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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Although this is likely a fibroadenoma, the patient should be referred for further investigations", "id": "32284", "label": "b", "name": "Reassure the patient that this is a benign breast lump", "picture": null, "votes": 846 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Although this is likely a benign breast lump, guidelines recommended an urgent referral to secondary care", "id": "32286", "label": "d", "name": "Follow up assessment in primary care in 6 months", "picture": null, "votes": 204 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "An urgent (two-week wait) referral is recommended for all women over 30 with an unexplained breast lump. For younger patients with no worrying features, a non-urgent referral is indicated", "id": "32285", "label": "c", "name": "Non-urgent referral to secondary care", "picture": null, "votes": 1363 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Although this is likely a benign breast lump, guidelines recommended an urgent referral to secondary care", "id": "32287", "label": "e", "name": "Follow up assessment in primary care in 12 months", "picture": null, "votes": 31 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "The breast lump is likely to be a fibroadenoma based on its characteristics and the patient's age. This is a common, benign breast lump that is common in younger women due to increased sensitivity to oestrogen. However, all women over 30 with an unexplained breast lump should be urgently referred to the breast clinic for further assessment. This is likely to include further clinical assessment, imaging and biopsy or fine-needle aspiration (FNA)", "id": "32283", "label": "a", "name": "Urgent referral to secondary care", "picture": null, "votes": 3371 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n \n\nBenign breast diseases are a variety of non-cancerous conditions that cause breast symptoms such as lumps, pain, and nipple discharge. They include fibroadenoma, breast cysts, mastitis, intraductal papilloma, radial scar, fat necrosis, fibrocystic breast disease, and mammary duct ectasia. Clinical examination, mammography, ultrasound, and biopsy are the key investigative tools, while management includes reassurance, medication, and sometimes surgical interventions.\n \n\n# Definition\n \n\nBenign breast diseases are a group of non-cancerous conditions affecting the breast, which often manifest as breast lumps, nipple discharge, or other abnormalities.\n \n\n# Epidemiology\n \n\nThe majority of patients referred for breast symptoms are diagnosed with benign breast disease, making it a highly common condition. Women of various age groups can be affected, with some conditions like fibroadenoma being more common in younger women and others like breast cysts or fibrocystic breast disease being more prevalent from age 35 until menopause.\n \n\n# Aetiology\n \n\n - **Fibroadenomas** arise from the breast lobule stroma.\n - **Breast cysts** occur due to the overgrowth of glandular and connective tissue, leading to blocked breast ducts and subsequent fluid accumulation.\n - **Mastitis** is typically caused by bacterial infections, often related to breaks in the skin around the nipple.\n - **Intraductal papilloma** is a benign tumour of the breast ducts.\n - **Radial scar** is a benign sclerosing breast lesion.\n - **Fat necrosis** is a response to adipose tissue damage.\n - **Fibrocystic breast disease** is due to an exaggerated hormonal response causing inflammation, fibrosis, cyst formation, or adenosis.\n - **Mammary duct ectasia** is due to inflammation and dilation of the large breast ducts.\n \n\n# Signs and Symptoms\n \nIn general, features that suggest a breast mass is benign include being round, mobile, well-demarcated and smooth. This contrasts features that suggest a breast mass is malignant such as being hard or firm, having irregular borders and being fixed to the underlying structures (i.e. muscles or ribs). \n\n - **Fibroadenoma**: Highly mobile, encapsulated breast masses.\n - **Breast cysts**: Presence of breast lumps, potentially with distension.\n - **Mastitis**: Breast redness, mastalgia, malaise, and fever.\n - **Intraductal papilloma**: Bloody discharge from the nipple which can present with/without a palpable mass. Breast tenderness may also be present.\n - **Radial scar**: Presents on the mammogram as a stellate pattern of central scarring surrounded by proliferating glandular tissue.\n - **Fat necrosis**: Painless breast mass, skin thickening, or radiographic changes on mammography.\n - **Fibrocystic breast disease**: Breast lumps, pain, and tenderness.\n - **Mammary duct ectasia**: Palpable peri-areolar breast mass, thick nipple discharge, and potential mammographic similarities to cancer.\n \n\n# Differential Diagnosis\n \n\n - **Breast cancer**: Characterised by hard, immobile lumps, nipple retraction, skin changes (like peau d'orange), or bloody nipple discharge.\n - **Gynecomastia**: Enlargement of male breast tissue, which may be tender or painful.\n - **Abscess**: A collection of pus in the breast tissue, often painful and associated with redness, warmth, and fever.\n - **Lipoma**: Soft, mobile, non-tender fatty lumps beneath the skin.\n - **Pregnancy**: During pregnancy and breastfeeding, women may experience an increase in the size of their breasts, darkening of the nipple and areola, and discharge of colostrum from the nipple. \n \n\n# Investigations\n \nNICE Guidelines recommend referral under two-week wait protocols for:\n\n- Women over 30 years with an unexplained breast lump\n- Women over 50 with changes to the nipple (i.e. discharge, retraction, skin changes)\n- A referral should also be considered in women with skin changes suggestive of breast cancer or for women aged over 30 years with an unexplained lump in the axilla.\n\nTwo-week wait clinic will consist of a triple assessment of: \n\n - Clinical breast examination: To identify any palpable abnormalities.\n - Mammography and ultrasound: To visualise the internal structures and evaluate any identified lumps or abnormalities.\n - Fine-needle aspiration or biopsy: To confirm the diagnosis of identified lumps or suspicious areas.\n\n\nIn cases of diagnostic uncertainty or when there is a more acute presentation, blood tests may be required to identify signs of infection or hormonal imbalances in certain cases.\n \n\n# Management\n \n\n - Reassurance: Often, benign breast diseases require only monitoring and reassurance, especially when symptoms are minimal and there is no sign of complications.\n - Conservative measures such as ensuring a well-fitting bra and warm compresses may offer some symptomatic relief. \n - Antibiotics: Used in case of infections such as mastitis.\n - Analgesics: To manage pain or discomfort associated with various conditions.\n - Surgical intervention: In some cases, like large fibroadenomas, persistent cysts, or symptomatic intraductal papillomas.\n - Hormonal therapy: May be considered in cases of fibrocystic breast disease.\n\n \n# Prognosis \n \nBenign breast disease can vary in prognosis from non-proliferative disorders with no associated increased breast cancer risk, to atypical hyperplasias with a significantly increased breast cancer risk. \n\n \n# NICE Guidelines \n\n[NICE Guidelines Breast Cancer Recognition and Referral](https://cks.nice.org.uk/topics/breast-cancer-recognition-referral/) \n \n \n# References\n\n[Patient Info Benign Breast Disease](https://patient.info/doctor/benign-breast-disease#types-of-benign-breast-diseases) \n\n[BMJ Best Practice Assessment of Breast Mass](https://bestpractice.bmj.com/topics/en-gb/1179/differentials)", "files": null, "highlights": [], "id": "1687", "pictures": [], "typeId": 2 }, "chapterId": 1687, "demo": null, "entitlement": null, "id": "1850", "name": "Benign breast disease", "status": null, "topic": { "__typename": "Topic", "id": "55", "name": "Breast Disease", "typeId": 2 }, "topicId": 55, "totalCards": 8, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 1850, "conditions": [], "difficulty": 1, "dislikes": 5, "explanation": null, "highlights": [], "id": "6457", "isLikedByMe": 0, "learningPoint": "All women over 30 with an unexplained breast lump should be urgently referred for further assessment, regardless of lump characteristics.", "likes": 14, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 32-year-old woman presents to her General Practitioner (GP) with a right-sided breast lump. She first noticed it one week ago and denies any other symptoms including breast pain, discharge, skin or nipple changes. She has no personal or family history of any cancers.\n\nOn examination, there is a smooth 1cm lump in the upper inner quadrant of the left breast. The borders are well defined, and the lump moves under the skin on palpation. There is no associated lymphadenopathy.\n\nWhich of the following is the best step in management?", "sbaAnswer": [ "a" ], "totalVotes": 5815, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "There is no indication for fundoscopy before starting neoadjuvant therapy in a patient with breast cancer", "id": "32292", "label": "e", "name": "Fundoscopy", "picture": null, "votes": 77 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "An ETT may be useful as part of an anaesthetic assessment before surgery; however, the most important investigation before neoadjuvant therapy with trastuzumab is an ECHO", "id": "32290", "label": "c", "name": "Exercise tolerance test (ETT)", "picture": null, "votes": 135 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "A DEXA scan is used to assess for osteoporosis. It would not routinely be performed before starting neoadjuvant therapy in breast cancer in a patient without any clear risk factors for osteoporosis", "id": "32291", "label": "d", "name": "Dual-energy X-ray absorptiometry (DEXA) scan", "picture": null, "votes": 2552 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "There is no clear evidence of decreased lung function with trastuzumab, and pulmonary function testing is not usually indicated", "id": "32289", "label": "b", "name": "Pulmonary function testing", "picture": null, "votes": 852 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Neoadjuvant therapy for a patient with HER2 positive breast cancer is likely to involve the monoclonal antibody trastuzumab (Herceptin). Cardiomyopathy is an important risk of trastuzumab treatment and therefore all patients should have a baseline ECHO before treatment", "id": "32288", "label": "a", "name": "Echocardiogram (ECHO)", "picture": null, "votes": 2420 } ], "comments": [ { "__typename": "QuestionComment", "comment": "I thought if patient was ER+ve they would go on aromatase inhibitors which could cause osteoporosis, so you would wanna do DEXA scan", "createdAt": 1656427247, "dislikes": 0, "id": "12629", "isLikedByMe": 0, "likes": 16, "parentId": null, "questionId": 6458, "replies": [ { "__typename": "QuestionComment", "comment": "Do we start on both treatments simultanously or ER is the first-line then HER-2 therapy??", "createdAt": 1681876569, "dislikes": 0, "id": "22176", "isLikedByMe": 0, "likes": 0, "parentId": 12629, "questionId": 6458, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Anterior Syndrome", "id": 24785 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Abigail ", "id": 23295 } }, { "__typename": "QuestionComment", "comment": "stupid q why make her positive for both its clearly reasonable to do a DEXA before starting anastrozole so we didnt know which one to pick", "createdAt": 1685018806, "dislikes": 0, "id": "26177", "isLikedByMe": 0, "likes": 3, "parentId": null, "questionId": 6458, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Malignant Benign", "id": 9716 } }, { "__typename": "QuestionComment", "comment": "you win some you lose some, this was 3 points dropped. Gutted.", "createdAt": 1737994513, "dislikes": 0, "id": "61682", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6458, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Gabriel Magalhaes", "id": 26529 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\n\nBreast carcinoma is the most prevalent form of cancer among women and the second leading cause of cancer death in the UK. It manifests in various histological subtypes including ductal, lobular, medullary, and phyllodes tumours, each displaying distinct characteristics. Certain genetic mutations, especially BRCA1 and BRCA2, can increase the risk for breast carcinoma. Notable signs and symptoms include unexplained breast mass, nipple discharge, retraction, or skin changes suggestive of breast cancer. Key investigations comprise a triple assessment—clinical examination, radiological examination, and biopsy. Treatment strategies encompass surgical management (wide local excision or mastectomy), radiotherapy, chemotherapy, biological therapy, and hormonal therapy. Risk factors for breast cancer include increased hormone exposure, susceptibility gene mutations, advancing age, and lifestyle factors like obesity, physical inactivity, and alcohol and tobacco use.\n\n\n# Definition\n\n\nBreast carcinoma refers to a malignant tumour originating from the cells of the breast tissue. It exhibits different subtypes each with unique cellular properties and clinical implications. The carcinomas can be invasive, indicating they have broken through the basement membrane of the tissue of origin and have the potential to metastasize, or non-invasive (in situ), suggesting they are confined to the initial location.\n\n\n# Epidemiology\n\n\nBreast carcinoma is the most common type of cancer in women and accounts for approximately 15% of new cancer cases, representing 50,000 new cases annually. It is the second most common cause of cancer death in the UK.\n\n\n# Aetiology\n\nMost breast cancers are either ductal (arising from the epithelial lining of the ducts) or lobular (originating from epithelial cells in the terminal ducts of the lobules).\n\n\nRisk factors for breast carcinoma include:\n\n\n- Being female\n- 99% of breast cancer cases occur in women\n- Increased hormone exposure\n- Early menarche or late menopause\n- Nulliparity or late first pregnancy\n- Oral contraceptives or Hormonal Replacement Therapy\n- Susceptibility gene mutations\n- Most commonly BRCA mutations (BRCA1/BRCA2)\n- Advancing age\n- Caucasian ethnicity\n- Obesity and lack of physical activity\n- Alcohol and tobacco use\n- History of breast cancer\n- Previous radiotherapy treatment\n\n\n# Classification\n\n\nBreast cancer is not a single disease, but a collection of several subtypes, each with its unique characteristics, prognosis, and treatment options.It can be classified based on its origin cell type such as:\n\n\n- **Invasive ductal carcinoma (IDC)**: This is the most common type, accounting for about 80% of all breast cancers. It starts in a milk duct, breaks through the wall of the duct, and invades the fatty tissue of the breast.\n- **Invasive lobular carcinoma (ILC)**: This type begins in the milk-producing glands (lobules) and can spread to other parts of the body.\n- **Ductal carcinoma in situ (DCIS)**: This is a non-invasive or pre-invasive cancer where the cells are confined to the ducts in the breast and have not spread into the surrounding breast tissue.\n- **Lobular carcinoma in situ (LCIS)**: This is not a cancer but an area of abnormal cell growth that increases a person's risk of developing invasive breast cancer later.\n- **Paget's disease of breast**: Infiltrating carcinoma of nipple epithelium.\n\n\nIt can also be classified based on the hormone receptors present on the surface of the breast cancer:\n\n- **Inflammatory breast cancer (IBC)**: This is a rare but aggressive type of breast cancer that causes the lymph vessels in the skin of the breast to become blocked.\n\n- **Triple-negative breast cancer (TNBC)**: This type lacks estrogen receptors, progesterone receptors, and does not have an excess of the HER2 protein on the cancer cell surfaces. It tends to be more aggressive and has fewer targeted treatments available.\n\n- **HER2-positive breast cancer**: This is a cancer that tests positive for a protein called human epidermal growth factor receptor 2 (HER2), which promotes the growth of cancer cells. It tends to be more aggressive than other types of breast cancer, but it may respond well to targeted therapies that can block HER2.\n\n\n# Signs and Symptoms\n\n\nCommon clinical manifestations of breast carcinoma include:\n\n\n- Unexplained breast mass in patients aged 30 and above, with or without pain\n- In those aged 50 and older, nipple discharge, retraction/inversion, or other concerning symptoms\n- This can also include eczema-type changes surrounding the nipple as seen in Paget's disease of the breast\n- Skin changes suggestive of breast cancer\n- This includes skin retraction, peau d'orange appearance or ulceration of the skin above an underlying mass.\n- Unexplained axillary mass in those aged 30 and above\n\n\nApproximately 25% of cases are found in routine breast cancer screening (mammography).\n\n\n# Differential Diagnosis\n\n\nWhile an unexplained breast mass is a key indicator of breast carcinoma, it can also represent various other conditions, each characterized by distinct signs and symptoms:\n\n\n- **Fibroadenoma**: Typically presents as a solitary, painless, and well-circumscribed breast lump in young women\n- **Breast Cyst**: Characterized by a round or oval, well-defined, and movable mass. It may be painful and size may vary with the menstrual cycle.\n- **Mastitis**: Typically presents in breastfeeding women, characterized by a painful, warm, red breast often accompanied by systemic symptoms like fever.\n- **Lipoma**: Presents as a soft, mobile, and painless lump.\n\n\n# Breast Cancer Screening in the UK\n\n\nIn the United Kingdom, the NHS Breast Screening Programme provides free breast screening services for all women registered with a GP. The programme invites women between the ages of 50 and 70 for breast screening every three years, with the first invitation to screening usually sent to women before they turn 53.\n\n\nThis screening process involves a mammogram, which is an X-ray of the breasts that can help detect breast cancers early, often before they can be felt. The aim of breast cancer screening is to find cancer at an early stage when treatment is most effective.\n\n\nIn 2018, the age range for screening was extended as part of a trial, and some women were invited for screening from the age of 47 up to the age of 73. Women over 70 can still self-refer for screening every three years.\n\n\n# Investigations\n\nCriteria for 2-week wait:\n\n- Age 30 or more with unexplained breast lump (with or without pain)\n- Age 50 or more with nipple discharge, retraction or other changes\n- Consider a 2-week wait if a patient is 30 or over with skin changes suggestive of breast cancer or an unexplained lump in the axilla\n\nNB: a non-urgent referral should be considered for patients under the age of 30 with an unexplained breast lump.\n\n### Triple Assessment\n\nTriple assessment is used to investigate suspected breast carcinoma:\n\n\n1. Clinical examination: of the breast and surrounding lymph nodes\n2. Radiological examination:\n\t- Ultrasound is used for women under the age of 40 or those with higher breast density.\n\t- A mammogram is commonly used for women over 40 years.\n\t- If there are concerns of metastatic disease, a CT or PET scan may be done.\n3. Biopsy: often a core needle biopsy or fine needle aspirate (FNA)\n\t- Fine needle aspiration (FNA): Often combined with mammography, however, has a high rate of false negatives.\n\t- Core needle biopsy: method of choice, can be combined with imaging to aid accuracy.\n\t- DCIS biopsy will show cellular atypia and hyperchromatic nuclei involving the ducts, but not passing the basement membrane\n\t- In invasive breast cancer, these abnormal cells will pass the basement membrane\n\t- In lobular carcinoma, the abnormal cells will be found within the lobular acini\n\n### Further Investigations\n\nFollowing the triple assessment, further investigations will include:\n\n- Biopsies to determine\n- Oestrogen and progesterone receptor status\n- Epidermal growth factor receptor status\n- Routine blood tests (i.e. LFTs)\n- CXR\n- MRI is not routinely used. It is used for women with:\n- Discrepancy between the extent of disease between clinical examination and imaging\n- Dense breast tissue limiting mammography\n- Invasive lobular carcinoma to evaluate tumour size when planning breast-conserving surgery\n- BRCA1/2 testing is done for women < 50 years with triple-negative breast cancer regardless of family history\n\n\n### Staging\n\nStaging involves the TNM system considering the size of the tumour (T), the spread to the lymph nodes (N), and the presence of metastases (M). For locally invasive breast cancer, this can include:\n\n- Axilla ultrasound with needle sampling if abnormal lymph nodes are identified\n\nIf the cancer is deemed to be advanced, staging investigations should include:\n\n- CT, MRI or bone scintigraphy to determine the presence and extent of visceral and bony metastasis\n- PET CT is only used to diagnose metastasis\n\n\n# Management\n\n\nThe management strategy for breast carcinoma can vary based on several factors including the subtype of carcinoma, stage, hormonal receptor status, and the patient's overall health and preferences.\n\n\n- Surgical management: Wide local excision (WLE) or mastectomy, with sentinel node biopsies for invasive cancers and possible axillary node clearance for positive nodes. Breast reconstruction can be done concurrently or later.\n- Radiotherapy: Adjuvant radiotherapy is commonly offered following WLE to reduce recurrence. It may also be given to patients with higher-stage cancers post-mastectomy.\n\n**Chemotherapy:**\n\n- Suggested for hormone receptor-negative and HER2 over-expressing patients. Neoadjuvant chemotherapy may be given to downstage tumours before surgery. This commonly includes an anthracycline (i.e. doxorubicin) and a taxane (i.e. paclitaxel)\n- Biological Therapy:\n\t- Trastuzumab (Herceptin) should be given to HER2-positive patients with tumour size T1c and above in combination with surgery, chemotherapy and radiotherapy. Patients should have regular cardiac function assessments.\n\t- Abermaciclib (selective inhibitor of cyclin-dependent kinases 4 and 6) for HER2-negative, hormone receptor-positive breast cancer\n\t- Pembrolizumab for triple-negative breast cancer\n\t- Olaparib (PSTP inhibitor) for BRCA positive, HER2 negative high-risk early breast cancer\n- **Hormonal Therapy** for oestrogen-positive breast cancer:\n\t- Anastrozole (aromatase inhibitor) for postmenopausal women\n\t- Tamoxifen (oestrogen receptor antagonist) for premenopausal patients\n\t- Bisphosphonates: May be used for reducing occurrence in node-positive cancers.\n\t- Zoledronic acid has been shown to improve disease-free survival in postmenopausal women with node-positive invasive breast cancer.\n\t- Bisphosphonates are also advised for treatment-induced menopause in women treated with aromatase inhibitors\n\n\n# Complications\n\n### Complications of Breast Carcinoma\n\n- Fatigue\n- Bone metastases\n- Brain metastases\n- Psychological difficulties: Anxiety, depression and damage to the individual's self-esteem.\n- Recurrence:\n\t- Local: recurrence in the same breast as the original tumour\n\t- Regional: recurrence in the axillary or sub-clavicular lymph nodes draining the breast cancer\n\t- Distant: recurrence once already metastasized to other parts of the body (i.e. liver, lungs, brain, bone)\n\n\n### Side Effects of Medication Used to Treat Breast Cancer\n\n\nTreatment for breast cancer often involves medication, including chemotherapy, hormone therapy, and targeted drug therapy. Each of these can have different side effects.\n\n\n**Chemotherapy** drugs are powerful medications that aim to destroy rapidly dividing cells, such as cancer cells. However, they can also affect healthy cells, leading to a range of side effects, including fatigue, hair loss, easy bruising and bleeding, infection, anaemia, nausea and vomiting, appetite changes, peripheral neuropathy, and problems with concentration or memory.\n\nChemotherapy agents can have specific side effects such as:\n\n- Doxorubicin is associated with cardiac toxicity (e.g. cardiac arrhythmias, myopericarditis)\n- Paclitaxel is associated with lung fibrosis.\n\n\n**Hormone therapy** drugs, such as tamoxifen and aromatase inhibitors, are used to treat hormone receptor-positive breast cancers. Common side effects include hot flushes, vaginal dryness or discharge, menstrual changes, fatigue, mood changes, and osteoporosis. In rare cases, tamoxifen can increase the risk of serious conditions like endometrial cancer and blood clots.\n\n\n**Targeted drug therapies** such as trastuzumab (Herceptin), pertuzumab (Perjeta), and ado-trastuzumab emtansine (Kadcyla), are designed to interfere with specific proteins or processes that contribute to cancer growth.\n\nSide effects include:\n\n- Infections\n- Bruising and easy bleeding\n- Anaemia\n- Cardiac (i.e. arrhythmias)\n- Insomnia\n- GI side effects (i.e. diarrhoea, vomiting, constipation, appetite loss, weight loss)\n- Runny nose\n- Conjunctivitis\n- Hair loss\n- Nail changes\n- Hand foot syndrome: the palms and plantar surfaces become sore, peel, crack and blister.\n- Hepatotoxicity\n\n\n\n### Surgical Complications\n\nKey surgical complications include:\n\n- Venous thromboembolism\n- Lymphoedema\n- Pain\n\n\n### Breast Cancer in Pregnancy\n\nBreast cancer is the most common malignancy to occur during pregnancy. Radiotherapy and chemotherapy are most commonly delayed until completion of pregnancy, but surgical intervention can be considered.\n\n# Prognosis\n\nThe prognosis for individuals with breast cancer has vastly improved, almost doubling over the past 50 years. The ten-year survival for breast cancer in England is 75.9%\n\nA poorer prognosis is associated with:\n\n- Advancing age\n- Being male\n- Stage III or IV\n- Tumour size\n- Tumour grade\n- Hormone receptor-negative tumours (oestrogen or progesterone receptor-negative)\n- HER 2 positive tumours\n\n\n# NICE Guidelines\n\n[NICE Guidelines on Early and Locally Advanced Breast Cancer](https://www.nice.org.uk/guidance/ng101)\n\n[NICE Guidelines on Advanced Breast Cancer](https://www.nice.org.uk/guidance/cg81)\n\n# References\n\n[Patient Info Breast Cancer](https://www.nice.org.uk/guidance/cg81)\n\n[BMJ Best Practice Breast Cancer](https://bestpractice.bmj.com/topics/en-gb/718?q=Metastatic%20breast%20cancer&c=suggested)\n\n[NHS Breast Cancer in Women](https://www.nhs.uk/conditions/breast-cancer-in-women/)\n\n[Cancer Research UK Breast Cancer](https://www.cancerresearchuk.org/about-cancer/breast-cancer/survival)", "files": null, "highlights": [], "id": "343", "pictures": [], "typeId": 2 }, "chapterId": 343, "demo": null, "entitlement": null, "id": "343", "name": "Breast Cancer", "status": null, "topic": { "__typename": "Topic", "id": "55", "name": "Breast Disease", "typeId": 2 }, "topicId": 55, "totalCards": 56, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "343", "name": "Breast Cancer" } ], "demo": false, "description": null, "duration": 522.07, "endTime": null, "files": null, "id": "149", "live": false, "museId": "NwAyTxS", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/oncology.png", "title": "Genetic syndromes and Cancer", "userViewed": false, "views": 271, "viewsToday": 42 } ] }, "conceptId": 343, "conditions": [], "difficulty": 2, "dislikes": 23, "explanation": null, "highlights": [], "id": "6458", "isLikedByMe": 0, "learningPoint": "Baseline echocardiogram is essential before initiating neoadjuvant therapy in HER2 positive breast cancer to assess the risk of trastuzumab-induced cardiomyopathy.", "likes": 8, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 56-year-old woman is diagnosed with HER2 (human epidermal growth factor receptor 2) positive breast cancer. Her case is discussed at the breast cancer multidisciplinary team (MDT) meeting, and it is decided that she would benefit from neoadjuvant therapy before surgery.\n\nWhich of the following is the most important investigation to perform before starting treatment?", "sbaAnswer": [ "a" ], "totalVotes": 6036, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "This patient has no risk factors for heart failure. It would be reasonable to check BNP levels as it has a high negative predictive value for heart failure, but, in this context, testing for proteinuria is more pertinent", "id": "32294", "label": "b", "name": "Serum brain natriuretic peptide (BNP)", "picture": null, "votes": 546 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "An ECHO to assess for heart failure would usually be performed after checking serum BNP levels", "id": "32295", "label": "c", "name": "Echocardiogram (ECHO)", "picture": null, "votes": 100 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Hypothyroidism is a rare cause of generalised oedema. This patient does not have any other symptoms of hypothyroidism which makes it less likely", "id": "32296", "label": "d", "name": "Check thyroid function", "picture": null, "votes": 16 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Checking renal function is vital given the likely diagnosis of nephrotic syndrome. However, renal function can be normal in the early stages of nephrotic syndrome and therefore the most important initial test is to check for proteinuria", "id": "32297", "label": "e", "name": "Check renal function", "picture": null, "votes": 933 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Chronic hepatitis C infection is a risk factor for membranoproliferative glomerulonephritis (MPGN). This can present with features of nephrotic syndrome, which include generalised oedema, hypoalbuminaemia and proteinuria. Nephrotic syndrome is also a pro-thrombotic state, and the recent DVT raises further suspicion in this context. The next best investigation is therefore a bedside urine dipstick to assess for proteinuria. If there is proteinuria, then this should be quantified using a UPCR. Nephrotic range proteinuria is > 3.5g/day which is equivalent to a UPCR value of 350 mg/mmol", "id": "32293", "label": "a", "name": "Urine dipstick +/- urinary protein:creatinine ratio (UPCR)", "picture": null, "votes": 2229 } ], "comments": [ { "__typename": "QuestionComment", "comment": "lol\n", "createdAt": 1709127910, "dislikes": 0, "id": "43130", "isLikedByMe": 0, "likes": 2, "parentId": null, "questionId": 6459, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Kinase Hallux", "id": 541 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nNephrotic syndrome refers to the clinical triad of proteinuria, hypoalbuminemia and peripheral oedema. It occurs due to increased permeability of the glomerular basement membrane, which occurs either due to a variety of both primary (idiopathic) or secondary diseases. Renal biopsy is the key investigation to differentiate between causes and should be considered in all adults. Other investigations include a urine dip and protein:creatinine ratio, LFTs for albumin and investigations for an underlying cause such as myeloma or diabetes. First-line management is usually with steroids; other immunosuppressants may need to be added. Management options for oedema include lifestyle changes (low salt diet, fluid restriction) and/or diuretics.\n\n# Definition\n\nNephrotic syndrome occurs when there is excessive loss of protein in the urine, leading to hypoalbuminemia and peripheral oedema. Other resulting features include hyperlipidaemia, abnormal coagulation and immunodeficiency. \n\n# Aetiology\n\nThe common underlying pathology leading to nephrotic syndrome is damage to the glomerular basement membrane leading to excessive leakage of protein into the urine.\n\nThere are a wide variety of conditions that may lead to nephrotic syndrome which may be classified as either primary (idiopathic) or secondary (due to another underlying disease) - these include:\n\n- **Minimal change disease** causes the majority of cases of nephrotic syndrome in young children\n- It is usually idiopathic but may rarely be associated with lymphoma or NSAID use\n- Glomeruli are normal under light microscopy\n- Electron microscopy shows diffuse effacement of the podocyte food processes\n- Steroid responsiveness is characteristic\n- **Focal segmental glomerulosclerosis** may be primary or secondary to conditions including HIV, extensive nephron loss or drugs (e.g. heroin)\n- Biopsy shows sclerosis of segments of the glomerular tuft, only affecting some glomeruli\n- **Membranous nephropathy** is the leading cause of nephrotic syndrome in older people\n- Biopsy shows thickening of the glomerular basement membrane without cellular proliferation\n- A classic \"spike and dome\" appearance is described where subepithelial immune deposits are interspersed with new basement membrane growth\n- Most cases are primary; usually associated with PLA2R antibodies\n- Others may be secondary to malignancy, infections, autoimmune disease or drugs\n- **Membranoproliferative glomerulonephritis** is also referred to as membranoproliferative glomerulonephritis\n- It can present with nephrotic or nephritic syndrome\n- It may be idiopathic or secondary to infections such as hepatitis C or systemic lupus erythematosus\n- **Diabetic nephropathy** may affect patients with longstanding type 1 or 2 diabetes\n- It tends to be a progression from microalbuminuria, especially if untreated\n- Patients are at risk of end-stage renal disease\n- Biopsy shows thickening of the glomerular basement membrane, mesangial expansion and Kimmelstiel-Wilson nodules\n- **Amyloidosis**, especially AA amyloid due to chronic inflammation\n- AL amyloid (due to light chain deposition) and hereditary amyloidosis can also cause nephropathy\n- On biopsy, amyloid deposits stain with Congo red and display apple green birefringence under polarized light\n- **Multiple myeloma** can present with a variety of renal manifestations, with proteinuria and renal insufficiency the most common\n- Nephrotic syndrome occurs in a minority of cases and may be due to a number of underlying mechanisms\n- **Lupus nephritis** i.e. renal involvement due to systemic lupus erythematosus\n- Class V (membranous lupus nephritis) is the most likely to cause nephrotic syndrome\n- This is characterised histologically by subepithelial immune complex deposition\n- **Medications** are a rarer cause of nephrotic syndrome, including:\n- Bisphosphonates\n- NSAIDs\n- D-penicillamine\n- Probenecid\n- Tolbutamide\n\n# Classification\n\nThe diagnosis of nephrotic syndrome requires the presence of all of:\n\n- Proteinuria > 3.5 grams/24 hours\n- Serum albumin < 30 grams/litre\n- Peripheral oedema\n\n# Signs and Symptoms\n\n**Symptoms include:**\n\n- Frothy urine due to proteinuria\n- Swelling of the face and body\n- Weight gain due to fluid retention\n- Fatigue\n- Lethargy\n- Anorexia\n\n**Signs include:**\n\n- Oedema - typically peripheral and periorbital\n- Muehrcke's lines refers to paired white transverse lines across the nails that may occur secondary to hypoalbuminemia\n- Signs of hyperlipidaemia such as xanthelasma (yellow plaques over the eyelids)\n- Signs of pleural effusion e.g. dull bases to percussion with decreased air entry\n\nPatients may also present with signs and symptoms of complications e.g. infection, thrombosis.\n\n# Differential Diagnosis\n\n- **Heart failure** is a common cause of peripheral oedema; typically however patients cannot lie flat due to breathlessness and so facial oedema is unusual; proteinuria is not a feature\n- **Cirrhosis** is commonly complicated by fluid accumulation, usually in the form of ascites; although ascites may occur in nephrotic syndrome it is less common than fluid accumulation in the peripheries and face; proteinuria is not a feature\n- **Chronic kidney disease** may present with fluid retention, especially in patients with end-stage renal disease - it may coexist with nephrotic syndrome however renal function is often preserved\n- **Medications** may cause peripheral oedema including calcium channel blockers, NSAIDs and corticosteroids\n\n# Investigations\n\n**Bedside tests:**\n\n- **Urine dipstick** looking for proteinuria; glycosuria may be present in diabetes but haematuria is not usually seen\n- **Urine protein:creatinine ratio** should be over 2 or **24 hour urine collection** should show proteinuria >3.5g/day\n\n**Blood tests:**\n\n- **LFTs** to confirm hypoalbuminemia\n- **U&Es** for renal function (significant impairment is unusual)\n- **FBC** may show anaemia in persistent nephrotic syndrome\n- **Vitamin D** may be low as this is lost in urine\n- **Bone profile** may show hypocalcemia secondary to decreased calcium absorption due to vitamin D deficiency\n- **Coagulation screen** is usually normal although there is a hypercoagulable state wiht increased risk of thromboembolism\n- **HbA1c** or **fasting glucose** for diabetes\n- **Lipid profile** often shows dyslipidemia\n- **CRP** and **ESR** may be raised due to an underlying inflammatory, malignant or infectious process\n- **Myeloma screen** i.e. immunoglobulins and serum protein electrophoresis if myeloma is suspected\n- **Autoimmune screen** e.g. for suspected systemic lupus erythematosus (antinuclear antibody, complement levels etc.)\n- **Infection screen** i.e. hepatitis B and C serology, HIV testing\n\n**Imaging tests:**\n\n- **Chest X-ray** if there are clinical signs of pleural effusion\n- **US KUB** (kidneys, ureters and bladder) if there is renal impairment to assess for obstruction and any structural abnormalities of the kidneys\n- Imaging may be required to diagnose complications, such as a **CT pulmonary angiogram** for suspected pulmonary embolism or **doppler ultrasound** of the limbs for suspected deep vein thrombosis\n\n**Special tests:**\n\n- **Renal biopsy** is the key investigation to diagnose the cause of nephrotic syndrome - this is important both for prognosis and to guide management \n- Biopsy is usually indicated in adults, however in children there are specific indications e.g. if not responsive to steroids\n\n# Management\n\n**Conservative:**\n\n- Restrict salt intake to <2g/day\n- Fluid restriction to <1.5L/day \n- Weight should be monitored, with a target of 1-2 kg weight loss per day until the patient reaches their predicted \"dry weight\" (i.e. weight when not oedematous)\n- Dietary changes (e.g. avoiding a high protein diet, limiting fat intake) may be advised and dietician input may be indicated\n- Mechanical thromboprophylaxis (TEDS) to reduce risk of venous thromboembolism\n\n**Medical:**\n\n- **Corticosteroids** are usually first-line for management of nephrotic syndrome - these should be weaned after remission is achieved\n- Other immunosuppressive drugs (e.g. ciclosporin, cyclophosphamide, mycophenolate mofetil or rituximab) may be added as steroid sparing agents or for severe or refractory cases\n- Diuretics are used to treat significant peripheral oedema, usually furosemide but potassium sparing and thiazide diuretics may be added as adjuncts\n- Risk of thromboembolism should be assessed and prophylactic anticoagulation considered\n- Antihypertensives may be required to maintain a normal blood pressure; ACE inhibitors and angiotensin II receptor blockers may also help to reduce proteinuria\n- Ensure patients are up to date with vaccinations (however live vaccines should not be given to patients who are immunocompromised)\n- In some cases hyperlipidaemia may require treatment with statins \n- Patients taking steroids may require co-administration of proton pump inhibitors for gastric protection and consideration of bone protection\n\n**Surgical:**\n\n- If nephrotic syndrome results in end-stage renal failure, renal replacement therapy may be required either with dialysis or renal transplantation\n\n# Complications\n\n- **Increased risk of infection** as immunoglobulins are lost in urine\n- **Venous thromboembolism** due to urinary loss of anti-thrombotic proteins such as antithrombin III\n- **Hyperlipidaemia** due to increased hepatic production of lipoproteins to compensate for hypoalbuminemia - this may also present with lipiduria (which may cause urine to appear milky) \n- **Acute kidney injury** may occur due to excessive diuresis or renal vein thrombosis\n- **Chronic kidney disease** may occur secondary to the underlying cause of nephrotic syndrome (e.g. diabetes, amyloidosis)\n- **Medication side-effects** especially with chronic steroid use (e.g. osteoporosis, psychiatric effects)\n- **Hypothyroidism** due to urinary losses of T4 and T3 with their binding proteins\n- **Vitamin D deficiency** as this is also lost in urine\n- **Anaemia** may result from persistent nephrotic syndrome as iron bound to transferrin and erythropoietin are lost in urine\n\n# Prognosis\n\nPrognosis varies between subtypes, for example minimal change disease rarely progresses to end-stage renal failure (1% of cases), whereas 50% of patients with FSGS will do over 5-10 years.\n\nMortality has been greatly reduced with the use of steroids and immunosuppression.\n\nRelapses are common and may require repeated courses of steroids or escalation to other immunosuppressive medications.\n\n# References\n\n[KDIGO Guidelines on Glomerular Diseases](https://kdigo.org/guidelines/gd/)\n\n[Patient UK - Nephrotic syndrome](https://patient.info/doctor/nephrotic-syndrome-pro)\n\n[Radiopaedia - Nephrotic syndrome](https://radiopaedia.org/articles/nephrotic-syndrome?lang=gb)", "files": null, "highlights": [], "id": "14", "pictures": [], "typeId": 2 }, "chapterId": 14, "demo": null, "entitlement": null, "id": "318", "name": "Nephrotic syndrome", "status": null, "topic": { "__typename": "Topic", "id": "33", "name": "Nephrology", "typeId": 2 }, "topicId": 33, "totalCards": 28, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "318", "name": "Nephrotic syndrome" } ], "demo": false, "description": null, "duration": 3028.61, "endTime": null, "files": null, "id": "590", "live": false, "museId": "erivGUb", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/nephrology.png", "title": "Quesmed Tutorial: Paediatric Nephrology", "userViewed": false, "views": 248, "viewsToday": 23 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "318", "name": "Nephrotic syndrome" } ], "demo": false, "description": null, "duration": 370.77, "endTime": null, "files": null, "id": "591", "live": false, "museId": "SwHqbCX", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/nephrology.png", "title": "Minimal change disease", "userViewed": false, "views": 89, "viewsToday": 12 } ] }, "conceptId": 318, "conditions": [], "difficulty": 2, "dislikes": 4, "explanation": null, "highlights": [], "id": "6459", "isLikedByMe": 0, "learningPoint": null, "likes": 2, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 45-year-old man with a history of hepatitis C with liver cirrhosis presents to his General Practitioner (GP) with increasing swelling of his legs, causing him discomfort when he walks. He denies any other symptoms including cough or shortness of breath.\n\nHe is currently on anticoagulation for an unprovoked deep-vein thrombosis (DVT) that occurred one month ago. Liver function tests at that point were at baseline.\n\nOn examination, his JVP is not raised with heart and lung sounds normal. The abdomen is soft and non-tender with no palpable masses. There is bilateral pitting oedema to the knees bilaterally.\n\nWhich of the following is the most appropriate initial investigation?", "sbaAnswer": [ "a" ], "totalVotes": 3824, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Mild hypercalcaemia is a feature of primary adrenal insufficiency of all causes. Infiltrative diseases such as sarcoidosis can cause primary adrenal insufficiency but this is rare", "id": "32302", "label": "e", "name": "Serum angiotensin-converting enzyme (ACE) levels", "picture": null, "votes": 453 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Pituitary disease can cause secondary adrenal insufficiency; however, this would not lead to hyperkalaemia (as potassium level homeostasis is not dependent on the pituitary-adrenal axis - it is mainly controlled by the renin-angiotensin-aldosterone system) or hyperpigmentation.\n\nHyperpigmentation and hyperkalaemia are suggestive of primary adrenal insufficiency", "id": "32299", "label": "b", "name": "CT pituitary", "picture": null, "votes": 204 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "The clinical vignette and blood test findings are suggestive of primary adrenal insufficiency. This would need to be confirmed with a screening test (usually 9 am cortisol level) and, if positive, a short-synacthen test.\n\nIn a patient with previous lung cancer, the most likely cause of primary adrenal insufficiency would be metastatic adrenal disease, for which a CT scan is the best investigation of choice. Imaging of the chest and pelvis is useful to assess for further sites of metastasis", "id": "32298", "label": "a", "name": "CT scan of the chest abdomen and pelvis (CT CAP)", "picture": null, "votes": 1607 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "MRI is the best modality to image the pituitary; however, as described above the history and blood tests findings are more suggestive of primary adrenal insufficiency in this case", "id": "32300", "label": "c", "name": "MRI pituitary", "picture": null, "votes": 1078 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Autoimmune disease is the most common cause of primary adrenal insufficiency in the UK. However, the history of recent lung cancer in an older patient makes metastatic disease more likely in this case", "id": "32301", "label": "d", "name": "Autoantibody screen", "picture": null, "votes": 580 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nAdrenal insufficiency is a condition where destruction of the adrenal cortex leads to reduced glucocorticoid production. It can be classified as primary (Addison's disease) or secondary, each with different causes. Key signs and symptoms include hypotension, fatigue, weakness, gastrointestinal symptoms, and increased pigmentation. Initial investigations should focus on levels of sodium, potassium, glucose, cortisol, ACTH, renin, and aldosterone, while further tests should be used to establish the underlying cause. Management includes patient education on 'sick day' rules, glucocorticoid and mineralocorticoid replacement, and regular screening for complications like adrenal crisis and osteoporosis.\n\n# Definition\n\nAdrenal insufficiency is a clinical syndrome that arises due to the insufficient production of glucocorticoids and mineralocorticoids from the adrenal cortex. \n\nIt can be categorized as primary, commonly known as Addison's disease, where the cause lies within the adrenal glands themselves, or secondary, where inadequate stimulation of the adrenal glands by the pituitary or hypothalamus is the culprit.\n\n\n# Epidemiology\n\nAdrenal insufficiency is a relatively rare disease. Primary adrenal insufficiency (Addison's disease) affects approximately 100-140 people per million in developed countries. Secondary adrenal insufficiency is considered more common but accurate prevalence rates are difficult to determine.\n\n# Pathophysiology\n\nAdrenal insufficiency can result from damage to the adrenal cortex or disruptions in the hypothalamus-pituitary-adrenal (HPA) axis. The HPA axis regulates adrenal hormone production. In primary adrenal insufficiency (Addison's disease), the adrenal glands are damaged, while secondary adrenal insufficiency is due to dysfunction in the hypothalamus or pituitary. The lack of cortisol then disrupts feedback mechanisms, leading to elevated adrenocorticotropic hormone (ACTH) levels.\n\n\nPrimary adrenal insufficiency (Addison's disease) can be caused by:\n\n- Auto-immune destruction (most common)\n- Surgical removal of the adrenal glands\n- Trauma to the adrenal glands\n- Infectious diseases, such as tuberculosis (more common in developing countries)\n- Haemorrhage (e.g., Waterhouse-Friderichsen syndrome)\n- Infarction\n- Less commonly, neoplasms, sarcoidosis, or amyloidosis\n\nSecondary adrenal insufficiency can occur due to:\n\n- Congenital disorders\n- Fracture of the base of the skull\n- Pituitary or hypothalamic surgery or Neoplasms in the pituitary or hypothalamus\n- Infiltration or infection of the brain\n- Deficiency of corticotropin-releasing hormone (CRH)\n\n# Signs and Symptoms \n\nClinical features of adrenal insufficiency include:\n\n- Hypotension\n- Fatigue and weakness\n- Gastrointestinal symptoms\n- Syncope\n- Skin pigmentation due to increased ACTH which stimulates production of alpha melanocyte stimulating hormone (MSH).\n\n[lightgallery]\n\nIn the case of auto-immune Addison's disease, approximately 60% of patients may also have vitiligo or other autoimmune endocrinopathies.\n\n[lightgallery1]\n\n# Differential Diagnosis\n\nAdrenal insufficiency can be misdiagnosed as several other conditions, including:\n\n- Chronic fatigue syndrome: Presents with persistent fatigue, cognitive difficulties, and other non-specific symptoms\n- Dehydration or septic shock: Hypotension and tachycardia can mimic adrenal insufficiency\n- Primary psychiatric illnesses: Depression or other psychiatric illnesses may present with fatigue, decreased appetite, and weight loss.\n\n# Investigations\n\n* First line investigations are U+E and serum cortisol, where you may find:\n\t* Hyponatraemia (low sodium)\n\t* Hyperkalaemia (high potassium)\n\t* Low serum cortisol\n- Glucose (typically low)\n- Therefore in a patient with Addison's who is acutely unwell, you would expect a blood gas to show a **hyperkalaemic, hyponatraemic, hypoglycaemic metabolic acidosis**\n- ACTH: High in primary insufficiency, low or low-normal in secondary insufficiency\n- Renin (high in Addison's disease)\n- Aldosterone (low in Addison's disease)\n\nAn ACTH (Short Synacthen) test is the gold standard investigation to confirm the diagnosis.\n\nFurther investigations to establish the cause can include:\n\n- Testing for adrenal auto-antibodies\n- Chest X-ray\n- CT scan of the adrenal glands\n- MRI of the brain\n\n# Management\n\n**Management of adrenal insufficiency involves:**\n\n- Patient education on 'sick day' rules, carrying a steroid card, and wearing a medical alert bracelet\n- Doubling the regular steroid medication dose during any intercurrent illness\n- Replacement of both glucocorticoids (typically with hydrocortisone) and mineralocorticoids (typically with fludrocortisone)\n- Regular screening for complications including an adrenal crisis and osteoporosis\n\n**Management of Addisonian Crisis**\n\nAn Addisonian crisis, a life-threatening condition characterized by severe hypotension and electrolyte imbalances, should be managed with:\n\n- Aggressive fluid resuscitation\n- Administration of intravenous/IM (if no access) steroids STAT\n- Glucose administration if hypoglycaemia is present\n\n# Complications\n* Addisonian crisis (life-threatening adrenal crisis)\n* Severe electrolyte imbalances\n* Cardiovascular collapse\n* Hypoglycemia\n* Side effects of long term corticosteroid use e.g. osteoporosis\n\n# NICE Guidelines\n\n[Click here for NICE CKS on Addison's disease](https://cks.nice.org.uk/topics/addisons-disease/)\n", "files": null, "highlights": [], "id": "662", "pictures": [ { "__typename": "Picture", "caption": "The appearance of acanthosis nigricans.", "createdAt": 1665036192, "id": "740", "index": 0, "name": "Addison_s - acanthosis.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/ab1cxi2n1665036171703.jpg", "path256": "images/ab1cxi2n1665036171703_256.jpg", "path512": "images/ab1cxi2n1665036171703_512.jpg", "thumbhash": "zigSHYSQhYiKhIiJdod5iFBvCfN2", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "The typical tanned appearnce seen in a woman with Addison's disease.", "createdAt": 1665036184, "id": "719", "index": 1, "name": "Addison_s - tanned appearance.png", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/cajo1y4c1665036171704.jpg", "path256": "images/cajo1y4c1665036171704_256.jpg", "path512": "images/cajo1y4c1665036171704_512.jpg", "thumbhash": "qkgKFYaF54hqh3eHiPiIiG9A8iZG", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 662, "demo": null, "entitlement": null, "id": "2203", "name": "Adrenal insufficiency and Addison's Disease", "status": null, "topic": { "__typename": "Topic", "id": "36", "name": "Clinical Chemistry", "typeId": 2 }, "topicId": 36, "totalCards": null, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 2203, "conditions": [], "difficulty": 3, "dislikes": 9, "explanation": null, "highlights": [], "id": "6460", "isLikedByMe": 0, "learningPoint": null, "likes": 1, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 67-year-old woman presents with increasing lethargy and dizziness on standing. Her past medical history is significant for lung cancer which was treated with chemotherapy two years ago.\n\nOn examination, there is hyperpigmentation of the buccal mucosa and a drop in blood pressure of 25mmHg on standing.\n\nBlood tests show mild eosinophilia, mild hypercalcaemia, hyperkalaemia and hypotonic hyponatraemia.\n\nWhich of the following is most likely to identify the cause of this patient's symptoms?", "sbaAnswer": [ "a" ], "totalVotes": 3922, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Hypomagnesaemia can lead to hypocalcaemia, and it is important to check magnesium levels after urgent treatment has been started", "id": "32307", "label": "e", "name": "Check serum magnesium levels", "picture": null, "votes": 316 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "ECG monitoring is essential as severe hypocalcaemia can lead to a prolongation of the QT interval, which in turn can trigger arrhythmias", "id": "32305", "label": "c", "name": "IV calcium gluconate", "picture": null, "votes": 410 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "PTH testing is important to determine the aetiology of hypocalcaemia. However, severe hypocalcaemia should be treated urgently. In this case, the recent thyroid surgery is likely to be the cause, and PTH levels would likely be low due to disruption of the parathyroid glands during surgery", "id": "32306", "label": "d", "name": "Urgent parathyroid hormone (PTH) level testing", "picture": null, "votes": 893 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This is severe hypocalcaemia which is defined as a serum calcium level of < 1.9 mmol/L or symptomatic with any calcium level below the reference range.\n\nIt is a medical emergency that should be managed with 10-20mL of IV calcium gluconate in 50-100mL of 5% dextrose over 10 mins. This should be followed up with a calcium infusion.\n\nECG monitoring is essential as hypocalcaemia can lead to a prolongation of the QT interval, which in turn can trigger arrhythmias", "id": "32303", "label": "a", "name": "IV calcium gluconate with cardiac monitoring", "picture": null, "votes": 1868 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Oral calcium replacement can be used for asymptomatic patients with a serum calcium of > 1.9 mmol/L. It is not suitable for severe hypocalcaemia", "id": "32304", "label": "b", "name": "Oral calcium replacement", "picture": null, "votes": 410 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nHypocalcaemia refers to an abnormally low serum calcium, adjusted for serum albumin concentration. A calcium of below 2.2 mmol/L is generally considered low although laboratory reference ranges may vary slightly. Causes include vitamin D deficiency, hypoparathyroidism, acute pancreatitis, chronic kidney disease and hypomagnesaemia. Symptoms usually occur when adjusted calcium falls below 1.9 mmol/L, and include muscle cramps, spasms and paraesthesias (classically perioral). Signs include carpopedal spasm and tetany. Investigations include an ECG, bone profile, parathyroid hormone (PTH) level, magnesium, U&Es and a vitamin D. Management involves treating the underlying cause and giving calcium supplementation - oral if mild (e.g. Calcichew tablets) and intravenous (e.g. calcium gluconate) if severe or symptomatic. Vitamin D and/or magnesium supplementation should be given if required. \n\n# Definition\n\nThe normal range for serum calcium is approximately 2.2-2.6 mmol/L. This is adjusted for serum albumin levels, which is important as approximately 40% of serum calcium is bound to albumin and so when albumin levels are low, serum calcium will be underestimated. \n\n99% of the body's calcium is stored in the skeleton and is crucial for the mineralisation of bone. It has many other roles in important functions such as muscle contraction, cardiac pacemaker activity, clotting, cell membrane stability and permeability.\n\nHypocalcaemia refers to an adjusted serum calcium of 2.2 mmol/L or lower.\n\n# Aetiology\n\n- Hypoparathyroidism\n - Iatrogenic due to parathyroid or thyroid surgery or radiotherapy\n - Autoimmune (may be part of a polyglandular syndrome)\n - Infiltration e.g. malignancy, thalassaemia, amyloidosis, Wilson's disease, haemochromatosis\n - Congenital e.g. DiGeorge syndrome (cleft palate, thymic aplasia, facial dysmorphism, cardiac defects and parathyroid agenesis)\n- Hypomagnesaemia (causes reversible functional hypoparathyroidism)\n- Vitamin D deficiency\n - Lack of sun exposure\n - Malnutrition\n - Malabsorption (e.g. due to pancreatic insufficiency)\n - Abnormal metabolism due to chronic kidney or liver disease\n- Medications \n - Calcimimetics (e.g. cinacalcet)\n - Bisphosphonates\n - Loop diuretics\n - Cisplatin\n - Foscarnet\n - Phenytoin\n - Ketoconazole\n- Genetic conditions such as autosomal dominant hypocalcaemia (due to a gain-of-function mutation in the calcium-sensing receptor (CaSR) gene) \n- Pseudohypoparathyroidism\n - PTH resistance due to genetic mutations in its signalling pathway\n - Manifests with hypocalcaemia, hyperphosphataemia and elevated PTH\n - May be associated with Albright hereditary osteodystrophy, where patients have a short stature, obesity, brachymetacarpals (especially the 4th and 5th digits), developmental delay and subcutaneous ossifications\n- Alkalosis causes a fall in ionised calcium (the metabolically active form) due to increased binding to albumin \n - This may be a respiratory alkalosis e.g. due to a panic attack or tachypnoea due to pneumonia or pulmonary embolism\n - Metabolic alkalosis may occur due to prolonged vomiting or excessive bicarbonate administration\n- Massive blood transfusion (as the citrate added to products to prevent clotting chelates calcium)\n - The same mechanism leads to hypocalcaemia in plasmapheresis (plasma contains citrate)\n- Renal replacement therapy with citrate used as an anticoagulant also causes chelation of calcium\n - Any form of continuous renal replacement therapy causes ongoing magnesium and calcium loss\n- Acute pancreatitis (due to saponification of calcium)\n- Hungry bone syndrome\n - Usually occurs after parathyroidectomy\n - There is prolonged PTH exposure with net bone resorption which suddenly shifts towards osteoblastic activity once PTH falls\n - There is a resulting influx of minerals into bone leading to hypocalcaemia and hypophosphataemia\n- Hyperphosphataemia (as phosphate binds with calcium), e.g. due to:\n - Chronic kidney disease\n - Tumour lysis syndrome\n - Rhabdomyolysis\n- Sepsis may lead to hypocalcaemia - this is multifactorial due to the effects of systemic inflammation on calcium homeostasis\n\n# Signs and Symptoms\n\nMild cases of hypocalcaemia (calcium > 2 mmol/L) are usually asymptomatic - once calcium falls below 2 the following symptoms may occur:\n\n- Paraesthesias (typically periorally and affecting the digits)\n- Muscle cramps\n- Muscle spasms\n- Anxiety and depression\n- Confusion\n- Weakness and fatigue\n- Myalgia\n- Dry skin\n- Coarse hair \n- Brittle nails \n\nSigns include:\n\n- Hyperreflexia\n- Muscle fasciculations\n- Chvostek's sign - tapping the facial nerve where it passes in front of the ear provokes muscular spasm of the face \n- This indicates neuromuscular hyperexcitability\n- Trousseau's sign of latent tetany - inflating a blood pressure cuff above the patient's systolic level and keeping this on for up to three minutes causes spasm of the forearm and hand muscles\n- The wrist and metacarpophalangeal joints flex, the fingers adduct and the distal and proximal interphalangeal joints extend\n- Hypotension (rarely)\n- Bradycardia\n- Decreased consciousness\n- Delirium\n- Papilloedema \n- Skin changes e.g. eczema, dermatitis, hyperpigmentation\n- Patchy alopecia\n- Transverse grooving of nails\n\n# Differential Diagnosis\n\n- **Pseudohypocalcaemia** occurs due to hypoalbuminaemia - total calcium will be low in these patients (hence the importance of correcting serum calcium for albumin levels)\n- **Contamination of blood bottles** with EDTA or citrate will lead to artefactual hypocalcaemia - hyperkalaemia will also be seen with EDTA and hypernatraemia with sodium citrate\n\n# Investigations\n\n**Bedside:**\n\n- **ECG** may show a prolonged QTc or rarely arrhythmias (e.g. atrial fibrillation)\n- **Blood gas** to rapidly confirm hypocalcaemia (NB blood gas machines measure ionised calcium only so the reference ranges are significantly lower)\n- **Urine dip** may be positive for protein in CKD or falsely positive for blood due to myoglobinuria in rhabdomyolysis\n\n**Blood tests:**\n\n- **Bone profile** to confirm hypocalcaemia and check phosphate levels\n- **PTH levels** are helpful to help identify a cause - they will be low in hypoparathyroidism and high for example in vitamin D deficiency or pseudohypoparathyroidism\n- **Full blood count** may show anaemia related to chronic disease (e.g. chronic kidney disease) or leukocytosis in sepsis\n- **U&Es** to look for chronic kidney disease\n- **CRP** to screen for inflammation for example in sepsis\n- **Magnesium** to check for hypomagnesaemia\n- **LFTs** to check albumin; liver function may be deranged in some causes e.g. metastatic malignancy \n- **Vitamin D level** to look for deficiency\n- **Amylase** if pancreatitis is suspected\n- **Creatine kinase** if rhabdomyolysis is suspected\n\n**Special tests:**\n\n- **Genetic testing** may be offered to patients with a suspected genetic mutation e.g. autosomal dominant hypocalcaemia\n\n# Management \n\n**Conservative:**\n\n- Identification and management of the underlying cause is key e.g. stopping causative medications where possible\n- Ensure oral intake of calcium is adequate (700 mg/day is recommended for most adults; patients with osteoporosis should have double this)\n- Patients with ECG changes require cardiac monitoring as well as urgent intravenous calcium replacement (see below)\n- Some patients with mild asymptomatic hypocalcaemia e.g. due to critical illness do not require treatment and should be monitored\n\n**Medical:**\n\n- Mild hypocalcaemia (calcium 1.9 mmol/L or higher) can be treated with oral replacement e.g. Calcichew 2 tablets twice a day\n- Severe hypocalcaemia (calcium < 1.9 mmol/L or symptomatic) should be treated urgently with intravenous calcium replacement \n- For example, 10-20 ml of calcium gluconate 10% in 5% glucose over 10 minutes\n- This can be repeated if necessary or followed by a calcium gluconate infusion\n- Vitamin D supplementation should be provided if low - colecalciferol (vitamin D3) is the usual supplement prescribed however other compounds may be required e.g. alfacalcidol (1α-hydroxycholecalciferol) in CKD\n- Replace magnesium if low (see hypomagnesaemia chapter for details) - hypocalcaemia is unlikely to resolve if magnesium is still low\n\n# Complications\n\n**Complications of acute hypocalcaemia:**\n\n- Seizures - may be generalised motor or absence seizures, or focal\n- Arrhythmias - e.g. torsades de pointes due to QTc prolongation\n- Laryngospasm - common in infancy but rarer in adults\n- Bronchospasm - also uncommon in adults, may mimic an asthma exacerbation\n\n**Complications of chronic hypocalcaemia:**\n\n- Cataracts - typically bilateral, not reversible with correction of hypocalcaemia\n- Dental disease - e.g. enamel hypoplasia, increased risk of caries\n- Basal ganglia calcification - may be asymptomatic or lead to movement disorders, parkinsonism or dementia\n\n# References\n\n[Patient UK - Hypocalcaemia](https://patient.info/doctor/hypocalcaemia)\n\n[BNF - Calcium imbalance](https://bnf.nice.org.uk/treatment-summaries/calcium-imbalance/)\n\n[GGC Medicines UK - Management of Hypocalcaemia](https://handbook.ggcmedicines.org.uk/guidelines/electrolyte-disturbances/management-of-hypocalcaemia/)\n\n[The Internet Book of Critical Care - Hypocalcaemia](https://emcrit.org/ibcc/hypocalcemia/)\n\n[Life in the Fast Lane - Hypocalcaemia ECG library](https://litfl.com/hypocalcaemia-ecg-library/)", "files": null, "highlights": [], "id": "165", "pictures": [], "typeId": 2 }, "chapterId": 165, "demo": null, "entitlement": null, "id": "168", "name": "Hypocalcaemia", "status": null, "topic": { "__typename": "Topic", "id": "36", "name": "Clinical Chemistry", "typeId": 2 }, "topicId": 36, "totalCards": 18, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 168, "conditions": [], "difficulty": 3, "dislikes": 2, "explanation": null, "highlights": [], "id": "6461", "isLikedByMe": 0, "learningPoint": null, "likes": 2, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 32-year-old man who had thyroid surgery three days ago presents with numbness and tingling in his fingertips. He also reports intermittent muscle spasms.\n\n\nBloods shows a serum calcium level of 1.8 mmol/L (normal range 2.2-2.6 mmol/L).\n\n\nWhich of the following is the next best step in management?", "sbaAnswer": [ "a" ], "totalVotes": 3897, "typeId": 1, "userPoint": null }

[]

{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "IBD is associated with erythema nodosum. The normal blood tests and absence of gastrointestinal or systemic symptoms would make this unlikely in this case", "id": "32312", "label": "e", "name": "Inflammatory bowel disease (IBD)", "picture": null, "votes": 726 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "The lesions described are typical of erythema nodosum. This is an inflammatory disorder affecting the subcutaneous fat. The cause is unknown in approximately 55% of patients, and most cases resolve within days to weeks", "id": "32308", "label": "a", "name": "Idiopathic", "picture": null, "votes": 4098 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Streptococcal infections are associated with erythema nodosum, but there is nothing in the history to suggest that this may be the cause in this case", "id": "32311", "label": "d", "name": "Post-streptococcal infection", "picture": null, "votes": 484 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Sarcoidosis is an important cause of erythema nodosum; however, the normal chest x-ray, blood tests and absence of symptoms make this unlikely", "id": "32310", "label": "c", "name": "Sarcoidosis", "picture": null, "votes": 791 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "TB is an important cause of erythema nodosum; however, the absence of systemic symptoms, risk factors and normal chest x-ray makes this unlikely", "id": "32309", "label": "b", "name": "Tuberculosis (TB)", "picture": null, "votes": 52 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nErythema nodosum is a panniculitis subtype characterised by tender, red, raised nodules typically affecting the shins. The cause is often idiopathic, although associations with certain medications and diseases like sarcoidosis and inflammatory bowel disease are known. Diagnosis is clinical, with the disease usually resolving spontaneously. Management primarily focuses on treating the underlying cause, if identified, and providing symptomatic relief.\n\n# Definition\n\nErythema nodosum represents a form of panniculitis, or inflammation of the subcutaneous fat, which manifests as tender, raised, erythematous nodules predominantly affecting the shin area.\n\n# Epidemiology\n\nErythema nodosum affects a broad range of individuals and is more common in women than men. Although it can occur at any age, it typically affects individuals between 20-30 years of age.\n\n# Aetiology\n\nThe aetiology of erythema nodosum is often idiopathic, accounting for up to 50% of cases. Other identifiable causes, conveniently remembered by the acronym **NODOSUM**, include:\n\n- **NO** cause (Idiopathic)\n- **D**rugs, particularly sulfonamides and dapsone\n- **O**ral contraceptive pill (OCP)\n- **S**arcoidosis\n- **U**lcerative colitis and Crohn's disease\n- **M**icroorganisms: Tuberculosis, Streptococcus, Toxoplasmosis\n\n# Signs and Symptoms\n\nClinically, erythema nodosum presents as:\n\n- Tender, raised, red or violet nodules, usually located on the anterior surface of the legs.\n- Accompanied by systemic symptoms such as fever, malaise, and arthralgia in some cases.\n\n[lightgallery]\n\n[lightgallery1]\n\n# Differential Diagnosis\n\nThe differential diagnoses for erythema nodosum and their key signs and symptoms include:\n\n- **Cellulitis**: Characterised by local warmth, redness, swelling and tenderness, fever, and possibly lymphadenopathy.\n- **Deep vein thrombosis (DVT)**: Presents with pain, swelling, and redness of the affected limb; Homan's sign might be present.\n- **Necrobiosis lipoidica**: Typically presents as shiny, reddish-brown patches which slowly grow into larger plaques with a yellowish centre.\n- **Vasculitis**: Manifests with palpable purpura, ulcers, or digital infarcts.\n\n# Investigations\n\nWhile erythema nodosum is primarily diagnosed clinically, additional investigations may be performed to rule out underlying causes. These can include:\n\n- Full Blood Count (FBC)\n- Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)\n- Throat culture for streptococci\n- Chest x-ray (to rule out sarcoidosis or tuberculosis)\n- Tests for inflammatory bowel disease if suspected (e.g. colonoscopy)\n\n\n# Management\n\nThe management of erythema nodosum primarily involves treating the underlying cause, if identified. Additional strategies include:\n\n- Nonsteroidal anti-inflammatory drugs (NSAIDs) to alleviate pain and inflammation\n- Rest and leg elevation\n- Potassium iodide or colchicine may be used in severe cases\n- Corticosteroids are used sparingly and typically reserved for severe, refractory cases\n\n# References\n\n[Erythema Nodosum - DermNet NZ](https://dermnetnz.org/topics/erythema-nodosum)", "files": null, "highlights": [], "id": "864", "pictures": [ { "__typename": "Picture", "caption": "An example of erythema nodosum on the shins.", "createdAt": 1665036195, "id": "911", "index": 0, "name": "Erythema nodosum.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/yvhq25ys1665036171715.jpg", "path256": "images/yvhq25ys1665036171715_256.jpg", "path512": "images/yvhq25ys1665036171715_512.jpg", "thumbhash": "ZBgKFIR9h3d/iIfPhneTeECHCA==", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": null, "createdAt": 1665036196, "id": "971", "index": 2, "name": "Erythema nodosum 3.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/yfsgrpr91665036171715.jpg", "path256": "images/yfsgrpr91665036171715_256.jpg", "path512": "images/yfsgrpr91665036171715_512.jpg", "thumbhash": "aCgGDwLAk4ylRXh1mFd3Z3d393FVCGsF", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "Another example of erythema nodosum on the shins.", "createdAt": 1665036195, "id": "916", "index": 1, "name": "Erythema nodosum 2.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/exjaz2ts1665036171715.jpg", "path256": "images/exjaz2ts1665036171715_256.jpg", "path512": "images/exjaz2ts1665036171715_512.jpg", "thumbhash": "3TgODYK393h0iHaId3h3eAh+dLBY", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 864, "demo": null, "entitlement": null, "id": "910", "name": "Erythema Nodosum", "status": null, "topic": { "__typename": "Topic", "id": "4", "name": "Dermatology", "typeId": 2 }, "topicId": 4, "totalCards": 2, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 910, "conditions": [], "difficulty": 2, "dislikes": 19, "explanation": null, "highlights": [], "id": "6462", "isLikedByMe": 0, "learningPoint": "Erythema nodosum presents as tender red nodules on the shins and often has an idiopathic aetiology, resolving spontaneously within weeks.", "likes": 6, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 24-year-old patient presents with tender red nodules on the anterior shins that developed over the last week. Full systems review is negative, and the patient cannot find any triggers that may have lead to the lesions.\n\nA chest x-ray and initial blood tests are normal.\n\nWhich of the following is the most likely cause of this patient's rash?", "sbaAnswer": [ "a" ], "totalVotes": 6151, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Meningococcal septicaemia can present with a purpuric rash, similar to that seen in small vessel vasculitis. However, the absence of any infective symptoms, normal observations and chronicity of the history favour a diagnosis of vasculitis", "id": "32315", "label": "c", "name": "Blood cultures", "picture": null, "votes": 391 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is an important test to look for any evidence of proteinuria (especially in a patient who is likely to have significant renal disease) but a simple urine dipstick should be done in the first instance", "id": "32314", "label": "b", "name": "Urine Protein Creatinine ratio", "picture": null, "votes": 1656 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "CRP levels are indicative of infective and inflammatory states and therefore are likely to be raised in vasculitis. However, it is a non-specific test. A urine dipstick is preferable as an initial test to exclude potentially life-threatening renal vasculitis", "id": "32317", "label": "e", "name": "Measure C-reactive protein (CRP) levels", "picture": null, "votes": 632 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Tryptase levels are increased in anaphylaxis. The rash in anaphylaxis is typically an urticarial rash, characterised by itchy weals and surrounding erythema. Also, there are no other signs or symptoms of anaphylaxis described", "id": "32316", "label": "d", "name": "Serum tryptase levels", "picture": null, "votes": 509 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "The rash combined with systemic symptoms and recurrent sinusitis is suggestive of small vessel vasculitis. In this context, recurrent sinusitis, in particular, is indicative of granulomatosis with polyangiitis (GPA). Vasculitis, in general, is commonly associated with renal disease, which can manifest with proteinuria and haematuria. Therefore, it is important to do a urine dipstick in all patients with this presentation to exclude significant renal complications", "id": "32313", "label": "a", "name": "Urine dipstick", "picture": null, "votes": 2464 } ], "comments": [ { "__typename": "QuestionComment", "comment": "nothing in the quesbook about a rash in this condition ", "createdAt": 1645528536, "dislikes": 2, "id": "7485", "isLikedByMe": 0, "likes": 1, "parentId": null, "questionId": 6463, "replies": [ { "__typename": "QuestionComment", "comment": "vascultis diseases tend to present with purpuric rash", "createdAt": 1683412743, "dislikes": 0, "id": "23610", "isLikedByMe": 0, "likes": 2, "parentId": 7485, "questionId": 6463, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Hematoma Hereditary", "id": 14701 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Dermis Cystic", "id": 4236 } }, { "__typename": "QuestionComment", "comment": "Features\nupper respiratory tract: epistaxis, sinusitis, nasal crusting\nlower respiratory tract: dyspnoea, haemoptysis\nrapidly progressive glomerulonephritis ('pauci-immune', 80% of patients)\nsaddle-shape nose deformity\nalso: vasculitic rash, eye involvement (e.g. proptosis), cranial nerve lesions", "createdAt": 1685362947, "dislikes": 0, "id": "26995", "isLikedByMe": 0, "likes": 2, "parentId": null, "questionId": 6463, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Intravenous Prone", "id": 19930 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nGranulomatosis with polyangiitis (GPA), previously known as Wegener's granulomatosis, is an ANCA associated vasculitis affecting small and medium sized vessels. The classic triad of manifestations is of upper respiratory tract involvement, lower respiratory tract involvement, and pauci-immune glomerulonephritis. Additional organs may be involved, including the skin, the eyes and the peripheral nerves. Key investigations are blood tests including ANCA (c-ANCA is usually positive), chest X-ray or CT showing nodules +/- cavitation and biopsy (showing necrotising granulomas with associated vasculitis). Acute management is usually with steroids with another immunosuppressive agent, the choice of which is dependent on the severity of disease. Steroids should be tapered once remission is achieved whilst another immunosuppressant is continued.\n\n# Definition\n\nGranulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, is a chronic granulomatous ANCA-associated vasculitis that primarily involves the upper and lower respiratory tracts and the kidneys. \n\n# Epidemiology\n\n- GPA is a rare disease with an annual incidence of 8.4 per million\n- Men are slightly more likely to be affected\n- Onset peaks between the ages of 35 to 55\n- There is a higher incidence of cases seen in the winter, suggesting that environmental exposures such as infections may trigger GPA\n- There is also a slightly increased risk in first degree relatives of people with GPA, indicating a genetic predisposition\n\n# Signs and Symptoms\n\nThe classic triad involved in GPA is as follows:\n\n- **Upper respiratory tract** \n- Chronic sinusitis with nasal obstruction and facial pain\n- Rhinorrhoea which is often bloody\n- Epistaxis\n- Ulceration and crusting in and around the nose\n- Destruction of nasal cartilage leading to a saddle-nose deformity \n- Subglottis stenosis may present with hoarseness, stridor or airway obstruction\n- Otitis media causing ear pain and fullness\n- Hearing loss\n- **Lower respiratory tract**\n- Cough\n- Haemoptysis due to pulmonary haemorrhage\n- Dyspnoea\n- Pleuritic chest pain\n- Wheeze\n- **Necrotising glomerulonephritis**\n- Haematuria\n- Frothy urine due to proteinuria\n- Oliguria\n\n**Systemic signs and symptoms** are common:\n\n- Fatigue\n- Malaise\n- Fevers\n- Night sweats\n- Anorexia\n- Weight loss\n- Arthralgia or arthritis\n\nOther organs may also be affected, for example:\n\n- **Skin**\n- Palpable purpura\n- Nodular, papular or vesicular rashes\n- Ulcers\n- **Eyes**\n- Granulomatous disease may cause an inflammatory mass in the orbit leading to proptosis \n- The optic nerve may also be compressed\n- Vasculitis may cause conjunctivitis, episcleritis, scleritis, uveitis, retinitis or optic neuritis\n- Eye pain, redness and visual loss may occur\n- **Peripheral nerves**\n- Mononeuritis multiple is the usual pattern seen\n- Sensory and motor deficits are seen in the distribution of particular peripheral nerves\n- Pain and paraesthesias of affected areas are common\n- **Central nervous system**\n- Granulomatous lesions\n- Vasculitis causing infarction\n- Intracranial haemorrhage\n- Symptoms include headaches, cranial nerve lesions, seizures, focal neurological deficits and altered consciousness\n- **Gastrointestinal (GI) tract**\n- Mouth ulcers\n- Strawberry gums (hyperplastic gingival lesions)\n- Ulceration elsewhere in the GI tract leading to bleeding or perforation\n- Ischaemic bowel disease\n- Symptoms include abdominal pain, vomiting and diarrhoea\n- **Heart**\n- Pericarditis or myocarditis\n- Coronary arteritis\n- Valvular disease\n- Conduction deficits\n- Symptoms include chest pain, dyspnoea, palpitations and dizziness\n\n# Differential Diagnosis\n\n- **Eosinophilic granulomatosis with polyangiitis** is another ANCA-associated systemic vasculitis which may share features of sinusitis, lung and renal involvement however almost all patients have asthma and eosinophilia\n- **Microscopic polyangiitis** is also an ANCA-associated systemic vasculitis which classically involves the lungs and kidneys, as well as the eyes, peripheral nerves, GI tract and skin, however features of sinusitis are not present\n- **Anti-GBM disease** (also known as Goodpasture's syndrome) causes diffuse pulmonary alveolar haemorrhage and rapidly progressive glomerulonephritis; antibodies against the glomerular basement membrane (GBM) are the key differentiating investigation; ANCA may also be positive\n- **Polyarteritis nodosa** also causes systemic symptoms and commonly involves the kidneys, however pulmonary involvement is very rare unlike in GPA\n- **IgA vasculitis** is an immune complex-mediated small vessel vasculitis that typically affects children; palpable purpura on the legs, abdominal pain and renal involvement are all shared features\n- **Infective endocarditis** causes similar systemic symptoms (e.g. fevers, malaise, weight loss) and septic emboli can affect the lungs and kidneys as well as the central nervous system\n- **Malignancy** may cause similar systemic symptoms of weight loss, fatigue, malaise and low-grade fevers, and specific malignancies may cause symptoms that mimic GPA (e.g. haemoptysis due to lung cancer, haematuria due to urological malignancies)\n\n# Investigations\n\n**Bedside tests:**\n\n- **Urine dip** for blood and protein\n- **Urinary protein:creatine ratio** if proteinuria present on urinalysis\n- **Urine microscopy** may show red blood cell casts\n\n**Blood tests:**\n\n- **Full blood count** which may show a normocytic anaemia and thrombocytosis due to chronic inflammation, or a microcytic anaemia due to alveolar haemorrhage or GI bleeding\n- **U&Es** looking for renal impairment due to glomerulonephritis\n- **LFTs** may show hypoalbuminemia due to inflammation or proteinuria\n- **CRP** and **ESR** are raised due to systemic inflammation\n- **Bone profile** is typically normal, hypercalcaemia should raise suspicion of malignancy as an important differential\n- **ANCA** is usually positive - anti-PR3 or c-ANCA is most commonly seen but a small proportion of people are anti-MPO or p-ANCA positive\n\n**Imaging tests:**\n\n- **Chest X-ray**\n- The most common finding is multiple nodules of various sizes throughout both lung fields\n- These may cavitate\n- Pulmonary haemorrhage may also be seen with patchy or diffuse opacification\n- Focal areas of alveolar consolidation may occur and can also cavitate\n- Pleural effusions may be seen secondary to cardiac or renal GPA\n- **CT chest** is more sensitive for the above findings and may also show:\n- Micronodules due to bronchial wall involvement or retained blood in the distal airways\n- Mild bronchiectasis\n- Ground glass changes secondary to haemorrhage\n- Tracheobronchial wall thickening\n- **CT of the sinuses** may show:\n- Mucosal thickening\n- Soft tissues nodules\n- Erosions +/- perforation of the cartilage and bones\n- Sclerosis and calcification may also be present\n- **CT** or **MRI** of the head and orbits may show central nervous system involvement or granulomatous disease of the orbits\n- **CT** of the kidneys typically shows a hypovascular mass\n- **FDG-PET CT** can be used to identify occult sites of disease and investigate for differentials such as chronic infection or malignancy\n\n**Special tests include:**\n\n- **Renal biopsy** shows crescentic and necrotising glomerular lesions with no or few immune deposits (pauci-immune)\n- Other affected sites may also be amenable to biopsy, including skin, nasal mucosa and lung tissues \n- **Flexible nasendoscopy** may be done to look for features such as ulceration, septal perforation, crusting and subglottic stenosis\n- **Lung function testing** with **flow-volume loops** may show evidence of fixed upper airway obstruction in subglottic stenosis\n- **Nerve conduction studies** and **electromyography** may be useful in the investigation of mononeuritis multiplex\n- **Endoscopy** may be required in GPA associated with gastrointestinal bleeding\n- **Bronchoalveolar lavage** may be indicated in evaluating pulmonary infiltrates e.g. alveolar haemorrhage\n\n# Management\n\n- Organ or life-threatening GPA should be treated with high dose steroids (usually 1mg/kg prednisolone or equivalent) with either rituximab or cyclophosphamide\n- Avacopan (an oral C5a-receptor antagonist) may be substituted for steroids in severe GPA\n- Plasma exchange is another option that may be used for salvage therapy, especially in severe renal impairment due to rapidly progressive glomerulonephritis\n- Patients may require supportive treatment e.g. intensive care admission with intubation and ventilation and/or renal replacement therapy\n- If GPA is not organ or life-threatening, steroids and rituximab (in some cases methotrexate or mycophenolate mofetil may be used instead of rituximab) are recommended\n- Prednisolone should be tapered over several months\n- Options for maintenance treatment once remission is achieved include rituximab, azathioprine or methotrexate \n- Maintenance immunosuppressive treatment is usually continued for 2 to 4 years (longer in relapsing disease)\n- Patients should be counselled on the risks of immunosuppressive treatments, and prophylactic co-trimoxazole given to patients on rituximab, cyclophosphamide or high-dose steroids\n- In some cases, surgical treatment is required e.g. reconstructive surgery for nasal deformities or for subglottic stenosis\n- Long-term renal replacement therapy (haemodialysis or transplant) may be required for patients who develop end-stage renal disease\n\n# Complications\n\n- Renal failure due to rapidly progressive glomerulonephritis \n- Respiratory failure due to diffuse pulmonary haemorrhage\n- Hearing loss\n- Vision loss\n- Septal perforation or saddle nose deformity\n- Increased cardiovascular risk due to chronic inflammation\n- Increased risk of bladder cancer in patients treatment with cyclophosphamide - patients should have regular urinalysis as part of follow up\n- Side effects of immunosuppression e.g. osteoporosis, diabetes, peptic ulceration with prolonged steroid courses\n- Psychological distress and negative impacts on quality of life due to the burden of disease and its treatments\n\n# Prognosis\n\n- Without treatment, GPA is usually fatal\n- Patients with both renal and respiratory tract involvement have an increased risk of early death\n- Mortality with effective treatment is 14% at 1 year\n- The majority of patients respond to treatment although relapses are frequent (50% at 8 years)\n\n# References\n\n[EULAR recommendations for the management of ANCA-associated vasculitis](https://ard.bmj.com/content/83/1/30)\n\n[Radiopaedia - Granulomatosis with polyangiitis](https://radiopaedia.org/articles/granulomatosis-with-polyangiitis?lang=gb)\n\n[Patient UK - Granulomatosis with polyangiitis](https://patient.info/doctor/granulomatosis-with-polyangiitis-wegeners-granulomatosis-pro)\n\n[DermNet - Granulomatosis with polyangiitis](https://dermnetnz.org/topics/granulomatosis-with-polyangiitis)\n\n[StatPearls - Granulomatosis with polyangiitis](https://www.ncbi.nlm.nih.gov/books/NBK557827/)", "files": null, "highlights": [], "id": "2030", "pictures": [], "typeId": 2 }, "chapterId": 2030, "demo": null, "entitlement": null, "id": "2654", "name": "Granulomatosis with polyangiitis (Wegener's Granulomatosis)", "status": null, "topic": { "__typename": "Topic", "id": "4", "name": "Dermatology", "typeId": 2 }, "topicId": 4, "totalCards": null, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 2654, "conditions": [], "difficulty": 3, "dislikes": 8, "explanation": null, "highlights": [], "id": "6463", "isLikedByMe": 0, "learningPoint": "Recurrent sinusitis and a purpuric rash could suggest granulomatosis with polyangiitis, making urine dipstick testing important to evaluate potential renal involvement.", "likes": 6, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 34-year-old man presents with a two-week history of a purple coloured rash on his lower limbs. He also reports approximately 5kg weight loss in the last two months. He is otherwise well, and his only significant past medical history is of recurrent episodes of sinusitis in the past year.\n\nOn examination, there is a widespread palpable purpuric rash on the anterior aspects of both legs. Examination and observations are otherwise normal.\n\nWhich of the following is the next best step in management?", "sbaAnswer": [ "a" ], "totalVotes": 5652, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Haematological malignancies can cause erythroderma; however, the lack of systemic symptoms, largely normal blood tests and absence of lymphadenopathy would go against this", "id": "32322", "label": "e", "name": "Haematological malignancy", "picture": null, "votes": 134 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Around 30% of cases of erythroderma are idiopathic. Most cases of erythroderma are associated with a pre-existing skin condition", "id": "32319", "label": "b", "name": "Idiopathic", "picture": null, "votes": 325 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "The rash is highly suggestive of erythroderma. Erythroderma is a dermatological emergency where there is widespread erythema affecting >90% of the skin surface. The increased urea level suggests dehydration, an important complication of erythroderma, and highlights the importance of the skin's function in fluid balance.\n\nThe most common cause of erythroderma is a pre-existing skin condition such as eczema or psoriasis", "id": "32318", "label": "a", "name": "Pre-existing skin condition", "picture": null, "votes": 1189 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Sezary syndrome is a type of cutaneous T-cell lymphoma and is a rare cause of erythroderma", "id": "32321", "label": "d", "name": "Sezary syndrome", "picture": null, "votes": 840 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Drug reactions can cause erythroderma; however, this is less likely than a pre-existing skin condition preceding erythroderma.", "id": "32320", "label": "c", "name": "Drug-reaction", "picture": null, "votes": 3334 } ], "comments": [ { "__typename": "QuestionComment", "comment": "nah", "createdAt": 1642001532, "dislikes": 2, "id": "6386", "isLikedByMe": 0, "likes": 32, "parentId": null, "questionId": 6464, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Amnesia Haemophilus", "id": 5209 } }, { "__typename": "QuestionComment", "comment": "dean's list student question lmao", "createdAt": 1647370450, "dislikes": 2, "id": "8613", "isLikedByMe": 0, "likes": 6, "parentId": null, "questionId": 6464, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Yellow Zebras", "id": 17804 } }, { "__typename": "QuestionComment", "comment": "Could just say she has a history of eczema. How are you supposed to deduce anything from such a short stem?", "createdAt": 1650365640, "dislikes": 0, "id": "9946", "isLikedByMe": 0, "likes": 32, "parentId": null, "questionId": 6464, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Myotonia Bladder", "id": 12619 } }, { "__typename": "QuestionComment", "comment": "there's literally nothing in the stem to suggest pre-existing skin condition but apparently that's the reason why drug-reaction is wrong", "createdAt": 1684850645, "dislikes": 0, "id": "25829", "isLikedByMe": 0, "likes": 19, "parentId": null, "questionId": 6464, "replies": [ { "__typename": "QuestionComment", "comment": "I dont think that's the reason. I think it's simply much more commonly caused by pre-existing skin conditions. Since there was nothing to point you towards any particular cause, the most likely one is the most common one", "createdAt": 1709050039, "dislikes": 0, "id": "43009", "isLikedByMe": 0, "likes": 1, "parentId": 25829, "questionId": 6464, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Ale", "id": 20565 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Kinase Power", "id": 16637 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nErythroderma, a serious dermatological emergency, is characterised by widespread erythema affecting over 90% of the skin surface. Its primary signs and symptoms include significant skin redness and potential systemic symptoms due to heat and fluid loss. A broad range of conditions, such as dermatitis and psoriasis, or external triggers like drug allergies, can provoke erythroderma. Investigations mainly involve skin biopsy and blood tests. Management primarily focuses on supportive care, including fluid replacement and emollients, alongside treatment of the underlying cause, usually under the guidance of a dermatology specialist.\n\n# Definition\n\nErythroderma, also referred to as exfoliative dermatitis, is a severe and potentially life-threatening dermatological condition where there is widespread erythema covering more than 90% of the body's skin surface. This condition can lead to significant heat and fluid loss, which can further induce systemic symptoms, including hypothermia.\n\n# Aetiology\n\nThe most common cause of erythroderma is the exacerbation of a pre-existing skin condition. These include:\n\n- Dermatitis: Atopic dermatitis, seborrhoeic dermatitis, contact dermatitis\n- Psoriasis\n- Pityriasis rubra pilaris\n\nOther causative factors include:\n\n- Drug allergies\n- Idiopathic triggers\n- Sezary syndrome, a type of cutaneous T-cell lymphoma, which leads to erythroderma, lymphadenopathy, and hepatosplenomegaly. It is defined by the presence of Sezary cells, which are atypical T cells, in the peripheral blood circulation.\n\n# Signs and Symptoms\n\n[lightgallery]\n\nThe main sign of erythroderma is extensive redness (erythema) affecting over 90% of the skin surface. Other associated symptoms can include:\n\n- Skin scaling or shedding\n- Pruritus (itching)\n- Fever and chills due to systemic involvement\n- Swelling of the limbs (edema)\n- Increase in heart rate (tachycardia)\n\n# Differential Diagnosis\n\nWhen assessing a patient with suspected erythroderma, other conditions that could cause similar symptoms need to be considered:\n\n- Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome: Symptoms include skin rash, fever, lymphadenopathy, and involvement of internal organs.\n- Toxic epidermal necrolysis (TEN) and Stevens-Johnson Syndrome (SJS): Key signs are extensive skin detachment, mucosal involvement, and systemic symptoms.\n- Staphylococcal scalded skin syndrome (SSSS): Characterised by extensive skin blistering and sloughing, often accompanied by systemic symptoms.\n\n# Investigations\n\nAlthough the mainstay of diagnosis is clinical observation, further investigations may include:\n\n- Full blood count (FBC), C-Reactive Protein (CRP) and other blood tests to assess systemic involvement and rule out infection.\n- Skin biopsy to confirm diagnosis and identify underlying cause.\n- Other tests depending on the suspected underlying cause, such as allergy testing or immunophenotyping for Sezary syndrome.\n\n# Management\n\n* The management of erythroderma should involve supportive care, including referral/admission under dermatology, fluid replacement to prevent dehydration and the use of emollients to soothe the skin\n* Additionally, the underlying disease causing the erythroderma should be identified and treated, for instance, by administering steroids for an exacerbation of atopic dermatitis\n* Hospitalisation may be necessary for severe cases due to the risk of life-threatening complications\n\n# References\n[Erythroderma - DermNet NZ](https://dermnetnz.org/topics/erythroderma)\n", "files": null, "highlights": [], "id": "857", "pictures": [ { "__typename": "Picture", "caption": "An example of erythroderma seen in a female patient.", "createdAt": 1665036195, "id": "912", "index": 0, "name": "Erythroderma.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/ae10zr0s1665036171716.jpg", "path256": "images/ae10zr0s1665036171716_256.jpg", "path512": "images/ae10zr0s1665036171716_512.jpg", "thumbhash": "HTgGDYTp03rvVWhMh2eZehkHgSJA", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 857, "demo": null, "entitlement": null, "id": "904", "name": "Erythroderma", "status": null, "topic": { "__typename": "Topic", "id": "4", "name": "Dermatology", "typeId": 2 }, "topicId": 4, "totalCards": 3, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "904", "name": "Erythroderma" } ], "demo": false, "description": null, "duration": 328.36, "endTime": null, "files": null, "id": "39", "live": false, "museId": "hs5ThRX", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/dermatology.png", "title": "Atopic dermatitis 1", "userViewed": false, "views": 159, "viewsToday": 10 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "904", "name": "Erythroderma" } ], "demo": false, "description": null, "duration": 3472.41, "endTime": null, "files": null, "id": "311", "live": false, "museId": "m1dDZby", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/dermatology.png", "title": "Quesmed Tutorial: Dermatology", "userViewed": false, "views": 799, "viewsToday": 49 } ] }, "conceptId": 904, "conditions": [], "difficulty": 3, "dislikes": 63, "explanation": null, "highlights": [], "id": "6464", "isLikedByMe": 0, "learningPoint": "A pre-existing skin condition, such as psoriasis, atopic dermatitis, or seborrheic dermatitis, is a risk factor for erythroderma", "likes": 3, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 32-year-old woman presents with a three-day history of a worsening rash across her body.\n\nOn examination, there is an erythematous rash covering the majority of the patient's skin, both anteriorly and posteriorly. The skin is hot to touch, and there is associated scaling. Systemic examination is otherwise normal.\n\nBlood tests reveal increased urea to creatinine ratio but no other significant findings.\n\nWhich of the following is the most likely cause of the rash described?", "sbaAnswer": [ "a" ], "totalVotes": 5822, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "This would not be appropriate as hoarseness could be a sign of underlying malignancy", "id": "32326", "label": "d", "name": "Reassure and discharge", "picture": null, "votes": 26 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Hoarseness is a red flag for laryngeal cancer. Guidelines suggest that all patients over 45 years old should be referred urgently to secondary care if they have unexplained and persistent hoarseness", "id": "32323", "label": "a", "name": "Urgent referral for investigation of laryngeal cancer", "picture": null, "votes": 5428 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Delay in investigations can affect prognosis, and it is therefore recommended that this patient be referred urgently under the 2-week wait pathway", "id": "32327", "label": "e", "name": "Arrange a follow-up GP appointment in two weeks to monitor symptoms", "picture": null, "votes": 95 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "GORD can lead to voice changes due to the effect of acid on the vocal cords. However, this patients GORD symptoms appear to be well controlled on omeprazole. Regardless, persistent hoarseness is concerning, and he should be referred urgently to exclude laryngeal cancer", "id": "32324", "label": "b", "name": "Increase omeprazole dosing to 20mg twice a day", "picture": null, "votes": 89 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Apical lung cancer can compress the recurrent laryngeal nerve and lead to hoarseness. However, the lung cancer pathways require an abnormal chest X-ray or unexplained haemoptysis in patients over 40 before urgent referral", "id": "32325", "label": "c", "name": "Urgent referral for investigation of lung cancer", "picture": null, "votes": 393 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nHoarseness, an inability to produce sound with altered voice pitch or quality, is a common complaint often indicative of underlying conditions such as laryngeal cancer, chronic laryngitis, acute laryngitis, or Reinke's Oedema. Hoarseness lasting more than three weeks necessitates an investigation due to its potential association with laryngeal cancer. Key signs and symptoms, investigations, and management strategies for each condition are detailed in the following sections.\n\n# Definition\n\nHoarseness is characterized by the inability to produce sound or a change in voice pitch or quality. It is often a symptom of an underlying condition and not a disease in itself.\n\n# Epidemiology\n\nHoarseness is a common presenting complaint in primary care and ENT clinics. While the exact prevalence is not known, it is frequently associated with a range of conditions from benign vocal cord lesions to more serious laryngeal cancers.\n\n# Aetiology\n\nThe primary causes of hoarseness include:\n\n**Laryngeal cancer**\n\n- Hoarseness lasting more than 3 weeks.\n- Significant smoking history is a common feature in the patient's history.\n\n**Chronic Laryngitis**\n\n- Associated with gastroesophageal reflux disease.\n- Often presents as worse in the morning.\n\n**Acute Laryngitis**\n\n- A common cause of hoarseness, typically viral and self-limiting.\n- May be secondary to gastroesophageal reflux disease (GORD) or autoimmune disease.\n\n**Reinke's Oedema**\n\n- Enlargement of the vocal cords associated with hypothyroidism, leading to persistent hoarseness.\n\n# Signs and symptoms\n\nThe primary symptom of these conditions is hoarseness. However, each condition has unique features:\n\n**Laryngeal cancer**\n\n- Hoarseness lasting more than 3 weeks.\n- A history of significant smoking.\n\n**Chronic Laryngitis**\n\n- Hoarseness, particularly severe in the morning.\n- Potential history of gastroesophageal reflux disease.\n\n**Acute Laryngitis**\n\n- Hoarseness, typically viral and self-limiting.\n- Can be secondary to GORD or autoimmune disease.\n\n**Reinke's Oedema**\n\n- Prolonged and persistent hoarseness.\n- Potential history of hypothyroidism.\n\n# Differential diagnosis\n\nThe differential diagnosis for hoarseness includes:\n\n- Laryngeal cancer: Characterized by hoarseness lasting more than 3 weeks and a history of significant smoking.\n- Chronic laryngitis: Hoarseness that is worse in the morning and potentially associated with gastroesophageal reflux disease.\n- Acute laryngitis: Hoarseness that is typically viral and self-limiting, and could be secondary to GORD or autoimmune disease.\n- Reinke's Oedema: Persistent hoarseness due to enlargement of the vocal cords, associated with hypothyroidism.\n\n# Investigations\n\nInvestigations for hoarseness primarily involve referral to an ENT specialist for further evaluation, which may include laryngoscopy, imaging studies, and potentially biopsy in cases where malignancy is suspected.\n\n# Management\n\nManagement strategies for hoarseness depend on the underlying cause:\n\n- Laryngeal cancer: Urgent referral to ENT specialists under a 2-week wait rule.\n- Chronic laryngitis: Management of underlying gastroesophageal reflux disease.\n- Acute laryngitis: Typically self-limiting and supportive care is often sufficient.\n- Reinke's Oedema: Treatment of underlying hypothyroidism and voice therapy.\n\n# References\n\n[Click here for NICE CKS on head and neck cancers - recognition and referral](https://cks.nice.org.uk/topics/head-neck-cancers-recognition-referral/)", "files": null, "highlights": [], "id": "284", "pictures": [], "typeId": 2 }, "chapterId": 284, "demo": null, "entitlement": null, "id": "282", "name": "Hoarseness", "status": null, "topic": { "__typename": "Topic", "id": "24", "name": "Ear, Nose & Throat", "typeId": 2 }, "topicId": 24, "totalCards": 7, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 282, "conditions": [], "difficulty": 1, "dislikes": 0, "explanation": null, "highlights": [], "id": "6465", "isLikedByMe": 0, "learningPoint": "All patients over 45 years old should be referred urgently to secondary care if they have unexplained and persistent hoarseness", "likes": 4, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 65-year-old man presents to his general practitioner (GP) complaining that his voice has become more hoarse over the last three months. He denies any other symptoms.\n\nHis past medical history is significant for gastro-oesophageal reflux disease (GORD), for which he takes 20mg of omeprazole once a day.\n\nThere are no notable findings on examination.\n\nWhich of the following is the next best step in management?", "sbaAnswer": [ "a" ], "totalVotes": 6031, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Acetic acid can be used in the very early stages of infection. In this case, the inflammation, discharge and pain favour using a combination antibiotic/steroid ear drop", "id": "32332", "label": "e", "name": "2% acetic acid ear drops", "picture": null, "votes": 633 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Uncomplicated otitis externa does not require referral to ENT. Persistent infection and infections in which there is concern about spread beyond the external ear canal would warrant referral", "id": "32329", "label": "b", "name": "Urgent referral to ENT", "picture": null, "votes": 134 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Oral antibiotics are usually not used in otitis externa due to poor penetration of the skin that lines the external ear canal. However, if there is spread beyond this (i.e. to bone or face), then oral antibiotics should be considered", "id": "32330", "label": "c", "name": "Oral flucloxacillin", "picture": null, "votes": 194 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Ribbon gauze can be used in severe otitis externa if there is significant inflammation of the ear canal that prevents ear drops from passing into the canal. There is only mild inflammation in this case, making topical antibiotics a better first-line option", "id": "32331", "label": "d", "name": "Insert ribbon gauze (Pope wick)", "picture": null, "votes": 30 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "The likely diagnosis is acute otitis externa, given the ear pain and characteristic appearances on otoscopy. Swimming and water sports are common risk factors for this condition. Treatment is with topical antibiotic/steroid drops and keeping the ear dry for 7-10 days", "id": "32328", "label": "a", "name": "Offer topical antibiotic/steroid drops and advise keeping the ear dry", "picture": null, "votes": 5320 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nOtitis externa, a common cause of otalgia, usually presents with minimal discharge, itch and pain due to acute inflammation of the skin of the external auditory meatus. The most common causative organisms are Pseudomonas species and Staphylococcus aureus. The condition is managed based on its severity, with systemic antibiotics reserved for patients with fever or lymphadenitis. Topical drops may be used for mild to moderate cases, while severe cases may require the use of a ribbon gauze known as “Pope” wicks for the application of topical antibiotics.\n\n# Definition\n\nOtitis externa is an inflammatory condition affecting the skin of the external auditory meatus, often resulting in otalgia. It is characterised by minimal discharge, itchiness and pain.\n\n# Epidemiology\n\nOtitis externa is a common condition, frequently seen in primary care and ENT practices. \n\n# Aetiology\n\nThe most common causative organisms of otitis externa are Pseudomonas species and Staphylococcus aureus.\n\n# Signs and Symptoms\n\nPatients with otitis externa typically present with the following symptoms:\n\n- Otalgia (ear pain)\n- Minimal discharge\n- Itchiness\n- Pain due to inflammation\n- Impaired hearing if the meatus becomes blocked by swelling or discharge\n\n[lightgallery]\n\n# Differential Diagnosis\n\nThe differential diagnosis for otitis externa includes:\n\n- Otitis media: Characterised by middle ear pain, fever, hearing loss and sometimes discharge.\n- Furunculosis: Presents with localised pain, swelling and redness, and occasionally fever.\n- Eczema: Features include itching, redness, and scaling of the skin.\n\n# Investigations\n\nThe diagnosis of otitis externa is primarily clinical. However, microbiological cultures may be useful in refractory or severe cases to determine the causative organism and guide antibiotic treatment.\n\n# Management\n\nThe management of otitis externa depends on the severity:\n\n- Mild to Moderate Otitis Externa: Can be treated with topical drops including combined antibiotic/steroid drops (e.g. Gentamix), acetic acid and other preparations. Patients should be advised to keep the ear dry for the next 7-10 days.\n- Severe Otitis Externa: Treated using a strip of ribbon gauze known as “Pope” wicks which can be used for the application of topical antibiotics (classically gentamicin) enabling deeper penetration.\n- Indications to Consider Oral Antibiotics: Cellulitis extending beyond the external ear canal, when the ear canal is occluded by swelling and debris and a wick cannot be inserted, and in people with diabetes or compromised immunity with severe infection or high risk of severe infection.\n\n# References\n\n[Click here for NICE CKS on otitis externa](https://cks.nice.org.uk/topics/otitis-externa/)", "files": null, "highlights": [], "id": "278", "pictures": [ { "__typename": "Picture", "caption": "An example appearance of otitis externa.", "createdAt": 1665036198, "id": "1074", "index": 0, "name": "Otitis externa.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/esq89yyt1665036171699.jpg", "path256": "images/esq89yyt1665036171699_256.jpg", "path512": "images/esq89yyt1665036171699_512.jpg", "thumbhash": "2zgSDYQ/mIZ4l4h0iXiHd1929lA2", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 278, "demo": null, "entitlement": null, "id": "275", "name": "Otitis Externa", "status": null, "topic": { "__typename": "Topic", "id": "24", "name": "Ear, Nose & Throat", "typeId": 2 }, "topicId": 24, "totalCards": 11, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "275", "name": "Otitis Externa" } ], "demo": false, "description": null, "duration": 3737.73, "endTime": null, "files": null, "id": "614", "live": false, "museId": "ZMAGtgf", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/cardiology.png", "title": "Quesmed Tutorial: General Practice", "userViewed": false, "views": 398, "viewsToday": 38 } ] }, "conceptId": 275, "conditions": [], "difficulty": 1, "dislikes": 1, "explanation": null, "highlights": [], "id": "6466", "isLikedByMe": 0, "learningPoint": "Patients with acute otitis externa require topical antibiotic/steroid drops and should be advised to keep the ear dry", "likes": 8, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 19-year-old woman presents to her general practitioner (GP) with pain and discharge from her right ear. She reports the symptoms began two days ago after returning from a beach holiday in Spain.\n\nShe has no significant past medical history, and her observations are all normal.\n\nOn examination, there is tenderness on gentle movement of the right ear. Otoscopy reveals a mildly inflamed and erythematous ear canal with scant white discharge. The tympanic membrane remains intact.\n\nWhich of the following is the next best step in management?", "sbaAnswer": [ "a" ], "totalVotes": 6311, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Cerumen (ear wax) in the ear canal is one of the most common causes of conductive hearing loss. It would not lead to a change in the appearance of the tympanic membrane", "id": "32336", "label": "d", "name": "Cerumen impaction", "picture": null, "votes": 195 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Tympanosclerosis refers to calcification of the middle ear and tympanic membrane. The aetiology is not fully understood, but the major risk factors are middle ear infections and grommet insertion. The condition is characterised by chalky white patches on the tympanic membrane and a conductive pattern of hearing loss", "id": "32333", "label": "a", "name": "Tympanosclerosis", "picture": null, "votes": 4109 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Chronic otitis media presents with ear discharge for greater than six weeks. Often there will also be perforation of the tympanic membrane on examination", "id": "32334", "label": "b", "name": "Chronic otitis media", "picture": null, "votes": 384 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "A vestibular schwannoma (acoustic neuroma) is usually a slow-growing tumour of the cerebellopontine angle. It can present with sensorineural hearing loss, vertigo and tinnitus", "id": "32337", "label": "e", "name": "Vestibular schwannoma", "picture": null, "votes": 168 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Otosclerosis is a condition in which there is abnormal bone growth in the middle ear. It is a cause of conductive hearing loss but would not explain the characteristic appearances of the tympanic membrane described", "id": "32335", "label": "c", "name": "Otosclerosis", "picture": null, "votes": 884 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Probably important to note here that negative Rinne's = BC>AC (referring to a true negative Rinne's) as I've only really seen it written out in full", "createdAt": 1678301483, "dislikes": 1, "id": "19653", "isLikedByMe": 0, "likes": 6, "parentId": null, "questionId": 6467, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Kawasaki Dominant", "id": 3457 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nTympanosclerosis is a condition characterised by chronic inflammation and scarring of the tympanic membrane, leading to its subsequent calcification. Patients typically present with significant hearing loss and chalky-white patches on the tympanic membrane. Key investigations include an otoscopic examination and audiometric testing. Management strategies include the use of hearing aids and, in refractory cases, surgical excision of the sclerotic areas and repair of the ossicular chain.\n\n# Definition\n\nTympanosclerosis is a chronic disease that involves inflammation, fibrosis, and calcification of the tympanic membrane and other structures within the middle ear.\n\n# Epidemiology\n\nThe epidemiology of tympanosclerosis is not well understood due to the paucity of data. However, it is known to be associated with certain risk factors such as a history of chronic otitis media and tympanostomy tube insertion.\n\n# Aetiology\n\nThe exact cause of tympanosclerosis remains unclear, but it is believed to be associated with chronic otitis media and the insertion of tympanostomy tubes, also known as grommets. Other potential contributing factors may include trauma, ototoxic drugs, and genetic predisposition.\n\n# Signs and Symptoms\n\nThe primary symptom of tympanosclerosis is significant hearing loss. Upon physical examination, the tympanic membrane will often display chalky white patches due to the calcification process.\n\n[lightgallery]\n\n# Differential Diagnosis\n\nThe differential diagnosis for tympanosclerosis includes:\n- Chronic otitis media: Characterised by recurrent ear infections, persistent ear discharge, fullness or pressure in the ear, and hearing loss.\n- Otosclerosis: Presents with progressive conductive hearing loss, tinnitus, and occasionally vertigo.\n- Cholesteatoma: Symptoms include hearing loss, ear discharge, and a sensation of fullness or pressure in the ear.\n\n# Investigations\n\nThe diagnosis of tympanosclerosis typically involves a comprehensive otoscopic examination and audiometric testing to assess the degree of hearing impairment.\n\n# Management\n\nManagement of tympanosclerosis primarily involves addressing the hearing loss. Common strategies include:\n- The use of hearing aids to improve auditory function.\n- In cases that are refractory to hearing aids, surgical intervention may be considered. This involves the excision of the sclerotic areas and repair of the ossicular chain.", "files": null, "highlights": [], "id": "285", "pictures": [ { "__typename": "Picture", "caption": "An example of tympanosclerosis seen on otoscopy.", "createdAt": 1665036192, "id": "745", "index": 0, "name": "Tympanosclerosis.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/01l53wuj1665036171703.jpg", "path256": "images/01l53wuj1665036171703_256.jpg", "path512": "images/01l53wuj1665036171703_512.jpg", "thumbhash": "GCgKBoIHU1aZdmlxpnaHZ3h29mR5+6Y=", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 285, "demo": null, "entitlement": null, "id": "283", "name": "Tympanosclerosis", "status": null, "topic": { "__typename": "Topic", "id": "24", "name": "Ear, Nose & Throat", "typeId": 2 }, "topicId": 24, "totalCards": 2, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 283, "conditions": [], "difficulty": 2, "dislikes": 4, "explanation": null, "highlights": [], "id": "6467", "isLikedByMe": 0, "learningPoint": "Tympanosclerosis is characterised by chalky white patches on the tympanic membrane and can lead to conductive hearing loss.", "likes": 3, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 40-year-old man with a history of recurrent right-sided otitis media presents with a one-month history of gradually worsening hearing loss in his right ear. He denies any other symptoms, and his past medical history is otherwise unremarkable.\n\nOn examination, otoscopy reveals chalky white patches on the tympanic membrane. Rinne's test is negative on the right, and Weber's test lateralises to the right ear.\n\nWhich of the following is the most likely diagnosis?", "sbaAnswer": [ "a" ], "totalVotes": 5740, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "A pulmonary embolism of the size needed to cause respiratory accessory muscle usage would be expected to cause a decrease in oxygen saturation and arterial oxygen levels", "id": "32341", "label": "d", "name": "Pulmonary embolism", "picture": null, "votes": 85 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Poorly maintained gas and heating appliances are a common cause of carbon monoxide poisoning. Presenting symptoms can include headache, confusion, nausea, shortness of breath and chest pain. Carbon dioxide binds preferentially with haemoglobin to form carboxy-haemoglobin, thereby reducing haemoglobin's carrying capacity of oxygen. Saturation probes cannot differentiate between oxy-haemoglobin and carboxy-haemoglobin, meaning that oxygen saturations are misleadingly normal. Arterial oxygen levels are also normal as there is no ventilation-perfusion mismatch. Elevated carboxy-haemoglobin levels on an ABG can confirm the diagnosis", "id": "32338", "label": "a", "name": "Carbon monoxide poisoning", "picture": null, "votes": 3655 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Methaemoglobinaemia is a condition in which the iron in haemoglobin is oxidised from the ferrous to the ferric state, thereby rendering it unable to bind to oxygen. It usually presents with cyanosis, oxygen saturations between 85-90% and normal arterial oxygen levels. Cyanosis is not usually seen in carbon monoxide poisoning as carboxy-haemoglobin has a bright red colour", "id": "32339", "label": "b", "name": "Methaemoglobinaemia", "picture": null, "votes": 414 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Normal findings on auscultation and normal oxygen saturations would make a pneumothorax an unlikely explanation for the significant symptoms that this patient has presented with", "id": "32340", "label": "c", "name": "Pneumothorax", "picture": null, "votes": 70 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "A subarachnoid haemorrhage is an important differential in this context, given the history of severe headache and reduced GCS. However, he is not in the right age range for a subarachnoid haemorrhage. In any case, you will likely get a CT Head for this patient but this is not the single best answer", "id": "32342", "label": "e", "name": "Subarachnoid haemorrhage", "picture": null, "votes": 874 } ], "comments": [ { "__typename": "QuestionComment", "comment": "wouldnt his wife have it too usually", "createdAt": 1653222410, "dislikes": 0, "id": "11071", "isLikedByMe": 0, "likes": 6, "parentId": null, "questionId": 6468, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Myopathy Qwave", "id": 12096 } }, { "__typename": "QuestionComment", "comment": "Would the oxygen saturations be wrongly high at 100%?\n", "createdAt": 1655227665, "dislikes": 0, "id": "12130", "isLikedByMe": 0, "likes": 12, "parentId": null, "questionId": 6468, "replies": [ { "__typename": "QuestionComment", "comment": "O2 sats are supposedly falsely high in CO poisoning as the sats probe detects 'bound' haemoglobin, which is the case of CO it strongly binds.", "createdAt": 1683888578, "dislikes": 0, "id": "24193", "isLikedByMe": 0, "likes": 2, "parentId": 12130, "questionId": 6468, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Witzelsucht", "id": 24993 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Anterior Jaundice", "id": 4508 } }, { "__typename": "QuestionComment", "comment": "So much wrong. Similarly an Arterial ABG would also show MetHB - wtf\n", "createdAt": 1670515209, "dislikes": 1, "id": "15147", "isLikedByMe": 0, "likes": 3, "parentId": null, "questionId": 6468, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Loose Contusion", "id": 20660 } }, { "__typename": "QuestionComment", "comment": "QUESENG(ineering)", "createdAt": 1683795315, "dislikes": 1, "id": "24065", "isLikedByMe": 0, "likes": 1, "parentId": null, "questionId": 6468, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Amaurosis Fugaxlegomenon", "id": 26260 } }, { "__typename": "QuestionComment", "comment": "for the love of all that is fuck, WHY does he have a severe headache?????????????????", "createdAt": 1685135382, "dislikes": 0, "id": "26463", "isLikedByMe": 0, "likes": 2, "parentId": null, "questionId": 6468, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Imran", "id": 20807 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nCarbon monoxide is a tasteless, odourless and invisible gas that may be produced by fires, faulty gas appliances and fuel-burning heaters. Signs and symptoms include confusion, nausea, vomiting, hypotension and dizziness. Pulse oximetry typically shows close to 100% oxygen saturations as monitors cannot differentiate between haemoglobin bound to oxygen or carbon monoxide. A blood gas will show high levels of carboxyhaemoglobin, and breath tests can be used to measure exhaled carbon monoxide. High-flow oxygen is the mainstay of treatment, with hyperbaric oxygen considered for certain high risk patients. \n \n\n# Definition\n \nCarbon monoxide poisoning is a serious and potentially fatal condition caused by acute or chronic inhalation of carbon monoxide gas. This gas is colourless and odourless, and can only be detected by equipment such as carbon monoxide alarms. It is produced by the incomplete combustion of fuel (when insufficient oxygen is present), for example in faulty heaters or cooking equipment.\n \n# Epidemiology\n \nIn England, there are approximately 4000 A&E attendances per year with carbon monoxide poisoning and approximately 40 deaths. Around half of cases are due to accidental exposure and around 40% are due to self-harm (e.g. from intentional inhalation of exhaust fumes in an enclosed space). \n\nPoisoning is more common in winter when heating equipment is more likely to be used, and is more common in groups affected by socio-economic deprivation.\n\nSome patient groups are more sensitive to the effects of carbon monoxide poisoning, including:\n\n- The elderly\n- Young children\n- Pregnant women \n- People with anaemia\n- People with cardiovascular disease\n\n# Aetiology\n\nInhaled carbon monoxide binds to haemoglobin with a much greater affinity than oxygen, forming carboxyhaemoglobin. This causes tissue hypoxia, especially affecting organ systems with a high oxygen demand such as the central nervous system and the cardiovascular system.\n\n**Prevention of carbon monoxide poisoning:**\n\n- Carbon monoxide alarms should be fitted in the home\n- Gas appliances should be correctly installed and be regularly serviced\n- Vulnerable patients (e.g. disabled or elderly patients) may be entitled to free annual gas safety checks\n- Landlords have a legal duty to ensure gas appliances are checked at least yearly\n- Do not burn charcoal indoors for cooking or heating\n- Do not use gas appliances if you suspect they may be faulty\n\n# Signs and Symptoms\n\n- Headache\n- Dizziness\n- Lethargy\n- Flushing\n- Myalgia and weakness\n- Confusion\n- Nausea and vomiting\n- Cherry red skin (rare)\n- Tachycardia and hypotension\n- Seizures\n\n# Differential Diagnosis\n \n- **Migraine:** headache is the predominant symptom of many cases of carbon monoxide poisoning; migraine is more likely to be associated with aura, photophobia and phonophobia\n- **Viral infections:** cause overlapping symptoms of headache and myalgia, may have other symptoms such as cough or fever not seen in carbon monoxide poisoning\n- **Diabetic ketoacidosis:** may have similar symptoms of nausea and vomiting, lethargy and weakness; blood glucose will be high with raised ketones\n \n# Investigations\n\n**Bedside tests:**\n\n- **Pulse oximetry** is likely to show close to 100% oxygen saturations; this is artifactual as the devices cannot differentiate carboxyhaemoglobin and oxyhaemoglobin.\n- A **blood gas** (either venous or arterial) should be taken to confirm the diagnosis by measuring carboxyhaemoglobin\n - The normal level in non-smokers is 1–2%\n - In smokers 5-10% is normal (heavy smokers can tolerate up to 15%)\n - Carboxyhaemoglobin of 10% or more is usually indicative of carbon monoxide poisoning\n - Toxicity usually manifests at levels of 15-20%\n - Carboxyhaemoglobin of 20% or higher is usually associated with severe cerebral or cardiac ischaemia\n- An **ECG** should be done to look for ischaemic changes\n- **Capillary blood glucose** to rule out hypoglycaemia or hyperglycaemia as a cause for lethargy and confusion\n\n**Blood tests:** \n\n- **FBC** for anaemia\n- **U&Es** for renal impairment\n- **CK** for rhabdomyolysis\n- **Troponin** for myocardial ischaemia\n- **Lactate** - may indicate concurrent cyanide exposure if high in the context of smoke exposure\n\n# Management\n \n- Take an **A to E approach** and ensure the airway is protected in the first instance\n- Administer **100% oxygen** via a tight-fitting face mask (if high-flow nasal cannulae available these can be used to administer up to 60L/min oxygen)\n- Continue high-flow oxygen until any symptoms have resolved and carboxyhaemoglobin levels are 2% or lower in non-smokers or 10% or lower in smokers\n- Correct hypotension with **IV fluids**\n- Contact the **National Poisons Information Service** (NPIS) if advice required\n- In certain severe cases (e.g. carboxyhaemoglobin > 25%) **hyperbaric oxygen therapy** may be considered however its use is currently not recommended by the NPIS\n- **Inform the local Health Protection Team** who will coordinate services to address the source of carbon monoxide poisoning\n\n# Complications\n\nMost patients will recover fully from carbon monoxide poisoning, although in a minority of people (generally those who have had severe or prolonged exposure) neuropsychiatric complications may develop, including:\n\n- Emotional lability and personality change\n- Difficulty concentrating\n- Insomnia\n- Lethargy\n- Movement disorders such as chorea and Parkinsonism\n- Memory impairment and dementia\n- Psychosis\n- Neuropathy\n\n# NICE Guidelines\n\n[NICE CKS - Carbon Monoxide Poisoning](https://cks.nice.org.uk/topics/carbon-monoxide-poisoning/)\n\n# References\n \n[RCEM Learning - Carbon Monoxide Poisoning](https://www.rcemlearning.co.uk/reference/carbon-monoxide-poisoning/)\n\n[London Fire Brigade - Carbon Monoxide Safety](https://www.london-fire.gov.uk/safety/the-home/carbon-monoxide-safety/)", "files": null, "highlights": [], "id": "661", "pictures": [], "typeId": 2 }, "chapterId": 661, "demo": null, "entitlement": null, "id": "712", "name": "Emergency Management of Carbon Monoxide poisoning", "status": null, "topic": { "__typename": "Topic", "id": "39", "name": "Emergency Medicine", "typeId": 2 }, "topicId": 39, "totalCards": 12, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "712", "name": "Emergency Management of Carbon Monoxide poisoning" } ], "demo": false, "description": null, "duration": 311.77, "endTime": null, "files": null, "id": "116", "live": false, "museId": "fyt23zP", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/ED.png", "title": "Emergency Management of Carbon Monoxide poisoning", "userViewed": false, "views": 41, "viewsToday": 0 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "712", "name": "Emergency Management of Carbon Monoxide poisoning" } ], "demo": false, "description": null, "duration": 4524.91, "endTime": null, "files": null, "id": "312", "live": false, "museId": "vf6znRM", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/oncology.png", "title": "Quesmed Tutorial: Drug Toxicity and Overdose", "userViewed": false, "views": 477, "viewsToday": 25 } ] }, "conceptId": 712, "conditions": [], "difficulty": 2, "dislikes": 29, "explanation": null, "highlights": [], "id": "6468", "isLikedByMe": 0, "learningPoint": "Carbon monoxide poisoning often presents with headache, confusion, and respiratory distress, despite normal oxygen saturation readings.", "likes": 1, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 75-year-old man presents to the Emergency Department (ED), having been found collapsed at his home by his wife. His wife tells you that they recently moved to a new house and had been moving things into the basement.\n\nOn assessment, he reports a severe headache and has a GCS of 14. On examination, there is significant accessory muscle usage, tachypnoea and vesicular breath sounds are heard throughout both lung fields. Oxygen saturations are 96% on room air. An arterial blood gas (ABG) shows a PaO₂ of 11.5kPa (>11kPa) and a PCO₂ of 5.1kPa (4.5-6kPa).\n\nWhich of the following is the most likely diagnosis?", "sbaAnswer": [ "a" ], "totalVotes": 5098, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": true, "explanation": "Given his underlying COPD and age, this patient has high risk characteristics associated with his pneumothorax. As it is greater than 2cm (i.e. amenable to drainage), guidelines suggest that chest drain insertion is the best management", "id": "32343", "label": "a", "name": "Chest drain insertion", "picture": null, "votes": 4462 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Insertion of a large bore cannula into the second intercostal space on the affected side would be indicated if the patient had a tension pneumothorax", "id": "32346", "label": "d", "name": "Emergency thoracentesis", "picture": null, "votes": 135 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This would be indicated if the patient was not breathless, the pneumothorax was less than 2cm and the patient was not keen on interventional management", "id": "32345", "label": "c", "name": "High flow oxygen and observation", "picture": null, "votes": 77 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Aspiration is not recommended for patients with a pneumothorax who have high risk characteristics", "id": "32344", "label": "b", "name": "Aspiration", "picture": null, "votes": 602 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is not appropriate given this patient's age and underlying lung disease, which would be considered as high risk characterstics according to BTS guidelines, necessitating chest drain insertion", "id": "32347", "label": "e", "name": "Discharge and review in ambulatory care clinic the next day", "picture": null, "votes": 23 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n \nA pneumothorax is characterised by the abnormal presence of air in the pleural cavity, which may be spontaneous or traumatic in origin. Key signs and symptoms include sudden-onset shortness of breath, pleuritic chest pain, reduced chest expansion and reduced or absent breath sounds on the affected side. Chest X-ray is the key diagnostic investigation (although in cases of tension pneumothorax the diagnosis should be clinical). Management decisions depend on the size of the pneumothorax, the patient's clinical condition and their wishes. Options include conservative management, needle aspiration, chest drain insertion or an ambulatory device. In cases of tension pneumothorax needle decompression is the initial emergency management.\n \n# Definition\n \nA pneumothorax refers to a collection of air in the pleural cavity which may cause collapse of the underlying lung parenchyma. \n\n# Classification\n\n- They may be **spontaneous** or **traumatic** (including iatrogenic causes).\n\n- Spontaneous pneumothoraces can be further divided into **primary** pneumothoraces (in patients without an underlying lung disease) and **secondary** (in patients with underlying lung diseases such as COPD or asthma).\n\n- Patients aged over 50 years old with a significant smoking history who present with a spontaneous pneumothorax are generally considered to have a secondary pneumothorax. \n\n- A **tension pneumothorax** occurs when the defect in the pleura that has led to the pneumothorax creates a one-way valve effect whereby air can enter the pneumothorax but not leave it.\n - This causes the pneumothorax to progressively expand, putting pressure on the heart and great vessels and causing **mediastinal shift**\n - This is a medical emergency that rapidly leads to cardiac arrest if untreated\n \n\n# Signs and Symptoms\n \nThere may be no signs or symptoms (small pneumothoraces may be detected incidentally on imaging) however in an emergency presentation these may include:\n\n- Sudden onset shortness of breath\n- Pleuritic chest pain\n- Dry cough\n- Tachypnoea and increased work of breathing\n\nThe following signs will be found on the affected side of the chest:\n\n- Unilateral reduced expansion\n- Unilateral hyper-resonance to percussion\n- Reduced or absent breath sounds\n- Reduced vocal resonance or tactile vocal fremitus\n \nPatients with a tension pneumothorax may also have:\n\n- Tracheal deviation to the contralateral side\n- Tachycardia\n- Hypotension\n- Distended neck veins\n\n# Investigations\n \nPatients with a suspected tension pneumothorax should be diagnosed and treated with needle decompression based on the clinical picture, with no delay for investigations.\n\nFor other patients, an **erect PA chest X-ray** is diagnostic. \n\n [lightgallery]\n \n\n [lightgallery1]\n \n**CT chest** should be used in high-risk patients where it is not clear from the chest X-ray whether it is safe to place a chest drain.\n\n**Arterial blood gases** are not usually indicated however they may be of use in certain situations e.g. titrating oxygen in a patient with COPD and low saturations.\n\n# Management \n\n**Tension Pneumothoraces:** \n\n- If a tension pneumothorax is suspected, emergency management is to decompress this by inserting a large-bore cannula into the second intercostal space on the affected side, mid-clavicular line, or fifth intercostal space, mid-axillary line if a traumatic cause is suspected, as per ATLS guidelines.\n\n\n- If this fails, open thoracostomy should be done immediately\n- After initial emergency decompression, a chest drain should be inserted\n\nFor **primary or secondary spontaneous pneumothoraces**, management is guided by the 2023 BTS Guidelines as summarised below:\n\n [lightgallery2]\n \n- **Conservative management** involves no intervention for the pneumothorax, and patients are monitored to ensure they do not deteriorate and any symptoms resolve\n- **Ambulatory devices** (e.g. pleural vents) are one-way valves which allow air to leave the pneumothorax but not re-enter it\n - They can be inserted in a simple procedure under local anaesthetic\n - Patients can then be followed up as outpatients\n- Symptomatic patients with larger pneumothoraces (usually 2cm or larger on CXR - CT may be used if unclear) or those with high-risk features (significant hypoxia, bilateral pneumothoraces, underlying lung disease, 50 or older with a significant smoking history, haemopneumothorax) require a **chest drain** and admission for monitoring\n- In symptomatic patients without high-risk features but with pneumothoraces large enough for treatment (2cm or larger), management depends on their priorities\n - Conservative management allows avoidance of any procedure\n - Both needle aspiration and ambulatory devices offer more rapid symptomatic relief (ambulatory device insertion may not be available in all hospitals) \n\n\n**Follow up:**\n\n- All patients should be reviewed in an outpatient clinic 2–4 weeks after presenting with a pneumothorax (with repeat chest imaging)\n- Patients should be advised on smoking cessation if relevant\n - Advise patients not to fly until 7 days after chest imaging has confirmed resolution of the pneumothorax\n - Advise patients they should not take part in underwater diving for life (except in rare cases where they have been treated with bilateral open surgical pleurectomy)\n \n# References\n \n[British Thoracic Society Guidelines](https://thorax.bmj.com/content/thoraxjnl/78/11/1143.full.pdf)\n\n[Royal College of Emergency Medicine - Spontaneous Pneumothorax](https://www.rcemlearning.co.uk/reference/spontaneous-pneumothorax/)\n\n[Radiopaedia - Tension Pneumothorax](https://radiopaedia.org/articles/tension-pneumothorax)\n\n[Pleural Vent Ambulatory Devices](https://www.nth.nhs.uk/resources/pleural-vent-ambulatory-device/)", "files": null, "highlights": [], "id": "331", "pictures": [ { "__typename": "Picture", "caption": "BTS Pneumothorax Pathway", "createdAt": 1704194603, "id": "2336", "index": 2, "name": "BTS Pneumothorax Flowchart.png", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/rshwwsgi1704194603121.jpg", "path256": "images/rshwwsgi1704194603121_256.jpg", "path512": "images/rshwwsgi1704194603121_512.jpg", "thumbhash": "NxgGDQS+meF5CWxWW3qHl6FpH/jz", "topic": { "__typename": "Topic", "id": "32", "name": "Respiratory", "typeId": 2 }, "topicId": 32, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "A left sided tension pneumothorax.", "createdAt": 1665036197, "id": "1031", "index": 1, "name": "Tension pneumothorax.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/pxbwgb3x1665036171696.jpg", "path256": "images/pxbwgb3x1665036171696_256.jpg", "path512": "images/pxbwgb3x1665036171696_512.jpg", "thumbhash": "IggOBoCLtohgeZh3h3Z4d3eHAAAAAAA=", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "A large right sided pneumothorax.", "createdAt": 1665036184, "id": "716", "index": 0, "name": "Pneumothorax.png", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/np3ie7n71665036171715.jpg", "path256": "images/np3ie7n71665036171715_256.jpg", "path512": "images/np3ie7n71665036171715_512.jpg", "thumbhash": "HQgKBwBH/JeSinmOd4Vnp3h2CAAAAAAA", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 4 }, "chapterId": 331, "demo": null, "entitlement": null, "id": "698", "name": "Emergency Management of Pneumothorax", "status": null, "topic": { "__typename": "Topic", "id": "39", "name": "Emergency Medicine", "typeId": 2 }, "topicId": 39, "totalCards": 34, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "698", "name": "Emergency Management of Pneumothorax" } ], "demo": false, "description": null, "duration": 580.93, "endTime": null, "files": null, "id": "284", "live": false, "museId": "fY1cqYh", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/respiratory.png", "title": "Pneumothorax 3", "userViewed": false, "views": 171, "viewsToday": 15 } ] }, "conceptId": 698, "conditions": [], "difficulty": 1, "dislikes": 1, "explanation": null, "highlights": [], "id": "6469", "isLikedByMe": 0, "learningPoint": "In patients with a significant pneumothorax, especially those with COPD, chest drain insertion may be required.", "likes": 5, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 65-year-old patient with a background of chronic obstructive pulmonary disease (COPD) presents with acute onset chest pain and shortness of breath.\n\nOn assessment, he has decreased chest expansion in the left upper zones with associated hyper-resonance and reduced air entry. A chest x-ray confirms a 2.5 cm left sided apical pneumothorax.\n\nWhich of the following is the next best step in management.", "sbaAnswer": [ "a" ], "totalVotes": 5299, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "300mg of amiodarone is used in cardiac arrest secondary to VF or VT. However, it is only given after the 3rd shock", "id": "32351", "label": "d", "name": "Administer 300mg of amiodarone (IV)", "picture": null, "votes": 1432 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This patient has a shockable rhythm, so it is important to administer a shock before recommencing chest compression", "id": "32349", "label": "b", "name": "Continue CPR for 2 minutes", "picture": null, "votes": 318 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "In the context of a patient in cardiac arrest, a regular broad-complex tachycardia is suggestive of pulseless ventricular tachycardia (pVT). Along with ventricular fibrillation (VF), pVT is an indication for defibrillation (unsynchronised cardioversion) at a setting of 200J", "id": "32348", "label": "a", "name": "Unsynchronised cardioversion at an energy setting of 200J", "picture": null, "votes": 2808 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Along with amiodarone, adrenaline is given after the 3rd shock in patients with cardiac arrest secondary to VF or pVT", "id": "32350", "label": "c", "name": "Administer 10mg of 1 in 10,000 adrenaline (IV)", "picture": null, "votes": 208 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Amiodarone and adrenaline are given in cases of cardiac arrest secondary to VF or VT; however, only after the 3rd shock", "id": "32352", "label": "e", "name": "Administer 300mg of amiodarone (IV) and 10mg of 1 in 10,000 adrenaline (IV)", "picture": null, "votes": 352 } ], "comments": [ { "__typename": "QuestionComment", "comment": "The question needs to make it clear whether he does or does not have a pulse at this point - this would determine whether or not we follow the ALS algorithm. ", "createdAt": 1645976434, "dislikes": 1, "id": "7747", "isLikedByMe": 0, "likes": 52, "parentId": null, "questionId": 6470, "replies": [ { "__typename": "QuestionComment", "comment": "Exactly!", "createdAt": 1653852109, "dislikes": 1, "id": "11495", "isLikedByMe": 0, "likes": 2, "parentId": 7747, "questionId": 6470, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "MannyOA", "id": 19743 } }, { "__typename": "QuestionComment", "comment": "I don't think you need to know he has a pulse at this stage, from the stem you know he's in VT and receiving CPR - whether or not he has a pulse he's going to need a shock. Although I do agree the stem should probably make it clearer he's in VT and not another rhythm. ", "createdAt": 1680275817, "dislikes": 8, "id": "21050", "isLikedByMe": 0, "likes": 0, "parentId": 7747, "questionId": 6470, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Axillary Gas", "id": 20974 } }, { "__typename": "QuestionComment", "comment": "if he has no pulse, you'd do shock. if he does have a pulse, it becomes VT so you wont do ALS.", "createdAt": 1682079458, "dislikes": 0, "id": "22359", "isLikedByMe": 0, "likes": 0, "parentId": 7747, "questionId": 6470, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Syndrome RNA", "id": 6187 } }, { "__typename": "QuestionComment", "comment": "“A man has a cardiac arrest in hospital” means no pulse chief, VT with pulse is not a cardiac arrest ", "createdAt": 1682974067, "dislikes": 0, "id": "23166", "isLikedByMe": 0, "likes": 9, "parentId": 7747, "questionId": 6470, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Liam", "id": 14761 } }, { "__typename": "QuestionComment", "comment": "tachycardia outpatient out here doing CPR on people with pulses...", "createdAt": 1709050479, "dislikes": 0, "id": "43011", "isLikedByMe": 0, "likes": 0, "parentId": 7747, "questionId": 6470, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Ale", "id": 20565 } }, { "__typename": "QuestionComment", "comment": "The stem says he's in cardiac arrest, i.e. pulseless... It could be clearer but that's absolutely clear enough to me. Also the option of synchronised cardioversion (treatment of choice for VT with a pulse with haemodynamic compromise - like collapse in this patient) is not an option. You're really missing the point of the question if you got this wrong guys", "createdAt": 1709659809, "dislikes": 0, "id": "43904", "isLikedByMe": 0, "likes": 0, "parentId": 7747, "questionId": 6470, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Gastro Complement", "id": 10404 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Tachycardia Outpatient", "id": 8178 } }, { "__typename": "QuestionComment", "comment": "VT needs a synchronised shock not unsycn", "createdAt": 1685352727, "dislikes": 0, "id": "26952", "isLikedByMe": 0, "likes": 9, "parentId": null, "questionId": 6470, "replies": [ { "__typename": "QuestionComment", "comment": "That's VT WITH a pulse, the case is describing WITHOUT a pulse as he has \"had a cardiac arrest\" and is \"receiving CPR\". Unsynchronised cardioversion is another way of saying defibrillation", "createdAt": 1709659896, "dislikes": 0, "id": "43906", "isLikedByMe": 0, "likes": 1, "parentId": 26952, "questionId": 6470, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Gastro Complement", "id": 10404 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Serotonin Embolism", "id": 12201 } }, { "__typename": "QuestionComment", "comment": "Questioning why they couldn't have just labelled this as \"requires shock\", in a real life situation I'm not going to state he needs unsynchronised cardioversion at 200j ", "createdAt": 1705069281, "dislikes": 0, "id": "38572", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6470, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "SimbaStatin", "id": 23115 } }, { "__typename": "QuestionComment", "comment": "You guys need to read the question properly and stop disliking questions you just get wrong lmao", "createdAt": 1709659928, "dislikes": 5, "id": "43907", "isLikedByMe": 0, "likes": 1, "parentId": null, "questionId": 6470, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Gastro Complement", "id": 10404 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nAdvanced Life Support (ALS) describes an algorithmic approach to the management of a cardiac arrest by those trained in delivering it. It involves early recognition, taking steps to secure the airway and initiate high quality chest compressions and obtaining intravenous or intraosseous access promptly. Cardiac monitoring should be applied to identify if the rhythm is shockable or non-shockable, which determines what treatment is given. Shockable rhythms require defibrillation, with adrenaline and amiodarone given later on; non-shockable rhythms are treated with adrenaline. \n\n# Definition\n\nAdvanced Life Support is a guideline-based approach to treating patients who have had a cardiac arrest to improve the chances of successful resuscitation and survival. \n\n# Epidemiology\n\nCardiac arrests can be categorised into those that occur out of hospital and those that occur in hospitals. Most out of hospital cardiac arrests occur at home (72%) and 8 out of 10 are due to a cardiac cause. In 7 out of 10 cases resuscitation is attempted, however only 9% of these patients survive to hospital discharge.\n\nIn hospital cardiac arrests tend to occur in older patients (average age 70), with return of spontaneous circulation (ROSC) achieved in 53% of patients. However, only 24% of patients survive to hospital discharge. \n\n# Aetiology\n\nCauses of cardiac arrest can be remembered using the 4Hs and 4Ts mnemonic:\n\n- Hypoxia\n- Hypovolaemia\n- Hypo/hyperkalaemia (and other electrolyte abnormalities)\n- Hypo/hyperthermia\n- Thromboembolism (pulmonary embolism or coronary artery thrombosis)\n- Tamponade\n- Tension pneumothorax\n- Toxins \n\n# Classification\n\nCardiac arrests are managed differently depending on whether the rhythm is **shockable** or **non-shockable**.\n\n**Shockable** rhythms are:\n\n- **Pulseless Ventricular Tachycardia (pVT)** - regular broad complex tachycardia\n- **Ventricular Fibrillation (VF)** - chaotic irregular deflections of varying amplitude\n\n**Non-shockable** rhythms are:\n\n- **Pulseless Electrical Activity (PEA)** - electrical activity that should produce a pulse, but doesn't due to absent or insufficient cardiac output \n- **Asystole** - no detectable electrical activity \n\n# Management\n\n## Management for all cardiac arrests\n\n- **Rapid recognition** of cardiac arrest (ineffective breathing or absent central pulse) is key \n- The first responder should start **cardiopulmonary resuscitation (CPR)** immediately and **call for help**, for example by asking for a cardiac arrest call (2222) to be put out\n- Every two minutes CPR should be stopped for a **rhythm check**\n- Secure the **airway**\n - Oropharyngeal or nasopharyngeal airways may be used initially with a bag valve mask for ventilation\n - Either a supraglottic airway (laryngeal mask airway or i-gel) or an endotracheal tube should be inserted\n - Tracheal intubation should only be attempted by those with a high success rate\n - Confirm the position of the endotracheal tube with waveform capnography (measuring end-tidal carbon dioxide)\n- Give **high-flow oxygen**\n- Gain IV access - if not possible the intraosseous (IO) route can be used\n- Consider reversible causes (as above) and treat as appropriate\n - IV or IO fluids if secondary to hypovolaemia\n - Thrombolysis if secondary to pulmonary embolism\n - Point of care ultrasound (POCUS) may be used to investigate for cardiac tamponade and pneumothorax\n \n## Management of shockable rhythms\n\n- **Defibrillation** should be delivered as early as possible\n - Remove oxygen (ventilator circuits can remain attached)\n - Ensure no one is touching the patient before the shock is delivered\n - No specific energy is specified in guidelines; anything from 120 to 360 joules is suitable\n- Immediately resume CPR after the shock is delivered for two minutes\n- After 3 shocks, give 300mg amiodarone and 1mg adrenaline IV or IO\n- Give repeat doses of adrenaline every 3-5 minutes (i.e. every other cycle)\n- After 5 shocks, give a further dose of amiodarone 150mg\n\n## Management of non-shockable rhythms \n\n- Give adrenaline 1mg IV or IO as soon as possible\n- Give repeat doses of adrenaline every 3-5 minutes (as per shockable rhythms)\n- Defibrillation and amiodarone are not used unless the rhythm changes to a shockable one\n\n# NICE Guidelines\n\n[NICE CKS - Advanced Life Support](https://cks.nice.org.uk/topics/cardiac-arrest-out-of-hospital-care/management/advanced-life-support-adult/)\n\n# References\n\n[Resuscitation Council UK - Adult Advanced Life Support Guidelines](https://www.resus.org.uk/library/2021-resuscitation-guidelines/adult-advanced-life-support-guidelines)\n \n[Resuscitation Council UK - Epidemiology of Cardiac Arrest](https://www.resus.org.uk/library/2021-resuscitation-guidelines/epidemiology-cardiac-arrest-guidelines)\n\n[BNF Treatment Summaries - Cardiopulmonary Resuscitation](https://bnf.nice.org.uk/treatment-summaries/cardiopulmonary-resuscitation/)", "files": null, "highlights": [], "id": "697", "pictures": [], "typeId": 2 }, "chapterId": 697, "demo": null, "entitlement": null, "id": "725", "name": "Advanced Life Support", "status": null, "topic": { "__typename": "Topic", "id": "39", "name": "Emergency Medicine", "typeId": 2 }, "topicId": 39, "totalCards": 10, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 725, "conditions": [], "difficulty": 2, "dislikes": 27, "explanation": null, "highlights": [], "id": "6470", "isLikedByMe": 0, "learningPoint": "Pulseless ventricular tachycardia (VT) is a shockable cardiac arrest rhythm, and defibrillation with unsynchronized cardioversion at an energy setting of 200J is used to deliver an electrical shock to attempt to restore a normal heart rhythm.", "likes": 5, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 56-year-old man has a cardiac arrest in hospital. Following prompt commencement of cardio-pulmonary resuscitation (CPR), he is found to have a regular broad-complex tachycardia at the first rhythm check.\n\nWhich of the following is the next best step in management?", "sbaAnswer": [ "a" ], "totalVotes": 5118, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "TMA is characterised by the formation of thrombi in the small vasculature and associated microangiopathic haemolytic anaemia (MAHA) due to fragmentation of red blood cells. TMA alone would not be associated with clotting abnormalities (i.e. raised PT and APTT)", "id": "32354", "label": "b", "name": "Secondary thrombotic microangiopathy (TMA) due to infection", "picture": null, "votes": 195 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "ITP is characterised by an isolated thrombocytopenia in the absence of an identifiable cause. Therefore, clotting would be normal", "id": "32356", "label": "d", "name": "Immune thrombocytopenic purpura (ITP)", "picture": null, "votes": 253 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Sepsis and trauma can lead to low platelets due to a 'consumptive state'. However, this would not be associated with clotting abnormalities", "id": "32357", "label": "e", "name": "Consumptive thrombocytopaenia due to infection", "picture": null, "votes": 203 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "MAHA is associated with intravascular haemolysis and can be seen in conjunction with a thrombotic microangiopathy (TMA) or disseminated intravascular coagulation (DIC). MAHA alone (e.g. due to haemolysis secondary to prosthetic heart valves) is not associated with low platelets or clotting abnormalities", "id": "32355", "label": "c", "name": "Microangiopathic haemolytic anaemia (MAHA)", "picture": null, "votes": 126 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "DIC is a life-threatening complication of sepsis. It results from over-activation of the coagulation pathway leading to increased risk of thrombosis and subsequent risk of bleeding due to depletion of clotting factors and platelets. It is characterised by raised PT, APTT and D-Dimer, and low platelet count and fibrinogen level. Treatment is supportive with blood products and treatment of the underlying cause", "id": "32353", "label": "a", "name": "Disseminated intravascular coagulation (DIC)", "picture": null, "votes": 4428 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\n\nDisseminated intravascular coagulation (DIC) is a haematological emergency, characterized initially by the inappropriate activation of the clotting cascades, leading to thrombus formation (in microvasculature) and depletion of clotting factors and platelets, which then results in bleeding. Key signs and symptoms include excessive bleeding (such as epistaxis, gingival bleeding, haematuria, and bleeding from cannula sites), fever, confusion, and potential coma. The physical signs include petechiae, bruising, confusion, and hypotension. Key investigations include testing for thrombocytopenia, increased prothrombin time, increased fibrin degradation products (such as D-dimer), and decreased fibrinogen. Management strategies revolve around treating the underlying cause and supportive care.\n\n\n# Definition\n\n\nDisseminated intravascular coagulation (DIC) is a complex condition that describes the inappropriate activation of the clotting cascades, resulting in thrombus formation and subsequently leading to the depletion of clotting factors and platelets.\n\n\n# Epidemiology\n\n\nDIC often occurs in the context of severe systemic disease (see aetiology below). DIC is often encountered in a hospital setting, particularly in intensive care units, surgical wards, and obstetric units due to the high prevalence of associated risk factors. It is associated with a high mortality rate, with the outcome is largely dependent on the prompt diagnosis and treatment of the underlying cause.\n\n\n# Aetiology\n\n\n- Major trauma or burns\n- Multi-organ failure\n- Severe sepsis or infection\n- Severe obstetric complications\n- Solid tumours or haematological malignancies \n- **Acute promyelocytic leukaemia (APL)** is an uncommon subtype of AML that is associated with DIC \n- **Note**: This comes up frequently in written exams\n\n\n# Signs and Symptoms\n\n\nPatients with DIC commonly present with:\n\n\n- Excessive bleeding e.g. epistaxis, gingival bleeding, haematuria, bleeding/oozing from cannula sites\n- Fever\n- Confusion\n- Potential coma\n\n\nPhysical signs include:\n\n\n- Petechiae\n- Bruising\n- Confusion\n- Hypotension\n\n\n# Differential Diagnosis\n\n\nThe differential diagnosis for DIC includes conditions that cause similar symptoms such as:\n\n\n- Other coagulopathies, which may also present with excessive bleeding and bruising\n- Sepsis, which can cause fever, confusion, and hypotension\n- Multi-organ failure, which can cause a similar range of systemic symptoms including confusion and hypotension\n\n\n# Investigations\n\n\n- Blood tests, including:\n- FBC (thrombocytopenia)\n- Blood film may show schistocytes due to microangiopathic haemolytic anaemia (MAHA)\n- Raised d-dimer (a fibrin degradation product)\n- Clotting profile - increased prothrombin time (due to consumption of clotting factors), increased APTT, decreased fibrinogen (consumed due to microvascular thrombi)\n\n\n# Management\n\n\nManagement of DIC is primarily focused on treating the underlying cause. Supportive care is also essential to manage symptoms and prevent complications. This may include transfusions of platelets or clotting factors, and in some cases, anticoagulation therapy may be necessary.", "files": null, "highlights": [], "id": "387", "pictures": [], "typeId": 2 }, "chapterId": 387, "demo": null, "entitlement": null, "id": "391", "name": "Disseminated intravascular coagulation (DIC)", "status": null, "topic": { "__typename": "Topic", "id": "8", "name": "Haematology", "typeId": 2 }, "topicId": 8, "totalCards": 3, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "391", "name": "Disseminated intravascular coagulation (DIC)" } ], "demo": false, "description": null, "duration": 123.67, "endTime": null, "files": null, "id": "97", "live": false, "museId": "j2JJJgK", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/hematology.png", "title": "Disseminated intravascular coagulation (DIC) 1", "userViewed": false, "views": 151, "viewsToday": 17 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "391", "name": "Disseminated intravascular coagulation (DIC)" } ], "demo": false, "description": null, "duration": 238.23, "endTime": null, "files": null, "id": "98", "live": false, "museId": "CkStHE2", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/hematology.png", "title": "Disseminated intravascular coagulation (DIC) 2", "userViewed": false, "views": 163, "viewsToday": 12 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "391", "name": "Disseminated intravascular coagulation (DIC)" } ], "demo": false, "description": null, "duration": 2943.27, "endTime": null, "files": null, "id": "319", "live": false, "museId": "dY59e7q", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/hematology.png", "title": "Quesmed Tutorial: Haematology", "userViewed": false, "views": 940, "viewsToday": 39 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "391", "name": "Disseminated intravascular coagulation (DIC)" } ], "demo": false, "description": null, "duration": 3551.42, "endTime": null, "files": null, "id": "320", "live": false, "museId": "xsyPfpT", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/hematology.png", "title": "Quesmed Tutorial: Haemolytic Anaemia", "userViewed": false, "views": 188, "viewsToday": 22 } ] }, "conceptId": 391, "conditions": [], "difficulty": 1, "dislikes": 0, "explanation": null, "highlights": [], "id": "6471", "isLikedByMe": 0, "learningPoint": "Disseminated intravascular coagulation (DIC) is a severe complication of sepsis, characterised by coagulopathy and multi-organ dysfunction.", "likes": 6, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 56-year-old man is being treated for Escherichia coli septicaemia secondary to pyelonephritis. He is currently on day three of treatment with gentamicin but continues to have fevers and rising inflammatory markers. In addition, his most recent blood tests show a low platelet count, low fibrinogen and raised prothrombin (PT) and activated partial thromboplastin (aPTT) times.\n\nWhich of the following is the most likely explanation for the patient's blood test results?", "sbaAnswer": [ "a" ], "totalVotes": 5205, "typeId": 1, "userPoint": null }

[]

{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "There is no indication to restart a VRII if the patient's blood glucose is well controlled following conversion to their usual subcutaneous insulin regime", "id": "32360", "label": "c", "name": "Start variable rate insulin infusion (VRII)", "picture": null, "votes": 357 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This patient is not hypoxic or in respiratory distress so there is no indication for an ABG", "id": "32362", "label": "e", "name": "Arterial blood gas (ABG)", "picture": null, "votes": 1508 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Ongoing confusion in a paediatric patient who has been treated for DKA is concerning for the development of cerebral oedema. A CT head is the best investigation to exclude this", "id": "32358", "label": "a", "name": "Computed tomography (CT) head", "picture": null, "votes": 2890 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Hypothyroidism is an important cause of acute confusion and would be part of a routine confusion screen. However, in this case, it is most vital to exclude cerebral oedema given the history of recently treated DKA in a paediatric patient", "id": "32361", "label": "d", "name": "Check thyroid function", "picture": null, "votes": 199 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "There is no indication to restart a FRII if the patient's blood glucose is well controlled following conversion to their usual subcutaneous insulin regime", "id": "32359", "label": "b", "name": "Restart fixed rate insulin infusion (FRII)", "picture": null, "votes": 168 } ], "comments": [ { "__typename": "QuestionComment", "comment": "I thought this could be hypoglycaemia..... happened to me when i was in DKA ", "createdAt": 1677159942, "dislikes": 1, "id": "18769", "isLikedByMe": 0, "likes": 6, "parentId": null, "questionId": 6472, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Gallbladder Tachycardia", "id": 7969 } }, { "__typename": "QuestionComment", "comment": "I thought this could be hypoglycaemia..... happened to me when i was in DKA ", "createdAt": 1677159942, "dislikes": 0, "id": "18770", "isLikedByMe": 0, "likes": 5, "parentId": null, "questionId": 6472, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Gallbladder Tachycardia", "id": 7969 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n \nDiabetic ketoacidosis (DKA) is a life-threatening medical emergency characterised by hyperglycemia, acidosis and ketosis. DKA may be triggered by infection, dehydration or fasting, or may be the initial presentation of Type 1 diabetes. Symptoms include a 'fruity' breath odour, vomiting, dehydration, abdominal pain and altered mental state. Key investigations include blood glucose and ketones, urea and electrolytes and a venous blood gas to check pH. Management involves IV fluids and a fixed rate insulin infusion, with close monitoring both clinically and biochemically. Important complications that should be monitored for include cerebral oedema, hypoglycaemia and hypokalaemia. \n\n# Definition\n \nDiabetic ketoacidosis (DKA) is a medical emergency characterised by the triad of:\n \n - Hyperglycemia (blood glucose >11 mmol/L)\n - Ketosis (blood ketones >3 mmol/L or urinary ketones ++ or higher)\n - Acidosis (pH <7.3 or bicarbonate <15 mmol/L)\n - Note: patients on SGLT-2 inhibitors may present with euglycemic DKA (where glucose is normal)\n \n\n# Epidemiology\n \nDKA is most common in individuals with Type 1 diabetes (T1DM) but around a third of cases occur in patients with Type 2 diabetes. The incidence of DKA is highest in young people aged 18-24. \n\nDKA is the leading cause of death in people aged under 58 years old with T1DM, with cerebral oedema the most common cause of mortality. However, mortality in the UK is still <1%.\n \n\n# Aetiology \n\n- DKA occurs due to insulin deficiency (absolute or relative) leading to hyperglycaemia\n- Ketones, including acetone, 3-beta-hydroxybutyrate, and acetoacetate, are produced from ketogenesis, whereby fatty acids are metabolised as an alternative energy source\n- These ketones are responsible for the acidosis seen\n- Hyperglycaemia causes an osmotic diuresis that contributes to severe dehydration as well as electrolyte imbalance\n- Vomiting and decreased fluid intake secondary to altered mental state also exacerbate dehydration\n\n**10-20% of presentations of DKA represent a first presentation of Type 1 Diabetes**\n\n**Common triggers for DKA include:**\n\n- Infections\n- Dehydration and fasting\n- Missing doses of insulin\n- Medications e.g. steroid treatment or diuretics\n- Surgery\n- Stroke or myocardial infarction\n- Alcohol excess or illicit drug use\n- Pancreatitis\n\n# Classification\n\nPatients with at least one of the following may be classified as having **severe DKA**, which should prompt consideration of referral for higher dependency care:\n\n- Blood ketones > 6mmol/L\n- Bicarbonate < 5mmol/L\n- Blood pH < 7\n- Anion gap above 16\n- Hypokalaemia on admission\n- GCS less than 12\n- Oxygen saturations < 92% in air\n- Systolic BP < 90mmHg\n- Brady or tachycardia (heart rate < 60 or > 100bpm)\n\n\n# Signs and Symptoms\n \n**Symptoms:**\n\n- Nausea and vomiting\n- Abdominal pain\n- Polyuria\n- Polydipsia\n- Weakness\n\n**Signs:**\n\n- Dry mucous membranes\n- Hypotension\n- Tachycardia\n- Altered mental state (drowsiness, confusion, coma)\n- Kussmaul's breathing (deep, sighing breathing to compensate for metabolic acidosis by blowing off carbon dioxide)\n- Fruit-like smelling breath (due to ketosis)\n\n# Investigations\n \n**Bedside tests:**\n \n - Capillary blood glucose\n - Blood or urinary ketones\n - Urine dip +/- MSU (looking for evidence of a urinary tract infection which may precipitate DKA)\n - ECG (for ischaemic changes which may precipitate DKA, or changes secondary to electrolyte imbalance e.g. hypokalaemia)\n\n**Blood tests:**\n\n- Venous blood gas (for acid-base balance)\n- Urea and electrolytes (for electrolyte imbalance and AKI)\n- Full blood count and CRP (for infection markers) \n- Blood cultures (if infection is suspected)\n- HbA1c (to assess diabetic control over recent months)\n\n**Imaging:**\n\n- Consider chest X-ray as part of septic screen (if signs of infection as a trigger for DKA)\n\n# Management\n\n**Initial management:** \n\n- Initial **A to E assessment**\n - Drowsy patients may require airway protection and an **NG tube** to prevent aspiration\n - Ensure adequate IV access\n - If hypotensive give up to 1L in **fluid boluses** then seek urgent senior input if not resolved\n - Consider urinary catheterisation and monitor fluid balance\n- **IV fluid replacement with normal saline**\n - A regimen of large volumes of IV fluid replacement given relatively quickly initially then over longer durations should be followed\n - Slower infusion rates should be considered in young adults, the elderly, those with heart or kidney failure or other serious comorbidities\n - An example in a healthy adult would be 1L over 1 hour, then 2x 1L over 2 hours, then 2x 1L over 4 hours, then 1L over 6 hours\n - **Potassium replacement** should be added after the first bag, depending on serum potassium levels, bearing in mind potassium can be infused at a maximum of 10mmol/h:\n\n| Potassium level (mmol/L) | Potassium replacement mmol/L of next infusion | \n| :---------------: | :----------------: \n| > 5.5 | Nil | \n| 3.5 - 5.5 | 40 mmol/L | \n| < 3.5 | senior review – additional potassium required | \n \n \n- After IV fluids have started, a **fixed rate insulin infusion** should be set up \n- This is provided as an infusion of 50 units of Actrapid in 50ml of 0.9% NaCl, at a rate of 0.1 units/kg/hour\n- Continue long-acting insulin if the patient is already on this \n- Investigation and management of any underlying triggers (e.g. septic screen and start antibiotics if evidence of infection)\n- Ensure **VTE prophylaxis** with low molecular weight heparin is prescribed as patients are at high risk of developing clots due to dehydration\n\n**Ongoing emergency management:**\n\n- Patients should be closely monitored with hourly blood glucose and ketones\n - The aim is for ketones to fall by > 0.5mmol/L/hour\n - Blood glucose should fall by 3 mmol/L/hour\n - If these targets are not met, the rate of insulin infusion should be continued\n- Once blood glucose is below 14, a **10% glucose infusion** should be started alongside ongoing saline and insulin\n- Regular venous blood gases should also be done to monitor potassium, bicarbonate and pH\n- DKA is considered resolved once ketones are less than 0.6 mmol/L and pH is over 7.3 \n - If at this point they are able to eat and drink, a subcutaneous regimen of insulin should be started (usually with the input of a specialist diabetes team)\n - The insulin infusion should be stopped half an hour after the first dose of subcutaneous short acting insulin has been given \n\n# References\n \n[ABCD Guidelines: The Management of Diabetic\nKetoacidosis in Adults](https://abcd.care/sites/default/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf)\n\n[RCEM - Diabetic Ketoacidosis](https://www.rcemlearning.co.uk/reference/diabetic-ketoacidosis/#1635853037528-05d8fa0f-621f)\n\n[Patient UK - Diabetic ketoacidosis](https://patient.info/doctor/diabetic-ketoacidosis#presentation)", "files": null, "highlights": [], "id": "1866", "pictures": [], "typeId": 2 }, "chapterId": 1866, "demo": null, "entitlement": null, "id": "696", "name": "Emergency Management of Diabetic Ketoacidosis", "status": null, "topic": { "__typename": "Topic", "id": "39", "name": "Emergency Medicine", "typeId": 2 }, "topicId": 39, "totalCards": 27, "typeId": null, 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"696", "name": "Emergency Management of Diabetic Ketoacidosis" } ], "demo": false, "description": null, "duration": 3685.7, "endTime": null, "files": null, "id": "629", "live": false, "museId": "Gh7FzZJ", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/ED.png", "title": "Quesmed Tutorial: Paediatric DKA", "userViewed": false, "views": 76, "viewsToday": 8 } ] }, "conceptId": 696, "conditions": [], "difficulty": 2, "dislikes": 3, "explanation": null, "highlights": [], "id": "6472", "isLikedByMe": 0, "learningPoint": "A CT scan can be used to diagnose cerebral oedema secondary to diabetic ketoacidosis (DKA), as it helps identify signs of swelling in the brain and rule out other potential complications or causes of altered mental status.", "likes": 11, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 16-year-old patient with type 1 diabetes mellitus is admitted after a short history of lethargy, vomiting and confusion. He is found to be in diabetic ketoacidosis (DKA) and is treated with IV fluids and a fixed rate insulin infusion.\n\nFollowing treatment, he meets the criteria for resolution of DKA and is safely bridged onto his normal regime of subcutaneous insulin. However, he remains confused with a GCS of 13.\n\nOther observations are as follows: heart rate 68bpm, blood pressure 110/55, respiratory rate 16, SpO2 99% on air, temperature 36.9.\n\nWhich of the following is the next best step in management?", "sbaAnswer": [ "a" ], "totalVotes": 5122, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Cerebral amyloid angiopathy is the most common cause of lobar intracerebral haemorrhage in older adults. A thalamic stroke is more likely to be due to hypertensive vasculopathy", "id": "32365", "label": "c", "name": "Cerebral amyloid angiopathy", "picture": null, "votes": 631 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Trauma can lead to intracerebral haemorrhage; however, the absence of any external injuries on examination would go against this as the most likely cause", "id": "32366", "label": "d", "name": "Trauma", "picture": null, "votes": 270 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Vasculitis can cause stroke, but it is rare and most commonly seen in younger patients", "id": "32367", "label": "e", "name": "Vasculitis", "picture": null, "votes": 184 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Hypertension is the most common cause of spontaneous intracerebral haemorrhage. The pathogenesis is due to hypertension leading to the formation, and subsequent rupture, of Charcot-Bouchard aneurysms in the small penetrating blood vessels of the brain", "id": "32363", "label": "a", "name": "Hypertensive vasculopathy", "picture": null, "votes": 3004 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "AVM are an important but less common cause of intracerebral haemorrhage", "id": "32364", "label": "b", "name": "Arteriovenous malformation (AVM)", "picture": null, "votes": 1058 } ], "comments": [ { "__typename": "QuestionComment", "comment": "B***, you test me", "createdAt": 1672924448, "dislikes": 1, "id": "15972", "isLikedByMe": 0, "likes": 4, "parentId": null, "questionId": 6473, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "George", "id": 3650 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nA haemorrhagic stroke results from the rupture of a cerebral vessel, leading to intracranial bleeding. Signs include severe headache, altered consciousness, meningism and focal neurological deficits. CT Head is the first-line investigation to quickly identify haemorrhage. MRI scans may be used to provide more detailed images and help identify an underlying cause. Management should be in a specialist unit (either a stroke unit or neurocritical care) with a focus on optimal blood pressure control, particularly in the early phase. Any anticoagulation treatment should be reversed and blood pressure control is key to optimising outcomes. In select cases, surgical decompression may be considered.\n\n# Definition\n\nHaemorrhagic stroke is a cerebrovascular event that occurs when there is bleeding into the brain parenchyma, ventricles or subarachnoid space. This may lead to haematoma formation with raised intracranial pressure, as well as neuronal damage.\n \n# Epidemiology\n\n- Haemorrhagic strokes contribute to 10% to 20% of strokes annually\n- Incidence is around 12 to 15% per 1,000,000 per year \n- Incidence is more common in men and increases with age\n- The case fatality rate is 25 to 30% \n\n\n# Aetiology\n \nRisk factors for haemorrhagic stroke include:\n\n - Older age \n - Male sex\n - Family history of haemorrhagic stroke\n - Haemophilia and other bleeding disorders\n - Cerebral amyloid angiopathy (CAA)\n - **Hypertension**\n - Anticoagulation therapy\n - Recreational drugs such as cocaine and amphetamines\n - Arteriovenous malformations (particularly in younger patients)\n\n# Signs and Symptoms\n \n- Severe headache\n- Altered consciousness, ranging from drowsiness to coma\n- Vomiting\n- Nuchal rigidity\n- Focal neurologic signs e.g. weakness, visual loss, sensory changes\n- Aphasia\n- Seizures\n- Hypertension\n \n# Differential Diagnosis\n \n- **Ischaemic stroke:** Both present with sudden onset neurological defict. Headache is more likely in haemorrhagic stroke. CT is required to rule out haemorrhage before treating for ischaemic stroke\n- **Space-occupying lesion:** e.g. a brain tumour can cause similar symptoms of headache, focal neurological deficits and altered consciousness however these are usually chronic and progressive rather than acute in onset\n- **Meningitis:** also causes headache, meningism and altered mental status; more likely to have features of infection e.g. fevers, tachycardia \n- **Hypertensive encephalopathy:** also presents with acute onset of headache, confusion, visual disturbances and seizures associated with hypertension; may have other complications e.g. myocardial ischaemia, renal dysfunction, differentiated from stroke with a CT head\n \n# Investigations\n \n**Bedside tests:**\n\n- **Capillary blood glucose** as maintaining normoglycaemia improves outcomes \n- **Blood pressure** is important to monitor as a potential cause and during the management blood pressure control is key\n- **ECG** as there may be cardiac complications of haemorrhagic stroke e.g. arrhythmias\n- **Urine toxicology screen** if illicit drug use is suspected\n\n**Blood tests:**\n\n- **FBC** and **CRP** for inflammatory markers \n- **Coagulation screen** to identify any bleeding diathesis\n- **U&Es** to identify any renal impairment that may be associated with hypertension\n- **LFTs** as a baseline\n\n**Imaging**\n\n- **Non Contrast CT head** is the key investigation to identify haemorrhagic stroke\n- **MRI head** may be done in some cases to give more detail, identify an underlying cause and plan treatment\n- **MR angiography** or **digital subtraction angiography** can help identify any vascular abnormalities that may have caused the haemorrhage\n\n# Management\n \n- Emergency management of a haemorrhagic stroke should involve urgently contacting the stroke team +/- critical care (for example in cases with reduced consciousness)\n- Urgent neurosurgical referral may be required e.g. for haematoma evacuation\n- Reverse any anticoagulation treatment or clotting disorders\n- Rapid blood pressure lowering should be initiated in patients with a systolic blood pressure of 150-220 mmHg \n - This is usually with IV antihypertensives such as GTN or labetalol\n - Aim for a systolic blood pressure of below 140 mmHg, but without a fall of > 60 mmHg in the first hour of treatment\n - This excludes patients with an underlying structural cause (e.g. an aneurysm), a GCS below 6 and those who are going for early neurosurgery\n- Make patients nil by mouth until they have had a swallowing assessment\n- Assess hydration and give fluids if dry\n- Management of subarachnoid haemorrhage and raised intracranial pressure is addressed in a separate chapter\n\n# Complications\n\n- Decreased mobility e.g. hemiparesis or hemiplegia\n- Seizures\n- Delirium\n- Hydrocephalus due to bleeding into the ventricles\n- Cardiac complications e.g. arrhythmias\n- Recurrence of haemorrhagic stroke\n- Increased risk of infection e.g. aspiration pneumonia\n- Increased risk of falls in the longer-term\n- Incontinence\n- Neuropathic or musculoskeletal pain\n- Fatigue\n- Cognitive decline\n\n# Prognosis\n\n- Mortality is significantly higher than in ischaemic stroke - approximately 30% at 30 days\n- There is also a higher risk of recurrence; 3.2 per 100 patient years in haemorrhagic stroke\n- Morbidity is also high - at 3-6 months after a haemorrhagic stroke only 20-30% of patients are able to live independently\n- Poor prognostic factors include larger volume haemorrhages, old age, intraventricular bleeding and impaired consciousness at presentation\n\n# NICE Guidelines\n\n[NICE - Stroke and transient ischaemic attack in over 16s](https://www.nice.org.uk/guidance/ng128)\n\n[NICE CKS - Stroke and TIA](https://cks.nice.org.uk/topics/stroke-tia/)\n\n# References\n\n[RCEM Learning - Stroke in the ED](https://www.rcemlearning.co.uk/reference/stroke-in-the-ed/)\n\n[National Clinical Guideline for Stroke for the UK and Ireland](https://www.strokeguideline.org/)\n \n[Patient UK - Cerebrovascular Events](https://patient.info/doctor/cerebrovascular-events)", "files": null, "highlights": [], "id": "181", "pictures": [], "typeId": 2 }, "chapterId": 181, "demo": null, "entitlement": null, "id": "2655", "name": "Haemorrhagic Stroke", "status": null, "topic": { "__typename": "Topic", "id": "39", "name": "Emergency Medicine", "typeId": 2 }, "topicId": 39, "totalCards": null, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 2655, "conditions": [], "difficulty": 2, "dislikes": 12, "explanation": null, "highlights": [], "id": "6473", "isLikedByMe": 0, "learningPoint": "Hypertension is the most common cause of spontaneous intracerebral haemorrhage.", "likes": 2, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "An 80-year-old woman presents to the Emergency Department (ED) with confusion.\n\nOn assessment, her GCS is 13, and a neurological examination reveals reduced power and sensation in the right upper and lower limbs. No external injuries are evident.\n\nAn urgent CT head shows a haemorrhagic stroke affecting the thalamus.\n\nWhich of the following is the most likely aetiology of the stroke?", "sbaAnswer": [ "a" ], "totalVotes": 5147, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Unsynchronised DC cardioversion (defibrillation) is used in cases of cardiac arrest in the presence of a shockable rhythm. The shock is delivered at any point in the cardiac cycle", "id": "32370", "label": "c", "name": "Unsynchronised DC cardioversion", "picture": null, "votes": 20 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Adenosine is contraindicated in poorly controlled asthmatics as it can cause bronchospasm. Therefore verapamil is often preferred in this cohort of patients who present with SVT if vagal manoeuvres fail", "id": "32372", "label": "e", "name": "Verapamil", "picture": null, "votes": 168 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "The history and ECG findings are suggestive of a supraventricular tachycardia (SVT). In the absence of adverse features (myocardial ischaemia, heart failure, syncope or shock), the first-line management of an SVT is vagal manoeuvres. These aim to stimulate the vagus nerve to slow down the heart rate", "id": "32368", "label": "a", "name": "Valsalva manoeuvre", "picture": null, "votes": 4435 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Synchronised DC cardioversion is used in cases of SVT where there are adverse features (myocardial ischaemic, heart failure, syncope or shock) present.\n\nIn synchronised cardioversion, the electrical shock is delivered during ventricular depolarisation in the cardiac cycle. This is important to reduce the risk of the rhythm changing into a life-threatening cardiac arrest rhythm (e.g. VF)", "id": "32369", "label": "b", "name": "Synchronised DC cardioversion", "picture": null, "votes": 283 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Adenosine is a medication that induces a transient block at the AV node. It is used if vagal manoeuvres are unsuccessful, initially at a dose of 6mg", "id": "32371", "label": "d", "name": "Adenosine", "picture": null, "votes": 181 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Should really put in the adenosine option that adenosine is contraindicated in asthma patients as it causes bronchospasm...", "createdAt": 1682713338, "dislikes": 0, "id": "22892", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6474, "replies": [ { "__typename": "QuestionComment", "comment": "Initial management is usually Valsalva anyway and not adenosine......", "createdAt": 1683118884, "dislikes": 0, "id": "23284", "isLikedByMe": 0, "likes": 2, "parentId": 22892, "questionId": 6474, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Intravenous Prone", "id": 19930 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "JAK Botox", "id": 14314 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nSupraventricular Tachycardia (SVT) is an umbrella term for several arrhythmias originating above the ventricles, including AV re-entry tachycardia and AV nodal re-entry tachycardia. Atrial fibrillation, atrial flutter and sinus tachycardias are all technically SVTs but are usually considered separately. Emergency treatment of SVT if the patient is stable involves vagal manoeuvres then administering adenosine if these are not successful. If the patient is unstable, cardioversion should be attempted with a synchronised DC shock.\n\n# Definition\n \nA Supraventricular Tachycardia (SVT) is any rhythm with a fast heart rate (over 100bpm) that originates from anywhere in the heart above the level of the Bundle of His. Unless there is aberrant conduction (e.g. bundle branch block), these will be narrow complex (i.e. QRS width is less than 120ms).\n \nSinus tachycardia, Atrial Fibrillation, Atrial Flutter, AV Re-entry Tachycardia (AVRT) and AV Nodal Re-entry Tachycardia (AVNRT) are examples of SVTs. Sinus tachycardia, Atrial Fibrillation and Atrial Flutter are considered separately and have different emergency management.\n \n[lightgallery]\n \n# Management \n\n**Unstable patients**\n \nPatients with any of the following adverse features should be treated with a synchronised DC shock, which can be repeated if unsuccessful:\n\n- Shock\n- Syncope\n- Heart Failure\n- Myocardial Ischaemia (usually presenting as chest pain)\n\nPatients who are conscious require sedation or anaesthesia prior to attempting cardioversion.\n\n**Stable patients**\n\nPatients with no adverse features should be treated initially with vagal manoeuvres, e.g. carotid sinus massage or the Valsalva manoeuvre (get the patient to blow into a 10ml syringe for 15-20 seconds)\n\nIf this fails, the next step is giving IV Adenosine 6mg, following this with 12mg then 18mg boluses if the previous one is unsuccessful. \n\nThis should be done with continuous ECG monitoring.\n\nIf adenosine fails to terminate the SVT, verapamil or a beta-blocker could be tried, with DC cardioversion also an option if medical treatment is unsuccessful.\n\n**Further information on Adenosine**\n \n- Adenosine is a medication that works by temporarily blocking conduction through the AV node\n- It is given as a rapid IV bolus over 1-3 seconds \n- Prior to administration, patients should be warned that they may experience difficulty breathing, chest tightness and flushing\n- Because of the risk of bronchospasm, patients with asthma should not be given adenosine (verapamil should be used instead)\n- In patients with a central line, a reduced dose of 3mg should be given\n\n# References\n\n[UK Resuscitation Council Adult Tachycardia Algorithm](https://www.resus.org.uk/sites/default/files/2021-04/Tachycardia%20Algorithm%202021.pdf)\n\n[BNF Treatment Summary - Arrhythmias](https://bnf.nice.org.uk/treatment-summaries/arrhythmias/#paroxysmal-supraventricular-tachycardia)", "files": null, "highlights": [], "id": "2032", "pictures": [ { "__typename": "Picture", "caption": null, "createdAt": 1639016761, "id": "382", "index": 0, "name": "Supraventricular tachycardia.jpg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/dio7r8pf1639016760443.jpg", "path256": "images/dio7r8pf1639016760443_256.jpg", "path512": "images/dio7r8pf1639016760443_512.jpg", "thumbhash": "NQgGBYCKp5iFeIhvl2eHjLCIcgu5", "topic": { "__typename": "Topic", "id": "35", "name": "Cardiology", "typeId": 2 }, "topicId": 35, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 2032, "demo": null, "entitlement": null, "id": "695", "name": "Emergency Management of Supraventricular tachycardia", "status": null, "topic": { "__typename": "Topic", "id": "39", "name": "Emergency Medicine", "typeId": 2 }, "topicId": 39, "totalCards": 13, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "695", "name": "Emergency Management of Supraventricular tachycardia" } ], "demo": false, "description": null, "duration": 739.31, "endTime": null, "files": null, "id": "123", "live": false, "museId": "NpPsybK", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/ED.png", "title": "Emergency Management of Supraventricular tachycardia 1", "userViewed": false, "views": 184, "viewsToday": 10 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "695", "name": "Emergency Management of Supraventricular tachycardia" } ], "demo": false, "description": null, "duration": 3068.97, "endTime": null, "files": null, "id": "329", "live": false, "museId": "i4W1n4P", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/paediatrics.png", "title": "Quesmed Tutorial: Paediatric Peri-arrest and Emergencies", "userViewed": false, "views": 96, "viewsToday": 9 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "695", "name": "Emergency Management of Supraventricular tachycardia" } ], "demo": false, "description": null, "duration": 6426.6, "endTime": null, "files": null, "id": "324", "live": false, "museId": "7AeyDdA", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/chemistry.png", "title": "Quesmed Tutorial: Medical Emergencies", "userViewed": false, "views": 949, "viewsToday": 49 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "695", "name": "Emergency Management of Supraventricular tachycardia" } ], "demo": false, "description": null, "duration": 395.84, "endTime": null, "files": null, "id": "124", "live": false, "museId": "QPPyct2", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/ED.png", "title": "Emergency Management of Supraventricular tachycardia 2", "userViewed": false, "views": 25, "viewsToday": 0 } ] }, "conceptId": 695, "conditions": [], "difficulty": 1, "dislikes": 0, "explanation": null, "highlights": [], "id": "6474", "isLikedByMe": null, "learningPoint": "The Valsalva manoeuvre is the first-line treatment for stable supraventricular tachycardia, promoting vagal stimulation to restore normal heart rhythm.", "likes": 0, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 22-year-old patient with a background of asthma is admitted with a four-hour history of palpitations.\n\nHis heart rate is 180bpm, blood pressure 110/68mmHg, respiratory rate 18, SpO2 98% on air\n\nHis ECG shows a heart rate of 183 bpm and a regular narrow complex tachycardia. The admission chest x-ray is clear, and troponin levels are normal.\n\nWhich of the following is the next best step in management?", "sbaAnswer": [ "a" ], "totalVotes": 5087, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Insulin can be used for steroid-induced diabetes; however, NovoRapid is a fast-acting insulin and would not help maintain normal glucose levels throughout the day. Intermediate-acting human insulins such as Humulin I would be a better option and may be started as an alternative to gliclazide at a dose of around 10 Units in the morning", "id": "32374", "label": "b", "name": "4 Units of NovoRapid administered after breakfast", "picture": null, "votes": 935 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Guidelines suggest starting treatment for steroid-induced diabetes if blood sugar levels are > 12mmol/L on two occasions in a single twenty-four hour period", "id": "32377", "label": "e", "name": "Monitor blood sugars and consider treatment if levels > 20mmol/l", "picture": null, "votes": 2111 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Dapagliflozin is a sodium-glucose co-transporter 2 (SGLT2) inhibitor. There is no evidence to support its use in the management of steroid-induced diabetes", "id": "32376", "label": "d", "name": "Start dapagliflozin", "picture": null, "votes": 760 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Pioglitazone is not usually used as a treatment for steroid-induced diabetes unless gliclazide and insulin are not appropriate", "id": "32375", "label": "c", "name": "Start pioglitazone", "picture": null, "votes": 147 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient has steroid-induced diabetes, and guidelines recommend starting treatment if blood glucose levels are greater than 12 mmol/L on two occasions in a single twenty-four hour period. A once-daily short-acting sulphonylurea such as gliclazide is the most commonly advocated treatment option. The dose can be increased up to 240mg in the morning, and an evening dose may also be added to achieve a maximum daily dose of 320mg", "id": "32373", "label": "a", "name": "Start gliclazide", "picture": null, "votes": 1634 } ], "comments": [ { "__typename": "QuestionComment", "comment": "not bad lol ", "createdAt": 1647370561, "dislikes": 1, "id": "8614", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6475, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Yellow Zebras", "id": 17804 } }, { "__typename": "QuestionComment", "comment": "Great question, I hated it", "createdAt": 1683676569, "dislikes": 1, "id": "23916", "isLikedByMe": 0, "likes": 10, "parentId": null, "questionId": 6475, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Mattp420", "id": 27438 } }, { "__typename": "QuestionComment", "comment": "Just until it goes down again?", "createdAt": 1688805864, "dislikes": 0, "id": "30241", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6475, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "RNA Gastro", "id": 13210 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nSecondary causes of type 2 diabetes mellitus (T2DM) encompass a variety of conditions and factors that can induce or exacerbate hyperglycemia. These range from pancreatic and endocrine disorders to specific medications and glycogen storage diseases. It's important to consider these in patients with new-onset diabetes that presents atypically or doesn't respond to typical management.\n\n# Definition\n\nSecondary diabetes refers to forms of the disease where there is a clear causative factor aside from the typical insulin resistance or pancreatic β-cell failure associated with T2DM.\n\n# Epidemiology\n\nThe prevalence of secondary diabetes varies based on the causative condition. While some causes such as pancreatic cancer are relatively common, others, like glycogen storage disorders, are quite rare.\n\n# Aetiology\n\nSecondary causes of T2DM include:\n\n**Pancreatic Causes**\n\n- Cystic fibrosis: An autosomal recessive disorder leading to mucus accumulation in various organs including the pancreas, resulting in fibrosis and loss of exocrine and endocrine function.\n- Chronic pancreatitis: Long-standing inflammation of the pancreas can result in damage to islet cells, leading to diabetes.\n- Haemochromatosis: Iron overload can lead to deposition in various organs including the pancreas, leading to diabetes.\n- Cancer: Pancreatic neoplasms can destroy the islet cells, leading to diabetes.\n\n**Endocrine Causes**\n\n- Cushing's syndrome/disease: Elevated cortisol levels increase insulin resistance.\n- Acromegaly: Excess growth hormone leads to insulin resistance.\n- Pheochromocytoma: These rare adrenal tumors can induce diabetes through chronic catecholamine-induced glucose intolerance.\n- Thyrotoxicosis: Thyroid hormone excess can enhance hepatic gluconeogenesis and glycogenolysis and impair insulin secretion.\n\n**Drug Causes**\n\n- Steroids: Chronic use can lead to glucose intolerance and diabetes due to increased insulin resistance.\n- Atypical neuroleptics: These medications can lead to weight gain and increased insulin resistance.\n- Thiazides: These diuretics may impair glucose tolerance, possibly by reducing insulin secretion.\n- Beta-blockers: They can impair glycemic control through inhibition of insulin secretion and promoting insulin resistance.\n\n**Glycogen Storage Disorders**\n\n- Glycogen Storage Disease Type 1 (von Gierke's disease): The inability to perform gluconeogenesis can lead to hypoglycemia and secondary hyperglycemia.\n- Glycogen Storage Disease Type 2 (Pompe disease): It affects the heart and skeletal muscles more than it causes diabetes, but can present with variable symptoms.\n\n# Management\n\nManagement primarily involves addressing the underlying condition responsible for secondary diabetes. In cases where this is difficult/not possible, for example, pancreatic cancer, patients may require insulin therapy to manage hyperglycemia.\n\n\n\n# NICE Guidelines\n\n[NICE CKS on type 2 diabetes](https://cks.nice.org.uk/topics/diabetes-type-2/)", "files": null, "highlights": [], "id": "198", "pictures": [], "typeId": 2 }, "chapterId": 198, "demo": null, "entitlement": null, "id": "667", "name": "Secondary causes of diabetes", "status": null, "topic": { "__typename": "Topic", "id": "5", "name": "Endocrinology", "typeId": 2 }, "topicId": 5, "totalCards": 3, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 667, "conditions": [], "difficulty": 3, "dislikes": 15, "explanation": null, "highlights": [], "id": "6475", "isLikedByMe": 0, "learningPoint": "Giant cell arteritis can result in steroid-induced diabetes, requiring blood glucose monitoring and, if necessary, the use of oral hypoglycaemic agents such as gliclazide.", "likes": 14, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 65-year-old man is diagnosed with giant cell arteritis (GCA) and is commenced on once-daily, high dose oral steroids as an inpatient.\n\n\nHe has no past medical history, and primary care records showed normal glycosylated haemoglobin (HBA1C) levels three months ago.\n\n\nRoutine capillary blood glucose testing consistently reveal levels in the range 14-19 mmol/L (normal <6.1 mmol/L) with normal serum ketone levels.\n\n\nWhich of the following is the most appropriate next step in management?", "sbaAnswer": [ "a" ], "totalVotes": 5587, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "A thyroglossal cyst would be expected to move upwards on protrusion of the tongue. It would also usually not present with pain", "id": "32379", "label": "b", "name": "Thyroglossal cyst", "picture": null, "votes": 1563 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "De Quervain's thyroiditis is a self-limiting thyroiditis that is often preceded by a viral infection. It can present with a painful goitre and thyrotoxicosis in the initial stages. The thyrotoxicosis is often followed by a transient period of hypothyroidism before thyroid function returns to normal. The normal thyroid function likely indicates that the patient is reaching the end of the illness. Treatment is symptomatic, and there is usually no role for anti-thyroid medications such as carbimazole", "id": "32378", "label": "a", "name": "De Quervain’s thyroiditis", "picture": null, "votes": 3750 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Grave's disease is the most common cause of thyrotoxicosis in the UK. It is an autoimmune condition that results in hyperthyroidism due to stimulatory autoantibodies against the thyroid-stimulating hormone (TSH) receptor. Normal thyroid function would exclude Grave's disease", "id": "32381", "label": "d", "name": "Grave's disease", "picture": null, "votes": 68 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Riedel thyroiditis usually presents as a painless thyroid mass that can be rapidly growing. It is characterised by a hardened, \"woody\" thyroid due to the replacement of the gland with fibrous tissue", "id": "32380", "label": "c", "name": "Riedel thyroiditis", "picture": null, "votes": 617 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Hodgkin's lymphoma usually presents with painless cervical or supra-clavicular lymphadenopathy that may be accompanied by B-symptoms (e.g. weight loss, night sweats, fevers)", "id": "32382", "label": "e", "name": "Hodgkin's lymphoma", "picture": null, "votes": 216 } ], "comments": [ { "__typename": "QuestionComment", "comment": "A patient that doesn't realise they have a problem... what a cheeky question", "createdAt": 1647370633, "dislikes": 0, "id": "8615", "isLikedByMe": 0, "likes": 1, "parentId": null, "questionId": 6476, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Yellow Zebras", "id": 17804 } }, { "__typename": "QuestionComment", "comment": "Would De Quervain’s thyroiditis not initially present thyrotoxic and have deranged TFTs?", "createdAt": 1650450529, "dislikes": 0, "id": "9974", "isLikedByMe": 0, "likes": 13, "parentId": null, "questionId": 6476, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Abrasion DNA", "id": 14831 } }, { "__typename": "QuestionComment", "comment": "so he's gone through the hyperthyroid phase, and the hypothyroid phase... and he didn't have any symptoms?", "createdAt": 1738068033, "dislikes": 0, "id": "61753", "isLikedByMe": 0, "likes": 3, "parentId": null, "questionId": 6476, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "NewJeans", "id": 22544 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\n| | TSH | T3 | T4 |\n| :--------------------------: | :--: | :----: | :----: |\n| Primary hypothyroidism | High | Low | Low |\n| Secondary hypothyroidism | Low | Low | Low |\n| Sub-clinical hypothyroidism | High | Normal | Normal |\n| Primary hyperthyroidism | Low | High | High |\n| Secondary hyperthyroidism | High | High | High |\n| Sub-clinical hyperthyroidism | Low | Normal | Normal |\n\n# References\n\n[Click here for NICE CKS on hypothyroidism](https://cks.nice.org.uk/topics/hypothyroidism/)", "files": null, "highlights": [], "id": "1967", "pictures": [], "typeId": 2 }, "chapterId": 1967, "demo": null, "entitlement": null, "id": "670", "name": "Patterns of Thyroid Disease", "status": null, "topic": { "__typename": "Topic", "id": "5", "name": "Endocrinology", "typeId": 2 }, "topicId": 5, "totalCards": 41, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "670", "name": "Patterns of Thyroid Disease" } ], "demo": false, "description": null, "duration": 406.57, "endTime": null, "files": null, "id": "634", "live": false, "museId": "zJa8z9F", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/endocrinology.png", "title": "Hyperthyroidism 2", "userViewed": false, "views": 19, "viewsToday": 4 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "670", "name": "Patterns of Thyroid Disease" } ], "demo": false, "description": null, "duration": 6426.6, "endTime": null, "files": null, "id": "324", "live": false, "museId": "7AeyDdA", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/chemistry.png", "title": "Quesmed Tutorial: Medical Emergencies", "userViewed": false, "views": 949, "viewsToday": 49 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "670", "name": "Patterns of Thyroid Disease" } ], "demo": false, "description": null, "duration": 3216.34, "endTime": null, "files": null, "id": "633", "live": false, "museId": "X5YwJBt", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/endocrinology.png", "title": "Quesmed Tutorial: Thyroid Disease", "userViewed": false, "views": 242, "viewsToday": 20 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "670", "name": "Patterns of Thyroid Disease" } ], "demo": false, "description": null, "duration": 426.09, "endTime": null, "files": null, "id": "125", "live": false, "museId": "ddPajRf", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/ED.png", "title": "Emergency management of thyrotoxic storm", "userViewed": false, "views": 160, "viewsToday": 7 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "670", "name": "Patterns of Thyroid Disease" } ], "demo": false, "description": null, "duration": 360.19, "endTime": null, "files": null, "id": "636", "live": false, "museId": "g8aYYtq", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/endocrinology.png", "title": "Hypothyroidism 2", "userViewed": false, "views": 12, "viewsToday": 2 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "670", "name": "Patterns of Thyroid Disease" } ], "demo": false, "description": null, "duration": 391.04, "endTime": null, "files": null, "id": "707", "live": false, "museId": "fFYFkhh", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/endocrinology.png", "title": "Hyperthyroidism 4", "userViewed": false, "views": 16, "viewsToday": 3 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "670", "name": "Patterns of Thyroid Disease" } ], "demo": false, "description": null, "duration": 432.47, "endTime": null, "files": null, "id": "706", "live": false, "museId": "CBzKRxX", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/endocrinology.png", "title": "Patterns of Thyroid Disease 1", "userViewed": false, "views": 29, "viewsToday": 0 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "670", "name": "Patterns of Thyroid Disease" } ], "demo": false, "description": null, "duration": 268.61, "endTime": null, "files": null, "id": "637", "live": false, "museId": "iznhBFz", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/endocrinology.png", "title": "Subclinical Hypothyroidism", "userViewed": false, "views": 24, "viewsToday": 4 } ] }, "conceptId": 670, "conditions": [], "difficulty": 2, "dislikes": 9, "explanation": null, "highlights": [], "id": "6476", "isLikedByMe": 0, "learningPoint": "De Quervain's thyroiditis is a self-limiting condition often triggered by viral infections, presenting with a painful goitre and transient thyroid dysfunction.", "likes": 2, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 25-year-old man presents with a history of a painful neck lump. He reports noticing the lump over the last two weeks following an upper respiratory tract infection. He denies palpitations, tremors, weight loss or night sweats.\n\nOn examination, there is a smooth central neck lump that moves with swallowing but not on protrusion of the tongue.\n\nBlood tests, including thyroid function, are normal.\n\nWhich of the following is the most likely diagnosis?", "sbaAnswer": [ "a" ], "totalVotes": 6214, "typeId": 1, "userPoint": null }

[]

{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Cushing's syndrome can be caused by an adrenal lesion such as an adenoma or carcinoma, and imaging may help confirm this diagnosis. However, this would usually be done once a diagnosis of Cushing's syndrome has been confirmed biochemically", "id": "32387", "label": "e", "name": "CT adrenal glands", "picture": null, "votes": 42 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "The symptoms and signs described are suggestive of Cushing's syndrome. Although a 24 hour urinary free cortisol can be used as an intial investigation to confirm cushing's syndrome, cortisol can be raised by high fluid intake, stress and medications. There are also difficulties with collecting 24 hour urine so an overnight dexamethasone suppression test is preferred these days. ", "id": "32383", "label": "a", "name": "24 hour urinary free cortisol", "picture": null, "votes": 1621 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "9 am cortisol levels are the initial screening test for primary adrenal insufficiency. Given that serum cortisol levels match the circadian rhythm, a serum 9 am cortisol has no use as a screening test for Cushing's syndrome", "id": "32384", "label": "b", "name": "9 am cortisol", "picture": null, "votes": 1755 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Cushing's disease is Cushing's syndrome caused by a pituitary adenoma. An MRI would be indicated to confirm the diagnosis of a pituitary adenoma; however, this would usually be done once a diagnosis of Cushing's syndrome has been confirmed biochemically", "id": "32386", "label": "d", "name": "MRI pituitary gland", "picture": null, "votes": 45 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "The symptoms and signs described are suggestive of Cushing's syndrome. The ovrnight dexamthasone suppression test is preferred these days to 24 hour urinary free cortisol given it's practicality. ", "id": "32385", "label": "c", "name": "Overnight dexamethasone suppression test", "picture": null, "votes": 2596 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Although correct, a low-dose dexamethasone test is now used more often in place of the 24h urinary free cortisol.", "createdAt": 1646312818, "dislikes": 2, "id": "7950", "isLikedByMe": 0, "likes": 27, "parentId": null, "questionId": 6477, "replies": [ { "__typename": "QuestionComment", "comment": "Spend more time at GP because you cannot do low dose dex test at GP that is usually done by endocrine specialist ", "createdAt": 1672792553, "dislikes": 15, "id": "15899", "isLikedByMe": 0, "likes": 2, "parentId": 7950, "questionId": 6477, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Elwyn D.", "id": 12340 } }, { "__typename": "QuestionComment", "comment": "oh we love a quesmed'er who is serious enough to have their actual name and leave a beautiful comment like this!", "createdAt": 1685282240, "dislikes": 0, "id": "26806", "isLikedByMe": 0, "likes": 3, "parentId": 7950, "questionId": 6477, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Witzelsucht", "id": 24993 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Defibrillator WBC", "id": 16607 } }, { "__typename": "QuestionComment", "comment": "why not 9 am cortisol? ", "createdAt": 1682406815, "dislikes": 1, "id": "22611", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6477, "replies": [ { "__typename": "QuestionComment", "comment": "in cushings cortisol will be elevated. at 9 am is when your cortisol is naturally highest due to its diurnal variation. so if a 9 am cortisol comes back elevated, it doesn't really tell you if someone has cushings. ", "createdAt": 1682760119, "dislikes": 0, "id": "22903", "isLikedByMe": 0, "likes": 5, "parentId": 22611, "questionId": 6477, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Botox Stasis", "id": 12383 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Raphael de la Ghetto", "id": 27073 } }, { "__typename": "QuestionComment", "comment": "\nThe two most commonly used tests are:\novernight dexamethasone suppression test\nthis is the most sensitive test and is now used first-line to test for Cushing's syndrome\npatients with Cushing's syndrome do not have their morning cortisol spike suppressed\n24 hr urinary free cortisol", "createdAt": 1685293565, "dislikes": 0, "id": "26877", "isLikedByMe": 0, "likes": 3, "parentId": null, "questionId": 6477, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Intravenous Prone", "id": 19930 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nCushing's syndrome is an endocrine disorder characterised by excess glucocorticoids, which can have ACTH-dependent or independent origins. Clinically, patients may present with symptoms such as proximal myopathy, obesity, hypertension, and various dermatological changes. Diagnosis is made through investigations such as a 24-hour urinary free cortisol test and low-dose dexamethasone suppression test, alongside imaging for localisation. Management includes medical therapy to reduce cortisol levels, surgery, radiotherapy, and the need for post-operative steroid replacement in successful cases.\n\n# Definition\n\nCushing's syndrome is an endocrine disorder characterised by excess glucocorticoids, often resulting in distinctive clinical symptoms and signs. It is important to distinguish Cushing's syndrome from **Cushing's disease,** which specifically refers to glucocorticoid excess caused by an adrenocorticotropic hormone (ACTH)-secreting pituitary tumour.\n\n# Epidemiology\n\nCushing's syndrome is a relatively rare condition, estimated to affect 2 to 3 per million people each year. It is more common in adults, particularly women, with a peak incidence between 25-40 years.\n\n# Aetiology\n\nThe causes of Cushing's syndrome can be divided into ACTH-dependent and ACTH-independent:\n\n- **ACTH-dependent disease:** This is caused by excessive production of ACTH, most often due to a pituitary tumour (Cushing's disease) or ectopic ACTH-producing tumours (e.g. lung carcinoids, thymic carcinoids, and others).\n- **ACTH-independent:** This arises from primary adrenal diseases, such as adrenal adenomas or adrenal carcinomas, which produce excess cortisol independently of ACTH stimulation. Exogenous steroids can also cause ACTH-independent Cushing's.\n\n# Signs and Symptoms\n\nClinical features of Cushing's syndrome may include:\n\n- Proximal myopathy\n- Striae and easy bruising\n- Osteoporosis and fractures\n- Glucose intolerance or diabetes mellitus\n- Obesity, particularly truncal or \"centripetal\" obesity\n- Hypertension\n- Hypokalaemia\n- Facial changes, such as moon face and acne\n- Hirsutism in women\n- Fat redistribution leading to interscapular and supraclavicular fat pads\n- Thin extremities due to muscle wasting\n- Thin, fragile skin\n- Erectile dysfunction in men\n- Psychological issues, such as depression or cognitive dysfunction\n- Osteopenia or osteoporosis\n\n[lightgallery]\n\n[lightgallery1]\n\n\n# Differential Diagnosis\n\nKey differentials include conditions that may cause similar clinical features, such as:\n\n- Metabolic syndrome\n- Polycystic ovary syndrome\n- Adrenal insufficiency\n- Alcohol excess\n- Depression. \n\nDistinguishing these conditions often relies on biochemical and imaging investigations.\n\n# Investigations\n\nTo confirm the diagnosis and identify the cause:\n\nBiochemical evidence of cortisol excess:\n\n- 24-hour urinary free cortisol test\n- Low-dose Dexamethasone suppression test:\n - Not suppressed by low dose - Cushing’s syndrome (e.g. exogenous steroid use)\n - Not suppressed by low dose but suppressed by high dose - Cushing’s disease (pituitary source)\n - Not suppressed by low dose or by high dose dexamethasone – ectopic ACTH (not under axis control, likely ACTH-producing tumour)\n\nLocalisation of the source:\n\n- Plasma ACTH levels to distinguish between ACTH-dependent and independent causes\n- High-dose dexamethasone suppression test for suspected Cushing's disease\n- Inferior petrosal sinus sampling for suspected pituitary cause\n- MRI of the pituitary and/or CT of chest and abdomen for tumour localisation\n\n\n# Management\n\nManagement of Cushing's syndrome varies according to the underlying cause and may involve a combination of medical, surgical, and radiotherapy options:\n\n- **Medical Management:** Initial therapy often involves medications to decrease cortisol levels. These include Metyrapone, an inhibitor of cortisol synthesis; Ketoconazole, an adrenolytic agent; Mifepristone, a glucocorticoid receptor antagonist; and Pasireotide, a somatostatin analog.\n\n- **Surgical Management:** Resection of the pituitary tumour is the treatment of choice for Cushing's disease, often after initial control of hypercortisolaemia with medical therapy to improve surgical outcomes.\n - NB: Old treatment for Cushing's disease used to be bilateral adrenalectomy, which has risk of developing into Nelson syndrome - enlarging of an adrenocorticotropic hormone-producing tumour in the pituitary gland.\n\n- **Radiotherapy:** May be considered for cases where hypercortisolaemia persists post-surgery, or in cases where surgery is not possible or declined.\n\nSuccessful treatment of Cushing's disease leads to cortisol deficiency and subsequently, steroid replacement post-operatively is essential. Patients need to carry a steroid card and ideally wear a medic alert bracelet in case of acute illness or emergency situations.\n\nPatients unfit for surgery or with unresectable lesions are managed with medical therapy alone.\n\n# References\n\n[BNF - Cushing's syndrome](https://bnf.nice.org.uk/treatment-summaries/cushings-syndrome/#:~:text=Cushing's%20syndrome%20results%20from%20chronic,%2C%20ectopic%20ACTH%2Dsecreting%20tumours.)", "files": null, "highlights": [], "id": "664", "pictures": [ { "__typename": "Picture", "caption": "A typical appearnce of hirsutism in a woman with a cushingoid face.", "createdAt": 1665036192, "id": "742", "index": 1, "name": "Cushings.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/docfcda81665036171703.jpg", "path256": "images/docfcda81665036171703_256.jpg", "path512": "images/docfcda81665036171703_512.jpg", "thumbhash": "ozgKDgZ61wc3qUfXqHB4aYloB3pzcEc=", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "Abdominal striae and central adiposity seen in a gentleman with cushings.", "createdAt": 1665036192, "id": "733", "index": 0, "name": "Cushings - 2.jpg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/7j4xp2171665036171702.jpg", "path256": "images/7j4xp2171665036171702_256.jpg", "path512": "images/7j4xp2171665036171702_512.jpg", "thumbhash": "VgkKDARViWe5iIC5SKgHiYWAdw==", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 664, "demo": null, "entitlement": null, "id": "691", "name": "Cushing's syndrome", "status": null, "topic": { "__typename": "Topic", "id": "5", "name": "Endocrinology", "typeId": 2 }, "topicId": 5, "totalCards": 7, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "691", "name": "Cushing's syndrome" } ], "demo": false, "description": null, "duration": 3606.76, "endTime": null, "files": null, "id": "631", "live": false, "museId": "TQG9EyR", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/endocrinology.png", "title": "Quesmed Tutorial: Cushings and Conns", "userViewed": false, "views": 114, "viewsToday": 10 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "691", "name": "Cushing's syndrome" } ], "demo": false, "description": null, "duration": 421.87, "endTime": null, "files": null, "id": "632", "live": false, "museId": "cSUBUqN", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/endocrinology.png", "title": "Pituitary disease 3", "userViewed": false, "views": 10, "viewsToday": 3 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "691", "name": "Cushing's syndrome" } ], "demo": false, "description": null, "duration": 357.16, "endTime": null, "files": null, "id": "699", "live": false, "museId": "s2HrSUU", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/endocrinology.png", "title": "Cushing's syndrome 3", "userViewed": false, "views": 47, "viewsToday": 6 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "691", "name": "Cushing's syndrome" } ], "demo": false, "description": null, "duration": 295.3, "endTime": null, "files": null, "id": "702", "live": false, "museId": "Pv7dKYq", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/endocrinology.png", "title": "Cushing's syndrome 4", "userViewed": false, "views": 21, "viewsToday": 3 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "691", "name": "Cushing's syndrome" } ], "demo": false, "description": null, "duration": 6218.77, "endTime": null, "files": null, "id": "313", "live": false, "museId": "2sWRMn1", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/endocrinology.png", "title": "Quesmed Tutorial: Endocrinology", "userViewed": false, "views": 1069, "viewsToday": 27 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "691", "name": "Cushing's syndrome" } ], "demo": false, "description": null, "duration": 349.99, "endTime": null, "files": null, "id": "698", "live": false, "museId": "8yiFZQP", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/endocrinology.png", "title": "Cushing's syndrome 2", "userViewed": false, "views": 44, "viewsToday": 6 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "691", "name": "Cushing's syndrome" } ], "demo": false, "description": null, "duration": 586.5, "endTime": null, "files": null, "id": "86", "live": false, "museId": "HDgbDmA", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/endocrinology.png", "title": "Cushing's syndrome", "userViewed": false, "views": 220, "viewsToday": 23 } ] }, "conceptId": 691, "conditions": [], "difficulty": 3, "dislikes": 18, "explanation": null, "highlights": [], "id": "6477", "isLikedByMe": 0, "learningPoint": "The diagnosis of Cushing's syndrome can be confirmed using a 24-hour urinary free cortisol test, which measures the amount of cortisol excreted in urine over a 24-hour period. Elevated levels of urinary free cortisol are indicative of hypercortisolism, supporting the diagnosis of Cushing's syndrome.", "likes": 7, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 45-year-old woman presents to her General Practitioner (GP) with weakness in her shoulders and hips. She also reports an unintentional weight gain of 5kg over the last three months and associated easy bruising.\n\nOn examination, she is hypertensive, with central adiposity and violaceous striae are present on her abdomen.\n\nShe is subsequently referred to an endocrinologist.\n\nWhich of the following is the best initial investigation given the likely underlying diagnosis?", "sbaAnswer": [ "c" ], "totalVotes": 6059, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Low strength capsaicin cream can be used for the treatment of localised neuropathic pain. This patient's pain is more widespread and so topical treatment is unlikely to be beneficial. A patch containing 8% capsaicin is an option for peripheral neuropathic pain and could be considered under specialist supervision", "id": "32392", "label": "e", "name": "Start 0.075% capsaicin cream", "picture": null, "votes": 725 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Neuropathic pain may be responsive to treatment with opioids such as morphine. However, it should be reserved for persistent symptoms refractory to treatment with anti-depressants (e.g. amitriptyline or duloxetine) and anti-epileptics (pregabalin or gabapentin)", "id": "32391", "label": "d", "name": "Start modified-release morphine sulphate", "picture": null, "votes": 148 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Regular paracetamol would not be particularly useful for the treatment of neuropathic pain", "id": "32390", "label": "c", "name": "Start regular paracetamol", "picture": null, "votes": 206 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient has signs and symptoms of diabetic neuropathy. Other symptoms of neuropathic pain include tingling, sensitivity to touch and electric-like sensations. NICE guidelines suggest using amitriptyline, duloxetine, pregabalin or gabapentin as the first-line treatment for neuropathic pain", "id": "32388", "label": "a", "name": "Start duloxetine", "picture": null, "votes": 5196 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID) and is not particularly useful for treating neuropathic pain. It would also not be appropriate in this case, given the history of a duodenal ulcer, as NSAIDs are a major cause of gastric and duodenal ulceration", "id": "32389", "label": "b", "name": "Start ibuprofen", "picture": null, "votes": 80 } ], "comments": [ { "__typename": "QuestionComment", "comment": "All Diabetics Get Peripheral (Neuropathy) -->\nAmitriptyline, Duloxetine, Gabapentin, Pregabalin", "createdAt": 1681997643, "dislikes": 0, "id": "22279", "isLikedByMe": 0, "likes": 16, "parentId": null, "questionId": 6478, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Fever Juice", "id": 30886 } }, { "__typename": "QuestionComment", "comment": "duloxetine increases bleeding risk (like NSAID) so would potentially not give in Hx of peptic ulcer disease ", "createdAt": 1683381351, "dislikes": 1, "id": "23552", "isLikedByMe": 0, "likes": 3, "parentId": null, "questionId": 6478, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "RNA Haemophilus", "id": 11995 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nDiabetic peripheral neuropathy (DPN) refers to a variety of peripheral nerve disorders as a result of diabetes. The primary causative factor is chronic hyperglycaemia, which leads to several distinct types of DPN, including Distal Symmetrical Sensory Neuropathy, Small-fibre Predominant Neuropathy, Diabetic Amyotrophy, Mononeuritis Multiplex, Autonomic Neuropathy and Charcot Arthropathy. Symptoms vary according to the subtype of DPN but usually involve sensory loss and/or pain in a glove and stocking distribution or proximal weakness. Key investigations focus on assessing the extent of neuropathy and rule out other potential causes of neuropathy. Management is primarily symptomatic and emphasises good glycaemic control. This section covers DPN broadly, with a later focus on Charcot arthropathy.\n\n# Definition\n\nDiabetic peripheral neuropathy (DPN) represents a spectrum of peripheral nerve disorders stemming from diabetes. The central driver behind their development is believed to be chronic hyperglycaemia.\n\n# Epidemiology\n\nDPN is a common complication of both type 1 and type 2 diabetes, with approximately 50% of long-term diabetic patients developing the condition. The risk increases with the duration of diabetes and poor glycemic control.\n\n# Aetiology\n\nChronic hyperglycaemia in diabetes is the primary cause of DPN, leading to damage to peripheral nerves through various mechanisms, including accumulation of advanced glycation end products, oxidative stress, and inflammatory pathways.\n\n# Clinical Features\n\nDPN can be categorised into several types, each presenting with distinct clinical features:\n\n## Distal Symmetrical Sensory Neuropathy\n\n- Most common form of DPN.\n- Resulting from loss of large sensory fibres.\n- Presents with sensory loss in a 'glove and stocking' distribution, typically affecting touch, vibration and proprioception.\n\n## Small-fibre Predominant Neuropathy\n\n- Due to the loss of small sensory fibres.\n- Manifests as deficits in pain and temperature sensation in a 'glove and stocking' distribution, often accompanied by episodes of burning pain.\n\n## Diabetic Amyotrophy\n\n- Originates from inflammation of the lumbosacral plexus or cervical plexus.\n- Characterised by severe pain around the thighs and hips, along with proximal weakness.\n\n## Mononeuritis Multiplex\n\n- Typically painful.\n- Defined as neuropathies involving two or more distinct peripheral nerves.\n\n## Autonomic Neuropathy\n\n- Presents with postural hypotension, gastroparesis, constipation, urinary retention, arrhythmias, and erectile dysfunction.\n\n# Differential Diagnosis\n\nThe differential diagnosis for DPN includes:\n\n- **Vitamin B12 deficiency**: Can present with peripheral neuropathy, typically in a glove and stocking distribution. May also feature megaloblastic anemia and glossitis.\n- **Alcohol-induced peripheral neuropathy**: Presents similarly to DPN but may also have accompanying signs of chronic alcohol misuse.\n- **Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)**: Often presents with both sensory loss and motor weakness, typically in a proximal and distal distribution.\n- **Hypothyroidism**: Can present with neuropathy, usually accompanied by other symptoms such as fatigue, weight gain, and cold intolerance.\n\n# Investigations\n\n- **Neurological examination**: To assess the extent of sensory and motor deficits.\n- **Nerve conduction studies**: To evaluate the nature and extent of neuropathy.\n- **Blood tests**: Including glucose levels, HbA1c, B12 levels, thyroid function tests, and liver function tests, to identify potential differential diagnoses or contributory conditions.\n\n# Complications\n\nIf uncontrolled, DPN can lead to serious complications such as foot ulcers due to loss of sensation, and autonomic neuropathy can lead to various cardiac, gastrointestinal, and genitourinary disturbances.\n\n# Management\n\nManagement strategies for DPN primarily revolve around the control of blood glucose levels to slow the progression of the disease. Symptomatic management may include pain control with medications such as gabapentin or pregabalin, as well as management of complications (e.g., treatment of foot ulcers, management of autonomic disturbances).\n\n# Charcot Arthopathy\n\n## Summary\n\nCharcot arthropathy is a chronic, progressive condition characterised by destructive changes in the bones and joints of patients with neuropathy, most commonly from diabetes. It presents with the '6Ds': Destruction, Deformity, Degeneration, Dense bones, Debris, and Dislocation. Diagnosis often involves imaging, typically with radiographs, and distinguishing it from osteomyelitis. Management focuses on immobilisation, orthotics, medication to manage pain and bone loss, and surgical interventions in advanced or refractory cases.\n\n## Definition\n\nCharcot arthropathy, also known as Charcot joint or neuropathic arthropathy, is a chronic, progressive condition characterised by painful or painless bone and joint destruction in the limbs that have lost sensory innervation. The condition primarily affects patients with peripheral neuropathy.\n\n## Epidemiology\n\nCharcot arthropathy is most commonly seen in patients with long-standing diabetes mellitus, with the prevalence being estimated to be around 0.1-0.9% in this group. It can occur at any age but is more frequently observed in the middle-aged and elderly population.\n\n## Aetiology\n\nThe underlying aetiology of Charcot arthropathy is primarily neuropathy. The most common cause of this is diabetes mellitus, which leads to microvascular disease, autonomic neuropathy, and peripheral neuropathy, resulting in cumulative damage to the joints. Other, rarer causes include conditions that cause neuropathy, such as syringomyelia, chronic alcohol abuse, and syphilis.\n\n## Signs and Symptoms\n\nCharcot arthropathy often presents with the '6Ds'(some of which are imaging features):\n\n- Destruction of bone and joint\n- Deformity\n- Degeneration\n- Dense bones\n- Debris of bone fragments\n- Dislocation\n\nIt classically affects the tarsometatarsal joints, but it can involve any joint in a limb that has lost sensation due to neuropathy.\n\n## Differential Diagnosis\n\nThe main differential diagnosis to rule out in the context of Charcot arthropathy is osteomyelitis, which also causes bone destruction but is typically associated with systemic symptoms like fever, increased inflammatory markers, and often a preceding or concurrent soft tissue infection.\n\n## Investigations\n\nThe diagnosis of Charcot arthropathy is primarily clinical but often involves imaging to assess the extent of the bone and joint involvement:\n\n- X-rays are usually the first-line imaging study. They can demonstrate bone destruction, debris, sclerosis (dense bones), and dislocation.\n- MRI can provide more detailed imaging, particularly in early disease or when osteomyelitis is suspected.\n- Bone scans may be used in complex cases or when other imaging is inconclusive.\n\n## Management\n\nThe management of Charcot arthropathy involves conservative and surgical strategies:\n\nConservative:\n- Prolonged off-loading, often involving special footwear or plaster casts, to allow healing and prevent further damage.\n- Use of orthotics for long-term management and prevention of recurrences.\n\nMedications:\n- Bisphosphonates can help slow down the process of bone destruction.\n- Neuropathic pain agents, such as gabapentin or pregabalin, for pain management.\n- Topical anesthetics can also be used to manage pain.\n\nSurgical:\n- Resection of bony prominences to prevent ulcers or improve fitting of footwear.\n- Correction of severe deformities, usually after the acute phase has settled.\n- Amputation may be required in severe cases or when there is a concurrent uncontrolled infection.\n\n\n# NICE Guidelines\n\n[Click here for NICE CKS on diabetes - type 2](https://cks.nice.org.uk/topics/diabetes-type-2/)\n", "files": null, "highlights": [], "id": "648", "pictures": [], "typeId": 2 }, "chapterId": 648, "demo": null, "entitlement": null, "id": "676", "name": "Diabetic Neuropathy", "status": null, "topic": { "__typename": "Topic", "id": "5", "name": "Endocrinology", "typeId": 2 }, "topicId": 5, "totalCards": 18, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 676, "conditions": [], "difficulty": 1, "dislikes": 3, "explanation": null, "highlights": [], "id": "6478", "isLikedByMe": 0, "learningPoint": "Duloxetine is an effective first-line treatment for neuropathic pain in patients with diabetic neuropathy.", "likes": 2, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 56-year-old man presents to his GP with a history of burning and numbness in his feet and lower legs for the last two months. His past medical history is significant for poorly controlled Type 1 diabetes and a previous duodenal ulcer.\n\nOn neurological examination, there is reduced sensation to pin-prick and fine-touch bilaterally from the feet to the knees.\n\nGiven the likely diagnosis, which of the following is the next best step in management?", "sbaAnswer": [ "a" ], "totalVotes": 6355, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "The patient has capacity and can communicate his decision. There's no indication of psychiatric illness here so a referral to psychiatry is not indicated or appropriate", "id": "32395", "label": "c", "name": "Refer to psychiatry for a full psychiatric assessment", "picture": null, "votes": 68 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "As long as the patient has retained, understood, weighed up and communicated a decision, there is no need for further justification unless you are unsure of the patient's understanding", "id": "32397", "label": "e", "name": "Ask the patient to justify his decision", "picture": null, "votes": 191 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "The three key components for informed consent are capacity, provision of adequate information and non-coercion. The patient has the capacity to decide about his feeding as he can understand, retain, weigh up, and communicate a decision. Therefore, his wishes should be accepted", "id": "32393", "label": "a", "name": "Accept the patient's decision and continue with risk-feeding", "picture": null, "votes": 4743 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "The patient has the capacity to make this decision as he can understand, retain, weigh up, and communicate his wishes", "id": "32394", "label": "b", "name": "Start a pureed diet as the patient lacks capacity", "picture": null, "votes": 10 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "As the patient has met the criteria for having the capacity to make a decision regarding his feeding, there is no need to reassess", "id": "32396", "label": "d", "name": "Reassess capacity the following day", "picture": null, "votes": 75 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Criteria used when assessing capacity in adults\n\nThere are **four criteria** used when assessing capacity in adults.\n\n1. The individual must be able to understand the information relating to the decision\n2. The individual must be able to retain that information\n3. The individual must be able to weigh up the information and reach a conclusion\n4. The individual must be able to communicate the decision they have made.\n\n# Ways to Meet the Criteria \n\nHelp and support can be provided in order to enable an individual to meet the above assessment criteria. For example, using simple language in order to explain the information, or allowing someone to communicate their decision in a number of ways (in writing, verbally, in sign-language, or their normal form of communication, etc.)\n\n# Mental Capacity Act \n\nIf an individual is not able to do any of the above four criteria, then the Mental Capacity Act (MCA) will assess them and therefore treat them as lacking capacity for that specific decision in question.\n\n# Fluctuating Capacity \n\nIt is important to note here that capacity is not absolute. Sometimes, an individual's capacity can fluctuate (e.g. someone with dementia). Or in other circumstances, someone will have the capacity to make a decision on something simple but not something more complex. It is therefore always important to assess whether individuals have the capacity to make a _specific_ decision at that time.", "files": null, "highlights": [], "id": "573", "pictures": [], "typeId": 2 }, "chapterId": 573, "demo": null, "entitlement": null, "id": "588", "name": "Criteria for assessing capacity in adults", "status": null, "topic": { "__typename": "Topic", "id": "30", "name": "Ethics and Law", "typeId": 2 }, "topicId": 30, "totalCards": 4, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 588, "conditions": [], "difficulty": 1, "dislikes": 0, "explanation": null, "highlights": [], "id": "6479", "isLikedByMe": 0, "learningPoint": "Patients with capacity have the right to refuse medical recommendations, even if it poses risks to their health.", "likes": 7, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 56-year-old man with progressive motor neurone disease is assessed by the speech and language team due to concerns about his swallowing.\n\nFollowing the assessment, the recommendation is that he would benefit from a pureed diet to reduce the risk of aspiration.\n\nHaving explained the recommendation and the risks associated with continuing with a normal diet, the patient refuses and states that he wishes to continue with a normal diet. He can understand, retain and weigh up the decision but only able to communicate in writing.\n\nWhich of the following is the next best step in management?", "sbaAnswer": [ "a" ], "totalVotes": 5087, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Drivers have a legal duty to inform the Driver and Vehicle Licensing Agency (DVLA) if they have a condition that impairs their ability to drive. A doctor should inform the patient of this duty and make every reasonable effort to make sure they do this. However, if a patient continues not to disclose the information, doctors have a **_professional duty_** to break confidentiality in the public's best interests", "id": "32399", "label": "b", "name": "Conditions that impair the ability to drive", "picture": null, "votes": 2292 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "In these cases, the doctor should first try and convince the patient to make the disclosure themselves. If this is not possible, a doctor should disclose the necessary information only and try and avoid identifying the patient where possible. This would be considered a case where a doctor may have a **legal defence** for breaching confidentiality in the public's best interests", "id": "32402", "label": "e", "name": "Disclosing personal information to a sexual partner", "picture": null, "votes": 64 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "If the harm is only to the patient, a doctor should accept a competent adult's refusal to disclose information. However, if there are any children involved, a referral to social services is mandated", "id": "32400", "label": "c", "name": "Domestic violence involving a young couple", "picture": null, "votes": 374 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Identification of patients who are suspected of committing a road traffic offence is one of the specific statutory requirements where doctors have a legal duty to break confidentiality", "id": "32398", "label": "a", "name": "Identification of a patient who committed a road traffic offence", "picture": null, "votes": 705 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "General Medical Council (GMC) guidance in 2017 has highlighted that there is no duty to inform the police in the case of serious crime. However, a doctor may still break confidentiality if they believe that it is in the public's best interests. In these cases, there may be a **legal defence** for breaching confidentiality", "id": "32401", "label": "d", "name": "Gunshot/knife wounds", "picture": null, "votes": 1293 } ], "comments": [ { "__typename": "QuestionComment", "comment": "The world is f***ed. a road traffic offense > terrible shit", "createdAt": 1647371001, "dislikes": 0, "id": "8617", "isLikedByMe": 0, "likes": 29, "parentId": null, "questionId": 6480, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Yellow Zebras", "id": 17804 } }, { "__typename": "QuestionComment", "comment": "quesnitch", "createdAt": 1675014673, "dislikes": 0, "id": "17411", "isLikedByMe": 0, "likes": 41, "parentId": null, "questionId": 6480, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Monoclonal Loose", "id": 5172 } }, { "__typename": "QuestionComment", "comment": "surely this is wrong?", "createdAt": 1677067237, "dislikes": 0, "id": "18718", "isLikedByMe": 0, "likes": 17, "parentId": null, "questionId": 6480, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Gallbladder Tachycardia", "id": 7969 } }, { "__typename": "QuestionComment", "comment": "say mums ", "createdAt": 1683080904, "dislikes": 0, "id": "23255", "isLikedByMe": 0, "likes": 21, "parentId": null, "questionId": 6480, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Viral Vitamin", "id": 4742 } }, { "__typename": "QuestionComment", "comment": "Do docs have to report you sell crack?", "createdAt": 1694612059, "dislikes": 0, "id": "31515", "isLikedByMe": 0, "likes": 3, "parentId": null, "questionId": 6480, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Monoclonal Supine", "id": 25376 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Overview\n\nPatients have a legal right to confidentiality (under both Common Law and Human Rights Law), and doctors have the corresponding legal duty to provide this right to confidentiality.\n\nHowever, this right to confidentiality is not absolute. There are a number of situations in which the law obliges doctors to breach confidentiality, i.e. there is a legal duty to breach confidentiality. There are also some situations where a doctor has a legal defence to breach confidentiality.\n\n# Legal Duties to Breach Confidentiality\n\n1. If ordered to by a court or judge\n2. To satisfy statutory requirements\n\n _e.g. to inform the local authority about notifiable diseases under the Public Health Act 1984_\n\n _e.g. under the Road Traffic Act, must provide identifying information to the police on request_\n\n _e.g. under the Terrorism Act 2000, must report any suspicions of terrorism_", "files": null, "highlights": [], "id": "564", "pictures": [], "typeId": 2 }, "chapterId": 564, "demo": null, "entitlement": null, "id": "578", "name": "Situations in which the law obliges doctors to breach confidentiality", "status": null, "topic": { "__typename": "Topic", "id": "30", "name": "Ethics and Law", "typeId": 2 }, "topicId": 30, "totalCards": 2, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 578, "conditions": [], "difficulty": 3, "dislikes": 51, "explanation": null, "highlights": [], "id": "6480", "isLikedByMe": 0, "learningPoint": "Doctors have a legal duty to breach confidentiality when a patient is suspected of committing a road traffic offence.", "likes": 3, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A junior medical student has learnt that all patients have a legal right to confidentiality. However, he is unsure of the circumstances in which confidentiality can be breached.\n\nIn which of the following situations does a doctor have a legal duty to breach confidentiality?", "sbaAnswer": [ "a" ], "totalVotes": 4728, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "CPR should be discussed with the patient prior to making a decision on whether they should be for it or not.", "id": "32407", "label": "e", "name": "Proceed with full treatment and keep the patient for CPR", "picture": null, "votes": 1195 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "It is good practice to discuss patients' wishes regarding CPR even in cases such as this where it is unlikely to be successful. This is important to maintain an honest and transparent patient-doctor relationship", "id": "32403", "label": "a", "name": "Explore the patient's wishes regarding CPR", "picture": null, "votes": 3322 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Although CPR is unlikely to be successful, it would be inappropriate to complete a DNACPR form without a discussion regarding the matter with the patient", "id": "32405", "label": "c", "name": "Complete a do not attempt cardiopulmonary resuscitation (DNACPR) as CPR is not likely to be successful", "picture": null, "votes": 133 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "It would not be appropriate to ask the patient's family for their opinion without the patient's prior consent unless this was done in the patient's best interest. There are no signs to suggest that the patient lacks capacity in this case so it would be worth speaking to the patient first", "id": "32406", "label": "d", "name": "Ask the patient's family about their thoughts on CPR", "picture": null, "votes": 11 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Although CPR is unlikely to be successful, there is no reason why active treatment for the patient's stroke and cancer should not continue", "id": "32404", "label": "b", "name": "Explain to the patient why active treatment will not be offered", "picture": null, "votes": 94 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Very good question. Finally some real quesmed stuff", "createdAt": 1709051181, "dislikes": 2, "id": "43013", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6481, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Ale", "id": 20565 } }, { "__typename": "QuestionComment", "comment": "but CPR is a medical decision? If the pt's decision was to be resuscitated it would probably be overriden anyway? \"exploring the pt's wishes\" sounds like the decision is being made by the patient", "createdAt": 1735904177, "dislikes": 0, "id": "59510", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6481, "replies": [ { "__typename": "QuestionComment", "comment": "Guess it's about making the patient feel heard before telling them anyway", "createdAt": 1736727565, "dislikes": 0, "id": "60392", "isLikedByMe": 0, "likes": 0, "parentId": 59510, "questionId": 6481, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Prolapsed Fissure", "id": 37601 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Amnesia Serotonin", "id": 16056 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Overview\n\nA Do Not Attempt CPR (DNACPR) decision can also be known as Do Not Attempt Resuscitation (DNAR)\n\nA DNACPR decision provides information to healthcare professionals present on the best action to take if an individual suffers a cardiac arrest. A DNACPR is recorded, normally on a CPR Decision form, but is not in itself legally binding. This means that a doctor can overrule an existing DNACPR if they believe the circumstances do mean CPR would be in the patient's best interests.\n\nA DNACPR can be made if cardiac or respiratory arrest is an expected part of the dying process, and either CPR will not be successful, or if CPR may be successful but the clinical outcomes (e.g. trauma and prognosis) mean it is not clinically appropriate. A patient with capacity may also refuse CPR.\n\n# Best Interests \n\nDoctors can ultimately make the decision to put a DNACPR in place if it is in the patient's _best interests_, even if the patient themselves or their family disagrees. However, following a legal case in 2014, doctors must engage the patient and those close to them on the decision to make a DNACPR, and inform them if the decision to make a DNACPR order has occurred.\n\n# R (Tracey) v Cambridge University Hospitals NHS Foundation Trust, 2014 \n\nJanet Tracey died in Addenbrooke's Hospital in March 2011. She had been diagnosed with terminal lung cancer and had subsequently been involved in a car crash, in which she sustained a spinal injury. She required ventilation in the Intensive Care Unit (ICU), and after attempts to remove her from the ventilator were unsuccessful, a DNACPR notice was placed in her medical notes. Neither Janet Tracey nor her family were consulted about or informed of this decision.\n\nThe legal case concluded in favour of Tracey, finding that her Human Rights had been breached. The case acknowledged that the decision to put a DNACPR in place is ultimately a medical decision, and patients cannot demand treatment. But, the case did result in changes to DNACPR guidance:\n\nFirstly, the decision to not tell a patient about a DNACPR notice can no longer be based on the fact that telling them would cause “distress”. Only if discussing a DNACPR order would cause the patient “physical or psychological harm”, can doctors justify not discussing it. In other circumstances, doctors are legally obliged to discuss a DNACPR order that has been made.\n\nSecondly, it used to be the case that doctors were not obliged to discuss a DNACPR decision if the clinical decision has been made that CPR would be futile. This case amended this, making it a legal obligation for doctors to inform the patient that a DNACPR decision has been made, regardless of whether or not CPR could ever be successful (i.e. futility of CPR is justification for doctors making a best interests decision to make a DNACPR order - even if the patient wants CPR, but doctors are still legally obliged to inform the patient that a DNACPR order has been made).\n\nA DNACPR decision relates only to CPR, and is not a refusal of any other treatment.", "files": null, "highlights": [], "id": "574", "pictures": [], "typeId": 2 }, "chapterId": 574, "demo": null, "entitlement": null, "id": "589", "name": "DNACPR decisions", "status": null, "topic": { "__typename": "Topic", "id": "30", "name": "Ethics and Law", "typeId": 2 }, "topicId": 30, "totalCards": 2, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 589, "conditions": [], "difficulty": 1, "dislikes": 6, "explanation": null, "highlights": [], "id": "6481", "isLikedByMe": 0, "learningPoint": "In advanced care planning, it is essential to discuss patients' wishes regarding CPR, regardless of their prognosis.", "likes": 4, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "An 85-year-old man with a background of metastatic prostate cancer is admitted to hospital with a stroke. On examination, he has significant left-sided weakness and sensory loss but no disturbance in cognition or speech.\n\nWhich of the following is the most appropriate next step in regards to advanced care planning?", "sbaAnswer": [ "a" ], "totalVotes": 4755, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Shared decision refers to a process where both the doctor and the patient contribute towards making a personalised decision on management", "id": "32412", "label": "e", "name": "Shared decision making", "picture": null, "votes": 31 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Duty of candour states that \"all healthcare professionals should be open and honest with patients when treatment or care causes, or has the potential to cause, harm or distress\". In this situation, the doctor should contact the patient as soon as possible and inform them of the error. They should also report the incident so it can be investigated internally to reduce similar occurrences in the future", "id": "32408", "label": "a", "name": "Professional duty of candour", "picture": null, "votes": 3949 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Informed consent relies on the principles of the patient being fully informed, having mental capacity and not being coerced into a decision. It is not applicable in this case as the patient has consented to a surgery based on the wrong information", "id": "32411", "label": "d", "name": "Informed consent", "picture": null, "votes": 78 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "The doctrine of double effect states that if the primary intervention was in a patient's best interests, then an unintended adverse effect is not necessarily unlawful. It does not apply in this case", "id": "32410", "label": "c", "name": "The doctrine of double effect", "picture": null, "votes": 182 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Confidentiality is a legal right that all patients have. Although the doctor has inadvertently breached confidentiality by informing the patient of another patients test results, duty of candour is more pertinent given that a patient is likely to undergo an unnecessary operation", "id": "32409", "label": "b", "name": "Confidentiality", "picture": null, "votes": 548 } ], "comments": [ { "__typename": "QuestionComment", "comment": "We thank you for your candour!", "createdAt": 1685953534, "dislikes": 0, "id": "27894", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6482, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Amaurosis Fugaxlegomenon", "id": 26260 } }, { "__typename": "QuestionComment", "comment": "are all dr's griffindor?", "createdAt": 1704405614, "dislikes": 0, "id": "37770", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6482, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Malignant Syndrome", "id": 15952 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Overview\n\nAccording to guidance from the General Medical Council, it is important to respond constructively when things go wrong. It is important to establish _open and honest_ communication, and do the following:\n\n- Apologise (**this is not an admission of liability**)\n- Explain what has happened\n- Notify a senior clinician\n- Direct the patient and their family to the Patient Advice and Liaison Service, and advise them on the complaints procedure\n- Explain to them what investigations will be carried out", "files": null, "highlights": [], "id": "584", "pictures": [], "typeId": 2 }, "chapterId": 584, "demo": null, "entitlement": null, "id": "596", "name": "Medical Workplace Errors", "status": null, "topic": { "__typename": "Topic", "id": "30", "name": "Ethics and Law", "typeId": 2 }, "topicId": 30, "totalCards": null, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 596, "conditions": [], "difficulty": 1, "dislikes": 2, "explanation": null, "highlights": [], "id": "6482", "isLikedByMe": 0, "learningPoint": "Duty of candour states that \"all healthcare professionals should be open and honest with patients when treatment or care causes, or has the potential to cause, harm or distress\"", "likes": 1, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 32-year-old woman attends an appointment in the emergency surgery clinic due to persistent abdominal pain.\n\nThe patient is seen by a doctor and listed for an outpatient cholecystectomy following a review of the imaging she had the previous day.\n\nHowever, it transpires that the doctor has mistakenly reviewed the imaging of a patient with the same name, having failed to check the patient's age and hospital number.\n\nWhich of the following principles is most pertinent following identification of this error?", "sbaAnswer": [ "a" ], "totalVotes": 4788, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Haemochromatosis is a disorder of iron overload and can either be primary (an autosomal recessive disorder that results in an inability to regulate iron absorption) or secondary (due to frequent blood transfusions in conditions such as thalassaemia major). Haemochromatosis can cause liver disease and diabetes; however, the strong metabolic risk factors make NAFLD more likely in this case", "id": "32415", "label": "c", "name": "Haemochromatosis", "picture": null, "votes": 165 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Although this patient drinks regular alcohol, his consumption is not excessive. It is, therefore, unlikely that he has alcoholic liver disease", "id": "32414", "label": "b", "name": "Alcoholic liver disease", "picture": null, "votes": 1432 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient has diabetes, hypertension and obesity, which are three major risk factors for NAFLD. NAFLD is the most common cause of liver disease worldwide and is characterised by fatty infiltration of hepatocytes without a secondary cause. It is strongly linked to metabolic syndrome, and the most typical liver enzyme abnormality is a raised ALT and/or GGT", "id": "32413", "label": "a", "name": "Non-alcoholic fatty liver disease (NAFLD)", "picture": null, "votes": 3919 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Viral hepatitis is less likely as the patient has no risk factors (e.g. recent travel, history of intravenous drug use, recent tattoos/piercings, blood transfusion etc.) or symptoms. Viral hepatitis would also usually present with a more significant rise in transaminases (i.e. ALT and AST). It should, however be excluded by conducting a full viral screen", "id": "32416", "label": "d", "name": "Viral hepatitis", "picture": null, "votes": 22 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Autoimmune hepatitis is a rare cause of chronic liver disease that is more common in women and those with a background of other autoimmune diseases (e.g. type 1 diabetes, autoimmune thyroid disease, ulcerative colitis). NAFLD is more likely in this case", "id": "32417", "label": "e", "name": "Autoimmune hepatitis", "picture": null, "votes": 130 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Is there a way to differentiate with blood results?", "createdAt": 1732377698, "dislikes": 0, "id": "57496", "isLikedByMe": 0, "likes": 1, "parentId": null, "questionId": 6483, "replies": [ { "__typename": "QuestionComment", "comment": "Only if you have AST and ALT. I think here the point is that he drinks within the limit, therefore not alcohol induced", "createdAt": 1737484884, "dislikes": 0, "id": "61178", "isLikedByMe": 0, "likes": 1, "parentId": 57496, "questionId": 6483, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Migraine Biopsy", "id": 41194 } }, { "__typename": "QuestionComment", "comment": "I was just out here thinking he was just lying about his intake", "createdAt": 1738435089, "dislikes": 0, "id": "62096", "isLikedByMe": 0, "likes": 0, "parentId": 57496, "questionId": 6483, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Positive Whiff Test", "id": 35787 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "S", "id": 22922 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "\n# Summary\n\nNon-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease globally. It encompasses a spectrum of liver conditions ranging from simple steatosis (fat accumulation) to non-alcoholic steatohepatitis (NASH), which can progress to fibrosis and ultimately cirrhosis. NAFLD is closely associated with metabolic syndrome, including obesity, type 2 diabetes, and hyperlipidaemia. Diagnosis often occurs incidentally through imaging or abnormal liver function tests. Management focuses on lifestyle modifications, managing comorbidities, and regular monitoring for liver complications. Early identification and intervention are crucial to prevent disease progression.\n\n# Definition\n\nNon-alcoholic fatty liver disease (NAFLD) refers to a range of liver conditions characterised by excessive fat accumulation in the liver in the absence of significant alcohol consumption. It includes simple steatosis, non-alcoholic steatohepatitis (NASH), and can progress to fibrosis and cirrhosis.\n\n# Epidemiology\nNAFLD is the leading cause of chronic liver disease worldwide, affecting approximately 25-30% of adults in developed countries. In the UK, the prevalence is similar, reflecting the high rates of obesity and type 2 diabetes, both of which are part of metabolic syndrome. NAFLD is increasingly recognised in children and adolescents, paralleling the rise in paediatric obesity.\n\n# Aetiology\nNAFLD is primarily associated with metabolic syndrome and its components:\n\n- **Obesity**\n- **Type 2 diabetes mellitus**\n- **Hyperlipidaemia (high triglycerides and low HDL)**\n- **Hypertension**\n\nOther risk factors include:\n\n- Jejunal bypass surgery\n- Rapid weight loss or prolonged starvation\n- Polycystic ovary syndrome (PCOS)\n- Hypothyroidism\n- Obstructive sleep apnoea\n\n# Pathophysiology\n\nNAFLD progresses through a continuum:\n\n- **Steatosis:** Simple fatty liver with fat accumulation in hepatocytes, usually asymptomatic and reversible with lifestyle changes.\n- **Non-Alcoholic Steatohepatitis (NASH):** Inflammation and hepatocellular injury in addition to fat accumulation, leading to fibrosis.\n- **Fibrosis and Cirrhosis:** Progressive scarring of the liver tissue, which can ultimately lead to liver failure and increased risk of hepatocellular carcinoma.\n\n# Signs and Symptoms\n\nNAFLD is often asymptomatic but can present with:\n\n- Fatigue\n- Right upper quadrant discomfort\n- Hepatomegaly\n\nAs the disease progresses to cirrhosis, symptoms may include:\n\n- Jaundice\n- Ascites\n- Peripheral oedema\n- Hepatic encephalopathy\n\n# Differential Diagnosis\n\n- **Alcoholic Liver Disease (ALD):** Similar histological features, but differentiated by history of significant alcohol intake.\n- **Chronic Hepatitis B and C:** Viral serologies positive; may have similar liver biopsy findings.\n- **Autoimmune Hepatitis:** Positive autoantibodies and elevated immunoglobulins.\n- **Wilson's Disease:** Low caeruloplasmin levels and elevated urinary copper.\n- **Haemochromatosis:** Elevated serum iron, ferritin, and transferrin saturation.\n- **Drug-Induced Liver Injury (DILI):** History of hepatotoxic drug use.\n\n# Investigations\n- **Bedside:**\n - Detailed history including alcohol consumption, medication use, and risk factors for liver disease.\n - Physical examination for signs of chronic liver disease.\n\n- **Bloods:**\n - Liver function tests (ALT, AST, GGT, ALP, bilirubin).\n - Full blood count.\n - Fasting glucose and lipid profile.\n - Tests to exclude other causes of liver disease: viral serologies (Hepatitis B and C), autoantibodies, serum iron studies, caeruloplasmin.\n\n- **Imaging:**\n - **Ultrasound:** Often the first test that shows fatty infiltration of the liver.\n - **Elastography (FibroScan):** Measures liver stiffness to assess fibrosis.\n - **Enhanced Liver Fibrosis (ELF) test:** Blood test assessing markers of fibrosis.\n\n- **Invasive:**\n - **Liver biopsy:** Considered the **gold standard** for diagnosing NASH and staging fibrosis, although often reserved for cases where non-invasive tests are inconclusive.\n\n# Management\n- **Conservative:**\n - Lifestyle modifications including weight loss if obese, exercise, and dietary changes.\n - Abstinence from alcohol.\n - Vaccination against hepatitis A and B.\n - Avoid hepatotoxic drugs where possible\n\n- **Medical:**\n - **Metabolic management:** Control of diabetes, hyperlipidaemia, and hypertension.\n - **Medications:** No specific drugs have been approved for NAFLD, but some off-label use of vitamin E (in non-diabetic patients) and pioglitazone in NASH.\n \t- These medications should only be prescribed in secondary care, and when consenting patients they should be made aware of the possible increase of 2-4% body weight (within 3 years of treatment) and the increased risk of bladder cancer and osteoporosis (in women). \n\n- **Monitoring and Screening:**\n - Regular follow-up with liver function tests and imaging.\n - Screening for hepatocellular carcinoma in patients with advanced fibrosis or cirrhosis.\n\n# Complications\n- **Reversible:**\n - Early steatosis with lifestyle changes.\n \n- **Irreversible:**\n - Progression to cirrhosis.\n - Liver failure.\n - Hepatocellular carcinoma.\n - Cardiovascular disease due to associated metabolic syndrome.\n\n# Prognosis\n\nThe prognosis of NAFLD varies widely. Simple steatosis generally has a good prognosis with lifestyle modifications. However, NASH can progress to fibrosis and cirrhosis, which are associated with significant morbidity and mortality. Early identification and management of risk factors are crucial in preventing disease progression.\n\n# NICE Guidelines\n\n[NICE CKS - Non-alcoholic fatty liver disease (NAFLD)\n](https://cks.nice.org.uk/topics/non-alcoholic-fatty-liver-disease-nafld/)", "files": null, "highlights": [], "id": "3293", "pictures": [], "typeId": 2 }, "chapterId": 3293, "demo": null, "entitlement": null, "id": "6185", "name": "Non-Alcoholic Fatty Liver Disease", "status": null, "topic": { "__typename": "Topic", "id": "23", "name": "Gastroenterology", "typeId": 2 }, "topicId": 23, "totalCards": null, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 6185, "conditions": [], "difficulty": 2, "dislikes": 16, "explanation": null, "highlights": [], "id": "6483", "isLikedByMe": 0, "learningPoint": "Non-alcoholic fatty liver disease (NAFLD) is commonly associated with obesity, diabetes, and hypertension, leading to elevated liver enzymes.", "likes": 7, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 56-year-old man with a background of type 2 diabetes and hypertension presents to his GP for a routine set of blood tests.\n\n\nHe reports regularly drinking approximately 14 Units of alcohol per week. His body mass index (BMI) is 30, and a set of routine observations are unremarkable.\n\n\nThe blood tests reveal an alanine transaminase (ALT) of 195 U/L (7-56 U/L) and a gamma-glutamyl transferase (GGT) level of 85 U/L (<10 U/L). Glycosylated haemoglobin levels (HBA1C) are noted to be 52 mmol/l (42-47 mmol/l).\n\n\nWhich of the following is the most likely explanation for the deranged liver function tests?", "sbaAnswer": [ "a" ], "totalVotes": 5668, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "This patient has symptoms suggestive of severe colitis, which has the potential to deteriorate significantly. He should be admitted to hospital for investigation and management", "id": "32422", "label": "e", "name": "Monitor symptoms and review in three days", "picture": null, "votes": 17 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Treatment for UC should be started by a gastroenterologist, following confirmation of the diagnosis. It would not be appropriate to start treatment in primary care", "id": "32420", "label": "c", "name": "Start oral steroids", "picture": null, "votes": 333 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient has a history suggestive of inflammatory bowel disease (IBD). The significant rectal bleeding and tenesmus (urge to constantly open his bowels) are more suggestive of ulcerative colitis (UC) than Crohn's disease. Using the Truelove and Witts scoring system for UC, this patient has severe UC due to the number of bowel motions per day and anaemia. Hospital admission is recommended for patients with features suggestive of severe disease", "id": "32418", "label": "a", "name": "Urgent hospital admission", "picture": null, "votes": 2748 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Patients with symptoms suggestive of milder UC would be more appropriate for outpatient review. The patient is anaemic with significant symptoms, which means that he would be better managed as an inpatient in secondary care", "id": "32419", "label": "b", "name": "Urgent outpatient gastroenterology referral", "picture": null, "votes": 991 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Faecal calprotectin is an inflammatory marker that is useful in the diagnosis of IBD. However, given that the patient satisfied the criteria for severe colitis, this patient should be admitted to hospital for investigation and management", "id": "32421", "label": "d", "name": "Check faecal calprotectin in primary care", "picture": null, "votes": 1545 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nUlcerative colitis (UC) is a chronic inflammatory disease that affects the large bowel. Symptoms include diarrhoea, urgency, tenesmus, weight loss, and fever. The disease can present with extra-intestinal features such as dermatological (erythema nodosum), ocular (anterior uveitis), musculoskeletal (finger clubbing), and hepatobiliary manifestations (jaundice due to primary sclerosing cirrhosis). Investigations include blood tests, microbiological investigations, endoscopic investigations, and imaging. The management of UC is based on severity and involves inducing and maintaining remission using medications like aminosalicylates, steroids, and biologics. Surgery may be required in severe cases or when medical treatment is unsuccessful. Long-term complications include colorectal cancer, cholangiocarcinoma and colonic strictures.\n\n# Definition\n\nUlcerative colitis (UC) is a chronic relapsing-remitting inflammatory disease that primarily affects the large bowel. It usually affects the rectum first, then can extend to the part of the colon (left-hand-side colitis) or the entire colon (pancolitis). It does not spread beyond the ileocaecal valve or to the small bowel, except where backwash ileitis can occur.\n\n# Epidemiology\n\nUC is the most commonly diagnosed inflammatory bowel disease. It has an annual incidence rate of 10 per 100,000 people and a prevalence rate of 243 per 100,000. Although UC can develop at any age, it most frequently occurs in two peak age groups: 15 to 25 years and 55 to 65 years.\n\n# Aetiology\n\nThe exact cause of UC is unknown, but it is believed to result from a combination of genetic predisposition, environmental factors, and dysregulation of the immune system. There is also a higher incidence of UC among non-smokers and ex-smokers.\n\n# Signs and Symptoms\n\nThe main symptoms of UC are gastrointestinal and systemic. \n\nGastrointestinal symptoms include:\n\n- Diarrhoea often containing blood and/or mucus\n- Tenesmus or urgency\n- Generalised crampy abdominal pain in the left iliac fossa\n\nSystemic symptoms include:\n\n- Weight loss\n- Fever\n- Malaise\n- Anorexia\n\nPhysical examination may reveal general signs such as pallor due to anaemia and clubbing. Abdominal examination may reveal distension or tenderness, and a PR examination may show tenderness, and blood/mucus. \n\n\nExtra-intestinal signs occur in 10-20% of patients and include:\n\n- Dermatological manifestations: erythema nodosum, pyoderma gangrenosum\n- Ocular manifestations: anterior uveitis, episcleritis, conjunctivitis\n- Musculoskeletal manifestations: clubbing, non-deforming asymmetrical arthritis, sacroiliitis\n- Hepatobiliary manifestations: jaundice due to primary sclerosing cholangitis (PSC). 80% of those with PSC have ulcerative colitis.\n- Other features include AA amyloidosis\n\n\n\n\n# Differential Diagnosis\n\nThe differential diagnoses for UC include Crohn's disease, infectious colitis, and ischemic colitis. Key signs and symptoms to differentiate these conditions include:\n\n- Crohn's disease: Abdominal pain, weight loss, diarrhea, oral ulcers, anal fissures, and perianal fistulas.\n- Infectious colitis: Acute onset of diarrhea, fever, and abdominal pain. May be associated with recent antibiotic use, travel, or consumption of contaminated food or water.\n- Ischemic colitis: Sudden onset of abdominal pain, blood in stools, and a history of vascular disease or risk factors.\n\n# Investigations\n\n**Bedside:**\n\n- Microbiological investigations: Stool microscopy (for ova/cysts/parasites), culture and sensitivity, and stool C. difficile toxin to exclude infective colitis\n- Faecal calprotectin: Distinguishes between inflammatory bowel syndrome (normal) and inflammatory bowel disease (raised)\n\n**Bloods:**\n\n- Blood tests: FBC (anaemia and a raised white cell count), ESR/CRP is typically raised, LFTs may show a low albumin\n\n**Imaging/Invasive:**\n\n- Radiological investigations: Abdominal X-ray and erect chest x-ray in acute settings to exclude toxic megacolon and perforation.\n\t- Long-standing UC will show 'lead-pipe' colon on AXR \n- Endoscopic investigations: Colonoscopy, barium enema, and biopsy are used to confirm the diagnosis.\n - Colonoscopy will reveal shows continuous inflammation starting at the rectum that does not go beyond the submucosa with an erythematous mucosa, loss of haustral markings, and pseudopolyps.\n - Biopsy: loss of goblet cells, crypt abscess, and inflammatory cells (predominantly lymphocytes)\n - Barium enema will reveal lead-piping inflammation (secondary to loss of haustral markings), thumb-printing (a marker of bowel wall inflammation), and pseudopolyps (due to areas of ulcerating mucosa adjacent to areas of regenerating mucosa). This is less commonly used nowadays due to the increasing availability of endoscopic investigations\n\n# Truelove and Witt's Criteria for Severity\n\nAn acute exacerbation of ulcerative colitis should be assessed using the Truelove and Witt's severity index.\n\n| | **Mild** | **Moderate** | **Severe** |\n| --------------------------------------------- | ----------------------------------- | ----------------------- | ------------------------------------------------------------------------------------ |\n| **Bowel movements (no. per day)** | Fewer than 4 | 4-6 | 6 or more plus at least one of the features of systemic upset (marked with \\* below) |\n| **Blood in stools** | No more than small amounts of blood | Between mild and severe | Visible blood |\n| **Pyrexia (temperature greater than 37.8°C)** | No | No | Yes |\n| **Pulse rate greater than 90 bpm** | No | No | Yes |\n| **Anaemia (< 10g/100mL)** | No | No | Yes |\n| **Erythrocyte sedimentation rate (mm/hour)** | 30 or below | 30 or below | above 30 |\n\n\n# Management\n\n\n## Mild-moderate disease\n\nThe aim of step 1 treatment is to induce remission. If this does not work after 4 weeks, or symptoms worsen, move to step 2.\n\nThe first step in management for a moderate first presentation is to offer a topical aminosalicylate as first-line treatment. If remission is not achieved within 4 weeks, consider adding an oral aminosalicylate. In acute moderate disease if all other measures haven't worked then a trial of Etrasimod (also known as Velsipity). This is a selective sphingosine 1-phosphate (S1P) receptor modulator.\n\n- **Proctitis and proctosigmoiditis:**\n - Step 1: Topical ASA or oral ASA.\n - Step 2: Consider adding oral prednisolone. If this does not help after 2-4 weeks or symptoms worsen, consider adding oral tacrolimus.\n- **Left sided or extensive disease**\n - Step 1: High dose oral ASA.\n - Step 2: Consider adding oral prednisolone. If this does not help after 2-4 weeks or symptoms worsen, consider adding oral tacrolimus.\n\n## Acute severe disease\n\n- Step 1: IV corticosteroids (if contraindicated or not tolerated, use IV ciclosporin).\n- Step 2: If no improvement in 72 hours or worsening symptoms, add IV ciclosporin or consider surgery (if IV ciclosporin contraindicated or not tolerated, consider infliximab).\n- Step 3: A trial of Etrasimod (also known as Velsipity). This is a selective sphingosine 1-phosphate (S1P) receptor modulator.\n- Indications for emergency surgery:\n - Surgery should be considered in patients with:\n - Acute fulminant ulcerative colitis\n - Toxic megacolon who have little improvement after 48-72 hours of intravenous steroids\n - Symptoms worsening despite intravenous steroids\n\n_Note that an alternative is to initiate rescue therapy (with ciclosporin or infliximab) if the patient has a sub-optimal response to intravenous steroids but is stable enough to delay surgery. Surgery should be considered if patients fail to respond to rescue therapy within 3 days._\n\n## Surgical options\n\n- Panproctocolectomy with permanent end ilesotomy\n- Colectomy with temporary end ileostomy (approximately 3 months later the ileostomy can be reversed by forming an ileorectal anastomosis, an alternative option is completion proctectomy with a permanent end ileostomy or ileal pouch anal anastomosis (IPAA)).\n\n## Indications for elective surgery\n\n- This can be considered in patients in which there is failure to induce remission by medical means.\n- Surgical options include: panproctocolectomy with permanent end ileostomy or IPAA. An alternative is a total colectomy with ileorectal anastomosis (i.e. no stoma).\n\n# Complications\n\n## Short-term/acute complications\n\n- Toxic megacolon: this describes a severe form of colitis, and is seen in around 15% of ulcerative colitis patients.\n- Massive lower gastrointestinal haemorrhage: this occurs in up to 3% of patients.\n\n## Long-term complications\n\n- Colorectal cancer: this occurs in 3-5% of patients. There is a higher risk with disease duration, severity and extent of colitis, and concomitant primary sclerosing cholangitis (PSC).\n\n_NICE guidance suggests offering colonoscopy surveillance to high risk patients._\n\n- Cholangiocarcinoma: ulcerative colitis approximately doubles the risk of cholangiocarcinoma.\n- Colonic strictures: these can cause large bowel obstruction.\n\n## Variable-term complications\n\n- Primary Sclerosing Cholangitis: this is characterised by inflammation and fibrosis of the extra- and intra-hepatic biliary tree and affects 3-7% of patients with ulcerative colitis. LFTs should be monitored yearly to check for the presence of PSC.\n- Inflammatory pseudopolyps: these are areas of normal mucosa between areas of ulceration and regeneration.\n- Increased risk of VTE - as with any inflammatory disease, but in the acute and chronic context, patients have an increased risk of developing blood clots, especially during flares\n\n# References\n\n[Click here for more information on NICE CKS about ulcerative colitis](https://cks.nice.org.uk/topics/ulcerative-colitis/)", "files": null, "highlights": [], "id": "717", "pictures": [ { "__typename": "Picture", "caption": "An abdominal x-ray showing toxic megacolon.", "createdAt": 1665036198, "id": "1046", "index": 0, "name": "Toxic megacolon.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/gfvvkg811665036171697.jpg", "path256": "images/gfvvkg811665036171697_256.jpg", "path512": "images/gfvvkg811665036171697_512.jpg", "thumbhash": "HwgKBgALeIiJl8iJd4l3enaHAAAAAAA=", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 717, "demo": null, "entitlement": null, "id": "749", "name": "Ulcerative Colitis", "status": null, "topic": { "__typename": "Topic", "id": "23", "name": "Gastroenterology", "typeId": 2 }, "topicId": 23, "totalCards": 42, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "749", "name": "Ulcerative Colitis" } ], "demo": false, "description": null, "duration": 167.57, "endTime": null, "files": null, "id": "716", "live": false, "museId": "NGXVhUW", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/gastroenterology.png", "title": "Crohn's disease 4", "userViewed": false, "views": 12, "viewsToday": 2 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "749", "name": "Ulcerative Colitis" } ], "demo": false, "description": null, "duration": 186.3, "endTime": null, "files": null, "id": "715", "live": false, "museId": "sdy9pRp", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/gastroenterology.png", "title": "Crohn's disease 3", "userViewed": false, "views": 15, "viewsToday": 2 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "749", "name": "Ulcerative Colitis" } ], "demo": false, "description": null, "duration": 491.37, "endTime": null, "files": null, "id": "400", "live": false, "museId": "kJ7hJXb", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/gastroenterology.png", "title": "Ulcerative Colitis", "userViewed": false, "views": 167, "viewsToday": 15 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "749", "name": "Ulcerative Colitis" } ], "demo": false, "description": null, "duration": 3432.19, "endTime": null, "files": null, "id": "639", "live": false, "museId": "tELr33y", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/gastroenterology.png", "title": "Quesmed Tutorial: Inflammatory Bowel Disease", "userViewed": false, "views": 94, "viewsToday": 10 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "749", "name": "Ulcerative Colitis" } ], "demo": false, "description": null, "duration": 586.97, "endTime": null, "files": null, "id": "712", "live": false, "museId": "RAmxzid", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/gastroenterology.png", "title": "Ulcerative Colitis 5", "userViewed": false, "views": 11, "viewsToday": 4 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "749", "name": "Ulcerative Colitis" } ], "demo": false, "description": null, "duration": 304.23, "endTime": null, "files": null, "id": "713", "live": false, "museId": "b4Lirni", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/gastroenterology.png", "title": "Ulcerative Colitis 6", "userViewed": false, "views": 11, "viewsToday": 4 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "749", "name": "Ulcerative Colitis" } ], "demo": false, "description": null, "duration": 603.26, "endTime": null, "files": null, "id": "711", "live": false, "museId": "aCyZPba", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/gastroenterology.png", "title": "Ulcerative Colitis 3", "userViewed": false, "views": 29, "viewsToday": 4 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "749", "name": "Ulcerative Colitis" } ], "demo": false, "description": null, "duration": 4509.5, "endTime": null, "files": null, "id": "314", "live": false, "museId": "rgWyy3w", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/gastroenterology.png", "title": "Quesmed Tutorial: Gastroenterology and Hepatology", "userViewed": false, "views": 1028, "viewsToday": 26 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "749", "name": "Ulcerative Colitis" } ], "demo": false, "description": null, "duration": 394.67, "endTime": null, "files": null, "id": "641", "live": false, "museId": "9bmGaYs", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/gastroenterology.png", "title": "Primary sclerosing cholangitis", "userViewed": false, "views": 50, "viewsToday": 4 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "749", "name": "Ulcerative Colitis" } ], "demo": false, "description": null, "duration": 415.3, "endTime": null, "files": null, "id": "710", "live": false, "museId": "P9adV65", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/gastroenterology.png", "title": "Ulcerative Colitis 2", "userViewed": false, "views": 46, "viewsToday": 8 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "749", "name": "Ulcerative Colitis" } ], "demo": false, "description": null, "duration": 358.23, "endTime": null, "files": null, "id": "714", "live": false, "museId": "7KanxMj", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/gastroenterology.png", "title": "Crohn's disease 2", "userViewed": false, "views": 20, "viewsToday": 4 } ] }, "conceptId": 749, "conditions": [], "difficulty": 3, "dislikes": 13, "explanation": null, "highlights": [], "id": "6484", "isLikedByMe": 0, "learningPoint": "Severe ulcerative colitis is characterised by frequent bloody stools, abdominal pain, and may require urgent hospital admission for management.", "likes": 10, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 23-year-old man presents to his GP with a history of bloody stool. For the last week, he reports opening his bowel six times per day with associated blood. He also notes associated mild abdominal pain and the constant urge to open his bowels.\n\n\nHe has no significant past medical history; however, he has a family history of type 1 diabetes and rheumatoid arthritis.\n\n\nOn assessment, he is haemodynamically stable. Abdominal examination is unremarkable apart from some diffuse mild abdominal tenderness, and blood tests show a haemoglobin level of 102 g/L (130-170 g/L).\n\n\nWhich of the following is the next best step in management?", "sbaAnswer": [ "a" ], "totalVotes": 5634, "typeId": 1, "userPoint": null }

[]

{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "There is no role for oesophagectomy in Barrett's. Oesophagectomy is a treatment option for oesophageal carcinoma", "id": "32426", "label": "d", "name": "Referral to the multi-disciplinary team (MDT) for consideration of an oesophagectomy", "picture": null, "votes": 340 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "RFA is a treatment option for Barrett's with high-grade dysplasia as there is a more significant risk of progressing to cancer", "id": "32425", "label": "c", "name": "Radiofrequency ablation (RFA)", "picture": null, "votes": 257 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "High dose PPI alone should be combined with regular surveillance endoscopies to monitor for the development of dysplasia and adenocarcinoma", "id": "32427", "label": "e", "name": "High dose PPI", "picture": null, "votes": 117 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "The histological appearances are consistent with a diagnosis of Barrett's oesophagus. This is usually a consequence of long-standing reflux disease and describes the abnormal, reversible change of the oesophageal epithelium from stratified squamous to simple columnar. The major risk factor of Barretts's is oesophageal adenocarcinoma. Treatment is with high dose PPI and regular endoscopies to screen for the development of dysplasia and adenocarcinoma", "id": "32423", "label": "a", "name": "High dose proton-pump inhibitor (PPI) and surveillance endoscopies", "picture": null, "votes": 4088 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "EMR is a treatment option for Barrett's with high-grade dysplasia as there is a more significant risk of progressing to cancer", "id": "32424", "label": "b", "name": "Endoscopic mucosal resection (EMR)", "picture": null, "votes": 740 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nBarrett's oesophagus is a condition seen in patients with long standing gastro-oesophageal reflux disease (GORD). It describes when chronic acid exposure leads to a _change in the distal oesophagus from the usual squamous epithelium to metaplastic columnar epithelium_, known as metaplasia, and this usually occurs in the distal third of the oesophagus. This condition increases risk of oesophageal adenocarcinoma 100-fold which is why monitoring and prompt management is vital.\n\n# Definition\n\nBarrett's oesophagus is defined as an oesophagus in which any part of the distal squamous epithelial lining has been replaced by metaplastic columnar epithelium, visible endoscopically (≥1 cm) above the gastro-oesophageal junction and confirmed histopathologically (e.g. from a biopsy). It is classified according to the degree of dysplasia.\n\n\n# Epidemiology\n\nPrimarily affecting males over 50 with longstanding GORD, the condition has become increasingly prevalent in the UK due to several factors including rising obesity rates and the ageing population. It is thought that about 1 in 20 people who have recurring acid reflux eventually develops Barrett's oesophagus. The risk is mainly in people who have had severe acid reflux for many years.\n\n\n# Aetiology\n\nThe main risk factor for developing Barrett's oesophagus is longstanding **GORD**, however, other risk factors include:\n\n* Obesity\n* Smoking\n* Hiatus hernia \n* Increasing age (peak incidence 50-70 years)\n\n# Signs and Symptoms\n\nThese are the same as those in GORD:\n\n* Pain in the upper abdomen and chest\r\n* Heartburn \r\n* Acid taste in the mouth\r\n* Bloating\r\n* Belching\r\n\nPresence of 'ALARM' signs and symptoms (anaemia, loss of weight, anorexia, recent onset/progressive symptoms, melaena) may suggest progression to adenocarcinoma.\n\n# Investigations\n- OGD is the gold-standard for diagnosing and classifying Barret's oesophagus\n\n### 2-week-wait referral criteria\n\n- If there is dysphagia or, in those aged 55 years and over with weight loss and any of the following: upper abdominal pain, reflux, or dyspepsia.\n- Consider non-urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people with haematemesis.\n\n# Management\n\nSymptoms should be managed as per GORD management. Further management of Barrett's oesophagus specifically can be categorised into either surveillance or ablation, depending on the classification.\n\n- If there is short-segment (less than 3 cm) Barrett's oesophagus without intestinal metaplasia then no further surveillance is required\n\n## Endoscopic surveillance\n\n- In long-segment (3 cm or longer) Barrett's oesophagus, there should be a repeat OGD every 2 to 3 years \n- In short-segment (less than 3 cm) Barrett's oesophagus with intestinal metaplasia this should be done every 3 to 5 years\n- Patients with indefinite dysplasia should have surveillance every 6 months\n\n## Ablation\n\nPatients with **dysplasia** are eligible for ablation therapy, of which there are two techniques of equal efficacy: endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD).\n\n- First-line management of patients with visible high-grade dysplasia is endoscopic ablation of visualised lesions\n- These patients should be followed up with endoscopic surveillance, with endoscopic ablation of any residual Barrett's oesophagus offered \n\n\n# Complications\n\nIt is an important condition to identify as it carries a risk of progression to **oesophageal adenocarcinoma**.\n\nThe risk of developing Barrett's oesophagus increases with the length and severity of reflux symptoms.\n\n# NICE Guidelines\n\n[Barrett's oesophagus and stage 1 oesophageal adenocarcinoma: monitoring and management](https://www.nice.org.uk/guidance/ng231/chapter/Recommendations)\n", "files": null, "highlights": [], "id": "30000", "pictures": [], "typeId": 2 }, "chapterId": 30000, "demo": null, "entitlement": null, "id": "764", "name": "Barrett's oesophagus", "status": null, "topic": { "__typename": "Topic", "id": "23", "name": "Gastroenterology", "typeId": 2 }, "topicId": 23, "totalCards": 2, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "764", "name": "Barrett's oesophagus" } ], "demo": false, "description": null, "duration": 3205.8, "endTime": null, "files": null, "id": "325", "live": false, "museId": "U3D5yEs", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/obstetrics.png", "title": "Quesmed Tutorial: Obstetrics 1", "userViewed": false, "views": 335, "viewsToday": 20 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "764", "name": "Barrett's oesophagus" } ], "demo": false, "description": null, "duration": 178.62, "endTime": null, "files": null, "id": "44", "live": false, "museId": "RidqHx6", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/gastroenterology.png", "title": "Barrett's oesophagus", "userViewed": false, "views": 202, "viewsToday": 10 } ] }, "conceptId": 764, "conditions": [], "difficulty": 1, "dislikes": 0, "explanation": null, "highlights": [], "id": "6485", "isLikedByMe": 0, "learningPoint": "Barrett's oesophagus is characterized by metaplastic changes in the oesophageal lining resulting from chronic gastro-oesophageal reflux disease, requiring PPI therapy and regular surveillance.", "likes": 7, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 60-year-old man is referred for an outpatient gastroscopy following worsening reflux symptoms over the last six months.\n\nGastrosopcy shows a red, velvety appearance of the oesophageal mucosa and biopsies from this region show \"metaplastic columnar epithelium replacing the oesophageal squamous epithelium\". There are no areas of dysplasia identified.\n\nWhich of the following is the best step in management?", "sbaAnswer": [ "a" ], "totalVotes": 5542, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": true, "explanation": "Pancreatic pseudocysts are a common complication of acute or chronic pancreatitis. They occur due to damage to the pancreatic ducts, which leads to cystic accumulation of pancreatic juices. Pseudocysts can be asymptomatic or present with signs of biliary obstruction (abdominal pain, jaundice) or gastric outlet obstruction (post-prandial vomiting) due to mass effect of an enlarging pseudocyst on adjacent structures. There is also the risk of secondary infection", "id": "32428", "label": "a", "name": "Pancreatic pseudocyst", "picture": null, "votes": 1675 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Cholangiocarcinoma is less likely given the age of the patient and lack of risk factors", "id": "32430", "label": "c", "name": "Cholangiocarcinoma", "picture": null, "votes": 249 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "PBC is less likely as it would not explain the symptoms of gastric outlet obstruction. Also, there is no pruritus (present in around 70% of cases of PBC)", "id": "32432", "label": "e", "name": "Primary biliary cholangitis (PBC)", "picture": null, "votes": 948 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Choledocholithiasis refers to gallstone disease in the common bile duct. Although this is often associated with pain and cholestatic liver function tests, the post-prandial vomiting would be unusual and is more suggestive of gastric outlet obstruction", "id": "32431", "label": "d", "name": "Choledocholithiasis", "picture": null, "votes": 1935 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Pancreatic cancer is unlikely given the age of the patient. It is also more common for pancreatic cancer to present without pain", "id": "32429", "label": "b", "name": "Pancreatic cancer", "picture": null, "votes": 390 } ], "comments": [ { "__typename": "QuestionComment", "comment": "No fever?", "createdAt": 1685789017, "dislikes": 0, "id": "27652", "isLikedByMe": 0, "likes": 3, "parentId": null, "questionId": 6486, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Vitamin Yellow", "id": 28964 } }, { "__typename": "QuestionComment", "comment": "Only if it becomes infected - this is then an abscess so will have a fever ", "createdAt": 1709041647, "dislikes": 0, "id": "42989", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6486, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Lung QRS", "id": 51012 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nChronic pancreatitis is a long-term condition characterised by progressive inflammation and fibrosis of the pancreas leading to irreversible destruction of the exocrine and endocrine functions of the pancreas. Common symptoms include epigastric pain, malabsorption, steatorrhoea, and symptoms of diabetes mellitus. Structural and functional investigations are key to diagnosing the condition, which may be caused by a variety of factors, the most common being chronic alcohol excess. Management strategies include lifestyle changes, medication, and in some cases, invasive interventions. \n\n# Definition\n\nChronic pancreatitis is a medical condition characterised by persistent inflammation and fibrosis of both the exocrine and endocrine components of the pancreas.\n\n# Epidemiology\n\nChronic pancreatitis is most commonly caused by chronic alcohol excess, accounting for approximately 80% of cases. Less common causes include genetic factors, obstructive factors, and metabolic factors, while up to 15% of cases are idiopathic.\n\n# Aetiology\n\nThe primary cause of chronic pancreatitis is chronic alcohol excess. Other less common causes include:\n\n- Genetic factors such as cystic fibrosis\n- Obstructive causes such as pancreatic cancer\n- Metabolic causes such as elevated triacylglycerides\n\n# Pathophysiology\n\nProgressive inflammation and the development of fibrotic tissue in the pancreas results in a loss of exocrine function (lipase, amylase) and endocrine function (insulin). This manifests as malabsorption and impaired impaired blood glucose control, respectively.\n\n# Signs and Symptoms\n\nPatients with chronic pancreatitis typically present with the following:\n\n- Epigastric pain which is typically exacerbated after eating fatty food and relieved by sitting forward\n\t- Usually 15-30 minutes after eating\n- Bloating\n- Weight loss \n- Symptoms of exocrine dysfunction, such as malabsorption and steatorrhoea\n\t- Specifically absorption of fat-soluble vitamins (A, D, E and K) is reduced/lost, resulting in vitamin deficiencies and their own complications\t\n- Symptoms of endocrine dysfunction, such as diabetes mellitus, with symptoms including thirst and polyuria\n- Physical examination may reveal epigastric tenderness and signs of chronic liver disease, which could suggest alcohol as a cause\n\n# Differential Diagnosis\n\nDifferential diagnoses for chronic pancreatitis include acute pancreatitis, pancreatic cancer, and peptic ulcer disease. The main signs and symptoms of these differentials include:\n\n- Acute pancreatitis: severe acute-onset epigastric pain radiating to the back, nausea, vomiting, and elevated serum amylase and lipase\n- Pancreatic cancer: weight loss, jaundice, and abdominal pain\n- Peptic ulcer disease: burning abdominal pain, bloating, and heartburn\n- Abdominal aortic aneurysm - abdominal/back pain, shock/hypotension, expansile and pulsatile mass palpable in the abdomen\n\n# Investigations\n\n- Bedside - blood glucose, and faecal elastase (low if there is exocrine insufficiency)\n- Blood tests - serum amylase and lipase are not typically raised in chronic pancreatitis, unlike in acute pancreatitis\n- Imaging - abdominal x-ray (to detect calcifications) and CT scan (to show pancreatic calcification), the latter being more sensitive at detecting calcification\n\n\n# Management\n\nManagement of chronic pancreatitis includes:\n\n- Conservative measures such as abstinence from alcohol and maintaining a healthy diet\n- Medical measures including pain control with analgesia, management of endocrine dysfunction with insulin, and management of exocrine dysfunction with pancreatic enzyme replacement therapy (Creon is a common brand name you may come across, containing mixtures of amylase, lipase, and protease).\n- Invasive interventions may be considered if the above measures fail, such as coeliac plexus block and pancreatectomy.\n\n# Complications\n\nComplications of chronic pancreatitis can be local (such as pseudocyst or pancreatic cancer) or systemic (endocrine dysfunction leading to diabetes mellitus, or exocrine dysfunction leading to malabsorption and steatorrhoea).\n\n# NICE Guidelines\n\n[Click here to see NICE CKS information on chronic pancreatitis](https://cks.nice.org.uk/topics/pancreatitis-chronic/)", "files": null, "highlights": [], "id": "725", "pictures": [], "typeId": 2 }, "chapterId": 725, "demo": null, "entitlement": null, "id": "756", "name": "Chronic pancreatitis", "status": null, "topic": { "__typename": "Topic", "id": "23", "name": "Gastroenterology", "typeId": 2 }, "topicId": 23, "totalCards": 6, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "756", "name": "Chronic pancreatitis" } ], "demo": false, "description": null, "duration": 514.47, "endTime": null, "files": null, "id": "669", "live": false, "museId": "d7y5KTL", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/gastroenterology.png", "title": "Chronic pancreatitis 3", "userViewed": false, "views": 21, "viewsToday": 4 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "756", "name": "Chronic pancreatitis" } ], "demo": false, "description": null, "duration": 3160.55, "endTime": null, "files": null, "id": "599", "live": false, "museId": "fyLon5U", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/gastroenterology.png", "title": "Quesmed Tutorial: Acute and Chronic Pancreatitis", "userViewed": false, "views": 126, "viewsToday": 19 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "756", "name": "Chronic pancreatitis" } ], "demo": false, "description": null, "duration": 172.22, "endTime": null, "files": null, "id": "668", "live": false, "museId": "TDaiSPF", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/gastroenterology.png", "title": "Chronic pancreatitis 2", "userViewed": false, "views": 26, "viewsToday": 4 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "756", "name": "Chronic pancreatitis" } ], "demo": false, "description": null, "duration": 504.26, "endTime": null, "files": null, "id": "601", "live": false, "museId": "cFmL7GC", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/gastroenterology.png", "title": "Alcohol withdrawal", "userViewed": false, "views": 29, "viewsToday": 9 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "756", "name": "Chronic pancreatitis" } ], "demo": false, "description": null, "duration": 164.74, "endTime": null, "files": null, "id": "667", "live": false, "museId": "x9LxZK9", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/gastroenterology.png", "title": "Chronic pancreatitis 1", "userViewed": false, "views": 42, "viewsToday": 7 } ] }, "conceptId": 756, "conditions": [], "difficulty": 3, "dislikes": 19, "explanation": null, "highlights": [], "id": "6486", "isLikedByMe": 0, "learningPoint": "Pancreatic pseudocysts are common complications of chronic pancreatitis, typically forming as fluid-filled sacs that develop in response to inflammation, necrosis, or ductal obstruction, and can lead to symptoms such as abdominal pain, nausea, and potential rupture or infection if left untreated.", "likes": 8, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 35-year-old woman with a history of chronic pancreatitis presents with post-prandial vomiting and abdominal pain. She denies weight loss, fevers, pruritus and any family history of malignancy.\n\nHer blood tests are significant for a cholestatic pattern of liver function tests.\n\nWhich of the following is the most likely diagnosis?", "sbaAnswer": [ "a" ], "totalVotes": 5197, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Faecal calprotectin is a measure of intestinal inflammation. It may be raised in coeliac disease and conditions such as inflammatory bowel disease, colorectal cancer and infectious colitis. The main use of faecal calprotectin is to exclude inflammatory bowel disease (IBD), given that it has a high specificity in this context", "id": "32436", "label": "d", "name": "Measure faecal calprotectin", "picture": null, "votes": 648 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "A duodenal biopsy is the gold standard test to confirm the diagnosis of Coeliac disease. It would be performed if serological tests are positive or if there is high clinical suspicion following multiple negative results from different serological tests", "id": "32435", "label": "c", "name": "Duodenal biopsy", "picture": null, "votes": 2112 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "The history of autoimmune disease, symptoms and associated microcytic anaemia are suggestive of Coeliac disease. The most commonly used screening test for Coeliac disease is checking for the presence of auto-antibodies against tissue transglutaminase (TTG). This has a high specificity and sensitivity; however, false negatives may be found in patients with IgA deficiency. IgA deficiency is more common in patient's with coeliac disease, and therefore, all patients should have IgA levels measured alongside antibodies against TTG. The next step in patients with IgA deficiency would be to measure antibodies against TTG from the IgG class", "id": "32433", "label": "a", "name": "Measure immunoglobulin G (IgG) TTG levels", "picture": null, "votes": 2288 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Low levels of faecal elastase are suggestive of exocrine pancreatic insufficiency. Causes include cystic fibrosis, chronic pancreatitis and biliary obstruction. Although the patient's symptoms may be due to pancreatic insufficiency, Coeliac disease is more likely given the history of autoimmune disease and IgA deficiency", "id": "32437", "label": "e", "name": "Measure faecal elastase", "picture": null, "votes": 113 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This patient has IgA deficiency and likely has a false-negative IgA anti-TTG level. Repeating the anti-TTG levels using the same immunoglobulin class (i.e. IgA) is likely to give the same result", "id": "32434", "label": "b", "name": "Repeat anti-TTG antibody levels", "picture": null, "votes": 118 } ], "comments": [ { "__typename": "QuestionComment", "comment": "According to the answer \"if there is enough clinical suspicion\" to do a duodenal biopsy- does the history and blood results not give us a high enough level of clinical suspicion? ", "createdAt": 1736438206, "dislikes": 0, "id": "60102", "isLikedByMe": 0, "likes": 2, "parentId": null, "questionId": 6487, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "wilnej", "id": 22423 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nCoeliac disease is a T cell-mediated autoimmune condition characterised by the body's inflammatory response to dietary gluten, leading to small bowel damage and malabsorption. Key signs and symptoms include gastrointestinal disturbances such as diarrhoea, abdominal pain, nausea, vomiting, and systemic symptoms like fatigue, weight loss or failure to thrive in children. Additionally, dermatitis herpetiformis may be observed. The gold standard for diagnosis involves an oesophago-gastroduodenoscopy (OGD) and duodenal/jejunal biopsy, supplemented by serological tests like anti-TTG IgA antibody measurement. The primary management strategy is a lifelong adherence to a gluten-free diet, alongside regular monitoring for complications. \n\n# Definition\n\nCoeliac disease is a T cell-mediated autoimmune disorder affecting the small intestine. The condition arises due to the production of an auto-antibody against gluten, specifically its component called prolamin, which results in inflammation and villous atrophy of the small bowel leading to malabsorption.\n\n# Epidemiology\n\nCoeliac disease is a prevalent chronic disorder, affecting roughly 0.5 to 1 percent of the general population worldwide. In areas such as Europe, the United States, and Australia, the prevalence varies, ranging from 1 in 80 to 1 in 300 children. The condition disproportionately affects females, with a female to male ratio of approximately 2:1. Coeliac disease exhibits a bimodal age of onset, presenting either in infancy or between the ages of 50-60. It is notably more prevalent in individuals of Irish descent.\n\n# Aetiology\n\nCoeliac disease is associated with a positive family history, the presence of the HLA-DQ2 allele, and other autoimmune diseases, including type 1 diabetes mellitus.\n\n# Signs and Symptoms\n\nGastrointestinal symptoms include:\n\n- Abdominal pain\n- Distension\n- Nausea and vomiting\n- Diarrhoea\n- **Steatorrhoea** (indication of severe disease)\n\nSystemic symptoms encompass:\n\n- Fatigue\n- **Weight loss or failure to thrive in children** (indication of severe disease)\n\nPhysical examination may reveal:\n\n- Pallor (secondary to anaemia)\n- **Short stature and wasted buttocks** (secondary to malnutrition)\n- Signs of vitamin deficiency due to malabsorption (e.g., bruising secondary to vitamin K deficiency)\n- Dermatological manifestations: **dermatitis herpetiformis** (pruritic papulovesicular lesions over the buttocks and extensor surfaces of the arms, legs, and trunk).\n- Abdominal distension\n\n[lightgallery]\n\n# Differential Diagnosis\n\nThe main differential diagnoses for coeliac disease include:\n\n- **Irritable bowel syndrome (IBS)**: Characterised by chronic abdominal pain, bloating, and altered bowel habits without any organic cause.\n- **Inflammatory bowel disease (IBD)**: Crohn's disease and ulcerative colitis are forms of IBD and may present with abdominal pain, diarrhoea, weight loss, and systemic signs of inflammation.\n- **Food intolerance/allergy**: Abdominal discomfort, bloating, and diarrhoea are common.\n- **Gastroenteritis**: Acute diarrhoea and vomiting, often with fever.\n- **Malabsorption syndromes (other than coeliac disease)**: Chronic diarrhoea, weight loss, and signs of specific nutrient deficiencies.\n\n# Investigations\n\nBedside:\n\n- Stool culture to exclude infectious causes. A faecal calprotectin may also be done as IBD is a differential.\n\nBloods:\n\n- Blood tests include FBC, U&E, bone profile, LFT, Iron, B12, and Folate levels.\n\t- It is important to screen for conditions related to malabsorption such as mixed anaemias, vitamin deficiencies.\n- First line serological tests such as anti-TTG IgA antibody and IgA level, followed by anti-TTG IgG, anti-endomyseal antibody, (anti-gliadin is not recommended by NICE.)\n\nImaging/Invasive:\n\n- Oesophago-gastroduodenoscopy (OGD) and duodenal/jejunal biopsy, is considered the gold standard for diagnosis.\n- Histology typically reveals sub-total villous atrophy, crypt hyperplasia, and intra-epithelial lymphocytes.\n\nNB: in the context of antibody blood tests and OGDs looking for changes, the patient needs to have been eating gluten for 6 weeks prior to the investigation.\n\n# Management\n\n- Primary management of coeliac disease is a lifelong commitment to a gluten-free diet. Patient education about food items containing gluten is crucial.\n- Common food items which contain gluten include bread, pasta, pastries and most beers.\n- Regular monitoring of the patient is necessary to ensure adherence to the diet and screen for potential complications. Serological tests can also be done to assess response to removing dietary gluten intake.\n- Dermatitis herpetiformis is managed with dapsone\n\n# Complications\n\n- Mixed anaemia\n- Hyposplenism (increasing susceptibility to encapsulated organisms). Patients with coeliac disease therefore require annual flu and one-off pneumovax vaccinations\n- Osteoporosis (a DEXA scan may be needed)\n- Enteropathy-associated T cell lymphoma (EATL; a rare type of non-Hodgkin lymphoma), the likelihood of which is proportional to the strength of adherence to a gluten-free diet.\n\n# NICE Guidelines\n\n[Click here to see information on NICE CKS about coeliac disease](https://cks.nice.org.uk/topics/coeliac-disease/)", "files": null, "highlights": [], "id": "719", "pictures": [ { "__typename": "Picture", "caption": null, "createdAt": 1665036193, "id": "774", "index": 0, "name": "Dermatitis herpetiformis.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/9zxcnc9z1665036171707.jpg", "path256": "images/9zxcnc9z1665036171707_256.jpg", "path512": "images/9zxcnc9z1665036171707_512.jpg", "thumbhash": "2kgKFIZfTLaKh4Z4eIcIe6fAaA==", "topic": { "__typename": "Topic", "id": "4", "name": "Dermatology", "typeId": 2 }, "topicId": 4, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 719, "demo": null, "entitlement": null, "id": "751", "name": "Coeliac disease", "status": null, "topic": { "__typename": "Topic", "id": "23", "name": "Gastroenterology", "typeId": 2 }, "topicId": 23, "totalCards": 31, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "751", "name": "Coeliac disease" } ], "demo": false, "description": null, "duration": 352.79, "endTime": null, "files": null, "id": "70", "live": false, "museId": "2GUQt5e", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/gastroenterology.png", "title": "Coeliac disease", "userViewed": false, "views": 153, "viewsToday": 13 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "751", "name": "Coeliac disease" } ], "demo": false, "description": null, "duration": 4509.5, "endTime": null, "files": null, "id": "314", "live": false, "museId": "rgWyy3w", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/gastroenterology.png", "title": "Quesmed Tutorial: Gastroenterology and Hepatology", "userViewed": false, "views": 1028, "viewsToday": 26 } ] }, "conceptId": 751, "conditions": [], "difficulty": 3, "dislikes": 24, "explanation": null, "highlights": [], "id": "6487", "isLikedByMe": 0, "learningPoint": "In patients with suspected Coeliac disease and low serum IgA, measure IgG anti-tissue transglutaminase (TTG) antibodies for accurate diagnosis.", "likes": 8, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 32-year-old with type 1 diabetes presents to her GP with a 6-month history of diarrhoea, weight loss and bloating.\n\nExamination reveals conjunctival pallor and a soft, non-tender abdomen.\n\nHer blood tests show a microcytic anaemia, thrombocytopenia, normal anti-tissue transglutaminase (TTG) antibody levels and low serum immunoglobulin A (IgA).\n\nWhich of the following is the next best investigation given the likely diagnosis?", "sbaAnswer": [ "a" ], "totalVotes": 5279, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "RSV can cause croup; however, parainfluenza is more common. RSV is the most common causative organism in bronchiolitis", "id": "32439", "label": "b", "name": "Respiratory syncytial virus (RSV)", "picture": null, "votes": 1680 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Croup (acute laryngotracheobronchitis) is an upper airways disease that is most common in children aged between 6 months to 3 years. It usually presents with difficulty in breathing, fever, stridor and a seal or dog-like barking-cough on the background of a coryzal illness. Parainfluenza virus is the most common causative organism", "id": "32438", "label": "a", "name": "Parainfluenza", "picture": null, "votes": 2947 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Bordetella is the causative agent in pertussis (whooping cough). This is a bacterial infection that is rarer than croup due to effective vaccination. Pertussis can present with an inspiratory gasp; however, the high-pitching rasping sound described in the question is more suggestive of stridor", "id": "32441", "label": "d", "name": "Bordetella pertussis", "picture": null, "votes": 558 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Mycoplasma is a rare cause of croup", "id": "32440", "label": "c", "name": "Mycoplasma pneumoniae", "picture": null, "votes": 45 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Rhinovirus is a well-recognised cause of croup; however, it is less common than parainfluenza", "id": "32442", "label": "e", "name": "Rhinovirus", "picture": null, "votes": 93 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Is the only reason this isn't bronchiolitis is that he has a high pitched rasping sound on inspiration?", "createdAt": 1684171756, "dislikes": 0, "id": "24674", "isLikedByMe": 0, "likes": 1, "parentId": null, "questionId": 6488, "replies": [ { "__typename": "QuestionComment", "comment": "Also somewhat out of the peak age bracket for it? I know things aren't that exact in real life but this is quesmed", "createdAt": 1684494198, "dislikes": 0, "id": "25243", "isLikedByMe": 0, "likes": 6, "parentId": 24674, "questionId": 6488, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Inpatient Syndrome", "id": 23480 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "WBC Zebras", "id": 30278 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n \n\nCroup (also known as acute laryngotracheobronchitis) is a common childhood infection characterised by a harsh barking cough and inspiratory stridor. It is usually mild and self-limiting, however, some cases may cause severe respiratory distress requiring hospitalisation and supportive treatment. Parainfluenza viruses are the commonest causes, but the diagnosis is a clinical one and as symptoms such as stridor can worsen if the child is distressed, investigations should only be done if necessary. Oral steroids should be given to all children; in moderate to severe cases nebulised adrenaline, supplementary oxygen and airway support may be indicated.\n \n\n# Definition\n \n\nCroup, or acute laryngotracheobronchitis, is an upper respiratory tract infection that in most cases has a viral aetiology. Key symptoms include a barking cough, hoarse voice and inspiratory stridor. \n\n# Epidemiology\n \n\nCroup commonly affects children aged from 6 months old to 3 years old, with the peak incidence at 2 years. It is uncommon after the age of 6.\n\nSimilar to other viral infections, it is commonest in the autumn and winter months and is linked to parainfluenza epidemics. \n\n# Aetiology\n \nThe commonest cause is the parainfluenza virus. Other viral causes include adenovirus, respiratory syncytial virus (RSV), rhinovirus and influenza.\nRarely, bacteria can cause croup (e.g. Mycoplasma pneumoniae).\n\nThe pathophysiology involves infection and resulting inflammation of the subglottic and laryngeal mucosa which causes partial obstruction of the airways leading to respiratory distress and stridor.\n\n# Signs and Symptoms\n\n- The prodromal phase of coryzal symptoms, fever and a non-specific cough usually lasts 12-72 hours.\n- Characteristic symptoms of croup such as the harsh barking cough, hoarse voice or cry and inspiratory stridor then develop - these tend to be worse at night.\n- In severe cases, children may become drowsy and lethargic, or conversely more agitated.\n- The usual course of disease is resolution of symptoms within 48 hours (up to a week at most).\n\nOn examination, look for the following red flags that may indicate impending respiratory failure:\n\n- Signs of respiratory distress e.g. intercostal recessions, accessory muscle usage, tachypnoea\n- Cyanosis\n- Decreased level of consciousness\n- Stridor may decrease due to worsening airway obstruction\n- Decreased air entry on auscultation of the chest\n- Tachycardia\n\n# Differential Diagnosis\n \n\n- **Epiglottitis**: Sudden onset high fever, drooling, and dysphagia are seen without the barking cough of croup. Usually secondary to Haemophilus influenzae B and so significantly rarer since routine immunisation against this.\n- **Bacterial tracheitis**: Suspect if acute deterioration following initial viral symptoms, with high fevers, stridor and respiratory distress.\n- **Foreign body aspiration**: No prodrome or fever, usually sudden onset of choking, cough or wheeze after eating or playing with small objects.\n- **Anaphylaxis**: Rapid onset stridor, possible urticarial rash and facial swelling; suspect if history of previous episodes with allergens or family history of atopy.\n \n\n# Investigations\n \nDiagnosis is clinical, and investigations need to be carefully considered as distressing the child may lead to worsening of symptoms due to agitation.\n\nFurther investigation may include: \n\n- Pulse oximetry should be done to determine if supplementary oxygen is required.\n- Chest X-ray may be of use if a differential diagnosis such as an inhaled foreign body is suspected. \n - In croup, an X-ray may show a steeple sign, where the upper trachea is seen to taper.\n \n\n# Management\n\nClassifying the severity of croup is key to determining appropriate management:\n\n| Severity | Description |\n|------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|\n| Mild | Seal-like barking cough but no stridor or sternal/intercostal recession at rest. |\n| Moderate | Seal-like barking cough with stridor and sternal recession at rest; no (or little) agitation or lethargy. |\n| Severe | Seal-like barking cough with stridor and sternal/intercostal recession associated with agitation or lethargy. |\n| Impending respiratory failure | Minimal barking cough, stridor may become harder to hear. Increasing upper airway obstruction, sternal/intercostal recession, asynchronous chest wall and abdominal movement, fatigue, pallor or cyanosis, decreased level of consciousness or tachycardia. The degree of chest wall recession may diminish with the onset of respiratory failure as the child tires. A respiratory rate of over 70 breaths/minute is also indicative of severe respiratory distress. |\n\nMild cases with no stridor or chest wall recessions at rest may be treated at home with a single dose of oral dexamethasone (0.15mg/kg). In children treated at home, families should be safety-netted on signs of deterioration and advised to check on the child regularly and encourage fluids. Paracetamol or ibuprofen can be used for fever and pain.\n\nChildren with any of the following should be considered for hospital admission:\n\n* Stridor and/or sternal recession at rest\n* High fever\n* Respiratory rate > 60\n* Cyanosis\n* Lethargy or agitation\n* Fluid intake < 75% of normal or no wet nappies for 12 hours\n* Aged under 3 months\n* Chronic conditions such as immunodeficiency, chronic lung disease or neuromuscular disorders\n\nManagement is supportive as there is no treatment indicated for the usual causative viruses, and may include:\n\n- Supplementary oxygen if low saturations - consider how best to deliver this so as not to distress the child (e.g. a parent holding an oxygen mask to the face)\n- Steroids for all - if unable to swallow oral dexamethasone or prednisolone can give nebulised budesonide\n- Nebulised adrenaline for temporary symptom relief\n- Anaesthetics +/- ENT input if concerns regarding airway or respiratory failure\n\n# Complications\n\n- Dehydration secondary to poor fluid intake during illness\n- Pneumonia due to secondary bacterial infection \n- Respiratory failure \n- Death is very rare (1 in every 30,000 cases)\n\n# Prognosis\n\nUsually, symptoms resolve within 48 hours but may last longer. Occasionally, severe upper airway obstruction can occur, causing respiratory failure and arrest.\n\n# NICE Guidelines\n\n[NICE CKS: Croup](https://cks.nice.org.uk/topics/croup/)\n\n# References\n \n[BNF Treatment summaries: Croup](https://bnf.nice.org.uk/treatment-summaries/croup/)\n\n[Patient.info: Croup](https://patient.info/doctor/croup-pro)", "files": null, "highlights": [], "id": "481", "pictures": [ { "__typename": "Picture", "caption": null, "createdAt": 1639016552, "id": "363", "index": 0, "name": "Steeple Sign.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/fsp35ozf1639016551489.jpg", "path256": "images/fsp35ozf1639016551489_256.jpg", "path512": "images/fsp35ozf1639016551489_512.jpg", "thumbhash": "FwgOBwAKh3eMdnWLhqeHl3eICAAAAAAA", "topic": { "__typename": "Topic", "id": "29", "name": "Paediatrics", "typeId": 2 }, "topicId": 29, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 481, "demo": null, "entitlement": null, "id": "489", "name": "Croup", "status": null, "topic": { "__typename": "Topic", "id": "29", "name": "Paediatrics", "typeId": 2 }, "topicId": 29, "totalCards": 2, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 489, "conditions": [], "difficulty": 3, "dislikes": 11, "explanation": null, "highlights": [], "id": "6488", "isLikedByMe": 0, "learningPoint": "Croup, characterised by stridor and a barking cough, is commonly caused by the parainfluenza virus in children aged 6 months to 3 years.", "likes": 6, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 2-year-old boy presents to the paediatric emergency department (ED) after his parents noted that he was struggling with his breathing. They note that for the last three days, he has had a dry cough and runny nose with mild temperature spikes.\n\nOn examination, the boy is tachypnoeic and using his accessory muscles. His temperature is 38°C, and there is a high-pitched rasping sound audible during inspiration.\n\nGiven the likely diagnosis, which of the following is the most likely causative organism?", "sbaAnswer": [ "a" ], "totalVotes": 5323, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Urgent breast clinic referral would be warranted if there are signs of a breast abscess. A breast abscess would present with a painful swollen lump in the breast, often with a history of recent mastitis", "id": "32445", "label": "c", "name": "Urgent referral to the breast surgery clinic", "picture": null, "votes": 89 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This woman has signs and symptoms consistent with mastitis. First-line management is with reassurance, simple analgesia and encouragement of breastfeeding", "id": "32443", "label": "a", "name": "Encourage breastfeeding and provide simple analgesia", "picture": null, "votes": 4050 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "It is essential that breastfeeding continues to help prevent stasis of breast milk which can predispose to infection and worsening of symptoms", "id": "32446", "label": "d", "name": "Advise against breastfeeding until symptoms resolve", "picture": null, "votes": 90 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "There are no signs that this patient is systemically unwell and in need of hospital admission. Oral antibiotics would be the next step if her symptoms do not respond to conservative management", "id": "32447", "label": "e", "name": "Admit to hospital for IV antibiotics", "picture": null, "votes": 97 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Antibiotics should be prescribed in cases that are likely to be due to infectious mastitis. These include the presence of a nipple fissure, symptoms not improving with continuous milk removal for 12-24 hours and a positive breast milk culture", "id": "32444", "label": "b", "name": "Prescribe oral flucloxacillin", "picture": null, "votes": 1171 } ], "comments": [ { "__typename": "QuestionComment", "comment": "why wedge shape?", "createdAt": 1686328422, "dislikes": 0, "id": "28316", "isLikedByMe": 0, "likes": 4, "parentId": null, "questionId": 6489, "replies": [ { "__typename": "QuestionComment", "comment": "Possibly trying to confuse us with another question about non lactational mastitis, in which they also have a wedge but needed co amoxiclav instead", "createdAt": 1736730472, "dislikes": 0, "id": "60400", "isLikedByMe": 0, "likes": 0, "parentId": 28316, "questionId": 6489, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Prolapsed Fissure", "id": 37601 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "hiney", "id": 20231 } }, { "__typename": "QuestionComment", "comment": "What is the significance of the wedge shaped erythema ?", "createdAt": 1687079882, "dislikes": 0, "id": "29018", "isLikedByMe": 0, "likes": 2, "parentId": null, "questionId": 6489, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Guten Morgen Deutschland", "id": 21227 } }, { "__typename": "QuestionComment", "comment": "She's got a fever, how is this not infective mastitis?", "createdAt": 1709563319, "dislikes": 0, "id": "43723", "isLikedByMe": 0, "likes": 3, "parentId": null, "questionId": 6489, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Botox Haemophilus", "id": 23208 } }, { "__typename": "QuestionComment", "comment": "it doesnt say how long she has had symptoms for which is what guides treatment !!", "createdAt": 1735905366, "dislikes": 0, "id": "59515", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6489, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Hematoma Gastro", "id": 12650 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n \n\nMastitis is an inflammation of the breast, often associated with lactation in postpartum women, referred to as puerperal mastitis. Key signs and symptoms include localised pain, tenderness, redness and heat in the breast, along with systemic symptoms such as fever, rigours, myalgia, fatigue, nausea and headache. Diagnosis is primarily clinical. Ultrasound may be used if a breast abscess is suspected. Management strategies focus on reassurance about continued breastfeeding, advice on milk removal, analgesia, antibiotics, and in severe cases, surgical intervention.\n \n\n# Definition\n \n\nMastitis is the inflammation of the breast tissue, which can be with or without an infection. When associated with lactation in postpartum women, the condition is specified as puerperal mastitis. Alternatively, mastitis can be seen in women who are not breastfeeding.\n \n\n# Epidemiology\n \n\nNon-lactational mastitis is significantly less common than \n \n\n# Aetiology\n \nMastitis unrelated to pregnancy and breastfeeding is typically due to obstruction of the ducts from cellular debris. This can result in a local inflammatory response in non-infectious mastitis. \n\nIn infectious mastitis, bacteria from the skin can then enter the ducts, causing inflammation and may progress to peri-areolar abscesses. The most common causative pathogen is Staphylococcus aureus. \n\nRisk factors for non-lactational mastitis include:\n\n- Cigarette smoking\n- Nipple rings \n- Diabetes mellitus\n- Immunocompromise \n \n\n# Signs and Symptoms\n \n\nMastitis diagnosis is primarily clinical, based on characteristic local and systemic symptoms.\n \n\n - Localised symptoms: Painful, tender, red, and hot breast.\n - Systemic symptoms: Fever, rigours, myalgia, fatigue, nausea, and headache.\n - Additional information: The condition is usually unilateral and tends to present within the first week postpartum.\n \n\nIn some cases, mastitis may develop into a breast abscess, manifesting as a fluctuant, tender mass with overlying erythema.\n \n\n# Differential Diagnosis\n \n\nThe differential diagnosis for mastitis should include other conditions that also cause breast pain and inflammation:\n \n\n - **Breast abscess**: Fluctuant mass, tenderness, overlying erythema, systemic signs of infection.\n - **Inflammatory breast cancer**: Swelling, skin changes resembling orange peel, nipple inversion, axillary lymphadenopathy.\n - **Breast engorgement**: Typically bilateral and associated with milk stasis, painful, and tense breasts.\n \n\n# Investigations\n \n\nWhile the diagnosis of mastitis is primarily clinical, further investigations may be necessary in certain circumstances.\n \n\n - Ultrasound: Utilised to identify a potential abscess, appearing as a collection of pus.\n - Additional information: Early referral to secondary care is vital if an abscess is suspected.\n \n\n# Management\n \n\nManaging mastitis involves multiple strategies:\n \n\n - Provide analgesia to manage symptoms (i.e. paracetamol, ibuprofen)\n\t - Warm and cold compresses may also help.\n - Antibiotics may be considered if acute pain, severe symptoms or symptoms lasting more than 12-24 hours, fever or positive cultures \n\t - Flucloxacillin or clindamycin for those with penicillin allergy\n\t - Treatment is indicated for 10-14 days.\n - In cases where the condition does not improve, consider intravenous antibiotics (i.e. vancomycin) or ultrasound to evaluate for the presence of a breast abscess.\n - Patients may also benefit from antifungal therapy (i.e. nystatin) for concomitant nipple candidiasis \n\n \n# Complications\n \nComplications of mastitis include:\n \n - Breast abscess\n - Recurrence:\n\t - More common if treatment is delayed or too short in duration \n \n\n# NICE Guidelines\n \n[NICE CKS on mastitis and breast abscess](https://cks.nice.org.uk/topics/mastitis-breast-abscess/)\n\n# References\n\n[BMJ Best Practice Mastitis and Breast Abscess](https://bestpractice.bmj.com/topics/en-gb/1084)\n\n[Patient Info Benign Breast Diseas](https://bestpractice.bmj.com/topics/en-gb/1084) \n\n[NHS Mastitis](https://www.nhs.uk/conditions/mastitis/)", "files": null, "highlights": [], "id": "310", "pictures": [], "typeId": 2 }, "chapterId": 310, "demo": null, "entitlement": null, "id": "348", "name": "Mastitis", "status": null, "topic": { "__typename": "Topic", "id": "55", "name": "Breast Disease", "typeId": 2 }, "topicId": 55, "totalCards": null, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 348, "conditions": [], "difficulty": 1, "dislikes": 3, "explanation": null, "highlights": [], "id": "6489", "isLikedByMe": 0, "learningPoint": "Mastitis in breastfeeding women is typically managed with reassurance, analgesia, and continued breastfeeding to promote drainage and healing.", "likes": 5, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 25-year-old woman presents to her GP with an 8 hour history of a red and swollen left breast. She is ten weeks post-partum and has been regularly breastfeeding with no complications.\n\nOn examination, she has a temperature of 37.6°C and an erythematous and tender left breast. The erythema is noted to extend in a wedge-shaped distribution.\n\nWhich of the following is the next best step in management?", "sbaAnswer": [ "a" ], "totalVotes": 5497, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "As this patient has symptoms of an untreated sexually transmitted infection, the IUD is contraindicated", "id": "32454", "label": "b", "name": "Offer the copper intrauterine device (IUD)", "picture": null, "votes": 1217 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Ulipristal acetate is a form of emergency contraception that can be given up to five days after UPSI. It is more effective than levonorgestrel but less effective than the copper intrauterine device (IUD). As there is a risk of pregnancy in this scenario, ulipristal is the most appropriate management option", "id": "32453", "label": "a", "name": "Offer ulipristal acetate", "picture": null, "votes": 2663 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "The earliest this woman could ovulate is day 14 in her cycle (shortest cycle length - 14 days). As she had UPSI on day 8, there is a risk of sperm meeting egg and therefore pregnancy, so emergency contraception is indicated", "id": "32456", "label": "d", "name": "Reassure that emergency contraception is not needed", "picture": null, "votes": 112 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "The COCP cannot be used as a form of emergency contraception", "id": "32457", "label": "e", "name": "Offer the combined oral contraceptive pill (COCP)", "picture": null, "votes": 47 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Levonorgestrel can only be taken up to three days after UPSI. It is also less effective than ulipristal", "id": "32455", "label": "c", "name": "Offer levonorgestrel", "picture": null, "votes": 375 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Up to 5 days and 5 days ago? I’d be crossing my fingers big time here", "createdAt": 1685103027, "dislikes": 0, "id": "26365", "isLikedByMe": 0, "likes": 3, "parentId": null, "questionId": 6491, "replies": [ { "__typename": "QuestionComment", "comment": "the reason why it's limited to 5 days is not because it won't work afterwards, but because once implantation happens the pregnancy is legally established, and therefore the pill would act as an abortive medication rather than as a contraceptive ie. preventing pregnancy (pregnancy starts at implantation legally)", "createdAt": 1709051833, "dislikes": 1, "id": "43017", "isLikedByMe": 0, "likes": 0, "parentId": 26365, "questionId": 6491, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Ale", "id": 20565 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Anterior Gallbladder", "id": 5111 } }, { "__typename": "QuestionComment", "comment": "Maximum of 120 hours. They really need to be more specific w/ Qs like this", "createdAt": 1710074641, "dislikes": 0, "id": "44355", "isLikedByMe": 0, "likes": 1, "parentId": null, "questionId": 6491, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "CT Position", "id": 24477 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n \n\nThe combined oral contraceptive pill (COCP) is a long-term contraceptive containing synthetic oestrogen and progestogen. It works by inhibiting ovulation, thickening cervical mucus, and altering the endometrium to prevent fertilisation and implantation. Indications for COCP use include contraception, menstrual cycle regulation, and treatment of dysmenorrhea, menorrhagia, acne, and hirsutism. Contraindications are categorised by UKMEC criteria, detailed in this chapter. \n \n# Definition\n \n\nThe combined oral contraceptive pill (COCP) is a long-term contraceptive. It contains synthetic versions of the female hormones oestrogen and progestogen. \n \n\n# Mechanism of Action\n \n\n* **Inhibition of Ovulation:** The COCP contains synthetic versions of the hormones oestrogen and progestogen. These hormones together suppress the release of gonadotrophins (LH and FSH) from the pituitary gland, preventing the maturation and release of an egg from the ovaries.\n \n\n* **Thickening of Cervical Mucus:** The progestogen component of the COCP increases the viscosity of cervical mucus, making it more difficult for sperm to enter the uterus and fertilise an egg.\n \n\n * **Alteration of the Endometrium:** The COCP induces changes in the lining of the uterus (endometrium), making it less suitable for the implantation of a fertilised egg.\n \n\n# Indications\n \n\nThere are a range of reasons for women to be recommended the oral combined contraceptive pill. For example:\n \n\n* **Contraception:** The COCP works as a long-term contraception. It is taken orally once a day, at around the same time each day. \n * **Menstrual Cycle Regulation:** The COCP can help regulate irregular menstrual cycles. \n * **Dysmenorrhea:** The COCP may be used to reduce menstrual cramps. \n * **Menorrhagia:** The COCP can decrease heavy menstrual bleeding.\n * **Acne and Hirsutism:** The COCP helps in the treatment of acne and excessive hirsutism in women, which may happen in conditions such as polycystic ovary syndrome (PCOS) or other androgen excess conditions.\n * **Premenstrual Syndrome (PMHS**: The COCP can alleviate symptoms of PMS, such as mood swings, bloating, and irritability.\n \n# Contraindications \n \nThere are numerous contra-indications to the Combined Oral Contraceptive Pill. These can be divided into absolute contraindications, known as ''UKMEC 4'', a situation where the disadvantages outweigh the advantages (UKMEC 3), a situation where the advantages outweigh the disadvantages (UKMEC 2), and a situation whereby there is no limit on that choice of contraception (UKMEC 1).\n \n\n## Absolute Contraindications to Contraception (UKMEC 4)\n \n \n * Known or suspected pregnancy\n * Hypertension with SBP ≥160 mmHg or DBP ≥100 mmHg\n * Smoker over the age of 35 who smokes >15 cigarettes a day \n * Current and history of ischaemic heart disease\n * History of stroke (including TIA) \n * Vascular disease\n * History or current VTE\n * Major surgery with prolonged immobilisation\n * Breastfeeding <6 weeks postpartum\n * Not breastfeeding and <3 weeks postpartum with other risk factors for VTE\n * Known thrombogenic mutations \n * Complicated valvular and congenital heart disease\n * Cardiomyopathy with impaired cardiac function\n * Atrial fibrillation \n * Migraine with aura (any age)\n * Current breast cancer \n * Severe (decompensated) cirrhosis \n * Hepatocellular adenoma and hepatocellular carcinoma\n * Positive antiphospholipid antibodies \n \n \n \n## Disadvantages of a contraceptive outweigh the advantages (UKMEC 3)\n \n * Obesity (BMI ≥35 kg/m2)\n * Multiple risk factors for cardiovascular disease (e.g. smoking, diabetes mellitus, hypertension, obesity, dyslipidaemia) \n * Well controlled hypertension, and hypertension with SBP >140-159 mmHg or DBP <90-99 mmHg\n * Smoker over age of 35 who smokes <15 cigarettes a day, or anyone over age of 35 who stopped smoking <1 year ago\n * Family history of thrombosis before 45 years old\n * Not breastfeeding and <3 weeks postpartum without other risk factors for VTE\n * Not breastfeeding and between 3-6 weeks postpartum with other risk factors for VTE\n * Organ transplant with complications (e.g. graft failure, rejection) \n * Immobility (unrelated to surgery)\n * Migraine without aura (any age) [applies to *continuation* of COCP]\n * History (≥5 years ago) of migraine\nwith aura (any age) \n * Undiagnosed breast mass or symptoms [applies to *initiation* of COCP] \n * Carriers of known gene mutations associated with breast cancer\n * Past breat cancer \n * Diabetes mellitus with nephropathy, retinopathy, neuropathy or other vascular complications \n * Symptomatic gall bladder disease treated medically or currently active \n * Past COCP associated cholestasis \n * Acute viral hepatitis [applies to *initiation* of COCP]\n \n \n \n## Advantages of a contraceptive outweigh the disadvantages (UKMEC 2)\n \n * Smokers under the age of 35, and people aged over 35 who stopped smoking over 1 year ago \n * Obesity (BMI ≥30–34 kg/m2) \n * Family history of VTE in first-degree relative aged ≥45 years\n * History of raised blood pressure in pregnancy \n * Breast feeding between 6 weeks-6 months postpartum\n * Not breastfeeding and between 3-6 weeks postpartum without other risk factors for VTE\n * Uncomplicated organ transplant \n * Known dyslipidaemia \n * Major surgery without prolonged immobilisation \n * Superficial venous thrombosis \n * Uncomplicated valvular and congenital heart disease\n * Cardiomyopathy with normal cardiac function \n * Long QT syndrome \n * Non-migrainous headaches [applies to *continuation* of COCP]\n * Migraine without aura [applies to *initiation* of COCP] \n * Idiopathic intracranial hypertension \n * Unexplained vaginal bleeding\n * Cervical cancer \n * Undiagnosed breast mass or symptoms [applies to *continuation* of COCP]\n * Insulin-dependent diabetes mellitus without vascular disease \n * Symptomatic gall bladder disease treated through cholecystectomy, or asymptomatic gall bladder disease, or history of pregnancy-related cholestasis \n * Acute viral hepatitis [applies to *continuation* of COCP]\n * Inflammatory bowel disease \n * Sickle cell disease \n * Rheumatoid arthritis\n * SLE without antiphospholipid antibodies \n \n\n \n\n# Side-effects and Complications\n \n**Common Side-Effects:**\n \n\n * Breast tenderness \n * Abdominal discomfort, nausea diarrhoea \n * Headaches\n * Mood changes\n * Reduced libido \n \n\n**Rare but Serious Side-Effects:**\n \n\n * Embolism or thrombus, including: DVT and PE, stroke, myocardial infarction\n * Increased risk of breast cancer\n * Increased risk of cervical cancer \n \n\n \n\n# Follow-up\n\nArrange follow up 3 months following initial prescription of a COCP, and annually thereafter.\n \n\nAt follow-up, ensure to: \n \n\n * Check blood pressure and BMI. \n * Ask about headaches (including migraine). \n * Check for risk factors that may be contraindicators to COCP (as per UKMEC criteria). \n * Enquire about side-effects. \n * Enquire about how woman is taking the COCP (i.e. adherence). \n \n\n \n\n# Missed Pill Rules\n \n\n**Missed One Pill:**\n \n\n* Advise patient to take the pill as soon as possible, even if it means taking two pills in one day.\n* * Continue taking the rest of the pack as usual.\nNo additional contraception needed if this is the only pill missed in the pack.\n \n\n**Missed Two or More Pills in Week 1 (Days 1-7):**\n \n\n * Advise patient to take the last pill they missed as soon as possible. \n * Continue taking the rest of the pack as usual.\n * Use additional contraception for the next 7 days.\n * If they had unprotected sex during this week, seek emergency contraception.\n \n\n**Missed Two or More Pills in Week 2 (Days 8-14):**\n \n\n * Take the last pill they missed as soon as possible. \n * Continue taking the rest of the pack as usual.\n * No additional contraception needed if they have taken pills correctly for the 7 days prior to the missed pill.\n \n\n**Missed Two or More Pills in Week 3 (Days 15-21):**\n \n\n* Finish the active pills in the current pack, then start a new pack immediately without taking the usual 7-day break.\n* No additional contraception needed if they have taken pills correctly for the 7 days prior to the missed pill.\n \n# NICE Guidelines \n \n\n[Click here to view NICE Guidelines on COCP](https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/management/combined-oral-contraceptive/)\n \n \n# References\n \n[Click here to see the UKMEC summary sheet on contraception](https://www.fsrh.org/standards-and-guidance/documents/ukmec-2016-summary-sheets/)", "files": null, "highlights": [], "id": "2047", "pictures": [], "typeId": 2 }, "chapterId": 2047, "demo": null, "entitlement": null, "id": "2639", "name": "Combined Hormonal Contraception", "status": null, "topic": { "__typename": "Topic", "id": "60", "name": "General Practice", "typeId": 2 }, "topicId": 60, "totalCards": null, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 2639, "conditions": [], "difficulty": 2, "dislikes": 15, "explanation": null, "highlights": [], "id": "6491", "isLikedByMe": 0, "learningPoint": null, "likes": 6, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 23-year-old woman presents to her GP requesting emergency contraception after an episode of unprotected sexual intercourse (UPSI) five days ago. She does not use any regular contraception and is on day 13 of a regular 28-day menstrual cycle.\n\nOn questioning, she reveals some dysuria and abnormal vaginal discharge for the last 24 hours.\n\nWhich of the following is the most appropriate step with regards to the provision of emergency contraception?", "sbaAnswer": [ "a" ], "totalVotes": 4414, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Home blood pressure monitoring (HBPM) is an alternative to ambulatory blood pressure monitoring. HBPM is not indicated if a diagnosis of hypertension has been confirmed with ambulatory monitoring", "id": "32461", "label": "d", "name": "Offer home blood pressure monitoring", "picture": null, "votes": 811 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Metformin would be the first-line management option for this patient's type 2 diabetes, but it would not be used for treating hypertension", "id": "32460", "label": "c", "name": "Start metformin", "picture": null, "votes": 796 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Nifedipine is a calcium-channel blocker. It would be indicated if this patient did not have co-existing type 2 diabetes", "id": "32459", "label": "b", "name": "Start nifedipine", "picture": null, "votes": 607 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient has stage 1 hypertension and type 2 diabetes. Therefore, the recommended first-line management of hypertension is with an angiotensin-converting enzyme (ACE) inhibitor. ACE inhibitors are renoprotective in type 2 diabetes and are therefore recommended for the management of hypertension regardless of age or ethnicity", "id": "32458", "label": "a", "name": "Start lisinopril", "picture": null, "votes": 3918 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Bendroflumethiazide is not an initial treatment option for hypertension. It can be considered if the patient is intolerant to lisinopril or if blood pressure is not controlled after the dose has been up-titrated", "id": "32462", "label": "e", "name": "Start bendroflumethiazide", "picture": null, "votes": 28 } ], "comments": [ { "__typename": "QuestionComment", "comment": "it is unclear whether the question is asking for treatment for the diabetes or hypertension \n", "createdAt": 1682093793, "dislikes": 7, "id": "22392", "isLikedByMe": 0, "likes": 8, "parentId": null, "questionId": 6492, "replies": [ { "__typename": "QuestionComment", "comment": "No it isnt, literally says for his HTN", "createdAt": 1682583701, "dislikes": 0, "id": "22761", "isLikedByMe": 0, "likes": 14, "parentId": 22392, "questionId": 6492, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Twisted Tezzy", "id": 29355 } }, { "__typename": "QuestionComment", "comment": "oh no moron alert", "createdAt": 1683459218, "dislikes": 10, "id": "23633", "isLikedByMe": 0, "likes": 3, "parentId": 22392, "questionId": 6492, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "His Majesty King Charles III", "id": 26583 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Malignant Metabolism", "id": 14188 } }, { "__typename": "QuestionComment", "comment": "could someone explain why we don't need home blood pressure monitoring/more readings? The information below says \"Single reading >140/90 mmHg AND average ambulatory readings >135/85 mmHg\". Does this differ if there's a comorbidity like diabetes? Thanks!", "createdAt": 1685270041, "dislikes": 0, "id": "26743", "isLikedByMe": 0, "likes": 4, "parentId": null, "questionId": 6492, "replies": [ { "__typename": "QuestionComment", "comment": "ambulatory means they have already done extended readings (eg, strapped on them or often multiple readings at home). We can therefore exclude white coat syndrome and start treatment.", "createdAt": 1685282794, "dislikes": 0, "id": "26811", "isLikedByMe": 0, "likes": 3, "parentId": 26743, "questionId": 6492, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Witzelsucht", "id": 24993 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Juice Migraine", "id": 19754 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\r\n\r\nPrimary hypertension, accounting for approximately 90-95% of cases of hypertension, is characterised by persistently elevated blood pressure due to age-related pathophysiological changes. It is a major risk factor for cardiovascular disease, cerebrovascular disease, chronic kidney disease, and peripheral vascular disease. Diagnosis is based on ambulatory blood pressure monitoring (ABPM) readings of 135/85mmHg or higher. Classification is determined by the severity of the hypertension. Management depends on the classification of the hypertension and involves lifestyle modifications and pharmacological anithypertensives according to NICE guidelines. Effective management, through lifestyle changes and medications, significantly reduces the associated risks and improves outcomes for individuals with hypertension.\r\n\r\n# Definition \r\n\r\nA 'normal' blood pressure ranges between 90/60mmHg to 140/90mmHg. The definition of hypertension is a 24h ambulatory blood pressure average reading (ABPM) that is more than or equal to 135/85mmHg. \r\n\r\n# Epidemiology\r\n\r\nIn 2015, it was reported that high blood pressure affected more than 1 in 4 adults in England (31% of men; 26% of women). In England, it is estimated that primary hypertension affects around 13.5 million people and contributed to 75,000 deaths.\r\n\r\n# Pathophysiology\r\n\r\nPrimary hypertension is as a result of a series of complex physiological changes as we age. Hypertension often occurs as a result of reduced elasticity of large arteries, age-related and atherosclerosis-related calcification, and degradation of arterial elastin. It may also be present in conditions associated with increased cardiac output, such as anaemia, hyperthyroidism and aortic regurgitation.\r\n\r\nAlthough the risk of cardiovascular disease increases progressively with increasing systolic and diastolic blood pressure, raised systolic pressure is more important than raised diastolic pressure as a risk factor for cardiovascular and renal disease.\r\n\r\n# Classification \r\n\r\nHypertension can be classified according to how high a patient's blood pressure is. \r\n\r\n* Stage 1: Clinic => 140/90mmHg; ABPM => 135/85mmHg \r\n* Stage 2: Clinic => 160/100mmHg; ABPM =>150/95mmHg \r\n* Stage 3: Clinic systolic BP (SBP) => 180 or diastolic BP (DBP) =>120mmHg\r\n\r\n\r\n# Symptoms and Signs\r\n\r\nHypertension, unless malignant, is asymptomatic and does not have any clinical signs. It is diagnosed with ABPM and further investigations should focus on diagnosing end-organ complications of hypertension. \r\n\r\n# Investigations\r\n\r\n[lightgallery]\r\n\r\n* Hypertensive patients are commonly first identified at GP appointments or during hospital admissions. Due to the prominence of 'white coat hypertension', ABPM is now required for the diagnosis of hypertension. \r\n* Hypertension should be suspected in a patient who has a clinic blood pressure of =>140/90mmHg. \r\n* **1st line: ABPM** or home blood pressure monitoring if ABPM is not tolerated or declined. \r\n* Alongside ABPM: assessment for end-organ damage and assessment of cardiovascular risk (QRISK2 scores). \r\n * Urine dip and albumin:creatinine level\r\n * Blood glucose, lipids and renal function\r\n * Fundoscopy for evidence of hypertensive retinopathy\r\n * ECG: look for evidence of LV hypertrophy\r\n\r\n\r\nN.B. if presentation is suspicious for secondary hypertension refer and investigate as appropriate (see section). \r\n\r\nN.B. Referral for same-day specialist assessment should be arranged for people with: \r\n\r\n* Clinic blood pressure of 180/120mmHg and higher with signs of retinal haemorrhage or papilloedema (accelerated hypertension) or life-threatening symptoms (e.g. new onset confusion, chest pain, heart failure signs or AKI). \r\n\r\n# Management\r\n\r\n## Principles of Management \r\n\r\n### Conservative Management \r\n\r\nControlling risk factors for cardiovascular disease:\r\n\r\n* Weight loss\r\n* Healthy diet (reduce salt and saturated fats)\r\n* Reduce alcohol and caffeine\r\n* Reduce stress\r\n* Stop smoking\r\n\r\n### Medical Management\r\n\r\nIndications to start pharmacological management of primary hypertension:\r\n\r\n* Stage 1 hypertensive patients who are <80 years old with end organ damage, CVS disease, renal disease, diabetes or 10-year CVS risk >10% OR\r\n* Anyone with stage 2 hypertension\r\n\r\n### 2019 NICE Guidelines for Pharmacological Management of Primary Hypertension \r\n\r\n[lightgallery1]\r\n\r\n* Step 1: \r\n\t* **ACE-inhibitor** (e.g. Ramipril) if <=55 years old\r\n\t* **DHP-Calcium Channel Blocker** (e.g. Amlodipine) if >55 years old OR African or Caribbean ethnicity\r\n\t* If unable to tolerate ACE-inhibitor then switch to _Angiotensin Receptor Blocker_ (e.g. Candesartan)\r\n* Step 2: \r\n\t* (If maximal dose of Step 1 has failed or not tolerated)\r\n\t* **Combine CCB and ACE-I/ARB**\r\n* Step 3:\r\n\t* (If maximal doses of Step 2 has failed or not tolerated)\r\n\t* **Add thiazide-like diuretic** (e.g. Indapamide)\r\n* Step 4: *Resistant Hypertension*\r\n\t* If blood potassium <4.5mmol/L then add **spironolactone**\r\n\t* If >4.5mmol/L **increase thiazide-like diuretic dose**\r\n\t* Other options at this point if the potassium is >4.5mmol/L include:\r\n\t\t* Alpha blocker (e.g. Doxazosin)\r\n\t\t* Beta blocker (e.g. Atenolol)\r\n\t\t* Referral to cardiology for further advice\r\n\r\n**ABPM Targets:**\r\n \r\n* Age <80 ABPM target <135/85\r\n* Age >80 ABPM target <145/85 (due to risk of postural drop and falls)\r\n* T1DM with end-organ damage <130/80\r\n\r\n# Complications\r\n\r\n* Increased risk of morbidity and mortality from all causes\r\n* Coronary artery disease\r\n* Heart failure\r\n* Renal failure\r\n* Stroke\r\n* Peripheral vascular disease\r\n\r\n# Prognosis \r\n\r\nHypertension remains one of the biggest risk factors for cardiovascular disease and its associated disabilities. Management of hypertension (with lifestyle modifications or pharmacological therapies) has been shown to reduce these risks significantly. \r\n\r\n# NICE Guidelines\r\n> <https://cks.nice.org.uk/topics/hypertension/> \r\n\r\n# References \r\n\r\n<https://patient.info/heart-health/high-blood-pressure-hypertension>\r\n<https://www.ahajournals.org/doi/full/10.1161/01.CIR.101.3.329> ", "files": null, "highlights": [], "id": "639", "pictures": [ { "__typename": "Picture", "caption": null, "createdAt": 1672906680, "id": "1419", "index": 0, "name": "Hypertension diagnosis (NICE).png", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/d1q848bd1672906675512.jpg", "path256": "images/d1q848bd1672906675512_256.jpg", "path512": "images/d1q848bd1672906675512_512.jpg", "thumbhash": "9fcFBYDQgSqZipmetziFe/S3Go/t", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": null, "createdAt": 1672906680, "id": "1423", "index": 1, "name": "Hypertension choice of drug (NICE).png", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/bcwkpi041672906675511.jpg", "path256": "images/bcwkpi041672906675511_256.jpg", "path512": "images/bcwkpi041672906675511_512.jpg", "thumbhash": "8+cFBYCJ+Vm3ZXRZiCd4lX/zxOm/", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 639, "demo": null, "entitlement": null, "id": "651", "name": "Primary (Essential) Hypertension", "status": null, "topic": { "__typename": "Topic", "id": "35", "name": "Cardiology", "typeId": 2 }, "topicId": 35, "totalCards": 49, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "651", "name": "Primary (Essential) Hypertension" } ], "demo": false, "description": null, "duration": 6426.6, "endTime": null, "files": null, "id": "324", "live": false, "museId": "7AeyDdA", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/chemistry.png", "title": "Quesmed Tutorial: Medical Emergencies", "userViewed": false, "views": 949, "viewsToday": 49 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "651", "name": "Primary (Essential) Hypertension" } ], "demo": false, "description": null, "duration": 449.37, "endTime": null, "files": null, "id": "187", "live": false, "museId": "xf1CzHD", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/cardiology.png", "title": "Hypertension", "userViewed": false, "views": 293, "viewsToday": 21 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "651", "name": "Primary (Essential) Hypertension" } ], "demo": false, "description": null, "duration": 3737.73, "endTime": null, "files": null, "id": "614", "live": false, "museId": "ZMAGtgf", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/cardiology.png", "title": "Quesmed Tutorial: General Practice", "userViewed": false, "views": 398, "viewsToday": 38 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "651", "name": "Primary (Essential) Hypertension" } ], "demo": false, "description": null, "duration": 418.43, "endTime": null, "files": null, "id": "675", "live": false, "museId": "fWoxrKV", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/cardiology.png", "title": "Hypertension 2", "userViewed": false, "views": 81, "viewsToday": 18 } ] }, "conceptId": 651, "conditions": [], "difficulty": 2, "dislikes": 7, "explanation": null, "highlights": [], "id": "6492", "isLikedByMe": 0, "learningPoint": "In patients with type 2 diabetes and hypertension, starting an ACE inhibitor is essential for cardiovascular protection and renal health.", "likes": 5, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 65-year-old Caucasian patient registers with a GP in the UK, having emigrated from Italy.\n\n\nFollowing a set of initial investigations, it is found that his ambulatory blood pressure is 145/90 mmHg. He also has a glycosylated haemoglobin (HBA1C) level of 52 mmol/mol (normal range 20-42 mmol/mol) and a fasting blood glucose of 7.2 mmol/L (normal <6.1 mmol/L).\n\n\nHe notes that he was recently diagnosed with type 2 diabetes but has not started any treatment.\n\n\nWhich of the following is the most appropriate next step in the management of this patient's hypertension?", "sbaAnswer": [ "a" ], "totalVotes": 6160, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "A CT head would be indicated if a central cause of vertigo (e.g. stroke) was suspected. Signs of central vertigo on a HINTS exam are a negative head impulse test, bidirectional nystagmus and an abnormal test of skew. The fact he is young and has no cardiac risk factors makes the diagnosis of stroke less likely", "id": "32464", "label": "b", "name": "Urgent CT head", "picture": null, "votes": 584 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Aspirin would be indicated if an ischaemic stroke was suspected as the cause of vertigo following exclusion of haemorrhage on a CT head", "id": "32465", "label": "c", "name": "Start aspirin 300mg", "picture": null, "votes": 38 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "There is no indication for treatment with antibiotics. Vestibular neuronitis is often a sequelae of a viral upper respiratory tract infection", "id": "32467", "label": "e", "name": "Start amoxicillin", "picture": null, "votes": 141 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Vestibular neuronitis usually self-resolves spontaneously; however, the symptoms can be debilitating. Treatment is therefore recommended if symptoms are troublesome", "id": "32466", "label": "d", "name": "Reassure with safety-net advice", "picture": null, "votes": 1135 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "The likely diagnosis is vestibular neuronitis. This is a peripheral cause of vertigo, and the findings described on the HINTS (head impulse, nystagmus and test of skew) examination are suggestive of this. Vestibular neuronitis is characterised by inflammation of the vestibular nerve, often after a viral infection. Common symptoms include acute, spontaneous vertigo, nausea, vomiting and unsteadiness. Prochlorperazine is often used for symptomatic treatment", "id": "32463", "label": "a", "name": "Oral prochlorperazine", "picture": null, "votes": 3789 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nVertigo is a sensory misperception or illusion of motion, often characterised as rotatory dizziness. The sensation can arise from various conditions such as Benign Positional Paroxysmal Vertigo (BPPV), Acute Labyrinthitis, Ménière's Disease, Acoustic Neuroma, Ramsay Hunt Syndrome, and Ototoxicity. Key investigations include the Hallpike manoeuvre for BPPV and hearing evaluation for conditions such as Acute Labyrinthitis and Acoustic Neuroma. Management strategies differ across conditions, and can include repositioning manoeuvres, use of sedatives, and antiviral therapy.\n\n# Definition\n\nVertigo is a sensory phenomenon where an individual perceives a false sensation of movement or spinning. This perceived motion frequently gives the impression of a tilting or spinning environment.\n\n# Epidemiology\n\nVertigo is a common presenting symptom in medical practice. The prevalence of vertigo increases with age and is more common in women than in men. The most common cause of vertigo is BPPV, followed by Ménière's disease and vestibular migraine. \n\n# Signs & Symptoms\n\nThe following table from NICE can help differentiate between central and peripheral causes:\n\n| **Clinical features** | **Peripheral** | **Central** |\n|--------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|\n| **Postural stability** | Can walk, although may be unstable and may not wish to mobilise. | Inability to stand up or walk even with the eyes open. |\n| **Hearing loss or tinnitus** | Possible with some causes (for example Meniere's disease, labyrinthitis). | Uncommon but may occur (for example stroke or intracranial tumour). |\n| **Other neurological symptoms** | No. | Usually (for example cranial nerve dysfunction, visual disturbance, speech defects, dysarthria, weakness, sensory changes, memory loss, and gait ataxia). However, not all people with vertigo due to a stroke will have focal neurological signs. |\n| **Nystagmus** | Horizontal nystagmus with a torsional component that does not alter in direction when the gaze changes. Beats away from the affected side. Disappears with fixation of the gaze. Large amplitude nystagmus is usually only seen early in the course of Meniere's disease or vestibular neuronitis. | Direction-changing nystagmus on lateral gaze (right beating on right gaze, left beating on left gaze). Purely vertical or torsional. Not suppressed by visual fixation. Non-fatiguable. Commonly large amplitude nystagmus. |\n| **Head impulse test** | May be positive with acute unilateral vestibular loss. | Negative, indicating a normal vestibulo-ocular reflex. |\n| **Dix-Hallpike manoeuvre** | In BPPV: latency of symptoms and nystagmus with fatiguability and habituation; severe vertigo. | Abnormal response (for example vertical nystagmus without latency or fatiguability; direction not classical horizontal towards the downward ear). |\n| **Alternate cover test** | Normal. | Slight vertical correction (up on one side, down on the other) suggestive of a central lesion such as stroke. |\n\n\n\n# Differential Diagnosis\n\nThe differential diagnosis for vertigo includes:\n\n- BPPV: Characterised by vertigo with positional change and fatiguable nystagmus.\n- Acute Labyrinthitis: Presents with severe, acute vertigo, associated with nausea and vomiting. Hearing loss and tinnitus may be present.\n- Stroke: Sudden onset vertigo, tends to present with other focal neurology, usually with cardiovascular risk factors\n- Ménière's Disease: Features recurrent episodes of vertigo, sensorineural hearing loss, tinnitus, and a feeling of fullness in the ear.\n- Acoustic Neuroma: Usually presents with unilateral hearing loss and cranial nerve dysfunction.\n- Ramsay Hunt Syndrome: Characterized by facial nerve palsy, which may be accompanied by vertigo, tinnitus, and hearing loss.\n- Ototoxicity: Presents with hearing loss or vertigo following exposure to ototoxic drugs.\n\nOther causes include systemic causes such as:\n\n- Orthostatic Hypotension\n- Cardiac Arrhythmias\n- Medications (e.g., aminoglycoside antibiotics and loop diuretics).\n\n\n\n# Investigations\n\n\n- Dix-Hallpike Manouvre\n\t- This test is crucial for diagnosing BPPV. \n\t- The patient is seated with their head turned 45 degrees to one side, and then quickly laid back so the head hangs slightly off the edge of the bed. \n\t- The test is positive if vertigo and nystagmus are elicited, indicating a peripheral cause like BPPV.\n\t- Nystagmus typically lasts a few seconds and fatigues with repeated testing.\n\nOther investigations may include:\n\n- Audiometry: For suspected cases of Ménière's Disease or Acoustic Neuroma.\n- Imaging (MRI/CT): To rule out central causes such as cerebrovascular disease or tumours.\n- Vestibular function tests: To further characterise and monitor vestibular dysfunction \n\n# Management\n\n\nStemetil (Prochlorperazine) is commonly used for symptomatic relief of vertigo, particularly in the acute setting.\n\nIn terms of specific conditions: \n\n- BPPV: Treated effectively with repositioning manoeuvres such as the Epley or Brandt-Doroff exercises, which aim to move the displaced otoliths back into the utricle.\n- Acute Labyrinthitis/Vestibular Neuritis: Managed with vestibular suppressants (e.g., antihistamines like cinnarizine or meclizine) and possibly corticosteroids.\n- Ménière's Disease: Managed with a combination of diuretics, low-sodium diet, and vestibular suppressants. Intratympanic steroid injections or surgery may be required in refractory cases.\n- Ramsay Hunt Syndrome: Treated with antiviral agents (e.g., acyclovir) and corticosteroids.\n\nFor patients with chronic vestibular disorders, vestibular rehabilitation can be considered. This nvolves exercises that aim to improve balance and reduce dizziness.", "files": null, "highlights": [], "id": "1879", "pictures": [], "typeId": 2 }, "chapterId": 1879, "demo": null, "entitlement": null, "id": "2328", "name": "Vertigo and Dizziness", "status": null, "topic": { "__typename": "Topic", "id": "24", "name": "Ear, Nose & Throat", "typeId": 2 }, "topicId": 24, "totalCards": null, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 2328, "conditions": [], "difficulty": 2, "dislikes": 4, "explanation": null, "highlights": [], "id": "6493", "isLikedByMe": 0, "learningPoint": "Oral prochlorperazine is used to manage the vertigo and nausea in vestibular neuronitis by blocking dopamine receptors, typically for short-term symptom relief.", "likes": 5, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 35-year-old man with presents to the Emergency Department with persistent dizziness since waking up four hours ago. He reports the room spinning around him and associated nausea but no vomiting.\n\nFull systems review is otherwise unremarkable; however, the patient does reveal having some mild coryzal symptoms a few days ago. On examination, there is a positive head impulse test, unidirectional nystagmus and no abnormal test of skew.\n\nGiven the likely diagnosis, which of the following is the most appropriate management?", "sbaAnswer": [ "a" ], "totalVotes": 5687, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Warfarin is not used in acute limb ischaemia. Commencement of warfarin would delay any surgical intervention that may be necessary due to its long half-life", "id": "32471", "label": "d", "name": "Warfarin", "picture": null, "votes": 51 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Fondaparinux is not used in acute limb ischaemia. It is commonly used for the management of non-ST elevation myocardial infarctions (NSTEMIs)", "id": "32472", "label": "e", "name": "Fondaparinux", "picture": null, "votes": 252 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "An unfractionated heparin infusion is preferable to treatment dose LMWH in the management of acute limb ischaemia. As unfractionated heparin has a shorter half-life than LMWH, patients can be taken to theatre more promptly with reduced bleeding risk", "id": "32470", "label": "c", "name": "Low molecular weight heparin (LMWH)", "picture": null, "votes": 2746 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Clopidogrel is not used in acute limb ischaemia. Commencement of clopidogrel would delay any surgical intervention that may be necessary due to its long half-life", "id": "32469", "label": "b", "name": "Clopidogrel", "picture": null, "votes": 700 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient has signs and symptoms consistent with acute limb ischaemia. The prominent popliteal pulsation suggests that the aetiology may be embolic disease from a popliteal aneurysm. Medical management of acute limb ischaemia is with high flow oxygen and initiation of an unfractionated heparin infusion. Surgical intervention may be necessary depending on classification using the Rutherford system", "id": "32468", "label": "a", "name": "Unfractionated heparin", "picture": null, "votes": 1221 } ], "comments": [ { "__typename": "QuestionComment", "comment": "in another question it said LMWH..", "createdAt": 1685548421, "dislikes": 0, "id": "27328", "isLikedByMe": 0, "likes": 16, "parentId": null, "questionId": 6494, "replies": [ { "__typename": "QuestionComment", "comment": "I think UFH IV is the right answer, from what I've found", "createdAt": 1719059446, "dislikes": 0, "id": "53497", "isLikedByMe": 0, "likes": 0, "parentId": 27328, "questionId": 6494, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Intubation Endoscope", "id": 22620 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "CEM", "id": 24430 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\n\nAcute limb ischaemia (ALI) is a severe, symptomatic hypoperfusion of a limb, typically presenting for less than 2 weeks. This condition is a surgical emergency demanding immediate intervention, ideally within 4-6 hours of presentation. The key signs and symptoms are summarised by the mnemonic \"6Ps\": pulseless, pain, pallor, paralysis, paraesthesia, and poikilothermia. Important investigations include complete blood count, U&E, group and save, clotting, and ECG. The management of ALI depends on the cause, with strategies varying for thrombotic and embolic causes. In some cases, limb amputation may be necessary.\n\n\n# Definition\n\n\nAcute limb ischaemia (ALI) is a severe, symptomatic hypoperfusion of a limb that has been occurring for less than 2 weeks. Although the definition specifies a 2-week period, this condition is considered a surgical emergency and demands urgent intervention, ideally within 4-6 hours, however, missed or delayed diagnosis is common. \n\n\n# Epidemiology\n\n\nIn the United Kingdom, acute limb ischaemia (ALI) is not uncommon and presents a significant clinical challenge. Although exact figures vary, incidence rates are estimated at approximately 14 cases per 100,000 persons annually. The condition is more prevalent in older populations, with the majority of cases occurring in individuals over the age of 60. Additionally, factors such as smoking, diabetes, and other forms of cardiovascular disease increase the risk of ALI.\n\n\n# Aetiology\n\n\nAcute limb ischaemia can be caused by:\n\n\n- Thrombosis (80-85%):\n- This often results from the rupture of atherosclerotic plaques.\n- Cardiac or aortic embolisation \n- This accounts for approximately 10-15% of cases. \n- Seen due to atrial fibrillation or mural thrombus formation post-myocardial infarction. \n- Aortic dissection\n- Hypercoagulable states \n- Thrombosis of a pre-existing graft \n- Vasospasm - such as observed in Raynaud's phenomenon.\n- External vascular compromise:\n- Trauma\n- Compartment syndrome\n\n\nAcute limb ischaemia secondary to thrombosis typically has a sub-acute onset and is associated with features of peripheral vascular disease in the contralateral limb. In contrast, ALI secondary to embolisation has a more acute onset and often results from atrial fibrillation.\n\nRisk factors for acute limb ischaemia are similar to those of general cardiovascular risk factors, such as:\n\n- Smoking\n- Diabetes mellitus\n- Obesity\n- Older age\n- Hypertension\n- Hypercholesterolaemia\n\nThe absence of risk factors for acute limb ischaemia should not exclude ALI from the differential diagnosis, as it can be seen in individuals in the absence of risk factors. \n\n\n# Classification \n\nThe Rutherford Classification system is commonly used to grade the severity of acute limb ischaemia.\n\n|**Rutherford Class**|**Sensory Impairment**|**Motor Impairment**|**Doppler Signals**|\n|----------------------------|--------------------------------------------------------|----------------------------|------------------------------------------|\n|**Class 1**|None|None|**Arterial:** Audible <br> **Venous:** Audible|\n|**Class 2a**|Minimal|None|**Arterial:** Audible <br> **Venous:** Audible|\n|**Class 2b**|Involves forefoot with possible rest pain|Mild to moderate|**Arterial:** Absent <br> **Venous:** Present|\n|**Class 3**|Insensate|Severe, rigorous|**Arterial:** Absent <br> **Venous:** Absent|\n\n\n\n# Signs and Symptoms\n\nAcute limb ischaemia most commonly occurs in the lower limbs, but can also occur elsewhere in the body, including the upper limb. \n\nThe signs and symptoms of ALI are represented by the mnemonic \"6Ps\":\n\n\n- **Pulseless**\n- Peripheral pulses may be difficult to palpate or impalpable.\n- **Painful**\n- The pain is described as constant and severe. It occurs at rest. \n- If it is worse on passive movement, this may be a sign of compartment syndrome, a severe complication of acute limb ischaemia. \n- **Pallour**\n- The limb may also have cyanosis or mottling. \n- **Poikilothermia**\n- This is also referred to as \"perishingly cold\" \n- **Paraesthaesia**\n- Loss of sensation occurs before loss of motor power due to the smaller diameter of sensory nerves compared to motor nerves. \n- **Paralysis**\n- Patients may have a reduction or complete loss of muscular power. \n\n\nIf a limb has already lost motor and sensory function, which are late signs seen in acute limb ischaemia, it is generally considered unsalvageable.\n\n### Distinguishing Signs and Symptoms based on Cause\n\nThe signs and symptoms of acute limb ischaemia vary slightly depending if the underlying cause is embolism or thrombosis.\n\n|**Characteristic**|**Thrombosis-Related ALI**|**Embolism-Related ALI**|\n|----------------------------------------|-------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------|\n|**Onset**|Gradual onset. Chronic peripheral arterial disease stimulates collateral vessel development.|Acute onset symptoms.|\n|**Ischemia Border**|No clear border of ischemia due to the presence of chronic peripheral arterial disease.|Well-demarcated area of ischemia, may have a mottled appearance.|\n|**Appearance of Unaffected Limb**|Signs of peripheral arterial disease, such as ulcers and reduced pulses, likely present.|Vascular exam of the other leg is typically normal.|\n\n\n\n# Differential Diagnosis\n\n\nThe main differential diagnoses for acute limb ischaemia include:\n\n\n- **Critical Limb Ischaemia**: This is limb ischaemia which has been occurring for more than 2 weeks. It will also have reduced or absent pulses, but will have ulcers and signs or gangrene. These limbs may have a pink colouration due to collateral formation and compensatory vasodilation surrounding the stenosis. \n- **Compartment syndrome** - Symptoms typically include severe pain, pallor, paresthesia, pulselessness, and paralysis.\n- **Deep vein thrombosis (DVT)** - Symptoms can include unilateral leg swelling, pain, and redness.\n- **Raynaud's phenomenon** - Symptoms are episodic and include pallor, cyanosis, and rubor in response to cold or stress.\n\n\n\n\n# Investigations\n\n\nInitial investigations should include:\n\n- Handheld Doppler ultrasound to determine arterial flow of peripheral vessels\n- This can be used to calculate the ankle-brachial index (ABI). This is where blood pressure is calculated in the ankle and the arm, and then applied to the following equation to determine the ABI. \n- ABI = Highest ankle systolic pressure (dorsalis pedis or posterior tibial) / Highest brachial systolic pressure (left or right arm)\n- < 0.7 is indicative of poor prognosis \n- ECG\n- This is particularly useful to detect atrial fibrillation, suggesting an embolic cause for ALI.\n- Bloods to include:\n- Full blood count (FBC), urea and electrolytes (U&E), creatinine kinase, blood grouping and save, clotting profile\n\nImaging may include:\n\n- Digital subtraction angiogram (DSA)\n- This is considered the standard investigation as it allows determination of the cause of the ischaemia and management can be initiated at the same time. \n- Crescent-shaped occlusion, also referred to as the meniscus sign suggests embolic cause \n- Thrombotic ALI is associated with atherosclerosis of other vessels and the presence of collaterals\n- Duplex Doppler ultrasound\n- CT angiogram \n- Enables visualisation of arteries perfusing the lower limb, however, is contraindicated in those with poor renal function due to the use of dyes. \n- MR angiogram \n- This also uses a dye as during the arterial phase of a contrast bolus the arteries can be visualised. \n\n\n# Management\n\nAcute limb ischaemia is a medical emergency which requires urgent assessment by a vascular surgeon.\n\nIn all cases, all patients should be kept nil by mouth in preparation for potential surgical interventions. Whilst awaiting definitive management, the patient should have:\n\n- Intravenous heparin to prevent thrombus propagation (dependent on local protocols and based on surgeons' advice)\n- Oxygen \n- Analgesia\n- NSAIDs should typically be avoided as many patients are vasculopaths and NSAIDs have an associated risk of cardiovascular events.\n- Intravenous fluids \n- Patients are commonly dehydrated, and risk renal damage due to the release of intracellular components.\n\n### Definitive Management \n\nThe management of acute limb ischaemia varies based on the patient's comorbidities, underlying cause and severity and duration of symptoms. Management options include:\n\n- Endovascular techniques such as:\n- Percutaneous catheter-directed thrombolysis \n- Thrombolytic drugs (i.e. alteplase) are used to dissolve the thrombus. \n- Percutaneous mechanical thrombectomy \n- The thrombus is removed using endovascular tools. \n- Surgery may be indicated due to severity or if endovascular techniques have failed. Options include:\n- Surgical thromboembolectomy\n- Endarterectomy\n- Bypass surgery \n- The occluded vessel is bypassed using a graft to restore perfusion. \n- Fasciotomies\n- These are commonly performed prophylactically for severe ALI with a high risk of developing compartment syndrome. \n- Amputation \n- Used when the limb is considered to be non-viable or if other treatments have failed. \n\n\n### Use of Rutherford Classification\n\nAcute limb ischaemia can be further classified according to the Rutherford criteria, which can help stratify management:\n\n* Stage I: Viable limb. There is an arterial signal that can be picked up with Doppler.\n* Stage IIa: Mild sensory deficit and no motor deficit.\n* Stage IIb: Severe sensory deficit; usually more than just the toes. There may also be rest pain and a motor deficit. \n* Limb salvage depends on immediate treatment.\n* Fasciotomies are often required.\n* Stage III: Irreversibly non-viable limb.\n* Sometimes patients with stage III undergo amputation due to significant risk of complications such as reperfusion injuries and high mortality. \n* Very early treatment can rarely result in some degree of reversal.\n\n\n### Follow Up\n\nFollowing the immediate management of an acutely ischaemic limb, follow-up should include:\n\n- Smoking cessation advice\n- Management of diabetes if present\n- Diet and exercise advice for weight loss \n- Lipid-lowering therapy should be considered \n- Use of anti-platelet agents for those with peripheral arterial disease should be started long-term \n\n\n# Complications\n\nIndividuals with ALI risk having the following complications:\n\n- Reperfusion injury:\n- Ischaemia causes tissue death. When perfusion is restored to the limb, potassium and hydrogen ions can be released, resulting in hyperkalaemia and acidosis. \n- Hyperkalaemia can result in weakness and cardiac arrhythmias. \n- Damage to the muscle causes the release of myoglobin, which can cause acute kidney injury. \n- Compartment syndrome: \nReperfusion of previously ischaemic tissue can cause oedema. This increases the pressure within a restricted fascial compartment, resulting in compartment syndrome. \n- This is an emergency which requires urgent fasciectomy to treat and reduce the loss of muscle. \n- Peripheral nerve injury:\n- Prolonged ischaemia can result in long-term damage to the nerves, resulting in chronic pain pathology. \n- Amputation:\n- If not diagnosed and treated within a timely manner, the limb may require amputation. \n- This is more common in cases caused by thrombosis due to the underlying peripheral arterial disease.\n\n\n# Prognosis\n\nAcute limb ischaemia is associated with an up to 20% mortality rate, which is often the result of reperfusion injury. A poorer prognosis is associated with more severe arterial disease and prolonged time to perfusion. This is seen as prolonged ischaemia time is associated with higher rates of amputation, as a 24-hour delay between symptom onset and reperfusion is associated with a 20% amputation rate. \n\n# NICE Guidelines\n\n[NICE Guidelines Peripheral Arterial Disease](https://bestpractice.bmj.com/topics/en-gb/431?q=Peripheral%20arterial%20disease&c=recentlyviewed) \n\n\n# References\n\n[NHS Peripheral Arterial Disease](https://www.nhs.uk/conditions/peripheral-arterial-disease-pad/) \n\n[BMJ Best Practice Peripheral Arterial Disease](https://bestpractice.bmj.com/topics/en-gb/431?q=Peripheral%20arterial%20disease&c=recentlyviewed) \n\n[Royal College of Emergency Medicine: Acute Limb Ischaemia](https://www.rcemlearning.co.uk/reference/acute-limb-ischaemia/) \n\n[European Society for Vascular Surgery 2020 Guidelines](https://esvs.org/wp-content/uploads/2021/08/Acute-Limb-Ischaemia-Feb-2020.pdf) \n\n[Patient Info: Limb Embolism and Ischaemia](https://patient.info/doctor/limb-embolism-and-ischaemia)", "files": null, "highlights": [], "id": "789", "pictures": [], "typeId": 2 }, "chapterId": 789, "demo": null, "entitlement": null, "id": "828", "name": "Acute limb ischaemia", "status": null, "topic": { "__typename": "Topic", "id": "126", "name": "Vascular Surgery", "typeId": 2 }, "topicId": 126, "totalCards": 9, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "828", "name": "Acute limb ischaemia" } ], "demo": false, "description": null, "duration": 438.23, "endTime": null, "files": null, "id": "12", "live": false, "museId": "XJvR3iz", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/surgery.png", "title": "Acute limb ischaemia", "userViewed": false, "views": 126, "viewsToday": 8 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "828", "name": "Acute limb ischaemia" } ], "demo": false, "description": null, "duration": 4865.83, "endTime": null, "files": null, "id": "315", "live": false, "museId": "eNd6PcR", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/surgery.png", "title": "Quesmed Tutorial: General and Vascular Surgery SBAs ", "userViewed": false, "views": 343, "viewsToday": 17 } ] }, "conceptId": 828, "conditions": [], "difficulty": 3, "dislikes": 15, "explanation": null, "highlights": [], "id": "6494", "isLikedByMe": 0, "learningPoint": "Medical management of acute limb ischaemia is with high flow oxygen and initiation of an unfractionated heparin infusion.", "likes": 5, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 56-year-old man with a background of type 2 diabetes, hypertension and ischaemic heart disease presents with a cold and painful left foot.\n\nHe reports that the symptoms came on suddenly around two hours ago. On examination, the left foot is pale and cold with absent dorsalis pedis and posterior tibial pulses; however, a prominent popliteal pulse is detected. Sensation and movement of the foot are preserved.\n\nWhich of the following is the most appropriate intervention whilst awaiting diagnostic imaging?", "sbaAnswer": [ "a" ], "totalVotes": 4970, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Endovascular intervention, including thrombolysis, may be indicated in this patient; however, a diagnosis of acute mesenteric ischaemia should first be confirmed by CT angiography", "id": "32476", "label": "d", "name": "Endovascular thrombolysis", "picture": null, "votes": 401 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Steroids are not used in the management of acute mesenteric ischaemia", "id": "32475", "label": "c", "name": "IV methylprednisolone", "picture": null, "votes": 83 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "An erect abdominal X-Ray is important to look for signs of perforation. However, a CT has higher sensitivity and has already been reported as normal in this scenario", "id": "32477", "label": "e", "name": "Erect abdominal X-Ray", "picture": null, "votes": 352 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Acute, severe abdominal pain, atrial fibrillation and pain out of proportion to findings on an examination suggest acute mesenteric ischaemia. The high lactate level is also highly suggestive. Although CTAP is normal, the most sensitive imaging modality is a CT angiogram, which would be indicated in this scenario given the high index of suspicion", "id": "32473", "label": "a", "name": "CT angiography", "picture": null, "votes": 2201 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "A laparotomy is not indicated as there are no signs of peritonitis, perforation or infraction at this stage. We are also not sure if this woman would be a candidate for surgery given her co-morbidities", "id": "32474", "label": "b", "name": "Laparotomy", "picture": null, "votes": 757 } ], "comments": [ { "__typename": "QuestionComment", "comment": "\"Management\" ", "createdAt": 1684512521, "dislikes": 0, "id": "25293", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6495, "replies": [ { "__typename": "QuestionComment", "comment": "i think here by 'management' they mean how best to manage the case, though I can see why it can be interpreted as asking for a treatment modality ", "createdAt": 1684847221, "dislikes": 0, "id": "25808", "isLikedByMe": 0, "likes": 0, "parentId": 25293, "questionId": 6495, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Kinin Polyps", "id": 15231 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Passmed>", "id": 26231 } }, { "__typename": "QuestionComment", "comment": "I thought: \n\n\"Management:\nimmediate laparotomy is usually required, particularly if signs of advanced ischemia e.g. peritonitis or sepsis\npoor prognosis, especially if surgery delayed\"", "createdAt": 1685215804, "dislikes": 0, "id": "26674", "isLikedByMe": 0, "likes": 4, "parentId": null, "questionId": 6495, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Axillary Stasis", "id": 20951 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nAcute mesenteric ischemia (AMI) is a serious and potentially fatal condition characterized by sudden onset intestinal hypoperfusion, typically involving the superior mesenteric artery. It presents with severe abdominal pain, often disproportionate to physical findings, nausea, vomiting, and signs of shock. Diagnostic confirmation is generally made through CT angiography. Key risk factors include atrial fibrillation, atherosclerosis, and any condition causing coagulopathy. Management primarily involves rapid diagnosis, stabilization of the patient, and both surgical and non-surgical interventions to restore perfusion.\n\n# Definition\n\nAcute mesenteric ischemia (AMI) is a life-threatening surgical emergency characterized by the abrupt onset of blood flow restriction (hypoperfusion) to a portion of the small intestine. This disruption may be either occlusive or non-occlusive, affecting primarily the superior mesenteric artery.\n\n# Epidemiology\n\nAcute mesenteric ischemia is a relatively rare but serious condition, representing approximately 0.1% of all hospital admissions. However, it's associated with high morbidity and mortality rates, with the mortality rate ranging from 60-80%. Age is a significant factor, with the majority of cases occurring in individuals over 60 years old.\n\n# Aetiology\n\nThe causes of AMI can broadly be categorized as follows:\n\n- **Arterial Embolism**: The most common cause, often resulting from atrial fibrillation or other embolic sources such as infective endocarditis or aortic aneurysm.\n- **Arterial Thrombosis**: Usually associated with atherosclerosis, especially in patients with a history of ischemic heart disease or peripheral vascular disease.\n- **Venous Thrombosis**: Occurs less commonly and is often linked to hypercoagulable states.\n- **Non-Occlusive Mesenteric Ischemia**: Typically associated with low-flow states such as heart failure, shock, or during major surgery.\n\n# Signs and Symptoms\n\nClinical presentation often includes:\n\n- Sudden severe abdominal pain and guarding, often out of proportion to the physical examination\n- Nausea and vomiting\n- Signs of shock, such as hypotension, tachycardia, altered mental status\n- Metabolic acidosis on arterial blood gas (ABG) analysis\n- Rectal bleeding can occasionally be seen in advanced ischemia\n\n# Differential Diagnosis\n\nOther conditions to consider that may present similarly include:\n\n- **Peptic Ulcer Disease**: Presents with epigastric pain, nausea, vomiting, and potential melena or hematemesis.\n- **Acute Pancreatitis**: Epigastric pain radiating to the back, nausea, vomiting, and increased serum lipase or amylase.\n- **Acute Cholecystitis**: Right upper quadrant abdominal pain, fever, nausea, vomiting, and positive Murphy's sign.\n- **Acute Appendicitis**: Right lower quadrant pain, nausea, vomiting, fever, and positive McBurney's point tenderness.\n- **Diverticulitis**: Left lower quadrant pain, altered bowel habits, and possible rectal bleeding.\n\n# Investigations\n\nThe initial work-up should include:\n\n- **Blood tests**: Full blood count, liver function tests, renal function, coagulation profile, and lactate levels\n- **Arterial blood gas (ABG)**: To identify metabolic acidosis\n- **Imaging**: CT angiography is the diagnostic modality of choice due to its ability to visualize the occlusion and surrounding bowel.\n\n# Management\n\nThe primary objectives in managing AMI are rapid diagnosis, stabilization of the patient, and restoration of bowel perfusion. This can be achieved through:\n\n- **Resuscitation**: Including fluid management and correction of metabolic abnormalities\n- **Anticoagulation**: Typically with intravenous heparin to limit progression of thrombosis or embolism\n- **Surgical intervention**: Including embolectomy, arterial bypass, or bowel resection if necrosis is present\n- **Non-surgical intervention**: Such as intra-arterial vasodilators or thrombolytic therapy\n- **Supportive care**: Including analgesia, antibiotics if needed, and nutritional support.", "files": null, "highlights": [], "id": "818", "pictures": [], "typeId": 2 }, "chapterId": 818, "demo": null, "entitlement": null, "id": "865", "name": "Acute mesenteric ischaemia", "status": null, "topic": { "__typename": "Topic", "id": "7", "name": "General Surgery", "typeId": 2 }, "topicId": 7, "totalCards": 14, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "865", "name": "Acute mesenteric ischaemia" } ], "demo": false, "description": null, "duration": 402.8, "endTime": null, "files": null, "id": "13", "live": false, "museId": "Sae7oh7", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/surgery.png", "title": "Acute mesenteric ischaemia", "userViewed": false, "views": 156, "viewsToday": 7 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "865", "name": "Acute mesenteric ischaemia" } ], "demo": false, "description": null, "duration": 4134.57, "endTime": null, "files": null, "id": "302", "live": false, "museId": "L3XLqqB", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/surgery.png", "title": "Quesmed Tutorial: Acute Abdomen", "userViewed": false, "views": 300, "viewsToday": 13 } ] }, "conceptId": 865, "conditions": [], "difficulty": 3, "dislikes": 7, "explanation": null, "highlights": [], "id": "6495", "isLikedByMe": 0, "learningPoint": null, "likes": 2, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 78-year-old lady with a background of atrial fibrillation and hypertension presents with a two-hour history of severe abdominal pain. She reports no other symptoms, and abdominal examination is unremarkable apart from some generalised abdominal tenderness.\n\n\nA venous blood gas reveals a lactate of 7mmol/L (normal range 0.6-1.4 mmol/L), and an urgent CT abdomen and pelvis (CTAP) shows no acute pathology.\n\n\nWhich of the following is the next best step in management?", "sbaAnswer": [ "a" ], "totalVotes": 3794, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "A peak flow measurement would not be possible in a patient who is intubated and ventilated", "id": "32480", "label": "c", "name": "Peak flow", "picture": null, "votes": 13 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "There are no features to suggest that infection is driving this patient's hypoxia; therefore IV antibiotics are not indicated", "id": "32482", "label": "e", "name": "Broad-spectrum IV antibiotics", "picture": null, "votes": 48 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Although recent surgery and immobility increase the risk of venous thromboembolism, the examination findings strongly suggest a pneumothorax", "id": "32479", "label": "b", "name": "CT pulmonary angiogram (CTPA)", "picture": null, "votes": 190 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "There are no signs of tension pneumothorax (e.g. tracheal deviation, haemodynamic instability), hence an emergency thoracentesis is not indicated", "id": "32481", "label": "d", "name": "Emergency thoracentesis", "picture": null, "votes": 584 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "The examination findings are suggestive of a left-sided apical pneumothorax. Mechanical ventilation is an important cause of iatrogenic pneumothorax, and should be considered as a cause of any acute drop in saturations in this context. CXR would be the best investigation to confirm the diagnosis", "id": "32478", "label": "a", "name": "Chest X-ray (CXR)", "picture": null, "votes": 2286 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n \nA pneumothorax is characterised by the abnormal presence of air in the pleural cavity, which may be spontaneous or traumatic in origin. Key signs and symptoms include sudden-onset shortness of breath, pleuritic chest pain, reduced chest expansion and reduced or absent breath sounds on the affected side. Chest X-ray is the key diagnostic investigation (although in cases of tension pneumothorax the diagnosis should be clinical). Management decisions depend on the size of the pneumothorax, the patient's clinical condition and their wishes. Options include conservative management, needle aspiration, chest drain insertion or an ambulatory device. In cases of tension pneumothorax needle decompression is the initial emergency management.\n \n# Definition\n \nA pneumothorax refers to a collection of air in the pleural cavity which may cause collapse of the underlying lung parenchyma. \n\n# Classification\n\n- They may be **spontaneous** or **traumatic** (including iatrogenic causes).\n\n- Spontaneous pneumothoraces can be further divided into **primary** pneumothoraces (in patients without an underlying lung disease) and **secondary** (in patients with underlying lung diseases such as COPD or asthma).\n\n- Patients aged over 50 years old with a significant smoking history who present with a spontaneous pneumothorax are generally considered to have a secondary pneumothorax. \n\n- A **tension pneumothorax** occurs when the defect in the pleura that has led to the pneumothorax creates a one-way valve effect whereby air can enter the pneumothorax but not leave it.\n - This causes the pneumothorax to progressively expand, putting pressure on the heart and great vessels and causing **mediastinal shift**\n - This is a medical emergency that rapidly leads to cardiac arrest if untreated\n \n\n# Signs and Symptoms\n \nThere may be no signs or symptoms (small pneumothoraces may be detected incidentally on imaging) however in an emergency presentation these may include:\n\n- Sudden onset shortness of breath\n- Pleuritic chest pain\n- Dry cough\n- Tachypnoea and increased work of breathing\n\nThe following signs will be found on the affected side of the chest:\n\n- Unilateral reduced expansion\n- Unilateral hyper-resonance to percussion\n- Reduced or absent breath sounds\n- Reduced vocal resonance or tactile vocal fremitus\n \nPatients with a tension pneumothorax may also have:\n\n- Tracheal deviation to the contralateral side\n- Tachycardia\n- Hypotension\n- Distended neck veins\n\n# Investigations\n \nPatients with a suspected tension pneumothorax should be diagnosed and treated with needle decompression based on the clinical picture, with no delay for investigations.\n\nFor other patients, an **erect PA chest X-ray** is diagnostic. \n\n [lightgallery]\n \n\n [lightgallery1]\n \n**CT chest** should be used in high-risk patients where it is not clear from the chest X-ray whether it is safe to place a chest drain.\n\n**Arterial blood gases** are not usually indicated however they may be of use in certain situations e.g. titrating oxygen in a patient with COPD and low saturations.\n\n# Management \n\n**Tension Pneumothoraces:** \n\n- If a tension pneumothorax is suspected, emergency management is to decompress this by inserting a large-bore cannula into the second intercostal space on the affected side, mid-clavicular line, or fifth intercostal space, mid-axillary line if a traumatic cause is suspected, as per ATLS guidelines.\n\n\n- If this fails, open thoracostomy should be done immediately\n- After initial emergency decompression, a chest drain should be inserted\n\nFor **primary or secondary spontaneous pneumothoraces**, management is guided by the 2023 BTS Guidelines as summarised below:\n\n [lightgallery2]\n \n- **Conservative management** involves no intervention for the pneumothorax, and patients are monitored to ensure they do not deteriorate and any symptoms resolve\n- **Ambulatory devices** (e.g. pleural vents) are one-way valves which allow air to leave the pneumothorax but not re-enter it\n - They can be inserted in a simple procedure under local anaesthetic\n - Patients can then be followed up as outpatients\n- Symptomatic patients with larger pneumothoraces (usually 2cm or larger on CXR - CT may be used if unclear) or those with high-risk features (significant hypoxia, bilateral pneumothoraces, underlying lung disease, 50 or older with a significant smoking history, haemopneumothorax) require a **chest drain** and admission for monitoring\n- In symptomatic patients without high-risk features but with pneumothoraces large enough for treatment (2cm or larger), management depends on their priorities\n - Conservative management allows avoidance of any procedure\n - Both needle aspiration and ambulatory devices offer more rapid symptomatic relief (ambulatory device insertion may not be available in all hospitals) \n\n\n**Follow up:**\n\n- All patients should be reviewed in an outpatient clinic 2–4 weeks after presenting with a pneumothorax (with repeat chest imaging)\n- Patients should be advised on smoking cessation if relevant\n - Advise patients not to fly until 7 days after chest imaging has confirmed resolution of the pneumothorax\n - Advise patients they should not take part in underwater diving for life (except in rare cases where they have been treated with bilateral open surgical pleurectomy)\n \n# References\n \n[British Thoracic Society Guidelines](https://thorax.bmj.com/content/thoraxjnl/78/11/1143.full.pdf)\n\n[Royal College of Emergency Medicine - Spontaneous Pneumothorax](https://www.rcemlearning.co.uk/reference/spontaneous-pneumothorax/)\n\n[Radiopaedia - Tension Pneumothorax](https://radiopaedia.org/articles/tension-pneumothorax)\n\n[Pleural Vent Ambulatory Devices](https://www.nth.nhs.uk/resources/pleural-vent-ambulatory-device/)", "files": null, "highlights": [], "id": "331", "pictures": [ { "__typename": "Picture", "caption": "BTS Pneumothorax Pathway", "createdAt": 1704194603, "id": "2336", "index": 2, "name": "BTS Pneumothorax Flowchart.png", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/rshwwsgi1704194603121.jpg", "path256": "images/rshwwsgi1704194603121_256.jpg", "path512": "images/rshwwsgi1704194603121_512.jpg", "thumbhash": "NxgGDQS+meF5CWxWW3qHl6FpH/jz", "topic": { "__typename": "Topic", "id": "32", "name": "Respiratory", "typeId": 2 }, "topicId": 32, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "A left sided tension pneumothorax.", "createdAt": 1665036197, "id": "1031", "index": 1, "name": "Tension pneumothorax.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/pxbwgb3x1665036171696.jpg", "path256": "images/pxbwgb3x1665036171696_256.jpg", "path512": "images/pxbwgb3x1665036171696_512.jpg", "thumbhash": "IggOBoCLtohgeZh3h3Z4d3eHAAAAAAA=", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "A large right sided pneumothorax.", "createdAt": 1665036184, "id": "716", "index": 0, "name": "Pneumothorax.png", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/np3ie7n71665036171715.jpg", "path256": "images/np3ie7n71665036171715_256.jpg", "path512": "images/np3ie7n71665036171715_512.jpg", "thumbhash": "HQgKBwBH/JeSinmOd4Vnp3h2CAAAAAAA", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 4 }, "chapterId": 331, "demo": null, "entitlement": null, "id": "2657", "name": "Pneumothorax", "status": null, "topic": { "__typename": "Topic", "id": "20", "name": "Respiratory Physiology", "typeId": 1 }, "topicId": 20, "totalCards": 1, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 2657, "conditions": [], "difficulty": 2, "dislikes": 1, "explanation": null, "highlights": [], "id": "6496", "isLikedByMe": 0, "learningPoint": null, "likes": 1, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 52-year-old man with a background of asthma is being ventilated in the intensive care unit (ICU) following repair of a ruptured abdominal aortic aneurysm (AAA).\n\nThe medical team are called to assess the patient as his oxygen saturations have dropped to 90% on a fraction of inspired oxygen (FiO₂) of 50%. All other observations are within the normal range.\n\nOn assessment, the patient is not in respiratory distress. His trachea is central, and breath sounds are vesicular apart from an area of hyper-resonance at the apex of the left lung. There is associated reduced vocal resonance in this area.\n\nWhich of the following is the next best step in management?", "sbaAnswer": [ "a" ], "totalVotes": 3121, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Hypocalcemia is an important complication of thyroid surgery due to disruption of parathyroid gland function. However, there are no symptoms of hypocalcemia described", "id": "32485", "label": "c", "name": "IV calcium gluconate", "picture": null, "votes": 38 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "High flow oxygen is an important immediate step in management given that the patient is desaturating due to airway obstruction. However, the most appropriate definitive management step is to relieve the obstruction by evacuating the haematoma", "id": "32486", "label": "d", "name": "High flow oxygen", "picture": null, "votes": 203 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient has acute airway obstruction secondary to a neck haematoma. Neck haematoma is a life-threatening complication of thyroid surgery and can present with signs of airway obstruction (e.g. stridor, respiratory distress), dysphagia, hoarseness and a painful neck mass. Definitive management is with an urgent return to theatre to open the stitches and evacuate the haematoma", "id": "32483", "label": "a", "name": "Open stitches and evacuate haematoma", "picture": null, "votes": 3876 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Steroids may be used as a supportive measure to reduce oedema that may be contributing to airway obstruction in this context; however, it is not the definitive step in management", "id": "32487", "label": "e", "name": "IV methylprednisolone", "picture": null, "votes": 141 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Although stridor is a feature of anaphylaxis, the clinical context suggests airway obstruction secondary to a neck haematoma", "id": "32484", "label": "b", "name": "IM adrenaline", "picture": null, "votes": 325 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nThyroid cancer, although an uncommon malignancy, is the most prevalent cancer of the endocrine system. It encompasses several types, including papillary, follicular, medullary, anaplastic, and thyroid lymphoma. These types differ in frequency, age of presentation, metastatic patterns, associated conditions, and prognosis. Key diagnostic investigations include thyroid ultrasound, fine-needle aspiration, and measurement of serum thyroid-stimulating hormone (TSH) and calcitonin levels. Management strategies are largely determined by the type and stage of thyroid cancer, and generally involve surgery, radioactive iodine treatment, external beam radiation, targeted therapy, or chemotherapy.\n\n# Definition\n\nThyroid cancer is a malignant tumour that originates in the cells of the thyroid gland, a butterfly-shaped organ located at the base of the neck that produces hormones that regulate the body's metabolism.\n\n# Aetiology\n\nThyroid cancer results from genetic changes or mutations that allow cells to grow and multiply rapidly. The accumulation of these abnormal cells forms a tumour. The type of thyroid cancer is determined by the specific cell type within the thyroid that has become cancerous.\n\n# Types of Thyroid Cancer\n\n1. **Papillary Thyroid Cancer**: Constitutes around 70% of all cases (think **P**apillary = **P**opular). Generally presents between 30-40 years of age and can metastasise to bone and lung. Small tumours carry an excellent prognosis.\n \n2. **Follicular Thyroid Cancer**: This type is more common in areas with low iodine and among women, and typically presents between 30-60 years of age. It tends to metastasise to lung and bones rather than locally invade.\n \n3. **Medullary Thyroid Cancer**: Comprising around 5% of thyroid cancer cases, it originates from calcitonin-producing C-cells. It can present with hypocalcaemia and diarrhoea due to increased calcitonin. While 75% of cases are sporadic, it is associated with Multiple Endocrine Neoplasia (MEN) syndrome type 2A and 2B. Metastasis often occurs to lymph nodes, and the prognosis is worse than papillary and follicular carcinoma.\n \n4. **Anaplastic Thyroid Cancer**: The rarest form, it generally presents between 60-70 years old. Characterised by its aggressive nature, patients present with rapidly growing masses. The prognosis is extremely poor with a median survival rate of 8 months.\n \n5. **Thyroid Lymphoma**: Accounts for 10% of thyroid cancers and is typically Non-Hodgkins lymphoma. It is mainly seen between 50-80 years old and is strongly associated with Hashimoto's thyroiditis.\n \n\n# Signs and Symptoms\n\nWhile the symptoms vary depending on the type of thyroid cancer, some common signs and symptoms include a lump or swelling in the neck, voice changes, difficulty swallowing, pain in the neck and throat, and persistent cough.\n\n# Differential Diagnosis\n\nThe differential diagnosis for a patient presenting with a thyroid mass includes:\n\n1. **Benign thyroid nodules**: Often asymptomatic, may present with compressive symptoms like dysphagia and dyspnea.\n2. **Thyroiditis (Hashimoto's or De Quervain's)**: Pain and swelling of the thyroid gland, with Hashimoto's often presenting with hypothyroid symptoms.\n3. **Thyroid cyst**: A fluid-filled sac in the thyroid, often asymptomatic but may cause neck swelling.\n4. **Goitre**: Swelling in the neck due to enlarged thyroid gland, often accompanied by hypothyroid or hyperthyroid symptoms depending on the cause.\n\n# Investigations\n\nThyroid cancer investigations include thyroid ultrasound for imaging of the gland, fine-needle aspiration for cytology, and measurement of serum thyroid-stimulating hormone (TSH) and calcitonin levels to determine the function of the gland and the activity of medullary thyroid cancer, respectively.\n\n# Management\n\nManagement of thyroid cancer is dependent on the type and stage of the disease, but strategies typically involve:\n\n1. **Surgery**: Thyroidectomy or lobectomy, often followed by radioactive iodine treatment.\n2. **Radioactive Iodine (RAI) Treatment**: Used post-surgery to destroy remaining thyroid tissue and treat thyroid cancer cells throughout the body.\n3. **External Beam Radiation Therapy (EBRT)**: Employed in inoperable cases or to relieve symptoms in advanced disease.\n4. **Targeted Therapy**: Used for advanced or metastatic disease, including tyrosine kinase inhibitors.\n5. **Chemotherapy**: Used sparingly, often in combination with radiation for anaplastic thyroid cancer.\n\n## Complications of Thyroid Surgery\n- **Hypocalcaemia** may arise due to accidental injury or removal of the parathyroid glands during thyroid surgery. Symptoms include tingling in the hands and face, muscle spasms, and, at its most severe, ventricular arrhythmias.\n- **Hypothyroidism** is a guaranteed outcome of total thyroidectomy and may occur following a partial thyroidectomy. Patients will need to be on lifelong thyroxine replacement therapy post-surgery.\n- **Damage to the recurrent or superior laryngeal nerves** results from surgical interference with these nerves. This leads to hoarseness and dyspnoea. Management of laryngeal nerve damage may involve speech therapy or reconstructive surgery.\n- **Neck haematoma** arises from post-operative bleeding within the neck. Can be confirmed with USS or CT, but if threatens airway function requires immediate surgical intervention.\n- **Thyrotoxic storm** can occur due to the manipulation of the thyroid gland in a patient who is hyperthyroid. Management of thyrotoxic storm includes beta-blockers, antithyroid medications, and supportive care.\n", "files": null, "highlights": [], "id": "832", "pictures": [], "typeId": 2 }, "chapterId": 832, "demo": null, "entitlement": null, "id": "878", "name": "Thyroid cancer", "status": null, "topic": { "__typename": "Topic", "id": "5", "name": "Endocrinology", "typeId": 2 }, "topicId": 5, "totalCards": 9, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "878", "name": "Thyroid cancer" } ], "demo": false, "description": null, "duration": 3216.34, "endTime": null, "files": null, "id": "633", "live": false, "museId": "X5YwJBt", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/endocrinology.png", "title": "Quesmed Tutorial: Thyroid Disease", "userViewed": false, "views": 242, "viewsToday": 20 } ] }, "conceptId": 878, "conditions": [], "difficulty": 1, "dislikes": 0, "explanation": null, "highlights": [], "id": "6497", "isLikedByMe": 0, "learningPoint": "The definitive management of acute airway obstruction due to a neck hematoma is an urgent return to the operating theatre to open the stitches and evacuate the hematoma, relieving the obstruction.", "likes": 1, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 43-year-old woman is recovering following a total thyroidectomy the previous day. The surgical notes reveal an uncomplicated operation, and all observations post-operatively have been normal.\n\nThe on-call doctor is called to see the patient urgently as her oxygen saturations have dropped acutely to 90% on room air. On assessment, the patient can speak in short sentences only and is using her accessory muscles. Examination of the lung fields are unremarkable; however, there is an intermittent high pitched sound heard on inspiration and an erythematous neck swelling.\n\nWhich of the following is the most appropriate definitive step in management?", "sbaAnswer": [ "a" ], "totalVotes": 4583, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "In low-risk patients, clopidogrel should be stopped for at least 7 days before surgery", "id": "32490", "label": "c", "name": "24 hours", "picture": null, "votes": 239 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "In low-risk patients, clopidogrel should be stopped for at least 7 days before surgery", "id": "32491", "label": "d", "name": "48 hours", "picture": null, "votes": 779 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient is at comparatively low risk of thrombosis, and guidelines recommend that clopidogrel should be withheld for 7 days before surgery in this case. If he had had a stroke, TIA or acute coronary event within the last year, this would increase the risk of thrombosis. In this case, a decision would need to be taken on continuing clopidogrel for longer following consideration of the risk of thrombosis vs the risk of perioperative bleeding", "id": "32488", "label": "a", "name": "7 days", "picture": null, "votes": 1492 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "In low-risk patients, clopidogrel should be stopped for at least 7 days before surgery", "id": "32489", "label": "b", "name": "5 days", "picture": null, "votes": 897 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "There would be no need to stop clopidogrel for longer than 7 days in this case as it would unnecessarily increase the risk of thrombosis without reducing the risk of perioperative bleeding", "id": "32492", "label": "e", "name": "14 days", "picture": null, "votes": 270 } ], "comments": [ { "__typename": "QuestionComment", "comment": "this patient had a TIA 2 years ago therefore shouldn't it just be 5 days as they are low risk???", "createdAt": 1651942178, "dislikes": 0, "id": "10492", "isLikedByMe": 0, "likes": 1, "parentId": null, "questionId": 6498, "replies": [ { "__typename": "QuestionComment", "comment": "you'd still stop it at 7 days, but start bridging therapy with LMWH ", "createdAt": 1652027804, "dislikes": 0, "id": "10510", "isLikedByMe": 0, "likes": 1, "parentId": 10492, "questionId": 6498, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Axillary Gas", "id": 20974 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Kinin Biopsy", "id": 12405 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# COPD\n\nPatients with COPD are at higher risk of post-op complications than other patients because of their impaired respiratory function. It is therefore advisable to arrange the following tests before surgery:\n\n- Lung function tests\n- Chest x-ray\n- Arterial blood gas (if the patient is known to retain carbon dioxide)\n\nFurthermore, it is prudent to encourage patients to give up smoking before the operation and to start chest physio early after the operation.\n\n# Drugs to stop\n\n- **Cardiovascular drugs:** Clopidogrel should be stopped 7 days before surgery, warfarin should be (generally) stopped 5 days before surgery and instead patients should be on low molecular weight heparin until the night before, ACE inhibitors should be stopped the day before surgery.\n- **Combined oral contraceptive pill** should be stopped 4-6 weeks before surgery, and re-started at least 2 weeks after surgery (when the patient is mobile). This reduces the risk of DVT.\n\n# Patients taking steroids\nWhen the body experiences acute stress (e.g. illness, trauma, surgery), the steroid demand increases. \n\nPatients on long term steroids cannot respond to this demand because their adrenal function is suppressed.\n\nTherefore, patients who are on long term steroids usually need more steroids than usual during periods of physiological stress e.g. surgery or acute illness.\n\n\n## Management\n\nPeri-operative management is as follows:\n\n1. Switch oral steroids to 50-100mg IV hydrocortisone.\n2. If there is associated hypotension then fludrocortisone can be added.\n3. For minor operations oral prednisolone can be restarted immediately post-operatively. If the surgery is major then they may require IV hydrocortisone for up to 72 hours post-op.\n\n# Diabetes\nPeri-operative management of diabetes, both non-insulin-dependent (type 2 diabetes) and insulin-dependent (type 1 diabetes), involves careful monitoring and adjustment of medication regimens to mitigate the risk of peri-operative complications. The need for specific peri-operative management in diabetics arises due to physiological changes in response to stress (such as surgery), combined with the patient's underlying metabolic disorder. Surgical stress can induce hyperglycemia, and alterations in medication timing or dosage may be necessary due to fasting or changes in renal function.\n\n## Potential complications\n\n- **Hyperglycemia**: Characterised by blood glucose levels >180 mg/dL, symptoms include polyuria, polydipsia, and unexplained weight loss.\n- **Hypoglycemia**: Characterised by blood glucose levels <70 mg/dL, symptoms include palpitations, tremor, sweating, anxiety, and confusion.\n- **Diabetic Ketoacidosis (DKA)**: Common in type 1 diabetics, symptoms include polyuria, polydipsia, nausea, vomiting, abdominal pain, and fruity-smelling breath.\n- **Lactic Acidosis**: A potential complication of metformin use, especially in renal impairment. Symptoms include abdominal discomfort, nausea, vomiting, muscle pain, and rapid breathing.\n\n\n## Management\n\n\n| Drug | Plan |\n| ---------------------------- | ---------------------------------------------- |\n| Metformin (taken once daily) | Take during the morning of surgery |\n| DDP-IV inhibitors | Take during the morning of surgery |\n| GLP-1 analogues | Take during the morning of surgery |\n| SGLT-2 inhibitors | Omit the day of surgery due to the risk of DKA |\n\nFor insulin-dependent diabetics, key principles are:\n\n1. Schedule the patient as early on the theatre list as possible, minimising the amount of time the patient is nil by mouth.\n2. If on long-acting insulin, this should be continued but reduced by 20%.\n3. Stop any other insulin and begin sliding scale insulin infusion from when the patient is placed nil by mouth.\n4. Continue infusion until the patient is able to eat post-operatively.\n5. Switch to the normal insulin regimen around their first meal.\n\n*For some operations (particularly those that do not require contrast media) metformin does not need to be stopped, but one should always consider the risk of lactic acidosis.\n\nAfter surgery, all oral medications should generally be restarted the morning following surgery.\n\n\n\n# NICE Guidelines\n\n[NICE Guidelines on Diabetes management during the Peri-operative period](https://bnf.nice.org.uk/treatment-summaries/diabetes-surgery-and-medical-illness/)", "files": null, "highlights": [], "id": "3268", "pictures": [], "typeId": 2 }, "chapterId": 3268, "demo": null, "entitlement": null, "id": "5406", "name": "Peri-operative Medication Optimisation", "status": null, "topic": { "__typename": "Topic", "id": "7", "name": "General Surgery", "typeId": 2 }, "topicId": 7, "totalCards": 17, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 5406, "conditions": [], "difficulty": 3, "dislikes": 2, "explanation": null, "highlights": [], "id": "6498", "isLikedByMe": 0, "learningPoint": null, "likes": 2, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 68-year-old patient is assessed in the pre-operative clinic before an elective total hip replacement.\n\nHe is currently taking 75mg clopidogrel once daily following a transient ischaemic attack (TIA) two years ago.\n\nHow many days should he be advised to withhold clopidogrel before surgery?", "sbaAnswer": [ "a" ], "totalVotes": 3677, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "IM ceftriaxone is the first-line treatment for uncomplicated anogenital gonorrhoea infections in the community. The white discharge and absence of any other genito-urinary symptoms make BV the most likely diagnosis.\nDoxycycline", "id": "32496", "label": "d", "name": "IM ceftriaxone", "picture": null, "votes": 46 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Microscopy of vaginal secretions may reveal \"clue cells\" in BV. However, testing is not required if the history and examination findings suggest the diagnosis in non-pregnant women at low risk of having a sexually transmitted infection (STI)", "id": "32494", "label": "b", "name": "Send vaginal secretions for microscopy", "picture": null, "votes": 321 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Doxycycline is the first-line treatment for Chlamydia. The white discharge and absence of any other genito-urinary symptoms make BV the most likely diagnosis", "id": "32497", "label": "e", "name": "Oral doxycycline", "picture": null, "votes": 197 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient's symptoms and examination findings are suggestive of bacterial vaginosis (BV). It is the most common cause of abnormal vaginal discharge in women of child-bearing age and is characterised by an overgrowth of anaerobic organisms in the vagina. In addition, there is an associated increase in vaginal pH to above 4.5. In most women with characteristic signs and symptoms, empirical treatment should be started without further investigations", "id": "32493", "label": "a", "name": "Oral metronidazole", "picture": null, "votes": 3615 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "If measured, vaginal pH would be greater than 4.5 in BV. However, testing is not required if the history and examination findings suggest the diagnosis in non-pregnant women at low risk of having a sexually transmitted infection (STI)", "id": "32495", "label": "c", "name": "Measure vaginal pH", "picture": null, "votes": 995 } ], "comments": [ { "__typename": "QuestionComment", "comment": "The Amsel criteria are often used to diagnose bacterial vaginosis. Three out of the four following features are needed to confer a diagnosis:\nVaginal pH >4.5\nHomogenous grey or milky discharge\nPositive whiff test (addition of 10% potassium hydroxide produces a fishy odour)\nClue cells present on wet mount\n\nSurely we don't start Abx yet?", "createdAt": 1701453528, "dislikes": 0, "id": "35299", "isLikedByMe": 0, "likes": 8, "parentId": null, "questionId": 6499, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "shrek is love", "id": 33424 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary \n \n \nBacterial Vaginosis (BV) is an imbalance in the vaginal microbiome characterised by an overgrowth of anaerobic bacteria and a loss of lactobacilli, leading to symptoms such as increased vaginal discharge with a characteristic \"fishy\" odour. It is the most common cause of abnormal vaginal discharge in women of childbearing age. Diagnosis is based on the Amsel criteria, which include elevated vaginal pH, homogeneous discharge, positive whiff test, and presence of clue cells on wet mount. Treatment involves the use of metronidazole or clindamycin, either orally or intravaginally. Pregnancy can increase the risk of BV and associated complications, although it generally does not cause issues in the majority of pregnancies.\n \n \n# Definition\n \n \nBacterial vaginosis is a bacterial imbalance of the vagina caused by an overgrowth of anaerobic bacteria, such as Gardnerella vaginalis, and a loss of lactobacilli, the dominant bacterial species responsible for maintaining an acidic vaginal pH.\n \n \n# Epidemiology\n \n \nBacterial vaginosis is the most common cause of abnormal vaginal discharge in women of childbearing age, with prevalence rates as high as 50% in some populations. It is more common in sexually active women, but it is not considered a sexually transmitted infection.\n \n \n# Aetiology\n \n \nThe precise cause of bacterial vaginosis is unknown, but it is associated with a change in the balance of the normal bacteria found in the vagina. Factors that may contribute to this imbalance include:\n \n \n- Having multiple sexual partners or a new sexual partner\n- Douching\n- Lack of consistent condom use\n- Hormonal changes, such as those that occur in pregnancy\n \n \n# Signs and Symptoms\n \n \n- Increased vaginal discharge\n- Grey-white watery discharge\n- Characteristic \"fishy\" smelling discharge, particularly after intercourse\n- Vaginal itching or irritation may be present but is less common\n \n \n# Differential Diagnosis\n \n \nWhen considering bacterial vaginosis, several other conditions can present with similar symptoms and should therefore be considered:\n \n \n- **Vulvovaginal Candidiasis**: Characterised by itching, burning, dyspareunia, and white, curd-like discharge.\n- **Trichomonas Vaginalis Infection**: Presents with purulent, frothy, greenish discharge, pruritus, dyspareunia, and dysuria.\n- **Chlamydia or Gonorrhoea infection**: May present with increased vaginal discharge and possibly lower abdominal pain, but are often asymptomatic.\n- **Atrophic Vaginitis**: Most commonly seen in postmenopausal women, presenting with dryness, burning, dyspareunia, and thin, watery discharge.\n \n \n# Investigations\n \n \nThe **Amsel criteria** are often used to diagnose bacterial vaginosis. Three out of the four following features are needed to confer a diagnosis:\n \n \n- Vaginal pH >4.5\n- Homogenous grey or milky discharge\n- Positive whiff test (addition of 10% potassium hydroxide produces a fishy odour)\n- Clue cells present on wet mount\n \n \n# Management\n \n \nThe treatment of choice for bacterial vaginosis is usually either Metronidazole or Clindamycin, which can be administered orally or intravaginally. Sexual partners do not typically require treatment. Recurrence is common and may require repeated or prolonged treatment. Avoidance of common triggers such as smoking, vaginal douching and bubble baths can help to prevent recurrence.\n \n \n# Pregnancy \n \n \nPregnant women are at increased risk of bacterial vaginosis due to hormonal changes. BV during pregnancy can increase the risk for premature birth and low birth weight, but in most cases, it causes no problems. If symptomatic, it can be managed with metronidazole (PO/PV). Regular antenatal care should include screening for BV and other infections to minimise potential risks.\n \n# NICE guidelines\n \n[Click here to see information on NICE about bacterial vaginosis](https://cks.nice.org.uk/topics/bacterial-vaginosis/)\n \n# References\n \n[WHO: Bacterial vaginosis](https://www.who.int/news-room/fact-sheets/detail/bacterial-vaginosis#", "files": null, "highlights": [], "id": "11", "pictures": [], "typeId": 2 }, "chapterId": 11, "demo": null, "entitlement": null, "id": "12", "name": "Bacterial Vaginosis", "status": null, "topic": { "__typename": "Topic", "id": "27", "name": "Genitourinary medicine", "typeId": 2 }, "topicId": 27, "totalCards": 17, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "12", "name": "Bacterial Vaginosis" } ], "demo": false, "description": null, "duration": 611.39, "endTime": null, "files": null, "id": "294", "live": false, "museId": "wyDpr1g", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/obstetrics.png", "title": "Preterm labour", "userViewed": false, "views": 157, "viewsToday": 11 } ] }, "conceptId": 12, "conditions": [], "difficulty": 1, "dislikes": 16, "explanation": null, "highlights": [], "id": "6499", "isLikedByMe": 0, "learningPoint": "Bacterial vaginosis is characterised by a fishy-smelling discharge and is treated with oral metronidazole.", "likes": 4, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 24-year-old woman presents to her GP with abnormal, fishy-smelling vaginal discharge for the last three days. She denies any other genitourinary symptoms.\n\nOn examination, there is a white homogenous discharge visible on the walls of the vagina.\n\nWhich of the following is the next best step in management?", "sbaAnswer": [ "a" ], "totalVotes": 5174, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Conservative management would be the first-line treatment for genital herpes. Genital herpes would present with painful genital ulceration and it is not associated with buboes", "id": "32502", "label": "e", "name": "Conservative management with analgesia", "picture": null, "votes": 80 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Ceftriaxone is the first-line treatment for uncomplicated, anogenital gonorrhoea. The clinical vignette is suggestive of LGV which is caused by Chlamydia species", "id": "32500", "label": "c", "name": "IM ceftriaxone", "picture": null, "votes": 444 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is the first-line treatment for syphilis. Although primary syphilis presents with a painless genital ulcer, secondary syphilis would present differently with features such as a maculopapular rash, generalised lymphadenopathy and constitutional symptoms", "id": "32499", "label": "b", "name": "IM benzathine penicillin", "picture": null, "votes": 2780 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Aciclovir can be used for recurrent cases of genital herpes which is caused by Herpes simplex virus. Genital herpes would present with painful genital ulceration and it is not associated with buboes", "id": "32501", "label": "d", "name": "Oral aciclovir", "picture": null, "votes": 484 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "The most likely diagnosis is lymphogranuloma venerum (LGV). This is a sexually transmitted infection that is caused by specific serovars of Chlamydia trachomatis. The primary infection of infection is characterised by painless genital ulceration. The secondary stage follows weeks later with painful, inguinal and/or femoral lymphadenopathy (buboes). The first-line treatment option is with a three-week course of doxycycline", "id": "32498", "label": "a", "name": "Doxycycline", "picture": null, "votes": 1215 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Would have been nice if stem mentioned whether lymphadenopathy is tender or not", "createdAt": 1649451324, "dislikes": 0, "id": "9596", "isLikedByMe": 0, "likes": 46, "parentId": null, "questionId": 6500, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Tanoy Kinase", "id": 4647 } }, { "__typename": "QuestionComment", "comment": "Doesn't mention painful lymphadenopathy at all. This could be syphilis? ", "createdAt": 1650366234, "dislikes": 1, "id": "9947", "isLikedByMe": 0, "likes": 33, "parentId": null, "questionId": 6500, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Myotonia Bladder", "id": 12619 } }, { "__typename": "QuestionComment", "comment": "stem did not mention pain. pain = LGV, painless = syphilis ", "createdAt": 1673713568, "dislikes": 1, "id": "16606", "isLikedByMe": 0, "likes": 23, "parentId": null, "questionId": 6500, "replies": [ { "__typename": "QuestionComment", "comment": "painless ulcer but painful lymphadenopathy in LGV*", "createdAt": 1685216102, "dislikes": 0, "id": "26675", "isLikedByMe": 0, "likes": 6, "parentId": 16606, "questionId": 6500, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Axillary Stasis", "id": 20951 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Spiderpig747", "id": 22414 } }, { "__typename": "QuestionComment", "comment": "My thoughts are if the majority of people get the answer wrong it's probably a vague question that would be taken out of the exam anyway so I am not gonna sweat it ", "createdAt": 1681904474, "dislikes": 1, "id": "22187", "isLikedByMe": 0, "likes": 16, "parentId": null, "questionId": 6500, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Gastro Flutter", "id": 7737 } }, { "__typename": "QuestionComment", "comment": "Is LGV bilateral a reason for it being answer ", "createdAt": 1684026651, "dislikes": 0, "id": "24429", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6500, "replies": [ { "__typename": "QuestionComment", "comment": "I thought LGV would usually be unilateral?", "createdAt": 1684083069, "dislikes": 0, "id": "24533", "isLikedByMe": 0, "likes": 0, "parentId": 24429, "questionId": 6500, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Acute Body", "id": 10999 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Serpiginous Zika", "id": 14072 } }, { "__typename": "QuestionComment", "comment": "Is the ans LGV because picture is showing 'groove sign'? ", "createdAt": 1686257207, "dislikes": 0, "id": "28226", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6500, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "anon", "id": 17795 } }, { "__typename": "QuestionComment", "comment": "This question came up on full screen whilst I was sat in a coffee shop. Can't imagine what the other people must've thought", "createdAt": 1736702482, "dislikes": 0, "id": "60352", "isLikedByMe": 0, "likes": 11, "parentId": null, "questionId": 6500, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Axillary RNA", "id": 31002 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\n\nLymphogranuloma venereum (LGV) is a sexually transmitted infection caused by specific serovars (L1, L2, or L3) of *Chlamydia trachomatis*. Characterised by painless genital ulcers and inguinal lymphadenopathy, LGV is more common in men who have sex with men. Its diagnosis is mainly based on molecular techniques, like PCR, to detect *C. trachomatis* from a swab of the ulcer. Management involves a 21-day course of antibiotics, including doxycycline, tetracycline, or erythromycin. \n\n\n# Definition\n\n\nLymphogranuloma venereum (LGV) is a sexually transmitted infection (STI) predominantly caused by the L1, L2, or L3 serovars of *Chlamydia trachomatis*.\n\n\n# Epidemiology\n\n\nLGV is more frequently observed in men who have sex with men (MSM). HIV infection is also a risk factor.\n\n\n# Aetiology\n\n\nThe aetiology of LGV involves infection with the L1, L2, or L3 serovars of *Chlamydia trachomatis*, typically through sexual contact.\n\n\n# Signs and Symptoms\n\n\n- Painless genital ulcer\n- Typically appears 3-12 days after infection\n- It might go unnoticed, particularly if it occurs inside the vagina\n- Inguinal lymphadenopathy, often noticeable\n- Proctitis, associated with rectal pain and discharge (in case of rectal infections)\n- Systemic symptoms can include fever and malaise\n\n\n# Differential Diagnosis \n\n\n- **Primary syphilis**: Presents with a solitary, painless genital ulcer (chancre) and regional lymphadenopathy.\n- **Herpes simplex virus infection**: Characterised by multiple painful vesicles or ulcers, systemic symptoms, and occasional inguinal lymphadenopathy.\n- **Chancroid**: Caused by *Haemophilus ducreyi*, it presents with painful genital ulcers and painful inguinal lymphadenopathy.\n\n\n# Investigations\n\n\nMolecular diagnostic techniques, such as polymerase chain reaction (PCR), are used to detect *C. trachomatis* from a swab of the genital ulcer.\n\nIt is also important to screen for other sexually transmitted infections and blood-borne infections such as HIV.\n\n\n# Management\n\n\nThe standard treatment for LGV involves antibiotics. Common regimes include:\n\n\n- Oral doxycycline: 100 mg administered twice daily for 21 days\n- Oral tetracycline: 2 g administered daily for 21 days\n- Oral erythromycin: 500 mg given four times daily for 21 days\n\n\n# References\n\n\n[BASHH guidelines: Lymphogranuloma venereum](https://www.bashhguidelines.org/media/1054/2013-lgv-guideline.pdf)", "files": null, "highlights": [], "id": "37", "pictures": [ { "__typename": "Picture", "caption": "Swollen inguinal lymph nodes in someone with lymphogranuloma venereum.", "createdAt": 1676958432, "id": "1468", "index": 0, "name": "Lymphogranuloma venerum - swollen nodes.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/w8soxra71676958427869.jpg", "path256": "images/w8soxra71676958427869_256.jpg", "path512": "images/w8soxra71676958427869_512.jpg", "thumbhash": "2GgGDYL7txeNhXaNZUl4hOl9j9/m", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "Lymphogranuloma venereum ulceration.", "createdAt": 1676958432, "id": "1460", "index": 1, "name": "Lymphogranuloma venereum - ulceration.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/50njbekr1676958427866.jpg", "path256": "images/50njbekr1676958427866_256.jpg", "path512": "images/50njbekr1676958427866_512.jpg", "thumbhash": "JmkWHIqVhoeneHiPh2hqWnClBQ==", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 37, "demo": null, "entitlement": null, "id": "31", "name": "Lymphogranuloma Venereum", "status": null, "topic": { "__typename": "Topic", "id": "27", "name": "Genitourinary medicine", "typeId": 2 }, "topicId": 27, "totalCards": null, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 31, "conditions": [], "difficulty": 3, "dislikes": 71, "explanation": null, "highlights": [], "id": "6500", "isLikedByMe": 0, "learningPoint": "Lymphogranuloma venereum, a sexually transmitted infection caused by Chlamydia trachomatis, is managed with doxycycline 100 mg twice daily for 21 days to eliminate the infection and prevent complications.", "likes": 7, "multiAnswer": null, "pictures": [ { "__typename": "Picture", "caption": null, "createdAt": 1639016599, "id": "365", "index": 0, "name": "Lymphogranuloma_venerum.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/mowppigj1639016598532.jpg", "path256": "images/mowppigj1639016598532_256.jpg", "path512": "images/mowppigj1639016598532_512.jpg", "thumbhash": "2GgGDYL7txeNhXaNZUl4hOl9j9/m", "topic": { "__typename": "Topic", "id": "27", "name": "Genitourinary medicine", "typeId": 2 }, "topicId": 27, "updatedAt": 1708373886 } ], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 24-year-old homosexual male presents with a two-week history of enlarging lumps in both sides of his groin. He reports noticing a painless penile ulcer around three weeks ago that resolved spontaneously.\n\nHe denies any other symptoms on questioning but reports having had multiple sexual partners over the last three months.\n\nExamination of his groin is significant for the findings shown in the image below.\n\n[lightgallery]\n\nGiven the likely diagnosis, which of the following is the most appropriate treatment option?", "sbaAnswer": [ "a" ], "totalVotes": 5003, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "TVUS is an invasive examination and would therefore not be the initial investigation of choice. A TVUS may be indicated where the pregnancy test is negative and polycystic ovary syndrome is a possible cause of her amenorrhoea", "id": "32506", "label": "d", "name": "Transvaginal ultrasound scan (TVUS)", "picture": null, "votes": 8 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "A high testosterone might indicate an androgen secreting tumour or polycystic ovary syndrome which is less likely in this example", "id": "32505", "label": "c", "name": "Serum testosterone level", "picture": null, "votes": 43 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Whilst the most likely cause is exercise induced amenorrhoea, a urinary pregnancy test is indicated in this patient in the first instance", "id": "32503", "label": "a", "name": "Urinary pregnancy test", "picture": null, "votes": 3602 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "A random cortisol level is part of the investigation for adrenal insufficiency and therefore will not aid diagnosis here", "id": "32507", "label": "e", "name": "Serum cortisol level", "picture": null, "votes": 160 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is a reasonable next step test if you are concerned that this is secondary amenorrhoea due to a hypothalamic or pituitary cause. In this case it's more likely to be due to intensive exercise", "id": "32504", "label": "b", "name": "Serum FSH and LH measurement", "picture": null, "votes": 1541 } ], "comments": [ { "__typename": "QuestionComment", "comment": "why all the thumbs down? good question as reminds you to always remember pregnancy", "createdAt": 1685096465, "dislikes": 1, "id": "26326", "isLikedByMe": 0, "likes": 11, "parentId": null, "questionId": 6501, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Sir Pep Guardiola", "id": 27715 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n \n \nSecondary amenorrhoea is characterised by the absence of menstruation for six months or more in a woman who previously had regular menstrual cycles. The most common cause is pregnancy, but other factors such as breastfeeding, menopause, intrauterine adhesions, PCOS, drug-induced amenorrhoea, physical stress, pituitary gland pathology, and thyroid issues can also be responsible. Key signs and symptoms include absence of menstruation, and depending on the underlying cause, symptoms of pregnancy, menopause, or other related conditions. Investigations typically involve pregnancy tests, hormone level checks, and imaging studies. Management strategies depend on the underlying cause and can range from lifestyle changes and medication to surgery in severe cases.\n \n \n# Definition\n \n \nSecondary amenorrhoea is defined as the absence of menstruation for six months or longer in a woman who has previously had regular menstrual cycles.\n \n \n# Epidemiology\n \n \nSecondary amenorrhoea is a common condition affecting approximately 4-5% of women of reproductive age. It is most frequently observed in women aged 20-39 years.\n \n \n# Aetiology\n \n \nThe potential causes of secondary amenorrhoea include:\n \n \n - Pregnancy (most common cause)\n - Breastfeeding\n - Menopause\n - Intrauterine adhesions leading to outflow tract obstruction (Asherman's syndrome)\n - Polycystic ovary syndrome (PCOS)\n - Drug-induced amenorrhoea (e.g. contraceptive use)\n - Physical stress, excess exercise, and weight loss\n - Pituitary gland pathology, such as Sheehan syndrome or hyperprolactinaemia\n - Hypothyroidism or hyperthyroidism\n \n \n# Signs and Symptoms\n \n \nThe primary symptom of secondary amenorrhoea is the absence of menstrual periods for six months or longer. Additional symptoms, depending on the underlying cause, may include:\n \n \n - Pregnancy signs: nausea, breast tenderness, increased urination, food cravings or aversions\n - Menopause symptoms: hot flashes, night sweats, sleep problems, mood changes\n - Symptoms of PCOS: acne, weight gain, hirsutism (excessive body hair), thinning hair\n - Symptoms of pituitary gland pathology: headaches, vision problems, unexplained weight gain or loss\n \n \n# Differential Diagnosis\n \n \nThe differential diagnosis for secondary amenorrhoea includes:\n \n \n - **Pregnancy:** confirmed by a positive pregnancy test, ultrasound, and physical examination\n - **Menopause:** diagnosed based on age, symptoms such as hot flashes and night sweats, and elevated FSH levels\n - **PCOS:** diagnosed based on irregular periods, signs of high testosterone levels (acne, hirsutism), and presence of numerous small cysts on the ovaries\n - **Asherman's Syndrome:** diagnosed based on history of uterine surgery and confirmed by hysteroscopy\n \n \n# Investigations\n \n **Bedside:**\n \n - Pregnancy test\n\n **Bloods:**\n \n - Hormone level checks, including FSH, LH, TSH, prolactin, and testosterone\n\n**Imaging:**\n\n - Ultrasound to identify potential structural abnormalities. Other imaging (e.g. MRI) may also be appropriate, but TVUSS is usually the first line option. \n\n**Invasive:**\n\n - Hysteroscopy, in cases where intrauterine adhesions are suspected\n \n \n# Management\n \n \nThe management of secondary amenorrhoea is largely determined by the underlying cause:\n \n \n - For pregnancy: regular prenatal care\n - For menopause: hormone replacement therapy (HRT) if symptoms are troublesome\n - For PCOS: lifestyle changes, hormonal contraceptives, and potentially metformin\n - For Asherman's syndrome: surgical removal of adhesions and hormone therapy\n - For drug-induced amenorrhoea: discontinuing the offending drug if possible and safe to do so\n - For conditions related to physical stress, weight loss, or excessive exercise: lifestyle modifications and nutritional counselling.\n \n\n# NICE Guidelines\n[Click here to read NICE guidelines](https://cks.nice.org.uk/topics/amenorrhoea/)\n\n# References \n\n[Patient info](https://patient.info/doctor/amenorrhoea)", "files": null, "highlights": [], "id": "925", "pictures": [], "typeId": 2 }, "chapterId": 925, "demo": null, "entitlement": null, "id": "970", "name": "Secondary amenorrhoea", "status": null, "topic": { "__typename": "Topic", "id": "26", "name": "Gynaecology", "typeId": 2 }, "topicId": 26, "totalCards": 5, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 970, "conditions": [], "difficulty": 2, "dislikes": 16, "explanation": null, "highlights": [], "id": "6501", "isLikedByMe": 0, "learningPoint": "In young female athletes, exercise-induced amenorrhoea is common, but a urinary pregnancy test should be performed to rule out pregnancy first.", "likes": 35, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 17 year old competitive triathlete presents to her GP concerned that her periods have stopped. She tells you she has been stressed recently as she is training intensively for an upcoming national competition.\n\nWhich is the most appropriate initial investigation?", "sbaAnswer": [ "a" ], "totalVotes": 5354, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Depending on the level of abdominal distention some patients may experience breathlessness due to their inability to take deep breaths. In this case, this would not explain her unilateral reduced air entry on examination", "id": "32511", "label": "d", "name": "Splinting of the diaphragm", "picture": null, "votes": 861 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient has a known benign solid ovarian tumour and the case vignette points towards Meigs' syndrome. Meigs' syndrome is defined as the triad of benign ovarian tumour (most commonly a fibroma), pleural effusion and ascites", "id": "32508", "label": "a", "name": "Pleural effusion", "picture": null, "votes": 4044 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Whilst patients may feel anxious about new symptoms when they have an underlying health condition, it would not explain her abdominal distension or chest findings", "id": "32510", "label": "c", "name": "Anxiety", "picture": null, "votes": 16 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "An ovarian fibroma is a benign tumour and therefore less likely to provoke a pulmonary embolism. The history does not suggest any other risk factors for PE. She also doesn't have any other features of PE aside from breathlessness, e.g. chest pain, leg swelling, haemoptysis", "id": "32509", "label": "b", "name": "Pulmonary embolism (PE)", "picture": null, "votes": 248 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is unlikely in this case as there is nothing in the history to suggest that this patient has heart failure and she has no other features of heart failure (e.g. peripheral oedema, raised JVP). Heart failure may cause _bilateral_ reduced air entry", "id": "32512", "label": "e", "name": "Heart failure", "picture": null, "votes": 227 } ], "comments": [ { "__typename": "QuestionComment", "comment": "nice and niche", "createdAt": 1709127120, "dislikes": 0, "id": "43126", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6502, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Kinase Hallux", "id": 541 } }, { "__typename": "QuestionComment", "comment": "Meigs BAPS\n\nBenign Ovarian Tumour\nAscites\nPleural effusion ", "createdAt": 1738653898, "dislikes": 0, "id": "62283", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6502, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "RS3 raami", "id": 68775 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n \n \nOvarian cancer is a major cause of gynaecological cancer-related mortality in the UK, due primarily to the non-specific nature of symptoms in early stages. The most common type is epithelial ovarian tumours, though germ cell tumours and sex cord stromal tumours also occur. Risk factors include older age, smoking, numerous ovulations, obesity, HRT, and BRCA genes. Parity, breastfeeding, early menopause, and COCP use can be protective. Symptoms typically include abdominal discomfort, bloating, early satiety, and urinary changes, with ascites signifying advanced disease. Differentials include IBS, fibroids, ovarian cysts, and other cancers. Initial investigations include CA-125 and pelvic and abdominal ultrasound. Management depends on disease stage and patient fitness, but can include surgery and chemotherapy.\n \n \n# Definition\n \n \nOvarian cancer is a malignancy originating from various cell types found within the ovary. \n \n \n# Aetiology\n \n \nThe causes of ovarian cancer can be divided into risk factors and protective factors. \n \n \nRisk factors include:\n \n \n - Advanced age\n - Smoking\n - Increased number of ovulations (early menarche, late menopause)\n - Obesity\n - Hormone replacement therapy (HRT)\n - Genetic predisposition (BRCA 1 and 2 genes)\n\nProtective factors include:\n\n - Childbearing (parity)\n - Breastfeeding\n - Early menopause\n - Use of combined oral contraceptive pill (COCP)\n\n\n# Classification\n \n \nThe types of ovarian cancers can be classified according to the cell type from which the cancer originates. The types include:\n \n \n**Epithelial ovarian tumours**\n \n \n - Originate from the epithelium which lines the fimbria of the fallopian tubes or the ovaries\n - Epithelial tumours are partially cystic, and the cysts can contain fluid. \n - The initial metastatic spread typically involves the peritoneal cavity, with seeding particularly affecting the bladder, paracolic gutters and the diaphragm. \n - Around 90% of ovarian cancers are epithelial ovarian tumours.\n \n \n**Germ cell tumours features**\n \n \n - Originate from the germ cells in the embryonic gonad. \n - These tumours typically grow rapidly and spread predominantly via the lymphatic route\n - Germ cell tumours most commonly arise in young women, which is atypical for most cases of ovarian cancer. \n - Tumour markers include alpha-fetoprotein and sometimes beta human chorionic gonadotrophin (B-HCG).\n \n \n**Sex cord stromal tumours**\n \n \n - Originate from connective tissue. \n - They are rare, making up less than 5% of all ovarian tumours. They are malignant tumours, but are much less aggressive than epithelial tumours. \n - Additionally, ovarian cancer can be secondary to another cancer elsewhere, which has metastasised to the ovary. A Krukenberg tumour refers to a \"signet ring\" sub-type of stromal tumour, typically gastrointestinal in origin, which has metastasised to the ovary. \n \n \n \n# Signs and Symptoms\n \n \nThe clinical features of ovarian cancer typically present late in the disease progression and include:\n \n \n - Abdominal discomfort\n - Bloating\n - Early satiety\n - Urinary frequency or change in bowel habits\n \n \nIn later stages, the disease may cause:\n \n \n - Ascites (due to vascular growth factors increasing vessel permeability)\n - Pelvic, back and abdominal pain\n - Palpable abdominal or pelvic mass\n \n \n# Differential diagnosis\n \n \nDifferential diagnoses for ovarian cancer include:\n \n \n- Gastrointestinal conditions (e.g., irritable bowel syndrome): characterised by abdominal pain, bloating, and changes in bowel habits. \n2. Fibroids: may cause heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation. \n3. Ovarian cysts: can cause pelvic pain, fullness or heaviness in the abdomen, and bloating.\n4. Other cancers (e.g., bladder, endometrial): may present with symptoms such as abnormal bleeding, pelvic pain, and urinary symptoms.\n \n \n# Investigations\n \n \nInvestigations for suspected ovarian cancer include:\n \n**Bedside:**\n \n * Abdominal examination: tenderness, abdominal mass\n * Bimanual examination: adnexal mass\n\n \n**Bloods:**\n \n* CA-125 levels\n * Measure CA125 in women (especially those aged over 50) with frequent or persistent symptoms of ovarian cancer (i.e. 12 or more times per month)\n * Consider this measurement in women with non-specific symptoms of malignancy, such as unexplained weight loss, fatigue or changes in bowel habit \n* AFP and beta-hCG levels (for younger women who may have germ cell cancers)\n\n \n**Imaging:**\n\n* Pelvic and abdominal ultrasound scan\n * May be helpful to rule out or identify malignancy where CA125 is 35 IU/ml or higher \n* CT chest/abdomen/pelvis (for staging)\n\n**Invasive:**\n \nFurther investigations may include:\n \n* Tissue biopsy \n \n \n**Risk of Malignancy Index** \n\nThese results can be used to calculate the Risk of Malignancy Index (RMI), which stratifies the likelihood of cancer: \n \n\n**RMI = U x M x CA125**\n\n\n* U = ultrasound result (between 0-3)\n* M = menopausal status (1 = premenopausal, 3 = postmenopausal) \n* Serum CA-125 is measured in IU/ml\n\n- NICE advise referring all women with an RMI I score of 250 or greater to a specialist multidisciplinary team\n\n\n**2 Week Wait (2WW) Referral Criteria:**\n\n* Physical examination showing ascites and/or a pelvic abdominal mass (that is not due to uterine fibroids) \n* Ultrasound findings suggestive of ovarian malignancy\n\n\n\n# Staging\n \n \nStage I (limited to the ovaries):\n \n - Stage IA: limited to one ovary, the capsule is intact\n - Stage IB: limited to both ovaries, capsules intact.\n - Stage IC: tumour limited to one or both ovaries with any of the following: capsule ruptured, tumour on ovarian surface, malignant cells in ascites or peritoneal washings.\n \n \nStage II (involving one or both ovaries with pelvic extension and/or implants):\n \n - Stage IIA: extension and/or implants on the uterus and/or Fallopian tubes. No malignant cells in ascites or peritoneal washings\n - Stage IIB: extension to and/or implants on other pelvic tissues. No malignant cells in ascites or peritoneal washings\n - Stage IIC: pelvic extension and/or implants (Stage IIA or Stage IIB) with malignant cells in ascites or peritoneal washings.\n \n \nStage III (involving one or both ovaries with microscopically confirmed peritoneal implants outside the pelvis):\n \n - Stage IIIA: microscopic peritoneal metastasis beyond pelvis (no macroscopic tumour)\n - Stage IIIB: macroscopic peritoneal metastasis beyond pelvis <2 cm\n - Stage IIIC: peritoneal metastasis beyond pelvis >2 cm and/or regional lymph node metastasis.\n \n \nStage IV: tumour involving one or both ovaries with distant metastasis.\n \n \n\n# Management\n \n \nManagement depends on the stage of the cancer and the patient's fitness for treatment.\n\nSurgery: \n\n* If early disease surgery can include removal of the uterus, ovaries, fallopian tubes and omentectomy\n* In advanced disease further debulking surgery can be performed.\n\n \nChemotherapy:\n\n* Adjuvant chemotherapy in combination with surgery\n* Intraperitoneal chemotherapy may be performed at the time of operation\n\nBiological therapies are being trialled \n \n \n# Complications\n\n* Bowel obstruction/constipation\n* Ascites\n* Chemotherapy complications: alopecia, intraperitoneal toxicity, neutropenia, peripheral neuropathy\n* Immunotherapy complications: bowel perforation or fistula, hypertension, poor wound healing \n* Surgical complications: thromboembolism, infection, haemorrhage, death\n* Death\n\n# Prognosis \n\n5-year survival:\n\n* 75% for women younger than 50\n* > 35% for women over 65\n* > 90% for women with localised disease on diagnosis\n* 30% for women with distant disease on diagnosis \n\n# NICE Guidelines\n \n \n [Click here to read NICE CKS on Ovarian cancer](https://cks.nice.org.uk/topics/ovarian-cancer/)\n \n \n# References \n\n[Patient Info](https://patient.info/doctor/ovarian-cancer-pro)", "files": null, "highlights": [], "id": "913", "pictures": [], "typeId": 2 }, "chapterId": 913, "demo": null, "entitlement": null, "id": "979", "name": "Ovarian cancer", "status": null, "topic": { "__typename": "Topic", "id": "26", "name": "Gynaecology", "typeId": 2 }, "topicId": 26, "totalCards": 5, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "979", "name": "Ovarian cancer" } ], "demo": false, "description": null, "duration": 522.07, "endTime": null, "files": null, "id": "149", "live": false, "museId": "NwAyTxS", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/oncology.png", "title": "Genetic syndromes and Cancer", "userViewed": false, "views": 271, "viewsToday": 42 } ] }, "conceptId": 979, "conditions": [], "difficulty": 2, "dislikes": 2, "explanation": null, "highlights": [], "id": "6502", "isLikedByMe": 0, "learningPoint": "Meigs' syndrome is characterised by the presence of a benign ovarian tumour, pleural effusion, and ascites.", "likes": 16, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "An 56 year old female with a known ovarian fibroma presents to accident and emergency with breathlessness and abdominal distension. On examination, she is breathless at rest with reduced air entry at the right base. Her abdomen is soft, non tender and distended with evidence of shifting dullness on percussion.\n\nWhat is the most likely cause of her breathlessness?", "sbaAnswer": [ "a" ], "totalVotes": 5396, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "A knee x-ray may be helpful in showing a large effusion but the history is not suggestive of a bony injury therefore x-ray will not give you a definitive diagnosis in this case", "id": "32519", "label": "b", "name": "Knee x-ray", "picture": null, "votes": 51 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "A blood film is useful in the initial diagnosis of sickle cell disease however this patient is already known to have sickle cell disease and this would not aid in the acute diagnosis", "id": "32522", "label": "e", "name": "Blood film assessment", "picture": null, "votes": 334 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient is septic and the most likely source is his knee. Patients with known sickle cell disease are more prone to septic arthritis and the way this is diagnosed is by aspiration of the joint in an aseptic manner and sending for culture", "id": "32518", "label": "a", "name": "Joint aspiration", "picture": null, "votes": 4621 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Whilst blood cultures should always be taken in patients who present with sepsis, a positive blood culture would not necessarily tell you the focus of the infection. As the knee is the presumed focus, an aspirate directly from the joint will likely yield the definitive diagnosis", "id": "32520", "label": "c", "name": "Blood culture", "picture": null, "votes": 225 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Ultrasound may be used in aiding joint aspiration if the joint space is narrow or the effusion present is small, but it would not provide the diagnosis", "id": "32521", "label": "d", "name": "Knee ultrasound", "picture": null, "votes": 107 } ], "comments": [ { "__typename": "QuestionComment", "comment": "You'd definitely Sepsis 6 him before aspirating his knee though?", "createdAt": 1686511323, "dislikes": 0, "id": "28527", "isLikedByMe": 0, "likes": 2, "parentId": null, "questionId": 6504, "replies": [ { "__typename": "QuestionComment", "comment": "Definitive Ix will still be aspiration", "createdAt": 1708929817, "dislikes": 0, "id": "42855", "isLikedByMe": 0, "likes": 0, "parentId": 28527, "questionId": 6504, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Fibrillation RNA", "id": 17890 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Cystic Juice", "id": 10376 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nSickle cell anaemia (SCA) is an autosomal recessive condition in which a point mutation in the beta chain on chromosome 11 leads to the production of HbS (rather than HbA). HbS polymerises when deoxygenated leading to sickled red blood cells. These cells are fragile and sticky, causing vaso-occlusive crises leading to pain and ischaemia of vital organs. The most common acute presentation is painful vaso-occlusive crises, while the most dangerous is acute chest crises. Diagnosis is typically made postnatally in the UK via a national screening programme but otherwise presents with progressive anaemia in early life. Investigations may reveal microcytic anaemia with variable degrees of haemolysis, and a definitive diagnosis is achieved with haemoglobin electrophoresis +/- genetic testing. Management strategies include high-flow oxygen, IV fluids and analgesia for acute crises, hydroxycarbamide, regular exchange transfusions, vaccinations and antibiotics for chronic disease management.\n\n# Definition\n\nSickle cell anaemia (SCA) is a genetic condition where normal haemoglobin (where variable HbS is present) tends to form abnormal haemoglobin molecules (HbS) upon deoxygenation leading to distortion of RBCs.\n\n# Epidemiology\n\nSickle cell disease is common among individuals of Central and West African descent, where having the carrier (trait) status confers some protection against malaria. \n\n# Pathophysiology \n\n- HbS is produced when the glutamic acid at the 6th position of the β chain is replaced by valine \n- In its deoxygenated state, HbS undergoes polymerisation, forming crystals that cause polymers to form, which in turn leads to the development of RBCs with a sickle shape \n- The abnormal shape of the RBCs causes clotting in the microvasculature, which precipitates vaso-occlusive crises, leading to ischaemia of vital organs and pain\n- Deformation of the RBCs leads to chronic haemolysis, which decreases the body's nitric oxide – typically needed for vasoregulation – and this leads to chronic complications such as pulmonary hypertension and leg ulcers\n\n## Inheritance \n\n- Sickle cell anaemia (HbSS) is an autosomal recessive condition. The most predominant and most severe form, homozygous HbS, represents just one of the sickle cell disease syndromes.\n- Other forms of sickle cell disease involve the coinheritance of HbS with other haemoglobin variants.\n - Most commonly HbC or β-thalassaemia, leading to the HbSC or HbS-βthal forms of sickle cell disease.\n\n## Mechanism of hyposplenism\n\nIn addition, sickled red cells commonly sequester in the spleen, where they undergo phagocytosis by the reticular endothelial system, leading to extravascular haemolysis\n\n- Initially, this leads to splenic congestion and splenomegaly\n- This is followed by splenic infarction, leading to hyposplenism\n- Because of splenic compromise, there is reduced immune function \n - Individuals with sickle cell disease are prone to bacteraemia – the spleen is necessary for phagocytosis of encapsulated bacteria. This means there is vulnerability to encapsulated organisms such as Haemophilus influenzae type B.\n - Affected individuals should have up to date vaccinations for S. pneumoniae, H. influenzae B and N. meningitidis.\n\n\n# Signs and Symptoms\n\n## Vaso-occlusive crises\n\nPainful vaso-occlusive crises are the most common acute presentation of sickle cell anaemia\n\n- Primarily caused by microvascular obstruction due to RBC sickling and inflammation\n- May be triggered by local hypoxia (eg. in cold weather)\n\n## Acute chest crisis\n\nAcute chest crises are the most dangerous acute presentation\n\n- 3% mortality rate, causing 25% of sickle cell-related deaths \n- The cause is often unknown (maybe infectious)\n- Patients present with tachypnoea, wheeze, and cough, with hypoxia and pulmonary infiltrates on chest X-ray\n\n## Other complications \n\n- Splenic infarction and subsequent immunocompromise\n- Sequestration crisis\n- Osteomyelitis\n- Stroke\n- Dactylitis\n- Poor growth\n- Chronic renal disease\n- Gallstones\n- Retinal disorders\n- Priapism\n- Pulmonary fibrosis and pulmonary hypertension\n- Iron overload from repeated blood transfusions\n- Red cell aplasia (due to parvovirus B19 infection in the presence of chronic haemolytic anaemia)\n\n**Clinical severity** is highly variable: some patients have few symptoms; others have severe and frequent crises, haemolytic anaemia and end-organ damage\n\n- This is due to a range of factors such as the amount of HbF (foetal haemoglobin) – higher levels of HbF reduce the severity of clinical complications\n- Patients with Hb SC disease have milder anaemia and suffer fewer crises than people with Hb SS disease \n- Patients with Hb SC disease are however more prone to sickle cell retinopathy \n - Ophthalmological review is needed annually for all patients with Hb SC disease\n\n# Investigations\n\n- Bedside - peak flow, which is essential for monitoring patients with chest crisis\n- **FBC** may show microcytic anaemia with variable degrees of haemolysis \n - Reticulocytosis and unconjugated hyperbilirubinemia may be noted\n\n- Typical **blood film** findings include: \n - characteristic sickle cells\n - target cells\n - reticulocytosis with polychromasia \n - features of functional hyposplenism (Howell–Jolly bodies, nucleated red cells)\n\nDefinitive diagnosis is with **haemoglobin electrophoresis** +/– genetic testing. However, many labs use high-performance liquid chromatography (HPLC) and/or isoelectric focusing (IEF) instead of HB electrophoresis. \n\n[lightgallery]\n\n## Screening for sickle cell disease\n\n- Sickle cell disease in the UK is typically diagnosed postnatally (by the national screening programme)\n- Additionally, all patients of African or Caribbean descent should have a sickle cell test prior to surgery \n- Otherwise, it can present with progressive anaemia in early life when levels of foetal haemoglobin (which contains γ-chains) fall and are replaced by HbS (containing the variant β-globin)\n\n# Management \n\n## Acute sickle cell crisis\n\nTreatments include: \n\n- High-flow oxygen \n- IV fluids and analgesia\n- Top-up transfusions – required in some severe cases\n\nNote: ABO-compatible red cells matched for Rhesus and Kell antigens should be given as this will inhibit the development of antibodies that can otherwise complicate future transfusions.\n\n\n## Chronic sickle cell disease\n\n* **Hydroxycarbamide** if frequent crises occur\n * Increases foetal haemoglobin concentrations – needs to be balanced with risks of marrow suppression, reduced fertility and risk of teratogenicity\n\n* Alternatively regular exchange transfusions may be required for frequent sickle cell crises, acute chest syndrome, priapism and stroke prevention \n* **Vaccinations** and **antibiotic prophylaxis** – in view of hyposplenism and subsequent immunocompromise\n* Newer therapies include: \n * crizaniluzumab (p-selectin inhibitor) for treatment of pain crises \n * voxelotor (haemoglobin oxygen-affinity modulator) for haemolytic complications\n\n* Bone marrow transplant and gene-editing techniques are now becoming possible curative options for some patients\n\n# NICE Guidelines\n\n[Click here to see information on NICE CKS on sickle cell](https://cks.nice.org.uk/topics/sickle-cell-disease/)", "files": null, "highlights": [], "id": "377", "pictures": [ { "__typename": "Picture", "caption": "A bloodfilm showing sickle cell disease.", "createdAt": 1665036193, "id": "777", "index": 0, "name": "Sickle cell.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/s98h68ab1665036171705.jpg", "path256": "images/s98h68ab1665036171705_256.jpg", "path512": "images/s98h68ab1665036171705_512.jpg", "thumbhash": "rPcBBYApv8aNqGiGeXqJeMNvCG6W", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 377, "demo": null, "entitlement": null, "id": "377", "name": "Sickle cell disease", "status": null, "topic": { "__typename": "Topic", "id": "8", "name": "Haematology", "typeId": 2 }, "topicId": 8, "totalCards": 16, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "377", "name": "Sickle cell disease" } ], "demo": false, "description": null, "duration": 4134.57, "endTime": null, "files": null, "id": "302", "live": false, "museId": "L3XLqqB", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/surgery.png", "title": "Quesmed Tutorial: Acute Abdomen", "userViewed": false, "views": 300, "viewsToday": 13 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "377", "name": "Sickle cell disease" } ], "demo": false, "description": null, "duration": 334.74, "endTime": null, "files": null, "id": "356", "live": false, "museId": "zzeXMCS", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/hematology.png", "title": "Sickle cell disease", "userViewed": false, "views": 141, "viewsToday": 11 } ] }, "conceptId": 377, "conditions": [], "difficulty": 1, "dislikes": 1, "explanation": null, "highlights": [], "id": "6504", "isLikedByMe": 0, "learningPoint": "Joint aspiration is crucial in patients with sickle cell disease who are at increased risk of septic arthritis, as it helps confirm the diagnosis, identify the causative organism, and guide targeted treatment.", "likes": 3, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 27 year old male with known sickle cell disease presents to his local accident and emergency department with an eight hour history of a painful right knee. His triage observations are as follows: SpO₂ 97% on air, respiratory rate 18, pulse 108 (regular), blood pressure 90/60 mmHg, temperature 39.2°C.\n\nHis knee is erythematous and hot to the touch and he has very minimal active movement.\n\nWhat test will give you the definitive diagnosis?", "sbaAnswer": [ "a" ], "totalVotes": 5338, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient has failed anticoagulation with a direct oral anticoagulant (DOAC). The National Institute for Health Care Excellence (NICE) guidance therefore suggests confirming her adherence to the medication and then either increasing the dosage of the medication or changing for an anticoagulant with a different mode of action. As she is already on the maximum dose of rivaroxaban changing her anticoagulation to warfarin is reasonable", "id": "32523", "label": "a", "name": "Commence warfarin", "picture": null, "votes": 1359 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "20mg once a day is already the maximum dose for rivaroxaban and therefore a dose increase should only be undertaken in complex cases under the advice of a haematologist. The better option here is to change to a difference mode of anticoagulation", "id": "32524", "label": "b", "name": "Increase her rivaroxaban dose", "picture": null, "votes": 962 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Apixaban is a factor Xa inhibitor, the same as rivaroxaban. This patient has already failed this therapy and therefore an anticoagulant with a different mechanism of action is indicated here", "id": "32526", "label": "d", "name": "Commence apixaban", "picture": null, "votes": 310 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Inferior vena cava filters are only indicated in patients who cannot take blood thinning medications. Changing to a different oral anticoagulant is the preferred option here", "id": "32525", "label": "c", "name": "Insert an inferior vena cava filter", "picture": null, "votes": 2142 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Venesection is a recognised treatment for some haematological conditions such as hereditary haemochromatosis and polycythaemia (both of which can increase the risk of DVT) however this woman has been investigated for these conditions previously, therefore this treatment is not indicated", "id": "32527", "label": "e", "name": "Regular venesection", "picture": null, "votes": 148 } ], "comments": [ { "__typename": "QuestionComment", "comment": "im not going to memorize the maximum dose for every drug??", "createdAt": 1645645854, "dislikes": 0, "id": "7568", "isLikedByMe": 0, "likes": 33, "parentId": null, "questionId": 6505, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Dermis Cystic", "id": 4236 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nDeep Vein Thrombosis (DVT) refers to intra-luminal occlusion of a deep vein with a blood clot, obstructing blood flow. Commonly these occur in the legs although other veins may be affected. DVTs are categorised as \"provoked\" if a transient risk factor such as pregnancy or surgery is identifiable, and \"unprovoked\" if not. Key signs and symptoms include leg pain, unilateral erythema, warmth and swelling and distention of superficial veins. The Wells score is commonly used to assess how likely a DVT is based on clinical findings and risk factors; this guides whether a D-dimer blood test or a Doppler ultrasound should be offered first-line. Management is usually with anticoagulation; in rare cases other strategies such as mechanical thrombectomy and IVC filters may be required.\n \n# Definition\n \nA deep vein thrombosis (DVT) is a blood clot or thrombus that blocks a deep vein, commonly in the legs or pelvis. \n \n# Epidemiology\n \n- Venous thromboembolism (which includes both DVT and pulmonary embolism) is common, affecting 1-2 per 1000 people per year\n- Two-thirds of cases are DVTs and one-third are pulmonary emboli (PE), with DVT being the main risk factor for PE\n- It is particularly common in unwell patients in hospital, with an incidence of up to 37% in critically ill patients\n\n# Aetiology\n \nRisk factors for DVT can be remembered with the mnemonic **THROMBOSIS:**\n \n\n * **T**hrombophilia\n * **H**ormonal (COCP, pregnancy and the postpartum period, HRT)\n * **R**elatives (family history of VTE)\n * **O**lder age (>60)\n * **M**alignancy\n * **B**one fractures\n * **O**besity\n * **S**moking\n * **I**mmobilisation (long-distance travel, recent surgery or trauma)\n * **S**ickness (e.g. acute infection, dehydration)\n\n# Signs and Symptoms\n \n- Unilateral erythema, warmth, swelling and pain in the affected area\n- Pain on palpation of deep veins\n- Distention of superficial veins\n- Difference in calf circumference if the leg is affected\n - This should be measured 10cm below the tibial tuberosity\n - > 3cm difference between the legs is significant\n\n# Differential Diagnosis\n\n- **Cellulitis** also causes erythema, warmth, swelling and pain and often affects the legs, patients may have other signs of infection e.g. fevers and there may be an obvious wound or discharge\n- **Calf muscle tear** also causes swelling, erythema and pain; there will usually be a history of trauma immediately preceding the development of symptoms\n- **Superficial thrombophlebitis** often occurs in the lower limbs in association with varicose veins, however pain is localised to a thrombosed vein rather than there being generalised pain and swelling of the limb\n- **Compartment syndrome** can be differentiated by severe pain out of proportion to clinical signs, often preceded by traumatic injury\n\n# Investigations\n \nThe two-level DVT Wells score is used to risk-stratify patients into patients likely or unlikely to have a DVT as follows:\n\n**Add one point** for each of:\n\n- Active cancer (treatment within the last 6 months or palliative)\n- Paralysis, paresis, or recent plaster immobilisation of the legs\n- Recently bedridden for 3 days or more, or major surgery within the last 12 weeks\n- Localised tenderness along the distribution of the deep venous system\n- Entire leg is swollen.\n- Calf swelling at least 3 cm larger than asymptomatic side\n- Pitting oedema confined to the symptomatic leg\n- Collateral superficial veins\n- Personal history of DVT\n\n**Minus 2 points** if an alternative cause is considered at least as likely as a DVT.\n\nIf the score is **2 or more**:\n \n- DVT is **likely** and an ultrasound doppler of the proximal leg veins should be done within 4 hours\n- If this isn't possible within 4 hours, do a D-dimer test, start interim anticoagulation and arrange the doppler to happen within 24 hours\n \nIf the score is **1 or less**:\n \n- DVT is **unlikely** and a D-dimer should be sent\n- If the results cannot be obtained within 4 hours, offer interim anticoagulation whilst awaiting results\n- If the D-dimer is positive, do an ultrasound doppler of the proximal leg veins \n- If it is negative, anticoagulation should be stopped if it was started and an alternative diagnosis considered\n\n[lightgallery] \n\nD-dimer is not a specific test and is often raised in infection, trauma, malignancy, post-surgery or haemorrhage. \n\nNote that separate guidelines exist for pregnant and postpartum women - linked below in references.\n\n**Baseline blood tests** should be taken when anticoagulation is started, including a FBC, U&Es, LFTs and a coagulation screen. \n\n# Management\n \n- First-line anticoagulant medications are **DOACs** (e.g. apixaban, rivaroxaban)\n- If these are not suitable, second-line options include low molecular weight heparin (LMWH) for at least 5 days followed by dabigatran or edoxaban, or LMWH bridging with warfarin (with a target INR of 2.5)\n- Treatment duration should be at least 3 months for all patients, and 3-6 months for people with active cancer\n- At this point the risk of VTE recurrence should be weighed against the risks of continuing anticoagulation to make a decision about whether to continue\n- In cases of provoked DVTs (where a major transient risk factor is identifiable e.g. surgery), anticoagulation would usually be stopped at 3 months\n- In cases of unprovoked DVTs, consider testing for thrombophilia with antiphospholipid antibodies in patients who are stopping anticoagulation\n- Patients with unprovoked DVTs should be reviewed with baseline blood tests and an examination to investigate the possibility of an undiagnosed cancer - further investigations should be guided by the patient's signs or symptoms\n\n[lightgallery1]\n \n# Complications\n\n- Pulmonary embolism\n- Post-thrombotic syndrome (chronic venous hypertension post-DVT that may cause significant morbidity)\n- Complications of anticoagulation e.g. gastrointestinal bleeding\n\n \n# NICE Guidelines\n \n[NICE CKS - DVT](https://cks.nice.org.uk/topics/deep-vein-thrombosis/)\n\n[NICE - Venous thromboembolic diseases](https://www.nice.org.uk/guidance/ng158/)\n \n# References\n\n[RCEM Learning - Deep Vein Thrombosis](https://www.rcemlearning.co.uk/reference/deep-vein-thrombosis)\n\n[RCOG - Thromboembolic Disease in Pregnancy and the Puerperium](https://www.rcog.org.uk/media/wj2lpco5/gtg-37b-1.pdf)", "files": null, "highlights": [], "id": "161", "pictures": [ { "__typename": "Picture", "caption": null, "createdAt": 1693463355, "id": "2217", "index": 1, "name": "Anticoagulation NICE.png", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/pmtxv4tf1693463348505.jpg", "path256": "images/pmtxv4tf1693463348505_256.jpg", "path512": "images/pmtxv4tf1693463348505_512.jpg", "thumbhash": "89cJHYiph5egiXiIiNd2bc+gxgtq", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": null, "createdAt": 1693463355, "id": "2218", "index": 0, "name": "DVT NICE.png", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/rk4fdo3x1693463348505.jpg", "path256": "images/rk4fdo3x1693463348505_256.jpg", "path512": "images/rk4fdo3x1693463348505_512.jpg", "thumbhash": "tOcJDYKlh6hqdoevdmeIWLOZT5r4", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 161, "demo": null, "entitlement": null, "id": "888", "name": "Deep Vein Thrombosis (DVT)", "status": null, "topic": { "__typename": "Topic", "id": "8", "name": "Haematology", "typeId": 2 }, "topicId": 8, "totalCards": 7, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "888", "name": "Deep Vein Thrombosis (DVT)" } ], "demo": false, "description": null, "duration": 318.87, "endTime": null, "files": null, "id": "88", "live": false, "museId": "7tsshSs", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/hematology.png", "title": "Deep Vein Thrombosis (DVT) 2", "userViewed": false, "views": 31, "viewsToday": 3 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "888", "name": "Deep Vein Thrombosis (DVT)" } ], "demo": false, "description": null, "duration": 4459.69, "endTime": null, "files": null, "id": "330", "live": false, "museId": "1QTvHhh", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/respiratory.png", "title": "Quesmed Tutorial: PE and DVT", "userViewed": false, "views": 110, "viewsToday": 11 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "888", "name": "Deep Vein Thrombosis (DVT)" } ], "demo": false, "description": null, "duration": 357.8, "endTime": null, "files": null, "id": "87", "live": false, "museId": "LZ4GpNW", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/hematology.png", "title": "Deep Vein Thrombosis (DVT) 1", "userViewed": false, "views": 49, "viewsToday": 4 } ] }, "conceptId": 888, "conditions": [], "difficulty": 3, "dislikes": 14, "explanation": null, "highlights": [], "id": "6505", "isLikedByMe": 0, "learningPoint": "In patients with recurrent DVT despite optimal DOAC therapy, switching to warfarin may be necessary for effective anticoagulation management.", "likes": 11, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 62 year old female has recurrent deep vein thromboses (DVT) for which she takes rivaroxaban 20mg once a day. Unfortunately she develops a new unilateral leg swelling and ultrasound investigation confirms a further deep vein thrombosis. She has been investigated previously for underlying hypercoagulable conditions and all the tests have been negative.\n\nHow should you treat this patient?", "sbaAnswer": [ "a" ], "totalVotes": 4921, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": true, "explanation": "Given the chronicity of this infection and the relative immunosuppression of a patient with poorly controlled diabetes, it is important to rule out osteomyelitis which would require extended intravenous antibiotic therapy. The best modality for this is MRI", "id": "32533", "label": "a", "name": "Magnetic resonance imaging (MRI) of the foot", "picture": null, "votes": 2178 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Venous doppler scanning is predominantly used to look for venous thrombosis. Whilst haemostasis in the legs due to poor drainage can cause venous ulceration the vignette here indicates this is a diabetic foot ulcer and therefore dopplers are not indicated", "id": "32536", "label": "d", "name": "Lower limb venous doppler", "picture": null, "votes": 611 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Arterial imaging would be of benefit if there was a concern about circulatory deficit preventing healing. The pathophysiology of diabetic foot ulcers is usually microvascular in nature and therefore arterial duplexes are not indicated", "id": "32535", "label": "c", "name": "Arterial lower limb duplex", "picture": null, "votes": 1357 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Blood cultures would be indicated if this patient had presented acutely septic, however this is a chronic infection and therefore blood cultures are unlikely to be positive or helpful in this case", "id": "32534", "label": "b", "name": "Blood cultures", "picture": null, "votes": 592 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Serum HbA1C is useful in determining both the initial diagnosis and long term control of diabetes. Whilst in this case we know the patient has poorly controlled diabetes and tighter diabetic control will lead to better outcomes it does not deal with the acute issue at hand", "id": "32537", "label": "e", "name": "Serum haemoglobin A1C (HbA1C) measurement", "picture": null, "votes": 234 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nCharcot arthropathy is a chronic, progressive condition characterised by destructive changes in the bones and joints of patients with neuropathy, most commonly from diabetes. It presents with the '6Ds': Destruction, Deformity, Degeneration, Dense bones, Debris, and Dislocation. Diagnosis often involves imaging, typically with radiographs, and distinguishing it from osteomyelitis. Management focuses on immobilisation, orthotics, medication to manage pain and bone loss, and surgical interventions in advanced or refractory cases.\n\n# Definition\n\nCharcot arthropathy, also known as Charcot joint or neuropathic arthropathy, is a chronic, progressive condition characterised by painful or painless bone and joint destruction in the limbs that have lost sensory innervation. The condition primarily affects patients with peripheral neuropathy.\n\n# Epidemiology\n\nCharcot arthropathy is most commonly seen in patients with long-standing diabetes mellitus, with the prevalence being estimated to be around 0.1-0.9% in this group. It can occur at any age but is more frequently observed in the middle-aged and elderly population.\n\n# Aetiology\n\nThe underlying aetiology of Charcot arthropathy is primarily neuropathy. The most common cause of this is diabetes mellitus, which leads to microvascular disease, autonomic neuropathy, and peripheral neuropathy, resulting in cumulative damage to the joints. Other, rarer causes include conditions that cause neuropathy, such as syringomyelia, chronic alcohol abuse, and syphilis.\n\n# Signs and Symptoms\n\nCharcot arthropathy often presents with the '6Ds'(some of which are imaging features):\n\n- Destruction of bone and joint\n- Deformity\n- Degeneration\n- Dense bones\n- Debris of bone fragments\n- Dislocation\n\nIt classically affects the tarsometatarsal joints, but it can involve any joint in a limb that has lost sensation due to neuropathy.\n\n# Differential Diagnosis\n\nThe main differential diagnosis to rule out in the context of Charcot arthropathy is osteomyelitis, which also causes bone destruction but is typically associated with systemic symptoms like fever, increased inflammatory markers, and often a preceding or concurrent soft tissue infection.\n\n# Investigations\n\nThe diagnosis of Charcot arthropathy is primarily clinical but often involves imaging to assess the extent of the bone and joint involvement:\n\n- X-rays are usually the first-line imaging study. They can demonstrate bone destruction, debris, sclerosis (dense bones), and dislocation.\n- MRI can provide more detailed imaging, particularly in early disease or when osteomyelitis is suspected.\n- Bone scans may be used in complex cases or when other imaging is inconclusive.\n\n# Management\n\nThe management of Charcot arthropathy involves conservative and surgical strategies:\n\nConservative:\n- Prolonged off-loading, often involving special footwear or plaster casts, to allow healing and prevent further damage.\n- Use of orthotics for long-term management and prevention of recurrences.\n\nMedications:\n- Bisphosphonates can help slow down the process of bone destruction.\n- Neuropathic pain agents, such as gabapentin or pregabalin, for pain management.\n- Topical anesthetics can also be used to manage pain.\n\nSurgical:\n- Resection of bony prominences to prevent ulcers or improve fitting of footwear.\n- Correction of severe deformities, usually after the acute phase has settled.\n- Amputation may be required in severe cases or when there is a concurrent uncontrolled infection.\n\n\n", "files": null, "highlights": [], "id": "1801", "pictures": [], "typeId": 2 }, "chapterId": 1801, "demo": null, "entitlement": null, "id": "2000", "name": "Charcot Arthropathy", "status": null, "topic": { "__typename": "Topic", "id": "5", "name": "Endocrinology", "typeId": 2 }, "topicId": 5, "totalCards": 3, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 2000, "conditions": [], "difficulty": 3, "dislikes": 24, "explanation": null, "highlights": [], "id": "6507", "isLikedByMe": 0, "learningPoint": "In diabetic patients with chronic foot ulcers, MRI is essential to rule out osteomyelitis when infection fails to improve with oral antibiotics.", "likes": 4, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 73 year old female with poorly controlled type two diabetes mellitus has had a chronically infected foot ulcer for six weeks and it is not improving with oral antibiotics. She's become increasingly unable to weight bear over the past week.\n\nWhich investigation will be most useful to guide your management?", "sbaAnswer": [ "a" ], "totalVotes": 4972, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "A quinsey is another term for a peritonsillar abscess. This is a more common complication of under-treated bacterial throat infections and often requires incision and drainage. A quinsey can develop into a parapharyngeal abscess if left untreated, but as with parapharyngeal abscess it does not always have an associated thrombosis and therefore is not the correct answer here", "id": "32540", "label": "c", "name": "Quinsey", "picture": null, "votes": 1185 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Reye's syndrome is acute encephalopathy and liver failure after a febrile viral illness such as influenza and upper respiratory tract infections. It does not present with neck swelling and liver failure is more commonly associated with bleeding as opposed to thrombosis. This is therefore not the correct answer", "id": "32541", "label": "d", "name": "Reye's syndrome", "picture": null, "votes": 473 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "A parapharyngeal abscess is another recognised complication of under-treated bacterial throat infections. It may present with a neck swelling and can lead to Lemierre's syndrome, but not all parapharyngeal abscesses have an associated thrombus, therefore this is not the correct answer. It can be life threatening as it may lead to airway compromise and thus must be surgically drained under general anaesthetic", "id": "32539", "label": "b", "name": "Parapharyngeal abscess", "picture": null, "votes": 721 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is a combination of symptoms that arise from damage to the sympathetic trunk. The classical signs are of miosis (constricted pupil), partial ptosis (weak droopy eyelid) and anhydrosis (reduced sweating). This presentation is more in keeping with an acute inflammatory/infective process as opposed to disruption of nerve signals", "id": "32542", "label": "e", "name": "Horner's syndrome", "picture": null, "votes": 43 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Lemierre's syndrome is an infective thrombophlebitis that can develop as a result of untreated bacterial throat infections in otherwise healthy young adults. It can lead to other further systemic complications such as bacteraemia and septic emboli", "id": "32538", "label": "a", "name": "Lemeirre's syndrome", "picture": null, "votes": 3425 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Lemierre not \"Lemeirre\"", "createdAt": 1654983546, "dislikes": 0, "id": "12033", "isLikedByMe": 0, "likes": 5, "parentId": null, "questionId": 6508, "replies": [ { "__typename": "QuestionComment", "comment": "Name checks out", "createdAt": 1673263229, "dislikes": 0, "id": "16265", "isLikedByMe": 0, "likes": 1, "parentId": 12033, "questionId": 6508, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Otitis Wilsons", "id": 11527 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Abscess Otitis", "id": 3800 } }, { "__typename": "QuestionComment", "comment": "When in doubt go for the most funny name", "createdAt": 1682789049, "dislikes": 0, "id": "22960", "isLikedByMe": 0, "likes": 12, "parentId": null, "questionId": 6508, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Intravenous Prone", "id": 19930 } }, { "__typename": "QuestionComment", "comment": "Low yield asf", "createdAt": 1683322164, "dislikes": 0, "id": "23507", "isLikedByMe": 0, "likes": 10, "parentId": null, "questionId": 6508, "replies": [ { "__typename": "QuestionComment", "comment": "Low yield until you're the ENT SHO, miss the diagnosis and pt has a stroke ", "createdAt": 1689167813, "dislikes": 6, "id": "30438", "isLikedByMe": 0, "likes": 1, "parentId": 23507, "questionId": 6508, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Brucie", "id": 26318 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Retrograde Vitamin", "id": 15717 } }, { "__typename": "QuestionComment", "comment": "diagnosis of exclusion..", "createdAt": 1686149513, "dislikes": 0, "id": "28100", "isLikedByMe": 0, "likes": 2, "parentId": null, "questionId": 6508, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Sir Pep Guardiola", "id": 27715 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n \n \nTonsillitis is a condition characterised by the inflammation of the tonsils due to infection. The main signs and symptoms include sore throat, headache, fever, and lymphadenopathy. Investigation methods such as throat swabs are not routinely performed, and blood tests are reserved for patients with immunodeficiency. Management strategies primarily include treatment with paracetamol and ibuprofen, with antibiotics prescribed in certain cases.\n \n \n# Definition\n \n \nTonsillitis is a medical condition that is characterised by the inflammation of the tonsils, which are the masses of lymphoid tissue located at the back of the throat. This inflammation is primarily due to an infection.\n \n \n# Epidemiology\n \n \nSore throat is a very common presenting complaint. Cases are highest in children during the winter months.\n \n# Aetiology\n \n \nThe aetiology of tonsillitis is usually due to a viral or bacterial infection. Common viruses include the Epstein-Barr virus, influenza virus, adenovirus, and rhinovirus. Bacterial tonsillitis can be caused by Group A streptococcus, which is also responsible for strep throat.\n \n \n# Signs and Symptoms\n \n \nPatients with tonsillitis typically present with the following symptoms:\n \n \n - Sore throat\n - Headache\n - Fever (pyrexia)\n - Enlarged and tender lymph nodes (lymphadenopathy)\n - Enlarged & erythematous tonsils\n - Tonsillar exudate\n - Some people may also experience abdominal pain, and nausea & vomiting\n - There may be signs of dehydration\n \n \n# Differential Diagnosis\n \n \nWhen diagnosing tonsillitis, it's important to differentiate it from other conditions with similar symptoms such as: \n \n - **Pharyngitis:** Symptoms include sore throat, fever, and headache. Unlike tonsillitis, patients do not usually present with lymphadenopathy.\n - **Infectious mononucleosis:** Characterised by fatigue, sore throat, fever, and swollen lymph nodes. A key difference is the presence of severe fatigue and splenomegaly.\n \n \n# Investigations\n \n \nInvestigations for tonsillitis typically involve clinical examination and patient history. Additional tests such as throat swabs are only used when an alternative bacterial cause is suspected. Blood tests are primarily reserved for those with suspected immunodeficiency.\n \n## Scoring systems to predict the need of antibiotic treatment:\n \n \n### Centor Criteria\n \n \nThe Centor Criteria is a set of clinical predictors used to identify patients with Group A streptococcal pharyngitis:\n \n \n - History of fever\n - Presence of tonsillar exudates\n - Absence of cough\n - Tender anterior cervical lymphadenopathy\n \n \nPatients presenting with three or four of these criteria should be considered for antibiotic treatment.\n \nFeverPAIN criteria:\n \n - Fever\n - Purulence (exudate)\n - Attended within 3 days of symptom onset\n - Inflamed tonsils\n - No cough or coryza (suggests viral origin)\n \nA score of four or five indicates a high probability of streptococcal infection and hence the need for antibiotics.\n \n \n# Management\n \n \nManagement strategies for tonsillitis include:\n \n \n - Symptomatic treatment with paracetamol and ibuprofen\n - Antibiotic therapy in cases featuring (phenoxymethylpenicillin is first-line):\n - Marked systemic upset\n - Three or more Centor criteria, or four or more FeverPAIN criteria\n - Underlying immunodeficiency\n - Increased risk of complications \n - Clarithromycin can be used if there is penicillin allergy \n - In some cases a delayed antibiotic prescription may be indicated\n \nIf a patient appears severely unwell, dehydrated or presents with complications, refer urgently to hospital or for specialist assessment.\n \nPatients may be referred to ENT for tonsillitis if they have recurrent episodes of tonsillitis. The criteria for this is:\n \n - 7+ episodes in one year\n - 5+ episodes per year for two years\n - 3+ episodes per year for three years\n \n# Complications\n \n \nPotential complications of tonsillitis include:\n \n \n - Recurrent Tonsillitis: This is the most common complication. The evidence base for tonsillectomies as a treatment is poor, leading to stricter referral criteria.\n - Retropharyngeal Abscess: A rare complication characterised by soft tissue swelling, more common in young children. Symptoms include a stiff and extended neck and refusal to eat or drink.\n - Peritonsillar Abscess (Quinsy): Presents with sore throat, difficulty swallowing, peritonsillar bulge, uvular deviation, trismus, and muffled voice. Treatment has shifted from surgical drainage to antibiotics and aspiration.\n - Lemierre's Syndrome: In this rare complication, inflammation leads to pharyngotonsilitis, inflammation within the internal jugular vein, and septic emboli. Treatment may require high-dose benzylpenicillin and debridement.\n \n \nComplications of streptococcal tonsillitis include:\n \n - Scarlet fever\n - Acute rheumatic fever\n - Post-streptococcal glomerulonephritis\n - Reactive arthritis\n \n# NICE Guidelines \n \n[Click here for NICE CKS on sore throat - acute](https://cks.nice.org.uk/topics/sore-throat-acute/)", "files": null, "highlights": [], "id": "253", "pictures": [ { "__typename": "Picture", "caption": null, "createdAt": 1672906680, "id": "1425", "index": 2, "name": "Sore throat - choice of antibiotics (NICE).png", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/rqu1vpup1672906675510.jpg", "path256": "images/rqu1vpup1672906675510_256.jpg", "path512": "images/rqu1vpup1672906675510_512.jpg", "thumbhash": "+PcFBYB6pXdQh3iGeKeJeodwgwdH", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "An example of a right sided quinsy.", "createdAt": 1665036198, "id": "1068", "index": 3, "name": "Peritonsilar abscess.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/n2yy75x31665036171698.jpg", "path256": "images/n2yy75x31665036171698_256.jpg", "path512": "images/n2yy75x31665036171698_512.jpg", "thumbhash": "IYkODgR6iAiWeHh4d3l1ZXiIo49L9To=", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "Bilateral exudate seen on the tonsils of someone with tonsilitis.", "createdAt": 1665036192, "id": "735", "index": 0, "name": "Tonsilitis.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/26jh2wny1665036171702.jpg", "path256": "images/26jh2wny1665036171702_256.jpg", "path512": "images/26jh2wny1665036171702_512.jpg", "thumbhash": "J+oGDoKDuIufWzdOo4VHWaeHj2nDJAk=", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": null, "createdAt": 1672906680, "id": "1432", "index": 1, "name": "Sore throat - prescribing (NICE).png", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/tbcciovy1672906675511.jpg", "path256": "images/tbcciovy1672906675511_256.jpg", "path512": "images/tbcciovy1672906675511_512.jpg", "thumbhash": "8vcJDYJgBWFVhneqecmKiZBYtr9Y", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 253, "demo": null, "entitlement": null, "id": "287", "name": "Acute Tonsillitis", "status": null, "topic": { "__typename": "Topic", "id": "24", "name": "Ear, Nose & Throat", "typeId": 2 }, "topicId": 24, "totalCards": 4, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 287, "conditions": [], "difficulty": 2, "dislikes": 23, "explanation": null, "highlights": [], "id": "6508", "isLikedByMe": 0, "learningPoint": "Lemierre's syndrome is a serious condition arising from untreated bacterial throat infections, leading to jugular vein thrombosis.", "likes": 5, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "An 18 year old female with recurrent tonsillitis presents to her local accident and emergency with a four day history of sore throat, fever and inability to swallow her own saliva. She has a tender swelling over the lateral aspect of her neck and targetted ultrasound reveals a thrombus in her jugular vein.\n\nWhat is the name of the likely condition?", "sbaAnswer": [ "a" ], "totalVotes": 5847, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": true, "explanation": "Sensitivity of a test is the ability of a test to correctly identify those with a disease.\n\nSensitivity = true positives / (true positives + false negatives)\n\nSo in this case 80/(80+15) = 84.2%", "id": "32543", "label": "a", "name": "84.2%", "picture": null, "votes": 2739 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is the number of true negatives expressed as a percentage, not the sensitivity", "id": "32544", "label": "b", "name": "92.0%", "picture": null, "votes": 492 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is the number of true positives expressed as a percentage, not the sensitivity", "id": "32545", "label": "c", "name": "80.0%", "picture": null, "votes": 239 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is the specificity of the test, not the sensitivity. Specificity of a test is the ability of the test to correctly identify those without a disease.\n\nSpecificity = true negatives / (true negatives + false positives).\nIn this case = 920/(920+3) = 99.7%", "id": "32546", "label": "d", "name": "99.7%", "picture": null, "votes": 336 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is the number of true negatives expressed as a percentage, not the sensitivity", "id": "32547", "label": "e", "name": "90.2%", "picture": null, "votes": 307 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Overview \n\nSeveral key parameters can be calculated to help describe how effective a certain test is at diagnosing a condition.\n\n| | Patients with colon cancer | No cancer |\n| ------------------ | :------------------------: | --------: |\n| Biomarker positive | a | b |\n| Biomarker negative | c | d |\n\n# Sensitivity\n\nSensitivity is the proportion of people with the condition who will have a positive result. If, for example, the sensitivity of a test is 80%, out of a hundred people with the condition, only 80 will have a positive test result.\n\nSensitivity = a/(a+c)\n\n# Specificity\n\nSpecificity describes the proportion of people without the disease who will have a negative test. A specificity of 90% can be interpreted as, out of 100 people without the disease, 90 will have a negative test result.\n\nSpecificity = d/(b+d)\n\n# Positive Predictive Value\n\nPositive predictive value (PPV) is the proportion of people with a positive test who actually have the disease. PPV varies with prevalence of disease in a population. The lower the prevalence, the lower the positive predictive value. A PPV of 78% will mean that if 100 people tested positive, 78 people will have the disease.\n\nPPV = a/(a+b)\n\n# Negative Predictive Value\n\nNegative predictive value (NPV) is the proportion of people with a negative test who truly do not have the disease.\n\nNPV varies with prevalence of disease in a population. The lower the prevalence, the higher the negative predictive value. An NPV of 97% will mean that if 100 people tested negative, 97 people will not have the disease.\n\nNPV = d/(c+d)\n\n# False positive rate\n\nThe false positive rate is the proportion of those without the condition who will test positive.\n\nFalse positive rate = 1 - specificity\n\nFalse negative rate = 1 - d/(b+d)\n\n# False negative rate\n\nThe false negative rate is the proportion of those with the condition who will test negative.\n\nFalse negative rate = 1 - sensitivity\n\nFalse negative rate = 1 - a/(a+c)\n", "files": null, "highlights": [], "id": "45", "pictures": [], "typeId": 2 }, "chapterId": 45, "demo": null, "entitlement": null, "id": "46", "name": "Evaluation of a diagnostic test", "status": null, "topic": { "__typename": "Topic", "id": "51", "name": "Medical Statistics", "typeId": 2 }, "topicId": 51, "totalCards": null, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 46, "conditions": [], "difficulty": 2, "dislikes": 5, "explanation": null, "highlights": [], "id": "6509", "isLikedByMe": 0, "learningPoint": "Sensitivity measures a test's ability to correctly identify individuals with a disease, calculated as true positives divided by the sum of true positives and false negatives.", "likes": 1, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A company develops a new coronavirus test. They trial it on 1000 people and have 83 positive tests, of which 80 were later confirmed to be positive through alternative means of testing. Of those who tested negative, 15 were later confirmed positive through alternative testing.\n\nWhat is the sensitivity of the new test?", "sbaAnswer": [ "a" ], "totalVotes": 4113, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "This is incorrect as this is the risk of developing diabetes in the placebo group", "id": "32551", "label": "d", "name": "0.72", "picture": null, "votes": 358 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "The relative risk or risk ratio is the probability of an outcome occurring in a patient group exposed to a change (in this case, a new drug). Of those given the drug, 50% went on to develop diabetes compared to 72% in the placebo group.\n\nRelative risk = risk in the group exposed to drug/risk in those not exposed to the drug.\n\n50/72 = 0.69", "id": "32548", "label": "a", "name": "0.69", "picture": null, "votes": 2278 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is incorrect as this is the risk of not developing diabetes in the placebo group", "id": "32552", "label": "e", "name": "0.28", "picture": null, "votes": 351 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is incorrect as this is the risk of developing diabetes in the group given the drug", "id": "32550", "label": "c", "name": "0.50", "picture": null, "votes": 726 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is incorrect as the group that has been exposed to the change is those given the drug", "id": "32549", "label": "b", "name": "1.44", "picture": null, "votes": 269 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Definition\n\nRisk in medical statistics refers to the probability of an outcome (either good or bad) occurring within a studied population. There are several different types of risk that are often used in medical studies.\n\n# What is Risk/Prevalence?\n\nThis is simply the probability of an event occurring within a defined population.\n\n# What is Risk Ratio (RR)?\n\nThe risk ratio (also known as relative risk) is the probability of an event occurring in an exposed group compared to the probability occurring in a non-exposed group.\n\nThe risk ratio is calculated by finding the ratio of incidence of a disease amongst the exposed population and the incidence amongst the non-exposed population.\n\nRisk ratios are used in cohort studies and in interventional studies in which the experimenter intervenes at some point during the study, such as in randomised controlled trials and pre-post studies.\n\nHowever, in cross-sectional studies and case-control studies, the incidence of the disease in the exposed and unexposed populations cannot be found, since the data only provides the cases and controls.\n\nConsequently,the risk ratio cannot be calculated for case-control studies and cross-sectional studies. Instead, an odds ratio must be found.\n\n# What is Absolute Risk Reduction (ARR)?\n\nThe absolute risk reduction is the absolute difference in the risk between the control group and the experimental group. It tells you in absolute terms how much an intervention changes an outcome of interest.\n\n# Calculation of Absolute Risk Reduction\n\nIt is calculated as follows:\n\n_ARR = Risk(control group) - Risk(experimental group)_\n\nA given ARR is generally considered significant if the 95% confidence interval does not cross 0.\n\nARR can then be used to calculate the number needed to treat (NNT).\n\n# What is Relative Risk Reduction (RRR)?\n\nThe relative risk reduction can be thought of as the proportional reduction in risk bestowed by the intervention compared to the control situation. It is more useful in helping you understand the efficacy of an intervention when the absolute risk of outcomes are rare (for example when considering the benefits of a statin for reducing MI in a given population).\n\n# Calculating RRR\n\nIt is calculated as follows:\n\n_RRR = 1 - [Risk(Experimental group) / Risk(Control group)]_\n\nA given RRR is generally considered significant if the 95% confidence interval does not cross 1.", "files": null, "highlights": [], "id": "594", "pictures": [], "typeId": 2 }, "chapterId": 594, "demo": null, "entitlement": null, "id": "608", "name": "Risk", "status": null, "topic": { "__typename": "Topic", "id": "51", "name": "Medical Statistics", "typeId": 2 }, "topicId": 51, "totalCards": null, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 608, "conditions": [], "difficulty": 3, "dislikes": 3, "explanation": null, "highlights": [], "id": "6510", "isLikedByMe": 0, "learningPoint": "Relative risk compares the likelihood of an event occurring in an exposed group to an unexposed group, calculated as the ratio of incidence in the exposed group to the unexposed group.", "likes": 4, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A new drug is developed that claims to prevent diabetes mellitus in patients with impaired glucose tolerance. A randomised control trial is undertaken in 100 patients with HbA1c of 42-47, where half the participants are given the new drug, and the other half are given a placebo.\n\nIn those who were given the new drug, 25 patients developed diabetes within five years; in the group who were not given the drug, 36 patients developed diabetes within five years.\n\nWhat is the relative risk of developing diabetes if treated with the new drug?", "sbaAnswer": [ "a" ], "totalVotes": 3982, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Whilst a CT of his abdomen and pelvis would be useful in aiding diagnosis, at the moment his renal function is poor and contrast is best avoided", "id": "32564", "label": "b", "name": "Computerised tomography (CT) of abdomen and pelvis with contrast", "picture": null, "votes": 1297 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient has a significant acute kidney injury, is anuric, and has a known intraabdominal malignancy. It is important to rule out a urological obstruction as cause for his presentation. The bladder scan does not show retention, however there may be an obstruction at the ureteric level", "id": "32563", "label": "a", "name": "Ultrasound renal tract", "picture": null, "votes": 2187 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "A FAST scan is used to detect free fluid in the abdomen in a trauma situation and therefore is not indicated in this case", "id": "32567", "label": "e", "name": "Focussed abdominal scanning in trauma (FAST) scanning", "picture": null, "votes": 369 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Whilst a urine dip might be helpful in diagnosis if obstruction is not the cause, he has reported he has not passed urine for over 12 hours therefore obtaining a urine sample may not be possible without inserting a catheter", "id": "32565", "label": "c", "name": "Urine dip", "picture": null, "votes": 614 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is not an unreasonable investigation, as patients with metastatic disease may present with cauda equina, however the bladder scan is not suggestive of urinary retention at a spinal level and therefore less likely than external compression of a ureter for example", "id": "32566", "label": "d", "name": "Magnetic resonance imaging (MRI) of the spine", "picture": null, "votes": 798 } ], "comments": [ { "__typename": "QuestionComment", "comment": "What are the chances of both ureters being obstructed at the same time?", "createdAt": 1694613728, "dislikes": 0, "id": "31517", "isLikedByMe": 0, "likes": 4, "parentId": null, "questionId": 6513, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Monoclonal Supine", "id": 25376 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nAcute kidney injury (AKI) refers to a sudden deterioration in kidney function which may lead to oliguria, electrolyte imbalance, and accumulation of urea and other waste products. It is characterised by increased serum creatinine levels and reduced urine output. Causes are typically categorised as pre-renal, renal and post-renal, with most cases being pre-renal. Initial investigations include a urine dip, U&Es and a bladder scan. If there is no obvious cause, common next steps involve an ultrasound of the kidneys, ureters and bladder to look for post-renal causes (i.e. obstruction) and bloods to look for renal causes. Management involves treating the underlying cause as well as addressing complications such as hyperkalaemia.\n\n# Definition\n\nAn acute kidney injury is characterised by a decline in renal function that happens rapidly (over hours to days). It is diagnosed based on the Kidney Disease: Improving Global Outcomes (KDIGO) criteria as below:\n\n- Increase in serum creatinine by >26.5 mmol/l within 48 h, or\n- Increase in serum creatinine > 1.5x the baseline within the last 7 days, or\n- Urine output < 0.5 ml/kg/h for 6 hours\n\nUnlike chronic kidney disease (CKD), AKI is typically reversible, at least in part. \n\n# Epidemiology\n\nAKI is common, affecting approximately 20% of patients admitted to hospital and up to 50% of critically unwell patients in intensive care.\n\nIt is a marker of severe illness, with a 90-day mortality rate of approximately 25%. \n\nPatients at increased risk of AKI include:\n\n- Patients with CKD\n- Elderly patients\n- Previous AKI \n- Malignancy\n- Medical conditions increasing risk of urinary obstruction (e.g. benign prostatic hyperplasia)\n- Cognitive impairment and disability (may be reliant on others for fluid intake) \n- Recent use of medications such as NSAIDs or ACE inhibitors\n- Recent administration of iodine-containing contrast media\n\n# Aetiology\n\nCauses AKI are categorised into pre-renal, renal, and post-renal causes:\n\n**Pre-renal causes** are the most common, and occur due to decreased renal perfusion e.g. due to:\n\n- Hypovolaemia (e.g. dehydration, haemorrhage, gastrointestinal losses, burns)\n- Renovascular disease (e.g. renal artery stenosis)\n- Medications reducing blood pressure or renal blood flow (e.g. NSAIDs, ACE inhibitors, ARBs, diuretics)\n- Hypotension due to reduced cardiac output (e.g. heart failure, sepsis)\n\n**Renal causes** occur due to structural damage to the kidneys, which may affect:\n\n- The glomeruli (e.g. acute glomerulonephritis, nephrotic syndrome)\n- The tubules (e.g. acute tubular necrosis due to ischaemia or toxins, rhabdomyolysis)\n- The interstitium (e.g. acute interstitial nephritis secondary to drugs)\n- The renal vessels (e.g. renal vein thrombosis, vasculitis)\n\n\n**Post-renal causes** involve obstructed to urinary flow anywhere along the urinary tract, which may be:\n\n- Luminal (e.g. ureteric stones or a blocked catheter) \n- Intramural (e.g. urethral or ureteric strictures, ureteric carcinomas) \n- Due to external compression (e.g. an abdominal or pelvic tumour, benign prostatic hyperplasia)\n\n# Classification\n\nAKIs are staged according to the KDIGO criteria as follows:\n\n**Stage 1 - any of:**\n\n- Creatinine rise of 26 micromol/L or more within 48 hours\n- Creatinine rise to 1.5-1.99x baseline within 7 days\n- Urine output < 0.5 mL/kg/hour for more than 6 hours\n\n**Stage 2 - any of:**\n\n- Creatinine rise to 2-2.99x baseline within 7 days \n- Urine output < than 0.5 mL/kg/hour for more than 12 hours\n\n**Stage 3 - any of:** \n\n- Creatinine rise to 3x baseline or higher within 7 days\n- Creatinine rise to 354 micromol/L or more with either\n- Acute rise of 26 micromol/L or more within 48 hours or\n- 50% or more rise within 7 days \n- Urine output < than 0.3 mL/kg/hour for 24 hours\n- Anuria for 12 hours\n\n# Signs and Symptoms\n\nAn AKI may be asymptomatic and be detected on blood tests only, or may be diagnosed due to a fall in urine output.\n\nSymptoms may be seen especially in severe cases where uraemia occurs, and include:\n\n- Nausea and vomiting \n- Fatigue\n- Confusion\n- Anorexia\n- Pruritus \n\nOn examination, look for:\n\n- Hypertension (a complication of AKI)\n- Bladder distension due to urinary retention\n- Hypotension and dehydration (in many pre-renal causes)\n- Signs of fluid overload (e.g. raised jugular venous pressure, pulmonary and peripheral oedema) as a complication of AKI\n- Signs related to the underlying cause (e.g., fevers in sepsis, rashes in vasculitis)\n- Pericardial rub (in uraemic pericarditis)\n\n# Investigations\n\n**Bedside tests:**\n\n- **Urinalysis** - urine dip may show blood and protein in glomerular disease, increased white blood cells may suggest infection or interstitial nephritis\n- **ECG** to screen for complications of hyperkalaemia\n- **Blood gas** to look for acidosis as a complication of AKI, allows rapid potassium measurement\n\n**Blood tests:**\n\n- **U&Es** to get creatinine for diagnosis (compare to baseline if available) and check for hyperkalaemia\n- **Full blood count** may show anaemia in vasculitis or raised white cells in infection\n- **LFTs** may be deranged in severe hypotension causing ischaemic hepatitis \n- **Clotting** as a baseline in case a renal biopsy is later required (rare)\n- **Bone profile** to screen for hypercalcaemia (seen in myeloma which can cause renal AKI)\n- **Creatinine kinase** to look for rhabdomyolysis\n- **CRP** may be raised in infection or vasculitis\n\n**Imaging:**\n\n- **Bladder scan** if urinary retention is suspected\n- **Ultrasound KUB (kidneys, ureters and bladder)** if a post-renal cause is suspected, may show hydronephrosis. The next line of imaging would be a **CT KUB** as this is a more sensitive modality.\n\nIf initial investigations do not reveal a cause, bloods for an acute **renal screen** may be done, including:\n\n- ANA\n- Double-stranded DNA\n- Anti-nuclear cytoplasmic antibodies\n- Anti-GBM antibodies\n- Erythrocyte sedimentation rate\n- Serum immunoglobulins\n- Serum electrophoresis\n- Serum free light chains\n- Complement levels (C3 and C4)\n- HIV screening\n- Hepatitis B and C serology\n\nIf the diagnosis is still unclear and a renal cause is suspected, a **renal biopsy** may be indicated.\n\n# Management\n\n- The key to AKI management is identification and treatment of the underlying cause\n- The **most common cause of AKI is dehydration,** and so for many patients IV fluid resuscitation will be required \n- Careful assessment of fluid status is crucial though, as in certain cases where the patient is fluid overloaded diuretic treatment rather than fluids may be required\n- Fluid balance should be monitored closely with consideration of catheterisation to monitor urine output \n- A catheter may be the definitive treatment in some cases (e.g. post-renal AKI due to urethral obstruction)\n- Screen for complications of AKI (e.g. hyperkalaemia, acidosis, pulmonary oedema) and instigate treatment promptly\n- Involve the renal team early in severe or complicated AKIs, where the cause is unclear or where a renal cause is suspected\n- Review regular medications and **suspend any nephrotoxic drugs** (e.g. NSAIDs, aminoglycosides, ACE inhibitors, ARBs) and review those that may cause complications in cases of renal impairment (e.g. opiates, metformin)\n- Low-risk patients with an uncomplicated stage 1 or 2 AKI may be considered for discharge if there is an identifiable cause that can be managed in the community\n- The following should prompt referral for consideration of renal replacement therapy with dialysis or haemofiltration (remembered by the AEIOU mnemonic): \n\t- **A**cidosis (severe metabolic acidosis with pH of <7.20)\n\t- **E**lectrolyte imbalance (resistant hyperkalaemia)\n\t- **I**ntoxication (AKI secondary to certain drugs or poisons)\n\t- **O**edema (refractory pulmonary oedema)\n\t- **U**raemia (uraemic encephalopathy or pericarditis)\n\n# NICE Guidelines\n\n[NICE CKS - Acute Kidney Injury](https://cks.nice.org.uk/topics/acute-kidney-injury/) \n\n[NICE: Acute kidney injury: prevention, detection and management](https://www.nice.org.uk/guidance/ng148) \n\n# References\n\n[KDIGO - AKI guideline](https://kdigo.org/guidelines/acute-kidney-injury/) \n\n[Patient UK - Acute Kidney Injury](https://patient.info/doctor/acute-kidney-injury-pro)", "files": null, "highlights": [], "id": "311", "pictures": [], "typeId": 2 }, "chapterId": 311, "demo": null, "entitlement": null, "id": "308", "name": "Acute kidney injury", "status": null, "topic": { "__typename": "Topic", "id": "33", "name": "Nephrology", "typeId": 2 }, "topicId": 33, "totalCards": 22, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "308", "name": "Acute kidney injury" } ], "demo": false, "description": null, "duration": 287.42, "endTime": null, "files": null, "id": "11", "live": false, "museId": "nU8kZE2", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/nephrology.png", "title": "Acute kidney injury 2", "userViewed": false, "views": 205, "viewsToday": 35 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "308", "name": "Acute kidney injury" } ], "demo": false, "description": null, "duration": 3507.09, "endTime": null, "files": null, "id": "333", "live": false, "museId": "PWmnGPT", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/nephrology.png", "title": "Quesmed Tutorial: Renal and Electrolytes", "userViewed": false, "views": 1031, "viewsToday": 44 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "308", "name": "Acute kidney injury" } ], "demo": false, "description": null, "duration": 616.47, "endTime": null, "files": null, "id": "10", "live": false, "museId": "3qJz7AW", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/nephrology.png", "title": "Acute kidney injury 1", "userViewed": false, "views": 512, "viewsToday": 55 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "308", "name": "Acute kidney injury" } ], "demo": false, "description": null, "duration": 314.9, "endTime": null, "files": null, "id": "402", "live": false, "museId": "6Jcw4vv", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/nephrology.png", "title": "Urinary tract infection", "userViewed": false, "views": 229, "viewsToday": 15 } ] }, "conceptId": 308, "conditions": [], "difficulty": 3, "dislikes": 2, "explanation": null, "highlights": [], "id": "6513", "isLikedByMe": 0, "learningPoint": "An ultrasound is performed in an anuric patient with a known intra-abdominal malignancy to assess for potential causes of urinary obstruction, such as tumor compression, hydronephrosis, or metastatic involvement of the urinary tract.", "likes": 13, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "An 83 year old male with metastatic colorectal cancer presents to the emergency department with abdominal pain. He reports not passing urine for the last 12 hours. On examination he has moist mucous membranes, his JVP is not raised and his abdomen is diffusely tender without being peritonitic. Bladder scan shows a volume of 20ml.\n\n\nHis admission bloods are as follows:\n\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|83 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|16.5x10⁹/L|3.0 - 10.0|\n|Platelets|235x10⁹/L|150 - 400|\n|Sodium|134 mmol/L|135 - 145|\n|Potassium|5.4 mmol/L|3.5 - 5.3|\n|Urea|14 mmol/L|2.5 - 7.8|\n|Creatinine|300 µmol/L|60 - 120|\n|C Reactive Protein|15 mg/L|< 5|\n\n\nWhat is the most important next investigation?", "sbaAnswer": [ "a" ], "totalVotes": 5265, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Whilst hypertension requires aggressive treatment in IgA nephropathy, 5mg is a high starting dose as patients are usually started at 1.25-2.5mg and then gradually increased at two weekly intervals", "id": "32570", "label": "c", "name": "Commence ramipril 5mg once daily", "picture": null, "votes": 1825 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "High blood pressure should be treated aggressively in patients with IgA nephropathy, and the antihypertensive medication of choice is an angiotensin-converting enzyme inhibitor (ACEi) such as ramipril. They protect kidney function and may even be beneficial with normal blood pressure", "id": "32568", "label": "a", "name": "Commence ramipril 1.25mg once daily", "picture": null, "votes": 1487 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "A loop diuretic is not the first line diuretic in this instance and may lead to electrolyte imbalance", "id": "32569", "label": "b", "name": "Commence furosemide 20mg once daily", "picture": null, "votes": 64 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "The National Institute of Clinical Excellence (NICE) states that calcium channel blocker is first line antihypertensive medication for those over the age of 55 or of African or Afro-Caribbean family origin. As this patient is young an ACEi is therefore first line", "id": "32572", "label": "e", "name": "Commence amlodipine 5mg once daily", "picture": null, "votes": 326 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "There is some role for steroids in the treatment of IgA nephropathy, however this does not address his hypertension", "id": "32571", "label": "d", "name": "Commence prednisolone 5mg once daily", "picture": null, "votes": 1382 } ], "comments": [ { "__typename": "QuestionComment", "comment": "pretty sure ramipril is nephrotoxic?\n", "createdAt": 1682560877, "dislikes": 0, "id": "22755", "isLikedByMe": 0, "likes": 1, "parentId": null, "questionId": 6514, "replies": [ { "__typename": "QuestionComment", "comment": "jAK spend time on the wards\n", "createdAt": 1683199869, "dislikes": 13, "id": "23370", "isLikedByMe": 0, "likes": 3, "parentId": 22755, "questionId": 6514, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Intravenous Prone", "id": 19930 } }, { "__typename": "QuestionComment", "comment": "good for GN bad for CKD as i understand it bcs it lowers pressure in glomerulus", "createdAt": 1684702188, "dislikes": 3, "id": "25599", "isLikedByMe": 0, "likes": 3, "parentId": 22755, "questionId": 6514, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "NICU Serotonin", "id": 26459 } }, { "__typename": "QuestionComment", "comment": "In the acute setting stop, long term these are renoprotective", "createdAt": 1686840198, "dislikes": 0, "id": "28822", "isLikedByMe": 0, "likes": 2, "parentId": 22755, "questionId": 6514, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Edema Dominant", "id": 29735 } }, { "__typename": "QuestionComment", "comment": "bad for aki,good for ckd, ", "createdAt": 1709054009, "dislikes": 0, "id": "43021", "isLikedByMe": 0, "likes": 3, "parentId": 22755, "questionId": 6514, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Ale", "id": 20565 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "JAK Yeast", "id": 9487 } }, { "__typename": "QuestionComment", "comment": "if someone's mad at me for not knowing this as an F1 then that's their f problem", "createdAt": 1685043665, "dislikes": 0, "id": "26275", "isLikedByMe": 0, "likes": 3, "parentId": null, "questionId": 6514, "replies": [ { "__typename": "QuestionComment", "comment": "you'd know this as an F1 if you spent more time on the wards mate", "createdAt": 1685381620, "dislikes": 20, "id": "27066", "isLikedByMe": 0, "likes": 5, "parentId": 26275, "questionId": 6514, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Bradykinin Botox", "id": 32802 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "lil' aneurysm", "id": 21164 } }, { "__typename": "QuestionComment", "comment": "wish I could just download the BNF to my brain", "createdAt": 1710778101, "dislikes": 0, "id": "44904", "isLikedByMe": 0, "likes": 4, "parentId": null, "questionId": 6514, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Serpiginous Defibrillator", "id": 8850 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nIgA nephropathy, also known as Berger disease, is the most common primary glomerulonephritis. It occurs due to deposition of immune complexes made up of immunoglobulin A (IgA) in the mesangium, which trigger glomerular inflammation. Patients typically present with macroscopic haematuria in the days following development of an upper respiratory tract infection. A significant proportion are asymptomatic and are diagnosed following an incidental finding of microscopic haematuria and proteinuria. Initial investigations include a urine dip and microscopy, as well as bloods for renal function. The gold standard diagnostic test is a renal biopsy. Management involves supportive care with blood pressure control, consideration of sodium-glucose cotransporter 2 (SGLT2) inhibitors for patients with significant proteinuria, followed by consideration of immunosuppression (e.g. steroids or an alternative such as mycophenolate mofetil). For most patients IgA nephropathy is a benign disease however approximately 40% progress to chronic renal disease.\n\n# Definition\n\nIgA nephropathy is a type of glomerulonephritis that occurs due to deposition of IgA in the mesangium of the glomerulus. It may lead to progressive renal impairment and chronic kidney disease. \n\n# Epidemiology\n\n- IgA nephropathy is the commonest primary glomerulonephritis, with a worldwide incidence of 2.5 cases per 100,000 people per year\n- However, there is wide geographic variation in prevalence; it is rare in African countries with the highest rates seen in Eastern and Pacific Asian countries\n- Median age at diagnosis is approximately 40 years old\n- In European and American patients, men are more commonly affected (there is an even gender split in other countries)\n\n# Aetiology\n\n- There is excessive generation of IgA1, often triggered by mucosal infection (e.g. upper respiratory tract or gastrointestinal)\n- There is no evidence that there is a specific infectious agent responsible\n- The IgA forms immune complexes that deposit in the glomerular mesangium\n- This immune complexes trigger glomerular inflammation, with mesangial cell proliferation, complement activation and recruitment of macrophages, monocytes and T cells\n- A small percentage of cases have a familial form of IgA nephropathy; the majority of cases are sporadic\n\n# Signs and Symptoms\n\n- Many patients are asymptomatic and are identified due to an incidental finding of microscopic haematuria or proteinuria (usually mild)\n- Most commonly, patients present with visible haematuria\n- This usually occurs 12-72 hours after an upper respiratory tract or gastrointestinal infection\n- It is typically self-limiting within a few days\n- Haematuria typically recurs with subsequent infections\n- Loin pain (either unilateral or bilateral) may accompany episodes of haematuria\n\nSigns include:\n\n- Hypertension\n- Oedema and frothy urine in patients presenting with nephrotic syndrome (approximately 5% of cases)\n\n# Differential Diagnosis\n\n- **Secondary IgA nephropathy** may occur due to a variety of other diseases that can cause renal IgA deposition - this is important as treatment in these cases should be directed at the underlying cause rather than consideration of immunosuppression\n- Liver cirrhosis causes reduced clearance of IgA complexes\n- Coeliac disease is another association\n- HIV is associated with higher serum IgA levels\n- Other infections such as hepatitis B are also associated with IgA nephropathy\n- **Post-streptococcal glomerulonephritis** also presents with visible haematuria after an infection, specifically beta-haemolytic streptococci (e.g. tonsillitis secondary to Streptococcus pyogenes) - typically this is 1-3 weeks after the infection rather than a couple of days in IgA nephropathy\n- **Henoch Schonlein Purpura** is a disease related to IgA nephropathy that usually occurs in children, which presents with a purpuric rash, arthralgia, haematuria and renal involvement (also with glomerular IgA deposits)\n- **Lupus nephritis** may involve IgA mesangial deposition as well as other immunoglobulins and complement - this is referred to as a \"full house\" on renal biopsy when all of IgA, IgG, IgM, C3 and C1Q are positive\n\n# Investigations\n\n**Bedside tests:**\n\n- **Urine dip** looking for blood and protein\n- **Urine microscopy and culture** to rule out infection and look for dysmorphic red blood cells and casts\n- **24 hour urinary protein** or a **protein:creatinine ratio** to quantify proteinuria - this is usually mild\n\n**Blood tests:**\n\n- **U&Es** to assess renal function\n- **Immunoglobulins** may show raised serum IgA1 levels in up to 50% of patients (however this does not correlate with disease severity)\n- **Complement** is usually normal\n- **Liver function tests** to rule out cirrhosis\n- **Full blood count** looking for anaemia and to check platelets prior to biopsy\n- **Clotting screen** to screen for coagulopathy prior to biopsy\n\n**Imaging tests:**\n\n- **Renal ultrasound** to check kidney size - this may be normal or kidneys may be small in chronic kidney disease\n\n**Special tests:**\n\n- **Renal biopsy** is the diagnostic test and shows diffuse mesangial IgA immune complex deposits\n\n# Management\n\n**Conservative management:**\n\n- All patients should be referred to secondary care services for confirmation of the diagnosis and ongoing management\n- Lifestyle changes including regular exercise, maintaining a healthy diet and weight and smoking cessation\n- Dietary salt should be restricted\n\n**Medical management:**\n\n- Control blood pressure with a target of < 120-130/80\n- ACE inhibitors or angiotensin II receptor blockers (ARBs) are first-line for hypertension and may also be used for proteinuria > 0.5 g/day\n- SGLT2 inhibitors can be added if patients with persistent haematuria despite an ACE inhibitor or ARB\n- Clinical trial enrollment should be considered for patients with high risk of progression\n- The next step is immunosuppression - options vary with patient ethnicity\n- Hydroxychloroquine and mycophenolate mofetil are options in Chinese patients\n- Systemic steroids may be required in some cases e.g. nephrotic syndrome or rapidly progressive glomerulonephritis\n\n**Surgical management:**\n\n- Patients with end-stage renal disease require renal replacement therapy with dialysis or transplant\n- However, IgA nephropathy often recurs after transplant (up to 30% of cases)\n\n# Prognosis\n\n- Disease severity varies significantly\n- Most patients experience persistent microscopic haematuria, although episodes of macroscopic haematuria typically become less frequent with time\n- Less than 10% of patients experience complete resolution of haematuria and proteinuria\n- Within 25 years of diagnosis, approximately 30% of patients progress to end-stage renal disease\n- Risk factors for renal failure include impaired renal function at diagnosis, significant proteinuria and hypertension\n\n# References\n\n[UK Kidney Association - IgA Nephropathy](https://ukkidney.org/rare-renal/clinician/iga-nephropathy)\n\n[Patient UK - IgA Nephropathy](https://patient.info/doctor/iga-nephropathy-bergers-disease-pro)\n\n[IgA nephropathy in adults - treatment standard](https://academic.oup.com/ndt/article/38/11/2464/7221084)\n\n[IgA Nephropathy: Core Curriculum in Nephrology](https://www.ajkd.org/article/S0272-6386(21)00598-9/fulltext)", "files": null, "highlights": [], "id": "305", "pictures": [], "typeId": 2 }, "chapterId": 305, "demo": null, "entitlement": null, "id": "309", "name": "IgA nephropathy", "status": null, "topic": { "__typename": "Topic", "id": "33", "name": "Nephrology", "typeId": 2 }, "topicId": 33, "totalCards": 4, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "309", "name": "IgA nephropathy" } ], "demo": false, "description": null, "duration": 3028.61, "endTime": null, "files": null, "id": "590", "live": false, "museId": "erivGUb", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/nephrology.png", "title": "Quesmed Tutorial: Paediatric Nephrology", "userViewed": false, "views": 248, "viewsToday": 23 } ] }, "conceptId": 309, "conditions": [], "difficulty": 3, "dislikes": 32, "explanation": null, "highlights": [], "id": "6514", "isLikedByMe": 0, "learningPoint": "Ramipril, an ACE inhibitor, is used in managing IgA nephropathy by reducing proteinuria and slowing disease progression through its effects on lowering blood pressure and decreasing intraglomerular pressure.", "likes": 6, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 31 year old male presents to the general practice with rose coloured urine and fatigue. He reports that he had a recent upper respiratory tract infection, but otherwise has no past medical history of note. He undergoes a renal biopsy and is diagnosed with IgA nephropathy. During his follow up he is found to have hypertension on serial blood pressure measurements.\n\nWhat single medication ought to be started in the first instance?", "sbaAnswer": [ "a" ], "totalVotes": 5084, "typeId": 1, "userPoint": null }

[]

{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Whilst vascular dementia may be the precipitating factor for his cognitive decline; it would not account for the changes in his blood tests", "id": "32574", "label": "b", "name": "Vascular dementia", "picture": null, "votes": 756 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Those who suffer from ADPKD can also develop liver cysts, which can alter liver function; however, it is unusual to develop new cysts in a transplanted kidney", "id": "32577", "label": "e", "name": "Progression of his ADPKD", "picture": null, "votes": 494 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Acute rejection is defined as rejection in the first few weeks to the first three months after transplantation", "id": "32575", "label": "c", "name": "Acute graft rejection", "picture": null, "votes": 62 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Chronic rejection is a possibility in this case and should be considered in clinical practice. However, the picture of declining renal function in chronic rejection is more gradual in nature and would not account for the changes in his liver function", "id": "32576", "label": "d", "name": "Chronic graft rejection", "picture": null, "votes": 1376 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Tremor and headache are two well-known symptoms of tacrolimus toxicity which is also both nephrotoxic and hepatotoxic. The fact that this patient might be mixing up his medications raises the concern that he may be overdosing his tacrolimus", "id": "32573", "label": "a", "name": "Calcineurin inhibitor toxicity", "picture": null, "votes": 2209 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nRenal transplantation is a form of renal replacement therapy (RRT) that may be offered to patients with end-stage renal disease (ESRD). Transplant is not suitable for all patients however long-term outcomes are better than other forms of RRT and quality of life is significantly improved. Donors are either living or deceased, with deceased donors being classified as either donation after circulatory death (DCD) or donation after brainstem death (DBD) donors. Thorough assessment and work-up is required prior to listing for transplant, with the patient's preferences and shared decision making central to the process. Lifelong immunosuppression is required following transplantation, which carries its own complications. Despite immunosuppression, transplants may be rejected in either the hyperacute, acute or chronic setting. Other complications include infection, thrombosis of the renal vein or artery and ureteric injury. \n\n# Definition\n\nRenal transplantation refers to the surgical implantation of a healthy kidney from a donor (either living or deceased) into a patient with end-stage renal failure or progressive chronic kidney disease. It is one form of **renal replacement therapy**, with the other main type being dialysis. \n\n# Epidemiology\n\n- Renal transplant is the most common solid organ transplant in the UK\n- From 2023-2024 there were 3094 adult kidney only transplants performed in the UK\n- 1142 were from DBD donors, 1115 from DCD donors and 837 from living donors\n- There were 5779 adults on the active UK transplant waiting list on 31st March 2024\n- There are significant inequalities in access to renal transplant\n- People from South Asian and Black backgrounds typically wait 168-262 days longer than white patients to receive a transplant\n- This is in part due to a shortage of donors from these communities\n- The average age of a renal transplant recipient is 51 years\n- More men than women receive renal transplants (reflecting the greater incidence of end-stage renal disease in men)\n\n# Aetiology\n\nRenal transplantation should be considered in patients with end-stage renal failure or chronic kidney disease (CKD) stage 4 with progressive disease - causes of these include:\n\n- Diseases causing intrinsic kidney damage:\n- Diabetes\n- Hypertension\n- Glomerulonephritis, which may be primary or secondary\n- Conditions causing urinary tract obstruction:\n- Recurrent urolithiasis\n- Structural abnormalities (e.g. ureteropelvic junction obstruction)\n- External compression (e.g. from a pelvic mass)\n- Bladder voiding problems (e.g. benign prostatic hyperplasia, neurogenic bladder)\n- Iatrogenic causes:\n- Radiotherapy\n- Nephrotoxic drugs, e.g. aminoglycosides, lithium, NSAIDs\n- Renal involvement secondary to multisystem diseases\n- HIV\n- Myeloma\n- Vasculitis\n- Systemic lupus erythematosus (lupus nephritis)\n- Amyloidosis\n- Genetic kidney diseases\n- Autosomal dominant polycystic kidney disease (ADPKD)\n- Alport's syndrome\n- Tuberous sclerosis\n- Cystinosis\n- Recurrent urinary tract infections\n- Often secondary to vesico-ureteric reflux or other anatomical defects\n- Leads to chronic pyelonephritis which may lead to end-stage renal disease\n\nNB important **absolute contraindications** to renal transplantation include:\n\n- Untreated malignancy\n- Active infection (including untreated HIV)\n- Active systemic vasculitis\n- Life expectancy < 2 years for any reason\n- Current IV drug abuse\n\n# Classification\n\nRenal transplants are categorised based on from whom the kidney has come from (i.e. the donor):\n\n- **Live donors**\n- May be related or unrelated, including non-directed altruistic donors (who do not know the recipient)\n- Patients need to have compatible blood groups and HLA matching with the donor\n- Donor-recipient pairs who are incompatible and so cannot directly donate are registered in the UK Living Kidney Sharing Scheme\n- This allows either paired donation between two donor-recipient pairs, or a pooled donation where more than two pairs are involved\n- Outcomes are best from live donors\n- **Deceased donors**\n- There are two main types - donors after brain death (DBD) and donors after circulatory death (DCD)\n- Kidneys are retrieved from DBD patients whilst the heart is still beating, and after the heart has stopped in DCD patients\n- The majority of DCD patients have had planned withdrawal of care (for example in intensive care)\n- Long term outcomes are similar between DBD and DCD kidneys however delayed graft function is more common with DCD\n\n# Investigations\n\nPrior to being listed for a renal transplant, potential recipients need to undergo assessment of their fitness:\n\n- Blood type (ABO) and tissue typing for HLA\n- Crossmatch with donor to look for antibodies\n- Baseline blood tests to ensure patients are optimised for surgery and to screen for undiagnosed comorbidities\n- FBC, U&Es, LFTs, bone profile, clotting, lipids, HbA1c, parathyroid hormone\n- Group and saves as for any surgery\n- Assessment of cardiovascular risk\n- All patients require a chest X-ray and ECG\n- Higher risk patients (e.g. diabetes, older age) should also have an echocardiogram and cardiac stress test +/- angiography\n- Testing for viral infections\n- Cytomegalovirus (CMV)\n- Epstein-Barr virus (EBV)\n- Varicella zoster virus (VZV)\n- Hepatitis B and C\n- HIV \n- Risk assess for tuberculosis \n- High risk patients (e.g. born in an endemic area) should be tested with an interferon gamma release assay (IGRA)\n- Malignancy screening\n- Ensure patients are up to date with national cancer screening (mammograms, cervical smear tests)\n- Men over the age of 50 may be offered a PSA test (not part of a national screening programme)\n- Patients with a heavy smoking history should be offered a CT chest to screen for occult lung cancer\n- Cystoscopy should be considered for patients at high risk of bladder cancer (e.g. high-level cyclophosphamide exposure)\n- Psychosocial assessment for all candidates \n- Specialist input (e.g. psychiatry, social work) may be required for patients at higher risk of poor outcomes, for example:\n- Difficulties understanding the treatment process\n- Lack of social support\n- Neurocognitive difficulties\n- Severe or poorly controlled mental illness\n- Substance misuse or dependence\n- Dental assessment to screen for dental and periodontal disease that may be an infection risk\n- Patients with respiratory disease or symptoms should have lung function tests\n\n# Management\n\n**Conservative:**\n\n- Ensure patients are well informed regarding their options for renal replacement therapy, including the option of conservative management\n- Ensure patients have regular opportunities to re-discuss decision making around renal replacement therapy and their concerns and preferences\n- After transplant, renal transplant recipients require lifelong follow-up with multidisciplinary team input\n- Monitoring adherence to immunosuppressive treatment is crucial\n\n**Medical:**\n\n- All renal transplant recipients (apart from some transplants between identical twins) require lifelong immunosuppressive treatment\n- Patients receive induction therapy for up to 2 weeks around the time of transplant - this is a more intensive immunosuppressive regimen\n- For example, tacrolimus + mycophenolate mofetil (MMF) + steroids + basiliximab (an interleukin-2 receptor antagonist)\n- Following this, lifelong maintenance therapy is commenced\n- Triple therapy is standard, e.g. tacrolimus + MMF + low-dose steroids\n\n**Surgical:**\n\n- Offer a pre-emptive living donor transplant if available or listing for deceased donor transplantation\n- During the transplant operation, a ureteric stent is usually placed to support the anastomosis of the bladder and ureter - this is removed around 6 weeks later\n- In most cases the graft (donor kidney) is placed extraperitoneally in the right iliac fossa\n- In most cases, the native kidneys are left in place \n- Nephrectomy of native kidneys (either before, during or after transplant) may be indicated e.g. in cases of recurrent pyelonephritis, or in autosomal dominant polycystic kidney disease if huge kidney size is a hindrance surgically\n\n# Complications\n\n## Immediate complications\n\n- **Hyperacute rejection** may occur immediately after perfusion of the allograft intraoperatively, or in the following minutes to hours\n- It is antibody mediated, e.g. due to ABO or HLA incompatibility\n- The transplanted kidney will not function and needs to be removed\n- Very rare in the UK due to pre-transplant cross-matching\n- **Haemorrhage** which may be massive e.g. due to dissection of the renal artery anastomosis \n- **Ureteric injury** may require repeat surgical intervention - the ureteric-bladder anastomosis may also break down also causing intra-abdominal leakage of urine\n\n## Early complications\n\n- **Delayed graft function** is defined as a requirement for dialysis in the first week after transplant \n- It is a risk factor for graft rejection and decreased longevity of the graft\n- Grafts with prolonged warm and/or cold ischaemia times are at increased risk \n- Warm ischaemia time refers to the time between the kidney being perfused by the donor to when it is perfused with preservation solution\n- Cold ischaemia time refers to the time between the kidney being perfused with preservation solution to when it is re-perfused by the recipient's blood\n- **Renal vein thrombosis** is a serious complication that leads to loss of the kidney in the majority of patients\n- Patients present with refractory pain, reduced urine output, haematuria and deteriorating renal function\n- Renal doppler ultrasound is first-line to confirm the diagnosis\n- **Renal artery thrombosis** is rarer than renal vein thrombosis but also usually leads to graft loss\n- Risk factors include hypercoagulable states, prolonged cold ischaemia time and hypovolaemia\n- Patients present with sudden onset oliguria with pain and tenderness over the graft\n- **Wound infection** is common especially as patients are on immunosuppressive treatment\n- Other risk factors include diabetes, wound haematomas and urinary fistulas\n- **Wound dehiscence** is not uncommon; patients are at increased risk due to poor wound healing because of prolonged uraemia and anaemia \n- Early, eg. bleeding, thrombosis, infection, urinary leak, lymphocele\n- Late, eg. RAS, ureteric stenosis, bladder dysfunction\n- **Acute graft rejection** usually occurs in the first few weeks or months after transplant\n- Typically there is a T-cell mediated immune response against the graft\n- A biopsy of the graft may be required for diagnosis\n- IV methylprednisolone is usually first-line treatment, followed by escalation of immunosuppression\n\n## Late complications\n\n- **Chronic graft rejection** usually occurs at least a year after transplant\n- It is characterised by a gradual deterioration in graft function, with interstitial fibrosis and tubular atrophy on biopsy\n- **Infection** may mimic graft rejection, with patients at risk of opportunistic infections due to immunosuppression\n- There is an increased risk of urinary tract infection in particular\n- Patients may be given prophylactic antibiotics (e.g. co-trimoxazole for pneumocystis jirovecii) and antivirals (e.g. valganciclovir for cytomegalovirus)\n- Cytomegalovirus (CMV) is the commonest opportunistic infection and manifests in a variety of ways including with fevers, cytopenias and gastrointestinal symptoms such as abdominal pain and diarrhoea\n- Epstein-Barr virus (EBV) may reactivate, which may cause a glandular fever-like syndrome or posttransplant lymphoproliferative disorder\n- BK virus is a type of polyomavirus that may reactivate due to immunosuppression and cause a nephropathy that can mimic acute rejection\n- **Side effects of immunosuppressive medications**, for example:\n- Corticosteroids: insomnia, weight gain, diabetes, hypertension, osteoporosis, Cushing syndrome, avascular necrosis of the hip\n- Tacrolimus: impaired glucose tolerance, nephrotoxicity, peripheral neuropathy, alopecia, tremor\n- Ciclosporin: nephrotoxicity, hirsutism, gingival hypertrophy, dyslipidemia\n- Mycophenolate mofetil: gastrointestinal upset, leukopenia, photosensitivity\n- Azathioprine: myelosuppression, pancreatitis, nausea\n- **Malignancy** affects transplant recipients at higher rates than the general population\n- Non-melanoma skin cancers are very common\n- Other malignancies (e.g. renal cell carcinoma, lymphomas) are also seen more frequently\n- Patients should undergo skin surveillance as well as national screening for cervical, breast and colorectal cancer\n\n# Prognosis\n\n- A kidney transplant from a deceased donor lasts on average 15-20 years\n- A transplant from a living donor lasts 20-25 years\n- However these are very variable, and 30-40% of grafts fail in the first 10 years after transplant\n- Approximately 3% of grafts fail annually, with these patients having to go back on dialysis (and possibly be listed for another transplant)\n- There is a significant survival benefit compared to dialysis \n- Good prognostic factors are younger age, shorter pre-transplant dialysis duration and absence of cardiovascular disease\n- Poor prognostic factors include acute rejection, post-transplant infections and delayed graft function\n\n# NICE Guidelines\n\n[NICE - Renal replacement therapy and conservative management](https://www.nice.org.uk/guidance/ng107)\n\n[NICE Technology Appraisal - Immunosuppressive therapy for kidney transplant in adults](https://www.nice.org.uk/guidance/ta481)\n\n# References\n\n[NHS Blood and Transplant - Annual Report on Kidney Transplantation 2023/2024](https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/34295/nhsbt-kidney-transplantation-report-2324.pdf)\n\n[Kidney Research UK - Kidney Health Inequalities](https://kidneyresearchuk.org/wp-content/uploads/2019/09/Health_Inequalities_lay_report_FINAL_WEB_20190311.pdf)\n\n[Patient UK - Renal Replacement Therapy and Transplantation](https://patient.info/doctor/renal-replacement-therapy-and-transplantation)\n\n[Royal Free Hospital Kidney Transplants - Types of donors](https://www.royalfree.nhs.uk/services/kidney-services/kidney-transplants/types-donors)\n\n[KDIGO Guideline on the Evaluation of Candidates for Kidney Transplantation](https://kdigo.org/wp-content/uploads/2018/08/KDIGO-Txp-Candidate-GL-FINAL.pdf)\n\n[Chronic Kidney Disease, Dialysis, and Transplantation - Infection in Renal Transplant Recipients](https://pmc.ncbi.nlm.nih.gov/articles/PMC7152484/)\n\n[British Transplantation Society - Post-Operative Care in the Kidney Transplant Recipient](https://ukkidney.org/sites/renal.org/files/FINAL-Post-Operative-Care-Guideline-1.pdf)", "files": null, "highlights": [], "id": "314", "pictures": [], "typeId": 2 }, "chapterId": 314, "demo": null, "entitlement": null, "id": "317", "name": "Renal transplant", "status": null, "topic": { "__typename": "Topic", "id": "33", "name": "Nephrology", "typeId": 2 }, "topicId": 33, "totalCards": 8, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "317", "name": "Renal transplant" } ], "demo": false, "description": null, "duration": 3652.16, "endTime": null, "files": null, "id": "322", "live": false, "museId": "xoefpS6", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/ID.png", "title": "Quesmed Tutorial: Infectious Diseases ", "userViewed": false, "views": 630, "viewsToday": 40 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "317", "name": "Renal transplant" } ], "demo": false, "description": null, "duration": 438.64, "endTime": null, "files": null, "id": "223", "live": false, "museId": "3Se6oXt", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/ID.png", "title": "Meningitis", "userViewed": false, "views": 156, "viewsToday": 15 } ] }, "conceptId": 317, "conditions": [], "difficulty": 2, "dislikes": 17, "explanation": null, "highlights": [], "id": "6515", "isLikedByMe": 0, "learningPoint": "Calcineurin inhibitor toxicity, caused by drugs like cyclosporine or tacrolimus, causes nephrotoxicity, hypertension, neurotoxicity, hyperkalemia, and infection risk, requiring regular drug level and kidney function monitoring.", "likes": 5, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 75-year-old male is seen in clinic and is noted to have renal and liver function off his usual baseline. His wife is concerned his memory isn't what it used to be, and he has been mixing up his medications of late. She has also noticed his hands are shaking. His past medical history includes autosomal dominant polycystic kidney (ADPKD) disease, for which he had a renal transplant ten years ago.\n\nWhat is the most likely cause for this clinical picture?", "sbaAnswer": [ "a" ], "totalVotes": 4897, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "This is the next step if two doses of benzodiazepines do not work and the patient continues to be in status epilepticus. Be aware that phenytoin infusions are likely to cause a drop in blood pressure", "id": "32580", "label": "c", "name": "Start a phenytoin infusion", "picture": null, "votes": 694 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This patient may well need a neurology review and further investigations; however, the acute issue is their seizures, and the patient needs to be stabilised before referring to a specialty", "id": "32582", "label": "e", "name": "Refer to neurology", "picture": null, "votes": 26 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This would be a reasonable choice if the patient did not have IV access, but as we have secured access in this patient, IV lorazepam is a better option as it is faster acting and does not run the risk of whoever is administering it being accidentally bitten by the patient while they seize", "id": "32579", "label": "b", "name": "Give 10mg buccal midazolam", "picture": null, "votes": 92 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient is in status epilepticus, defined as a seizure lasting >5 minutes; or repeated seizures without regaining consciousness. Initial management is basic life support alongside benzodiazepines.", "id": "32578", "label": "a", "name": "Give a further intravenous (IV) 4mg lorazepam", "picture": null, "votes": 4455 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Whilst airway protection is an important consideration and should be part of your initial and continuous assessment; we do not yet need to intubate in this instance. Other airway adjuncts may be better in the first instance, such as a nasopharyngeal airway", "id": "32581", "label": "d", "name": "Intubate the patient", "picture": null, "votes": 89 } ], "comments": [ { "__typename": "QuestionComment", "comment": "30 minutes is the old definition", "createdAt": 1647773981, "dislikes": 0, "id": "8825", "isLikedByMe": 0, "likes": 4, "parentId": null, "questionId": 6516, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Relapse Complement", "id": 17241 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nStatus Epilepticus is defined as a seizure lasting 5 minutes or more, or multiple seizures occurring within a 5-minute window without regaining full consciousness between episodes. It is a medical emergency, and treatment should begin promptly at the 5-minute mark. Initial management involves administering benzodiazepines, such as rectal diazepam, buccal midazolam, or intravenous lorazepam. If there is no response to two doses of benzodiazepines, second-line treatments include levetiracetam, phenytoin, or sodium valproate. Refractory cases may require general anesthesia with agents like propofol or midazolam. Investigations include blood tests, toxicology screen as well as neuroimaging and CSF analysis if the cause remains unclear\n\n# Definition\n\nStatus epilepticus is defined as a seizure lasting 5 minutes or more OR multiple seizures over 5 minutes without returning to a full level of consciosuness between episodes.\n\nIt should be assumed at 5 minutes and appropriate treatment and investigations initiated.\n\n# Acute management of status epilepticus\n\nEmergency AED therapy for convulsive status epilepticus [NICE guidelines](https://www.nice.org.uk/guidance/ng217/chapter/7-Treating-status-epilepticus-repeated-or-cluster-seizures-and-prolonged-seizures):\n\n\n\n\n**Premonitory stage (0-10 minutes)** \n\n- Diazepam 10−20 mg given rectally, repeated once 15 minutes later if status continues to threaten, or midazolam 10 mg given buccally. If seizures continue, treat as below.\n\n**Early status (0-30 minutes)** \n\n- If in the community:\n\t- Buccal Midazolam or Rectal Diazepam \n- If IV access is obtained and resuscitation facilities are available:\n\t- Lorazepam (intravenous) 0.1 mg/kg (usually a 4 mg bolus, repeated once after 10−20 minutes; rate not critical). \n\n**Established status (0-60 minutes)** \n\n- If not responding to 2 doses of benzodiazepine, give any of the following as second-line treatment\n\t- Levitiracetam\n\t- Phenytoin\n\t- Sodium Valproate\n\n**Refractory status (30-90 minutes)**\n\n- General anaesthesia, with one of:\n\n\t- Propofol (1–2 mg/kg bolus, then 2–10 mg/kg/hour) titrated to effect\n\t- Midazolam (0.1–0.2 mg/kg bolus, then 0.05–0.5 mg/kg/hour) titrated to effect\n\t- Thiopental sodium (3–5 mg/kg bolus, then 3–5 mg/kg/hour) titrated to effect; after 2–3 days infusion rate needs reduction as fat stores are saturated\n\t- Anaesthetic continued for 12−24 hours after the last clinical or electrographic seizure, then dose tapered.\n\n\n# Investigations\n\n- Arterial Blood Gas\n- Routine Blood tests including FBC, U&E, LFT, CRP, Clotting, Bone Profile \n- Toxicology screen (urine)\n- Anti-epileptic drug levels (if appropriate)\n- If the underlying cause is unclear, further investigations can include:\n\t- CT/MRI Brain Imaging\n\t- Lumbar Puncture \n\n\n# References\n\n[Click here for the NICE guidelines on managing status epilepticus](https://www.nice.org.uk/guidance/ng217/chapter/7-Treating-status-epilepticus-repeated-or-cluster-seizures-and-prolonged-seizures)", "files": null, "highlights": [], "id": "196", "pictures": [], "typeId": 2 }, "chapterId": 196, "demo": null, "entitlement": null, "id": "196", "name": "Status Epilepticus", "status": null, "topic": { "__typename": "Topic", "id": "34", "name": "Neurology", "typeId": 2 }, "topicId": 34, "totalCards": 12, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "196", "name": "Status Epilepticus" } ], "demo": false, "description": null, "duration": 490.97, "endTime": null, "files": null, "id": "129", "live": false, "museId": "9WkzgUc", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/neurology.png", "title": "Epilepsy syndromes", "userViewed": false, "views": 457, "viewsToday": 32 } ] }, "conceptId": 196, "conditions": [], "difficulty": 1, "dislikes": 0, "explanation": null, "highlights": [], "id": "6516", "isLikedByMe": 0, "learningPoint": "Status epilepticus requires immediate treatment with benzodiazepines, such as lorazepam.", "likes": 3, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 24-year-old male is brought to the emergency department by ambulance after a witnessed generalised tonic-clonic seizure. He had initially appeared to recover but did not regain consciousness on his way to the hospital and has now started seizing again. Intravenous access is obtained, and he is given 4mg of lorazepam, but after 10 minutes, there is no response.\n\nWhat is the next step in your management?", "sbaAnswer": [ "a" ], "totalVotes": 5356, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "This is less likely to be the case here as the movements described are not typical of a tonic-clonic seizure where the movements are more synchronous jerking of the limbs, with the head often remaining still. Tongue biting in epileptic seizure is more commonly a lateral bite, and incontinence is frequently reported", "id": "32584", "label": "b", "name": "Tonic-clonic seizure", "picture": null, "votes": 2373 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This is a relatively typical description of non-epileptic attack disorder. The more informal term for this condition is a pseudoseizure. The movements described in terms of back arching and pelvic thrusting are less in keeping with a tonic-clonic seizure. The eyes tend to remain open, and making noise is less likely in true epileptic seizures. Tongue biting may occur in both true seizures and non-epileptic attacks; however in epileptic seizures, it is usually the sides of the tongue that are bitten as opposed to the tip. Other signs that would point towards non-epileptic attacks are if they always occur in the company of others or if stressful or highly emotional situations induce them", "id": "32583", "label": "a", "name": "Non-Epileptic Attack Disorder", "picture": null, "votes": 2461 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Whilst vasovagal syncope is common in young females, the description above is more in keeping with a non-epileptic attack than a vasovagal syncope as syncopal episodes usually only last 30 seconds to 2 minutes, and any movements are also short-lived. Tongue biting is also rare in syncope, and the patient usually reports more prodromal symptoms such as disturbed vision, palpitations and feeling warm", "id": "32586", "label": "d", "name": "Vasovagal syncope", "picture": null, "votes": 92 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Absence seizures are a form of epilepsy most common in children and are commonly associated with being very still, fluttering of the eyelids and suddenly stopping activity. They can occur with muscle jerking and shaking, though this is less common than with other forms of epileptic seizure", "id": "32587", "label": "e", "name": "Absence seizure", "picture": null, "votes": 28 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "There is no evidence in the case vignette that this episode is related to low blood sugar, and the blood tests are reported to be normal. It is always good to bear in mind hypoglycaemia in young women and, in particular, in diabetic patients on insulin or sulfonylureas such as gliclazide.\nSymptoms of low blood sugars include sweating, dizziness, tingling lips and can cause unusual behaviour, seizures and collapse if untreated", "id": "32585", "label": "c", "name": "Hypoglycaemic episode", "picture": null, "votes": 18 } ], "comments": [ { "__typename": "QuestionComment", "comment": "😀😀😀", "createdAt": 1710778150, "dislikes": 0, "id": "44905", "isLikedByMe": 0, "likes": 1, "parentId": null, "questionId": 6517, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Serpiginous Defibrillator", "id": 8850 } }, { "__typename": "QuestionComment", "comment": "hip thrusting is usually specific to NEAD...", "createdAt": 1736357507, "dislikes": 0, "id": "59979", "isLikedByMe": 0, "likes": 3, "parentId": null, "questionId": 6517, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Jargon Hereditary", "id": 14217 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n \nSyncope means a transient loss of consciousness and is a common emergency presentation. There are many causes with important differentials being reflex syncope, orthostatic hypotension and cardiac syncope. The term \"blackouts\" is commonly used to refer to a loss of consciousness, and includes differentials such as seizures. A thorough history (including a collateral if available) is important to help to differentiate the above, followed by examination including a lying-standing blood pressure. Initial investigations include an ECG, a blood glucose and consideration of a basic set of bloods to screen for abnormalities such as hyponatraemia that could trigger seizures. Emergency management encompasses ruling out serious causes, treating any injuries sustained during the episode and referral on for specialist investigations and management as appropriate.\n\n# Definition \n\nBlackouts refer to episodes of transient loss of consciousness, which occur for a variety of reasons. Syncope refers to a transient loss of consciousness secondary to cerebral hypoperfusion, with syncopal presentations making up the majority of cases of blackouts.\n \n# Epidemiology \n \nBlackouts are common, with an estimated 50% of the population experiencing at least one in their lifetime. 3% of emergency department presentations and 1% of hospital admissions in the UK are due to blackouts.\n \n# Aetiology\n \n**Causes of cardiac syncope:**\n\n- Structural\n - Acute myocardial infarction \n - Aortic stenosis \n - Ischaemic cardiomyopathy\n - Hypertrophic obstructive cardiomyopathy\n - Cardiac tamponade\n- Electrical \n - Tachyarrhythmias e.g. superventricular tachycarcia (SVT), ventricular tachycardia (VT), ventricular fibrillation (VF)\n - Bradyarrhythmias e.g. sick sinus syndrome, heart block\n - Inherited channelopathies e.g. Brugada syndrome\n\n**Causes of reflex syncope:**\n \n - Vasovagal syncope (\"fainting\")\n - Situational syncope e.g. following defecation, post-exercise, or straining to pass urine\n - Carotid sinus syndrome - occurs due to hypersensitivity of the carotid sinus baroreceptor\n\n**Other causes of syncope:**\n \n - Orthostatic hypotension\n - Pulmonary embolism\n - Occult haemorrhage e.g. subarachnoid haemorrhage, GI bleeding, ruptured aortic aneurysm\n - Head trauma\n - Hypoglycaemia\n\n **Non-syncopal causes of blackouts:**\n \n - Seizures\n - Psychogenic pseudosyncope\n - Psychogenic non-epileptic seizures\n\n# Symptoms and Signs\n \nWhen taking a history and examining a patient after a blackout, there are several additional symptoms and signs to elicit that can help identify the likely cause. If the blackout was witnessed, take a collateral history also. \n\n**Questions to ask about before the blackout:**\n\n- What were they doing/any triggers?\n - Exertional syncope (cardiac)\n - After exercise (vasovagal/orthostatic hypotension)\n - Head movements/pressure on neck (carotid sinus syndrome)\n - Prolonged standing (orthostatic hypotension)\n - Pain (vasovagal)\n - Repeated episodes after defecation/micturition/swallowing/coughing (situational syncope)\n - After a meal (vasovagal or orthostatic hypotension)\n- Prodromal symptoms?\n - Feeling warm/hot, sweating, nausea (vasovagal)\n - Déjà vu or jamais vu (epilepsy)\n- Intercurrent illness?\n - e.g. diarrhoea and vomiting leading to dehydration and hypotension\n- Associated symptoms?\n - Palpitations/chest pain/shortness of breath (cardiac/PE)\n - Headache (subarachnoid haemorrhage)\n - Visual disturbance (if worse on standing may be orthostatic hypotension/vasovagal)\n - Lightheadedness (orthostatic hypotension/vasovagal)\n \n**Questions to ask about during the blackout:**\n \n- Any protective measures taken?\n - e.g. hands outstretched to break fall \n - It can be difficult to ascertain whether the patient lost consciousness\n - If protective measures were observed may be a fall rather than a blackout\n - Patients having a vasovagal may lower themselves to the floor\n- Tongue biting?\n - Lateral tongue typical in epilepsy\n - Tip of tongue typical in vasovagal\n- Incontinence of bowels or bladder? (epilepsy)\n- Duration of loss of consciousness\n - Less than 30 seconds (suggests syncope)\n - Over 1 minute (suggests epilepsy)\n - Over 5 minutes (psychogenic causes more likely)\n- Seizure activity observed?\n - Myoclonic jerks are common in vasovagal syncope\n - Prolonged limb jerking and abnormal posturing suggests a seizure\n- Appearance during blackout e.g. pallor, eyes closed or open? \n \n\n**Questions to ask about after the blackout:**\n\n- Any injuries sustained during the blackout?\n - Ask about site and severity\n- Confusion or amnesia after conciousness regained?\n - If lasts minutes may indicate post-ictal state after a seizure\n- Focal neurological signs (e.g. weakness down one side)\n\n**Other important questions:**\n\n- Any previous blackouts/similar events?\n- Past medical history e.g. any heart disease?\n- Medications (may contribute to orthostatic hypotension)\n- Family history including sudden cardiac or unexplained death in young relatives\n- Recreational drug and alcohol use (alcohol may exacerbate orthostatic hypotension)\n\n**On examination:**\n\n- Do a full set of observations including a lying standing blood pressure to assess for a postural drop\n - A fall in systolic blood pressure by 20mmHg or more or diastolic by 10mmHg or more, or a fall in the systolic to <90mmHg with symptoms indicates orthostatic hypotension\n- Full systems examination focusing on the heart (e.g. any murmurs or abnormalities of the pulse?)\n- Neurological examination including cognitive function (may be abnormal in the post-ictal state)\n \n# Investigations\n \nInitial investigations as follows should be carried out in the emergency setting; patients should also be referred for further specialist investigations (e.g. EEG for epilepsy, Holter monitoring for suspected arrhythmias) as appropriate.\n\n- **Blood glucose** for hypoglycaemia\n- **ECG** looking for arrhythmias, ischaemic changes or evidence of structural abnormalities (e.g. left ventricular hypertrophy in severe aortic stenosis)\n- **Blood tests** looking for electrolyte abnormalities that could trigger seizures or arrhythmias, anaemia in haemorrhage, raised inflammatory markers in intercurrent illness, AKI in dehydration\n- **Transthoracic Echocardiography** should be done in suspected structural heart disease (e.g. aortic stenosis)\n- **24 hour ambulatory blood pressure monitoring** with an activity diary may be useful to assess for e.g. post-prandial hypotension\n \n# Management\n \n- Specific emergency management may be required for any serious cause identified (e.g. head injury, ruptured aortic aneurysm).\n- Investigate for and treat any injuries resulting from the collapse and provide analgesia.\n- Some patients can be discharged with reassurance and advice e.g. uncomplicated vasovagal episode, situational syncope.\n- Patients with suspected epilepsy should be referred to a first fit clinic.\n- Patients with suspected psychogenic causes of blackouts should also be referred for neurology assessment as these can be difficult to differentiate from epilepsy\n- Patients with suspected cardiac syncope (e.g. abnormal ECG, exercise-induced syncope, heart murmur, heart failure, new/unexplained breathlessness or family history of sudden cardiac death in the young/inherited cardiac condition) should be referred for specialist review within 24 hours.\n- Consider urgent referral for cardiovascular review in all patients over 65 with syncope and no prodromal symptoms.\n- All patients with syncope of unclear cause should be referred for specialist cardiovascular review (with urgency based on the clinical picture)\n\n **Driving advice for patients with syncope:**\n\n- Patients with unexplained syncope must inform the DVLA and their licence will be revoked for 6 months (12 months if Group 2) \n- Patients with a vasovagal whilst standing can drive and need not inform the DVLA if they are Group 1 drivers (Group 2 drivers must not drive and should inform the DVLA)\n- Patients with cardiac syncope must not drive and should inform the DVLA - group 1 drivers may be allowed to drive after 4 weeks if a cause is identified and treated\n- Full guidance including for seizures can be found in the references section\n \n# NICE Guidelines\n \n[NICE CKS Guidance on Blackouts](https://cks.nice.org.uk/topics/blackouts/)\n\n[NICE: Transient loss of consciousness ('blackouts') in over 16s](https://www.nice.org.uk/guidance/cg109)\n \n# References \n \n[DVLA guidance on transient loss of consciousness](https://www.gov.uk/guidance/neurological-disorders-assessing-fitness-to-drive#transient-loss-of-consciousness-blackouts--or-lostaltered-awareness)", "files": null, "highlights": [], "id": "242", "pictures": [], "typeId": 2 }, "chapterId": 242, "demo": null, "entitlement": null, "id": "239", "name": "Syncope", "status": null, "topic": { "__typename": "Topic", "id": "34", "name": "Neurology", "typeId": 2 }, "topicId": 34, "totalCards": 6, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "239", "name": "Syncope" } ], "demo": false, "description": null, "duration": 190.27, "endTime": null, "files": null, "id": "148", "live": false, "museId": "JNBryeQ", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/neurology.png", "title": "Generalised seizures", "userViewed": false, "views": 117, "viewsToday": 6 } ] }, "conceptId": 239, "conditions": [], "difficulty": 3, "dislikes": 42, "explanation": null, "highlights": [], "id": "6517", "isLikedByMe": 0, "learningPoint": "Non-Epileptic Attack Disorder, or pseudoseizures, often presents with unusual movements and can be triggered by emotional stress.", "likes": 13, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 16-year-old female presents to the emergency department after an episode of loss of consciousness witnessed by her mother. Her mother reports that her daughter fell to the floor without warning then started shaking and making grunting noises. Her eyes were closed throughout, and her main movements were back arching and pelvic thrusting. She reports that she has bitten the tip of her tongue but retained continence. The episode lasted about 5-10 minutes in total.\nBlood tests, urinalysis and examination findings are all normal.\nWhat is the most likely diagnosis?", "sbaAnswer": [ "a" ], "totalVotes": 4972, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "A lumbar puncture in Guillain-Barré Syndrome typically shows an elevated cerebrospinal fluid (CSF) protein with a normal cell count. LP findings do not correlate with severity of illness or need for intubation", "id": "32590", "label": "c", "name": "Lumbar puncture (LP)", "picture": null, "votes": 258 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Whilst a chest x-ray would rule out other causes of breathlessness, this patient is presumed to have Guillain-Barré Syndrome, and a chest x-ray is likely to be normal, and would not help to predict the need for intubation", "id": "32589", "label": "b", "name": "Chest x-ray", "picture": null, "votes": 74 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "In the absence of signs and symptoms of pulmonary embolism, CTPA is unlikely to be of value in this case. A normal CTPA does not preclude the need for intubation in Guillain-Barré Syndrome", "id": "32592", "label": "e", "name": "CT pulmonary angiogram (CTPA)", "picture": null, "votes": 57 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "An arterial blood may be normal in Guillain-Barré Syndrome, with hypoxia or hypercapnoea being a late sign of impending neuromuscular respiratory failure. Spirometry is recommended as a more accurate reflection of a patients requirement for respiratory support", "id": "32591", "label": "d", "name": "Arterial blood gas (ABG)", "picture": null, "votes": 1603 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient has Guillain-Barré Syndrome (GBS), characterised by the preceding gastrointestinal illness and the pattern of bilateral ascending weakness. Bedside spirometry, particularly forced vital capacity (FVC) has a significant correlation with the risk of respiratory failure and need for intubation. If the FVC < 20mL/Kg, the patient likely needs intensive care, and if <15mL/Kg, likely requires intubation", "id": "32588", "label": "a", "name": "Bedside spirometry", "picture": null, "votes": 3256 } ], "comments": [ { "__typename": "QuestionComment", "comment": "My dude you feel like shit? Here blow into the plastic tube for me.", "createdAt": 1684775851, "dislikes": 0, "id": "25702", "isLikedByMe": 0, "likes": 9, "parentId": null, "questionId": 6518, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Anterior Gallbladder", "id": 5111 } }, { "__typename": "QuestionComment", "comment": "See I knew that but I didn't know that", "createdAt": 1710778297, "dislikes": 0, "id": "44906", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6518, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Serpiginous Defibrillator", "id": 8850 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "## Summary\n\nGuillain-Barré Syndrome (GBS) is an acute inflammatory demyelinating polyneuropathy characterised by a rapid, progressive, ascending symmetrical weakness, often preceded by infection. Diagnosis is largely clinical but supported by specific investigations such as lumbar puncture and nerve conduction studies. Treatment is mainly supportive, with options for disease-modifying treatments like intravenous immunoglobulins (IVIG) or plasmapheresis in severe cases.\n\n## Definition\n\nGBS is an ascending inflammatory demyelinating polyneuropathy, typified by an acute onset of bilateral and roughly symmetric limb weakness. \n\n## Epidemiology\n\nThe prevalence of GBS is approximately 1-2 cases per 100,000 worldwide.\n\n## Aetiology\n\nGBS typically occurs 1-3 weeks following an infection, with common culprits being Campylobacter, mycoplasma, and Epstein-Barr Virus (EBV). \n\n40% of cases, however, are idiopathic. \n\nOther potential triggers include infections such as CMV, HIV, Hepatitis A, or following certain vaccinations such as for tetanus, rabies, or swine flu.\n\n## Signs and symptoms\n\nNeurological decline often progresses over days to weeks.\n\nClinical features of GBS include:\n\n- Progressive ascending symmetrical limb weakness (usually starting with the lower limbs)\n- Lower back pain due to radiculopathy\n- Paraesthesia, often preceding motor symptoms\n- Potential respiratory muscle involvement in severe cases\n- Potential cranial nerve involvement leading to diplopia, facial droop\n- **Lower motor neurone** signs in the lower limbs: hypotonia, flaccid paralysis, areflexia\n- Cranial nerve signs: ophthalmoplegia, lower motor neurone facial nerve palsy, bulbar palsy\n- Potential autonomic dysfunction (e.g., arrhythmia, labile blood pressure)\n\n## Variants\n\nSeveral variants of GBS exist, each presenting with unique characteristics:\n\n- Paraparetic variant\n - Primarily affects the lower limbs\n\n- Miller-Fisher syndrome\n - Presents with ataxia, ophthalmoplegia, and areflexia\n - Associated with **anti-GQ1B antibodies**\n\n- Pure motor variant\n - Ascending weakness without sensory involvement\n\n- Bilateral facial palsy with paraesthesias\n - Affects the cranial nerves\n\n- Pharyngeal-brachial-cervical weakness\n - Results in weakness of the upper limbs\n - Associated with **anti- GT1a antibodies**\n- Bickerstaff's Brainstem Encephalitis\n - Presents with encephalitis, ophthalmoplegia, and ataxia\n\nIt's worth noting that these variants rarely present purely as described, and there's often overlap in clinical presentation.\n\n\n## Differential diagnosis\n\n- Vascular: occasionally, brainstem strokes may present similarly\n- Infective/Inflammatory: \n - Polio: asymmetrical weakness from myelitis\n - Lyme disease\n - CMV\n - HIV\n - TB\n - Transverse myelitis \n - Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) \n - Myasthenia gravis\n- Traumatic/Structural:\n - Spinal cord compression\n- Metabolic:\n - Porphyrias: may result in an acute neuropathy\n - Electrolyte derangements: hypokalaemia, hypophosphataemia, hypermagnesaemia\n\t\n\n## Investigations\n\nInvestigations for GBS include:\n\n- Monitoring of forced vital capacity (FVC) for respiratory muscle involvement\n- Cardiac monitoring for autonomic instability\n- Blood tests, including arterial blood gas (ABG)\n- Serological tests: Anti-ganglioside antibodies\n- Lumbar puncture: may show **albuminocytological dissociation** \n\t- Increased level of protein (albumin) without a corresponding increase in white blood cells (cytology)\n- Nerve conduction studies\n\t- May show prolongation or loss of the F wave\n- Identification of the underlying cause: stool cultures, serology, CSF virology\n\n## Management\n\nManagement of GBS is primarily supportive and includes:\n\n- Regular monitoring of FVC\n\t- Early involvement of intensive care is essential if any reduction in FVC as deterioration may be rapid\n- Venous thromboembolism (VTE) prophylaxis: TEDS + LMWH\n- Analgesia: NSAIDs or opiates for radiculopathy-related back pain\n- Management of cardiac arrhythmias as per ALS guidelines\n- Careful use of antihypertensives due to potential autonomic dysfunction\n- Consideration of enteral feeding in those with unsafe swallow\n\nSpecific medical management for those with significant disability (e.g., inability to walk) include:\n\n- Intravenous immunoglobulin (IVIG) over a 5-day course\n- Plasmapheresis, which has similar efficacy to IVIG but is associated with more side effects.\n\n## Prognosis\n\nWhile GBS can be life-threatening, particularly when respiratory muscles are affected or in the presence of autonomic dysfunction, the majority of patients experience full recovery. \n\nHowever, residual fatigue and weakness can persist in some patients. Certain variants of GBS, like Miller-Fisher syndrome, generally have a good prognosis with full recovery being the norm. \n\nPrognostic indicators include speed of onset, severity at nadir, age and the presence of preceding diarrhoeal illness.\n\n## References\n\n1. Van den Berg, B., Walgaard, C., Drenthen, J., Fokke, C., Jacobs, B. C., & Van Doorn, P. A. (2014). Guillain–Barré syndrome: pathogenesis, diagnosis, treatment and prognosis. Nature Reviews Neurology, 10(8), 469-482.\n\n2. Yuki, N., & Hartung, H. P. (2012). Guillain–Barré syndrome. New England Journal of Medicine, 366(24), 2294-2304.\n\n3. Hughes, R. A., & Cornblath, D. R. (2005). Guillain-Barré syndrome. The Lancet, 366(9497), 1653-1666.\n\n4. Willison, H. J., Jacobs, B. C., & Van Doorn, P. A. (2016). Guillain-Barré syndrome. The Lancet, 388(10045), 717-727.\n", "files": null, "highlights": [], "id": "221", "pictures": [], "typeId": 2 }, "chapterId": 221, "demo": null, "entitlement": null, "id": "218", "name": "Guillain-Barré Syndrome", "status": null, "topic": { "__typename": "Topic", "id": "34", "name": "Neurology", "typeId": 2 }, "topicId": 34, "totalCards": 22, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "218", "name": "Guillain-Barré Syndrome" } ], "demo": false, "description": null, "duration": 258.07, "endTime": null, "files": null, "id": "154", "live": false, "museId": "oDW6CbJ", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/neurology.png", "title": "Guillain-Barre Syndrome", "userViewed": false, "views": 173, "viewsToday": 12 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "218", "name": "Guillain-Barré Syndrome" } ], "demo": false, "description": null, "duration": 3526.7, "endTime": null, "files": null, "id": "247", "live": false, "museId": "Dy6PDaW", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/neurology.png", "title": "Quesmed Tutorial: Neurology", "userViewed": false, "views": 2155, "viewsToday": 63 } ] }, "conceptId": 218, "conditions": [], "difficulty": 2, "dislikes": 8, "explanation": null, "highlights": [], "id": "6518", "isLikedByMe": 0, "learningPoint": "In Guillain-Barré Syndrome (GBS), bedside spirometry is used to assess respiratory function, detecting weakness in respiratory muscles. Reduced vital capacity and peak flow suggest the need for respiratory support or monitoring.", "likes": 7, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 65-year-old male attends the Emergency Department complaining of progressive numbness and weakness that started in his legs and moved slowly up his body. He has recently had an episode of diarrhoea and vomiting after eating a \"dodgy takeaway\".\n\nHe has been transferred to the hospital's adjoining tertiary neurology centre with a presumed diagnosis of Guillain-Barré Syndrome (GBS). On arrival in the neurology ward, he appears breathless.\n\nWhat is the most appropriate investigation to help predict the need for intubation?", "sbaAnswer": [ "a" ], "totalVotes": 5248, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Infection is a common cause of falls in the elderly. Common sources are urine and chest; however, there is nothing in the history suggestive of infection; therefore, whilst this is always worth checking, it is unlikely to provide a diagnosis here", "id": "32596", "label": "d", "name": "Urinalysis", "picture": null, "votes": 144 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "We know that this patient has postural hypotension, and therefore lying and standing blood pressure measurements would prove this to be true. However, there are many causes for postural hypotension in the elderly, and therefore this would not prove a Parkinson's plus syndrome", "id": "32594", "label": "b", "name": "Lying and standing blood pressure measurement", "picture": null, "votes": 2207 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "The two main differential diagnoses in this scenario are Progressive Supranuclear Palsy (PSP) and Multiple system atrophy (MSA). This patient likely has a Parkinson's plus syndrome as he has symptoms of autonomic instability (urinary incontinence, postural hypotension and recurrent chest infections, which raises a concern about poor swallow), and the co-benyldopa does not seem to have had much effect. It's important to test for vertical gaze palsy to help you narrow down your differential diagnosis. ", "id": "32593", "label": "a", "name": "Testing vertical gaze", "picture": null, "votes": 1721 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This history is not suggestive of syncopal episodes as a cause for his falls. Whilst an ECG should always be performed in patients with recurrent falls to look for arrhythmias; a stand-alone ECG is unlikely to pick up a cause for falls. 24 hour Halter monitoring is more sensitive and would be a reasonable investigation if there were concerns about a cardiac cause for his falls", "id": "32595", "label": "c", "name": "12 lead ECG", "picture": null, "votes": 304 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Parkinson's disease is closely linked to Lewy Body Dementia, and therefore in all patients with Parkinson's disease, it is important to assess cognitive function. However, this would not account for the recurrent falls and would not be likely to aid further diagnosis here.", "id": "32597", "label": "e", "name": "Abbreviated Mental Test (AMT)", "picture": null, "votes": 489 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Sweet lord, are you telling me I was supposed to infer poor swallow from recurrent chest infections? ", "createdAt": 1672926628, "dislikes": 1, "id": "15975", "isLikedByMe": 0, "likes": 17, "parentId": null, "questionId": 6519, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "George", "id": 3650 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nParkinsonism refers to a group of neurological conditions that share the core motor features of Parkinson’s disease—bradykinesia, rigidity, resting tremor, and postural instability. While Parkinson’s disease is the most common cause of parkinsonism, several other important neurodegenerative conditions can present with a similar signs and symptoms. These conditions are collectively known as **Parkinson-plus syndromes**. These include **progressive supranuclear palsy (PSP)**, **multiple system atrophy (MSA)**, **Lewy body dementia (LBD)**, and **corticobasal degeneration (CBD)**. \n\n## Progressive Supranuclear Palsy (PSP)\n\n- Also known as **Steele-Richardson-Olszewski syndrome**\n- Early postural instability and frequent falls.\n- **Impairment of vertical gaze** (particularly downgaze).\n- Stiff, broad-based gait.\n- Parkinsonism (bradykinesia, rigidity).\n- An MRI of the brain may show a **hummingbird sign**, a characteristic shape of midbrain atrophy seen in PSP.\n\n\n\n## Multiple System Atrophy (MSA)\n\n- Presents with parkinsonism and early **autonomic dysfunction**. \n- It is divided into two types based on the predominant symptoms:\n\t1. **MSA-P** (Parkinsonian type): Similar to Parkinson's disease but with early autonomic issues.\n\t2. **MSA-C** (Cerebellar type, also known as Shy-Drager syndrome): Presents with **cerebellar ataxia**, alongside parkinsonism. Early signs include **postural hypotension**, **urinary incontinence**, and **erectile dysfunction** (an early prominent feature in men).\n- Generally exhibits poor response to levodopa therapy\n\n\n## Lewy Body Dementia (LBD)\n\n- Characterised by **dementia and parkinsonism**, often occurring within one year of each other. \n- The hypothesised pathophysiology involves the early death of dopaminergic neurons in the **cerebrum**, which then extends to the basal ganglia, leading to motor symptoms.\n- Unlike Alzheimer’s, LBD affects **attention and executive function** early on, with less involvement of memory (hippocampus). \n- **Visual hallucinations** are a prominent feature and tend to occur early in the disease.\n\n## Corticobasal Degeneration (CBD)\n\n### Key Clinical Features:\n- Unilateral parkinsonism, typically affecting one limb.\n- **Alien limb phenomenon**.(patients feel that their limbs move involuntarily outside of their control\n- **Cortical sensory loss** (patients cannot recognise objects by touch despite normal sensory input).\n- **Apraxia** (difficulty with purposeful movement despite intact motor function).\n\n\n## Other Conditions Mimicking Parkinsonism\n\n### Vascular Parkinsonism\n\n- Often affects the **lower limbs** and is seen in patients with a history of **vascular disease** (e.g., strokes). \n- Patients develop gait issues with rigidity and bradykinesia predominantly in the lower extremities.\n\n### Dementia Pugilistica\n\n- Also known as **chronic traumatic encephalopathy** (CTE), this condition arises from **repetitive head trauma**, commonly seen in **boxers**. \n- It presents with parkinsonism and cognitive decline.\n\n### Drug-Induced Parkinsonism\n\n- Caused by medications such as **antipsychotics** (e.g., haloperidol, risperidone), **metoclopramide**, and **prochlorperazine**.\n- Onset is typically **rapid** and **bilateral**.\n- Management involves stopping the offending drug and, in some cases, using **procyclidine** to manage symptoms.\n- Can lead to **neuroleptic malignant syndrome** (a life-threatening condition characterized by fever, rigidity, and altered mental status).\n", "files": null, "highlights": [], "id": "2040", "pictures": [], "typeId": 2 }, "chapterId": 2040, "demo": null, "entitlement": null, "id": "205", "name": "Parkinson-plus syndromes", "status": null, "topic": { "__typename": "Topic", "id": "34", "name": "Neurology", "typeId": 2 }, "topicId": 34, "totalCards": 13, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "205", "name": "Parkinson-plus syndromes" } ], "demo": false, "description": null, "duration": 423.06, "endTime": null, "files": null, "id": "264", "live": false, "museId": "sYx2wL9", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/neurology.png", "title": "Parkinsonism", "userViewed": false, "views": 163, "viewsToday": 12 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "205", "name": "Parkinson-plus syndromes" } ], "demo": false, "description": null, "duration": 421.46, "endTime": null, "files": null, "id": "263", "live": false, "museId": "CaMxjHf", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/neurology.png", "title": "Parkinson's Disease", "userViewed": false, "views": 282, "viewsToday": 20 } ] }, "conceptId": 205, "conditions": [], "difficulty": 3, "dislikes": 32, "explanation": null, "highlights": [], "id": "6519", "isLikedByMe": 0, "learningPoint": "In Parkinson's Plus Syndromes, vertical gaze testing reveals difficulty with downward gaze, impaired saccades, and smooth pursuit", "likes": 9, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 74-year-old male is referred to the falls clinic after he suffers three mechanical falls at home within two months. He has a past medical history that includes postural hypotension, urinary incontinence, recurrent chest infections and six months ago was diagnosed with Parkinson's disease. He currently takes, co-benyldopa and has just finished a course of amoxicillin. On examination, you note that he has hypomimia, rigidity and bradykinesia with a very mild tremor.\n\nYou suspect a Parkinson's Plus Syndrome. Which of the following would you perform next?", "sbaAnswer": [ "a" ], "totalVotes": 4865, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Multiple Sclerosis is a definite cause of a medical third nerve palsy. However, the normal MRI Head, lack of any previous neurological history and significant vascular risk factors in her history point towards a more vasculopathic process", "id": "32601", "label": "d", "name": "Multiple Sclerosis", "picture": null, "votes": 749 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Urinary tract infection is unlikely to be implicated in causing an isolated third nerve palsy", "id": "32600", "label": "c", "name": "Urinary tract infection", "picture": null, "votes": 65 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is the cause of a 'surgical' third nerve palsy. Note that this is a medical third nerve palsy which is pupillary sparing rather than a 'surgical' third nerve palsy where aneurysms, tumours and raised intracranial pressure can push on the outer autonomic fibres of the nerve, causing the pupil to dilate. In a medical third palsy, only the inner motor fibres are affected so the pupils are spared", "id": "32599", "label": "b", "name": "Cerebral artery Aneurysm", "picture": null, "votes": 838 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "There are no real signs of raised intracranial pressure in this scenario. Also you would expect there to be pupillary dilatation secondary to pressure on the outer autonomic fibres of the third cranial nerve", "id": "32602", "label": "e", "name": "Raised intracranial pressure", "picture": null, "votes": 1225 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient has an oculomotor nerve palsy (cranial nerve III), and one of the common medical causes of this presentation is due to vasculopathic ischaemia to the third nerve. Note that this is a medical third nerve palsy which is pupillary sparing rather than a 'surgical' third nerve palsy where aneurysms, tumours and raised intracranial pressure can push on the outer autonomic fibres of the nerve, causing the pupil to dilate. In a medical third palsy, only the inner motor fibres are affected so the pupils are spared", "id": "32598", "label": "a", "name": "Diabetes", "picture": null, "votes": 1978 } ], "comments": [ { "__typename": "QuestionComment", "comment": "what", "createdAt": 1705002387, "dislikes": 1, "id": "38533", "isLikedByMe": 0, "likes": 6, "parentId": null, "questionId": 6520, "replies": [ { "__typename": "QuestionComment", "comment": "what", "createdAt": 1731520923, "dislikes": 0, "id": "57067", "isLikedByMe": 0, "likes": 1, "parentId": 38533, "questionId": 6520, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Retrograde Hematoma", "id": 9385 } }, { "__typename": "QuestionComment", "comment": "what", "createdAt": 1738525928, "dislikes": 0, "id": "62173", "isLikedByMe": 0, "likes": 0, "parentId": 38533, "questionId": 6520, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Chronic Prognosis", "id": 65086 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Imran", "id": 20807 } }, { "__typename": "QuestionComment", "comment": "wow", "createdAt": 1738528475, "dislikes": 0, "id": "62180", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6520, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Warren", "id": 79117 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nDiplopia is commonly caused by third, fourth, and sixth nerve palsies which refer to paralysis of the oculomotor, trochlear, and abducens nerves respectively. Each nerve controls different sets of extraocular muscles, contributing to various distinct clinical presentations. \n\n# Epidemiology\n\nThese nerve palsies are relatively rare, with an estimated prevalence ranging from 1 in 1,000 to 1 in 10,000 depending on the specific nerve involved. They can occur in all age groups but tend to be more prevalent in older adults due to higher rates of vascular disease and diabetes which are common aetiological factors.\n\n# Aetiology\n\n- **Third nerve palsy**: This condition can result from surgical lesions (compressive) such as a posterior communicating artery aneurysm, or medical lesions (non-compressive), such as multiple sclerosis or vascular causes like diabetes.\n\t- Compressive lesions compresse parasympathetic fibres which are at the outermost of the nerve, leads to unopposed sympathetic action which leads to fixed pupil dilatation. This doesn’t happen in medical pathologies as no physical compression of those outermost parasympathetic fibres. Please see section on medical third nerve palsy for more information\n- **Fourth nerve palsy**: Common causes include ocular trauma and diabetes mellitus.\n- **Sixth nerve palsy**: Common causes are diabetic neuropathy, stroke, infection, multiple sclerosis and trauma. It's known for being a 'false localizing sign' due to the path of the sixth nerve within the brain, making it easily compromised in a state of raised intracranial pressure.\n\n# Signs and Symptoms\n\n- **Third nerve palsy**: The eye's classic resting position is looking 'down and out'. Other features include ptosis, proptosis, and a fixed pupil dilatation if the lesion is compressive rather than medical.\n\n[lightgallery]\n\n\n- **Fourth nerve palsy**: The presentation is a result of paralysis or partial paralysis of the superior oblique muscle. At rest, the eye points upwards and inwards, and the patient may present with a tilted head to compensate for the palsy. Patients present with double vision worse in the vertical plane, and potentially hypertropia.\n\n- **Sixth nerve palsy**: The eye fails to ABduct due to paralysis of the abducens nerve. It may be medially deviated at rest, and diplopia worsens when the patient is asked to look horizontally away from the midline on the side of the lesion.\n\n[lightgallery1]\n\n# Differential Diagnosis \n\nThe primary systemic differentials include:\n\n- **Myasthenia gravis**: Presents with weakness that is exacerbated by continued use of the muscle. Patients often have ocular symptoms of diplopia and ptosis that worsen throughout the day or while watching television.\n- **Strabismus**: Common cause of diplopia in children and occasionally in adults. Esotropia – a convergent squint – is the commonest type, where the malaligned eye diverges inwards towards the midline.\n- **Thyroid eye disease**: Exophthalmos in Graves' disease can cause double vision through compression of the extraocular muscles and lack of space for the eye to rotate.\n\n[lightgallery2]\n\n# Investigations\n\n- Typically, the workup includes a comprehensive ophthalmologic examination to evaluate eye movements, visual acuity, and pupillary function. \n- Neuro-imaging, such as MRI or CT scan, is often necessary, particularly for third nerve palsy, to identify any compressive lesions. \n- Additional tests depend on the suspected aetiology and may include blood tests, cerebrospinal fluid analysis (LP), and nerve conduction studies.\n\n# Management\n\n- Management strategies vary depending on the specific nerve involved, aetiology, and severity of symptoms. Initial management may include prismatic glasses to correct diplopia and use of occlusion for troublesome diplopia. \n- Definitive management may include strabismus surgery or treatment of the underlying cause (e.g. blood sugar control in diabetic neuropathy, immunosuppression in multiple sclerosis). \n- In some cases, spontaneous recovery can occur.\n\n# References\n\n1. Rucker JC. \"Cranial Neuropathies: Oculomotor, Trochlear, and Abducens Nerve Palsies.\" In: Brazis PW, Masdeu JC, Biller J, editors. Localization in Clinical Neurology. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2016. pp. 239-256.\n \n2. Brazis PW. \"Isolated palsies of cranial nerves III, IV, and VI.\" Semin Neurol. 2009;29(1):14-28. doi:10.1055/s-0028-1124022.\n\n3. Malik SRK, Gupta AK, Choudhry S. \"Strabismus and Ocular Paralysis.\" In: Clinical Ophthalmology: Modern Perspectives. New Delhi, India: Jaypee Brothers Medical Publishers; 2019. pp. 307-334.\n\n4. Bahn RS. \"Graves' ophthalmopathy.\" N Engl J Med. 2010;362(8):726-738. doi:10.1056/NEJMra0905750.\n\n", "files": null, "highlights": [], "id": "961", "pictures": [ { "__typename": "Picture", "caption": "The classic 'down and out' pupil and ptosis in oculomotor nerve palsy.", "createdAt": 1665036184, "id": "705", "index": 0, "name": "Oculomotor nerve palsy.png", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/f57lea511665036171706.jpg", "path256": "images/f57lea511665036171706_256.jpg", "path512": "images/f57lea511665036171706_512.jpg", "thumbhash": "JhgKBIJyqnYvlohch4efo+R3Cw==", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "An abducens palsy.", "createdAt": 1665036193, "id": "763", "index": 1, "name": "Abducens palsy.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/z5b0xiks1665036171706.jpg", "path256": "images/z5b0xiks1665036171706_256.jpg", "path512": "images/z5b0xiks1665036171706_512.jpg", "thumbhash": "4mgOC4IFl3V3iJeHCHS7BOc=", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "A typical appearance of exophthalmos seen in a patient with grave's disease.", "createdAt": 1665036193, "id": "757", "index": 2, "name": "Thyroid eye disease.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/k3vq2u0b1665036171704.jpg", "path256": "images/k3vq2u0b1665036171704_256.jpg", "path512": "images/k3vq2u0b1665036171704_512.jpg", "thumbhash": "pmkODYQERmeJhXh6ead4hTOAiwiI", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 961, "demo": null, "entitlement": null, "id": "2407", "name": "Cranial nerve palsies and the eye", "status": null, "topic": { "__typename": "Topic", "id": "34", "name": "Neurology", "typeId": 2 }, "topicId": 34, "totalCards": 4, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 2407, "conditions": [], "difficulty": 3, "dislikes": 27, "explanation": null, "highlights": [], "id": "6520", "isLikedByMe": 0, "learningPoint": "Medical third nerve palsy, often caused by diabetes, involves damage to the oculomotor nerve, resulting in ptosis, ocular misalignment (\"down and out\" eye), and normal pupil reaction.", "likes": 12, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 58-year-old female presents to the Emergency Department concerned she has had a stroke. Her past medical history includes hypertension, gout, recurrent urinary tract infections, chronic kidney disease (CKD) stage three, type two diabetes on insulin, and a previous N-STEMI. On examination, she is GCS 15/15 and talking in complete and coherent sentences. She has normal power, tone, sensation, reflexes and coordination in all four limbs. She has double vision and a mild ptosis. Her pupils are both symmetrical and equal.\n\nAn MRI Head is performed which is normal.\n\nWhich of the following is the most likely underlying cause of her presentation?", "sbaAnswer": [ "a" ], "totalVotes": 4855, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Whilst liver function tests would help confirm whether this was true jaundice, they would not help diagnose the underlying cause", "id": "32605", "label": "c", "name": "Liver function tests", "picture": null, "votes": 626 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "A liver ultrasound would be useful in diagnosing biliary atresia, serious but rare cause of neonatal jaundice. However, biliary atresia usually develops around three weeks after birth. This history is more in keeping with an acute haemolytic cause for jaundice than a structural issue", "id": "32606", "label": "d", "name": "Liver ultrasound", "picture": null, "votes": 112 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Breastfeeding is a common cause for prolonged jaundice in newborns; however, it would not develop in the first few hours of life. Visible jaundice in the first 24 hours of life is always abnormal", "id": "32607", "label": "e", "name": "Withdrawal of breastfeeding", "picture": null, "votes": 120 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This history suggests rhesus haemolytic disease of the newborn, as this is a woman in her second pregnancy, and the jaundice is apparent in the first 24 hours after birth. You would therefore expect a positive direct Coombs test. A direct Coombs test is used to test for autoimmune haemolytic anaemia where the immune system breaks down red blood cells, leading to anaemia. The direct Coombs test is used to detect antibodies or complement proteins attached to the surface of red blood cells", "id": "32603", "label": "a", "name": "Direct Coombs test", "picture": null, "votes": 3811 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "An indirect Coombs test looks at antibodies floating freely in the blood and, therefore, can be used in prenatal testing for pregnant women or in testing prior to blood transfusion. A positive indirect Coombs would not diagnose the cause for haemolysis in this case", "id": "32604", "label": "b", "name": "Indirect Coombs test", "picture": null, "votes": 473 } ], "comments": [ { "__typename": "QuestionComment", "comment": "I'm confused - are we testing the mum or the baby?\nIndirect Coombs test would be positive in the baby due to the alloimmune destruction wouldn't it? ", "createdAt": 1653906323, "dislikes": 0, "id": "11514", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6521, "replies": [ { "__typename": "QuestionComment", "comment": "The baby ", "createdAt": 1738153613, "dislikes": 0, "id": "61859", "isLikedByMe": 0, "likes": 0, "parentId": 11514, "questionId": 6521, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Fronk", "id": 31477 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Myotonia Chronic", "id": 20026 } }, { "__typename": "QuestionComment", "comment": "good question\n", "createdAt": 1682092592, "dislikes": 0, "id": "22389", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6521, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Dorsal RNA", "id": 32111 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nHaemolytic Disease of the Newborn (HDN) is an immunological disorder that occurs when a rhesus negative mother becomes sensitised to her baby's rhesus positive blood cells in utero. Key signs and symptoms include hydrops foetalis, yellow amniotic fluid, neonatal jaundice, kernicterus, foetal anaemia, hepatomegaly or splenomegaly, and severe oedema if hydrops foetalis was present in utero. It is vital to identify and manage HDN to prevent complications including neurodevelopmental issues and foetal death. Key investigations include Direct Antiglobulin Test (DAT), Ultrasound, and LFTs. Management strategies include intrauterine transfusions, early delivery, and postnatal management with phototherapy or exchange transfusion.\n\n\n# Definition\n\n\n\nHaemolytic Disease of the Newborn (HDN) is an immunological condition that arises when a rhesus negative mother becomes sensitised to the rhesus positive blood cells of her baby while in utero.\n\n\n# Epidemiology\n\n\n\nHDN is relatively rare, but it can have serious consequences if not properly managed. It is most common in pregnancies where there is blood group incompatibility between the mother and the foetus. \n\n\n# Aetiology\n\n\n\nHDN occurs due to immune response following rhesus or ABO blood group incompatibility between the mother and foetus. The sensitisation events are responsible for enabling foetal blood to cross the placenta into the maternal circulation. These events include antepartum haemorrhage, placental abruption, abdominal trauma, external cephalic version, invasive uterine procedures such as amniocentesis and chorionic villus sampling, rhesus positive blood transfusion to a rhesus negative woman, intrauterine death, miscarriage or termination, ectopic pregnancy, and delivery.\n\n\n# Signs and Symptoms\n\n\nThe features of haemolytic disease of the newborn include:\n\n- Hydrops foetalis appearing as foetal oedema in at least two compartments, seen on antenatal ultrasound\n- Yellow coloured amniotic fluid due to excess bilirubin\n- Neonatal jaundice and kernicterus\n- Foetal anaemia causing skin pallor\n- Hepatomegaly or splenomegaly\n- Severe oedema if hydrops foetalis was present in utero\n\n\n# Differential Diagnosis\n\n\nIt is important to differentiate HDN from other conditions that can present with similar symptoms, including:\n\n- Spherocytosis: Characterised by haemolytic anaemia, jaundice, and splenomegaly\n- G6PD deficiency: Causes episodic haemolysis, jaundice and pallor\n- Thalassemia: Presents with anaemia, hepatosplenomegaly, and jaundice\n\n# Investigations\n\n\nInvestigations for HDN include:\n\n- Direct Antiglobulin Test (DAT)\n- Ultrasound to detect foetal oedema\n- Liver function tests (LFTs) to check for complications\n\n# Management\n\n\nManagement of HDN includes:\n\n- Intrauterine transfusions if severe anaemia is detected in the foetus\n- Early delivery if the condition is severe\n- Postnatal management with phototherapy or exchange transfusion to manage high bilirubin levels\n- Immunoglobulin administration to the newborn to prevent further haemolysis\n- Regular follow-up to assess for any developmental issues", "files": null, "highlights": [], "id": "2034", "pictures": [], "typeId": 2 }, "chapterId": 2034, "demo": null, "entitlement": null, "id": "137", "name": "Haemolytic disease of the newborn", "status": null, "topic": { "__typename": "Topic", "id": "38", "name": "Obstetrics", "typeId": 2 }, "topicId": 38, "totalCards": 4, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "137", "name": "Haemolytic disease of the newborn" } ], "demo": false, "description": null, "duration": 3551.42, "endTime": null, "files": null, "id": "320", "live": false, "museId": "xsyPfpT", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/hematology.png", "title": "Quesmed Tutorial: Haemolytic Anaemia", "userViewed": false, "views": 188, "viewsToday": 22 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "137", "name": "Haemolytic disease of the newborn" } ], "demo": false, "description": null, "duration": 334.27, "endTime": null, "files": null, "id": "163", "live": false, "museId": "Pa5oMyH", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/hematology.png", "title": "Haemolytic disease of the newborn", "userViewed": false, "views": 283, "viewsToday": 19 } ] }, "conceptId": 137, "conditions": [], "difficulty": 2, "dislikes": 3, "explanation": null, "highlights": [], "id": "6521", "isLikedByMe": 0, "learningPoint": "Rhesus haemolytic disease of the newborn typically presents with jaundice within 24 hours of birth and is confirmed by a positive direct Coombs test.", "likes": 13, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 28-year-old female gives birth to her second child at full term following an uneventful pregnancy. You check on the baby three hours after delivery, and you notice that the neonate is jaundiced. Observations are otherwise normal.\n\nWhat test would confirm your diagnosis?", "sbaAnswer": [ "a" ], "totalVotes": 5142, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Asking the mother to lie in the left lateral position can shift weight off the maternal vessels and correct cord compression, however as the foetal blood sampling is abnormal, the foetus needs to be delivered. Therefore, this is not the right answer", "id": "32612", "label": "e", "name": "Ask the mother to lie in the left lateral position", "picture": null, "votes": 309 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is an abnormal and very worrying result, and therefore time is of the essence. NICE guidance suggests that if pH < 7.20 or lactate is >4.9mmol/L, the foetus should be delivered immediately. If the pH were 7.21 - 7.24 or lactate were 4.2 -4.8mmol/L, it would be reasonable to retest in the first instance", "id": "32609", "label": "b", "name": "Repeat the test in 30 minutes", "picture": null, "votes": 49 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "The cardiotocograph will give you an accurate assessment of foetal heart rate (and, in this case, is showing abnormal decelerations). Auscultation would unlikely add anything in this scenario", "id": "32611", "label": "d", "name": "Auscultate for foetal heart rate", "picture": null, "votes": 447 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is an abnormal and very worrying result, and therefore, time is of the essence, and the baby needs to be delivered urgently. Whilst it is important to stay calm and keep the mother reassured, it is important not to give false reassurance at the gravity of the situation", "id": "32610", "label": "c", "name": "Reassure the mother that everything is normal", "picture": null, "votes": 11 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This is a concerning blood sample indicating that the foetus is acidotic, implying hypoxia and therefore needs urgent delivery", "id": "32608", "label": "a", "name": "Urgent delivery", "picture": null, "votes": 4335 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Notes below say prolonged deceleration is a contraindication to FBS. So why was it done?", "createdAt": 1683129387, "dislikes": 0, "id": "23303", "isLikedByMe": 0, "likes": 8, "parentId": null, "questionId": 6522, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Yersinia Jaundice", "id": 21156 } }, { "__typename": "QuestionComment", "comment": "CAT1 C-Section \n", "createdAt": 1685462246, "dislikes": 1, "id": "27195", "isLikedByMe": 0, "likes": 2, "parentId": null, "questionId": 6522, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Syndrome Bradykinin", "id": 16421 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\n\nFoetal blood sampling (FBS) is a procedure used during labour to confirm whether foetal hypoxia is present in the cases of a suspicious cardiotocograph. The procedure involves a small transvaginal incision in the foetal scalp to collect blood for analysis of acidaemia. It is contraindicated in certain situations such as prolonged decelerations on cardiotocography, maternal infections, and prematurity. The interpretation of FBS results involves either pH or lactate measurements, with results guiding further management which may involve informing a senior obstetrician and the neonatal team, discussing the situation with the woman and her birth companion(s), and potentially expediting the birth.\n\n# Definition\n\n\nFoetal blood sampling (FBS) is a technique used during labour to assess the presence or absence of foetal hypoxia. \n\nThe need for FBS arises from situations where foetal hypoxia is suspected, often indicated by abnormal foetal heart rate patterns on cardiotocography.\n\n\n# Signs and Symptoms\n\n\nClinical scenarios that may prompt the use of FBS include:\n\n- Suspicious cardiotocograph\n- Lack of progress in labour\n- Abnormal pH or lactate measurements in previous samples\n\n\n# Differential Diagnosis\n\n\nThe main differential diagnoses for the findings that prompt FBS include:\n\n- Normal labour variation: Characterised by occasional decelerations in the foetal heart rate with good recovery and no other signs of foetal distress.\n- Foetal distress: Characterised by persistent decelerations in the foetal heart rate, poor variability, or late decelerations.\n- Maternal hypotension: Characterised by sudden prolonged decelerations in the foetal heart rate, often with a rapid recovery once the mother's blood pressure is corrected.\n\n# Interpretation of FBS\n\nUse either pH or lactate when interpreting foetal blood sample results.\n\nUse the following classifications for foetal blood sample results:\n\npH:\n\n- normal: 7.25 or above\n- borderline: 7.21 to 7.24\n- abnormal: 7.20 or below\n\nOR\n\nLactate:\n\n- Normal: 4.1 mmol/l or below\n- Borderline: 4.2 to 4.8 mmol/l\n- Abnormal: 4.9 mmol/l or above\n\nInterpret foetal blood sample results taking into account:\n\n- Any previous pH or lactate measurement\n- Clinical features of the woman and baby, such as rate of progress in labour and cardiotocography\n\nIf the foetal blood sample result is abnormal:\n\n- Inform a senior obstetrician and the neonatal team\n- Talk to the woman and her birth companion(s) about what is happening and take her preferences into account and\n- Expedite the birth\n\nIf the foetal blood sample result is borderline and there are no accelerations in response to foetal scalp stimulation, consider taking a second foetal blood sample no more than 30 minutes later.\n\nIf the foetal blood sample result is normal and there are no accelerations in response to foetal scalp stimulation, consider taking a second foetal blood sample no more than 1 hour later.\n\n# References\n\n[NICE guidelines](https://www.nice.org.uk/guidance/cg190/chapter/recommendations#fetal-blood-sampling)\n\n\n", "files": null, "highlights": [], "id": "120", "pictures": [], "typeId": 2 }, "chapterId": 120, "demo": null, "entitlement": null, "id": "119", "name": "Interpretation of foetal blood sampling", "status": null, "topic": { "__typename": "Topic", "id": "38", "name": "Obstetrics", "typeId": 2 }, "topicId": 38, "totalCards": null, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 119, "conditions": [], "difficulty": 1, "dislikes": 3, "explanation": null, "highlights": [], "id": "6522", "isLikedByMe": 0, "learningPoint": "Prolonged fetal heart rate decelerations accompanied by acidosis suggest fetal hypoxia, requiring immediate delivery to avoid potential complications.", "likes": 4, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 37-year-old primigravida is established in the first stage of labour, and you notice some prolonged decelerations on the cardiotocograph. Foetal blood sampling is performed, and the results are as follows:\n\n\n||||\n|--------------|:-------:|------------------|\n|pH|7.14|7.35 - 7.45|\n|Lactate|5.3 mmol/L|0.6 - 1.4|\n\n\n\nWhat should you do?", "sbaAnswer": [ "a" ], "totalVotes": 5151, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "This is a reasonable differential diagnosis; however, as he has never suffered with this before, this would need to be a diagnosis of exclusion given the patient's age and comorbidities", "id": "32614", "label": "b", "name": "Ocular migraine", "picture": null, "votes": 19 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This would be a differential and is important to exclude; however, it is less common, and the history is more suggestive of retinal detachment. Retinal artery occlusion usually presents with dramatic visual loss within seconds of occlusion. It should be considered a form of stroke as it is often thromboembolic in origin. Therefore the risk factors are similar to other causes of stroke (smoking, heart disease, atrial fibrillation, diabetes, hypercholesterolaemia)", "id": "32615", "label": "c", "name": "Retinal artery occlusion", "picture": null, "votes": 707 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is the most prevalent degenerative condition of the retina and usually presents with night blindness followed by daytime peripheral and central visual loss. This does not fit with the acute clinical picture here", "id": "32617", "label": "e", "name": "Retinitis pigmentosa", "picture": null, "votes": 26 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This is a classic history suggestive of retinal detachment. Risk factors for exudative retinal detachment include hypertension, vasculitis and macular degeneration, whereas myopia is a cause for tractional detachment. Other causes of detachment may be traumatic in nature, allowing fluid to pass from the vitreous space into the subretinal space", "id": "32613", "label": "a", "name": "Retinal detachment", "picture": null, "votes": 4538 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "A cataract is an opacity of the lens of the eye and is usually a gradual age-related process. Presentation is usually with gradual blurring of the vision. Whilst diabetes is a risk factor for cataracts; this history is too acute", "id": "32616", "label": "d", "name": "Cataract", "picture": null, "votes": 28 } ], "comments": [ { "__typename": "QuestionComment", "comment": "I thought that retinal detachment typically caused progressive lateral vision loss, and vascular causes lead to top-down vision loss? confusing. ", "createdAt": 1679574442, "dislikes": 1, "id": "20636", "isLikedByMe": 0, "likes": 1, "parentId": null, "questionId": 6523, "replies": [ { "__typename": "QuestionComment", "comment": "same", "createdAt": 1686772393, "dislikes": 0, "id": "28774", "isLikedByMe": 0, "likes": 0, "parentId": 20636, "questionId": 6523, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Poisoning Vaccine", "id": 24584 } }, { "__typename": "QuestionComment", "comment": "yeah top down vision as in a curtain coming down", "createdAt": 1713745901, "dislikes": 0, "id": "47551", "isLikedByMe": 0, "likes": 0, "parentId": 20636, "questionId": 6523, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Retrograde Recessive", "id": 29991 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Lateral Endoscope", "id": 11948 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nRetinal detachment is a medical condition referring to the separation of the retina from the retinal pigment epithelium (RPE), commonly caused by trauma. Characterized by symptoms such as floaters, photopsia, reduced visual acuity and visual field impairment, this condition can cause irreparable sight loss if the detachment progresses to the macula. Diagnosis can be confirmed through a variety of examinations and tests, such as fundoscopy, ultrasound or optical coherence tomography. Management strategies include surgical and non-surgical treatments like laser therapy, cryotherapy, vitrectomy, scleral buckling and pneumatic retinopexy.\n\n# Definition\n\nRetinal detachment is a medical condition that refers to a separation of the retina from the retinal pigment epithelium (RPE). There are different types of retinal detachment, but the most common is rhegmatogenous retinal detachment, commonly caused by trauma.\n\n# Epidemiology\n\nEpidemiological data on retinal detachment varies, but it is generally agreed that the condition is more common in individuals over the age of 40 and in those with a history of severe myopia or previous eye surgery.\n\n# Aetiology \n\nRetinal detachment can occur due to a variety of causes, including:\n\n- Trauma, which can create tears or holes in the retina\n- Severe myopia, which can thin the retina and make it more prone to tears\n- Previous eye surgery, particularly cataract surgery\n- Certain diseases, such as diabetes or sickle cell disease\n- Age-related changes in the vitreous, which can pull the retina away from the back of the eye\n\n# Signs and Symptoms\n\nPatients with retinal detachment may present with the following symptoms:\n\n- Floaters\n- Photopsia (flashes of light)\n- Progressive and rapidly reduced visual acuity and visual field loss\n- Painlessly in most cases\n\nThe danger is that if the detachment progresses to the macula, sight may be irreparably lost.\n\n# Differential Diagnosis\n\nThe main differentials for retinal detachment include:\n\n- Posterior vitreous detachment: Characterized by floaters, light flashes, and a \"\"cobweb\"\" effect in vision\n- Age-related macular degeneration: Symptoms include blurred or reduced central vision, distorted vision, and difficulty reading or recognizing faces\n- Vitreous hemorrhage: Presents with sudden loss of vision, floaters or shadows in the field of vision\n\n# Investigations \n\nTo diagnose retinal detachment, a variety of examinations and tests may be used, such as:\n\n- Fundoscopy: To visually inspect the back of the eye \n\t- One of the key findings to note in retinal detachments is if the macula is attached **(macula-on)** or macula-detached **(macula-off).** It is the status of the macula that defines the urgency with which surgical repair should be undertaken\n- Ultrasound: To get a detailed image of the eye\n- Optical coherence tomography: To provide cross-sectional images of the retina\n\n# Management\n\nThere are various surgical and non-surgical treatments available for retinal detachment, depending on the extent of the condition. If the macula remains attached, there should be greater urgency to act faster as any vision-loss may still be salavagable, with poorer outcomes for macula-off RD. These include:\n\n- Laser therapy or cryotherapy: To seal retinal tears or holes\n- Vitrectomy: To remove the vitreous and replace it with a gas bubble or silicone oil\n- Scleral buckling: To push the sclera toward the retinal tear\n- Pneumatic retinopexy: To push the retina back into place using a gas bubble.", "files": null, "highlights": [], "id": "806", "pictures": [], "typeId": 2 }, "chapterId": 806, "demo": null, "entitlement": null, "id": "1004", "name": "Retinal detachment", "status": null, "topic": { "__typename": "Topic", "id": "16", "name": "Ophthalmology", "typeId": 2 }, "topicId": 16, "totalCards": 5, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 1004, "conditions": [], "difficulty": 1, "dislikes": 8, "explanation": null, "highlights": [], "id": "6523", "isLikedByMe": 0, "learningPoint": "Painless visual loss described as a curtain falling is characteristic of retinal detachment, often associated with myopia and diabetic retinopathy.", "likes": 3, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 58-year-old male presents to the Emergency Department with painless visual loss that he describes as a curtain coming down over his vision. He has never had this happen before. His only past medical history is well-controlled diabetes, and he is short-sighted.\n\nWhat is the most likely diagnosis?", "sbaAnswer": [ "a" ], "totalVotes": 5318, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient has untreated hyperthyroidism and has symptoms suggestive of thyroid eye disease that has gone untreated, and her symptoms suggest optic nerve compression. It is important to treat her underlying thyroid disease, but as she has developed visual disturbance, surgical decompression should be considered as part of the acute treatment here", "id": "32618", "label": "a", "name": "Surgical decompression of the optic nerve", "picture": null, "votes": 2269 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This patient has a history suggestive of thyroid eye disease and compression of the optic nerve; therefore, referring to an optician would not benefit her acute management", "id": "32620", "label": "c", "name": "Referral to an optician", "picture": null, "votes": 965 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Eye taping at night is beneficial if unable to close the eyelid to help prevent drying and abrasions whilst sleeping. Some patients with severe thyroid eye disease and very protuberant eyes may need assistance with lid closure; however, this intervention would not address the patient's visual loss", "id": "32621", "label": "d", "name": "Eye taping at night", "picture": null, "votes": 1081 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Whilst patients with thyroid eye disease are at risk of dry eyes and developing conjunctivitis and abrasions; there is no evidence in this history of active infection that would require topical treatment", "id": "32619", "label": "b", "name": "Topical chloramphenicol", "picture": null, "votes": 440 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Laser eye surgery can correct refractive errors in vision; however, that is not the diagnosis here", "id": "32622", "label": "e", "name": "Laser eye surgery", "picture": null, "votes": 169 } ], "comments": [ { "__typename": "QuestionComment", "comment": "So the GP can sUrGiCalLy dEcoMpReSs the optic nerve???????", "createdAt": 1686586141, "dislikes": 1, "id": "28580", "isLikedByMe": 0, "likes": 9, "parentId": null, "questionId": 6524, "replies": [ { "__typename": "QuestionComment", "comment": "qs doen't imply this, it simply asks for the intervention likely needed. not the next best step", "createdAt": 1709054417, "dislikes": 1, "id": "43024", "isLikedByMe": 0, "likes": 0, "parentId": 28580, "questionId": 6524, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Ale", "id": 20565 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Embolism Transplant", "id": 14284 } }, { "__typename": "QuestionComment", "comment": "Poor answers lol ", "createdAt": 1709126956, "dislikes": 0, "id": "43124", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6524, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Kinase Hallux", "id": 541 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nThyroid Eye Disease, also known as Graves' Ophthalmopathy, is a complex autoimmune condition closely associated with hyperthyroidism. It manifests with a range of ocular symptoms, including eyelid retraction, proptosis, double vision, and ocular discomfort. The disease primarily affects the orbital tissues and extraocular muscles due to an immune response targeting the thyroid gland and surrounding structures. Diagnosis relies on clinical evaluation, imaging, and thyroid function tests. Management encompasses medical therapy, supportive care, and in severe cases, surgical interventions to address disfiguring or vision-threatening complications. \n\n# Definition\n\nThyroid eye disease (TED) is a complication of Grave's disease, which is an autoimmune hyperthyroidism. An inflammatory process results in swelling of the extraocular muscles and orbital fat, which leads to multiple ocular complications.\n\n# Pathophysiology\n\nAn idiopathic autoimmune inflammatory process is responsible for TED, the exact mechanism of which remains unclear. Evidence suggests that an autoimmune reaction to TSH receptors results in lymphocyte infiltration into orbital tissues, which initiates an inflammatory process.\n\nThe **inflammatory phase** of TED typically lasts 6–24 months and results in the swelling of extraocular muscles and orbital fat – it is only during this initial inflammatory phase that TED is responsive to medical management.\n\nAfter the inflammatory phase, there is an **inactive fibrotic phase**, which is nonresponsive to medical therapy.\n\nHyperthyroidism and TED usually present within 18 months of each other, but each can be present in isolation.\n\n# Epidemiology\n\n- Roughly half of patients with Grave's disease develop TED\n- 80% of cases of TED are due to Grave's disease\n\n# Risk factors\n\n- **Smoking** – the most important risk factor for development and increased severity of TED in patients with Grave's disease, so it is important to counsel patients on the importance of smoking cessation\n- Family history of Grave's disease and other autoimmune disease\n- Female sex\n- Poor thyroid control\n\n\n# Signs and Symptoms\n\n- Ocular pain – often worse on movement\n- Dry, red eyes\n- 'Bulging eyes'\n- Painful eyelids\n- Proptosis/exophthalmos\n- Lid retraction and lid lag\n- Chemosis\n- Orbital fat prolapse\n- Exposure keratopathy\n\n[lightgallery] \n\n\n\n# Management \n\nEarly medical management of TED has the potential to stabilise, slow or even reverse the disease process. Good control of thyrotoxicosis is essential and other medical therapies, such as steroids or other immunosuppressants, may be used.\n\nIn sight-threatening TED, urgent surgical orbital decompression may be required, followed by intravenous corticosteroids.\n\nConservative therapy consists of artificial tears, ointments and prisms to help with the symptoms of dry eye and diplopia.\n\n# Complications\n\nSight-threatening complications include:\n\n- **Exposure keratopathy** – where corneal damage and infection occur as the patient is unable to close their eyes\n\n- **Compressive optic neuropathy** – occurs when the retro-orbital swelling begins to compress on the optic nerve \n - suspect this when signs of optic nerve involvement occur – reduced visual fields, reduced colour vision, reduced visual acuity, relative afferent pupillary defect\n\n- **Diplopia** – due to fibrosis of the extraocular muscles limiting gaze in various directions\n\n# References\n\nDenniston AK, Murray PI. Oxford Handbook of Ophthalmology. Fourth Edition. Oxford University Press. 2018.\n\n[Click here for an in-depth review of TED on the Patient UK website](https://patient.info/doctor/thyroid-eye-disease-pro)\n", "files": null, "highlights": [], "id": "973", "pictures": [ { "__typename": "Picture", "caption": "A typical appearance of exophthalmos seen in a patient with grave's disease.", "createdAt": 1665036193, "id": "757", "index": 0, "name": "Thyroid eye disease.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/k3vq2u0b1665036171704.jpg", "path256": "images/k3vq2u0b1665036171704_256.jpg", "path512": "images/k3vq2u0b1665036171704_512.jpg", "thumbhash": "pmkODYQERmeJhXh6ead4hTOAiwiI", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 973, "demo": null, "entitlement": null, "id": "1031", "name": "Thyroid eye disease", "status": null, "topic": { "__typename": "Topic", "id": "16", "name": "Ophthalmology", "typeId": 2 }, "topicId": 16, "totalCards": 8, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "1031", "name": "Thyroid eye disease" } ], "demo": false, "description": null, "duration": 3216.34, "endTime": null, "files": null, "id": "633", "live": false, "museId": "X5YwJBt", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/endocrinology.png", "title": "Quesmed Tutorial: Thyroid Disease", "userViewed": false, "views": 242, "viewsToday": 20 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "1031", "name": "Thyroid eye disease" } ], "demo": false, "description": null, "duration": 359, "endTime": null, "files": null, "id": "635", "live": false, "museId": "VczUsdc", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/endocrinology.png", "title": "Hyperthyroidism 3", "userViewed": false, "views": 29, "viewsToday": 3 } ] }, "conceptId": 1031, "conditions": [], "difficulty": 2, "dislikes": 34, "explanation": null, "highlights": [], "id": "6524", "isLikedByMe": 0, "learningPoint": "Thyroid eye disease can cause optic nerve compression, which may lead to vision impairment; surgical decompression is often required when visual disturbances or threat to vision become significant.", "likes": 6, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 28-year-old female presents to her GP complaining that she struggles to read and has discomfort with eye movement. She has never had issues with her vision before. On examination, she is very slim with protuberant eyes and is flushed despite it being cold in the practice. She has significantly reduced visual acuity. She has no past medical history of note.\n\nWhat intervention is likely to be indicated?", "sbaAnswer": [ "a" ], "totalVotes": 4924, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "A foreign body may cause irritation and lead to inflammation of the eye; however, this history does not suggest trauma to the eye", "id": "32626", "label": "d", "name": "Foreign body", "picture": null, "votes": 9 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Patients with acute closed angle glaucoma usually present with nausea and vomiting. However, they rarely have visual complaints, and only about 25% will have a headache and a painful red eye", "id": "32627", "label": "e", "name": "Acute closed angle glaucoma", "picture": null, "votes": 594 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Scleritis is a generalised inflammation of the sclera itself and is strongly associated with systemic disease, commonly vasculitis and rheumatoid arthritis. Ocular movements are painful, and often headache and photophobia are present. As the vessels of the sclera are deeper, they will not blanch on probing. Management is guided by underlying cause and ranges from steroids and topical NSAIDs to immunosuppressive therapy such as cyclophosphamide and rituximab", "id": "32623", "label": "a", "name": "Scleritis", "picture": null, "votes": 4222 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Episcleritis is inflammation below the conjunctiva and often associated with an inflammatory nodule. As these vessels are more superficial, they will move and blanch on probing with a phenylephrine soaked cotton bud", "id": "32624", "label": "b", "name": "Episcleritis", "picture": null, "votes": 196 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is harmless bleeding of blood behind the conjunctiva and is often associated with the use of anticoagulants. It is usually more alarming than anything else and would not normally cause pain and therefore is not the most likely diagnosis here", "id": "32625", "label": "c", "name": "Subconjunctival haemorrhage", "picture": null, "votes": 126 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nScleritis and episcleritis are ocular conditions characterized by inflammation of the sclera and the episclera respectively. Both conditions present with red eye. However, scleritis is associated with severe pain, pain on ocular movement and nonblanching vessels, and may be associated with systemic illnesses such as rheumatoid arthritis. Episcleritis, on the other hand, has milder symptoms and often resolves without intervention. Key investigations for scleritis include urine dipstick, FBC, CRP, U&Es, LFT and autoimmune serology. Management strategies include NSAIDs for mild scleritis and corticosteroids for severe or necrotising scleritis.\n\n# Definition\n\nScleritis is a severe inflammation of the sclera, and episcleritis is an inflammation of the episclera, the layer underneath the conjunctiva.\n\n\n# Aetiology\n\nScleritis may be associated with systemic illnesses such as rheumatoid arthritis or granulomatosis with polyangiitis.\n\n# Signs and Symptoms\n\n[lightgallery]\n[lightgallery1]\n\n## Scleritis\n\n- Red eye\n- Severe pain in the orbit\n- Pain on eye movement\n- Bluish tinge to the white of the eye in severe or necrotising scleritis\n- Systemic symptoms in ~50% of patients\n\n## Episcleritis\n\n- Sectoral redness\n- Tenderness over the inflamed area\n- Milder pain compared to scleritis\n- Episcleral vessels move or blanch when pressed with a cotton bud\n\n\n\n# Investigations\n\n## For Scleritis:\n\n- Urine dipstick to identify renal disease\n- FBC, CRP, U&Es, LFT to identify anaemia of chronic disease, neutrophilia, renal function\n- Autoimmune serology\n- Phenylephrine eye drops - these blanch the conjunctival and episcleral vessels but not the scleral vessels. So if there is no blanching this is suggestive of scleritis\n\n# Management\n\nManagement of episcleritis is mostly supportive with the majority of cases self-resolving within weeks. Artifical tears may be used for symptomatic relief.\n\n## For Scleritis:\n\n- NSAIDs such as fluriprofen PO 100 mg TDS for mild cases\n- Corticosteroids such as oral prednisolone or pulsed IV methylprednisolone for severe or necrotising cases\n- Steroid-sparing therapies for long-term treatment\n\n# Prognosis\n\nLess than 5% of patients lose useful vision long-term; however, vision deteriorates in 25% of patients in the years following scleritis and some patients develop cataracts.\n\n# References\n\n- [Scleritis](https://eyewiki.aao.org/Scleritis)\n- [EpiScleritis](https://eyewiki.aao.org/Episcleritis)", "files": null, "highlights": [], "id": "948", "pictures": [ { "__typename": "Picture", "caption": "The typical appearance of scleritis.", "createdAt": 1665036184, "id": "707", "index": 0, "name": "Scleritis.png", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/vt2js7jf1665036171708.jpg", "path256": "images/vt2js7jf1665036171708_256.jpg", "path512": "images/vt2js7jf1665036171708_512.jpg", "thumbhash": "VXoKLYgBOohuhIaXd3h4hwJqNHA2", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "The typical appearance of episcleritis.", "createdAt": 1665036194, "id": "809", "index": 1, "name": "Episcleritis.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/l5y41r4b1665036171708.jpg", "path256": "images/l5y41r4b1665036171708_256.jpg", "path512": "images/l5y41r4b1665036171708_512.jpg", "thumbhash": "mTgOFYYAh5iZhIiFeXiIiGB0B2Rn", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 948, "demo": null, "entitlement": null, "id": "997", "name": "Episcleritis and Scleritis", "status": null, "topic": { "__typename": "Topic", "id": "16", "name": "Ophthalmology", "typeId": 2 }, "topicId": 16, "totalCards": 7, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 997, "conditions": [], "difficulty": 2, "dislikes": 3, "explanation": null, "highlights": [], "id": "6525", "isLikedByMe": 0, "learningPoint": "Scleritis presents with severe eye pain, redness, and is often associated with systemic conditions like rheumatoid arthritis.", "likes": 7, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 56-year-old man presents to the Emergency Department with headache, photophobia and a very painful, red eye that has gradually worsened over the past two days. He reports no noticeable discharge from the eye. His past medical history includes diabetes, high cholesterol and rheumatoid arthritis. On examination, the entire sclera is bright red, and there is discomfort on eye movements. On probing with a phenylephrine soaked cotton bud, the redness does not change.\n\nWhat is the most likely diagnosis?", "sbaAnswer": [ "a" ], "totalVotes": 5147, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient remains unwell despite broad-spectrum antibiotics. As a prosthesis is involved, he will likely need a surgical washout of the joint in theatres and may even need removal of the prosthesis to control his sepsis. Samples should be taken intraoperatively for microbiology. Aspiration of a septic joint where there is a prosthesis should never be undertaken outside of the sterile theatre environment, as by performing the aspiration, you run the risk of introducing infection", "id": "32633", "label": "a", "name": "Surgical washout", "picture": null, "votes": 3687 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Whilst it is important to obtain samples for microbiology to determine whether the knee is the source of infection and help guide antimicrobial therapy in a joint containing a prosthesis, this is best undertaken in the theatre environment. In suspected septic joints where there is no prosthesis involved, it would be reasonable to undertake aspiration in an aseptic manner in the ward or the Emergency Department prior to starting antibiotics", "id": "32634", "label": "b", "name": "Aspiration of the joint on the ward", "picture": null, "votes": 1404 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "It may be worth speaking to the microbiologists and changing the antibiotics to a different combination; however, it would be difficult for them to provide advice without a causative organism or confirmed diagnosis. As this patient has been on broad-spectrum antibiotics for 48 hours and is not improving, it is important to get source control of his sepsis, and this is best done by a washout in theatres", "id": "32635", "label": "c", "name": "Change antibiotics", "picture": null, "votes": 118 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "A PCA may be of benefit in helping this patient with his pain; however, it would not help treat the underlying cause of his illness and therefore is not the next step in the management of his sepsis", "id": "32636", "label": "d", "name": "Start a patient controlled analgesia (PCA)", "picture": null, "votes": 68 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "A CT of the knee would be beneficial if you were trying to determine whether there was osteomyelitis or bone involvement which would be a more chronic infection. Also, as this patient has had a recent prosthesis made of metal, there would likely be a significant artefact from this. So imaging would unlikely move you forward in management", "id": "32637", "label": "e", "name": "CT of the knee", "picture": null, "votes": 55 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Would you not give analgesia first then do the washout straight after?", "createdAt": 1681993100, "dislikes": 0, "id": "22269", "isLikedByMe": 0, "likes": 3, "parentId": null, "questionId": 6527, "replies": [ { "__typename": "QuestionComment", "comment": "If you're taking them to be anaesthetised you probably wouldn't bother with analgesia before ", "createdAt": 1683400417, "dislikes": 0, "id": "23598", "isLikedByMe": 0, "likes": 1, "parentId": 22269, "questionId": 6527, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "lil' aneurysm", "id": 21164 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Monoclonal Gas", "id": 31305 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nSeptic arthritis is an infection of the joint characterized by acute inflammation and swelling. It is caused by a bacterial or viral pathogen that infects the synovial fluid. The most commonly implicated organism is Staphylococcus aureus. Noteworthy clinical signs include a tender, swollen joint with reduced mobility, often accompanied by systemic illness. Key investigations include joint aspiration for Microscopy Culture and Sensitivity, along with blood tests showing increased white blood cell count and elevated ESR/CRP. Management typically involves IV antibiotics, joint washout under general anaesthesia, and physiotherapy once the acute infection has resolved.\n\n# Definition\n\nSeptic arthritis is an infection of the joint, specifically the synovial fluid. It is typically caused by a bacterial or viral pathogen and necessitates prompt medical intervention due to the high risk of joint damage and other severe complications.\n\n# Epidemiology\n\nSeptic arthritis has an annual incidence of 4-10 cases per 100,000 patients in Western Europe. It can affect individuals of any age, though certain populations are at a higher risk due to underlying conditions.\n\n# Aetiology\n\nThe most prevalent organism implicated in septic arthritis is Staphylococcus aureus. Other responsible organisms include:\n\n- Gonococcus: primarily in sexually active individuals\n- Streptococcus spp.\n- Gram-negative bacilli\n\nRisk factors contributing to septic arthritis include:\n\n- Pre-existing joint diseases such as rheumatoid arthritis\n- Chronic kidney disease\n- Immunosuppressive states\n- Presence of prosthetic joints\n\n# Signs and Symptoms\n\nThe clinical presentation of septic arthritis usually involves:\n\n- Acute onset of tender, swollen joint\n- Reduced range of joint movement\n- Systemic symptoms such as fever, malaise, or chills\n\n# Differential Diagnosis\n\nDifferential diagnoses for septic arthritis include:\n\n- Gout and pseudogout: characterized by intense joint pain, redness, and swelling, often in the big toe or knee.\n- Osteoarthritis: presents with joint pain, stiffness, and sometimes swelling, generally improving with movement.\n- Rheumatoid arthritis: marked by joint pain, swelling, and stiffness, often symmetrical and worse after rest.\n- Lyme disease: may show erythema migrans rash, flu-like symptoms, and possibly migratory joint pains.\n\n# Investigations\n\nDiagnostic investigations for septic arthritis include:\n\n- Joint aspiration for Microscopy, Culture, and Sensitivity: The aspirate usually appears turbid and yellow, resembling pus.\n- Blood tests: elevated white cell count, high ESR/CRP\n- Blood cultures: to identify causative organisms\n- Imaging: X-ray of the joint may be performed to evaluate for osteomyelitis or other complications.\n\n# Management\n\nThe treatment of septic arthritis involves:\n\n- IV antibiotics guided by local antibiograms and susceptibilities\n- Consideration of joint washout under general anaesthesia to remove infected material\n- Physiotherapy following the resolution of acute infection to restore joint function\n\nComplications of septic arthritis can include:\n\n- Osteomyelitis: infection of the bone\n- Chronic arthritis: persistent joint inflammation\n- Ankylosis: joint fusion resulting in immobility\n\n# References\n\n[Click here for the BNF Treatment Summary for Musculoskeletal infections](https://bnf.nice.org.uk/treatment-summary/musculoskeletal-system-infections-antibacterial-therapy.html)\n\n[Click here for the BMJ Best Practice Summary of Septic Arthritis](https://bestpractice.bmj.com/topics/en-us/486)", "files": null, "highlights": [], "id": "438", "pictures": [], "typeId": 2 }, "chapterId": 438, "demo": null, "entitlement": null, "id": "2658", "name": "Septic Arthritis", "status": null, "topic": { "__typename": "Topic", "id": "37", "name": "Orthopaedics", "typeId": 2 }, "topicId": 37, "totalCards": 21, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 2658, "conditions": [], "difficulty": 2, "dislikes": 3, "explanation": null, "highlights": [], "id": "6527", "isLikedByMe": 0, "learningPoint": "In cases of septic arthritis involving a prosthesis, surgical washout is essential if symptoms persist despite broad-spectrum antibiotics.", "likes": 7, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 63-year-old male has been admitted to hospital with sepsis following a recent total knee replacement. His knee is red, hot and swollen, and so he is started on broad-spectrum antibiotics. After 48 hours, he is still pyrexial, in significant pain, and his inflammatory markers continue to rise.\n\nWhat is the next step in management?", "sbaAnswer": [ "a" ], "totalVotes": 5332, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "This would indicate hypoxaemia, commonly seen respiratory failure in conditions such as chronic obstructive pulmonary disease (COPD). Hypoxaemia is not a common finding in DKA", "id": "32639", "label": "b", "name": "A PaO2 of 7.1kPa", "picture": null, "votes": 57 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Reduced conscious level in a young patient with high peripheral blood sugars should make you think of the first presentation of type 1 diabetes. This vignette is a classic example of a patient in diabetic ketoacidosis where she cannot utilise glucose for her energy needs and has therefore gone into a ketotic state. You would therefore expect her blood gas to show a metabolic acidosis. She has a high respiratory rate as she is trying to use hyperventilation to compensate for her acidosis by expelling her carbon dioxide", "id": "32638", "label": "a", "name": "A pH of 7.20", "picture": null, "votes": 4492 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This blood gas demonstrates an alkalosis which may be caused by loss of electrolytes (commonly potassium) as seen in severe vomiting and diarrhoea. DKA cause an acidosis, demonstrated by a low pH", "id": "32641", "label": "d", "name": "A pH of 7.49", "picture": null, "votes": 418 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This patient has DKA, and you would therefore expect the blood gas to show hyperglycaemia. Patients can rarely have euglycaemic diabetic ketoacidosis but this is often associated with certain medications such as SGLT2 inhibitors", "id": "32642", "label": "e", "name": "A glucose of 10.4mmol/L", "picture": null, "votes": 99 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This blood gas shows a hypercapnoea. This is common in acute respiratory presentations such as an acute asthma attack. In DKA the carbon dioxide tends to be low due to compensatory hyperventilation for the acidosis", "id": "32640", "label": "c", "name": "A PaCO2 5.4kPa", "picture": null, "votes": 84 } ], "comments": [ { "__typename": "QuestionComment", "comment": "I thought increased respiratory rate points towards hyperventilation --> respiratory alkalosis and hence a high pH (7.49)?", "createdAt": 1682508967, "dislikes": 0, "id": "22699", "isLikedByMe": 0, "likes": 5, "parentId": null, "questionId": 6528, "replies": [ { "__typename": "QuestionComment", "comment": "I did the same thing ", "createdAt": 1683138398, "dislikes": 0, "id": "23322", "isLikedByMe": 0, "likes": 0, "parentId": 22699, "questionId": 6528, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "JAK Suture", "id": 20842 } }, { "__typename": "QuestionComment", "comment": "The raised RR is to compensate for the metabolic acidosis but it will only be partial.", "createdAt": 1685100549, "dislikes": 0, "id": "26347", "isLikedByMe": 0, "likes": 0, "parentId": 22699, "questionId": 6528, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Rhinoplasty Contusion", "id": 16821 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Rhinoplasty Recessive", "id": 10885 } }, { "__typename": "QuestionComment", "comment": "I need to go back to primary school at this rate", "createdAt": 1710778442, "dislikes": 0, "id": "44909", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6528, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Serpiginous Defibrillator", "id": 8850 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n \n\nDiabetic ketoacidosis (DKA) is a serious complication often associated with type 1 diabetes, characterised by hyperglycaemia, ketonaemia, and acidosis. Key signs and symptoms include fruity-smelling breath, vomiting, dehydration, abdominal pain, hyperventilation, and altered mental status. Investigations include blood glucose and ketone measurements, blood gas analysis, urea and electrolytes, and possibly blood cultures if infection is suspected. Management strategies largely depend on the patient's condition, including hydration and insulin administration via various routes and in various volumes based on severity. The major complication is cerebral oedema, a rare but potentially fatal condition that might be caused by rapid correction of dehydration with IV fluids.\n \n\n# Definition\n \n\nDiabetic ketoacidosis (DKA) is a severe and life-threatening medical complication characterised by hyperglycaemia, acidosis and ketonaemia.\n\nIt is defined by acidosis (bicarbonate < 15 mmol/l or pH <7.3) and ketones >3.0 mmol/L. \n \n\n# Epidemiology\n \n\nDKA is most commonly seen in individuals with type 1 diabetes. However, it can occur in those with type 2 diabetes under extreme stress or illness. The condition can be the first presentation of diabetes, especially type 1 diabetes in children and young adults.\n\nIt is more common in children under 5. \n \n\n# Aetiology\n \n\nDKA can be precipitated by several factors, including infection, dehydration, stress, burns, fasting, or untreated type 1 diabetes. It is important to note that fever is not a typical part of DKA presentation. A raised temperature could indicate an underlying infection that may have triggered the DKA.\n\nRisk factors include:\n\n- Previous episodes of DKA \n- Peripubertal and adolescent girls \n- Comorbidities including psychiatric disorders\n- Difficult home life\n- Insulin pump therapy \n\n\n# Classification\n\n- Mild: pH 7.1-7.29 or bicarbonate < 15 mmol/L. Dehydration 5%\n- Moderate: pH 7.1-7.19 or bicarbonate < 10 mmol/L. Dehydration 5%\n- Severe: pH <7.1 or bicarbonate < 5 mmol/L\n \n\n# Signs and Symptoms\n \n\nPatients with DKA may present with:\n \n\n - Fruity-smelling breath (due to the presence of acetone)\n - Vomiting\n - Dehydration secondary to polydipsia and polyuria \n - Abdominal pain\n - Deep, sighing respiration (Kussmaul respiration)\n - Signs of hypovolaemic shock\n - Altered mental status, including drowsiness or coma\n \n\n# Differential Diagnosis\n \n\nThe main differential diagnoses for DKA in children include:\n \n - **Lactic Acidosis**: This may present with rapid breathing, abdominal pain, and altered mental status. The patient may have a history of severe illness or sepsis, hepatic failure or metformin use.\n - **Starvation Ketosis**: This usually presents with weight loss, nausea, and clear mental status. The condition is mild, with low-level ketonaemia.\n - **Inborn errors of metabolism**: Tend to present earlier in life with metabolic disturbances or failure to thrive. \n - **Sepsis**: The child will be generally unwell, with a high or low temperature, hypotension and tachycardia. \n \n\n# Investigations\n \n\nDiagnosis of DKA involves assessment of clinical features along with:\n \n\n - Blood glucose (>11.1mmol/L)\n - Blood ketones (>3mmol/L)\n - Urea and electrolytes\n - Blood gas analysis\n - Urinary glucose and ketones\n - Blood cultures (if evidence of infection)\n - Cardiac monitoring/ECG (for any ischaemic changes or changes secondary to hypokalaemia)\n \n\nNote that hyperglycaemia may not always be present in DKA.\n \n\n# Management\n \n\nManagement of DKA should be based on the A to E approach followed by the following treatments: \n\n - IV fluids (initial bolus of 10ml/kg 0.9% NaCl, even if the patient is shocked) given over 15 minutes.\n - Repeat as needed to restore circulation\n - At 40 ml/kg then discuss with a senior for consideration for inotropes \n - Insulin infusion at 0.1 units/kg/hour 1 hour after starting IV fluids\n\n\nFluids:\n\n- Further fluids, following initial boluses should contain 40 mmol/l potassium chloride to protect against hypokalaemia. \n- Total fluid required = deficit + maintenance\n- Hourly rate = [(Deficit - initial bolus) / 48 hours ] + maintenance per hour \n- Deficit \n - A 5% fluid deficit is assumed for children with mild or moderate DKA\n - A 10% fluid deficit is assumed for children with severe DKA\n - Deficit should be replaced over 48 hours alongside maintenance fluids \n- Maintenance \n - Calculated by Holliday-Segar formula: 100 ml/kg/day for the first 10 kg, 50 ml/kg/day for the next 10 kg, and 20 ml/kg/day for each additional kg over 20 kgs. \n \nImportant points to consider: \n\n- Monitoring should include hourly blood glucose and ketones, neurological observations and fluid balance. \n- Investigations should be done to determine the cause of the DKA. \n- Many patients will require HDU-level care. \n- Intravenous insulin infusion should not be stopped until 1 hour after subcutaneous insulin has been given.\n- Long-acting insulin should continue to be given.\n\n\n# Resolving DKA\n\nIVF can be stopped once ketosis is resolving and oral fluids are tolerated without nausea or vomiting. \n\nSubcutaneous insulin can be started once ketosis is resolving and should be started at least 30 minutes before stopping intravenous insulin. \n\nDischarge can be considered once a child is eating and drinking, and stabilised on their subcutaneous insulin regime. \n \n\n# Complications\n\n\nImportant complications to monitor for include:\n\n- Cerebral oedema:\n - Can occur several hours after the onset of DKA due to rapid correction of dehydration with IV fluids. \n - Due to the potential risk, fluid deficit correction is recommended to be performed slowly, over 48 hours. \n - Though rare, this complication is fatal in 1 in 4 children. \n - Risk factors include younger age and longer duration of symptoms. \n - Management includes hypertonic (2.7%) sodium chloride and restriction of IV fluids. \n- Hypokalaemia \n- Aspiration pneumonia \n- Venous thromboembolism \n - Thromboembolic prophylaxis is not recommended in children < 16 years \n- Inadequate resuscitation \n- Hypoglycaemia\n - Blood glucose levels can fall rapidly with intravenous insulin, and if blood glucose falls below 14 mmol/L, IV fluids should include glucose. \n\n# Prognosis\n\nEarly detection and treatment results in good outcomes for patients with DKA, with many children discharged within a few days of DKA. Poorer outcomes are associated with delays in treatment and the development of cerebral oedema. \n\n\n# NICE Guidelines\n\n[BNFC Treatment Summaries: Diabetic hyperglycaemic emergencies](https://bnfc.nice.org.uk/treatment-summaries/diabetic-hyperglycaemic-emergencies/) \n \n\n# References\n \n[BSPED Guidelines for Management of DKA in Children](https://www.bsped.org.uk/media/1959/dka-guidelines.pdf)\n \n[Patient Info: Childhood ketoacidosis](https://patient.info/doctor/childhood-ketoacidosis#ref-2)", "files": null, "highlights": [], "id": "670", "pictures": [], "typeId": 2 }, "chapterId": 670, "demo": null, "entitlement": null, "id": "2646", "name": "Emergency Management of Diabetic Ketoacidosis", "status": null, "topic": { "__typename": "Topic", "id": "29", "name": "Paediatrics", "typeId": 2 }, "topicId": 29, "totalCards": null, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 2646, "conditions": [], "difficulty": 1, "dislikes": 2, "explanation": null, "highlights": [], "id": "6528", "isLikedByMe": 0, "learningPoint": "In diabetic ketoacidosis (DKA), an arterial blood gas (ABG) typically shows metabolic acidosis with a low pH (usually <7.35), decreased bicarbonate (HCO3-) levels, and an anion gap that is often elevated due to the accumulation of ketoacids.", "likes": 6, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 14-year-old female is brought into the Emergency Department by her parents due to a reduced consciousness level. On examination, she is thin and appears dehydrated and drowsy. Her observations are as follows:\n\n\n - Temperature 36.5°C\n - Blood pressure 110/65 mmHg\n - Heart rate 120 bpm\n - Respiratory rate 32 bpm\n - Oxygen saturations 99% (on air)\n - Peripheral blood glucose 25mmol/L (normal <6.1 mmol/L)\n\n\nWhich of the following findings are you most likely to find on an arterial blood gas?", "sbaAnswer": [ "a" ], "totalVotes": 5150, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Levetiracetam is an antiepileptic medication that can be used in the treatment of childhood epilepsy. However, this child has only had one self-limiting episode and does not yet have a confirmed diagnosis of epilepsy; therefore, starting an antiepileptic medication is not indicated here", "id": "32644", "label": "b", "name": "Start levetiracetam", "picture": null, "votes": 41 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Paracetamol is one of the mainstays of treatment in febrile convulsions. This child is well, and no fever is reported; therefore, paracetamol is not currently indicated", "id": "32647", "label": "e", "name": "Administer paracetamol", "picture": null, "votes": 109 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This child may have had a first presentation of epilepsy and therefore needs to be followed up in a specialist clinic such as a first fit clinic", "id": "32646", "label": "d", "name": "Reassure and discharge", "picture": null, "votes": 565 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This child may well be developing epilepsy and, therefore, should be followed up in a first fit clinic. The parents should be educated on what do to if it happens again and advised on when to present to the hospital (if seizures ongoing for an extended period of time or if having multiple seizures in quick succession). They should also be advised to try to record any further episodes", "id": "32643", "label": "a", "name": "Refer to first fit clinic", "picture": null, "votes": 4369 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Buccal midazolam is useful in the management of acute seizure and status epilepticus. This child is currently well and has recovered from the episode, so the use of benzodiazepines is not indicated here", "id": "32645", "label": "c", "name": "Administer buccal midazolam", "picture": null, "votes": 79 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Including that the child has been recently well without preceding viral illness would make the history a touch more complete for us", "createdAt": 1681922156, "dislikes": 1, "id": "22221", "isLikedByMe": 0, "likes": 7, "parentId": null, "questionId": 6529, "replies": [ { "__typename": "QuestionComment", "comment": "I agree, but here's what I found online: Most febrile seizures occur between 6 months and 3 years of age with the peak incidence at 18 months. Approximately 6–15% occur after 4 years, and onset after 6 years is unusual.", "createdAt": 1702987940, "dislikes": 0, "id": "36401", "isLikedByMe": 0, "likes": 2, "parentId": 22221, "questionId": 6529, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "duodeno duodenos tommy", "id": 15232 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Pleomorphic Adenoma", "id": 22277 } }, { "__typename": "QuestionComment", "comment": "if he is still drowsy wouldnt this be status epilepticus \n", "createdAt": 1738505561, "dislikes": 0, "id": "62133", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6529, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Hypertension Kinase", "id": 8318 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n \n\nEpilepsy is a group of neurological disorders typified by chronic and recurrent unprovoked seizures, which result from abnormal electrical brain activity. Both focal and generalised seizures may occur, with symptoms corresponding to the affected brain areas. Diagnosis is primarily through EEG, and management involves a comprehensive approach, including optimising anti-epileptic medications, preparing emergency seizure plans, and providing support.\n \n \n# Definition\n \n\nEpilepsy refers to a spectrum of neurological disorders characterised by chronic and recurrent unprovoked seizures. This stems from abnormal brain electrical activity, which can be either synchronous or excessive, leading to focal (restricted to a single lobe) or generalised (involving both hemispheres) symptoms and signs.\n \nStatus epilepticus is defined as a seizure lasting 5 minutes or more, or two or more seizures without complete recovery between episodes. \n \n\n# Epidemiology\n \n\n - Epilepsy affects roughly 1% of the population in the UK.\n - One in every 220 children in the UK has epilepsy, with over 60,000 children and young people in the UK affected. \n - It occurs more commonly in children than adults. \n \n\n# Aetiology\n \n\nEpilepsy can be due to an idiopathic generalised epilepsy syndrome (see classification below), or can be caused by various factors including:\n\n- Genetic predispositions\n - Children of parents with epilepsy are more likely to have seizures, however, the overall risk is still low. \n- Head trauma\n- Tumours\n - More common in supratentorial tumours \n - Can be seen due to hamartomas in Tuberous Sclerosis \n- Infectious diseases\n - Meningitis and encephalitis \n- Prenatal injuries\n- Electrolyte disturbances \n - Hyper and hyponatraemia \n - Hypoglycaemia\n - Hypocalcaemia\n - Hypomagnesaemia\n- Developmental disorders\n- Metabolic disorders\n - Maple Syrup Urine Disease\n - MCAD deficiency \n\nIn children with established epilepsy, seizures can be triggered by:\n \n - Sleep deprivation \n - Playing video games or watching television \n\n\n## Febrile Convulsions \n\nAn important cause of seizures in children is fever. Febrile convulsions, or febrile seizures, are common in children between 6 months to 6 years, presenting as seizures that occur during a fever. The seizures are typically generalised tonic-clonic in nature and usually last less than 5 minutes. Approximately 1 in 20 children will have a febrile seizure. \n \nDiagnosis is generally made from history alone, and management involves treating the underlying fever cause and ensuring the child is safe whilst they are having the seizure. \n\n\n# Classification\n\nThere are many idiopathic epilepsy syndromes affecting children. These include: \n\n\n## Childhood Absence Epilepsy (CAE)\n\nAbsence seizures can occur up to 100 times per day, and many episodes may not be noticed. It is common in children aged 4-10 years and often does not persist into adulthood. Diagnosis is often based on clinical history and EEG showing spike and wave activity, stimulated by hyperventilation. \n\nCAE is typically responsive to anti-epileptics such as ethosuximide. CAE is associated with a good prognosis, as children often do not develop other types of seizures.\n\n\n## West Syndrome\n \n\nWest Syndrome, or infantile spasms, starts between 4-8 months of age. The primary symptom is myoclonic jerking, termed 'jack-knife' spasms, which usually occur in clusters. This syndrome is often associated with developmental regression and high morbidity. Diagnosis is typically made based on the distinctive form of seizure activity and characteristic EEG findings of hypsarrhythmia. Most children may have genetic abnormalities, metabolic conditions or brain injuries/malformations, however, 1 in 3 have no known cause for the seizures. \n\nManagement usually includes prednisolone, ACTH, and/or vigabatrin. Early treatment optimises the child's development, as most children will have intellectual disability later in life. Many children with West syndrome develop Lennox-Gastaut later in childhood.\n \n## Dravet's Syndrome\n \nSevere myoclonic epilepsy typically onsets in infancy in an otherwise healthy infant. Typically will present with convulsive status epilepticus during intercurrent illness or following a vaccination. It is typically refractory to anti-epileptic treatment. \n\nThe syndrome is also associated with loss of developmental milestones and Autism Spectrum Disorder. \n\nDiagnosis is achieved by genetic testing, and management includes multidisciplinary team engagement. Unfortunately, there is an estimated 15% mortality by age 20.\n\n## Lennox Gastaut Syndrome\n\nA syndrome of tonic, atonic and atypical absence seizures occurring in children aged 3-5 years. Absence seizures are considered atypical as they last longer and have a gradual onset when compared to typical absence seizures. EEG will show classic findings of generalised spike-and-wave discharges.\n\nIt is subdivided into idiopathic or symptomatic. In idiopathic Lennox Gastaut syndrome, the child has normal psychomotor development. In symptomatic Lennox Gastaut syndrome, there are associated neurological or neuroradiological abnormalities (i.e. tuberous sclerosis, brain malformations, birth injuries). \n\nIn addition to seizures, children often have motor, behavioural and language dysfunction. \n\nManagement is difficult, as seizures are commonly refractory to anti-epileptics. Sodium valproate is used first line, but other options include lamotrigine and clobazam. Surgical intervention including corpus callostomy and vagus nerve stimulation may be tried for refractory cases. \n\n## Juvenile Myoclonic Epilepsy \n\nMost commonly onset in adolescence and early adulthood, patients will have early morning myoclonic jerks of the upper limbs - with arms \"flinging\" in the air. After a few months, the myoclonic jerks commonly progress to generalised tonic-clonic seizures. Patients may also suffer from absence seizures, and children may have a history of childhood absence seizures. \n\nWhile many have a family history of JME in distant relatives, there is no genetic test specific for JME. Seizures are often triggered by lack of sleep, stress, flashing lights or alcohol intake. Management focuses on avoiding these triggers. It is typically well controlled using anti-epileptic medications, with sodium valproate and lamotrigine being the medications of choice. Most patients require lifelong treatment with anti-epileptic drugs. \n\n## Panayiotopoulos Syndrome\n\nFeatures autonomic seizures with ictal vomiting, pupil dilation and syncope lasting up to 30 minutes. Some children will have vision changes including flashing lights, blurring, and loss of vision. It onsets in childhood, around age 3-6 years. EEG will show characteristic multiple shifting foci predominantly in the occipital region. \n\nChildren have otherwise normal development; typically, seizures stop after 2-3 years. There is no associated increased risk of epilepsy later in life. \n\n## Benign Epilepsy with Centrotermporal Spikes (BECTS) \n\nThis condition, formerly known as Benign Rolandic Epilepsy, typically affects children aged 3-10 years and mostly occurs during sleep. Parents might notice the child experiencing a tonic seizure overnight or find the child on the floor or with disrupted bedding in the morning. The diagnosis is based on history and characteristic EEG findings during sleep of centro-temporal spikes.\n\nIt is the most common form of childhood epilepsy and is associated with an excellent prognosis, with resolution in most children by adolescence. \n \n\n# Signs and Symptoms\n \nEpilepsy may present with focal seizures, generalised seizures, or both. \n\nFocal seizures may produce symptoms specific to the involved lobe: \n\n- Occipital lobe seizures may cause visual phenomena \n- Temporal lobe seizures may cause the child to experience unusual smells \n\n\nGeneralised seizures may include:\n\n- Typical absence seizures:\n - Brief, sudden onset, episodes of unresponsiveness where the child may stop what they are doing and stare \n - The child may also flutter their eyelids or movements of their arms \n - They will not respond even to vigorous stimulation\n- Atypical Absence seizures:\n - Children will be unresponsive and commonly stare blankly, but these episodes occur more gradually and last longer than typical absence seizures. \n- Tonic: muscle stiffening\n- Tonic-clonic: muscle stiffening followed by rhythmic jerking\n- Myoclonic: brief jerking movements\n - Such as seen in infantile spasms or juvenile myoclonic epilepsy\n- Atonic: sudden falls, the child suddenly becomes limp \n - Can be seen in Lenox-Gastaut or Dravet syndrome \n\n \n\n# Differential Diagnosis\n \n\n - **Syncope**: A brief loss of consciousness, with rapid recovery. Often associated with prodromal symptoms of dizziness, nausea and changes to the vision. Associated with a history of prolonged standing, dehydration or heat. \n - **Non-epileptic attack**: Also referred to as dissociative seizures, the child or young person may have convulsive movements of their body/limbs, become incontinent or become unresponsive. These seizures tend to last longer than epileptic seizures and are not managed with benzodiazepines. \n - **Night terrors**: Episodes occur at night, when the child awakens inconsolably, crying and screaming. The child does not remember the episodes in the morning, and children outgrow these episodes by age 10. \n - **Day Dreaming**: A common differential for absence seizures. This typically onsets more gradually. It is able to be ended by others attempting to gain the child's attention. \n\n# Investigations\n \n\nRefer children urgently (less than 2 weeks) for assessment by a paediatrician with expertise in assessing first seizures. \n\n - Epilepsy is diagnosed based on history and examination\n - An EEG may be used to provide information about seizure type, but an EEG is not used to exclude a diagnosis of epilepsy. \n - Seizures can be provoked by hyperventilation, photic stimulation, or sleep deprivation.\n - Imaging modalities such as MRI or CT are usually performed to rule out structural brain abnormalities.\n - An ECG may be done to identify cardiac conditions which may mimic epilepsy. \n\nIf epilepsy onset is below age 2 or there are other features (i.e. learning disability, structural abnormality, autism spectrum disorder), then whole genome sequencing may be done. \n \n\n# Management\n\nWhen there is a known reversible cause for the seizure (i.e. electrolyte or metabolic disturbance), this should be managed appropriately (i.e. glucose for hypoglycaemia). \n\nFor idiopathic seizures or those associated with epilepsy syndromes, management necessitates a multidisciplinary approach to optimise the child's care. This may include: \n\n- Anti-epileptic medications\n- Some children will be recommended a ketogenic diet or low glycaemic diet \n- Surgery may be used in refractory cases or if the seizures are caused by tumours\n - This may include removal of a tumour, vagus nerve stimulation or corpus callosotomy \n- MDT support for comorbidities such as educational and psychological support \n- Emergency seizure plans for both home and school \n - Parents should be advised to ensure their child is safe whilst having a seizure, to call 999 and start a timer. Once the seizure has finished, they should place the child in the recovery position. \n\n# Complications\n\nThe rates of complications depend on the underlying cause of epilepsy, but may include:\n\n- Mood disorders\n- Status Epilepticus \n - Prolonged seizure activity lasting more than 5 minutes. \n- Sudden Unexpected Death in Epilepsy (SUDEP)\n - A rare complication of epilepsy in which an otherwise healthy individual with epilepsy dies unexpectedly. \n- Developmental delay or regression \n\n# Prognosis \n\nThe prognosis of epilepsy in childhood is dependent on the underlying cause. Childhood Absence seizures and Benign Rolandic Epilepsy both are associated with a good prognosis. \n\n# NICE Guidelines\n \n[NICE Guidelines on Epilepsies in Children, Young People and Adults](https://www.nice.org.uk/guidance/ng217) \n\n# References \n\n [NHS page on Febrile Seizures](https://www.nhs.uk/conditions/febrile-seizures/)\n \n [Resuscitation Council UK Paediatric Status Epilepticus Algorithm](https://www.resus.org.uk/sites/default/files/2022-03/RCUK%20Paediatric%20emergency%20algorithms%20and%20resources%20Mar%2022%20V1.pdf) \n \n [Non Epileptic Attack Disorder](https://www.mind.org.uk/information-support/types-of-mental-health-problems/dissociation-and-dissociative-disorders/nead/)\n \n [Patient Info Epilepsy in Children and Young People](https://patient.info/doctor/epilepsy-in-children-and-young-people) \n \n [Patient Info Lennox-Gastaut Syndrome](https://patient.info/doctor/lennox-gastaut-syndrome) \n \n [Epilepsy Society Children with Epilepsy](https://epilepsysociety.org.uk/children)\n \n [Epilepsy Action Childhood Absence Epilepsy](https://www.epilepsy.org.uk/info/syndromes/childhood-absence-epilepsy-cae)", "files": null, "highlights": [], "id": "441", "pictures": [], "typeId": 2 }, "chapterId": 441, "demo": null, "entitlement": null, "id": "448", "name": "Seizures in paediatrics", "status": null, "topic": { "__typename": "Topic", "id": "29", "name": "Paediatrics", "typeId": 2 }, "topicId": 29, "totalCards": 3, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 448, "conditions": [], "difficulty": 1, "dislikes": 5, "explanation": null, "highlights": [], "id": "6529", "isLikedByMe": 0, "learningPoint": "In a child experiencing their first seizure, referral to a first fit clinic is essential for further evaluation and management.", "likes": 5, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 5-year-old boy is brought to the Emergency Department after his parents witness a seizure at home. This has never happened before, and they are understandably very concerned. On review in the department, his observations are normal; he is well though slightly drowsy.\n\nWhat is your next step in management?", "sbaAnswer": [ "a" ], "totalVotes": 5163, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "This patient has clearly stated that she is already having intercourse with her boyfriend and is requesting contraception. Refusing to provide her with treatment is unsafe and not in her best interests", "id": "32651", "label": "d", "name": "Refuse her request", "picture": null, "votes": 7 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is a breach of confidentiality and would only be acceptable if you felt that she was putting herself or others at risk. It is important that you try to persuade her that involving her parents is a good idea however you cannot force her to tell them, nor can you tell them without her permission", "id": "32650", "label": "c", "name": "Arrange a consultation with her and her parents", "picture": null, "votes": 26 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This patient has fulfilled the Fraser Guidelines to be provided with contraception and has requested the implant, not the contraceptive pill. It is worth exploring her choice to make sure she is fully informed; however, she has requested the implant, and therefore this should be what you provide", "id": "32649", "label": "b", "name": "Prescribe the contraceptive pill", "picture": null, "votes": 1329 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This would be a reasonable choice if you felt that she was being pressured into intercourse or if there was a suggestion that the intercourse was with someone older or otherwise inappropriate. She has attended her appointment with a partner who appears supportive, and there is no suggestion here that there is abuse in this case", "id": "32652", "label": "e", "name": "Make a referral to safeguarding", "picture": null, "votes": 93 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient fulfils the Fraser Guidelines and therefore should be prescribed contraception. The Fraser Guidelines are as follows:\n\n- They understand the doctor's advice\n- The young person cannot be persuaded to inform their parents that they are seeking contraceptive advice\n- They are likely to begin or continue having intercourse with or without the contraceptive treatment\n- Unless they receive the contraception, their physical or mental health is likely to suffer\n- It is in the young person's best interests to provide contraceptive advice and/or treatment without parental consent", "id": "32648", "label": "a", "name": "Arrange for her to have the implant fitted", "picture": null, "votes": 3656 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Additionally to Frasier considerations (and her preference), Nexplanon is the contraceptive of choice in young people due to concerns about reliability of taking the pill and concerns about the effect of Depo on bone mineral density :)", "createdAt": 1683021180, "dislikes": 0, "id": "23196", "isLikedByMe": 0, "likes": 6, "parentId": null, "questionId": 6530, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "amygdala", "id": 33081 } }, { "__typename": "QuestionComment", "comment": "hope i read the question in the exam ", "createdAt": 1684860334, "dislikes": 0, "id": "25877", "isLikedByMe": 0, "likes": 24, "parentId": null, "questionId": 6530, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "HarryDM", "id": 20900 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary \n \n\nThe Fraser guidelines are a set of criteria that must be met for a health professional to advise a child <16 years old regarding contraception and sexual health without breaking confidentiality. \n \n\n# Guidelines\n \n\n 1. He/she has sufficient maturity and intelligence to understand the nature and implications of the proposed treatment\n 2. He/she cannot be persuaded to tell her parents or to allow the doctor to tell them\n 3. He/she is very likely to begin or continue having sexual intercourse with or without contraceptive treatment\n 4. His/her physical or mental health is likely to suffer unless he/she receives advice or treatment\n 5. The advice or treatment is in the young person's best interests.\n \n\nIf all of the above criteria are met, the child is deemed to be \"Fraser competent\" and can therefore receive advice without breaking confidentiality.\n \nIf the child does not meet these criteria, parental consent should be sought. \n \nThe Fraser criteria apply to England and Wales, while in Scotland it is a similar criteria called the Age of Legal Capacity Act 1991.\n \n\n# NICE Guidelines\n \n[NICE Clinical Knowledge Summary (CKS): Contraception](https://cks.nice.org.uk/topics/contraception-assessment/)\n\n# References\n\n[Gillick v West Norfolk and Wisbech Area Health Authority and Department of Health and Social Security 1985](https://swarb.co.uk/gillick-v-west-norfolk-and-wisbech-area-health-authority-and-department-of-health-and-social-security-hl-17-oct-1985/)\n\n[National Society for the Prevention of Cruelty to Children (NSPCC): Gillick competency and Fraser guidelines](https://learning.nspcc.org.uk/child-protection-system/gillick-competence-fraser-guidelines)", "files": null, "highlights": [], "id": "1007", "pictures": [], "typeId": 2 }, "chapterId": 1007, "demo": null, "entitlement": null, "id": "2237", "name": "Fraser Guidelines", "status": null, "topic": { "__typename": "Topic", "id": "29", "name": "Paediatrics", "typeId": 2 }, "topicId": 29, "totalCards": null, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 2237, "conditions": [], "difficulty": 2, "dislikes": 2, "explanation": null, "highlights": [], "id": "6530", "isLikedByMe": 0, "learningPoint": "Under Fraser Guidelines, competent minors can receive contraceptive advice and treatment without parental consent if it serves their best interests.", "likes": 6, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 15-year-old female presents with her boyfriend, who is in the same year at school, to General Practice requesting the contraceptive implant. She and her boyfriend are already sleeping together, and she is adamant that she will not discuss this with her parents. She understands the risk of pregnancy and would like to discuss different types of contraception. She is able to weigh up the pros and cons of each.\r\n\r\nWhat should you do?", "sbaAnswer": [ "a" ], "totalVotes": 5111, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "This newborn has a positive Ortolani and therefore investigation and prompt treatment are indicated", "id": "32657", "label": "e", "name": "Reassure and discharge", "picture": null, "votes": 173 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Ultrasound examination is indicated in this baby, however serial ultrasounds are not of benefit, particularly if developmental dysplasia is detected as it does not treat the problem.\nIn babies where there is no clinical suspicion of developmental dysplasia, Public Health England does not recommend routine ultrasound examination unless specific risk factors are present:\n\n1. There is a first-degree family history of hip problems in early life unless DDH was definitively excluded.\n2. There is a breech presentation:\n\n- At or after 36 completed weeks of pregnancy, irrespective of presentation at delivery or mode of delivery; or\n- At delivery if this is earlier than 36 weeks.\n- In the case of a multiple birth, if any of the babies fall into either of these categories, all babies in this pregnancy should have an ultrasound examination", "id": "32655", "label": "c", "name": "Serial ultrasounds", "picture": null, "votes": 291 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Bracing is the first line treatment in newborns when developmental dysplasia. Whilst physiotherapy may be of benefit in older children who are not diagnosed in childhood in a newborn this is not the correct management", "id": "32656", "label": "d", "name": "Physiotherapy", "picture": null, "votes": 110 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This baby has a positive Ortolani's test and an ultrasound suggestive of developmental dysplasia of the hip. Risk factors include: breech presentation, female gender, family history of developmental dysplasia.\n\nEarly detection and management are key, with bracing as the first-line treatment. Surgery is reserved for those who do not respond to bracing or are diagnosed later (after six months of age) and where bracing is contraindicated (for example, if the hip is irreducible). Harness or splint treatment is much less successful if it is started after 6-8 weeks", "id": "32653", "label": "a", "name": "Hip bracing", "picture": null, "votes": 4361 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Surgery is reserved for those who do not respond to bracing or are diagnosed later (after six months of age) and where bracing is contraindicated (for example, if the hip is irreducible). Harness or splint treatment is much less successful if it is started after 6-8 weeks", "id": "32654", "label": "b", "name": "Surgical fixation", "picture": null, "votes": 346 } ], "comments": [ { "__typename": "QuestionComment", "comment": "\"A newborn baby is examined as part of the routine 6-week baby check and the on gentle gentle forward pressure of the left there is movement palpable suggesting that the hip is dislocated or subluxed, but reducible.\"\n\nQuesmed please hire a proofreader, that is actually awful :/", "createdAt": 1682603159, "dislikes": 0, "id": "22786", "isLikedByMe": 0, "likes": 19, "parentId": null, "questionId": 6531, "replies": [ { "__typename": "QuestionComment", "comment": "I have officially applied for the job, hopefully they have the sense to get back to me and hire me! Or anyone else haha, it's needed!", "createdAt": 1685174594, "dislikes": 0, "id": "26486", "isLikedByMe": 0, "likes": 2, "parentId": 22786, "questionId": 6531, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Amnesia Defibrillator", "id": 21454 } }, { "__typename": "QuestionComment", "comment": "im cnofused is the baby 6w old or 4w old?", "createdAt": 1685217328, "dislikes": 0, "id": "26682", "isLikedByMe": 0, "likes": 1, "parentId": 22786, "questionId": 6531, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Axillary Stasis", "id": 20951 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "BruceMcCornKicker", "id": 24901 } }, { "__typename": "QuestionComment", "comment": "the on gentle gentle forward pressure of the left", "createdAt": 1685276391, "dislikes": 0, "id": "26776", "isLikedByMe": 0, "likes": 2, "parentId": null, "questionId": 6531, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "canIhave12bottlesofbleachplease", "id": 15020 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n \n\nDevelopmental Dysplasia of the Hip (DDH) is a congenital abnormality where the femoral head and the acetabulum do not articulate correctly. This condition can lead to easy dislocation and abnormal development of the joint. Key signs and symptoms include limited hip abduction, asymmetrical gluteal and thigh skinfolds, and limb length discrepancy. Barlow and Ortolani manoeuvres serve as primary screening tools. The condition's diagnosis mainly relies on hip ultrasonography. Management ranges from observation in mild cases to the use of a Pavlik harness or surgery in more severe cases.\n \n\n# Definition\n \n\nDevelopmental dysplasia of the hip (DDH) is a congenital abnormality of the hip joint in which the ball of the femur (femoral head) and the socket of the pelvis (acetabulum) do not articulate appropriately. This mal-alignment can result in the joint dislocating easily and continuing to develop abnormally.\n \n\n# Epidemiology\n \n\nThe incidence of DDH varies worldwide, ranging from 1 to 34 cases per 1000 births. The variability is due to differing diagnostic criteria and screening practices among countries. In the UK, it is estimated to affect 1-2% of newborns. \n\nIt is more common in the left hip than the right, but occurs bilaterally in 20% of cases. \n \n\n# Aetiology\n \n\nDDH is commonly associated with certain risk factors known as the 5 Fs:\n \n\n - Female: The condition is more prevalent in females in a 4:1 female-to-male ratio. \n - Firstborn: Firstborn children have a higher risk.\n - Family history: DDH often runs in families.\n - Frank breech presentation: Babies presenting buttocks or feet first in the womb have a 17-fold higher risk of DDH.\n - Fluid: Low amniotic fluid levels (oligohydramnios) can increase the risk.\n\nOther risk factors include:\n \n - Prematurity\n - Multiple pregnancy \n - Neuromuscular conditions (i.e. cerebral palsy)\n \n\n# Signs and Symptoms\n \n\nClinical presentation may vary based on age. In infants, key signs include:\n \n\n - Limited hip abduction, especially when the hip is flexed.\n - Asymmetry of gluteal and thigh skinfolds.\n - Apparent limb length discrepancy.\n \n\nIn older children, the following signs may be present:\n \n - Galeazzi sign: Unilateral femoral shortening is a positive result. This may suggest DDH but it can also be due to other causes of discrepency of limb length. \n - Walking difficulties or a limp.\n - Delayed walking.\n - Waddling gait in bilateral cases.\n\nIn cases of bilateral DDH:\n \n - Waddling gait with hyperlordosis.\n - Typically it is difficult to diagnose as there is often less pronounced limb length discrepency. \n \n\n# Differential Diagnosis\n \n\nDifferential diagnoses for DDH include:\n \n\n - **Transient synovitis**: Presents with acute onset of hip pain, refusal to bear weight, and fever.\n - **Septic arthritis**: Similar to transient synovitis but with a high fever and systemic symptoms. Prompt diagnosis is crucial to prevent joint damage.\n - **Legg-Calve-Perthes disease**: Typically presents in children aged 4-10 years with a gradual onset of limping, pain in the hip, thigh, or knee, and decreased range of motion.\n - **Slipped Upper Femoral Epiphysis (SUFE)**: Common in obese preteens and teenagers. Symptoms include hip pain, limping, and sometimes knee pain.\n \n\n# Investigations\n \n\nScreening Examination\n \n- Barlow (tests for posterior dislocation) and Ortolani (tests for relocation on hip abduction) manoeuvres are primary screening tools. \n- Both are used during the newborn physical screening examination and the infant screening examination at 6-8 weeks. \n\nFor infants with risk factors (i.e. family history of DDH, breech presentation), then a screening ultrasound should be done within the first 6 weeks of life. \n\nIf DDH is clinically suspected, hip ultrasonography should be ordered for confirmation, especially in infants less than 6 months of age. For older infants and children, pelvic radiography may be more suitable.\n \n\n# Management\n \n\nThe management approach is largely dependent on the severity and age at diagnosis:\n \n\n - In mild cases or those detected early, the condition may be self-limiting within the first few months of life.\n - A Pavlik harness may be used to maintain the hip in a flexed and abducted position for 6-12 weeks.\n - More severe cases, those diagnosed > 6 months of age, or those not responding to non-operative management, may necessitate surgical intervention for reduction and stabilization.\n \n# Complications\n\nDDH can result in degeneration of the hip joint and pain in the lower back and hip. It is responsible for approximately 1 in 3 hip replacements before the age of 60. \n\n# NICE Guidelines\n \n[NICE Guidelines for Childhood Limp](https://cks.nice.org.uk/topics/acute-childhood-limp/diagnosis/differential-diagnosis/) \n\n# References \n \n [NHS UK - DDH](https://www.nhs.uk/conditions/developmental-dysplasia-of-the-hip/)\n \n [Patient Info - Developmental dysplasia of the hip](https://patient.info/doctor/developmental-dysplasia-of-the-hip-pro)", "files": null, "highlights": [], "id": "431", "pictures": [], "typeId": 2 }, "chapterId": 431, "demo": null, "entitlement": null, "id": "445", "name": "Developmental Dysplasia of the hip", "status": null, "topic": { "__typename": "Topic", "id": "29", "name": "Paediatrics", "typeId": 2 }, "topicId": 29, "totalCards": 4, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 445, "conditions": [], "difficulty": 1, "dislikes": 12, "explanation": null, "highlights": [], "id": "6531", "isLikedByMe": 0, "learningPoint": "Developmental dysplasia of the hip (DDH) is a condition where an infant's hip joint develops abnormally, leading to instability or dislocation, and is often treated with hip bracing, such as the Pavlik harness, to promote proper alignment and development.", "likes": 9, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A newborn baby is examined as part of the routine 6-week baby check and the on gentle gentle forward pressure of the left there is movement palpable suggesting that the hip is dislocated or subluxed, but reducible. Ultrasound examination is undertaken at 4 weeks of age which is suspicious of developmental dysplasia of the hip joint.\n\nWhat is the correct management?", "sbaAnswer": [ "a" ], "totalVotes": 5281, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "A single dose of oral corticosteroid (such as prednisolone or dexamethasone) may be given in the initial treatment of croup. If the child is too unwell to take the steroid orally, it is reasonable to administer it intramuscular (such as dexamethasone) or nebulised (such as budesonide). However, croup is not the most likely diagnosis here as there is no cough, stridor or temperature", "id": "32662", "label": "e", "name": "Nebulised corticosteroids", "picture": null, "votes": 322 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Antibiotics would be indicated if you felt that this was an acute infective respiratory diagnosis; however, at four days old and without any other signs of infection and no temperature, this is not the likely diagnosis here. If bronchiolitis was suspected, this would also not necessarily be an indication for antibiotics as bronchiolitis is usually viral in origin, with the management being mainly supportive", "id": "32659", "label": "b", "name": "Intravenous antibiotics", "picture": null, "votes": 488 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This baby is likely to have a cyanotic congenital heart abnormality such as transposition of great arteries or tetralogy of Fallot. There is not always a clinically audible murmur present. This typically presents as an increasingly cyanotic newborn in the first few days of life, as the previously patent ductus arteriosus closes and the newborn can no longer rely on it to allow oxygenated blood into the systemic circulation. These babies don't appear to work so hard to breathe compared with babies with lung disease. Another clue that this is less likely to be a respiratory condition is the minimal improvement with high flow oxygen. A prostaglandin infusion will help keep the ductus arteriosus open whilst awaiting specialist input", "id": "32658", "label": "a", "name": "Prostaglandin E infusion", "picture": null, "votes": 3235 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "The use of CPAP may be indicated in those children with impending respiratory failure, for example, due to bronchiolitis. However, this clinical presentation is more in keeping with a cardiac cause for cyanosis as opposed to a respiratory cause. Although there is minimal improvement with high flow oxygen, and there is a temptation to start a more intense form of respiratory support, it is unlikely to improve the neonate's clinical picture", "id": "32661", "label": "d", "name": "Start continuous positive airway pressure (CPAP)", "picture": null, "votes": 740 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Nebulised bronchodilators such as salbutamol are used to treat reversible airway obstruction, such as acute asthma exacerbations. As this neonate is only four days old, the concern here is of a cyanotic congenital heart abnormality, and therefore salbutamol is not indicated", "id": "32660", "label": "c", "name": "Nebulised salbutamol", "picture": null, "votes": 301 } ], "comments": [ { "__typename": "QuestionComment", "comment": "when do you want to close the PDA vs keep it open?", "createdAt": 1682166529, "dislikes": 0, "id": "22428", "isLikedByMe": 0, "likes": 1, "parentId": null, "questionId": 6532, "replies": [ { "__typename": "QuestionComment", "comment": "PDA open if its the only thing keeping them alive i.e. in cyanotic heart diseases like TOF. If they have a PDA that didn't close by itself and no other heart conditions, then you want to close it with indomethacin.", "createdAt": 1685282605, "dislikes": 0, "id": "26809", "isLikedByMe": 0, "likes": 3, "parentId": 22428, "questionId": 6532, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Imran", "id": 20807 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Kinase Power", "id": 16637 } }, { "__typename": "QuestionComment", "comment": "If its PDA why was there no murmur heard when listening to heart sounds?", "createdAt": 1685387698, "dislikes": 0, "id": "27076", "isLikedByMe": 0, "likes": 5, "parentId": null, "questionId": 6532, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Acute Dermis", "id": 25412 } }, { "__typename": "QuestionComment", "comment": "oh come on, you can't just give us a condition and then give it to us in a rare presentation with no murmur. ffs.", "createdAt": 1705002526, "dislikes": 0, "id": "38534", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6532, "replies": [ { "__typename": "QuestionComment", "comment": "literally got thrown off becoz no murmur mentioned", "createdAt": 1707919763, "dislikes": 0, "id": "41581", "isLikedByMe": 0, "likes": 2, "parentId": 38534, "questionId": 6532, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "BeethovenVirus-ed", "id": 14961 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Imran", "id": 20807 } }, { "__typename": "QuestionComment", "comment": "yeh sure lets just whack prostaglandins into a 4 day old baby when we're just guessing whats wrong with them", "createdAt": 1707763493, "dislikes": 0, "id": "41415", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6532, "replies": [ { "__typename": "QuestionComment", "comment": "get on the wards, mate!", "createdAt": 1713746074, "dislikes": 1, "id": "47552", "isLikedByMe": 0, "likes": 0, "parentId": 41415, "questionId": 6532, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Retrograde Recessive", "id": 29991 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "ButtMuncher", "id": 47721 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n \nCongenital cardiac disease refers to a variety of heart abnormalities present at birth, often influenced by maternal risk factors such as infectious disease during pregnancy (e.g. rubella), exposure to teratogenic drugs (e.g. thalidomide, isotretinoin, lithium), substance misuse (e.g., alcohol), and poorly controlled type 1 or 2 diabetes. Identification primarily relies on signs and symptoms observed in newborns, with murmurs often being present, with/without cyanosis, and confirmatory investigations such as echocardiography. Management is typically multidisciplinary and can involve medical therapy, interventional procedures, or surgery, depending on the severity and type of heart defect.\n \n \n# Definition\n \n\nCongenital cardiac disease is a general term referring to abnormalities in the heart's structure that arise before birth. These defects can involve the heart walls, heart valves, or the arteries and veins near the heart.\n \n\n# Epidemiology\n \n\nThe global incidence of congenital heart disease is estimated to be around 1% of live births, making it the most common type of congenital disorder. \n \n\n# Aetiology\n \n\nSeveral factors can contribute to the development of congenital heart disease:\n \n\n- Infectious causes: \n - Maternal rubella infection during pregnancy\n- Teratogenic drugs: \n - Exposure to certain medications during pregnancy, such as thalidomide, isotretinoin, and lithium, increases the likelihood of developing congenital heart disease.\n- Substance misuse: \n - Maternal misuse of substances such as alcohol can also lead to this condition.\n- Maternal diabetes: \n - Poorly controlled type 1 and type 2 diabetes during pregnancy\n - Maternal gestational diabetes is not a known risk factor \n- Family history of congenital heart disease\n - Risk is also increased in consanguineous couples \n\n \n# Classification\n\nCongenital heart disease can be divided into cyanotic or acynotic heart disease.\n\nCyanotic Heart Disease:\n\n- Transposition of the great arteries (TGA)\n- Pulmonary and tricuspid atresias\n- Tetralogy of Fallot (ToF)\n- Total anomalous pulmonary venous return \n- Persistent truncus arteriosus\n- Hypoplastic left heart\n\nAcyanotic Heart Disease:\n\n- Ventricular septal defect (VSD)\n- Atrial septal defect (ASD)\n- Patent ductus arteriosus (PDA)\n- Aortic stenosis \n- Pulmonic stenosis \n- Coarctation of the aorta \n- Endocardial fibroelastosis \n \n\n# Signs and Symptoms\n \n\nNewborns with congenital cardiac disease may present with a variety of signs and symptoms, including:\n \n\n - Cyanosis\n - Fast or troubled breathing\n - Fatigue\n - Poor feeding\n - Delayed growth\n - Heart murmur on auscultation\n \n\nThese symptoms can vary widely depending on the type and severity of the heart defect.\n \n\n# Differential Diagnosis\n \n\nIn an infant presenting with the signs and symptoms of congenital heart disease, several conditions should be considered:\n \n\n - **Respiratory distress syndrome**: This condition can cause fast, troubled breathing, and fatigue. However, it is typically associated with prematurity.\n - **Pneumonia**: Can also lead to breathing difficulties and fatigue, but it is often accompanied by fever and abnormal lung sounds on auscultation.\n - **Gastrointestinal disorders**: These can cause poor feeding and delayed growth but are typically accompanied by vomiting, diarrhoea, or abdominal distension.\n \n\n# Investigations\n \n\nWhilst some cases are detected during prenatal scans, many cases are detected after birth. The following investigations are key to diagnosing congenital heart disease:\n \n\n - Pulse oximetry: To detect low oxygen levels in the blood. This should be measured both pre and post-ductal, with > 3% difference being significant. \n - Chest X-ray: Can reveal an enlarged heart or abnormal heart shape.\n - Electrocardiogram (ECG): Can detect abnormal heart rhythms.\n - Echocardiogram: The gold standard in diagnosing congenital heart disease, providing a detailed image of the heart's structure and function.\n \n\n# Management\n \n\nThe management of congenital heart disease is complex and depends on the type and severity of the heart defect.\n\nRed flag features require more urgent management. These features include:\n\n- Lower limb saturations < 96%\n- More than 3% pre/post ductal difference \n- Signs of heart failure or shock\n\n\nIt typically involves a multidisciplinary team and can include:\n\n- Conservative management:\n - For certain defects (i.e. mild atrial septal defects, a watch-and-wait approach may be adopted as many will close by age 1)\n\n- Medical management:\n - Some patients will require medications including diuretics and ACE inhibitors depending on the type of congenital heart disease. \n- Interventional procedures: Catheter-based procedures to repair certain types of heart defects.\n \n- Surgical intervention: For more complex or severe heart defects, surgery may be necessary.\n\n# Complications\n\nDepending on the type and severity of congenital heart disease, potential complications include:\n\n- Learning difficulties\n- Pneumonia \n- Infective Endocarditis \n- Pulmonary hypertension \n- Heart failure \n\nSudden cardiac death is very rare. \n\n# Prognosis\n\nSurgically corrected congenital heart disease, particularly when isolated, has a good prognosis, however, there is still a reduced life expectancy when compared to the general population. \n\n# NICE Guidelines\n\n[NICE Guidelines on Structural Heart Defects](https://www.nice.org.uk/guidance/conditions-and-diseases/cardiovascular-conditions/structural-heart-defects) \n\n \n# References\n \n [NHS Congenital Heart Disease](https://www.nhs.uk/conditions/congenital-heart-disease/#:~:text=Congenital%20heart%20disease%20is%20a,babies%20born%20in%20the%20UK.) \n \n [British Heart Foundation Congenital Heart Disease](https://www.bhf.org.uk/informationsupport/conditions/congenital-heart-disease) \n \n [Patient Info Congenital Heart Disease in Children](https://patient.info/doctor/congenital-heart-disease-in-children) ", "files": null, "highlights": [], "id": "510", "pictures": [], "typeId": 2 }, "chapterId": 510, "demo": null, "entitlement": null, "id": "522", "name": "Maternal risk factors for congenital heart disease", "status": null, "topic": { "__typename": "Topic", "id": "38", "name": "Obstetrics", "typeId": 2 }, "topicId": 38, "totalCards": 1, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "522", "name": "Maternal risk factors for congenital heart disease" } ], "demo": false, "description": null, "duration": 4773.14, "endTime": null, "files": null, "id": "309", "live": false, "museId": "5tx4c3x", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/paediatrics.png", "title": "Quesmed Tutorial: Congenital Heart Defects", "userViewed": false, "views": 680, "viewsToday": 35 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "522", "name": "Maternal risk factors for congenital heart disease" } ], "demo": false, "description": null, "duration": 381.99, "endTime": null, "files": null, "id": "222", "live": false, "museId": "RjECjom", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/paediatrics.png", "title": "Maternal risk factors for congenital heart disease", "userViewed": false, "views": 42, "viewsToday": 5 } ] }, "conceptId": 522, "conditions": [], "difficulty": 2, "dislikes": 12, "explanation": null, "highlights": [], "id": "6532", "isLikedByMe": 0, "learningPoint": "Prostaglandin E infusion is used in cyanotic cardiac conditions, such as transposition of the great arteries or tetralogy of Fallot, to maintain the patency of the ductus arteriosus, which helps ensure adequate mixing of oxygenated and deoxygenated blood", "likes": 12, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A new mother presents to the Emergency Department with her four-day-old child, concerned about his breathing and colour. Initial observations are as follows:\n\n- Temperature 36.8°C\n- Heart rate 200 bpm\n- Blood pressure 80/50 mmHg\n- Respiratory rate 80 bpm\n- Oxygen saturations 80% (on room air), which improves to 85% on 100% oxygen.\n\nThe neonate is a mottled blue colour, but lung fields are clear on auscultation, and heart sounds are normal. Alongside your initial A-E assessment, what other treatment is important to initiate in this case?", "sbaAnswer": [ "a" ], "totalVotes": 5086, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": true, "explanation": "This is a case of bronchiolitis, the most common respiratory presentation in children under the age of two years old, peaking between the ages of three and six months. It is usually commonly viral in origin and most often due to RSV. Other viral causative agents include human metapneumovirus (hMPV), adenovirus, rhinovirus, and parainfluenza and influenza viruses", "id": "32663", "label": "a", "name": "Respiratory syncytial virus (RSV)", "picture": null, "votes": 4289 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Streptococcus pneumonia is a common cause for bacterial pneumonia and should be considered in the differential diagnosis; however, as this child had a preceding coryzal illness and the crackles are widespread, this leans more towards a viral diagnosis such as bronchiolitis. In bacterial pneumonia, crackles are more likely to be localised to one zone", "id": "32665", "label": "c", "name": "Streptococcus pneumoniae", "picture": null, "votes": 255 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Pseudomonal pneumonia is not a common pathogen as a cause of pneumonia and should prompt consideration of underlying conditions such as cystic fibrosis or immunodeficiency", "id": "32666", "label": "d", "name": "Pseudomonas aeruginosa", "picture": null, "votes": 18 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Group B streptococcal infections are a potentially life-threatening cause of sepsis in neonates. One in four women carry group B streptococci vaginally, which can infect the amniotic fluid before delivery or infect the baby during delivery, causing sepsis, pneumonia, or meningitis. Early-onset infections usually occur in the first seven days of life, and late-onset infections are usually from seven to 90 days of life. Pneumonia is more commonly associated with early-onset infection, as the baby swallows infected amniotic fluid during the delivery. This case vignette is not likely to be due to Group B streptococcus", "id": "32667", "label": "e", "name": "Group B streptococcus", "picture": null, "votes": 262 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Parainfluenza virus can be a cause of bronchiolitis but is more commonly implicated in croup. Croup usually affects young children aged between six months and three years, with most cases occurring in one-year-olds and presents with a distinctive barking cough", "id": "32664", "label": "b", "name": "Parainfluenza virus", "picture": null, "votes": 247 } ], "comments": [ { "__typename": "QuestionComment", "comment": "where's the wheeze?", "createdAt": 1685794041, "dislikes": 0, "id": "27665", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6533, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Kinase Power", "id": 16637 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n \nBronchiolitis is a prevalent chest infection that primarily affects infants aged 1-12 months. This infection is typically caused by the Respiratory Syncytial Virus (RSV) and is characterised by symptoms such as a cough, laboured breathing, wheezing, tachypnoea, intercostal recession, grunting, and nasal flaring. Diagnosis is typically made through clinical presentation and possibly chest X-rays. Management includes prophylactic measures in high-risk patients, supportive care, and oxygen therapy, which may escalate to mechanical ventilation. Ribavirin may be used in severe cases. The key complications of bronchiolitis include bronchiolitis obliterans, also known as popcorn lung, which may result from the overactive cellular repair process. \n \n\n# Definition\n \n\nBronchiolitis is a widespread chest infection, predominantly affecting infants aged 1-12 months. This lower respiratory tract disease targets the bronchioles, causing inflammation and congestion.\n \n\n# Epidemiology\n\nBronchiolitis is very common, affecting around 1 in 3 infants. Bronchiolitis mainly affects children under the age of 1, with approximately 90% of affected children being aged between 1-9 months. It is rare beyond the age of 1 year. \n\nBronchiolitis epidemics are typically observed during winter months from October to March. \n \n\n# Aetiology\n \n\nThe majority of bronchiolitis cases (around 80%) are attributable to the Respiratory Syncytial Virus (RSV). The virus infects epithelial cells of bronchioles. This causes inflammation, mucous production and the epithelial cells to slough off, obstructing the airways. This obstruction results in hypoxia and breathlessness. \n\nRisk factors for developing bronchiolitis include:\n\n- Nursery attendance or having older siblings\n- Passive smoking in the household\n- Overcrowding \n- Exclusive formula-feeding \n\nMore severe bronchiolitis is seen in infants with the following risk factors:\n\n- Prematurity or low birth weight \n- Age < 12 weeks\n- History of mechanical ventilation, chronic lung disease, congenital heart disease or neurological disease\n- Immunocompromise\n- Congenital defects of the airway\n- Down's Syndrome \n \n\n# Signs and Symptoms\n \n\nA diagnosis of bronchiolitis should be considered in an infant with the following:\n \n- Preceding coryzal symptoms for 1-3 days \n- Cough\n- Either tachypnoea or chest recession \n- Either wheeze or crackles on auscultation\n\nOther symptoms they may present with:\n\n- Fever (typically < 39C) \n- Reduced oral intake \n- Apnoea \n\n\n# Differential Diagnosis\n \n\nThe differential diagnoses for bronchiolitis primarily include the following:\n \n\n - **Asthma**: Characterised by recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. This is typically seen in older children than those affected by bronchiolitis. \n - **Pneumonia**: Symptoms include cough with phlegm or pus, high fever (>39C) and persistently focal crackles. \n - **Viral Induced Wheeze**: Seen in children with persistent wheeze and a family history of atopy, more commonly seen in children over the age of 1. \n - **Foreign body aspiration**: This condition may present with sudden onset of respiratory distress, choking, gagging, wheezing, or coughing.\n \n\n# Investigations\n \n\nDiagnosis of bronchiolitis is primarily clinical based on the characteristic symptoms. \n\nFurther investigations may include:\n\n- Pulse oximetry to monitor oxygen saturation\n- Throat swab for respiratory viruses \n- Chest X-rays if focal chest signs or deterioration is seen \n \n\n# Management\n \nThe majority of patients can be managed at home, but admission may be indicated for children with:\n \n - Tachypnoea (>60 breaths/min)\n - Reduced oral intake (< 50% normal) \n - Clinical dehydration\n - Oxygen saturation less than 92% \n - Cyanosis \n - Apnoea \n - Respiratory distress (grunting, intercostal or subcostal recession, tracheal tugging) \n\n\nManagement of bronchiolitis involves:\n \n- Supportive Care:\n - Adequate hydration and nutrition\n - If not tolerating oral intake, an NG tube can be used to provide fluids. \n - If fever is causing distress to the infant, paracetamol may be used. \n- Oxygen Therapy: \n - For oxygen saturations less than 90% for children over 6 weeks.\n - This may be escalated to CPAP in severe cases with threatened respiratory failure.\n- Antiviral Therapy: Ribavirin may be used in severe cases.\n\nAntibiotics, steroids and salbutamol are not used in the management of bronchiolitis. \n \nPrevention may include the administration of Palivizumab (a monoclonal antibody) in high-risk patients (i.e. with haemodynamically significant congenital heart disease). This reduces the risk of RSV-related hospital and PICU admission.\n\n# Complications\n\nBronchiolitis may result in the following complications:\n\n- Respiratory failure requiring intubation \n- Dehydration \n- Cough lasting weeks following bronchiolitis \n- Bronchiolitis obliterans \n \n\nBronchiolitis obliterans:\n\n- A rare, chronic complication of bronchiolitis, colloquially known as popcorn lung. \n- The bronchioles are injured due to infection (usually adenovirus) or inhalation of a harmful substance, leading to an overactive cellular repair process and subsequent build-up of scar tissue. The scar tissue obstructs the bronchioles, impairing oxygen absorption in the body. The scarring and narrowing of the bronchioles may continue to worsen over time, potentially leading to respiratory failure. \n- Lung transplant recipients are at particular risk of developing bronchiolitis obliterans syndrome, with about 50% developing the condition within five years of transplant due to organ rejection.\n\n\n# Prognosis \n\nFortunately for many infants, bronchiolitis can be managed at home and the illness lasts for up to 7 days. The cough may take up to 3 weeks to resolve. \n\n2-3% of infants, however, require hospitalisation. Risk factors for more severe bronchiolitis include chronic lung disease, immunodeficiency, age under 3 months, prematurity, congenital heart disease and neuromuscular disorders. In these high-risk infants, the mortality rate is roughly 3%. \n\n# NICE Guidelines \n\n[NICE Guidelines on Bronchiolitis](https://www.nice.org.uk/guidance/ng9) \n \n\n# References\n\n[NHS Information on Bronchiolitis](https://www.nhs.uk/conditions/bronchiolitis/) \n\n[Great Ormond Street Hospital Bronchiolitis Information](https://media.gosh.nhs.uk/documents/Bronchiolitis_F1533_A5_col_FINAL_Mar16.pdf)\n\n[Patient Info Bronchiolitis](https://patient.info/doctor/bronchiolitis-pro)", "files": null, "highlights": [], "id": "2029", "pictures": [], "typeId": 2 }, "chapterId": 2029, "demo": null, "entitlement": null, "id": "541", "name": "Bronchiolitis", "status": null, "topic": { "__typename": "Topic", "id": "29", "name": "Paediatrics", "typeId": 2 }, "topicId": 29, "totalCards": 8, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "541", "name": "Bronchiolitis" } ], "demo": false, "description": null, "duration": 301.23, "endTime": null, "files": null, "id": "52", "live": false, "museId": "eGr1sRJ", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/paediatrics.png", "title": "Bronchiolitis", "userViewed": false, "views": 209, "viewsToday": 17 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "541", "name": "Bronchiolitis" } ], "demo": false, "description": null, "duration": 4773.14, "endTime": null, "files": null, "id": "309", "live": false, "museId": "5tx4c3x", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/paediatrics.png", "title": "Quesmed Tutorial: Congenital Heart Defects", "userViewed": false, "views": 680, "viewsToday": 35 } ] }, "conceptId": 541, "conditions": [], "difficulty": 1, "dislikes": 1, "explanation": null, "highlights": [], "id": "6533", "isLikedByMe": 0, "learningPoint": "Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis in infants, particularly those under six months old.", "likes": 3, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A five-month-old baby is brought to the Emergency Department with laboured breathing and a raised temperature following a short coryzal illness. On examination, he has subcostal recession and audible, widespread crackles on chest auscultation.\n\nWhat is the likely causative organism for this presentation?", "sbaAnswer": [ "a" ], "totalVotes": 5071, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Benzodiazepines such as lorazepam are used in the treatment of serotonin syndrome, which occurs as a result of high levels of serotonin in the body. It is an uncommon but serious side effect of certain medications used to treat psychiatric conditions such as depression (for example, citalopram, fluoxetine, sertraline). This patient's symptoms could be explained by serotonin syndrome; however, he is not taking any medications that might induce this", "id": "32672", "label": "e", "name": "Intravenous lorazepam", "picture": null, "votes": 128 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Oral antibiotics from the tetracycline, fluoroquinolone or macrolide class would be a reasonable treatment if suspecting an atypical pneumonia such as legionnaires disease. Legionnaires disease is associated with water from ventilation systems. Most people become infected when they inhale microscopic water droplets containing legionella bacteria, e.g., the spray from a shower, faucet or whirlpool, or water from the ventilation systems. Whilst atypical pneumonia such as legionella may present with gastrointestinal symptoms, it would be uncommon to have no respiratory symptoms, and there is no history of a fever. It would also not account for the tremor that the patient has reported", "id": "32669", "label": "b", "name": "Oral doxycycline", "picture": null, "votes": 192 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Chelation is a treatment for heavy metal poisoning, for example, with lead or mercury. It is not used in the treatment of lithium toxicity, and there is no evidence that this patient has come into contact with any heavy metals", "id": "32671", "label": "d", "name": "Chelation therapy", "picture": null, "votes": 523 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient is showing signs of lithium toxicity, for which intravenous fluids is the mainstay of treatment. Common causes of lithium toxicity include dehydration, alcohol intake and angiotensin-converting enzyme inhibitors (ACE-i) such as ramipril as they reduce glomerular filtration rate (GFR) and enhance the tubular reabsorption of lithium (thus increasing plasma concentrations of lithium). In addition, the patient has recently been through a time zone change and therefore may have taken his medications at different times to his usual; therefore, one should be alert to the possibility of lithium toxicity", "id": "32668", "label": "a", "name": "Intravenous fluids", "picture": null, "votes": 4510 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This patient's presentation could be due to traveller's diarrhoea; however, it would not explain the tremor. If traveller's diarrhoea was the diagnosis, then management is mainly supportive (for example, with intravenous fluids). Antibiotics are generally not indicated in traveller's diarrhoea, however in some cases, they have been shown to improve symptoms, and a fluoroquinolone such as azithromycin may be a reasonable choice. Still, it would not be the basis of treatment", "id": "32670", "label": "c", "name": "Oral azithromycin", "picture": null, "votes": 144 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nLithium, commonly used in psychiatric disorders, may produce a range of side effects, which can be categorised into those seen at a therapeutic dose and those indicating toxicity. Therapeutic dose side effects may include fine tremor, dry mouth, GI disturbances, increased thirst and urination, drowsiness, and thyroid dysfunction. Signs of toxicity encompass coarse tremor, CNS disturbance (including seizures, impaired coordination, dysarthria), arrhythmias, and visual disturbance. Diagnosis relies on identifying these clinical features and serum lithium levels. Management involves supportive measures, electrolyte balance maintenance, renal function monitoring, seizure control, IV fluid therapy, and, in severe cases, haemodialysis.\n\n# Indications\n\nLithium is used primarily to treat bipolar disorder and mania, but can also be used in depression (especially if recurrent) and as mood stabiliser for aggressive/self-harming behaviour.\n\nIt is contraindicated in: Addison’s disease, cardiac disease associated with rhythm disorder, personal/family history of Brugada syndrome, low sodium diets and untreated hypothyroidism.\n\nIt should be avoided in severe renal impairment due to the risk of toxicity, as it has a very narrow therapeutic index.\n\n# Side Effects\n\nCan be remembered with the mneumonic LITHIuM:\n\n* **L**eucocytosis\n* **I**nsipidus\n* **T**remor (fine)\n* **H**ypothyroid\n* **I**ncreased weight\n* **U**\n* **M**etallic taste \n\nWomen of child bearing age should take contraception if commenced on lithium, which is generally avoided in pregnancy due to the high risk of development of cardiac malformations in the first trimester.\n\n# Monitoring\n\n- Before starting: renal (U+Es), cardiac (ECG), and thyroid function (TFTs). BMI and FBC should also be done beforehand.\n- Monitor body-weight or BMI, serum electrolytes, eGFR, and thyroid function every 6 months during treatment, and more often if there is evidence of impaired renal or thyroid function, or raised calcium levels\n\n\n# Lithium Toxicity\n\n## Signs and Symptoms\n\n### Clinical features at therapeutic dose \n\n- Fine tremor\n- Dry mouth\n- Gastrointestinal disturbance\n- Increased thirst\n- Increased urination\n- Drowsiness\n- Thyroid dysfunction\n\n### Clinical features in lithium toxicity\n\n- Coarse tremor\n- Central nervous system disturbance, which may include seizures, impaired coordination, and dysarthria\n- Cardiac arrhythmias\n- Visual disturbance\n\n\n\n\n## Differential Diagnosis\n\nLithium side effects and toxicity may be mistaken for several other conditions:\n\n- **Neurological conditions**: Given the tremors, dysarthria, and impaired coordination, conditions like Parkinson's disease or cerebellar disorders may be considered.\n- **Endocrine disorders**: Increased thirst and urination could point towards diabetes insipidus or diabetes mellitus.\n- **Cardiac conditions**: Arrhythmias might suggest primary cardiac disease.\n- **Substance intoxication or withdrawal**: Some symptoms overlap with those of alcohol or benzodiazepine withdrawal, or other substance intoxications.\n\n## Investigations\n\n- Serum lithium levels: This is the gold standard for diagnosing lithium toxicity.\n- Electrolyte levels: To assess for any electrolyte imbalance.\n- Thyroid function tests: Given the potential for thyroid dysfunction.\n- Renal function tests: Given lithium's potential to cause renal impairment.\n- ECG: To assess for arrhythmias.\n\n## Management\n\nManagement of lithium toxicity is largely supportive and often requires specialist input. Key strategies include:\n\n- Maintaining electrolyte balance\n- Monitoring renal function\n- Seizure control\n- IV fluid therapy and urine alkalisation, which enhance the excretion of the drug\n- Benzodiazepines may be used to treat agitation and seizures\n- Haemodialysis might be required if renal function is poor\n\n# References\n\n[Click here to see the BNF guidance on Lithium](https://bnf.nice.org.uk/drug/lithium-carbonate.html)", "files": null, "highlights": [], "id": "911", "pictures": [], "typeId": 5 }, "chapterId": 911, "demo": null, "entitlement": null, "id": "957", "name": "Lithium", "status": null, "topic": { "__typename": "Topic", "id": "18", "name": "Psychiatry", "typeId": 2 }, "topicId": 18, "totalCards": 7, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "957", "name": "Lithium" } ], "demo": false, "description": null, "duration": 211.33, "endTime": null, "files": null, "id": "213", "live": false, "museId": "q8gJ62N", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/psychiatry.png", "title": "Lithium toxicity 1", "userViewed": false, "views": 188, "viewsToday": 16 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "957", "name": "Lithium" } ], "demo": false, "description": null, "duration": 3495.64, "endTime": null, "files": null, "id": "331", "live": false, "museId": "j9Xmzrc", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/psychiatry.png", "title": "Quesmed Tutorial: Psychiatry", "userViewed": false, "views": 828, "viewsToday": 32 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "957", "name": "Lithium" } ], "demo": false, "description": null, "duration": 438.04, "endTime": null, "files": null, "id": "214", "live": false, "museId": "U46gavJ", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/psychiatry.png", "title": "Lithium toxicity 2", "userViewed": false, "views": 55, "viewsToday": 3 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "957", "name": "Lithium" } ], "demo": false, "description": null, "duration": 4524.91, "endTime": null, "files": null, "id": "312", "live": false, "museId": "vf6znRM", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/oncology.png", "title": "Quesmed Tutorial: Drug Toxicity and Overdose", "userViewed": false, "views": 477, "viewsToday": 25 } ] }, "conceptId": 957, "conditions": [], "difficulty": 1, "dislikes": 3, "explanation": null, "highlights": [], "id": "6534", "isLikedByMe": 0, "learningPoint": "Intravenous fluids are the mainstay of treatment for lithium toxicity, as they help to increase hydration, enhance renal clearance, and facilitate the elimination of excess lithium from the body.", "likes": 9, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 46-year-old man presents to the Emergency Department with abdominal pain, diarrhoea and vomiting. He feels weak and reports a new-onset tremor. He has just come back from a cruise in the Caribbean. His only past medical history is bipolar disorder, for which he takes lithium and newly diagnosed hypertension, for which his GP has recently started him on ramipril.\n\nWhat intervention should form the basis of your treatment?", "sbaAnswer": [ "a" ], "totalVotes": 5497, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Patients started on risperidone should be monitored for prolactin concentration at the start of therapy, at six months, and then yearly. Clozapine can cause agranulocytosis and therefore requires differential white blood cell monitoring weekly for 18 weeks, then fortnightly for up to one year, and then monthly. This is not the case for risperidone", "id": "32676", "label": "d", "name": "Increased risk of agranulocytosis", "picture": null, "votes": 637 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Risperidone has a lower risk of producing extrapyramidal side effects than typical antipsychotics such as chlorpromazine and haloperidol; however, there is still a risk of drug-induced Parkinsonism, particularly at higher doses. It does not, however, cause Parkinson's Disease", "id": "32675", "label": "c", "name": "Increased risk of Parkinson's Disease", "picture": null, "votes": 678 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Risperidone is associated with hypotension (usually dose-related) as opposed to hypertension", "id": "32677", "label": "e", "name": "Increased risk of hypertension", "picture": null, "votes": 401 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Antipsychotic medications can cause weight gain and a rise in blood sugar; therefore are associated with an increased risk of developing diabetes, though this is less likely to be relevant in this case as it is a long-term effect", "id": "32674", "label": "b", "name": "Increased risk of hypoglycaemia", "picture": null, "votes": 332 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "There is a small increased risk of stroke when starting certain antipsychotic medications. The National Institute for Health and Care Excellence (NICE) quotes an absolute risk increase of 1.22% (an extra 12 strokes per 1000 people starting an antipsychotic)", "id": "32673", "label": "a", "name": "Increased risk of stroke", "picture": null, "votes": 3491 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Damn got me on the wording, gotta remember PD =/= Parkinsonism", "createdAt": 1685981210, "dislikes": 0, "id": "27942", "isLikedByMe": 0, "likes": 2, "parentId": null, "questionId": 6535, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Acute Suture", "id": 1239 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\n\n\n# Typical antipsychotics\n\n- Also known as 'first-generation' antipsychotics, these not only act as antagonists to D2 receptors but also on cholinergic, adrenergic and histaminergic receptors. The most commonly used medication in this class is **Haloperidol**, though other examples include Chlorpromazine and flupentixol. \n- Side effects can therefore be grouped according to receptor blockade (see below).\n\n### Dopamine D2 Receptor Blockade:\n\n1. **Extrapyramidal Symptoms (EPS):**\n - **Acute Dystonia:** Involuntary muscle contractions causing spasms.\n - **Akathisia:** Restlessness and an inability to sit still.\n - **Parkinsonism:** Tremors, rigidity, and bradykinesia (slowed movements).\n - **Tardive Dyskinesia:** Involuntary, repetitive movements, especially of the face.\n\n2. **Hyperprolactinemia:**\n - Elevated levels of prolactin, leading to:\n - Menstrual irregularities in women.\n - Gynecomastia (breast enlargement) in men.\n - Sexual dysfunction in both genders.\n\n### Other Receptors:\n\n1. **Histamine H1 Receptor Blockade:**\n - **Sedation:** Drowsiness and sleepiness.\n\n2. **Alpha-1 Adrenergic Receptor Blockade:**\n - **Orthostatic Hypotension:** A sudden drop in blood pressure upon standing, leading to dizziness or fainting.\n\n3. **Muscarinic Receptor Blockade:**\n - **Anticholinergic Effects:**\n - Dry mouth.\n - Constipation.\n - Blurred vision.\n - Urinary retention.\n\n\n# Atypical antipsychotics\n\n- Also known as 'second-generation' antipsychotics, these are D2, D3 and 5-HT2A antagonists, with less overspill into other receptors. \n- As effective as typical antipsychotics (even slightly better at negative symptoms), and have a more favourable side effect profile with reduced extrapyramidal effects, but increased metabolic side-effects. \n- They are 1st line for new-onset psychosis. Examples include risperidone, quetiapine, olanzapine, aripiprazole and clozapine (see below). \n\n### Dopamine Receptor Blockade:\n\n1. **D2 Receptor Blockade:**\n - **EPS (Extrapyramidal Symptoms):**\n - Atypicals generally have a lower risk of causing EPS compared to typicals.\n - Lower risk of tardive dyskinesia.\n\n### Serotonin Receptor Blockade:\n\n1. **5-HT2A Receptor Blockade:**\n - **Lower Risk of EPS:** Atypicals have a reduced risk of causing EPS due to serotonin receptor blockade.\n\n### Other Receptors:\n\n1. **Histamine H1 Receptor Blockade:**\n - **Sedation:** Although less common than with typicals, some atypicals can cause drowsiness.\n\n2. **Alpha-1 Adrenergic Receptor Blockade:**\n - **Orthostatic Hypotension:** Some atypicals may cause a drop in blood pressure upon standing.\n\n3. **Muscarinic Receptor Blockade:**\n - **Anticholinergic Effects:**\n - Generally less pronounced compared to typicals.\n - Mild dry mouth, constipation, or blurred vision.\n\n### Metabolic Effects:\n\n1. **Weight Gain:**\n - **Common Side Effect:** Atypical antipsychotics, in general, have a higher risk of causing weight gain compared to typicals.\n - **Varying Degrees:** The degree of weight gain can vary among different atypicals.\n\n2. **Dyslipidemia and Glucose Metabolism:**\n - **Increased Risk:** Some atypicals are associated with an increased risk of dyslipidemia and impaired glucose metabolism.\n\n3. **Prolactin Elevation:**\n - **Variable:** Some atypicals may elevate prolactin levels, leading to menstrual irregularities and sexual dysfunction.\n\n### Other side effects:\n\n1. **Seizures:**\n - **Low Risk:** Generally, atypicals have a lower risk of lowering the seizure threshold compared to typicals.\n\n2. **QT Prolongation:**\n - **Potential Risk:** Some atypicals may have a mild effect on the QT interval, but the clinical significance varies.\n\n3. **Increased risk of VTE and stroke in elderly**\n\n### Monitoring\n\n* Weight should be measured at the start of therapy, then weekly for the first 6 weeks, then at 12 weeks, at 1 year, and then yearly.\n* Fasting blood glucose, HbA1c, and blood lipid concentrations should be measured at baseline, at 12 weeks, at 1 year, and then yearly. \n* Prolactin concentrations should also be measured at baseline.\n* Before initiating antipsychotic drugs, an ECG may be required, particularly if there are cardiovascular risk factors (e.g. high blood pressure), if there is a personal history of cardiovascular disease, or if the patient is being admitted as an inpatient.\n* Blood pressure monitoring before starting therapy, at 12 weeks, at 1 year and then yearly during treatment and dose titration of antipsychotic drugs.\n\n# Clozapine\n\n- Clozapine is an atypical antipsychotic that is indicated if there is failure of treatment of 2 other antipsychotic medication, known as treatment-resistant schizophrenia.\n- Treats both positive and negative symptoms, slightly more effective than other antipsychotics.\n- Important side effects include: **agranulocytosis**, neutropenia, reduced seizure threshold, myocarditis, slurred speech (due to hypersalivation), constipation (most common cause of mortality when related to clozapine use).\n\n### Monitoring\n\n- Due to its unique and potentially serious side effect profile, monitoring while on clozapine is very important.\n- Patients should have weekly FBC (to look at white cell counts) for the first 18 weeks of treatment then fortnightly for up to one year, and then monthly.\n- Blood lipids and weight should be measured at baseline, every 3 months for the first year, and then yearly.\n- Fasting blood glucose should be tested at baseline, after one months’ treatment, then every 4–6 months.\n\n\n# Neuroleptic Malignant Syndrome\n\nNeuroleptic Malignant Syndrome (NMS) is a rare, but potentially life-threatening, idiosyncratic reaction to antipsychotic medications, particularly those that block dopamine receptors. It typically occurs as a response to the introduction or an increase in the dosage of neuroleptic medications.\n\n### Clinical Features\n\n1. **Hyperthermia:**\n - Profound elevation of body temperature is a hallmark feature.\n \n2. **Altered Mental Status:**\n - Fluctuating levels of consciousness, ranging from confusion to catatonia.\n\n3. **Autonomic Dysregulation:**\n - Dysautonomia characterized by fluctuations in blood pressure, tachycardia, and diaphoresis.\n\n4. **Rigidity:**\n - Generalized muscle stiffness, often described as \"lead-pipe\" rigidity.\n\n### Differential Diagnosis\n\n- **Malignant Hyperthermia** - a rare, genetic condition triggered by certain medications, often during anaesthesia.\n\n- **Serotonin Syndrome** similar to NMS but associated with serotoninergic medications. Presents with hyperthermia, autonomic dysregulation, and altered mental status.\n\n### Investigations \n\n- Bloods:\n\t- FBC - Monitoring for potential leukocytosis or signs of infection.\n - **Creatine Kinase (CK) Levels:** Markedly elevated CK levels are often observed due to muscle breakdown.\n - Renal and Liver Function Tests: monitoring organ function due to the potential systemic effects.\n \n### Management\n\n1. **Discontinuation of Causative Agent:**\n - Immediate cessation of the implicated neuroleptic medication.\n\n2. **Supportive Care:**\n - Aggressive cooling measures to address hyperthermia, including cooling blankets and IV fluids to prevent renal failure.\n\n3. **Benzodiazepines:**\n - Administering benzodiazepines to manage agitation and muscle rigidity.\n\n4. **Dantrolene:**\n - Consideration of dantrolene, a skeletal muscle relaxant, in severe cases.\n\n5. **Intensive Monitoring:**\n - Continuous monitoring of vital signs, fluid balance, and laboratory parameters.", "files": null, "highlights": [], "id": "1783", "pictures": [], "typeId": 2 }, "chapterId": 1783, "demo": null, "entitlement": null, "id": "1965", "name": "Antipsychotics", "status": null, "topic": { "__typename": "Topic", "id": "18", "name": "Psychiatry", "typeId": 2 }, "topicId": 18, "totalCards": 8, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 1965, "conditions": [], "difficulty": 2, "dislikes": 9, "explanation": null, "highlights": [], "id": "6535", "isLikedByMe": 0, "learningPoint": "Risperidone use in elderly patients with dementia is associated with a small increased risk of stroke.", "likes": 7, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 76-year-old female is diagnosed with Alzheimer's dementia. Over the last few years, her cognition has declined, and her behaviour has become less manageable. She is now becoming aggressive towards staff and other residents in her care home. Her GP is considering starting risperidone to help manage her aggression as behavioural measures are failing.\n\nWhich of the following is a recognised risk of risperidone?", "sbaAnswer": [ "a" ], "totalVotes": 5539, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "This is a reasonable differential as the signs and symptoms of alcohol and opiate withdrawal are very similar, however, dilated pupils are more commonly associated with opiate withdrawal than alcohol", "id": "32680", "label": "c", "name": "Alcohol withdrawal", "picture": null, "votes": 1763 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This patient may well be anxious as they have just been arrested, and anxiety can account for some of the symptoms described but would not account for the shivering or the dilated pupils", "id": "32679", "label": "b", "name": "Anxiety attack", "picture": null, "votes": 199 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Drug abuse can lead to drug-induced psychosis. However, this is not the clinical picture here", "id": "32681", "label": "d", "name": "Acute psychosis", "picture": null, "votes": 30 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Drug and alcohol abuse (particularly cocaine use) can raise the risk of myocardial infarction; however, this is not the most likely diagnosis", "id": "32682", "label": "e", "name": "Acute myocardial infarction", "picture": null, "votes": 13 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient is showing some of the classic signs and symptoms of early opiate withdrawal. Treatment in the first instance should be supportive, and patients may require fluid resuscitation to replace fluids lost through sweating and diarrhoea. Should they wish it, the patient can have withdrawal management with either buprenorphine or methadone; however, this should be managed by an experienced professional", "id": "32678", "label": "a", "name": "Opiate withdrawal", "picture": null, "votes": 3268 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Pinpoint pupils = opiate misuse/overdose, withdrawal causes dilation. ", "createdAt": 1684581046, "dislikes": 1, "id": "25387", "isLikedByMe": 0, "likes": 17, "parentId": null, "questionId": 6536, "replies": [ { "__typename": "QuestionComment", "comment": "basic", "createdAt": 1736214999, "dislikes": 2, "id": "59837", "isLikedByMe": 0, "likes": 0, "parentId": 25387, "questionId": 6536, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Viral Sclerosis", "id": 15852 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Impatient patient", "id": 29148 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "\n# Substance misuse\n\n### Definition\n- According to ICD-10, mental and behavioural disorders secondary to substance misuse may be categorised as follows: \n\t- Acute intoxication\n\t- Harmful use (damage to health, either physical or mental)\n\t- Dependence syndrome\n\t- Withdrawal state\n\t- Withdrawal state with delirium\n\t- Psychotic disorder\n\t- Amnesic syndrome\n\t- Residual and late-onset psychotic disorder\n \n# Opiate Intoxication and Withdrawal \n- This includes heroin, and they exert their effects through acting on the opioid receptors\n- Features are:\n\t- Drowsiness\n\t- Confusion\n\t- Decreased respiratory rate\n\t- Decreased heart rate\n\t- Constricted pupils\n\t- Track marks (needle marks) if the intravenous route has been used; abscesses at injection sites; veins thrombosed and damaged causing difficulties with intravenous access (causing difficulty in \n- Opiate withdrawal is a common issue that may be encountered within general medicine due to the prevalence of opiate abuse. Withdrawal from heroin can begin as early as 6 hours after the last dose, with symptoms peaking at 36-72 hours. Unlike alcohol withdrawal, it is unpleasant but not especially dangerous or life-threatening.\n- Features include: \n\t- Agitation\n\t- Anxiety and irritability \n\t- Muscle aches or cramps\n\t- Chills\n\t- Runny eyes\n\t- Runny nose\n\t- Sweating\n\t- Hypersalivation\n\t- Yawning\n\t- Insomnia\n\t- Gastrointestinal disturbance such as abdominal cramps, nausea, diarrhoea and vomiting\n\t- Dilated pupils\n\t- Piloerection \n\t- Increased heart rate and blood pressure\n- Drugs used in the management of opiate abuse include:\n\t- **During withdrawal** the following drugs may be used to help with symptoms:\n\t\t- Methadone: beware, may cause prolonged QTc\n\t\t- Lofexidine (alpha 2 receptor agonist)\n\t\t- Loperamide (for diarrhea) \n\t\t- Anti-emetics (for nausea)\n\t\t- Benzodiazepines (for agitation)\n\t\t--> NICE advises against prescribing opiates during opiate withdrawal, but prefers symptomatic management or use of lofexidine. \n\t- **Detox programmes** use methadone and buprenorphine (the latter is a partial agonist of the opiate receptor, so can trigger withdrawal) \n\t- **Relapse** can be prevented using neltrexone once detox is complete.\n\t- **Overdose** can be managed with naloxone \n\n# Alcohol Intoxication, Withdrawal, and Wernicke-Korsakoff Syndrome \n- Alcohol abuse is common. Features of intoxication include:\n\t- Ataxic gait\n\t- Nausea and vomiting\n\t- Reduced GCS\n\t- Dysarthria\n\t- Impaired judgement \n- Alcohol withdrawal is a potentially life-threatening syndrome with characteristic features. Onset is usually 12 hours after the last drink:\n\t- Nausea and vomiting\n\t- Tremor\n\t- Sweating\n\t- Anxiety\n\t- Agitation\n\t- Headache\n\t- Clouding of consciousness \n\t\t- These features are summarised by the 'CIWA' score - Clinical Institute Withdrawal Assessment for Alcohol - which could be used to monitor for signs of alcohol withdrawal, and to guide management.\n\t\t- Prevention and treatment of alcohol withdrawal is with short acting benzodiazepines such as chlordiazepoxide (Librium) and oxazepam (latter if there is evidence of liver injury.)\n\t\t- Supportive treatment includes fluids, anti-emetics, and Pabrinex (to prevent Wernicke-Korsakoff's syndrome.)\n\t\t- Referral to local drug and alcohol liaison teams should be offered.\n\t- Delirium tremens is a life threatening medical emergency, and usually occurs at day 3 of withdrawal, and lasts 3 days, characterised by paranoid delusions, visual/auditory and classically haptic (tactile) hallucinations (sensation of crawling e.g. formication), and seizures. Once delirium tremens starts, NICE recommends oral lorazepam as first line, and if the oral route cannot be used for whatever reason, parenteral lorazepam or haloperidol. \n- Wernicke-Korsakoff Syndrome:\n\t- A syndrome associated with chronic alcohol abuse that occurs due to B1 (thiamine) deficiency, resulting in mammillary body atrophy. It is not exclusive to alcohol abuse, however, with any individual with severe nutritional deficiency at risk. \n\t- It may be precipitated by a period of excess vomiting (which may reduce nutrition further) and giving a glucose load prior to provision of B vitamins in a hypoglycaemic, malnourished patient. \n\t- Wernicke's encephalopathy - a reversible presentation (treaed with high dose intravenous thiamine, e.g. Pabrinex), characterised by a classical tetrad of: \n\t\t- Confusion\n\t\t- Ataxia\n\t\t- Ophthalmoplegia: classically of the lacteral rectus, but can also be an internuclear ophthalmoplegia or upward-gaze defects \n\t\t- Nystagmus \n\t\t- Less classical features include urinary incontinence and hypothermia due to autonomic neuropathy, making normal pressure hydrocephalus a key differential. \n\t- Korsakoff's psychosis - this is an irreversible manifestation of untreated Wernicke's encephalopathy. It is characterised by:\n\t\t- Retrograde amnesia\n\t\t- Anterograde amnesia\n\t\t- Confabulation \n\n# Cannabis Intoxication\n- This includes marijuana, and they exert their effects through acting on the cannabinoid receptors\n- Features are:\n\t- Drowsiness\n\t- Impaired memory\n\t- Slowed reflexes \n\t- Slowed motor skills \n\t- Conjunctival injection \n\t- Increased appetite\n\t- Paranoia and psychotic symptoms (contrast with cannabinoid associated schizophrenia, which has a more insidious onset, over many years)\n\t- Tachycardia\n\t- Dry mouth \n\n# LSD (Lysergic Acid Dethylamide) Intoxication\n- LSD, a psychedelic drug, acts at the dopamine receptors primarily.\n- Features include: \n\t- Labile mood\n\t- Hallucinations\n\t- Increased blood pressure\n\t- Increased heart rate\n\t- Increased temperature\n\t- Sweating\n\t- Insomnia\n\t- Dry mouth\n\n# Stimulant Intoxication\n- These include cocaine, methamphetamine, or MDMA (ecstasy) \n\t- MDMA induces rapid serotonin and dopamine release, and directly binds to the 5HT2 receptor\n\t- Cocaine prevents reuptake of dopamine, noradrenaline, and seroton, resulting in increased levels of free serotonin and dopamine\n\t- Methamphetamine acts at the sigma receptors, which induces dopamine release \n\t- Stimulants such as cocaine or methamphetamine can, in low doses, produce a feeling of increased concentration and focus. Cocaine acts at dopamine receptors. Methamphetamine acts at TAAR1 (Trace Amine-Associated Receptor 1) receptors. Both increase the available amount of dopamine in the brain, producing the associated pleasurable effects of the drugs.\n- Features include:\n\t- Euphoria\n\t- Hypertensive crises\n\t- Increased heart rate\n\t- Dilated pupils\n\t- Increased temperature\n\t- Rhabdomyolysis \n\t- Seizures\n\t- Agitation \n\t- Arrythmias \n\t- Psychosis \n\t- Excessive thirst and SIADH, resulting in water overload and hyponatraemia, especially with MDMA, and associated complications from this.\n\t- Ischaemic events (cardiac, pulmonary, bowel, CNS) with cocaine due to vasospasm \n- Deaths can occur due to hyperpyrexia and hypertension, so cooling, use of antihypertensives such as nitroprusside or GTN, and benzodiazepines, is the mainstay of management. \n- Withdrawal syndromes are not a typical feature of stimulant abuse.\n\n\n", "files": null, "highlights": [], "id": "917", "pictures": [], "typeId": 2 }, "chapterId": 917, "demo": null, "entitlement": null, "id": "963", "name": "Substance misuse", "status": null, "topic": { "__typename": "Topic", "id": "18", "name": "Psychiatry", "typeId": 2 }, "topicId": 18, "totalCards": 20, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 963, "conditions": [], "difficulty": 3, "dislikes": 9, "explanation": null, "highlights": [], "id": "6536", "isLikedByMe": 0, "learningPoint": "Opiate withdrawal presents with symptoms such as tremors, sweating, dilated pupils, and gastrointestinal disturbances.", "likes": 8, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "The police bring a 32-year-old male to the Emergency Department after being injured whilst resisting arrest for theft. On review, he has only minor injuries, but you notice that he is starting to shiver, sweat, retch and has a tremor. His pupils are dilated.\n\nWhat is the most likely diagnosis?", "sbaAnswer": [ "a" ], "totalVotes": 5273, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "There is no evidence to suggest that this patient has an advanced directive or care plan in place stating that they do not want active treatment. Therefore, you should initiate treatment of all reversible causes of their deterioration, including antibiotics and managing sepsis. However, if they deteriorate and require more intensive treatment such as non-invasive ventilation or intubation, then it should be considered whether this is in their best interests", "id": "32687", "label": "e", "name": "Symptom control", "picture": null, "votes": 83 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient has a community acquired pneumonia and a CURB-65 score of at least 4 (confusion, respiratory rate, diastolic blood pressure, age) even without the blood results for urea and therefore should be treated as severe pneumonia and admitted for intravenous antibiotics. The CURB-65 score is as follows:\n\n- Confusion +1\n- Urea >19mg/dL (>7mmol/L) +1\n- Respiratory rate >30 +1\n- SBP <90 or DBP <60 +1\n- Age >65 +1", "id": "32683", "label": "a", "name": "Admission for intravenous antibiotics", "picture": null, "votes": 2742 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This patient is unwell with a community-acquired pneumonia and a CURB 65 score of at least 4 and therefore has a high 30-day mortality risk. They should be admitted for intravenous antibiotics", "id": "32684", "label": "b", "name": "Oral antibiotics", "picture": null, "votes": 43 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This patient has a community-acquired pneumonia with localising signs pointing towards a bacterial cause (single-zone lung crackles). Therefore, though oxygen is indicated in this patient's treatment, the definitive management is antibiotics according to the hospital's microbiology policy", "id": "32686", "label": "d", "name": "Admission for oxygen therapy alone", "picture": null, "votes": 32 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Whilst this patient has severe pneumonia, they are maintaining their airway, and we do not have any evidence that they are tiring. They may eventually require further airway support, and it is important to have this in mind however, intubation is not currently indicated", "id": "32685", "label": "c", "name": "Intubation", "picture": null, "votes": 114 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary \n \nPneumonia is a radiological diagnosis, often due to a lower respiratory tract infection causing inflammation of the alveoli and terminal bronchioles, leading to consolidation of bronchopulmonary segment or lobe. Key signs and symptoms include rapid onset of high fever and productive cough for typical bacterial causes. Key investigations include blood tests, sputum culture, urinary antigen tests, and chest x-ray. Management strategies involve use of antibiotics, assessment of severity using CURB-65 score and inpatient treatment for severe cases.\n \n \n# Definition\n \n- Lower Respiratory Tract Infection/ Pneumonia is caused by infection and subsequent inflammation of the alveoli and terminal bronchioles.\n- This leads to an entire bronchopulmonary segment or lobe becoming consolidated, which means that tissue is filled with inflammatory cells and oedema.\n \n \n# Community Acquired Pneumonia (CAP)\n \n \n## Bacterial Causes\n \n \n- Typicals - so called because of the classical rapid onset of symptoms, including high fever and productive cough;\n- Streptococcus pneumoniae (gram +ve cocci found in pairs, also known as 'Pneumococcus')\n- Staphylococcus aureus\n- Haemophilus influenzae (gram -ve rod, potent beta-lactamase producer)\n- Moraxella catarrhalis (gram -coccus, potent beta-lactamase producer)\n- Atypicals: so called because of the more gradual onset of symptoms, which may be non-specific initially (fever, myalgia, dry cough). The organisms are also intracellular;\n- Mycoplasma pneumoniae\n- Chlamydia pneumoniae\n- Legionella pneumophila\n- Coxiella burnettii\n- Chlamydia psittaci\n \n \n## Viral Causes \n \n- Most commonly Influenza A, which can predispose to superadded Staph aureus (or strep pneumoniae) pneumonia.\n- Others: CMV, HSV, VZV\n \n## Fungal Causes\n \nCan be seen after silver staining and microscopy:\n \n- Candida - dimorphic yeast\n- Aspergillus - fungus with hyphae\n- Cryptococcus - encapsulated yeast\n \n \n## Specific Causes \n \nCOPD: \n \n- Pneumococcus still most common\n- Haemophilus influenzae\n- Morexella catarrhalis\n \nCystic Fibrosis:\n \n \n- Staph aureus\n- Pseudomonas aeruginosa\n- Burkholderia cepacia\n \nCauses in Homeless people: malnourished, alcohol or drug dependent, immunosuppressed:\n \n \n- Mycobacterium tuberculosis\n- Aspiration pneumonia (infection with normal flora of mouth and anaerobes, also consider in any patient with an unsafe swallow or with depressed consciousness)\n- Klebsiella pneumoniae (causes 'red-current jelly' sputum, and commonly causes lung abscess formation and empyema)\n \n \nOccupational/travel situations:\n \n- Aerosols from humidifiers and airconditioning (e.g. at holiday resorts) - Legionella pneumophila.\n- Patients can present with diarrhoea and vomiting, develop hepatorenal syndrome and have a low sodium. Severe pneumonia develops, with other rare complications such as:\n- Pancreatitis\n- Peritonitis\n- Myocarditis, endocarditis, pericarditis\n- Glomerulonephritis\n \n \nClosed populations e.g. schools, offices\n \n- Mycoplasma pneumoniae\n- Extra respiratory symptoms:\n- Erythema multiforme, erythema nodosum\n- Guillain-Barre Syndrome (and rarely other neurological complications e.g. aseptic meningitis, cerebellar disease, transverse myelitis).\n- Cold agglutinin production with haemolytic anaemia\n- Chlamydia pneumoniae\n \n \nZoonotic Causes: \n \n- In Abattoir worker, farmer, vets\n- Coxiella burnettii\n- Brucella spp.\n \n- Animal hide importers/sorters\n- Bacillus anthracis\n- Coxiella burnettii\n \n \n- Following exposure to birds\n- Chlamydia psittaci (causes psittacosis)\n- Exposure to bats/bat droppings\n- Histoplasma capsulatum (a fungus, classically affects cave-explorers)\n \n \n## Investigations\n \n \n- Bloods: including FBC, U+Es, CRP, WCC and blood cultures\n- Sputum culture\n- Urinary antigen tests for Legionella and pneumococcus\n- Chest X-Ray\n- Could assess pleural fluid aspirate in patients with pleural effusion\n \n \n## CURB-65 \n \n \n- Use the CURB-65 score to aid in deciding the severity of pneumonia and further management based on this\n- Components (1 point for each if present):\n- Confusion +/-\n- Urea >7\n- Respiratory Rate >30\n- Blood pressure: systolic < 90 or diastolic <60\n- More than 65 years old\n \n \nCURB-65 mortality by score:\n \n- 0 or 1 - 1.5%\n- 2 - about 10%\n- 3 or more - 10% or more \n \n \n \n \n## Management\n \nIf a patient is very unwell, adopt an A-E approach, initiate the sepsis six and seek early senior input.\n \n- Management based on CURB-65 score:\n- 0/1: home-based care, give oral amoxicillin for 5 days (macrolide e.g. clarithromycin, doxycycline or tetracycline if penicillin allergic).\n- 2: hospital-based care, 7-10 day course of dual antibiotic therapy with amoxicillin (IV or oral) and a macrolide\n- 3: Hospital/ITU-based care, 7-10 day course of dual antibiotic therapy with IV co-amoxiclav/ceftriaxone/tazocin and a macrolide.\n \n \n- Atypical and typical community-acquired pneumonia are both managed in the same way initially.\n- Liaise with microbiology to guide targeted antibiotics following culture results e.g. flucloxacillin for staph aureus pneumonia.\n- A repeat chest x-ray is required after 6 weeks to assess for underlying pathology.\n \n \n## Complications\n \n \n- Pleural effusion\n- Empyema (suspect if persistent, swinging fever with leucocytosis found after antibiotic therapy)\n- Abscess (can be caused by S. pneumoniae, Klebsiella, staph aureus). Can develop pyopneumothorax.\n- Pneumothorax\n- Septicemia\n- Atrial fibrillation\n- Post-infective bronchiectasis\n \n \n \n \n# Hospital Acquired Pneumonia\n \n \n## Definition\n \n \nLower respiratory tract infection that develops more than 48 hours after admission to hospital\n \n \n## Risk Factors\n \n \n- Poor hand hygiene and hospital infection control\n- Intubation and ventilation\n \n \n## Causative Organisms\n \n \n- Pseudomonas aeruginosa\n- E. coli\n- Klebsiella pneumoniae\n- Acinetobacter species (can acquire high potency beta-lactamases, known as ESBLs)\n- Serratia species (can acquire high potency beta-lactamases, known as ESBLs)\n \n \n## Investigations\n \nMay include:\n \n- Bloods: including FBC, U+Es, CRP, WCC and blood cultures\n- Sputum culture\n- Urinary antigen tests for Legionella and pneumococcus\n- Chest X-Ray\n- Could assess pleural fluid aspirate in patients with pleural effusion\n \n \n## Management \n \nIf a patient is very unwell, adopt an A-E approach, initiate the sepsis six and seek early senior input and discussion with microbiology. Empirical antibiotics are guided by severity and likelihood of resistant organisms:\n \n- HAP within 5 days of admission: co-amoxiclav is usually first line for non-severe symptoms\n- HAP more than 5 days after admission (associated with higher risk of resistance) or severe symptoms: tazocin or cephalosporin (e.g. ceftazidime) or quinolone first-line.\n- If MRSA is suspected, add vancomycin\n \n \n# Aspiration Pneumonia \n \n \n- Caused by any cause of depressed consciousness or impairment of the swallowing mechanism\n- Infection caused by mixed aerobic and anaerobic mouth flora, which can cause cavitary pneumonia or empyema\n- Same empirical therapy as for non-aspiration pneumonia, but later antibiotic choice made by pathogen and sensitivities. Metronidazole often added in to cover for anaerobic organisms. Local guidance should be sought.\n \n \n# NICE Guidelines\n \n \n[Click here for NICE CKS on chest infections](https://cks.nice.org.uk/topics/chest-infections-adult/)\n \n[Click here for NICE guidance on antimicrobial prescribing in hospital-acqui", "files": null, "highlights": [], "id": "271", "pictures": [], "typeId": 2 }, "chapterId": 271, "demo": null, "entitlement": null, "id": "2650", "name": "Pneumonia", "status": null, "topic": { "__typename": "Topic", "id": "20", "name": "Respiratory Physiology", "typeId": 1 }, "topicId": 20, "totalCards": 5, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 2650, "conditions": [], "difficulty": 1, "dislikes": 0, "explanation": null, "highlights": [], "id": "6537", "isLikedByMe": null, "learningPoint": null, "likes": 0, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 76-year-old male is brought from his residential home to the Emergency Department with difficulty breathing. He is disorientated, breathing fast, and on auscultation of his chest, you note coarse crackles at the right base.\n\n- Temperature 37.9°C\n- Blood pressure 90/50 mmHg\n- Heart rate 105 bpm\n- Respiratory rate 32 breaths per minute\n- Saturations 95% (on air)\n\nWhat should your management be?", "sbaAnswer": [ "a" ], "totalVotes": 3014, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "An ABG would help determine if this patient has type one or type two respiratory failure; however, it would not provide an underlying diagnosis", "id": "32690", "label": "c", "name": "Arterial blood gas (ABG)", "picture": null, "votes": 18 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Spirometry would be useful in diagnosing the difference between different patterns of lung disease (restrictive vs obstructive patterns) and, therefore would be of use if you were concerned about smoking-associated diseases such as chronic obstructive pulmonary disease (COPD). Whilst COPD can occasionally lead to SIADH, it is more important to rule out cancer. Changes due to COPD would also be evident on a CT chest", "id": "32689", "label": "b", "name": "Spirometry", "picture": null, "votes": 38 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "A number of lung diseases can cause SIADH. Serum ACE is a test for sarcoidosis. In this case, the significant smoking history, weight loss and lack of other features makes lung cancer more likely favouring a CT Chest as the most useful investigation", "id": "32692", "label": "e", "name": "Serum ACE", "picture": null, "votes": 103 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Paired urine and serum osmolalities are useful in determining whether this is a renal or other cause for hyponatraemia. In healthy individuals, if serum osmolality is low, urine osmolality should also be low as the kidneys should be working hard to retain solute. In SIADH, the excess of ADH results in water retention, but not solute retention. As a result, concentrated urine, which is relatively high in sodium is produced, despite low serum sodium. Whilst paired osmolalities would be useful in the workup of this patient; they are unlikely to provide a definitive diagnosis", "id": "32691", "label": "d", "name": "Paired urine and serum osmolalities", "picture": null, "votes": 601 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient is a smoker with weight loss and euvolaemic hyponatraemia, which should raise the concern of syndrome of inappropriate antidiuretic hormone secretion (SIADH) from a small cell lung cancer. The gold standard investigation for this would be a CT chest", "id": "32688", "label": "a", "name": "CT Chest", "picture": null, "votes": 2243 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nLung cancers are divided into two main subtypes: small cell and non-small cell, with small cell lung cancers being more aggressive and incurable. Types of non-small cell lung cancer include squamous cell and adenocarcinomas, with several rarer subtypes. Most cases of lung cancer are linked to smoking. Lung cancers may present with chest symptoms such as cough, breathlessness or haemoptysis, systemic symptoms of weight loss and anorexia or symptoms of metastatic disease such as bone pain or seizures. Chest X-ray is the initial investigation of choice, followed by CT chest and a biopsy. Staging scans are done after diagnosis to help plan treatment. Management can be curative or palliative depending on the stage of the cancer, the subtype and the patient’s overall health. It may include chemotherapy, radiotherapy, immunotherapy, targeted therapies to specific mutations and surgery. \n\n\n# Definition\n\nLung cancer refers to a primary malignancy arising from the lung parenchyma or the bronchi. Cancers are classified as small cell (SCLC) or non-small cell (NSCLC), with 80% being non-small cell. The main histological subtypes of NSCLC are squamous cell cancers and adenocarcinomas.\n\n# Epidemiology\n\nLung cancer makes up the largest proportion of cancer deaths of any tumour type, with nearly 35,000 deaths per year in the UK (21% of all cancer deaths). It is the second most common cancer in both males and females (after prostate and breast respectively). \n\nIncidence is strongly related to age, with the highest rates in people aged over 75 years old. Although non-smokers can also get lung cancer, 86% of cases are linked to smoking and so the majority of cases are felt to be preventable.\n\n# Aetiology\n\nRisk factors for lung cancer include:\n\n- Tobacco smoking (e.g. cigarettes, pipes, cigars)\n- Passive smoke exposure\n- Occupational exposures (e.g. beryllium, cadmium, arsenic, asbestos, silica)\n- Radon exposure\n- Family history of lung cancer\n- Radiation to the chest (e.g. in lymphoma treatment)\n- Air pollution\n- Immunosuppression (e.g. HIV, medications)\n- Increasing age\n\n# Classification\n\nLung cancers are classified by the cell of origin of the malignancy. Small cell cancers come from neuroendocrine cells of the lung. Non-small cell cancers are split into adenocarcinomas (coming from alveolar type 2 epithelial cells), squamous cell carcinomas (coming from basal epithelial cells) and large cell carcinomas (which come from a variety of epithelial cells). There are also rarer subtypes of lung cancer such as sarcomatoid or salivary gland-type lung cancers which come under the NSCLC umbrella.\n\nStaging is also an important way to classify lung cancers depending on how advanced they are. TNM (tumour, node, metastasis) staging is used to describe how large the tumour is and where it has spread to. This can then be used to classify lung cancers into stage 1 to 4, where stage 1 is localised and small (under 4cm), stages 2 and 3 are locally advanced and stage 4 is metastatic. \n\n# Signs and symptoms\n\n**Symptoms include:**\n\n- Persistent cough\n- Haemoptysis\n- Dyspnoea especially on exertion\n- Chest pain\n- Weight loss\n- Recurrent chest infections, or infections resistant to treatment\n- Anorexia\n\n**Signs include:**\n\n- Cachexia\n- Finger clubbing\n- Lymphadenopathy (supraclavicular or persistent cervical)\n- If there is lung collapse due to an obstructing tumour - absent breath sounds, trachea deviated towards side of collapse\n- If there is a malignant pleural effusion - stony dull on percussion, decreased breath sounds over affected area\n\n**Other signs and symptoms related to paraneoplastic presentations of lung cancer:**\n\n- **Cushing syndrome** - usually SCLC producing ectopic ACTH, presents with dorsal cervical fat pads, truncal obesity, hypertension, striae and proximal muscle weakness\n- **Syndrome of inappropriate ADH secretion (SIADH)** - usually SCLC, present with symptoms of hyponatraemia e.g. fatigue, nausea, weakness, confusion or seizures\n- **Lambert-Eaton myasthenic syndrome (LEMS)** - usually SCLC, due to autoantibodies to presynaptic calcium channels at the neuromuscular junction develop proximal muscle weakness that improves with repeated movement, as well as autonomic effects such as dry mouth, lightheadedness, constipation, urinary symptoms and erectile dysfunction\n- **Humoral hypercalcaemia of malignancy** - usually squamous cell carcinomas (SCC) that release parathyroid hormone-related protein (PTHrP) that mimics PTH and causes hypercalcaemia, leading to symptoms of bone pain, constipation, anorexia, abdominal pain, excessive thirst and confusion\n- **Hypertrophic pulmonary osteoarthropathy** - usually adenocarcinomas which cause a periosteal reaction of bones, resulting in clubbing and arthritis especially affecting wrists and ankles\n\n# Differential diagnosis\n\n- Lung metastases from another primary cancer (e.g. breast or colorectal cancer)\n- Mesothelioma (cancer of the pleura, strongly related to asbestos exposure)\n- Tuberculosis \n- Bronchiectasis\n\n# Investigations\n\nIn primary care, patients should be referred on a 2 week wait pathway in the following situations:\n\n- Aged 40+ with unexplained haemoptysis\n- Chest X-ray findings suspicious for lung cancer\n\nUrgent chest X-rays (to be done within 2 weeks) should be done for patients aged 40+ who have one of these symptoms and have ever smoked (or two symptoms if they are never smokers):\n\n- Cough\n- Fatigue\n- Shortness of breath\n- Chest pain\n- Weight loss\n- Anorexia\n\nAn urgent chest X-ray should be considered in patients aged 40+ with any of:\n\n- Persistent/recurrent chest infection\n- Finger clubbing\n- Supraclavicular or persistent cervical lymphadenopathy\n- Thrombocytosis\n- Chest signs consistent with lung cancer (e.g. reduced breath sounds, dullness to percussion)\n\nChest X-ray findings include:\n\n- Lung mass (may be rounded or spiculated, squamous cell carcinomas may cavitate)\n- Consolidation (where there is infection downstream of the tumour obstructing an airway)\n- Bulky hilum (especially squamous cell carcinomas which often arise centrally)\n- Lobar collapse (due to bronchial obstruction, especially squamous cell carcinomas)\n- Pleural effusion\n\n[lightgallery]\n\nOther initial investigations include:\n\n- **Sputum cytology** - low sensitivity but may be of use in patients who decline or cannot have a biopsy\n- **Diagnostic thoracocentesis** - i.e. a pleural tap; if a pleural effusion is present this should be done and the fluid sent for cytology as well as cell count, microscopy, culture, glucose, LDG and protein (to determine whether it is a transudate or exudate)\n- **Blood tests** - including FBC for anaemia and thrombocytosis, U&Es for hyponatraemia and baseline renal function, LFTs for baseline liver function (may be deranged in liver metastases), bone profile for hypercalcaemia, CRP for superadded infection, clotting if interventions planned\n- **CT chest with contrast** - should be done after chest X-ray to better characterise any lesion seen and investigate for local spread\n- **Biopsy** - to confirm the diagnosis and subtype of cancer, may be done percutaneously for peripheral tumours or via bronchoscopy for central masses\n\nOnce a lung cancer is diagnosed, further investigations may include:\n\n- **Spirometry** - to assess lung function to determine if a patient is suitable for surgical intervention\n- **CT chest abdomen and pelvis** - to stage the cancer (determine if there are any metastases)\n- **PET-CT scan** - a more sensitive way to stage the cancer and look for local or distant spread\n- **CT or MRI head** - may be done as part of staging investigations if curative treatment is planned, or if there are symptoms suspicious of intracranial metastases \n\n# Management \n\n**Conservative:**\n\n- **Holistic support** and an **MDT approach** (e.g. clinical nurse specialist involvement, palliative care input for troubling symptoms or end of life care, signpost to support e.g. Macmillan groups)\n- **Smoking cessation**\n- Discussions around **advance care planning** where appropriate\n\n**Medical**\n\n- **Chemotherapy** is first line in most cases of small cell lung cancer and stage 3 or 4 non-small cell lung cancer - this is with palliative intent (i.e. not aiming to cure the disease but to prolong life and improve symptoms). It is also offered to some patients prior to (neoadjuvant) or after (adjuvant) curative surgery.\n- **Immunotherapy** is also used especially in advanced non-small cell lung cancer; this includes medications such as pembrolizumab or atezolizumab (again with palliative intent).\n- Other **targeted therapies** exist for patients with specific mutations, e.g. erlotinib for patients with advanced non-small cell lung cancers with EGFR-TK mutations.\n- **Radiotherapy** may be curative (for example in early non-small cell lung cancer) or palliative - it is often combined with chemotherapy or other treatment modalities.\n- **Supportive therapies** include analgesia, oxygen if hypoxic and opioid treatment for breathlessness.\n\n**Surgical**\n\n- **Lobectomy** is the standard curative therapy for early stage lung cancers (which can be open or thoracoscopic in approach).\n- Some small tumours can be removed with a **wedge resection.**\n- More extensive surgery such as a **pneumonectomy** (removal of a lung) may be required depending on the size and location of the tumour, however patients need to have adequate FEV1 on pre-operative spirometry to be appropriate for surgery (over 2L for a pneumonectomy).\n- All patients undergoing surgery should also have **mediastinal and hilar lymph nodes sampled** (to look for metastases) or **resected** (removed) to reduce the chances of recurrence.\n\n# Complications\n\n**Common sites of metastatic spread include:**\n\n- Lymph nodes\n- Liver - this can cause significant pain due to stretching of the liver capsule\n- Brain - may cause nausea and vomiting, headaches, seizures, personality changes, sensory or motor symptoms, dysphasia or cerebellar symptoms, depending on where in the brain is affected\n- Bones - mostly osteolytic metastases, can cause bony pain and pathological fractures; there is a risk of metastatic spinal cord compression with vertebral metastases\n- Adrenal glands - may cause flank pain and adrenal insufficiency\n- The contralateral lung or elsewhere in the ipsilateral lung\n\n**Local complications include:**\n\n- Horner’s syndrome - due to an apical (Pancoast) tumour, causes ipsilateral anhidrosis, miosis and partial ptosis\n- Superior vena cava obstruction (SCVO) - lung cancer is the commonest cause of SCVO, causing symptoms of breathlessness, dizziness, headache and swelling of the face, neck and arms. This is a medical emergency due to the risk of airway obstruction.\n- Malignant pleural effusion\n- Hoarse voice - secondary to invasion of left recurrent laryngeal nerve\n- Persistent lower respiratory tract infection due to obstructing tumour\n- Raised hemidiaphragm secondary to invasion of phrenic nerve\n- Brachial plexus injury secondary to tumour invasion from a Pancoast tumour\n\n# Prognosis\n\nOverall prognosis is poor, with an average 5 year survival rate of 17%. This is lower for small cell lung cancer and for metastatic cancers, both of which have around a 5% 5 year survival. Small cell lung cancers are aggressive and are usually metastatic at the time of presentation, hence curative treatment is not possible\n\nIn early stage cancers survival is better, with 70% of patients with stage 1 NSCLC undergoing curative surgery surviving 5 years from diagnosis.\n\n# NICE Guidelines\n\n[Lung cancer: diagnosis and management](https://www.nice.org.uk/guidance/ng122)\n\n[NICE CKS - recognition and referral of lung and pleural cancers](https://cks.nice.org.uk/topics/lung-pleural-cancers-recognition-referral/)\n\n# References\n\n[Radiopaedia - lung cancer](https://radiopaedia.org/articles/lung-cancer-3?lang=gb)\n\n[Patient UK - lung cancer](https://patient.info/doctor/lung-cancer-pro)\n\n[Cancer Research UK - lung cancer statistics](https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/lung-cancer)", "files": null, "highlights": [], "id": "213", "pictures": [ { "__typename": "Picture", "caption": "A chest x-ray of an individual with a left sided lung cancer.", "createdAt": 1665036197, "id": "1027", "index": 0, "name": "Lung cancer.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/3qgbltgx1665036171692.jpg", "path256": "images/3qgbltgx1665036171692_256.jpg", "path512": "images/3qgbltgx1665036171692_512.jpg", "thumbhash": "FggKB4A391dzfIiZdVVoiHd0BwAAAAAA", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 213, "demo": null, "entitlement": null, "id": "2659", "name": "Lung cancer", "status": null, "topic": { "__typename": "Topic", "id": "20", "name": "Respiratory Physiology", "typeId": 1 }, "topicId": 20, "totalCards": null, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 2659, "conditions": [], "difficulty": 1, "dislikes": 3, "explanation": null, "highlights": [], "id": "6538", "isLikedByMe": 0, "learningPoint": null, "likes": 0, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 67-year-old male smoker is noted to be hyponatraemic at 128 on routine bloods done at his general practice. All other bloods are normal. He is euvolaemic, and physical examination is normal. He also discloses that he has had some weight loss recently. He has no past medical history. He is a smoker with a 30 year pack history.\n\nWhich of the following investigations is most likely to provide a diagnosis?", "sbaAnswer": [ "a" ], "totalVotes": 3003, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": true, "explanation": "The criteria for LTOT in COPD are patients either a PaO2 <7.3 when stable or PaO2 7.3–8 kPa when stable and also have either secondary polycythaemia, peripheral oedema, or evidence of pulmonary hypertension (minimum of 15 hours per day). A haemoglobin of >160g/L in women is considered polycythaemia", "id": "32693", "label": "a", "name": "An arterial blood gas demonstrating PaO2 7.5 kPa and a Hb 170g/L in a stable patient who is no longer smoking", "picture": null, "votes": 1541 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "LTOT can be considered in the treatment of obstructive sleep apnoea in symptomatic patients despite continuous positive airways pressure therapy after specialist assessment", "id": "32695", "label": "c", "name": "A patient newly diagnosed with sleep apnoea", "picture": null, "votes": 38 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Smoking is an absolute contraindication for starting LTOT", "id": "32694", "label": "b", "name": "An arterial blood gas demonstrating PaO2 7.5 kPa and a Hb 170g/L in a stable patient who has reduced their smoking", "picture": null, "votes": 84 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "NICE guidance states that LTOT should be considered in patients with heart failure with daytime PaO2<7.3 kPa when breathing air or with nocturnal hypoxaemia", "id": "32696", "label": "d", "name": "A patient with heart failure with daytime PaO2 of 7.4 kPa on air", "picture": null, "votes": 396 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "In COPD, patients with PaO2 <7.3 kPa when stable and who do not smoke should be considered for LTOT, even without any other secondary sequelae of COPD (minimum of 15 hours per day)", "id": "32697", "label": "e", "name": "An arterial blood gas demonstrating PaO2 7.4 kPa in an otherwise well patient who is no longer smoking", "picture": null, "votes": 855 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nChronic obstructive pulmonary disease (COPD) is a chronic obstructive disease of the airways with the two main components being chronic bronchitis and emphysema. It usually develops due to smoking, with other risk factors including occupation exposures and air pollution. Patients present with breathlessness, a chronic productive cough and wheeze. Key investigations are spirometry (to confirm obstruction), full blood count (to identify anaemia or polycythaemia) and a chest X-ray to exclude lung cancer or other causes of symptoms. Management includes smoking cessation, pulmonary rehabilitation, consideration of long term oxygen therapy, inhaled or nebulised medical treatment and consideration of other medications e.g. mucolytics. Acute exacerbations of COPD may be infective or non-infective, and can be treated by increasing bronchodilator therapy, oral prednisolone and antibiotics (if an infective cause is suspected).\n\n# Definition\n\nChronic obstructive pulmonary disease (COPD) involves airway obstruction that is usually progressive. It encompasses both emphysema (where alveolar wall destruction leads to enlargement of the distal airspaces) and chronic bronchitis (persistent or recurrent productive cough usually due to mucus hypersecretion). \n\n# Epidemiology\n\nIn the UK 1.2 million people have a diagnosis of COPD, with an estimated 2 million people living with it undiagnosed. It is the 5th commonest cause of death in the UK, causing almost 30,000 deaths per year. \n\nAround 90% of COPD cases in the UK are caused by smoking, with household pollution being a bigger contributing factor in low and middle income countries.\n\n# Risk Factors\n\n- Tobacco smoking and passive smoke exposure\n- Marijuana smoking \n- Occupational exposure to dusts and fumes\n- Household air pollution from wood or coal burning\n- Alpha-1 antitrypsin deficiency\n\nPrognosis is variable, with the following factors associated with higher morbidity and mortality:\n\n- Poor exercise tolerance\n- Smoking\n- Low body mass index\n- Multi-morbidity and frailty\n- Exacerbations requiring admission to hospital or frequent exacerbations\n- Severe obstruction on spirometry (as measured by a lower FEV1)\n- Chronic hypoxia\n- Cor pulmonale\n\n# Pathophysiology\n\nChronic Bronchitis:\n\n- As a protective reaction to smoke or other pollutants, goblet cells hypersecrete mucus in the bronchi and bronchioles of the lungs.\nCilia are not able to remove the excess mucus and so it obstructs the small airways.\nOngoing inflammation causes remodelling and thickening of the airway walls that also contributes to obstruction.\n\nEmphysema:\n\n- Inflammation in the lungs is usually countered by antiproteases such as alpha-1 antitrypsin, however the activity of these is reduced by smoke and other pollutants. \n- Without sufficient antiprotease activity, proteolytic enzymes produced by inflammatory cells break down the walls of the alveoli.\n- This causes enlargement of the terminal airspaces and reduces the surface area available for gas exchange.\n\n# Classification\n\nThe Global Initiative for Chronic Obstructive Lung Disease (GOLD) classifies COPD severity using airflow limitation (as measured by FEV1), severity of symptoms and frequency of exacerbations. \n\n| GOLD Grade | Severity | Post-Bronchodilator FEV₁ (% Predicted) |\n|------------|--------------------------|----------------------------------------|\n| 1 | Mild | ≥ 80% |\n| 2 | Moderate | 50-79% |\n| 3 | Severe | 30-49% |\n| 4 | Very Severe | < 30% |\n\n\nThe two measures used to quantify symptom severity are the CAT (COPD Assessment Test) and the mMRC (modified Medical Research Council) dyspnoea scale which is given below:\n\n| Grade | Description |\n|-------|----------------------------------------------------------------------------------------------------|\n| 0 | I only get breathless with strenuous exercise. |\n| 1 | I get short of breath when hurrying on level ground or walking up a slight hill. |\n| 2 | On level ground, I walk slower than people of the same age because of breathlessness, or I have to stop for breath when walking at my own pace. |\n| 3 | I stop for breath after walking about 100 yards or after a few minutes on level ground. |\n| 4 | I am too breathless to leave the house, or I am breathless when dressing or undressing. |\n\n# Signs and symptoms\n\n- Shortness of breath that worsens with exertion\n- Reduced exercise tolerance\n- Chronic productive cough\n- Recurrent lower respiratory tract infections\n- Wheeze\n- In more advanced cases, systemic symptoms such as weight loss and fatigue may be present\n\nExamination may be normal, though signs may include:\n\n- Wheeze or crackles on auscultation\n- Accessory muscle usage\n- Pursed lip breathing (this creates a small amount of positive end expiratory pressure to prevent the alveoli from collapsing)\n- Cyanosis \n- Hyperinflation of the chest\n- Cachexia\n- Raised JVP and peripheral oedema (indicating cor pulmonale has developed)\n\n# Investigations\n\n- **Spirometry** - the diagnostic investigation for COPD and key to classification of severity, may be used to monitor progression of the disease. A FEV1/FVC ratio <0.7 confirms obstruction.\n\n- **Bloods** - Full blood count looking for polycythaemia (resulting from chronic hypoxaemia) or anaemia (usually anaemia of chronic disease), consider BNP to assess for heart failure (with an **echocardiogram** if suspected, alpha-1 antitrypsin in young patients/minimal smoking history/strong family history\n- **ECG** - the following ECG changes are often seen in advanced COPD with features of e.g. cor pulmonale, and include:\n\t- Right axis deviation\n\t- Prominent P waves in inferior leads\n\t- Inverted P waves in high lateral leads (I, aVL)\n\t- Low voltage QRS\n\t- Delayed R/S transition in leads V1-V6\n\t- P pulmonale\n\t- Right ventricular strain pattern\n\t- RBBB\n\t- Multifocal atrial tachycardia\n\n- **Chest X-ray** - used to rule out other causes of symptoms (e.g. lung cancer, bronchiectasis), may show features of COPD including hyperinflation of the chest with flattening of the hemidiaphragms and bullae.\n\n[lightgallery1]\n\n- **Sputum culture** - during exacerbations to target antibiotic therapy\n\n# Differential diagnosis\n\n- **Asthma:** may coexist with COPD, suspect if onset of symptoms <35, history of atopy, non-smoker, variable or nocturnal symptoms.\n- **Bronchiectasis:** copious secretions and coarse crepitations on examination, triggering factors include severe childhood respiratory tract infections.\n- **Heart Failure:** suspect in patients with ischaemic heart disease, may have orthopnoea and paroxysmal nocturnal dyspnoea.\n- **Interstitial Lung Disease:** dry rather than a productive cough, fine crackles on examination.\n- **Lung cancer:** patients with COPD are usually at higher risk due to smoking history, need to investigate for malignancy in cases with a persistent cough/haemoptysis/weight loss.\n- **Tuberculosis:** similar symptoms, systemic manifestations include fevers and weight loss, consider in at-risk groups.\n\n# Management of Chronic COPD\n\n**Conservative:**\n\n- Patient education, ensure all patients have a personalised self-management plan\n- Smoking cessation support\n- Nutritional support and dietician referral if malnourished\n- Annual influenza and one-off pneumococcal vaccination\n- Pulmonary rehabilitation (refer if grade 3 and above on mMRC dyspnoea scale or a recent admission for an acute exacerbation)\n- Consider referral for respiratory physiotherapy to help with sputum clearance and breathing techniques\n\n**Medical:**\n\n\n- For patients whose activities are limited by breathlessness, start a short-acting beta-2 agonist (SABA, e.g. salbutamol) or short-acting muscarinic antagonist (SAMA, e.g. ipratropium) inhaler\n- The next step depends on if they have features of asthma or steroid responsiveness: if these are present then add a long-acting beta-2 agonist (LABA, e.g. formoterol) and an inhaled corticosteroid (ICS, e.g. beclomethasone). If these are not present then add a LABA and a long-acting muscarinic antagonist (LAMA, e.g. tiotropium). \n- If patients do not respond adequately to this, the third inhaler can then be trialled (i.e. all patients would be on a SABA/SAMA + LABA + LAMA + ICS).\n\nPatients who require further therapy should be referred to a specialist for ongoing management which may include oral steroids, oral theophylline or oral phosphodiesterase-4 inhibitors (e.g. roflumilast).\n\nManagement of stable COPD is can be tailored according to the patient’s clinical phenotype. The following groups are defined according to 2024 NICE guidance:\n\n**Group A**\n \n- **Definition**: Patients with minimal symptoms (mMRC grade 0–1 or CAT score <10) and no history of exacerbations requiring hospitalisation or oral corticosteroids in the last year. \n- **Management**:\n - Start with a **short-acting bronchodilator (SABA or SAMA)** as needed for symptom relief.\n - If symptoms are not controlled, consider switching to a long-acting bronchodilator: \n - **LAMA** or **LABA**, depending on individual tolerance and symptom profile. \n\n**Group B**\n \n- **Definition**: Patients with significant symptoms (mMRC grade ≥2 or CAT score ≥10) but no exacerbations requiring hospitalisation or oral corticosteroids in the last year. \n- **Management**: \n - Initiate treatment with a **LAMA** or **LABA** as maintenance therapy. \n - If symptoms persist despite monotherapy, escalate to **dual therapy (LABA + LAMA)**. \n\n**Group E**\n \n- **Definition**: Patients with frequent exacerbations (≥2 per year or ≥1 requiring hospitalisation) regardless of symptom burden. \n- **Management**: \n - First-line therapy is **LAMA** for exacerbation prevention. \n - If exacerbations persist, escalate to: \n\t - **Dual therapy (LABA + LAMA)**. \n\t - If asthmatic features or steroid responsiveness are present (e.g., eosinophilia or a history of asthma), consider **LABA + ICS**. \n - For patients who continue to experience exacerbations despite dual therapy, switch to **triple therapy (LABA + LAMA + ICS)**. \n\n\n\n| **Group** | **Phenotype** | **Initial Therapy** | **Escalation Therapy** | \n|-------------|--------------------------------|------------------------------|------------------------------------| \n| **Group A** | 0 or 1 moderate exacerbation not leading to hospitalisation | SABA or SAMA as needed | LAMA or LABA | \n| **Group B** | 0 or 1 moderate exacerbation not leading to hospitalisation| LAMA or LABA | LABA + LAMA | \n| **Group E** | 2 or more moderate exacerbations or 1 or more exacerbations leading to hospitalisation\t | LAMA | LABA + LAMA or LABA + LAMA + ICS | \n\n\nOther medical treatments that may be considered include:\n\n- Oral mucolytic therapy - for patients with a chronic cough productive of sputum.\n- Prophylactic antibiotics - in cases of frequent infective exacerbations, should be discussed with a specialist, a common choice would be azithromycin 3x per week.\n- Nebuliser therapy - for patients with disabling breathlessness despite optimised use of inhalers.\n- Long-term oxygen therapy (LTOT) - see below for more details\n\n\n**Surgical:**\n\n- In certain cases of severe COPD when patients have not responded to maximal medical therapies, surgical intervention may be considered. \n- Both the NICE recommended options involve lung volume reduction (which involves removing emphysematous areas of the lung so that the healthy lung can expand) - this can be done either by surgical resection or using bronchoscopy to site a one-way valve in one of the larger airways to collapse the diseased lung. \n\n### Long term oxygen therapy (LTOT)\n\n**The following patients should be referred for assessment for LTOT:**\n\n- Oxygen saturations <92% in air or cyanosis\n- FEV1 <30% predicted (consider referring if <49%)\n- Polycythaemia\n- Peripheral oedema or raised jugular venous pressure (suggesting cor pulmonale)\n\nThis assessment involves ensuring that patients are medically optimised and their COPD is stable (i.e. they’re not recovering from a recent exacerbation). Patients who are current smokers cannot be offered LTOT because of the risk of burns and fires. \n\nPatients then have two ABGs in air at least 3 weeks apart and the following patients should be offered LTOT (with the advice to use the oxygen for at least 15 hours per day):\n\n- PaO2 below 7.3kPa\n- PaO2 7.3-8kPa with any of secondary polycythaemia, peripheral oedema or pulmonary hypertension\n\n# Complications\n\n## Acute exacerbations\n\n- These present with worsening breathlessness, productive cough and wheeze, and patients may be febrile, tachycardic and tachypnoeic. \n- Patients who are clinically well may be treated at home with an increase in their usual inhalers, a short course of oral steroids (usually 30mg prednisolone for 5 days) and oral antibiotics if bacterial infection is suspected. \n- Those who have frequent exacerbations may be given a “rescue pack” of steroids and antibiotics to keep at home and start using in case of an exacerbation (alongside seeking medical help).\n\n- Patients requiring hospital admission should also receive steroids and antibiotics if indicated. \n- They may require nebulised bronchodilators, supplementary oxygen and in case of deterioration respiratory support with non-invasive ventilation may be required. \n- Advanced care planning and ensuring that escalation status is discussed with patients is therefore key, so that if they deteriorate to the point of needing intensive care support it is established whether or not this is appropriate and in line with their wishes.\n\n## Polycythaemia\n\n- Chronic tissue hypoxia as seen in COPD leads to a compensatory overproduction of erythropoietin, which leads to increased red blood cell production (i.e. secondary polycythaemia). \n- This causes an increase in blood viscosity that in turns increases risk of both arterial and venous thrombosis. \n\n\n## Cor Pulmonale\n\nCor pulmonale refers to right ventricular dilation or hypertrophy in response to pulmonary hypertension caused by chronic lung disease - COPD is not the only cause of this but it is the most common.\n\nThe pathophysiology is as follows:\n\n- Changes in the lungs and chronic hypoxaemia cause the walls of the pulmonary arteries to thicken.\n- This increases vascular resistance in the lungs.\n- The right ventricle then has to pump against greater resistance, which causes it to either dilate or hypertrophy.\n- Ultimately this leads to right heart failure, with resulting peripheral oedema, hepatomegaly and elevated jugular venous pressure (JVP).\n\nPeripheral oedema may be treated symptomatically with diuretics and long-term oxygen therapy has been shown to reduce morbidity and mortality. All patients with suspected cor pulmonale should be referred to secondary care.\n\n## Pneumothorax\n\n- COPD is a common cause of secondary pneumothoraces (i.e. a pneumothorax secondary to underlying lung disease). These occur when a bulla ruptures, releasing air into the pleural cavity. \n- Investigations and treatment are as per the BTS guidelines (see Pneumothorax chapter for more details).\n\n## Depression and anxiety\n- Over 1 in 3 people with COPD report symptoms of depression and anxiety so screening for this is important during patient reviews. \n- The COPD Assessment Test (CAT) can be used to assess the impact of COPD on everyday life. \n- Referral to psychological services for support may be appropriate, as well as holistic assessment and management.\n\n# NICE Guidelines\n\n[Click here for the NICE Guidelines](https://www.nice.org.uk/guidance/ng115)\n\n[NICE CKS - COPD](https://cks.nice.org.uk/topics/chronic-obstructive-pulmonary-disease/)\n\n# References\n\n[Patient UK - COPD](https://patient.info/doctor/chronic-obstructive-pulmonary-disease-pro)\n\n[GOLD report 2023](https://goldcopd.org/2023-gold-report-2/)\n\n[Radiopaedia - COPD](https://radiopaedia.org/articles/chronic-obstructive-pulmonary-disease-1?lang=gb)\n\n[Patient UK - Cor Pulmonale](https://patient.info/doctor/cor-pulmonale)", "files": null, "highlights": [], "id": "333", "pictures": [ { "__typename": "Picture", "caption": null, "createdAt": 1672906681, "id": "1438", "index": 0, "name": "COPD Management (NICE).png", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/mkmpa7kp1672906675509.jpg", "path256": "images/mkmpa7kp1672906675509_256.jpg", "path512": "images/mkmpa7kp1672906675509_512.jpg", "thumbhash": "9PcFBQD5tpaJhmhHiFnnyP2Bx0+o", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "A chest x-ray showing hyperinflated lungs and a flattened diaphragm in an individual with COPD.", "createdAt": 1665036254, "id": "1089", "index": 1, "name": "COPD.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/7sn9efza1665036171695.jpg", "path256": "images/7sn9efza1665036171695_256.jpg", "path512": "images/7sn9efza1665036171695_512.jpg", "thumbhash": "G/gNDQAH2XeJeHiHd4lnd7K3D22q", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 333, "demo": null, "entitlement": null, "id": "2643", "name": "Chronic obstructive pulmonary disease (COPD)", "status": null, "topic": { "__typename": "Topic", "id": "20", "name": "Respiratory Physiology", "typeId": 1 }, "topicId": 20, "totalCards": 3, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 2643, "conditions": [], "difficulty": 3, "dislikes": 1, "explanation": null, "highlights": [], "id": "6539", "isLikedByMe": 0, "learningPoint": null, "likes": 1, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 72-year-old female is admitted to hospital and treated for a non-infective exacerbation of her chronic obstructive pulmonary disease (COPD). She clinically improves with a short period of non-invasive ventilation (NIV), nebulisers and steroids; however, she has an ongoing oxygen requirement of 1-2 litres via nasal cannula to maintain her saturations.\n\nWhich of the following statements is a criterion for starting long term oxygen therapy (LTOT)?", "sbaAnswer": [ "a" ], "totalVotes": 2914, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Oral steroids are reasonable in symptomatic sarcoid; however, intravenous pulsed steroids are rarely indicated in sarcoidosis", "id": "32699", "label": "b", "name": "Pulsed high dose intravenous steroids", "picture": null, "votes": 147 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "For patients who cannot be treated with low-dose glucocorticoids and an antimetabolite, anti-tumour necrosis factor (TNF) monoclonal antibodies have been shown to control disease. However, anti-TNF drugs are associated with substantial toxic effects and, in some cases, are ineffective", "id": "32702", "label": "e", "name": "Intravenous infliximab", "picture": null, "votes": 77 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Oral steroids are often used to treat stage two and above or in symptomatic stage one sarcoidosis; however, as this patient is otherwise well and asymptomatic, it is reasonable to watch and wait in the first instance", "id": "32700", "label": "c", "name": "Oral steroids", "picture": null, "votes": 1758 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "In patients with stage one sarcoid who are otherwise asymptomatic, many will spontaneously resolve without the need for any treatment", "id": "32698", "label": "a", "name": "Watch and wait", "picture": null, "votes": 812 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Antimetabolites such as methotrexate, azathioprine and mycophenolate may be used to treat symptomatic sarcoidosis as an alternative to steroids; however, as this patient is otherwise well and asymptomatic, it is reasonable to watch and wait in the first instance", "id": "32701", "label": "d", "name": "Oral methotrexate", "picture": null, "votes": 133 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Quesbook needs more detail", "createdAt": 1645792348, "dislikes": 0, "id": "7635", "isLikedByMe": 0, "likes": 5, "parentId": null, "questionId": 6540, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Dermis Cystic", "id": 4236 } }, { "__typename": "QuestionComment", "comment": "But shes symptomatic? ", "createdAt": 1646141979, "dislikes": 1, "id": "7825", "isLikedByMe": 0, "likes": 4, "parentId": null, "questionId": 6540, "replies": [ { "__typename": "QuestionComment", "comment": "You only treat w steroids if there is visual disturbance AFAIK", "createdAt": 1647683954, "dislikes": 0, "id": "8790", "isLikedByMe": 0, "likes": 1, "parentId": 7825, "questionId": 6540, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Supine Thermoregulator", "id": 12470 } }, { "__typename": "QuestionComment", "comment": "steroids in stage 2/3 disease only if organs other than just the lungs are involved (eye, heart, neuro) or if there is hypercalcaemia", "createdAt": 1680278370, "dislikes": 0, "id": "21057", "isLikedByMe": 0, "likes": 3, "parentId": 7825, "questionId": 6540, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Axillary Gas", "id": 20974 } }, { "__typename": "QuestionComment", "comment": "yh dry cough is symptomatic", "createdAt": 1704823285, "dislikes": 0, "id": "38320", "isLikedByMe": 0, "likes": 0, "parentId": 7825, "questionId": 6540, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Malignant Syndrome", "id": 15952 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Monoclonal Fracture", "id": 13300 } }, { "__typename": "QuestionComment", "comment": "Pulmonary sarcoidosis radiographic staging\n\nStage 0: normal\n\nStage I: bilateral hilar lymphadenopathy\n\nStage II: bilateral hilar lymphadenopathy plus pulmonary infiltrates\n\nStage III: pulmonary infiltrates without hilar lymphadenopathy\n\nStage IV: extensive fibrosis with distortion.", "createdAt": 1647388453, "dislikes": 1, "id": "8625", "isLikedByMe": 0, "likes": 5, "parentId": null, "questionId": 6540, "replies": [ { "__typename": "QuestionComment", "comment": "Flexxx", "createdAt": 1648903060, "dislikes": 0, "id": "9342", "isLikedByMe": 0, "likes": 1, "parentId": 8625, "questionId": 6540, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Gas Womb", "id": 11041 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Yellow Zebras", "id": 17804 } }, { "__typename": "QuestionComment", "comment": "She's literally symptomatic tho ???", "createdAt": 1655210516, "dislikes": 0, "id": "12106", "isLikedByMe": 0, "likes": 6, "parentId": null, "questionId": 6540, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Epidermis Biopsy", "id": 11461 } }, { "__typename": "QuestionComment", "comment": "indications for steroids = PUNCH\nParenchymal lung disease\nUveitis\nNeuro involvement\nCardiac involvement\nHypercalcemia", "createdAt": 1684848324, "dislikes": 0, "id": "25815", "isLikedByMe": 0, "likes": 6, "parentId": null, "questionId": 6540, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Kinin Polyps", "id": 15231 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Epidemiology\n\nAround 4,500 people are diagnosed with sarcoidosis in the UK each year representing an annual incidence rate of 7 people per 100,000.\n\n# Definition\n\nSarcoidosis is a multi-system disease characterised by granuloma formation, resulting in widespread inflammatory changes and complications.\n\n# Acute sarcoidosis features\n\nAcute sarcoidosis: fever, polyarthralgia, erythema nodosum, and bilateral hilar lymphadenopathy. This is also known as **Löfgren syndrome**.\n\n# Chronic sarcoidosis features\n\n- Pulmonary (most common manifestation): dry cough, dyspnoea, reduced exercise tolerance. Examination may reveal crepitations.\n\n- Constitutional: fatigue, weight loss, arthralgia, and low-grade fever. General signs include lymphadenopathy and enlarged parotid glands.\n\n- Neurological: meningitis, peripheral neuropathy, bilateral Bell's palsy.\n\n- Ocular: uveitis, keratoconjunctivitis sicca.\n\n- Cardiac: arrhythmias, restrictive cardiomyopathy.\n\n- Abdominal: hepatomegaly, splenomegaly, renal stones.\n\n- Dermatological: erythema nodosum, lupus pernio.\n\n# Investigation\n\nTissue biopsy (eg. lung, lymph nodes) is diagnostic, which typically finds non-caseating granulomas. However, other investigations can point towards a diagnosis of sarcoidosis.\n\n- Bloods: Raised ESR, ACE (not specific or diagnostic) and calcium; reduced lymphocytes.\n\n- Chest x-ray or CT:\n - Stage 1 - bilateral hilar lymphadenopathy (BHL)\n - Stage 2 - BHL with peripheral infiltrates\n - Stage 3 - peripheral infiltrates alone\n - Stage 4 - pulmonary fibrosis\n\n# Management\n\n- Bilateral hilar lymphadenopathy alone - usually self-limiting\n- Acute sarcoidosis - bed rest, NSAIDs\n- Steroid treatment: oral or IV, depending on severity of disease\n- Immunosuppressants: in severe disease", "files": null, "highlights": [], "id": "1813", "pictures": [], "typeId": 4 }, "chapterId": 1813, "demo": null, "entitlement": null, "id": "2648", "name": "Sarcoidosis", "status": null, "topic": { "__typename": "Topic", "id": "20", "name": "Respiratory Physiology", "typeId": 1 }, "topicId": 20, "totalCards": null, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 2648, "conditions": [], "difficulty": 3, "dislikes": 5, "explanation": null, "highlights": [], "id": "6540", "isLikedByMe": 0, "learningPoint": null, "likes": 0, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 34-year-old female presents to GP with a mild persistent dry cough and rash. Observations and routine bloods are normal other than a raised erythrocyte sedimentation rate (ESR); her doctor refers her for a chest x-ray which shows bilateral hilar lymphadenopathy.\n\nWhat is the most appropriate treatment?", "sbaAnswer": [ "a" ], "totalVotes": 2927, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "The National Institute for Health and Care Excellence (NICE) recommends that nicotine replacement therapy (NRT) with varenicline OR bupropion, as appropriate, to people planning to stop smoking; however, these medications should not be used in combination. In addition, patients should be advised not to smoke whilst on NRT", "id": "32707", "label": "e", "name": "Offer nicotine replacement therapy (NRT) with varenicline AND bupropion", "picture": null, "votes": 218 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Some patients may find acupuncture beneficial; however, it has not been shown to be effective in clinical trials and therefore is not currently recommended", "id": "32706", "label": "d", "name": "Acupuncture", "picture": null, "votes": 0 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Some patients may find hypnotherapy beneficial; however, it has not been shown to be effective in clinical trials and, therefore, is not recommended", "id": "32705", "label": "c", "name": "Referral for hypnotherapy", "picture": null, "votes": 3 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Whilst behavioural therapy can be helpful in stopping smoking in identifying triggers and craving coping strategies, behavioural therapy alone has a lower success rate than when used in conjunction with NRT", "id": "32704", "label": "b", "name": "Cognitive behavioural therapy alone", "picture": null, "votes": 177 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "The National Institute for Health and Care Excellence (NICE) recommends that nicotine replacement therapy (NRT) with varenicline or bupropion, as appropriate, to people planning to stop smoking. Patients should be advised not to smoke whilst on NRT", "id": "32703", "label": "a", "name": "Offer nicotine replacement therapy (NRT) with varenicline OR bupropion", "picture": null, "votes": 2590 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nSmoking is a major public health issue, leading to premature death and multiple health conditions including cancers, COPD and cardiovascular diseases. Encouraging smoking cessation is therefore an important aspect of health promotion. The main strategies include behavioural therapies and pharmacotherapies, which include nicotine replacement therapy (NRT), bupropion, and varenicline. E-cigarettes and vaping are popular aids to smoking cessation and may be offered alongside behavioural support.\n\n# Epidemiology\n\nSmoking is the single biggest cause of premature death in the UK. There are around 10 million active smokers and approximately 50% will eventually die from smoking related conditions (on average 10 years earlier than non-smokers).\n\nConditions associated with smoking include:\n\n- Cancer - smoking is the commonest cause of lung cancer, and contributes to the development of many other tumour types\n- COPD\n- Cardiovascular disease - including stroke, ischaemic heart disease and peripheral vascular disease\n- Peptic ulcers\n- Pregnancy complications (e.g. stillbirth, birth defects, low birth weight)\n- Infertility\n- Osteoporosis\n- Dementia\n- Dental disease\n\nPassive smoking (exposure to second-hand smoke) is also associated with increased risk of lung cancer and heart disease as well as asthma, chest infections and otitis media in children.\n\n# Nicotine Withdrawal Symptoms\n\nWhen attempting to stop smoking, people may experience a variety of unpleasant symptoms due to both physical and psychological dependence on smoking and nicotine. \n\nMost people find they improve within 2-3 weeks of stopping smoking although some may last longer.\n\nSymptoms include:\n\n- Mood changes (irritability, frustration, anger, anxiety, depression)\n- Insomnia\n- Poor concentration\n- Increased appetite and weight gain\n- Restlessness\n- Cravings for cigarettes\n\n# Management\n\n- Patients should be asked if they smoke at every opportunity\n- Those who do smoke should be offered Very Brief Advice (VBA), also known as the 3 As:\n- **Ask** patients if they smoke\n- **Advise** those who smoke that the best way to quit is with specialist support\n- **Act** refer to smoking cessation services if they wish to quit\n- Those who do not want to quit smoking should be offered advice about harm reduction and encouraged to seek support if they are considering quitting\n- Harm reduction strategies include:\n- Cutting down with or without NRT \n- Temporarily stopping smoking with or without NRT\n- Using an e-cigarette\n\n## Behavioural Advice\n\n- Abrupt quitting is the most effective way to stop smoking\n- Encourage patients to set a quit date\n- After this date they should commit to not smoking at all (\"not a puff\" rule)\n- Think about ways to avoid other people smoking and situations in which they would usually smoke\n- Discuss individual barriers to stopping smoking\n- Signpost to resources e.g. free helplines, phone apps\n- Individual and group support services are also available \n- Offer follow up and ongoing support\n\n## Medical Management\n\nOnly one of the following should be prescribed at any time.\n\n- **Nicotine replacement therapy (NRT)**\n\t- Reduces cravings and nicotine withdrawal symptoms\n\t- Multiple formulations are available including patches, gums, sprays and lozenges\n\t- Should be started on the day of quitting\n\t- Common side-effects include nausea, dizziness, vivid dreams and palpitations\n\t- Combination NRT is the most effective - this involves using a patch for 'background' cravings and a short-acting preparation (e.g. a mouth spray) for 'breakthrough' cravings\n- **Bupropion**\n\t- Acts by inhibiting reuptake of dopamine and noradrenaline\n\t- Tablet taken once a day for 6 days then twice a day for 7-9 weeks\n\t- Should be started 7-14 days before the quit date\n\t- Contraindicated in:\n\t- Epilepsy (decreases seizure threshold)\n\t- Eating disorders\n\t- Bipolar disorder\n\t- Brain tumours\n\t- Current benzodiazepine or alcohol withdrawal\n\t- Pregnancy and breast-feeding\n\t- Important side-effects include insomnia, hypersensitivity reactions and rarely seizures\n- **Varenicline**\n\t- Works as a partial nicotinic receptor agonist\n\t- Taken as an oral medication which is uptitrated in dose over the first week\n\t- Start 7-14 days before the quit date, usually continued for 12 weeks\n\t- Contraindicated in pregnancy and end-stage renal disease\n\t- Important side-effects include psychiatric effects (e.g. suicidal thoughts, depression and hallucinations), nausea and headaches\n- **E-cigarettes**\n\t- These are not licensed medications and are not available on the NHS currently but patients may wish to buy them \n\t- Patients should be advised that there is not enough evidence to know whether there are long-term harms of vaping\n\t- However, available evidence suggests that vaping is significantly less harmful than smoking and can help people stop smoking\n\t- Advise patients using e-cigarettes to stop smoking tobacco completely\n\n# Prognosis\n\nAround half of people using NHS Stop Smoking services are successful in quitting at four weeks, with evidence suggesting that people who stop smoking for a month are five times more likely to quit long term. \n\nStopping smoking before the age of 50 halves the risk of dying of smoking-related disease.\n\n\n# NICE Guidelines\n\n[NICE - Tobacco dependence](https://www.nice.org.uk/guidance/ng92)\n\n[NICE CKS - Smoking Cessation](https://cks.nice.org.uk/topics/smoking-cessation/)\n\n# References\n\n[Action on Smoking and Health](https://ash.org.uk/)\n\n[NHS advice on e-cigarettes](https://www.nhs.uk/live-well/quit-smoking/using-e-cigarettes-to-stop-smoking/)\n\n[National Centre for Smoking Cessation and Training](https://www.ncsct.co.uk/)", "files": null, "highlights": [], "id": "1861", "pictures": [], "typeId": 2 }, "chapterId": 1861, "demo": null, "entitlement": null, "id": "2660", "name": "Smoking Cessation", "status": null, "topic": { "__typename": "Topic", "id": "20", "name": "Respiratory Physiology", "typeId": 1 }, "topicId": 20, "totalCards": 1, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 2660, "conditions": [], "difficulty": 1, "dislikes": 1, "explanation": null, "highlights": [], "id": "6541", "isLikedByMe": 0, "learningPoint": null, "likes": 0, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 45-year-old male presents to General Practice requesting help and advice on quitting smoking.\n\nWhat is the most appropriate treatment?", "sbaAnswer": [ "a" ], "totalVotes": 2988, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Warfarin is an anticoagulant that is sometimes used in patients who are pro-coagulant or who have venous thrombosis, particularly if they have failed treatment with a direct oral anticoagulant (DOAC). It is also used in patients with metal heart valves. It is not of benefit in this patient's case", "id": "32710", "label": "c", "name": "Warfarin", "picture": null, "votes": 42 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient most likely has Raynaud's phenomenon as she is experiencing paroxysmal digital ischaemia when exposed to the cold. It is often associated with underlying rheumatological conditions, including systemic sclerosis, rheumatoid arthritis and systemic lupus erythematosus (SLE). Treatment is mostly trigger management - keeping fingers warm, smoking cessation and avoiding stress - however in some cases, nifedipine may help symptoms", "id": "32708", "label": "a", "name": "Nifedipine", "picture": null, "votes": 4598 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Aspirin is an antiplatelet medication often used in peripheral vascular disease. While this patient has digital ischaemia, it is paroxysmal; therefore, aspirin is not the treatment of choice", "id": "32709", "label": "b", "name": "Aspirin", "picture": null, "votes": 232 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Epoprostenol is also known as prostaglandin I2 and is an effective vasodilator. It is sometimes used to treat severe attacks of Raynaud's, e.g. where there are concerns about digital gangrene or the development of digital necrosis. It is a rescue therapy and is not used routinely. Relapse is common after infusion, and some patients with severe disease require regular infusions, particularly in the winter months", "id": "32712", "label": "e", "name": "Epoprostenol", "picture": null, "votes": 353 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Apixaban is an anticoagulant (in the DOAC category) that is often used in the treatment of deep vein thrombosis and in patients who are pro-coagulant. It is not currently used in the treatment of Raynaud's phenomenon", "id": "32711", "label": "d", "name": "Apixaban", "picture": null, "votes": 116 } ], "comments": [ { "__typename": "QuestionComment", "comment": "how does everyone know this lol", "createdAt": 1686221178, "dislikes": 0, "id": "28155", "isLikedByMe": 0, "likes": 6, "parentId": null, "questionId": 6542, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "hiney", "id": 20231 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nRaynaud's phenomenon refers to episodes of vasospasm of small arteries and arterioles, which leads to reduced blood flow to the extremities, usually the fingers and toes. This classically manifests with the digits going pale, then cyanosed, then erythematous (with this final stage often being uncomfortable). Triggers include cold exposure and emotional stress. The majority of cases are classified as primary, however around 10% of cases are associated with underlying disease such as systemic sclerosis or polycythaemia. Diagnosis is clinical; however underlying causes should be screened for with a full blood count, ESR and antinuclear antibodies. Other investigations should be carried out if an underlying cause is suspected. Management involves lifestyle changes such as wearing gloves and warm footwear, smoking cessation and reviewing medications that may exacerbate Raynaud's. If conservative measures are ineffective, medical treatment with nifedipine can be considered. Patients with suspected secondary Raynaud's phenomenon should be referred to rheumatology. \n\n# Definition\n\nRaynaud's phenomenon is a condition where arteries or arterioles constrict, decreasing blood flow to the affected areas. Attacks are usually triggered by cold exposure, with other triggers including emotional stress, vibration injury, smoking and medications (e.g. beta-blockers). The fingers and toes are the most commonly affected areas. \n\n# Epidemiology\n\n- Primary Raynaud's phenomenon is common and affects around 5% of people\n- It is more common in women and in people living in colder climates\n- Other risk factors include:\n- Family history\n- Smoking\n- Migraine\n- Secondary Raynaud's phenomenon is much less common, making up 10-20% of cases\n- Patients with secondary Raynaud's phenomenon tend to be older than patients with primary disease (suspect if symptoms start over the age of 30)\n\n# Classification\n\n**Primary Raynaud's phenomenon** (PRP, also known as \"idiopathic\" Raynaud's) is not associated with an underlying cause\n\n- It typically develops between the ages of 10 and 30\n- It is usually a benign condition which may improve with age\n- Although some patients may experience significant discomfort with severe primary Raynaud's, complications such as ischaemia or ulceration are not seen\n\n**Secondary Raynaud's phenomenon** (SRP) may be associated with a variety of pathologies including:\n\n- Rheumatological conditions e.g. systemic sclerosis, systemic lupus erythematosus, dermatomyositis, rheumatoid arthritis and Sjogren's syndrome\n- Haematological conditions e.g. polycythaemia, protein C/S/antithrombin III deficiency, paraproteinaemia, Factor V Leiden\n- Medications e.g. beta-blockers, methylphenidate, some chemotherapy agents and interferons\n- Recreational drugs e.g. cocaine, amphetamines\n- Occupational causes e.g. vinyl chloride exposure, hand-arm vibration syndrome (due to long-term use of tools such as chainsaws or grinders)\n- Extrinsic compression of vessels e.g. carpal tunnel syndrome\n- Endocrine conditions e.g. hypothyroidism, carcinoid syndrome and phaeochromocytoma\n\nSymptoms of secondary Raynaud's phenomenon are usually more severe than in PRP, especially in cases secondary to a connective tissue disorder.\n\nFeatures that should raise suspicion of SRP include:\n\n- Onset after age 30\n- Asymmetrical digit involvement\n- Intense and painful episodes\n- Digital ulcers, gangrene or ischaemia\n- Abnormal nail fold capillaroscopy\n- Clinical features suggestive of underlying disease (e.g. sclerodactyly)\n- Positive antinuclear antibodies\n\n# Signs and Symptoms \n\n- Typically the tips of the digits go pale - this may spread proximally and is clearly demarcated\n- They may then become blue and cyanosed\n- The affected digits may be numb or painful\n- This is often followed by a hyperaemic phase where the affected areas become erythematous with associated discomfort and paraesthesias\n- The thumb is usually spared\n- Other areas that may be affected include:\n- Tip of the nose\n- Ear lobes\n- Nipples\n- Tongue\n\n[lightgallery] \n\nEspecially in PRP, there may be no signs on examination unless the patient is currently experiencing an attack. \n\nSigns in SRP may include:\n\n- Abnormal nailfold capillaries (examine with a dermatoscope)\n- Asymmetrical peripheral pulses or blood pressure between arms\n- Ulceration, ischaemia or necrosis of digits\n- Scarring\n- Secondary infection\n\n# Differential Diagnosis\n\n- **Frostbite** - occurs when tissues are frozen, causing microvascular occlusion and ischaemia. Skin is cold and numb, and may be discoloured and purple with blistering and necrosis in more severe cases.\n- **Chilblains** - localised inflammatory lesions caused by cold exposure; itchy, red-purple swellings form that may blister and ulcerate.\n- **Acrocyanosis** - persistent painless cyanosis of the extremities that is exacerbated by cold exposure, usually associated with clamminess and hyperhidrosis\n- **Erythromelalgia** - vasodilatation of small vessels causes burning pain, warmth and erythema of the hands and feet which may be continuous or episodic; often triggered by heat or exercise\n- **Livedo reticularis** - red-blue mottling of the skin that in physiological cases is triggered by cold weather (in pathological cases the rash is persistent)\n- **Vascular occlusion** e.g. acute cholesterol embolism may cause blue discolouration of the toes however this is not episodic; there is often ischaemia of other organs and a systemic inflammatory response\n\n# Investigations\n\n- Patients should all have basic bloods for the following:\n- **Full blood count** - looking for polycythaemia, a thrombocytosis may be seen in inflammatory states\n- **Erythrocyte sedimentation rate** (ESR) - raised in inflammatory conditions\n- **Antinuclear antibodies** (ANA) - positive in around 10% of the general population, associated with some causes of SRP such as systemic lupus erythematosus and scleroderma \n\nOther investigations should be targeted if there are signs and symptoms of another underlying cause, e.g. thyroid function tests, testing for prothrombotic conditions, chest X-ray looking for a cervical rib\n\nPatients with suspected SRP should be referred for nailfold capillaroscopy to examine these for abnormalities (such as widened capillaries and microhaemorrhages in systemic sclerosis)\n\n# Management\n\n**Conservative:**\n\n- Lifestyle advice and education:\n- The whole body should be kept warm, with gloves and warm footwear worn in cold weather\n- Hand and foot warming devices may be useful\n- Regular exercise\n- Smoking cessation\n- Address emotional stress if this is a trigger\n- Review medications for triggers (such as beta-blockers) and consider stopping or switching to an alternative if possible\n- Occupational health referral for patients whose Raynaud's phenomenon may be work-related (e.g. secondary to vibrating tools)\n- Patients with suspected secondary Raynaud's phenomenon should be referred to rheumatology, as well as patients with severe or treatment-resistant primary Raynaud's\n- Patients with severe ischaemia of digits or other significant complications require emergency hospital admission\n\n**Medical:**\n\n- Nifedipine (a calcium channel blocker) as the first-line prophylactic treatment\n- If this is not tolerated (common side-effects being headaches, flushing, ankle swelling, palpitations and dizziness), an alternative is amlodipine\n- Patients may take this regularly or intermittently e.g. when the weather is cold or when doing outdoor activities\n- Secondary care options for patients with severe complications include intravenous prostaglandins (e.g. iloprost), sildenafil and bosentan (an endothelin receptor antagonist)\n\n**Interventional:**\n\n- Rarely, some patients with severe disease may be offered a sympathectomy, where sympathetic nerves that cause vasoconstriction are resected surgically\n- Botox injections to block the sympathetic nerves in the hands and/or feet are also an option\n\n# Prognosis\n\n- Primary Raynaud's syndrome is typically benign and may improve over time\n- Some patients enter a state of remission where they no longer experience episodes\n- However some patients who have severe symptoms may find their quality of life is affected by discomfort and functional impairment\n- Secondary Raynaud's syndrome is in general more severe and may lead to complications including:\n- Digital ischaemia, with pitting, ulceration or gangrene\n- Tissue loss and scarring\n- Poor wound healing and secondary infection\n- The prognosis for secondary Raynaud's syndrome is variable depending on the underlying cause and whether this is avoidable or treatable\n\n# NICE Guidelines\n\n[NICE CKS - Raynaud's Phenomenon](https://cks.nice.org.uk/topics/raynauds-phenomenon/)\n\n# References\n\n[Patient UK - Raynaud's Phenomenon](https://patient.info/doctor/raynauds-phenomenon-pro)", "files": null, "highlights": [], "id": "418", "pictures": [ { "__typename": "Picture", "caption": "The typical appearance of raynaud's syndrome.", "createdAt": 1665036198, "id": "1042", "index": 0, "name": "Raynauds.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/rvb7tj051665036171696.jpg", "path256": "images/rvb7tj051665036171696_256.jpg", "path512": "images/rvb7tj051665036171696_512.jpg", "thumbhash": "mUgGE4RXdNl/Z5mW33OECRc=", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 418, "demo": null, "entitlement": null, "id": "422", "name": "Raynaud's phenomenon", "status": null, "topic": { "__typename": "Topic", "id": "54", "name": "Rheumatology", "typeId": 2 }, "topicId": 54, "totalCards": 7, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "422", "name": "Raynaud's phenomenon" } ], "demo": false, "description": null, "duration": 193.41, "endTime": null, "files": null, "id": "340", "live": false, "museId": "fXy1P72", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/rheumatology.png", "title": "Raynaud's phenomenon", "userViewed": false, "views": 41, "viewsToday": 1 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "422", "name": "Raynaud's phenomenon" } ], "demo": false, "description": null, "duration": 3438.81, "endTime": null, "files": null, "id": "336", "live": false, "museId": "zevTJAw", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/rheumatology.png", "title": "Quesmed Tutorial: Rheumatology", "userViewed": false, "views": 260, "viewsToday": 16 } ] }, "conceptId": 422, "conditions": [], "difficulty": 1, "dislikes": 0, "explanation": null, "highlights": [], "id": "6542", "isLikedByMe": 0, "learningPoint": "Nifedipine, a calcium channel blocker, is commonly used to treat Raynaud's disease by relaxing blood vessels and improving blood flow, reducing the frequency and severity of episodes of vasoconstriction and color changes in the fingers.", "likes": 5, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 48-year-old female presents to General Practice complaining of cold, painful fingers. She reports that her fingers go blue after being outside (particularly if she forgets her gloves) but that they regain their colour when she comes inside. Her only past medical history is significant for rheumatoid arthritis, for which she takes methotrexate.\n\nWhat medication should you consider starting?", "sbaAnswer": [ "a" ], "totalVotes": 5341, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Steroid injections may be of benefit in reducing her symptoms but are not always effective and carry risks, including that of introducing infection; as she has diabetes, this risk is even more of a concern. Other interventions should be considered first in this case", "id": "32714", "label": "b", "name": "Steroid injection", "picture": null, "votes": 172 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This patient has the start of osteoarthritis as seen in her x-ray changes and therefore should be advised on lifestyle modifications to prevent the progression of symptoms", "id": "32716", "label": "d", "name": "Watch and wait", "picture": null, "votes": 19 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "TKR is often the best way to deal with severe arthritis when it impacts the quality of life; however, this patient has a short history and has yet to attempt any non-surgical management. In addition, TKRs only last around 15 years, and as this patient is young, this is best avoided at present", "id": "32717", "label": "e", "name": "Total knee replacement (TKR)", "picture": null, "votes": 16 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen are beneficial in treating the pain associated with osteoarthritis; however, this patient already has a degree of reflux, which would be exacerbated by NSAID use. If NSAIDs were required, topical would be first-line, or if that was ineffective, ibuprofen would likely be the first-line oral option as it is not as strong. She would require gastric protection, for example, with a proton pump inhibitor (PPI). She has a relatively short history, and therefore lifestyle interventions would be of benefit in the first instance in this case", "id": "32715", "label": "c", "name": "Naproxen", "picture": null, "votes": 974 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient has osteoarthritis. As she is morbidly obese and young, one of the first interventions should be lifestyle advice and weight loss, particularly as she also has diabetes and hypertension. Weight loss would reduce the stress on her load-bearing joints and also improve her health generally as well as her diabetes and hypertension", "id": "32713", "label": "a", "name": "Advise the patient to lose weight", "picture": null, "votes": 4540 } ], "comments": [ { "__typename": "QuestionComment", "comment": "i'm not sure you'd really tell this poor cleaner with pain to lose weight and not prescribe an NSAID? how long would weight loss take to have an effect?\n\n\n", "createdAt": 1683757822, "dislikes": 0, "id": "24048", "isLikedByMe": 0, "likes": 21, "parentId": null, "questionId": 6543, "replies": [ { "__typename": "QuestionComment", "comment": "spend more time in the gym", "createdAt": 1687880800, "dislikes": 3, "id": "29746", "isLikedByMe": 0, "likes": 6, "parentId": 24048, "questionId": 6543, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Diabeetus Emeritus", "id": 10888 } }, { "__typename": "QuestionComment", "comment": "thats what threw me off too initial managment ?? what about their pain ", "createdAt": 1723415964, "dislikes": 0, "id": "54652", "isLikedByMe": 0, "likes": 2, "parentId": 24048, "questionId": 6543, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Wilsons CT", "id": 66995 } }, { "__typename": "QuestionComment", "comment": "This is why patients complain about 'fatphobia'", "createdAt": 1736729820, "dislikes": 0, "id": "60397", "isLikedByMe": 0, "likes": 1, "parentId": 24048, "questionId": 6543, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Prolapsed Fissure", "id": 37601 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Sir Pep Guardiola", "id": 27715 } }, { "__typename": "QuestionComment", "comment": "There wasn't even reference to their BMI...", "createdAt": 1709126853, "dislikes": 1, "id": "43122", "isLikedByMe": 0, "likes": 1, "parentId": null, "questionId": 6543, "replies": [ { "__typename": "QuestionComment", "comment": "it says they're morbidly obese", "createdAt": 1736538073, "dislikes": 0, "id": "60209", "isLikedByMe": 0, "likes": 2, "parentId": 43122, "questionId": 6543, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "SJ", "id": 40345 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Kinase Hallux", "id": 541 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nOsteoarthritis (OA) is a chronic, degenerative joint disease characterised by loss of articular cartilage, remodelling of bone with osteophyte formation and mild synovitis. The main risk factor is older age, although obesity, joint injury and genetics also contribute. Presentation is with gradual onset pain that is worse with activity, with associated functional limitations. The most commonly affected joints are the knees, hips and small joints of the hands. Diagnosis is clinical, and severity of disease on X-ray does not correlate well with severity of symptoms. Management should be individualised, with important components being exercise, simple analgesia and optimisation of risk factors (such as maintaining a healthy weight). Where there is ongoing pain and disability, options include intra-articular steroid injections and surgical intervention (such as joint replacement).\n\n# Definition\n\nOsteoarthritis (OA) is the commonest form of arthritis, which is characterised by degenerative changes affecting the entirety of joints affected. Cartilage is lost, the subchondral bone becomes sclerosed with formation of osteophytes and subchondral cysts and there is inflammation of the synovial membrane lining the joint capsule (synovitis). \n\n# Epidemiology\n\n- Approximately 10 million people in the UK have osteoarthritis\n- More women than men are affected\n- Average age of onset is 55 \n- The commonest joint affected is the knee, followed by the hip then the hand\n\n# Aetiology\n\nOsteoarthritis develops due to a combination of factors, with important contributors including:\n\n- Older age\n- Female sex\n- Overweight or obesity\n- Family history of OA\n- Previous joint injury\n- Joint damage due to inflammation (e.g. in patients with inflammatory arthritis)\n- Physical inactivity and reduced muscle strength\n- Low bone density \n- Deformities such as development dysplasia of the hip or leg length discrepancy\n- Stresses on joints due to occupational factors (e.g. repetitive squatting or kneeling) or exercise\n\n# Signs and Symptoms\n\nKey symptoms include:\n\n- Pain in the affected joint exacerbated by use\n- Pain may radiate e.g to the thigh, knee and ankle in hip OA, or to the wrist in hand OA\n- Joints may feel stiff (although prolonged morning stiffness is suggestive of inflammatory arthritis)\n- Functional limitations such as difficulty opening jars (hand OA) or mobilising (knee or hip OA)\n- Locking or giving way of the knee\n\nExamination findings include:\n\n- Restricted and painful range of motion (e.g. in hip OA internal rotation with the hip flexed is particularly painful)\n- Crepitus (friction between bone and cartilage) \n- Affected joints may appear swollen or enlarged\n- A small effusion may form, especially when the knee is affected\n- Synovitis may present with mild soft tissue swelling, tenderness and warmth\n- Muscle wasting and weakness can result from disuse atrophy\n- Joint instability\n- An antalgic gait (\"limping\") in knee OA\n- Trendelenburg gait in hip OA (due to weak abductors patients lurch towards the affected hip)\n- Deformities, including:\n- Heberden's nodes (bony nodules over the distal interphalangeal joints) \n- Bouchard's nodes (bony nodules over the proximal interphalangeal joints) \n- Fixed flexion of the first carpometacarpal joint with hyperextension of the distal joints\n- This may lead to squaring of the joint with subluxation and remodelling\n- Ulnar or radial deviation of joints in the hand may occur\n- In severe hip OA the leg may be shortened due to fixed flexion and external rotation\n- Varus (most commonly) or valgus deformities of the knees \n\n# Differential Diagnosis\n\n- **Inflammatory arthritis** such as rheumatoid arthritis, ankylosing spondylitis; pain that improves with activity and morning stiffness lasting over 30 minutes are differentiating factors, systemic symptoms such as malaise and weight loss may be present\n- **Septic arthritis** is an important differential for all patients presenting with an acutely painful swollen joint (which may occur in an acute flare of osteoarthritis); patients may be systemically unwell with fevers\n- **Fracture** e.g. of the tibial plateau may mimic OA symptoms of pain and limited mobility; usually the patient is unable to weight bear with swelling of the affected area; a history of trauma should be elicited\n- **Malignancy** including bone metastases, multiple myeloma or sarcoma may cause mechanical pain leading to functional limitations; red flags include weight loss, night sweats, persistent pain not relieved by rest and night pain\n- **Greater trochanteric pain syndrome** most commonly occurs in middle-aged women and causes lateral hip pain and tenderness worsened by activity; it may also radiate to the lateral knee\n- **Iliotibial band syndrome** presents with lateral knee pain worse with activity, which is often accompanied by clicking or clunking sounds when the knee is moved; occurs most commonly due to repetitive knee flexion e.g. cyclists or runners \n- **Meniscal tear** may occur after an injury involving a twisting or pivoting movement; similar symptoms of pain, swelling, locking and giving way of the knee and range of motion may be limited on examination\n- **Trigger thumb** may mimic OA of the hand with pain, clicking and catching when the thumb is flexed; a nodule may be palpable in the tendon\n- **Ganglion cysts** occur more commonly in people with OA and present as soft tissue swellings e.g. at the base of the thumb; often asymptomatic but may cause pain and limit movement of the joint\n\n# Investigations\n\nDiagnosis of OA is clinical and can be made without any investigations in a patient of 45 or older if there are no features suggesting another underlying cause of symptoms.\n\nIf there is diagnostic uncertainty or a rapid deterioration in symptoms, **X-rays** of affected joints may be of use. Typical findings can be remembered with the mnemonic \"LOSS\":\n\n- **L**oss or narrowing of joint space due to thinning of cartilage\n- **O**steophytes i.e. formation of new bony spurs at the joint margins\n- **S**ubchondral sclerosis i.e. increased bone density beneath the cartilage\n- **S**ubchondral cysts which are fluid-filled sacs in the subchondral bone\n\n[lightgallery]\n\nHowever, severity of OA features on X-ray may not correlate well with severity of clinical disease.\n\nOther investigations if the diagnosis is in doubt should be targeted to the differential suspected, and may include:\n\n- Further imaging such as MRI to look for ligament or cartilage damage (e.g. a meniscal tear)\n- Joint aspiration with synovial fluid analysis to exclude septic arthritis or crystal arthritis\n- Blood tests for inflammatory markers, rheumatoid factor and anti-CCP (for example) if rheumatoid arthritis is suspected\n\nBaseline bloods for renal function and full blood count should be considered in all patients starting NSAID treatment, especially older patients who are at higher risk of adverse effects.\n\n# Management\n\n**Conservative management:**\n\n- Patient education and advice on self-care e.g. appropriate footwear\n- Weight loss advice and signposting to services in patients with excess body weight\n- Exercise has many benefits including strengthening muscles, improving fitness, reducing pain and improving function\n- Options include online fitness programmes designed for people with arthritis, physiotherapy and supervised exercise sessions\n- Physiotherapy services may also be able to offer manual therapies and joint supports such as braces or splints to reduce load and improve instability\n- Occupational health input may be needed in patients with functional impairment to assess their working environment and suggest adaptations\n- Patients should be asked about psychosocial stressors and support offered e.g. for associated depression and anxiety\n- Occupational therapy input may be helpful to advise on aids and devices to assist with activities of daily living (e.g. walking sticks, sock aids, grab rails, tap turners)\n- Podiatry input may be useful to assess the biomechanics of joint pain and advise on orthotic devices such as insoles\n- Referral to a pain management service may be appropriate for patients who have not responded to maximal medical (and if appropriate, surgical) management of OA\n- Assess falls risk and consider referral to specialist services for patients at risk (e.g. those with abnormal gait or balance, or who have had a fall in the last year)\n\n**Medical management:**\n\n- First-line analgesia is with topical NSAIDs (such as ibuprofen gel) - patients should be made aware that some systemic absorption may occur\n- If this is ineffective or unsuitable, oral NSAIDs should be considered (with a PPI for gastroprotection if there are risk factors for gastrointestinal side effects)\n- Paracetamol or weak opioids (e.g. codeine) may also be used in the short-term\n- Topical capsaicin is another option, especially for knee OA\n- Intra-articular steroid injections may be considered if other treatments are not effective, and/or to enable therapeutic exercise\n\n**Surgical management:**\n\n- Patients with OA of the hip, knee or shoulder who have symptoms significantly impacting quality of life despite optimal medical management should be considered for orthopaedic referral\n- The usual operation offered is an arthroplasty (joint replacement)\n- Rehabilitation before and after surgery is key to optimising outcomes\n\n# Complications\n\n- Joint deformities (as above)\n- Increased risk of falls\n- Functional limitations, e.g. hand OA may making writing, turning keys or fasting buttons challenging\n- Reduced mobility \n- Sleep difficulties\n- Low mood and anxiety\n- Chronic pain\n\n# Prognosis\n\n- Not all cases of OA are progressive and the disease course is variable\n- OA of the hands generally has a good prognosis, especially interphalangeal joint involvement\n- Hip OA has a poorer prognosis with many patients requiring arthroplasty\n- Knee arthroplasties for OA are also common however many patients' symptoms improve or remain stable with time \n- Intermittent flares of OA may occur, where symptoms increase in intensity suddenly\n- Flares tend to last for a few days before improving\n\n# NICE Guidelines\n\n[NICE CKS - Osteoarthritis](https://cks.nice.org.uk/topics/osteoarthritis)\n\n[NICE - Osteoarthritis in over 16s: diagnosis and management](https://www.nice.org.uk/guidance/ng226/)\n\n# References\n\n[WHO fact sheet - Osteoarthritis](https://www.who.int/news-room/fact-sheets/detail/osteoarthritis)\n\n[BNF Treatment Summaries - Osteoarthritis](https://bnf.nice.org.uk/treatment-summaries/osteoarthritis/)\n\n[Patient UK - Osteoarthritis](https://patient.info/doctor/osteoarthritis-pro)", "files": null, "highlights": [], "id": "434", "pictures": [ { "__typename": "Picture", "caption": "Heberden's nodes.", "createdAt": 1665036194, "id": "828", "index": 1, "name": "Heberden_s nodes.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/ir1qnl2r1665036171708.jpg", "path256": "images/ir1qnl2r1665036171708_256.jpg", "path512": "images/ir1qnl2r1665036171708_512.jpg", "thumbhash": "YDkKFYQ3aIeAeXeHd2h4iMd/lfxX", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "Osteoarthritis of the knees.", "createdAt": 1665036194, "id": "834", "index": 0, "name": "OA - x-ray.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/b7bnyk4t1665036171709.jpg", "path256": "images/b7bnyk4t1665036171709_256.jpg", "path512": "images/b7bnyk4t1665036171709_512.jpg", "thumbhash": "FfgVBICXB2h4d4eHeHeWkFD51g==", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 434, "demo": null, "entitlement": null, "id": "433", "name": "Osteoarthritis", "status": null, "topic": { "__typename": "Topic", "id": "54", "name": "Rheumatology", "typeId": 2 }, "topicId": 54, "totalCards": 19, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "433", "name": "Osteoarthritis" } ], "demo": false, "description": null, "duration": 3737.73, "endTime": null, "files": null, "id": "614", "live": false, "museId": "ZMAGtgf", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/cardiology.png", "title": "Quesmed Tutorial: General Practice", "userViewed": false, "views": 398, "viewsToday": 38 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "433", "name": "Osteoarthritis" } ], "demo": false, "description": null, "duration": 574.23, "endTime": null, "files": null, "id": "617", "live": false, "museId": "zYAZGCi", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/rheumatology.png", "title": "Gout 2", "userViewed": false, "views": 38, "viewsToday": 3 } ] }, "conceptId": 433, "conditions": [], "difficulty": 1, "dislikes": 29, "explanation": null, "highlights": [], "id": "6543", "isLikedByMe": 0, "learningPoint": "Weight loss is a crucial initial management strategy for osteoarthritis, particularly in morbidly obese patients, to reduce joint stress and improve overall health.", "likes": 7, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 46-year-old female presents to General Practice with bilateral knee pain that has been present for six months. She currently works part-time as a cleaner. Her past medical history includes type two diabetes mellitus, hypertension, gastro-oesophageal reflux (GORD) and morbid obesity.\nKnee x-rays are requested and show loss of joint space with some subchondral sclerosis.\n\nWhat is your initial management?", "sbaAnswer": [ "a" ], "totalVotes": 5721, "typeId": 1, "userPoint": null }

[]

{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "300mg of aspirin would be the treatment of choice if this patient were suspected of having a transient ischaemic attack (TIA); however, whilst TIAs can present with blindness, they do not usually cause headache and would not explain the scalp or jaw pain", "id": "32719", "label": "b", "name": "Stat dose 300mg aspirin", "picture": null, "votes": 95 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Low dose amitriptyline may be used in neuropathic pain and migraine prophylaxis; however, whilst migraine can cause headache and visual loss/disturbance in some cases, it is unlikely for a patient to have a new diagnosis of migraine at the age of 63 and therefore other causes should be considered", "id": "32720", "label": "c", "name": "Start 10mg amitriptyline", "picture": null, "votes": 84 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This history is suspicious for temporal arteritis, aka giant cell arteritis (GCA). As she has experienced vision loss, it is important to start high dose steroid treatment immediately; otherwise, she may have permanent loss. Symptoms of GCA include scalp tenderness, jaw claudication and headache. Patients usually require steroids for a two-year course then have complete remission, and steroids can be reduced once symptoms have resolved. The main cause of death and morbidity in GCA are related to long term steroid use, so risks and benefits of treatment should be considered carefully, and gastric and bone protection should be considered", "id": "32718", "label": "a", "name": "Start high dose steroids", "picture": null, "votes": 4809 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Thrombolysis with alteplase would be an appropriate treatment for an ischaemic stroke within 4.5 hours of the onset of symptoms. Whilst ischaemic stroke can cause blindness, it would not usually cause headaches and would not explain the scalp or jaw pain", "id": "32722", "label": "e", "name": "Stat dose 900mcg/kg altepalase", "picture": null, "votes": 26 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Carbemazipine is the first line treatment for trigeminal neuralgia. This would be in the differential for unilateral facial pain; however, it would not account for the blindness, and the pain she describes does not sound neuropathic", "id": "32721", "label": "d", "name": "Start 100mg carbamazepine", "picture": null, "votes": 427 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nGiant cell arteritis (GCA) is a form of vasculitis which affects medium and large arteries. It classically affects the branches of the external carotid artery and the ophthalmic artery, which is often referred to as temporal arteritis. Key signs and symptoms include a temporal headache, jaw claudication, amaurosis fugax, thickening and tenderness of the temporal artery, and scalp tenderness. Systemic symptoms and features of polymyalgia rheumatica are common. The diagnosis is clinical in the first instance, and patients with visual symptoms should be treated immediately with high-dose steroids, however supportive investigations include full blood count, CRP and ESR. Confirmation of the diagnosis is with vascular ultrasound and temporal artery biopsy. Management is with high-dose steroids, with steroid sparing agents considered in patients who relapse when steroids are weaned.\n\n# Definition\n\nGiant cell arteritis (GCA) is a large vessel vasculitis which commonly affects the extracranial external carotid artery branches. Involvement of other vessels may occur, with patients presenting atypically with systemic symptoms and aortic involvement rather than temporal arteritis.\n\n# Epidemiology\n\n- GCA is the most common primary vasculitis \n- Age is an important risk factor - GCA is rare in the under 50s, with cases peaking in those aged 70-79\n- Women are 2-3x more likely to be affected than men\n- Northern European descent is also a risk factor\n\n# Signs and Symptoms\n\n**Symptoms include:**\n\n- Headache - usually temporal but may be generalised, occipital or parietal; present in 2/3 of people with GCA\n- Jaw or tongue claudication (pain on chewing food)\n- Amaurosis fugax (transient monocular blindness, often described as a dark curtain descending vertically)\n- Diplopia\n- Changes to colour vision\n- Fatigue\n- Anorexia and weight loss\n- Depression\n- Features of polymyalgia rheumatica e.g. pain and stiffness of shoulders and pelvic girdle\n\n**Signs include:**\n\n- Tenderness, thickening or nodularity of the temporal artery\n- Pulsation of the temporal artery may be reduced or absent\n- Scalp tenderness or necrosis\n- Visual field defect\n- Low-grade fever\n- On fundoscopy: pallor and oedema of the optic disc, \"cotton-wool\" patches and retinal haemorrhages\n- Involvement of extracranial vessels may be associated with arterial bruits, difference in blood pressure between arms and decreased arterial pulses\n\n# Differential Diagnosis\n\n- **Other causes of headaches** e.g. tension headaches, migraines - lack associated features e.g. jaw claudication, less likely to be new in an older patient\n- **Acute angle closure glaucoma** leads to visual loss and headaches, eye will be painful and red and feel hard on palpation\n- **Shingles** leads to pain and systemic features may be present, however a rash typically appears over the affected area within a few days\n- **Transient ischaemic attack** can cause amaurosis fugax, other features such as headache are not usually present\n\n\n# Investigations\n\n**Bedside tests:**\n\n- Urgent ophthalmological assessment for patients with visual symptoms \n\n**Blood tests:**\n\n- **ESR** and **CRP** - raised in GCA\n- **Full blood count** often shows an elevated platelet count and a normochromic normocytic anaemia\n- Baseline bloods for liver and renal function (**LFTs** and **U&Es**) and a **bone profile** for calcium should be considered to screen for alternative diagnoses e.g. other vasculitides\n- Bloods to screen for increased risk of complications with steroids (such as diabetes or osteoporosis) include an **HbA1c**, **vitamin D** and **thyroid function tests** \n\n**Imaging tests:**\n\n- **Doppler ultrasonography** of the temporal and axillary arteries can be used as a confirmatory diagnostic test\n- **Halo sign** refers to hypoechoic wall thickening of the artery imaged\n- This disappears with steroid treatment\n- Stenosis of the vessel may also be visualised\n- **MRI brain** with vessel wall imaging is an alternative\n- GCA is supported by findings of mural inflammation in the superficial temporal arteries\n- MRI can also be used to look for complications such as ischaemic stroke as well as involvement of other arteries\n- **FDG-PET scanning** can be useful to rule out differential such as malignancy or infection\n- In GCA there will be uptake in affected arteries\n- It can be particularly useful to demonstrate involvement of other arteries e.g. the aorta\n- A **DEXA** scan for baseline bone density should be done for patients starting long-term steroids (due to the risk of osteoporosis)\n\n**Invasive tests:**\n\n- **Temporal artery biopsy**\n- This is the definitive investigation for GCA\n- Typical histological features include granulomatous inflammation of arteries with inflammatory cells including multinucleated giant cells\n- Inflammation is often segmental with \"skip lesions\" i.e. normal parts of the artery in between areas of inflammation, and so false negative biopsies can occur\n- Biopsies may remain positive for several weeks after starting steroids\n\n# Management\n\n- Patients with visual loss usually require **IV steroid treatment** e.g. pulsed methylprednisolone\n- All other patients should be treated with **high dose oral steroids**, usually 40-60 mg prednisolone once a day\n- **Safety netting** patients to seek urgent medical attention if they develop visual symptoms or a relapse on steroids is key\n- Patients seen in primary care should be **referred urgently to rheumatology** for confirmation of the diagnosis and ongoing management\n- **Steroids are tapered** gradually once symptoms and raised inflammatory markers have resolved\n- **Steroid sparing agents** such as methotrexate or tocilizumab (an anti-IL6 biologic) may be added to help with steroid tapering e.g. in patients with recurrent relapses or at increased risk of side effects with steroids\n- All patients should be assessed for risk of steroid side effects:\n- Consider gastric protection with a proton pump inhibitor\n- Consider bone protection e.g. vitamin D and calcium supplementation, bisphosphonates\n- Monitor for steroid-induced diabetes, hypertension and glaucoma\n- Advise on immunosuppression e.g. avoiding contact with patients with diseases such as chickenpox if not immune\n- Give patients a blue steroid card and advise them not to suddenly stop steroids due to the risk of adrenal crisis\n- Aspirin is currently **not** recommended for adjunctive treatment of GCA \n\n# Complications\n\n- Loss of vision - may occur in up to 30% of people with GCA (either total or partial)\n- Scalp necrosis\n- Ischaemic stroke\n- Aortic aneurysms - in 10-20% of people with GCA, most commonly in the thoracic aorta\n- Aortic dissection and aortic regurgitation are less common than aneurysms\n- Stenosis of large arteries\n- Increased risk of cardiovascular disease including stroke, myocardial infarction and peripheral arterial disease\n- Side-effects from long-term steroids e.g. osteoporosis and fragility fracture, weight gain, diabetes, gastric ulcers\n\n# Prognosis\n\n- Most patients respond rapidly to steroids - failure to respond should prompt investigations for an alternative diagnosis\n- Up to 50% of people will experience relapsing disease however\n- Most patients require at least 1-2 years of steroid treatment, with an increased risk of relapse if steroids are stopped within a year of diagnosis\n\n# NICE Guidelines\n\n[NICE CKS - Giant Cell Arteritis](https://cks.nice.org.uk/topics/giant-cell-arteritis/)\n\n# References\n\n[British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis](https://academic.oup.com/rheumatology/article/59/3/e1/5714024)\n\n[Radiopaedia - Giant Cell Arteritis](https://radiopaedia.org/articles/giant-cell-arteritis?lang=gb)\n\n[Patient UK - Giant Cell Arteritis](https://patient.info/doctor/giant-cell-arteritis-pro)", "files": null, "highlights": [], "id": "413", "pictures": [], "typeId": 2 }, "chapterId": 413, "demo": null, "entitlement": null, "id": "416", "name": "Giant Cell Arteritis", "status": null, "topic": { "__typename": "Topic", "id": "54", "name": "Rheumatology", "typeId": 2 }, "topicId": 54, "totalCards": 46, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "416", "name": "Giant Cell Arteritis" } ], "demo": false, "description": null, "duration": 300.93, "endTime": null, "files": null, "id": "152", "live": false, "museId": "VV7AXhF", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/rheumatology.png", "title": "Giant Cell Arteritis ", "userViewed": false, "views": 290, "viewsToday": 11 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "416", "name": "Giant Cell Arteritis" } ], "demo": false, "description": null, "duration": 3606.96, "endTime": null, "files": null, "id": "335", "live": false, "museId": "dh9LRhf", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/rheumatology.png", "title": "Quesmed Tutorial: Rheumatology", "userViewed": false, "views": 579, "viewsToday": 27 } ] }, "conceptId": 416, "conditions": [], "difficulty": 1, "dislikes": 1, "explanation": null, "highlights": [], "id": "6544", "isLikedByMe": 0, "learningPoint": "Giant cell arteritis (GCA) is an inflammatory condition affecting large blood vessels, often presenting with symptoms like headache and vision changes; it requires prompt treatment with high-dose steroids to prevent complications such as vision loss and reduce inflammation.", "likes": 6, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 63-year-old female presents to Accident and Emergency with sudden right-sided blindness associated with a headache. She has never had issues with headaches before. On further questioning, she reveals that she has tenderness on brushing her hair and has been to the dentist recently with toothache but did not need any dental work done.\n\nWhat should your initial management be?", "sbaAnswer": [ "a" ], "totalVotes": 5441, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "This is infection/inflammation of the testis and epididymis. It is often caused by sexually transmitted infections such as chlamydia but also caused by viral causes such as mumps. Patients report a tender generalised swelling and may have other associated features of infection (temperature, dysuria, penile discharge). Treatment is with antibiotics depending on the likely source (NB if sexually transmitted infection deemed likely source then contact tracing and treatment of partners should be initiated)", "id": "32725", "label": "c", "name": "Epididimo-orchitis", "picture": null, "votes": 122 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is unlikely but should be carefully considered in the differential as testicular tumours are the commonest malignancy in this age demographic. They usually present as a painless, firm lump in the testes found after trauma/infection and may have a secondary hydrocoele", "id": "32726", "label": "d", "name": "Testicular tumour", "picture": null, "votes": 466 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "A varicocele is caused by dilated veins of the pampiniform plexus and often may only be present on standing. 90% occur on the left. They are associated with subfertility, but surgical repair appears to have little effect on subsequent pregnancy rates. Treatment is with scrotal support or surgery (varicocelectomy)/embolisation", "id": "32723", "label": "a", "name": "Varicocoele", "picture": null, "votes": 1936 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This would be in the differential and are caused by fluid within the tunica vaginalis; however, the description and the lack of transillumination make varicocoele more likely", "id": "32724", "label": "b", "name": "Hydrocoele", "picture": null, "votes": 176 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This presents as a painless nodule at the head of the epididymis adjacent to the inferior pole of the testis and will transilluminate. They may contain clear or milky (spermatocele) fluid", "id": "32727", "label": "e", "name": "Epididymal cyst", "picture": null, "votes": 1834 } ], "comments": [ { "__typename": "QuestionComment", "comment": "how dare you not say bag of worms", "createdAt": 1683139753, "dislikes": 0, "id": "23325", "isLikedByMe": 0, "likes": 78, "parentId": null, "questionId": 6545, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "lil' aneurysm", "id": 21164 } }, { "__typename": "QuestionComment", "comment": "WHERE BAG OF WORMS ", "createdAt": 1736461217, "dislikes": 0, "id": "60140", "isLikedByMe": 0, "likes": 2, "parentId": null, "questionId": 6545, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Transplant Tazocin", "id": 15111 } }, { "__typename": "QuestionComment", "comment": "\"lump\" is not a good description of a varicocele...", "createdAt": 1738606612, "dislikes": 0, "id": "62254", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6545, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Sydney Sweeney", "id": 30184 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nVaricocele is defined as an enlargement of the scrotal veins, often asymptomatic but may cause a sense of aching or heaviness within the scrotum. They can also contribute to male infertility, accounting for 25-40% of such cases. Diagnostic investigations include physical examination, Doppler ultrasound, and possibly hormonal assays. Management is dependent on symptom severity and includes options such as watchful waiting, embolization, and surgery.\n\n# Definition\n\nVaricocele is a condition characterized by an enlargement of the veins within the scrotum, similar in nature to varicose veins that can occur elsewhere in the body.\n\n# Epidemiology\n\nWhile varicocele is relatively common, affecting around 15-20% of all men, its prevalence significantly increases in the infertile population, reaching up to 40%. It typically develops in adolescence and early adulthood.\n\n# Aetiology\n\nVaricoceles develop due to faulty valves within the spermatic cord veins, causing blood to pool and enlarge these veins. Although the exact mechanism that leads to male infertility is unclear, it's hypothesized that increased testicular temperature and oxidative stress may play a role. In a minority of cases, left-sided varicoceles can be caused by compression of the gonadal vein, such as from a renal cell carcinoma.\n\n# Signs and Symptoms\n\nWhile many varicoceles are asymptomatic, when symptoms do present, they may include:\n\n- Aching or heavy feeling in the scrotum\n- Visibly enlarged or twisted veins in the scrotum, often described as a \"bag of worms\"\n- Testicular atrophy\n- Impaired fertility\n\n# Differential Diagnosis\n\nThe primary conditions to consider when diagnosing varicocele include:\n\n- Epididymitis: Key signs and symptoms include scrotal pain and swelling, potentially with fever and urinary symptoms.\n- Testicular torsion: This presents with sudden severe testicular pain, swelling, nausea, and vomiting.\n- Inguinal hernia: Symptoms typically include a visible bulge in the groin region or scrotum, pain, and possible bowel or bladder symptoms.\n- Hydrocele: This condition usually causes painless scrotal swelling.\n\n# Investigations\n\nThe following investigations can aid in diagnosing varicocele:\n\n- Physical examination: Varicoceles can often be identified by palpation of the scrotum, especially while standing or during a Valsalva maneuver.\n- Doppler ultrasound: This imaging modality can identify the enlarged veins and assess for retrograde blood flow, confirming the diagnosis.\n- Hormonal assays: In cases where infertility is suspected, evaluation of testosterone, FSH, LH, and semen analysis can be useful.\n\n# Management\n\nThe management strategy for a varicocele depends largely on the symptom severity and patient’s fertility desires. Options include:\n\n- Watchful waiting: For asymptomatic varicoceles or those not causing fertility problems.\n- Embolization: This minimally invasive procedure involves blocking the blood flow to the enlarged veins.\n- Surgery: Varicocele repair surgery can be performed through open surgery, laparoscopically, or with robotic assistance.", "files": null, "highlights": [], "id": "1594", "pictures": [], "typeId": 2 }, "chapterId": 1594, "demo": null, "entitlement": null, "id": "2005", "name": "Varicocele", "status": null, "topic": { "__typename": "Topic", "id": "22", "name": "Urology", "typeId": 2 }, "topicId": 22, "totalCards": 2, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 2005, "conditions": [], "difficulty": 3, "dislikes": 21, "explanation": null, "highlights": [], "id": "6545", "isLikedByMe": 0, "learningPoint": "A varicocele, often present only when standing and typically occurring on the left, is caused by dilated veins of the pampiniform plexus, associated with subfertility, and treated with scrotal support or surgery/embolization.", "likes": 2, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 34-year-old male presents to the sexual health clinic concerned about a lump he has found in his left testicle. He is sexually active but does not complain of any penile discharge or any urinary symptoms. On examination, there is a soft fleshy lump that is separate from the spermatic cord. It is only palpable when the patient is standing and not when lying down. It does not transilluminate.\n\nWhat is the most likely diagnosis?", "sbaAnswer": [ "a" ], "totalVotes": 4534, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Whilst the stone is 6mm and therefore unlikely to pass spontaneously, the main issue here is the infected obstructed system that requires urgent intervention. If she was not septic, then medical expulsive therapy with tamsulosin would be a reasonable choice", "id": "32730", "label": "c", "name": "Tamsulosin", "picture": null, "votes": 49 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient has an obstructed infected urinary system that needs urgent decompression. As her stone is 6mm and in the upper part of the urethra, decompression with a nephrostomy is indicated. She should also be managed in accordance with sepsis six and started on antibiotics", "id": "32728", "label": "a", "name": "Urgent right nephrostomy", "picture": null, "votes": 4028 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This patient has an infected obstructed system which requires urgent intervention. She is also septic, and therefore treatment with oral antibiotics is unlikely to be sufficient", "id": "32729", "label": "b", "name": "Oral antibiotics", "picture": null, "votes": 151 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Analgesia is indicated in this patient's case; however, it will not treat her underlying condition", "id": "32732", "label": "e", "name": "Analgesia", "picture": null, "votes": 211 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "If medical expulsion therapy does not work in stable patients with stones >5mm, then ESWL is a reasonable choice. This patient is septic and therefore requires urgent decompression with a nephrostomy or ureteric stenting", "id": "32731", "label": "d", "name": "Extracorporeal shockwave lithotripsy (ESWL)", "picture": null, "votes": 738 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "\"# Summary\n\nUrolithiasis refers to stones that may form anywhere in the urinary tract (usually in the kidneys). They are often asymptomatic but may cause pain +/- obstruction of the flow of urine. Stones usually form due to supersaturation of urine, with the main types including calcium oxalate, calcium phosphate, uric acid, struvite and cystine stones. A common presentation is with renal or ureteric colic, where there is severe spasmodic pain that classically moves from loin to groin. Other symptoms include nausea, vomiting and haematuria; patients who develop an infected obstructed urinary system may be systemically unwell and febrile. Investigations include a urine dip and culture, blood tests for renal function and inflammation markers and a non-contrast CT KUB. Ultrasound is an alternative for young people and pregnant women. Management depends on how likely stones are to pass spontaneously based on location and size as well as symptom severity, presence of complications (e.g. infection, obstruction) and the patient's background. Options include watchful waiting with analgesia, medical expulsive therapy, percutaneous nephrolithotomy, ureteroscopy, shock wave lithotripsy, or (rarely) open surgery. Thought should be given to whether an underlying condition (such as hyperparathyroidism) may be driving stone formation and patients should be advised on how to reduce the risk of recurrence. Preventative medical treatment may be indicated in some cases of recurrent stones.\n\n# Definition\n\nUrolithiasis refers to urinary calculi (stones) anywhere in the urinary tract. They form due to supersaturation of urine causing crystal formation, which then aggregate into larger stones.\n \n# Epidemiology\n \n- Urinary tract stones are common, with a lifetime prevalence of 12% in men and 7% in women\n- Peak incidence is between 35-45 years of age\n- Modifiable risk factors include:\n - Obesity\n - Chronic dehydration\n - High ambient temperatures\n - Diet high in oxalate, urate, sodium and animal protein\n- Non-modifiable risk factors include:\n - White ethnicity\n - Family history of stone formation\n - Structurally abnormal renal tract (e.g. vesicoureteric reflux, horseshoe kidney)\n - Comorbidities including diabetes, gout, hyperparathyroidism, Crohn's disease, cystinuria \n \n# Aetiology\n\n- **Calcium oxalate stones**\n - Majority (approximately 70%) of stones\n - Radiopaque\n - Can form in any urine pH\n - Associated with low urine volume and hypercalciuria\n- **Calcium phosphate stones**\n - Approximately 10% of stones\n - Radiopaque\n - Tend to form in alkaline urine\n - Associated with renal tubular acidosis types 1 and 3\n - Associated with primary hyperparathyroidism\n- **Uric acid stones**\n - Approximately 10% of stones\n - Radiolucent\n - Only form in acidic urine (pH < 5.5)\n - Associated with diabetes, obesity and gout\n - May occur due to malignancy (due to high cell turnover, especially due to chemotherapy)\n- **Struvite stones**\n - Approximately 5% of stones\n - Radiopaque\n - Composed of magnesium, ammonium and phosphate\n - Often occur due to urease-producing bacterial infection (e.g. Proteus, Enterobacter, Klebsiella)\n - Associated with alkaline urine\n - May form staghorn calculi (which involve the renal pelvis and extend into mulitple calyces)\n- **Cystine stones**\n - 1% of stones\n - Faintly radiopaque\n - Occur due to cystinuria (an autosomal recessive condition affecting renal reabsorption of amino acids)\n - More likely to form in alkaline urine\n - Often occur in young patients\n- **Medication-induced stones**\n - 1% of stones\n - Occur due to crystallisation of medications or their compounds\n - e.g. indinavid, ceftriaxone, allopurinol, zonisamide\n \n# Signs and Symptoms\n \n- Stones are often asymptomatic, especially if small, and may be detected incidentally on imaging\n- The classic presentation is with renal or ureteric colic\n - There is severe, spasmodic pain that often starts in one flank (or \"\"loin\"\")\n - It may then radiate to the groin (i.e. \"\"loin to groin\"\" pain)\n - It may also radiate to the scrotum, labia or anterior thigh\n - Onset is usually sudden\n - Patients may be restless and pace or writhe around due to severe pain\n- Renal angle tenderness may be present on examination\n- Visible haematuria (or may be microscopic and detected on dipstick only)\n- Dysuria, urinary frequency and having to strain to pass urine may occur (due to detrusor muscle irritation)\n- Nausea and vomiting\n- Fever, diaphoresis, rigors and hypotension may be present if there is concurrent infection\n- There may be urinary hesitancy or an intermittent stream if there is obstruction\n \n# Differential Diagnosis\n \n- **Pyelonephritis** presents with fever, flank pain, nausea and vomiting and urinary symptoms such as frequency, urgency and dysuria - it may complicate obstruction due to urinary stones but often occurs in the absence of stones (often due to an ascending lower urinary tract infection)\n- **Appendicitis** presents with periumbilical pain migrating to the right lower quadrant (rather than flank pain), nausea, vomiting and fever are common and patients may have classic examination findings (e.g. maximal tenderness at McBurney's point, Rovsing's sign)\n- **Diverticulitis** presents with intermittent left lower quadrant pain and tenderness, fever is common as well as altered bowel habit (often with the passage of blood and/or mucus) \n- **Ovarian torsion** presents with acute severe pelvic or lower abdominal pain (which may be intermittent and radiate to the flank), nausea and vomiting; there may be a palpable mass on examination\n- **Ectopic pregnancy** presents with lower abdominal or pelvic pain and vaginal bleeding, often in women with a history of a recent missed period; if there is tubal rupture patients may develop vomiting, tachycardia, hypotension and shock \n- **Rupture or dissection of an abdominal aortic aneurysm** may mimic renal colic, especially in older men presenting with flank and groin pain and haemodynamic instability\n\n# Investigations\n\n**Bedside:**\n\n- **Urinalysis** for haematuria; nitrites and leukocytes may be present in infection (leucocytes may also be present in urine due to ureteral irritation) - urine pH may also guide the likely cause of stones\n- **Urine MC&S** looking for any bacteria that may be causing a complicating infection or struvite stones\n- **24 hour urine collection** in recurrent stone formers to assess urine volume, calcium, oxalate, uric acid, citrate, sodium and creatinine\n\n**Bloods:**\n\n- **Full blood count** may show raised white cell count due to infection\n- **U&Es** may show deranged renal function e.g. if there is obstruction\n- **CRP** which may be significantly raised in infection\n- **Bone profile** looking for hypercalcaemia\n- **Serum urate** if raised may increase suspicion of uric acid stones\n- **Venous blood gas** may show acidosis and low bicarbonate if there is underlying renal tubular acidosis; lactate may be raised in patients systemically unwell with infection\n- **Coagulation screen** to check for a bleeding diathesis prior to intervention \n- **Blood cultures** in patients with suspected infection\n\n**Imaging:**\n \n- **Non-contrast CT KUB** should be done urgently in patients with suspected renal colic\n- **Ultrasound KUB** is an alternative that should be offered to pregnant women and under 16 year olds\n- **Abdominal X-ray** also has a role e.g. to follow up radio-opaque stones that are being managed conservatively\n\n**Special tests:**\n\n- **Stone analysis** to identify their composition and guide prophylactic management - sieving urine may be advised to retrieve fragments especially if there is recurrent stone formation\n \n# Management \n \n**Conservative:**\n\n- Patients should be educated on urinary tract stones and safety-netted regarding risks (e.g. infection, obstruction)\n- As stones often pass spontaneously, watchful waiting may be appropriate for asymptomatic stones < 5mm with no complications (this may also be trialled in larger stones if patients have been counselled regarding risks and benefits)\n- Dietary and lifestyle advice should be provided on how to reduce recurrence risk\n - Drink 2.5-3 litres of water per day\n - Avoid carbonated drinks (may acidify urine)\n - Add fresh lemon juice to water (contains citrate which reduces stone formation)\n - Eat a balanced diet and maintain a healthy weight\n - Reduce salt intake\n - Do not restrict dietary calcium intake \n\n**Medical:**\n\n- Analgesia should be provided promptly\n - Non-steroidal anti-inflammatory drugs (NSAIDs) are first-line\n - Alternatives to the oral route (e.g. PR or IM diclofenac) may be required if patients are vomiting\n - IV paracetamol may be given if NSAIDs are contraindicated or insufficient\n - Opioid analgesia is the next step if neither of these are sufficient\n- Medical expulsive therapy can be considered for patients with distal ureteric stones < 10mm \n - This involves using an alpha-blocker (e.g. tamsulosin) to relax smooth muscle and promote passage of stones\n- Patients with suspected infection secondary to renal stones should be treated urgently with IV antibiotics (e.g. gentamicin, co-amoxiclav)\n- IV fluids may be required for patients dehydrated due to vomiting, decreased oral intake or infection\n- Antiemetics may be required for vomiting\n- Medical prophylaxis may be considered for recurrent stone formation\n - Potassium citrate is used for recurrent calcium oxalate stones\n - Thiazide diuretics may also be used for recurrent calcium oxalate stones \n\n**Surgical:**\n\n- Patients with obstruction and hydronephrosis require urgent decompression with nephrostomy insertion\n- Stenting is another option for ureteric obstruction\n- Extracorporeal shockwave lithotripsy (ESWL) refers to using high-energy shock waves to fragment a stone under fluoroscopic guidance\n - It can be used for stones < 2 cm in size and is first-line if < 1cm\n - It is contraindicated in pregnancy, coagulopathy and infection\n- Ureteroscopy refers to retrieving stones endoscopically\n - First-line for ureteric stones 1-2 cm in size\n - Stenting may be offered in patients after retrieval of larger stones\n- Percutaneous nephrolithotomy is used for renal stones > 2cm including complex stones such as staghorn calculi\n - It may also be used in smaller stones when other treatment approaches have failed\n- Open stone surgery is rarely required but may be needed in complex cases or when other options have failed\n\n# Complications\n\n- **Obstruction** of the urinary tract by a stone leads to acute kidney injury and may cause irreversible renal impairment if not urgently decompressed\n- **Infection** of an obstructed urinary system may be severe and life-threatening - pyelonephritis (upper urinary tract infection) and pyonephrosis (a buildup of pus in the kidney) may occur and there is a risk of sepsis\n- **Ureteric strictures** may form if ureteric stones are not passed within a couple of weeks\n- **Increased risk of renal cancers** (both renal cell carcinomas and upper tract urothelial carcinomas) is seen in patients with renal stones\n- **Renal calyx rupture** is a rare complication and may lead to a urinoma (collection of urine in the abdomen)\n\n# Prognosis\n\n- 95% of stones < 5mm will pass spontaneously within 40 days\n- 70% of distal ureteric stones (of all sizes) will pass spontaneously\n- Rates of spontaneous passage are lower for more proximal stones (25% of proximal ureteric stones pass spontaneously)\n- Recurrence rates are high - 80% at 10 years - although 50% of these people will only have one recurrence\n- Frequent recurrence is seen in approximately 10% of patients\n \n# NICE Guidelines\n\n[NICE CKS - Renal or ureteric colic](https://cks.nice.org.uk/topics/renal-or-ureteric-colic-acute/)\n\n[NICE - Renal and ureteric stones: assessment and management](https://www.nice.org.uk/guidance/ng118/)\n \n# References\n\n[Radiopaedia - Ureteric calculi](https://radiopaedia.org/articles/ureteric-calculi?lang=gb)\n\n[Patient UK - Urinary tract stones](https://patient.info/doctor/urinary-tract-stones-urolithiasis)\n\n[RCEM Learning - Renal colic](https://www.rcemlearning.co.uk/reference/renal-colic/)\n\"", "files": null, "highlights": [], "id": "839", "pictures": [], "typeId": 2 }, "chapterId": 839, "demo": null, "entitlement": null, "id": "884", "name": "Renal Stones and Renal Colic", "status": null, "topic": { "__typename": "Topic", "id": "22", "name": "Urology", "typeId": 2 }, "topicId": 22, "totalCards": 52, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 884, "conditions": [], "difficulty": 1, "dislikes": 5, "explanation": null, "highlights": [], "id": "6546", "isLikedByMe": 0, "learningPoint": "In cases of obstructed pyelonephritis, urgent nephrostomy is essential to relieve obstruction and prevent further renal damage.", "likes": 3, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 25-year-old female presents to the Emergency Department with right-sided loin to groin pain that she describes as coming in waves and is associated with nausea but no vomiting. Her observations at triage show she is pyrexial at 38.8, tachycardic and hypotensive. Her urine dip is positive for blood and nitrites and negative for pregnancy, and her blood tests reveal raised inflammatory markers.\nA CT of kidneys, ureters and bladder (KUB) is performed, demonstrating a right-sided 6mm obstructing calculus associated with hydroureter and hydronephrosis.\n\nWhat treatment is urgently required?", "sbaAnswer": [ "a" ], "totalVotes": 5177, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Hyponatreamia can be a sign of paraneoplastic syndromes such as syndrome of inappropriate ADH. It is not in keeping with tumour lysis syndrome", "id": "32736", "label": "d", "name": "Sodium 128 mmol/L", "picture": null, "votes": 134 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is a normal potassium level. A high potassium level would be associated with TLS", "id": "32737", "label": "e", "name": "Potassium 4.2 mmol/L", "picture": null, "votes": 354 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Breakdown of cells includes the breakdown of their nucleic acid, which has a phosphate group, and therefore a high phosphate is expected in TLS. As phosphate leads to calcium chelation, patients will also have low calcium rather than high calcium. High calcium is associated with malignancy with boney metastasis, for example, lung cancer, breast cancer and renal cancer", "id": "32735", "label": "c", "name": "Adjusted Calcium 3.70 mmol/L", "picture": null, "votes": 991 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "As rapid cell breakdown releases potassium, a low potassium would be unusual in TLS", "id": "32734", "label": "b", "name": "Potassium 2.9 mmol/L", "picture": null, "votes": 296 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "TLS is a severe metabolic disturbance caused by the abrupt release of cellular components following the rapid lysis of malignant cells upon initiation of treatment. Therefore high potassium, high urea, high phosphate and low calcium are expected.\n\nLactate, urate and LDH may also be increased and so should be monitored, but are not diagnostic.\n\nIt is usually within 1-5 days of starting chemotherapy and can cause seizures, cardiac arrhythmias, kidney injury and even death. Management is through prevention and careful monitoring and treatment of any complications should they occur", "id": "32733", "label": "a", "name": "Urea 22 mmol/L", "picture": null, "votes": 2859 } ], "comments": [ { "__typename": "QuestionComment", "comment": "I know in tumour lysis syndrome there is raised K, PO4 and uric acid with low Ca. But is urea the same as uric acid (ie urate)?", "createdAt": 1646646001, "dislikes": 0, "id": "8153", "isLikedByMe": 0, "likes": 1, "parentId": null, "questionId": 6547, "replies": [ { "__typename": "QuestionComment", "comment": "innit? i was thinking the samee bc notes say high urate rather than urea idk if they are used interchangeablyyy", "createdAt": 1653662711, "dislikes": 0, "id": "11355", "isLikedByMe": 0, "likes": 0, "parentId": 8153, "questionId": 6547, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Suture Bradykinin", "id": 8766 } }, { "__typename": "QuestionComment", "comment": "They're not the same.", "createdAt": 1683323089, "dislikes": 0, "id": "23508", "isLikedByMe": 0, "likes": 0, "parentId": 8153, "questionId": 6547, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Financiers ", "id": 23861 } }, { "__typename": "QuestionComment", "comment": "the urea is raised due to AKI due to the TLS", "createdAt": 1707763654, "dislikes": 0, "id": "41416", "isLikedByMe": 0, "likes": 0, "parentId": 8153, "questionId": 6547, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "ButtMuncher", "id": 47721 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Lueh Chien", "id": 5088 } }, { "__typename": "QuestionComment", "comment": "Feel like this is a bit mean and also kind of teaching people that uric acid and urea are the same thing (they're not). The lab criteria of TLS is uric acid, calcium, phosphate and potassium.", "createdAt": 1734979092, "dislikes": 0, "id": "58847", "isLikedByMe": 0, "likes": 1, "parentId": null, "questionId": 6547, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Relapse Retrograde", "id": 28133 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\n\nTumour lysis syndrome is a potentially lethal condition caused by the rapid death of tumour cells often following chemotherapy or rapid progression of haematological malignancies, resulting in the massive release of intracellular contents. It is an oncological emergency. Patients commonly present with acute-onset dysuria/oliguria, abdominal pain, or weakness. Key investigations include measurements of U&E (showing raised potassium and phosphate), calcium (typically low), uric acid (raised), and ECG to detect metabolic abnormalities and life-threatening arrhythmias. Initial management involves the correction of electrolyte abnormalities and intravenous fluid administration.\n\n\n# Definition\n\n\nTumour lysis syndrome is a serious metabolic disorder caused by the rapid death of tumour cells in response to chemotherapy. This results in a massive release of intracellular contents into the bloodstream, leading to significant electrolyte imbalances.\n\n\nTumour lysis syndrome is most commonly associated with aggressive, rapidly proliferating tumours such as acute leukaemia and high-grade lymphomas, particularly after the initiation of cytotoxic therapy. \n\n\n# Aetiology\n\n\nThe syndrome occurs due to the rapid release of intracellular contents from dying tumour cells, often following chemotherapy. It can however also be caused by high-grade lymphomas and acute leukaemias. This leads to hyperuricaemia, hyperphosphatemia, hyperkalaemia, and hypocalcaemia. These metabolic abnormalities lead to the clinical manifestations including acute kidney injury and arrhythmias.\n\n\n# Signs and symptoms\n\n\nPatients may present with symptoms related to electrolyte abnormalities and hyperuricaemia, which include:\n\n\n* Dysuria or oliguria\n* Abdominal pain\n* Weakness\n* Nausea or vomiting\n* Muscle cramps\n* Seizures\n* Cardiac arrhythmias\n* Gout/joint swelling\n\n\n# Differential diagnosis\n\n\nDifferential diagnosis should consider other causes of similar symptoms and laboratory abnormalities, such as:\n\n\n* **Acute kidney injury**: while tumour lysis syndrome can cause AKI, other causes should be considered. For example, patients may have significant dehydration or have received nephrotoxic drugs contributing to AKI. Careful history-taking and the absence of other features of tumour lysis syndrome should raise suspicion of AKI due to other causes. It is important to note though, that AKI can cause significant electrolyte abnormalities, so careful monitoring is required.\n* **Isolated hyperkalaemia**: presents with muscle weakness, fatigue, palpitations, and potentially life-threatening cardiac arrhythmias. Patients may have a history of renal failure or taking potassium-sparing medications. Uric acid, phosphate and calcium levels would be normal.\n* **Isolated hyperphosphateamia**: presents with muscle cramps, itching, and perioral tingling or numbness. Uric acid and potassium would be normal.\n* **Isolated hypocalcaemia**: presents with numbness and tingling in the hands, feet, and around the mouth, muscle cramps, and seizures. Uric acid, potassium and phosphate would be normal\n\n\n# Investigations\n\n\nKey investigations for tumour lysis syndrome include:\n\n* Basic observations\n* U&E: Potassium and phosphate are usually raised, raised Cr suggestive of AKI/renal failure.\n* Calcium: Typically low in tumour lysis syndrome.\n* Uric acid: Usually elevated.\n* ECG: To assess risk of arrhythmias caused by electrolyte abnormalities.\n* Hyperkalaemia may cause tented T waves, broad QRS, flattened P-wave and a prolonged PR interval. \n* Hypocalcaemia may cause a prolonged QT interval.\n\n\n# Management\n\n\nManagement of tumour lysis syndrome primarily focuses on:\n\n\n* Correction of electrolyte imbalances & mitigation of arrhythmia risk.\n* For example in severe hyperkalaemia, calcium gluconate is given followed by an insulin-dextrose infusion or nebulised salbutamol. Further management may include calcium resonium to prevent further potassium absorption from the gut.\n* Severe hypocalcaemia may require parenteral replacement.\n* Dialysis may be required in severe cases.\n* Administration of intravenous fluids to help flush out the intracellular contents released by the dying tumour cells.\n* Medications: rasburicase (a recombinant form of the urate oxidase enzyme) transforms uric acid into allantoin. Allantoin is more soluble in urine than uric acid, and more easily eliminated by the kidney.\n\n\n### Prevention \n\n\n* Low/intermediate risk patients can be managed with a combination of adequate hydration and allopurinol. \n* Rasburicase (a recombinant form of the urate oxidase enzyme) can be used as a prophylactic agent in adults with hyperuricaemia that is inadequately managed by allopurinol or febuxostat.\n\n\n# References\n\n[British Society for Haemotology: Management of Tumour Lysis Syndrome in Adults and Children with Haematological Malignancies](https://b-s-h.org.uk/guidelines/guidelines/management-of-tumour-lysis-syndrome-in-adults-and-children-with-haematological-malignancies)\n\n[Patient.info: Oncological emergencies](https://patient.info/doctor/oncological-emergencies#tumour-lysis-syndrome)", "files": null, "highlights": [], "id": "389", "pictures": [], "typeId": 2 }, "chapterId": 389, "demo": null, "entitlement": null, "id": "622", "name": "Tumour Lysis Syndrome", "status": null, "topic": { "__typename": "Topic", "id": "25", "name": "Oncology and Palliative Care", "typeId": 2 }, "topicId": 25, "totalCards": 3, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "622", "name": "Tumour Lysis Syndrome" } ], "demo": false, "description": null, "duration": 331.63, "endTime": null, "files": null, "id": "388", "live": false, "museId": "LPYn8S6", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/hematology.png", "title": "Tumour lysis syndrome", "userViewed": false, "views": 240, "viewsToday": 10 } ] }, "conceptId": 622, "conditions": [], "difficulty": 1, "dislikes": 10, "explanation": null, "highlights": [], "id": "6547", "isLikedByMe": 0, "learningPoint": "Tumor lysis syndrome occurs when cancer cells rapidly die, releasing nucleic acids that break down into uric acid, overwhelming the kidneys, causing hyperuricemia, renal dysfunction, and elevated blood urea levels.", "likes": 5, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 24-year-old male is treated for Hodgkin's lymphoma with chemotherapy.\n\nAs he has a high tumour burden, he is deemed at high risk of tumour lysis syndrome (TLS); which of the following blood tests would suggest tumour lysis syndrome?", "sbaAnswer": [ "a" ], "totalVotes": 4634, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Pleural effusions can be associated with malignancy, and these are usually exudative. Pleural effusions are usually associated with reduced air entry and dull percussion notes as opposed to fine crackles", "id": "32740", "label": "c", "name": "Exudative pleural effusion", "picture": null, "votes": 359 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is unlikely to be the diagnosis here. Although the patient is likely to be at risk of developing infections such as pneumonia, no other signs of infection are present. Pneumonia does not usually produce fine crackles throughout the lung fields on auscultation", "id": "32739", "label": "b", "name": "Community-acquired pneumonia", "picture": null, "votes": 80 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Pulmonary fibrosis is a recognised side effect of bleomycin, and fine crackles on auscultation should prompt this diagnosis. A chest x-ray should be performed, and the medication may need to be stopped", "id": "32738", "label": "a", "name": "Pulmonary fibrosis", "picture": null, "votes": 3996 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Transudative pleural effusions are usually caused by fluid overload, such as organ failure (kidney, liver, heart) or through iatrogenic causes. Pleural effusions are usually associated with reduced air entry and dull percussion notes as opposed to fine crackles", "id": "32741", "label": "d", "name": "Transudative pleural effusion", "picture": null, "votes": 280 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Asthma can cause breathlessness, but this is not usually progressive in nature. Auscultation of the chest would reveal polyphonic wheeze or, in a severe attack, may be silent", "id": "32742", "label": "e", "name": "Asthma", "picture": null, "votes": 5 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Toxicity bear! :D ", "createdAt": 1682192950, "dislikes": 0, "id": "22476", "isLikedByMe": 0, "likes": 6, "parentId": null, "questionId": 6548, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Endoscopic retrograde cholangiopancreatogra-chap", "id": 18249 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary \n\n\nCytotoxic drugs, or chemotherapeutics, are medicines which are capable of destroying cells at particular stages of the cell cycle. Typically, they have more effect on rapidly dividing cells, such as cancer cells. The action of chemotherapeutic agents varies with different classes of medication available and each class will have specific side effect profiles.\n\n\n# Side effects\n\nCommon side effects of many cytotoxic drugs include:\n\n- Increased risk of infection\n- Anaemia\n- Easy bruising\n- Fatigue\n- Gastrointestinal upset\n- Appetite loss\n- Mucositis\n- Hair loss\n- Skin & nail changes\n- Emotional & cognitive changes\n- Increased risk of infertility\n\nBefore each cycle of chemotherapy, blood tests including FBC, U&Es & LFTs are carried out to assess for toxicity, and to check fitness for chemotherapy treatment.\n\n# Specific chemotherapy drugs\n\nSome chemotherapy drugs carry an increased risk of some side effects. It is important to be aware of these in exam settings and in clinical practice as a patient may present with long-term side effects of anticancer treatments.\n\n### Doxorubicin\n\nDoxorubicin is a member of the anthracycline family of **cytotoxic** antibiotics. It inhibits topoisomerase II, an enzyme which joins the DNA double helix, therefore halting the cell cycle. Doxorubicin also generates free radicals which damage the DNA and cell membrane structures. It is used to treat **haematological cancers** and solid tumours including **breast cancer**.\n\nDoxorubicin can cause **cardiomyopathy**, which presents up to 15 years after treatment. Doxorubicin's cardiotoxic effects range from isolated ECG changes to pericarditis and established cardiomyopathy. Before treatment begins cardiac function should be assessed with an ECG and/or echocardiogram.\n\n### Cisplatin\n\nCisplatin is a platinum-based agent which works by crosslinking with DNA purine bases, causing DNA damage and disrupting repair mechanisms. It is used to treat **testicular, ovarian, lung, bladder, cervical** and **head and neck** cancers.\n\nKey side effects of cisplatin use are **peripheral neuropathy** and **hearing loss**. It is also known for causing severe nausea and vomiting.\n\n### Cyclophosphamide\n\nCyclophosphamide is an alkylating agent which damages DNA, and is activated by the liver. It is used to treat a number of cancers including **haematological** cancers and **breast** cancer. It is also used as an immunosuppressant.\n\nCyclophosphamide can cause urothelial toxicity, specifically **haemorrhagic cystitis** and, in the longer term, transitional cell carcinoma of the bladder. Mesna is used with high dose cyclophosphamide to reduce the concentration of active metabolite in the urinary tract and reduce the risk of this occurring.\n\n### Bleomycin\n\nBleomycin is a cytotoxic antibiotic that works by inhibiting DNA synthesis. It is used to treat metastatic **germ cell** cancers, **head and neck** cancers and some **non-Hodgkin's lymphomas**.\n\nOne key side effect to be aware of is **lung fibrosis**. Respiratory side effects typically begin 1-6 months after treatment completion, although may occur sooner if a hypersensitivity reaction occurs.\n\n### Cytarabine\n\nCytarabine is an antimetabolite chemotherapeutic drug. It prevents the synthesis and repair of DNA. It is used to treat **haematological** cancers.\n\nCytarabine can cause **ataxia** due to an acute cerebellar syndrome, especially at higher doses. This may also cause **dysarthria.**\n\n### Methotrexate\n\nMethotrexate is an **antifolate** drug, commonly used as an immunosuppressant but is also used in treatment for a number of cancers including **haematological** cancers, **gestational trophoblastic** disease and **breast cancer**.\n\nSide effects to be aware of include **bone marrow suppression, gastrointestinal toxicity, photosensitivity, liver and pulmonary toxicity**. Folinic acid is typically given alongside and FBC should be monitored closely.\n\n\n# References\n\n[BNF: Cytotoxic drugs](https://bnf.nice.org.uk/treatment-summaries/cytotoxic-drugs/)\n\n[BNF: Cisplatin](https://bnf.nice.org.uk/drugs/cisplatin-specialist-drug/)\n\n[BNF: Bleomycin](https://bnf.nice.org.uk/drugs/bleomycin-specialist-drug/)\n\n[BNF: Cytarabine](https://bnf.nice.org.uk/drugs/cytarabine-specialist-drug/)\n\n[BNF: Methotrexate](https://bnf.nice.org.uk/drugs/methotrexate/)\n\n[NHS: Chemotherapy side effects](https://www.nhs.uk/conditions/chemotherapy/side-effects/)\n\n[Cancer research UK: Cytarabine](https://www.cancerresearchuk.org/about-cancer/treatment/drugs/cytarabine)\n\n[An overview of doxorubicin formulations in cancer therapy](https://journals.lww.com/cancerjournal/fulltext/2014/10040/an_overview_of_doxorubicin_formulations_in_cancer.9.aspx)\n\n[Doxorubicin-induced cardiomyopathy: from molecular mechanisms to therapeutic strategies](https://www.sciencedirect.com/science/article/pii/S0022282812001150)\n\n[Cancer research UK: doxorubicin](https://www.cancerresearchuk.org/about-cancer/treatment/drugs/doxorubicin)\n\n[StatPearls: Cyclophosphamide](https://www.ncbi.nlm.nih.gov/books/NBK553087/#:~:text=Cyclophosphamide%20is%20a%20medication%20primarily,anti%2Dneoplastic%20effects%20through%20alkylation.)\n\n[Drugbank.com: Bleomycin](https://go.drugbank.com/drugs/DB00290)\n\n[Chemotherapy agents with known pulmonary side effects and their anaesthetic and critical care implications](https://www.sciencedirect.com/science/article/abs/pii/S1053077015005698)\n\n[Cytarabine induced acute cerebellar syndrome during hyper-CVAD treatment for B-cell acute lymphoblastic leukaemia](https://pmc.ncbi.nlm.nih.gov/articles/PMC5437478/)\n\n[Drugbank.com: Methotrexate](https://go.drugbank.com/drugs/DB00563#)", "files": null, "highlights": [], "id": "605", "pictures": [], "typeId": 2 }, "chapterId": 605, "demo": null, "entitlement": null, "id": "624", "name": "Specific Side Effects of Chemotherapy", "status": null, "topic": { "__typename": "Topic", "id": "25", "name": "Oncology and Palliative Care", "typeId": 2 }, "topicId": 25, "totalCards": 6, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "624", "name": "Specific Side Effects of Chemotherapy" } ], "demo": false, "description": null, "duration": 316.39, "endTime": null, "files": null, "id": "363", "live": false, "museId": "8ZZjLBo", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/oncology.png", "title": "Specific Side Effects of Chemotherapy 1", "userViewed": false, "views": 90, "viewsToday": 10 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "624", "name": "Specific Side Effects of Chemotherapy" } ], "demo": false, "description": null, "duration": 2847.77, "endTime": null, "files": null, "id": "323", "live": false, "museId": "V96YeRb", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/hematology.png", "title": "Quesmed Tutorial: Lymphoma", "userViewed": false, "views": 209, "viewsToday": 21 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "624", "name": "Specific Side Effects of Chemotherapy" } ], "demo": false, "description": null, "duration": 2980.74, "endTime": null, "files": null, "id": "328", "live": false, "museId": "ptyhs2C", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/oncology.png", "title": "Quesmed Tutorial: Oncology and Palliative Care", "userViewed": false, "views": 302, "viewsToday": 27 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "624", "name": "Specific Side Effects of Chemotherapy" } ], "demo": false, "description": null, "duration": 321.07, "endTime": null, "files": null, "id": "364", "live": false, "museId": "rMLVT1H", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/oncology.png", "title": "Specific Side Effects of Chemotherapy 2", "userViewed": false, "views": 55, "viewsToday": 5 } ] }, "conceptId": 624, "conditions": [], "difficulty": 1, "dislikes": 1, "explanation": null, "highlights": [], "id": "6548", "isLikedByMe": 0, "learningPoint": "Bleomycin can cause pulmonary fibrosis, characterised by fine crackles on auscultation and progressive breathlessness in affected patients.", "likes": 1, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 74-year-old male diagnosed with Non-Hodgkin's lymphoma and started on bleomycin. He presents to General Practice complaining about progressive breathlessness. On auscultation of his chest, you notice bilateral fine crackles.\n\nWhat is the likely diagnosis?", "sbaAnswer": [ "a" ], "totalVotes": 4720, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": true, "explanation": "She is ambulatory and capable of all self-care but unable to carry out any work activities. She is up and about more than 50% of the day", "id": "32743", "label": "a", "name": "Grade 2", "picture": null, "votes": 2297 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Grade 0 would require her to be fully active and able to carry out all activities of daily living", "id": "32744", "label": "b", "name": "Grade 0", "picture": null, "votes": 102 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Garde 1 would require her to be able to carry out light housework or work of a sedentary nature", "id": "32745", "label": "c", "name": "Grade 1", "picture": null, "votes": 1196 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Grade 4 is completely disabled, unable to self-care, and confined to a chair or bed", "id": "32747", "label": "e", "name": "Grade 4", "picture": null, "votes": 141 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Grade 3 would suggest that she is only capable of limited self-care and is confined to a bed or chair for >50% of the day", "id": "32746", "label": "d", "name": "Grade 3", "picture": null, "votes": 835 } ], "comments": [ { "__typename": "QuestionComment", "comment": "we don't know about her waking hours why is the answer not grade 1?\n", "createdAt": 1705940684, "dislikes": 0, "id": "39579", "isLikedByMe": 0, "likes": 4, "parentId": null, "questionId": 6549, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "RNA Retrograde", "id": 2980 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\n\nWHO Performance status classification categorises patients into different groups dependent on their physical fitness, measured by their ability to perform activities of daily living. It is used to assess their suitability for chemotherapy, and has some prognostic significance. \n\n\nChemotherapy as a treatment is not without its side effects, which can limit quality of life and have negative impacts on other comorbidities. Treatment decisions involve a risk-benefit analysis, and as such a patients' performance status has a significant bearing on what treatment options are most appropriate.\n\n\n# Classification\n\n\nThe WHO performance status classification categorises patients as:\n\n\n- 0: able to carry out all normal activity without restriction\n- 1: restricted in strenuous activity but ambulatory and able to carry out light work\n- 2: ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours\n- 3: symptomatic and in a chair or in bed for greater than 50% of the day but not bedridden\n- 4: completely disabled; cannot carry out any self-care; totally confined to bed or chair.\n\n\n# References\n\n[NICE Appendix C: WHO performance status classification](https://www.nice.org.uk/guidance/ta121/chapter/appendix-c-who-performance-status-classification#:~:text=The%20WHO%20performance%20status%20classification,to%20carry%20out%20light%20work)\n\n[JAMA Oncology: Performance status in patients with cancer](https://jamanetwork.com/journals/jamaoncology/fullarticle/2432463)", "files": null, "highlights": [], "id": "604", "pictures": [], "typeId": 2 }, "chapterId": 604, "demo": null, "entitlement": null, "id": "623", "name": "WHO Performance Status", "status": null, "topic": { "__typename": "Topic", "id": "25", "name": "Oncology and Palliative Care", "typeId": 2 }, "topicId": 25, "totalCards": 2, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 623, "conditions": [], "difficulty": 2, "dislikes": 20, "explanation": null, "highlights": [], "id": "6549", "isLikedByMe": 0, "learningPoint": "A WHO performance status of Grade 2 indicates that the patient is \"up and about more than 50% of waking hours but is not fully active\", meaning they are able to perform light activities but are unable to carry out strenuous work or activities.", "likes": 2, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "An 86 year old female is being referred to the bowel cancer multi-disciplinary team (MDT) for consideration of treatment.\nShe lives alone in a bungalow, is completely independent with self-care and has an active social life visiting her neighbours, but has to have help from her family with shopping, cleaning and cooking.\n\nWhat is her WHO performance status?", "sbaAnswer": [ "a" ], "totalVotes": 4571, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Nebulised salbutamol is used in the treatment of airway inflammation. As this patient does not currently have symptoms of airway inflammation, this is not currently indicated, and the use of the nebuliser may be more distressing for the patient", "id": "32751", "label": "d", "name": "Nebulised salbutamol", "picture": null, "votes": 86 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Glycopyrronium is a medication from the muscarinic anticholinergic group. It is often used for respiratory tract secretions in palliative care patients who can no longer manage their own secretions due to impaired cough reflex", "id": "32748", "label": "a", "name": "Glycopyrronium", "picture": null, "votes": 3908 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "High flow oxygen can be very uncomfortable and not well tolerated. This patient's issues are related to respiratory secretions, and oxygen will not assist with those secretions", "id": "32752", "label": "e", "name": "High flow nasal oxygen", "picture": null, "votes": 27 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Pain in the palliative setting is important to bear in mind and manage as patients may not be able to communicate fully. Morphine will cause respiratory depression, which again may be of benefit in this patient; however will not help with the distressing secretions", "id": "32750", "label": "c", "name": "Morphine", "picture": null, "votes": 228 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Haloperidol is often used in the palliative care setting for agitation and delirium. It may well be beneficial in this case; however, as this patient is likely agitated from his secretions, glycopyrronium will be of more help", "id": "32749", "label": "b", "name": "Haloperidol", "picture": null, "votes": 472 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Just give us hyoscine hydrobromide please!", "createdAt": 1687160010, "dislikes": 0, "id": "29076", "isLikedByMe": 0, "likes": 10, "parentId": null, "questionId": 6550, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Botox Ben", "id": 29771 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nMedications in end-of-life care focus on alleviating distressing symptoms in patients nearing death. A holistic approach is vital, considering physical, emotional, and social aspects of symptoms, often involving a multidisciplinary team. For pain management, the WHO pain ladder guides pharmacological strategies, with morphine as the primary strong opioid. Specific treatments for other symptoms depend on the underlying cause and it is important to consider reversible causes and non-pharmacological measures.\n\n\n\n# Definition\n\nMedications used in end of life care aim to relieve distressing symptoms which may appear in the last days, weeks, or months of life. They are commonly prescribed as 'anticipatory' or 'just in case' medications for a patient known to be nearing the end of life.\n\n\nThey can be administered:\n\n\n- Orally - if the patient is safely able to swallow\n- Subcutaneously - via single dose or continuous syringe pump\n- Transdermally - especially for stable symptoms and if available\n- Intramuscularly - less common\n- Intravenously - less common, but may be helpful if a patient already has access\n\n## A note on holistic care\n\nIn palliative care, and in medicine, it is important to consider all symptoms in context. There are many different aspects to symptoms. These include the physical cause, the patient's beliefs about their illness and symptoms, social contributors and impacts, their emotional and behavioural responses. Holistic assessment and management are crucial, which is why the multidisciplinary team is so important. \n\nFor example, a patient may have been prescribed very effective analgesia but is unable to administer medicines themselves. They may also have a very strong emotional response to pain or believe that they deserve their symptoms. They may benefit from a package of care or financial support for terminal illness which a social worker could help with, or an occupational therapist to help with activities of daily living. Counselling may give the patient a space to explore their feelings around their symptoms and their illness, while spiritual support could alleviate some existential distress. These additional interventions work alongside pharmacological therapy to optimise a person's quality of life through their illness.\n\nThis chapter focuses on medications for symptoms towards the end of life, but it is crucial to remember that each patient has a different combination of needs which requires an individual assessment and management plan, often with input from a range of health and social care professionals.\n\n# Pain\n\n\nInitial pharmacological management of pain should follow the WHO pain ladder. Once patients have reached the top of this ladder (requiring regular strong opioids), careful optimisation is necessary to ensure the right level of pain relief while minimising side effects.\n\n- Morphine is the first-line strong opioid analgesic. This can be given as a modified release or immediate release form. \n- Generally, patients would have a regular 'background' dose based on their 24-hour requirements, plus a PRN dose available for **breakthrough pain.** PRN doses are usually 1/6-1/10 of the 24 hour dose. Analgesia requirements should be reviewed regularly, for example every 24 hours.\n- Alternatives to morphine may be necessary for patients with poor renal function. These include oxycodone, alfentanyl or buprenorphine.\n- When prescribing opioid analgesia consider co-prescribing a regular laxative and an as-required anti-emetic. Monitor for signs of opioid toxicity (respiratory depression, sedation, myoclonus) and switch to alternatives or dose reduce as necessary.\n\nWhen switching analgesia, it is helpful to convert the dose first to oral morphine before converting to the desired medication. Please note that different routes also have different equivalent doses, so it is always safest to check guidelines.\n\n\nThe following table shows dose equivalents of 10mg oral morphine\n\n\n| Analgesic/Route | Dose | Conversion Factor |\n| ----------------------------- | ------- | ----------------- |\n| Codeine/tramadol/dihydrocodeine oral | 100mg | x10 |\n| Diamorphine IM/IV/Subcut | 3mg | x3.3 |\n| Morphine IM/IV/Subcut | 5mg | x2 |\n| Oxycodone oral\\* | 5mg\\* | x2\\* |\n| Oxycodone Subcut\\* | 2.5mg\\* | x4\\* |\n| Alfentanil Subcut | 0.3mg | x30 |\n\n\n*NB - oral oxycodone potency is between 1.3-2x that of oral morphine. Different trusts will adopt different guidance on which you should use. If in doubt, always opt for the lower dose and titrate up.\n\n\n# Breathlessness\n\nConsider non-pharmacological measures for breathlessness first. For example, sitting the patient up, opening a window or setting up a fan can all help.\n\nPharmacological management may involve low-dose opioids, benzodiazepines or therapeutic oxygen, and should be tailored to the patient.\n\n\n# Nausea and vomiting\n\nIt is important to consider the likely cause of nausea and vomiting, as medications target different parts of the vomiting pathway. Perform a full assessment to determine the likely cause of the nausea and vomiting. Consider parenteral routes of administration - patients may have severe gastrointestinal disturbance or at least may not be able to keep down oral antiemetics long enough to be effective.\n\nThe following table shows the primary site of activity and side effects of commonly used antiemetics:\n\n| Antiemetic | Receptor activity | Side effects & cautions | Useful for |\n|---|---|---|---|\n| Metoclopramide | Dopamine antagonist | Extrapyramidal symptoms, drowsiness, restlessness, diarrhoea. Do not give with antimuscarinics or in mechanical bowel obstruction | Gastric stasis, functional bowel obstruction |\n| Cyclizine | Histamine, acetylcholine antagonist | Drowsiness, antimuscarinic | Raised intracranial pressure, vestibular dysfunction |\n| Hyoscine | Acetylcholine antagonist | Antimuscarinic | Motion sickness |\n| Haloperidol | Dopamine antagonist | Less common in palliative care doses | Chemical |\n| Levomepromazine | Dopamine, histamine, acetylcholine, 5HT2 antagonist | Sedation, postural hypotension, antimuscarinic |Broad range |\n| Ondansetron | 5HT3 antagonist | Constipation, arrhythmias, movement disorder | Cytotoxic-related |\n\n- For chemically-mediated symptoms (for example medications, metabolic derangemenet), aim to treat the underlying cause. Antiemetics that may be helpful include haloperidol, metoclopramide or levomepromazine.\n- For nausea and vomiting due to raised intracranial pressure, cyclizine is usually used first-line. Dexamethasone or radiotherapy may be helpful to reduce the pressure-associated symptoms.\n- For patients with vestibular disturbance (for example symptoms associated with movement), cyclizine usually used first-line. Alternatives include hyoscine hydrobromide.\n- For patients with bowel obstruction, seek specialist advice. If due to peristaltic failure, review medications and consider starting metoclopramide (providing there is no colic). Likewise for gastric stasis, consider metoclopramide. For patients with mechanical obstruction and/or colic, do not give metoclopramide. Exclude constipation, give cyclizine for nausea and treat colic with hyoscine butylbromide.\n- If nausea and vomiting is due to compression from an abdominal or pelvic tumour, cyclizine should be used first-line.\n- For anxiety-related nausea and vomiting, begin with non-pharmacological measures for anxiety, such as CBT. A benzodiazepine or levomepromazine would be first-line pharmacological options.\n\n# Agitation\n\nAs with other symptoms, aim to manage reversible causes of agitation and possible delirium first. Consider non-pharmacological measures such as environmental modification. For patients in their last days of life, haloperidol or low-dose midazolam may be prescribed. Often, this is done as part of anticipatory prescribing.\n\n\n# Respiratory tract secretions\n\nRespiratory tract secretions often occur in the last days of life as a person becomes less able to clear their airways. They are rarely a cause of distress to the patient, but may be upsetting for family members or those close to the patient. An antimuscarinic such as hyoscine butylbromide or glycopyrronium bromide may be prescribed for noisy respiratory secretions.\n\n\n# NICE guidelines\n\n\n[NICE Guidance: Care of dying adults in the last days of life](https://www.nice.org.uk/guidance/ng31)\n\n[NICE CKS: Palliative care - general issues](https://cks.nice.org.uk/topics/palliative-care-general-issues/)\n\n[NICE CKS: Palliative care - dyspnoea](https://cks.nice.org.uk/topics/palliative-care-dyspnoea/)\n\n[NICE CKS: Palliative care - nausea and vomiting](https://cks.nice.org.uk/topics/)\n\n[NICE CKS: Palliative care - secretions](https://cks.nice.org.uk/topics/)\n\n[NICE CKS: Palliative cancer care - pain](https://cks.nice.org.uk/topics/)\n\n# References\n\n[Pallcare.info](https://www.pallcare.info/book.php)\n\n[BNF: Ondansetron](https://bnf.nice.org.uk/drugs/ondansetron/#drug-action)\n\n[BNF: Nausea and labyrinth disorders](https://bnf.nice.org.uk/treatment-summaries/nausea-and-labyrinth-disorders/)\n\n[BNF: Prescribing in palliative care](https://bnf.nice.org.uk/medicines-guidance/prescribing-in-palliative-care/)", "files": null, "highlights": [], "id": "1035", "pictures": [], "typeId": 2 }, "chapterId": 1035, "demo": null, "entitlement": null, "id": "1094", "name": "End of Life Care Medications", "status": null, "topic": { "__typename": "Topic", "id": "25", "name": "Oncology and Palliative Care", "typeId": 2 }, "topicId": 25, "totalCards": null, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "1094", "name": "End of Life Care Medications" } ], "demo": false, "description": null, "duration": 2980.74, "endTime": null, "files": null, "id": "328", "live": false, "museId": "ptyhs2C", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/oncology.png", "title": "Quesmed Tutorial: Oncology and Palliative Care", "userViewed": false, "views": 302, "viewsToday": 27 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "1094", "name": "End of Life Care Medications" } ], "demo": false, "description": null, "duration": 471.7, "endTime": null, "files": null, "id": "127", "live": false, "museId": "aaSimwn", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/oncology.png", "title": "SBAs in Palliative Care Prescribing", "userViewed": false, "views": 199, "viewsToday": 16 } ] }, "conceptId": 1094, "conditions": [], "difficulty": 1, "dislikes": 3, "explanation": null, "highlights": [], "id": "6550", "isLikedByMe": 0, "learningPoint": "Glycopyrronium is an effective anticholinergic medication used to reduce respiratory secretions in palliative care patients.", "likes": 2, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "An 87-year-old male is admitted to hospital from a nursing home with aspiration pneumonia. He clinically deteriorates, and after discussion with his family, the decision is made to palliate and control his symptoms.\nHis family are concerned he is becoming increasingly agitated due to his respiratory secretions.\n\nWhat medication might be of benefit here?", "sbaAnswer": [ "a" ], "totalVotes": 4721, "typeId": 1, "userPoint": null }

[]

{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "This is incorrect as the horizontal line on a forest plot indicates the confidence intervals as opposed to the range of the data sets. A wide confidence interval indicates instability of results, for example, due to a very small data set", "id": "32554", "label": "b", "name": "James et al. have the largest range of results", "picture": null, "votes": 2446 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is false as all of the forest plot lines are above 1. In risk ratios or relative risk, if the ratio is >1, then this means that the intervention has a less favourable risk than in the group not subject to the intervention, i.e. greater risk of hernia recurrance.", "id": "32557", "label": "e", "name": "All the studies suggest that her method has a lower risk of hernia recurrence", "picture": null, "votes": 399 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is incorrect as the horizontal line is a representation of the confidence intervals. A wide confidence interval is more likely to be representative of a smaller data set", "id": "32556", "label": "d", "name": "James et al. likely had the most participants in their study", "picture": null, "votes": 170 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This is true as all of the forest plot lines are at or above 1. In risk ratios or relative risk, if the ratio is >1, then this means that the intervention has a less favourable risk than in the group not subject to the intervention, i.e. greater risk of hernia recurrance.", "id": "32553", "label": "a", "name": "None of the studies suggest that her method has a lower risk of hernia recurrence", "picture": null, "votes": 662 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This is incorrect as the ratio here is very close to 1, indicating that the risk of recurrence from her technique is very similar to the risk of recurrence from other techniques", "id": "32555", "label": "c", "name": "Edwards et al. show the biggest difference in the risks of hernia recurrence between her technique and other techniques", "picture": null, "votes": 317 } ], "comments": [ { "__typename": "QuestionComment", "comment": "No because Edwards et al has a range from below 1 to above 2", "createdAt": 1720859110, "dislikes": 2, "id": "54222", "isLikedByMe": 0, "likes": 5, "parentId": null, "questionId": 6511, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "BradySclerosis", "id": 35569 } }, { "__typename": "QuestionComment", "comment": "also shade on the colleague", "createdAt": 1721064051, "dislikes": 0, "id": "54323", "isLikedByMe": 0, "likes": 1, "parentId": null, "questionId": 6511, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "BradySclerosis", "id": 35569 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Definition \n\nA type of clinical study in which participants are assigned to groups that receive one or more intervention/treatment (or no intervention) so that researchers can evaluate the effects of the interventions on biomedical or health-related outcomes.\n\n# Types of interventional trials \n\nA randomized control trial is the strongest type of interventional trial, but other forms include non-randomised controlled trials, pre-post studies and quasi experiments.\n\nA pre-post study is a study in which occurrence of an outcome is measured both before and after an intervention is administered; it is in this way that the effect of the intervention can be properly assessed. If the occurrence of the outcome was only measured after the intervention; the exact effect of the intervention cannot be determined.\n\nAnother form of trial is a crossover randomized control trial. A crossover RCT is a type of interventional study design where study participants intentionally “crossover” to the other treatment arm.\n\n# Uses \n\nInterventional studies are used to answer study questions relating to either therapeutic agents, and evaluating the efficacy of therapeutic agents, or are used to assess mechanisms of preventing potential causes of damage.", "files": null, "highlights": [], "id": "592", "pictures": [], "typeId": 2 }, "chapterId": 592, "demo": null, "entitlement": null, "id": "605", "name": "Interventional studies", "status": null, "topic": { "__typename": "Topic", "id": "51", "name": "Medical Statistics", "typeId": 2 }, "topicId": 51, "totalCards": null, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 605, "conditions": [], "difficulty": 3, "dislikes": 68, "explanation": null, "highlights": [], "id": "6511", "isLikedByMe": 0, "learningPoint": "A forest plot visually displays results from multiple studies, showing effect sizes with confidence intervals; points crossing the line of no effect indicate non-significance", "likes": 1, "multiAnswer": null, "pictures": [ { "__typename": "Picture", "caption": null, "createdAt": 1639016607, "id": "366", "index": 0, "name": "Forest Plot.jpg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/sz53a4b71639016606466.jpg", "path256": "images/sz53a4b71639016606466_256.jpg", "path512": "images/sz53a4b71639016606466_512.jpg", "thumbhash": "PggCBICDeGVvdYeiiXwAAAAAAA==", "topic": { "__typename": "Topic", "id": "51", "name": "Medical Statistics", "typeId": 2 }, "topicId": 51, "updatedAt": 1708373886 } ], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "Your colleague has a particular way of performing inguinal hernia repairs that is less commonly used. She wants to know whether her technique has a higher or lower rate of recurrence. She finds five studies that use her method compared to the routine method and plots them in a forest plot (x-axis represents the relative risk of recurrence in your colleague's method compared to the routine method).\n\n[lightgallery]\n\nWhich of these statements about her findings is true?", "sbaAnswer": [ "a" ], "totalVotes": 3994, "typeId": 1, "userPoint": null }

[]

{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Ropinirole is a dopamine agonist used to treat Parkinson's. Side effects include postural hypotension, hallucinations and movement disorders. It is unlikely to lead to third degree heart block", "id": "32754", "label": "b", "name": "Ropinirole", "picture": null, "votes": 1102 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Atorvastatin is a HMG-CoA reductase inhibitor that is used in secondary prevention post-suspected transient ischaemic attack. Side effects include myalgia and myopathy", "id": "32756", "label": "d", "name": "Atorvastatin", "picture": null, "votes": 82 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Aspirin is an anti-platelet medication that is used in secondary prevention post-suspected trans ischaemic attack. Aspirin can lead to bronchospasm but would not lead to third degree heart block", "id": "32757", "label": "e", "name": "Aspirin", "picture": null, "votes": 57 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Amlodipine is a calcium channel blocker that is used in secondary prevention post-suspected transient ischaemic attack. Side effects of amlodipine are more likely to be tachycardia than bradycardia", "id": "32755", "label": "c", "name": "Amlodipine", "picture": null, "votes": 1135 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Donepezil is an anticholinesterase inhibitor that is used to treat Alzheimer's dementia. It can lead to third degree heart block, which is where there is complete dissociation of P waves and QRS complexes", "id": "32753", "label": "a", "name": "Donepezil", "picture": null, "votes": 3324 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Causes of Third Degree Heart Block:\n\nMyocardial infarction (especially inferior)\nDrugs acting at the AV node (beta blockers, calcium channel blockers)\nIdiopathic fibrosis.\n\nok... ", "createdAt": 1683081303, "dislikes": 0, "id": "23256", "isLikedByMe": 0, "likes": 12, "parentId": null, "questionId": 6551, "replies": [ { "__typename": "QuestionComment", "comment": "Thanks vitamins !", "createdAt": 1685694269, "dislikes": 0, "id": "27529", "isLikedByMe": 0, "likes": 3, "parentId": 23256, "questionId": 6551, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Nightshift Dorsal", "id": 6952 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Viral Vitamin", "id": 4742 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\r\n\r\nHeart block refers to an obstruction in the electrical conduction system of the heart. This obstruction can occur at various points in the conduction system, including the sinoatrial node, atrioventricular node, Bundle of His, or bundle branches. Atrioventricular heart block specifically affects the conduction between the atria and ventricles. The severity of heart block can range from first degree, which is generally benign, to second degree (Mobitz Type I and II), to complete (third degree) heart block, which requires immediate management with a permanent pacemaker due to the risk of asystole. The underlying causes and management strategies differ for each type of heart block.\r\n\r\n# Definition \r\n\r\nHeart block occurs due to an obstruction in the electrical conduction system of the heart. It can occur anywhere along the conduction system of the heart from the sinoatrial node to the atrioventricular node to the Bundle of His or within the bundle branches themselves. \r\n\r\nSinoatrial node block rarely leads to symptoms as the atrioventricular node acts as a secondary pacemaker. Bundle branch blocks are a form of heart block but they are discussed in a separate section. The rest of this section will discuss atrioventricular block in more detail. \r\n\r\nPatients with atrioventricular heart block may be asymptomatic or may present with fatigue, lightheadeness, syncope, shortness of breath and most seriously in cardiac arrest or with sudden death. \r\n\r\n# First Degree Heart Block\r\n\r\n## Definition\r\n\r\nThis is caused by prolonged conduction of electrical activity through the AV node. It can be identified on ECG by finding a PR interval >200ms.\r\n\r\n[lightgallery]\r\n\r\n## Causes\r\n\r\n* High vagal tone: e.g. athletes\r\n* Acute inferior MI\r\n* Electrolyte abnormalities: e.g. hyperkalaemia\r\n* Drugs: e.g. NHP-CCBs, beta-blockers, digoxin, cholinesterase inhibitors\r\n\r\n## Management\r\n\r\nFirst degree heart block itself is benign and does not need treating. However, any pathological underlying cause should be reversed.\r\n\r\n# Second Degree Heart Block \r\n\r\nSecond degree heart block is split into Mobitz Type I and Mobitz Type II heart block. \r\n\r\n# Mobitz Type I\r\n\r\n## Definition\r\n\r\nWenckebach phenomenon or Mobitz type I is a type of second degree heart block that is usually due to reversible conduction block at the AV node. It is characterised by progressive lengthening of the PR interval which results in a P wave that fails to conduct a QRS.\r\n\r\n[lightgallery1]\r\n\r\n## Causes\r\n\r\n* MI (mainly inferior)\r\n* Drugs such as beta/calcium channel blockers, digoxin\r\n* Professional athletes due to high vagal tone\r\n* Myocarditis\r\n* Cardiac surgery\r\n\r\n## Management\r\n\r\nIt is generally asymptomatic and does not require any specific management as the risk of high AV block/complete heart block is low. If symptoms do arise, ECG monitoring may be required, precipitating drugs must be stopped and if they are bradycardic with adverse features they should be treated with atropine.\r\n\r\n# Mobitz Type II\r\n\r\n## Definition\r\n\r\nMobitz type II block is a type of second degree AV block where there are intermittent non-conducted P waves. The _PR interval is constant_ (may be normal or prolonged) and there may no pattern or fixed ratios such as 2:1 or 3:1 block. It is usually caused by conduction system failure, especially at the His-Purkinje system.\r\n\r\nIn most cases there is a broad QRS indicating a distal block in the His-Purkinje system and many patients have pre-existing left bundle branch block/bifascicular block.\r\n\r\n[lightgallery2]\r\n\r\n## Causes\r\n\r\n* Infarction: particularly anterior MI which damages the bundle branches\r\n* Surgery: mitral valve repair or septal ablation\r\n* Inflammatory/autoimmune: rheumatic heart disease, SLE, systemic sclerosis, myocarditis\r\n* Fibrosis: Lenegre's disease\r\n* Infiltration: sarcoidosis, haemochromatosis, amyloidosis\r\n* Medication: beta-blockers, calcium channel blockers, Digoxin, amiodarone\r\n\r\n## Management\r\n\r\nDefinitive management is with a permanent pacemaker as these <u>_patients are at risk of complete heart block_</u> and at risk of becoming haemodynamically unstable.\r\n\r\n# Complete (Third degree) Heart Block\r\n\r\n## Definition\r\n\r\nComplete heart block occurs when atrial impulses fail to be conducted to the ventricles. Sufficient cardiac output may be secondary to a ventricular or junctional escape rhythm.\r\n\r\nECG shows severe bradycardia and complete dissociation between the P waves and the QRS complexes. These patients are at high risk of asystole, ventricular tachycardia and cardiac arrest. \r\n\r\n[lightgallery3]\r\n\r\n## Causes\r\n\r\n* Myocardial infarction: especially inferior\r\n* Drugs acting at the AVN: beta blockers, dihydropyridine calcium channel blockers, or adenosine\r\n* Idiopathic fibrosis\r\n\r\n## Management\r\n\r\nManagement of complete (third degree) heart block is via the acute bradycardia guideline (see below). Permanent pacemaker insertion is eventually required due to the risk of sudden death.\n\nAcute management:\n\nFor emergencies, always follow an A-E structure. Identify reversible causes (dyselectrolytaemias, drugs, cardiac causes etc.) \r\n\r\n*If there are adverse signs (e.g. shock, syncope, heart failure, myocardial ischaemia):* \r\n\r\n* **1st line** = **500 micrograms atropine IV**\r\n * Atropine blocks the vagal nerve which increases firing rate of the SAN. \r\n* **2nd line** = if the first dose of atropine is not working can consider giving additional doses of atropine 500mcg up to 3mg until response. Alternatively, **transcutaenous pacing** or **isoprenaline** or **adrenaline** or **alternative drugs** including aminophylline, adrenaline, glucagon (in beta-blocker or calcium channel blocker overdose). \r\n\r\n*If there are no adverse signs but a risk of asystole, or a satisfactory response to 500mcg atropine:*\r\n\r\n* Risk of asystole: recent asystole, mobitz type II block, complete heart block + broad QRS, ventricular pauses >3s. \r\n* **1st line** = administer **500 micrograms atropine IV**. Alternatively, **transcutaenous pacing** or **isoprenaline** or **adrenaline** or **alternative drugs** including aminophylline, adrenaline, glucagon (in beta-blocker or calcium channel blocker overdose). \r\n\r\n*If there are no adverse signs and there is no risk of asystole*\r\n\r\n* Observe\r\n\r\n# NICE Guidelines\r\n\n[NICE Guidelines on Pacing](<https://www.nice.org.uk/guidance/ta88/chapter/2-clinical-need-and-practice>) \r\n\r\n# References\r\n\r\n[Life in the Fast Lane Heart Block ECG Summary](https://litfl.com/heart-block-and-conduction-abnormalities/)\r\n\r\n[Resuscitation Council Adult Bradycardia Algorithm](<https://www.resus.org.uk/sites/default/files/2020-05/G2015_Adult_bradycardia.pdf>)", "files": null, "highlights": [], "id": "619", "pictures": [ { "__typename": "Picture", "caption": "First degree heart block.", "createdAt": 1665036193, "id": "769", "index": 0, "name": "First Degree Heart Block.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/o84o7ha81665036171703.jpg", "path256": "images/o84o7ha81665036171703_256.jpg", "path512": "images/o84o7ha81665036171703_512.jpg", "thumbhash": "tkgCA4D41rmEiOhnqX+d+sc=", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "Mobitz type I.", "createdAt": 1665036183, "id": "694", "index": 1, "name": "Mobitz Type I.png", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/6waeua8n1665036171702.jpg", "path256": "images/6waeua8n1665036171702_256.jpg", "path512": "images/6waeua8n1665036171702_512.jpg", "thumbhash": "OCgCBYJ2hmZwd4d+dwhmf4ePcvcX", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "Complete heart block.", "createdAt": 1665036193, "id": "764", "index": 3, "name": "Complete heart block.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/sfujefok1665036171701.jpg", "path256": "images/sfujefok1665036171701_256.jpg", "path512": "images/sfujefok1665036171701_512.jpg", "thumbhash": "sUgCC4AFanekjIh5f4jHT4Y=", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "Mobitz type II.", "createdAt": 1665036192, "id": "738", "index": 2, "name": "Mobitz Type II.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/pzhhne1c1665036171703.jpg", "path256": "images/pzhhne1c1665036171703_256.jpg", "path512": "images/pzhhne1c1665036171703_512.jpg", "thumbhash": "oDgGBICveHeLd3d3h3h/nKf5Nw==", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 619, "demo": null, "entitlement": null, "id": "642", "name": "Heart Block", "status": null, "topic": { "__typename": "Topic", "id": "35", "name": "Cardiology", "typeId": 2 }, "topicId": 35, "totalCards": 25, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "642", "name": "Heart Block" } ], "demo": false, "description": null, "duration": 416.94, "endTime": null, "files": null, "id": "674", "live": false, "museId": "7hcFDzw", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/cardiology.png", "title": "Heart Block", "userViewed": false, "views": 179, "viewsToday": 15 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "642", "name": "Heart Block" } ], "demo": false, "description": null, "duration": 4294.36, "endTime": null, "files": null, "id": "610", "live": false, "museId": "8JoZgLE", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/cardiology.png", "title": "Quesmed Tutorial: Arrhythmias", "userViewed": false, "views": 591, "viewsToday": 35 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "642", "name": "Heart Block" } ], "demo": false, "description": null, "duration": 508.63, "endTime": null, "files": null, "id": "384", "live": false, "museId": "rWpGE8d", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/ED.png", "title": "Treatment of bradycardia with adverse features", "userViewed": false, "views": 196, "viewsToday": 8 } ] }, "conceptId": 642, "conditions": [], "difficulty": 2, "dislikes": 18, "explanation": null, "highlights": [], "id": "6551", "isLikedByMe": 0, "learningPoint": "Donepezil can cause third-degree heart block, characterised by complete dissociation of P waves and QRS complexes, particularly in elderly patients.", "likes": 4, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 90-year-old woman is brought to A&E because she has been complaining of chest pain. She is a poor historian because of known Alzheimer's dementia. She also has a past medical history of Parkinson's and a previous suspected transient ischaemic attack. On examination, she is visibly short of breath.\n\nOn her ECG, there is complete dissociation of the P waves and QRS complexes.\n\nHer current medication is as follows: donepezil, ropinirole, amlodipine, atorvastatin, aspirin. Which of these medications is most likely to have caused this problem?", "sbaAnswer": [ "a" ], "totalVotes": 5700, "typeId": 1, "userPoint": null }

[]

{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Hypotension and raised jugular venous pressure may occur in pneumothorax, especially a tension pneumothorax. However, this is likely to be accompanied by sudden onset pleuritic chest pain, making it less likely. Therefore, a needle thoracostomy would not be appropriate", "id": "32762", "label": "e", "name": "Needle thoracostomy", "picture": null, "votes": 155 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Sertraline is a selective serotonin reuptake inhibitor (SSRI), which may be appropriate if the patient was suffering from a panic disorder. Although the patient is anxious, a panic disorder is less likely due to the pattern of the observations and the examination findings", "id": "32760", "label": "c", "name": "Sertraline", "picture": null, "votes": 21 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "The patient cannot talk in full sentences, which is one of the features of an acute severe asthma attack. However, this is less likely when considering the raised jugular venous pressure and bibasal crepitations without wheeze. Therefore, nebulised salbutamol would not be appropriate", "id": "32761", "label": "d", "name": "Nebulised salbutamol", "picture": null, "votes": 152 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "The patient is displaying all the three hallmarks of Beck's triad. These are distended neck veins, hypotension and muffled heart sounds. When presenting acutely, the first presentation may be anxiety and fatigue. Dyspnoea, tachycardia and tachypnoea are also seen. Therefore, the definitive treatment is pericardiocentesis, where a needle is inserted into the pericardium to drain fluid", "id": "32758", "label": "a", "name": "Pericardiocentesis", "picture": null, "votes": 4467 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This would be appropriate in acute heart failure. The patient does display some signs and symptoms in keeping with acute heart failure, such as dyspnoea, raised jugular venous pressure, and bibasal crepitations. However, this wouldn't explain the muffled heart sounds", "id": "32759", "label": "b", "name": "IV furosemide", "picture": null, "votes": 825 } ], "comments": [ { "__typename": "QuestionComment", "comment": "i believe it should say \"Beck's triad\" rather than Back's", "createdAt": 1645872848, "dislikes": 0, "id": "7680", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6552, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Dermis Cystic", "id": 4236 } }, { "__typename": "QuestionComment", "comment": " (systolic blood pressure 111-219 mmHg) ???", "createdAt": 1682031120, "dislikes": 0, "id": "22328", "isLikedByMe": 0, "likes": 1, "parentId": null, "questionId": 6552, "replies": [ { "__typename": "QuestionComment", "comment": "maybe it's trying to hint at pulsus parodoxus with a rising and falling systolic BP, but those numbers (the cut-off is a variability of 10 mmhg) and the way it's written make absolutely no sense", "createdAt": 1682084137, "dislikes": 0, "id": "22368", "isLikedByMe": 0, "likes": 0, "parentId": 22328, "questionId": 6552, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Axillary Gas", "id": 20974 } }, { "__typename": "QuestionComment", "comment": "I think it's because on NEWS2 you don't score for hypertension until it's 220 systolic so the 'normal' values are indicating what is a NEWS2 of 0. Even though I probably wouldn't be chilled if someone had a systolic of 219. ", "createdAt": 1682847523, "dislikes": 0, "id": "22992", "isLikedByMe": 0, "likes": 0, "parentId": 22328, "questionId": 6552, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Epidermis Pudendal", "id": 13943 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Hypertension Monoclonal", "id": 29509 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n \nCardiac tamponade is a life-threatening emergency that occurs when fluid (or occasionally gas or malignant tissue) accumulates in the pericardial sac, compressing the heart and impairing cardiac filling. It is often caused by trauma leading to bleeding into the pericardial sac, but may also result from pericarditis or malignancy. Beck's triad refers to the classical findings of a raised jugular venous pressure (JVP), hypotension and muffled heart sounds. Diagnosis can be reached rapidly with an echocardiogram. Pericardiocentesis is the usual emergency treatment. \n\n# Definition\n \nCardiac tamponade refers to the compression of the heart by fluid accumulation (often blood, occasionally gas or malignant tissue) in the pericardial sac. This compression impairs cardiac filling during diastole, compromising cardiac output and rapidly leading to cardiac arrest if untreated. \n \n# Aetiology\n \nThe commonest cause of acute cardiac tamponade is trauma, especially penetrating injuries. These may occur in road traffic accidents.\n\nIatrogenic causes (e.g. cardiothoracic surgery) can also lead to blood tamponading the heart. \n\nOther causes include:\n\n- Pericarditis, which may be secondary to:\n - Malignancies\n - Myocardial infarction\n - Infections e.g. HIV, tuberculosis\n - Connective tissue diseases\n - Radiation\n - Chronic kidney disease\n- Aortic dissection\n- Medications (e.g. minoxidil, hydralazine)\n- Cardiac perforation during diagnostic procedures\n- Pneumopericardium (e.g. secondary to a gastropericardial fistula)\n\n# Signs and Symptoms\n\nThe presentation of cardiac tamponade varies depending on the underlying cause and on how acutely it has developed. \n\nSymptoms include:\n\n- Fatigue\n- Dyspnoea\n- Cold and clammy peripheries due to hypoperfusion\n- Confusion due to reduced cardiac output\n\nSigns include:\n\n- Beck's triad (raised jugular venous pressure, hypotension and muffled heart sounds)\n- Pulsus paradoxus (a decrease in systolic blood pressure by more than 10 mmHg during inspiration)\n- Tachycardia\n- Tachypnoea\n- Altered mental state\n- Hepatomegaly\n- Pericardial friction rub\n- Cyanosis\n- JVP shows an absent Y descent (due to reduced diastolic filling of the ventricles)\n\n# Differential Diagnosis\n\n- **Acute heart failure** - overlapping features of dyspnoea and peripheral oedema, pulmonary oedema can occur in tamponade. Can be distinguished with echocardiography (showing ventricular dysfunction in heart failure).\n- **Constrictive pericarditis** occurs when the pericardium is rigid or thickened (rather than fluid in the pericardial sac). It is usually chronic rather than acute, pericardial calcification may be seen on chest X-ray and Kussmaul's sign may be seen (when venous distention and pressure paradoxically increase in inspiration - rare in tamponade).\n- **Pulmonary embolism** also causes sudden onset dyspnoea, associated with pleuritic chest pain and may have haemoptysis. Can also lead to cardiac arrest if massive; distinguished with echocardiography in the emergency setting and CTPA if stable enough for CT.\n- **Tension pneumothorax** can also result from trauma and lead to rapid cardiac arrest, also causes acute dyspnoea but can be distinguished with examination findings of unilateral hyperresonance and reduced breath sounds, tracheal deviation to the contralateral side. \n \n\n# Investigations\n\n**Bedside tests:**\n\n- **ECG** may show electrical alternans, where the height of QRS complexes alternate due to movement of the heart in the pericardial space \n\n**Blood tests:**\n\n- **Full blood count and CRP** looking for raised inflammatory markers in infective or inflammatory causes of tamponade\n- **U&Es** as uraemia may cause pericarditis leading to tamponade\n- **Coagulation screen** is important if attempting interventions such as pericardiocentesis\n- **HIV testing** if this is a suspected cause of pericarditis\n- **Group and Save** especially if bleeding is the cause of tamponade\n- **Troponin** may be elevated in cardiac trauma or myocardial infarction\n\n**Imaging:**\n\n- An **echocardiogram** is the usual diagnostic test, looking for a pericardial effusion and evidence of impaired cardiac function\n- **Chest X-ray** may show cardiomegaly; the epicardial fat pad sign may be seen (suggestive of pericardial effusion)\n- **CT** sometimes detects evidence of tamponade (e.g. in the context of trauma)\n\n**Other tests:**\n\n- If the cause of tamponade is not clear, fluid drained from a pericardial effusion should be sent for culture and cytology\n\n# Management\n\n- Call for help - alert cardiology and intensive care\n- Supportive therapies e.g. oxygen, IV fluids and inotropes\n- Avoid positive-pressure ventilation as this may decrease venous return, worsening cardiac output\n- Perform **pericardiocentesis** (aspirating pericardial fluid, usually at the bedside under echocardiography guidance)\n- Open surgical drainage may be required in some cases e.g. ongoing intrapericardial bleeding\n- Options for recurrent tamponade include percutaneous balloon pericardiotomy, pericardiodesis or pericardiectomy\n- Treat the underlying cause e.g. infection, repair of traumatic injuries\n \n# References\n\n[Radiopaedia - Cardiac Tamponade](https://radiopaedia.org/articles/cardiac-tamponade)\n\n[Patient UK - Cardiac Tamponade](https://patient.info/doctor/cardiac-tamponade)\n\n[European Society of Cardiology - Cardiac Tamponade](https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-15/Cardiac-tamponade-a-clinical-challenge)", "files": null, "highlights": [], "id": "688", "pictures": [], "typeId": 2 }, "chapterId": 688, "demo": null, "entitlement": null, "id": "2652", "name": "Emergency Management of Cardiac Tamponade", "status": null, "topic": { "__typename": "Topic", "id": "35", "name": "Cardiology", "typeId": 2 }, "topicId": 35, "totalCards": null, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 2652, "conditions": [], "difficulty": 1, "dislikes": 3, "explanation": null, "highlights": [], "id": "6552", "isLikedByMe": 0, "learningPoint": "Pericardiocentesis is the definitive treatment for cardiac tamponade, characterised by Beck's triad: distended neck veins, hypotension, and muffled heart sounds.", "likes": 8, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 67-year-old woman attends A&E with anxiety and fatigue. She has been experiencing worsening shortness of breath and is unable to talk in full sentences. On examination, she has raised jugular venous pressure and bibasal crepitations, and it is difficult to hear heart sounds. Her observations are as follows:\n\n- Temperature - 37.1 (36 - 38 degrees centigrade)\n- Respiratory rate - 25 (12-20 breaths per minute)\n- Heart rate - 110 (50-90 beats per minute)\n- Blood pressure - 87/64 (systolic blood pressure 111-219 mmHg)\n- Oxygen saturations - 92 (>96%)\n\nWhat is the definitive treatment?", "sbaAnswer": [ "a" ], "totalVotes": 5620, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "The left anterior descending artery supplies the anterior section of the heart. An anterior STEMI would usually show ST elevation in V1, V2, V3 and V4. Anterior infarcts have the poorest outcomes", "id": "32764", "label": "b", "name": "Left anterior descending artery", "picture": null, "votes": 716 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "There is marked ST elevation present in leads II, III and aVF. There is reciprocal ST depression in aVL. This pattern of ST elevation suggests an inferior ST-elevation myocardial infarction (STEMI). Therefore, this is most likely due to blockage of either the right coronary artery or the circumflex branch of the left coronary artery. In this case, it is the right coronary artery as the ST elevation is most significant in lead III compared to II, and there are reciprocal changes in lead I, plus mildly elevated ST waves in V1 and V2. These findings point towards right ventricular damage", "id": "32763", "label": "a", "name": "Right coronary artery", "picture": null, "votes": 4918 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Occlusion of the circumflex branch of the left coronary artery can lead to inferior STEMI. However, this would be more likely if there was ST elevation higher in lead II compared to lead III, without any reciprocal changes in lead I", "id": "32765", "label": "c", "name": "Circumflex branch of the left coronary artery", "picture": null, "votes": 269 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "The sinoatrial artery supplies the atrial node. Therefore, it operates in the superior part of the heart. It is a branch of the right coronary artery which means that some acute inferior STEMIs may also have concurrent problems with the area supplied by the sinoatrial artery. This occurs if the occlusion to the right coronary artery is proximal to the branch of the sinoatrial artery. However, the ECG of this patient shows ischaemia in the inferior leads II, III and aVF. Occlusion to only the sinoatrial artery could not lead to these changes", "id": "32767", "label": "e", "name": "Sinoatrial artery", "picture": null, "votes": 59 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Blockage of the diagonal branch of the left coronary artery leads to lateral STEMI. Therefore, the leads that are most likely to be affected are the so-called lateral leads. These are leads I, aVL, V5 and V6", "id": "32766", "label": "d", "name": "Diagonal branch of the left coronary artery", "picture": null, "votes": 72 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\r\n\r\nAcute coronary syndrome (ACS) refers to a set of symptoms and signs that occur due to reduced blood flow to the heart at rest. It encompasses 3 distinct diagnoses: unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST elevation myocardial infarction (STEMI). In the case of infarction, this is a medical emergency requiring urgent treatment. ACS is most commonly caused by the rupture of atherosclerotic plaques in coronary arteries leading to further narrowing, and potentially complete occlusion, of these critical blood vessels. Diagnosis involves clinical evaluation, ECGs, and troponin levels. Treatment strategies differ for STEMI and NSTEMI/unstable angina but include oxygen therapy if hypoxic, antiplatelet medication, glyceryl trinitrates, morphine, and percutaneous coronary intervention (PCI). Post-MI management includes aspirin, dual antiplatelet therapy, beta-blockers, ACE inhibitors, high-dose statins, and cardiac rehabilitation. There are many complications to be aware of post-ACS and these include arrhythmias, heart failure, and cardiac tamponade, and others.\r\n\r\n# Definition \r\n\r\nAcute coronary syndrome is a set of symptoms and signs that occur due to decreased blood flow to the heart at rest. It broadly refers to three distinct diagnoses: unstable angina, non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI). \r\n\r\n# Epidemiology \r\n\r\nIn the UK, there are over 80,000 hospital admissions due to ACS every year. Coronary artery disease remains the largest cause of death in the UK. \r\n\r\n# Pathophysiology\r\n\r\nCoronary artery disease refers to the narrowing of coronary arteries by atherosclerosis and plaque formation. In stable angina, when the demand for myocardial oxygen increases with exertion, narrowed coronary arteries cannot meet this increased demand leading to myocardial ischaemia and pain. Conversely, in ACS, the symptoms occur at rest. This is because there is sudden plaque rupture and clot formation in the narrowed coronary arteries. If there is partial occlusion of the coronary artery this leads to ischaemia and chest pain at rest (unstable angina). If the coronary artery becomes more occluded or fully occluded this leads to significant hypoperfusion of the myocardium and ultimately leads to infarction (death) of the myocardial tissue (NSTEMI or STEMI). \r\n\r\n# Risk Factors\r\n\r\nCoronary artery disease and the development of plaques can be attributed to non-modifiable and modifiable risk factors. Modifiable risk factors must be addressed in the management of IHD. \r\n\r\n* Non-modifiable:\r\n * Age\r\n * Male sex\r\n * Family history\r\n * Ethnicity (particularly South Asians)\r\n* Modifiable:\r\n * Smoking\r\n * Hypertension\r\n * Hyperlipidaemia\r\n * Hypercholesterolaemia\r\n * Obesity\r\n * Diabetes\r\n * Stress\r\n * High fat diets\r\n * Physical inactivity\r\n\r\n# Classification \r\n\r\nAcute coronary syndrome can be split up into three distinct diagnoses: \r\n\r\n1. **Unstable angina**: caused by partial occlusion of a coronary artery. Troponin negative chest pain with normal/abnormal ECG signs. \r\n2. **Non-ST Elevation Myocardial Infarction**: caused by severe but incomplete occlusion of a coronary artery. Troponin positive chest pain without ST elevation. \r\n3. **ST-Elevation Myocardial Infarction**: caused by complete occlusion of a coronary artery. Troponin positive chest pain with ST elevation on ECG. \r\n\r\n*Myocardial Ischaemia vs. Myocardial Infarction and the Release of Troponin*\r\n\r\nIt is important at this stage to distinguish between angina (stable angina is on exertion and unstable angina is at rest) and myocardial infarction. Angina refers to myocardial ischaemia that causes chest pain but does not lead to the death of myocardial tissue and does not lead to a troponin rise. In myocardial infarction, the hypoperfusion of the myocardium is so profound that it leads to the death of myocardial tissue. It is when there is myocardial tissue death that troponin is released into the bloodstream and a troponin rise is found on blood tests.\r\n\r\n*Type 2 Myocardial Infarction* \r\n\r\nIt is also important to mention that some patient may have myocardial infarctions due to cardiac hypoperfusion for other reasons (e.g. severe sepsis, hypotension, hypovolaemia or coronary artery spasm). These are usually termed type 2 myocardial infarctions and may not require the conventional treatment outlined below. \r\n\r\n# Symptoms and Signs\r\n\r\n* Chest pain - the classical presentation can be considered in terms of the SOCRATES mnemonic:\r\n * Site - Central/left sided\r\n * Onset - Sudden\r\n * Character - Crushing ('like someone is sitting on your chest')\r\n * Radiation - Left arm, neck and jaw\r\n * Associated symptoms - Nausea, sweating, clamminess, shortness of breath, sometimes vomiting or syncope\r\n * Timing - Constant\r\n * Exacerbating/relieving factors - Worsened by exercise/exertion and may be improved by GTN\r\n * Severity - Often extremely severe\r\n* Atypical presentations may include:\r\n * Epigastric pain\r\n * No pain (more common in elderly and **patients with diabetes**):\r\n * Acute breathlessness\r\n * Palpitations\r\n * Acute confusion\r\n * Diabetic hyperglycaemic crises\r\n * Syncope\r\n\r\n# Differential Diagnoses\r\n\r\nIt is important to remember that there are non-MI causes of chest pain and these should be considered when making a diagnosis:\r\n\r\n* Cardiac\r\n * Myocarditis\r\n * Pericarditis\r\n * Cardiomyopathy\r\n * Valvular disease\r\n * Cardiac trauma\r\n* Pulmonary\r\n * PE\r\n * Pneumonia\r\n * Pneumothorax\r\n* Vascular\r\n * Aortic dissection\r\n* GI\r\n * Oesophageal spasm\r\n * Oesophagitis\r\n * Peptic ulcer\r\n * Pancreatitis\r\n * Cholecystitis\r\n* MSK\r\n * Rib fracture\r\n * Costochondritis\r\n * Muscle injury\r\n * Herpes zoster\r\n\r\n# Diagnosis of ACS \r\n\r\nDiagnosis depends on a combination of clinical, ECG and biochemical findings which helps distinguish between the various types of ACS.\r\n\r\n* Unstable angina - cardiac chest pain at rest + abnormal/normal ECG + **normal troponin**.\r\n* NSTEMI - cardiac chest pain at rest + abnormal/normal ECG (but not ST-elevation) + **raised troponin**\r\n* STEMI - cardiac chest pain at rest + **persistent ST-elevation/new LBBB** (note that there is no need for a troponin in this case).\r\n\r\n## Diagnosis of STEMI\r\n\r\n* ST segment elevation **>2mm** in adjacent chest leads\r\n* ST segment elevation **>1mm** in adjacent limb leads\r\n* New left bundle branch block (LBBB) with chest pain or suspicion of MI\r\n\r\n## Diagnosis of NSTEMI\r\n\r\nDiagnosis of NSTEMI requires two of the following:\r\n\r\n* Cardiac chest pain\r\n* Newly abnormal ECG which does not demonstrate ST-elevation e.g. ST depression, T wave inversion or non-specific changes. \r\n* Raised troponin (with no other reasonable explanation)\r\n\r\n# Investigations\r\n\r\n## Bedside \r\n\r\n* ECG \r\n\t* Looking for ST-elevation, LBBB or other ST abnormalities\r\n\t* This is the most important investigation and should not be delayed for other investigations (e.g. bloods) because this will define immediate management.\r\n\t* If an ECG shows STEMI then troponin is essentially irrelevant and the patient requires immediate treatment.\r\n\r\n## Bloods \r\n\r\n* Troponin: performed **at least 3 hours** after pain starts. It will also need to be repeated (usually 6 hours after the first level) in order to demonstrate a dynamic troponin rise. \r\n* Renal function: good renal function is required for coronary angiogram +/- PCI due to the use of contrast. \r\n* HbA1c and lipid profile: looking for modifiable risk factors for coronary artery disease. \r\n* FBC and CRP - rule out infectious causes of chest pain\r\n* D-dimer - may be used in _appropriate_ patients to rule out PE. *Be very careful about who you do a D-dimer on!*\r\n\r\n## Imaging \r\n\r\n* CXR: should be completed in all those presenting with a chest symptoms. It will help to rule out other causes of chest pain (e.g. pneumothorax) and look for complications of a large MI (e.g. pulmonary oedema in acute heart failure). \r\n\r\n# ECG Interpretation - Cardiac Territories and Affected Vessels\r\n\r\nThe importance of a 12-lead ECG is that it allows one to view electrical activity of the heart from different \"views\". In MI (particularly STEMI) this allows you to understand which territory (and therefore which vessel) is being affected.\r\n\r\n| Location of ST elevation | Area of myocardium | Coronary artery |\r\n| -------------------------- | ------------------ | -------------------- |\r\n| II, III, aVF | Inferior | RCA |\r\n| V1-2 | Septal | Proximal LAD |\r\n| V3-4 | Anterior | LAD |\r\n| V5-6 | Apex | Distal LAD/ LCx/ RCA |\r\n| I, aVL | Lateral | Lcx |\r\n| V7-V9 (ST depression V1-3) | Posterolateral | RCA/ LCx |\r\n\r\n\r\nRCA: right coronary artery, LAD: left anterior descending, LCx: Left circumflex\r\n\r\n[lightgallery]\r\n\r\n[lightgallery2]\r\n\r\n[lightgallery3]\r\n\r\n[lightgallery4]\r\n\r\n\r\nNSTEMIs may also show T wave abnormalities (such as ST depression and T wave inversions) in vascular territories as above. However, changes can also often not include all the specific leads of that territory in an NSTEMI.\r\n\r\n# Troponin Interpretation\r\n\r\nTroponin is a myocardial protein that is released into the bloodstream when cardiac myocytes are damaged. Serum levels typically rise **3 hours** after myocardial infarction begins.\r\n\r\nDifferent hospitals have differing guidelines (and assays) for interpretations of results. In general there are three groups of troponin levels:\r\n\r\n* Low - definitely no myocardial cell death. The patient is not having an MI although they may be experiencing unstable angina.\r\n* Mildly raised - This is an equivocal result and may be due to other non-MI related factors (see below). These patients usually need a <u>6-12 hour repeat test</u>.\r\n * If repeat troponin is raised on the repeat they are having an MI.\r\n * If repeat troponin is stable or falling then they are unlikely to be having an MI.\r\n* Definitely raised with sequential dynamic troponin rises - MI confirmed (be aware of the possibility of a Type 2 MI)\r\n\r\n## Non-ACS causes of a raised troponin\r\n\r\nAlthough troponin is often used diagnose myocardial infarction, there are in fact many causes of a raised troponin:\r\n\r\n* Myocardial infarction\r\n* Pericarditis\r\n* Myocarditis\r\n* Arrythmias\r\n* Defibrillation\r\n* Acute heart failure\r\n* Pulmonary embolus\r\n* Type A aortic dissection\r\n* Chronic kidney disease\r\n* Prolonged strenuous exercise\r\n* Sepsis\r\n\r\nIt is therefore critical to have good clinical grounds to test a troponin in order to avoid unnecessary treatments and investigations.\r\n\r\n# Management\r\n\r\nAcute management depends on the type of acute coronary syndrome. It is broadly split into the management of STEMI and the management of NSTEMI/unstable angina. \r\n\r\n# Management of STEMI\r\n\r\n[lightgallery5]\r\n\r\nFor emergencies, always follow A-E structure. \r\n\r\n1. Targeted oxygen therapy (aiming for sats >90%)\r\n2. Loading dose of **PO aspirin 300mg**\r\n - Note that some hospital protocols will also call for a loading dose of a second anti-platelet agent such as clopidogrel (300mg) or ticagrelor (180mg)\r\n - For those going on to have PCI, NICE guidance suggests adding prasugrel (if not on anti-coagulation) or clopidogrel (if on anti-coagulation)\r\n3. **Sublingual GTN spray** - for symptom relief\r\n4. **IV morphine/diamorphine** - in addition this causes vasodilation reducing preload on the heart\r\n5. Primary percutaneous coronary intervention (PPCI) for those who:\r\n - Present **within 12 hours of onset of pain** AND\r\n - Are **<2 hours** since <u>first medical contact</u>\r\n\r\nRemember that (particularly in STEMI) _time is heart_ therefore urgent treatment, escalation, and delivery of PPCI is critical to good outcomes.\r\n\r\n# Management of NSTEMI/Unstable Angina\r\n\r\n[lightgallery6]\r\n\r\nFor emergencies, always follow A-E structure. \r\n\r\n1. Targeted oxygen therapy (aiming for sats >90%)\r\n2. Loading dose of **PO aspirin 300mg** and fondaparinux\r\n * Patients should have their 6 month mortality score (often the GRACE score) calculated as early as possible - all those who are anything other than lowest risk should also be given **prasugrel or ticagrelor** unless they have a high risk of bleeding where **PO clopidogrel 300mg** is more appropriate.\r\n3. **Sublingual GTN spray** - for symptom relief\r\n4. **IV morphine/diamorphine** - in addition this causes vasodilation reducing preload on the heart\r\n5. Start antithrombin therapy such as **treatment dose low molecular weight heparin** or **fondaparinux** if they are for an immediate angiogram\r\n6. Patients with <u>high 6 month risk of mortality</u> should be offered an angiogram within 96 hours of symptom onset.\r\n\r\nNote that management of unstable angina is similar to that of NSTEMI with aspirin for all patients and fondaparinux and early angiography for those at high risk.\r\n\r\n# Post-MI management\r\n\r\n[lightgallery7]\r\n\r\n* ALL patients post-MI patients should be started on the following 5 drugs:\r\n 1. **Aspirin 75mg OM** + second anti-platelet (**clopidogrel 75mg OD** or **ticagrelor 90mg OD**)\r\n 2. **Beta blocker (normally bisoprolol)**\r\n 3. **ACE-inhibitor (normally ramipril)**\r\n 4. **High dose statin (e.g. Atorvastatin 80mg ON)**\r\n* All patients should have an **ECHO** performed to assess systolic function and any evidence of heart failure should be treated.\r\n* All patients should be referred to **cardiac rehabilitation**.\r\n* Patients who have been treated without angiography should be considered for ischaemia testing to assess for inducible ischaemia. \r\n\r\n# Complications\r\n\r\n* Ventricular arrhythmia\r\n* Recurrent ischaemia/infarction/angina\r\n* Acute mitral regurgitation\r\n* Congestive heart failure\r\n* 2nd, 3rd degree heart block\r\n* Cardiogenic shock\r\n* Cardiac tamponade\r\n* Ventricular septal defects\r\n* Left ventricular thrombus/aneurysm\r\n* Left/right ventricular free wall rupture\r\n* Dressler's Syndrome\r\n* Acute pericarditis\r\n\r\n## Ventricular Arrhythmias\r\n\r\n* Ventricular arrhythmias can occur as a consequence of MI, during cardiac catheterisation, or after reperfusion.\r\n* Most post-MI ventricular arrhythmias are short lived and self-resolve.\r\n* However if sustained VT or VF occurs they should be treated as per the Advanced Life Support protocols.\r\n\r\n## Recurrent Ischaemia/Infarction/Angina\r\n\r\n* Occasionally inserted stents can thrombose requiring reintervention.\r\n* New infarcts can occur in different vascular territories - this is less likely in the age of PCI where all territory are imaged during the procedure.\r\n* Angina and chest pain can continue for some time after an MI and is more common in NSTEMI patients.\r\n\r\n## Congestive Heart Failure\r\n\r\n* Heart failure can occur as a consequence of impairment heart muscle function secondary to ischaemia.\r\n* It should be treated as any other acute heart failure.\r\n* Ventricular function may improve over months as the heart muscle recovers.\r\n\r\n## Heart Block\r\n\r\n* Various levels of heart block are common - particularly following **inferior** infarcts (because the right coronary artery supplies the SAN).\r\n* These may be treated with:\r\n * Simple observation (as many will revert back to sinus rhythm)\r\n * Transcutaneous/venous pacing (if symptomatic)\r\n * Permanent pacing (if failing to resolve)\r\n\r\n## Left Ventricular Thrombus/Aneurysm\r\n\r\n* Aneurysm can occur following an anterior MI where the myocardium can be susceptible to wall stress leading to an aneurysm.\r\n* It may be silent, cause arrhythmias or embolic events.\r\n* It is definitely diagnosed on ECHO but ECG may show persisting ST elevation.\r\n* Thrombus can form either within an above described aneurysm or around hypokinetic regions of the myocardium.\r\n* Thrombi can embolise causing complications such as stroke, acute limb ischaemia and mesenteric ischaemia.\r\n\r\n## Left/Right Ventricular Free Wall Rupture\r\n\r\n* Necrosis of the free walls of either ventricle can lead to rupture allowing blood into the pericardial space.\r\n* This leads to a rapid tamponade and normally leads to cardiac arrest/death within seconds.\r\n* Treatment includes pericardiocentesis and surgery but prognosis is extremely poor.\r\n\r\n## Acute Mitral Regurgitation\r\n\r\n* This can occur because of papillary muscle rupture and carries a poor prognosis. Occurs commonly due to infero-osterior MI. \r\n* This presents with:\r\n * Pansystolic murmur heard best at the apex\r\n * Severe and sudden heart failure\r\n* It is diagnosed on echocardiogram and may require surgical correction.\r\n\r\n## Ventricular Septal Defect\r\n\r\n* Interventricular septal rupture is a short-term complications of myocardial infarction.\r\n* Rupture caused by an anterior infarct is generally apical and simple.\r\n* Rupture caused by an inferior infarct is generally basal and more complex.\r\n* Without reperfusion, septal rupture typically occurs within the first week after the infarction.\r\n* Features of septal rupture include:\r\n * Shortness of breath\r\n * Chest pain\r\n * Heart failure\r\n * Hypotension\r\n * Harsh, loud pan-systolic murmur along the left sternal border.\r\n * Palpable parasternal thrill.\r\n* Diagnosis is with echocardiogram.\r\n* Patients are managed with emergency cardiac surgery.\r\n\r\n## Dressler's syndrome\r\n\r\n* Dressler's syndrome or post-infarction pericarditis typically presents with persistent fever and pleuritic chest pain **2-3 weeks** or up to a few months after an MI.\r\n* Note that patients can get pericarditis immediately following MI which is NOT considered Dressler's syndrome.\r\n* Symptoms usually resolve after several days.\r\n* Occasionally it can also present with features of pericardial effusion and has become relatively uncommon since the introduction of PCI.\r\n* Management: **high dose aspirin**\r\n\r\n# Prognosis \r\n\r\nDue to the development of PPCI and post-MI care (cardiac rehabilitation) the mortality rates following myocardial infarction continue to decline. Those patients who go on to develop heart failure after myocardial infarction have a significantly worse prognosis than those who do not. \r\n\r\n# NICE Guidelines\r\n\n[NICE Guidelines for Unstable Angina and NSTEMI](https://www.nice.org.uk/guidance/cg94)\r\n\n[NICE Guidelines for STEMI](https://www.nice.org.uk/guidance/cg167)\r\n\r\n# References\r\n\r\n[Patient UK Information on Acute Coronary Syndrome](<https://patient.info/doctor/acute-coronary-syndrome-pro>)", "files": null, "highlights": [], "id": "641", "pictures": [ { "__typename": "Picture", "caption": null, "createdAt": 1672906680, "id": "1422", "index": 6, "name": "NSTEMI (NICE).png", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/8zcda6v21672906675511.jpg", "path256": "images/8zcda6v21672906675511_256.jpg", "path512": "images/8zcda6v21672906675511_512.jpg", "thumbhash": "qvcJDYZrpbpdiHh+qQhpZXtffngI", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", 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"239", "live": false, "museId": "J2z73Sc", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/cardiology.png", "title": "Myocardial infarction and Acute Coronary Syndrome (ACS) 3", "userViewed": false, "views": 132, "viewsToday": 12 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "662", "name": "Acute Coronary Syndrome (ACS)" } ], "demo": false, "description": null, "duration": 449.37, "endTime": null, "files": null, "id": "187", "live": false, "museId": "xf1CzHD", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/cardiology.png", "title": "Hypertension", "userViewed": false, "views": 293, "viewsToday": 21 } ] }, "conceptId": 662, "conditions": [], "difficulty": 1, "dislikes": 2, "explanation": null, "highlights": [], "id": "6553", "isLikedByMe": 0, "learningPoint": "Inferior ST-elevation myocardial infarction (STEMI) is commonly associated with right coronary artery occlusion, presenting with ST elevation in leads II, III, and aVF.", "likes": 9, "multiAnswer": null, "pictures": [ { "__typename": "Picture", "caption": null, "createdAt": 1639016635, "id": "367", "index": 0, "name": "InferiorSTEMIECG.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/bc3r45ed1639016634378.jpg", "path256": "images/bc3r45ed1639016634378_256.jpg", "path512": "images/bc3r45ed1639016634378_512.jpg", "thumbhash": "dxgCAoCrlnWQh4h3ZXxP9Yc=", "topic": { "__typename": "Topic", "id": "35", "name": "Cardiology", "typeId": 2 }, "topicId": 35, "updatedAt": 1708373886 } ], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 68-year-old woman attends A&E due to new-onset left shoulder pain with accompanying nausea. She has an ECG (shown below):\n\n[lightgallery]\n\nWhich coronary artery has most likely been affected?", "sbaAnswer": [ "a" ], "totalVotes": 6034, "typeId": 1, "userPoint": null }

[]

{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Indapamide is a thiazide-type diuretic, it inhibits sodium reabsorption in the distal convoluted tubules. It is more likely to lead to hypokalaemia than hyperkalaemia", "id": "32769", "label": "b", "name": "Indapamide", "picture": null, "votes": 362 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Pheochromocytoma is a tumour found in the adrenal medulla. As well as hypertension, typical symptoms include tachycardia and sweating. It is unlikely to lead to hyperkalaemia", "id": "32771", "label": "d", "name": "Pheochromocytoma", "picture": null, "votes": 156 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Spironolactone is a potassium-sparing diuretic which acts as an anti-mineralocorticoid. A common side effect of spironolactone is hyperkalaemia", "id": "32768", "label": "a", "name": "Spironolactone", "picture": null, "votes": 4854 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Conn's syndrome, also known as primary aldosteronism, leads to hypersecretion of aldosterone from the adrenal glands. It is more likely to lead to hypokalaemia than hyperkalaemia", "id": "32770", "label": "c", "name": "Conn's syndrome", "picture": null, "votes": 377 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Renal artery stenosis is a cause of secondary hypertension. It is most likely to occur due to atherosclerosis, and results in activation of the renin-angiotensin system and is more likely to lead to hypokalaemia than hyperkalaemia", "id": "32772", "label": "e", "name": "Renal artery stenosis", "picture": null, "votes": 379 } ], "comments": [ { "__typename": "QuestionComment", "comment": "spironlactone, aldosterone antagonist. Aldosterone's job is to reabsorb water + sodium and get rid of potassium. Antagnoist act reduces BP and leads to potassium build up\n", "createdAt": 1685959108, "dislikes": 0, "id": "27906", "isLikedByMe": 0, "likes": 2, "parentId": null, "questionId": 6554, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Serpiginous Yeast", "id": 13388 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\r\n\r\nPrimary hypertension, accounting for approximately 90-95% of cases of hypertension, is characterised by persistently elevated blood pressure due to age-related pathophysiological changes. It is a major risk factor for cardiovascular disease, cerebrovascular disease, chronic kidney disease, and peripheral vascular disease. Diagnosis is based on ambulatory blood pressure monitoring (ABPM) readings of 135/85mmHg or higher. Classification is determined by the severity of the hypertension. Management depends on the classification of the hypertension and involves lifestyle modifications and pharmacological anithypertensives according to NICE guidelines. Effective management, through lifestyle changes and medications, significantly reduces the associated risks and improves outcomes for individuals with hypertension.\r\n\r\n# Definition \r\n\r\nA 'normal' blood pressure ranges between 90/60mmHg to 140/90mmHg. The definition of hypertension is a 24h ambulatory blood pressure average reading (ABPM) that is more than or equal to 135/85mmHg. \r\n\r\n# Epidemiology\r\n\r\nIn 2015, it was reported that high blood pressure affected more than 1 in 4 adults in England (31% of men; 26% of women). In England, it is estimated that primary hypertension affects around 13.5 million people and contributed to 75,000 deaths.\r\n\r\n# Pathophysiology\r\n\r\nPrimary hypertension is as a result of a series of complex physiological changes as we age. Hypertension often occurs as a result of reduced elasticity of large arteries, age-related and atherosclerosis-related calcification, and degradation of arterial elastin. It may also be present in conditions associated with increased cardiac output, such as anaemia, hyperthyroidism and aortic regurgitation.\r\n\r\nAlthough the risk of cardiovascular disease increases progressively with increasing systolic and diastolic blood pressure, raised systolic pressure is more important than raised diastolic pressure as a risk factor for cardiovascular and renal disease.\r\n\r\n# Classification \r\n\r\nHypertension can be classified according to how high a patient's blood pressure is. \r\n\r\n* Stage 1: Clinic => 140/90mmHg; ABPM => 135/85mmHg \r\n* Stage 2: Clinic => 160/100mmHg; ABPM =>150/95mmHg \r\n* Stage 3: Clinic systolic BP (SBP) => 180 or diastolic BP (DBP) =>120mmHg\r\n\r\n\r\n# Symptoms and Signs\r\n\r\nHypertension, unless malignant, is asymptomatic and does not have any clinical signs. It is diagnosed with ABPM and further investigations should focus on diagnosing end-organ complications of hypertension. \r\n\r\n# Investigations\r\n\r\n[lightgallery]\r\n\r\n* Hypertensive patients are commonly first identified at GP appointments or during hospital admissions. Due to the prominence of 'white coat hypertension', ABPM is now required for the diagnosis of hypertension. \r\n* Hypertension should be suspected in a patient who has a clinic blood pressure of =>140/90mmHg. \r\n* **1st line: ABPM** or home blood pressure monitoring if ABPM is not tolerated or declined. \r\n* Alongside ABPM: assessment for end-organ damage and assessment of cardiovascular risk (QRISK2 scores). \r\n * Urine dip and albumin:creatinine level\r\n * Blood glucose, lipids and renal function\r\n * Fundoscopy for evidence of hypertensive retinopathy\r\n * ECG: look for evidence of LV hypertrophy\r\n\r\n\r\nN.B. if presentation is suspicious for secondary hypertension refer and investigate as appropriate (see section). \r\n\r\nN.B. Referral for same-day specialist assessment should be arranged for people with: \r\n\r\n* Clinic blood pressure of 180/120mmHg and higher with signs of retinal haemorrhage or papilloedema (accelerated hypertension) or life-threatening symptoms (e.g. new onset confusion, chest pain, heart failure signs or AKI). \r\n\r\n# Management\r\n\r\n## Principles of Management \r\n\r\n### Conservative Management \r\n\r\nControlling risk factors for cardiovascular disease:\r\n\r\n* Weight loss\r\n* Healthy diet (reduce salt and saturated fats)\r\n* Reduce alcohol and caffeine\r\n* Reduce stress\r\n* Stop smoking\r\n\r\n### Medical Management\r\n\r\nIndications to start pharmacological management of primary hypertension:\r\n\r\n* Stage 1 hypertensive patients who are <80 years old with end organ damage, CVS disease, renal disease, diabetes or 10-year CVS risk >10% OR\r\n* Anyone with stage 2 hypertension\r\n\r\n### 2019 NICE Guidelines for Pharmacological Management of Primary Hypertension \r\n\r\n[lightgallery1]\r\n\r\n* Step 1: \r\n\t* **ACE-inhibitor** (e.g. Ramipril) if <=55 years old\r\n\t* **DHP-Calcium Channel Blocker** (e.g. Amlodipine) if >55 years old OR African or Caribbean ethnicity\r\n\t* If unable to tolerate ACE-inhibitor then switch to _Angiotensin Receptor Blocker_ (e.g. Candesartan)\r\n* Step 2: \r\n\t* (If maximal dose of Step 1 has failed or not tolerated)\r\n\t* **Combine CCB and ACE-I/ARB**\r\n* Step 3:\r\n\t* (If maximal doses of Step 2 has failed or not tolerated)\r\n\t* **Add thiazide-like diuretic** (e.g. Indapamide)\r\n* Step 4: *Resistant Hypertension*\r\n\t* If blood potassium <4.5mmol/L then add **spironolactone**\r\n\t* If >4.5mmol/L **increase thiazide-like diuretic dose**\r\n\t* Other options at this point if the potassium is >4.5mmol/L include:\r\n\t\t* Alpha blocker (e.g. Doxazosin)\r\n\t\t* Beta blocker (e.g. Atenolol)\r\n\t\t* Referral to cardiology for further advice\r\n\r\n**ABPM Targets:**\r\n \r\n* Age <80 ABPM target <135/85\r\n* Age >80 ABPM target <145/85 (due to risk of postural drop and falls)\r\n* T1DM with end-organ damage <130/80\r\n\r\n# Complications\r\n\r\n* Increased risk of morbidity and mortality from all causes\r\n* Coronary artery disease\r\n* Heart failure\r\n* Renal failure\r\n* Stroke\r\n* Peripheral vascular disease\r\n\r\n# Prognosis \r\n\r\nHypertension remains one of the biggest risk factors for cardiovascular disease and its associated disabilities. Management of hypertension (with lifestyle modifications or pharmacological therapies) has been shown to reduce these risks significantly. \r\n\r\n# NICE Guidelines\r\n> <https://cks.nice.org.uk/topics/hypertension/> \r\n\r\n# References \r\n\r\n<https://patient.info/heart-health/high-blood-pressure-hypertension>\r\n<https://www.ahajournals.org/doi/full/10.1161/01.CIR.101.3.329> ", "files": null, "highlights": [], "id": "639", "pictures": [ { "__typename": "Picture", "caption": null, "createdAt": 1672906680, "id": "1419", "index": 0, "name": "Hypertension diagnosis (NICE).png", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/d1q848bd1672906675512.jpg", "path256": "images/d1q848bd1672906675512_256.jpg", "path512": "images/d1q848bd1672906675512_512.jpg", "thumbhash": "9fcFBYDQgSqZipmetziFe/S3Go/t", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": null, "createdAt": 1672906680, "id": "1423", "index": 1, "name": "Hypertension choice of drug (NICE).png", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/bcwkpi041672906675511.jpg", "path256": "images/bcwkpi041672906675511_256.jpg", "path512": "images/bcwkpi041672906675511_512.jpg", "thumbhash": "8+cFBYCJ+Vm3ZXRZiCd4lX/zxOm/", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 639, "demo": null, "entitlement": null, "id": "651", "name": "Primary (Essential) Hypertension", "status": null, "topic": { "__typename": "Topic", "id": "35", "name": "Cardiology", "typeId": 2 }, "topicId": 35, "totalCards": 49, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "651", "name": "Primary (Essential) Hypertension" } ], "demo": false, "description": null, "duration": 6426.6, "endTime": null, "files": null, "id": "324", "live": false, "museId": "7AeyDdA", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/chemistry.png", "title": "Quesmed Tutorial: Medical Emergencies", "userViewed": false, "views": 949, "viewsToday": 49 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "651", "name": "Primary (Essential) Hypertension" } ], "demo": false, "description": null, "duration": 418.43, "endTime": null, "files": null, "id": "675", "live": false, "museId": "fWoxrKV", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/cardiology.png", "title": "Hypertension 2", "userViewed": false, "views": 81, "viewsToday": 18 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "651", "name": "Primary (Essential) Hypertension" } ], "demo": false, "description": null, "duration": 449.37, "endTime": null, "files": null, "id": "187", "live": false, "museId": "xf1CzHD", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/cardiology.png", "title": "Hypertension", "userViewed": false, "views": 293, "viewsToday": 21 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "651", "name": "Primary (Essential) Hypertension" } ], "demo": false, "description": null, "duration": 3737.73, "endTime": null, "files": null, "id": "614", "live": false, "museId": "ZMAGtgf", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/cardiology.png", "title": "Quesmed Tutorial: General Practice", "userViewed": false, "views": 398, "viewsToday": 38 } ] }, "conceptId": 651, "conditions": [], "difficulty": 1, "dislikes": 0, "explanation": null, "highlights": [], "id": "6554", "isLikedByMe": 0, "learningPoint": "Spironolactone causes hyperkalemia because it inhibits the action of aldosterone in the kidneys, which normally promotes the excretion of potassium. By blocking aldosterone, spironolactone reduces potassium excretion, leading to an accumulation of potassium in the blood.", "likes": 11, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 60-year-old male patient attends GP due to hypertension. He is currently taking four different medications to try and control it:\n\n\nAmlodipine, ramipril, indapamide, spironolactone.\n\n\nHis most recent bloods are as follows:\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|135 mmol/L|135 - 145|\n|Potassium|5.7 mmol/L|3.5 - 5.3|\n|Urea|3.6 mmol/L|2.5 - 7.8|\n|Creatinine|74 µmol/L|60 - 120|\n|eGFR|85 mL/min/1.73m²|> 60|\n\n\n\nHis blood pressure in the GP was 145/95.\n\n\nWhat is the most likely cause of his hyperkalaemia?", "sbaAnswer": [ "a" ], "totalVotes": 6128, "typeId": 1, "userPoint": null }

[]

{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Anticoagulation should be avoided in Dressler's syndrome due to the risk of haemorrhage into the pericardium and cardiac tamponade", "id": "32775", "label": "c", "name": "Treatment dose low molecular weight heparin", "picture": null, "votes": 270 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "The first-line management for Dressler's syndrome is NSAID therapy with aspirin. If the patients symptoms do not resolve, elective coronary angiography may be indicated", "id": "32777", "label": "e", "name": "Elective coronary angiogram", "picture": null, "votes": 47 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Corticosteroids are not the first line treatment in this case. However, corticosteroids may be used to treat Dressler's syndrome if non-steroidal anti-inflammatory drugs (NSAIDs) are contra-indicated or if symptoms are refractory or recurrent. This regimen is typically given in severe or critical COVID-19 patients", "id": "32774", "label": "b", "name": "Hydrocortisone", "picture": null, "votes": 903 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "This patient likely has Dressler's syndrome. Dressler's syndrome is a self-limiting secondary pericarditis which occurs after myocardial injury such as a myocardial infarction. High doses of non-steroidal anti-inflammatory drugs (NSAIDs), tapered down after two weeks, are the first line treatment", "id": "32773", "label": "a", "name": "Higher doses of aspirin", "picture": null, "votes": 3084 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Non-steroidal anti-inflammatory drugs (NSAIDs) are the first line treatment in Dressler's syndrome. In the absence of new ECG changes or raised troponin levels, angiogram is not indicated", "id": "32776", "label": "d", "name": "Urgent coronary angiogram", "picture": null, "votes": 1237 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Just wondering, aren't NSAIDs contraindicated/cautioned in cardiovascular disease?", "createdAt": 1736420760, "dislikes": 0, "id": "60043", "isLikedByMe": 0, "likes": 0, "parentId": null, "questionId": 6555, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Hematoma Dominant", "id": 15760 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\r\n\r\nAcute pericarditis is the inflammation of the pericardium, the sac surrounding the heart. It is commonly seen in patients with chest pain following a viral infection, with pain typically relieved by leaning forward. The condition can be caused by various factors including infections (viral, bacterial), malignancies, cardiac causes, radiation, drugs/toxins, and rheumatological diseases. Diagnosis is based on clinical evaluation, ECG findings (ST elevation, PR depression), and imaging such as echocardiogram. Treatment options include NSAIDs, colchicine, and corticosteroids depending on the underlying cause. Complications are rare, and the prognosis is generally excellent with a low risk of long-term sequelae. \r\n\r\n# Definition \r\n\r\nAcute pericarditis is inflammation of the pericardium, the fibroelastic sac that surrounds the heart. Inflammation can also extend to the myocardium (heart muscle), in which case the condition is referred to as perimyocarditis or myopericarditis depending on which is predominant. \r\n\r\n# Epidemiology \r\n\r\nAcute pericarditis is one of the most common causes of pericardial disease and is estimated to occur in approximately 27.7 per 100,000 people annually. \r\n\r\n# Pathophysiology\r\n\r\nThe pathophysiology of pericarditis depends on the cause. The causes of pericarditis are discussed below. \r\n\r\n# Causes\r\n\r\nThe classification of pericarditis can be considered according to cause of the pericarditis. \r\n\r\n* Idiopathic\r\n\r\n* Infective causes\r\n\r\n * Viruses - viruses which cause pericarditis are **coxsackie B viruses**, echovirus, CMV, herpesvirus, HIV among other rarer causes.\r\n * Bacteria - staphylococcus, pneumococcus, streptococcus (rheumatic carditis), haemophilus and M. tuberculosis.\r\n * Fungi and parasites (rare)\r\n\r\n* Malignant causes\r\n\r\n * Lung cancer\r\n * Breast cancer\r\n * Hodgkin's lymphoma\r\n\r\n* Cardiac causes\r\n\r\n * Heart failure may cause pericarditis\r\n * Post-cardiac injury syndrome (Dressler's syndrome) including post-traumatic\r\n\r\n* Radiation - often secondary to therapy for other malignancies\r\n\r\n* Drugs and toxin causes\r\n\r\n * Anthracycline chemotherapy (Doxorubicin)\r\n * Hydralazine\r\n * Isoniazid\r\n * Methyldopa\r\n * Phenytoin\r\n * Penicillins (hypersensitivity)\r\n\r\n* Rheumatological disease\r\n\r\n * Systemic lupus erythematous (SLE)\r\n * Rheumatoid arthritis\r\n * Sarcoidosis\r\n * Vasculitides (Takayasu's, Behcet's)\r\n\r\n* Other causes\r\n * Renal failure (uraemia) - indication for emergency dialysis. \r\n * Hypothyroidism\r\n * Inflammatory bowel disease\r\n * Ovarian hyperstimulation\r\n \r\n# Symptoms\r\n\r\n* Pleuritic chest pain: central, worse on inspiration. \r\n* Postural chest pain: worse on lying flat and relieved on leaning forward.\r\n* Fever\r\n\r\n# Signs\r\n\r\n* Pericardial friction rub - high-pitched scratching noise, best heard over the left sternal border during expiration. Pathogonomonic of pericarditis. \r\n* Pericarditis can lead to the development of a pericardial effusion and cardiac tamponade in which case signs such as hypotension, raised JVP and muffled heart sounds (Beck's Triad) may be present. \r\n\r\n# Differential Diagnoses \r\n\r\n* **Acute Coronary Syndrome** \r\n\t* **Similarities**: both present with chest pain. \r\n\t* **Differences**: pericarditic chest pain is often described as sharp, pleuritic in nature, and relieved on sitting forward. In ACS, the chest pain is often described as a squeezing pressure that is not positional. \r\n\r\n\r\n* **Pleuritic Chest Pain e.g. Pulmonary Embolism or Pneumonia** \r\n\t* **Similarities**: both present with pleuritic chest pain. \r\n\t* **Differences**: PE and pneumonia will often present with very different histories and clinical features. Patients with pneumonia will describe a productive cough and fevers, whereas patients who have a pulmonary embolism will describe acute-onset pleuritic chest pain and will likely have risk factors for VTE. \r\n\r\n* **Musculoskeletal Chest Pain** \r\n\t* **Similarities**: various MSK conditions including costochondritis or muscle strains can cause chest pain that resembles pericarditis. These pains may also be positional. \r\n\t* **Differences**: MSK pain is reproducible with palpation or certain movements. \r\n\r\n\r\n* **Gastro-oesophageal Reflux Disease (GORD)** \r\n\t* **Similarities**: chest pain seen in GORD may be similar to that seen in pericarditis. Those with GORD may describe that symptoms are worse on lying flat, similar to pericarditis. \r\n\t* **Differences**: pericarditic pain is often described as sharp, whereas GORD discomfort may be described as a burning sensation that is worse with certain foods and bending over. \r\n\r\n\r\n# Investigations\r\n\r\nThe diagnosis of pericarditis is often clinical, but the following investigations can help aid diagnosis. \r\n\r\n## Bedside\r\n\r\n**1st line** = ECG \r\n\r\nECG features include: \r\n\r\n* Widespread saddle ST elevation (not following vascular territories) and PR depression. \r\n\r\nECG changes can sometimes evolve over weeks:\r\n\r\n* 1-3 weeks: normalisation of ST changes, T wave flattening\r\n* 3-8 weeks: flattened T waves become inverted\r\n* 8+ weeks: ECG returns to normal\r\n\r\n[lightgallery]\r\n\r\n## Bloods \r\n\r\n* Serial troponins: tend not to peak as in an MI, but tend to stay consistently elevated in the acute phase. \r\n* Inflammatory markers: raised inflammatory markers (WCC, CRP and ESR) are in keeping with an acute pericarditis. \r\n* Viral serology: may help to identify cause of the acute pericarditis. \r\n\r\n## Imaging\r\n\r\n* Echocardiogram - used to assess for pericardial effusion and distinguish between pericarditis and MI (e.g. looking for the absence of regional wall motion abnormalities). \r\n* Angiogram - shows normal coronary arteries (which excludes MI).\r\n* Cardiac MRI - in atypical cases, cardiac MRI can be used to visualise inflammation of the pericardium. \r\n\r\n# Management\r\n\r\n## Idiopathic or Viral Pericarditis \r\n\r\n**1st line**: exercise restriction, NSAIDS (+ PPI) for 1-2 weeks and colchicine for 3 months\r\n\r\n**2nd line**: colchicine (SE: diarrhoea, use in caution in those with renal or hepatic impairment). \r\n\r\n**3rd line**: corticosteroids (for those who cannot tolerate or refractory to NSAIDS). \r\n\r\n## Bacterial Pericarditis \r\n\r\n**1st line**: IV antibiotics +/- pericardiocentesis if purulent exudate present. \r\n\r\nRare cases - pericardectomy may be performed if adhesions or recurrent tamponade occurs. \r\n\r\n## Non-Infective Pericarditis \r\n\r\n**1st line**: corticosteroids (due to the risk of reactivation and if infection has been ruled out). \r\n\r\n# Complications\r\n\r\nComplications are rare but include cardiac tamponade and pericardial effusion requiring pericardiocentesis. In the long term patients occasionally develop constrictive pericarditis.\r\n\r\n# Prognosis \r\n\r\nAcute pericarditis has an excellent prognosis with less than 0.5% going on to develop long-term sequelae (e.g. constrictive pericarditis). \r\n\r\n# NICE Guidelines\r\n\r\n[NICE Guidelines on Cardiac Causes of Chest Pain](<https://cks.nice.org.uk/topics/chest-pain/diagnosis/cardiac-causes/>)\r\n\r\n# References\r\n\r\n[UptoDate Article on Acute Pericarditis: Treatment and Prognosis](<https://www.uptodate.com/contents/acute-pericarditis-treatment-and-prognosis>)", "files": null, "highlights": [], "id": "615", "pictures": [ { "__typename": "Picture", "caption": "Widespread ST segment changes in someone with pericarditis.", "createdAt": 1665036192, "id": "744", "index": 0, "name": "Pericarditis - ecg.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/l1d4sen71665036171703.jpg", "path256": "images/l1d4sen71665036171703_256.jpg", "path512": "images/l1d4sen71665036171703_512.jpg", "thumbhash": "KRgCA4Brd3hvh2iIMIkKpXg=", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 615, "demo": null, "entitlement": null, "id": "635", "name": "Acute Pericarditis", "status": null, "topic": { "__typename": "Topic", "id": "35", "name": "Cardiology", "typeId": 2 }, "topicId": 35, "totalCards": 16, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "635", "name": "Acute Pericarditis" } ], "demo": false, "description": null, "duration": 485.8, "endTime": null, "files": null, "id": "239", "live": false, "museId": "J2z73Sc", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/cardiology.png", "title": "Myocardial infarction and Acute Coronary Syndrome (ACS) 3", "userViewed": false, "views": 132, "viewsToday": 12 } ] }, "conceptId": 635, "conditions": [], "difficulty": 2, "dislikes": 3, "explanation": null, "highlights": [], "id": "6555", "isLikedByMe": 0, "learningPoint": "Dressler's syndrome, a type of autoimmune pericarditis that can occur after a myocardial infarction or heart surgery, is typically treated with high doses of non-steroidal anti-inflammatory drugs (NSAIDs), which are tapered down after two weeks to manage inflammation and symptoms.", "likes": 6, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 75-year-old woman presents to A&E with pleuritic chest pain radiating to her left shoulder, which is worse on lying flat. She also feels hot and sweaty. She had an ST-elevation myocardial infarction (STEMI) 4 weeks ago and had two drug-eluting stents inserted. Her ECG shows widespread ST elevation.\n\nWhat is the most appropriate initial management?", "sbaAnswer": [ "a" ], "totalVotes": 5541, "typeId": 1, "userPoint": null }

[]

{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": true, "explanation": "First degree atrioventricular heart block involves a prolongation of the PR interval of more than 200ms. In this case, the ECG shows a PR interval of greater than 300ms. The ECG also shows sinus bradycardia", "id": "32778", "label": "a", "name": "First degree atrioventricular heart block", "picture": null, "votes": 1851 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Second degree atrioventricular heart block (type one) is also known as Mobitz type one or Wenckebach phenomenon. It leads to progressive elongation of the PR interval, which will lead to an eventual missed QRS complex. In this case, the ECG shows a constant PR interval of greater than 300ms, which indicates first degree atrioventricular heart block", "id": "32780", "label": "c", "name": "Second degree atrioventricular heart block (type one)", "picture": null, "votes": 259 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Sick sinus syndrome, also known as sinus node dysfunction, can lead to sinus bradycardia, seen in the ECG. However, there is also prolongation of the PR interval, which is less likely to be seen in sick sinus syndrome", "id": "32779", "label": "b", "name": "Sick sinus syndrome", "picture": null, "votes": 120 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Third degree atrioventricular heart block occurs when there is no direct communication between the atria and the ventricles. Therefore, the P waves and QRS complexes are found to be independent of one another on ECG. In this case, the ECG shows a constant PR interval of greater than 300ms, which indicates first degree atrioventricular heart block", "id": "32782", "label": "e", "name": "Third degree atrioventricular heart block", "picture": null, "votes": 357 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Second degree atrioventricular heart block (type two), also known as Mobitz type two, leads to intermittent dropping of QRS complexes. This usually follows a pattern of 3:1 or 4:1. In this case, the ECG shows a constant PR interval of greater than 300ms, which indicates first degree atrioventricular heart block", "id": "32781", "label": "d", "name": "Second degree atrioventricular heart block (type two)", "picture": null, "votes": 733 } ], "comments": [ { "__typename": "QuestionComment", "comment": "thats such a horrible ecg picture and i cant even enlarge it ", "createdAt": 1704916321, "dislikes": 0, "id": "38468", "isLikedByMe": 0, "likes": 11, "parentId": null, "questionId": 6556, "replies": [ { "__typename": "QuestionComment", "comment": "Click on it", "createdAt": 1707998589, "dislikes": 9, "id": "41674", "isLikedByMe": 0, "likes": 0, "parentId": 38468, "questionId": 6556, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "test123", "id": 2 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "NICU Serotonin", "id": 26459 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\r\n\r\nHeart block refers to an obstruction in the electrical conduction system of the heart. This obstruction can occur at various points in the conduction system, including the sinoatrial node, atrioventricular node, Bundle of His, or bundle branches. Atrioventricular heart block specifically affects the conduction between the atria and ventricles. The severity of heart block can range from first degree, which is generally benign, to second degree (Mobitz Type I and II), to complete (third degree) heart block, which requires immediate management with a permanent pacemaker due to the risk of asystole. The underlying causes and management strategies differ for each type of heart block.\r\n\r\n# Definition \r\n\r\nHeart block occurs due to an obstruction in the electrical conduction system of the heart. It can occur anywhere along the conduction system of the heart from the sinoatrial node to the atrioventricular node to the Bundle of His or within the bundle branches themselves. \r\n\r\nSinoatrial node block rarely leads to symptoms as the atrioventricular node acts as a secondary pacemaker. Bundle branch blocks are a form of heart block but they are discussed in a separate section. The rest of this section will discuss atrioventricular block in more detail. \r\n\r\nPatients with atrioventricular heart block may be asymptomatic or may present with fatigue, lightheadeness, syncope, shortness of breath and most seriously in cardiac arrest or with sudden death. \r\n\r\n# First Degree Heart Block\r\n\r\n## Definition\r\n\r\nThis is caused by prolonged conduction of electrical activity through the AV node. It can be identified on ECG by finding a PR interval >200ms.\r\n\r\n[lightgallery]\r\n\r\n## Causes\r\n\r\n* High vagal tone: e.g. athletes\r\n* Acute inferior MI\r\n* Electrolyte abnormalities: e.g. hyperkalaemia\r\n* Drugs: e.g. NHP-CCBs, beta-blockers, digoxin, cholinesterase inhibitors\r\n\r\n## Management\r\n\r\nFirst degree heart block itself is benign and does not need treating. However, any pathological underlying cause should be reversed.\r\n\r\n# Second Degree Heart Block \r\n\r\nSecond degree heart block is split into Mobitz Type I and Mobitz Type II heart block. \r\n\r\n# Mobitz Type I\r\n\r\n## Definition\r\n\r\nWenckebach phenomenon or Mobitz type I is a type of second degree heart block that is usually due to reversible conduction block at the AV node. It is characterised by progressive lengthening of the PR interval which results in a P wave that fails to conduct a QRS.\r\n\r\n[lightgallery1]\r\n\r\n## Causes\r\n\r\n* MI (mainly inferior)\r\n* Drugs such as beta/calcium channel blockers, digoxin\r\n* Professional athletes due to high vagal tone\r\n* Myocarditis\r\n* Cardiac surgery\r\n\r\n## Management\r\n\r\nIt is generally asymptomatic and does not require any specific management as the risk of high AV block/complete heart block is low. If symptoms do arise, ECG monitoring may be required, precipitating drugs must be stopped and if they are bradycardic with adverse features they should be treated with atropine.\r\n\r\n# Mobitz Type II\r\n\r\n## Definition\r\n\r\nMobitz type II block is a type of second degree AV block where there are intermittent non-conducted P waves. The _PR interval is constant_ (may be normal or prolonged) and there may no pattern or fixed ratios such as 2:1 or 3:1 block. It is usually caused by conduction system failure, especially at the His-Purkinje system.\r\n\r\nIn most cases there is a broad QRS indicating a distal block in the His-Purkinje system and many patients have pre-existing left bundle branch block/bifascicular block.\r\n\r\n[lightgallery2]\r\n\r\n## Causes\r\n\r\n* Infarction: particularly anterior MI which damages the bundle branches\r\n* Surgery: mitral valve repair or septal ablation\r\n* Inflammatory/autoimmune: rheumatic heart disease, SLE, systemic sclerosis, myocarditis\r\n* Fibrosis: Lenegre's disease\r\n* Infiltration: sarcoidosis, haemochromatosis, amyloidosis\r\n* Medication: beta-blockers, calcium channel blockers, Digoxin, amiodarone\r\n\r\n## Management\r\n\r\nDefinitive management is with a permanent pacemaker as these <u>_patients are at risk of complete heart block_</u> and at risk of becoming haemodynamically unstable.\r\n\r\n# Complete (Third degree) Heart Block\r\n\r\n## Definition\r\n\r\nComplete heart block occurs when atrial impulses fail to be conducted to the ventricles. Sufficient cardiac output may be secondary to a ventricular or junctional escape rhythm.\r\n\r\nECG shows severe bradycardia and complete dissociation between the P waves and the QRS complexes. These patients are at high risk of asystole, ventricular tachycardia and cardiac arrest. \r\n\r\n[lightgallery3]\r\n\r\n## Causes\r\n\r\n* Myocardial infarction: especially inferior\r\n* Drugs acting at the AVN: beta blockers, dihydropyridine calcium channel blockers, or adenosine\r\n* Idiopathic fibrosis\r\n\r\n## Management\r\n\r\nManagement of complete (third degree) heart block is via the acute bradycardia guideline (see below). Permanent pacemaker insertion is eventually required due to the risk of sudden death.\n\nAcute management:\n\nFor emergencies, always follow an A-E structure. Identify reversible causes (dyselectrolytaemias, drugs, cardiac causes etc.) \r\n\r\n*If there are adverse signs (e.g. shock, syncope, heart failure, myocardial ischaemia):* \r\n\r\n* **1st line** = **500 micrograms atropine IV**\r\n * Atropine blocks the vagal nerve which increases firing rate of the SAN. \r\n* **2nd line** = if the first dose of atropine is not working can consider giving additional doses of atropine 500mcg up to 3mg until response. Alternatively, **transcutaenous pacing** or **isoprenaline** or **adrenaline** or **alternative drugs** including aminophylline, adrenaline, glucagon (in beta-blocker or calcium channel blocker overdose). \r\n\r\n*If there are no adverse signs but a risk of asystole, or a satisfactory response to 500mcg atropine:*\r\n\r\n* Risk of asystole: recent asystole, mobitz type II block, complete heart block + broad QRS, ventricular pauses >3s. \r\n* **1st line** = administer **500 micrograms atropine IV**. Alternatively, **transcutaenous pacing** or **isoprenaline** or **adrenaline** or **alternative drugs** including aminophylline, adrenaline, glucagon (in beta-blocker or calcium channel blocker overdose). \r\n\r\n*If there are no adverse signs and there is no risk of asystole*\r\n\r\n* Observe\r\n\r\n# NICE Guidelines\r\n\n[NICE Guidelines on Pacing](<https://www.nice.org.uk/guidance/ta88/chapter/2-clinical-need-and-practice>) \r\n\r\n# References\r\n\r\n[Life in the Fast Lane Heart Block ECG Summary](https://litfl.com/heart-block-and-conduction-abnormalities/)\r\n\r\n[Resuscitation Council Adult Bradycardia Algorithm](<https://www.resus.org.uk/sites/default/files/2020-05/G2015_Adult_bradycardia.pdf>)", "files": null, "highlights": [], "id": "619", "pictures": [ { "__typename": "Picture", "caption": "First degree heart block.", "createdAt": 1665036193, "id": "769", "index": 0, "name": "First Degree Heart Block.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/o84o7ha81665036171703.jpg", "path256": "images/o84o7ha81665036171703_256.jpg", "path512": "images/o84o7ha81665036171703_512.jpg", "thumbhash": "tkgCA4D41rmEiOhnqX+d+sc=", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "Mobitz type I.", "createdAt": 1665036183, "id": "694", "index": 1, "name": "Mobitz Type I.png", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/6waeua8n1665036171702.jpg", "path256": "images/6waeua8n1665036171702_256.jpg", "path512": "images/6waeua8n1665036171702_512.jpg", "thumbhash": "OCgCBYJ2hmZwd4d+dwhmf4ePcvcX", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "Complete heart block.", "createdAt": 1665036193, "id": "764", "index": 3, "name": "Complete heart block.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/sfujefok1665036171701.jpg", "path256": "images/sfujefok1665036171701_256.jpg", "path512": "images/sfujefok1665036171701_512.jpg", "thumbhash": "sUgCC4AFanekjIh5f4jHT4Y=", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "Mobitz type II.", "createdAt": 1665036192, "id": "738", "index": 2, "name": "Mobitz Type II.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/pzhhne1c1665036171703.jpg", "path256": "images/pzhhne1c1665036171703_256.jpg", "path512": "images/pzhhne1c1665036171703_512.jpg", "thumbhash": "oDgGBICveHeLd3d3h3h/nKf5Nw==", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 619, "demo": null, "entitlement": null, "id": "3433", "name": "Heart Block", "status": null, "topic": { "__typename": "Topic", "id": "59", "name": "ECG Interpretation", "typeId": 4 }, "topicId": 59, "totalCards": null, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 3433, "conditions": [], "difficulty": 3, "dislikes": 6, "explanation": null, "highlights": [], "id": "6556", "isLikedByMe": 0, "learningPoint": null, "likes": 1, "multiAnswer": null, "pictures": [ { "__typename": "Picture", "caption": null, "createdAt": 1639016639, "id": "368", "index": 0, "name": "BradycardiawithfirstdegreeheartblockECG.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/v1r89z0g1639016638578.jpg", "path256": "images/v1r89z0g1639016638578_256.jpg", "path512": "images/v1r89z0g1639016638578_512.jpg", "thumbhash": "OhgCAoCO15Z/hsd3xYwPOTc=", "topic": { "__typename": "Topic", "id": "35", "name": "Cardiology", "typeId": 2 }, "topicId": 35, "updatedAt": 1708373886 } ], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 60-year-old man attends his GP for a routine check-up; he is noted to have a low pulse rate. His ECG is as follows:\n\n[lightgallery]\n\nWhat incidental finding is seen?", "sbaAnswer": [ "a" ], "totalVotes": 3320, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Metformin is the first line treatment for type 2 diabetes mellitus. Common side effects include nausea, diarrhoea and abdominal pain. An important, rare side effect is lactic acidosis. Heart failure is not a known side effect", "id": "32786", "label": "d", "name": "Metformin", "picture": null, "votes": 114 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Tamoxifen is an anti-oestrogen medication use to treat breast cancers that are oestrogen receptor positive. A common side effect is fluid retention, however, it is unlikely to also lead to breathing difficulties", "id": "32784", "label": "b", "name": "Tamoxifen", "picture": null, "votes": 957 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Linagliptin is a dipeptidylpeptidase-4 inhibitor that acts to increase insulin secretion. It is a second line treatment for type 2 diabetes mellitus. Heart failure is not a known side effect", "id": "32787", "label": "e", "name": "Linagliptin", "picture": null, "votes": 492 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Carbimazole is used in the treatment of hyperthyroidism. An important, rare side effect is bone marrow failure. Heart failure is not a known side effect", "id": "32785", "label": "c", "name": "Carbimazole", "picture": null, "votes": 492 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Trastuzumab (brand name Herceptin), is a monoclonal antibody against the HER2 receptor. It is prescribed in patients who have breast cancer that overexpresses the HER2 gene. Heart failure is a common side effect of this medication, affecting up to 1 in 10 patients and therefore, regular monitoring is required", "id": "32783", "label": "a", "name": "Trastuzumab", "picture": null, "votes": 3070 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\n\nBreast carcinoma is the most prevalent form of cancer among women and the second leading cause of cancer death in the UK. It manifests in various histological subtypes including ductal, lobular, medullary, and phyllodes tumours, each displaying distinct characteristics. Certain genetic mutations, especially BRCA1 and BRCA2, can increase the risk for breast carcinoma. Notable signs and symptoms include unexplained breast mass, nipple discharge, retraction, or skin changes suggestive of breast cancer. Key investigations comprise a triple assessment—clinical examination, radiological examination, and biopsy. Treatment strategies encompass surgical management (wide local excision or mastectomy), radiotherapy, chemotherapy, biological therapy, and hormonal therapy. Risk factors for breast cancer include increased hormone exposure, susceptibility gene mutations, advancing age, and lifestyle factors like obesity, physical inactivity, and alcohol and tobacco use.\n\n\n# Definition\n\n\nBreast carcinoma refers to a malignant tumour originating from the cells of the breast tissue. It exhibits different subtypes each with unique cellular properties and clinical implications. The carcinomas can be invasive, indicating they have broken through the basement membrane of the tissue of origin and have the potential to metastasize, or non-invasive (in situ), suggesting they are confined to the initial location.\n\n\n# Epidemiology\n\n\nBreast carcinoma is the most common type of cancer in women and accounts for approximately 15% of new cancer cases, representing 50,000 new cases annually. It is the second most common cause of cancer death in the UK.\n\n\n# Aetiology\n\nMost breast cancers are either ductal (arising from the epithelial lining of the ducts) or lobular (originating from epithelial cells in the terminal ducts of the lobules).\n\n\nRisk factors for breast carcinoma include:\n\n\n- Being female\n- 99% of breast cancer cases occur in women\n- Increased hormone exposure\n- Early menarche or late menopause\n- Nulliparity or late first pregnancy\n- Oral contraceptives or Hormonal Replacement Therapy\n- Susceptibility gene mutations\n- Most commonly BRCA mutations (BRCA1/BRCA2)\n- Advancing age\n- Caucasian ethnicity\n- Obesity and lack of physical activity\n- Alcohol and tobacco use\n- History of breast cancer\n- Previous radiotherapy treatment\n\n\n# Classification\n\n\nBreast cancer is not a single disease, but a collection of several subtypes, each with its unique characteristics, prognosis, and treatment options.It can be classified based on its origin cell type such as:\n\n\n- **Invasive ductal carcinoma (IDC)**: This is the most common type, accounting for about 80% of all breast cancers. It starts in a milk duct, breaks through the wall of the duct, and invades the fatty tissue of the breast.\n- **Invasive lobular carcinoma (ILC)**: This type begins in the milk-producing glands (lobules) and can spread to other parts of the body.\n- **Ductal carcinoma in situ (DCIS)**: This is a non-invasive or pre-invasive cancer where the cells are confined to the ducts in the breast and have not spread into the surrounding breast tissue.\n- **Lobular carcinoma in situ (LCIS)**: This is not a cancer but an area of abnormal cell growth that increases a person's risk of developing invasive breast cancer later.\n- **Paget's disease of breast**: Infiltrating carcinoma of nipple epithelium.\n\n\nIt can also be classified based on the hormone receptors present on the surface of the breast cancer:\n\n- **Inflammatory breast cancer (IBC)**: This is a rare but aggressive type of breast cancer that causes the lymph vessels in the skin of the breast to become blocked.\n\n- **Triple-negative breast cancer (TNBC)**: This type lacks estrogen receptors, progesterone receptors, and does not have an excess of the HER2 protein on the cancer cell surfaces. It tends to be more aggressive and has fewer targeted treatments available.\n\n- **HER2-positive breast cancer**: This is a cancer that tests positive for a protein called human epidermal growth factor receptor 2 (HER2), which promotes the growth of cancer cells. It tends to be more aggressive than other types of breast cancer, but it may respond well to targeted therapies that can block HER2.\n\n\n# Signs and Symptoms\n\n\nCommon clinical manifestations of breast carcinoma include:\n\n\n- Unexplained breast mass in patients aged 30 and above, with or without pain\n- In those aged 50 and older, nipple discharge, retraction/inversion, or other concerning symptoms\n- This can also include eczema-type changes surrounding the nipple as seen in Paget's disease of the breast\n- Skin changes suggestive of breast cancer\n- This includes skin retraction, peau d'orange appearance or ulceration of the skin above an underlying mass.\n- Unexplained axillary mass in those aged 30 and above\n\n\nApproximately 25% of cases are found in routine breast cancer screening (mammography).\n\n\n# Differential Diagnosis\n\n\nWhile an unexplained breast mass is a key indicator of breast carcinoma, it can also represent various other conditions, each characterized by distinct signs and symptoms:\n\n\n- **Fibroadenoma**: Typically presents as a solitary, painless, and well-circumscribed breast lump in young women\n- **Breast Cyst**: Characterized by a round or oval, well-defined, and movable mass. It may be painful and size may vary with the menstrual cycle.\n- **Mastitis**: Typically presents in breastfeeding women, characterized by a painful, warm, red breast often accompanied by systemic symptoms like fever.\n- **Lipoma**: Presents as a soft, mobile, and painless lump.\n\n\n# Breast Cancer Screening in the UK\n\n\nIn the United Kingdom, the NHS Breast Screening Programme provides free breast screening services for all women registered with a GP. The programme invites women between the ages of 50 and 70 for breast screening every three years, with the first invitation to screening usually sent to women before they turn 53.\n\n\nThis screening process involves a mammogram, which is an X-ray of the breasts that can help detect breast cancers early, often before they can be felt. The aim of breast cancer screening is to find cancer at an early stage when treatment is most effective.\n\n\nIn 2018, the age range for screening was extended as part of a trial, and some women were invited for screening from the age of 47 up to the age of 73. Women over 70 can still self-refer for screening every three years.\n\n\n# Investigations\n\nCriteria for 2-week wait:\n\n- Age 30 or more with unexplained breast lump (with or without pain)\n- Age 50 or more with nipple discharge, retraction or other changes\n- Consider a 2-week wait if a patient is 30 or over with skin changes suggestive of breast cancer or an unexplained lump in the axilla\n\nNB: a non-urgent referral should be considered for patients under the age of 30 with an unexplained breast lump.\n\n### Triple Assessment\n\nTriple assessment is used to investigate suspected breast carcinoma:\n\n\n1. Clinical examination: of the breast and surrounding lymph nodes\n2. Radiological examination:\n\t- Ultrasound is used for women under the age of 40 or those with higher breast density.\n\t- A mammogram is commonly used for women over 40 years.\n\t- If there are concerns of metastatic disease, a CT or PET scan may be done.\n3. Biopsy: often a core needle biopsy or fine needle aspirate (FNA)\n\t- Fine needle aspiration (FNA): Often combined with mammography, however, has a high rate of false negatives.\n\t- Core needle biopsy: method of choice, can be combined with imaging to aid accuracy.\n\t- DCIS biopsy will show cellular atypia and hyperchromatic nuclei involving the ducts, but not passing the basement membrane\n\t- In invasive breast cancer, these abnormal cells will pass the basement membrane\n\t- In lobular carcinoma, the abnormal cells will be found within the lobular acini\n\n### Further Investigations\n\nFollowing the triple assessment, further investigations will include:\n\n- Biopsies to determine\n- Oestrogen and progesterone receptor status\n- Epidermal growth factor receptor status\n- Routine blood tests (i.e. LFTs)\n- CXR\n- MRI is not routinely used. It is used for women with:\n- Discrepancy between the extent of disease between clinical examination and imaging\n- Dense breast tissue limiting mammography\n- Invasive lobular carcinoma to evaluate tumour size when planning breast-conserving surgery\n- BRCA1/2 testing is done for women < 50 years with triple-negative breast cancer regardless of family history\n\n\n### Staging\n\nStaging involves the TNM system considering the size of the tumour (T), the spread to the lymph nodes (N), and the presence of metastases (M). For locally invasive breast cancer, this can include:\n\n- Axilla ultrasound with needle sampling if abnormal lymph nodes are identified\n\nIf the cancer is deemed to be advanced, staging investigations should include:\n\n- CT, MRI or bone scintigraphy to determine the presence and extent of visceral and bony metastasis\n- PET CT is only used to diagnose metastasis\n\n\n# Management\n\n\nThe management strategy for breast carcinoma can vary based on several factors including the subtype of carcinoma, stage, hormonal receptor status, and the patient's overall health and preferences.\n\n\n- Surgical management: Wide local excision (WLE) or mastectomy, with sentinel node biopsies for invasive cancers and possible axillary node clearance for positive nodes. Breast reconstruction can be done concurrently or later.\n- Radiotherapy: Adjuvant radiotherapy is commonly offered following WLE to reduce recurrence. It may also be given to patients with higher-stage cancers post-mastectomy.\n\n**Chemotherapy:**\n\n- Suggested for hormone receptor-negative and HER2 over-expressing patients. Neoadjuvant chemotherapy may be given to downstage tumours before surgery. This commonly includes an anthracycline (i.e. doxorubicin) and a taxane (i.e. paclitaxel)\n- Biological Therapy:\n\t- Trastuzumab (Herceptin) should be given to HER2-positive patients with tumour size T1c and above in combination with surgery, chemotherapy and radiotherapy. Patients should have regular cardiac function assessments.\n\t- Abermaciclib (selective inhibitor of cyclin-dependent kinases 4 and 6) for HER2-negative, hormone receptor-positive breast cancer\n\t- Pembrolizumab for triple-negative breast cancer\n\t- Olaparib (PSTP inhibitor) for BRCA positive, HER2 negative high-risk early breast cancer\n- **Hormonal Therapy** for oestrogen-positive breast cancer:\n\t- Anastrozole (aromatase inhibitor) for postmenopausal women\n\t- Tamoxifen (oestrogen receptor antagonist) for premenopausal patients\n\t- Bisphosphonates: May be used for reducing occurrence in node-positive cancers.\n\t- Zoledronic acid has been shown to improve disease-free survival in postmenopausal women with node-positive invasive breast cancer.\n\t- Bisphosphonates are also advised for treatment-induced menopause in women treated with aromatase inhibitors\n\n\n# Complications\n\n### Complications of Breast Carcinoma\n\n- Fatigue\n- Bone metastases\n- Brain metastases\n- Psychological difficulties: Anxiety, depression and damage to the individual's self-esteem.\n- Recurrence:\n\t- Local: recurrence in the same breast as the original tumour\n\t- Regional: recurrence in the axillary or sub-clavicular lymph nodes draining the breast cancer\n\t- Distant: recurrence once already metastasized to other parts of the body (i.e. liver, lungs, brain, bone)\n\n\n### Side Effects of Medication Used to Treat Breast Cancer\n\n\nTreatment for breast cancer often involves medication, including chemotherapy, hormone therapy, and targeted drug therapy. Each of these can have different side effects.\n\n\n**Chemotherapy** drugs are powerful medications that aim to destroy rapidly dividing cells, such as cancer cells. However, they can also affect healthy cells, leading to a range of side effects, including fatigue, hair loss, easy bruising and bleeding, infection, anaemia, nausea and vomiting, appetite changes, peripheral neuropathy, and problems with concentration or memory.\n\nChemotherapy agents can have specific side effects such as:\n\n- Doxorubicin is associated with cardiac toxicity (e.g. cardiac arrhythmias, myopericarditis)\n- Paclitaxel is associated with lung fibrosis.\n\n\n**Hormone therapy** drugs, such as tamoxifen and aromatase inhibitors, are used to treat hormone receptor-positive breast cancers. Common side effects include hot flushes, vaginal dryness or discharge, menstrual changes, fatigue, mood changes, and osteoporosis. In rare cases, tamoxifen can increase the risk of serious conditions like endometrial cancer and blood clots.\n\n\n**Targeted drug therapies** such as trastuzumab (Herceptin), pertuzumab (Perjeta), and ado-trastuzumab emtansine (Kadcyla), are designed to interfere with specific proteins or processes that contribute to cancer growth.\n\nSide effects include:\n\n- Infections\n- Bruising and easy bleeding\n- Anaemia\n- Cardiac (i.e. arrhythmias)\n- Insomnia\n- GI side effects (i.e. diarrhoea, vomiting, constipation, appetite loss, weight loss)\n- Runny nose\n- Conjunctivitis\n- Hair loss\n- Nail changes\n- Hand foot syndrome: the palms and plantar surfaces become sore, peel, crack and blister.\n- Hepatotoxicity\n\n\n\n### Surgical Complications\n\nKey surgical complications include:\n\n- Venous thromboembolism\n- Lymphoedema\n- Pain\n\n\n### Breast Cancer in Pregnancy\n\nBreast cancer is the most common malignancy to occur during pregnancy. Radiotherapy and chemotherapy are most commonly delayed until completion of pregnancy, but surgical intervention can be considered.\n\n# Prognosis\n\nThe prognosis for individuals with breast cancer has vastly improved, almost doubling over the past 50 years. The ten-year survival for breast cancer in England is 75.9%\n\nA poorer prognosis is associated with:\n\n- Advancing age\n- Being male\n- Stage III or IV\n- Tumour size\n- Tumour grade\n- Hormone receptor-negative tumours (oestrogen or progesterone receptor-negative)\n- HER 2 positive tumours\n\n\n# NICE Guidelines\n\n[NICE Guidelines on Early and Locally Advanced Breast Cancer](https://www.nice.org.uk/guidance/ng101)\n\n[NICE Guidelines on Advanced Breast Cancer](https://www.nice.org.uk/guidance/cg81)\n\n# References\n\n[Patient Info Breast Cancer](https://www.nice.org.uk/guidance/cg81)\n\n[BMJ Best Practice Breast Cancer](https://bestpractice.bmj.com/topics/en-gb/718?q=Metastatic%20breast%20cancer&c=suggested)\n\n[NHS Breast Cancer in Women](https://www.nhs.uk/conditions/breast-cancer-in-women/)\n\n[Cancer Research UK Breast Cancer](https://www.cancerresearchuk.org/about-cancer/breast-cancer/survival)", "files": null, "highlights": [], "id": "343", "pictures": [], "typeId": 2 }, "chapterId": 343, "demo": null, "entitlement": null, "id": "343", "name": "Breast Cancer", "status": null, "topic": { "__typename": "Topic", "id": "55", "name": "Breast Disease", "typeId": 2 }, "topicId": 55, "totalCards": 56, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "343", "name": "Breast Cancer" } ], "demo": false, "description": null, "duration": 522.07, "endTime": null, "files": null, "id": "149", "live": false, "museId": "NwAyTxS", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/oncology.png", "title": "Genetic syndromes and Cancer", "userViewed": false, "views": 271, "viewsToday": 42 } ] }, "conceptId": 343, "conditions": [], "difficulty": 1, "dislikes": 4, "explanation": null, "highlights": [], "id": "6557", "isLikedByMe": 0, "learningPoint": "Trastuzumab is a targeted monoclonal antibody used to treat HER2-positive breast cancer by inhibiting the growth of cancer cells; however, it can cause heart failure, leading to symptoms like shortness of breath and peripheral edema, making regular cardiac monitoring essential during treatment.", "likes": 7, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 56-year-old woman presents to her GP with worsening shortness of breath which is worse on exertion. She also experiences breathlessness when lying flat and at night. She has a history of breast cancer, hyperthyroidism and type II diabetes mellitus. On examination, she has bilateral pitting oedema in her ankles. Her medications include tamoxifen, trastuzumab, carbimazole, metformin and linagliptin.\n\nWhich of her medications is most likely to be the cause of her symptoms?", "sbaAnswer": [ "a" ], "totalVotes": 5125, "typeId": 1, "userPoint": null }

[]

{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Chemotherapy may be recommended if the tumour was malignant", "id": "32791", "label": "d", "name": "Chemotherapy", "picture": null, "votes": 92 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "The tumour is benign; therefore, lymph node clearance is not necessary", "id": "32790", "label": "c", "name": "Mastectomy plus lymph node clearance", "picture": null, "votes": 544 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Phyllodes tumours account for less than 1% of all breast cancers. Surgery is the main treatment. Tumours can either be benign, borderline or malignant. In this case, the tumour is benign; therefore, a lumpectomy is the best management choice", "id": "32788", "label": "a", "name": "Lumpectomy", "picture": null, "votes": 4371 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "If the tumour is benign, the usual treatment is a lumpectomy. However, if the tumour is larger, then a mastectomy may be more likely to be performed", "id": "32789", "label": "b", "name": "Mastectomy", "picture": null, "votes": 375 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "This tumour is benign; therefore, radiotherapy is not required. Radiotherapy is not often performed in phyllodes tumours", "id": "32792", "label": "e", "name": "Radiotherapy", "picture": null, "votes": 144 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Would we ever consider not operating on it? If it is benign and the patient doesnt care much for it shouldnt it be fine?", "createdAt": 1682085394, "dislikes": 0, "id": "22371", "isLikedByMe": 0, "likes": 2, "parentId": null, "questionId": 6558, "replies": [ { "__typename": "QuestionComment", "comment": "One third of phyllodes tumours convert to malignancy according to teach me surgery therefore they are excised to reduce risk ", "createdAt": 1684180861, "dislikes": 0, "id": "24711", "isLikedByMe": 0, "likes": 7, "parentId": 22371, "questionId": 6558, "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Jc161", "id": 30600 } } ], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Serotonin Suture", "id": 28170 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\n\nBreast carcinoma is the most prevalent form of cancer among women and the second leading cause of cancer death in the UK. It manifests in various histological subtypes including ductal, lobular, medullary, and phyllodes tumours, each displaying distinct characteristics. Certain genetic mutations, especially BRCA1 and BRCA2, can increase the risk for breast carcinoma. Notable signs and symptoms include unexplained breast mass, nipple discharge, retraction, or skin changes suggestive of breast cancer. Key investigations comprise a triple assessment—clinical examination, radiological examination, and biopsy. Treatment strategies encompass surgical management (wide local excision or mastectomy), radiotherapy, chemotherapy, biological therapy, and hormonal therapy. Risk factors for breast cancer include increased hormone exposure, susceptibility gene mutations, advancing age, and lifestyle factors like obesity, physical inactivity, and alcohol and tobacco use.\n\n\n# Definition\n\n\nBreast carcinoma refers to a malignant tumour originating from the cells of the breast tissue. It exhibits different subtypes each with unique cellular properties and clinical implications. The carcinomas can be invasive, indicating they have broken through the basement membrane of the tissue of origin and have the potential to metastasize, or non-invasive (in situ), suggesting they are confined to the initial location.\n\n\n# Epidemiology\n\n\nBreast carcinoma is the most common type of cancer in women and accounts for approximately 15% of new cancer cases, representing 50,000 new cases annually. It is the second most common cause of cancer death in the UK.\n\n\n# Aetiology\n\nMost breast cancers are either ductal (arising from the epithelial lining of the ducts) or lobular (originating from epithelial cells in the terminal ducts of the lobules).\n\n\nRisk factors for breast carcinoma include:\n\n\n- Being female\n- 99% of breast cancer cases occur in women\n- Increased hormone exposure\n- Early menarche or late menopause\n- Nulliparity or late first pregnancy\n- Oral contraceptives or Hormonal Replacement Therapy\n- Susceptibility gene mutations\n- Most commonly BRCA mutations (BRCA1/BRCA2)\n- Advancing age\n- Caucasian ethnicity\n- Obesity and lack of physical activity\n- Alcohol and tobacco use\n- History of breast cancer\n- Previous radiotherapy treatment\n\n\n# Classification\n\n\nBreast cancer is not a single disease, but a collection of several subtypes, each with its unique characteristics, prognosis, and treatment options.It can be classified based on its origin cell type such as:\n\n\n- **Invasive ductal carcinoma (IDC)**: This is the most common type, accounting for about 80% of all breast cancers. It starts in a milk duct, breaks through the wall of the duct, and invades the fatty tissue of the breast.\n- **Invasive lobular carcinoma (ILC)**: This type begins in the milk-producing glands (lobules) and can spread to other parts of the body.\n- **Ductal carcinoma in situ (DCIS)**: This is a non-invasive or pre-invasive cancer where the cells are confined to the ducts in the breast and have not spread into the surrounding breast tissue.\n- **Lobular carcinoma in situ (LCIS)**: This is not a cancer but an area of abnormal cell growth that increases a person's risk of developing invasive breast cancer later.\n- **Paget's disease of breast**: Infiltrating carcinoma of nipple epithelium.\n\n\nIt can also be classified based on the hormone receptors present on the surface of the breast cancer:\n\n- **Inflammatory breast cancer (IBC)**: This is a rare but aggressive type of breast cancer that causes the lymph vessels in the skin of the breast to become blocked.\n\n- **Triple-negative breast cancer (TNBC)**: This type lacks estrogen receptors, progesterone receptors, and does not have an excess of the HER2 protein on the cancer cell surfaces. It tends to be more aggressive and has fewer targeted treatments available.\n\n- **HER2-positive breast cancer**: This is a cancer that tests positive for a protein called human epidermal growth factor receptor 2 (HER2), which promotes the growth of cancer cells. It tends to be more aggressive than other types of breast cancer, but it may respond well to targeted therapies that can block HER2.\n\n\n# Signs and Symptoms\n\n\nCommon clinical manifestations of breast carcinoma include:\n\n\n- Unexplained breast mass in patients aged 30 and above, with or without pain\n- In those aged 50 and older, nipple discharge, retraction/inversion, or other concerning symptoms\n- This can also include eczema-type changes surrounding the nipple as seen in Paget's disease of the breast\n- Skin changes suggestive of breast cancer\n- This includes skin retraction, peau d'orange appearance or ulceration of the skin above an underlying mass.\n- Unexplained axillary mass in those aged 30 and above\n\n\nApproximately 25% of cases are found in routine breast cancer screening (mammography).\n\n\n# Differential Diagnosis\n\n\nWhile an unexplained breast mass is a key indicator of breast carcinoma, it can also represent various other conditions, each characterized by distinct signs and symptoms:\n\n\n- **Fibroadenoma**: Typically presents as a solitary, painless, and well-circumscribed breast lump in young women\n- **Breast Cyst**: Characterized by a round or oval, well-defined, and movable mass. It may be painful and size may vary with the menstrual cycle.\n- **Mastitis**: Typically presents in breastfeeding women, characterized by a painful, warm, red breast often accompanied by systemic symptoms like fever.\n- **Lipoma**: Presents as a soft, mobile, and painless lump.\n\n\n# Breast Cancer Screening in the UK\n\n\nIn the United Kingdom, the NHS Breast Screening Programme provides free breast screening services for all women registered with a GP. The programme invites women between the ages of 50 and 70 for breast screening every three years, with the first invitation to screening usually sent to women before they turn 53.\n\n\nThis screening process involves a mammogram, which is an X-ray of the breasts that can help detect breast cancers early, often before they can be felt. The aim of breast cancer screening is to find cancer at an early stage when treatment is most effective.\n\n\nIn 2018, the age range for screening was extended as part of a trial, and some women were invited for screening from the age of 47 up to the age of 73. Women over 70 can still self-refer for screening every three years.\n\n\n# Investigations\n\nCriteria for 2-week wait:\n\n- Age 30 or more with unexplained breast lump (with or without pain)\n- Age 50 or more with nipple discharge, retraction or other changes\n- Consider a 2-week wait if a patient is 30 or over with skin changes suggestive of breast cancer or an unexplained lump in the axilla\n\nNB: a non-urgent referral should be considered for patients under the age of 30 with an unexplained breast lump.\n\n### Triple Assessment\n\nTriple assessment is used to investigate suspected breast carcinoma:\n\n\n1. Clinical examination: of the breast and surrounding lymph nodes\n2. Radiological examination:\n\t- Ultrasound is used for women under the age of 40 or those with higher breast density.\n\t- A mammogram is commonly used for women over 40 years.\n\t- If there are concerns of metastatic disease, a CT or PET scan may be done.\n3. Biopsy: often a core needle biopsy or fine needle aspirate (FNA)\n\t- Fine needle aspiration (FNA): Often combined with mammography, however, has a high rate of false negatives.\n\t- Core needle biopsy: method of choice, can be combined with imaging to aid accuracy.\n\t- DCIS biopsy will show cellular atypia and hyperchromatic nuclei involving the ducts, but not passing the basement membrane\n\t- In invasive breast cancer, these abnormal cells will pass the basement membrane\n\t- In lobular carcinoma, the abnormal cells will be found within the lobular acini\n\n### Further Investigations\n\nFollowing the triple assessment, further investigations will include:\n\n- Biopsies to determine\n- Oestrogen and progesterone receptor status\n- Epidermal growth factor receptor status\n- Routine blood tests (i.e. LFTs)\n- CXR\n- MRI is not routinely used. It is used for women with:\n- Discrepancy between the extent of disease between clinical examination and imaging\n- Dense breast tissue limiting mammography\n- Invasive lobular carcinoma to evaluate tumour size when planning breast-conserving surgery\n- BRCA1/2 testing is done for women < 50 years with triple-negative breast cancer regardless of family history\n\n\n### Staging\n\nStaging involves the TNM system considering the size of the tumour (T), the spread to the lymph nodes (N), and the presence of metastases (M). For locally invasive breast cancer, this can include:\n\n- Axilla ultrasound with needle sampling if abnormal lymph nodes are identified\n\nIf the cancer is deemed to be advanced, staging investigations should include:\n\n- CT, MRI or bone scintigraphy to determine the presence and extent of visceral and bony metastasis\n- PET CT is only used to diagnose metastasis\n\n\n# Management\n\n\nThe management strategy for breast carcinoma can vary based on several factors including the subtype of carcinoma, stage, hormonal receptor status, and the patient's overall health and preferences.\n\n\n- Surgical management: Wide local excision (WLE) or mastectomy, with sentinel node biopsies for invasive cancers and possible axillary node clearance for positive nodes. Breast reconstruction can be done concurrently or later.\n- Radiotherapy: Adjuvant radiotherapy is commonly offered following WLE to reduce recurrence. It may also be given to patients with higher-stage cancers post-mastectomy.\n\n**Chemotherapy:**\n\n- Suggested for hormone receptor-negative and HER2 over-expressing patients. Neoadjuvant chemotherapy may be given to downstage tumours before surgery. This commonly includes an anthracycline (i.e. doxorubicin) and a taxane (i.e. paclitaxel)\n- Biological Therapy:\n\t- Trastuzumab (Herceptin) should be given to HER2-positive patients with tumour size T1c and above in combination with surgery, chemotherapy and radiotherapy. Patients should have regular cardiac function assessments.\n\t- Abermaciclib (selective inhibitor of cyclin-dependent kinases 4 and 6) for HER2-negative, hormone receptor-positive breast cancer\n\t- Pembrolizumab for triple-negative breast cancer\n\t- Olaparib (PSTP inhibitor) for BRCA positive, HER2 negative high-risk early breast cancer\n- **Hormonal Therapy** for oestrogen-positive breast cancer:\n\t- Anastrozole (aromatase inhibitor) for postmenopausal women\n\t- Tamoxifen (oestrogen receptor antagonist) for premenopausal patients\n\t- Bisphosphonates: May be used for reducing occurrence in node-positive cancers.\n\t- Zoledronic acid has been shown to improve disease-free survival in postmenopausal women with node-positive invasive breast cancer.\n\t- Bisphosphonates are also advised for treatment-induced menopause in women treated with aromatase inhibitors\n\n\n# Complications\n\n### Complications of Breast Carcinoma\n\n- Fatigue\n- Bone metastases\n- Brain metastases\n- Psychological difficulties: Anxiety, depression and damage to the individual's self-esteem.\n- Recurrence:\n\t- Local: recurrence in the same breast as the original tumour\n\t- Regional: recurrence in the axillary or sub-clavicular lymph nodes draining the breast cancer\n\t- Distant: recurrence once already metastasized to other parts of the body (i.e. liver, lungs, brain, bone)\n\n\n### Side Effects of Medication Used to Treat Breast Cancer\n\n\nTreatment for breast cancer often involves medication, including chemotherapy, hormone therapy, and targeted drug therapy. Each of these can have different side effects.\n\n\n**Chemotherapy** drugs are powerful medications that aim to destroy rapidly dividing cells, such as cancer cells. However, they can also affect healthy cells, leading to a range of side effects, including fatigue, hair loss, easy bruising and bleeding, infection, anaemia, nausea and vomiting, appetite changes, peripheral neuropathy, and problems with concentration or memory.\n\nChemotherapy agents can have specific side effects such as:\n\n- Doxorubicin is associated with cardiac toxicity (e.g. cardiac arrhythmias, myopericarditis)\n- Paclitaxel is associated with lung fibrosis.\n\n\n**Hormone therapy** drugs, such as tamoxifen and aromatase inhibitors, are used to treat hormone receptor-positive breast cancers. Common side effects include hot flushes, vaginal dryness or discharge, menstrual changes, fatigue, mood changes, and osteoporosis. In rare cases, tamoxifen can increase the risk of serious conditions like endometrial cancer and blood clots.\n\n\n**Targeted drug therapies** such as trastuzumab (Herceptin), pertuzumab (Perjeta), and ado-trastuzumab emtansine (Kadcyla), are designed to interfere with specific proteins or processes that contribute to cancer growth.\n\nSide effects include:\n\n- Infections\n- Bruising and easy bleeding\n- Anaemia\n- Cardiac (i.e. arrhythmias)\n- Insomnia\n- GI side effects (i.e. diarrhoea, vomiting, constipation, appetite loss, weight loss)\n- Runny nose\n- Conjunctivitis\n- Hair loss\n- Nail changes\n- Hand foot syndrome: the palms and plantar surfaces become sore, peel, crack and blister.\n- Hepatotoxicity\n\n\n\n### Surgical Complications\n\nKey surgical complications include:\n\n- Venous thromboembolism\n- Lymphoedema\n- Pain\n\n\n### Breast Cancer in Pregnancy\n\nBreast cancer is the most common malignancy to occur during pregnancy. Radiotherapy and chemotherapy are most commonly delayed until completion of pregnancy, but surgical intervention can be considered.\n\n# Prognosis\n\nThe prognosis for individuals with breast cancer has vastly improved, almost doubling over the past 50 years. The ten-year survival for breast cancer in England is 75.9%\n\nA poorer prognosis is associated with:\n\n- Advancing age\n- Being male\n- Stage III or IV\n- Tumour size\n- Tumour grade\n- Hormone receptor-negative tumours (oestrogen or progesterone receptor-negative)\n- HER 2 positive tumours\n\n\n# NICE Guidelines\n\n[NICE Guidelines on Early and Locally Advanced Breast Cancer](https://www.nice.org.uk/guidance/ng101)\n\n[NICE Guidelines on Advanced Breast Cancer](https://www.nice.org.uk/guidance/cg81)\n\n# References\n\n[Patient Info Breast Cancer](https://www.nice.org.uk/guidance/cg81)\n\n[BMJ Best Practice Breast Cancer](https://bestpractice.bmj.com/topics/en-gb/718?q=Metastatic%20breast%20cancer&c=suggested)\n\n[NHS Breast Cancer in Women](https://www.nhs.uk/conditions/breast-cancer-in-women/)\n\n[Cancer Research UK Breast Cancer](https://www.cancerresearchuk.org/about-cancer/breast-cancer/survival)", "files": null, "highlights": [], "id": "343", "pictures": [], "typeId": 2 }, "chapterId": 343, "demo": null, "entitlement": null, "id": "343", "name": "Breast Cancer", "status": null, "topic": { "__typename": "Topic", "id": "55", "name": "Breast Disease", "typeId": 2 }, "topicId": 55, "totalCards": 56, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "343", "name": "Breast Cancer" } ], "demo": false, "description": null, "duration": 522.07, "endTime": null, "files": null, "id": "149", "live": false, "museId": "NwAyTxS", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/oncology.png", "title": "Genetic syndromes and Cancer", "userViewed": false, "views": 271, "viewsToday": 42 } ] }, "conceptId": 343, "conditions": [], "difficulty": 1, "dislikes": 3, "explanation": null, "highlights": [], "id": "6558", "isLikedByMe": 0, "learningPoint": "Phyllodes tumors are rare breast tumors that can be benign or malignant and are characterized by rapid growth; management typically involves surgical removal with a lumpectomy to ensure complete excision and reduce the risk of recurrence.", "likes": 6, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 52-year-old woman presented to her GP with a firm lump in her left breast. This was fast-growing and had noticeably increased in size over the last few weeks so that it is now 1cm by 2cm by 1cm. She was sent for an urgent mammogram, ultrasound and biopsy. The biopsy showed a benign phyllodes tumour.\n\nWhat is the most appropriate initial management?", "sbaAnswer": [ "a" ], "totalVotes": 5526, "typeId": 1, "userPoint": null }

[]

{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "Be careful to multiply the sodium concentration by two rather than square it", "id": "32796", "label": "d", "name": "13933.5 mOsmo/kg", "picture": null, "votes": 16 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Remember to use the blood urea nitrogen rather than urea. In reality, these two are often used interchangeably. However, in this exercise, the urea is in the wrong units for the equation", "id": "32795", "label": "c", "name": "241.9 mOsmo/kg", "picture": null, "votes": 383 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Remember that division should be performed before addition in calculations. The order of mathematical operations can be remembered using the BODMAS mnemonic: brackets, orders, division, multiplications, addition, subtraction", "id": "32794", "label": "b", "name": "10.3 mOsmo/kg", "picture": null, "votes": 75 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Ensure that the glucose concentration used is in mg/dL rather than mmol/L", "id": "32797", "label": "e", "name": "240.3 mOsmo/kg", "picture": null, "votes": 826 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "Plasma osmolality = (2 [118]) + (81/18) + (11.2/2.8)\n\nNote the units used in this calculation are not the same as the units usually given for blood results. In reality, it is safer to calculate plasma osmolality on an online calculator, be aware that units of calculators are often interchangeable", "id": "32793", "label": "a", "name": "244.5 mOsmo/kg", "picture": null, "votes": 1823 } ], "comments": [ { "__typename": "QuestionComment", "comment": "Quesmaths", "createdAt": 1684890754, "dislikes": 0, "id": "25936", "isLikedByMe": 0, "likes": 6, "parentId": null, "questionId": 6559, "replies": [], "user": { "__typename": "User", "accessLevel": "subscriber", "displayName": "Amaurosis Fugaxlegomenon", "id": 26260 } } ], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nSyndrome of Inappropriate ADH secretion (SIADH) refers to excessive antidiuretic hormone (ADH) release, causing water to be retained resulting in a euvolemic hyponatraemia. There are a wide range of causes including medications, malignancy, central nervous system (CNS) disorders and infections. Patients may be asymptomatic and detected through an incidental finding of a low serum sodium, or may present with features of severe hyponatraemia (e.g. confusion, seizures) and/or the underlying cause of SIADH. Key investigations include U&Es for sodium, cortisol and thyroid function to rule out other causes of hyponatraemia and urinary sodium and osmolality (which will be greater than 30 mmol/L and 100 mOsm/kg respectively). First-line management is with fluid restriction to 500-1000 ml/day, as well as treating the underlying cause (e.g. stopping causative medications). Severe cases may require hypertonic saline, and resistant cases may be treated with tolvaptan (an vasopressin V2-receptor antagonist).\n\n# Definition\n\nSyndrome of Inappropriate ADH secretion (SIADH) is an important cause of hyponatraemia that occurs when there is inappropriate release of antidiuretic hormone (ADH) outside of normal homeostatic mechanisms, which leads to reduced urine output. The increase in total body water effectively dilutes serum sodium, leading to hyponatraemia. \n\nNormally, ADH (also referred to as vasopressin) is produced in the hypothalamus and released from the posterior pituitary when serum osmolality is high. It acts to normalise osmolality by acting on the distal convoluted tubules and collecting ducts of the kidney to stimulate increased water reabsorption. \n\nSIADH may involve excessive release of ADH from the pituitary gland or production of ADH by an abnormal non-pituitary source (e.g. a tumour).\n\n# Aetiology\n\nSIADH has a wide range of causes - these are some examples:\n\n- Pulmonary causes:\n\t- Pneumonia\n\t- Chronic Obstructive Pulmonary Disease (COPD)\n\t- Tuberculosis (TB)\n- Central Nervous System (CNS) disorders:\n\t- Meningitis\n\t- Stroke\n\t- Subarachnoid haemorrhage\n\t- Traumatic brain injury\n\t- Psychosis\n- Malignancies:\n\t- Small cell lung cancer\n\t- Pancreatic cancer\n\t- Lymphoma\n\t- Mesothelioma\n\t- Thymoma\n\t- Nasopharyngeal cancer\n- Medications:\n\t- Carbamazepine\n\t- Selective Serotonin Reuptake Inhibitors (SSRIs)\n\t- Opiates\n\t- Anti-psychotics\n\t- Cyclophosphamide\n- Other: \n\t- HIV\n\t- Surgery\n\t- Acute intermittent porphyria\n\t- Idiopathic\n\n# Signs and Symptoms\n\nSIADH presents with a euvolaemic hyponatraemia, and so patients may be asymptomatic or present with features of the underlying cause (e.g. pneumonia).\n\nSigns and symptoms of hyponatraemia are more likely to develop in severe cases and where sodium has fallen rapidly:\n\n- Lethargy\n- Anorexia\n- Headache\n- Nausea and vomiting\n- Muscle cramps\n- Drowsiness\n- Confusion\n- Seizures\n\n# Differential Diagnosis\n\nSee the Hyponatraemia chapter for a full list of differentials - other causes of a euvolaemic hyponatraemia include:\n\n- **Beer potomania** is a cause of hyponatraemia in the context of alcohol excess combined with low solute intake due to a poor diet\n- **Primary polydipsia** occurs when people drink excessive amounts of water, leading to polyuria with dilute urine (as opposed to the smaller volume of concentrated urine seen in SIADH)\n- **Hypothyroidism** may cause hyponatraemia in severe cases; patients will usually have other symptoms such as fatigue, cold intolerance and constipation\n- **Adrenal insufficiency** causes hyponatraemia with hyperkalaemia; other features include hypotension, abdominal pain and weakness\n- **Exercise-induced hyponatraemia** occurs during or in the 24 hours following prolonged exercise (e.g. running a marathon), usually due to excess intake of hypotonic fluids\n- **Hypotonic intravenous fluids** such as 5% dextrose or 0.45% saline may lead to iatrogenic hyponatraemia\n\n# Investigations\n\n**Bedside:**\n\n- **Venous blood gas** to confirm hyponatraemia - if there is a significant discrepancy between the sodium on the gas and the U&Es, suspect pseudohyponatremia (see Hyponatraemia chapter for details) \n- **Urine osmolality** will be high (> 100 mOsm/kg)\n- **Urine sodium** will be high (> 30 mmol/L)\n- NB urine osmolality and sodium cannot be interpreted in patients taking diuretics and so these need to be stopped prior to investigations\n\n**Blood tests:**\n\n- **U&Es** to confirm hyponatraemia; urea will also likely be low due to dilution\n- **Serum osmolality** will be low (< 280 mOsm/kg)\n- **Thyroid function tests** to exclude hypothyroidism as a cause of hyponatraemia\n- **9am serum cortisol** to exclude adrenal insufficiency as a cause of hyponatraemia\n\n**Imaging:**\n\n- **Chest X-ray** if there is no obvious cause of SIADH as an initial screen for malignancy and pulmonary disease (e.g. tuberculosis, pneumonia)\n- **CT chest, abdomen and pelvis** and **MRI head** may be considered to exclude occult malignancy if there is no identified cause\n\n# Management\n\n**Conservative:**\n\n- Identify and treat the underlying cause (e.g. stopping causative medications where possible)\n- Patients with suspected SIADH in primary care should be referred to endocrinology to confirm the diagnosis and advise on treatment\n- Closely monitor sodium levels and ensure these are corrected no faster than 8-10 mmol/L per 24 hours \n- Fluid restriction is the first-line management in most cases, usually to 500-1000 ml/day \n\n**Medical:**\n\n- Severe hyponatraemia should be treated with hypertonic saline, usually in the intensive care setting\n- In some cases (e.g. SIADH resistant to fluid restriction), tolvaptan may be considered - this is a vasopressin V2-receptor antagonist\n\n# Complications\n\n- **Cerebral oedema** may complicate severe and/or acute hyponatraemia and may be life-threatening - patients develop raised intracranial pressure with symptoms of vomiting, headache, seizures and coma\n- **Central pontine myelinolysis** is a complication of rapid correction of hyponatraemia - patients may present with confusion, ataxia, spastic quadriparesis and pseudobulbar palsy with dysphagia and dysarthria\n- Chronic hyponatraemia, especially in the elderly, increases the risk of **falls** as well as **cognitive impairment**\n\n# NICE Guidelines\n\n[NICE CKS - Hyponatraemia](https://cks.nice.org.uk/topics/hyponatraemia/)\n\n# References\n\n[Life in the Fast Lane - Hyponatraemia](https://litfl.com/hyponatraemia/)\n\n[Life in the Fast Lane - SIADH](https://litfl.com/siadh-syndrome-of-inappropriate-adh-secretion/)\n\n[Whittington Hospital Hyponatraemia Guideline](https://www.whittington.nhs.uk/document.ashx?id=6089)", "files": null, "highlights": [], "id": "152", "pictures": [], "typeId": 2 }, "chapterId": 152, "demo": null, "entitlement": null, "id": "153", "name": "Syndrome of Inappropriate ADH release (SIADH)", "status": null, "topic": { "__typename": "Topic", "id": "36", "name": "Clinical Chemistry", "typeId": 2 }, "topicId": 36, "totalCards": 10, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "153", "name": "Syndrome of Inappropriate ADH release (SIADH)" } ], "demo": false, "description": null, "duration": 3495.64, "endTime": null, "files": null, "id": "579", "live": false, "museId": "FkiyEVw", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/respiratory.png", "title": "Quesmed Tutorial: Lung Cancer", "userViewed": false, "views": 132, "viewsToday": 17 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "153", "name": "Syndrome of Inappropriate ADH release (SIADH)" } ], "demo": false, "description": null, "duration": 6426.6, "endTime": null, "files": null, "id": "324", "live": false, "museId": "7AeyDdA", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/chemistry.png", "title": "Quesmed Tutorial: Medical Emergencies", "userViewed": false, "views": 949, "viewsToday": 49 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "153", "name": "Syndrome of Inappropriate ADH release (SIADH)" } ], "demo": false, "description": null, "duration": 1027.09, "endTime": null, "files": null, "id": "376", "live": false, "museId": "akpx4rY", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/chemistry.png", "title": "Syndrome of Inappropriate ADH release (SIADH)", "userViewed": false, "views": 108, "viewsToday": 7 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "153", "name": "Syndrome of Inappropriate ADH release (SIADH)" } ], "demo": false, "description": null, "duration": 373.7, "endTime": null, "files": null, "id": "582", "live": false, "museId": "XWiHgAL", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/chemistry.png", "title": "Lung Cancer 5", "userViewed": false, "views": 5, "viewsToday": 0 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "153", "name": "Syndrome of Inappropriate ADH release (SIADH)" } ], "demo": false, "description": null, "duration": 251.73, "endTime": null, "files": null, "id": "374", "live": false, "museId": "PXMSwJ1", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/oncology.png", "title": "Superior Vena Cava Obstruction", "userViewed": false, "views": 79, "viewsToday": 2 } ] }, "conceptId": 153, "conditions": [], "difficulty": 2, "dislikes": 15, "explanation": null, "highlights": [], "id": "6559", "isLikedByMe": 0, "learningPoint": null, "likes": 1, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "An 84-year-old woman is admitted to A&E due to severe drowsiness. She cannot speak in full sentences, but her daughter states that she had been complaining of increased nausea and vomiting over the last few days. Her bloods are as follows:\n\n\n||||\n|---------------------------|:-------:|------------------------------|\n|Fasting Glucose|4.5 mmol/L|3.5 - 5.5|\n|Sodium|118 mmol/L|135 - 145|\n|Potassium|4.2 mmol/L|3.5 - 5.3|\n|Urea|4 mmol/L|2.5 - 7.8|\n|Creatinine|65 µmol/L|60 - 120|\n|eGFR|75 mL/min/1.73m²|> 60|\n|Blood Urea Nitrogen|11.2 mg/dL|7 - 22|\n\n\n\nUsing the formula below, calculate the patient's plasma osmolality.\n\n\nPlasma osmolality = 2 [Na+ mEq/L] + [Glucose mmol/L + [Blood Urea Nitrogen mg/dL]/2.8", "sbaAnswer": [ "a" ], "totalVotes": 3123, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "This is highly unlikely given nothing in the history is mentioned about possible overdose or suicidal ideation. Furthermore, ethylene glycol poisoning would result in a high anion gap metabolic acidosis.", "id": "32802", "label": "e", "name": "Ethylene glycol poisoning", "picture": null, "votes": 0 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Uraemia could occur as a result of an acute kidney injury secondary to the vomiting and diarrhoea. However, this would cause an increased anion gap metabolic acidosis and the anion gap here is normal.", "id": "32801", "label": "d", "name": "Uraemia", "picture": null, "votes": 0 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Lactic acidosis would cause a metabolic acidosis with a low pH and patients with renal impairment can get a metformin induced lactic acidosis. However, this would cause a raised anion gap metabolic acidosis, and the anion gap here is normal.", "id": "32800", "label": "c", "name": "Lactic acidosis", "picture": null, "votes": 25 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Diabetic ketoacidosis would cause a metabolic acidosis with a low pH, but the anion gap would be high as there is excess acid in the blood. The anion gap in this case is normal.", "id": "32799", "label": "b", "name": "Diabetic ketoacidosis", "picture": null, "votes": 24 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "The pH here is below the normal range, implying an acidosis. The carbon dioxide also also below the normal range, implying that this must be a metabolic acidosis with partial respiratory compensation.\n\nThe anion gap is calculated as follow: [Na+] - ( [Cl-] + [HCO3-] ). A normal anion gap is 8-12 mmol/L. The anion gap in this case is 137-(117+10)=10. This represents a normal anion gap acidosis. One of the most common causes of a normal anion gap metabolic acidosis is diarrhoea, due to the significant bicarbonate loss from the gut.", "id": "32798", "label": "a", "name": "Gastroenteritis", "picture": null, "votes": 25 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n\nMetabolic acidosis is a type of acid-base imbalance where blood pH is low due to an increase in hydrogen ions (H+), a decrease in bicarbonate (HCO3-) or both. Causes can be split into those that cause a raised anion gap (calculated as sodium plus potassium minus both chloride and bicarbonate) and those where the anion gap is normal. Causes of a raised anion gap metabolic acidosis include diabetic ketoacidosis (DKA), uraemia, lactic acidosis and medications such as salicylates or isoniazid. Causes of a normal anion gap metabolic acidosis include diarrhoea, renal tubular acidosis and medications such as acetazolamide and spironolactone. The key diagnostic investigation is a blood gas, with further investigations and management tailored based on the clinical presentation and suspected cause.\n\n# Definition\n\nA metabolic acidosis refers to a state where the blood pH is less than 7.35 (i.e. an acidosis) with a low bicarbonate (less than 22 mmol/L). It occurs due to a variety of causes that derange the normal acid-base balance.\n\n# Classification\n\nMetabolic acidoses are classified depending on the anion gap. This is calculated using the following formula:\n\nAnion Gap = (Sodium + Potassium) - (Bicarbonate + Chloride)\n\nA normal anion gap is between 10-20 mmol/L (or 8-16 mmol/L if potassium is excluded from the equation)\n\nThe anion gap is a way of quantifying anions that are not measured by a blood gas machine, for example ketones in diabetic ketoacidosis. \n\nNormal anion gap metabolic acidoses are caused by bicarbonate loss, and high anion gap metabolic acidoses are caused by accumulation of organic acids or reduced excretion of hydrogen ions.\n\n# Signs and Symptoms\n\nClinical presentation depends on the underlying cause, for example fruity smelling breath in diabetic ketoacidosis. \n\nDyspnoea and tachypnoea are common features due to respiratory compensation (hyperventilation causes \"\"blowing off\"\" of carbon dioxide as a way to reduce blood pH).\n\nNausea, vomiting and anorexia are also common symptoms. \n\nIn severe metabolic acidosis, patients may be lethargic or comatose, and hypotension may occur secondary to myocardial suppression.\n\n# Differential Diagnosis\n\n**Causes of a raised anion gap metabolic acidosis include:**\n\n- Lactic acidosis (e.g. secondary to septic shock, haemorrhage, heart failure, respiratory failure)\n- Ketoacidosis (e.g. DKA, alcohol excess, starvation)\n- Uraemia (secondary to acute or chronic renal failure)\n- Drugs (salicylates, iron, metformin, isoniazid, ciclosporin) \n- Poisoning (methanol, ethylene glycol, sulphur)\n\n**Causes of a normal anion gap metabolic acidosis include:**\n\n- Diarrhoea\n- High output ileostomies\n- Fistulae (pancreatic, ureteric, biliary, small bowel)\n- Renal tubular acidosis\n- Adrenal insufficiency\n- Chloride excess (e.g. excessive normal saline administration)\n- Acetazolamide\n\n# Investigations\n\n**Bedside tests:**\n\n- A **blood gas** is the diagnostic investigation - this may be arterial or venous, with an arterial gas preferred if accurate measurement of PaCO2 and PaO2 is required\n- pH is low and bicarbonate is also low\n- PaCO2 may also be low due to respiratory compensation\n- This also provides the information needed to calculate the anion gap \n- It also measures lactate and glucose (for lactic acidosis and DKA respectively)\n- **ECG** looking for arrhythmias which may lead to shock and lactic acidosis\n- **Urinalysis and urine MC&S** as part of a septic screen; there may be glycosuria and high urinary ketones in DKA; urine pH is important in differentiating between types of renal tubular acidosis\n- **Sputum MC&S** as part of a septic screen if there is a productive cough\n- **Stool MC&S, viral PCR and C difficile** if there is diarrhoea\n\n**Blood tests:**\n\n- **FBC** which may show anaemia due to haemorrhage, or raised white cells due to infection\n- **U&Es** may be deranged in uraemia\n- **LFTs** may be abnormal e.g. in alcohol excess\n- **Magnesium** and **bone profile** as electrolytes may be deranged due to diarrhoea/fistulae/high output stomas\n- **CRP** looking for evidence of infection\n- **Clotting screen** looking for coagulopathy secondary to sepsis or a bleeding diathesis in haemorrhage\n- **Group and save** or **cross-match** in cases of haemorrhage in case transfusion is required\n- **Blood cultures** if there are signs or symptoms of infection\n- **Cortisol** in suspected adrenal insufficiency\n- **Salicylate levels** or levels of other medications in suspected toxicity e.g. iron\n- **Plasma ketones** in suspected DKA**\n\n**Imaging:**\n\n- **Chest X-ray** looking for evidence of infection or heart failure\n- Other imaging may be indicated based on the presentation e.g. **abdominal ultrasound** in suspected biliary sepsis, **CT** or **MRI** for suspected fistulae\n\n# Management\n\n- Management revolves around treatment of the underlying cause and the severity of illness\n- Early intensive care involvement should be sought in patients with severe acidosis or reduced levels of consciousness\n- Cases of poisoning or medication overdose should be managed with input from toxicology services (e.g. Toxbase, the National Poisons Information Service)\n- Additional management options for correcting a severe acidosis include sodium bicarbonate and renal replacement therapy\n\n# Complications\n\n- Hypotension (secondary to both vasodilation and myocardial depression)\n- Arrhythmias\n- Coma\n- Seizures\n\n# References\n\n[Patient UK - Metabolic acidosis](https://patient.info/doctor/metabolic-acidosis)\n\n[Life in the Fast Lane - Metabolic acidosis](https://litfl.com/metabolic-acidosis-evaluation/)\n\n[Life in the Fast Lane - Anion gap](https://litfl.com/anion-gap/)\n\n[BNF - Fluids and electrolytes](https://bnf.nice.org.uk/treatment-summaries/fluids-and-electrolytes/)", "files": null, "highlights": [], "id": "143", "pictures": [], "typeId": 2 }, "chapterId": 143, "demo": null, "entitlement": null, "id": "149", "name": "Metabolic acidosis", "status": null, "topic": { "__typename": "Topic", "id": "36", "name": "Clinical Chemistry", "typeId": 2 }, "topicId": 36, "totalCards": 14, "typeId": null, "userChapter": null, "userNote": null, "videos": [] }, "conceptId": 149, "conditions": [ { "__typename": "Condition", "id": "1", "name": "Acid-base abnormality", "topic": { "__typename": "UkmlaTopic", "id": "1", "name": "Acute and emergency" }, "topicId": 1 } ], "difficulty": 2, "dislikes": 1, "explanation": null, "highlights": [], "id": "6560", "isLikedByMe": 0, "learningPoint": null, "likes": 0, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 63-year-old woman attends A&E. She has a background of type 2 diabetes mellitus and is usually on metformin. She has been experiencing vomiting and diarrhoea since returning from holiday to Sri Lanka. On examination, she is breathing rapidly.\n\n\nAn arterial blood gas (ABG) is performed:\n\n\n||||\n|--------------|:-------:|------------------|\n|pH|7.29|7.35 - 7.45|\n|PaO₂|11.2 kPa|11 - 15|\n|PaCO₂|3.5 kPa|4.6 - 6.4|\n|Bicarbonate|10 mmol/L|22 - 30|\n|Chloride|117 mmol/L|96-106|\n|Sodium|137 mmol/L|134-145|\n|Potassium|5.2 mmol/L|3.5 - 5.3|\n|Glucose|20 mmol/L|5-8|\n\n\n\nWhat is the most likely cause of these blood gas results?", "sbaAnswer": [ "a" ], "totalVotes": 74, "typeId": 1, "userPoint": null }

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{ "__typename": "QuestionSBA", "choices": [ { "__typename": "QuestionChoice", "answer": false, "explanation": "The white cell count is slightly raised. However, it is not raised above the levels required to score a point in the Glasgow score. The Glasgow score is used to assess whether a patient needs to be treated in the intensive care unit", "id": "32805", "label": "c", "name": "White cell count", "picture": null, "votes": 140 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "Although the Haemoglobin is slightly low, it does not indicate a poor prognosis. Haemoglobin is not one of the Glasgow score criteria used to assess whether a patient needs to be treated in the intensive care unit", "id": "32804", "label": "b", "name": "Haemoglobin", "picture": null, "votes": 180 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "The albumin is slightly low. However, it is not at the level where it would score a point in the Glasgow score. The Glasgow score is used to assess whether a patient needs to be treated in the intensive care unit", "id": "32807", "label": "e", "name": "Albumin", "picture": null, "votes": 632 }, { "__typename": "QuestionChoice", "answer": true, "explanation": "The calcium is the only marker in this example where the value would score a point on the Glasgow score. A Glasgow score of more than 3 indicates severe pancreatitis, and the patient may need to go to the intensive care unit. The values used to calculate the Glasgow score can be remembered by the PANCREAS mnemonic.\n\n- P - PO2 <8 kPa\n- A - Age > 55\n- N - Neutrophils: WCC > 15x109/L\n- C - Calcium, < 2mmol/L\n- R - renal function: urea >16 mmol/L\n- E - Enzymes: LDH > 600iu/L or AST >200iu/L\n- A - Albumin <32g/L\n- S - sugar: blood glucose > 10mmol/L\n\nTherefore, it is important to request all of these investigations when assessing a patient with suspected pancreatitis because it will inform you next stages of management", "id": "32803", "label": "a", "name": "Calcium", "picture": null, "votes": 5363 }, { "__typename": "QuestionChoice", "answer": false, "explanation": "The urea is raised. However, it is not raised above the levels required to score a point in the Glasgow score. The Glasgow score is used to assess whether a patient needs to be treated in the intensive care unit", "id": "32806", "label": "d", "name": "Urea", "picture": null, "votes": 1079 } ], "comments": [], "concept": { "__typename": "Concept", "chapter": { "__typename": "Chapter", "explanation": "# Summary\n \nAcute pancreatitis refers to inflammation of the pancreas; there are a wide variety of causes and severity ranges from mild and self-resolving pancreatitis to life-threatening multi-organ failure. The main symptom is acute-onset epigastric pain which radiates to the back, which may be accompanied by nausea and vomiting. Diagnosis is primarily with bloods showing an elevated amylase or lipase. Abdominal ultrasound is another important investigation to look for gallstones (the commonest cause of acute pancreatitis). General management includes aggressive fluid resuscitation, analgesia, antiemetics and nutritional support. \n\n# Definition\n\nAcute pancreatitis refers to an inflammatory process affecting the pancreas as well as local or distant tissues and organs in some cases.\n \n\n# Epidemiology\n \n- Acute pancreatitis has an incidence of approximately 30 cases per 100,000 people per year\n- There are many causes as detailed below\n- Half of cases are caused by gallstones, and around a quarter of cases by alcohol\n- 10% of cases are idiopathic\n- The majority of cases (around 80%) are mild and self-limiting, with low mortality rates (1-3%)\n- The 20% of patients with moderate or severe disease have a higher risk of death (estimated at 13-35%)\n\n# Aetiology\n\nCauses of acute pancreatitis can be remembered using the mnemonic GET SMASHED:\n \n - Gallstones \n - Ethanol (alcohol)\n - Trauma\n - Steroids\n - Mumps\n - Autoimmune disease (e.g. systemic lupus erythematosus, Sjogren's syndrome)\n - Scorpion stings\n - Hypercalcaemia, hypertriglyceridemia, hypothermia\n - ERCP\n - Drugs (e.g. thiazides, azathioprine, sulphonamides)\n\nOther causes include blunt abdominal trauma or local surgery, microlithiasis (tiny gallstones and biliary sludge), pancreatic tumours and cholangiocarcinomas and congenital abnormalities such as pancreas divisum. \n\n# Classification\n\nSeverity of pancreatitis is stratified using the Glasgow Score - each of the following scores 1 point and a score of **3 or more** predicts severe pancreatitis:\n\n- PaO2 < 8kPa\n- Age > 55 years\n- Neutrophils > 15\n- Calcium < 2\n- Renal i.e. Urea > 16 \n- Enzymes i.e. LDH > 600 or AST > 200\n- Albumin < 32\n- Sugar i.e. Glucose > 10\n\nThis should be calculated on admission and at 48 hours.\n \n# Signs and Symptoms\n\n- The main symptom of acute pancreatitis is epigastric pain which may radiate to the back\n- Nausea and vomiting are also common symptoms\n- Diarrhoea can occur\n \nOn examination, signs may include:\n\n- Abdominal tenderness\n- Peritonism, rebound tenderness and guarding may be seen\n- Abdominal distension \n- Fevers (which may be due to inflammation or superadded infection)\n- Tachycardia and hypotension if shocked\n- Haemorrhagic pancreatitis may present with Grey-Turner's sign (bruising in the flank area), Cullen's sign (bruising around the umbilicus) or Fox's sign (bruising over the inguinal ligament)\n\n[lightgallery]\n \n[lightgallery1]\n \n# Differential Diagnosis\n \n- **Acute Coronary Syndrome** may present atypically with epigastric rather than chest pain with nausea and vomiting - an ECG should be done to look for ischaemic changes.\n- **Perforated Peptic Ulcer** may present with sudden onset severe abdominal pain with nausea and vomiting and signs of peritonitis; amylase may be raised and a chest X-ray may show air under the diaphragm.\n- **Ruptured Abdominal Aortic Aneurysm** shares features of abdominal pain radiating to the back; patients are typically very unwell with haemodynamic instability. A bedside ultrasound can be done for rapid diagnosis.\n- **Bowel Obstruction** causes abdominal pain and distension with nausea and vomiting, constipation is seen rather than diarrhoea and pain is usually colicky in nature.\n- **Cholecystitis** typically presents with right upper quadrant pain and fever with a positive Murphy's sign on examination, also commonly related to gallstones \n\n# Investigations\n \n**Bedside tests:**\n\n- **ABG** if low oxygen saturations to help with risk stratification (the pO2 is needed for the Glasgow criteria)\n- **ECG** to rule out acute coronary syndrome as a cause of pain\n- **Pregnancy test** in women of child-bearing age to rule out causes of abdominal pain such as ectopic pregnancy\n- **Capillary blood glucose** as hyperglycaemia indicates severe pancreatitis\n\n**Blood tests:**\n\n- **FBC** and **CRP** for inflammatory markers\n- **U&Es** to look for kidney injury; urea is part of the Glasgow criteria\n- **LFTs** are often deranged; a low albumin and high AST indicate severe pancreatitis\n- **Amylase** is the key diagnostic test, with levels over 3x the upper limit of normal indicating acute pancreatitis\n- **Lipase** is not usually measured but can also be used to diagnose pancreatitis - it is more sensitive and specific than amylase\n- **LDH** and a **bone profile** for calcium are also required for the Glasgow criteria with hypocalcaemia being a poor prognostic factor\n- **Blood cultures** in patients with fevers or other signs of infection \n- **Coagulation screen** as a baseline - may be deranged in severe illness\n- **Lipid profile** if hypertriglyceridaemia is suspected as a cause of pancreatitis\n- **Autoimmune markers** if the cause of pancreatitis is unclear\n \n**Imaging:**\n \n- **Abdominal ultrasound** looking for gallstones and duct dilation\n- **Chest X-ray** for complications such as pleural effusions or acute respiratory distress syndrome\n- **CT pancreas with contrast** should be done in patients who are deteriorating or have signs of sepsis or organ failure after 6-10 days - may detect complications such as pseudocysts or necrotising pancreatitis\n- **Magnetic Resonance Cholangiopancreatography (MRCP)** may be required in cases of pancreatitis secondary to gallstones \n \n# Management\n\n**Conservative:**\n\n- Ensure patients with severe pancreatitis (e.g. Glasgow score 3+, hypotension, oliguria, respiratory distress) are referred for intensive care assessment and input\n- Catheterise and monitor input-output\n- Insert an NG tube if significant vomiting\n- If the patient can eat, encourage oral intake as tolerated - they should not be made nil by mouth unless there is another reason for this\n- Enteral nutrition should be started within 72 hours of presentation (e.g. NG feeding) - if this fails parenteral nutrition should be considered\n\n**Medical:**\n\n- IV fluid resuscitation is the mainstay of treatment - crystalloids should be used and should be titrated to achieve an adequate urine output\n- Ensure adequate analgesia is given - opioids may be required\n- Antiemetics for nausea and vomiting\n- Antibiotics should not be given routinely - in some cases (e.g. confirmed pancreatic necrosis) broad-spectrum antibiotics should be given\n- Monitor for and treat any complications\n- For alcohol-related pancreatitis, alcohol withdrawal treatment may be required (i.e. benzodiazepines and pabrinex)\n\n**Surgical:**\n\n- The underlying cause of pancreatitis should be treated; an ERCP may be required for gallstones in cases of jaundice, cholangitis or a dilated common bile duct on imaging\n- Laparoscopic cholecystectomy for gallstone pancreatitis should ideally be done in the same admission unless the patient is not fit for surgery\n- Surgical or interventional management may be required for complications e.g. drainage of large pancreatic pseudocysts or debridement of pancreatic necrosis\n\n# Complications\n\n**Local complications include:**\n\n- A **pancreatic pseudocyst** is a fluid-filled sac that lacks a true epithelial lining (the wall is vascular and fibrotic); typically these form weeks after an episode of acute pancreatitis and can become infected, rupture, haemorrhage or cause compression of surrounding structures\n- **Pancreatic necrosis** occurs due to ischaemia of the pancreas and may become infected causing systemic inflammation and multi-organ failure\n- **Peripancreatic fluid collections** may occur, which can get infected leading to abscess formation\n- **Haemorrhage** from local vessels (e.g. pancreatic or splenic arteries or veins) can occur due to inflammation and enzyme release\n- **Pancreatic fistulae** may form due to pancreatic duct disruption, causing these to communicate with for example the skin, the abdominal cavity or the pleural space\n \n**Systemic complications include:**\n\n- **Acute Respiratory Distress Syndrome (ARDS)** which is a severe lung injury with non-cardiogenic pulmonary oedema and respiratory failure\n- **Acute kidney injury** is a common complication which may require renal replacement therapy; often secondary to intravascular volume depletion due to third spacing \n- **Disseminated intravascular coagulation** \n- **Sepsis** for example secondary to infected pancreatic necrosis\n- **Multi-organ failure** which may lead to death\n- **Hypocalcaemia** occurs due to free fatty acids reacting with serum calcium to form salts, a process called saponification; this can cause tetany if severe\n- **Hyperglycaemia** due to disruptions in insulin production due to pancreatic destruction as well as systemic inflammation\n \n# NICE Guidelines\n\n[NICE CKS - Acute Pancreatitis](https://cks.nice.org.uk/topics/pancreatitis-acute/)\n\n[NICE - Pancreatitis](https://www.nice.org.uk/guidance/ng104/)\n \n# References\n\n[UK guidelines for the management of acute pancreatitis](https://gut.bmj.com/content/54/suppl_3/iii1)\n\n[British Society of Gastroenterology - Practical Guide to Acute Pancreatitis](https://www.bsg.org.uk/clinical-resource/practical-guide-to-the-acute-pancreatitis)", "files": null, "highlights": [], "id": "1872", "pictures": [ { "__typename": "Picture", "caption": "Cullen's sign seen in acute pancreatitis.", "createdAt": 1665036198, "id": "1058", "index": 1, "name": "Acute pancreatitis - cullens.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/0ciuya7d1665036171698.jpg", "path256": "images/0ciuya7d1665036171698_256.jpg", "path512": "images/0ciuya7d1665036171698_512.jpg", "thumbhash": "YhgGJYbd0tlmi4hPuGdpji9Z8pIF", "topic": null, "topicId": null, "updatedAt": 1708373886 }, { "__typename": "Picture", "caption": "Grey-Turner's sign seen in acute pancreatitis.", "createdAt": 1665036198, "id": "1044", "index": 0, "name": "Acute pancreatitis - GTs.jpeg", "overlayPath": null, "overlayPath256": null, "overlayPath512": null, "path": "images/4yi4xcqb1665036171698.jpg", "path256": "images/4yi4xcqb1665036171698_256.jpg", "path512": "images/4yi4xcqb1665036171698_512.jpg", "thumbhash": "awgGFIJAlrZSdnhsiHhqc8A3CA==", "topic": null, "topicId": null, "updatedAt": 1708373886 } ], "typeId": 2 }, "chapterId": 1872, "demo": null, "entitlement": null, "id": "850", "name": "Acute pancreatitis", "status": null, "topic": { "__typename": "Topic", "id": "7", "name": "General Surgery", "typeId": 2 }, "topicId": 7, "totalCards": 33, "typeId": null, "userChapter": null, "userNote": null, "videos": [ { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "850", "name": "Acute pancreatitis" } ], "demo": false, "description": null, "duration": 4865.83, "endTime": null, "files": null, "id": "315", "live": false, "museId": "eNd6PcR", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/surgery.png", "title": "Quesmed Tutorial: General and Vascular Surgery SBAs ", "userViewed": false, "views": 343, "viewsToday": 17 }, { "__typename": "Video", "concepts": [ { "__typename": "Concept", "id": "850", "name": "Acute pancreatitis" } ], "demo": false, "description": null, "duration": 580.4, "endTime": null, "files": null, "id": "15", "live": false, "museId": "1BUtiGR", "osceStation": null, "startTime": null, "status": null, "thumbnail": "images/videos/surgery.png", "title": "Acute pancreatitis", "userViewed": false, "views": 138, "viewsToday": 13 } ] }, "conceptId": 850, "conditions": [ { "__typename": "Condition", "id": "18", "name": "Acute pancreatitis", "topic": { "__typename": "UkmlaTopic", "id": "11", "name": "Gastrointestinal including liver" }, "topicId": 11 }, { "__typename": "Condition", "id": "19", "name": "Acute pancreatitis", "topic": { "__typename": "UkmlaTopic", "id": "25", "name": "Surgery" }, "topicId": 25 } ], "difficulty": 1, "dislikes": 8, "explanation": null, "highlights": [], "id": "6561", "isLikedByMe": 0, "learningPoint": "A low calcium level in a patient with suspected pancreatitis is a sign of severe disease requiring closer monitoring and potential intensive care unit admission.", "likes": 15, "multiAnswer": null, "pictures": [], "prescribeAnswer": null, "presentations": [], "psaSectionId": null, "qaAnswer": null, "question": "A 63-year-old woman attends A&E due to abdominal pain. The pain was sudden onset and is localised to the epigastric region and radiates to the back. The patient has also vomited twice whilst in the department. The consultant suspects pancreatitis and orders some investigations.\n\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|109 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|12x10⁹/L|3.0 - 10.0|\n|Calcium|1.9 mmol/L|2.2 - 2.6|\n|Urea|11 mmol/L|2.5 - 7.8|\n|Albumin|33 g/L|35 - 50|\n\n\nWhich of these most indicates a poor prognosis?", "sbaAnswer": [ "a" ], "totalVotes": 7394, "typeId": 1, "userPoint": null }