Random stuff - Part 1

• Conduction deafness - Paget's disease, Otosclerosis, Fracture through the petrous temporal bone, Otitis media. Sensorineural - Acoustic neuroma
• Epistaxis - Mostly idiopathic, upper parts - Internal carotid artery (REST EXTERNAL), hereditary haemorrhagic telangiectasia (HHT) nosebleed treated with oestrogens or mucosal skin grafts, external carotid artery ligation, antibiotic cover for postnasal space packing
• Sinusitis - Kartagener's syndrome, usually viral, broad-spectrum antibiotics, not from thickened-mucosa on CT (meaningless), removal of entire sinus mucosa is a treatment option
• Oral cavity carcinomas - squamous cell carcinomas mainly, alcohol consumption of is risk factor, lateral border of tongue and floor of the mouth, treatment both sides and lymph nodes need to be removed
• Tonsillitis - in hospital use Paul Bunnell (monospot for EBV) test, Peritonsillar abscess with tonsillitis is quincy, can cause acute glomerulonephritis
• Hypokalaemia - aggravates digoxin toxicity and is common in alkalosis
• Eosinophilia - Toxoplasma (is a protozoan!), Hookworm infestation, Hodgkin's lymphoma, asthma, and allergic bronchopulmonary aspergillosis
• Prophylaxis of classical migraine - Pizotifen and Propranolol. Ergotamine is DURING attack. Carbamazepine is for trigeminal neuralgia
• Acanthosis nigricans - intra-abdominal neoplasia, squamous papilloma is benign, and cutaneous malignancy relations are - (Leucoplakia, Solar keratosis, Bowen's disease)
• Increased cardiac size - Pericardial effusion, aortic regurgitation and congestive cardiomyopathy
• Raised intracranial pressure - CN5 and 7 are spared, but 3 and 6 are not. Convulsions. Pupil dilated
• Polycystic kidney disease - have children with disease, die of subarach, episodes of haematuria, urolithiasis, develop carcinoma of the kidney
• Non-suppurative otitis media - Especially common in children with cleft palate, painless loss of hearing, facial nerve palsy is COMPLICATION of this, sterile middle ear effusion
• Paget's disease of the nipple is ductal carcinoma (in situ) of the breast with good prognosis
• Gallstones: Oral contraceptive pill, may be silent through life, may cause small bowel obstruction, iron deficiency anaemia increases likelihood of gallstones, carcinoma of bladder presents with gallstones
• Paralytic ileus, whole bowel (large and small)
• Oesophageal carcinoma - plummer vinson (web due to iron deficiency anaemia), achalasia, reflux oesophagitis and coeliac disease predispose
• Dupuytren's contracture - Hereditary basis, high recurrence, may need to amputate
• Genito-urinary fistulae - malignant disease, radiotherapy, surgical trauma, chronic inflammatory conditions, obstructed labour and difficult instrumental delivery
• Diabetes insipidus - autosomal recessive
• SLE - eosinophilia, pericarditis, splenomegaly, (non-erosive) arthritis, butterfly rash
• Hypoparathyroidism is not associated with growth retardation but pseudohypoparathyroidism is
• Renal cell carcinoma - PERSISTENT PYREXIA, tumour embolism, polycythaemia and bone metastases
• Entamoeba histolytica - amoebic liver abscess. Right lobe, drain not surgical, occur with intestinal amoebiasis
• Osteomyelitis doesn't need early surgical treatment if you give antibiotics early and it works
• Distal fragment in Colles' fracture is impacted, laterally angulated, dorsally angulated, displaced and supinated
• Anencephalic fetus - Polyhydramnios often present, gestation is prolonged, fetal adrenal hypoplasia, dystocia, female fetus
• Wide pulse pressure - LOW PERIPHERAL VASCULAR RESISTANCE. Seen with Complete heart block, thyrotoxicosis, PDA. constrictive pericarditis and mitral stenosis don't cause it.
• Testes are atrophied in Klinefelter's syndrome and myotonic dystrophy hence male infertility
• Ulcerative colitis does NOT cause malabsorption because it's only in large intestine!
• Constrictive pericarditis - raised JVP raised even more on inspiration (Kussmaul's sign) and with splenomegaly, ascites and hepatic congestion
• Haemophilia is X linked recessive. Haemachromatosis and phenylketonuria are autosomal recessive
• Third heart sound - Mitral incompetence, heart failure, physiological in children
• Aortic stenosis doesn't cause AF. AF caused by: diabetes mellitus, thyrotoxicosis, rheumatic fever and dressler's syndrome. Ischaemic heart disease and hypertension and alcohol as well.
• Iron deficiency anaemia - can be caused by chronic infection (Hookworm infestation most common cause in world)
• Fistula in ano - lining of anus to perianal skin: Leukaemic patients, crohn's disease, anorectal tumours. Diverticulitis doesn't cause
• Cholelithiasis - MORE common in WOMEN, associated with crohn's and cirrhosis. no relation to kidney stones.
• Ectopic pregnancy: 95% fallopian tube, ovary, endometriosis, hormonal contraception, tubal abortion
• Polyhydramnios - malformations :)
• Pleural effusion - PE, sarcoidosis, TB, pneumonia, Dressler's
• Butterfly rash - Rosacea or SLE
• Ventricular outflow obstruction - narrow pulse pressure
• Carcinoma of the bronchus - gynaecomastia because of prolactin ectopic production, myasthenic syndrome, hypertrophic pulmonary osteoarthropathy (HPOA) related to cancer and finger clubbing (painful ankles and wrists), hypokalaemia due to SIADH
• AAA associated with popliteal aneurysm, presents as renal colic and is a familial condition
• Anterior dislocation of shoulder - Axillary nerve injury (Regimental badge). Posterior fracture dislocation of the hip - sciatic nerve injury
• Postmenopausal bleeding - cancer, senile vaginitis, urethral caruncle
• Some broad spectrum antibiotics such as chloramphenicol and co-trimoxazole cause bone marrow suppression -> Thrombocytopenia
• Multiple myeloma - Back pain, vertebral fractures, spastic paraplegia, anaemia, immune paresis, hyperviscosity syndrome, hypercalcaemia, peripheral neuropathy and amyloidosis
• Crohn's - transmural involvement, rectal sparing and gallstones
• Neomycin therapy causes malabsorption
• Rheumatoid arthritis - afternoon fatigue
• Metronidazole for trichomonas
• Alcohol dependence syndrome - increased tolerance to alcohol, relief or avoidance of withdrawal syndromes by further drinking, subjective awareness of the compulsion to drink and a narrowing of drinking repertoire
• Cannabis intake - euphoria with drowsiness, distorted and heightened images, altered tactile sensations, tachycardia, hypertension, and ataxia with visual and auditory hallucinations. Injections - vomiting within minutes, profuse watery diarrhoea after an hour
• ASD can cause ESM
• Turner's syndrome and coarctation, Myxoedema and cardiomyopathy
• High blood pressure doesn't change mortality in MI
• Central cyanosis - when concentration of reduced haemoglobin in blood exceeds 5g/dl AND haemoglobin concentration, when venous blood by-asses the lungs. Finger clubbing in children - 3 months of age begin
• Large ventricular septal defect - pulmonary hypertension, present towards end of first month of life, congestive heart failure, surgically treated
• Atrial septal defect - Mitral regurgitation. Ventricular septal defect - Aortic regurgitation
• Drug metabolism - in the liver. Oxidation and conjugation
• Atlanto-axial subluxation in RA. BEWARE
• Double left cardiac border - Left lower lobe collapse
• External fixation - Mobilise limb early, infected or contaminated fractures, delayed healing due to over distraction, good for compound fractures
• In cerebral oedema on CT scan, there is loss of sulci and 'ground glass' appearance of oedema. Intravenous mannitol infusion would reduce cerebral oedema
• Onycholysis - separation of nail plate from nail bed. Seen in Trauma, Psoriasis, HLA B27 diseases and hyperthyroidism
• Right hemidiaphragm is higher than the left because it is PUSHED UP by the liver. Hila are opposite. Left hilum is higher than right ALWAYS unless pathological
• Chest drain definitely needed in tension pneumothorax
• Materal mortality rate - per 100000 live births. Infant mortality rate - number of deaths among infants under one year of age per 1000 live birth. Neonatal mortality rate - number of deaths among infants under 28 days of age per 1000 live births. Stillbirth rate - delivered after 24 weeks or more weeks of gestation, which did not, at any time, breathe or show any signs of life per 1000 deliveries. The number of deliveries consists of live births + stillbirths. Perinatal mortality rate - Stillbirth rate + up to 6 days post delivery. (Early neonatal)
• S.mansoni causes schistosomiasis. Freshwater snails. Causes eosinophilia and treated by praziquantel or oxamniquine.
• Leptospirosis - L.interrogans, 2-20 days incubation, Renal failure, hypercatabolic. 30:1 urea/creatinine ratio. Some cause jaundice. Doxycycline
• Leprosy: Foot drop, lagophthalmos, hypopigmented macules, testicular atrophy
• Malaria - Plasmodium falciparum, Leishmaniasis - Kala azar
• Unconjugated bilirubinaemia in infancy - Normal liver enzymes, pale stools and jaundice
• Chronic hepatitis - oxyphenisatin, nitrofurantoin, methyldopa. Hepatitis C and Wilson disease can also cause it.
• Primary biliary cirrhosis - women, osteoporosis relations. anti nuclear antibodies and anti mitochondrial antibodies
• Hepatic ascites - increased hepatic lymph production, decreased albumin production and decreased plasma colloid pressure
• Pigment stones are associated with bacteria, symptomatic stones - cholecystectomy. Many stones remain symptomless.
• Hepatocellular carcinoma - DON't biopsy, AFP raised, >2cm on USS
• Systemic amyloidosis - proteinuria, Heart block, Macroglossia, Purpura, Peripheral neuropathy
• Polyarteritis nodosa - veins as well. Men>women. 30-60 age group. Small-medium vessel vasculitis. Prednisolone and azathioprine. p-ANCA
• Beta-HCG (Seminoma + teratoma) and AFP (teratoma)
• Quadriceps - femoral nerve. Gastrocnemius - sciatic nerve. Interossei - ulnar
• Hypercalcaemia doesn't cause seizures
• Intracranial aneurysms: Anterior communicating, internal carotid, and middle cerebral arteries. Familial and not associated with hypertension
• AV malformation: Intracerebral > subarachoid bleeding. Has worse prognosis than intracerebral aneurysms
• Meningiomas are benign tumours. Malignant gliomas are most common intracranial tumours. Over age 40 mostly. Respond to radiotherapy. Recurs following surgical resection
• MND - unknown aetiology. 50-70. Riluzole increase survival by 3 months. Respiratory failure most common cause of death.
• Acute facial palsy - sarcoidosis (bilateral), Guillaine Barre syndrome, Lyme disease (Bilateral), Herpes zoster oticus, HIV infection (Bilateral)
• Cow's milk has more protein than human's milk however they have similar fat contents. Vitamin K levels are low in breast milk. Vitamin K given to infants as prophylaxis. 1mg I.M or S.C. Iron deficiency in exclusively breastfed babies starts at around 6 months.
• Muscle weakness in malignant hypercalcaemia, which is the most common life-threatening metabolic disorder associated with cancer. Diuretics, calcitonin, diphosphates to treat
• Cerebral hemisphere more likely affected than cerebellum -> Cerebral mets
• Superior vena-caval obstruction - distension of superficial thoracic veins, proptosis, conjunctival oedema
• Risk of breast cancer increases with early menarche. High socioeconomic status is linked (not low). Also, incomplete pregnancies don't seem to affect risk.
• Increasing risk of cervical cancer: cervical intra-epithelial neoplasia, teenage sexual intercourse, OCP, increasing parity and smoking
• Endometrial cancer - well differentiated adenocarcinoma. Haven't spread to local lymph glands at diagnosis
• Bone tumours seldom metastasise to lymph nodes, and bone fractures are painful (as opposed to pain free in mets). Bence-jones protein in urine not blood in Multiple Myeloma
• Osteosarcoma most common bone tumour, Most tumours affect ends of long bones, Radiology is very effective, Bone tumours seldom metastasise to lymph nodes. Surgery + chemo is mainstay, not surgery + radiotherapy
• Gingival swelling - ciclosporin, phenytoin, nifedipine
• Dry mouth: Monoamine oxidase inhibitors, antihistamines, bronchodilators, phenothiazines, amphetamines
• Pigmented mucosal lesions in mouth - Kaposi's sarcoma, Haemochromatosis
• Lead poisoning - Desferrioxamine mesylate. Dimercaprol or Penicillamine - arsenic poisoning and mercury poisoning
• Activated charcoal - best adsorbent currently available. Not for acids, alkalis or ethanol however
• Salicylate overdose - hypotension and cardiac arrest, bradycardia, hyperventilation, deafness and sweating
• Lithium poisoning: Nystagmus and cardiac rhythm disturbances
• Schizophrenia - Lack of catatonic symptoms - worse outcome
• Reduced appetite and difficulty sleeping are recognised effects of 5HT re-uptake inhibitors
• Tricyclic antidepressants -> Anticholinergic effects -> Blurred vision, constipation, tachycardia
• Puerperal psychosis begins in the first week postpartum following a 'lucid interval' of several days. Mood changes, irritability and sleepiness. Keep mother and child together in specialised mother and baby units. 2-3 months recovery and 35% risk of recurrence after subsequent delivery
• Solvent abuse - disinhibited, excited state which disappears within a few minutes
• Down's syndrome -> HYPOTHYROIDISM! Also remember Alzheimer's disease
• Renal ultrasonography -> Good for delineating renal parenchyma, bad for small caliceal lesions.
• Muscle cramps - furosemide, Cutaneous flushing+headaches+fluid retention - Calcium channel blocker, Hirsutism - powerful vasodilator minoxidil and ciclosporin
• Nocturnal enuresis - Urodynamic studies often unhelpful, tricyclics work but don't know why
• Childhood urinary tract infection: mostly benign outcome, is diagnosed once culture of fresh urine yields pure bacterial growth is greater than 10^5/ml, vesicoureteric reflux 2/3 children, caused by unsuspected surgical disorder in 5% of children
• UTI affects approximately 25-35% of all women at some time in their lives. UTI more common in women than men, but NOT true after 65. UTI usually E.coli but if with catheter or any other instrumentation - Pseudomonas spp.
• Wilms' tumour is most common tumour in children (RCC less common!)
• Acute epiglottitis (EP) usually caused Haemophilus Influenzae type B, 2-3 years most commonly, should be managed in hospital
• Foreign body imaging - Not there at first but may appear later
• PFTs in children start from 7-8 years of age
• 80% of patients with idiopathic pulmonary fibrosis die within 5 years. Patients don't need high dose steroids but can be considered for lung transplantation. Not classified as an occupational disease
• Progressive massive fibrosis: lung opacities greater than 10mm in diameter. Upper lobes are affected first. Associated with emphysema, and develop after worker has stopped coalmining
• Smoking - No genetic association, 80-84 age range of diagnosis, 6:5 men:women in the UK
• Bronchiectasis - Tuberculosis, Histoplasmosis, Allergic aspergillosis, Measles, Pertussis
• Rheumatoid arthritis - depression and generalised lymphadenopathy
• AK as prevalent as RA. Can have normal ESR
• Pseudogout -> Preformed calcium pyrophosphate dihydrate crystals from deposits mainly in the fibrocartilage. Systemic features are common. self limiting. 1-3 weeks resolves
• Gout can cause renal impairment
• NEW pacemakers can be used in MRI scanners now
• Hyperkalaemia, red cell aplasia and haemolytic anaemia -> NSAIDs side effects
• Ultrasound and bone scintigraphy - GOOD FOR STRESS FRACTURES
• Osteomalacia - pseudofractures - Looser's zones and milkman fractures. proximal myopathy. ALP raised. Bone pain in osteomalacia
• Parathyroid hormone is secreted in response to hypocalcaemia
• Anaerobic (or bacterial) vaginosis is a multibacterial infection in which Gardnerella vaginalis and Bacteroides play an important role
• Tertiary syphilis - Cranial nerve lesions, Gummatous lesions of the skin, Aortitis, Tabes dorsalis
• Genital herpes causes inguinal lymphadenopathy
• Pork liver and cranberry juide - INR target disruptors (Pork liver because high in vit K)
• Myeloma and squamous cell lung cancer -> Cause severe hypercalcaemia
• Radiotherapy side effect: Indigestion, Cystitis, Sensory neuropathies, Skin pigmentation and cataracts
• Congenital cytomegalovirus: Microcephaly, chorioretinitis, sensorineural hearing loss
• Anorexia nervosa has no loss of axillary and pubic hair unlike hypopituitarism, and are fatigued due to altered sleep patterns
• lead exposure (occupational) leads to gout
• Haemochromatosis can cause secondary diabetes mellitus
• Classical renal tubular acidosis does not cause increased anion gap
• Achalasia - Painful dysphagia. Oesophageal manometry better than barium swallow
• Carcinoid syndrome: Flush and Diarrhoea
• Erythromycin and peptic ulcers DONT cause acute pancreatitis
• Chronic pancreatitis - Splenic vein thrombosis, Diabetes, Non-diabetic retinopathy
• Cardiac syncope: Rhythm related or right/left outflow obstruction
• Mitral regurgitation: Osteogenesis imperfecta, alcohol, Marfan's syndrome, Hypertrophic cardiomyopathy
• Coarctation of the aorta: distal to left subclavian, common in males, Noonan's syndrome, surgical repair can be complicated by abdominal pain
• Liver and adrenal metastases are common in Bronchial Carcinoma
• Upper zone fibrosis - Radiation, extrinsic allergic alveolitis, Ankylosing spondylitis, tuberculosis.
• Lower zone fibrosis - Drugs (amiodarone), Asbestos exposure, Connective tissue diseases (including rheumatoid disease), idiopathic
• High resolution CT for fibrosis
• Paget's disease requires mastectomy, nearly always associated with intraduct carcinoma
• Erythema nodosum (painful nodules): Bacterial infection (streptococcal infection), drugs (OCP, sulphonylureas and sulphonamides), sarcoidosis, tuberculosis, inflammatory bowel disease (ulcerative colitis)
• Small bowel diverticulae - congenital jejunal diverticulae (commonest) occur on mesenteric border. Meckel's, remnant of vitellointestinal duct, occurs on antemesenteric border -> Contains Gastric type epithelium which can bleed.
• Intussussception - does not usually show signs of large bowel obstruction on plain abdominal film. Treated by hydrostatic barium enema. Mass felt per rectum
• Colon cancer spread to liver not usually bone.
• Full thickness rectal biopsy is necessary for the diagnosis of Hirschprung's disease - block of large intestine due to improper muscle movement in the bowel (neurological - nerves are missing from part of the bowel)
• 'Junctional escape' rhythm is when the atria are not controlling and it's just like the ventricles or AV node in charge
• Microcytic anaemia - lead poisoning and aluminium toxicity
• Megaloblastic anaemia: Vitamin B12 deficiency, Folate deficiency
• Non-megaloblastic anaemia: Alcohol excess, liver disease, myxoedema (hypothyroidism), pregnancy, reticulocytosis, drugs (cytotoxics, azathioprine)
• Meig's - transudate
• Hyperkalaemia doesn't cause prolonged QT
• Pneumaturia can be caused by diverticular disease. Low residue diets CAUSE diverticular disease
• Branchial cysts because incomplete fusion of the branchial arch system. Thyroid gland migrates from foramen caecum.
• Splenectomy indicated for blunt abdominal trauma and idiopathic thrombocytopenia
• Developmental dysplasia of the hip (DDH): may be associated with other congenital abnormalities.
• Irritable hip in children - bed rest without traction
• Osteoporosis - ALP normal unless fracture, male<female, can be produced by steriod therapy and associated with rheumatoid arthritis
• Internal fixation complications: Infection, implant failure, re-fracture, non-union, nerve damage
• Thrombocytopenia is a well recognised side effect of many antibiotics
• Flail chest - usually multiple rib fractures (not just 1)
• Secondary hydrocele MAY be caused by ascites
• Branchial cyst - squamous or columnar epithelium
• Popliteal aneurysms bilateral in about 50% of cases. Other 50% unilateral
• Splenic rupture - abdominal ultrasound. Rectal examination reveals tenderness. Splenectomy avoided if feasible in children under 5 years
• Medullary carcinoma of thyroid gland: calcitonin producer, NOT radiosensitive, cold nodule on radioactive isotope studies
• Haustrae - large bowel obstruction. Valvulae conniventes - small bowel obstruction
• FNA - breast and thyroid diagnosis ONLy
• Hesitancy (and terminal dribbling) are cardinal signs of BPH. dysuria, frequency and urgency suggest infection or secondary detrusor instability. Impotence is not associated with BPH. Bleeding may occur from the enlarged gland, and bladder neck obstruction may cause thickening and trabeculation (of the bladder)
• Almost everything you can use positive pressure ventilation (within reason)
• During pregnancy - increase in tidal lung volume
• Gastrin release - stimulated by gastric distension and protein ingestion. Main action is stimulation of gastric acid secretion primarily from parietal cells. Duodenal ulcer - H.pylori induced hypergastrinaemia
• Osteoblasts - mesenchymal stromal cell system. Osteoclasts - Haemopoietic system. Osteoblasts are activated by parathyroid hormone and 1,25 dihydroxycholecalcalciferol
• If deceased was not seen immediately after death then CORONER
• In older people, haemoglobin concentration falls and residual volume in lungs fall although total lung volume stays the same
• Stress fractures in the leg: second and third metatarsals most commonly affected, plaster of paris not really necessary. X rays may appear normal but bone scintigraphy is good to diagnose. Insonation by Physiotherapist's ultrasound application is good.
• Back and leg pain may come about with intestinal distension
• Colonic pain can go to thighs or back
• VAGUS doesn't transmit pain
• Pancreatic pain - RELIEVED by curling up and made worse with lying flat
• Small intestinal pain is central and midline, usually colicky and radiating to the back
• NO is synthesised from L-arginine in endothelial cells and other tissues. half life a few seconds and rapidly deactivated by haemoglobin. Stimulated by: Sheer stress, aggregating platelets, acetylcholine, bradykinin and substance P
• Phase 0: Na+ influx, Phase 1: K+ efflux, Phase 2: Ca++ influx, Phase 3: repolarisation
• Ichthyosis vulgaris , peutz jegher and neurofibromatosis are autosomal dominant
• Fasting plasma phosphate concentration is determined by rate of renal tubular reabsorption
• Retinal vein occlusion may take place overnight (hours), subsequent improvement of vision is NOT rare, glaucoma important risk factor. No evidence for aspirin long term
• Diabetes - cataract, glaucoma, retinal vein occlusion
• Microalbuminaemia can't be done using normal dipstix. Tamm-horsfall protein is the sole constituent of hyaline casts (secreted in distal convoluted tubule by distal convoluted tubular cells) - possible link to renal stones
• DMSA technetium-based and avidly retained in tubular cells allowing for assessment of scarring in reflux nephropathy
• Captopril renography has good sensitivity and specificity for renal artery stenosis detection
• In nephrotic syndrome, SALT RESTRICTION IS BETTER THAN WATER RESTRICTION!
• SLE is associated with ANCA positive vasculitis
• Proteinuria drugs: Gentamicin, Penicillamine, Lithium, Cisplatin, Tetracycline
• Genital herpes: 20 days first attack duration, Neonatal form can be avoided by caesarean section delivery, recurrent attacks are shorter than first (UNLESS IMMUNOCOMPROMSIED THEN LONGER)
• Bacterial vaginosis doesn't involve inflamamtion of the vagina (that's why no pruritus). Metronidazole is best. Can recur again.
• Melanocytes are found in the epidermis. Skin bloodflow can increase by a factor of 100x when vasodilation occurs
• Severe pain on compression of leiomyoma, neuroma and glomus tumour (a glomus body is a component of the dermis layer involved in body temperature regulation)
• Gastric atrophy and presence of antibody to the parietal cell - vitiligo and alopecia areata
• Pigmentation (and malnutrition) of skin associated with Whipple's disease
• Schizophrenia - 25% lasting recovery, 25% develop chronic disorder, 50% repeated episodes with varying recovery between illnesses
• 1-2% of women in GB fulfill the criteria for BN
• Alzheimer's disease - 1/14 of people over 65. Schizophrenia no relation to dementia late rin life.
• Deliberate self harm patients - 25-50% have underlying personality disorder
• Ecstacy and hyperthermia, Cardiac arrhythmias and glue/cocaine, Pulmonary oedema and cocaine, Candida infection and heroin
• Alcohol withdrawal - visual hallucinations, tachycardia, grand mal fits, hyperacusis
• Diverticula occur at the site where colonic vessels penetrate the wall, diabetic patients are prone to diverticular disease, fully developed diverticulum is covered by mucosa, connective tissue and peritoneum but no muscle (THERE IS MUSCLE ATROPHY)
• Only 10-15% with familial adenomatous polyposis (FAP) of the small bowel develop a malignancy - most commonly an adenocarcinoma of the Ampulla of Vater. Coeliac disease -> increased incidence of bowel cancer
• Surgery does not always have success in chronic intestnial ischaemia (due to atheroma)?
• Chlamydia infection in females: endocervical bleeding, mucopurulent cervical discharge, intermentrual bleeding, dysuria and abdominal pain. Most are asymptomatic though. Think macrolides, tetracycline based regimes or ampicillin.
• Pegaptanib and ranibizumab are anti-VEGF agents
• Carbon monoxide poisoning: CT scanning demonstrates cerebral oedema, MRI later shows white matter demyelination. Sudden cardiac death may occur. Permanent neurological impairment manifesting as minor personality changes may occur. Features of CO poisoning: Carboxyhaemoglobin levels above 20-25% with significant acute neurological impairment
• Internal jugular line insertion is associated with less complications than subclavian line insertion.
• Beta 1 for heart, Beta 2 for lungs. Beta-1 receptor stimulation leads to an increase in the force and frequency of cardiac contraction
• Morning vomiting: pregnant women, alcoholics, uraemia
• During or soon after a meal: Psychological causes
• Soon after a meal: pyloric canal ulcers
• Delayed vomiting: peptic ulcer, gastric carcinoma, gall bladder disease, intestinal obstruction
• Projectile vomiting: Pyloric stenosis or raised ICP
• HYPERCALCAEMIA causes constipation, not hypocalcaemia. In Crohn's you can have constipation due to partial stricture in the intestines (although it is still mostly diarrhoea)
• Transfusion should aim to increase haemoglobin to at least 10g/dl in most patients
• Central venous lines should be more readily offered to older people due to their vulnerability to circulatory collapse
• Recurrent oral ulcers (age range 10-40), is familial, Oral ulcers extending to vulvovaginal sites is part of Behcet's syndrome.
• Xerostomia - Chemotherapy, Hypertensive drugs, Diabetes, Anaemia
• Oesophageal damage: Tetracycline, captopril, slow-release theophylline, bisphosphonates. (Pills that go through slowly)
• Duodenal ulcers: almost all have H pylori, reduces relapse, duodenal ulcers do not occur in anacidic patients (and opposite true for Zollinger Ellison), more acid is secreted, urban>rural
• Coeliac disease - only small intestine, may be complicated by T cell lymphoma
• Whipple's disease - pigmentation NOT vitiligo, clubbing, pleurisy, arthritis, hypotension. Caused by actinomycete Tropheryma whipplei
• Tropical sprue - adults more than children, acute diarrhoea, fever and malaise FOLLOWED BY chronic diarrhoea, steatorrhoea, weight loss, anorexia, malaise and nutritional deficiencies. Can occur in stomach, small intestine and large intestine (all)
• Crohn's disease - complicated by amyloid. All classes equally affected. Also, abdominal mass (UC less likely)
• Women with UC: NORMAL fertility
• Scromboid poisoning occurs in poorly refrigerated fish in which the bacteria have caused breakdown of histine in fish muscle to saurine, a histamine-like subtance. The effect of eating the fish is rather like histamine poisoning with diarrhoea, flushing, urticaria, myalgia, and swelling of tongue and throat.
• Haemochromatosis can lead to hepatocellular carcinoma.
• Porphyria cutanea tarda is characterised by skin light sensitivity.
• Wilson's disease - haemolytic anaemia. NOT haemochromatosis. Both affect liver.
• Onset of diabetes after age of 50 years without any other signs (no obesity etc) should alert one to pancreatic cancer. Other things include thrombophlebitis, bleeding from oesophageal varices, icterus, scratch marks. NOT bone pain
• Haemolytic anaemia - Won't have bilirubinuria
• Hepatitis A - patients under 30 anicteric throughout course of the illness. IgM anti-HAV in patient's blood is diagnostic.
• Closure of aortic valve precedes pulmonary closure
• Nitrates and calcium antagonists relieve oesophageal spasm AS WELL AS angina
• Gliclazide and carbamazepine are CYP450 enzyme inducers. Reduce effectiveness of OCP
• Hepatic failure avoid prodrugs such as: Enalapril, Diamorphine, Aciclovir, Valaciclovir
• Methaemaglobinaemia: rare conditon that occurs when the iron component carrying haemoglobin is oxidised to ferric iron. This prevents it from carrying oxygen adequately to the tissues and leads to tissue hypoxia. Even with NORMAL PaO2. Fungicides, amyl nitrate and dapsone (for leprosy) cause it.
• Digoxin and glibenclamide excreted by kidneys. Beware in RENAL FAILURE!
• MEN 1 - Parathyroid, Pancreatic, Pituitary adenoma.
• MEN 2a- thyroid and adrenals (with parathyroid too)
• MEN 2b- Mouth, eyes and, adrenal, thyroid, submucosa of almost all organs in first decade of life. Sons twice as likely to get MEN 2b than daughters
• Kallman's syndrome (single gene mutation): failure of episodic GnRH secretion and anosmia. Absent olfactory bulbs on MRI. Testosterone replacement as treatment. Pulsed exogenous gonadotrophins for restoration of fertility, but remember to stop testosterone. Increased cleft palate and lip.
• Femoral triangle: Superiorly = inguinal ligament. Medially = adductor longus. Laterally = sartorius. Floor = iliopsoas, pectineus and adductor longus
• Inguinal canal = spermatic cord in man, round ligament in women and ilioinguinal nerve in both
• Conjoint tendon. Fusion of transversus abdominis and internal oblique (POSTERIOR WALL)
• Hip joint stability: Iliofemoral, ischiofemoral, and pubofermoal.
• Zygoma articulates with sphenoid, temporal and maxillary bones
• Ethmoid, maxilla and vomer - nasal septum
• External carotid: Superior thyroid, Ascending pharyngeal, Lingual, Facial, Occipital, Posterior auricular, Superficial temporal, Maxillary.
• Epiploic foramen: Lesser omentum (hepatic artery, portal vein and bile duct) anteriorly, Inferior vena cava posteriorly, Caudate process of caudate lobe of liver superiorly, First part of the duodenum inferiorly.
• Parietal, frontal, sphenoid (greater wing), temporal - Pterion
• Antecubital fossa: laterally: Brachioradialis muscle, medially: pronator teres muscles, base: line connecting epicondyles of the humerus
• Anterior compartment: Sartorius, iliacus, psoas, pectineus, and quadriceps femoris - Femoral artery and femoral nerve.
• Medial compartment: gracilis, obturator externus muscles, adductor longus, brevis and magnus - profunda femoris and obturator arteries and innervation by obturator nerve
• Posterior compartment: Biceps femoris, semitendinosus, semimembranosus - profunda femoris artery and SCIATIC nerve
• Bones of foot: Calcaneus - heel bone. Talus - ankle bone. Navicular - in front of talus, Cuboid - in front of calcaneus, cuneiform - lateral, medial and infermediate in front of navicular.
• Chorda tympani - from facial nerve VII. 2/3 tongue. 1/3 posterior from glossopharyngeal
• Cricopharyngeus and aorta make natural indentations in the oesophagus
• Contents of popliteal fossa: popliteal vessels, small saphenous vein, common peroneal and tibial nerves, posterior cutaneous nerve of thigh, genicular branch of the obturator nerve, fat and lymph nodes
• Lower leg: Anterior (Anterior tibial artery and deep peroneal nerve), posterior (Posterior tibial artery and tibial nerve), and lateral (Peroneal artery and superficial peroneal nerve) compartments. Different from thigh.
• Urgent fasciotomy - for compartment syndrome
• Flexor digitorum superficialis(middle phalange insertion) and flexor digitorum profundus (distal phalange insertion) both run through the carpal tunnel
• Rib: Head, neck, tubercle, angle, shaft
• External laryngeal nerve (from superior laryngeal nerve which is from vagus nerve) (vocal cord cannot be tensed due to loss of cricothyroid function) and recurrent laryngeal nerve (vagus nerve) can both be destroyed during surgery
• Anatomical snuffbox: Medial border: Extensor pollicis longus. Lateral border: Extensor pollicis brevis and abductor pollicis longus
• Hip bone - Ilium, ischium and pubis
• Roof of orbit: frontal bone and lesser wing of sphenoid. Medial wall: Lesser wing of sphenoid, ethmoidal, lacrimal, and maxillary bones. Floor: zygoma and maxilla. Lateral wall: zygoma and greater wing of sphenoid
• Clozapine - >350 micrograms / litre and <1000 micrograms/litre or you get seizurs. 600micrograms/litre is okay.
• Men have lower QTc range (up to 440). Women have (up to 470). More than 500, stop offending agent. Methadone.
• VAN - top to bottom - intercostal
• Angle of Louis - T4.
• Taenia Coli - Large bowel. Valvulae Conniventes - Small bowel
• Heart failure can't be diagnosed on a chest X ray
• MRI for unilateral hearing loss. MRI also better for spine
• Biliary colic: Ultrasound first before MRCP
• Plain abdominal radiograph is necessary for barium enema
• Cohort studies may be prospective or retrospective
• In women, breast cancer more likely but lung cancer more likely to KILL
• Father registered at time of birth has rights.
• General practice - don't need to anonymise patient information. Also, generic flyer posted to all patients in the general practice is sufficient notification
• If minor refuses life saving treatment, doctors can tell parents and break confidentiality. Refusing life saving treatment automatically invalidates Gillick competence.
• HIV more prevalent in women, but only by a little bit. Seroconversion happens 2-8 weeks after acute infection and patients may have flu-like illness, fever, lymphadenopathy, rash, malaise
• Neisseria gonorrhoea - treat with Ceftriaxone, Cefixime, Spectinomycin - Infects any columnar epithelium. Causes ophthalmia neonatorum, reactive arthritis. Azithromycin in children. Doxycycline and azithromycin in adults
• Ziehl-Nielson test can test both tuberculosis and cryptosporidia - BOTH are AIDS defining illnesses. Stage 1A cervical cancer is also an AIDS defining illness. HIV positive patients can't use BCG against tuberculosis because it won't work. Kaposi's sarcoma don't need biopsy. Classic purple nodular lesions on the skin.
• Glioblastoma multiforme - 53 years of age mean. Combined surgery, radiotherapy, chemotherapy, Temozolomide (DNA replication interference). Median survival - one year
• Hepatocellular carcinoma: Chinese male:female 8:1. Hepatitis B. 6-20 months survival. 75% tumours unifocal.
• Pemphigus vulgaris - increased prevalence in people of jewish descent. IgG against cell surface of keratinocytes (Desmosomes). 1mg/kg PO prednisolone controls acute flare. Lesions heal without permanent scarring. C3 seen less than IgG
• Multi-infarct dementia - Association with tobacco use, alcohol protective, Donepezil NOT prescribed, Anti-platelet agents effective, Mortality around 50% at 4 years
• Creatinine 200-300. ALT/AST above twice normal. Positive end expiratory pressure - >10cm H2O highly suggestive of ARDS
• HOCM: Autosomal dominant, myomectomy improves symptoms, infective endocarditis occurs in this condition, Beta-myosin coding genes are commonly affected
• Turner's syndrome cardiac AORTIC abnormalities: coarctation of the aorta, aortic dissection, bicuspid aortic valve.
• Migraine linked to coronary artery vasospasm: Can give Diltiazem, amlodipine, Isosorbide dinitrate
• Long QT syndrome: Needs implantable cardioverter/defibrillator. Beta blockage and cervicothoracic stellectomy reduce the risk of sudden cardiac arrest
• QRS must not exceed 120msecs (3 small squares). V1 20% T wave inversion is normal, but invariably abnormal in T wave inversion in V4-V6
• Atrial fibrillation in thyrotoxicosis - Don't rush to cardiovert until you've resolved the thyrotoxicosis.
• Pre-excitation syndrome: tricuspid valve abnormalities are associated. accessory pathway conduction becomes slower with advancing age
• Ostium primum defects - left axis deviation. Ostium secundum defects - right axis deviation
• Rheumatic fever: cariditis, polyarthritis, chorea, erythema.
• Aortic regurgitation - association with ulcerative colitis. Durosiez's sign is the presence of a diastolic murmur in the femoral artery heard proximally after compression of the femoral artery. Aortic regurgitation can have ESM. Length of murmur doesn't tell you anything
• Cardiac involvement in SLE is seen in 50-60%. Death from these is common. Libman Sachs is non-infective endocarditis. High titres of antiphospholipid antibodies are associated with cardiac and particularly valvular involvement
• Deviation of both eyes towards the irrigated ear following caloric stimulation indicates an intact brain stem
• Doll's eye movements - dependent on functioning long tracts. If a patient is unconscious you can move their head rapidly from side to side, and eyes will catch up later.
• Crepitations most common finding in pneumonia.
• Coxiella Burnetii - Q fever - obligate intracellular gram-negative -> Doxy?
• Asthma - small airways dysfunction not large airways. Exercise induced asthma worsens AFTER exercise if is finished (5-10 minutes after). may have cough but no wheezing. Prevented by B2 agonist or sodium cromoglycate. Samter asthma triad: Aspirin intolerance, nasal polyps and asthma
• CF gene long arm of chromosome 7. CFTR (Cystic fibrosis transmembrane conductance regulator). CF patients have atopy and asthma. Infection organisms start conventional and progress to pseudomonas.
• Diuretic therapy may raise serum glucose levels. Recognised association with acute arthritis. Can lead to a high bicarbonate level. Magnesium and potassium levels are often reduced.
• Bronchiectasis - associated with alpha-1 antitrypsin deficiency. Brain abscesses ARE a complication. Bronchiectasis is widespread. Occur with IgG subclass deficiencies.
• COPD: Ipratropium bromide is as good as salbutamol. Nocturnal desaturation. Trial of steroids in COPD patients. Long term oxygen therapy reduces admissions. Weight loss may be normal.
• IPF: Frequently in subjects with a history of smoking. Ground glass appearance on CT associated with better prognosis. Associated with a polyclonal increase in immunoglobulin. A high bronchoalveolar lavage (BAL) lymphocyte count is associated with better response to treatment. Azathioprine + prednisolone is better than prednisolone alone.
• Anti-DNA topoisomerase antibodies is associated with diffuse systemic sclerosis and is associated with pulmonary fibrosis and pulmonary vascular disease. Alveolar proteinosis (lipoproteinaceous material), histiocytosis X (Langerhans cells). Clubbing not associated with Extrinsic allergic alveolitis
• Mesothelioma - latent period up to 40 years. Mesothelioma extremely difficult to treat with no curative therapy. Median survival 18 months.
• EAA - not type 3. granulomatous disorder of the lung characterised by symptoms typically appearing 6-9 hours after exposure to the allergen
• C-ANCA (towards PR3) -> Wegener's granulomatosis. P-ANCA (Towards MPO) -> Churg strauss, microscopic polyangitis, goodpasture's
• Alveolar arterial gradient (A-a gradient) - severity of impaired oxygenation by the lung
• Nasal CPAP for obstructive sleep apnoea (OSA)
• Reactive arthritis - arthritis, conjunctivitis, urethritis, circinate balanitis, anterior uveitis, oral ulcers, keratoderma blennorrhagica and enthesitis
• Septic arthritis - haemophilus influenzae under 2 years of age, Staphylococcus - more than 2 and in patients with rheumatoid arthritis
• Arthritis - hepatitis B, mumps, coccidiomycosis
• Rapidly progressive glomerulonephritis - SLE (most common cause of death), polyarteritis, Wegener's granulomatosis.
• SLE: Nephritis, Raynaud's phenomenon, Thrombocytopenia, Pulmonary atelectasis (collapse of part or all of a lung)
• Paget's disease of bone: Many patients require no treatment. ALP good indicator of STATUS of paget's. Osteosarcoma less than 1%. Fewer than 5% of those with disease have symptoms. 3-4% of people aged over 40 have it, but fewer than 5% of THESE have symptoms
• Morphine - can be given orally because it is well-absorbed. Active ingredient morphine -6-glucuronide passes slowly through BBB. Plasma half life 3 hours that's why morphine given 4 hourly
• Acute myeloblastic leukaemia - Elderly, from pluripotent stem cell, Auer rods diagnostic but only 25% of cases. M3 promyelotic type has the t(15,17) translocation and gives rise to problems with coagulation. frequently DIC
• Iron - in vegetable foods is poorly absorbed. 60-70% of total body iron is present in haemoglobin.
• Hereditary haemochromatosis - iron overload - autosomal recessive - hypogonadism is due to damage at the hypothalamic-pituitary axis. Venesection keep Hb at 12g/dl. Recently, hepatocellular carcinoma is commonest cause of death.
• Thalassaemia major, desferrioxamine started after 10-20 infusions usually at around 2 years of age. If started later irreversible problems from iron load may already be established
• Vitamin B12 deficiency: Due to pernicious anaemia, is characterised by intrinsic factor antibodies although in atrophic gastritis, parietal cell antibodies may be present (these of which may also be present in pernicious anaemia).
• B12 deficiency: Pernicious anaemia - 3 fold risk in getting gastric carcinoma, Directly - Severe symmetrical neuropathy without anaemia), B12 deficiency more frequent in HIV people, and if due to dietary deficiency can be treated with 50 mcg of oral cyanocobalamin daily
• Sickle cell anaemia - Haemoglobin SS - Parvovirus B19 may cause profound anaemia in any haemolytic state. This is an aplastic crisis and is due to transient red cell asplasia
• Polycythaemia rubra vera - raised platelet count. if associated with reduced haemoglobin P50, due to smoking. PCV shouldn't exceed 48% since this means that there is decrease in cerebral blood flow.
• High affinity haemoglobin variants causing reduced oxygen delivery to the tissues causes polycythaemia
• Middle of healthy lymph nodes: small follicular cells in the germinal centres (AKA small-cleaved cells or centrocytes). Addision's disease can enlarge these. In infectious mononucleosis show marked paracortical (T-cell) expansion.
• Bone marrow and thymus lymphoid tissue migrate to spleen in infants. Spleen does not make them
• Antithrombin III deficiency: AUTOSOMAL DOMINANT. Gives both venous and arterial thrombotic events.
• The factor V mutation causing activated protein C resistance is called factor V Leiden
• Pruritus can happen with these things too: Iron deficiency, Polycythaemia, Hyperthyroidism, Hodgkin's lymphoma
• Lichen planus: Violaceous papules, Increased lipogenesis due to increased androgen activity, Wickham striae, Alopecia
• Acne vulgaris: increase in size of sebaceous glands, increase in amount of sebum produced, blockage of pilosebaceous ducts, increased lipogenesis due to increased androgen activity
• Vitiligo - face and neck early. Axillary areas later
• Urticaria - mediators of inflammation working on small blood vessels, 1/4 cases of acute hepatitis present with this, H1 blockers better than H2 blockers. Don't even bother combining them
• Pyoderma gangrenosum - Myeloma, leukaemia, Behcet's disease, rheumatoid arthritis
• Cerebellopontine angle (CPA) tumours are mostly benign schwannomas. Radiotherapy plays little part in treatment. Surgical option!
• Anisocoria common in bilateral Argyll-Robertson pupils
• Trigeminal neuralgia may be seen in multiple sclerosis. Weight loss may develop because eating may be a trigger.
• Subacute combined degeneration of the cord (B12) - degeneration of cord, brain and peripheral nerves in absence of anaemia despite severe disease.
• Syrinx causes pain and temperature loss with preservation of vibration and joint sense.
• Dura is supplied by both external and internal carotid arteries
• Lacunar infarct (small deep infarct usually in the basal ganglia, thalamus, internal capsule, cerebral peduncle and pons) can be purely sensory
• Left cerebral hemisphere lesion - head turn left. Left brainstem lesion - head turn right
• Friedreich's ataxia - autosomal recessive condition with onset in childhood. Degeneration of dorsal root ganglion cells, loss of myelinated peripheral nerve fibres, degeneration of dorsal columns and Clarke's column, loss of fibres in the spinocerebellar and corticospinal tracts. Nystagmus 25%, pupillary reactions normal. Skeletal abnormalities, T wave inversion and ventricular hypertrophy in 70%
• NF1: 17. NF2: 22.
• Tuberous sclerosis - epilepsy and even though AD no family history. Depigmentation, adenoma sebaceum, multiple fibromas and shagreen patch
• Von-Hippel-Lindau is on chromosome
• Ataxia telangiectasia autosomal recessive condition begins in early childhood - death occurs in second decade
• Hereditary angioedema - Reduced C4

Hodgkin's lymphoma and prognosis

Nodular sclerosing - Good
Mixed cellularity - Good
Lymphocyte rich - Good
Lymphocyte depleted - Poor

Abdominal Ultrasound and Jaundice

An abdominal ultrasound is of key importance in such cases in order to assess evidence of bile duct dilatation.

Rheumatoid arthritis and Osteoarthritis first line drug

Osteoarthritis - Paracetamol. Can try with NSAIDs too
Rheumatoid arthritis - Methotrexate (Try TNF alpha blcokers later)

Causes of thoracotomy scar

• Fungal infection
• Tuberculosis
• Cancer
• Emphysema
• Abscess that does not clear on antibiotics

Hydatid disease

Hydatid disease occurs because of chronic tapeworm infection. The sheep is an intermediate host for the tapeworm, and as such farmers are likely to be exposed to tapeworm eggs. Patients may suffer progressive liver symptoms over a number of years, and the diagnosis can be an incidental finding. Rapid worsening of symptoms can occur with cyst rupture or infection. Surgical excision of large cysts, coupled with albendazole in repeated 1 month courses or a 3-6 month course of albendazole.

Ventilator acquired pneumonia

Given that this man is pyrexial, with chest signs on the right hand side that match his X-ray picture, the most likely diagnosis is ventilator acquired pneumonia. It occurs because of contamination of the respiratory tract due to aspiration of oropharyngeal secretions which isn't prevented by a cuffed ET tube. Diagnosis is clinical and is supported by bronchial washings. Initial antibiotic therapy should cover anaerobes, MRSA, pseudomonas and acinetobacter until definitive culture and sensitivity testing is available.