Cardiology

Offer a mineralcorticoid receptor antagonist, in addition to an ACE

inhibitor (or ARB) and beta-blocker, to people who have heart failure
with reduced ejection fraction if they continue to have symptoms of
heart failure

Patients who've had a catheter ablation for atrial fibrillation still

require long-term anticoagulation as per their CHA2DS2-VASc score

Following elective DC cardioversion for AF, anticoagulation should be

continued even if sinus rhythm is maintained

Carvedilol, bisoprolol and nebivolol are the B-blockers that are

licensed in the United Kingdom for the treatment of heart failure

Complete heart block following an anterior MI suggests significant

damage to the myocardium and will likely require pacing, in contrast
to complete heart block following an inferior MI

Electrical alternans is suggestive of cardiac tamponade

Elderly male patients who present with presyncope/syncope and are

on alpha-blockers as treatment for BPH should be assessed for
orthostatic hypotension as a first step in evaluation
First line management of acute pericarditis involves combination of
NSAID and colchicine

Accelerated idioventricular rhythm is common and unconcerning

following recent MI

New AF in mitral regurgitation -> refer for mitral valve replacement

The most appropriate medication in patients with acute heart failure

and a preserved ejection fraction who have signs of volume overload
is addition/up-titration of a loop diuretic

Statins are the only lipid-regulating drugs that are used in secondary
prevention of cardiovascular disease (with the exception of
ezetimibe in cases of primary hypercholesterolaemia)

Multiple episodes of inappropriate shocks from an ICD can be both

unpleasant and dangerous. Ultimately the device will need
interrogated from a pacemaker technician, however the most
immediate management should be to place a ring magnet over the
ICD to prevent further inappropriate shocks.

AV blocking drugs and vagal manoeuvres are absolutely

contraindicated in patients with AF and pre-excitation
In patient with BBB and unexplained syncope but an ejection fraction
>35% proceed with further testing (e.g. carotid sinus massage,
electrophysiological studies) prior to initiation of management

Patients with SVT who are haemodynamically stable and who do not
respond to vagal manoeuvres, the next step is treating with
adenosine

Dextrocardia is associated with an inverted P wave in lead I, right axis

deviation, and loss of R wave progression

In black individuals who are already taking a calcium channel blocker

and ACE-inhibitor, and who continue to have blood pressure that is
difficult to control, adding a thiazide diuretic is the next most
appropriate step

In coronary vasospasm (Prinzmetal’s angina, or variant angina), the

ECG shows ST elevation that is very similar to an acute STEMI.
However, unlike acute STEMI the ECG changes are transient,
reversible with vasodilators and not associated with myocardial
necrosis

Digoxin administration is not recommended in cardiac amyloidosis

owing to a higher risk of digoxin toxicity, as the drug binds avidly to
amyloid fibrils

As part of the broad lifestyle approach to heart failure, annual

influenza vaccine should be offered
The combination of heart failure, mitral stenosis/regurgitation, and
neurological features is suggestive of either cardiac myxoma or
infective endocarditis with systemic embolisation

Hydrazine and nitrate should be considered for Afro-Caribbean

patients with heart failure who are not responding to ACE-inhibitor,
beta-blocker and aldosterone antagonist therapy

Aortic stenosis - a soft S2 is a feature of severe disease

ECG changes in Brugada syndrome are more apparent following the

administration of flecainide or ajmaline - this is the investigation of
choice in suspected cases

Sacubitril-valsartan is considered in heart failure patients with a LVEF

< 35% who are still symptomatic on ACE-inhibitors & beta-blockers

In the initial phase following an ACS/PCI patients who also have AF

are generally given 2 antiplatelets + 1 anticoagulant

Delivery of the baby is the treatment of HELLP syndrome

Right ventricle infarction -> tricuspid regurgitation

Cardiac magnetic resonance imaging has been shown to be very

useful in diagnosing myocarditis by visualising markers for
inflammation of the myocardium
Ivabradine use may be associated with visual disturbances including
phosphenes and green luminescence

A chest xray is an essential investigation when investigating a PE

In pre-excited AF don’t give anything that blocks conduction at AV

node (including calcium channel blockers, adenosine or digoxin) as
this can cause ventricular tachycardia

Ischaemic changes in leads I, aVL +/- V5-6 - left circumflex

Tricuspid valve endocarditis can cause tricuspid regurgitation, which

may manifest with a new pan-systolic murmur, large V waves and
features of pulmonary emboli

Methadone is a common cause of QT prolongation

Females with Turner's syndrome have just one X chromosome.

Therefore they have the same probability of being affected by an X
linked recessive disease as males

Wellens’ syndrome is a pattern of deeply inverted or biphasic T

waves in V2-3. It is highly specific for critical stenosis of the left
anterior descending artery (LAD). It should be treated as a STEMI
with urgent angiography and revascularisation
ACE inhibitors offer prognostic benefit in chronic heart failure

In an hypertensive urgency, treatment aims to lower blood pressure

with the use of oral anti-hypertensive medication like a calcium
channel blocker

If angina is not controlled with a beta-blocker, a calcium channel

blocker should be added

In patients with Mobitz type II AV block, or complete heart block, a

DDD or DDDR pacemaker is indicated

Widespread T wave inversion in the chest leads can be a normal

variant in patients with Afro-Caribbean ethnicity

Deeply inverted or biphasic T waves in V2-V3 suggests Wellen's

syndrome and high risk of critical LAD stenosis

In patients with PFO and migraine, closure of the cardiac lesion,

according to PRIMA and PREMIUM, is not of value in relieving
symptoms

Aortic stenosis co-occurs with atherosclerotic disease -> perform

angiogram prior to surgical intervention
Both primum and secondum atrial septal defects result in RBBB. The
axis can be of use in distinguishing between ostium primum ASDs
(usually have a LAD) and ostium secondums (usually have RAD).

Patients with ventricular ectopics can usually be managed by

reassurance and lifestyle modifications. If pharmacological
management is required, then beta blockers are first line

The most characteristic ECG finding in arrhythmogenic right

ventricular dysplasia (ARVD) is the epsilon wave (a small positive
deflection at the end of the QRS complex)

Acute heart failure not responding to treatment - consider CPAP

Arrhythmogenic right ventricular cardiomyopathy - T wave inversion

in V1-3

Distinguishing between VT and SVT with BBB can be challenging. The

presence of RBBB and RAD favours a diagnosis of SVT with BBB

Patients who present with syncope and have an ECG showing

incomplete trifascicular block need a Holter test to assess for
episodes of complete heart block

A VVI pacemaker will pace and sense the right ventricle. In the
presence or organised atrial activity, a VVI pacemaker may pace the
ventricles out of sync with the atria resulting in pacemaker
syndrome.

5HT-3 receptor antagonists shouldn't be used as antiemetics in

patients with long-QT syndrome

Nice guidelines now recommend secondary prevention with

ticagrelor and aspirin, not clopidogrel and aspirin after ACS

Patients with severe aortic stenosis and signs and symptoms of heart
failure should be referred for consideration of aortic valve
replacement surgery

If a cardiac MIBI scan shows that the defect is present on both stress
and rest, this is suggestive of a fixed defect such as myocardial
necrosis and fibrosis secondary to infarction

Sacubitril-valsartan should be initiated following ACEi or ARB wash-

out period

Strong suspicion of PE but a delay in the scan: start on treatment

dose anticoagulant meanwhile

Cardiac resynchronisation therapy can be used in patients with a QRS

duration of >130 msec and LBBB morphology to improve
symptomatology
Major bleeding - stop warfarin, give intravenous vitamin K 5mg,
prothrombin complex concentrate

VVI or VVR pacemakers are useful for pure sustained AF. Since the
atria are not functioning they do not require sensing or pacing

Mitral stenosis with cross sectional area of <1cm2 warrants surgical

intervention

IV vancomycin + rifampicin + low-dose gentamicin is the empirical

treatment of choice in prosthetic valve endocarditis

Myocarditis can be a secondary complication of diphtheria

Posterior MI typically present on ECG with tall R waves V1-2

Lown–Ganong–Levine syndrome (LGL) is a pre-excitation syndrome

of the heart characterised by a short PR interval and normal QRS
width

Mitral stenosis - loud S1

In AF with decompensation the correct management is synchronised

DC cardioversion

In pure sinus node dysfunction without AF or evidence of AV block,

an AAIR or DDDR pacemaker can be used. Most cardiologists would
choose a DDDR pacemaker since many of these patients go onto
develop AV block

Inherited long QT syndrome, sensorineural deafness - Jervell and

Lange-Nielsen syndrome

Pleuritic chest pain at <48hrs after MI -> pericarditis

Intravenous immunoglobulin , uses include: Kawasaki disease

Bleeding on dabigatran? Can use idarucizumab to reverse

First degree heart block and Wenckebach phenomenon are normal

variants in an athlete. They do not require intervention

Early signs of pacemaker lead failure are a 'necked' appeared on

imaging

Ischaemic changes in leads II, III, aVF - right coronary

S1Q3T3 is a classic but uncommon ECG finding in PE

The first-line management of SVT is vagal manoeuvres: e.g. Valsalva

manoeuvre or carotid sinus massage
Cardiac MRI is the investigation of choice alongside
echocardiography in order to identify the potential cause of
cardiomyopathy

Patients with very poor dental hygiene may develop endocarditis

secondary to Viridans streptococci e.g. Streptococcus sanguinis

INR > 8.0 (no bleeding) - stop warfarin, give oral vitamin K 1-5mg,
repeat dose of vitamin K if INR high after 24 hours, restart when INR
< 5.0

Ivabradine should be considered in heart failure if the patient has

sinus rhythm > 75/min and a LVEF < 35% and have not responded to
to ACE-inhibitor, beta-blocker and aldosterone antagonist therapy

Hypertension in diabetics - ACE-inhibitors are first-line regardless of

age

If a cardiac MIBI scan shows that the defect is present on stress, but
not at rest, this is suggestive of a reversible defect (e.g. myocardial
ischaemia secondary to coronary artery stenosis)

The presence of ST elevation without reciprocal depression shortly

following a myocardial infarction is suggestive of a left ventricle
aneurysm. Left ventricle aneurysms predispose to both ventricular
arrhythmias and cardiac thrombo-embolisms.
RBBB +left anterior or posterior hemiblock + 1st-degree heart block =
trifasicular block

The most specific ECG finding in acute pericarditis is PR depression

IV magnesium sulfate is used to treat torsades de pointes

Strep endocarditis presents insidiously with new murmur

Transoesophageal echocardiography (TOE) may be a useful

investigation in clinically unstable patients with a suspected aortic
dissection

In patients with cardiovascular risk factors and symptoms suggestive

of claudication with an equivocal/borderline ankle brachial pressure
index study result, the next best study is an ankle brachial pressure
index after exercise

Patients with heart failure and an ejection fraction < 35% who are
euvolaemic and are already taking an ACE-inhibitor and a beta-
blocker should have an aldosterone antagonist added to their
regimen as a next step

AKI following angiography can be caused by contrast-induced

nephropathy or cholesterol emboli
Poorly controlled hypertension, already taking an ACE inhibitor,
calcium channel blocker and a standard-dose thiazide diuretic. K+ >
4.5mmol/l - add an alpha- or beta-blocker

The effects of adenosine are enhanced by dipyridamole

In the context of a tachyarrhythmia, a systolic BP < 90 mmHg → DC

cardioversion

Drug-induced angioedema without urticaria is most frequently

associated with angiotensin converting enzyme inhibitors or, less
frequently, angiotensin II receptor blockers

Ischaemic changes in leads V1-V4 - left anterior descending

Prominent V waves on JVP → tricuspid regurgitation

DC cardioversion should be given to a patient presenting with

ventricular tachycardia with haemodynamic compromise

During a cardiology clinical examination, a sustained apical impulse is

consistent with left ventricular hypertrophy, which can be verified on
an ECG by identifying deep S waves in V1 and V2 and tall R-waves in
V5 and V6

Following myocardial infarction, patients with objective heart failure

(moderate to severe left ventricular dysfunction) should be initiated
on an ACE inhibitor, a beta-blocker, a statin and a mineralocorticoid
receptor antagonist provided no contra-indications exist
Twiddling refers to pacemaker dysfunction due to patients
interfering with the wires

Poorly controlled hypertension, already taking an ACE inhibitor and a

calcium channel blocker - add a thiazide diuretic

Streptococcus bovis endocarditis is associated with colorectal cancer

Intravenous diuretics are first line therapy in acute heart failure,

even in renal failure, with strict fluid management

Myocarditis presents with ST elevation and acute pulmonary oedema

in a young patient with a recent flu-like illness

Thiazides may cause photosensitivity

Newly diagnosed patient of black African or African–Caribbean origin

with hypertension - add a calcium channel blocker

Dermatology

Niacin (B3) deficiency is characterised by dermatitis, diarrhoea and

dementia, a condition known as pellagra

People aged between 70-79 years old are eligible for shingles vaccine
Systemic glucocorticoids are the first-line treatment in pemphigus
vulgaris

People with shingles should be advised that they are infectious until
the vesicles have crusted over, usually 5-7 days following onset

An itchy rash affecting the face and scalp distribution is commonly

caused by seborrhoeic dermatitis
Dermatitis herpetiformis is typically treated with a gluten-free diet
and topical dapsone

Cholestasis induced pruritus can be managed with rifampicin,

sertraline or cholestyramine as first-line agents

Topical potent corticosteroid + vitamin D analogue is first-line for

chronic plaque psoriasis

Seborrhoeic dermatitis - an inflammatory reaction to Malassezia

furfur

Bandaging can help control itching in eczema to prevent further

scratching

In scabies, advise all close contacts to be treated as well as the

patient twice, with applications one week apart

Acne rosacea treatment:

mild/moderate: topical metronidazole
severe/resistant: oral tetracycline

Seborrhoeic dermatitis - first-line treatment is topical ketoconazole

Zinc deficiency causes a characteristic skin rash (mainly at the

intertriginous and perioral areas), alopecia, taste impairment,
glucose intolerance, and diarrhoea
The abrupt appearance of multiple seborrhoeic keratoses suggests
underlying cancer (Leser- Trelat sign)

Adding urea to emollients increases moisturising effect, but can be

inflammatory

Flexural psoriasis is characterised by well defined, erythematous,

non-painful rash

Niacin (B3) deficiency is characterised by dermatitis, diarrhoea and

dementia, a condition known as pellagra

Acne rosacea features:

nose, cheeks and forehead
flushing, erythema, telangiectasia → papules and pustules

The most common malignancy associated with acanthosis nigricans

is gastrointestinal adenocarcinoma

Pseudo-comedones and pale spots help distinguish seborrhoeic

lesions from malignant melanomas

In scabies treatment failure, if application was applied appropriately,

then treat with difference insecticide, e.g. malathion 0.5% or
permethrin 5%

Topical 5-FU, imiquimob or difclofenac can be used as first line

treatment for actinic keratosis

Blisters/bullae
no mucosal involvement (in exams at least*): bullous pemphigoid
mucosal involvement: pemphigus vulgaris
Clobetasol is the most potent topical steroid compared to
clobetasone, betamethasone valarate and hydrocortisone

Calcineurin inhibitors are an alternative to topical steroids in eczema

Corticosteroids can be used in refractory pain in shingles if simple

analgesia and neuropathic analgesia do not help, but only for acute
shingles

Scalp psoriasis - first-line treatment is topical potent corticosteroids

Koebner phenomenon - Warts And ALL (warts, autoimmune, AIDS, n

Beta-blockers are known to exacerbate plaque psoriasis

Prednisolone treatment for eczema flares needs several weeks of

treatment and then tapering off to prevent rebound

Endocrinology

Myocardial infarction can precipitate diabetic ketoacidosis

If there is active Grave’s eye disease then radioiodine therapy is not

recommended as it can worsen the eye disease

Primary hyperaldosteronism: manage with spironolactone

Magnesium deficiency causes hypocalcaemia

Intravenous calcium gluconate is used for the acute management of

hypocalcaemia
A cortisol curve can be used to assess how appropriate dosing of
glucocorticoid steroids in Addison’s disease patients is

In an adrenal crisis, hydrocortisone is needed at high dose and

fludrocortisone can be omitted as hydrocortisone has
mineralocorticoid activity

In newly diagnosed adults with type 1 diabetes, the first-line insulin

regime should be a basal–bolus using twice‑daily insulin detemir

DKA in the acute setting fixed rate insulin should be continued even
if BM levels are <14; IV dextrose should be added instead

Serum IGF-1 levels are now the first-line test for acromegaly

Pioglitazone may cause fluid retention

Patients with acromegaly should be offered regular colonoscopic

screening, starting at the age of 40 years. The frequency of repeat
colonoscopy should depend on the findings at the original screening
and the activity of the underlying acromegaly

SGLT-2 inhibition is the best option for glucose control in a patient

with IHD and heart failure failing glycaemic control on metformin
because there is good evidence for outcome benefit across the class

Fibrates are the most effective drug for treating

hypertriglyceridaemia

IV fluid therapy is the first-line management in patients with

hypercalcaemia
A patient with Addisons’ disease who undertakes significantly
strenuous activity should double the dose of glucocorticoid and
mineralocorticoids

Women with hypothyroidism may need to increase their thyroid

hormone replacement dose by up to 50% as early as 4-6 weeks of
pregnancy

First line treatment in diabetic neuropathy is with amitriptyline,

duloxetine, gabapentin or pregabalin

Hypernatraemia associated with hypervolaemia can occur due to

hypertonic saline, hypertonic sodium bicarbonate, excess salt in diet,
or hyperaldosteronism

In thyroid storm with IV beta-blockers are a important first-line

treatment

Raised total T3 and T4 but normal fT3 and fT4 suggest high
concentrations of thyroid binding globulin, which can be seen during
pregnancy

Pregnant woman with a history of Grave’s disease should have

thyroid stimulating hormone binding antibody titres measured even
if euthyroid as the antibodies can cross the placental barrier

The oral glucose tolerance test remains the investigation of choice

for gestational diabetes

Type 2 renal tubular acidosis may be caused by Fanconi syndrome

Goitre with unexplained hoarseness should be referred urgently

In thyroid storm, hyperpyrexia, tachycardia, cardiac failure and

agitation are the key diagnostic elements
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

Patient with diabetes who have had two hypoglycaemic episodes

requiring help needs to surrender their driving licence

Primary hypothyroidism can cause hyperprolactinaemia. High leveles

of thyrotrophin releasing hormone (TRH) stimulate prolactin release
Distal renal tubular acidosis can cause calcium phosphate renal
stones and is linked to Sjogrens syndrome

APS type 2 patients have Addison's disease plus either T1DM or

autoimmune thyroid disease

Thyrotoxic storm is treated with beta blockers, propylthiouracil and

hydrocortisone

Iodine in CT contrast media can precipitate thyrotoxicosis or thyroid

storm

If myxedema coma is suspected, IV corticosteroids should be given

alongside IV thyroid replacement until coexisting adrenal
insufficiency has been excluded

Fibrates are the most effective drug for treating

hypertriglyceridaemia

Following surgery and radioiodine therapy, patients with papillary

thyroid cancer should be monitored with thyroglobulin annually

The PTH level in primary hyperparathyroidism may be normal

The long Synacthen test can be used to distinguish primary adrenal
failure from secondary adrenal failure

Hypernatraemia associated with hypovolaemia occurs due to a free

water deficit. Common causes include reduced water intake (e.g.
elderly), GI losses (e.g. vomiting and diarrhoea), skin losses (e.g.
burns), and renal losses (e.g. osmotic diuresis)

Radioiodine therapy should be avoided until 8 weeks following CT

contrast administration

Patients with T2DM should not be routinely started on statins; their

QRISK2 score should be calculated

IV fluid therapy is the first-line management in patients with

hypercalcaemia

In pregnant woman who develop hyperthyroidism in the first

trimester, propylthiouracil is preferred over carbimazole due to
lower risk of foetal malformation

Thyrotoxicosis is associated with reversible cardiomyopathy

The high-dose dexamethasone suppression test is useful for

distinguishing between ACTH dependent (e.g. pituitary source) and
non-ACTH dependent (e.g. ectopic and adrenal source) causes of
Cushings's syndrome

Over-replacement with thyroxine increases the risk for osteoporosis

Hypokalaemia, osteomalacia - type 2 renal tubular acidosis

A new thyroid nodule does not need FNAC if the ultrasound features
are benign
A non-palpable thyroid mass less than 1cm in size found incidentally
without worrying features does not need biopsy

Hypokalaemia, nephrocalcinosis - type 1 renal tubular acidosis

First line management for familial hypercholesterolaemia is high

dose statins. Ezetimibe is used as a second line agent

Thiazolidinediones are associated with an increased risk of bladder

cancer

Any patient who is taking 40 mg or more of prednisiolone for more

than 7 days or who is taking 20 mg or more of prednisolone for more
than 14 days is classed as immunocompromised

In thyroid storm, treat acutely with propylthiouracil rather than

carbimazole or surgery

Completion of Whipple’s triad is required before further

investigations for insulinoma

The presence of an elevated prolactin level along with secondary

hypothyroidism and hypogonadism is indicative of stalk compression
due to pituitary adenoma

Replace magnesium before correcting hypokalaemia.

Hypomagnesmia prevents potassium absorption

Beer potomania is a cause of hyponatremia which occurs due to a

low dietary intake of solutes. Urine osmolarity will be low (<100
mosmol/kg) indicating that ADH is appropriately suppressed

Metastatic malignancy can cause Addison's disease

A person with Addisons’ who vomits should take IM hydrocortisone
until vomiting stops

Primary hypoadrenalism is diagnosed by a short synacthen test and a

failure to increase cortisol levels to above 500nmol/L

In hyponatraemia, a low urinary sodium makes diuretics an unlikely

cause

When managing hyperglycaemia in an insulin dependent diabetic,

avoid the use of stat insulin, unless the patient is symptomatic or has
high ketones (>0.6 mmol/l). It is safer to increase the 'usual' insulin if
persistently hyperglycaemic

Treatment of RTA involves correction of the acidaemia with oral

sodium bicarbonate, sodium citrate or potassium citrate

SGLT2 inhibitors can cause normoglycaemic ketosis in type 2

diabetes

Patients with Addison's should be given a hydrocortisone injection kit

for adrenal crises

A patient with recurrent admissions for DKA can be started on

degludec to reduce readmission rate

In De Quervain's thyroiditis there is globally reduced uptake of

iodine-131 during thyroid scintigraphy

Calcitonin can be used as a marker to monitor for Medullary thyroid

carcinoma in MEN type II in those unwilling to undergo prophylactic
thyroidectomy

Refractory hypercalcaemia of malignancy may be treated with

subcutaneous calcitonin if therapy with fluids and pamidronate fails
In male patients with low libido have been found to have a low
testosterone first line investigation should include prolactin and LH
to assess for a central cause

Hypokalaemia is a rare cause of polyuria and polydipsia

In the acute management of DKA, insulin should be fixed rate whilst

continuing regular injected long-acting insulin but stopping short
actin injected insulin

A common endocrine complication of small cell lung cancer is SIADH

In hypothyroidism with adrenal failure do not start thyroid hormone

replacement before glucocorticoid replacement as otherwise an
adrenal crisis can be precipitated

The PTH level in primary hyperparathyroidism may be normal

Whipple’s triad can be used to distinguish the significance of

borderline hypoglycaemia

Hypogonadism secondary to prolactinaemia would be associated

with low testosterone and low or normal FSH and LH

In sulphonylurea overdoses, if the patient remains hypoglycaemic

despite infusion of sufficient glucose, consider administration of
octeotride

Treatment of abetalipoproteinemia involves dietary restriction of

fats, and high-dose vitamin E therapy

T3 levels should be performed where tests show normal T4 with

suppressed TSH
Measuring serum TSH antibodies can distinguish Graves disease from
other forms of hyperthyroidism

Recovering DKA are at risk of hypophosphataemia

Sick euthyroid is common in unwell, elderly patients and often needs

no treatment

MODY is inherited in an autosomal dominant fashion so a family

history is often present

Gitelman's syndrome: normotension, hypokalaemia + hypocalciuria

Dopamine agonists (e.g. cabergoline, bromocriptine) are first-line

treatment for prolactinomas, even if there are significant
neurological complications

Fanconi syndrome causes proximal renal tubular acidosis and can be

drug induced

In hyperthyroidism, if TSH antibodies are negative then a

radionuclide uptake scan can distinguish between types of
hyperthyroidism

According to NICE guidelines, the first-line treatment for obesity is a

combination of dietary, exercise, and lifestyle interventions

Measuring PTH level is the first step in investigating hypercalcaemia

Pregnancy is an important differential to consider when assessing a

female patient with hyperprolactinaemia

Acromegaly: if patients are not suitable for trans-sphenoidal surgery,

or have residual symptoms, then octreotide may be used
Canakinumab is a human monoclonal antibody that selectively
inhibits interleukin-1 beta receptor binding. It can be used for
treatment of acute gout has not responded adequately to treatment
with NSAIDs or colchicine, or who are intolerant of them

Normal pregnancy can cause a raised ALP - it doesn't necessarily

imply liver problems

An elevated C-peptide level following administration of IV insulin can

confirm insulinoma

Diabetic gastroparesis is best managed long term with domperidone

Treat subclinical hypothyroidism if the TSH is greater then 10mU/l as

long as they are younger than 70

Ovarian teratomas can produce exogenous TSH

During Ramadan, one-third of the normal metformin dose should be

taken before sunrise and two-thirds should be taken after sunset

Low urinary calcium in the presence of hypercalcaemia is suggestive

of either familial hypocalciuric hypercalcaemia or thiazide diuretic
use

Medullary thyroid cancer is associated with MEN-2

In sulphonylurea overdoses, if the patient remains hypoglycaemic

despite infusion of sufficient glucose, consider administration of
octeotride

Hyperlipidaemia can cause pseudohyponatraemia

Arginine-GHRH stimulation test is employed to assess GH secretion in
patients with ischemic heart disease or seizures where insulin
tolerance test will be inappropriate

Gas on the X-ray of the foot of a patient with an acutely infected

diabetic ulcer should be referred for urgent incision and drainage

Latent autoimmune diabetes of adulthood is a subtype of diabetes in

which patients may present with phenotypic features of T2DM, while
displaying the presence of markers of autoimmunity (anti-GAD
antibodies)

CAH due to 11-beta hydroxylase deficiency can cause apparent

mineralocorticoid excess syndrome (AMES) resulting in hypertension
and hypokalemia

Features of change of thyroid function are rarely seen in thyroid

malignancy

Anosmia in the context of male hypogonadism, low testosterone and

normal or low FSH and LH makes Kallman Syndrome likely

De Quervain's thyroiditis: initial hyperthyroidism, painful goitre and

globally reduced uptake of iodine-131

Female with hypothyroidism → immediately increase levothyroxine

and monitor TSH closely

Magnesium deficiency causes hypocalcaemia

Radioiodine therapy is the treatment of choice for patients with a

relapse of Graves disease in the absence of contraindications, such as
pregnancy and active severe Graves ophthalmopathy
SIADH criteria includes Na < 135, serum osmolality <271 and urinary
osmolality >100 in a euvolaemic patient

Medullary thyroid cancer - calcitonin is used for screening, prognosis

and monitoring

Metoclopramide may result in galactorrhoea

Propranolol should be used in new cases of Graves' disease to help

control symptoms

Constitutional delay (CD) is one of the commonest aetiology for short

stature and delayed puberty in the adolescent age group

Patients with T1DM for over 10 years should be considered for statin
therapy atorvastatin 20mg OD

Patients taking carbimazole need to be warned about potential

hepatic impairment and the relevant symptoms

If SIADH is resistant to fluid restriction then the drug demeclocycline

can be used

Pioglitazone - contraindicated by: heart failure

Patients with familial benign hypocalciuric hypercalcaemia may have

a normal or raised PTH

Adrenal venous sampling (AVS) can be used to distinguish between

unilateral adenoma and bilateral hyperplasia in primary
hyperaldosteronism

Rapid correction of hyponatraemia can result in central pontine

myelinolysis (CPM). CPM features are variable, however the classical
presentation is spastic quadriparesis, pseudobulbar palsy, and
emotional lability (pseudobulbar affect)

A patient with T2DM with a new diagnosis of hypertension should be

treated with an ACE inhibitor as first line treatment, regardless of
age

For patients on steroid replacement when working shift work, doses

should be taken from when waking

Following radioiodine treatment, patients should avoid becoming

pregnant for at least 6 months

Patients with diabetes should have increased frequency of retinal

screening during pregnancy due to increased risk of retinopathy

The insulin tolerance test can be used to distinguish Cushing's

syndrome from pseudo-Cushing's

Elevated C-peptide in fasting hypoglycaemia is suggestive of

insulinoma

In acute thyrotoxicosis, stop aspirin as it can worsen the storm by

displacing T4 from thyroid binding globulin

Pseudohyponatraemia is characterised by a normal measured serum

osmolarity, however the calculated osmolarity (based on an
erroneously low plasma sodium result) is reduced. This results in a
raised osmolar gap

The short synacthen test is the best test to diagnose Addison's

disease
A patient with low testosterone should have LH and FSH tested as
first line investigation to separate primary and secondary
hypogonadism

Features of over-replacement of corticosteroids require dose

adjustment

Gastroenterology

Combined oral contraceptive pill use + acute abdominal

pain/distension → ?Budd-Chiari syndrome

Gastric MALT lymphoma - eradicate H. pylori

Acute mesenteric ischaemia usually requires an immediate

laparotomy, particularly if signs of advanced ischemia e.g. peritonitis
or sepsis

CT abdomen is an important first line investigation to rule out

complications in a patient with ulcerative colitis presenting with
severe systemic symptoms

Primary biliary cholangitis are at x20 risk of hepatocellular carcinoma

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

HBsAg negative, anti-HBs positive, IgG anti-HBc positive - previous

infection, not a carrier

Bile-acid malabsorption may be treated with cholestyramine

Screening for haemochromatosis
general population: transferrin saturation > ferritin
family members: HFE genetic testing

Faecal calprotectin is a highly sensitive and specific test for

inflammatory bowel disease

Biliary obstruction in cholestasis is a contraindication to liver biopsy

Diarrhoea, weight, arthralgia, lymphadenopathy, ophthalmoplegia

?Whipple's disease

Patients with ascites (and protein concentration <= 15 g/L) should be

given oral ciprofloxacin or norfloxacin as prophylaxis against
spontaneous bacterial peritonitis

Patients with haemochromatosis are at an increased risk of

hepatocellular carcinoma

Dumping syndrome can cause post-prandial hypoglycaemia following

gastric bypass or bariatric surgery

PPIs are a risk factor for Clostridium difficile infection

Obesity with abnormal LFTs - ? non-alcoholic fatty liver disease

Flucloxacillin is a well recognised cause of cholestasis

Steroids are a cause of acute pancreatitis

A non-cardioselective B-blocker (NSBB) is used for the prophylaxis of

oesophageal bleeding

Serology for Echinococcus granulosuscan be useful in the

investigation of suspected hydatid cysts

Patients must eat gluten for at least 6 weeks before they are tested

Fidaxomicin is used for Clostridium difficile infections that don't

respond to metronidazole/vancomycin

Mesalazine > sulfasalazine in terms of pancreatitis risk

Paracentesis induced circulatory dysfunction can occur due to large

volume paracentesis (> 5 litres). It is associated with a high rate of
ascites recurrence, development of hepatorenal syndrome, dilutional
hyponatraemia, and high mortality rate

If a patient with ulcerative colitis has had a severe relapse or >=2

exacerbations in the past year they should be given either oral
azathioprine or oral mercaptopurine to maintain remission

If a mild-moderate flare of ulcerative colitis does not respond to

topical or oral aminosalicylates then oral corticosteroids are added

If C. difficile does not respond to first line metronidazole, oral

vancomycin should be used next, except in life-threatening infections

Acute hypoperfusion (e.g. low BP secondary to blood loss) may result

in ischaemic hepatitis

Adults with cirrhosis should be screened for hepatocellular

carcinoma by ultrasound (with or without measurement of serum
alpha‑fetoprotein) every 6 months

Liver abscesses are generally managed with a combination of

antibiotics & drainage
Autoimmune pancreatitis can be diagnosed with a combination of
imaging and raised serum IgG4

Flucloxacillin is a well recognised cause of cholestasis

Dietary modification and topical steroids are used in the

management of eosinophilic oesophagitis

Cholestyramine is used to provide symptomatic relief of pruritus in

PBC

Ulcerative colitis + cholestatis (e.g. jaundice, raised ALP) → ? primary

sclerosing cholangitis

Antinuclear antibodies, anti-smooth muscle antibodies and raised

IgG levels are characteristic of autoimmune hepatitis

Primary biliary cholangitis - the M rule

IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females

Lactulose and rifaximin are used for the secondary prophylaxis of

hepatic encephalopathy

Pridoxine (vitamin B6) should be co-administered with isoniazid to

prevent peripheral neuropathy

PPIs are a risk factor for Clostridium difficile infection

Lactulose should be prescribed in all patients with suspected hepatic

encephalopathy

Gallstone ileus is a mechanical small bowel obstruction which occurs

due a gallstone obstruction most often in the ileum
In the assessment of diarrhoea, a very large daily stool weight
indicates organic pathology. Maintenance of large volume stool
weight on fasting suggests a secretory diarrhoea

An isolated rise in bilirubin in response to physiological stress is

typical of Gilbert's syndrome

Full blood count, ESR, CRP, antibody testing for coeliac disease –
endomysial antibodies or tissue transglutaminase are first-line
investigations which are expected to be normal in patients with
suspected irritable bowel syndrome.

Fidaxomicin is used for Clostridium difficile infections that don't

respond to metronidazole/vancomycin

If a mild-moderate flare of distal ulcerative colitis doesn't respond to

topical (rectal) aminosalicylates then oral aminosalicylates should be
added

A combination of low vitamin B12 and high folate levels favours

small bowel bacterial overgrowth

Hydrogen breath testing is an appropriate first line test for diagnosis

of small bowel overgrowth syndrome

In patients with acute on chronic pancreatitis, the amylase may not

be raised if there is significantly poor residual pancreatic function

Dumping syndrome features include osmotic diarrhoea, distension of

the small bowel leading to abdominal pain, and intravascular
depletion

Budd-Chiari syndrome can cause decompensation of chronic liver

disease
Prokinetic agents such as metoclopramide can be very effective in
incomplete bowel obstruction. However they are contraindicated in
complete bowel obstruction and in the presence of colic

In a mild-moderate flare of ulcerative colitis extending past the left-

sided colon, oral aminosalicylates should be added to rectal
aminosalicylates, as enemas only reach so far

Unintentional weight loss of more than 15% over 3-6 months: high
risk of refeeding syndrome

Patients with NAFLD who have evidence of advanced fibrosis may

benefit from pioglitazone

Vitamin A is essential to maintain visual acuity, immunological

functions and cellular proliferation

Metoclopramide can cause drug-induced hyperprolactinaemia

presenting as hypogonadism in men

Mesalazine can cause drug-induced pancreatitis

Raised LFTs + recent appendicitis -> liver abscess

Dubin-Johnson Syndrome is characterised by a raised conjugated

bilirubin

Treatment for Wilson's disease is currently penicillamine

Faecal elastase is the most useful initial investigation in patients with

possible chronic pancreatitis to determine exocrine pancreatic
insufficiency

SeHCAT is the investigation of choice for bile acid malabsorption

Lactulose and rifaximin are used for the secondary prophylaxis of
hepatic encephalopathy

Sjogren's syndrome is common in patients with PBC

Budd-Chiari syndrome presents with the triad of sudden onset

abdominal pain, ascites, and tender hepatomegaly

Dysplasia on biopsy in Barrett's oesophagus requires an endoscopic

intervention

PBC -> high risk for osteomalacia

In patients with non-alcoholic fatty liver disease, enhanced liver

fibrosis (ELF) testing is recommended to aid diagnosis of liver fibrosis

Transjugular intrahepatic portosystemic shunt may precipitate

hepatic encephalopathy

Primary biliary cholangitis - the M rule

IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females

Faecal calprotectin is a highly sensitive and specific test for

inflammatory bowel disease

Biologic therapy is considered in treatment of an acute flare of

Crohn's disease when symptoms don't improve after 5 days of IV

hydrocortisone

Vitamin B1 deficiency may cause peripheral neuropathy

In Vitamin D deficiency, there is usually low serum calcium, low
serum phosphate and high serum alkaline phosphatase

Gastric MALT lymphoma - eradicate H. pylori

SSRIs are linked to the development of microscopic colitis

Labetolol can cause acute hepatitis

Metronidazole is the first line antibiotic for use in patients with

Clostridium difficile infection
In heart failure, both passive congestion of the liver secondary to
right heart failure and decreased cardiac output, predisposes to
ischaemic hepatitis

SeHCAT is bile acid analogue which can be detected by a nuclear

medicine scan. The SeHCAT test involves a baseline scan, and then a
7 day scan. A 7-day SeHCAT retention value of less than 15% is
generally considered indicative of bile salt malabsorption

Screening for haemochromatosis

general population: transferrin saturation > ferritin
family members: HFE genetic testing

Zieve syndrome is a triad of symptoms: haemolytic anemia,

cholestatic jaundice, and transient hyperlipidemia

Geriatrics

Acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) can help

alleviate the features of Lewy body dementia
Donepezil is generally avoided (relative contraindication) in patients
with bradycardia and is used with caution in other cardiac
abnormalities

Lewy body dementia typically presents with fluctuating cognition in

contrast to other forms of dementia

Quetiapine may be useful in the management of patients with

Parkinson's disease who are in an acute confusional state

The Confusion Assessment Method (CAM) is the best way to

differentiate between delirium and dementia

Hematology

A delayed transfusion reaction occurs 7-10 days after the transfusion

Acquired haemophilia A is diagnosed in patients without previous or

familial histories of bleeding who have isolated prolongation of the
activated partial thromboplastin time (aPTT), reduced FVIII levels as
well as evidence of FVIII inhibitor activity

Activated protein C resistance (Factor V Leiden) is the most common

inherited thrombophilia

Acute myeloid leukaemia can present acutely with hyperviscosity

syndrome

Anaphylaxis - adult adrenaline dose = 500 mcg (0.5 ml of 1 in 1,000)

Anaphylaxis - serum tryptase levels rise following an acute episode

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

Ascorbic acid is the treatment of choice for NADH

methaemoglobinaemia reductase deficiency

Auer rods on blood film strongly suggests acute promyelocytic

leukaemia

BRAF is mutated in hairy cell leukaemia

Burkitt's lymphoma - t(8:14)

Cancer patients with VTE - 6 months of a DOAC

CLL - immunophenotyping is investigation of choice

CML may present with massive splenomegaly

Dapsone is a common cause of methaemoglobinaemia

del 17p is associated with a poor prognosis in CLL

Deranged coagulation in sepsis -> DIC

DIC is a severe complication of acute promyelocytic leukaemia

Disproportionately low MCV think thalassaemia

Elective splenectomy is appropriate in a patient with hereditary

spherocytosis who has recurrent anaemia

First-line treatment for ITP is oral prednisolone

Fresh frozen plasma is offered to bleeding patients who have either a
prothrombin time or activated partial thromboplastin time greater
than 1.5 times normal

G6PD deficiency: G6PD level may be normal during an acute

haemolytic episode

Gaucher disease causes splenomegaly

Gram colony stimulating factor (G-CSF) can be used to boost

neutrophil numbers in neutropenia

Haem arginate and 10% dextrose can be used to treat flares of acute
intermittent porphyria

Hereditary angioedema: the acute management is IV C1-inhibitor

concentrate or fresh frozen plasma if this is not available

Hereditary spherocytosis is an explanation for anaemia in recurrent

gallstones

HLA-matched platelets and single-donor platelets are used for

individuals that are refractory to platelet transfusions and have
developed anti-HLA or antiplatelet antibodies

Human immunoglobulin (IVIG) is an alternative to steroids in treating

ITP, particularly if the platelets need to be raised quickly

Hyper IgM syndrome characteristically presents with infections e.g.

Pneumocystis pneumonia, hepatitis, diarrhoea

Ibrutinib is effective and can be used for the treatment of CLL in

patients who have failed a previous therapy
If a 2-level DVT Wells score is ≥ 2 points then arrange a proximal leg
vein ultrasound scan within 4 hours

If a diagnosis of DVT is made less than 7 days before surgery, an IVC

filter must be inserted pre-op

IgA deficiency is associated with anaphylactic reaction to blood

products

In acute intermittent porphyria, urinary porphobilinogen is typically

raised

In approximately 1-2% of myeloma cases, the myeloma cells produce

very low amounts of paraprotein, which can only be detected using
the serum free light chain test. This is called oligosecretory myeloma

In bleeding patients with DIC and prolonged prothrombin time (PT)

and activated partial thromboplastin time (aPTT), administration of
fresh frozen plasma (FFP) may be useful

In bleeding patients with DIC with severe hypofibrinogenaemia (<1

g/l) that persists despite FFP replacement, then fibrinogen
concentrate or cryoprecipitate is indicated

In cold AIHA, samples for DAT testing must be taken 'hot' to the lab
and not allowed to fall below 37 degrees

In DIC fibrinogen can be normal or elevated in over 50% of cases

especially early on (as fibrinogen is an acute phase marker)

Innate defective glycoprotein IIb/IIIa -> Glanzmann's thombasthenia

Lead poisoning is often occupational and comprises gastrointestinal

and neuropsychiatric symptoms and anaemia due to interruption to
the haem biosynthetic pathway.
Leukapheresis can be used to acutely lower the white cell count in
AML

Lymph node pain when drinking alcohol is very specific for Hodgkin's
lymphoma (although it occurs rarely)

Massive splenomegaly may early satiety and vomiting which can

mimic gastric cancer

Mediastinal mass + symptoms of myasthenia = thymoma

Methylene blue can be used to treat methaemoglobinaemia. It

causes a reduction of Fe3+ (ferric) to Fe2+ (ferrous)

Mucositis can be a source of neutropenic sepsis

Myelodysplasia can transform in to AML

Neutropenic patients should avoid soft cheese due to risk of

listeriosis

Neutropenic sepsis with no response to antibiotics at 48 hrs - >

possible fungal infection

New B-symptoms in CLL -> Richter's transformation

Nitrates, including recreational nitrates such as amyl nitrite

('poppers') may cause methaemoglobinaemia

Nitrofurantoin can cause eosinophilia

Paroxysmal cold haemoglobinuria should be confirmed with urinary

heamosiderin
Piperacillin with tazobactam (Tazocin) is the empirical antibiotic of
choice for neutropenic sepsis

Rivaroxaban and apixaban can be reversed by andexanet alfa

The risk of transfusion associated graft versus host disease in

Hodgkin’s lymphoma is unrelated to the treatment modality and/or

disease stage. Individuals with Hodgkin’s lymphoma should therefore
receive X- or gamma-irradiated blood for life

The use of CMV-seronegative blood products is reserved for CMV-

seronegative individuals that are likely to proceed to haematopoietic
stem cell transplant, or neonates

Thrombocytopenia -> indication to start treatment in CLL

TP53 mutation is associated with a poor prognosis in CLL

TTP - plasma exchange is first-line

Warm autoimmune haemolytic anaemia can be confirmed with the

presence of anaemia, spherocytes on blood film and positive direct
Coombs test for IgG or C3d

Whole body MRI 1st line imaging in suspected multiple myeloma

Infectious diseases

Legionella pneumophilia is best diagnosed by the urinary antigen test

Chlamydia - treat with doxycycline

Coxiella burnetii is a cause of atypical pneumonia and Q fever. It is
usually transmitted by infected cattle or sheep

P. vivax and ovale have hypnozoite forms, which can cause clinical
disease long after patients leave the endemic area or may cause
relapsing disease following treatment

Acute schistomiasis is usually associated with marked eosinophilia,

cough, bloody diarrhoea, and splenomegaly

Albendazole is the treatment of choice for cutaneous larva migrans

Candidiasis in immunocompromised patients should be treated using

high dose fluconazole

Carbapenemase producing enterobacteriaceae (CPE) are multi-drug

resistant coliforms. They can be treated with polymyxins (e.g.
colistin), tigecycline, fosfomycin or aminoglycosides (e.g. gentamicin)

Chickenpox is a risk factor for invasive group A streptococcal soft

tissue infections including necrotizing fasciitis

Chickenpox is a risk factor for invasive group A streptococcal soft

tissue infections including necrotizing fasciitis

Chikungunya can present with debilitating joint pain

Chikungunya can present with debilitating joint pain

Common causes of E. coli bacteraemia include urinary tract, large

bowel and biliary tract pathology

Confusion in returned traveller from Asia -> Japanese encephalitis

Demonstration of parasites on bone marrow or splenic aspirate
remains gold standard for diagnosing visceral leishmaniasis

Diethylcarbamazine is the drug of choice for lymphatic filariasis

Exposure to bats/caves is a risk factor for Marburg virus, which

results in a viral haemorrhagic fever

Exposure to bats/caves is a risk factor for Marburg virus, which

results in a viral haemorrhagic fever

Farmer, fever, transaminitis ?Q fever

First line treatment for early Lyme disease is a 14-21 day course of
oral doxycycline

HIV, neuro symptoms, headache, CSF India ink positive - CNS

cryptococcal infection

HIV, neuro symptoms, multiple brain lesions with ring enhancement -

toxoplasmosis

HIV, neuro symptoms, single brain lesions with homogenous

enhancement - CNS lymphoma

HIV, neuro symptoms, widespread demyelination - progressive

multifocal leukoencephalopathy

Immunocompromised patients with toxoplasmosis are treated with

pyrimethamine plus sulphadiazine

In confirmed isoniazid resistance, ethambutol is continued for 6

months of treatment
In lymphoedema, management of cellulitis should be with IV rather
than oral antibiotics even when patient not systemically unwell

In order to confirm the diagnosis of TB, it is necessary to culture

Mycobacterium tuberculosis from a respiratory specimen.

Bronchoscopy will produce the best respiratory specimen for acid-

fast staining and mycobacterial culture

Intramuscular ceftriaxone is the treatment of choice for Gonorrhoea

Ivermectin is the drug of choice for treatment of strongyloidiasis

Kaposi's sarcoma - caused by HHV-8 (human herpes virus 8)

Liver cirrhosis where previously lived abroad -> schistomiasis

Low-risk patients with influenza who present 48 hours after
symptoms are recommended for supportive treatment

Lyme disease can be diagnosed clinically if erythema migrans is

present → give antibiotics

Lyme disease can be diagnosed clinically if erythema migrans is

present → give antibiotics

Lyme's disease can present with a facial nerve palsy

Parvovirus B19 can cause fever, rash and pancytopenia (due to an

aplastic crisis)

People who have been exposed to a patient with confirmed bacterial

meningitis should be given prophylactic antibiotics if they been
exposed to respiratory secretion, regardless of closeness of contact
People who have been exposed to a patient with confirmed bacterial
meningitis should be given prophylactic antibiotics if they have close
contact within the seven days before onset

Pneumocystis jiroveci penumonia is treated with co-trimoxazole,

which is a mix of trimethoprim and sulfamethoxazole

Pneumocystis jiroveci pneumonia - pneumothorax is a common

complication

PPIs are contraindicated in patients on Eviplera

(emtricitabine/rilpivirine/tenofovir). They reduce the absorption of
rilpivirine which can cause viral blips, with subsequent virological
failure and resistance

Pregnant women ≥ 20 weeks who develop chickenpox are generally

treated with oral aciclovir if they present within 24 hours of the rash

Rifaxamin is licensed for the treatment of cryptosporidiosis

Risk of vertical transmission for hepatitis C is 6%

Serology is the most commonly used test for the diagnosis of

leptospirosis, however, antibodies may not be present until after 7
days

Serology is the most commonly used test for the diagnosis of

leptospirosis, however, antibodies may not be present until after 7
days

Staphylococcus aureus bacteraemia (SAB) is a serious condition

which may occur secondary to soft tissue, joint, bone, indwelling IV
line or cardiac infection. It is treated with a minimum of two weeks
IV flucloxacillin
Stereotypical history of mycoplasma pneumonia: worsening flu-like
symptoms and a dry cough. Erythema multiforme is noted on
examination

Stereotypical history of mycoplasma pneumonia: worsening flu-like

symptoms and a dry cough. Erythema multiforme is noted on
examination

The Jarisch-Herxheimer reaction is a known phenomenon following

syphilis treatment that does not require any specific treatment or
investigations other antipyretics

The plague is caused by the gram-negative bacterium Yersinia pestis.

Three clinical presentations can occur: bubonic (most common),

pneumonic and septicaemic

There is no need for prophylactic antibiotics for Lyme disease in

asymptomatic patients bitten by a tick

Those exposed to measles can be given immunoglobulin to reduce

the risk of infection

Treatment for tick-borne encephalitis is supportive

Treatment for tick-borne encephalitis is supportive

Treponemal specific antibody tests (e.g. TPHA) are very specific to

Treponema but not necessarily syphillis, as the species Treponema
can cause a variety of diseases including syphilis, yaws and pinta

Type 1, or polymicrobial, necrotising fasciitis is the most common

Type 1, or polymicrobial, necrotising fasciitis is the most common

Unwell vet with fever, malaise, arthralgia and lower back pain ?
Brucellosis

Vancomycin Resistant Enterococcus (VRE) can be treated with

linezolid, daptomycin and tigecycline

Neurology,ophthalmology & psychiatry

'Foot drop' - ?common peroneal nerve lesion

123I‑FP‑CIT SPECT can be used to help differentiate essential tremor

from Parkinson's

A combination of thrombolysis AND thrombectomy is recommend

for patients with an acute ischaemic stroke who present within 4.5
hours

Abrupt cessation of antiparkinsonian medication (dopamine

agonists) can lead to neuroleptic malignant syndrome

Absence seizures: sodium valproate and ethosuximide are first-line

Acne and hyperpigmentation -> tuberous sclerosis

Acute amnesia with preserved cognition -> transient global amnesia

Acute dystonic reactions are an adverse effect of antipsychotic

medications

Agoraphobia describes a fear of open spaces. It may or may not be

associated with panic disorder
Agranulocytosis/neutropenia is a life-threatening side effect of
clozapine - monitor FBC

Alongside eye drops, IV acetazolamide is used in the initial

emergency medical management of acute angle-closure glaucoma

Aminoglycoside antibiotics are contraindicated in patients with

myasthenia gravis due to the risk of fatal myasthenic crisis and
respiratory failure

Anterior uveitis is most likely to be treated with a steroid +

cycloplegic (mydriatic) drops

Anterior uveitis presents with acutely painful red eye, photophobia,

small pupil, reduced visual acuity. It is often associated with pus in
the anterior chamber (a hypopyon)

Antipsychotics have the greatest efficacy at treating tics

Antipsychotics may cause tardive dyskinesia

Atypical grief reactions are characterised by either delayed grief (e.g.

onset > 2 weeks since bereavement) or prolonged grief (e.g. > 12
months)

Benzodiazepine overdose is best managed supportively and with

airway protection and ventilation if needed. Flumazenil should be
avoided unless for reversal of anaesthesia

Carbamazepine is known to exhibit autoinduction. hence when

patients start carbamazepine they may see a return of seizures after
3-4 weeks of treatment
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

Cataplexy occurs during heightened emotion. Differential to consider

with collapse of unknown cause

Central nervous system Lyme disease can be diagnosed with CSF

analysis. The results are similar to the 'typical' bacterial picture with
low glucose and high protein, however in Lyme disease we would
expect a lymphocytic pleocytosis

Central retinal vein occlusion - sudden painless loss of vision, severe

retinal haemorrhages on fundoscopy

Cerebellar haemangioblastomas release erythropoietin so can cause

a rise in haemoglobin

Chlordiazepoxide or diazepam are used in the treatment of delirium

tremens/alcohol withdrawal

Chronic paroxysmal hemicrania is characterised by multiple (5+)

short (5-30 min) headaches centered around the eye. CPH headaches
are shorter and more frequent than cluster headaches

CIDP is like GBS but with a more chronic onset and treated with
steroids

Clouded consciousness and fever -> encephalitis

Clozapine can cause myocarditis. A baseline ECG should be

performed before initiating treatment
Cluster headache - acute treatment: subcutaneous sumatriptan +
100% O2

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

Contralateral hemiparesis and sensory loss with the upper extremity

being more affected than the lower, contralateral homonymous
hemianopia and aphasia - middle cerebral artery

Difficulty in breathing due to immediate heamatoma is an

emergency and needs immediate action

Don’t given IV magnesium in myasthenia as can precipitate a crisis

Early age SAH occur in Von Hippel Lindau

Erectile dysfunction is an early autonomic feature of multiple system

atrophy

Features of raised intracranial pressure and fever points towards a

cerebral abscess

Following a subarachnoid haemorrhage, most intracranial aneurysms

are now treated with a coil by an interventional neuroradiologist

Following thyroid removal, checking calcium is important to assess

for hypoparathyroidism

For thrombectomy in acute ischaemic stroke, an extended target

time of 6-24 hours may be considered if there is the potential to
salvage brain tissue, as shown by imaging such as CT perfusion or
diffusion-weighted MRI sequences showing limited infarct core
volume

For thrombectomy in acute ischaemic stroke, an extended target

time of 6-24 hours may be considered if there is the potential to
salvage brain tissue, as shown by imaging such as CT perfusion or
diffusion-weighted MRI sequences showing limited infarct core
volume

FVC is used to monitor respiratory function in Guillain-Barre

syndrome

Herpes simplex meningitis does not require treatment. This is in

contrast to herpes simplex encephalitis which requires 14-21 days of
intravenous aciclovir

Histrionic personality disorder is characterised by excessive

attention-seeking and emotional overreaction

Hoarseness following total thyroidectomy should be investigated

with laryngoscope

Hypertension in Von Hippel Lindau -> phaeochromocytoma

Idiopathic intracranial hypertension -> lumbar puncture is 2nd line

treatment

In non-traumatic subarachnoid haemorrhages, a CT angiogram

should be performed to identify intracranial aneurysms

Ketamine can be used as a third line agent in the management of

neuropathic pain which is poorly responsive to titrated opioids and
oral adjuvant analgesics
L-carnitine can be used in the treatment of hepatotoxicity or
hyperammonemic encephalopathy in the context of an acute or
chronic overdose of sodium valproate

Lung carcinoma can present with a brachial neuritis

Management of autonomic dysreflexia involves removal/control of

the stimulus and treatment of any life-threatening hypertension
and/or bradycardia

Meningioma primary brain tumors show contrast enhancement on a

CT scan

Meningitis which occurs as a complication of an ear infection is

nearly always caused by Streptococcus pneumoniae

Metoclopramide can cause extrapyramidal effects, especially in

children and young adults (15–19 years old)

Migraine
acute: triptan + NSAID or triptan + paracetamol
prophylaxis: topiramate or propranolol

MRI brain with diffusion-weighted imaging is the preferred modality

in patients with suspected TIA who require brain imaging

MRI changes in thalamus/basal ganglai -> CJD

Narcissistic personality disorder is characterised by a grandiose sense

of self importance

Nimodipine is used to prevent vasospasm in aneurysmal

subarachnoid haemorrhages
Non-convulsive status epilepticus can present with subtle signs, such
as twitching or blinking and/or fluctuating mental status

Non-invasive ventilation (NIV) should be the treatment of choice for

patients with chest wall or neuromuscular disease causing type 2
respiratory failure. Additional LTOT may be required
in case of hypoxaemia not corrected with NIV

Of the antiparkinson drugs, levodopa is associated with the greatest

improvement in symptoms and activities of daily living

Older man + quadriceps and finger/wrist flexors weakness + raised

CK → inclusion body myositis

One of the most common side effects of clozapine is

constipation/intestinal obstruction

One of the most common side effects of clozapine is

constipation/intestinal obstruction

Paroxysmal hemicrania is completely responsive to treatment with

indomethacin

Phenytoin can cause lymphadenopathy

Pneumothorax -> can fly 1 week after treatment if chest x-ray shows
resolution

POEMS syndrome is a rare paraneoplastic syndrome caused by a

clone of abnormal plasma cells. It is associated with polyneuropathy,
organomegaly, endocrinopathy, M-protein band from a
plasmocytoma, and skin pigmentation

Pontine haemorrhage commonly presents with reduced GCS,

paralysis and bilateral pin point pupils
Postural headache but normal imaging -> idiopathic intracranial
hypertension

Prodromal viral illness with associated vertigo and nystagmus is

suggestive of vestibular neuronitis

Progressive supranuclear palsy: postural instability, impairment of

vertical gaze, parkinsonism, frontal lobe dysfunction

Propranolol is preferable to topiramate in women of childbearing

age (i.e. the majority of women with migraine)

Propranolol is preferable to topiramate in women of childbearing

age (i.e. the majority of women with migraine)

Pyridostigmine is a long-acting acetylcholinesterase inhibitor that

reduces the breakdown of acetylcholine in the neuromuscular
junction, temporarily improving symptoms of myasthenia gravis

Pyridostigmine is a long-acting acetylcholinesterase inhibitor that

reduces the breakdown of acetylcholine in the neuromuscular
junction, temporarily improving symptoms of myasthenia gravis

Recurrence of the same neurological signs or symptoms is unlikely to

be due to TIA

Retinal + cerebellar haemangiomas = Von Hippel-Lindau syndrome

Schizotypal personality disorder is characterised by social isolation

and odd beliefs

Severe constant headache on a background of rhinitis is likely

sinusitis
Sodium valproate is a well known cause of hyperammonemic
encephalopathy

ST elevation can occur in subarachnoid haemorrhage

Statins should be initiated for secondary prevention of stroke 48

hours following ischaemic event

Tetracyclines increase the risk of idiopathic intracranial hypertension

The Epley manoeuvre is successful in treating around 80% of cases of

BPPV

The NIHSS score is useful in stroke for assessing patients suitability

for thrombolysis

The only absolute contraindication for electroconvulsive therapy is

raised intracranial pressure

The standard target time for thrombectomy in acute ischaemic

stroke is 6 hours

TIAs do not cause loss of consciousness

Topical antiviral treatment is not given in herpes zoster ophthalmicus

Tuberous sclerosis - adenoma sebaceum

Ultrasound neck is the most appropriate 1st line imaging for a neck
mass

Uncal herniation results in pressure on the midbrain resulting in

ipsilateral CN III palsy (mydriasis is the earliest sign) and contralateral
hemiparesis
Unexplained symptoms
Somatisation = Symptoms
hypoChondria = Cancer

Up to 15 percent of individuals with Guillain-Barre syndrome will

experience long-term weakness

Verapamil is used for long-term prophylaxis of cluster headaches

Verapamil is used for long-term prophylaxis of cluster headaches

Vestibular neuritis stereotypical history: recovering from an upper

respiratory tract infections presents with recurrent attacks of vertigo
associated with nausea and vomiting. There is no hearing loss or
tinnitus

VMAT inhibitors such as reserpine can cause drug induced

depression

Weber's syndrome is a form of midbrain stroke characterised by the

an ipsilateral CN III palsy and contralateral hemiparesis

When interpreting NCS, a reduced amplitude but normal conduction

velocity is indicative of axonal pathology

When interpreting NCS, a reduced conduction velocity but normal

amplitude is indicative of demyelinating pathology

Renal Medicine

A patient who has an elevated PSA should not have testosterone

even if deficient
Acute interstitial nephritis causes an 'allergic' type picture consisting
usually of raised urinary WCC, IgE, and eosinophils, alongside
impaired renal function

Acute kidney injury following a percutaneous coronary

intervention→ ?contrast-induced nephropathy

Aggressive treatment with 0.9% saline in DKA commonly causes a

hyperchloraemic metabolic acidosis

Alport syndrome can cause anti-GBM disease following renal

transplantation

Amyloidosis can cause nephrotic syndrome and the majority of cases

are AL type (secondary to plasma cell dyscrasias)

Anaemia in CKD - aim for 10-12 g/dl

Anaemia in CKD: correct iron deficiency before starting

erythropoiesis-stimulating agents

Anaemia in CKD: correct iron deficiency before starting

erythropoiesis-stimulating agents

Arteriovenous fistula stenosis presents with acute limb pain

Arteriovenous fistula with no bruit has thrombosed

Before a renal biopsy is performed, patients should have a renal tract

ultrasound. The presence of polycystic kidneys, obstruction of the
urinary tract, or hydronephrosis are regarded as absolute
contraindications to biopsy
Chronic paracetamol use can lead to raised anion gap metabolic
acidosis caused by 5-oxoproline

CKD induced secondary hyperparathyroidism is a common

contributing factor to fragility fractures, and all patients presenting
with fragility fractures should be investigated for underlying causes

Diabetes insipidus is characterised by a high plasma osmolality and a

low urine osmolality

Diabetes insipidus is characterised by a high plasma osmolality and a

low urine osmolality

Dialysis disequilibrium syndrome results in cerebral oedema which

can present as focal neurological deficits, papilloedema and a
decreased level of consciousness. It can be treated with mannitol or
hypertonic saline

Dialysis should be started in CKD stage 5 if symptomatic or when

eGFR drops to 5-7

Eculizumab (a C5 inhibitor monoclonal antibody) has evidence of

greater efficiency than plasma exchange alone in the treatment of
adult atypical HUS

Eplerenone can be used in patients with troublesome gynaecomastia

on spironolactone

Granular casts can be found in both acute tubular necrosis (ATN) and
hepatorenal syndrome (HRS), but renal epithelial cells are more
suggestive of ATN

Haematuria in sickle cell anaemia -> renal papillary necrosis

Henoch-Schonlein purpura classically presents with abdominal pain,
arthritis, haematuria and a purpuric rash over the buttocks and
extensor surfaces of arms and legs

HIV infection is a cause of focal segmental glomerulosclerosis

HIV-associated nephropathy (HIVAN) causes collapsing FSGS and

usually presents as nephrotic syndrome

IgA nephropathy is more common in coeliac disease

In a patient with hypercalciuria and renal stones, calcium excretion

and stone formation can be decreased by the use of thiazide
diuretics

Indications for plasma exchange in ANCA-associated vasculitis:

rapidly progressive renal failure or pulmonary haemorrhage

Initial management of CKD-mineral bone disease: Correct

hyperphosphataemia first; start with dietary changes before starting
a phosphate binder

Initial management of CKD-mineral bone disease: Correct

hyperphosphataemia first; start with dietary changes before starting
a phosphate binder

Lactic acidosis occurs due to tissue hypoxia. Tissue hypoxia occurs

due to one of four main mechanisms: 1. Hypoxaemia (e.g. respiratory
pathology), 2. Toxic (e.g. carboxyhemoglobinemia, or cyanide
poisoning), 3. Perfusional (e.g. shock), or 4. Severe anaemia
Lithium is a recognised cause of nephrogenic diabetes insipidus

Membranous nephropathy is frequently associated with malignancy

Myeloma can cause secondary amyloidosis

People with erectile dysfunction who cycle for more than three
hours per week should be advised to stop

Prevention of contrast-induced nephropathy: volume expansion with

0.9% saline

Renal complications of HAART: Indinavir can cause renal stones

Renal papillary necrosis presents with loin pain and visible

haematuria

Rhabdomyolysis can result from co-prescription of clarithromycin

and statins

Stool culture looking for Shiga toxin-producing Escherichia coli

should be sent in patients with suspected haemolytic uraemic
syndrome

The first-line investigation of a testicular mass is an ultrasound

Tolvaptan has been shown to reduce the rate of CKD progression in

ADPKD (and is approved by NICE)

Trial of sildenafil is appropriate unless contraindicated for erectile

dysfunction, regardless of underlying aetiology

Ultrasound detects only 95% of urinary tract obstruction in AKI

Untreated FSGS has a < 10% chance of spontaneous remission

Untreated FSGS has a < 10% chance of spontaneous remission

Urinalysis in acute kidney injury: presence of blood and protein is

suggestive of inflammatory renal cause
Young woman presenting with AKI and visual disturbance think TINU
(tubulointerstitial nephritis with uveitis)

Respiratory medicine

Chlamydia psittaci is a cause of atypical pneumonia. It is transmitted

via aerosol inhalation of faecal and urinary products on bird feathers

Acetazolamide can be used to prevent acute mountain sickness. It

causes a primary metabolic acidosis and compensatory respiratory
alkalosis which increases respiratory rate and improves oxygenation

Acute eosinophilic pneumonia is highly responsive to steroids

Adult with asthma not controlled by a SABA - add a low-dose ICS

Aeronautical engineers -> risk of berylliosis

All cases of pneumonia should have a repeat chest X-ray at 6 weeks

after clinical resolution

Aminophylline loading dose should be done with cardiac monitoring

Amphotericin or itraconazole are the pharmacological agents of

choice for histoplasmosis

Anaerobic bacteria in sputum culture suggest aspiration pneumonia

Appropriate treatment of Pseudomonas positive bronchiectasis
failing to respond to ciprofloxacin includes IV tazocin, ceftazidime,
aztreonam or meropenem

Appropriate treatment of Pseudomonas positive bronchiectasis

failing to respond to ciprofloxacin includes IV tazocin, ceftazidime,
aztreonam or meropenem

Attempts at Pseudomonas aeruginosa eradication are important in

patients with cystic fibrosis

Bronchial carcinoid is the most common lung cancer in adolescents

and can present with recurrent pneumonia

Bubbling of a chest drain inserted to drain an empyema may

indicates that a bronchopleural fistula has occurred

Chronic pulmonary embolisms can lead to pulmonary hypertension

Churg-Strauss syndrome - eosinophilia

Churg-Strauss syndrome - positive pANCA serology

Combined pulmonary fibrosis and emphysema (CPFE) has a much

higher rate of lung cancer than emphysema alone

Consider allergic bronchopulmonary aspergillosis in asthma patients

who have developed difficult to control symptoms and/or have
become dependent on oral steroids

COPD - still breathless despite using SABA/SAMA and asthma/steroid

responsive features → add a LABA + ICS

COPD - still breathless despite using SABA/SAMA and no

asthma/steroid responsive features → add a LABA + LAMA
COPD - still breathless despite using SABA/SAMA and a LABA + ICS →
add a LAMA

COPD in a non smoker should prompt suspicion of alpha-1

antitrypsin deficiency

Copious secretions are a contraindication to non-invasive ventilation

Current smokers -> liver enzyme induction -> higher doses

aminophylline required

Diagnostic criteria for ARDS; Clinical + CXR + pO2/fiO2<26 kpa

(200mmHg)

Eosinophilic granulomatosis with polyangiitis is a necrotizing small

vessel vasculitis

Excessive salbutamol use in acute asthma can lead to

hyperlactatemia

Following NICE 2017, patients with asthma who are not controlled
with a SABA + ICS should first have a LTRA added, not a LABA

Following NICE 2017, patients with asthma who are not controlled
with a SABA + ICS should first have a LTRA added, not a LABA

Following weight loss, CPAP is the first-line treatment for

moderate/severe obstructive sleep apnoea

Histoplasmosis can affect the lung and present with acute respiratory
failure
If a secondary pneumothorax > 2cm and/or the patient is short of
breath then patient should be treated with chest drain (not
aspiration) as first-line

If the pleural fluid appears bloody, a haematocrit can be obtained if

there is doubt as to whether it is a haemothorax. If the haematocrit
of the pleural fluid is more than half of the patient’s peripheral blood
haematocrit, the patient has a haemothorax

If the pleural fluid is turbid or milky it should be

centrifuged. If the supernatant (liquid which lies above the sediment)
is clear, the turbid fluid was due to cell debris and empyema is likely

In cases of severe theophylline toxicity, charcoal haemoperfusion can

be used

In the assessment of a pleural effusions, if the clinical picture

suggests a transudate, then you should treat the cause initially. If this
does not resolve the effusion then perform a diagnostic aspiration

Indications for corticosteroid treatment for sarcoidosis are:

parenchymal lung disease, uveitis, hypercalcaemia and neurological
or cardiac involvement

Klebsiella most commonly causes a cavitating pneumonia in the

upper lobes, mainly in diabetics and alcoholics

Lumacaftor/Ivacaftor (Orkambi) can be used to treat cystic fibrosis

patients who are homozygous for the delta F508 mutation

Mepolizumab and other anti-IL-5 therapies can be used in adults

with eosinophilic asthma

Mepolizumab may be used for asthma with high eosinophils

Nitrofurantoin causes a pulmonary eosinophilia
Omalizumab can be used to treat allergic asthma with elevated IgE
levels

Opioids can precipitate respiratory failure in patients with chronic

respiratory disease

Oral glucocorticoids are the treatment of choice for allergic

bronchopulmonary aspergillosis

Patients diagnosed with pneumonia who have COPD should be given

corticosteroids even if no evidence of the COPD being exacerbated

Patients who develop a respiratory acidosis and/or a rise in PaCO2 of

>1 kPa (7.5 mmHg) during an LTOT assessment may have clinically
unstable disease. These patients should undergo further medical
optimisation and be reassessed after 4 weeks

Patients who develop a respiratory acidosis and/or a rise in PaCO2 of

>1 kPa (7.5 mmHg) during an LTOT assessment on two repeated
occasions, while apparently clinically stable, should only have
domiciliary oxygen ordered in conjunction with nocturnal ventilatory
support

Patients with cystic fibrosis and diabetes should follow a high calorie
diet and use extra insulin to control their blood sugar

Pirfenidone and nintedanib can be used as drug management

options in idiopathic pulmonary fibrosis as they may decrease the
functional decline, prolong survival and potentially reduce acute
exacerbations

Pneumothorax can occur following high pressure non-invasive

ventilation
Pulmonary fibrosis can occur following pneumonia

Rheumatoid arthritis causes a severe form of coal workers

pneumoconiosis called Caplan’s syndrome

Roflumilast is recommended in COPD where there are >=2

exacerbations per year and FEV1<50%

Roflumilast should be used in COPD for patients who are losing

control on triple inhaled therapy

Several drugs are known to cause pleural effusion including

nitrofurantoin, methotrexate, and amiodarone

Significant air leak from the mask will prevent adequate pressures
being achieved with non-invasive ventilation

Silicosis increases susceptibility to tuberculosis

Small cell lung carcinoma secreting ACTH can cause Cushing's

syndrome

The bulging fissure sign is classical of Klebsiella pneumonia

Theophylline poisoning presents with hypokalaemia,

hyperglycaemia, tachycardia and increased myocardial contractility

Type 2 respiratory failure with normal CXR -> neuromuscular

weakness

Untreated OSA -> compensated respiratory acidosis

Upper zones lung fibrosis: ankylosing spondylitis

When draining a pneumothorax, if after 3-5 days there is persistent
air leak (e.g. bubbling chest drain) or failure of the lung to re-expand,
a thoracic surgical opinion should be sought

Rheumatology

A positive pathergy test is suggestive of Behcet's syndrome

A raised CRP in a patient with known SLE may indicate an underlying

infection

Adhesive capsulitis is a clinical diagnosis and does not need imaging

or arthroscopy to confirm the diagnosis

An MRI scan of the spine is the most appropriate investigation to

diagnose infected discitis as it has the greatest sensitivity

Ankylosing spondylitis features - the 'A's

Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis

Anti-RNP antibodies can be positive in systemic lupus erythematosus

in nearly 40% of patients

Anti-synthetase antibodies are specifically associated with

polymyositis
Azathioprine and allopurinol have a severe interaction causing bone
marrow suppression

Azathioprine and allopurinol have a severe interaction causing bone

marrow suppression

Azathioprine is associated with increased risk of non-melanoma skin

cancer

Biopsy (renal, nasal, skin) can be useful in the diagnosis of ANCA

associated vasculitis (e.g. glomerulonephritis with polyangiitis)

Bisphosphonates and denosumab can be used to prevent

pathological fractures in bone metastases. If the eGFR < 30,
denosumab is preferred

Chondrocalcinosis helps to distinguish pseudogout from gout

Co-trimoxazole contains trimethoprim and therefore should never be

prescribed with methotrexate

Denosumab - RANKL inhibitor

Dermatomyositis is commonly a paraneoplastic phenomenon

Diagnosis of ankylosing spondylitis can be best supported by sacro-

ilitis on a pelvic X-ray

Ehlers-Danlos syndrome: angioid retinal streaks is a feature

Epoprostenol (amongst other prostaglandins) can be used in the

treatment of Raynaud's phenomenon
Febuxostat can be used in the prevention of gout in patients where
the allopurinol side effects have been deemed intolerable or the
renal function does not allow sufficient dose escalation

Folinic acid is the treatment of choice for methotrexate toxicity

For gout, if NSAIDs and colchicine are contraindicated or not

tolerated (e.g. chronic kidney disease), the next option is a steroid

Local muscle strengthening exercises and general aerobic fitness is

an important component of knee and hip osteoarthritis

Loin pain + haematuria in antiphospholipid syndrome -> renal vein

thrombus

Malignancy + raised CK → ?polymyositis

Methotrexate can be used as a steroid-sparing agent in difficult to

control, frequently relapsing giant cell arteritis

Muscle biopsy is the gold standard investigation for the diagnosis of

polymyositis

Nifedipine is a pharmacological option for Raynaud's phenomenon

NSAIDs -> trigger asthma exacerbation

NSAIDs are the first line treatment for Still's disease, not steroids

Osteoporosis in a man - check testosterone

Paget's disease of the bone is treated with bisphosphonates

Polymyalgia rheumatic is characterised by abrupt onset of bilateral

early morning stiffness in the over 60s
Psoriatic arthropathy can present before psoriatic skin lesions - a
positive family history of psoriasis may point towards this diagnosis

Relapsing polychondritis is a multi-systemic condition which most

commonly causes relapsing episodes of auricular chondritis

Renal complications of systemic sclerosis - ACE-inhibitors

Renal impairment, respiratory symptoms, joint pain, systemic

features → consider ANCA associated vasculitis

Salivary gland biopsy is the most definitive way of confirming the

diagnosis of primary Sjogren’s syndrome - sections will show a typical
lymphocytic infiltrate

Spinal stenosis is often relieved by sitting down or leaning forward

Start alendronate in patients >= 75 years following a fragility

fracture, without waiting for a DEXA scan

The concurrent use of methotrexate and trimethoprim containing

antibiotics may cause bone marrow suppression and severe or fatal
pancytopaenia

The most common cause of death in systemic sclerosis is respiratory

involvement: interstitial lung disease and pulmonary arterial
hypertension

Urgent admission and administration of corticosteroids is important

in giant cell arteritis associated with visual loss
Theraputics and toxicology

Acute on chronic overdose of lithium can lead to serious toxicity

even after a modest overdose, as the the extracellular tissues are
already saturated with lithium

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

Anabolic steroids are a cause of cholestasis

Bleomycin may cause pulmonary fibrosis

Carbamazepine is a P450 enzyme inductor

Ciclosporin may cause nephrotoxicity

Ciprofloxacin may lead to tendinopathy

Co-administration of aminophylline and ciprofloxacin can cause

significant toxicity and should be avoided

Cocaine toxicity - avoid beta-blockers

Cocaine toxicity - avoid beta-blockers

Disulfram is an acetaldehyde dehydrogenase inhibitor. When

combined with alcohol, it results in high levels of acetaldehyde which
can cause flushing of the skin, nausea, vomiting, arrhythmias, and
even death

Folinic acid can be used in methanol poisoning to reduce

ophthalmological complications

For multiple daily dose regimens of gentamicin, if the pre-dose

(‘trough’) concentration is high, the interval between doses must be
increased. If the post-dose (‘peak’) concentration is high, the dose
must be decreased

Heparin-induced thrombocytopenia: anticoagulation can be provided

by direct thrombin inhibitor e.g. argatroban

In amiodarone induced hypothyroidism, amiodarone can be

continued with levothyroxine

In amiodarone induced thyrotoxicosis type 2 the management is with

corticosteroids rather than carbimazole

Intrathecal baclofen withdrawal syndrome is associated with severe

spasticity, rhabdomyolysis, acute renal failure and multisystem organ
failure

Lithium toxicity can be precipitated by thiazides

Local anaesthetic toxicity can present with CNS (e.g. reduced GCS,
seizures) and cardiovascular (e.g. tachyarrhythmias, hypotension,
bradyarrhythmias) features. Treatment of severe toxicity is with IV
lipid emulsion.

Long-term use of olanzapine is a significant risk factor for the

development of type 2 diabetes mellitus
Metabolic acidosis with a high anion gap and high osmolar gap is
seen in ethylene glycol poisoning

Metabolic acidosis with a high anion gap and high osmolar gap is
seen in ethylene glycol poisoning

Methanol poisoning is preferentially treated with IV fomepizole; this

should be commenced immediately the suspicion is raised

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

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

Octreotide may reduce high output diarrhoea following ileostomy or

colectomy. It can be given by continuous subcutaneous infusion

Organophosphate insecticide - atropine

Organophosphate insecticide - atropine

Organophosphate poisoning occurs due to inhibition of

acetylcholinesterase leading to upregulation of nicotinic and
muscarinic cholinergic neurotransmission

PDE 5 inhibitors (e.g. sildenafil) - contraindicated by nitrates and

nicorandil
Quinine toxicity (cinchonism) presents with myriad ECG changes,
hypotension, metabolic acidosis, hypoglycaemia and classically
tinnitus, flushing and visual disturbances. Flash pulmonary oedema
may occur

Quinolones -> inhibit liver enzymes -> risk of theophylline toxicity in

COPD/asthma exacerbation

Rifampicin is a P450 enzyme inductor

Salicylate overdose can cause a mixed primary respiratory alkalosis

and metabolic acidosis

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

Stop theophylline when CYP450 inhibitors are prescribed

Thallium poisoning is a rare cause of painful polyneuropathy, mood

change and alopecia. Treatment is chelation therapy with oral
Prussian Blue

The combination of trastuzumab + anthracyclines (both often used

for breast cancer) is particularly cardiotoxic

Tramadol co-prescribed with SSRIs is a common cause of serotonin

syndrome

Treatment of cocaine toxicity is largely supportive with judicious

usage of benzodiazepines

Treatment of severe serotonin syndrome- cyproheptadine (5-HT2

receptor antagonist)
Trimethoprim should be avoided in the first 3 months of pregnancy

Whist carbon monoxide poisoning is most associated with exposure

to house/industrial fires, cyanide toxicity from burning of synthetic
materials should also be considered

You risk causing 1:1 conduction if you give flecainide in atrial flutter

You should still use bisoprolol in patients with COPD and IHD,
because it carries an important outcome benefit

Oncology

Dexamethasone with ondansetron is effective in refractory

chemotherapy-induced vomiting

Anthracyclines (e.g. doxorubicin) may cause cardiomyopathy

In a massive terminal haemorrhage, a large dose of midazolam

(10mg) can be given as part of 'crisis management' to relieve
distress. Red or green towels or blankets should be available to soak
up and mask the colour of blood

Enlarged goitre can be a rare cause of SVC obstruction

Levomepromazine is a 'dirty drug' which blocks lots of different
receptors (e.g. ACh, DA, 5HT). It is therefore a broad spectrum anti-
emetic. It is first line in the last days of life.

Cancer of unknown primary have very poor prognosis

Use of cyclophosphamide in granulomatosis with polyangiitis is

associated with increased risk of bladder cancer

Breakthrough dose = 1/6th of daily morphine dose

Dexamethasone is the most useful agent in preventing the delayed

phase of chemotherapy-induced emesis

Transdermal fentanyl absorption is increased by heat (e.g. hot water

bottle) or pyrexia, potentially leading to opioid toxicity

Methadone can be used as a third line opioid for patients with

complex pain that is poorly responsive to other opioids and
adjuvants

Ketamine can cause raised intracranial pressure. It is important to

monitor for side effects such as headache, papilloedema, and
vomiting
Incident pain is defined as pain which comes on as a result of an
action or activity, for example during personal care. Sublingual
fentanyl has rapid onset and is a short-acting opioid, and is therefore
a good choice for treating this type of pain

Denosumab is an unlicensed medication for bony metastasis pain

Metabolic causes of nausea and vomiting, for example uraemia and

hypercalcaemia, cause nausea and vomiting by stimulating dopamine
type 2 (D2) receptors on the chemoreceptor trigger zone. This
pathway is most effectively blocked by using a central dopamine
antagonist such as haloperidol

If neoplastic spinal cord compression is suspected, high-dose oral

dexamethasone should be given whilst awaiting investigations

Compiled by-
Dr Mahbub Alam Chhondo
MBBS,FCPS part 1(Medicine),MRCP part 1
Honorary Medical Officer
Dhaka Medical College & Hospital
Bangladesh