id
int64 173M
173M
| flagged
bool 1
class | index
int64 1
98
| questionChoiceId
null | marksheetId
int64 6.49M
6.5M
| timeTaken
null | isAnswered
bool 1
class | striked
sequencelengths 0
0
| mark
null | questionId
int64 264
22.8k
| question
dict | __typename
stringclasses 1
value |
|---|---|---|---|---|---|---|---|---|---|---|---|
173,458,867 | false | 34 | null | 6,494,976 | null | false | [] | null | 10,128 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Atorvastatin does not commonly cause renal impairment.",
"id": "50370",
"label": "b",
"name": "Atorvastatin",
"picture": null,
"votes": 108
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Paracetamol does not commonly cause renal impairment. It can sometimes cause renal impairment if taken as an overdose, however in this scenario the patient has not taken an overdose.",
"id": "50373",
"label": "e",
"name": "Paracetamol",
"picture": null,
"votes": 11
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Salmeterol does not commonly cause renal impairment.",
"id": "50371",
"label": "c",
"name": "Salmeterol",
"picture": null,
"votes": 1
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Losartan is a cause of renal acute kidney injury. It alters the vascular tone of both the afferent and efferent arterioles. In turn, the blood flowing across the glomerulus is altered. This then reduces the glomerular filtration rate which causes a reduction in renal function.",
"id": "50369",
"label": "a",
"name": "Losartan",
"picture": null,
"votes": 2921
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Tiotropium does not commonly cause renal impairment.",
"id": "50372",
"label": "d",
"name": "Tiotropium",
"picture": null,
"votes": 58
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3657",
"name": "The use of losartan is linked to acute kidney injury",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
},
"topicId": 9,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3657,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10128",
"isLikedByMe": null,
"learningPoint": null,
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 6,
"qaAnswer": null,
"question": "Case Presentation: A 64-year-old gentleman is admitted to AMU with leg pain.\n\n\n\n\n **PH** Hypertension, COPD, Hypercholesterolaemia\n\n\n **DH** Atorvastatin 20mg PO daily, Losartan 100mg PO daily, Salmeterol 50micrograms INH BD, Tiotropium 5micrograms INH daily, Paracetamol 1g PO QDS\n\n\n **On examination**\n\n\nBP 142/82mmHg, HR 82, RR 12, Weight 80kg\n\n\n **Investigation**\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|138 mmol/L|135 - 145|\n|Potassium|4.3 mmol/L|3.5 - 5.3|\n|Urea|8.0 mmol/L|2.5 - 7.8|\n|Creatinine|182 µmol/L|60 - 120|\n|eGFR|48 mL/min/1.73m<sup>2</sup>|> 60|\n\n\nQuestion: Select the medication that is most likely to have contributed to the reduction in renal function.",
"sbaAnswer": [
"a"
],
"totalVotes": 3099,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,868 | false | 35 | null | 6,494,976 | null | false | [] | null | 10,136 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hepatic function monitoring isn't routinely used for corticosteroid treatment",
"id": "50412",
"label": "d",
"name": "Liver function tests",
"picture": null,
"votes": 67
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Cardiac monitoring is not routinely used for corticosteroid treatment",
"id": "50413",
"label": "e",
"name": "ECG",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Prolonged steroid treatment is linked with growth alterations. Paediatric patients are likely to weigh more and have a reduced height if they are taking steroids for a prolonged time. Any slowing in growth should prompt a referral to a paediatrician",
"id": "50409",
"label": "a",
"name": "Height and weight",
"picture": null,
"votes": 3788
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Fundoscopy isn't routinely used to monitor for adverse effects of corticosteroid treatment",
"id": "50410",
"label": "b",
"name": "Fundoscopy",
"picture": null,
"votes": 96
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A chest x-ray isn't routinely used to monitor for adverse effects of corticosteroid treatment",
"id": "50411",
"label": "c",
"name": "Chest X-ray",
"picture": null,
"votes": 18
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "bnf says need to regularly check for cataracts and glaucoma - so fundoscopy should be correct?",
"createdAt": 1706629740,
"dislikes": 0,
"id": "40276",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10136,
"replies": [
{
"__typename": "QuestionComment",
"comment": "fundoscopy looks at the back of the eye. I think you can see the beginnings of a cataract with the naked eye ",
"createdAt": 1706644116,
"dislikes": 2,
"id": "40312",
"isLikedByMe": 0,
"likes": 0,
"parentId": 40276,
"questionId": 10136,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Neoplasia Nightshift",
"id": 46473
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "aaaaa",
"id": 9972
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3665",
"name": "Monitoring height and weight is required in children taking corticosteroids",
"status": null,
"topic": {
"__typename": "Topic",
"id": "91",
"name": "Paediatrics",
"typeId": 5
},
"topicId": 91,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3665,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10136",
"isLikedByMe": null,
"learningPoint": null,
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 7,
"qaAnswer": null,
"question": "Case Presentation: A 9-year-old girl is seen in the outpatient paediatrics with swollen, stiff and painful knees. This has been going on for the last 10 weeks.\n\n\n\n\n **Investigations**\n\n\nBoth knees are red in appearance. Both are swollen. Limited range of motion due to pain and stiffness.\n\n\nANA: +ve\n\n\nRheumatoid factor: +ve\n\n\nCRP: 36 mg/L (< 5mg/L)\n\n\nIt is decided that she is likely suffering from juvenile idiopathic arthritis and requires treatment with ibuprofen, methotrexate and prednisolone.\n\n\nQuestion: If she takes the prednisolone for a prolonged period of time, what parameters should be monitored?",
"sbaAnswer": [
"a"
],
"totalVotes": 3971,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,869 | false | 36 | null | 6,494,976 | null | false | [] | null | 10,138 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The enzyme thiopurine methyltransferase is responsible for the metabolism of thiopurine drugs. If TPMT activity is reduced, there is an increased risk of myelosuppression (and subsequent severe infection) as there is improper clearance of azathioprine.",
"id": "50419",
"label": "a",
"name": "TPMT activity",
"picture": null,
"votes": 2680
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There are no common ophthalmic side effects associated with azathioprine use. Therefore monitoring is not required.",
"id": "50423",
"label": "e",
"name": "Fundoscopy",
"picture": null,
"votes": 3
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Azathioprine is not known to impair hepatic function. If hepatic function is impaired when taking azathioprine, a full blood count should be monitored more frequently.",
"id": "50420",
"label": "b",
"name": "Liver function tests",
"picture": null,
"votes": 31
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Azathioprine is not known to impair renal function. If renal function is impaired when taking azathioprine, a full blood count should be monitored more frequently.",
"id": "50421",
"label": "c",
"name": "Renal function",
"picture": null,
"votes": 16
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There are no common cardiovascular side effects associated with azathioprine use. Therefore monitoring is not required.",
"id": "50422",
"label": "d",
"name": "ECG",
"picture": null,
"votes": 3
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3667",
"name": "TPMT activity should be measured in patients before initiating azathioprine treatment",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
},
"topicId": 9,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3667,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10138",
"isLikedByMe": null,
"learningPoint": null,
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 7,
"qaAnswer": null,
"question": "Case Presentation: A 24-year-old gentleman is admitted to hospital following 2 weeks of abdominal pain, diarrhoea and blood in his stool. Weight 60kg.\n\n\n\n\n **Investigations**\n\n\nCRP: 65 mg/L (< 5mg/L)\n\n\nImaging: Sigmoidoscopy shows oedematous mucosa, erythema and bowel inflammation shown up to the level of the sigmoid colon.\n\n\nIt is decided that based on his history and investigations that he has a diagnosis of ulcerative colitis. This is treated acutely with IV hydrocortisone.\n\n\nTo maintain remission, azathioprine 120mg PO OD is prescribed.\n\n\nQuestion: Which investigation is necessary before this patient can start his azathioprine?",
"sbaAnswer": [
"a"
],
"totalVotes": 2733,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,870 | false | 37 | null | 6,494,976 | null | false | [] | null | 10,139 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin doesn't cause cardiac side effects therefore ECG monitoring isn't warranted.",
"id": "50426",
"label": "c",
"name": "ECG",
"picture": null,
"votes": 1
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "One of the most important side effects of metformin is lactic acidosis. Renal impairment increases the likelihood of this occurring due to improper clearance of metformin. It is therefore very important to monitor renal function prior to starting metformin therapy.",
"id": "50424",
"label": "a",
"name": "Renal function",
"picture": null,
"votes": 2667
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst metformin can cause a reduced absorption of vitamin B12, this is a very rare side effect and therefore isn't routinely monitored.",
"id": "50427",
"label": "d",
"name": "Full blood count",
"picture": null,
"votes": 5
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin doesn't cause side effects involving the thyroid therefore thyroid function test monitoring isn't warranted.",
"id": "50428",
"label": "e",
"name": "Thyroid function tests",
"picture": null,
"votes": 5
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst metformin can cause hepatic injury through hepatitis, this is a very rare side effect and therefore isn't routinely monitored for.",
"id": "50425",
"label": "b",
"name": "Liver function tests",
"picture": null,
"votes": 51
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3668",
"name": "Renal function should be monitored before starting metformin due to the increased risk of lactic acidosis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "131",
"name": "Obstetrics & Gynaecology/Paediatrics",
"typeId": 5
},
"topicId": 131,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3668,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10139",
"isLikedByMe": null,
"learningPoint": null,
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 7,
"qaAnswer": null,
"question": "Case Presentation: A 31-year-old woman attends the outpatient gynaecology department.\n\n\n**PMH** Polycystic ovary syndrome, Depression\n\n**DH** Sertraline 50mg PO OD\n\nShe wants to conceive and has already been treated with clomifene citrate. Unfortunately, this hasn't worked and her Gynaecologist has recommended metformin 500mg PO OD as the next step in her management.\n\nQuestion: Which investigation should this patient undergo prior to starting metformin?",
"sbaAnswer": [
"a"
],
"totalVotes": 2729,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,871 | false | 38 | null | 6,494,976 | null | false | [] | null | 10,135 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Prior to starting lithium renal, cardiac and thyroid function should be monitored. Renal function is monitored due to the risk of toxicity if there is improper clearance of lithium. Cardiac function is monitored due to the risk of cardiac disease such as QT interval prolongation.\nBody weight should also be measured prior to starting treatment and a full blood count should be taken.",
"id": "50404",
"label": "a",
"name": "ECG, renal function, thyroid function tests",
"picture": null,
"votes": 3589
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Prior to starting lithium renal, cardiac and thyroid function should be monitored. Body weight should also be measured prior to starting treatment and a full blood count should be taken. Whilst there have been reported LFT abnormalities in patients taking lithium, these are rare and do not require monitoring. A CT head is not a required part of monitoring either.",
"id": "50408",
"label": "e",
"name": "ECG, liver function, CT head",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Prior to starting lithium renal, cardiac and thyroid function should be monitored. Body weight should also be measured prior to starting treatment and a full blood count should be taken. Whilst there have been reported LFT abnormalities in patients taking lithium, these are rare and do not require monitoring.",
"id": "50406",
"label": "c",
"name": "ECG, liver function, renal function",
"picture": null,
"votes": 65
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Prior to starting lithium renal, cardiac and thyroid function should be monitored. Body weight should also be measured prior to starting treatment and a full blood count should be taken. A chest x-ray is not routinely be used for monitoring prior to starting lithium.",
"id": "50407",
"label": "d",
"name": "Chest X-ray, thyroid function test, renal function",
"picture": null,
"votes": 71
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Prior to starting lithium renal, cardiac and thyroid function should be monitored. Body weight should also be measured prior to starting treatment and a full blood count should be taken. A chest x-ray wouldn't routinely be used for monitoring prior to starting lithium.",
"id": "50405",
"label": "b",
"name": "Chest X-ray, ECG, renal function",
"picture": null,
"votes": 8
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3664",
"name": "Monitoring is required prior to starting lithium",
"status": null,
"topic": {
"__typename": "Topic",
"id": "90",
"name": "Psychiatry",
"typeId": 5
},
"topicId": 90,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3664,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10135",
"isLikedByMe": null,
"learningPoint": null,
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 7,
"qaAnswer": null,
"question": "Case presentation: A 28 year old woman is seen in the outpatient psychiatry clinic and is diagnosed with bipolar disorder. She is advised to commence treatment with lithium carbonate (Camcolit) 400mg PO OD.\n\n\nQuestion: Select the most appropriate monitoring that this patient should undergo prior to starting lithium carbonate.",
"sbaAnswer": [
"a"
],
"totalVotes": 3735,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,872 | false | 39 | null | 6,494,976 | null | false | [] | null | 10,134 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "An elevation in cardiac enzymes may suggest some ongoing myocardial ischaemia and can be useful in the general clinical setting on a background of acute chest pain, but is of limited usefulness with respect to starting this drug",
"id": "50403",
"label": "e",
"name": "Troponin",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Impaired hepatic function isn't listed as a known side effect of hydroxychloroquine. Therefore it doesn't need to be routinely monitored.",
"id": "50402",
"label": "d",
"name": "Liver function tests",
"picture": null,
"votes": 62
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Impaired renal function isn't listed as a known side effect of hydroxychloroquine. Therefore it doesn't need to be routinely monitored.",
"id": "50401",
"label": "c",
"name": "Renal function",
"picture": null,
"votes": 249
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hydroxychloroquine can cause a range of haematological disorders such as agranulocytosis, leucopenia and thrombocytopenia. The frequency of these side effects occurring however is unknown, therefore monitoring for them is not recommended.",
"id": "50400",
"label": "b",
"name": "Full blood count",
"picture": null,
"votes": 42
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Retinopathy is a common side effect of hydroxychloroquine. It is important to ensure that there are no pre-existing issues with the retina prior to starting hydroxychloroquine due to the increased risk of worsening these pre-existing issues. Annual monitoring of the retina is initiated following 5 years of treatment (it can be started earlier if there is an increased risk of retinopathy).",
"id": "50399",
"label": "a",
"name": "Fundus photograph and Optical Coherence Tomography (OCT)",
"picture": null,
"votes": 2742
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3663",
"name": "Taking hydroxychloroquine requires ophthalmological monitoring due to the increased risk of retinal toxicity",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
},
"topicId": 9,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3663,
"conditions": [],
"difficulty": 1,
"dislikes": 4,
"explanation": null,
"highlights": [],
"id": "10134",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 7,
"qaAnswer": null,
"question": "Case Presentation: A 34-year-old woman is referred to rheumatology due to ongoing joint pain and facial rashes. \n\n\n**PMH** Nil\n\n**DH** NKDA. Ibuprofen 200mg PO QDS\n\n**SH** smokes 10 cigarettes a day (5 pack year history)\n\n**Investigations**\n\nAnti-CCP antibodies: -ve\n\nANA: +ve\n\nAnti dsDNA antibodies: +ve\n\nRheumatoid factor: -ve\n\nBased on her symptoms and blood results, she is diagnosed with systemic lupus erythematosus and the decision is made to start hydroxychloroquine sulfate.\n\nQuestion: Select the most appropriate monitoring option required before initiating hydroxychloroquine sulfate.",
"sbaAnswer": [
"a"
],
"totalVotes": 3097,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,873 | false | 40 | null | 6,494,976 | null | false | [] | null | 10,137 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "No routine monitoring of factor V is required with apixaban use.",
"id": "50417",
"label": "d",
"name": "Factor V",
"picture": null,
"votes": 1
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "No routine monitoring is required with apixaban use. INR would be monitored in patients taking warfarin.",
"id": "50415",
"label": "b",
"name": "INR",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "No routine monitoring of prothrombin concentration is required with apixaban use.",
"id": "50418",
"label": "e",
"name": "Prothrombin",
"picture": null,
"votes": 8
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "No routine monitoring is required with apixaban use. This is because direct oral anticoagulants have a predictable pharmacokinetic and pharmacodynamic response when given at a set dose, unlike warfarin for example which has a higher degree of unpredictability.",
"id": "50414",
"label": "a",
"name": "No routine monitoring required",
"picture": null,
"votes": 3041
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "No routine monitoring is required with apixaban use. Factor Xa is the clotting protein that apixaban inhibits, it does not need to be monitored.",
"id": "50416",
"label": "c",
"name": "Factor Xa",
"picture": null,
"votes": 17
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3666",
"name": "Patients taking apixaban (DOACs) require no routine monitoring of their clotting factors",
"status": null,
"topic": {
"__typename": "Topic",
"id": "74",
"name": "Elderly Care",
"typeId": 5
},
"topicId": 74,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3666,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10137",
"isLikedByMe": null,
"learningPoint": null,
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 7,
"qaAnswer": null,
"question": "Case Presentation: A 64-year-old gentleman is discharged from hospital following a diagnosis of atrial fibrillation. \n\n\n**PMH** Hypertension, Type 2 diabetes mellitus, Atrial fibrillation\n\n**DH** Ramipril 10mg PO OD, Metformin 500mg PO BD, Atenolol 50mg PO OD, Apixaban 5mg PO BD\n\nBoth the atenolol and apixaban are new prescriptions.\n\nQuestion: What routine monitoring is required for his new apixaban prescription?",
"sbaAnswer": [
"a"
],
"totalVotes": 3069,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,874 | false | 41 | null | 6,494,976 | null | false | [] | null | 10,141 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Increasing the dose would exacerbate the risk of agranulocytosis, as clozapine is directly linked to this haematological side effect.",
"id": "50436",
"label": "c",
"name": "Increase clozapine dose to 125mg PO BD",
"picture": null,
"votes": 6
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Clozapine is associated with a risk of agranulocytosis, a severe reduction in neutrophils. This patient has neutropenia (neutrophils <1.5x10⁹/L) and agranulocytosis (neutrophils <0.5x10⁹/L), making the continuation of clozapine unsafe. Immediate discontinuation is necessary to prevent life-threatening infections and further haematological decline.",
"id": "50434",
"label": "a",
"name": "Stop clozapine immediately",
"picture": null,
"votes": 3598
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Reducing the dose does not prevent further neutropenia or adequately address the agranulocytosis risk. This approach delays appropriate action and increases the risk of complications.",
"id": "50435",
"label": "b",
"name": "Reduce clozapine dose to 75mg PO BD and repeat bloods in one week",
"picture": null,
"votes": 847
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Continuing clozapine in the presence of agranulocytosis is contraindicated. This approach puts the patient at significant risk of sepsis or other severe complications.",
"id": "50438",
"label": "e",
"name": "Continue treatment and repeat bloods in one week",
"picture": null,
"votes": 65
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Monitoring at such an extended interval is unsafe given the acute risk of infection associated with agranulocytosis. The priority is immediate cessation and haematology referral.",
"id": "50437",
"label": "d",
"name": "Reduce clozapine dose to 75mg PO BD and repeat bloods in one month",
"picture": null,
"votes": 72
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Where can you find this in the BNF?",
"createdAt": 1705076652,
"dislikes": 0,
"id": "38581",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10141,
"replies": [
{
"__typename": "QuestionComment",
"comment": "im wondering the same thing",
"createdAt": 1706018288,
"dislikes": 0,
"id": "39655",
"isLikedByMe": 0,
"likes": 1,
"parentId": 38581,
"questionId": 10141,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Just Another Med Student",
"id": 46240
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Yersinia Jaundice",
"id": 21156
}
},
{
"__typename": "QuestionComment",
"comment": "control f \"agranulocytosis\" in the clozapine monograph. under cautions",
"createdAt": 1706613809,
"dislikes": 0,
"id": "40239",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10141,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Neoplasia Nightshift",
"id": 46473
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3670",
"name": "Clozapine increases the risk of agranulocytosis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "90",
"name": "Psychiatry",
"typeId": 5
},
"topicId": 90,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3670,
"conditions": [],
"difficulty": 1,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "10141",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 8,
"qaAnswer": null,
"question": "Case Presentation: A 31-year-old female attends psychiatric outpatients for a review of her bloods.\n\n\n\n\n **PMH**\nSchizophrenia\n **DH**\nClozapine 100mg PO BD\n **Investigations**\n\n\n\n||||\n|--------------|:-------:|---------------|\n|White Cell Count|1.6x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|234x10<sup>9</sup>/L|150 - 400|\n|Neutrophils|0.6x10<sup>9</sup>/L|2.0 - 7.5|\n|Lymphocytes|1.2x10<sup>9</sup>/L|1.5 - 4.0|\n|Monocytes|0.5x10<sup>9</sup>/L|0.2 - 1.0|\n|Eosinophils|0.2x10<sup>9</sup>/L|0 - 0.4|\n|Basophils|0.08x10<sup>9</sup>/L|0 - 0.1|\n|Sodium|136 mmol/L|135 - 145|\n|Potassium|4.1 mmol/L|3.5 - 5.3|\n|Urea|3.3 mmol/L|2.5 - 7.8|\n|Creatinine|61 µmol/L|60 - 120|\n\n\n\nQuestion: Select the most appropriate decision option based on this data",
"sbaAnswer": [
"a"
],
"totalVotes": 4588,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,875 | false | 42 | null | 6,494,976 | null | false | [] | null | 10,140 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Venous thromboembolism is not a recognised side effect of amlodipine. Therefore, there is no need to stop this drug.",
"id": "50431",
"label": "c",
"name": "Stop amlodipine",
"picture": null,
"votes": 206
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has presented with a DVT. Patients who are taking tamoxifen are at an increased risk of developing blood clots. This is because the liver produced more clotting factors in response to processing more oestrogen. This patient should have her hormone replacement therapy switched over to a patch or gel.",
"id": "50429",
"label": "a",
"name": "Stop tamoxifen",
"picture": null,
"votes": 4233
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Venous thromboembolism is not a recognised side effect of paracetamol. Therefore there is no need to stop this drug.",
"id": "50432",
"label": "d",
"name": "Stop paracetamol",
"picture": null,
"votes": 7
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Venous thromboembolism is not a recognised side effect of ramipril. Therefore, there is no need to stop this drug.",
"id": "50430",
"label": "b",
"name": "Stop ramipril",
"picture": null,
"votes": 52
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Venous thromboembolism is not a recognised side effect of atorvastatin. Therefore, there is no need to stop this drug.",
"id": "50433",
"label": "e",
"name": "Stop atorvastatin",
"picture": null,
"votes": 84
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "why cant this be cellulitis - in which case the pt would be started on flucloxacillin - in BNF interactions paracetamol and flucloxacillin are listed as severe interactions",
"createdAt": 1737242902,
"dislikes": 0,
"id": "60948",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10140,
"replies": [
{
"__typename": "QuestionComment",
"comment": "The interaction listed in the BNF is high anion gap metabolic acidosis (anecdotal evidence quality), which is unlikely present as a DVT and more like DKA or aspirin OD",
"createdAt": 1737486221,
"dislikes": 0,
"id": "61184",
"isLikedByMe": 0,
"likes": 0,
"parentId": 60948,
"questionId": 10140,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "DJnR",
"id": 36829
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Schistosomiasis",
"id": 27336
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3669",
"name": "Tamoxifen increase the risk of venous thromboembolisms",
"status": null,
"topic": {
"__typename": "Topic",
"id": "131",
"name": "Obstetrics & Gynaecology/Paediatrics",
"typeId": 5
},
"topicId": 131,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3669,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10140",
"isLikedByMe": null,
"learningPoint": null,
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 8,
"qaAnswer": null,
"question": "Case Presentation: A 54-year-old woman attends her GP complaining of a sore leg.\n\n\n**PMH**\nHypertension, hypercholesterolaemia\n**DH**\nRamipril 10mg PO OD, amlodipine 10mg PO OD, atorvastatin 20mg PO OD, tamoxifen 20mg PO OD, paracetamol 1g PO QDS\n**Examination**\nThe right calf appears red, swollen and painful to touch. When compared to the other leg it is around 3cm bigger. Their observations are normal.\n\nQuestion: Select the most appropriate decision option based on this data.",
"sbaAnswer": [
"a"
],
"totalVotes": 4582,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,876 | false | 43 | null | 6,494,976 | null | false | [] | null | 10,144 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient's HbA1c level is being adequately controlled by his current antidiabetic medication. His HbA1c has dropped from 59 mmol/mol to 51 mmol/mol with 3 months of treatment. Stopping metformin now would be premature as his HbA1c is still above 48 mmol/mol.",
"id": "50451",
"label": "c",
"name": "Stop his metformin",
"picture": null,
"votes": 4
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "his patient's HbA1c level is being adequately controlled by his current antidiabetic medication. His HbA1c has dropped from 59 mmol/mol to 51 mmol/mol. There is no clinical indication to start gliclazide 40mg PO OD.",
"id": "50452",
"label": "d",
"name": "Add gliclazide 40mg PO OD",
"picture": null,
"votes": 336
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient's HbA1c level is being adequately controlled by his current antidiabetic medication. His HbA1c has dropped from 59 mmol/mol to 51 mmol/mol with 3 months of treatment. ",
"id": "50450",
"label": "b",
"name": "Increase his metformin dose to 1g PO BD",
"picture": null,
"votes": 1473
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient's HbA1c level is being adequately controlled by his current antidiabetic medication. His HbA1c has dropped from 59 mmol/mol to 51 mmol/mol with 3 months of treatment. He should continue on this medication for another 3 months, if his HbA1c drops below 48 mmol/mol then his metformin dose may be reduced.",
"id": "50449",
"label": "a",
"name": "Make no changes to his anti diabetic medications",
"picture": null,
"votes": 2128
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "his patient's HbA1c level is being adequately controlled by his current antidiabetic medication. His HbA1c has dropped from 59 mmol/mol to 51 mmol/mol. There is no clinical indication to start insulin treatment.",
"id": "50453",
"label": "e",
"name": "Start humulin I long acting insulin",
"picture": null,
"votes": 5
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Isn't the target 48 if on metformin only? Why can't we increase the metformin?",
"createdAt": 1675355966,
"dislikes": 0,
"id": "17626",
"isLikedByMe": 0,
"likes": 22,
"parentId": null,
"questionId": 10144,
"replies": [
{
"__typename": "QuestionComment",
"comment": "literally",
"createdAt": 1706711460,
"dislikes": 0,
"id": "40364",
"isLikedByMe": 0,
"likes": 1,
"parentId": 17626,
"questionId": 10144,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Lateral Kinase",
"id": 3545
}
},
{
"__typename": "QuestionComment",
"comment": "He is above target, so you should titrate the metformin dose",
"createdAt": 1735817785,
"dislikes": 0,
"id": "59432",
"isLikedByMe": 0,
"likes": 0,
"parentId": 17626,
"questionId": 10144,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Neutrophillia",
"id": 10669
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Migraine Serotonin",
"id": 21640
}
},
{
"__typename": "QuestionComment",
"comment": "48 = Add metformin\n53 = Target\n58 = Add another drug e.g. sulfonylurea",
"createdAt": 1706710423,
"dislikes": 7,
"id": "40362",
"isLikedByMe": 0,
"likes": 2,
"parentId": null,
"questionId": 10144,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Respect",
"id": 1205
}
},
{
"__typename": "QuestionComment",
"comment": "'Increased if necessary...2 g total daily dose may alternatively be given as 1 g twice daily with meals only if control not achieved with once daily dose regimen. If control still not achieved then change to standard release tablets.'\n\nI suppose control is technically being achieved. Perhaps the take away here, is that if the clinician is struggling to overcome increased HbA1c, he should titrate up; if it's working don't interfere.\n\nJust to be clear, I got it wrong too",
"createdAt": 1737152199,
"dislikes": 0,
"id": "60848",
"isLikedByMe": 0,
"likes": 3,
"parentId": null,
"questionId": 10144,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Retake Prophylaxis ",
"id": 48391
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3673",
"name": "When to change anti-diabetic medications based on HbA1c levels in patients with type 2 diabetes mellitus",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
},
"topicId": 9,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3673,
"conditions": [],
"difficulty": 1,
"dislikes": 9,
"explanation": null,
"highlights": [],
"id": "10144",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 2,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 8,
"qaAnswer": null,
"question": "Case Presentation: A 66-year-old gentleman attends the diabetes clinic for a review of his type 2 diabetes mellitus. \n\n\n**PMH** Type 2 diabetes mellitus, hypercholesterolaemia, hypertension, depression\n\n**DH** Metformin 500mg PO BD, simvastatin 20mg PO OD, lisinopril 10mg PO OD, mirtazapine 15mg PO BD\n\n**Investigations**\n\nHbA1c 3 months ago: 59 mmol/mol (< 42 mmol/mol)\n\nHbA1c today: 51 mmol/mol (< 42 mmol/mol)\n\nQuestion: Select the most appropriate decision option based on this data",
"sbaAnswer": [
"a"
],
"totalVotes": 3946,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,877 | false | 44 | null | 6,494,976 | null | false | [] | null | 10,145 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has Addison's disease. When patients with Addison's disease have a concurrent illness their hydrocortisone dose should be doubled whilst their fludrocortisone dose should remain unchanged.",
"id": "50456",
"label": "c",
"name": "Increase her hydrocortisone to 40mg PO BD and increase her fludrocortisone dose to 100 micrograms PO OD",
"picture": null,
"votes": 319
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has Addison's disease. When patients with Addison's disease have a concurrent illness their hydrocortisone dose should be doubled whilst their fludrocortisone dose should remain unchanged.",
"id": "50454",
"label": "a",
"name": "Increase her hydrocortisone to 40mg PO BD, don't change her fludrocortisone dose",
"picture": null,
"votes": 2336
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has Addison's disease and will be steroid dependent. Her corticosteroid and mineralocorticosteroid medications must not be stopped.",
"id": "50458",
"label": "e",
"name": "Stop both her hydrocortisone and fludrocortisone immediately",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has Addison's disease. When patients with Addison's disease have a concurrent illness their hydrocortisone dose should be doubled whilst their fludrocortisone dose should remain unchanged.",
"id": "50455",
"label": "b",
"name": "Increase her fludrocortisone dose to 100 micrograms PO OD, do not change her hydrocortisone dose",
"picture": null,
"votes": 52
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has Addison's disease. When patients with Addison's disease have a concurrent illness their hydrocortisone dose should be doubled whilst their fludrocortisone dose should remain unchanged.",
"id": "50457",
"label": "d",
"name": "Make no changes to her medications",
"picture": null,
"votes": 14
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3674",
"name": "Sick day rules in patients with Addison's disease",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
},
"topicId": 9,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3674,
"conditions": [],
"difficulty": 1,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "10145",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 1,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 8,
"qaAnswer": null,
"question": "Case Presentation: A 48-year-old woman is attends her GP due to an ongoing cough. She has had this cough for the last 2 days. It is productive of green sputum. She has also been experiencing feverish symptoms since her cough started.\n\n\n**PMH** Addison's disease\n\n**DH** Hydrocortisone 20mg PO BD, Fludrocortisone 50 micrograms PO OD\n\nQuestion: Select the most appropriate decision option based on this data",
"sbaAnswer": [
"a"
],
"totalVotes": 2723,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,878 | false | 45 | null | 6,494,976 | null | false | [] | null | 10,143 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient hasn't been taking her levothyroxine medication as intended. This can be inferred due to the blood results in the investigations section of this question. She therefore doesn't need her levothyroxine dose adjusting and instead requires counselling on the importance of taking her levothyroxine as prescribed.",
"id": "50447",
"label": "d",
"name": "Decrease this patients levothyroxine to 25 micrograms PO OD",
"picture": null,
"votes": 75
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient hasn't been taking her levothyroxine medication as intended. This can be inferred due to the blood results in the investigations section of this question. She therefore doesn't need her levothyroxine dose adjusting and instead requires counselling on the importance of taking her levothyroxine as prescribed.",
"id": "50448",
"label": "e",
"name": "Increase this patients levothyroxine to 125 micrograms PO OD",
"picture": null,
"votes": 41
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient hasn't been taking her levothyroxine medication as intended. This can be inferred due to the blood results in the investigations section of this question. She therefore doesn't need her levothyroxine dose adjusting and instead requires counselling on the importance of taking her levothyroxine as prescribed.",
"id": "50446",
"label": "c",
"name": "Decrease this patients levothyroxine to 50 micrograms PO OD",
"picture": null,
"votes": 2153
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient hasn't been taking her levothyroxine medication as intended. This can be inferred due to the blood results in the investigations section of this question. She therefore doesn't need her levothyroxine dose adjusting and instead requires counselling on the importance of taking her levothyroxine as prescribed.",
"id": "50445",
"label": "b",
"name": "Increase this patients levothyroxine to 100 micrograms PO OD",
"picture": null,
"votes": 631
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient hasn't been taking her levothyroxine medication as intended as indicated by the normal T3/T4 level and raised TSH. This can be inferred due to the blood results in the investigations section of this question. She therefore doesn't need her levothyroxine dose adjusting and instead requires counselling on the importance of taking her levothyroxine as prescribed.",
"id": "50444",
"label": "a",
"name": "Make no changes to her medication",
"picture": null,
"votes": 1451
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Should you not continue levothyroxine replacement until TSH also normalises? or does this take a longer period of time?",
"createdAt": 1737740539,
"dislikes": 0,
"id": "61451",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10143,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Edema Womb",
"id": 15284
}
},
{
"__typename": "QuestionComment",
"comment": "Could someone explain how we deduce that the patient isnt taking her levothyroxine? ",
"createdAt": 1738081431,
"dislikes": 0,
"id": "61782",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10143,
"replies": [
{
"__typename": "QuestionComment",
"comment": "It's that her T3 and T4 are normal with a raised TSH. TSH should also be within normal range if she were taking her levothyroxine as instructed",
"createdAt": 1738101194,
"dislikes": 0,
"id": "61816",
"isLikedByMe": 0,
"likes": 0,
"parentId": 61782,
"questionId": 10143,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Monoclonal Myopathy",
"id": 34341
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Simple squamous cell",
"id": 28581
}
},
{
"__typename": "QuestionComment",
"comment": "There's a section on subclinical hypothyroidism if you type in the hypothyroidism treatment summary -> management of primary hypothyroidism",
"createdAt": 1738164557,
"dislikes": 0,
"id": "61875",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10143,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "lil' aneurysm",
"id": 21164
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3672",
"name": "Thyroid function tests when a patient is not taking their medication properly",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
},
"topicId": 9,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3672,
"conditions": [],
"difficulty": 1,
"dislikes": 23,
"explanation": null,
"highlights": [],
"id": "10143",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 8,
"qaAnswer": null,
"question": "Case Presentation: A 33-year-old female attends her GP to review her blood tests.\n\n\n\n\n **PMH** Hypothyroidism\n\n\n **DH** Levothyroxine 75 micrograms PO OD\n\n\n **Investigations**\n\n\n||||\n|---------------------------|:-------:|------------------------------|\n|Thyroid Stimulating Hormone|9.8 mU/L|0.3 - 4.2|\n|Free T4|21 pmol/L|9 - 25|\n|Free T3|5 pmol/L|3.1 - 6.8|\n\n\n\n\nQuestion: Select the most appropriate decision option based on this data.",
"sbaAnswer": [
"a"
],
"totalVotes": 4351,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,879 | false | 46 | null | 6,494,976 | null | false | [] | null | 10,142 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is the first step in management of asthma in children over 5 years of age. Salbutamol monotherapy is no longer recommended. Indications for escalating treatment if symptoms remain uncontrolled include: using an inhaled short-acting beta2 agonist three times a week or more, having symptoms of asthma three times a week or more, or waking at night due to asthma symptoms at least once a week.",
"id": "50439",
"label": "a",
"name": "Prescribe salbutamol and a regular low dose inhaled corticosteroid ",
"picture": null,
"votes": 4045
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The first step of asthma management is a SABA (salbutamol) and an inhaled corticosteroid, rather than a preventer inhaler alone.",
"id": "50440",
"label": "b",
"name": "Prescribe regular low dose inhaled corticosteroid",
"picture": null,
"votes": 234
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be inappropriate as he is not suffering an acute exacerbation and should be managed with inhaled corticosteroids.",
"id": "50442",
"label": "d",
"name": "Prescribe oral prednisolone",
"picture": null,
"votes": 20
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Salbutamol monotherapy is no longer recommended at any stage of asthma treatment across all age groups.",
"id": "50441",
"label": "c",
"name": "Prescribe salbutamol inhaler",
"picture": null,
"votes": 66
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a combination inhaler which is first line management in patients >12 years old, and may be considered as part of a MART regimen if this patient's symptoms remain uncontrolled.",
"id": "50443",
"label": "e",
"name": "Prescribe formoterol/beclometasone combined inhaler",
"picture": null,
"votes": 212
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "are the new MART guidelines only for over 12yos?",
"createdAt": 1737649213,
"dislikes": 0,
"id": "61351",
"isLikedByMe": 0,
"likes": 6,
"parentId": null,
"questionId": 10142,
"replies": [
{
"__typename": "QuestionComment",
"comment": "arghhhh what is going on ",
"createdAt": 1738167859,
"dislikes": 0,
"id": "61886",
"isLikedByMe": 0,
"likes": 0,
"parentId": 61351,
"questionId": 10142,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Defibrillator Dominant",
"id": 16561
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Vaccine Complement",
"id": 17667
}
},
{
"__typename": "QuestionComment",
"comment": "Was surprised I chose a \"1%\" answer. \nIt seems as if the boy has not yet been prescribed an inhaler, as he is using his brothers. So of course prescribe salbutamol, however not sure why we giving ICS already.\nBNFc states- \"A paediatric low-dose of ICS should be started as maintenance therapy in children who present with any one of the following features: using an inhaled short-acting beta2 agonist three times a week or more, symptomatic three times a week or more, or waking at night due to asthma symptoms at least once a week.\"\nNone of these features were apparent in this tiny stem, so didn't think he needs it?\nIf evident in the BNF, could someone show it here?",
"createdAt": 1738171042,
"dislikes": 0,
"id": "61893",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10142,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "placementpals",
"id": 80366
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3671",
"name": "Asthma if not controlled, based on PEFR and symptoms, requires movement up the asthma treatment ladder",
"status": null,
"topic": {
"__typename": "Topic",
"id": "91",
"name": "Paediatrics",
"typeId": 5
},
"topicId": 91,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3671,
"conditions": [],
"difficulty": 1,
"dislikes": 6,
"explanation": null,
"highlights": [],
"id": "10142",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 8,
"qaAnswer": null,
"question": "Case Presentation: A 9-year-old boy attends an asthma clinic with his mother following a new diagnosis. She explains that he is still feeling short of breath despite using his brother's blue inhaler. \n\n\n**PMH**\nAsthma\n\n**DH**\nNone\n\nQuestion: Select the most appropriate decision option based on this data",
"sbaAnswer": [
"a"
],
"totalVotes": 4577,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,880 | false | 47 | null | 6,494,976 | null | false | [] | null | 10,146 | {
"__typename": "QuestionQA",
"choices": [],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3675",
"name": "Gentamicin dosing",
"status": null,
"topic": {
"__typename": "Topic",
"id": "13",
"name": "Neurosurgery",
"typeId": 5
},
"topicId": 13,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3675,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": "This question asks for the maximum dose possible therefore the answer would be (95 x 7) which is 665mg.",
"highlights": [],
"id": "10146",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 1,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 5,
"qaAnswer": [
{
"__typename": "QuestionQAAnswer",
"dose": "665",
"units": "mg"
}
],
"question": " \n\nCase Presentation: A 52-year-old patient has been admitted to the general surgical ward due to an episode of acute diverticulitis. They are prescribed antibiotics for this infection, one of which is a STAT dose of gentamicin. Gentamicin can be given IV 5-7mg/kg once daily at a maximum of 7mg/kg. He weighs 95kg.\n\nWhat is the maximum dose of gentamicin that this gentleman should receive in one day.",
"sbaAnswer": null,
"totalVotes": null,
"typeId": 2,
"userPoint": null
} | MarksheetMark |
173,458,881 | false | 48 | null | 6,494,976 | null | false | [] | null | 10,150 | {
"__typename": "QuestionQA",
"choices": [],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3679",
"name": "Total number of tablets needed when tapering the steroid dose needed after a diagnosis of giant cell arteritis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "92",
"name": "General Practice",
"typeId": 5
},
"topicId": 92,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3679,
"conditions": [],
"difficulty": 1,
"dislikes": 1,
"explanation": "WEEK 1: 40mg dose / 5 = 8\n\nTherefore 8 x 5mg tablets are needed per day for 7 days.\n\n8 x 7 = 56 tablets are needed in week 1.\n\nWEEK 2: 30mg dose / 5 = 6\n\nTherefore 6 x 5mg tablets are needed per day for 7 days.\n\n6 x 7 = 42 tablets are needed in week 2.\n\nWEEK 3: 20mg dose / 5 = 4\n\nTherefore 4 x 5mg tablets are needed per day for 7 days.\n\n4 x 7 = 28 tablets are needed in week 3.\n\nWEEK 4: 10mg dose / 5 = 2\n\nTherefore 2 x 5mg tablets are needed per day for 7 days.\n\n2 x 7 = 14 tablets are needed in week 2.\n\n56 + 42 + 28 + 14 = 140 tablets needed",
"highlights": [],
"id": "10150",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 2,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 5,
"qaAnswer": [
{
"__typename": "QuestionQAAnswer",
"dose": "140",
"units": "tablets"
}
],
"question": " \n\nCase Presentation:\n\nA 65-year-old gentleman is discharged from the hospital following a diagnosis of Giant Cell Arteritis (GCA).\n\nHe has been given the following information on how his condition is to be treated:\n\nPrednisolone PO 40mg/day for 7 days.\n\nPrednisolone PO 30mg/day for 7 days\n\nPrednisolone PO 20mg/day for 7 days.\n\nPrednisolone PO 10mg/day for 7 days.\n\nHe has been told to take 5mg prednisolone tablets to treat his condition.\n\nHow many prednisolone tablets does this patient require to complete his GCA treatment?",
"sbaAnswer": null,
"totalVotes": null,
"typeId": 2,
"userPoint": null
} | MarksheetMark |
173,458,882 | false | 49 | null | 6,494,976 | null | false | [] | null | 10,148 | {
"__typename": "QuestionQA",
"choices": [],
"comments": [
{
"__typename": "QuestionComment",
"comment": "where do we find the deficit equation in the BNF?",
"createdAt": 1675279147,
"dislikes": 0,
"id": "17560",
"isLikedByMe": 0,
"likes": 4,
"parentId": null,
"questionId": 10148,
"replies": [
{
"__typename": "QuestionComment",
"comment": "It's not in the bnf sadly",
"createdAt": 1675365868,
"dislikes": 0,
"id": "17639",
"isLikedByMe": 0,
"likes": 2,
"parentId": 17560,
"questionId": 10148,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Hereditary Hematoma",
"id": 25272
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Nightshift Relapse",
"id": 27931
}
},
{
"__typename": "QuestionComment",
"comment": "Should dehydration not be corrected over 48hrs?",
"createdAt": 1675352936,
"dislikes": 1,
"id": "17614",
"isLikedByMe": 0,
"likes": 21,
"parentId": null,
"questionId": 10148,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Serpiginous NICU",
"id": 12525
}
},
{
"__typename": "QuestionComment",
"comment": "Is this fluid deficit equation just for children?",
"createdAt": 1705303748,
"dislikes": 0,
"id": "38829",
"isLikedByMe": 0,
"likes": 2,
"parentId": null,
"questionId": 10148,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Relapse Complement",
"id": 19555
}
},
{
"__typename": "QuestionComment",
"comment": "This answer is wrong!! The equation is for 48 hours so you need to divide by 2 to get the amount for 24 hours? So the 900 should be divided by 2",
"createdAt": 1706115996,
"dislikes": 4,
"id": "39767",
"isLikedByMe": 0,
"likes": 8,
"parentId": null,
"questionId": 10148,
"replies": [
{
"__typename": "QuestionComment",
"comment": "For children with ≤5% dehydration, replace deficit in the first 24 hours",
"createdAt": 1710170860,
"dislikes": 1,
"id": "44457",
"isLikedByMe": 0,
"likes": 1,
"parentId": 39767,
"questionId": 10148,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Sarah",
"id": 52883
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Just Another Med Student",
"id": 46240
}
},
{
"__typename": "QuestionComment",
"comment": "Also would you not need to add resuscitation fluids as well as replacement and maintenance?",
"createdAt": 1706177989,
"dislikes": 1,
"id": "39808",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10148,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "RNA Yellow",
"id": 27771
}
},
{
"__typename": "QuestionComment",
"comment": "do you not need to minus the initial bolus from the fluid deficit as the patient isnt shocked?",
"createdAt": 1736907194,
"dislikes": 0,
"id": "60627",
"isLikedByMe": 0,
"likes": 2,
"parentId": null,
"questionId": 10148,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Hereditary Myopathy",
"id": 16676
}
},
{
"__typename": "QuestionComment",
"comment": "why this equation, why not weight (grams) x Dehydration (as decimal)...... 18000*0.05=900",
"createdAt": 1737057952,
"dislikes": 0,
"id": "60777",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10148,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Ortho bro",
"id": 31025
}
},
{
"__typename": "QuestionComment",
"comment": "how do you even estimate someone as being 5% dehydrated...?!?",
"createdAt": 1738006960,
"dislikes": 0,
"id": "61719",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10148,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Positive Whiff Test",
"id": 35787
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3677",
"name": "Fluid maintenance + replacement therapy",
"status": null,
"topic": {
"__typename": "Topic",
"id": "91",
"name": "Paediatrics",
"typeId": 5
},
"topicId": 91,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3677,
"conditions": [],
"difficulty": 1,
"dislikes": 6,
"explanation": "The first 10kg of weight replaces fluid at a rate of 100 ml/kg/day.\n\nThe second 10kg of weight replaces fluid at a rate of 50 ml/kg/day.\n\nThen any extra kg in weight above 20kg total weight is replaced at a rate of 20 ml/kg/day.\n\nThis patient weighs 18kg. Therefore he will need 1000ml for his first 10kg of weight and 400ml for his next 10kg of weight. Therefore this patient requires 1400ml of **maintenance** fluid therapy.\n\nHe is also 5% dehydrated. To calculate the amount of **replacement** fluid therapy you use the following equation:\n\nFluid deficit (mL) = % dehydration x weight (kg) x 10\n\nSo in this case the amount of fluid that needs to be replaced would be:\n\n5 x 18 x 10 = 900ml\n\n900 + 1400 = 2300ml total fluid needed over 24 hours.",
"highlights": [],
"id": "10148",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 2,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 5,
"qaAnswer": [
{
"__typename": "QuestionQAAnswer",
"dose": "2300",
"units": "ml"
}
],
"question": "Case Presentation:\n\nA 4-year-old boy is admitted to the paediatric ward with diarrhoea and vomiting. Weight 18kg.\n\n**On examination**\n\nBP 104/62mmHg, HR 110, RR 23, patient is alert.\n\nMucus membranes appear to be dry.\n\nCapillary refill time <2 seconds.\n\nThis patient is determined to be 5% dehydrated. It is therefore determined that they require fluid replacement therapy alongside their regular maintenance therapy.\n\nWhat **total** volume of 0.9% sodium chloride + 5% glucose should be prescribed for this patient's daily fluid intake?",
"sbaAnswer": null,
"totalVotes": null,
"typeId": 2,
"userPoint": null
} | MarksheetMark |
173,458,883 | false | 50 | null | 6,494,976 | null | false | [] | null | 10,147 | {
"__typename": "QuestionQA",
"choices": [],
"comments": [
{
"__typename": "QuestionComment",
"comment": "i thought you would also add 5% dehyrdration lol ",
"createdAt": 1706787394,
"dislikes": 0,
"id": "40445",
"isLikedByMe": 0,
"likes": 2,
"parentId": null,
"questionId": 10147,
"replies": [
{
"__typename": "QuestionComment",
"comment": "maintenance not replacement",
"createdAt": 1736944971,
"dislikes": 0,
"id": "60643",
"isLikedByMe": 0,
"likes": 2,
"parentId": 40445,
"questionId": 10147,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Ortho bro",
"id": 31025
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "RNA Retrograde",
"id": 2980
}
},
{
"__typename": "QuestionComment",
"comment": "sometimes I can't whether you want the absolute fluid volume or a real volume in terms of bags",
"createdAt": 1710087616,
"dislikes": 0,
"id": "44384",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10147,
"replies": [
{
"__typename": "QuestionComment",
"comment": "In the actual PSA they will make it clear as to what they're asking for, because you're right, I don't think will be prescribing 1580 mL, at the very least not for maintenance fluids",
"createdAt": 1737485699,
"dislikes": 0,
"id": "61182",
"isLikedByMe": 0,
"likes": 1,
"parentId": 44384,
"questionId": 10147,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "DJnR",
"id": 36829
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Suture Zygomatic",
"id": 25921
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3676",
"name": "Fluid maintenance therapy in children",
"status": null,
"topic": {
"__typename": "Topic",
"id": "91",
"name": "Paediatrics",
"typeId": 5
},
"topicId": 91,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3676,
"conditions": [],
"difficulty": 1,
"dislikes": 2,
"explanation": "The first 10kg of weight replaces fluid at a rate of 100 ml/kg/day.\n\nThe second 10kg of weight replaces fluid at a rate of 50 ml/kg/day.\n\nThen any extra kg in weight above 20kg total weight is replaced at a rate of 20 ml/kg/day.\n\nThis patient weighs 24kg. Therefore he will need 1000ml for his first 10kg of weight, 500ml for his next 10kg of weight and another 80ml for the last 4kg.",
"highlights": [],
"id": "10147",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 2,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 5,
"qaAnswer": [
{
"__typename": "QuestionQAAnswer",
"dose": "1580",
"units": "mL"
}
],
"question": " \n\nCase Presentation:\n\nA 6 year old boy is admitted to the paediatric ward with abdominal pain and nausea. Weight 24kg.\n\n**On examination**\nBP 102/64mmHg, HR 101, RR 22, patient is alert.\n\nMucus membranes appear moist.\n\nSkin turgor is normal.\n\nCapillary refill time is > 2 seconds.\n\nDue to the boy's nausea he is unable to tolerate oral fluids. It is decided that IV maintenance fluids should be prescribed to ensure adequate hydration is maintained.\n\nWhat **total** volume of 0.9% sodium chloride + 5% glucose should be prescribed for this patient's daily maintenance fluids?",
"sbaAnswer": null,
"totalVotes": null,
"typeId": 2,
"userPoint": null
} | MarksheetMark |
173,458,884 | false | 51 | null | 6,494,976 | null | false | [] | null | 10,149 | {
"__typename": "QuestionQA",
"choices": [],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3678",
"name": "Calculation of injection concentration",
"status": null,
"topic": {
"__typename": "Topic",
"id": "90",
"name": "Psychiatry",
"typeId": 5
},
"topicId": 90,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3678,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": "This faces a 25% reduction due to his renal impairment:\n\n(800/100) x 75 = 600mg per dose\n\nThis 600mg is given in a 5ml injection.\n\nSo the amount given in 1ml = 600/5 = 120mg per 1 ml",
"highlights": [],
"id": "10149",
"isLikedByMe": null,
"learningPoint": null,
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 5,
"qaAnswer": [
{
"__typename": "QuestionQAAnswer",
"dose": "120",
"units": "mg/ml"
}
],
"question": "Case Presentation:\n\nA 47-year-old patient with generalised tonic clonic seizures was initially prescribed sodium valproate at a maintenance dose of 800mg twice daily.\n\nDue to co-existing renal impairment, it has been decided that the dose should be reduced by 25% as per the manufacturer's advice. Each dose needs to be diluted in 5mL of 0.9% sodium chloride solution prior to injection.\n\nWhat is the dose of sodium valproate per ml given in each injection?",
"sbaAnswer": null,
"totalVotes": null,
"typeId": 2,
"userPoint": null
} | MarksheetMark |
173,458,885 | false | 52 | null | 6,494,976 | null | false | [] | null | 10,151 | {
"__typename": "QuestionQA",
"choices": [],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Why is subcut dose divided by 2?",
"createdAt": 1675178702,
"dislikes": 1,
"id": "17500",
"isLikedByMe": 0,
"likes": 5,
"parentId": null,
"questionId": 10151,
"replies": [
{
"__typename": "QuestionComment",
"comment": "Good qn\n",
"createdAt": 1678461401,
"dislikes": 0,
"id": "19770",
"isLikedByMe": 0,
"likes": 0,
"parentId": 17500,
"questionId": 10151,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Axillary Dominant",
"id": 13973
}
},
{
"__typename": "QuestionComment",
"comment": "Subcutaneous morphine is twice as strong as oral morphine (so you only need half as much of it)",
"createdAt": 1678706186,
"dislikes": 0,
"id": "19983",
"isLikedByMe": 0,
"likes": 1,
"parentId": 17500,
"questionId": 10151,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "DNA Haemophilus",
"id": 5504
}
},
{
"__typename": "QuestionComment",
"comment": "It's on the BNF under palliative care pain prescribing. There's a whole table to convert doses",
"createdAt": 1706302381,
"dislikes": 0,
"id": "39919",
"isLikedByMe": 0,
"likes": 2,
"parentId": 17500,
"questionId": 10151,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Acute DNA",
"id": 28385
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Yoghurt Pot",
"id": 19839
}
},
{
"__typename": "QuestionComment",
"comment": "This question is a bit pointless if you're not giving them the dose of the breakthrough morphine",
"createdAt": 1738074507,
"dislikes": 0,
"id": "61770",
"isLikedByMe": 0,
"likes": 2,
"parentId": null,
"questionId": 10151,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Troll9000",
"id": 35701
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3680",
"name": "Conversion of morphine from oral formulation to subcutaneous formulation",
"status": null,
"topic": {
"__typename": "Topic",
"id": "74",
"name": "Elderly Care",
"typeId": 5
},
"topicId": 74,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3680,
"conditions": [],
"difficulty": 1,
"dislikes": 5,
"explanation": "4 x 15 = 60mg needed as a baseline\n\n60/6 = 10mg x 2 = 20mg needed as a breakthrough dose\n\n60 + 20 = 80mg needed orally to manage pain.\n\n80/2 = 40mg needed subcutaneously to manage pain.",
"highlights": [],
"id": "10151",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 1,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": 5,
"qaAnswer": [
{
"__typename": "QuestionQAAnswer",
"dose": "40",
"units": "mg"
}
],
"question": " \n\nCase Presentation:\n\nA 86-year-old gentleman is currently on the care of the elderly ward. His regular medicines are listed below. Weight 60kg.\n\n**PH** Metastatic prostate cancer, Osteoarthritis, Hypertension, Hypercholesterolaemia\n\n**DH** Morphine 15mg PO QDS, ramipril 5mg PO OD, Atorvastatin 20mg PO OD\n\nIn addition to his regular morphine, this patient requires **TWO** breakthrough doses of morphine throughout the day. This manages his pain.\n\nHe has been having difficulty swallowing and the decision has been made to switch the formulation of his medication from oral to another formulation that doesn't require swallowing.\n\nWhat is the total dose of morphine required daily to manage this patient's pain if it is given subcutaneously?",
"sbaAnswer": null,
"totalVotes": null,
"typeId": 2,
"userPoint": null
} | MarksheetMark |
173,458,943 | false | 1 | null | 6,494,981 | null | false | [] | null | 10,631 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The occipital lobe is involved in visuospatial processing, colour perception and facial recognition. It is not involved in the gag reflex. Occipital lobe damage may present with the above features, alongside a visual field defect of contralateral homonymous hemianopia with macular sparing.",
"id": "52856",
"label": "e",
"name": "Occipital lobe",
"picture": null,
"votes": 70
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The midbrain may be damaged as a consequence of head injury; however, the nuclei of CN IX and X are found in the medulla, not the midbrain. The midbrain contains the nuclei of CN III and IV. These are not involved in the gag reflex.",
"id": "52854",
"label": "c",
"name": "Midbrain",
"picture": null,
"votes": 448
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Skull fractures sustained during head injury can be a risk factor for septic cavernous sinus thrombosis. However, in this scenario, there is no fracture (the CT head is normal) and no clinical features of a septic cavernous sinus thrombosis, including involvement of nerves III, IV, Va, Vb and VI, which run through the cavernous sinus.",
"id": "52855",
"label": "d",
"name": "Cavernous sinus",
"picture": null,
"votes": 103
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The pons may be damaged as a consequence of head injury; however, the nuclei of CN IX and X are found in the medulla, not the pons. The pons contains the nuclei of CN V, VI, VII and VIII. These are not involved in the gag reflex.",
"id": "52853",
"label": "b",
"name": "Pons",
"picture": null,
"votes": 698
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The gag reflex is an evolutionary reflex with the primary role being to prevent foreign body inhalation. This reflex is made up of the glossopharyngeal nerve (CN IX) as the afferent limb and the vagus nerve (CN X) as the efferent. These two nerves have their nuclei in the brainstem medulla, alongside CN XI and XII. Compression may be as a result of raised intracranial pressure secondary to injury, given that no focal abnormalities were noted on his head scan.",
"id": "52852",
"label": "a",
"name": "Medulla oblongata",
"picture": null,
"votes": 1843
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Stolen from another question:\n\nMidbrain CN 1,2,3,4\nPons CN 5,6,7,8\nMedulla CN 9,10,11,12",
"createdAt": 1683827717,
"dislikes": 0,
"id": "24142",
"isLikedByMe": 0,
"likes": 40,
"parentId": null,
"questionId": 10631,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Supine Body",
"id": 1961
}
},
{
"__typename": "QuestionComment",
"comment": "Was anyone else completely humbled by this mock",
"createdAt": 1718792638,
"dislikes": 0,
"id": "53259",
"isLikedByMe": 0,
"likes": 29,
"parentId": null,
"questionId": 10631,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Claire",
"id": 44985
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nRaised intracranial pressure (ICP) can result from various underlying causes and presents with a range of symptoms. Concerning features include **headaches**, particularly those worse in the morning or with bending over, **visual disturbances**, **nausea and vomiting**, and **focal neurological deficits**. Additional worrying signs related to the underlying cause include **weight loss** and **night sweats**. Prompt recognition and management are essential to prevent serious complications like **seizures**, **reduced Glasgow Coma Scale (GCS)**, and potentially fatal outcomes such as **brain herniation (coning)** and death.\n\n# Definition\n\nRaised ICP refers to increased pressure within the skull, which can lead to brain damage and death if left untreated. The **Monro-Kellie Doctrine** explains that the skull is a fixed volume, and any increase in the volume of brain tissue, blood, or cerebrospinal fluid (CSF) must be compensated for by a decrease in another component to maintain normal pressure. Failure to compensate leads to elevated ICP, increasing the risk of **coning** (herniation of brain tissue) and **brainstem death**.\n\n# Aetiology\n\nThe causes of raised ICP are varied and can be classified using the **VITAMIN C DEF** mnemonic:\n\n- **V**ascular: Stroke, intracranial hemorrhage (subdural, epidural, subarachnoid).\n- **I**nfective: Meningitis, encephalitis, brain abscess.\n- **T**rauma: Traumatic brain injury.\n- **A**utoimmune: Vasculitis.\n- **M**etabolic: Hepatic encephalopathy, hypercapnia.\n- **I**atrogenic: Post-surgical or procedural complications.\n- **N**eoplastic: Primary or metastatic brain tumors.\n- **C**ongenital: Hydrocephalus.\n- **D**egenerative: Normal pressure hydrocephalus (in elderly patients).\n- **E**ndocrine: Pituitary adenoma, hypothyroidism (myxedema coma).\n- **F**unctional: Idiopathic intracranial hypertension (IIH).\n\n# Symptoms and Signs\n\n## Symptoms\n\n- **Headaches**: Worse in the morning, with coughing, straining, or bending over.\n- **Nausea and vomiting**: Often early signs of raised ICP.\n- **Visual disturbances**: Blurred vision, diplopia, or papilledema (swelling of the optic disc).\n- **Seizures**: May occur as ICP rises.\n- **Focal neurological deficits**: Varies depending on the underlying cause (e.g., weakness, sensory changes).\n\n## Signs\n\n- **Cranial nerve involvement**: \n - **Abducens nerve (CN VI)** is most vulnerable due to its long course, leading to **lateral gaze palsy**.\n - **Third cranial nerve palsy** (uncal herniation): Ptosis, fixed dilated pupil, and eye deviation.\n- **Cushing’s triad**: A late sign of impending brain herniation, includes:\n - **Bradycardia**.\n - **Hypertension**.\n - **Irregular breathing**.\n\n# Investigations\n\n## Clinical assessment\n\n- **History and examination**: Look for signs of raised ICP and focal neurological deficits.\n- **Observations**: Watch for **Cushing’s triad** as a sign of impending coning.\n\n## Blood tests\n\n- Focus on identifying the underlying cause (e.g., infection, metabolic derangements).\n\n## Neuroimaging\n\n- **CT head (CTH)**: First-line imaging to assess for mass lesions, hemorrhage, or hydrocephalus.\n- **MRI**: May be used for further characterization of lesions or if clinical suspicion remains despite normal CT findings.\n\n# Management\n\n## Initial Assessment\nManagement begins with a standardized **ABCDE approach**:\n\n- **Airway, Breathing, Circulation**: Ensure airway patency and adequate oxygenation.\n- **Disability**: Assess using the **Glasgow Coma Scale (GCS)**.\n- **Exposure**: Check for signs of trauma, infection, or other causes of raised ICP.\n\n# Medical Management\n\n1. **Seizure management**: Detect and treat seizures with **anticonvulsants** as per the **status epilepticus protocol**.\n2. **Positioning**: Elevate the bed to **30-40 degrees** to facilitate venous drainage and reduce ICP.\n3. **Sedation and airway protection**: If **GCS < 8**, consult an **anesthetist** for airway management.\n4. **Hyperosmolar therapy**: \n - **Hypertonic saline** is preferred for reducing ICP through osmotic effects.\n - **Mannitol** may also be used, but carries risks such as **unpredictable pharmacokinetics** and potential **anaphylaxis**.\n5. **Control of underlying cause**: Treat infection (e.g., antibiotics for meningitis), control metabolic derangements, or manage systemic conditions contributing to raised ICP.\n\n# Surgical Management\n\n1. **Neurosurgical referral**: If the cause is a mass lesion, intracranial hemorrhage, or hydrocephalus, neurosurgical input is required.\n2. **Definitive interventions**: These may include:\n - **Decompressive craniectomy** to relieve pressure.\n - **Ventriculostomy** or **ventriculoperitoneal (VP) shunt** for drainage of CSF in cases of hydrocephalus.\n\n# Monitoring and Follow-Up\n\n- Continuous monitoring of **GCS** and **ICP** is critical.\n- Regular neuroimaging may be required to assess the progression of the underlying cause and response to treatment.\n\n",
"files": null,
"highlights": [],
"id": "1706",
"pictures": [],
"typeId": 2
},
"chapterId": 1706,
"demo": null,
"entitlement": null,
"id": "1889",
"name": "Raised intracranial pressure",
"status": null,
"topic": {
"__typename": "Topic",
"id": "34",
"name": "Neurology",
"typeId": 2
},
"topicId": 34,
"totalCards": 3,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 1889,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10631",
"isLikedByMe": 0,
"learningPoint": "Lesions in the medulla oblongata can impair the gag reflex, indicating potential brainstem injury or raised intracranial pressure.",
"likes": 4,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 32-year-old man is brought in by ambulance to A&E after a road traffic collision. On examination, he has a large wound at the back of his head. His Glasgow Coma Score is 3. A CT scan of the head shows no abnormalities. A rapid sequence induction of anaesthetic is performed to secure his airway. A week into his admission, extubation is attempted on the Intensive Care Unit but this is unsuccessful. A gag reflex is documented as being absent in his medical notes.\n\nWhere is the lesion causing his clinical presentation?",
"sbaAnswer": [
"a"
],
"totalVotes": 3162,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,944 | false | 2 | null | 6,494,981 | null | false | [] | null | 10,633 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "There should be suspicion of a previously unwitnessed fall due to the presence of bruising along the patient's arm and reported low staffing levels by the carer. Unwitnessed falls can lead to head injury. The elderly are at higher risk of subdural haematomas after head injury due to brain atrophy stretching the bridging veins within the subdural space. Therefore, this presentation likely represents a subdural haematoma. A CT head can be used to confirm the diagnosis; the patient will have a crescent-shaped mass.",
"id": "52862",
"label": "a",
"name": "Subdural haematoma",
"picture": null,
"votes": 2606
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Extradural haematomas typically present after a head injury with a blow to the temples resulting in rupture of the middle meningeal artery. There is typically an initial loss of consciousness, followed by a period of lucidity then rapid decline in conscious level. There are no clinical features to suggest an extradural haematoma. The CT head would show a convex-shaped mass.",
"id": "52864",
"label": "c",
"name": "Extradural haematoma",
"picture": null,
"votes": 249
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A subarachnoid haemorrhage would typically present with sudden-onset thunderclap headache and rapid clinical deterioration. Given the suspicion of a fall and the subacute presentation, a subdural haematoma is more likely in this age group due to brain atrophy and bridging vein tethering.",
"id": "52865",
"label": "d",
"name": "Subarachnoid haemorrhage",
"picture": null,
"votes": 86
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Urinary tract infections (UTIs) can cause acute confusional states (delirium). This patient is presenting acutely confused; therefore, it is a diagnosis worth considering. However, there are no clinical features of UTI in either the history (such as dysuria, frequency or urgency), or examination (such as fever or suprapubic pain). This makes a UTI unlikely.",
"id": "52863",
"label": "b",
"name": "Urinary tract infection",
"picture": null,
"votes": 140
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Normal pressure hydrocephalus is a possible differential for the falling and confused patient. These patients are typically described as 'wet, wobbly and weird', relating to urinary incontinence, ataxia and confusion respectively. However, there is an absence of these features in the clinical history and a subdural haematoma is a diagnosis to exclude first.",
"id": "52866",
"label": "e",
"name": "Normal pressure hydrocephalus",
"picture": null,
"votes": 254
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "\n### Summary\n\nA subdural haematoma (SDH) is a neurological condition characterized by the accumulation of venous blood between the dura mater and arachnoid mater, often following minor trauma in elderly patients. It can present with a reduced Glasgow Coma Scale (GCS), and is commonly seen in patients with fluctuating GCS. Diagnosis is typically established through a CT scan, with the appearance of the clot varying based on its age. Management strategies largely depend on the stage of the haematoma, with craniotomy indicated for acute haemorrhages, and burr holes recommended for chronic haemorrhages.\n\n### Definition\n\nA subdural haematoma is characterised by the accumulation of venous blood in the potential space between the dura mater and arachnoid mater of the brain.\n\n### Epidemiology\n\nSubdural haematomas typically occur in elderly individuals, particularly those over 65 years of age. It is often a consequence of minor trauma, leading to shearing forces that tear bridging veins between the cortex and dura mater. Risk factors include:\n\n- Advancing age (>65 years old)\n- Bleeding disorders or anticoagulant therapy\n- Chronic alcohol use\n- Trauma.\n\n### Aetiology\n\nThe haematoma results from shearing forces that tear the bridging veins between the cortex and dura mater. These forces commonly arise from minor head traumas but can also occur spontaneously in patients with bleeding disorders, anticoagulant therapy, or chronic alcohol use.\n\n### Signs and Symptoms\n\nClinical presentation of a subdural haematoma varies but may include:\n\n- Headache\n- Nausea or vomiting\n- Confusion\n- Fluctuating GCS\n- Behavioural change.\n\n\n### Differential Diagnosis\n\nDifferential diagnoses for subdural haematoma include:\n\n- Epidural haematoma: Characterized by a brief loss of consciousness, followed by a \"lucid interval\" and then rapid neurological deterioration.\n- Traumatic brain injury: Symptoms may include headache, confusion, lightheadedness, dizziness, blurred vision, or tired eyes.\n- Stroke: Presents with sudden numbness or weakness, especially on one side of the body, confusion, trouble speaking or understanding, trouble seeing in one or both eyes, and trouble walking, dizziness, or loss of balance or coordination.\n- Dementia: Gradual cognitive decline without fluctuating GCS.\n- Migraine: Recurrent headaches that might be accompanied by nausea, vomiting, and sensitivity to light and sound.\n\n### Investigations\n\nDiagnosis of a subdural haematoma is primarily established through a CT scan. \n\nThe appearance of the clot varies based on its age:\n\n- Hyperacute phase (<1 hour): The clot may appear isodense, with underlying cerebral oedema.\n- Acute phase (<3 days): The clot appears as a crescent-shaped hyperdense extra-axial collection over the affected hemisphere.\n- Sub-acute phase (3 days to 3 weeks): The clot appears more isodense compared to the adjacent cortex, making identification more difficult. Contrast-enhanced CT or MRI can aid identification. There may be associated mass effect causing midline shift and sulcal effacement.\n- Chronic phase (>3 weeks): The haematoma appears hypodense relative to the adjacent cortex.\n\n[lightgallery]\n\n[lightgallery1]\n\nFurther investigations may include:\n\n- Routine blood tests including FBC, Renal Profile, Liver Function Tests\n- Clotting profile (to assess for coagulopathy)\n\n### Management\n\nManagement of a subdural haematoma depends on the stage, patient’s premorbid baseline, and functional status. Many cases are managed conservatively, especially if there is no midline shift or cerebral oedema. However, for more severe cases, neurosurgical referral is required.\n\n- **Conservative management**: If no significant midline shift or cerebral oedema.\n\t- For patients taking the DOAC dabigatran, Idarucizumab is a licensed NICE-approval reversal agent which can be given.\n- **Surgical management**: In cases where intervention is necessary, options include:\n - **Craniotomy**: Typically for acute haemorrhages.\n - **Burr holes**: Typically for chronic haemorrhages.\n",
"files": null,
"highlights": [],
"id": "186",
"pictures": [
{
"__typename": "Picture",
"caption": "A subdural haemorrhage.",
"createdAt": 1665036196,
"id": "945",
"index": 0,
"name": "Subdural.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/2jkcw7l91665036171691.jpg",
"path256": "images/2jkcw7l91665036171691_256.jpg",
"path512": "images/2jkcw7l91665036171691_512.jpg",
"thumbhash": "1fcJBgA3LLloeBcKlYxmdLdYYfOMm/g=",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
},
{
"__typename": "Picture",
"caption": "Acute on chronic subdural haemorrhage",
"createdAt": 1548086881,
"id": "62",
"index": 1,
"name": "acuteChronicSubdural.png",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/210mu8h11548086881678.jpg",
"path256": "images/210mu8h11548086881678_256.jpg",
"path512": "images/210mu8h11548086881678_512.jpg",
"thumbhash": "GwgKBgAIN2iGeDgniIiIdYdIAAAAAAA=",
"topic": {
"__typename": "Topic",
"id": "19",
"name": "Radiology",
"typeId": 4
},
"topicId": 19,
"updatedAt": 1728982463
}
],
"typeId": 2
},
"chapterId": 186,
"demo": null,
"entitlement": null,
"id": "189",
"name": "Subdural Haemorrhage",
"status": null,
"topic": {
"__typename": "Topic",
"id": "34",
"name": "Neurology",
"typeId": 2
},
"topicId": 34,
"totalCards": 16,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "189",
"name": "Subdural Haemorrhage"
}
],
"demo": false,
"description": null,
"duration": 502.76,
"endTime": null,
"files": null,
"id": "165",
"live": false,
"museId": "ncKMYZA",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/neurology.png",
"title": "Haemorrhagic stroke",
"userViewed": false,
"views": 646,
"viewsToday": 43
}
]
},
"conceptId": 189,
"conditions": [],
"difficulty": 1,
"dislikes": 5,
"explanation": null,
"highlights": [],
"id": "10633",
"isLikedByMe": 0,
"learningPoint": "Elderly patients are at increased risk of subdural haematomas due to brain atrophy, often following unwitnessed falls and resulting head injuries.",
"likes": 8,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "An 83-year-old man with mild vascular dementia is brought to A&E by one of his carers. They report that he has not been himself for the past few weeks. He was previously independent with his activities of daily living but is now unable to feed or dress himself due to increasing confusion. This morning he was found to be very drowsy and withdrawn during breakfast. The carer admits that over the past few weeks they have been understaffed due to staff sickness. On examination, there is fading bruising along his left arm and shoulder. \n\nWhat is the most likely explanation for his presentation?",
"sbaAnswer": [
"a"
],
"totalVotes": 3335,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,945 | false | 3 | null | 6,494,981 | null | false | [] | null | 10,634 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has a cavernous sinus syndrome, probably due to a thrombus secondary to cavernous sinus infection. She is at higher risk of infection due to her poorly controlled diabetes and her recent paranasal sinus surgery. The cavernous sinus houses cranial nerves III, IV, VI, Va and Vb, and the internal carotid artery. The changes are ipsilateral to the side of the lesion. There is also an issue with venous drainage from the facial vein leading to chemosis, periorbital oedema, orbital pain and proptosis. Associated complications include seizures, septic emboli, Horner syndrome and intracranial hypertension.",
"id": "52867",
"label": "a",
"name": "Abducens nerve palsy",
"picture": null,
"votes": 880
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Sensation to the skin overlying the chin is provided by Vc (the mandibular branch of the trigeminal nerve). This does not run through the cavernous sinus.",
"id": "52871",
"label": "e",
"name": "Loss of sensation over the chin",
"picture": null,
"votes": 151
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Sensorineural deafness occurs due to disorders of the vestibulocochlear (VIII) nerve. This nerve does not run through the cavernous sinus.",
"id": "52870",
"label": "d",
"name": "Sensorineural deafness on the left",
"picture": null,
"votes": 292
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Relative afferent pupillary defects are present when there are issues with the afferent pathway of the pupillary reflex, that is, retinal or optic nerve pathology. Neither are involved in cavernous sinus syndrome.",
"id": "52869",
"label": "c",
"name": "Relative afferent pupillary defect",
"picture": null,
"votes": 1072
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The facial nerve does not run through the cavernous sinus; therefore, this option is incorrect.",
"id": "52868",
"label": "b",
"name": "Facial nerve palsy",
"picture": null,
"votes": 665
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "A very good question- tests anatomy and clinical knowledge x",
"createdAt": 1687122175,
"dislikes": 2,
"id": "29071",
"isLikedByMe": 0,
"likes": 4,
"parentId": null,
"questionId": 10634,
"replies": [
{
"__typename": "QuestionComment",
"comment": "allow being a sweat. \n",
"createdAt": 1709400792,
"dislikes": 2,
"id": "43490",
"isLikedByMe": 0,
"likes": 20,
"parentId": 29071,
"questionId": 10634,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Fever Hallux",
"id": 7282
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Retrograde Vitamin",
"id": 15717
}
},
{
"__typename": "QuestionComment",
"comment": "Not me thinking that this patient has hyperthyroidism...",
"createdAt": 1737295610,
"dislikes": 0,
"id": "60986",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10634,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Monoclonal Lumbar",
"id": 10449
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nCentral Venous Sinus Thrombosis (CVST) is a rare but serious condition involving the occlusion of cerebral venous sinuses. It primarily affects younger individuals, with women at higher risk, particularly those of childbearing age. Risk factors include hormonal influences, prothrombotic conditions, systemic diseases, and local factors like trauma or infection. Symptoms are variable but often include headaches, neurological deficits, and seizures. Diagnosis is typically confirmed with imaging, such as CT venogram. Management involves anticoagulation therapy, usually starting with low molecular weight heparin and possibly transitioning to Warfarin, along with addressing underlying causes.\n\n# Definition\n\nCentral Venous Sinus Thrombosis (CVST) refers to occlusion of venous vessels in sinuses of the cerebral veins\n\n# Epidemiology\n\nCVST has an incidence of approximately 3-4 cases per million people per year. Representing 0.5%-3% of all the types of stroke, affecting predominantly younger people. Women are affected more than men and mostly between the ages of 20 and 35. This is hypothesised to be due to pregnancy and the use of the COCP.\n\n# Risk factors\n\nRisk factors are similar to those for venous thromboembolism and include: \n\n- Hormonal factors (the pill, pregnancy, and the peri-partum period)\n- Prothrombotic haematological conditions or malignancy\n- Systemic disease (such as dehydration or sepsis)\n- Local factors (skull abnormalities, trauma, or local infection\n-\n\n# Presentation\n\n- Presentation is variable but common symptoms include headache, confusion/drowsiness, impaired vision, and nausea/vomiting.\n\n- Other signs include seizures, reduced consciousness, focal neurological deficits, cranial nerve palsies, and papilloedema.\n\n# Investigations\n\n- Non-contrast CT reveals a hyperdensity in the affected sinus.\n\n- CT venogram is used to look for a filling defect ('the empty delta sign').\n\nThe most common form of dural venous thrombosis affects the superior sagittal sinus.\n\nCavernous sinus thrombosis is less common. It is typically caused by spreading sinus infection and presents with chemosis, exophthalmos, and peri-orbital swelling.\n\n# Management\n\nThe mainstay of treatment is with low molecular weight heparin (LMWH) and addressing any underlying risk factors that may increase risk of clotting e.g. cancer, autoimmune disease.\n\nFollowing initial therapy with LMWH, this can be further bridged to a vitamin K antagonist such as Warfarin. \n\n# References\n\n[Click here for more info on intracranial venous thrombosis](https://patient.info/doctor/intracranial-venous-thrombosis)",
"files": null,
"highlights": [],
"id": "189",
"pictures": [],
"typeId": 2
},
"chapterId": 189,
"demo": null,
"entitlement": null,
"id": "191",
"name": "Central Venous Sinus Thrombosis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "34",
"name": "Neurology",
"typeId": 2
},
"topicId": 34,
"totalCards": 8,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "191",
"name": "Central Venous Sinus Thrombosis"
}
],
"demo": false,
"description": null,
"duration": 328.3,
"endTime": null,
"files": null,
"id": "200",
"live": false,
"museId": "E4a9A6x",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/neurology.png",
"title": "Intracranial Venous Thrombosis",
"userViewed": false,
"views": 84,
"viewsToday": 5
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "191",
"name": "Central Venous Sinus Thrombosis"
}
],
"demo": false,
"description": null,
"duration": 4529.73,
"endTime": null,
"files": null,
"id": "304",
"live": false,
"museId": "XBigS3j",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/neurology.png",
"title": "Quesmed Tutorial: Advanced Neurology",
"userViewed": false,
"views": 486,
"viewsToday": 29
}
]
},
"conceptId": 191,
"conditions": [],
"difficulty": 1,
"dislikes": 9,
"explanation": null,
"highlights": [],
"id": "10634",
"isLikedByMe": 0,
"learningPoint": "Cavernous sinus syndrome can present with cranial nerve palsies, particularly affecting the abducens nerve, leading to diplopia and ocular motility issues.",
"likes": 14,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 42-year-old woman presents with a 2-d history of reduced sensation to the left side of her face. She also has double vision and is struggling with pain in her left eye. She has a past medical history of poorly controlled type 2 diabetes and underwent paranasal sinus surgery 4 d ago. On examination, there is extensive left-sided periorbital oedema and proptosis. Her temperature is 38.4 °C.\n\nWhat additional finding might be present on physical examination?",
"sbaAnswer": [
"a"
],
"totalVotes": 3060,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,946 | false | 4 | null | 6,494,981 | null | false | [] | null | 10,635 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient likely has orbital cellulitis, as indicated by the presence of erythema and swelling surrounding the left eye, fever, diplopia (due to extraocular eye muscle involvement) and pain. The diplopia occurs due to complex ophthalmoplegia, which is when eye signs cannot be attributed to a single cranial nerve. The orbit is made up of seven bones, including the zygomatic, palatine and maxillary bones. Fractures of any of these bones are a risk factor for developing orbital cellulitis. This is a potentially sight-threatening emergency and can be further complicated by infective extension into the cavernous sinus. The best test is a CT orbit for this condition.",
"id": "52872",
"label": "a",
"name": "CT orbit",
"picture": null,
"votes": 1880
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a highly sensitive imaging modality for evaluating thromboses within the venous sinuses, not for identifying orbital cellulitis.",
"id": "52874",
"label": "c",
"name": "CT venogram",
"picture": null,
"votes": 65
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "An MRI is rarely done because a CT orbit is quicker to carry out and most often confirms the diagnosis. On T1, a low signal will be observed.",
"id": "52875",
"label": "d",
"name": "T1 MRI brain with orbits",
"picture": null,
"votes": 467
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a reasonable option and a CT of the head is often performed alongside a dedicated scan of the orbit. However, a dedicated scan of the orbit is still required, so this is not the best investigation.",
"id": "52873",
"label": "b",
"name": "CT head with contrast",
"picture": null,
"votes": 292
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "An MRI is rarely done because a CT orbit is quicker to carry out and most often confirms the diagnosis. On T2, a high signal will be observed.",
"id": "52876",
"label": "e",
"name": "T2 MRI brain with orbits",
"picture": null,
"votes": 553
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "What is a T1 vs T2 MRI?",
"createdAt": 1736095206,
"dislikes": 0,
"id": "59726",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10635,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Embolism Intubation",
"id": 14475
}
},
{
"__typename": "QuestionComment",
"comment": "ct a child?",
"createdAt": 1738437074,
"dislikes": 0,
"id": "62103",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10635,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "RNA Synthase",
"id": 21930
}
},
{
"__typename": "QuestionComment",
"comment": "seeing T1 and T2 scared me ",
"createdAt": 1738579243,
"dislikes": 0,
"id": "62203",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10635,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Pulseless Electrical Activity",
"id": 30718
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nOrbital cellulitis is a serious infection of the structures behind the orbital septum, presenting a sight- and life-threatening emergency. Key signs and symptoms include periocular pain and swelling, fever, malaise, erythematous, swollen and tender eyelid, chemosis, proptosis and restricted eye movements. The gold standard investigation for orbital cellulitis is a CT orbit. Management involves hospital admission for IV antibiotics and close monitoring. Preseptal cellulitis is a less severe infection of the tissue anterior to the orbital septum, which can progress to orbital cellulitis if not properly managed. \n\n# Definition\n\n**Orbital cellulitis** is a sight- and life-threatening emergency. It describes infection of the structures behind the orbital septum.\n\nThe orbital septum is a membranous sheet that forms the anterior border of the orbit, extending from the orbital rims (superior and inferior) and into the eyelids. \n\n**Preseptal cellulitis** refers to infection of tissue anterior to the orbital septum. It is much more common than orbital cellulitis and 80% of cases occur in children under the age of 10 years. It is less severe than orbital cellulitis, unless it spreads past the septum (which is not fully developed) and becomes orbital cellulitis.\n\n# Epidemiology\n\nOrbital cellulitis is less common than preseptal cellulitis, with the latter accounting for 80% of cases, mostly occurring in children under the age of 10.\n\n\n# Risk factors \n\n* Trauma\n* Surgical – ocular, adnexal or sinus\n* Sinus disease – ethmoidal sinusitis is the most common site of infection that spreads to the orbit\n* Other facial infections – preseptal, dental abscess or dacryocystitis\n\n# Signs and Symptoms\n\nOrbital cellulitis:\n\n* Periocular pain and swelling\n* Fever\n* Malaise\n* Erythematous, swollen and tender eyelid\n* Chemosis\n* Proptosis\n* Restricted eye movements +/– diplopia\n\nThe typical patient with **preseptal cellulitis** is a *child with an erythematous swollen eyelid, mild fever and erythema surrounding the orbit.*\n\n[lightgallery]\n\nImportant findings that suggest preseptal cellulitis, rather than orbital cellulitis, are:\n\n* No proptosis\n* Normal eye movements\n* No chemosis\n* Normal optic nerve function\n\n\n# Investigations\n\n- Blood tests: FBC, CRP to screen for raised inflammatory markers\n- Swabs sent for microscopy, culture and sensitivity\n- **CT orbit** is the gold standard investigation to distinguish orbital cellulitis from preseptal cellulitis\n\n# Management\n\n- Patients with orbital cellulitis require admission for IV antibiotics and close monitoring with input from the ophthalmology, ear, nose and throat and medical teams.\n- Preseptal cellulitis - Young or systemically unwell children should be admitted for IV antibiotics.\nOtherwise, treatment is with oral antibiotics and daily outpatient review.\n\n\n# References\n\nDenniston AK, Murray PI. Oxford Handbook of Ophthalmology. Fourth Edition. Oxford University Press. 2018.",
"files": null,
"highlights": [],
"id": "963",
"pictures": [
{
"__typename": "Picture",
"caption": "A typical appearance of orbital cellulitis.",
"createdAt": 1665036193,
"id": "789",
"index": 0,
"name": "Orbital cellulitis.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/if7sudg41665036171706.jpg",
"path256": "images/if7sudg41665036171706_256.jpg",
"path512": "images/if7sudg41665036171706_512.jpg",
"thumbhash": "JEgOC4QFWGiJd6d4WaCAUFk=",
"topic": {
"__typename": "Topic",
"id": "16",
"name": "Ophthalmology",
"typeId": 2
},
"topicId": 16,
"updatedAt": 1708373886
}
],
"typeId": 2
},
"chapterId": 963,
"demo": null,
"entitlement": null,
"id": "1018",
"name": "Orbital and preseptal cellulitis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "16",
"name": "Ophthalmology",
"typeId": 2
},
"topicId": 16,
"totalCards": 11,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 1018,
"conditions": [],
"difficulty": 1,
"dislikes": 2,
"explanation": null,
"highlights": [],
"id": "10635",
"isLikedByMe": 0,
"learningPoint": "A CT scan of the orbit is an essential imaging tool for evaluating orbital cellulitis, as it helps to identify the extent of infection, detect any associated complications such as orbital abscess or sinusitis, and distinguish it from other conditions that may affect the orbital structures.",
"likes": 9,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 14-year-old adolescent is brought to A&E after a week-long history of painful left eye movements and diplopia. One week ago, she was struck in the face with a hockey stick and sustained an undisplaced fracture of the zygomatic bone. She was sent home with analgesia and clinic follow-up with ophthalmology. On examination, you note swelling and erythema around the left eye. She has a complex ophthalmoplegia but the remainder of her cranial nerve examination is unremarkable. Her temperature is 38.7 °C.\n\nWhich of the following is the next best investigation?",
"sbaAnswer": [
"a"
],
"totalVotes": 3257,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,947 | false | 5 | null | 6,494,981 | null | false | [] | null | 10,636 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "In Huntington's disease, there are pathological expansions in CAG repeats, with paternal inheritance being associated with higher genetic instability and therefore expansion. CTG repeats are the underlying cause for myotonic dystrophy type I, which is also autosomal dominant and exhibits anticipation. The other notable group of diseases that have pathological CAG repeats are the spinocerebellar ataxias (SCAs).",
"id": "52879",
"label": "c",
"name": "CTG triplet repeat with anticipation through spermatogenesis",
"picture": null,
"votes": 986
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Huntington's disease is an autosomal dominant disorder with observed genetic anticipation through spermatogenesis. It is caused by expansion of the triplet repeat, CAG encoding glutamine, in the huntingtin gene (*HTT*) on chromosome 4. Around 37+ CAG repeats are needed to develop the disease. In the earliest stages, the symptoms and signs are nonspecific, including low mood, difficulties with concentrating, coordination problems and irritability. As the disease progresses, chorea (involuntary jerking or dancing movements) and dementia occur. Anticipation is the process whereby expansion of a pathological repeat sequence, in this case CAG repeats, are observed after each generation. In the case of Huntington's disease, this is more notable with paternal inheritance. The longer the repeat sequence, the earlier the onset of the disorder. In this case, there has likely been inheritance from the paternal side due to earlier onset of the disorder being illustrated in the son and father's past medical history.",
"id": "52877",
"label": "a",
"name": "CAG triplet repeat with anticipation through spermatogenesis",
"picture": null,
"votes": 1269
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "In Huntington's disease, there are pathological expansions in CAG repeats, with paternal inheritance being associated with higher genetic instability and anticipation. CCTG repeat is the pathological basis behind myotonic dystrophy type II.",
"id": "52881",
"label": "e",
"name": "CCTG repeat with anticipation through spermatogenesis",
"picture": null,
"votes": 91
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "In Huntington's disease, there are pathological expansions in CAG repeats, with paternal inheritance being associated with higher genetic instability and therefore expansion. CTG repeats are the underlying cause for myotonic dystrophy type I, which is also autosomal dominant and exhibits anticipation. The other notable group of diseases that have pathological CAG repeats are SCAs.",
"id": "52880",
"label": "d",
"name": "CTG repeat with anticipation through oogenesis",
"picture": null,
"votes": 221
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "CAG repeat expansions and anticipation are the cause of the early presentation of this patient's Huntington's disease. However, anticipation in Huntington's is observed through spermatogenesis and paternal transmission and not oogenesis/maternal transmission.",
"id": "52878",
"label": "b",
"name": "CAG triplet repeat with anticipation through oogenesis",
"picture": null,
"votes": 413
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "bruh",
"createdAt": 1683659125,
"dislikes": 0,
"id": "23893",
"isLikedByMe": 0,
"likes": 21,
"parentId": null,
"questionId": 10636,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Hematoma Hallux",
"id": 20554
}
},
{
"__typename": "QuestionComment",
"comment": "quesbiomed",
"createdAt": 1685112206,
"dislikes": 0,
"id": "26409",
"isLikedByMe": 0,
"likes": 7,
"parentId": null,
"questionId": 10636,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Seretonin Yeast ",
"id": 6750
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nHuntington's disease is an autosomal dominant neurodegenerative disorder characterized by choreoathetosis and dementia. Diagnosis is confirmed by genetic testing, and management involves a multidisciplinary approach to symptomatic relief and patient support. The disease progression is inevitable and usually leads to mortality due to complications from physical decline or suicide.\n\n# Definition\n\nHuntington's disease is a genetic disorder that causes progressive breakdown of nerve cells in the brain. It is characterised by motor, cognitive, and psychiatric abnormalities.\n\n# Epidemiology\n\nAs the most common hereditary neurodegenerative disorder, the prevalence of Huntington's disease is estimated to be between 1 in 10,000 and 1 in 20,000 individuals.\n\n# Aetiology\n\nHuntington’s disease is caused by an autosomal dominant mutation involving an excessive repetition of the CAG trinucleotide (>38 repeats) in the huntingtin gene, which encodes the huntingtin protein. \n\nThe number of CAG repeats is directly correlated with disease severity and age of onset, with **anticipation** observed in families—meaning that symptoms often present earlier in successive generations due to an increase in the number of repeats.\n\nThe pathogenesis is closely related to the gradual degeneration of specific brain regions, particularly the **caudate nucleus and putamen**, which are key components of the basal ganglia. This degeneration leads to the characteristic motor, cognitive, and psychiatric symptoms of the disease.\n\n# Signs and Symptoms\n\nHuntington's disease presents with a characteristic triad of symptoms:\n\n- Choreoathetosis: Unpredictable, flowing, and writhing movements\n- Cognitive impairment: Dementia, often marked by problems with judgment, memory, and other cognitive functions\n- Psychiatric abnormalities: Depression, irritability, apathy, and sometimes psychosis\n\n# Differential Diagnosis\n\nHuntington's disease should be differentiated from other disorders presenting with similar symptoms, such as:\n\n- **Parkinson's disease**: Characterized by bradykinesia, resting tremor, rigidity, and postural instability\n- **Wilson's disease**: Presents with liver disease, Kayser-Fleischer rings in the eye, and neurological symptoms such as dystonia, tremor, and dysarthria\n- **Huntington's disease-like disorders (HDL1, HDL2, HDL3, and HDL4)**: Present with a similar clinical picture but have different genetic backgrounds\n- **Neuroacanthocytosis syndromes**: Characterized by movement disorders and spiculated red blood cells (acanthocytes)\n\n# Investigations\n\nInvestigations in Huntington's disease include:\n\n- **Neuroimaging**: MRI and CT scans may show loss of striatal volume and an enlarged frontal horn of the lateral ventricles in moderate to severe disease stages\n- **Genetic testing**: Confirmatory, and also allows for predictive testing in at-risk family members with pre-test genetic counseling \n\n# Management\n\nAlthough no treatments can halt disease progression, management strategies aim at symptomatic relief and supporting the patient and their family:\n\n- **Chorea management**: Medications such as tetrabenazine are commonly used, with the most evidence base\n- **Depression management**: Selective serotonin reuptake inhibitors (SSRIs) are typically the first-line treatment\n- **Psychosis management**: Antipsychotics, preferably newer atypical agents, are used due to lower rates of extrapyramidal side effects\n- **Supportive care**: This includes a significant amount of physical and emotional support from a multidisciplinary team\n\n# Prognosis\n\nThe prognosis for Huntington's disease is poor, with an invariable decline in physical and cognitive abilities. Death usually occurs due to complications related to physical decline such as pneumonia, while suicide is the second most common cause of death.\n\n# References\n\n[Click here for more on Huntington's Disease](https://patient.info/doctor/huntingtons-disease-pro#nav-0)",
"files": null,
"highlights": [],
"id": "2039",
"pictures": [],
"typeId": 2
},
"chapterId": 2039,
"demo": null,
"entitlement": null,
"id": "229",
"name": "Huntington's disease",
"status": null,
"topic": {
"__typename": "Topic",
"id": "34",
"name": "Neurology",
"typeId": 2
},
"topicId": 34,
"totalCards": 2,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 229,
"conditions": [],
"difficulty": 1,
"dislikes": 26,
"explanation": null,
"highlights": [],
"id": "10636",
"isLikedByMe": 0,
"learningPoint": "Huntington's disease is an autosomal dominant disorder caused by CAG repeat expansion in the HTT gene, leading to progressive neurodegeneration.",
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 27-year-old man presents to the Neurology Clinic with a 1-year history of progressive difficulty with concentrating, issues with coordination and irritability. Six months ago, he was admitted after a suicide attempt. He does not know his biological parents because he was adopted at a young age but he has been told that one of his biological parents had previously tried to kill themselves and are currently being reviewed by the memory clinic aged 45.\n\nWhat is the genetic basis of his underlying diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 2980,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,948 | false | 6 | null | 6,494,981 | null | false | [] | null | 10,638 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is a likely case of delirium precipitated by recent orthopaedic surgery. Despite the previous injury to staff earlier in the day, it would be most appropriate for you to try and de-escalate the situation using verbal reassurance and orientation before you consider pharmacological management. This is since it recognised that some of the drugs to treat delirium, for example, benzodiazepines, can worsen it and nonpharmacological measures if used appropriately can be quite effective. Interventions, such as reducing noise by nursing in a side room if safe, using familiar nurses, orientating with a clock and calendar, using photographs and inviting in the family, can often have a positive effect on these patients in their transient delirium.",
"id": "52887",
"label": "a",
"name": "Verbal reassurance and orientation",
"picture": null,
"votes": 2387
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Haloperidol is a recognised treatment for delirium. However, nonpharmacological interventions should be trialled in the first instance in this case. On occasion, pharmacological interventions may be tried as first-line treatment if necessary and proportionate, that is, if the patient poses an immediate risk to themselves or others. There is no evidence in this case that the patient is currently posing an immediate risk to herself or anyone around her. Haloperidol is a butyrophenone antipsychotic and antagonises the dopamine (D2) receptor. Therefore, it is avoided in patients with Parkinson's disease or Lewy body dementia, due to the risk of precipitating rigidity. The QTc should be checked before providing haloperidol wherever possible due to the risk of causing prolongation. Haloperidol may also worsen delirium in some patients.",
"id": "52888",
"label": "b",
"name": "Haloperidol",
"picture": null,
"votes": 316
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Lorazepam is a benzodiazepine given intravenously or orally. It can be used in the treatment of delirium alongside other types of benzodiazepines. However, it should not be used before nonpharmacological interventions in this case. Side effects include drowsiness and worsening of delirium. It is a suitable alternative to haloperidol in patients with Parkinson's disease or Lewy body dementia.",
"id": "52889",
"label": "c",
"name": "Lorazepam",
"picture": null,
"votes": 152
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Olanzapine is an atypical antipsychotic that can be used for the management of delirium. However, in this case, it would be most appropriate to trial nonpharmacological treatments first. In the elderly, olanzapine has also been associated with increased episodes of venous thromboembolism and may also worsen delirium. Like haloperidol, it should not be used in patients with Parkinson's disease or Lewy body dementia, due to its antidopaminergic effects and subsequent risk of precipitating rigidity.",
"id": "52890",
"label": "d",
"name": "Olanzapine",
"picture": null,
"votes": 13
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Risperidone is an atypical antipsychotic that can be used for the management of delirium. However, in this case, it would be most appropriate to trial nonpharmacological interventions first. Like haloperidol, it should not be used in patients with Parkinson's disease or Lewy body dementia, due to its antidopaminergic effects and subsequent risk of precipitating rigidity. It can also cause worsening of delirium in some patients.",
"id": "52891",
"label": "e",
"name": "Risperidone",
"picture": null,
"votes": 27
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Do you still try verbal reassurance if the patient is manic?",
"createdAt": 1722031534,
"dislikes": 0,
"id": "54489",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10638,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Myotonia Malignant",
"id": 16192
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nDelirium tremens (DT) is a severe form of alcohol withdrawal that presents with acute confusion, hallucinations, autonomic hyperactivity, and, in rare cases, seizures. Typically occurring around 72 hours after the cessation of alcohol intake, DT necessitates immediate medical attention and management. The first-line treatment is lorazepam, administered either orally or parenterally, followed by maintenance management strategies.\n\n# Definition\n\nDelirium tremens is a life-threatening condition characterized by a rapid onset of confusion often precipitated by alcohol withdrawal. It generally develops around 72 hours after the cessation of alcohol intake and can persist for several days. This condition is marked by extreme autonomic hyperactivity and neuropsychiatric symptoms.\n\n# Aetiology\n\nThe primary cause of delirium tremens is abrupt withdrawal or a significant reduction in alcohol intake in a person with prolonged, heavy alcohol use. Other factors that can precipitate DT include infection, trauma, or illness in a person with a history of chronic alcoholism.\n\n# Signs and Symptoms\n\nSymptoms typically peak between the 4th and 5th day post-withdrawal. The clinical features of delirium tremens include:\n\n- Confusion and disorientation\n- Hallucinations, which can be visual or tactile (e.g., formication – the sensation of crawling insects on or under the skin)\n- Autonomic hyperactivity, manifesting as sweating and hypertension\n- Rarely, seizures\n\n\n# Differential Diagnosis\n\nDelirium tremens must be distinguished from other conditions that can present with similar symptoms:\n\n- **Alcohol withdrawal syndrome:** Features include anxiety, insomnia, anorexia, tremor, and autonomic hyperactivity, but without the severe confusion or hallucinations seen in DT.\n- **Wernicke-Korsakoff syndrome:** This condition is characterized by ataxia, ophthalmoplegia, and confusion but lacks the autonomic instability of DT.\n- **Encephalitis:** Features include fever, headache, altered mental status, and focal neurological signs which are not typically observed in DT.\n- **Meningitis:** This presents with fever, neck stiffness, and altered mental status but without the characteristic hallucinations seen in DT.\n\n\n\n# Investigations\n\nInvestigations largely aim to rule out other conditions. These include:\n\n- Routine Blood panel including B12, Folate, Thyroid Function\n- Infection screen: Chest Xray, Urine dip, Blood Cultures\n- CT Head to assess for evidence of a structural brain lesion e.g. subdural haemorrhage in patients presenting with an unwitnessed fall while intoxicated\n- Lumbar Puncture if meningitis or encephalitis are suspected\n\n\n# Management\n\nNICE guidelines suggest offering oral lorazepam as the first-line treatment. \n\nIf symptoms persist, or oral medication is declined, offer parenteral lorazepam or haloperidol.\n\nFor maintenance management of alcohol withdrawal, the following steps are recommended:\n\n- Administer Chlordiazepoxide. Eventually this can be tapered according to **Clinical Institute Withdrawal Assessment for Alcohol (CIWA)** scoring\n- Ensure adequate hydration with fluids\n- Provide anti-emetics to manage nausea\n- Pabrinex to replenish vitamins\n- Refer the patient to local drug and alcohol liaison teams for further support and management\n\nWhen patients present with seizures, sometimes they remain in hospital for inpatient detoxification. This is however rare and the evidence shows that community detoxification is more effective.\n\n# NICE Guidelines\n\n[NICE CKS - Alcohol-use disorders](https://www.nice.org.uk/guidance/cg100/chapter/Recommendations)",
"files": null,
"highlights": [],
"id": "905",
"pictures": [],
"typeId": 2
},
"chapterId": 905,
"demo": null,
"entitlement": null,
"id": "2680",
"name": "Delirium tremens",
"status": null,
"topic": {
"__typename": "Topic",
"id": "34",
"name": "Neurology",
"typeId": 2
},
"topicId": 34,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2680,
"conditions": [],
"difficulty": 1,
"dislikes": 2,
"explanation": null,
"highlights": [],
"id": "10638",
"isLikedByMe": 0,
"learningPoint": "Delirium in elderly patients post-surgery can often be managed effectively with verbal reassurance and orientation before considering pharmacological interventions.",
"likes": 2,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "An 82-year-old woman is agitated after a total knee replacement 1d ago. The nurse in the bay has asked for help from the on call team as the patient is trying to leave her bed unattended and is shouting out non-specifically. The nurse reports that the patient settles if asked to remain in bed. The patient is often sleeping during the day but awake and eating throughout the night. She pushed over one of the physiotherapists earlier in the morning but there have been no further instances of aggression. The patient has no significant past medical or social history.\n\nWhat is the first step in the management of this patient?",
"sbaAnswer": [
"a"
],
"totalVotes": 2895,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,949 | false | 7 | null | 6,494,981 | null | false | [] | null | 10,639 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The radial nerve supplies the BEST muscles: brachioradialis, extensors of the forearm, supinator and triceps. It also supplies sensation to the dorsal arm and forearm, and the dorsal aspect of the radial 3 1/2 fingers. Finger abduction/adduction will not be affected since the interossei are innervated by the ulnar nerve. The radial nerve can be damaged at multiple points, including the wrist (eg. tight handcuffs), which causes finger drop (loss of finger extension), proximal forearm or in the spiral groove (eg. a fracture of the humerus or prolonged tourniquet), which presents with wrist drop, or at the level of the brachial plexus (crutches or a honeymoon/Saturday night palsy), which causes loss of triceps as well wrist drop.",
"id": "52894",
"label": "c",
"name": "Radial nerve palsy",
"picture": null,
"votes": 433
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The axillary nerve supplies the deltoid and teres minor muscles. This manifests with inability to abduct the arm. It also supplies sensation to the regimental badge area. Finger abduction is conducted by the interossei muscles, which are innervated by the ulnar nerve. The axillary nerve does not supply any intrinsic hand muscles.",
"id": "52895",
"label": "d",
"name": "Axillary nerve palsy",
"picture": null,
"votes": 42
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The musculocutaneous nerve supplies the coracobrachialis (which flexes and adducts the shoulder), biceps brachii (which flexes and supinates the forearm) and brachialis muscles (flexes the forearm). Injury to this nerve manifests with inability to flex and adduct the shoulder and flex the elbow. Finger abduction is conducted by the interossei muscles, which are innervated by the ulnar nerve. The musculocutaneous nerve does not supply any intrinsic hand muscles.",
"id": "52896",
"label": "e",
"name": "Musculocutaneous nerve",
"picture": null,
"votes": 104
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "In the hand, the ulnar nerve provides motor innervation to the interossei muscles, which are responsible for finger abduction and adduction. It also supplies the third and fourth lumbricals, the adductor pollicis and sensation over the hypothenar eminence and ulnar 1 and 1/2 fingers. The ulnar nerve runs medially around the elbow, through the cubital tunnel and along the medial aspect of the forearm. The most likely area of impingement is around the elbow, where there is notable swelling on examination. Damage can either occur due to bony impingement in the context of a fracture or oedema compressing the ulnar nerve through its course in the cubital tunnel.",
"id": "52892",
"label": "a",
"name": "Ulnar nerve",
"picture": null,
"votes": 1955
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "In the hand, the median nerve supplies the muscles of the thenar eminence (opponens pollicis, abductor pollicis brevis and flexor pollicis brevis), as well as the radial 2 lumbricals. Its motor supply can be remembered using the helpful mnemonic LOAF. It also supplies sensation to the thenar eminence and the radial 3 1/2 fingers on their palmar aspect. Finger abduction/adduction will not be affected since the interossei are innervated by the ulnar nerve. The most common site of compression of the median nerve is at the carpal tunnel.",
"id": "52893",
"label": "b",
"name": "Median nerve palsy",
"picture": null,
"votes": 560
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Finger abduction- ulnar\nPincer grip strength between thumb and index finger- median\nWrist extension strength against resistance- radial",
"createdAt": 1685283338,
"dislikes": 0,
"id": "26820",
"isLikedByMe": 0,
"likes": 10,
"parentId": null,
"questionId": 10639,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Monoclonal Metabolism",
"id": 25350
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nThe ulnar nerve, deriving from nerve roots C8-T1, is integral to motor and sensory functions in the arm. Motor functions include innervating most of the intrinsic hand muscles and two muscles in the forearm, while sensory functions encompass innervation to the skin of the medial 1.5 digits and associated palm area. Noteworthy anatomical landmarks include its passage in the cubital tunnel at the elbow and Guyon's canal in the wrist, and its bifurcation into deep and superficial branches.\n\n# Definition\n\nThe ulnar nerve is a peripheral nerve that arises from the medial cord of the brachial plexus, with its roots in the C8-T1 nerve roots. It serves both motor and sensory functions in the forearm and hand.\n\n# Epidemiology\n\nUlnar nerve injuries, often a result of elbow trauma or continuous pressure on the elbow, are relatively frequent. Individuals at high risk include those participating in physical activities, sports, or with specific medical conditions predisposing them to nerve compression or trauma.\n\n# Aetiology\n\nThe ulnar nerve can be injured through various mechanisms, including:\n\n- Direct trauma or injury to the nerve\n- Compression or entrapment (e.g., in conditions such as cubital tunnel syndrome or Guyon's canal syndrome)\n- Iatrogenic causes during surgical procedures\n- Systemic diseases that affect the peripheral nerves (e.g., diabetes mellitus)\n\n# Anatomical Course\n\n \n\nThe ulnar nerve comes off the medial cord of the brachial plexus, and passes through the axilla with the axillary artery on its lateral side and the axillary vein on its medial side. In the arm, the ulnar nerve travels alongside the brachial artery until half-way down, where it passes through the medial septal fascia to enter the posterior compartment of the arm. The ulnar nerve then passes posterior to the elbow through a small space between the medial epicondyle and olecranon called the ulnar tunnel.\n\n \n\nIn the forearm, the ulnar nerve pierces between the two heads of flexor carpi ulnaris, and travels deep to the muscle alongside the ulna. Three branches come off the ulnar nerve in the forearm:\n\n \n\n- Muscular branch = innervates muscles of the anterior compartment\n\n \n\n- Palmar cutaneous branch = innervates the medial half of the palm\n\n- Dorsal cutaneous branch = innervates the dorsal surface of the medial 1 1/2 digits and associated dorsal hand area\n\n \n\nThe ulnar nerve passes through the wrist superficial to the flexor retinaculum and medial to the ulnar artery, and enters the hand through the ulnar (or Guyon's) canal. It terminates into two branches:\n\n \n\n- Superficial = innervates the palmar surface of the medial 1 1/2 digits\n\n- Deep = intrinsic muscles of the hand (hypothenar muscles, medial two lumbricals, adductor pollicis, palmar and dorsal interossei, palmaris brevis)\n\n \n\n**\"LOAF\"**.\n\n \n\n*All the muscles in the hand are supplied by the ulnar nerve except LOAF which are supplied by the median nerve*\n\n \n\nL - lateral two lumbricals\n\n \n\nO - opponens pollicis\n\n \n\nA - abductor pollicis brevis\n\n \n\nF - flexor pollicis brevis\n\n \n\nThe majority of the intrinsic muscles of the hand are supplied by the deep branch of the ulnar nerve, except palmaris brevis which is supplied by the superficial branch of the ulnar nerve.\n\n**Summary table**\n\n \n\n| Nerve roots | C8-T1 |\n| --------------------- | ------------------------------------------------------------ |\n| **Motor functions** | Innervates flexor carpi ulnaris and the medial half of flexor digitorum profundus. Innervates the intrinsic muscles of the hand (except for the LOAF muscles*) |\n| **Sensory functions** | Innervates the medial 1 1/2 digits and the associated palm area |\n\n# Signs and Symptoms\n\nSigns and symptoms of ulnar nerve injury may include:\n\n- Weakness or paralysis of the muscles innervated by the ulnar nerve (e.g., most of the intrinsic hand muscles and two muscles in the forearm)\n- Numbness, tingling, or pain in the sensory distribution of the ulnar nerve (skin of the medial 1.5 digits and associated palm area)\n\n# Differential Diagnosis\n\nOther conditions that could present with similar symptoms include:\n\n- Brachial Plexopathy: Similar motor and sensory loss, but usually involves other nerves of the brachial plexus.\n- Carpal Tunnel Syndrome: Primarily causes sensory changes in the palmar aspect of the hand and motor weakness in the median nerve distribution.\n- Radial Neuropathy: Presents with sensory and motor deficits in the radial nerve distribution, including the dorsal surface of the lateral 3 1/2 digits.\n- Cervical Radiculopathy: Symptoms may overlap with ulnar nerve injury, but there may also be neck pain, and symptoms may be exacerbated by neck movements.\n\n# Investigations\n\nInvestigations for a suspected ulnar nerve injury may include:\n\n- Neurological examination: to assess sensory and motor deficits\n- Electromyography (EMG) and Nerve Conduction Studies (NCS): to evaluate nerve function\n- MRI or CT scan: to identify any anatomical causes of nerve injury such as a fracture or mass lesion\n\n# Management\n\nThe management of ulnar nerve injuries depends on the underlying cause:\n\n- Conservative measures: including rest, physical therapy, and use of splints to prevent muscle contractures in cases of mild nerve injury\n- Pharmacological interventions: such as analgesics for pain management\n- Surgical interventions: in cases of severe nerve injury or where the cause is a correctable lesion such as a tumor or fracture",
"files": null,
"highlights": [],
"id": "986",
"pictures": [],
"typeId": 2
},
"chapterId": 986,
"demo": null,
"entitlement": null,
"id": "1047",
"name": "Ulnar nerve injuries",
"status": null,
"topic": {
"__typename": "Topic",
"id": "37",
"name": "Orthopaedics",
"typeId": 2
},
"topicId": 37,
"totalCards": 2,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 1047,
"conditions": [],
"difficulty": 2,
"dislikes": 2,
"explanation": null,
"highlights": [],
"id": "10639",
"isLikedByMe": 0,
"learningPoint": "The ulnar nerve innervates the interossei muscles, crucial for finger abduction and adduction, and can be injured by supracondylar fractures.",
"likes": 4,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 43-year-old right-handed man presents to A&E after an accident at work. He was carrying a large glass window when he tripped and fell onto his left side. You note extensive bruising and swelling around his left elbow. An X-ray demonstrates a supracondylar fracture of the elbow. You assess his range of movement and find he is unable to abduct his fingers.\n\nWhich nerve has been damaged?",
"sbaAnswer": [
"a"
],
"totalVotes": 3094,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,950 | false | 8 | null | 6,494,981 | null | false | [] | null | 10,640 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is presenting with acute dystonia in the form of torticollis (cervical dystonia) and an oculogyric crisis. Ondansteron is an antiemetic particularly used in the case of nausea and vomiting caused by chemotherapy. It is a serotonin 5 HT3 receptor antagonist. It does not have any effect on the D2 receptors; therefore, acute dystonias are not a recognised side effect.",
"id": "52901",
"label": "e",
"name": "Ondansetron",
"picture": null,
"votes": 161
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient is presenting with acute dystonia in the form of torticollis (cervical dystonia) and an oculogyric crisis. Metoclopramide is primarily a D2 receptor antagonist and acts on the receptors in the chemoreceptor trigger zone in the central nervous system. It is also a prokinetic agent via its muscarinic activity. Due to antagonism at the D2 receptor, it may also cause blockade in the extrapyramidal circuits, leading to side effects including acute dystonia (such as oculogyric crises and cervical dystonias), and, with chronic use, tardive dyskinesias. The risk of acute dystonic reactions is increased with higher doses and younger patients.",
"id": "52897",
"label": "a",
"name": "Metoclopramide",
"picture": null,
"votes": 1941
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is presenting with acute dystonia, in the form of torticollis (cervical dystonia) and an oculogyric crisis. Cyclizine is a histamine H1 receptor antagonist. Side effects may include urinary retention but extrapyramidal side effects are not reported.",
"id": "52898",
"label": "b",
"name": "Cyclizine",
"picture": null,
"votes": 240
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is presenting with acute dystonia in the form of torticollis (cervical dystonia) and an oculogyric crisis. Chlopromazine is an antipsychotic that antagonises the D2 receptor and would not ordinarily be used to treat nausea and vomiting. Less commonly, it causes acute dystonias but it is known to cause tardive dyskinesia and akathisia, which are more likely at higher doses.",
"id": "52899",
"label": "c",
"name": "Chlopromazine",
"picture": null,
"votes": 322
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is presenting with acute dystonia in the form of torticollis (cervical dystonia) and an oculogyric crisis. Promethazine is a first-generation antihistamine, antagonising the H1 receptor, and is generally used for its sedative effects, as opposed to its antiemetic effects. It has some antidopaminergic effects, which may lead to tardive dyskinesia, dystonias and akathisia but these are uncommon.",
"id": "52900",
"label": "d",
"name": "Promethazine",
"picture": null,
"votes": 217
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "does this hurt the fish",
"createdAt": 1683748663,
"dislikes": 1,
"id": "24016",
"isLikedByMe": 0,
"likes": 3,
"parentId": null,
"questionId": 10640,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Recessive Hallux",
"id": 15586
}
},
{
"__typename": "QuestionComment",
"comment": "This is an unfair question, chlopromazine is one of the anti-nausea medications recommended for treating N&V in pregnancy. It is also a typical antipsychotic- hence may also lead to acute dystonias in the same way as metoclopromide ",
"createdAt": 1686921440,
"dislikes": 0,
"id": "28886",
"isLikedByMe": 0,
"likes": 8,
"parentId": null,
"questionId": 10640,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Relapse Otitis",
"id": 18947
}
},
{
"__typename": "QuestionComment",
"comment": "Metoclopramide is a second line anti-emetic in N&V in pregnancy. Chlorpromazine is first line and can also cause extra-pyramidal side effects.... ",
"createdAt": 1737720133,
"dislikes": 0,
"id": "61417",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10640,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "JAH ",
"id": 33543
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Definition\n\nDystonias refer to a spectrum of movement disorders, characterised by involuntary muscle contractions leading to abnormal, often repetitive, movements and postures. These contractions can be prolonged and are often painful.\n\n# Epidemiology\n\nDystonias are considered the third most common movement disorder, following tremor and Parkinson's disease. It can occur at any age, but the timing and type of dystonia may vary based on whether it's primary or secondary.\n\n# Aetiology\n\n* **Primary dystonias** are idiopathic in nature, often genetic, and can be generalised or focal. A known example is the autosomal dominant generalised dystonia, also known as Flatau-Sterling syndrome. This usually starts in childhood and commences in the lower limbs before spreading to the rest of the body. Focal dystonia is limited to one part of the body, such as musician's cramp or spasmodic torticollis (cervical dystonias).\n* **Secondary dystonias** are usually attributable to specific causes or conditions, often related to drug use or neurological diseases. Common culprits include anti-dopaminergic drugs such as antipsychotics or anti-emetics (typically metoclopramide).\n\n# Signs and symptoms\n\nCommon signs and symptoms of dystonia include:\n\n* Prolonged muscle contractions\n* Abnormal postures\n* Repetitive movements\n* Cramping or pain in the affected muscles\n* Specific examples include: \n * Oculogyric crisis - upward deviation of the eyes\n \t\t* Commonly associated with starting a neuroleptic agent \n * Torticollis or cervical dystonia - abnormal, often painful, neck positioning\n * Trismus or lockjaw - difficulty opening the mouth due to muscle spasm\n\n# Differential diagnosis\n\nDystonias should be differentiated from other movement disorders and conditions that present with similar symptoms. Major differentials include:\n\n* **Parkinson's disease**: Characterized by bradykinesia, rigidity, rest tremor, and postural instability.\n* **Essential tremor**: Mainly causes action tremors, typically affecting the hands, head, or voice.\n* **Tardive dyskinesia**: Typically caused by long-term use of neuroleptic drugs, it manifests as involuntary, repetitive body movements such as grimacing, sticking out the tongue, or smacking the lips.\n* **Myoclonus**: Characterized by sudden, brief, involuntary muscle jerks.\n\n# Investigations\n\nInvestigation of dystonia often includes:\n\n* Detailed medical history\n* Neurological examination\n* Neuroimaging (e.g., MRI Head +- Spine)to assess for any structural cause\n* Genetic testing, especially in suspected primary dystonias\n* Evaluation of response to pharmacologic interventions\n\n\nplease can you re-group Mx section into primary and secondary dystonias. It’s a mid muddled here. Mainstay in secondary dystonia is stopping the offending drug e.g. neuroleptic/metoclopramide and managing the acute, painful dystonic reaction (with anticholinergics).\n\n# Management\n\nManagement of dystonia depends on whether it is primary (genetic or idiopathic) or secondary (due to an external factor such as medication or another condition):\n\n### Primary Dystonias\nFor primary dystonias (those that are genetic or idiopathic), the following treatments are often used:\n\n* **Botulinum toxin injections**: Particularly effective for focal dystonias.\n* **Oral medications**: These can include anticholinergics, benzodiazepines, and dopamine agonists to help manage symptoms.\n* **Physical therapy**: Helps to manage muscle function and reduce disability.\n* **Deep brain stimulation (DBS)**: Used for refractory cases that do not respond to other treatments.\n* **Genetic counseling**: Recommended for patients and their families to understand hereditary aspects.\n\n### Secondary Dystonias\nIn secondary dystonias (those caused by an identifiable external factor, such as medication):\n\n* **Withdrawal of offending agents**: Stopping the neuroleptic or metoclopramide that triggered the dystonia is essential.\n* **Management of acute dystonic reactions**: This often involves the use of anticholinergic medications to relieve painful muscle spasms.\n* **Further pharmacological therapies**: Botulinum toxin injections and oral medications (e.g., anticholinergics, benzodiazepines) may still be useful in ongoing management.\n* **Physical therapy**: Can aid in recovery and functional improvement.\n\n# References\n\nJankovic J. Treatment of dystonia. Lancet Neurology. 2006;5(10):864-872. doi:10.1016/S1474-4422(06)70572-1\n\nAlbanese A, Bhatia K, Bressman SB, et al. Phenomenology and classification of dystonia: a consensus update. Movement Disorders. 2013;28(7):863-873. doi:10.1002/mds.25475\n\nCloud LJ, Jinnah HA. Treatment strategies for dystonia. Neurotherapeutics. 2011;8(4):722-730. doi:10.1007/s13311-011-0074-7\n\n",
"files": null,
"highlights": [],
"id": "177",
"pictures": [],
"typeId": 2
},
"chapterId": 177,
"demo": null,
"entitlement": null,
"id": "181",
"name": "Dystonia",
"status": null,
"topic": {
"__typename": "Topic",
"id": "34",
"name": "Neurology",
"typeId": 2
},
"topicId": 34,
"totalCards": 2,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 181,
"conditions": [],
"difficulty": 1,
"dislikes": 5,
"explanation": null,
"highlights": [],
"id": "10640",
"isLikedByMe": 0,
"learningPoint": "Metoclopramide can cause acute dystonia, including torticollis and oculogyric crises, particularly in younger patients and with higher doses.",
"likes": 8,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 33-year-old pregnant woman presents with persistent nausea and vomiting in the first trimester. She reports that she cannot keep any food down, and this has been the case for 5 d. She has managed small sips of water. On examination, she is tachycardic at 110 bpm, blood pressure 115/70 mmHg, respiratory rate 18 and is afebrile. A diagnosis of hyperemesis gravidarum is made by the admitting team and she is prescribed antiemetics and fluids. Two hours later the patient's head has rotated to one side and her eyes are periodically deviating upwards.\n\nWhat is the most likely antiemetic to have caused this side effect?",
"sbaAnswer": [
"a"
],
"totalVotes": 2881,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,951 | false | 9 | null | 6,494,981 | null | false | [] | null | 10,641 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has been recently started on lithium, which is associated with AVP-resistance (nephrogenic diabetes insipidus). In AVP-R, the collecting ducts are insensitive to the effects of antidiuretic hormone (ADH) and aquaporins cannot be mounted. This results in an inability to concentrate urine and excessive free water loss. Patients typically present with polydipsia and polyuria and are at risk of dehydration if they do not maintain a good volume of oral fluid intake. The serum sodium may be raised or at the upper limit of normal due to dehydration. The best investigation for AVP deficiency or resistance in the first instance is paired urine and sodium osmolalities. Serum osmolality should be greater than 300 mOsm/kg and urine osmolality less than 750 mOsm/kg in this condition.",
"id": "52902",
"label": "a",
"name": "Urine and serum osmolality",
"picture": null,
"votes": 1575
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The recreational drug Ecstasy (3,4-methylenedioxy-methamphetamine) directly triggers ADH release, producing a syndrome of inappropriate antidiuretic hormone secretion. The drug also stimulates thirst, which can worsen the hyponatraemia by drinking. There is no suggestion of recreational drug use in the clinical history and the symptoms indicate the more likely diagnosis of AVP resistance (nephrogenic diabetes insipidus) secondary to lithium therapy. Sodium is also raised in this case.",
"id": "52905",
"label": "d",
"name": "Urine toxicology screen",
"picture": null,
"votes": 121
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is presenting with polyuria and polydipsia, after recent commencement on lithium therapy for bipolar disorder. A diagnosis of AVP resistance (nephrogenic diabetes insipidus should be suspected). Diabetes insipidus is split into AVP deficiency (cranial DI) and AVP resistance. AVP deficiency is a deficiency of ADH, which is released from the posterior pituitary gland, whereas in AVP resistance, ADH is present but there is a failure of response in the renal collecting ducts. An MRI head would be indicated to evaluate for a central cause. In this case, given the initiation of lithium therapy and the absence of any neurological history or signs, AVP resistance is more likely. In any case, the diagnosis is still best initially made using paired serum and urine osmolalities.",
"id": "52903",
"label": "b",
"name": "MRI head with contrast",
"picture": null,
"votes": 12
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has presented with polyuria and polydipsia in the context of recent initiation of lithium therapy. The patient should be investigated for AVP resistance (nephrogenic diabetes insipidus), with the first investigation being paired serum and urine osmolalities. There would be a lack of response to desmopressin administration after water deprivation, due to resistance to desmopressin in the renal collecting ducts. In AVP deficiency (central diabetes insipidus), there is a deficiency of ADH; therefore, there should be a marked response to desmopressin administration, with over a 50% increase in urine osmolality. The desmopressin challenge may be useful further down the line during a water deprivation test line but not in the first instance.",
"id": "52906",
"label": "e",
"name": "Desmopressin challenge",
"picture": null,
"votes": 234
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has presented with polyuria and polydipsia in the context of recent initiation of lithium therapy. The patient should be investigated for AVP resistance (nephrogenic diabetes insipidus) and in the first instance a paired serum and urine osmolality should be used. Water deprivation is a confirmatory test done further down the line since it is more time-consuming. During the water deprivation test, patients with AVP deficiency or resistance will develop an increasing osmolality of their serum as they become dehydrated. However, the urine remains dilute since they are unable to concentrate their urine in response to dehydration. A desmopressin challenge can be provided to distinguish between deficiency or resistance during this test. A response to desmopressin (ie. concentration of urine) would indicate a central cause. In AVP resistance there is little to no response to a desmopressin challenge.",
"id": "52904",
"label": "c",
"name": "Water deprivation test",
"picture": null,
"votes": 1494
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nArginine vasopressin disorder, formerly known as Diabetes Insipidus, is a condition characterised by the reduced production or response to arginine vasopressin (AVP), also called antidiuretic hormone (ADH), resulting in excessive urination and thirst. The aetiology of DI varies with deficiency of AVP (AVP-D, more common) and AVP resistance (AVP-R) causes, such as head trauma, drug reactions, and genetic factors. Key clinical features include the production of large volumes of dilute urine, nocturia, and excessive thirst. Diagnostic investigations include urea and electrolyte tests, blood glucose tests, and measurement of paired serum and urine osmolality. Management depends on the underlying cause, and can include desmopressin, correction of metabolic abnormalities, and, in the case of AVP-R, potentially the use of a thiazide diuretic and a non-steroidal anti-inflammatory drug.\n\n# Definition\n\nArginine vasopressin disorder (formally diabetes insipidus) is an endocrine condition characterised by either an inadequate production (AVP-D) or an insufficient renal response (AVP-R) to arginine vasopressin (AVP), also called antidiuretic hormone (ADH).\n\n# Epidemiology\n\nIt is a rare condition, with AVP-D more common than AVP-R. The prevalence is approximately 1 in 25,000 individuals.\n\n# Aetiology\n\n**Causes of AVP Deficiency (Cranial DI)**\n\n- Head trauma\n- Inflammatory conditions (e.g., sarcoidosis)\n- Cranial infections such as meningitis\n- Vascular conditions such as sickle cell disease\n- Rare genetic causes\n\n**Causes of AVP Resistance (Nephrogenic DI)**\n\n\n- Drugs (e.g., lithium)\n- Metabolic disturbances (e.g., hypercalcaemia, hypokalaemia, hyperglycaemia)\n- Chronic renal disease\n- Rare genetic causes (e.g., Wolfram's syndrome)\n\n# Signs and Symptoms\n\n- Large volumes of dilute urine (>3 litres in 24 hours and a urine osmolality of <300 mOsm/kg)\n- Nocturia\n- Excessive thirst\n\nIn children, additional symptoms may include:\n\n- Failure to thrive\n- Enuresis\n\n# Differential Diagnosis\n\n- Diabetes mellitus: Polyuria, polydipsia, and weight loss\n- Primary polydipsia (compulsive water drinking): Large urine output, thirst\n- Chronic kidney disease: Fatigue, anemia, pruritus, electrolyte imbalances\n\n# Investigations\n\n- Urea and electrolytes (sodium may be raised)\n- Blood glucose (to rule out diabetes mellitus)\n- Urine dip\n- Paired serum and urine osmolality measurements\n\nArginine vasopressin disorder is present when the serum osmolality is raised (>295 mOsm/kg) with inappropriately dilute urine (urine osmolality < 300 mOsm/kg).\n\nIf the diagnosis remains uncertain, a **water deprivation test** can be performed:\n\n* This should only be done if there is evidence of hypovolaemia or hypernatraemia\n* The patient is deprived of fluids while monitored for urine osmolality and body weight changes\n* In AVP-D, urine osmolality increases with ADH administration\n* In AVP-R, urine osmolality remains low/unchanged despite ADH administration\n\n### Interpretation of water deprivation test\n\n| | AVP-D | AVP-R | Normal Results |\n|-----------------------------------|--------------------------|-------------------------|----------------------|\n| **Initial Urine Osmolality (Uosm)** | Reduced (<300 mOsm/kg) | Reduced (<300 mOsm/kg) | Elevated (>300 mOsm/kg) |\n| **Initial Serum Osmolality (Sosm)** | Elevated (>300 mOsm/kg) | Elevated (>300 mOsm/kg) | Stable (~280-300 mOsm/kg) |\n| **Urine Osmolality after ADH (Uosm)** | Rapidly increases | Remains low | Rapidly increases |\n| **Interpretation** | Partial response to ADH | No response to ADH | Adequate response to ADH |\n\nNB: The deprivation test also distinguishes arginine vasopressin disorder from primary polydipsia which is a condition characterised by similar symptoms of polydipsia and polyuria. The latter condition is usually due to a psychological cause of excessive drinking. Upon testing, urine osmolality is normal both after fluid deprivation and after desmopressin is given.\n\n# Management\n\n**Management of AVP-D (Cranial DI)**\n\n- AVP-D can be managed with desmopressin, a medication which mimics the action of endogenous ADH.\n- Sodium levels should be monitored routinely due to the risk of hyponatraemia.\n\n**Management of AVP-R (Nephrogenic DI)**\n\n- AVP-R is managed by correcting any underlying metabolic abnormalities and discontinuing any offending drugs.\n- High dose desmopressin has been used with variable results.\n- Other potential treatments include using a thiazide diuretic (counter-intuitive, we know) and a non-steroidal anti-inflammatory drug to reduce urine volume.\n\n# References\n\n[Patient.info - Diabetes insipidus](https://patient.info/doctor/diabetes-insipidus-pro)\n\n[NHS UK - DI](https://www.nhs.uk/conditions/diabetes-insipidus/causes/)",
"files": null,
"highlights": [],
"id": "1970",
"pictures": [],
"typeId": 2
},
"chapterId": 1970,
"demo": null,
"entitlement": null,
"id": "683",
"name": "Arginine vasopressin disorder (Diabetes Insipidus)",
"status": null,
"topic": {
"__typename": "Topic",
"id": "5",
"name": "Endocrinology",
"typeId": 2
},
"topicId": 5,
"totalCards": 7,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 683,
"conditions": [],
"difficulty": 1,
"dislikes": 23,
"explanation": null,
"highlights": [],
"id": "10641",
"isLikedByMe": 0,
"learningPoint": "Lithium can cause nephrogenic diabetes insipidus, a condition where the kidneys become resistant to antidiuretic hormone (ADH), leading to the production of large volumes of dilute urine, decreased urine osmolality, and an elevated serum osmolality due to the body’s inability to concentrate urine properly.",
"likes": 7,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 34-year-old woman is referred to A&E from an inpatient psychiatric unit with a 3-d history of polyuria. She also reports being excessively thirsty despite drinking lots of water. Four weeks ago, she was diagnosed with epilepsy and bipolar disorder and was commenced on lithium and carbamazepine with good effect. Routine bloods performed by the psychiatry team are unremarkable, except for a sodium of 146.\n\nWhich of the following is the next best investigation?",
"sbaAnswer": [
"a"
],
"totalVotes": 3436,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,952 | false | 10 | null | 6,494,981 | null | false | [] | null | 10,642 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Berry aneurysms are a recognised feature of autosomal dominant polycystic kidney disease (ADPCKD), which is an inherited cause of end-stage renal failure. The palpable bilateral flank masses should raise suspicion of underlying ADPCKD. Berry aneurysms have a propensity to rupture leading to a subarachnoid haemorrhage, presenting with a traditional sudden-onset 'thunderclap' headache and rapid neurological deterioration.",
"id": "52907",
"label": "a",
"name": "Subarachnoid haemorrhage",
"picture": null,
"votes": 2827
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "An abdominal aortic aneurysm rupture may present with shock due to bleeding and subsequent reduced consciousness. Headache is not a typical component of the presentation and there is no evidence of haemodynamic instability here. Abdominal aortic aneurysms are also more likely in older male patients.",
"id": "52909",
"label": "c",
"name": "Abdominal aortic aneurysm rupture",
"picture": null,
"votes": 220
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "An extradural haematoma typically presents after a traumatic head injury with a brief loss of consciousness followed by recovery (lucid interval) and subsequent rapid deterioration in conscious level. It occurs typically due to a blow to the temples and rupture of the middle meningeal branch of the maxillary artery (a branch of the external carotid). There is no history of trauma in this patient and the clinical features of a lucid interval are not present.",
"id": "52911",
"label": "e",
"name": "Extradural haematoma",
"picture": null,
"votes": 48
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A myocardial infarction (MI) typically presents with chest pain, breathlessness or syncope. Patients are typically older with cardiovascular risk factors. Younger patients may present with MIs, especially if there are strong risk factors such as use of cocaine or hereditary hypercholesterolaemia. ADPKD does not typically increase the risk of MI until there is a significant degree of renal impairment. The most likely cause of this presentation is a berry aneurysm rupture.",
"id": "52910",
"label": "d",
"name": "Myocardial infarction",
"picture": null,
"votes": 6
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Meningitis can cause headache and reduced consciousness. However, the natural history in this case is hyperacute, and therefore a haemorrhage is more likely since meningitis tends to have a more insidious onset. There are also no clinical features of infection, such as fever, or other features of meningism, such as neck stiffness. Furthermore, in this case the presence of bilateral flank masses should also raise suspicion of autosomal dominant polycystic kidney disease and the presence of a ruptured berry aneurysm.",
"id": "52908",
"label": "b",
"name": "Meningitis",
"picture": null,
"votes": 35
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "\"Complained of a headache\" is underselling SAH pain a little",
"createdAt": 1686327909,
"dislikes": 0,
"id": "28314",
"isLikedByMe": 0,
"likes": 5,
"parentId": null,
"questionId": 10642,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Cystic Juice",
"id": 10376
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nAutosomal Dominant Polycystic Kidney Disease (ADPKD) is the commonest inherited renal disease. It arises due to mutations in the PKD1 and PKD2 genes. PKD1 mutations are more common and tend to cause more severe disease. The disease is characterised by cyst formation both in the kidneys and in other organs, such as the liver, ovaries, spleen, pancreas and seminal vesicles. Patients may be detected on screening if family members are affected, or present with symptoms of loin pain, haematuria or abdominal masses. Patients may also present with complications such as hypertension and renal impairment. Other complications include cyst haemorrhage or infection, renal stones and an increased risk of cerebral berry aneurysms which may rupture, causing subarachnoid haemorrhage. Ultrasound is the first-line diagnostic investigation to identify renal cysts; genetic testing is not usually required but may be considered in some cases (e.g. atypical renal imaging). Management is primarily supportive, including lifestyle changes, regular monitoring and genetic counselling. Tolvaptan is used in some patients with rapidly progressive chronic kidney disease to slow the growth of renal cysts and renal impairment. Renal replacement therapy may be required if patients develop end-stage kidney disease.\n\n# Definition\n\nAutosomal Dominant Polycystic Kidney Disease (ADPKD) is an inherited renal disorder characterised by continuous formation and growth of cysts in the kidneys. This leads to progressive renal impairment due to destruction of nephrons and may cause end-stage kidney disease (ESKD). \n\nADPKD also has several extrarenal manifestations, including cyst formation in the liver and other organs and intracranial aneurysms.\n\n# Epidemiology\n \n- ADPKD is the most common genetic kidney disorder in adults\n- Prevalence is approximately 1:1000\n- Men and women are affected equally, and it occurs in patients of all ethnicities\n- It is responsible for up to 10% of end-stage renal disease\n- Approximately 85% of patients have PKD1 mutations and 15% have PKD2 mutations\n- Around 15% of patients with ADPKD have no family history of the condition (for example due to de novo mutations)\n \n# Aetiology\n\n- The PKD genes cause mutations in polycystin 1 and 2, which lead to cyst formation and expansion\n- PKD1 is located on chromosome 16, and PKD2 is located on chromosome 4\n- Disease is typically more severe with PKD1 mutations\n- A large number of causative mutations have been identified\n- Inheritance is autosomal dominant\n\n# Signs and Symptoms\n \nPatients may present with symptoms of:\n \n- Flank pain \n - May be acute, secondary to cyst haemorrhage, infection or urinary tract stones\n - Chronic pain is common and may be severe\n- Haematuria (often due to cyst rupture)\n- Fever and systemic illness due to infection i.e. malaise, nausea and vomiting\n - May present with recurrent urinary tract infections\n- Polyuria and nocturia\n- Chronic kidney disease e.g. lethargy, peripheral oedema, pruritus\n\nExamination findings include:\n\n- Bilateral large masses in the flanks (palpable enlarged kidneys)\n- Hepatomegaly (up to 70% have liver cysts)\n- Hypertension\n- Splenomegaly is rarer (5% have splenic cysts)\n\n# Differential Diagnosis\n\n- **Simple renal cysts** are very common and incidence increases with age\n - Patients have normal sized kidneys and renal function is not affected\n - Symptoms are rare\n - They are often an incidental finding on imaging or autopsy\n- **Acquired cystic kidney disease** is common in patients with chronic kidney disease\n - Patients on dialysis are particularly affected\n - Multiple bilateral small cysts are seen\n - Kidneys are often small in size\n - Cysts are usually asymptomatic\n- **Autosomal recessive polycystic kidney disease** is much rarer than ADPKD and manifests in infancy\n - It occurs when two copies of a mutated PKHD1 gene are inherited\n - Patients may be diagnosed in utero and pulmonary hypoplasia may be fatal in neonates\n - Biliary dysgenesis causes cholangitis and portal hypertension\n- **Tuberous sclerosis** is an autosomal dominant neurocutaneous disorder that usually occurs due to spontaneous mutations of tumour suppressor genes TSC1 or TSC2\n - Renal cysts are common as well as angiomyolipomas (benign renal tumours)\n - Seizures, learning difficulties and cardiac rhabdomyomas are common features\n - Cutaneous lesions include hypopigmented macules (ash leaf spots), facial angiofibromas (adenoma sebaceum) and shagreen patches\n- **Von Hippel-Lindau disease** is a rare autosomal dominant condition that leads to cysts and tumours developing in various organs\n - It is caused by a VHL gene mutation\n - Renal cysts are usually benign and asymptomatic\n - Renal cell carcinoma is more common and patients require surveillance for this\n - Retinal angiomas, haemangioblastomas of the cerebellum or spinal cord, pancreatic neuroendocrine tumours and phaeochromocytomas are other features not seen in ADPKD\n- **Medullary cystic kidney disease** is a rare autosomal dominant disease\n - Multiple small medullary cysts are seen\n - Kidneys are small or normal in size\n - Chronic tubulointerstitial nephritis leads to end stage renal disease\n\n# Investigations\n\n**Bedside tests:**\n\n- **Urine dip** for haematuria and proteinuria (microalbuminuria may be seen but heavy proteinuria is rare)\n- **Urinary albumin:creatinine ratio** to grade CKD\n- **Urine MC&S** if infection is suspected\n\n**Blood tests:**\n\n- **FBC** may show polycythaemia (as polycystic kidneys may produce excessive erythropoietin); leukocytosis may be seen in infection\n- **U&Es** to monitor renal function\n- **Bone profile** is important in patients with chronic kidney disease to look for electrolyte derangement such as hyperphosphatemia\n- **LFTs** are usually normal despite hepatic cysts; rarely large cysts or biliary cystic lesions may cause obstructive jaundice\n\n**Imaging tests:**\n\n- **Ultrasound of the kidneys** is the key diagnostic test and is used for screening adult family members \n - 3+ renal cysts in total if aged 15-39 is sufficient to diagnose ADPKD\n - 2+ cysts in each kidney if aged 40-59 is sufficient to diagnose ADPKD\n - No cysts if aged 40+ is sufficient to exclude ADPKD\n- **CT** or **MRI** of the kidneys is more sensitive and so may be used in specific circumstances e.g. living donor evaluations\n- **MRI head** is indicated for screening of patients with a family history of intracranial aneurysms or subarachnoid haemorrhage\n- **Abdominal ultrasound** may also detect hepatic or splenic cysts\n- **Echocardiogram** if there is suspected valvular disease or hypertensive heart disease\n\n**Special tests:**\n\n- **Genetic testing** is challenging due to the heterogeneity of mutations seen\n - Up to 15% of patients with suspected ADPKD have no identifiable mutation\n - The majority of patients do not require genetic testing\n - It may be useful in atypical cases (e.g. significant asymmetry of cystic disease, no family history) or severe disease\n- **Renal biopsy** may be considered in specific cases, for example in patients with nephrotic-range proteinuria to rule out another renal pathology\n \n# Management\n \n**Conservative management:**\n\n- All patients should be referred to specialist services for diagnosis and management\n- Patient education, including providing information regarding implications for family members\n- Screening of at-risk adult relatives should be offered - children at risk should have regular blood pressure monitoring\n- Advise patients to avoid contact sports which may cause abdominal trauma and cyst rupture\n- Lifestyle advice on how to reduce cardiovascular risk should be provided (smoking cessation, healthy diet and regular exercise)\n- Avoid nephrotoxic drugs and oestrogens (promote hepatic cyst growth)\n- Patients require regular monitoring including serial ultrasounds to monitor renal volume\n\n**Medical management:**\n\n- Tolvaptan is an option for patients with stage 2 or 3 CKD with rapidly progressive disease, to slow cyst growth and renal impairment\n- Antihypertensives may be required to maintain a blood pressure of < 130/80\n - ACE inhibitors or angiotensin-II receptor antagonists are first-line\n- Analgesia is an important component of pain management, which may be acute or chronic\n- Antibiotics may be required for urinary tract infections, including cyst infections\n\n**Surgical management:**\n\n- Drainage of painful or infected renal cysts may be done percutaneously, laparoscopically or via a laparotomy\n- Nephrectomy may be required in some cases e.g. very large cysts, uncontrolled haemorrhage, symptomatic mass effect\n- For patients with ESRD requiring renal replacement therapy, renal transplant is preferred \n - Patients often have few comorbidities and so are good candidates\n - In some cases, removal of the native kidney may be required prior to transplantation to make space\n - Rarely, combined liver/kidney transplants are required if there is concurrent severe hepatic cyst disease\n- Symptomatic liver cysts may also require drainage or resection\n- Intracranial aneurysms detected on screening may be treated prophylactically (e.g. clipping or coiling) - observation is also an option \n\n# Complications\n\n- **Cyst haemorrhage** and **haematuria** are usually self-limiting\n - Rarely persistent or severe bleeding may cause subcapsular or retroperitoneal haematomas\n - Tranexamic acid may be used to treat bleeding\n - Investigating for malignancy may be appropriate e.g. in older patients or persistent haematuria\n- **Cyst infection** usually presents with fever, abdominal pain and raised inflammatory markers\n - Prolonged courses of IV antibiotics may be required\n - Infected cysts may be drained percutaneously or surgically\n- **Recurrent urinary tract infections** including pyelonephritis may be seen\n- **Renal stones** are common due to increased urinary static and metabolic abnormalities\n - CT is used for diagnosis\n - Treatment is the same as for patients without ADPKD\n- **Liver cysts** are the commonest extrarenal manifestation \n - 80% of patients have liver cysts by the age of 30\n - These increase with age, especially in women\n - 20% of patients will develop symptoms\n - These include abdominal and back pain, abdominal distension, early satiety and gastro-oesophageal reflux\n - Liver cysts may also rupture, bleed or become infected\n - Treatment options include aspiration and sclerotherapy or fenestration of cysts\n - In some cases liver resection is indicated for symptomatic relief\n- **Pancreatic cysts** are seen in around 10% of ADPKD patients\n - They usually cause no symptoms\n - If they compress the pancreatic duct, chronic pancreatitis may result\n- **Seminal vesicle cysts** are seen in 40% of male ADPKD patients\n - These are usually asymptomatic\n - There is no clear association with infertility\n- **Arachnoid membrane cysts** are typically asymptomatic and are found in 8-12% of ADPKD patients\n - However they may increase the risk of subdural haematoma\n- **Intracranial aneurysms** may lead to **subarachnoid haemorrhage** if they rupture\n - Decision making around whether to intervene if an unruptured aneurysm is detected is complex\n - Morbidity and mortality from aneurysm rupture are high\n - The majority of aneurysms are in the anterior circulation\n- **Aneurysm** may occur elsewhere and lead to arterial dissection\n - The aortic, popliteal, coronary and splenic arteries may be affected\n- **Cardiac valvular disease** including mitral valve prolapse and aortic insufficiency with aortic root dilatation\n - These may be progressive but rarely require valve replacement\n- **Chronic pain** especially in the flanks is common in ADPKD\n - It may develop after an acutely painful episode\n - Pain may be severe and disabling, with impacts on sleep, activities and mood\n - Treatment involves both medical management with analgesia, and considering interventional options\n - If cyst aspiration relieves pain, more permanent approaches such as cyst scleroisis or fenestration may be considered\n- **End stage renal disease** occurs in the majority of patients\n - Renal replacement therapy should be considered early as in all cases of CKD\n\n# Prognosis\n\n- Approximately 50% of patients reach ESRD by the age of 60; this rises to 75% by age 70\n- Poor prognostic factors include:\n - PKD1 genotype\n - Younger age of onset\n - Larger kidneys\n - Hypertension\n - Male sex\n\n# NICE Guidelines\n\n[NICE Technology Appraisal - Tolvaptan for treating autosomal dominant polycystic kidney disease](https://www.nice.org.uk/guidance/ta358/)\n\n# References\n\n[KDIGO - Autosomal Dominant Polycystic Kidney Disease](https://kdigo.org/wp-content/uploads/2017/02/KDIGO-ADPKD-Supplemental-Full-Report-FINAL.pdf)\n\n[Patient UK: Polycystic kidney disease](https://patient.info/doctor/autosomal-dominant-polycystic-kidney-disease)\n\n[Genomics Education - Polycystic kidney disease](https://www.genomicseducation.hee.nhs.uk/blog/polycystic-kidney-disease-and-genomic-testing/)\n\n[Radiopaedia - Autosomal dominant polycystic kidney disease](https://radiopaedia.org/articles/autosomal-dominant-polycystic-kidney-disease-1?lang=gb)",
"files": null,
"highlights": [],
"id": "302",
"pictures": [
{
"__typename": "Picture",
"caption": "An abdominal CT scan showing multiple renal cysts in someone with polycystic kidney disease.",
"createdAt": 1549131061,
"id": "162",
"index": 0,
"name": "polycysticKidney.jpg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/3cep3yus1549131061509.jpg",
"path256": "images/3cep3yus1549131061509_256.jpg",
"path512": "images/3cep3yus1549131061509_512.jpg",
"thumbhash": "W+YFVYwFrpvEunq3jquLiAaFZUBo",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
}
],
"typeId": 2
},
"chapterId": 302,
"demo": null,
"entitlement": null,
"id": "305",
"name": "ADPKD (Autosomal-Dominant Polycystic Kidney Disease)",
"status": null,
"topic": {
"__typename": "Topic",
"id": "33",
"name": "Nephrology",
"typeId": 2
},
"topicId": 33,
"totalCards": 4,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 305,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10642",
"isLikedByMe": 0,
"learningPoint": "Autosomal dominant polycystic kidney disease is associated with berry aneurysms, which can rupture and cause subarachnoid haemorrhage.",
"likes": 3,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 38-year-old woman is brought in by ambulance to A&E. She was having lunch with a friend when she complained of a headache and lost consciousness soon after. On examination, she has a Glasgow Coma Scale score of 3 and bilateral flank masses palpable on her abdomen. Her observations are otherwise within normal parameters.\n\nWhat is the cause of her neurological presentation?",
"sbaAnswer": [
"a"
],
"totalVotes": 3136,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,953 | false | 11 | null | 6,494,981 | null | false | [] | null | 10,643 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is the treatment for preproliferative/proliferative diabetic retinopathy. Photocoagulation is also done for maculopathy but more locally. Alternatives include intravitreal antivascular endothelial growth factor treatment. This patient has only got background changes on her retinal imaging. The treatment for this is good glycaemic control and maintaining a healthy and active lifestyle. This patient should be advised to stop smoking.",
"id": "52913",
"label": "b",
"name": "Panretinal photocoagulation",
"picture": null,
"votes": 652
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is one of the first-line pharmacological treatments for acute angle closure glaucoma (AACG). Diabetic patients have a higher risk of AACG; however, this patient has no symptoms consistent with this, such as pain, loss of vision or vomiting. The patient also has normal optic discs; in glaucoma there is a raised cup:disc ratio. The retinal findings are consistent with background diabetic retinopathy; therefore, first-line treatment is lifestyle advice and good glycaemic control.",
"id": "52914",
"label": "c",
"name": "Acetazolamide",
"picture": null,
"votes": 173
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is a patient with type 2 diabetes with background changes (also known as mild preproliferative retinopathy) on her retinal photography (dot/blot/flame haemorrhages, microaneurysms, hard exudates.) There is no evidence of preproliferative change (soft exudates, also known as cotton wool spots, or venous changes) or proliferative changes (new vessels and frank haemorrhage). There are no changes at the macula or within one optic disc space of the macula, which would indicate a diagnosis of maculopathy. The optic disc is normally vertically oval in shape and the central depression is otherwise known as the optic cup. The normal cup:disc ratio is 0.3. For background changes, the mainstay of treatment is lifestyle modifications, such as weight loss, smoking cessation and healthy diet. Glycaemic control is good in this case and it is important to note that rapid tightening of glycaemic control can make retinopathy acutely worse; long-term, gradual control is important for improving long-term outcomes.",
"id": "52912",
"label": "a",
"name": "Lifestyle modifications",
"picture": null,
"votes": 2132
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is the definitive management for AACG. This patient has no features of glaucoma on clinical presentation or on her retinal photographs. The retinal photography findings describe the normal appearance of the optic discs and of background diabetic retinopathy, the first-line treatment for which is lifestyle advice.",
"id": "52915",
"label": "d",
"name": "Peripheral iridotomy",
"picture": null,
"votes": 125
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The retinal image findings are consistent with background diabetic retinopathy; therefore, the first-line treatment is lifestyle advice and good glycaemic control. This patient continues to smoke and has a high BMI. Advice to lose weight and quit smoking can improve her long-term outcomes, both in terms of microvascular disease but also macrovascular disease.",
"id": "52916",
"label": "e",
"name": "No treatment required",
"picture": null,
"votes": 170
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nDiabetic retinopathy is a serious complication of diabetes mellitus characterised by vascular occlusion and leakage in the retinal capillaries, leading to potential sight loss if unmanaged. Key signs on fundoscopy include 'dots' (microaneurysms), hard exudates, 'blots' (haemorrhages), engorged tortuous veins, and cotton wool spots. Diagnosis is primarily through fundoscopy, with advanced stages confirmed by fluorescein angiography. Management involves optimal blood glucose control, with advanced cases requiring laser photocoagulation, vitrectomy or intravitreal injections of anti-vascular endothelial growth factor agents.\n\n# Definition\n\nDiabetic retinopathy is a sight-threatening complication of diabetes mellitus, resulting from poor glycaemic control. This leads to vascular occlusion and leakage from the capillaries that supply the retina, causing retinal ischaemia, neovascularisation and, if left untreated, potential loss of sight.\n\nDiabetic retinopathy is a broad term encompassing two primary stages: non-proliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR). NPDR presents in three severity levels:\n\n- **Mild NPDR:** Microaneurysms and dot haemorrhages on fundoscopy.\n- **Moderate NPDR:** Microaneurysms, dot and blot haemorrhages, cotton-wool spots, and hard exudates.\n- **Severe NPDR:** Beaded veins, intraretinal microvascular abnormalities (IRMA), and extensive retinal hemorrhages.\n\nPDR involves neovascularisation and fibrous proliferation on the retina or vitreous, posing a higher risk of severe vision loss.\n\n\n\n# Epidemiology\n\nDiabetes is the leading cause of severe visual impairment among working-age individuals in England, Wales, and Scotland. The risk of diabetic retinopathy increases with the duration of diabetes and poor glycaemic control.\n\n# Pathophysiology\n\nChronic hyperglycaemia in diabetes mellitus causes structural changes to the retinal capillaries, including thickening of the basement membrane and loss of pericytes. This results in capillary occlusion and leakage, leading to retinal ischaemia and formation of new, fragile vessels.\n\n# Signs and symptoms\n\nEarly stages of diabetic retinopathy may be asymptomatic. As the disease progresses, symptoms can include:\n\n- Floaters or dark spots in the vision\n- Blurred or distorted vision\n- Difficulty seeing at night\n- Sudden loss of vision\n\n# Differential diagnosis\n\nOther conditions that can cause similar symptoms include:\n\n- Age-related macular degeneration: Mainly affects central vision. Symptoms include distorted vision and difficulty recognising faces.\n- Retinal vein occlusion: Sudden painless loss of vision in one eye, often associated with a history of hypertension, hyperlipidaemia or glaucoma.\n- Hypertensive retinopathy: Characterised by arteriolar narrowing, copper or silver wiring, flame haemorrhages, and cotton wool spots.\n\n# Investigations\n\n- Fundoscopy: \n\t- Signs of milder disease include:\n\t\t- Microaneurysms\n\t\t- Hard exudates\n\t\t- Blot haemorrhages \n\t- Severe disease presents with:\n\t\t- Engorged tortuous veins\n\t\t- Large blot haemorrhages. \n\t- In proliferative diabetic retinopathy (PDR), neovascularisation can be observed on the retina or optic disc.\n- Optical Coherence Tomography (OCT): Can be used to detect macular oedema.\n- Fluorescein angiography: Used in advanced cases to evaluate the extent of neovascularisation and guide treatment.\n\n[lightgallery]\n\n[lightgallery1]\n\n[lightgallery3]\n\n\n\n# Management\n\nManagement strategies include:\n\n- Optimisation of blood glucose control to slow the progression of retinopathy.\n- Laser photocoagulation for proliferative diabetic retinopathy and clinically significant macular oedema.\n- Intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) agents for diabetic macular oedema.\n- Vitrectomy surgery for advanced cases with complications such as vitreous haemorrhage or retinal detachment.\n\n[lightgallery2]\n\n# Complications\n\n* **Vitreous Hemorrhage:** Can cause sudden vision loss.\n* **Tractional Retinal Detachment:** May lead to blindness.\n* **Macular Oedema:** Causes central vision loss.\n* **Neovascular Glaucoma:** Can result in severe pain and vision loss.\n* **Blindness:** The ultimate complication in untreated or advanced cases.\n\n# References\n\n[Click here for more information on diabetic retinopathy](https://patient.info/doctor/diabetic-retinopathy-and-diabetic-eye-problems)\n",
"files": null,
"highlights": [],
"id": "955",
"pictures": [
{
"__typename": "Picture",
"caption": "An example of flame haemorrhages and hard exudate deposits on a diabetic retina.",
"createdAt": 1665036193,
"id": "786",
"index": 0,
"name": "Diabetic retinopathy 3.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/ilkibpna1665036171706.jpg",
"path256": "images/ilkibpna1665036171706_256.jpg",
"path512": "images/ilkibpna1665036171706_512.jpg",
"thumbhash": "z4gKJYoWWGhvd4Z2d4d4hwVth4BH",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
},
{
"__typename": "Picture",
"caption": "Diabetic retinopathy that has been treated with laser photocoagulation.",
"createdAt": 1665036198,
"id": "1073",
"index": 2,
"name": "Diabetic retinopathy - tretaed.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/vz36pn971665036171700.jpg",
"path256": "images/vz36pn971665036171700_256.jpg",
"path512": "images/vz36pn971665036171700_512.jpg",
"thumbhash": "F/oKNJAIVnh5d4d5hogIh3dQOA==",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
},
{
"__typename": "Picture",
"caption": "An example of diabetic retinopathy.",
"createdAt": 1665036194,
"id": "806",
"index": 1,
"name": "Diabetic retinopathy.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/xiie51511665036171708.jpg",
"path256": "images/xiie51511665036171708_256.jpg",
"path512": "images/xiie51511665036171708_512.jpg",
"thumbhash": "2HgKHYYHFld4eHdzhYl4hgaIAmA5",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
},
{
"__typename": "Picture",
"caption": "Fundoscopy of patient with mild non-proliferative retinopathy, Credit: Clare Gilbert",
"createdAt": 1699290216,
"id": "2289",
"index": 3,
"name": "mild NPR.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/l2x7fhdl1699290185029.jpg",
"path256": "images/l2x7fhdl1699290185029_256.jpg",
"path512": "images/l2x7fhdl1699290185029_512.jpg",
"thumbhash": "2XkKHYQESGiJd3eEdneHhgOINWBp",
"topic": {
"__typename": "Topic",
"id": "16",
"name": "Ophthalmology",
"typeId": 2
},
"topicId": 16,
"updatedAt": 1708373886
}
],
"typeId": 2
},
"chapterId": 955,
"demo": null,
"entitlement": null,
"id": "1007",
"name": "Diabetic retinopathy",
"status": null,
"topic": {
"__typename": "Topic",
"id": "16",
"name": "Ophthalmology",
"typeId": 2
},
"topicId": 16,
"totalCards": 4,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 1007,
"conditions": [],
"difficulty": 2,
"dislikes": 6,
"explanation": null,
"highlights": [],
"id": "10643",
"isLikedByMe": 0,
"learningPoint": "Lifestyle modifications, including weight loss and smoking cessation, are crucial for managing background diabetic retinopathy in type 2 diabetes patients.",
"likes": 4,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 45-year-old woman with type 2 diabetes mellitus presents for her routine eye screening appointment. She is on metformin monotherapy and her last HbA1c was 44. She is a current smoker. On examination, she has a body mass index (BMI) of 30. Retinal photography reveals dot and blot haemorrhages and hard exudates. There is no evidence of microvascular growth. The optic discs are vertically oval in shape with a central depression, which has a ratio compared with the disc of 0.3.\n\nWhat is the most appropriate management for this patient?",
"sbaAnswer": [
"a"
],
"totalVotes": 3252,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,954 | false | 12 | null | 6,494,981 | null | false | [] | null | 10,644 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has haematuria with voiding lower urinary tract symptoms. He should therefore be investigated for malignancy in a dedicated one-stop clinic in the first instance. Transurethral resection of the prostate is performed for benign prostatic hypertrophy (BPH) with symptoms recalcitrant to optimum medical therapy (usually a combination of finasteride and tamsulosin). Therefore, it is not appropriate to refer the patient for this at this stage, where the diagnosis remains uncertain, and the BPH treatment is not yet optimised.",
"id": "52918",
"label": "b",
"name": "Refer for transurethral resection of the prostate",
"picture": null,
"votes": 282
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be the investigation of choice if evaluating for metastatic spread of confirmed cancer. It is done further down the line once a malignancy is diagnosed. In the first instance, the patient needs to be reviewed in the one-stop haematuria service, where biopsies may be taken if a lesion is identified to clinch the diagnosis.",
"id": "52921",
"label": "e",
"name": "CT chest, abdomen and pelvis",
"picture": null,
"votes": 104
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The presence of voiding lower urinary tract symptoms and microscopic haematuria and the patient's age and occupational history (factory work, with potential exposure to dyes and rubber) should raise suspicion of bladder cancer. Prostate cancer may also present in a similar way. Patients in the one-stop Haematuria Clinic are thoroughly evaluated for a malignant cause of their symptoms, including flexible cystoscopy to evaluate the bladder and prostate, CT or ultrasound scanning of the urinary tree, bloods (such as for the prostate-specific antigen) and urine dipstick testing.",
"id": "52917",
"label": "a",
"name": "Refer to one-stop Haematuria Clinic",
"picture": null,
"votes": 1553
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has a mildly raised PSA and has been diagnosed with BPH. This does not rule out prostate cancer; however, the patient's symptoms can certainly be explained by the presence of a prostatic malignancy but this is less likely given the presence of microscopic haematuria and the history of factory work. Referral to a one-stop haematuria service is the first step in the management of this presentation due to the presence of haematuria, which requires a dedicated set of investigations. An MRI prostate may be requested further down the line if there is concern that there is prostate cancer if no explanation for his symptoms are identified during the one-stop service or as a first-line investigation for suspected prostate cancer.",
"id": "52920",
"label": "d",
"name": "MRI prostate",
"picture": null,
"votes": 1022
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Prostate-specific antigen (PSA) has high sensitivity but low specificity for prostate cancer. It can be raised in other conditions, such as benign prostatic hypertrophy; thus, alone it cannot be used to diagnose prostate cancer. Furthermore, a negative PSA does not rule out malignancy of the prostate or elsewhere in the urinary tract. Given the continuation of this patient's urinary symptoms after pharmacological management and the presence of haematuria, malignancy should be ruled out in a dedicated one-stop Haematuria Clinic.",
"id": "52919",
"label": "c",
"name": "Repeat prostate-specific antigen",
"picture": null,
"votes": 100
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nBladder cancer, primarily characterised by transitional cell carcinoma, is the 11th most common cancer in the UK. Key risk factors vary by subtype and include smoking, exposure to aromatic amines, schistosomiasis infection, long-term catheterisation, and the presence of other types of bladder cancer. The hallmark sign is visible haematuria, along with potential systemic symptoms like weight loss and night sweats, and local symptoms such as UTIs and hydronephrosis. The disease primarily metastasises to the lungs, liver, and bone. Diagnosis involves various investigations including urine dip, CT urogram, flexible cystoscopy, and other imaging studies. Management strategies differ based on whether the cancer is muscle invasive or non-muscle invasive, and can include surgery, chemotherapy, immunotherapy, and radiotherapy.\n\n# Definition\n\nBladder cancer is a malignant growth within the urinary bladder. The most common histological subtype in developed countries is transitional cell carcinoma, accounting for 90% of all bladder cancers, followed by squamous cell carcinoma and other types.\n\n# Epidemiology\n\nBladder cancer is the 11th most common cancer in the UK. In developed countries, 90% of bladder cancers are transitional cell carcinomas, while the remainder are primarily squamous cell carcinomas.\n\n# Aetiology\n\nRisk factors vary depending on the histological subtype of the cancer:\n\n## Risk factors for Transitional Cell Carcinoma\n\n- Smoking\n- Exposure to aromatic amines (employed in rubber, dyes, and chemical industry)\n- Use of Cyclophosphamide\n\n## Risk factors for Squamous Cell Carcinoma\n\n- Schistosomiasis infection\n- Long-term catheterisation (10+ years)\n\n## Risk factors for Adenocarcinoma\n\n- Presence of other types of bladder cancer\n- Local bowel cancer\n\n## Risk factors for Small Cell Bladder Cancer\n\n- Association with other types of bladder cancer\n\n# Signs and Symptoms\n\nThe cardinal sign of bladder cancer is **painless visible haematuria.** Clinical features can be grouped into local and systemic categories, with the severity depending on the advancement of the disease.\n\nLocal features:\n- Painless haematuria\n- Recurrent UTIs\n- Hydronephrosis\n\nBladder cancer can also invade adjacent structures such as the obturator nerve, resulting in neuropathic pain on the medial thigh.\n\nSystemic features:\n- Unintended weight loss\n- Night sweats\n\n# Differential Diagnosis\n\nBladder cancer should be differentiated from other conditions presenting with similar symptoms:\n\n- Urinary tract infection: Characterised by dysuria, frequency, urgency, lower abdominal pain and potentially haematuria.\n- Kidney stones: Present with colicky flank pain, haematuria, and potentially UTI symptoms.\n- Benign prostatic hyperplasia: Symptoms include nocturia, urinary hesitancy, and a weak stream. There may be microscopic haematuria but typically no gross haematuria.\n- Interstitial cystitis: Characterised by chronic pelvic pain, urinary frequency, and urgency in the absence of an identifiable cause.\n\n# Investigations\n\nInitial bedside investigations include a urine dipstick test to identify haematuria. If there's doubt over the presence of true haematuria, a lab sample can be sent (urine MCS) to confirm the presence of red blood cells, as well as casts (if there are dysmorphic red blood cells it suggests bleeding is glomerular in nature and not from lower urinary tract).\n\nImaging investigations are crucial for diagnosis and staging:\n\n- CT Urogram: Contrast is injected into a vein, filtered by the kidney, and excreted into the urinary collecting system. A CT scan then visualises the urinary tract to identify filling defects indicating a tumour.\n\n- Flexible cystoscopy: Allows for visualisation of any defects in the bladder and the morphology of any suspicious lesions. If a lesion is identified, a biopsy can be taken.\n\nFurther staging investigations may include radiographs, CT scans, MRI scans, and bone isotope scans.\n\n## 2 week wait referral criteria\n\nRefer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for bladder cancer:\n\n- If they are aged 45 years and over and have:\r\n\t- Unexplained visible haematuria without urinary tract infection, or\r\n\t- Visible haematuria that persists or recurs after successful treatment of urinary tract infection.\r\n- If they are aged 60 years and over and have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test.\r\n- Consider non-urgent referral for bladder cancer in people aged 60 years and over with recurrent or persistent unexplained urinary tract infection.\r\n\n\n# Classification\n\nBladder cancer can be classified according to stage and grade, utilising the WHO TNM system. The staging system is based on localised tumour invasion (T), presence of lymph nodes (N), and distant disease (M). Both imaging modalities and pathological specimens are used for staging, with a key objective being differentiation between muscle invasive and non-muscle invasive bladder cancer.\n\nThe grade of cancerous cells can be histologically graded from 1-3, with 1 being the least aggressive and 3 the most aggressive.\n\nWhen it comes to classification and staging the most important aspect is whether the tumour is non-invasive or muscle-invasive as this determines treatment:\n\n-\tNon-muscle invasive: Tis (non-invasive, in situ), Ta – non-invasive, T1 – tumour invades inner lining and connective tissues. \r\n-\tMuscle invasive: T2 (tumour invades muscle), T3 (invades perivesical fat and LN), T4 (metastatic spread). \r\n\n\n# Management\n\nThe management of bladder cancer is categorised based on whether the cancer is muscle invasive or non-muscle invasive.\n\n## Non-muscle invasive bladder cancer\n\nThis includes stages CIS, Ta, and T1 and is managed with:\n- Surgery: Transurethral resection of the bladder tumour (TURBT) is the gold standard.\n- Chemotherapy: The bladder can be instilled with chemotherapeutic agents such as Mitomycin C (single dose if low risk, 6 week course if intermediate risk).\n- Immunotherapy: BCG immunotherapy can be instilled into the bladders of patients with high-risk non-muscle invasive cancers or carcinoma in situ (CIS).\n- If there is high-risk muscle non-muscle invasive cancer/CIS a radical cystectomy may still be considered.\n\n## Muscle invasive bladder cancer\n\nThis includes any stage from T2 and above. The gold standard treatment is a radical cystectomy with urinary diversion, with options including an ileal conduit, neo-bladder, or Mitrofanoff procedure. Non-surgical treatment options include radiotherapy and chemotherapy, which can be used in both curative and palliative capacities.\n\n# NICE Guidelines\n\n[Click here for the NICE Guidelines](https://www.nice.org.uk/guidance/ng2)\n\n[NICE CKS - Urological cancers - recognition and referral\n](https://cks.nice.org.uk/topics/urological-cancers-recognition-referral/)",
"files": null,
"highlights": [],
"id": "759",
"pictures": [],
"typeId": 2
},
"chapterId": 759,
"demo": null,
"entitlement": null,
"id": "791",
"name": "Bladder cancer",
"status": null,
"topic": {
"__typename": "Topic",
"id": "22",
"name": "Urology",
"typeId": 2
},
"topicId": 22,
"totalCards": 25,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 791,
"conditions": [],
"difficulty": 3,
"dislikes": 17,
"explanation": null,
"highlights": [],
"id": "10644",
"isLikedByMe": 0,
"learningPoint": "In patients over 50 with urinary symptoms and haematuria, a referral to the haematuria clinic is required for evaluation of potential bladder or prostate cancer.",
"likes": 9,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 73-year-old man is referred to the Urology Clinic with a 3-month history of voiding symptoms. He finds he has intermittent poor stream and hesitancy when passing urine. He denies any weight loss, fatigue or night sweats and any other urinary symptoms. He is a retired factory worker. His GP had detected an enlarged prostate and a mildly raised prostate-specific antigen 3 months ago and diagnosed him with benign prostatic hypertrophy. He has been taking tamsulosin since but his symptoms are unchanged. His urine dipstick in clinic today is positive for blood.\n\nWhich of the following is the best next step in the management of this patient?",
"sbaAnswer": [
"a"
],
"totalVotes": 3061,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,955 | false | 13 | null | 6,494,981 | null | false | [] | null | 10,645 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "A flexible sigmoidoscopy only passes through the rectum, sigmoid colon and proximal parts of the descending colon. Therefore, colon cancer could be missed further up in the ascending or transverse sections. Thus, a colonoscopy should be conducted. This patient has symptoms that are concerning for an underlying colon malignancy. The National Institute for Health and Care Excellence (NICE) guidelines state that patients over 60 with iron deficiency anaemia or changes in their bowel habit should be referred for investigation under a 2-week wait pathway.",
"id": "52922",
"label": "a",
"name": "Colonoscopy",
"picture": null,
"votes": 1142
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A positron emission tomography scan can be useful for the evaluation of metastases, particularly in the case of bowel cancer to nearby lymph nodes and the liver. However, the primary site of malignancy has not been confirmed; therefore, it would be inappropriate to expose a patient to radiation at this stage.",
"id": "52926",
"label": "e",
"name": "Fluorodeoxyglucose-positron emission tomography scan",
"picture": null,
"votes": 29
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is presenting with chronic symptoms and there is nothing in the history suggestive of infection. A colorectal malignancy should therefore be ruled out.",
"id": "52924",
"label": "c",
"name": "Stool cultures",
"picture": null,
"votes": 148
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A flexible sigmoidoscopy can only evaluate part of the colon for malignancy and therefore this is insufficient to rule out a malignancy of the colon. In the context of his age and the recent change in bowel habit, the NICE guidelines state this patient needs evaluation for colorectal malignancy. A colonoscopy is required.",
"id": "52925",
"label": "d",
"name": "Discharge with lifestyle advice",
"picture": null,
"votes": 238
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Carcinoembryonic antigen (CEA) is only used when monitoring response to treatment for a confirmed colorectal malignancy. It is not a good screening or diagnostic test because its specificity is low. Furthermore, a negative result does not exclude malignancy; therefore, it does not exclude the need for colonoscopy.",
"id": "52923",
"label": "b",
"name": "Measure carcinoembryonic antigen",
"picture": null,
"votes": 219
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nColorectal cancer is the fourth most common cancer and the second leading cause of cancer death in the UK. The disease is characterized by malignant growth in the colon or rectum. Risk factors include age, hereditary syndromes, increased alcohol intake, smoking, processed meat intake, obesity, previous radiation exposure, and inflammatory bowel disease. Signs and symptoms may include rectal bleeding, weight loss, change in bowel habit, abdominal pain, and iron-deficiency anaemia. Diagnosis typically involves colonoscopy, biopsies, and CT scanning. Management strategies depend on the stage and location of the cancer, and the patient's overall health. Treatment options include surgery, chemotherapy, and radiotherapy.\n\n# Definition\n\nColorectal cancer is a type of malignancy that starts in the colon or rectum. It is a result of uncontrolled cell growth in the lining of the colon or rectum. It may start as benign polyps, which can over time progress to cancerous tumours if not removed.\n\n# Epidemiology\n\nColorectal cancer is the fourth most common cancer in the UK. It is also the second most common cause of cancer death.\n\n**Strong risk factors**\n\n- Increasing age\n- Hereditary syndromes\n - Familial adenomatous polyposis\n - Hereditary nonpolyposis colorectal cancer (Lynch Syndrome)\n - Juvenile polyposis\n - Peutz-Jeghers syndrome\n- Increased alcohol intake\n- Smoking tobacco\n- Processed meat\n- Obesity\n- Previous exposure to radiation\n- Inflammatory bowel disease\n\n**Weak risk factors**\n\n- Lack of dietary fibre\n- Limited physical activity\n- Asbestos exposure\n- Red meat (non-processed)\n\n# Signs and Symptoms\n\n* Rectal bleeding: Often noticed as blood in the stool.\n* Unexplained weight loss \n* Change in bowel habit: Patients might experience alterations in their bowel movements, such as diarrhea or constipation.\n* Abdominal pain: Persistent abdominal discomfort or pain may be present.\n* Iron-deficiency anaemia: This can result from chronic bleeding.\n* Bowel obstruction: advanced tumours can obstruct the bowel, resulting in abdominal pain, nausea and vomiting\n\n\n\n# TNM staging \n\nThe TNM (tumour, node, metastases) is a more recent classification system (replacing the Duke's classification), which provides a more uniform classification of colorectal cancer.\n\n- T: Tis (carcinoma in situ/intramucosal cancer), T1 (extends through the mucosa into the submucosa), T2 (extends through the submucosal into the muscularis), T3 (extends through the muscularis into the subserosa), T4 (extends into neighbouring organs or tissues).\n- N: N0 (no regional lymph node involvement), N1 (metastasis to 1-3 regional lymph nodes), N2 (metastasis to 4 or more regional lymph nodes).\n- M: M0 (no distant metastasis), M1 (distant metastasis).\nStaging informs both the prognosis and the treatment plan.\n\nPatients with Duke's stage C or stage III (T1-4, N1-2, M0) colon cancer benefit from adjuvant chemotherapy. Note that patients without lymph node involvement but with high risk features (such as vascular or perineural invasion) also show improved survival with adjuvant chemotherapy.\n\n# Screening\n\nThe aim of screening is to detect cancer at an earlier (asymptomatic) stage, when it is easier to treat and patients have a better chance of survival.\n\nCurrent NHS screening programmes include:\n\n- Faecal immunochemical test (FIT) every 2 years for men and women age 54-74. If positive patients are referred for colonoscopy.\n- One-off flexible sigmoidoscopy has now been _discontinued_.\n\nThis screening programme reduces the risk of dying from bowel cancer by 16%. NB: screening will soon be changed so that it is offered from the age of 50-74.\n\n# Urgent 2 week wait referral criteria\n\nNICE Guidance now recommends faecal immunochemical testing (FIT) to guide referral for suspected colorectal cancer in adults:\n\n* With an abdominal mass.\n* With a change in bowel habit.\n* With iron-deficiency anaemia.\n* Aged 40 years and over with unexplained weight loss and abdominal pain.\n* Aged under 50 years with rectal bleeding and either of the following unexplained symptoms:\n\t* Abdominal pain.\n\t* Weight loss.\n* Aged 50 years and over with any of the following unexplained symptoms:\n\t* Rectal bleeding.\n\t* Abdominal pain.\n\t* Weight loss.\n* Aged 60 years and over with anaemia even in the absence of iron deficiency.\n\nIf they have a FIT result of at least 10 micrograms, they should be referred for an urgent (within 2 weeks) colonoscopy.\n\n- FIT testing should be offered even if they have had a negative result from the screening programme previously.\n- Adults with a rectal mass should still be considered for a suspected cancer pathway referral (for an appointment within 2 weeks) and do not need a prior FIT test.\n\n\n\n# Investigations\n\n- Bloods - FBC (anaemia), iron studies, and carcinoembryonic antigen (CEA) are useful initial investigations\n\t- CEA is not used as a diagnostic tool but is a tumour marker that can be used to monitor therapeutic response to interventions.\n* The gold standard investigation is a **colonoscopy**. It allows \n\t* Direct visualisation of the colon\n\t* Biopsies to be taken\n\t* Removal of any polyps seen\n* If colonoscopy cannot be performed, either due to technical difficulties, poor tolerance of bowel preparation or there is an increased risk of colonic perforation a CT colonoscopy is a suitable alternative but does not allow biopsy.\n* After a histological diagnosis is made, a CT chest, abdomen and pelvis should be performed to stage the disease, so an appropriate intervention can be planned.\n* In rectal disease, a pelvic MRI or endorectal ultrasound are preferred over CT scan, as are better for identifying locally invasive disease.\n\n\n# Management\n\nManagement depends on factors relating to both the tumour (the stage and location) and the patient (surgical fitness).\n\n# Surgery for Colon Cancer\n\nFor patients with **colon cancer** suitable for surgery:\n\n- **Stage I-III disease:** surgical resection ± adjuvant chemotherapy.\nThe type of surgery depends on the tumour site: right hemicolectomy for tumours of the caecum and ascending colon, left hemicolectomy for tumours of the distal transverse colon and descending colon, and sigmoid colectomy for tumours of the sigmoid colon.\n- **Stage IV disease (metastases):** treatment is as above, but neoadjuvant chemotherapy may also be performed. The staged colectomy and resection of metastatic disease is performed after neoadjuvant chemotherapy.\n- In terms of specific surgical procedures, patients with caecal and ascending colon tumours undergo right hemicolectomy\n\n# Surgery of Rectal Cancer\n\nFor patients with **rectal cancer** suitable for surgery:\nAnterior resection for tumours >8 cm from the anal canal or involving the proximal 2/3 of the rectum.\nAbdomino-perineal (AP) resection for tumours <8 cm from the anal canal or involving the distal 1/3 of the rectum.\n\nPatients with stage III disease benefit from adjuvant chemotherapy.\n\nPatients with stage IV disease benefit from adjuvant chemoradiotherapy\n\n# Non-surgical management\n\nFor patients unsuitable for surgery management is with chemotherapy (FOLFOX or FOLFIRI i.e. oxaliplatin/irinotecan plus folinic acid plus fluorouracil are the preferred regimens).\n\nNew monoclonal antibody therapies are becoming available. Note that NICE concluded that cetuximab (anti-EGFR), but not bevacizumab (anti-VEGF), is cost effective in combination with chemotherapy for metastatic colorectal cancer.\n\nNote that stenting may be used as a palliative measure for patients with obstructing tumours of the sigmoid colon or rectum.\nIf the patient presents with acute bowel obstruction, a Hartmann's procedure may be required as an interim measure (resection of the rectosigmoid colon with formation of a temporary end colostomy and anorectal stump).\n\n\n# Familial adenomatous polyposis (FAP)\n\nCaused by a mutation in the adenomatous polyposis coli (APC) gene and has an autosomal dominant inheritance pattern.\n\nPatients develop hundreds of adenomatous polyps in their teens and are _virtually guaranteed_ to develop colorectal cancer by their 20s, unless they undergo prophylactic proctocolectomy.\n\nNote that there is a high risk of developing duodenal cancer, so patients undergo regular endoscopic surveillance.\n\n> _Gardener's syndrome_ is a variant of FAP in which patients may also develop epidermal cysts, supernumerary teeth, osteomas, and thyroid tumours.\n\n# Hereditary non-polyposis colorectal cancer (HNPCC)/Lynch syndrome\n\nIs caused by a mutation in the mismatch repair genes MLH1/MSH2 and has an autosomal dominant inheritance pattern.\n\nPatients have an 80% risk of developing colorectal cancer by their 30s.\n\nThere is increased risk of additional cancers such as gastric, endometrial, breast, and prostate cancer.\n\nPatients are managed with regular endoscopic surveillance.\n\n# Peutz-Jeghers syndrome\n\nIs caused by a mutation in the STK11 gene and has an autosomal dominant inheritance pattern.\n\nPatients typically present in their teens with mucocutaneous pigmentaiton and hamartomatous polyps.\n\nNote that the risk of neoplastic transformation of hamartomatous polyps is low, but many polyps are present so patients are at increased risk of developing colorectal cancer. They are managed with regular endoscopic surveillance.\n\n# References\n\n[Click here to see diagrams of colonic resections on Bowel Cancer UK](https://www.bowelcanceruk.org.uk/about-bowel-cancer/treatment/surgery/types-of-surgery/)\n\n[Click here to see the NICE guidelines on lower GI cancers](https://cks.nice.org.uk/topics/gastrointestinal-tract-lower-cancers-recognition-referral/)",
"files": null,
"highlights": [],
"id": "733",
"pictures": [],
"typeId": 2
},
"chapterId": 733,
"demo": null,
"entitlement": null,
"id": "838",
"name": "Colorectal cancer",
"status": null,
"topic": {
"__typename": "Topic",
"id": "7",
"name": "General Surgery",
"typeId": 2
},
"topicId": 7,
"totalCards": 53,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "838",
"name": "Colorectal cancer"
}
],
"demo": false,
"description": null,
"duration": 651.16,
"endTime": null,
"files": null,
"id": "397",
"live": false,
"museId": "BABUnf8",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/surgery.png",
"title": "Types of colonic resection 2",
"userViewed": false,
"views": 63,
"viewsToday": 8
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "838",
"name": "Colorectal cancer"
}
],
"demo": false,
"description": null,
"duration": 362.86,
"endTime": null,
"files": null,
"id": "72",
"live": false,
"museId": "eE1PR1s",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/surgery.png",
"title": "Colorectal cancer 1",
"userViewed": false,
"views": 124,
"viewsToday": 6
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "838",
"name": "Colorectal cancer"
}
],
"demo": false,
"description": null,
"duration": 243.56,
"endTime": null,
"files": null,
"id": "74",
"live": false,
"museId": "VCPmB8w",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/surgery.png",
"title": "Colorectal cancer 3",
"userViewed": false,
"views": 45,
"viewsToday": 5
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "838",
"name": "Colorectal cancer"
}
],
"demo": false,
"description": null,
"duration": 5321.62,
"endTime": null,
"files": null,
"id": "594",
"live": false,
"museId": "9ShHFQz",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/surgery.png",
"title": "Quesmed Tutorial: Bowel Obstruction",
"userViewed": false,
"views": 149,
"viewsToday": 19
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "838",
"name": "Colorectal cancer"
}
],
"demo": false,
"description": null,
"duration": 3432.34,
"endTime": null,
"files": null,
"id": "308",
"live": false,
"museId": "G5yq5GS",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/surgery.png",
"title": "Quesmed Tutorial: Colorectal Cancer ",
"userViewed": false,
"views": 59,
"viewsToday": 5
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "838",
"name": "Colorectal cancer"
}
],
"demo": false,
"description": null,
"duration": 304.23,
"endTime": null,
"files": null,
"id": "76",
"live": false,
"museId": "W41FfjE",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/surgery.png",
"title": "Colorectal cancer 5",
"userViewed": false,
"views": 37,
"viewsToday": 6
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "838",
"name": "Colorectal cancer"
}
],
"demo": false,
"description": null,
"duration": 396.63,
"endTime": null,
"files": null,
"id": "78",
"live": false,
"museId": "1fHwRS6",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/surgery.png",
"title": "Colorectal cancer 7",
"userViewed": false,
"views": 9,
"viewsToday": 3
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "838",
"name": "Colorectal 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
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "838",
"name": "Colorectal cancer"
}
],
"demo": false,
"description": null,
"duration": 392.11,
"endTime": null,
"files": null,
"id": "73",
"live": false,
"museId": "z9pAJ4Z",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/surgery.png",
"title": "Colorectal cancer 2",
"userViewed": false,
"views": 75,
"viewsToday": 6
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "838",
"name": "Colorectal cancer"
}
],
"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": "838",
"name": "Colorectal cancer"
}
],
"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": "838",
"name": "Colorectal cancer"
}
],
"demo": false,
"description": null,
"duration": 389.04,
"endTime": null,
"files": null,
"id": "75",
"live": false,
"museId": "f7c8vcB",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/surgery.png",
"title": "Colorectal cancer 4",
"userViewed": false,
"views": 31,
"viewsToday": 3
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "838",
"name": "Colorectal cancer"
}
],
"demo": false,
"description": null,
"duration": 446.59,
"endTime": null,
"files": null,
"id": "77",
"live": false,
"museId": "hypq8oK",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/surgery.png",
"title": "Colorectal cancer 6",
"userViewed": false,
"views": 37,
"viewsToday": 3
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "838",
"name": "Colorectal cancer"
}
],
"demo": false,
"description": null,
"duration": 442.07,
"endTime": null,
"files": null,
"id": "79",
"live": false,
"museId": "Whiyo7q",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/surgery.png",
"title": "Colorectal cancer 8",
"userViewed": false,
"views": 23,
"viewsToday": 1
}
]
},
"conceptId": 838,
"conditions": [],
"difficulty": 1,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "10645",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 5,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 64-year-old man undergoes a flexible sigmoidoscopy after a 4-month change to his bowel habit, where he reports intermittent constipation and loose stools. He denies any blood in the stool or any systemic symptoms. On flexible sigmoidoscopy no abnormality is found.\n\nWhat is the next best step in his management?",
"sbaAnswer": [
"a"
],
"totalVotes": 1776,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,956 | false | 14 | null | 6,494,981 | null | false | [] | null | 10,646 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Co-cyprindiol is an oral contraceptive pill with antiandrogenic effects. It contains cyproterone acetate (antiandrogenic) and ethinyloestradiol. NICE guidelines recommend this medication in patients with polycystic ovary syndrome and acne not responding to conventional first-line topical and oral antibiotic therapies. Therefore, this patient does not qualify for this treatment and would be contraindicated anyway due to the presence of previous DVT.",
"id": "52931",
"label": "e",
"name": "Co-cyprindiol",
"picture": null,
"votes": 67
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This drug is reserved for initiation by a dermatologist for patients with severe acne who are unresponsive to two courses of oral antibiotic therapy. This patient does not currently fulfil these criteria.",
"id": "52929",
"label": "c",
"name": "Oral isotretinoin",
"picture": null,
"votes": 702
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This could be a service to offer this patient in conjunction with acne treatment if her mental health were significantly affected: symptoms of depression, anxiety, body dysmorphia, suicidal ideation or self-harm. This is not the case here. Furthermore, it would not treat her condition alone since psychological support would not address the root cause (ie. the acne) of any mood disorder if present.",
"id": "52928",
"label": "b",
"name": "Referral to psychological services",
"picture": null,
"votes": 13
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has moderate acne indicated by the presence of many inflammatory lesions (pustules and inflammatory papules). Mild acne is defined by the presence of mostly comedones with few inflammatory lesions. There are no markers of severe acne (nodules, cysts and scars). She has not responded to topical agents, so as per National Institute for Health and Care Excellence (NICE) guidelines oral antibiotics are indicated. This is usually doxycycline or lymecycline but alternatives include clarithromycin or trimethoprim. Topical agents should be continued while on oral antibiotics. Combined oral contraceptives with antiandrogenic effects (such as co-cyprindiol) could be considered in some patients but this would not be an option in the context of previous deep vein thrombosis.",
"id": "52927",
"label": "a",
"name": "Oral lymecycline",
"picture": null,
"votes": 2504
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Short courses of prednisolone can be used to treat some severe acne flares, such as acne fulminans. It has no place in the routine or long-term management of most acne presentations.",
"id": "52930",
"label": "d",
"name": "Prednisolone",
"picture": null,
"votes": 38
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "All this moderate?",
"createdAt": 1684174380,
"dislikes": 0,
"id": "24685",
"isLikedByMe": 0,
"likes": 3,
"parentId": null,
"questionId": 10646,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Nightshift NICU",
"id": 25674
}
},
{
"__typename": "QuestionComment",
"comment": "You would refer to derm cuz of scarring no?\n",
"createdAt": 1737748098,
"dislikes": 0,
"id": "61463",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10646,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Migraine Biopsy",
"id": 41194
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nAcne vulgaris is a common chronic disorder of the pilo-sebaceous unit, resulting in blockage of the follicle, formation of comedones and inflammation. Key signs and symptoms include open/closed comedones, inflammatory papules and pustules, and in severe cases, nodules and cysts. The disorder predominantly affects the face, neck, chest, and back, and has a significant psychological impact due to altered physical appearance. Acne is primarily diagnosed clinically, with further investigations necessary only in uncertain cases or prior to commencing certain treatments like isotretinoin. Treatment is guided by severity and may involve topical or systemic therapy based on the NICE guidelines. Potential complications include post-inflammatory hyperpigmentation, hypopigmentation, erythema, psycho/social/sexual dysfunction, and scarring.\n\n\n# Definition\n\n- A a chronic disorder of the skin affecting the pilo-sebaceous unit, in which there is blockage of the follicle leading to comedones and inflammation. \n- Vulgaris translates as \"common\", which is true as this condition affects over 80% of adolescents.\n\n# Epidemiology\n\n* It is one of the most common dermatological conditions globally, affecting individuals of all ethnicities and ages.\n* Prevalence is highest in adolescents and young adults, with up to 80% of individuals experiencing some degree of acne during their lifetime.\n* While most common in adolescents, adult-onset acne can occur, affecting people well into their 30s and beyond.\n* Acne affects both males and females, but the prevalence and severity may vary between genders.\n* The psychological impact of acne can be significant, affecting self-esteem and overall quality of life.\n\n# Risk Factors\n\nSeveral factors contribute to the development and exacerbation of acne, including:\n\n* Hormonal changes (e.g. during puberty, menstrual cycle, polycystic ovary syndrome)\n* Increased sebum (oil) production\n* Blockage of hair follicles and sebaceous glands by keratin and sebum\n* Bacterial colonization (Propionibacterium acnes)\n* Family history of acne\n* Certain medications (e.g. corticosteroids, hormonal treatments)\n\n# Pathophysiology\n\n- In normal skin, skin cells in the stratum corneum of the epidermis (corneocytes) desquamate successfully without blocking pilo-sebaceous units.\n- In acne, the corneocytes are excessively cohesive. They do not detach successfully.\n- Because of this, the keratin rich corneocytes accumulate and block off hair follicles causing follicular hyperkeratinisation.\n- Sebum is trapped in the hair follicle since it cannot be drained away. Androgens may also contribute to this causing sebaceous gland hyperplasia and increased sebum production. \n- This combination of sebum and keratin forms micro-comedones - the earliest feature of acne vulgaris. This is only visible under a microscope.\n- Gradually, the follicle becomes more distended with keratin and sebum, and the micro-comedone enlarges to become a comedone. \n- Initially, these are closed comedones, referred to as whiteheads. The contents are not exposed to the skin surface or oxygen, and therefore appear as fleshy/white papules. \n- Eventually, closed comedones become open comedones. As their contents become exposed to oxygen, they oxidise which causes black discolouration. Open comedones are therefore referred to as blackheads.\n- Comedones are then colonised with a gram positive bacillus called Propionibacterium (Cutibacterium) acnes. This is a commensal organism (part of the normal skin flora) but leads to an inflammatory response in the right conditions of the comedone, in a predisposed patient. \n- The comedone is subsequently transformed into an inflammatory papule, which is now associated with erythema. A papule is a solid, raised lesion less than 0.5cm in diameter. \n- As things progress and more neutrophils accumulate, the inflammatory papule becomes a pustule; this is a lesion less than 0.5cm in diameter that contains pus. \n- Eventually, the inflammatory papule or pustule becomes so distended that it ruptures into the dermis, triggering a marked and deep seated inflammatory response. \n- This leads to the formation of nodules/cysts, which are painful and red. A nodule is a solid lesion larger than 0.5cm, and cysts are walled off fluid containing structures. \n\n[lightgallery]\n\n# Classification\n\n- Non-inflammatory: blackheads and whiteheads.\n- Inflammatory: inflammatory papules, pustules, and nodules (cysts.)\n- Mild acne: predominantly non-inflammatory lesions. \n- Moderate acne: predominantly inflammatory papules and pustules. \n- Severe acne: nodules (cysts), scarring, acne fulminans, and acne conglobata. \n\n# Clinical Features\n\n- Open/closed Comedones, inflammatory papules and pustules, nodules, and cysts may be present.\n- The face is most often affected. The neck, chest and back may also be affected.\n- Psychological dysfunction due to changes physical appearance\n- Scarring: associated with inflammatory acne. Hypertrophic and keloid scars are more common in darker skin tones. \n\t- Atrophic: flat or indented, such as ice-pick, box-car, or rolling scars.\n\t- Hypertrophic: raised scars.\n\t- Keloid: raised scars that extend beyond the initial boundaries of the injury. \n- Post-inflammatory hyperpigmentation and hypopigmentation: associated with inflammatory acne. \n- Post inflammatory erythema: associated with inflammatory acne.\n- Acne fulminans: an uncommon but severe, serious acne presentation. \n\t- Inflammatory nodules/cysts that are painful, ulcerating, and haemorrhagic appear, with associated systemic upset (raised white cell count, joint pain, fever, fatigue.) \n\t- These patients should be reviewed urgently within 24 hours. It usually affects teenage male patients.\n- Acne conglobata: another uncommon presentation of severe nodular/cystic acne with interconnecting sinus tracts and extensive scaring. \n\n[lightgallery1]\n\n[lightgallery2]\n\n# Investigations\n\n- Acne is a clinical diagnosis and investigations are not usually needed. \n- Swabs may be indicated if the diagnosis is uncertain (e.g. if ruling out infectious pustules.)\n- Investigations will be required prior to commencing isotretinoin if indicated.\n- In some particular presentations where an endocrine cause is suspected, there may be endocrinological investigations (hyperandrogenic states such as PCOS or androgen secreting tumours.)\n\n# Treatment\n\nManagement of acne is multifaceted including education, topical/oral treatments and lifestyle modifications. \n\n- Each treatment combination is given as a 12 week course. \n- Combination therapies help reduce antimicrobial resistance. \n- Antibiotics are used predominantly since they have anti-inflammatory effects, rather than for their antimicrobial effects.\n- **Mild-moderate acne** is treated with any 2 of the following in combination:\n\t- Topical benzoyl peroxide.\n\t- Topical antibiotics (clindamycin)\n\t- Topical retinoids (tretinoin/adapalene)\n- **Moderate-severe acne** is treated with a 12-week coures of the following first line options:\n\t- Topical retinoids (tretinoin/adapelene) + topical benzoyl peroxide.\n\t- Topical retinoids + topical antibiotics (clindamycin)\n\t- Topical benzoyl peroxide + topical retinoid (tretinoin/adapelene) + oral antibiotic (lymecycline/doxycycline.) \n\t- Topical azelaic acid + oral antibiotic (lymecycline/doxycycline) \n\t- Second line oral antibiotics: trimethoprim and erythromycin e.g. in pregnant/breast-feeding women where tetracyclines are contra-indicated. \n\t- Combined oral contraceptives (COCPs) (if not contraindicated) in combination with topical agents can be considered as an alternative to systemic antibiotics in women\n\nNB: topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning a pregnancy, and so women of childbearing potential will need to use effective contraception, or choose an alternative treatment to these options.\n\t\n- As per NICE guidelines, referral to specialist Dermatology is indicated in the case of:\n\t- Acne fulminans.\n\t- Mild-moderate acne not responding to two 12 week courses of treatment as above.\n\t- Moderate-severe acne not responding to one 12 week course of treatment as above, including an oral antibiotic.\n\t- Psychological distress/mental health disorder contributed to by acne.\n\t- Acne with persistent pigmentary changes.\n\t- Acne with scarring.\n- Other available agents:\n\t- Co-cyprindiol: anti-androgenic contraceptive agent - may be trialled in primary care on female patients, but usually second line COCP due to increased risk of venous thromboembolism, and can only be given for 3 months. \n\t- Spironolactone: anti-androgenic - not often used. Not for male patients. \n\t- **Isotretinoin (oral retinoid):** the usual next step if the standard treatment fails and is prescribed by a dermatologist. \n\t\t* Notable adverse effects: dry skin/mouth/eyes/lips (most common), teratogenecity, photosensitivity, low mood, nose bleeds, hair thinning, raised triglycerides, intracranial hypertension \n\t\t* Isotretinoin is a well established teratogen that results in miscarriages and severe birth defects. As a result, the manufacturer recommends that all female patients taking isotretinoin are also using two forms of contraception from one month before until one month after use. For this reason a pregnancy test should also be done before initiating treatment\n\t\t* There is a controversial association between isotretinoin and depression/suicide. Recent research has shown that concerns about links between isotretinoin and depression or suicide are not established. This has now been included into the NICE guidelines. However it is still important to screen for depression/suicidal ideation before prescribing and during treatment.\n\t\n\t\n# Complications\n\n- Post-inflammatory erythema\n- Post-inflammatory hyper- and hypo- pigmentation\n- Psycho/social/sexual dysfunction \n- Scars (atrophic, hypertrophic, keloid)\n\t- Keloid scars: over-proliferating scar tissue/collagen extending beyond the boundaries of the lesion. Takes 3-4 weeks typically to develop after injury. They can cause itch and pain. It is fleshy, smooth, firm, and does not regress with time. The original injury may be minor, for example piercing or insect bite. Treatment is usually with intralesional steroids (triamcinolone). Cryotherapy and laser may also be used. Surgical resection is unlikely to be successful due to further scarring. Risk factors include:\n\t\t- Darker skin/Chinese/Hispanic origin \n\t\t- Less than 30 years of age\n\t\t- Previous keloid scarring \n\t- These are distinct from hypetrophic scars, which are thick and raised but remain within the injured boundary and tend to improve over time. \n\n# NICE Guidelines\n\n[NICE CKS for Acne Vulgaris](https://cks.nice.org.uk/topics/acne-vulgaris/)",
"files": null,
"highlights": [],
"id": "849",
"pictures": [
{
"__typename": "Picture",
"caption": "*A mixture of papules, pustules and comedones seen on the anterior aspect of the chest.*",
"createdAt": 1665036196,
"id": "948",
"index": 1,
"name": "Acne vulgaris 2.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/z1qreg9z1665036171730.jpg",
"path256": "images/z1qreg9z1665036171730_256.jpg",
"path512": "images/z1qreg9z1665036171730_512.jpg",
"thumbhash": "ZSgCBYL/a6avaHmUZ2eVeVZqkFUH",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
},
{
"__typename": "Picture",
"caption": "*Ice pick scarring seen on the cheeks following severe acne.*",
"createdAt": 1665036196,
"id": "935",
"index": 2,
"name": "Acne vulgaris 3.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/dsmfvp5y1665036171729.jpg",
"path256": "images/dsmfvp5y1665036171729_256.jpg",
"path512": "images/dsmfvp5y1665036171729_512.jpg",
"thumbhash": "kmoGFYJdiXePiHeYaKiHeC1vN/Jk",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
},
{
"__typename": "Picture",
"caption": "*An example of moderate acne vulgaris seen on the face.*",
"createdAt": 1665036196,
"id": "961",
"index": 0,
"name": "Acne vulgaris.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/iwkx46ju1665036171730.jpg",
"path256": "images/iwkx46ju1665036171730_256.jpg",
"path512": "images/iwkx46ju1665036171730_512.jpg",
"thumbhash": "E1kOFYYEaHeEiIiDiYh3hwN2NXBH",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
}
],
"typeId": 2
},
"chapterId": 849,
"demo": null,
"entitlement": null,
"id": "893",
"name": "Acne Vulgaris",
"status": null,
"topic": {
"__typename": "Topic",
"id": "4",
"name": "Dermatology",
"typeId": 2
},
"topicId": 4,
"totalCards": 6,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "893",
"name": "Acne Vulgaris"
}
],
"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
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "893",
"name": "Acne Vulgaris"
}
],
"demo": false,
"description": null,
"duration": 226.09,
"endTime": null,
"files": null,
"id": "4",
"live": false,
"museId": "EoFXN7C",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/dermatology.png",
"title": "Acne Vulgaris",
"userViewed": false,
"views": 141,
"viewsToday": 17
}
]
},
"conceptId": 893,
"conditions": [],
"difficulty": 1,
"dislikes": 8,
"explanation": null,
"highlights": [],
"id": "10646",
"isLikedByMe": 0,
"learningPoint": "Oral antibiotics like lymecycline are recommended for moderate acne unresponsive to topical treatments.",
"likes": 2,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 20-year-old female presents to general practice with questions regarding her ongoing acne. She has extensive pustules and erythematous papules across her face and upper back. She is embarrassed of her skin but denies any low mood. She has previously tried combinations of topical Differin, topical benzoylperoxide and topical clindamycin with no improvement. She has had a previous deep vein thrombosis (DVT) after surgery. She takes no regular medications currently and has no drug allergies.\n\nWhat is the most appropriate next step in management?",
"sbaAnswer": [
"a"
],
"totalVotes": 3324,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,957 | false | 15 | null | 6,494,981 | null | false | [] | null | 10,647 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a large stone with radiological evidence of obstruction and hydronephrosis in the context of a single kidney. Therefore, it would be inappropriate to manage this expectantly since the stone is unlikely to be spontaneously passed and more urgent treatment is required due to susceptibility to acute kidney injury, long-term sequelae for his solitary kidney and risk of urosepsis.",
"id": "52933",
"label": "b",
"name": "Expectant management with regular diclofenac",
"picture": null,
"votes": 61
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Haemofiltration may be required if this patient presents with certain features of severe kidney injury, such as treatment-resistant fluid overload, hyperkalaemia, acidosis or uraemia. This patient is at risk of acute kidney injury and may require filtration further down the line if the obstruction is not rapidly relieved. There is no indication that this is an issue at present, with his blood tests within normal parameters.",
"id": "52934",
"label": "c",
"name": "Urgent haemofiltration",
"picture": null,
"votes": 16
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be the treatment of choice for removal of stones less than 20 mm in size. This breaks the stone up and allows the patient to pass the pieces through the urine. This is not the best approach in acute obstructions with hydronephrosis and would not be appropriate for this patient where the stone is 30 mm in size.",
"id": "52935",
"label": "d",
"name": "Extracorporeal shock lithotripsy",
"picture": null,
"votes": 409
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "There is radiographic evidence of renal obstruction with an associated large stone in the context of a single kidney. This patient is at significant risk of deterioration from sepsis due to the obstruction. Prompt action is also required due to the presence of a single kidney to protect his long-term kidney health but also due to the absence of a second kidney to compensate in terms of providing adequate renal function in the acute setting. In the first instance, decompression with a nephrostomy is required. The stone is likely to require subsequent surgical removal due to its large size (> 10 mm).",
"id": "52932",
"label": "a",
"name": "Percutaneous nephrostomy",
"picture": null,
"votes": 2522
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Since this patient has only one kidney, they are at risk of end-stage renal disease and may, eventually, require a renal transplant. Kidney transplants are reserved for patients with established end-stage renal failure (which this patient does not have). It can take several years for an appropriate donor match to be identified, so it is not an acute form of renal replacement therapy; if this patient went on to sustain a severe acute kidney injury, haemofiltration may be required. If they did not recover from the acute injury, then they would need long-term dialysis as a bridge to transplant.",
"id": "52936",
"label": "e",
"name": "Renal transplant",
"picture": null,
"votes": 7
}
],
"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": 0,
"explanation": null,
"highlights": [],
"id": "10647",
"isLikedByMe": 0,
"learningPoint": "In patients with a single kidney and obstructive uropathy, prompt decompression via percutaneous nephrostomy is crucial to prevent renal deterioration.",
"likes": 1,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 43-year-old man presents with left-sided loin-to-groin pain. He has vomited twice. On examination, he appears to be in significant discomfort but his vital signs are within normal parameters. He is given a dose of diclofenac and a CT kidneys, ureters and bladder is performed. The CT scan reveals a left single kidney with a 30mm stone at the pelvico-ureteric junction and evidence of associated hydronephrosis. His blood tests are unremarkable.\n\nWhat is the next best step in management?",
"sbaAnswer": [
"a"
],
"totalVotes": 3015,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,958 | false | 16 | null | 6,494,981 | null | false | [] | null | 10,648 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A nasopharyngeal airway is an airway adjunct that will help maintain an airway at risk of obstruction/obstructed at the nasopharyngeal level. It does not provide definitive airway support and will not enable mechanical ventilation, which this tiring patient with asthma with a near-fatal flare-up requires at this stage.",
"id": "52938",
"label": "b",
"name": "Insert a nasopharyngeal airway",
"picture": null,
"votes": 22
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has raised carbon dioxide levels, indicating that he is tiring. This represents a near-fatal asthma exacerbation. An intensive care review is now required since he will need intubation and ventilation. Practically, a 2222 call may need to be placed to summon the intensive care team immediately.",
"id": "52937",
"label": "a",
"name": "Immediate intensive care review",
"picture": null,
"votes": 1761
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has already had ipratropium bromide at the correct dose. Ipratropium is not provided back to back because it does not provide additional benefit in this manner and has anticholinergic side effects. The next dose would be due in 6-h time (500 μg 4 times a day). Furthermore, no additional time should be spent on medical management as a next step since seeking intensive care review with a view to intubation and ventilation is most important at this stage.",
"id": "52941",
"label": "e",
"name": "Provide a further dose of nebulised ipratropium bromide",
"picture": null,
"votes": 230
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Inhaled corticosteroids will not provide immediate benefit to a patient presenting with an acute asthma flare-up. They have a role in long-term asthma control. They should be continued on the drug chart if a patient is admitted with an asthma flare-up and is already on them in the community; adding them in the acute setting will not provide significant rapid relief. Oral steroids are indicated in the management of acute asthma exacerbations. In the context of a raised PaCO<sub>2</sub>, this patient requires mechanical ventilation without delay.",
"id": "52939",
"label": "c",
"name": "Add high-dose inhaled corticosteroids",
"picture": null,
"votes": 155
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be a sensible addition. However, this patient is tiring and so while magnesium may be provided, the next step should be summoning the intensive care team immediately with a view to intubation and ventilation before any further time is spent on medical management.",
"id": "52940",
"label": "d",
"name": "Start a magnesium sulphate infusion",
"picture": null,
"votes": 566
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nAsthma is a common disease of the airways, involving reversible bronchoconstriction, hyperreactivity and chronic inflammation. When bronchoconstriction is triggered (an “asthma attack” or exacerbation), patients experience episodes of wheeze, dyspnoea, cough and chest tightness. Initial investigations in an asthma exacerbation include doing a peak flow measurement, an arterial blood gas (ABG) if oxygen saturations are low or hypercapnia is suspected, and a chest X-ray in selected cases (e.g. where there are signs of pneumonia). Management involves supplementary oxygen, bronchodilators (either inhaled or nebulised) and steroids. Patients with severe or life-threatening asthma exacerbations may require additional treatments including escalation to intensive care for intubation and ventilation in some cases.\n\n# Definition\n\nAsthma is a common disease in both adults and children, characterised by intermittent []()exacerbations with wheeze, cough, shortness of breath and chest tightness. There are several underlying mechanisms that centre around reversible bronchoconstriction, hyperreactivity and chronic inflammation.\n\n# Epidemiology\n\nIn the UK, approximately 8 million people have been diagnosed with asthma, of which 5.4 million are on treatment. Onset is usually in childhood and some find symptoms remit with age, although relapse is possible after long periods of being well.\n\nAsthma exacerbations are the cause of 60,000 hospital admissions per year in the UK. Over 1000 people die of asthma per year, with two-thirds of these deaths thought to be preventable. An estimated 7/10 people with asthma do not receive basic preventative care such as inhaler technique checks and a personalised asthma plan.\n\nPeople experiencing socioeconomic deprivation are more likely to have asthma and to have worse outcomes (e.g. higher rates of hospitalisation). This is multifactorial, with these groups more likely to be exposed to triggers such as smoking and air pollution, and to have lower health literacy and access to healthcare.\n\n# Aetiology\n\nAsthma is often associated with a personal and/or family history of atopy, including the atopic triad of asthma, allergic rhinitis, and eczema. In asthma, there is an exaggerated response to a wide range of triggers. These include:\n\n- Cold air and exercise\n- Pollution and cigarette smoke\n- Allergens such as animal dander, dust mites and pollen\n- Irritants such as perfumes, paints or air fresheners\n- Medications such as NSAIDs or beta-blockers\n\nThese trigger a type 1 hypersensitivity reaction which is mediated by IgE. T Helper 2 cells produce IL4, IL5 and IL13 cytokines which activate the humoral immune system, leading to the proliferation of eosinophils, mast cells and dendritic cells. These cells then produce more inflammatory mediators such as leukotrienes and histamine.\n\nThis inflammation contributes to airway hyperresponsiveness leading to bronchospasm, as well as mucus hypersecretion that also obstructs airways. Over time in severe asthma, airway remodelling mediated by fibroblasts causes chronic obstruction and thickening of smooth muscle.\n\n# Classification\n\nAcute asthma exacerbations are graded in severity as below:\n\n\n| Severity | Clinical Features |\n|-----------------------|-----------------------------------------------|\n| Moderate | PEFR > 50% of predicted or best |\n| | No features of severe/life-threatening asthma |\n| Severe | PEFR 33-50% of predicted or best |\n| | Heart rate > 110 |\n| | Respiratory rate > 25 |\n| | Unable to complete sentences in one breath |\n| | Accessory muscle use |\n| Life-threatening | PEFR < 33% of predicted or best |\n| | Oxygen saturation < 92% or cyanosis |\n| | Altered conciousness/confusion |\n| | Exhaustion/poor respiratory effort |\n| | Cardiac arrhythmia |\n| | Hypotension |\n| | Silent chest |\n| Near fatal | Raised PaCO2 |\n| | Requiring mechanical ventilation with raised inflation pressures |\n\n\n# Signs and Symptoms\n\nPatients experiencing an asthma exacerbation present with progressive worsening of the following symptoms, usually over the course of several hours:\n\n- Wheeze\n- Difficulty breathing\n- Struggling to eat, speak or sleep due to breathlessness\n- Cough\n- Chest tightness\n- Dizziness\n\nOn examination, patients may have:\n\n- Tachypnoea\n- Increased work of breathing\n- Hyperinflated chest\n- Expiratory polyphonic wheeze throughout the lung fields\n- Decreased air entry \n- Cyanosis\n- Tachycardia\n- Altered mental state, e.g. drowsiness or confusion\n- Exhaustion\n- Hypotension\n\nThey may be able to identify a trigger and have signs and symptoms of this (e.g. fever and coryza in viral infection).\n\n\n# Differential diagnosis\n\n- **Pulmonary embolism** - associated with risk factors e.g. immobility, malignancy; shares features of shortness of breath and cough, may have haemoptysis and pleuritic chest pain.\n- **Vocal cord dysfunction** - shares many triggers with asthma, inspiration more difficult than expiration, may have stridor.\n- **Acute exacerbation of chronic obstructive pulmonary disease** - patients usually >35 years old with a significant smoking history, may overlap with asthma in some.\n- **Gastro-oesophageal reflux disease** - microaspiration of stomach acid due to reflux can cause episodes of cough and wheeze which mimic asthma (although these may coexist and reflux can trigger asthma exacerbations). Symptoms are often postural and related to eating.\n- **Anaphylaxis** - also may present with sudden-onset shortness of breath and wheeze, usually more rapid onset and may have skin and mucosal changes such as urticaria and lip swelling\n\n# Investigations \n\n**Bedside tests:**\n\n- **Peak expiratory flow rate (PEFR)** to help assess severity as per the classification above and monitor response to treatment.\n- **Arterial blood gas** if the patient is hypoxic to assess oxygenation and ventilation in patients - CO2 is expected to be low due to hyperventilation and if this is raised this indicates the asthma attack is near fatal.\n- **ECG** to look for arrhythmias especially if tachycardic.\n\n**Blood tests:**\n\n- **FBC** and **CRP** for inflammatory markers\n- **U&Es** and **LFTs** as a baseline - patients may develop acute kidney injury if too breathless to drink for prolonged periods\n- **Blood cultures** if bacterial infection suspected e.g. an unwell patient with fevers\n\n**Imaging:**\n\n- **Portable chest X-ray** if a trigger such as pneumonia or a complication such as pneumothorax is suspected clinically.\n\n# Management \n\n- Recognise that this may be a medical emergency, assess using an ABCDE approach and escalate early to senior colleagues/critical care if not responding to treatment\n- Titrate oxygen to maintain saturations of 94-98%\n- Nebulised salbutamol (5mg) driven by oxygen (if out of hospital, give up to 10 puffs of inhaled salbutamol and call an ambulance if not responding)\n- If the attack is severe or life-threatening or if response to salbutamol has been poor, add nebulised ipratropium bromide (500mcg 4-6 hourly)\n- Give prednisolone 40-50 mg OD orally, or 100mg IV hydrocortisone QDS if the patient is unable to swallow\n- Continue steroids for at least 5 days or until recovery (whichever is longer)\n- Can consider IV magnesium sulphate (1.2-2 grams over 20 minutes) and/or aminophylline if the patient is not responding to nebulisers\n- If the patient continues to deteriorate despite maximal therapy, they may require intubation and ventilation in an intensive care setting (for example in cases of severe hypoxia or exhaustion)\n- Antibiotics should not be given routinely, especially as many infectious triggers of asthma exacerbations are viral\n\nFollow up after an acute asthma attack is crucial, with NICE guidelines stating that patients should be reviewed within 2 days of discharge from hospital to assess their symptoms, inhaler technique and current management. Ensure all patients have an up-to-date personalised asthma action plan.\n\n# Complications\n\n- **Respiratory failure** which may be type 1 (hypoxaemia alone) or type 2 (hypoxaemia with hypercapnia)\n- **Pneumothorax** - airway obstruction during asthma exacerbations may cause barotrauma and alveolar rupture, causing pneumothoraces or pneumomediastinum\n- **Status asthmaticus** - repeated asthma attacks without recovery in between, or which do not respond to treatment\n- **Death** - patients with previous severe asthma attacks and those adverse psychosocial factors are more likely to die of asthma (e.g. drug or alcohol abuse, repeated failure to attend appointments and learning difficulties)\n\n# NICE Guidelines\n\n[NICE CKS - Asthma](https://cks.nice.org.uk/topics/asthma/)\n\n# References\n\n[British Thoracic Society Asthma Guidelines](https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/)\n\n[BNF - Acute Asthma](https://bnf.nice.org.uk/treatment-summaries/asthma-acute/)\n\n[Report on health inequalities and asthma](https://www.asthmaandlung.org.uk/sites/default/files/2023-03/auk-health-inequalities-final.pdf)",
"files": null,
"highlights": [],
"id": "2025",
"pictures": [],
"typeId": 2
},
"chapterId": 2025,
"demo": null,
"entitlement": null,
"id": "731",
"name": "Emergency Management of Acute Asthma Exacerbation",
"status": null,
"topic": {
"__typename": "Topic",
"id": "39",
"name": "Emergency Medicine",
"typeId": 2
},
"topicId": 39,
"totalCards": 46,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "731",
"name": "Emergency Management of Acute Asthma Exacerbation"
}
],
"demo": false,
"description": null,
"duration": 337.3,
"endTime": null,
"files": null,
"id": "106",
"live": false,
"museId": "Rz5tqRZ",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/ED.png",
"title": "Emergency Management of Acute Asthma Exacerbation 2",
"userViewed": false,
"views": 49,
"viewsToday": 6
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "731",
"name": "Emergency Management of Acute Asthma Exacerbation"
}
],
"demo": false,
"description": null,
"duration": 4433.3,
"endTime": null,
"files": null,
"id": "310",
"live": false,
"museId": "rmfLvCe",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/respiratory.png",
"title": "Quesmed Tutorial: COPD and Asthma ",
"userViewed": false,
"views": 193,
"viewsToday": 21
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "731",
"name": "Emergency Management of Acute Asthma Exacerbation"
}
],
"demo": false,
"description": null,
"duration": 5074.09,
"endTime": null,
"files": null,
"id": "334",
"live": false,
"museId": "C69sCWc",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/respiratory.png",
"title": "Quesmed Tutorial: Respiratory",
"userViewed": false,
"views": 747,
"viewsToday": 19
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "731",
"name": "Emergency Management of Acute Asthma Exacerbation"
}
],
"demo": false,
"description": null,
"duration": 457.9,
"endTime": null,
"files": null,
"id": "108",
"live": false,
"museId": "GD2zUnf",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/ED.png",
"title": "Emergency Management of Acute Asthma Exacerbation 4",
"userViewed": false,
"views": 39,
"viewsToday": 5
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "731",
"name": "Emergency Management of Acute Asthma Exacerbation"
}
],
"demo": false,
"description": null,
"duration": 194.67,
"endTime": null,
"files": null,
"id": "105",
"live": false,
"museId": "v6FHyNs",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/ED.png",
"title": "Emergency Management of Acute Asthma Exacerbation 1",
"userViewed": false,
"views": 109,
"viewsToday": 7
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "731",
"name": "Emergency Management of Acute Asthma Exacerbation"
}
],
"demo": false,
"description": null,
"duration": 530.03,
"endTime": null,
"files": null,
"id": "107",
"live": false,
"museId": "maCN2iJ",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/ED.png",
"title": "Emergency Management of Acute Asthma Exacerbation 3",
"userViewed": false,
"views": 141,
"viewsToday": 11
}
]
},
"conceptId": 731,
"conditions": [],
"difficulty": 1,
"dislikes": 13,
"explanation": null,
"highlights": [],
"id": "10648",
"isLikedByMe": 0,
"learningPoint": "In severe asthma exacerbations, rising carbon dioxide levels signal potential respiratory failure. Immediate intensive care review is crucial to provide interventions, support breathing, and prevent life-threatening complications from impaired gas exchange.",
"likes": 3,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 23-year-old man attends A&E with a 1-d history of shortness of breath. He reports no cough and no fever. He has a past medical history of asthma and takes a salbutamol and corticosteroid inhaler. On examination, his chest is diffusely wheezy with reduced air entry bilaterally. He ahs increased work of breathing. His vital signs are within normal parameters. He is commenced on back-to-back salbutamol and oral prednisolone. Nebulised ipratropium (500 μg) has also been provided. His arterial blood gases (ABGs) after an hour of medical therapy are shown below:\n\n\n||||\n|--------------|:-------:|------------------|\n|pH|7.34|7.35 - 7.45|\n|PaO₂|12.2 kPa|11 - 15|\n|PaCO₂|6.5 kPa|4.6 - 6.4|\n|Bicarbonate|23mmol/L|22 - 30|\n|Base Excess|mmol/L|-2 to +2 \nO<sub>2</sub> saturation|99%|94-98%\n\n\nWhat is the next step in his management?",
"sbaAnswer": [
"a"
],
"totalVotes": 2734,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,959 | false | 17 | null | 6,494,981 | null | false | [] | null | 10,649 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Enlarged tonsils, adenoids or a narrowed airway can be risk factors for OSA. A laryngoscopy could be used to evaluate any structural abnormalities narrowing the airway. However, this is not first line and is generally reserved for patients undergoing potential surgical treatment, where standard medical therapy such as continuous positive airway pressure has failed or not been tolerated.",
"id": "52945",
"label": "d",
"name": "Laryngoscopy",
"picture": null,
"votes": 27
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The history of snoring and daytime somnolence in a patient who is obese points towards a diagnosis of obstructive sleep apnoea (OSA). Acting out dreams can be a rapid eye movement (REM) disorder, which can also be seen in a small number of these patients. The first-line investigation for OSA would be polysomnography.",
"id": "52942",
"label": "a",
"name": "Polysomnography",
"picture": null,
"votes": 2849
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A sleep diary is unlikely to yield much additional information since the patient and his wife have already given detailed accounts of his sleep patterns. Their accounts point towards a diagnosis of OSA; therefore, he should be referred for polysomnography.",
"id": "52944",
"label": "c",
"name": "Sleep diary",
"picture": null,
"votes": 220
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Waking in the middle of the night can occur in the context of heart failure, where the patient reports waking up breathless and coughing pink, frothy sputum (paroxysmal nocturnal dyspnoea (PND)). In this case, there are no reported heart failure symptoms, such as shortness of breath, PND, orthopnoea or ankle swelling. The clinical presentation is more in keeping with OSA.",
"id": "52946",
"label": "e",
"name": "Brain natriuretic peptide",
"picture": null,
"votes": 29
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Acting out dreams can indicate a REM disorder. This can be an early feature of Parkinson's disease, where a DaTscan can illustrate loss of dopaminergic neurones in the basal ganglia. However, given the patient demographics and the absence of any parkinsonian features, the more likely underlying cause of the REM sleep disorder is OSA. The first-line investigation would be polysomnography.",
"id": "52943",
"label": "b",
"name": "DaTscan",
"picture": null,
"votes": 22
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nObstructive sleep apnoea (OSA) is caused by intermittent obstruction of the upper airways during sleep when there is loss of oropharyngeal muscle tone. Patients predisposed to this include those with obesity, large neck circumferences, anatomically smaller airways and decreased muscle tone due to alcohol or drugs (amongst other risk factors). The intermittent airway obstruction and resulting hypoxaemia leads to frequent awakening from sleep and so symptoms include excessive daytime sleepiness, morning headaches and poor concentration. The diagnostic investigation is polysomnography (a sleep study) to determine how many apnoeic or hypopnoeic episodes a patient is experiencing. Treatment includes modifying risk factors such as excess body weight and sleeping position, and continuous positive airway pressure (CPAP) devices to prevent airway obstruction overnight. \n\n# Definition\n\nObstructive sleep apnoea (OSA) is a condition where the upper airway becomes completely or partially obstructed during sleep, causing apnoeas (where breathing temporarily stops) or hypopnoeic episodes (decreased airflow during breathing). These episodes cause oxygen desaturations which cause brief arousals from sleep which can be hundreds of times per night. This leads to poor sleep quality which causes symptoms of daytime drowsiness, morning headaches and impaired concentration.\n\n# Epidemiology\n\nOSA is common, affecting an estimated 1.5 million adults in the UK, however around 85% of these are undiagnosed. Around half of people affected are overweight or obese, with 40% of obese people and 77% of morbidly obese people having OSA.\n\nOSA is strongly linked with cardiovascular disease and the metabolic syndrome, and is a significant risk factor for coronary artery disease, type 2 diabetes and stroke.\n\nDaytime sleepiness is an important consideration, especially in patients who drive or whose jobs require vigilance. Patients who drive for work and so are on the road for long periods of time and may be driving large vehicles are of particular concern due to the increased risk of injury to themselves and other road users.\n\n# Aetiology\n\nDuring sleep there is a normal loss of muscle tone in the oropharynx. In most people, there is still sufficient airway patency during sleep so that it does not become obstructed. Patients with OSA, however, require the muscle tone when awake to counteract additional pressures on their airway and so are unable to maintain patency when asleep.\n\nRisk factors for OSA include:\n\n- Obesity\n- Male sex\n- Older age\n- Decreased muscle tone - e.g. alcohol excess, sedative medications, muscular dystrophy or other neuromuscular disorders\n- Anatomical defects - e.g. retrognathia, macroglossia\n- Large neck circumference\n- Adenotonsillar hypertrophy (particularly in children)\n- Sleeping supine\n- Down’s syndrome\n\n# Signs and symptoms\n\n- Unrefreshing sleep, or frequent waking at night\n- Daytime sleepiness\n- Others may witness snoring, apnoeas, gasping or choking during sleep\n- Difficulty concentrating\n- Morning headaches\n- Behavioural problems and hyperactivity in children\n\nOn examination, patients may be drowsy and may have some of the risk factors above such as:\n\n- Obesity (check BMI)\n- Large neck circumference (can measure or ask collar size) \n- Jaw abnormalities (retrognathia or micrognathia)\n- Mouth breathing or nasal speech (due to nasopharyngeal obstruction, e.g. due to adenotonsillar enlargement)\n\nAlso look for signs and symptoms of complications of OSA such as hypertension or arrhythmias. \n\n# Differential Diagnosis\n\n- **Insomnia** - defined as difficulty falling asleep, staying asleep or poor sleep quality that leads to daytime impairment, commonly associated with other mental and physical health conditions\n- **Sleep disturbance** - for example due to shift work\n- **Restless legs syndrome** - patients get irresistible urges to move their legs accompanied by unpleasant sensations, often at night disturbing sleep\n- **Narcolepsy** - excessive daytime sleepiness, sudden attacks of sleep, excessive dreaming are common, may be associated with cataplexy (sudden loss of muscle tone, often triggered by strong emotions)\n- **Hypothyroidism** - also a risk factor for OSA, causes fatigue, poor concentration, weight gain and depression among other symptoms\n- **Depression** - associated with OSA, overlapping symptoms include low energy levels, poor concentration and low mood\n- **Medications** - SSRIs, antiepileptic medications and benzodiazepines can cause symptoms of daytime sleepiness and disturbed sleep\n- **Gastro-oesophageal reflux disease** - mimics nocturnal symptoms of choking and gasping, can disturb sleep\n\n# Investigations\n\nInitial screening for OSA symptoms and severity should be done using a questionnaire - the two recommended are STOP-Bang and the Epworth sleepiness scale.\n\n**STOP-Bang** asks about snoring, sleepiness, apnoeas, hypertension, obesity, neck circumference, age and sex and gives a low, medium or high risk of OSA.\n\nThe **Epworth sleepiness scale** focuses on daytime sleepiness and asks how likely the patient would be to fall asleep in a variety of situations (e.g. when watching TV). This gives a result of either normal daytime sleepiness or mild, moderate or severe excessive daytime sleepiness.\n\nThe definitive investigation is **polysomnography** (also called a sleep study) which would usually be arranged by a specialist clinic.\n\nPatients should be referred for this urgently (to be seen within 4 weeks) if:\n\n- Excessive sleepiness is impacting on their safety to work (e.g. professional driver)\n- They have a related comorbid condition such as treatment resistant hypertension or COPD\n- They have upcoming major surgery \n- They are pregnant\n\nPatients who do not fall into the above categories but have moderate or severe OSA or mild OSA which is impacting quality of life should be referred routinely to a sleep clinic for consideration of polysomnography.\n\nUsually polysomnography is done as an outpatient and patients can do the study at home overnight. In some situations an overnight admission may be required.\n\nThe study looks at how many episodes of apnoeas or hypopnoeas lasting 10 seconds or more patients have per hour of sleep (referred to as the apnoea-hypopnoea index or AHI). Five or more is diagnostic of OSA and severity is classified as below:\n\n- Mild OSA: AHI 5-14 per hour\n- Moderate OSA: AHI 15-30 per hour\n- Severe OSA: AHI over 30 per hour\n\nThe number of episodes of oxygen desaturation per hour is also measured, with more episodes of desaturation predictive of poorer cardiovascular outcomes.\n\n# Management\n\n**Conservative management includes:**\n\n- Patient education, especially concerning driving (see section on driving advice)\n- Advise to sleep on their side rather than supine where possible (aids such as repositioning pillows may be of help)\n- Weight loss advice and support (including diet, exercise, medications and surgery)\n- Reduction in alcohol intake\n- Smoking cessation\n\n**Medical management includes:**\n\n- Continuous Positive Airway Pressure (CPAP) therapy - this is first line in symptomatic OSA and is a long-term treatment. \n- A mask over the nose or face is used to deliver additional airway pressure that splints open the airways and prevents the collapse seen in OSA. \n- Education and support are key as tolerance can be a problem and masks need to fit well to be effective.\n- If patients do not tolerate or respond to CPAP, an intra-oral mandibular advancement device is another option. \n- These devices pull the mandible forward, opening the airway and preventing obstruction. \n- Management of comorbidities including hypertension, diabetes and depression is also important.\n\n**Surgical management includes:**\n\n- In cases where there is oropharyngeal obstruction e.g. due to adenotonsillar enlargement, surgery may be considered to relieve this for example a tonsillectomy.\n\n# Driving advice\n\nAll patients with daytime sleepiness due to OSA should be advised as follows:\n\n- If OSA is suspected or mild, advise patients not to drive until symptoms are controlled. If this is not achieved within 3 months, they should inform the DVLA.\n- If OSA is moderate or severe, patients should inform the DVLA immediately and not drive; this will be reviewed by the DVLA and they may be allowed to drive once symptoms are controlled.\n\nThis is the same for group 1 drivers (cars and motorbikes) and group 2 (lorries, buses and coaches), however group 2 drivers returning to driving after symptom control is achieved require annual reviews of this (rather than 3 yearly for group 1 drivers).\n\n# Complications\n\nComplications related to daytime sleepiness include:\n\n- Road traffic collisions - patients with OSA have a 2.5x increased risk compared to those without the condition\n- Accidents at home or at work\n- Deterioration in mental health, including irritability and depression\n\nCardiovascular and metabolic complications include:\n\n- Stroke\n- Coronary artery disease\n- Hypertension that may be treatment resistant\n- Congestive heart failure\n- Type 2 diabetes\n\n# NICE Guidelines\n\n[NICE CKS - Obstructive sleep apnoea syndrome](https://cks.nice.org.uk/topics/obstructive-sleep-apnoea-syndrome/)\n\n# References\n\n[Patient UK - Obstructive sleep apnoea](https://patient.info/doctor/obstructive-sleep-apnoea-syndrome-pro) \n\n[British Lung Foundation - OSA Toolkit](https://www.asthmaandlung.org.uk/sites/default/files/OSA_Toolkit_2015_BLF_0.pdf) \n\n[DVLA - Tiredness can kill: advice for drivers](https://www.gov.uk/government/publications/tiredness-can-kill-advice-for-drivers)",
"files": null,
"highlights": [],
"id": "338",
"pictures": [],
"typeId": 2
},
"chapterId": 338,
"demo": null,
"entitlement": null,
"id": "341",
"name": "Obstructive Sleep Apnoea",
"status": null,
"topic": {
"__typename": "Topic",
"id": "32",
"name": "Respiratory",
"typeId": 2
},
"topicId": 32,
"totalCards": 11,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 341,
"conditions": [],
"difficulty": 1,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "10649",
"isLikedByMe": 0,
"learningPoint": "Polysomnography is the gold standard investigation for diagnosing obstructive sleep apnoea, it simultaneously records brain activity, eye movement, muscle activity, heart rate, respiratory effort, airflow, and oxygen saturation during sleep to identify apneic episodes and assess their severity.",
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 42-year-old man attends his GP after a 6-month history of difficulty sleeping. He reports waking up multiple times a night gasping for breath and then napping more regularly in the day. His wife has also noticed that he tends to act out his dreams while asleep and snores heavily. On examination, his body mass index is 35 and otherwise unremarkable.\n\nWhat is the best next investigation for his poor sleep?",
"sbaAnswer": [
"a"
],
"totalVotes": 3147,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,960 | false | 18 | null | 6,494,981 | null | false | [] | null | 10,650 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Premature ovarian failure refers to loss of normal ovarian function before the age of 40. It is confirmed by oligo/amenorrhoea for at least 4 months and an elevated FSH on two occasions at least 4 weeks apart. In premature ovarian insufficiency, there is hypergonadotrophic hypogonadism since loss of negative feedback of ovarian hormones results in raised gonadotrophic hormones (whereas these would be low in functional hypothalamic amenorrhea).",
"id": "52947",
"label": "a",
"name": "Premature ovarian insufficiency",
"picture": null,
"votes": 28
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Prolactinoma can result in secondary amenorrhoea as the elevated prolactin levels inhibit the release of FSH and LH. These patients would have a low oestradiol, low FSH/LH and high prolactin levels.",
"id": "52951",
"label": "e",
"name": "Prolactinoma",
"picture": null,
"votes": 1
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Functional hypothalamic amenorrhoea is a common cause of secondary amenorrhoea. Stress, anorexia or intense exercise result in reduced hypothalamic secretion of gonadotropin-releasing hormone, leading to reduced follicle-stimulating hormone (FSH) and luteinising hormone (LH) and subsequently oestrogen. This is also termed hypogonadotrophic hypogonadism. In this patient, the high FSH and LH levels go against this diagnosis.",
"id": "52948",
"label": "b",
"name": "Functional hypothalamic amenorrhoea",
"picture": null,
"votes": 12
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "In patients under 40 who undergo ovarian failure, this is deemed as premature ovarian insufficiency. However, in women over 40 with menopause symptoms and a low FSH, this is deemed menopause.",
"id": "52949",
"label": "c",
"name": "Menopause",
"picture": null,
"votes": 5
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Polycystic ovarian syndrome (PCOS) can result in amenorrhoea and often presents with evidence of hyperandrogenism, such as hirsutism, acne or elevated testosterone. These patients tend to have a normal FSH but an elevated LH:FSH ratio and can have a normal, low or high oestradiol. The patient in this case has a high FSH and LH and no signs of hyperandrogenism on examination, which goes against the diagnosis of PCOS.",
"id": "52950",
"label": "d",
"name": "Polycystic ovarian syndrome",
"picture": null,
"votes": 10
}
],
"comments": [],
"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": "3508",
"name": "Secondary amenorrhoea",
"status": null,
"topic": {
"__typename": "Topic",
"id": "60",
"name": "General Practice",
"typeId": 2
},
"topicId": 60,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3508,
"conditions": [],
"difficulty": 2,
"dislikes": 3,
"explanation": null,
"highlights": [],
"id": "10650",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 3,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 34-year-old woman presents to her GP with amenorrhoea. She had normal periods up until the last year but has had no periods for the last 4 months. Apart from feeling tired, which she attributes to travelling a lot for work, she reports no other symptoms. Her examination is normal. Her pregnancy test is negative. She has an elevated FSH and LH, a low oestradiol level and a normal prolactin and testosterone level. \n\nWhat is the most likely cause of her amenorrhoea?",
"sbaAnswer": [
"a"
],
"totalVotes": 56,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,961 | false | 19 | null | 6,494,981 | null | false | [] | null | 10,651 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient is presenting with an addisonian crisis postsurgery, as evidenced by refractory hypotension, hyperkalaemia, low-normal sodium and the past medical history of autoimmune disease. A 9 a.m. cortisol < 50 is usually sufficient to make the diagnosis and > 550 to rule out the diagnosis. In between, further testing is required. For primary adrenal insufficiency (Addison's disease), this test will be a short synacthen test.",
"id": "52952",
"label": "a",
"name": "Short synacthen test",
"picture": null,
"votes": 2178
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Cortisol levels fluctuate during the course of the day and with stress, such as that induced by surgery. Although the levels of a random cortisol may be within a normal range, it is still possible that the patient could have a diagnosis of adrenal insufficiency since even apparently normal values may be insufficient for that patient at that particular moment in time. Therefore, a random cortisol will not provide adequate definitive diagnostic information.",
"id": "52955",
"label": "d",
"name": "Random cortisol level",
"picture": null,
"votes": 102
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Assessment of adrenal size and architecture can be useful for the evaluation of adrenal insufficiency, especially if there is concern that there may be an underlying cause, such as malignancy or infection. This is unlikely in this patient since there is no suggestion of there being an underlying cause; it is most likely that this patient has autoimmune Addison's disease, especially given the history of vitiligo.",
"id": "52953",
"label": "b",
"name": "CT abdomen",
"picture": null,
"votes": 91
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Secondary adrenal insufficiency is caused by insufficient production of adrenocorticotropic hormone (ACTH) from the pituitary gland. Assessment of the size and architecture of the pituitary gland could be useful if this was suspected. This usually comes to light during a short synacthen test, where the baseline ACTH is evaluated, which would be low in the case of secondary adrenal insufficiency. Secondary adrenal insufficiency responds normally to short synacthen with a rise in cortisol; however, prolonged secondary adrenal insufficiency may result in underactive adrenal glands that do not respond well to short synacthen; in this case, a long synacthen test will be needed to stimulate cortisol release.",
"id": "52954",
"label": "c",
"name": "MRI pituitary",
"picture": null,
"votes": 235
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Aldosterone is also produced by the adrenal glands, alongside cortisol. It can also be deficient in Addison's disease and fludrocortisone replacement may be required alongside hydrocortisone in these cases. However, the first step in suspected Addison's disease is to evaluate the cortisol insufficiency since this is the most classical feature. A short syncathen test evaluates cortisol levels in response to exogenous ACTH administration and is the definitive initial test. In the case of Addison's disease (primary adrenal insufficiency), there will not be a rise in cortisol levels after ACTH administration.",
"id": "52956",
"label": "e",
"name": "Aldosterone and renin levels",
"picture": null,
"votes": 805
}
],
"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": "689",
"name": "Adrenal insufficiency and Addison's Disease",
"status": null,
"topic": {
"__typename": "Topic",
"id": "5",
"name": "Endocrinology",
"typeId": 2
},
"topicId": 5,
"totalCards": 28,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 689,
"conditions": [],
"difficulty": 1,
"dislikes": 5,
"explanation": null,
"highlights": [],
"id": "10651",
"isLikedByMe": 0,
"learningPoint": "The Short Synacthen Test is used to diagnose Addison's disease by evaluating the adrenal glands' ability to produce cortisol in response to synthetic ACTH stimulation, with a low or absent cortisol response indicating adrenal insufficiency.",
"likes": 5,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 58-year-old man has been referred to intensive care by the anaesthetic registrar in orthopaedic theatre. He has had a knee replacement but has developed a persistent vasopressor requirement despite extensive intravenous fluids. His past medical history is significant for type 2 diabetes, hypertension, osteoarthritis and vitiligo. His blood gases reveal the following: \n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|137 mmol/L|135 - 145|\n|Potassium|6.2 mmol/L|3.5 - 5.3|\n|Fasting Glucose|3.9 mmol/L|3.5 - 5.5|\n\n\nWhat is the definitive investigation for his underlying disease?",
"sbaAnswer": [
"a"
],
"totalVotes": 3411,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,962 | false | 20 | null | 6,494,981 | null | false | [] | null | 10,652 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is in DKA. The initial management is fluid resuscitation, followed by an insulin infusion of 0.1 U/kg/h. 0.05 U/kg/h is the treatment of choice for hyperosmolar hyperglycaemic state if there is inadequate response to fluid therapy. Patients with DKA are profoundly dehydrated due to the osmotic effects of hyperglycaemia; therefore, fluid resuscitation is the first action to take, followed by insulin administration to enable ketone clearance.",
"id": "52959",
"label": "c",
"name": "0.05 U/kg/h Actrapid in 50 ml 0.9% NaCl",
"picture": null,
"votes": 46
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient is in diabetic ketoacidosis (DKA). The initial management is fluid resuscitation, followed by an insulin infusion of 0.1 U/kg/h. The key elements of the history supporting the diagnosis include polyuria, confusion and recent illness in someone who is a known diabetic. When patients become unwell and eat less, they can omit insulin doses due to concerns over hypoglycaemia, pushing themselves instead into DKA. This is the likely situation for this patient.",
"id": "52957",
"label": "a",
"name": "One litre 0.9% NaCl over 1 h",
"picture": null,
"votes": 2464
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is in DKA. The initial management is fluid resuscitation, followed by an insulin infusion of 0.1 U/kg/h. Patients with DKA are profoundly dehydrated due to the osmotic effects of hyperglycaemia; therefore, fluid resuscitation is the first action to take, followed by insulin administration to enable ketone clearance.",
"id": "52958",
"label": "b",
"name": "0.1 U/kg/h of Actrapid in 50 ml 0.9% NaCl",
"picture": null,
"votes": 358
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is in DKA. The initial management is fluid resuscitation, followed by an insulin infusion of 0.1 U/kg/h. This patient's potassium is within the normal range at present, but will fall once the insulin infusion is running since this will drive potassium intracellularly. Therefore, potassium replacement is usually given in subsequent bags of normal saline; however, the first bag of normal saline, which is given rapidly over an hour, should not contain any potassium.",
"id": "52961",
"label": "e",
"name": "1 litre 0.9% NaCl with 40 mmol KCl over 4 h",
"picture": null,
"votes": 284
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is in DKA. The initial management is fluid resuscitation, followed by an insulin infusion of 0.1 U/kg/h. Patients with DKA are profoundly dehydrated due to the osmotic effects of hyperglycaemia; therefore, fluid resuscitation is the first action to take, followed by insulin administration to enable ketone clearance.",
"id": "52960",
"label": "d",
"name": "10% glucose infusion at 125 ml/h",
"picture": null,
"votes": 41
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "shouldnt fluid therapy in this case be a bolus stat (15mins)?",
"createdAt": 1684700296,
"dislikes": 1,
"id": "25595",
"isLikedByMe": 0,
"likes": 6,
"parentId": null,
"questionId": 10652,
"replies": [
{
"__typename": "QuestionComment",
"comment": "His BP ain't the worst of worst",
"createdAt": 1684769805,
"dislikes": 0,
"id": "25687",
"isLikedByMe": 0,
"likes": 0,
"parentId": 25595,
"questionId": 10652,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Intravenous Prone",
"id": 19930
}
},
{
"__typename": "QuestionComment",
"comment": "no bc its >90 SBP",
"createdAt": 1685907772,
"dislikes": 0,
"id": "27865",
"isLikedByMe": 0,
"likes": 0,
"parentId": 25595,
"questionId": 10652,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "CEM",
"id": 24430
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Acanthosis Nigracan't",
"id": 27370
}
}
],
"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": "2214",
"name": "Diabetic Ketoacidosis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "5",
"name": "Endocrinology",
"typeId": 2
},
"topicId": 5,
"totalCards": 5,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "2214",
"name": "Diabetic Ketoacidosis"
}
],
"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": "2214",
"name": "Diabetic Ketoacidosis"
}
],
"demo": false,
"description": null,
"duration": 715.67,
"endTime": null,
"files": null,
"id": "339",
"live": false,
"museId": "7r1VM38",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/chemistry.png",
"title": "Raised anion gap metabolic acidosis 2",
"userViewed": false,
"views": 41,
"viewsToday": 4
}
]
},
"conceptId": 2214,
"conditions": [],
"difficulty": 1,
"dislikes": 2,
"explanation": "One litre 0.9% NaCl over 1 h",
"highlights": [],
"id": "10652",
"isLikedByMe": 0,
"learningPoint": "In the management of diabetic ketoacidosis (DKA), initial treatment typically involves administering fluids, such as one litre of 0.9% NaCl over 1 hour, to rapidly rehydrate the patient and restore circulatory volume.",
"likes": 3,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 19-year-old man presents to A&E with a 3 day history of drowsiness, polyuria, vomiting and confusion. His mother reports he has recently been eating less due to an episode of food poisoning a week ago. He denies any recreational drug use. He has type 1 diabetes and uses a combination of short- and long-acting insulin. His heart rate is 110 bpm, blood pressure 100/75 mmHg, temperature 37.2 °C and oxygen saturation of 98% on air.\n\n\n\nArterial blood gases (ABGs) on room air:\n\n\n||||\n|--------------|:-------:|------------------|\n|pH|7.28|7.35 - 7.45|\n|PaO₂|8.9 kPa|11 - 15|\n|PaCO₂|3.6 kPa|4.6 - 6.4|\n|Bicarbonate|12 mmol/L|22 - 30|\n|Sodium|136 mmol/L|135 - 145|\n|Potassium|4.2 mmol/L|3.5 - 5.3|\n|Fasting Glucose|22 mmol/L|3.5 - 5.5|\n\n\n\n\nA urine dipstick is positive for ketones (++++) and glucose (+++).\n\n\n\nWhat is the next step in his management?",
"sbaAnswer": [
"a"
],
"totalVotes": 3193,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,963 | false | 21 | null | 6,494,981 | null | false | [] | null | 10,653 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Lactulose is an osmotic laxative. Excessive use of lactulose can cause electrolyte abnormalities, such as hypokalaemia, instead of hyperkalaemia.",
"id": "52966",
"label": "e",
"name": "Lactulose",
"picture": null,
"votes": 7
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Omeprazole is a proton pump inhibitor, which can cause hyponatraemia and hypomagnesaemia but is not known to cause hyperkalaemia.",
"id": "52963",
"label": "b",
"name": "Omeprazole",
"picture": null,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Furosemide is a loop diuretic which blocks the reabsorption of sodium, potassium and chloride. It can cause hypokalaemia instead of hyperkalaemia.",
"id": "52964",
"label": "c",
"name": "Furosemide",
"picture": null,
"votes": 31
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Losartan is an angiotensin-receptor blocker used for the treatment of hypertension, diabetic nephropathy and heart failure. As it works on the renin-angiotensin-aldosterone system as a blocker, it can cause a reduced sodium and a raised potassium.",
"id": "52962",
"label": "a",
"name": "Losartan",
"picture": null,
"votes": 33
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Indapamide is a thiazide-like diuretic which can cause hypokalaemia instead of hyperkalaemia.",
"id": "52965",
"label": "d",
"name": "Indapamide",
"picture": null,
"votes": 9
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nHyperkalaemia is a potentially life-threatening electrolyte abnormality, defined as a serum potassium concentration greater than 5.5mmol/L. A potassium of 6.0-6.5 mmol/L is classed as moderate hyperkalaemia, and > 6.5 mmol/L is classed as severe. Causes include acute or chronic renal impairment, medications such as ACE inhibitors, adrenal insufficiency and rhabdomyolysis. Pseudohyperkalaemia is also common and occurs when there is haemolysis of the blood collected that causes potassium to leak from cells. Key investigations include an ECG, a blood gas to confirm hyperkalaemia is true, and U&Es for renal function. Management depends on the severity of hyperkalaemia and may include calcium gluconate or calcium carbonate to stabilise the myocardium and insulin-dextrose infusion to drive potassium into the cells, as well as treating the cause of hyperkalaemia. Potassium binders such as sodium zirconium cyclosilicate (Lokelma) may also be used. The main complication is cardiac conduction abnormalities, with possible findings including tall tented T waves, flattened P waves, bradyarrhythmias and QRS widening with bizarre morphology. \n\n# Definition\n\nHyperkalaemia is a common electrolyte abnormality that is defined as an abnormally high serum potassium. The normal range is 3.5-5.0 mmol/L, with a level of > 5.5 mmol/L generally described as hyperkalaemia. It is seen in around 1-10% of hospital inpatients and is often asymptomatic.\n\n# Aetiology\n\n- Impaired excretion of potassium\n - Acute kidney injury\n - Chronic kidney disease\n - Medications (ACE inhibitors, potassium sparing diuretics, NSAIDs, heparin, trimethoprim, ciclosporin)\n - Type 4 renal tubular acidosis\n - Hypoadrenalism (e.g. Addison's disease)\n- Increased potassium intake\n - Oral intake (especially if combined with impaired excretion)\n - Excessive IV potassium\n- Increased cellular release \n - Metabolic acidosis\n - Hyperglycaemia\n - Rhabdomyolysis\n - Tumour lysis syndrome\n - Packed red blood cell transfusion\n - Digoxin toxicity\n - Beta blockers\n - Severe burns\n - Hyperkalaemic periodic paralysis\n\n# Classification\n\nThe European Resuscitation Guidelines stratify severity of hyperkalaemia as follows:\n\n||Serum potassium (mmol/L)|\n|--------------------------|------------------------------------|\n|**Mild**|5.5–5.9|\n|**Moderate**|6.0–6.4|\n|**Severe**|≥6.5|\n\n# Signs and Symptoms\n\nHyperkalaemia is often asymptomatic and only detected on blood tests - there may be symptoms or signs of the underlying cause however (e.g. dark urine in rhabdomyolysis)\n\n**Symptoms include:**\n\n- Palpitations\n- Fatigue\n- Chest pain\n- Shortness of breath\n- Paralysis\n\n**Signs include:**\n\n- Arrhythmias (e.g. bradycardia)\n- Reduced muscle power +/- flaccid paralysis\n- Hyporeflexia\n\n# Differential Diagnosis\n\n**Pseudohyperkalaemia** is common and refers to an artifactual increase in potassium in the sample tested - causes of this include:\n\n- Prolonged tourniquet time\n- Difficult venepuncture\n- Excessive fist clenching\n- Delayed specimen processing\n- Contamination with potassium EDTA anticoagulant in FBC bottles\n- Thrombocytosis\n- Leukocytosis\n\n# Investigations\n\n- **Blood gas** to confirm hyperkalaemia rapidly and check acid-base status and lactate\n- **ECG** to look for cardiac conduction abnormalities associated with hyperkalaemia. ECG changes include tall-tented T waves, PR prolongation, p wave flattening and QRS broadening.\n- **U&Es** to confirm hyperkalaemia, check sodium (may be an associated hyponatraemia e.g. in adrenal insufficiency) and renal function\n\n# Management \n\n**Conservative management:**\n\n- Stop any potassium-containing fluids\n- Address any underlying causes e.g. stop any contributing medications where possible, manage constipation\n- Consider advising the patient on a low potassium diet (e.g. in patients with chronic kidney disease) - dietician referral may be helpful\n- Patients with ECG changes may require cardiac monitoring\n- Mild-moderate cases of hyperkalaemia without ECG changes may be managed by addressing the underlying cause alone\n\n**Medical management:**\n\n- Patients with ECG changes or severe hyperkalaemia require treatment\n- Give 10 ml of IV 10% calcium carbonate or 30ml of IV 10% calcium gluconate immediately\n- This does not reduce serum potassium but acts to stabilise the myocardium and reduce the risk of arrhythmias\n- Further doses may be given if required\n- Give an insulin and glucose infusion (e.g. 10 units of Actrapid in 50 ml of 50% glucose over 15-30 minutes\n- This reduces serum potassium by shifting potassium into cells, however does not eliminate potassium from the body\n- Nebulised salbutamol may be given in addition which has the same effect\n- Potassium binders may be considered to eliminate potassium via the gut, especially in patients with chronic or refractory hyperkalaemia\n- Newer agents such as sodium zirconium cyclosilicate (Lokelma) are better tolerated than older resins (e.g. sodium polystyrene sulfonate)\n- Furosemide may also be useful to increase urinary potassium excretion especially in patients with fluid overload\n- Consider sodium bicarbonate for patients with acidosis and hyperkalaemia\n- Medical treatment may be required to correct the cause of hyperkalaemia (e.g. IV fluids for a pre-renal AKI or rhabdomyolysis)\n\n**Interventional management:**\n\n- Refractory hyperkalaemia despite medical therapy is an indication for emergency dialysis\n\n# Complications\n\nThe main complication of hyperkalaemia is cardiac conduction abnormalities and arrhythmias which in the most severe cases may cause cardiac arrest - changes in order of increasing severity are:\n\n1. Tall tented T-waves\n2. Flattened P-waves\n3. Prolonged PR interval\n4. Widened QRS complexes\n5. Idioventricular rhythms (bradycardia of ventricular origin)\n6. Sine wave pattern (pre-terminal rhythm)\n7. Ventricular fibrillation/asystole\n\n# References\n\n[BNF Treatment Summary - Hyperkalaemia](https://bnf.nice.org.uk/treatment-summaries/hyperkalaemia/)\n\n[The Renal Association - Treatment of Acute Hyperkalaemia in Adults](https://www.ukkidney.org/sites/default/files/RENAL%20ASSOCIATION%20HYPERKALAEMIA%20GUIDELINE%20-%20JULY%202022%20V2_0.pdf)\n\n[Patient UK - Hyperkalaemia in adults](https://patient.info/doctor/hyperkalaemia-in-adults)\n\n[Whittington Hospital Hyperkalaemia Guideline](https://www.whittington.nhs.uk/document.ashx?id=6250)\n\n[Life in the Fast Lane - Hyperkalaemia](https://litfl.com/hyperkalaemia-ecg-library/)",
"files": null,
"highlights": [],
"id": "153",
"pictures": [
{
"__typename": "Picture",
"caption": "ECG changes seen in someone with hyperkalaemia.",
"createdAt": 1665036193,
"id": "791",
"index": 0,
"name": "Hyperkalaemia ecg.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/6f36tetq1665036171704.jpg",
"path256": "images/6f36tetq1665036171704_256.jpg",
"path512": "images/6f36tetq1665036171704_512.jpg",
"thumbhash": "dSgCA4Dp5seGh/lnSImAlAg=",
"topic": null,
"topicId": null,
"updatedAt": 1713538168
}
],
"typeId": 2
},
"chapterId": 153,
"demo": null,
"entitlement": null,
"id": "154",
"name": "Hyperkalaemia",
"status": null,
"topic": {
"__typename": "Topic",
"id": "36",
"name": "Clinical Chemistry",
"typeId": 2
},
"topicId": 36,
"totalCards": 50,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "154",
"name": "Hyperkalaemia"
}
],
"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": "154",
"name": "Hyperkalaemia"
}
],
"demo": false,
"description": null,
"duration": 401.54,
"endTime": null,
"files": null,
"id": "184",
"live": false,
"museId": "6i8cnZd",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/chemistry.png",
"title": "Hyperkalaemia ",
"userViewed": false,
"views": 112,
"viewsToday": 4
}
]
},
"conceptId": 154,
"conditions": [],
"difficulty": 2,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10653",
"isLikedByMe": null,
"learningPoint": null,
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "An 87-year-old man presents with a 3 day history of palpitations. On examination, his heart rate is 110 bpm. The remainder of the examination is unremarkable. A venous blood gas confirms a potassium of 7.2 mmol/L (3.5 - 5.3 mmol/L) and an ECG shows sinus tachycardia with peaked T waves. He is given calcium gluconate and insulin-dextrose.\n \nWhich of his regular medications should be held?",
"sbaAnswer": [
"a"
],
"totalVotes": 89,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,964 | false | 22 | null | 6,494,981 | null | false | [] | null | 10,654 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient likely has hypocalcaemia, secondary to parathyroid gland removal during total thyroidectomy. The sign elicited on examination is Chvostek sign, one of the two signs for hypocalcaemia, the other being Trousseau's. Trousseau's sign is carpopedal spasm when a blood pressure cuff is applied and inflated on the arm. The patient has also presented with a seizure, suggesting profound hypocalcaemia. An ECG would also be an important investigation due to these patients being at risk of prolonged QTc and subsequent torsades de pointes.",
"id": "52967",
"label": "a",
"name": "IV calcium gluconate",
"picture": null,
"votes": 1955
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is likely vitamin D-deficient due to parathyroid gland removal during total thyroidectomy surgery. Correcting the hypocalcaemia is the first port of call due to her having had a seizure. Vitamin D replacement is important for long-term management.",
"id": "52969",
"label": "c",
"name": "Oral high-dose vitamin D",
"picture": null,
"votes": 158
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has had a seizure, which has terminated with one dose of lorazepam. If she had another seizure then another dose may be given as part of the emergency management. However, given that there are no current seizures, treating the underlying cause to prevent further episodes is the best next step. Therefore, calcium gluconate is the best answer.",
"id": "52971",
"label": "e",
"name": "Lorazepam",
"picture": null,
"votes": 68
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has had a seizure, terminated by one dose of lorazepam. Phenytoin is given after multiple unsuccessful doses of lorazepam 10 min apart. The likely cause of the seizure is hypocalcaemia and therefore it is best to treat the underlying cause to prevent further seizures.",
"id": "52970",
"label": "d",
"name": "Phenytoin",
"picture": null,
"votes": 124
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be the treatment of choice for mild hypocalcaemia. This patient likely has profound hypocalcaemia due parathyroid gland removal during total thyroidectomy surgery. This patient has had serious complication of hypocalcaemia, including a seizure, and therefore IV calcium gluconate is the most appropriate initial treatment.",
"id": "52968",
"label": "b",
"name": "Oral calcium carbonate",
"picture": null,
"votes": 784
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Great question author",
"createdAt": 1683839629,
"dislikes": 0,
"id": "24168",
"isLikedByMe": 0,
"likes": 5,
"parentId": null,
"questionId": 10654,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Edema Contusion",
"id": 28592
}
},
{
"__typename": "QuestionComment",
"comment": "warra question",
"createdAt": 1684836431,
"dislikes": 0,
"id": "25780",
"isLikedByMe": 0,
"likes": 5,
"parentId": null,
"questionId": 10654,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "a1 ramzy",
"id": 25869
}
},
{
"__typename": "QuestionComment",
"comment": "I would like half a mark for realising its hypocalcaemia",
"createdAt": 1737737455,
"dislikes": 0,
"id": "61448",
"isLikedByMe": 0,
"likes": 3,
"parentId": null,
"questionId": 10654,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Acute Myopathy",
"id": 18942
}
}
],
"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": "2391",
"name": "Hypocalcaemia",
"status": null,
"topic": {
"__typename": "Topic",
"id": "5",
"name": "Endocrinology",
"typeId": 2
},
"topicId": 5,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2391,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10654",
"isLikedByMe": 0,
"learningPoint": "Hypocalcaemia can occur after total thyroidectomy, presenting with seizures and Chvostek's sign; immediate treatment includes intravenous calcium gluconate.",
"likes": 11,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 32-year-old woman is brought to A&E by ambulance accompanied by her mother. She was discharged from hospital 3 d ago after a total thyroidectomy for papillary thyroid cancer. Today, her mother witnessed her having a tonic-clonic seizure, which terminated after a single dose of lorazepam provided by paramedics. There have been no further seizures. On examination, gentle tapping over the facial nerve produces spasm of her face ipsilaterally.\n\nWhat is the first-line initial treatment for her diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 3089,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,965 | false | 23 | null | 6,494,981 | null | false | [] | null | 10,655 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient had hypertension during a previous pregnancy which puts her at high risk of pre-eclampsia. For women at high risk of pre-eclampsia, NICE recommend that aspirin 75—150 mg daily is prescribed from 12 weeks' gestation until birth. Women are considered to be high risk of pre-eclampsia if they have at least one of the following risk factors: a history of hypertensive disease during a previous pregnancy, chronic kidney disease, autoimmune disease such as systemic lupus erythematosus or antiphospholipid syndrome, type 1 or type 2 diabetes, or chronic hypertension.",
"id": "52972",
"label": "a",
"name": "Aspirin",
"picture": null,
"votes": 382
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Insulin therapy should be considered in patients with gestational diabetes, guided by a specialist. Gestational diabetes is diagnosed if the woman has either a fasting plasma glucose level of 5.6 mmol/L or above or a 2‑hour plasma glucose level of 7.8 mmol/litre or above. This patient has a normal fasting plasma glucose.",
"id": "52973",
"label": "b",
"name": "Insulin therapy",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is at high risk of pre-eclampsia, therefore she should be started on aspirin.",
"id": "52975",
"label": "d",
"name": "No medication required",
"picture": null,
"votes": 233
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Labetalol is used in the management of women with hypertensive disease in pregnancy. This patient has a normal blood pressure at this visit so does not require anti-hypertensive therapy at this time.",
"id": "52974",
"label": "c",
"name": "Labetalol",
"picture": null,
"votes": 10
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Folic acid supplementation should be started pre-conception in women who are planning a pregnancy, or in women who are in the early stages of pregnancy and should be continued until 12 weeks gestation. This is to reduce the risk of neural tube defects. The woman here is already at 12 weeks gestation so folic acid supplementation is no longer required.",
"id": "52976",
"label": "e",
"name": "Folic acid",
"picture": null,
"votes": 106
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nPre-eclampsia is a placental condition that often affects pregnant women from around 20 weeks of gestation, characterised by hypertension and proteinuria. Other symptoms include peripheral oedema, severe headache, drowsiness, visual disturbances, epigastric pain, nausea/vomiting and hyperreflexia. The exact aetiology is not entirely understood, but it may be due to dysfunctional trophoblast invasion of the spiral arterioles. Key investigations include blood pressure and urine protein measurements. Management strategies include anti-hypertensive treatment, with labetalol as the first-line agent. Magnesium sulphate is used to prevent and treat eclamptic seizures, but the ultimate curative treatment is delivery of the placenta.\n\n# Epidemiology\n\n\n\nPre-eclampsia affects a significant percentage of pregnancies worldwide, although the exact number varies significantly between different populations and healthcare settings. Risk factors include nulliparity, a previous history or family history of pre-eclampsia, increasing maternal age, pre-existing diseases such as hypertension, diabetes, renal disease, autoimmune disease, obesity, and multiple pregnancies.\n\n\n# Aetiology\n\n\n\nThe exact aetiology of pre-eclampsia remains unclear. However, it's believed to be related to dysfunctional trophoblast invasion of the spiral arterioles, which results in decreased uteroplacental blood flow and subsequent endothelial cell damage.\n\n\n# Signs and Symptoms\n\n\nPre-eclampsia is characterised by:\n\n- Hypertension\n- Proteinuria\n- Peripheral oedema\n- Severe headache\n- Drowsiness\n- Visual disturbances\n- Epigastric pain\n- Nausea/vomiting\n- Hyperreflexia\n\n# Maternal complications\n\n- Eclampsia (seizures due to cerebrovascular vasospasm)\n- Organ failure\n- Disseminated intravascular coagulation (DIC)\n- HELLP syndrome (the presence of haemolysis (H), elevated liver enzymes (EL) and low platelets (LP))\n\n# Foetal complications\n\n- Intrauterine growth restriction\n- Pre-term delivery\n- Placental abruption\n- Neonatal hypoxia\n\n\n# Differential Diagnosis\n\n\nThe differential diagnosis for pre-eclampsia includes other conditions that can present with hypertensive disorders in pregnancy, such as chronic hypertension, gestational hypertension, and HELLP syndrome. Key signs and symptoms for these conditions include persistent high blood pressure, proteinuria, and various combinations of haemolysis, elevated liver enzymes, and low platelet levels.\n\n# Investigations\n\n\nKey investigations for pre-eclampsia include:\n\n- Blood pressure measurement: To confirm hypertension.\n- Urinalysis: To confirm proteinuria.\n- Blood tests: To assess kidney function, liver function, and clotting status.\n\n# Management\n\nAspirin is used for prophylaxis against the development of pre-eclampsia. It is given from 12 weeks gestation until birth to women with one high risk factor or two (or more) moderate risk factors. \n\nManagement of pre-eclampsia primarily involves anti-hypertensive treatment, with labetalol being the recommended first-line agent. Other agents that can be used include Nifedipine, Methyldopa and hydralazine. \n\nMagnesium sulphate can be administered for the prevention and treatment of eclamptic seizures. \n\nThe only definitive curative treatment is the delivery of the placenta. It is also crucial to monitor the mother and foetus closely for complications.\n",
"files": null,
"highlights": [],
"id": "97",
"pictures": [],
"typeId": 2
},
"chapterId": 97,
"demo": null,
"entitlement": null,
"id": "97",
"name": "Pre-eclampsia",
"status": null,
"topic": {
"__typename": "Topic",
"id": "38",
"name": "Obstetrics",
"typeId": 2
},
"topicId": 38,
"totalCards": 3,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "97",
"name": "Pre-eclampsia"
}
],
"demo": false,
"description": null,
"duration": 3166.74,
"endTime": null,
"files": null,
"id": "642",
"live": false,
"museId": "bjWyPRB",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/endocrinology.png",
"title": "Quesmed Tutorial: Obstetrics 2",
"userViewed": false,
"views": 238,
"viewsToday": 12
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "97",
"name": "Pre-eclampsia"
}
],
"demo": false,
"description": null,
"duration": 172.91,
"endTime": null,
"files": null,
"id": "645",
"live": false,
"museId": "8rxWyrL",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/obstetrics.png",
"title": "Hypertension without proteinuria in pregnancy",
"userViewed": false,
"views": 41,
"viewsToday": 4
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "97",
"name": "Pre-eclampsia"
}
],
"demo": false,
"description": null,
"duration": 3055.89,
"endTime": null,
"files": null,
"id": "620",
"live": false,
"museId": "eriRASf",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/gynecology.png",
"title": "Quesmed Tutorial: Obstetric Emergencies",
"userViewed": false,
"views": 874,
"viewsToday": 45
}
]
},
"conceptId": 97,
"conditions": [],
"difficulty": 1,
"dislikes": 2,
"explanation": null,
"highlights": [],
"id": "10655",
"isLikedByMe": 0,
"learningPoint": "Aspirin may be indicated in pregnancy to reduce the risk of preeclampsia, particularly in women with high-risk factors such as a history of preeclampsia, chronic hypertension, or certain medical conditions like diabetes.",
"likes": 4,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 36-year-old female presents for her 12-week scan after a positive pregnancy test at 6 weeks. She has had one previous pregnancy, during which she had hypertension with no proteinuria. She has felt well so far throughout this pregnancy. On examination, her blood pressure is 121/74 mmHg. Urine dipstick is negative and her fasting blood glucose is 5.5mmol/L.\n\nWhat is the next best step in management?",
"sbaAnswer": [
"a"
],
"totalVotes": 733,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,966 | false | 24 | null | 6,494,981 | null | false | [] | null | 10,656 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Duloxetine is a serotonin-noradrenaline reuptake inhibitor used to manage stress incontinence by increasing urethral tone. However, this is after lifestyle changes and pelvic floor exercises for at least 3 months.",
"id": "52978",
"label": "b",
"name": "Duloxetine",
"picture": null,
"votes": 143
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This woman gives a typical history of stress incontinence. She passes small amounts of urine involuntarily when her abdominal pressure is increased, such as when coughing or after eating a large meal. She has risk factors for stress incontinence such as being female, overweight, smoking and drinking coffee. She would be advised to limit her alcohol and coffee intake and be offered help to lose weight and quit smoking. She would also be referred for pelvic floor exercises.",
"id": "52977",
"label": "a",
"name": "Pelvic floor exercises",
"picture": null,
"votes": 2993
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is yet to try lifestyle changes and pelvic floor exercises. Failure to respond to medical therapy may prompt surgical management.",
"id": "52979",
"label": "c",
"name": "Referral for mesh repair surgery",
"picture": null,
"votes": 12
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a beta 3 agonist used for the management of urge (overactive bladder) incontinence. The history here is not consistent with urge incontinence.",
"id": "52980",
"label": "d",
"name": "Mirabegron",
"picture": null,
"votes": 56
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is yet to try lifestyle changes and pelvic floor exercises. Failure to respond to medical therapy may prompt surgical management. In this procedure, a bulking agent is injected into the bladder neck (usually under local anaesthetic) to improve its contraction and reducing urine leakage.",
"id": "52981",
"label": "e",
"name": "Intramural urethral bulking",
"picture": null,
"votes": 15
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "man why did I think pelvic floor exercises were part of lifestyle advice, now i'm part of the 5% that chose duloxetine :(",
"createdAt": 1736466109,
"dislikes": 0,
"id": "60155",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10656,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Transplant Tazocin",
"id": 15111
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nUrinary incontinence refers to the involuntary loss of urine and can be categorised into stress, urge, overflow, functional, and mixed types. Key signs and symptoms vary, ranging from involuntary urine leakage when intra-abdominal pressure is raised in stress incontinence, to an abrupt and uncontrollable urge to urinate in urge incontinence. Essential investigations encompass physical examination, questionnaires, bladder diaries, urinalysis, and occasionally cystometry or cystograms. Management strategies depend on the type and severity of incontinence, encompassing conservative methods (like lifestyle modifications), medical treatment (such as Duloxetine, anticholinergics), and surgical options (for example, incontinence pessaries, mid-urethral slings). Generally, stress incontinence is managed with pelvic floor exercises, whereas urge incontinence is initially managed with bladder re-training exercises.\n\n# Types \n\nUrinary incontinence can be categorised into:\n\n1. Stress incontinence\n2. Urge incontinence\n3. Overflow incontinence\n3. Functional incontinence\n4. Mixed incontinence \n\nReversible causes of urinary incontinence can be remembered using the mneumonic **'DIAPPERS':**\n\nD - Delirium\n\nI - Infection\n\nA - Atrophic vaginitis or urethritis\n\nP - Pharmaceutical (medications)\n\nP - Psychiatric disorders\n\nE - Endocrine disorders (e.g. diabetes)\n\nR - Restricted mobility\n\nS - Stool impaction\n\n\n# Approach to Incontinence\n\nOne of the keys is to rule out reversible causes and then try to work out which type of urinary incontinence is. A framework or approach to this is below:\n\n- Physical examination\n\n - An examination will identify features of pelvic organ prolapse as well as the ability to contract pelvic floor muscles.\n\n- Questionnaires\n\n - These are recommended in order to quantify the symptoms and assess the severity on patients quality of life which may help when deciding if a patient would benefit from more invasive treatment\n\n- Bladder diary\n\n - These are also useful for quantifying symptoms and documenting the number and type of episodes of incontinence. They may potentially show a relationship between causes and symptoms.\n\n- Urinalysis\n\n - This will help to rule out infection as an acute cause\n\n- Cystometry\n\n - This is an investigation which measures bladder pressure whilst voiding. It is not recommended in patients with clear histories where the diagnosis is clear.\n\n- Cystogram\n\n - If a fistula is suspected, contrast is instilled into the bladder and a radiological image is obtained in order to see if the contrast travels anywhere else.\n\n\n# Stress incontinence\n\nThis involves leaking of urine when intra-abdominal pressure is raised, putting pressure on the bladder. The pressure of the urine overcomes the mechanisms designed to maintain continence.\n\n## Risk factors \n\n- Childbirth (especially vaginal).This may be due to a combination of injury to the pelvic floor musculature and connective tissue (for example leading to prolapse), as well as nerve damage as a result of pregnancy and labor.\n- Hysterectomy\n\n\n## Triggers\n\nActs such as coughing, laughing, sneezing or exercising can increase abdominal pressure sufficiently.\n\n## Causes\n\nAny abnormality in the anatomy of the bladder, sphincters and urethra can result in stress incontinence.\n\n\n## Conservative management\n\nGeneral lifestyle advice such as avoiding caffeine, fizzy and sugary drinks, as well as avoiding excessive fluid intake, can go far in helping incontinence.\n\nPelvic floor exercises when done with good technique and consistently strengthen the muscles of the pelvic floor. It can help both stress and urge incontinence and can be more effective than drug treatment.\n\n## Medical management\n\nDuloxetine can help with stress incontinence, but it's only recommended if conservative measures fail and the patient is not a surgical candidate.\n\n## Surgical management \n\n- Incontinence pessaries are placed transvaginally and apply pressure to the anterior vaginal wall. This helps to support the urethra and sphincters. However, the evidence for them is poor in individuals without prolapse and isn't recommended by NICE. It would be worth trying if there was a clinical prolapse.\n- Bulking agents are injectable materials placed at the bladder neck to improve continence. This procedure is typically reserved for patients who are poor surgical candidates and isn't as efficacious as other methods\n- Colposuspension and fascial slings involve suspending the anterior vaginal wall to the iliopectineal ligament of Cooper.\n- Mid-urethral slings are the gold standard surgical treatment of stress incontinence. It compresses the urethra against a supportive layer and assists in the closure of the urethra during increased intra-abdominal pressures. It's minimally invasive and can be performed in the outpatient setting.\n\n\n# Urge incontinence\n\n## Definition \n\nThis involves the sudden and involuntary loss of urine associated with urgency.\n\n## Risk factors \n\nRisk factors for urgency include:\n\n- Recurrent urinary tract infections\n- High BMI\n- Advancing age\n- Smoking\n- Caffeine\n\n\n## Conservative management \n\nGeneral lifestyle advice such as avoiding caffeine, fizzy and sugary drinks as well as avoiding excessive fluid intake can go far in helping incontinence. Chemicals contained in these drinks can irritate the bladder, contributing to urge symptoms.\n\nPelvic floor exercises when done with good technique and consistently, strengthen the muscles of the pelvic floor. It can help both stress and urge incontinence and can be more effective than drug treatment. In urge incontinence, contraction of the pelvic floor relaxes the detrusor. Bladder training is also helpful.\n\n## Medical/surgical management\n\n- Pharmacological management\n\t- Anticholinergic medications can help reduce the symptoms of urge and overactive bladder by inhibiting the parasympathetic action on the detrusor muscle.\n\t\t- Examples include: **Oxybutynin, Tolterodine, Fesoterodine, Solifenacin**. If one agent has limited impact, it can be combined with another. Use with caution in elderly however due to increased risk of delirium (side-effect).\n\t- Mirabegron (beta-3 receptor agonist) can be used in older people, but should be used with caution in patients with hypertension.\n\n- Bladder instillation\n\n - Intravesical injection of Botox can be used to paralyse the detrusor muscle and reduce the symptoms of urge and overactive bladder.\n\n- Sacral neuromodulation\n\n - Sacral nerve stimulation has been shown to control symptoms of an overactive bladder. This is only done in tertiary centres for patient who have failed or are unsuitable for all other treatments.\n\n\n# Functional incontinence\n\n## Definition \n\nThis involves an individual having the urge to pass urine, but for whatever reason they're unable to access the necessary facilities and as a result are incontinent.\n\n## Causes \n\nFunctional incontinence associated with:\n\n- Sedating medications\n- Alcohol\n- Dementias\n\n# Overflow incontinence\n\n## Definition \n\nThis occurs when small amounts of urine leak without warning. When the pressure within the bladder overcomes the pressures of the outlet structures urine leaks.\n\n## Causes \n\nThis occurs either due to underactivity of the detrusor muscle such as from neurological damage, or if the urinary outlet pressures are too high, as in constipation or prostatism.\n\n\n\n# NICE Guidelines\n\n[NICE Guidance - Urinary incontinence and pelvic organ prolapse in women: management](https://www.nice.org.uk/guidance/ng123)",
"files": null,
"highlights": [],
"id": "766",
"pictures": [],
"typeId": 2
},
"chapterId": 766,
"demo": null,
"entitlement": null,
"id": "799",
"name": "Types of urinary incontinence",
"status": null,
"topic": {
"__typename": "Topic",
"id": "22",
"name": "Urology",
"typeId": 2
},
"topicId": 22,
"totalCards": 32,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 799,
"conditions": [],
"difficulty": 1,
"dislikes": 4,
"explanation": null,
"highlights": [],
"id": "10656",
"isLikedByMe": 0,
"learningPoint": "Pelvic floor exercises are the first-line management for stress incontinence, particularly in women with risk factors like obesity and smoking.",
"likes": 3,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 42-year-old woman presents to her GP with frequent leaking of small volumes of urine. This is worse when she drinks coffee, coughs or eats a large meal. She denies urinary urgency or any other urinary symptoms. She is a current smoker and on examination her body mass index is 30.\n\nApart from lifestyle advice, what is the next best step in management?",
"sbaAnswer": [
"a"
],
"totalVotes": 3219,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,967 | false | 25 | null | 6,494,981 | null | false | [] | null | 10,657 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A knee X-ray is often requested to assess for other differentials, such as chondrocalcinosis/fractures, or to assess if there has been any joint damage secondary to infection. However, this does not represent the most important initial investigation since a diagnosis of septic arthritis needs to be ruled out using a joint aspirate sent for microscopy, culture and sensitivity.",
"id": "52984",
"label": "c",
"name": "Knee X-ray",
"picture": null,
"votes": 18
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Gout or pseudogout can present with an acutely hot and painful joint. However, it is not typical for the paediatric age range. Moreover, given the presentation, septic arthritis is the most important diagnosis to exclude; thus, an aspirate for microscopy, culture and sensitivity is the best first test.",
"id": "52983",
"label": "b",
"name": "Joint aspiration and electron microscopy with polarised light",
"picture": null,
"votes": 77
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The most important diagnosis to exclude is septic arthritis. This happens to be the most likely diagnosis in this case due to the fever, inability to bear weight and recent chest infection, which could have been the origin of the organism that has seeded haematologically to the joint. A joint aspirate should be done with cultures to isolate the organism. Empirical antibiotics should be commenced while awaiting the results.",
"id": "52982",
"label": "a",
"name": "Joint aspiration and microscopy, culture and sensitivities",
"picture": null,
"votes": 3179
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be considered if a diagnosis of septic arthritis were confirmed. However, at this stage, the diagnosis is uncertain; thus, performing an aspirate in the first instance is the next best step.",
"id": "52986",
"label": "e",
"name": "Send to theatre for surgical washout",
"picture": null,
"votes": 71
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A knee MRI would be a sensible investigation if there was a suspicion of an alternative diagnosis or if the joint aspiration were inconclusive. However, it would not represent an initial investigation.",
"id": "52985",
"label": "d",
"name": "Knee MRI",
"picture": null,
"votes": 38
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Septic arthritis has systemic upset\nTransient synovitis is just ouch hurt after viral infection",
"createdAt": 1684247755,
"dislikes": 0,
"id": "24800",
"isLikedByMe": 0,
"likes": 6,
"parentId": null,
"questionId": 10657,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Intravenous Prone",
"id": 19930
}
},
{
"__typename": "QuestionComment",
"comment": "overlying cellulitis is a contraindication to joint aspiration though...",
"createdAt": 1709729297,
"dislikes": 0,
"id": "43998",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10657,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Botox Haemophilus",
"id": 23208
}
}
],
"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": 1,
"dislikes": 2,
"explanation": null,
"highlights": [],
"id": "10657",
"isLikedByMe": 0,
"learningPoint": "In cases of suspected septic arthritis, joint aspiration is crucial for diagnosis and guiding appropriate antibiotic therapy.",
"likes": 5,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 14-year-old adolescent presents with a red-hot swollen knee joint after a chest infection last week. He has been unable to walk due to the pain in his knee despite analgesia. He has a background history of type 1 diabetes managed with an insulin pump. On examination there is erythema overlying the joint and pain whenever the joint is moved in any direction. His temperature is 38.3 °C.\n\nWhat is the most important next step?",
"sbaAnswer": [
"a"
],
"totalVotes": 3383,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,968 | false | 26 | null | 6,494,981 | null | false | [] | null | 10,658 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has recently undergone radiotherapy to the pelvis for the treatment of a rectal tumour. This has likely caused a vesicovaginal fistula, which would mean a constant leakage of urine from the bladder through to the vagina. There are no clinical features suggestive or urge or stress incontinence, such as urgency or leakage on coughing respectively.",
"id": "52987",
"label": "a",
"name": "Vesicovaginal fistula",
"picture": null,
"votes": 1871
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Chronic cystitis would more typically give a history of dysuria, pelvic pain, urinary urgency and frequency. This patient describes urinary leakage throughout the day with no mention of pain in the history. The most likely diagnosis is a vesicovaginal fistula given the painless continuous leakage of urine plus recent pelvic radiotherapy.",
"id": "52991",
"label": "e",
"name": "Chronic cystitis",
"picture": null,
"votes": 193
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient denies any symptoms of urgency. The urine leakage is consistent throughout the day, which is most in keeping with a vesicovaginal fistula, especially in the context of recent radiotherapy to the pelvis.",
"id": "52988",
"label": "b",
"name": "Urge incontinence",
"picture": null,
"votes": 203
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient denies any symptoms of leakage following raised abdominal pressure, for example, with coughing or sneezing. Urine leakage is consistent throughout the day, which is most in keeping with a vesicovaginal fistula, especially in the context of recent radiotherapy to the pelvis.",
"id": "52989",
"label": "c",
"name": "Stress incontinence",
"picture": null,
"votes": 150
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A rectovaginal fistula would cause the passage of faeces through the vagina, with an increased risk of urinary tract infections. This patient describes a continuous urine leakage throughout the day, with recent pelvic radiotherapy, making a vesicovaginal fistula the most likely diagnosis.",
"id": "52990",
"label": "d",
"name": "Rectovaginal fistula",
"picture": null,
"votes": 547
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nUrinary incontinence refers to the involuntary loss of urine and can be categorised into stress, urge, overflow, functional, and mixed types. Key signs and symptoms vary, ranging from involuntary urine leakage when intra-abdominal pressure is raised in stress incontinence, to an abrupt and uncontrollable urge to urinate in urge incontinence. Essential investigations encompass physical examination, questionnaires, bladder diaries, urinalysis, and occasionally cystometry or cystograms. Management strategies depend on the type and severity of incontinence, encompassing conservative methods (like lifestyle modifications), medical treatment (such as Duloxetine, anticholinergics), and surgical options (for example, incontinence pessaries, mid-urethral slings). Generally, stress incontinence is managed with pelvic floor exercises, whereas urge incontinence is initially managed with bladder re-training exercises.\n\n# Types \n\nUrinary incontinence can be categorised into:\n\n1. Stress incontinence\n2. Urge incontinence\n3. Overflow incontinence\n3. Functional incontinence\n4. Mixed incontinence \n\nReversible causes of urinary incontinence can be remembered using the mneumonic **'DIAPPERS':**\n\nD - Delirium\n\nI - Infection\n\nA - Atrophic vaginitis or urethritis\n\nP - Pharmaceutical (medications)\n\nP - Psychiatric disorders\n\nE - Endocrine disorders (e.g. diabetes)\n\nR - Restricted mobility\n\nS - Stool impaction\n\n\n# Approach to Incontinence\n\nOne of the keys is to rule out reversible causes and then try to work out which type of urinary incontinence is. A framework or approach to this is below:\n\n- Physical examination\n\n - An examination will identify features of pelvic organ prolapse as well as the ability to contract pelvic floor muscles.\n\n- Questionnaires\n\n - These are recommended in order to quantify the symptoms and assess the severity on patients quality of life which may help when deciding if a patient would benefit from more invasive treatment\n\n- Bladder diary\n\n - These are also useful for quantifying symptoms and documenting the number and type of episodes of incontinence. They may potentially show a relationship between causes and symptoms.\n\n- Urinalysis\n\n - This will help to rule out infection as an acute cause\n\n- Cystometry\n\n - This is an investigation which measures bladder pressure whilst voiding. It is not recommended in patients with clear histories where the diagnosis is clear.\n\n- Cystogram\n\n - If a fistula is suspected, contrast is instilled into the bladder and a radiological image is obtained in order to see if the contrast travels anywhere else.\n\n\n# Stress incontinence\n\nThis involves leaking of urine when intra-abdominal pressure is raised, putting pressure on the bladder. The pressure of the urine overcomes the mechanisms designed to maintain continence.\n\n## Risk factors \n\n- Childbirth (especially vaginal).This may be due to a combination of injury to the pelvic floor musculature and connective tissue (for example leading to prolapse), as well as nerve damage as a result of pregnancy and labor.\n- Hysterectomy\n\n\n## Triggers\n\nActs such as coughing, laughing, sneezing or exercising can increase abdominal pressure sufficiently.\n\n## Causes\n\nAny abnormality in the anatomy of the bladder, sphincters and urethra can result in stress incontinence.\n\n\n## Conservative management\n\nGeneral lifestyle advice such as avoiding caffeine, fizzy and sugary drinks, as well as avoiding excessive fluid intake, can go far in helping incontinence.\n\nPelvic floor exercises when done with good technique and consistently strengthen the muscles of the pelvic floor. It can help both stress and urge incontinence and can be more effective than drug treatment.\n\n## Medical management\n\nDuloxetine can help with stress incontinence, but it's only recommended if conservative measures fail and the patient is not a surgical candidate.\n\n## Surgical management \n\n- Incontinence pessaries are placed transvaginally and apply pressure to the anterior vaginal wall. This helps to support the urethra and sphincters. However, the evidence for them is poor in individuals without prolapse and isn't recommended by NICE. It would be worth trying if there was a clinical prolapse.\n- Bulking agents are injectable materials placed at the bladder neck to improve continence. This procedure is typically reserved for patients who are poor surgical candidates and isn't as efficacious as other methods\n- Colposuspension and fascial slings involve suspending the anterior vaginal wall to the iliopectineal ligament of Cooper.\n- Mid-urethral slings are the gold standard surgical treatment of stress incontinence. It compresses the urethra against a supportive layer and assists in the closure of the urethra during increased intra-abdominal pressures. It's minimally invasive and can be performed in the outpatient setting.\n\n\n# Urge incontinence\n\n## Definition \n\nThis involves the sudden and involuntary loss of urine associated with urgency.\n\n## Risk factors \n\nRisk factors for urgency include:\n\n- Recurrent urinary tract infections\n- High BMI\n- Advancing age\n- Smoking\n- Caffeine\n\n\n## Conservative management \n\nGeneral lifestyle advice such as avoiding caffeine, fizzy and sugary drinks as well as avoiding excessive fluid intake can go far in helping incontinence. Chemicals contained in these drinks can irritate the bladder, contributing to urge symptoms.\n\nPelvic floor exercises when done with good technique and consistently, strengthen the muscles of the pelvic floor. It can help both stress and urge incontinence and can be more effective than drug treatment. In urge incontinence, contraction of the pelvic floor relaxes the detrusor. Bladder training is also helpful.\n\n## Medical/surgical management\n\n- Pharmacological management\n\t- Anticholinergic medications can help reduce the symptoms of urge and overactive bladder by inhibiting the parasympathetic action on the detrusor muscle.\n\t\t- Examples include: **Oxybutynin, Tolterodine, Fesoterodine, Solifenacin**. If one agent has limited impact, it can be combined with another. Use with caution in elderly however due to increased risk of delirium (side-effect).\n\t- Mirabegron (beta-3 receptor agonist) can be used in older people, but should be used with caution in patients with hypertension.\n\n- Bladder instillation\n\n - Intravesical injection of Botox can be used to paralyse the detrusor muscle and reduce the symptoms of urge and overactive bladder.\n\n- Sacral neuromodulation\n\n - Sacral nerve stimulation has been shown to control symptoms of an overactive bladder. This is only done in tertiary centres for patient who have failed or are unsuitable for all other treatments.\n\n\n# Functional incontinence\n\n## Definition \n\nThis involves an individual having the urge to pass urine, but for whatever reason they're unable to access the necessary facilities and as a result are incontinent.\n\n## Causes \n\nFunctional incontinence associated with:\n\n- Sedating medications\n- Alcohol\n- Dementias\n\n# Overflow incontinence\n\n## Definition \n\nThis occurs when small amounts of urine leak without warning. When the pressure within the bladder overcomes the pressures of the outlet structures urine leaks.\n\n## Causes \n\nThis occurs either due to underactivity of the detrusor muscle such as from neurological damage, or if the urinary outlet pressures are too high, as in constipation or prostatism.\n\n\n\n# NICE Guidelines\n\n[NICE Guidance - Urinary incontinence and pelvic organ prolapse in women: management](https://www.nice.org.uk/guidance/ng123)",
"files": null,
"highlights": [],
"id": "766",
"pictures": [],
"typeId": 2
},
"chapterId": 766,
"demo": null,
"entitlement": null,
"id": "799",
"name": "Types of urinary incontinence",
"status": null,
"topic": {
"__typename": "Topic",
"id": "22",
"name": "Urology",
"typeId": 2
},
"topicId": 22,
"totalCards": 32,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 799,
"conditions": [],
"difficulty": 1,
"dislikes": 2,
"explanation": null,
"highlights": [],
"id": "10658",
"isLikedByMe": 0,
"learningPoint": "Vesicovaginal fistula can occur post-radiotherapy, leading to continuous urinary leakage without urgency or stress-related symptoms.",
"likes": 3,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 72-year-old female presents to her GP with leakage of urine. She says that urine leaks continuously throughout the day and is affecting her ability to leave the house since she frequently has to change her underwear. She does not report her symptoms worsening with alcohol, caffeine, straining or coughing. She does not report any urinary urgency or any other urinary symptoms. She underwent radiotherapy after resection of a rectal tumour 4 months ago. There has been no signs of recurrence from her most recent follow-up. She is otherwise well, has never smoked and has a body mass index of 25. She had one child via caesarian section 40 years ago.\n\nWhat is the most likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 2964,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,969 | false | 27 | null | 6,494,981 | null | false | [] | null | 10,659 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A urinary tract infection may cause abdominal pain and may complicate kidney stones. However, this patient has seen some improvement in her pain without antibiotics and a urine dipstick yesterday was negative for leukocytes and nitrites. The persistent pain is in the left iliac fossa and so gynaecological causes should be excluded. Therefore, the next best step is a pregnancy test.",
"id": "52996",
"label": "e",
"name": "Urine microscopy, culture and sensitivity",
"picture": null,
"votes": 39
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be a useful investigation to evaluate for any free fluid in the pelvis or ovarian cysts, without exposing her to the radiation of a CT scan. It is likely she will have this test further down the line if the pain persists but a pregnancy test is a quick, noninvasive, appropriate immediate next step to further guide diagnosis.",
"id": "52993",
"label": "b",
"name": "Pelvic ultrasound",
"picture": null,
"votes": 261
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is unlikely to tolerate a CT abdomen since she has already declined one because of claustrophobia. Furthermore, an ultrasound examination is usually preferred in young female patients in the first instance. Before any imaging, a pregnancy test will be a sensible next step to guide the diagnostic process.",
"id": "52994",
"label": "c",
"name": "CT abdomen",
"picture": null,
"votes": 14
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Abdominal X-rays provide limited information in the context of acute abdominal pain. They can help diagnose bowel obstruction, mega-colon, chronic inflammatory bowel disease changes and radio-opaque kidney stones. She requires a pregnancy test in the first instance to guide the diagnostic process.",
"id": "52995",
"label": "d",
"name": "Abdominal X-ray",
"picture": null,
"votes": 33
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Since this patient did not have a CT kidneys, ureters and bladder, a pregnancy test may have been missed by the assessing doctor, who may have otherwise been prompted to do one before exposing a woman of child-bearing age to radiation. In any woman of child-bearing age presenting with abdominal pain, a pregnancy test should always be done to rule out life-threatening causes of abdominal pain, such as ectopic pregnancy.",
"id": "52992",
"label": "a",
"name": "Pregnancy test",
"picture": null,
"votes": 2552
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "guess that doctor didn't use Quesmed for his exams LOL!",
"createdAt": 1686842900,
"dislikes": 0,
"id": "28831",
"isLikedByMe": 0,
"likes": 4,
"parentId": null,
"questionId": 10659,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Kinase Sclerosis",
"id": 2697
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n \n \nEctopic pregnancy is a gynaecological emergency, referring to a fertilised ovum that has implanted anywhere outside the endometrial cavity. This may present with pelvic pain, shoulder tip pain, abnormal vaginal bleeding, and haemodynamic instability if ruptured. Diagnosis is confirmed by positive pregnancy test and a transvaginal ultrasound that has located the pregnancy outside the uterine cavity. Management strategies include conservative management, medical management with methotrexate, and surgical management, the choice of which depends on the patient's presentation and level of risk.\n \n \n \n# Definition\n \nAn ectopic pregnancy refers to a fertilised ovum that has implanted outside the endometrial cavity, usually in the fallopian tubes. This is a gynaecological emergency. \n \n \n \n \n# Epidemiology\n\n \nThe estimated incidence of ectopic pregnancies in the UK is 1.1%. The risk is higher in women with a history of pelvic inflammatory disease, genital infection, pelvic surgery, an intrauterine device in situ, assisted reproduction, previous ectopic pregnancy, or endometriosis.\n \n \n \n \n# Aetiology \n \n \nEctopic pregnancy usually presents in the 6-8th week of pregnancy, but can occur earlier or later. They can occur anywhere outside the endometrial cavity, but most commonly in the fallopian tube. \n\nRisk of an ectopic increases with conditions that impair the passage of a fertilised egg into the uterine cavity, or with conditions that cause the fertilised egg to implant prematurely. However, most ectopics are not associated with any risk factor. \n \nSpecific risk factors include: \n \n - Pelvic inflammatory disease and previous STIs\n - Pelvic surgery\n - Having an intrauterine device e.g. copper coil or Levonorgestrel-releasing intrauterine system (e.g. Mirena) in situ\n - Assisted reproduction e.g. IVF\n - Previous ectopic pregnancy\n - Endometriosis\n \n \n \n# Signs and Symptoms\n \nClinical features of ectopic pregnancy may include:\n \n \n - Pelvic pain, which may be unilateral to the side of the ectopic\n - Shoulder tip pain - If the ectopic pregnancy bleeds, the blood can irritate the diaphragm causing shoulder tip pain\n - Abnormal vaginal bleeding e.g. missed period or intermenstrual bleeding\n - Haemodynamic instability caused by blood loss if the ectopic ruptures, resulting in syncope/fainting\n - Abdominal examination may reveal unilateral tenderness\n - Cervical tenderness (chandelier sign) on bimanual examination\n \n \n# Differential Diagnosis\n\n1. **Miscarriage:** will also present with bleeding following a positive pregnancy test. However, less likely to have shoulder tip pain, beta-hCG levels will not be as high as in an ectopic (and will fall), and TV USS may show intrauterine pregnancy (if not yet completely expelled). \n\n\n2. **Pelvic inflammatory disease:** presents with abdominal pain and cervical tenderness, and may have bloody vaginal discharge. However, pregnancy test will be negative and inflammatory markers raised. Can be confirmed with positive swab. \n\n\n3. **Ovarian torsion:** also presents with abdominal pain, usually unilateral. Less likely to present with vaginal bleeding and will have negative pregnancy test. \n\n# Investigations\n \nThe investigations for ectopic pregnancy include:\n\n**Bedside**\n\n- Pregnancy test (to confirm pregnancy) \n\n \n**Bloods**\n\n* FBC (check for anaemia)\n* Serum beta-hCG (will help guide management)\n\n**Imaging**\n\n - Transvaginal ultrasound (to locate the pregnancy)\n \n \n# Management\n \n \nThere are three management options for ectopic pregnancy:\n \n \n **Conservative:**\n \n \n - This is an option for a small number of women with an ectopic pregnancy who have minimal or no symptoms, who are considered low risk (usually because there is a plateau or drop in beta-hCG levels indicating self-resolution of the ectopic). \n - These patients require close follow-up with serial repeat b-hCG tests. If the levels do not decrease at a satisfactory rate, medical/surgical management is recommended.\n \n \n**Medical:**\n \n \n - Involves administration of a one-off dose of methotrexate\n - Criteria for methotrexate treatment include: \n - No significant pain\n - Low hCG level (below 1500 IU/L)\n - Unruptured ectopic pregnancy measuring below 35mm and with no visible heartbeat\n - Ability to attend follow-up\n - Adherence to avoiding pregnancy for a period following treatment\n - No intrauterine pregnancy (confirmed on an ultrasound scan). \n - If the initial dose of methotrexate fails to treat the ectopic pregnancy, a second dose of methotrexate or surgical management may be indicated\n \n\n**Surgical:**\n \n - Recommended as first-line option if: \n - Patient is unable to attend follow-up\n - Serum hCG level of 5000 IU/L or higher \n - Adnexal mass of 35mm or greater\n - Foetal heartbeat is visible on ultrasound scan\n - Patient is in significant pain\n - Patient is haemodynamically unstable\n - Also offered second line in cases where medical manamgement has failed \n - The preferred surgical management is a **salpingectomy**, where the fallopian tube containing the ectopic pregnancy is removed. For patients with only one patent fallopian tube (e.g. due to previous PID or ectopic, or past removal of a fallopian tube), a **salpingotomy** may be performed instead, where only the ectopic pregnancy is removed and the ends of the fallopian tube are re-attached. \n - There is a risk with salpingotomy that not all the tissue may have been removed, and so serial serum b-hCG measurements are performed to exclude any remaining trophoblastic tissue within the fallopian tube\n - Offer **anti-D immunoglobulin** to all rhesus-negative women who have had surgical management of ectopic pregnancy. \n \n\n**Borderline Cases: Choosing Between Medical and Surgical Management**\n\n* There are some women who may be offered a choice of either methotrexate or surgical management as first-line.\n* This applies to women who: \n * Have a serum hCG level between 1500 IU/L and 5000 IU/L\n * Are able to return for follow up\n * Have no significant pain\n * Have an unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat.\n * Have no intrauterine pregnancy (confirmed on an ultrasound scan). \n \n\n# NICE Guidelines \n \n [Click here for NICE CKS on ectopic pregnancy ](https://cks.nice.org.uk/topics/ectopic-pregnancy/) \n \n# References\n\n\n[NHS UK - Ectopic pregnancy](https://www.nhs.uk/conditions/ectopic-pregnancy/)\n \n[Patient Info - Ectopic pregnancy](https://patient.info/doctor/ectopic-pregnancy-pro)",
"files": null,
"highlights": [],
"id": "927",
"pictures": [],
"typeId": 2
},
"chapterId": 927,
"demo": null,
"entitlement": null,
"id": "2283",
"name": "Ectopic pregnancy",
"status": null,
"topic": {
"__typename": "Topic",
"id": "38",
"name": "Obstetrics",
"typeId": 2
},
"topicId": 38,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2283,
"conditions": [],
"difficulty": 1,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "10659",
"isLikedByMe": 0,
"learningPoint": "Always perform a pregnancy test in women of child-bearing age presenting with abdominal pain to exclude life-threatening conditions like ectopic pregnancy.",
"likes": 6,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 28-year-old woman was admitted to hospital overnight with severe left-sided loin-to-groin pain. A urine dipstick revealed blood, no nitrites or leukocytes. Due to claustrophobia, she declined a CT scan and she was subsequently diagnosed with kidney stones clinically and treated with analgesia. Today, she reports she no longer has any flank pain but has persistent pain in the left iliac fossa.\n\nWhat is the next most important test to conduct?",
"sbaAnswer": [
"a"
],
"totalVotes": 2899,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,970 | false | 28 | null | 6,494,981 | null | false | [] | null | 10,660 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The liver produces albumin, the main component of the blood-maintaining oncotic pressure. When albumin levels drop, fluid moves from the intravascular space to the interstitial space, causing peripheral oedema and ascites. The half-life of albumin is 3 weeks; therefore, it is not a good measure of liver function in the acute setting.",
"id": "53001",
"label": "e",
"name": "Albumin",
"picture": null,
"votes": 340
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This will be raised in hepatitis but it is not a measure of synthetic liver function or a good prognosticator for fulminant hepatic failure.",
"id": "52999",
"label": "c",
"name": "Aspartate transaminase",
"picture": null,
"votes": 139
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This will be raised in hepatitis but it is not a measure of synthetic liver function or a good prognosticator for fulminant hepatic failure.",
"id": "52998",
"label": "b",
"name": "Alanine transaminase",
"picture": null,
"votes": 232
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Liver injury typically causes prolongation of the prothrombin time and therefore the international normalised ratio. The activated partial thromboplastin time is usually spared.",
"id": "53000",
"label": "d",
"name": "Activated partial thromboplastin time",
"picture": null,
"votes": 905
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The international normalised ratio is the best prognostic indicator for patients who have sustained hepatic injury due to paracetamol overdose. This is because it represents the synthetic function of the liver.",
"id": "52997",
"label": "a",
"name": "International normalised ratio",
"picture": null,
"votes": 1376
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "why not APTT?\n",
"createdAt": 1709488853,
"dislikes": 0,
"id": "43622",
"isLikedByMe": 0,
"likes": 3,
"parentId": null,
"questionId": 10660,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Zygomatic Gland",
"id": 45640
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n \nParacetamol overdose accounts for 44% of all adult self-poisoning cases in the UK and results in approximately 150,000 hospital admissions annually. Some patients may be asymptomatic, or present with nausea, vomiting, abdominal pain, jaundice or altered mental state. Investigations should include baseline bloods including a clotting and a blood gas, as well as a paracetamol level. Management depends on the dose taken, timing of ingestion and the patient's clinical condition, with N-acetylcysteine being the mainstay of treatment. The decision to treat is often guided by a nomogram although in certain situations N-acetylcysteine should be started immediately.\n \n# Definition \n \nParacetamol overdose refers to when a potentially toxic dose of paracetamol is taken, either accidentally or in the context of a self-harm or suicide attempt. \n \n# Epidemiology \n \nParacetamol is the most common agent ingested in the context of intentional self-harm in the UK. Paracetamol overdose accounts for 44% of all adult self-poisoning cases in the UK, with approximately 150,000 people admitted to hospital each year due to poisoning.\n \n\n# Aetiology\n \n- The pathophysiology of paracetamol toxicity involves the build-up of its toxic metabolite NAPQI (N-acetyl-p-benzoquinone-imine). \n- Normally, NAPQI is inactivated by glutathione in the blood, but in a paracetamol overdose, glutathione stores are rapidly depleted. \n- NAPQI therefore accumulates, unmetabolised, and binds to cellular proteins, causing cell death.\n- This causes both severe hepatotoxicity and nephrotoxicity that can lead to liver and kidney failure. \n\n# Classification\n \n - **Acute overdose** - excessive paracetamol taken in less than 1 hour, usually in the context of self-harm\n - **Staggered overdose** - excessive paracetamol ingested over longer than 1 hour, usually in the context of self harm\n - **Therapeutic excess** - excessive paracetamol taken with the intent to treat pain or fever and without self-harm intent, ingested at a dose greater than 75mg/kg/24 hours.\n\n\n# Signs and Symptoms\n \n- These depend on how long has passed since the overdose was taken\n- In the first 24 hours patients may be asymptomatic or have nausea and vomiting\n- After this, up to around 72 hours, right upper quadrant pain and hypotension may develop\n- From 72 to 96 hours patients may develop liver and renal failure with resulting metabolic acidosis, encephalopathy and coagulopathy, with symptoms of:\n - Confusion\n - Drowsiness\n - Reduced urine output\n - Loin pain\n - Jaundice\n - Bleeding diathesis\n\n# Differential Diagnosis \n\n - **Acute gastroenteritis:** has similar symptoms of nausea, vomiting and abdominal pain; may have diarrhoea and history of unwell contacts\n - **Renal colic:** may also present with haematuria, nausea and vomiting; pain more likely to be \"loin to groin\" rather than right upper quadrant\n - **Decompensation of chronic liver disease:** can present with jaundice, abdominal pain and encephalopathy\n - **Sepsis:** can lead to a lactic acidosis and acute kidney injury; patients are often febrile and may have localising signs or symptoms of infection\n \n# Investigations\n \nBlood tests for paracetamol levels should be taken at least 4 hours after ingestion, as this is when plasma paracetamol concentration peaks so an earlier blood test may underestimate levels\n\nOther important blood tests include:\n \n - Full Blood Count (FBC)\n - Urea and Electrolytes\n - Clotting Screen\n - Liver Function Tests\n - Venous Blood Gas (may show metabolic acidosis)\n - Blood glucose (could also do a bedside capillary blood glucose)\n - Salicylate levels (to look for a mixed overdose with aspirin)\n\n# Management\n \n**Conservative:**\n\n- Weigh patient (important for determining dose of paracetamol taken per kg and to calculate N-acetylcysteine dosing)\n- Consider if any other substances may have been taken with paracetamol\n- If overdose was intentional, refer to liaison psychiatry for a mental health assessment\n - Consider if 1:1 observations are required for high-risk patients\n - Assess risk to self and ongoing suicidal ideation\n - Discharge planning and assess need for ongoing psychiatric input\n- Treat any other self-harm\n\n**Medical:**\n\nDecisions on medical treatment are guided by a nomogram which plots paracetamol levels against time from ingestion. \n\nThe management of paracetamol overdose is dependent on the timing of ingestion, the dose taken, and the patient's clinical condition:\n \n - **Ingestion less than 1 hour ago + dose >150mg/kg**: Administer activated charcoal\n - **Ingestion 1-4 hours ago**: Wait until 4 hours to take a level and treat with N-acetylcysteine (NAC) based on level\n - **Ingestion within 4-8 hours + dose >150mg/kg**: Start NAC immediately if there is going to be a delay of ≥8 hours in obtaining the paracetamol level, otherwise wait for level and treat if level high (above the treatment line on the nomogram)\n - **Ingestion within 8-24 hours + dose >150mg/kg**: Start NAC immediately\n - **Ingestion >24 hours ago**: Start NAC immediately if the patient has jaundice, right upper quadrant tenderness, elevated ALT, INR >1.3 or if the paracetamol concentration is detectable\n - **Staggered overdose**: Start NAC immediately\n \nNAC is given as an IV medication - it acts by increasing glutathione levels thereby preventing toxicity. \n\nThere are two ways to give NAC:\n\n- Standard regimen of 3 consecutive infusions totalling 21 hours in duration \n- The newer SNAP protocol (now recommended by Royal College of Emergency Medicine as standard) where the same dose of NAC is given over 12 hours in two infusions\n- If after either of these are completed, bloods show deranged LFTs, clotting or renal function NAC infusions should be continued and the patient discussed with local liver transplant services\n- Anaphylactoid reactions are a common side effect of NAC, characterised by urticaria, angioedema, nausea and vomiting, tachycardia and bronchospasm but rarely shock\n- These are managed by suspending treatment and giving chlorphenamine and salbutamol nebulisers before restarting (possibly at a slower rate)\n \n**Surgical:**\n\nPatients who develop acute liver failure may require an urgent liver transplant as a life-saving measure - the following groups of patients should be transferred to a liver transplant centre:\n\n- INR > 3 at 48 hours or > 4.5 at any time\n- Oliguric or creatinine > 200\n- pH < 7.3 despite fluid resuscitation\n- Hypotension (systolic blood pressure < 80mmHg)\n- Severe thrombocytopenia\n- Encephalopathy\n \nThe King's College Criteria is used to predict mortality from paracetamol overdose and to identify those patients who would potentially benefit from liver transplantation. It advises consideration of liver transplantation if:\n \n- Blood pH < 7.3\n \n\nOr **all** of:\n \n- Serum creatinine > 300 µmol/L\n- INR > 6.5 (Prothrombin time > 100s)\n- Grade III or IV hepatic encephalopathy\n\n# NICE Guidelines\n\n[NICE CKS - Poisoning or overdose](https://cks.nice.org.uk/topics/poisoning-or-overdose/)\n\n# References\n\n[BNF - Poisoning](https://bnf.nice.org.uk/treatment-summary/poisoning-emergency-treatment.html)\n\n[MHRA - Treating paracetamol overdose with intravenous acetylcysteine](https://www.gov.uk/drug-safety-update/treating-paracetamol-overdose-with-intravenous-acetylcysteine-new-guidance)\n\n[RCEM - SNAP Protocol Position Statement](https://rcem.ac.uk/wp-content/uploads/2021/11/Use_of_SNAP_for_Treatment_of_Paracetamol_Toxicity_Nov_2021.pdf)\n\n[Life in the Fast Lane - liver transplanation for paracetamol toxicity](https://litfl.com/liver-transplantation-for-paracetamol-toxicity/)",
"files": null,
"highlights": [],
"id": "666",
"pictures": [],
"typeId": 2
},
"chapterId": 666,
"demo": null,
"entitlement": null,
"id": "2221",
"name": "Paracetamol Overdose",
"status": null,
"topic": {
"__typename": "Topic",
"id": "23",
"name": "Gastroenterology",
"typeId": 2
},
"topicId": 23,
"totalCards": 3,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2221,
"conditions": [],
"difficulty": 1,
"dislikes": 10,
"explanation": null,
"highlights": [],
"id": "10660",
"isLikedByMe": 0,
"learningPoint": "In paracetamol overdose, an elevated International Normalised Ratio (INR) is an important prognostic indicator, as it signifies liver dysfunction and a higher risk of severe complications, including bleeding and potential liver failure",
"likes": 5,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 28-year-old man presents to A&E after an overdose of paracetamol. He said he took 40 tablets over a 6-h period yesterday evening. It is now 11 a.m.\n\nWhich of the following tests provides the best prognostic indicator?",
"sbaAnswer": [
"a"
],
"totalVotes": 2992,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,971 | false | 29 | null | 6,494,981 | null | false | [] | null | 10,661 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has positive IgG antibodies to the core antigen of hepatitis B virus and positive surface antigen antibodies. If this were an acute infection, we would expect positive IgM antibodies to the core antigen, as well as positive surface antigen due to the presence of virus particle production.",
"id": "53004",
"label": "c",
"name": "Acute infection with hepatitis B",
"picture": null,
"votes": 158
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has positive IgG antibodies to the core antigen of hepatitis B virus and positive surface antigen antibodies. Early acute infection would have a positive surface antigen present, without presence of antibodies. The first type of antibody to appear would then be IgM.",
"id": "53006",
"label": "e",
"name": "Early acute hepatitis B virus infection",
"picture": null,
"votes": 62
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has positive IgG antibodies to the core antigen of hepatitis B virus and positive surface antigen antibodies. This is in keeping with previous exposure to hepatitis B virus with recovery and the presence of current antibodies.",
"id": "53002",
"label": "a",
"name": "Previous exposure and recovery to hepatitis B",
"picture": null,
"votes": 1967
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has positive IgG antibodies to the core antigen of the hepatitis B virus and positive surface antigen antibodies. Previous vaccination would mean only antibodies for the surface antigen would be present since there is no core antigen present in the vaccine. This patient has antibodies to both, indicating previous infection with immunity.",
"id": "53005",
"label": "d",
"name": "Vaccination against hepatitis B",
"picture": null,
"votes": 561
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has positive IgG antibodies to the core antigen of hepatitis B virus and positive surface antigen antibodies. If the infection were chronic, we would expect a positive surface antigen to be present due to ongoing virus particle production. The surface antigen is currently negative, indicating recovery from the infection.",
"id": "53003",
"label": "b",
"name": "Chronic infection with hepatitis B",
"picture": null,
"votes": 415
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Formatting the results would have been nice",
"createdAt": 1685453985,
"dislikes": 0,
"id": "27182",
"isLikedByMe": 0,
"likes": 31,
"parentId": null,
"questionId": 10661,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Metabolism Neoplasia",
"id": 8527
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "### Summary\n\nHepatitis is an inflammation of the liver caused by a variety of infectious and non-infectious factors. The most prevalent causes of viral hepatitis in the UK are hepatitis A, B, and C viruses. Hepatitis can present with symptoms such as fatigue, nausea, vomiting, and jaundice. The different hepatitis viruses can cause different spectra of disease, with some more likely to cause an acute hepatitis, and others a chronic hepatitic picture. The differential diagnosis includes conditions such as drugs, toxins, alcohol, EBV, CMV, leptospirosis, and malaria. Key investigations include serology for specific hepatitis types. The management of hepatitis is largely supportive, with some patients requiring antiviral treatment depending on the type of hepatitis.\n\n### Definition\n\nHepatitis refers to the inflammation of the liver. It is typically caused by viral infection but can also result from non-infectious aetiologies such as toxins and alcohol. \n\nHepatitis A and Hepatitis E can lead to acute liver failure, whereas Hepatitis B and Hepatitis C tend to lead to chronic liver failure. Hepatitis D only occurs in individuals who are infected with Hepatitis B. \n\n### Epidemiology\n\nViral hepatitis is common in the UK with the primary causes being hepatitis A, B, and C viruses. These can cause acute disease, but hepatitis B and C can also lead to chronic infection, liver fibrosis, and hepatocellular carcinoma. The prevalence of Hepatitis A is higher in developing countries, while Hepatitis B is the most common cause of hepatitis globally.\n\nOther causes of acute hepatitis include drugs, toxins, alcohol, EBV, CMV, hepatitis E, leptospirosis, and malaria.\n\nNB: All infectious hepatitis cases are notifiable diseases in the UK.\n\n### Signs and Symptoms\n\n#### Acute liver failure\n\n- Predominantly caused by Hepatitis A and E\n- Prodromal viral illness:\n\u0001- Fever\n\u0001- Malaise\n\u0001- Anorexia\n\u0001- Nausea and vomiting\n\n#### Acute hepatitis\n\n- Right upper quadrant pain\n- Jaundice\n- Tender hepatosplenomegaly (due to swelling of the liver capsule)\n\n#### Chronic liver failure\n\n- Hepatic encephalopathy\n- Jaundice\n- Ascites\n- Coagulopathy due to abnormal clotting\n\n\n### Hepatitis A\n\n- RNA picornavirus, transmitted by faecal-oral route (occasionally through food sources or through anal sex)\n\n#### Epidemiology \n\n- Prevalence is high in developing countries.\n- Increasing age is the only real determinant of disease severity, with the greatest morbidity and mortality in those over 50 years old.\n- Travellers and those at risk can be offered immunisation\n- It is transmitted via the faecal-oral route (commonly through shellfish)\n\n#### Presentation \n\n- Flu-like symptoms followed by jaundice, pale stools (in some), dark urine and abdominal pain\n- Incubation period of 2-6 weeks, presents only as an **acute** hepatitis with no chronic phase\n- Complete recovery can take up to 6 months.\n\n#### Investigations \n\n- Hepatitic LFTs, with ALT/AST as high as in the 1000s\n- IgM and IgG antibodies to HAV\n\n#### Management \n\n- Management is largely supportive\n\n#### Hepatitis E\n- Similarly spread via faecal-oral route (commonly undercooked pork)\n- It is **e**xtremely dangerous in pregnancy, with a mortality rate up to 20%\n- Similar to Hepatitis A with only an acute presentation and no chronic phase, with management also supportive in nature\n\n### Hepatitis B \n\n- dsDNA virus of Hepadnaviridae family\n- Primarily causes an acute hepatitis, with the main and most severe complication being progression to chronic hepatitis infection\n\n#### Epidemiology\n\n- Most common cause of hepatitis globally\n- High prevalence regions include sub-Saharan Africa, Asia and the Pacific Islands.\n- Decline of disease in children and adolescents in the UK is due to **routine vaccination**\n- Incubation period usually 60-90 days.\n\n#### Transmission\n\n- Transmission is via infected blood or body fluids\n - Vaginal/anal intercourse\n - Transfusion\n - Vertical transmission (in 90% of pregnancies where the mother is HBeAg positive, and 10% where this is negative).\n - In developing countries, infection is mostly in childhood through vertical or horizontal transmission. In areas of low endemicity (such as the UK), infections are mostly acquired in adulthood.\n\n#### Presentation\n\n- Children - Only 5% of children have jaundice and severe symptoms i.e. it is mostly an asymptomatic primary infection, but the majority (90%) develop chronic disease with only 10% able to clear the virus\n- Adults - more likely to have an acute hepatitis picture with jaundice, fever, malaise, viral prodrome and occasionally darkening of urine and lightening of stool. Some develop fulminant liver failure with decompensation (ascites, encephalopathy etc.). 90% clear the infection, with only around 10% developing chronic disease\n- Chronic features occur when the virus has been unable to be cleared for more than 6 months - development of cirrhosis, decompensated liver failure, and increased risk for **hepatocellular carcinoma**\n- Rarer features of hepatitis B infection include glomerulonephritis, cryoglobulinaemia and polyarteritis nodosa\n\n#### Investigations\n\n- HBsAg is detected 3-5 weeks after infection. If present for >6 months, this defines carrier status (5-10% of infections).\n- In carriers, HBeAg-positive patients are the most infectious. If HBeAg-negative (and anti-HBe-antibody positive), they have lower infectivity.\n- Patients with chronic infection who are HBeAg -ve may get immune escape phase when the virus mutates despite anti-HBe antibodies being present. These patients are the main pool for the spread in the UK, and so all chronically infectious patients need yearly screens to identify this.\n\nA summary table of the serology in Hepatitis B is below:\n\n\n| Marker | Description |\n|-----------------------------|-------------------------------------------------|\n| HBsAg (Hepatitis B Surface Antigen) | Indicates current infection; persists >6 months |\n| Anti-HBs (Hepatitis B Surface Antibody) | Indicates immunity from past infection or vaccination |\n| HBeAg (Hepatitis B e Antigen) | Indicates active viral replication; higher infectivity |\n| Anti-HBe (Hepatitis B e Antibody) | Indicates lower infectivity; seroconversion is associated with reduced viral replication |\n| HBcAb (Hepatitis B Core Antibody) | IgM indicates acute infection; IgG indicates past infection or vaccination |\n| HBV DNA (Hepatitis B Virus DNA) | Quantifies viral load; used to monitor response to treatment |\n\n- Biopsy of the liver in chronic hepatitis B infection will reveal 'ground-glass' hepatocytes on light microscopy\n\n#### Management \n\n- There is no **cure** for chronic hepatitis B, but there is a *functional* cure as you can prevent liver disease with pegylated interferon\n- Indications for antiviral treatment\n\u0001- Adults aged 30 years and older who have HBV DNA greater than 2000 IU/ml and abnormal ALT on 2 consecutive tests conducted 3 months apart\n\u0001- Adults who have HBV DNA greater than 20,000 IU/ml and abnormal ALT on 2 consecutive tests conducted 3 months apart regardless of age or the extent of liver disease\n\u0001- Adults with cirrhosis and detectable HBV DNA, regardless of HBeAg status, HBV DNA and ALT levels\n- Pegylated interferon alfa-2a is the first line, with tenofovir and entecavir as second-line alternatives\n\u0001- Pegylated interferon can lead to viral suppression which leads to ALT normalisation and improved liver histology\n\nIf a patient with hepatitis B becomes suddenly very unwell with a worsening hepatitic picture, consider if they are now suffering co-infection with **Hepatitis D**\n\n### Hepatitis C \n\n- RNA virus of the Flaviviridae family, with 6 major genetic types (genotypes 1 and 3 are most common in the UK, and genotype 1 is associated with longer treatment and worse prognosis)\n- There is no vaccination for Hepatitis C, currently\n\n#### Transmission\n\n- Transmitted via exchange of blood and bodily fluids:\n - Intravenous drug use\n - Blood transfusion\n - Haemodialysis (rare in the UK)\n - Sexual transmission (less than 1% per year of relationship, but rate higher if co-infected with HIV)\n - Needlestick injuries in healthcare facilities - 3% risk of transmission.\n - Perinatal infection from infected mother.\n- Incubation period of 6-9 weeks.\n\n#### Presentation\n\n- Most infections are asymptomatic, and only 15-25% clear the virus. 75% go on to develop chronic infection\n- Patients with chronic infection have persistently high LFTs, and cirrhosis develops in 20-30%\n- 1-4% of patients with cirrhosis develop hepatocellular carcinoma, and 2-5% develop liver failure\n- Additional features – arthralgia/arthritis, Sjogren’s syndrome, cryoglobulinaemia, porphyria cutanea tarda, membranoproliferative glomerulonephritis\n\n#### Investigations \n\n- Anti-HCV serology - 90% are positive 3 months after infection but it may take many months to become positive for some\n- Even if the virus has been cleared, HCV antibodies can remain positive for months afterwards\n- HCV RNA - if positive for more than two months then need to be treated.\n\n#### Management \n\n- Symptomatic treatment in the early stages of the disease\n- There is a **c**ure (Hepatitis **C** for **C**ure), unlike in Hepatitis B\n- Drug therapy should be considered for all patients and depends on the genotype of the virus. Nucleoside analogs are generally preferred e.g. Sofosbuvir and often lead to undetectable viral loads\n- Sofosbuvir and daclatsavir may be used as combination therapy\n- Antivirals of proven benefit in basically every patient irrespective of the amount of cirrhosis and fibrosis\n- Manage any underlying cirrhosis\n\n### NICE Guidelines\n\n[Click here for NICE CKS on hepatitis A](https://cks.nice.org.uk/topics/hepatitis-a/)\n\n[Click here for NICE CKS on hepatitis B](https://cks.nice.org.uk/topics/hepatitis-b/#!references)\n\n[Click here for NICE CKS on hepatitis C]([https://cks.nice.org.uk/topics/hepatitis-c/)",
"files": null,
"highlights": [],
"id": "1867",
"pictures": [],
"typeId": 2
},
"chapterId": 1867,
"demo": null,
"entitlement": null,
"id": "2224",
"name": "Hepatitis viruses",
"status": null,
"topic": {
"__typename": "Topic",
"id": "23",
"name": "Gastroenterology",
"typeId": 2
},
"topicId": 23,
"totalCards": 4,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2224,
"conditions": [],
"difficulty": 1,
"dislikes": 17,
"explanation": null,
"highlights": [],
"id": "10661",
"isLikedByMe": 0,
"learningPoint": "Positive IgG anti-HBc and positive anti-HBs indicate previous hepatitis B infection with subsequent recovery and immunity.",
"likes": 3,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 42-year-old man has some blood tests conducted by his hepatology team in the outpatient department. The results are shown below:\n\nHepatitis B surface antigen - negative\nAnti-hepatitis B surface antibody - positive\nIgM anti-HBc - negative\nIgG anti-HBc - positive\n\nWhich of the following is the most likely explanation for these results?",
"sbaAnswer": [
"a"
],
"totalVotes": 3163,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,972 | false | 30 | null | 6,494,981 | null | false | [] | null | 10,662 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Histology indicates which treatments would be effective for the cell types of breast cancer. Generally, positivity for the oestrogen receptor, progesterone receptor or HER2 allow specific therapies to be employed. However, the response to therapy is variable and other factors influence prognosis, most notably staging. The better and more direct answer is that histology helps guide treatment.",
"id": "53008",
"label": "b",
"name": "As a sole indicator of prognosis",
"picture": null,
"votes": 296
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Histology is crucial for breast cancer management because cell type governs the chemotherapy or hormonal treatments offered. The main subtypes of clinical relevance include oestrogen receptor, progesterone receptor and human epidermal growth factor receptor 2 (HER2) status. For this patient, her breast cancer is oestrogen receptor-positive, meaning it could be susceptible to an aromatase inhibitor, such as anastrozole, or a selective oestrogen receptor modulator, such as tamoxifen. The other factors that influence the choice of chemotherapy or hormonal therapy include age, comorbidities and cancer stage.",
"id": "53007",
"label": "a",
"name": "To guide drug treatment",
"picture": null,
"votes": 2374
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "For breast cancer, we know that the common sites of spread include the lungs, brain and bones. Histology, alongside other factors, may give us an idea of prognosis and the degree of aggression and therefore propensity to metastasise but it does not suggest where those sites will be.",
"id": "53011",
"label": "e",
"name": "Predicts likely sites of metastases",
"picture": null,
"votes": 150
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Sentinel lymph nodes are identified intraoperatively using radioactive blue dye. The surgeon injects the dye under the nipple and identifies the sentinel lymph node using radioactive readings and colour change.",
"id": "53010",
"label": "d",
"name": "To help identify the sentinel lymph node",
"picture": null,
"votes": 223
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Certain hereditary cancer syndromes, such as *BRCA1*/*BRCA2*, are associated with triple-negative breast cancers (negative for the oestrogen and progesterone receptors and the HER2 receptor). However, patients who do not possess these mutations can also be triple-negative; therefore, diagnosis of hereditary cancer syndromes cannot be made on histology alone.",
"id": "53009",
"label": "c",
"name": "To diagnose hereditary cancer syndromes",
"picture": null,
"votes": 81
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "It says in the Q that they already know the hormonal status",
"createdAt": 1685550900,
"dislikes": 1,
"id": "27343",
"isLikedByMe": 0,
"likes": 22,
"parentId": null,
"questionId": 10662,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Transplant Pudendal",
"id": 17013
}
}
],
"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": 10,
"explanation": null,
"highlights": [],
"id": "10662",
"isLikedByMe": 0,
"learningPoint": "Histological analysis of breast cancer tissue determines the appropriate hormonal or chemotherapy treatment based on receptor status and cancer subtype.",
"likes": 1,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 45-year-old woman who is recovering from a recent wide local excision for an oestrogen receptor-positive breast cancer attends her outpatient follow-up appointment in the oncology department. She asks what the purpose is behind sending the breast tissue for histology.\n\nWhat explanation should be offered to the patient?",
"sbaAnswer": [
"a"
],
"totalVotes": 3124,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,973 | false | 31 | null | 6,494,981 | null | false | [] | null | 10,663 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has presented with pruritus in the third trimester of pregnancy, which should raise the suspicion of intrahepatic cholestasis of pregnancy. The best test for this would be serum bile acids. There is a raised bilirubin in only a quarter of cases and raised bilirubin lacks specificity for this pathology.",
"id": "53016",
"label": "e",
"name": "Serum bilirubin",
"picture": null,
"votes": 1388
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Uraemia can cause skin itching; however, this patient has no known risk factors for renal failure and no other signs consistent with it on history or examination, such as asterixis, confusion or pericarditis.",
"id": "53013",
"label": "b",
"name": "Serum urea",
"picture": null,
"votes": 58
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has presented with pruritus in the third trimester of pregnancy, which should raise the suspicion of intrahepatic cholestasis of pregnancy. The best test for this would be serum bile acids. ALT/AST may be raised mildly in 60% of cases and they lack specificity for this pathology.",
"id": "53014",
"label": "c",
"name": "Serum ALT",
"picture": null,
"votes": 215
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient likely has intrahepatic cholestasis of pregnancy, which presents typically with persistent itching (especially on the hands/feet and nocturnally) in the third trimester and can run in families. Alanine transaminase (ALT)/aspartate transaminase (AST) may be mildly elevated, as well as bilirubin, but total serum bile acid is the most specific test and will be markedly raised in around 80% of cases. There is an increased risk of foetal compromise and stillbirth with this condition; therefore, early delivery may be indicated.",
"id": "53012",
"label": "a",
"name": "Bile acids",
"picture": null,
"votes": 1483
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has presented with pruritus in the third trimester of pregnancy, which should raise the suspicion of intrahepatic cholestasis of pregnancy. The best test for this would be serum bile acids. ALT/AST may be raised mildly in 60% of cases and they lack specificity for this pathology.",
"id": "53015",
"label": "d",
"name": "Serum AST",
"picture": null,
"votes": 78
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "this is so dumb you're never going to order just one liver investigation.. and you need to see the other results to exclude other causes anyway",
"createdAt": 1685741666,
"dislikes": 1,
"id": "27620",
"isLikedByMe": 0,
"likes": 13,
"parentId": null,
"questionId": 10663,
"replies": [
{
"__typename": "QuestionComment",
"comment": "preach my brother!\n",
"createdAt": 1738441380,
"dislikes": 0,
"id": "62106",
"isLikedByMe": 0,
"likes": 0,
"parentId": 27620,
"questionId": 10663,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Serpiginous Retrograde",
"id": 9908
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Kawasaki Dermis",
"id": 34637
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\n\nObstetric cholestasis is a pregnancy-related condition typically occurring after 24 weeks of gestation, characterised by the accumulation of bile acids. Key signs and symptoms include pruritus, fatigue, nausea, loss of appetite, occasional mild maternal jaundice, and right upper quadrant abdominal pain. Key investigations encompass liver function tests, bile acids measurement, and fetal monitoring. Management strategies include administration of chlorphenamine and vitamin K, early delivery planning, and off-license use of Ursodeoxycholic Acid (UDCA).\n\n\n# Definition\n\n\nObstetric cholestasis, also known as intra-hepatic cholestasis of pregnancy, is a pregnancy-related hepatobiliary disorder that typically manifests after the 24th week of gestation. The condition is characterised by impaired bile flow leading to the accumulation of bile acids.\n\n# Aetiology\n\n\nThe exact cause of obstetric cholestasis is not fully understood. However, it is believed to be influenced by hormonal and genetic factors, as well as environmental triggers.\n\n\n# Signs and Symptoms\n\nClinical manifestations of obstetric cholestasis include:\n\n- Pruritus: This is often severe and typically more intense on the hands and feet. It is not associated with a rash, although excoriation marks from scratching may be present.\n- General discomfort: Patients may experience fatigue or malaise.\n- Gastrointestinal symptoms: Nausea and loss of appetite are common.\n- Jaundice: Mild maternal jaundice characterised by dark urine and pale stools may occasionally occur.\n- Abdominal pain: Pain is typically localised in the right upper quadrant.\n\n\n# Differential Diagnosis\n\n\nThe differential diagnoses for obstetric cholestasis include:\n\n- Pruritic urticarial papules and plaques of pregnancy (PUPPP): Characterised by itchy, red bumps and large patches of hives.\n- Prurigo of pregnancy: Characterised by small, itchy bumps on the skin.\n- Pruritus gravidarum: Generalised itching during pregnancy with no apparent cause.\n- Other hepatobiliary disorders: These include viral hepatitis and gallstones, which can present with similar symptoms.\n\n# Investigations\n\nInvestigations for obstetric cholestasis focus on liver function tests and bile acids measurement. Fetal monitoring may be required due to the risk of spontaneous intrauterine death associated with the condition.\n\n# Management\n\nObstetric cholestasis is managed with the administration of chlorphenamine and emollients to alleviate itching, vitamin K to minimize the risk of bleeding, and early delivery planning to reduce the prolonged risk of spontaneous intrauterine death. Ursodeoxycholic Acid (UDCA) can be used on an off-license basis to reduce serum bile acids and relieve pruritus, but its routine use is no longer recommended by RCOG.\n\n# References\n\n[RCOG - Intrahepatic cholestasis of pregnancy (Green-top Guideline No. 43)](https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/1471-0528.17206)",
"files": null,
"highlights": [],
"id": "128",
"pictures": [],
"typeId": 2
},
"chapterId": 128,
"demo": null,
"entitlement": null,
"id": "126",
"name": "Obstetric cholestasis",
"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": "126",
"name": "Obstetric cholestasis"
}
],
"demo": false,
"description": null,
"duration": 250.77,
"endTime": null,
"files": null,
"id": "647",
"live": false,
"museId": "MX9aFoe",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/obstetrics.png",
"title": "HELLP Syndrome",
"userViewed": false,
"views": 82,
"viewsToday": 4
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "126",
"name": "Obstetric cholestasis"
}
],
"demo": false,
"description": null,
"duration": 287,
"endTime": null,
"files": null,
"id": "644",
"live": false,
"museId": "wPkjGU8",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/obstetrics.png",
"title": "Rash in pregnancy",
"userViewed": false,
"views": 32,
"viewsToday": 0
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "126",
"name": "Obstetric cholestasis"
}
],
"demo": false,
"description": null,
"duration": 3166.74,
"endTime": null,
"files": null,
"id": "642",
"live": false,
"museId": "bjWyPRB",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/endocrinology.png",
"title": "Quesmed Tutorial: Obstetrics 2",
"userViewed": false,
"views": 238,
"viewsToday": 12
}
]
},
"conceptId": 126,
"conditions": [],
"difficulty": 2,
"dislikes": 14,
"explanation": null,
"highlights": [],
"id": "10663",
"isLikedByMe": 0,
"learningPoint": "Intrahepatic cholestasis of pregnancy presents with intense itching, particularly on palms and soles, and is diagnosed by elevated serum bile acids.",
"likes": 10,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "463",
"name": "Pruritus",
"topic": {
"__typename": "UkmlaTopic",
"id": "8",
"name": "Dermatology"
},
"topicId": 8
},
{
"__typename": "Presentation",
"id": "464",
"name": "Pruritus",
"topic": {
"__typename": "UkmlaTopic",
"id": "11",
"name": "Gastrointestinal including liver"
},
"topicId": 11
},
{
"__typename": "Presentation",
"id": "465",
"name": "Pruritus",
"topic": {
"__typename": "UkmlaTopic",
"id": "18",
"name": "Obstetrics and gynaecology"
},
"topicId": 18
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 34-year-old primigravida woman who is 35 weeks pregnant presents with itchy skin for 5 d to A&E. There has been no response to antihistamines or creams. The itching is particularly intense on her palms and soles and at night. Her pregnancy has been unremarkable so far and she has no prior health conditions. She reports that her mother had a similar problem during her pregnancies. On examination, she has extensive scratch marks to her arms and abdomen. The remainder of the examination is normal.\n\nWhich investigation is most specific for her underlying diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 3222,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,974 | false | 32 | null | 6,494,981 | null | false | [] | null | 10,664 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is inappropriate to contact the police on the emergency line as there is no imminent threat of harm to the patient. She is also an adult who should consent to you notifying the police. If they want the police to be notified, it is advised that cases are reported using 101.",
"id": "53018",
"label": "b",
"name": "Contact the police immediately on 999",
"picture": null,
"votes": 314
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient is not a child and there is no mention of a particular vulnerability or other relatives at risk. Therefore, it would be best to explore this with the patient and then notify if there were any concerns. It would be most suitable to discuss whether she would want any psychological support and refer to gynaecology if they have experienced any physical complications from FGM, for example, incontinence, painful menstruation and frequent urinary tract infections.",
"id": "53020",
"label": "d",
"name": "Refer to safeguarding team",
"picture": null,
"votes": 981
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient is a competent adult and there is no apparent immediate risk to others or legal obligation to break her confidentiality. Therefore, one should only offer to contact the police and respect her wishes if she chooses not to. It is advised that FGM, which is illegal, should be reported to the police; however, in an adult patient (over 18), this should be done with her consent. In a patient less than 18 years of age (ie. a child), it is a legal duty to contact the police via 101 to disclose this information and you are therefore allowed to break confidentiality in this case. As ever, if breaking confidentiality, it is important to inform the patient of this and the rationale, that is, a legal obligation.",
"id": "53017",
"label": "a",
"name": "Offer to contact the police",
"picture": null,
"votes": 704
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is a competent adult and there is no apparent immediate risk to others or legal obligation to break her confidentiality. Therefore, one should only offer to contact the police and respect her wishes if she chooses not to. It is advised that FGM, which is illegal, should be reported to the police but in an adult patient (over 18), this should be done with her consent. In a patient less than 18 years of age (ie. a child), it is a legal duty to contact the police via 101 to disclose this information and you are therefore allowed to break confidentiality in this case. As ever, if breaking confidentiality, it is important to inform the patient of this and the rationale, that is, a legal obligation.",
"id": "53019",
"label": "c",
"name": "Contact the police immediately on 101",
"picture": null,
"votes": 481
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Examination at this moment would provide little added useful information and may potentially cause unnecessary distress in the context of a first disclosure. It is sensible to examine the patient at one point, with a chaperone present, to determine the extent of the injury and guide further management but this is usually within an expert setting.",
"id": "53021",
"label": "e",
"name": "Ask to examine the patient",
"picture": null,
"votes": 385
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\n\nFemale Genital Mutilation (FGM), often referred to as \"\"cutting\"\" or \"\"female circumcision,\"\" involves the injury or cutting of the female genitalia without medical justification. It comes in four types, ranging from clitoridectomy to other non-medical procedures like piercing. Complications include major tearing during labour, urethral damage and increased pain. Management of FGM, which is illegal in the UK, includes making a child protection referral if FGM is suspected, and performing an anterior episiotomy under local anaesthetic or regional block during the second stage of labour.\n\n\n# Definition\n\n\nFemale Genital Mutilation (FGM) is the harmful practice of injuring or cutting the female genitalia for non-medical reasons, often referred to as \"\"cutting\"\" or \"\"female circumcision.\"\"\n\n# Classification\n\nFGM is classified into four types:\n\n- Type I – Clitoridectomy: Partial or total removal of the clitoris and/or the prepuce.\n- Type II – Excision: Partial or total removal of the clitoris and the inner labia, with or without excision of the outer labia.\n- Type III – Infibulation: The narrowing of the vaginal opening by repositioning the inner or outer labia, with or without removal of the clitoris.\n- Type IV – Other: All other harmful procedures to the female genitalia for non-medical purposes, such as piercing, incising, scraping, or cauterising.\n\nThese procedures can cause significant complications including major tearing during labour, urethral damage and increased pain.\n\n\n# Management\n\nFGM is illegal in the UK. If there's suspicion that a child may be at risk of FGM, an immediate child protection referral must be made. Current management recommendations include performing an anterior episiotomy during the second stage of labour under local anaesthetic or regional block. Deinfibulation should be performed by experienced healthcare professionals, with careful measures to protect the urethra.\n",
"files": null,
"highlights": [],
"id": "74",
"pictures": [],
"typeId": 2
},
"chapterId": 74,
"demo": null,
"entitlement": null,
"id": "143",
"name": "Female Genital Mutilation (FGM)",
"status": null,
"topic": {
"__typename": "Topic",
"id": "38",
"name": "Obstetrics",
"typeId": 2
},
"topicId": 38,
"totalCards": 3,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 143,
"conditions": [],
"difficulty": 3,
"dislikes": 42,
"explanation": null,
"highlights": [],
"id": "10664",
"isLikedByMe": 0,
"learningPoint": "Healthcare professionals must report suspected cases of female genital mutilation in under-18s to the police within 28 days of discovery.",
"likes": 14,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 21-year-old woman attends her GP to renew her oral contraceptive prescription. The patient would like to try an intrauterine device but indicates that there may be issues with inserting it due to previous female genital mutilation (FGM). She says she has never discussed this with anyone before and becomes visibly upset. She tells you it was done during early childhood in her home country by a relative who has since passed away.\n\nWhich of the following is the most appropriate response to the situation?",
"sbaAnswer": [
"a"
],
"totalVotes": 2865,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,975 | false | 33 | null | 6,494,981 | null | false | [] | null | 10,665 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The formula for the calculation of the estimated delivery date is: first day of last menstrual period + 1 year − 3 months + 7 d. To calculate this with some accuracy, the patient needs to have had a regular cycle before this.",
"id": "53022",
"label": "a",
"name": "1 June 2023",
"picture": null,
"votes": 2119
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The formula for the calculation of the estimated delivery date is: first day of last menstrual period + 1 year − 3 months + 7 d. To calculate this with some accuracy, the patient needs to have had a regular cycle before this. The 1 May is 36 weeks of pregnancy.",
"id": "53024",
"label": "c",
"name": "1 May 2023",
"picture": null,
"votes": 322
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The formula for the calculation of the estimated delivery date is: first day of last menstrual period + 1 year − 3 months + 7 d. To calculate this with some accuracy, the patient needs to have had a regular cycle before this. The 18 May is 38 weeks of pregnancy.",
"id": "53026",
"label": "e",
"name": "18 May 2023",
"picture": null,
"votes": 888
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The formula for the calculation of the estimated delivery date is: first day of last menstrual period + 1 year − 3 months + 7 d. To calculate this with some accuracy, the patient needs to have had a regular cycle before this. The 25 May is incorrect since this does not include the 1 week added to reach the 40th week of pregnancy.",
"id": "53023",
"label": "b",
"name": "25 May 2023",
"picture": null,
"votes": 563
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The formula for the calculation of the estimated delivery date is: first day of last menstrual period + 1 year − 3 months + 7 d. To calculate this with some accuracy, the patient needs to have had a regular cycle before this. The 25 June is 3 weeks after the estimated delivery date.",
"id": "53025",
"label": "d",
"name": "25 June 2023",
"picture": null,
"votes": 306
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "surely just +9 months rather than + 12/12 - 3/12 - 7d",
"createdAt": 1722085995,
"dislikes": 0,
"id": "54492",
"isLikedByMe": 0,
"likes": 11,
"parentId": null,
"questionId": 10665,
"replies": [
{
"__typename": "QuestionComment",
"comment": "+7d ^",
"createdAt": 1736119720,
"dislikes": 1,
"id": "59759",
"isLikedByMe": 0,
"likes": 0,
"parentId": 54492,
"questionId": 10665,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "GIMP101",
"id": 26542
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "hiney",
"id": 20231
}
},
{
"__typename": "QuestionComment",
"comment": "I actually don't even know why Naegelle's rule is so overhyped, just add 9 months and then 1 more week. Rather than that long +12 -3 months + 1 week.... ",
"createdAt": 1730038657,
"dislikes": 0,
"id": "56259",
"isLikedByMe": 0,
"likes": 9,
"parentId": null,
"questionId": 10665,
"replies": [
{
"__typename": "QuestionComment",
"comment": "I thought this, however it doesn't always work. \n\nFor example, \n\nLMP = 30th November 2024\n\nUsing Naegele’s rule:\n(30 Nov + 7 days) = 7 Dec\n(7 Dec - 3 months) = 7 Sept\n(7 Sept + 1 year) = 7 Sept 2025\n\nUsing your method:\n(30 Nov + 9 months) = 30 Aug\n(30 Aug + 1 week) = 6 Sept 2025",
"createdAt": 1738503713,
"dislikes": 0,
"id": "62129",
"isLikedByMe": 0,
"likes": 0,
"parentId": 56259,
"questionId": 10665,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "MM",
"id": 42301
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "TheSecretSayer",
"id": 69759
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\n\n\nA booking appointment is a comprehensive health assessment conducted before 10 weeks gestation to identify women who may require additional support throughout their pregnancy. It involves taking a detailed history and conducting various health checks and tests.\n\n\n# Investigations\n\n\nDuring a booking appointment, the following investigations are typically conducted:\n\n- Comprehensive medical, psychiatric, surgical, obstetric, gynaecological and social histories\n- Height, weight and BMI\n- Urinalysis\n- Blood pressure\n- Blood tests for full blood count, blood group, rhesus status, red cell alloantibodies, blood borne viruses (HIV, syphilis, hepatitis B)\n- Blood tests for sickle cell and thalassaemia if indicated\n\n# Management\n\n\nThe booking appointment serves as an opportunity to discuss and plan management strategies for the pregnancy. This can include discussing ultrasound scans and other screening and diagnostic tests, as well as diet and supplements during pregnancy. Following the appointment, further testing and treatment may be planned as necessary to reduce the risk to the patient and fetus during pregnancy and labour.",
"files": null,
"highlights": [],
"id": "99",
"pictures": [],
"typeId": 2
},
"chapterId": 99,
"demo": null,
"entitlement": null,
"id": "139",
"name": "Booking appointment (obstetrics)",
"status": null,
"topic": {
"__typename": "Topic",
"id": "38",
"name": "Obstetrics",
"typeId": 2
},
"topicId": 38,
"totalCards": 2,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 139,
"conditions": [],
"difficulty": 2,
"dislikes": 40,
"explanation": null,
"highlights": [],
"id": "10665",
"isLikedByMe": 0,
"learningPoint": "The estimated delivery date can be calculated by adding one year, subtracting three months, and adding seven days to the first day of the last menstrual period.",
"likes": 9,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "409",
"name": "Normal pregnancy and antenatal care",
"topic": {
"__typename": "UkmlaTopic",
"id": "18",
"name": "Obstetrics and gynaecology"
},
"topicId": 18
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 30-year-old woman presents to her GP after a positive pregnancy test. She is happy about the pregnancy and wants antenatal advice and referral to the relevant secondary care services. She says the first day of her last menstrual period was the 25 August 2022. She has a regular 28-d cycle normally.\n\nWhat is her estimated delivery date?",
"sbaAnswer": [
"a"
],
"totalVotes": 4198,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,976 | false | 34 | null | 6,494,981 | null | false | [] | null | 10,666 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Six-to-eight weeks is the typical period of time needed for open abdominal wounds to heal fully. During this time, patients are advised to rest and not do any heavy lifting for the abdominal muscles and surrounding tissues to heal. Returning to heavy lifting earlier than this risks wound dehiscence.",
"id": "53029",
"label": "c",
"name": "1–2 weeks",
"picture": null,
"votes": 148
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Six-to-eight weeks is the typical period of time needed for open abdominal wounds to heal fully. During this time, patients are advised to rest and not do any heavy lifting for the abdominal muscles and surrounding tissues to heal.",
"id": "53031",
"label": "e",
"name": "5–7 d",
"picture": null,
"votes": 20
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Six-to-eight weeks is the typical period of time needed for open abdominal wounds to heal fully. During this time, patients are advised to rest and not do any heavy lifting for the abdominal muscles and surrounding tissues to heal. Returning to heavy lifting earlier than this risks wound dehiscence.",
"id": "53028",
"label": "b",
"name": "2–4 weeks",
"picture": null,
"votes": 674
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Six-to-eight weeks is the typical period of time needed for open abdominal wounds to heal fully. During this time, patients are advised to rest and not do any heavy lifting for the abdominal muscles and surrounding tissues to heal. Delaying return to work beyond this is not usually necessary. Furthermore, remaining stationary for prolonged periods, as may be the case if you are off work, increases the risk of certain postoperative complications, such as deep vein thrombosis.",
"id": "53030",
"label": "d",
"name": "12–16 weeks",
"picture": null,
"votes": 718
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is the typical period of time needed for open abdominal wounds to heal fully. During this time, patients are advised to rest and not do any heavy lifting for the abdominal muscles and surrounding tissues to heal. Other complications of hysterectomy include temporary bowel, vaginal and bladder disturbances, such as constipation, urinary retention and vaginal bleeding. If the ovaries have been removed, they will experience severe menopausal symptoms, such as hot flushes and emotional disturbance.",
"id": "53027",
"label": "a",
"name": "6–8 weeks",
"picture": null,
"votes": 3109
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "how do people know the weeks for these things esp DVLA rules? in real life you'd just google it",
"createdAt": 1684935451,
"dislikes": 1,
"id": "26014",
"isLikedByMe": 0,
"likes": 2,
"parentId": null,
"questionId": 10666,
"replies": [
{
"__typename": "QuestionComment",
"comment": "guessed",
"createdAt": 1685378401,
"dislikes": 0,
"id": "27060",
"isLikedByMe": 0,
"likes": 13,
"parentId": 26014,
"questionId": 10666,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "lil' aneurysm",
"id": 21164
}
},
{
"__typename": "QuestionComment",
"comment": "Keeping a patients confidence in you as a doctor is quite important. Common sense but there's also research into this. A patients perception of their doctor has significant effects on their adherence to treatment, following of medical advice and actually medical outcomes themselves (likely in part the placebo effect coming into play enhanced by the doctor - patient relationship).\n\nAll this to say, being able to tell a patient something off the top of your head is much better than saying 'I don't know, I'd have to Google that' if you want them to trust you with their health ",
"createdAt": 1721135247,
"dislikes": 14,
"id": "54354",
"isLikedByMe": 0,
"likes": 0,
"parentId": 26014,
"questionId": 10666,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Supine Metabolism",
"id": 33234
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "RNA Retrograde",
"id": 2980
}
},
{
"__typename": "QuestionComment",
"comment": "You are sitting on the other side of the table in the GP for a reason....\n",
"createdAt": 1728490160,
"dislikes": 2,
"id": "55651",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10666,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "TheSecretSayer",
"id": 69759
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n \n \nEndometrial cancer is a malignancy that occurs in the endometrium of the uterus. It is the sixth most common cancer in women and the 15th overall. Key risk factors include exposure to unopposed oestrogen, obesity, early menarche, late menopause, nulliparity, polycystic ovary syndrome, and oestrogen-only hormone replacement therapy. Common signs and symptoms include postmenopausal bleeding, abnormal vaginal bleeding, dyspareunia, pelvic pain, weight loss, anaemia, and abdominal discomfort. Diagnostics primarily include transvaginal ultrasound and endometrial biopsy. Management strategies are dependent on the stage of the cancer and can involve surgical interventions, radiotherapy, and chemotherapy.\n \n \n# Definition\n \n \nEndometrial cancer is a malignancy that originates from the endometrium, the inner lining of the uterus.\n \n \n# Epidemiology\n \n \nEndometrial cancer is the sixth most commonly diagnosed cancer in women globally and stands 15th in overall cancer occurrences. There were approximately 380,000 new cases reported worldwide in 2018.\n \n \n# Aetiology\n \n \nThe main risk factor for endometrial cancer is exposure to unopposed oestrogen. This includes:\n \n \n - Nulliparity\n - Obesity\n - Early menarche\n - Late menopause\n - Polycystic ovary syndrome\n - Oestrogen-only hormone replacement therapy\n\nFamily history of endometrial, ovarian, breast or colorectal cancers, Lynch syndrome or PTEN syndromes are also risk factors for endometrial cancer. \n \n# Signs and Symptoms\n \n \nClinical manifestations of endometrial cancer may vary, but the most common include:\n \n \n - **Postmenopausal bleeding**\n - Abnormal vaginal bleeding, such as intermenstrual bleeding\n - Dyspareunia\n - Pelvic pain\n - Abdominal discomfort or bloating\n - Weight loss\n - Anaemia\n \n \nOn bimanual pelvic examination, an enlarged uterus (due to presence of a mass) may be detected, although the gross uterus size may remain unchanged in some cases.\n \nEndometrial cancer is staged using the FIGO Staging System (from 0 to IV). \n \n# Differential Diagnosis\n \n \nGiven the clinical features of endometrial cancer, several conditions must be considered in the differential diagnosis:\n \n \n- **Uterine fibroids:** characterised by heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation.\n- **Endometrial polyps:** symptoms may include irregular menstrual bleeding, bleeding between menstrual periods, excessively heavy menstrual periods, and vaginal bleeding after menopause.\n- **Cervical cancer:** signs can include abnormal vaginal bleeding (including intermenstrual and postcoital bleeding), postmenopausal bleeding, and pelvic pain.\n \n \n# Investigations\n \n \n**Bedside:**\n\n* Bimanual and speculum examination \n\n**Bloods:**\n\n* FBC (for anaemia) \n* LFTs (for liver or bone involvement)\n* U&Es (for renal involvement) \n\n**Imaging:**\n\n* Transvaginal ultrasound scan (for endometrial thickness measurement) \n * **If thickness is >4mm**, investigate further with invasive tests \n* CT of chest, abdomen, pelvis (for staging)\n* MRI or uterus, pelvis, abdomen (for extent of involvement)\n\n**Invasive:**\n\n* Endometrial biopsy (via hysteroscopy or pipelle) \n\n**Two Week Wait (2WW) Referral Criteria:**\n\n* Women aged 55 years or older with post-menopausal bleeding\n* *Consider* referral if woman is under age of 55 \n \n \n# Management\n \n \nThe management of endometrial cancer is dependent on the stage of the disease:\n \n \n - For cancer limited to the uterus, a hysterectomy with bilateral salpingo-oophorectomy and lymphadenectomy can be curative. This may be done laparoscopically or as an open procedure. \n - In cases where the cancer has spread outside of the uterus, treatment often involves a combination of surgery, radiotherapy, and chemotherapy.\n \n \n# Complications\n\n* Chemotherapy complications: toxicity (e.g. mouth ulcers, GI bleeding, diarrhoea, peripheral neuropathy)\n* Radiotherapy complications: vaginal atrophy and stenosis, bowel and bladder fistulae \n* Surgical complications: infertility, menopause, bladder instability \n\n# Prognosis \n\n5-year prognosis depends on stage at diagnosis:\n\n* Localised: >90%\n* Distant: >20% \n\n# NICE Guidelines\n\n[Click here for NICE Guidance](https://www.nice.org.uk/guidance/conditions-and-diseases/cancer/endometrial-cancers) \n\n# References\n \n[BMJ Best Practice](https://bestpractice.bmj.com/topics/en-gb/266) \n \n[BGCS Guidance](https://www.bgcs.org.uk/wp-content/uploads/2021/11/British-Gynaecological-Cancer-Society-v13-for-website-with-figure1.pdf)",
"files": null,
"highlights": [],
"id": "936",
"pictures": [],
"typeId": 2
},
"chapterId": 936,
"demo": null,
"entitlement": null,
"id": "987",
"name": "Endometrial cancer",
"status": null,
"topic": {
"__typename": "Topic",
"id": "26",
"name": "Gynaecology",
"typeId": 2
},
"topicId": 26,
"totalCards": 3,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 987,
"conditions": [
{
"__typename": "Condition",
"id": "249",
"name": "Endometrial cancer",
"topic": {
"__typename": "UkmlaTopic",
"id": "18",
"name": "Obstetrics and gynaecology"
},
"topicId": 18
}
],
"difficulty": 1,
"dislikes": 12,
"explanation": null,
"highlights": [],
"id": "10666",
"isLikedByMe": 0,
"learningPoint": "Patients recovering from open hysterectomy should avoid heavy lifting for 6–8 weeks to ensure proper healing of abdominal wounds.",
"likes": 8,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 62-year-old patient is 3 d post-open hysterectomy and recovering on the surgical ward. The operation was without complications and she is recovering well. The patient would like to know when she can return to work. Her job involves lifting heavy boxes and operating heavy machinery in a warehouse.\n\nWhat is the advised recovery period for this patient before they return to work?",
"sbaAnswer": [
"a"
],
"totalVotes": 4669,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,977 | false | 35 | null | 6,494,981 | null | false | [] | null | 10,667 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "National guidance states that follow-up post-LLETZ should be at 6 months. At the 6-month repeat smear, normal/borderline/mild dyskariotic cells prompt an HPV test of cure, where high-risk HPV is looked for. If positive for high-risk HPV, or if there are moderate/severe dyskariotic cells, the patient is sent back to colposcopy. If the test of cure is negative, then they return to a 3-year recall.",
"id": "53035",
"label": "d",
"name": "12 months",
"picture": null,
"votes": 1495
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "A follow-up smear is performed 6 months after a LLETZ procedure to determine if any further treatment is required, provided the histology sent from the LLETZ does not confirm a diagnosis of cancer. Of those women post-LLETZ procedure, typically 20% need further treatment. At the 6-month repeat smear, normal/borderline/mild dyskariotic cells prompt a human papillomavirus (HPV) test of cure, where high-risk HPV is looked for. If positive for high-risk HPV, or if there are moderate/severe dyskariotic cells, the patient is sent back to colposcopy. If the test of cure is negative, then they return to a 3-year recall.",
"id": "53032",
"label": "a",
"name": "6 months",
"picture": null,
"votes": 1973
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "National guidance states that follow-up post-LLETZ should be at 6 months. At the 6-month repeat smear, normal/borderline/mild dyskariotic cells prompt an HPV test of cure, where high-risk HPV is looked for. If positive for high-risk HPV, or if there are moderate/severe dyskariotic cells, the patient is sent back to colposcopy. If the test of cure is negative, then they return to a 3-year recall.",
"id": "53033",
"label": "b",
"name": "6 weeks",
"picture": null,
"votes": 224
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "National guidance states that follow-up post-LLETZ should be at 6 months. At the 6-month repeat smear, normal/borderline/mild dyskariotic cells prompt an HPV test of cure, where high-risk HPV is looked for. If positive for high-risk HPV, or if there are moderate/severe dyskariotic cells, the patient is sent back to colposcopy. If the test of cure is negative, then they return to a 3-year recall.",
"id": "53036",
"label": "e",
"name": "3 months",
"picture": null,
"votes": 999
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "National guidance states that follow-up post-LLETZ should be at 6 months. At the 6-month repeat smear, normal/borderline/mild dyskariotic cells prompt an HPV test of cure, where high-risk HPV is looked for. If positive for high-risk HPV, or if there are moderate/severe dyskariotic cells, the patient is sent back to colposcopy. If the test of cure is negative, then they return to a 3-year recall.",
"id": "53034",
"label": "c",
"name": "12 weeks",
"picture": null,
"votes": 154
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Exam Trick: 12 Weeks = 3 moths, so these two options should easily be excluded. Leaves you with 3 options to choose from :)",
"createdAt": 1728843922,
"dislikes": 1,
"id": "55789",
"isLikedByMe": 0,
"likes": 5,
"parentId": null,
"questionId": 10667,
"replies": [
{
"__typename": "QuestionComment",
"comment": "still got it wrong",
"createdAt": 1734416636,
"dislikes": 1,
"id": "58493",
"isLikedByMe": 0,
"likes": 5,
"parentId": 55789,
"questionId": 10667,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "hannahparris",
"id": 62751
}
},
{
"__typename": "QuestionComment",
"comment": "i dont think UKMLA writers would be that nice to us unfortuantly ",
"createdAt": 1737151517,
"dislikes": 0,
"id": "60847",
"isLikedByMe": 0,
"likes": 1,
"parentId": 55789,
"questionId": 10667,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Haemolytic antibody",
"id": 30159
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Serotonin Ventral",
"id": 17782
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n \n \nCervical cancer is the 3rd most common cancer worldwide and the 4th largest cause of cancer death. It is primarily caused by persistent human papillomavirus (HPV) infection and is commonly squamous cell carcinoma. The key clinical features include vaginal discharge, bleeding, discomfort, and changes in urinary or bowel habits. Investigations involve an urgent colposcopy and CT scans for staging. Management strategies depend on the stage of cancer and the patient's fertility desires, ranging from conisation and radical trachelectomy for early-stage cancers to radiotherapy and chemotherapy for more advanced cases.\n \n \n# Definition\n \n \nCervical cancer is a type of cancer that occurs in the cells of the cervix (the lower part of the uterus that connects to the vagina). The majority of cervical cancers are squamous cell carcinomas. \n \n \n# Epidemiology\n \n \nCervical cancer is the 4th most common cancer in women worldwide. In the UK, it is the 14th most common cancer amongst women.\nOver 90% of cervical cancer deaths and similarly higher prevalence is seen in low- and middle-income countries (LMICs), highlighting inequity in access to HPV-prevention (vaccination), cervical cancer screening and treatment options between LMICs and high-income countries. \n \n \n# Aetiology\n \nCervical cancer is strongly associated with persistent human papilloma virus (HPV) infection. The majority of cases are squamous cell carcinoma.\n \nRisk factors for cervical cancer include: \n \n - HPV 16 and 18 infection (accounts for 70% of cases)\n - Multiple sexual partners\n - Smoking\n - Immunosuppression (e.g. HIV or organ transplants)\n \n \n# Signs and symptoms\n \n \nMost cases of cervical cancer are picked up asymptomatically at cervical screening. Other clinical features include:\n \n - Vaginal discharge\n - Bleeding (e.g. postcoital or with micturition or defaecation)\n - Vaginal discomfort\n - Urinary or bowel habit change\n - Suprapubic pain\n - Abnormal white/red patches on the cervix.\n - Pelvic bulkiness on PV examination\n - Mass felt on PR examination\n \n \n# Differential diagnosis\n \n \nThe differential diagnosis for cervical cancer includes other causes of abnormal vaginal bleeding or discharge such as vaginitis, cervicitis, endometrial cancer, and cervical polyps. Key signs and symptoms of these differentials include:\n \n \n1. **Vaginitis:** itching, burning, pain, and abnormal discharge\n2. **Cervicitis:** abnormal discharge, pelvic pain, and postcoital bleeding\n3. **Endometrial cancer:** abnormal vaginal bleeding, pelvic pain, and unintentional weight loss\n4. **Cervical polyps:** abnormal vaginal bleeding, discharge, and pain during intercourse\n \n \n# Investigations\n\n**Bedside:**\n\n* Speculum examination (with sample for cytology and HPV testing) \n\n**Bloods:**\n\n* FBC (anaemia)\n* LFTs (liver involvement)\n* U&Es (renal involvement) \n\n**Imaging:**\n\n* CT chest/abdomen/pelvis (for staging)\n\n**Invasive:** \n\n* Colposcopy (urgent) and cervical biopsy \n \n\n# Management\n \n \nThe treatment for cervical cancer depends on the stage of the cancer, and also whether the woman wants to retain fertility.\n \n \n - For very small cancers in stage IA treatment options include conisation with free margins if aiming to spare fertility. Conisation is done using a scalpel (cold-knife conisation), laser, or electrosurgical loop, and is usually performed as an outpatient.\n - Radical trachelectomy can be done for slightly more advanced, yet still early-stage cancers when the aim is to spare fertility. This involves removal of the cervix, the upper vagina and pelvic lymph nodes.\n - Where maintaining fertility is not an aim a laparoscopic hysterectomy and lymphadenectomy is offered for women for early-stage cancer.\n - For invasive, infiltrating and early metastatic cancer a radical (Wertheim's) hysterectomy can be performed which involves removal of the uterus, primary tumour, pelvic lymph nodes, and sometimes the upper third of the vagina and uterovesical and uterosacral ligaments.\n - If the cancer has spread outside the cervix and uterus, then surgical management is often unlikely to be curative. These cancers are treated with radiotherapy and/or chemotherapy.\n \n# Complications \n\n* Surgical complications: bladder dysfunction, leg oedema (due to lymphadenectomy), preterm birth \n* Radiation complications: vaginal stenosis, vaginal atrophy, bladder dysfunction, urethral strictures\n\n# Prognosis \n\nCervical cancer is preventable through screening. Mortality has decreased significantly as a result of improved treatment and screening programmes. Overall 5-year survival is 67%. However, this varies based on stage of disease at diagnosis:\n\n* Stage I: >90%\n* Stage II-III: 50-70%\n* Stage IV: <20%\n\n# Cervical Screening\n \n \n - For all women and people with a cervix between the age of 25-64 years. \n - Cervical sample is taken and tested for high-risk HPV viruses. \n - From 24 to 49 women are called every three years, and afterwards every five years.\n- The idea behind the screening process is to identify dyskaryotic cells which are pre-cancerous allowing management before invasive cancer can develop.\n \n \n## Outcomes in screening\n \n \nOutcomes from screening can be as follows:\n \n \n - Anybody with a negative HPV test is returned to routine recall.\n - Anybody with a positive HPV test has cytological testing. \n - Patients who are HPV positive but have negative cytology results should have a repeat HPV test in 12 months and again at 24 months if still positive. If they remain positive at 24 months they should be referred to colposcopy.\n - In some cases the sample may be inadequate, in which case the smear should be repeated. If it still not adequate for the next two samples, then the woman should be referred for colposcopy.\n \n \n# HPV Vaccination\n \n \n - Girls and boys aged 12 to 13 years are offered the HPV vaccine as part of the NHS vaccination programme\n - The vaccine helps protect against cancers caused by HPV, including cervical cancer, some mouth and throat cancers and some cancers of the anal and genital areas. It also helps protect against genital warts\n - Gardasil is the vaccination used and protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58\n \n# NICE Guidelines\n \n [Click here for NICE CKS on Cervical cancer](https://cks.nice.org.uk/topics/cervical-cancer-hpv/)\n \n \n [Click here for NICE CKS on Cervical cancer screening](https://cks.nice.org.uk/topics/cervical-screening/)\n \n \n# References\n \n[Cancer UK](https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/cervical-cancer) \n[NHS Page](https://www.nhs.uk/conditions/cervical-cancer/)",
"files": null,
"highlights": [],
"id": "931",
"pictures": [],
"typeId": 2
},
"chapterId": 931,
"demo": null,
"entitlement": null,
"id": "974",
"name": "Cervical cancer",
"status": null,
"topic": {
"__typename": "Topic",
"id": "26",
"name": "Gynaecology",
"typeId": 2
},
"topicId": 26,
"totalCards": 7,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 974,
"conditions": [
{
"__typename": "Condition",
"id": "144",
"name": "Cervical screening (HPV)",
"topic": {
"__typename": "UkmlaTopic",
"id": "18",
"name": "Obstetrics and gynaecology"
},
"topicId": 18
}
],
"difficulty": 3,
"dislikes": 6,
"explanation": null,
"highlights": [],
"id": "10667",
"isLikedByMe": 0,
"learningPoint": "Following a LLETZ procedure for cervical intraepithelial neoplasia, a follow-up smear is scheduled for 6 months to assess further treatment needs.",
"likes": 10,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 34-year-old woman undergoes a large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia 2 cervical cancer. The procedure is completed successfully. The patient asks how long it will be before her next smear is due after the procedure.\n\nWhen will her next smear be scheduled for?",
"sbaAnswer": [
"a"
],
"totalVotes": 4845,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,978 | false | 36 | null | 6,494,981 | null | false | [] | null | 10,668 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Regular unprotected intercourse for 1 year, without a successful pregnancy, should lead to a referral for further investigations at a fertility service. There, they may undergo semen analysis and serum hormone levels may be taken, alongside other tests. Neither party has any known risk factors for infertility at the moment, which could have otherwise prompted consideration for earlier referral.",
"id": "53037",
"label": "a",
"name": "9 months",
"picture": null,
"votes": 2745
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Regular unprotected intercourse for 1 year, without a successful pregnancy, should lead to a referral for further investigations at a fertility service. There, they may undergo semen analysis and serum hormone levels may be taken, alongside other tests. Neither party has any known risk factors for infertility at the moment, which could have otherwise prompted consideration for earlier referral.",
"id": "53039",
"label": "c",
"name": "3 months",
"picture": null,
"votes": 44
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Regular unprotected intercourse for 1 year, without a successful pregnancy, should lead to a referral for further investigations at a fertility service. There, they may undergo semen analysis and serum hormone levels may be taken, alongside other tests. Neither party has any known risk factors for infertility at the moment, which could have otherwise prompted consideration for earlier referral.",
"id": "53041",
"label": "e",
"name": "6 months",
"picture": null,
"votes": 36
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Regular unprotected intercourse for 1 year, without a successful pregnancy, should lead to a referral for further investigations at a fertility service. There, they may undergo semen analysis and serum hormone levels may be taken, alongside other tests.",
"id": "53038",
"label": "b",
"name": "21 months",
"picture": null,
"votes": 533
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Regular unprotected intercourse for 1 year, without a successful pregnancy, should lead to a referral for further investigations at a fertility service. There, they may undergo semen analysis and serum hormone levels may be taken, alongside other tests.",
"id": "53040",
"label": "d",
"name": "12 months",
"picture": null,
"votes": 955
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "RTFQ!",
"createdAt": 1685484293,
"dislikes": 0,
"id": "27236",
"isLikedByMe": 0,
"likes": 18,
"parentId": null,
"questionId": 10668,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Sir Pep Guardiola",
"id": 27715
}
},
{
"__typename": "QuestionComment",
"comment": "math",
"createdAt": 1685526445,
"dislikes": 0,
"id": "27252",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10668,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Nicu Prone",
"id": 17710
}
},
{
"__typename": "QuestionComment",
"comment": "'They are not related' so random",
"createdAt": 1686404219,
"dislikes": 0,
"id": "28406",
"isLikedByMe": 0,
"likes": 7,
"parentId": null,
"questionId": 10668,
"replies": [
{
"__typename": "QuestionComment",
"comment": "actually that question should be part of a full routine obstetric history",
"createdAt": 1709209955,
"dislikes": 7,
"id": "43222",
"isLikedByMe": 0,
"likes": 1,
"parentId": 28406,
"questionId": 10668,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Ale",
"id": 20565
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Lateral Kinase",
"id": 3545
}
},
{
"__typename": "QuestionComment",
"comment": "cheeky",
"createdAt": 1738684203,
"dislikes": 0,
"id": "62306",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10668,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "CeCe",
"id": 36099
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n \n \nSubfertility is defined as the diminished ability of a couple to conceive a child, which may be due to a variety of definable causes or an unexplained failure to conceive over a two-year period. Key signs and symptoms vary based on the underlying cause but generally revolve around the inability to achieve pregnancy despite regular unprotected sexual intercourse. Investigations typically include hormonal studies, semen analysis, and imaging studies. The management of infertility is dependent on the underlying cause and often involves a combination of lifestyle modifications, medical interventions, and assistive reproductive technology. \n \n \n \n# Definition\n \nInfertility is the diminished ability of a couple to conceive a child. This may result from a definable cause such as ovulatory, tubal, or sperm problems, or may be an unexplained failure to conceive over a two-year period despite regular (3-4 times a week) unprotected sexual intercourse.\n \n \n \n# Epidemiology\n \n \nStatistically, a couple stands an 80% chance of conceiving within one year if the woman is younger than 40 years, they do not use contraception, and they have regular intercourse (3-4 times per week). This overall probability increases to 90% if considered over two years.\n \n \n# Aetiology\n\n \nFactors affecting natural fertility include:\n \n - Increasing age\n - Obesity\n - Smoking\n - Tight-fitting underwear (males)\n - Excessive alcohol consumption\n - Anabolic steroid use\n - Illicit drug use\n \n \n\nCauses of infertility can be classified into:\n \n \n - **Genetic causes:** This includes Turner's syndrome (XO) and Kleinfelter's syndrome (XXY).\n - **Ovulation/endocrine disorders:** Examples are polycystic ovary syndrome, pituitary tumours, Sheehan's syndrome, hyperprolactinaemia, Cushing's syndrome, and premature ovarian failure.\n - **Tubal abnormalities:** These can be due to congenital anatomical abnormalities or adhesions secondary to pelvic inflammatory disease (often caused by chlamydia or gonorrhoea).\n - **Uterine abnormalities:** These include bicornate uterus, fibroids, and Asherman's syndrome (uterine adhesions).\n - Endometriosis\n - **Cervical abnormalities:** These include cervical damage after biopsy or LLETZ procedure.\n - **Testicular disorders:** Disorders such as cryptorchidism, varicocele, testicular cancer, and congenital testicular defects fall in this category.\n - **Ejaculatory disorders:** These include obstruction of the ejaculatory system and disorders of ejaculation such as retrograde ejaculation and premature ejaculation.\n \n \n# Investigations\n \n \nInvestigations for infertility are divided into those for men and women. \n\n*For women:*\n\n**Bedside:**\n \n- Thorough history, including past medical history, sexual history and details of past pregnancies. \n- Speculum and bimanual examination: To investigate physical anomalies (e.g. large fibroids). \n- STI screen\n \n \n**Bloods:**\n \n - Serum progesterone testing (performed 7 days before the end of the menstrual cycle): A rise in progesterone indicates that the corpus luteum has formed and is releasing progesterone due to occurrence of ovulation.\n - Prolactin\n - LH/FSH \n - Anti-mullerian hormone (AMH): Measure of ovarian reserve\n - TFTs \n\n \n**Imaging:**\n \n- Transvaginal ultrasound scan: To identify any physical anomalies of the uterus, and check antral follicle count (measure of ovarian reserve)\n- Hysterosalpingography: Assess tubal patency.\n- Laparsocopy and dye: Assess tubal patency in presence of co-morbidities (e.g. PID, ectopic pregnancy, endometriosis). \n\n\n*For men:*\n\n**Bedside:**\n \n- Thorough history, including past medical history, sexual history and details of past pregnancies. \n- Testicular examination: To investigate visible physical anomalies (e.g. varicocele). \n- Semen analysis: To evaluate sperm count, motility, and morphology. \n \n \n**Bloods:**\n \n - Serum testosterone \n - LH/FSH \n - TFTs \n \n \n# Management\n \n \nThe management of infertility is tailored to the underlying cause but may include:\n \n**Conservative:**\n\n - Weight loss\n - Smoking cessation \n - Reduction of alcohol intake\n - Stress-reduction strategies\n\n**Medical:**\n\nMedications may be used for ovulation induction, such as: \n\n - Clomiphene\n - FSH and LH injections\n - GnRH or DA agonists\n\n \n**Surgical:**\n \n - Assisted reproductive technology, including in vitro fertilisation or intracytoplasmic sperm injection.\n\n\nIn addition to all of the above, if an underlying cause of infertility is found (e.g. fibroids, endometriosis), then those causes should be managed. \n\n\n# NICE Guidelines\n\n[Click here for NICE Guidelines on fertility problems](https://www.nice.org.uk/guidance/cg156)\n\n[Click here for NICE Guidelines on infertility](https://cks.nice.org.uk/topics/infertility/)\n\n# References \n\n[BMJ Best Practice](https://bestpractice.bmj.com/topics/en-gb/498)\n\n[Fields et al., 2023 - BMJ](https://www.bmj.com/bmj/section-pdf/187753?path=/bmj/346/7896/Practice.full.pdf)",
"files": null,
"highlights": [],
"id": "929",
"pictures": [],
"typeId": 2
},
"chapterId": 929,
"demo": null,
"entitlement": null,
"id": "976",
"name": "Subfertility",
"status": null,
"topic": {
"__typename": "Topic",
"id": "26",
"name": "Gynaecology",
"typeId": 2
},
"topicId": 26,
"totalCards": 6,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 976,
"conditions": [],
"difficulty": 1,
"dislikes": 48,
"explanation": null,
"highlights": [],
"id": "10668",
"isLikedByMe": 0,
"learningPoint": "Couples under 35 should seek fertility evaluation after one year of regular unprotected intercourse without conception.",
"likes": 11,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "520",
"name": "Subfertility",
"topic": {
"__typename": "UkmlaTopic",
"id": "18",
"name": "Obstetrics and gynaecology"
},
"topicId": 18
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 27-year-old woman attends her GP with difficulty conceiving. She has been having frequent vaginal intercourse without contraception for 3 months with no subsequent pregnancy. She has never been pregnant before and has a regular 29-d cycle. She is not related to her partner and neither of them have any past medical history. They have never received investigation for infertility. On examination, her body mass index is 28.\n\nHow much longer should they keep trying to conceive before a referral is made to a local fertility service?",
"sbaAnswer": [
"a"
],
"totalVotes": 4313,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,979 | false | 37 | null | 6,494,981 | null | false | [] | null | 10,669 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be a very early delivery and would only be considered if there were concerns over foetal compromise and a careful discussion as part of a multidisciplinary team regarding the benefits and risks. There is no history suggesting this; therefore, the current recommendation for dichorionic diamniotic twins would be a delivery around 37 weeks.",
"id": "53046",
"label": "e",
"name": "35–36 weeks",
"picture": null,
"votes": 679
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The lambda sign on ultrasound indicates a dichorionic diamniotic twin pregnancy. They each have their own placenta and amnion. The [current guidance](https://www.nice.org.uk/guidance/ng137/resources/twin-and-triplet-pregnancy-pdf-66141724389829) recommends delivery around 37 for this type of twin pregnancy. Earlier delivery may be necessary depending on how the pregnancy progresses but this is not routinely performed.",
"id": "53042",
"label": "a",
"name": "37 weeks",
"picture": null,
"votes": 2106
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The lambda sign on ultrasound indicates a dichorionic diamniotic twin pregnancy. They each have their own placenta and amnion; 39–40 weeks would be preferred gestation period for a medically unremarkable singleton pregnancy.",
"id": "53044",
"label": "c",
"name": "39–40 weeks",
"picture": null,
"votes": 265
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As the gestation of a singleton passes 40 weeks, there can be concerns regarding the risk of foetal compromise and stillbirth; therefore, induction is discussed and offered. These risks would be higher in a twin pregnancy; therefore, induction would be offered even earlier.",
"id": "53045",
"label": "d",
"name": "41 weeks",
"picture": null,
"votes": 19
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The lambda sign on ultrasound indicates a dichorionic diamniotic twin pregnancy. They each have their own placenta and amnion. The current guidance recommends delivery at around 37 for this type of twin pregnancy. Earlier delivery may be necessary depending on how the pregnancy progresses but this is not routinely performed. Women with monochorionic diamniotic pregnancies are offered delivery at 36–36+6 weeks due to these pregnancies being at higher risk, such as of twin–twin transfusion syndrome.",
"id": "53043",
"label": "b",
"name": "36 weeks",
"picture": null,
"votes": 1072
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Women with dichorionic twin pregnancies should be offered elective birth from 37 weeks 0 days.\n",
"createdAt": 1719140219,
"dislikes": 3,
"id": "53589",
"isLikedByMe": 0,
"likes": 2,
"parentId": null,
"questionId": 10669,
"replies": [
{
"__typename": "QuestionComment",
"comment": "no shi sherlock, that's literally the answer ",
"createdAt": 1731021148,
"dislikes": 1,
"id": "56780",
"isLikedByMe": 0,
"likes": 5,
"parentId": 53589,
"questionId": 10669,
"user": {
"__typename": "User",
"accessLevel": "editor",
"displayName": "deleted_user",
"id": 59901
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Supine Bladder",
"id": 35998
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "\n# Summary\n\n\nTwin pregnancies are classified according to three main criteria: zygosity, chorionicity, and amnionicity. Dizygotic twins, or non-identical twins, result from the fertilisation of two distinct eggs by two different sperm cells, while monozygotic twins, or identical twins, occur when a single egg fertilised by a single sperm splits. Monozygotic twins are at a higher risk of certain complications, requiring careful monitoring during pregnancy.\n\n# Types of twins\n\nTwin pregnancies can be classified according to the zygosity, chorionicity and amnionicity.\n\n- Monozygotic twins (identical) result from fertilisation of one egg and one sperm.\n\n - Depending on when the fertilised egg has split the twins maybe:\n\n - Dichorionic and diamniotic (two different sacs)\n - Monochorionic and diamniotic (same outer sac, two inner sacs)\n - Monochorionic and monoamniotic (same sacs)\n\n - Monozygotic twins are at increased risk of certain complications (e.g. twin-to-twin transfusion syndrome) and must be monitored more carefully during pregnancy than dizygotic twins.\n\n- Dizygotic twins (non-identical) result from fertilisation of two different eggs with two different sperms. Dizygotic twins are all dichorionic and diamniotic (two separate outer and inner sacs) and have separate placentas.\n\n# Epidemiology\n\nIn general about two thirds of twins conceived naturally are dizygotic and one third are monozygotic.",
"files": null,
"highlights": [],
"id": "92",
"pictures": [],
"typeId": 2
},
"chapterId": 92,
"demo": null,
"entitlement": null,
"id": "112",
"name": "Twin pregnancies",
"status": null,
"topic": {
"__typename": "Topic",
"id": "38",
"name": "Obstetrics",
"typeId": 2
},
"topicId": 38,
"totalCards": 1,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 112,
"conditions": [],
"difficulty": 2,
"dislikes": 12,
"explanation": null,
"highlights": [],
"id": "10669",
"isLikedByMe": 0,
"learningPoint": "In dichorionic diamniotic twin pregnancies, delivery is typically advised around 37 weeks to optimise outcomes for both foetuses.",
"likes": 13,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "409",
"name": "Normal pregnancy and antenatal care",
"topic": {
"__typename": "UkmlaTopic",
"id": "18",
"name": "Obstetrics and gynaecology"
},
"topicId": 18
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 30-year-old woman presents to secondary care for her second antenatal ultrasound scan. The scan shows two foetuses and the presence of the lambda sign.\n\nWhich of the following will be the advised delivery period?",
"sbaAnswer": [
"a"
],
"totalVotes": 4141,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,980 | false | 38 | null | 6,494,981 | null | false | [] | null | 10,670 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Vasa praevia is a condition where foetal blood vessels lie against the internal cervical os and are unsupported by the placenta, making them particularly vulnerable to rupture during labour. The typical triad for vasa praevia is membrane rupture, painless vaginal bleeding and foetal bradycardia/death. Vasa praevia is more common in multiple gestations and in vitro fertilisation. The history given here is more in keeping with placental abruption due to painful bleeding with a tense uterus.",
"id": "53050",
"label": "d",
"name": "Vasa Praevia",
"picture": null,
"votes": 105
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Uterine rupture is a reasonable diagnosis given the pain and shock. However, a more typical history would include a description or tearing pain, with midline abdominal tenderness and minimal blood loss vaginally. During a uterine rupture there can be amniotic fluid leakage into the abdominal cavity and there may be rapid foetal deterioration. Risk factors for uterine rupture include previous uterine surgery, such as C-section, which this patient has not had.",
"id": "53048",
"label": "b",
"name": "Uterine rupture",
"picture": null,
"votes": 215
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This typically presents with an acute history of shortness of breath and cardiovascular collapse during or shortly after delivery. Disseminated intravascular coagulation may be present. There are risk factors for this, including advancing maternal age, cardiac disease and multiparity but its occurrence is unpredictable and not completely understood. Amniotic fluid and foetal components enter the maternal circulation, triggering a cascade of pulmonary vasoconstriction and disseminated intravascular coagulation. This patient is in shock but there is no evidence of coagulopathy, making placental abruption more likely.",
"id": "53051",
"label": "e",
"name": "Amniotic fluid embolism",
"picture": null,
"votes": 47
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Placenta praevia refers to when the placenta lies low in the uterus, covering the cervix, and thus the path the foetus will have to take during labour in part or full. The bleeding in placenta praevia is typically painless and bright red, with a soft abdomen. The placenta may be palpable in the lower segment on examination. In this case, the patient has marked pain, a woody tense uterus and dark coloured blood, making a diagnosis of abruption more likely.",
"id": "53049",
"label": "c",
"name": "Placenta praevia",
"picture": null,
"votes": 168
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The key features indicating placental abruption are the presence of a tense 'woody' uterus, dark red blood passed vaginally, pain and evidence of shock. In placental abruption, the external blood losses may be disproportionate to the degree of shock, as indicated in this case with only 100 ml of blood apparently lost but the presence of a significant tachycardia. This is because the blood mostly remains between the placenta and the uterine wall and so external losses can be minimal. Risk factors for placental abruption include maternal hypertension, trauma, polyhydramnios and cocaine use.",
"id": "53047",
"label": "a",
"name": "Placental abruption",
"picture": null,
"votes": 3497
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nPlacental abruption is a serious obstetrical complication characterised by the premature separation of the placenta from the uterine wall, resulting in maternal haemorrhage. Clinical features include sudden and severe abdominal pain, a \"\"woody\"\" hard uterus, contractions, possible vaginal bleeding, reduced foetal movements, and hypovolaemic shock. Risk factors include maternal trauma, pre-eclampsia, advanced maternal age, polyhydramnios, a history of abruption, substance abuse, and coagulation disorders. Investigations can be challenging due to the potential for concealed haemorrhage but may include ultrasound and cardiotocography (CTG). Management is dependent on the health of the foetus, and can range from emergency delivery to conservative management. Anti-D prophylaxis should be given in rhesus D negative women.\n\n# Definition\n\nPlacental abruption is the premature separation of the placenta from the uterine wall during pregnancy, resulting maternal haemorrhage.\n\nIt is important to note that placental abruption may be concealed.\n\n# Clinical features\n\n- Abdominal pain (often sudden and severe)\n- “Woody” hard uterus\n- Contractions\n- Vaginal bleeding (However in some cases haemorrhage may be confined to the uterus and thus concealed)\n- Reduced foetal movements and abnormal CTG\n- Hypovolaemic shock which is often disproportionate to the amount of vaginal bleeding visible\n\n# Risk factors\n\n- Maternal trauma for example assault, road traffic accident, iatrogenic\n- Pre-eclampsia or hypertension\n- Multiparity or increased maternal age\n- Polyhydramnios\n- Previous history of abruption\n- Substance abuse during pregnancy (particularly smoking and cocaine)\n- Existing coagulation disorders\n\n# Management\n\nAny woman presenting with a significant antepartum haemorrhage should be resuscitated using an ABCDE approach. Do not delay maternal resuscitation in order to determine foetal viability.\n\nThe ongoing management of placental abruption is dependent on the health of the foetus:\n\n- Emergency delivery – indicated in the presence of maternal and/or foetal compromise and usually this is by caesarean section unless spontaneous delivery is imminent or operative vaginal birth is achievable.\n\n- Even if an in-utero foetal death has been diagnosed, a caesarean section may still be indicated if there is maternal compromise.\n\n- Induction of labour – for haemorrhage at term without maternal or foetal compromise, induction of labour is usually recommended to avoid further bleeding.\n\n- Conservative management – for some partial or marginal abruptions not associated with maternal or foetal compromise (dependant on the gestation and amount of bleeding).\n\n- In all cases, give anti-D within 72 hours of the onset of bleeding if the woman is rhesus D negative.",
"files": null,
"highlights": [],
"id": "110",
"pictures": [],
"typeId": 2
},
"chapterId": 110,
"demo": null,
"entitlement": null,
"id": "109",
"name": "Placental abruption",
"status": null,
"topic": {
"__typename": "Topic",
"id": "38",
"name": "Obstetrics",
"typeId": 2
},
"topicId": 38,
"totalCards": 3,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "109",
"name": "Placental abruption"
}
],
"demo": false,
"description": null,
"duration": 1368.34,
"endTime": null,
"files": null,
"id": "274",
"live": false,
"museId": "a5eDzWK",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/obstetrics.png",
"title": "Placenta praevia 1",
"userViewed": false,
"views": 180,
"viewsToday": 17
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "109",
"name": "Placental abruption"
}
],
"demo": false,
"description": null,
"duration": 385.71,
"endTime": null,
"files": null,
"id": "622",
"live": false,
"museId": "fTwad4o",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/obstetrics.png",
"title": "Placenta praevia",
"userViewed": false,
"views": 51,
"viewsToday": 5
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "109",
"name": "Placental abruption"
}
],
"demo": false,
"description": null,
"duration": 3055.89,
"endTime": null,
"files": null,
"id": "620",
"live": false,
"museId": "eriRASf",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/gynecology.png",
"title": "Quesmed Tutorial: Obstetric Emergencies",
"userViewed": false,
"views": 874,
"viewsToday": 45
}
]
},
"conceptId": 109,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10670",
"isLikedByMe": 0,
"learningPoint": "Placental abruption is a serious pregnancy complication where the placenta separates prematurely from the uterine wall, leading to bleeding, abdominal pain, and potential risk to both the mother and foetus.",
"likes": 4,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "86",
"name": "Bleeding antepartum",
"topic": {
"__typename": "UkmlaTopic",
"id": "1",
"name": "Acute and emergency"
},
"topicId": 1
},
{
"__typename": "Presentation",
"id": "87",
"name": "Bleeding antepartum",
"topic": {
"__typename": "UkmlaTopic",
"id": "18",
"name": "Obstetrics and gynaecology"
},
"topicId": 18
},
{
"__typename": "Presentation",
"id": "88",
"name": "Bleeding antepartum",
"topic": {
"__typename": "UkmlaTopic",
"id": "21",
"name": "Perioperative medicine and anaesthesia"
},
"topicId": 21
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 38-year-old woman presents at 39 + 4 weeks gestation with severe abdominal pain and dark red blood loss of an estimated 100 ml vaginally. This is her first pregnancy and apart from gestational diabetes with polyhydramnios, there have been no other concerns regarding the pregnancy. On examination, she has a heart rate of 126 bpm. Her other vital signs are unremarkable. Her abdomen is tense and she appears in significant pain.\n\nWhat is the most likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 4032,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,981 | false | 39 | null | 6,494,981 | null | false | [] | null | 10,671 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Oxytocin has multiple obstetric uses, including as an induction agent, to accelerate stage 2 of labour and reduce the risk of postpartum haemorrhage. There is no current indication for requiring oxytocin at this stage. The patient's labour is progressing well and the baby has descended into the birth canal with the head now visible.",
"id": "53054",
"label": "c",
"name": "Oxytocin infusion",
"picture": null,
"votes": 220
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Forceps delivery may be required where the labour is not progressing or delivery requires expediting. This is not required for this case. The patient's labour is progressing well and the baby has descended into the birth canal with the head now visible; transient bradycardia is not significant in this context.",
"id": "53055",
"label": "d",
"name": "Attempt forceps delivery",
"picture": null,
"votes": 473
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The labour is progressing well with the head now in the birth canal and visible. The cardiotocography trace does not represent any significant pathology. Therefore, an emergency caesarian section is not required at this stage.",
"id": "53053",
"label": "b",
"name": "Emergency caesarian section",
"picture": null,
"votes": 545
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Foetal bradycardia is defined as a heart rate of less than 110 bpm sustained for over 5–10 min. Upon pressure to the foetal head, mild, transient bradycardia is common due to a vagal response and will improve spontaneously after the pressure is relieved. The labour is otherwise progressing well with no other abnormalities described on the cardiotocography. The foetus has now descended into the birth canal with the head visible and so vaginal delivery can continue at present.",
"id": "53052",
"label": "a",
"name": "Continue with vaginal delivery",
"picture": null,
"votes": 2574
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ventouse delivery may be required where labour is not progressing or delivery requires expediting. This is not required for this case. The patient's labour is progressing well and the baby has descended into the birth canal with the head now visible; transient bradycardia is not significant in this context.",
"id": "53056",
"label": "e",
"name": "Attempt ventouse delivery",
"picture": null,
"votes": 480
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Fetal bradycardia causes: cord compression, epidural anaesthesia, fetal head compression due to rapid fetal descent /cervical dilatation, etc.\nValues between 100 and 110 bpm may occur in normal fetuses, especially in postdate pregnancies. ",
"createdAt": 1732723005,
"dislikes": 0,
"id": "57622",
"isLikedByMe": 0,
"likes": 2,
"parentId": null,
"questionId": 10671,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "EventualAsystole",
"id": 58284
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nThe second stage of labour commences with full cervical dilation and concludes with the delivery of the foetus. The main signs during this stage include the desire of the mother to push and the repositioning of the foetus in preparation for birth. A prolonged second stage of labour is defined by specific time frames for nulliparous and multiparous women, both with and without epidural. Management of a prolonged second stage can involve an instrumental delivery or, in some cases, a caesarean section, which is associated with increased maternal morbidity.\n\n\n# Definition\n\n\n\nThe second stage of labour is defined as the period beginning with complete cervical dilation and ending with the delivery of the foetus.\n\n\n# Signs and Symptoms\n\n\n\nThe hallmark signs and symptoms of the second stage of labour include:\n\n- Foetal head flexion, descent, and engagement into the pelvis\n- Foetal internal rotation to face the maternal back\n- Foetal head extension to deliver the head\n- Foetal external rotation (restitution) after delivery of the head, positioning the shoulders in the AP position\n- Delivery of the anterior shoulder first, followed by the rest of the foetus\n- Maternal desire to push\n\n# Management\n\n\nThe management of a prolonged second stage involves:\n\n- Instrumental delivery: This can be implemented if possible and conditions are favourable.\n- Caesarean section: This may be considered if instrumental delivery is not possible or contraindicated. However, a caesarean section in the second stage is associated with increased maternal morbidity.",
"files": null,
"highlights": [],
"id": "136",
"pictures": [],
"typeId": 2
},
"chapterId": 136,
"demo": null,
"entitlement": null,
"id": "136",
"name": "Second stage of labour",
"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": "136",
"name": "Second stage of labour"
}
],
"demo": false,
"description": null,
"duration": 367.6,
"endTime": null,
"files": null,
"id": "351",
"live": false,
"museId": "ifMZ85b",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/obstetrics.png",
"title": "Second stage of labour",
"userViewed": false,
"views": 104,
"viewsToday": 7
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "136",
"name": "Second stage of labour"
}
],
"demo": false,
"description": null,
"duration": 2921.86,
"endTime": null,
"files": null,
"id": "326",
"live": false,
"museId": "VK2DzjU",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/obstetrics.png",
"title": "Quesmed Tutorial: Obstetrics 2",
"userViewed": false,
"views": 236,
"viewsToday": 15
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "136",
"name": "Second stage of labour"
}
],
"demo": false,
"description": null,
"duration": 241,
"endTime": null,
"files": null,
"id": "287",
"live": false,
"museId": "1EMRxon",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/obstetrics.png",
"title": "Polyhydramnios",
"userViewed": false,
"views": 80,
"viewsToday": 4
}
]
},
"conceptId": 136,
"conditions": [],
"difficulty": 2,
"dislikes": 5,
"explanation": null,
"highlights": [],
"id": "10671",
"isLikedByMe": 0,
"learningPoint": "Transient foetal bradycardia during labour can occur due to vagal stimulation and typically resolves spontaneously, allowing for continued vaginal delivery.",
"likes": 11,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "333",
"name": "Labour",
"topic": {
"__typename": "UkmlaTopic",
"id": "18",
"name": "Obstetrics and gynaecology"
},
"topicId": 18
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "A primiparous 30-year-old woman is 39 + 6 weeks pregnant. She is in stage 2 of labour and has been pushing for 30 min. The midwife supports the foetus' head as it descends through the birth canal and becomes visible. At this moment, the cardiotocography shows a heart rate of 100 bpm for 1 min, before returning to a heart rate of 140–150 bpm.\n\nWhat is the next best step in management?",
"sbaAnswer": [
"a"
],
"totalVotes": 4292,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,982 | false | 40 | null | 6,494,981 | null | false | [] | null | 10,672 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This injection must be provided every 3 months; therefore, for contraceptive cover this would be impractical due to the patient going abroad for 4 months. Moreover, it does not necessarily stop periods in all patients, with some patients having spotting and irregular bleeding.",
"id": "53061",
"label": "e",
"name": "Intramuscular progesterone injection",
"picture": null,
"votes": 421
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The progesterone-only pill could provide reliable contraceptive cover if taken daily and may also help with endometriosis. However, it does not protect against irregular bleeding or reliably stop periods and so it would not be the best choice in this patient.",
"id": "53058",
"label": "b",
"name": "Progesterone-only pill",
"picture": null,
"votes": 352
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The combined oral contraceptive pill provides reliable contraceptive cover and can be taken back to back to prevent bleeding. It can also help with endometriosis-related pain. This patient has no contraindications for the combined oral contraceptive pill such as migraine with aura or smoking and so can be offered this.",
"id": "53057",
"label": "a",
"name": "Combined oral contraceptive pill",
"picture": null,
"votes": 1534
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Intrauterine devices are copper-based systems that do not stop periods and can in fact make them heavier and more prolonged. They will not help with endometriosis-related pain although will offer good contraception. Therefore, it does not fulfil all of the patient's criteria.",
"id": "53059",
"label": "c",
"name": "Intrauterine device",
"picture": null,
"votes": 229
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Intrauterine systems release local progestogens and help thin the lining of the uterus, reducing bleeding and providing effective contraception. They can help with endometriosis pain. However, they do not reliably stop periods or breakthrough bleeding; therefore, they are not a suitable option for the patient.",
"id": "53060",
"label": "d",
"name": "Intrauterine system",
"picture": null,
"votes": 1041
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "but then wont she have a bleed during the 'pill free' week?\n",
"createdAt": 1704566787,
"dislikes": 0,
"id": "37969",
"isLikedByMe": 0,
"likes": 4,
"parentId": null,
"questionId": 10672,
"replies": [
{
"__typename": "QuestionComment",
"comment": "they can be given continuously without a pill free week, so they won't have a bleed",
"createdAt": 1709988199,
"dislikes": 1,
"id": "44277",
"isLikedByMe": 0,
"likes": 4,
"parentId": 37969,
"questionId": 10672,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Intubation Hypertension",
"id": 28779
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Malignant Serotonin",
"id": 3366
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Management of missed combined oral contraception pills\n\n\nIf patients are sick (vomit) within 3 hours of taking a combined pill, or within 2 hours of taking a progestogen-only pill, it probably will not have been absorbed by their body. Patients should take another pill straight away.\nAs long as they're not sick again, they will still be protected against pregnancy.\nPatient should be advised to take their next pill as usual.\n\n\nThe pill free week is the 7 days between taking packets of pills. There is occasionally a breakthrough bleed, a small bleed similar to a period, however the absence of a breakthrough bleed does not indicate pregnancy.\n\n\nMissed pill rules:\n\n\n- If pills are missed in week 1: use emergency contraception if she had UPSI in pill free interval for 1 week\n\n\n- If pills are missed in week 2: no need for emergency contraception\n\n\n- If pills are missed in week 3: Take the last pill that was missed, finish the current pack and start the next pack immediately after.\n\n\n# References\n\n\n[Click here to see information on NICE about missed pills](https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/management/combined-oral-contraceptive/#missed-coc-pills-except-qlaira-zoely)",
"files": null,
"highlights": [],
"id": "8",
"pictures": [],
"typeId": 2
},
"chapterId": 8,
"demo": null,
"entitlement": null,
"id": "3456",
"name": "Missed combined oral contraceptive pills",
"status": null,
"topic": {
"__typename": "Topic",
"id": "27",
"name": "Genitourinary medicine",
"typeId": 2
},
"topicId": 27,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3456,
"conditions": [],
"difficulty": 3,
"dislikes": 18,
"explanation": null,
"highlights": [],
"id": "10672",
"isLikedByMe": 0,
"learningPoint": "The combined oral contraceptive pill is effective for contraception and can alleviate endometriosis-related pain while suppressing menstrual bleeding.",
"likes": 8,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "171",
"name": "Contraception request/advice",
"topic": {
"__typename": "UkmlaTopic",
"id": "12",
"name": "General practice and primary healthcare"
},
"topicId": 12
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 22-year-old woman attends her GP for contraceptive advice. She is going abroad for 4 months and would like to have a reliable form of contraception, which will also prevent her having any periods or bleeding while away. She has known endometriosis with chronic menstrual pain and adhesions. She takes no regular medications and has never smoked. On examination, her body mass index is 20.\n\nWhich of the following is the most appropriate option for this patient?",
"sbaAnswer": [
"a"
],
"totalVotes": 3577,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,983 | false | 41 | null | 6,494,981 | null | false | [] | null | 10,673 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Pituitary apoplexy is bleeding or infarction of the pituitary, usually in the context of a pre-existing pituitary adenoma or in postpartum haemorrhage. This would lead to a fall in the pituitary hormones LH and FSH and subsequently low levels of oestrogen. In this case, there is no history consistent with pituitary apoplexy, such as a sudden-onset headache, and the levels of FSH and LH are high, indicating primary ovarian failure.",
"id": "53065",
"label": "d",
"name": "Pituitary apoplexy",
"picture": null,
"votes": 405
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Primary ovarian failure results in a reduction of ovarian oestrogen production. The drop in oestrogen reduces negative feedback on the pituitary gland, which produces more LH and FSH in response. Her AMH is also low; this is a measure of the number of eggs that the patient has remaining, further pointing towards ovarian failure.",
"id": "53062",
"label": "a",
"name": "Primary ovarian failure",
"picture": null,
"votes": 3554
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hypothyroidism can cause amenorrhoea and infertility in females. It causes a hypogonadotrophic hypogonadism as raised thyrotropin-releasing hormone levels stimulate prolactin release, which suppresses gonadotropin-releasing hormone release. In this patient, the LH/FSH are raised, making this less likely. This patient also lacks other features of hypothyroidism, such as weight gain, hair loss and cold intolerance.",
"id": "53066",
"label": "e",
"name": "Hypothyroidism",
"picture": null,
"votes": 148
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "During pregnancy, LH and FSH levels are low due to negative feedback from higher levels of oestrogen. This patient has low oestrogen levels alongside low FSH and LH. This indicates ovarian failure rather than pregnancy. They do not report any symptoms in keeping with pregnancy either, such as morning sickness, weight gain or breast tenderness. However, in practice a pregnancy test would be conducted to definitively rule this out in any patient presenting with secondary amenorrhea.",
"id": "53063",
"label": "b",
"name": "Current pregnancy",
"picture": null,
"votes": 104
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hypothalamic hypogonadism would result in low levels of LH, FSH and subsequently oestrogen, due to lack of gonadotropin-releasing hormone release stimulating the pituitary gland. This usually occurs in the context of anorexia or excess exercise. The patient in this case has a normal body mass index and there is no mention of excessive exercise.",
"id": "53064",
"label": "c",
"name": "Hypothalamic hypogonadism",
"picture": null,
"votes": 489
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Why is the Prolactin high? As well as the TSH?\n",
"createdAt": 1719141278,
"dislikes": 0,
"id": "53595",
"isLikedByMe": 0,
"likes": 19,
"parentId": null,
"questionId": 10673,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Supine Bladder",
"id": 35998
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n \n \nSubfertility is defined as the diminished ability of a couple to conceive a child, which may be due to a variety of definable causes or an unexplained failure to conceive over a two-year period. Key signs and symptoms vary based on the underlying cause but generally revolve around the inability to achieve pregnancy despite regular unprotected sexual intercourse. Investigations typically include hormonal studies, semen analysis, and imaging studies. The management of infertility is dependent on the underlying cause and often involves a combination of lifestyle modifications, medical interventions, and assistive reproductive technology. \n \n \n \n# Definition\n \nInfertility is the diminished ability of a couple to conceive a child. This may result from a definable cause such as ovulatory, tubal, or sperm problems, or may be an unexplained failure to conceive over a two-year period despite regular (3-4 times a week) unprotected sexual intercourse.\n \n \n \n# Epidemiology\n \n \nStatistically, a couple stands an 80% chance of conceiving within one year if the woman is younger than 40 years, they do not use contraception, and they have regular intercourse (3-4 times per week). This overall probability increases to 90% if considered over two years.\n \n \n# Aetiology\n\n \nFactors affecting natural fertility include:\n \n - Increasing age\n - Obesity\n - Smoking\n - Tight-fitting underwear (males)\n - Excessive alcohol consumption\n - Anabolic steroid use\n - Illicit drug use\n \n \n\nCauses of infertility can be classified into:\n \n \n - **Genetic causes:** This includes Turner's syndrome (XO) and Kleinfelter's syndrome (XXY).\n - **Ovulation/endocrine disorders:** Examples are polycystic ovary syndrome, pituitary tumours, Sheehan's syndrome, hyperprolactinaemia, Cushing's syndrome, and premature ovarian failure.\n - **Tubal abnormalities:** These can be due to congenital anatomical abnormalities or adhesions secondary to pelvic inflammatory disease (often caused by chlamydia or gonorrhoea).\n - **Uterine abnormalities:** These include bicornate uterus, fibroids, and Asherman's syndrome (uterine adhesions).\n - Endometriosis\n - **Cervical abnormalities:** These include cervical damage after biopsy or LLETZ procedure.\n - **Testicular disorders:** Disorders such as cryptorchidism, varicocele, testicular cancer, and congenital testicular defects fall in this category.\n - **Ejaculatory disorders:** These include obstruction of the ejaculatory system and disorders of ejaculation such as retrograde ejaculation and premature ejaculation.\n \n \n# Investigations\n \n \nInvestigations for infertility are divided into those for men and women. \n\n*For women:*\n\n**Bedside:**\n \n- Thorough history, including past medical history, sexual history and details of past pregnancies. \n- Speculum and bimanual examination: To investigate physical anomalies (e.g. large fibroids). \n- STI screen\n \n \n**Bloods:**\n \n - Serum progesterone testing (performed 7 days before the end of the menstrual cycle): A rise in progesterone indicates that the corpus luteum has formed and is releasing progesterone due to occurrence of ovulation.\n - Prolactin\n - LH/FSH \n - Anti-mullerian hormone (AMH): Measure of ovarian reserve\n - TFTs \n\n \n**Imaging:**\n \n- Transvaginal ultrasound scan: To identify any physical anomalies of the uterus, and check antral follicle count (measure of ovarian reserve)\n- Hysterosalpingography: Assess tubal patency.\n- Laparsocopy and dye: Assess tubal patency in presence of co-morbidities (e.g. PID, ectopic pregnancy, endometriosis). \n\n\n*For men:*\n\n**Bedside:**\n \n- Thorough history, including past medical history, sexual history and details of past pregnancies. \n- Testicular examination: To investigate visible physical anomalies (e.g. varicocele). \n- Semen analysis: To evaluate sperm count, motility, and morphology. \n \n \n**Bloods:**\n \n - Serum testosterone \n - LH/FSH \n - TFTs \n \n \n# Management\n \n \nThe management of infertility is tailored to the underlying cause but may include:\n \n**Conservative:**\n\n - Weight loss\n - Smoking cessation \n - Reduction of alcohol intake\n - Stress-reduction strategies\n\n**Medical:**\n\nMedications may be used for ovulation induction, such as: \n\n - Clomiphene\n - FSH and LH injections\n - GnRH or DA agonists\n\n \n**Surgical:**\n \n - Assisted reproductive technology, including in vitro fertilisation or intracytoplasmic sperm injection.\n\n\nIn addition to all of the above, if an underlying cause of infertility is found (e.g. fibroids, endometriosis), then those causes should be managed. \n\n\n# NICE Guidelines\n\n[Click here for NICE Guidelines on fertility problems](https://www.nice.org.uk/guidance/cg156)\n\n[Click here for NICE Guidelines on infertility](https://cks.nice.org.uk/topics/infertility/)\n\n# References \n\n[BMJ Best Practice](https://bestpractice.bmj.com/topics/en-gb/498)\n\n[Fields et al., 2023 - BMJ](https://www.bmj.com/bmj/section-pdf/187753?path=/bmj/346/7896/Practice.full.pdf)",
"files": null,
"highlights": [],
"id": "929",
"pictures": [],
"typeId": 2
},
"chapterId": 929,
"demo": null,
"entitlement": null,
"id": "976",
"name": "Subfertility",
"status": null,
"topic": {
"__typename": "Topic",
"id": "26",
"name": "Gynaecology",
"typeId": 2
},
"topicId": 26,
"totalCards": 6,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 976,
"conditions": [
{
"__typename": "Condition",
"id": "423",
"name": "Menopause",
"topic": {
"__typename": "UkmlaTopic",
"id": "18",
"name": "Obstetrics and gynaecology"
},
"topicId": 18
}
],
"difficulty": 2,
"dislikes": 5,
"explanation": null,
"highlights": [],
"id": "10673",
"isLikedByMe": 0,
"learningPoint": "Primary ovarian failure is characterised by elevated LH and FSH levels, low oestradiol, and decreased anti-Müllerian hormone, indicating reduced ovarian function.",
"likes": 16,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "520",
"name": "Subfertility",
"topic": {
"__typename": "UkmlaTopic",
"id": "18",
"name": "Obstetrics and gynaecology"
},
"topicId": 18
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 32-year-old woman presents to her GP concerned over her periods. She used to have regular 28-d cycles but over the past 2 years she has experienced these becoming irregular and then ceasing for the past 4 months. Her GP arranges for her to have some blood tests, which are shown below:\n\n||||\n|--------------|:-------:|---------------|\n|Luteinising Hormone|12.2 IU/L|1 - 11 (Luteal)|\n|Follicle Stimulating Hormone|42.3 IU/L|2 - 8 (Luteal)|\n|Testosterone|1.1 nmol/L|(M) 9.9 - 27.8, (F) 0.2 - 2.9|\n|Prolactin|520 IU/L|(M) 90 - 320, (F) 100 - 500|\n|Thyroid Stimulating Hormone|4.5 mU/L|0.3 - 4.2|\n|Oestradiol|22 pmol/L|45 - 854|\n|Anti-Müllerian hormone (AMH)|2.2 pmol/L|6.8 - 47.8|\n\n\nWhat is the most likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 4700,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,984 | false | 42 | null | 6,494,981 | null | false | [] | null | 10,674 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The intrauterine device is a copper-based system that provides contraception but does not deliver any hormones either systemically or locally. As such, it does not influence the hormonal variations that are thought to cause premenstrual syndrome and are of no benefit in managing this condition.",
"id": "53069",
"label": "c",
"name": "Intrauterine device",
"picture": null,
"votes": 470
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient describes symptoms in keeping with premenstrual syndrome (PMS). She experiences mood swings, cognitive issues and irritability during the luteal phase of her cycle, with symptom cessation with the onset of menses. All women are advised to keep a period diary to document the frequency and severity of their symptoms, although this patient already provides an adequate history. The severity of PMS is based on clinical judgement without any scoring criteria; features indicating more severe symptoms include impact on quality of life, mood disturbance or impact on function. Lifestyle changes are an important first-line measure in all women, such as exercise, regular sleep, good diet and restricting alcohol intake. However, this patient reports that the symptoms are affecting her day-to-day life and she is also seeking pharmacological therapy. She most likely has moderate disease, in the absence of more severe features such as depression and loss of function. The first-line treatment as per National Institute for Health and Care Excellence (NICE) guidelines for moderate PMS is the combined oral contraceptive. This will also help her periods, which she says are heavy. A selective serotonin reuptake inhibitor (SSRI) is an alternative, for example, where this may be indicated, or first-line for severe disease.",
"id": "53067",
"label": "a",
"name": "Combined oral contraceptive",
"picture": null,
"votes": 2404
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although this patient suffers from irritability, she does not report any symptoms indicative of psychosis, such as hallucinations or delusions. If she were experiencing these, then specialist input would be appropriate to rule out any alternative diagnoses.",
"id": "53070",
"label": "d",
"name": "Antipsychotic agent",
"picture": null,
"votes": 6
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As per the NICE guidelines, progesterone-only treatments do not have adequate evidence and are not recommended in the management of premenstrual syndrome. Moderate disease is treated with the combined oral contraceptive pill, and severe disease with SSRIs.",
"id": "53068",
"label": "b",
"name": "Progesterone-only pill",
"picture": null,
"votes": 683
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "An SSRI would be first-line for severe PMS, for example, if she were experiencing low mood and disabling emotional lability affecting her daily function. However, for moderate disease, the first-line agent is the combined oral contraceptive pill. This will also help her periods, which she reports are heavy.",
"id": "53071",
"label": "e",
"name": "Selective serotonin reuptake inhibitor",
"picture": null,
"votes": 827
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "she has migraines??!?!!!",
"createdAt": 1684064703,
"dislikes": 3,
"id": "24465",
"isLikedByMe": 0,
"likes": 16,
"parentId": null,
"questionId": 10674,
"replies": [
{
"__typename": "QuestionComment",
"comment": "without aura in this case, migraines WITH aura will be classified under UKMEC4 where it is an absolute contraindication",
"createdAt": 1684129391,
"dislikes": 0,
"id": "24587",
"isLikedByMe": 0,
"likes": 14,
"parentId": 24465,
"questionId": 10674,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Kawasaki Neoplasia",
"id": 26081
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "evieeee",
"id": 20602
}
},
{
"__typename": "QuestionComment",
"comment": "With or without aura... would any one realistically prescribe it to a pt with this history? Patient's aren't always great at describing their symptoms...",
"createdAt": 1685632722,
"dislikes": 0,
"id": "27458",
"isLikedByMe": 0,
"likes": 5,
"parentId": null,
"questionId": 10674,
"replies": [
{
"__typename": "QuestionComment",
"comment": "I think if you explain exactly what you mean by aura, ask specific \"do you get feeling x or y\" before/with the headache etc. a reasonable patient would be able to say yes or no and I would be confident in prescribing it",
"createdAt": 1709210376,
"dislikes": 0,
"id": "43227",
"isLikedByMe": 0,
"likes": 3,
"parentId": 27458,
"questionId": 10674,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Ale",
"id": 20565
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Tazocin Suture",
"id": 30623
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nPremenstrual syndrome (PMS) is characterised by psychological, physical or behavioural symptoms occurring in the luteal phase of the menstrual cycle that cause distress or disruption to the patient. Key signs and symptoms vary but often include mood swings, fatigue, and physical discomfort. Diagnosis is usually clinical and may involve the patient keeping a diary of symptoms. Management strategies include both non-pharmacological and pharmacological approaches, such as dietary modification, increasing exercise, stress reduction, and medication including the combined oral contraceptive pill and antidepressants.\n\n# Definition\n\nPremenstrual syndrome (PMS) refers to a cluster of psychological, physical, and behavioural symptoms that occur in the luteal phase of the menstrual cycle and cause distress or disruption to the patient's life. It is crucial to obtain a comprehensive medical history from the patient and consider suggesting the patient keep a diary of symptoms to aid in the diagnosis.\n\n# Epidemiology\n\nThe prevalence and severity of PMS vary widely. It is estimated that as many as 30-40% of menstruating women experience some degree of PMS. Severe PMS, also known as premenstrual dysphoric disorder (PMDD), affects approximately 3-8% of women. \n\n# Aetiology\n\nThe exact cause of PMS is unclear. However, it is likely related to hormonal changes during the menstrual cycle. Some researchers believe that PMS is connected to the rise and fall of hormones, specifically estrogen and progesterone, during the menstrual cycle.\n\n# Signs and Symptoms\n\nSymptoms of PMS can vary widely from woman to woman and from cycle to cycle. They can be physical, emotional, or behavioural and commonly include:\n\n- Mood swings and irritability\n- Depression and anxiety\n- Fatigue and sleep problems\n- Physical symptoms such as bloating, breast tenderness, headaches, and joint or muscle pain\n- Changes in appetite and food cravings\n- Difficulty concentrating\n\n# Differential Diagnosis\n\nConditions that can mimic PMS include:\n\n- Thyroid disease: Symptoms can include fatigue, depression, and weight changes.\n- Chronic fatigue syndrome: Main symptoms are persistent and unexplained fatigue, sleep problems, and post-exertional malaise.\n- Depression or anxiety disorders: These conditions can cause mood changes, irritability, and fatigue, similar to PMS.\n\n# Investigations \n\nPMS is usually a clinical diagnosis based on the patient's symptoms. Keeping a symptom diary for at least two menstrual cycles can be helpful in confirming the diagnosis. Further investigations may be needed if the diagnosis is uncertain or if other conditions are suspected.\n\n# Management \n\nManagement of PMS can include both non-pharmacological and pharmacological approaches:\n\nNon-pharmacological:\n\n- Dietary modification: reduce fat, sugar, caffeine, alcohol and increase fibre, fruit and aim for more frequent snacks.\n- Increasing exercise\n- Vitamin supplementation: there is some evidence for vitamin B supplementation\n- Stress reduction: relaxation techniques\n- Cognitive behavioural therapy\n\nPharmacological:\n\n- Combined oral contraceptive pill (COCP)\n- Danazol\n- Transdermal oestrogen\n- GnRH analogues: effectively induce a menopausal state\n- Antidepressants: particularly selective serotonin reuptake inhibitors (SSRIs) and selective noradrenalin reuptake inhibitors (SNRIs)\n\n# References\n\n- [NICE Clinical Knowledge Summary (CKS): Premenstrual syndrome](https://cks.nice.org.uk/topics/premenstrual-syndrome/)\n- [Royal College of Obstetricians & Gynaecologists: Management of premenstrual syndrome](https://www.rcog.org.uk/globalassets/documents/guidelines/gt48managementpremensturalsyndrome.pdf)",
"files": null,
"highlights": [],
"id": "2614",
"pictures": [],
"typeId": 2
},
"chapterId": 2614,
"demo": null,
"entitlement": null,
"id": "3458",
"name": "Premenstrual syndrome",
"status": null,
"topic": {
"__typename": "Topic",
"id": "26",
"name": "Gynaecology",
"typeId": 2
},
"topicId": 26,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3458,
"conditions": [],
"difficulty": 2,
"dislikes": 30,
"explanation": null,
"highlights": [],
"id": "10674",
"isLikedByMe": 0,
"learningPoint": "Combined oral contraceptives are first-line treatment for moderate premenstrual syndrome, alleviating both mood symptoms and heavy menstrual bleeding.",
"likes": 2,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "376",
"name": "Menstrual problems",
"topic": {
"__typename": "UkmlaTopic",
"id": "18",
"name": "Obstetrics and gynaecology"
},
"topicId": 18
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 23-year-old woman attends her GP. She says she has been struggling with her periods recently and would like some help to make them more manageable. She says that in the days leading up to her period she becomes very irritable and has poor concentration. This gradually resolves once menstruation occurs. She says her periods are also heavy. She is concerned about the impact of her condition on her relationship, although her partner is very supportive. Her past medical history includes migraine without aura. She has no drug allergies. She is keen to start a medication that will help with her symptoms.\n\nWhat is the next most suitable step in management?",
"sbaAnswer": [
"a"
],
"totalVotes": 4390,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,985 | false | 43 | null | 6,494,981 | null | false | [] | null | 10,675 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "An ultrasound would not be able to reliably detect pregnancy in its early stages. Before sterilisation, patients are advised to be on effective contraceptive for a month to minimise the risk of pregnancy at the time of the procedure, which can lead to ectopics occurring. This patient has not been taking effective contraception and has had sex recently; thus, her procedure should be cancelled.",
"id": "53076",
"label": "e",
"name": "Ultrasound to assess for pregnancy and, if negative, proceed",
"picture": null,
"votes": 352
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Before sterilisation, patients are advised to be on effective contraceptive for a month to minimise the risk of pregnancy at the time of the procedure, which can lead to ectopics occurring. This patient has not been taking effective contraception and has had sex recently; thus, her procedure should be cancelled. Pregnancy tests may be negative in the very early stages of a pregnancy and as such a negative pregnancy test on the day of the procedure is not reliable enough to enable the operation to proceed. This should be explained to the patient and suitable contraception offered; in this case, due to issues with taking oral contraception or barrier methods previously, a LARC may be the best option but this is a conversation to be had with the patient. Levonelle is an emergency contraceptive medication, which is provided within 3 d of unprotected intercourse to prevent pregnancy; there is nothing in the question to suggest the patient wants emergency contraception, and even if she did this would not be an option available to her since her unprotected intercourse was 2 weeks ago. If Levonelle were an option, you would still not proceed with the procedure due to the subsequent risk of pregnancy still being relatively too high and you would postpone until the patient has been taking contraception for a month.\n.",
"id": "53075",
"label": "d",
"name": "Give levonorgestrel (Levonelle) and proceed",
"picture": null,
"votes": 58
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Before sterilisation patients are advised to be on effective contraceptive for a month to minimise the risk of pregnancy at the time of the procedure, which can lead to ectopics occurring. Pregnancy tests may be negative in the very early stages of a pregnancy and as such a negative pregnancy test on the day of the procedure is not reliable enough to enable the operation to proceed. This patient has not been taking effective contraception and has had sex recently; thus, her procedure should be cancelled.",
"id": "53074",
"label": "c",
"name": "Perform a pregnancy test and, if negative, proceed",
"picture": null,
"votes": 1882
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Before sterilisation, patients are advised to be on effective contraceptive for a month to minimise the risk of pregnancy at the time of the procedure, which can lead to ectopics occurring. This patient has not been taking effective contraception and has had sex recently; thus, her procedure should be cancelled. Pregnancy tests may be negative in the very early stages of a pregnancy and as such a negative pregnancy test on the day of the procedure is not reliable enough to enable the operation to proceed. This should be explained to the patient and suitable contraception offered; in this case, due to issues with taking oral contraception or barrier methods previously, a long-acting reversible contraception (LARC) may be the best option but this is a conversation to be had with the patient.",
"id": "53072",
"label": "a",
"name": "Postpone sterilisation",
"picture": null,
"votes": 1325
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Before sterilisation, patients are advised to be on effective contraceptive for a month to minimise the risk of pregnancy at the time of the procedure, which can lead to ectopics occurring. This patient has not been taking effective contraception and has had sex recently; thus, her procedure should be cancelled. Pregnancy tests may be negative in the very early stages of a pregnancy and as such a negative pregnancy test on the day of the procedure is not reliable enough to enable the operation to proceed. This should be explained to the patient and suitable contraception offered; in this case, due to issues with taking oral contraception or barrier methods previously, a LARC may be the best option but this is a conversation to be had with the patient.",
"id": "53073",
"label": "b",
"name": "Proceed with sterilisation",
"picture": null,
"votes": 83
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Not really clear from the stem whether she has been taking the pill or not",
"createdAt": 1734017396,
"dislikes": 1,
"id": "58266",
"isLikedByMe": 0,
"likes": 2,
"parentId": null,
"questionId": 10675,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Monoclonal Metabolism",
"id": 25350
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Management of missed combined oral contraception pills\n\n\nIf patients are sick (vomit) within 3 hours of taking a combined pill, or within 2 hours of taking a progestogen-only pill, it probably will not have been absorbed by their body. Patients should take another pill straight away.\nAs long as they're not sick again, they will still be protected against pregnancy.\nPatient should be advised to take their next pill as usual.\n\n\nThe pill free week is the 7 days between taking packets of pills. There is occasionally a breakthrough bleed, a small bleed similar to a period, however the absence of a breakthrough bleed does not indicate pregnancy.\n\n\nMissed pill rules:\n\n\n- If pills are missed in week 1: use emergency contraception if she had UPSI in pill free interval for 1 week\n\n\n- If pills are missed in week 2: no need for emergency contraception\n\n\n- If pills are missed in week 3: Take the last pill that was missed, finish the current pack and start the next pack immediately after.\n\n\n# References\n\n\n[Click here to see information on NICE about missed pills](https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/management/combined-oral-contraceptive/#missed-coc-pills-except-qlaira-zoely)",
"files": null,
"highlights": [],
"id": "8",
"pictures": [],
"typeId": 2
},
"chapterId": 8,
"demo": null,
"entitlement": null,
"id": "3456",
"name": "Missed combined oral contraceptive pills",
"status": null,
"topic": {
"__typename": "Topic",
"id": "27",
"name": "Genitourinary medicine",
"typeId": 2
},
"topicId": 27,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3456,
"conditions": [],
"difficulty": 3,
"dislikes": 19,
"explanation": null,
"highlights": [],
"id": "10675",
"isLikedByMe": 0,
"learningPoint": "Prior to female sterilisation, ensure effective contraception is used for at least one month to reduce the risk of unintended pregnancy, a contraindication for sterilsation.",
"likes": 12,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "172",
"name": "Contraception request/advice",
"topic": {
"__typename": "UkmlaTopic",
"id": "18",
"name": "Obstetrics and gynaecology"
},
"topicId": 18
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 34-year-old woman attends the surgical admission unit as she is scheduled to undergo female sterilisation today. She reports she has been using the combined oral contraceptive pill sporadically and does not use barrier contraception regularly. She has had sex in the past 2 weeks and her last menstrual period was 2 weeks ago. She has irregular cycles lasting between 25 and 32 d.\n\nWhat is the next best step in her management?",
"sbaAnswer": [
"a"
],
"totalVotes": 3700,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,986 | false | 44 | null | 6,494,981 | null | false | [] | null | 10,676 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is still having periods every 4 months and therefore HRT should be given cyclically. Continuous HRT would be the first-line treatment if her periods had ceased for over a year. She still has a uterus and therefore needs progesterone protection to reduce the risk of endometrial cancer from unopposed oestrogen.",
"id": "53081",
"label": "e",
"name": "Cyclical oestrogen-only hormone replacement replacement therapy",
"picture": null,
"votes": 308
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is still having periods every 4 months and therefore HRT should be given cyclically. Continuous HRT would be the first-line treatment if her periods had ceased for over a year. She still has a uterus and therefore needs progesterone protection to reduce the risk of endometrial cancer from unopposed oestrogen.",
"id": "53080",
"label": "d",
"name": "Continuous oestrogen-only hormone replacement therapy",
"picture": null,
"votes": 211
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has symptoms in keeping with the menopause that are affecting her quality of life and so is appropriately seeking treatment. Selective serotonin reuptake inhibitors (SSRIs) are not advised as first-line treatments by National Institute for Health and Care Excellence, with HRT providing added benefits such as on bone mineral density. SSRIs may be considered in situations where HRT is contraindicated, such as breast cancer. There are no such contraindications in this case.",
"id": "53079",
"label": "c",
"name": "Selective serotonin reuptake inhibitor",
"picture": null,
"votes": 107
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has symptoms in keeping with menopause and is of average menopausal age. She is still having periods every 4 months and therefore hormone replacement therapy (HRT) should be given cyclically. She has no risk factors that would contraindicate oral HRT (such as malignancy or venous thromboembolism) and her symptoms are impacting her quality of life significantly. She still has a uterus and therefore needs progesterone protection to reduce the risk of endometrial cancer from unopposed oestrogen and is not keen on an intrauterine system. Therefore a combination HRT is the most appropriate.",
"id": "53077",
"label": "a",
"name": "Cyclical combined hormone replacement therapy",
"picture": null,
"votes": 2829
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is still having periods every 4 months and therefore HRT should be given cyclically. Continuous HRT would be the first-line treatment if her periods had ceased for over a year. She has no risk factors that would contraindicate HRT and her symptoms are impacting her quality of life significantly. She still has a uterus and therefore needs progesterone protection to reduce the risk of endometrial cancer from unopposed oestrogen. She is not keen on an intrauterine system; therefore, combination HRT is the most appropriate.",
"id": "53078",
"label": "b",
"name": "Continuous combined hormone replacement therapy",
"picture": null,
"votes": 779
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary \n \n \nHormone Replacement Therapy (HRT) is a treatment strategy used to alleviate menopausal symptoms by replacing diminishing hormones. It typically involves small doses of oestrogen and progestogen (if the woman has a uterus) to reduce endometrial cancer risk. HRT may be administered systemically or vaginally and can help manage symptoms such as flushing, insomnia, headaches, vaginal atrophy, and dryness. However, it may also have side effects including breast tenderness, leg cramps, bloating, nausea, and headaches. Key investigations involve assessing the history and physical examination of the patient to decide the need for HRT. Management strategies include careful dose regulation and monitoring for side effects.\n \n \n# Definition \n \n \nHormone replacement therapy (HRT) is a treatment to relieve symptoms of menopause by replacing hormones that decrease as a woman approaches the menopause. It typically involves small doses of oestrogen combined with a progestogen if a woman has a uterus to reduce the risk of endometrial cancer.\n \n \n \n# Indications \n \n \n - Symptomatic relief of vasomotor symptoms such as flushing, insomnia, headaches, vaginal atrophy and dryness\n - Decreases the risk of osteoporosis and colorectal cancer\n - In premature ovarian insufficiency, HRT should be continued until the age of 50. This is to help prevent the development of osteoporosis\n \n \n# Contraindications\n \n \n - Undiagnosed vaginal bleeding\n - Pregnancy\n - Breastfeeding\n - Oestrogen receptor-positive breast cancer\n - Acute liver disease\n - Uncontrolled hypertension\n - History of breast cancer or venous thromboembolism (VTE)\n - Recent stroke, myocardial infarction or angina\n\n\n# Types\n\n\nHRT can be given systemically, either via oral tablets, transdermal patches or gels, or can be given vaginally for urogenital atrophy, in the form of tablets, creams, pessaries or vaginal rings. Transdermal is the preferred route if the woman is at risk of VTE.\n\n\nHormones that can be given as part of HRT are:\n\n\n - **Oestrogens:** oestradiol, estrone and conjugated oestrogen are generally used.\n - **Progestogens:** Medroxyprogesterone, norethisterone, levonorgestrel and drospirenone are typically used. A levonorgestrel-releasing intrauterine system (e.g. Mirena coil) may be used as part of the progestogen component of HRT, so the woman may just take oral oestrogen and have endometrial protection via the intrauterine system\n - **Tibolone:** this is a synthetic compound containing oestrogen, progestogen and androgens.\n\n\nAll women require a combination of oestrogen and progesterone as part of their HRT, unless they have had a hysterectomy, in which case oestrogen-only is enough. This is due to risk of endometrial cancer if oestrogen is given alone. \n\nHRT can be given continuously (for postmenopausal women not having periods) or cyclically (for perimenopausal women still having some periods). Cyclical can include:\n\n- Monthly: Oestrogen every day of the month + progesterone for the last 14 days \n- Every three months: Oestrogen every day for 3 months + progesterone for the last 14 days\n\n\n# Side Effects\n\n\n - Oestrogen: breast tenderness, leg cramps, bloating, nausea, headaches\n - Progestogen: premenstrual syndrome-like symptoms, mood swings, breast tenderness, backache, depression, pelvic pain, fluid retention, weight gain\n - Cholestatic jaundice\n - Increased risk of breast cancer, endometrial cancer, VTE, stroke and ischaemic heart disease\n\n \n# NICE Guidelines\n\n[CLick here for NICE guidelines on HRT](https://cks.nice.org.uk/topics/menopause/prescribing-information/hormone-replacement-therapy-hrt/)\n\n# References\n\n\n[Primary Care Women's Health Forum](https://pcwhf.co.uk/resources/hrt-types-doses-and-regimens/#)\n\n[Hickey & Davison 2012, The BMJ](https://www.bmj.com/content/344/bmj.e763.long)\n\n[NHS Website](https://www.nhs.uk/medicines/hormone-replacement-therapy-hrt/types-of-hormone-replacement-therapy-hrt/)",
"files": null,
"highlights": [],
"id": "1003",
"pictures": [],
"typeId": 2
},
"chapterId": 1003,
"demo": null,
"entitlement": null,
"id": "2365",
"name": "Hormone replacement therapy",
"status": null,
"topic": {
"__typename": "Topic",
"id": "26",
"name": "Gynaecology",
"typeId": 2
},
"topicId": 26,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2365,
"conditions": [
{
"__typename": "Condition",
"id": "423",
"name": "Menopause",
"topic": {
"__typename": "UkmlaTopic",
"id": "18",
"name": "Obstetrics and gynaecology"
},
"topicId": 18
}
],
"difficulty": 1,
"dislikes": 3,
"explanation": null,
"highlights": [],
"id": "10676",
"isLikedByMe": 0,
"learningPoint": "Cyclical combined hormone replacement therapy is recommended for menopausal women with irregular periods to alleviate symptoms and protect the endometrium.",
"likes": 10,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "373",
"name": "Menopausal problems",
"topic": {
"__typename": "UkmlaTopic",
"id": "18",
"name": "Obstetrics and gynaecology"
},
"topicId": 18
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 55-year-old woman attends her GP seeking advice over her menopausal symptoms, which started just under a year ago. She gets regular hot flushes, which make her work in retail very difficult, as well as irritability at home, which has started interfering with her relationship. She says she still has the occasional period once every 4 months. She is otherwise fit and well with no past medical or surgical history. She would like treatment to help her symptoms and does not want any intrauterine devices or systems.\n\nWhich treatment would be most appropriate for this patient?",
"sbaAnswer": [
"a"
],
"totalVotes": 4234,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,987 | false | 45 | null | 6,494,981 | null | false | [] | null | 10,677 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "An oestrogen pessary can improve vaginal dryness in postmenopausal women. It will not help in the case of an overactive bladder.",
"id": "53084",
"label": "c",
"name": "Oestrogen pessary",
"picture": null,
"votes": 87
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Duloxetine is a serotonin-noradrenaline reuptake inhibitor, which works by increasing urethral tone and reducing urinary leaks. It is indicated as a second-line option to surgery where surgery is not a possible treatment (ie. if the patient is not fit for, or does not want to have, surgery, as in this case). Common side effects include gastrointestinal disturbance and drowsiness. It is used with caution in the elderly and may reduce the seizure threshold.",
"id": "53082",
"label": "a",
"name": "Duloxetine",
"picture": null,
"votes": 2423
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Mirabegron is a beta 3 agonist approved for use in overactive bladder, otherwise known as urge incontinence. It has been shown to have equal efficacy to tolterodine and solifenacin for urge incontinence. Its side effects include raised blood pressure and increased risk of urinary tract infection. This would not be a treatment for stress incontinence.",
"id": "53085",
"label": "d",
"name": "Mirabegron",
"picture": null,
"votes": 259
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has committed to pelvic floor exercises for 6 months without improvement of her symptoms. National Institute for Health and Care Excellence guidelines state that at least 3 months of pelvic floor exercises should be trialled and further treatments considered if this fails. Therefore, it would be inappropriate to ask her to complete another 6 months of pelvic floor exercises and she should now be considered for pharmacological or surgical management.",
"id": "53083",
"label": "b",
"name": "Further 6 months of pelvic floor exercises",
"picture": null,
"votes": 35
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient does not want surgical management. Colposuspension is a surgical treatment for stress urinary incontinence, which involves securing the bladder neck with stitches, so that it does not drop down and cause urinary leakage.",
"id": "53086",
"label": "e",
"name": "Referral for colposuspension",
"picture": null,
"votes": 48
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nUrinary incontinence refers to the involuntary loss of urine and can be categorised into stress, urge, overflow, functional, and mixed types. Key signs and symptoms vary, ranging from involuntary urine leakage when intra-abdominal pressure is raised in stress incontinence, to an abrupt and uncontrollable urge to urinate in urge incontinence. Essential investigations encompass physical examination, questionnaires, bladder diaries, urinalysis, and occasionally cystometry or cystograms. Management strategies depend on the type and severity of incontinence, encompassing conservative methods (like lifestyle modifications), medical treatment (such as Duloxetine, anticholinergics), and surgical options (for example, incontinence pessaries, mid-urethral slings). Generally, stress incontinence is managed with pelvic floor exercises, whereas urge incontinence is initially managed with bladder re-training exercises.\n\n# Types \n\nUrinary incontinence can be categorised into:\n\n1. Stress incontinence\n2. Urge incontinence\n3. Overflow incontinence\n3. Functional incontinence\n4. Mixed incontinence \n\nReversible causes of urinary incontinence can be remembered using the mneumonic **'DIAPPERS':**\n\nD - Delirium\n\nI - Infection\n\nA - Atrophic vaginitis or urethritis\n\nP - Pharmaceutical (medications)\n\nP - Psychiatric disorders\n\nE - Endocrine disorders (e.g. diabetes)\n\nR - Restricted mobility\n\nS - Stool impaction\n\n\n# Approach to Incontinence\n\nOne of the keys is to rule out reversible causes and then try to work out which type of urinary incontinence is. A framework or approach to this is below:\n\n- Physical examination\n\n - An examination will identify features of pelvic organ prolapse as well as the ability to contract pelvic floor muscles.\n\n- Questionnaires\n\n - These are recommended in order to quantify the symptoms and assess the severity on patients quality of life which may help when deciding if a patient would benefit from more invasive treatment\n\n- Bladder diary\n\n - These are also useful for quantifying symptoms and documenting the number and type of episodes of incontinence. They may potentially show a relationship between causes and symptoms.\n\n- Urinalysis\n\n - This will help to rule out infection as an acute cause\n\n- Cystometry\n\n - This is an investigation which measures bladder pressure whilst voiding. It is not recommended in patients with clear histories where the diagnosis is clear.\n\n- Cystogram\n\n - If a fistula is suspected, contrast is instilled into the bladder and a radiological image is obtained in order to see if the contrast travels anywhere else.\n\n\n# Stress incontinence\n\nThis involves leaking of urine when intra-abdominal pressure is raised, putting pressure on the bladder. The pressure of the urine overcomes the mechanisms designed to maintain continence.\n\n## Risk factors \n\n- Childbirth (especially vaginal).This may be due to a combination of injury to the pelvic floor musculature and connective tissue (for example leading to prolapse), as well as nerve damage as a result of pregnancy and labor.\n- Hysterectomy\n\n\n## Triggers\n\nActs such as coughing, laughing, sneezing or exercising can increase abdominal pressure sufficiently.\n\n## Causes\n\nAny abnormality in the anatomy of the bladder, sphincters and urethra can result in stress incontinence.\n\n\n## Conservative management\n\nGeneral lifestyle advice such as avoiding caffeine, fizzy and sugary drinks, as well as avoiding excessive fluid intake, can go far in helping incontinence.\n\nPelvic floor exercises when done with good technique and consistently strengthen the muscles of the pelvic floor. It can help both stress and urge incontinence and can be more effective than drug treatment.\n\n## Medical management\n\nDuloxetine can help with stress incontinence, but it's only recommended if conservative measures fail and the patient is not a surgical candidate.\n\n## Surgical management \n\n- Incontinence pessaries are placed transvaginally and apply pressure to the anterior vaginal wall. This helps to support the urethra and sphincters. However, the evidence for them is poor in individuals without prolapse and isn't recommended by NICE. It would be worth trying if there was a clinical prolapse.\n- Bulking agents are injectable materials placed at the bladder neck to improve continence. This procedure is typically reserved for patients who are poor surgical candidates and isn't as efficacious as other methods\n- Colposuspension and fascial slings involve suspending the anterior vaginal wall to the iliopectineal ligament of Cooper.\n- Mid-urethral slings are the gold standard surgical treatment of stress incontinence. It compresses the urethra against a supportive layer and assists in the closure of the urethra during increased intra-abdominal pressures. It's minimally invasive and can be performed in the outpatient setting.\n\n\n# Urge incontinence\n\n## Definition \n\nThis involves the sudden and involuntary loss of urine associated with urgency.\n\n## Risk factors \n\nRisk factors for urgency include:\n\n- Recurrent urinary tract infections\n- High BMI\n- Advancing age\n- Smoking\n- Caffeine\n\n\n## Conservative management \n\nGeneral lifestyle advice such as avoiding caffeine, fizzy and sugary drinks as well as avoiding excessive fluid intake can go far in helping incontinence. Chemicals contained in these drinks can irritate the bladder, contributing to urge symptoms.\n\nPelvic floor exercises when done with good technique and consistently, strengthen the muscles of the pelvic floor. It can help both stress and urge incontinence and can be more effective than drug treatment. In urge incontinence, contraction of the pelvic floor relaxes the detrusor. Bladder training is also helpful.\n\n## Medical/surgical management\n\n- Pharmacological management\n\t- Anticholinergic medications can help reduce the symptoms of urge and overactive bladder by inhibiting the parasympathetic action on the detrusor muscle.\n\t\t- Examples include: **Oxybutynin, Tolterodine, Fesoterodine, Solifenacin**. If one agent has limited impact, it can be combined with another. Use with caution in elderly however due to increased risk of delirium (side-effect).\n\t- Mirabegron (beta-3 receptor agonist) can be used in older people, but should be used with caution in patients with hypertension.\n\n- Bladder instillation\n\n - Intravesical injection of Botox can be used to paralyse the detrusor muscle and reduce the symptoms of urge and overactive bladder.\n\n- Sacral neuromodulation\n\n - Sacral nerve stimulation has been shown to control symptoms of an overactive bladder. This is only done in tertiary centres for patient who have failed or are unsuitable for all other treatments.\n\n\n# Functional incontinence\n\n## Definition \n\nThis involves an individual having the urge to pass urine, but for whatever reason they're unable to access the necessary facilities and as a result are incontinent.\n\n## Causes \n\nFunctional incontinence associated with:\n\n- Sedating medications\n- Alcohol\n- Dementias\n\n# Overflow incontinence\n\n## Definition \n\nThis occurs when small amounts of urine leak without warning. When the pressure within the bladder overcomes the pressures of the outlet structures urine leaks.\n\n## Causes \n\nThis occurs either due to underactivity of the detrusor muscle such as from neurological damage, or if the urinary outlet pressures are too high, as in constipation or prostatism.\n\n\n\n# NICE Guidelines\n\n[NICE Guidance - Urinary incontinence and pelvic organ prolapse in women: management](https://www.nice.org.uk/guidance/ng123)",
"files": null,
"highlights": [],
"id": "766",
"pictures": [],
"typeId": 2
},
"chapterId": 766,
"demo": null,
"entitlement": null,
"id": "799",
"name": "Types of urinary incontinence",
"status": null,
"topic": {
"__typename": "Topic",
"id": "22",
"name": "Urology",
"typeId": 2
},
"topicId": 22,
"totalCards": 32,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 799,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10677",
"isLikedByMe": 0,
"learningPoint": "Duloxetine is an effective second-line treatment for stress incontinence, enhancing urethral tone when conservative measures fail.",
"likes": 4,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 65-year-old woman with known stress incontinence presents to her GP after having completed 6 months of pelvic floor exercises and lifestyle changes without significant improvement of her incontinence. She reports good compliance with her pelvic floor exercises. She has no significant past medical history or drug allergies. She does not want any surgical treatment at this stage.\n\nWhat is the next most appropriate management to offer her?",
"sbaAnswer": [
"a"
],
"totalVotes": 2852,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,988 | false | 46 | null | 6,494,981 | null | false | [] | null | 10,679 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is presenting with features of severe pelvic inflammatory disease. The severity is a clinical diagnosis but fever, signs of pelvic peritonitis or tubo-ovarian abscess usually confer severe disease. These patients require 14 d of doxycycline and metronidazole plus IV ceftriaxone until there is a clinical improvement.",
"id": "53094",
"label": "c",
"name": "Oral doxycycline and metronidazole (for 14 d)",
"picture": null,
"votes": 203
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is presenting with features of severe pelvic inflammatory disease. The severity is a clinical diagnosis but fever, signs of pelvic peritonitis or tubo-ovarian abscess usually confer severe disease. These patients require 14 d of doxycycline and metronidazole plus IV ceftriaxone until there is a clinical improvement.",
"id": "53096",
"label": "e",
"name": "Oral doxycycline (for 7 d)",
"picture": null,
"votes": 161
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is presenting with features of severe pelvic inflammatory disease. The severity is a clinical diagnosis but fever, signs of pelvic peritonitis or tubo-ovarian abscess usually confer severe disease. These patients require 14 d of doxycycline and metronidazole, plus intravenous ceftriaxone until there is a clinical improvement.",
"id": "53093",
"label": "b",
"name": "IM ceftriaxone (single dose)",
"picture": null,
"votes": 207
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient is presenting with features of severe pelvic inflammatory disease. The severity is a clinical diagnosis, but fever, signs of pelvic peritonitis or tubo-ovarian abscess usually confer severe disease. These patients require 14 d of doxycycline and metronidazole plus IV ceftriaxone until there is a clinical improvement.",
"id": "53092",
"label": "a",
"name": "IV ceftriaxone (until improving clinically), oral doxycycline and metronidazole (for 14 d)",
"picture": null,
"votes": 3157
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is presenting with features of severe pelvic inflammatory disease. The severity is a clinical diagnosis but fever, signs of pelvic peritonitis or tubo-ovarian abscess usually confer severe disease. These patients require 14 d of doxycycline and metronidazole plus IV ceftriaxone until there is a clinical improvement. Intramuscular benzylpenicillin is used for suspected syphilis infection. This patient lacks symptoms of syphilis, such as a rash or genital ulcer.",
"id": "53095",
"label": "d",
"name": "IM benzylpenicillin (single dose), oral doxycycline and metronidazole (for 14 d)",
"picture": null,
"votes": 751
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "is the ceftriaxone normally IV or can it be IM?",
"createdAt": 1686921634,
"dislikes": 0,
"id": "28887",
"isLikedByMe": 0,
"likes": 3,
"parentId": null,
"questionId": 10679,
"replies": [
{
"__typename": "QuestionComment",
"comment": "pretty sure it can be either, in this case youd probably want it IV if its severe PID ",
"createdAt": 1726601569,
"dislikes": 0,
"id": "55129",
"isLikedByMe": 0,
"likes": 1,
"parentId": 28887,
"questionId": 10679,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "GIMP101",
"id": 26542
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Nightshift Hypertension",
"id": 20777
}
},
{
"__typename": "QuestionComment",
"comment": "But it says she is not able to tolerate any oral intake?",
"createdAt": 1686922609,
"dislikes": 0,
"id": "28895",
"isLikedByMe": 0,
"likes": 6,
"parentId": null,
"questionId": 10679,
"replies": [
{
"__typename": "QuestionComment",
"comment": "I made the same mistake, the answer says IV until she's improving clinically, then the oral course of medication for 14 days. So by the time she's taking oral medication she should be able to tolerate it ",
"createdAt": 1728376162,
"dislikes": 0,
"id": "55585",
"isLikedByMe": 0,
"likes": 6,
"parentId": 28895,
"questionId": 10679,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Thermoregulator Metabolism",
"id": 20929
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Relapse Otitis",
"id": 18947
}
},
{
"__typename": "QuestionComment",
"comment": "Messi 2012 type numbers",
"createdAt": 1737475345,
"dislikes": 0,
"id": "61147",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10679,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "MetastaticMainoo",
"id": 55347
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\n\nPelvic Inflammatory Disease (PID) is a sexually transmitted infection that spreads from the vagina into the cervix and upper genital tract. The primary pathogens are Chlamydia trachomatis and Neisseria gonorrhoeae, though often, no pathogen can be isolated. Patients typically present with generalised abdominal pain, discharge, postcoital bleeding, adnexal tenderness, cervical motion tenderness, and sometimes right upper quadrant pain due to Fitz-Hugh-Curtis syndrome. The diagnostic approach includes pelvic examination, pregnancy test, swabs for gonorrhoea and chlamydia, blood tests, and transvaginal ultrasound. Management typically consists of a combination of antibiotics, usually administered in an outpatient setting, and analgesia as required.\n\n\n# Definition\n\n\nPelvic inflammatory disease (PID) is a condition that arises when an infection spreads from the vagina to the cervix, and subsequently to the upper genital tract.\n\n\n# Aetiology\n\n\nWhile Gonorrhoea and Chlamydia contribute to approximately 20% of PID cases, various anaerobic bacteria are also implicated. In certain instances, no pathogen can be isolated. PID is predominantly spread via sexual contact.\n\n\n# Signs and Symptoms\n\n\nPID is typically diagnosed based on clinical symptoms and signs. These include:\n\n\n- Bilateral abdominal pain\n- Vaginal discharge\n- Post-coital bleeding\n- Adnexal tenderness\n- Cervical motion tenderness upon bi-manual examination\n- Fever\n\n\nApproximately 10% of patients present with right upper quadrant pain, secondary to inflammation of the liver capsule. This condition is referred to as Fitz-Hugh-Curtis syndrome (see below).\n\n\n# Differential Diagnosis\n\n\nSeveral conditions may present similarly to PID and should be considered in the differential diagnosis:\n\n\n- **Appendicitis:** Presents with right lower quadrant abdominal pain, fever, nausea, and vomiting.\n- **Ectopic Pregnancy:** Symptoms may include unilateral lower abdominal pain and vaginal bleeding. A positive pregnancy test is a key distinguishing factor.\n- **Endometriosis:** Chronic pelvic pain, dysmenorrhea, and dyspareunia are common. Pain typically worsens during menstruation.\n- **Ovarian Cyst:** Symptoms can include unilateral lower abdominal pain, bloating, and a palpable mass on examination.\n- **Urinary Tract Infection:** Symptoms usually include dysuria, frequency, urgency, suprapubic pain, and possible fever.\n\n\n# Investigations\n\n\nThe following investigations are usually carried out to diagnose PID:\n\n\n**Bedside:**\n\n\n- Bimanual examination, which may show cervical motion tenderness\n- Pregnancy test\n- Swabs for gonorrhoea and chlamydia, or urinary NAAT testing \n\n\n**Bloods:**\n\n\n- FBC, including WCC \n- CRP \n\n\n**Imaging:** \n\n- Transvaginal ultrasound\n\n\n# Management\n\n\nTreatment of PID is **medical** involves a combination of antibiotics, the first-line being:\n\n- Ceftriaxone (given intramuscularly) + doxycycline + metronidazole\n\n\nIf the infection is mild/moderate, these antibiotics are given orally (except ceftriaxone which is intramuscularly) and in an outpatient setting. \nIf the infection is severe, all three antibiotics are given intravenously (and may later be converted to oral) in an inpatient setting.\n\n\n\n\nIn addition, it is important to avoid unprotected intercourse whilst PID is untreated to prevent spread of infection to sexual partners.\n\n\n# Complications\n\n\nThe potential complications associated with PID are:\n\n\n- Chronic pelvic pain: This is likely a result of tubal damage, secondary to inflammation. \n- Infertility: Occurs as a result of tubal damage, impairing passage of an ovum and/or sperm for fertilisation to occur. \n- Ectopic pregnancy: Occurs as a result of tubal damage and scarring causing impaired passage of a fertilised ovum through to the endometrium. \n- Fitz-Hugh-Curtis Syndrome (see below). \n\n# Fitz-Hugh-Curtis Syndrome\n\n\nFitz-Hugh-Curtis syndrome occurs when adhesions form between the anterior liver capsule and the anterior abdominal wall or diaphragm in the context of PID. Despite this, liver function tests are usually normal. An abdominal ultrasound should be performed to rule out the presence of stones. A definitive diagnosis and treatment typically require laparoscopy and administration of antibiotics.\n\n\n# NICE Guidelines\n\n[Click here to see information on NICE about PID](https://cks.nice.org.uk/topics/pelvic-inflammatory-disease/)\n\n# References\n\n\n[Patient Info](https://patient.info/womens-health/pelvic-pain-in-women/pelvic-inflammatory-disease)",
"files": null,
"highlights": [],
"id": "15",
"pictures": [],
"typeId": 2
},
"chapterId": 15,
"demo": null,
"entitlement": null,
"id": "2088",
"name": "Pelvic inflammatory disease",
"status": null,
"topic": {
"__typename": "Topic",
"id": "38",
"name": "Obstetrics",
"typeId": 2
},
"topicId": 38,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2088,
"conditions": [
{
"__typename": "Condition",
"id": "511",
"name": "Pelvic inflammatory disease",
"topic": {
"__typename": "UkmlaTopic",
"id": "18",
"name": "Obstetrics and gynaecology"
},
"topicId": 18
}
],
"difficulty": 1,
"dislikes": 8,
"explanation": null,
"highlights": [],
"id": "10679",
"isLikedByMe": 0,
"learningPoint": "Severe pelvic inflammatory disease requires intravenous ceftriaxone initially, followed by a 14-day course of doxycycline and metronidazole for complete treatment.",
"likes": 13,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 28-year-old woman presents to A&E with 3 d of fever, lower abdominal pain and deep dyspareunia. She tells you she has recently had treatment 1 month ago for *Chlamydia*,* but did not complete the course of antibiotics. She has had at least 7 sexual partners in the last 3 months and has not used any barrier methods of contraception. She has no other medical history and has no drug allergies. On examination, she is vomiting and unable to tolerate any oral intake. She has a fever of 38.9 °C.\n\nWhich of the following is the best treatment?",
"sbaAnswer": [
"a"
],
"totalVotes": 4479,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,989 | false | 47 | null | 6,494,981 | null | false | [] | null | 10,680 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The dorsal columns are responsible for fine touch, vibration and proprioception. The patient has no issues with these sensory modalities and so this is not responsible for his symptoms. Progression of the syrinx can, over time, impinge on the dorsal columns and cause deficiencies within these sensory modalities.",
"id": "53099",
"label": "c",
"name": "Dorsal columns",
"picture": null,
"votes": 275
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has evidence of corticospinal tract involvement since there is evidence of motor dysfunction with associated hand clawing. However, this would not explain his sensory symptoms, which is the question being asked.",
"id": "53098",
"label": "b",
"name": "Corticospinal tracts",
"picture": null,
"votes": 275
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The description of loss of pain and temperature over the neck and back (in a cape-like distribution) and predominant upper-limb dysfunction with bilateral hand clawing fits with a diagnosis of syringomyelia. Syringomyelia is a fluid-filled cyst (syrinx) that forms within the centre of the spinal cord, initially compressing the decussation of the spinothalamic tract and leading to localised loss of pain and temperature sensation. Over time, it gets larger and can expand to multiple levels of the cord as well as other structures, such as the anterolateral corticospinal tracts, which this patient has evidence of due to the presence of motor symptoms, and the dorsal columns.",
"id": "53097",
"label": "a",
"name": "Spinothalamic tract",
"picture": null,
"votes": 2073
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The motor cortex is a cerebral structure within the frontal lobe. A lesion in the motor cortex causes upper motor neurone pathology and spasticity (hyperreflexia, pyramidal distribution of weakness and a velocity-dependent increase in tone). Sensory involvement is spared. A lesion in the motor cortex will therefore not explain this patient's symptoms.",
"id": "53100",
"label": "d",
"name": "Motor cortex",
"picture": null,
"votes": 17
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The somatosensory cortex is a cerebral structure within the parietal lobe. Depending on the precise location of the lesion in the somatosensory cortex, any sensory modality may be lost in the distribution as dictated by the sensory homunculus. However, sensory loss with cerebral lesions do not have such a defined pattern of presentation, with dorsal column sparing and a cape-like distribution. Loss of sensation in this pattern should raise clinical suspicion of a spinal lesion.",
"id": "53101",
"label": "e",
"name": "Somatosensory cortex",
"picture": null,
"votes": 132
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Spain = (s)pain = Spinothalamic ",
"createdAt": 1708878421,
"dislikes": 0,
"id": "42757",
"isLikedByMe": 0,
"likes": 5,
"parentId": null,
"questionId": 10680,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Liver Anterior",
"id": 8747
}
},
{
"__typename": "QuestionComment",
"comment": "sPinoThalamic (Pain and Temp)",
"createdAt": 1738450479,
"dislikes": 0,
"id": "62109",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10680,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "j.g.73",
"id": 80093
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nSyringomyelia is a neurological condition characterised by a fluid-filled cavity, known as a syrinx, that forms within the spinal cord. This condition typically manifests with distinct neurologic symptoms such as pain and temperature loss in a 'shawl-like distribution' across the upper body, tactile sensory loss, muscle weakness, and autonomic dysfunction including bladder, bowel, and sexual dysfunction. Diagnosis is typically confirmed via imaging techniques, primarily MRI of the spinal cord and CT of the bony spinal canal. Management approaches are generally tailored to the individual, ranging from physiotherapy and rehabilitation to surgical intervention when symptomatology and the nature of the lesion warrant such.\n\n# Definition\n\nSyringomyelia is a neurological disorder characterised by the formation of a fluid-filled cavity or cyst, known as a syrinx, within the spinal cord. This syrinx often expands and elongates over time, exerting pressure on the spinal cord and damaging nerve fibres.\n\n# Epidemiology\n\nSyringomyelia is a relatively rare condition, with the prevalence reported as approximately 8.4 per 100,000 individuals, with a slight male predominance. The condition is typically diagnosed in adulthood, most often between the ages of 20 and 40.\n\n# Aetiology\n\nThe formation of a syrinx in syringomyelia can be attributed to a variety of causes:\n\n* Cerebrospinal Fluid (CSF) blockage or disruption, often secondary to conditions such as arachnoiditis or presence of space-occupying lesions.\n* Spina Bifida\n* Post-traumatic syringomyelia following spinal cord injury.\n* Spinal cord tumours, which may create a blockage of CSF flow.\n* Idiopathic syringomyelia, where no specific cause can be identified.\n* Familial predisposition has also been noted in some cases.\n\n# Signs and Symptoms\n\nThe clinical manifestations of syringomyelia can be diverse and primarily revolve around damage to various neural pathways:\n\n* Pain and temperature loss, typically presenting in a 'shawl-like distribution' over the arms, shoulders, and upper body due to damage to the spinothalamic tract.\n* Impaired light touch, vibration and position senses as the syrinx enlarges and further compromises the spinal cord.\n* Muscle weakness and atrophy may ensue as the syrinx extends and damages the anterior horn cells and their lower motor neurons.\n* Autonomic dysfunction leading to bladder, bowel, and sexual dysfunction may also occur.\n\n# Differential Diagnosis\n\nThe clinical presentation of syringomyelia can mimic other neurological disorders, warranting consideration for the following differential diagnoses:\n\n* Multiple Sclerosis: Characterised by episodic neurologic deficits that change over time and space, including optic neuritis, limb weakness, and ataxia.\n* Amyotrophic Lateral Sclerosis (ALS): Characterised by progressive muscle weakness, atrophy, and fasciculations due to a combination of upper and lower motor neuron damage.\n* Spinal cord tumour: May present with back pain, sensory changes, motor weakness, and bladder/bowel dysfunction similar to syringomyelia.\n* Cervical Spondylotic Myelopathy: Presents with neck pain, hand clumsiness, gait imbalance, and sometimes bladder symptoms.\n\n# Investigations\n\nThe diagnosis of syringomyelia is typically confirmed through imaging studies:\n\n* MRI of the spinal cord: This is the gold standard diagnostic modality, providing detailed visualisation of the syrinx and surrounding spinal cord structures.\n* CT of the bony spinal canal: May provide supplementary information regarding any bony abnormalities or spinal cord compression.\n\n# Management\n\nThe management of syringomyelia is patient-specific and depends on the severity of the symptoms and the underlying cause of the syrinx:\n\n* Physiotherapy and Rehabilitation: Helps to manage symptoms such as muscle weakness and improve overall functional capacity.\n* Surgery: May be recommended in cases where there are severe or worsening symptoms, or where the nature of the lesion (such as a tumour or significant CSF blockage) necessitates surgical intervention.\n",
"files": null,
"highlights": [],
"id": "2683",
"pictures": [],
"typeId": 2
},
"chapterId": 2683,
"demo": null,
"entitlement": null,
"id": "3684",
"name": "Syringomyelia",
"status": null,
"topic": {
"__typename": "Topic",
"id": "34",
"name": "Neurology",
"typeId": 2
},
"topicId": 34,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3684,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10680",
"isLikedByMe": 0,
"learningPoint": "Syringomyelia causes a characteristic 'cape-like' distribution of pain and temperature loss due to compression of the spinothalamic tract in the spinal cord.",
"likes": 1,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 32-year-old man presents to the Neurology Clinic with impaired sensation over his neck and upper back. He says he cannot feel pain over this region when he pinches the skin, as well as weakness in his hands. On examination, he has a loss of pain and temperature sensation over his neck, back and upper shoulders. There is some clawing of his hands bilaterally with atrophy of the muscles of the forearm. Fine touch, proprioception and vibration are spared. There are no sensory or motor abnormalities of the lower limbs.\n\nWhere is the lesion responsible for his sensory symptoms?",
"sbaAnswer": [
"a"
],
"totalVotes": 2772,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,990 | false | 48 | null | 6,494,981 | null | false | [] | null | 10,681 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This scan can be requested later on by a specialist within the hospital setting. A CT chest is useful to further characterise how the sarcoidosis has affected the patient's lungs. This would be requested after a CXR, since starting with simple, least invasive/harmful investigations is most appropriate in the first instance.",
"id": "53105",
"label": "d",
"name": "CT chest",
"picture": null,
"votes": 294
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Serum ACE levels are raised in sarcoidosis, however it would not be the next best investigation since ACE is neither specific to, nor diagnostic of, sarcoidosis.",
"id": "53103",
"label": "b",
"name": "Angiotensin-converting enzyme (ACE) levels",
"picture": null,
"votes": 915
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a specialist investigation which would not be requested by the GP. This investigation can be diagnostic for sarcoidosis, but it does not represent the next best investigation. Typically, you would find non-caseating granulomas on a biopsy.",
"id": "53106",
"label": "e",
"name": "Lung biopsy",
"picture": null,
"votes": 50
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "CRP can be raised in any infection or conditions that cause inflammation in the body. It is a non-specific marker which would not be helpful in determining the cause of this patient's symptoms, since it may be raised in conditions such as sarcoidosis, but also other inflammatory conditions, including pneumonia.",
"id": "53104",
"label": "c",
"name": "C-reactive protein",
"picture": null,
"votes": 62
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has sarcoidosis which explains her long-term symptoms. In the early stages, a CXR may show evidence of bilateral hilar lymphadenopathy and fibrosis in the later stages. It can also rule out other causes of shortness of breath and crepitations, such as pneumonia.",
"id": "53102",
"label": "a",
"name": "Chest X-Ray",
"picture": null,
"votes": 1939
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "If patient is in GP would they not do a blood test first? Agree CXR is the 'better' investigation, but 'next' would be a blood test?",
"createdAt": 1685031984,
"dislikes": 0,
"id": "26242",
"isLikedByMe": 0,
"likes": 10,
"parentId": null,
"questionId": 10681,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "RNA Relapse",
"id": 6421
}
},
{
"__typename": "QuestionComment",
"comment": "ngl i thought it was TB with spinal infection :/",
"createdAt": 1687793898,
"dislikes": 0,
"id": "29665",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10681,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Pudendal Syndrome",
"id": 4941
}
},
{
"__typename": "QuestionComment",
"comment": "what is causing the tingling down her legs?",
"createdAt": 1703685660,
"dislikes": 0,
"id": "36966",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10681,
"replies": [
{
"__typename": "QuestionComment",
"comment": "It can cause neuro Sx such as peripheral neuropathy, ( meningitis, bilateral Bell’s palsy)",
"createdAt": 1709501722,
"dislikes": 0,
"id": "43655",
"isLikedByMe": 0,
"likes": 0,
"parentId": 36966,
"questionId": 10681,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Fibrillation RNA",
"id": 17890
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Amnesia Syndrome",
"id": 12641
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nSarcoidosis is an inflammatory disease characterised by granuloma formation in various organs, with the most commonly affected being the lungs. Symptoms include fever, polyarthralgia, erythema nodosum, dry cough, dyspnoea, fatigue and weight loss. Investigations include blood tests (with calcium and serum ACE being important), chest X-ray and biopsy of a granuloma. Management depends on the severity of disease and may include NSAIDs, corticosteroids and other immunosuppressants.\n\n# Definition\n\nSarcoidosis is a multi-system disease that is characterised by the formation of non-caseating granulomas around the body. This leads to inflammation and scarring in the organs affected, most commonly the lungs and skin. Other organs affected include the nerves, the brain, the heart, the liver and the eyes.\n\n# Epidemiology\n\nIn the UK, there are approximately 4,500 new diagnoses of sarcoidosis each year, with a prevalence around 1 in 10,000 people. Prevalence varies significantly depending on region, with the highest rates seen in Northern Europe (e.g. Sweden, Finland and Denmark). Some ethnicities are more at risk than others, with people of African descent being affected more often and with more severe disease.\n\nPeak onset is in adults aged between 30 and 55 years old, and it is slightly more common in women than men.\n\n# Aetiology\n\nThe cause of sarcoidosis is not known, with the main theories being that it is an inflammatory response to a yet unidentified environmental exposure or infection, or that is is caused by autoimmunity.\n\nA small percentage of cases are familial and the wide variation in prevalence across different populations suggests that genetic factors are likely to contribute to its development.\n\n# Signs and Symptoms\n\n**Pulmonary manifestations**\n\n- Dry cough\n- Dyspnoea\n- Reduced exercise tolerance\n- Chest pain\n- Clubbing\n- Fine crackles on auscultation\n\n**Dermatological manifestations**\n\n- Erythema nodosum (inflammation of subcutaneous fat leading to tender nodules especially on the shins)\n- Lupus pernio (red/purple plaques and nodules on the face)\n- Hyper or hypopigmentation of the skin\n\n**Neurological manifestations**\n\n- Meningitis\n- Peripheral neuropathy\n- Facial nerve palsy (may be bilateral)\n- Headache\n- Seizures/encephalopathy\n\n**Ocular manifestations**\n\n- Uveitis\n- Keratoconjunctivitis sicca\n- Glaucoma\n\n**Cardiac manifestations**\n\n- Arrhythmias\n- Restrictive cardiomyopathy\n- Syncope\n\n**Abdominal manifestations**\n\n- Hepatomegaly\n- Splenomegaly\n- Renal stones\n\n**Systemic manifestations**\n\n- Fatigue\n- Weight loss\n- Arthralgia\n- Low-grade fevers\n- Lymphadenopathy\n- Enlarged parotid glands\n\n**Lofgren's syndrome** refers to the acute onset of:\n\n- Fever\n- Polyarthralgia\n- Erythema nodosum\n- Bilateral hilar lymphadenopathy (seen on chest X-ray)\n\n**Heerfordt's syndrome** refers to the combination of:\n\n- Fever\n- Uveitis\n- Parotid swelling\n- Facial nerve palsy\n\n# Differential Diagnosis\n\n- **Tuberculosis:** may present very similarly with chronic cough, night sweats, weight loss, bilateral hilar lymphadenopathy so important to rule out (see investigations).\n- **Lymphoma:** also may present with unexplained weight loss, fever, night sweats and lymphadenopathy, pulmonary symptoms less predominant, can be distinguished on biopsy.\n- **Other causes of interstitial lung disease:** similar pulmonary features of dyspnoea, cough and chest pain, and may have weight loss and malaise. Extrapulmonary features (e.g. rashes and hypercalcaemia) seen in sarcoidosis help to differentiate.\n\n# Investigations\n\n**Bedside investigations include:**\n\n- **ECG** looking for arrhythmias or changes related to hypercalcaemia (e.g. QT shortening)\n- **Mantoux test** looking for evidence of exposure to tuberculosis (an important differential)\n- **Lung function testing** - if pulmonary sarcoidosis suspected\n- **Ophthalmological examination** if ocular sarcoidosis suspected\n\n**Blood tests include:**\n\n- **FBC** may show lymphopenia, anaemia or raised white cells\n- **LFTs** for liver disease\n- **Renal function** for renal impairment (not common in sarcoidosis)\n- **Bone profile** for hypercalcaemia\n- **ESR** may be raised due to chronic inflammation\n- **Serum ACE** is elevated in around 60% and normalises if the disease resolves (with or without treatment)\n\n**Imaging studies include:**\n\n- **Chest X-ray** can be used to stage sarcoidosis as below:\n\t- Stage 1 - Bilateral hilar lymphadenopathy (BHL)\n\t- Stage 2 - BHL with peripheral infiltrates\n\t- Stage 3 - Peripheral infiltrates alone\n\t- Stage 4 - Pulmonary fibrosis\n- **High-resolution CT chest** should be done if sarcoidosis suspected on chest X-ray to further assess for pulmonary fibrosis \n- **PET scanning** may be used if there is ongoing diagnostic uncertainty\n- **Echocardiogram** if cardiac disease is suspected\n\n**Other investigations include:**\n\n- **Biopsy** is required to confirm the diagnosis in most cases (with a classic presentation of chronic pulmonary disease or a clear case of Lofgren's syndrome being exceptions) - this is looking for the classic finding of noncaseating granulomas\n- **Bronchoalveolar lavage** may also be done in suspected pulmonary sarcoidosis, with classic findings of raised lymphocytes and an elevated CD4/CD8 ratio\n\n[lightgallery]\n\n# Management\n\n**Conservative treatment includes:**\n\n- Patient education and support\n- Smoking cessation\n- **No active treatment is needed in many cases of sarcoidosis** \n\n**Medical treatment includes:**\n\n- Steroids e.g. oral prednisolone with a higher dose at induction which is then reduced to a lower maintenance dose\n- Second line immunosuppressants (e.g. if steroids contraindicated or not effective) include methotrexate, mycophenolate or azathioprine\n- Third line treatment is usually with biologics (e.g. infliximab)\n\n**Note - Medical treatment should be started only if sarcoidosis symptoms are affecting quality of life or there is significant risk of morbidity or mortality from sarcoidosis**\n\n**Surgical treatment includes:**\n\n- Rarely in severe cases of pulmonary sarcoidosis a lung transplant may be considered\n- In cases of pulmonary sarcoidosis complicated by aspergilloma, surgical management of haemoptysis is sometimes required\n\n# Complications\n\n- Pulmonary fibrosis (stage IV pulmonary sarcoidosis\n- Cor pulmonale\n- Pulmonary hypertension\n- Aspergillomas can form in cavities left by granulomatous pulmonary disease\n- Arrhythmias and sudden death in cardiac sarcoidosis\n- Low mood and anxiety\n- Complications of long-term steroid use (e.g. osteoporosis, hyperglycaemia)\n\n# Prognosis\n\n- In general prognosis is good, with two-thirds of people experiencing disease remission within 2-5 years (usually with no treatment required).\n- Around 20% of people develop chronic disease requiring treatment\n- Remission is more common in earlier stages of sarcoidosis\n- Only 6-8% of people with sarcoidosis have a reduced life expectancy, with the commonest cause of death being pulmonary disease (interstitial lung disease and pulmonary hypertension)\n\n# NICE Guidelines\n\n[NICE CKS - Sarcoidosis](https://cks.nice.org.uk/topics/sarcoidosis/)\n\n# References\n\n[Patient UK - Sarcoidosis](https://patient.info/doctor/sarcoidosis-pro)\n\n[Radiopaedia - Sarcoidosis](https://radiopaedia.org/articles/sarcoidosis-1?lang=gb)",
"files": null,
"highlights": [],
"id": "326",
"pictures": [
{
"__typename": "Picture",
"caption": "Bilateral hilar lymphadenopahy on a chest x-ray of someone with sarcoidosis.",
"createdAt": 1665036198,
"id": "1048",
"index": 0,
"name": "Hilar adenopathy - Sarcoidosis.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/l2kejqh81665036171697.jpg",
"path256": "images/l2kejqh81665036171697_256.jpg",
"path512": "images/l2kejqh81665036171697_512.jpg",
"thumbhash": "IQgKBoCG+XdyeYiNd0RniGd3AAAAAAA=",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
}
],
"typeId": 2
},
"chapterId": 326,
"demo": null,
"entitlement": null,
"id": "328",
"name": "Sarcoidosis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "32",
"name": "Respiratory",
"typeId": 2
},
"topicId": 32,
"totalCards": 16,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "328",
"name": "Sarcoidosis"
}
],
"demo": false,
"description": null,
"duration": 5476.4,
"endTime": null,
"files": null,
"id": "332",
"live": false,
"museId": "iHK3We4",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/radiology.png",
"title": "Quesmed Tutorial: Radiology",
"userViewed": false,
"views": 425,
"viewsToday": 37
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "328",
"name": "Sarcoidosis"
}
],
"demo": false,
"description": null,
"duration": 255.94,
"endTime": null,
"files": null,
"id": "349",
"live": false,
"museId": "iSoPHmz",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/respiratory.png",
"title": "Sarcoidosis",
"userViewed": false,
"views": 338,
"viewsToday": 18
}
]
},
"conceptId": 328,
"conditions": [],
"difficulty": 1,
"dislikes": 5,
"explanation": null,
"highlights": [],
"id": "10681",
"isLikedByMe": 0,
"learningPoint": "Sarcoidosis commonly presents with fatigue, shortness of breath, and lymphadenopathy; a chest X-ray is essential for diagnosis and assessment.",
"likes": 3,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 35-year-old female presents to the GP with a 6-month history of fatigue. During this time, she also describes feeling short of breath when running for the bus and recurrent episodes of tingling down her leg. On examination, she has swollen lymph nodes and crepitations on chest auscultation. She has a temperature of 37.7.\n\nWhich of the following is the next best investigation?",
"sbaAnswer": [
"a"
],
"totalVotes": 3260,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,991 | false | 49 | null | 6,494,981 | null | false | [] | null | 10,682 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is because an abdominal aorta diameter of 3.3cm is considered to be small and so he would be offered annual ultrasound scans in this case. Note that all men in the UK are offered a one-off ultrasound scan at the age of 65 which determines the frequency of scanning if needed. Patients are usually asymptomatic unless the aneurysm has ruptured. Operative management is offered 5.5cm+. AAA's measuring 3-4.4cm are scanned every 12 months, and every 3 months between 4.5-5.4cm.",
"id": "53107",
"label": "a",
"name": "12-monthly ultrasound scan",
"picture": null,
"votes": 2420
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a common surgical option to repair large or rapidly expanding aneurysms. It involves the insertion of a stent within the abdominal aorta. However, this is not required for this patient as the AAA is only 3.3cm. The indication for repair is when the aneurysm is above 5.5cm or expanding >1cm each year.",
"id": "53108",
"label": "b",
"name": "Endovascular aneurysm repair (EVAR)",
"picture": null,
"votes": 25
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because ultrasound scanning is only repeated every 3 months or yearly. This would not be an option for this patient.",
"id": "53111",
"label": "e",
"name": "6-monthly ultrasound scan",
"picture": null,
"votes": 288
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be required if the aneurysm is of medium size, between 4.5 to 5.4cm. However, this is not required for this patient as the AAA is only 3.3cm. The indication for repair is when the aneurysm is above 5.5cm or expanding >1cm each year.",
"id": "53109",
"label": "c",
"name": "3-monthly ultrasound scan",
"picture": null,
"votes": 115
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be indicated if the patient presented with a ruptured aneurysm, or as an elective procedure to repair large or rapidly expanding AAAs where anatomical considerations make EVAR's unsuitable. A ruptured AAA presents with shock and abdominal pain radiating to the back/back pain. This patient has no features of a ruptured AAA and he does not require repair at this stage due to the small size of the AAA. Open repair surgery is much more invasive than EVAR procedures, and some patients may not be fit enough for this procedure.",
"id": "53110",
"label": "d",
"name": "Open repair",
"picture": null,
"votes": 5
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "A different question said if >3cm refer to vascular surgeon within 12 weeks ??",
"createdAt": 1686317819,
"dislikes": 1,
"id": "28287",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10682,
"replies": [
{
"__typename": "QuestionComment",
"comment": "This patient may have been symptomatic or had a rapidly expanding aneurysm (>1cm per year), in which case guidelines would suggest elective repair",
"createdAt": 1686324596,
"dislikes": 0,
"id": "28297",
"isLikedByMe": 0,
"likes": 2,
"parentId": 28287,
"questionId": 10682,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Axillary Dermis",
"id": 15725
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Poisoned Lyme ",
"id": 30108
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\n\nAn abdominal aortic aneurysm (AAA) is a common, potentially life-threatening condition characterised by an abdominal aorta diameter greater than 3cm. It's most frequently located between the renal and inferior mesenteric arteries. Key signs and symptoms include a typically asymptomatic presentation, occasionally manifesting as a pulsatile, expansile abdominal mass. Diagnosis primarily relies on abdominal ultrasound screening, with follow-up frequency varying based on the aneurysm size. Management strategies focus on surgical repair, with indications being a size >5.5cm or rapid expansion, encompassing open repair or Endovascular Aneurysm Repair (EVAR).\n\n\n# Definition\n\n\nAbdominal aortic aneurysm (AAA) is a prevalent, potentially lethal condition characterised by an enlargement of the abdominal aorta exceeding a diameter of 3cm. This dilatation affects all three layers of the arterial wall. Many individuals with AAA are asymptomatic and do not cause any problems to the individual. In the absence of repair, a ruptured AAA is generally fatal.\n\n\n# Epidemiology\n\n\nAbdominal aortic aneurysm (AAA) predominantly affects older adults, especially those over 65 years of age. At the time of screening at age 95, 0.92% of men undergoing screening are found to have an abdominal aortic aneurysm. It is approximately 4-6 times more prevalent among men than women. An estimated 4-8% of men and 1-2% of women aged over 65 years are affected, but due to the asymptomatic nature of the condition, the actual prevalence may be higher. \n\nThere is a significant geographic and ethnic variation, with higher prevalence reported in Western countries. Lifestyle factors such as smoking and a history of cardiovascular disease increase the risk. \n\nAAA morbidity and mortality are reducing in the UK due to increasing elective repair of AAA and a reduction in smoking rates. \n\n\n# Aetiology\n\n\nThe precise aetiology of AAA is complex and multifactorial, typically involving a combination of genetic, environmental, and lifestyle factors.\n\n\nRisk factors include:\n\n- Being male\n- Age 65 or over\n- Smoking \n- Hypertension\n- Hypercholesterolaemia \n- Family history of AAA\n- Personal history of peripheral arterial disease or myocardial infarction\n- COPD\n- Connective tissue disorders (i.e. Marfan's) \n\n\n\n# Signs and Symptoms\n\n\nMost AAAs remain asymptomatic for a long time and are often detected incidentally during radiological investigations for other abdominal or pelvic conditions. \n\nWhen symptomatic, the clinical presentation can vary:\n\n\n- Pulsatile abdominal mass: \n- The most classical finding on physical examination is a pulsatile, expansile abdominal mass. This is typically non-tender unless rupture is imminent.\n- Approximately 3 in 5 AAA over 3 cm are palpable.\n- This may also be associated with abdominal bruit.\n\n- Abdominal or back pain: \n- Pain is usually a late manifestation, suggesting rapid expansion or impending rupture of the aneurysm. \n- It is typically severe, constant, and localised in the abdomen or lower back, often radiating to the flank or groin.\n- There can also be testicular pain if the blood supply to this area is compromised by rupture\n- 90% of aortic aneurysms are infrarenal (originating below the renal arteries) \n\n\nIn advanced cases, a large aneurysm may cause symptoms due to compression or displacement of adjacent structures, resulting in early satiety, nausea, weight loss, altered bowel habits, or deep venous thrombosis (due to compression of the inferior vena cava).\n\n\n# Differential Diagnosis\n\n\nDifferential diagnoses for AAA include, but are not limited to:\n\n\n- **Renal colic**: Typically presents with severe, sudden onset flank pain that can radiate to the groin, accompanied by haematuria and urinary urgency.\n- **Pancreatitis**: Characterised by persistent, severe epigastric pain radiating to the back, often associated with nausea, vomiting, and elevated pancreatic enzymes.\n- **Peptic ulcer disease**: Often presents with burning epigastric pain that is relieved by eating, weight loss, and potential signs of bleeding like melaena or hematemesis.\n- **Diverticulitis**: Usually presents with left lower quadrant pain, fever, and changes in bowel habits.\n\n\n\n# Investigations\n\nNHS AAA screening programme: \n\n- Offered to men at age 65\n- Consists of an abdominal ultrasound\n- Follow-up screening depends on the size of the aneurysm:\n\n- Small AAA (3-4.4cm): Yearly repeat ultrasound is offered.\n- Medium AAA (4.5-5.4cm): Repeat ultrasound every 3 months is offered.\n- Large AAA (>5.5cm): Surgical intervention is generally recommended.\n\nOnce an abdominal aortic aneurysm has been detected, further investigations may be required, including: \n\n- **Computed Tomography (CT) Angiography:** \n- CT angiography is the imaging modality of choice for preoperative evaluation, determining the size, shape, and extent of the AAA, and planning the surgical approach. \n- It provides detailed information about the aneurysm's relationship to branch arteries and the potential presence of thrombus or calcification within the aneurysm. \n- It is also the preferred imaging modality in suspected rupture cases due to its rapid acquisition time and high sensitivity and specificity.\n\n- **Magnetic Resonance Angiography (MRA):** MRA is an alternative to CT angiography for patients who cannot be exposed to ionizing radiation or iodinated contrast medium. MRA can provide high-resolution images of the AAA and surrounding structures but is less readily available and takes more time than CT.\n\n- **Blood tests:** While there is no specific blood test to diagnose AAA, complete blood count, coagulation profile, renal function tests, and electrolyte levels are typically evaluated prior to surgery.\n\n\n\nFinally, regular surveillance of known AAAs is critical. The frequency of surveillance depends on the size of the aneurysm, with smaller aneurysms monitored less frequently and larger ones requiring closer observation.\n\n\n# Management\n\n### Conservative \n\nManagement of abdominal aortic aneurysms may be through conservative measures such as: \n\n- Surveillance:\n- This is typically offered for smaller aneurysms with a lower risk of rupture. It is very rare for smaller AAA to rupture. \n- Small AAA (3-4.4cm): Yearly repeat ultrasound is offered.\n- Medium AAA (4.5-5.4cm): Repeat ultrasound every 3 months is offered.\n- Large AAA (>5.5cm) require referral to vascular surgery to be seen within 2 weeks of diagnosis. \n- Measures to reduce the risk of rupture:\n- Referral to a stop-smoking service\n- Management of hypertension \n\n\n### Surgical \n\n\nElective repair of AAA may be considered for individuals with AAA who meet the following criteria:\n\n- They are symptomatic \n- Their AAA has grown by more than 1 cm in 1 year and is larger than 4 cm\n- Their AAA is 5.5 cm or larger \n\n\nTwo primary surgical options are available for managing AAA: \n\n- Open surgical repair\n- Typically best for men under age 70. \n- However, it can be contraindicated by anaesthetic risks, medical comorbidities or anatomic difficulties (i.e. horseshoe kidney, stoma, numerous previous surgeries resulting in significant adhesions)\n- Endovascular Aneurysm Repair (EVAR)\n- A stent graft is inserted through the femoral arteries into the aorta, where it channels blood flow into the iliac arteries. The surrounding aneurysm then becomes thrombosed around the graft. \n- EVAR has reduced perioperative deaths and is associated with shorter hospital stays. However, it has an overall higher long-term morbidity and mortality than open repair. \n\n\n# Complications\n\n\n### Rupture\n\nAAA rupture is a surgical emergency. Abdominal aortic aneurysms are more likely to rupture in women than men but are more common in men and such account for more presentations in men. \n\nAAA tend to enlarge over time and with increasing size, the risk of rupture increases. \n\n\n### Embolization\n\nRarely distal embolisation from mural thrombus can lead to symptoms related to ischemia, most commonly affecting the distal extremities, such as blue toe syndrome.\n\n### Open Repair-Related Complications\n\nThose undergoing open surgical repair of an AAA have risks including:\n\n- Spinal cord ischaemia \n- Anastomotic pseudoaneurysm \n- Graft infection \n- Death (mortality during elective repair is reported to be 5% of men and 7% of women)\n\n### EVAR-Related Complications\n\nPatients who have undergone EVAR may require surveillance for EVAR-related complications. \n\n- Endoleak\n- Defined as the presence of blood flow within the aneurysm sac but outside the EVAR graft\n- Contrast-enhanced CT angiography, or contrast-enhanced ultrasound if CT is contraindicated, is used to assess for endoleak. \n- They can be repaired using open, endovascular or percutaneous intervention for endoleak \n- Post-implantation syndrome \n- Cytokine release due to EVAR can cause fever, back pain and feeling generally unwell following EVAR.\n\n# Prognosis \n\nAbdominal aortic aneurysms will continue to increase in diameter, with the ultimate outcome being rupture. However, many individuals with AAA do not rupture during their lifetimes. The rupture of AAA is fatal for many individuals. \n\nFor those who have had their AAA electively repaired before rupture, those who have had an open surgical repair tend to fare better with reduced complications and overall improved survival. \n\n\n# NICE Guidelines\n\n[NICE guidelines: Abdominal Aortic Aneurysm](https://www.nice.org.uk/guidance/ng156)\n\n\n# References\n\n[NHS Abdominal Aortic Aneurysm](https://www.nhs.uk/conditions/abdominal-aortic-aneurysm/) \n\n[NHS Inform Abdominal Aortic Aneurysm](https://www.nhsinform.scot/illnesses-and-conditions/a-to-z/abdominal-aortic-aneurysm/) \n\n[Patient Info Abdominal Aortic Aneurysms](https://patient.info/doctor/abdominal-aortic-aneurysms)",
"files": null,
"highlights": [],
"id": "838",
"pictures": [],
"typeId": 2
},
"chapterId": 838,
"demo": null,
"entitlement": null,
"id": "883",
"name": "Abdominal aortic aneurysms",
"status": null,
"topic": {
"__typename": "Topic",
"id": "126",
"name": "Vascular Surgery",
"typeId": 2
},
"topicId": 126,
"totalCards": 12,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "883",
"name": "Abdominal aortic aneurysms"
}
],
"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": "883",
"name": "Abdominal aortic aneurysms"
}
],
"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": "883",
"name": "Abdominal aortic aneurysms"
}
],
"demo": false,
"description": null,
"duration": 686.51,
"endTime": null,
"files": null,
"id": "2",
"live": false,
"museId": "wFRkweA",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/surgery.png",
"title": "Abdominal aortic aneurysms 1\n",
"userViewed": false,
"views": 168,
"viewsToday": 13
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "883",
"name": "Abdominal aortic aneurysms"
}
],
"demo": false,
"description": null,
"duration": 237.06,
"endTime": null,
"files": null,
"id": "3",
"live": false,
"museId": "E8vHqDj",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/surgery.png",
"title": "Abdominal aortic aneurysms 2",
"userViewed": false,
"views": 77,
"viewsToday": 7
}
]
},
"conceptId": 883,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10682",
"isLikedByMe": 0,
"learningPoint": "An abdominal aortic aneurysm measuring 3.3cm requires annual ultrasound monitoring due to its small size and low risk of rupture.",
"likes": 4,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 65-year-old male undergoes an abdominal ultrasound scan as part of screening. His ultrasound report states that his abdominal aorta has a diameter of 3.3cm. He states that he currently has no symptoms, but he has a smoking history of 12 pack years.\n\nWhich of the following is the best next step in the management of this patient?",
"sbaAnswer": [
"a"
],
"totalVotes": 2853,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,992 | false | 50 | null | 6,494,981 | null | false | [] | null | 10,683 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because needle decompression is required for a tension pneumothorax. The stem clearly states that there is no evidence of tracheal deviation and although he is slightly tachypnoeic, he is not unstable. This patient has a 3cm primary spontaneous pneumothorax. Aspiration should be tried in the first instance. Note that needles must be inserted just above ribs to avoid neurovascular damage.",
"id": "53116",
"label": "e",
"name": "Needle decompression in the left 2nd intercostal space, mid-clavicular line, below the third rib",
"picture": null,
"votes": 294
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although it is recommended to provide high flow oxygen to patients with pneumothoraces in order to facilitate lung re-expansion, the next best step is aspiration. He is oxygenating well on air and at this stage, applying high flow oxygen is not a priority.",
"id": "53114",
"label": "c",
"name": "High flow oxygen",
"picture": null,
"votes": 46
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient is presenting with a symptomatic, large (>2cm) primary spontaneous pneumothorax. Smoking is a known risk factor. As per the British Thoracic Society guidelines, the pneumothorax should be aspirated initially. If aspiration is successful, he can be discharged with follow up. If unsuccessful, a chest drain must be inserted.",
"id": "53112",
"label": "a",
"name": "Aspirate",
"picture": null,
"votes": 1302
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because this patient has a primary spontaneous pneumothorax. A chest drain is indicated once an aspiration is performed and deemed unsuccessful. Patients with underlying respiratory conditions such as asthma or COPD are classed as having a secondary pneumothorax, and if they have additional high risk factors, can necessitate a chest drain without the need for aspiration in the first instance.",
"id": "53113",
"label": "b",
"name": "Chest drain",
"picture": null,
"votes": 780
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because needle decompression is required for a tension pneumothorax. The stem clearly states that there is no evidence of tracheal deviation and although he is slightly tachypnoeic, he is not unstable. This patient has a 3cm primary spontaneous pneumothorax. Aspiration should be tried in the first instance. Note that needles must be inserted just above ribs to avoid neurovascular damage.",
"id": "53115",
"label": "d",
"name": "Needle decompression in the left 2nd intercostal space, mid-clavicular line, above the third rib",
"picture": null,
"votes": 1084
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Aren't needle decompression and aspiration the same thing?",
"createdAt": 1720876765,
"dislikes": 1,
"id": "54230",
"isLikedByMe": 0,
"likes": 2,
"parentId": null,
"questionId": 10683,
"replies": [
{
"__typename": "QuestionComment",
"comment": "Thoracentesis and needle decompression are both terms for a medical procedure that involves inserting a hollow needle into the chest to remove fluid or air: \n\nThoracentesis: This procedure can be used for diagnostic or therapeutic purposes.\n \nNeedle decompression: This procedure is used in an emergency to treat a tension pneumothorax, which is a condition where air becomes trapped in the pleural space. ",
"createdAt": 1726939078,
"dislikes": 1,
"id": "55198",
"isLikedByMe": 0,
"likes": 1,
"parentId": 54230,
"questionId": 10683,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Dr D.R.E.",
"id": 12779
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Serotonin Xeno",
"id": 50646
}
},
{
"__typename": "QuestionComment",
"comment": "Decompression is for a tension",
"createdAt": 1726938934,
"dislikes": 0,
"id": "55197",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10683,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Dr D.R.E.",
"id": 12779
}
},
{
"__typename": "QuestionComment",
"comment": "i cant lie i still havent figured out the different pneumothoraxes",
"createdAt": 1731836171,
"dislikes": 0,
"id": "57234",
"isLikedByMe": 0,
"likes": 2,
"parentId": null,
"questionId": 10683,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "streptocockus",
"id": 36854
}
},
{
"__typename": "QuestionComment",
"comment": "OK so pneumothoraces:\n- Not symptomatic --> ALWAYS conservative Mx\n\nSymptomatic AND >2cm:\n - high risk? (bilateral, Hx of PTx, unstable, >50yo with smoking Hx) --> chest drain\n - NOT high risk --> needle aspiration\n\n- recurrent --> VATS for pleurodesis\n\nI don't see a role for needle decompression in the BTS guidelines? pls correct me if im wrong but i think its just a thing to see in TV shows ig",
"createdAt": 1737309959,
"dislikes": 0,
"id": "61011",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10683,
"replies": [
{
"__typename": "QuestionComment",
"comment": "needle decompression for tension. If aspiration fails in a non high risk patient - for chest drain insertion\n",
"createdAt": 1738585610,
"dislikes": 0,
"id": "62211",
"isLikedByMe": 0,
"likes": 0,
"parentId": 61011,
"questionId": 10683,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "CeCe",
"id": 36099
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Pseudopseudopseudopseudohypoparathyroidism",
"id": 51334
}
}
],
"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": [
{
"__typename": "Condition",
"id": "584",
"name": "Respiratory failure",
"topic": {
"__typename": "UkmlaTopic",
"id": "1",
"name": "Acute and emergency"
},
"topicId": 1
}
],
"difficulty": 3,
"dislikes": 34,
"explanation": null,
"highlights": [],
"id": "10683",
"isLikedByMe": 0,
"learningPoint": "A primary spontaneous pneumothorax in young smokers often requires initial aspiration, especially if symptomatic and larger than 2cm.",
"likes": 8,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "112",
"name": "Breathlessness",
"topic": {
"__typename": "UkmlaTopic",
"id": "1",
"name": "Acute and emergency"
},
"topicId": 1
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 23-year-old male presents to A&E with a 2 hour history of chest pain. He has no significant past medical history. He trains as a basketball player and has a smoking history of 7 pack years. On examination, he appears distressed and he is working hard to breathe. There is no evidence of tracheal deviation. His respiratory rate is 27, and his saturations are 98% on air. A Chest X-ray shows 3cm rim of air between the lung and chest wall.\n\nWhich of the following is the best next step in the management of this patient?",
"sbaAnswer": [
"a"
],
"totalVotes": 3506,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,993 | false | 51 | null | 6,494,981 | null | false | [] | null | 10,684 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because this describes the finding in vascular dementia. Patients typically have a step-wise decline in function following a cerebrovascular event. They usually have cardiovascular risk factors such as hypertension, hypercholesterolaemia or diabetes.",
"id": "53120",
"label": "d",
"name": "Multiple infarcts with white matter damage",
"picture": null,
"votes": 32
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because this describes the finding in normal pressure hydrocephalus. The classic symptoms for this condition can be remembered by wet, weird and wobbly: urinary incontinence, dementia, and recurrent falls. Note that this is a type of reversible dementia.",
"id": "53121",
"label": "e",
"name": "Enlarged ventricles",
"picture": null,
"votes": 98
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has Alzheimer's disease. Histopathology would demonstrate beta amyloid plaques and neurofibrillary tangles made of tau protein.",
"id": "53117",
"label": "a",
"name": "Amyloid plaques",
"picture": null,
"votes": 2243
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Alpha-synuclein inclusions are found within the substantia nigra in Parkinson's disease and Lewy Body Dementia. These conditions are characterised by a typical triad of bradykinesia, rigidity and a resting tremor, which this patient does not have. Lewy Body Dementia is also classically associated with visual hallucinations, typically of Lilliputian bodies.",
"id": "53118",
"label": "b",
"name": "Alpha-synuclein",
"picture": null,
"votes": 169
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because this describes the finding in frontotemporal dementia. Frontotemporal dementia typically affects patients who are younger than 65 years and causes changes in their behaviour and personality. Memory and visuospatial skills are relatively preserved.",
"id": "53119",
"label": "c",
"name": "Frontal and temporal lobe atrophy",
"picture": null,
"votes": 450
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nAlzheimer's disease, the most common form of dementia, is a progressive neurodegenerative disorder that leads to cognitive decline, memory impairment, and a range of behavioural and psychological symptoms. Its impact extends beyond the individual, affecting families and healthcare systems worldwide. This comprehensive guide explores the key aspects of Alzheimer's disease, from its definition and pathophysiology to clinical features, diagnostic considerations, management approaches, and prognosis. Adherence to NICE guidelines ensures evidence-based care for patients with this challenging condition.\n\n# Definition\n\nAlzheimer's disease is a chronic, neurodegenerative disorder characterized by the progressive accumulation of abnormal protein deposits, primarily amyloid plaques and tau tangles, in the brain. This leads to the deterioration of cognitive function, memory loss, and various behavioural and psychological symptoms.\n\n\n# Epidemiology\n\nAlzheimer's disease is a global health concern, with an increasing prevalence as the population ages. It is estimated that millions of individuals worldwide are affected, with higher incidence rates in older age groups. Women are more commonly affected than men, and several genetic and environmental factors influence disease risk.\n\n\n# Pathophysiology\n\n\nAlzheimer's disease is a complex and progressive neurodegenerative disorder characterized by distinct pathophysiological hallmarks. These hallmarks are responsible for the gradual decline in cognitive function and the characteristic clinical features observed in affected individuals.\n\n1. **Amyloid Plaques:** The accumulation of beta-amyloid protein fragments outside nerve cells in the form of plaques is a hallmark feature. These abnormal protein deposits are believed to disrupt neuronal communication, trigger inflammation, and ultimately lead to cell death.\n\n2. **Tau Tangles:** Inside nerve cells, abnormal tau protein accumulates, forming neurofibrillary tangles. These tangles interfere with the transport of essential nutrients within neurons, contributing to their dysfunction and eventual demise.\n\n3. **Neuronal Loss and Brain Atrophy:** As the disease progresses, significant neuronal loss occurs, particularly in brain regions responsible for memory and cognitive function, such as the hippocampus and the cerebral cortex. This loss is associated with brain atrophy, visible on imaging studies.\n\n4. **Neurotransmitter Imbalance:** Alzheimer's disease disrupts the balance of neurotransmitters, particularly acetylcholine, which plays a crucial role in memory and learning. Reduced acetylcholine levels further contribute to cognitive decline.\n\n5. **Inflammatory Response:** Chronic neuroinflammation, characterized by the activation of microglia and astrocytes, is a prominent feature in Alzheimer's disease. Inflammation may exacerbate neuronal damage and contribute to the progression of the disease.\n\n# Risk Factors\n\nSeveral factors influence an individual's risk of developing Alzheimer's disease. These include:\n\n- **Age:** Advanced age is the most significant risk factor, with the incidence of Alzheimer's disease increasing exponentially after the age of 65.\n\n- **Genetic Predisposition:** Mutations in specific genes, such as the apolipoprotein E (APOE) gene, increase the risk of developing Alzheimer's disease. Additionally, individuals with Down's syndrome are at a higher risk due to a triplication of chromosome 21, which carries the amyloid precursor protein (APP) gene.\n\n- **Family History:** Having a first-degree relative with Alzheimer's disease can increase one's susceptibility.\n\n- **Cardiovascular Risk Factors:** Conditions like hypertension, diabetes, obesity, and hypercholesterolemia have been associated with an elevated risk of Alzheimer's disease.\n\n- **Lifestyle Factors:** Physical inactivity, smoking, and a diet high in saturated fats may contribute to increased risk.\n\n- **Traumatic Brain Injury:** A history of head injuries, particularly repeated concussions, has been linked to a higher risk of developing Alzheimer's disease.\n\n- **Low Educational Attainment:** Lower levels of education may be associated with an increased risk.\n\nUnderstanding these risk factors and their relationship to the disease's pathophysiology is crucial for early identification, prevention, and management of Alzheimer's disease.\n\n# Clinical Features\n\nAlzheimer's disease is characterized by a constellation of cognitive and behavioural symptoms, which may include:\n\n* **Memory Impairment:** Early in the disease, individuals often experience difficulties in recalling recent events and conversations.\n* **Language Impairment:** This may manifest as difficulty finding words, struggling to express oneself, and, in later stages, aphasia.\n* **Executive Dysfunction:** Impaired ability to plan, organize, and carry out tasks, leading to difficulties in activities of daily living.\n* **Behavioural Changes:** Individuals may exhibit agitation, aggression, or apathy, sometimes accompanied by mood swings and irritability.\n* **Psychological Symptoms:** Hallucinations, delusions, and paranoia can occur, particularly in later stages of the disease.\n* **Disorientation:** Affected individuals may become disoriented in familiar surroundings, unable to recognize places or people.\n* **Loss of Motor Skills:** In advanced stages, motor skills decline, leading to difficulties with mobility and self-care.\n\n# Differential Diagnosis\n\n\n1. **Vascular Dementia:** Cognitive impairment in vascular dementia often presents suddenly and is associated with a history of cerebrovascular events.\n\n2. **Lewy Body Dementia:** Visual hallucinations and fluctuating cognitive impairment are more common in Lewy body dementia.\n\n3. **Frontotemporal Dementia:** This condition typically presents with profound behavioural and personality changes, often affecting social conduct.\n\n4. **Mild Cognitive Impairment (MCI):** MCI is a transitional state between normal cognitive aging and dementia. Unlike Alzheimer's, MCI may not significantly impact daily functioning.\n\n5. **Normal Age-Related Cognitive Decline:** Age-related cognitive changes are common but do not interfere significantly with daily activities.\n\n# Investigations\n\nDiagnosing Alzheimer's disease may involve a series of assessments, including:\n\n- **History** - including a functional history, which may be informed using a structured instrument such as the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) or the Functional Activities Questionnaire (FAQ). A collateral history may be necessary, and a risk assessment should also be taken.\n- Assess cognitive decline using an approved scoring tool such as MMSE, MOCA, 10-point Cognitive Screener (10-CS), 6-item Cognitive Impairment Test (6-CIT), 6-item Screener, Memory Impairment Screen (MIS), Mini-Cog, Test Your Memory (TYM) \n- **Examination** - physical examination including a full neurological examination looking for abnormaliities in coordination, gait, sensation and motor signs.\n- **Blood tests** - to rule out reversible causes, this is known as a confusion screen and is often done in primary care. It includes FBC, U&E, LFTs, CRP/ESR, Ca2+, TFTs, B12, folate, syphilis, HIV. If there is an acute onset of symptoms delirium should be considered as this is a different pathway.\n- Once reversible causes are ruled out and a diagnosis of dementia is still suspected, refer to a specialist dementia diagnostic service (such as a memory clinic or community old age psychiatry service. Here, a full functional assessment is carried out and the patient will be referred for **neuroimaging**, such as CT or MRI.\n\t- **Brain Imaging:** Magnetic resonance imaging (MRI) and positron emission tomography (PET) scans can reveal brain atrophy and the presence of amyloid plaques.\n\t- **Cerebrospinal Fluid Analysis:** May be used to detect specific biomarkers associated with Alzheimer's disease.\n\n# Management\n\n- **Non-Pharmacological Approaches:** Psychological interventions, cognitive stimulation therapy, and occupational therapy can help manage behavioural and psychological symptoms.\n\n- **Support for Caregivers:** Education and support for family members and caregivers are vital to help them navigate the challenges of providing care.\n\n- **Patient-Centered Care:** Tailoring interventions to the individual's needs and preferences, while ensuring their safety and well-being.\n- **Pharmacological Intervention:** Medications, such as cholinesterase inhibitors (e.g. donepezil) and N-methyl-D-aspartate (NMDA) receptor antagonists (e.g. memantine), may be prescribed to manage cognitive symptoms.\n\t- Pharmacological treatments may have modest benefits, and include the cholinesterase inhibitors rivastigamine, galantamine, and donpezil in mild-moderate dementia, and the NMDA inhibitor memantine in severe dementia (as classified using the MMSE score: severe: <10; moderate: 10-20; mild: 21-26/30. \n\t- If there is evidence of behavioral and psychological symptoms of dementia (BPSD), low-dose risperidone may be started\n\n\n# NICE Guidelines\n\n[NICE CKS - Dementia](https://cks.nice.org.uk/topics/dementia/)\n\n# References\n\n[NHS UK - Alzheimer's Disease](https://www.nhs.uk/conditions/alzheimers-disease/)\n\n[Alzheimer's Association](https://www.alz.org/alzheimers-dementia/what-is-alzheimers)\n\n\n\n\n\n",
"files": null,
"highlights": [],
"id": "901",
"pictures": [],
"typeId": 2
},
"chapterId": 901,
"demo": null,
"entitlement": null,
"id": "2446",
"name": "Alzheimer's disease",
"status": null,
"topic": {
"__typename": "Topic",
"id": "57",
"name": "Geriatrics",
"typeId": 2
},
"topicId": 57,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2446,
"conditions": [],
"difficulty": 1,
"dislikes": 5,
"explanation": null,
"highlights": [],
"id": "10684",
"isLikedByMe": 0,
"learningPoint": "Alzheimer's disease is characterised by the presence of amyloid plaques and neurofibrillary tangles in the brain.",
"likes": 2,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 74-year-old female presents to the memory clinic after referral by her GP. Her family report that her memory for recent events is worsening, and she is struggling to manage her finances, remember words, and recognise objects. Her childhood memories remain relatively preserved.\n\nGiven the most likely diagnosis, which of the following is the most likely pathological finding?",
"sbaAnswer": [
"a"
],
"totalVotes": 2992,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,994 | false | 52 | null | 6,494,981 | null | false | [] | null | 10,685 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because spironolactone is rarely used as a first-line treatment for acne vulgaris. It is also important to avoid prescribing this drug in males because it is an anti-androgen medication which works by reducing testosterone levels and can cause feminising side effects.",
"id": "53125",
"label": "d",
"name": "Spironolactone",
"picture": null,
"votes": 4
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because this is the treatment for impetigo which is an infection typically caused by Staphylococcus aureus and usually affects infants. It presents with golden crusted lesions which this patient does not have. Impetigo is usually managed in primary care with oral antibiotics and topical fusidic acid.",
"id": "53124",
"label": "c",
"name": "Oral flucloxacillin and topical fusidic acid",
"picture": null,
"votes": 183
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct because this patient has severe acne vulgaris which is evident by the presence of widespread inflammatory lesions and scarring. This would be the best next step in management. Topical adapelene with topical benzoyl peroxide should be prescribed with an oral antibiotic such as lymecycline to prevent antibiotic resistance. Tetracyclines have anti-inflammatory effects, but note that these are contraindicated in pregnancy or breast-feeding which does not apply to this case.",
"id": "53122",
"label": "a",
"name": "Topical adapelene with topical benzoyl peroxide and oral lymecycline",
"picture": null,
"votes": 2504
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because oral isotretinoin is prescribed for patients with severe acne vulgaris resistant to traditional topical and systemic antibiotic therapies. This patient has not tried topical medication or antibiotics yet. Although this patient wants stronger medication, isotretinoin is not prescribed within primary care due to its side effect profile. Some of these include deranged liver function, increased risk of suicide and depression, and teratogenicity.",
"id": "53126",
"label": "e",
"name": "Oral isotretinoin",
"picture": null,
"votes": 430
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because this is the treatment for mild acne rosacea. In acne rosacea, patients typically present with papules, pustules and flushing of the nose, cheeks and forehead. It usually affects an older patient demographic and can present with telangiectasia. Topical metronidazole is not used for acne vulgaris.",
"id": "53123",
"label": "b",
"name": "Topical metronidazole",
"picture": null,
"votes": 91
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Is this not severe enough for isotretinoin?????",
"createdAt": 1684170364,
"dislikes": 0,
"id": "24668",
"isLikedByMe": 0,
"likes": 8,
"parentId": null,
"questionId": 10685,
"replies": [
{
"__typename": "QuestionComment",
"comment": "innit scarring is usually an indication for isotretinoin????",
"createdAt": 1684576942,
"dislikes": 0,
"id": "25374",
"isLikedByMe": 0,
"likes": 0,
"parentId": 24668,
"questionId": 10685,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "HarryDM",
"id": 20900
}
},
{
"__typename": "QuestionComment",
"comment": "I think the GP has to try the initial management methods, before referring him to derm for isotretinoin.",
"createdAt": 1684850272,
"dislikes": 1,
"id": "25824",
"isLikedByMe": 0,
"likes": 3,
"parentId": 24668,
"questionId": 10685,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Acute Body",
"id": 10999
}
},
{
"__typename": "QuestionComment",
"comment": "GPs dont prescribe oral isotretinoin",
"createdAt": 1738593925,
"dislikes": 0,
"id": "62231",
"isLikedByMe": 0,
"likes": 0,
"parentId": 24668,
"questionId": 10685,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Sydney Sweeney",
"id": 30184
}
},
{
"__typename": "QuestionComment",
"comment": "why refer to dermatology for actual treatment when you can just let a 15 year old get extensive scarring first (clowns)",
"createdAt": 1738600949,
"dislikes": 0,
"id": "62248",
"isLikedByMe": 0,
"likes": 0,
"parentId": 24668,
"questionId": 10685,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "anon",
"id": 80212
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Nightshift NICU",
"id": 25674
}
},
{
"__typename": "QuestionComment",
"comment": "Once scarring has started any GP in their right mind should be turning to accutane, that's what mine said at least. ",
"createdAt": 1685395194,
"dislikes": 0,
"id": "27103",
"isLikedByMe": 0,
"likes": 5,
"parentId": null,
"questionId": 10685,
"replies": [
{
"__typename": "QuestionComment",
"comment": "no GP should be prescribing accutane mate",
"createdAt": 1738593944,
"dislikes": 0,
"id": "62232",
"isLikedByMe": 0,
"likes": 0,
"parentId": 27103,
"questionId": 10685,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Sydney Sweeney",
"id": 30184
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "lil' aneurysm",
"id": 21164
}
},
{
"__typename": "QuestionComment",
"comment": "If there's scarring he should be referred to dermatology for isotretinoin. ",
"createdAt": 1738579468,
"dislikes": 0,
"id": "62204",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10685,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Pulseless Electrical Activity",
"id": 30718
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nAcne vulgaris is a common chronic disorder of the pilo-sebaceous unit, resulting in blockage of the follicle, formation of comedones and inflammation. Key signs and symptoms include open/closed comedones, inflammatory papules and pustules, and in severe cases, nodules and cysts. The disorder predominantly affects the face, neck, chest, and back, and has a significant psychological impact due to altered physical appearance. Acne is primarily diagnosed clinically, with further investigations necessary only in uncertain cases or prior to commencing certain treatments like isotretinoin. Treatment is guided by severity and may involve topical or systemic therapy based on the NICE guidelines. Potential complications include post-inflammatory hyperpigmentation, hypopigmentation, erythema, psycho/social/sexual dysfunction, and scarring.\n\n\n# Definition\n\n- A a chronic disorder of the skin affecting the pilo-sebaceous unit, in which there is blockage of the follicle leading to comedones and inflammation. \n- Vulgaris translates as \"common\", which is true as this condition affects over 80% of adolescents.\n\n# Epidemiology\n\n* It is one of the most common dermatological conditions globally, affecting individuals of all ethnicities and ages.\n* Prevalence is highest in adolescents and young adults, with up to 80% of individuals experiencing some degree of acne during their lifetime.\n* While most common in adolescents, adult-onset acne can occur, affecting people well into their 30s and beyond.\n* Acne affects both males and females, but the prevalence and severity may vary between genders.\n* The psychological impact of acne can be significant, affecting self-esteem and overall quality of life.\n\n# Risk Factors\n\nSeveral factors contribute to the development and exacerbation of acne, including:\n\n* Hormonal changes (e.g. during puberty, menstrual cycle, polycystic ovary syndrome)\n* Increased sebum (oil) production\n* Blockage of hair follicles and sebaceous glands by keratin and sebum\n* Bacterial colonization (Propionibacterium acnes)\n* Family history of acne\n* Certain medications (e.g. corticosteroids, hormonal treatments)\n\n# Pathophysiology\n\n- In normal skin, skin cells in the stratum corneum of the epidermis (corneocytes) desquamate successfully without blocking pilo-sebaceous units.\n- In acne, the corneocytes are excessively cohesive. They do not detach successfully.\n- Because of this, the keratin rich corneocytes accumulate and block off hair follicles causing follicular hyperkeratinisation.\n- Sebum is trapped in the hair follicle since it cannot be drained away. Androgens may also contribute to this causing sebaceous gland hyperplasia and increased sebum production. \n- This combination of sebum and keratin forms micro-comedones - the earliest feature of acne vulgaris. This is only visible under a microscope.\n- Gradually, the follicle becomes more distended with keratin and sebum, and the micro-comedone enlarges to become a comedone. \n- Initially, these are closed comedones, referred to as whiteheads. The contents are not exposed to the skin surface or oxygen, and therefore appear as fleshy/white papules. \n- Eventually, closed comedones become open comedones. As their contents become exposed to oxygen, they oxidise which causes black discolouration. Open comedones are therefore referred to as blackheads.\n- Comedones are then colonised with a gram positive bacillus called Propionibacterium (Cutibacterium) acnes. This is a commensal organism (part of the normal skin flora) but leads to an inflammatory response in the right conditions of the comedone, in a predisposed patient. \n- The comedone is subsequently transformed into an inflammatory papule, which is now associated with erythema. A papule is a solid, raised lesion less than 0.5cm in diameter. \n- As things progress and more neutrophils accumulate, the inflammatory papule becomes a pustule; this is a lesion less than 0.5cm in diameter that contains pus. \n- Eventually, the inflammatory papule or pustule becomes so distended that it ruptures into the dermis, triggering a marked and deep seated inflammatory response. \n- This leads to the formation of nodules/cysts, which are painful and red. A nodule is a solid lesion larger than 0.5cm, and cysts are walled off fluid containing structures. \n\n[lightgallery]\n\n# Classification\n\n- Non-inflammatory: blackheads and whiteheads.\n- Inflammatory: inflammatory papules, pustules, and nodules (cysts.)\n- Mild acne: predominantly non-inflammatory lesions. \n- Moderate acne: predominantly inflammatory papules and pustules. \n- Severe acne: nodules (cysts), scarring, acne fulminans, and acne conglobata. \n\n# Clinical Features\n\n- Open/closed Comedones, inflammatory papules and pustules, nodules, and cysts may be present.\n- The face is most often affected. The neck, chest and back may also be affected.\n- Psychological dysfunction due to changes physical appearance\n- Scarring: associated with inflammatory acne. Hypertrophic and keloid scars are more common in darker skin tones. \n\t- Atrophic: flat or indented, such as ice-pick, box-car, or rolling scars.\n\t- Hypertrophic: raised scars.\n\t- Keloid: raised scars that extend beyond the initial boundaries of the injury. \n- Post-inflammatory hyperpigmentation and hypopigmentation: associated with inflammatory acne. \n- Post inflammatory erythema: associated with inflammatory acne.\n- Acne fulminans: an uncommon but severe, serious acne presentation. \n\t- Inflammatory nodules/cysts that are painful, ulcerating, and haemorrhagic appear, with associated systemic upset (raised white cell count, joint pain, fever, fatigue.) \n\t- These patients should be reviewed urgently within 24 hours. It usually affects teenage male patients.\n- Acne conglobata: another uncommon presentation of severe nodular/cystic acne with interconnecting sinus tracts and extensive scaring. \n\n[lightgallery1]\n\n[lightgallery2]\n\n# Investigations\n\n- Acne is a clinical diagnosis and investigations are not usually needed. \n- Swabs may be indicated if the diagnosis is uncertain (e.g. if ruling out infectious pustules.)\n- Investigations will be required prior to commencing isotretinoin if indicated.\n- In some particular presentations where an endocrine cause is suspected, there may be endocrinological investigations (hyperandrogenic states such as PCOS or androgen secreting tumours.)\n\n# Treatment\n\nManagement of acne is multifaceted including education, topical/oral treatments and lifestyle modifications. \n\n- Each treatment combination is given as a 12 week course. \n- Combination therapies help reduce antimicrobial resistance. \n- Antibiotics are used predominantly since they have anti-inflammatory effects, rather than for their antimicrobial effects.\n- **Mild-moderate acne** is treated with any 2 of the following in combination:\n\t- Topical benzoyl peroxide.\n\t- Topical antibiotics (clindamycin)\n\t- Topical retinoids (tretinoin/adapalene)\n- **Moderate-severe acne** is treated with a 12-week coures of the following first line options:\n\t- Topical retinoids (tretinoin/adapelene) + topical benzoyl peroxide.\n\t- Topical retinoids + topical antibiotics (clindamycin)\n\t- Topical benzoyl peroxide + topical retinoid (tretinoin/adapelene) + oral antibiotic (lymecycline/doxycycline.) \n\t- Topical azelaic acid + oral antibiotic (lymecycline/doxycycline) \n\t- Second line oral antibiotics: trimethoprim and erythromycin e.g. in pregnant/breast-feeding women where tetracyclines are contra-indicated. \n\t- Combined oral contraceptives (COCPs) (if not contraindicated) in combination with topical agents can be considered as an alternative to systemic antibiotics in women\n\nNB: topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning a pregnancy, and so women of childbearing potential will need to use effective contraception, or choose an alternative treatment to these options.\n\t\n- As per NICE guidelines, referral to specialist Dermatology is indicated in the case of:\n\t- Acne fulminans.\n\t- Mild-moderate acne not responding to two 12 week courses of treatment as above.\n\t- Moderate-severe acne not responding to one 12 week course of treatment as above, including an oral antibiotic.\n\t- Psychological distress/mental health disorder contributed to by acne.\n\t- Acne with persistent pigmentary changes.\n\t- Acne with scarring.\n- Other available agents:\n\t- Co-cyprindiol: anti-androgenic contraceptive agent - may be trialled in primary care on female patients, but usually second line COCP due to increased risk of venous thromboembolism, and can only be given for 3 months. \n\t- Spironolactone: anti-androgenic - not often used. Not for male patients. \n\t- **Isotretinoin (oral retinoid):** the usual next step if the standard treatment fails and is prescribed by a dermatologist. \n\t\t* Notable adverse effects: dry skin/mouth/eyes/lips (most common), teratogenecity, photosensitivity, low mood, nose bleeds, hair thinning, raised triglycerides, intracranial hypertension \n\t\t* Isotretinoin is a well established teratogen that results in miscarriages and severe birth defects. As a result, the manufacturer recommends that all female patients taking isotretinoin are also using two forms of contraception from one month before until one month after use. For this reason a pregnancy test should also be done before initiating treatment\n\t\t* There is a controversial association between isotretinoin and depression/suicide. Recent research has shown that concerns about links between isotretinoin and depression or suicide are not established. This has now been included into the NICE guidelines. However it is still important to screen for depression/suicidal ideation before prescribing and during treatment.\n\t\n\t\n# Complications\n\n- Post-inflammatory erythema\n- Post-inflammatory hyper- and hypo- pigmentation\n- Psycho/social/sexual dysfunction \n- Scars (atrophic, hypertrophic, keloid)\n\t- Keloid scars: over-proliferating scar tissue/collagen extending beyond the boundaries of the lesion. Takes 3-4 weeks typically to develop after injury. They can cause itch and pain. It is fleshy, smooth, firm, and does not regress with time. The original injury may be minor, for example piercing or insect bite. Treatment is usually with intralesional steroids (triamcinolone). Cryotherapy and laser may also be used. Surgical resection is unlikely to be successful due to further scarring. Risk factors include:\n\t\t- Darker skin/Chinese/Hispanic origin \n\t\t- Less than 30 years of age\n\t\t- Previous keloid scarring \n\t- These are distinct from hypetrophic scars, which are thick and raised but remain within the injured boundary and tend to improve over time. \n\n# NICE Guidelines\n\n[NICE CKS for Acne Vulgaris](https://cks.nice.org.uk/topics/acne-vulgaris/)",
"files": null,
"highlights": [],
"id": "849",
"pictures": [
{
"__typename": "Picture",
"caption": "*A mixture of papules, pustules and comedones seen on the anterior aspect of the chest.*",
"createdAt": 1665036196,
"id": "948",
"index": 1,
"name": "Acne vulgaris 2.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/z1qreg9z1665036171730.jpg",
"path256": "images/z1qreg9z1665036171730_256.jpg",
"path512": "images/z1qreg9z1665036171730_512.jpg",
"thumbhash": "ZSgCBYL/a6avaHmUZ2eVeVZqkFUH",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
},
{
"__typename": "Picture",
"caption": "*Ice pick scarring seen on the cheeks following severe acne.*",
"createdAt": 1665036196,
"id": "935",
"index": 2,
"name": "Acne vulgaris 3.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/dsmfvp5y1665036171729.jpg",
"path256": "images/dsmfvp5y1665036171729_256.jpg",
"path512": "images/dsmfvp5y1665036171729_512.jpg",
"thumbhash": "kmoGFYJdiXePiHeYaKiHeC1vN/Jk",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
},
{
"__typename": "Picture",
"caption": "*An example of moderate acne vulgaris seen on the face.*",
"createdAt": 1665036196,
"id": "961",
"index": 0,
"name": "Acne vulgaris.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/iwkx46ju1665036171730.jpg",
"path256": "images/iwkx46ju1665036171730_256.jpg",
"path512": "images/iwkx46ju1665036171730_512.jpg",
"thumbhash": "E1kOFYYEaHeEiIiDiYh3hwN2NXBH",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
}
],
"typeId": 2
},
"chapterId": 849,
"demo": null,
"entitlement": null,
"id": "893",
"name": "Acne Vulgaris",
"status": null,
"topic": {
"__typename": "Topic",
"id": "4",
"name": "Dermatology",
"typeId": 2
},
"topicId": 4,
"totalCards": 6,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "893",
"name": "Acne Vulgaris"
}
],
"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
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "893",
"name": "Acne Vulgaris"
}
],
"demo": false,
"description": null,
"duration": 226.09,
"endTime": null,
"files": null,
"id": "4",
"live": false,
"museId": "EoFXN7C",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/dermatology.png",
"title": "Acne Vulgaris",
"userViewed": false,
"views": 141,
"viewsToday": 17
}
]
},
"conceptId": 893,
"conditions": [],
"difficulty": 1,
"dislikes": 14,
"explanation": null,
"highlights": [],
"id": "10685",
"isLikedByMe": 0,
"learningPoint": "Acne can be effectively managed with a combination of topical adapalene, which is a retinoid that helps to clear blocked pores and reduce inflammation, topical benzoyl peroxide, which has antimicrobial and anti-inflammatory properties, and oral lymecycline, an antibiotic that reduces bacteria and inflammation.",
"likes": 1,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 15-year-old male presents to the GP with concerns regarding changes to his skin. He says this has occurred over the past year and he has used several over-the-counter facial washes which have not helped. On examination, there are widespread inflammatory papules and pustules, nodules, and scars on his face, neck, and shoulders. He is adamant that he wants to try a stronger medication.\n\nWhich of the following is the best next step in the management of this patient?",
"sbaAnswer": [
"a"
],
"totalVotes": 3212,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,995 | false | 53 | null | 6,494,981 | null | false | [] | null | 10,686 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because Cryptosporidium parvum typically presents with chronic watery, green diarrhoea in patients who are immunosuppressed (typically, those patients with HIV.)",
"id": "53131",
"label": "e",
"name": "Cryptosporidium parvum",
"picture": null,
"votes": 319
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Leptospirosis is caused by Leptospira interrogans which can be transmitted by rats. Occupational exposure may occur through working in sewers. The key symptoms here are headache, fever, red eyes, deranged liver function tests, acute kidney injury, and reduced platelets. Note that patients with leptospirosis can also get diarrhoea, abdominal pain, and a rash. Liver and kidney failure may complicate its course.",
"id": "53127",
"label": "a",
"name": "Leptospirosis",
"picture": null,
"votes": 1811
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because lead poisoning would present with abdominal pain, mood changes, motor neuropathy and memory loss. Lead poisoning can also cause a microcytic anaemia and Burton's lines in the gums which appear blue. This is a good differential as lead poisoning can also present with headaches and may relate to this patient's occupation. However, the presence of conjunctivitis, his deranged blood results, acute presentation, and occupation should point towards leptospirosis.",
"id": "53128",
"label": "b",
"name": "Lead poisoning",
"picture": null,
"votes": 194
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because Bartonella henselae causes a condition known as Cat Scratch disease. This presents with painful local lymphadenopathy and fever. There is no mention of a cat scratch in this case.",
"id": "53130",
"label": "d",
"name": "Bartonella henselae",
"picture": null,
"votes": 124
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because asbestosis presents with gradually worsening shortness of breath. Occupational exposure may occur in those who work in construction or on boilers.",
"id": "53129",
"label": "c",
"name": "Asbestosis",
"picture": null,
"votes": 10
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "I may not know the featurs of lepto but I sure do know you get it in the sewers",
"createdAt": 1685040391,
"dislikes": 0,
"id": "26265",
"isLikedByMe": 0,
"likes": 14,
"parentId": null,
"questionId": 10686,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Supine Body",
"id": 1961
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n \n \nLeptospirosis is a zoonotic infection caused by a spirochete found in the urine of multiple animal species. It is typically misdiagnosed as malaria due to its similar presenting features. The disease is characterised by a biphasic illness, with an acute febrile phase followed by a phase marked by fever and potential complications such as liver failure and meningitis. Diagnosis is primarily achieved through serology, blood culture, and urine culture, while PCR of blood for *Leptospira* may also be used. Treatment is dependent on the severity of the disease and generally includes antibiotics such as doxycycline alongside supportive measures.\n \n \n# Definition\n \n \nLeptospirosis is a spirochete that represents a zoonotic infection found in the urine of multiple animal species. Typical animal hosts include **rodents** (main host), cattle, pigs, dogs, sheep and goats. Infection can be misdiagnosed as malaria.\n \n \n# Epidemiology\n \n \n - Approximately 1 million cases per year \n - Human infections occur from exposure to infected animals who excrete the organism in their urine, although it can also occur through cuts\n - Found widely in tropical regions \n - Occupational exposure – increased risk in farmers, sewage and abattoir workers, as well as those from lower socioeconomic groups\n \n \n# Signs and Symptoms\n \n \n - Spectrum of clinical features from self-limiting mild symptoms to life-threatening fatal disease\n - Classically a **biphasic illness**: first phase – acute febrile disease (2–9 days); second phase – fever and complications (eg. liver failure, meningitis etc.)\n - First phase presents with **abrupt fever**, **rigors**, **myalgia** and **headache** (75–100% of cases)\n - Classically conjunctival redness (can easily be missed)\n - Second phase can cause hepatosplenomegaly and skin rash as well as:\n - **Weil's disease** – presence of jaundice and renal failure (which can require dialysis)\n - **Life-threatening complications**– acute respiratory distress syndrome, pulmonary haemorrhage, myocarditis\n - **Aseptic meningitis**\n \n \n \n \n# Investigations\n \n \n - **FBC** (may show thrombocytopenia), **U&E's** (low sodium & altered renal function), **raised CK**\n - **Serology** is the most frequently used test for diagnosis – can be delayed, becoming positive only on day 5–7 of the illness (**note:** if in an endemic area, it may be positive due to previous and not acute infection)<\n - **Blood culture** (gold standard) and **urine culture** can be used to confirm leptospirosis (during the first and second weeks of illness, respectively)\n - **PCR** of blood for *Leptospira* (if available)\n - **Chest X-ray**\n \n \n# Management\n \n \n - Most cases are self-limiting and as such do not require treatment\n - There is a risk of **Jarisch–Herxheimer reaction** on administering antibiotics\n - For mild disease – doxycycline 7 days (if pregnant azithromycin)\n - For severe disease (eg. Weil's disease) – ceftriaxone \n - ICU may be indicated for severe disease\n \n \n### Prevention\n \n \nAvoiding potential sources of infection (eg. stagnant water, rodent control and avoidance of food contamination)\n \n \n# References\n \n \n 1. [Costa F et al. Global Morbidity and Mortality of Leptospirosis: A systematic review. *PLoS Negl Trop Dis*.2015;9(9)](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4574773/)\n 2. [Guerrier G, D'Ortenzio E. The Jarisch-Herxheimer reaction in leptospirosis: a systematic review. *PLoS One*.2013;8(3):]([https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3608636/)\n 3. [Click here for further information about Leptospirosis](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8813018/pdf/clinmed-22-1-14.pdf)\n 4. [Patient.info: Leptospirosis](https://patient.info/doctor/leptospirosis-weils-disease)",
"files": null,
"highlights": [],
"id": "2681",
"pictures": [],
"typeId": 2
},
"chapterId": 2681,
"demo": null,
"entitlement": null,
"id": "3681",
"name": "Leptospirosis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "58",
"name": "Infectious Diseases",
"typeId": 2
},
"topicId": 58,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3681,
"conditions": [],
"difficulty": 1,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "10686",
"isLikedByMe": 0,
"learningPoint": "Leptospirosis, caused by Leptospira interrogans, presents with fever, headache, conjunctival suffusion, and can lead to liver and kidney dysfunction.",
"likes": 2,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 40-year-old man presents to A&E with a headache and itchy, red eyes for the past 8 days. He works as a water engineer and spends a lot of time in the sewers. He has no significant past medical history. On examination, his eyes are red and his liver edge is palpable. He has a low-grade fever of 37.7. Blood tests show a mildly raised AST and ALT, low platelets, and a high urea and creatinine.\n\nWhich of the following is the most likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 2458,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,996 | false | 54 | null | 6,494,981 | null | false | [] | null | 10,687 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because VZV can cause shingles in the later years of life when a patient is immunosuppressed. This would present as a painful, vesicular, dermatomal rash which this patient does not have. VZV is also screened for prior to a renal transplant.",
"id": "53135",
"label": "d",
"name": "Varicella Zoster Virus",
"picture": null,
"votes": 39
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because Hepatitis C would present with fever, malaise, and jaundice, with other risk factors in the history such as transmission through blood, birth, or sexual intercourse. Note that Hepatitis C would also cause deranged LFTs, but CMV infection is more likely in this patient following a renal transplant.",
"id": "53136",
"label": "e",
"name": "Hepatitis C",
"picture": null,
"votes": 326
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because Hepatitis B would present with fever, malaise, and potentially jaundice, with other risk factors in the history such as transmission through blood, birth, or sexual intercourse. Note that acute Hepatitis B would also cause deranged LFTs with the AST and ALT possibly in the 1000s. However, CMV infection is more common in this patient following a renal transplant.",
"id": "53134",
"label": "c",
"name": "Hepatitis B",
"picture": null,
"votes": 508
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because EBV would present with fever, lymphadenopathy and a sore throat. Hepatosplenomegaly may also be found on palpation. EBV infection in transplant patients typically occurs due to reactivation of latent EBV from donor tissue. It generally takes longer to present (6 months+), and is often associated with post transplant lymphoproliferative disorder. As such, this case is too early post transplant to raise suspicion of an EBV mediated pathology.",
"id": "53133",
"label": "b",
"name": "Epstein-Barr Virus",
"picture": null,
"votes": 279
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct because this patient has recently undergone a renal transplant. These patients are at risk of reactivation of latent CMV from within donor tissue within the first 6 weeks after a transplant secondary to immunosuppression. Note that a fever and deranged LFTs are key features for identifying CMV infection. It is managed with ganciclovir.",
"id": "53132",
"label": "a",
"name": "Cytomegalovirus",
"picture": null,
"votes": 1881
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "thank you renal placement xxx",
"createdAt": 1685109154,
"dislikes": 0,
"id": "26389",
"isLikedByMe": 0,
"likes": 2,
"parentId": null,
"questionId": 10687,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Monoclonal Versicolor",
"id": 28726
}
},
{
"__typename": "QuestionComment",
"comment": "sees renal transplants, clicks cmv",
"createdAt": 1709210799,
"dislikes": 0,
"id": "43228",
"isLikedByMe": 0,
"likes": 2,
"parentId": null,
"questionId": 10687,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Ale",
"id": 20565
}
}
],
"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": 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
},
{
"__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
}
]
},
"conceptId": 317,
"conditions": [],
"difficulty": 1,
"dislikes": 2,
"explanation": null,
"highlights": [],
"id": "10687",
"isLikedByMe": 0,
"learningPoint": "Cytomegalovirus reactivation from latent infection of the donor organ is a common complication in renal transplant patients, often presenting with symptoms such as fever, fatigue, and abnormal liver function tests, and may lead to more severe systemic illness if not promptly managed.",
"likes": 7,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 49-year-old man presents to A&E with fever and myalgia. He denies any recent unwell contacts or coryzal symptoms. His past medical history includes chronic kidney disease stage 5, hypertension and a kidney transplant 6 weeks ago. On examination, he appears pale. He has a temperature of 38.5. His blood tests reveal deranged liver function.\n\nWhich of the following is the most likely causative organism?",
"sbaAnswer": [
"a"
],
"totalVotes": 3033,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,997 | false | 55 | null | 6,494,981 | null | false | [] | null | 10,689 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Beta-blockers are usually indicated in the management of ACS, to reduce chest pain by reducing myocardial oxygen demand and also improve long-term outcomes. This question indicates that ACS management according to guidelines has already been commenced. As such, at this stage the priority should be to correct the anaemia.",
"id": "53146",
"label": "e",
"name": "Atenolol",
"picture": null,
"votes": 740
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because this is the management for pericarditis. Pericarditis presents as pleuritic chest pain which improves on leaning forward and worsens on lying flat. Classical ECG findings are PR depression and widespread saddle-shaped ST elevation. It has many causes including viral infections. The first line treatment is usually an NSAID, and alternative treatments include colchicine.",
"id": "53144",
"label": "c",
"name": "Ibuprofen",
"picture": null,
"votes": 140
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Cardiac patients at risk of myocardial ischaemia/with myocardial ischaemia, as in this case, should have a target haemoglobin level of above 80. Therefore, this patient requires a red blood cell transfusion as his haemoglobin is 76. This is in order to maintain adequate myocardial perfusion. As he has already been initiated on ACS treatment, treating his haemoglobin should be the next priority.",
"id": "53142",
"label": "a",
"name": "Red blood cell transfusion",
"picture": null,
"votes": 2345
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because this patient is having an NSTEMI and requires admission therefore, for treatment, cardiology review, monitoring, and a secondary percutaneous coronary intervention. Furthermore, his haemoglobin is low enough to meet the threshold for transfusion in a patient with cardiac ischaemia (<80.) It would be inappropriate to discharge him from A&E at this stage.",
"id": "53143",
"label": "b",
"name": "Discharge patient",
"picture": null,
"votes": 74
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because FFP contains clotting factors which is used in the context of bleeding disorders or massive haemorrhage. This is not indicated in this patient because this would not help increase the haemoglobin level and there is no evidence of coagulopathy.",
"id": "53145",
"label": "d",
"name": "Fresh frozen plasma transfusion",
"picture": null,
"votes": 198
}
],
"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",
"caption": "A posterior STEMI.",
"createdAt": 1665036193,
"id": "798",
"index": 4,
"name": "Posterior STEMI.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/8fmhcpq11665036171703.jpg",
"path256": "images/8fmhcpq11665036171703_256.jpg",
"path512": "images/8fmhcpq11665036171703_512.jpg",
"thumbhash": "eDgCBILYt6iDeXh/lYVojIDGCA==",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
},
{
"__typename": "Picture",
"caption": null,
"createdAt": 1672906681,
"id": "1437",
"index": 7,
"name": "Secondary prevention post MI (NICE).png",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/jdniw1l11672906675510.jpg",
"path256": "images/jdniw1l11672906675510_256.jpg",
"path512": "images/jdniw1l11672906675510_512.jpg",
"thumbhash": "ZOcJBYJY2Vd+dnd/mtd5d0le/1Qj",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
},
{
"__typename": "Picture",
"caption": "An anterolateral STEMI.",
"createdAt": 1665036193,
"id": "753",
"index": 2,
"name": "Anterolateral STEMI.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/6b6d62x21665036171702.jpg",
"path256": "images/6b6d62x21665036171702_256.jpg",
"path512": "images/6b6d62x21665036171702_512.jpg",
"thumbhash": "JwgKA4A/d3drh2iHB3q181U=",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
},
{
"__typename": "Picture",
"caption": "An anterior STEMI.",
"createdAt": 1665036193,
"id": "767",
"index": 1,
"name": "Anterior STEMI.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/cdi2n93z1665036171703.jpg",
"path256": "images/cdi2n93z1665036171703_256.jpg",
"path512": "images/cdi2n93z1665036171703_512.jpg",
"thumbhash": "ORgCBIBYRmafp3eCp3x3hHA4CA==",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
},
{
"__typename": "Picture",
"caption": "A left bundle branch block.",
"createdAt": 1665036198,
"id": "1081",
"index": 3,
"name": "LBBB.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/75p0c58h1665036171701.jpg",
"path256": "images/75p0c58h1665036171701_256.jpg",
"path512": "images/75p0c58h1665036171701_512.jpg",
"thumbhash": "MRgGBIBleXiPiIiGiIlvTorAaA==",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
},
{
"__typename": "Picture",
"caption": null,
"createdAt": 1672906680,
"id": "1426",
"index": 5,
"name": "STEMI (NICE).png",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/lkv1opvv1672906675512.jpg",
"path256": "images/lkv1opvv1672906675512_256.jpg",
"path512": "images/lkv1opvv1672906675512_512.jpg",
"thumbhash": "aPcJDYTpioeOZnh/d2mXZ+l/n2UG",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
},
{
"__typename": "Picture",
"caption": "An inferior STEMI.",
"createdAt": 1665036192,
"id": "741",
"index": 0,
"name": "Inferior STEMI.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/82faisu41665036171703.jpg",
"path256": "images/82faisu41665036171703_256.jpg",
"path512": "images/82faisu41665036171703_512.jpg",
"thumbhash": "dzgCBIBnd4d/eHeLh36ZgJUHCA==",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
}
],
"typeId": 2
},
"chapterId": 641,
"demo": null,
"entitlement": null,
"id": "662",
"name": "Acute Coronary Syndrome (ACS)",
"status": null,
"topic": {
"__typename": "Topic",
"id": "35",
"name": "Cardiology",
"typeId": 2
},
"topicId": 35,
"totalCards": 40,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "662",
"name": "Acute Coronary Syndrome (ACS)"
}
],
"demo": false,
"description": null,
"duration": 915.37,
"endTime": null,
"files": null,
"id": "245",
"live": false,
"museId": "X5GsBaf",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/cardiology.png",
"title": "Myocardial infarction and Acute Coronary Syndrome (ACS) 9",
"userViewed": false,
"views": 31,
"viewsToday": 8
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "662",
"name": "Acute Coronary Syndrome (ACS)"
}
],
"demo": false,
"description": null,
"duration": 437.14,
"endTime": null,
"files": null,
"id": "109",
"live": false,
"museId": "34MAhJA",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/ED.png",
"title": "Emergency Management of Acute Coronary Syndrome 1",
"userViewed": false,
"views": 294,
"viewsToday": 18
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "662",
"name": "Acute Coronary Syndrome (ACS)"
}
],
"demo": false,
"description": null,
"duration": 513.9,
"endTime": null,
"files": null,
"id": "241",
"live": false,
"museId": "pZnENZP",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/cardiology.png",
"title": "Myocardial infarction and Acute Coronary Syndrome (ACS) 5",
"userViewed": false,
"views": 23,
"viewsToday": 6
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "662",
"name": "Acute Coronary Syndrome (ACS)"
}
],
"demo": false,
"description": null,
"duration": 418.3,
"endTime": null,
"files": null,
"id": "110",
"live": false,
"museId": "oybmaNF",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/ED.png",
"title": "Emergency Management of Acute Coronary Syndrome 2",
"userViewed": false,
"views": 132,
"viewsToday": 15
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "662",
"name": "Acute Coronary Syndrome (ACS)"
}
],
"demo": false,
"description": null,
"duration": 4692.22,
"endTime": null,
"files": null,
"id": "306",
"live": false,
"museId": "AdKRmxV",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/cardiology.png",
"title": "Quesmed Tutorial: Cardiology",
"userViewed": false,
"views": 2232,
"viewsToday": 47
},
{
"__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
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "662",
"name": "Acute Coronary Syndrome (ACS)"
}
],
"demo": false,
"description": null,
"duration": 3920.55,
"endTime": null,
"files": null,
"id": "303",
"live": false,
"museId": "6rkQd9F",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/cardiology.png",
"title": "Quesmed Tutorial: Acute Coronary Syndrome ",
"userViewed": false,
"views": 111,
"viewsToday": 22
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "662",
"name": "Acute Coronary Syndrome (ACS)"
}
],
"demo": false,
"description": null,
"duration": 442.77,
"endTime": null,
"files": null,
"id": "237",
"live": false,
"museId": "m6Y3xBx",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/cardiology.png",
"title": "Myocardial infarction and Acute Coronary Syndrome (ACS) 1",
"userViewed": false,
"views": 251,
"viewsToday": 28
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "662",
"name": "Acute Coronary Syndrome (ACS)"
}
],
"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": "662",
"name": "Acute Coronary Syndrome (ACS)"
}
],
"demo": false,
"description": null,
"duration": 178.84,
"endTime": null,
"files": null,
"id": "244",
"live": false,
"museId": "CBhGH6J",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/cardiology.png",
"title": "Myocardial infarction and Acute Coronary Syndrome (ACS) 8",
"userViewed": false,
"views": 35,
"viewsToday": 8
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "662",
"name": "Acute Coronary Syndrome (ACS)"
}
],
"demo": false,
"description": null,
"duration": 394.24,
"endTime": null,
"files": null,
"id": "240",
"live": false,
"museId": "5vYTVVJ",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/cardiology.png",
"title": "Myocardial infarction and Acute Coronary Syndrome (ACS) 4",
"userViewed": false,
"views": 40,
"viewsToday": 7
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "662",
"name": "Acute Coronary Syndrome (ACS)"
}
],
"demo": false,
"description": null,
"duration": 382.23,
"endTime": null,
"files": null,
"id": "242",
"live": false,
"museId": "LsMqF4k",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/cardiology.png",
"title": "Myocardial infarction and Acute Coronary Syndrome (ACS) 6",
"userViewed": false,
"views": 35,
"viewsToday": 9
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "662",
"name": "Acute Coronary Syndrome (ACS)"
}
],
"demo": false,
"description": null,
"duration": 359.36,
"endTime": null,
"files": null,
"id": "243",
"live": false,
"museId": "6Xbcy7S",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/cardiology.png",
"title": "Myocardial infarction and Acute Coronary Syndrome (ACS) 7",
"userViewed": false,
"views": 44,
"viewsToday": 8
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "662",
"name": "Acute Coronary Syndrome (ACS)"
}
],
"demo": false,
"description": null,
"duration": 306.54,
"endTime": null,
"files": null,
"id": "238",
"live": false,
"museId": "HAnPpE4",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/cardiology.png",
"title": "Myocardial infarction and Acute Coronary Syndrome (ACS) 2",
"userViewed": false,
"views": 100,
"viewsToday": 8
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "662",
"name": "Acute Coronary Syndrome (ACS)"
}
],
"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": 662,
"conditions": [],
"difficulty": 1,
"dislikes": 5,
"explanation": null,
"highlights": [],
"id": "10689",
"isLikedByMe": 0,
"learningPoint": "In acute coronary syndrome, patients with a haemoglobin level below 80 g/L require a red blood cell transfusion.",
"likes": 4,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 59-year-old man presents to A&E with a 3-hour history of chest pain. He says this came on suddenly whilst at work. He is currently taking amlodipine for hypertension and atorvastatin for hypercholesterolaemia. On examination, he appears clammy. His ECG shows ST depression and his blood tests reveal a raised troponin and a haemoglobin of 76. He has been initiated on treatment according to the Acute Coronary Syndrome (ACS) protocol.\n\nWhich of the following is the next best step in the management of this patient?",
"sbaAnswer": [
"a"
],
"totalVotes": 3497,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,998 | false | 56 | null | 6,494,981 | null | false | [] | null | 10,690 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because this patient clearly meets the guidelines for a 2-week-wait referral to the breast clinic. Her lump has not been proven as benign and as such it would be wrong to reassure her at this stage.",
"id": "53150",
"label": "d",
"name": "Reassure patient",
"picture": null,
"votes": 373
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because this is the management for fibrocystic disease. This would present as bilateral breast lumps which are commonly found in the upper, outer quadrant and patients usually experience breast pain. This is generally related to menstruation due to the build-up of oestrogen. This patient does not have typical features of fibrocystic disease, and requires further investigation.",
"id": "53151",
"label": "e",
"name": "Analgesia and support bra",
"picture": null,
"votes": 103
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct because this patient is over the age of 30 with an unexplained breast lump. This satisfies the criteria for a 2 week wait referral to the breast clinic where she will undergo a triple assessment. Note that this involves history and examination, ultrasound scanning, and a tissue biopsy if required. Although this patient is pregnant, there is no evidence of inflammation in the question stem to suggest alternative diagnoses.",
"id": "53147",
"label": "a",
"name": "Referral to breast clinic under 2 week wait pathway",
"picture": null,
"votes": 3345
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because incision and drainage is performed within the hospital setting by the surgical team if there is evidence of an abscess. There is nothing to indicate the presence of an abscess, such as fevers or erythema, in this case.",
"id": "53149",
"label": "c",
"name": "Incision and drainage",
"picture": null,
"votes": 65
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because this is the management for mastitis, which is associated with breast-feeding. Mastitis usually presents as a painful breast lump with associated inflammatory skin changes, such as erythema. Oral flucloxacillin would be the correct management for mastitis as it is commonly caused by Staphylococcus aureus. Prior to prescribing antibiotics, supportive measures like analgesia and encouraging lactation is the first line treatment. Antibiotics are prescribed if there is evidence of an infected nipple fissure, if the breast milk culture is positive, or if symptoms do not improve despite supportive measures.",
"id": "53148",
"label": "b",
"name": "Oral flucloxacillin",
"picture": null,
"votes": 21
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Fix to the skin does not mean that it is more likely benign?",
"createdAt": 1722511507,
"dislikes": 3,
"id": "54555",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10690,
"replies": [
{
"__typename": "QuestionComment",
"comment": "likely, but unconfirmed.",
"createdAt": 1724274366,
"dislikes": 1,
"id": "54754",
"isLikedByMe": 0,
"likes": 0,
"parentId": 54555,
"questionId": 10690,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "AsciticImmigrant",
"id": 30255
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Distinction candidate",
"id": 65624
}
}
],
"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": [
{
"__typename": "Condition",
"id": "110",
"name": "Breast cancer",
"topic": {
"__typename": "UkmlaTopic",
"id": "3",
"name": "Cancer"
},
"topicId": 3
}
],
"difficulty": 1,
"dislikes": 2,
"explanation": null,
"highlights": [],
"id": "10690",
"isLikedByMe": 0,
"learningPoint": "A breast lump in a woman over 30 years old warrants a 2-week referral to a breast clinic for further assessment.",
"likes": 8,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "106",
"name": "Breast lump",
"topic": {
"__typename": "UkmlaTopic",
"id": "3",
"name": "Cancer"
},
"topicId": 3
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 35-year-old female presents to the GP with a painless lump in her breast. She says she found the lump this morning whilst she was in the shower and is alarmed by its presence. She is currently 24 weeks pregnant. On examination, the breast lump measures 2cm in the left breast, in the 6 o'clock position. It appears fixed to the skin. There is no evidence of axillary lymphadenopathy.\n\nWhat is the next best step in the management of this patient?",
"sbaAnswer": [
"a"
],
"totalVotes": 3907,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,999 | false | 57 | null | 6,494,981 | null | false | [] | null | 10,691 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient may have an underlying diagnosis of COPD given his extensive smoking history and the presence of a productive cough. However, there is no wheeze at present, and his shortness of breath can be explained by the X-ray findings of collapse. As such, it does not seem necessary to treat him as an exacerbation of COPD at present. Bronchodilators are often prescribed to help encourage clearance of secretions, and so whilst this may be an appropriate option, the best initial treatment is chest physiotherapy, and the addition of oral steroids is not necessary.",
"id": "53154",
"label": "c",
"name": "Nebulised salbutamol and oral prednisolone",
"picture": null,
"votes": 231
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Carbocisteine is a mucolytic sometimes provided to help loosen secretions and allow them to be coughed up. However, in the first instance, chest physiotherapy remains the best treatment option.",
"id": "53155",
"label": "d",
"name": "Carbocisteine",
"picture": null,
"votes": 121
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct because the goal in atelectasis is to re-expand the collapsed lung, and chest physiotherapy helps to clear the thick sputum and secretions, which are likely contributing to the collapse in this case. Atelectasis is a very common cause of post-operative pyrexia.",
"id": "53152",
"label": "a",
"name": "Chest physiotherapy",
"picture": null,
"votes": 1011
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Bronchoscopy may be used to help remove secretions at a later stage, if initial medical management has failed. As such, this option does not represent the best, next step.",
"id": "53156",
"label": "e",
"name": "Bronchoscopy",
"picture": null,
"votes": 98
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because this is the management for mild, community-acquired pneumonia. Patients with pneumonia typically present with fever, productive cough with green sputum, and shortness of breath. On auscultation, you would hear crackles. You would also expect the chest X-ray to show consolidation. This patient is at risk of pneumonia, but at present does not display the clinical features suggestive of this. Oral amoxicillin would not be the best choice even if a diagnosis of pneumonia were made, as this would not be the treatment for a hospital acquired pneumonia.",
"id": "53153",
"label": "b",
"name": "Oral amoxicillin",
"picture": null,
"votes": 143
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "But he needs abx too?? Not my fault you only put the wrong one as an option. Shit question",
"createdAt": 1685198062,
"dislikes": 3,
"id": "26592",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10691,
"replies": [
{
"__typename": "QuestionComment",
"comment": "But he doesnt?",
"createdAt": 1685306532,
"dislikes": 0,
"id": "26919",
"isLikedByMe": 0,
"likes": 0,
"parentId": 26592,
"questionId": 10691,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Twisted Tezzy",
"id": 29355
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Monoclonal Metabolism",
"id": 25350
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nPost-operative pyrexia, or fever following surgery, can be the result of several causes, commonly remembered by the \"5 Ws\" mnemonic: Wind (pneumonia and atelectasis), Water (urinary tract infection), Wound (infection), Wonder drugs (anesthetic reactions), and Walking (deep vein thrombosis). Timelines for the emergence of these causes can vary, but are typically seen within specific post-op periods. It's essential to recognize these symptoms promptly, carry out the relevant investigations such as cultures, imaging, or blood tests, and initiate appropriate management like antibiotics, anticoagulants, or potentially further surgical intervention.\n\n# Definition\n\nPost-operative pyrexia refers to the development of fever following a surgical procedure, usually classified as a core body temperature above 38 degrees Celsius.\n\n# Epidemiology\n\nPost-operative pyrexia is a common occurrence, especially in the first 48 hours post-surgery due to the systemic inflammatory response. The incidence can vary based on the type and invasiveness of the surgery, patient characteristics, and the perioperative care quality.\n\n# Aetiology\n\nCauses of post-operative pyrexia can be remembered using the **5 Ws** mnemonic:\n\n- **W**ind: Pneumonia and atelectasis (1-2 days post-op)\n- **W**ater: Urinary tract infection (UTI) (>3 days)\n- **W**ound: Surgical site infections (> 5 days)\n- **W**onder drugs: Drug-induced fever, commonly due to anaesthesia\n- **W**alking: Deep vein thrombosis (DVT) (>1 week)\n\nIn addition to these, a developing abscess post-operatively can also cause pyrexia.\n\n# Signs and Symptoms\n\n- **Pneumonia and atelectasis**: Cough, dyspnea, sputum production, chest pain, decreased breath sounds on examination\n- **Urinary tract infection (UTI)**: Dysuria, urgency, frequency, suprapubic pain, foul-smelling urine\n- **Surgical site infections**: Pain, erythema, swelling at the wound site, purulent discharge\n- **Drug-induced fever**: Fever associated with recent drug use, but typically no other localized symptoms\n- **Deep vein thrombosis (DVT)**: Leg pain, swelling, erythema, warmth\n\n# Differential Diagnosis\n\n- **Non-infectious causes of fever**: These could include malignancy, collagen vascular disease, thromboembolism, or medication effects. Main symptoms might include widespread symptoms with no localized signs.\n- **Infection not associated with surgery**: Infections elsewhere in the body may cause fever post-operatively. The signs and symptoms would correspond to the organ system affected.\n- **Abscess formation**: This would typically present with localized signs of infection (redness, pain, swelling) at the site of the abscess.\n\n# Investigations\n\nInvestigations will depend on the suspected underlying cause. They may include:\n\n- **Blood tests**: Full blood count, CRP, blood cultures\n- **Cultures**: Urine, wound, or sputum cultures as applicable\n- **Imaging**: Chest X-ray, CT scan, or ultrasound depending on the suspected site\n\n# Management\n\nThe management of post-operative pyrexia depends on the underlying cause but could include:\n\n- **Antibiotics**: For bacterial infections like pneumonia, UTI, or wound infections\n- **Anticoagulants**: For DVT\n- **Modification or cessation of the offending drug**: For drug-induced fever\n- **Further surgical intervention**: In case of abscess formation or severe wound infection",
"files": null,
"highlights": [],
"id": "732",
"pictures": [],
"typeId": 2
},
"chapterId": 732,
"demo": null,
"entitlement": null,
"id": "837",
"name": "Post-operative pyrexia",
"status": null,
"topic": {
"__typename": "Topic",
"id": "7",
"name": "General Surgery",
"typeId": 2
},
"topicId": 7,
"totalCards": 1,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 837,
"conditions": [],
"difficulty": 1,
"dislikes": 5,
"explanation": null,
"highlights": [],
"id": "10691",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 1,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 59-year-old man had an uncomplicated coronary artery bypass graft under general anaesthetic two days ago. During the ward round, he is found to be visibly short of breath. He is occasionally coughing clear, thick sputum, but is struggling to fully expectorate this. He has a 21 pack year smoking history. On examination, there is dullness to percussion and reduced breath sounds in the left lower zone of the lungs. His respiratory rate is 24 breaths per minute, heart rate 103bpm, and temperature 37.8. A chest X-ray shows lung collapse in the left lower zone.\n\nWhich of the following is the next best step in the management of this patient?",
"sbaAnswer": [
"a"
],
"totalVotes": 1604,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,000 | false | 58 | null | 6,494,981 | null | false | [] | null | 10,692 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Glenohumeral instability results in recurrent subluxation or dislocation of the shoulder joint. It is typically found in young, athletic individuals, or individuals with hypermobility disorders. Patients are unable to maintain the humeral head within the glenoid fossa, so they hold their arm close to their body with the unaffected hand to compensate for instability. They do not present with pain on shoulder abduction, unless there was dislocation during the movement.",
"id": "53161",
"label": "e",
"name": "Glenohumeral instability",
"picture": null,
"votes": 172
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients with biceps teninditis present with acute, intense pain at the anterior aspect of the shoulder. On examination, you would expect to find tenderness when palpating the biceps tendon which becomes worse with supination of the forearm and elbow flexion, rather than shoulder abduction.",
"id": "53159",
"label": "c",
"name": "Biceps tendinitis",
"picture": null,
"votes": 182
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because cervical radiculopathy usually presents with radicular, nerve-type pain (i.e. shooting or tingling down the arm), and myotomal/dermatomal loss of function. There may be associated neck pain due to osteoarthritis, which may be the cause of the radiculopathy. There may be loss of tendon reflexes. This patient has a normal neurovascular examination and no evidence of myotomal/dermatomal loss of function, nor nerve-type pain.",
"id": "53160",
"label": "d",
"name": "Cervical radiculopathy",
"picture": null,
"votes": 65
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct because this patient describes symptoms of pain in her shoulder with a history of repetitive overhead activities. Pain with active abduction of the shoulder at 60-120 degrees with reduced range of motion is typical for subacromial bursitis. This is due to an inflamed bursa which separates the supraspinatus tendon from the acromial arch and deltoid muscle. This is a clinical diagnosis and first line management is rest with NSAIDs. Steroid injections are sometimes also considered.",
"id": "53157",
"label": "a",
"name": "Subacromial bursitis",
"picture": null,
"votes": 2048
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Adhesive capsulitis is also know as frozen shoulder syndrome as there is inflammation of the glenohumeral joint causing restricted passive and active shoulder movements in all directions. It is usually associated with other conditions such as diabetes mellitus, thyroid disease, rheumatoid arthritis, or recent immobility (for example after surgery or a fracture.) Patients typically have a more chronic course, presenting with shoulder pain followed by freezing (over 6-9 weeks), and then gradual recovery over months. This patient has a relatively acute presentation, and her range of movement is not restricted in all directions. She does not have any of the typical risk factors associated with frozen shoulder syndrome, either.",
"id": "53158",
"label": "b",
"name": "Adhesive capsulitis",
"picture": null,
"votes": 1475
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "wouldn't you be able to see a bursa?",
"createdAt": 1683813436,
"dislikes": 1,
"id": "24107",
"isLikedByMe": 0,
"likes": 4,
"parentId": null,
"questionId": 10692,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "NICU Fever",
"id": 4984
}
},
{
"__typename": "QuestionComment",
"comment": "how would you differentiate this from a supraspinatus tear?",
"createdAt": 1703686370,
"dislikes": 0,
"id": "36968",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10692,
"replies": [
{
"__typename": "QuestionComment",
"comment": "tear = weakness, bursitis = pain without weakness?",
"createdAt": 1733938693,
"dislikes": 0,
"id": "58225",
"isLikedByMe": 0,
"likes": 0,
"parentId": 36968,
"questionId": 10692,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "moins que",
"id": 27495
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Amnesia Syndrome",
"id": 12641
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nSubacromial bursitis is an inflammatory condition often linked to shoulder pain. Key signs and symptoms include shoulder pain, reduced range of motion, and tenderness over the shoulder joint. It's usually caused by repetitive overhead activities, minor trauma, subacromial impingement, and other multifactorial causes. Key investigations include routine blood tests, shoulder X-ray, and MRI. Management predominantly involves nonoperative treatment methods such as rest, NSAIDs, physical therapy, and corticosteroid injections.\n\n# Definition\n\nSubacromial bursitis refers to an inflammatory condition of the subacromial bursa, a small fluid-filled sac located between the acromion (part of the shoulder blade that forms the top of the shoulder) and the rotator cuff. This condition often results in shoulder pain.\n\n# Epidemiology\n\nSubacromial bursitis is commonly seen in both athletic populations and sedentary individuals. Its prevalence tends to increase with age and is more common in those engaged in activities involving repetitive overhead arm movements.\n\n# Aetiology\n\nThe aetiology of subacromial bursitis can be multifactorial, often attributed to:\n\n- Subacromial impingement\n- Repetitive overhead activities or overuse of the shoulder joint\n- Direct trauma such as falls\n- Crystal deposition diseases\n- Subacromial haemorrhage\n- Infection\n- Autoimmune diseases, such as rheumatoid arthritis\n\n# Signs and Symptoms\n\nThe typical signs and symptoms of subacromial bursitis include:\n\n- Pain in the shoulder, often worsening with overhead activities\n- Reduced range of motion\n- Tenderness over the shoulder joint\n- Possible swelling and redness in severe cases\"\n\n# Differential Diagnosis\n\nIn the differential diagnosis of subacromial bursitis, the following conditions should be considered, which present with similar signs and symptoms:\n\n- Rotator cuff tendinopathy: Presents with shoulder pain, difficulty lifting objects, and reduced range of motion.\n- Adhesive capsulitis (Frozen shoulder): Characterized by stiffness, pain, and limited range of motion in the shoulder.\n- Shoulder osteoarthritis: Manifests as gradual shoulder pain, stiffness, and restricted movement.\n- Glenohumeral joint instability: Results in shoulder pain, a sensation of the shoulder giving way, and reduced shoulder function.\n\n# Investigations\n\nThe investigation of subacromial bursitis typically involves:\n\n- Routine Blood Tests: To rule out systemic causes such as infection or rheumatoid arthritis.\n- Shoulder X-ray: To evaluate for bone abnormalities and changes in joint space.\n- Shoulder MRI: To assess soft tissue structures, including the bursa and rotator cuff.\n\n# Management\n\nThe management of subacromial bursitis generally involves nonoperative treatment modalities, which include:\n\n- Rest: To allow the inflammation to subside.\n- Non-steroidal anti-inflammatory medications (NSAIDs): To manage pain and reduce inflammation.\n- Physical therapy: To improve range of motion and strengthen shoulder muscles.\n- Corticosteroid injections: For severe cases where pain and inflammation are not managed with the above treatments.",
"files": null,
"highlights": [],
"id": "2684",
"pictures": [],
"typeId": 2
},
"chapterId": 2684,
"demo": null,
"entitlement": null,
"id": "3682",
"name": "Subacromial bursitis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "37",
"name": "Orthopaedics",
"typeId": 2
},
"topicId": 37,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3682,
"conditions": [
{
"__typename": "Condition",
"id": "121",
"name": "Bursitis",
"topic": {
"__typename": "UkmlaTopic",
"id": "16",
"name": "Musculoskeletal"
},
"topicId": 16
}
],
"difficulty": 2,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "10692",
"isLikedByMe": 0,
"learningPoint": "Subacromial bursitis presents with shoulder pain during active abduction, often linked to repetitive overhead activities and relieved by rest and NSAIDs.",
"likes": 10,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "150",
"name": "Chronic joint pain/stiffness",
"topic": {
"__typename": "UkmlaTopic",
"id": "16",
"name": "Musculoskeletal"
},
"topicId": 16
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 45-year-old woman presents to the GP with pain in her left shoulder. She says this has been going on for the past 3 weeks and is limiting her ability to work. She works for a food packaging company and has to move heavy boxes and stack tall shelves as part of her job. She has no significant past medical history. On examination, there is tenderness at the anterolateral aspect of her left shoulder. There is pain with active abduction of the arm at 90 degrees, limiting further abduction. There is a good range of movement elsewhere. Except for weakness attributed to pain, neurovascular examination of the upper limb is normal.\n\nWhich of the following is the most likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 3942,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,001 | false | 59 | null | 6,494,981 | null | false | [] | null | 10,693 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Retinal detachment occurs when there is separation of the neuro-sensory retina from the retinal pigment epithelium. This also presents with painless visual loss, but patients complain of flashing lights and floaters, and possibly a 'curtain' obscuring their vision (which would be the detached flap of retina.) Fundoscopy can reveal a detached homogenous floating grey membrane. This patient has none of these clinical features.",
"id": "53166",
"label": "e",
"name": "Retinal detachment",
"picture": null,
"votes": 180
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Central retinal vein occlusion does result in sudden onset painless loss of vision. However, on fundoscopy, you would expect to find a stormy-sunset appearance with widespread haemorrhage, cotton wool spots, swollen optic discs, engorged veins, and chronically proliferative changes. This patient's fundoscopic examination is normal. Risk factors include pro-thrombotic stages as well as cardiac risk factors, which this patient does not have.",
"id": "53163",
"label": "b",
"name": "Central retinal vein occlusion",
"picture": null,
"votes": 100
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Branch retinal vein occlusion does result in sudden onset painless loss of vision. However, on fundoscopy, you would expect to find haemorrhage, cotton wool spots, swollen optic discs, and engorged veins within the area of occlusion. This patient's fundoscopic examination is normal. Risk factors include pro-thrombotic stages as well as cardiac risk factors, which this patient does not have.",
"id": "53164",
"label": "c",
"name": "Branch retinal vein occlusion",
"picture": null,
"votes": 253
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because damage to the superior optic radiation within the parietal lobne would cause an inferior homonymous quadrantanopia.",
"id": "53165",
"label": "d",
"name": "Lesion of the superior optic radiation",
"picture": null,
"votes": 1012
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has a right superior homonymous quadrantanopia visual field defect caused by damage to the left inferior optic radiation. This is likely due to her recent temporal lobe surgery. the left temporal lobe. Damage to the temporal optic radiation fibres (Meyer's loop) causes superior contralateral quadrantanopias. Damage to the parietal optic radiation fibres result in inferior contralateral quadrantanopias.",
"id": "53162",
"label": "a",
"name": "Lesion of the inferior optic radiation",
"picture": null,
"votes": 1526
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Inferior radiation does superior vision ",
"createdAt": 1683667251,
"dislikes": 0,
"id": "23899",
"isLikedByMe": 0,
"likes": 2,
"parentId": null,
"questionId": 10693,
"replies": [
{
"__typename": "QuestionComment",
"comment": "and the numbers 12-3 are where on a clock",
"createdAt": 1684664538,
"dislikes": 1,
"id": "25509",
"isLikedByMe": 0,
"likes": 2,
"parentId": 23899,
"questionId": 10693,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Amnesia Transplant",
"id": 24039
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Chronic Bladder",
"id": 10247
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nVisual field loss encompasses a range of distinct patterns, each indicative of underlying pathologies affecting different segments of the visual pathway. Monocular vision loss often results from retinal, optic nerve, or corneal disorders in one eye. Bitemporal hemianopia, characteristic of pituitary tumours and craniopharyngiomas, involves the loss of outer visual fields in both eyes. Contralateral homonymous hemianopia points to stroke or occipital lobe lesions, with loss of half the visual field in both eyes on the same side. Quadrantanopias may stem from stroke or trauma, leading to the loss of a quarter of the visual field. In occipital lobe lesions, macular sparing preserves central vision despite peripheral field loss. Recognizing these patterns and their differentials is crucial for accurate diagnosis and tailored management.\n\n\n# Pathologies seen at different parts of the optic pathway\n\nDifferent parts of the optic pathway present as various forms of visual deficits when disrupted.\n\n\n| **Visual Field Loss Pattern** | **Optic Pathway** | **Differential Diagnoses** |\n|----------------------------------------|-------------------------|----------------------------------------------------|\n| Monocular Vision Loss | Optic Nerve | - Retinal disorders, optic nerve disorders, corneal disorders |\n| Bitemporal Hemianopia | Optic Chiasm | - Pituitary tumours |\n| Contralateral Homonymous Hemianopia | Optic Radiation | - Stroke affecting optic radiation, occipital lobe lesions |\n| Quadrantanopias | Optic Radiation | - Stroke affecting specific pathways in the optic radiation, trauma, craniopharyngioma |\n| Macular Sparing in Occipital Lobe Lesions | Occipital Lobe | - Occipital infarcts or haemorrhages |\n\n\n[lightgallery]\n\n[lightgallery1]\n\n# Further Details \n\nConsidering that the fibres of each optic radiation that correspond to the lower retina (which receives stimulation by the upper half of the visual field) pass through the temporal lobe while the fibres that carry visual stimuli from the upper retina (representing the lower half of the visual fields) pass through the parietal lobe, it is clear that:\n\n- A lesion in the temporal lobe would cause contralateral homonymous superior (upper) quadrantanopia\n\n[lightgallery2]\n\n- A lesion in the parietal lobe would cause contralateral homonymous inferior (lower) quadrantanopia\n\t- A mneumonic for remembering this is **PITS** - P - parietal I - inferior; T - temporal S - superior\n- Parietal lobe damage also manifests as a defect of attention in the contralateral visual field, astereognosis, constructional apraxia (non-dominant), dressing apraxia (non-dominant) and ideomotor apraxia (dominant). Right hemisphere (i.e. non-dominant) parietal lesions are particularly prone to producing visual neglect. \n- A lesion in the occipital lobe would cause contralateral homonymous hemianopia\n\t- When an occipital lobe lesion occurs, it may damage a specific area of the visual cortex, resulting in visual field loss. However, the central representation of the macula has a larger cortical area dedicated to it, making it less vulnerable to damage. As a result, the central vision remains intact, creating a spared or preserved area of vision even in the presence of peripheral visual field loss.\n\n# References\n\n1. [Neuro-Ophthalmology Review Manual](https://www.thieme.com/books-main/ophthalmology/product/1040-neuro-ophthalmology-review-manual)\n2. [NICE Guidelines: Stroke and Transient Ischaemic Attack](https://www.nice.org.uk/guidance/cg68)\n3. [Visual Field Defects Overview on MedlinePlus](https://medlineplus.gov/ency/article/003879.htm)",
"files": null,
"highlights": [],
"id": "246",
"pictures": [
{
"__typename": "Picture",
"caption": "How the visual fields are affected in a quadrantanopia.",
"createdAt": 1665036197,
"id": "998",
"index": 2,
"name": "Quadrantanopia.png",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/o5hvxcro1665036171693.jpg",
"path256": "images/o5hvxcro1665036171693_256.jpg",
"path512": "images/o5hvxcro1665036171693_512.jpg",
"thumbhash": "NggKBYDin3VRy1iaZ9ZqmgAAAAAA",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
},
{
"__typename": "Picture",
"caption": "How the visual fields are affected in a bitemporal hemianopia",
"createdAt": 1665036197,
"id": "988",
"index": 1,
"name": "Bitemporal hemianopia.png",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/8grbbcvz1665036171691.jpg",
"path256": "images/8grbbcvz1665036171691_256.jpg",
"path512": "images/8grbbcvz1665036171691_512.jpg",
"thumbhash": "LggWA4A4+PiHd7iXAAAAAAA=",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
},
{
"__typename": "Picture",
"caption": "How the visual fields are affected in a homonymous hemianopia.",
"createdAt": 1665036196,
"id": "950",
"index": 0,
"name": "Homonymous hemianopia.png",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/e0mzf6ux1665036171691.jpg",
"path256": "images/e0mzf6ux1665036171691_256.jpg",
"path512": "images/e0mzf6ux1665036171691_512.jpg",
"thumbhash": "LggSA4CK/XCHh8h3AAAAAAA=",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
}
],
"typeId": 2
},
"chapterId": 246,
"demo": null,
"entitlement": null,
"id": "2109",
"name": "Visual field loss",
"status": null,
"topic": {
"__typename": "Topic",
"id": "16",
"name": "Ophthalmology",
"typeId": 2
},
"topicId": 16,
"totalCards": 6,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2109,
"conditions": [],
"difficulty": 1,
"dislikes": 18,
"explanation": null,
"highlights": [],
"id": "10693",
"isLikedByMe": 0,
"learningPoint": "Damage to the left inferior optic radiation can cause right superior homonymous quadrantanopia, often following temporal lobe surgery.",
"likes": 12,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 54-year-old woman presents to A&E with sudden, painless loss of vision. This has not happened to her before. There was no obvious trigger, since she was sitting at home when this happened. She has a past medical history of severe left temporal lobe epilepsy and recently underwent surgery for this. When asked to point out the numbers on a clock face, she is only able to see from number 4 to 11 in both eyes. Fundoscopic examination is unremarkable.\n\nWhat is responsible for this patient's visual field defect?",
"sbaAnswer": [
"a"
],
"totalVotes": 3071,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,002 | false | 60 | null | 6,494,981 | null | false | [] | null | 10,694 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Abdominal x-rays may be useful to rule out bowel obstruction (dilated bowel loops) and perforation (Rigler sign) if these were within the differentials. It would not be able to identify the cause of this patient's presentation, however, with no clinical features to suggest perforation or obstruction in this case.",
"id": "53168",
"label": "b",
"name": "Abdominal X-Ray",
"picture": null,
"votes": 157
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient is at high risk of diverticulitis given the presence of left lower quadrant pain, fever, and history of constipation. CT abdomen is the gold standard for diagnosis. Diverticulitis occurs when diverticulae (outpouchings of bowel) become inflamed, causing nausea, vomiting, fever, and abdominal pain.",
"id": "53167",
"label": "a",
"name": "CT abdomen",
"picture": null,
"votes": 762
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A flexible sigmoidoscopy is used to view the rectum, sigmoid and descending colon to aid with diagnosis of diverticular disease; diverticulae especially affect the recto-sigmoid colon so a flexible sigmoidoscopy is an adequate technique to diagnose most cases. However, this is not performed in the acute setting due to risk of perforation.",
"id": "53169",
"label": "c",
"name": "Flexible sigmoidoscopy",
"picture": null,
"votes": 465
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Colonoscopy is usually performed after acute diverticulitis to fully investigate the bowel for any underlying disease, such as cancer leading to constipation. It is not useful in the acute setting, and may risk perforation.",
"id": "53170",
"label": "d",
"name": "Colonoscopy",
"picture": null,
"votes": 259
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Blood cultures will be indicated in this febrile patient. However, it will not be the best next test to confirm the diagnosis; a CT scan will be required to do this.",
"id": "53171",
"label": "e",
"name": "Blood cultures",
"picture": null,
"votes": 58
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nDiverticular disease is a clinical condition characterized by the presence of diverticula, or outpouchings of the mucosa and submucosa, typically affecting the sigmoid colon. Key signs and symptoms include constipation, left lower quadrant abdominal pain, and potentially rectal bleeding. Key investigations include physical examination, abdominal imaging, and blood tests. In cases of inflammation of the diverticula, known as diverticulitis, the primary management strategy includes oral antibiotics, and in more severe cases, hospital admission and intravenous antibiotics. Surgical intervention may be required for complications such as perforation, abscess formation, and fistulas.\n\n\n# Definition\n\n**Diverticular disease** is a term used to describe conditions related to the presence of diverticula, which are small, bulging pouches that can form in the lining of the digestive system, most commonly in the lower part of the colon (sigmoid colon).\n\n**Diverticulosis** refers to the simple presence of diverticula. In many cases, diverticulosis is asymptomatic, and individuals may not even be aware that they have these diverticula as they are typically discovered incidentally during tests for other conditions.\n\n**Diverticulitis**, a subset of diverticular disease, occurs when these diverticula become inflamed or infected. This condition is typically characterized by severe abdominal pain, fever, and nausea. Diverticulitis often requires treatment, which can include antibiotics, pain relievers, and, in severe cases, surgery.\n\n# Epidemiology\n\nDiverticular disease is most common in individuals over the age of 50 and those who consume a Western (low fibre) diet.\n\n# Aetiology\n\nThe primary risk factor for diverticular disease is age, with the condition being more prevalent in individuals over the age of 50. Other risk factors include consuming a low-fibre Western diet, obesity, lack of exercise, and certain medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) and opiates.\n\n# Signs and Symptoms\n\nDiverticular disease typically presents with:\n\n- Constipation\n- Left lower quadrant abdominal pain\n- Possible rectal bleeding\n\nPhysical examination may be normal or may demonstrate tenderness in the left lower quadrant on digital rectal examination.\n\nIn cases of diverticulitis, the condition presents acutely with:\n\n- Left lower quadrant abdominal pain\n- Fever\n- Nausea/vomiting\n- Pyrexia and left lower quadrant tenderness/guarding on physical examination\n- Diffuse abdominal tenderness suggestive of perforation or generalised peritonitis.\n\n# Differential Diagnosis\n\nThe differential diagnosis for diverticular disease includes:\n\n- Irritable bowel syndrome: Characterised by chronic abdominal pain, bloating, and alterations in bowel habits without an identifiable cause.\n- Colonic carcinoma: Presents with a change in bowel habits, rectal bleeding, abdominal pain, and unexplained weight loss.\n- Inflammatory bowel disease: Marked by abdominal pain, diarrhoea, bloody stools, weight loss, and fatigue.\n- Gynaecological disorders (in women): May present with abdominal or pelvic pain, menstrual irregularities, and various urinary symptoms.\n- Urological disorders: These may involve symptoms such as frequency, urgency, dysuria, and lower abdominal pain.\n\n# Investigations\n\nDiverticular disease can be confirmed through a variety of tests, such as:\n\n- Abdominal imaging (CT scan or ultrasound)\n- Blood tests demonstrating inflammation (leukocytosis)\n- Colonoscopy/endoscopy\n\n# Management\n\nManagement of diverticular disease depends on the severity and symptoms presented:\n\n- Asymptomatic diverticulosis: No treatment is required if diverticula are seen incidentally on imaging or endoscopy.\n- Symptomatic diverticular disease: Patients should be advised to increase dietary fibre intake and hydration. If there is evidence of diverticulitis (leukocytosis, fever), patients are initially managed with oral antibiotics (e.g. 7 days co-amoxiclav). Analgesia may also be required, prescribed in a step-wise fashion, starting with oral paracetamol. A low residue diet is also advised.\n- Management of diverticulitis: Patients unresponsive to antibiotics, or presenting with an abscess, perforation, stricture, or obstruction may require surgical intervention. A localised abscess may be drained under CT/ultrasound guidance, with surgery considered if this fails.\n- Recurrent severe episodes of diverticulitis may necessitate consideration for elective colectomy.\n- For acute rectal bleeding: Haemodynamic stabilisation of the patient should be followed by endoscopic haemostasis. Surgery is an option if bleeding continues despite endoscopy.\n\n# Complications\n\nDiverticular disease can lead to both short and long-term complications:\n\nShort-term complications include:\n\n- Abscess formation: Initially managed with bowel rest, broad-spectrum antibiotics ± CT-guided percutaneous drainage. Surgical management is considered if medical management fails.\n- Perforation: A surgical emergency suspected in cases of generalised peritonitis. Free air on the abdominal x-ray and high clinical suspicion necessitate urgent exploratory laparotomy.\n\nLong-term complications include:\n\n- Fistula formation: Most commonly colovesical fistulas, presenting with pneumaturia, faecaluria, and recurrent UTIs. Diagnosed with cystoscopy or cystography and require surgical repair. Colovaginal, coloenteric, colouterine, and colourethral fistulas may also occur.\n- Fibrosis: Secondary to inflammation, resulting in strictures and large bowel obstruction.",
"files": null,
"highlights": [],
"id": "782",
"pictures": [],
"typeId": 2
},
"chapterId": 782,
"demo": null,
"entitlement": null,
"id": "819",
"name": "Diverticular disease",
"status": null,
"topic": {
"__typename": "Topic",
"id": "7",
"name": "General Surgery",
"typeId": 2
},
"topicId": 7,
"totalCards": 21,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "819",
"name": "Diverticular disease"
}
],
"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": "819",
"name": "Diverticular disease"
}
],
"demo": false,
"description": null,
"duration": 449.17,
"endTime": null,
"files": null,
"id": "99",
"live": false,
"museId": "Ce66ae3",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/surgery.png",
"title": "Diverticular disease",
"userViewed": false,
"views": 126,
"viewsToday": 6
}
]
},
"conceptId": 819,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10694",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 3,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 62-year-old woman presents to A&E with a 2-day history of abdominal pain and nausea. She has also experienced some rectal bleeding but she thinks this is due to straining. She last opened her bowels earlier this morning. Her diet has been poor since her husband recently passed away. On examination, there is tenderness in the left lower quadrant and her abdomen is non-distended. Her vital signs are: HR 102 bpm, RR 15 breaths per minute, BP 139/97mmHg, temperature of 39.2.\n\nWhich of the following is the next best investigation to confirm the most likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 1701,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,003 | false | 61 | null | 6,494,981 | null | false | [] | null | 10,695 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This child has acute epiglottis, which is often caused by Haemophilus influenzae type B. Fortunately, due to vaccinations, this is becoming less common, but this child has not had all of his childhood vaccinations. He has evidence of airway obstruction, and so the immediate next step is to secure his airway. Any further delay may result in complete airway obstruction. It is important to do nothing to cause additional distress, including cannulation or further examination, since this may result in further emotional distress and sudden loss of the airway.",
"id": "53172",
"label": "a",
"name": "Call the anaesthetists for intubation and ventilation",
"picture": null,
"votes": 3610
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because intramuscular adrenaline is a treatment for anaphylaxis. This is an important differential diagnosis because anaphylaxis causes shortness of breath and stridor. However, one would expect additional clinical features, such as acute onset, rash, itch, and onset after exposure to an allergic trigger. However, this patient does not have anaphylaxis, and the priority in any case in the context of apparent airway obstruction is to secure his airway.",
"id": "53174",
"label": "c",
"name": "Intramuscular adrenaline",
"picture": null,
"votes": 109
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Oral dexamethasone is provided for children with croup, which is caused by Parainfluenza virus. Croup is an important differential diagnosis for acute epiglottitis because it can present with stridor, but the child is well and able to eat and drink (though may be off food.) Fevers are usually low-grade, and the child has a characteristic barking cough. Drooling is not a feature.",
"id": "53175",
"label": "d",
"name": "Oral dexamethasone",
"picture": null,
"votes": 233
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This child has acute epiglottis, which is often caused by Haemophilus influenzae type B. Fortunately, due to vaccinations, this is becoming less common, but this child has not had all of his childhood vaccinations. He has evidence of airway obstruction, and so the immediate next step is to secure his airway. Any further delay may result in complete airway obstruction. It is important to do nothing to cause additional distress since this may result in sudden loss of the airway. Applying a nebuliser mask to this clearly upset, crying child who is in pain may cause further distress which can precipitate acute airway obstruction, and furthermore delay the most important next step, which is to prioritise securing the airway at this stage.",
"id": "53176",
"label": "e",
"name": "Nebulised adrenaline",
"picture": null,
"votes": 230
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This child has acute epiglottis, which is often caused by Haemophilus influenzae type B. Fortunately, due to vaccinations, this is becoming less common, but this child has not had all of his childhood vaccinations. He has evidence of airway obstruction, and so the immediate next step is to secure his airway. Any further delay may result in complete airway obstruction. It is important to do nothing to cause additional distress, including cannulation for intravenous antibiotic administration, or further examination, since this may result in further emotional distress, airway spasm, and sudden loss of the airway. Intravenous antibiotics can be provided once the airway is secured.",
"id": "53173",
"label": "b",
"name": "Intravenous antibiotics",
"picture": null,
"votes": 239
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "why can't I just intubate myself",
"createdAt": 1685548879,
"dislikes": 0,
"id": "27333",
"isLikedByMe": 0,
"likes": 3,
"parentId": null,
"questionId": 10695,
"replies": [
{
"__typename": "QuestionComment",
"comment": "If you intubate yourself there will be noone left to treat the patient",
"createdAt": 1686083326,
"dislikes": 0,
"id": "28053",
"isLikedByMe": 0,
"likes": 13,
"parentId": 27333,
"questionId": 10695,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Metabolism Benign",
"id": 30446
}
},
{
"__typename": "QuestionComment",
"comment": "Yeah not appropriate really, good thing the SJT has been scrapped ",
"createdAt": 1686478006,
"dislikes": 0,
"id": "28466",
"isLikedByMe": 0,
"likes": 0,
"parentId": 27333,
"questionId": 10695,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "LolWilkesLol",
"id": 25154
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Intravenous Prone",
"id": 19930
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n \n\nEpiglottitis is inflammation of the epiglottis and surrounding tissues that can result in abrupt blockage of the upper airway and potentially death. It is most prevalent in children aged 1-6 years and is preventable through the Haemophilus influenza B (Hib) vaccine. Key signs and symptoms include high fevers, an intensely painful throat, soft inspiratory stridor, and the child maintaining an upright, open-mouth position. It's crucial to identify potential differential diagnoses such as croup, peritonsillar abscess, and bacterial tracheitis. Immediate management involves securing the airway, potentially via endotracheal intubation, followed by administration of IV antibiotics, specifically cefuroxime.\n \n\n# Definition\n \n\nEpiglottitis is a rapidly progressive infection that leads to inflammation of the epiglottis and adjacent tissues. This inflammation can swiftly progress to blockage of the upper airway, posing a risk of death.\n \n\n# Epidemiology\n \n\nEpiglottitis is most common in children aged 1-6 years, but it can occur at any age. With the widespread use of the Haemophilus influenza B (Hib) vaccine, the incidence of epiglottitis has significantly decreased, making it a rare condition, particularly in developed countries like the UK. It affects 1 in every 100,000 in the UK. \n \n\n# Aetiology\n \n\nThe primary aetiological agent of epiglottitis is Haemophilus influenza B (Hib).\n \nLess common causes include Streptococcus pneumoniae, fungal infections and Varicella Zoster virus. \n \n\n# Signs and Symptoms\n \n\nPatients with epiglottitis often present with:\n \n\n - High fevers\n - Appear ill or toxic\n - Intense throat pain that prevents speaking or swallowing, leading to drooling\n - Soft inspiratory stridor\n - Rapid increase in respiratory difficulty over hours\n - A tendency to sit upright with an open mouth to optimise airway patency\n - Minimal or absent cough\n - Muffled or hoarse voice \n - Stridor \n \n\n# Differential Diagnosis\n \n\n - **Croup:** Characterised by a barking cough, inspiratory stridor, and hoarseness.\n - **Peritonsillar abscess:** Presents with severe throat pain, muffled \" hot potato\" voice, drooling, and trismus (difficulty opening the mouth).\n - **Bacterial tracheitis:** Severe respiratory distress, high fever, and purulent tracheal secretions can be noted.\n \n\n# Investigations\n \n\nConfirmatory diagnosis of epiglottitis involves direct visualisation of the inflamed epiglottis, which should only be performed by experienced clinicians due to the risk of triggering airway obstruction. This is typically done using laryngoscopy after securing the airway. \n\nFurther investigations may include:\n\n- Throat swab, once the airway is secure, may isolate the causative organism \n- Lateral neck X-ray may show the thumb sign: thickening of aryepiglottic folds\n- CT or MRI may be required if there are concerns about abscess formation \n \n\n# Management\n \n\nEpiglottitis is a medical emergency requiring prompt intervention. Management includes:\n \n\n - Do not examine or upset the child without senior support\n - Securing the airway, possibly through endotracheal intubation, is a priority\n - Culturing and examination of the throat once the airway is secure\n - Administration of IV antibiotics, typically cefuroxime\n\n# Complications \n \n - Abscess formation\n - Bacteraemia and sepsis\n - Meningitis \n - Pneumothorax \n - Airway obstruction and death\n\n# Prognosis \n \nEarly diagnosis and detection enable many children to make a complete recovery and reduce the need for intubation. \n \n\n# NICE Guidelines\n \n [NICE Guidance for Sore throat - acute](https://cks.nice.org.uk/topics/sore-throat-acute/management/management/) \n \n# References\n \n [NHS Information on Epiglottitis](https://www.nhs.uk/conditions/epiglottitis/) \n\n [BMJ Best Practice page on epiglottitis](https://bestpractice.bmj.com/topics/en-gb/452)\n \n [Patient Info Epiglottitis](https://patient.info/doctor/epiglottitis-pro)",
"files": null,
"highlights": [],
"id": "459",
"pictures": [],
"typeId": 2
},
"chapterId": 459,
"demo": null,
"entitlement": null,
"id": "462",
"name": "Acute Epiglottitis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "29",
"name": "Paediatrics",
"typeId": 2
},
"topicId": 29,
"totalCards": 10,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 462,
"conditions": [
{
"__typename": "Condition",
"id": "254",
"name": "Epiglottitis",
"topic": {
"__typename": "UkmlaTopic",
"id": "5",
"name": "Child health"
},
"topicId": 5
}
],
"difficulty": 1,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "10695",
"isLikedByMe": 0,
"learningPoint": "The management of acute epiglottitis involves immediate securing of the airway, often through endotracheal intubation or, in severe cases, a tracheostomy, along with administration of antibiotics to treat the underlying infection and corticosteroids to reduce inflammation.",
"likes": 9,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "78",
"name": "Behavioural difficulties in childhood",
"topic": {
"__typename": "UkmlaTopic",
"id": "5",
"name": "Child health"
},
"topicId": 5
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 3-year-old boy is brought to A&E with his mother as she is concerned he has not been eating since the morning. She says she has heard him making strange breathing noises which she cannot explain. He has not had all of his childhood vaccines, but his past medical history is otherwise unremarkable. On examination, he is sitting upright with his mouth open and drooling, and there is evidence of inspiratory stridor. He is crying out in pain and has a muffled voice when he tries to talk. He is unable to eat and drink. His vital signs show HR 160bpm, 45 breaths per minute, a systolic BP of 70mmHg, and temperature of 39.9.\n\nWhich of the following is the most appropriate next step in his management?",
"sbaAnswer": [
"a"
],
"totalVotes": 4421,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,004 | false | 62 | null | 6,494,981 | null | false | [] | null | 10,696 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Furosemide does not need to be routinely stopped prior to a surgical procedure. Stopping may precipitate fluid overload and render the patient unfit for a general anaesthetic.",
"id": "53180",
"label": "d",
"name": "Furosemide",
"picture": null,
"votes": 186
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Bisoprolol does not need to be stopped prior to a surgical procedure. Stopping this may precipitate tachyarrythmia and render the patient unfit for a general anaesthetic.",
"id": "53181",
"label": "e",
"name": "Bisoprolol",
"picture": null,
"votes": 298
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Atorvastatin does not need to be stopped prior to a surgical procedure.",
"id": "53179",
"label": "c",
"name": "Atorvastatin",
"picture": null,
"votes": 132
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct because ramipril must be stopped prior to surgery as it causes profound hypotension and haemodynamic instability in anaesthesia. A useful mnemonic to remember which drugs to stop prior to surgery is ILACKOP which includes insulin, lithium, anti-platelets and anti-coagulants, COCP, potassium-sparing diuretics, oral hypoglycaemic drugs and ACE inhibitors.",
"id": "53177",
"label": "a",
"name": "Ramipril",
"picture": null,
"votes": 897
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Levothyroxine does not need to be stopped prior to a surgical procedure.",
"id": "53178",
"label": "b",
"name": "Levothyroxine",
"picture": null,
"votes": 78
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "My favourite mnemonics are the ones that don’t make sense",
"createdAt": 1684165067,
"dislikes": 0,
"id": "24651",
"isLikedByMe": 0,
"likes": 14,
"parentId": null,
"questionId": 10696,
"replies": [
{
"__typename": "QuestionComment",
"comment": "honestly thought i was crazy, reread it like 3 times",
"createdAt": 1686923410,
"dislikes": 0,
"id": "28899",
"isLikedByMe": 0,
"likes": 5,
"parentId": 24651,
"questionId": 10696,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Relapse Otitis",
"id": 18947
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Acute Complement",
"id": 21656
}
},
{
"__typename": "QuestionComment",
"comment": "There’s literally another question in this qbank saying you should stop ramipril the day before not on the day of",
"createdAt": 1687353360,
"dislikes": 0,
"id": "29251",
"isLikedByMe": 0,
"likes": 5,
"parentId": null,
"questionId": 10696,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Bladder Lumbar",
"id": 26004
}
}
],
"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": 1,
"dislikes": 2,
"explanation": null,
"highlights": [],
"id": "10696",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 1,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 68-year-old male attends a pre-assessment clinic for a diagnostic knee arthroscopy. His past medical history includes hypertension, hypothyroidism, hypercholesterolaemia, and heart failure.\n\nWhich of the following medications must be stopped on the day of surgery?",
"sbaAnswer": [
"a"
],
"totalVotes": 1591,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,005 | false | 63 | null | 6,494,981 | null | false | [] | null | 10,697 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Thyrotoxicosis can result in sweating, palpitations, anxiety, and hypertension. However, this patient has normal thyroid function tests, and no clinical features of hyperthyroidism, such as tremor, diarrhoea, or a goitre.",
"id": "53185",
"label": "d",
"name": "Thyroxine",
"picture": null,
"votes": 205
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has likely got a pheochromocytoma which is a catecholamine-secreting tumour in the adrenal medulla. Excess of circulating catecholamines result in hypertension, headaches, flushing, palpitations, and anxiety.",
"id": "53182",
"label": "a",
"name": "Adrenaline and noradrenaline",
"picture": null,
"votes": 1988
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Vasopressin, also known as anti-diuretic hormone, is essential for enabling the reabsorption of free water from the collecting duct in the nephron through aquaporin channels. Excess vasopressin results in excessive free water reabsorption, and a classical euvolaemic hyponatraemia as seen in SIADH. Low sodium results in non-specific symptoms, such as confusion and lethargy, and, if very low, seizures. This patient's bloods are normal, and there are no clinical features suggestive of low sodium.",
"id": "53183",
"label": "b",
"name": "Vasopressin",
"picture": null,
"votes": 118
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Excess growth hormone, usually from a pituitary adenoma, results in acromegaly. Pituitary tumours can cause headaches, and excessive growth hormone may result in hypertension, as seen in this case. However, acromegalous features are absent in this patient, such macroglossia, prognathism, changes in physical appearance, and growing hands/feet.",
"id": "53184",
"label": "c",
"name": "Growth hormone",
"picture": null,
"votes": 124
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Excess cortisol leads to Cushing's syndrome, which is associated with hypertension. However, other features of Cushing's syndrome are notably absent, such as proximal weakness, striae, central adiposity, and thinning/bruising of the skin. Cushing's disease refers to Cushing's syndrome secondary to a pituitary tumour, whilst Cushing's syndrome is excess cortisol of any cause, including secondary to exogenous steroid use.",
"id": "53186",
"label": "e",
"name": "Cortisol",
"picture": null,
"votes": 687
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "i think it should be more clear that these symptoms are episodic - phaeo wouldn't typically have constant headaches, hypertension and sweating",
"createdAt": 1683301742,
"dislikes": 0,
"id": "23476",
"isLikedByMe": 0,
"likes": 8,
"parentId": null,
"questionId": 10697,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Axillary Gas",
"id": 20974
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n \n\nA pheochromocytoma is a catecholamine-secreting tumour originating in the chromaffin cells of the adrenal medulla, while a paraganglioma arises in sympathetic nerve tissue elsewhere in the body. These tumours commonly manifest between the 3rd and 5th decades of life, with an incidence of 0.5 to 2 in 1,000 hypertension patients. They may present with episodic hypertension, anxiety, weight loss, palpitations, among other signs and symptoms. Symptoms can be precipitated by stress, exercise, and certain medications. Diagnostic investigations focus on confirming catecholamine excess with plasma and urinary metanephrines tests. CT and MRI scans are also performed to locate the tumour. Management includes surgical resection, preceded by alpha blockade with phenoxybenzamine to prevent hypertensive crises.\n \n\n# Definition\n \n\nA pheochromocytoma is a catecholamine-secreting tumour that originates in the adrenal medulla. When a similar tumour arises in sympathetic nerve tissue elsewhere in the body, it is termed a paraganglioma.\n \n\n# Epidemiology\n \n\nPheochromocytomas and paragangliomas occur in between 0.5 and 2 in 1,000 patients diagnosed with hypertension. The condition most commonly manifests between the 3rd and 5th decades of life.\n \n\n# Aetiology\n \n\nThe aetiology of pheochromocytoma and paraganglioma is multifactorial and can be sporadic or hereditary. Multiple genes are implicated in familial cases, such as RET, VHL, NF1, and SDH.\n \n\n# Signs and Symptoms\n \n\nThe clinical presentation can vary, with the following symptoms commonly reported:\n \n\n - Episodic hypertension\n - Anxiety\n - Weight loss\n - Fatigue\n - Palpitations\n - Excessive sweating\n - Headaches\n - Flushing\n - Fever\n - Difficulty breathing (dyspnea)\n - Abdominal pain\n \n\nPhysical examination may reveal:\n \n\n - Hypertension\n - Postural hypotension\n - Tremor\n - Hypertensive retinopathy\n \n\nSymptoms can be precipitated by stress, exercise, surgery, straining, and certain medications like beta blockers, anaesthetic agents, and opiates.\n \n\n# Differential Diagnosis\n \n\nThe differential diagnosis for pheochromocytoma includes:\n \n\n - **Anxiety disorders:** Manifest with anxiety, palpitations, sweating, but lack the characteristic episodic hypertension of pheochromocytoma.\n - **Hyperthyroidism:** Features weight loss, tremor, palpitations, but typically includes symptoms like heat intolerance and changes in hair and skin texture.\n - **Essential hypertension:** Chronic high blood pressure without an identifiable secondary cause. It lacks the episodic nature of pheochromocytoma.\n \n\n# Investigations\n \n\nThe evaluation of suspected pheochromocytoma involves confirming catecholamine excess and identifying the tumour's location. This includes:\n \n\n - Plasma metanephrines testing followed by urinary metanephrines.\n - Adrenal imaging should be pursued only after biochemical confirmation. CT of the chest, abdomen, and pelvis is the modality of choice, followed by MRI if needed.\n - Extra-adrenal pheochromocytomas can be identified using specific imaging studies such as iodine-labeled metaiodobenzylguanidine (MIBG) scans or PET scans.\n \n\n# Management\n \n\nThe definitive treatment for pheochromocytoma and paraganglioma is surgical resection of the tumour. Preoperative management includes:\n \n\n - Alpha blockade with phenoxybenzamine is initiated first to prevent intraoperative hypertensive crises.\n - Beta blockade can be added subsequently if necessary, to manage tachycardia or arrhythmias after adequate alpha blockade is achieved.\n \n\n# References\n \n\n [Patient.info - Phaeochromocytoma](https://patient.info/doctor/phaeochromocytoma-pro)",
"files": null,
"highlights": [],
"id": "656",
"pictures": [],
"typeId": 2
},
"chapterId": 656,
"demo": null,
"entitlement": null,
"id": "684",
"name": "Phaeochromocytoma",
"status": null,
"topic": {
"__typename": "Topic",
"id": "5",
"name": "Endocrinology",
"typeId": 2
},
"topicId": 5,
"totalCards": 10,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 684,
"conditions": [],
"difficulty": 1,
"dislikes": 5,
"explanation": null,
"highlights": [],
"id": "10697",
"isLikedByMe": 0,
"learningPoint": "Pheochromocytoma is a catecholamine-secreting tumour causing symptoms like hypertension, headaches, anxiety, and nocturnal sweating due to excess adrenaline and noradreanline.",
"likes": 8,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 52-year-old woman presents to her GP with a headache for a month. She has also been waking in the middle of the night feeling sweaty which is unusual for her, and has been feeling more anxious. She has reported no change to her physical appearance. On examination, her blood pressure is 167/98mmHg, and the remainder of her physical assessment is unremarkable. Blood tests show a normal white cell count, normal urea and electrolytes, and normal thyroid function.\n\nWhich of the following hormones is the most likely cause of this patient's presentation?",
"sbaAnswer": [
"a"
],
"totalVotes": 3122,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,006 | false | 64 | null | 6,494,981 | null | false | [] | null | 10,698 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has been given excessive volumes of normal saline in a short period of time which has led to high levels of chloride and a hyperchloraemic metabolic acidosis. In this stem, the patient has been managed in A&E rather than a dedicated burns unit, which may have resulted in this error. Parkland's formula is used to calculate resuscitation fluid required over the first 24 hours according to the estimated % of burn and the patient's weight. This patient should have received 6.5L of fluid over the first 8 hours and 6.5L over the next 16 hours. Aggressive fluid resuscitation can cause electrolyte imbalances. He would also be at risk of hypernatraemia in this case, and subsequent cerebral oedema. Some patients experience no symptoms with high levels of chloride whilst others may have muscle weakness, excessive thirst, and confusion.",
"id": "53187",
"label": "a",
"name": "Hyperchloraemia",
"picture": null,
"votes": 591
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has had high volumes of normal saline and is therefore likely to be hypernatremic as opposed to hyponatraemic, and abnormalities in the sodium alone are unlikely to explain any acid-base disturbance.",
"id": "53191",
"label": "e",
"name": "Hyponatraemia",
"picture": null,
"votes": 487
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hypercalcaemia typically presents with 'stones, bones, abdominal groans, thrones and psychiatric overtones'. This refers to kidney stones bone pain, constipation, excessive thirst and mood changes. Hypercalcaemia can be caused by multiple myeloma, paraneoplastic conditions, medication, sarcoidosis and over-active parathyroid glands. Patients with burns are at risk of tissue breakdown and rhabdomyolysis, which may actually result in initial hypocalcaemia. Hypercalcaemia is not associated with a metabolic acidosis but has been associated with a metabolic alkalosis.",
"id": "53190",
"label": "d",
"name": "Hypercalcaemia",
"picture": null,
"votes": 49
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is unlikely to be hypokalaemic, since in fact burns lead to tissue breakdown and potential rhabdomyolysis, which may cause hyperkalaemia. Hyperkalaemia can also cause a metabolic acidosis due to displacement of intracellular hydrogen ions and competition for excretion in the distal tubule. Hypokalaemia would actually be associated with a metabolic alkalosis.",
"id": "53189",
"label": "c",
"name": "Hypokalaemia",
"picture": null,
"votes": 296
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because this patient has received a large volume of normal saline, which would lead to hyperchloraemia. Hypochloraemia is usually associated with diarrhoea and vomiting. This is not associated with a metabolic acidosis.",
"id": "53188",
"label": "b",
"name": "Hypochloraemia",
"picture": null,
"votes": 211
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nBurns patients necessitate prompt evaluation and intervention, including the measurement of burn size and depth. The primary treatment priorities include securing the airway, managing pain, and ensuring adequate fluid resuscitation. Utilization of the Parkland formula can guide fluid resuscitation, while application of the 'Rule of 9s' assists in estimating the body surface area (BSA) affected by the burn. Referral to a burns unit is critical in cases of full thickness burns covering >5% BSA, partial thickness burns covering >10% BSA, or if the patient is of extreme age (either very young or elderly).\n\n# Definition\n\nA burn is a type of injury to skin, or other tissues, caused by heat, cold, electricity, chemicals, friction, or radiation. Burns that affect only the superficial skin layers are known as superficial or first-degree burns. When the damage extends to deeper layers, they are classified as partial-thickness (second-degree) or full-thickness (third-degree) burns.\n\n# Epidemiology\n\nBurns can occur to anyone at any age but are particularly common in the very young or elderly. They can result from a variety of sources including domestic accidents, industrial mishaps, and natural disasters.\n\n# Aetiology\n\nBurns can be caused by multiple factors including:\n\n- Thermal (flames, scalds, contact with hot objects)\n- Chemical (acids, alkalis, organic compounds)\n- Electrical (low and high voltage)\n- Radiation (sunlight, tanning booths, radiotherapy)\n- Friction (road rash, rope burns)\n\n# Signs and Symptoms\n\nThe signs and symptoms of burns may include:\n\n- Pain (can be absent in severe burns due to nerve damage)\n- Redness and swelling\n- Blisters\n- Peeling skin\n- White or charred skin (in severe burns)\n\n\n# Differential Diagnosis\n\nIn addition to burns, several other conditions can present with similar features and should therefore be considered in the differential diagnosis. These include:\n\n- **Frostbite**: Characterized by skin that appears waxy and cold, changes in skin color from white or yellow to purple, numbness, and possible blister formation.\n \n- **Dermatitis**: Includes signs such as a skin rash, itching, redness, swelling, and possible blistering. Types of dermatitis include atopic dermatitis (eczema), contact dermatitis, and seborrheic dermatitis.\n \n- **Cellulitis**: Presents with skin redness, warmth, swelling, and tenderness. Fever and chills may also be present.\n \n- **Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis**: These severe reactions to medication or infection can cause skin pain, facial swelling, hives, and shedding of the skin.\n \n- **Necrotizing fasciitis**: This rapidly progressing bacterial infection of the fascia and subcutaneous tissue can lead to symptoms similar to severe burns, such as severe pain, fever, and erythema that progresses to necrosis.\n \n- **Deep Vein Thrombosis**: Pain, swelling, redness, and warmth over the affected area may mimic some of the signs of a burn, particularly in the extremities.\n \n- **Vasculitis**: Inflammation of the blood vessels can result in lesions that could be confused with burns. Symptoms can include a rash, fever, pain, and general discomfort.\n \n- **Pyoderma Gangrenosum**: This rare, ulcerative skin condition can be confused with burns due to its necrotic appearance. It is often associated with systemic diseases like inflammatory bowel disease or rheumatoid arthritis.\n \n\nEach of these conditions has a different course of management and treatment, so accurate diagnosis is critical.\n\n# Investigations\n\nInvestigations for burns can include:\n\n- Examination of burn depth and extent\n- Basic blood tests (Complete Blood Count, Urea, Electrolytes)\n- Arterial blood gas (in cases of smoke inhalation)\n- Chest X-ray (if smoke inhalation suspected)\n- Urinalysis (to check for myoglobin if rhabdomyolysis suspected)\n\n# Management\n\nManagement strategies for burns include:\n\n- Ensuring airway patency, breathing, and circulation (ABCs)\n- Pain management, usually with opioids\n- Intravenous fluids will be required for children with burns greater than 10% of total body surface area, and adults with burns greater than 15% of total body surface area\n- Fluid resuscitation using the **Parkland formula.** The Parkland formula calculates the total fluid volume needed for the first 24 hours after a burn injury. It is calculated as follows:\n\t- Total body surface area of the burn % x weight (Kg) x 4\n\t- Half of the fluid is administered in the first 8 hours and the remaining half is administered over the next 16 hours.\n- Wound care (debridement, topical antibiotics, dressings)\n- Tetanus prophylaxis\n- Referral to a burns unit in severe cases or as defined by local protocol (often burns involving the face/hand/perineum and burns >10% in adults and >5% in children)\n\n# Rule of 9's for Estimating Burns\n\nThe 'Rule of 9s' is a useful method to approximate the BSA affected by a burn:\n\n- Head = 9%\n- Torso (front) = 18%\n- Torso (back) = 18%\n- Whole arm = 9%\n- Hand = 1%\n- Whole leg = 18%\n\n# Complications\n\n- **Curling Ulcer:** Patients with severe burns are at risk of developing Curling ulcers, which are stress-induced gastric ulcers. These can result from the physiological stress response to burn injuries.\n\n- **Airway Compromise:** In cases of burn injuries involving smoke inhalation, there is a risk of airway compromise due to the inhalation of hot gases and toxic substances. This can lead to respiratory distress and necessitates immediate attention.\n\n# References\n\n[Click here to see a diagram explaining the Rule of 9s](https://en.wikipedia.org/wiki/Wallace_rule_of_nines#/media/File:513_Degree_of_burns.jpg)",
"files": null,
"highlights": [],
"id": "139",
"pictures": [],
"typeId": 2
},
"chapterId": 139,
"demo": null,
"entitlement": null,
"id": "815",
"name": "Burns",
"status": null,
"topic": {
"__typename": "Topic",
"id": "7",
"name": "General Surgery",
"typeId": 2
},
"topicId": 7,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 815,
"conditions": [],
"difficulty": 3,
"dislikes": 2,
"explanation": null,
"highlights": [],
"id": "10698",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 1,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 35-year-old male presents to A&E with extensive burns from a house fire. His burns are widely disseminated over his back, left leg, and left arm. He is rapidly resuscitated with 13L of 0.9% normal saline over the next 8 hours as he awaits transfer within the department to the local burns unit. He weighs 72kg. On the following day, he appears confused and complains of a headache and fatigue. An ABG shows metabolic acidosis.\n\nWhich of the following electrolyte imbalances is the most likely cause of his acid-base disturbance?",
"sbaAnswer": [
"a"
],
"totalVotes": 1634,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,007 | false | 65 | null | 6,494,981 | null | false | [] | null | 10,699 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "IgM antibodies are made initially by the immune system after exposure to an antigen. The MMR vaccine is a live attenuated vaccine that will trigger the body's adaptive immune system to produce antibodies, with memory cells providing long lasting immunity.",
"id": "53192",
"label": "a",
"name": "IgM",
"picture": null,
"votes": 2822
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "IgG antibodies are produced in the latter stages of the adaptive immune response, and if the body is re-exposed to the antigen in the future.",
"id": "53193",
"label": "b",
"name": "IgG",
"picture": null,
"votes": 769
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "IgD antibodies do not form a significant part of the post-vaccine response. Their function remains unclear, but they are present on immature B cells and make up part of the innate immune system.",
"id": "53195",
"label": "d",
"name": "IgD",
"picture": null,
"votes": 25
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "IgE antibodies are associated with atopy, parasitic infections, and allergic conditions. They do not form significant part of the post-vaccine response.",
"id": "53196",
"label": "e",
"name": "IgE",
"picture": null,
"votes": 182
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "IgA antibodies are present in saliva, tears, and on mucosal surfaces to provide an immune 'shield', neutralising any pathogens before they have the opportunity to enter the body. They do not form a significant part of the post-vaccine response.",
"id": "53194",
"label": "c",
"name": "IgA",
"picture": null,
"votes": 236
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "as part of the initial immune response",
"createdAt": 1737220508,
"dislikes": 0,
"id": "60906",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10699,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "BradySclerosis",
"id": 35569
}
},
{
"__typename": "QuestionComment",
"comment": "i always mix up IgG and IgM does anyone have a clever way to remeber the two lmao",
"createdAt": 1738962334,
"dislikes": 0,
"id": "62552",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10699,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Ali",
"id": 23184
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary \n\nThe UK routine vaccination schedule includes vaccines for diphtheria, tetanus, whooping cough, polio, Haemophilus influenzae type b, hepatitis B, rotavirus, meningitis B and C, measles, mumps, rubella, human papillomavirus, and influenza. Vaccinations start from birth and continue into adolescence, ensuring comprehensive protection against various infectious diseases.\n\n\n# Schedules and further information:\n \n\n - The UK schedule regularly changes. Always use the authoritative summary provided by the UK Gov website for the latest schedule\n - For any information, refer to the 'Green Book' - also found on the UK Gov website. It contains information on indications for different vaccines, including catch-up schedules for people who have missed vaccines or were not immunised\n - It is advised to take vaccines at the correct time to provide early protection, but the schedule can be resumed at any time\n - There are also additional vaccinations offered to high-risk groups. \n - The BCG vaccine is offered to infants from areas in the UK with TB incidence rates > 40/100,000 or with parents or grandparents from high-incidence countries. \n - Hepatitis B vaccination is offered at birth, 4 weeks and 12 months to babies born from hepatitis B-infected mothers \n\n| Age | Vaccine(s) |\n|-------------------------|----------------------------------------------------------------------------|\n| 8 weeks | 6-in-1 vaccine (diphtheria, tetanus, whooping cough, polio, Hib, hepatitis B) |\n| | Rotavirus vaccine |\n| | MenB vaccine \n| 12 weeks | 6-in-1 vaccine (2nd dose) |\n| | Rotavirus vaccine (2nd dose) ||\n| | Pneumococcal (PCV) vaccine |\n| 16 weeks | 6-in-1 vaccine (3rd dose) |\n| | MenB vaccine (2nd dose) |\n| 1 year | Hib/MenC vaccine |\n| | MMR (measles, mumps, and rubella) vaccine |\n| | Pneumococcal (PCV) vaccine (2nd dose) |\n| | MenB vaccine (3rd dose) |\n| 2-10 years (annually) | Children's flu vaccine (annual) |\n| 3 years and 4 months | MMR (measles, mumps, and rubella) vaccine (2nd dose) |\n| | 4-in-1 pre-school booster (diphtheria, tetanus, whooping cough, polio) |\n| 12-13 years (girls) | HPV vaccine (2 doses) |\n| 14 years | 3-in-1 teenage booster (tetanus, diphtheria, polio) |\n| | MenACWY vaccine |\n| 65 years | Pneumococcal (PPV) vaccine |\n| 65 years and over | Flu vaccine (annual) |\n| 70 years | Shingles vaccine | \n \n\n# Common side effects of vaccinations\n \n\nVaccinations are generally very safe and effective. Any vaccination can cause side effects from a local and systemic immune response:\n \n\n - Locally, there may be tenderness and aches around the injection site\n \n\n - Systemically, the patient may have a fever and feel unwell for a few hours\n \n\n - Fever is particularly common with the meningococcal vaccine; parents should be asked to give prophylactic paracetamol to their child and warned that a fever is very likely. This will help to reduce unnecessary worry, A&E attendance and unnecessary investigations.\n \n\n# Rare side effects of vaccinations\n\n - Anaphylaxis\n - Rotavirus vaccination can rarely cause intussusception.\n - The MMR vaccine can cause seizures (1/1000 doses) and ITP (idiopathic thrombocytopenic purpura) (1/24,000 doses).\n \n\n# Contraindications to vaccinations\n \n\n - **Egg allergy**: \n - Children with egg allergy should not receive yellow fever vaccination\n - The standard preparation of the influenza vaccine is only contraindicated in children who have been admitted to PICU as a result of their egg allergy. All other cases of children with egg allergy can safely have the standard vaccine in primary care settings.\n - The MMR vaccine is safe for children with an egg allergy. It is a common misconception that it contains components from eggs.\n - **Previously proven anaphylaxis to vaccine components**: Children with serology confirming allergy to vaccine components should not receive further doses of that particular vaccine.\n - **Immunosuppression**: Children with immunosuppression (e.g. from confirmed severe primary immunodeficiencies, chemotherapy or other immunosuppressive medications, or radiotherapy) should not receive live attenuated vaccines, such as the MMR vaccine, inhaled influenza vaccine or the varicella vaccine.\n - **Intussusception**: children with a history of intussusception cannot have the rotavirus vaccination\n \n\n# NICE Guidelines\n \n [NICE Guidelines for Immunizations - childhood](https://cks.nice.org.uk/topics/immunizations-childhood/) \n\n# References\n \n\n[GOV.UK Complete Vaccination Schedule](https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/147824/Green-Book-Chapter-6-v2_0.pdf)\n\n[Patient Info Immunisation](https://patient.info/childrens-health/immunisation)",
"files": null,
"highlights": [],
"id": "520",
"pictures": [],
"typeId": 2
},
"chapterId": 520,
"demo": null,
"entitlement": null,
"id": "529",
"name": "Vaccinations",
"status": null,
"topic": {
"__typename": "Topic",
"id": "29",
"name": "Paediatrics",
"typeId": 2
},
"topicId": 29,
"totalCards": 3,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 529,
"conditions": [],
"difficulty": 1,
"dislikes": 4,
"explanation": null,
"highlights": [],
"id": "10699",
"isLikedByMe": 0,
"learningPoint": "IgM antibodies are the first immunoglobulins produced by the immune system in response to an antigen.",
"likes": 16,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "572",
"name": "Vaccination",
"topic": {
"__typename": "UkmlaTopic",
"id": "5",
"name": "Child health"
},
"topicId": 5
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 12-month-old boy presents to the GP with his mother for his Measles, mumps, and rubella vaccination.\n\nWhich of the following class of immunoglobulins are made by the immune system initially?",
"sbaAnswer": [
"a"
],
"totalVotes": 4034,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,008 | false | 66 | null | 6,494,981 | null | false | [] | null | 10,700 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because this is one of the investigations for hereditary spherocytosis, which presents in childhood with jaundice, anaemia, and splenomegaly. There is typically a family history as the condition is inherited in an autosomal dominant pattern. It is a type of haemolytic anaemia, but this question stem ludes to warm autoimmune haemolytic anaemia caused by chronic lymphocytic leukaemia.",
"id": "53199",
"label": "c",
"name": "Osmotic fragility test",
"picture": null,
"votes": 100
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Haptoglobin is a useful test when suspecting intravascular haemolysis. This patient has a past history of haemolytic anaemia but his haemaglobin at present is acceptable. There is no indication that he requires investigating for haemolysis at this stage.",
"id": "53200",
"label": "d",
"name": "Haptoglobin",
"picture": null,
"votes": 334
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because bone marrow biopsies are rarely carried out as part of the initial work-up for CLL, since the diagnosis can be made on peripheral blood cytometry alone. It may be required further down the line, such as prior to initiating treatment, or to assess response to treatment.",
"id": "53201",
"label": "e",
"name": "Bone marrow biopsy",
"picture": null,
"votes": 2060
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because this is used to diagnose G6PD deficiency. This is an X-linked recessive disorder which usually presents with jaundice in neonates or during earlier years of life. It can be triggered by recent infections, fava beans, and medications such as primaquine, nitrafurantoin, and quinolones. G6PD deficiency results in intravascular haemolysis, raised LDH, bilirubinuria, reticulocytosis, and bite cells/heinz bodies.",
"id": "53198",
"label": "b",
"name": "Glucose-6-Phosphate-Dehydrogenase enzyme assay",
"picture": null,
"votes": 291
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Flow cytometry of peripheral blood is the first line investigation for chronic lymphocytic leukaemia, which this patient most likely has as indicated by the raised lymphocyte count and previous history of warm autoimmune haemolytic anaemia, which this patient has. CLL is often diagnosed incidentally since it remains asymptomatic for a prolonged period of time. Blood films show characteristic smudge/smear cells.",
"id": "53197",
"label": "a",
"name": "Flow cytometry of peripheral blood",
"picture": null,
"votes": 796
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "why's the WCC really high if its lymphocytic leukaemia?",
"createdAt": 1684244893,
"dislikes": 2,
"id": "24790",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10700,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "WBC Zebras",
"id": 30278
}
},
{
"__typename": "QuestionComment",
"comment": "Wcc includes lymphocytes and granulocytes e.g. neutrophils ",
"createdAt": 1685007749,
"dislikes": 0,
"id": "26127",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10700,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Kinase Sclerosis",
"id": 2697
}
},
{
"__typename": "QuestionComment",
"comment": "Reference ranges pleaaaassseee",
"createdAt": 1686511367,
"dislikes": 0,
"id": "28528",
"isLikedByMe": 0,
"likes": 3,
"parentId": null,
"questionId": 10700,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Cystic Juice",
"id": 10376
}
},
{
"__typename": "QuestionComment",
"comment": "it doest ask for first line, I give up",
"createdAt": 1737323726,
"dislikes": 0,
"id": "61025",
"isLikedByMe": 0,
"likes": 5,
"parentId": null,
"questionId": 10700,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Migraine Ketone",
"id": 27033
}
},
{
"__typename": "QuestionComment",
"comment": "Biopsy will be the best test for diagnosis, flow cytometry will be the next test",
"createdAt": 1737804148,
"dislikes": 0,
"id": "61482",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10700,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Abscess Flutter",
"id": 10469
}
},
{
"__typename": "QuestionComment",
"comment": "genuinely am NEVER going to be able to understand haematology for finals - send help and resources",
"createdAt": 1738878693,
"dislikes": 0,
"id": "62508",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10700,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Anti-D",
"id": 19456
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nHaemolytic anaemia is a condition characterised by the premature destruction of red blood cells (RBCs), resulting in a reduced RBC lifespan. It can be categorised into hereditary and acquired forms, and further divided into intravascular or extravascular and autoimmune or non-autoimmune subtypes. The epidemiology varies depending on the specific type. Diagnosing haemolytic anaemia requires a comprehensive set of investigations, including a complete blood count (FBC), split bilirubin, haptoglobin, lactate dehydrogenase (LDH), reticulocytosis, and blood film analysis. Additional tests may be needed, such as direct antiglobulin test (DAT), electrophoresis, and further blood film examination. Management involves addressing the underlying cause and may include blood transfusions, immunosuppressive therapy, or splenectomy. Complications can include severe anaemia, gallstones, and organ damage.\n\n# Definition\n\nHaemolytic anaemia is a condition characterised by the premature destruction of red blood cells (RBCs), leading to a decrease in their lifespan. This condition can be classified into hereditary and acquired forms, with further subdivisions based on the site of haemolysis, either intravascular or extravascular, and the underlying cause, autoimmune or non-autoimmune.\n\n\n# Epidemiology\n\nThe prevalence and distribution of haemolytic anaemia vary significantly based on the specific subtype and its underlying causes:\n\n- Sickle cell disease predominantly affects individuals of African descent, and is most prevalent in sub-Saharan Africa.\n- Thalassemias: The distribution of thalassemias is linked to regions with a high prevalence of consanguineous marriages, notably in Mediterranean countries.\n- The prevalence of autoimmune haemolytic anaemia varies, but it is often associated with autoimmune diseases like systemic lupus erythematosus. It can affect individuals of any age and ethnicity. \n- The incidence of intravascular haemolysis may be higher in conditions involving mechanical trauma, such as prosthetic heart valves or microangiopathic disorders. \n- Extravascular haemolysis is often observed in hereditary conditions like hereditary spherocytosis and can affect individuals worldwide.\n\n# Classification\n\n### Hereditary Haemolytic Anaemia\nIncludes conditions like sickle cell disease, thalassemias, and hereditary spherocytosis, often caused by genetic mutations affecting RBC structure or function.\n\n### Acquired Haemolytic Anaemia\n\nCan result from autoimmune disorders, infections (e.g., malaria), medication reactions, or mechanical trauma.\n### Intravascular Haemolysis\n\nOccurs within the bloodstream, leading to the release of free haemoglobin into the circulation and the excess of haemoglobin is dealt with in many ways: \n\n- Combination with haptoglobin\n- Combination with albumin (**methaemalbuminaemia**)\n- Loss in the urine (**haemoglobinuria**)\n- Storage in tubular epithelial cells as **haemosiderin** \n- Shedding into the urine (haemosiderinuria)\n\t\nCauses of intravascular haemolytic anaemia include:\n\n- Intrinsic cellular injury (eg. G6PD deficiency)\n- Intravascular complement-mediated lysis (some autoimmune haemolytic anaemias)\n- Paroxysmal nocturnal haemoglobinuria and acute transfusion reactions\n- Mechanical injury – microangiopathic haemolytic anaemia and cardiac valves\n- Autoimmune haemolytic anaemia (AIHA)\n\n### Extravascular Haemolysis\n\n- Takes place outside the bloodstream, primarily in the spleen and liver, where RBCs are phagocytosed. It is not associated with dramatic release of free haemoglobin into the circulation. \n- Splenomegaly and hepatomegaly are typical.\n\nCauses include:\n\n- Abnormal red cells (e.g. sickle cell anaemia and hereditary spherocytosis)\n- Normal cells having been marked by antibodies for splenic phagocytosis\n\n### Autoimmune Haemolytic Anaemia\n\nRBC destruction is triggered by autoantibodies that target the body's own RBCs.\n\nTwo major causes include:\n\n1. Warm AIHA:\n\t- An **IgG-mediated extravascular** haemolytic disease, in which the spleen tags cells for splenic phagocytosis. \n\t- Causes: **SLE,** idiopathic, lymphoproliferative neoplasms (eg. chronic lymphocytic leukaemia and lymphoma), drugs (methyldopa)\n\t- Managed with prednisolone or immunosupression (e.g. AZT) and transfusions if severe \n2. Cold AIHA:\t\n\t- **IgM-mediated** haemolytic disease, in which IgM fixes **complement** causing **direct intravascular haemolysis**. It includes cold agglutinin disease\n\t- The IgM agglutinates also cause the hands and feet to become blue in cold conditions (**acrocyanosis**)\n\t- Causes: post-infectious (usually after **Mycoplasma** or EBV), idiopathic, lymphoproliferative disorders\n\t- Treatment is mostly supportive, warmed blood is transfused if required and resistant cases may trial rituximab\n\n### Non-Autoimmune Haemolytic Anaemia\n\nCaused by factors other than autoantibodies, such as infections or mechanical stress:\n\n- Microangiopathic haemolytic anaemia\n- Paroxysmal nocturnal haemoglobinuria (PNH)\n- Physical lysis of red cells (e.g. malaria, patients with mechanical heart valves)\n- Haemolytic uraemic syndrome (HUS) – often caused by *E. coli* 0157:H7\n- Infectious causes of disseminated intravascular coagulation (DIC) such as fulminant meningococcaemia\n\n# Signs and Symptoms\n\n**Haemolytic Anaemia - General:**\n\nHaemolytic anaemia, regardless of its underlying cause, often presents with a constellation of symptoms related to the accelerated breakdown of red blood cells and the body's response to anaemia. Common signs and symptoms include:\n\n- Fatigue \n- Pallor\n- Jaundice - Haemolysis releases bilirubin into the bloodstream, causing yellowing of the skin and sclera \n- Splenomegaly - The spleen becomes enlarged as it works to remove and destroy the damaged red blood cells.\n- Dark Urine\n- Gallstones - Excess bilirubin can accumulate in the gallbladder, increasing the risk of gallstone formation.\n- Leg Ulcers - In severe cases, reduced blood flow and oxygen supply can lead to painful leg ulcers.\n- Shortness of Breath\n- Heart Palpitations\n\n**Specific Causes and Their Signs and Symptoms:**\n\n- **Sickle Cell Disease:** Vaso-occlusive pain, acute chest syndrome, and strokes.\n- **Thalassemias:** Profound anaemia, skeletal deformities, and organ enlargement.\n- **Hereditary Spherocytosis:** Splenomegaly and fatigue due to haemolysis.\n- **Autoimmune Haemolytic Anaemia:** Variable symptoms linked to haemolysis extent and underlying autoimmune conditions.\n- **Infections (e.g., Malaria):** Fever, fatigue, and organ dysfunction.\n- **Medication-Induced:** Variable symptoms, jaundice, and specific drug-related effects.\n\n# Investigations\n\n1. First Identify Haemolytic Anaemia:\n\n\t* Full Blood Count (FBC): Reveals low haemoglobin levels, elevated reticulocytes, and alterations in RBC indices.\n\t* Reticulocytosis: Increased levels of reticulocytes indicate active RBC production.\n\t* Blood Film Analysis: reveals characteristic changes in RBC morphology depending on underlying cause.\n\t* LFTs may reveal raised bilirubin\n\t* Raised LDH indicative of high cell turnover\n\t* Raised urinary urobillinogen\n\n2. Identify the Cause:\n\n\t* Direct Antiglobulin Test (DAT): Detects the presence of autoantibodies on the RBC surface in autoimmune haemolytic anaemia.\n\t* Electrophoresis: Helps diagnose haemoglobinopathies like thalassemias and sickle cell disease.\n\t* Blood Film Examination: Further evaluates RBC morphology and inclusions.\n\n# Management\n\nTreatment aims to address the underlying cause and alleviate symptoms. General management principles include:\n\n* **Supportive Care:** Blood transfusions to manage severe anaemia however this won't be curative as there will be ongoing haemolysis if the underlying cause is not managed.\n* **Immunosuppressive Therapy:** In autoimmune haemolytic anaemia, medications like corticosteroids can reduce antibody production.\n* **Splenectomy:** May be considered in certain cases, particularly hereditary spherocytosis.\n* Specific management strategies depend on the type of haemolytic anaemia.\n\n\n# References\n\n[Patient.info - Haemolytic Anaemia](https://patient.info/doctor/haemolytic-anaemia)",
"files": null,
"highlights": [],
"id": "374",
"pictures": [],
"typeId": 2
},
"chapterId": 374,
"demo": null,
"entitlement": null,
"id": "378",
"name": "Haemolytic anaemia",
"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": "378",
"name": "Haemolytic anaemia"
}
],
"demo": false,
"description": null,
"duration": 205.44,
"endTime": null,
"files": null,
"id": "164",
"live": false,
"museId": "dY46zdd",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/nephrology.png",
"title": "Haemolytic Uraemic Syndrome",
"userViewed": false,
"views": 177,
"viewsToday": 14
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "378",
"name": "Haemolytic anaemia"
}
],
"demo": false,
"description": null,
"duration": 299.14,
"endTime": null,
"files": null,
"id": "160",
"live": false,
"museId": "WEWkzPn",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/hematology.png",
"title": "Haemolytic anaemia 6",
"userViewed": false,
"views": 12,
"viewsToday": 3
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "378",
"name": "Haemolytic anaemia"
}
],
"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": "378",
"name": "Haemolytic anaemia"
}
],
"demo": false,
"description": null,
"duration": 412.8,
"endTime": null,
"files": null,
"id": "162",
"live": false,
"museId": "NgaGL5e",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/hematology.png",
"title": "Haemolytic anaemia 8",
"userViewed": false,
"views": 11,
"viewsToday": 1
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "378",
"name": "Haemolytic anaemia"
}
],
"demo": false,
"description": null,
"duration": 315.43,
"endTime": null,
"files": null,
"id": "158",
"live": false,
"museId": "3TFV7QF",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/hematology.png",
"title": "Haemolytic anaemia 4",
"userViewed": false,
"views": 56,
"viewsToday": 4
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "378",
"name": "Haemolytic anaemia"
}
],
"demo": false,
"description": null,
"duration": 411.63,
"endTime": null,
"files": null,
"id": "155",
"live": false,
"museId": "KAidvtZ",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/hematology.png",
"title": "Haemolytic anaemia 1",
"userViewed": false,
"views": 193,
"viewsToday": 9
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "378",
"name": "Haemolytic anaemia"
}
],
"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": "378",
"name": "Haemolytic anaemia"
}
],
"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
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "378",
"name": "Haemolytic anaemia"
}
],
"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": "378",
"name": "Haemolytic anaemia"
}
],
"demo": false,
"description": null,
"duration": 254.76,
"endTime": null,
"files": null,
"id": "83",
"live": false,
"museId": "TvFjF88",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/hematology.png",
"title": "Complications of blood transfusions 2",
"userViewed": false,
"views": 91,
"viewsToday": 7
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "378",
"name": "Haemolytic anaemia"
}
],
"demo": false,
"description": null,
"duration": 146.56,
"endTime": null,
"files": null,
"id": "161",
"live": false,
"museId": "g9j7rTs",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/hematology.png",
"title": "Haemolytic anaemia 7",
"userViewed": false,
"views": 8,
"viewsToday": 1
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "378",
"name": "Haemolytic anaemia"
}
],
"demo": false,
"description": null,
"duration": 255.17,
"endTime": null,
"files": null,
"id": "159",
"live": false,
"museId": "QCgHpKR",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/hematology.png",
"title": "Haemolytic anaemia 5",
"userViewed": false,
"views": 14,
"viewsToday": 2
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "378",
"name": "Haemolytic anaemia"
}
],
"demo": false,
"description": null,
"duration": 305.77,
"endTime": null,
"files": null,
"id": "156",
"live": false,
"museId": "yK6iqBi",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/hematology.png",
"title": "Haemolytic anaemia 2",
"userViewed": false,
"views": 85,
"viewsToday": 7
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "378",
"name": "Haemolytic anaemia"
}
],
"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": "378",
"name": "Haemolytic anaemia"
}
],
"demo": false,
"description": null,
"duration": 391.89,
"endTime": null,
"files": null,
"id": "157",
"live": false,
"museId": "C5GekbJ",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/hematology.png",
"title": "Haemolytic anaemia 3",
"userViewed": false,
"views": 80,
"viewsToday": 11
}
]
},
"conceptId": 378,
"conditions": [
{
"__typename": "Condition",
"id": "30",
"name": "Anaemia",
"topic": {
"__typename": "UkmlaTopic",
"id": "6",
"name": "Clinical haematology"
},
"topicId": 6
}
],
"difficulty": 3,
"dislikes": 26,
"explanation": null,
"highlights": [],
"id": "10700",
"isLikedByMe": 0,
"learningPoint": "Chronic lymphocytic leukemia (CLL) is a type of cancer characterized by the accumulation of abnormal B cells, and flow cytometry of peripheral blood is a key diagnostic tool that identifies these cells based on their specific surface markers, confirming the presence of CLL.",
"likes": 5,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "264",
"name": "Fatigue",
"topic": {
"__typename": "UkmlaTopic",
"id": "6",
"name": "Clinical haematology"
},
"topicId": 6
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 71-year-old male presents to the GP for a follow-up appointment after conducting blood tests for fatigue. He says this has been going on for the past 8 months. He has a past medical history of warm autoimmune haemolytic anaemia. His blood tests reveal the following: \n\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|95 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|90x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|200x10<sup>9</sup>/L|150 - 400|\n|Neutrophils|6.5x10<sup>9</sup>/L|2.0 - 7.5|\n|Lymphocytes|70x10<sup>9</sup>/L|1.5 - 4.0|\n\nHis thyroid function, vitamin B12, and folate levels are normal.\n\n\nWhich of the following investigations is most likely to confirm the underlying diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 3581,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,009 | false | 67 | null | 6,494,981 | null | false | [] | null | 10,701 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Doxycycline is used instead of amoxicillin for patients with a penicillin allergy, which this patient does not have, in the management of community acquired pneumonia. An alternative medication is oral clarithromycin which is also taken for 5 days.",
"id": "53206",
"label": "e",
"name": "Oral doxycycline",
"picture": null,
"votes": 131
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because this woman's CRB65 score of 1 does not currently warrant hospital admission. If her CRB65 score were 2 or above, hospital admission would be considered as intravenous antibiotics would be needed.",
"id": "53205",
"label": "d",
"name": "Admit to hospital",
"picture": null,
"votes": 233
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct because this woman has a CRB65 score of 1. She scores 1 point for her age as she is above 65 years old. Note that the CRB65 scoring system is used in the GP setting for pneumonia because the urea is not immediately available. A 5-day course of oral amoxicillin 500mg three times daily (since she has no known allergies) is suitable for this patient as she has a CRB65 score of 1.",
"id": "53202",
"label": "a",
"name": "Oral amoxicillin",
"picture": null,
"votes": 2533
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because steroids are not used in the routine management of community-acquired pneumonia, unless they are complicating an exacerbation of an obstructive airways disease. This patient has no wheeze or past medical history of obstructive airway pathology, and as such steroids will not be required in her management.",
"id": "53204",
"label": "c",
"name": "Oral prednisolone",
"picture": null,
"votes": 27
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because this woman has a CRB65 score of 1 and there is clinical evidence of a community-acquired pneumonia on examination. NICE guidelines clearly state that an antibiotic must be offered for people with community-acquired pneumonia.",
"id": "53203",
"label": "b",
"name": "No treatment",
"picture": null,
"votes": 144
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Does AMTS score of 9/10 not indicate confusion?",
"createdAt": 1685009610,
"dislikes": 0,
"id": "26135",
"isLikedByMe": 0,
"likes": 2,
"parentId": null,
"questionId": 10701,
"replies": [
{
"__typename": "QuestionComment",
"comment": "confusion = abbreviated mental test score 8 or below\n",
"createdAt": 1685979337,
"dislikes": 0,
"id": "27938",
"isLikedByMe": 0,
"likes": 0,
"parentId": 26135,
"questionId": 10701,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "CEM",
"id": 24430
}
},
{
"__typename": "QuestionComment",
"comment": "It's normally 8 or less",
"createdAt": 1685989981,
"dislikes": 0,
"id": "27959",
"isLikedByMe": 0,
"likes": 0,
"parentId": 26135,
"questionId": 10701,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Cystic Juice",
"id": 10376
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Metabolism Myopathy",
"id": 2011
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\n\nPneumocystis Pneumonia (PCP) is a fungal infection caused by _Pneumocystis Jirovecii_ that affects immunocompromised patients. Key symptoms include fever, a dry cough, and exertional breathlessness. Desaturation on exertion is characteristic of PCP pneumonia. Chest X-ray may be normal or show bilateral infiltrates, and a definitive diagnosis is reached with either sputum samples or bronchoscopy with bronchoalveolar lavage. Management involves antibiotics, usually co-trimoxazole as the first line treatment, with steroids added for more severe cases.\n\n\n# Definition\n\n\nPneumocystis Pneumonia (PCP) is an infection caused by the fungus _Pneumocystis Jirovecii_. It usually affects patients who are immunocompromised, for example patients with late-stage HIV or those on immunosuppressant medications after an organ transplant.\n\n\n# Epidemiology\n\n\nIn the UK, rates of PCP are falling in patients with HIV due to improvements in antiretroviral therapies. However, there has been an increase in PCP in patients immunosuppressed for other reasons (such as transplant or haematological malignancies). Currently around half of patients with PCP have HIV and half do not.\n\n\nPatients at risk of PCP should be treated with prophylaxis (usually oral co-trimoxazole) - this includes all patients with HIV with a CD4 count of below 200. \n\n\n# Aetiology\n\n\nPCP is caused by _Pneumocystis Jirovecii_, a fungus that causes pulmonary infections. Patients at risk of PCP are those who are immunocompromised (it is classed as an opportunistic infection, and an AIDS-defining illness in those with HIV). \n\n\nRisk factors include:\n\n\n- HIV with a CD4 count below 200\n- Steroids or other immunosuppressive medications\n- Previous organ transplant\n- Congenital immunodeficiencies (e.g. hypogammaglobulinaemia)\n- Severe malnutrition\n- Comorbid lung disease\n- Haematological malignancies\n\n\n# Signs and Symptoms\n\n\n- Fever\n- Dry cough\n- Exertional breathlessness\n- Chest pain\n\n\nOn examination, the chest may be clear, or end-inspiratory crackles and wheeze may be present.\n\n\n# Differential Diagnosis\n\n\n- Bacterial or viral pneumonia: similar symptoms, more likely to have a productive cough.\n- Tuberculosis: chronic cough, haemoptysis, weight loss, night sweats and fever. \n- Pulmonary embolism: less likely to have fevers, dry cough and shortness of breath on exertion typical, may have haemoptysis.\n\n\n# Investigations\n\n\n**Bedside tests include:**\n\n\n- Oxygen saturations on exertion \n- Arterial blood gas for hypoxia, important to grade severity and determine if steroids are indicated\n- Sputum samples (may need to be induced e.g with saline nebulisers): **silver staining** is used to confirm the diagnosis of PCP (shows a characteristic Mexican hat appearance), also send sputum for routine and mycobacterial culture (to rule out TB or other infections)\n\n\n**Blood tests include:**\n\n\n- Routine bloods for FBC and CRP (looking for infection markers) and baseline liver and renal function prior to starting antibiotics\n- HIV testing\n- CD4 count if HIV positive\n\n\n**Imaging includes:**\n\n\n- Chest X-ray: often shows bilateral hilar interstitial infiltrates, however 10% have a normal chest X-ray.\n- High-resolution CT scan: if chest X-ray is normal and PCP is suspected, a high-resolution CT is more sensitive.\n\n\n**Other investigations:**\n\n\n- Bronchoscopy with bronchoalveolar lavage: if sputum samples are negative, this is the definitive investigation to gain a respiratory sample for staining. \n\n\n[lightgallery]\n\n\n# Management\n\n\n- Supportive treatment with analgesia, oxygen if hypoxic, consider holding immunosuppressant treatment (with liaison with specialist teams as needed)\n- Patients with mild disease (only mild changes on CXR, normal oxygen saturations) can be treated as outpatients; moderate and severe cases should be admitted\n- High dose co-trimoxazole is the primary treatment\n- Alternative therapies if co-trimoxazole is contraindicated or not tolerate include: atovaquone, dapsone with trimethoprim or pentamidine. \n- Steroids should be given in all patients with moderate or severe PCP (i.e.PaO2<11kPa) - either oral prednisolone or IV hydrocortisone. \n\n\n# NICE Guidelines\n\n\n[NICE CKS - HIV infection and AIDS](https://cks.nice.org.uk/topics/hiv-infection-aids/)\n\n\n# References\n\n\n[Patient UK - Pneumocystis Jirovecii Pneumonia](https://patient.info/doctor/pneumocystis-jirovecii-pneumonia)\n\n\n[BNF treatment summary - Pneumocystis Pneumonia](https://bnf.nice.org.uk/treatment-summary/pneumocystis-pneumonia.html)",
"files": null,
"highlights": [],
"id": "17",
"pictures": [
{
"__typename": "Picture",
"caption": "The typical 'mexican hat' appearance seen in PCP.",
"createdAt": 1676958432,
"id": "1462",
"index": 0,
"name": "Pneumocystis J - Mexican hat appearance.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/sm2q9o0x1676958427867.jpg",
"path256": "images/sm2q9o0x1676958427867_256.jpg",
"path512": "images/sm2q9o0x1676958427867_512.jpg",
"thumbhash": "OwgGBYL2OqWHeYaKZUindRU930BW",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
}
],
"typeId": 2
},
"chapterId": 17,
"demo": null,
"entitlement": null,
"id": "2132",
"name": "Pneumocystis Pneumonia",
"status": null,
"topic": {
"__typename": "Topic",
"id": "32",
"name": "Respiratory",
"typeId": 2
},
"topicId": 32,
"totalCards": 1,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2132,
"conditions": [],
"difficulty": 1,
"dislikes": 3,
"explanation": null,
"highlights": [],
"id": "10701",
"isLikedByMe": 0,
"learningPoint": "In patients over 65 with pneumonia, a CRB65 score of 1 indicates the need for oral antibiotics like amoxicillin.",
"likes": 2,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 68-year-old woman presents to the GP with a 3-day history of a cough productive of green phlegm, as well as exertional dyspnoea. She has no past medical history, takes no regular medications, and has no drug allergies. Her vital signs are: HR 89bpm, RR 14 breaths per minute, O2 saturation 99% on room air, BP 145/78mmHg. Her AMTS is 9/10. On examination, there are crepitations in the left lower zone of her chest.\n\nWhich of the following is the next best step in the management of this patient?",
"sbaAnswer": [
"a"
],
"totalVotes": 3068,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,010 | false | 68 | null | 6,494,981 | null | false | [] | null | 10,702 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Escherichia coli can present in a similar way to C. Jejuni with bloody diarrhoea, fever, and abdominal pain in the context of food poisoning. It is important to remember the 0157: H7 strain which can trigger haemolytic uraemic syndrome. However, E. Coli is a gram negative rod, as opposed to spiral/comma shaped.",
"id": "53209",
"label": "c",
"name": "Escherichia coli",
"picture": null,
"votes": 228
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Bacillus cereus is a gram positive rod presenting with rapid onset, toxin mediated food poisoning (within hours.) It is classically associated with takeaways or reheating rice. It is not associated with bloody diarrhoea. The incubation period in this case, findings on stool culture, and bloody diarrhoea point against Bacillus cereus.",
"id": "53211",
"label": "e",
"name": "Bacillus cereus",
"picture": null,
"votes": 49
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "C. jejuni is a spiral or comma-shaped gram negative organism, which commonly presents with a flu-like prodrome, crampy abdominal pain, and bloody diarrhoea. It is a common cause of food poisoning and has a long incubation period of around 5 days. It is associated with Guillain Barre syndrome, which presents with ascending, bilateral weakness in the lower limbs; this child is complaining of lower limb weakness, so this should raise clinical suspicion of this complication.",
"id": "53207",
"label": "a",
"name": "Campylobacter jejuni",
"picture": null,
"votes": 2036
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Salmonella enteritidis can present in a similar way to C. Jejuni with bloody diarrhoea, fever, and abdominal pain in the context of food poisoning. However, it presents earlier than C. jejuni as the incubation period is shorter (around 12-48 hours.) Furthermore, Salmonella is a gram-negative rod rather than a spiral-shaped/comma-shaped organism.",
"id": "53208",
"label": "b",
"name": "Salmonella enteritidis",
"picture": null,
"votes": 599
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Entamoeba histolytica causes amoebic dysentery. It is associated with foreign travel and stool microscopy would show trophozoites.",
"id": "53210",
"label": "d",
"name": "Entamoeba histolytica",
"picture": null,
"votes": 91
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "don't know my rods from my spirals\n",
"createdAt": 1738042322,
"dislikes": 0,
"id": "61740",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10702,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Gabriel Magalhaes",
"id": 26529
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n \nGastroenteritis is an enteric infection causing acute-onset diarrhoea, sometimes with additional symptoms. Food poisoning results from consuming contaminated substances, while acute diarrhoea involves three or more liquid or semi-liquid stools in 24 hours, lasting less than 14 days. Prolonged diarrhoea lasts over 14 days, and dysentery is acute infectious diarrhoea with blood and mucus. Infectious diarrhoea is commonly spread via the faeco-oral route and often caused by viruses like norovirus, rotavirus, and adenovirus. Bacterial causes include Campylobacter, E. coli, Salmonella, Cholera, Shigella, and Yersinia. Parasites like Cryptosporidium, Entamoeba histolytica, and Giardia can also cause prolonged diarrhoea. Symptoms include sudden-onset diarrhoea, nausea, vomiting, fever, and abdominal pain. Diagnosis often involves assessing hydration status and may require stool cultures or blood tests. Treatment includes rehydration and, in some cases, antimicrobials. Preventative measures include proper food hygiene and handwashing. Certain infections must be reported to health authorities. High-risk groups include young children, the elderly, immunocompromised individuals, and pregnant women, who may face complications such as dehydration, haemorrhagic colitis, and sepsis.\n \n# Definition\n \n **Gastroenteritis:** an enteric infection causing acute-onset diarrhoea, with or without associated symptoms\n \n **Food poisoning:** illness caused by eating or drinking substances contaminated with disease-causing pathogens, toxins or chemicals.\n \n **Acute diarrhoea:** 3+ episodes liquid/semi-liquid stools in in a 24h period, lasting less than 14 days\n \n **Prolonged diarrhoea:** acute-onset diarrhoea lasting over 14 days\n \n **Dysentery:** is acute infectious diarrhoea with blood & mucus, often with associated symptoms\n \n# Aetiology\n \nMost cases of infectious diarrhoea are spread by the faeco-oral route and are caused by viruses. These include:\n \n - **Norovirus:** **most common** cause in the population, and often causes outbreaks. Typically causes projectile vomiting and non-bloody diarrhoea.\n - **Rotavirus:** the most common cause of gastroenteritis in children.\n - **Adenovirus:** typically causes respiratory tract infections but may cause gastrointestinal symptoms in children.\n \nBacteria causing infectious diarrhoea include:\n \n - **Campylobacter**: often associated with contaminated food & drink (in exams: a recent barbeque!), this is the most common cause of bacterial gastroenteritis in the UK. On microscopy, gram-negative rods are seen with characteristic 'seagull' shape, which release enterotoxin in the gut and invade the mucosa. Incubation period is 1 - 5 days and may cause bloody diarrhoea, though vomiting is rare.\n - **E. coli**: the most common cause of traveller's diarrhoea. In the UK, O157:H7 is the most common type and may cause bloody diarrhoea. Sources include improperly cooked meat. Associated complications include haemolytic uraemic syndrome, which typically affects the very young are old and can be fatal.\n - **Salmonella** is associated with consumption of contaminated foods, particularly poultry, eggs and milk. These are gram negative bacteria with an incubation of 16-48 hours. *Salmonella* can cause bloody diarrhoea and is associated with complications such as sepsis, endocarditis, mycotic aneurysm and osteomyelitis.\n - **Cholera** is associated with contaminated water supplies and causes very watery diarrhoea associated with dehydration.\n - **Shigella** and *Yersinia* tend to occur in children. The former can cause severe, bloody diarrhoea.\n - **Bacillus cereus** are gram-positive rods that produce two toxins causing diarrhoea and vomiting within hours of eating contaminated food (in exams, this is usually reheated rice).\n - **Staphylococcus aureus** produces a heat-stable enterotoxin that causes profuse vomiting with mild diarrhoea and abdominal pain. The incubation period is short (under 6 hours) after eating contaminated foods. The bacteria are usually introduced from the skin of the person preparing the food. Foods which do not require cooking carry greater risk.\n \nParasites can be spread by ingestion of contaminated food/drink or from person to person, and often associated with recent travel.\n \n - **Cryptosporidium**: a protozoal infection which may cause prolonged symptoms\n - **Entamoeba histolytica**: most cases are mild but severe cases cause dysentery\n - **Giardia**: causing diarrhoea, constitutional symptoms and bloating which may be prolonged\n \n# Signs and Symptoms\n \nSymptoms include:\n \n - Sudden-onset diarrhoea, with or without blood\n - Faecal urgency\n - Nausea & vomiting\n - Fever, malaise\n - Abdominal pain\n - Associated symptoms specific to the cause\n \n \n# Differential Diagnosis\n \n - ***Clostridium difficile*** infection, causing antibiotic-associated (in particular, cephalosporins) diarrhoea. Patients usually have predisposing risk factors such as recent antibiotics, immunocompromise or PPI use. Typically causes foul-smelling diarrhoea and can cause severe systemic upset and GI complications.\n - Other causes of **diarrhoea**, including irritable bowel syndrome, inflammatory bowel disease, malignancy, endocrine conditions such as thyrotoxicosis. These usually have a more prolonged history and may be associated with other systemic symptoms (except IBS).\n - Other causes of **abdominal pain**, such as appendicitis, intestinal obstruction, diverticulitis, pancreatitis. These are associated with other symptoms such as absolute constipation and vomiting (obstruction) or pain relieved on leaning forward (pancreatitis). Often, there is also more systemic upset and deranged blood tests.\n \n# Investigations\n \n - Often, infectious diarrhoea is a clinical diagnosis and, providing the patient is not systemically unwell, may not need further investigation. \n - It is important to assess hydration status and consider whether the person can tolerate oral fluids.\n - A stool culture may be needed if there are any higher risk features. These include if the person is systemically unwell, is immunocompromised, presents with dysentery or prolonged diarrhoea, there is increased risk of transmission, food poisoning is suspected or symptoms are associated with recent travel.\n - If a person is unwell presenting to secondary care, consider performing blood tests to include FBC, U&Es, CRP, LFTs and TFTs. \n - Consider a VBG, blood cultures and monitoring urine output if they appear septic.\n \n \n# Management\n \n - If a person is systemically unwell, or severely dehydrated, adopt an A-E approach and consider initiating the sepsis six. Admit the patient and seek senior help early. They may need IV fluids, antiemetics or antibiotics.\n - Conservative: advise regular fluids, with or without rehydration salts, and safetynet for signs of dehydration. Antidiarrhoeal drugs are not routinely used, and should be avoided if the patient has symptoms of dysentery or suspected *E. coli 0157*.\n - Medical: antimicrobials are not routinely indicated, but clinical suspicion or positive cultures of the following may prompt initiation of antibiotics:\n \n - *Campylobacter*: macrolide e.g. clarithromycin\n - *Amoeba, Giardia*: anti-protozoal e.g. metronidazole\n - *Cholera*: tetracycline\n \n - If a patient is systemically unwell, immunosuppressed or elderly, consider empirical antibiotics following local pathways and microbiology advice.\n \n - Infectious diarrhoea can be prevented by avoiding foods that are undercooked or prepared in unsanitary conditions, and handwashing at appropriate times and hygiene measures. \n - Enhanced precautions such as isolation and barrier nursing along with handwashing can prevent spread in clinical settings. People should not return to work until 48 hours after their symptoms have resolved.\n \nThe following are notifiable diseases, and should be reported to the local health protection scheme:\n \n - Food poisoning\n - Haemolytic uraemic syndrome\n - Dysentery\n - Enteric fever\n - Cholera\n \n# Complications\n \nYoung children, elderly, people with comorbidities or immunocompromised and pregnant women are at highest risk of complications. These include:\n \n - Dehydration, electrolyte disturbance, acute kidney injury\n - Haemorrhagic colitis, haemolytic uraemic syndrome, thrombotic thrombocytopenic purpura\n - Reactive arthritis\n - Toxic megacolon\n - Sepsis\n \nLonger-term complications include: faltering growth, irritable bowel syndrome and lactose intolerance.\n \nSpecific complications may occur depending on the causative organism.\n \n# NICE Guidelines\n [NICE CKS: Gastroenteritis](https://cks.nice.org.uk/topics/gastroenteritis/)",
"files": null,
"highlights": [],
"id": "742",
"pictures": [],
"typeId": 2
},
"chapterId": 742,
"demo": null,
"entitlement": null,
"id": "774",
"name": "Gastroenteritis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "23",
"name": "Gastroenterology",
"typeId": 2
},
"topicId": 23,
"totalCards": 27,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "774",
"name": "Gastroenteritis"
}
],
"demo": false,
"description": null,
"duration": 292.8,
"endTime": null,
"files": null,
"id": "197",
"live": false,
"museId": "HnRjwTX",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/ID.png",
"title": "Infective gastroenteritis",
"userViewed": false,
"views": 138,
"viewsToday": 12
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "774",
"name": "Gastroenteritis"
}
],
"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
}
]
},
"conceptId": 774,
"conditions": [],
"difficulty": 1,
"dislikes": 5,
"explanation": null,
"highlights": [],
"id": "10702",
"isLikedByMe": 0,
"learningPoint": "Campylobacter jejuni commonly causes food poisoning, presenting with crampy abdominal pain, bloody diarrhoea, and can lead to Guillain-Barré syndrome.",
"likes": 5,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 14-year-old boy presents to A&E with his dad complaining of abdominal pain. He describes it as crampy, which paracetamol has not relieved. Over the last 2 days, he is complaining of leg weakness, fever, and bloody diarrhoea. His dad is concerned that he may have ulcerative colitis. There is no travel history of note. They went to a barbecue 5 days ago where they ate chicken. On examination, the patient has a temperature of 39.8. A faecal sample is taken which shows a spiral shaped organism.\n\nWhich of the following organisms is the most likely cause?",
"sbaAnswer": [
"a"
],
"totalVotes": 3003,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,011 | false | 69 | null | 6,494,981 | null | false | [] | null | 10,703 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "An open skull fracture is when the fracture has led to skin breakage, resulting in bone protruding. This patient has no scalp lacerations and there is no evidence of a compound fracture, therefore.",
"id": "53213",
"label": "b",
"name": "Open skull fracture",
"picture": null,
"votes": 29
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Diastatic skull fractures are fractures that occur along suture lines, resulting in widening. They are usually seen in newborns and infants as their skull bones take time to develop.",
"id": "53216",
"label": "e",
"name": "Diastatic skull fracture",
"picture": null,
"votes": 74
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A linear skull fracture is when there is a fracture without any movement or distortion of the bone. Hence, the fracture just appears as a thin line/crack in the skull. These are less serious than basal skull fractures, require observation only and do not usually require any surgical management. They are not associated with the characteristic features as in this case of a basal skull fracture, and rarely develop any complications.",
"id": "53214",
"label": "c",
"name": "Linear skull fracture",
"picture": null,
"votes": 110
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Fractures of the skull base can occur following head injury sustained during road traffic accidents. The commonest location of these fractures is the petrous part of the temporal bone. Classical features are haemotympanum (bleeding behind the tympanic membrane), periorbital ecchymoses (raccoon eyes), bruising of the mastoid (Battle's sign) and rhinorrhea (due to CSF leakage.) Most require observation only, but in some cases surgical correction may be required, such as in the case of persistent CSF risk. Complications are serious, including meningo-encephalitis and cavernous sinus thrombosis.",
"id": "53212",
"label": "a",
"name": "Basal skull fracture",
"picture": null,
"votes": 3625
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A depressed skull fracture is when the bone sinks downwards towards the brain. These may require surgical intervention, especially if the underlying brain tissue is compressed. This patient is displaying classical features of a basal skull fracture, however, and so this is the most likely diagnosis at this stage. Furthermore, this patient's skull is reported as having a smooth contour, making any depressions unlikely.",
"id": "53215",
"label": "d",
"name": "Depressed skull fracture",
"picture": null,
"votes": 165
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nA base of skull fracture refers to a break in one or more bones at the base of the skull, typically the temporal bone but possible in the occipital, sphenoid, or ethmoid bones. Key signs and symptoms include reduced consciousness, bruising around the eyes or mastoid process, CSF leakage from the ear, cranial nerve palsy, and bleeding from the nose or ears. The primary investigation is a CT head scan. Management is based on the specific injury, often involving the management of raised intracranial pressure, potential neurosurgery and antibiotics for possible meningitis.\n\n# Definition\n\n- Base of skull fracture refers to the fracture of one or more bones at the base of the skull. These bones typically include the temporal bone, but can also be the occipital, sphenoid, or ethmoid bones.\n- The anterior cranial fossa includes the superior sphenoid and ethmoid bones.\n- The posterior cranial fossa comprises of the occipital, temporal, and part of the sphenoid bone.\n\n# Epidemiology\n\n- The exact prevalence of base of skull fractures is not well known due to the necessity of advanced imaging for diagnosis. However, it is a common occurrence in severe head injuries resulting from blunt force trauma.\n\n# Aetiology\n\n- Base of skull fractures are usually caused by severe head injury or blunt force trauma. This can occur from road traffic accidents, falls, assaults, or other forms of high-energy impact.\n\n# Signs and symptoms\n\n- History of severe head injury\n- Reduced consciousness\n- Battle's sign: bruising of the mastoid process\n- Raccoon eyes: periorbital bruising\n- Rhinorrhoea: CSF leakage from the nose\n- Otorrhoea: CSF leaking from the ear\n- Cranial nerve palsy\n- Epistaxis or otorrhagia: Bleeding from the nose or ears\n- Haemotympanum: blood visible behind the tympanic membrane\n\n# Differential diagnosis\n\n- Concussion: Symptoms include headache, confusion, lack of coordination, memory loss, nausea, vomiting, dizziness, ringing in the ears, sleepiness, and excessive fatigue.\n- Intracranial hemorrhage: Signs may include severe headache, weakness, numbness, decreased alertness, and nausea or vomiting.\n- Brain contusion: Symptoms can include headache, confusion, memory loss, reduced concentration, and in severe cases, unconsciousness.\n- Skull fracture without base involvement: This may present with similar symptoms as a base of skull fracture; however, Battle's sign and raccoon eyes are typically absent.\n\n# Investigations\n\n- The principal investigation for a suspected base of skull fracture is a CT head scan. This imaging modality can highlight bone fractures and any associated intracranial injuries.\n\n# Management\n\n- Management of a base of skull fracture is dependent on the severity of the injury.\n- Raised intracranial pressure is managed with medications, and in severe cases, surgery.\n- Neurosurgery might be required depending on the extent of the injury.\n- Antibiotics are administered if there is a risk of meningitis, especially in situations where there is CSF leakage. \n\n# External links\n\n[- Radiopaedia: Base of Skull Fracture](https://radiopaedia.org/articles/base-of-skull-fracture?lang=gb)\n[- BMJ Best Practice: Skull Fractures](https://bestpractice.bmj.com/topics/en-gb/398)\n[- Life In The Fast Lane: Base of Skull Fractures](https://litfl.com/base-of-skull-fracture/)\n[- Simon LV & Newton EJ. Basilar Skull Fractures](https://www.ncbi.nlm.nih.gov/books/NBK470175/)",
"files": null,
"highlights": [],
"id": "1062",
"pictures": [],
"typeId": 2
},
"chapterId": 1062,
"demo": null,
"entitlement": null,
"id": "2322",
"name": "Basal skull fracture",
"status": null,
"topic": {
"__typename": "Topic",
"id": "24",
"name": "Ear, Nose & Throat",
"typeId": 2
},
"topicId": 24,
"totalCards": 1,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2322,
"conditions": [],
"difficulty": 1,
"dislikes": 2,
"explanation": null,
"highlights": [],
"id": "10703",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 5,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 23-year-old male presents to A&E via ambulance following a road traffic accident. On examination, there is bruising around the eyes and bleeding behind his tympanic membrane. There are no lacerations on his scalp and his skull has a smooth contour. His Glasgow Coma Score is 11. A CT head is requested.\n\nWhich of the following is the most likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 4003,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,012 | false | 70 | null | 6,494,981 | null | false | [] | null | 10,704 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Zollinger-Ellison syndrome presents with recurrent ulcers in the stomach and duodenum secondary to excessive gastrin levels released from gastrinomas, which are malignant. Gastrin stimulates mucosal growth of the stomach and the release of acid from gastric parietal cells. These patients also present with diarrhoea due to excessive gastric acid leading to inactivation of lipase and subsequent fat malabsorption. Endoscopy would reveal multiple ulcers, as well as thickened gastric folds. This condition is commonly associated with multiple endocrine neoplasia 1 (MEN1.) Treatment is with high dose PPI or somatostatin analogues.",
"id": "53219",
"label": "c",
"name": "Zollinger-Ellison syndrome",
"picture": null,
"votes": 477
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Oesophageal cancer typically presents with progressive dysphagia, initially for solids and eventually for liquids, as well as hoarseness of the voice if there is compression of the recurrent laryngeal nerve which runs close to the oesophagus in the thorax. Risk factors include smoking, acid reflux (due to Barrett's oesophagus), and high levels of alcohol intake. Helicobacter pylori causes achlorhydria chronically, and as such is actually protective against oesophageal adenocarcinoma. Weight loss and anorexia may also occur. This patient's endoscopy reveals no oesphageal lesion, with the only finding in the stomach, and reports no dysphagia. Therefore, oesophageal malignancy is unlikely.",
"id": "53221",
"label": "e",
"name": "Oesophageal cancer",
"picture": null,
"votes": 319
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Crohn's disease is an inflammatory bowel disorder, which can present with abdominal pain and weight loss. Additional clinical features usually include diarrhoea, which is absent in this case. Inflammation can be present throughout the entire GI tract, from mouth to anus, and additional clinical features, such as mouth ulcers, may be present. The history of abdominal pain worse on eating, relieved by antacids, and the appearances on endoscopy, are not consistent with a diagnosis of Crohn's disease.",
"id": "53220",
"label": "d",
"name": "Crohn's disease",
"picture": null,
"votes": 88
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient's endoscopy findings are in keeping with a peptic ulcer. His symptoms of epigastric pain, worsened on eating, typically indicate a gastric ulcer (with pain from duodenal ulcers relieved by eating.) This patient has rheumatoid arthritis, and it is possible he may use NSAIDs frequently; this, alongside his smoking history, places him at higher risk of peptic ulcer disease. Another key risk factor is Helicobacter pylori infection, which this patient will be tested for during endoscopy. It is important to note that this patient was referred for endoscopy appropriately under the 2-week-wait pathway as he fit the criteria for urgent investigation due to his age over 55, weight loss, and abdominal pain, in line with NICE guidance.",
"id": "53217",
"label": "a",
"name": "Peptic ulcer disease",
"picture": null,
"votes": 1104
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Gastric cancer may also present with epigastric pain, weight loss, and anorexia. Patients may also have iron deficiency anaemia. Risk factors for gastric cancer are similar to peptic ulcer disease, and include smoking as well as Helicobacter pylori infection. The endoscopic appearances here are in keeping with an ulcer, however, as opposed to gastric cancer, and the clinical feature of pain worsening on eating should also raise suspicion of an ulcer.",
"id": "53218",
"label": "b",
"name": "Gastric adenocarcinoma",
"picture": null,
"votes": 1136
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "man said unintenional weight loss and smoking history. WHAT YOU PLAYING AT QUESMED?",
"createdAt": 1685967084,
"dislikes": 1,
"id": "27921",
"isLikedByMe": 0,
"likes": 5,
"parentId": null,
"questionId": 10704,
"replies": [
{
"__typename": "QuestionComment",
"comment": "I think it's because unintentional weight loss and smoking history can be suggestive of cancer, and that's why he'd qualify for an endoscopy. But the endoscopy findings are not consistent with gastric carcinoma ",
"createdAt": 1686403792,
"dislikes": 0,
"id": "28404",
"isLikedByMe": 0,
"likes": 4,
"parentId": 27921,
"questionId": 10704,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Embolism Womb",
"id": 17849
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Serpiginous Yeast",
"id": 13388
}
},
{
"__typename": "QuestionComment",
"comment": "and the weight loss could have been eluded to the fact that he may not be eating as much",
"createdAt": 1710164956,
"dislikes": 0,
"id": "44441",
"isLikedByMe": 0,
"likes": 2,
"parentId": null,
"questionId": 10704,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "BeethovenVirus-ed",
"id": 14961
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nPeptic ulcer disease, encompassing both duodenal and gastric ulcers, is a condition where the stomach lining's self-protection mechanisms fail, often due to the presence of external factors like H. Pylori. Key signs and symptoms include pain, nausea, vomiting and loss of appetite. The primary investigation tool is endoscopy, which allows for a direct visual inspection of the ulcers. Management strategies include both pharmaceutical interventions, such as PPI treatment, and lifestyle changes, like cessation of smoking and dietary adjustments.\n\n# Definition\n\nPeptic ulcer disease refers to painful sores or ulcers in the lining of the stomach or the first part of the small intestine, known as the duodenum. The frequency of duodenal ulcers is four times higher than that of gastric ulcers. It is an endoscopic diagnosis (NB: dyspepsia is a clinical diagnosis). Peptic ulcer disease can be uncomplicated, or complicated (perforation, bleeding).\n\n# Epidemiology\n\nPeptic ulcer disease is a common condition, with the prevalence of duodenal ulcers being four times that of gastric ulcers. It's noteworthy that approximately 90% of duodenal ulcers are caused by H. Pylori infection.\n\n# Aetiology\n\nThe primary cause of duodenal ulcers is the infection by H. Pylori. Other factors contributing to the development of these ulcers include:\n\n- NSAIDs\n- Chronic use of steroids\n- SSRIs\n- Increased secretion of gastric acid\n- Smoking\n- Blood group O\n- Accelerated gastric emptying \n\nFor gastric ulcers, the risk factors include:\n\n- NSAIDs\n- H. Pylori infection\n- Smoking\n- Delayed gastric emptying\n- Severe stress\n\n# Signs and Symptoms\n\nPatients with peptic ulcer disease may present with:\n\n- Abdominal pain\n- Nausea\n- Vomiting\n- Loss of appetite\n- Unexplained weight loss\n- Patients with complicated peptic ulcer disease may present with coffee ground vomiting (bleeding), and can be haemodynamically unstable due to perforation\n\nDuodenal ulcers typically present with epigastric pain typically relieved on eating (closure of pyloric sphincter, less acid irritating ulcerated surface). Symptoms of gastric ulcers on the other hand are often worsened by eating - stomach increases acid production in response to food and irritates ulcerated surface.\n\n# Differential Diagnosis\n\nThe symptoms of peptic ulcer disease can mimic those of other conditions, including:\n\n- Gastritis: inflammation of the stomach lining, presenting with nausea, vomiting, and abdominal discomfort.\n- Gastro-oesophageal reflux disease (GORD): chronic acid reflux, characterized by heartburn, regurgitation, and swallowing difficulties.\n- Stomach cancer: may cause similar symptoms, but often accompanied by significant weight loss, loss of appetite, and anemia.\n\n# Investigations\n\n- Patients >55 with weight loss and dyspepsia should be referred for an urgent OGD (within 2 weeks) to investigate for oesophageal and gastric cancer\n- Patients should be investigated for H.pylori infection with C-13 urea breath test (ensure the person has not taken a PPI in the past 2 weeks, or antibiotics in the past 4 weeks)\n- Investigation tools for peptic ulcer disease primarily include endoscopy, which allows a direct visual inspection of the ulcers. Biopsies may be taken to rule out malignancy.\n\n# Management\n\nManagement of H. Pylori-negative peptic ulcer disease involves a 4-8 week course of full-dose PPI treatment in conjunction with lifestyle advice, such as:\n\n- Smoking cessation\n- Reducing alcohol intake\n- Regular, small meals and avoiding eating 4 hours before bedtime\n- Avoidance of acidic, fatty or spicy foods, and coffee\n- Weight loss if overweight \n- Stress management\n- Avoidance of NSAIDs, steroids, bisphosphonates, potassium supplements, SSRIs, and crack cocaine\n- Over-the-counter antacids\n\n\n- If the patient is H.pylori positive with a proven gastric/duodenal ulcer which is:\n\t- Associated with NSAID use: 8 week PPI therapy followed by first-line eradication therapy - PPI (omeprazole/lansoperazole) + amoxicillin + clarithromycin/metronidazole for 7 days\n\t\t- If penicillin allergic, offer: PPI + clarithromycin + metronidazole for 7 days \n\t- Not associated with NSAID use: eradication therapy with PPI (omeprazole/lansoperazole) + amoxicillin + clarithromycin/metronidazole for 7 days\n\t- If the person is allergic to pencillin and has had previous exposure to clarithromycin, offer a 7-day quadruple therapy regimen of:\nPPI + metronidazole + tetracycline hydrochloride + bismuth subsalicylate\n\n- For patients with gastric ulcers, a repeat endoscopy 6-8 weeks following the start of PPI treatment is recommended to ensure ulcer healing and rule out malignancy, as well as H.pylori re-testing (C-13 urea breath test first-line, stool antigen test second line) if appropriate.\n- Complicated peptic ulcer disease requires urgent surgical intervention with OGD for underunning of ulcers and haemostasis\n\t- Perforated peptic ulcers present initially with localised epigastric pain which later becomes generalised and peritonitic. These patients require an AXR and erect CXR to look for pneumoperitoneum. \n\n# NICE Guidelines\n\n[Click here to see more information NICE CKS on peptic ulcer disease](https://cks.nice.org.uk/topics/dyspepsia-proven-peptic-ulcer/management/management-proven-peptic-ulcer/)",
"files": null,
"highlights": [],
"id": "740",
"pictures": [],
"typeId": 2
},
"chapterId": 740,
"demo": null,
"entitlement": null,
"id": "772",
"name": "Peptic ulcer disease",
"status": null,
"topic": {
"__typename": "Topic",
"id": "23",
"name": "Gastroenterology",
"typeId": 2
},
"topicId": 23,
"totalCards": 32,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "772",
"name": "Peptic ulcer disease"
}
],
"demo": false,
"description": null,
"duration": 497.02,
"endTime": null,
"files": null,
"id": "27",
"live": false,
"museId": "DekGUen",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/surgery.png",
"title": "Approach to Epigastric pain",
"userViewed": false,
"views": 125,
"viewsToday": 5
}
]
},
"conceptId": 772,
"conditions": [],
"difficulty": 1,
"dislikes": 23,
"explanation": null,
"highlights": [],
"id": "10704",
"isLikedByMe": 0,
"learningPoint": "Peptic ulcer disease can present with epigastric pain exacerbated by eating, often associated with NSAID use and smoking history.",
"likes": 4,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 57-year-old male presents to the GP with a 7-month history of epigastric pain which gets worse after eating. Over the same time period, he has lost his appetite and 1.5kg unintentionally. He has a past medical history of rheumatoid arthritis and a smoking history of 31 pack years. He admits that he often uses over-the-counter antacids, which help occasionally. He is referred for a two-week wait upper gastrointestinal endoscopy, which reveals granulation tissue with a necrotic layer.\n\nWhich of the following is the most likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 3124,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,013 | false | 71 | null | 6,494,981 | null | false | [] | null | 10,705 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Recombinant factor IX is used in the management of Haemophilia B, which is an X linked recessive disorder characterised by factor IX deficiency. Haeomophilia B is also known as Christmas disease.. Blood tests reveal a prolonged APTT.",
"id": "53225",
"label": "d",
"name": "Recombinant clotting factor IX",
"picture": null,
"votes": 24
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient is presenting with a ruptured abdominal aortic aneurysm. He will need transfusing according to a major haemorrhage protocol, which involves providing platelets, fresh frozen plasma, and packed red cells in a 1:1:1 ratio. Once stabilised, he will be able to go to theatre for either endovascular or open abdominal aortic aneurysm repair.",
"id": "53222",
"label": "a",
"name": "Packed red cells, platelets and fresh frozen plasma (FFP)",
"picture": null,
"votes": 2342
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Recombinant factor VIII is used in the management of Haemophilia A, which is an X linked recessive disorder characterised by factor VIII deficiency. Haemophilia A is the most common inherited bleeding disorder which presents with recurrent haemarthroses and bruising. Blood tests reveal a prolonged APTT.",
"id": "53224",
"label": "c",
"name": "Recombinant clotting factor VIII",
"picture": null,
"votes": 45
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Cryoprecipitate, which contains high levels of von Willebrand Factor and fibrinogen, may be required during massive haemorrhage, but it is not routinely provided, unlike packed red cells, platelets, and FFP. The decision to provide cryoprecipitate depends on close monitoring of bloods during the resuscitation efforts, and is usually required when the fibrinogen levels are less than 1. Treatment of massive haemorrhage should utilise the expertise of a haematologist since coagulopathy and complications can be extreme.",
"id": "53223",
"label": "b",
"name": "Cryoprecipitate",
"picture": null,
"votes": 222
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is presenting with a ruptured abdominal aortic aneurysm. He will need transfusing according to a major haemorrhage protocol, which involves providing platelets, fresh frozen plasma, and packed red cells in a 1:1:1 ratio. It will be incorrect to transfuse him packed red cells only since this will not correct/worsen any coagulopathy sustained because of the massive haemorrhage.",
"id": "53226",
"label": "e",
"name": "Packed red cells only",
"picture": null,
"votes": 137
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\n\nAn abdominal aortic aneurysm (AAA) is a common, potentially life-threatening condition characterised by an abdominal aorta diameter greater than 3cm. It's most frequently located between the renal and inferior mesenteric arteries. Key signs and symptoms include a typically asymptomatic presentation, occasionally manifesting as a pulsatile, expansile abdominal mass. Diagnosis primarily relies on abdominal ultrasound screening, with follow-up frequency varying based on the aneurysm size. Management strategies focus on surgical repair, with indications being a size >5.5cm or rapid expansion, encompassing open repair or Endovascular Aneurysm Repair (EVAR).\n\n\n# Definition\n\n\nAbdominal aortic aneurysm (AAA) is a prevalent, potentially lethal condition characterised by an enlargement of the abdominal aorta exceeding a diameter of 3cm. This dilatation affects all three layers of the arterial wall. Many individuals with AAA are asymptomatic and do not cause any problems to the individual. In the absence of repair, a ruptured AAA is generally fatal.\n\n\n# Epidemiology\n\n\nAbdominal aortic aneurysm (AAA) predominantly affects older adults, especially those over 65 years of age. At the time of screening at age 95, 0.92% of men undergoing screening are found to have an abdominal aortic aneurysm. It is approximately 4-6 times more prevalent among men than women. An estimated 4-8% of men and 1-2% of women aged over 65 years are affected, but due to the asymptomatic nature of the condition, the actual prevalence may be higher. \n\nThere is a significant geographic and ethnic variation, with higher prevalence reported in Western countries. Lifestyle factors such as smoking and a history of cardiovascular disease increase the risk. \n\nAAA morbidity and mortality are reducing in the UK due to increasing elective repair of AAA and a reduction in smoking rates. \n\n\n# Aetiology\n\n\nThe precise aetiology of AAA is complex and multifactorial, typically involving a combination of genetic, environmental, and lifestyle factors.\n\n\nRisk factors include:\n\n- Being male\n- Age 65 or over\n- Smoking \n- Hypertension\n- Hypercholesterolaemia \n- Family history of AAA\n- Personal history of peripheral arterial disease or myocardial infarction\n- COPD\n- Connective tissue disorders (i.e. Marfan's) \n\n\n\n# Signs and Symptoms\n\n\nMost AAAs remain asymptomatic for a long time and are often detected incidentally during radiological investigations for other abdominal or pelvic conditions. \n\nWhen symptomatic, the clinical presentation can vary:\n\n\n- Pulsatile abdominal mass: \n- The most classical finding on physical examination is a pulsatile, expansile abdominal mass. This is typically non-tender unless rupture is imminent.\n- Approximately 3 in 5 AAA over 3 cm are palpable.\n- This may also be associated with abdominal bruit.\n\n- Abdominal or back pain: \n- Pain is usually a late manifestation, suggesting rapid expansion or impending rupture of the aneurysm. \n- It is typically severe, constant, and localised in the abdomen or lower back, often radiating to the flank or groin.\n- There can also be testicular pain if the blood supply to this area is compromised by rupture\n- 90% of aortic aneurysms are infrarenal (originating below the renal arteries) \n\n\nIn advanced cases, a large aneurysm may cause symptoms due to compression or displacement of adjacent structures, resulting in early satiety, nausea, weight loss, altered bowel habits, or deep venous thrombosis (due to compression of the inferior vena cava).\n\n\n# Differential Diagnosis\n\n\nDifferential diagnoses for AAA include, but are not limited to:\n\n\n- **Renal colic**: Typically presents with severe, sudden onset flank pain that can radiate to the groin, accompanied by haematuria and urinary urgency.\n- **Pancreatitis**: Characterised by persistent, severe epigastric pain radiating to the back, often associated with nausea, vomiting, and elevated pancreatic enzymes.\n- **Peptic ulcer disease**: Often presents with burning epigastric pain that is relieved by eating, weight loss, and potential signs of bleeding like melaena or hematemesis.\n- **Diverticulitis**: Usually presents with left lower quadrant pain, fever, and changes in bowel habits.\n\n\n\n# Investigations\n\nNHS AAA screening programme: \n\n- Offered to men at age 65\n- Consists of an abdominal ultrasound\n- Follow-up screening depends on the size of the aneurysm:\n\n- Small AAA (3-4.4cm): Yearly repeat ultrasound is offered.\n- Medium AAA (4.5-5.4cm): Repeat ultrasound every 3 months is offered.\n- Large AAA (>5.5cm): Surgical intervention is generally recommended.\n\nOnce an abdominal aortic aneurysm has been detected, further investigations may be required, including: \n\n- **Computed Tomography (CT) Angiography:** \n- CT angiography is the imaging modality of choice for preoperative evaluation, determining the size, shape, and extent of the AAA, and planning the surgical approach. \n- It provides detailed information about the aneurysm's relationship to branch arteries and the potential presence of thrombus or calcification within the aneurysm. \n- It is also the preferred imaging modality in suspected rupture cases due to its rapid acquisition time and high sensitivity and specificity.\n\n- **Magnetic Resonance Angiography (MRA):** MRA is an alternative to CT angiography for patients who cannot be exposed to ionizing radiation or iodinated contrast medium. MRA can provide high-resolution images of the AAA and surrounding structures but is less readily available and takes more time than CT.\n\n- **Blood tests:** While there is no specific blood test to diagnose AAA, complete blood count, coagulation profile, renal function tests, and electrolyte levels are typically evaluated prior to surgery.\n\n\n\nFinally, regular surveillance of known AAAs is critical. The frequency of surveillance depends on the size of the aneurysm, with smaller aneurysms monitored less frequently and larger ones requiring closer observation.\n\n\n# Management\n\n### Conservative \n\nManagement of abdominal aortic aneurysms may be through conservative measures such as: \n\n- Surveillance:\n- This is typically offered for smaller aneurysms with a lower risk of rupture. It is very rare for smaller AAA to rupture. \n- Small AAA (3-4.4cm): Yearly repeat ultrasound is offered.\n- Medium AAA (4.5-5.4cm): Repeat ultrasound every 3 months is offered.\n- Large AAA (>5.5cm) require referral to vascular surgery to be seen within 2 weeks of diagnosis. \n- Measures to reduce the risk of rupture:\n- Referral to a stop-smoking service\n- Management of hypertension \n\n\n### Surgical \n\n\nElective repair of AAA may be considered for individuals with AAA who meet the following criteria:\n\n- They are symptomatic \n- Their AAA has grown by more than 1 cm in 1 year and is larger than 4 cm\n- Their AAA is 5.5 cm or larger \n\n\nTwo primary surgical options are available for managing AAA: \n\n- Open surgical repair\n- Typically best for men under age 70. \n- However, it can be contraindicated by anaesthetic risks, medical comorbidities or anatomic difficulties (i.e. horseshoe kidney, stoma, numerous previous surgeries resulting in significant adhesions)\n- Endovascular Aneurysm Repair (EVAR)\n- A stent graft is inserted through the femoral arteries into the aorta, where it channels blood flow into the iliac arteries. The surrounding aneurysm then becomes thrombosed around the graft. \n- EVAR has reduced perioperative deaths and is associated with shorter hospital stays. However, it has an overall higher long-term morbidity and mortality than open repair. \n\n\n# Complications\n\n\n### Rupture\n\nAAA rupture is a surgical emergency. Abdominal aortic aneurysms are more likely to rupture in women than men but are more common in men and such account for more presentations in men. \n\nAAA tend to enlarge over time and with increasing size, the risk of rupture increases. \n\n\n### Embolization\n\nRarely distal embolisation from mural thrombus can lead to symptoms related to ischemia, most commonly affecting the distal extremities, such as blue toe syndrome.\n\n### Open Repair-Related Complications\n\nThose undergoing open surgical repair of an AAA have risks including:\n\n- Spinal cord ischaemia \n- Anastomotic pseudoaneurysm \n- Graft infection \n- Death (mortality during elective repair is reported to be 5% of men and 7% of women)\n\n### EVAR-Related Complications\n\nPatients who have undergone EVAR may require surveillance for EVAR-related complications. \n\n- Endoleak\n- Defined as the presence of blood flow within the aneurysm sac but outside the EVAR graft\n- Contrast-enhanced CT angiography, or contrast-enhanced ultrasound if CT is contraindicated, is used to assess for endoleak. \n- They can be repaired using open, endovascular or percutaneous intervention for endoleak \n- Post-implantation syndrome \n- Cytokine release due to EVAR can cause fever, back pain and feeling generally unwell following EVAR.\n\n# Prognosis \n\nAbdominal aortic aneurysms will continue to increase in diameter, with the ultimate outcome being rupture. However, many individuals with AAA do not rupture during their lifetimes. The rupture of AAA is fatal for many individuals. \n\nFor those who have had their AAA electively repaired before rupture, those who have had an open surgical repair tend to fare better with reduced complications and overall improved survival. \n\n\n# NICE Guidelines\n\n[NICE guidelines: Abdominal Aortic Aneurysm](https://www.nice.org.uk/guidance/ng156)\n\n\n# References\n\n[NHS Abdominal Aortic Aneurysm](https://www.nhs.uk/conditions/abdominal-aortic-aneurysm/) \n\n[NHS Inform Abdominal Aortic Aneurysm](https://www.nhsinform.scot/illnesses-and-conditions/a-to-z/abdominal-aortic-aneurysm/) \n\n[Patient Info Abdominal Aortic Aneurysms](https://patient.info/doctor/abdominal-aortic-aneurysms)",
"files": null,
"highlights": [],
"id": "838",
"pictures": [],
"typeId": 2
},
"chapterId": 838,
"demo": null,
"entitlement": null,
"id": "883",
"name": "Abdominal aortic aneurysms",
"status": null,
"topic": {
"__typename": "Topic",
"id": "126",
"name": "Vascular Surgery",
"typeId": 2
},
"topicId": 126,
"totalCards": 12,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "883",
"name": "Abdominal aortic aneurysms"
}
],
"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": "883",
"name": "Abdominal aortic aneurysms"
}
],
"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": "883",
"name": "Abdominal aortic aneurysms"
}
],
"demo": false,
"description": null,
"duration": 686.51,
"endTime": null,
"files": null,
"id": "2",
"live": false,
"museId": "wFRkweA",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/surgery.png",
"title": "Abdominal aortic aneurysms 1\n",
"userViewed": false,
"views": 168,
"viewsToday": 13
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "883",
"name": "Abdominal aortic aneurysms"
}
],
"demo": false,
"description": null,
"duration": 237.06,
"endTime": null,
"files": null,
"id": "3",
"live": false,
"museId": "E8vHqDj",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/surgery.png",
"title": "Abdominal aortic aneurysms 2",
"userViewed": false,
"views": 77,
"viewsToday": 7
}
]
},
"conceptId": 883,
"conditions": [],
"difficulty": 1,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "10705",
"isLikedByMe": 0,
"learningPoint": "A ruptured abdominal aortic aneurysm requires immediate resuscitation with packed red cells, platelets, and fresh frozen plasma in a 1:1:1 ratio.",
"likes": 4,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 68-year-old male presents to A&E feeling generally unwell. He is unable to give a history as he is feeling light-headed. On examination, his abdomen is tender, and there is a pulsatile, expansile abdominal mass. Observations: HR 130bpm, RR 19 breaths per min, O2 saturations 98% on room air, BP 98/60mmHg, temperature 36.7. Blood tests show: \n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|121 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|1.9x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|38x10<sup>9</sup>/L|150 - 400|\n\nA CT scan is requested and he is prepared for immediate surgery.\n\n\nGiven the most likely diagnosis, which of the following will he require during his resuscitation?",
"sbaAnswer": [
"a"
],
"totalVotes": 2770,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,014 | false | 72 | null | 6,494,981 | null | false | [] | null | 10,706 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has thrombotic thrombocytopenic purpura (TTP), presenting with the classic pentad of symptoms: acute kidney injury, neurological features, microangiopathic haemolytic anaemia, low platelets, and fever. It is usually an acquired disorder of ADAMTS13, where neutralising antibodies against this metalloprotease results in accummulation of high molecular weight multimeters of Von Willebrand Factor, which are highly active. ADAMTS13 usually cleaves these HMW multimers. This leads to excess platelet activation and clumping, leading to microangiopathic haemolytic anaemia. The clotting cascade is not activated, and so clotting factors are not consumed, resulting in a normal PT, APTT, fibrinogen, and d-dimers. Definitive treatment is plasma exchange to remove circulating antibodies.",
"id": "53227",
"label": "a",
"name": "Plasma exchange",
"picture": null,
"votes": 1187
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Rituximab an anti-CD20 monoclonal antibody that depletes B cells, which produce antibodies that neutralise the ADAMTS13 protein. It may be considered in the management of TTP resistant to plasma exchange.",
"id": "53231",
"label": "e",
"name": "Rituximab",
"picture": null,
"votes": 262
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a monoclonal antibody that inhibits Von Willebrand Factor, and may be considered in the management of TTP resistant to plasma exchange.",
"id": "53230",
"label": "d",
"name": "Caplacizumab",
"picture": null,
"votes": 65
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Splenectomy may be considered in the management of TTP resistant to medical management. The spleen is responsible for making antibodies which block the ADAMTS13 protein. Removing the spleen means that antibodies are no longer made against the ADAMTS13 protein.",
"id": "53229",
"label": "c",
"name": "Splenectomy",
"picture": null,
"votes": 802
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Steroids may be considered in the management of TTP resistant to plasma exchange.",
"id": "53228",
"label": "b",
"name": "Steroids",
"picture": null,
"votes": 857
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Why does it say definitive treatment then give first line as correct answer? ",
"createdAt": 1676978063,
"dislikes": 0,
"id": "18640",
"isLikedByMe": 0,
"likes": 21,
"parentId": null,
"questionId": 10706,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Jaundice Dermis",
"id": 8483
}
},
{
"__typename": "QuestionComment",
"comment": "would splenectomy not be the definitive treatment?",
"createdAt": 1685177436,
"dislikes": 0,
"id": "26495",
"isLikedByMe": 0,
"likes": 3,
"parentId": null,
"questionId": 10706,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Retrograde Sclerosis",
"id": 15817
}
},
{
"__typename": "QuestionComment",
"comment": "why not ITP?\n",
"createdAt": 1709495997,
"dislikes": 1,
"id": "43643",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10706,
"replies": [
{
"__typename": "QuestionComment",
"comment": "I think the suddenness of the onset is more characteristic of TTP than ITP",
"createdAt": 1736700317,
"dislikes": 0,
"id": "60344",
"isLikedByMe": 0,
"likes": 0,
"parentId": 43643,
"questionId": 10706,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Dr Bob Kelso",
"id": 38800
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Zygomatic Gland",
"id": 45640
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nThrombotic Thrombocytopenic Purpura (TTP) is a disorder caused by abnormally cleaved von-Willebrand factor due to abnormal ADAMST13 activity, which leads to platelet aggregation, thrombus formation and systemic microangiopathy. Key signs and symptoms include fever, Microangiopathic haemolytic anaemia (MAHA), Thrombocytopenic purpura, CNS involvement and Acute Kidney Injury. Investigation through urine dipstick, FBC, U&E, clotting tests, blood film, LFT, LDH, D-dimer, and haptoglobin levels are crucial. Low ADAMST13 activity is diagnostic. Management strategies include steroids and plasma exchange.\n\n# Definition\n\nThrombotic Thrombocytopenic Purpura (TTP) is a disorder caused by abnormally cleaved von-Willebrand factor due to abnormal ADAMST13 activity. This condition leads to platelet aggregation, thrombus formation and systemic microangiopathy.\n\n\n# Causes\n\n- Hereditary: Congenital mutation of ADAMST13\n- Auto-immune: AI inhibition of ADAMST13\n\n\n# Clinical Features\n\nThe **pentad** to remember:\n\n- Fever\n- Microangiopathic haemolytic anaemia (MAHA)\n- Thrombocytopaenic purpura\n- CNS involvement: headache, confusion, seizures\n- AKI\n\n# Investigations\n\n- Urine dipstick may show haematuria and non-nephrotic range proteinuria\n- FBC shows a normocytic anaemia (secondary to haemolysis), thrombocytopenia, and possibly a raised neutrophil count\n- U&E shows a raised urea and creatinine\n- Clotting is typically normal\n- The blood film will reveal reticulocytes (secondary to haemolysis) and schistocytes (fragmented red cells)\n- LFT, LDH, D-dimer will be raised and haptopglobins will be low consistent with haemolysis\n- **Low ADAMST13 activity is diagnostic**\n\n# Management\n\n- Fresh frozen plasma (**FFP**) – contains vWF-cleaving protease and complement components \n- **Plasma exchange** – removes antibodies and toxins associated with the pathogenesis of the disease\n- High-dose steroids, low-dose aspirin and rituximab can also be given \n\n",
"files": null,
"highlights": [],
"id": "2682",
"pictures": [],
"typeId": 2
},
"chapterId": 2682,
"demo": null,
"entitlement": null,
"id": "3683",
"name": "Thrombotic thrombocytopenic purpura (TTP)",
"status": null,
"topic": {
"__typename": "Topic",
"id": "8",
"name": "Haematology",
"typeId": 2
},
"topicId": 8,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3683,
"conditions": [
{
"__typename": "Condition",
"id": "30",
"name": "Anaemia",
"topic": {
"__typename": "UkmlaTopic",
"id": "6",
"name": "Clinical haematology"
},
"topicId": 6
}
],
"difficulty": 2,
"dislikes": 19,
"explanation": null,
"highlights": [],
"id": "10706",
"isLikedByMe": 0,
"learningPoint": "Thrombotic thrombocytopenic purpura (TTP) is a life-threatening blood disorder treated primarily with plasma exchange, which removes harmful substances and restores functional ADAMTS13",
"likes": 2,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "469",
"name": "Purpura",
"topic": {
"__typename": "UkmlaTopic",
"id": "6",
"name": "Clinical haematology"
},
"topicId": 6
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 32-year-old female presents to A&E following a seizure. She is post-ictal and unable to give a history. On examination, she has a low grade fever and has multiple purpura across her body. There is no evidence of meningism. Her blood tests show the following: \n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|54 g/L|(M) 130 - 170, (F) 115 - 155|\n|Platelets|22x10<sup>9</sup>/L|150 - 400|\n\nHer creatinine is raised, but no baseline is available. A blood film reveals schistocytes. Her PT, APTT, fibrinogen, and d-dimers are within normal range.\n\n\nWhat is is the definitive treatment for this presentation?",
"sbaAnswer": [
"a"
],
"totalVotes": 3173,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,015 | false | 73 | null | 6,494,981 | null | false | [] | null | 10,707 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Acamprosate is a medication prescribed to patients who have already successfully achieved abstinence, to prevent relapse through reducing cravings. This patient has not reached that stage yet.",
"id": "53236",
"label": "e",
"name": "Prescribe acamprosate",
"picture": null,
"votes": 77
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct because this patient is willing to quit alcohol and she needs further advice on how to do so. A GP can either refer patients to local drug and alcohol services or offer treatment at the practice. Patients who are not comfortable approaching the GP also have the option to self-refer to the local drug and alcohol service. Patient activation measures assess the knowledge, skills and confidence of patients to manage their health and has been consistently used as an outcome measure of health interventions. In this case, level 3 suggests that this patient is willing to take action, that she has good self-management skills, and feels that she is part of the healthcare team.",
"id": "53232",
"label": "a",
"name": "Referral to local community drug and alcohol services",
"picture": null,
"votes": 2383
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients must first be assessed by community drug and alcohol services, who will try to aid abstinence in the community. If community support fails, referral may be made for intensive rehabilitation, and so this is not the next step.",
"id": "53234",
"label": "c",
"name": "Refer to intensive rehabilitation",
"picture": null,
"votes": 101
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Chlordiazepoxide is a short acting benzodiazepine drug used to aid alcohol detoxification since it ameliorates the side-effects of alcohol withdrawal and protects against life threatening delirium tremens. Detoxification programmes using chlordiazepoxide need careful planning with the support of local drug and alcohol services and as such the patient needs to be referred to see them first before this is commenced. Detox is usually done as an inpatient, but community detoxification programmes are being increasingly undertaken.",
"id": "53233",
"label": "b",
"name": "Prescribe chlordiazepoxide",
"picture": null,
"votes": 83
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient may require cognitive behavioural therapy if she has problems with her mental health in terms of mood and anxiety. However, this is not her current priority, and she seems to be managing her mental health well. Cognitive behavioural therapy referral at this stage will not directly assist her desire to overcome her addiction to alcohol, and as such does not represent the best next step.",
"id": "53235",
"label": "d",
"name": "Refer for cognitive behavioural therapy",
"picture": null,
"votes": 199
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nHarmful alcohol consumption is very common in the UK, and prolonged periods of alcohol excess can lead to dependence. An important complication of alcohol dependence is acute withdrawal, when patients abruptly stop drinking or significantly reduce their alcohol consumption. Key signs and symptoms of withdrawal include agitation, tremor, nausea and vomiting, sweating and hallucinations. Seizures can occur, usually 24-48 hours after stopping drinking. Delirium tremens describes severe alcohol withdrawal characterised by delirium, haemodynamic instability and autonomic instability. Management strategies involve monitoring for symptoms of alcohol withdrawal using the CIWA scoring tool, giving a reducing course of benzodiazepines (usually chlordiazepoxide) and giving Pabrinex to prevent Wernicke-Korsakoff syndrome.\n \n\n# Definition\n \nAlcohol withdrawal is a syndrome that occurs when a patient who is alcohol dependent suddenly stops or drastically reduces their alcohol consumption. There are several stages of alcohol withdrawal that occur over the days following stopping drinking, and severity of withdrawal symptoms ranges from mild symptoms of tremor and insomnia to life-threatening manifestations such as delirium tremens or withdrawal seizures. \n \n# Epidemiology\n \n- Alcohol misuse is very common in the UK, with an estimated 24% of adults drinking in a harmful or hazardous way.\n- Around 600,000 adults in England are thought to be dependent on alcohol and so at risk of alcohol withdrawal.\n- Only 18% of these people with alcohol dependence are receiving treatment.\n- In England, there are approximately 1 million alcohol related hospital admissions per year (although alcohol withdrawal represents only a proportion of these)\n\n# Aetiology\n \nChronic alcohol excess causes tolerance to its effects, with reduced GABA and increased glutamate activity in the brain. The patient then relies on alcohol to balance this, and so when they stop drinking the imbalance manifests leading to excess glutamate and over-stimulation of the central nervous system. \n\nPatients often develop alcohol withdrawal after hospital admission as they are unable to maintain their normal intake whilst an inpatient.\n\nOther cases may occur when a patient decides to go \"cold turkey\" and stop drinking - patients should be advised to seek help to cut down on their alcohol intake safely.\n\n# Signs and Symptoms\n \nFrom 6 to 12 hours after the last drink, mild withdrawal symptoms may occur:\n\n- Insomnia\n- Tremors\n- Anxiety\n- Agitation\n- Nausea and vomiting\n- Sweating\n- Palpitations\n\nAt 12-24 hours, alcohol hallucinosis may begin:\n\n- Visual hallucinations\n- Auditory hallucinations\n- Tactile disturbances e.g. sensations of crawling bugs on the skin\n\nAlcohol withdrawal seizures are most likely to occur at 24-48 hours - these are usually generalised and tonic-clonic in nature.\n\nAt 48-72 hours, delirium tremens may occur:\n \n- Delirium and agitation\n- Hallucinations and delusions\n- Tachycardia\n- Hypertension\n- Hyperthermia\n- Diaphoresis\n- Coarse tremor\n \n# Differential Diagnosis\n\n- **Benzodiazepine withdrawal**: shares symptoms of insomnia, anxiety, tremor, sweating and nausea, and can also cause seizures; may coexist with alcohol withdrawal and is managed similarly with tapering doses of benzodiazepines. \n- **Sepsis**: can cause delirium and agitation, tachycardia and diaphoresis; hypotension is more common than the hypertension seen in severe alcohol withdrawal and patients may have focal signs of infection.\n- **Hepatic encephalopathy**: may occur in patients with decompensated cirrhosis secondary to alcohol, and has similar symptoms of tremor and confusion; ammonia will be elevated and there is often a background of chronic liver disease.\n- **Psychosis**: e.g. secondary to schizophrenia may cause similar symptoms of hallucinations, delusions and agitation.\n- **Hypoglycaemia**: causes similar symptoms of anxiety, agitation, tremor and diaphoresis; increased risk in patients who drink alcohol.\n\n# Investigations\n \n**Bedside tests:**\n\n- **ECG** - arrhythmias and other abnormalities (e.g. QT prolongation) may be seen in severe alcohol withdrawal\n- **Capillary blood glucose** for hypoglycaemia \n\n**Blood tests:**\n\n- **FBC** and **CRP** for inflammatory markers\n- **LFTs** for alcoholic liver disease\n- **U&Es** for baseline renal function and electrolytes\n- **Bone profile** and **magnesium** to monitor electrolytes for refeeding syndrome\n- **Blood cultures** if there are signs of infection\n\n**Imaging:**\n\n- **Chest X-ray** if there are signs of aspiration, especially if the patient has had a seizure or has a low GCS\n- **CT head** if evidence of head injury or ongoing seizures\n\n# Management\n \n- Patients presenting with or at risk of seizures or delirium tremens, or those who are vulnerable, frail or with significant comorbidities should be admitted for medical treatment of alcohol withdrawal\n- This involves use of the CIWA (Clinical Institute Withdrawal Assessment of Alcohol) scoring system, which is a standardised way of assessing severity of alcohol withdrawal symptoms in the following domains:\n - Nausea and vomiting\n - Tremor\n - Sweating\n - Anxiety\n - Agitation\n - Tactile disturbances\n - Auditory disturbances\n - Visual disturbances\n - Headache\n - Orientation\n- Each domain is scored from 0-7 other than orientation which is 0-4\n- A total score of 0-9 represents mild or no withdrawal, 10-19 is moderate withdrawal and > 20 is severe withdrawal\n- Higher scores warrant more frequent monitoring of symptoms\n- The CIWA score is used to guide prescription of benzodiazepines, which may be given PRN to manage withdrawal symptoms or regularly in a fixed-dose reducing regime over several days (plus PRNs when required)\n- Chlordiazepoxide is the first line benzodiazepine used, with oxazepam or lorazepam (shorter-acting benzodiazepines) being used for patients with liver disease\n- Alcohol withdrawal seizures should be treated with short acting benzodiazepines (e.g. IV lorazepam) in the first instance\n- Delirium tremens is also treated with oral lorazepam, with parenteral lorazepam or haloperidol being second line options\n- Pabrinex (1 pair of ampoules once daily) should be given to prevent Wernicke's encephalopathy - if there are signs or symptoms such as ataxia or nystagmus, give treatment dose (two pairs of ampoules TDS)\n- Monitor bloods for refeeding syndrome in malnourished patients\n- Ensure patients are followed up on discharge and referred to community support services\n\n# NICE Guidelines\n\n[NICE - Alcohol-use disorders: diagnosis and management of physical complications](https://www.nice.org.uk/guidance/cg100/)\n \n[NICE CKS - Alcohol Withdrawal](https://cks.nice.org.uk/topics/alcohol-problem-drinking/management/alcohol-misuse/)\n \n# References\n\n[BNF - Alcohol Dependence](https://bnf.nice.org.uk/treatment-summaries/alcohol-dependence/) \n\n[RCEM Learning - Acute Alcohol Withdrawal](https://www.rcemlearning.co.uk/reference/acute-alcohol-withdrawal/)\n\n[Patient UK - Acute alcohol withdrawal and delirium tremens](https://patient.info/doctor/acute-alcohol-withdrawal-and-delirium-tremens)",
"files": null,
"highlights": [],
"id": "718",
"pictures": [],
"typeId": 2
},
"chapterId": 718,
"demo": null,
"entitlement": null,
"id": "750",
"name": "Alcohol withdrawal",
"status": null,
"topic": {
"__typename": "Topic",
"id": "23",
"name": "Gastroenterology",
"typeId": 2
},
"topicId": 23,
"totalCards": 10,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "750",
"name": "Alcohol withdrawal"
}
],
"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
}
]
},
"conceptId": 750,
"conditions": [],
"difficulty": 1,
"dislikes": 3,
"explanation": null,
"highlights": [],
"id": "10707",
"isLikedByMe": 0,
"learningPoint": "Referral to community drug and alcohol services is essential for patients with liver cirrhosis seeking support to quit alcohol.",
"likes": 1,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 37-year-old female presents to the GP concerned about her recent diagnosis of liver cirrhosis secondary to chronic alcoholism. Her past medical history includes moderate depression and chronic fatigue syndrome. She is managing both conditions well. However, she does not have any support at home or at work and she lives alone. Her GP conducts a motivational interview and concludes that she is keen to quit alcohol but she is unsure about how to do this. Her GP measures her patient activation level as 3.\n\nWhich of the following is the next best step in the management of this patient?",
"sbaAnswer": [
"a"
],
"totalVotes": 2843,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,016 | false | 74 | null | 6,494,981 | null | false | [] | null | 10,708 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Osteoarthritis presents with chronic joint pain made worse on activity. There are no associated blood abnormalities or increased risk of fractures, and so this diagnosis does not, therefore, explain the clinical presentation.",
"id": "53240",
"label": "d",
"name": "Osteoarthritis",
"picture": null,
"votes": 39
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has renal impairment, anaemia, hypercalcaemia, and evidence of fractures. These characteristics make myeloma the most likely diagnosis. Myeloma is a haematological malignancy caused by the clonal proliferation of plasma cells which secrete monoclonal antibodies. Myeloma investigation requires a combination of serum immunoglobulins, serum protein electrophoresis, and serum free light chains, to identify a monoclonal gammopathy with isotype suppression. Serum free light chains function in lieu of urinary Bence Jones proteins, which are liable to false negative results if not processed rapidly. The ALP is normal in multiple myeloma.",
"id": "53237",
"label": "a",
"name": "Multiple myeloma",
"picture": null,
"votes": 3313
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Light chain amyloidosis is a potential complication of multiple myeloma. Amyloidosis can cause dysfunction in virtually any organ due to widespread deposition of the proteins. This patient may well have amyloidosis secondary to his multiple myeloma, but this does not represent the underlying diagnosis, and so the better answer is multiple myeloma. Histology of fat biopsies (taken from samples of the rectum or abdomen) typically shows apple green birefringence with congo red stain under polarised light.",
"id": "53241",
"label": "e",
"name": "Amyloid light chain amyloidosis",
"picture": null,
"votes": 88
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Waldenstrom's macroglobulinaemia is a lymphoplasmacytic lymphoma (non-Hodgkin) where there is excess production of IgM paraprotein. The clinical features of myeloma are absent, such as hypercalcaemia, bone lesions (which are characteristically lytic), anaemia, and kidney disease, and the patient presents with hyperviscosity syndrome instead (such as bleeding gums, blurred vision, headache, confusion.) Since this is a lymphoma, lymphadenopathy and hepatosplenomegaly may be present. These features are not present in this case.",
"id": "53238",
"label": "b",
"name": "Waldenstrom's macroglobulinemia",
"picture": null,
"votes": 82
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Paget's disease is usually found incidentally on a blood test with an isolated raised ALP. It clinically presents with bone pain and pathological fractures. This question stem eludes to the use of a back brace secondary to a recent compression fracture. Although this is expected for myeloma and Paget's, you would expect to see bony deformities in Paget's disease (such as frontal bossing), as well as a raised ALP.",
"id": "53239",
"label": "c",
"name": "Paget's disease",
"picture": null,
"votes": 153
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "give reference ranges.",
"createdAt": 1686933686,
"dislikes": 2,
"id": "28916",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10708,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Bartholin Cyst",
"id": 22117
}
},
{
"__typename": "QuestionComment",
"comment": "why is every answer multiple myeloma",
"createdAt": 1732621959,
"dislikes": 0,
"id": "57580",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10708,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Kawasaki Body ",
"id": 46030
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary \n\nMultiple myeloma is a malignant plasma cell dyscrasia characterized by the proliferation of abnormal plasma cells in the bone marrow. These plasma cells secrete monoclonal antibodies (most commonly of the Ig subtype) and antibody fragments into the serum and the urine. There is also a relative deficiency of functional antibodies, resulting in a relative hypogammaglobulinaemia. This condition leads to bone destruction, kidney dysfunction, anaemia, and a range of systemic symptoms. Multiple myeloma primarily affects older adults and is associated with genetic and environmental factors. The management of multiple myeloma involves a combination of chemotherapy, immunomodulatory drugs, and stem cell transplantation, aiming to control the disease, alleviate symptoms, and improve overall survival.\n\n# Definition\n\nMultiple myeloma is a **plasma cell dyscrasia** characterised by abnormal clonal proliferation of post-germinal B cells (plasma cells)\n\n\n# Epidemiology\n\nMultiple myeloma is the second most common haematologic malignancy, accounting for approximately 1% of all cancers. It predominantly affects older adults, with the median age at diagnosis around 69 years, and those of Afro-Caribbean descent are affected twice as frequently as Caucasians, and men more than women.\n\n# Aetiology\n\nThe development of multiple myeloma is multifactorial. It is associated with several risk factors, including genetic predisposition, exposure to radiation or certain chemicals, and immunosuppressive conditions.\n\n\n\n\n# Signs and Symptoms\n\nThe clinical features of multiple myeloma can be remembered by the mnemonic CRAB HAI:\n\n- Hyper**C**alcaemia – arises primarily owing to increased osteoclast-mediated bone resorption. Results in: moans (painful bones), stones (renal stones), groans (GI symptoms) and psychiatric moans (neurological effects such aslethargy, fatigue, memory loss, psychosis, depression)\n- **R**enal impairment – occurs because of multiple factors (eg. light chain deposition in the kidneys and hypercalcaemia)\n- **A**naemia – other cytopenias (eg. thrombocytopenia and leukopenia) can also occur due to marrow infiltration by the tumour \n- **B**one pathology – **Back pain** is very common. Osteolytic lesions are common, which can lead to pathological fractures and vertebral compression fractures\n- **H**yperviscosity – can present with headache, visual disturbance and thrombosis\n- **A**myloidosis (AL subtype) – can have multiple sequelae including cardiac failure and neuropathy\n- **I**nfection – recurrent infection occurs secondary to leukopenia and immunoparesis (ie. low levels of functional IgG)\n\n# Differential Diagnosis\n\n* **Monoclonal Gammopathy of Undetermined Significance (MGUS):** MGUS is a precursor condition to multiple myeloma, characterized by the presence of M-proteins. It is typically asymptomatic and does not meet the criteria for myeloma.\n* **Waldenström Macroglobulinaemia:** This condition, like myeloma, involves the overproduction of immunoglobulins, but it predominantly affects B cells and presents with hyperviscosity syndrome and lymphoplasmacytic lymphoma.\n* **Amyloidosis:** Amyloidosis can manifest with similar symptoms, including renal dysfunction, but it results from the deposition of abnormal protein fibers (amyloids) rather than the proliferation of plasma cells.\n\n# Investigations\n\nInvestigations can be classified into those that form part of the initial work-up, diagnostic tests and investigations to inform prognosis.\n\n- Work-up investigations\n\n - **FBC** – may show anaemia\n - **U&E** – may show renal impairment (particularly raised serum creatinine) and/or hypercalcaemia (with normal ALP), which is a common feature\n - Raised ESR (the positive charge of the protein neutralises the negative charge of the sialic acid on the red cell membrane, reducing the red cells natural tendency to repulse each other, so they fall down the column faster)\n - **Skeletal survey** – typically done with X-rays, but CT/MRI are more sensitive\n - Findings include osteolytic bone lesions and pathological fractures\n\n- Diagnostic investigations\n\n - **Serum and/or urine electrophoresis** – This will show a paraprotein spike (typically IgG)\n - **Serum free light chain** assay (Bence Jones protein)\t\n \t\t- Can be kappa or lambda \n \t- Serum-free light chain levels are high in myeloma\n \t - can be a useful test in the 1–2% of patients with nonsecretory multiple myeloma (ie. those who do not have a serum/urine monoclonal protein on electrophoresis)\n\n - Tissue diagnosis typically by **bone marrow** aspirate and biopsy \n - Myeloma is confirmed if there are >10% plasma cells in the bone marrow\n\n\n# Management \n\nMyeloma can present as an acute emergency: \n\n- Acute renal failure – swift treatment of volume depletion is critical, as well as early involvement of renal physicians \n- Hypercalcaemia – fluid and bisphosphonates needed\n- Hyperviscosity – requires plasmapheresis\n- Spinal cord compression – should be treated as a radiotherapy emergency\n\nSpecific treatment for myeloma depends on the presence of poor prognostic factors and comorbidities – there is no complete cure for myeloma but treatments attempt to induce remission.\n\n- **Conservative management**\n - An option for patients with minimal symptoms and no end-organ damage\n - Patients will require regular follow-up, with consideration of initiation of therapy when/if signs of active disease appear\n\n- **Haematopoietic stem cell transplantation**\n\n - A treatment option for younger patients who have minimal comorbidities – most haematologists will consider this option up to the age of 70 years\n - The patient will require **induction therapy** with a nonchemotherapeutic (eg. bortezomib, thalidomide and dexamethasone) (VTD) given together with Daratumumab (monoclonal antibody binding CD38) (DVTD). The standard upfront trajectory for myeloma is DVTD then Autograft then DVTD consolidation then Lenalidomide maintenance.\n \n - Non-chemotherapeutic options are replacing chemotherapeutic options as they have a lower toxicity rate.\n\n - A **conditioning regimen** (high-dose melphalan) followed by **autologous stem cell transplant** is the preferred option\n\n - Autologous transplants have a low transplant mortality rate (<1%), but also a lower remission rate (40%) than allogeneic transplants\n\n - Allogeneic transplants have a higher transplant mortality rate but also a higher remission rate\n\n\n- **Patients unsuitable for stem cell transplantation**\n - The standard of care for such patients is melphalan, prednisolone and thalidomide (MPT)\n - This induces good event-free survival\n - Lenalidomide (antiangiogenic) is an alternative to thalidomide\n - Most patients will relapse after initial treatment\n - Further combination therapies of thalidomide, melphalan, lenalidomide, bortezomib (proteasome inhibitor) or dexamethasone can be used such as VMP.\n\n\n- **Supportive management**\n\nPatients should be monitored regularly, with the frequency of monitoring depending on how aggressive their disease is.\n\n# Complications\n\n* **Bone Disease:** Multiple myeloma often leads to bone destruction, pathological fractures, and skeletal-related events. Treatment includes bisphosphonates and denosumab to strengthen bones.\n* **Renal Dysfunction:** Kidney impairment is a common complication, requiring close monitoring and potential interventions.\n* **Infections:** Patients with myeloma are at increased risk of infections due to weakened immune function. Preventative measures and prompt treatment are essential. Influenza and pneumococcal vaccination should be given for infection prevention.\n* **Anaemia:** Should be managed with erythropoietin (± transfusion) for anaemia\n\n# Prognosis\n\nThe prognosis in multiple myeloma is influenced by various factors that help assess the overall outlook and guide treatment decisions. One significant prognostic tool is the International Staging System (ISS), which stratifies patients into three stages based on the levels of two serum markers: beta-2 microglobulin and albumin.\n\n- Investigations to inform prognosis include:\n\n - **β2 microglobulin** (a very high or very low level confers poor prognosis)\n\t - Used in the staging of myeloma by the International Staging System (ISS), which relates to β2 microglobulin and albumin levels\n - **LDH** (the higher the level, the worse the prognosis)\n - CRP (the higher the level, the worse the prognosis)\n - FISH and cytogenetic analysis – This may also inform the type of treatment used\n\n**Note**: High serum creatinine and low albumin are also poor prognostic markers.\n\n- Median survival for myeloma is 50% at 5 years.\n- High ISS is associated with poor prognosis.\n\n# NICE Guidelines\n\n[NICE CKS - Multiple Myeloma](https://cks.nice.org.uk/topics/multiple-myeloma/)",
"files": null,
"highlights": [],
"id": "368",
"pictures": [
{
"__typename": "Picture",
"caption": "A lytic lesion secondary to multiple myeloma.",
"createdAt": 1665036193,
"id": "754",
"index": 0,
"name": "Myeloma - lytic lesion.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/oc16176x1665036171705.jpg",
"path256": "images/oc16176x1665036171705_256.jpg",
"path512": "images/oc16176x1665036171705_512.jpg",
"thumbhash": "GAgKAwCvcVaXd3Z2AAAAAAA=",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
},
{
"__typename": "Picture",
"caption": "The typical appearance of multiple myeloma.",
"createdAt": 1665036193,
"id": "771",
"index": 1,
"name": "Multiple myeloma.jpeg",
"overlayPath": null,
"overlayPath256": null,
"overlayPath512": null,
"path": "images/zma0yvcb1665036171705.jpg",
"path256": "images/zma0yvcb1665036171705_256.jpg",
"path512": "images/zma0yvcb1665036171705_512.jpg",
"thumbhash": "s0YGFYL5nqd2mIdmiZd5e/h3VoCY",
"topic": null,
"topicId": null,
"updatedAt": 1708373886
}
],
"typeId": 2
},
"chapterId": 368,
"demo": null,
"entitlement": null,
"id": "373",
"name": "Myeloma",
"status": null,
"topic": {
"__typename": "Topic",
"id": "8",
"name": "Haematology",
"typeId": 2
},
"topicId": 8,
"totalCards": 12,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "373",
"name": "Myeloma"
}
],
"demo": false,
"description": null,
"duration": 352.88,
"endTime": null,
"files": null,
"id": "236",
"live": false,
"museId": "1ZxgtoN",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/hematology.png",
"title": "Myeloma",
"userViewed": false,
"views": 228,
"viewsToday": 15
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "373",
"name": "Myeloma"
}
],
"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
}
]
},
"conceptId": 373,
"conditions": [
{
"__typename": "Condition",
"id": "436",
"name": "Multiple myeloma",
"topic": {
"__typename": "UkmlaTopic",
"id": "3",
"name": "Cancer"
},
"topicId": 3
}
],
"difficulty": 1,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "10708",
"isLikedByMe": 0,
"learningPoint": "Multiple myeloma is characterised by renal impairment, anaemia, hypercalcaemia, and bone fractures due to clonal plasma cell proliferation.",
"likes": 1,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "263",
"name": "Fatigue",
"topic": {
"__typename": "UkmlaTopic",
"id": "3",
"name": "Cancer"
},
"topicId": 3
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 61-year-old male under investigation for a 6 month history of fatigue returns to his GP for follow up results of his blood tests. On examination, he is wearing a back brace as he has sustained a recent vertebral fracture. His blood test results show: \n\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|97 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|2.1 x10<sup>9</sup>/L|3.0 - 10.0|\n|Sodium|140 mmol/L|135 - 145|\n|Potassium|4.1 mmol/L|3.5 - 5.3|\n|Urea|7.9 mmol/L|2.5 - 7.8|\n|Calcium|3.1 mmol/L|2.2 - 2.6|\n|eGFR|49 mL/min/1.73m<sup>2</sup>|> 60|\n\nLiver function tests are normal.\n\n\nWhich of the following is the most likely underlying diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 3675,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,017 | false | 75 | null | 6,494,981 | null | false | [] | null | 10,709 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Diabetes insipidus presents with polyuria and polydipsia. The patients are at risk of dehydration, and sodium levels tend to trend towards the upper limit of normal. Potassium and blood pressure are spared (unless there is profound dehydration.) Therefore, diabetes insipidus is not in keeping with the clinical picture of this question.",
"id": "53244",
"label": "c",
"name": "Cranial diabetes insipidus",
"picture": null,
"votes": 21
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Cushing's syndrome, which occurs due to cortisol excess, may be associated with hypertension, alongside the other classical clinical features of Cushing's such as striae, bruising, and central adiposity (which are absent in this case.) Cortisol has a mild mineralocorticoid effect, which can cause similar changes with a high sodium and low potassium. However, these changes are usually more mild, and in the absence of clinical feature's of Cushing's, this diagnosis remains unlikely.",
"id": "53246",
"label": "e",
"name": "Cushing's syndrome",
"picture": null,
"votes": 171
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient is presenting with hypertension, raised sodium, and low potassium levels, and so the most likely diagnosis is hyperaldosteronism, which results in excess sodium absorption at the expense of potassium and is a secondary cause of hypertension. Muscle weakness and paraesthesiae are precipitated by the electrolyte abnormalities. Conn's syndrome refers to hyperaldosteronism secondary to an adrenal adenoma.",
"id": "53242",
"label": "a",
"name": "Primary hyperaldosteronism",
"picture": null,
"votes": 1069
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Addison's disease is primary adrenal insufficiency, resulting in deficiencies of cortisol and mineralocorticoids. This results in hypotension, low sodium, and raised potassium, which is opposite to the current clinical picture.",
"id": "53243",
"label": "b",
"name": "Addison's disease",
"picture": null,
"votes": 101
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Secondary hyperparathyroidism is an appropriate response of the parathyroid glands to hypocalcaemia. This patient's calcium levels are within normal range, but this would not necessarily exclude secondary hyperparathyroidism since the PTH may have successfully returned the calcium to normal. A PTH level will be required (which will be inappropriately raised despite the normal calcium) to confirm the diagnosis. However, secondary hyperparathyroidism would not explain the hypertension, the low potassium, or the raised sodium.",
"id": "53245",
"label": "d",
"name": "Secondary hyperparathyroidism",
"picture": null,
"votes": 59
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nHyperaldosteronism, either primary or secondary, is typically associated with treatment-resistant hypertension and hypokalaemia. Key symptoms include polyuria, polydipsia, lethargy, and headaches, with a noted association with osteoporosis. Causes include adrenal adenoma (Conn's Syndrome), bilateral adrenal hyperplasia, familial hyperaldosteronism, and adrenal carcinoma. Key investigations encompass blood tests such as FBC/UE/LFT, ESR, Bone profile, thyroid function tests, imaging techniques such as chest X-ray and CT/MRI, and notably, aldosterone/renin ratio and selective adrenal venous sampling. The mainstay of management is identifying the underlying cause and if applicable, surgically removing the affected adrenal gland or using medication such as potassium-sparing diuretics for bilateral adrenal disease.\n\n# Definition\n\nHyperaldosteronism is a medical condition where there is overproduction of aldosterone hormone by the adrenal glands, resulting in fluid retention, high blood pressure, and low serum potassium levels. This condition can be primary (originating from the adrenal glands themselves) or secondary (caused by processes outside the adrenal glands).\n\nNB: Secondary hyperaldosteronism can also occur due to conditions outside the adrenal glands, such as renal artery stenosis, reduced renal perfusion, and increased renin production.\n\n# Epidemiology\n\nPrimary hyperaldosteronism is considered the most common form of secondary hypertension, affecting approximately 6-13% of patients with hypertension.\n\n# Aetiology\n\nThe causes of hyperaldosteronism include:\n\n- Adrenal adenoma (Conn's Syndrome): Often associated with primary hyperaldosteronism.\n- Bilateral adrenal hyperplasia: Common cause of Conn's Syndrome.\n- Familial hyperaldosteronism: Rare genetic conditions leading to excessive aldosterone production.\n- Adrenal carcinoma: A rare malignant growth within the adrenal gland.\n\n# Signs and Symptoms\n\nPatients with hyperaldosteronism may present with:\n\n- Polyuria: Increased frequency of urination.\n- Polydipsia: Increased thirst.\n- Lethargy: Persistent tiredness and fatigue.\n- Headaches: Often severe and frequent.\n- Association with osteoporosis: There is an increased risk of osteoporosis due to excessive excretion of calcium in the urine.\n\n# Differential Diagnosis\n\nConditions that may mimic hyperaldosteronism include:\n\n- Essential hypertension: Characterised by high blood pressure with no identifiable cause.\n- Cushing's syndrome: It includes signs of weight gain, particularly around the waist and face, a rounded \"moon\" face, thinning skin, and easy bruising.\n- Pheochromocytoma: Symptoms can include episodic headaches, sweating episodes, palpitations, and pallor.\n\n# Investigations\n\nTo diagnose hyperaldosteronism, the following tests are commonly used:\n\n- First-line:\n\t- Aldosterone/Renin ratio: A high ratio is suggestive of hyperaldosteronism.\n- Second-line:\n\t- High-Resolution CT (HRCT) or MRI: To locate potential adrenal lesions.\n\t- Selective adrenal venous sampling: Considered the gold standard for localising the source of excess aldosterone, especially when distinguishing between Conn's Syndrome and bilateral adrenal hyperplasia.\n\n# Management\n\nThe management of hyperaldosteronism includes:\n\n- Identifying the underlying cause: Using imaging or selective adrenal venous sampling.\n- Surgical intervention: If the excess aldosterone is due to a tumour or lesion, removing the affected adrenal gland may be necessary.\n- Medication: In cases of bilateral adrenal disease, medications such as potassium-sparing diuretics (e.g., Amiloride, Spironolactone, Eplerenone) are used to manage the condition.\n\n\n\n# References\n\n[Patient.info - Hyperaldosteronism](https://patient.info/doctor/hyperaldosteronism)\n\n[GPnotebook - Conn's syndrome](https://gpnotebook.com/simplepage.cfm?ID=-1335164924)",
"files": null,
"highlights": [],
"id": "663",
"pictures": [],
"typeId": 2
},
"chapterId": 663,
"demo": null,
"entitlement": null,
"id": "2202",
"name": "Hyperaldosteronism and Conn's syndrome",
"status": null,
"topic": {
"__typename": "Topic",
"id": "36",
"name": "Clinical Chemistry",
"typeId": 2
},
"topicId": 36,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2202,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10709",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 3,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 43-year-old male presents to A&E with muscle weakness and tingling. He says this has occurred intermittently for the past 2 months but he has never consulted a doctor about it. His vitals show a blood pressure of 160/95 mmHg. Blood tests show: \n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|148 mmol/L|135 - 145|\n|Potassium|2.0 mmol/L|3.5 - 5.3|\n|Calcium|2.4 mmol/L|2.2 - 2.6|\n\n\nWhich of the following is the most likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 1421,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,018 | false | 76 | null | 6,494,981 | null | false | [] | null | 10,710 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a possible differential and distinguishing schizophrenia from mood disorders with psychosis can be difficult, especially since the negative symptoms of schizophrenia can mimic mood disorders closely. Since this patient's psychosis is occurring in the context of a clear, preceding mood disorder, it makes a diagnosis of schizophrenia less likely. Schizophrenia patients will exhibit psychosis in the absence of an identifiable mood disorder. Additional features, such as thought insertion/withdrawal/broadcasting, made impulses, and somatic passivity, make a diagnosis of schizophrenia more likely, which are absent in this case.",
"id": "53248",
"label": "b",
"name": "Schizophrenia",
"picture": null,
"votes": 363
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Bipolar affective disorder presents with periods of mania and depression. Though this patient reports symptoms of depression, there is no report of episodes of mania, where patients typically experience increased energy, elevated mood, reduced need for sleep, and mood congruent psychotic symptoms including grandiose delusions and hallucinations.",
"id": "53250",
"label": "d",
"name": "Bipolar affective disorder",
"picture": null,
"votes": 97
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Drug induced psychosis is an important differential, and a comprehensive drug history, and potential drug screen, can be useful in patients presenting with first episodes of psychosis. This question does not refer to the consumption of any drugs, and therefore this option is less likely than psychotic depression.",
"id": "53251",
"label": "e",
"name": "Drug-induced psychosis",
"picture": null,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is important to rule out organic conditions in patients presenting with mental health disturbance, and space occupying lesions can be associated with psychosis. However, the patient does not have other clinical features of a tumour, such as headaches, weight loss, or neurological disturbance. There is also a life event that has triggered his symptoms in the form of his wife leaving him. As such, an organic cause is unlikely.",
"id": "53249",
"label": "c",
"name": "Cerebral tumour",
"picture": null,
"votes": 3
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has had a depressive episode lasting more than two weeks, as indicated by the presence of low mood, anhedonia, and loss of appetite. He is also experiencing psychotic symptoms (auditory hallucinations and delusions of reference.) This is termed psychotic depression because he has a major depressive disorder with symptoms of mood congruent psychotic symptoms.",
"id": "53247",
"label": "a",
"name": "Psychotic depression",
"picture": null,
"votes": 3787
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "is psychotic depression the same as schizoaffective disorder?",
"createdAt": 1686061423,
"dislikes": 2,
"id": "28019",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10710,
"replies": [
{
"__typename": "QuestionComment",
"comment": "psychotic depression: psychotic symptoms only appear during episodes of severe depression and resolve when mood improves. the psychosis usually aligns with depressive themes.\n\nschizoaffective disorder: involves both psychotic and mood symptoms, with psychosis occurring independently of mood episodes for at least two weeks, making it part of the schizophrenia spectrum.\n\nmanagement -> schizoaffective disorder typically requires antipsychotic medication even outside of mood episodes, while psychotic depression focuses primarily on managing depression and the associated psychosis.",
"createdAt": 1731195432,
"dislikes": 0,
"id": "56887",
"isLikedByMe": 0,
"likes": 0,
"parentId": 28019,
"questionId": 10710,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "The Happy Hypopyon",
"id": 41518
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Intubation Hypertension",
"id": 28779
}
},
{
"__typename": "QuestionComment",
"comment": "Can you diagnose someone with depression, when they only have 3 sx as presented in the clinical vignette above. Dont you need like 5 out of 9 sx (MSIGECAPS) [but must have at least 1 of the core sx- either anhedonia or low mood] present for 2 weeks in order to dx depression?",
"createdAt": 1728171823,
"dislikes": 0,
"id": "55510",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10710,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "NMDAr encephalitis",
"id": 31039
}
},
{
"__typename": "QuestionComment",
"comment": "what if his wife is just psycho",
"createdAt": 1730765865,
"dislikes": 0,
"id": "56608",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10710,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "streptocockus",
"id": 36854
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nDepression is a common mental health disorder typified by low mood, anhedonia, significant weight change, sleep and activity changes, fatigue, feelings of guilt or worthlessness, or poor concentration. It is defined by the DSM as the presence of 5 out of 8 symptoms for at least 2 weeks. It is more prevalent in females. Key investigations include FBC, TFT, U+E, LFT, Glucose, B12/folate, cortisol, toxicology screen, and CNS imaging to rule out organic causes. Management strategies encompass low to high intensity psychological interventions, pharmacotherapy including anti-depressants, and in severe cases, lithium or ECT.\n\n# Definition\n\nDepression is a mental health disorder characterised by:\n\n- **ICD-11 Criteria:**\n - Depressive Episode: Depressed mood, loss of interest (anhedonia), and reduced energy (fatigue) persisting for at least two weeks.\n\n- **DSM-V Criteria:**\n - Major Depressive Disorder (MDD): Presence of a major depressive episode lasting at least two weeks, with specific criteria regarding mood, cognitive, and physical symptoms.\n - Persistent Depressive Disorder (Dysthymia): A chronic form of depression lasting for at least two years. \n\nThis consists of the presence of at least five out of a possible eight defining symptoms, during the same two-week period, where at least one of the symptoms is depressed mood or loss of interest or pleasure\n\n**Severity:**\n\n- Mild: Few, if any, symptoms in excess of those required to make the diagnosis (associated symptoms, see below), and the symptoms result in minor functional impairment.\n- Moderate: Symptoms or functional impairment between \"mild\" and \"severe.\"\n- Severe: The number of symptoms, intensity, and impairment are all greatly increased.\n\n\n# Epidemiology\n\nDepression is a highly prevalent mental health disorder. It represents the third most common reason for consulting a general practitioner in the UK. Depression demonstrates a higher prevalence in females.\n\n# Aetiology\n\nThe aetiology of depression involves a complex interplay of genetic and environmental factors. History of previous mental health issues, physical illnesses, and social challenges like divorce, poverty, and unemployment can all contribute to its development.\n\n# Clinical Features\n\nDepression is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) as the presence of 5 out of the following 9 symptoms, occurring nearly every day for at least 2 weeks:\n\n1. **Depressed mood or irritability** for most of the day, indicated by either subjective report (feels sad or empty) or observation by others (appears tearful).\n2. **Anhedonia:** Decreased interest or pleasure in most activities, most of the day.\n3. Significant **weight change** (5%) or change in appetite.\n4. **Sleep alterations:** Insomnia or hypersomnia.\n5. **Activity changes:** Psychomotor agitation or retardation.\n6. **Fatigue** or loss of energy.\n7. **Guilt or feelings of worthlessness:** Excessive or inappropriate guilt or feelings of worthlessness.\n8. **Cognitive issues:** Diminished ability to think or concentrate, or increased indecisiveness.\n9. **Suicidality:** Thoughts of death or suicide, or formulation of a suicide plan.\n\n### Additional Features (Severe Depression)\n- **Psychotic Features:** Delusions (e.g. nihilistic delusions, Cotard's syndrome) and hallucinations.\n- **Depressive Stupor:** Profound immobility, mutism, and refusal to eat or drink, sometimes necessitating electroconvulsive therapy (ECT).\n\n# Differential Diagnosis\n\nThe main differentials and their key signs and symptoms include:\n\n- **Bipolar Disorder:** Characterised by periods of mania/hypomania (elevated mood, inflated self-esteem, decreased need for sleep, increased talkativeness, distractibility, increased goal-directed activity) alternating with depressive episodes.\n- **Anxiety Disorders:** Persistent and excessive worry, restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance.\n- **Psychotic Disorders:** Hallucinations, delusions, disorganised speech, grossly disorganised or catatonic behaviour.\n- **Substance/Medication-Induced Mood Disorder:** Mood disturbance associated with intoxication or withdrawal from substances or side effects of medications.\n- **Adjustment Disorders:** Development of emotional or behavioural symptoms in response to identifiable stressors.\n\n\nVarious organic causes should be considered and ruled out through careful history-taking, physical examination, and relevant investigations. These include:\n\n- Neurological disorders such as Parkinson's disease, dementia, and multiple sclerosis.\n- Endocrine disorders, especially thyroid dysfunction and hypo/hyperadrenalism (e.g., Cushing's and Addison's disease).\n- Substance use or medication side effects (e.g., steroids, isotretinoin, alcohol, beta-blockers, benzodiazepines, and methyldopa).\n- Chronic conditions such as diabetes and obstructive sleep apnea.\n- Long-standing infections, such as mononucleosis.\n- Neoplasms and cancers - low mood can theoretically be a presenting complaint in any cancer, with pancreatic cancer being a notable example.\n\n\n# Investigations\n\n- Standard investigations for depression may include Full Blood Count (FBC), Thyroid Function Test (TFT), Urea and Electrolytes (U&E), Liver Function Test (LFT), Glucose, B12/folate levels, cortisol levels, toxicology screen, and imaging of the Central Nervous System (CNS).\n- These help rule out organic causes (listed above) such as endocrine disorders (e.g. thyroid disorders).\n- There are several questionnaires that can also be used to help assess depressive symptoms, such as the Hospital Anxiety and Depression (HAD) Scale and Patient Health Questionnaire (PHQ-9).\n\n# Management\n\nDepression is usually managed in primary care. GPs can refer to secondary care (Psychiatry) if there is a high-suicide risk, symptoms of bipolar disorder, symptoms of psychosis, or if there is evidence of severe depression unresponsive to initial treatment.\n\r\n**Persistent subthreshold depressive symptoms or mild-to-moderate depression:**\n\n- 1st line = Low-intensity psychological interventions (individual self-help, computerised CBT). \r\n- 2nd line = High-intensity psychological interventions (individual CBT, interpersonal therapy) \r\n- 3rd line = Consider antidepressants \r\n\r\n**Mild depression unresponsive to treatment and moderate-to-severe depression:**\n\n- 1st line = High-intensity psychological interventions + antidepressants (1st line = SSRI)\r\n- 2nd line (Treatment-resistant depression) – switch antidepressants and then use adjuncts \r\n\r\n**Severe depression and poor oral intake/psychosis/stupor:**\n\n- 1st line = ECT \n- Although the exact mechanism remains elusive, it is thought that the induced seizure, rather than the ECT procedure itself, has therapeutic benefits. Short-term side effects of ECT include headache, muscle aches, nausea, temporary memory loss, and confusion, while long-term side effects can include persistent memory loss. Due to the induced seizure, there is a risk of oral damage, and due to the general anaesthetic, a small risk of death.\r\n\n**Recurrent depression:** \n\n- Treated with antidepressant + lithium \r\n\n\nMedical management of depression - additional notes:\n\n- First-line pharmacological treatment typically involves a Selective Serotonin Reuptake Inhibitor (SSRI) such as sertraline. SNRIs such as venlafaxine can also be used first-line, but are less preferable due to the risk of damage from overdose, which is less likely with SSRIs.\n- In people aged 18-25 there is an increased risk of impulsivity and suicidal risk upon commencing antidepressant medication and so they should have a follow-up appointment arranged after one week to monitor progress. Initial reviews can otherwise be arranged 2-4 weeks after starting medication in patients >25.\n- Continuation of antidepressants for at least six months post-remission is recommended to mitigate relapse risk. Tapering should be done gradually over a four-week period when discontinuing antidepressants.\n\n\n\n# NICE Guidelines\n\n[NICE Guidance on the Management of Depression](https://www.nice.org.uk/guidance/cg90)",
"files": null,
"highlights": [],
"id": "910",
"pictures": [],
"typeId": 2
},
"chapterId": 910,
"demo": null,
"entitlement": null,
"id": "956",
"name": "Depression",
"status": null,
"topic": {
"__typename": "Topic",
"id": "18",
"name": "Psychiatry",
"typeId": 2
},
"topicId": 18,
"totalCards": 14,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "956",
"name": "Depression"
}
],
"demo": false,
"description": null,
"duration": 437.44,
"endTime": null,
"files": null,
"id": "290",
"live": false,
"museId": "N3SPChs",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/psychiatry.png",
"title": "Postpartum depression",
"userViewed": false,
"views": 101,
"viewsToday": 4
}
]
},
"conceptId": 956,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10710",
"isLikedByMe": 0,
"learningPoint": null,
"likes": 6,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 54-year-old male presents to the GP with concerns about hearing his wife shouting at him in the early hours of the morning. He says his wife has been sending him angry messages through the radio for the past 2 days. He has been experiencing low mood for the past 5 weeks since his wife left him and he no longer finds interest in anything. He says he has stopped eating 3 meals a day during this time. During the consultation, his voice is quiet and monotonous, and he appears distressed.\n\nWhich of the following is the most likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 4259,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,019 | false | 77 | null | 6,494,981 | null | false | [] | null | 10,711 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Schizoaffective disorders are characterised by schizophrenia with episodes of mood disturbance, such as depression or mania. This patient does not display any mood disturbance.",
"id": "53253",
"label": "b",
"name": "Schizoaffective disorder",
"picture": null,
"votes": 406
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Bipolar affective disorder presents with periods of mania and depression. There are no symptoms of depression in this case, and no reported episodes of mania, where patients typically experience increased energy, elevated mood, reduced need for sleep, and mood congruent psychotic symptoms including grandiose delusions.",
"id": "53254",
"label": "c",
"name": "Bipolar affective disorder",
"picture": null,
"votes": 65
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Borderline (or emotionally unstable) personality disorder presents with recurrent episodes of self harm, rapid fluctuations of mood, chronic feelings of low mood and loneliness, and unstable persona relationships. This patient does not display these clinical features.",
"id": "53255",
"label": "d",
"name": "Borderline personality disorder",
"picture": null,
"votes": 29
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is the correct answer because this patient has classic first rank symptoms of Schizophrenia. These include thought broadcasting, thought insertion, and delusional perceptions. These are known as positive symptoms. Risk factors for developing schizophrenia include heavy cannabis use, poor maternal health, and traumatic childhood events.",
"id": "53252",
"label": "a",
"name": "Schizophrenia",
"picture": null,
"votes": 4409
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Schizotypal personality disorder is characterised by eccentric changes in behaviour and thinking which causes difficulty with relationships and social interactions. Patients present with unusual beliefs, inappropriate emotional responses, paranoia and social anxiety.",
"id": "53256",
"label": "e",
"name": "Schizotypal personality disorder",
"picture": null,
"votes": 277
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "would be nice to have a time frame for diagnosis \n",
"createdAt": 1732182798,
"dislikes": 0,
"id": "57410",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 10711,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Jargon Kawasaki",
"id": 32375
}
},
{
"__typename": "QuestionComment",
"comment": "S p i d e r",
"createdAt": 1737460023,
"dislikes": 0,
"id": "61120",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10711,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Motilin Monster",
"id": 40170
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nSchizophrenia is a chronic or relapsing and remitting form of psychosis characterized by positive symptoms (such as hallucinations, delusions, thought disorders) and negative symptoms (including alogia, anhedonia, and avolition). Diagnosis is based on clinical criteria and supported by investigations to exclude organic causes of psychosis. Management typically includes second-generation antipsychotic medications and psychotherapy. \n\n# Definition\n\n- **ICD-11 Criteria:** Symptoms present for at least 1 month, causing significant impairment.\n \n- **DSM-5 Criteria:** Symptoms persist for at least 6 months, encompassing at least one month of active-phase symptoms (must include one prominent 'ABCD' symptom). \n\nSubtypes include:\n\n- **Paranoid Schizophrenia:** Characterized by delusions and hallucinations, often with a persecutory theme.\n- **Catatonic Schizophrenia:** Features motor disturbances and waxy flexibility.\n- **Hebephrenic Schizophrenia:** Marked by disorganized thinking, emotions, and behavior.\n- **Residual Schizophrenia:** Residual symptoms persist after a major episode.\n- **Simple Schizophrenia:** Characterized by a gradual decline in functioning without prominent positive symptoms.\n\n\n# Epidemiology\n\nIn the UK, the lifetime prevalence of schizophrenia and related disorders is approximately 14.5 per 1000 individuals, but these estimates vary. The risk of developing schizophrenia in the general population is around 1%. \n\n# Aetiology\n\nThe pathophysiology of schizophrenia is multifactorial and includes both genetic and environmental factors.\n\n- Genetic Factors: The risk of developing schizophrenia is significantly increased in individuals with a positive family history, with the risk being proportional to the degree of genetic relationship. For example, the risk is:\n\t- 2% with an affected first cousin\n\t- 5% with an affected grandparent, aunt/uncle, niece/nephew\n\t- 10% if either a parent or sibling is affected\n\t- 50% if both parents are affected or an identical twin is affected\n- Environmental Factors: Several environmental factors have been associated with an increased risk of schizophrenia, including: \n\t- Childhood trauma, such as poor maternal bonding, poverty, or exposure to natural disasters\n\t- Heavy cannabis use in childhood\n\t- Maternal health issues, including malnutrition and infections like rubella and cytomegalovirus\n\t- Birth trauma, particularly hypoxia and blood loss\n\t- Urban living and immigration to more developed countries\n\n# Clinical Features\n\n**Positive Symptoms ('ABCD' Mnemonic):**\n\n- **Auditory Hallucinations:** Commonly involving third-person auditory experiences, broadcasting of thoughts, control issues, and delusional perceptions.\n- **Broadcasting of Thoughts:** Belief that one's thoughts are being broadcasted to others.\n- **Control Issues:** The sense of external control over one's thoughts or actions.\n- **Delusional Perception:** Distorted interpretations of reality, often with false beliefs.\n\n**Negative Symptoms:**\n\n- Negative symptoms that often overlap with features of depressive disorders. These include:\n\t- Alogia\n\t- Anhedonia\n\t- Affective incongruity or blunting\n\t- Avolition\n- Negative symptoms are more common in chronic and treated schizophrenia.\n\n**Risk Indicators:**\n\nPotential risks involve harm to self or others, with violence being rare. Risk indicators include command hallucinations, a history of deliberate self-harm or suicidal ideation, and fixation on specific individuals.\n\n\n# Differential Diagnosis\n\nDifferential diagnosis involves distinguishing schizophrenia from other conditions that present with similar symptoms. This is often done through a combination of history, examination, and investigations.\n\n- Substance-induced psychotic disorder: Associated with hallucinations and delusions; typically precipitated by drug use or withdrawal\n- Organic psychosis: Typically accompanied by neurological symptoms or changes in mental status; conditions such as infections, brain injuries, or CNS diseases like Wilson's disease or encephalitis can lead to organic psychosis\n- Metabolic disorders: Hyperthyroidism and hyperparathyroidism can present with agitation, restlessness, and altered mental status\n- Depression and dementia: May present with psychotic symptoms alongside cognitive decline and mood symptoms\n- Autoimmune encephalitis: May present with subacute psychosis alongside focal neurological deficits or seizures\n- Schizoaffective Disorder: Combines mood disorder features with psychotic symptoms. Distinguished by the duration of mood episodes independent of psychotic symptoms.\n\n# Investigations\n\nWhile schizophrenia is primarily a clinical diagnosis based on history and examination, investigations can help exclude organic causes of psychosis. \nThis includes:\n\n- Brain imaging (CT/MRI) to rule out structural abnormalities\n- Blood tests to exclude infectious (e.g.,HIV, syphilis) or metabolic causes (e.g., thyroid function tests)\n- Drug screening to identify substance misuse\n\n# Management\n\nThe primary treatment for schizophrenia is pharmacological, with second-generation (atypical) antipsychotics such as risperidone being the first line of treatment. \n\n- In acute episodes, sedatives like lorazepam, promethazine, or haloperidol may be used to manage dangerous behaviour. Oral atypical antipsychotics such as risperidone/olanzepine/quetiapine (sometimes IM/depot injections may be necessary). Patients should be referred for psychiatric liaison review.\n- Maintenance therapy with antipsychotics is determined and prescribed by Psychiatrists.\n- All second generation antipsychotics have similar efficacy profiles, though their side effect profiles vary. See dedicated section on antipsychotic medication.\n- Clozapine is considered when schizophrenia is resistant to other antipsychotics (in those who have not responded to 2 other trials of antipsychotics). Due to its potential lethal side effects, it requires intensive monitoring.\n\nPsychotherapy, such as cognitive-behavioural therapy, is also an essential part of management. Providing support to patients and families and coordinating care with mental health professionals are critical for long-term management. \n\n# Prognosis\n\nPrognosis varies significantly among individuals with schizophrenia. Factors associated with a better prognosis include higher IQ/education level, sudden onset, presence of a precipitating factor, a strong support network, and predominance of positive symptoms. According to the rule of quarters:\n\n- 25% of individuals never have another episode\n- 25% improve substantially with treatment\n- 25% show some improvement\n- 25% are resistant to treatment\n\n\n# NICE Guidelines\n\n[NICE CKS on Psychosis and Schizophrenia](https://cks.nice.org.uk/topics/psychosis-schizophrenia/)\n\n\n# References\n\n1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.\n2. Leucht, S., Cipriani, A., Spineli, L., Mavridis, D., Örey, D., Richter, F., ... & Davis, J. M. (2013). Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. The Lancet, 382(9896), 951-962.\n3. McGrath, J., Saha, S., Chant, D., & Welham, J. (2008). Schizophrenia: a concise overview of incidence, prevalence, and mortality. Epidemiologic reviews, 30(1), 67-76.\n",
"files": null,
"highlights": [],
"id": "875",
"pictures": [],
"typeId": 2
},
"chapterId": 875,
"demo": null,
"entitlement": null,
"id": "935",
"name": "Schizophrenia",
"status": null,
"topic": {
"__typename": "Topic",
"id": "18",
"name": "Psychiatry",
"typeId": 2
},
"topicId": 18,
"totalCards": 18,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": [
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "935",
"name": "Schizophrenia"
}
],
"demo": false,
"description": null,
"duration": 629.21,
"endTime": null,
"files": null,
"id": "350",
"live": false,
"museId": "pF5qsQE",
"osceStation": null,
"startTime": null,
"status": null,
"thumbnail": "images/videos/psychiatry.png",
"title": "Schizophrenia",
"userViewed": false,
"views": 247,
"viewsToday": 18
},
{
"__typename": "Video",
"concepts": [
{
"__typename": "Concept",
"id": "935",
"name": "Schizophrenia"
}
],
"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
}
]
},
"conceptId": 935,
"conditions": [
{
"__typename": "Condition",
"id": "596",
"name": "Schizophrenia",
"topic": {
"__typename": "UkmlaTopic",
"id": "15",
"name": "Mental health"
},
"topicId": 15
}
],
"difficulty": 1,
"dislikes": 3,
"explanation": null,
"highlights": [],
"id": "10711",
"isLikedByMe": 0,
"learningPoint": "First-rank symptoms of schizophrenia include auditory hallucinations, thought insertion, thought withdrawal, thought broadcasting, delusions of control, delusions of reference, and perceptual disturbances, which are considered highly characteristic of the disorder",
"likes": 6,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "70",
"name": "Auditory hallucinations",
"topic": {
"__typename": "UkmlaTopic",
"id": "15",
"name": "Mental health"
},
"topicId": 15
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 17-year-old female presents to the psychiatric intensive care unit after being brought in to hospital by her friend. Her friend was concerned as she repeatedly said another person was controlling her thoughts and everyone around her was able to hear what she was thinking. Before arriving at the hospital, she said that she saw the traffic light turn green so she knew her friend was going to murder her. Her friend says that she had a similar episode a few years ago. \n\nWhich of the following is the most likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 5186,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,020 | false | 78 | null | 6,494,981 | null | false | [] | null | 10,712 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has haemophilia. The clinical presentation of nosebleeds and excessive bleeding alongside family history suggests an inherited bleeding disorder. His maternal grandfather would have been treated with clotting factors. Males only carry one X chromosome which contains the mutation in the gene. This means that they pass on their X chromosome to their daughters who become carriers, but do not present with the disease (or may have very mild manifestations) due to the inheritance being x-linked recessive. Carrier females can pass the affected X chromosome to their sons, which has happened in this case.",
"id": "53257",
"label": "a",
"name": "X-linked recessive",
"picture": null,
"votes": 2446
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because haemophilia is not an autosomal recessive condition. In an autosomal recessive condition, disease occurs when a child inherits one mutated copy of a gene from both parents. There is no suggestion to state that this patient's father is a carrier. His sister is unaffected which suggests that it is related to the inheritance of the X chromosome from his mother.",
"id": "53259",
"label": "c",
"name": "Autosomal recessive",
"picture": null,
"votes": 370
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because haemophilia is not an autosomal dominant condition. In an autosomal dominant condition, a single copy of the mutated gene is enough to cause disease. This patient's mother is a carrier but she is unaffected which suggests that this is not autosomal dominant. You would expect any family member who inherits the mutated gene to have the disease.",
"id": "53260",
"label": "d",
"name": "Autosomal dominant",
"picture": null,
"votes": 376
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because haemophilia is not inherited through an X-linked dominant pattern. In an X-linked dominant condition, one copy of the mutated gene is enough to cause disease in males and females. As the patient's mother is a carrier and unaffected, this suggests that the condition is inherited through an X-linked recessive pattern instead.",
"id": "53258",
"label": "b",
"name": "X-linked dominant",
"picture": null,
"votes": 375
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because haemophilia is not inherited via mitochondrial inheritance. This is a rare pattern of maternal inheritance due to mutated genes within the mitochondrial DNA within oocytes, which is subsequently passed on to the developing embryo (and child, therefore.) Spermatozoa have mitochondria but their mitochondria are degraded shortly after fertilisation, so genetic defects within the spermatozoa's mitochondrial DNA cannot be transmitted to the foetus.",
"id": "53261",
"label": "e",
"name": "Mitochondrial",
"picture": null,
"votes": 24
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Bleeding from the gums I thought VWD would be more likely, as well as nose bleeds. They of course could happen in both, however could some kind person tell us other reasons why haemophilia was more likely?",
"createdAt": 1678538727,
"dislikes": 0,
"id": "19828",
"isLikedByMe": 0,
"likes": 14,
"parentId": null,
"questionId": 10712,
"replies": [
{
"__typename": "QuestionComment",
"comment": "VWD is autosomal dominant which means the mother or father will need to be affected for the boy to have the disease. Haemophilia A is x-linked recessive and so for a boy to be affected, the pathology will come from the mother's side and usually skips a generation. ",
"createdAt": 1678872690,
"dislikes": 0,
"id": "20128",
"isLikedByMe": 0,
"likes": 9,
"parentId": 19828,
"questionId": 10712,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Monoclonal Polyps",
"id": 1456
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Jargon Defibrillator",
"id": 20309
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nHaemophilia A and B are inherited bleeding disorders caused by deficiencies in clotting factors VIII and IX respectively, both of which are integral components of the instrinsic pathway of the coagulation cascade. They typically present early in life with deep and severe bleeding into soft tissues, joints, and muscles. Diagnosis is established with a factor assay (VIII for Haemophilia A and IX for Haemophilia B). Minor bleeds can be managed with Desmopressin (for Haemophilia A), and major bleeds with recombinant factor VIII (for Haemophilia A) or recombinant factor IX (for Haemophilia B).\n\n# Definition\n\nHaemophilia A and B are both X-linked recessive inherited bleeding disorders, caused by deficiencies in clotting factors VIII and IX respectively, both of which are integral components of the instrinsic pathway of the coagulation cascade.\n\n# Aetiology \n\n\n| Haemophilia A | Haemophilia B | \n| :-------------: |:-------------:| \n| X-linked recessive inherited bleeding disorder that causes a deficiency in clotting factor VIII | X-linked recessive inherited bleeding disorder that causes deficiency in clotting factor IX \n|Occurs in 1 in 5,000 men worldwide | Affects 1 in 25,000 men | \n| Caused by a range of mutations within the factor VIII gene – 70% of these mutations are inherited and 30% are spontaneous\n\n# Signs and Symptoms\n\n- They typically presents early in life with spontaneous deep and severe bleeding into soft tissues, joints and muscles – historically, joint damage resulted in a deforming arthropathy\n- Boys often present with excessive bleeding following trauma or surgical intervention (e.g. tonsillectomy)\n- Cerebral haemorrhage was a major cause of mortality in severe haemophilia before the widespread use of blood products\n\n# Differential Diagnosis\n\n* **Von Willebrand Disease**: This inherited bleeding disorder is often confused with hemophilia due to similar symptoms but is caused by a deficiency or dysfunction of von Willebrand factor.\n* **Factor Deficiencies**: Rare factor deficiencies, such as deficiencies in factors I, V, VII, X, XI, and XIII, can lead to bleeding tendencies and mimic haemophilia.\n* **Platelet Disorders**: Conditions like idiopathic thrombocytopenic purpura (ITP) and thrombocytopathy can result in bleeding symptoms and should be considered.\n* **Liver Disease**: Liver dysfunction can lead to impaired synthesis of clotting factors, resembling a bleeding disorder.\n* **Haematological Malignancies**: Leukemias, lymphomas, and myelodysplastic syndromes can lead to coagulation abnormalities and bleeding.\n* **Trauma**: Traumatic injuries can lead to bleeding and may be mistaken for hemophilia in cases where the family history is unknown.\n* **Infectious Diseases**: Certain infections, such as dengue fever or viral hepatitis, can lead to bleeding tendencies.\n* **Vasculitis**: Conditions like Henoch-Schönlein purpura can result in skin and joint bleeding.\n* **Drug-Induced Thrombocytopenia**: Some medications, such as heparin or quinine, can lead to low platelet counts and bleeding.\n\n\n# Investigations\n\n- Diagnosis is with a factor VIII/IX assay \n\t- For boys with severe haemophilia A or B (factor VIII or factor IX <1%, respectively):\n\t - Two-thirds are diagnosed at birth when the boy is born to a known or suspected carrier \n\t - The rest are picked up later on in childhood when the baby begins to crawl or fall, or there is an eruption of dentition\n\t- Some patients have a milder clinical severity – this is directly related to higher factor levels \n\t - Mild haemophilia >5% \n\t - Moderate haemophilia 1–5% \n- Blood tests show:\n - Clotting profile - APTT is elevated\n - vWF antigen is normal in haemophilia A\n - Defective platelet function \n\n# Management \n\n- Minor bleeds in patients with Haemophilia A can be managed with **desmopressin** (DDAVP) – increases factor VIII sufficiently to deal with the minor bleeding \n- Major bleeds require **recombinant factor VIII or IX**\n- In patients with severe haemophilia, the use of regular prophylactic recombinant clotting factor treatment, physiotherapy and education in learning how to avoid bleeds have all contributed to the prevention of joint arthropathy \n - Gene therapy has also been shown to be successful\n- Mild and moderate haemophilia require 'on demand' treatment in response to bleeding or in preparation for surgery\n- Supportive management includes:\n - **Antifibrinolytics** (eg. tranexamic acid) – useful for bleeding wounds but should be avoided in muscle haematomas, haemarthrosis and urinary bleeding as they can lead to fibrosis\n - Vaccination against hepatitis B, hydrotherapy, orthopaedic and dental advice are also beneficial \n\n- One-third of boys with severe haemophilia A will develop an **inhibitor to factor VIII** following factor VIII treatment\n - This can worsen bleeding and complicate therapy\n - Treatment of haemophilia with inhibitors should be directed from a specialist centre\n- Life expectancy for patients with haemophilia A and B is well into middle age in this era of blood product-free concentrates\n\n\nHistorical context of haemophilia treatment:\n\n- Before viral screening for HIV and hepatitis C was introduced, the use of blood products however lead to high levels of viral transmission resulting in AIDS, hepatocellular carcinoma and death \n- Many of these patients have also been exposed to the prion that causes Creutzfeldt–Jakob disease, with the effects of this still presently unknown \n- Viral transmission is no longer an issue following the change to the use of recombinant factor VIII\n\n# References\n\n[The Haemophilia Society - Haemophilia](https://haemophilia.org.uk/bleeding-disorders/haemophilia-a-and-b/)\n\n[NHS UK - Haemophilia](https://www.nhs.uk/conditions/haemophilia/)",
"files": null,
"highlights": [],
"id": "378",
"pictures": [],
"typeId": 2
},
"chapterId": 378,
"demo": null,
"entitlement": null,
"id": "382",
"name": "Haemophilia",
"status": null,
"topic": {
"__typename": "Topic",
"id": "8",
"name": "Haematology",
"typeId": 2
},
"topicId": 8,
"totalCards": 3,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 382,
"conditions": [
{
"__typename": "Condition",
"id": "305",
"name": "Haemophilia",
"topic": {
"__typename": "UkmlaTopic",
"id": "6",
"name": "Clinical haematology"
},
"topicId": 6
}
],
"difficulty": 1,
"dislikes": 2,
"explanation": null,
"highlights": [],
"id": "10712",
"isLikedByMe": 0,
"learningPoint": "Haemophilia is an X-linked recessive disorder, primarily affecting males, leading to prolonged bleeding due to deficient clotting factors.",
"likes": 8,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [
{
"__typename": "Presentation",
"id": "235",
"name": "Epistaxis",
"topic": {
"__typename": "UkmlaTopic",
"id": "6",
"name": "Clinical haematology"
},
"topicId": 6
}
],
"psaSectionId": null,
"qaAnswer": null,
"question": "An 11-year-old boy presents to the GP with his mother with several nosebleeds and excessive bleeding from his gums after visiting the dentist. He says his 8-year-old sister does not have any of these symptoms, but his maternal grandfather used to have regular hospital appointments for an injection. His blood tests show a prolonged APTT.\n\nGiven the most likely diagnosis, which of the following is the most likely pattern of inheritance?",
"sbaAnswer": [
"a"
],
"totalVotes": 3591,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,021 | false | 79 | null | 6,494,981 | null | false | [] | null | 10,713 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "A retrospective cohort study begins with a cohort of patients who have already achieved the outcome that is being evaluated, in this case bladder cancer. The study investigators then look back in time i.e. retrospectively, to identify whether the cohort were exposed or not exposed to the given risk factor, in this case aniline dyes. The exposure has already occurred. This is a type of observational study.",
"id": "53262",
"label": "a",
"name": "Retrospective cohort study",
"picture": null,
"votes": 1303
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Case control studies analyse those with the disease (cases) versus those without (controls) and look retrospectively back in time to see if exposure occurred to a risk factor. This is not a case control study therefore; if this were, the study design would be as follows: the history of individuals with bladder cancer and individuals without bladder cancer are reviewed to see if they had exposure to aniline dyes in the past or not.",
"id": "53265",
"label": "d",
"name": "Case-control study",
"picture": null,
"votes": 387
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A cross-sectional study is when a snap-shot is taken of a population at a specific point in time to identify the prevalence or frequency of a certain risk factor or disease. This is not a cross sectional study. This is not a cross-sectional study, since it is not giving us an idea of the frequency or prevalence of either aniline dye exposure or bladder cancer within the population.",
"id": "53263",
"label": "b",
"name": "Cross-sectional study",
"picture": null,
"votes": 143
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A prospective cohort study starts with two groups of individuals who are either exposed or not exposed to a certain risk factor, then followed up in time to see if an outcome is obtained. This is not a prospective cohort study, therefore. If it were, the study design would be as follows: individuals who have been exposed to aniline dyes versus not exposed are followed up over a certain period of time to see if they develop bladder cancer.",
"id": "53264",
"label": "c",
"name": "Prospective cohort study",
"picture": null,
"votes": 64
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because an experimental study is a type of interventional study. This involves assessing the effect of an intervention. The researcher is able to control the variables and interact with participants which is different to an observational study. A common experimental study design is that of a randomised controlled trial.",
"id": "53266",
"label": "e",
"name": "Experimental study",
"picture": null,
"votes": 7
}
],
"comments": [],
"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": 1,
"dislikes": 6,
"explanation": null,
"highlights": [],
"id": "10713",
"isLikedByMe": 0,
"learningPoint": "A retrospective cohort study is a type of observational research that looks back at existing data to compare outcomes between groups that were exposed to a particular factor and those that were not.",
"likes": 1,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A study looking at risk factors associated with bladder cancer disease recruit 500 patients diagnosed with transitional cell carcinoma of the bladder. The study found that 250 of the patients were exposed to aniline dyes during their earlier stages of their lives, whilst 250 were not, and concluded that aniline dyes may be a risk factor associated with the development of transitional cell carcinoma.\n\nWhich of the following study design is described in the question stem?",
"sbaAnswer": [
"a"
],
"totalVotes": 1904,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,022 | false | 80 | null | 6,494,981 | null | false | [] | null | 10,714 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Urological surgery may be warranted if the testis remains undescended by 6 months. Unilateral undescended testis is common and usually resolves spontaneously within the first 3-6 months of life. Therefore, urological review is not required at this stage or urgently. This baby needs follow up at 3 months to see if the testicles have descended or not; by then, the child will be 4-5 months of age, and if the testicle hasn't persisted, will warrant referral to a urologist for review, as per NICE guidelines.",
"id": "53271",
"label": "e",
"name": "Refer to urology routinely",
"picture": null,
"votes": 71
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Urological surgery may be warranted if the testis remains undescended by 6 months. Unilateral undescended testis is common and usually resolves spontaneously within the first 3-6 months of life. Therefore, urological review is not required at this stage or urgently.",
"id": "53269",
"label": "c",
"name": "Refer urgently to a senior urologist within 2 weeks",
"picture": null,
"votes": 177
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Annual l follow-up is required if the testes descend after 3 months but remain retractile since there is a risk of the testes ascending over time. This baby needs follow up at 3 months to see if the testicles have descended or not; by then, the child will be 4-5 months of age, and if the testicle hasn't persisted, will warrant referral to a urologist for review, as per NICE guidelines.",
"id": "53270",
"label": "d",
"name": "Annual follow-up",
"picture": null,
"votes": 112
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Bilateral undescended testes may represent a serious underlying endocrinological or developmental abnormality, such as congenital adrenal hyperplasia, and as such the NICE guidelines suggest urgent review within 2 weeks by a paediatrician.",
"id": "53268",
"label": "b",
"name": "Refer urgently to a senior paediatrician within 2 weeks",
"picture": null,
"votes": 220
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This newborn has a unilateral undescended testicle which has been noted on the 8-week baby check up. This is a common presentation at the baby check with around 1/25 boys being born with undescended testicles. In most instances, these will descend naturally during the first 3-6 months of life, and no treatment will be required. Therefore, at this stage, follow up in 3 months is all that is required. If undescended by 6 months, then it is unlikely they will descend spontaneously, and as such surgery is warranted, ideally before the child reaches 12 months of age. Referral is usually done around 4-5 months of age if the testicles are undescended, in order to minimise delays. Note that by the first year of life, 2/3 of undescended testes resolve spontaneously. Note that undescended testes are a big risk factor for testicular tumours which are identified as an inguinal lump later on in life.",
"id": "53267",
"label": "a",
"name": "Review at 3 months",
"picture": null,
"votes": 2151
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nUndescended testes, or cryptorchidism, is a condition present at birth where one or both of the male testes have not descended into the scrotum prior to birth. It occurs in about 1-4.5% of term and 30-45% of premature newborns, with around two-thirds spontaneously descending by the first year of life. Key symptoms include the absence of one or both testes in the scrotum. Orchidopexy is a common treatment, and management strategies depend on whether the condition is unilateral or bilateral. Management of this condition is important as undescended testes are a risk factor for testicular cancer.\n\n# Definition\n\nCryptorchidism, or undescended testes, is a congenital condition in which one or both of the testes fail to descend into the scrotum before birth.\n\n# Epidemiology\n\nCryptorchidism is present in approximately 1-4.5% of term newborns and about 30-45% of premature newborns. By the first year of life, around two-thirds of these cases will have spontaneously descended.\n\n# Aetiology\n\nThe exact cause of cryptorchidism is unknown, but it is thought to be multifactorial, with genetic, maternal, and environmental factors potentially playing roles. Maternal factors may include alcohol consumption, smoking, and exposure to certain medications during pregnancy. Cryptorchidism is also more common in premature and low birth weight infants.\n\n# Signs and Symptoms\n\nThe primary sign of cryptorchidism is the absence of one or both testes in the scrotum. This can often be identified during a physical examination.\n\n# Differential Diagnosis\n\nWhen considering cryptorchidism, other conditions that may present with similar symptoms include:\n\n- **Retractile testes:** The testes may be in the scrotum at times but can retract into the inguinal canal when the cremaster muscle contracts. Key signs include the ability to manipulate the testes into the scrotum and staying in place at least temporarily.\n- **Inguinal hernias:** These present with a palpable mass in the inguinal region which can increase in size with crying or straining. They are often associated with discomfort or pain.\n- **Ectopic testes:** This condition is characterized by testes that have deviated from the normal path of descent and are located in abnormal positions, such as the perineum or femoral region.\n\n# Investigations\n\nThe initial investigation of cryptorchidism involves a thorough physical examination. In some cases, further investigations like ultrasound or MRI may be considered, especially in cases of non-palpable testes. Hormonal testing may also be needed in certain cases.\n\n# Management\n\nThe primary management of cryptorchidism is surgical, with the most common procedure being orchidopexy, a surgery designed to bring the undescended testes into the scrotum.\n\nManagement strategies vary depending on whether the condition is unilateral or bilateral:\n\n- For undescended testes that are **bilateral** at birth, an urgent referral to a senior paediatrician within 24 hours is needed for potential endocrine or genetic investigation (e.g. congenital adrenal hyperplasia, or CAH). If these conditions are ruled out and the testes remain undescended by 3 months, the child should be referred to surgeons by 6 months of age.\n- For undescended testes that are **unilateral** at birth, arrange a review at 6-8 weeks of age. If the testis remains undescended at the 3-month review, re-examine at 4-5 months\n- At 4–5 months (corrected for gestational age), if the testis remains undescended, arrange referral to paediatric surgery or urology for specialist management depending on local referral pathways, to be seen by 6 months of age\n- The British Association of Paediatric Surgeons (BAPS) recommends that if orchidopexy is indicated, it should be performed around 12 months of age\n\n\n# NICE Guidelines\n\n[NICE CKS - Undescended Testes](https://cks.nice.org.uk/topics/undescended-testes/)\n",
"files": null,
"highlights": [],
"id": "1859",
"pictures": [],
"typeId": 2
},
"chapterId": 1859,
"demo": null,
"entitlement": null,
"id": "2168",
"name": "Undescended testes",
"status": null,
"topic": {
"__typename": "Topic",
"id": "22",
"name": "Urology",
"typeId": 2
},
"topicId": 22,
"totalCards": 6,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2168,
"conditions": [],
"difficulty": 1,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "10714",
"isLikedByMe": 0,
"learningPoint": "Unilateral undescended testicles often resolve spontaneously within the first six months, infants should be reviewed at 3 months.",
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "An 8-week-old baby boy presents to the GP with his father for his baby check. He is currently feeding well, opening his bowels and passing urine. There are no concerns regarding his growth and development as he is following the centiles adequately. On examination, he is fixing and following objects and smiling at his dad. The GP notices that he has a right unilateral undescended testicle.\n\nWhich of the following is the next best step in the management of this patient?",
"sbaAnswer": [
"a"
],
"totalVotes": 2731,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,459,023 | false | 81 | null | 6,494,981 | null | false | [] | null | 10,715 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because lithium levels are taken if there are concerns regarding a lithium overdose. Lithium is a mood stabiliser indicated for the long-term treatment of bipolar disorder. This question stem states that this patient has Schizophrenia. It is important to note that therapeutic levels of lithium is associated with a fine tremor whereas a coarse tremor is associated with lithium toxicity. Other features of lithium toxicity include ataxia and seizures.",
"id": "53273",
"label": "b",
"name": "Lithium levels",
"picture": null,
"votes": 1315
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because imaging is not routinely used to diagnose neuroleptic malignant syndrome. It can be used to exclude other conditions such as structural lesions within the brain, intracranial haemorrhage, or trauma. These are examples of differential diagnoses for NMS which can cause a change in mental state and extra-pyramidal symptoms. However, NMS should be the primary differential in this case given evidence of recent treatment with neuroleptics, hyperthermia, and muscle rigidity.",
"id": "53276",
"label": "e",
"name": "CT Head",
"picture": null,
"votes": 43
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because blood tests are useful to show complications of NMS including acute renal failure secondary to rhabdomyolysis but they are not specific to the diagnosis.",
"id": "53275",
"label": "d",
"name": "Urea and electrolytes",
"picture": null,
"votes": 659
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect because an ECG is not likely to aid the diagnosis of neuroleptic malignant syndrome. It can show evidence of tachycardia because NMS can cause autonomic instability, but this is not specific.",
"id": "53274",
"label": "c",
"name": "Electrocardiogram",
"picture": null,
"votes": 251
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has neuroleptic malignant syndrome (NMS). Neuroleptic malignant syndrome is a life-threatening complication of taking dopamine antagonist medication. Most cases start within 4-14 days of commencing the medication, but some cases may occur many years after taking the same drug, at the same dose. It is likely this patient has been started on an antipsychotic medication, which has triggered his NMS. Clinical signs and symptoms include fever, muscle rigidity, confusion, rhabdomyolysis (hence the raised creatine kinase and subsequent electrolyte derangements such as hyperkalaemia and hypocalcaemia), metabolic acidosis, autonomic lability, and a raised white cell count. It takes up to 2 weeks to recover after stopping the medication. Treatment is with supportive measures (fluids, keeping the patient cool), dopamine agonists such as bromocriptine, or dantrolene.\n\n-",
"id": "53272",
"label": "a",
"name": "Creatine kinase",
"picture": null,
"votes": 3191
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "I know we don't really need to know it in this much detail yet but how would the patient's schizophrenia be managed when the antipsychotics are stopped and then would they eventually be restarted on a different one?",
"createdAt": 1728296953,
"dislikes": 0,
"id": "55539",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10715,
"replies": [
{
"__typename": "QuestionComment",
"comment": "start them on 2nd gen like aripip or olan as they have lowered risk of NMS, then usual stuff like start low dose and taper up etc.",
"createdAt": 1732399671,
"dislikes": 0,
"id": "57517",
"isLikedByMe": 0,
"likes": 0,
"parentId": 55539,
"questionId": 10715,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "hud",
"id": 44886
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Chill Pill",
"id": 34903
}
}
],
"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": [
{
"__typename": "Condition",
"id": "596",
"name": "Schizophrenia",
"topic": {
"__typename": "UkmlaTopic",
"id": "15",
"name": "Mental health"
},
"topicId": 15
}
],
"difficulty": 2,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "10715",
"isLikedByMe": 0,
"learningPoint": "Neuroleptic malignant syndrome is a life-threatening reaction to antipsychotic medications characterized by hyperthermia, muscle rigidity, altered mental status, and autonomic dysfunction, often with a significant elevation in creatine kinase levels due to muscle breakdown.",
"likes": 21,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 42-year-old male presents to A&E feeling unwell for the past 48 hours. He feels feverish and is concerned as he has developed a tremor. He was recently diagnosed with schizophrenia and commenced on medication last week, but he cannot remember the name or the dose. On examination, there is evidence of muscle rigidity. His AMTS is 4/10. His vital signs are: HR 103bpm, RR 21 breaths per min, O2 saturations on air 98%, BP 138/82mmHg, temperature of 38.5.\n\nWhich of the following investigations is likely to aid the diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 5459,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
Subsets and Splits