MRCP Part 1

Pregnancy and Thyroid Hormone - answer-Pregnancy increases the amount of TBG (thyroid binding globulin) so increases the total thyroxin levels but not free thyroxine Hyperthyroid in pregnancy - answer-Untreated - fetal loss, premature labour, maternal heart failure Graves disease most common HCG can activate TSH receptors - transient gestational hyperthyroid - these fall in trimester 2 & 3 treatment - propylthiouracil in first trimester this can cause hepatic injury carbimazole in 2nd trimester once lower risk of congenital abnormalities Monitoring - free thyroxine levels should be kept upper third normal so to avoid fetal hypothyroid - thyrotrophin receptor stimulating antibodies should be checked weeks 30-36 DO NOT - block and replace or use radioiodine. Hypothyroid in pregnancy - answer-Thyroxine replacement is safe in pregnancy and breastfeeding TSH measured each trimester and 6-8 weeks post partum Women often require an increased dose - up to 50% by weeks 4-6 untreated - developmental abnormalities, miscarriage, still birth, low birth weight, pre-eclampsia, anaemia Gentamicin - answer-Aminoglycoside antibioitic Given IV or topically Ototoxic - irreversible due to auditory or vestibular nerve damage Nephrotoxic - causes tubular necrosis, accumulates in renal failure requiring increased monitoring, furosemide increases this risk CI - Myasthenia Gravis Dosed via height and weight and renal function. Peak and trough levels monitored with dose adjustments based on trough levels CSF: Protein levels - answer-normal = 0.2-0.4 g/L Causes of raised CSF protein GBS Froin's syndrome - a spinal canal blockage characterised by xanthochromia, raised protein and CSF hypercoagulability TB, bacterial or fungal meningitis viral encephalitis Vigabatrin - answer-Irreversibly inhibits GABA transaminase--increased GABA levels in synapse Uses = tx infantile spasms (Viga"Baby"trin) Or used as adjunct therapy for adults with refractory complex partial seizures SE = visual field constriction and even visual loss in 40% of patients- visual fields must be checked every 6 months as visual loss can be irreversible Tricuspid regurgitation - answer-Signs: pansystolic murmer, parasternal heave, giant V waves, pulsatile hepatomegaly causes: IVDU endocarditis, rheumatic heart disease, right ventricle infarction, pulmonary hypertension, carcinoid syndrome, epsteins anamoly (rare heart defect that causes tricuspid regurg) Corticosteroid side effects - answer-COME IN PIGG Cushings opthalmic - glaucoma, catterachts M - musculoskeletal - OP, proximal myopathy, avascular necrosis Endocrine- hyperglycaemia, weight gain, hirsuitism, high lipids Immunosupression Neutrophilia Psychiatric - mania, psychosis, insomnia, depression Intracranial hypertension Gastric - pancreatitis, ulcers, Growth suppression in kids Acne - Systemic glucocorticoids can cause drug-induced acne. This is characterised as monomorphic papular rash without comedones or cysts. This does not respond to acne treatment but improves on drug discontinuation Therapeutic Steroids - answer-Fludocortisone - mostly mineralocorticoid hydrocortisone - some glucocorticoid, some mineralocoticoid Dexamethsone - high glucocorticoid Medication overuse headache - answer-Headache for over 15 days a month, whilst taking regular analgesia triptans and opioids are highest risk very common, can affect 1/50 people management - stop simple analgesia and triptans, wean down any opioids the headaches may initially worsen before getting better in severity and duration other withdrawal symptoms - anxiety, vomiting, restlessness, sleep disturbance, tachycardia, hypotension Multiple Myeloma - answer-malignant tumor of plasma cells in the bone marrow Peak age 60-70s Presentation: Signs of hypercalcaemia, including confusion, bone pain and fractures, renal failure, lethargy, infections, Ix - high calcium, low phosphate, high total protein, high Cr or low EGFR Further Ix - Bence Jones proteins, whole body MRI, bone marrow biopsy Dx- one major and one minor criteria OR 3 minor +signs and symptoms major criteria are based on bone marrow: Plasmacytoma (as demonstrated on evaluation of biopsy specimen) 30% plasma cells in a bone marrow sample Elevated levels of M protein in the blood or urine minor: 10% to 30% plasma cells in a bone marrow sample. Minor elevations in the level of M protein in the blood or urine. Osteolytic lesions (as demonstrated on imaging studies). Low levels of antibodies (not produced by the cancer cells) in the blood. Investigation of HTN - answer-clinic measurement 140/90 - offer home BP monitoring or ambulatory if 150/95 - stage 2 HTN - treat everyone if 135/85 - stage 1 - treat if under 80 AND one of - renal disease, diabetes, cardiovascular disease, signs end organ damage or 10 yr CV risk 10% Management HTN - answer-lifestyle: low Na diet, less caffeine, exercise, weight loss, balanced diet, stop smoking, reduce alcohol Pharmocotherapy If 55 or T2DM - A, then A+C or A+D, then A+C+D, then if K 4.5 add spiro, if 4.5 add alpha or beta blocker If 55 or black - C, then C+A or C+D, then A+C+D, then as above if on 4 drugs and not controlled: specialist referral (A = ACE inhibitor or ARB, C is calcium channel blocker, D is thiazide diriuretic) Target - 80 - 140/90 in clinic, 135/85 at home 80 - 150/90 in clinic, 145/85 at home Plummer-Vinson syndrome - answer-Dysphagia due to oesophageal webs glossitis iron deficiency anaemia treatment - iron replacement and dilation of the webs via OGD Behcets - answer-Behcet's syndrome is a complex multisystem disorder associated with presumed autoimmune-mediated inflammation of the arteries and veins. The precise aetiology has yet to be elucidated however. The classic triad of symptoms are oral ulcers, genital ulcers and anterior uveitis Epidemiology more common in the eastern Mediterranean (e.g. Turkey) more common in men (complicated gender distribution which varies according to country. Overall, Behcet's is considered to be more common and more severe in men) tends to affect young adults (e.g. 20 - 40 years old) associated with HLA B51 around 30% of patients have a positive family history Features classically: 1) oral ulcers 2) genital ulcers 3) anterior uveitis thrombophlebitis and deep vein thrombosis arthritis neurological involvement (e.g. aseptic meningitis) GI: abdo pain, diarrhoea, colitis erythema nodosum In severe cases: vision loss and stroke Diagnosis no definitive test diagnosis based on clinical findings Difficult to diagnose - CRP/ESR may only be mildly elevated positive pathergy test is suggestive (puncture site following needle prick becomes inflamed with small pustule forming) Thyroid Cancer - answer-70% papillary - often young females, excellent prognosis 20% follicular - usually single nodule 5% medullary - medullary C cells, secrete calcitonin, part of Men 2 1 % anaplastic - elderly females, locally invasive, highly aggressive, poor prognosis (5yr 7-14%), resect if possible, mostly palliative with radiotherapy lymphoma is rare (association with hashimotos/autoimmune thyroiditis) mx papillary and follicular - total thyroidectomy, radioiodine then year thyroglobulin tests Papillary carcinoma - Usually contain a mixture of papillary and colloidal filled follicles. Histologically tumour has papillary projections and pale empty nuclei. Seldom encapsulated. Lymph node metastasis predominate. Haematogenous metastasis rare Follicular adenoma - Usually present as a solitary thyroid nodule. Malignancy can only be excluded on formal histological assessment Follicular carcinoma. May appear macroscopically encapsulated, microscopically capsular invasion is seen. Without this finding the lesion is a follicular adenoma. Vascular invasion predominates. Multifocal disease rare Medullary carcinoma - C cells derived from neural crest and not thyroid tissue. Serum calcitonin levels often raised. Familial genetic disease accounts for up to 20% cases. Both lymphatic and haematogenous metastasis are recognised, nodal disease is associated with a very poor prognosis. Anaplastic carcinoma. Most common in elderly females. Local invasion is a common feature. Treatment is by resection where possible, palliation may be achieved through isthmusectomy and radiotherapy. Chemotherapy is ineffective. Vancomycin - answer-Glycopeptide antibioitic used for G+ve infections, particularly MRSA prevents polymerisation of peptidoglycans in bacterial cell walls SE: ototoxic, nephrotoxic, red man syndrome (widespread red blanching rash, thought to be due to IgE mast cell degranulation , thrombophlebitis Wernicke's encephalopathy - answer-thiamine deficiency in chronic alcoholics. TRIAD: Confsion, opthalmoplegia/horizontal nystagmus, ataxia Can also get sensory neuropathy treat by replacing thiamine if untreated - kosakoffs - amnesia and confabulation Purjinke fibers - answer-Premature ventricular contractions almost always originate from the Purkinje fibres. Purkinje fibres possess the fastest conduction velocities within the heart. This is due to their wide diameter, relative to other cells. Purkinje fibres do have their own automacity but with a rate of just 20-40 beats/min and so this is suppressed in favour of the sinoatrial node's pacemaker ability. Purkinje fibres arise from the bundle branches and infiltrate the ventricles. Purkinje fibres have the largest diameter of cells within the heart. This contributes to their fast conduction velocity. Spread of electrical activity through Purkinje fibres leads to ventricular depolarisation, which coincides with the QRS complex. Haemochromatosis - answer-Haemochromatosis is an autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation. It is caused by inheritance of mutations in the HFE gene on both copies of chromosome 6. Presentation: Most patients are asymptomatic (75%) and are diagnosed when elevated serum iron levels are noted on a routine chemistry screening panel or when screening is performed because a relative is diagnosed with hemochromatosis. The classic triad of cirrhosis, diabetes mellitus, and skin pigmentation occurs late in the disease, when total iron body content is 20 g (ie, 5-times normal). Early symptoms include severe fatigue (74%), impotence (45%), and arthralgia (44%); fatigue and arthralgia are the most common symptoms prompting a visit to a physician. The most common signs at the time of presentation are hepatomegaly (13%), skin pigmentation, and arthritis. Clinical manifestations include the following: