photocoagulation - Radiotherapy

common causative organisms of pneumonia

-BACTERIA -Streptococcus pneumoniae -Haemophilus influenzae ( GRAM -VE ROD) -atypical bacteria (ie, Chlamydia/ chlamidophila pneumoniae, Mycoplasma pneumoniae, Legionella (hyponaetraemia) -Chlamydia psittaci - RARE, in px exposed to birds -P.aeruginosa -> common cause of pneumo in *cys. F* , AIDS, bronchiectasis *VIRUSES* - syncytial virus (RSV), adenovirus, influenza viruses, metapneumovirus, and parainfluenza viruses. VZV & CMV (immunocompromised individuals)

URINARY TRACT INFECTION 1A

-Bacteriuria - bacteria within the urine -Urinary tract infection - pure growth of >105 organisms per ML of fresh mid-stream urine or 2 consecutive growths of the same organism -Lower UTI - urethritis, cystitis, prostatitis -Upper UTI - pyelonephritis -Abacterial cystitis/urethral syndrome - negative MSU in symptomatic women 2. AEx: E.coli, proteus mirabilis ( boys), klebsiella, pseudomonas ( structural kidney abnormalities) b. RF: females, coitus, pregnancy, menopause, DM, obstruction 3. urgency, frequency, haematuria, dysuria, dyspareunia, suprapubic pain 5. urinalysis, MSU, culture sensitivity, cytoscopy, CT KUB, CT abdopelvis 6. Rx. Nitrofurantoin, trimethroprim

Thiazide dieuretics (bim)

-Bendroflumethiazide, indapamide, metolazone (bim) - Inhibit the NaCl transporter in the distalconvoluted tubule - This leads to reduced sodium reabsorption andincreased water loss into the filtrate by osmosis - SE - hypocalciuria, hypokalaemia,hyperuricaemia, hyponatraemia, metabolic alkalosis, hyperglycaemia, gout

GLAUCOMA MEDS AND MOA

-Beta blockers i.e timolol , act by *reducing aqueous secretion by the ciliary body.* Prostaglandin analogues ie. latanoprost, act by *increasing aqueous outflow* via the uveoscleral route. Sympathomimetics act by reducing aqueous secretion and increasing aqueous outflow. Miotics i.e pilocarpine, act by opening the aqueous drainage channels in the trabecular meshwork. therefore increase uveoscleral outflow Diode laser cycloablation destroys part of the secretory component of the ciliary body, thereby reducing aqueous secretion. Carbonic anhydrase inhibitors (e.g. Dorzolamide) Reduces aqueous production

Rx of oesophageal varices:

-Bleeding: resuscitation, free airway -vasoactive drugs: somatostatin, terlipressin, ocreotide -endoscopic variceal ligation- tying rubber bands on varices repeasted until varices obliterated -ocreotide -small, not bleeding : b-blockers (40mg/OD ) --> reduce pressure in varices --> reduced bleeding transjugular intrahepatic porto-systemic shunt (TIPS) for resistant varices.

renal osteodystrophy

-Bone lesions due to secondary hyperparathyroidism due to chronic renal disease - presents with hypocalcaemia, hyperphosphataemia and elevated PTH -Kidneys is responsible for Vit D metabolism and calcium resorption -kidney also cannot excrete phosphorus so it builds up in the body - renal failure means Ca+ is not resorbed and Vit D is not being synthesised - body tries to get Ca+ through breaking down bone -phops -Vit D helps absorption of Ca= in intestine, retention in kidneys 1. 25-OH Vit D2 converted to 1,25 OH vit d3 by kidneys . 2. renal failure means no VIt D3 --> low Ca+ --> ( osteomalacia as no mineralisation ) 3. in renal failure phospahte not excreted --> posphate binds Ca+ --> reduced serum Ca+ --> no mineralisation --> osteomalacia 4. Low ca+ --> PTH release --> osteclasts breakdown already soft bone for Ca+ ( subperiosteal bone resorption) 5. pseudofractures , microfractures (osteitis fibrosa cystics) Ix: Ca+ , PhO4, Vitamin D, X-ray

what is Bronchogenic carcinoma (1B)

-Bronchogenic carcinomas begin as a small focus of atypical epithelial cells within the bronchial mucosa. -As the lesion progresses it becomes malignant and the neoplasm grows in size. - can completely obstruct bronchus -4 subtyoes: adenocarcinoma, SCC, small and large cell cancer--> split into small and non-small ((including squamous cell carcinoma, adenocarcinoma and large cell carcinoma)

APLASTIC ANAEMIA/ PANCYTOPENIA 1B

-Characterised by pancytopaenia and a hypoplastic ( lack of pluripotent stem cells in BM) bone marrow - peak incidence of acquired: 30 years old - can progress to AML and myelodysplasia, PNH Causes: -Autoimmune -Fanconi's anaemia- common cause -Dyskeratosis congenita -Schwann-Diamond syndrome -Benzene, toluene -Chemotherapy -Drugs - azathioprine, NSAIDs, penicillamine, gold, chloramphenicol, phenytoin -Ionising radiation -HIV, TB -Associated with PNH, pregnancy, coeliac disease and SLE -idiopathic Features: anaemia, bleeding/bruing/ petechia ( lack of platelets, infections IX FBC BM biopsy Rx -Transfusion of red cells, platelets and antibiotics -Prednisolone -Ciclosporin -Allogeneic stem cell transplantation -ANTITHYMOCYTE GLOBULIN

idiopathic pulmonary fibrosis (2B)

-Chronic interstitial pneumonia of unknown cause characterized histologically by temporal and spatial heterogeneity, with areas of fibrosis and architectural distortion interspersed with areas of normal lung.- IPF is the result of failed tissue repair, injury and healing by fibrosis - Inflammation results in release of growth factors, cytokines and endothelin-1 - Endothelin-1 recruits fibroblasts and stimulates angiogenesis for tissue repair - Fibroblasts are converted to myofibroblasts by TGF-beta and secrete collagen, which fibroses lung parenchyma - Eventual end-stage is honeycombing of the lung - More common in men aged 50-70

dental abscess 1B

-Collection of infected material (pus) resulting from a bacterial infection in the center of a tooth - usually Streptococcus viridans -aures RARELY involves UNLIKELY -can remain localised or cause cellulitis features: dental pain/toothache; intra-oral and/or extra-oral oedema, erythema, or discharge; and thermal hypersensitivity. Ix: FBC, panoramic x-ray , CRP, ESR, MRI, cultures, U&Es

Conjugated vs unconjugated bilirubin

-Conjugated (direct) is loosely bound to albumin and therefore water soluble. -When present in excess, it is excreted in urine...therefore DARK URINE IS ONLY SEEN WITH CONJUGATED BILIRUBIN! -Unconjugated bilirubin is tightly bound to albumin and therefore not water soluble. It cannot be excreted in urine even fi blood levels are high; it is toxic - the unbound form can cross the BBB and cause neurologic deficits

what's consolidation ?

-Consolidation is the result of replacement of air in the alveoli by transudate, pus, blood, cells or other substances.

Hep B virus

-DNA virus 2nd most common cause of hepatitis -transmitted parenterally, typically by contaminated blood or blood products. i.e needles, sexually - risk of chronic development is higher if acquired at young age . i.e infants 90% risk. Adults risk is 5% -sx: anorexia, malaise, and jaundice, fever , N&V - Chronic infection can lead to cirrhosis and/or hepatocellular carcinoma. Ix: -Hepatitis B surface antigen (HBsAg) - LFTs -FBC U&Es - Coag - Serum HBsAg - implies infectivity of the blood, appears during incubation period 1-6 weeks -serum Anti-HBS ( - Anti-HBc: recovery from HB, previously caught Rx: Chronic: supportive care + antiviral therapy PEP Rx: if vaccinated then booster, If not then HBIG + booster vaccine -can also be self-limiting Constipation can be a trigger for liver decompensation in cirrhotic patients Hepatitis D superinfection is an differential for chronic hepatitis B patients with acute flare up- presents w/ fever, jaundice , pruiritis

Features of early AMD

-Drusen deposition in subretinal space -Focal Geographic Chorioretinal Thinning & Atrophy -Subretinal Pigment Epithelial (RPE) Changes

Whipple's Dz

-Due to infection with gram-positive bacillus Tropheryma whipplii . common in middle aged male farmers. - Leads to widened and flattened villi -Intestinal: malabsoprtion with weight loss, diarrhoes, occult blood loss -CNS: Progressive dementia, ophthalmoplegia, and Cardiovascular system. CVD: Endocarditis, myocarditis, or pericarditis. Musculoskeletal system. Seronegative polyarthralgia is common. psychiatric symptoms

nappy dermatitis 1B

-Due to infrequent changing of nappies -Leads to faecal or urea irritating the skin and predisposing to infection - Ammonia dermatitis - most common, red desquamating rash, spares the skin folds, due to retention of moisture - *RX frequent nappy changing, nappy-free periods, drying, emollients (zinc oxide cream)* -Candida/thrush - 50% of nappy rash, *satellite lesions*, flexural sparing? - RX clotrimazole, 1% hydrocortisone cream - if you try to scrape the patch off it bleeds - pathognomonic -Seborrhoeic dermatitis - *diffuse, red, shiny rash extending into the skin folds, occipital rash (cradle cap)* - RX frequent nappy changing, nappy-free periods, drying, emollients (zinc oxide cream) -Isolated psoriasis-like plaques - rare, hard to treat -Atopic eczema -Granuloma gluteale infantum: red or purple nodules -Impetigo (Staphylococcus aureus and/or Streptococcus pyogenes): irregular blisters and pustules.

Ix for oesophageal varices

-Endoscopy --> diagnostic. also identifies varices at risk of bleeding and other causes of upper GI bleed i.e ulcers -coagulation screen (INR/ prothrombin time) --> varices associated w/ serious liver impairment (should be normal/ elevevated) -FBC--> Hb and MCV due to bleeding . low platelets would suggest portal hypertension. microcytic anaemia pic LFTs --> severity of liver disease --> elevates AST, ALT, Alk phosp, bilirubin test for Hep B&C as causes of cirrhosis

What is dacryoadenitis?

-Enlarged and inflamed lacrimal glands -Presents with an acutely painful swollen lacrimal gland that is tender to palpation, has reduced tear production, and results in an S-shaped deformity to the lid and upper lid ptosis. - can be oart of orbital inflammatory disease -Orbital imaging and biopsy are indicated if inflammation persists. - isolated responds well to NSAIDS

Ix for volume depletion

-FBC: normal or decreased HCT -U&Es: hyper or hypokalaemia, hypernatraemia -serum creatinine -urinalysis -urine na:<20mmol -urine CL : <20mmol -urine creatinine: elecated urine osmolality: >450mmol/kg

Pre-hepatic jaundice

-Haemolytic anaemia -Gilbert's syndrome or Criggler-Najjar syndrome

IDIOPATHIC (Immune) THROMBOCYTOPAENIC PURPURA 1B

-IgG and IgM immune mediated reduction in the platelet count - Antibodies are directed against the glycoprotein IIb/IIIa or Ib-V-IX complex Acute ITP: - more commonly seen in children - equal sex incidence - may follow an infection or vaccination compylobacter - usually runs a self-limiting course over 1-2 weeks Chronic ITP: - more common in young/middle-aged women - tends to run a relapsing-remitting course Features: haemorrhagia, purpura, epistaxis, menorrhagia, bleeding gums Ix FBC: thrombocytopaenia -> can be diagnosed just from isolated thrombocytopaenia Film: megakaryoblasts APTT: normal PT: normal Rx 1. Mild- no treatment 2. Prednisolone 3. Iv IgG 4. Splenectomy

VERTIGO 2B

-Illusion of rotational movememnt of the environment around the px -True vertigo (ear dz) : BPPV, menieres dz, labyrinthitis, vestibular migraine, vestibular neuritis False: cerebrovascular dz infarction or haemorrhage , neoplastic dz ( accoustic neuroma, intracranial tumour) Features: diziness, lightheaded, lossof balance, nystagmus, blurred vision, diaphoresis, vomitting Ix Reassure pt and give explanation Meclizine Dramamine compazine Reglan PT for vestibular rehab

What are some causes of uveitis?

-Infections such as shingles virus, herpes simplex virus, syphilis, Lyme disease, and parasites such as toxoplasmosis. - a systemic inflammatory disease such as inflammatory bowel disease (IBS), rheumatoid arthritis or lupus - an eye injury -smoking

Contact Dermatitis 1B

-Inflammation of the skin due to contact with an exogenous chemical Can be allergic or irritant - allergic is type 4 hypersensitivity has sensitisation stage and an elicitation stage Rhus dermatitis (Posion ivy, sumac, oak) reactions to cashew trees, mango trees, Japanese lacquer trees, and ginkgo shoe dermatitis: Mercaptobenzothiazole rubber used in shoes metal dermatitis: nickle, jewellery, gold Clinically- eyrthematous based vesicles in linear fashion, Tx: steroids, topical steroids, antihistamines

Cauda Equina Syndrome 2B

-Injury at the L1 level and below resulting in a LMN lesion -Flaccid paralysis w/no spinal reflex activity o radiculopathy syndrome affecting both legs, perineum and bladder/bowel function i.e urinary incontinence or retention, saddle anasthesia, erectile dysfunction, lax anal sphincter tine o Due to subtotal/total occlusion of the spinal canal - abductor pollicis longus pulls MC shaft proximally and radially causing adduction of thumb treat with percutaneous pinning, thumb spica x 6 wk

MENIERE'S DISEASE (endolymphatic hydrops) 1B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

-Inner ear disorder in which volume and pressure of inner ear fluid increases - TRIAD of: recurrent attacks/episodes of sensorineural hearing loss , tinnitus, vertigo . attacks usually last 20 mins but can last 2-4 hrs - common in middle aged Px 40-60, F>M ** R/O accoustic neuroma 3. Symptoms: vertigo, aural fullness, N&V, tinnitus 4. Signs: nystagmus ( always present) , rombergs +ve, sensorineural hearing loss , tinnitus, vertigo Cause: unknown -resolves in 10-15 yrs but leaves hearing loss IX -audiometry : unilateral sensorineural hearing loss -Echochochleography Rx 1. Diet: Low Na+ intake and diuretics 2. . Acute: Prochlorperazine (Buccastem® 3mg/8h bucally; short-term as vestibular sedative ) Prophylaxis: betahistine 16mg/8h PO 3. Steroids: predinisolone 4. Hearing aids 5. -Beta-histine - vestibular suppression 6. Stop driving and inform the DVLA -Surgical - trans-tympanic gentamicin, endolymph decompression, labyrinthectomy

Psoriasis Vulgaris, chronic plaque psoriasis

-Involves pink-red scaly, well-demarcated plaques affecting extensor surfaces with silver scale Typical areas of elbows, knees, scalp, nails, usually sparing palms and soles and face. Can be small papules to large plaques, chronic and recurrent course

Pemphigus Vulgaris 1B

-Lethal Autoimmune, intra epidermal Blistering and erosion of skin and mucous membranes -most common inside mouth -common in >50, jewsm indians -Can occur secondary to captopril or penicillamine IgG complement antibodies against the cell attachments (desmosomes) desmoglein 3 --> keratinocytes separate from each other, and are replaced by fluid, the blister Blisters on trunk, abdomen, extremities, Oral erosions , face, scalp Ix: biopsy (separetd keratinocytes), Tx: Steroids, cyclophosphamide , dapsone, azothioprine, IV IG, rituximab

Short acting analogues

-Lispro 10-20 min, peak 1 hr, 3-5 hrs -asprat same as above -gluisine

Diagnosis of cirrhosis

-Liver biopsy showing fibrosis with nodular regeneration no longer done dute to complications i.e bleeding - USED INSTEAD ARE transient elastography and acoustic radiation force impulse imaging -thrombocytopaenia (platelet count <150,000 mm^3) is the most sensitive and specific lab finding for diagnosis of liver cirrhosis in those with chronic liver disease

Basal Cell Carcinoma (BCC) 1B

-Low grade malignancy developing from the basal layer of the epidermis , related to sun exposure, locally aggressive but rarely metastasizes telangiectactic papule/ulcer" - shiny pearly dome-shaped nodule with smooth surface blood vessels across surface central depression/ulceration if older tumour Superficial and nodular - RF: common in elderly males, sun damage, fitzpatrick I -Ix: biopsy -rx:excision, cryo, photodynamic therapy, imiquimoid cream, Fluorouracil cream, radiotherapy

Risk factors for diverticulosis

-Low-fibre and high-fat diet - age (>80) - connective tissue disorders -Reduced dietary fibre intake -High alcohol, caffeine and red meat intake -Obesity -Steroids -NSAIDs -Saint's triad of hiatus hernia, diverticulae and gallstones;

Nutritional assessment 1A

-MUST score ->2 dietician step 1_ BMI step 2: unplanned weight step 3: acute disease effect (Acutely ill and no nutritional intake or likelihood of no intake for more than 5 days) 4: scores ,2,3 for overall risk 5: follow management guidelines

androgenic alopecia 1A

-Male pattern baldness - due to androgens and genetic predisposition -Abdominal sensitivity of hair follicles to androgens -Leads to frontal recession and then thinning of the crown -Family history is positive -RX minoxidil

EPISTAXIS

-Nose bleed - Commonly occurs anterior nasal septum - little's area ( 4 confluent arteries) - usually benign and self-limiting Rx 1. sit forward, mouth open, spit out blood. Compression pinch cartilagenous (soft area) for 15 mins- breather through mouth 2. Anterior packing if bleeding site cannot be determined - use top anesthetic spray . Pack the patient's nose while they are sitting with their head forward, following the manufacturer's instructions. 3. Cautery- persistent ] FINALLY - if 1st step works then NAseptin (chlorhexidine and neomycin) to reduce crusting and the risk of vestibulitis

what is aspiration pneumonia

-Pneumonia that follows the aspiration of exogenous material or endogenous secretions into the lower respiratory tract. - occurs in elderly, and dysphagia px , motor neurone dz, alcool , reduced consciousness, ITU Rx -suction or bronchoscopy - steroids -Abx also given in absence of infection to prevent secondary infections: Tazocin

signs and symptoms of pneumonia

-SYMPTOMS : pleuritic chest pain, fever, productive cough, purulent sputum, tachy, dyspnoea, tachypnoea, tachycardia. also: aches, athralgia, Elderly: LOC of confusion DNV in children SIGNS: fever, tachypnea, tachycardia, crackles, bronchial breath sounds, dullness on percussion, reduced breath sounds

Gram-positive bacteria

-Staphylococcus- cocci -Streptococcus- cocci -Bacillus- rod -Clostridium- rod -Corynebacterium -Listeria

Trigger Finger 1B

-Stenosing tenosynovitis -repeate trauma to palm --> thickening of flexor tendon to fingers --> cant run freely in & out narrow mouth of tunnels --> causes fingers to jam and flex with click and cannot extend until helped - S&S: *painless nodule in flexor tendon* Dx: clinical Tx: - activity mod., splinting, NSAIDs -steroid injection into tendon sheath -surgical release

VASCULITIS: POLYARTERITIS NODOSA 2B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

-Systemic necrotising vasculitis affecting small and medium sized muscular arteries. - leads to formation of aneurysms >M, >20-40., Renal disease 70% cases. associated with Hep B. Angiography may show saccular or fusiform aneurysms and arterial stenoses - common in middle aged men S&S MAINLY vasculitic oic with no pulmonary involvement Livedo reticularis, ulceration, bullae, vesicles, purpura and skin infarction Fever prolonged myalgia Abdominal pain , weight loss HAematuria Purpura weight loss Proteinuria Parasthesia Pericarditis Purpura Coronary arteritis jaundice testicular pain haematuria and renal failure IX - Raised ESR and CRP - FBC: Thrombocytosis - U&Es: Raised creatinine in renal ischaemia - Raised LFTs - Conventional digital subtraction angiography Rx - Oral corticosteroids - Azathioprine, cyclophosphamide

INSTUSSCEPTION 1-7

-The telescoping/ prolapse of one part of the intestinal tract into another, common in *ileocaecal region* - Inflammation of Peyer's patches are common cause. - Older children may have intestinal polyps or Meckel's diverticulae as lead points - common in infants between 3-12 months following infection - colicky abdo pain/spasms - bilious vomiting -sausage mass currant jelly stools, target sign on ultrasound - PR bleed/ red currant jelly stool. Rx - IV fluid resuscitation - Analgesia - Antibiotics for perforation - NGT for vomiting - If no peritonitis, can be radiologically reduced radiology-guided insufflation of air into the bowel - Laparotomy is last-line or for perforation, peritonitis or necrosis COmplications - Perforation - Wound infection - Intestinal obstruction - Peritonitis/sepsis -necorsis -dehydration

WHat is interstitial lung disease? NOM

-This term encompasses diseases which cause inflammation and fibrosis of alveoli and the septal interstitium resulting in pulmonary fibrosis reduced lung compliance and honeycombing e.g sarcoidosis, Lymphangioleiomyomatosis, ank spond, good pastures, RA, sjohren, SLE, ssytemic sclerosis , IPF 3/4 - -Progressive,worsening dyspnoea - Non-productive,dry cough - Fine,end-inspiratory crackles on auscultation Ix - CXR findings are reticulo-nodular shadowing whereas -HRCT reveals honeycombing and a ground-glass appearance of fibrosis -PFT: estrictive defect: low fev, low fcv, low tlc, vc, KO due to inefficient gas exchange Rx analgesia, oxygen

TRANSIENT SYNOVITIS 1A

-Transient synovitis is a self-limiting inflammatory disorder of the hip that commonly affects young children. -dz in kids 2-12 esp boys -secondary to a viral upper respiratory tract infection. FEATURES: - presnt w/ mild to moderate hip pain and limp., limited movement -Able to weight bear -positive log roll -Rx: NSAIDs complicaion: destruction of femur head

HAEMOPHILIA 2B

-X-linked recessive disorder of coagulation - Up to 30% of patients have no family history of the condition Haemophilia A: due to deficiency of factor VIII Haemophilia B (Christmas disease): lack of factor IX Up to 10-15% of patients with haemophilia A develop antibodies to factor VIII treatment symptom presentation : severe shows 1st year of lifeeasy bruising and bleeding out of proportion to injury, moderate 1-5% factor lvl mild: >5% FEatures: Haemarthrosis; spontaneous bleeding into joints (knees>elbows>ankles>hips>wrists) produce local tingling, pain; later—swelling, limitation of movement, warmth, redness, severe pain Ix: 1. PT normal, APTT depending on degree of deficiency (note: a normal APTT does not exclude mild disease) 2. Assay VIII first, then IX. Exclude vWD

Lipomas 1A

-a benign, slow-growing fatty tumor located between the skin and the subcutaneous layer - more common in women features: smooth, soft eggshaped lump, mobile. rubbery with dough consistency. usually painless until become angiolipoma--> gained BV common in : neck, shoulders, trunk and arms -skin moves over lipoma vs sebacious cyst Ix: skin biopsy exc. liposarcoma ( vrare) Rx: none, surgical excision, liposuction

ASPERGILLOMA

-a fungal ball generally found in a preformed cavity of the lung, composed of a mass of Aspergillus hyphae - existing lung cavities usually due to tuberculosis, ;ung cancer, emphysema or CF - Features include: cough, haemoptysis, lack of improvement with abx Ix -chest x-ray containing a rounded opacity. A crescent sign may be present -high titres Aspergillus precipitins

what is the Juxtamedullary apparatus?

-a group of cells between glomerulus and thick descending limb -3 cell tyoes - Granular cells: Make renin- start of renin angiotensin system Macula densa: TAL columnar cells Detects Nacl is passing through DCT and sends signal to granular cells to release renin Juxtaglomerular cells :Afferent arteriole smooth muscle cells

HAIRY LEUKOPLAKIA

-a white rough patch that arises on the LATERAL tongue. -Usually seen in immunocompromised and is due to EBV induced squamous cell hyperplasia. N -nOT pre-malignant.

needlestick injury

-accidental puncture wound caused by a used hypodermic needle, potentially transmitting an infection. -encourage bleeding and hold under water -wash wound with soap and water dry and cover -report to Occupational health -Ix: bloods for Hep B, C, HIV, CMV, EBV Rx: Abx, vaccinatiopn, PEP HIV, councelling HIV: PEP can be started up to 72 hrs later . antiretrovirals for 4 weeks, then blood test HEP A: Human Normal Immunoglobulin (HNIG) or hepatitis A vaccine may be used depending on the clinical situation HEP B: booster if they respond to vaccine and HBIG HEP C: monthly PCR interferon +/- ribavirin

Risk factors for pneumonia

-age >65 years, residence in a healthcare setting, COPD, exposure to cigarette smoke, alcohol abuse, poor oral hygiene, and contact with children.

POLYMYOSITIS (def 2B

-autoimmune inflammatory dz affecting muscle - Common after 20s an din women -- Associated with non-Hodgkin's lymphoma, RA, IBD, breast, lung, ovary and colon cancer - Involves T cell and monocyte infiltration of muscle fibres leading to muscle fibre necrosis, degeneration and eventual phagocytosis - Rarely seen in children 10-14

FANCONI ANAEMIA NOM but useful

-autosomal recessive disease that causes BM failure --> mutations in FANCA gene (nonsense, missense, insertions etcc) -results in pancytopaenia and aplastic anaemia -common in ashkenazi jews -onset 5-10 -features: bleeding, skeletal abnormalities/deformities, neuro and renal problems, deafness -Ix: hypocellular BM replaced by fat -Rx: steroids, transplant

colorectal polyps 1B

-benign tissue growths on the mucous membrane lining the large intestine and rectum; - can be neoplastic adenomans, harmatomas, hyperplastic or metaplastic or inflammatory polyps of pseudopolyps -adenomatous types are precancerous and likely to develop into malignancy Hereditary Nonpolyposis Colorectal Carcinoma; HNPCC- start off as single adenoma - ➡ dominant increases CRC cancer -FAP: causes numenous polyps in colon increases cancer risk

COLON and RECTAL CANCER 1B

-cancer of colon and rectum -most adenocarcinoma 71% colon 21% rectum S&S *Right sided* Anaemia from chronic blood loss, weight loss, anorexia, weakness, vague abdo pain *left sided* obstructing lesions leading to obstruction with change in bowel habits and/or blood streaked stools *rectal* - tenesmus ,fresh blood in stool *generally* -change in bowel habit, melaena, tenesmus , abdominal pain O/E - Palpable abdominal mass - Features of anaemia - Abdominal distension - Palpable lesion on DRE with left-sided disease

Colorectal cancer (adenocarcinoma of the colon and rectum and features

-cancer of colon and rectum -most adenocarcinoma 71% colon 21% rectum -change in bowel habit, malaena, tenesmus , abdominal pain O/E - Palpable abdominal mass - Features of anaemia - Abdominal distension - Palpable lesion on DRE with left-sided disease

FIBROMYALGIA 2B

-chronic dz of unknown cause - characterised by widespread pain throughout the body with tender points at specific anatomical sites -lethargy, sleep disturbance, headaches, mental cloudiness, pain/aching muscle stiffness, fatigue , poor sleep & other somatic symptoms - pain in 11/18 points - - more common in women 30-50 years -Ix: clinical dx -Rx: exercise, local heat, stress management, sleep medication amitriptyline, cyclobenzapine, duloxetine

Cat bite 1A

-common in children and female adults , most are provoked - result in scratches or deep puncture wounds. -prophylactically tx with a five day course of amoxicillin/clavulante. Worse than dog bites. Infections Pasteurella multocida (up to 75%). Staphylococcus aureus (20%) Streptococcus pyogenes Various anaerobes. Bartonella henselae,: the causative agent of catscratch disease , can also be transmitted via a bite from an infected cat. rx wounds should be irrigated, debrided, incised and drained as required. cultures prophylactic abx : 1. Amoxicillin clavulanate 2. erythromycin, and clindamycin. hospital if fever, swollen lymph nodes, cellulitis

L5 radiculopathy

-compression of the L5 nerve root commonly due to vertebral disc herniation or spinal formaninal stenosis. Features 1. back pain radiating down the leg with sensory loss over the buttocks, lateral thigh and calf, and dorsal foot. 2. There also may be weakness of foot dorsiflexion, inversion, eversion, and toe extension.

cretinism

-congenital hypothyroidism -presents with mental retardation and short stature -impaired motor development -protuberant

CAUSES OF PAINFUL EYE

-contact lens keratitis -corneal abrasion or FB -corneal ulcer - photophobia, red eye -Keratoconjuctivitis- grittiness, red eyes bilaterally, preauricular adenopathy, eyelid oedema -Herpes Zoster ophthalmicus- vesicles and crusts on face, red eye, lid oedema -Herpes Simplex keratitis- Onset after conjunctivitis, blisters on eyelid -acute glaucoma -anterior uveitis - Ocular ache, ciliary flush, photophobia ( RF autoimmune dz) -Endophthalmitis- Ocular ache, intense conjunctival hyperemia, photophobia, severely decreased visual acuity ( RF surgery, truma) -optic neuritis- mild pain, worsens w/ movement, visual loss -Orbital cellulitis -conjuctivitis -scleritis REFERRED PAIN - sinisitis -migraine -cluster headache

PSORIATIC ARTHROPATHY NOM

-correlates poorly with cutaneous psoriasis and often precedes the development of skin lesions - Around 10-20% percent of patients with skin lesions develop an arthropathy with males and females being equally affected Types: - rheumatoid-like polyarthritis: (30-40%, most common type) - asymmetrical oligoarthritis: typically affects hands and feet (20-30%) - sacroilitis - DIP joint disease (10%) - arthritis mutilans (severe deformity fingers/hand, 'telescoping fingers') X-Ray: pencil-in-cup deformity (due to periarticular erosions and bone resorption) and plantar spur

what is Inflammatory Bowel Disease?

-decribes inflammatory disease of GIT -includes crohns and ulcerative colitis - chrons is 2x more common in young children 25% cases present in childhood

meniscal cyst

-degenerative cyst common in middle age and elderly -ass/w meniscal tears -evident on knee extension

Venous stasis dermatitis 1B

-dermatitis that results from: venous HTN, edema, chronic inflamm and microangiopathy - Venous incompetence leads to increased hydrostatic pressure with capillary damage and extravasation of fluid - Seen in elderly people with a history of venous disease, thrombosis and varicose surgery -Features: bilat involvment, commonly above medial malleolus. -Itchy red, blistered and crusted plaques; or dry fissured and scaly plaques on one or both lower legs, brown pigmentation due to haemosiderin depositin - no fever or leukocytosis, Rx: - dont stand for long, leg raise , regular walks -compression stockings longterm -Dry up oozing patches with Condy's solution (potassium permanganate) -PO Abx -flucoxacillin for secondary infection --> impetiginisation w. s aureus and cellulitis common - moisturising creams

CHRON'S DISEASE 2B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

-describe inflammatory relapsing remitting disease of GIT from mouth to anus - mostly colon and small intestine - chrons is 2x more common in young children 25% cases present in childhood 2. AEx - presents in childhood, peak onset is 20-40 years , second smaller peak in older adults 60-80, askenazi jews, COCP, NSAIDs, smoking - more common in women 3. Path - relapse, remitting dz, Affects any part of the GIT from the mouth to the anus, affects ALL layers of the GI tract -skip lesions is hallmark of the disease -granuloma formation (TNF ) -incurable - PRESENTATION : Abdo: Cramping colicky abdominal pain (diffuse in colitis, RLQ in ileitis), watery diarrhoea, steatorrhoea. , lethargy, weight loss, BO, perianal dz, fistula, *RLQ mass* , stones , anaemia *ABDO PAIN MOST PC IN CHILDREN* Ix - USS - CT -endoscopy Rx - Steroids: prednisolone/ budesonide ( more effective less side effects ) -anti TNF - anti-integrin -MTX -surgery -nutritional rx

Patella #

-direct blow to patella , fall MVC indirect trauma by sudden flexion aaonst contracted quads -ss: tenderness, unable to extend knee, cant straight leg , deformity, -/+ effusion

Aex of small bowel bacterial overgrowth

-disorders which lead to pertubation of intestinal microbiota - anatomical alteration : short bowel syndrome - intestinal motility disorders can also impair bacterial clearance -diabetes STRONG LINKS

Pseudo-obstruction

-distention without mechanical blockage -functional obstruction -> failure of propulsion (disorder of smooth muscle, disorder of innervation or both), paralytic (adynamic) ileus following peritoneal irritation -- Secondary to surgery, tumour, trauma and DM

describe the bowmans capsule

-encases glomerulus -lined by podocytes ( allow plasma to pass through ) -drains in renal tubules#/images/upload-flashcards/65/46/66/30654666_m.jpg

eye changes- grave's eye disease

-exophthalmos due to due to abnormal connective tissue deposition in the orbit and extraocular muscles. -Ophthalmoplgeia paralysis of muscles surrounding eyes -conjuctival oedema -papillodema optic swelling Keratopathy -eyelid lag & retraction Grave's eye disease can be graded using the mnemonic NOSPECS No signs / symptoms Only signs (e.g: upper lid retraction) Signs & symptoms (including soft-tissue involvement) Proptosis Extra-ocular muscle involvement Corneal involvement Sight loss due to optic nerve involvement

Genu valgum (knock knees)

-femoratibial angular deformity in which the knees touch but the ankles do not. -normal up to age 9 -can cause OA if not treated , more prone to injuries too aex: normal, Vit D&C deficiency , RA, OA, obesity Ix: X-ray Rx: surgery at age 10

FOLATE DEFICIENCY 1A

-folate absorbed in jejunum and is important for DNA synthesis -found in spinach, broccoli, liver and kidney Aex of deficiency -Poor intake: old age, starvation, alcoholism -GI pathology : Crohn's disease, coeliac disease, tropical sprue -Anti-folate medication - methotrexate, trimethoprim, COC, phenytoin, sulfasalazine -Pregnancy and breastfeeding -Haematological - haemolysis, cancer, inflammation -Inborn errors of metabolism SS -mild jaundice due to hemolysis of RBCs secondary to ineffective hemoglobin synthesis -glossitis and angular stomatitis -melanin pigmentation (rare) - purpura secondary to thrombocytopenia (rare) -unlike B12 deficiency, folate deficiency has no neurologic manifestations -anaemia: tiredness, palpitation, pale, SOB Ix: - Low serum folate -Low red cell folate -Low Hb, high MCH, high MCV -Thrombocytopenia and neutropenia (due to defective DNA synthesis) -Low reticulocytes -Blood film - oval macrocytes, hyper-segmented neutrophil, howell-jolly bodies, polymorphs -Raised LDH -Raised bilirubin -Raised homocysteine Rx: Folic acid 5mg OD for 4 months - start with B12 (NEVER GIVE FOLATE ALONE. folate alone worsens features of B12 anaemia)

Loop diuretics (ACTION) SE

-furosemide, bumetanide - Block the Na-K-2Cl co-transporter in the thickascending limb - This leaves NaCl in the filtrate, keeping ithypertonic and therefore reducing water absorption as water stays alongsideNaCl - Leads to loss of water, NaCl, K+ and H+ - Used for pulmonary/peripheral oedema andhypercalcaemia -SE - metabolic alkalosis (due to loss of K+ andH+, hypovolaemia, *ototoxicity*, allergic reactions, hyponatraemia, hypokalaemia,hyperuricaemia, gout

OSTEOSCLEROSIS nom

-fusion of stapes foot plate to oval window so that it cannot vibrate. normal bone replaced by spongy bione. -common in females -occurs at young age (20-40) - leads conductive hearing loss -AEx: genetic, autosomal dominant -Features: progressive hearing loss , worsening tinnitus -Rx: hearing aid, stapedectomy

Signs/Symptoms of uveitis?

-having a red eye with or without pain -being very sensitive to bright light -having blurry vision -seeing "floaters" (specks or moving clouds in your vision) all of a sudden

SENSORINEURAL HEARING LOSS

-hearing loss caused by damage to the cochlea's receptor cells or to the auditory nerves; also called nerve deafness -congenital or acquired CONGENITAL CAUSES 1. syndromic 2. nonsyndromic genetic hearing loss 3. gestational infections (TORCH -Toxoplasmosis, rubella, cytomegalovirus, herpes, HIV ) ACQUIRED 1. Perinatal causes (hypoxia/jaundice) 2. Infective/inflammatory (meningitis, measles, mumps) 3. Trauma (surgery, head injury, noise exposure, baro-trauma) 4.. Drugs (aminoglycosides, cytotoxics) 5. Neoplasia (vestibular schwannoma) 6.. Idiopathic (sudden SNHL, Ménière's) 7. Ageing (presbyacusis): 70% >70, usually bilateral, loss of sensitivity of hair cells 8. noise-induced 9.

hepatocellular adenoma

-hepatocellular adenoma: benign glandular epithelial tumou. common in women of childbearing age, linked to Contraceptive pills. regress when OC is stopped do not casue symtopms. sometimes RUQ discomfort, pain, mass and peritonitis (rare) Ix USS, CT, MRI , biopsy

Varicella pneumonia

-https://www.cram.com/2/images/upload-flashcards/000/2746383/30667422_m.jpeg^-Infection with vzv Which results in pneumonia symptoms: dyspnoea, cough, tachypnoea, cough, fever, pleuritic chest pain, cyanosis and haemoptysis Radiology: nodules in paranchyema Risk factors: Common in HIV and immunosuppressed

Bone remodeling cycle

-if hormone stimulates bone resorption, other signal will stimulate bone formation -3 steps Resorption Reversal Formation

Clavicle fracture 1B

-incidence: proximal (5%), middle (80%), or distal (15%) third of clavicle • common in children (unites rapidly without complications) -due to fall on shoulder or direct trauma -S/S: pain and tenting of skin, arm clasped to stop , movement , pain radiates to nect, tender swollen AC joint , limited ROM -document pulses -Ix: Xray, CT, crossover test complication : Medial 1/3 fracture may have complication of subclavian artery or intrathoracic injury. brachial plexus nerve damage Rx - middle and lateral third fractures- broad arm sling for 2 weeks - medial 3rd: orthopaedics assessment

what is small bowel bacterial overgrowth nom

-increased count of gut bacteria and changes of the normal flora bacterial colonies in small intestine -resulting in gastrointestinal symptoms INCLUDING of vitamin malabsorption, malnutrition, and weight loss. fEAURES: Vit B12 deficiency -weight loss -fat malabsorption - bloating, and excess flatulence - diarrhoea and steatorrhoea abdo pain Advanced - microcytic anaemia due to IDA -macrocytic due to b-12 deficienct -steatorrhoea night blindness] ix -14C-xylose breath test or quantitative culture of intestinal aspirate - bowel biopsy breath hydrogen analysis - stool analysis - bile acid breath xylose breath test - Gram-negative bacteria metabolize xylose, D-lactate levels : bacteria fermentation of lactosis Rx Dietary modification 2 wks oral ABx : tetracycline, amoxicillin/clavulanic, cephalaxin, metronizadole Dietary modification

ACNE VULGARIS 1A

-inflammation of the pilosebaceous glands, i-nvolves hyperkeratinisation of hair follicle --> creates keratin plug ( microcomedone). -secretion of sebum by adrogenic hormones --> proliferation of P.acnes in sebum rich environment of plugged hair follicle --> inflammation --> papules and pustule - creates open commedines ( blackheads- central dark keratin plug ) or closed commedones ( white heads) - common in puberty esp females Apperance: open or closed comedones, inflammatory papules, pustules, cysts, scarring Rx -Regular washing and acne soaps -Extraction of comedones -Intra-cystic steroid injection, excision and cryotherapy -Local: benzoyl peroxide, topical tretinoin (0.01 to 0.1%), topical clindamycin, topical azelaic acid, isotretinoin and adapalene, or add TOP clindamycin, erythromycin -Systemic - oxytetracycline, lymecycline, doxycycline, erythromycin and trimethoprim - Ovranette in females Retinoids *monitor LFTs and lipids* tetragenic SE: cracked, dry skin, epistaxis, hair loss, myalgia, mood changes

Osgood-Schlatter disease 1A

-inflammation or irritation of the tibia at its point of attachment with the patellar tendon - self-limiting -common in adolescents during growth spurt 12-15 (8 in girls) -ss: gradual pain and swelling below knee relieved by rest worse on activity Ix Hip examination is important because some childhood hip conditions (eg, slipped capital femoral epiphysis) can refer pain to the knee., X-ray rx: NSAIDS, steroid injection, advice on exercise first , physio,

Folliculitis 1A

-inflammatory hair follicle dz due to bacterial infection. occurs on all hair bearing sites. Features: -erythematous papules or pustules around hair follicles. -pustules and papules can coalesce ino large painful carbuncles and furncles Aex: Most common form Staph folliculitis by S.aureus. soometimes psedomonas -eosinophilic tye in diabetics , HIV and immunocompromised other causes: fungis, VZV, mechanical ( hair pulling back , razors, chronic friction), 3. Path: infection with s.aureus --> infiltration w/ inflammatory cells --> large abcess 4: Ix: Tissue culture for organism, HSV1 &2 and VZV DFAA, skin biopsy 5: antiseptic( triclosan, benzalkonium chloride, chlorhexidine, and bleach bath ), sodium fusidate, flucloxacillin, cefalaxin.

ACUTE OTITIS MEDIA 1A 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

-infxn or inflamm of middle ear after viral URI (1-7 days) - 6-18 months (shorter euschian tube, M>F) -bacteria usually *h.influenzae in non vaccinated* OM with effusion (glue ear) collection of non-infected/sterile fluid in the middle ear behind intact TM due to blockage of the Eustachian tube which leads to thick accumulation of fluid AEx: S VIral -->if not then in order : Haemophilus influenzae, Streptococcus pneumoniae and *Moraxella catarrhalis* Features: fever, irritability, loss of balance, earache, otorrhoea if perf., tinnitus, mastoid tenderness. HEARING LOSS Ix: Otoscope: bulging red TM, landmarks not well visualized, decreased mobility with air/fluid behind , no light reflex , pus Rx: SELF-LIMITING NSAIDS IF REALLY UNWELL, <2 , bilateral , perf or dx: AMOXICILLIN 1st line or coamox 2nd amoxicillin, azithromycin if <6 months NSAIDS, culture if not better ~3 days treat neonate IV cefotaxime

Dupuytren contracture/disiease 1B

-inherited progressive dz that results in contracture of the palmar fascia of the hand or foot. commonly bilateral . -Contracture causes flexion of the MPJ and PIPJ. -Begins as a pit or nodule in palm, spreads distally into the fingers -commonly affects little finger -common in european men >40 that drink alcohol - Trauma might trigger the predisposed individual - Prevalence higher in diabetics and epileptics o Little and ring fingers most severely involved. -positive hueston table-top test -Feet - plantar fascia nodule Peyronies' disease - penis If in younger age group Both hands involved Ix: clinial/ USS Rx -Treatment: surgical referral if hand cannot be flat on the surface Complications: o Recurrence o Extension to other parts of hand o Maceration if left untreated o If neurovascular bundle damaged surgically - numbness or cold intolerance

URGE INCONTINENCE

-involuntary urine leakage accompanied by, or immediately preceded by, urgency of micturition. -This means a sudden and compelling desire to urinate that cannot be deferred. -detrusor instability or hyperreflexia leading to inluntary detrusor muscle contraction. AEx: PD, MS, dementia, spinal cord injury

IRON DEFICIENCY ANAEMIA 1A 1-7

-iron absorbed in duodenum and jejunum. enhanced by Vit C via DMT-1 receptors (regulated by hepcidin) -goes into circulation via feroportin, picked up by apotransferrin , becomes transferrin and taken to BM -stored as ferritin *2. Causes*: ▪dietary ▪malabsorption : gastrectomy, chrons, coeliac, hookworm, atrophic gastritis bleeding ▪chronic disease/blood loss: ulcers, hookworms, haemorrhoids, colon cancer, diverticular , IBD, polyps, NSAIDs use, hernia, neoplasms cancer : ANY PATIENT OVER 60 WITH IDA NEEDS COLONOSCOPY ▪vegan/ vegetarian ▪periods ▪puberty Features: koilonychia, leukonychia, glossitis, dysphagia, lassitide and fatigue, pica, brittle hair and nails. Ix - first line investigation for all people with IDA is coeliac - ani-ttg, gliadin, villous atrophy -⬇ Hb, ⬇MCV -⬇ Ferritin , ⬆ TIBC, ⬆ Transferrin, ⬇reticulocytes -blood film: POIKILOCYTOSIS (SHAPE) , ANISOCYTOSIS (SIZE), -target and pencil cells , hypochromic, microcytic Rx: 1. manage underlying cause 2. - Oral ferrous sulphate (200mg TDS ) , fumarate or gluconate for 3-6 months ther- TDS proph- OD 3. Vitamin C supplementation to increase iron absorption 4. *In severe situations, parenteral iron - iron dextran or IV ferric gluconate (risk of anaphylaxis)* 5. Red cell transfusions for severe, symptomatic anaemia at rest SE: constipation, dark stools, N&V, teeth staining

nephroptosis

-kidney which descends more than 2 vertebral bodies -common in women (kidneys enlarge during menstrual cycle) -associated with : ─ Pyelonephritis ─ Renal calculi ─Hematuria ─Hypertension ─ Renal ischemia ─Flank pain #/images/upload-flashcards/65/46/83/30654683_m.jpg

OSTEOMALACIA/ RICKETS 1B (NONM)

-lack of bone mineralisation due to vitamin D deficiency resulting in deformed, fragile, pliable bones which fracture easily . -Can lead to *secondary hyperparathyroidism* -Rickets is a disorder of the growing skeleton due to inadequate mineralisation of bone as it is laid down at epiphyseal growth plates - it leads to widening at the ends of the long bones which can lead to bowing AEx; : CDP - Exclusive breastfeeding for 12 months - Calcium deficiency - Vitamin D deficiency - dietary, sunlight, malabsorption, genet i- Phosphate deficiency - renal tubular loss of phosphate, Fanconi syndrome, renal tubular acidosis, nephrotoxic drugs 3/4. S&S - Bone pain and aching - Weakness ( muscle ?) & Fractures - Waddling gait - Bowed legs (varus deformity) -knock knee - Growth delay - Swollen wrists 5. Ix Bloods: - Phosphate, calcium, Vit D low -PTH raised secondary hyperparathyroidism - Raised bone-specific ALP - Biopsy may show demineralised bone - X-ray and wrist X-ray - generalised osteopenia, cupping and fraying at metaphyses (in rickets), bowing Rx calcium and vitamin D

what is Pneumoconiosis

-lung diseases caused by the reaction of the lung to the inhalation inorganis and some organic dusts-inhaled particles reach the terminal airways and alveoli and settle on the epithelial lining. they might be cleared by macrophages or alveolar cells, lymphatics or stay in alveolus -this results in inflammation in lungs--> causes characteristic alterations in pulmonary structure and radiological abnormalities

Galactorrhoea 1B

-milky secretion from the breast not due to breast feeding -more common in women -prolactin is inhibited by dopamine Causes of raised prolactin prolactinoma pregnancy oestrogens physiological: stress, exercise, sleep acromegaly: 1/3 of patients polycystic ovarian syndrome primary hypothyroidism (due to thyrotrophin releasing hormone (TRH) stimulating prolactin release) Drug causes of raised prolactin metoclopramide, domperidone phenothiazines (chlorpromazine, prochlorperazine, thioridazine, trifluoperazine) haloperidol H-2 antagonists very rare: SSRIs, opioids Ix -PRL levels -TFTs ( hypothyroidism) -U&Es -LFTs -pregnancy test Rx -exclude other pathologies, drugs -treat underlying cause -bromochroptine/cabergoline: dopamine agonist -testosterone for men -oestrogen for women

ANTERIOR CRUCIATE LlGAMENT TEAR

-most common tear - Ligament tear is a sprain - indirect varus blow to knee - hyperextension of the knee + tilt mal rotation - audible pop, knee instability, "giving way" - immediate swelling - inability to continue activity Physical o posterolateral joint line tenderness o positive Lachman, anterior drawer o effusion. +/- haemarthrosis o +/- associated medial meniscus tear, MCL injury (O'Donahue's Unhappy Triad) o Special tests Anterior drawer sign Positive Lachman's test - more sensitive and specific Diagnosis: o X-ray - may be associated with avulsion fracture of anterior tibial tubercle o Clinical diagnosis best confirmed with MRI Treatment: o based on activity and functional impairment o stable with minimal functional impairment early mobilization physio and quadriceps strengthening o instability with functional impairment / high demand Iifestyle ACL reconstruction

WHAT IS ERYTHEMA AB IGNE

-mottled (splotchy) skin in area that is habitually exposed to heat (IR) radiation -classified as a 2nd degree burn -WILL show up where pt have been using hot water bottles or exposing skin to heat ( sitting next to open fire) - can cause SCC

Paracetamol overdose 2B

-overdose is > 4g in 24 hrs in adults > 10g may be fatal lower in alcoholics > 24 hours = n & v -asymptomatic or GI symptoms massive overdose: coma and severe metabolic acidosis. - A staggered overdose is the ingestion of multiple doses of paracetamol over a period of >1 hour, usually with the intention of self-harm. - Acute presentation: minor until >48 hours 0-24 hrs: N&V 24-72 hrs: RUQ pain, LFT and nbilirubin elevated 72-96 hrs: M&V, liver failure symptoms, raised LFTS, bilirubin and INR >5 days: , hepatotoxicity resolves or progresses to multiple organ failure, which can be fatal. renal failure and pancreatitis Ix serum acetaminophen levels . if drawn before 4 hrs show no peaks , LFTs, U&Es , INR, pH, lactate Rx Oral or IV N-acetylcysteine ( most effective within 8 hrs) Possibly activated charcoal Poor prognosis: >INR3, hypoglycaemaia, ph <7.3 , creatinine >2.6

Incisional hernia

-postoperative hernia caused by a weakness in the abdominal wall from the incision or postoperative complications - can strangulate -common in elderly and obese S/s: lump ,pain ,intestinal obstruction ( distention ,colic, vomiting ,constipation , sever pain in the lump ) Ix: Abdo USS, CT, MRI rx- mest repair

liver transplantation

-procedure to remove a severely damaged liver from a patient with end-stage liver disease and insert a new liver from a donor - Indication: cirrhosis, HCC, biliary atresia, hepatic necrosis , PSC, -contraindications: sepsis, advance HCC with Mets, severe pulmonary HTN, elevated intracranial pressure -come from brain-dead people, heart-beating -left liver-lobe

umbilical hernia

-protrusion of the intestine through a weakness in the abdominal wall around the umbilicus (navel) -mostly congenital but can be acquired due to obesity, old age, ascites, pregnancy, or chronic peritoneal dialysis. -can strangulate -common in children -s/sx: pain/pressure at hernia site, bulge esp on coughing Rx: USS, Xray, surgery

Volume depletion, causes and symptoms

-reduction in ECF -caused by haemorrhage, vomiting, diarrhoea, diuresis, burns, sweating excessively, Third-space sequestration i.e Loss of extracellular fluid into the interstitial space or into a body cavity - postural dizziness, fatigue, confusion, muscle cramps, chest pain, abdominal pain, postural hypotension, or tachycardia.

Dyshidrotic Eczema 2B

-relapsing remitting vesicular eruption of palsm and soles, very pruritic - exacerbated by frequent hand washing, hyperhidrosis (excessive sweating), and stress

cuff arthropathy

-result of chronic rotator cuff tear - rotator cuff supports head --> failure ---> drift of ulnar superiorly -synovial fluid can also escape the capsule resulting in destruction of joint surfaces progressing to arthritis - features: pain and weakness of rotator cuff

Osteoarthritis and RA in shoulder joint

-results in pain and ROM i.e cant undo bra, wipe bottoms,

curb-65

-sereverity scale for pneumonia determines admission to hospital determines Abx to be used >2 admit , 4-5 HDU CURB-65 score core factors • Confusion New mental confusion defined as AMTS ≤8 (see Box 40.2) • Urea >7mmol/L • Rr raised ≥30/min • BP Systolic BP <90 and/or diastolic BP ≤60 • 65 Age ≥65.^-/images/upload-

Gallbladder functions

-stores/concentrates bile from the liver - contracts and secretes bile into the common bile duct to the duodenum under cholecystokinin -bile emulsifies fat for digestion

CHRONIC OTITIS MEDIA 1B

-suppurative perforation of tympanic membrane AEx: acute OM, eustachian tube obstruction, mechanical trauma, thermal or chemical burns, blast injury, cranioacial abnormalities ( downs cri du chat , cleft) , cholesteatoma Bacteria: S.aureus features: painless foul smelling ottorhoea , conductive hearing loss, necrosis of long process of the incus if persistent Ix: ottocope , CT if cholesteatoma suspected then CT or MRI Complications: - aural polyps, cholesteatoma,

Charcot arthropathy

-syndrome in patients who have neuropathy or loss of sensation. It includes fractures and dislocations of bones and joints that occur with minimal or no known trauma - common in poorly controlled diabetes - bone remodelling seen on xray swelling, redness and increased warmth of the foot and ankle

Non-accidental trauma/ child abuse

-the wide-ranging effects of maltreatment on the child's ongoing physical and emotional development - common in under 5 YOs -risk factors: unplanned preg, step kids, disabilities, first born, premature, single parent, uneployed, drug abuse, abuse as a child. signs: injury incosistent with injury, delay in seeking care, long bone structure in nonmobile child. - coexisting injuries -rib fractres, scapula fractures, bucket handle fractures , shearing strain, Abuse head trauma: subdural haemorrhage in <1, head injury no explanation of trauma, bruising of head, neck, retinal haemorrhage bits: >3cm more likely to be from an adult, bites on breast and neck in kids burns: scalds usually on lower extremeties, buttock or perineum Ix: forensic dental exam for bites, swabs, FBC, fundoscopy, photo of injuries, CT brain, LFTs, amylase

Subclinical hypothyroidism + management

-thyroid function is inadequate but increased TSH maintains T4 levels within normal range; elevated LDL levels -no symptoms -elevated TSH, normal T4 NICE 1. TSH 4-10 and normal Free T4 - <65 + symptoms = trial levothyroxine 2.TSH is > 10mU/L and the free thyroxine level is within the normal range start treatment (even if asymptomatic) with levothyroxine if <= 70 years 'in older people (especially those aged over 80 years) follow a 'watch and wait' strategy, generally avoiding hormonal treatment'

Lymphocytopenia

-total lymphocyte count of < 1/μL in adults - Aex : acuired or inherited - acuired: AIDS, hepatitis, influenza, TB, typhoid fever, and sepsis, autoimmune dz (sle, ra, sarrcoidosis etc..) - inherited: Aplasia of lymphopoietic stem cells Ataxia-telangiectasia Cartilage-hair hypoplasia syndrome Idiopathic CD4+ T lymphocytopenia Immunodeficiency with thymoma Severe combined immunodeficiency associated with a defect in the IL-2 receptor gamma-chain, deficiency of ADA or PNP, or an unknown defect Wiskott-Aldrich syndrome features: -asymptomatic -Absent or diminished tonsils or lymph nodes, indicative of cellular immunodeficiency -Skin abnormalities (eg, alopecia, eczema, pyoderma, telangiectasia) -hematologic disease (eg, pallor, petechiae, jaundice, mouth ulcers) - lymphadenopathy and splenomegaly, which may suggest HIV infection or Hodgkin lymphoma complications - Pneumocystis jirovecii, cytomegalovirus, rubeola, and varicella infections -Ix : fbc rx: -Treatment of associated infections Treatment of underlying disorder Sometimes IV or subcutaneous immune globulin Possibly hematopoietic stem cell transplantation

IgA nephropathy

-type of glomerulonephritis associated with URTI or gastroenteritis - due to deposition of IgA immune complexes in glomeruli. -common in teens, most common GN -causes haematuria, +/-PROTEINURIA AND RENAl insufficiency - other presentation: malignant HTN, CKD, nephrotic syndrome - diagnosed with urinalysis and biopsy -treated with ACE inhibitors and steroids for nephritis

What are the causes of IBS 1A

-unknown -gut hypersensitivity to visceral pain and perception -altered GI motility -Serotonin NT in gut and brain -psychological abnormalities -post-infective sensitisation - food intolerance: Studies of dietary restriction followed by reintroduction suggest food intolerance in 30-60% of IBS patients associated with either abnormal perception of intestinal activity or abnormal intestinal motility • abnormal motility: multiple abnormalities described; unclear if associations or if causative • psychological: stress may increase IBS symptoms but does not cause IBS

Colles Fracture 1A

-• extra-articular transverse distal radius fracture (~2 cm proximal to the radiocarpal joint) with dorsal displacement ± ulnar styloid fracture -FOOSH -common in >40 esp women w/ osteoporosis -obesity -compaction -dinner fork deformity Elderly person, fall on an outstretched hand** S/S: -swelling, tenderness and contusion over distal radius/ulna - appearance often called a "silverfork" deformity* Dx: -x-ray, distal radius fracture with dorsal angulation* Tx: -closed reduction and full cast + immmobilisation 6-8 wks -cast extends from below the elbow to the metacarpal heads - if intra-articular or comminuted fx = requires surgery complications: median nerve at risk of compression

Necrotising fasciitis

-• rapidly spreading, very painful infection of the fascia with necrosis of surrounding tissues -• infection spreads rapidly along deep fascial plane and is limb and life threatening - well at first then becomes very sick/toxic -b-hemolytic Streptococcus -usually lower leg -within 24hrs of minor injury -pathogens- mixed features -pain out of proportion w/ clinical finding -oedema, tenderness, blistering, ecchymoses, -flu-like illness later: fever, malaise, nausea -late findings : blue black skin, formation of bullae, gangrene - some gases show on x-ray produced by bacteria Investigation - surgical exploration and tissue biopsy -presense of fascial necrosis and mynecrosis, loss of ofascial integrity -finger sweep test -raised CRP -USS - Treatment Rx: ABC,urgent surgical debridement, IV abx Empirically: surgically debride THEN IV meropenem + clindamycin + vancomycin If swabbed and strep --> Benpen + clindamycin IV If swabbed and clostridium perfrigens --> IV Benpen

1. Tinea pedis (athletes foot) 1A

. 1. A ringworm fungus of the foot (athlete's foot) Occurs in the toe clefts due to dermatophyte fungus : Trichophyton (T.) rubrum, T. interdigitale. Rubrum most comon b. Patterns of T. pedis i. Mocassin tinea pedis - involves whole foot ii. Interdigital tinea pedis - toe web spaces iii. Bullous tinea pedis - painful blisters 2. common in males, adolescents 3. Aex: occluive footwear, excessive sweating, DM, HIV 4. features: itchy scaly erosions between the toes Fungal nail infection may also occur 5.Rx 1. topical antifungals : azoles, allylamines, butenafine, ciclopirox, and tolnaftate 2. PO antifungals if no response to topicals : Terbinafine Itraconazole Fluconazole Griseofulvin

SULFONYLUREAS

. 1.glipizide, glyburide, glimepiride, PO 2. Works by stimulating pancreatic beta cells to secrete insulin 3. SE: hypoglycemia, HYPONATRAEMIA WEIGHT GAIN, skin rash, nausea, epigastric fullness, and heartburn

Scarlet Fever nom

. aka: scarlatina- NOTIFIABLE B. childhood infection caused by GAS C. Clinical findings: Viral prodrome of pharyngitis, fever, nausea, emesis, headache and abdominal pain 1-2 days *BEFORE* to rash *STARTS ON TRUNK* -Rash: punctate rash and strawberry tongue -throat swab D. Treatment: Penicillin FOR 10 days if allergic then, erythromycin

C8 Radiculopathy presentation

.-Weak flexion of fingers - paresthesia of ulnar border of wrist and forearm

type 3 hyperseonsitivity rxn

.excess of antigen, leading to small immune complexes being formed that fix complement and are not cleared from the circulation. It involves soluble antigens that are not bound to cell surfaces (as opposed to those in type II hypersensitivity).

causes of meningitis in neonates

0 - 3 months Group B Streptococcus (most common cause in neonates) E. coli Listeria monocytogenes

wesley croup scores

0-17 used for croup mild: 2, no stridor at rest, stridor when upset, crying moderare: 3, stridor at rest, mild retractions severe: 8, stridor at rest, severe retractions

Rx HHS

0.9% saline, no insulin for 1st 12 hours then low dose insulin Anticoagulate 1. Normalise the osmolality (gradually) 2. Replace fluid and electrolyte losses ( they lose 100-220ml/kg ) - 3-6 litres by 12 hours 3. Normalise blood glucose (gradually)- fluids will result in a gradual decline of blood glucose and osmolarity. sliding scale Insulin treatment prior to adequate fluid replacement may result in cardiovascular collapse as the water moves out of the intravascular space, with a resulting decline in intravascular volume. If significant ketonaemia is present (3β-hydroxy butyrate is more than 1 mmol/L) this indicates relative hypoinsulinaemia and insulin should be started at time zero , if NOT then DONT start rx

RETINAL DETACHMENT 1B 1-6

1 . separation of neurosensory retina from the underlying retinal pigment epithelium. Normally these two layers are loosely attached to each other with a potential space in between. Sight threatening Untreated, it almost always leads to a blind eye. 2. AEx/RF - rhegmatogenous ( involves retinal break /hole through which subretinal fluid (SRF) seeps and separates the sensory retina from the pigmentary epithelium.) : myopia, cataract surgery, ocular trauma, FH - traction RD: sickle cells *features*: flashes, floaters, retinal breaks, -serous detachment: results from transudation of fluid into the subretinal space. Causes include severe uveitis, choroidal haemanggiomas , choroidal mets. 3/4: S+S 1. painless visual disturbance/loss 2. floaters, flashes, a curtain or dark cloud coming across the field of vision 2.photopsia 3. floaters Ix 1. opthalmoscopy w/ dilation - shows retinal detachment 2. Visual field charting: reveals scotomas corresponding to the area of detached retina 3. Rx 1. sealing 2. scleral buckling 3. pneumaic retinopexy 4. Vitrectomy

What are the three chambers of the eye?

1) Anterior chamber (filled with aqueous humour) 2) Posterior chamber (filled with aqueous humour) 3) Vitreous chamber (filled with vitreous humour)

What 4 things can cause Renal Papillary Necrosis?

1) Diabetes Mellitus 2) Acute pyelonephritis 3) acetominophen use 4) sickel cell anemia

How can DM lead to blindness?

1) Diabetic Macular Edema -Most common cause of reduced central vision -Visual acuity is unaffected until retinal thickening or associated lipid deposits threaten the center of the macula 2) Non-resolving Vitreous Hemorrhage 3) Fibrovascular Proliferation with Traction Retinal Detachment 4) Neovascular glaucoma 5) Macular Ischemia

General Rules for Steriod use

1) Do not use class I or II on face or intertriginous areas (axilla, groin, inframammary) 2) Do not use class I II or III on children, especially age 2 or younger 3) Apply BID in all cases no benefit to more frequent applications 4) Give a 2 week trail and re-evaluate (if clear do not stop wean to lower strength or q a day application for an additional week) If not improved check compliance and increase strength 5) Do not use steroid/anti-fungal combinations 6) Do not use ultrapotent steroid longer than 2 weeks (ultravate, Temovate) 7) Never give refills of mid or high potency steroids

Progression of AMD

1) Early AMD - presence of a few medium-sized drusen, pigmentary abnormalities 2) Intermediate AMD - Presence of at least one druse, numerous medium-sized drusen, geographic atrophy that does not extend to the center of the macula 3) Advanced non-neovascular AMD - Drusen and geographic atrophy extending to the center of the macula 4) Advanced neovascular AMD "Wet" - Choroidal neovascularization and any of its potential sequelae, including subretinal fluid, lipid deposition, hemorrhage, retinal pigment epithelium detachment, and a fibrotic scar

Which bones make up the orbit?

1) Frontal 2) Zygomatic 3) Greater + Lesser Wing of Sphenoid 4) Maxilla 5) Lacrimal 6) Ethmoid 7) Palatine

What are causes of CN III Palsy?

1) Ischemic (DM/HTN, Giant Cell Arteritis) 2) Trauma 3) Compression (aneurysm/tumor) 4) Infiltrative (leukemia, sarcoid)

How do photoreceptors work?

1) Light activates rhodopsin 2) Cis-retinal--> trans-retinal 3) Retina detaches from opsin 4) Hyperpolarization stimulates bipolar cells

drugs associated with psoriasis

1) Lithium 2) Beta Blockers 3) Antimalarials - Plaquenil 4) Systemic Steroids

Trace the flow of aqueous humor.

1) Made by ciliary body 2) Secreted into posterior chamber 3) Flows freely through pupil opening into anterior chamber 4) Outflow through trabecular meshwork into blood vessels 5) Drains through Schlemm's canal in limbic area (border b/t cornea and sclera) into aqueous veins.

Who has a higher risk for retinal detachment?

1) Middle-aged or elderly 2) Severe myopia (nearsighted)

What parts of the eye does the vitreous adhere to?

1) Optic nerve 2) Retinal vessels 3) Fovea 4) Peripheral retina

What are three types of retinal detachments?

1) Rhegmatogenous - rupture, fraction, rip 2) Tractional [scar tissue pulling on membranes] - DM, epiretinal membranes 3) Serous [fluid behind retina, BV bounce up] - inflammatory conditions, malignant HTN

What are thecommon infective agents in osteomyelitis 1A

1) S. aureus - most common 2) N. gonorrhoeae - sexually active young adults 3) Salmonella - sickle cell disease 4) Pseudomonas - diabetics or IV drug abuse 5) Pasteurella - dog or cat bite/scratch 6) TB - Pott disease of the vertebra

Layers of eyeball from OUTSIDE, in.

1) Tear film (oil, water and mucous) 2) Conjunctiva - thin membrane over sclera 3) fibrous tunic - cornea and sclera 4) vascular tunic - uvea - iris, ciliary body and choroid 5) Nervous tunic - retina

What are the six components of the ophthalmic screening examination?

1) Visual acuity 2) Visual fields 3) External examination 4) Pupils 5) Motility and alignment 6) Ophthalmoscopic examination [fundoscopy]

What are some clinical signs of a ruptured globe?

1) Visual acuity of 20/400 or worse 2) IOP < 7 mm Hg or significantly less than non-ruptured eye 3) Presence of afferent pupillary defect 4) abnormally deep or shallow anterior chamber 5) Severe intraocular or periocular hemorrhage 6) Vitreous strands directed towards the possible rupture side 7) CT scan showing flattening of the posterior contour of the sclera (flat-tire sign)

What are the three types of conjunctiva?

1) bulbar conjunctiva 2) palpebral conjunctiva 3) fornix conjunctiva

ORAL HERPES SIMPLEX

1)HSV-1 infection 2) Cold sores. Latent virus usually in trigeminal ganglia 3) MOT = Close contact with active lesions 4) triggers: sunlight, fevdf, menstruation, stress, trauma 5? features: pruiritic, erythematous clustered vesicles on the lip, in the oral cavity which rupture forming thin yellow crust 6) Rx: analgesics, acyclovir , self-limiting 7) complications: herpetic gingivostomatitis in kids or herpetic pharyngitis. dysphaggia

HAEMORRHOIDS 1-7

1. - Dilatation of anal veins surrounded by anal tissue - Associated with raised intra-abdominal pressure e.g. constipation, pregnancy, chronic cough etc. - internal : above dentate line -external : below dentate line --> associated with blood on PR or fresh blood on stool FEATURES - lump -fresh blood in stool or on wiping -pain ( due to thrombosis) and pruritus ani Ix PR exam Colonoscopy Rx -Haemorrhoidectomy - Increased dietary fibre and water intake - Topical steroids/ lidocaine - Band ligation - Sclerotherapy Extra - First degree - internal haemorrhoids within the anal canal - Second degree - prolapsed out of the anus on straining but spontaneously reduce - Third degree - as second degree but require manual reduction - Fourth degree - are irreducible

Rx of DKA 1B

1. 1L normal saline/hr (priority) + insulin 0.1/kg/hr 2. once BM <15mmols then 5% dextrose 2. correct hypokalaemia 3. 1L saline/1hrs, then 1L PLUS K+ over 2 hrs, then 1L normal saline + K+ over 2 hrs, then 1L PLUS K+ over 4 hrs, 1L PLUS K+ over 4 hrs then 1L PLUS K+ over 6 hrs usually deplete 5-6 L If on insulin insulin should be fixed rate whilst continuing regular injected long-acting insulin but stopping short actin injected insulin

PSORIASIS Rx as per NICE

1. 1st line Topical steroids mild (Hydrocortisone) or moderate (Betnovate-RD/Eumovate) 2. Offer second- or third-line treatment options (phototherapy or systemic therapy) at the same time in extensive disease >10% affected and nail disease 3. r/v in 4 weeks after nre treatment, 2 weeks in kids 4. Trunk and limbs: potent steroid (betamethasone dip-, fluticasone, ) + Vitamin D ( OD if no better than BD) r or a coal tar preparation applied once or twice daily 5. very potent steroid Face and flexure, geitals - short term mild or mderate potency steroid OD or BD - areas rticularly vulnerable to steroid atrophy and that corticosteroids should only be used for short-term treatment of psoriasis (1-2 weeks per month). UVB for guttate or plaque psoriasis

Helicobacter Pylori 1 A 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. A bacteria found in the stomach, can lead to cancer or ulcers 2. acquired infection, common in older people >60, common in blacks and asians 3. dysbiosis can result in opportunistic infection Ix: Urea breath test: ammonia is produced by urea metabolism which occurs due to H.pylori Stool antigen test Endoscopic biopsy: can detect H.pylori on histology or culture - CLO test IgG antibodies Rx Triple therapy: PPI + amoxicillin + clarithromycin or metronidazole FOR 7 DAYS

PEPTIC ULCER DISEASE ( PUD) 1A 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. A break or ulceration in the protective mucosal lining of the lower oesophagus, stomach, or duodenum than 5 mm in diameter with depth to the submucosa 2. AEx: NSAIDS Alcohol zollinger syndrome ( gastric secreting tumour, MEN-1) Chron's disease H pylori 3/4 1. *Peptic*: chronic dull pain or burning epigastric pain , can radiate to back relieved by antacids. 1. *Duodenal* : alleviated by eating, gastric: worse on eating 2. malaena, haematemesis 3. perforation -Peritonitic 4. Anaemia 5. weight loss due to dyspepsia Ix 1. urgent gastroscopy+ biospy 1. FBC: Hb, urea 2. OGD 3. Urea breath test H, Pylori 4. biiopsy R/O cancer 5. gastrin levels - zollinegr 6. AXR r/o perf ( air under diaphragm) Rx acute 1. fluids 2. blood transfusion 3. IV PPIs 4. gastroscopy control bleeding Long term Antacids if no response THEN PPIs omeprazole 20 mg BD or H2 blockers, treat any H pylori infections H. pylori- erradication no alcohol, chocolate, weight loss

BLOWOUT FRACTURE 1B

1. A fracture of the floor of the orbit usually caused by a blow/blunt trauma to the eye: punch , balls. - can result in inferior displacement of the globe, entrapment of the infraorbital nerve. 3. symptoms -parasthesia and anaesthesia in area of distribution of infraorbital nerves - ipsilateral epitaxis -proptosis -enopthlasmos and mechanical ptosis 4. -enophthalmos- inward displacement of the eye - increased intraorbital pressure -oedema -emphyseam of eyelids- avoid blowing nose -diplopia vertical due to mechanical restriction of upgaze. Ix plain xrays CT and MRI Rx surgical repair

Varicella Chicken Pox 1A

1. A highly contagious viral desease, caused by varicella-zoster virus 2. Usually in children prior to puberty; more serious in adults 3. March, April, May most common 4. Contagious 2 days prior to rash and until the last lesion is crusted 5. Vaccine now available 6. Incubation period 14 days, prodrome of fever, malaise, headache 1. Lesions begin on the trunk and scalp and spread to the extremities (centrifugal spread) and are a thin walled vesicle with an erythematous base "dew drop on a rose petal" 2. Lesions begin to crust by day 4, but is common to see new and crusted lesions together 3. Fever can be as high as 105 C 4. Oral and mucosal lesions are common 5. Lesions can be very pruritic, but heal without scarring Rx 1. Antipruritic lotions (Sarna, menthol), antihistamines, antibiotics (for secondary infection) 2. Acyclovir will decrease time of disease by 1 day and cut down the number of lesions by 30%. Persons to be treated are adults and immunocompromised 3. Varicella Zoster immune globulin (VZIG) for acutely ill immunocompromised, newborns, premature infants, pregnant women 4. Varicella immunization - most pediatricians recommend, still some controversy

Leukocytoclastic vasculitis

1. A hypersensitivity reaction with the development of small purpuric papules (palpable purpura) in crops that last for 1-4 weeks 2. Etiology: Drugs, infection, connective tissue disease 3. Internal involvement: Kidneys (hematuria), nervous system (peripheral neuropathy), GI (abdominal pain), Lung, joints (pain), heart (arrhythmias)

MALLORY WEISS TEAR

1. A linear mucosal tear in the oesophagus at the gastroesophageal junction. > ALCOHOLICS, binge drinking, clyclical vomitting 2. result of rapid increases in gastric pressure from retching/vomiting against a closed glottis 3/4: hematemesis ± melena, classically following an episode of retching without blood Ix -clinical FBC, urea, LFTs, PT, APPT, CXR, cross-match - OGD Rx -endoscopy w/ noradrenaline injection and surgical repair - IV ocerotide reduce portal venous flow -most heal spontaneously 90%

What is sarcoidosis (2B)

1. A multi-system inflammatory disorder of unknown cause results in lots of nodules ( non-ceasiating granulomas- collection of immune cell)) throughout the body . results in tissue damage and eventual fibrosis after healing >40, >F, > Africans 2. AEx: genetic, autoimmune 3. Granulomas Erythema nodosum Restrictive lung defects ( ⬇ PFTs, Wheeze, dry cough, chest pain) Malaise, fatigue Arthralgia, asteroid bodies Nodes- Hilar lympadenopathy lungs A: ACE goes up C: chest pain Eye: uveitis

HYPOKALAEMIA 1A

1. A potassium level of <2.5mmol/L importance of K+ -K+ is a major cation inside cells -allows cells to generate APs important in muscles, neurotransmission and heart Causes vomiting + diarrhea diuretics- Loop diuretics inhibit sodium Cushing's syndrome Conn's syndrome (primary hyperaldosteronism) renal tubular acidosis DKA (partially treated) fistula Features - Hypotonia - Hypo-reflexia - Muscle cramps, weakness and tetany - Palpitations - Light-headedness - Constipation -alkalosis - Prolonged PR interval (AV block) - Peaked P waves - ST depression - Flattened T waves - U waves Rx - Oral potassium replacement if >2.5 mmol ( sandok) review - Stop diuretics or causative drugs - IV potassium chloride - at a rate of no more than 20mmol/hr in central lines and no more than 10mmol in peripheral line

Meningococcal septicemia

1. A potentially fatal (6-10%) infection with Neisseria meningitidis 2. Systemic invasion form nasopharynx leads to bacteremia with subsequent CNS invasion 3/4: presents with purpuric rash 3. Rx IM benzylpenicillin immediately hospital

Herpes Zoster (shingles) 1A

1. A reactivation of varicella-zoster virus (chicken pox), occurring in 10-20% of the population 2. Lesions are erythematous based, tender vesicles that involve a whole nerve dermatome 3. Reactivation of the varicella-zoster virus may be due to age, emotional stress, immunosuppressive drugs, CA, illness, and radiation therapy 4. A patient with an active outbreak of herpes zoster could cause a close contact to develop chicken pox, if not previously immune 5. Ix clinical 6. Rx -aciclovir 800mg 5x daily - treat ASAP to prevent herpetic neuralgia

WILMS TUMOUR 1B

1. AKA Neuroblastoma. a rare type of malignant tumor of the kidney that occurs in young children. Contains embryonic kidney structures. 3/4: painless , palpable abdo mass, haematuria, HTN, anaemia, abdo pain, N&V , bone pain, hepatomegaly, paraplegia , pallor + weight loss 5. Ix: Urinalysis, USS, CT, MRI - biopsy -raised urinary vanillylmandelic acid (VMA) -homovanillic acid (HVA) levels 6. Rx: 1. urgent 48 hr referral for assessment nephroctomy, chemo , high cure rate >90

Gynaecomastia 1B

1. Abnormal increased breast tissue in men. benign breast lump in males >2cm high oestrogen to testosterone ratio 2. AEx Physiologocal: young boys, babies, older men increased oestrogen: cirrhosis, testicular tumours (leydig, germ cell), lung, gasric, rCC and hepatoms (hCG secreting), obesity lack of testosteone: kleifelter, congenital absence of testes Drugs: androgen blockers: Metronidazole ,Ketoconazole, Spironolactone (can be switched to eplerenone ) testosterone inhibitors: PPIs, H2 receptor antagonists Anti-androgens: flutamide, bicalutamide, finasteride, dutasteride MARIJUANA STEROIDS (ANABOLIC) others : antidepressants , digoxin, CCBs, ACE-Is, amiodarone Ix U&Es LFTs Liver disease TFTs Hormone profile Estradiol Testosterone Prolactin Beta- hCG levels Alpha-fetoprotein (the liver, testicles, and ovaries) LH , donazol Rx -self-limiting at times so observe -testosterone, tamoxifen (if pain and embarassed)

HYPOPARATHYROIDISM 1A

1. Abnormally low levels of Ca+ due to lack of or reduced PTH -PTH --> ca+ cannot be reabsorbed from urine and from GI tract - Results in low calcium, high phosphate, normalALP and features of hypocalcaemia 2 AEx: PRIMARY : GENETIC: ASKD b. Digeorgi syndrome . deletion on Chrom 22. abnormal dev. of Parathyroid gland, thymus, heart c. Kearnes-Sayre syndrome: due to deletions in the mitochondrial genome and can include hypoparathyroidism, encephalopathy, and stroke-like episodes. b. Sanjad-Sakati syndrome includes hypoparathyroidism, short stature, and mental disability due to autosomal recessive mutations in tubulin-folding cofactor E e. Autoimmune polyendocrine syndrome type 1 SECONDARY a. post thryroidectomy , POST radiation damage 3/4. Signs and Symptoms : CATS Cramps( muscle), convulsions Aarrythmias Perioral paresthesia Tetany Seizures / stridor 5. Ix PRIMARY & SECONDARY a. calcium ⬇ b. phosphate ⬆ c. PTH low or normal c. albumin normal d. ECG: low calcium, high phosphate, normalALP and Rx - Calcium supplementation - Calcitriol

ACROMEGALY 1B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. Acromegaly is the excessive secretion of GH by pituitary somatotroph adenoma or hyperplasia (in 1%) - May also be due to ectopic carcinoid which releases GH - 5% are associated with MEN-1 syndrome - GH stimulates bone and tissue growth through IGF-1 - Associated with hyperprolactinaemia due to disinhibition syndrome FEATURES - Coarsening of the facial features - frontal bossing, prognathism, separation of the teeth, large supra-orbital ridge, skin tags, scalp folds, darkening of skin - Acroparesthesia (burning, tingling, or pricking sensations or numbness in the extremities present on awaking due to nerve compression during sleep) - Amenorrhoea, loss of libido, galactorrhoea ( raised prolactin) -features of pituitary tumour: hypopituitarism, headaches, bitemporal hemianopia - Organomegaly - hepatomegaly, splenomegaly, macroglossia - increase in shoe size COMPLICATIONS hypertension diabetes (>10%) CARDIOMYOPATHY, arrhythmias, ischaemic heart disease and stroke colorectal cancer sleep apnoea Ix - !st line test is Serum IGF-1 - Oral glucose tolerance test with GH assay - GH fails to suppress - Pituitary MRI- pituitary adenoma - CT chest/abdomen - ECG - Echocardiogram Rx - Trans-sphenoidal resection- first line - Somatostatin analogues - octreotide suppresses GH + dopamine agonists (bromocriptine) - Pegvisomant - GH receptor blocker - Sellar radiotherapy

patterns of Lichen Planus

1. Actinic - sun-exposed areas 2. Annular - trunk, external genitalia 3. Atrophic - any area 4. Erosioulcerative - soles of feet, mouth 5. Follicular (lichen plano pilaris) - scalp 6. Guttate (numerous small papules) - trunk 7. Hypertrophic - lower limbs (especially ankles) 8. Linear - zosteriform (leg), scratched area 9. Nail disease - fingernails 10. Papular (localized) - flexor surface (wrists and forearms) 11. Vesiculobuilous - lower limbs, mouth

Acute Uritcaria 1B

1. Acute Urticaria - intense pruritic transient wheals due to acute dermal oedema or angio-oedema -A type 1 hypersensitivity reaction with cross-linkage of IgE on the mast cell membrane leading to leaky capillaries and oedema Aetx - Stinging nettles - Infection - Drug reactions - Food allergy - Physical stimuli - Latex - Autoimmune disease Physical urticaria - Cold - Pressure - Cholinergic (stress or heat) - Solar - Aquagenic - Contact Rx b. A detailed history is usually helpful, labs not necessary -Treat with antihistamines -avoid causes

Erysipeloid

1. Acute skin infection with Erysipelothrix rhusiopathiae (sporulating gram positive rod) 2. Etiology - organism comes from contaminated animals or animal products (fisherman, butchers, farmers, veterinarians) Tx:1. Penicillins, cephalosporins, erythromycin, and clindamycin 2. Can be a self limited course and can have recurrence up to 6 months later due to L. form conversion of the bacteria (loses cell wall)

PYELONEPHRITIS 1B

1. Acute: Inflammation of the kidney due to bacterial infection due to ascending UTI . can cause swelling in kidneys b. Chronic pyelonephritis : characterised by chronic tubulointerstitial inflammation and deep segmental cortical renal scarring and clubbing of the pelvic calyces as the papillae retract into the scars. due to vesicoureteral reflux (VUR) 2. Aex a. Ascending UTI b. protatitis and BPH -> du eto obstruction c. common in elderly, diabetics, immunosupressed 3. symptoms a. severe flank/ loin pain b. fever and rigors c. N&V d. frequency and urgency 4. Ix a. urinalysis b. urine culture and stain c. FBC d. ESR e. CRP f. Blood culture g. CTKUB h. CT AP Rx Empiric abx i.e ciproflaxin

PANCREATIC CANCER 1B

1. Adenocarcinoma in the head of the pancreas most common 2. AEx Smoking, chronic pancreatitis, fam hx, increasing age, M>F, DM, processed meat 3/4: -Painless jaundice, steatorrhoea Later: weight loss, epigastric pain to back , nausea and vomiting - Courvoisier's law - painless palpable gallbladder due to head of pancreas pressing upon it and obstructive jaundice - migratory thrombophlebitis: Trousseau sign Ix CA 19-9 ⬆ CT without contrast Rx palliative chemo wipples procedure

PRESBYCUSIS

1. Age-related hearing loss which presents as sensorineural deafness initially affecting high-frequency tones 2/3. elderly common with ageing. >60s, more commonin males 4/5: reduced hearing, especially in noisy environments 5. Ix: - audiometry: bilateral high-frequency hearing loss, Air conduction better than bone conduction - otoscopy: normal -tympanometry: Normal middle ear function with hearing loss (Type A)

Pneumothorax 1A 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. Air in pleural space 2. AEx Primary: smoking, tall, young , occurs at rest Secondary: underlying dz COPD, bronchiectasis , asthma -> bullae blebs Iatrogenic: :ventilation tension : 1-way valve, stab wound , thoracentesis 3/4 : signs &symptoms - sudden SOB - Tachycardia TENSION PNEUMOTHORAX S&S -pleuritic chest pain -mediastinal shift -tracheal deviation away from pneumothorax -hypotension -rasied JVP -SOB -reduced chest expansion - Tachycardia -hyperresonance on percusion Ix CXR: radio-lucency due to absent lung markings, tracheal deviation Surgical therapy - Pleurectomy - Talc or tetracycline, pleomycin pleurodesis PRIMARY PNEUMOTHORAX Rx - <2 cm, no SOB then discharge - >2cm then attempt aspiration, fail then chest drain SECONDARY >50, >2cm- chest drain

Lichen Striatus

1. An uncommon, unilateral and linear eruption of erythematous, flat topped and scaly papules that may extend the length of a limb 2. Age of onset 3-14 years, Females > males Etiology: unknown Tx: 1. Spontaneous involution occurs by 9 months duration 2. Topical and intralesional steroids

Treatment of Urticaria

1. Antihistamines: block histamine receptor sites on the cell surface therefore preventing vasodilation, pruritus b. Side effects: Anticholinergic (dry mouth, blurred vision, constipation), CNS sedation in adults, stimulation in children (sedation effect becomes suppressed with long term use) c. H1 antihistamines are used primarily for skin, whereas H2 blockers are more for gastric acid hypersecretion First Generation: Chlorpheniaramine maleate (Chlor-trimeton) Hydroxyzine Hydrochloride (Atarax) Diphenhydramine hydropchloride (Benadyrl)

Ascites and Spontaneous bacterial peritonitis (SBP) 2B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. Ascites: Fluid in Peritoneal cavity SBP: infection of fluid in cavity 2. Aex: Liver failure, portal HTN, hapatorenal disease 3. s/s: abdo pain and tenderness, fever, ascites, N&V, diarrhoea, altered mental status, GI bleed . hypothermia, hypotension, tachy , distended abdomen 4. Ix: -paracentesis : neutrophil >250cells/ul , usually e.COli -FBC: ⬆ WCC, ⬇ HB? due to GI bleed? - creatinine - may be eleveated - ascitic fluid appearance -LFTs -PT/ INR -Cultures 5. Rx: cefotaxime, spironaloctone and PROPHYLACTIC ciproflaxin

CYSTIC FIBROSIS 2B

1. Autosomal recessive lung dz affects lots of other system. 1 in 25 carriers AEx: abnormalities in cystic fibrosis transmembrane conductance receptor gene on chromosome 7 stylised as CFTR b. - CFTR usually facilitates chloride movement and is involved in production of thin, non-viscous mucus --> draws water in secretions to thin them out --> no gene --> thick secretions --> mucus build up --> bronchiectasis, lung remodelling, fibrosus Signs and symptoms : CF pancreas Chronic wheezing and coughing Liver: cirrhosis, cholestasis, jaundice Infection Failure to thrive T-resp: pneumothorax, eventual cor pulmonale, hyperinflation, wheeze, haemoptysi Pancreatic insufficiency ( pancreatitis, fat malbsorption, diabetes, gallstones, steatorrhoea , liver cirrhosis ) Alkalosis Neonatal intestinal obstruction (meconium ileus)/ Nasal polyps Clubbing of fingers/ Chest radiograph with characteristic changes Rectal prolapse Electrolyte elevation in sweat, salty skin Absence or congenital atresia of vas deferens Sputum with Staph or Pseudomonas (mucoid)an 1) Sweat testing - chloride >60mmol/L 2) Genetic testing and phenotyping - 2 DNA mutations present 3) Chest X-ray - hyperinflation, diffuse infiltration, bronchiectasis 4) HRCT - confirms bronchiectasis, cysts, abscesses 5) faecal elastae 6) Spiro- lung function 7) screening at birth

HODGKIN'S LYMPHOMA 1B

1. B-CELL PROLIFERATION , REED STERNBERG CELLS (Mirror image nuclei ) - bimodal age distributions being most common in th e20-40 and >70s Aex: EBV, HHV6, familial NODULAR SCLEROSING: most common (70%) , good prognosis, more common in women MIXED CELLULARITY: 20%, Good prognosis LYMPHOCYTE PREDOMINANT: 5%, BEST PROGNOSIS Lymphocyte-depleted Hodgkin lymphoma (LDHL) S&S Asymptomatic cervical lymphadenopathy, B symptoms (poor prognosis), haemoptysis pruiritis Ix -FBC - neutrophilia, eosinophilia, lymphopenia, anaemia, mild , thrombocytosis -Raised ESR - poor prognosis -Raised LDH -Lymph node aspiration or core biopsy - Reed-Sternberg cells (*gold standard* -Immunophenotyping Rx Rituximab chemo radiotherapy

ASCENDING CHOLANGITIS

1. Bacterial infection of the biliary tree secondary to obstruction from choledocolithiasis 2. AEx: stones 3/4: fever. RUQ pain and jaundice. low blood pressure and mental status changes, it is known as Reynolds' pentad 5. Ix 1. FBC, WCC, CRP, Amylase, LFTs 2. ERCP 3. USS Rx Often need ICU for stabilisation, IV ABs, emergent bile duct decompression via ERCP or open surgery.

NASAL POLYPS 1B

1. Benign growths in nasal cavity due to repeated inflammation results in mucosal hypertrophy a. Antrochoanal polyps most common in children, are unilateral, extends from maxillary sinus b. Ethmoidal polyps in adults, are bilateral, extend from ethmoidal sinus tissue c. Samter's triad: Asthma, NSAIDs, nasal polyps 2. AEx a. CF b. FHx c. Aspirin sensitivity (Samter's Triad) d. Asthma e. Kartagener's syndrome f. Churg-Strauss syndrome 3. Symptoms: -Nasal obstruction -Rhinorrhoea and postnasal drip -Snoring -Sneezing -Anosmia -sinusitis 4: signs: Nasal obstruction 5. Ix : Rhinoscopy 6. Rx: 1. UNILATERAL -> URGENT ENT referral suspect nasopharyngeal Ca 2. bilateral: saline douche, intra-nasal beclomethasone, fluticasone 3. polypectomy, ethmoidectomy

Steven Johnson Syndrome/ TEN 1B

1. Bullous disease of the skin and mucosa occurring in children & young adults - Mortality is up to 10% 2. 3. Clinically: URI type prodromal symptoms, followed by *flat purpuric tender macules that become bullae.* start on trunk then on face and limbs. lesions can be targetoid, or blisters flaccid ( not tense) -characterised by erythroderma loss >90% skin other: crusted lips, painful mouth ulcers, diarrhoea, URTI TEN is >30% skin affected AEx Drugs- 3Ps 2s ◼ Allopurinol ▪Penicillin , phenobarbital, phenytoin ▪sulfasalazine Ix5.. -skin biopsy, exclude SSS histopathology: keratinocyte necrosis bloods: anaemia, leucopaenia, eosinophilia, proteinuria (mild) Rx 1 . intesive care, topical steroids, antihistamins, withdraw all drugs, Abx, Iv Ig ciclosporin 2. analgesia

RADIAL NERVE

1. C5-8 2. extension of wrist and fingers 3. Humeral midshaft fracture 4. Palsy results in wrist drop

MEDIAN NERVE

1. C6,8, T1 2. LOAF muscles LOAF muscles Lateral two lumbricals Opponens pollis Abductor pollis brevis Flexor pollis brevis 3. Injury/compression: carpal tunne

HYPERCALCAEMIA 1A (emergency )

1. CA+ levels >10.2mg/DL OR >2.63 mmol/L , Ca+ levels >3.0mmol/L --> URGNET polydipsia, polyuria 2. CHIMPANZEES C - Calcium supplementation H - Hydrochlorothiazide (THIAZIDE DIURETICS!!) I - Iatrogenic, immobilization M - Multiple myeloma, milk-alkali syndrome, medication (e.g Lithium) P - Parathyroid hyperplasia or adenoma A - Alcohol, addisons N - Neoplasm (e.g breast cancer, lung cancer)* Z - Zollinger Ellison syndrome E - Excessive vitamin D E - Excessive vitamin A S - Sarcoidosis * NEOPLASM: increased bone resorption, localised. some tumors( breast and lung) can secrete PTH-rP -> bone resorption, inc. VIt D synthesis etc.. 3/4. S&S: QT ( cute) BOOt CAMPS QT interval on ECG (SHORTENED QT interval) Bone pain / brown tumour (Osteitis fibrosa cystica- where decalcification leaves large punched out areas in bones) Osteoporosis Osteopaenia Constipation , confusion Anxiety and depression , abdo pain Muscle cramps weakness Parasthaesias, polyuria, polydipsia Stones ( kidney) Ix 1. PTH 2. U&Es: Ca+ , Mg, Phosphte 3. bone imaging 4. Dexa scan 5. 24-hr urinary calcium 6. Vitamin D levels 7. ESR, FBC 8. ECG Rx 1. Fluids normal saline 4l/24 hrs 1L/6hrs , calcitonin, 2. IV bisphosphontaes ( sodium pamidronate )in malignancy related 3. steroids i.r prednisolone in granulomatous dz

CATARACTS 1-6 1B

1. Cataract is opacification of the crystalline lens ( becomes cloudy) that can lead to decreased visual acuity and/or functional impairment; can lead to vision loss. -leading cause of blindness worldwide - >65 2. Ageing, trauma, metabolic dz, meds, congenital (TORCH), RF: UV exposure, poor nutrition, cigarette smoking, diabetes, steroids, down's, hypocalcaemia 3/4: Sx -painless, gradual decrease in vision : blurred vision -glares or halos - sometimes night blindness. -washed out colour vision, 4. signs -defects in red light reflex 5. Ix -Diagnosis is suggested by history -asymmetrical or absent red reflex; it is confirmed when slit lamp examination finds lens opacity. -glare vision test -anterior chamber slit: catarct 6. Rx 1. observe 2. stronger glasses, brighter lighting 2. if functional impairment- surgery: phacoemulsification ± intra-ocular lens implant

REIDEL THYROIDITIS

1. Chronic inflammation with extensive fibrosis of the thyroid gland presenting as "hard as wood painless goitre " dense fibrous tissue replaces thyroid parancyema 2. issues with air ways 3. common in 30-40s 3. Clinically mimics *anaplastic carcinoma*, however with Riedel the patients are younger & malignant cells are absent on histology 4: hoarseness, hypothyroidism, dysphagia, stridor

ULCERATIVE COLITIS 2B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. Chronic inflammatory disease affecting the colon - Begins in the rectum and then extends proximally to affect the entire colon in a continuous inflammation with eventual backwash ileitis 2. More common in men, 15-25 years of age, smoking helps 3. autoimmune inflammatory disease 4/5: PRESENTATION: bloody diarrhoea, rectal bleeding and mucus, Lower colicky abdominal pain - LLQ , tenesmus, faecal incontinence 6: Ix - AXR : loss of haustral markings, lead pipe colon, NO skip leasions - Colonoscopy - Biopsy Rx - mesalazine -azathioprine - steroids

ASTHMA 1A

1. Chronic respiratory dz characterised airway inflammation triggering stimuli resulting in partially or completely reversible,bronchosonstriction -Type 1 hypersensitivity IgE mediated -> stimulates B-cells to produce IgE antibodies to allergens-> bind to IgE-> mat cels+ leukotrienes released -> bronchospasmsm -symptoms start at age 3-5 and may improve with age 2. AEx complex, multifactorial possibly intercation of genetic + environmental ( allergens + infection) history of atopy-eczema 3. Symptoms & signs: -dry cough -tight chest -SOB -barrel chest if poorly controlled -wheezing throughout chest -crackles (clear coughing) -prolonged expiatory phase 5.Ix -FEV1/FVC ratio : <.7 -FEV1: <.7 (⬇⬇), FVC : normal -PEFR: check norms for height and gender -CXR- hyperinflation or normal -FBC: eosinophilia or neutrophilic -IgE immunoassay : positive -Fractional Exhaled Nitric oxide testing: used in sprio is inconclusive ADULT DIAGNOSIS FeNO test and spirometry with reversibility FEV1: forced expiratory volume - volume that has been exhaled at the end of the first second of forced expiration FVC: forced vital capacity - volume that has been exhaled after a maximal expiration following a full inspiration Avoid aspirin in asthma and other NSAIDS

DIABETES INSIPIDUS 2B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. Condition characterised by a deficiency in ADH (CRanial DI) or insensitivity of renal cells to ADH (nephrogenic) which results in pasing large amounts of dilute urine - ADH causes reabsorption of water in the collecting ducts --> deficiency --> hypertonic blood- hypernatremia 3. Pathophysiology Causes of cranial DI ( cant make enough ADH) idiopathic post head injury pituitary surgery craniopharyngiomas histiocytosis X DIDMOAD is the association of cranial Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness (also known as Wolfram's syndrome) Causes of nephrogenic DI ( kidneys don't respond to ADH) genetic: the more common form affects the vasopression (ADH) receptor, the less common form results from a mutation in the gene that encodes the aquaporin 2 channel electrolytes: hypercalcaemia, hypokalaemia drugs: demeclocycline, lithium tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis S&S - Polyuria - Polydipsia - Dehydration - Hypovolaemic hypernatraemia -lethargy -dry skin - Ix -high plasma osmolality >300, low urine osmolality (<100) -Desmopressin stimulation test - differentiates between cranial and nephrogenic. -a urine osmolality of >700 mOsm/kg excludes diabetes insipidus. -water deprivation test ( no water for 8 hrs give desmopressin then measure urine osmolalty 8 hrs later ( will increase in CDI or remain low after desmopressin in NDI) - U&Es: Hypernatraemia MAINLY :Diabetes insipidus is characterised by a high plasma osmolality and a low urine osmolality Rx - Thiazide diuretics : to induce hyponatremia and hypokalaemia -Desmopressin for CDI

OPTIC ATROPHY 1B

1. Conditions which result in optic nerve degeneration Classifications 1. Primary (simple) optic atrophy : MS, optic neuritis, leber's, tumours i.e pituitary, 2. Consecutive optic atrophy: due to destruction of ganglion cells secondary to degenerative or inflammatory lesions of the choroid and/or retina. causes: diffuse chorioretinitis, retinal pigmentary dystrophies such as retinitis pigmentosa, CVRO. 3. Glaucomatous optic atrophy : long standing raised intraocular pressure --> compression on nerve 4. Post-neuritic optic atrophy : sequelae to long-standing papilloedema or papillitis. 5. Vascular (ischaemic) optic atrophy. : disc ischaemia i.e GCA 6: others: optic nerve compression (glaucoma, thyroid eye disease) 7: congenital/genetic: 3/4: s+s - loss of vision - sudden or gradual , partial loss - poor colour vision -dilated fixed pupil -visual field loss - poor peripheral vision -reduced visual acuity Ix fundoscopy- pallor of disk, decrease in small blood vessel s Rx - underlying cause -nothing once atrophy severe

boundaries of femoral canal

1. Cooper's ligament posteriorly 2. Inguinal ligament anteriorly 3. Femoral vein laterally 4. Lacunar ligament medially

Malaria 1B

1. Defi and epidemiology ▪Vector borne protozoan infection caused by 5 main species : P. falciparum, p. malariae, P. ovale, P. vivax, P.knowlesi P. falciparum and P. vivax most common ▪Common in children ▪Protective factors: G6PD deficiency, ovalocytosis, sickle cell, thalassaemia 2. Features ▪flu-like prodrome , abdominal pain, diarrhea, myalgia, H/A- jaundice, and cough ▪hepatosplenomegaly and thrombocytopenia without leukocytosis ▪paroxysms of high spiking fever and shaking chills (due to synchronous systemic lysis of RBCs) (lasts several hours) ▪Cerebral malaria: Coma, convulsions, abnormal posturing , 3. Ix - Blood films: thick - organism present or not, thin stain - type of organism -NAAT, antigen detection test Rx chloroquine + primaquine ( vivax and ovale, malariae, knowlesi) cloroquine resistance: atovaquone/proguanil + primaquine or quinine and doxycycline + primaquine SEVERE MALARIA (>2% parasitaemia) : intravenous artesunate

COPD 1A 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs

1. Definition - chronic progressive irreversible deterioration of lung function -Minimal or no reversibility with bronchodilators -Minimal variability in day-to-day symptoms -Comprosises chronic bronchitis and emphysema 2a. Epidemiology - more common in men - older people >65+ , long-term effects of smoking 2b. AEx -95% cases are smoke-related >20 pack years. - possible genetic susceptibility ( only occurs in 10-20 smokers) a-1 antitrypsin deficiency -exposure to dust, chemicals, air pollution 3. Pathophysiology exposure to smoke results in: -Mucous gland (gobet cell) hyperplasia:,esp, in large airway in response to chronic irritation by noxious particles and gases --> hypersecretion of mucus --> chronic productive cough AND mucus plugging --> obstruction -> reduced airflow - Squamous metaplasia : ciliated columnar replaced by squamous epithelium--> Loss of cilial leads to impairment of the functioning of the mucociliary escalator--> cough (bronchitis) + plugging of mucus - Chronic inflammation -> cytokines -> proteases i.e elastase -> breakdown elastin + connective tissues in lung -> lung paranchyema destruction -> loss of recoil + alveolar septa -->Lung hyperinflation, airflow limitation, and air trapping follow. -> emphysema - in a-1 antitrypsin defficiency , there isnt enough to fight day to day releas or proteases as a result of inflammation -Airspaces enlarge and may eventually develop blebs or bullae. blue bloater -> bronchitis pink puffer emphysema 3/4: S&S 1. productive cough chronic( most days/wk >3 months), progressive/worsening SOB 2. signs: hyperresonance, tripod positin, hyerinflation/barrel chest, pursed lips, chachexia, muscle wasting , cyanosis, wheezing and crackles , clubbing

CHRONIC DIARRHOEA

1. Diarrhoea lasting more than 2-4 weeks 2. Causes ▪ Viral: giardiasis (non-bloody) , cholera ▪ IBD, IBS, coeliac, lactose intolerance, *cancer* , microscopic colitis (PPI SE) - addisons, hypoparathyroidisn, hyperthyroidism -drugs Ix -Stool analysis - leukocytes, culture. -calprotectin -Sigmoidoscopy useful in patients with bloody diarrhoea with no obvious clinical suspicion. -colonoscopy OGD coealiac IgA abs ( coeliac) FBC, LFT, TFTs , ESR, CRP

DYSPHAGIA

1. Difficulty swallowing 2. Neurologic or muscular, including stroke, Parkinson's disease, myasthenia gravis, prolonged intubation and Zenker diverticulum IDA- severe IDA can dysphagia due to post-cricoid webs (part of Plummer-Vinson syndrome)- glossitis, angular stomatitis 'Nutcracker' oesophagus: Extremely high‐amplitude contractions can cause chest pain and dysphagia Obstruction: strictures, Schatzki rings, webs, carcinoma. Motility disorder: achalasia, scleroderma, esophageal spasm. Ix Gastroscopy, do barium swallow first if hx of radiation or strictures as this increases the risk of perforation.

Treatment of Lyphgranuloma Venerum

1. Doxycycline 2. Erythromycin 3. Sulfisoxazole

Treatment of Granuloma Inguinale (donovanosis )

1. Doxycycline 2. Erythromycin 3. Tetracycline 4. Bactrim

Macrovascular complications of diabetes

1. Due to accelerated atherosclerosis and endothelial damage due to glucose. 2. CVD, stroke, HTN, renovascular dz and , PVD

ECTROPION 1B

1. Eversion of the lid, usually lower lid 2. types and causes ◾Senile ectropion : due to slackness of the pretarsal parts of the orbicularis oculi and of the palpebral ligament in old age ◾Cicatricial ectropion due to scarring and contraction of the skin and subcutaneous fat after tumors, trauma, burns, and surgery ● Congenital ectropion due to hypotrophy of the orbicularis oculi ● Spastic ectropion in blepharospasm ●Paralytic ectropion due to weakness of the orbicularis oculi in facial nerve paresis 3/4 epiphora and conjuctivitis 5. Ix -clinical 6.Rx surgical- medical conjuctival repair etc...

CORNEAL FOREIGN BODY 1B

1. FOREIGN body in or on cornea, rust ring if metallic COMPLICATION: keratitis 2. Features - tearing, photophobia, foreign body sensation, red eye -conjunctival injection,foreign body, corneal oedema Ix slit lamp Rx -remove foreign body or refer -abx Fusidic acid

Furuncles / Carbuncles

1. Furuncle - a walled off, painful, firm, fluctuent collection of puswith single opening 2. Carbuncle - an aggregate of furuncles, multiple openings 3. Etiology - Staph aureus, most common cause Clinically 1. Occurs in areas prone to friction (buttocks, groin, axillae) 2. Chronic furunculosis is a chronic and recurrent disease in which patients continue to form multiple furuncles due to nasal carriage of Staph aureus 3. Immune defects may predispose some patients Treatment: 1. Warm compresses 2. Incision and drainage / intralesional steroids 3. Oral antibiotics (anti Staph aureus - pcn, cephalosporins) after appropriate culture 4. Topcal bactroban (mupirocin) is applied to the anterior nares BIDfor 5-7 days to try to decrease carriage rate

Angioedema

1. General Info a. Subcutaneous, painful nonpruritic, hive-like swelling usually involving the head and neck, palms, soles, trunk, and genitalia b. Gastrointestinal and respiratory involvement leads to dysphagia and dyspnea

Erythema Multiforme 1B

1. General: a. An acute inflammatory disease characterized by targetoid "iris" erythematous papules, plaques and bullae with central clearing - The lesions are first seen on the backs of hands and/or tops of feet, and then spread along the limbs towards the trunk. -hypersensitivity rxn triggered by infection usually HSV 2. Etiology: Viral Infections (herpes simplex usually ) - mycoplasma pneumoniae - connective tissue disease, pregnancy, malignancy, - Mycoplasma pneumonia, herpes simplex, penicillin, sulphonamides, phenytoin, carbamazepine 3. Clinically: Lesions are itchy, burning, painful and heal in 4 weeks cann affect mouth, anus, genitals, GI tract Ix -CXR, biopsy 4. Treatment: - If mild, no treatment. (self-limiting ) -> does not progress -Prednisone, acyclovir (herpes associated EM), dapsone, azathioprine -antiseptic mouthwash , anasthetics - opthlamology if eye involvement

Toxic Epidermal Necrolysis (Lyell's syndrome) thought to be same as SJS 1B

1. General: Mucocutaneous drug reaction pattern with skin and mucosal tenderness, erythema, followed by extensive cutaneous and mucosal exfoliation <10% more likely to be SJS but TEN if >10% -SCORTEN scoring system 2. Etiology: 80% medication; chemicals, Mycoplasma pneumonia, viral infections, immunization (Sulfa drugs allopurinol, hydantoins, carbamazepine, phenylbutazone piroxicam, chlormezanone, amithiozone, aminopenicillins) -common drugs: penicillins, allopurinol, phenytoin, NSAIDs, carbamazepine, sulphonamides , cephalosporins, tetracyclines. 3. Sings/symptoms - Flu-like ssymptoms -fever - painful skin- burning sensation - erythema progressing to widespread subepidermal blistering which rupture easily -mucosal involvement ( 4. Mortality is 35-40%, sepsis as usual cause of death Ix: skin biopsy, excluse SSS histopathology: keratinocyte necrosis bloods: anaemia, leucopaenia, eosinophilia, proteinuria (mild) 5. Treatment: - refer to Burn unit/ICU to be managed like a burn, -stop drug -plasmaphoresis -fluid and electrolyte management. -Steroids controversial -stop offending drugs regulate temperature -pain management

Erythema Nodusum

1. General: an acute inflammatory/immunologic reaction of the subcutaneous fat characterized by painful, tender red nodules on the legs 2. Epidemiology: Ages 15 to 30 years; females > males 3. Etiology: a. Infections - Streptococci, Upper respiratory infection, Tuberculosis, Psittacosis, Yersiniosis, Lymphogranuloma venereum, Cat-scratch disease, Coccidioidomycosis b. Drugs - Oral contraceptives, Sulfonamides, Bromides c. Systemic illnesses - Sarcoidosis, Inflammatory bowel disease, Hodgkin's disease d. Pregnancy 4. Constitutional symptoms: Fever, malaise arthralgia (50%) 5. Labs: Throat culture, ASO titer, CXR 6. Treatment: Self limited, potassium iodide, Salicylates, Prednisone

Herpes Simples HSV-1 HSV2

1. HSV1 (usually oral infections) & HSV2 (usually genital infections) 2. Can commonly be an asymptomatic infection 3. Transmission is by contact or airborne 4. Clinically: 3-7 days after exposure, tenderness, pain, parasthesias develop as prodrome. May be associated with headache, myalgias, fever and lymphadenopathy. Next, grouped vesicles develop on an erythematous base 5. Lesions develop into cloudy pustules and then crust over in 5-10 days. 6. HSV then enters nerve endings and becomes latent within the dorsal root ganglia 7. Recurrences due to trauma, UV light, menses, illness, stress; usually occur 2-3 times per year; if greater than 6 times per year, prophylactic therapy should be undertaken tx: Acyclovir (Zovirax), Valciclovir (Valtrex), Famciclovir (Famvir)

HIATUS HERNIA 1A 1-6

1. Herniation of the stomach upwards into the chest through the diaphragm due to weakness in diaphragm. >50 2. aex: pressure on abdo from pregnancy, relaxed LOS, alcoholism, smoking, excess alcohol -coffee/choc --> LOS relaxation . 1. Sliding (95%): gastroesophageal junction and some of the stomach are displaced above the diaphragm, no symptoms. 2. Paraesophageal (5%): gastroesophageal junction remains below the diaphragm but the fundus herniates into the thorax, can lead to strangulation. 3. Mixed: rare features: asymptomatic, GORD Ix: endoscopy, GORD, CXR, Rx: life style changes, antacids ad alginates ( form foam barrier), PPIs, surgery.

Ramsey Hunt's Syndrome

1. Herpes zoster of the geniculate ganglion 2. Triad of facial nerve paralysis, vesicles in or on the pinna, and deafness auricular pain, vertigo, tinnitus

Herpes zoster opthalmicus

1. Herpes zoster of the opthalmic division of the trigeminal nerve 2. Vesicles involving the tip or side of the nose, due to nasociliary nerve branch involvement is known as Hutchinson's sign 3. This is an ocular emergency due to anterior uveitis and should be seen by Opthalmologist

TOXIC NODULAR GOITRE

1. Hyperthyroidism arises from a multinodular goitre which autonomously functioning thyroid nodule which secretes T3&4. common in OLDER women S&S: hyperthyroidism symptoms AND possible DYSPHAGIA Ix NO anti-tsh antibodies patchy uptake of iodine -Low TSH and high T3/4

Primary sclerosing cholangitis 2B

1. Idiopathic Progressive inflammation and fibrosis of the bile ducts ➡ obstructive jaundice -associated with IBD (80%) >F, young - linked to cholangiocarcinoma and uc, hiv PRESENTATION: PSC Pruritus (cholestasis) Jaundice Cholangitis ( recurrent episodes), Cirrhosis ( biliary) eventually RUQ pain BG of UC fatigue Ix: ERCP: multiple biliary strictures giving a 'beaded' appearance MRCP: dilatation of bile ducts raised bilirubin and LFTs ANCA maybe positive rx- ERCP with dilation and stenting of strictures. Liver transplant.

coeliac disease 1B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. IgA mediated chronic Autoimmune inflammation of the small bowel due to gluten (prolamin and gliadin) intolerance. cytotoxic T-cell infiltration of lamina propria -> apoptosis of enterocytes villous atrophy, crypt hyperplasia. - associated with small bowel lymphoma , osteomalacia and osteoporosis - Leads to malabsorption - Associated with HLADQ2, HLAB8, HLADR3, HLADR7 and HLADQ8 - Gluten is found in wheat, barley, rye and sometimes coeliac patients also react to oats - Family history is common associated w 3/4 - Steatorrhoea, foul smelling -"frothy stool" - Abdominal pain, bloating, distension, vomiting. - Weight loss - Fatigue - Delayed growth and short stature OE/ - Angular stomatitis - Aphthous ulceration -dermatitis herpetiformis Ix - 1st line : ANti TTG (IgA) - second line : GLiadin and endomysial antibody (IgA) - Endoscopy with duodenal biopsy (whilst patient is still eating gluten 6 weeks) -IgA depleted - Bloods - anaemia, hypocalcaemia, vitamin D deficiency - DEXA for osteoporosis - Positive anti-tissue transglutaminase, - biospsy: villous atrophy, crypt hyperplasia., increase in intraepithelial lymphocytes, lamina propria infiltration with lymphocytes Rx diet treat deficiency complication - Iron deficiency - pallor (haem iron is absorbed in the duodenum) - Folate deficiency (folate is absorbed in the jejunum) --> hyposplenism - B12 deficiency (absorbed in the terminal ileum) - Vitamin D and calcium deficiency - coeliac crisis: - Life-threatening dehydration due to severe malabsorptive diarrhoea, Rare in developed countries - Autoimmune thyroid disease - T1DM - Vitiligo - Addison's diseasechronic folate deficiency, - IgA deficiency - Down's, William's and Turner's syndromes - Autoimmune liver disease - dermatitis herptiformis hyposplenism- dye to chronic folate deficiency,

MESENTERIC ISCHAEMIA

1. Infarction of bowel tissue due to obstruction of superior mesenteric ( usually) artery usually due to embolism. potentially necrosis. - older people >70 2. AF or CV disorder , HTN, hypercoagulable 3. occlusion to blood flow in the abdomen 4/5: sudden severe colicky abdo pain and bloody stool ( red-currant jelly ) may be pyrexial. pain out of proportion w/ findings Ix - CT angio gold standard -USS or MRI - lactate - raised -amylase -CRP - normal or raised -FBC: ⬆WCC NB: can be chronic which is rare Rx -fluids + oxygen NG tube -abx IV heparin Complications: death , sepsis

OPTIC NEUROPATHY/ATROPHY

1. Infarction of the optic disk thus lack of blood to optic nerve 2 which can be arteritic or nonateritic, characterised by painless loss of vision . acute ischaemia causes nerve oedema, which further worsens ischaemia. a. non arteritic comon in >50+ , hard to treat. atherosclerosis followed by hypotension may be a cause in non-arteric b. arteritic, linked to GCA-> claudication etc.... vision is not restored bu protects other eye. >70+ s/s: sudden painless vision loss evidence of optic neuropathy (disc edema or pallor) decreased vision, +APD GCA signs Ix ESR, C-reactive protein, and CBC CT or MRI if vision loss is progressive Rx steroids in GCA high dose

DACRYOCYSTITIS 1A 1-7

1. Infection and inflammation of the lacrimal excretory system(lacrimal sac/duct) due to blockage of nasolacrimal duct. usually staph or strep 2. presents with pain, redness, swelling and severe epiphora , sometimes decreased visual acuity , purulent discharge. 3. Ix - culture send to microbiology -CT scan of orbit and paranasal sinuses -A dacryocystography (DCG) may be performed where structural abnormalities are suspected. 4. Tx-supportive care of warm compresses and antibiotics(oral/Systemic) *CHILDREN* - co-amoxiclav or cefaclor + top clor 1% *ADULTS* - co-amoxiclav or cefalexin (although be guided by microbiology results. + top cloramph 1% - INCISION and drainage in chronic cases - can cause fistula so avoided -dacryocystorhinostomy

BRONCHIOLITIS + hospitalisation 1A

1. Infection of bronchioles with RSV --> mucus build up and necrosis, damage to mucociliary escalator -> obstuction. kids <2, seasonal winter and autumn. common cause of obstructive LRTI in kids 2. AEx and RFs a. underlying lung resp and heart dz b. premature, not breastfed c. exposure to smoke d. downs 3/4: cough, coryza, congestion, crackles,/wheeze, cyanosis , wheeze, tachypnoea, fever 5. Ix CXR: normal, consolidation, collapse, hyperinflation pulse oximetry c. swabs RSV PCR 6. Rx a. supportive.: fluids, oxygen, analgesia (paracetamol) b. severe: oxygen, NGT feeding, bronchodilators ( salbumatol, ICS) , Ribavirin prednisolone if wheezy Indication for hospitalisation - Respiratory distress : severe tachypnoea, apnoes , Sats <92% , RR >70, chest retraction, reduced feeding , weight loss 7. prevention: IgG vaccination ( synagis) breast feed, handwash complication atelecatsis in immature lungs hyperinflation , pneumonia, asthma

Labyrinthitis 1A

1. Infection of labyrinth which may be viral or bacterial . causes sensorineural hearing loss Sudden onset of severe vertigo, vomiting and nausea. follows URTI 2. caused by viral infection which irritates vestibular nerve AEx: Viral ( HIV, MMR, CMV, VZV) , bacterial( Trepona pallidum, H.influenza, Staph, Strep, NIsseireia) Features: - sudden severe vertigo worse on head movement , hearing loss, tinnitus ,nystagmus, N&V, otorrhea, *sensorineural hearing loss- impairment not completely deaf * Ix: audiogram, rinnes, webbers' tests CT to r/o mastoiditis i Rx: prochlorperazine,promethazine, cyclizine, , dark room , steroids

Threadworms A

1. Infection with intestinal nematode Strongyloides stercoralis 2. transmission: larvae penetrating skin --> migrate into tissue via venus system to lungs and then migrate to airways and swallowed. Features: asymptomatic, abdo pain, N&V, diarrhoea weight loss due to malasbsorption perianal itching, particularly at night girls may have vulval symptoms chronic GI and skin complaints and asthma-like symptoms Wheezing, cough, abdominal pain, diarrhoea, N&V, rash, eosinophilia Hyperinfection syndrome Fever sepsis meningism Ix: sellotape to perianal area larvae in stool or small bowel content or sputum, FBC Rx: 1. Membendazole 2. ivermectin 3. albendazole

Rabies 2B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. Infection with rabies RNA rhabdovirus causing acute encephalitis 2. More common in rural areasof africa and asia, commonly affecting kids. 3. virus mainly transmitted through dog bites but also bat saliva, dogs, cats 4/5: - Prodrome of fever, headache, agitation -depression, , followed by agitation, excessive salivation, and hydrophobia provoking muscle spasms -Negri bodies: cytoplasmic inclusion bodies found in infected neurons Ix: saliva PCR, viral culture, CFS cytology bio, and IgM and IgG Rx: Isolation, wound cleansing, immunisation, rabies IgG, palliative --> haloperidol

Mumps/Parotitis 1A

1. Infectious illness caused by RNA paramyxovirus, spread by resp droplets Common in school children (5-15 yrs ) , in countries w/out vaccine 2-5 yrs characterised by bilateral swelling and inflammation of parotid glands at jaw angle ( parotitis) , ear ache, sore testicles Serious complications include meningitis, encephalitis, and orchitis even in absence of parotitis. Ix: salivary mumps IgM, FBC, PCR Rx: isolation + supportive care, notifiable dz mnemonic potems Paramyxovirus, parotid glad swelling , PCR (dx) Orchitis Testicular pain Encephalitis , ear ache Meningitis, Salivary IgM Complications of Mumps: - Viral meningitis - Encephalitis - Orchiditis - Oophoritis - Pancreatitis - Thyroiditis - Sensorineural deafness - Ophthalmitis - Arthritis - Myocarditis - Nephritis

LARYNGITIS 1A

1. Inflammation of larynx resulting in oedema of true vocal cords a. Acute < 2 weeks b. chronic > hoarseness lasting >3 weeks, R/O malignancy 2. AEx a. viral: rhinovirus, then parainfluenza virus, respiratory syncytial virus, influenza, and adenoviruses b. bacterial: Group A Streptococcus -Haemophilus influenzae, Streptococcus pneumoniae , Staphylococcus aureus , and Klebsiella pneumoniae c. mechanical acute voice strain --> submucosal hemorrhage --> ocal cord edema --> hoarseness d. environmental: toxic fume inhalation 3.symptoms: URTI symptoms, hoarseness, aphonia, cough attacks, ± dyspnea 4. signs: true vocal cords erythematous/edematous with vascular injection and normal mobility, feverodynophagia, cough, fever, and respiratory distress 5. Ix: laryngoscopy, cultures, biopsy during laryngoscopy, fbc 6. rx a. airway maintenance + supportive care b. rest and hydration c. abx if bacterial: phenoxymethylpenicillin, erythromycin d. dipthria-> isolate, abx, dip antitoxin

ISCHAEMIC COLITIS 1B 1. def & path 2. Causes & risk factors 3. Signs and symptoms 4. investigations 5. Management

1. Insufficient blood supply to the colon, resulting in ischaemia. commonly occurs in left colon, particularly the "watershed" area at the splenic flexure. supplied by the IMA L3 2. risk factors /causes -Old age -AF- clots -Atherosclerosis - clotting disorder - hx of smoking 3. S&S - sudden severe abdo pain in LLQ - blood in stool/ bloody diarrhoea -N&V - pain exacerbated by eating or exertion --> increased blood flow -fever Ix -CT scan with contrast - shows thickened bowel wall with atherosclerosis. (gold standard) - Colonoscopy - shows pale mucosa with petechial bleeding. extent of necrosis - AXR: thumb pritinng -CRP -FBC: raised WCC -raised lactate Rx - Supportive therapy with bowel rest, IV fluids and broad-spectrum ABs (cef and met). most recover w/ conservative management - enteral nutrition -Surgical bowel resection is indicated for infarction, fulminant colitis and obstruction. 5. Rx - Supportive therapy with bowel rest, -IV fluids and emperic Abx (cef and met). - enteral nutrition -bowel rest -Surgical bowel resection is indicated for infarction, fulminant colitis and obstruction.

SECONDARY HYPERPARATHYROIDISM 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. Involves an appropriately increased secretion of parathyroid hormone in response to hypocalcaemia a. CKD --> ⬇ active Vit D + ⬆ phosphate ( causes hypoca+) ➡ hypocalcaemia --> ⬆ PTH secretion 3. signs and symptoms of h*HYPOcalcaemia* *CATS go numb* -coma, arrhythmia, tetany, spasms, numbness, perioral anaesthia INVESTIGATIONS - Low calcium - Low vitamin D - Raised PTH - Raised phosphate -U&Es -eGFR, creatinine -X-ray Rx - Increased fluid intake - Parathyroidectomy( SE hypoparathyroidism, recurrent laryngeal nerve palsy, hungry bone syndrome) definitive treatment - Bisphosphonates - Management of hypercalcaemia

HAEMOCHROMATOSIS 2B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. Iron overload in which heamosiderin accumulates in the liver, pancreas, heart, adrenals and pituitary 2. affects 9-10% N americans and N europeans 3.. Primary: autosomal recessive causing mutations in the HFE gene resulting in excessive absorption of dietary iron. Secondary: in patients receiving chronic transfusion therapy 3/4 "Haemochromatosis Can Cause Deposits Anywhere seriously ": Hypogonadism , hyperpigmentation Cancer (hepatocellular) Cirrhosis (liver ) Cardiomyopathy- dilated and restrictive, , HF Diabetes mellitus, depression , dysfunction (erectile) Arthropathy, Atrophy (testicular) Ix IRon studies: ⬆ iron & ferritin ⬇ transferrin ( iron bound) liver biopsy -genetic testing -molecular genetic testing for the C282Y and H63D Rx - venesection is first line ( regular) , iron chelating agents ##9desferoxamine) avoid red meats.

AGE-RELATED MACULAR DEGENERATION 2B

1. Loss of or blurred central vision, due to sclerosis of arteries supplying retina. - leading cause of blindness in elderly in developed countries - Dry and Wet DRY ARMD- non serous- atrophic degeneration -90% cases -causes atrophy of the retinal pigmentation(RPE) -Atrophy later causes hemorrhage and fibrosis - drunsen spots WET ARMD - serous fluid and haemorhage -10% - rapidly progressive marked loss of vision. occurs through stages: Stage of drusen formation Stage of retinal pigment epithelium (RPE) detachment, Stage of choroidal neovascularisation (CNV) ( Stage of haemorrhagic detachment of RPE Stage of haemorrhagic detachment of neurosensory retina, and Stage of disciform (scarring) macular degeneration. Features: distorted viformation. lines occurs wavy, bent, fuzzy- metamorphopsia. difficulty reading sion due to central shadowing due to drusen fundoscopy: drusen, pale areas in retina, irregular or clustered pigmentation Ix -fundus fluroscein and indocyanine green angiography help in detecting choroidal neovascularization (CNV) in relation to foveal avascular zone. -distortion of line perception may be noted on Amsler grid testing Rx none? antioxidants for prevention

PARALYTIC ILEUS

1. Loss of peristalsis without structural obstruction RF: Recent surgery or GI procedure, severe illness, immobility, hypokalaemia, hypothyroidism, diabetes, meds that slow GI motility ie. opioids 2. FEATURES: Diffuse, constant abdo discomfort, nausea, vomiting, absence of flatus or bowel movements Diffuse tenderness, distension, decreased/absent bowel sounds IX CXR: Distended loops of small and large bowel with air seen throughout the colon and rectum RX Stop the drugs causing slow motility, rest the bowel: temporarily decrease or stop oral feeds, bowel decompression: NG decompression, supportive fluids and electrolyte replacement

METABOLIC ACIDOSIS (high) 1B

1. Low base-excess and low bicarb, low pH Anion gap = Na - (Cl+ HCO3) = ~9MeQ 2. AEx causes: ( Production of acids in body, ingestion of acids, excessive loss of HCO3-) * G — glycols (ethylene glycol (antifreeze) & propylene glycol) * O — oxoproline, a metabolite of paracetamol * L — L-lactate * D — D-lactate * M — methanol * A — aspirin, addisons * R — renal failure: tubular acidosis not excreted i.r uric acid * K — ketoacidosis, ketones generated from starvation, alcohol, and diabetic ketoacidosis Ix ABG U&Es

MESOTELIOMA 2B

1. MALIGNANt tumour of mesothelium ( lines pleurae) resulting in fibrosis, pleural thickening --> restrictive lung defects 2. AEx: exposure to asbestosis 3/4: SOB, cough, haemoptysis, weight loss, sweating Ix CXR CT biopsy cytology fluid

Pseudofolliculitis Barbae

1. Mechanical irritation due to foreign body reaction of hairs "ingrowing" after shaving 2. Typically seen in individuals with curly hair who like a close slave 3. Treatment is to dislodge the ingrown hair, antibiotics, and moisturizing shave gels to soften hair prior to shaving, can also use lasors

NASAL CANCERS

1. Most SCC ~80%, then adenocarcinoma. >50, rare 2. wood, shoes, hardwood dust, air pollution, chronic rhinosinusitis 3. features : Unilateral nasal obstruction Epistaxis, rhinorrhea 4. Ix: CT/MRI Biopsy

ACHALASIA 2B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. Motility disorder of the esophagus characterised by impaired relaxation of the lower esophageal sphincter and loss of peristalsis in the lower 2/3 of the esophagus, SCC risk factor 2. Onset usually 20-30 YO 2. AEx: degeneration of the ganglia in the distal oesophagus and LOS (related to disturbed nitric oxide synthesis). 3/4: difficulties swallowing liquids and solids, regurgitation and nocturnal cough , weight loss , chest pain Ix -barium swallow - birds beak -manometry - definitive dx , LES pressure increased , incomplete or absent sphincter relaxation - endoscopy to R/O mucosal pathology Rx Short term: nitrates, calcium channel blockers or botox into the LES. Long term: pneumatic balloon dilation or surgical myotomy. DDx esophageal spasm, trypanosomiasis(Chagas's disease), and pseudoachalasia

HYPONATRAEMIA 1A

1. NA+ <135 mmol resulting in osmolality <135 hypovolaemic, euvolumaec of hyper volumic 2. AEx Hyperlipidaemia Hypovolaemic urine >20mmol: diuretic, addison osmolar diuresis urine <2ommol: diarrhoea, vomiting, sweating, burns , CF, SBO Hypervolaemic nephrotic syndomr, CHF, cirrhosis, renal failure Urine osmolality >100mmol: SIADH, water overload, hypothyroidism, adrenal insufficiency Drugs: vasopressin, diuretics, antidepressants (ssris), opioids Pseudohyponatraemia: - Normal plasma osmolality (solute is unchanged), Artefactual result due to hyperlipidaemia or high protein content artefactual: sample from drip arm, hyperglycaemia 3/4 Stupor/Coma Addison's Lethargy Tendons ( hyporeflexia) Loss: DnV, sweating, burns Orthostatic Hypotension Seizures/headaches SSRIS SIADH Ix -U&Es inc Na+,K+, glucose, creatinine -serum Osmolality: <275mmol/kg ( hypotonic) , >295 (hypertonic) -Urine osmolality : >300mmol - SIADH, <100mmol - polydipsia - Urine Na+ >20mmol/L urinary loss -TSH -cortisol -lipids Rx chronic: isotonic fluid acute: hypertonic saline (3%) treat underlying cause) hyper: fluid restriction , loop diuretic Rapid correction of hyponatraemia can cause osmotic demyelination syndrome

spinal stenosis 2B

1. Narrowing of spinal canal causing nerve compression. degenerative, manual labour, >40. 2. Degeneratiive, slipped disc , bone dz, tumour Clinical presentation: Lumbar (75%) : back pain aggaravated by standing relieved by sitting , scieatica, numbness, tingling, ache in buttocks/legs , foot drop. incontinence. neurologic cludication Cervical: neck pain, weakness, paralysis Thoracic: rare o Examination often unremarkable with lack of clinical findings o Often hyporeflexia

DIABETIC NEPHROPATHY

1. Nephrotic syndrome due to thickening and lesions that occur among the glomeruli including proliferation of mesangial cells and sclerosis due to chronic glucose exposure.. 2. results in Kimmelstiel-Wilson nodules.

CHRONIC LYMPHOCYTIC LEUKAEMIA 1B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. Non-HL. chronic malignant proliferation of mature lymphocytes in blood.99% are B-cells - occurs commonly in . >60-80 YOs , M:F (2:1) (CD5, CD19, and CD20, CD23) 2. Unknown. familial symptoms: - asymptomatic 70- 80% -discovered on routine FB - weight loss -B-symptoms. massive splenomegaly lymphoadenopathy, Ix 1. blood film: *Smudge cells* 2. immunophenotyping 3. LDH increased 4. abnormal LFTs 5. FBC: thrombocytopaenia , high wcc Rx: 1. asymptomatic: observation Ibrutinib - labetalol for BP whilst awaiating diagnosis complications - hypogammaglobulinaemia leading to recurrent infections - *warm autoimmune haemolytic anaemia* in 10-15% of patients - *transformation to high-grade non-hodgkins lymphoma (Richter's transformation)*

SIGNS & cuses OF RAISED IOP 2B

1. Normal: 10 - 21 mmHg 2. persistently elevated IOP is called ocular htn SIGNS - corneal oedema -visual loss/ visual defect - eye pain causes - blockage of mesh worrk, caal of schelmm -trauma -excessive production of aueous humour -drugs- i.e stroids -other eye conditions

EPISTAXIS 1B

1. Nose bleed 2 Aex a. Trauma: fractures, digital, foreign body b. iatrogenic: nasal, sinus, orbit surgery c. Dryness: septal deformitis, dy air d. Tumours: benign- polyps, inverting papilloma, angiofibroma , malignant : SCC, esthesioneuroblastoma (olfactory neuroblastoma) e. chemical : cocaine, nasal sprays, ammonia, etc. f. systemic: meds (NSAIDs, anti-coags), haemophilias, coagulopahies, liver failure, uraemia, Haematological disease - beware ALL in children , htn, Ix: -Anterior rhinoscopy and rigid rhinoscopy -FBC, cross-match, clotting profile -ABC approach with resuscitation (IV fluids if necessary) and suction of blood -Compression of Little's area -Breathe through the mouth -Sit upright -Tilt head forwards -Spit and catch blood in a container or bowel Further steps in first aid measures fail: -Lidocaine then silver nitrate stick cautery - topical naseptin cream for 2 weeks afterward -Anterior nasal packing with MEROCEL or rapid rhino nasal tampon -Posterior nasal packing and balloon tamponade -Surgery - cautery with diathermy, ligation or clipping

BRANCH RETINAL ARTERY OCCLUSION (BRAO) 1B

1. OCCLUSION of retinal branch artery usually due to embolus or arteritis, results in permanent visual field defect in affected area 2. AEx ▪emboli: fat, plaques, atrial myxoma ▪thrombosis - due to GCA, SLE - common in HTN and CV dsiseases - Raised IOP - more common in males than females - usually unilateral 3/4 ▪sudden painless unilateral severe loss of vision ▪poor or absent pupillary light reflex 5. Ix ▪fundoscopy : pale opaque fundus w/ red fovea, sometimes emboli visible, retina becomes milky white, narrow arteries ▪cherry-red spot in macular area/pale retina 6. Rx 1. immediate lowering of IOP: ocular hypoensives- timolol, acetazolamide

ORBITAL CELLULITIS : 1-6 1A

1. ORBITAL: Infection of muscles and fat within the orbit, posterior or deep to the orbital septum, not involving the globe. - can cause cavernous sinus thrombosis -> death PERIORBITAL: inflammation and infection of the superficial eyelid- usually superficial source 2. usually due to bacterial sinusitis (s. pneumoniae, s.aureus, s.pyogenes) , Hib, trauma, 3. Sx - Periocular pain, double vision, pain with eye movement, restricted eye movement, decreased vision (can lead to blindness!), fever, malaise 4. Signs - Violaceous discoloration. hyperemia and chemosis, decreased intraocular movements, proptosis, tense eyelids. 5. Ix- temp, FBC< blood culture, CT (orbit, sinus, brain), MRI 6. IV abx cefuroxime or ceftriaxome 1-2g BD

ACUTE ANGLE CLOSURE GLAUCOMA 1B

1. Obstructed anterior chamber angle resulting in imbalance f of production and removal of aqueous humour ➡ sudden increase in IOP 2. - Has a closed or narrow angle between the iris and cornea RF: black, HTN, DM, FH 3/4 features 1. severe ocular pain , redness, decreased vision, coloured halos around lights 2. headache, nausea, vomiting. 3. elevated IOP 4. fixed dilated pupil 5. elevated IOP 6. corneal oedema 5. Ix ▪Assess visual fields ▪stereoscopic slit lamp biomicrosopy: assess optic nerve & fundus ▪tonometry ▪measure corneal thickness ▪ * TRIAD OF:Injected conjunctiva, cloudy or "steamy" cornea, and fixed dilated pupil* 6. Rx ▪!st line: prostaglandin analogue (Latanoprost, travoprost, bimatoprost) ▪also 1ts line: BB blockers ( timolol oph, carteolol oph, metipranolol) others: carbonic anhydrases: brinzolamide, dorzalaminde, a-2 agonists, surgery

PULMONARY EMBOLISM 1A

1. Obstruction of part of or the entire, pulmonary vascular tree, usually caused by thrombus from a distant site, usually DVT 2. AEx Virchow's triad 3/4 Tachy, hypotension, pleural rub, JVP, SOB, haemoptysis , tracheal deviation , pleuritic chest pain. Ix ABCDE: oxygen 1. Wells score >4, CTPA, Treat 2. Bloods: D-dimer, CRP, INR, U&Es (baseline for anticoags), LFTs 3. ECG; S1, Q3, T3 , RBBB, RV strain , normal Rx 1. LMWH Heparin: 80units/kg/hr IV bolus followed by 18units/Kg/hr every 12 hrs 2. start warfarin after 5mg for 3 months (INR 2-3) - thrombolysis : alteplase/reteplase OR embolectomy, or catheter LOWRISK RIVAROXABAN 15mg BD for 3 weeks then 20mg BD until 3 or 6 months MASSIVE PE Alteplase 50mg stat IV (if imminent cardiac arrest) or 10mg stat IV then 90mg infusion over 120mins

CONGENITAL CATARACTS 2B

1. Opacification of the lens in newborns, bilaterall and symmetrical - punctate: small dots on iris -zonular- specific zones 2. AEx: The common causes are hypoglycemia, trisomy (eg, Down, Edward, and Patau syndromes), myotonic dystrophy, infectious diseases (eg, toxoplasmosis, rubella, cytomegalovirus, and herpes simplex [TORCH]), and prematurity. 3/4 - white reflex on ppupil, black opacity against red background 5. Ix -eye exam -B and A scan ultrasonography - full metabolic workup, genetic testing, and testing for infections -FBC, LFTs, UEs, Rx none -myiadrisis with atropine iridectomy lens aspiration lensectomy

Chancroid

1. Organism: Gram meg rod, H. ducreyi MALES!! Incubation 3-5 days Presentation: PAINFUL!! - ulcer with painful lymphadenopathy LABS: Show "School of Fish"

Diverticula disease, Diverticulitis, Diversticulosis 1A

1. Outpouching of the mucosa and submucosa that herniate through the colonic muscle layers in areas of high intraluminal pressure (typically sigmoid colon)- diverticular dz is when they cause symptoms 2. Diverticulosis: presence of outpunchings , >40 3. diverticulitis: acute Inflammation and micro-perforation of a diverticula secondary to fecalith impaction AEX -Low-fibre and high-fat diet (obsesity) - age (>80) - connective tissue disorders -High alcohol, caffeine and red meat intake -Steroids -NSAIDs -Saint's triad of hiatus hernia, diverticulae and gallstones signs and symptoms a. Diverticular dz: symptoms from it b. Diverticulitis: LLQ colicky pain, fever, leucocytosis, occult blood in stool, diarrhoea c. Diverticulosis: Asymptomatic until patients present with sudden, intermittent, painless bleeding Ix - CT scan: outpouchings - Colonoscopy : definitive diagnosi - bloods: FBC, urea -AXR -Cytoscopy : tumours Rx - High-fibre diet or fibre supplements - NG tube - Infective: cefuroxime OR cipro PLUS MEtronidazole -surgery if complex : hartmas procedure with colon resection + colostomy and rectal stump --> colostomy reversal in 3-6 months) - drainage and sigmoid colectomy BLEED Transfuse and rehydrate as needed. If bleeding does not stop spontaneously can do colonscopy with haemostasis, angiography with embolisation or surgery

Complications of Zoster

1. Post herpetic neuralgia (PHN) a. Pain at the site of Herpes zoster eruption that persists months or years after it has healed b. Pain can be sharp and severe in nature c. Older patients more likely to get PHN 2. Disseminated Herpes zoster - occurs in immunocompromised patients and can be fatal 3. Motor paresis can occur, and is usually temporary 4. Encephalitis - is rare, but can occur especially in immuno- compromised patients

Giardiasis diarrhea/GIARDIASIS

1. Prolonged, non-bloody diarrhoea lasting few weeks to months caused by protozoa giardia lamblia Features: -fatigue, cramps , weight loss and fever - causes fat malabsorption so faeces float in toiler , greasy stool - resistant to chlorination, hence risk of transfer in swimming pools. Ix -stool sample - ask about travel in diarrhoes Rx Metronidazole

Ecthyma Gangrenosum

1. Pseudomomas aeruginosa infection of the skin from a blood-borne, metastatic, or primary lesion 2. Rare disease, but mortality can occur 3. Associated with immunocompromised patients (Cancer, immunosuppressives, malnutrition, diabetes, burn patients) 4. Clinically: hemorrhagic pustules coalescing to gangrenous ulcerations 5. Treatment: Antibiotics after proper cultures; wound care, mortalityrate 15% for bacteremic form

PTERYGIUM 1-6 1A

1. Pterygium is benign, wing-shaped growth of conjunctival tissue, which grows from the nasal side towards the cornea. It will grow over the cornea and affect vision. It is very vascular. ▪F>M, ⬆ elderly, non white 2. excessive sun exposure, working outdoors; and exposure to dust, allergens, and noxious chemicals. 3/4. - sensation of FB - Dryness of the eye and the sensation of a foreign body - Inflammation, ocular discomfort, and tear flow if irritated by air pollutants or dust - Possible obstruction to vision if left untreated - recurrence rate is high with surgery Ix - slit lamp -fluorescein staining Rx -artificial tears - steroid drops -surgery

Hepatitis D

1. RNA delta Ag, parenteral, sexual and vertical transmission route 2. causes HCC and Chronic prevention - hbv vaccine -NEEDS HEP B , causes hepatocellular carcinoma this cannot replicate without the presence of hbv HBsAg Features: abdo pain, nausea, vomiting, fatigue, fulminant hepatic failure, chronic liver disease, cirrhosis and hepatocellular carcinoma rx pegylated interferon alfa and liver transplantation, which can be curative. Management is otherwise supportive.

Hepatitis 1. type 2. transmission 3. presentation : signs and symptoms 4. Ix 5. Rx

1. RNA virus 2. faeco-oral route mainly uncooked pork , unclean water . developing countries 3> FEatures: anorexia, fever, malaise, N&V, jaundice. RQU pain. *Deadly in pregnant women* 4. Ix: antibody testing. 5. Rx Treatment is supportive.

NASOPHARYNGEAL CARCINOMA

1. SCC of nasopharynx , common in southern china . otherwise rare 2. AEx: EBV mono, with atypical lymphocytes 3/4: unilateral serous otitis media, epistaxis, nsal obstruction, discharge CN III-VI palsies

WHAT IS SIADH ? 1B

1. SIADH is inappropriate ADH secretion characterised by hypotonic hyponatraemia, concentrated urine, and a euvolaemic state.secondary to the dilutional effects of excessive water retention. NB: ADH causes water retention at DCT and collecting duct. where water reabsoption takes place. by producing more aquaporins which allow water to move into cells. ---> concentrated urine. - also causes vasoconstriction less ADH --> no aquaporins open---> less water reabsorption --> dilute urine excreted water goes out ADH usually released at increased plasma osmolality in SIADH ADH is released even when osmolality has decreased. water dilutes other solutes in blood lien Na. Results in increased water in body --> aldosterone stops being released --> excretion of Na and water

2A URETHRITIS

1. STD that presents with dysuria, urethral discharge (classic physical finding), and/or pruritus at the end of the urethra.. ◾M>F ◾15-24 YOs, ◾ MSM 2. aetiology #1 gonococcal, Chlamydia trachomatis ,Mycoplasma genitalium , and Ureaplasma urealyticum 3. urethral dx, orchalgia, pruritis, dysuria Ix: gram stain, culture of discharge, HIV test, NAAT , VDRL ( syphilis) Rx: Doxy or Erythromycin (pregnant) refer to GUM

Complications of Chicken Pox

1. Secondary bacterial infection is most common complication, which can lead to scarring 2. Encephalitis, usually complete resolution in children, mortality rate of 35% in adults 3. Reye's syndrome - an acute encephalopathy associated with = hepatitis in which 20% are associated with varicella; Salicylate used during varicella may increase this risk 4. Pneumonia- most common serious complication in adults, butfatalities are rare

Allergic Phases

1. Senseitization- hapten (lower molecular weight substance) combines with skin proteins and stimulated T cell production over 5-10 days 2. Elicitation- Re-exposure to antigen causes Tcell activation and release of lymphocytes leading to inflammation over 12-48 hours 3. Cross sensitization- a hapten or allergic substance may induce inflammation because the body recognizes it as a previously sensitized molecule, without prior exposure (posion ivy & raw cashews )

ANKYLOSING SPONDYLITIS 1B

1. Seronegative polyarthritis 1b. Fibrosis, ossification then fusion of vertebra. SPine sacroiliac joint first affected 3. HLA-B 27 , YOUNG (20-40) - M> F AEx: genetic S&S ▪nocturnal back pain and stiffness worse in morning improves w/ exercise ▪Chest pain due to enthesis dyspnoea due to reduced chest expansion ▪Kyphosis Other features: (the A's) Apical fibrosis,Amyloidosis Anterior uveitis/iritis Achilles tendonitis Aortic regurgitation, AV node block Others cauda equina syndrome peripheral arthritis (25%, more common if female) Ix CXR Antibodies ESR, CRP x-ray of the sacroiliac joints sacroilitis: - subchondral erosions, sclerosis - squaring of lumbar vertebrae - 'bamboo spine' (late & uncommon) - syndesmophytes: due to ossification of outer -fibers of annulus fibrosus - Squaring of vertebral bodies Examination - reduced lateral flexion - reduced forward flexion - Schober's test - reduced chest expansion Rx -referred to rheumatology exercise: swimming , physio first line: nsaids ( 2 BEFORE TNF) Second line: TNF-alpha blockers (infliximab and etanercept) -steroid injections -bisphosphonates sulfasalazine (DMARD)

What are the 3 types of hiatal hernia

1. Sliding (95%): gastroesophageal junction and some of the stomach are displaced above the diaphragm, no symptoms. 2. Paraesophageal (5%): gastroesophageal junction remains below the diaphragm but the fundus herniates into the thorax, can lead to strangulation. 3. Mixed: rare

SMALL BOWEL OBSTRUCTION 1B

1. Small bowel obstruction (SBO) is a mechanical disruption in the patency of the gastrointestinal tract. 2. can be partial (only a portion of intestine is occluded, allows passage of some gas & fluid, less likely to be strangulated) and closed-loop obstruction ( i.e voluvulous) 2. Causes/ RF *Intraluminal*: intussception, gallstones, Bezoars, constipation *Intramural*: chrons, radiation stricture, cancer *extramural*: adhesions, hernia, peritoneal carcinomatosis *3. Signs and Symptoms* ▪colicky abdominal pain, guarding. ▪rebound tenderness in perforation ▪vomiting faeculent matter ▪Abdominal distention ▪Abdominal pain ▪High pitched tinkling sounds, later silent ▪no passage of flatus/stool 4. Investigations ▪AXR: Dilated small bowel loops, air-fluid levels, plicae circularis, central location ▪CT : bowel dilation and decompresiion distally ▪bloods: creatinine, u&es, lactate ⬆ (late sign), WBC (necrosis) , low Hb (bleeding) Rx ▪ NBM, IV fluids ▪NG tube for decompression ▪Surgery

Epidermis Layers

1. Stratum Corceum (corneal layer) 2. Stratum Lucidum (lucid layer) thick skin only on the palms and soles 3. Stratum granulosum (granular layer) 4. Stratum Spinosum (spinous layer, prickle cell layer) 5. Straum Basale (Basal Layer) 6. Stratum Germinativum - Stratum spinosum and Stratum Basale

LARGE BOWEL OBSTRUCTION

1. Surgical emergency where a mechanical interruption in large bowel (either complete or partial). - can result in necrosis, perforation or perforation 2. Causes -most (90%) due to cancer - Sigmoid volvulus - Caecal volvulus - Benign stricture (diverticular, inflammatory bowel disease, ischaemic, radiation, anastomotic) Features: CRAMP -Colicky central abdo pain / constipation -Rectal bleeding / emptiness -Abdo distension -Mass ( palpable rectal and abdominal mass, recent weight loss) -Positive faecal occult test -Tinkling -Tenesmus (nausea and vomiting but uncommon) Tenesmus, tinkling on auscultation SILENT bowel sounds in ileus Fever, tachy, severe tenderness perforation/ strangulation Ix - abdo exam: distended, pain, rebound if perf -AXR: Dilated loops ( >6cm) of peripheral bowel with haustral markings which do not cross the entire bowel width - Visible caecal or sigmoid volvulus - Bloods - raised WCC, raised urea, hyponatraemia, hypokalaemia, alkalosis (due to vomiting and dehydration) - Hb - U&Es - Erect CXR to check for free sub-diaphragmatic air (due to perforation) - Abdominal CT - positive occult stoll test Rx - NBM - IV fluids and electrolytes - NG tube decompression - Emergency laparotomy - Sigmoid volvulus - sigmoidopexy, fixation,, sigmoidoscopy to untwist - Caecal volvulus - caecopexy, resection points to right side - Malignancy or diverticular disease - endoscopy and stenting - Sigmoidoscopy

Henoch-Schonlein purpura (HSP) (not on matrix)

1. Systemic IgA small vessel vasculitis seen in children aged 3-10 - More common in boys, in winter -Often preceded by URTI Features: - palpable Purpura on legs - extensor surfaces - buttocks,extensors, ankles, trunk usually spared - urticarial then progresses to amaculopapular purpura that lasts for several weeks - Polyarthritis with periarticular oedema - Abdominal pain with GI bleeding - haematemesis, melena- risk of intussusception, ileus, protein-losing enteropathy - Nephritis with haematuria - IgA and IgG complexes activate complement which is deposited in affected organs - FBC and film: unremarkable - platelets and fucntion fine. -raised ESR Rx analgesia for arthralgia treatment of nephropathy is generally supportive. There is inconsistent evidence for the use of steroids and immunosuppressants self-resolving within a month

MINIMAL CHANGE DISEASE 1-6

1. T-cell and cytokine mediated destruction of podocytes (effacements) ➡ albumin leaks through - common in <10s - commonly follows rti - most respond well to steroids but may have more episodes Causes - most cases are idiopathic - Drugs: NSAIDS, rifampicin - lymphoma and infectious mononucleosis Signs and symptoms - oedema, proteinuria, normotensive* Investigations -proteinuria -hypoalbunaemia -hyperlipidaemia -biopsy- ELECTRON: normal glomeruli or mild mesangial proliferation, electron microscope effacement of podocytes Rx -Steroids : 60 mg/square metre of body surface area/day orally for 6 weeks, followed by 40 mg/square metre of body surface area/day orally on alternate days for 6 weeks -cyclophosphonamide -rituximab NB: affects glomeruli which filter things in and out . usually allow small molecules Na, H20 out . in neprhotic syndrome glomeruli more permeable let large molecules through - hyperlipidaemia : liver compensates by increasing the synthesis of albumin, as well as other molecules including LDL and VLDL and lipoprotein(a), contributing to the development of lipid abnormalities including hypercholesterolaemia and hypertriglyceridaemia Hypercoagulability

BLADDER CANCER 1B

1. TCC 90% , common in males, blacks >60 2. AEx : smoking, aniline dyes, rubber, cycloposphonamide, benzene, pyoglitazone SCC: schistomiasis: foreign person SPread: haematogenous liver (38%), lung (36%), adrenal gland (21%), and bone (27%). 3/4: painless Haematuria, dusuria, voiding problems if late , hydronephorsis, hydroureter. later - cancer sx - pallor, cachexia s-NVH w/ LUTS, hesitancy, frequency, urgency Ix 1. Urine dip and culture 2. FBC: anaemia 3. Cytoscopy + Bx 4. CT Abdo pelvis Rx cystectomy

Trigger Factors for Atopic Dermatitis

1. Temperature changes 2. Low humidity 3. Over Washing 4. Irritants 5. Allergens 6. Super infection (staph aureus etc.) 7. Foods ( eggs, peanuts, milk , fish etc.) 8. Stress

Acute urinary retention causes and Ix 1B

1. Tender distended bladder containing over 500-800 of urine , anuria , suprapubic pain a. presents with palpable bladder, suprapubic pain . unable to empty bladder b. difficulty urination, incomplete voiding, hesitancy, urgency, noctururia, incontinence dribbling, 2. causes OUTFLOW OBSTRUCTION a. Bladder neck or urethra: calculus, clot, foreign body, neoplasm, neurological (DSD) b. Prostate: BPH, prostate cancer c. Urethra: stricture, phimosis, traumatic disruption d. Miscellaneous: constipation, pelvic mass BLADDER INNERVATION a. Intracranial: CVA, tumour, Parkinson's, cerebral palsy b. Spinal cord: injury, disc herniation, MS, cauda equina c. DM d. Post-abdominal or pelvic surgery PHARMACOLOGICAL A. Anticholinergics b. Narcotics c. Antihypertensives (ganglionic blockers, methyldopa) d. OTC cold medications containing ephedrine or pseudoephedrine e. Antihistamines f. Psychosomatic substances (e.g. ecstasy) INFECTION A. GU: UTI, prostatitis, abscess, genital herpes B. Infected foreign body C. Varicella zoster Investigations a. urinalysis b. USS , bladder and renal c. FBC d. CT scan , pyelogram e. PSA f. C abdopelvis Rx Analgesia Catheterise Nephrostomy with stenting Suprapubic catheterisation Tamsulosin For clot retention - 3-way catheter and bladderwashout

What is the ciliary body?

1. The ciliary body is a circular band of muscle that is connected to and sits immediately behind the iris, contains secretory cells 2. Controls lens shape by pulling or relaxing on the lens zonules. 3. Produces aqueous humor which fills the posterior and anterior chambers and provides nutrition for avascular tissues in the eye such as the cornea.

What is the vitreous body?

1. The vitreous body/humour is the clear gel that fills the space between the lens and the retina of the eyeball. 2. makes 80% of eye, keeps eye spherical and clear so that light can get to the retina and vision can begin 3. The gel and its fluid allow oxygen and nutrients to flow from the front of the eye to the back of the eye 4.need constant replacement + has phagocytes which breakdown and remove obstacles/ floaters.

Lung Neoplasms 1B

1. Tumour in the lungs a. SCC : most common (35%) lung cancer from epithelial cells . Men and smokers. cavitating hilar mass . PTH-rp, HPOA, TSH ( hyperthyroidism) b. Adenocarcinoma; 30% , glandular epithelium. not related to smoking. peripheral masses. gynacomastia c. SCLC: from neuroendocrine cells in bronchial tree, aggressive, early mets poor prognosis. mets to liver and bone, brain, adrenals. associated with SIADH( hyponatraemia). Mass in ilar region . ACTH, ADH, Lambert-eaton . HTN, hypokalaemia, 3/4: cogh, sob, chest pain, weight loss hilar cavitating mass , haemoptysis, horners. erosion of first rib, -Pain in the arm radiating to the fourth and fifth fingers signs: monophonic wheeze, supreclavicular lymbphoadenopathy , clubbing Ix 1. CXR - mass 2. CT - OFFERED STRAIGHT AFTER CXR PER NICE GUIDANCE 3. PET : more in SCLC -bloods -sputum cytology -diagnostic tap -USS -MRI -CT head -Bone scan

EPIDIDYMORCHITIS 2A

1. UNILATERAL Inflammation of the epididymis and/or testicle causing pain and unilateral swelling. M sexually active M < 35, 2. AEx a. STD: chlamydia, gonorrhoea in men <35 YO b. UTI : gram -ve in men >35 E.colie, E. faecalis in older people c. catheters , urologic abnormalities d. TUBERCULOSIS, SYPHILIS d. *ORCHITIS* tends to be due to *MUMPS*, nearly always viral --> symptoms 5-7 days after parotid swelling, 3. UTI symptoms: urethral discharge, and fever , hot, tender, dysuria, .a. scrotal pain referred to abdomen and swelling, erythematous b. scrotum: *tender, erythematous, swollen, thick spermatic cord* c. infective signs: Fever, malaise, nausea, headace, myalgia 4. signs: a. tenderness and swelling b. erythema c. positive cremasteric reflex d.positive prehns test 5. Ix a. gram stain of secretions b. dipstick urine c. culture urine and secretions d. NAAT of secretions d. coulour duplex USS ( exclude torsion) e. scrotal USS 6. Rx a. analgesia b. >35: Cipro, doxy, oxaflaxacin c. <35 yo refer to GUM

cryptorchidism 1B

1. Undescended testes through inguinal canals into the scrotum during the 1st trimester, Spontaneous descent may occur in first 6 months but unlikely afterwards. review at 3 months 2. Increases risk of testicular cancer and infertility, torsion and trauma 3. Presents with asymmetrical testes, non palpable testes in scrotum 4. Treated with orchiopexy -> surgical

Frozen shoulder : DEFINITION 1B

1. Unknown - may be due to a neurovascular reflex 2. Primary Adhesive Capsulitis - Idiopathic - often associated with diabetes mellitus; osteoarthritis 3. Secondary Adhesive Capsulitis - due to .prolonged immobilization ("use it or lose it") - "Shoulder-Hand Syndrome" - hand in cast, (voluntary) immobilized shoulder ' - following Ml, stroke, shoulder trauma -common in women 3 Phases: 1. Increasing shoulder pain with increasing stiffness - aggravated by movement and alleviated with rest. - Sleep interrupted if the patient rolls onto the shoulder. 2. Stiffness with some pain - Marked decrease in all active and passive movements (exclude scapulothoracic movement when testing abduction) - MAINLY EXTERNAL ROTATION 3. Recovery phase - minimal pain with progressive improvement in movement COMMON IN DIABETES

Candidiasis 1-6 1A

1. Usually form normal flora in GI tract and skin, become infectious in excessive abx use and immunocompromised Other risks include: Abx, surgery, central venous lines, immunosuppressant therapy , AIDS 2. MOST caused by C. albicans. also C. tropicalis, C. parapsilosis, C. glabrata and C. pseudotropicalis in immunocompromised 3/4:Depends on site of infection Oesophagus candidiasis (oesophagitis) is common in AIDS manifested by dysphagia Candidaemia causes fever, shock, oliguria, renal shutdown and DIC Candidal endophthalmitis starts as white retinal lesions, can cause scarring. Cottage-cheese like plaques on mucosal surfaces Commonly infect skin and nail bed Ix NAAT Culture (blood) Biopsy Serum beta-glucan testing Lactate LFTs Glucose U&Es Rx Amphotericin in severe infection Imiadazoles (fluconazole, itraconazole Caspofungin, anidulafungin 5-flucytosine nystatin for thrush oral

UVEITIS 1-7

1. Uveitis occurs when the middle layer of the eyeball (uveal tract; comprises iris, ciliary body, and choroid) gets inflamed. This layer has many blood vessels that nourish the eye. Uveitis can damage vital eye tissue, leading to permanent vision loss. anterior: intermediatw: vitrous posterior: retina + choroid Causes Most idiopathic *Infections*: HSV, VZV, CMV , syphilis , lyme *Autoimmune*: JIA, Sarcoid, *symptoms* - PAin -photophopbia -reduced acuity -asymptomatic -erythema especially anterior uveitis IX - viral PCR - bacteria: bloods -

ACUTE TONSILLITIS 1A

1. Viral infection of tonsils common in children between 5-15. common in winter and spring . bilateral 2. AEx a. Rhinovirus b. coronavirus c. less commonly: influenza virus, the parainfluenza virus, enteroviruses, or herpes viruses d. BACTERIAL: GASBHS 3. signs : oedema, swelling , erythema, tonsillar exudate, ant cervical lymphadenopathy 4. Symptoms: dysphagia, sore throat, fever, headache , abdo . no runny nose or cough if bacterial viral 5. Ix a. swabs and cultures b. bloods c. CENTOR SCORE: exudate, fever, absence of cough, lymphoadenopathy >3 give abx d. FEVERPAIN ( fever in past 24hrs, no cough/coryza, sx onset <3, exudate, tonsil inflammation ) Rx 1. analgesics : paracetamol, ibruprofen 2. Abx -> phenoxymethylpenicillin in compromised and systemic upset 3. recurrent tonsillectomy

G6PD deficiency 2B

1. X-linked disorder resulting in Glucose-6-phosphate dehydrogenase. 2. High prevalence in mediterranean and african areas RBCs lyse with oxidative stress (fava beans, sulfa drugs, antimalarials, naphthalene) Chronic hemolysis and splenomegaly Heinz body formation (oxidized Hb inclusion) - spleen turns into bite and blister cells. - 3. Pathophysiology G6PD is needed for HMP ( pentose phosphate shunt) whch generates NADP, NADPH and glutathione -> maintain Hb and RBC membrane integrity, and reverse oxidant damage to RBC membrane and RBC components). -⬇ glutathione -> RBCs cannot respond to oxidative stress -> shorter half-life span and more susceptible to haemolysis particularly in response to drugs (e.g. nitrofurantoin, ciproflaxin,primaquine)), infection, acidosis and certain dietary agents (e.g. fava beans). -Oxidants ➡denatured Hb ➡methaemoglobin ➡Heinz bodies ➡ RBC less deformable ➡destroyed by spleen. -4/5 S&S neonatal jaundice is often seen intravascular haemolysis gallstones are common splenomegaly may be present Heinz bodies on blood films. Bite and blister cells may also be seen 5. Ix -G6PD enzyme assay

Anorectal fistula: definition, epidemiology and risk factors 1B

1. a chronically inflamed GI tract creates an abnormal passage from inner anus or rectum out to skin surrounding anus -common in women ages 20-40 - associated with anorectal abcess (1/3) due to - Crohn's disease - Anal surgery - Pelvic radiation - Pelvic trauma

Peri-oral dermatitis

1. a common transient, recurrent or persistent rash characterised by scaly, papular eruption with surrounding erythema around mouth, nose and eyes. may be pruritic 2. causes Topical steroids - especially potent products Inhaled or intranasal topical steroids Moisturisers - especially thick ones Sunscreens and other cosmetics Inadequate face-washing Pregnancy or other hormonal change Rx: -Avoid oil-based facial creams -Cleanse face twice daily with mild soap or non-soap non-cream - Abx : tetracycline 250-500 mg, doxycycline 100mg or minocycline 100mg daily for 4-8 weeks. Use erythromycin in pregnanc - TOPICAL AGENTS NOT EFFECTIVE

Cyclical Vomiting Syndrome (CVS)

1. a disorder of unknown cause characterized by repeated, sudden episodes of severe nausea, vomiting, and physical exhaustion. 2. Rare, ommon in children, also more common in females 2a. Cause is unknown.. 25-80% patients also have migraines features: Severe nausea, vomiting, exhaustion . well between episodes . - weight loss, abdo pain, diarrhoea, diziness Ix clinical - r/o pregnancy in females Rx - Ondansetron -Prochlorperazine - Triptans

TYMPANIC MEMBRANE PERFORATION 1A

1. a hole in or rupture of the eardrum 2. AEx; chronic suppurutive OM, trauma, cholesteatoma, loud noise, pressure change - diving, flying a. chronic suppurative OM : due to infection , self-limiting features: asymptomatic, some conductive hearing loss , discjarge during URTI, earache pain then instant relief, ear noise (buzz or hum) Rx: ABx

Oesophageal stricture 1B

1. a significant narrowing of the Oesophagus that may significantly interfere with swallowing 1b. often a result of GORD which results in inflammation and scar tissue. results in dysphagia

ANTIPHOSPHOLIPID SYNDROME NOM

1. acquired disorder characterised by predisposition to both venous and arterial thromboses, recurrent fetal loss and thrombocytopenia. ulcers, TIAs, MIs - primary disorder or secondary to other conditions (SLE) - antiphospholipid syndrome causes an paradoxical rise in the APTT (due to ex-vivo reaction of the lupus anticoagulant autoantibodies with phospholipids involved in the coagulation cascade) - (paradoxically) prolonged APTT + low platelets - anti-Cardiolipin antibody can assist Associations other than SLE: other autoimmune disorders lymphoproliferative disorders phenothiazines (rare rx aspirin, warfarin

THYROID STORM 1B

1. acute exacerbations of hyperthyroidism symptoms 2. AEx precipitatedby infection, trauma, surgical emergency or radiation thyroiditis, DKA 3/4 Thyperthermia and mental disturbance, tachycardia, arrythmias accompanied by pulmonary oedema or congestive heart failure. N&V and diarrhoea Ix -TFT- inc. T3&4, undetectable TSH -ECG-arrythmias LFTs- elevated BM: hyperglycaemia U&Ehyperkalaemia, hypercalcaemia Rx beta blockers, propylthiouracil and hydrocortisone/dexa

Pseudomomas Folliculitis

1. aka: Hot tub folliculitis 2. Etiology: Pseudomomas aeruginosa from contaminated hot tub 3. Clinically: multiple pruritic papules and pustules, developing in 1-5 days after exposure, worse under bathing suit 4. Treatment: Self limited, can use oral Cipro if not clear by 7-10 days SEEN IN THE BATHING SUIT AREA !!

Eczema Herpeticum

1. aka: Kaposi's varicelliform eruption, Spread of HSV over skin surface in immunocompromised skin (atopic dermatitis) 3. Usually starts as an oral infection, then spreads and is associated with fever and adenopathy can start of as eczema and skin is penetrated 4. Can be fatal if not recognized and treated early Ix: swabs viral and bacteria Rx acyclovir complication: blindness

REACTIVE ARTHRITIS/ REITER'S SYNDROME 2B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. asymmetrical arthritis that develops post infection . symptoms last 4-6 months ( seronegative HLA b-27) . >M, >20-40 - common arthritis in childhood - COMMON POST-INFECTION : - Enteric bacteria - salmonella, shigella, campylobacter, Yersinia - Viral infection - Chlamydia, gonorrhoea - Mycoplasma - Lyme disease 3. s&s (cant see, cant pee, cant climb a tree) FACADE B Fever( low grade) Arthritis, aortitis Conjuctivitis / uveitis Apthous ulcers Dactylitis Enthesis Balanitis- painless vesicles Keratoderma blennorrhagica ( (waxy yellow/brown papules on palms and soles)) Inv - Raised ESR and CRP - X-ray is normal - Culture and gram stain -auto antibodies: ANA, RF -arthrocentesis Management - symptomatic: analgesia, NSAIDS, intra-articular steroids - sulfasalazine and methotrexate are sometimes used for persistent disease -intra-articular steroid injections - symptoms last more than 12 months

TEMPORAL ARTERITIS/ GCA 2A 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. autoimmune small and medium vessel vasculitis, affects temporal arteries. 2. > F, > 60, 2. headache, jaw claudication, visual disturbances. aching proximal joints, morning stiffness , fever . associated with PMR rapid onset palpable temporal artery around 50% have features of PMR: aching, morning stiffness in proximal limb muscles (not weakness) 2 Ix: ESR (>50), CRP, ANA, RF, UA, urine/blood culture, head CT, biopsy, temporal artery CK and EMG- normal 3 prednisone (40-60mg) , aspirin, omeprozole, calcium, vit D, dexa scan (ready for alendronate) I forget: blood and urine culture, dexa scan and omeprozole (steroid kit) and aspirin GCA and PMR are associated HLA-DR4 like RA other sx stroke claudication in limbs dementia PUO

MARFAN'S SYNDROME NOM

1. autosomal dominant connective tissue disorder - defect in the FBN1 gene on chromosome 15 2. AEx: inherited 3. signs and symptoms MISS TRAPE Mitral valve prolapse (75%), myopia Ingunal hernia Spontaneous pneumothorax Scoliosis/kyphosis Tall Retinal detachment Aortic regurgitation , dissection, aneurysm pectus excavatum/ pes planus/ pneumothorax Eyes: blue sclera

SICKLE CELL ANAEMIA (1B) 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations

1. autosomal recessive condition which results in an abnormal haemoglobin chain termed HbS due to mutation in HBB gene. - results in sickle shaped RBCs which are fragile 2. Epidemiology - more common in people of African descent as the heterozygous condition offers some protection against malaria - Around 10% of UK Afro-Caribbean's are carriers of HbS: only symptomatic if severely hypoxic Symptoms in homozygotes don't tend to develop until 4-6 months when the abnormal HbSS molecules take over from fetal haemoglobin - HBs carry oxygen fine but when deoxygenated they polymerise causing them to stick to each other and sickle - several conditions cause sickling. sickle cells are fragile and haemolyse; they block small blood vessels and cause infarction Triggers of sickling -Deoxygenation -Infection -Dehydration -Acidosis -Cold -Hypoxia Syndromes/types: -HbSS - severe disease -HbSC - intermediate disease -HbSA - sickle trait, asymptomatic, protects against falciparum malaria Investigations -DNA-based haemoglobin assay - HbSS -Haemoglobin electrophoresis - HbSS -Haemoglobin isoelectric focussing -HPLC -Blood film - nucleated red cells, sickle cells, schistocytes and Howell-Jolly (due to Hyposplenism) bodies -Reticulocytosis -Anaemia on FBC- *Normocytic anaemia* -Plain X-rays of long bones - bony infarction -CXR - pulmonary infiltrates in acute chest syndrome Complications - more prone to infections w/ s. .pneumonia H. influenzae N. menigitidis salmonella Rx -avoid dehydration, extremes of temperature -analgesia for crises

Cellulitis 1A 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. bacterial infection of the skin and subcutaneous tissue by S.aureus or S. pyogenes, MRSA feaures: pain, erythema, and oedema and fever. May have regional lymphnode enlargement . may develop bullae and vesicles which may rupture . indistinct borders Ix: FBC, culture, bipsy. Usually clinical diagnosis Rx: 1. flucoxacillin 2. Clarithromycin or clindamycin is recommend in patients allergic to penicillin. 3. severe give benzylpenicillin + flucloxacillin.

SIALADENITIS 2B

1. bacterial infxn of *parotid or submandibular salivary glands* due to obstruction with stone or gland hyposecretion. Staphylococcus aureus common - common in 50-60s -anorexic adolescents -Sjögren syndrome: diminished lacrimal and salivary gland secretion -> dry eyes and mouth 2. AEx: dehydration, poor oral hygiene, mumps,. autoimmune conditions 3. Features: fever, pain with meals, inflammation, pus from glands , erythema 4. signs: gland palpation --> secretion Ix: CT, clinical diagnosis , MRI, ultrasound , FBc Rx; lemon drops, Abx, surgical ddrainage -clincamycin, cephalosporin, diclox

CONJUCTIVITIS 1-6

1. bacterial or viral infection of the eyes. commonly presents as sore red eye (S) - 3/4 Bacterial: sticky eyes, purulent discharge , usually unilateral Viral: watery, red, itchy eyes, tends to be bilateral 5. Ix - clinical diagnosis 6. Rx - self-limiting settles within -2 weeks - chloramphenicol 2-3 hrly -top fusidic in pregnant women BD -do not share towels

BAROTRAUMA OF EAR 1B

1. barotrauma is tissue injury caused by pressure-related change in body compartment gas volume🔈 - results in ear pain, hearing loss, and/or vestibular symptoms Inner ear baro-trama: rupture of oval window tinnitus, sensorineural hearing loss, vertigo, nausea, and vomiting. labyrinthine fistula and perilymph leakage can permanently damage the inner ear. 2. AEx: A. Diving: if pressure no relieved can lead to middle ear hemorrhage or tympanic membrane rupture b. flying c. euchian tube bloackage 3. Features: ostalgia, hearing loss, middle ear hemorrhage or tympanic membrane rupture, Deafness may get relieved by swallowing and yawning. 4. Ix: Audiometry and vestibular testing 5. Rx: decongestants, analgesics, PO steroids, surgical repair ( in order)

incontience investigations

1. bladder diaries at least 3 days 2. urine Dip 3. vaginal exam- pelvic organ prolapse 4. PR exam for prostate in males 5. post-void USS 6. urodynamic studies 7. cytometry

CYSTITIS 1A

1. bladder infection, common in young sexually active women 2. Aex a. E.coli b. Staphylococcus saprophyticus (4%) c. Klebsiella pneumoniae (4%) d. Proteus mirabilis (4%), 3. symptoms a. Flank, suprapubic and abdominal pain b. dysuria and dyspareunia (painful sex) c. urgency and frequency d. fever e. haematuria 4. SIGNS a. fever 5. Ix a. dipstick urinalysis : proteinuria, nitrities, leukocytes, haematuria b. msu c. urine culture and sensitivity d. Others: CTKUB 6. Rx a. nitrofurantoin (100mg) BD 5 days b. trimethroprim 160-800mg BD 3 days

Cholangiocarcinoma 1B

1. cancer of the bile duct , most adenocarcinoma , Klatskin tumour, common in >55 2. AEx: liver dz, Hep C or B, bile dct Dz, PSC, UC, fluke infection, HIV, thorium dioxide exposure 3. S&S: painless jaundice, weight loss, anorexia, biliary colic . palpable mass in the RUQ (Courvoisier sign), virchow lympoadenopathy - Ix:LFTs, CA-19-9, CEA, CA-125, USS abdo, CT an MRI abdo, cholangiography, ERCP, MRCP -Rx: surgery, liver transplant

BLEPHARITIS : 1-6 1A

1. chronic Inflammation of eye lids/lashes due to poor ocular hygiene . F> M 2. Due to Meibomian gland dysfunction, seborrhoea and staphylococcal infection. 3/4: S/S - burning and itching of eye -bilateral -grittiness, sticking tearfulness - greasy lashes stuck together -.Soft greasy scales are found over the entire lid margin. -lid erythema -corneal changes in severe cases: scarring, ulceration, perf, visual impairment -dry eye -Foreign body sensation -lash loss -photophobia Ix -clinical dx -lid biopsy , culture Rx 1. seldcare, lid hygiene- warm compresses w/ cotton bud bd and wash with cotton bud and baby shampoo (1st line) i 2. Abx eye drops : chloramphenicol or fusidic acid if self-care innefcetive 2a. PO abx if top abx innefective: oxytetracycline (500mg bd 4 wks then 250 mg bd) or doxy (100mg OD 4 wks then 50mg OD) 6wk trial 3. topical steroids 4. artificial tears

BRONCHIECTASIS 2B

1. chronic irreversible widening and thickening of the bronchi due to chronic inflammatory damage. 1a. neutrophils release inflammatory mediators that destroy elastin, cartilage, and muscle in larger airways, resulting in irreversible bronchodilation, at the same time macrophages and lymphocytes inflitrates thicken mucosal walls --> results in airway obstruction. b. mucociliary escalator damage -> mucus not cleared > colonised > reccurent RTIs AEx Bronchial obstruction ( tumours, mucus, Foreign BOd) Cystic fibrosis Ifenctions ( pertusis, HIV, TB ) Katarger syndrome Primary ciliary dyskinesia pulmonary fibrosis 3&4 1. Chronic productive cough with purulent sputum 2. Halitosis 3. Haemoptysis 4. Breath sounds: Ronchi, crackles, wheeze IX -CXR -CT -sputum culture Rx Abx -draining of mucus to remove mucus

ACUTE MYELOID LEUKAEMIA 1B

1. clonal malignant proliferation of myeloid hematopoietic precursor cells characterised by increased immature myeloid cells in BM and peripheral blood. -sudden symptoms which get worse rapidly . >60s BF: *myeloblasts with auer rods ,20% of nucleated cells are blasts* Aetiology -Fanconi anaemia, Diamond-Blackfan anaemia, dyskeratosis congenita, trisomy 21, trisomy 8, myelodysplasia -Ionising radiation -Benzene -Smoking -Cyclophosphamide, busulfan and melphalan (chemo) Pathology -T(8;21), T(16;16), T(15;17), T(9;11) fusion genes and oncoproteins -Leads to maturation block and proliferation of blast cells -FAB - 7 morphological sub-types 3/4. signs and symptons : GPLANT Gingival hypertrophy Pain: abdo and bone Lymphoadenopathy Anaemia -> pallor , palpitations, dizziness, SOB Neutropaenia: infections , fever Thrombocytopaenia: ecchymoses or petechiae -Tumour lysis syndrome - raised urate, LDH, K+, raised creatinine 5. Investigations a. FBC - low Hb, neutropenia, leucocytosis, thrombocytopenia, b. LDH a1. PT, PTT : prolonged b. Blood film - *myeloblasts containing Auer rods* c. Marrow biopsy/trephine - over 20% of nucleated cells are blasts -Immunophenotyping - to determine sub-type -Karyotyping and FISH - determine cytogenetic abnormality -RT-QPCR Treatment -Supportive therapy - antibiotics, transfusions, allopurinol for hyperuricaemia -Chemotherapy - cytarabine -Bone marrow transplantation

RENAL CELL CARCINOMA 1B

1. common adult kidney tumour, 95% 1a. TRIAD hematuria flank/abdominal pain palpable mass -HTN & hypercalcemia common also present with anaemia, oedema ( ankle), varicocele, Ix urinalysis renal function tests FBC CT renal IV urigram cytoscopy CXR

TESTICULAR CARCINOMA 1B

1. common tumour in young men 15-40, germi-cell (97%), most seminoma and teroma ( AFP/ HCG raised ) S: 20-30, T: 30-40 2. AEx/RF: cryptorchidism, hernia, infertility, mumps orchitis , kleinfelter syndrome 3/4: painless testicular nodule, gynacomastia, dull pain, testicular heaviness, hydrocoele. . dyspnoAe with mets, abdo pain, adenopathy 5. Ix: scrotal USS 1st line), hormone studies: HCG, LH, , AFP, LLDH, CXR for mets

CUSHING SYNDROME 1B

1. condition characterised by adrenal corticosteroid excess. a. Steroid use b. Cushings disease ACTH secreting tumour 2. AEx 1. STEROIDS a. Cushings disease-> pituitary adenoma secreting ACTH (rare) b. ectopic ACTH from SCLC or carcinoid c. adrenal adenoma, carcinoma ( RARE) --> LOW ACTH d. Ectopic ACTH- small cell lung cancer S&S Cardio: HTN, palpitations, headaches GI: diabetes, hypoglycaemia , glucose intolerance , central obesity skinl: moon facies, central obesity, striae, thin skin , easy bruising , acne , buffalo hump CNS: tremor, headaches MSK: proximal muscle weakness, osteoporosis muscle weakness Genitourinary: amenorrhoea , osteoporosis ,⬇ libido Complications diabetes ,dyslipidaemia, HTN 5. Ix 1. 24 hr urinary cortisol 2. dexamethasone suppression test: >50 nanomol/L (>1.8 micrograms/dL). 1ST LINE !! done overnight 11pm-8am --> confirmed with late night salivary cortisol or 24-hr cortisol urine. Tumour responds to high dose dexamethasone 3. glucose 4. pregnancy test 5. U&Es: ⬆ Na+, ⬇K+, Rx - trans-sphenoidal resection if tumour

PARAPHIMOSIS 1B

1. condition in which a retracted prepuce cannot be pulled forward to cover the glans leading to oedema and vascular engorgement . painful medical emergency as can cause necrosis 2. Aex: bad hygiene, balanitis , uncircumcision 3. Penile pain, swollen glans, retracted foreskin , erythema Rx: emergency surgery

DIABETIC RETINOPATHY 1B

1. damage to the retina as a complication of uncontrolled diabetes. HYPERGLYCEMIA causes damage to pericytes which surround vessels in the eye ➡ weakened vessels ➡ resulting in microaneurysms, leakage due to decreased vascular permeability ( proteins and lips leak out- appear yelow) , retinal ischaemia ➡ neovascularisation Now: NPDR ( mild moderate, severe NPDR - mild: 1 microaneurysm - moderate: multiple microanerysms, dot and blot haemorrhages, eading, cotton wool spots - severe: venous beading, cotton-wool spots , severe intraretinal microvascular abnormalities (IRMA) Proliferative retinopathy -Occlusion leads to release of vaso-proliferative substances -Neovascularisation -New vessels at the disc or elsewhere -Sight-threatening Diabetic maculopathy (more common in T2DM) - Can coexist at any stage of retinopathy - Hard exudates around the macula - often described as being circinate exudates Treatment -For maculopathy - intra-vitreal ranibizumab (anti-VEGF) -Laser photocoagulation for neovascularisation - scattered or at points of leakage -Tight glycaemic, blood pressure and lipid control -Statin -Assess for macular oedema with OCT -Vitrectomy for vitreous detachment

Calcitonin effects

1. decreases Ca+ by inhibiting osteoclasts 2. decreases phosphate reabsorption in kidneys

CROUP 1A

1. describe conditions which result in barking cough and inspiratory stridor such as laryngotracheitis, spasmodic croup and laryngotracheobronchitis. commonin kids 6mo-3yrs 2. AEx a. Viral croup COMMON: parainfluenza viruses others include influenza, RSV, rhinovirus, adenovirus, mycoplasma b. Bacterial croup/laryngotracheobronchitis/ laryngotracheobronchopneumonitis: S.aureus, streptococci, h. Influenza A&B c. spasmodic croup: non-inflammatory oedema in subglottic region. Associated w. Mild URT infection w/out inflammation. no coryza sympts 3. coryza, fever, stridor worse at night 5. Ix- pulse oximetry, CXR 6. Rx b. corticosteroids as soon as diagnosis i.e dexamethasone if moderate-severe (stridor at resy + retractions) c. oxygen in severe d. -nebulised adrenanline DDX: anaphylaxis, inhaled foreign body, dipthrea,

HYPERTENSIVE RETINOPATHY 2B

1. destructive retinal changes caused by hypertension, changes can be acute if experiencing malignant HTN 4 stages 1. Arterial Arteriolar narrowing and tortuosity Increased light reflex - silver wiring 2. Arteriovenous nipping 3. Cotton-wool exudates Flame and blot haemorrhages 4. Papilloedema ( swelling /narrowing of optic disc- cant see it well) Malignant HTN retinopathy: arteriolar narrowing, papilloedema (an essential feature of malignant hypertension) retinal oedema, disc oedema, clusters of superficial flame-shaped haemorrhages cotton wool spots Ix ▪fundoscopy Rx 1. treat HTN 2. anti VEGF 3. laser

HOW DO YOU MANAGE TIIDM ? 1A

1. diet 2. metformin ( diarrhoea, GI upset, lactic acidosis) + diet ( OR gliptin or sulf or pio if not tolerated) 3. Hba1C >58 then MEtformin + sulfo or gliptin or pioglitazone Or sglt-2 inhibitor ) → sulfonylurea: gliclazide *SE → gliptin: *SE → pioglitazone → SGLT-2 inhibitor if despite this the HbA1c rises to, or remains above 58 mmol/mol (7.5%) then triple therapy with one of the following combinations should be offered: → metformin + gliptin + sulfonylurea → metformin + pioglitazone + sulfonylurea → metformin + sulfonylurea + SGLT-2 inhibitor → metformin + pioglitazone + SGLT-2 inhibitor → OR insulin therapy should be considered

PAGET'S DISEASE OF THE BONE 1B

1. disease of increased & uncontrolled bone remodelling characterised by excessive osteoclastic resorption followed by increased defective osteoblastic activity to compensate --> disorganised woven thick bones which are weak, painful and bendable Rx bisphosphonates which inhibit osteoclasts. - Paget's disease is common (UK prevalence 5%) but symptomatic in only 1 in 20 patients Predisposing factors: age, male, FH s&s 1. bone pain , warm and tender to touch 2. deformities -> bowing of tibia , skull enlargement 3. deafness and tinnitus due to bony compression of the vestibulocochlear nerve - chronic facial pain - hydroccephalus 4. only ~5% are symptomatic Ix X-ray: woven bone, lytic lesions - Bloods - hypercalcaemia, raised bone-specific ALP - Bone scintigraphy - multiple hot spots within bony areas of increased turnover - Raised urinary hydroxyproline Rx bisposponates , calcitonin

POLYCYSTIC KIDNEY DISEASE 1B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. disorders characterised by renal cysts and numerous systemic and extrarenal manifestations. There are 2 types: autosomal-dominant PKD (ADPKD) PKD1 or 2 mutations and autosomal-recessive PKD (ARPKD).. 2 less severe a. associated with extrarenal cysts, intracranial aneurysms and dolichoectasias (elongated and distended arteries), aortic root dilation and aneurysms, mitral valve prolapse, and abdominal wall hernias. b. cysts grow and compress renal architecture and vasculature --> fibrosis, tubular atrophy, renal impairment (progressive) . c. hypoperfusion --> RAAS --> HTN , Stones due to urinary stasis ( haematuria and renal colic) 2. inherited 3. features 1. UTIs, loin pain, haematuria , HTN, flank pain Extra-renal features -Liver cysts (70%) -Intra-cranial aneurysm -Subarachnoid haemorrhage - Mitral valve prolapse (murmur) -HEPATOMEGALY- due to hepatic cysts Ix: 1. *Renal USS - diagnostic / SCREENING* two cysts, unilateral or bilateral, if aged < 30 years two cysts in both kidneys if aged 30-59 years four cysts in both kidneys if aged > 60 years 2. CT abdopelvis 3. MRI 4. urinalysis 5 U&Es, creatinine 6. ECG 7. CT head Rx Ace inhibitors for HTN Abx for UTI analgesia drainage of systs transplant dialysis

OESOPAGEAL VARICES 1B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. distended, tortuous collareral veins in oesophageal submucosa OR proximal stomach 2. common complication of Portal hypertension --> back up of blood into veins , can lead to severe bleeding resulting in shock, haemorrhage Others: cirrhosis, buddchiari, tumour ( compression of hepatic vein, increased flow due to myeloproliferative dz , Heart dz leading to pulmonary htn 3/4. S&S 1. liver disease: gynacomastia, spider naevi, dupytrens, jaundice, grey turner, hepatic flap 2. raised JVP, hepatomegaly, pulmonary HTN Ix Endoscopy + ligation coagulation screen, INR ( liver disease) FBC -> Hb, MCV LFTs -> liver dz Rx Tube ligation Terlipressin whilst awaiting surgery propranolol can be given for prophylaxis correct clotting: FFP, Vitamin K complication rupture encepalopathy spontaneous bacterial peritonitis

PAEDIATRIC PRESENTATION OF DKA

1. drowsy, confusded, abdo pain, vomitting

VARICOCELE 1B

1. enlarged veins of the spermatic cord, COMMON IN l. Scrotum. associated with infertility 2. AEx: renal carcinoma ( left >right) due to pressure on testicular vein 3. dull ache, bag of worms , scrotal mass , small testicle 4: visible distended scrotal vessels, bag of worms. 5. Ix: USS, semen analysis, FSH, testosterone, CT apdopelvis 6. Rx surgery or embolisation

ADDISONIAN CRISIS AND PRESENTATION 1A

1. exacerbation of addison's disease characterised by severe hyponatremia and *hypovolaemia* 2. Crisis: due to severe physical stress (trauma/ infection- TB, AIDs,/sweating/ haemorrhage, ketoconazole, pregnancy)-> adrenal glands cant supply extra corticosteroids and dehydroepiandrosterone --> leads to life-threatening symptoms: adrenal insufficiency symptoms acutely PRESENTATION: presents with hypotension, hyponatraemia and hyperkalaemia , severe abdo pain, lower back or leg pain and vomiting symptoms are vague: i.e abdo pain, drowsy, confusion, delerium look for uses of long ter steroid -> adrenal insufficiency

CONN'S SYNDROME (HYPERALDOSTERONISM) NOM

1. excessive production of aldosterone leading to HTN , HYPOkalaemia and metabolic alkalosis ( hypokalaemia) 2. AEx: Adrenal adenoma ( conn's) , adrenal hyperplasia, adrenal carcinoma , 3. Na+ retention and K+ excretion 4/5: presents with: severe HTN resistant to treatment, nocturia, polyuria, mood disturbances, difficulty concentrating Ix a renin:aldosterone ratio Rx excision spironolactone

HYPERTHYROIDISM 1A 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. excessive thyroid hormone production. Normal feedback mechanism: • TSH secreted by the pituitary stimulates the thyroid to secrete principally T4 and also T3 . TRH stimulates the synthesis and secretion of TSH. • T4 and T3 are bound to TBG, TTR, and albumin. The remaining free hormones inhibit the synthesis and release of TRH and TSH. • T4 is converted peripherally to the metabolically active T3 or the inactive rT3 • T4 and T3 are metabolized in the liver by conjugation with glucuronate and sulphate. 2. AEx - 99% autoimmune graves is the most common cause -1% secreting tumour, Thy horm. resistance and gonadotrophin-secreting tumour --thyroiditis -toxic nodular goiter -exogenous iodine excess -pituitary tumors -thyroid cancer -toxic adenoma -high iodine intake, smoking -amiodarome 3. Pathophysiology Graves : IgG mediated autoimmune dz. Th2 cells stimulate production of autoAbs to TSH-Receptors on thyroid follicular cells --> Abs bind to TSH-Rs --> increase thyroid hormone synthesis. GOITRE due to increased stimulation of follicular cells by TSH-R Abs --> hyperplasia F cells 3/4 eye disease skin: pretibial myxedema, warm an sweaty, thin hair, hyperpigmentation Thyroid acropachy: extreme manifestation, with clubbing,painful finger and toe swelling, and periosteal reaction in limb bones. cardiac: AF, palpitations , tachy MSK: tremor, brisk reflexes, weakness, wasting Nero: psycosis, anxiety, irritaility Ix TSH ⬇ Free T4 ⬆ Anti-TSH-R Rx BLOCK AND REPLACE block and replace (highdose c arbomazole + levothyroxine TITRATE 1. Beta-blockers 2. Carbimazole -> tirate 3. PTU -> pregnancy safe, stronger dose SE : agranulocytosis, thrombocytopaenia hepatonecrosis (PTU)

GLP-1 analogues (TIDES)

1. exenatide , subcutaneous take BEFORE breakfast and dinner NOT AFTER MEALS 2. Enhance incretin effect also, suppresses appetite --> inhibit glucagon --> inhibits gluconeogenesis, increases insluin release. -side effects: Weight loss, AKI, nausea, vomiting, pancreatitis Lastline, subcutaneous (GLP-1) produced from the distal ileum.

CHOLELITHIASIS 1B

1. formation of gallstones in gall bladder 2. R/F Fat, female, forty and fertile, fair -Female- Oestrogen increases cholesterol stone formation and oral contraceptives containing oestrogen -Fat/obesity- increased cholesterol --> increased chol. stone formation -rapid weight loss: rapid loss of lipids--> imbalance in bile formation --> increased risk of stone formation 3. Features -Postprandial abdo pain in the RUQ, radiates to the right subscapular area or the epigastrium, -nausea and vomiting -murphy's sign -low grade-fever 4. Ix - U/S: stones in the gallbladder -FBC- ⬆WCC ( infection due to obstruction) -LFTs- normal or elevated -Lipase/amylase: Pancreatitis? -- US, MRCP, EUS, ERCP Rx -Cholecystectomy for symptomatic patients -ERCP -shock wave lithotripsy -stenting and balloon dialation

Zollinger-Ellison Syndrome (ZES)

1. gastric secreting tumour , presents Unresponsive, recurrent burning abdo pain, diarrhoea, nausea, vomiting, fatigue, weight loss, weakness and GI bleeding. Ix: gastrin levels Control symptoms with moderate to high-dose PPIs. Surgical resection of the gastrinoma.

Thyrpoid gland and hormones

1. gland embedded in posterior surface of thyroid gland, usually 4 pairs but can be more or less. secretes PTH in response to low levels of Ca+ which stimulates osteoclasts -> releasing CA antagonises calcitonin also: -reabsorption of Ca ++ by kidneys, reducing urinary losses

WHAT IS RHINITIS (ALLERGIC) and how does it present ? 1A

1. hayfever, inflammation of nasal mucosa that is IgE medicatiated. common in <20s Triggered by Perennial - inhaled: house dust, wool, feathers, foods, tobacco, hair, mould - ingested: wheat, eggs, milk, nuts - occurs intermittently for years with no pattern or may be constantly present 2. presents with: nasal obstruction with pruritus, sneezing, rhinorrhoea ( contains eosinophils), itching and tearing of eyes.

HYPERTRIGLYCERADAEMIA 2A

1. high levels of triglycerides results from increased VLDL synthesis or reduced clearance or both . - fasting triglyceride level of >2.3 mmol -can be primary or secondary Primary cases include familial hypertriglyceridaemia (types IV and V), familial combined dyslipidaemia (types IIb and IV), polygenic hypercholesterolaemia (type IIb), and broad beta disease (type III). Secondary causes .◾endocrine: obesity/metabolic syndrome, hypothyroidism (more for high LDL, not TG), acromegaly, Cushing's syndrome, DM, renal: chronic renal failure, polyclonal and monoclonal hypergammaglobulinemia, unopposed oestrogen hepatic: chronic liver disease, hepatitis, glycogen storage disease • drugs: BIG THAG B-blockers Isotrentinoin Glucocorticosteroids Thiazide diuretics HIV meds Anabolic steroids, atypical antipsychotics ( olanzapine/ clozapine) Glucocorticoids 2. AEx Primary secondary causes obesity DM hypothyroidism Liver diseases CF HIV cushings SLE sarcoidosis drugs S&S eruptive xanthomata early CAD obesity diabetes Ix - Lipid profile : high TC, LDL, TGL, -Low HDL -TFTs: high/low TSH low T4 Rx -atorvastatin (40-80mg) -lifestyle modification

hypercholesterolaemia/dyslipidaemia (1A)

1. high total cholesterol (TC) ( (>7.5 mmol/L or/and LDL >4.9 mmol/L or non-HDL cholesterol (TC-HDL) * associated with TC, LDL-cholesterol, <3 the 10th percentile, *assoctaed with atherosclerosis, CVD ,PVD, stroke, MI , erectile dysfunction - common in people with CHD (80%) AEx 1.primary autosomal dominant -> mutations LDL receptor gene protein chrom 19 . can't be cleared properly 2. secondary Obesity alcohol diabetes renal failure liver disease ( liver clears LDLS) drugs: thag Thiazide diuretics HIV meds Anabolic steroids, atypical antipsychotics ( olanzapine/ clozapine) Glucocorticoids S&S: a. asymptomatic until atherosclerotic event b. corneal arcus <45 c. xanthomata, xanthelasma Ix - Lipid profile : high TC, LDL, TGL, low HDL -TFTs: high/low TSH low T4 Rx -atorvastatin (20-80mg) , Rosuvastatin: 10-40 mg , Simvastatin: 80 mg -lifestyle modification

Pheochromocytoma 2B

1. hypersecretion of epi/norepi BY ADRENAL TUMOUR features: persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA, flushing , tremor , headache Ix Urine analysis of vanillymandelic acid (VMA) urine metanephrine levels. CT and MRI Rx - alphablockes: Phenoxybenzamine given before BB -surgery

BENIGN PROSTATIC HYPERPLASIA 1A

1. hypertrophy of the prostate gland ( walnut sized) due to cellular proliferation in transitional zone results in bladder outlet obstruction -> Lower UT symptoms 2. common in older men >50s, ageing *Complications: UTI, retension, stones, obstructive nephropathy* DDX: tumour, stones, foreign body , stricture 3. Features: frequency, urgency, nocturia, poor or intermittent stream, dribbling, incomplete bladder emptying 4. Ix - palpable bladder - PR: pain ?, enlarged prostate -MSU -PSA eGFR -USS : •Prostate and bladder volumes may predict response to treatment. -Transrectal ultrasound (TRUS): For detailed volumetric assessment. Rx a1-blockers ( tamsulosin 0.4mg) : affect smooth muscle tone. *SE*: postural HTN, diziness, ejaculatory probs, sansal congestion 5-a reductase ( finastride 5mg PO od): reduce size, block growth. *SE* .⬇ libido, erectile dysfunction, ejaculatory disorder, gynaecomastia TURP

PYLORIC STENOSIS 1B

1. hypertrophy of the pyloric sphincter results in narrowing of the pyloric canal. It is the most common cause of gastric outlet obstruction in the 2- to 12-week-old age group. 2. congenital 3/4: 1. projectile vomiting 2. poor feeding , failure to thrive 3. hungry irritable baby 4. -dehydration & metabolic acidosis -Hypovolaemia and hypochloraemic, hypokalaemic metabolic alkalosis Ix: Abdo USS Rx IV fluid resus pyloromyotomy

HYPOGLYCAEMIA 1A (emergency)

1. hypoglycaemia due to excessive insulin. Blood glucose <3 mmol/L (<4 in hospital),. whipples triad- symptoms of hypoglycaemia, low plasma levels and response to glucose 2. AEx 1. anti-diabetics ( insulin, SGLT2 inhibitors- glifozins) 2. insulinoma 3. growth hormone insufficiency 4. adrenal insufficiency - addisonian crisis 5. post-pradnial reactive 6. IGF-II secreting tumour 3.4 CNS: neuroglycopaenia due to decreased cns glucose: confusion, incordination,drowsiness , coma, convulsions , tremoir . ataxia- can be mistaken for being drunk Eyes: blurred vision SKin: sweating Cardiac: palpitations Resp: difficulty breathing Gi: hunger Ix BMs BMs BMs BMs !!!!!!!!!! LFTs U&Es TSH Cortisol observed 48-72 hr fast >2.8mmol glucose Rx NICE 10- 20g fast acting glucose : Jelly babies or gluucogel - repeat BMs every 10-15 mins, if low give 10-20g 1-3 times 20G long acting banas HYPOGLYCAEMIC COMA 1. 75-80 ml 20% glucose or 150-160 ml of 10% 2. glucagon 1mg IM ( if at home or IV access not abailable) 50% not recommended

RETINAL VEIN OCCLUSION (EMERGENCY LOST) 1B

1. i unilateral sudden painlessVisual loss due to occlusion of retinal vein . emergency as it can cause permenant loss -- central ischaemic or non-ischaemic OR branch retinal vein occlusion 2. AEx/ RF - pressure from sclerotic artery - hyperviscocity i.e polycythaemia -raised IOP -periphlebitis -glaucoma -diabetes 3/4; s&s - usually sudden painless loss of vion - visual loss can be gradual 5. Ix -fundoscopy: ischaemic CRVO ➡massive engorgement, congestion and tortuousity of retinal veins, massive retinal haemorrhage, whole fundus alsmost full of haemorrhages. , soft exudages, papilloedema. Macular area is full of haemorrhages and is severely oedematous. In late stages, marked sheathing around veins and collaterals is seen around the disc. neovascularisation Rx 1. ICRVO: Panretinal photocoagulation (PRP) or cryo-application 2. firm oclar massage if 90-100 minutes later 3. lower IOP --4dilation of arteries 5. intra-arterial fibrinlysis

ACUTE SINUSITIS 1A

1. iNFLAMMATION of mucosal lining of nasal cavity and paranasal sinuses due to viral infection -> oedeoma of nasal mucosa a. acute: symptoms for 3-4wks b. chronic: vs symptoms for 4-12 wks ( c. recurrent : 3 or more episodes of ACUTE sinusitis in 1 yr AEx: 1. viral : S. pneumonia, H. influenza, M. catarrhalis 2. nasal polyps 3. Signs: purulent drainage, fever , PND, asomia 4: symptoms: facial pain, pressure, congestion, sore throat , teeth pain , cough, myalgia, hyposomia 5. Ix a. rhinoscopy b. CT 6. Rx ACUTE a.supportive, analgesia, decongestant , if bacterial then : a. co-amoxiclav or erythromycin b. Paracetamol and codeine c. Oxymetazoline d. Intranasal beclomethasone e. Functional endoscopic sinus surgery 7. Complications of sinusitis -Mucociliary damage and further infections -Periorbital cellulitis via ethmoid air cells - lid oedema, diplopia, chemosis, loss of colour vision -Paranasal mucocele -Meningitis -Extra-dural and sub-dural abscesses -Frontal lobe abscess -Osteomyelitis of the frontal bone Pott's puffy tumour of the skull

OSTEOPOROSIS 1-5 1A 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. imbalance between bone remodelling. osteoclast vs osteoblasts. - Age-related: oestrogen protective 2. AEx/RF -old-age, alcohol, lack of weight bearing exercise, smoking , steroid use , low bmi , *STEROIDS* -endocrine disorders: hyperparathyroidism, hyperthyroidism, hypogonadism (e.g. Turner's, testosterone deficiency), growth hormone deficiency,diabetes mellitus multiple myeloma, lymphoma -gastrointestinal disorders: malabsorption ( ibd, coeliac ) - chronic kidney disease osteogenesis imperfecta, homocystinuria Medication causes: SSRIs antiepileptics proton pump inhibitors glitazones long term heparin therapy aromatase inhibitors e.g. anastrozole S&S Height loss Kyphosis Paraspinal pain Restrictive lung disease Protruding abdomen Fractures Ix X-ray wrist, spine, heel, hip : compression fractures, loss of cortical bone, loss of trabeculla bone and cortical thinning - DEXA scan: T score <2.5 and Z score <2 -CT quantitative - sserum Ca+, ALP, albumin, phospahe, Vit D, PTH, -TFT, PTHFs, testoserone, urinary free cortisol Rx - Weight-bearing exercise- stimulates bone remodelling - Smoking and alcohol cessation - Calcium and vitamin D supplementation - *Bisphosphonates* - *Denusomab*- if cant tolerate bisphosphonates -raloxifene ( Selective oestrogen recept mod) --> osteoclast activity - Calcitonin - inhibits osteoclast function and shrinks them - In steroid users start bisphosphonates T-score less than -1.5 - in women >75 start bisphosphonates dexa not required Alendronate most stomachs hate, So I swap them to risedronate, And if they're still complaing on that, Strontium ranelate comes up to bat.

PRIMARY HYPERPARATHYROIDISM 1B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. inappropriate secretion of PTH by PTGland --> hypercalcaemia. -presents as hypercalcaemia- polyuria + polydipsia . ->F, >40 -1 in 500 - U&Es fine , if not then consider tertiary 2. AEx a. Primary: parathyroid adenoma (80%) > abnormal secretion of PTH does not respond to negative feedback . Multiple endocrine neoplasia (MEN) syndrome 1&2 autosomal dominant other causes: multifocal disease occurs in 10-15% and parathyroid carcinoma in 1% or lessl 4/5. signs and symptoms of hyperparathyroidism/hypercalcaemia: BOO CAMPS Bone pain / brown tumour (Osteitis fibrosa cystica- where decalcification leaves large punched out areas in bones) Osteoporosis Osteopaenia Constipation / confusion Anxiety and depression Muscle cramps, weakness Parasthaesia/ Pepperpot skull Stones ( kidney) Ix Calcium ⬆ PTH⬆, CAN BE NORMAL - Inappropriately meaning that normally in hypercalcaemia the PTH should go down. Phosphate ⬇ ALP ⬆ Urea ⬆ Vit D levels ⬆ Urinary calcium ⬆ X-ray: pepperpot skull -X-ray: 1.Sub-periosteal erosions 2. Cysts 3.Acro-osteolysis Rx - Increased fluid intake - Parathyroidectomy( SE hypoparathyroidism, recurrent laryngeal nerve palsy, hungry bone syndrome) definitive treatment - Bisphosphonates - Management of hypercalcaemia

Toxoplasmosis 2B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. infection caused by Protozoan parasite Toxoplasma gondii 2. asymptomatic lifelong infection , isymptomatic in immunocompromised 3. pathophysiology: transmitted through food, Or water , meat from feline faeces . migrates to eyes, brain and muscle. 3. Immunocompetent: flu-like symptoms: non-tender cervical or axillary lymphoadenopathy (like mononucleosis), mild flu-like syndrome of fever, malaise, myalgia, hepatosplenomegaly, and less commonly, pharyngitis, which can mimic infectious mononucleosis and include lymphadenitis . - SYMPTOMATIC in immunocopmromised esp HIV : HEADACHE, COMA ,CONFUSION , HALLUCINATIONS , CNS involvement Congenital infection : Retinochoroiditis, seizures, and intellectual disability Ix: PCR, histology, antigen/antibody testing Rx: prophylactic pyrimethamine: 50-75 mg orally once daily + suladiazine, calcium folinate for 6 weeks

PERITONSILLAR ABCESS/ QUINSY 1B

1. infection/inflammation of *tonsils and pharynx* and peritonsillar *pus collection in the peritonsillar space* which lies between tonsil capsule and the superior constrictor muscle - usualy due to tonsillitis - tends to affect adults 2. Aex: Streptococcus viridans , Staphylococcus aureus , Streptococcus epidermidis Features -severe unilateral sore throat -swelling, dysphagia, otalgia , -uvula deviation - dysphagia -reduced neck mobility -trismus Ipsilateral referred otalgia: Cranial nerve (CN) IX supplies tonsil, as well as ear - halitosis, hot potato voice Ix: clinica diagnosis examination: te: Congestion and swelling anterior and superior to the tonsil , swollen oedematous uvula , CT rarely needed Rx: a. urgent ENT review , analgesia a. Steroids + neb adrenaline for compromise airway b. IV penicillin ( erythromycin f allergic) , drainage, tonsillectomy

Lyme disease 2A 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. infectous dz due to spirochaete Borrelia burgdorferi 2. adventure holidays, forests, woods 3. early: erythema chronicum migrans ( target lesion that gets bigger) + systemic features (fever, arthralgia) early disseminated: , malaise, generalized lymphadenopathy,,hepatitis, arthritis late persistent: arthritis, neuro stuff , cardiac stuff CVS: heart block, myocarditis neuro: cranial nerve palsies, meningitis Ix immunosorbent assay (ELISA) antibodies to Borrelia burgdorferi are the first-line test ( blood test for serology) Rx doxycycline ( photosensitivity, darkening of teeth in kids, angiodema) if early disease POP 100mg BD for 21 days Amoxicillin is an alternative if doxycycline is contraindicated (e.g. pregnancy) ceftriaxone if disseminated disease

OPTIC NEURITIS 1B

1. inflammation and demyelination of the optic nerve most cases are idiopathic F>M 2. AEx ▪hereditary optic neuritis- lebers disease ▪demylinatin disorders i.e multiple sclerosis, neuromyelitis optica (Devic's disease) and diffuse periaxial encephalitis of Schilder. ▪infections: rubella, mups, chicken pox, monocleosis. may occur following immunisation -syphilis 3. Symptoms - asymptomatic - sudden, progressive visual loss -dark adaptation -visual obscuration - impaired colour vision always present - colours are faint - depth perception esp. moving object -pain on eye movements ▪multiple sclerosis, neuromyelitis optica (Devic's disease) and diffuse periaxial encephalitis of Schilder.-Episodic transient obscuration of vision on exertion and on exposure to heat, which recovers on resting or moving away from the heat ▪Uhthoff's symptom: Temporary deterioration in vision in association with physical exertion 4. Signs - impaired visual acuity, colour vision -. A relative pupillary afferent defect is always present - visual field changes IX -MRI -Fundoscopy- central scotomas, optic disk oedema Rx treat underlying cause -high dose sterpids

ACUTE CHOLECYSTITIS 1A

1. inflammation and infection of gallbladder due to blockage of the cystic duct -causes inflammation in gallbladder AEx - Hx gallstones - fat, female, forty, fertile S&S fever, RUQ pain, N&V, Murphy's sign positive Ix ▪USS (90% specific) diagnostic: pericholecystic fl uid, gallbladder wall thickening >4 mm, and presence of gallstones ▪ mural thickening, distension, fat-stranding ▪FBC: Raised WCC -Bloods: ⬆amylase, ⬆CRP, ⬆ESR, ⬆ ALP, ⬆ WCC -MRI and AXR - pneumoperitoneum etc. Rx admit, NBM, analgesia IV fluids Abx ( cefuroxime + metronidazole) OR cefuroxime cholecystectomy

CONJUNCTIVITIS 1A 1-7

1. inflammation of conjunctiva resulting in red, sore, discharging eye but NORMAL visual acuity 2. A/E ◾Viral: adenovirus , highly infectious ◾bacterial: staph aureus, strep, pneum, gonococcal , H. influenzae 3/4: S&S 1. Bacterial : Bilateral diffuse injection, Gonococcal - rapid onset, lots of discharge, chemosis, adenopathy 2. Viral: burning stinging pain, watery mucous dx 3. chlamydial: Mild ocular discomfort and redness then micro-pannus formation 4. Allergic: IgE mediated , pruritus, injection, lacrimation, cobblestone appearing mucosa 5: Ix -clinical 6. Rx 1. Bacterial: self-limiting 5-7 days. top abx if severe i.e chloramphenicol 0.5% ( 1 drop 2 hourly for 2 days then 4 qds for 5 days.), fusidic acid (1%, second line, BD 7 days) oral penicillin 2. Viral: hygiene, avoid sharing towels, cold compresses . self-limiting 3. chlamydial: azithromycin, erythromycin 4. allergic: anti-histamines, sodium cromoglycate, top steroids

EPIGLOTTItiS 1A

1. inflammation of epiglottis and surrounding areas.(supreglottis) . inflammation results in pedema --> med emergency-> airway compromise. common in kids <6 2. AEx - H. influenza B, S pneumonia, MRSA 3. symptoms/ signs: sorethroat, stridor, drooling, dysphagia, fever, no Hib vaccination . Predisposes to SIDS due to hyponatraemia and encephalopathy in rare cases Ix a. do not examine b. laryngoscopy --> establishes airway/ diagnostic c. neck radiograph, thumbprint d. FBC: WCC e. culture 6. Rx a. admit , isolate b. secure airway : endotracheal intubation c. V antibiotics Cephalosporins for 7-10 days (cefotaxime, ceftriaxone) - Rifampicin for close contacts

PNEUMONIA 1A def.

1. inflammation of lungs parenchyma -> consolidation 2. viral or bacterial

BACTERIAL KERATITIS 1B

1. inflammation of the cornea, ocular emergency, can cause blindness 2. Staph, strep, pseudomonas ( contact lens wearers, moraxella, serratia 2a. RF include corneal trauma, contact lens wear, and breakdown of the corneal epithelium. 3/4. ulceration of epithelium - decreased visual acuity -photophobia -⬆ intraocular pressure -increased ant. chamber rxn corneal infiltrate (w/ or w/out hypopyon) -Upper eyelid edema -Surrounding corneal inflammation -Conjunctival hyperemia -Adherent mucopurulent exudate -Endothelial inflammatory plaque -erythema, pain, Ix -slit lamp examination -corneal scraping- microscope sline - cultur/ sensitivity -FBC -HIV test Rx -refer to ophthalmology - top abx -review daily Cornea:The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber.

1A BALANITIS/ BALANOPHOSTHITIS

1. inflammation of the glans of the penis AND PREPUCE in uncircumcised males Aex: eczema, seb. dermatitis ( yeast Pityrosporum ovale ) lischen sclerosus , gonorrhoea , human papillomavirus (HPV) , poor hygiene Symptoms: red scaly patches, pruritis, erosions, blisters, shiny erythematous plaques Ix: swabs for microbiology and virology, dark field microscopy, skin biopsy, patch testing Rx -topical steroids and suportive measures -hydrocortisone 2.5 -antifunghal in dermatitis : ketoconazole topical: (2%)

What is acute pancreatitis? 1A

1. inflammation of the pancreas 10% mortality rate *Causes* IGETMASHED - Idiopathic - Gallstones - Ethanol (alcohol) - Trauma - Steroids - Mumps - Autoimmune - Scorpion bits, sphincter dysfunction - Hyperlipidaemia, hypothermia, hypercalcaemia - ERCP - Drugs - azathioprine, 5-ASA, ACEI, isoniazid, trimethoprim, thiazide diuretics - Infection - coxsackie, CMV, Mumps* *Presentation* Abrupt onset of severe epigastric pain increasing in intensity over 15-60 mins radiates to the back worse on movement , supine position alleviated by foetal position nausea, vomiting, fever, shock. Pain is worst when supine. Signs Tachy cardia, tachypnoea hypovolaemia epigastric tenderness radiating to back fever abdo distenstion - Absent bowel sounds due to peritonism and ileus - Rigidity, rebound tenderness, tenderness and guarding due to peritonism - Grey-Turner's sign - flank discolouration due to vessel autodigestion - Cullen's sign - discolouration in the umbilical region for the same reason - Pancreatic ascites - leakage of fluid from a disrupted pancreatic duct into the peritoneal cavity - Fever Rx - Mostly supportive, NBM - Aggressive fluid resuscitation - Opioid analgesia and metoclopramide (avoid morphine due to increased sphincter tone) - Nutritional support with NJ tube - ERCP treatment of stones - sphincterotomy, cholecystectomy - Necrosis - necrostomy or necrosectomy (pancreatectomy for necrosis) METOCHLORPROMIDE SE: D2 antagonist extrapyramidal effects: oculogyric crisis. This is particularly a problem in children and young adults hyperprolactinaemia tardive dyskinesia parkinsonism

PROSTATITIS 2A

1. inflammation of the prostate usually due current or recent infection, reflux of infected urine to prostate -M <50 a. can be acute or chronic (> 3 months) b. bacterial or nonbacterial 2. Aex a. BActerial usually due to E.coli, Klebsiella, pseudomonas b. Non-bacterial : due to incomplete relaxation of the urinary sphincter and dyssynergic voiding 3. Symptoms a. Infective: fever, chills, and malaise , nausea, vomitting b. urinary: frequency and urgency, dysuria, hesitancy, retention c. urogenital: perineal discomfort, referred pain to penis and groin perineum, and lower back or suprapubic 4. Signs: a. swollen prostate and tender b. FEver, tachycardia, tachypnoa 5. Ix a. urinalysis : leukocytosis, bacteria b MSU c.blood cultures - bloods: FBC, U&Es, CRP c. serum PSA d. PR exam RX a. ACUTE/SEPTIC : IV piperacillin/tazobactam: 4.5 g intravenously every 8 hours OR cefotaxime: 1-2 g intravenously every 8-12 hours B. aseptic: ciprofloxacin

POLYMYALGIA RHEUMATICA 1B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. inflammatory rheumatological illness characterised by rapid onset of aching, morning stiffness in proximal limb muscles (NOT WEAKNESS) esp. neck, shoulder girdle, and/or pelvic girdle ->F, >50 - mean age 70 AEX: PVB19, mycoplasma pneumonia, chlamydia pneumoniae, s&s: usually rapid onset (e.g. < 1 month) also mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats Ix ESR > 30 mm/hr CRP⬆ Ultrasound FBC USS Rx 1. Prednisolone 15mg OD then gradually decrease ( rx for 1-2 years maybe longer) 2. MTX +add Calciferol and bisphosphonate ( T-score < -1.5) + folic acid complications 1.GCA

Wilson's disease 2B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. inherited diseases resulting in copper overload due to defective copper transport . -Metabolic abnormalities include increased copper absorption from the small intestine and decreased hepatic copper excretion. leads to accumulation and deposition of copper in the liver and brain. 2. Autosomal recessive,, symptoms present from 10-30 years 3/4 signs ans symptoms Kay has crazy jumpy moves -Kayser-Fleischer -Hepatitis(4) , cirrhosis, hepatomegaly , haemolytic anaemia -Crazy ( psych / neuro abnormalities)/copper , dementia, altered mood/behaviour Jaundice Moves- rigidity, asterixis, spasticity, chorea (jerky involuntary movements affecting especially the shoulders, hips, and face., tremor), parkinsonism others: blue nails , haemolysis ( jaundice), blue gum Ix reduced serum caeruloplasmin reduced serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin) increased 24hr urinary copper excretion Rx penicillamine (chelates copper) 1st line trientine hydrochloride tetrathiomolybdate is a newer agent that is currently under investigation

ENTROPION 1B

1. inversion of the eleyod ◾Senile ectropion : due to slackness of the pretarsal parts of the orbicularis oculi and of the palpebral ligament in old age ◾Cicatricial ectropion due to scarring and contraction of the skin and subcutaneous fat after tumors, trauma, burns, and surgery ● Congenital ectropion due to hypertrophy of the the marginal zone of orbicularis oculi ● Spastic ectropion in blepharospasm ●Paralytic ectropion due to weakness of the orbicularis oculi in facial nerve paresis 3/4: trichiasis, rubing of lashes on cornea, conjuctiva w/ epiphora, foreign-body sensation Ix- clinicla diagnosis Rx- surgical correction , good prognosis

SLEEP APNOEA (Obstructive) 1B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. irregular breathing and snoring patterns during sleep , momentarily stop breathing probs due to partial or complete closure of upper airways. to pharyngeal collapse leads to upper airways obstruction 2a. affects 2-9% adults , more common in men and obese people 2b. AEx: GEO SPAM - Genetic -Environment : i.e allergens leading to obstructive airways -obesity -sedatives -polyps -alcohol -macroglossia: large tongue 3. Pathophysiology - pharyngeal collapse/ narrowing during sleep 3/4: S&S 1. fatigue/ exhaustion 2. irritability 3. sleeping during the day/ activities 4. witnessed apnoea/snoring 5 dry throat 6. headacjes Ix -polysomnography - EEGrecords sleep stages - Electro-oculogram: detects REM - Thermistor; detects airflow at the nose and mouth - Magnetometers: monitor chest movement - Oximetry measures sats - ECG measures the HR - Video and tracings record the events Rx - General- weight loss, diet, exercise, avoid alcohol and sedatives - Remove contributory factors - tonsillectomy, nasal polypectomy - Manage heart disease - CPAP- 1st ine after general management . continuous positive airway pressure at night prevents collapse and maintains patency - Uvulopalatopharyngoplasty - Tracheostomy - Short-term modafinil to reduce somnolence - Bariatrics urgery - Mandibularadvancement device

FEMORAL NERVE

1. knee extension , thigh flexion 2. damage from hip and pelvic fractures

ADDISON'S DISEASE 1A 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. lack of cortisol due destruction of adrenal cortex ab. primary corticoadrenal insufficiency --> autoimmune destruction of adrenal CORTEX ➡glucocorticoid (cortisol) and mineralocorticoid (aldosterone) deficiency. most *common cause 70%* - other causes - infection: TB inflammation: sarcoidosis, histiocytosis X, haemochromatosis, lymphocytic hypophysitis. • Iatrogenic—surgery, radiotherapy. • Other—isolated ACTH deficiency, trauma, malignancy - >F, >30-50 2. S&S: slow progress, show when 90% adrenal destroyed 1. Head: 2. Heart: postural THN 3. Lungs: 4. GI : nausea, diarhoea , vomitting abdo pain , weight loss , salt craving 5. Renal : *hyponaetraemia , hyperkalaemia, hypotension* MSK: arthralgia and myalgia , weakness ( Skin: hyperpigmentation (buccal) due to high ACTH- stimulates melanocytes , hair loss -infections ( low cortisol due to ⬇ glucocorticoids) -insulin sensitiviyt increased 5. Ix 1. U&Es ( Na+, K+), urea , glucose 2. ACTH high , low cortisol (ACTH, measure cortisol after 30 mins) 2. morning (9am) cortisol ➡ < 100 nmol/l is definitely abnormal confirm with synatchin test 3. Autoantibodies :-> anti 21-hydroxylase (80%) 4. ACTH Synacthen test 5. Insulin-induced hypoglycemia test- measuring blood glucose and cortisol levels after injecting insulin. Insul should normally decrease 6. CT Abdo MRI if 2ndary suspect pituitary causes Rx 1. Hydrocortisone --> increase in crisis 2. Fludrocortisone CRISIS: 100MG HYDROCORTISONE 6 HRLY IV 1 litre normal saline infused over 30-60 mins or with dextrose if hypoglycaemic

ACUTE LYMPHOCYTIC LEUKAEMIA 1B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. malignant proliferation of precursor cells of lymphoid cells (B&T cells). which replace normal haematopoietic cells of the bone marrow and further infiltrating various body organs - 85% of ALL is B-ALL 2. Epidemiology - AE unknow: radiation, down's, viruses, chemicals -common in children (80% childhood leukaemia) ages 2-10. -rare in adults -ALL increases Down syndrome risk by 20. 3. Pathophyiology 3 types: ALL-L1- ALL-L3 Translocations t(1;19)and t(5;15) in Pre-B cell ALL in adults t(4;11) is common in infants (MLL gene) t(8;14) in L3 type, (Burkitt) t(9;22), BCR-ABL (=Ph chromosome-very poor prognostic t(12;21) in children, good prognosis S&S: Bleeding: bruising, pallor, petechiae, anaemia Neutropenia: recurrent infections, fever and malaise infiltrates: papilloedema bone pain Enlarged testicles hepatosplenomegaly Ix: 1. BM aspiration/ trephine biopsy 2. BM biopsy >20% lymphoblasts 3. FBC URGENT 48HRS : low Hb, thrombocytopenia, neutropenia, lymphocytosis 4. Blood smear: lymphoblastosis 5. U&Es, LFTs, 6. lactate , LDH 7. PT, aPTT, fibrinogen, D-dimer 8. LDH raised Rx: 1. asparaginase + cyclophosphamide- high doses (T-cells) 2. Mature B-cell ALL needs to be with short-term intensive chemotherapy, including high-dose methotrexate (MTX), cytarabine, cyclophosphamide and over a 6-month period. 3. imatinib for Ph-positive --> tyrosine kinase associated with the BCR-ABL defect 4. Chemo 5. BM transplant

Hyperosmolar hyperglycaemic non-ketotic state (HONK) 1A

1. medical emergency, condition characterised by hypocalcaemia, severe hyperglycaemia and no ketonaemia. Hyperglycaemia results in osmotic diuresis - more common in elderly 2. AEx undiagnosed TIIDM - Thiazide diuretics - Steroids - Illness - High sugar intake - MI - Vomiting - Stroke - VTE 3/4: General: fatigue, lethargy, nausea and vomiting Neurological: altered level of consciousness, headaches, papilloedema, weakness Haematological: hyperviscosity (may result in myocardial infarctions, stroke and peripheral arterial thrombosis) Cardiovascular: dehydration, hypotension, tachycardia other: Hyponaetraemia, hypokalaemia Complication - VTE - Rhabdomyolysis - Lactic acidosis - Hyperlipidaemia - Renal failure - Stroke - Cerebral oedema Ix BMs >30mmol Biarb >15mmol osmolarity >320 mmosmol/Kg Ketones + < Urea ⬆ creatinine ⬆ Na+ , Mg , Ca ⬇ Rx 1. ICU admission 2. Fluids - Normal saline 1-2L/HR ( need 10-20mL/kg/hr) ( same as DKA) 3. THEN 500mL/hr for 4 hrs thrn 250ml for 4 hrs 4. add dextrose once BMS <250-300mg/dL ( ) 5. vasopressors due to hypotension Noradrenaline insulin 0.24/kg/hr 6. anticoagulation

WHAT IS TYPE 1 DIABETES MELLITUS : def and patho 1B

1. metabolic syndrome characterised by hyperglycaemia , polydipsia and polyuria. 2. T 1DM is due to autoimmune destruction of pancreatic b-cells by anti IA2 and IA2-beta resulting in insulin deficiency . Problems occur when gland is 80-90 destroyed

What is Barrett esophagus (2B)

1. metaplasia of mucosa in distal oesophagus from squamous to Columnar. -pre malignant state associated with increased oesophageal adenocarcinoma 2. secondary to chronic GORD 3/4: S&S 1. GORD- burning sensation in throat, reflux, cough, voice hoarseness -epigastric pain, dyspepsia aggravated by meals, lying down etc.. cough -asymptomatic - Endoscopy : erythematous epithelium Ix endoscopy :: Intestinal metaplasia with a villiform pattern noted. Multiple intermediate mucous cells and goblet cells noted.. Rx - Radiofrequency ablation - Photodynamic therapy - Oesophagectomy for high-grade dysplasia

MASTOIDITIS 1B

1. middle ear infection of mastoid hair cells usually after untreated AOM Young kids 6-18mos peak incidence 2. AEx: untreated AOM , S. pneumoniae, H. influenzae, M. catarrhalis, S. pyogenes, S. aureus) 3. Features: redness, tenderness, swelling, and fluctuation over the mastoid process, with displacement of the pinna. fever, headache, hearing loss 4. Ix a. CT head/neck b. Skull x-ray c. clinical Rx a. IV ceftazidime, ceftriaxone b. mastoidectomy ± tympanoplasty complications 1. Conductive and/or sensorineural hearing loss. 2. Labyrinthitis. 3. Osteomyelitis or bone erosion. 4 Extension to the zygoma (zygomatic mastoiditis). 5. Sub-periosteal abscess (abscess between the 6. periosteum and mastoid bone; gives appearance of a protruding ear). 6. Cranial nerve palsies (especially V, VI and VII). 7. Intracranial spread leading to extra-dural abscess, cerebral abscess, subdural empyema and meningitis. 8. Intracranial venous sinus thrombosis (e.g., lateral sinus thrombosis).

STRABISMUS 1B

1. misalignment of the eyes/ squinting . can be latent or manifest , 2. CNVI palsy (esotropia), acquired, congenital - CN IV palsy is a common cause of vertical strabismus. -retinoblastoma -catarcat 3/4: -double vision in adults, visual confusion, -amblyopia- decreased vision in normal eye due to suppression in kids ( lazy eye), squinting 5. Ix -Hirschberg's test: degree of strabismus - ;look for other abnormalities -cover test - eye exam- acuity, motility, accomodation, fixation, refraction

ORAL CANCER

1. most SCC (95%), >50, ant 2/3 tongue 2. RF: smoking, poor hygiene, erythroplakia, leukoplakia, HPV , EBV 3. excessive salivation, non-healing ulcer, leuko and erythoplakia, dysphagia, neck lump , ear- otitis media, otalgia Ix: Biopsy , CT

TUBERCULOSIS 1B

1. mulstisystem Infectious disease caused by mycobacterium tuberculosis. commonly has a period of latency before infection. transmitted via inhalation of droplets -affects: lungs, joints, brain, skin, kidneys -common in Africa, india, china, indonesia -travels to alveoli, engulfed by alveolar mphages -can be destroyed by m'phages -some multiply inside mphage and kill it --> this results in inflammatory response by Th 1 cells--> release cytokines --> form granulomas ( tubercles to contain and stop further growth. (latent in 5-10%) -> surroundided by langerhan cells-> ghon focus --> Ghon focus and hilar lymph nodes is known as a Ghon complex -LATENT TB IS NOT INFECTION BUT CAN BE REACTIVATED if immunocompromised -sometimes bacteria multiply in macrophages and become disseminated and go in blood stream --> extrapulmonary TB AKA MILLIARY TB 2. AEx: - M tuberculosis - M. bovis - M. africanum -M microti -M. leprae causes (leprosy) -M. ulcerans (Buruli ulcer) -Opportunisyic: M. kansasii, scrofulaceum RF: immunosupression, extreme age, smoking, diabetes 3/4: fever, night sweats, weight loss, lymphadenopathy, dry cough that becomes productive Ix - CXR: abnormal in immunocompromised, fibronodular opacities in upper lobes with/out cavitation -Sputum acid-fast bacilli smear: positive for acid-fast bacilli (AFB). -FBC: leukocytosis, anaemia Tuberculin skin test: can give false negatives, only useful if strongly positive HIV test CT Rx RIPE -rifampicine: CYP450 inductio -> COCP, warfarin, immunosuupressants -Isoniazid: hepatoxicity, peripheral neuritis -Pyrazinamide: hepatotoxicity , hyperuraecimia -Ethambutamol ( 6 months ) opti neuritis Last 2 first 2 months rest for 6 months Bedaquiline- new drug

FOCAL SEGMENTAL GLOMERULOSCLEROSIS AKA Membranous Glomerulonephritis

1. nephrotic syndrome, common in AIDS and IV heroin abuse - primary FSG is (idiopathic ) Path: sclerosis of specific glomeruli allowing protein to filter through --> proteinuria a. light microscopy shows segmental areas of mesangial collapse and sclerosis affecting some but not all glomeruli (focal disease). features: proteinuria, oedema, thrombotic , fatigue Ix: biopsy, urinalysis transplant -> increases risk of CMV virus

Hepatic encephalopathy 1B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. neuropsychiatric syndrome caused by acute or chronic hepatic insufficiency -due to impaired ammonia metabolism causes cerebral edema. -common complication of cirrhosis/ liver failure -acute liver failure -s/s: -LOC/coma/confusion/, memory loss -asterixis (flapping tremor) ( grade 2-3) -impaired handwriting, hyperventilation w/ resp alkalosis - behaviour change -Ix: LFTs ⬆ *Tests most indicative of Liver failure: ALbumin ⬇, PT ⬆, Bilirubin ⬆* BMs INR , APPT, MSU, blood cluture, USS ( show protal HTN) , pschometric tests, CT head , platelets ⬇ Rx: lactulose, low protein, safety, rest -Lactulose and rifaximin are used for the secondary prophylaxis of hepatic encephalopathy

Intrinsic asthma

1. non-allergic asthma common in middle aged px associated with eosinophils -Triggered by stress, cold air and smoke-reponds poorly to ICS -negative allergy skin test

OSTEOARTHRITIS 1A 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. non-inflammatory degeneration of cartilage in synovial joints. results in LOSS -mainly affects hands (DIP), knees, hip and foot , spine (L4-5, L5-S1) . RAARRREEELY ELBOW AEx: age, genetic, obesity, F, trauma 3. S&S pain with movement, better with rest crepitus of passive movements joint line tenderness limited ROM Periarticular muscle atrophy joint locking *HANDS*: bouchards PIP, heberden nodes DIP *HIP*: crepitus, limb shortening, fixed flexion, trendelenburg +Ve 5. Ix CRP ESR RF, ANA synovial fluid X-rays : LOSS loss of joint space osteophytes forming at joint margins subchondral sclerosis subchondral cysts Rx NSAIDs 1st weight loss capsaicin, steroids joint replacement

CENTRAL RETINAL ARTERY OCCLUSION 1B (EMERGENCY )

1. occlusion of central retinal artery due to embolus 2. AEx emboli: fat, plaques, atrial myxoma thrombosis - due to GCA, SLE - common in HTN and CV dsiseases - Raised IOP - more common in males than females - usually unilateral 3/4 ▪sudden painless unilateral severe loss of vision ▪poor or absent pupillary light reflex 5. Ix ▪fundoscopy : pale opaque fundus w/ red fovea, sometimes emboli visible, retina becomes milky white, narrow arteries ▪cherry-red spot in macular area 6. Rx 1. immediate lowering of IOP: ocular hypoensives- timolol, acetazolamide

Diabetic FOOT AND CHARCOT JOINT / ARTHROPATHY

1. occrs due to combination of neuropathy and PVD 2. presents with neuropathy: loss of sensation ischaemia: absent foot pulses, reduced ankle-brachial pressure index (ABPI), intermittent claudication complications: calluses, ulceration, Charcot's arthropathy, cellulitis, osteomyelitis, gangrene charcot joint: red, warm, inflammed foot with deformities

Acutemanagement of asthma

1. oxygen 100% oxygen via facemask aiming for 94-98% saturations 2. Salbutamol ( nebulised) 3. IV hydrocortisone 100mg OR oral prednisolone 40mg 4) Nebulised ipratropium bromide 500mcg 5) Single dose of IV magnesium sulphate 6) Escalate 6) Admission to ITU

MCL damage

1. passive abduction of knee 2. damaged from skiing valgus stress

DYSPEPSIA

1. persistent indigestion/ pain/discomfort in upper abdomen for at ;east 12 weeks. usually caused by GORD, 2. common causes: gord, PUD, medications 3. IX - refer if red sx : mass, haematemesis, low HB, receurrent vomiting , GI bleed --FBC 9 RD - review meds : calcium antagonists, nitrates, theophyllines, bisphosphonates (especially alendronate), steroids, NSAIDs. - lifestyle advice

CHRONIC PANCREATITIS 1-6 1B

1. persistent inflammation of the pancreas that results in permanent structural damage with *fibrosis* and *ductal strictures*. -results in secondary DM bue to descrtuction of pancreatic b-cells -results malabsorption, pancreatic acini destroyed 2. causes - alcohol -smoking S/S - Abdo pain after food better when leaning forward/sitting, - steatorrhoea - weight loss - epigastric pain radiating to the back - Anorexia Ix CT with contrast : calcification AXR: calcification -ERCP : rarely used for chronic as its invasive -Amylase , lipase -CT: detects calcification bloods: FBC, LFTs, bilirubin Rx - pain control - creon to manage malabsorption -manage diabetes - manage complications:portal htn, portal vein thrombosis, pancreatic cancer

Thiazolidinediones

1. pioglitazone - PO 2. Increase insulin sensitivity via activation of PPAR-gamma And works by activating PPAR-gamma receptor in adipocytes to promote adipogenesis and fatty acid uptake 3. SE - weight gain, bladder cancer, oedema, fractures (OSTEOPOROSIS) , liver impairment (do not use in heart failure), FLUID RETENTION avoid in HF - BLADDER CANCER -OSTEOPOROSIS --> FRACTURES

TIBIAL NERVE

1. plantar flexion and inversion 2. posterior knee dislocation causes damage but this is rare , well protected

ASBESTOSIS 2B

1. pneumoconiosis which results in diffuse parenchymal lung fibrosis develops as a result of heavy prolonged exposure to asbestos - Lag phage of 10-25 years usually but can be up to 45 years in 3/4 -cough -progressive dypnoea -clubbing -fine bi-basal crackles -restrictive defect of PFTs ( normal or high FEV/FVC, low FEV1, low fvc, low TLCO cor pulmonale Ix CXR HCRT PFT biopsy for asbestosis sputum

ACTINIC KERATOSIS ( solar keratosis) 1B

1. precancerous skin lesion of horny tissue formation that results from excessive exposure to sunlight 2. due to DNA damage by short wavelength UVB. 3. features: flat or thickened papule or plaque that is white/yellow, scly, warty or horny. Skin coloured or pigmented. can be tender or asymptomatic 4: Ix: biopsy to exclude SCC 5: Rx: excision, shave curettage, cryo, imiquimoid, 5-fluorouracil

HAEMOLYTIC ANAEMIA 1B

1. premature destruction of RBCs and erythropoesis to compensate --> NORMOCYTIC ANAEMIA HEREDITARY: - membrane defects : hereditary spherocytosis/elliptocytosis - metabolism: G6PD deficiency ( INTRAVASCULAR, X-LINKED) - haemoglobinopathies: sickle cell, thalassaemia ACQUIRED: 1. IMMUNE: - autoimmune: warm/cold antibody type - alloimmune: transfusion reaction, haemolytic disease newborn - drug: methyldopa, penicillin 2. NON-IMMUNE: - microangiopathic haemolytic anaemia (MAHA): TTP/HUS, DIC, malignancy, pre-eclampsia - prosthetic cardiac valves - paroxysmal nocturnal haemoglobinuria - infections: malaria - drug: dapsone Features: Pallor, jaundice, fatigue, SOB, dizziness, splenomegaly dark urine due to haemoglobinuria, hepatosplenomegaly Ix 1 Check FBC. 2 Peripheral blood film —polychromasia, spherocytosis, fragmentation (schistocytes), helmet cells, echinocytes., spherocyes 3. reticulocytes. 4. serum bilirubin (unconjugated). 5. LDH. 6. direct coombs test - autoimmune HA

PRIMARY OPEN ANGLE-GLAUCOMA (CHRONIC) 2B

1. progressive neurodegenerative slow build up of intraocular pressure usually due to dysfunctional outflow of aqueous humour. its an optic neuropathy which may be due to : ▪sclerosis of the trabecular meshwork. ▪The endothelial lining of the canal of Schlemm may also be sclerosed. ▪degeneration of retinal ganglion cells 1b :Has a wide and open angle between the iris and cornea 2. AEx/RF - asymptomatic - IOP >21mmH ->50 years > FH, black race 3/4: - primary causes visual field defects - complete loss of vision eventually - decreased visual acuity -sluggish pupillary response IN MUCH LATER STAGE - mild headache. -disc changes Ix diagnosis ▪Tonometry ▪Gonioscopy. It reveals a wide open angle of anterior chamber. Its primary importance in POAG is to rule out other forms of glaucoma. ▪direct opthalmoscopy: cup to disc ratio of >0. 7 (0.4-7 normal) ▪Intraocular pressure ⬆ or normal ▪ visual field defects ▪ scotomas , parasternal scotoma ▪loss of nerve fibre layer ▪notching of optic nerve cup -optic disk pallor Rx 1. carbonic anhydrase inhibitors +/- bb, +/- a-2 agonist PLUS iridotomy after acute attack has resolved others: ant. chamber paracentesis,

PRIMARY PULMONARY HTN AND SECONDARY HTN 1B 1-5

1. pulmonary hypertension is mean pulmonary artery pressure >25 mmHg at rest( 12-15 normally) - the blood vessels in the lungs narrow and the pressure in the pulmonary artery rises far above normal levels. PRIMARY idiopathic, >30 possible mechanism: -high levels of endothelin 1- vasoconstrictor. low NO & prostacyclin metabolite levels whoch are vasodilators. -TAX2 metabolites increases--> vasoconstrictor SECONDARY : due to underlying dz . Lung disease (COPD,CF,ILD, interstitial fibrosis ) -causes hypoxic vasoconstriction --> ⬆ pulmonary pressure --> RV hypertrophy due to increased force ainst high pulmonary pressure PE: sudden increased pressure -connective tissue dz decreased area of pulmonary vascular bed -> ⬆ resting pulmonary arterial pressure. 3; Signs: RV heave, P2 ( delayed closure of pulmonic valve), raised JVP, raynauds 4. symptoms: SOB, fatigue, syncope 5. Ix CXR- Enlarged main pulmonary artery is seen in 90% and enlarged hilar vessels ECG: tall R wave and small S wave,RVH Echo PFT: restrictive pic LFT: exclude liver disease or portal hypertension as a cause of secondary pulmonary hypertension. Nocturnal oximetry: Nocturnal de-saturation seen in about 70% to 77% HIV serology ABG: copd HRCT- lund disease CTPA: Pe associated ANCA: scleroderma, rheumatoid disease

EMPYEMA/PYOTHORAX def. 1A

1. pus in pleural space, usually following pneumonia, < glucose and <pH <7.2 2. AEx/ RFx: PAD: pneumonia, alcohol abuse, diabetes b. S. pneumoniae, S. milleri, Staphy spp. Signs and symptoms ( FREP DB) Fever Rigors Effusion ( recent) Pneumonia Dull percsion Breath sounds recuded Ix ( BCCTU) - cultures: infective organism, abx sensitivity - bloods: CRP ( high), WCC (high) -CXR: urgent in px with sepsis & resp symptoms, lateral and AP, blunting of costophrenic angle or effusion on affected side, -thoracentesis: pus, cloudy, bad odour, low pH <7.2, >30g/dL protein, LDH >2-3 times upper normal limit, -USS: pleural effusion Rx 1 IV abx: cefuroxime AND metronidazole 2 chest drain under uss guidance pH >7.2 3 suppurtive care: analgesia, antipyrtics, oxygen malignancy, TB (when the pleural fluid is usually lymphocytic), and rheumatoid pleuritis

CHRONIC SINUSITIS 1A

1. recurring acute sinusitis lasting *longer than 3 months*. The ciliated epithelial sinus lining is replaced by thickened stratified squamous lining, with absent cilia, due to repeated infection. more susceptible to anerobic infections. FEatures:: frontal headaches, worseon leaing forward, maxillary pain, pain over bridge of nose (ethmoidal sinusitis), retro-orbital headache (sphenoidal sinusitis), with purulent nasal discharge and blockage. Ix: -not needed usually. -*sinus radiograph* may show an air-fluid level, with thickened mucosal lining RX CHRONIC 1. abx + nasal irrigation -2 weeks of antibiotics active against H. influenzae such as doxycycline or co-amoxiclav 3. steroid intranasal + decongestant

GASTRO-OESOPHAGEAL REFLUX DISEASE 1A

1. reflux of gastric contents into the esophagus 2.transient LOS relaxation, hernia, - Can also result from an incompetent LES, gastroparesis, Zollinger-Ellison syndrome (gastrin-secreting tumour) RF: obesity, fatty diet, coffee, chocolate, alcohol , pregnancy 3/4 1. burning epigastric pain, improves w/ antacids, frequent belching, hoarseness, cough in the morning 2. RED FLAGS: weight loss, dysphagia 5. Ix OGD PPI trial manometry-> LOS competency 6. Rx -Lifestyle includes weight loss, elevate head of the bed, reduce meal size -, eat well before bed, avoid substances which decrease LES tone (alcohol, chocolate, spicy foods, coffee). Pharmacological treatment includes antacids 1. 1st line PPIs : Omeprazole (20mg), lansoprazole (30mg), ( STOP 2 WEEKS BEFORE OGD) *SE: Abdo pain, constipation, diarrhoea, headache, arthralgia,hyponaetraemia, hypomagnaesimia, ⬆ fractures, osteoporosis* -2nd line: H2 antagonists: ranitidine, famotidine, nizatidine *SE: constipation, diarrhoea, myalgia, gynaecomastia, Complications 1. oesophagitis, barrets, adenocarcinoma, upper GI bleed, strictures, ulcers

Impetigo 1A

1. s. aureus and GAS strep skin infection, honey coloured crusty lesions exclude from school till all lesions have scabbed over 2. Can lead to glomerulonephritis Bullous Impetigo 1. Staph as a cause, phage Group II 2. Intra epidermal cleavage occurs within the stratum granulosum 3. features - Numerous erythematous based vesicles that become pustular and often rupture revealing a deeply erythematous base 4. Occurs on intact skin Non-Bullous impetigo 1. Strep or staph as cause 2. Occurs on unintact skin, i.e after minor trauma 3. Clinically - erythematous based, honey c 1tc 1. Topical muciprocin or fusidic acid if localised 2 Oral antibiotics *ADULT*: 500mg QDS flucoxacillin *CHILD*: 250 mg QDS flucloxacilllin

Actions of PTH overall action on Ca+ metabolism

1. secreted in response to ⬇ serum Ca+ 2. PTH increases calcium in blood by stimulating osteoclasts 3. DECREASES phosphate reuptake in kidneys Phosphate ions form water-insoluble salts with calcium. Thus, a decrease in the phosphate concentration of the blood plasma (for a given total calcium concentration) increases the amount of calcium that is ionized 4. stimulates hydroxylation of 25-dihydroxychocalciferol ( liver) --> 1,25 dihydroxycholecalciferol ( kidney) 5. Vit D 3 stimulates GI absorption of calcium and phosphate , enhances PTH action on bone

ACUTE PHARYNGITIS 1A

1. self-limiting infection of pharynx characterised by acture sore throat,NO COUGH, nasal congestion and discharge common in winter 2. AEx: a. group A Streptococcus (GAS): S.pyogenes (children) b. Candida in immunocompromised c. Mycoplasma species and Arcanobacterium haemolyticum ( some adults) Viral: EBV, adenoviruses, enteroviruses, influenza A and B, and parainfluenza, HSV, CMV, coxackie 3. signs a. cervical adenopathy b. pharyngeal exudates c. fever d. lack of cough, rhinorrhoea UNLESS viral 4. symptoms a. sore throat b. fever c. headache d. N&V, abdo pain in kids e. dysphagia 5. Ix a. rapid antigen test for GAS b. cultures and swabs Rx a. self-limiting b. hydration, rest c. recurrent abx, antifungals

MELANOMA 1B

1. several types: amelanotic melanoma ( appears very quick, very metastatic) , lentigo maligna 3/4. asymmetrical, irregular borders, lack of uniform colour , may bleed, rapidly growing, uneven thickness

Pseudomembranous Colitis (NOM ) 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. signs and sx of bowel obstruction without a physical occluding lesion. 2. n/a 3. Caused by disorders of smooth muscle, myenteric plexus or extra-intestinal nervous system, surgery, trauma, electrolyte disturbances DRUGS: *Clindamycin, ampicillin, cephalosporins* ALSO: ( OPIATES , phenothiazines, ANTICHOLINERGICS , tricyclics, calcium channel blockers) 4. pain, distension, and vomiting depending Rx supportive nutritional support electrolyte balance acute: decompression

SQUAMOUS CELL CARCINOMA

1. skin cancer, rolled raised edges, keratinous 2. excessive sunlight exposure to chemical carcinogens, chronic irritation 3/4: itchy, rolled edges , 5. Ix biopsy

CENTRAL SLEEP APNOEA

1. sleepING disorder with periods of diminished or absent respiratory effort due to a *disruption in signals sent from the brain that regulate breathing* 3. PATHOPHYSIOLOGY - brain stops making an effort to keep breathing resulting in hypoxaemia -starts with episode of hyperapnoea -results in hypocapnea - hypocapnia below certain threshold results in apnoea - causes CO2 to rise - rise in CO2 results in hypercapnia - triggers hyperapnoea again

PROSTATE CANCER 1B

1. slow growing tumor, most adenocarcinoma (95%), increasing age . screening from age 50 2. AEx/RF = genetics, diet high in fat, obesity, AA, age, red meat 3. symptoms: none / obstructive LUTS: hesitancy, weak stream, straining to urinate, dribbling. haematuria, haematospermia , perineal pain, impotence 4: signs: bone pain from mets, sciatica, lymphoadenopathy, anuria (ureteric obstruction by lymph nodes) , anaemia, weight loss 5. Ix: - *multiparametric MRI 1st line* -biopsy 2nd line a. PR exam: hard, nodular asymetrical b. PSA >10 c. needle bx d. urinalysis PSA - Raised with BPH, prostatitis, UTI, ejaculation, exercise, urinary retention, instrumentation, DRE - normal in 20% prostate Ca

Chrondromalacia Patella ( DNT NEED TO KNOW )

1. softening (degeneration) on articular surface of posterior patella. 2. MOI: direct trauma to the patella, abnormal patella tracking 3. Signs/Symptoms: anterior knee pain while running, pain whilst walking, squatting, going up steps, - swelling around patella, -crepetition when flexing and extending knee (grinding noise) -pain going down stairs

PHIMOSIS

1. stenosis or narrowing of foreskin so that it cannot be retracted over the glans penis 2. resolves by age 5 3. Rx: betamethasone cream applied

How are gallstones formed?

1. supersaturation of bile with cholesterol--> too much cholesterol in bile --> cant be help in solution --> cholesterol comes out of solution as solid 2. insufficient bile salts and acids --> cholesterol cant be held in solution ---> chol precipitates out of solution 3. gallbladder stasis --> can cause cholesterol to precipitate out as solid, separates if sat too long 4. too much bilirubin --> combines with ca+ --> pigmented stones --> seen easily in x-ray

PAEDIATRIC COMPLICATONS OF DKA

1. susceptible to *cerebral oedema*, following fluid resus, need 1:1 nursing and neuro obs, headaches, irritability, visual disturbances 2. likely to occur 4-12 hrs after start of rx

COPD exacerbation

1. sustained (>24-48 h) worsening of dyspnea, cough, or sputum production leading to an increased use of medications 2. viral URTI, bacteria, air pollution, CHF, PE, MI 3/4. worsening SOB, cough, sputum 5. Ix CXR Peak flow/ spirometry ABG 6. Rx -oxygen 88-92 ( *high-flow oxygen initially* !!!! -bronchodilators by MDI with spacer or nebulizer -SABA + anticholinergic, e.g. salbutamol and ipratropium bromide via nebulizers -systemic corticosteroids -Amoxicillin or tetracycline or clarithromycin doxy or tetra

HYDRONEPHROSIS NOM

1. the dilation (swelling) of one or both kidneys- includes ureters, pelvis, calyces AEX: urinary retention- chronic, obstruction- stones, tumours, strictures, VUR,

PULMONARY NODULES 2B

1. these are focal, round, or oval areas of increased opacity in the lung, measuring <3cm in diameter. they are detected on CXr or Ct. -most are benign -some can be cancerous -suspect cancersous in smokers, old, AEx Fibroma (a lump of fibrous connective tissue) Hamartoma (an abnormal grouping of normal tissues) Neurofibroma (a lump made up of nerve tissue) cancer An infectious fungus (histoplasmosis, coccidioidomycosis, cryptococcosis, or aspergillosis, for example) Tuberculosis (TB) A lung abscess rheumatoid wegner sarcoidosis Ix 1. CT/ PET 2. excision 3. biopsy

BUDD-CHIARI SYNDROME

1. thrombosis of hepatic veins and/or adjacent IVC classic triad: sudden onset abdominal pain, ascites, and tender hepatomegaly 2. causes/RF - thrombic conditions (Protein S/Ceff, antithrombin, FV leiden) , antipospholipid , IDB 3.-can be asymptomatic - liver failure, cirrhosis - Acute obstruction: fatigue, RUQ pain , nausea, jaundice, vomitting, ascites Ix USS is 1st line Rx supportive restore blood flow

CORNEAL ABRASION 1B

1. trauma to cornea leading to loss of corneal epithelium 2. tauma, idiopathic 3/4 1. severe pain, worse on blinking 2. lacrimation 3.blepharospasm- inability to open eye 4. photophobia, foreign body sensation 5. Ix fluorescein drops and blue light - green-stained abrasion 6. Rx -Topical tetracaine 1% -Protective pad/eye-patch -Chloramphenicol 5 days - heal within 48 hrs -RV 24 hrs

TESTICULAR TORSION 1B

1. twisting of the spermatic cord causing decreased blood flow to the testis, Ischaemia and necrosis . common in boys <12 2. AEx: cryptorchidism 3. severe sudden unilateral testicular pain, N&V, abdopain, unable to walk 4. tender, hot, swollen testicle, high testicle, no relief on raising testicle (prehns sign) , reactive hydrocoele, absent cremasteric reflex Rx -Orchidectomy, exploration and fixation -Bilateral fixation - orchidopexy

what are carcinoid tumours (pulmonary)

1. uncommon primary lung tumour from neuroendocrine cells -slow benign tumour, there are aggressive -more common in women 40-50 , smoking not a factor -features: asymptomatic , broncial --> wheeze, dyspnea, recurrent infections, haemoptysis, lobar collapse 1. SIADH- HYPOnatraemia 2. carcinsoid sundrome: flushing, diarrhoea , bronchocosntriction 3. ACTH, ppigmentation Ix CXR broncoscopy w/ biopsy -> histology CT Bloods serotonin

Constipation 1A

1. unsatisfactory defecation characterised by infrequent stools, difficult stool passage, or defecation that is both infrequent and/or difficult. - increases with age -common in females *primary*: abnormal regulation of colonic ad neuromucular functions and brain-gut function *Diet*: too little fluid or fiber Lack of physical activity *Medications*: opiates, anticholinergics *Medical illness*: IBS, diabetes, hypothyroidism Depression *Neurologic disease*: Parkinson's, MS Decreased motility, irregular Ix - CT colonoscopy - PR exam -TFTs -U&Es -glucose (diabetes ) -AXR (impaction) -barium enema

Overactive Bladder

1. urgency, with or without urge incontinence, usually with frequency, nocturia, difficulty with urination, incomplete bldder emptying. 2. Etiologies: - Due to detrusor muscle overactivity. causing uncontrolled increases in pressure, CNS and neural dysfunction, stroke, parkinson's disease, MS, ageing, diabetes. 3 Ix: 1. diptsick urinalyis 2. bladder diary 3. cytometry Rx: -Bladder training - timed, resist, timetable -Absorbent pads, incontinence pads -Anti-cholinergics (tolterodine, oxybutynin) - suppress detrusor activity -Sympathomimetics - Mirabegron - bladder antispasmodic -Intravesical botulinum toxin injection -Neuromodulation via sacral nerve stimulation (S3 nerve root) -Psychotherapy -Clam ileocystoplasty -Oestrogens in post-menopausal

FRANK/VISIBLE HAEMATURIA / MACROSCOPIC causes 1B

1. urine that is visibly red/blood 2. 1. urothelial cancer (66%): M, >35, smoker, Exposures to benzene, aromatic amines, carcinogens, chemotherapy, or high doses of analgesics- CYTOSCOPY GOLD STANDARD for bladder cancer 1. Infection: cystitis, tuberculosis, prostatitis, urethritis, schistosomiasis, infective endocarditis. 2. Tumour: renal carcinoma, Wilms' tumour, carcinoma of the bladder, prostate cancer, urethral cancer or endometrial cancer. 3. Trauma: renal tract trauma due to accidents, catheter or foreign body, prolonged severe exercise, rapid emptying of an overdistended bladder (eg, after catheterisation for acute retention). 4. Inflammation: glomerulonephritis, Henoch-Schönlein purpura, IgA nephropathy, Goodpasture's syndrome, polyarteritis, post-irradiation. 5. Structural: calculi (renal, bladder, ureteric), simple cysts, polycystic renal disease, congenital vascular anomalies. 6. Haematological: sickle cell disease, coagulation disorders, anticoagulation therapy. Surgery: invasive procedures to the prostate or bladder. 7. oxins: sulfonamides, cyclophosphamide, non-steroidal anti-inflammatory drugs. 8. Others: genital bleeding, including child abuse; menstruation; Münchhausen's syndrome or fabricated or induced illness by carers. Ix Dipstick urine to exclude transient cause including UTI. MSU if clinically indicated. Plasma creatinine/eGFR. nephritic syndrome

COR PULMONALE 1B

1. when lung disorders cause R ventricular hypertrophy which can cause R sided heart failure a. lung dz > hypoxia in alveoli . constriction of arterioles of affected alveoli to divert blood flow> increased pulmonary pressure > pulmonary HTN ( >25mmhg) > RV hypertrophy pump harder against⬆ pulmonary pressure to get blood to lungs > subesequent failure AEx: PE ( rapid rise in pressure) , COPD, Scoliosis ( lungs cant expand propely 3/4. Please Read His text peripheral oedema Raised JVP HEpasomegaly Tricuspid imcompetnce ( pan systolic murmur) cyanosis, fatiggue, SOB syncope RV heave 5. Ix Echo CXR Rx - treat underlying lung dz - diuretics -digoxin

ORAL CANDIDIASIS 1B

1. when oral candida albicans grows out of control and causes thrush. ASSOCIATED W/ IMMUNOLOICAL SUPPRESSION - seen in infants and older adults -common in females >60 2. AEx : hyposalivation, poor oral hygiene in dentures, advanced malignancy, chemo, HIV, endocrine disturbances (DM, thyr dz,), immunosuppression , Inhaled corticosteroids. 3/4. creamy white/yelowish plaques, cracks, ulcers, crusted fissures . candidiasis can be rubbed off. leukoplakia cannot 5. smear of lesion, biopsy, culture, mouth rinse Rx. clotrimazole oropharyngeal, miconazole, nystatin

metabolic alkalosis 1B

1. ⬆HCO3 ⬆BE, Low Ph >7.45 AEx Conns Cushing's D&V , diuretics NG tube aspiration S&S muscle cramps, weakness, arrhythmias, seizures , coma Ix ABG U&Es

1. ⬇ Vit B12 ( cobalamin) needed for DNA synthesis. absorbed in terminal ileum *bound to intrinsic factor produced by gastric parietal cells*. 2. results in Macrocytic megaloblastic anaemia. > 110fl MCV 3. Causes 1. diet: veganism, vegetarian 2. gastric: mucosal atrophy due to gastritis, gastrectomy 3.. malabsorption: chrons, pancreatic insufficency, tapeworn, resection of ileum 4: autoimmune : destruction of parietal cells --> no seceretion of intrinsic factor 5. drugs: PPI, antacids, H2 antagonists, anticonvulsants 4.Features: -fatigue -SOBOE - parasthesiae -no vibration sense - loss of proprioception -angular stomatitis, glossitis Ix -For pernicious anaemia - anti-IF, anti-parietal cell, raised gastrin -FBC - low Hb, high MCV, low HCT -Megaloblasts in the bone marrow -Low serum B12 -Schilling test -Raised bilirubin -Raised LDH -Blood film - oval macrocytes, hyper-segmented neutrophil polymorphs -Low reticulocytes -Raised methylmalonic acid and homocysteine Rx -Oral cyanocobalamin or hydroxocobalamin IM - 1mg 3x week for 2 weeks then once every 3 weeks then once every 3 months for life -Folic acid - 1mg OD -Adjunctive transfusions in severe cases

1. ⬇ Vit B12 ( cobalamin) needed for DNA synthesis. absorbed in terminal ileum *bound to intrinsic factor produced by gastric parietal cells*. 2. results in Macrocytic megaloblastic anaemia. > 110fl MCV 3. Causes -pernicious anemia ( >40, associated/ oher autoimmune i.e hypothyroid) -gastreactomy -chrons - vegan 4.Features: -fatigue -SOBOE - parasthesiae -no vibration sense - loss of proprioception -angular stomatitis, glossitis Ix -FBC: ⬇ Hb, ⬆MCV - iron studies: - Film: , poikilocytosis, basophilic stippling, Howell-Jolly bodies, - IFA diagnostic for pernicious anaemia Rx - correct cause -hydroxocobalamin 1mg IM and folic acid PO

CHALAZION : 1-6 1A

1.) Cyst which is the result of obstruction of the duct of a meibomian gland with *secondary lipogranulomatous inflammation* (accessory gland of eyelids) - clogged oil gland causing focal inflammation ->Basically a cyst ***Can cause cellulitis if becomes infected 2. S.aureus , S. epidermidis RF: blepharitis, ocular rosacea, seb dermatitis, DM 3/4: erythematous swelling on eyelid, not painful Ix: Clinical , biopsy, Rx lid massage, warm compresses, curettage or SC triaminocycline -incision and curettage

VIRAL KERATITIS (HSV) - OPHTHALMACUS 1-6 1B

1.. Reactivation of HZV in the ophthalmic division of the trigeminal ganglion. usually unilateral 2. herpes zoster 3/4 -Vesicular rash in V1 distribution -Dermatome Distribution -Severe neuralgia pain HUTCHINSON'S SIGN (lesions at tip of nose indicative of corneal involvement) --Often not involving eyeball -Dendritic Corneal Lesion -Uveitis -reduced acuity -photophobia Ix wood lamp examination - ASSESS acuity, corneal stain, corneal response, vesicles on slit lamp Rx refer Aggressive topical antivirals Ophthalmic consultation ? Oral antiviral agents ? Corneal Transplantation

WHAT INVESTIGATIONS WOULD YOU DO FOR TIDM 1B

1..fasting > 7.1/6.9 mmols or 2-hr RG >11.1 mmol 2. OGTT: >11.1 mmols 3. HbA1c: >6.5% (>48MMOL) 4. random glucose/ 2hr > 11 mmol 5. Ketones ++

Seborrhoeic Dermatitis 1B

1.General info: Chronic fungal ( malassaezia) skin infection affecting sebaceous, gland-rich regions of the scalp, face, beard, and trunk. *Rash*: papulosquamous scaly patches 2. Aetiology: Parkinsons, HIV patients more susceptible 3: RF: PD, oily skin, immunosupression, tardive dyskinesia, downs, stress 4: features: Ill-defined localised scaly patches or diffuse scale in the scalp, -salmon-pink thin, scaly, and ill-defined plaques in skin folds on both sides of the face, -Petal or ring-shaped flaky patches on hair-line and on anterior chest,Rash in armpits, under the breasts, in the groin folds and genital creases - 3.Clinically: 1. Cradle Cap - baby 2. Tinea Amiantacea - Scalp of children 3. Seborrheic Blepharitis - EYE Lids 4. Classic adult Seborrheic Dermatitis - AIDS pt Rx- NICE - *Scalp and beard*: Ketoconazole 2% shampoo BD for 4 weeks, then once every 1-2 wks for maintenance PLUS steroid if intense itching -*face and body*: *Ketoconazole 2% cream or other imidazole cream* , *shampoo* which can be used as body wash *PLUS mildly potent steroids to help with inflammation* -*severe widespread dz*: consider alternative diagnosis i.e psoarisis. immunocompromised?

HYPOCALCAEMIA 1A

1.Low levels of calcium <2.2 mmol 2. AEx a. hyporarathyroidism and its causes b.pseudohypoparathyroidism (target cells insensitive to PTH) b. parathyroidectomy b. Chronic kidney disease/Renal failure (less 1,25-OH-D3, high PTH, hyperphosphatemia) d. Vit D deficiency (high PTH, poor nutrition, lack of sun Drugs: glucocorticoids; anticonvulsants, chelating agents : citrate, EDTA 3/4 PACTS Perioral Paresthesia Arrhythmias (prolonged QT interval), anxiety and depression Convulsions, cramps, Chvostek's sign ( tapping over parotid causes facial muscles to twitch), seizures Tetany , troussaeu signs ( wrist flexion) Skin: hyperpigmentation, dermatitis, eczema, alopaecia, brittle nails ( chronic) *twitching!!* CATS go vum: Convulsions, convulsions arrhythmias tetany numbness in hands, feet, around mouth IX 1. PTH 2. U&Es: Ca+ , Mg, Phosphte 3. bone imaging 4. Dexa scan 5. 24-hr urinary calcium 6. Vitamin D levels 7. ESR, FBC 8. ECG 9. ALP Rx IV Calcium gluconate 1-2 g over 10-20 min followed by slow infusion i.e calcium gluconate 10ml of 10% over 10 mins if necessary *nb Hypocalcaemia is an indication that kidney disease is chronic and not acute*

GOUT 1A

1.microcrystal synovitis caused by the deposition of monosodium urate monohydrate in the synovium --> attacks of acute inflammatory arthritis, tophi and possible joint destruction -commonly affects 1st metatarsophalangeal joint but can affect any joint AEx -chronic hyperuricaemia (uric acid > 0.45 mmol/l) DARTH D- iuretics: thiazides, loops, salicytes A- lcohol R- enal disease ( urate under-excretion) T- rauma H- HTN and hypothyrpodism S&S: severe painful, warm, red, shiny joint with gouty tophi - Associated with nephritis and nephrolithiasis Ix ESR ⬆ CRP ⬆ Uric acid levels > 7mg M or > 6mg in F Arthrocentesis : negatively birefringent crystals under polarised light X-ray : erosions USS Rx 1. indomethacin / NSAIDs 2. colchicine ( SE diarrhoea) 3. intra-articular steroids 4. Allopurinol prophylaxis >2weeks after attack ( associated with TEN, SJS, DRESS syndrome) 5. lifestyle: ⬇ alcohol, ⬇ weight ⬇ liver, kidneys, seafood, oliy fish

Nephrolithiasis (1A/B) 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1.presence and formation stones in kidneys and ureters. high levels of urinary solutes : Ca+, uric acid, oxalate, Na+ and low levels of stone inhibitors Mg and citrate . 1. 80% calcium ( 80% calcium oxalate, 20% calcium phosphate) 2. 10-20% uric acid stones 3. 1% cyctic ( cystinuria, genetic) 4. 1-5% struvite/ infection stones( common in women -> UTI) RF: obesity, high protein and salt intake, dehydration , vit c overdose -> oxalate 2. Renal colic is pain associated with obstruction of collecting system/ ureters with stones 3. signs and symtoms a. severe loin to groin pain -> radiates to groin, intemittent, colic b. costovertebral angle and ipsilateral flank tenderness c. worse on staying still c. testicular pain b. N&V c. fever, rigos if pyelonephritis d. Haematuria ( micro and macroscopic) e. dysuria features of renal colic -Severe, acute loin to groin pain radiates to back , worse o staying still -haematuria - nausea and vomitting -testicular pain Ix -urinalysis -FBC for U&Es , CRP, renal function, Ca+ , phosphate, Ca+ , urate -pregnancy test -ultrasound in pregnant women , children and young people is first life - *CTKUB FIRST LINE IN MALES AND OLDER WOMEN* - AXR - IV pyelogram/urogram Rx 1. analgesia ( IM/rectal diclofenac 75mg ) 2. anti-emetic - cyclyzine, metoclopramide, ondasteron 3. increase fluids 3. infection gentamicin/cefuroxim 4. admit if shock/ sepsis / pregnant 5. -Extracorporeal shock wave lithotripsy if < 2cm -Ureteroscopy with basket removal or laser <2 AND PREGNANT -Percutaneous nephrostomy or nephrolithotomy withor without ureteric stenting -Open surgery

OESOPHAGEAL STRICTURE 1B qs.

1/2. Narrowing of oesophagus due to scar tissue from inflammation from GORD 3/4. dysphagia , regurgitation, weight loss, something stuck 5. Ix - barrium swallow - OGD Rx - endoscopic dilation -stent -treat GORD : H2 antagonists , PPI -surgery

Ix SIBO NOM

1st line: Hydrogen breath test SB aspirate and culture abx trial OTHER TESTS -14C-xylose breath test or quantitative culture of intestinal aspirate - bowel biopsy breath hydrogen analysis - stool analysis - bile acid breath xylose breath test - Gram-negative bacteria metabolize xylose, D-lactate levels : bacteria fermentation of lactosis

BETA-THALASSAEMIA TRAIT 2B

2 B goblin genes trait is 1 missing Beta-thalassaemia trait is an autosomal recessive condition characterised by a mild hypochromic, microcytic anaemia - usually asymptomatic features - mild hypochromic, microcytic anaemia - microcytosis is characteristically disproportionate to the anaemia - HbA2 raised (> 3.5%) IX 1. Hb may be ⬇ but is not usually <10.0g/dL. 2.vMCV ⬇ to ~63-77fL 3. Blood film: microcytic, hypochromic RBCs; target cells often present. Basophilic stippling especially in Mediterraneans. 4. RCC 4. 2 HbA2 (a2d2) 4—provides useful diagnostic test for b thalassaemia trait. 2 Occasionally confused with iron deficiency anaemia, however, in thalassaemia trait the serum iron and ferritin are normal (or increaesd) whereas in IDA they are 5.

MEN 2A

2PM Parathyroid hyperplasia Phaeochromocytoma Medullary thyroid carcinoma Hirschsprung's disease as an associated feature

Pediatric Risk factors for eustachian tube dysfunc

2nd hand smoke prematurity, low birth wt young age craniofacial abnormalities adenoid hypertophy GERD attend day care low SES

Rx TENSION PNEUMOTHORAX

2nd interostal space midclavilar line large bore cannula - Immediate aspiration from the 2nd intercostal space, mid-clavicular line to relieve pressure - Then intercostal drain 5th intercostal space, mid-axillary line as below - Then insert a chest tube and perform CXR - Insert a 16G cannula attached to a 3-way tap and syringe - 5nd intercostal space, anterior axillary line - Aspirate 2.5L of air then insert a chest tube/drain in the safe triangle IF unsuccessful (still >2cm defect) - Safe triangle - latissimus dorsi, nipple, axillary line and pectoralis major (the 5th intercostal space anterior to the mix-axillary line) - If the lungs are less than 2cm from edge, then discharge and follow-up

Tertiary Syphilis

3 to 60 years Gummas, CNS, Cardiovascular Misdiagnosed as Leprosy

Toxic Shock Syndrome

3. Clinically: a. Temp > 102F b. Diffuse maculopapular eruption that desquamates in 1-2 weeks +/- petechiae c. Mucuous membrane hyperemia, strawberry tongue d. Multi-system involvement: Hypotension, GI upset, elevated creatinine kinase, CNS changes, elevated BUN & creatinine, elevated bilirubin, low platelets, pulmonarysymptoms to include ARDS 4. Treatment: Beta-lactamase resistant antibiotics (oxacillin, nafcillin, cefoxitin, etc.) and supportive therapy

S&S ORBITAL CELLULITIS 1A

3. Sx - Periocular pain, double vision, pain with eye movement, restricted eye movement, decreased vision (can lead to blindness!) 4. Signs - Violaceous discoloration. hyperemia and chemosis, decreased intraocular movements, proptosis, tense eyelids.

What is amaurosis fugax?

A "black curtain" coming down vertically into the field of vision in one eye.

SEBACIOUS CYST

A closed sac found just under the skin containing a cheeselike material formed from skin secretions. Rx -drain : freeze w/ ethyl chloride then drain --> leave open

Compylobacter

A flu-like prodrome is usually followed by crampy abdominal pains, fever and diarrhoea which may be bloody May mimic appendicitis Complications include Guillain-Barre syndrome

Ehlers-Danlos syndrome (interest)

A group of inherited disorders that affect your connective tissues — primarily your skin, joints and blood vessel walls. People who have this syndrome usually have overly flexible joints and stretchy, fragile skin. This can become a problem if you have a wound that requires stitches, because the skin often isn't strong enough to hold them.

Maturity onset diabetes of the young (MODY)

A group of inherited genetic disorders affecting the production of insulin. Results in younger patients developing symptoms similar to those with T2DM, i.e. asymptomatic hyperglycaemia with progression to more severe complications such as diabetic ketoacidosis. -C peptide can be used to differentiate , low in T1DM ( pancreas is not making enough insulin precursor,which breaks down to form C-peptide and insulin) - C-peptide normal or high in individuals with T2DM

What is a hernia and what are common causes?

A hernia is a protrusion of a viscus or part of a viscus through a defect of the walls of its containing cavity into an abnormal position. -caused by Heavy lifting, diarrhoea, constipation, coughing, sneezing

What is hyphema?

A hyphema is a pooling or collection of blood inside the anterior chamber of the eye

What is the retina?

A layer at the back of the eyeball containing 10 layers of cells that are sensitive to light and that trigger nerve impulses that pass via the optic nerve to the brain, where a visual image is formed. .

What is a Mallory-Weiss tear? Aex?

A linear mucosal tear in the oesophagus at the gastroesophageal junction. -result of rapid increases in gastric pressure from retching/vomiting against a closed glottis - common in alcoholics - hiatus hernia

What is the fovea?

A small depression in the retina of the eye where visual acuity is highest. The center of the field of vision is focused in this region, contains cones only - colour vision in good lighting

Pustular psoriassis of the palms and soles

A tender pustular eruption of the palms and soles where pustules come to the surface and desquamate, but do not rupture Higher in SMOKERS!! Very resistant to standard therapy Can have some brown looking spots

carcinoid tumour

A tumours of low grade malignancy composed of neuroendocrine cells (for instance in the GI, excessive production of Serotinin) also produce acth and gnrh common in GI and lungs diarrhoea, sob, flusing

acute chest syndrome

A vasoocclusive crisis that can be associated with pneumonia; common signs and symptoms include chest pain, fever, and cough; associated with sickle cell disease. features: dyspnoea, chest pain, cough, hypoxia and new pulmonary infiltrates seen on chest x-ray

Molluscum Contagiosum 1A

A. A common viral infection of the skin with a pox virus - molluscum contagiosum virus (MCV) transfer: skin-skin, shared towel, razors, STD B. Clinically: Multiple, flesh colored papules ( white or pink pearly papules) with central umbilication, commonly seen in children <10 - seen in adults as an STD in groin, abdomen -Consider sexual abuse if seen in genital region on children C. Treatment: *spontaneous resolution within 18 months* - avoid sharing towels - highly infectious , currettage, cryosurgery, Retin A, salicylic acid (duofilm), cantharidin (blister beetle), bichloracetic and tricholoracetic acid, laser

Blistering Distal Dactylitis

A. Acute skin infection of the volar fat pad of the fingers B. Etiology - Group A beta hemolytic streptococci (most common),or Staph aureus C. Clinically: Vesicles on volar fingertips in children (2-16 years) D. Treatment 1. Incision and drainage 2. Anti strep antibiotics (Penicillins, cephalosporins, erythromycin, and clindamycin) for 10 days

Cutaneous Drug Reactions 1A

A. Cutaneous Drug Reactions 1. Rashes are the most common reaction to medications and may occur years after initiating a medication 2. Types a. Immunologic- any of the four types of hypersensitivity b. Non-immunologic- at least 75 % of all drug reactions 3. Maculopapular and urticarial drug eruptions are the most common types A. Cutaneous Drug Reactions (con't) 4. Most frequent medications are anti-microbial and anti- inflammatory meds (see table p 5) 5. Onset is within 4-10 days while on the offending agent, but may been on the medication for years 6. Ampicillin rash is usually maculopapular, not a true allergy, and seen in 50-80% of patients with infectious mononucleosis and on ampicillin A. Cutaneous Drug Reactions (con't) 7. Fixed Drug Eruption: a. Dusky red papules, plaques, or bullae occurring in response to an ingested drug b. Lesions recur in the exact same spot when the drug is re-administered c. Commonly associated meds include Tetracycline & phenolphthalein

Erythema Infectiosum

A. aka: 5th disease, slapped-cheek disease B. Etiology: parvovirus B19 C. Clinical findings: 1. Incubation period 13-18 days 2. Mild prodrome of malaise, mild fever, arthralgias 3. Rash has 3 stages a. Slapped cheek - facial erythema with circumoral sparing is first and fasdes in 4 days b. Nelike rash - fishnetlike rash on trunk 2 days afterthe facial erythema that lasts 6-14 days c. Recurrent phase - rash can come and go for 2-3 weeks D. Arthritis and Pruritus - syndrome seen in adult women exposed toparvovirus B19 E. Treatment: not necessary F. Complications/prognosis: Pregnant women at risk for spontaneous abortion and sickle cell patients are likely to go into aplasticcrisis

Rubella

A. aka: German Measles, 3 day measles B. Etiology: Rubella virus C. Clinical findings: 1. Incubation period 18 days 2. Malaise, mild fever, headache, with neck lymphandenopathy- POSTERIOR OCCIPITAL LYMPHOADENOPATHY 4-7 days prior to rash 3. Maculopapular rash starting on neck for 1 day, spreads to trunk for one day, then disappears by day 3 D. Treatment: not necessary E. COMPLICATIONS: If pregnant woman in first trimester gets rubella, then baby at risk for congenital rubella syndrome (cataracts, deafness, heart defects)

Cellulitis 1A

A. bacterial Skin infection characterized by erythema, oedema and pain, hot . fever may b present. has indistinct borders S/S : Commonly caused by Group A Beta hemolytic Streptococci and Staph aureus (adults) and Haemophilus influenza type B in children or MRSA D.Rx: *flucoxacillin for 7 days* -clarithromycin if penicillin allergy -mark area to monitor process E. Treatment for children is with second generation cephalosporins (cefuroxime) due to H. influenza as cause

Ecthyma

A. deep ulcerated lesions., oyster shell like cursts common exudative holes B. Associated with poor hygiene! and HIV, drug users C. Caused by Group A Beta hemolytic Streptococci D. Heal with scarring-- involves dermis E. Treat with 10 day course of cloxacillin, dicloxacillin, or cephalosporins, erythromycin Dermis- can see scarring

second line rx for c. diff

ADULTS: vancomycin 125 mg every 6 hours for 10 days, followed by, either tapering the dose (gradually reducing until 125 mg daily) or a pulse regimen (125-500 mg every 2-3 days for at least 3 weeks) KIDS:

WHAT ARE THE RISK FACTORS/ CAUSES OF DKA 1B

AEx Infections non-compliance with insulin undiagnoes TIDM starvation MI stroke pancreatitis Drugs: SGLT-2 inhibtors, thiazides, steroids

rotator cuff tear

AEx: Hard, fast movements, such as in tennis and baseball can tear one of these tendons resulting in pain and decreased mobility of the shoulder. Surgery may be needed to repair a torn tendon.

When do you check a patient's vision if they have a chemical injury?

AFTER the eyes are flushed

Subacromial Impingement

AKA - Painful arc Sd - Supraspinatus Sd - Swimmer's shoulder - Thrower's shoulder - as arm is lifted RC pushes humeral head under acromion . -not pushed down properly and thus too close to acromion -irritation and inflammation of rotator cuff tendons (mainly supraspinatus) as they pass through subacromial space - producing a painful arc of movement - pain when attempting to perform overhead activities ( this is when the tendon is pinched causing pain) --> common in plasterers and decorators. -night pain w/ progression eventually cant raise arm -Aex: thickening, inflamation or partial tear in tendon -Ix: hawkins test : arm is held in flexion and then internally rotated.. makes space even smaller--> mimics symptoms -Rx:

full thickness burn: appearance + management 1B

AKA 3rd degree burn ATL protocol -resus with parkland formula - refer to secondary care 3rd degree: Through epidermis and dermis Injury to underlying tissue structures (e.g. muscle, bone) features: insensate, hard leathery escahar that's black, grey/white or cherry in colour. no hairs attached. Management -refer to secondary care - Top Abx to prevent prevent infections most common organisms: S. aureus, P. aeruginosa and C. albicans, - surgical removal of necrotic tissue

External hordeolum (stye)

AKA Hordeolum acute abscess within a lash follicle and its associated glands of Zeis and Moll. usually infection w staph or strep -*features*: pain and swelling of lump , small yellowish pustule on eyelind margin, diffuse oedema vision not affected Rx 1st line: warm steaming as first line treatment for stye 2. drainage

SGLT2 inhibitors

AKA glifozins Inhibit sodium-glucose transport protein 2 Leads to reduced tubular reabsorption of glucose- excretion in urine - cal exacerbae thrush SE- ketoacidosis, UTI, hypoglycaemia, weight loss

What LFTs indicate cholestasis

ALP and bilirubin

Diagnosis of chronic hepatitis

ALT and AST are mildly elevated for >3-6 months. Hepatic serology.

APLASTIC CRISIS

APLASTIC CRISES: - caused by infection with parvovirus B19 - sudden fall in haemoglobin and low reticulocyte count due to sudden drop in marrow production Rx analgesia e.g. opiates rehydrate oxygen consider antibiotics if evidence of infection blood transfusion exchange transfusion: e.g. if neurological complications

BLOOD CLOTTING TESTS: HAEMOPHILIA

APTT: increased PT: normal Bleeding time: normal

What LFTs indicate hepatocellular injury

AST and ALT

Diagnosis and treatment or gallstone ileus

AXR shows subacute SBO and gas in the biliary tree. Treatment is laparotomy with stone extraction, closure of the fistula and cholecystectomy.

Acute management if ulcer perforation suspected

AXR to rule out free air under the diaphragm, consider CT if AXR not diagnostic, surgery

PPIs SE

Abd pain Diarrhea Flatulence Headache *B12 deficiency* Hypo Mg and Ca Hyponatraemia

Lead poisoning features and diagnosis and Rx

Abdo and neuro signs 1. Abdo: pain constipation 2. Neuro signs: peripheral neuropathy (mainly motor) 3. others: fatigue, blue lines on gum margin (only 20% of adult patients, very rare in children), m 4. - Diagnosis: blood lead level >10 mcg/dl significant - full blood count: microcytic anaemia. Blood film shows red cell abnormalities including basophilic stippling and clover-leaf morphology - raised serum and urine levels of delta aminolaevulinic acid can be seen Rx Various chelating agents are currently used: - dimercaptosuccinic acid (DMSA) - D-penicillamine - EDTA - dimercaprol

Abetalipoproteinemia

Abetalipoproteinemia causes malabsorption of fat-soluble vitamins resulting in symptoms associated with Vitamin A, D, E and K deficiency neurological signs i.e weakness weight loss diarhoea especially after fatty meal failure to thrive + developmental delay steatorrhoea retinitis pigmentosa cerebellar signs deep tendon reflexes are absent acanthocytosis hypocholesterolaemia

Scar

Abnormal Collagen deposition due to injury

Salter- Harris Fracture Classification - II

Above. The fracture lies above the physis, or Away from the joint Most Common

ACNE ROSACEA 1A 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

Acne rosacea 1. chronic skin condition characterised by redness, flushing, and sometimes pustules in the central face. 3. 2. Etiology: unknown; associated with overgrowth of demodex folliculorum (folliclemite), RF: 1. Alcohol 2. Hot beverages 3. Sun exposure 4. Stress 5. Rapid temperature changes 6. Spicy foods 2. features 1. Erythema, edema, papules, pustules, and telangiectasias (dilated blood vessels) on cheeks, chin and forehead, flusing 2. Deep papules and nodules (granulomatous rosacea), and rhinophyma (nasal hypertrophy) can occur 5. Rosacea occular involvement common, i.e. rosacea blepharitis ( watery eyes , blepharitis, keratitis, conjunctivitis) IX : N/A Rx 1. self-management i.e suncream, avoiding triggers 2. topical brimonidine-alpha-adrenergic agonist, helps with redness 3. moderate: Topical ivermectin 4. moderate to severe: ivermectin + doxycycline

signs and symptoms of gastritis

Acute - Abdominal discomfort - Anorexia/Nausea/Vomiting - Headache - Hiccupping Chronic -Asymptomatic - Anorexia/Nausea/Vomiting - Belching - Heartburn after eating - Sour taste in mouth - Vitamin B12 deficiency -asymptomatic -haematemesis and malaena -anaemia -pancreatitis if ulcer penetrate pancreas

What are serious causes of RED EYE?

Acute angle closure glaucoma, corneal ulcer, HSV/HZV, scleritis, uveitis, cellulitis, bacterial conjunctivitis, endophthalmitis, trauma/ruptured globe, tumor

NOTIFIABLE DISEASES

Acute encephalitis Acute infectious hepatitis Acute meningitis Acute poliomyelitis Anthrax Botulism Brucellosis Cholera Diphtheria Enteric fever (typhoid or paratyphoid fever) Food poisoning Haemolytic uraemic syndrome (HUS) Infectious bloody diarrhoea Invasive group A streptococcal disease Legionnaires Disease Leprosy Malaria Measles Meningococcal septicaemia Mumps Plague Rabies Rubella SARS Scarlet fever Smallpox Tetanus Tuberculosis Typhus Viral haemorrhagic fever (VHF) Whooping cough Yellow fever

Gutatte psoriasis

Acute eruption, with TEAR DROP shaped lesions (pinpoint to 1cm ) occuring 1-2 weeks after upper respiratory infection with strep Obtain throat culture, and anti streptolysin O titers Tx: abx with rapid resolution of lesions

Cholera 2B

Acute small bowel illness caused by gram -ve caused by Vibrio cholera. Transmitted via contaminated water and food in developing countries mostly Characterised by massive painless, fluid "rice water diarrhoea" (up to 20 L per day), vomiting severe dehydration and electrolyte imbalance. Ix: clinical diagnosis in endemic areas, culture of organism, rapid dipstick test Rx: rehydration (glucose and salt), IV fluids in severe cases, azithromycin, doxy, tracycline

Treatment for a ruptured globe

Admit to Hospital Examine BOTH eyes Do NOT disturb affected eye Immediately place eye shield IV antibiotics ? Tetanus booster Radiologic evaluation Primary surgical repair

ANV of the femoral head 1B

Aetiology o Trauma - subcapital fracture, dislocation of hip o Idiopathic - Perthe's disease (Spontaneous avascular necrosis of the femoral head) o Infection - Tom Smith's arthritis o Caisson's disease - diver's bends -alcohol, steroid and storage dz Clinical presentation -progressive wosening symptoms - pain on movement, weight bearing then ... - sudden onset of severe pain, related to weight-bearing o worse at night o rapid progression (compared to OA) -severe arthritis Diagnosis o x-ray - h/o hip fracture o bone scan - may see a healing fracture o MRI (best) Treatment o early: vascularized fibular graft to preserve femoral head. l o rotation osteotomy in a young patient with moderate disease o late - hip replacement

lower back pain

Aex MECHANICAL: train, Sprain, Annular Tear, Herniated Nucleus Pulposis DEGENERATIVE: Degenerative Disc Disease, Facet Arthropathy, Spinal Stenosis INFLAMMATORY: Rheumatoid Arthritis, Ankylosing Spondylitis INFECTIOUS: Discitis, Osteomyelitis, Epidural Abcess (Pyogenic, Tuberculous, Fungal) TRAUMATIC: Fracture, Subluxation, Dislocation ONCOLOGIC: Benign or Malignant Spine Tumor, Metastatic Spine Tumor CONGENITAL: Scheuermann's Disease, Scoliosis IDIOPATHIC: Unknown PSYCHOGENIC: Psychiatric Disorders with manifestation of back pain ss: back pain, stenosis may present with weakness, numbness in bottom and thighs. sppine infections --> fever chills and weight loss physical: erythema, acchymosis, Ix: x-ray, MRI, CT , CRP, ESR, creatine . calcium, vit D, PTH, ALP ( bone) , RF, anti-CCP Rx: surgery, ice, NSAIDs, massage, accupucnture, orthotics, rest

Non modifiable risk factors for AMD

Age (older) Gender: Women > Men. Genetics Race (Caucasian and Asian)

Gonorrhea

Age 15-30 Common 1. Male - exudative urethral discharge and dysuria/asymptomatic 2. Female - urethritis, cervicitis, PID, Bartholins gland involvement or asymptomatic 3. Incubation period: 3-5 days Organism: Neisseria Gonorrheae (Gram - Diplo-coc) Some people may have more systemic issues, like arthirits, fever, endocarditis, myocarditis

What are soft drusen?

Age-related Cottony Larger in size than hard: "fluffy" Associated with AMD and vision loss.

2WW REFERRALS FOR HAEMATURIA

Aged >= 45 years AND: unexplained visible haematuria without urinary tract infection, or visible haematuria that persists or recurs after successful treatment of urinary tract infection Aged >= 60 years AND have unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test

Generalized pustular psoriasis (medical emergency)

Aka: von Zumbusch Clinically: Rare disease characterized by tiny sterile pustules coalescing into lakes of pus. -Pit is febriles, toxic, and elevated WBCs , Usually hospitalized patient, almost treated like a burn Patient -Renal and liver impairment -usually afetr prescription of oral steroids tx: wet dressings topical steroids, may require oral therapy with etretinate, methotrexate or cyclosporine

a 40 yo male presents with the following findings on his bloods . asymptomatic and drinks around 40 units of alcohol per week. Bilirubin 21 µmol/l ALP 100 u/l ALT 67 u/l γGT 110 u/l Albumin 40 g/l Hepatitis B Negative Hepatitis C Negative Serum ferritin 550 microg/L (25-300 microg/L) Immunoglobulins Normal Ultrasound liver Fatty changes Transferrin saturation 41% (<50%) what si the diagnosis

Alcohol excess The normal transferrin saturation effectively excludes iron overload as a cause of the raised ferritin. It is therefore likely that this is caused by his alcohol exces

What happens to the eye in a base injury?

Alkali chemicals are lipophilic and penetrate cell membranes through saponification of membrane lipids. Hydroxyl ions denature the collagen matrix of the cornea and facilitate further chemical penetration. Affected tissues can undergo liquefactive necrosis, in which the inflammatory response triggers release of proteolytic enzymes, leading to a cascade of damage. Potent alkalis can reach the anterior chamber in less than 15 seconds, causing destruction of tissues in the cornea and anterior chamber (including the trabecular meshwork, lens, and ciliary body). Penetration can continue to occur long after the initial exposure takes place.

How does a patient with GCA present?

Almost all of these patients are aged older than 50. Common classic symptoms include headache, scalp tenderness, tongue and jaw claudication, and loss of vision, often with nonspecific constitutional symptoms, such as fever and weight loss

sinusitis

An inflammation of the mucous membranes of one or more of the sinuses. -Swelling can obstruct the flow of secretions from the sinuses, which may then become infected. -The disorder often follows rhinitis. Other conditions leading to sinusitis include deviated nasal septum, nasal polyps or tumors, inhaled air pollutants or cocaine, facial trauma, nasal intubation, dental infection, or decreased immune function. symptoms: frontal headache, worse on leaning down , chronic cough possibly post-nasal drip. Rx steroids nasal

What is Endophthalmitis?

An intraocular infection which can be caused by candida (opportunistic). S/sx: pain, redness, hypopyon, blurring, floaters

What is an optometrist?

An optometrist is an eye doctor who has earned the Doctor of Optometry (OD) degree. Optometrists examine eyes for both vision and health problems, and correct refractive errors by prescribing eyeglasses and contact lenses. Some optometrists also provide low vision care and vision therapy. An optometrist generally must complete a four-year college degree program in the sciences, plus four years of post-graduate professional training in optometry school.

What is intraocular pressure determined by?

Aqueous production Aqueous outflow

Tendon or ligament injuries Clinical manifestations

Are painful and usually accompanied by soft-tissue swelling and changes in tendon or ligament contour.

What are signs of chronic hypertensive retinopathy?

Arteriolar narrowing (silver & copper wiring), retinal hemorrhages (flame and dot blot), cotton wool spots (nerve fiber layer infarcts), exudates, retinal edema.

biphasic insulin

Aspart Novomix 30: 70% insulin aspart protamine (intermediate-acting) Lispro Humalog Mix 25: 25% insulin lispro (rapid-acting), 75% insulin lispro protamine (intermediate-acting) lispro Humalog Mix 50 Inject before food

Presentation of chronic hepatitis

Asymptomatic. May cause fatigue and joint/muscle pains. Jaundice and complications of portal HTN (encephalopathy, ascites, esophageal varices) occur when the disease progresses to cirrhosis.

Atopic Dermatitis Infantile Childhood Adult

Atopy a term given to patients with a history of hay fever, asthma, dry skin, and eczema - intensely pruritic condition -Associated with atopy and involves a type 1 hypersensitivity reaction -Filaggrin gene mutation leads to a disrupted skin barrier, increased penetration of irritants and antigens -This drives an IgE-mediated hypersensitivity with inflammation due to elevated T lymphocytes activation -Breastfeeding delays onset of eczema -Resolves in 50% by age 12 features: Xerosis, pruiritis , erythema, scaling, vesicles, papules , excoriations , Ichthyosis Vulgaris Most have three or more Major Features (Pruitis , typical morphology - flexural lichenification, facial involvement , Dermatitis, Personal or Family history of Atopy) Thee or more Minor Features - (Icthyosis, Xerosis, keratosis pilaris, palmar hyperlinearity, wool intolerence, IgE elevated, Eczema, food intolerence etc. ) Clinically:"The itch that rashes" Infantile: Starts 3rd month of life Cheeks, trunks, extremeties, spares diaper area Resolves in 50% of infants by 18 months Childhood: Flexural involvement - antecubital fossae, neck, wrists, ankles, popliteal fossae Perspirations of opposing skin surfaces leads to increased pruritus and initiates the itch scratch cycle- leading to linchenificaiton Adult: Flexural involvement, like in childhood phase, hand dermatitis, periocular dermatitis, lichenification of the anogential area. Ix: allergy testing , IgE levels, skin biopsy Rx: 1. emollients 2. steroids: hydrocortisone > triamcinolone/mometasone/betamethasome >clobetasol 3. Oral Abx for s.aureus -Topical tacrolimus (calcineurin inhibitors - reduced IL-2) -Antihistamines -Short courses of steroids for relapses -Wet dressings, baths, emollients, occlusive bandaging - UVA and PUVA - Ciclosporin and azathioprine -coal tar

Hereditary non-polyposis colorectal cancer (HNPCC)

Autosomal Dominant. Mutation in gene's for MLH1 on Chromosome 3, or MSH2 on Chromosome 2. (90%). -Genetic Predisposition for colon and oancreatic cancer. -Screen with colonscopy starting at age 25. Look for Microsatellite expansions, which will accumulate in those with this mutation. Mutation in MMR (mismatch repair)

Juvenile polyposis

Autosomal dominant Pedunculated vascular polyps Increased gastric and colon cancer risk

What is Gilbert syndrome

Autosomal recessive disorder of bilirubin glucuronidation due to decreased activity of the enzyme glucuronyl transferase. Patients have unconjugated bilirubinaemia but normal CBC, blood smear and LFTs. Benign condition.

Respiratory causes of clubbing

BBLLAME Bronchial carcinoma Bronchiectasis Lung fibrosis Lung abscess Mesothelioma Emoyema

What could purulent discharge indicate?

Bacterial conjunctivitis, corneal ulcer, orbital cellulitis

What is ascending cholangitis

Bacterial infection of the biliary tree secondary to obstruction from choledocolithiasis

Signs/Symptoms of pinguecula?

Because a pinguecula is a raised bump on the eyeball, the natural tear film may not spread evenly across the surface of the eye around it, causing dryness. This can cause dry eye symptoms, such as a burning sensation, stinging, itching, blurred vision and foreign body sensation.

When should you normally check a patient's vision that has red eye?

Before any manipulation of the eye.

Cavernous haemangioma

Benign liver neoplasms -Cavernous hemangioma: masses of abnormal blood vessels, more common in women 20-50, asymptomatic . may cause symptoms when they get bigger. Sx include discomfort, fullness, and, less often, anorexia, nausea, early satiety, and pain secondary to bleeding or thrombosis. Ix USS, CT, MRI , biopsy

Hepatic Granulomas

Benign liver neoplasms -hepatic granulomas: many causes i.e drugs, infections, parasitic infections, HEp and CMV, PBC, TB, sarcoidosis, PMR,. -S&S: asymptomatic, can cause hepatic inflammation, fibrosis, portal hypertension. IX liver biopsy -Rx : treat underlying disorder

brachial cyst

Branchial cyst 76% swelling l side of neck Branchial cysts are remnants of the branchial cleft. They may become infected. A branchial cyst is typically a benign lesion that is situated in the lateral neck, superficial to the sternocleidomastoid muscle. The classical pathological finding in a branchial cyst is an acellular fluid with cholesterol crystals.

Budd-Chiari syndrome nom

Budd-Chiari syndrome, or hepatic vein thrombosis, is usually seen in the context of underlying haematological disease or another procoagulant condition Causes polycythaemia rubra vera thrombophilia: activated protein C resistance, antithrombin III deficiency, protein C & S deficiencies pregnancy oral contraceptive pill Features abdominal pain: sudden onset, severe ascites tender hepatomegaly ltrasound with Doppler flow studies is very sensitive and should be the initial radiological investigation

Rx of Constipation

Bulk-forming (isphagula husk): Increased faecal mass Stimulates peristalsis Can cause flatulence, distension, faecal impaction Stimulant (Senna): Increased motility Can cause colonic atony and hypokalaemia Faecal softeners (liquid paraffin): Lubricate and soften impacted faeces making exit easier Osmotic laxatives (lactulose, macrogol) Cause fluid to be retained within the bowel Promotes faecal movement Can cause dehydration Enemas, suppositories, large volume polyethylene glycol (PEG) solution (macrogols), stimulant laxatives, or disimpaction with sedation

Palliative prescribing in Kidney failyre

Buprenorphine or fentanyl are the opioids of choice for pain relief in palliative care patients with severe renal impairment, as they are not renally excreted and therefore are less likely to cause toxicity than morphine

How to distinguish b/w insulinoma and facticious insulin administration

C peptide is co-secreted with insulin, in patients with an insulinoma both will be raised. In patients with facticious insulin administration they would have low C peptide as the increased insulin is exogenous.

ULNAR NERVE

C8-T1 innervates first 2 fingers WRIST FLEXION damaged in medial epicondyle fracture --> claw hand Flexor carparis ulnaris supplies all muscles EXCEPT LOAF *LOAF muscles Lateral two lumbricals Opponens pollis Abductor pollis brevis Flexor pollis brevis

PROPHYLACTIC TREATMENT FOR SPONTANEOUS BACTERIAL PERITONITIS

CIPROFLOXACIN OR NORFLOXACIN

CKD (not on matrix)

CKD is impaired renal function for >3 months due to abnormal structure/function or an eGFR <60ml/min/1.732 for over 3 months 1. .>90 eGFR but damage 2. 60-90 egfr +plus damage 3. 45-60 no damage 4.15-29 5. <15

Granuloma Inguinale (Donovanosis)

Calymmatobacterium granulomatis INcubation -14- 50 days Painless ulcer BEEFY BASE granulation tissue Bleeds easily No Lymphandenopathy Giemsa Stian- with Donovan Bodies (Bascilli within histiocytes )

Sacral Zoster

Can be associated with autonomic nerve (virus migration) dysfunction causing a neurogenic bladder

Osteocytic osteolysis

Canaliculi provide means for transfer of calcium from interior to the exterior of bone and into extracellular fluid -only removes calcium from most recently formed bone, so bone mass is not reduced

Causes of chronic secretory diarrhoea

Carcinoid tumours, VIPomas, enterohepatic circulation, Campylobacter

Cat scratch dz

Caused by Bartonella hensela. Characterised by popular lesion, at site and lymphadenopathy. abdominal pain, lethargy and sweats. Disseminated infection in immunocompromised . Clinical diagnosis

Diphthria 2B

Caused by Corynebacterium diphtheriae. Produces diphtrea toxin which *acts myocardium and peripheral NS* Causes *myocarditis, neuropathy and paralysis and respiratory obstruction* Features: depends on affated but stridor and low-grade fever Respiratory diphtheria: sore throat, low grade fever, *adherent pseudomembrane that can cover the tonsils and the mucosa of the pharynx, larynx, and nose*. Ix: NAAT, bac culture and microscopy RX: antitoxin and erythromycin

Septic bursitis

Caused by a wound infection.

HIP PAIN: MERALGIA PARAESTHETICA

Caused by compression of lateral cutaneous nerve of thigh Typically burning sensation over antero-lateral aspect of thigh

Meralgia paraesthetica

Caused by compression of lateral cutaneous nerve of thigh Typically burning sensation over antero-lateral aspect of thigh. -common in 30-40s, mostly men -Occurs more commonly in those with diabetes than in the general population. - features: Burning, tingling, coldness, or shooting pain in antero-lateral aspect of thigh

THROMBOCYTOPENIA

Causes of severe: - ITP - DIC - TTP - haematological malignancy Causes of moderate: - heparin induced thrombocytopenia (HIT) - drug-induced (e.g. quinine, diuretics, sulphonamides, aspirin, thiazides) - alcohol - liver disease - hypersplenism - viral infection (EBV, HIV, hepatitis) pregnancy - SLE/antiphospholipid syndrome - vitamin B12 deficiency

What is Reynolds pentad

Charcots triad plus septic shock and altered mental state

Physical Exam of Pupils

Check for equal and reactive pupils (direct and indirect)

What is the characteristic look of a "serious" red eye condition?

Ciliary flush (ring of red or violet spreading out from around the cornea of the eye)

Plaque

Circumscribed change in texture >1cm

Bulla

Circumscribed collection of clear fluid > 1cm

Pustule

Circumscribed collection of cloudy fluid (WBC's) any size

Tumor

Circumscribed deep lesion > 1cm

Nodule

Circumscribed solid deep lesion <1cm

Risk factors for HCC

Cirrhosis, chronic hep B - particularly from vertical transmission (even without cirrhosis), haemochromotosis (200x risk)

Complications of chronic liver disease

Cirrhosis, portal hypertension and HCC (3-5%)

Klebsiella pneumoniae

Classically seen in alcoholics pleural empyema ais associate red currant jelly sputum

What is the cornea?

Clear structure that vaults over pupil/iris 0.5 mm thick in center Type I collagen fibers arranged REGULARLY, DEHYDRATED Avascular

What is the conjunctiva?

Clear, transparent membrane that lines the inner surfaces of the eyelids and and continues on to cover the front surface of the eyeball, except for the central clear portion of the outer eye (cornea).

Perioral Dermatitis

Clinically: 1. Erythematous papules with scale occurring in the perioral, perinasal and periocular region, with sparing of the vermillion border Etiology: Topical steroids, moisturizer abuse. Aggravated by drying agents TX:1. Oral tetracycline, Minocycline, erythromycin and Topical antibiotics looks like acne but has scaly - treat like acne

Fracture Classification Complete

Closed/Open Comminuted Linear Oblique Spiral Transverse Impacted Pathologic Avulsion Displaced

Codeine to morphine conversion factor

Codeine to morphine - divide by 10

E.coli 0157:H7 diarrhoea

Common amongst travellers Watery stools Abdominal cramps and nausea

PREAURICULAR SINUS

Common congenital condition in which an epithelial defect forms around the external ear Small sinuses require no treatment Deeper sinuses may become blocked and develop episodes of infection, they may be closely related to the facial nerve and are challenging to excise

Supracondylar Fracture

Common in children*, caused by direct blow or fall on outstretched hand S/S: -Pain and swelling over distal humerus - Evaluate radial/ulnar nerve and arter Dx: -x-ray, look for posterior fat pad sign* - bilateral x-rays helpful in children Tx: - non-displaced- long arm cast - displaced- refer to surgeon complications: bracial artery injury, median/ ulnar nerver injury , compartment syndrome (leads to Volkmann's ischemic contracture), malalignment cubitus varus (distal fragment tilted into varus

HIP PAIN: PUBIC SYMPHYSIS DYSFUNCTION

Common in pregnancy Ligament laxity increases in response to hormonal changes of pregnancy Pain over the pubic symphysis with radiation to the groins and the medial aspects of the thighs. A waddling gait may be seen

MELANOCYTIC NAEVUS

Common mole. Benign, but melanoma can arise in congenital or atypical moles. Intradermal nevi are papular. Junctional nevi are flat macules EVENLY pigmented

PResentation of viral hepaitis

Common symptoms include: nausea and vomiting, anorexia myalgia lethargy right upper quadrant (RUQ) pain Questions may point to risk factors such as foreign travel or intravenous drug use

Management for bacterial pneumonia

Community acquired 1. oxygen , fluids, analgesia 2. Mild: Amoxicilllin 5 days 3. moderate severity : Dual abx : amoxicillin + *macrolide if atypical pathogen suspected* ( erythromycin, azithromycin and clarithromycin. ) 4. igh severeity beta lacta + macrolide --> cephalosporin + erythromycin 5. followup cxr 6 weeks 7. Atypical pneumoni: macrolides Doxycycline ( SE photosensitivity) 100 mg orally, 12-hourly for 5 to 7 days HAP pneumonia HAP (nasocomial)gram -ve organisms : ceftazidime, aminoglycoside, (e.g. gentamicin. Metronidazole forthose risk of anaerobic infection.· time period: 7 days in uncomplicated, 7-10 for severe and 14-21 if Legionella, staphylococcal disease, or Gram-negative enteric bacteria suspected follow up: CXR in 6 weeks check for consolidation

Avulsion

Complete separation of a tendon/ligament from its bony attachments

Treatment for hearing loss: (2)

Conductive: myringotomy tubes and fixing perforations Sensorineural: chochlear impalnt

What is conjunctival injection?

Conjunctival redness caused by inflamed or dilated blood vessels.

Subluxation

Contact bt two joint surfaces is only partially lost

What are benign causes of RED EYE?

Contact dermatitis, allergic and viral conjunctivitis, blepharitis, dry eye, chalazion, pterygium, pinguecula, corneal abrasion, surface foreign body, subconjunctival hemorrhage

What are some characteristics of the pigmented layer of the retina?

Contains epithelial cells that absorb light and store Vitamin A.

Treatment of zollinger-ellison syndrome

Control symptoms with moderate to high-dose PPIs. Surgical resection of the gastrinoma.

What structures are responsible for the refractive power of the eye?

Cornea (2/3) and the lens (1/3)

What is the pathway of light through the eye?

Cornea --> Pupil --> Lens--> Vitreous humor --> Retina

What is the most common eye injury seen in the ER?

Corneal abrasion

Symptoms of carcinoid syndrome 2B

Cutaneous flushing, diarrhoea, abdo cramps, wheezing and right-sided cardiac valvular lesions Tricuspid insufficiency and pulmonary stenosis weight gain/moon facies, cushingoid features - can secrete ACTH and other pituitary hormones - SOB if carcinoid of the lung

Pilar Cyst (Wen)

Cysts of hair follicle origin, present on scalp

Cytomegalovirus (CMV) 2B

D-DNA virus AKA HHP5, β-herpes. transmitted vertically or close contact, transfusion , organ transplant 50% UK affected Common in young Features of CMV# Asymptomatic OR similar to EBV fever, lymphadenopathy, and atypical lymphocytosis, diarrhoea Severe in neonatal, later deafness Immunocompromised: pneumonitis, retinitis or colitis, nephritis Ix CMV# CMV pp65 antigen PCR Viral culture Histopathology NAAT Bloods: LFTS, CD4 count CXR Rx CMV# Self-limiting Ganciclovir with Ig IV in severe dz Valganciclovir PO

POORLY CONTROLLED ASTHMA

DANGERS Daytime Sx 4 times/wk Activities reduced Nightime Sx 1 time/wk GP visits ER visits Rescue puffer (SABA) use 4 times/wk School and work absences

Wrist sprain

DEF: most common wrist injury. due to injury to ligaments. includes microscopic tears or completely torn ligaments MOI: fall on an outstretched hand, twisting S/S: pain, point tender, swelling, absence of pain over scaphoid bone TX: PRICEMM, taping, x-ray to rule out fracture Rx- can take days if mild, weeks to months if more severe

Risk factors for gingivitis: (7)

DM Malocclusinon (crowding) poor dental hygeine mouth breathing faulty dental restoration HIV positive pregnancy

What happens to the eye in an acid injury?

Damage by denaturing and precipitating proteins in the eye. The coagulated proteins act as a barrier to prevent further penetration (unlike alkali injuries). This protein coagulation produces the ground-glass appearance of the cornea often seen in severe acid burns. Acid injuries are less severe than alkali injuries.

Restrictive pattern

Decreased FEV1 Decreased FVC TLC low ( cant fill lungs) FVC v low cant fill lungs FEV1 decreased FEV1:FVC ratio increases (>80%) increased fibrosis increases (relatively) elasticity

OBSTRUCTIVE PFT FUNCTION

Decreased FEV1 <.80 Decreased FVC or normal Decreased FEV1/FVC - <70% predicted FEV1 used to follow severity in COPD TLC normal or high ( residual air )

Amoebiasis 2B

Diarrhoeas and colitis caused by *parasite Entamoeba histolytica* via ingestion >7 days incubation Common in infants in low-income countries bloody diarrhoea, cramps, weight loss. anchocy sauve like aspirate Complications include liver abscess which can lead to pleural and pericardial effusion. Pericarditis, empyema, brain abscess , liver abcess RUQ pain, fever Ix: stool antigen test, PCR, serum Ab test Rx: metronidazole

Scleroderma

Diffuse Scleroderma General: Systemic, autoimmune, multi-system disorder characterized by skin hardening sausaging of fingers and claw deformity of sclerodactly, Raynaud's phenomenon (pallor, cyanosis, hyperermia) GI fibrosis and atrophy of the smooth muscle (dysphagia & esophageal dysfunction) lungs with ↓ vital capacity & dyspnea Anti Scl-70 antibodies Tx: Steroids, Colchicine ,

What is the characteristic look of scleritis?

Diffuse redness (tender/inflamed)

Smith's fracture

Distal radius fracture with volar angulation (reverse Colles) - fall onto back of hand flexed -Ix: Xray Rx - ORIF -mild angulation- closed reduction and cast sig. angulation- open reduction + internal fixation - poor perative cand --> long arm cast

Herpes simplex 1A 1-7

Double stranded DNA virus HSV-1 spread by direct contact and HSV-2 is more sexually transmtted HSV-1 associated with oral herpes (cold sores) Causes: genital herpes,oral herpes, encephalitis, URTI, pneumonia, viral meningitis Remains latent in sensory or autonomic ganglia and reactivate through triggers such as stress, weather, trauma, menstruation etc.. S&S APPEARANCE: pruritic , herpetiform (grouped) painful vesicles which burst and heal tingling sensation,, headache meningism HSV-1: Adults: Pharyngitis, tonsillitis, keratoconjuctivitis ( can cause corneal scarring, Encephalitis) HSV-1 Kids: fever, vesicular gingivostomatitis and lymphadenopathy. Ix Viral culture HSV PCR Serological IgG assay Tzack smear Rx for HSV-1 1. HSV1 Topical acyclovir for genital/oral lesions 2..Acute: IV 5-10mg acyclovir in encephalitis, pneumonia, hepatitis. Genital: Acute : IV acyclovir or PO acyclovir (400mg TDS 1wk) , famciclovir (250 TDS), valacyclovir (1000mg BD) + paracetamol or ibuprofen Oral: acyclovir 200mg

Varicella Zoster virus 1A 1-5

Double stranded DNA virus , Airborne, infected vesicles, direct contact . Infection common in children 4-10 Causes chicken px and Reactivation causes shingles Recovery = long-life immunity Features of VZV Unilateral dermal eruption following 3-5 days pain and paraesthesia Chicken pox: lesions on all parts of body inc. oropharynx, genitourinary last 7-10 days. progress through macules and papules to vesicular eruption --> rupture spontaneous healing Shingles: Vesicles, bullae, pustules on erythematous, oedematous base Hutchinson's sign: Shingles on the tip of the nose signifies eye involvement VZV Ix clinical NAAT culture of fluid in vesicle PCR Rx VZV famciclovir, valacyclovir, or acyclovir for 7 d must initiate within 72 h to be of benefit analgesia for pain VZV DDX dermatitis, HSV, trigeminal neuralgia Complications of VZV secondary infection with S.aures and S. pyogenes pneumonia, encephalitis, ocular damage and neuralgia in immunocompromised

Asteatotic Eczema

Dry skin, excessive dryness leading to inflammation History: Previous Eczema underlying atopic state, winter exacerbation Clinically: dryness cracking superficial fissures, lower legs, "Cracked" porcelain" appearance pain rather than itching Tx: Based on stage, topical steroids, cool compress, oral abx, and frequent moisturizing

common pre-renal causes of AKI

Due to reduced blood flow to kidneys § Renal artery stenosis plus ACEI use § Heart failure § Dehydration § Haemorrhage § Over-diuresis § Oedematous states e.g. nephrotic § Cardiogenic or anaphylactic shock § Hypovolaemia § Sepsis

Greater trochanteric pain syndrome (Trochanteric bursitis)

Due to repeated movement of the fibroelastic iliotibial band Pain and tenderness over the lateral side of thigh Most common in women aged 50-70 years

HIP PAIN: GREATER TROCHANTERIC PAIN SYNDROME (TROCHANTERIC BURSITIS)

Due to repeated movement of the fibroelastic iliotibial band Pain and tenderness over the lateral side of thigh Most common in women aged 50-70 years

Fibromuscular Dysplasia (FMD)

Dysplasia of the media wall layer from an overgrowth of collage causing multiple arterial stenoses Is a non-atherosclerotic disease occuring mostly in young females, rarely males - due to aci Found in the carotid & renal arteries Patitnes may have nonspecific or no ultrasound abnormalities, but have a bead-like appearance on angiography

Gram-negative bacteria

E. coli P aeruginosa , legionella Klebsiella Coxiella H influenza, h ducreyi H pyori Nisseria gonorhoea , N. menigitides, T. pallidum Chlamydia Moxarella Bordetella pertusis compylobacter

What are the symptoms of low K+ in the plasma? ECG changes

ECG: U waves and flat T waves on EKG, SS: arrythmias, paralysis, hypotonia, muscle weakness

Ix HIV

ELISA HIV rapid test CD4 cell count Viral load Hep B, C, U&Es, tuberculin test, urinalysis

SUDDEN HEARING LOSS

EMERGENCY --> immediate ENT referal Hearing loss >30db over last 3 days can be unilateral or bilateral 1. tumpur -> vestibular schwannoma 2. vascular -> ISCAHEMIC DAMAGE to chochlea 3. Viral Rx: highdose prednisolone

Congenital Syphilis

Early congenital- rash snuffles Late- Saddle nose, teeth and eye Hutchinson's Triad ( teeth, 8th nerve palsy, keratitis) Pathognomonic for late congenital syphilis

Syringoma

Eccrine Sweat duct tumors , flesh colored, dome shaped, periocular papules

Presentation of cirrhosis

Effects of liver cell failure: jaundice, spider naevi, gynecomastia, bruising. Effects of portal hypertension: ascites, hepatic encephalopathy, oesophageal varices and thrombocytopenia., coffe-ground vomit, malaena ( econdary to GI haemorrhage from gastro-oesophageal varices in portal HTN.) telangiectasia

What are the canthi?

Either corner of the eye where the upper and lower eyelids meet.

Treatment for fulminant liver failure

Emergent liver transplant

Test for Supraspinatus

Empty can (Jobe test) Abduction against resistance

Liver in right heart failure

Enlarged liver palpable pulsatile smooth, tebder

Mastocytosis

Excess numbers of Mast cells 2. Skin and internal disease exist 3. Urticaria Pigmentosa a. Infantile development of red-brown pruritic papules, collections of mast cells b. Uncommonly has internal involvement (bone marrow, GI) c. Itching, flushing, headaches; if internal involvement: bronchospasm, abdominal pain d. Darier's Sign: Wheal and flare reaction elicited when a lesion is scratched e. Exacerbating factors: exercise, stress, hot/cold water, rubbing of lesions, Aspirin, Codeine f. Prognosis: Most resolve by age 2

Test of Infraspinatus

External rotation lag sign (against resistance)

Rheumatoid arthritis complications

Extra-articular: - respiratory: pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, pleurisy - ocular: keratoconjunctivitis sicca (most common), episcleritis, scleritis, corneal ulceration, keratitis, steroid-induced cataracts, chloroquine retinopathy - osteoporosis - ischaemic heart disease: RA carries a similar risk to type 2 diabetes mellitus - increased risk of infections - depression Less common: Felty's syndrome (RA + splenomegaly + low white cell count) amyloidosis

NORMAL HBA1C

FASTING <6.0 MMOL/L 4-6% 41 MMOL

GI bleed Ix

FBC (check Hb, platelets) Coagulation profile Blood gas and lactate (if haemodynamically unstable) Other investigations as appropriate if underlying liver disease or other bleeding disorders suspected Consider testing for H. pylori if appropriate OGD colonocopy endoscopy

INTRACAPSULAR FRACTURE

FEMUR IS BROKEN INSIDE THE JOINT FRACTURES OF FEMORAL . Rx internal fixture w/ cannulated screws in young, hemi arthro if unfit

MAnagement of COPD 1A

FEV>50% 1. SABA OR SAMA 2. SABA OR LAMA + SABA 3. LAMA + SABA OR LABA+ ICS ( if asthmatic features) 4. LAMA+ LABA+ ICS <50 FEV>50% 1. SABA OR SAMA 2. LABA + ICS OR LABA+LAMA ( ICS not tolerated) 3. LAMA+ LABA+ ICS

achlorhydria

Failure to produce HCl Diagnosed by pH less than 6.5 absence of hydrochloric acid in the gastric secretions --> more susceptible to GI infections and lack nutrients --> HCL breaks down protein and other nutrients

Calcaneal Fracture

Fall from a height onto heels Osteoporosis Diabetes Loss of foot height Typically require ORIF SPLINT- Post mold OR Vacuum splint, NWB ss: swellingm bruising on heel/sole , varus heel

Ix and Rx of oesophageal strictures

Features - dysphagia - weight loss -regurgitaion - sensation of something stuck -reflux - barrium swallow - OGD Rx -dilation -stent -treat PPI : H2 antagonists , PPI -surgery

HIP PAIN: REFERRED LUMBAR SPINE PAIN Cause + Test

Femoral nerve compression may cause referred pain in the hip Femoral nerve stretch test may be positive - lie the patient prone. Extend the hip joint with a straight leg then bend the knee. This stretches the femoral nerve and will cause pain if it is trapped

Lower lobe fibrosis

Fibrosis predominately affecting the lower zones BRASCO B: bronchiectasis R: rheumatoid arthritis A: asbestosis, aspiration pneumonia S: scleroderma C: collagen vascular diseases O: other (drugs, e.g. busulfan, bleomycin, nitrofurantoin, hydralazine, methotrexate, amiodarone)

Dematofibroma

Firm indurated red borwn or hyperpigmented papule - trauma or insect bite? when squeeze laterally it should damp down

What are signs/symptoms of retinal detachment?

Flashers, floaters, asymmetric red reflex, described as a curtain or dark cloud coming across the field of vision. Keep patient supine

Symptoms of retinal detachment

Flashes - no pain sensors in retina. When retina moves, flashes of light. Floaters Changes in Vision Curtain falling or rising over vision "spider webs"

Erosion

Focal loss of epidermis

What is the characteristic look of subconjunctival hemorrhage?

Focal redness (well demarcated)

Giardia lamblia NOM

Food/waterbourne infection causes prolonged bacteria Features: self-limited mild watery diarrhea to malabsorption syndrome (chronic giardiasis where the parasite coats the small intestine and thus prevents fat absorption) nausea, malaise, abdominal cramps, bloating, flatulence, fatigue, weight loss, steatorrhea NO hematochezia (no invasion into intestinal wall), no mucous in stool Ix: stool samples, bowel biopsy, stool antigen test Rx: metronidazole

Treatment for penetrating injury/globe injury/IOFB (intraocular foreign body)

Fox shield Keep NPO IV antibiotics (usually flouroquinolones) Consider imaging to rule out foreign body. Call ophthalmology to examine / repair eye (ideally repair within 24 hours). Clear patient medically for surgery.

Treatment for hyphema

Fox shield Limited physical activity (bed rest) Elevation of head Topical steroid drops, cycloplegia. IOP lowering medications as needed. Consider antifibrinolytics (Amicar) Ophthalmology Consult Consider hospitalization. Surgical removal of blood / clot if necessary. Have patients avoid ASA, NSAIDS.

Jefferson fracture

Fracture of C1 (atlas) caused by a compressive downward force from the occipital condyles

Clay Shoveler's Fracture

Fracture of C6 or C7 spinous process, relatively innocuous. Stable fx. MOI: Flexion Radiographic findings: Avulsion of posterior aspect of spinous process; frequently an incidental finding

Bennett's fracture

Fracture of the base of the first metacarpal bone - abductor pollicis longus pulls MC shaft proximally and radially causing adduction of thumb Rx: treat with percutaneous pinning, thumb spica x 6 wk

Odontoid fracture

Fracture of the dens of C2 - Type II and III are unstable and these may present with neurologic impairment

How fractures are displaced

Fractures can be displaced by: - Force of injury - Effects of gravity - Pull of muscles attached to the site

Course complete fracture - Impacted

Fragments jammed tightly together and fracture line is indistinct

Course complete fracture - Transverse

Fragments usually remain in place after reduction

Chest drain swinging

Fuid should rise on inspiration and fall on expiration.

Tinea Capitis 1B

Fungal infection (ringworm) of the hair/scapl, Trichophyton tonsurans most common cause a. Patterns of T. capitis i. Black dot-hair break off at skin level and leave "dots" ii. Inflammatory Kerion - hyper allergic response iii. Seborrheic dermatitis like iv. Pustular type b. Infection is usually endothrix (within the hair shaft) andtherefore will not flouresce with a wood's light c. Clinical pearl: Almost always see lymphadenapathy ofthe neck d. Treatment i. Oral antifungals are necessary to eradicate infection(griseofulvin, intraconazole, fluconazole, terbinafine) ii. Antifungal shampoos for the patient and family members iii. Consider oral steroids for extensive kerion involvement

Hidradenitis Suppurativa 1B

General info: 1. A chronic suppurative and scarring condition of apocrine sweat glands seen in axillae and groin 2. Etiology: unknown; Apocrine gland occulsion vs. keratinous folllicular plug Clinically: 1. "Double Comedone," papules, pustules, nodules abcesses and scarring 2. Chronic and episodic course, associated with obesity, arthropathy,and follicular occulsion triad (acne conglobata, hidradenitis suppurativa, and dissecting cellulitis of the scalp) Tx: Inflammatory conidition... 1. Oral antibiotics (tetrecycline, minocycline, doxycycline, and erythromycin 2. Topcal Retin A 3. Intralesional Steroids 4. Accutane for resistant cases 5. Surgical Excision for very resistant cases

Pityriasis Rosea 1A

General info: - Papulosquamous eruption characterised by Scaly eruption onset 2nd-3rd decade of life (ave. age 23 years),winter and summer outbreaks common. post-viral infection Etiology: Unknown, thought to be viral related, possible "slow virus". possibly HHV6 or 7 Clinically: 1. Starts with a single lesion ("herald patch") usually on the trunk resembling "ringworm," - followed by eruption of oval to round thin, pink papules and plaques with fine scaly margin in christmas tree distribution - rash spares the face, palms, and soles 3. Lesions usually confined to trunk and proximal aspects of the arms and legs. Rarely on face. Tx: 1. Self limiting within 6 weeks 2. steroids, UVB DDX: guttate psoriasis, drug rxn

Psoriatic Arthritis

General info: Rheumatoid factor negative 5% of psoriatic have true psoriatic arthritis , and usually have more extensive cutaneous involvement Tx: with NSAIDS, gold, methotrexate!!

Pityriasis Rubra Pilaris (PRP)

General info: a rare, chronic disease characterized by thickened and yellow palms and soles, erythroderma (red skin all over) Etiology: Uknown Onset in adulthood (most common) or childhood ( typticall more red) Adults will be more yellowish Clinically: Red scaling plaque on face or upper body that enlarges over days to weeks with thickening of the palms and soles SKIP AREAS of redness occur and red follicular papules on elbows and knees, ITCHING IS ABSENT Other features: thickened nails, ectropion Duration of disease- 3 years in 80 % of patients Childhood PRP- red to orange keratotic plaques confined to the elbows and knees with a longer chronic course Tx: Lubricants, Vit D3, retinoids (accutane, etretinate) methotrexate

Polymyositis (PM)

General: An inflammatory, autoimmune muscle disease Muscle disease only = polymyositis dermatomyositis usually more severe case of myositis

Dermatomyositis (DM) 1-7

General: An inflammatory, autoimmune muscle disease affecting skin and muscle Skin and Muscle disease = dermatomyositis Heliotrope rash, gottron's papules, Violaceous Scaling patches, Peri-ungual erythema, telangiectosia, poikiloderma proximal muscle weakness, +/-tenderness difficulty arising from a chair or climbing stairs. difficulty lifting heavy items, brushing hair etc.. interstitial lung disease dysphagia, dysphonia does not affect facial muscles Investigations (anti-synthetase antibodies), including: antibodies against histidine-tRNA ligase (also called Jo-1) antibodies to signal recognition particle (SRP) anti-Mi-2 antibodies ANA (80%) CK CRP ESR Muscle biopsy EMG Tx: Steroids, methotrexate

Nummular Eczema/discoid eczema/dematitis 1B

General: Coin shaped papules and plaques of eczema . Wet or dry - wet/ exudative: can be caused by S.aureus-plaque appears after trauma or infection: thermal burn, scabies, varicose vein surgery, insect bite, impetigo , drug allergy wet can last months, starts acutely Dry discoid eczema: usually due to dry skin - dry sometimes associated w/ elevated skin lesions such as seborrhoeic keratoses and melanocytic naevi (Meyerson's naevus). both - common in females >50 History:, worse in winter, back of hand most common site, extremities clinically: erythematous, annular papules, and plaques, can display vesicles, dryness, and scale, itching is moderate to severe site: common on back of hands but also occurs affect scalp, face, trunk and limbs. Rx: skin swabs, culture , fungal culture to R/O tinea corporis tx: 1. emmolients 2. topical steroids - mild for dry and potent for exudative 3. PO anti-staph Abx: flucoxacillin, dicloxicillin, erythromycin, trime+ sulphamethoxazole 4. wet dressings if severe+ steroids

Nevus subaceous

General: a conglomerate of immature sebaceous and pluripotent cells usually found on scalp Tx: get them removed by plastic surgeon because may turn malignant later in life

CREST SYNDROMe

General: a more benign, chronic variant of systemic sclerosis Clinically: Calcinosis - palmar finger tips, knees, elbows, spine, painful and red Raynaud's Phenomenon - vasospastic disorder of the fingers and toes precipitated by temperature changes Esophageal Dysomotility Sclerodactyly Telangiectasia Labs: Positive Anticentromere antibody

Pyogenic Granuloma

General: proliferative vascular lesion due to trauma Clinically: single, violaceous and eroded exophytic papules occuring in response to trauma; "proud flesh" or granulation tissue

Lichen Sclerosus et Atrophicus NOM

Generally 1. A chronic mucocutaneous disosrder, charactized by white, angular, well defined and indurated papules and plaques 2. Mainly adults, but some children (1-13 years) 3. Female : Male 10 : 1 Etiology: unknown Clinically: 1. Non-genital lesions are usually asymptomatic; genital often asymptomatic, however, vulvar lesions may be painful, (dysuria; dyspareunia) 2. Whitish, sharply demarcated, macules and forming plaques with keratin plugs (dells) 3. Kraurosis vulvae--female anogenital vulvar plaques with a keyhole or hour glass shaped arrangement; lesions may become maceratedand vulva may become atrophic & shrunken. Fusion of labiaminora and majora may occur 4. Balanitis xerotica obliterans - In males, prepuce becomes scerotic and cannot be retracted leading to acquired phimosis 5. Squamous cell carinoma, although very uncommon may develop in genital lesions, predominantly in females. Tx: 1. Waxes and wanes, may undergo spontaneous resolution 2. Patients should be followed every 12 months to moniter for carcinoma development 3. Topical corticosteroids, topical testosterone, antimalarials, circumcision in males

Which conditions is a slit lamp good for diagnosing?

Generally, conditions in the anterior segment of the eye: corneal epithelial defect, keratoconjunctivitis, hyphema, hypopyon, lens dislocation, herpetic infections, iritis, or evaluation of the red eye.

What is a Darwin tubercle?

Genetic linked thickening along the upper ridge of the ear

What is Giant Cell Arteritis?

Giant cell arteritis is a vasculitis of large- and medium-sized arteries that predominantly involves arteries of the carotid system, especially the temporal artery and branches of the ophthalmic artery

Gilbert's syndrome

Gilbert's syndrome is an autosomal recessive* condition of defective bilirubin conjugation due to a deficiency of UDP glucuronyl transferase. Features unconjugated hyperbilinaemia (i.e. not in urine) jaundice may only be seen during an intercurrent illness Investigation and management investigation: rise in bilirubin following prolonged fasting or IV nicotinic acid no treatment required

Long term complications of chemical injury

Glaucoma Dry Eye Secondary eyelid problems -Entropian -Ectropian

Sequelae of AACG

Glaucomflekken (opaque flecks) Iris atrophy Optic nerve atrophy, but not necessarily cupping (may just see pallor) Vision loss

Tetanus 2B

Gram +ve Bacterium Clostridium tetani infects deep wounds Occurs in developing countries, in developed country elderly following gardening incident due to lowered immunity Characterised by paralysis and muscle spasms (painful), trismus (lockjaw, rigidity, dysphagia or autonomic dysfunction , resp failure Perioral muscle spasm (risus sardonicus) and spinal spasm (opisthotonus) may develop Ix: hx and features , organism isolation not diagnostic Rx: wound cleaning, tetanus vaccine, tetanus IgG

Shigellosis 1A

Gram, negative bacterium Spread via faecal-oral contact , contaminated water or food common in developing countries in children <5 S. dysenteriae is the most common agen 2-3 days incubation Causes mild self-limiting diarrhoea, fever, abdominal pain , tenesmus, volume depletion Ix: stool microscopy, culture, and sensitivity, serum urea and creatinine, FBC Rx: Self-limiting but Abx can be used to shorten dz, empirical Abx for severe dz

IX gastritis and duodenitis

H.pylori urea breath test: >90% sensitivity, can monitor response to therapy -H. pylori faecal antigen test: diagnose active infection -FBC: Phlegmonous gastritis --> leukocytosis, low Hb, low Hct -Endoscopy: consider in Px >55 w/ suspicious features of upper GI malig Intrisic factor Abs: 90% px w/ atrophic gastritis Vit B12: reduced in chronic gastritis

HAEMOLYTIC CRISIS

HAEMOLYTIC CRISES: - rare - fall in haemoglobin due to an increased rate of haemolysis uncommon; markedly reduced red cell lifespan. May be drug-induced, 2° to infection (e.g. malaria) or associated G6PD deficiency Rx analgesia e.g. opiates rehydrate oxygen consider antibiotics if evidence of infection blood transfusion exchange transfusion: e.g. if neurological complications

Pneumocystis jiroveci

HIV px pneumonia bilateral perihilar butterfly consolidation Rx -intravenous co-trimoxazole subsequently converted to oral therapy, usually continued for 3 weeks. IV pentamidine or clindamycin with primaquin -prophylaxis :Trimethoprim/sulfamethoxazole (TMP/SMX) 80/400 mg to 160/800 mg orally once daily acute :Trimethoprim/sulfamethoxazole 15-20mg/kg/day IV 6-8 hrs -sterods dapsone

Underlying disease causes of uveitis

HLA-B27 disorders: ankylosing spondylitis, Reiter Syndrome, IBS - psoriatic arthritis - Sarcoidosis - syphilis - TB - SLE - RA - Wegener's granulomatosis - lymphoma - CA

HPV and cancer

HPV-16 and 18 common causes of cervical cancer (70%) Peak infection is teen- early 20s HPV can incubate for 15 years Oncoproteins stop function of P53 which monitors genes Features: abnormal vaginal bleeding, multiple sexual partners, pelvic pain, dyspareunia Ix: speculum, colposcopy, biopsy, HPV testing HPV vaccine: Quadrivalent (6,11,16, 18) age 12-13 Since 2016 in US (9-valent (protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58).

Genital Herpes

HSV 1 and HSV2 ( More commonly HSV2 ) Incubation 3-7 days Presentation: Painful with Tender ulceration Lymphadenopathy recurrence likely- first episode is the worst! Tzanck Smear and PCR testing, Giemsa Elevated IgM HSV

Features of upper GI bleeding

Haematemesis, maelena, shock, uraemia

Vascular sickle cell

Haemolytic anaemia resuls in reduced levels of NO caused by release of haemoglobin and arginase from lysed red blood cells --> vasoconstriction , prolifera tive vasculopathy, pulmonary hypertension. pulmonary hypertension --> RV failure AVN of hip or shoulder chronic anaemia--> low O2 --> heart pumps faster and harder for more O2 --> cardiomegaly - iron overload --> HF

which bacterium are people with splenectomies partcularly susceptible to ??

Haemophilus influenzae and Neisseria meningitidis Penicillin V for prophylaxis

What are risk factors for developing retinal detachment?

High Myopia (LASIK pts!!) Lattice Degeneration Retinal Detachment in the fellow eye Cataract surgery (increased with complications) Family history of RD Trauma

Dx of carcinoid syndrome 2B

High urine levels of 5-HIAA and then CT scan to localise the tumour

Iliopsoas abscess

Hip flexion ( T12-L5) abcess: Collection of pus in iliopsoas compartment (iliopsoas and iliacus) common in IVDU commonly caused by staph aureus and sttrep S&S: -fever -backpain radiating to groin or just back pain -problem on hip flexion -better on lying back common in IVDU

MCL tear

History o valgus force to knee o +/- "pop" heard o severe pain with partial tears o complete tear may be painless Physical o swelling o tender above and below medial joint line o assess joint space opening with valgus force pain MCL laxity with end point - partial tear absence of end point - complete tear may be associated with ACL and medial meniscus tear Diagnosis: o X-ray - may be associated with an avulsion fracture of medial femoral epicondyle o Clinical diagnosis best confirmed with MRI Treatment o minor immobilize briefly. early ROM and strengthening o moderate hinged ROM brace and protected weight bearing early PT with ROM and strengthening o severe or combined surgical repair of associated injuries surgical repair of isolated MCL tear is rarely indicated

Which cancer gets worse with alcohol consumption

Hodgkin's lymphoma can cause severe pain on alcohol consumption

Cutaneous Larva Migrans

Hookworm Larve Ancylostoma braziliense; aka creeping eruption Southern US/ Carribean Dogs and Cats are normal host - doesnt get to where it needs to live in a human , migrates through the epidermis then dies 2-8 weeks TX: Thaibendazole topical / oral

Clinical findings for alkali injury

Hyperemia of conjunctiva. Chemosis (edema of the conjunctiva - eye irritation sign) Corneal epithelial erosions and mild haziness. Corneal edema. Anterior chamber inflammation. Corneal opacification. Limbal ischemia.

Presentation of insulinoma

Hypoglyaemia

Cause of chronic inflammatory diarrhoea

IBD

How does the cornea respond to infection/inflammation or injury?

INTENSE PAIN and a foreign body sensation

FROZEN SHOULDER INVESTIGATIONS 1A

INVESTIGATIONS: Radiology: 1. plain x-rays to exclude significant pathology 2. MRI arthrogram shows reduced joint volume - esp. decreased axillary fold 3. often there are incidental tears of the rotator cuff

What is thyroid ophthalmopathy?

IR/LR muscle inflammation/scarring due to autoimmune thyroid disease. T-lymphocytes infiltrating muscles and orbital area, pushing out eyeball.

What is Fundus Autofluorescence?

Identifies lipofuscin accumulations, a sign of cellular metabolism and aging. Can be used to characterize and follow the progression of geographic atrophy.

7. Senile / Solar Comedones (Favre Rachouchot's syndrome)

a. Large open comedones in periocular region b. Due to excessive sunlight and collagen degeneration of the skin

Steroid Acne

a. Monomorphous eruption of papules, sudden onset, after oral steroid therapy (i.e. asthma attack) b. Considered a drug eruption c. Treatment is to stop the steroids, and use benzoyl peroxides They all come out at once, all look the same

Neonatal Acne

a. Papules and pustules may develop in the neonatal period b. Due to maternal hormonal influence on baby's sebaceous glands, which shrink down over 2-4 weeks and do not become active again until puberty

Cholinergic Utricaria

a. Small, 2-4 mm papules with erythematous flare occurring usually on the chest and neck after exercise, stress, or overheating b. Onset occurs 2-20 minutes after above with usually mild itching, tingling, burning, warmth, and last only about 30 minutes c. Treatment: limit activity or stress, prophylactic antihistamines

Demographism

a. aka: "skin writing" due to hive production by rubbing the skin b. Most common form of physical urticaria, occurring in 5% of the general population c. Recurrent and chronic coarse with remissions and exacerbations d. Treatment: Antihistamines

Sweets Syndrome

a. aka: Acute Febrile Neutrophilic dermatosis b. Associations: URI, malignancy, inflammatory bowel disease, pregnancy c. Clinically: Sudden onset of fever, arthralgias, tender red plaques and ↑ WBC count. Lesions occur on head, neck, hands, trunk d. Labs: ↑ WBC count, with ↑ neutrophil count, ↑ ESR, and skin biopsy with infiltrate of neutrophils e. Treatment: Steroids

Majocchi's Granuloma 1B

a. tinea corporis involving the hair follicles resulting in pustules and nodules. zoophilic fungus (from animals) that penetrates in and around the hair follicles b. Requires oral antifungals for cure

THROMBOPHILIA NOM

abnormality of blood coagulation that increases the risk of thrombosis. INHERITED: - factor V Leiden (activated protein C resistance): most common cause of thrombophilia - prothrombin gene mutation: second most common cause Deficiencies of naturally occurring anticoagulants: - antithrombin III deficiency - protein C deficiency - protein S deficiency ACQUIRED: - Antiphospholipid syndrome Drugs: combined oral contraceptive pill

THROMBOCYTOSIS NOM

abnormally high platelet count, usually > 450 * 109/l Aex - reactive: acute, platelet count in creases as response to stress: a. severe infection b. haemorrhage c. IDA c. splenectomy d. inflammatory dz ESSENTIAL THROMBOCYTOSIS part of another myeloproliferative disorder such as chronic myeloid leukaemia or polycythaemia rubra vera - Features: asymptomatic, vasomotor (light-headed, syncope, cehst pain, parasthesia), thrombotic haemorrhagic symptoms , splenomegaly - hydroxyurea (hydroxycarbamide) is widely used to reduce the platelet count - interferon-α is also used in younger patients - low-dose aspirin may be used to reduce the thrombotic risk

BETA-THALASSAEMIA MAJOR 2B

absence of both beta-globin chains autosomal recessive results in rbc destruction -> heme in blood -> iron+ bilirubin -> secondary haemochromatosis ( arrhythmias, pericarditis, cirrhosis, hypothyroidism, diabetes ) - increased RBC in extramedullary tissue- bones, spleen, liver- enlargement point mutation chromosome 11 presents in first year of life with failure to thrive and hepatosplenomegaly. 3-6 months fine due to HbF Features: microcytic anemia- pallor, sob, palpitations, hepatosplenomegaly, chipmunk facies, hair appearance on skull Ix FBC: low hb , mcv, mchc - HB electrophoresis- diagnostic: ⬇HbA, ⬆HbF ⬆HbA2 >3.5% Rx to maintain the patient's haemoglobin while simultaneously suppressing enhanced erythropoiesis. -lifelong transfusions - s/c infusion of desferrioxamine- stop iron overload

A person has fever, costovertebral tenderness, white cell casts in urine, normal glomeruli and vessels but inflammed cortex. What do they have?

acute pyelonephritis

What do muddy brown, granular casts in the urine suggest?

acute tubular necrosis

VTE prophylaxis factors in pregnancy

age >35 years, BMI > 30 kg/m² and presence of gross varicose veins. history of clots coagulopathies

Measles 1A

aka: Rubeola, morbilli Etiology: the measles virus, a paramyxovirus C. Clinical findings: 1. Incubation period 10 days 2. Cough, coryza, conjuctivitis and fever 3-4 days prior to rash 3. Maculopapular rash starting behind the ears and spreads to the trunk "morbilliform," followed by light desquamation 4. Koplik's spots - blue-white macules with red halos on the buccal mucosa 1-2 days prior to rash D. Treatment: Supportive, Oral Vitamin A for extensive cases, Immunglobulin E. Complications/prognosis: COPE : cornea, ot media, pnemonia, Encephalitis/ eye involvement

which diuretics cause increased urine potassium?

all of them except the K+-sparing ones: spironolactone, triamterene, amiloride, eplerenone

angina pectoris treatment

all patients with stable angina are started on aspirin and atorvastatin, and verapamil (a rate-limiting calcium channel blocker) Nitrates, calcium channel blockers and beta blockers, anti-platelet medications like aspirin 81 mg and/or clopidrogrel 75 mg. Possible percutaneous interventions.

Typhoid

an infectious bacterial fever with an eruption of red spots on the chest and abdomen and severe intestinal irritation, splenomegaly caused by Salmonella paratyphi (types A, B & C)

bedsore/decubitus ulcers 1B

an ulcer, sore, or inflammation of the skin that results from prolonged pressure on the skin generally this occur over the bony parts of the body - common in Px admitted - RF: older people, modbiliy issues , impaired sensation ( diabetes) features: shallow open wound or tissue loss on areas subjected to pressure ( grade 2) can be full thickness ( G 3 and 4) . tenderness and warmth on the area -clinical dx, swabs of wounds

BISPHOSPHONATES

analogues of pyrophosphate, a molecule which decreases demineralisation in bone - inhibit osteoclasts by reducing recruitment and promoting apoptosis Clinical uses: - prevention and treatment of osteoporosis - hypercalcaemia - Paget's disease - pain from bone metatases Tablets should be swallowed whole with plenty of water while sitting or standing; to be given on an empty stomach at least 30 minutes before breakfast (or another oral medication); patient should stand or sit upright for at least 30 minutes after taking tablet

Name 9 consequences of uremia

anemia, low Vit D, hyperkalemia, metabolic acidosis, encephalopathy, CHF, edema, pyelonephritis, hypertension

Cutaneous Manifestations of Diabetes Necrobiosis Lipoidica ( Diabeticorum) NL

annular eythematous asymptomatic papules with yellow brown center 50 % of people have diabetes lower legs- women Tx: Topical steroids

unhappy triad

anterior cruciate ligament medial collateral ligament meniscus

Diffuse scleroderma ab rsentation

anti-Scl-70 antibodies presentation : fibrosis of organs, crest syndrome

SJOGREN'S SYNDROME 2B

autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces. there is lymphocytic infiltration of exocrine glands - may be primary (PSS) or secondary to rheumatoid arthritis or other connective tissue disorders - usually develops around 10 years after the initial onset - much more common in females (from 14:1 to 24:1) - marked increased risk of lymphoid malignancy (40-60 fold) 4/5 Features - Xerophthalmia ( no production of tears) - Xerostomia ( dry mouth) with depapillation - Dysphagia - Dysphasia - Dental cavitation and poor dental hygiene -Dyspareunia due to dry vagina - Fatigue, fever, weight loss and other systemic features -hearing loss -autoimmune thyroiditis arthralgia Raynaud's, myalgia sensory polyneuropathy renal tubular acidosis (usually subclinical) -fatigue, raynauds, pulmonary fibrosis, Parotid or submandibular gland swelling Ix - rheumatoid factor (RF) positive in nearly 100% of patients - ANA positive in 70% & anti-Ro (SSA) antibodies in 70% of patients with PSS - anti-La (SSB) antibodies in 30% of patients with PSS - Schirmer's test: filter paper near conjunctival sac to measure tear formation -salivary gland biopsy salivary flow rate - histology: focal lymphocytic infiltration - also: hypergammaglobulinaemia, low C4 -ESR ⬆, CRP ⬆ -FBC: leukopaenia, thrombocytopaenia Rx artificial saliva and tears pilocarpine may stimulate saliva production

FIbronodular hyperplasia

benign solid liver tumour 2nd most common can be congenital common in women of childbearing age may be linked to conraceptive use ? do not casue symtopms. sometimes RUQ discomfort, pain, mass and peritonitis (rare) Ix USS, CT, MRI , biopsy no Rx

What is papilloedema?

bilateral optic disc edema secondary to elevated intracranial pressure

What is the cause of post-renal acute renal failure?

bilateral outflow obstruction, due to stones, tumors, or benign prostatic hypertrophy

Ix Jaundice

bilirubin, ALT, albummin, hepatitis serology

IX for basal cell carcinoma

biopsy

Melanosis coli

black bowel from use of phenanthracene laxatives

features of E.Coli infection

bloody diarrhoea , abdo pain, volume depletion, fever haemolytic uraemic syndrome : rapid fall in hematocrit and platelet count, elevated serum creatinine, hypertension, and possibly signs of fluid overload, bleeding diathesis, and neurologic symptoms and signs.

Azathioprine side effects

bone marrow depression nausea/vomiting pancreatitis

What would an audiogram of sensorineural hearing loss look like

both air and bone conduction are impaired in mixed hearing loss both air and bone conduction are impaired, with air conduction often being 'worse' than bone

Hydroxychloroquine side effects

bull's eye retinopathy - may result in severe and permanent visual loss - colour retinal photography and spectral domain optical coherence tomography scanning of the macula

PTH and osteoclast/blast

can stimulate bone resorption by binding to PTH receptors on osteoblasts, increasing cytokine synthesis to stimulate osteoclasts

What is the ocular manifestation of Von Hippel Lindau syndrome?

capillary hemangioma of retina - afferent and efferent vessel to and from

Auricular hematoma forms between:

cartilage and skin compromising blood flor wo the cartilage

Describe eustachian tube

cartilaginous and bony passageway btwn nasopharynx and middle ear

Pathologic

caused by diseases that weakens the bones

MALIGNANT OTITIS EXTERNA

caused by pseudomonas. common in elderly and immunocompromised. Do a CT scan, emergent ENT consult, admission. IV abx with: IV aminoglycoside + anti-pseudomonal PCN, cephalosporin or fluoroquinolone usually Ciproflaxin

FUNGAL PNEUMONIA 2B

caused mainly by Pneumocystis jirovecii in HIV Aspergillus fumigatus or Candida albicans and sometimes Cryptococcal pneumonia ALL mainly in AIDs and severely immunocompromised Ix antibody immunofluorescence from: sputum broncoscopy bronchoalveolar lavage Rx KEtoconazole Co-trimoxazole ( PCP)

CAUSES OF HYPERKALAEMIA 1A

causes • Oliguric renal failure. • K+-sparing diuretics.( furosemide, bumetanide) • Rhabdomyolysis - > Myoglobinuria causes renal failure by tubular cell necrosis - blood transusions • Metabolic acidosis (DM). • Excess K+ therap • Addison's disease • Massive blood transfusion. • Burns. • Drugs, eg ACE-i, suxamethonium. • Artefactual result

NEONATAL JAUNDICE > 14 DAYS

causes and investigations after 14 days a prolonged jaundice screen is performed, including: conjugated and unconjugated bilirubin: the most important test as a raised conjugated bilirubin could indicate biliary atresia which requires urgent surgical intervention direct antiglobulin test (Coombs' test) TFTs FBC and blood film urine for MC&S and reducing sugars U&Es and LFTs Causes of prolonged jaundice biliary atresia hypothyroidism galactosaemia urinary tract infection breast milk jaundice congenital infections e.g. CMV, toxoplasmosis

Osteoclasts

cells on bone surface responsible for bone resorption -secrete acid and enzymes into space and increase solubility of bone, degrading matrix with enzymes

complications of malaria

cerebral malaria: seizures, coma acute renal failure: blackwater fever, secondary to intravascular haemolysis, mechanism unknown acute respiratory distress syndrome (ARDS) hypoglycaemia disseminated intravascular coagulation (DIC)

Neurogenic Bladder Disorder

characterised by detrusor muscle and external urethral sphincter dysfuntion due to nervous system dysfunction includes spastic bladder: failure to store urine--> results in reflex bladder spasm and decreased bladder urine associated with inflammation, injury, or drugs that are associated with T12 and above. e flaccid bladder: large colume low pressure Rx bladder training anticholinergics anti-muscarinics catheter

Causes of upper lobe fibrosis

charts C - Coal worker's pneumoconiosis H - Histiocytosis/ hypersensitivity pneumonitis A - Ankylosing spondylitis R - Radiation T - Tuberculosis S - Silicosis/sarcoidosis

Rheumatoid arthritis crystals

cholesterol crystals, these are rhombic/brick-shaped with a negative birefringence

ASTHMA Rx

chronic Rx in asthma 1. SABA PRN 2. ICS (low-dose) + SABA 3. ICS (low-doe)+SABA+ LTRA 4. ICS low + LABA+ SABA +/- LTRA 5.low-dose ICS + LABA (MART) 6. mod ICS+ LABA mart + SABA 7. High-dose IICS+LABA + SABA 6. oral steroid+ high dose ICS+ LABA+ immunomodulator

What is Kearns-Sayre syndrome?

chronic progressive external ophthalmoplegia mitochondrial DNA disease cardiac conduction disturbance retinitis pigmentosa

Macule

circumscribed change in color <1cm

Patch

circumscribed change in color > 1cm

Papule

circumscribed change in texture <1cm descriptive modifiers, umbilicated, verrucoid, flat-topped, excoriated, atrophic, follicular etc.

Purpura

circumsribed blood deposit >.5

Tinea incognito

clinically masked dermatophyte infection due to inappropriate therapy with topical steroids

Curschmann spirals

coiled basophilic plugs of mucus found in asthma

1. what type of treatment is needed for good control of insulin in TIDM

combination of rapid and long acting , rapid at meal times breakfast, dinner, lunch

NEUTROPENIC SEPSIS

common complication of cancer therapy (usually chemotherapy) - neutrophil count of <0.5x10^9 in a patient with anticancer treatment and one of the following: 1. Temperature >38oC 2. other signs or symptoms consistent with clinically significant sepsis - Antibiotics started immediately, do not wait for WBC - Empirical Abx: piperacillin + tazobactam (Tazocin) immediately - if patients still febrile and unwell after 48 hours, alternative Abx: meropenem +/- vancomycin

Hip fracture 1B

common fracture in elderly (greater incidence of osteopenia) o female > male o in osteopenic individuals, fracture may precede simple fall (muscle stronger than bone) o in younger individuals, fracture related to high energy injury markedly displaced associated with other injuries S+S: unable to bear weight on affected limb o limb shortened, externally rotated, painful ROM, antalgic gait if patient can weight bear Ix: AP of pelvis and lateral of involved hip o if findings equivocal - MRI, bone scan and tomograms Rx- Intracapsular hip fracture: Undisplaced Fracture: internal fixation, or hemiarthroplasty if unfit. Displaced Fracture: young and fit i.e. <70 years- Reduction and internal fixation (if possible) Extracapsular hip fracture dynamic hip screw if reverse oblique, transverse or subtrochanteric: intramedullary device . older and reduced mobility- Hemiarthroplasty or total hip replacement.

supply to cystic duct

common hepatic artery - cystic duct branch of common hepatic

Haemophilus influenzae pneumonia

common in patients with COPD GRAM -VE ROD

autoimmune hepatitis

common in young associated with amenorrhoea Ix +ve ANA, anti-SM antibodies, anti-liver-kidney microsomal-1 antibodies deranged LFTs , high albumin 1. steroids (severe) 1st line 2. ursodeoxycholic acid

MONGOLIAN SPOT

common variation of hyperpigmentation in Black, Asian, American Indian, and Hispanic newborns usually at the butt or sacrum

BEHCET'S SYNDROME

complex multisystem disorder associated with presumed autoimmune mediated inflammation of the arteries and veins. characterised by : Recurrent attacks of oral aphthous ulcers, genital ulcers, uveitis, and skin lesions - more common in the eastern Mediterranean (e.g. Turkey) and Asia - more common in men - tends to affect young adults (20 - 40 years old) - associated with HLA B5 and MICA6 allele - around 30% of patients have a positive family history features classically: 1) oral ulcers 2) genital ulcers 3) anterior uveitis thrombophlebitis arthritis neurological involvement (e.g. aseptic meningitis) GI: abdo pain, diarrhoea, colitis erythema nodosum, DVT Ix clinical Rx steroids immunosupressive drugs

MYELOFIBROSIS NOM

condition in which bone marrow is replaced with fibrous tissue characterised by: marrow fibrosis, splenomegaly, extramedullary haematopoiesis and teardrop poikilocytes and leucoerythroblastosis in the peripheral blood fi lm path: JAK2 mutations have been found presentation - asymptomati - anaemia , hepatosplenomegaly, lethargy, infections, bleeding, pallor , abdo discomfort - lethargy - most common PC - bleeding gums IX FBC, blood film , BM aspirate, trephine biopsy

dermoid cyst

congenital tumor composed of displaced embryonic tissue (teeth, bone, cartilage, and hair); typically found in an ovary and usually benign can be found on skin as painless, swelling. they are lined by hair and squamous epithelium

Osteocytes

contact between these are through channels (canaliculi), help transfer nutrients and waste.

What are some complications of RA?

corneal and scleral inflammation scleritis (diffuse or nodular) peripheral ulcerative keratitis Sjogren syndrome = RA + dry eye + dry mouth

what types of nephrons are there

cortical medullary nephrons

Calot's triangle

cystic duct, cystic artery, common hepatic duct CONTAINS cystic artery

epithelial inclusion cyst 2B

cysts are fluid filled or semifluid filled nodules - benign cysts occurring on neck, scalp , trunk -this cyst is a response to an injury. Skin is tucked in to form a sac that is lined by normal epidermal cells that continue to multiply, mature and form keratin. -can turn in to cancer

Why does uremia cause anemia?

damaged kidney can't make erythropoeitin, so you have less RBCs being made

Gastroparesis

delayed gastric emptying due to decreased motility of stomach muscles idiopathic, neuropathy 2nary to diabetes results in difficult to control BMs

Child-Pugh score

determines mortality after portacaval shunt Pour Another Beer At Eleven PT/INR, ascites, bilirubin, albumin, encephalopathy each component 1-3 5-6 10% mortality >10 60% mortality

Risk factors for osteomyelitis

diabetes mellitus sickle cell anaemia intravenous drug user immunosuppression due to either medication or HIV alcohol excess

Diagnosis and treatment of acute brinchitis

diagnosis - history -CXR - exclude other things treatment -self-limiting -exacerbation: amoxicillin 500mg 7 days SE nause and diarrhoes bronchodilators (SABA) ICS: beclometasone, mometasone

CAUSES OF METABOLIC ACIDOSIS AND NORMAL ANION GAP

diarrhea, glue sniffing, renal tubular acidosis, hyperchloremia

LEFLUNOMIDE

disease modifying anti-rheumatic drug (DMARD) mainly used in the management of rheumatoid arthritis - very long half-life which should be remembered considering it's teratogenic potential CI: pregnancy and pre-existing lung and liver disease Monitoring: FBC/LFT and blood pressure Stopping: leflunomide has a very long wash-out period of up to a year which requires co-administration of cholestyramine

How do triamterene and amiloride work?

diuretics that physically block sodium channels in the collecting tubule. cause sodium excretion

HAEMOLYTIC ANAEMIA 1B

divided in to 'warm' and 'cold' types, according to at what temperature the antibodies best cause haemolysis -intravascular or extravascular - commonly idiopathic Intravascular haemolysis: causes mismatched blood transfusion G6PD deficiency* red cell fragmentation: heart valves, TTP, DIC, HUS paroxysmal nocturnal haemoglobinuria cold autoimmune haemolytic anaemia: mycoplasma, EBV, lymphoma, AIHA is usually IgM . direct antiglobulin test( coombs) Extravascular haemolysis: causes haemoglobinopathies: sickle cell, thalassaemia hereditary spherocytosis haemolytic disease of newborn warm autoimmune haemolytic anaemia: lymphoma, CLL, SLE . Ix AIHA is characterised by a positive direct antiglobulin test (Coombs' test) normal HA methaemalbumin (detected by Schumm's test). Free haemoglobin is excreted in the urine as haemoglobinuria, haemosiderinuria

signs and symptoms of RSV

dyspnea, cough, wheezing, and/or crackles on chest auscultation , tachy

perforated TM

ear ache, green, yellow dx, none or low grade fever 6-8 weeks no treatment amoxicillin if painful ENT referral after 6 weeks no healing = myringoplasty

Preauricular pits mark:

entrance to sinus tract

In normal english, how would you describe uremia?

failure of the kidneys to make urine or excrete nitrogenous waste

What is Fanconi's syndrome?

failure of the proximal tubule to absorb glucose, amino acids, ions, and uric acid.

Features of IBS 1A

features - Pain is relieved by defecation - Bloating, flatulence, wind - No structural or pathological abnormalities are demonstrable - Can be diarrhoea-predominant, constipation-predominant or mixed - Stool may pass alongside rectal mucus RED FLAG Night symptoms, vomiting, weight loss, rectal bleeding, constitutional symptoms

What are the symptoms of Drug-Induced Interstitial Nephritis?

fever, rash, eosinophilia, hematuria 2 weeks after you take the drug

layers of the eye

fibrous layer (sclera) , vascular layer (choroid) , inner layer (retina)

Cutaneous Horn

firm conical projection made of keratin, Resembles animal Horn FACE, ARMS, hand, ears hard as a rock!

How does adult polycystic kidney disease present?

flank pain, hematuria, hypertension, UTI's, progressive renal failure

Inhaled Corticosteroids (ICS)

fluticasone mometasone budesonide beclomethasone pref for persistent asthma need consistent daily use for optimal effect (NOT PRN) SE: - Oropharyngeal candidiasis/thrush - Increased risk of URI - Dysphonia: changes in voice ,Cushing's, vomiting, sleep disturbance, weight gain, infections

what is hydrostatic pressure

force blood exerts on /BV --> can be caused by HF oncotic pressure is when solutes like albumin cant cross capillary byosmosis fluid moves from low to high conc. from outside to pleura space --> e.g cirrhosis few proteins i.e albumin made and

Pilonidal disease

forceful insertion of hairs into skin on natal cleft --> Acute abcess in the sacrococcygeal area, ruptures spontaneously leaving unhealed sinus tract w/chronic damage. -common in young men of working age 16-40 -characterised by sacrococcygeal discharge sacrococcygeal pain and swelling sacrococcygeal sinus tracts -clinical dx -Rx: surgery , hair removal, local hygiene

LENTIGO MALIGNA

freckle-like proliferation of melanin-producing cells that may develop on sun-exposed skin; may transform later into melanoma perisist in winter can be found in some conditions i.e Carney complex, Peutz-Jeghers syndrome

Osteoblasts

from mesenchymal stem cells, form sheet on forming bone, synthesize osteoids, which are mineralized, surround osteoblasts, and make osteocytes

Tinea unguium (onychomycosis) 1B

fungal infection of the nail due to Dermatophytes such as Trichophyton rubrum (T rubrum), T. interdigitale. The infection is also known as tinea unguium. increases with age features: white yellow opaque streat o n side of nail, end of nail lifts up, thickening of nail plate Rx i. Anitfungal Creams for mild to moderate cases (terbinafine, econazole, etc.) ii. Oral antifungals for extensive or resistant cases (griseofulvin, intraconazole, fluconazole, terbinafine)

Which diuretics cause increased urine calcium?

furosemide, ethacrynic acid

Which diuretics can cause sulfa allergies?

furosemide, thiazides, acetazolamide

complications of DKA rx

gastric stasis thromboembolism arrhythmias secondary to hyperkalaemia/iatrogenic hypokalaemia iatrogenic due to incorrect fluid therapy: cerebral oedema*, hypokalaemia, hypoglycaemia acute respiratory distress syndrome acute kidney injury

Leflunomide side effects

gastrointestinal, especially diarrhoea hypertension weight loss/anorexia peripheral neuropathy myelosuppression pneumonitis

Salmonellosis 1A Aex, Ix, Rx

gram negative bacteria mainly S. enterica and S.nongori which cause infection confined to the bowel 6-48 hrs transmitted via oral route causes gastroenteritis characterised by acute-self limiting diarrhoea, N&V, fever myalgia, headaches, volume depletion, abdominal tenderness complications include: bacteraemia, septicaemia or osteomyelitis. Risk factors: v. young or V. old, immunosuppression, exposure to infected people and animals, Abx use Ix: stool studies, WBCs, cultures Rx: fluid replacement, , anti-emetics (ondansetron4-8 mg), ciprofloxacin (quinolone) or cotrimaxazole SE: tendon damage, vision, myalgia

E. Coli 0157

gram negative bacterium , commensal but can colonise GIT infection also through ingestion of contaminated food. commonest cause of enterotoxigenic E coli ( traveller's diarrhoea) causes HUS: microangiopathic haemolytic anaemia, thrombocytopaenia, AKI

Charcot-Marie-Tooth disease

hereditary condition characterized by peripheral neuropahy predominately motor foot drop, pes cavus hammer toes, distal muscle weakness and atrophy, hyporeflexia

External Hernia

herniates through abdominal wall

Obstructive jaundice bloods

high ALP, bilirubin, normal AST colicky pain w/ eating stones in hepatic duct

knee disclocation

high energy trauma caused by tears of multiple ligaments -ss: effusion, pian, knee instability, iscahemic limb Specific Complications • high incidence of associated injuries popliteal artery tear peroneal nerve injury capsular tear • chronic: instability, stiffness, post-traumatic arthriti

BACTERIAL MENINGITIS CSF

high protein, decreased glucose, increased WBC with >80% neutrophils

SUBTROCHANTERIC :

high trauma, osteoporosis ss: ss: acute hip pain , cant weight bear, short &externall rotatated leg, painful RO

What does this show, causes.

https://www.cram.com/2/images/upload-flashcards/000/2746383/30667459_m.jpeg^This x ray reveals very prominent hilar shadows indicating bilateral hilar lymphadenopathy.Causes includeTuberculosisLymphomaHIVSarcoid.

pyloric stenosis 1B 1-7

hypertrophy of the pyloric sphincter results in narrowing of the pyloric canal. It is the most common cause of gastric outlet obstruction in the 2- to 12-week-old age group. S&S -olive size mass in RUQ (moveable/firm) -poor feeding, failure to thrive -peristaltic waves during and after feedings -projectile vomiting!** -hungry and irritable after vomiting -dehydration & metabolic acidosis -Hypovolaemia and hypochloraemic, hypokalaemic metabolic alkalosis Ix: Abdo USS: thickened appendiceal wall Rx IV fluid resus pyloromyotomy

What are common causes of respiratory alkalosis?

hyperventilation : AEX: anxiety, pain etc... -pregnancy -pulmonary embolism -Icp

What are some thiazide toxicities?

hypokalemia, hyponatremia, hyper- -glycemia, -lipidemia, -uricemia, -calcemia. Sulfa allergy.

why do coeliacs have to get pneumococcal vaccine

hyposplenism they receive the pneumococcal vaccine and yearly influenza vaccines, as hyposplenism can cause mild immunosuppression.

Associated Features of Atopic Dermatitis hyperlinearity of palms

i

Respiratory alkalosis

increased pH, reduced CO2

Anti-HBs

indicates immunity to HBV, either natural or vaccinated

What can cause diffuse cortical necrosis?

infarction of both kidneys due to vasospasm, DIC, septic shock, and pregnancy issues

paronychia 1A

inflammation around the nail bed mainly with S.aureus (common) , MRSA, S.pyogenes, peudomonas, HSV 1, candia acute <6 weeks chronic > 6 weeks Aex: nail biting, ingrown toe nails, manicuring, oral retinoids ( causes drying) . EGFRs and BRAF chronic form common is: dairy farmers, fishermenm houewives, cleansers features: pain, redness , swelling. yellow/white us if HSV yellow puss under cuticle, nail bed lifts (onycholysis) if pyogenes : fever lymphangitis, tender lymphoadenopathy Complications: hand cellulitis Ix: culture, swab, gram stain microscopy, Tzanck smear, nail clipping culture for mycology Rx: 1. soak in warm water 2. avoid wet work, waterproof gloves 3. keep fingernails clean 4. emolients 5. topical steroids 6. steroid injections 7. antiseptics or antifungals 8.Oral antifungal agent (itraconazole or fluconazole), if C albicans is confirmed.

Acute pancreatitis 1A

inflammation of the pancreas 10% mortality rate IGETMASHED - Idiopathic - Gallstones - Ethanol (alcohol) - Trauma - Steroids - Mumps - Autoimmune - Scorpion bits, sphincter dysfunction - Hyperlipidaemia, hypothermia, hypercalcaemia - ERCP - Drugs - azathioprine, 5-ASA, ACEI, isoniazid, trimethoprim, thiazide diuretics, sodium valroate in young people - Infection - coxsackie, CMV, Mumps 3/4 Abrupt onset of severe epigastric pain increasing in intensity over 15-60 mins radiates to the back worse on movement , supine position alleviated by foetal position nausea, vomiting, fever, shock. Pain is worst when supine. Signs Tachy cardia, tachypnoea hypovolaemia epigastric tenderness radiating to back fever abdo distenstion - Absent bowel sounds due to peritonism and ileus - Rigidity, rebound tenderness, tenderness and guarding due to peritonism - Grey-Turner's sign - flank discolouration due to vessel autodigestion - Cullen's sign - discolouration in the umbilical region for the same reason - Pancreatic ascites - leakage of fluid from a disrupted pancreatic duct into the peritoneal cavity - Fever rx -Amylase -Lipase ( more sensitive) -Abdo U/S or CT may show an enlarged pancreas with stranding, abscess, haemorrhage, necrosis or pseudocyst - FBC, U&E, LFT - Raised WCC - Raised HCT - predicts necrosis, important monitoring test - ABGs - Raised CRP - Clotting profile - Serum lactate - raised due to necrosis - Glucose - CXR - pleural effusion - AXR - sentinel loop sign - US - inflammation, stranding, fluid - CT - irregular, enlarged, non-homogeneous pancreas, fat-stranding - MRCP and ERCP - stones, enlargement, ERCP can perform sphincter manometry

vestibular neuritis

inflammation of vestibular nerve. usually precipiated by URTI or vascular disease in the elsderyly AE: 20-40 common in young Features: sudden severe vertigo, dizziness, N&V UNILATERAL ear pain NO HEARING PROBLEMS i.e tinnitus or deafness Rx resolves on its own in 6-12 weeks Symptomatic treatment with antivertiginous medications (e.g. prochlorperazine 5mg tds) should be given only in the first few days since they may delay recovery by affecting central compensation mechanisms

DERMATOMYOSITIS

inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions - may be idiopathic or associated with connective tissue disorders or underlying malignancy (typically ovarian, breast and lung cancer, found in 20-25% - more if patient older) - polymyositis is a variant of the disease where skin manifestations are not prominent

POLYCYSTIC LIVER DISEASE

inherited in an autosomal dominant pattern that affects 1 in 500 individuals. Polycycstic liver disease (PLD) : inherited dz, common a growth of numerous abnormally shaped (malformed) bile ducts, known as ductal plate malformation. PLD may occur with polycystic kidney disease (PKD) or alone but is less common and milder than the kidney form.

How does Acetazolamide work?

inhibits carbonic anhydrase, so you excrete all your bicarb in the proximal tubule It's a diuretic

compartment syndrome 1B

involves the compression of nerves and blood due increased interstitial pressure in an anatomical "compartment" (forearm, calf) with little room for expansion, resulting in decreased perfusion and potential muscle/nerve necrosis associated with SUPRACONDYLAR ( common in children from FOOSH) AND TIBIAL SHAFT FRACTURES look for "the 6 Ps" - ss: o pain on passive movement (out of proportion to injury) and respond to normal dose of analgesics o pallor o paralysis (inability to move limb) o pulse discrepancies o parasthesia o polar (cold) Ix: compartment pressure monitoring in unresponsive or unreliable patients ( pressure >20mmHg abnormal, 40mmHg diagnostic - CK -myoglobin • requires prompt decompression: remove constrictive casts, dressings; fasciotomy may be needed emergently Rx Fasciectomy

reducible hernia

is a hernia in which the contents of the hernial sac can be returned to their normal position. (Inguinal Hernia)

What are some eye problems associated with sarcoidosis?

lacrimal gland swelling [painless, bilateral, dry eye] conjunctival & iris nodules (granulomas) uveitis

Achilles Tendon Rupture

loading activity stop and go sports secondary to chronic tendonitis, steroid injection usually one to two inches above tendinous insertion on calcaneous, greatest btwn 30-50 yrs of age, typically be unable to stand on their toes and tend to exhibit a positive Thompson test pop, sudden pain, sensation of being kicked in heel , palpable gap weak plantar flexion

saddle anesthesia

loss of sensation restricted to the area of the buttocks and perineum - young men -emergency

What is the pathophys behind tinnitus?

loud sounds cause the cilia to bend more than they should and become damaged - high-pitched ringing sensation

Chondrosarcoma

malignant tumor of cartilage >40 YO

HYDROXYCHLOROQUINE

management of rheumatoid arthritis and systemic/discoid lupus erythematosus Monitoring: Ask patient about visual symptoms and monitor visual acuity annually using the standard reading chart

What drug must be avoided in bowel obstruction

metoclorpramide

Cherry Angioma (Senile Angioma)

most common vascular lesion, EVERYONE WILL ALMOST GET TEHM single or multiple red papules trunk, extremities, genitals, oral mucosa, bleed easily with trauma

PCL tear

much less common than ACL injury History o fall onto flexed knee with plantar flexed foot o hit anterior tibia on dashboard in motor vehicle accident o hyperflexion or hyperextension with anterior tibial force Physical o positive posterior sag sign o false positive anterior drawer o true positive posterior drawer Diagnosis: o X-ray - may be associated with an avulsion fracture of posterior tibial tubercle o Clinical diagnosis best confirmed with MRI Treatment o Vast majority managed non-surgically and do well. Reconstruction only indicated in multiple ligamentous injuries of the knee and those that have instability despite adequate non-surgical management

Methotrexate side effects

mucositis myelosuppression pneumonitis pulmonary fibrosis liver cirrhosis Pregnancy: women should avoid pregnancy for at least 3 months after treatment has stopped men using methotrexate need to use effective contraception for at least 3 months after treatment

3 drainage pathways of sinuses - what do that drain?

nasofrontal duct - frontal sinus osteomeatal unit - anterior ethmoid sinus and maxillary sinus sphenoethmoidal recess - drains posterior ethmoid and sphenoid sinus

S. aureus pneumonia

new pneumonia after influenza infection Rx co-prescription of flucloxacillin to the standard antibiotic (amoxicillin) in such a situation.

WALDENSTROM'S MACROGLOBULINAEMIA

non- hoghkins -infiltration of plasmocyte lymphocytes in BM, organs which secerte monoclonal IgM paraprotein. rare, common in old men Cytopaenias ( anaemia, thrombocytopenia, pancytopenia) Leucocytosis Anaemia Neutropaenia: infections, fever Enlargements Symptoms of hyperviscosity (headache, dizziness, visual upset, bleeding, ataxia, CCF and somnolence, stupor and coma) , stroke , anaemia, epistaxis, recurrent infection, dyspnoea, CCF, and weight loss. Peripheral neuropathy—usually sensory or sensorimotor (720%): distal, symmetrical, slowly progressive, usually lower extremities. • Hepatomegaly (725%); splenomegaly and lymphadenopathy less frequent. • Fundoscopy reveals distended sausage-shaped veins, retinal haemorrhage ± papilloedema -NO BONE symptoms

Bursae (bursitis) of the knee 1B

o Prepatellar (nursemaid's knee) - overlying the patella commonest bursa of knee o Infrapatellar - overlying the patellar ligament and tibial tuberosity o Due to chronic kneeling - e.g. carpet layers, wrestlers o Commonly infected o Soft cystic swelling over front of knee o Check for inflammation o Aspiration and culture/sensitivity Treatment o Aspiration and steroid injection - recurrence 20% o Surgery Excision Incision and drainage if infected

femoral diaphysis fracture 1B

o high energy (MVA, fall from height, gunshot wounds) o low energy (spiral fracture in children) o high morbidity/.mortality (haemorrhage, fat embolism, ARDS, MODS) o blood replacement often required o frequently comminuted o associated soft tissue trauma Clinical findings o leg is shortened, externally rotated o unable to weight bear o assess neurovascular status o examine for evidence of an open fracture, with soft tissue compromise o suspect child abuse with spiral femoral shaft fractures in children Treatment o ABC's of trauma are essential o immobilize leg with Thomas Splint o adequate analgesia . o surgical fixation (intramedullary nail) within 24 hours high rate of surgical union after 6 to 12weeks o early mobilization of hip and knee

meniscal tear

o medial meniscus torn 8x more the lateral o ½ are traumatic,1/2 are degenerative o often associated with other ligamentous injuries if traumatic History: o twisting force when the knee is partly or completely flexed e.g., squatting and then rotating rapidly, skiing, football, tennis o acute - immediate pain, difficulty weight bearing.+/-Iocking o chronic - pain, swelling, instability Types of meniscal tears 1. Horizontal 2. Oblique 3. Circumfrencial 4. Transverse 5. Degenerative 6. Bucket-Handle Clinical presentation o Locking, clicking, giving way of knee o effusion o kick of full extension (locking) o pinpoint joint line tenderness o McMurray's or Thessaly test positive Diagnosis and Treatment o MRI for diagnosis only Treatment o conservative (unless locked) ROM and strengthening exercises NSAIDs o failed conservative - persistent pain, locking, giving way arthroscopy (diagnostic and therapeutic) o excise torn section o repair marginal tears

multiple myeloma

o most common primary malignant tumour of bone in adults o anaemia, anorexia, renal failure, nephritis, o weakness, bone pain Diagnosis o osteoporosis, punched out lesions in cancellous bone (esp. skull), compression fracture of spine o ESR elevated o serum / urine protein electrophoresis o bone marrow aspirate`

Acute fatty liver of pregnancy

often asymptomatic, but may have nausea, malaise, headache abdominal pain, pruritis . 50% also have PREECLAMPSIA and 60% will develop acute RENAL FAILURE. Biopsy will show microvesicular fat deposition in hepatocytes, but NO NECROSIS. Labs can show elevated PT and LFTs

Sulfasalazine side effects

oligospermia *Stevens-Johnson syndrome* pneumonitis / lung fibrosis myelosuppression, Heinz body anaemia, megaloblastic anaemia may colour tears → stained contact lenses

pharyngeal pouch

one of a pair of structures in the throat region of a chordate elderly man complains of dysphagia, halitosis, regurgitation and cough

Toxic nodular goiter

one or more nodules become TSH independent and develop "hot" nodules secrete Thyroid hormone cause thyrotoxicosis

What would an audiogram of conductive hearing loss look like ?

only air conduction is impaired in mixed hearing loss both air and bone conduction are impaired, with air conduction often being 'worse' than bone

OXIC AMBLYOPIAS (CHRONIC RETROBULBAR NEURITIS)

optic nerve fibres are damaged by the exogenous poisons such as: 1. Mild toxic agents—Tobacco, ethyl alcohol, carbon disulphide, iodoform, etc. They produce central scotoma due to initial effect on papillomacular bundle. 2. Severe amblyopia—It is produced by quinine organic arsenic, etc. They produce marked peripheral contraction of the visual field or even blindness. 2. usually bilateral, chronic and associated with progressive deterioration

MULTIPLE MYELOMA 1B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

paraproteinaemia - PROLIFERATION OF PLASMA CELLS (differentiated b-cells) that produce M protein, -RF- BLACK, >70 -OSTEOPOROSIS AND ⬆ ESR --> TINK MM also. PERSISTENT BACK PAIN Aex: benzene, HHV 8 , genetics S&S: BASH -BONE LYSIS: HYPERCALCAEMIA, FRACTURES, OSTEOPOROSIS , BONE PAIN -ANAEMIA (technically a pancytopenia), lethargy -SPINAL CORD COMPRESSION BACK PAIN -HYPERVISCOSITY: CLOTTING-> RENAL FAILURE, STROKE, MI, ETC Ix - BJ PROTEINS urine and serum - ↑ *ESR IS RAISED !!!* and PV (plasma viscocity), ↑ Creatinine, β2 microglobulin, LDH (lactate dehydrogenase), uric acid Hypercalcaemia X-rays: "raindrop skull" bone lysis, osteoporosis, fractures Bone marrow aspiration - myeloma cells Immunophenotyping -, CD19+/-,CD56+, CD38+, CD138+, cytoplasmic monoclonal ƙ or λ -plasmacytosis (>30% plasma cells ) - blood film: *ROULEAUX FORMATION* - NICE recommends whole body MRI instead of skeletal xray Raised ESR and osteoporosis represents multiple myeloma unless proven otherwise Diagnosis requires one major and one minor criteria or three minor criteria in an individual who has signs or symptoms of multiple myeloma. Major criteria Plasmacytoma (as demonstrated on evaluation of biopsy specimen) 30% plasma cells in a bone marrow sample Elevated levels of M protein in the blood or urine Minor criteria 10% to 30% plasma cells in a bone marrow sample. Minor elevations in the level of M protein in the blood or urine. Osteolytic lesions (as demonstrated on imaging studies). Low levels of antibodies (not produced by the cancer cells) in the blood. Rx: thalidomide, lenolidomide Clinicians should offer very urgent protein electrophoresis and a Bence Jones protein urine test (within 48 hours) to assess for myeloma in people aged 60 and over with hypercalcaemia or leukopenia and a presentation that is consistent with possible myeloma.

Sister Mary Joseph

paraumbilical met of gastric ca

Associated Features of Atopic Dermatitis Pityriasis alba

patches of hypo pigmentation thought to represent subtle areas of inflammation associated with atopic dermatitis

What are the symptoms of high K+ in the plasma?

peaked T waves and wide QRS on EKG, arrythmias

ankle anaotmy

pic

osteomyelitis CT

pic

renal osteodystrophy xray

pic

Auspitz's Sign

pin point bleeding when scale is removed

Associated Features of Atopic Dermatitis keratosis pilaris

pinpoint hyperkeratotic papules of posterior arms, anterior thighs, buttocks, face

signs/features of pleurisy

pleural rub pleuritic chest pain -cough -fever

Cause of bilateral kidney enlargement

polycystic kidney disease HIV associated nephropathy

What are the symptoms of high Ca++ in the plasma?

polydipsia, polyuria, delirium, kidney stones, abdominal pain

pre-renal aki vs acute tubular necrosis

pre-renal Na+ urine <20mmol/ urine osm >500mOsm/kg odium - urine osmolality high, urine sodium low Acute tubular necrosis urine na+: >40mmol urine osmol <350

6 functions of the nose and sinuses

preferred airway olfaction taste resonance lighten skull humidify, filtrate, and warm air mucociliary clearance of trapped particles Defense system : IgA Abs secretion to kill bacteria and viruses. mucus secretion w/ protein lysozymes

IFN-gamma

produced by T lymphocytes & NK cells weaker antiviral action, more of a role in immunomodulation particularly macrophage activation may be useful in chronic granulomatous disease and osteopetrosis

IFN-beta

produced by fibroblasts antiviral action reduces the frequency of exacerbations in patients with relapsing-remitting MS

proteinurea

protein on urinalysis raised in: - Diabetes mellitus - Hypertension - Minimal change disease

what is used to test liver function?

prothrombin because it has a shorter half-life (60 hrs) making it a better measure of acute liver failure

PPIs Mechanism SE

proton pump inhibitors (PPI) cause irreversible blockade of H+/K+ ATPase of the gastric parietal cell. Examples include omeprazole and lansoprazole. Adverse effects hyponatraemia, hypomagnasaemia osteoporosis → increased risk of fractures microscopic colitis increased risk of Clostridium difficile infections Interstitial nepritis? Myopathy

Isomorphic Koebner's Phenomenon

psoriasis developing in the site of skin trauma

Histoplasmosis

pulmonary and hematogenous disease caused by *Histoplasma capsulatum (mould)* transmitted through inhalation symptoms: pneumonia-fever, cough, myalgias, chest pain, and malaise of varying severity (primary ) *chronic histioplasmosis*: pulmonary lesions that are often apical and resemble cavitary TB. Worsening cough, dyspnoea *Progressive disseminated histoplasmosis*: hepatosplenomegaly, lymphadenopathy, bone marrow involvement, and sometimes oral or GI ulcerations. Ix: sputum culture,urine antigen test Rx: amphotericin B or an azole

Inactivated preparations of vaccines

rabies hepatitis A influenza (intramuscular)

WHAT HAPPENS WHEN YOU GIVE AMOXICILLIN IN MONONUCLEOSIS ?

rash !!

Legionella pneumononia presentation and rx

recent travel to hot country, more severe infection, - hyponatraemia in bloods - deranged LFTs younger px - SIADH rx clarithromycin /erythromycin neurological symptoms, evidence of multi-system disease (e.g. abnormal liver enzymes and raised CK) younger patients, smokers,

Bacillus cereus

reheated rice diarrhoea

Tx of gingivitis (6)

remove irritating factors practice good oral hygeine regular dental check-ups NO smoking warm saline rinses Abx's for acute infxn

What is chronic cholecystitis 1B ?

repeated or prolonged attacks of cholecystitis where gallstones repeatedly/intermittently obstruct cystic duct Due to chemical irritation from longstanding choleithiasis. resulting in prolonged inflammation of gall bladder Herniation of gallbladder mucosa into the muscular wall - Rokitanky-Aschoff sinus). s/sx: Postprandial RUQ pain, biliary colic . Late complication is porcelain gallbladder - increased risk for carcinoma) Ix: USS (shrunken fibrotic gallbadder. ) Rx: surgery - laparoscopic cholecystectomy

Sjogren syndrome antibodies

rheumatoid factor (RF) positive in nearly 100% of patients ANA positive in 70% anti-Ro (SSA) antibodies in 70% of patients with PSS anti-La (SSB) antibodies in 30% of patients with PSS

What are some complications of Fanconi's syndrome?

rickets, osteomalacia, hypokalemia, metabolic acidosis

Lateral cutaneous nerve of the thigh

sensory only lateral and posterir surfaces of thigh -> tingling and numbness

hypomagnesaemia 1B

serum > 0.7mmol causes GI Losses starvation/malabsorption vomiting/diarrhea alcoholism acute pancreatitis excess renal loss 2o hyperaldosteronism due to cirrhosis and CHF hyperglycemia hypokalemia hypocalcemia loop and thiazide-type diuretics nephrotoxic medications proton-pump inhibitors hungry bone- post parathyroidectomy --> osteoblasts need ions --> take magnesium from blood S&S 1. tetany, muscle spasms ( trousseau sign ) due to increased excitability 2. parasthesia 3. seizures, arrhythmias 4. decreased pth-> hypocalcaeimia 5. chvostek sign ECG widened QRS, prolonged PR, T-wave abnormalities, Torsades de pointes Ix U&Es Rx PO magnesium salts <0. 4mmol then IV magneium 40mmol/24hrs

MYXOEDEMA COMA

severe hypothyroidism complicated by trauma, sepsis, cold exposure, MI stressful events - medical emergency! FEATRES: decreased mental status and hypothermia; hyponatremia, hypotension, hypoglycemia, bradycardia, hypoventilation, and generalized edema often present. Reduced reflexes. Rx -ABC: ICU -hydrocortisone -thyroxine

diaphyseal

shaft of a long bone

Swimmers Itch

shistosome cercarial (flatworm larva) exposure Fresh water great lakes Region Itchy papules and pustules on EXPOSED skin Cool compresses, antihistamines, topical steroids

Blood or serous discharge from auditory canal indicate: (2)

skull fracture or ruptured TM

What are the 4 potassium-sparing diuretics?

spironolactone, triamterene, amiloride, eplerenone

Anterior cruciate ligament injury

sports Damage may result from twisting injuries Anterior drawer test and Lachman test may be positive if damaged RAPID joint swelling (haemoarthrosis)

herniated nucleus pulposus features 1B

ss: sudden back pain relieved with rest - causes pain, parasthesia and weakness of affected nerve root , muscle spasms -tenderness at spinous process -muscle spasms back dominant pain (central herniation) or leg dominant pain (lateral herniation) Ix: lumbar herniations --> straight-leg raises stretch the lower lumbar roots and exacerbate back or leg pain -Cervical herniation causes pain during neck flexion or tilting. Ix MRI CT Rx analgesia

what drg can cause depigmentation of the skin

steroids (topical) especially in dark skinned people

B-2 agonists

stimulates beta-2 receptors (bronchodilates) SABA; SALBUTAMOL LABA: SALMETEROL, FORMATEROL SE: tremor , hypokalemia --> arrhythmias, nausea, dyspepsia, worsening of diabetes melitus( hyperglycaemia) GI: dyspepsia and nausea

Ix and Rxfor E Coli

stool culture and toxin assay supportive care - rehydration ciproflaxin , oxoflacin

how is pneumoconioses treated

stop exposure or use protective equipment

spine special tests

straight-leg test Lasegue maneuver: dorsiflexion of foot during straight leg raise makes symptoms worse or, if leg is less elevated, dorsiflexion will bring on symptoms femoral stretch test: with patient prone, flexing the knee of the affected side and passively extending the hip results in radicular symptoms of unilateral pain in anterior thigh

shoulder strain 1B

stretching or tearing of a muscle or tendon in the shoulder. -aex: heavy backback on while shoulder, swimming, tennis

symptoms and signs of pleural effusion 1B

symptoms - increasing sob -cough signs - Dyspnoea - Pleuritic chest pain - Stony dullness to percussion on the affected side - Reduced chest expansion on affected side - Reduced breath sounds and air entry on affected side - Reduced vocal fremitus and resonance - Audible pleural friction rub

what do we worry about in flail chest

tension pneumothorax

What are the symptoms of low Ca++ in the plasma?

tetany, neuromuscular irritability

Epiphysis

the end part of a long bone, initially growing separately from the shaft.

Inner ear

the innermost part of the ear, containing the cochlea, semicircular canals, and vestibular sacs responsible for balance

CMV infections are most significant in

the perinatal period and in immoncompromised patients and transplant patients

What is accommodation

the process by which the eye's lens changes shape to focus near or far objects on the retina

inguinal hernia

the protrusion of a small loop of bowel or bladder through a weak place in the lower abdominal wall or groin ->95% hernias are inguinal - most are indirect ( through hesselback triangle) -can descend to scrotal sac - Inderect common in children -Rx: surgical repair , lap repair, perm sutures, mesh repaire

a-THALASSAEMIA 2B

there are 4 alpha globin genes (aa/aa) silent thalassaemia : -a/aa no symptoms 2 missing genes/ trait: a-/a- or aa/-- no symptoms, mild to moderare microcytic anaemia, no symptoms Hb H z: --/-a: mild anaemia, low MCV and MCH . Hepatosplenomegaly, chronic leg ulceration and jaundice (reflecting underlying haemolysis) Hb Bart hydros foetalis : --/-- . Common cause of stillbirth in South East Asia blood film: heinz-bodies

Which diuretics cause decreased urine calcium?

thiazides

Bulbar palsy

type of MND characterized by dysfunction of the muscles controlled by the cranial nerves of the lower brain stem (the "bulb") -- specifically, the glossopharyngeal nerve (IX), vagus nerve (X), and hypoglossal nerve (XII). Features: dysphagia, dysphagia, drooling, weak and wasted tongue, dysphonia and problems articulating.

Types of spinal fractures

types: - compression (flexion) : anterior vertebra breaks and loses height, usually stable neurological problems are rare -Axial burst fracture: both front and back of vertebra broken . stable - fracture dislocations: when ligaments or discs connecting vertebrae are stretche or torn results in instability and compression -flexion distraction: hyperflexion and distraction of posterior elements SS: localised neck pain , stiffness. numbness or weakness if compression . difficulty breathing -Rx: stabalisation surrgery or braces Ix: CT, MRI, Xray

Renal colic ddx

upper UTI's, ectopic pregnancies, ovarian torsion, adnexal masses testicular torsion acute aortic syndromes renal artery aneurysms renal infarction splenic infarction bowel obstruction diverticulitis appendicitis biliary colic cholecystitis, Acute intestinal ischemia, pneumonia, pulmonary embolism, retroperitoneal hematoma, iliopsoas abscess.

rotator cuff muscles (SITS) (shoulder)

upraspinatus (suprascapular nerve), abduction infraspinatus (suprascapular nerve, external rotation ) teres minor (axillary nerve, exterbal rotation ) , subscapularis (subscapular nerve, internal rodation and adduction )

Tophi are __ and may indicate __

uric acid crystal, indicate gout

patella dislocation

usually a non-contact twisting injury - lateral displacement of patella after contraction of quadriceps at the start of knee flexion in an almost straight knee joint - direct blow, e.g. knee/helmet to knee collision -young female, obesity , highriding patela ss: knee give way when walking, severe pain , tenderness, weak knee extension, effusion Treatment - Reduce patella - gentle ROM - Strengthen quadriceps - Support during sporting activities

Ankle Fracture

usually involves - ipsilateral ligamentous tears or transverse bony avulsion contralateral shear fractures (oblique or spiral) • classification systems Danis-Weber Lauge-Hansen: based on foot's position and motion relative to leg Type A (infra-syndesmotic): pure inversion injury, avulsion of lateral malleolus below plafond or torn calcaneofibular ligament , ± shear fracture of medial malleolus • Type B (trans-syndesmotic): external rotation and eversion (most common), ± avulsion of medial malleolus or rupture of deltoid ligament, spiral fracture of lateral malleolus starting at plafond • Type C (supra-syndesmotic): pure external rotation avulsion of medial malleolus or torn deltoid ligament, ± posterior malleolus avulsion with posterior tibio-fibular ligament, fibular fracture is above plafond (called Maisonneuve fracture if at proximal fibula) frequently tears syndesmosis

Venous Lake

violet blue papules on oral mucosa or pinna in elderly

Human papilloma virus (HPV) lesions 1A

virus transmitted through skin to skin contact genital warts transmitted sexually causes several lesions HPV lesions and features Warts (Verruca Vulgari): elevated epithelial growths with papillated surface (Paring of surface reveals punctate, red-brown specks (thrombosed capillaries) caused by 80 types of HPV Verruca plantaris/palmaris ( plantar/palmar warts) : caused by HPV 1,2,4, 10. Hyperkeratotic, shiny, sharply marginated growths Paring of surface reveals red-brown specks (capillaries) Verruca Planae (Flat Warts ): HPV 3,10. Multiple discrete, skin coloured, flat topped papules grouped or in linear configuration, Common in children Condyloma Acuminata ( genital warts): HPV 6 and 11 HPV 16, 18, 31, 33 cause cervical dysplasia, SCC. Appearance Skin-coloured pinhead papules to soft cauliflower like masses in clusters. Common in young adults infants and children. Highly contagious, usually sexually transmitted. Ix for Human papilloma virus Clinical diagnosis NAAT Rx HPV Topicals: Podophyllotoxin 0.5%, imiquimod (immune modulator) 5%, sinecatechins 15% (SE: inflammation, itching, burning, pain), Trichloroacetic acid Cryotherapy or surgery

what is RSV

virus which causes seasonal LRTI especially in infants and young children . transmitted through respiratory droplets -causes bronchiolitis and pneumonia in severe cases

what is reabsorbed in the nephron

water (60-80), electrolytes(K+, HCO3), glucose and amino acids in the nephron

what is reabsorbed in dital tubles and collecing ducts

water and chloride under aldosterone and ADH influence

What does specific gravity indicate?

§ Concentration of urine § High can cause kidney stones § Diabetes insipidus and

MIcrovascular complications of TIIDM

§ Retinopathy § Nephropathy (including microalbuminuria) § Neuropathy - peripheral and autonomic Microvascular complications occur due to endothelial dysfunction, accumulation of advanced glycation end products, reactive oxygen species, free radicals and presence of sorbitol. More common in children.

criteria for exudate effusion and causes

· Highprotein content · Dueto increased permeability or secretion · >30g/Lprotein >200u/L LDHCauses -protein/serum protein ratio is >0.5, the effusion is an exudate - LDH to serum : >0.6 -- Malignancye.g. bronchial carcinoma - SVCobstruction - Infectione.g. TB (pneumonia most common) - Rheumatoidarthritis - Amyloidosis - Sarcoidosis Myocardial infarction-

how is sarcoidosis diagnosed

• CBC (cytopenias from spleen or marrow involvement) • serum electrolytes, creatinine, liver enzymes, calcium (hypercalcemia/hypercalciuria due to vitamin D activation by granulomas) • hypergammaglobulinemia, occasionally RF positive • elevated serum ACE (non-specific and non-sensitive) • CXR: predominantly nodular opacities especially in upper lung zones ± hilar adenopathy • PFTs: normal, obstructive pattern, restrictive pattern with normal flow rates and decreased DLCO, or mixed obstructive/restrictive pattern • ECG: to rule out conduction abnormalities • slit-lamp eye exam: to rule out uveitis

Pulled elbow (nursemaid's elbow)

• Distal *subluxation of radius*; Radial head slips out of annular ligament • Forceful pull on hand-pick up heavy object, sudden forceful pulling -common in children up to 7 years, bones and muscles still developing ss: pain., child holds arm still in flexed position Ix: clinical diagnosis • Displacement is reduced (closed) - May be followed by sling with elbow flexed and supinated.

what are the functions of the kidneys

• Filter blood plasma to remove waste • Regulate blood volume and blood pressure • Regulate red blood cell count • Regulate electrolyte balance • Regulate pH of body fluids • Detoxify free radicals and drugs - Regulation of composition of ECF to determinethe composition of blood - Synthesis of erythropoietin - Synthesis of renin - Synthesis of 1,25 - hydroxylase to activatevitamin D

LARYNX CANCER

• SQUAMOUS CELL CARCINOMA • Risk Factors - smoking and alcohol use SCC most common 3 sites: 1. supraglottic (30-35%), 2. glottic (60-65%), 3. subglottic (1%) feature: Dysphagia, odynophagia, globus Otalgia, hoarseness Dyspnea/stridor Cough/hemoptysis Cervical nodes (rare with glottic CA) Laryngoscopy CT/MRI

where are the kidneys located

• Upper pole is level of T12 • Lower pole is L3 • Between 11th and 12th ribs

sick euthyroid syndrome

• changes in circulating thyroid hormones amongst patients with serious illness, trauma, or stress • not due to intrinsic thyroid or pituitary disease -*normal/low * TSH, LOW t3 t4 -when they recover TSH shoots up

plantar faciitis

• inflammation of plantar aponeurosis at calcaneal origin • common in athletes (especially runners, dancers) • also associated with obesity, DM, seronegative and seropositive arthritis due to : repetitive injury causng microtears and inflammation of plantar fascia • insidious onset of heel pain, pain when getting out of bed and stiffness -intense pain when walking from rest that subsides as patient continues to walk, worse at end of day with prolonged standing -

ANKLE FRACTURE: lateral ligament complex tear Anterior Talofibular, Calcaneofibular, Posterior Talofibular

• inversion injury, >90% of all ankle sprains • ATF most commonly and severely injured if ankle is plantar flexed • swelling and tenderness anterior to lateral malleolus • ++ ecchymoses • positive ankle anterior drawer • may have significant medial talar tilt on inversion stress x-ray

Shoulder sprain 1B

• separation/ subluxation of acromialclavicular ligament/joint - falling onto shoulder/sstretched arm , fracture may be present, contact sports -Trauma from car accident - - grade 1 ( stretch ) grade 2( partial tear , grade 3 (separation, minor cvla displacement, grade 4-6 Both ligaments ruptured, significant displacement of clavicle ) -S/S: pain, swelling, bruising, limited movement , outer end of the clavicle is abnormally prominent and tender, may see lump ( clavicle which has become detached) . pain on adduction or palpaption on AC joint , limited ROM Ix: Xray bilateral AP Rx: sling 1-3 2 wks, analgesia, rehab operatiom grades 4-6 ortho surgeron

distal humeral fracture 1B

• young: high energy trauma (MVC) • elderly: FOOSH S/S: elbow pain and swelling • assess brachial artery Investigations: x-ray: AP and lateral of humerus and elbow , CT scan: helpful when suspect shear fracture of capitulum or trochlea Classification: supracondylar, distal single column, distal bicolumnar and coronal shear fractures

αGlucosidase Inhibitors

•There is only 1 - acarbose •Intestinal disaccharidase inhibitor • •Taken one with each meal •If they don't eat, no need to take the tablet

Greenstick Fx

Incomplete fx breaks occurs in one side bc the rest bend. common in children (bones softer & more elastic)

Which two parameters mark uremia?

Increased BUN and increased serum creatinine

Diagnosis of cholangitis

Increased WBC, bilirubin and ALP. Positive blood cultures. U/S for CBD dilation. ERCP for diagnosis and treatment.

Dx of zollinger-ellison syndrome

Increased fasting gastrin levels and increased gastrin with administration of secretin

Markers for haemachromatosis

Increased ferritin and transferrin saturation >50%. Liver biopsy shows high iron index

Diagnosis of insulinoma

Increased serum insulin, increased C peptide. Patient develops profound or symptomatic hypoglycaemia after a prolonged fast.

Risk factors for tinnitus (8)

Increases w/ age (40-70) Males> Smoking Renal/hepatic impairment pregnancy excessive noise exposure ototoxic meds sensorineural hearing loss

Colorectal cancer risk factors

Increasing age, family hx, IBD, syndromes (FAP, HNPCC), adenomatous polyps - Genetics (FAP, family history, HNPCC, juvenile polyposis) - Obesity, physical inactivity, increased caloric intake - Ulcerative colitis and Crohn's disease - Reduced dietary fibre intake - Reduced folic acid intake - Excessive red meat and saturated fat intake - Smoking tobacco

Bursitis

Inflammation of Bursal sacs They are smalls sacs lined with synovial membrane and filled with synovial fluid; bursa are located among the tendons, muscles, and bony prominences.

Epicondylitis/Elbow Sprains and strain 1A

Inflammation of a tendon where it attaches to a bone. -Sprain is a tear or stretch in the ligrament -Tear or stretch in tendon or muscle - due to overuse Tennis elbow: Lateral epicondylitis Golfer's elbow: Medial epicondylitis

What is viral hepatitis? 1B

Inflammation of liver parenchyma, usually d/t hepatitis virus ((Hep A, B, C, D and E); other causes include EBV & CMV. Acute presentation - Jaundice (CB & UCB), dark urine (CB), fever, malaise, nausea, and ↑liver enzymes *(ALT>AST)*. Inflammation involves lobules & portal tracts Chronic presentation - > 6 months. Inflammation predominantly involves portal tracts.

What is dacryocystitis?

Inflammation of the nasolacrimal sac. Most common in newborns. Tx: warm compress

SCLERITIS

Inflammation of the sclera 1. severe pain, red eye, photophobia, lacrimation, pain on touching eye 2. RF- RA Rx-NSAIDs and corticosteroids

What is uveitis?

Inflammation of the uvea, which has a lot of vital blood vessels inside. Can lead to damage of vital eye tissue --> permanent vision loss

pathophysiology of acute bronchitis

Influenza virus from inhalation/contact. As the body fights the virus,swelling occurs and mucus produced. Lesser known causes are bacteria, fungalinfections and irritants (smoke, dust, fumes).

Benign Familial Chronic Pemphigus (Hailey-Hailey) disease

Inheritable ! intra epidermal Vesicular Disease Abnormal Keratincoyte adhesion Itchy annular vesicles developing in tertriginois areas back and neck - worse in summer UV exposure and friction tx: Abx, topical steroids, sunscreen

Prophyria Cutanea Tarda

Inheritable - sub epidermal blistering - in patients with liver disease "were wolf disease" Ass. with Hep C deficiency in Uroporphrinogren Decarboxylase Blisters - sun exposure, photosensitivy Urine maybe red brown in color, Pink under woods light Ts: Alcohol use, Phlebotomy, Cholorquine

How do the thiazides work?

Inhibits NaCl absorption in the distal tubule. Water follows salt, so you excrete more water.

Extrinsic muscles of the eye

Innervated by CN III (oculomotor nerve) ◾Superior rectus: Pulls the eyeball upwards and inwards - elevates, adducts and medially rotates ◾Inferior rectus: Pulls the eyeball downwards and inwards - depresses, adducts and laterally rotates ◾Medial rectus: horizontal only , Pulls the eyeball inwards - adducts the globe ◾Inferior oblique: Pulls the eyeball up and out - elevates, adducts and laterally rotates the globe Innervated by CN VI (abducens) Lateral rectus: Abducts the globe - pulls the eyeball outwards Innervated by CN IV (trochlear) Superior oblique- Down and out- depresses and abducts vertical diplopia , headtilt, up and out

INSULINOMA

Insulin secreting tumour associated with MEN type 1presents with hypoglycaemia ( profound after fasting) Ix Increased serum insulin AND increased C peptide together Rx: surgery

Comprehensive Geriatric Assessment

Integrated approach Combines physical, functional, and psychosocial components into one instrument Generally comprehensive and lengthy Provides a basis for a detailed plan of care

INTERFERON

Interferons (IFN) are cytokines released by the body in response to viral infections and neoplasia - IFN-alpha and IFN-beta bind to type 1 receptors whilst IFN-gamma binds only to type 2 receptors

How do you interpret the results of a Seidel test?

Interpretation: Findings suggestive of Globe Rupture (Positive Seidel Test) - Fluorescein dye diluted by aqueous fluid - Darker, diluted Fluorescein dye streams from globe rupture site - Bright green concentrated dye surrounds leak site (above and to side)

Gardner's Syndrome

Intestinal Polyposis Skull osteomas Adenomatous polyposis of colon Epidermal inclusion cysts 100% malignancy - Colectomy

extrahepatic jaundice

Intra-luminal causes, such as gallstones Mural causes, such as cholangiocarcinoma, strictures, or drug-induced cholestasis Extra-mural causes, such as pancreatic cancer or abdominal masses (e.g. lymphomas)

Bowenoid Papulosis/ Bowen's disease

Intraepithelial Squamous Cell carcinoma (bowen's disease) Associated with HPV 16 bcc IN SITU Appearance: dark or erythematous warty/scaly plaque which is well defined flat edges TX: Electrosurgery , Laser, incision

Common causes of cirrhosis

Intrahepatic: all causes of chronic hepatitis. Extrahepatic: biliary tract disease (PBC, PSC) and posthepatic ie. R-sided heart failure, constrictive pericarditis and Budd-Chiari syndrome

Myasis

Invasion of Human skin by Maggots!! Dermatobia hominis - botfly; Cordylobia anthropophaga - tumbu fly Red papule Resembling furuncle , central pore for larvae, pain, exudate Tx: Petroleum, bacon occlusion

Stress Incontinence 1B

Involuntary leakage of urine due to weak pelvic muscles occurs when there is increased pressure ( laughing, coughing, running) b. bladder neck/urethral hypermobility and/or neuromuscular defects causing intrinsic sphincter deficiency -Increased risk for females after birth, and eldery, after prostate surgey, forcepts delivery, prolapse, obesity Associated with uterine prolapse and urethrocele Ix: 1. Urine dipstick 2. Bladder diary for at least 3 days 3. assess residual volume urodynamic studies not necessary rX: weight loss, pelvic floor exercises ( 1st line for at least 3 months) , duloxetine (SNRI enhances sphincter) - Surgery with tension-free vaginal tape or transobturator tape (mid-urethral sling) - TVT - tape in U-shaped under mid-urethra - TOT - tape through transobturator foramen, transobturator and puborectalis muscles

Muscarinic antagonists

Ipratropium bromide Tiotropium

What could ocular pain indicate?

Iritis, keratopathy, glaucoma, scleritis, periorbital cellulitis, corneal abrasions

Nonunion

Is the failure of the bone ends to grow together. Gap between the broken ends of the bone fills with dense fibrous and fibrocartilaginous tissue. Occasionally, fibrous tissue contains a fluid-filled space that resembles a joint: Referred to as a false joint or a pseudarthrosis.

RETROBULBAR NEURITIS acute neuritis 1B`

It is an acute inflammation of the optic nerve situated behind the eyeball associated with acute PAINFUL loss of vision features: transient blured vision initially profound visual loss unusally unilateral rapid complete blindness Marcus Gunn pupil -Field of vision—Central, paracentral, sectorial scotomas or ring-shaped scotoma around fixation point may be present -. Early loss of colour vision and contrast sensitivity may be present due to involvement of optic nerve Rx 1. Retrobulbar injection of dexamethasone is very effective. 2. Systemic corticosteroids are given in full doses. 3. Vasodilators (systemic or local) may be effective. 4. Vitamin B1, B6 and B12 administered in high doses are useful adjunct.

Investigations in COPD 1A

Ix - spirometry: FEV1/FVC ratio <0.7 ( FEV1 ⬇, FVC/FEV1 ⬇ or ↔ - pulse oximetry: 88-94% in chronic COPD, initial presentation of <92% do ABG -ABG: hypercapnia, hypoxia, resp. acidosis -CXR: emphysema. barrel chest, hyperinflation -FBC: polycythaemia >55% hct, anaemia, leukocytosis -ECG: arrhythmia, ischaemia, RV hypertrophy -sleep study : sleep apnoea common in copd, increases risk of death and ospitalisation -sputum culture

Ix and Rx of mallory weiss syndrome

Ix -clinical FBC, urea, LFTs, PT, APPT, CXR, cross-match - OGD Rx -endoscopy w/ noradrenaline injection and surgical repair - IV ocerotide reduce portal venous flow -most heal spontaneously 90%

INVESTIGATIONS FOR DKA 1B

Ix BM >11mol (unrecordable/ v high) Ketone ++ or >3mmol bicarb <15mmol pH <7.3 lactate

what investigations can you do for allergic rhinitis and what are the findings 1A

Ix 1. Hx 2. Direct exam - pale boggy nose 3. Allergy testing

Investigations for gatsrtis

Ix H.pylori urea breath test: >90% sensitivity, can monitor response to therapy- off PPIs 2 weeks -H. pylori faecal antigen test: diagnose active infection -FBC: Phlegmonous gastritis --> leukocytosis, low Hb, low Hct -Endoscopy: consider in Px >55 w/ suspicious features of upper GI malig Intrisic factor Abs: 90% px w/ atrophic gastritis Vit B12: reduced in chronic gastritis

Ix for osteomyelitis

Ix: ESR: raised or normal CRP: raised WCC: raised X-rays MRI- best imaging modality culture of bone abcess

IX and Rx of anorectal fistula 1B

Ix: Hx, chrons , clinical exam - surgical drainage -fistulotomy

What is used to diagnose polycythaemia vera

JAK 2 mutation

What is he presentation of cholestasis

Jaundice and pruritus dark urine

Seabather's Eurption

Jelly fish larva (Cnidaria) exposure SALT WATER Itchy papules on bathing suit COVERED skin 3-4 days Cool compress, antihistamine, topical steroids

Black Widow Spider Bites

Lactrodectus mactans, shoe-button spider (Eats mate after copulation) Asymptomatic painful bite- 2hrs later abdominal pain rigidity and numbness .. 2-3 days later shock and death Tx: Ice , morphine , Calcium Gluconate, Antivenin

Fissure

Linear Loss of Epidermis and Dermis

Chronic Cutaneous LE (Discoid Lupus)

Localized chronic cutaneous form of lupus, red topped plaques "carpet tack" scale heal with atrophy scarring and alopecia ANA ( usually negative) TX: high potency Steroids

What does furosemide do?

Loop diuretic that inhibits ion transport in the ascending loop of Henle. Destroys concentration gradient in the medulla

MACROCYTIC ANAEMIA: normoblastic

Low Hb + MCV : >100 can be due to b12/folate deficiency Symptoms/signs - glossitis, fatigue, palpitation Blood film: hyper-segmented neutrophil polymorphs Normoblastic causes: - alcohol - liver disease - hypothyroidism - pregnancy - reticulocytosis - myelodysplasia - drugs: cytotoxics

Markers for Wilson's disease

Low caeruloplasmin, high urinary copper, Kayser-Fleischer rings.

Salter- Harris Fracture Classification - III

Lower. The fracture is below the physis in the epiphysis.

Brown Recluse Spider Bites

Loxoscelidae reclusus, fiddle-back spider Southern half of USA Yellow Tan to brown with dark violin shape on back Bee ting like bite with bulla formation, pain, local necrosis, greyish halo, wound may heal weeks to months Posible DIC and renal failure and death. TX: Ice elevation, Dapsone, Rest Abx for secondary infection

What endocrine syndrome is zollinger-ellison syndrome associated with

MEN 1 (pancreatic islet cell tumours ie. GASTRINOMAS, parathyroid hyperplasia and pituitary adenomas

Cervical Fractures

MOI: Axial loading of the cervical vertebra from a force to the top of the head combined with flexion of the neck S/S: point tender; restricted movement; cervical muscle spasm; pain, numbness; weakness; paralysis in limbs or trunk; loss of bladder and/or bowl control Tx: treat for neck injury, refer MD CErvical break of C1-C7 C1-2: may need ventilation, breathing affacted C4- pain in lower neck, trapezius C5- pain in neck shoulder and dorsal forearm C6/7: shoulder pain, radiates to fingers Lumbar ones: pain in thigh, ankle, buttocks - dislocation : injury of ligamanet in the neck and spinal bones become disconnected -Aex: MVAs, falls, violence, sport activities. abrupt imapct or twisting of neck -common in ages 12-25

Extras for malaria

Malaria extra Lifeclycle: human host for asexual reproduction and mosquito for sexual reproduction • sporozoites from mosquitoes infect human liver cells, where they multiply and are released as merozoites. merozoites infect RBCs and cause disease yconjugate gaze, and retinal hemorrhages. P. vivax and P. ovale: chills and fever x48h but can be variable P. malariae: chills and fever x72h but can be variable P. falciparum: less predictable fever interval, can be highly variable (>90% ill within 30 d) P.falciparum has rapid progression and can cause cerebral malaria

When there is orbital metastasis, what are the common primaries in men, women and children?

Men: prostate + lung Women: breast Children: neuroblastoma

What are some features of Non Proliferative Diabetic Retinopathy (NPDR)?

Microaneurysms Dot/Blot/Flame Hemorrhages Cotton Wool Spots - ischemic area of retina (infarcts of nerve fiber layer) Retinal Edema Accumulation of sorbitol Lipid exudates Venous Beading Intraretinal Microvascular Abnormalities *selective loss of vascular pericytes

What would you find on PE with iritis?

Miosis with pain (direct and consensual)

What is the classic triad of Horner's Syndrome?

Miosis, ptosis, anhydrosis (it rhymes!)

Acute management for active bleeding of ulcer

Monitor BP, IV fluids, blood transfusion, IV PPIs. Urgent gastroscopy to control bleeding.

Treatment for Wet AMD

Monoclonal Antibodies Requires intravitreous injection Reduce neovascularization and symptoms progression in patients with Late AMD. Ranibizumab (Lucentis) is the gold standard for AMD therapy, 1st drug used in eye Bevacizumab (Avastin)* is a parenteral anti-cancer agent and originally made for Breast CA. It is cheaper and can be used off-label Aflibercept (Eylea) is the newest drug and it works, but it is VERY expensive

Pemphigus Foliaceous

More superficial - intra epidermal blistering disease IgG and complement 3 against desmosomes in high epidermis Erythema, scaling, crusting, starts on FACE or trunk- resembles CORN FLAKES on skin FOgo selvagem: PF in brazil that is related to black fly bites Tx: Steroids, cyclophosphamide, dapsone, Azothioprine

Anal cancer

Most are squamous cell carcinomas, which are associated with HPV infection, hiv, syphylis, HPV, fistulae, smoling and immune supression Adenocarcinomas originate in the glands near the anus Basal cell carcinoma and malignant melanoma features include rectal bleeding, pain, or mass

What is diffuse esophageal spasm

Motility disorder in which normal peristalsis is periodically interrupted by high-amplitude non-peristaltic contractions - common in middle aged men -presents with angina like pain features Heartburn, chest pain, dysphagia and odynophagia. Precipitated by ingestion of hot or cold liquids, relieved by GTN, weight loss, hoarse voice , coughing after swallowing Ix Gastroscopy to rule out structural abnormalities, barium swallow show a cork-shaped oesophagus Rx 1. CCB 2. TCA 3. Nitrates

MEMBRANOUS NEPHROPATHY 1B

NEphrotic syndrome 1. most common cause of NS in adults, particularly the elderly BM thickening due to proliferation and infiltration . -common in white patients and males - IgG depositions --> increased permeability --> proteinuria - peak incidence 30-40 and 50-60 AEx: Hep B and C, drugs ( penicillamine, nsaids), SLE, cancer, thyroiditis, parasites Features: - oedema face and legs -frothy urine - proteinuria ++++ -VTE Ix -LFT -albumin -bone profule ⬆LDL, cholesterol -renal biopsy

WHAT INITIAL INVESTIGATION HELPS DIFFERENTIATE BETWEEN IBS AND IBD

NICE advise the use of faecal calprotectin to help differentiate between IBS and IBD in primary care. -It is released in the bowel in the presence of inflammation and is not degraded so can be detected in a stool sample. -reduces the need for referral of patients w/ typical IBS symptoms and the use of invasive diagnostic testing e.g. Colonoscopy.

Staphylococcal Scalded Skin Syndrome 1B

NOT ON THE SKIN_ BUT SOMEWHERE ELSE !!! 1. aka: Ritter's disease, SSSS; an epidermolytic toxin syndrome seen in children less than 5 years old 2. Etiology: Staph aureas phage group II (types 55, 71 3A, 3B). Toxin is epidermolytic toxin A or epidermolytic toxin B which cleaves the epidermis beneath the granular layer 1. Begins as a localized infection of the throat, conjuctiva, nares or umbilicus 2. Toxin develops and causes tender erythema with a sandpaper like texture. 3. Fever associated and skin forms fragile blisters and peels off and heals within 7-10 days 4. Can be localized or widespread Diagnosis: 1. Bullous impetigo will usually have positive skin cultures 2. SSSS will have negative skin cultures, because skin lesions are due to the toxin 3. Skin biopsy shows split in the stratum granulosum Treatment: 1. NO Steroids!! 2. Oral antibiotics for localized, IV antibiotics and hospitalization for more extensive cases

INVESTIGATIONS FOR SIADH 1B

Na+ - low -Hyponatraemia -hypotonic plasma (osmolality <270mOsm/kg) -• Inappropriate urine osmolality >100mOsm/kg. • Excessive renal sodium loss (>30mmol/L, often >50mmol/L). • Absence of clinical evidence of hypovolaemia or of volume overload

What are signs of proliferative diabetic retinopathy?

Neovascularization and/or vitreous or pre-retinal hemorrhage; traction retinal detachment

Rapidly progressive glomerulonephritis

Nephritic syndrome that progresses to renal failure in weeks to months. associated with the formation of epithelial crescents in the majority of glomeruli. Causes Goodpasture's syndrome Wegener's granulomatosis others: SLE, microscopic polyarteritis Features nephritic syndrome: haematuria with red cell casts, proteinuria, hypertension, oliguria features specific to underlying cause (e.g. haemoptysis with Goodpasture's, vasculitic rash or sinusitis with Wegener's)

What is Alport's syndrome?

Nephritic. Collagen IV mutation. Split basement membrane. Also affects eyes and ears.

How does Amyloidosis affect the kidney?

Nephrotic. Congo-red stain, apple-green birefringence. Associated with RA, TB, multiple myeloma

Lichen Simplex Chronicus

Neurodermatitis, chronic itchy spot Excessive rubbing and scratching Previous eczema or itchy skin, subconscious rubbing Clinically: well-circumscribed erythematous, hyperpigmented, patches and plaques of thickened lichenified skin commonly occurring on the neck, ankles, scalp, pubis, vulva, scrotum, and extensor forearms, as a result of chronic rubbing and scratching. Can lead to true neurotic excoriations tx: Topical steroids, antihistamines and frequent moisturizing

Alarm symptoms that should not be present in IBS

Night symptoms, vomiting, weight loss, rectal bleeding, constitutional symptoms

Gastric Polyps

No malignant potential, they are usually caused by PPI use--REASSURANCE Do colonoscopy only if there is dysplasia on the pathology, or age < 40

Treatment for Dry AMD

No specific, effective treatment Nutritional Interventions: -Diet: Low fat / increased green leafy vegetables -*Vitamin Supplements (lutein, zeaxanthin, beta carotene (not for smokers), vitamin E (not for CHF), Zn, Cu Benefits established for patients with advanced "dry" AMD. -Low-vision aids -Handheld magnifiers for reading -Telescopes to see into the distance -Talking watches -Computers that talk or that use large type faces -Encourage patients to use remaining peripheral vision -Test vision daily with "Amsler Grid" for acute changes. STOP SMOKING

BURKITT'S LYMPHOMA

Non-HL -high-grade B-cell neoplasm -*Endemic*: Childhood lymphoma in Africa and Papua New Guinea. 90% associated with EBV infection; aggressive but curable disease. -Jaw tumours and adenopathy, sometimes abdo mass -may be CNS involvement - *Sporadic*: Aggressive, associated with HIV, (ileocaecal tumours) EBV and malaria . usually presents in 30s . rapidly growing lymphadenopathy, often intra-abdominal mass - associated with the c-myc gene translocation usually t(8:14) Microscopy findings: 'starry sky' appearance: lymphocyte sheets interspersed with macrophages containing dead apoptotic tumour cells Rx Chemi

What sort of urinary casts will you see in a person with acute cystitis?

None, but you will see free WBCs. Casts only appear when the kidneys are involved.

SVC SYNDROME

Occurs due to a tumor usually obstructing the SVC, commonly LUNG CANCER followed by lymphoma. S/Sx include: Causes "facial plethora", facial edema, neck (Jugular venous distension) and upper extremities (edema). Medical emergency, can raise ICP, cause headache, dizziness, risk of aneurysm/rupture in brain. *dilated collateral veins in the upper trunk* !!! Work-up: CXR and CT with contrast Treatment: ABC/IV/O2/Monitor + airway support + elevation of HOB + Lasix + IV corticosteroids + emergent onc, ENT, and interventional radiology consults

Functional Incontinence 1B

Occurs when there is a delayed time between feeling the need to urinate and actually urinating. due to cognitive or physical impairments (eg, due to dementia or stroke) or environmental barriers that interfere with control of voiding. For example, the patient may not recognize the need to void, may not know where the toilet is, or may not be able to walk to a remotely located toilet. patient cant reach toilet in time Etiologies: Elderly, psychological issues, medications.

intrahepatic jaundice

Occurs with disease or damage to hepatocytes Hepatitis or cirrhosis -hepatitis (infections ) - NAFLD - Alcoholic liver dz -paracetamol -drug induced : Abx i.e phenytoin, carbamazepine, lamotrigine -PBC PSC Sepsis Post-operative/TP -HCC -autoimune hepatitis -HCC -cholangiocarcinoma

Treatment of carcinoid syndrome 2B

Octreotide and surgical resection of the tumour

What is neonatal conjunctivitis?

Ocular emergency! Conjunctivitis in first month of life Chemical (0-1 Days) Gonorrhea (2-5 Days) Chlamydia (4-10 Days) Bacteria (Anytime) Treat with topical erythromycin, then oral

Symptoms of gastritis/duodenitis

Often asymptomatic. -Symptoms include epigastric pain, nausea, vomiting, haematemesis and malaena -anaemia -pancreatitis if ulcer penetrate pancreas

Where do you see the Teardrop sign?

Orbital floor fracture (orbital contents spilling into maxillary sinus)

PROPTOSIS

Outward bulging of the eye out of the orbit. Also called exophthalmos. Bilateral - Graves disease. Unilateral - orbital tumor, orbital cellulitis

What is exotropia?

Outward turning of the eyes.

Features of Anal fissure

Pain on defecation lasting for hours They begin to hold in poop to avoid passing BM, then get constipated and this worsens the fissure - Pain on defecation - Bleeding - Tearing sensation - Anal spasm - *SENTINEL PILE* - skin tag grows near the fissure

Features of Anal fissure

Pain on defecation lasting for hours They begin to hold in poop to avoid passing BM, then get constipated and this worsens the fissure - Pain on defecation - Bleeding - Tearing sensation - Anal spasm - Sentinel pile - skin tag grows near the fissure

What are some signs/symptoms of a corneal foreign body?

Pain, photophobia, foreign body sensation, redness

Dislocation and subluxation Clinical manifestations

Pain, swelling, limitation of motion, joint deformity

Post-thrombotic syndrome

Pain, ulcerations, oedema etc. due to DVT Risk factors: age > 65, more proximal DVT, recurrent or persistent DVT, and obesity. Catheter-directed intrathrombus lysis of iliofemoral DVT is performed to prevent post-thrombotic syndrome. Rx graduated compression stockings

Carpal Tunnel Syndrome

Painful Disorder secondary to *Median nerve compression* due *repetitive wrist flexion* -more common in females -aex: tumours, fractures, hypothyroidism, acromegaly, RA, infections. S/S: - Numbness , tingling and night-time pain in thumb, index and middle finger .. fingers feel swollen, - *+/- thenar muscle wasting (late in disease)* -positive *Phalen( prayer sign til parasthesia) & Tinel ( percussion on medan nerve causing parasthesia)* sign Dx: clinical, EMG/NCV if unsure of diagnosis Tx: - night-time splinting, steroid injection, surgical release

Pronator Sd - Definition (nerve & muscle) - Causes

Painful disorder of wrist & hand caused by compression of median nerve by pronator muscle Holding lower arm away from torso of body

Chondrodermatitis Nodularis chronica Helicus

Painful eythematous papule of the pinna in the elderly trauma or sun exposure

Rotator cuff Tendinitis

Painful inflammation of muscle tendons in shoulder region

Complications of acute pancreatitis

Pancreatic pseudocysts, fistula formation, sepsis, ARDS, renal failure, - Hypomagnesaemia - Hyperglycaemia - DIC - Necrosis and bleeding - Hypoxia - Acute lung injury - Pleural effusion - Pancreatic abscess - GIT - variceal bleeding, erosions, duodenal obstruction, obstructive jaundice, ascites, portal HTN, enteric fistulation - Chronic - chronic pancreatitis, insufficiency, DM, calcification

PAPILLITIS - acute optic neuritis subtypes 1B

Papillitis is an acute inflammation of the optic nerve head (papilla or optic disc) associated with rapid loss of vision. It is the ophthalmoscopically visible or anterior part of the optic nerve. It is often unilateral. AEx: -MS - cNS disorders: herpes, encephalitis, poliomyelitis, - Local: retinitis, uveitis, meningitis -infection: inluenza, mumps, rubella, mono -metabolic- diabetes, anemia, starvation 3/4 transient blured vision initially profound visual loss unusally unilateral rapid complete blindness signs - slow or absent light reflex -papillodoema, exudates, turtuous retinal veins, oedematous retina -post-neurotic atrophy blurred disc margin - Physiological cup gets filled up with organized fibrous tissue.

Paraproteinemia

Paraproteinaemia represents a group of related diseases characterised by an unbalanced or disproportionate proliferation of immunoglobulin-producing cells, usually from a single clone. Paraproteinaemia represents a group of related diseases characterised by an unbalanced or disproportionate proliferation of immunoglobulin-producing cells, usually from a single clone.

Peduculosis (Lice infection)

Pediculus humanus capitis (head), Pediculus humanus corporis (body), & Pthirus pubis (crabs); Insects Children - Girls - rare in African - american kids Humans - live 10 days off hair, can involve eye lashes Transmission is close contact - can have fever associated with it Corporis ( on the body ) - itchy Pediculosis Pubis - Contagious STD, sensation of bugs crawling "Maculae Cerulae- Grey blue patches 1-2cm Rx:malathion, permethrin or ivermectin

IgM

Pentamer, first Ig secreted in response Acute infections Cant cross placenta

Main causes of upper GI bleeding

Peptic ulcer diseases esophagitis/gastritis Mallory-Weiss tear esophageal varices Malignancy Aortoduodenal ulcers Diverticulae

Clinical findings in AACG

Perimlimbal injection Mid - dilated pupil Corneal edema Markedly elevated IOP (often more than 50) Shallow peripheral chamber Usually narrow angle in fellow eye

Peutz-Jegher's syndrome

Peutz-Jeghers syndrome is an autosomal dominant condition characterised by numerous hamartomatous polyps in the gastrointestinal tract . It is also associated with pigmented freckles on the lips, face, palms and soles. Although the polyps themselves don't have malignant potential, around 50% of patients will have died from another gastrointestinal tract cancer by the age of 60 years.

What 4 things are associated with transitional cell carcinoma?

Phenacetin, Smoking, Aniline dyes, and Cyclophosphamide

Pigmented Basal cell carcinoma

Pigmented nodule BCC increased melanin production may contain pigmented flecks can simulate melanoma

What is the iris?

Pigmented, thin, circular structure in the eye which controls diameter and size of the pupil and thus the amount of light reaching the retina. Contains sphincter and dilator muscles.

What is the characteristic look of viral conjunctivitis?

Pink tinge with preauricular lymphadenopathy

complications of influenzA

Pneumonia, secondary bacterial pneumonia- follows acute influenza. Improvement of the patient's condition over 2-3 days is followed by a reappearance of fever along with clinical signs and symptoms of bacterial pneumonia, inc. cough and purulent sputum Primary influenza pneumonia- rare, presents as acute influenzas but does not resolve. it progresses with persistent fever, dyspnoea, and eventual cyanosis. Sputum and mucus. sputum can contain blood haemorrhagic bronchitis and death (in high risk groups).

Toxoid (inactivated toxin)

Polio diptheria pertusis

Secondary Syphilis

Polymorphic, asymtomatic Great Imitator! 3 weeks to 2 years , beings after the chancre resolves Classic Palms and Soles with flu like symptoms and adenopathy

MILD, MODERATE, SEVERE AND VERY SEVERE COPD

Post-bronchodilator FEV1/FVC FEV1 (of predicted) Severity < 0.7 > 80% Stage 1 - Mild** < 0.7 50-79% Stage 2 - Moderate < 0.7 30-49% Stage 3 - Severe < 0.7 < 30% Stage 4 - Very severe

Hungry bone syndrome

Post-parathyroidectomy, unmineralized bone made when Ca was high begins to mineralize when PTH level becomes normal, dropping the Ca and phos quickly.

What are treatments for retinal detachment?

Posterior Vitreous Detachment - Ophthalmology/Retina Specialist Referral Retinal Tear Hole/Tear -Laser Retinopexy -Cryopexy -Pneumatic Retinopexy Retinal Detachment Repair (Surgical) -Pars Plana Vitrectomy -Scleral Buckle -Combination

Acute renal failure can be categorized according to where the problem is. These categories are:

Pre-renal Intra-renal Post-renal

presentation of oesophageal cancer

Progressive dysphagia, firstly to solids and then liquids. Weight loss, odynophagia, GORD, GI bleeding and vomiting. horse voice coughing after swallowing pneumonia, pleural effusion

Hepatorenal syndrome 2B

Progressive renal failure associated with hepatic failure due to vasoconstriction and altered renal autoregulation, such that renal blood flow is much more dependent on mean arterial pressure characterized by a sudden decrease in urinary output, elevated blood urea nitrogen and creatinine levels, decreased urine sodium excretion, and increased urine osmolarity Type 1: rapidly progressing, creatinine doubles, ppoor prognosis Type 2: slowly progressive S/S: ascites, GI bleed (malaena, haematemesis), fever, cough, dypnoea, dysuria. signs of chronic liver dz IX: LFTs, U&Es, CT, MRI, INR, PT, aPPT, blood culture , CXR Rx: ABx for SBP, Terlipressin, albumin (increase volume expansion) , supportive care, others: ocretide. haemodialysis, Liver transplant curative

Epidermal Nevus

Proliferation of cells in the epidermis , keratinocyte proliferation, usually verrucoid and linear present at birth or childhood

What is the lens?

Proteinaceous structure located just posterior to pupil. Held in place by zonular fibers (attached to ciliary body) helps refract light to be focused on the retina changes shape to focus on objects at different distances through contraction an drelaxation of ciliary body

THROMBOTIC THROMBOCYTOPENIC PURPURA 1B

RARE - abnormally large and sticky multimers of von Willebrand's factor cause platelets to clump within vessels --> increased platelet aggregation --> due deficiency of protease which breakdowns large multimers of von Willebrand's factor --> increased clots--> reduced platelets - overlaps with haemolytic uraemic syndrome (HUS) - common in adults <60, HUS in kids <6 - RARE features: pentad of features: 1. Microangiopathic haemolytic anaemia. (maha) 2. Severe thrombocytopenia. 3. Neurological involvement. 4. *Renal impairment*.:haematuria, proteinuria, urea and creatinine 5. Fever 6. Others: haemolysis, thrombocytopaenia, reanl (, fever Ix - clinical -FBC: anaemia , thrombocytopaenia Film: reticulocytes, LDH - urinary Hb +ve Rx - no antibiotics - may worsen outcome - First line: plasma exchange - steroids, immunosuppressants - vincristine

Measles 1B

RNA morbillivirus Four Red Kings in ears become brown Fever, koplik spots, koryza, konjuctivitis, kough erythematous rash *behind ear* first which spreads to centrifugally and becoming brownish. Complications: *Secondary pneumonia, otitis media and croup (laryngotracheitis). Encephalitis is rare*. IX Clinical ELISA NAAT Rx Supportive care (paracetamol), notifiable dz

HIV and AIDS

RNA retrovirus. Common in Gay men, IV drug use, sex work, sub-Saharan Africa mainly by heterosexual Affects CD4 cells, dendritic cells and macrophages Virus infects CD4 count declines viral load increased risk of infection CD4 drops below 200 and AIDS-defining diagnosis arise Extra: Cellular tropism is the ability for HIV virus to enter particular cell types. It enters by surface proteins gp41 and gp120. Binds gp120 protein receptor on CD4 cell in the host conformational change to facilitate binding of co-receptors CCR5 and CXCR4. Binding causes the release of gp41 which allows fusion w/ host cell membrane and release of the viral core (containing viral RNA integrase, protease and reverse transcriptase) into the cytoplasm. RNA release and reverse-transcribed w/ reverse transcriptase migrates nucleus w/ viral intergrase genome integration

biliary colic

RUQ pain, intermittent, usually begins abruptly and subsides gradually. Attacks often occur after eating. Nausea is common.

What is charcots triad?

RUQ pain, jaundice and fever

Presentation of HCC

RUQ tenderness, abdo distension, signs of chronic liver disease ie. bruising, jaundice.

- Rx HIV ( not requires 1B)

RX - anti-retroviral therapy with: Nucleoside reverse transcriptase inhibitors - lamivudine Non-nucleoside reverse transcriptase inhibitors - nevirapine, efavirenz Protease inhibitors - lopinavir, ritonavir, indinavir (CYP450 metabolism) CCR5 inhibitors - maraviroc Integrase inhibitors - dolutegravir , raltegravir AVOID BREASTFEEDING

Diagnosis and treatment of choledocolithiasis

Raised ALP and bilirubin, MRCP/ERCP. Treatment is ERCP to remove the stones followed by cholecystectomy.

Diagnosis of acute liver failure aka fulminant hepatitis

Raised INR and hepatic encephalopathy

Indicators of liver failure

Raised INR, low albumin and low platelets

Salter- Harris Fracture Classification - V

Rammed (crushed). The physis has been crushed.

What is MALT lymphoma

Rare gastric tumour that occurs in patients with chronic H pylori infection. Only tumour that can be cured with ABs.

Features of Crohn's disease

Rectal bleeding: occasionally Abdominal pain: common Rectal involvement: 50% Fistula formation: common stricture, obstruction: common perianal, perirectal abscesses: common type of involvement: discontinuous (skip areas) depth of involvement: transmural small bowel involvement: often involved risk of malignancy: moderately increased

Subacute Dermatitis

Red, scale, fissuring, parched appearance Symptoms: Slight to moderate itch, Pain, Stinging, burning Etiology: Allergy, irritation, atopic dermatitis, fingertip eczema Tx: Topical Steroids, Lubrication, antihistamines, abx

Hernia types

Reducible/ irreducible direct/indirect intra/extra abdominal femoral, incisional, inguinal, umbilical , epigastic, ventral, hiatus

What is Reiter syndrome?

Reiter syndrome is a type of reactive arthritis that happens as a reaction to a bacterial infection in the intestines, genitals, or urinary tract. Reiter syndrome includes redness, joint swelling and pain, often in knees, ankles, and feet, along with inflammation of the eyes and urinary tract.

What is the most common kidney malignancy in adults?

Renal cell carcinoma

rounded masses in lungs point to...

Renal cell carcinoma can metastasise to the lungs, causing 'cannonball metastases'

Cat scratch Disease

Rochalimaea henselae Contact with immature cats Non itchy red macule at contact site then crusts in 3-5 days, may have adenopathy lesions heal in couple weeks then varioliform scar Can be self limited but neuro changes

Management of osteoporosis

Rx - Weight-bearing exercise- stimulates bone remodelling - Smoking and alcohol cessation - Calcium and vitamin D supplementation - Bisphosphonates e.g. aldendronic acid or risodrenatr if not tolerated - Denusomab (monoclonal antibody decoy receptor for RANK-ligand) if cant tolerate bisphosphonates -raloxifene ( Selective oestrogen recept mod) --> osteoclast activity - Calcitonin - inhibits osteoclast function and shrinks them - In steroid users start bisphosphonates T-score less than -1.5 - in women >75 start bisphosphonates dexa not required Alendronate most stomachs hate, So I swap them to risedronate, And if they're still complaing on that, Strontium ranelate comes up to bat.

Rx HYPERKALAEMIA 1A

Rx 1. 10mL of 10% calcium chloride or 30mL or 10% calcium gluconate (10-20ml slow IV infusion) 2. insulin/dextrose infusion: IV insulin *10 units actrapid* 50ml of 50% glucose over 10-15 min 3. salbutamol nebuliseD 5. dialysis ? 6. if stable no ECG changes then IV fluids NB: insulin and sal push K+ back into cells Calcium stops heart excitability

Treatments for allergic rhinitis 1A

Rx 1. PO antihistamines ( (e.g. cetirizine, loratadine and fexofenadine) 2. allergen avoidance / education 3. nasal steroids 4. oral decongestants (e.g. pseudoephedrine, phenylpropanolamine) 5. Top steroids (fluticasone) 6. oral steroids if severe

Rx of gastritis

Rx S- Prevention in stress: anti-secretory i.e Ranitidine 50mg, Pantoprazole (40mg), cimetadine (300mg) -H.pylori associated: H.pylori eradication triple therapy ->PPI AND Amoxicillin 1000mg AND Clarithomycin 500mg/ metronidazole 500 mg PO, BD 14 days or quadruple therapy quadruple therapy (claritho resistance) : PPI+Bismuth subsalicylate 524 mg + Metronidazole 250 mg + Tetracycline 500 mg qid Others: stop NSAIDS and alcohol

Rx for SIADH 1b

Rx fluid restriction high salt and protein diet treat underlying cause demeclocycline correction of electrolytes ADH receptor antagonists - tolvaptan, conivaptan

Osteomyelitis Rx 1A

Rx: Abx penicillinase-resistant (eg, nafcillin or oxacillin , flucloxacillin or vancomycin 1 g IV q 12 h 1st line flucoxacillin for 6 weeks clindamycin in penicillin allergy

Rx osteomyelitis 1A

Rx: high dose Abx local protocols usually - IV anx 2-4 wks ,( nafcillin or oxacillin, flucoxacillin ) -immobolise wound. Chronic: Ampicillin/sulbactam 3 g IV q 6 h or

SIGNS AND SYMPTOMS OF DKA 1B

S&S 1. polydipsia, polyuria , abdominal pain 2. abdominal pain, vomitting espcially in children 2b. confusion 3. acetone breath 4. Kussmaul breathing due to metabolic acidosis 6. thromboembolism, arrythmias due to hypo/hyperkalaemia 7. can be mistakenly APPEAR DRUNK- CONFUSION

S&S OF SIADH

S&S: CNS: ⬇Na ➡neurones swell leading to cerebral oedema➡seizures, coma, headaches , altered mental status ( confusion) GI: nausea and vomitings msk: cramp, tremors

Treatment of gastritis/ duodenits

S- Prevention in stress: anti-secretory i.e Ranitidine 50mg, Pantoprazole (40mg), cimetadine (300mg) -H.pylori associated: H.pylori eradication triple therapy -> Iansoprazle 30mg/Omeprazole 20mg + Clarithomycin 500mg + Amoxicillin 1000mg/ metronidazole 500 mgPO, BD 14 days or quadruple therapy quadruple therapy (claritho resistance) : PPI+Bismuth subsalicylate 524 mg + Metronidazole 250 mg + Tetracycline 500 mg qid Others: stop NSAIDS and alcohol

pneumonia after influenza

S.aureus

SEQUESTRATION CRISIS

SEQUESTRATION CRISES: - sickling within organs such as the spleen or lungs causes pooling of blood with worsening of the anaemia. abdo pain , SPLENOMRGALY - acute chest syndrome: dyspnoea, chest pain, pulmonary infiltrates, low pO2 - the most common cause of death after childhood -mainly kids - increased leukocytes Rx analgesia e.g. opiates rehydrate oxygen consider antibiotics if evidence of infection blood transfusion exchange transfusion: e.g. if neurological complications

WHAT ARE THE S&S of T1DM 1B

SIGNS - weight loss -pearl drop breath -hyperglycaemia SYMPTOMS -polydipsia, polyuria, polyphagia -fatigue

ROTATOR CUFF MUSCLES

SITS: supraspinaus: ABDuction -> most commonly injured infraspinatus: lateral rotation teres minor: ADDuction, external rotation, axillar n. subscapularis: ADDuction and medial rotation

INFERIOR GLUTEAL

SITTING , CLIMBING STAIRS ADDUCTING HIP LATERAL ROTATION AND HIP EXTENSION

During sleep, are the pupils larger or smaller?

SMALLER, due to loss of inhibition of the Edinger-Westphal nucleus (parasympathetic).

What are the signs and symptoms of osteomyelitis ? 1A

SS: acute: weight loss, fatigue, fever, and localized warmth, swelling, erythema, and tenderness. back pain in vertebral osteomyelitis.. advance dz can cause caude equina - chronic: intermittent bone pain and tenderness

OPEN FRACTURE MANAGEMENT

STAND Splint Tetanus prophylaxis Antibiotics IV Neurovascular status (before and after) Take photo Dressings (to cover wound)- erile soaked gauze and impermeable film. Cover wound

Syphylis (1B) 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

STI by Treponema pallidum Transmission can be congenital or by transfusion Features of syphilis Primary : 3wk after infection single red painless chancre at site of infection, lip or anus. Non-tender regional lymphoadenopathy < 1wk after chancre Secondary: 2-6 mths, lymphadenopathy, splenomegaly, headache, chills, fever, arthralgias, myalgias, malaise, photophobia. -Skn: macules, papules, condyloma lata around genitals, mucous patches in oral mucosa Tertiary syphilis: rare, 3-7 years later : Gumma : non-tender 'Gumma' - a granulomatous nodules, can also present in brain 12-20 yrs: deafness, optic atrophy or paretic neurosyphilis ( mengeal sx, ataxia, eye problems IX syphilis Swab of lesions T. pallidum particle agglutination (TPPA) serum T pallidum haemagglutination (TPHA) cardiolipin ICA -Venereal disease research laboratory (VDRL) and rapid plasma reagin (RPR) : can diagnose both syphylis and genital herpes Rx syphilis IM benzathine benzylpenicillin or doxycycline ( predinisolone b4 doxy)

superficial BCC

SUPERFICIAL BCC second most common common in younger adults Slowest growing least aggressive Slightly scaly, irregular superficial plaque resembles psoriasis or eczema thin, translucent rolled border stretch skin to make peraly broder obvious Multiple microerosions

Hindgut

SUPPLIED BY IMA distal 1/3 of transverse colon to anal canal above pectinate line

S/S OF HYPERKALAEMIA 1A

SYMPTOMS - Palpitations - Tachycardia - Chest pain - Weakness SIGNS - Peaked, tall, tented T waves - Prolonged PR interval -wide QRS complex (>120ms) - Flattened P waves - Broad QRS - Sine wave pattern ECG

What is the characteristic look of lymphoma (in eye)?

Salmon colored patch

Treatment of Zoster

Same Antivirals but triple the dose Cold compress Oral steriods, if a lot of pain

How does ethcrynic acid work?

Same as furosemide, but no Sulfa allergy or gout sensitivity

Scabies 1A

Sarcoptes scabiei mite (arachnid family) Incubation 3-5 weeks Lives only 2 days off host in Stratum Corneum ; life cycle 30 days Spread by close personal contact , sexual contact -Severe nocturnal Pruritus, burrows, papules, - affects finger webs, wrists, hands, feet , ass, ankles Usually no neck or face involvement Diagnosis- with glass slide from scraping Rx: 1. creams: *Permethrin*, Malathion, Ivermectin 2. Benzyl benzoate 3. Treat all contacts and perform contact tracing

Treatment for PDR?

Scatter PRP (pan-retinal photocoagulation) Vitrectomy Anti-VEGF Tx -Bevacizumab -Ranibizumab -Aflibercept

Considerations for those with Sickle Cell Disease and hyphema

Screening should be done in African Americans. May have higher IOPs. Optic nerve more susceptible to damage. Avoid CAIs (Diamox) and osmotic agents (Mannitol).

What is episcleritis?

Self-limited, generally benign inflammation of episcleral tissues. Redness without irritation, slightly tender. Like a bruise to outer eye wall. Tx: topical/oral NSAIDS

Three tiny fluid filled tubes that help maintain balance

Semicircular canals

Features of HIV

Seroconversion 2-4 weeks after exposure - flu-like symptoms, rash, adenopathy, malaise, pharyngitis Fever malaise, weight loss, skin rashes, ulcers -Oral hairy leucoplakia, oropharyngeal candida, CMV ulceration, recurrent respiratory tract infections, TB, unexplained weight loss, diarrhoea, adenopathy AIDS - PCP, TB, lymphoma, meningitis due to Cryptococcus, cerebral abscess, mycobacterium avium, CMV retinitis, oral candidiasis, Kaposi sarcoma, gingivitis, CMV, PJP and other pneumonia (Co-trimoxazole gold standard Rx) 0.3% TRANSMISSION RISK

How to test for H pylori

Serology: IgG antibodies (stay +ve even when infection is cured), Urea breath test: ammonia is produced by urea metabolism which occurs due to H.pylori, Stool antigen test, Endoscopic biopsy: can detect H.pylori on histology or culture - CLO test

Why do patients with carcinoid syndrome get pellagra

Serotonin is produced from tryptophan and sometimes the tumours can be so active that they use up the majority of the tryptophan. However niacin is also derived from tryptophan and so as a result it doesn't get produced and the patient becomes deficient

Erythrodermic Psoriasis

Severe disease usually occuring in previous psoriatic patients where precipitating factors (systemic steroids , stress, illness etc. ) Has lead to worsening state ->90% of skin - can result in hypothermia -also occrus in Tx: cool compresses oatmeal baths, and systemic therapy with etretinate or methotrexate, fluid balance, keep pt warm, emollients, top steroid. treat underlyihg disease

features of anorectal abcess

Severe perianal pain and swelling are the most common presenting complaints. Other symptoms include fever, chills, or urinary retention. loss of faecal material/pus

s. aureus gastro

Severe vomiting Short incubation period

Condyloma Accuminatum/ Viral Warts ( 1A ) GEt notes from obs&gybae

Sexually transmitted lesion due to HPV HP 6& 11 Most common Vrial STD Typical Presentation, intravaginal, intraurethral and, intraoral lesions fleshy papules may bleed or itch Diagnosis - Biopsy Acetic Acid soaks - "Aceto-whitening "

lumbar spinal lesion effect

Should be able to sit Flaccid paralysis in the lower limbs

Lichenification

Skin thickening with accentuated skin lines

PEARLY PENILE PAPULES

Small skin colored bumps that often form in rows around the glans. Considered a normal anatomic variant, not contagious, and are asx Considered harmless, they will decrease with age, but can last throughout ones lifetime

Modifiable risk factors for AMD

Smoking* -Risk persists 15 - 20 years -Dose dependent Obesity CV Disease Nutrition Low dietary anti-oxidants and zinc High saturated fat and cholesterol High blood cholesterol level Alcohol (?) ASA (?)

Hypernatraemia 1B

Sodium >145mmol/L. increased Na+ in ECF--> draws water out of cells Na+ - high in ECF ( BVs, Iterstium,) AEx CODE Cushings, COnn's Osmotic diuresis (HOS) Diabetes insioidus, dehydration, diarrroea Excess IV fluids exc SHALTED Seizures Hyperreflexia, spasms , cramps Agitation, restlessm , confsutin Low weight- weightloss Thirst Edema Dehydration- dry mucous membranes, decreased urine output Ix U&Es BM urine and serum osmolality urine flow rate electrolyte-free water excretion desmopressin challenge test- test for diabetes insipidus Rx - Rehydration without added sodium or normals aline to prevent demyelination - Oral rehydration - IV 5% dextrose -rapid collection leads to cerebral oedema especially in kds

What is the anterior chamber?

Space between cornea and iris/pupil Filled with aqueous fluid/humpur (produced in ciliary body, located posterior to iris)

Wheal

Specific type of papule or plauque resulting from fluid accumulation in dermis

Lymes Disease

Spirochete, Borrelia burgdorferi White deer ticks ( Ixodes dammini East USA ) I. pacificus (west coast USA), I. ricinus (Europe) and White footed mouse Tick must be attached 24-48 Hours for transmission Erythema Chronicum Migrans (EM) - wheel hive like plaque expands over 2-3 weeks then disappears 60-80% of cases Stages of Disease - 1 (3-32 days) constitutional type symptoms 2- Disseminated infection - AV block, tendonitis, Bell' palsy 3- ACA atrophy , Chronic memory, mood, sleep disturbances. *DIAGNOSIS enzyme-linked immunosorbent assay (ELISA) antibodies to Borrelia burgdorferi are the first-line test* Early - Doxycycline , amox, azithro Disseminated: Ceftriaxone Prophylaxis: not necessary for person bit by tick

K+ sparing diuretics

Spironolactone, eplenerone - These are aldosterone antagonists - Leads to inhibition of sodium retention andpotassium retention -Amiloride, triamterene - Block sodium channels in the collecting ducts - Leads to loss of sodium SE - Hyperkalaemia - Metabolic acidosis - Gynaecomastia - Hypotension

Hyposplenism

Spleen is anatomically present, but peripheral blood smear shows signs of asplenism (*Howell-Jolly bodies*, Pappenheimer bodies, acanthocytes, Heinz bodies and siderocytes (g6PD))

Tendon or ligament injuries Treatment

Splinting, promotion of early motion, and rehabilitation Suturing: To treat a complete rupture - If suturing is not possible: Tendon or ligament grafting Prolonged rehabilitation exercises

What is the most likely organism that will be found on ascitic fluid culture in this patient?

Spontaneous bacterial peritonitis: most common organism found on ascitic fluid culture is E. coli

Ligament tear

Sprain

DENGUE FEVER

Spread by Aedes aegypti mosquitoi; causes fever, severe myalgia and skin rash 7 days incubation Low platelets

Initial management of GI bleeds

Stabilise the pt with IV fluids and packed RBCs, establish the cause of the bleed. Upper GI: NG lavage, lower GI: mesenteric angiography Need endoscopy within 24hrs addmission

Bee Stings

Stinger imbedded - venom Toxic Rxn- pin prick, wheal , burning, multiple stings could lead to death Allergic rxn- Urticaria, angioedema, anaphylaxis TX: antihistamine SQ Epinephrine , IV fluids, Benedryl

Herpes Gestationis (pemphigoid Gestationis)

Sub - epidermal Blistering disease of Pregnancy IgG against protein in DEJ Edematous itchy papules - blisters on trunk can have recurrence with preg. or menses - maybe premature delivery Tx: Systemic Steroids

Cicartricial Pemphigoid

Sub epidermal Scarring, diseasing disease of oral and ocular mucosa IgG - against protein of DEJ Tx: Topical Steroids, Dapsone, Prednisone, Cyclophosphamide Can lead to blindness

Cyst

Subcutaneous fluid filled cavity

Muscle Strain

Sudden, forced motion, causing the muscle to become stretched beyond its normal capacity. Causes local muscle damage. Can also involve the tendons. Regardless of the cause of trauma, muscle cells can usually regenerate. May take up to 6 weeks.

History/symptoms of CRAO

Sudden, painless, and complete loss of vision. Irreversible vision loss in as little as 90 minutes.

Treatment of HCC

Surgical: partial hepatectomy. Nonsurgical: radiofrequency ablation. Palliative care.

What innervates the pupillary dilator muscle?

Sympathetic nervous system (alpha receptors)

HIP PAIN: AVASCULAR NECROSIS

Symptoms may be of gradual or sudden onset May follow high dose steroid therapy or previous hip fracture of dislocation

symptoms & signs of acute bronchitis

Symptoms: productive cough, small-volume streaky haemoptysis, and fever (rare). chest tightness/pain signs: Wheeze chest sound, cyanosis

PRIMARY IMMUNODEFICIENCY: DIGEORGE SYNDROME

T-cell disorder: 22q11.2 deletion, failure to develop 3rd and 4th pharyngeal pouches - Common features include congenital heart disease (e.g. tetralogy of Fallot), learning difficulties, hypocalcaemia, recurrent viral/fungal diseases, cleft palate

Type IV- delayed hypersensitivity

T-cell mediated i.e: TB, scabies, contact dermatitis, MS

coeliac trunk

T12 supplies organs of upper abdomen (stomach, spleen, liver) foregut

MEN-1

TAP3 Thyroid / Adrenal adenomas Parathyroid hyperplasia Pituitary adenoma- prolactinoma Pancreatic islet cell tumour Would result in - Peptic ulceration, galactorrhoea, hypercalcaemia - -may also jhave signs of diabetes i.e polyuria, polydipsia

Pott's disease

TB of the spine. inetrvertebral joints

LATERAL EPICONDYLITIS 1-7 1A

TENNIS ELBOW 1. typically follows unaccustomed activity such as house painting or playing tennis 2. most common in people aged 45-55 years and typically affects the dominant arm 3. repetitive movements 4/5. Features -pain and tenderness localised to the lateral epicondyle -pain worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended -episodes typically last between 6 months and 2 years. -Patients tend to have acute pain for 6-12 weeks Ix - clinical Rx advice on avoiding muscle overload simple analgesia steroid injection physiotherapy

THROMBOTIC CRISIS

THROMBOTIC CRISES: - painful crises or vaso-occlusive crises - precipitated by infection, dehydration, deoxygenation - infarcts occur in various organs including the bones (avascular necrosis of hip, hand-foot syndrome in children, lungs, spleen and brain) -Patients complain of severe bone, joint and abdominal pain. Bone pain affects long bones and spine, and is due to occlusion of small vessels.

WHAT IS TIIDM ? 1A

TIIDM: Hyperglycemia due to insulin resistance or reduced insulin production . caused by obbesity usually, diet . (90%) ( -Part of metabolic syndrome - hypertension, NAFLD, hyperlipidaemia, PCOS. Acutely complicated by hyperosmolar hyperglycaemic non-ketotic state Epidemiology -obese -blacks and asians - FH s/s - polydipsia, polyuria, polyphagia, weight gain Ix 1..fasting > 7./6.9 mmols or 2-hr PG >11.1 mmol 2. OGTT: >11.1 mmols 3. HbA1c: >6.5% (48mmols 4. random glucose/ 2hr > 11 mmol 5. Ketones ++ Rx

WHAT TEST IS USED TO MONITOR HYPOTHYROIDISM

TSH LEVELS

NEUTROPAENIC SEPSIS

Tazocin is recommend as the first-line antibiotic by NICE <0.4 neutrophils temp 38C

What is the technical definition of dry eye?

Tear film disorder due to tear deficiency or excessive tear evaporation causing damage to the interpalpebral ocular surface and associated with symptoms of ocular discomfort.. resulting from localized immune-mediated inflammation affecting both the lacrimal gland and the ocular surface.

How is a Seidel test performed?

Technique 1) Prepare Slit Lamp 2) Apply Topical Eye Anesthetic 3) Gently apply moistened Fluorescein dye strip to eye injury site 4) Visualize injury site under cobalt blue light source

Dislocation

Temporary displacement for its normal position in a joint - Simple - Complex (involves fracture)

Treatment for chronic Hep B

Tenofovir and entecavir

treatment for tension pneumothorax

Tension pneumothorax:

What is the Tensilon test?

The Tensilon test uses the drug Tensilon (edrophonium) to help diagnose myasthenia gravis. Tensilon prevents the breakdown of the chemical acetylcholine, a neurotransmitter that nerve cells release to stimulate your muscles.

Myoglobinuria

The abnormal presence of a hemoglobin-like chemical of muscle tissue in the urine; it is the result of muscle deterioration.. -encephalopathy is an indicator for haemodialysis

What is the anterior segment of the eye?

The anterior segment is the front sixth of the eye that includes the structures in front of the vitreous humour: the cornea, iris, ciliary body, and lens.

What is the limbus?

The area where the conjunctiva starts at the edge of the cornea.

Anaplastic thyroid carcinoma 1B

The rarest, and most dangerous type of thyroid CA. These tumors are made of poorly differentiated cells that grow quickly and cause mass effects. -VERY POOR PROGNOSIS -anaplastic: 1%, no effective therapy, fatal. elderly and women. rapid painful enlargement. hard as wood", non-tender thyroid gland.

kyphosis 1B

The thoracic spine is rounded - excessive rounding of the thoracic spine is kyphosis o A curve of more than 45˚ is considered excessive o Thoracic spine curve increases with age. Causes o Postural - poor posture o Idiopathic - Scheuermann's disease o Congenital o Neuromuscular o Post-fracture dislocation o Post-infection e.g. tuberculosis o Metabolic - osteoporosis Clinical presentation o Deformity o Pain o Stiffness o Tenderness o Fatigue Diagnosis o Radiology Treatment o Non-operative - physiotherapy, back strengthening, abdominal core strengthening o Surgery - for severe symptomatic deformity

What is the fornix conjunctiva?

The transition portion, forming the junction between the posterior eyelid and the eyeball.

What is the uvea?

The uvea comprises the iris, ciliary body, and the choroid. They are all connected to each other and are histologically similar.

When testing visual acuity, what does it mean if the pt's vision improves with using a pinhole?

There is likely a refractive error [nearsighted, farsighted, astigmatism] (correctable with glasses or contact lenses).

Chronic Dermatitis

Thickened skin, skin lines and accentuated, excoriations, fissuring Symptoms: Moderate itch, maybe periods of intense itch Etiology: Atopic dermatitis, lichen simplex, chapped fissure feet, fingertip eczema, hyperkeratotic eczema Tx: Topical steroids, intralesional steroids, Antihistamines, Abx

Epidermal cyst:

This cyst can develop into what type of cancer. Discharge of a foul-smelling "cheese-like" material

What is the fluorescein eye stain test?

This is a test that uses orange dye (fluorescein) and a blue light to detect foreign bodies in the eye. This test can also detect damage to the cornea. Any problems on the surface of the cornea will be stained by the dye and appear green under the blue light.

Vesicoureteral Reflux

This is the *back up and stasis* of the urine from lower urinary tract into the ureters and kidneys. This results in the bladder becoming over-stretched , overflow continence occurs. - also renal scarring which --> HTN in future - hydronephosis due to dilatation of the ureter, renal pelvis, and calyce Ix- Vesicouretrography AEx: congenital, strictures, lumps and bumps etc.. e

What is the bulbar conjunctiva?

This portion of the conjunctiva covers the anterior part of the sclera. The bulbar conjunctiva stops at the junction between the sclera and cornea; it does not cover the cornea. (thin) Contains goblet cells which secrete mucin.

Where are indirect hernias and what is the cause

Through both external and internal rings, lateral to the inferior epigastric vessels. Caused by congenital patent processus vaginalis.

Where are indirect inguinal hernias and what is the cause

Through both external and internal rings, lateral to the inferior epigastric vessels. Caused by failure of the processus vaginalis to close

Where are direct hernias and what is the cause

Through the floor of the Hesselbach triangle, medial to the epigastric vessels. Caused by mechanical breakdown in transversalis fascia resulting from age.

Gamekeeper's Thumb

Thumb forced into radial deviation*, stresses ulnar collateral ligament (ski pole) S/S: -pain with radial stress of thumb* Dx: Radial deviation > than opposite side Tx: - Partial lig. rupture- thumb spica cast - Complete lig. rupture- ORIF

Treatment of Psoriasis less than 20% of skin involved

Topical steroids: •Advantages - rapid response, controls inflammation and itching, best for intertriginous areas and face, convenient, not messy •Disadvantages - temporary relief (tolerance occurs), less effective with continued use, atrophy and telangiectsia occur with continued use, brief remissions, very expensive •Comments - best results occur with pulse dosing (e.g., 2 weaks of medication and 1 week of lubrication only); plastic occlusion is very effective Calcipotriol (Dovonex): Vitamin D analog - normalizes keratinization process •Advantages - well tolerated, long remissions possible •Disadvantages - burning, skin irritation, expensive •Comments - best for moderate plaque psoriasis Anthralin: •Advantages - convenient short contact programs, long remissions, effective for scalp •Disadvantages - purple-brown staining, irritating, careful application (only to plaque) required •Comments - used on chronic (not inflamed) plaques; best results occur when used with UVB light Tar: •Advantages - new preparations are pleasant •Disadvantages - only moderately effective in a few patients •Comments - most effective when combined with UVB (Goeckerman regimen) e.) UVB and lubricating agents or tar: •Advantages - insurance may cover part or all of treatment, effective for 70% of patients, no need for topical steroids •Disadvantages - expensive, office-based therapy •Comments - used only on plaque and guttate psoriasis, travel and time required Tape or occlusive dressing: •Advantages - convenient, no mess •Disadvantages - expensive; only for a limited disease •Comments - may be used to occlude topical steroids Intralesional steroids: •Advantages - convenient, rapidly effective, long remissions •Disadvantages - only for limited areas, atrophy and telangiectasia occur at injection site •Comments - ideal for chronic scalp and body plaques when small and few in number Tazorac (tartarozene) topical retinoid/normalizes cell differentiation

HOW SHOULD TRANEXAMIC ACI DBE GIVEN IN HAEMORRHAGE

Tranexamic acid is given as an IV bolus followed by an infusion in cases of major haemorrhage has been shown to be of benefit in bleeding trauma when administered in the first 3 hours.

pain relief for palliative patients who cant swallow

Transdermal opioid patch formulations are first-line choice in palliative care patients whom oral treatment is not suitable Alfentanil, buprenorphine and fentanyl are the preferred opioids in patients with chronic kidney disease.

Treatment for Incontinence

Treatment of underlying disorder if possible, behavior training, fluid management, timed voiding, pelvic floor exercises, bladder retraining. Drugs and surgical procedures.

FROZEN SHOULDER RX

Treatment: 1. active and passive ROM (physiotherapy) when thawing commences 2. NSAlDs and intra-articular steroid injections (although little proven benefit) 3. MUA (manipulation under anaesthesia) - may cause dislocation, fracture or rotator cuff tear 4. Arthroscopy for debridement decompression (rarely used) - may be best used in phase where movement starts to recover Prognosis: 1. Idiopathic adhesive capsulitis is commonly a self-limiting condition with eventual spontaneous recovery in 9-18 months of a good ROM (usually not a complete ROM) 2. Diabetics usually have a poor outcome

Plummer-Vinson syndrome

Triad of: dysphagia (secondary to oesophageal webs) glossitis iron-deficiency anaemia Treatment includes iron supplementation and dilation of the webs

renal causes of AKI

Tubular: § Acute tubular necrosis (a result of pre-renal damage or nephrotoxicity due to radiological contrast, aminoglycosides, myoglobinuria in rhabdomyolysis) § Crystal damage (uric acid) § Myeloma § Hypercalcaemia Glomerular: § SLE § Henoch-Schonlein purpura § Drugs § Infection § Primary glomerulonephritis Interstitial: § Drugs: Gentamicin ,diuretics, ACE-I (young women, fibromuscular dysplasia) § Lymphoma § Infection § Tumour lysis syndrome after chemotherapy Vascular: § Vasculitis § Malignant hypertension § Thrombus § Cholesterol emboli § HUS/TTP § Large vessel occlusion

What is carcinoid syndrome 2B

Tumours arising from enterochromaffic cells s (derived from neural crest cells: also called APUD cells (Amine Precursor Uptake and Decarboxylation) . they metastasise most commonly arise from the ileum and appendix and produce serotonin amongst other hormones - carcinoid syndrome Only occurs following metastasis as prior to this most secreted hormones undergo first pass metabolism by the liver and do not cause systemic symptoms - in the the syndrome , hormonal load exceeds the capacity of the monoamine oxidase in the liver and lung to metabolize serotonin

IgE

Type 1 hypersensitivity rxns mediator , binds to Fc receptors on mast cells and basophils Provide immunity against parasites i.e protozoa Sensitisation then, Th2 cells, second exposure ,

UC vs Crohns: extraintestinal manifestations

UC- apthous stomatitis, uveitis, primary sclerosing cholangitis, erythema nodosum Crohns: Similar to above plus fistulas to the skin, bladder or other bowel loops

UC vs Crohns: treatment

UC: 5-ASA agents ie. sulfasalazine, mesalamine, corticosteroids for flare-ups and immunomodulators or biologics ie. azathioprine or infliximab Crohns: Same

UC vs Crohns: hx/symptoms

UC: bloody diarrhoea, abdo cramps, tenesmus, urgency. Crohns: abdo pain, mass, low-grade fever, weight loss, watery diarrhoea

UC vs Crohns: colonoscopy

UC: diffuse and continuous rectal involvement, pseudopolyps Crohns: cobblestoning, skip lesions, creeping fat on the outside of the bowel

UC vs Crohns: site

UC: rectum extending proximally Crohns: any portion, particularly iliocaecel, discontinuous

What are causes of pinguecula?

UV radiation is the primary cause, but frequent exposure to dust and wind also appear to be be risk factors. Dry eye disease also may be a contributing factor.

Treatment of Psoriasis with greater than 20% of the body involved

UVB and tar administered in physician's office: •Advantages - more effective than UVB alone •Disadvantages - more expensive and carcinogenic than UVBalone; requires many office visits PUVA: •Advantages - allows patients to be ambulatory; effective •Disadvantages - many treatments needed; many office visitsrequired Methotrexate:*** •Advantages - "gold standard" for efficacy; helps arthritis •Disadvantages - hepatotoxicity; liver biopsy periodically required Etretinate: •Advantages - effective for palmer-planter-pustular, erythrodermic, and pustular types of psoriasis; fast, effective; helps arthritis •Disadvantages - teratogenic; usually ineffective as a single therapy for plaques Newer version of retinoid now available Cyclosporine: •Advantages - fast, effective; helps arthritis •Disadvantages - hepatotoxic; nephrotoxic; •Neoral g.) Hospitalization or office say treatment for tar, anthrain, and combinations of all therapies above: •Advantages - most effective for those who are unresponsive to topical agents or for whom systemic agents are inappropriate •Disadvantages - time-consuming; expensive New Tumor Necrosis Factor inhibitors (TNF inhibitors) FDA approved for RA (Remicade)

Drop arm test

Unable to lower arm further with control Tear rotator cuff (mostly supra) (deltoid function able to lower arm to 90`)

What is anisocoria?

Unequal pupil size.

prolonged APTT

Unfractionated heparin (UFH), haemophilia A or B, lupus anticoagulant, rarely vWD affects APTT, factor VIII inhibitors are rare but typically prolong APTT.

What are some symptoms of retinal detachment?

Unilateral photopsia or a sensation of flashing light, an increased number of floaters (posterior vitreous detachment), decreased visual acuity and metamorphopsia

Presentation of zollinger-ellison syndrome

Unresponsive, recurrent burning abdo pain, diarrhoea, nausea, vomiting, fatigue, weight loss, weakness and GI bleeding.

what are some ILDs

Upper Lung Disease (FASSTEN) -Farmer's lung (hypersensitivity pneumonitis) -Ankylosing -spondylitis Sarcoidosis Silicosis -TB -Eosinophilic granuloma (Langerhans-cell histiocytosis) -Neurofibromatosis Lower Lung Disease (BADRASH) -Bronchiolitis obliterans with organizing pneumonia (BOOP) -Asbestosis -Drugs (nitrofurantoin, hydralazine, INH, amiodarone, many chemo drugs) -Rheumatologic disease -Aspiration -Scleroderma -Hamman Rich (acute interstitial pneumonia) and IPF

thoracic spinal lesion efect

Upper limbs are spared but there is spastic paralysis of the legs May not be able to sit unaided

UREA BREATH TEST

Used to test H pylori : Patient ingests drink containing Urea with radio labeled Carbon Measures exhaled radio labeled Carbon - broken down by H. pylori . your breath is then analysed to see whether or not you have an H. pylori infection. < urea means H pylori infection no antibiotics in past 4 weeks, no antisecretory drugs (e.g. PPI) in past 2 weeks no gaviscon etc... 24hrs before no ranitidine, cmetidine 3 days before

Acute diarrhoea causes and treatment

Usually infectious and self-limited. Most common: campylobacter. Treat with oral rehydration and treat symptoms ie. antidiarrhoeal agents unless the patient has a high fever or bloody stools

Clinical findings of CRAO

VA often in range of 20/40-20/400. VA in range of LP may indicate choroidal vascular insufficiency (obstruction of ophthalmic artery also). Cherry red spot in retina. Emboli seen in CRA in about 20% of cases.

Syphilis Labs

VDRL/ RPR - measures IgG and IgM FTA-ABS ( directly detects T. Pallidum antibodies) Dark Field Microscopy - Spirochetes

HbeAg

VERY INFECTIOUS acute/chronic infection infectivity wild type viral infection

Abx for MRSA

Vancomycin Synercid Bactrim Linezolid Ciprofloxacin Minocylcine

Signs of conjunctival inflammation

Vasodilation, swelling and discharge

RAYNAUD'S 1-7

Vasospastic disorder characteristically causing discolouration of fingers and toes (white -> blue -> red). Classic triggers: cold and emotional stress Primary: Raynaud's disease Secondary: Raynaud's phenomenon typically present in young women with symmetrical attacks Features: Factors suggesting underlying connective tissue disease: onset after 40 years unilateral symptoms rashes presence of autoantibodies features which may suggest rheumatoid arthritis or SLE, for example arthritis or recurrent miscarriages digital ulcers, calcinosis very rarely: chilblains Secondary causes: connective tissue disorders: scleroderma (most common), rheumatoid arthritis, SLE leukaemia type I cryoglobulinaemia, cold agglutinins use of vibrating tools drugs: oral contraceptive pill, ergot cervical rib First line: calcium channel blockers (nifedipine) Second line: IV prostacyclin infusion: effects may last several weeks/months

Acanthosis Nigricans

Velvety hyperkeratosis of the intertriginous area ( neck, axillae, groin) Skin tags Ass. Diabetes, Obesity, Insulin Resistance , Stomach CA TX: Treat underlying issue

Acute Dermatitis

Vesicles and Blisters intense red Symptoms: intense itch Etiology: Contact allergy (poison ivy) severe irritation Tx: Cold wet compress, oral or IM steroids, topical steroids, Abx, antihistamines

What could watery eye discharge indicate?

Viral conjunctivitis, chemical irritants

Influenza 1A

Virus spread by droplets that causes upper and lower RTI 4 Types(A-D). A&B more common common in young elderly and immunocompromised it has seasonal epidemics (December to march) Features include fever, coryza, cough, headache and malaise and in KIDS N&V Ix: pulse oximetry, CXR, PCR Rx: self-limiting 2-3 days in vulnerable Antiretrovils Oseltamivir (PO) Zanamivir (inhaled) --> bind to the active site of the neuraminidase protein--> virus cant escape host cell and infect others

Most common causes of chronic hepatitis

Viruses (Hep C and B), alcohol, autoimmune and metabolic syndromes (Wilson's, haemachromatosis)

Occupational factors astmaad

WILD -Antiibiotics -Wooddust -Isocyanates -Latex - Dyes - Allergens (pesy, dust, allergens)

Weber vs Rinne Test

Weber: tuning fork on midline and ask what ear hearing in - conductive hearing loss lateralized to affected ear -sensorineural lateralizes to normal ear Rinne: put tuning for on mastoid and ask when no longer hearing it then move near canal air conduction (AC) is normally better than bone conduction (BC) if BC > AC then conductive deafness

Bone remodeling is self regulated by bone

When osteoblasts get embedded in mineral, so do growth factors. During resorption, they release the growth factors, which stimulate osteoblasts to reform bone that was resorbed. --osteoclasts stimulated by factors released by osteoblasts

What is syneresis?

When the vitreous humor thins out due to a breakdown of collagen; normal with age.

Stingray management (4)

With a stingray there are two issues, the physical injury from the barb tail and then the venom. Pain normally lasts up to 48 hours, but is most severe in the first 30-60 minutes. The physical injury depends where it is. If on the lower leg. Normally the barb is not left in. Can be relatively minor. Does depend on the size of the ray. The wounds can bleed a lot so local pressure is needed to try to stop the bleeding, due to the venom. If the injury is higher especially if the chest it can be fatal. All stingray injuries should be medically assessed sTING RAY EFFECTS #Severe pain at the site of injury Tissue necrosis — myonecrosis (in some situations involving cardiac muscle) is often noted in histological specimens of wounds Nausea and vomiting, diarrhoea Salivation Sweating Respiratory depression Muscle fasciculations and cramps Syncope and hypotension Convulsions Cramping abdominal pain Arrhythmias (including bigeminy, all degrees of heart block and asystole) Myocardial ischaemia

How do you treat GCA?

Workup: (ESR>100, check CRP + plt) Prompt treatment with corticosteroids is imperative to prevent permanent vision loss and can be initiated urgently, even before a temporal artery biopsy is performed

Alport syndrome

X-linked defect in Type IV collagen. Results in thinning/splitting of basement membrane. Clinical symptoms are: Isolated hematuria, sensory hearing loss and ocular disturbances.

Dislocation and subluxation most common in persons

Younger tha 20y2

superficial burn 1A

a burn that involves only the epidermis, the outer layer of the skin. It is characterized by reddening of the skin and perhaps some swelling. An example is a sunburn. Also called a first-degree burn. Erythema involving the epidermis only Usually dry and painful Typical of severe sunburn. Ix: FBC, ABG, biopsy, culture - cleaning, topical creams, keep moist, +/- aloa - NSAIDS, analgesia -prophylactic abx silver sulfadiazine, mafenide topical

What is cirrhosis?

a chronic disease of the liver marked by degeneration of cells, inflammation, and fibrous thickening of tissue. It is typically a result of alcoholism or hepatitis. -endstage liver disease

PREDIABETES HB1AC

a condition in which the blood sugar level is higher than normal, but not high enough to be classified as type 2 diabetes 42-47 MMOLS 6.1-6.9

Subacute Cutaneous LE (SCLE)

a cross over of cutaneous and systemic lupus Skin findings: erythematous papulosquamous or annular polycyclic pattern on trunk, arms, axillae, but spare the knuckles and below the waist; adherent scale and atrophy are NOT seen; photosensitivity, periungual telangiectasias, vasculitis; Diagnosis: clinical annular lesions + photosensitivity + post Anti Ro/SSA antibody

ganglion cyst

a harmless fluid-filled swelling that occurs most commonly on the outer surface of the wrist arising from a joint or tendon sheath. -tansilluminable -painless o May present because of pressure effects on adjacent structures: Ulnar nerve in tunnel of Guyon. Radial artery on palmar side of the wrist Carpal tunnel syndrome with volar ganglia Diagnosis o Diagnosis is made clinically - reassure - review if not settling

patellofemoral syndrome

a heterogenous group of patellofemoral conditions causing anterior knee pain o commonly seen in young adults, especially females o softening of, fissuring and ulceration of articular cartilage, usually medial aspect of patella Aetiology o overuse - excessive knee strain (athletes) o malalignment and mal-tracking of the patella - subluxation, recurrent dislocation of patella, genu valgum, femoral anteversion, high patella (patella alta), shallow intercondylar groove o quadriceps muscle imbalance o tight iliotibial band and lateral retinaculum History: o deep aching anterior knee pain o exacerbated by prolonged sitting, strenuous athletic activities, stair climbing Clinical presentation: o crepitus in the patellofemoral joint o effusion o tenderness on palpation of underside of medially displaced patella o mal-tracking of the patella in ROM o pain on resisted knee extension localised to the anterior aspect of the knee o Clark's sign - Patient lies supine with knee in extension. Place the web space of the thumb and index finger against the superior pole of the patient's patella and ask the patient to perform an isometric quadriceps contraction. A positive test is indicated by the presence of pain sufficient to prevent the patient from maintaining a quadriceps contraction against resistance. Non-specific for patellafemoral conditions. Diagnosis o X-Rays: AP, lateral, skyline o Best seen on MRI Treatment: o conservative treatment physio (isometric quads strengthening) NSAIDs o surgical treatment with refractory patients arthroscopic debridement, in carefully selected patients with excessive lateral pressure, lateral release may benefit release of lateral retinaculum Realignment of extensor mechanism

Gastrointestinal perforation (everything) 1A

a hole that develops through the whole wall of the esophagus, stomach, small intestine, large bowel, rectum, or gallbladder. - can be free or contained ( hole but no leakage of contnts) - can cause peritonitis ( contents leak out into abdo cavity --> bacteria--> peritonitis -This condition is a medical emergency. if untreated --> sepsis --> septic shock , multi organ dysfunction, and death. Causes -PUD, foreign boddy, appendicitis, diverticulitis, ischaemia, colitis ( fistula formation, toxic megacolon, volvulous, gallstones, NSAIDs --> ulcers trauma: surgery, endoscopy , Features: - abdo pain worse on movement -abdo distention -shoulder tip pain, back pain, RIF pain if retroperitoneal -fever , chills, malaise, vomitting, nausea IX: CXR: Rigler's sign - both sides of the bowel wall can be seen, due to free intra-abdominal air acting as an additional contrast. Psoas sign - loss of the sharp delineation of the psoas muscle border, secondary to fluid in the retroperitoneum. CT scan Bloods: infection Rx: IV access, IV Abx ( metro, genta, emergency surgery, PUD ( PPI, bowel rest) , oesophageal : stent, NG feed, divertula --> remove, surgery Abx

Gastrointestinal perforation 1A 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

a hole that develops through the whole wall of the esophagus, stomach, small intestine, large bowel, rectum, or gallbladder. - can be free or contained ( hole but no leakage of contnts) - can cause peritonitis ( contents leak out into abdo cavity --> bacteria--> peritonitis -This condition is a medical emergency. if untreated --> sepsis --> septic shock , multi organ dysfunction, and death. Causes -PUD, foreign boddy, appendicitis, diverticulitis, ischaemia, colitis ( fistula formation, toxic megacolon, volvulous, gallstones, NSAIDs --> ulcers trauma: surgery, endoscopy , Features: - abdo pain worse on movement -abdo distention -shoulder tip pain, back pain, RIF pain if retroperitoneal -fever , chills, malaise, vomitting, nausea IX: CXR: Rigler's sign - both sides of the bowel wall can be seen, due to free intra-abdominal air acting as an additional contrast. Psoas sign - loss of the sharp delineation of the psoas muscle border, secondary to fluid in the retroperitoneum. CT scan Bloods: infection Rx: IV access, IV Abx ( metro, genta, emergency surgery, PUD ( PPI, bowel rest) , oesophageal : stent, NG feed, divertula --> remove, surgery Abx

Faecal impaction

a mass of dry, hard stool that remains packed in the rectum and cannot be expelled S/Sx : paradoxical overflow and diarrhoea liquid passes blockage

Achilles tendinitis

a painful inflammation of the Achilles tendon *CAUSES:* -excessive stress being placed on that tendon i.e foor fitting footwear - *QUINOLONES* i.e ciprofloxacin -thickened tendon, palpable mass, pain, stiffness, crepitus

Strawberry Hemangiomas

a proliferation of endothelial cells seen in 1-3% of neonates, UNCOMMON bright red papule or nodules, 1/3 present at birth or within the first month of life;

Port Wine Stain ( Nevus Flammeus)

a vascular malformation or dilation of vessels (in contrast to proliferation of endothelial cells) that does NOT fade with age

Acute Anigoedema

a. Acute form: (type I hypersensitivity reaction) due to food, drugs (NSAIDS, ACE inhibitors), insects, pollen, contrast dye

Acne Fulminans

a. Acute onset of cystic acne associated with myalgias, arthralgias, and fever b. Usually adolescent boys c. Associated with wt. Loss, fever, leukocytosis, and elevated ESR d. Treatment with oral antibiotics, accutane, prednisone

Pyoderma Faciale (Rosecea Fulminans)

a. Acute onset of cystic acne confined to the face b. Usually adult women, no prior history of acne c. Usually "flushers and blushers" d. Treatment with oral antibiotics, accutane, prednisone

Acne Conglobata

a. Chronic, inflammatory, cystic acne characterized by the "double comedone", papules, pustules, cysts, abscesses and draining sinustracts b. Associated with the "follicular occlusion triad of acne conglobata, hidradenitis suppurativa, and dissecting cellulitis of the scalp c. 85% of patients are African-American d. Arthralgias seen, but no fever or wt. Loss

Hereditary Angioedema

a. Cutaneous swelling, severe upper airway and GI involvement b. 30% mortality rate (resp failure) c. onset late childhood, with swelling developing over 12-18 hours and lasts 2-3 days d. Etiology: Lack of C1 esterase inhibitor e. Treatment: fresh frozen plasma (steroids and antihistamines not helpful)

Pressure Uticaria

a. Deep, pruritic, burning and painful hives occurring 4-6 hours after pressure stimulus b. Age of onset is early 30's, chronic course lasting 1-40 years c. Associated with malaise, fatigue, fever, chills and arthralgia; also with chronic urticaria and angioedema d. Treatment: systemic steroids, antihistamines are of no help

Tinea Barbae

a. Fungal infection of the beard area, usually caused by a zoophilic dermatophyte with inflammatory like reaction b. Treatment requires oral antifungals in order to eradicate infection (griseofulvin, intraconazole, fluconazole, terbinafine)

Tinea Manuum 1B

a. Fungal infection of the hand, Trichophyton rubrum mostcommon cause b. Frequently misdiagnosed as dry skin or eczema c. Two foot one hand syndrome - is tinea pedis and tineamanuum of one hand. Look for foot involvement when hands are involved d. Treatment i. Anitfungal Creams for mild to moderate cases (terbinafine, econazole, etc.) ii. Oral antifungals for extensive or resistant cases (griseofulvin, intraconazole, fluconazole, terbinafine)

Tinea Cruris (jock itch) 1B

a. Fungal infection of the skin of the groin w/ Trichophyton rubrum c. Erythrasma is a bacterial infection (corynibacterium minutissimun). flourescescoral red with a wood's light and is treated with topical erythromycin d. Treatment i. Creams for mild to moderate cases (terbinafineeconazole, etc.) ii. Oral antifungals for extensive or resistant cases (griseofulvin, intraconazole, fluconazole, terbinafine) iii. Decrease moist environment

Pyoderma Gangrenosum

a. General: an ulcerating chronic and recurrent skin disease b. Associations: Ulcerative colitis, Crohn's disease, rheumatoid arthritis, hepatitis, malignancy c. Clinically: tender red papules that progresses to nodules that enlarges and ulcerates, most commonly on lower legs, can be solitary or multiple d. Treatment: Avoid trauma, IL steroids, oral steroids, dapsone

HSV infection of a non mucosal surface

a. Herpetic whitlow - HSV of the finger tip, used to be commonly seen in healthcare workers (contact with oral secretions) b. Buttock and trunk lesions c. Neck lesions

Cold Urticaria

a. Hives and/or angioedema occurring after sudden drop in air temperature or exposure to cold water b. Treatment: Cyproheptadine (periactin), doxepin, avoidance

deep reflexes dermatomes

"1,2,3,4,5,6,7,8": S1-2: ankle L3-4: knee C5-6: biceps, supinator C7-8: triceps

What is a fundoscopic exam finding in central vein occlusion?

"Blood and Thunder fundus" (diffuse retinal hemorrhages) -optic disc edema -dilated and tortuous veins -exudate and sometimes neovascularization

Coxiella burnetii

(q fever) Dry cough, high fever, headache, ♂, animal exposure, e.g. sheep and goats

Mixed respiratory and metabolic alkalosis

* ↑ pH * ↓ CO2 * ↑ HCO3- * Liver cirrhosis with diuretic use * Hyperemesis gravidarum * Excessive ventilation in COPD

Bunions -Hallux Valgus Deformities 1B

*medial displacement* of 1st metatasrsal and *lateral deviaton of hallux* -valgus alignment of 1st metatarsal -associated w/ poor fitting shoes, heridtory, sec to Oa -more common in women -reactive exostosis forms with thickening of the skin creating a bunion -ss: pain and redness, bursitis medial to the joint, and mild synovitis. rx: shoe with a wide toe box, protective pads, and orthotics steroid injection for bursitis or synovitis

Boxer Fracture 1A

-Closed fist injury*, usually by hitting a wall or person, acute angulation of neck of metacarpal of little finger into palm -S/S: swelling, tenderness over 4th/5th metacarpals Dx: X-ray: fracture of neck of metacarpal with volar angulation. Triangular fragment at base o 4-5the metacarpal Always suspect "closed fist syndrome"; punch to teeth= human bite= OR + IV antibiotics Rx: closed reduction, ulnar gutter splint for 2-3 wk if stable,

Ae of pneumonia in CF

-Pseudomonas aeruginosa Rx ciproflaxin

HIV PEP

-initiate prophylaxis as soon as possible! -recommendations for HIV PEP include a basic 4-week anti-retroviral regimen

Rx for depletion volume

-isotonic saline -packed RBC -FFP

Respiratory acidosis

-low oxygen, high CO2, normal or low pH (type 2) -common in COPD, drug use, foreign body aspiration -ABG hypoxaemia + hypercapnia = t2rf hypoxaemia +normocapnia = T1RF

anti-virals in pneumonia

-oseltamivir,zanamivir , or peramivir

treatments for sarcoidosis

-steroids for lung dysfunction -MTX suppress immune system

Serum Osmolality

-urine osmolality 50-1200 mOsmol/kg H2O - >450 in hypovolaemia -serum osmolality 275-300 mOsm/kg

capal tunnerl pic

.

Treatment of Chancroid

1. Ceftriaxone 2. Azithromycin 3. Erythromycin 4. Augmentin 5. Cipro

ACUTE HEPATITIS 1B

1. Inflammation of the liver 2. Features Nonspecific viral prodrome (malaise, nausea, vomiting) followed by jaundice and RUQ tenderness, hepatomegaly, scleral jaundice 3. Ix -LFTs: ⬆ AST/ALT ⬆ ALP ⬆GGT - Hepatitis serology

IMPAIRED GLUCOSE TOLERANCE

1. fasting <6.1-6.9 (<7.0 mmol) 2. OGTT >7.8 -11.1 mmol

MAnagement of clot retention

1. first line is Continuous bladder irrigation with 3-way urethral atheter

MENISCAL INJURY

1. from twisting 2. locking and giving way 3. popping senstation - cannot extend the leg

DIARRHOEA def.

1. increase in bowel movement and/or watery stool 2. AEx infections - self-limited malabsorption IBS IBD cancer

diabetic retinopathy

1. increased blood flow due to thickened blood vessels due to hypoglycaemia 2. eventually BV become occluded - Capillary hypoperfusion then leads to chronic retinal ischaemia and release of VEGF as an attempt at repair - This then results in neovascularisation, scarring and fibrosis

Increases of anion gap

1. indicates acidosis CAT MUDPILES Carbon monoxide Aminoglycosides Theophyline Methanol Uraemua DKA Paracetamol, phenformin Iron overload, isoniazid Lactid acidosis Ethalyne glycon, ethanol Salicylates/ASA/ aspirin

BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV) NOM

1. recurrent sudden onset of vertigo on head movement 10-20 seconds, ass. w. nausea. >55s 2. dysfunc of the rotational velocity sensors in inner ear due to Displaced otoliths - Ca particles within semi-circular canals - common in >50s iX: Dix- hallpike test ( sit Pt quickly at 30-405 --> nystagmus Rx Epley maneuver

INFLUENZA 1A

1. virus that causes upper and lower RTI it has seasonal epidemics (December to march) 2.common in young elderly and immunocompromised 3/4: fever, coryza, dry cough, headache and malaise, myalgia , lethargy Kids: abdo pain, nausea, vom -4 types : A-D A&B more common Ix CXR PCR sputum NAAT cultures Rx 1. self-limiting 2. n vulnerable Antiretrovils Oseltamivir (PO) Zanamivir (inhaled) complication: pneumonia ( s.aures) recurrence of symptoms after getting better primary influenza pneumonia-> rare, blood in sputum

RISK FACTORS FOR PSEUDOGOUT 1B

5 Hs Hypomagnesaemia Hypophosphataemia Hypothyroidism Hyperparathyroidism Haemochromatosis ( wilsons) Acromegraly KIDNEY disease

Ondasteron

5-ht3 antagonist - used for chemo induced nausea -SE: constipation

Complications of Crohn's Disease

> Fistulas, Obstruction, Colon Cancer (UC > CD) > Calcium Oxalate renal calculi (increased reabsorption of oxalate through inflamed mucosa) > Bile salt deficiency --> Malabsorption > B12 deficiency --> Macrocytic anemia - Toxic megacolon - GI perforation - Pseudopolyps due to chronic inflammation - Strictures leading to vomiting and bowel obstruction - Sinuses, abscesses, fistulae, stenosis - Short bowel syndrome - Increased risk of colonic, anal and MALT cancers - Oxalate nephrolithiasis - Gallstones - Hepatic steatosis - Granulomatous hepatitis - Malabsorption ADEK deficiency, osteoporosis - Protein-losing enteropathy

Kawasaki Syndrome

A. aka: mucocutaneous lymph node syndrome B. Etiology: unknown, but thought to be an infectious agent C. Is an acute, multi-system vasculitis that is diagnosed clinically by criteria on next slide D. Treatment: high dose aspirin and gamma globulin E. Prognosis: Cardiac involvement leads to morbidity and mortality

Roseola Infantum (6th disease) 1A

AKA exanthema subitum, sixth disease childhood febrile disease between 2-24 months human herpesvirus (HHV)-6B (CD3+) and occasionally by HHV-7 (CD4+) Fever for a few days no other symptoms 3-5 days, then Rash. generalised maculopapular rash. Ix: PCR , clinical Rx: supportive, Foscarnet or ganciclovir in immunocompromised.

BLOOD CLOTTING TESTS: VITAMIN K DEFICIENCY

APTT: increased PT: increased Bleeding time: normal

What is strabismus?

Any misalignment of the eyes.

Treatment of an insulinoma

Benign tumour - needs surgical resection

Treatment of Syphilis

Benzathine penicillin G 2.4 MU IM single dose: 1B. Follow up with VDRL in 3,6,12 months

Hangman's fracture

Bilateral fracture of pedicles of C2 due to hyperextension - Unstable

tests for IPF

Bloods: ESR & CRP raised PFTS: restrictive picture CXR: reticular or reticulonodular pattern with lower lung predominance

shigella diarrhoea

Bloody diarrhoea Vomiting and abdominal pain

Torus

Buckling of cortex

What is the optic nerve?

CNII - paired nerve that transmits visual information from the retina to the brain. Contains axons of ganglion cells in retina. Extends intracranially from optic disc --> optic nerves--> optic chiasm --> optic tract --> lateral geniculate nucleus --> pretectal nuclei --> superior colliculus

investigations for pleurisy

CXR-

buckle fracture

Compression injury, the bone buckles rather than breaks

What is a sign of HIV retinopathy?

Cotton wool spots

When should you be screened for diabetic retinopathy if you have DM1, DM2 or DM and pregnant?

DM1 - 5 years after dx and annually DM2 - at time of dx and annually DM and pregnant - before or soon after conception and every 3 months (each trimester)

SULFASALAZINE

DMARD used in rheumatoid arthritis and IBD Cautions: GP6D deficiency allergy to aspirin or sulphonamides (cross-sensitivity)

Crust

Dried Serum

Drug Induced LE

Drug induced SLE most commonly procainamide (80% of patients on this medicine develop drug induced LE), azatghioprine Diagnosis: clinical findings + positive antihistone antibody titer

What is miosis?

Excessive constriction of the pupil.

adenoid hypertrophy

Excessive development (enlargement) of adenoids. features nasal obstruction, l ong-term mouth breather; enlarged adenoids on nasopharyngeal exam

IMA LEVEL

L3

A Monteggia fracture

MURder M-onteggia U-lnar #, R-adial disloc Proximal ulnar shaft fracture with radial head dislocation

Rheumatoid arthritis: drug side effects

Methotrexate SE: Myelosuppression Liver cirrhosis Pneumonitis Sulfasalazine SE: Rashes Oligospermia Heinz body anaemia Interstitial lung disease Leflunomide SE: Liver impairment Interstitial lung disease Hypertension Hydroxycholorquine SE: Retinopathy Corneal deposits Prednisolone SE: Cushingoid features Osteoporosis Impaired glucose tolerance Hypertension Cataracts Gold SE: Proteinuria Penicillamine SE: Proteinuria Exacerbation of myasthenia gravis Etanercept SE: Demyelination Reactivation of tuberculosis Infliximab SE: Reactivation of tuberculosis Adalimumab SE: Reactivation of tuberculosis Rituximab SE: Infusion reactions are common NSAIDs (naproxen, ibuprofen) SE: Bronchospasm in asthmatics Dyspepsia/peptic ulceration

obstructed hernia

Obstructed hernias prevent bowel contents from passing through leading to intestinal obstruction

hyperparathyroidism

PT gland --> secretes PTH in response to low Ca+ PTH increases Ca+ absorption from intestine, increases Ca+ re-absorption from kidneys , increases osteoclast activity in bones --> Ca+ increase Vit D: increases Ca+ absorption PTH converts Vit D to active form Primary- tumour --> increased secretion --> increased Ca+ and increased PTH secondary: Low Vit D, or renal failure --> hypocalcaemia --> PTH excrete more PTH to compesate --> overtime increase in PTH glands (hyperplasia) --> secrete more PTH . serum Ca++ is normal but PTH is raised Tertiary PTH--> chronic secondary HPTH --> hyperplasia of prarathyroid gland --> increase in PTH --> high absorption of Ca+ in intestine, kidney

Palliative prescribing

Pain 1. NSAIDS , non-opipoid 2. COdeine OR Tramadol 3. morphine or buprenophrine, fentanyl, methadone, oxycodon 4. confusion: haloperidol (1xt line) OR chlorpromazine, levomepromazine

HIP PAIN: INFLAMMATORY ARTHRITIS

Pain in the morning Systemic features Raised inflammatory markers

What is odynophagia

Pain with swallowing

How does a patient with a corneal ulcer present?

Pain, FBS, Redness Reduced Vision Tearing, Photophobia

What innervates the pupillary constrictor muscle (sphincter)?

Parasympathetic nervous system (cholinergic receptors)

ESSENTIAL THROMBOCYTOSIS

RBCs: - WBCs: - Platelets: increased Philadelphia chromosome: negative JAK2 mutations: Positive (30-50%) Similar to polycythemia vera, but specific for megakaryocytes.

What is the treatment for a hyphema?

REST! Topical Steroids, Cycloplegics - dilating drops Monitor IOP, Check Sickle Prep

Rock Mountain Spotted Fever

Rickettsia rickettsii South Atlantic States Tick must be attached for 6-10 hours for transmission 3-21 days after bite - fever, Headache, myalgia, emesis Rash: day 4 macular petechial, ankles wrists palms soles, trunk. 15% no rash Systemic - pulm GI CNS issues can die if untreated Tetracycline, Doxycycline Chloramphenicol for pregnant women and children under 8

Rx for BCC

Rx: excision, cryo, photodynamic therapy, imiquimoid cream, Fluorouracil cream, radiotherapy

What is a sebaceous cyst?

Sac-like collection of dead skin cells and oils

Adult Risk factors for eustachian tube dysfunc

Smoking, pollutants GERD allergy chronic sinus Adenoid hypertophy Sleep apnea w/ CPAP use Fam hx

What is the palpebral conjunctiva?

This portion covers the inner surface of both the upper and lower eyelids. (thick)

Why would kid need a myringotomy tube?

To drain fluid from middle ear to reduce infxn

What is tuberous sclerosis?

Tuberous sclerosis complex (TSC) is a neurocutaneous syndrome with multisystem involvement most commonly affecting skin, brain, kidneys, lungs, and eyes. The retinal astrocytoma usually appears as a white, superficial retinal lesion.

Osteoblastoma 2B

Tumors of the bone arising from osteoblasts common in spine and long bones -grown rapidly -painful rx: excision

p-ANCA

UC, PSC, everyting else

Dx of hiatal hernia

Usually asymptomatic and picked up incidentally on XR.

What is pellagra

Vitamin B3 (Niacin) deficiency. Causes diarrhoea, dementia, dermatitis and death - presents with: Dermatitis ( erythematous rash over limbs in sun exposed areas ) , diarrhoea, dementia/delusions, leading to death - linked to strict vegan diet

Neurofibromatosis (NF)

Von Recklinghausen Cafe au lait Macules - Crow's Sign , lische nodules (eye hamartomas) Pheochromocytoma, schwannoma, optic glioma, CML

What is the sclera?

White, opaque wall of the eye. Continuous with cornea Type I collagen fibers arranged more IRREGULARLY, HYDRATED

Osteosarcoma 2b 1-7

a malignant tumor of bone in which there is a proliferation of osteoblasts. - usually presents in 10-30s, more common in males - hx of pagets -frequently metastasises features: o painfully tender, poorly defined swelling o x-ray shows Codman's Triangle: characteristic periosteal elevation and spicule formation (sunray) representing tumour extension beneath the periosteum with calcification -bony destruction o treatment with complete resection (limb salvage, rarely amputation) adjunctive chemo, radiotherapy

features and rx of Salicylate poisoning

acidosis then alkalosis - abdo pain -vomitting -tinnitus Rx- urinary alkalinization with intravenous sodium bicarbonate - enhances elimination of aspirin in the urine

What are some toxicities of acetazolamide?

acidosis, neuropathy, ammonia toxicity, Sulfa allergy

ACUTE PAINFUL LOSS OF VISION

acute angle closure glaucoma, uveitis, corneal ulcer, orbital cellulitis , keratitis HSV

inverse psoriasis/ flexural

aka: Psoriasis inversus Clinically: Intertriginous psoriasis ( gluteal fold, groin , diaper area) characterized by red, smooth plaques that commonly fissure at the base of the body crease)

Aplastic crisis in Hs

aplastic crisis secondary to parvovirus infection. reduced reticulocyte count <3

aspirin-intolerant asthma

asthma caused by aspirin- non atopic

Still's disease features

autoimmune dz characterised by pyrexia, artralgia, salmon pink rah 16-40 elevated serum ferritin rash: salmon-pink, maculopapular and rash lymphadenopathy rheumatoid factor (RF) and anti-nuclear antibody (ANA) negative manage w/ NSAID and steroids , MTX

Chronic Angioedema

b. Chronic form: i. Idiopathic: 40-50 year old women, milder form ii. Acquired C1 inhibitor deficiency: Complement deficiency leads to angioedema and can be associated with malignancy (Lymphoma/Leukemia) or autoimmune disease

S&S of gingivitis (6)

bad breath gum swelling gum redness change in normal gum contours gum bleeding w/ brushing edema of interdental papillae

Achrochordons / papillomas, skin tags

benign growth of epidermis and dermis and subcutaneous tissue. flesh colored

Polycycstic liver disease (PLD) :

benign liver neoplasm inherited dz, common a growth of numerous abnormally shaped (malformed) bile ducts, known as ductal plate malformation. PLD may occur with polycystic kidney disease (PKD) or alone but is less common and milder than the kidney form.

Biceps tendonitis Cause

by overuse of the biceps muscles, usually heavy or excessive lifting

Clostridium perfringens

causes gas gangrene

What happens during Acute Tubular Necrosis?

cells lose polarity, epithelial cells detach, muddy-brown casts, necrosis

Petechiae

circumscribed blood deposit <.5cm

COMPLICATIONS OF OTIIS MEDIA

complication perf **acute mastoiditis Facial n. paralysis Meningitis** hearing impairment scarring of eardrum Cholesteatoma, P. aeruginosa

complications of rhinitis

complications -sinustis -serous otitis media

Hypopituitarism

condition of diminished hormone secretion from the anterior pituitary gland Features -hyponatraemia -fatigue Ix insulin stress test

What are causes of pre-renal acute renal failure?

decreased renal blood flow (hypotension) leading to decreased GFR. sodium and urea retained by the kidney.

Telangiectasia

dilated superficial blood vessel

What are the symptoms of low Na+ in the plasma? causes ?

disorientation, coma, stupor, thirsty , dehydration 2. SCLC (ADH), drugs ( SSRIs, thiazides, ecstasy), infections (legionella pneumonia), addisons.

How do spironolactone and eplerenone work?

diuretics that block aldosterone receptors in the collecting tubule. Cause sodium excretion

what is pleural effusion

fluid between parietal and visceral pleura - pleural fluid can be exudate or transudate

What is FTA-ABS?

fluorescent treponemal antibody absorption (FTA-ABS) test is a blood test that checks for the presence of antibodies to Treponema pallidum bacteria.

What BMs should T1DM aim for

generally 48mmol or lower same for TIIDM

gout sxray

gout1

physis

growth plate

IN WHAT CONDITIONS IF HBA1C NOT USED FOR DIAGNOSIS

haemoglobinopathies haemolytic anaemia untreated iron deficiency anaemia suspected gestational diabetes children HIV chronic kidney disease people taking medication that may cause hyperglycaemia (for example corticosteroids)

strangulated hernia

hernia that is constricted, cut off from circulation, and likely to become gangrenous - emergency

Gingivitis d/t: Which gender more seen in? Commonly seen in: (condition)

inadequate plaque removal males = females pregnancy

What could photophobia indicate?

iritis, keratopathy, glaucoma, corneal abrasions

Overflow Incontinence

leakage of urine when the bladder is abnormally distended with large residual volumes. 2nd most common type of incontinence in men. Ae: AKI, BPH, obstructive uropathy

NON-HODGKIN'S LYMPHOMA

median age = 55-60 years Aex: EBV, HepCV, Features: - painless widespread lymphadenopathy, hepatosplenomegaly - raised LDH, paraproteinaemia, AIHA -pancytopaenias - B-symptoms occur less - itshy skin Types Diffuse l arge B - c ell lymphomas (DLBCL)- most common Waldernstrom macroglobulinaemia small lympocytic leukaemia follicular lymphoma Burkitt

MEN 2B

medullary thyroid cancer, pheochromocytoma, Marfanoid neuromucco- gangliomas

Nail psoriasis

nail pitting- most common and well known cause of nail pitting Onycholysis- lifting of the nail, plate off of the nail bed subungal hyperkeratosis- scale under the nail plate nail deformity- if nail matrix is involved

Portuguese man-of-war sting

not a jellyfish -liberally rinse with salt / seawater, for at least 30 seconds. -scrape to remove stinger(s). -Heat as tolerated (not to exceed 110 degrees)

LCL

o varus force to knee o similar history, physical to MCL o often associated with *common peroneal nerve* injury o treatment as for MCL

What can lead to vision loss in neurofibromatosis?

optic nerve glioma (benign, but lead to vision loss)

Purulent or foul smelling discharge from auditory canal may indicate: (2)

otitis externa or foreign body

What are some toxicities of furosemide?

ototoxic, hypokalemia, dehydration, nephritis, gout, Sulfa allergy

Meigs syndrome

ovarian fibroma, ascites, right-sided pleural effusion

CNIII PALSY

pain, ptosis, and pupil dilation. 1. may be first sign of posterior communicating artery stroke 2.aneurysm 1) Ischemic (DM/HTN, Giant Cell Arteritis) 2) Trauma 3) Compression (aneurysm/tumor) 4) Infiltrative (leukemia, sarcoid) IX LP (CSF for oligoclonal bands; Glu; protein; xanthochromia; microscopy, culture, and sensitivity (MC&S); cytology)

Bullous Myringitis

painful fluid-filled vesicles on TM and sudden onset of severe pain in ear Small vesicles containing blood on the drum; accompany mycoplasma pneumonia and virus infections

Osteitis fibrosa cystica pic

pic

STERILE PYURIA

positive urine leukocyte esterase but negative standard culture; TB, C. trachomatis -Sterile pyuria and white cell casts in the setting of rash and fever should raise the suspicion of acute interstitial nephritis, which is commonly due to antibiotic therapy

IFN-alpha

produced by leucocytes antiviral action useful in hepatitis B & C, Kaposi's sarcoma, metastatic renal cell cancer, hairy cell leukaemia SE: flu-like symptoms and depression

What are some orbital signs of orbital cellulitis?

pupil abnormality decreased color vision restricted EOMs (ophthalmoplegia) diplopia proptosis

Common cold cause

rinovirus

Common causes of infectious diarrhoea

rotavirus, norovirus, enteric adenovirus, Campylobacter, clostridium difficile, E coli, salmonella, shigella

IV catheter common bug

s. epidermidis

Atrophy

thinned skin

Claw hand

ulnar nerve damage c8-t1

When should platelet transfusion be considered

with platelets <30

Risk factors for fatal or near-fatal asthma

• Previous near-fatal asthma - previous admissions for • Three or more classes of asthma medication • Repeated A&E attendances • High β2agonist use • Adverse psychosocial features • Background difficult asthma

What are two fundoscopic exam findings in retinal artery occlusion?

"Box carring" - small segments of narrowing of the arterioles "Cherry red spot" - Blood is flowing to this spot (coming from different artery), yet rest of retina/fundus is pale.

Irritant Hand Dermatitis

"Housewives Hands " Excessive dryness leading to inflammation Could be from frequent hand washing Tx: based on stage (Acute, Subacute, Chronic) and prevention

Shoulder Joints

- AC joint - Glenohumeral joint

MANAGEMENT OF DOG/CAT BITE

- Decide whether wound needs closing /high chance of infection ? - leave open if large wound as closing= high risk of infection - facial wounds need to be seen by plastics - Dog wounds usually Pasteurella multocida which is resistant to both erythromycin and flucloxacillin - Rx * coamoxiclav * - determine tetanus and rabies risks - if never been vaccinated against rabies should get : 4 doses of rabies vaccine, day 1,3,7 and 14 AND rabies IgG OR Coamoxiclav + Booster or 4 doses if never vaccinated doxycycline ( photosensitivity, angioedema black hairy tongue, discolouration of teeth before 12 )and metronidazole ( disulfiram effect w/ alcohol) if penicillin allergy

Treatment of diverticular dz/ diverticulitis

- High-fibre diet or fibre supplements - NG tube -- or diverticulitis - co-amoxiclav, ciprofloxacin, metronidazole, paracetamol (or tramadol, morphine), low residue diet -surgery : hartmas procedure with colon resection + colostomy and rectal stump --> colostomy reversal in 3-6 months) - drainage and sigmoid colectomy -bleed: transfuse, fluids

IX for alcohol related liver disease

- Hx alcohol use LFTs, CBC -liver biopsy -PT, INR -CT MRI

Test for Subscapularis

- Internal rotation lag sign (against resistance) - Gerbers lift off test - Belly press sign

What investigations would you carry out is osteomyelitis ? 1 A

- Ix: FBC (WCC) ESR, CRP, Xray, MRI, culture of bone, abcess or both , WBC MRI preferred

MRSA Nasal management

- Nasal muciprocin _ chlorhexeidine for skin if surgical patient

Rotator cuff tears Positive test for impingement

- Neer's test - Hawkins sign - Drop arm test -painful arc test

Diabetic nephropathy

- Nephropathy due to hyperglycaemic damage to the glomerulus, ischaemia and recurrent infections - Microalbuminuria (30-300mg/day) - Albumin : creatinine ratio of >2.5 in men or >3.5 in women Rx - ACEI/ARB - Strict glycaemic control - Management of hypertension - Statin - Eventually renal replacement therapy

whats moderate asthma

- PEFR50-75% - Normalspeech - RR<25 - Pulse<110

Klinefelter's syndrome

- Tall , slim,small testes , infertile , gynacomastia -47 xxy

UC complications

- Toxic megacolon - Bowel perforation - Infection with CMV, C. difficile - Haemorrhage - Colonic cancer - Strictures - Pseudopolyps - Increased risk of primary sclerosing cholangitis and cholangiocarcinoma - Adenocarcinoma of bowel

INVESTIGATIONS FOR HYPERKALAEMIA 1A

- U&Es k+ >5.5 -ECG

Features of the oesophageal varices

- asymptomatic -signs and symptoms of liver failure - haematemesis

Talar Fracture

- axial loading or hyperdorsiflexion MOI- falling from a height and landing on the foot in a crouched position -talor neck most common -requires closed reduction with cast or ORIF -3+ months NWB

PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE

- if Q-risk >10%, 20mg atorvastatin is first line

Baker's cyst 1-7

- popliteal cyst, a fluid filled sac behind the knee more obvious on standing . not true cyst,they are distension of the gastrocnemius-semimembranosus bursa. - idiopathic or related to osteoarthritis and usually seen in adults ss: tightness at back of knee, persistent aching - ruptured bakers cyst can sometimes present like a DVT, tenderness, swelling, hot Rx: excision

Nasolacrimal duct obstruction

- teary or wet eye - discharge and sticking of lids in AM - most resolve during 1st year of life - treatment necessary to avoid acute dacryocystitis

What is bile composed of?

-Bile salts (formed from cholesterol) -Bile pigments (bilirubin) -Phospholipids (lecitin) -Cholesterol -Water -Na+, K+, Ca2+, Cl-, and HCO3-

Palmo-plantar psoriasis

-Confined to the hands and feet -Sterile pustules that fade to leave brown pinpoint lesions -Pain in affected areas -More common in smokers Rx -top steroids - smol -coal tar 20% , 40% added w/ salicylic acid -diathranol -Vit D analogues ( Calcipitiol)

tympanic membrane

-The eardrum. - pearly, opaque, produces light reflex - separates the outer ear from the middle ear and vibrates in response to sound waves.

diagnosis & treatment of RSV

-clinical diagnosis -PCR treatment -supportive -in immunocompromised antivirals

What are oesophageal varices?

-distended, tortuous collareral veins in oesophageal submucosa -can also be in proximal stomach -common complication of Portal hypertension --> back up of blood into veins - can lead to severe bleeding resulting in shock, haemorrhage

The external auditory meatus

-ear canal -25 mm - has wax producing glands

medial ligaments of the ankle tear

-eversion injury -avulses medial or posterior malleolus and strains syndenosis

respiratory alkalosis with metabolic compensation

-increased pH -hypocapnaenia -reduced HCO3

Acute bronchitis 1A

-infection of bronchi or tracheobronchial tree causing inflammation --> mucus secretion, therefore breathing difficulty. Can last for up to several weeks -caused by viral infection mainly H.influenza

what is pleurisy/pleuritis

-inflammation of lung pleura which can cause pleuritic chest pain -caused by : viral: coxsackie B virus. -infection i.e pneumonia -chest trauma -neoplasms

DACTYLITIS

-kids mainly - Metacarpals, metatarsals, backs of hands and feet swollen and tender (small vessel occlusion and infarction). -Recurrent, can result in permanent radiological abnormalities in bones of the hands and feet (rare) with digit shortening

breast development

-oestrogen stimulates breast duct development in presensence of GH, FSH, LH- Progesterone stimulates development of breast alveoli. -Androgens oppose oestrogen action

osteomyelitis Risk factors 1A

-open wounds -bone fractures -recent surgery -diabetes sickle cells- salmonella IV drug use -alcohol excess

what are asbestos-related lung diseases

-pleural effusion -pleurisy -mesothelioma -asbestosis -pleural plaques -pleural thickening -mesothelioma -pericarditis

Biceps tendonitis Tx

-rest, ice, sling, NSAIDs, steroid injection-not into tendon sheath

ulnar nerve anatomy

.

Layers of RETINA (and beyond) from INSIDE, OUT.

1) Nerve fibers (to optic nerve) 2) Ganglion Cell 3) Bipolar Cell 4) Horizontal Cell 5) Cone [photoreceptor] 6) Rod [photoreceptor] 7) Pigmented epithelium 8) Bruch's membrane 9) Choroid 10) Sclera

Acne Keloidalis

1. A chronic scarring folliculitis of the posterior scalp, commonly seen in African-American males 2. Starts as a folliculitis and then developed indurated papules that become keloids. This can progress to very large keloids in predisposed individuals 3. Treatment is with antibiotics, intralesional steroids, and surgical excision People prone to thickened collagen

cirrhosis of the liver

1. A severe medical condition where scar tissue in the liver replaces functional tissue. AEx PBC alcohol NLFD Ix first line is Transient elastography

EXAMINATION FOR ACUTE VISUAL LOSS

1. Acuity snellen , finger counting, head movements 2. Ciliary flush 3. Visual fields 4. Pupils 5. fundoscopy

What's extrinsic asthma

1. Allergic asthma, associated w/ atopy, IgE mediated . common in younger people 2. due to allergens- pollen, dust, pets

GALLSTONE ILEUS 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

1. Bowel obstruction secondary to gallstone through fistula. 2. AEx: gallstones 3. path : gallstones erode from the gallbladder, creating a fistula to the small bowel that may cause a bowel obstruction 3/4: SBO symptoms, nausea, vomiing, constipation, obstipation, distension , severe abdominal pain 5 Ix AXR : gas in bowel and gallbladder Rx laparotomy with stone extraction, closure of the fistula and cholecystectomy.

Liver Abscess

1. Condition that may be pyogenic, amebic, or fungal; occur more often as complications of biliary tract disease, surgery , or trauma can occur after appendicitis- pre abx era -• Infections usually polymicrobial, involving gut-derived Gram-negative (e.g., E. coli, Klebsiella ), Gram-positive (e.g., Enterococci, Streptococcus milleri ), and anerobic organisms (e.g., Bacteroides spp). - features: RUQ pain, fever, septic shock, FUO, weight loss, anorexia , dull abdo pain Ix -deranged LFTs -⬆⬆ WCC ⬆ESR CRP cultures CT scan Rx - ABx and drainage

DPP4 inhibitors

1. Gliptins- linagliptin, sitagliptin- PO 2. DPP4 prevents breakdown of GLP-1 -> increase incretin -> glucagon inhibition -> inhibit gluconeogenesis GOOD IN OBESE PATIENTS 3. SE - weight neutral, pancreatitis, Oral

GASTRITIS : def & types 1A

1. Inflammation of the gastric/ duodenal mucosa 2. Aex - non-eruptive gastritis: mainly caused by H.pylori --> stimulates gastrin production, causes the greatest hyperacidity and duodenal ulceration -Eruptive gastritis --> Alcohol, Aspirin/NSAID 9inhibit prostaglandin production ( prostaglandings inhibit HCO3 secretion and increase mucus protection) misuse and bile reflux due to previous gastric surgery or cholecystectomy -Stress Gastritis: due to ulceration due to stress -autoimmune gastritis- auto anti-bodies to parietal cells and intrinsic factor resulting in inflammatory infiltration and atrophy of the corpus mucosa phlegmonous gastritis (gangrene of the stomach) where severe abdominal pain accompanied by nausea and vomiting of potentially purulent gastric contents can be the presenting symptoms. Fever, chills, and hiccups also may be present.-> extremely rare -Granulomatous: TB, crohn's, foreign body -Infectious: h.oylori, foreign bodies

OESOPHAGITIS 1A 1-7

1. Inflammation of the oesophagus 2. MAny causes GORD dyspepsia - Chemo -fungus infections -behecets, pemphigus -pemphigus IX - OGD

OBTURATOR NERVE

1. L2-L4, HIP ADDUCTION

SUPERIOR GLUTEAL

1. L4-S1, HIP ABDUCTION 2. Positive trendelenberg in injury DAMAGE Misplaced intramuscular injection Hip surgery Pelvic fracture Posterior hip dislocation

Biguanides

1. Metformin, PO ` 2. Reduce hepatic gluconeogenesis , Increase glucose uptake into tissues (Increases insulin sensitivity) 3. SE:, reduced B12, lactic acidosis and metabolic acidosis , diarrhoea

TOXIC MEGACOLON 1B

1. Non-obstructive dilatation of the colon >6cm in width with signs of systemic toxicity and sepsis 2. RF: PPIs, C. diff, IBD 3.-infection colitis wk before -diarrhoea +/- blood abdo distension , tenderness or peritoneal signs - FEver, inc. HR >120, high WBC, and anaemia 4. IX AXR - dilated colon > 6cm, loss of haustration CRP, ESR, culture, U&Es, stool sample, stool culture Rx - Resuscitation with IV fluid, correct electrolytes - Transfusion for anaemia - NBM, relieve symptoms - NG tube decompression - Broad-spectrum ABX (piperacillin/tazobactam) - Total colectomy

Malignant External Otitis

1. Overgrowth of Pseudomomas aeruginosa in chronic external otitis, mainly in diabetics, with extension to the skull base 2. Clinically: painful, swollen ear, worse at night, with a purulent drainage 3. Treatment: Cipro by mouth for 6 weeks - 6 months

Pseudomomas Cellulitis

1. Overgrowth of Pseudomomas aeruginosa in compromised areas, i.e. toe webs, groin, foreskin 2. Clinically: painful, dusky red, ulcerated lesions giving sweet, fruity-smelling discharge 3. Treatment: Acetic acid soaks, Cipro by mouth

Acanthosis nigricans is associated with

1. PCOS 2. Cushings 3. Obesity 4. TIIDM 5. Gastric cancer Addisons has more generalised hyperpigmentation

Hypothyroidism (1A)

1. Reduced production of thyroid hormone due to destruction of thyroid gland. ◾Common in females 30-40. Goitrous type and atrophic type. A. atrophic thyroiditis, end-stage thyroiditis , thyroid tissue destroyed, extensive fibrosis. B. Goitrous: infiltration with lymphocytes destroying tissue -> resultant fibrosis. Gland creates more cells follicular cells compensate resulting in a goitre. Destruction of gland ➡ transient thyrotoxicosis. 2. AEx a. IgG mediated production of anti-TSHR ANTI-TGB and anti-tpo. Associated with anti-tpo antibodies( 90-100%) - most common HASHIMOTO b. high iodine intake c. stress and infection - dequaverian thyroiditis/ sick euthyroid d. autoimmune disease: pernicious anaemia, SLE, addissons, vitiligo, coeliac, turners e. pituitary failure 3. Signs and symptoms Head: mental slowing, depression Cardiac: bradycardia , hypotension Resp: hypoventilation GI: weight gain , constipation, no apetitie MSK: lethargy , carpal tunnel ,delayed reflexes, cramps Uro: menorrhagia, loss of libido, reduced fertility Skin: dry coarse skin, myxedema ( pufiness), hair loss, thinning of skin Ix ⬆ TSH ⬇ free T4 Antii-Tpo (90%) antTGB ( 60%) ANti tsh (10-20) Rx Levothyroxine Beta-blocker SE: none really

TERTIARY HYPERPARATHYROIDISM

1. Results when parathyroid activity becomes autonomous and excessive in patients with secondary hyperparathyroidism; results in hypercalcemia Investigation X-ray: 1. Sub-periosteal erosions 2. Cysts 3.Acro-osteolysis 4. pepperpot skull Rx - Increased fluid intake - Parathyroidectomy( SE hypoparathyroidism, recurrent laryngeal nerve palsy, hungry bone syndrome) definitive treatment - Bisphosphonates - Management of hypercalcaemia

OROPHARYNX CANCER

1. SCC (95%), >50-70 , >M, RF: smoking, ETOH, HPV 16, oral sex featurs : Odynophagia, otalgia Ulcerated/enlarged tonsil Fixed tongue/trismus/dysarthria Oral fetor, bloody sputum HPV+ OPC predominantly arises at base of tongue or tonsillar region Cervical lymphadenopathy (60%) Distant mets: lung/bone/liver (7%) Ix: Biopsy Determine HPV status via RT=PCR: positive if presence of HPV DNA and p16 overexpression CT

WHAT IS DISSEMINATED INTRAVASCULAR COAGULATION (DIC) NOM but common

1. Syndrome complicating a lot of illnesses -> activation of coagulation--> results in excessive production of fibrin and thrombin --> excessive fibrin causes clot formation + organ failure and excessive consumption of coagulation occur + platelets results in bleeding. - platelets are used up resulting in excessive bleeding - clots everywhere can cause ischaemia and necrosis can cause organ damage Causes 2. infection, cancer , placenta rupture) , sepsis, shock , malignancy , severe liver failure , toxins ( snake bites, drugs) signs and symptoms - echymoses at sites of injections -GI bleed -signs of DVT Investigations Prothrombin time: prolonged APTT: prolonged Bleeding time: prolonged Platelet count: low Low fibrin ➡ cryoprecipitate D-dimer ( fibrin degradation products) ⬆ thrombin time⬆ protamine test factor V, VIII, X, XIII Rx - treat cause -heparin -Possibly replacement therapy (eg, platelets, cryoprecipitate, fresh frozen plasma))

Nephrotic syndrome 1B

1. The triad of: - Proteinuria >3.g/day (ACR>250mg/mmol) -Hypoalbuminaemia (<30g/L) -hyperlipidaemia -peripheral Oedema -(Hyperlipidaemia >10mmol/L) - (Pro-thrombotic state- loss of antithrombin-III, proteins C and S) changes result in : - Podocyte injury - Effacement of foot processes - Loss of podocytes Types a. postinfectious glomerulonephritis after strep A infction -- b. autoimmune dz (diabetes, SLE, amyloidosis) c. Minimal change dz - common cause in kids d. primary glomerular diseases in adults e. FSGS in young adults f. Membranous nephropathy in elderly g. drugs ( (NSAIDs, penicillamine, anti-TNF, gold) h. paraneoplastic dz I. IgA nephropathy f. NSAIDS , gold, penicillinase, captopril, heroin, mercury 3. Symptoms a. proteinuria b. hypoalbuminaemia Ix a. 24-hr urine collection : protein uria > 3g b. Urinalysis shows +++ protein c. Bloods. Hypoalbuminaemia , Lipid profile,U%E d. Serologican studies: ANA, free light chains, Hep B&C e. Renal biopsy Rx for nephrotic syndro a. treat oedema - furosemide, fluid and saltrestriction b. Treat proteinuria - ACE inhibitors and ARB c. Reduce thrombotic risk - anticoagulation d. Statin e. Pneumovax II - vaccination f. Treat the cause results in hypercoagulability due to loss os antithrombin III and increases in factor V, VIII, X

stress fracture

1. a small crack in the bone that often develops from chronic, excessive impact - Most common in the weight bearing bones - lower extremity commonest site - metatarsals 2 and 3 other common sites - calcaneus, fibula , talus, narvicular and the navicular. o may go on to displace if untreated and activity continues o will usually heal in 2 months Diagnosis o often difficult to see on a first x-ray o may not be visible until several weeks later when callus appears o can be detected earlier by CT, MRI and bone scan Treatment o Ceasing activity o Rest o Splintage

Pleural plaques 1B

1. accumulation of inhaled asbestos fibres on the parietal pleura which calcify. 2. they cause pleural thickening 3. do not affect lung function or become cancerous 4. aymptomatic, RARELY chest pain and SOB 5 best seen on CT sometimes on xray

Prutitic Urticarial Papules and Plaques of Pregnancy (PUPP)

1. aka: Polymorphic eruption of pregnancy 2. Third trimester primigravidas with a sudden onset, of pruritic hives developing within abdominal striae, with spread to proximal body in 2-3 days. 3. Eruption usually clears within one week after delivery 4. Infants are unaffected 5. Treatment: Supportive therapy, steroids if necessary

Schamberg's Disease

1. aka: Progressive, pigmented purpuric dermatosis 2. Petechiae and patches of redish brown "cayenne pepper" like lesions of the legs 3. Etiology: unknown; Males > females; cosmetic problem only- usually older pt. 4. Treatment is difficult, symptomatic itch relieved with topical steroids

Henoch-Schonlein Purpura

1. aka: anaphylactoid purpura/ IgA vasculitis 2. A benign, self limiting hypersensitivity reaction of palpable purpura over legs and buttocks associated with with abdominal pain & GI bleeding (40%), arthralgia (80%), hematuria (20-50%) and URTI 3. More common in spring, preceding URI by history, usually younger patient 4. Diagnosis: Elevated ESR, Decreased complement, IgA deposits in walls of blood vessels via skin biopsy - Urine dipstick: haematuria -hx of joint pains -BP -Swabs 5. Treatment: Treat underlying problem (infection malignancy, food or drug reaction. +/- plasmapheresis, Prednisone

NEONATAL JAUNDICE <24HRS

1. always pathological 2. test bilirubin urgently 3. causes : rhesus haemolytic disease ABO haemolytic disease hereditary spherocytosis glucose-6-phosphodehydrogenase

HYDROCOELE 1B

1. an excessive collection of fluid in the tunica vaginalis which surrounds the testes. - common in young kids/infants . 2. AEx: torsion, trauma, infection , varococoele , tumour 3. painless enlarged testicles , water filled balloon 4. signs: painless, soft , fluctuant swelling , can get above it , transilluminates 5. Ix: clinical diagnosis, USS 6: Rx: observation , surgery, aspiration

Dermatitis Herpetiformis 1B

1. blistering disease associated . with gluten sensitive Enteropathy, Hypothyroidism, small bowel lymphoma Features: extremely Itchy papules, burning, elbows, knees, butt. NEVER see intact because so itchy IgA against portion of DEJ Ix - anti IgA TTG , endomyseal, -biopsy Tx: Dapsone (1-2mg/kg/day)—itching will subside within 48-72h. - , sulfapyridine, gluten free diet

Mycoplasma pneumoniae- atypical pneumonia

1. common in young and healthy. 2. presents with flu like symptoms, dry cough, erythema multiforme ( sometimes nodosum) and cold autoimmune haemolytic anaemia.(IgM) 3/4 bilateral consolidation, +ve cold agglutination test Ix - mycoplasma serology Rx: erythromycin (250-500 mg QDS 5 days) /clarithromycin (500mg OD 7-14 days) or doxycyline ( photosensitivity)

What is IBS 1A ? definition

1. definition common chronic functional bowel disease of unknown cause characterised by : - Chronic abdominal cramping pain associated with bowel dysfunction but no abnormalities on investigation - Rome - 3 months of 2 + symptoms - pain related to defecation, change in frequency, change in form 3 types - IBC-C -IBS-D -IBS- mixed 2. AEx - common in women -< 50s

Myositis 1-5

1. disease of promixam muscle weakness and inflammation in muscle 3/4; S&S - proximal muscle weakness - muscle atrophy -shawl rash -frequent falls/trips - weight loss -fatigue 5. Invx - Jo-1 and Mi-2 antibodis -CK: raised -fever -EMG -ESR -muscle biopsy

COMMON PERONEAL/FIBULAR NERVE

1. divides from sciatic, behind knee, around fibula head, DIVIDES IN 2 BRANCHES 2. foot eversion, dorsiflexion, extensor hallucis 2. damage -> foot drop Tibialis anterior is the muscle that acts to dorsiflex and invert the foot and is innervated by the deep peroneal nerve Tibialis posterior is responsible for the plantar flexion and eversion of the foot

CHOLEDOCOLELITHIASIS 1-7

1. gallstones in the common bile duct, cause obstructive jaundice 2. 4 Fs 3/4: Biliary colic, jaundice, afebrile 5. Ix ALP bilirubin MRCP ERCP Rx colecystectomy

Amoebiasis 1B

1. infections with entamoeba hystolica parasite. 2. causes intestinal and extraintestinal disease including abscesses in liver, lung, heart and brain. Intestinal features: Gradual onset bloody diarrhoea, abdominal pain and tenderness which may last for several weeks, toxic megacolon, chronic colitis Liver abscess is the commonest : features include fever, RUQ pain, weight loss and cough Abscess darin looks like anchovy sauce.

PERTUSSIS/ WHOOPING COUGH 1A

1. infectious URTI charcaterised spasmodic coughing that usually ends in a prolonged, high-pitched, crowing inspiration (the whoop) -common in developing world & *INFANTS <6months* 2. AEx: bordetella pertusiss,B. parapertussis. B. bronchioseptica 3. - Stage 1 - catarrhal - coryza, fever, cough, sneezing, tearing -Stage 2 - paroxysmal coughing fits with red/blue colour change, flow of mucus, inspiratory whooping noise and vomiting - worse at night - Stage 3 - convalescent - symptoms ease and are over within a month Ix a. cultures/ swabs b. FBC Rx - admission and isolate for 5 days - MACROLIDES: Erythromycin for 14 days (or clarithromycin or azithromycin for 7 days) -Immunisation for close contacts under 7 - Erythromycin for close contacts - *STOP STATIN IF TAKING MACROLIDES* COMPLRICATIONS -pneumonia with subsequent respiratory failure and death. - otitis media - Haemorrhage into the brain, eyes, skin, and mucous membranes can result from severe paroxysms and consequent anoxia. -hernia -coma and death

METHOTREXATE

1. inhibits dihydrofolate reductase, an enzyme essential for the synthesis of purines and pyrimidines Indications: inflammatory arthritis, especially rheumatoid arthritis psoriasis some chemotherapy acute lymphoblastic leukaemia - methotrexate is a drug with a high potential for patient harm - methotrexate is taken weekly, rather than daily - FBC, U&E and LFTs need to be regularly monitored - folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after methotrexate dose CI: avoid prescribing trimethoprim or cotrimoxazole concurrently - increases risk of marrow aplasia

AXILLARY NERVE

1. innervates deltoid and teres minor 2. C5-C6 bracial plexus 3. abduction of arm , internal rotation and flexion 4. damaged in humeral neck fracture/ dislocation 5. Gives rise to upper lateral cutaneous nerve of arm, which innervates the skin over the lower deltoid ('regimental badge area').

neck and back pain 1B

1. mechanical or nerve compression (>90%) - degenerative (disc, facet, ligament) - peripheral nerve compression (disc herniation) - spinal stenosis (congenital, osteophyte, central disc) - cauda equina syndrome -sciatica myeloma, discitis : sinister backache 2. others (<10%) - neoplastic (primary, metastatic, multiple myeloma) -infectious (osteomyelitis, TB) , especially in IVDUs -metabolic (osteoporosis) - traumatic fracture (compression, distraction, translation, rotation) - spondyloarthropathies (ankylosing spondylitis) -referred (aorta, renal, ureter, pancreas)

NEONATAL JAUNDICE 2-14 DAYS

1. physiological, common in breastfed babies

INSULIN MOA SE

1. replaces endogenous insulin -> increase duptaje of glucose SE Hypoglycaemia Weight gain Lipodystrophy deterioration retinopathy neuritis

Pityriasis Versicolor ( TInea Veriscolour ) 1A

1. skin yeast infection due to Over growth of Pityrosporum (Malassezia furfur) skin yeast . 1a. common in young adults esp. men affects trunk, scalp and back Highly recurrent in summer common in dry climates Features: ▪hypopigmented erythematous, red-brown scaly macules ▪dark-skinned people have pale/while patches (pityriasis versicolour alba) -may persist for months, until melanocytes are stimulated by sun exposure. -asymptomatic Ix: wood lamp, fungal culture, skin biopsy, microscopy using KOH tx: NICE 1. topical antifungals 1st line: ketoconazole shampoo 2% OD for 5 days 2nd line: selenium sulfide 2.5% shampoo OD for 7 days SMALL AREAS: Imidazole creams: (such as clotrimazole [preferred in pregnancy], econazole, or ketoconazole) can be applied twice a day. 2-3 weeks 2. oral anti-fungals: fluconazole, terbinafine 3. once gone pale skin will remain pale until stimulated by sun

ORAL LEUKKOPLAKIA 1B

1. white plaques in oral mucosa , common in males >40 -mixed areas of leukoplakia and erythroplakia and also may be precursors of cancer. 2. AEx: smoking alcohol chronic irritation from denturs candidiasis vit def endo distrubances and possibly a virus (HSV) 3. white plaques on tongue which does not come off 4. Ix: incisional biopsy brush biopsy, ANA, DNA, smith antigen , trepona pallidum serology Rx: treat underlying cause

POLYCYTHAEMIA 1B

1.excessive production of RBC and increased HCt or PVC on FBC Relative causes: - dehydration - stress: Gaisbock syndrome Primary: - polycythaemia rubra vera-> myeloproliferative dz of bone marrow --> increased production on rbc - classically: intense itching which usually occurs after exposure to hot water or hot and humid weather - in Primary O2 levels likely to be normal ! and EPO is normal Secondary causes: - COPD - altitude - obstructive sleep apnoea - excessive erythropoietin: cerebellar haemangioma, hypernephroma, hepatoma, uterine fibroids To differentiate between true (primary or secondary) polycythaemia and relative polycythaemia: red cell mass studies - In true polycythaemia the total red cell mass in males > 35 ml/kg and in women > 32 ml/kg

What is the average age of onset of AMD?

75

Morton's Neuroma 1B 1. Definition 2. RF/ Epidemiology 3. Pathophysiology 4. Symptoms 5. Signs 6. Investigations 7. Treatment

A Morton's neuroma is a fibrous thickening of nerves. located between *the third and fourth metatarsal heads'* where the nerve is the thickest because it receives branches from both the medial and the lateral plantar nerves 2. common in 40-50s, more common in females (4:1) Aex: idiopathic , chronic inflammation 3. Irritation due to compression ss: pain, burning, numbness and tingling between two of the toes of the foot. pain starts in balls of feet Ix: MRI, CT, XRAY Rx: orthotics, pads in shoes, steroid or anasthetic injections, cryotherapy , surgery

VIPOMA

A VIP-producing tumour, highly malignant (VIP: vasoactive intestinal polypeptide) presents with Watery diarrhoea, dehydration, muscle weakness, flushing Ix stool sample , hyperglycaemia , hyperglycaemia, hypercalcaemia and hypokalaemia - high serum VIP levels

What is a Wood's lamp examination?

A Wood's lamp is a small handheld device that uses black light to illuminate areas of your skin. The light is held over an area of skin in a darkened room. The presence of certain bacteria or fungi, or changes in the pigmentation of your skin will cause the affected area of your skin to change color under the light.

Hepatocellular adenoma:

A benign tumor of the liver most frequently associated with oral contraceptives

What is a scotoma?

A blind spot in vision.

Fracture

A break in the continuity of a bone. Occurs when force is applied that exceeds the tensile or compressive strength of the bone

irreducible hernia

A hernia that cannot be reduced or placed back into the abdominal cavity; requires immediate surgical evaluation.

What is the orbital septum?

A membranous sheet that acts as the anterior boundary of the orbit. It extends from the orbital rims to the eyelids. It forms the fibrous portion of the eyelids.

What does 20/20 vision mean/ 6/6 in the UK

A person with 20/20 vision can see what an average individual can see on an eye chart when they are standing 20 feet away. Normal vision.

What is Behcet's disease?

A rare disorder that causes blood vessel inflammation throughout your body. S/Sx: mouth sores, eye inflammation (uveitis), skin rashes and lesions, and genital sores.

Perianal Cellulitis

A. Bright red erythema, perianal region in children with painful defecation and tenderness B. Treatment with oral antibiotics, penicillin, erythromycin Ages 2-5

MOST COMMON OESOPHAGEAL CA

ADENOCARCINOMA

Pustular psoriasis of the digit

Acrodermatitis continua Clinically: Localized form of psoriasis, found on the finger with tender, eroded and fissured surface Very resistant to standard therapy

FACTOR V LEIDEN

Activated Protein C resistance - most common inherited thrombophilia (5% population) - gain of function h in the Factor V Leiden protein - mis-sense mutation is that activated factor V (a clotting factor) is inactivated 10 times more slowly by activated protein C than normal - Heterozygotes have a 4-5 fold risk of venous thrombosis. - Homozygotes have a 10 fold risk of venous thrombosis increases risk of DVT

What is the most common cause of acute renal failure?

Acute tubular necrosis

Familial adenomatous polyposis (FAP)

An autosomal dominant trait resulting in the development of polyps and benign growths in the colon. Polyps often develop into malignant growths and cause cancer of the colon and/or rectum.

What is Virchow's node

An enlarged left supraclavicular lymph node, gastric cancer may present with this

External ear

Auricle (pinna)

Course complete fracture - Oblique or spiral

Bone tend to shorten and redisplace even if it is splinted

Presentation of cholangitis

Charcot triad and Reynolds pentad

Vesicle

Circumscribed Collection of clear fluid <1cm

What does the cochlea do?

Convert mechanical vibrations into sensory impulses and transmit sound to 8th CN

Epstein-Barr virus/ infectious mononucleosis 1A

DS-DNA virus, HHV 4 Common in young enters via pharynx and infects B-cells CD21 can immortalise B-cells causing Burkitt's lymphoma,nasopharyngeal carcinoma, hodkins lymphoma in immunocompromised Features of EBV -Triad: sore throat, lymphadenopathy, pyrexia malaise, anorexia, *splenomegaly- AVOID CONTAC SPORTS* -palatal petechia -hepatitis, haemolytic anaemia, pharyngitis -PHARYNGITIS ( not in CMV) Symptoms last 2 weeks Ix EBV Rapid slide agglutination technique. detection of specific IgM to EBV viral capsid antigen. -monospot test - Epstein-Barr viral serology. NAAT Epstein-Barr nuclear antigencomplex (EBNA) LFTS FBC: ⬆ lymphocytes Rx EBV self-limiting supportive corticosteroids if thrombocytopaenia IV Ig in patients with IM-associated immune thrombocytopenia. avoid playing contact sports for 8 weeks after having glandular fever to reduce the risk of splenic rupture -a maculopapular, pruritic rash develops in around 99% of patients who take ampicillin/amoxicillin whilst they have infectious mononucleosis

WHAT IS A COMMON DDX FOR AKI

Dehydration - it is is characterised by a urea that is proportionally higher than the rise in creatinine - Na+ is usually high

Treatment for AACG

Digital pressure over pupil. Medications Drops (multiple) Oral Agents (Diamox) Hyperosmotic agents (IV mannitol) Placement of laser peripheral iridotomy is definitive. Surgery as last resort.

What is mydriasis?

Dilation of the pupil.

HORNERS 1B

Disorder of sympathetic pathway. Causes miosis (excessive pupillary constriction) + ptosis (eyelid droop) + anhidrosis (inability to sweat) AEx: Lung cancer pancoast tumour pressing on sympathetic chain, trauma, surgery , thyroid masses also T1 nerve damage Tx - • With apraclonidine a-1 agonist - dilates pupil measure at 0 and 60 mins - cocaine

Causes of lower GI bleed

Diverticulosis Angiodysplasia IBD Ischemic colitis Cancer Anticoagulation treatment haemmorhouds

Delayed Union

Does not occur until approximately 8 to 9 months after a fracture.

Drugs that cause jaundice

Drugs: paracetamol , Abx ( drug induced liver

What are Drusen?

Drusen are very small yellow or white spots (protein and fat) that appear in Bruch's membrane (one of the layers of the retina in the eye). A possible cause of drusen is that the eye is unable to eliminate some waste products from cells of the rods and cones.

Sebaceous Hyperplasia

Enlarged sebaceous glands yellowish umbiliticated papules on face

Epidermal Cyst

Epidermal lined fluid filled cavity Flesh colored, soft/ firm subcutaneous cyst containing yellow keratin typically has central pore opening

Tuberous Sclerosis Complex

Epiloa ( Epilepsy, low intellect, adenoma sebaceum) Ash Leaf , hypo-pigmented macules Adenoma sebaceum - face Shagreen patch - Periungual fibromas

What is epiphora?

Epiphora is an overflow of tears onto the face. A clinical sign or condition that constitutes insufficient tear film drainage from the eyes in that tears will drain down the face rather than through the nasolacrimal system

What are preauricular tags?

Epithelial mounds or pedunculated skin

Excoriation

Erosion due to scratching

Hand foot and mouth disease

Etiology: Coxsackie virus B. Clinical findings: 1. Incubation period 4-6 days 2. Prodrome of mild fever, sore throat, malaies, lymphandenopathy 3. Punctate, white oral lesions; hand and foot vesicles also butt and other places last 7-10 days C. Treatment: Supportive

Sebaceous gland

Except on palms and Soles - Everywhere

Ulcer

Focal Loss of epidermis and dermis

Dermatophytes

Fungi that cause infection of the hair, skin, and nails. by richophyton, Microsporum, and Epidermophyton genera.

What is choledocolithiasis? 1

Gallstones in the common bile duct

Differentiating gastric from duodenal ulcers on hx

Gastric ulcers are more painful after meals (stomach acidity increases) and duodenal ones improve with meals

Features of lower GI bleeding

Haematochezia (passage of fresh blood), malaena

Type III : Immune complex

IgA + IgG combine , SLE, post-streptococcal glomerulonephritis

Type 1 hypersensitivity: Anaphylactic/ immediate

IgE mediated binds to FC receptor on mast cells i.e anaphylaxis, atopy (asthma)

Type II hypersensitivity: Cell bound

IgG or IgM binds to antigens i.e ITP, goodpastures, rheumatic fever, pemphigus vulgaris, pernicious anaemia basically autoimune stuff

When there is a ruptured globe and pupil displacement, which direction will the pupil point?

In the direction of the hole.

How does Mannitol work as a diuretic?

In the proximal tubule, it osmotically draws water into the lumen

Tx for auricular hematoma:

Incise and drain and prevent reaccumulation - FUP in 24-48 hrs

Greenstick

Incomplete fx Perforates one cortex and splinters spongy bone

Neonatal Herpes

Infants born to infected mothers Neurologic and respiratory symptoms 50 % mortality Rate Higher incidence in women who acquire primary infection while pregnant

Hookworms/Roundworms 1A

Infection caused by Necator americanus and Ancylostoma duodenale common in developing countries Transmitted via oral ingestion Goes through liver, lungs then coughed up and swallowed -> remain in intestine feed on blood GI symptoms in early infection, Can cause severe IDA ( dypnoea, weakness, lassitude, tachy, oedema) ,If severe then dysentery-like syndrome Ix: stool sample to identify e eggs Rx: albendazole or mebendazole

Hesselbach's triangle

Inferior epigastric artery, Lateral border of the rectus abdominus, and Inguinal ligament

Burrow

Intraepidermal channel due to parasite

What does Kaposi's sarcoma in the eye look like?

Large, juicy sentinel vessel present. Looks like subconjunctival hemorrhage. Does not go away with time.

Cowden's Disease

Multiple Hamartoma Syndrome Skin: Facial, Verrucoid papules on hands, oral mucosal papules BREAST CA ( 25% mastectomy) Thyroid cancer

NOF #

NECK OF FEMUR: -young due to MVC -fall from height. elderly: twisting, fall from standing. - ss: acute hip pain , can't weight bear, short &externall rotatated leg, painful ROM RX- Idynamic hip screw or hemiarthroplasty if unfit. Extracapsular: dynamic hip screw

nodular BCC

NODULAR BCC Most common "telangiectactic papule/ulcer" - shiny pearly dome-shaped nodule with smooth surface blood vessels across surface central depression/ulceration if older tumour

What are hard drusen?

NOT Age-related Small yellow granular sub-retinal deposits NOT strongly assoc. with increased risk of AMD

Churg-Strauss syndrome

Necrotizing granulomatous inflammation with eosinophils involving multiple organs, especially lungs and heart - wheeze -nasal polyps -sob - pANCA

Gram negative cocci

Neisseria gonorrhoeae Neisseria meningitidis Moraxella catarrhalis

causes of meningitis in 3-6 months

Neisseria meningitidis Streptococcus pneumoniae Haemophilus influenzae

What is emmetropia?

Normal. Light targeted on retina.

Treatment of severe acute pancreatitis

Often have multi-organ failure - take to ICU or they may still be unwell at day 3-5 and have developed pancreatic necrosis for which you give ABs

Treatment of cholangitis

Often need ICU for stabilisation, IV ABs, emergent bile duct decompression via ERCP or open surgery.

Which cranial nerve is the cornea innervated by?

Ophthalmic division of CN V

What is orbital fat?

Orbital fat lies posterior to the orbital septum and anterior to the levator aponeurosis (upper lid) or the capsulopalpebral fascia (lower lid).

What is a diverticula disease 1A

Outpouching of the mucosa and submucosa that herniate through the colonic muscle laters in areas of high intraluminal pressure (typically sigmoid colon)

cholera diarrhea

Profuse, watery diarrhoea Severe dehydration resulting in weight loss Not common amongst travellers

Argyll Robertson Pupil

Pupils constrict to accommodation, but not to light. Seen in tertiary stage of neurosyphilis Ix VDRL

DVT Wells score and management

Score >2 DVT likely Ultrasound of leg within 4 hours ] score <2, D-dimer ultrasound of the leg

Muir Torre Syndrome

Sebaceous gland tumors Keratoacanthomas COlon Cancer!

Tendon tear

Strain

Gram (-) Negative Acne

Sudden onset of perinasal pustules in patients on long term antibiotic Carriage of E.coli, Proteus, Klebsiella, etc. Tx. Ampicillin, trimethoprim/sulfamethoxazole

Milia

Superficial keratin Cysts

What is the choroid?

The choroid is a bed of blood vessels that lie right under the retina. The choroid supplies nutrition to the outer one-third of the retina which includes the rod and cone photoreceptors.

What is the posterior chamber?

The fluid filled space between the iris and the lens.

Why does the pinhole correct refractive errors?

The pinhole eliminates peripheral light rays and allows central light rays through, which gives the person better vision.

Salter- Harris Fracture Classification - IV

Through Everything. The fracture is through the metaphysis, physis, and epiphysis

Treatment of diverticular bleeding

Transfuse and rehydrate as needed. If bleeding does not stop spontaneously can do colonscopy with haemostasis, angiography with embolisation or surgery

What kind of cancer can present anywhere along the urinary tract?

Transitional cell carcinoma

Signs/Symptoms of WET AMD

Usually Monocular Distortion in vision Changes may be acute and more severe in onset Metamorphopsia -Straight lines looking irregular or bent -Objects appearing a different color or shape in each eye Scotoma Visual field defects Frequently in CENTRAL vision

What are some causes of intra-renal acute renal failure?

Usually due to acute tubular necrosis or ischemia/toxins, or the nephritic/nephrotic syndromes

What is the most common place for a bulbar rupture?

Where the extraocular muscles penetrate into the eye wall.

In which genetic condition will you see Kayser-Fleischer rings under slit lamp examination?

Wilson's Disease (copper metabolism disorder leading to ring deposits of copper around the cornea).

Flea Bites

Wingless insects Carried by cats and dogs Methoprene - prevents flea larvae from maturing BUBONIC PLAGUE

What does 20/40 vision mean?

You can see at 20 feet what a normal person can see at 40 feet away.

Why does uremia cause CHF and edema?

You can't make urine, you get hypervolemic, so the vessels leak and the heart can't handle all the extra volume

What are signs of acute hypertensive retinopathy?

[Due to acute severe elevation in BP (malignant hypertension)] Disc edema, retinal edema, diffuse retinal hemorrhages, cotton wool spots

How do you test someone's vision who cannot see the big E?

[vision is worse than 20/200] 1) Count fingers 2) Hand motion 3) Light perception

UC vs Crohns: cancer risk

_high risk of colorectal cancerCrohns_ higher than normal, lower than UC

UC vs Crohns: depth of wall affected

_mucosa and submucosaCrohns_ transmural

UC vs Crohns: surgery

_total proctocolectomy can be curative for long-standing disease or toxic megacolon, also decreases cancer riskCrohns_ resection for perforation, stricture, fistula or abscess

osteophytes and pic

a bony outgrowth associated with the degeneration of cartilage at joints. common in OA AS

EISENMENGER SYNDOMRE

a congenital L to R shunt changes and becomes R to left due to pulmonary arterial HTN

Scurvy

a disease caused by lack of vitamin C -can present with lethargy, bleeding gums, easy bruising gingivitis, loose teeth poor wound healing bleeding from gums, haematuria, epistaxis general malaise - common in alcoholics and poor people , elderly- not eating properly

Radial Head Fracture

a fall on outstretched hand * - common # in young adults S/S: - present splinting in flexion - swelling and diffuse elbow pain over lateral elbow, dec ROM at elbow +/- mechanical block to forearm pronation and supination • pain on pronation/supination Dx: X-ray, look for posterior fat pad sign*(demonstrates blood in joint) Tx: -non-displaced or occult: sling 2-4 wks displaced : ORIF

AZATHIOPRINE

immunosupressant inibits purine synthesis used in autoiimne dz IB, RA, - thiopurine methyltransferase (TPMT) test may be needed to look for individuals prone to azathioprine toxicity SE: pancretitis, BM depression Interactions: - Allopurinol (both inhibitors of xanthine oxidase): causes bone marrow suppression

respiratory acidosis with metabolic compensation

increased HCO3 (base to compesate) normal or reduced pH

aetiology of acute bronchitis

influenza Aor B rhinovirus RSV Less common causes : Mycoplasma pneumoniae Bordetella pertussis Chlamydia pneumoniae. L

COPD vaccinations

influenza annual (all patients >50); reduces serious death and illness by 50% annual influenza vaccination one-off pneumococcal vaccination

What are the symptoms of high Na+ in the plasma?

irritability, delirium, coma dehydration cushings AKI

tympanic cavity

middle ear; houses the auditory ossicles; located within the temporal bone

-Streptococcus pneumoniae presentation aka pneumococcus

most common Increasing age, comorbidity (especially cardiovascular), acute onset, high fever, and pleuritic chest pain , productive with *sputum with a red/brown rusty colour* ssociated with high fever, rapid onset and herpes labialis

If kid has gingivitis think : (2)

mouth breather sleep apnea

HISTORY FOR LOSS OF VISION

see pic

Sick day advice for diabetes

•never stop insulin •monitor more frequently - Drink more fluids •maintain your hydration with sugar free drinks •Check for ketones •Know when & how to call for help

Rx for GI bleed

- ABCD - Large bore IV - Oxygen (15L/min non re-breathable) - transfusion -

Rx alcohol liver dz 1B

- Abstinence ( naltrexone or nalmefene opioid antagonists , disulfiram,) gamma-aminobutyric acid receptors (baclofen or acamprosate - supportive ( b-vitamins -steroids, enteral nutririon -transplant

Appendicitis 1B 1-7

- Acute inflammation of the vermiform appendix due to obstruction by faecoliths, stool, infection or lymphoid hyperplasia - The lumen distal to obstruction fills with mucous and becomes a closed-loop obstruction - Leads to distension and increased intraluminal pressure AEx - common in children S&S - Mid-abdominal pain which shifts to the RUQ within 1-2 hours - Constant pain, worse on movement or coughing - Associated anorexia, nausea and vomiting - Peritonism - rebound tenderness, guarding, absent bowel sounds, rigidity - Rovsing's sign - RLQ pain upon compression of LLQ - Psoas sign - pain on extension of right hip - Obturator sign - pain on internal rotation of a flexed right thigh - Dunphy sign - pain on coughing - Tenderness over McBurney's point (2/3 from umbilicus to ASIS) - Child may hold their knees in a flexed position - Fever Ix Urine dip pregnancy USS - 1st line AXR CT : enlargement, appendicolith, fat-stranding and peri-appendiceal inflammation. fat stranding, mural thickening, extraluminal fluid FBC U&Es Amylase Rx 1) Appendicectomy - laparoscopic or open 2) Supportive care - fluids and NBM 3) IV cefoxitin or tazobactam before surgery

What is Crohn's disease?

- Also called regional enteritis, inflammation and erosion of the ileum. - Affects any part of the GIT from the mouth to the anus - Bimodal distribution of peak incidence - 20-40 and 60-80 - Incurable -ileum, ileocolic region and the colon

Eczema

- An inflammatory eruption of the skin characterized by itching vesicles and scale. Dermatitis and Eczema may be used synonymously . Anti-histamine to treat itching

UC extraintestinal manifestations

- Arthritis - Aphthous ulcers - Pyoderma gangrenosum - Erythema nodosum - Spondylitis - Erythema gangrenosum - Anterior uveitis - Episcleritis - Digital clubbing

What is PBC?

- Autoimmune disorder characterised by destruction of intrahepatic bile ducts, inflammation and eventual cirrhosis and fibrosis - common in >40-60s FEMALES antimitochondrial antibody (AMA) or PBC-characteristic ANA often found , raised LFTs, -features: fatigue, xanthelasma, pruritus , jaundice. features of chronic liver diz in advance stages Ix ALP ⬆, GGT raised, ⬆ bilitubin , anti-mitochondrial antibody , ⬆ cholesterol rx: ursodeoxycholic acid, predisolone

associations of coeliac

- Autoimmune thyroid disease - T1DM - Vitiligo - Addison's disease - IgA deficiency - Down's, William's and Turner's syndromes - Autoimmune liver disease - dermatitis herptiformis -malt lymphoma

VITAMIN B-12 DEFICIENCY 1-6 1A

- B12 is absorbed in terminal ileum, it binds intrinsic factor secreted by gastric parietal cells -important for DNA synthesis and neurological functioning and synthesis of HB in RBCs -found in meat fish dairy AEx: 1. diet: veganism, vegetarian 2. gastric: mucosal atrophy due to gastritis, gastrectomy 3.. malabsorption: chrons, pancreatic insufficency, tapeworn, resection of ileum 4: autoimmune : destruction of parietal cells --> no seceretion of intrinsic factor 5. drugs: PPI, antacids, H2 antagonists, anticonvulsants Functions: important in functioning of nervous system a Features: glossitis, angular stomatitis, fatigue NErvous system features: polyneuropathy, degenration of spinal cord ( UMN signs, loss of vibration, loss of proprioception- lack of balanc) hyporeflexia, parasthesia, ataxia, dementia, hallucination -For pernicious anaemia - anti-IF, anti-parietal cell, raised gastrin -FBC - low Hb, high MCV, low HCT -Megaloblasts in the bone marrow -Low serum B12 -Schilling test -Raised bilirubin -Raised LDH -Blood film - oval macrocytes, hyper-segmented neutrophil polymorphs -Low reticulocytes -Raised methylmalonic acid and homocysteine -Oral cyanocobalamin or hydroxocobalamin IM - 1mg 3x week for 2 weeks then once every 3 weeks then once every 3 months for life -Folic acid - 1mg OD -Adjunctive transfusions in severe cases

Features of UC

- Bloody diarrhoea, rectal bleeding and mucus - Lower colicky abdominal pain - LLQ - Faecal urgency - Tenesmus - Systemic symptoms are far less prominent that in Crohn's

Features of metastasis of lung cancer

- Bonepain and fracture - Hemiparesis,seizures and focal neurological signs - Jaundiceand hepatosplenomegaly - Nodules - Exudativepleural effusions

Diagnosis of diverticular disease

- CT scan: outpouchings - Colonoscopy : definitive diagnosi - bloods: FBC -AXR -Cytoscopy : tumours

lupus nephritis (not on matrix)

- Can cause any histological type of glomerularpathology - Can be nephrotic or nephritic - Due to anti-dsDNA antibodies binding glomerulartargets - Low C3 and C4 treated with steroids

Low compliance with thyroixine result

- High TSH--> means body was deficient in last few days/weeks - Free T4- normal

Non-alcoholic fatty liver disease 1B

- NAFLD describes steatosis ( abnormal retention of fat), steatohepatitis ( inflammation of the liver with concurrent fat accumulation in liver) ,and eventual cirrhosis in the absence of excessive alcohol consumption - can also result in cirrhosis, portal HTN, -imbalance in catabolism and synthesis of fat --> steatosis --> oxidative stress ( free radicals) --> steatohepatitis --> fibrosis -associated with metabolic syndrome ( CHD, hyperlipidaemia, HTN, DM, obesity, insulin resistance Features: - Asymptomatic - Mild fatigue, malaise and RUQ discomfort - RUQ pain - Late stage - chronic liver disease ( duptytren contracture, jandice, portal HTN, clubbing, pal,ar erythema, spider navaie, caput mudusa, hepatosplenomegaly Ix Ultrasound- increased echogenicity of the liver CT MRI LFTs (ALT hisgher than AST) -bilirubin (elevated) -PT, NR, ANA, antismooth muscle antibody Iron studies -Liver elastography (fibroscan) biopsy and histology - stenosis, balooning, mallory bodies, peri-sinusodal fibrosis Rx - diet & exercise - weight loss - gastric bypass -lipid lowering drugs -Liver transplant

RENA =L VEIN THROMBOSIS

- Nephrotic syndrome is associated with a hypercoagulable state due to loss of antithrombin III via the kidneys - nephrotic picture

SPINAL INJURY 1A

- Neurogenic shock: hypotension following SCI due to inteuption to sympathetics, loss of muscle tone due to skeletal paralysis Spinal shock: transient loss of all neurologic function below the level of the spinal cord injury, causing flaccid paralysis and areflexia for variable periods whiplash: : traumatic injury to the soft tissue structures in the region of the cervical spine due to hyperflexion, hyperextension, or rotational injury to the neck Rx: ABCDE. immobilisation, foley catheter, temp regulation. motor and sensory assess,ents: pinprick, light touch, proprioception , XRAY< MRI, CT

treatment for IPF

- O2 • N-acetylcysteine (anti-oxidant) • pirfenidone and nintedanib may slow disease progression • lung transplantation for advanced disease

Post-streptococcal glomerulonephritis/Post-infectious glomerulonephritis

- Occurs 1-12 weeks after GAS infection - Streptococcal antigens are deposited on the glomerulus leading to immune complex formation and deposition which precipitates nephritis -Biopsy with immunofluorescence revealsinflammation of the glomerulus and IgG and C3 deposition - Serology is positive for low C3 and raised ASOT,anti-DNAse B -S&S: haematuria, sometimes proteinuria Treatment - Supportive therapy - Steroids

Complications of peptic ulcers

- Perforation - mostly gastroduodenal artery - haemorrhage: malaena/haematemesis -IDA - obstruction - cancer if H. pylori

complications of cholelithiasis

- Post-ERCP problems - Bouveret's syndrome - erosion into duodenum causing fistulation and bowel obstruction - Gallstone ileus - pain, distension, vomiting - Cholecystitis - Cholangitis - Pancreatitis - Mirizzi's syndrome - impaction in the cystic duct/gallbladder neck leading to obstructive jaundice - Porcelain gallbladder - Strictures - Carcinoma

Aex of oesophageal varices

- Pre-hepatic: *Portal & Splenic vein occlusion *Congenital stenosis of the portal vein *Extrinsic compression of the portal vein (tumour) Hepatic: Pre-sinusoidal: Sarcoidosis, Schistosomiasis Congenital hepatic fibrosis, Primary biliary cirrhosis, Idiopathic portal HTN Sinusoidal: Cirrhosis (all aetiologies) Alcoholic hepatitis Post-sinusoidal: Veno-occlusive disease Budd-Chiari syndrome Post-hepatic Constrictive pericarditis Restrictive cardiomyopathy Valvular heart disease Web lesion of inferior vena cava. Increased flow Portal vein: Myeloproliferative disorders. Hepatic artery: Hepatic artery-portal vein fistula.

features of IPF

- Progressive,worsening dyspnoea - Dry,non-productive cough - Fineend-inspiratory crackles on auscultation - Reducedchest expansion - Digitalclubbing

Dislocation and subluxation Treatment

- Reduction and immobilization for 2 to 6 weeks - Exercises to keep normal ROM

Rx of pulmonary oedema due to AKI

- Sit patient up and give high-flow oxygen via afacemask - Diamorphine 2.5mg IV with 50mg IV Cyclizine - Furosemide 80mg IV - IV or GTN nitrates - CPAP - Haemodialysis

AEx crohns dz

- Smoking (worsens disease activity) - Positive family history - Diet high in refined sugar - Combined oral contraceptive use - NSAID use - Ashkenazi Jews

Management of diabetic retinopathy

- Strict glycaemic control - Fundoscopy screening - Control blood pressure - target of 130/80 - For neovascularisation à panretinalphotocoagulation, ranibizumab (anti-VEGF) or vitrectomy

Jellyfish sting

- Sx: intense, stinging pain, itching, rash, and raised welts., nausea, vomiting, diarrhea, lymph node swelling, abdominal pain, numbness/tingling, and muscle spasms. Sever rxn: difficulty breathing, coma, and death. No death has ever been reported from a UK jelly fish sting. -liberally rinse with salt / seawater, for at least 30 seconds. -scrape to remove stinger(s). -Heat as tolerated (not to exceed 110 degrees)

SYSTEMIC SCLEROSIS/ SCLERODERMA 2B

- a multi-system, autoimmune disease, characterised by functional and structural abnormalities of small blood vessels, fibrosis of skin and internal organs ( fribroblast dysfunction), and production of auto-antibodies. - four times more common in females, 50-60. -anti-centromere antibodies 3 patterns of disease: 1. Limited cutaneous systemic sclerosis : skin, neck, face, hands, CREST 2. Diffuse cutaneous systemic sclerosis : widespread skin dz , early visceral- renal and pulmonary fibrosis 3. Scleroderma: AFFECTS face and distal limbs predominately associated with CREST syndrome: - Calcinosis : deposition of Ca in skin - Raynaud's phenomenon - oEsophageal dysmotility - Sclerodactyly - Telangiectasia: spider veins-> widened venules Ix for scleroderma - antobodies: anti-scl 70, anti-topoisomerase, RNA polymeras --> ANA 70% , RF (30%), anti-centromere -FB C -ESR -CRP - CXR, ECG, PFTs

What is Optical Coherence Tomography (OCT)?

- a noninvasive technique that produces a cross-sectional image of the posterior retina in vivo. - Laser that measures height of retina across macula. Looking for bulges which may related to Drusen or rebleeds. - Especially useful in evaluating wet AMD.

HAEMOLYTIC URAEMIC SYNDROME

- a triad of microangiopathic haemolytic anaemia (MAHA), renal failure and thrombocytopenia - due to *E.COLI 0157:H7 produced by SHIGELLA TOXIN* - ss: abdo pain, bloody diarrhoea few days after food poisoning , renal failure . kids <6 Aex: Escherichia coli strain O157:H7 Ix schisstocytes thrombocytopaenia proteinuria, haematuria stool culture

Syringomyelia

- abnormal longitudinal cavities in the spinal cord cause paresthesias and muscle weakness - can cause incontinence - loss of pain and temperature sensation - more notes in neurology

Rheumatoid arthritis 1B

- chronic autoimmune inflammatory condition affecting PIPs, MCP jpints and small joints of the hands and feet -RARELY , can affect knees, hips, DIPs - common in older people >50 -Associated with HLADR4 and HLADR1 FEATURES : RHEUMATISM Rheumatoid factor (RF) +ve in 70% HLA-DR1 and DR-4/ haemoptysis ESR + CRP ⬆/Extra-articular features (PULMONARY fibrosis, subcutaneous nodules, serositis) Ulnar deviation of fingers Morning stiffness better with exercise/MCP+PIP joint swelling Ankylosis/Atlanto-axial joint subluxation/ Autoimmune/ANA +ve in 30%/ Anti-CCP T-cells (CD4)/TNF Osteopenia Inflammatory synovial tissue/ Idiopathic/ IL-1 Deformities (swan-neck, boutonniere) Ix X-rays : Loss of joint space, Erosions Soft tissue Swelling, Soft bones (osteopenia) RF anti-CCP CXR ESR and CRP Rx MTX sulfalazine rituximab adalimumab Other conditions associated with a positive RF include: Sjogren's syndrome (around 100%) Felty's syndrome (around 100%) infective endocarditis (= 50%) SLE (= 20-30%) systemic sclerosis (= 30%) general population (= 5%) rarely: TB, HBV, EBV, leprosy DAS score - Assesses severity of disease - Assessment of 28 joints for tenderness and swelling - number of swollen joints, number of tender joints, ESR/CRP, patient global assessment of health - 1.2 is an improvement - 5.2 is an indication for biologic therapy

Tuberculosis Arthritis

- chronic, inflammatory, slowly destructive arthritis with few if any systemic signs - only 50% of CXR (+) - synovial bx are diagnostic; joint cultures may or may not be (+) for organism - tx= Rifampin Features: joint pains, night sweats, fever, erythema noodsum

Biceps tendonitis Dx

- clinical - x-ray to r/o other injury

Von Willebrand Disease 1B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

- common autosomal dominant bleeding dz due to reduced vWF -vWF ligand for platelet adhesion and carrier protein of FVIII --> reduced function --> increased bleeding - 3 types , type 1 autosomal dominant &0% most common ( reduction in vWF) -type 2 abnormal form of VWF type 3- total lack of vWF (autosomal recessive) -features : mucocutaneous bleeding, easy bruising, nose bleeds, prolonged bleeding from cuts, dental extractions, trauma, surgery and menorrhagia. - Haemarthroses do not typically occur Ix prolonged bleeding time or normal ( no longr used routinely) APTT may be prolonged/ mildly factor VIII levels may be moderately reduced or normal (vWF is the carrier protein for FVIII protecting it from proteolysis there is a 2° defi ciency of FVIII associated with vWFdeficiency, but it is a low vWF level that is primarily responsible for bleeding in most patients) defective platelet aggregation with ristocetin Platelet count: normal Rx - Tranexamic acid -desmopressin (DDAVP): raises levels of vWF by inducing release of vWF from Weibel-Palade bodies in endothelial cells -factor VIII concentrate

CERUMEN IMPACTION 1A

- common cause of hearing loss in >50 and <5 -M>F - common in Downs - buildup of earwax in the ear canal -Features: hearing loss, tinnitus, dizziness, aural fulness Ix: otoscope, speculum -Rx: olive oil, mineral oil, irrigation with syringe , manual removal by ENT specialist -Prevention: dont use cotton buds

Dog bites 1A

- common in kids <5 - commonly result in crush injuries, but may also cause scratches, deep cuts, puncture wounds, and tearing of the skin and underlying flesh. -amoxicillin/clavulante. common infections: Pasteurella spp. (50%) Staphylococcus aureus (20%) Streptococcus pyogenes Capnocytophaga canimorsus Various anaerobes. rx prophylactic abx : 1. Amoxicillin clavulanate 2. erythromycin, and clindamycin. hospital if fever, swollen lymph nodes, cellulitis

URETERIC TRAUMA 2B

- common in surgical procedures hysterectomies, ureteoscopy,, AAA repair - injury: gunshot wounds, stab, blunt trauma

Elbow joint

- flexion and extrenion of forearm -pronation and supination

Dislocation and subluxation are associated generally with.............

- fractures --congenital/adquire disorders --- muscle imbalance ---rheumatoid arthritis --other joint instability

features of mallory -eWiss tear

- hematemesis ± melena, classically following an episode of retching without blood • can lead to fatal hematemesis

Radius and ulnar shaft #

- high energy direct or indirect (MVA, fall from height, sports) trauma - fractures usually accompanied by displacement due to high force - ss: deformity, pain, swelling, loss of function in hand or forearm Ix: Xray, CT Rx: ORIF with plates complications: soft tissue contracture resulting in limited forearm rotation - surgical release of tissue may be warranted

Humeral shaft fracture 1B

- high energy in young, -low eegry : FOOSH, twisting, metastases (elderly) - s/s: pain, swelling, weakness ± shortening, motion/crepitus at fracture site. NErve test: drop twist, sensory mpairement dorsum of hand Ox: Xray complications: radial nerve palsy

Distal Femur Fracture

- high force - three types: extra articular, partial articular, complete articula - ss: extree pain, knee effusion, short, externally rotated , NV deficits Complications *femoral artery tear* - *popliteal injury* • nerve injury • extensive soft tissue injury • angulation deformities*

Rx ADDISONIAN CRISIS 1A

- hydrocortisone 100 mg im or iv -1 litre normal saline infused over 30-60 mins or with dextrose if hypoglycaemic -HYPOGLYCAEMIA -continue hydrocortisone 6 hourly until the patient is stable. No -fludrocortisone is required because high cortisol exerts weak mineralocorticoid action oral replacement may begin after 24 hours and be reduced to maintenance over 3-4 days

Bile acid malabsorption 2B

- inability to absorb bile acids -> extrabile acids in intestine --> diarrhoea - causes foul-smelling, bulky floating stools. -Associated with weight loss, abdo pain, flatus and bloating. -common in chrons, coeliac, small intetsine dz, pancreatic dz and SIBO -Caused by ileal resection or disease Limited resection (<100cm): - Malabsorbed bile acids enter colon and stimulate secretion - No steatorrhea (fat <24g/day) Extensive resection (>100cm): - Bile acids severely malabsorbed with impaired enterohepatic circulation - Inadequate liver synthesis with impaired micelles, causing fat malabsorption and secretion in colon - Manage with a low fat diet and medium chain triglycerides

MICROCYTIC ANAEMIA

- iron-deficiency anaemia - thalassaemia - congenital sideroblastic anaemia - anaemia of chronic disease (more commonly a normocytic, normochromic picture) - lead poisoning

Pes Planus (Flatfoot)) 1A

- loss of arch - > help absorb shock -Flat appearance of infants' feet normal and results from thick fat pads in soles of feet -Flat feet in adolescents and adults results from "fallen arches" usually medial parts of longitudinal arches -can be normal development in children byt developed by age 10 -can be caused by obesity in kids -can be due to neurological probs i.e cerebral palsy or polio -can be due to bony abnormalities: tarsal coalition (fusion of tarsal bones), accessory navicular bone (a small bone which sits in the posterior tibial tendon, weakening support to the arch). -ehlers-danlos syndrome, marfans SS: foot pain in heel or arch, ankle swelling, tight heel cords Ix: x-ray, CT, MRI Rx: arch support, orthotics, stretching exercise, rest, NSAIDs, weight loss, surgery

Monocytopaenia

- low monocytes - monocytes turn into macrophages - increases risk of infection -AEx: chemoinduced, Haematopoetic cell mutation GATA2 -leukaemia and lymphoma -corticosteroids

food bolus obstruction 1B 1. definition 2. Epidemiology and risk factors 3. pathophysiology 4. Symptoms 5. signs 6. investigations 7. Management

- medical emergency - common in children, psychiatric px , underlying oesophageal disorder ( eosinophilic oesophagitis, tatziki rings, strictures, webs, cancer) - obstruction of food bolus - can be caused by eosinophilic oesophagitis - common foods include meat -Px present with drooling, regurgitation, dysphagia -complications include perfoation of oesophagus, aspiration pneumonia Ix- endoscopy , CXR Rx- surgery if drooling , nasogastric tube observation if stable

PSEUDOGOUT 1B 1-7

- microcrystal synovitis with Calcium pyrophosphate dihydrate deposition in synovium of large joints - >60 -commonly affects: Knees, wrists, shoulders, ankles, elbows,. -associated w/ arthritis - mimics osteoarthritis Features: acute pain, stiffness, warmth and swelling of affected joint bony deformities Ix ▪CRP, ESR, Urate, Ca+ ▪Joint apirate: exclude septic arthritis ▪Arthrocentesis: positively bifringent rhomboid crystals X-ray: cartilage calcification AKA chondrocalcinosis Rx NSAIDS steroids oral or intra articular

What is hypopyon?

- milky white fluid level in the inferior part of the anterior chamber. - due to the sedimentation of white blood cells which can be secondary to either an inflammatory or infective process. - always represents a serious sight threatening condition and requires immediate referral for specialist treatment.

Hip disclocation 1B

- more common post THA anterior -blow to knee (anterior) --limb fixed in external toration and abducted position posterior - force to knee with hip flexed --> dashborad in MVA - SHORTENED AND INTERNALLY ROTATED -can cause sciatic nerve injury associated with acetabular # Complications o post-traumatic arthritis due to articular cartilage injury or intra-articular loose body o femoral head injury including osteonecrosis + fracture: 100% if > 12 hours before reduction o sciatic nerve palsy in 25% (10% permanent) o fracture of femoral shaft or neck o knee injury (PCL tear with dashboard injury)

Scaphoid Fracture 1A

- most common carpal fracture -common in young men not children -associated with colles' fracture -Fall on outstretched hand -s/s: pain w/ resisted pronation, tenderness in snuffbox, pain with long axis compression into scaphoid -Ix: xray views maybe negative , MRI confirm diagnosis , CT scan -Rx: non-displaced- thumb spica cast 6-20 wks , displaceed ORIF if suspect- immobilize and repeat x-ray in 1 wk or r/o with MRI or bone scan High non-union rate with scaphoid waist and proximal fractures** COmplications: most common: non-union/mal-union (use bone graft from iliac crest or distal radius with fixation to heal) • AVN of the proximal fragment • delayed union (recommend surgical fixation) • scaphoid nonunion advanced collapse (SNAC) - chronic nonunion leading to advanced collapse and arthritis of wrist

HEREDITARY SPHEROCYTOSIS

- most common hereditary (dominant) haemolytic anaemia in people of northern European descent - autosomal dominant defect of red blood cell cytoskeleton - the normal biconcave disc shape is replaced by a sphere-shaped red blood cell - red blood cell survival reduced as destroyed by the spleen - extravascular haemolysis Blood film: spherocytes (round, lack of central pallor) features failure to thrive jaundice, gallstones splenomegaly aplastic crisis precipitated by parvovirus infection degree of haemolysis variable MCHC elevated Ix cryohaemolysis test and EMA binding

Subtypes of gastritis

- non-eruptive gastritis: mainly caused by H.pylori -Eruptive gastritis --> Alcohol, Aspirin/NSAID misuse and bile reflux due to previous gastric surgery or cholecystectomy -Stress Gastritis: due to ulceration due to stress -autoimmune gastritis- auto anti-bodies to parietal cellsand intrinsic factor resulting in inflammatory infiltration and atrophy of the corpus mucosa -- phlegmonous gastritis (gangrene of the stomach) where severe abdominal pain accompanied by nausea and vomiting of potentially purulent gastric contents can be the presenting symptoms. Fever, chills, and hiccups also may be present. -extremely uncommon -ICU admission

Human bite 1A

- penetration of skin with human teeth - occurs through violence , rough play, daycare, aggressive sexual play/assault, -high rate of infection ss: tender to touch, semi-circular or oval red ptach +/- bruising signs of infection : fever, redness, swelling, tender,, purulent dx complications: infections with Streptococci Staphylococcus aureus Eikenella Fusobacterium Peptostreptococcus Prevotella Porphyromonas spp. Rx -sterilise wound - pressure to stop bleeding - swabs -prophylactic Abx i.e amoxicillin-clavulanate, metronidazole, doxycycline -tetanus IG

Verrucae (plantar wartwart) 1A

- plantar warts caused by HPV 6&11 - common in children and adolescents -can occur on condyloma b. Can be flat topped or filiform (finger projections) c. "seed warts" black thrombosed capillaries within wart b. Usually painful and multiple (mosaic warts) d. Treatment with spontaneous resolution, salicylic acid (duofilm),cryosurgery,electrocautery, cantharidin (blister beetle) e. When involving the nail (periungual) may be very difficult to treat Rx: Treatment more difficult: spontaneous resolution, Retin A,cryosurgery, cantharidin (blister beetle), electrocautery, efudex (5 fluroruracil), mmunotherapy (DNCB, Interferon), bleomycin (chemotherapeutic agent), laser Use Retin A - help exfoliate and stim immune system

TUMOUR LYSIS SYNDROME & PROPHYLAXIS NOM

- potentially deadly condition related to the treatment of high grade lymphomas and leukaemias - can occur in the absence of chemotherapy but is usually triggered by the introduction of combination chemotherapy - can occur with steroid treatment alone - high potassium - high phosphate - low calcium -⬆ serum creatinine Suspected in any patient with AKI in the presence of a high phosphate and high uric acid level Prophylaxis: IV allopurinol or IV rasburicase immediately prior to and during first days of chemotherapy - Rasburicase is a recombinant version of urate oxidase, an enzyme that metabolizes uric acid to allantoin (much more water soluble than uric acid and is therefore more easily excreted by the kidneys) - Low risk groups: oral allopurinol

Biceps tendonitis S/S

- presents as anterior shoulder pain - bicipital groove tenderness - pain with resisted supination of forearm

EXAMINATIONS TO CONSIDER IN PAINFUL EYE

- slit lamp -fluroscein staining -fundoscopy - culture- ulcers, keratitis

Patella Tendon Rupture

- sudden forceful contraction of quadriceps during an attempt to stop -Extreme pain with an immediate drop in pain Significant swelling Window shade effect Complete loss of knee extension Previous history of chronic tendinitis -audible pop effusion IX: straight leg test cant complete -> fail

Melasma 1B

- symmetrical Brownish pigmentation of the face during pregnancy; also called chloasma and "mask of pregnancy" - can also occur in men 20-40s - common in brown-skinned people -aex: sunexposure , pregnancy, hormone treatment distributions: Centrofacial pattern: forehead, cheeks, nose and upper lips Malar pattern: cheeks and nose Lateral cheek pattern Mandibular pattern: jawline Reddened or inflamed forms of melasma (also called erythrosis pigmentosa faciei) Poikiloderma of Civatte: reddened, photoaging changes seen on the sides of the neck, mostly affecting patients older than 50 years Brachial type of melasma affecting shoulders and upper arms (also called acquired brachial cutaneous dyschromatosis).

PAPILLARY THYROID CANCER 1B

- the most common type of thryoid cancer. 80-90% of thyroid cancers. -more common in young females 30-40. mets to cervical nodes and lungs - good prognosis -diagnosed by fine-needle aspiration by characteristic cell morphology showing large cells with nuceli contained finely dispersed chromatin with a ground-glass appreance (Oprphan Annie eye) They also may have psammoma bodies. - RX: total thyroidectomy followed by radioiodine (I-131) to kill residual cells yearly thyroglobulin levels to detect early recurrent disease

Venous leg ulcers 1B

- ulcer is abnormal break in the skin or mucous membrane - venous leg ulcer is ulceration of lower leg from midcalf -due to calf muscle pump dysfunction --> venous insufficiency -RF: prior DVT, cellulitis, varicose veins, immonility, klinefelter syndrome -fatures: shallow ulcer with irregular border, granulating base. swollen lower legs that feel more comfortable when elevated. chronic lymphoedema, thrombosis, blue-red patch prior to ulceration . pain at the end of the day Ix: ABPI, swabs Rx: compression dressing, wet dressing

Scoliosis 1B

-*lateral curvature* of spine with *vertebral rotation* -common in 10-16 -more frequent and severe in women -can co-occur with kyphosis aex: idiopathic, congenital, UMN or LMN lesion, myopathy ss: back pain, curve where spine is affected, asymmetrical shoulder height -adams test : rib hump when bending over prominent scapulae, creased flank, asymmetric pelvi associated pes cavus or leg atrophy# Ix: spine xray Rx: bracing, surgery - spinal fusion

Investigations for pneumonia

-- CXR: infiltrative picture, consolidation esp. in lower lobes, pleural effusion in some cases, lyphoadenopathy -USS: less radiation, diagnostic, consolidation -Bloods( FBC, U&Es, LFTs, CRP): elevated CRP, leukocytosis, elevated neutrophils, other stuff normal. deranged LFTs in severe infection - Blood culture: causative organism --> abx -sputum culture: causative organism -ABG: reduced Oxygen - test for respiratory viruses: pcrs,

Presentation and diagnosis of lactose intolerance

-- Post-viral gastroenteritis after rotavirus infection (lasts for 4-6 weeks) - leads to loss of lactase from brush border billi - Congenital lactase deficiency -Abdo pain, bloating, flatulence, cramping and watery diarrhoea following lactose ingestion. -Hydrogen breath test show increased hydrogen following ingestion of lactose

DDX for pneumonia

--Acute bronchitis: self-limiting URTI, cough >2 weeks caused by inflammation of bronchial airways - Congestive heart failure: oedema -COPD exacerbation: fever, SOB, -Asthma exacerbation: worsening SOB, wheeze and cough, tight chest -Bronchiectasis exacerbation- permanent dilation of bronchi due to the destruction of the elastic and muscular components of the bronchial wall. associated w/ reccurent pulmonary infections, including a chronic daily productive cough with mucopurulent sputum. cough, sputum, haemoptysis -Tuberculosis: infection of lungs with M. tuberculosis, can affect many other organs. notifiable disease. -Lung cancer or lung metastases -Empyema: pus in pleural space, usually develops following pneumonia

Sphincter of Oddi dysfunction 2B

--Failure of the sphincter to relax/open, most _SOO joins bile duct and pancreatic duct -results in backup of digestive juice --> severe abdo pain -Presents as episodic RUQ abdominal pain with mildly elevate aminotransferase and alkaline phosphatase, N&V, fever, chills, diarrhoea triggered by opioid ingestion can cause pancreatitis Ix: oddi manometry , LFTs, U&Es, USS bile duct, liver, pancreas, MRCP, ERCP Rx: analgesia , sphincterotomy. ( cut the muscles)

High median nerve/anterior interosseus nerve entrapment `

-Anterior interosseous nerve innervates FPL, FDP to index and middle fingers, and pronator quadratus - has no cutaneous innervation -In isolation, AIN palsy causes paralysis of IPJ flexion of the thumb and DIPJ flexion of the index and middle fingers (positive O-sign)- NOT loss of flexion of the fingers or sensory deficit -Where the nerve lesion is above the take off of the AIN (i.e. In upper arm) a full median nerve palsy is evident. - only FCU and FDP to little and ring finger function -Special test O-Sign - opposition of the tips of the thumb and index finger only with IP and DIPJs straight

Anti-HBc

-Antibody to HBcAg; -IgM = acute/recent infection; -IgG = prior exposure or chronic infection. -IgM anti-HBc may be the sole positive marker of infection during window period.

Describe femoral hernia 1A

-Hernia Below the inguinal ligament through the femoral canal, below and lateral to the pubic tubercle. -Caused by increased intra-abdominal pressure, weakened pelvic floor - F>M. - more common in females, usually irriducible and strangulates easily due to rigidity of canal borders -occurs in middle aged- old ladies 80s Presentation: -presents as mass in upper medial thigh , no bowel movemeny, vomitting, swelling in groin lateral to pubic tubercle, pian/pressure at hernia site

intermediate insulins

-InsulinGlargine Lantus 2-4 hrs, peakless, 20-24 hrs -Insulin Detemir Levemir -Insulin Degludec 30-90 mins, peakless >42 hrs duration

What are some clinical signs of Proliferative Diabetic Retinopathy (PDR)?

-Neovascularization of the Disc -Neovascularization of Elsewhere -Vitreous/Preretinal Hemorrhage (red hazy retina) -Tractional Retinal Detachment

HAP is most commonly caused by

-Staph aureus

What are signs and symptoms of retinopathy?

-Vitreous hemorrhage -Floaters, or small objects that drift through the field of vision -Decreased visual acuity -"Curtain falling" over eyes

septic arthritis

-inflammation of the joint caused by infection - common after joint surgery, DM, hip/knee prsthesis, Immudofe. - Aex: S.aureus, esp. MRSA - ss: single swolllen joint with pain on movement, fever rigors, unwillingness to move in kids signs: swollen, warm , tender, effusion Ix: FBC, cultures, synovial fluid examination (culture) , synovial tissue culture, PCR, USS< CT, MRI. Rx: Abx: flucox, meticillin,

base excess

-marker of metabolic acidosis or alkalosis -high BE metabolic alkalosis/ compesated resp acidosis -Low BE: metabolic acidosis/ compesated resp alkalosis

Hepatitis A

-most common cause of Hepatitis - RNA -IgM anti-HAV - faecal-oral transmission -not chronic, not linked to liver cancer s/sx: asymptomatic, anorexia, malaise, and jaundice Rx: supportive FSelf-limiting hepatitis, may lead to acute liver failure. Most common cause of acute viral hepatitis.

CONDUCTIVE HEARING LOSS 1B

-occurs when sound waves are prevented from passing from the air to the fluid-filled inner ear ( ffrom the external canal, middle ear, or ossicles) - can be congenital or acquired Congenital causes 1. ossicular abnormalities 2. pinna abnormality (microtia, anotia) 3. external auditory canal abnormality ( i.e atresia) 4. Hypoxia and jaunice (#1) Acquires 1. Cerumen impaction 2. otitis external 3. foreign bodies 4. AOM w/ effusion (glue ear ) 5. chronic supurrative OM 6. osteosclerosis : abnormal bone arpund stapes, F>M, 7. ossicular disruption (trauma, itragenic) 8. TM perf 9. tumours

Slipped Capital Femoral Epiphysis 1B

-occurs when the head of the femur becomes displaced due to a separation at the growth plate -most common adolescent hip disorder, peak incidence at pubertal growth spurt - *risk factors*: male, obese (#1 factor), hypothyroid (risk of bilateral involvement) -Aex: genetic, sex hormone secretion that stabilised physis not releases, overweight, trauma SS: severe acute hip pain with limp, chronic: geoin pain and ant. thigh pain -positive trendelenberg sign - restricted *internal rotation*, abduction, flexion - Whitman's sign: obligatory external rotation during passive flexion of hip Ix: x-ray : posterior and medial slip of epiphysis, disruption Klein line Rx: ORIF if severe, stabilisation Complications • AVN (roughly half of unstable hips), chondrolysis (loss of articular cartilage, resulting in narrowing of joint space), pin penetration, premature OA, loss of ROM

What are the main causes of retinopathy?

1) Diabetes 2) HTN 3) UV damage 4) Sickle-Cell Anemia

Sycosis Barbae

1. Deep bacterial (and occasionally fugal) folliculitis in male beards 2. Treatment with oral antibiotics, after bacterial and fungal culture done

Osteomyelitis def and features 1A

1. Infection of bone most commonly caused by S.aureus often due to open fractures, or haematogenous spreads. -in adults usually affects vertebra and in kids, femur, tibia, humerus 2. presents with localised bone pain, tenderness , swelling and erythema, low grade fever

what Frax score warrants dexa scan

10%

C. diff treatment

1st Metro recurrent: Vancomycin

Neuropathic pain Rx

1st line: Duloxetine ( SNRI ) OR gabapentin OR amitriptyline - tramadol as rescue therapy -amitriptyline not good in BPHP or other conditions risking retention as it causes urinary retention

life threatening asthma

33 92 chest · 33: PEFR below 33% predicted. · 92: Pulse oximetry below 92% · C: Cyanosis · H: Hypotension · E: Exhaustion · S: Silent chest (on auscultation) · T: Tachycardia (not always included under "life-threatening")

COPD OXYGEN TARGET

88-92%

over how long is a unit of blood transfused if not urgent

90 mins - 120 mins

Stages of diabetic retinopathy

:- *Non-proliferative/background*- microaneurysms, hard exudates (if around macula then maculopathy) - *Pre-proliferative*- cotton wool spots, dot and blot haemorrhages - *Proliferative*- neovascularisation at the disc or elsewhere - *Other changes* - macular oedema, cataract, glaucoma, ocular nerve palsies,rubeosis iridis (new vessels on the iris causing glaucoma)

Patterns of diabetic neuropathy

:Distal symmetrical sensory polyneuropathy -Glove and stocking distribution of sensory loss (vibration, pain, temperature) -Loss of reflexes -Paraesthesia -Dull pain -Weakness and muscle atrophy Proximal asymmetrical motor neuropathy -Progressive weakness and proximal muscle wasting -Anterior pain -Hyperesthesia - Somatic mono-neuropathy - Autonomic neuropathy § CNS - postural hypotension, tachycardia, fixed heart rate § GIT - dysphagia, gastroparesis ( erratic BMs, bloating) , diarrhoea, constipation GUM - infections, incontinence

When should RBC transfusion be considered

<70g/dL in normal people ( NO ACS) <80g/DL in people with ACS

what is sever hypoxaemia

<8kPa OA

T scores on DEXA scan

> -1.0 = normal -1.0 to -2.5 = osteopaenia < -2.5 = osteoporosis

Modified Glasgow Scale

> severe

What is orthotropia?

A condition of the eye in which there is no deviation of the visual axis with respect to a given meridian of the eye [normal]

Campylobacter gastro

A flu-like prodrome is usually followed by crampy abdominal pains, fever and diarrhoea which may be bloody Complications include Guillain-Barre syndrome

what is Acute osteomyelitis and chronic osteomyelitis 1A

Acute inflammation of the bone and bone marrow which leads to destruction of bone Most commonly the result of a periapical abscess May follow fracture of a bone May result from a bacteremia -can occlude local blood vessels resulting in bone necrosis

causes of Hyponatremia

Adding Sid's Hair Dye Creates Seriously Low Volume Adding Addison's SIADH HYPOTHYROID , hyperparathyroid (2nd) , DIURETICS ( THIAZIDES) Carbamazepine SSRIs - Citalopram Low volume: vom, diarrrhoea, sweating, rectum adenoma

Dermatosis Papulosa Nigra

African American seborrheic Keratosis MORGAN FREEMAN

Erythema Infectiosum (Fifth Disease) 1A

Aka 5th disease childhood disease caused by Parvovirus B19, DNA virus - *COMMON CAUSE OF APLASTIC CRISIS in sickle cell disease* -Virus suppresses erythropoesis 3/4: -low grade fever -slapped cheek appearance rash with a lacy eruption on the torso and extremities -arthropathy/arthralgia , purpuric cutaneous eruption. Complications: suppresses erythropoiesis transiently thus anaemia, aplastic crisis, hydrop foetalis, fetal demise, viraemia in immunocompromised Ix: Clinical , PCR Rx: supportive care, Iv Ig in immunocompromised to stop viraemia and aplastic anaemia

What could itchy eyes indicate?

Allergic conjunctivitis VIRAL conjuctivitis blepharitis

What could mucoid discharge indicate?

Allergic conjunctivitis, chlamydial infection

What is an ophthalmologist?

An ophthalmologist is a MD or DO who specializes in eye and vision care. They are trained to perform eye exams, diagnose and treat disease, prescribe medications and perform eye surgery. They also write prescriptions for eyeglasses and contact lenses.

What is CMV retinitis?

An opportunistic infection by the cytomegalovirus seen in HIV+ population when CD4<50

HIP PAIN: TRANSIENT IDIOPATHIC OSTEOPOROSIS

An uncommon condition sometimes seen in the third trimester of pregnancy Groin pain associated with a limited range of movement in the hip Patients may be unable to weight bear ESR may be elevated

Treatment of chronic pancreatitis

Analgesia, enzyme replacement, avoidance of causative agents, endoscopic dilation of pancreatic duct, surgery lithotripsy

Cutaneous Manifestations of Diabetes Granuloma Annulare (GA)

Annular flesh colored Asymptomatic papules of hands and feet Tx: Steroids , self limiting

Long term management of peptic ulcers

Antacids, PPIs or H2 blockers, treat any H pylori infections

Effects of H.Pylori

Antral-predominant infection results in increased gastrin production via inhibition somatostatin release. --> hypersecretion of acid predisposes to prepyloric and duodenal ulcer. -Body-predominant infection --> gastric atrophy and decreased acid production --> gastric ulcers and adenocarcinoma

What do hyaline casts in the urine represent?

Anything. It's non-specific

Clostridium difficile diarrhoea association, treatment and complication

Associated with recent AB use. Treatment is with oral metronidazole or vancomycin. Complication is toxic megacolon - seen on AXR.

Diverticulosis presentation

Asymptomatic until patients present with sudden, intermittent, painless bleeding

WHICH MEDICIATION EXACERBATE PSORIASIS

BETA-BLOCKERS

2B Ix and Rx for glomerulonephritis

Bloods: - FBC, LFT, U&E, ESR, CRP, IG - Electrophoresis - Complement - Antibodies - ANA, ANCA, anti-dsDNA, anti-GBM - Blood culture - ASOT - Hepatitis serology Urine: - Casts ARE EVIDENCE OF GLOMERULAR BLEEDING - Microscopy, culture and sensitivities - Bence-Jones protein - Albumin to creatinine ratio Imaging: - CXR - USS Renal biopsy - Determines what is affected - Focal/diffuse - Segmental/global - Immunofluorescence and electron microscopy Rx - Maintain blood pressure <130/80 - Give an ACE inhibitor or ARB to reduce bloodpressure, reduce renal burden and increase perfusion

What is a symptom of corneal edema?

Blurred vision

Comminuted

Bone breaks into > 2 fragments

Botulism 2B

Botulinum toxin ingestion produced by Clostridium botulinum ( gram +ve) which results in cranial nerve palsies,ptosis, oculobulbar weakness, and descending, symmetrical flaccid paralysis in the absence of fever. Affected patients do not complain of sensory deficits. voluntary muscles of the neck, shoulders, and upper extremities, followed by the proximal and distal lower extremities. Tendons work initially then no reflexes Ix: clinical diagnosis Rx: supportive care ( mech ventilation, assess cough reflex, oropharangeal secretion control o2 SATS), botulism antitoxin , gastric lavage, botulin Ig

Breakthroup pain dose calculation

Breakthrough dose = 1/6th of daily morphine dose

Treatment Gonorrhea

Ceftriaxone 1000mg IM STAT

SICKLE CELL CRISES

Characterised by periods of good health with intervening crisis Four main types of crises are recognised: - thrombotic: 'painful crises' - sequestration - aplastic - haemolytIC

Examples of OCULAR EMERGENCIES!

Chemical Injury (base > acid) CRAO (Central retinal artery occlusion) AACG (Acute angle closure glaucoma) Hyphema Penetrating Injury / Open globes

Lymphgranuloma Venerum

Chlamydia trachomatis Incubation is 5-21 days SMALL PAINLESS Erosions Heals unnoticed Lymphadenopathy , fever, arthritis Groove sign with buboes can be Clinical Diagnosis - Culture of bubo pus on McCoy cells 50% positive

Chronic Urticaria

Chronic Urticaria - hives occurring for 6 weeks or more in duration a. May last for months or years and end spontaneously b. Cause usually not found c. Investigations i. Rule-out physical urticatia ii. Sinus imaging- sinus films found occult infection in 17% of patients with chronic urticaria and when treated with antibiotics, hives improved * Auto immune Thyroid Patients Also see this.. Skin biopsy is appropriate for these patients

INTESTINAL ANGINA

Chronic mesenteric ischemia - occurs when there is atherosclerosis in blood supply to mesenteric arteries causing pain within an hour of meals as blood is shunted to abdomen for digestion Pain, weight loss bc avoid food, atherosclerotic disease

Epidermolysis Bullosa Acquisita

Chronic resistant sub epidermal auto-immune mechanicobullous disease IgG and complement 3 against portion of DEJ Blisters hands and feet immunoflourescent studies help diagnose Tx: Prednisone , cyclosporine, Immunoglobins

Ciclosporin side effects

Ciclosporin is classically associated with gingival hypertrophy and hirsutism.- avoided in women

Causes of cholestasis

Drugs The following drugs tend to cause a hepatocellular picture: paracetamol sodium valproate, phenytoin MAOIs halothane anti-tuberculosis: isoniazid, rifampicin, pyrazinamide statins alcohol amiodarone methyldopa nitrofurantoin The following drugs tend to cause cholestasis (+/- hepatitis): combined oral contraceptive pill antibiotics: flucloxacillin, co-amoxiclav, erythromycin* anabolic steroids, testosterones phenothiazines: chlorpromazine, prochlorperazine sulphonylureas fibrates rare reported causes: nifedipine Liver cirrhosis methotrexate methyldopa amiodarone

What could a scratchy sensation in the eye indicate?

Dry eyes, foreign body, blepharitis

watery diarrhoea

E.coli travelling , developing world

spread of bronchogenic carcinomas

Eventually, the neoplasm spreads to regional lymph nodes and distant organs such as the liver, brain and bone. Most bronchogenic carcinomas form a mass in or near the hilus.

Scale

Excess Stratum Corneum

Genital Herpes Treatment

Famciclovir Valciclovir Acyclovir

HPI of benign causes of red eye

Good vision, mild redness, mild pain, burning, itching, foreign body sensation

Signs/symptoms of DRY AMD

Gradual (months to years) visual changes in one or both eyes -Blurred vision -Difficulty reading or driving -Scotomas -Need bright light or magnification for fine visual acuity -Blurred or decreased central close-up and distance vision

Fracture Classification Incomplete

Greenstick Torus Bowing Stress Transchondral

What are Grey Turner and Cullen signs in acute pancreatitis?

Grey Turner is flank bruising (turn to your flanks) and Cullen is periumbilical discolouration (cullen-colour)

Malunion

Healing of the bone in a nonanatomic position.

Internal hernia

Hernia into or involving intra-abdominal structures

What is a hiatal hernia

Herniation of the stomach upwards into the chest through the diaphragm -due to weakness in diaphragm -aex: pressure on abdo from pregnancy, relaxed LOS, alcoholism, smoking, excess alcohol -coffee/choc --> LOS relaxation . sliding hernia: paraoesophageal. stomach pushed up through hole in diaphragm -common in >50 features: asymptomatic, GORD Ix: endoscopy, GORD, CXR, Rx: life style changes, antacids ad alginates ( form foam barrier), PPIs, surgery.

hiccups in palliative care

Hiccups in palliative care - chlorpromazine or haloperidol

Rotator cuff Tendinitis causes

Holding elbow above waist level Holding upper arm away from the body

SYSTEMIC LUPUS ERYTHEMATOSUS 2B 1-5

IgG mediated autoimmune disease ( HLA B8, DR2, DR3) e characterized by the production of autoantibodies, which deposit within tissues and fix complement leading to systemic inflammation.. > F (9:1), > african, asian, 20-40 can affect any organ including the skin, joints, kidneys and brain AEx autoimmune drug induced : hydralazine, isoniazid, procainamide, phenytoin (HIPP) MD SOAP BRAN -Malar rash - butterfly -Discoid rash - scarring on sun-exposed areas -S erositis - pleurisy, pericarditis, abdominal pain -O ral aphthous ulceration -A rthritis, bone disease and myalgia -P hotosensitivity: avoid going in sun -Blood pathology - anaemia, haemolytic anaemia, leucopenia, thrombocytopenia, antiphospholipid syndrome, lymphopaenia -Renal - nephritis , HTN, proteinuria, nephrotic syndrome and CKD -Autoantibodies - ANA, A dsDNA -Raynaud's syndrome -Neurological pathology - seizures, headache, psychosis, depression and anxiety Ix FBC , U&Es aPTT ESR, CRP - autoantibodies: ANA (99*%), ENA, anti-dsDNA ( highly specific >99%) , anti-smith ( most specific >99%) , anti-histone (80-90%), anti-ro ( cause bradycardia), antiphospholipid, RF, Anti-ro/La CXR ECG Rx - NSAIDs - Hydroxychloroquine- may result in a severe and permanent retinopathy, monitor eye - Steroids - Cyclophosphamide - Rituximab for severe disease Monitoring - ESR , CRP is normal during active disease - Complement C3, C4 low in active dz

What is gastritis and duodenitis

Inflammation of the gastric/ duodenal mucosa

What is the classic triad seen in Closed Angle Glaucoma?

Injected conjunctiva, cloudy or "steamy" cornea, and fixed dilated pupil.

HOW DO YOU MANAGE TIDM ?

Insulin

What is esotropia?

Inward turning of the eyes.

What is the first thing you do when there is a chemical eye injury?

Irrigate with 3L saline or LR

What are some toxicities of Mannitol as a diuretic?

It can cause pulmonary edema, dehydration. Contraindicated in CHF

What is dry eye NOT?

It is NOT an ophthalmic nuisance and it is NOT necessarily a normal part of the aging process. It IS a pathology c/b dysfunctional tear film.

What is the caruncle?

It is the small, pink, globular nodule at the inner corner (the medial canthus) of the eye. It is made of skin covering sebaceous and sweat glands.

IX and Rx oesophageal carcinoma

Ix *1st LINE*: aogd *OTHERS*: barium swallow - staging with CT Rx: Chemoradiation and surgical resection are first-line. Poor prognosis.

Diverticulitis presentation

LLQ colicky abdominal pain, fever, nausea, vomiting, rectal bleeding , constipation, palpable mass, impacted faeces in diverticulae

Treatment for NPDR?

Laser - stabilization of VA Focal Grid Anti-VEGF Tx Bevacizumab or Ranibizumab or Aflibercept Steroids

What could eye burning indicate?

Lid, conjunctival or corneal disorders

Xanthomas

Lipid Deposits in the Skin Periocular, palms, eyelids - Biliary Cirrhosis Tuberous - subQ tissue - hypertriglyceridemia Tendinous- Hypercholesterolemia

Enterobius vermicularis

Live in large intestine migrate to perianal area Features perinanl itching worse at night scratching spread of eggs

Candidiasis / Monoilaisis

Lives on normal flora of the mouth, vagina, gut Over growth can be due to pregnancy, BCP, antibiotics, Diabetes, and moist environments Vulvovaginitis- vaginal infx Oral Candidiasis- mouth infx Candida balinitis - Penis! Candida INtertrigo- In the inguinal crease Candida diaper - babies Angular Chelitis - Angles of the mouth Tx: Topical or oral antifungal agents - that are effective against yeast

Bowing Fx

Longitudinal force is applied to a bone. Common forearm, fibula

post-renal causes of AKI

Luminal: § Sloughed papillae § Calculi § Clot retention Mural: § Ureteric, bladder or prostate malignancy § Benign prostatic hypertrophy § Strictures e.g. meatal stenosis, phimosis andparaphimosis § Posterior urethral valves Extrinsic compression of the outflow tract: § Pelvic malignancy Retroperitonealfibrosis

WHAT ARE THE CAUSES OF SIADH ?

MIND Malignancy: some tumours can secrete ADH. SCLC, pancreas, prostate , lymphoma, leukaemia Infections: TB, pneumonia , COPD, CF Neuro: things that affect secretion: stroke all types, meningitis, abcess , head injury Drugs: SSRIs, trycyclics, cyclophophonamise, vincristine, carbamazepine, Nsaids, ANTIPSYCHOTICS( RISPERIDONE) Surgery:

malignant neoplastic liver disease 1B

Malignant neoplasms - primary liver cancer AKA hepatoma -Hepatocellular carcinoma (HCC) arises in px with cirrhosis due to any cause - also occurs in Hep B , C, aflatoxin, PSC, PBC, hereditary haemochromatosis, alpha-1 antitrypsin deficiency -most are asymptomatic , diagnosed after screening -metastatic carcinoma 2 ndary liver neoplasm -most liver cancer is secondary from breast, colon, lungs, pancreas fibromellar carcinoma: common in young adults HEpatoblastoma: rare, primary biliary cancer in infant esp. with Fhx familial adenomatous polyposis. features: right upper quadrant abdominal pain, jaundice, abdominal distension, leg oedema, early satiety, and weight loss. stigmata of liver diz Ix: Alpha-fetoprotein elevates, liver biopsy , USS , MRI , LFTs -Rx: resection, transplant, percutaneous ablation therapy and chemo-embolism

Order of ossicles from tympanic membrane

Malleus (can see), incus, stapes

Diagnosis of HCC

Mass on U/S or CT, abnormal LFTs and raised alpha feto-protein. Do not biopsy the liver. AFP to monitor

posterior cruciate ligament

Mechanism: hyperextension injuries Tibia lies back on the femur Paradoxical anterior draw test

IgG

Monomer, Enhances phagocytosis of bacteria and viruses Crosses placenta

IgA

Monomer, Found in breast milk. Secretion of GI, Resp and urogenital tracts. Commonly produced in body

IgD

Monomer, inactivated B-cells

What is the formula for the anion gap?

Na+ - (Cl- + HCO3)

Tennis elbow: Lateral epicondylitis Cause S/S Dx Tx

Overuse-repetitive supination and wrist extension* S/S: -point tenderness over lateral epicondyle, pain on resisted wrist extension . pain when gripping, pronating or wrist flexion due to strain on common extensor tendon on lateral epicondyle Dx: -clinical, x-ray to r/o arthritis or loose body Tx: -rest, ice, NSAIDs, counter force strap, steroid injection

Golfer's (pitcher's) elbow: Medial epicondylitis Cause S/S Dx Tx

Overuse-repetitive wrist flexion and pronation* S/S: -point tenderness over medial epicondyle, pain on resisted wrist flexion Dx: -clinical, x-ray to r/o arthritis or loose body Tx: -rest, ice, NSAIDs, steroid injection, stretching exercises

Primary Syphilis

Painless indurated well demarcated chancre Incubation: 18-21 days up to 3 months Organism present in lesions (T. Pallidum)

Causes of malabsorptive/osmotic diarrhoea

Pancreatic insufficiency, lactose intolerance, coeliac disease, laxative abuse

Causes of upper GI bleed

Peptic ulcer disease Esophageal or gastric varices, erosive esophagitis Erosive gastritis Mallory-Weiss tear Gastric cancer Epistaxis

Comedone

Plugged pilosebaceous unit

Anti-Jo-1 diseases

Polymyositis, dermatomyositis muscle weakness

Signs of retinal detachment

Poor vision Visual field defect Pigmented cells in the anterior vitreous Bleeding Vitreous hemorrhage

What do you call the disorder where the kidneys don't form at all in the fetus?

Potter's syndrome --> oligohydramnios leading to facial deformities, limb deformities, pulmonary hypoplasia

Sialolithiasis

Presence of a stone in the salivary gland 80% of all salivary gland calculi occur in the submandibular gland 70% of these calculi are radio-opaque Stones are usually composed of calcium phosphate or calcium carbonate Patients typically develop colicky pain and post prandial swelling of the gland Investigation involves sialography to demonstrate the site of obstruction and associated other stones Stones impacted in the distal aspect of Wharton's duct may be removed orally, other stones and chronic inflammation will usually require gland excision

ABNORMAL COAGULATION: HEPARIN

Prevents activation factors 2,9,10,11

Cryptococcosis 2B

Pulmonary or disseminated infection caused by C.gattii inhalation from soil. other species infect immunocompormised mostly found in tropical settng Characterised by symptoms of pneumonia and meningitis ( affects lungs and meninges) Can involve skin, bones, viscera Symptoms non specific (headache, blurred vision, confusion, depression, agitation, other behavioral changes) Lung infection may be asymptomatic , pneumonia, acute dyspnoe Skin: acne lesions, molluscum contagiosum, BCC Rx: amphotericin B, for meningeal then fluconazole.

Galeazzi fracture

RADIAL FRACTURE at wrist with dislocation of DISTAL radioulnar joint GRUsome G-aleazzi R-adius #, U-lnar-radial disloc

FELTY'S SYNDROME

Rheumatoid arthritis Splenomegaly Neutropenia

WHAT ARE X-RAY FINDINGS IN RA 1B

Rheumatoid presents with 'LESS'- Loss of joint space, Erosions, Soft bones, Soft tissue swelling.

Treatment of hiatal hernia

Sliding: medical therapy and lifestyle modifications to decrease GORD. Paraesophageal: surgical gastropexy to prevent gastric volvulus

Salter- Harris Fracture Classification - I

Slip (separated or straight across). Fracture of the cartilage of the physis (growth plate)

Fire Ants

Small Aggressive stinging Painful! papule vesicle 10 days Tx: Cool compresses, baking soda, antihistamines , prednisone

What is the macula?

The central part of the retina, with the highest concentration of photoreceptors. site of maximum visual acuity

What is the posterior segment of the eye?

The posterior segment is the back five-sixths of the eye that includes the anterior hyaloid membrane and all of the optical structures behind it: the vitreous humor, retina, choroid, and optic nerve.

What is a slit lamp?

The slit lamp is a binocular microscope that provides the examiner with a stereoscopic (ie, three dimensional) view of the eye

What is the tarsal plate?

The tarsal plate is a fibrous layer that gives the lids shape, strength, and a place for muscles to attach.

What is a Seidel test?

The test used to reveal ocular leaks from the cornea, sclera or conjunctiva following injury or surgery and sometimes disease.

What is the trabecular meshwork?

The trabecular meshwork is an area of tissue in the eye located around the base of the cornea, near the ciliary body, and is responsible for draining the aqueous humor from the eye via the anterior chamber.

Tendinopathy is cause by

Trauma or repetitive stress

UC vs Crohns: examination

UC- _frank blood on PR -Crohns_ perianal fissures or tags, fistulas

Prolonged PT and APTT

Warfarin overdose, vitamin K deficiency, liver failure, DIC.

Prolonged PT causes

Warfarin, vitamin K deficiency, early liver disease, rarely congenital factor VII deficiency

What is metamorphopsia?

Wavy vision. SEEN in ARMD

GALLSTONE ILEUS xray

obstruction of small bowel with gallstone + air in biliary tree

What drugs can cause Drug-Induced Interstitial Nephritis, and ow do they do it?

penicillins, NSAIDS, diuretics can all act as haptens that induce hypersensitivity

MEN-1

ppp parathyroid pancreas( elen and insulinoma pituitary adrenal + tyroid

Ruptured achilles

results from jumping- sudden pain above heel. impossible to tiptoe

HPI serious causes of red eye

severe pain, photophobia, reduction of vision, marked redness, purulent discharge, white spot on cornea, irregular pupil, hypopyon, hyphema

metaphyseal

the flared portion of the bone at the ends of the shaft

oral morphine to diamorphine conversion factor

total daily morphine dose divided by 3

What are 3 common causes of Acute Tubular Necrosis?

trauma, shock, toxins -compartment syndrome

Psoriatic arthropathy management

treat as rheumatoid arthritis - but better prognosis

What do WBC casts in the urine suggest?

tubulointerstitial disease, acute pyelonephritis, glomerular disorders

ACL injury

twisting positive anterior drawer test

osteomyelitis xray

x-ray: become abnormal after 2 to 4 wk, showing periosteal elevation, bone destruction, soft-tissue swelling, and, in the vertebrae, loss of vertebral body height or narrowing of the adjacent infected intervertebral disk space and destruction of the end plates above and below the disk.

INTERTROCHANTERIC FRACTURE:

young due to MVC, fall from height. elderly: twisting, fall from standing. ss: acute hip pain , cant weight bear, short &externall rotatated leg, painful ROM Rx: dynamic hip screw

Metaglinides

•There are 2 - repaglinide and nateglinide •Short acting insulin secretogogues - work by binding to the sulphonylurea receptor and 'squeezing' the β cell to release insulin •They stimulate first-phase insulin release in a glucose-sensitive manner