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What should you be careful of when you diurese someone with nephrotic syndrome?
- Renal vein thrombosis.
- They lose a lot of coag factors (esp. antithrombin III) and then you dehyfrate them and precipitate a thrombus.
Presents as indolent or acute worsening of renal function.
What is tropical sprue?
Basically its Coeliac's without a known trigger.
Occurs 30 degrees north and south of the equator.
Clinically the same as Coeliacs. Flattened villi, lymphocytic infiltrate and
What is the commonest marker to investigate for suspected HIV infection?
IgG to envelope antigens (gp120 and its subunits)
What is peas and wheats?
- Phenytoin, Phenylbutazone
List of drugs that are metabolised via Zero-order kinetics...i.e. The enzymes that metabolise them are saturable.
Ask lisa to explain the fast and slow pathways of AV nodal re entry tachycardias.
- Fast is along the septum anteriorly near the tricuspid annulus
- Slow is posterior near the coronary sinus ostium.
What biopsies are best for lymphoma?
- A whole lymph node.
- NOT FNA
- if there is one palpable, get it.
- Other wise get one from the mediastinum.
- Bone marrow biopsy as last resort.
What type of kidney stones does short bowel predispose to?
Changes to gut flora + electrolyte resorption.
What should you think if you see eosinophils in urine?
Acute tubulointerstitial nephritis.
Cause by drug reactions to NSAIDs, antibiotics, allopurinol and phenytoin.
Presents with arthralgia, fever, rash and renal failure
What is corrected calcium equation?
Treatment of hypercalcaemia?
CorrectCa = Measured Ca + [40-albumin] x0.027
- Stop Thiazides and NSAIDS,
- Stop calcium and Vit D
- 2L of IV rehydration at least
- Then bisphosphonates
- Consider calcitonin if resistant.
Mortality of variceal bleed?
50% with each bleed
What causes fixed obstructive airways disease in lung transplant patients?
What is a risk factor for this?
- Bronchiolitis obliterans
What is onychomadesis?
Abnormal nail matrix causing shedding.
Why is co-trimoxazole not used commonly?
Risk of blood dyscrasias
Characteristics of Bacterial overgrowth in the small bowel?
- Offensive diarrhoea + Wt.loss
- B12 malabsorption - not corrected by intrinsic factor (schilling test)
- Small bowel diverticulae
- Elevated folate as the bacteria produce it and you absorb it.
What is multifocal motor neuropathy? (MMN)
- Like ALSMND but LMN signs only.
- Usually presents in hands
- Thought to have autoimmune aetiology
- IVIG, cyclophos andor ritux work very well.
- Steroids an plasmapheresis make it WORSE
What causes HIT?
What is the main risk of having HIT?
How do you manage it?
HIT is caused by a antiheparin-platelet 4 antibody. Classified as a 50% drop in platelets following Heparin.
Main risk = its a prothrombotic state
Manage with Hirudin, bivalrudin or argatroban
How do you define Torsade de Point?
What are the treatment options for torsades de point?
Polymorphic VT in which the axis twists around the isoelectric line.
- Rx: Magnesium + Potassium
- Overdrive pacing - pacing at a rate greater than native rate
- Isoproterenol infusion - chemically increases pulse rate. Use as interim measure until overdrive pacing can be given
What is Multifocal Atrial Tachycardia?
How do you treat it?
- At east 3 different p-wave morphologies with changing PP and PR intervals.
- Occurs in COPD patients who are Hypoxic and Hypercapnic.
- Need to correct PaCO2 and PaO2.
- Give verapamil as long as they are not in failure
What is the role of nebulised aminoglycosides and colistin for Pseudomonal infections?
- No role for acute infections.
- Can be used to prevent flare ups in colonised patients
How do you differentiate between hypercalcaemia due to Myeloma or hyperparathyroidism?
- Myeloma = High Ca2 and normal Phosphate
- Hyperparathyroidism = High Ca2 and Low phosphate
What is the classic pentad of TTP?
- Neurological dysfunction
- Renal failure
- Haemolytic anaemia
How would you investigate Painless macroscopic haematuria?
- Urine microscopy for Malignant cells
- CT renal with contrast to rule out upper urinary tract pathology
- Flexi Cystoscopy to rule out lower urinary tract pathology.
What is the definitive treatment for PSC?
Transplantation - nothing else works
- Pruritus can be treated with SSRIS like sertraline
- Nutritional supplementation with ADEK vits can help as PSC is primarily cholestatic.
What is livedo reticularis?
A reticular reddish-purple rash mainly on lower limbs.
- Causes =
- SLE and connective tissue disorders
- Anti phospholpid syndrome,
What is peripartum Cardiomyopathy?
How do you treat it?
Dilated cardiomyopathy of unknown aetiology occuring in last month of pregnancy and upto 5 months post partum.
Treat as any other heart failure, avoid ACE inhibitors.
What is inclusion body myositis?
- The most common acquired myopathy in over 50s.
- Slower onset than PolyM or DermatoM
- Affects quads and long finger flexors.
What is Bornholm disease?
Coxsackie B infection of the intercostal muscles causing chest and abdominal pain.
Treatment for Coronary Artery Vasospasm?
What is contraindicated?
GTN or Calcium channel blockade
B-blocker can make spasm worse.
Most common presenting symptoms for PBC?
- Jaundice (median survival of 2 years once this is present)
What are the King's College transplant criteria for non-paracetamol liver failure?
Or any 3 of the following 5:
- Age < 11 or > 40
- Serum Bili > 300 micromolesl
- Time from jaundice to coma >7days
- INR > 3.5
- Drug toxicity regardless of whether it was the cause of the liver failure.
How do you deal with Hypocalcaemia secondary to renal disease?
So their Calcium will be low and their PTH high.
If not on dialysis then give Alphacalcidiol
If on dialysis and PTH very high then use Cinacalcet (PTH antag)
If phosphate goes high - Sevelamer is a phosphate binding agent
What is the most common cause for renal impairment in a patient with non-hodgkins lymphoma?
Ureteric obx cuase by abdominal or pelvoc lymph node enlargment!!
What is the downside of succesful chemo for non-hodgkins lymphoma?
Leaves you at an increased risk of developing Leukaemia!
Incidence peaks at 5 years
Which 3 ARVs cause renal dysfunction and in what way?
- Abacavir - Acute interstitial nephritis
- Nelfinavir - Renal colic
- Stavudine - Proximal tubular dysfunctionfanconis
What would you find on immunophenotyping if a patient had CLL?
CLL is a B-cell disease but paradoxically you would expect to find a T-cell marker (CD5) on these cells which are also positive for CD19 and 20.
First line therapies for Postural hypos?
Stop offending meds if poss
- Compression stockings
- Fludrocortisone - encourages salt + water retention.
What is the most common composition of a kidney stone?
Calcium Oxolate (they are radio-opaque) - 60% of all stones
What is the composition of kidney stones caused by an infectious agent?
What are the agents?
- MAP stones: Magnesium-ammonium-phosphate
- Proteus, Klebsiella, Pseudomonas.
Which antibody is associated with Paroxysmal cold haemoglobinuria?
Donath-landsteiner antibody against the P blood group.
Polyurethane foam fires...
Most likely exposed to cyanide:
Dicobalt editate or sodium thiosulphate QUICK!
How would you differentiate a hydatid cyst from an amoebic liver abscess?
- Hydatid cysts happen to people near rural sheep farms in china, russia, japan and wales.
- They are generally asymptomatic but can cause: hepatomegaly, obx jaundice, fever, cholangitis.
Amoebic liver abscesses are caused by entamoeba histiolytica; can bee seen in stool.
How do you Test for EPO and how long after the last injection can you test for it?
Test urine for a few weeks after the last injection
What is DIDMOAD syndrome also known as?
- Diabetes Insipidus
- Diabetes Mellitus
- Optic Atrophy
What is effected in polyglandular syndrome type 1?
- Mucocutaneous candidiasis
What is effected in polyglandular syndrome type 2?
- Pancreas (Diabetes melitus)
What conditions are common between Polyglandular 1 and 2?
- Pernicious anaemia
What is Wolman's syndrome?
- Adrenal failure
What is lofgrens syndrome?
- Acute Sarcoidosis
- Erythema Nodosum
- Bilat Hilar Lymphadenopathy
- Joint symptoms
What is lofflers syndrome?
Lung full of eosinophils secondary to parasitic infection.
What is Felty's syndrome?