Clinical science

AIP - porphobilinogen deAminase; PCT - uroporphyrinogen deCarboxylase

Absolute risk reduction = (Control event rate) - (Experimental event rate)
Adrenal cortex mnemonic: GFR ACD
Anaphylaxis = type I hypersensitivity reaction
Anticipation in trinucleotide repeat disorders = earlier onset in successive
generations
Antidiuretic hormone (ADH) - site of action = collecting ducts
Autosomal recessive conditions are 'metabolic' - exceptions: inherited
ataxias
Autosomal dominant conditions are 'structural' - exceptions:
hyperlipidaemia type II, hypokalaemic periodic paralysis
BNP - actions:
vasodilator
diuretic and natriuretic
suppresses both sympathetic tone and the renin-angiotensinaldosterone system
Cohort studies - relative risk
Combined B- and T-cell disorders: SCID WAS ataxic (SCID, Wiskott-Aldrich
syndrome, ataxic telangiectasia)
Correlation
parametric (normally distributed): Pearson's coefficient
non-parametric: Spearman's coefficient
DiGeorge syndrome - a T-cell disorder
Epidermis - 5 layers - bottom layer = stratum germinativum which gives rise
to keratinocytes and contains melanocytes
Funnel plots - show publication bias in meta-analyses
Hereditary angioedema - C1-INH deficiency
1

Hereditary angioedema - C4 is the best screening test inbetween attacks

Human genome - 25,000 protein-coding genes
Hypokalaemia - U waves on ECG
Klinefelter's? - do a karyotype
Methaemoglobinaemia = oxidation of Fe2+ in haemoglobin to Fe3+
Mitochondrial diseases follow a maternal inheritance pattern
Molecular biology techniques
SNOW (South - NOrth - West)
DROP (DNA - RNA - Protein)
NNT = 1 / Absolute Risk Reduction
Nitric oxide - vasodilation + inhibits platelet aggregation
Obesity hormones
Leptin Lowers appetite
Ghrelin Gains appetite
Odds - remember a ratio of the number of people who incur a particular
outcome to the number of people who do not incur the outcome
NOT a ratio of the number of people who incur a particular outcome to the
total number of people
Osteomalacia
low: calcium, phosphate
raised: alkaline phosphatase
Oxygen dissociation curve
shifts Left - Lower oxygen delivery - Lower acidity, temp, 2-3 DPG
- also HbF, carboxy/methaemoglobin
shifts Right - Raised oxygen delivery - Raised acidity, temp, 2-3
DPG
Power = 1 - the probability of a type II error
Prolactin - under continuous inhibition
2

Pulmonary surfactant - main constituent is dipalmitoyl phosphatidylcholine

(DPPC)
Refeeding syndrome causes hypophosphataemia
Relative risk = EER / CER
Renal tubular acidosis causes a normal anion gap
Rheumatoid arthritis - HLA DR4
Rheumatoid factor is an IgM antibody against IgG
Rituximab - monoclonal antibody against CD20
SIADH - drug causes: carbamazepine, sulfonylureas, SSRIs, tricyclics
Skewed distributions
alphabetical order: mean - median - mode
'>' for positive, '<' for negative
Standard error of the mean = standard deviation / square root (number of
patients)
The PTH level in primary hyperparathyroidism may be normal
Transfer factor
raised: asthma, haemorrhage, left-to-right shunts, polycythaemia
low: everything else
Vitamin B12 is actively absorbed in the terminal ileum
Warfarin - clotting factors affected mnemonic - 1972 (10, 9, 7, 2)
Wiskott-Aldrich syndrome
recurrent bacterial infections (e.g. Chest)
eczema
thrombocytopaenia
X-linked conditions: Duchenne/Becker, haemophilia, G6PD
X-linked recessive conditions - there is no male-to-male transmission.
Affected males can only have unaffected sons and carrier daughters.
3

Cardiology
Streptococcus bovis endocarditis is associated with colorectal cancer
Aortic dissection
type A - ascending aorta - control BP(IV labetalol) + surgery
type B - descending aorta - control BP(IV labetalol)
Aortic stenosis - S4 is a marker of severity
Aortic stenosis - most common cause:

younger patients < 65 years: bicuspid aortic valve

older patients > 65 years: calcification

Aortic stenosis management: AVR if symptomatic, otherwise cut-off is

gradient of 50 mmHg
Atrial fibrillation - cardioversion: amiodarone + flecainide
Atrial fibrillation: rate control - beta blockers preferable to digoxin
Bosentan - endothelin-1 receptor antagonist
Calcium channel blockers are now preferred to thiazides in the treatment of
hypertension
Complete heart block following a MI? - right coronary artery lesion
Complete heart block following an inferior MI is NOT an indication for
pacing, unlike with an anterior MI
Congenital heart disease

cyanotic: TGA most common at birth, Fallot's most common

overall
acyanotic: VSD most common cause

DVLA advice following angioplasty - cannot drive for 1 week

DVLA advice post MI - cannot drive for 4 weeks
Flash pulmonary oedema, U&Es worse on ACE inhibitor, asymmetrical
kidneys renal artery stenosis - do MR angiography
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HOCM is the most common cause of sudden cardiac death in the young
Hypertension - NICE now recommend ambulatory blood pressure
monitoring to aid diagnosis
Hypertension - step 4
+
K < 4.5 then spironolactone
+
K > 4.5 then higher-dose thiazide-like diuretic
Inferior MI - right coronary artery lesion
JVP: C wave - closure of the tricuspid valve
Labetalol is first-line for pregnancy-induced hypertension
Methadone is a common cause of QT prolongation
Most common cause of endocarditis:

Streptococcus viridans
Staphylococcus epidermidis if < 2 months post valve surgery

Myoglobin rises first following a myocardial infarction

Patent ductus arteriosus - collapsing pulse
Patients with established CVD should take atorvastatin 80mg on
Prosthetic heart valves - mechanical valves last longer and tend to be given
to younger patients
Second heart sound (S2)

loud: hypertension
soft: AS
fixed split: ASD
reversed split: LBBB

Sudden death, unusual collapse in young person - ? HOCM

Tachycardia with a rate of 150/min ?atrial flutter
Turner's syndrome - most common cardiac defect is bicuspid aortic valve
5

Ventricular tachycardia - verapamil is contraindicated

Young man with AF, no TIA or risk factors, no treatment is now preferred to
aspirin

Cardiac action potential: phases

Phase 3 - efflux of potassium
Congenital heart disease
Pulmonary valve stenosis is cyanotic
Drug adverse effects
Amiodarone may cause hyperthyroidism
Amiodarone may cause photosensitivity
Amlodipine may cause flushing
Amiodarone may cause thrombophlebitis
Amiodarone may cause slate-grey appearance
Spironolactone may cause precipitation of digoxin toxicity
Drug indications
Cholestyramine , uses include: treatment resistant diarrhoea
in Crohn's disease
Drug mechanism of action
Amiodarone - blocks potassium channels
Ticagrelor - antagonist of the P2Y12 adenosine diphosphate (ADP) receptor
ECG: coronary territories
Ischaemic changes in leads II, III, aVF - right coronary
Tall R waves V1-2 - usually left circumflex, also right coronary
ECG: pathological changes
PR depression pericarditis
Right axis deviation - Wolff-Parkinson-White syndrome (left-sided accessory pathway)
Features (cardiovascular disorders)
Patent ductus arteriosus - collapsing pulse
6

Heart sounds
Reversed split S2 LBBB
Fourth heart sound - aortic stenosis
Soft S2 - aortic stenosis
Fixed split S2 - atrial septal defect
Loud S2 - atrial septal defect
Loud S1 - mitral stenosis
Third heart sound - constrictive pericarditis
Reversed split S2 - WPW type B
Reversed split S2 - aortic stenosis
Loud S1 - left-to-right shunts
Loud S2 - hyperdynamic states
Fourth heart sound HOCM
Hypertension levels
Blood pressure target (< 80 years, clinic reading) - 140/90 mmHg
Blood pressure target (> 80 years, clinic reading) - 150/90 mmHg
Definition of stage 2 hypertension (Clinic reading) - 160/100 mmHg
Criteria for considering immediate treatment - 180/110 mmHg
Definition of stage 2 hypertension (ABPM/HBPM) - 150/95 mmHg
Hypertension: next step
Poorly controlled hypertension, already taking an ACE inhibitor, calcium channel
blocker and a thiazide diuretic. K+ > 4.5mmol/l - increase dose of thiazide diuretic
Infective endocarditis
Colorectal cancer - Streptococcus bovis
Patients with no past medical history - Streptococcus viridians
Prosthetic valves after two months - Streptococcus viridians

JVP
An absent Y descent in the JVP may be caused by cardiac tamponade
A paradoxical rise in the JVP during inspiration may be caused by constrictive
pericarditis
Murmurs
Atrial septal defect - ejection systolic murmur
Graham-Steel murmur (pulmonary regurgitation) - early diastolic murmur, highpitched and 'blowing' in character
Ventricular septal defect - holosystolic murmur, 'harsh' in character
Mitral regurgitation - holosystolic murmur, high-pitched and 'blowing' in character
Pulses
Pulsus parodoxus - severe asthma
Pulsus parodoxus - cardiac tamponade
Slow-rising/plateau pulse - aortic stenosis
Collapsing pulse - patent ductus arteriosus
Bisferiens pulse - mixed aortic valve disease
Collapsing pulse - hyperkinetic states

Stereotypical histories (cardiovascular disorders)

A 30-year-old man presents with recurrent palpitations and syncope. A resting ECG
shows T wave inversion in V1-3 and epsilon waves. He has a family history of sudden
death - arrhythmogenic right ventricular cardiomyopathy
A patient develops acute heart failure 5 days after a myocardial infarction. A new pansystolic murmur is noted on examination - ventricular septal defect

Clinical Hematology and Oncology

Activated protein C resistance (Factor V Leiden) is the most common
inherited thrombophilia
Acute myeloid leukaemia - good prognosis: t(15;17)
Acute myeloid leukaemia - poor prognosis: deletion of chromosome 5 or 7
Acute promyelocytic leukaemia - t(15;17)
Anaplastic thyroid cancer - aggressive, difficult to treat and often causes
pressure symptoms
Antiphospholipid syndrome in pregnancy: aspirin + LMWH
Antiphospholipid syndrome: (paradoxically) prolonged APTT + low platelets
Burkitt's lymphoma - c-myc gene translocation
Burkitt's lymphoma is a common cause of tumour lysis syndrome
CLL - immunophenotyping is investigation of choice
CLL - treatment: Fludarabine, Cyclophosphamide and Rituximab (FCR)
CML - Philadelphia chromosome - t(9:22)
Cancer patients with VTE - 6 months of LMWH
Cetuximab - monoclonal antibody against the epidermal growth factor
receptor
Chronic myeloid leukaemia - imatinib = tyrosine kinase inhibitor
Cisplatin is associated with hypomagnesaemia
Colorectal cancer screening - PPV of FOB = 5 - 15%
Cyclophosphamide - haemorrhagic cystitis - prevent with mesna
Desmopressiin - induces release of von Willebrand's factor from endothelial
cells
Disproportionate microcytic anaemia - think beta-thalassaemia trait
9

EBV: associated malignancies:

Burkitt's lymphoma
Hodgkin's lymphoma
nasopharyngeal carcinoma

Factor V Leiden mutation results in activated protein C resistance

Gastric adenocarcinoma - signet ring cells
Gingival hyperplasia: phenytoin, ciclosporin, calcium channel blockers and
AML
HRT: adding a progestogen increases the risk of breast cancer
Hereditary haemorrhagic telangiectasia - autosomal dominant
Hodgkin's lymphoma - best prognosis = lymphocyte predominant
Hodgkin's lymphoma - most common type = nodular sclerosing
ITP - give oral prednisolone
IgM paraproteinaemia - ?Waldenstrom's macroglobulinaemia
Metastatic bone pain may respond to NSAIDs, bisphosphonates or
radiotherapy
Myelofibrosis - most common presenting symptom lethargy
Oesophageal adenocarcinoma is associated with GORD or Barrett's
Paraneoplastic features of lung cancer

squamous cell: PTHrp, clubbing, HPOA

small cell: ADH, ACTH, Lambert-Eaton syndrome

Patients with Sjogren's syndrome have an increased risk of lymphoid

malignancies
Philadelphia translocation, t(9;22) - good prognosis in CML, poor prognosis
in AML + ALL

10

Polycythaemia rubra vera - JAK2 mutation

Polycythaemia rubra vera - around 5-15% progress to myelofibrosis or AML
Polycythaemia rubra vera is associated with a low ESR
Rasburicase - a recombinant version of urate oxidase, an enzyme that
metabolizes uric acid to allantoin
Screening for haemochromatosis

general population: transferrin saturation > ferritin

family members: HFE genetic testing

TTP - plasma exchange is first-line

Taxanes (e.g. Docetaxel) prevent microtubule disassembly
Tear-drop poikilocytes = myelofibrosis
Trastuzumab (Herceptin) - cardiac toxicity is common
Trimethoprim may cause pantcytopaenia
Venous thromoboembolism - length of warfarin treatment

provoked (e.g. recent surgery): 3 months

unprovoked: 6 months

Vincristine - peripheral neuropathy

Blood film abnormalities

Tear-drop poikilocytes myelofibrosis
Drug adverse effects
Primaquine may cause haemolysis in patients with G6PD deficiency
Drug mechanism of action
Imatinib - inhibitor of the tyrosine kinase associated with the BCR-ABL defect
Haemolytic anaemia
Extravascular haemolysis - warm autoimmune haemolytic anaemia
11

Clinical Pharmacology
Amiodarone may cause hyperthyroidism
Amiodarone may cause photosensitivity
Amlodipine may cause flushing
Amiodarone may cause thrombophlebitis
Amiodarone may cause slate-grey appearance
Spironolactone may cause precipitation of digoxin toxicity
Drug indications
Cholestyramine , uses include: treatment resistant diarrhoea in Crohn's disease
Drug mechanism of action
Amiodarone - blocks potassium channels
Ondansetron - 5-HT3 antagonist
Ticagrelor - antagonist of the P2Y12 adenosine diphosphate (ADP) receptor
Churg-Strauss syndrome - p-ANCA
Rheumatoid arthritis - HLA-DR4
Secretin - increased pancreatic bicarbonate secretion
Infective endocarditis
Colorectal cancer - Streptococcus bovis
Patients with no past medical history Streptococcus viridians
Prosthetic valves after two months - Streptococcus viridians
Chi-squared test - non-parametric test used to compare proportions or percentages
Student's t-test - parametric test of paired or unpaired data
Specificity - proportion of patients without the condition who have a negative test result

12

Dermatology
Acne rosacea treatment:
mild/moderate: topical metronidazole
severe/resistant: oral tetracycline
Blisters/bullae
no mucosal involvement (in exams at least*): bullous pemphigoid
mucosal involvement: pemphigus vulgaris
Blisters/bullae
no mucosal involvement: bullous pemphigoid
mucosal involvement: pemphigus vulgaris
Dermatitis herpetiformis - caused by IgA deposition in the dermis
Dermatophyte nail infections - use oral terbinafine
Discoid lupus erythematous - topical steroids oral hydroxychloroquine
Dry skin is the most common side-effect of isotretinoin
Flexural psoriasis - topical steroid
Impetigo - topical fusidic acid oral flucloxacillin / topical retapamulin
Keloid scars - more common in young, black, male adults
Keloid scars are most common on the sternum
Lichen

planus: purple, pruritic, papular, polygonal rash on flexor surfaces.

Wickham's striae over surface. Oral involvement common
sclerosus: itchy white spots typically seen on the vulva of elderly women

Management of venous ulceration - compression bandaging

Melanoma: the invasion depth of the tumour is the single most important prognostic
factor
Polymorphic eruption of pregnancy is not associated with blistering

13

Porphyria cutanea tarda

blistering photosensitive rash
hypertrichosis
hyperpigmentation
Psoriasis: common triggers are beta-blockers and lithium
Scabies - permethrin treatment: all skin including scalp + leave for 12 hours + retreat
in 7 days
Seborrhoeic dermatitis - first-line treatment is topical ketoconazole
Topical steroids
moderate: Clobetasone butyrate 0.05%
potent: Betamethasone valerate 0.1%
very potent: Clobetasol propionate 0.05%
Urinary histamine is used to diagnose systemic mastocytosis
Waterlow score - used to identify patients at risk of pressure sores

Stereotypical histories (dermatology)

An elderly women develops itchy, tense blisters around the flexures. There is no mucosal
involvement - bullous pemphigoid
An elderly Jewish woman develops painful, flaccid, easily ruptured vesicles and bullae
on the skin. They are not itchy and were preceded by mouth lesions - pemphigus
vulgaris

14

Endocrinology
PHaeochromocytoma - give PHenoxybenzamine before beta-blockers
Acromegaly: increased sweating is caused by sweat gland hypertrophy
Addison's disease is associated with a metabolic acidosis
Bartter's syndrome is associated with normotension
Bilateral idiopathic adrenal hyperplasia is the most common cause of primary
hyperaldosteronism
Cushing's syndrome - hypokalaemic metabolic alkalosis
Diabetes diagnosis: fasting > 7.0, random > 11.1 - if asymptomatic need two readings
Diabetes mellitus - HbA1c of 6.5% or greater is now diagnostic (WHO 2011)
During Ramadan, one-third of the normal metformin dose should be taken before
sunrise and two-thirds should be taken after sunset
Exenatide causes vomiting
Flushing, diarrhoea, bronchospasm, tricuspid stenosis, pellagra carcinoid with
liver mets - diagnosis: urinary 5-HIAA
Gitelman's syndrome: normotension with hypokalaemia
Glitazones are agonists of PPAR-gamma receptors, reducing peripheral insulin
resistance
Graves' disease is the most common cause of thyrotoxicosis
Haemochromatosis is autosomal recessive
Hashimoto's thyroiditis = hypothyroidism + goitre + anti-TPO
Hashimoto's thyroiditis is associated with thyroid lymphoma
HbA1C - recheck after 2-3 months
Hypercholesterolaemia rather than hypertriglyceridaemia: nephrotic syndrome,
cholestasis, hypothyroidism
15

In the primary prevention of CVD using statins aim for a reduction in non-HDL
cholesterol of > 40%
Infertility in PCOS - clomifene is superior to metformin
Insulinoma is diagnosed with supervised prolonged fasting
Liddle's syndrome: hypokalaemia + hypertension
Meglitinides - stimulate insulin release - good for erratic lifestyle
Metformin should be titrated slowly, leave at least 1 week before increasing dose
Obesity - NICE bariatric referral cut-offs

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

no risk factors: > 40 kg/m^2

Patients on insulin may now hold a HGV licence if they meet strict DVLA criteria
Patients on long-term steroids should have their doses doubled during intercurrent
illness
Phaeochromocytoma: do 24 hr urinary metanephrines, not catecholamines
Polycystic ovarian syndrome - ovarian cysts are the most consistent feature
Small cell lung cancer accounts 50-75% of case of ectopic ACTH
The diagnostic test for acromegaly is an oral glucose tolerance with growth hormone
measurements
The overnight dexamethasone suppression test is the best test to diagnosis Cushing's
syndrome
The short synacthen test is the best test to diagnose Addison's disease
Thiazides cause hypercalcaemia
Thyrotoxicosis with tender goitre = subacute (De Quervain's) thyroiditis

16

Gastroenterology
Wilson's disease - serum caeruloplasmin is decreased
24hr oesophageal pH monitoring is gold standard investigation in GORD
E. coli is the most common cause of travellers' diarrhea
H. pylori eradication:
PPI + amoxicillin + clarithromycin, or
PPI + metronidazole + clarithromycin
Causes of villous atrophy (other than coeliacs): tropical sprue, Whipple's, lymphoma,
hypogammaglobulinaemia
Coeliac disease - tissue transglutaminase antibodies first-line test
Deterioration in patient with hepatitis B - ? hepatocellular carcinoma
Dysphagia affecting both solids and liquids from the start - think achalasia
Flucloxacillin + co-amoxiclav are well recognised causes of cholestasis
Gastric MALT lymphoma - eradicate H. pylori
Give 50% of normal energy intake in starved patients (> 5 days) to avoid refeeding
syndrome
Hepatocellular carcinoma
hepatitis B most common cause worldwide
hepatitis C most common cause in Europe
Obese T2DM with abnormal LFTs - ? non-alcoholic fatty liver disease
Paracetamol overdose - high risk if chronic alcohol, HIV, anorexia or P450 inducers
Peutz-Jeghers syndrome - autosomal dominant
Primary biliary cirrhosis - the M rule
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females

17

Screening for haemochromatosis

general population: transferrin saturation > ferritin
family members: HFE genetic testing
The gold standard test for achalasia is oesophageal manometry
Ulcerative colitis - the rectum is the most common site affected
Urea breath test - no antibiotics in past 4 weeks, no antisecretory drugs (e.g. PPI) in
past 2 weeks
Whipple's disease: jejunal biopsy shows deposition of macrophages containing
Periodic acid-Schiff (PAS) granules
Zollinger-Ellison syndrome: epigastric pain and diarrhoea

Drug mechanism of action

Ondansetron - 5-HT3 antagonist
Inflammatory bowel disease: key differences
Ulcerative colitis - primary sclerosing cholangitis
Crohn's disease granulomas
Stereotypical histories (gastroenterology)
A 45-year-old man is being investigated for diarrhoea, weight loss and arthralgia. Jejunal
biopsy shows deposition of macrophages containing PAS-positive granules - Whipple's
disease
A 30-year-old woman presents with foul smelling oily diarrhoea, abdominal bloating,
fatigue and weight loss. On examination she has papulovesicular lesions on the extensor
aspects of her arms - coeliac disease
Stereotypical histories (hepatobiliary disorders)
A 65-year-old man with a history of chronic hepatitis b infection presents with
symptoms and signs of liver cirrhosis. Alpha-fetoprotein is elevated. - hepatocellular
carcinoma
Stereotypical histories (upper gastrointestinal disorders)
A patient with a history of heartburn presents with odynophagia. There no weight loss,
vomiting or anorexia oesophagitis
18

Infectious Diseases
Legionella pneumophilia is best diagnosed by the urinary antigen test
Chlamydia - treat with azithromycin or doxycycline
Chickenpox exposure in pregnancy - first step is to check antibodies
Genital ulcers
painful: herpes much more common than chancroid
painless: syphilis more common than lymphogranuloma
venereum + granuloma inguinale
Live attenuated vaccines
BCG
MMR
oral polio
yellow fever
oral typhoid
Schistosoma haematobium causes haematuria
Supportive therapy is the mainstay of treatment in Cryptosporidium
diarrhoea
URTI symptoms + amoxicillin rash ?glandular fever
Antibiotic guidelines
Animal or human bite - co-amoxiclav
Bacteria: classification
Neisseria meningitidis - Gram-negative cocci

19

Nephrology
Goodpasture's syndrome
IgG deposits on renal biopsy
anti-GBM antibodies

Neurology
'Fasciculations' - think motor neuron disease
Chorea is caused by damage to the basal ganglia, in particular the Caudate nucleus
Dystrophia myotonica - DM1
distal weakness initially
autosomal dominant
diabetes
dysarthria
Absence seizures - good prognosis: 90-95% become seizure free in adolescence
Antiplatelets
TIA: clopidogrel
ischaemic stroke: clopidogrel
Asymmetrical symptoms suggests idiopathic Parkinson's
Bitemporal hemianopia
lesion of optic chiasm
upper quadrant defect > lower quadrant defect = inferior chiasmal
compression, commonly a pituitary tumour
lower quadrant defect > upper quadrant defect = superior chiasmal
compression, commonly a craniopharyngioma
Burning thigh pain - ? meralgia paraesthetica - lateral cutaneous nerve of thigh
compression
CT head showing temporal lobe changes - think herpes simplex encephalitis
Cluster headache - acute treatment: subcutaneous sumatriptan + 100% O2
DVLA advice post CVA: cannot drive for 1 month
20

DVLA advice post multipler TIAs: cannot drive for 3 months

Eclampsia - give magnesium sulphate first-line
Epidural haematoma - lucid interval
Epilepsy + pregnancy = 5mg folic acid
Epilepsy medication: first-line
generalised seizure: sodium valproate
partial seizure: carbamazepine
Episodic eye pain, lacrimation, nasal stuffiness occurring daily - cluster headache
Essential tremor is an AD condition that is made worse when arms are outstretched,
made better by alcohol and propranolol
FVC is used to monitor respiratory function in Guillain-Barre syndrome
Fluctuating confusion/consciousness? - subdural haematoma
Fluctuating consciousness = subdural haemorrhage
Hemiballism is caused by damage to the subthalamic nucleus
Horner's syndrome - anhydrosis determines site of lesion:
head, arm, trunk = central lesion: stroke, syringomyelia
just face = pre-ganglionic lesion: Pancoast's, cervical rib
absent = post-ganglionic lesion: carotid artery
Hypertension should not be treated in the initial period following a stroke
Kearns-Sayre syndrome
mitochondrial inheritance
onset < 20-years-old
external ophthalmoplegia
retinitis pigmentosa
Lateral medullary syndrome - PICA lesion - cerebellar signs, contralateral sensory
loss & ipsilateral Horner's
Loss of corneal reflex - think acoustic neuroma

21

Medication overuse headache

simple analgesia + triptans: stop abruptly

opioid analgesia: withdraw gradually

Migraine

acute: triptan + NSAID or triptan + paracetamol

prophylaxis: topiramate or propranolol

Miller Fisher syndrome - areflexia, ataxia, ophthalmoplegia

Motor neuron disease riluzole
Motor neuron disease - treatment: NIV is better than riluzole
Neuroimaging is required to diagnose dementia
Nitrofurantoin may cause peripheral neuropathy
Obese, young female with headaches / blurred vision think idiopathic intracranial
hypertension
Painful third nerve palsy = posterior communicating artery aneurysm
Patients cannot drive for 6 months following a seizure
Progressive supranuclear palsy: parkinsonism, impairment of vertical gaze
Prolactinoma management - medical therapy is almost always first-line
Ptosis + dilated pupil = third nerve palsy; ptosis + constricted pupil = Horner's
Restless leg syndrome - management includes dopamine agonists such as ropinirole
Ropinirole - dopamine receptor agonist
Stroke thrombolysis - only consider if less than 4.5 hours and haemorrhage excluded
Syringomyelia - spinothalamic sensory loss (pain and temperature)
Trigeminal neuralgia - carbamazepine is first-line
Urinary incontinence + gait abnormality + dementia = normal pressure
hydrocephalus
22

V for Vigabatrin - V for Visual field defects

Visual field defects:
left homonymous hemianopia means visual field defect to the left, i.e.
lesion of right optic tract
homonymous quadrantanopias: PITS (Parietal-Inferior, TemporalSuperior)
incongruous defects = optic tract lesion; congruous defects= optic
radiation lesion or occipital cortex
Wilson's disease - autosomal recessive

Brain anatomy
Frontal lobe lesions may cause perseveration
Stereotypical histories (neurological disorders)
A 55-year-old presents with fever, headache, confusion and aphasia. A CT shows
petechial haemorrhages in the temporal lobe - herpes simplex encephalitis

23

Ophthalmology
Drusen = Dry macular degeneration
Acute angle closure glaucoma is associated with hypermetropia, where as primary
open-angle glaucoma is associated with myopia
Central retinal vein occlusion - sudden painless loss of vision, severe retinal
haemorrhages on fundoscopy
Flashes and floaters - vitreous/retinal detachment
Holmes ADIe = DIlated pupil, females, absent leg reflexes
Horner's syndrome - anhydrosis determines site of lesion:
head, arm, trunk = central lesion: stroke, syringomyelia
just face = pre-ganglionic lesion: Pancoast's, cervical rib
absent = post-ganglionic lesion: carotid artery
Macular degeneration - smoking is risk factor
Red eye - glaucoma or uveitis?
glaucoma: severe pain, haloes, 'semi-dilated' pupil
uveitis: small, fixed oval pupil, ciliary flush
Retinitis pigmentosa - night blindness + funnel vision
Scleritis is painful, episcleritis is not painful
Treatment of acute glaucoma - acetazolamide + pilocarpine

24

Psychiatry
Alcohol withdrawal
symptoms: 6-12 hours
seizures: 36 hours
delirium tremens: 72 hours
Anorexia features
most things low
G's and C's raised: growth hormone, glucose,
salivary glands, cortisol,cholesterol, carotinaemia
Antipsychotics in the elderly - increased risk of stroke and VTE
Atypical antipsychotics commonly cause weight gain
Clozapine is no longer used first-line due to the risk of agranulocytosis
Dosulepin - avoid as dangerous in overdose
Lofepramine - the safest TCA in overdosage
Parkinson's disease - most common psychiatric problem is depression
Paroxetine - higher incidence of discontinuation symptoms
Post-natal depression is seen in around 10% of women
SSRI + NSAID = GI bleeding risk - give a PPI
Unexplained symptoms
Somatisation = Symptoms
hypoChondria = Cancer

25

Respiratory Medicine
Streptococcus pneumoniae is associated with cold sores
Saccharopolyspora rectivirgula causes farmer's lung, a type of EAA
Alpha-1 antitrypsin deficiency - autosomal recessive / co-dominant
Aspergillus clavatus causes malt workers' lung, a type of EAA
Asthma - intermediate probability - do spirometry first-line
Asthma diagnosis - if high probability of asthma - start treatment
Bronchiectasis: most common organism = Haemophilus influenza
COPD - LTOT if 2 measurements of pO2 < 7.3 kPa
COPD - reason for using inhaled corticosteroids - reduced exacerbations
COPD - still breathless despite using inhalers as required?
FEV1 > 50%: LABA or LAMA
FEV1 < 50%: LABA + ICS or LAMA
CTPA is the first line investigation for PE according to current BTS guidelines
Contraindications to lung cancer surgery include SVC obstruction, FEV < 1.5,
MALIGNANT pleural effusion, and vocal cord paralysis
Erythema nodosum is associated with a good prognosis in sarcoidosis
Flow volume loop is the investigation of choice for upper airway compression
Isocyanates are the most common cause of occupational asthma
Lung adenocarcinoma
most common type in non-smokers
peripheral lesion
Massive PE + hypotension thrombolyse
Mycoplasma pneumonia if allergic/intolerant to macrolides doxycycline
Mycoplasma? - serology is diagnostic
26

Paraneoplastic features of lung cancer

squamous cell: PTHrp, clubbing, HPOA
small cell: ADH, ACTH, Lambert-Eaton syndrome
Pneumocystis jiroveci pneumonia - pneumothorax is a common complication
Pneumonia in an alcoholic Klebsiella
Preceding influenza predisposes to Staphylococcus aureus pneumonia
Pulmonary embolism - CTPA is first-line investigation
Pulmonary embolism - normal CXR
Sarcoidosis CXR
1 = BHL
2 = BHL + infiltrates
3 = infiltrates
4 = fibrosis
Serial peak flow measurements at work and at home are used to detect occupational
asthma
Sleep apnoea causes include obesity and macroglossia
Symptom control in non-CF bronchiectasis - inspiratory muscle training + postural
drainage
The majority of patients with sarcoidosis get better without treatment
Transfer factor
raised: asthma, haemorrhage, left-to-right shunts, polycythaemia
low: everything else

27

Rheumatology
Ankylosing spondylitis - x-ray findings: subchondral erosions, sclerosis
and squaring of lumbar vertebrae
Ankylosing spondylitis features - the 'A's
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
Anti-Jo-1 antibodies are more common in polymyositis than dermatomyositis
Anti-cyclic citrullinated peptide antibodies are associated with rheumatoid arthritis
Anti-ribonuclear protein (anti-RNP) = mixed connective tissue disease
Antiphospholipid syndrome: arterial/venous thrombosis, miscarriage, livedo
reticularis
Azathioprine - check thiopurine methyltransferase deficiency (TPMT) before
treatment
Dermatomyositis antibodies: ANA most common, anti-Mi-2 most specific
Gout: start allopurinol if >= 2 attacks in 12 month period
Lateral epicondylitis: worse on resisted wrist extension/suppination whilst elbow
extended
Limited (central) systemic sclerosis = anti-centromere antibodies
NICE recommend co-prescribing a PPI with NSAIDs in all patients with osteoarthritis
Oral ulcers + genital ulcers + anterior uveitis = Behcet's
Osteoarthritis - paracetamol + topical NSAIDs (if knee/hand) first-line
Osteoporosis in a man - check testosterone
Paget's disease - old man, bone pain, raised ALP
28

Pseudogout - positively birefringent rhomboid shaped crystals

Raynaud's disease (i.e. primary) presents in young women with bilateral symptoms
Rheumatoid arthritis - TNF is key in pathophysiology
Rheumatoid arthritis: patients have an increased risk of IHD
SLE - antibodies associated with congenital heart block = anti-Ro
SLE: ANA is 99% sensitive - anti-Sm & anti-dsDNA are 99% specific
SLE: C3 & C4 low
Scleritis is painful, episcleritis is not painful
Septic arthritis - most common organism: Staphylococcus aureus
The vast majority of gout is due to decreased renal excretion of uric acid
Urethritis + arthritis + conjunctivitis = reactive arthritis
cANCA = Wegener's; pANCA = Churg-Strauss + others

29

On examination learning points

Endocrinology

Hyponatreamia with urine sodium <30, raised BUN and hypotension is likely
multifactorial and should be treated with Normal Saline

Hyponatraemia should be corrected slowly except where seizures or significant

neurological dysfunction occurs.

Hypoadrenalism is associated with hyponatreamia, hyperkalaemia, elevated TSH and

mild hypercalcaemia

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

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

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

sensitivity and specificity for diagnosing Cushing's syndrome

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

Cushing's disease

Hypokalaemic metabolic alkalosis is seen in Cushing's syndrome.

Petrosal sinus sampling helps to differentiate pituitary from ectopic ACTH-dependent

Cushing's syndrome

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

Short synacthen test confirms diagnosis of Addison's disease

Hypogonadotrophic hypogonadism in the presence of raised prolactin is likely secondary

to microprolactinoma

Hypogonadotrophic hypogonadism (low testosterone with inappropriately low or

normal LH & FSH) requires pituitary investigation primarily.

Abnormal GTT with GH measurement is diagnostic of acromegaly.

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

30

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

Congenital GnRH deficiency (hypogonadotrophic hypogonadism) due to Kallmann's

syndrome is associated with anosmia, deafness, colour blindness and midline deformity.

In women with oopthrectomy unopposed oestrogen HRT is appropriate

Oestrogen therapy causes raised thyroxie binding globulin, effecting total thyroid
hormone levels.

AntiTPO antibodies are present in 10% females without thyroid pathology

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

Propylthiouracil is best used in breast feeding mothers.

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

Follicular thyroid cancer is treated surgically.

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

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

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

hyperparathyroidism

Psuedohypoparathyroidism is associated with slipped epiphyseal plate in childhood.

Amitryptilline can also cause glaucoma

Klinefelters does not have a genetic pattern of inheritance

Serum ferritin is a useful screenig test for haemochromatosis

Osteopenia is T score -1 to -2.5

Proven interventions in the treatment of diabetic nephropathy include ACE inhibitors

(greatest benefit), low dietary protein and improved glycaemic control

Reducing insulin requirements, weight loss and hypoglycaemia should alert you to
autoimmune hypoadrenalism if found in a type 1 diabetic

Beta cell mass is reduced by 65% in Type 2 and 90% in Type 1 diabetic patients
31

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

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

Testosterone replacement may improve bone mineral density

Respiratory Medicine

Hyponatreamia with urine sodium <30, raised BUN and hypotension is likely
multifactorial and should be treated with Normal Saline

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

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

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

treated conservatively.

Post-extubation stridor occurs frequently in extubated patients and may be associated

with respiratory failure due to airway obstruction requiring reintubation.

A raised PaCO2 in acute asthma is an important sign that the patient is deteriorating and
intubation may be required (near fatal asthma).

Yellow nail syndrome is caused by hypoplastic lymphatics and is characterised by the

triad of lymphoedema, pleural effusions, and yellow discolouration of the nails.

illicit drug use can cause pulmonary hypertension

Oxygen titration in COPD based on arterial blood gas interpretation

This man has a severe pneumonia with a history highly suggestive of underlying
immunosuppression from HIV. As a result he is at risk from atypical and opportunistic
organisms especially Pneumocystis pneumonia.

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

32

Gastroenterology

Manifestations and management of hereditary haemorrhagic telangectasia

Carcinoid heart disease has a poor prognosis

Liver biopsy is diagnostic of haemochromatosis and is the gold standard for diagnosis. In
patients homozygous for the HFE gene, a liver biopsy is indicated where there is
abnormal liver biochemistry or ferritin > 1000 microg/l. All liver biopsies should be
stained for iron (Perls' stain).

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

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

Anti-intrinsic factor antibodies are diagnostic of pernicious anaemia though

may be absent in up to 50% of patients with the condition

33

Cardiology

Patients under the age of 40 with less than 20% cardiovascular risk at 10 years
should be initially offered lifestyle interventions to deal with hypertension.

Many drugs have been associated with gynecomastia, including phytoestrogens,

oestrogens and drugs with oestrogen-like properties, inhibitors of testosterone synthesis
or action, and other agents with unknown mechanisms.

Features of myotonic dystrophy include frontal baldness in men, atrophy of temporalis,

masseters, and facial muscle, and bilateral ptosis.

An ASD is likely to present with right bundle branch block and left axis deviation on ECG

Common intra-operative management goals in mitral regurgitation include avoiding

raised SVR (systemic vascular resistance), avoiding bradycardia, and avoiding factors
exacerbating pulmonary hypertension.

Intra-aortic balloon pump counter-pulsation may be an effective bridging therapy in

cardiogenic shock, particularly in the setting of acute myocardial infarction.

Intra-aortic balloon pump is contraindicated in aortic regurge and it sould be inflated at

the middle of T wave (beginning of diastole)

Although less commonly placed in the 21st century, pulmonary artery catheters may be
beneficial in cases of right ventricular dysfunction to assess filling.

Unopposed beta-antagonism should be avoided in malignant hypertension until the

cause is identified

AV node ablation is reserved for those patients where pharmacological rate control is
unsuccessful or not tolerated. The procedure is invasive and requires permanent
pacemaker implantation.

The management of tachyarrhythmias requires the candidate to demonstrate

knowledge of unstable vs. stable features and then broad vs. narrow complex
arrhythmias to instigate treatment correctly.

The first step in post-cardiac arrest care is to give aspirin and clopidogrel. This can
usually be achieved quickly and easily whilst other investigations and treatments are
organised.
34

Dual antiplatelet therapy should be continued following the insertion of a drug eluting
cardiac stent insertion for a year unless the surgery is urgent.

If blood pressure remains uncontrolled with optimal or maximum tolerated doses of

four drugs, seek expert advice if it has not yet been obtained.

Aortic valve endocarditis can be associated with aortic root abscess which can be
identified by prolongation of the PR interval on a 12 lead ECG.

Guidance from the European Society of Cardiology states that, after a silent cerebral
embolism or TIA (in patient with infective endocarditis), surgery is recommended
without delay if an indication remains.

Old age, presence of prosthetic valve endocarditis, insulin dependent diabetes mellitus
and severe co-morbidities are all poor prognostic factors in infective endocarditis.

Thrombolysis can be given during an arrest situation if PE is suspected, but CPR must be
continued for 90 minutes

Flecainide is the treatment of choice for paroxysmal AF with aberrant conduction due to
accessory pathway (Wolff- Parkinson- White syndrome)

Mobitz type II heart block post MI is an indication for transvenous cardiac pacing.

Atropine is no longer recommended for use in asystolic cardiac arrest

Theophylline is indicated for the management of bradycardia in patients who have had
cardiac transplantation

Atropine is the first step in the management of bradycardia secondary to beta blocker or
calcium channel blocker overdose. if atropine failed give glucagon

Bicarbonate is indicated in tricyclic overdose

Amiodarone can prolong QT interval

The management of tachycardias depends on the presence of any adverse features.

Echocardiography can be used in the periarrest diagnose (or exclude) pericardial

tamponade.

Fenofibrate is used to treat isolated hypertriglyceridaemia, though it should not be

prescribed routinely for primary or secondary prevention of hypercholesterolaemia.
35

Knowledge of coding systems used for pacemaker functions and that asystole with no
ventricular escape rhythm requires dual chamber pacing

Low TSH with normal thyroid hormone levels is subclinical hyperthyroidism and is
unlikely to cause LVF

Tendinous xanthomata is pathognomonic for type II(a) hyperlipidaemia (familial

hypercholesterolaemia)

Beta blocker and ACE inhibitors are used for treatment of heart failure

Management of tachyarrhythmias in patients with pacemakers

Recognition of common conduction problems on ECG

BP control shows greater reduction in CV risk than tight glyceamic control in UKPDS

Amiodarone can prolong QT interval

36

Dermatology

Skin appearance and systemic manifestations of pseudoxanthoma elasticum

Group B Streptococcus has a predilection for cellulitis in diabetes

Mycosis fungoides (a cutaneous T cell lymphoma) presents as a pruritic eczematous rash

and develops telangiectasias and areas of 'cigarette paper' atrophy.

Gastric CA may progress from gastric ulcer and may present with Acanthosis nigricans

PUVA is an effective treatment for psoriasis and may be useful where compliance with
topical therapy may be an issue

A plaque is a descriptive term for a skin lesion that is raised and greater than 1 cm in
diameter.

Lichenification of the skin is due to epidermal thickening characterised by visible and

palpable thickening of the skin with accentuation of skin markings.

Basal cell carcinoma presents with a typical 'rodent ulcer' with rolled pearly edges and
small telangiectasias. It is the commonest malignant skin tumour and most commonly
occurs in elderly patients with sun-damaged skin.

37

Infectious Diseases

Treatment of PCP includes co trimoxazole, or iv pentamidine, or clindamycin &

primaquine. Steroids should be started in conjunction.

A positive rubella haemagglutination inhibition (HAI) combined with a negative rubella

IgM is consistent with early acute infection with rubella, previous vaccination, or
previous rubella infection.

The importance of early recognition of clostridium difficile colitis/diarrhoea and the

need to start treatment urgently

Severe sepsis requires the SIRS syndrome plus evidence of infection and organ
dysfunction.

CVC blood stream infection is an important cause of morbidity and mortality in critical
care patients. Considerable research has been undertaken to address this.

Ensure that adequate fluid resuscitation is achieved in the management of septic shock.

Necrotising fasciitis is a rapidly fatal condition that requires emergency treatment.

Have a low threshold for testing for HIV, be aware of the clinical indicator diseases and
that HIV testing does not require extensive pre-test counselling.

The order of removing personal protective equipment is important to reduce

contamination.

Septic shock presents with hypothermia, tachycardia and hypotension, and often with
decreased consciousness in the elderly.

Gynaecomastia is one of the less common side effects of efavirenz together with the
more common neuropsychiatry side effects.

The yellow fever vaccine is safe, especially if the patient's CD4+ is above 200 cells/mm3.

The resistant organisms produce PBPs that have a low affinity for binding betalactamase antibiotics. Other organisms which do the same
are Pneumococciand Enterococci.

How to draw Bood Culture in suspected IE

Sepsis may be complicated by disseminated intravascular coagulation

38

Septic shock presents with hypothermia, tachycardia and hypotension, and often with
decreased consciousness in the elderly.

Identification of dilated oesophagus on CT

Treatment of PCP includes co trimoxazole, or iv pentamidine, or clindamycin &

primaquine. Steroids should be started in conjunction.

Ireland is among the countries with the highest reported prevalence of sarcoidosis
worldwide. Biopsy of granuloma is diagnostic for the disease.

39

Neurology

Tetrabenezine is used in the management of hemiballismus

Upto date trials in stroke managent include CHADS2VASC risk scoring and PROGRESS

Cyproheptadine treats serotonin syndrome

Patients with syncope can commonly have jerking of the limbs when they are
unconscious and this does not mean they have had a seizure. Tilt table testing is useful
to support the diagnosis of vasovagal syncope.

Strokes presenting within 6 hours, confirmed infarct with no CIs should be thrombolysed

Features of neurofibromatosis Type 2 include cerebellar and retinal

haemangioblastomas, caf-au-lait spots, and acoustic neuromas.

Early sets of blood cultures remain the most important investigation in a suspected case
of infective endocarditis.

OCP can cause stroke like episodes, in patients suffering with migraine.

Orbital apex syndrome

Knowledge of classical presentations of stroke based on an understanding of functional

neuroanatomy

Pituitary apoplexy can cause compression of the occular nerves and trigeminal nerve
within the cavernous sinus.

Treatment of JME includes lamotrigine, sodium valproate and topiramate

The Hunt and Hess scale grades subarachnoid haemorrhage

Cerebral ischaemia from cerebral vasospasm is the most common cause of death and
disability following aneurysmal subarachnoid hemorrhage (SAH).

Brain stem death testing confirms absence of respiratory effort and tests a series of
cranial nerve responses.

The young age of the patient, rapid onset of dementia and presence of myoclonic jerks
and EEG are characteristic of Creutzfeldt-Jakob disease.

40

Occlusion of the middle cerebral artery produces contralateral hemiparesis and

hemisensory loss with speech disturbance if the dominant hemisphere is involved.

ABCD2 score aims to identify those at high risk of stroke following a TIA.

Myasthenia Gravis can present with negative acetyl choline receptor antibodies.

Guillain-Barr syndrome is investigated using CSF analysis, NCS (F wave) and by

monitoring FVC.

Wilsons disease presents with KF rings and have abnormal brain MR findings.

Only life threatening or function changes in MS require high dose pulsed

methylprednisolone.

Elderly and falls cay result in sudural haematoma, symptoms may be present subacutely

Median nerve supplies the LOAF muscles: Lateral 2 lumbricals, Opponens pollicis,
ABductor pollicis brevis, Flexor pollicis brevis

Differential diagnoses of non-convulsive status include: metabolic encephalopathy,

transient ischaemia, migraine, infection, psychiatric causes.

HSMN has various types. Genetic testing usually reveals the diagnosis and EMG and NCS
help distinguish between the types.

Vivid dreams and lethargy may be due to nocturnal hypoglycaemia

41

Oncology

Papillary thyroid cancer is treated with total thyroidectomy followed radioiodine-131

therapy.

Parathyroid carcinoma is more likely when PTH is grossly elevated

Neuroendocrine tumours (carcinoid syndrome) usually respond well to somatostatin

analogues

In the case of terminal care, it is important to be honest with relatives and to fully
document any discussion.

Surgical resection of an isolated hepatic metastases or small number of hepatic

metastases from a previous colon cancer is potentially curative in approximately 25% of
patients.

Fulvestrant is a new novel therapy for endocrine treatment of metastatic breast cancer,
it selectively down regulates oestrogen receptors and has been shown to be equivalent
to anastrazole in terms of efficacy.

Treatment with adjuvant chemotherapy plus trastuzumab reduces the risk of recurrence
and mortality in patients with early stage, HER2-positive breast cancer.

One of the significant complications of trastuzumab is its effect on the heart.

Trastuzumab is associated with cardiac dysfunction in 2-7% of cases. As a result, regular
cardiac screening with echocardiography is commonly undertaken during the
trastuzumab treatment period.

Lumpectomy with sentinel lymph node biopsy followed by breast irradiation is the
appropriate management of women with small, focal breast cancer.

Long term cancer survivors do not need any more screening than age appropriate cancer
screening.

Prophylactic cranial irradiation reduces central nervous system relapse and improves
survival in patients with limited stage small cell lung cancer.

This patient has a likely diagnosis of Lambert-Eaton myasthenic syndrome from an

underlying small cell lung cancer.
42

50-70% of all presentations of LEMS are due to an underlying small cell lung cancer with
the vast majority linked to smoking tobacco.

Hospice care is appropriate for patients who have metastatic squamous cell lung cancer
to the brain.

An elevated serum AFP is indicative of a nonseminoma testicular tumors

seminomas are associated with a normal serum alpha-fetoprotein level.

Surgical castration or gonadotropin hormone-releasing hormone (GnRH) agonists are

first line therapies for an asymptomatic patient with metastatic prostate cancer.

Ovarian cancer screening is not recommended in general population as no survival

benefit from earlier diagnosis and therapy has been shown.

CA125 is most commonly used to monitor ovarian cancer but can also be raised in
endometrial, lung, breast and gastrointestinal cancers.
Patients diagnosed with stage I, grade 1 ovarian cancer have 90% cure rate with surgery
alone.
Patients with history of cancer need anticoagulation indefinitely or till the underlying
malignancy is cured when they have any history of deep vein thrombosis or pulmonary
embolism.
Patients with active cancer who are found to have venous thromboembolic disease are
recommended to have anticoagulation indefinitely or till the time they are cured from
cancer.
Typhlitis or neutropenic colitis is a rare but serious complication of profound
neutropenia which requires intravenous antibiotics.
Cetuximab works by blocking the extracellular domain of EGFR preventing ligand binding
and therefore preventing downstream signal transduction. The patients tumour must
express K-Ras wild type as K-Ras mutated is constitutively active regardless of whether a
ligand is attached or not.
Epstein-Barr virus is believed to be the primary etiologic agent in the pathogenesis of
nasopharyngeal carcinoma.
Only alcohol has been linked with nasopharyngeal cancer and breast cancer; a high
consumption may increase the risk of developing both of these cancers.

43

Palliative Care

Nausea is common in a palliative care setting and choice of antiemetic is important.

Haloperidol is the first choice antiemetic for opiate induced nausea.

Opioids are very useful in the treatment of breathlessness in palliative care. Oxygen
therapy is mainly used for the hypoxic patient.

Non-convulsive seizures can present as abnormal behaviour in a patient with a brain tumour.

Management options for malignant hypercalcaemia and of a palliative care emergency.

Management of nausea and vomiting in palliative medicine.

Pain management : opioids, opioid switching . Pharmacology and therapeutics : opioid

switching (dose conversions).

Causes, assessment and management of GI symptoms : constipation

Causes, assessment and management of skin problems lymphoedema.

Pain management drug treatment.

Principles of pain and symptom management drugs pain management drug

treatment.

Causes, assessment and management of other symptoms last days of life.

Law death certification and post mortems.

Presentation and management of emergencies hypercalcaemia disease process and

management common malignancies.

Care of the dying patient. Management of concurrent clinical problems alternative

methods of nutrition and hydration.

Causes, assessment and management of neurological and psychiatric problems MCA

and MHA

Management of anaemia and coagulopathies

Principles of pain and symptom management Drugs presentation and management of

emergencies acute dystonia

Principles of pain and symptom management drugs presentation and management of

emergencies neuroleptic malignant syndrome

Pain management characteristics of different pains causes, assessment and

management of GI symptoms intestinal obstruction

Pain management opioids, opioid switching (dose conversions)

44

Rheumatology

Thyrotoxicosis is associated with high alkaline phosphatase secondary to increased bone

turnover

In women with oopthrectomy unopposed oestrogen HRT is appropriate

Clinical presentation and radiological features of osteomyelitis

Peri articular erosion is seen in RA

Whilst the first carpometacarpal joint can be affected in rheumatoid arthritis and
psoriatic arthritis it is rarely in isolation, whereas this is a frequent site of osteoarthritis
in post menopausal women.

Side effects of hydroxychloroquine

Lyme disease transmission

Differential diagnosis of SLE nephritis

Biologics mechanisms of action

Febuxostat mechanism of action

Parvovirus B19 is caused by HHV 6 and can result in a small joint arthropathy.

45

Haematology

Oral iron chelation with deferasirox is the first line gold standard treatment for iron
chelation in iron overload related to repeated transfusions in patients with chronic
anaemias.

It is imperative to recognize the syndrome of thrombotic thrombocytopenic purpura,

and institute plasma exchange with fresh frozen plasma as soon as possible to avoid the
diseases high mortality rate.

The most likely cause of abnormal haematology following the loss of a large volume of
blood is inadequate fluid resuscitation. This can be compounded by hypothermia and
acidosis.

K-DOQI guidelines suggest maintaining Hb >110 g/L in CRF

Presentation of myelodysplastic syndrome (pancytopenia, blood film findings, and bone

marrow findings)

Sepsis may be complicated by disseminated intravascular coagulation

Radiotherapy is very useful in the management of back pain secondary to myeolma

Mycosis fungoides (a cutaneous T cell lymphoma) presents as a pruritic eczematous rash

and develops telangiectasias and areas of 'cigarette paper' atrophy.

Multiple myeloma may present with roleaux formation on blood film and raised total
protein (globulin component).

Peripheral blood flow cytometry (is an often overlooked diagnostic test for chronic
lymphocytic leukaemia, but is now the gold standard for diagnosis, so candidates should
be aware of this development)

Recognition of common complications of chemotherapy

Knowledge of treatment options for low grade lymphoma

Management of polycythaemia

This question relates to the management of acute lymphoblastic leukaemia.

This question relates to the management of relapsed Hodgkin lymphoma.

46

This management of essential thrombocythaemia is based on cytoreduction with

hydroxycarbamide and an antiplatelet agent such as aspirin to decrease the thrombotic
risk.

This question covers the management of travel related venous thromboembolism.

This question concerns the management of pre-operative assessment of bleeding risk.

Nephrology

methyl pred for 3 days, then a steroid sparing drug for long term

In ATN urinay sodium losses are usually greater than 60 mmol/L

ADPK disease progresses to renal replacement therapy after 40-60 years

Recurrent UTIs in a diabetic can be reduced with good glycaemic control

IV furosemide not effective in HD patients

Renal Vein Thrombosis is often clinically silent. Association with hypercoagulable state,
peripheral leg oedema and flank pain in a patient presenting with AKI are all pertinent
clues.

Psychiatry

Paranoid schizophrenia is dominated by relatively stable, often paranoid delusions,

usually accompanied by hallucinations, particularly of the auditory variety, and
perceptual disturbances.

Citalopram is the safest antidepressant to use in patients who are also prescribed
warfarin.

Ophthalmology

Nystagmus and photophobia are common findings in albinos.

47

Toxicology

Methanol poisoning presents with a wide anion gap,the definitive management involves
haemodiaylysis.

Normal anion gap 8-16 mEq/L - in INH overdose it is wide

Critical Care

Brain stem death testing confirms absence of respiratory effort and tests a series of
cranial nerve responses.

Seizures can be divided into partial or complex and with careful examination the focus of
the seizure can be found.

Acute cocaine overdose is initially best treated with benzodiazepines.

Cardiology

Smoking cessation will have greatest impact on CV risk in diabetic obese population

Calcium antagonists and nitrates do not prevent cardiovascular events occurring.

BP control shows greater reduction in CV risk than tight glyceamic control in UKPDS

Amiodarone can prolong QT interval

Amiodarone inhibits peripheral conversion of T4 to T3.

Diabetes

ACEi is first line blood pressure treatment in diabetes (but needs to be gradually titrated
to avoid side-effects)

BP control shows greater reduction in CV risk than tight glyceamic control in UKPDS

Emergency Medicine

Drugs that may cause SIADH include Selective serotonin reuptake inhibitors (SSRIs),
Tricyclic antidepressants, Sulphonylureas, Thiazides, and Carbamazepine.

Neurology

Strokes presenting within 6 hours, confirmed infarct with no CIs should be thrombolysed

Toxicology

Normal anion gap 8-16 mEq/L - in INH overdose it is wide

48

ACE inhibitors are first-line for hypertension in diabetics, irrespective of the patients
age
APML is a haematological emergency. Treatment is with all-trans retinoic acid (ATRA)
to force immature granulocytes into maturation to resolve a blast crisis prior to more
definitive chemotherapy
Adder bites are rare, but when they occur may be extremely painful; the mainstay of
treatment is analgesia and supportive therapy. Discuss the use of antivenin with NPIS
and do not apply a tourniquet
Aminoglycoside antibiotics are contraindicated in patients with myasthenia gravis due
to the risk of fatal myasthenic crisis and respiratory failure
Benzodiazepine overdose is best managed supportively and with airway protection and
ventilation if needed. Flumazenil should be avoided unless for reversal of anaesthesia
Blisters/bullae

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

mucosal involvement: pemphigus vulgaris

Cancer patients with VTE - 6 months of LMWH
Care should be taken in status epilepticus due to drug toxicities refractory to
benzodiazepines; phenytoin is cardiotoxic and phenobarbital is a potent respiratory
depressant. Intubation is often safest
Central retinal vein occlusion - sudden painless loss of vision, severe retinal
haemorrhages on fundoscopy
Co-administration of aminophylline and ciprofloxacin can cause significant toxicity and
should be avoided
Cocaine toxicity - avoid beta-blockers

Concomitant use of ergotamine and macrolides may cause ergot poisoning (ergotism)
with confusion, headache, seizures, psychosis and global vasoconstriction leading to
critical limb ischaemia, cardiac ischaemia and bowel hypoperfusion
Cyanide poisoning occurs due to interruption of cellular aerobic respiration by binding
to the mitochondrial cytochrome oxidase a-a3 complex, halting the electron transport
chain
49

Dapagliflozin is a SGLT-2 inhibitor which causes increased renal glucose loss to

control diabetic glycaemia. It may cause recurrent urinary infections due to high
urinary glucose load
During Ramadan, one-third of the normal metformin dose should be taken before
sunrise and two-thirds should be taken after sunset
Factor V Leiden is the most common inherited thrombophilia
Female with hypothyroidism immediately increase levothyroxine and monitor TSH
closely
HIV - multiple ring enhancing lesions = toxoplasmosis
Hereditary angioedema (HAE) is pathophysiologically separate from anaphylaxis and is
treated differently. Therapeutic options are: intravenous infusion of human C1-esterase
inhibitor or subcutaneous injection of the bradykinin receptor inhibitor icatibant
IV amoxicillin is the empirical treatment of choice in native valve endocarditis
IV vancomycin + rifampicin + low-dose gentamicin is the empirical treatment of choice
in prosthetic valve endocarditis
Intravenous diuretics are first line therapy in acute heart failure, even in renal failure,
with strict fluid management
Ivabradine use may be associated with visual disturbances including phosphenes and
green luminescence

Lead poisoning is often occupational and comprises gastrointestinal and

neuropsychiatric symptoms and anaemia due to interruption to the haem biosynthetic
pathway. Wrist drop is a pathognomonic sign
MODY is inherited in an autosomal dominant fashion so a family history is often
present
Management of significant tricyclic overdose is with potent sodium bicarbonate
infusion and lipid emulsion therapy second-line
Mediastinal mass + symptoms of myasthenia = thymoma
Medullary thyroid cancer - calcitonin is used for screening, prognosis and monitoring
Methanol poisoning is preferentially treated with IV fomepizole; this should be
commenced immediately the suspicion is raised
Mild community acquired pneumonia (CURB 0-1) should be treated with oral penicillin
therapy alone assuming no allergies and no other complicating factors
50

NRG-1, a synthetic cathinone, can cause agitation, hyponatraemia and serotonin

syndrome. Treatment is with benzodiazepines, cooling and hypertonic saline if
hyponatraemic. Patients may require intubation and paralysis to control hyperpyrexia
Nephrocalcinosis may be caused by renal tubular acidosis type 1, hyperparathyroidism
and medullary sponge kidney
Nitrofurantoin is best avoided in patients with CKD stage 3 or higher due to the
significant risk of treatment failure and occurrence of side effects due to drug
accumulation
Nitrous oxide use can precipitate severe vitamin B12 deficiency with pronounced
neurological and haematological signs, particularly in susceptible individuals
Offer compression stockings to all patients with deep vein thrombosis
Oral iron supplement absorption may be impaired by calcium, zinc or magnesium
containing gastric coating suspensions causing treatment failure. An alternative route
of administration should be considered
Organophosphate poisoning occurs due to inhibition of acetylcholinesterase leading to
upregulation of nicotinic and muscarinic cholinergic neurotransmission
Poppers (alkyl nitrites) may rarely cause methaemoglobinaemia which is treated first
line with methylthioninium chloride solution (methylene blue)
Propranolol is preferable to topiramate in women of childbearing age (i.e. the majority
of women with migraine)
Quinine toxicity (cinchonism) presents with myriad ECG changes, hypotension,
metabolic acidosis, hypoglycaemia and classically tinnitus, flushing and visual
disturbances. Flash pulmonary oedema may occur
Refractory hypercalcaemia of malignancy may be treated with subcutaneous calcitonin
if therapy with fluids and pamidronate fails
Retinal + cerebellar haemangiomas = Von Hippel-Lindau syndrome
Scalp psoriasis - first-line treatment is topical potent corticosteroids
Severe iron toxicity presents with liver failure, gastrointestinal caustic damage and
coagulopathy with raised APTT. Early hyperglycaemia and extensively haemolysed
samples may also indicate significant iron burden
Start alendronate in patients >= 75 years following a fragility fracture, without waiting
for a DEXA scan

51

Thallium poisoning is a rare cause of painful polyneuropathy, mood change and

alopecia. Treatment is chelation therapy with oral Prussian Blue
The combination of verapamil and beta-blockers, particularly intravenously, is
absolutely contraindicated due to the risk of cardiovascular collapse or arrest
The concurrent use of methotrexate and trimethoprim containing antibiotics may cause
bone marrow suppression and severe or fatal pancytopaenia
The oral glucose tolerance test remains the investigation of choice for gestational
diabetes
Theophylline poisoning presents with hypokalaemia, hyperglycaemia, tachycardia and
increased myocardial contractility
Topical potent corticosteroid + vitamin D analogue is first-line for chronic plaque
psoriasis
Warfarin is the only licensed anticoagulant drug for stroke prevention in AF in those
with structurally abnormal valves

Bone disorders: lab values

Normal serum calcium, normal serum phosphate, raised ALP and

normal PTH - Paget's disease
Features (musculoskeletal disorders)

Marfan's syndrome - dilation of the aortic sinuses

Marfan's syndrome - mitral valve prolapse
Key question features (musculoskeletal disorders)

Bamboo spine - ankylosing spondylitis

Child, bone pain in skull/proximal femur, cutaneous nodules, recurrent otitis
media/mastoiditis - Langerhans cell histiocytosis
Tall, long fingered, downward lens dislocation, learning difficulties, DVT
homocystinuria
Repeated fractures, false allegation of child abuse, blue sclera - osteogenesis
imperfect
'double/soap bubble' x-ray appearance around epiphysis of femur - giant cell
tumour of bone
52

Tall, long fingered, aortic pathology, pneumothoraces - Marfan's syndrome

STI --> arthritis, urethritis, conjunctivitis - reactive arthritis
Stereotypical histories (musculoskeletal disorders)

A 25-year-old man develops a painful and swollen knee associated with dysuria
and conjunctivitis - reactive arthritis
A 65-year-old woman presents with aching and morning stiffness in the proximal
limb muscles. She is having difficulty getting out of a chair - polymyalgia
rheumatic
A 25-year-old man is admitted to hospital following a pneumothorax. On
examination he is noted to be tall with arachnodactyly and pectus excavatum Marfan's syndrome
Treatment of choice

Paget's disease of the bone , treatment of choice: a bisphosphonate

53

Cardiology
HOCM

TTT
1) Amiodarone
2) Beta-blockers or verapamil for
symptoms
3) Cardioverter defibrillator
4) Dual chamber pacemaker
5) Endocarditis prophylaxis

Brugada syndrome

ICD

arrhythmogenic right
ventricular dysplasia
(ARVD)

1) drugs: sotalol is the most widely

Contraindicated
nitrates
ACE inhibitors
inotropes

changes may be more

apparent following
flecainide

used antiarrhythmic
2) catheter ablation to prevent

ventricular tachycardia
Catecholaminergic
polymorphic
ventricular tachycardia
(CPVT)
MAT

3) ICD
1) beta-blockers
2) ICD

calcium channel blockers

Not useful
Cardioversion
Digoxin

SVT

1)
2)
3)
4)

Valsalva Maneuver
Adenosine
If asthmatic give verapamil
Electrical cardioversin

WPW

Definitive treatment: radiofrequency

ablation
medical therapy: sotalol**,
amiodarone, flecainide

**sotalol should be avoided

if there is coexistent atrial
fibrillation may deteriorate
into ventricular fibrillation

AF

Pharmacological cardioversion:
amiodarone if structural heart
disease,
flecainide in those without
structural heart disease
sotalol

Agents used to control

rate:
1) beta-blockers
2) calcium channel
blockers
3) digoxin

Atrial Flutter

1) similar to that of atrial fibrillation

although mediction may be less

effective
2) atrial flutter is more sensitive to
cardioversion however so lower
energy levels may be used
3) radiofrequency ablation of the
tricuspid valve isthmus is
curative for most patients
54

Peri-arrest rhythms
Bradycardia

If there is adverse signs

1) Atropine is the first line
treatment in this situation.
2) If this fails to work, or there is the
potential risk of asystole then
transvenous pacing is indicated
If there is a delay in the provision of
transvenous pacing the following
interventions may be used:
1) atropine, up to maximum of 3mg
2) transcutaneous pacing
3) adrenaline infusion titrated to
response

peri-arrest
tachycardias

If there is any adverse signs then

synchronised DC shocks should
be given

1) Broad-complex tachycardia
Regular:
assume ventricular
tachycardia (unless
previously confirmed SVT
with bundle branch block)
loading dose of amiodarone
followed by 24 hour infusion
Irregular:
1. Polymorphic VT (e.g. Torsade
de pointes) - IV magnesium
2. AF with bundle branch block treat as for narrow complex
tachycardia.
2) Narrow-complex tachycardia
Regular:
vagal manoeuvres followed
by IV adenosine
if above unsuccessful
consider diagnosis of atrial
flutter and control rate (e.g.
Beta-blockers)
Irregular:
probable atrial fibrillation
if onset < 48 hr consider
electrical or chemical
cardioversion
If onset > 48 hr then rate
control (e.g. Beta-blocker or
digoxin) and anticoagulation

55

Anticoagulation

The European Society of Cardiology published updated guidelines on the management

of atrial fibrillation in 2012.
They suggest using the CHA2DS2-VASc score to determine the most appropriate
anticoagulation strategy. This scoring system superceded the CHADS2 score.

Risk factor

Points

Congestive heart failure

Hypertension (or treated hypertension)

A2

Age >= 75 years

Age 65-74 years

Diabetes

S2

Prior Stroke or TIA

Vascular disease (including ischaemic heart disease and peripheral arterial

disease)

Sex (female)

The table below shows a suggested anticoagulation strategy based on the score:

Score

Anticoagulation

No treatment

Males: Consider anticoagulation

Females: No treatment

2 or more

Offer anticoagulation

Doctors have always thought carefully about the risk/benefit profile of starting
someone on warfarin.
A history of falls, old age, alcohol excess and a history of previous bleeding are
common things that make us consider whether warfarinisation is in the best interests
of the patient.
NICE now recommend we formalise this risk assessment using the HASBLED scoring
system.

56

Risk factor

Points

Uncontrolled Hypertension, , systolic BP > 160 mmHg

Abnormal renal function (dialysis or creatinine > 200)

Or
Abnormal liver function (cirrhosis, bilirubin > 2 times normal,
ALT/AST/ALP > 3 times normal

1 for any renal

abnormalities

Stroke, history of

Bleeding, history of bleeding or tendency to bleed

Labile INRs (unstable/high INRs, time in therapeutic range <

60%)

Elderly (> 65 years)

Drugs Predisposing to Bleeding (Antiplatelet agents, NSAIDs)

Or
Alcohol Use (>8 drinks/week)

1 for drugs

57

1 for any liver

abnormalities

1 for alcohol

Transient ischemic attack

NICE issued updated guidelines relating to stroke and transient ischemic attack (TIA) in
2008.
They advocated use of ABCD2 prognostic score for risk stratifying patient who've had
suspected TIA:

Age

>60 years

1 point

Blood pressure at presentation

>140/90 mmHg

1 point

Clinical features

Unilateral weakness

2 points

Speech disturbance without weakness

1 point

More than 60 minutes

2 points

10-59 minutes

1 point

Present

1 point

D2

Duration of symptoms

Diabetes

This gives a total score ranging from 0 to 7:

1) People who have had a suspected TIA who are at a higher risk of stroke (ABCD2 score 4)
should have:
aspirin (300 mg daily) started immediately
specialist assessment and investigation within 24 hours of onset of symptoms
measures for secondary prevention introduced as soon as the diagnosis is confirmed,
including discussion of individual risk factors
2) If the ABCD2 risk score is 3 or below:
specialist assessment within 1 week of symptom onset, including decision on brain
imaging
if vascular territory or pathology is uncertain, refer for brain imaging
3) People with crescendo TIAs (2 or more episodes in a week)
Should be treated as being at high risk of stroke, even though they may have an
ABCD2 score of 3 or below.

58

Antithrombotic therapy:
(From passmedicine notes)
clopidogrel is recommended first-line (as for patients who've had a stroke)
aspirin + dipyridamole should be given to patients who cannot tolerate clopidogrel
These recommendations follow the 2012 Royal College of Physicians National clinical
guideline for stroke.
These guidelines may change following the CHANCE study (NEJM 2013;369:11). This
study looked at giving high-risk TIA patients aspirin + clopidogrel for the first 90 days
compared to aspirin alone. 11.7% of aspirin only patients had a stroke over 90 days
compared to 8.2% of dual antiplatelet patients
With regards to carotid artery endarterectomy:
recommend if patient has suffered stroke or TIA in the carotid territory and are not
severely disabled should only be considered if carotid stenosis > 70% according ECST*
criteria or > 50% according to NASCET** criteria

Treatment of TIA:
(From on examination)
Clopidogrel is the NICE approved treatment of choice for secondary prevention in
stroke, but is not licensed for treatment of TIA.
2
NICE TA210 recommends Aspirin and Dipyridamole.
It is suggested that all patients are started on Aspirin 300mg, and that a choice is made
on future antiplatelet therapy at TIA clinic, depending on symptoms, presence of
infarction on CT scan, tolerability of drugs, co morbidities.
Clopidogrel may be preferred in patients who cannot tolerate dipyridamole; those with
multivascular disease (eg coronary or peripheral vascular disease); those with overt
infarction on CT brain.
There is no strong evidence regarding appropriate treatment of patient who suffers TIA
/ stroke whilst on anti-platelet therapy.
These drugs reduce, but do not eliminate, the risk of recurrent stroke/TIA.
Some patients are resistant to anti-platelet effect of Clopidogrel so can consider
changing - also consider cardiac investigations looking for embolic source/arrhythmia.
There is evidence that early Aspirin is beneficial for 1-14 days, but no evidence for
immediate initiation of other antiplatelet drugs.

59

Dermatology
Bacterial infections
Disease
Impetigo

Causative organism

TTT

Staphylcoccus aureus

Limited, localised disease:

or

1) topical fusidic acid is first-line

2) topical retapamulin is used second-line if

Streptococcus pyogenes

fusidic acid has been ineffective or is not

tolerated
3) MRSA: Topical mupirocin (Bactroban)
should be used in this situation
(Not susceptible to either fusidic acid or
retapamulin)

Extensive disease:

Bullous
impetigo /
staphylococ
cal scalded
skin
syndrome

Cellulitis

Rarely Staphylococcus
releases an exfoliating
toxin which acts high up
in the epidermis:

oral flucloxacillin
oral erythromycin if penicillin allergic
Both bullous impetigo and SSSS are
treated with antistaphylococcal
antibiotics (e.g. flucloxacillin) and
supportive care.

A) Toxin A:
Causes blistering at

the site of infection

(bullous impetigo).
B) Toxin B
Spreads through the
body causing more
widespread blistering
(staphylococcal
scalded skin
syndrome, SSSS).
Streptococcus
1) The BNF recommends flucloxacillin as
pyogenes and Staphylc
first-line treatment for mild/moderate
occus aureus are the
cellulitis.
commonest causative
2) Clarithromycin or clindamycin is
organisms.
recommended in patients allergic to
Group
penicillin.
B Streptococcus has a
3) Many local protocols now suggest the
predilection for
use of oral clindamycin in patients who
diabetic patients.
have failed to respond to flucloxacillin.
4) Severe cellulitis should be treated with
intravenous benzylpenicillin +
flucloxacillin.

60

Ecthyma

Erythrasma

Folliculitis

Streptococcus or
Staphylococcus
aureus or occasionally
both.

Phenoxymethylpenicillin (penicillin V) &

flucloxacillin (both 500mg 4time/day) 1014 days

diphtheroid
Corynebacterium
minutissimum

Staphylococcus aureus

1) is with topical antiseptics, topical

Topical miconazole or antibacterial are

usually effective.
Oral erythromycin may be used for more
extensive infection

antibiotics (e.g. sodium fusidate) or

2) oral antibiotics (e.g. flucloxacillin 500 mg

or erythromycin 500 mg both four times

daily for 24 weeks)
Boils
(furuncles)

Staphylococcus

1) oral antibiotics (e.g. erythromycin 500 mg

four times daily for 1014 days)

2) Occasionally need incision and drainage.
3) Prophylaxis: Antiseptics such as

povidone iodine or chlorhexidine (as

soap) and using a bath oil can be useful
in prophylaxis
Erysipelas

Streptococcus pyogenes

Leprosy

Mycobacterium leprae.

IV antibiotics such as benzylpenicillin and

erythromycin.
In penicillin allergic patient a macrolide is
the drug of choice.

WHO recommended triple

therapy:
1) rifampicin,
2) dapsone and
3) clofazimine

Lupus vulgaris

The most common form of

cutaneous TB

61

Viral Infections
Herpes
simplex
virus

Eczema
herpeticum

HSV-1 and HSV-2.

Management:
1) gingivostomatitis: oral aciclovir,

chlorhexidine mouthwash
2) cold sores: topical aciclovir although the
evidence base for this is modest
3) Genital herpes: oral aciclovir. Some
patients with frequent exacerbations may
benefit from longer term acyclovir

Severe primary
infection of the skin by
HSV 1 or 2.
It is more commonly
seen in children with
atopic eczema.

Treatment requires systemic anti-virals,

for example, aciclovir.
Systemic antibiotics may be required if
lesions are secondarily impetiginised.
If life threatening, children should be
admitted for IV acyclovir

Parvovirus
B19

(erythrogen
ic virus)

Molluscum
contagiosu
m

no treatment is recommend in the initial

phase due to the benign nature of the
condition

62

Genital
warts
condylomata
accuminata

HPV 6&11

1) Topical podophyllum or cryotherapy is

commonly used as first-line treatments

depending on the location and type of
lesion:
Multiple, non-keratinised warts are
generally best treated with topical
agents
Solitary, keratinised warts respond
better to cryotherapy
2) imiquimod is a topical cream which is
generally used second line
3) genital warts:
are often resistant to treatment and
recurrence is common
although the majority of anogenital
infections with HPV clear without
intervention within 1-2 years

63

Fungal infections
Pityriasis
versicolor

Malassezia furfur

1) topical antifungal e.g. terbinafine or

selenium sulphide
2) extensive disease or failure to respond to

(tinea
versicolor)
Tinea
capitis
(Scalp
ringworm)

Tinea
corporis
(Ringworm)

topical treatment then consider oral

itraconazole

most common cause

is Trichophyton
tonsurans in the UK
and the USA
may also be caused
by Microsporum
canis acquired from
cats or dogs

1) Oral antifungals:
Terbinafine for Trichophyton

Trichophyton
rubrum and
Trichophyton
verrucosum (e.g. From
contact with cattle)

oral fluconazole

tonsurans infections and

Griseofulvin for Microsporum infections.
2) Topical ketoconazole shampoo should be

given for the first 2 weeks to reduce

transmission

Tinea pedis
(Athlete's
foot)

Fungal nail
infections

1) dermatophytes: mainly

Trichophyton rubrum,
accounts for 90% of
cases
(Onychomyc
2)
yeasts: such
osis)
as Candida
3) non-dermatophyte
moulds

A) Dermatophyte infection:
1) oral terbinafine is currently
recommended first-line
2) Oral itraconazole as an alternative.
3) fingernail infections 6 weeks - 3
months therapy is needed
Toenails infections 3 - 6 months
B) Candida infection:
1) mild disease should be treated with
topical antifungals (e.g. Amorolfine)
2) more severe infections should be
treated with oral itraconazole for 12
weeks

64

Infestations

Scabies

the mite Sarcoptes scabiei 1) permethrin 5% is first-line

2) malathion 0.5% is second-line
3) pruritus persists for up to 4-6 weeks post
eradication

Crusted
seen in patients with
(Norwegian) suppressed immunity,
especially HIV
scabies

1) Ivermectin is the treatment of choice

2) isolation is essential

65

Acne
rosacea

unknown aetiology

1) topical metronidazole may be used for

2)
3)
4)
5)

Acne
vulgaris

colonisation by the
anaerobic bacterium
Propioni-bacterium
acnes

mild symptoms (i.e. Limited number of

papules and pustules, no plaques)
more severe disease is treated with
systemic antibiotics e.g. Oxytetracycline
recommend daily application of a highfactor sunscreen
camouflage creams may help conceal
redness
laser therapy may be appropriate for
patients with prominent telangiectasia

A simple step-up management scheme often

used in the treatment of acne is as follows:
1) single topical therapy (topical retinoids,

benzyl peroxide)
2) combination topical therapy (topical

antibiotic, benzoyl peroxide, topical

retinoid)
3) Oral antibiotics: e.g. Oxytetracycline,
doxycycline.
Improvement may not be seen for 3-4
months.
Minocycline now considered less
appropriate due to the possibility of
irreversible pigmentation.
Gram negative folliculitis may occur
as a complication of long-term
antibiotic use
high-dose oral trimethoprim is
effective if this occurs
4) oral isotretinoin: only under specialist
supervision
5) There is no role for dietary modification in
patients with acne

66

Seborrhoeic
dermatitis
in adults

Malassezia furfur

Scalp disease management:

1) over the counter preparations

containing zinc pyrithione ('Head &

Shoulders') and tar ('Neutrogena T/Gel')
are first-line
2) the preferred second-line agent is
ketoconazole (Nizoral)
3) selenium sulphide and topical
corticosteroid may also be useful
Face and body management:
1) topical antifungals: e.g. Ketoconazole
2) topical steroids: best used for short

periods
3) difficult to treat - recurrences are
common

Infectious diseases
Palatal petechiae: Infectious mononucleosis

Palatal vesicles:
Dengue fever
Koplik spots: measles

67