Вы находитесь на странице: 1из 67

Clinical science

AIP - porphobilinogen deAminase; PCT - uroporphyrinogen deCarboxylase

Absolute risk reduction = (Control event rate) - (Experimental event rate)

Adrenal cortex mnemonic: GFR – ACD

Anaphylaxis = type I hypersensitivity reaction

Anticipation in trinucleotide repeat disorders = earlier onset in successive


generations

Antidiuretic hormone (ADH) - site of action = collecting ducts

Autosomal recessive conditions are 'metabolic' - exceptions: inherited


ataxias
Autosomal dominant conditions are 'structural' - exceptions:
hyperlipidaemia type II, hypokalaemic periodic paralysis

BNP - actions:
 vasodilator
 diuretic and natriuretic
 suppresses both sympathetic tone and the renin-angiotensin-
aldosterone system

Cohort studies - relative risk

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


syndrome, ataxic telangiectasia)

Correlation
 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
4
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

7
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, high-
pitched 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 pan-
systolic murmur is noted on examination - ventricular septal defect

8
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, Temporal-
Superior)
 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 beta-
lactamase 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, café-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-Barré 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 patient’s 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
disease’s 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
TTT
HOCM 1) Amiodarone Contraindicated
2) Beta-blockers or verapamil for  nitrates
symptoms  ACE inhibitors
3) Cardioverter defibrillator  inotropes
4) Dual chamber pacemaker
5) Endocarditis prophylaxis

Brugada syndrome ICD changes may be more


apparent following
flecainide
arrhythmogenic right 1) drugs: sotalol is the most widely
ventricular dysplasia used antiarrhythmic
(ARVD) 2) catheter ablation to prevent
ventricular tachycardia
3) ICD
Catecholaminergic 1) beta-blockers
polymorphic 2) ICD
ventricular tachycardia
(CPVT)
MAT calcium channel blockers Not useful
Cardioversion
Digoxin

SVT 1) Valsalva Maneuver


2) Adenosine
3) If asthmatic give verapamil
4) Electrical cardioversin

WPW Definitive treatment: radiofrequency **sotalol should be avoided


ablation if there is coexistent atrial
medical therapy: sotalol**, fibrillation may deteriorate
amiodarone, flecainide into ventricular fibrillation

AF Pharmacological cardioversion: Agents used to control


 amiodarone if structural heart rate:
disease, 1) beta-blockers
 flecainide in those without 2) calcium channel
structural heart disease blockers
 sotalol 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 If there is adverse signs
Bradycardia 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  If there is any adverse signs then


tachycardias 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

C Congestive heart failure 1

H Hypertension (or treated hypertension) 1

A2 Age >= 75 years 2

Age 65-74 years 1

D Diabetes 1

S2 Prior Stroke or TIA 2

V Vascular disease (including ischaemic heart disease and peripheral arterial 1


disease)

S Sex (female) 1

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

0 No treatment

1 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

H Uncontrolled Hypertension, , systolic BP > 160 mmHg 1

A Abnormal renal function (dialysis or creatinine > 200) 1 for any renal
Or abnormalities
Abnormal liver function (cirrhosis, bilirubin > 2 times normal,
ALT/AST/ALP > 3 times normal 1 for any liver
abnormalities

S Stroke, history of 1

B Bleeding, history of bleeding or tendency to bleed 1

L Labile INRs (unstable/high INRs, time in therapeutic range < 1


60%)

E Elderly (> 65 years) 1

D Drugs Predisposing to Bleeding (Antiplatelet agents, NSAIDs) 1 for drugs


Or
Alcohol Use (>8 drinks/week) 1 for alcohol

57
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:
A Age >60 years 1 point

B Blood pressure at presentation >140/90 mmHg 1 point

C Clinical features Unilateral weakness 2 points

Speech disturbance without weakness 1 point

D2 Duration of symptoms More than 60 minutes 2 points

10-59 minutes 1 point

Diabetes Present 1 point


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 Causative organism TTT

Impetigo 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:

 oral flucloxacillin
 oral erythromycin if penicillin allergic
Bullous Rarely Staphylococcus  Both bullous impetigo and SSSS are
impetigo / releases an exfoliating treated with antistaphylococcal
staphylococ toxin which acts high up antibiotics (e.g. flucloxacillin) and
supportive care.
cal scalded in the epidermis:
skin A) Toxin A:
syndrome  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).
Cellulitis  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  Streptococcus or  Phenoxymethylpenicillin (penicillin V) &
Staphylococcus flucloxacillin (both 500mg 4time/day) 10-
aureus or occasionally 14 days
both.

Erythrasma diphtheroid  Topical miconazole or antibacterial are


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

Folliculitis Staphylococcus aureus 1) is with topical antiseptics, topical


antibiotics (e.g. sodium fusidate) or
2) oral antibiotics (e.g. flucloxacillin 500 mg
or erythromycin 500 mg both four times
daily for 2–4 weeks)

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


(furuncles) four times daily for 10–14 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  IV antibiotics such as benzylpenicillin and


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

Leprosy ‫جذام‬ Mycobacterium leprae. WHO recommended triple


therapy:

1) rifampicin,
2) dapsone and
3) clofazimine

Lupus vulgaris The most common form of


cutaneous TB

61
Viral Infections

Herpes HSV-1 and HSV-2. Management:


simplex
1) gingivostomatitis: oral aciclovir,
virus
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

Eczema  Severe primary  Treatment requires systemic anti-virals,


herpeticum infection of the skin by for example, aciclovir.
HSV 1 or 2.  Systemic antibiotics may be required if
 It is more commonly lesions are secondarily impetiginised.
seen in children with  If life threatening, children should be
atopic eczema. admitted for IV acyclovir

Parvovirus
B19

(erythrogen
ic virus)

Molluscum no treatment is recommend in the initial


contagiosu phase due to the benign nature of the
m condition

‫المليساء المعدية‬

62
Genital HPV 6&11 1) Topical podophyllum or cryotherapy is
warts commonly used as first-line treatments
depending on the location and type of
condylomata
lesion:
accuminata  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 Malassezia furfur 1) topical antifungal e.g. terbinafine or


versicolor selenium sulphide
2) extensive disease or failure to respond to
(tinea topical treatment then consider oral
versicolor) itraconazole

Tinea  most common cause 1) Oral antifungals:


capitis is Trichophyton  Terbinafine for Trichophyton
tonsurans in the UK tonsurans infections and
(Scalp and the USA  Griseofulvin for Microsporum infections.
 may also be caused 2) Topical ketoconazole shampoo should be
ringworm)
by Microsporum given for the first 2 weeks to reduce
canis acquired from transmission
cats or dogs

Tinea  Trichophyton oral fluconazole


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

Tinea pedis

(Athlete's
foot)

Fungal nail 1) dermatophytes: mainly A) Dermatophyte infection:


infections Trichophyton rubrum, 1) oral terbinafine is currently
accounts for 90% of recommended first-line
(Onychomyc cases 2) Oral itraconazole as an alternative.
osis) 2) yeasts: such 3) fingernail infections → 6 weeks - 3
as Candida months therapy is needed
3) non-dermatophyte Toenails infections → 3 - 6 months
moulds 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 1) Ivermectin is the treatment of choice


(Norwegian) suppressed immunity, 2) isolation is essential
scabies especially HIV

65
Acne unknown aetiology 1) topical metronidazole may be used for
rosacea mild symptoms (i.e. Limited number of
papules and pustules, no plaques)
2) more severe disease is treated with
systemic antibiotics e.g. Oxytetracycline
3) recommend daily application of a high-
factor sunscreen
4) camouflage creams may help conceal
redness
5) laser therapy may be appropriate for
patients with prominent telangiectasia

Acne  colonisation by the A simple step-up management scheme often


vulgaris anaerobic bacterium used in the treatment of acne is as follows:
Propioni-bacterium
acnes 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 Malassezia furfur Scalp disease management:
dermatitis
1) over the counter preparations
in adults
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