Rapid-recall takeaways distilled from the MRCP Part 1 question bank, grouped by specialty. One pearl per high-frequency concept. Use it for last-pass revision alongside questions, not as a replacement for them.
4,791 pearls · 978 specialties · Generated 6 November 2026
Clinical Pharmacology
80 high-yield facts
Naloxone is a competitive mu-opioid receptor antagonist with rapid onset and a short half-life - re-dose or infuse to maintain reversal, especially when the offending opioid is long-acting (e.g. methadone).
Severe digoxin toxicity (life-threatening arrhythmia, K+ >5 mmol/L, very high level) → digoxin-specific antibody fragments; avoid IV calcium; haemodialysis is ineffective (large Vd).
Severe beta-blocker overdose - IV glucagon 5-10 mg bolus then infusion is first-line (TOXBASE/NPIS); escalate with HIET, lipid emulsion and ECMO; correct hypoglycaemia with IV dextrose.
Pure benzodiazepine overdose - supportive care with airway protection is the mainstay; avoid flumazenil in epilepsy, chronic benzodiazepine use or mixed overdose because of seizure risk (BNF/TOXBASE).
Paracetamol overdose - UK uses the single 100 mg/L (4 h) treatment line since 2012 (MHRA/CHM); treat above the line with NAC (21-hour or SNAP regimen); start within 8 hours where possible (NPIS/TOXBASE/BNF).
Mycophenolate highly teratogenic (40-50% risk - ear/facial/cardiac malformations); two contraception methods + monthly pregnancy tests; continue 6 weeks post-treatment; male partners use condoms + 90 days; azathioprine safer alternative if pregnancy planned.
Isoniazid neuropathy (10-20%) via B6 depletion; prevent with pyridoxine 25-50 mg daily; other causes: vincristine (dose-limiting), metronidazole (chronic), amiodarone; metformin depletes B12 not B6.
HIT = IgG anti-PF4/heparin antibodies; platelet activation → thrombosis + thrombocytopenia; stop heparin, use argatroban; never rechallenge; warfarin alone dangerous.
DILE = hydralazine/procainamide + anti-histone + normal complement + no renal/CNS; Stop drug = curative (symptoms resolve weeks-months); Anti-dsDNA negative distinguishes from SLE.
Enzyme induction = gradual onset (1-3 weeks maximum effect); rifampicin + COCP = use barrier contraception throughout + 4-8 weeks post; induction persists weeks after stopping.
Drug Toxicity
80 high-yield facts
Methotrexate = WEEKLY dosing! Daily dosing error = potentially fatal pancytopenia + mucositis. Rescue with folinic acid (leucovorin) 15mg every 6h. Always give folic acid 5mg weekly on different day. Monitor FBC/LFTs regularly!
Gentamicin = ATN from direct proximal tubular toxicity! Granular casts on urinalysis. Monitor trough levels (<1 mg/L). Once-daily dosing reduces toxicity. Usually reversible if caught early - STOP the drug!
Severe salicylate toxicity → urinary alkalinisation (urine pH 7.5-8.0) + haemodialysis; replace K⁺; charcoal only if early; avoid intubation if possible - discuss with NPIS.
Type 1 Gaucher (90%, most common) - NO CNS. Ashkenazi Jewish. Glucocerebrosidase deficiency. Massive hepatosplenomegaly, bone crisis (avascular necrosis, Erlenmeyer flask), cytopenia.
Aa × Aa gives 25% affected, 50% carriers, 25% unaffected; the simple carrier risk for any pregnancy is 50%, but if the sibling is known to be unaffected the carrier risk rises to 2/3 by conditional probability - important when counselling families per the NHS Genomic Medicine Service.
Evidence-Based Medicine
80 high-yield facts
NNT = 1/ARR (absolute risk reduction); number to treat to prevent 1 event; lower NNT = better (2-5 excellent, >50 marginal); this case: ARR 2% → NNT=50; contextual (disease severity, outcome); differs from RRR (relative, can mislead); NNH for harms; aspirin post-MI NNT~40.
I² = heterogeneity statistic in meta-analysis! >50% = substantial heterogeneity. I²=78% means most variation is real differences between studies, not chance. High I² → investigate why studies differ! NOT the same as statistical significance or power!
LR+ = sens/(1-spec); >10 strong rule-in; this troponin LR+ 8.6 = good diagnostic test; independent of prevalence; positive test increases post-test probability MI by 8.6-fold; LR- 0.056 = excellent rule-out.
95% CI excludes null (1.0 for ratios, 0 for differences) → significant; narrow = precise; CI > p-value (shows magnitude); statistical ≠ clinical significance.
OR > RR when outcome common (>10%); OR ≈ RR when outcome rare (<10%).
Statistical significance requires both p < 0.05 AND 95% CI excluding null value (1.0 for ratios, 0 for differences).
Incidence = new cases (risk); Prevalence = existing cases (burden); Prevalence = Incidence x Duration; chronic = high prevalence, fatal = low prevalence.
Randomization eliminates confounding (known and unknown); RCTs = gold standard for treatment efficacy.
Clinical Biochemistry
80 high-yield facts
Rhabdomyolysis CK >10,000 = STOP drug + FLUIDS (urine >200ml/h). NO IV calcium despite low Ca²⁺ (deposits in muscle; risks calcification with high PO₄³⁻). Statin + CKD = high risk!
Acute porphyria = abdominal pain + neuropathy + psych symptoms + dark urine + autonomic dysfunction! Diagnose with urine PBG/ALA (very high in attack). Treat with IV haem arginate + dextrose. AVOID triggers (drugs, fasting, alcohol)!
Isoniazid neuropathy = NAT2 slow acetylators + B6 antagonism; pyridoxine 10 mg daily prophylaxis (NICE NG33, BNF); drug-induced lupus (hydralazine, procainamide, isoniazid) is anti-histone positive and resolves on stopping the drug.
High Ca²⁺ + Low PO₄³⁻ + High PTH = Primary hyperparathyroidism! Malignancy suppresses PTH (low). Vitamin D raises both Ca²⁺ AND PO₄³⁻. FHH = low urine calcium despite high serum calcium!
SIADH = euvolaemic hyponatraemia + low serum osmolality + inappropriately concentrated urine + high urinary sodium; treat with fluid restriction; hypertonic saline only for severe symptoms; correct slowly to avoid osmotic demyelination.
Anion gap = Na − (Cl + HCO₃); DKA is the archetypal high-anion-gap metabolic acidosis.
Central DI = ADH deficiency, post-neurosurgery most common; low urine osmolality + polyuria; desmopressin first-line; nephrogenic DI = lithium, doesn't respond to desmopressin; correct Na⁺ <10/24h.
CDI = ADH deficiency → dilute polyuria + hypernatraemia; responds to desmopressin (vs nephrogenic = no response); water deprivation test diagnostic; causes: pituitary surgery, craniopharyngioma, idiopathic; treatment: desmopressin.
Osmolar gap = measured − calculated; >25 suggests toxic alcohol; methanol → blindness, ethylene glycol → renal failure; fomepizole first-line (ADH inhibitor); haemodialysis if severe; normal gap doesn't exclude if metabolised.
anion gap = [Na⁺] − ([Cl⁻] + [HCO₃⁻]); here 32 mmol/L = ; recall ; manage DKA per with fixed-rate IV insulin, saline and potassium, targeting ketones <0.6 mmol/L.
Drug Interactions
80 high-yield facts
Allopurinol + azathioprine = xanthine oxidase inhibition → 3-5× rise in toxic 6-TGN → severe pancytopenia. Avoid the combination (BNF Appendix 1); if essential, reduce azathioprine to ~25% and check TPMT before starting any thiopurine.
Type III = immune complexes deposit in tissues → complement activation → neutrophilic inflammation; serum sickness = 1-2 weeks post-drug (classically cefaclor), low C3/C4; Arthus = local, 4-10 hours; lupus nephritis and post-streptococcal GN are also Type III.
Type III hypersensitivity = immune complex deposition → complement activation → inflammation; serum sickness onset 7-21 days with fever/rash/arthralgia/low complement.
CVID = IgG <4 AND (IgA or IgM), age >4, normal/low B-cells; recurrent sinopulmonary, autoimmune 20-30%, lymphoma 50×; lifelong IVIg 400-600 mg/kg every 3-4 weeks, target >5 g/L.
Selective IgA deficiency = most common primary immunodeficiency; IgA <0.07, normal IgG/IgM; recurrent sinopulmonary infections, celiac disease (10-15×), anaphylaxis to blood products (anti-IgA antibodies); no specific treatment (antibiotics, avoid IgA-containing transfusions); may progress to CVID; differs from CVID (IgG + IgA low).
Pharmacokinetics
80 high-yield facts
Warfarin's delayed onset reflects depletion of existing vitamin K-dependent clotting factors (Factor II half-life ~60 h) - bridge with LMWH until INR ≥2 for 24 h and ≥5 days of LMWH per NICE NG158.
Zero-order = enzyme saturation, constant amount eliminated; phenytoin Km 4-7, therapeutic 10-20 (exceeds Km); small dose → large disproportionate increase; adjust 25-50mg only; ethanol 7-10g/h.
Lipophilic = cross membranes, large Vd, long t½; hydrophilic = plasma-confined, small Vd; BBB = tight junctions (lipophilic cross, inflammation ↑permeability); placenta - heparin/insulin safe; protein-bound = inactive.
High ER flow-limited (propranolol, morphine, heart failure/cirrhosis reduce clearance), low ER capacity-limited (warfarin, phenytoin, enzyme activity determines clearance, fluconazole/rifampicin significant effects).
Per BNF, digoxin dose must be adjusted for renal function - steady state timing scales with half-life prolongation.
Partial agonist = submaximal response + ceiling effect; buprenorphine = partial mu agonist (safer, ceiling for respiratory depression); precipitated withdrawal if given with full agonist (wait 12-24h).
FD + H. pylori → triple therapy eradication (10% improve); PPI 4-8w (30-40%); prokinetics for PDS; TCA refractory; red flags: dysphagia/weight loss/age >55.
Whipple disease = diarrhoea + weight loss + arthralgia + PAS-positive diastase-resistant macrophages - treat with IV ceftriaxone 2g daily for 2 weeks then co-trimoxazole 960mg BD for 12 months (Feurle randomised induction trial; relapse 15-40% if undertreated).
pulmonary contusion → restrictive fluids to euvolaemia, early NIV, excellent analgesia; peaks 24-48 h, resolves 5-7 days; liberal fluids and aggressive diuresis both worsen outcomes.
HPS = Cirrhosis + hypoxemia (PaO₂ less than 10.6) + platypnea-orthodeoxia + contrast echo 3-6 cycles; Liver transplant definitive (resolves 80%, mortality 15-20%); No effective medical therapy; MELD exception if PaO₂ less than 8; Survival 20% vs 80% with transplant.
Barrett LGD (confirmed) → RFA ablation (90% eradication, reduces cancer 90%); HGD/visible lesion → EMR + RFA; NDBE → surveillance 3-5 years; LGD annual cancer risk 10-13%; PPI optimization essential; Post-RFA surveillance 3-monthly year 1, then annual.
Angiodysplasia = elderly + CKD + recurrent IDA + normal OGD/colonoscopy; capsule endoscopy first-line (60%); APC (70-80%); thalidomide/octreotide if refractory; recurrence 30-50%.
Refractory ascites = max diuretics failed; TIPSS ↓ paracentesis 70-80%; HE 30-40%; vs LVP + albumin (no survival difference); 1y 50%.
Cell Biology
75 high-yield facts
Necroptosis = RIP3/MLKL-dependent, morphologically necrotic but programmed; differs from caspase-dependent apoptosis.
Lysosomal storage disorders cause accumulation of undegraded substrates; Tay-Sachs = hexosaminidase A deficiency → GM2 accumulation.
ER - protein folding. Chaperones (BiP, calnexin, calreticulin) assist. Misfolded proteins → ER stress → UPR (↓protein synthesis, ↑chaperones, ↑ERAD). Prolonged UPR → apoptosis.
Mitochondrial inheritance = maternal only (all offspring of affected mother at risk, NO male transmission); heteroplasmy → variable severity; LHON (optic neuropathy, complex I mutation, males > females); MELAS, MERRF, Kearns-Sayre also mtDNA; high-energy tissues affected; no cure, idebenone for LHON.
Overlap features + high titre anti-RNP = MCTD - watch for pulmonary hypertension.
SLE + acute psychosis + active serology = NPSLE - treat aggressively, don't miss it.
Anti-centromere + limited skin = lcSSc - better prognosis but watch for PAH.
Anti-ribosomal P antibodies point towards neuropsychiatric SLE (psychosis and depression); confirm by excluding other causes, then treat active disease with corticosteroids plus immunosuppression (BSR 2018 guideline on the management of SLE in adults; EULAR recommendations on NPSLE).
SSc + chalky deposits on fingertips = calcinosis - think calcium deposits, not tophi.
SSc + LV dysfunction + normal coronaries = scleroderma heart disease - think myocardial fibrosis, not ischaemia.
Acute Kidney Injury
63 high-yield facts
Atheroembolic = post-procedure + AKI + blue toes + eosinophilia + cholesterol clefts; supportive only; stop anticoagulation; 50% dialysis.
If creatinine plummets with fluids, think pre-renal; if it stalls despite good volume, suspect intrinsic renal injury such as ATN.
AIN = drug exposure + AKI + eosinophilia + eosinophiluria; stop drug first; steroids if severe/refractory.
Rhabdomyolysis = ↑↑CK + AKI + hyperK+ + dipstick blood/no RBCs; IV saline (urine >200mL/h); fasciotomy if compartment syndrome; avoid early calcium.
CIN prevention = IV saline hydration + hold metformin/ACEi + minimise contrast + monitor Cr.
Diabetes plus CKD plus contrast equals high CIN risk - IV saline hydration 12 hours pre/post-contrast reduces risk 50%.
CK >15,000 plus AKI plus myoglobinuria equals rhabdomyolysis - immediate aggressive IV fluids prevent irreversible kidney damage.
CIN = AKI 48-72h post-contrast; CKD eGFR <60 strongest risk; IV saline 1mL/kg/h most effective; NAC controversial; hold metformin/nephrotoxins.
PPI/NSAID-induced AIN = subacute AKI + sterile pyuria + WBC casts + urinary eosinophils; stop the drug immediately; steroids if no improvement within 7 days (KDIGO AKI 2012).
Myeloma kidney = non-albumin proteinuria + AKI + lytic lesions; urgent bortezomib + aggressive hydration; 50-80% dialysis-dependent if delayed.
Hyperkalaemia + ECG changes = dialyse immediately - medical management buys time only.
KDIGO Stage 3 AKI = creatinine ≥3× baseline, ≥354 µmol/L, urine <0.3 mL/kg/h for ≥24 h, anuria ≥12 h, or RRT - treat the pre-renal cause with fluids, stop nephrotoxins, and escalate early (NICE NG148).
Cardiomyopathy
57 high-yield facts
HCM sudden death risk factors = family history, NSVT, massive LVH (≥30mm), unexplained syncope, abnormal BP response to exercise. ICD if high risk!
Always check TFTs in new DCM - thyroid disease is reversible! Also screen for alcohol, thiamine, tachyarrhythmias.
Cardiac sarcoid + complete heart block + active PET = pacemaker-ICD PLUS intensify steroids!
Dilated CM + persistent tachyarrhythmia + dramatic LVEF recovery with rate control = tachycardia-induced cardiomyopathy, not primary dilated CM.
Constrictive = thick pericardium + septal bounce + e' preserved + low BNP → pericardiectomy; restrictive = normal pericardium + e' reduced + high BNP → medical.
Apical HCM with giant negative T waves has excellent prognosis - beta-blockers + surveillance sufficient, ICD rarely needed unless high-risk features present.
DCM + TTN mutation + family history = cascade genetic testing for relatives - lifelong surveillance if mutation-positive!
Heart failure presenting last month of pregnancy to 5 months postpartum = think PPCM. Prognosis varies - 50% recover normal function, but recurrence risk in future pregnancies is high.
Latent LVOT obstruction (provoked gradient >30 mmHg) in HCM → start beta-blocker; surgery/ablation only if symptoms persist despite maximal meds.
CYP2D6 metabolises ~25% of drugs. PM = codeine ineffective; UM = codeine toxicity (MHRA 2013 - avoid in <12s and in breastfeeding). Avoid fluoxetine/paroxetine with tamoxifen. Pharmacogenetic testing supports personalised prescribing.
Phase II glucuronidation = UGT adds glucuronic acid → water-soluble; bilirubin conjugation; immature in neonates → jaundice.
Statistics and Evidence-Based Medicine
52 high-yield facts
p-value = probability of results this extreme IF no difference exists. p=0.001 means 0.1% chance. Does NOT mean 99.9% chance drug works! Always check confidence intervals (magnitude + precision) AND clinical significance.
OR = (ad)/(bc); case-control studies; OR=1 no association, >1 ↑risk, <1 protective; approximates RR when outcome rare; CI excludes 1 → significant.
Regression to mean = extreme values drift toward average; requires control groups to distinguish from real effects.
Publication bias = positive results preferentially published; detect via funnel plot asymmetry + Egger's test; prevent via trial registration + publish all results.
P-value = probability if no difference (p <0.05 = significant). Statistical significance ≠ clinical importance. CI not crossing null = significant.
Lower threshold → ↑sensitivity (fewer false negatives) but ↓specificity (more false positives) - used in screening contexts where missing disease is worse than overdiagnosis (UK National Screening Committee; NICE QS122).
Hazard ratio = instantaneous risk over time - HR <1 reduces risk, accounts for censored data and event timing (vs RR at fixed time).
95% CI = likely range for true value; narrow = precise; excludes null → significant; null = 0 (differences) or 1 (ratios); statistical ≠ clinical significance.
ROC curves help select thresholds; rule-out tests need high sensitivity (minimize false negatives); rule-in tests need high specificity (minimize false positives).
MALA = metformin accumulation in AKI; stop + IV saline + dialysis if severe; sick day rules essential.
Clozapine constipation 30-60%; complications 5-10% (ileus/perforation, mortality 25-30%); prophylactic laxatives for ALL patients; urgent assessment if >3d + red flags.
MALA = stop metformin + IV fluids + treat precipitant; haemodialysis if severe; eGFR <30 contraindicated.
HIT = thrombocytopenia + thrombosis; stop all heparin + argatroban/fondaparinux; no LMWH/warfarin alone; warfarin only when platelets >150.
Stop statin if CK >5× ULN with symptoms (NICE NG181 / BNF); rechallenge with low-dose alternative statin once CK has normalised; ezetimibe or PCSK9 inhibitor if intolerant.
CK >10x ULN + muscle symptoms = STOP statin immediately! Don't reduce dose or switch - STOP first, reassess when CK normalizes.
ACE inhibitor angioedema is bradykinin-mediated - adrenaline and antihistamines do not work.
Per BNF and MHRA Drug Safety Update, SSRI + elderly + symptomatic hyponatraemia within 2-4 weeks = SIADH; stop the drug, restrict fluid, and correct sodium slowly.
HSP = purpura + abdominal pain + arthritis + IgA deposition; self-limiting children; monitor renal; steroids if severe GI.
Behçet + uveitis = azathioprine or anti-TNF + steroids (prevent blindness 25%); colchicine for mucocutaneous.
Respiratory Medicine
48 high-yield facts
EGFR TKI progression → Rebiopsy for T790M (60% of resistance); T790M positive → osimertinib (ORR 60-70%, PFS 10m); T790M negative → chemotherapy; Immunotherapy ineffective in EGFR-mutant.
PAP (anti-GM-CSF positive) → Crazy-paving HRCT + milky BAL diagnostic; WLL first-line (improvement 80-90%, lasts 6-24 months); GM-CSF therapy alternative (response 50-60%); Steroids ineffective.
LAM → Young women, cysts, recurrent pneumothorax (50-70%); VEGF-D greater than 800 + CT diagnostic; 20% have TSC (angiofibromas, angiomyolipomas); Sirolimus slows decline 50%; Estrogen-driven, female-exclusive.
Recurrent MPE + lung re-expands → Talc pleurodesis via chest drain (success 70-90%); VATS poudrage if loculated/trapped; IPC for trapped lung or poor PS; Single procedure, cost-effective.
Goodpasture = Hemoptysis + AKI + anti-GBM positive; Triple therapy immediately; Do not delay; Untreated mortality 90%, treated survival 80-95%; Renal recovery better if Cr <500.
Primary PTX greater than 2cm or symptomatic → Aspiration first (success 60%); Small-bore drain if fails; Surgery for recurrence (50% rate); Secondary PTX needs drain (complications higher).
PAVM + HHT → Embolize if feeding vessel greater than 3mm; Prevents stroke (30%) and brain abscess (5-10%); Success 95-99%; Antibiotic prophylaxis for procedures.
Young patient, “pure” nephrotic syndrome (protein only, normal BP/creatinine) ⇒ minimal change until proven otherwise, and responds dramatically to steroids.
RPGN = rising creatinine + RBC casts + crescents on biopsy; pauci-immune crescentic GN = ANCA vasculitis; urgent cyclophosphamide or rituximab plus steroids ± plasma exchange (PEXIVAS).
Membranous = nephrotic + PLA2R+ + subepithelial deposits; conservative ×6m; rituximab/cyclophosphamide if persistent; anticoagulate albumin <20; screen secondary.
“Nephritic = blood + blood pressure” (haematuria, red cell casts, hypertension), while “Nephrotic = protein + puffiness” (heavy proteinuria, low albumin, massive oedema, lipid abnormalities).
RPGN with ANCA vasculitis requires urgent steroids plus cyclophosphamide or rituximab - delay causes irreversible renal failure.
In IgA nephropathy, think “P = Prognosis” - Persistent Proteinuria and Pressure (hypertension) predict progression; low protein and normal BP favour long-term renal survival.
IgA = synpharyngitic haematuria + mesangial IgA; ACEi first-line; steroids if persistent proteinuria ≥1g/d.
TAVI contraindications = inadequate annular size (<18mm or >29mm), bicuspid valve (relative), severe iliofemoral disease without alternative access, hostile anatomy. Consider SAVR if young!
Severe symptomatic AS = intervene! TAVI if age >75 or high surgical risk; SAVR if young and low risk. Never delay once symptomatic!
Young woman planning pregnancy + needs valve replacement = bioprosthetic (avoid warfarin) - accept re-operation in 10-15 years!
Severe TR + RV dilatation 48mm + progressive = SURGERY indicated even if asymptomatic - prevent irreversible RV failure!
Severe MAC + mixed MS/MR + NYHA III = surgical MVR only option - very high risk but necessary!
LVESD ≥40mm or new AF in severe primary MR = refer for surgery even if asymptomatic; waiting risks irreversible ventricular dysfunction.
Acute severe MR + cardiogenic shock = IABP reduces afterload/MR - bridge to urgent surgery!
Mechanical valves in pregnancy = LMWH (weeks 6-12) → warfarin (weeks 13-36) → LMWH (week 36-delivery). This 'warfarin sandwich' balances embryopathy prevention with effective maternal anticoagulation.
Low-flow low-gradient AS? Dobutamine stress echo distinguishes true severe (AVR helps) from pseudo-severe (won't help)!
Severe AR with LVESD approaching 50 mm or progressive LV dilatation = refer for AVR even if asymptomatic. Don't wait for symptoms or LVEF to drop.
Asymptomatic severe primary MR → operate if LVEF <60%, LVESD >40mm, PASP >50mmHg, or new AF. Don't wait for symptoms!
Electrolyte Disorders
45 high-yield facts
Corrected calcium >3.5 plus confusion equals hypercalcemic crisis - aggressive IV saline rehydration plus bisphosphonate prevent cardiac arrest.
Hypervolemic hyponatremia (hyponatremia + edema + elevated JVP + urine Na <20 + heart failure/cirrhosis) = total body Na/water increased - fluid restriction + treat cause, vs SIADH (euvolemic, urine Na >40).
Hypomagnesemia-induced hypocalcemia (low Ca + low Mg + inappropriately low PTH + refractory to calcium) = impairs PTH secretion and causes PTH resistance - MUST replace magnesium FIRST (calcium will not correct until Mg repleted), common with Crohn/diarrhea/PPI.
Symptomatic severe hyponatraemia (confusion, seizures, coma) = IV 3% hypertonic saline immediately, with controlled correction ≤10 mmol/L/24 h (ESE 2014) - fluid restriction alone is for mild, asymptomatic SIADH.
Hyperkalaemia + ECG changes = calcium first (stabilises heart), then shift K+ intracellularly.
Chronic SIADH refractory to fluid restriction (persistent Na 125 + SCLC + euvolemic + good compliance) = tolvaptan or demeclocycline - second-line agents, tolvaptan aquaretic (expensive), demeclocycline induces nephrogenic DI (cheaper, slower).
“High Ca²⁺ dries the kidney out” - hypercalcaemia leads to nephrogenic DI with dilute urine and hypernatraemia, not SIADH or primary polydipsia.
In exams, for K⁺ ≥6.5 mmol/L with ECG changes, think “Calcium FIRST, then shift and remove” - calcium gluconate, insulin-dextrose, salbutamol, and dialysis when needed.
Hypocalcaemia unresponsive to IV calcium + long-term PPI = check magnesium; IV magnesium sulfate plus stopping the PPI corrects both; MHRA 2012 Drug Safety Update identifies PPIs as a reversible cause of severe hypomagnesaemia.
Young + complete heart block + Lyme = temporary pacing + IV ceftriaxone - 90% resolve in 1 week!
AV dissociation = V rate > A rate (junctional rhythm overtakes sinus); complete heart block = A rate > V rate (ventricles escape slower than blocked atrial impulses).
Symptomatic complete heart block = permanent pacemaker. DDD > VVI to maintain AV synchrony and prevent pacemaker syndrome!
Post-cardiac surgery tachycardia + adenosine-resistant + fever = JET - cool the patient and use amiodarone.
Post-meal palpitations + normal cardiac workup + hiatus hernia = Roemheld syndrome; small meals, avoid lying post-meal, treat hernia.
RBBB + left axis deviation = bifascicular block (RBBB + LAFB). If symptomatic with syncope or documented high-degree AV block, urgent pacing is essential - these patients are at high risk of sudden cardiac death.
Paracetamol ALF with arterial pH <7.3 after resuscitation = immediate transplant referral - predicts 95% mortality without transplant.
Large volume paracentesis (>5L) = IV albumin 8g per liter removed - prevents post-paracentesis circulatory dysfunction and renal impairment in 70% vs. no albumin.
Severe alcoholic hepatitis (DF ≥32, typically bilirubin >80 µmol/L + prolonged PT) = prednisolone 40mg for 28 days - reduces 1-month mortality from 35% to 15%.
HPS = cirrhosis + platypnoea-orthodeoxia + hypoxaemia + intrapulmonary shunt on contrast echo (3-6 cycles); liver transplant only cure (80-85% resolution); no effective medical therapy; TIPS and pulmonary vasodilators ineffective (vasodilators may worsen shunting).
Wilson disease (low caeruloplasmin + Kayser-Fleischer rings + raised urinary copper) = lifelong chelation with penicillamine or trientine - untreated disease is fatal.
Aminoglycosides = concentration-dependent killing; once-daily dosing = high peaks + low troughs; target trough <1 mg/L; limit to <7 days; monitor U&Es.
Zero-order kinetics; small dose ↑ = large level ↑; TI 10-20mg/L; adjust 25-50mg; free levels if albumin low; CYP2C9/2C19 substrate.
TDM for narrow index (digoxin, lithium, phenytoin, vancomycin, gentamicin); trough most common; sample at steady state; phenytoin = zero-order kinetics.
Vancomycin = time-dependent; trough 15-20 mg/L for bacteremia/endocarditis; nephrotoxicity if >20 mg/L; monitor creatinine; dose adjust in renal impairment.
Vancomycin TDM essential; target trough 15-20 mg/L for serious MRSA infections; increase dose if subtherapeutic, recheck after 4 doses.
Phenobarbital auto-induction = induces own CYP → ↓levels over 2-3 weeks despite same dose. TDM essential at steady state (2-3 weeks). Also induces other drugs (warfarin, OCP, antiepileptics) → ↓their levels. Therapeutic 15-40 mg/L.
Theophylline TI 10-20 mg/L; zero-order kinetics; CYP1A2 inhibitors ↑levels; MDAC for decontamination; benzodiazepines for seizures; haemodialysis if severe.
Digoxin toxicity = GI + xanthopsia + arrhythmias; hypokalaemia potentiates; Digibind for severe cases; avoid calcium.
Warfarin INR 2-3 (AF/VTE); major bleeding = PCC + IV vit K 10mg; ↑INR with macrolides/azoles/amiodarone; ↓INR with rifampicin/carbamazepine.
Major warfarin bleeding = PCC (rapid) + IV vitamin K; PCC > FFP (faster, smaller volume).
Toxic MNG - longstanding goiter, TSH <0.01 + T4 38 + T3 12, hot nodules (patchy vs Graves diffuse), antibodies negative, AF 10-20% elderly, radioiodine I-131 (first-line elderly 80-90%, hypothyroidism 40-70%, OR thyroidectomy if compressive), pre-treat carbimazole 4-6w (stop 3-5d before), anticoagulate AF, monitor TFTs 6-weekly.
Sick euthyroid = low T3, low-normal T4, normal TSH in critical illness; adaptive (NOT hypothyroidism); do NOT treat; resolves on recovery; only treat if TSH >20 or pre-existing.
Postpartum thyroiditis (thyrotoxicosis at 3 months → hypothyroidism at 6 months + TPO antibodies + low uptake + first year postpartum) = triphasic pattern - beta-blockers for thyrotoxic phase (NOT antithyroid drugs), levothyroxine for hypothyroid phase, 50% permanent hypothyroidism.
Thyroid nodule with high-risk ultrasound features + Bethesda V (suspicious for malignancy) = thyroid surgery (lobectomy/total thyroidectomy) - likely papillary thyroid carcinoma, excellent prognosis (>95% 10-year survival).
Graves + planning pregnancy = ATD first-line, switch to PTU pre-conception/1st trimester (then carbimazole); avoid RAI within 6 months of conception; thyroidectomy if remission unlikely (BTA Graves 2018; RCOG/RCP guidance; NICE CKS Hyperthyroidism).
GOLD spirometry = simple numbers: ≥80, 50-79, 30-49, <30. Think "8-5-3" stepping down by roughly half each time. Don't confuse spirometric grade (1-4) with symptom groups (A-D) - they're different!
Green sputum = bacterial infection in COPD exacerbations. Purulence is the key trigger for antibiotics - simple increased breathlessness alone does not need them!
Eosinophils ≥300, exacerbations ≥2, despite therapy = time for biological therapy! Think mepolizumab when COPD patients keep bouncing back to hospital despite maximal inhalers.
Smoking cessation is the only intervention that slows COPD progression - reduces FEV1 decline by 50%.
NIV indications = pH 7.25-7.35 + PaCO2 >6 + no improvement; Target SpO2 88-92% in COPD.
PPFE = upper lobe fibrosis + platythorax + cachexia + rapid FVC decline; no medical therapy works; lung transplant only option; opposite distribution to IPF.
PLCH = young smoker + bizarre cysts upper zones + nodules + pneumothorax; smoking cessation = treatment; 50-60% improve.
RB-ILD = young smoker + centrilobular nodules upper-mid zones; smoking cessation = treatment (70-80% improve); milder than DIP.
AIP = Acute respiratory failure in healthy person + DAD histology; ARDS-like presentation; High mortality 50-70%; Poor steroid response; Survivors recover or develop fibrosis.
IPF with DLCO <40% or declining FVC = refer for transplant assessment early; don't wait for end-stage.
IPF = basal honeycombing on HRCT + UIP pattern; treat with antifibrotics, not steroids.
ALL incidentalomas = metanephrines (pheo) + dexamethasone (Cushing) + ARR if hypertensive; always screen before biopsy/surgery; >4cm or suspicious = consider adrenalectomy.
Secondary hyperaldosteronism (hypertension + hypokalemia + HIGH renin + high aldosterone + asymmetric kidneys + low ARR <20) = renal artery stenosis - vs primary (low renin, ARR >30) - investigate with renal artery imaging, revascularization if severe.
Suspected Addison's = Short Synacthen test (cortisol fails to rise >550 nmol/L). Then check ACTH (high = primary, low = secondary)!
Suspect pheochromocytoma = episodic headache + sweating + palpitations + hypertension. First test = plasma or urinary metanephrines (>95% sensitive). Then image adrenals!
Primary hyperaldosteronism = high aldosterone + low renin + resistant HTN + hypokalemia. Image adrenals then ADRENAL VEIN SAMPLING to confirm lateralization before surgery!
Pheochromocytoma preoperative preparation (before adrenalectomy) = alpha-blockade (phenoxybenzamine/doxazosin) 10-14 days first, then beta-blocker if tachycardia - NEVER beta-block first (unopposed alpha causes hypertensive crisis).
Confirmed phaeochromocytoma = alpha-blockade first (phenoxybenzamine or doxazosin) for 10-14 days pre-operatively with volume repletion; add a beta-blocker only after alpha-blockade; never give a beta-blocker alone (unopposed alpha-stimulation precipitates hypertensive crisis).
Screen for Cushing's with 1mg overnight DST (cortisol fails to suppress <50 nmol/L). Then check ACTH to differentiate pituitary/ectopic/adrenal!
Small Bowel Disorders
31 high-yield facts
Carcinoid syndrome = flushing + secretory diarrhoea + bronchospasm + right-heart valve disease + raised urinary 5-HIAA → start a long-acting somatostatin analogue (octreotide LAR or lanreotide) first-line per UKINETS/ENETS; PROMID/CLARINET trials confirm antiproliferative benefit.
Painless GI bleeding in young patient (normal upper/lower endoscopy) = technetium-99m pertechnetate scan - detects ectopic gastric mucosa in Meckel diverticulum.
Negative celiac serology (tTG-IgA) + low total IgA = check IgG-based antibodies (tTG-IgG/DGP-IgG) - IgA deficiency causes false-negative results.
Peutz-Jeghers syndrome carries a very high lifetime cancer risk - it needs intensive multi-organ surveillance (GI, pancreas, breast, gynaecological), not isolated colonoscopy or prophylactic resection.
IgA vasculitis with severe GI symptoms (abdominal pain + GI bleeding + duodenal purpura) = corticosteroids 1mg/kg - reduces complications, prevents intussusception.
Whipple disease (diarrhea + arthralgia + PAS-positive macrophages + T. whipplei PCR) = IV ceftriaxone 2 weeks then co-trimoxazole 12 months - CNS penetration essential, prevents relapse.
Bile acid malabsorption (chronic diarrhea + ileal disease/resection + low SeHCAT <15%) = colestyramine or colesevelam - response 70-90%, improves quality of life.
SIBO = bloating + diarrhoea + low B12; positive hydrogen breath test; rifaximin 550 mg TDS × 14 days (off-licence) with treatment of the underlying cause; recurrence 40-50%.
SBS <100cm without colon = permanent TPN; teduglutide ↓ TPN 30-50%; transplant if complications; 5y 60%.
Simple adhesive SBO without strangulation signs deserves 48-72 hour trial of conservative management before surgery.
Pituitary Disorders
29 high-yield facts
Acromegaly (acral enlargement + elevated IGF-1) = confirm with 75g OGTT (GH fails to suppress <1 ng/mL) - gold standard dynamic test, then MRI to localize, transsphenoidal surgery first-line, random GH unreliable (pulsatile).
Macroprolactinoma - cabergoline first-line even with chiasmal compression (BNF/NICE CKS); transsphenoidal surgery only for resistance, intolerance, or apoplexy; monitor prolactin, MRI, and visual fields throughout.
Nelson syndrome = post-bilateral-adrenalectomy ACTH pituitary tumour + hyperpigmentation → transsphenoidal surgery ± stereotactic radiotherapy; cortisol-lowering drugs have no role.
Thunderclap headache + visual loss + known pituitary adenoma → IV hydrocortisone stat, then MRI and neurosurgical review.
Cushing disease → transsphenoidal adenomectomy first-line; medical/radiotherapy for failures; consider IPSS if MRI non-localising.
Acromegaly diagnosis = elevated IGF-1 + GH fails to suppress <1 ng/mL on OGTT. Then MRI pituitary to localize adenoma!
Macroprolactinoma + chiasmal compression - cabergoline first-line (BNF, Endocrine Society); surgery only for resistance, intolerance, or apoplexy; monitor prolactin, MRI, and visual fields throughout.
Sheehan's = PPH → failure to lactate + amenorrhoea + fatigue, low prolactin + low TSH with low T4 + low cortisol, hydrocortisone BEFORE thyroxine.
Nelson's = bilateral adrenalectomy for Cushing's → severe hyperpigmentation + pituitary macroadenoma + very high ACTH. Prevented by avoiding bilateral adrenalectomy.
Pleuritic/positional chest pain + young age + no risk factors + troponin <5 ng/L = very low ACS probability; safe to discharge without further cardiac workup.
Anterior ST elevation + emotional or physical trigger + unobstructed coronaries + apical ballooning crossing multiple coronary territories = Takotsubo, not STEMI.
Anaphylaxis + STEMI + coronary spasm = Kounis syndrome - give adrenaline anyway (life-saving), then nitrates/CCBs for vasospasm.
NSTEMI risk stratification = GRACE score. Intermediate risk (109-140) = angiography within 72 hours; high risk (>140) = within 24 hours!
STEMI = primary PCI if achievable within 120 minutes; thrombolyse if PCI delayed beyond 120 minutes and within 12 hours of symptom onset!
Chronic Kidney Disease
28 high-yield facts
Advanced CKD plus gadolinium equals NSF risk - avoid contrast or use a macrocyclic agent at the lowest dose and dialyse promptly; there is no effective treatment once it is established.
Pre-eclampsia = >20w + HTN + proteinuria; MgSO₄ for all severe; delivery = only cure; HELLP = haemolysis + ↑LFTs + ↓platelets.
“Analgesic kidneys = small, scarred, and papillae gone” - chronic NSAID exposure, papillary necrosis, sterile pyuria, and calcified papillae on imaging point strongly to analgesic nephropathy as the cause of CKD.
Chronic NSAID use plus small kidneys plus papillary calcifications equals analgesic nephropathy - stop NSAIDs immediately, screen for urothelial cancer.
In diabetes, “ACR ≥3 = ACE/ARB” - albuminuria is both a renal and cardiovascular risk marker, and RAAS blockade is first-line reno-protective therapy.
eGFR 30-44 = G3b; ACR ≥30 mg/mmol = A3; continue ACE inhibitor/ARB, add an SGLT2 inhibitor, and refer only if eGFR <30 or ACR ≥70 per NICE NG203.
CKD anemia (Hb <100 + CKD 4-5 + low ferritin/TSAT) = IV iron FIRST (correct deficiency), then epoetin if Hb remains low - target Hb 100-120 g/L (NOT >130), ESAs ineffective without iron.
CKD-MBD = control phosphate first, then vitamin D, then calcimimetics if PTH still high.
Uraemic pericarditis = inadequate dialysis + friction rub + diffuse saddle-shaped ST elevation; intensify dialysis (heparin-free) and avoid NSAIDs (BNF / Renal Association); pericardiocentesis only if tamponade.
Diabetic patient with PCR >100 mg/mmol meets the NICE NG203 nephrology referral threshold - start an ACEi/ARB plus an SGLT2 inhibitor and target BP <130/80 mmHg (NICE NG203, NG28, TA775).
Congenital Heart Disease
26 high-yield facts
Athlete + anomalous left main from right sinus + inter-arterial = SURGERY - high SCD risk, NOT cleared for sport!
Fontan patients develop FALD from chronic venous hypertension - monitor LFTs and image liver regularly. Consider combined heart-liver transplant in advanced cases.
In repaired TOF with severe PR, intervene before RV dilatation becomes irreversible - aim for PVR when RVEDVI approaching 160 mL/m² or symptoms develop. Late intervention = poor RV functional recovery.
Large VSD + FTT + PAH 45 + Qp:Qs 3.2 = SURGERY NOW - prevent irreversible Eisenmenger by age 1-2!
Left main from right + inter-arterial + athlete = surgery essential - too high SCD risk!
Fleischner 2017 = Solid nodules (size + risk); High-risk (smoker, cancer history); 6-8mm: CT 6-12, 18-24 months; >8mm: CT 3 months or PET-CT/biopsy; Sub-solid different protocol; Document characteristics; Smoking cessation.
Confirmed mesothelioma needs PET-CT staging then MDT review - first-line treatment is platinum/pemetrexed or nivolumab plus ipilimumab (CheckMate-743); epithelioid type has the best prognosis, and all patients should be signposted to asbestos compensation.
NSCLC stage IIIA (N2 nodes) = concurrent chemoradiotherapy; surgery if minimal N2 only.
SIADH = hyponatraemia + urine osm >100 + euvolaemia; SCLC most common cause; fluid restriction first-line; correct Na⁺ max 10mmol/L/24h.
Lung cancer screening = LDCT (NOT X-ray); Criteria: age 55-74 + ≥30 pack-years; Reduces mortality 20%.
Wilson disease (Kayser-Fleischer rings + low ceruloplasmin + elevated urinary copper + neurological symptoms) = D-penicillamine or trientine plus zinc - lifelong therapy prevents progression.
Hepatic adenoma >5cm (OCP use + incidental finding) = stop OCP + surgical resection - rupture risk 30-50%, malignant transformation 5-10%, regression possible if <5cm after stopping hormones.
Any new dominant stricture in PSC = rule out malignancy with tissue sampling before attributing to benign disease progression.
Gilbert syndrome (mild unconjugated hyperbilirubinemia + normal liver enzymes + precipitated by fasting/illness) = reassurance only - benign condition, no treatment needed.
Acute cholangitis (Charcot triad + septic shock + E. coli bacteremia) = Grade III severity, urgent ERCP <24 hours + IV antibiotics - emergency decompression critical, mortality 10-30% without drainage.
Porcelain gallbladder (gallbladder wall calcification + chronic cholecystitis) = prophylactic cholecystectomy if fit for surgery - eliminates low but real gallbladder cancer risk.
Gallbladder polyp ≥10mm or any polyp showing growth = cholecystectomy - eliminates malignancy risk (37% if >10mm).
Post-cholecystectomy pain without objective findings (Type III SOD) - try medical therapy, avoid sphincterotomy (high pancreatitis risk, no benefit over sham).
PSC (cholestatic enzymes + bile duct beading + IBD association) = surveillance for cholangiocarcinoma + colonoscopy + transplant if decompensated - no proven medical therapy.
Glomerulonephritis
22 high-yield facts
Chronic inflammation + amyloid = AA amyloidosis - treat the inflammation to save the kidneys.
Tram-track GBM + low C3 + cryoglobulins = MPGN Type I - check for hepatitis C.
Random fibrils + Congo red negative = fibrillary GN - distinct from amyloid, often progressive.
Hemoptysis plus rapidly progressive GN plus anti-GBM positive equals Goodpasture - urgent plasma exchange within hours saves kidneys and prevents fatal pulmonary hemorrhage.
Pauci-immune crescents + ANCA = AAV → induce with cyclophosphamide or rituximab + steroids; PEXIVAS reduced steroid dosing and demoted plasma exchange in renal disease.
Anti-GBM + crescents = plasmapheresis immediately - every day counts, delay = dialysis.
Lynch syndrome (MMR gene mutation + strong family history) = colonoscopy every 1-2 years from age 25 - intensive surveillance reduces CRC mortality by 70%.
Microscopic colitis (chronic watery diarrhea + normal colonoscopy + collagen band >10 μm) = budesonide 9mg for 8 weeks - induces remission 80%; Benign, no cancer risk.
Heart Failure
19 high-yield facts
HFpEF management = treat symptoms with diuretics + aggressively manage ALL comorbidities (HTN, AF, obesity, sleep apnea). SGLT2i emerging as beneficial!
HFrEF triple therapy = ACE-I + beta-blocker + MRA (+ SGLT2i now!). Each drug independently reduces mortality.
Acute severe HF congestion → IV furosemide bolus + infusion; oral diuretics inadequate due to gut oedema reducing absorption.
HFpEF + symptomatic = SGLT2 inhibitor (dapagliflozin/empagliflozin) - ONLY drug class proven to reduce HF hospitalizations!
HFrEF symptomatic despite ACE-i/BB/MRA/SGLT2i = consider switching ACE-i to ARNI (after 36-hour washout). ARNI superior to ACE-i in reducing mortality.
HFpEF finally has treatment! SGLT2 inhibitors (empagliflozin/dapagliflozin) reduce HF hospitalizations - class IIa!
Type 2 CRS = chronic heart failure causing chronic kidney disease over months; distinguished from type 1 (acute HF → AKI) by timeframe.
Sequential nephron blockade (loop + thiazide) more effective than increasing loop diuretic dose alone for overcoming diuretic resistance.
TAPSE <17 mm signifies RV systolic dysfunction, and a value of 12 mm denotes severe impairment - a powerful independent predictor of mortality in cor pulmonale.
ACE inhibitor cough = switch to ARB. ARB cough incidence <5% (much lower than ACE-i). Never stop RAAS blockade in HFrEF without replacing it.
childhood/young-adult foot drop + pes cavus + 'inverted champagne bottle' legs + multigenerational family history + uniformly slow NCVs <38 m/s = CMT1A (PMP22 duplication, autosomal dominant); supportive care with AFOs; avoid vincristine and nitrofurantoin.
GBS = ascending paralysis + areflexia + high CSF protein. Treat with IVIg 0.4g/kg/day x 5 days OR plasma exchange. Monitor FVC - intubate if <15 mL/kg!
Carpal tunnel syndrome = median nerve distribution + nocturnal + flick sign + Tinel's. First-line: wrist splint neutral position at night x 6 weeks. Surgery if failed conservative or severe!
CPN palsy = foot drop + weak eversion + preserved inversion + intact ankle reflex; AFO + observe; 80% recover.
CMT = childhood distal weakness + pes cavus + champagne bottle legs + FHx; AFOs + physio + genetic testing; no cure; normal lifespan.
Miller Fisher = ophthalmoplegia + ataxia + areflexia + anti-GQ1b (90-95%); self-limiting; 90-95% full recovery.
GBS with a declining FVC needs urgent ITU monitoring plus prompt IVIg or plasma exchange - intubate if FVC falls below about 1.5 L (20 mL/kg).
GBS unable to walk 10 meters = IV immunoglobulin or plasma exchange immediately; corticosteroids ineffective.
CIDP = chronic (over 8 weeks) symmetrical motor and sensory demyelinating neuropathy with areflexia and raised CSF protein; first-line is IVIg, corticosteroids, or plasma exchange (EAN/PNS 2021 guideline).
Chronic progressive proximal and distal weakness plus areflexia plus demyelinating studies equals CIDP - IVIG or steroids induce remission 60-80%.
Movement Disorders
19 high-yield facts
Huntington disease (chorea + psychiatric symptoms + dementia + family history + caudate atrophy) = HTT CAG repeat testing; autosomal dominant (50% offspring risk); anticipation with paternal inheritance.
Bilateral action tremor + alcohol-responsive + family history = essential tremor; treat with propranolol or primidone if disabling.
PD with wearing-off + dyskinesias = add COMT inhibitor (extends duration without worsening dyskinesias); amantadine for dyskinesias.
Wearing-off plus peak-dose dyskinesia after years of levodopa therapy = add COMT inhibitor (entacapone) ± MAO-B inhibitor (rasagiline) per NICE NG71. Amantadine for troublesome dyskinesia. DBS for refractory motor complications. Avoid anticholinergics in elderly (delirium risk).
Wearing-off plus dyskinesias equals motor complications from pulsatile levodopa - add COMT inhibitor to smooth delivery, reduce dose fluctuations.
Bilateral postural tremor plus family history plus alcohol responsiveness equals essential tremor - propranolol reduces tremor amplitude 50-70%.
Essential tremor = bilateral action/postural tremor + NO resting tremor + NO parkinsonian signs + improves with alcohol. Treat if impairing: propranolol 40-320mg OR primidone 50-750mg!
Parkinson's with significant functional impairment = start levodopa. Most effective treatment. Motor complications develop after 4-6 years but benefits outweigh risks!
"Wearing-off = Give levodopa MORE FREQUENTLY!" Reduce dosing interval first, then add COMT/MAO-B inhibitor if needed.
RLS = urge to move + worse rest + relieved movement + worse evening; check ferritin → iron if <75 (improves 60%); then dopamine agonist or gabapentin.
Wilson disease (young adult + movement disorder + KF rings + low ceruloplasmin) = penicillamine or trientine lifelong; early treatment prevents progression.
Esophageal Disorders
19 high-yield facts
EoE = atopic young adult + dysphagia/food impaction + rings/furrows + ≥15 eosinophils/HPF (BSG 2022); first-line = high-dose PPI for 8 weeks, then swallowed topical steroids; confirm histological remission at 8-12 weeks.
Dysphagia to solids AND liquids + bird's-beak + absent peristalsis with IRP >15 mmHg = achalasia; laparoscopic Heller myotomy with partial fundoplication or POEM are first-line (BSG; NICE IPG463).
SABA >3 times weekly or symptoms at night = time for ICS! If your asthma wakes you up or you are reaching for the blue inhaler more than 3 times weekly, you need a preventer steroid.
Bronchial thermoplasty = Bronchoscopic radiofrequency ablation airway smooth muscle; Severe asthma uncontrolled on maximal therapy + biologics; Reduces exacerbations 30-50% (not FEV1); 3 procedures (3-week intervals); Best if non-eosinophilic (<300); NICE approved; Durable benefits 5+ years.
Normal pCO2 in acute asthma equals life-threatening - respiratory muscle exhaustion, urgent treatment prevents arrest.
Asthma pregnancy - continue all medications (ICS/LABA safe); Uncontrolled asthma = greater risk to mother/fetus (hypoxemia, pre-eclampsia, preterm, low birth weight); Optimize treatment same as non-pregnant; Treat exacerbations aggressively; Regular monitoring; Reassure safety.
Switching ICS: beclometasone/budesonide to fluticasone = halve the dose (fluticasone twice as potent); always check inhaler technique.
Peak flow = Twice daily (morning/evening) 2-4 weeks; Same meter; >80% personal best + <20% diurnal variation = good control; Action plan: Green >80%, Amber 60-80%, Red <60%; <60% = seek help urgently; Effort-dependent (technique important).
VCD = stridor NOT wheeze; Inspiratory flow limitation; Speech therapy NOT salbutamol; Often misdiagnosed as severe asthma.
Asthma plus eosinophilia plus IgE >1,000 plus central bronchiectasis equals ABPA - steroids prevent fibrosis, itraconazole reduces fungal load.
Inhaler technique errors = 50-80% patients; Always ask to demonstrate (verbal unreliable); DPI (Accuhaler/Turbohaler): exhale AWAY, inhale FAST/FORCEFUL, hold 10 seconds; MDI: slow inhalation, coordinate; Correcting technique improves control 50% without medication change; Check EVERY visit; Moisture ruins DPI powder.
Inflammatory Bowel Disease
18 high-yield facts
ASUC = ≥6 bloody stools + fever/tachy/anaemia/↑CRP; IV hydrocortisone 100mg QDS; infliximab/ciclosporin if fails day 3-5; colectomy if refractory.
Complex perianal Crohn fistulas need both drainage (seton) and anti-TNF - neither alone is sufficient for optimal outcomes.
Severe UC = ≥6 bloody stools + Truelove-Witts; IV hydrocortisone 100mg QDS; avoid antidiarrhoeals; infliximab/ciclosporin rescue; colectomy if refractory.
UC + cholestasis + multifocal strictures on MRCP = PSC; runs independent of IBD activity; cholangiocarcinoma 10-15% (annual CA19-9 + USS) and CRC ↑5× (annual colonoscopy); UDCA improves LFTs; transplant for end-stage.
Long fibrotic Crohn stricture (>4cm, non-enhancing MRI) causing obstruction = surgical resection/stricturoplasty - medical therapy cannot reverse established fibrosis.
ASUC + megacolon = IV steroids + surgical review immediately.
Chronic watery diarrhoea + normal colonoscopy = biopsy to diagnose microscopic colitis.
Toxic megacolon (colon >6cm + systemic toxicity) failing IV steroids = urgent surgery - do not delay for medical rescue.
Acute severe UC unresponsive to 5 days IV corticosteroids = rescue therapy with IV ciclosporin or infliximab - both achieve 60-80% response, avoiding colectomy.
Steroid-dependent UC (cannot taper prednisolone without relapse + normal TPMT) = azathioprine 2-2.5 mg/kg - effective steroid-sparing maintenance in 60-70%.
Toxic megacolon (colon >6 cm + systemic toxicity) = urgent surgical colectomy; medical rescue contraindicated.
Amiodarone requires baseline TFTs + LFTs + CXR + PFTs before starting. Monitor TFTs/LFTs every 6 months lifelong!
to prevent nitrate tolerance, build in an 8-12 hour daily nitrate-free interval - a once-daily modified-release mononitrate (or asymmetric BD dosing) achieves this; never dose nitrates symmetrically around the clock.
Propranolol in thyroid storm = dual benefit (beta-blockade + blocks T4→T3 conversion); unique advantage over other beta-blockers.
Tamponade = absent y descent, pulsus paradoxus >10mmHg, muffled heart sounds. Constrictive pericarditis = BOTH x and y descents present!
Equalised diastolic pressures + pericardial knock + prominent JVP x/y descents + post-TB or post-cardiac-surgery history = constrictive pericarditis - pericardiectomy is the definitive treatment (ESC 2015 pericardial guidelines).
Recurrent malignant pericardial effusion with reasonable prognosis = pericardial window (or sclerotherapy) plus systemic anti-cancer therapy; median survival 3-4 months reflects underlying malignancy, so management aims for durable palliation rather than cure.
Tamponade = pericardial effusion + haemodynamic compromise (Beck's triad, pulsus paradoxus, RA/RV diastolic collapse) → urgent pericardiocentesis; IV fluids only as temporising measure; diuretics contraindicated (ESC 2015).
Always add colchicine to NSAIDs for first episode acute pericarditis - halves recurrence rate (from ~30% to ~15%).
RA + large pericardial effusion + low glucose + active disease = rheumatoid pericarditis - treat with corticosteroids/immunosuppression.
Inflammatory Arthritis
17 high-yield facts
For RA think the '3 S's' - Symmetrical, Small joints and Stiff in the morning (>30-60 minutes) - which strongly favour an inflammatory polyarthritis over osteoarthritis.
RA + splenomegaly + neutropenia = Felty's - think autoimmune destruction, not drugs.
In RA patients with an ILD picture, think “rheumatoid lung” - restrictive pattern, reduced DLCO, UIP/NSIP on HRCT - an important cause of morbidity and mortality requiring early recognition and respiratory input.
For RA and pregnancy, “MTX and leflunomide must go; sulfasalazine can stay (with folate)” - stop methotrexate 3 months before, continue sulfasalazine, and switch to safer alternatives if needed.
ACR/EULAR score ≥6 = definite RA - start DMARDs early to prevent damage.
RA + extensor surface nodules = rheumatoid nodules - think severe disease, watch for extra-articular complications.
For RA, think “long, slow mornings” - stiffness >60 minutes that eases with use, whereas OA mornings are short and joints worsen with prolonged activity.
In RA, “check the neck before the anaesthetist checks the airway” - cervical spine imaging for AAS is vital in long-standing disease with neck pain or neurological symptoms before major surgery.
Recurrent attacks + complete resolution + positive RF = palindromic rheumatism - may progress to RA.
Psychopharmacology
17 high-yield facts
MAOI + tyramine-rich food = hypertensive crisis. Key foods: aged cheese, cured meats, red wine, Marmite. Treat with phentolamine.
TCA overdose + QRS >100ms = IV sodium bicarbonate immediately. Fatal triad: cardiac arrhythmia, seizures, anticholinergic. Never give flumazenil.
"Lithium = 3-6 rule!" Levels every 3 months, renal/thyroid every 6 months. Narrow therapeutic window = vigilant monitoring!
Mirtazapine = sedation + appetite stimulation (H1 blockade). Lower doses are MORE sedating than higher doses. Good for depressed patients with insomnia and weight loss.
Tardive dyskinesia = late onset + orofacial movements (lip-smacking, tongue) + chronic antipsychotic use. May be irreversible. Switch to clozapine. VMAT2 inhibitors for treatment.
Lamotrigine SJS risk = rapid titration. MUST titrate slowly (25mg increments every 2 weeks). Mucosal involvement + targetoid lesions + fever = SJS until proven otherwise.
Akathisia = inner restlessness + inability to sit still + distressing. Treat with dose reduction + propranolol. Most distressing EPS - major cause of non-adherence and suicide risk.
Olanzapine and clozapine = highest metabolic risk (weight gain, diabetes, dyslipidaemia). Monitor metabolic parameters regularly. Aripiprazole = lowest metabolic risk. Consider switching if metabolic syndrome develops.
Sertraline and fluoxetine = safest SSRIs in pregnancy. Paroxetine = avoid. Untreated severe depression in pregnancy carries significant risks - usually continue treatment.
Chylothorax = milky fluid + pleural triglycerides >1.24 mmol/L; chest drain + MCT diet/TPN for 2-4 weeks first per BTS guidance; surgery or duct embolisation if output >1 L/day or failure (success ~90%).
Light's criteria (protein ratio >0.5, LDH ratio >0.6, or pleural LDH >2/3 ULN) = exudate needs further workup.
Pleural fluid pH <7.20 plus pneumonia equals complicated effusion - chest drain plus IV antibiotics mandatory, antibiotics alone insufficient.
Pneumothorax >2 cm rim plus breathless equals large PSP - aspiration first-line, successful 60-80%, avoids drain.
Pleural effusion with pH <7.2 equals complicated parapneumonic effusion - chest drain plus antibiotics prevent organization and need for surgery.
Diabetes
16 high-yield facts
HHS - glucose >30 + osmolality >320 + minimal ketones, IV saline (slower than DKA) + insulin 0.05 (lower than DKA) + LMWH, mortality 5-15%.
DKA = IV 0.9% saline 1 L first hour → fixed-rate insulin 0.1 u/kg/h (no bolus) → K⁺ replacement → 10% glucose when <14; bicarbonate contraindicated; SC insulin before stopping IV (JBDS-IP 2023).
IDM hypoglycaemia = macrosomia + jittery/lethargic at 1-2 h; buccal dextrose gel first-line (BAPM); early feeding; IV 10% dextrose if refractory; recheck 30 min post-intervention.
DKA - fluids BEFORE insulin, K replacement essential (prevent fatal hypoK), dextrose when <15 (continue insulin until ketones clear).
Stroke
16 high-yield facts
Lateral medullary syndrome (crossed sensory loss + Horner + ataxia + dysphagia) = PICA stroke; anticoagulate if AF (start 2 weeks post-stroke if not contraindicated).
Malignant MCA infarction (>50% MCA territory + declining GCS + midline shift + herniation signs + age 60 or under) requires urgent decompressive hemicraniectomy within 48 hours, which reduces mortality from about 80% to 30%; medical management alone is insufficient.
All suspected TIA needs aspirin 300 mg immediately and specialist assessment within 24 hours (NICE NG128) - ABCD2 scoring is no longer recommended for triage.
Bilateral brainstem signs plus reduced GCS and a hyperdense basilar artery = basilar occlusion - confirm with CTA and arrange emergency thrombectomy (window up to 24 hours); antiplatelets or thrombolysis alone are insufficient.
Warfarin with INR above 1.7 contraindicates IV alteplase - correct the INR first, and refer for mechanical thrombectomy, which anticoagulation does not preclude.
Locked-in = awake + quadriplegic + vertical gaze preserved + ventral pons; establish communication FIRST; not coma.
Acute stroke + LVO (e.g. M1 MCA) + NIHSS >=6 + within window = IV thrombolysis PLUS mechanical thrombectomy (NICE NG128; RCP National Clinical Guideline for Stroke), with thrombectomy extending to 24 hours if perfusion imaging is favourable.
PCOS desiring fertility (oligo-ovulation + hyperandrogenism + polycystic ovaries + obesity + insulin resistance) = weight loss + metformin - improves ovulation 60-70%, then clomifene/letrozole if needed.
PCOS with obesity = lifestyle modification + metformin FIRST (improves insulin resistance, fertility, reduces diabetes risk). Add COCP for cycle regulation and endometrial protection!
Klinefelter = tall, small firm testes, gynecomastia, azoospermia, low testosterone + HIGH LH/FSH. Confirm with karyotype (47,XXY). Commonest chromosomal cause of male infertility!
Pubertal gynecomastia - bilateral tender 4 cm, Tanner 4 (60-90% boys 13-14), normal testosterone 18 + testes 15 mL (excludes Klinefelter), normal estradiol/liver/no drugs, reassurance (resolves 12-18m 90%), monitor 6-monthly, surgery if >2y distressing, prognosis 90% spontaneous resolution.
Hypogonadotrophic hypogonadism + anosmia + absent olfactory bulbs = Kallmann syndrome; testosterone replacement for virilisation and bone protection; pulsatile GnRH or hCG/FSH for fertility (~70%); lifelong therapy with X-linked counselling.
POI = oestrogen replacement (HRT or COCP) until the average age of menopause to protect bone and cardiovascular health (NICE NG23); progestogen alone is insufficient and clomifene will not restore fertility when FSH is high.
47,XXY = small firm testes (pathognomonic) + azoospermia + hypergonadotropic hypogonadism; testosterone undecanoate 1000mg IM 12-weekly lifelong; TESE + ICSI for fertility; screen osteoporosis/metabolic.
Atrial Fibrillation
14 high-yield facts
CHA₂DS₂-VASc ≥2 (male) or ≥3 (female) = anticoagulate with DOAC or warfarin. DOACs are first choice unless contraindicated (mechanical valve, severe renal impairment).
Rate vs rhythm? Rate control first-line for older patients/persistent AF/LA dilation - beta-blockers first-line!
Most AF patients do NOT need bridging peri-op; stop warfarin 5 days pre-op, restart evening of surgery - bridging only for mechanical valves.
AF + CHA₂DS₂-VASc 5 + recurrent major bleeding on OAC = LAA occlusion device - non-inferior stroke prevention!
AF + CHA₂DS₂-VASc ≥2 + recurrent major bleeding = LAAO device - stroke protection without systemic anticoagulation.
Post-TAVI with AF? Anticoagulation alone - adding antiplatelets increases bleeding without benefit!
Symptomatic paroxysmal AF + failed antiarrhythmics + young + normal heart = catheter ablation (PVI). First-line in selected patients per 2020 ESC guidelines.
AF with heart failure = beta-blocker first-line for rate control. Avoid rate-limiting CCBs (diltiazem/verapamil) in HFrEF - they worsen failure.
Major bleeding on apixaban/rivaroxaban → andexanet alfa (specific reversal); dabigatran → idarucizumab; PCC second-line if unavailable.
AF cardioversion = anticoagulate at time of cardioversion + 4 weeks after, even if AF <48 hours. Then reassess based on CHA₂DS₂-VASc for long-term.
Acute limb ischaemia in AF patients should prompt investigation for cardiac source - LA/LAA thrombus requires lifelong anticoagulation.
LAAO = high stroke risk AF + anticoagulation contraindicated; 90% thrombi from LAA; not first-line (DOACs preferred).
Occupational Lung Disease
14 high-yield facts
Pleural plaques = Benign marker asbestos exposure; Bilateral calcified (diaphragm/posterolateral); Asymptomatic (do NOT cause symptoms); Do NOT increase mesothelioma risk; Lung cancer risk 5-fold (smoking synergistic); Surveillance needed; No treatment for plaques; Distinguish from mesothelioma (nodular, effusion, symptomatic).
ReA = asymmetric arthritis + conjunctivitis + urethritis after infection; the genitourinary trigger is Chlamydia trachomatis, while enteric triggers are Salmonella, Shigella, Campylobacter and Yersinia; check HLA-B27 (BASHH; EULAR).
AS + axial symptoms = NSAIDs first - think inflammation, not DMARDs.
AS = exercise is essential - think maintain mobility, prevent fusion, not rest.
Acute gout = NSAID or colchicine first-line - think rapid anti-inflammatory, not allopurinol during attack.
Allopurinol = start low (100 mg), titrate slowly, give colchicine prophylaxis - prevents flares and AHS.
ULT = start after attack resolves if recurrent attacks - think prevent future attacks, not treat current one.
Gout crystals = needle-shaped + strongly negative birefringence - think yellow needles, not blue rhomboids.
Gout risk = hyperuricaemia + male + age + alcohol + diuretics - address modifiable factors.
In a red, hot joint, especially in the elderly, “sepsis until proven otherwise” applies - crystals and negative Gram do not automatically rule out septic arthritis.
For allopurinol, think “start low, go slow, and protect with prophylaxis” - low starting dose, gradual titration, plus colchicine or NSAID to prevent flares.
Acute gout = treat inflammation first, start allopurinol later - don't start urate-lowering during attack.
Chronic pancreatitis with steatorrhea (fecal elastase <100 + pancreatic calcifications) = PERT ≥40,000 units lipase per meal - corrects malabsorption 90%.
Acute pancreatitis (amylase >3x upper limit + typical pain) = aggressive balanced crystalloid at 5-10 mL/kg/hour in the first 24 hours; use the modified Glasgow (Imrie) score for UK severity assessment; antibiotics only for confirmed infected necrosis (NICE NG104, BSG).
Insulinoma = fasting hypoglycaemia + Whipple's triad + high insulin + HIGH C-peptide + negative sulfonylurea. 72h fast diagnostic. EUS best localisation. Surgery curative 90%.
ZES (refractory ulcers + fasting gastrin >1000 or secretin test positive) = secretin stimulation test confirms diagnosis - gastrin rise >200 pg/mL diagnostic.
Necrotizing pancreatitis with clinical deterioration = aspirate and culture necrosis - reserve intervention for confirmed infected necrosis, delay until >4 weeks if possible.
IgG4-related AIP with typical imaging deserves steroid trial before surgery - dramatic response confirms diagnosis and avoids Whipple.
Symptomatic mature pancreatic pseudocyst (>4-6 weeks, formed wall) adjacent to stomach = endoscopic cystogastrostomy first-line - less invasive than surgery.
Acute pancreatitis with infected WON (>4 weeks, persistent fever, gas on CT) = percutaneous/endoscopic drainage first - step-up approach reduces mortality versus immediate surgery.
Necrotizing pancreatitis = wait 4 weeks before intervention; prophylactic antibiotics NOT recommended for sterile necrosis.
Small Bowel Disease
14 high-yield facts
Coeliac = IDA refractory oral iron + diarrhoea + anti-tTG IgA + villous atrophy (Marsh 3); lifelong GFD only treatment; check total IgA; screen T1DM/thyroid; lymphoma <1%.
AA amyloidosis = chronic inflammation (e.g. rheumatoid arthritis) plus Congo red positive deposits with apple-green birefringence; treat the underlying inflammatory disease, whereas AL is managed as a plasma cell dyscrasia and ATTR with TTR stabilisers such as tafamidis.
SMA syndrome is treated by restoring weight and the mesenteric fat pad - feed distal to the obstruction (nasojejunal) and reserve duodenojejunostomy for refractory cases.
Vincristine intrathecal = NEVER EVENT, 100% fatal; dispense in minibags NOT syringes; separate day from intrathecal chemo.
Non-selective beta-blockers = absolute contraindication in asthma; cardioselective relatively safer but use with caution.
Medication reconciliation - compare current medications with new prescriptions at transitions; unintentional discrepancies (omissions, duplications) cause 20-40% of preventable ADEs.
Negative inotrope; contraindicated HF EF <40%; never combine with beta-blockers; constipation commonest; increases digoxin 50-70%; amlodipine safe alternative in HF.
Isotretinoin = ~100% teratogenicity; PPP mandates 2 contraceptives + monthly pregnancy tests + signed Risk Acknowledgement Form + 30-day prescription limit; continue contraception 1 month after stopping; no blood donation.
Valproate = 10% malformations + 30-40% neurodevelopmental disorders; CONTRAINDICATED in women of childbearing potential unless full MHRA PPP conditions met (LARC + annual specialist review + dual specialist sign-off); use lamotrigine or levetiracetam instead.
Cerebrovascular Disease
14 high-yield facts
CVT = headache + seizures + haemorrhagic infarct (non-arterial territory); anticoagulate EVEN with haemorrhage; 80-90% recover.
Acute stroke <4.5 hours + no hemorrhage = IV alteplase 0.9mg/kg (10% bolus, 90% over 1 hour). NO antiplatelet x 24h. NNT=7!
Suspected TIA equals aspirin 300 mg now plus specialist assessment within 24 hours (NICE NG128); ABCD2 is no longer used to triage; anticoagulate AF-related TIA after excluding haemorrhage.
Acute stroke <4.5h + NIHSS >4 + CT clear = alteplase 0.9mg/kg; NNT 7; aspirin at 24h; thrombectomy if LVO.
Thunderclap headache plus negative CT >6 hours requires LP for xanthochromia - CT misses 15-50% SAH after 6 hours.
In CVST, start therapeutic heparin immediately - a haemorrhagic venous infarct is not a contraindication; stop the COCP and anticoagulate. (ESO 2017 CVST guideline.)
Sudden severe headache + CT negative + xanthochromia (>12h) = SAH. Next = CT angiography/DSA. Treat with nimodipine 60mg 4-hourly x 21 days. Endovascular coiling preferred. Mortality 50%!
PRES = severe HTN + headache + visual + seizures + bilateral parieto-occipital oedema; eclampsia commonest; reversible if urgent BP control; vasogenic not cytotoxic oedema.
Ipsilateral Horner plus ataxia plus contralateral body sensory loss equals Wallenberg syndrome - PICA territory, thrombolysis if <4.5 hours.
Aortic Disease
13 high-yield facts
Type A dissection (ascending aorta)? Urgent surgery - medical alone kills 50% within 48 hours!
Bicuspid valve + aorta 4.4cm = echo every 1-2 years + MRI/CT every 3-5 years - 50% progress!
Small intimal tear + no dissection/IMH = medical therapy + serial imaging - most stay stable but monitor for progression!
Type A dissection + pericardial effusion = EMERGENCY SURGERY within hours - AVOID pericardiocentesis, mortality 1-2%/hour untreated!
Type A dissection + even if stable = EMERGENCY SURGERY - 1-2% mortality per hour, don't delay!
Aortic dissection = Type A (ascending) = SURGERY; Type B (descending) = MEDICAL unless complicated! Always beta-block BEFORE vasodilators!
Type B aortic IMH treated medically unless complications develop - intensive BP control (target <120/80) essential to prevent progression to dissection/rupture.
Descending aortic IMH = aggressive medical therapy (beta-blockade + BP control) - surgery only if complications develop.
Descending aortic PAU + stable + small = aggressive medical therapy - intervene only if complications develop.
Uncomplicated type B dissection → medical therapy with IV beta-blockers targeting HR <60 bpm and BP 100-120 mmHg; TEVAR reserved for complicated features.
Marfan + aortic root 4.8cm + no high-risk = continue surveillance, surgery at 5.0cm!
Marfan syndrome with aortic root 48mm → surveillance + beta-blockers; surgery at ≥50mm (or ≥45mm if family history/pregnancy planned/rapid growth).
Pleural Diseases
13 high-yield facts
Parapneumonic = Simple (pH >7.2, antibiotics alone) vs Complicated (pH <7.2 or glucose <3.4, needs drain); pH <7.2 most sensitive predictor; Chest drain prevents empyema/fibrothorax; Fibrinolytics if loculated; Surgery if drain fails.
Tension PTX = Tracheal deviation + Hypotension + Distended veins; Needle 2nd ICS MCL; DO NOT wait for CXR; Positive pressure worsens.
Empyema = pH <7.2 or pus or organisms; Intrapleural fibrinolytics if poor drainage/loculations (alteplase 10mg + DNase 5mg BD × 3 days); MIST2 trial - reduces surgery 50%; Early drainage essential; Surgery if fibrinolytics fail; 3-6 weeks antibiotics.
Re-expansion pulmonary edema = Rapid drainage large chronic effusion; Dyspnoea + frothy sputum post-drainage; Ipsilateral alveolar infiltrates; Prevent: limit ≤1.5L per session, stop if chest pain; Risk: large effusion >7 days; Treatment supportive (oxygen, ventilation); Mortality 20% if severe; Diuretics NOT helpful.
Secondary PTX = Higher risk than primary; >2cm OR breathless = chest drain; Admit all secondary PTX; Target SpO2 88-92% in COPD; Aspiration less successful than primary; Consider surgery if persistent leak >5 days or recurrent.
Chylothorax = milky fluid + triglycerides >1.24 mmol/L + chylomicrons; conservative (NBM, TPN, octreotide, drainage) is first-line; surgical/IR ligation if failing at 2 weeks (BTS 2023).
Parasitic Infections
13 high-yield facts
Amoebic liver abscess = travel + prior dysentery + solitary right-lobe lesion + positive *E. histolytica* serology; treat with metronidazole/tinidazole PLUS a luminal amoebicide (paromomycin or diloxanide furoate); drainage only if large, left-lobe, or failing medical therapy.
Giardia = chronic watery diarrhoea + greasy stools + travel; metronidazole 400mg TDS for 5-7 days (BNF) or tinidazole 2g single dose; expect post-infection lactose intolerance.
Cyclospora = prolonged traveler's diarrhea + acid-fast oocysts 8-10μm (larger than Crypto); co-trimoxazole 960mg BD for 7-10 days; ciprofloxacin if sulfa allergy.
Katayama fever = fever + eosinophilia + urticaria 2-8 weeks post-swimming in Lake Malawi; praziquantel + prednisolone, repeat praziquantel at 4-6 weeks.
Hepatic hydatid cyst = albendazole + surgery/PAIR; NEVER aspirate without chemotherapy (anaphylaxis/dissemination risk); "honeycomb" appearance pathognomonic.
Treat empirically first - multiple ring-enhancing lesions + low CD4 = toxoplasmosis until proven otherwise.
Giardia (cysts with 2-4 nuclei, greasy diarrhoea and malabsorption) = metronidazole or tinidazole first-line (NICE CKS).
Lymphatic filariasis = elephantiasis + microfilariae (midnight blood) + endemic exposure; DEC + albendazole; manage lymphoedema with hygiene/compression.
Cryptosporidium in AIDS (CD4 <100) = start ART immediately (only cure); supportive care crucial; nitazoxanide ineffective if CD4 <50.
Multiple brain cysts with scolex in Latin American patient = neurocysticercosis; start AED first, then consider albendazole + steroids for viable cysts.
Athlete's heart = bradycardia + LVH voltage + dilated LV cavity + wall thickness ≤13 mm + normal diastolic function. Don't confuse with HCM.
Endurance athlete + bradycardia + voltage LVH + early repolarisation + small inferior Q + normal echo = physiological - cleared!
Athlete + TWI V1-V4 + LAD + LAE + echo 14 mm = NOT physiological - cardiac MRI to exclude HCM/ARVC.
Grey-zone LVH (13-15 mm) with a dilated cavity and normal diastolic function in an endurance athlete - detrain for 3 months and repeat imaging; athlete's heart regresses, HCM does not.
SADS = SCD with normal autopsy; mandates family screening for channelopathies (Long QT, Brugada, CPVT); 30-50% families have identifiable mutation.
Young athlete + chest impact + VF + entirely normal cardiac work-up = commotio cordis; outcome hinges on immediate CPR and early defibrillation (Resuscitation Council UK guidance), and survivors with a normal evaluation can usually return to play.
Athlete SCD <35 = HCM most common - screen with history + examination + 12-lead ECG (echo only if abnormal); cascade-screen first-degree relatives of the deceased per ESC 2023 cardiomyopathy guideline / CRY.
Marfan syndrome with aortic root ≥40 mm absolutely contraindicates competitive sports - dissection risk during exertion outweighs athletic participation benefits.
Left main + SYNTAX <22 + favourable anatomy (ostial/mid-shaft) + high surgical risk = PCI is a reasonable alternative to CABG (ESC/EACTS 2018 Revascularisation Guidelines, NICE NG185).
Mid-LAD milking + systolic compression + stress ischaemia = myocardial bridging - beta-blockers first, surgery only if refractory; avoid stents and nitrates.
Typical angina + positive stress test + NORMAL coronaries = Cardiac Syndrome X - treat with beta-blockers + CCB + aspirin!
Angina + normal coronaries + delayed TIMI flow = CSF → antiplatelets + statins + CCB for microvascular dysfunction.
Left main disease + diabetes + intermediate SYNTAX favours CABG over PCI - better long-term outcomes (FREEDOM trial, ESC/EACTS 2018).
Stable CAD + DES + 12 months DAPT + no events = STOP P2Y12 inhibitor, continue aspirin - standard duration complete!
WHO FC III + 6MWT 165-440m = intermediate-risk PAH → upfront combination (ambrisentan + tadalafil), NOT monotherapy!
Echo RVSP >40 mmHg plus symptoms = suspected PAH - right heart catheterization mandatory to confirm diagnosis and guide therapy.
PAH intermediate-high risk - upfront combination ERA + PDE5i reduces events 30-50% vs monotherapy, target multiple pathways simultaneously.
Elevated RVSP on echo in systemic sclerosis warrants right heart catheterisation per ESC/ERS 2022 - confirm mPAP, PAWP, and PVR before starting PAH therapy.
Progressive dyspnoea post-PE + mismatched VQ defects = CTEPH until proven otherwise; potentially curable with pulmonary endarterectomy surgery.
CTEPH is only curable PH - all patients need expert center assessment for pulmonary endarterectomy operability, potentially curative with excellent outcomes.
Vascular Disorders
12 high-yield facts
Mesenteric ischaemia = pain OUT OF PROPORTION + AF + high lactate; CTA gold standard; emergency laparotomy if peritonitis; mortality 60-80%; "time is bowel."
Primary Raynaud = bilateral + normal capillaries + ANA negative + no ulcers; lifestyle first; nifedipine if severe; <1% progress to secondary.
Primary Raynaud phenomenon = young patient, normal capillaroscopy, negative autoantibodies - manage with warmth, smoking cessation, and reassurance first (NICE CKS Raynaud's phenomenon).
Always check TFTs before diagnosing anxiety or depression. Hyperthyroidism = anxiety mimic. Hypothyroidism = depression mimic. Organic causes must be excluded before psychiatric diagnosis.
"Psychic groans" = psychiatric symptoms of hypercalcaemia. Always check calcium in new depression/confusion. Raised Ca + raised PTH = primary hyperparathyroidism. Parathyroidectomy is definitive.
Young-onset dementia + personality change + disinhibition + preserved memory = frontotemporal dementia. Frontal and temporal atrophy on MRI. No effective pharmacotherapy.
Korsakoff = anterograde amnesia + confabulation after Wernicke encephalopathy. Thiamine deficiency → mammillary body damage. Largely irreversible. Always give thiamine BEFORE glucose.
Bacterial Infections
12 high-yield facts
Tetanus-prone wound + uncertain vaccination = tetanus immunoglobulin plus tetanus vaccine plus debridement, then complete the 5-dose course (UK Green Book).
Bacterial meningitis = CSF neutrophils + low glucose; ceftriaxone + dexamethasone immediately; add ampicillin if >50 or immunocompromised (Listeria).
Cellulitis with systemic features (Eron class II or above) needs admission for IV flucloxacillin first-line - escalate and reassess promptly if necrotising infection is suspected.
Psittacosis = bird exposure + atypical pneumonia + relative bradycardia + failed amoxicillin; treat with doxycycline for 10-14 days; it is a notifiable disease.
MDR-TB = rifampicin resistance on GeneXpert; Group A agents (FQ + bedaquiline + linezolid); 18-20m; DOT essential.
Mucormycosis in DKA = black necrotic eschar + orbital invasion; urgent surgical debridement + liposomal amphotericin 5-10mg/kg - voriconazole has NO activity.
Truncal hypopigmented scaly macules + "spaghetti and meatballs" on KOH = pityriasis versicolor - first-line is topical ketoconazole 2% shampoo (NICE CKS); reserve oral itraconazole for extensive or recurrent disease.
Todd paresis (focal weakness immediately after witnessed seizure + post-ictal confusion + normal CT) = observe for spontaneous resolution <24 hours; avoid thrombolysis unless stroke certain.
Status epilepticus (seizures >30 min + failed 2 lorazepam doses) = phenytoin 20 mg/kg IV loading second-line - general anesthesia if refractory >60 min.
Convulsive status epilepticus lasting >5 minutes - give IV lorazepam 4 mg first-line (NICE NG217), then a second-line IV antiepileptic, with anaesthesia reserved for refractory cases.
JME in a woman of childbearing potential = levetiracetam first-line (lamotrigine alternative) per NICE NG217 and MHRA Pregnancy Prevention Programme; valproate contraindicated unless strict PPP; avoid carbamazepine/phenytoin (worsen generalised seizures); counsel contraception and 5 mg folic acid.
Focal epilepsy = levetiracetam/lamotrigine first-line; avoid valproate in women; 12m seizure-free to drive.
Carbamazepine = common SIADH cause (6-40%); euvolemic hyponatremia + concentrated urine = switch to alternative AED.
Carbamazepine SIADH = ↑ADH release and potentiation; inappropriately concentrated urine is the key diagnostic feature; stop drug + fluid restrict (BNF / MHRA / Society for Endocrinology UK); correct Na⁺ ≤10 mmol/L/24 h to avoid osmotic demyelination.
ACEi + spironolactone = dual RAAS blockade (NICE NG106, RALES trial); check K⁺ at 1-2 weeks then monthly ×3; hold MRA if K⁺ >5.5; ECG changes → IV calcium gluconate + insulin-glucose + salbutamol (UK Renal Association 2020); avoid triple therapy with NSAIDs (MHRA).
IV bisphosphonate + low vitamin D = symptomatic hypocalcemia; always check/correct vitamin D first.
Loop diuretics + PPIs - combined renal wasting + malabsorption cause severe hypomagnesemia; causes refractory hypokalemia and digoxin toxicity; replace magnesium first.
NSAIDs + marathon + excessive water = exercise-associated SIADH; treat severe symptomatic hyponatraemia with 3% saline; correct Na max 10 mmol/L/24h; avoid pre-race NSAIDs.
PPI hypomagnesaemia = ↓intestinal absorption (>1yr); causes hypoCa²⁺ + hypoK⁺ (refractory until Mg²⁺ corrected); IV MgSO₄; stop PPI/switch famotidine.
CKD + ACEi = start K⁺ low (20-40mmol), monitor weekly initially; avoid spironolactone; IV max 10mmol/h peripheral.
LEMS (proximal weakness + autonomic features + post-tetanic facilitation + incremental EMG response) in a smoker means urgent CT chest for SCLC; confirm with anti-VGCC antibodies and treat with 3,4-diaminopyridine.
Adrenal
12 high-yield facts
Conn - HTN + hypokalemia + ARR >40 + adenoma, adrenalectomy curative if AVS lateralizes, spironolactone for bilateral.
Late-onset CAH - hirsutism + oligomenorrhea + 17-OHP >30 on ACTH stimulation, low-dose dexamethasone 0.25-0.5 mg nocte (suppresses ACTH), differentiate from PCOS by 17-OHP.
Primary aldosteronism - resistant HTN + hypokalaemia + high aldosterone/low renin, adrenal vein sampling BEFORE surgery (CT misleads 25-40%), adrenalectomy if unilateral, spironolactone if bilateral.
Adrenal crisis - shock + hyponatremia + hyperkalemia + hypoglycemia, IV hydrocortisone 100 mg stat (DO NOT delay), IV saline, treat precipitant, mortality 5-10%.
Addison - hyperpigmentation diagnostic (high ACTH), needs hydrocortisone PLUS fludrocortisone (dual deficiency), sick day rules essential (double dose illness, IM emergency kit).
Mumps orchitis = parotitis followed by testicular pain 3-10 days later; supportive care only; testicular atrophy in 10-30% but sterility rare.
Common warts (rough "cauliflower" black dots, immunocompetent): reassure self-limiting 65% resolve 2 years; cryotherapy/salicylic acid 17% first-line; avoid excision.
Adult shingles within 72 hours → oral aciclovir 800 mg five times daily × 7 days (NICE CKS / BNF); offer Shingrix to eligible patients.
HFMD = enterovirus, self-limiting in 7-10 days; hydration, soft diet and simple analgesia only - no aciclovir, no antibiotics, no steroids (NICE CKS; UKHSA).
Shingles = dermatomal vesicular rash, unilateral; antivirals within 72h; vaccinate with Shingrix.
HEV pregnancy (3rd trimester) = fulminant liver failure 15-25% mortality; supportive care; ribavirin contraindicated; no specific treatment.
Disseminated VZV + stroke in immunosuppressed patient = IV aciclovir 10-15mg/kg, reduce steroids urgently.
Hepatitis A = travel + acute hepatitis + IgM positive; entirely supportive care; vaccinate at-risk contacts and travellers; no chronic infection.
Norovirus outbreak equals close the ward plus soap and water (not alcohol gel) plus chlorine-based cleaning plus staff off until 48 h symptom-free; highly contagious with a low infectious dose.
EBV with splenomegaly = no contact sports for ≥4 weeks - splenic rupture risk highest in acute phase.
Post-MI + weeks later + fever + pericarditis = Dressler's - aspirin + colchicine, NOT steroids first-line!
Suboptimal TTE cannot exclude LV thrombus post-MI - use contrast echo or cardiac MRI for definitive assessment before anticoagulation decisions.
Dressler = pericarditis WEEKS post-MI. Treat with aspirin (not NSAIDs!) + colchicine for 3 months!
New loud apical pansystolic murmur + shock days after an inferior MI = papillary muscle rupture - urgent MVR with IABP support; medical therapy alone is almost always fatal.
Acute severe MR 2-7 days post-inferior MI + flail leaflet = papillary muscle rupture; emergent surgical referral - medical therapy alone has 50-90% mortality.
Pericarditis 2-6 weeks post-MI + fever + high ESR = Dressler syndrome (autoimmune), NOT viral or early pericarditis.
LV thrombus post-MI? Warfarin INR 2-3 for 3-6 months - reassess with echo for thrombus resolution!
Post-MI PEA + tamponade = free wall rupture - pericardiocentesis temporises, emergency surgery only chance of survival!
New pansystolic murmur + shock days post-MI? VSD - urgent surgery with IABP support!
Post-MI + new pansystolic murmur + shock + VSD = emergency surgery within 48 hours!
Degenerative Joint Disease
11 high-yield facts
OA = joint replacement when severe symptoms + failed conservative Rx + radiographic changes; 90% excellent outcomes; lifespan 15-20yr.
Knee OA = exercise and weight loss plus a topical NSAID first-line; reserve paracetamol for short-term, infrequent use only.
Think “LOSS” for OA X-rays - Loss of joint space, Osteophytes, Subchondral Sclerosis - distinguishing it from the erosions and osteopenia of RA.
Mechanical pain + brief stiffness + no inflammation = OA - think wear and tear, not inflammation.
OA = Heberden's/Bouchard's nodes + osteophytes - think degenerative, not inflammatory.
OA X-ray = joint space narrowing + osteophytes + subchondral sclerosis - think degenerative, not inflammatory.
OA care starts with “move more and weigh less” - exercise and weight reduction are as important as any pill in improving symptoms and function.
Hand OA = “bony big joints at the tips” - chronic pain, Heberden’s/Bouchard’s nodes, worse with use, better with rest, and little morning stiffness compared with inflammatory arthritis.
Knee OA (NICE NG226) - exercise + weight loss + topical NSAID first-line; oral NSAID with PPI second-line; reserve joint replacement for refractory disease.
OA risk = age + obesity + injury + genetics - address modifiable factors.
Upper GI Disorders
11 high-yield facts
Autoimmune gastritis (anti-IF antibodies + atrophic gastritis body/fundus + low B12) = lifelong IM B12 injections plus endoscopic surveillance every 3-5 years - gastric cancer risk 3-6×.
Erosive esophagitis + partial PPI response = double dose to twice daily (e.g., omeprazole 40mg BD) for 8-12 weeks - most patients respond.
Menetrier disease (giant gastric folds + protein loss + hypoalbuminemia) - test and treat H. pylori first, achieves remission in many cases.
H. pylori = PPI BD + amoxicillin 1g BD + clarithromycin 500mg BD × 7d; confirm UBT ≥4w post-Rx; if fails → bismuth quadruple 14d.
Young atopic male + dysphagia/food impaction + >=15 eosinophils/hpf + rings/furrows = EoE; swallowed topical budesonide or fluticasone first-line (BSG 2022); dupilumab for refractory disease (NICE TA708).
Refractory gastroparesis with weight loss after failed prokinetics → consider gastric electrical stimulation (60-70% symptom improvement); avoid metoclopramide >5 days (MHRA) and prefer jejunal feeding over PEG.
Uncomplicated GERD = lifestyle + PPI 4w (omeprazole 20mg, >80% respond); no OGD if no alarm features; step down to lowest dose; fundoplication if refractory.
Acute gastric volvulus (Borchardt triad: pain + retching without vomiting + cannot pass NG tube) = emergency surgical reduction and gastropexy - prevents gastric strangulation.
HDGC (CDH1 mutation + family history) = prophylactic total gastrectomy ages 20-40 - prevents inevitable gastric cancer (70-80% risk), endoscopic surveillance inadequate.
Diabetic gastroparesis = optimize glucose control + dietary changes (small frequent low-fat meals) + metoclopramide - medical therapy before considering surgery.
TPP = young thyrotoxic man with carbohydrate-triggered hypokalaemic paralysis - replace potassium slowly with cardiac monitoring, add propranolol, and treat the thyrotoxicosis (NICE NG145 Thyroid disease); avoid potassium boluses to prevent rebound hyperkalaemia.
Primary hypothyroidism - start levothyroxine 25-50 μg (lower if elderly/cardiac), increase every 4-6 weeks, check TSH 6-8 weeks, lifelong treatment.
Thyroid storm - fever + HR >140 + altered mental status, PTU THEN Lugol iodine 1h later PLUS propranolol PLUS hydrocortisone, mortality 10-20%.
Bethesda III - 10-30% malignancy, repeat FNA (50% reclassified) or molecular testing, hemithyroidectomy if high-risk/persistent, avoid total thyroidectomy upfront.
Riedel - "woody" hard fixed goitre + compressive symptoms + dense fibrosis FNA + IgG4 ↑ 60%, surgery (decompress airway), prednisolone 30-60 mg, tamoxifen if refractory, screen retroperitoneal fibrosis.
NICE NG31 = individualised care plan, shared decisions, anticipatory medications, assess hydration individually (not routine IV fluids). Replaced the Liverpool Care Pathway.
Just in case box = SC morphine (pain) + midazolam (agitation) + glycopyrronium (secretions) + haloperidol (nausea). All subcutaneous, all PRN.
DNACPR is a clinical decision based on whether CPR could realistically work, but UK practice (Tracey 2014; GMC end-of-life guidance; Resuscitation Council UK / BMA / RCN decisions relating to CPR) requires that the patient or family be consulted and informed - families cannot demand futile CPR, and a best-interests process under the Mental Capacity Act applies when capacity is lacking.
ADRT = legally binding refusal of specific treatment (written + signed + witnessed if life-sustaining). LPA-HW = appoints decision-maker. Next of kin ≠ legal authority. Both require capacity at time of creation.
Death rattle = antisecretory agents (glycopyrronium or hyoscine butylbromide) + repositioning. Avoid suction. Reassure family the patient is not distressed.
Enabling home death = community palliative care + anticipatory medications + 24-hour advice + carer support. Document preferred place of death in advance care plan.
Catastrophic haemorrhage plan = midazolam for sedation, dark towels, advance care plan. Focus on minimising distress, not resuscitation.
Mouth care (moistened swabs + lip balm) is the best treatment for dry mouth in dying patients - more effective than IV fluids. Perform every 1-2 hours.
Hydration in dying patients - assess individually, discuss benefits/burdens with family, provide excellent mouth care. Avoid routine IV fluids (may worsen secretions/oedema).
Palliative sedation = midazolam CSCI for refractory symptoms in the dying. Intent is comfort, not hastening death (double effect principle).
Upper GI Bleeding
11 high-yield facts
High-risk ulcer (Forrest IIa) → IV PPI 72h + eradicate H. pylori + restart aspirin within 3d (secondary prevention) + lifelong PPI.
Mallory-Weiss tear that is haemodynamically stable with no active bleeding at endoscopy = conservative management with acid suppression - most settle spontaneously.
An upper GI bleed with a Glasgow-Blatchford score of 0-1 is low risk and suitable for outpatient management with early endoscopy, avoiding unnecessary admission (NICE CG141).
Mallory-Weiss = vomiting BEFORE haematemesis + longitudinal tear GEJ + self-limiting 80-90%; conservative if stable; endoscopic if bleeding (90-95%); vs Boerhaave's (perforation).
Watermelon stomach + chronic iron-deficiency anaemia in cirrhosis or systemic sclerosis = endoscopic APC (BSG/ESGE); TIPS does NOT help GAVE - that is for portal hypertensive gastropathy.
Rockall ≥8 = mortality >25%; age + shock + comorbidity + diagnosis + stigmata; IV PPI 72h post-endoscopic haemostasis; transfuse Hb <70.
GAVE (watermelon stomach with chronic anemia) = endoscopic argon plasma coagulation - reduces transfusions in 70-90%, multiple sessions usually needed.
Dieulafoy lesion (massive bleeding + tiny mucosal defect with visible vessel + NO ulcer) = endoscopic combination therapy (injection + thermal/clips) - single modality insufficient, rebleeding 15-40%.
Isolated fundal gastric varices (IGV1) → endoscopic cyanoacrylate glue injection (controls ~90%, superior to band ligation); TIPS or BRTO if refractory (Baveno VII consensus).
Device Therapy
10 high-yield facts
CIED infection with positive cultures = extract entire system (device + all leads) - antibiotics alone have very high failure rates!
ICD shocks with 1:1 AV relationship = likely SVT misclassified as VT; true VT shows AV dissociation (V>A) - reprogram device and treat SVT.
Post-MI with LVEF ≤35% = wait 40 days minimum, ideally 3 months on optimal medical therapy before ICD. Don't implant early - let LV remodelling stabilize first.
CIED infection + positive blood cultures = complete system extraction mandatory. Never leave infected hardware in situ - treatment failure and mortality risk.
CRT non-responder with good BiV pacing % = optimise AV/VV intervals first - converts 30% to responders.
ADPKD = ACEi <130/80 + tolvaptan if rapid; PKD1 ESRD 54y vs PKD2 74y; screen aneurysm 8-10%; ESRD 50% by 60.
Fabry = X-linked + acroparaesthesiae + angiokeratomas + cornea verticillata + concentric LVH + short PR; confirm with α-Gal A activity and GLA mutation; commission ERT through NHS England HSS service early.
ADPKD = “big kidneys + big risks in the brain and liver” - think hepatic cysts and berry aneurysms, and screen carefully when there is a positive family or symptom history.
Young male with hematuria plus deafness plus family history CKD equals Alport syndrome - X-linked, ESRF by 30s.
Cystinuria = hexagonal crystals + young stones; fluids + alkalise pH >7.5 + tiopronin if refractory.
Leflunomide = FBC + LFTs monthly for 6 months then 12-weekly (BSR/BHPR 2017); stop if transaminases >2× ULN or cytopenias; teratogenic - cholestyramine washout if pregnancy planned or toxicity.
Azathioprine = test TPMT first - think prevent severe myelosuppression, not just monitor FBC.
For methotrexate, think “check bloods little and often” - at least fortnightly then monthly at initiation, never “set and forget” for a year.
HCQ monitoring = baseline ophthalmology + annual from year 5; dose ≤5mg/kg ideal weight; SD-OCT most sensitive; irreversible if advanced.
Hydroxychloroquine >5 years = annual screening - visual fields + SD-OCT, not just fundoscopy.
Sulfasalazine = monitor FBC/LFTs frequently early - most side effects in first 3 months.
Methotrexate + folic acid = reduces side effects without reducing efficacy - don't skip the folic acid.
Methotrexate hepatotoxicity = monitor LFTs regularly, consider biopsy/FibroScan if high cumulative dose - think fibrosis risk, not just transaminases.
MTX monitoring = FBC/LFTs every 2wk then monthly; folic acid 5mg weekly; contraception; pneumonitis 5% = stop immediately.
Severe vitamin D deficiency + osteomalacia = colecalciferol loading (~300,000 IU total) + calcium + maintenance 800-2,000 IU daily (NICE CKS; Royal Osteoporosis Society 2018); Looser zones pathognomonic; replete vitamin D before bisphosphonates.
Mild hypercalcaemia + non-suppressed PTH + low urinary calcium + CCCR <0.01 + family history = FHH; reassure and avoid parathyroidectomy - confirm with CASR genetic testing where doubt remains.
Bone pain + proximal myopathy + low vitamin D → loading dose cholecalciferol, then maintenance; correct calcium deficiency concurrently.
Osteoporosis secondary - GIOP (prednisolone 10 mg 5y, ≥7.5 mg >3m, fragility fracture L1 diagnostic, DEXA -3.2 lumbar + -2.8 femoral <-2.5), hypogonadism (testosterone 8 <10), BMI 19, smoking (↓ density 30%), alcohol 30 units (>14 inhibits osteoblasts), vitamin D 35 (<50 impairs Ca absorption), alendronic acid 70 mg weekly (first-line GIOP, ↓ fracture 50%, fasting 30 min upright) PLUS calcium 1g + vitamin D 800 units daily PLUS lifestyle (weight-bearing exercise, ↓ alcohol, stop smoking ↓ fracture 30%), consider testosterone if <10 twice, fracture liaison referral, DEXA 2y, bisphosphonates ↓ fracture 50% (3-5y minimum).
Osteomalacia = bone pain + proximal myopathy + low 25-OH vitamin D + high ALP → loading cholecalciferol with calcium; avoid bisphosphonates until replete.
Brief electric-shock facial pain with trigger zones equals trigeminal neuralgia - carbamazepine 70-80% effective, surgery if refractory.
Acute unilateral LMN facial palsy including forehead equals Bell palsy - prednisolone within 72 hours improves recovery, eye protection prevents corneal damage.
Bell's = LMN VII + no rash + no other signs; pred 60mg <72h; eye protection; 85% recovery.
Secondary trigeminal neuralgia red flags (young age, sensory loss, background pain, structural lesion on MRI) need neurosurgical referral - medical therapy alone is not definitive.
Bell's = acute LMN VII (forehead involved); pred 50mg ×10d <72h + eye protection; 90% recovery with steroids.
Classical trigeminal neuralgia = carbamazepine first-line (NICE CKS); microvascular decompression if medical therapy fails or is not tolerated.
Symptom Management
10 high-yield facts
Malignant bowel obstruction - syringe driver with antispasmodic + antiemetic + opioid. Metoclopramide is CONTRAINDICATED in complete obstruction.
Cyclizine precipitates at high concentrations and with dexamethasone/saline. Always use water for injection as diluent and check compatibility charts.
Lymphoedema = decongestive lymphatic therapy (compression + massage + exercise + skin care). Diuretics do NOT work. Avoid BP/bloods in the affected arm.
Dexamethasone 16 mg daily for raised ICP and cord compression; 2-4 mg for appetite. Give mornings, taper after >1 week.
Cancer cachexia = cytokine-driven metabolic syndrome, NOT simple starvation. Nutritional support alone cannot reverse it. Treat with short-term corticosteroids or megestrol for appetite.
Cholestatic pruritus with complete obstruction = rifampicin (induces bile acid metabolism). Cholestyramine requires bile flow. Monitor LFTs.
Match antiemetic to mechanism - gastric stasis = metoclopramide (prokinetic), chemical = haloperidol (CTZ), raised ICP = cyclizine, refractory = levomepromazine.
Malignant ascites refractory to diuretics = therapeutic paracentesis. Diuretics less effective than in cirrhotic ascites. Consider indwelling drain for recurrent drainage.
Oral to SC morphine = divide by 2. Oral to SC diamorphine = divide by 3. Always prescribe SC breakthrough doses (1/6th of 24h SC dose).
Psychiatric Drugs
10 high-yield facts
Clozapine requires FBC weekly for 18 weeks, fortnightly to week 52, then monthly lifelong via CPMS; stop permanently if neutropenia develops.
Long-term benzodiazepine withdrawal = gradual taper over 8-12 weeks minimum. NEVER stop abruptly - seizure risk! Reduce 10-25% every 1-2 weeks.
SSRI + aspirin/NSAID/anticoagulant = high GI bleeding risk, especially >65 years or prior peptic ulcer; co-prescribe a PPI (NICE CG184; MHRA DSU); consider mirtazapine or sertraline if bleeding risk is dominant.
Olanzapine causes metabolic syndrome - switch to aripiprazole or amisulpride within first year for reversibility.
Benzodiazepines in elderly/dementia = paradoxical agitation risk (1-5%); stop drug immediately, manage supportively.
MAO inhibitors + tyramine = hypertensive crisis - treat with nifedipine or phentolamine, never beta-blockers.
Distal RTA Type 1 = inappropriately alkaline urine pH (>5.5) + hypokalaemia + nephrocalcinosis/stones; treat with oral NaHCO₃ + potassium citrate; screen for Sjögren's (UK Renal Association).
Type 2 = pH <5.5 + Fanconi + NO nephrocalcinosis; myeloma; high-dose alkali needed.
Normal anion-gap acidosis + hyperkalaemia + urine pH that can fall (<5.5) in diabetes/CKD/ACEi = Type 4 RTA (hyporeninaemic hypoaldosteronism). Stop the offending drug, give bicarbonate, consider fludrocortisone.
HAGMA = MUDPILES; metformin + CKD = type B lactic acidosis; stop metformin + dialysis.
STEC-HUS (bloody diarrhea prodrome + thrombocytopenia + MAHA + AKI + E. coli O157 + child) = supportive care only (fluids, dialysis, BP) - antibiotics WORSEN (increase Shiga toxin release), self-limiting, 90% recover, vs atypical HUS (no diarrhea, eculizumab).
Atypical HUS (thrombocytopenia + MAHA + AKI + NO diarrhea + normal ADAMTS13 >50% + complement mutation) = eculizumab (anti-C5 antibody) - 80-90% recovery with eculizumab, 50% death/ESRD untreated, vs STEC-HUS (diarrhea, supportive), vs TTP (ADAMTS13 <10%, plasma exchange).
Pain Management
10 high-yield facts
Oral morphine to SC diamorphine - divide by 3 (120 mg PO = 40 mg SC); oral morphine to SC morphine - divide by 2.
Opioid rotation - reduce calculated equianalgesic dose by 25-50% for safety.
Elderly with CKD + peptic ulcer + warfarin = avoid oral NSAIDs and be cautious with opioids. Topical NSAIDs are safe and effective for localised OA (knee, hand). NICE recommends topical before oral.
Constipation is the only opioid side effect that persists - always co-prescribe laxatives. Tolerance develops to drowsiness, nausea, and dry mouth within a week.
Oral morphine 30 mg/24h ≈ fentanyl 12 mcg/hr. Patch takes 12-24 hours to work; change every 72 hours.
Codeine = CYP2D6 prodrug; 7-10% Europeans are PM (no analgesia); switch to morphine/oxycodone.
Avoid morphine in severe renal failure (eGFR <30) - M6G accumulates causing toxicity. Fentanyl and alfentanil are safe alternatives (inactive metabolites).
Breakthrough dose = 1/6th of total 24-hour opioid dose. If >2-3 rescues daily, increase the background dose.
Breakthrough oral morphine = 1/6 of the total 24-hour oral morphine dose; review background dose if rescue use is ≥4/day.
Transfusion Medicine
10 high-yield facts
Dyspnoea + hypertension + pulmonary oedema during transfusion = TACO; stop and give furosemide; contrast with TRALI (hypotension, normal heart); prevent with slow rate, restrictive threshold, and prophylactic diuretic; report to SHOT.
TACO = dyspnoea + hypertension + ↑JVP + ↑BNP within 6 h of transfusion; stop transfusion + O₂ + sit upright + IV furosemide; prevent with TACO risk assessment, single-unit policy and slow rate (NICE NG24, SHOT/BSH 2017).
MTP = 1:1:1 ratio + TXA within 3h + calcium; prevents lethal triad; mortality 30-50%.
TRALI = hypoxia + bilateral infiltrates + hypotension + normal BNP; supportive only, NO diuretics; male-only plasma prevents.
Cardiac Arrest
9 high-yield facts
VF/pVT cardiac arrest = immediate defibrillation (150-200J biphasic)! CPR + shock cycles. Drugs AFTER 3rd shock if VF persists.
Digoxin toxicity + ventricular ectopy/severe brady = immediate Digibind - NEVER give calcium!
CCB overdose causes hyperglycaemia and refractory shock - treat with high-dose insulin-glucose therapy, which is more effective than vasopressors alone.
Myocardial contusion = monitor for arrhythmias - echo for structural injury, not thrombolysis!
Precordial strike + instant VF in young athlete = commotio cordis - survival depends on immediate CPR/defibrillation.
"Not dead until warm and dead" - continue resuscitation during rewarming.
PEA arrest + recent central line + not responding = tension pneumothorax/tamponade - decompress thorax/pericardium immediately.
Beta-blocker overdose with shock/bradycardia → glucagon 5-10 mg IV; works via non-adrenergic pathway bypassing blocked beta-receptors.
Type 1 vWD with minor mucocutaneous bleeding → DDAVP first-line per BSH; add tranexamic acid as adjunct; reserve vWF/FVIII concentrate for type 2/3 or severe bleeding; avoid DDAVP in type 2B.
Acquired hemophilia (elderly, spontaneous bleeding, APTT high, factor VIII low, inhibitor positive) = bypassing agents rFVIIa - factor VIII ineffective.
Haemophilia A = prolonged aPTT + haemarthroses + low FVIII; IV FVIII target 50-100%; prophylaxis 3×/week.
Prolonged PT/APTT plus low fibrinogen plus elevated D-dimer equals DIC - treat underlying sepsis first, blood products supportive only.
Haemophilia A = raised aPTT + low FVIII + normal vWF; factor VIII replacement; DDAVP for mild.
Vitamin K deficiency = prolonged PT (FVII first) + corrects with vitamin K; IV 10mg; PCC if life-threatening; IM 1mg neonatal.
DIC = ↓plt + ↓fibrinogen + ↑D-dimer + ↑PT/aPTT; treat cause first; cryoprecipitate if fibrinogen <1.0; mortality 40-80%.
MODY (young <25 + non-obese + 3-generation family history + antibody-negative + preserved C-peptide) = genetic testing for HNF1A/HNF4A/GCK - HNF1A very sensitive to sulfonylureas (first-line, not metformin/insulin), GCK mild stable (no treatment), changes management/counseling.
MEN 2 = MTC + pheochromocytoma + hyperparathyroidism. ALWAYS screen for pheochromocytoma BEFORE surgery (life-threatening if undiagnosed). Adrenalectomy before thyroidectomy!
APS-2 = Addison's + hypothyroidism ± T1DM. ALWAYS hydrocortisone BEFORE levothyroxine (T4 accelerates cortisol metabolism → crisis if not replaced first).
McCune-Albright (café-au-lait with jagged borders + polyostotic fibrous dysplasia + precocious puberty) = post-zygotic GNAS mutation (mosaic) - gonadotropin-independent puberty (aromatase inhibitors, not GnRH analogs), distinguish from neurofibromatosis (smooth café-au-lait).
MEN1 = parathyroid + pituitary + pancreas (3 P's); gastrinoma is the commonest PNET; image the pancreas with CT/MRI and offer MEN1 genetic testing with cascade family screening.
Wolfram/DIDMOAD (diabetes mellitus + optic atrophy + diabetes insipidus + deafness + consanguinity) = WFS1 mutation causing ER stress - progressive neurodegenerative disorder, median survival 30 years, distinguish from mitochondrial diabetes (maternal inheritance, myopathy).
McCune-Albright triad = fibrous dysplasia + coast of Maine café-au-lait + peripheral precocious puberty; GNAS mosaic; letrozole (not GnRH); pamidronate for bones; screen endocrinopathies.
CNS Infections
9 high-yield facts
Gram-positive rods in CSF = Listeria until proven otherwise - add amoxicillin and gentamicin, never rely on ceftriaxone alone.
suspected bacterial meningitis + altered GCS = ceftriaxone + dexamethasone + aciclovir immediately after blood cultures; do NOT wait for LP; add amoxicillin if >50.
Nephrogenic DI - dilute urine + desmopressin response <50%, lithium commonest drug cause, amiloride + thiazide (↓ polyuria 30-50%), switch lithium if possible.
Cranial DI (post-TBI) → desmopressin; check for concurrent anterior-pituitary hormone deficiencies; never restrict fluids.
Prolactinoma - prolactin >1,000 diagnostic, cabergoline first-line (normalizes 85-90%, shrinks 80-90%), surgery reserved for drug resistance.
Acromegaly - ↑IGF-1 + GH fails suppress <1 on OGTT, trans-sphenoidal surgery first-line, somatostatin analogues if residual, screen diabetes/OSA/colonic polyps.
Post-TBI hypopituitarism - screen 3-6m, hydrocortisone FIRST then levothyroxine (NEVER T4 before cortisol), testosterone, GH if QoL impaired, sick-day rules essential.
Nelson - hyperpigmentation + ACTH >200 + pituitary macroadenoma post-bilateral adrenalectomy, radiotherapy first-line (controls 80-90%), surgery if visual loss, continue lifelong replacement.
Pituitary apoplexy - thunderclap headache + visual defects + adrenal crisis, IV hydrocortisone 100mg IMMEDIATELY, surgery if visual loss/↓GCS, lifelong replacement 70-90%.
Acromegaly - ↑ IGF-1 + failed GH suppression <1 on OGTT, trans-sphenoidal surgery first-line (70-80% micro, 50-60% macro), somatostatin analogues if residual.
Sheehan - PPH + failure to lactate + empty sella, replace hydrocortisone FIRST then levothyroxine (NEVER thyroid before cortisol), sick day rules essential.
Haematology
9 high-yield facts
In chronic phase CML (Ph+ / BCR-ABL1), imatinib is first-line per NICE TA251; monitor response with quantitative BCR-ABL1 PCR every 3 months aiming for major molecular response at 12 months; reserve allogeneic transplant for TKI failure or advanced phase.
Auer rods + DIC + young adult = suspect APL → start ATRA before genetics return. Standard-risk APL is now cured chemo-free with ATRA + arsenic trioxide.
B12 deficiency with neurological features - give IM hydroxocobalamin on alternate days until no further improvement, then every 2 months for life (BNF).
DLBCL = aggressive, treat promptly with R-CHOP (NICE/BSH); Stage I-II non-bulky: 3-4 cycles + IFRT or 6 cycles; Stage III-IV: 6 cycles; ~60-70% cure rate; transplant only for relapse (GELA LNH-98.5).
HIT = thrombosis risk, not bleeding risk - stop all heparin, start argatroban or fondaparinux, and avoid warfarin until platelets recover.
BSH ITP first line = oral prednisolone for symptomatic adults with platelets <20 × 10⁹/L; IVIG if rapid rise needed.
Iron deficiency = microcytic, hypochromic film with pencil cells and target cells, low ferritin and low transferrin saturation - always investigate the underlying cause per NICE CKS/BSG guidance.
Above-diaphragm nodal disease only + B symptoms = Stage IIB Hodgkin lymphoma (Ann Arbor / Cotswolds; BSH and NICE NG52 framework). PET-CT is the preferred UK staging modality; ABVD ± radiotherapy is the standard early-stage regimen.
Sepsis + low platelets + prolonged PT/APTT + low fibrinogen + high D-dimer = DIC - treat the underlying cause and replace blood products guided by BSH guidance.
Substance Misuse
9 high-yield facts
Opioid substitution therapy (methadone/buprenorphine) = gold standard for opioid dependence. Reduces mortality, injecting, and crime. Buprenorphine = safer in overdose (partial agonist).
Post-detox relapse prevention: acamprosate (reduces craving) or naltrexone (blocks reward) first-line. Disulfiram = supervised patients only. Never long-term benzodiazepines.
Cocaine toxicity = benzodiazepines first-line plus GTN for chest pain (per TOXBASE/RCEM); never give beta-blockers - unopposed alpha stimulation worsens hypertension and coronary vasospasm.
SIADH = euvolaemic hyponatraemia + urine osm >100 + urine Na⁺ >30 + normal thyroid/adrenal (Society for Endocrinology UK); SCLC is the commonest malignant cause; fluid restrict first, correct <10 mmol/L/24 h.
PPV depends on prevalence as well as test accuracy - high sensitivity and specificity do not guarantee a high PPV in low-prevalence populations.
TLS = hyperK⁺ + hyperPO₄³⁻ + hyperuricaemia + hypoCa²⁺ + AKI; Burkitt lymphoma is highest-risk; prevent with IV hydration + rasburicase in high-risk disease (BSH 2015); only replace calcium if symptomatic.
NNT = 1/ARR; always report the time period over which the outcome was measured.
Cytochrome c release + APAF-1/apoptosome + caspase-9 = the intrinsic (mitochondrial) pathway driven by DNA damage; death receptors + caspase-8 = the extrinsic pathway.
Hypophosphorylated pRb holds E2F at the G1/S restriction point; cyclin D-CDK4/6 phosphorylation releases E2F, and biallelic RB1 loss (two-hit hypothesis) abolishes this checkpoint.
Selective IgA deficiency with possible transfusion - use IgA-deficient donor blood or washed red cells per BSH transfusion guidelines to prevent anaphylaxis.
Vertical transmission affecting both sexes with ~50% offspring risk indicates autosomal dominant inheritance - HCM follows this pattern; offer cascade family screening per NHS Genomic Medicine Service pathways.
Anticipation = earlier onset and greater severity across generations due to repeat expansion - DM1 CTG repeats expand during meiosis; counsel families about worsening severity using NHS Genomic Medicine Service pathways.
Psychotic Disorders
9 high-yield facts
Dilated pupils + tachycardia + hypertension + hyperthermia + psychosis = stimulant intoxication. Treat with benzodiazepines, not antipsychotics.
Capgras = familiar person replaced by imposter. Most common misidentification delusion. Seen in dementia (especially DLB) and schizophrenia. Mechanism: face recognition intact but emotional recognition disrupted.
"ABCD"): 1. Auditory hallucinations: Third-person discussing patient, running commentary on actions, thought echo (hearing own thoughts aloud) 2.
Negative symptoms = 5 A's (Avolition, Affect flat, Alogia, Anhedonia, Asociality). Major cause of disability, poorly responsive to medication.
FEP = low-dose atypical antipsychotic first-line + early intervention team. Clozapine = third-line only after 2 failed trials.
Schizoaffective = psychotic + mood symptoms equally prominent and simultaneous. If mood dominates → psychotic depression. If psychosis dominates → schizophrenia.
Catatonia first-line = IV lorazepam (benzodiazepine challenge). If no response → ECT. STOP antipsychotics (can worsen). Waxy flexibility + mutism + posturing = catatonia.
De Clerambault/erotomania = delusional belief someone of higher status loves them. Rejection interpreted as proof. Risk of stalking/violence. Subtype of delusional disorder.
Congenital Lung Disease
9 high-yield facts
Sequestration = recurrent pneumonias same location + systemic arterial supply from aorta; surgical lobectomy curative 95-100%.
Pulmonary agenesis = ipsilateral mediastinal shift + absent hilum; conservative if isolated; 50% mortality if multiple anomalies.
Scimitar = Anomalous right pulmonary vein to IVC; 'Scimitar sign' (curved opacity); Hypoplastic right lung; Surgical if symptomatic/Qp:Qs >1.5:1; Good prognosis.
Bronchopulmonary sequestration = Congenital lung tissue + Systemic arterial supply from aorta + No bronchial connection; Intralobar (75%, venous to pulmonary veins) vs extralobar; LLL commonest; Recurrent infections same location; Surgical resection curative; Preoperative embolization feeding vessel.
Williams-Campbell = distal bronchiectasis + expiratory collapse 'balloon-on-a-string' + normal proximal airways; manage per BTS bronchiectasis guideline with airway clearance and prompt antibiotics; no cure.
CPAM = recurrent pneumonias same location + lung cysts; Type 1 most common (60%); surgical resection curative; resect <2yr optimal.
Scimitar = scimitar sign CXR + anomalous R pulmonary veins→IVC + hypoplastic right lung; surgical repair if symptomatic.
Inotrope-dependent Stage D heart failure in a transplant candidate facing a long wait → LVAD as a bridge to transplant (ESC 2021; NICE TA314).
Advanced HF + 15% weight loss + persistent oedema = cardiac cachexia - assess for transplant, prognosis poor!
Post-transplant surveillance = serial EMB (gold standard) - only reliable method to detect/grade rejection!
LVAD + recurrent GI bleeding = AvWS from shear stress destroying vWF - octreotide helps!
LVAD requires lifelong anticoagulation; recent stroke (<6-12 months) with deficit = strong relative contraindication due to hemorrhagic transformation risk.
LVAD + elevated power + reduced flow + dark urine + very high LDH = pump thrombosis - intensify anticoagulation and consider thrombolysis or pump exchange (per ISHLT mechanical circulatory support guidance).
DT-LVAD suits transplant-ineligible end-stage HFrEF (NYHA IV, inotrope-dependent) - REMATCH showed benefit over medical therapy, while MOMENTUM 3 compared HeartMate 3 vs HeartMate II, not LVAD vs medical therapy.
Transplant + diffuse distal coronary disease + normal biopsy = CAV - consider re-transplantation if severe.
Advanced HF with inotrope dependence + transplant eligible = LVAD as bridge to transplant. Don't wait until multi-organ failure makes patient untransplantable.
Pharmacogenomics
9 high-yield facts
Allopurinol in Han Chinese/CKD = screen HLA-B*5801 first; positive = contraindication (use febuxostat instead).
TPMT deficiency + azathioprine = severe myelosuppression; screen TPMT pre-treatment.
SVCO = dexamethasone + urgent SVC stent for rapid relief. Chemotherapy for SCLC, radiotherapy for NSCLC. Stent works within 24-72 hours.
Fever + neutrophils <0.5 = neutropenic sepsis; piperacillin-tazobactam within 1h; do not wait cultures.
TLS = ↑K⁺, ↑PO₄³⁻, ↑urate, ↓Ca²⁺ + AKI; prevent and treat with hydration and rasburicase per BSH guidance.
For TLS, think 'everything UP except calcium' - K⁺, PO₄³⁻, and urate high, Ca²⁺ low - with AKI shortly after chemotherapy in a bulky tumour burden patient.
Neutropenic sepsis = empirical IV antibiotics within 1 hour. Piperacillin-tazobactam is first-line. Never delay for cultures.
SM = major + minor WHO criteria (KIT D816V + tryptase ≥20 + CD25/CD2 + spindle aggregates); Darier sign in urticaria pigmentosa; ISM → H1/H2 antihistamines + adrenaline autoinjector; ASM/MCL → midostaurin; imatinib only if D816V-negative.
Philadelphia chromosome + left shift + basophilia = CML; imatinib; 10y survival 85%; monitor BCR-ABL q3m.
ET = platelets >450 with JAK2/CALR/MPL; give aspirin to all, add hydroxycarbamide when high-risk (age ≥60 or prior thrombosis), per BSH guidance.
Platelets >450 plus JAK2+ plus age >40 equals ET intermediate risk - aspirin plus hydroxycarbamide reduces thrombotic events 50%.
Tear-drop cells plus dry tap plus massive splenomegaly equals myelofibrosis - ruxolitinib reduces spleen/symptoms, HSCT only cure (high-risk patients).
Bipolar II = recurrent depression + hypomania (no marked impairment, no psychosis, no admission); it is impairment - not duration alone - that separates hypomania from mania.
Treatment-resistant depression after 3 failed trials plus CBT = augment (lithium or antipsychotic) or combine antidepressants (NICE NG222); reserve ECT for failure of augmentation or life-threatening depression.
Acute mania = rapid-acting oral antipsychotic first-line (NICE CG185); benzodiazepines are an adjunct for agitation; reserve ECT for severe or treatment-resistant mania.
Cyclothymia = chronic subthreshold mood swings for ≥2 years, never meeting criteria for mania or depression, no 2-month symptom-free period. 15-50% progress to bipolar disorder.
SAD = seasonal depression (winter onset), atypical features (hypersomnia, weight gain, carb craving). Light therapy 10,000 lux first-line. ≥2 consecutive years of seasonal pattern required.
Bipolar II = hypomania (≥4 days, no impairment) + depression. Often misdiagnosed as recurrent depression. Always screen for hypomania. Antidepressant monotherapy can trigger mania.
Depression = "Low mood OR anhedonia + ≥4 symptoms for ≥2 weeks!" Early morning wakening = biological depression feature.
Dysthymia = chronic low-grade depression ≥2 years, never meeting major depression criteria, no 2-month symptom-free period. Patients say "I've always been like this." CBT + SSRI for treatment.
Hypertension
8 high-yield facts
Resistant HTN + hypokalaemia = screen for primary hyperaldosteronism with ARR; most common secondary cause of resistant HTN.
HTN + 3 drugs including diuretic + adherent + BP 155/95 = resistant HTN - add spironolactone 25mg!
Hypertension + diabetes or CKD = start ACE-I/ARB regardless of age or ethnicity! For uncomplicated HTN: <55 = ACE-I; ≥55 or Black = CCB.
Hypertensive emergency with end-organ damage = controlled IV labetalol, ≤25% MAP reduction in the first hour per NICE NG136 - overshooting risks ischaemic stroke and AKI.
Resistant HTN + ACE-inhibitor renal decline + vascular disease = renovascular HTN - use MRA to diagnose.
Hypertensive emergency (BP >180/120 + end-organ damage) → IV labetalol or nicardipine, reduce 10-20% in the first hour, NOT normalise. Sublingual nifedipine is contraindicated.
Fungal Lung Disease
8 high-yield facts
CPA = Chronic Aspergillus in cavity (>3 months); Post-TB commonest; Long-term azoles; Often indefinite; 5-year mortality 50-80%.
Asthma + eosinophilia + very high IgE + fleeting infiltrates = ABPA; confirm with Aspergillus-specific antibodies.
ABPA = asthma + high IgE + Aspergillus IgE/IgG + central bronchiectasis; prednisolone + itraconazole; monitor IgE.
Aspergilloma = Fungal ball in cavity (air crescent sign); Conservative unless massive haemoptysis; Antifungals not first-line; Surgery if life-threatening bleed.
Aspergilloma = fungal ball in cavity + air crescent sign; observe if asymptomatic; surgery if recurrent haemoptysis; antifungals NOT first-line.
Aspergilloma + recurrent haemoptysis + good function = surgery (lobectomy); antifungals not first-line; embolisation is temporising.
IPA = Neutropenic + Halo sign + Galactomannan; IV voriconazole immediately; DO NOT wait for culture; High mortality if delayed.
IA = Neutropenic + Fever + Halo sign; Galactomannan >0.5; Voriconazole first-line; DO NOT wait; Mortality 30-50%.
Airway Disorders
8 high-yield facts
TBO = Calcified nodules in trachea; SPARES posterior membrane (highly characteristic); Cobblestone on bronchoscopy; Elderly men; Benign, slowly progressive; Supportive management; Bronchoscopic debulking if severe; NOT inflammatory (steroids ineffective).
Tracheomalacia = Airway 'collapses' on expiration; Barking cough; >50% collapse on dynamic bronchoscopy; Conservative (CPAP pneumatic stenting); Tracheobronchoplasty if severe; Associated with COPD/prolonged intubation.
Tracheobronchial amyloidosis = waxy nodules + Congo red/apple-green birefringence; bronchoscopic debulking; exclude systemic disease; no chemo for localised.
Tracheo-innominate = sentinel bleed then massive haemorrhage days 3-30; hyperinflate cuff immediately; emergency surgery; 75% mortality.
TBM (barking cough + dyspnoea + dynamic expiratory collapse >50% + post-intubation) is managed first-line with CPAP to splint the airway open; reserve stenting or tracheobronchoplasty for severe refractory disease.
Metastatic carcinoid with flushing, diarrhoea and right-sided valve disease - start octreotide LAR (or lanreotide), add liver-directed therapy and consider lutetium-177 DOTATATE PRRT for progressive disease (NETTER-1).
Carcinoid syndrome = flushing + diarrhoea + raised urinary 5-HIAA, often with right-sided valve disease; octreotide/lanreotide is first-line per UKINETS and NICE NG151.
VIPoma/WDHA (profuse watery secretory diarrhea >3L + severe hypokalemia + achlorhydria + pancreatic mass) = VIP excess - octreotide dramatically controls diarrhea, distinguish from gastrinoma (gastric acid HIGH, not low).
Somatostatinoma (diabetes + gallstones + steatorrhea + pancreatic mass + achlorhydria) = excess somatostatin inhibits insulin/CCK/enzymes - surgical resection first-line, octreotide helps (paradoxical), rare but high malignancy rate.
Carcinoid syndrome + surgery (especially liver/tumour manipulation) = perioperative IV octreotide bolus plus infusion to prevent carcinoid crisis; UKI NETS / ENETS endorse this approach and it reduces crisis incidence to under 10%.
Hypoglycemia timing = which insulin to adjust. 3am hypo = reduce bedtime BASAL insulin!
Metformin contraindicated if eGFR <30! Stop during AKI, restart when renal function recovers.
Metformin-intolerant obese T2DM with high HbA1c → GLP-1 receptor agonist (e.g. semaglutide) with NICE NG28 stop rule reviewed at 6 months; weight-gain agents (sulfonylureas, insulin, pioglitazone) less attractive in obesity.
Pioglitazone contraindicated in bladder cancer history; ↑risk 20-40%; also avoid in HF NYHA III-IV; use SGLT2i/GLP-1 RA instead.
Conscious hypoglycaemia = oral glucose (Rule of 15); IM glucagon/IV only if unconscious/cannot swallow.
AHI >30 plus daytime somnolence = severe OSA - CPAP therapy first-line, improves symptoms and reduces cardiovascular risk, weight loss adjunct.
Obesity (BMI >30) + chronic hypercapnia + no severe lung disease = OHS; treat with BiPAP.
Narcolepsy 1 = EDS + cataplexy + SOREMPs + low hypocretin; modafinil for sleepiness; sodium oxybate/venlafaxine for cataplexy.
AHI >30 plus EDS equals severe OSA - CPAP therapy first-line, improves symptoms and reduces cardiovascular risk.
Excessive sleepiness plus cataplexy plus sleep-onset REM equals narcolepsy type 1 - modafinil for sleepiness, sodium oxybate for cataplexy.
Severe OSA (AHI >30 + symptoms + desaturations) = CPAP therapy; reduces cardiovascular risk and accidents.
Leg discomfort worse at rest relieved by movement plus evening onset equals RLS - check ferritin, replace iron if <75, dopamine agonist if severe.
Narcolepsy type 1 (EDS + cataplexy triggered by emotion + hypnagogic hallucinations) = modafinil for sleepiness + sodium oxybate for cataplexy; hypocretin deficiency.
CKD Complications
8 high-yield facts
For counselling, emphasise that “CKD is a heart disease multiplier” - controlling BP, cholesterol, and albuminuria is as important as protecting the kidneys themselves.
In dialysis patients, persistent high phosphate despite good dialysis points to “binders at the dinner table” - start or optimise phosphate binders taken with meals, alongside dietary counselling.
In renal OSCEs and MCQs, “dialysis unit = think hepatitis B risk” - vaccinate early, use higher doses, and monitor titres to ensure ongoing protection.
CKD-MBD = hyperphosphataemia + hypocalcaemia + raised PTH; treat with phosphate binders + vitamin D + calcimimetics.
TSAT <20% = IV iron first; EPO after; target 100-120 NOT >120; avoid transfusion.
In CKD, “high PTH + high PO₄ + bone pain” = secondary hyperparathyroidism with osteitis fibrosa cystica; treatment focuses on phosphate restriction/binders, vitamin D analogues, and sometimes calcimimetics or parathyroidectomy.
When a CKD patient becomes drowsy, confused, and asterixis-positive with no other explanation, the answer is usually start dialysis now, not further conservative management.
Inherited Cardiac Conditions
8 high-yield facts
HCM proband → cascade genetic test + serial ECG/echo for all first-degree relatives (annually ages 10-21, then every 3-5 years lifelong) per ESC 2023 cardiomyopathy guideline; risk-stratify with HCM Risk-SCD.
DCM genetic diagnosis → cascade test relatives → echo surveillance for gene carriers only.
ARVC causes sudden death in young athletes - epsilon waves + T-wave inversion V1-V3 + ventricular arrhythmias suggest diagnosis, requiring ICD and sports restriction.
Warfarin + clarithromycin = major interaction - always use azithromycin for respiratory infections.
Suspected HIT = stop all heparin, never use warfarin alone or platelet transfusion; bridge with argatroban or fondaparinux per BSH guideline until platelets >150.
DOAC reversal - andexanet alfa for apixaban/rivaroxaban; idarucizumab for dabigatran; use specific agents for best outcomes.
Major warfarin bleeding = IV vitamin K + PCC (immediate reversal); PCC superior to FFP.
BRIDGE trial showed no bridging is safer - avoid routine bridging in AF; only bridge mechanical valves or recent stroke.
LMWH accumulates eGFR <30; reduce enoxaparin 50% or use UFH; dabigatran contraindicated CrCl <30; apixaban safest DOAC.
Headache
8 high-yield facts
IIH = obese young woman + papilloedema + normal MRI; confirm LP >25cmH₂O; weight loss + acetazolamide.
Cluster = severe unilateral + autonomic + restless + episodic; O₂ 12-15L/min acute; verapamil prophylaxis with ECG.
Hemiplegic migraine (transient hemiparesis + headache + family history + normal imaging) = avoid triptans/ergots (use NSAIDs instead); rare but important stroke mimic.
MOH = chronic daily headache + medication overuse (≥10 days/month triptans/opioids or ≥15 days/month simple analgesics); stop ALL acutes; prophylaxis only AFTER detox (NICE CG150).
Chronic tension-type headache (daily bilateral pressing headache, mild-moderate, no migraine features, can work through) = low-dose amitriptyline at night for prophylaxis plus trigger and stress management; avoid triptans.
MOH = baseline headache + frequent analgesic use → stop the overused drug abruptly, start prophylaxis immediately, warn of 2-4 weeks of withdrawal worsening; ≈70% improve by 3 months.
A CURB-65 of 2 means consider or arrange hospital admission; a score of ≥3 should prompt assessment for critical care (BTS/NICE NG138 community-acquired pneumonia guidance).
CURB-65 score 2 = intermediate risk; consider admission based on clinical context and social factors.
Severe CAP + diarrhoea + hyponatraemia + relative bradycardia = Legionella; urinary antigen test rapid diagnosis.
CURB-65 ≥3 = severe CAP - admit and assess for ICU; empirical IV co-amoxiclav + macrolide (BTS 2015 / NICE NG138).
PCP = CD4 <200 + bilateral infiltrates; Co-trimoxazole 21 days; Steroids if PaO2 <10.6; ART 2 weeks later.
CURB-65 score 2 equals moderate CAP - dual antibiotics (amoxicillin plus macrolide) cover typical and atypical pathogens.
Lung abscess (aspiration + foul sputum + cavity) = co-amoxiclav or amoxicillin + metronidazole for 6 weeks total.
CURB-65: C-U-R-B-65; 0-1 outpatient; 2 consider admission; 3-5 inpatient ± ITU; IV co-amoxiclav + clarithromycin if severe.
Endocrinology & Diabetes
8 high-yield facts
Low morning cortisol with high ACTH plus hyponatraemia/hyperkalaemia = primary adrenal insufficiency - confirm with the short Synacthen test (Society for Endocrinology / Addison's clinical guidance).
T2DM + established cardiovascular disease on metformin = add an SGLT2 inhibitor with cardiovascular outcome data (empagliflozin, dapagliflozin, canagliflozin) per NICE NG28 - EMPA-REG OUTCOME first showed mortality benefit and reframed second-line therapy.
Ketoacidosis with glucose <14 mmol/L on an SGLT2 inhibitor = euglycaemic DKA. Stop the SGLT2i immediately and treat as DKA per JBDS-IP with fluids, fixed-rate insulin, and early dextrose co-infusion; apply MHRA sick-day rules to all patients on these drugs.
PHPT surgery indications - calcium >0.25 above ULN, T-score ≤−2.5, eGFR <60, age <50, or renal stones; low phosphate and elevated PTH with hypercalcaemia confirm the diagnosis.
Titrate levothyroxine in 25 microgram steps every 6-8 weeks guided by TSH; an elevated TSH means increase the dose, but avoid large jumps and avoid suppressing the TSH (NICE CKS; BTA).
Suppressed PTH + raised PTHrP + hilar lung mass = humoral hypercalcaemia from PTHrP; treat with saline and IV bisphosphonate.
Acromegaly screening - IGF-1 first; confirm with OGTT (GH fails to suppress <1 µg/L); MRI to localise; transsphenoidal surgery is first-line treatment.
Prolactinoma first-line = cabergoline regardless of size or visual field defect (NICE CKS; Society for Endocrinology); surgery only for dopamine agonist resistance/intolerance or unresponsive acute visual loss; monitor with prolactin, perimetry and MRI.
Haematological Malignancies
8 high-yield facts
Early MF (patches/plaques) = narrowband UVB phototherapy - skin-directed therapy, not systemic chemotherapy.
Gastric MALT + H. pylori = eradicate first - 60-80% achieve remission with antibiotics alone.
PTCL-NOS (aggressive T-cell, CD3+/CD30-, high LDH) = CHOP chemotherapy - poor prognosis 5-year survival 30-40%, consolidate ASCT.
ALCL = CD30+ T-cell lymphoma - ALK-positive has excellent prognosis, CHOP or brentuximab-CHP first-line.
ATLL (flower cells + hypercalcemia + HTLV-1) = zidovudine-interferon - superior to chemotherapy, consolidate with HSCT.
CLL to DLBCL (95%); rapid node enlargement + B symptoms + high LDH; excisional biopsy; R-CHOP; poor prognosis 5-8 months; allo-SCT only cure.
FL is incurable but indolent - defer treatment until symptomatic.
Metabolic Disorders
8 high-yield facts
Selenium deficiency on TPN (dilated cardiomyopathy + low T3 with normal T4/TSH + prolonged TPN) = Keshan disease + impaired deiodinase - selenoprotein cofactor, cardiomyopathy reversible with supplementation, ensure TPN contains selenium.
Hemochromatosis (diabetes + hypogonadism with low LH/FSH + bronze pigmentation + very high ferritin) = iron deposition in pituitary/pancreas - venesection removes iron but endocrine damage often irreversible, testosterone replacement needed (not gonadotropins).
Cluster headache = excruciating unilateral orbital pain + lacrimation/nasal congestion + restlessness + 15-180 min duration. Acute treatment: SC sumatriptan 6mg OR high-flow oxygen 12-15L/min (equally effective). Oral analgesics useless!
IIH = obese young woman + headache + papilloedema + visual obscurations + LP >25 + normal MRI/CSF; weight loss + acetazolamide; monitor vision.
Severe unilateral periorbital pain plus lacrimation plus restlessness plus nocturnal attacks equals cluster headache - 100% oxygen aborts attacks, verapamil prevents recurrence.
Acute migraine = triptan at onset; migraine with aura + combined pill = stroke risk, so stop the oestrogen-containing contraceptive.
Cluster headache acute therapy = high-flow oxygen + subcutaneous sumatriptan (not oral triptans or simple analgesics); verapamil is first-line prophylaxis (NICE CKS Cluster headache; British Association for the Study of Headache guidelines).
Migraine with aura = STOP COCP (stroke risk) + sumatriptan acute + propranolol prophylaxis if ≥4/month; switch POP/IUD.
Migraine ≥4 attacks/month = prophylaxis. First-line: topiramate 50mg BD OR propranolol 80-160mg daily. Trial 3 months. CGRP mAbs for refractory!
Spondyloarthropathy
7 high-yield facts
The old mnemonic “can’t see, can’t pee, can’t climb a tree” captures reactive arthritis - conjunctivitis, urethritis, and arthritis following an infection.
AS + inadequate NSAIDs = anti-TNF; BASDAI ≥4; screen TB; sulfasalazine only peripheral; physiotherapy lifelong.
Reactive arthritis = post-infection oligoarthritis + urethritis + conjunctivitis; NSAIDs first-line; antibiotics only if active Chlamydia; self-limiting 50%.
AS = inflammatory back pain <40yr + bilateral sacroiliitis + HLA-B27; continuous NSAIDs (slow progression) + daily physiotherapy; anti-TNF if refractory.
For AS, think “young, stiff, and better with movement” - chronic morning stiffness and improvement on exercise in a young adult male should always raise suspicion of inflammatory back pain rather than mechanical strain.
Fistula infection + bacteraemia = IV antibiotics + don't use infected access - protect the access and patient.
PD peritonitis = cloudy bag + WCC >100/µL with neutrophilia; empirical intraperitoneal vancomycin + gentamicin (or ceftazidime); IP route is superior to IV; remove catheter for fungal, refractory or relapsing peritonitis (ISPD 2022 guidelines).
In PD patients, “cloudy bag = peritonitis until proven otherwise” - treat promptly with intraperitoneal antibiotics, not oral therapy alone, and only abandon PD if infections are severe or recurrent.
First dialysis + neurological symptoms = disequilibrium - start slow and short.
Cloudy dialysate + dialysate WCC >100/mm³ with >50% neutrophils = PD peritonitis. Start empirical intraperitoneal antibiotics covering both Gram-positive and Gram-negative organisms (vancomycin + gentamicin); do not stop CAPD.
In dialysis patients, “S. aureus in the blood = treat the line as guilty” - remove the catheter, give IV antibiotics, and investigate for endocarditis rather than trying to salvage the line.
Inflammatory Conditions
7 high-yield facts
Proximal girdle pain + raised ESR + normal strength = PMR - think GCA and give steroids.
PMR = no synovitis + normal strength - think muscle pain, not joint disease.
FHH - Ca 2.75 (mild lifelong asymptomatic), PTH 4.5 inappropriately normal (vs primary >7.0), urinary Ca 1.5 LOW (pathognomonic, vs primary >2.5), CCCR 0.008 (<0.01 diagnostic), FH autosomal dominant CaSR, NO stones (vs primary 20%), observation (benign), avoid parathyroidectomy (contraindicated), family screen 50% offspring.
Metabolic Bone Disease
7 high-yield facts
Pre-collapse femoral head AVN (MRI double-line sign, Ficat I-II) → core decompression; once the head has collapsed → total hip arthroplasty; minimise corticosteroid exposure.
Paget = ↑ALP + normal Ca²⁺ + cotton-wool skull; zoledronic acid 5mg IV if symptomatic; osteosarcoma <1%.
BP differential + arm claudication + vertebrobasilar symptoms = subclavian steal - PTA/stenting relieves "steal" from brain!
ABPI >1.3 = arterial calcification (common in diabetes) - use TBI instead for accurate PAD diagnosis.
Symptomatic subclavian steal (VBI + arm claudication + inter-arm BP difference >20 mmHg + retrograde vertebral flow on Doppler) → endovascular angioplasty and stenting first-line.
Arm exercise symptoms + BP differential + reversed vertebral flow = subclavian steal - revascularise if symptomatic.
Endocrine Drugs
7 high-yield facts
Hypothyroidism under-replacement = increase levothyroxine by 25mcg, recheck TFTs in 6-8 weeks. Target TSH 0.5-2.5 mU/L!
Adrenal insufficiency sick day rules - double/triple dose for illness; IM hydrocortisone 100 mg if vomiting (life-saving).
(BNF): prolactinoma = bromocriptine 1.25 mg nocte with food, titrate by 1.25 mg every 3-7 days to 2.5-7.5 mg/day; cabergoline preferred outside pregnancy; check prolactin at 4 weeks and MRI at 6-12 months.
Propranolol in thyrotoxicosis = dual action (β-blockade + T4→T3 inhibition); rapid symptom relief within hours.
Cinacalcet = CaSR agonist → ↓PTH; monitor Ca²⁺ (hypocalcaemia risk); target PTH 150-300; combine with vitamin D + phosphate binders.
Steroid conversion - 5 mg prednisolone = 20 mg hydrocortisone; IV to oral requires bioavailability adjustment.
Secondary Prevention
7 high-yield facts
Offer supervised cardiac rehabilitation to all suitable patients after MI (NICE CG172) - it reduces cardiovascular mortality and readmissions and improves quality of life.
Post-ACS = atorvastatin 80mg (or rosuvastatin 20-40mg) for LIFE! Target LDL <1.4 mmol/L. Add ezetimibe if target not met.
Previous VTE + long-haul flight (>4 hours) → compression stockings (15-30 mmHg) first-line; LMWH reserved for active cancer/major thrombophilia, not routine.
Uncomplicated MI + physical job → exercise stress test at 4-6 weeks before returning to work; assess capacity and exclude inducible ischemia.
CYP2C19 poor metabolizer + stent thrombosis concern → switch from clopidogrel to prasugrel/ticagrelor (not prodrugs); don't increase clopidogrel dose.
Post-MI + stable + 2 weeks = CARDIAC REHABILITATION Class I - reduces mortality 20-30%, improves capacity/QoL!
Statin-intolerant patient post-MI = add ezetimibe. Simple, effective, affordable, and proven to reduce events. Ezetimibe should be considered in ALL patients not reaching LDL targets on statins.
SLE - hydroxychloroquine for everyone (BSR 2018), screen all for lupus nephritis (urine PCR) and APS (especially with thrombosis or pregnancy loss); high-dose steroids only for organ-threatening flares.
MCTD = anti-U1-RNP + Raynaud + puffy fingers + synovitis ± myositis; treat the active flare with prednisolone and refer to rheumatology; screen annually for pulmonary hypertension (echo + PFTs).
Secondary Sjögren in RA = symptomatic tear and saliva substitutes first-line (BSR/EULAR); pilocarpine for refractory xerostomia; investigate persistent parotid swelling - MALT lymphoma risk.
Secondary Raynaud's in systemic sclerosis - first-line is a dihydropyridine calcium-channel blocker (nifedipine MR); escalate to sildenafil, IV iloprost, or bosentan for digital ulcers; immunosuppression does not treat vasospasm.
Pseudogout = weakly positively birefringent rhomboid crystals + chondrocalcinosis on X-ray; treat with NSAID, colchicine or intra-articular steroid (NOT allopurinol); always screen for hyperparathyroidism, haemochromatosis, hypomagnesaemia and hypothyroidism.
Gout = sudden 1st MTP + negatively birefringent crystals; NSAID/colchicine/steroid acutely; do NOT initiate allopurinol during the attack (NICE NG219).
Chronic CPPD = arthritis in atypical joints + chondrocalcinosis; no disease-modifying Rx; paracetamol + colchicine prophylaxis; screen metabolic causes.
Chronic gout = allopurinol (start low, titrate to target <300) + colchicine 6mo prophylaxis; do NOT start during attack; stop thiazides.
Acute gout = colchicine or steroids (if CKD → avoid NSAIDs); do NOT start allopurinol during attack.
Renal Vascular Disease
7 high-yield facts
RAS + declining eGFR = optimise medical management first, revascularise if function continues to fall.
RVT = membranous highest risk; anticoagulate while nephrotic; PE 30-40% untreated.
Atheroembolic = post-procedure + subacute AKI + eosinophilia + blue toes + cholesterol clefts; supportive only; 60% ESRD.
FMD = young woman + string of beads + mid-distal renal artery; angioplasty WITHOUT stent first-line (60-80% HTN cure); screen carotids; antihypertensives per NICE NG136.
Nutcracker = thin woman + haematuria + LRV angle <35°; conservative + weight gain first; stenting if refractory.
Page kidney = post-trauma + new hypertension + subcapsular haematoma + raised renin; percutaneous drainage is first-line definitive management per BAUS/EAU.
RAS = resistant HTN + Cr rise on ACEi + flash oedema; medical first; angioplasty for FMD/refractory.
Neurology
7 high-yield facts
High-risk TIA with symptomatic carotid stenosis of 50-99% needs short-course dual antiplatelet therapy plus urgent carotid endarterectomy within 7 days (NICE NG128).
NICE CG173 neuropathic pain first-line = amitriptyline OR duloxetine OR gabapentin OR pregabalin (monotherapy, switch rather than combine); amitriptyline 10 mg nocte preferred when sleep disturbed; NSAIDs ineffective; tramadol second-line.
Multiple sclerosis = dissemination in space AND time per McDonald 2017 criteria - unmatched CSF oligoclonal bands can substitute for dissemination in time; refer urgently to neurology for DMT under NICE NG220.
Convulsive status epilepticus - give two doses of benzodiazepine (IV lorazepam 4 mg preferred when IV access is available) before moving to a second-line agent (levetiracetam, valproate or phenytoin) per NICE NG217 and the ESETT trial.
Breakthrough RRMS on first-line DMT = escalate to high-efficacy agent (natalizumab, ocrelizumab); natalizumab preferred if JCV-negative due to low PML risk; monitor JCV serology 6-monthly per NICE NG220.
Spontaneous ICH with SBP 150-220 mmHg - aim for SBP <140 mmHg within 1 hour (INTERACT2; RCP 2023); avoid <120 mmHg (ATACH-2 renal harm); titrate IV labetalol or nicardipine; neurosurgery for GCS ≤8 or posterior fossa bleed.
GBS + unable to walk or respiratory involvement → IVIg 0.4 g/kg/day × 5 days (or plasma exchange) per ABN guidelines; HDU/ITU with FVC monitoring; steroids have NO role in GBS (unlike CIDP); intubate if FVC <1 L or <20 mL/kg.
Fraser guidelines = specific criteria for contraception in under-16s. Gillick competence = general principle of child's capacity to consent. Child can consent but cannot refuse life-saving treatment against parents' wishes.
DoLS = person lacking capacity + continuous supervision + not free to leave. Applies in care homes and hospitals. Contentment is irrelevant. Acid test from Cheshire West.
Section 2 = assessment, 28 days, 2 doctors + AMHP. Section 3 = treatment, 6 months. Use Section 2 when diagnosis is unclear or first presentation.
Section 5(2) = doctor's holding power, 72 hours, inpatients only, one doctor needed. Section 5(4) = nurse's holding power, 6 hours. Emergency measure while arranging full MHA assessment.
Section 136 = police remove from public place to place of safety, up to 24 hours. Section 135 = warrant for private premises. Health-based place of safety preferred over police custody.
Reproductive
7 high-yield facts
In POI, give combined HRT until ~age 51 (NICE NG23) - this is physiological replacement, not conventional menopausal HRT, and does not carry the same breast cancer risk.
McCune-Albright = peripheral precocious puberty + cafe-au-lait macules + polyostotic fibrous dysplasia - GnRH agonists fail because the puberty is gonadotrophin-independent; use an aromatase inhibitor or tamoxifen and monitor bone age (BSPED/ESPE precocious puberty guidance).
Low testosterone + small testes + symptoms = hypogonadism requiring TRT (unless fertility desired or contraindications present).
Pubertal gynecomastia - bilateral subareolar age 13-14, reassurance (resolves 90% 1-2y), tamoxifen/surgery if persistent >2y or severe distress.
Dermatology
7 high-yield facts
A pearly papule with a rolled edge, telangiectasia, and central crusting on a sun-exposed site is a nodular BCC - locally invasive but rarely metastasising; excise, with Mohs surgery reserved for high-risk facial sites.
Moderate eczema uncontrolled on hydrocortisone 1% - increase emollients and step up to moderately potent topical steroid for flares per NICE CG57; avoid very potent steroids in children.
Bullous pemphigoid = tense subepidermal blisters, negative Nikolsky, linear IgG/C3 at the basement membrane zone, antibodies to BP180/BP230; first-line treatment is potent topical steroids (BAD).
psoriasis plus DIP arthritis, nail pitting and pencil-in-cup deformity with negative RF/anti-CCP points to psoriatic arthritis - refer early to rheumatology (NICE NG65).
Breslow thickness is the key prognostic factor in cutaneous melanoma and guides NICE NG14 excision margins; ulceration is an independent adverse feature that upstages the tumour.
Work-related vesicular hand dermatitis that improves away from work points to allergic contact dermatitis - confirm the allergen with patch testing, not skin prick testing.
Pseudohypoparathyroidism 1A (hypocalcemia + high PTH + shortened 4th/5th metacarpals + round face + subcutaneous ossifications) = maternal GNAS mutation causing PTH resistance with AHO - use calcitriol (not standard vitamin D), distinguish from hypoparathyroidism (low PTH).
Hungry bone syndrome (severe hypocalcemia + hypophosphatemia + hypomagnesemia post-parathyroidectomy + pre-op severe hyperparathyroidism/osteoporosis) = avid bone remineralization - high-dose IV/oral calcium + calcitriol + magnesium essential, vs hypoparathyroidism (HIGH phosphate).
In PHPT, osteoporosis (T-score ≤ −2.5 at any site), calcium >0.25 mmol/L above the upper limit, age <50, or eGFR <60 each indicate parathyroidectomy - even when hypercalcaemia is asymptomatic.
Sarcoidosis hypercalcemia (elevated 1,25-OH-D + suppressed PTH + hilar lymphadenopathy + vitamin D supplementation) = extrarenal granulomatous 1α-hydroxylase (substrate-driven, not PTH-regulated) - stop vitamin D, use steroids, distinguish from vitamin D intoxication (mild hypercalcemia, normal 1,25-OH-D).
FHH (hypercalcemia + mildly elevated/normal PTH + LOW urinary calcium + CCCR <0.01 + family history + asymptomatic) = inactivating CaSR mutation - NO treatment needed (benign), avoid parathyroidectomy (harmful), distinguish from PHPT (HIGH urinary calcium, CCCR >0.02).
Calcium >3.0 + suppressed PTH + raised PTHrP + cancer → IV saline 3-6 L then IV zoledronate; denosumab if eGFR <30; treat the tumour; median survival 1-3 months.
Demyelinating Disease
6 high-yield facts
Post-infectious encephalopathy plus multifocal demyelination plus no oligoclonal bands equals ADEM - steroids improve outcomes, usually monophasic unlike MS.
Optic neuritis plus previous neurological episode plus periventricular lesions equals MS - IV methylprednisolone speeds recovery from acute relapse.
MS relapse = IV methylpred 1g ×3-5d (accelerates recovery, not long-term); oral pred inferior; PLEX if refractory; consider DMT escalation.
MS = ≥2 attacks + ≥2 CNS areas. RRMS = relapses with recovery. Start disease-modifying therapy early!
ADEM (child + encephalopathy + multifocal deficits + large bilateral MRI lesions + post-viral + negative oligoclonal bands) = IV methylprednisolone 1g × 3-5 days - monophasic, 80-90% recovery.
Bone
6 high-yield facts
Post-thyroidectomy hypoparathyroidism - oral calcium plus alfacalcidol (active vitamin D) and replete magnesium; target calcium 2.0-2.25 mmol/L and 24-h urine Ca <7.5 mmol/day (ESE 2015, Society for Endocrinology UK 2020).
Fragility fracture = osteoporosis (treat even if DEXA normal), alendronate first-line, glucocorticoids ≥5 mg >3m → start bisphosphonate, calcium/vitamin D essential.
Vitamin D deficiency - bone pain + proximal myopathy + ↑ALP/PTH + low vitamin D, colecalciferol 20,000-40,000 IU weekly 8-12w + calcium, maintenance 800-1,000 IU daily.
Paget - bone pain + deformity + very ↑ALP + normal Ca, zoledronic acid 5 mg single infusion (normalizes ALP 90%), monitor for deafness/fractures/osteosarcoma.
Vitamin D toxicity = ↑Ca + ↑PO₄ (vs PHPT ↓PO₄) + ↓PTH + 25-OH vitamin D >375 nmol/L; stop supplements + IV saline + bisphosphonate if severe + prednisolone if refractory.
Vitamin D deficiency - bone pain + proximal myopathy + raised ALP/PTH + low vitamin D + Looser zones, colecalciferol 20,000-40,000 IU weekly 8-12 weeks + calcium, maintenance 800-1,000 IU daily.
Asymmetric weakness (finger flexors, quadriceps) + rimmed vacuoles = IBM - resistant to treatment, poor prognosis.
Dermatomyositis = screen for cancer - 15-30% have malignancy, screen within 3 years.
Proximal weakness + no skin + endomysial CD8+ cells = polymyositis - different from dermatomyositis.
IBM = slowly progressive + asymmetric + rimmed vacuoles + poor steroid response - think degenerative + inflammatory, not treatable.
IBM = elderly >50; asymmetric quadriceps + finger flexor weakness (pathognomonic); rimmed vacuoles on biopsy; refractory to treatment (unlike PM).
Bleeding Disorders
6 high-yield facts
vWD = “platelet-type bleeding with normal platelet count” and low ristocetin cofactor, often in women with heavy menses; treatment includes desmopressin or vWF-containing concentrates for procedures or major bleeds.
Factor XIII deficiency = delayed bleeding 24-72h + normal coagulation screen; umbilical stump bleeding pathognomonic; treat cryoprecipitate.
Haemophilia B = FIX deficiency, X-linked; FIX concentrate (longer t½ than FVIII); DDAVP ineffective; inhibitors 3-5%.
Mediterranean G6PD deficiency - primaquine/dapsone/fava beans → bite cells and Heinz bodies → stop trigger, hydrate, transfuse if severe; consult the BNF G6PD appendix before any new drug.
DAT C3d only + cold triggers = cold agglutinin; rituximab first-line; steroids/splenectomy ineffective.
Painful genital umbilicated vesicopustules + lymphadenopathy in MSM = mpox until proven otherwise - isolate and notify UKHSA immediately.
Zika in pregnancy = risk congenital Zika syndrome (microcephaly); serial ultrasound monitoring; counsel on risks; no specific treatment.
Yellow fever = unvaccinated traveler to Africa + jaundice + hemorrhage + hepatorenal failure; supportive care only; vaccine gives lifelong immunity - mandatory for endemic travel.
Chikungunya = Caribbean travel + severe symmetrical polyarthralgia + fever + rash; supportive care (NSAIDs for joints); chronic arthralgia in 30-40%.
Long COVID with PESE = paced activity (not push through) - MDT referral, avoid boom-bust cycles.
Japanese encephalitis = rural Asia exposure + encephalitis + flaccid paralysis + bilateral thalamic involvement; supportive care only (no antiviral); vaccinate travelers to rural endemic areas.
Parathyroid
6 high-yield facts
Tertiary hyperparathyroidism - dialysis + hypercalcemia (vs secondary low/normal Ca) + PTH >80, parathyroidectomy curative 90%, hungry bone post-op, cinacalcet if surgery contraindicated.
PHP - low Ca + high PTH (resistance) + short metacarpals (Albright), calcium + alfacalcidol (active vitamin D), target Ca 2.0-2.2, avoid PTH therapy (ineffective), GNAS1 maternal mutation.
Hungry bone - severe hypoCa + hypoPO4 + hypoMg post-parathyroidectomy, IV Ca infusion essential (oral inadequate), high-dose alfacalcidol, monitor Ca 4-6h.
Primary hyperparathyroidism - ↑Ca + inappropriately normal/↑PTH diagnostic, parathyroidectomy curative (indications: symptomatic, Ca >2.85, osteoporosis, age <50, eGFR <60), post-op monitor hungry bone syndrome.
Severe hypercalcemia >3.5 - IV saline FIRST (most important immediate step), bisphosphonate (onset 24-48h), calcitonin (rapid bridge), parathyroidectomy once stable.
Diabetes Mellitus
6 high-yield facts
HHS = glucose >30 + osmolality >320 + pH >7.30. Fluid resuscitation SLOWLY over 48 hours with 0.9% saline. Low-dose insulin. High VTE risk - give LMWH!
Type 1 diabetes = basal-bolus insulin (long-acting basal + rapid-acting with meals). Gold standard! Offers flexibility and physiological insulin replacement!
Type 1 diabetes honeymoon period (recent diagnosis + reduced insulin requirement + hypoglycemia + detectable C-peptide + anti-GAD+) = partial beta-cell recovery - temporary (weeks-years), reduce insulin but continue, eventually progress to complete dependence, do NOT stop insulin.
DKA = glucose >11 + ketones >3 + pH <7.3. Treat with FLUIDS FIRST, then fixed-rate IV insulin (0.1 units/kg/h)!
GDM not controlled after 1-2 weeks of diet → start metformin (NICE NG3); add insulin if targets are still not met; avoid sulfonylureas, SGLT-2 inhibitors, GLP-1 RAs and DPP-4 inhibitors in pregnancy.
Type 2 diabetes + established ASCVD = add SGLT-2 inhibitor (proven CV death reduction). GLP-1 RA if BMI >35 or prefer weight loss!
Cat or kitten scratch plus tender regional lymphadenopathy equals cat-scratch disease; self-limiting in the immunocompetent, with azithromycin (per BNF dosing) optional to speed resolution and aspiration reserved for fluctuant nodes.
Skin Cancer
6 high-yield facts
Melanoma >1 mm Breslow - wide local excision with a 2 cm margin plus SLNB; completion lymphadenectomy no longer routine after MSLT-II; offer adjuvant pembrolizumab/nivolumab in resected stage IIB+ disease (NICE NG14/BAD).
Melanoma >2 mm Breslow = 2 cm excision margin + sentinel lymph node biopsy. Breslow thickness is the key prognostic factor.
Low-risk BCC equals surgical excision with a 4-5 mm margin; reserve Mohs surgery for high-risk or critical facial (H-zone) lesions.
Changing pigmented lesion + ABCDE features → 2-week-wait dermatology referral (NICE NG12); excisional biopsy first, never punch/shave a suspected melanoma; wide local excision and SLNB by Breslow depth (BAD 2022).
Lip SCC + Breslow 6 mm + PNI = high-risk; Mohs surgery + cross-sectional imaging + MDT; cemiplimab (NICE TA592) for advanced disease.
Invasive cutaneous SCC with high-risk features = wide local excision (≥6 mm margin) plus FNAC/biopsy of any palpable node and skin-MDT review; topical chemotherapy and cryotherapy are for in-situ disease only.
Pulmonary Embolism
6 high-yield facts
Provoked PE (surgery/trauma) = 3 months anticoagulation then stop; unprovoked = reassess for extended therapy.
PE likely (Wells >4) + postpartum = immediate CTPA imaging; start anticoagulation if delay.
High Wells score plus clinical DVT equals high-probability PE - start anticoagulation immediately before CTPA, delay increases mortality.
Wells score >4? Skip D-dimer, go straight to CTPA - high pre-test probability demands definitive imaging!
eGFR <30 + normal CXR → V/Q scan (no nephrotoxic contrast); CTPA first-line otherwise; V/Q high probability = treat PE.
Wells score >6 plus post-surgery equals high-probability PE - CTPA plus immediate anticoagulation without waiting, do not delay for D-dimer.
Calcium and Bone Disorders
6 high-yield facts
Primary hyperparathyroidism with osteoporosis (T-score ≤-2.5) = parathyroidectomy. Surgery is curative in 95%!
Paget's disease = high ALP + bone pain/deformity + skull/long bone involvement + mixed lytic/sclerotic X-ray changes. Treat with IV zoledronic acid 5mg (single dose, years of remission)!
Post-thyroidectomy hypocalcemia = check calcium/PTH within 24 hours. Symptomatic = IV calcium gluconate + start oral calcium + alfacalcidol. Permanent in 1-3%!
FHH = mild hypercalcaemia + family hx + LOW urinary Ca + CCCR <0.01. Benign, NO treatment, do NOT operate.
Symptomatic vitamin D deficiency = loading dose colecalciferol 20,000 units weekly x 7 weeks, then maintenance 800-2000 units daily. Check compliance and ongoing sun exposure!
Anxiety Disorders
6 high-yield facts
"OCD = Obsessions + Compulsions >1 hour daily!" 1st-line = CBT with ERP. High-dose SSRIs if medication needed.
"GAD = ≥6 months excessive worry + ≥3 symptoms!" 1st-line = CBT, NOT benzodiazepines. SSRIs/SNRIs if medication needed.
Social anxiety = fear of negative evaluation in social situations + avoidance + functional impairment. Most common anxiety disorder, onset in adolescence. CBT first-line, SSRI for moderate-severe.
"Panic disorder = Recurrent unexpected attacks + Fear of attacks + Avoidance!" CBT first-line, SSRIs second-line.
Agoraphobia = fear of situations where escape is difficult/help unavailable, leading to extensive avoidance. NOT fear of open spaces specifically. CBT with graded exposure first-line.
Blood-injection-injury phobia = unique vasovagal response (fainting). Applied tension technique + graded exposure = specific treatment. SSRIs not first-line for specific phobias. Exposure therapy is the gold standard.
Cardiology
6 high-yield facts
NICE NG196 - rate control with a beta-blocker is first-line for most AF; a dilated left atrium (>5 cm) predicts poor success with rhythm control.
HFrEF first-line = ACE inhibitor (or ARB) plus a heart-failure beta-blocker; layer on MRA, then sacubitril/valsartan and an SGLT2 inhibitor; use loop diuretics for symptoms only - start low and uptitrate.
Unstable pre-excited AF (WPW) - synchronised DC cardioversion immediately; avoid AV nodal blockers (adenosine, verapamil, diltiazem, digoxin) as they risk degeneration to ventricular fibrillation.
HFrEF NYHA II-IV symptomatic on optimal triple therapy → switch ACE inhibitor to sacubitril/valsartan after 36-hour washout (NICE NG106, NICE TA388, PARADIGM-HF).
High-risk NSTEMI = aspirin + ticagrelor + fondaparinux, plus early angiography within 72 hours. Switch to unfractionated heparin if angiography is planned within 24 hours or in renal impairment.
Takotsubo = postmenopausal woman + emotional stressor + apical ballooning + normal coronaries; troponin disproportionately low for the ECG/wall motion changes; treat supportively with conventional heart failure drugs until LV function recovers.
Early syphilis, including secondary, is a single dose of IM benzathine penicillin per BASHH 2015 - reserve the three-dose course for late syphilis, and always test for HIV.
DGI = triad of arthritis + pustular rash + recent STI symptoms; treat with IV then oral ceftriaxone plus azithromycin.
LGV proctitis in MSM = Chlamydia serovars L1-L3; doxycycline 100mg BD for 21 days (NOT 7 days) - prevent strictures/fistulae.
CSF VDRL positive = neurosyphilis confirmed; negative doesn't exclude it.
Infection Prevention
6 high-yield facts
Surgical prophylaxis = single dose IV cefuroxime at anaesthetic induction, not prolonged post-op courses - single dose as effective, reduces resistance.
Meningococcal prophylaxis = household/kissing contacts + index patient; ciprofloxacin 500mg single dose; within 24h.
UK (NICE) = no routine dental IE prophylaxis (even prosthetic valves); USA (AHA) = prophylaxis for high-risk; good oral hygiene most important.
HIV-positive source + hollow-bore needle + high viral load → start PEP within hours (target <1h, window <72h); 28 days triple ART; follow-up HIV testing at 6 and 12 weeks; document immunity means no HBIG.
Soap and water (not alcohol gel) for C. difficile and norovirus; TB needs a negative-pressure room with an FFP3 respirator; MRSA needs contact precautions with gloves and apron. Reference: NICE NG139 and epic3 national evidence-based guidelines.
≥2mm horizontal ST depression at peak exercise = high specificity for CAD; diagnostic accuracy improves when ST changes occur early and persist into recovery.
Cystic Fibrosis
6 high-yield facts
DIOS = CF + RIF mass + obstruction; oral Gastrografin first-line; ensure enzyme compliance; surgery only if medical failure.
CF exacerbation = dual IV antibiotics; Single oral agent risks resistance; CFTR modulators for baseline, not acute.
Neuropsychiatry
6 high-yield facts
FND = positive neurological signs of inconsistency (Hoover test), NOT a diagnosis of exclusion. Symptoms are genuine, not fabricated. Multidisciplinary treatment (physio + CBT).
PNES = normal EEG during event (video telemetry gold standard). Eyes closed, waxing-waning, prolonged, normal post-ictal prolactin. Not fabricated. Treat with CBT.
Charles Bonnet = visual hallucinations + visual impairment + full insight + no psychiatric illness. Reassure - not psychosis. Optimise remaining vision.
Dissociative amnesia = loss of personal identity/autobiographical memory after psychological trauma + normal neurology. Fugue = amnesia + purposeful travel. Not organic (preserved general knowledge).
BDD = preoccupation with imagined/slight appearance defect + mirror checking + avoidance + distress. OCD spectrum. Treat with CBT + high-dose SSRI. Cosmetic surgery does NOT help.
Genetic Lung Disease
6 high-yield facts
PCD = Ciliary dysfunction causing bronchiectasis + sinusitis + hearing loss; Only 50% have situs inversus (Kartagener); Low nasal NO (<77) diagnostic; High-speed microscopy; DNAH5/DNAI1 mutations; Daily airway clearance essential; Male infertility.
PiZZ AATD = basal pan-lobular emphysema + liver disease; IV AAT augmentation for FEV₁ 35-65% (RAPID trial, ERS 2017) but not routinely NHS-funded - refer to a specialist centre; smoking cessation essential.
TSC-LAM = diffuse thin-walled cysts in all zones + TSC features + angiomyolipomas and raised VEGF-D - treat with long-term sirolimus (MILES trial), avoid oestrogen, and offer pleurodesis for recurrent pneumothorax.
Kartagener = situs inversus + sinusitis + bronchiectasis + infertility; nasal NO <77; daily physio lifelong; no cure.
Young non-smoker + basal panacinar emphysema + cirrhosis + PAS-positive, diastase-resistant globules = A1AT deficiency (PiZZ); confirm by phenotype/genotype; smoking cessation is the single most important intervention; six-monthly USS and AFP for HCC surveillance.
Adult Congenital Heart Disease
6 high-yield facts
Anomalous left coronary from right sinus with interarterial course requires surgical correction - high SCD risk with exercise, not suitable for conservative management.
Adult coarctation requires intervention if gradient >20 mmHg - percutaneous stenting preferred, but lifelong surveillance essential for associated complications.
Ebstein = apical displacement of tricuspid valve + atrialised RV + severe TR; surgical repair indicated when symptomatic with RV dysfunction/cyanosis.
Fontan failure + FALD = chronic elevated CVP causing hepatic cirrhosis; manage with optimisation; may need heart or heart-liver transplant.
FALD = chronic venous congestion causing liver cirrhosis in Fontan patients; risk of HCC; may need transplant.
A ruptured sinus of Valsalva aneurysm presenting with sudden dyspnoea and a continuous murmur is a surgical emergency - urgent patch closure restores normal physiology with an excellent prognosis.
Portal Hypertension
6 high-yield facts
Acute portal vein thrombosis (<7 days, no peritonitis) = immediate anticoagulation with heparin - prevents thrombus propagation and achieves recanalization in 40-75%.
RAS = resistant HTN + flash oedema + ↑Cr post-ACEi + asymmetric kidneys; revascularise only specific indications; avoid ACEi if bilateral; medical Rx most.
In exams, “ACEi + big creatinine jump in a vasculopath = think bilateral renal artery stenosis”, especially when urinalysis is bland and BP previously resistant.
FMD = young woman + string of beads on angiography; treat with balloon angioplasty WITHOUT a stent - cure or improvement of hypertension in around 90%.
RAS = resistant HTN + bruit; Doppler/CT angiography; medical + stent if severe.
RAS = resistant HTN + flash oedema + creatinine rise on ACEi; medical management preferred; revascularise only for FMD or refractory bilateral disease (CORAL/ASTRAL).
Renal artery stenosis (resistant hypertension + flash pulmonary edema + asymmetric kidneys + epigastric bruit + creatinine rise with ACE inhibitor) = CTA/MRA to diagnose - revascularize if flash edema/declining function, fibromuscular dysplasia responds well to angioplasty.
Red Cell Disorders
6 high-yield facts
Schistocytes + thrombocytopenia + intravascular haemolysis with normal clotting = MAHA - suspect TTP and start plasma exchange urgently; never transfuse platelets routinely.
Haemolysis + spherocytes + DAT positive IgG = warm AIHA; prednisolone 1mg/kg; rituximab/splenectomy if refractory.
Hemoglobinuria plus absent CD55/CD59 equals PNH - eculizumab blocks complement, reduces hemolysis/thrombosis, vaccinate against meningococcus first (lifesaving precaution).
Acute hemolysis plus Heinz bodies plus oxidative drug equals G6PD deficiency - stop trigger immediately, supportive care, lifelong trigger avoidance (sulfonamides, antimalarials, fava beans).
Spherocytes + family history + splenomegaly = HS; splenectomy curative; vaccinate first; lifelong penicillin.
EGPA = Asthma + Eosinophilia (>1.5) + Vasculitis; Mononeuritis multiplex common; p-ANCA (MPO) 40%; High-dose steroids + cyclophosphamide if organ-threatening; Cardiac involvement (myocarditis) commonest cause death; 90% remission with treatment; Late-onset severe asthma clue.
Goodpasture = Haemoptysis + AKI + Anti-GBM; Urgent triple therapy; Prognosis depends on creatinine; Smoking trigger.
EGPA = Severe asthma + Eosinophilia + Peripheral neuropathy; p-ANCA 40-60%; Cardiac = death risk; High-dose steroids + cyclophosphamide.
Infectious Diseases
6 high-yield facts
In true penicillin anaphylaxis with moderate CAP, choose respiratory fluoroquinolone (levofloxacin or moxifloxacin) monotherapy and avoid all beta-lactams, including cephalosporins (BTS / NICE NG138).
IVDU endocarditis - empirical vancomycin plus gentamicin to cover MRSA; switch to flucloxacillin if MSSA confirmed on cultures.
HBeAg-positive immune-active HBV = high DNA plus raised ALT - treat with tenofovir or entecavir; immune-tolerant phase has high DNA but normal ALT.
Dengue warning signs - cautious IV crystalloids and close monitoring; avoid NSAIDs; platelet transfusion only for severe bleeding or platelets <10.
Severe falciparum malaria (including parasitaemia >2%) → IV artesunate (UKHSA/WHO; SEAQUAMAT/AQUAMAT) followed by full oral ACT; monitor for delayed post-artesunate haemolysis up to 4 weeks; uncomplicated falciparum = oral artemether-lumefantrine.
In at-risk patients with influenza presenting within 48 hours, give treatment-dose oseltamivir 75 mg twice daily for 5 days; avoid zanamivir in COPD/asthma, and offer annual influenza vaccination as primary prevention (NICE TA168).
Acute Leukemia
6 high-yield facts
Abnormal promyelocytes plus DIC equals APML - start ATRA immediately before cytogenetics, do not delay, reverses DIC and saves life.
AML with t(15;17)/PML-RARA = APL - start ATRA immediately and treat with ATRA plus arsenic trioxide (NICE TA526), not '7+3'; faggot cells and DIC are the clues.
ALL = commonest childhood cancer; lymphadenopathy prominent; CNS prophylaxis essential; children 90% cure vs adults 40%.
APL = t(15;17) + severe DIC; treat ATRA immediately before confirmation; 80-90% cure.
Blasts ≥20% + Auer rods = AML; DA "3+7" remission 70%; HSCT if high-risk.
ALL + t(9;22) = Ph+ ALL; chemo + imatinib; allo-HSCT in CR1 essential; CNS prophylaxis mandatory.
Inflammatory Disorders
5 high-yield facts
PMR = “pain and stiffness, not weakness” in the shoulders/hips of the elderly, and responds beautifully and quickly to modest doses of prednisolone.
PMR with headache + jaw claudication = GCA until proven otherwise - start prednisolone 40-60mg immediately (do NOT wait for biopsy), prevents permanent blindness, temporal artery biopsy within 7 days.
Potato nodes (BHL) alone = Stage I = watch and wait! Most resolve spontaneously. Only treat if symptomatic. Löfgren syndrome (erythema nodosum + arthralgia) has best prognosis of all.
Cardiac sarcoidosis = 5% clinical (25% autopsy); Leading cause death sarcoidosis; Heart block commonest; Patchy LGE basal/lateral on MRI; High-dose prednisolone 40-60mg; Pacemaker/ICD often needed; EF <35% = ICD; Sudden death risk.
Löfgren = BHL + Erythema nodosum + Ankle arthritis; Acute sarcoidosis; >90% spontaneous remission; NSAIDs first-line; Short steroids if severe; Rarely progresses; Young women, Northern Europeans.
High-dose anthracyclines = 3-monthly echo surveillance - early LVEF decline prompts cardioprotective therapy before irreversible damage!
Radiation + multi-valve disease = high CAD risk - always perform angiography before cardiac surgery.
Trastuzumab toxicity is REVERSIBLE - 3-monthly echo monitoring enables early detection and treatment pause.
Doxorubicin cumulative dose >300 mg/m² → dexrazoxane (iron chelator) reduces cardiotoxicity by 50-70%; combine with baseline and serial echo plus biomarkers, and start ACEi/β-blocker for any LVEF/strain decline (ESC Cardio-Oncology 2022, BSE/BCOS).
acute
5 high-yield facts
AFM = post-viral + child + asymmetric flaccid weakness + no sensory loss + anterior horn T2 MRI; poor recovery (irreversible); vs GBS (symmetric, recovers).
Vestibular neuronitis = acute vertigo + positive HIT + no hearing loss + no focal signs; sedatives <48 h then rehab; HINTS excludes stroke (NICE CKS).
ADEM = child + encephalopathy + multifocal white matter + deep grey matter + post-infection; IV methylpred; monophasic 60-80% recovery; vs MS (relapsing, periventricular).
HINTS - normal HIT + vertical/direction-changing nystagmus + positive skew = central stroke; one central feature triggers urgent posterior fossa imaging; more sensitive than early MRI in the first 48 hours (NICE NG128).
Drug-Induced Kidney Disease
5 high-yield facts
NSF = Gd + eGFR <30; no treatment; prevention = avoid Gd or use macrocyclic + dialysis.
AIN = drug-induced AKI + triad (10%) + WBC casts + eosinophiluria; STOP drug (recovery 60-70%); steroids if severe/no improvement 7d.
APN = oral sodium phosphate prep + subacute AKI + biopsy calcium phosphate (von Kossa+); no treatment; irreversible 20-50%; use PEG instead.
CIN prophylaxis = IV isotonic saline 12 h pre + 12 h post + withhold metformin 48 h + continue ACEi; NAC and bicarbonate not proven (PRESERVE; RCR 2023).
DRESS (RegiSCAR criteria: acute rash, fever, lymphadenopathy, eosinophilia or atypical lymphocytes, and internal organ involvement, typically 2-8 weeks after a culprit drug such as carbamazepine) is managed by immediate withdrawal of the offending drug plus high-dose systemic corticosteroids (prednisolone 1-2 mg/kg/day) with a slow taper; monitor for hepatitis and HHV-6 reactivation.
A simple maculopapular drug rash on co-trimoxazole in HIV should prompt stopping the drug and switching to an alternative such as dapsone or atovaquone; watch for SJS/TEN and DRESS as red-flag severe reactions.
In SJS/TEN the priority is to stop the culprit drug immediately and transfer to a burns unit/ICU for supportive care; allopurinol and anticonvulsants are common triggers, and a positive Nikolsky sign with extensive detachment defines TEN.
SJS/TEN - STOP the drug immediately, transfer to a burns unit/HDU, urgent ophthalmology; allopurinol and aromatic anticonvulsants are top UK culprits; document a lifelong drug ban with cross-reactivity warning on the patient record.
Plasma Cell Disorders
5 high-yield facts
AL amyloidosis = periorbital purpura + macroglossia + restrictive CMP + nephrotic; Congo red birefringence; bortezomib ± ASCT; cardiac worst.
MGUS = "Paraprotein <30, Plasma cells <10%, NO CRAB, Watch and wait!" 1% per year transforms to myeloma.
CRAB features plus a paraprotein and >10% clonal plasma cells define symptomatic myeloma - UK first-line is a bortezomib-based regimen (eg Dara-VTd, NICE TA897) with autologous stem cell transplant in fit, transplant-eligible patients.
MGUS = M-protein <30 + plasma cells <10% + no CRAB; 1%/year progression; observe 6-12 monthly; 90% never progress.
Bartter syndrome (hypokalemic metabolic alkalosis + normotension + high urine K/Cl + high renin/aldosterone + not on diuretics) = loop of Henle defect - mimics loop diuretics, NSAIDs + K supplementation, vs Gitelman (thiazide-like, hypocalciuria).
Ethylene glycol = high osmolar gap initially, then high anion gap + oxalate crystals; fomepizole preferred over ethanol.
Methanol → formate → metabolic acidosis + blindness; give fomepizole 15 mg/kg IV plus haemodialysis if methanol >500 mg/L or severe acidosis; folinic acid accelerates formate clearance; always discuss with NPIS via TOXBASE.
Prescribing
5 high-yield facts
In any older adult on a cholinesterase inhibitor with new confusion or falls, screen the medication list for anticholinergic burden and deprescribe before adding new drugs.
Elderly + CKD + aminoglycoside = extend dosing interval + mandatory TDM. Age-related GFR decline is the most important pharmacokinetic change in elderly. Narrow therapeutic index drugs need dose adjustment.
STOPP/START = evidence-based tool for medication review in elderly. NSAIDs in CKD = highest immediate risk (AKI, GI bleed). Review all medications but prioritise by harm potential.
Prescribing cascade = treating side effects with more drugs. Always ask "could this new symptom be a drug side effect?" before adding new medication. Review and stop the offending drug first.
Deprescribe when time to benefit > life expectancy. Statins for primary prevention = first to stop in limited prognosis. Use STOPPFrail criteria. Also check renal dosing (metformin + eGFR 18 = stop).
Anaemia
5 high-yield facts
Ferritin <15 = IDA; GI endoscopy if >50/male/postmenopausal; oral iron 3m; vs thal (ferritin normal).
Sideroblastic anaemia = ring sideroblasts + iron overload; pyridoxine trial for hereditary; treat underlying cause for acquired.
IDA labs = “LOW ferritin, LOW saturation, HIGH transferrin”; ACD = “HIGH ferritin, LOW transferrin” - ferritin is the key discriminating marker in exam questions.
In macrocytic anaemia, “B12 = Brain + Back cord” - neurological signs point strongly to B12 deficiency rather than folate lack.
HBeAg-positive chronic hepatitis B with high viral load, raised ALT, and fibrosis needs first-line tenofovir or entecavir (high genetic barrier) per NICE CG165 and EASL-aligned UK practice - not lamivudine, interferon, or biopsy.
Chronic hep B with HBV DNA >2,000 + raised ALT + fibrosis ≥F2 = start tenofovir/entecavir indefinitely.
Chronic HBV treat if DNA >2000 + ↑ALT + fibrosis ≥F2; tenofovir or entecavir (indefinite); 6-monthly HCC surveillance.
Chronic HCV = treat ALL with DAAs; sofosbuvir/velpatasvir 12w or glecaprevir/pibrentasvir 8w; >95% cure; SVR12 = cure.
Chronic hepatitis C = pan-genotypic DAA combination (e.g. sofosbuvir/velpatasvir) for 8-12 weeks with >95% cure; confirm SVR12 and check drug interactions.
Class III = K⁺ channel blockers (prolong QT); amiodarone most effective but multiple toxicities; correct K⁺ >4.5 before starting.
ARBs = no bradykinin accumulation → cough <2%; equivalent efficacy to ACEi; switch if cough; never combine.
Haemolytic Anaemia
5 high-yield facts
G6PD = "Mediterranean male + DRUGS + Bite cells + Dark urine!" AVOID primaquine, dapsone, sulfonamides!
HS triad = “Hereditary, Haemolysis, (pigment) Gallstones” with spherocytes on film and splenomegaly; splenectomy may reduce haemolysis in severe cases.
Warm AIHA = DAT IgG + spherocytes + splenomegaly; prednisolone 1mg/kg; rituximab/splenectomy if refractory.
PCH = Donath-Landsteiner IgG + intravascular haemolysis + children post-viral + DAT C3d only; self-limiting 1-2w; steroids ineffective.
“Warm = IgG = spleen” - IgG-mediated extravascular haemolysis with positive DAT and spherocytes defines warm AIHA, distinct from cold IgM-mediated disease.
Syncope + delta waves + family history sudden death = HIGH RISK WPW - urgent EP study + ablation!
POTS = HR rise ≥30 bpm within 10 minutes of standing + orthostatic symptoms + no drop in BP in a young woman; first-line is fluid, salt, compression and graded exercise reconditioning; add ivabradine, low-dose β-blocker, midodrine or fludrocortisone only if first-line measures fail.
Syncope + structural heart disease (MI, low LVEF)? Think VT - Holter/EP study to document, ICD if confirmed!
Unexplained syncope + bifascicular block + previous MI → high risk for CHB/VT; EPS guides pacemaker/ICD decision.
Respiratory Infections
5 high-yield facts
Legionella = pneumonia + diarrhoea + hyponatremia; beta-lactams don't work - use macrolide or fluoroquinolone.
empyema = pH <7.2, glucose <2.2 mmol/L, or frank pus/organisms → chest drain + IV antibiotics 3-6 weeks; alteplase + DNase if loculated (MIST2); VATS if refractory (BTS pleural infection guideline 2023).
Influenza antivirals (oseltamivir) = Neuraminidase inhibitor; Reduces symptoms ~1 day, reduces complications 30-50% high-risk; Start <48h onset (75mg BD 5 days); High-risk: age ≥65, diabetes, chronic disease, pregnancy, immunosuppressed; Treat even >48h if severe; Prophylaxis close contacts.
Long-term PPI on healed oesophagitis → step-down to famotidine or on-demand PPI. Annual review. Ranitidine withdrawn UK 2019. Continue indefinitely only for Barrett's/severe oesophagitis. Reference: NICE CG184; BSG GORD 2019.
IPT = depression treatment targeting interpersonal difficulties (grief, role disputes, role transitions, interpersonal deficits). 16 sessions. NICE-recommended alternative to CBT for depression.
CBT = first-line for depression and anxiety disorders (NICE). Targets negative thoughts and behaviours. 12-20 sessions. Also effective for OCD (with ERP), PTSD (trauma-focused), and bulimia.
Anemia
5 high-yield facts
Microcytic + ferritin <15 = IDA; oral iron + urgent GI investigation mandatory in men (exclude malignancy).
Macrocytosis + hypersegmented neutrophils + neuropathy = B12 deficiency; IM hydroxocobalamin lifelong; never folate alone first.
Microcytic + normal ferritin + low TIBC = ACD; treat inflammation; avoid iron (hepcidin blocks utilisation).
Megaloblastic anaemia → check MMA/homocysteine if borderline; never folate alone before B12 (precipitates SACD).
Drug-Induced Nephrotoxicity
5 high-yield facts
Aminoglycoside AKI = high trough + non-oliguric; stop drug immediately for recovery.
Halve amphotericin nephrotoxicity with 1 L 0.9% saline IV pre-dose; replace K⁺/Mg²⁺ aggressively; switch to liposomal formulation if creatinine rises or risk is high.
Triple whammy - NSAID + ACE inhibitor + diuretic causes AKI via impaired renal autoregulation; avoid combination, especially in elderly/dehydration.
Tocilizumab (anti-IL-6R) - monitor FBC, LFTs and lipids per BSR/BHPR; think neutropenia, hepatotoxicity and hyperlipidaemia. Stop if ALT >5× ULN.
Abatacept = blocks T-cell co-stimulation - think CD80/CD86, different from anti-TNF.
Thrombotic Disorders
5 high-yield facts
Recurrent unprovoked VTE (with or without prothrombin G20210A) warrants lifelong anticoagulation - DOAC first-line per NICE NG158; avoid oestrogen-containing contraception.
Recurrent thrombosis + pregnancy loss + persistent aPL = APS; lifelong warfarin; aspirin + LMWH in pregnancy.
Schistocytes plus thrombocytopenia plus neurological symptoms equals TTP - urgent plasma exchange saves life, never give platelets (worsens thrombosis).
Skin necrosis on day 3-5 of warfarin = protein C deficiency. Stop warfarin, give IV vitamin K + FFP + therapeutic LMWH; always bridge when restarting warfarin, or use a DOAC (BSH 2018, BNF).
Heterozygous factor V Leiden with a single provoked VTE = 3-6 months anticoagulation (not lifelong); avoid the COCP and give prophylactic LMWH in future pregnancies.
Platelet Disorders
5 high-yield facts
Isolated thrombocytopenia plus mucocutaneous bleeding plus increased megakaryocytes equals ITP - prednisolone 1 mg/kg first-line, IVIG if severe bleeding.
Isolated thrombocytopenia with normal film equals ITP - but always exclude HIV/hepatitis C first.
Glanzmann = normal plt count + absent aggregation ALL agonists EXCEPT ristocetin; tranexamic acid + rFVIIa; GP IIb/IIIa = fibrinogen receptor.
BSS = GP Ib deficiency; giant platelets + absent RIPA + normal ADP/collagen; tranexamic acid; DDAVP ineffective.
Plt drop >50% + thrombosis on heparin days 5-10 = HIT; stop heparin, argatroban; never platelets.
Electrolytes
5 high-yield facts
Severe symptomatic hyponatraemia = 150 mL 3% saline bolus (repeat up to 3×), with a cap of 10 mmol/L rise in 24 hours to avoid osmotic demyelination - fluid restriction is for asymptomatic SIADH only.
Symptomatic severe hyponatraemia (confusion, seizures, reduced GCS) is treated with IV 3% hypertonic saline whatever the cause, capping the sodium rise at under 10 mmol/L in 24 hours to prevent osmotic demyelination (Society for Endocrinology acute hyponatraemia guidance; European hyponatraemia clinical practice guideline 2014).
CSW - hyponatremia + HYPOVOLEMIA (postural drop, negative balance) + high urine Na post-SAH, IV saline + oral NaCl (NOT fluid restriction - opposite of SIADH), correct slowly max 10/24h.
Severe hypomagnesaemia = tetany + torsades + refractory hypoK/hypoCa; IV MgSO₄ 2 g emergency dose; correct Mg BEFORE Ca; alcohol and PPI common UK causes (MHRA 2012).
Drug Allergy
5 high-yield facts
Sulfonamide ANTIBIOTIC allergy ≠ cross-reactivity with sulfonylureas/thiazides/furosemide/celecoxib. Different structures, different mechanisms, SAFE to use!
Carbapenems have <1% cross-reactivity with penicillin - safe even in confirmed anaphylaxis.
Desensitization induces temporary tolerance through graded exposure - NOT permanent cure; must continue drug without interruption.
90% "penicillin allergy" not true; non-severe rash → cephalosporins safe; anaphylaxis → avoid or specialist desensitisation; allergy testing de-labels 90-95%.
Raised Intracranial Pressure
5 high-yield facts
Young obese woman plus papilledema plus high opening pressure equals IIH - acetazolamide plus weight loss prevent blindness, monitor visual fields closely.
IIH (obese woman + papilloedema + raised LP opening pressure + normal imaging) → sustained weight loss 5-10% is most important; acetazolamide as adjunct; serial visual fields essential (NICE CKS; IIHTT).
IIH = obese young woman + papilloedema + normal MRI + LP >25cmH₂O; acetazolamide + weight loss; surgery if vision worsening.
Renal Transplantation
5 high-yield facts
Declining graft + intranuclear inclusions + BK viraemia = reduce immunosuppression - don't treat as rejection.
Acute transplant rejection (rising creatinine 3 weeks post-transplant + tender graft + therapeutic drug levels + no obstruction) = renal biopsy GOLD STANDARD - differentiate T-cell (steroids) vs antibody-mediated (plasma exchange + IVIG), early treatment crucial for graft survival.
Post-transplant AKI plus new DSA plus C4d deposition equals antibody-mediated rejection - plasmapheresis plus IVIG remove antibodies, steroids alone insufficient.
ACR = tubulitis + lymphocytes on biopsy; pulse methylpred ×3d; ATG if resistant.
Rapid creatinine rise + tubulitis = acute cellular rejection - pulse steroids immediately to save the graft.
Poisoning and Overdose
5 high-yield facts
Flumazenil = seizure risk in chronic users/co-ingestion; supportive care safer for most benzodiazepine OD.
Plot level on nomogram; NAC <8h = near 100% protection; extend if ALT rising; King's criteria for transplant.
Salicylate overdose = respiratory alkalosis (early/adults) PLUS metabolic acidosis (late/severe); mixed acid-base on ABG.
CCB OD = IV calcium first-line (overcomes competitive blockade) + HIET if refractory; prolonged monitoring (amlodipine t½ 30-50h).
Transfusion Reactions
5 high-yield facts
TACO = dyspnoea + hypertension + ↑JVP + ↑BNP within 6 h of transfusion; stop transfusion and give IV furosemide; vs TRALI (hypotension, normal BNP, no diuretics). Commonest UK transfusion mortality (SHOT) - report it.
Shock + PE = lyse immediately! Do not wait for formal echo or more tests if BP is dropping. Right heart failure from massive PE needs thrombolysis NOW - it is the only thing that can save them.
DOACs for PE: high dose first, then drop - both rivaroxaban and apixaban start with double-dose loading phases, then reduce. And always STOP the pill - it caused the clot!
D-dimer rules OUT PE when negative (high sensitivity), but never rules IN (poor specificity). In post-op patients with high Wells score, go straight to CTPA - don't let a positive D-dimer delay definitive imaging.
PESI = 11 variables predicting 30-day mortality; Low risk (Class I-II) = outpatient safe (<3% mortality); Simplified sPESI easier (6 variables); Age, vitals, comorbidities key; Outpatient requires social support + no bleeding risk; High risk needs admission.
Gastroenterology & Hepatology
4 high-yield facts
Exocrine pancreatic insufficiency (low faecal elastase) with steatorrhoea is treated with titrated PERT taken with food per NICE NG104, adding a PPI if the response is suboptimal.
Crohn's maintenance (NICE NG129) - azathioprine first-line (check TPMT); mesalazine ineffective; long-term steroids not recommended; escalate to methotrexate or anti-TNF biologics if thiopurines fail.
IgA-tTG plus total IgA is first-line for coeliac disease (NICE NG20); keep the patient on gluten during testing; duodenal biopsy confirms diagnosis in adults.
Severe alcoholic hepatitis (Maddrey ≥32) → prednisolone 40 mg/day for 28 days (NICE CG100; STOPAH); reassess with Lille at day 7 and stop if >0.45; pentoxifylline is no longer recommended; early transplant only for highly selected non-responders.
NMOSD (optic neuritis + LETM + AQP4 antibody) = rituximab for relapse prevention (NOT MS drugs - they worsen NMOSD); each attack causes permanent damage.
ADEM (post-infection encephalopathy + multifocal demyelination + grey matter involvement in child) = high-dose IV methylprednisolone 20-30 mg/kg × 3-5 days; monophasic, good prognosis.
RRMS diagnosis = start moderate-efficacy DMT (interferon/glatiramer) immediately; escalate to high-efficacy if breakthrough disease.
Painful unilateral visual loss with RAPD and central scotoma = optic neuritis → IV methylprednisolone 1 g daily for 3 days (ONTT trial); avoid oral prednisolone alone because it increases recurrence; investigate for MS with MRI brain/spine and CSF oligoclonal bands.
Vestibular Disorders
4 high-yield facts
Vestibular migraine (episodic vertigo 5 min-72 hours + migraine features + migraine history + no hearing loss) = propranolol or topiramate prophylaxis if frequent; triptans for acute attacks.
NTM-MAC lung disease in bronchiectasis = rifampicin + ethambutol + clarithromycin for ≥12 months after culture conversion - not standard TB therapy.
Infective Endocarditis
4 high-yield facts
Early PVE + abscess/dehiscence/persistent sepsis → urgent surgery + ≥6wk IV antibiotics; Staph aureus most common.
Duke criteria - 2 major OR 1 major + 3 minor = definite IE. Blood cultures + vegetation = diagnosis confirmed!
Prosthetic valve IE + AF + no neuro complications = CONTINUE warfarin - stopping increases stroke risk more than bleeding risk.
Prosthetic valve IE + abscess + new AV block? Urgent surgery within 24-48 hours!
Pancreatic Neuroendocrine Tumors
4 high-yield facts
Whipple's triad with raised insulin and C-peptide and a negative sulphonylurea screen plus a localised pancreatic lesion = insulinoma - surgical resection is curative; diazoxide bridges to theatre (ENETS 2016, UKINETS/Society for Endocrinology UK).
Face = mild steroid only; clobetasol is very potent, never for facial use.
Personality Disorders
4 high-yield facts
BPD treatment = DBT or MBT (NICE-recommended). No medication for core BPD symptoms. DBT: 4 components (individual, skills group, phone coaching, therapist team).
ASPD = conduct disorder before 15 + persistent violation of others' rights + lack of remorse. Cluster B. More common in males. No effective pharmacological treatment.
BPD = unstable relationships + abandonment fear + mood lability over hours + recurrent self-harm. Per NICE CG78, first-line is DBT/MBT, not medication. Bipolar = sustained episodes (days-weeks).
Cluster A = odd/eccentric ("Mad"), Cluster B = dramatic/emotional ("Bad"), Cluster C = anxious/fearful ("Sad"). Mnemonic: A-B-C = Mad-Bad-Sad.
IBS = Rome IV + red flags excluded + normal investigations; first-line per NICE CG61 is dietary and lifestyle advice plus soluble fibre, then a supervised low-FODMAP trial; antispasmodics and low-dose tricyclics are second-line.
IBS = pain + altered bowel habit + no red flags + calprotectin <50; low-FODMAP + antispasmodic first-line; amitriptyline or CBT second-line (NICE CG61; BSG 2021).
AIP acute attack (severe abdominal pain + neuropsychiatric symptoms + dark urine + elevated PBG) = IV hemin plus high-dose glucose - specific therapy resolves attack 24-48 hours.
IBS diagnosis requires Rome IV criteria + normal basic investigations - start low FODMAP diet and symptom-directed therapy, avoid over-investigation.
Investigations
4 high-yield facts
CAC >400 = high-risk regardless of other scores - intensive preventive therapy (high-intensity statin, individualized aspirin decision after bleeding risk assessment, strict BP/glucose control). CAC is atherosclerotic burden score, not stenosis assessment.
Cardiac sarcoid = patchy epicardial/mid-wall LGE in basal/lateral walls, sparing subendocardium. Think sarcoid when non-ischaemic cardiomyopathy has patchy enhancement NOT following coronary territories.
LAD + normal QRS duration = think LAFB. LBBB would widen QRS ≥120 ms.
LBBB makes ECG/nuclear stress tests unreliable (false-positive septal defects); stress cardiac MRI best functional test - unaffected by conduction abnormalities.
Toxicology
4 high-yield facts
DILI = stop drug immediately; Hy's Law (ALT >3× + bili >2×) = 10% mortality if continued; NAC for paracetamol; RUCAM score.
In thrombophilia questions, “APC resistance + FVL = factor V that won’t switch off” - resistance to APC cleavage, not deficiency of protein C itself, is the mechanism.
Protein C deficiency = WISN day 3-8 if warfarin without heparin; always LMWH overlap ≥5d; DOACs safer.
Heparin resistance plus a strong family history of young VTE points to antithrombin deficiency - give antithrombin concentrate with LMWH/fondaparinux, then lifelong anticoagulation (BSH Thrombophilia Testing and Management 2010; BSH VTE in Pregnancy 2015).
DITP = severe plt <20 + temporal drug relationship; stop drug → recovery 1-2w; quinine commonest; IVIg if life-threatening.
In exam scenarios, “low platelets, normal film, otherwise well = ITP”, and the initial answer is almost always “start steroids (± IVIG if severe)”, not platelet transfusion alone.
HIT-2 = IgG anti-PF4/heparin + platelet drop ≥50% + paradoxical thrombosis; stop all heparin, start argatroban or fondaparinux, avoid platelet transfusion, and only start warfarin once platelets >150.
ITP = isolated platelets <100×10⁹/L with normal Hb/WCC; observe if >30 and no bleeding; prednisolone 1 mg/kg first-line when <30 or bleeding per BSH 2023; IVIg reserved for emergencies.
Rheumatoid Arthritis
4 high-yield facts
RA EAMs = nodules + sicca + ILD - think systemic disease, not just joints.
RA classification = ≥6 points out of 10 - think joint involvement + serology + acute phase + duration.
RA first-line = methotrexate - think gold standard, unless contraindicated use sulfasalazine/leflunomide.
Ethics and Law
4 high-yield facts
Double effect = foreseeable harm permitted if intention is good, harm is not the means, and action is proportionate. Underpins all palliative symptom management.
DNACPR is a clinical decision - families are consulted but cannot demand futile CPR. DNACPR applies ONLY to CPR; all other treatment continues. Tracey judgement mandates consultation.
Continuous deep sedation ≠ euthanasia. Requires refractory symptoms + imminent death + specialist input + consent/best interests + proportionate dosing. Supported by double effect doctrine.
MCA 2005 best interests framework governs treatment decisions for incapacitated patients. Withdrawing = withholding in law. Court only needed for CANH in prolonged unconsciousness.
Secondary Glomerular Disease
4 high-yield facts
Myeloma cast nephropathy = FLC-driven AKI; urgent IV fluids + bortezomib-based chemotherapy per BSH/UK Myeloma Forum; avoid loop diuretics and contrast.
MCD = foot process effacement + normal LM; pred 60mg/m²/d; 95% remission; relapses 50-70%.
Autoimmune Blistering
4 high-yield facts
Elderly + tense blisters + negative Nikolsky + linear IgG/C3 on direct IF = bullous pemphigoid; potent topical clobetasol is first-line per BAD guideline.
Tense blisters with linear IgG/C3 at the basement membrane in an elderly patient = bullous pemphigoid; first-line is a potent topical or oral corticosteroid (around 0.5 mg/kg/day prednisolone for generalised disease) per BAD guidance.
Pemphigus vulgaris = flaccid blisters + oral erosions + positive Nikolsky sign + anti-desmoglein 3 antibodies; first-line treatment is high-dose oral prednisolone (1-2 mg/kg/day) plus an early steroid-sparing agent, with rituximab as a first-line biologic for moderate-to-severe or refractory disease (BAD pemphigus vulgaris guideline).
Flaccid blisters + mucosal erosions + positive Nikolsky + intercellular 'fishnet' IgG = pemphigus vulgaris - treat with high-dose prednisolone plus rituximab or another steroid-sparing agent (BAD 2017 pemphigus guideline).
Glucose Disorders
4 high-yield facts
Ketoacidosis + normal glucose + SGLT2 inhibitor + recent fasting/surgery/illness = euglycaemic DKA - stop the SGLT2i, treat per JBDS DKA protocol with insulin AND dextrose; stop SGLT2i 3-4 days pre-elective surgery (MHRA DSU 2016/2020; JBDS DKA guideline).
Insulinoma (Whipple triad + high insulin + HIGH C-peptide + suppressed ketones during hypoglycemia + negative sulfonylurea) = endogenous hyperinsulinism - surgical resection curative, distinguish from exogenous insulin (LOW C-peptide) and sulfonylurea (positive screen).
Suspected insulinoma (Whipple triad + low glucose + elevated insulin/C-peptide) = supervised 72-hour fast - confirms inappropriate insulin secretion, then endoscopic ultrasound for localization, surgical resection curative 90%.
Hypoglycemia with high insulin + LOW C-peptide + negative sulfonylurea = exogenous insulin administration (factitious) - C-peptide suppressed distinguishes from insulinoma (high C-peptide), common in healthcare workers.
Renal Pharmacology
4 high-yield facts
Beta-lactams accumulate in AKI - always adjust dose to prevent neurotoxicity.
Loop diuretic plus aminoglycoside = synergistic ototoxicity (10-20 times); avoid the combination; hearing loss is often permanent (BNF; MHRA Drug Safety Update).
Hereditary pancreatitis (PRSS1 mutation + recurrent pancreatitis + family history) = annual MRI/EUS surveillance from age 40 - 40-55% cancer risk, early detection critical.
Chronic pancreatitis + steatorrhoea + low faecal elastase = PERT with every meal.
Renal Medicine
4 high-yield facts
CKD anaemia with ferritin <200 µg/L or TSAT <20% - give IV iron first (NICE NG8, TREAT, PIVOTAL); only add an ESA if Hb stays <100 g/L once iron-replete, targeting Hb 100-120 g/L.
In chronic hypernatraemia, cap sodium correction at 10-12 mmol/L per 24 hours and replace the free water deficit slowly with frequent monitoring.
Distal (type 1) RTA - hypokalaemic hyperchloraemic acidosis with urine pH >5.5 and calcium phosphate stones; proximal (type 2) wastes bicarbonate ± Fanconi; type 4 is hyperkalaemic; treat with bicarbonate or potassium citrate.
ECG changes in hyperkalaemia - calcium gluconate first for membrane stabilisation, then insulin-dextrose; dialysis for definitive removal in oliguric AKI.
Diuretic-resistant CRS-1 = furosemide infusion + metolazone; ultrafiltration if refractory; avoid ACEi if hypotensive.
CRS-1 = venous congestion primary; aggressive diuresis; continue ACEi; Cr rise OK if improving.
Cardiorenal syndrome Type 1 (acute HF decompensation + worsening renal function + diuretic resistance: high-dose IV furosemide but low urine Na + refractory fluid overload) = ultrafiltration - extracorporeal fluid removal, improves symptoms without worsening GFR, 25-30% mortality.
Non-Cancer Palliative Care
4 high-yield facts
Advanced dementia care = best interests discussion with family, individualised decisions, goals-of-care approach. Use MCA 2005 framework for those lacking capacity.
Refractory breathlessness in COPD = low-dose oral morphine (1-2 mg) + hand-held fan + breathing techniques. Benzodiazepines are second-line only.
Palliative care in heart failure = parallel with active treatment. Low-dose opioids for refractory breathlessness. Discuss ICD deactivation. Trajectory is unpredictable.
Conservative kidney management = active symptom control + anaemia management + ACP, without dialysis. In frail elderly with comorbidities, dialysis may offer no survival advantage.
Drug-Induced Hepatotoxicity
4 high-yield facts
Statin hepatotoxicity = ALT >3× ULN = stop drug; LFTs normalize in weeks, consider lower-dose rechallenge.
Erythromycin = cholestatic hepatitis (ALP > ALT); 1-3wk onset; usually reversible; avoid macrolide class if previous reaction.
TB drug hepatotoxicity (ALT >5× ULN or symptomatic) = stop ALL drugs immediately; sequential rechallenge when normalized.
Diabetes Complications
4 high-yield facts
DKA priorities per JBDS 2023 = Fluids, Insulin, Potassium - IV 0.9% saline first; fixed-rate insulin 0.1 units/kg/hour; replace K⁺ once <5.5 mmol/L; avoid routine bicarbonate; add 10% dextrose when glucose <14 mmol/L.
HHS = glucose >30 + osmolality >320 + no ketoacidosis; IV saline gradual (slower than DKA); insulin 0.05u/kg/h (half DKA); LMWH mandatory; mortality 15-20%.
Diabetic kidney disease = start SGLT-2 inhibitor (40% CKD progression reduction). Add ACE-I/ARB for BP control. Target BP <130/80 mmHg!
HHS - glucose 55 (>30), osm 385 (>320), dehydration 8-12L, Na 155, ketones 0.4 (vs DKA >3), pH 7.38 normal (vs DKA <7.3), GCS 11, IV saline 1 L/hour (PRIORITY) THEN insulin 0.05 units/kg/hour AFTER 1-2L (lower than DKA), K replacement if <5.5, dextrose when <15, Na hourly (avoid >10/24h), LMWH, mortality 10-20%.
FAP (>100 adenomas + APC mutation) = prophylactic colectomy late teens/20s - 100% cancer risk by age 40 if colon retained.
Breast Cancer
3 high-yield facts
ER-positive = endocrine therapy backbone! HER2 status determines trastuzumab. Chemotherapy reserved for high-risk disease. Node status and grade crucial for risk stratification.
TNBC requires chemotherapy as the backbone of treatment - endocrine therapy and anti-HER2 agents are ineffective. Neoadjuvant anthracycline-taxane is standard.
HER2-positive breast cancer requires trastuzumab for 12 months - monitor cardiac function with regular echocardiography every 3 months during treatment.
Eating Disorders
3 high-yield facts
Bulimia = Binge + Purge + Normal weight. Anorexia = low BMI. BED = binge WITHOUT purge.
Refeeding syndrome hallmark = hypophosphataemia after refeeding a malnourished patient. Prevent: start low, go slow (10-20 kcal/kg/day) + prophylactic thiamine + monitor electrolytes daily.
"Refeeding = Start LOW calories, Go SLOW, Replace phosphate/K+/Mg²+!" Thiamine first, then feed cautiously. Monitor ECG + electrolytes daily.
Respiratory Emergencies
3 high-yield facts
Massive haemoptysis (>300 mL/24h) = resuscitate + urgent bronchial artery embolization; surgery if BAE fails.
HAPE = Rapid ascent >2,500m + Pink frothy sputum; Immediate descent essential; Oxygen + nifedipine; DO NOT use diuretics; Prevention: gradual ascent, acetazolamide.
Papulosquamous
3 high-yield facts
Pityriasis rosea - herald patch then a 'Christmas tree' truncal rash; self-limiting over 6-12 weeks; reassurance and symptomatic care only; exclude tinea and secondary syphilis (palms/soles).
Sudden teardrop papules + recent streptococcal pharyngitis + raised ASO = guttate psoriasis - emollients ± vitamin D analogue first-line per NICE CG153/BAD, narrowband UVB if persistent; avoid oral steroids and don't re-treat cleared streptococcal infection.
Cutaneous lichen planus (6 Ps) = potent topical corticosteroid (clobetasol) first-line; it is not an infection, so antibiotics and antifungals are wrong.
Pharmacovigilance
3 high-yield facts
The Yellow Card scheme captures suspected ADRs - reporting is essential for Black Triangle (▼) medicines, reactions in pregnancy, and any unexpected adverse effects; any healthcare professional or patient can report to the MHRA.
Yellow Card - report all suspected ADRs to black triangle drugs; serious ADRs to established drugs; anyone can report.
Black triangle (▼) drugs - report ALL suspected adverse reactions via Yellow Card; intensive monitoring detects rare serious reactions in first 5 years.
CYP2C19 poor metabolizers (*2/*2) = clopidogrel ineffective. Switch to ticagrelor or prasugrel - both bypass CYP2C19 requirement!
Recurrent events on aspirin - add clopidogrel temporarily, do not just increase aspirin dose.
Drug-Induced Liver Injury
3 high-yield facts
R ratio - cholestatic <2, mixed 2-5, hepatocellular >5; co-amoxiclav is the UK-leading cause of cholestatic DILI; stop the drug, never rechallenge, and Yellow Card it.
Hepatocellular = ALT >> ALP (ratio ≥5); paracetamol = NAPQI toxicity; NAC <8h; Hy's Law = 10% mortality.
Drug cholestatic injury = ALP >2×, ratio <2; co-amoxiclav commonest (clavulanate); stop drug, never rechallenge; resolves 2-6m.
NPH = gait (first) + incontinence + dementia + ventriculomegaly + normal pressure; tap test predicts shunt response; VP shunt 50-80% improve; reversible dementia.
Mild-moderate AD (MMSE 10-26) → start an AChE-I (donepezil first-line). Severe AD (MMSE <10) or AChE-I intolerance → memantine. Always exclude reversible causes before starting therapy.
APS pregnancy = aspirin pre-conception + LMWH from positive test to 6wk postpartum; 70-80% live birth treated vs 10% untreated; continue hydroxychloroquine.
Myeloma AKI (high free light chains + Bence Jones protein) = aggressive IV fluids + bortezomib - rapid light chain reduction saves kidneys.
Myeloma cord compression (leg weakness + sensory level + bladder dysfunction) needs immediate high-dose dexamethasone plus urgent radiotherapy within 24 hours to preserve neurological function.
Myeloma hypercalcemia >3.5 = IV fluids THEN zoledronic acid 4mg - bisphosphonates inhibit osteoclasts.
Self-Harm and Suicide
3 high-yield facts
Middle-aged, divorced, unemployed men carry the highest completed-suicide risk; female sex is protective, not predictive.
All self-harm presentations need a psychosocial assessment before discharge (NICE NG225). Assess intent, current risk, mental state, and protective factors. Never dismiss as "attention-seeking."
Previous attempt = strongest single risk factor for completed suicide. Male sex, older age, social isolation, mental illness, and organised plan all increase risk. Gender paradox: females attempt more, males complete more.
Bone Disorders
3 high-yield facts
Paget disease (elevated ALP + cotton wool skull + bone deformity + deafness) = IV zoledronate 5mg single infusion - normalizes bone turnover 90%, sustained effect 2-5 years, deafness often irreversible.
Osteoporosis (T-score ≤-2.5 OR fragility fracture) = alendronate 70mg weekly + calcium/vitamin D - reduces fractures 50%, take on empty stomach, remain upright 30 minutes.
Osteomalacia (bone pain + muscle weakness + low vitamin D + low phosphate + elevated ALP + PTH + Looser zones) = high-dose vitamin D 20,000 units weekly 8-12 weeks - excellent response, symptoms improve weeks.
Biologic Therapy
3 high-yield facts
Anti-TNF = screen ALL for TB; latent TB → isoniazid 6mo or rifampicin 4mo; ≥3wk before starting biologic.
Before anti-TNF, think “TB, Hep B/C, HIV, and vaccination status” - especially latent TB screening via history, imaging, and IGRA to prevent potentially fatal reactivation.
ECOG PS 2 = ambulatory, self-caring, unable to work, up >50%. Performance status is the most important factor in determining fitness for chemotherapy.
T3 = through muscularis propria into pericolorectal tissue. N1 = 1-3 positive nodes. TNM staging is the universal framework for solid tumour classification.
Rising CEA post-colorectal resection = CT staging to detect potentially resectable recurrence, especially liver metastases.
Antimicrobial stewardship = de-escalate to narrowest spectrum once organism known; penicillin-sensitive pneumococcus = amoxicillin, stop broad-spectrum.
Stop antibiotics when clinically improved (afebrile 24h, improving symptoms) - 5 days sufficient for uncomplicated CAP; don't wait for CRP/CXR normalization.
Co-amoxiclav and the ‘4 Cs’ carry the highest C. difficile risk; use narrow-spectrum nitrofurantoin or pivmecillinam for UTI per NICE NG109; shortest effective course is essential in high-risk elderly patients.
Liaison Psychiatry
3 high-yield facts
Somatic symptom disorder = multiple genuine physical symptoms + normal investigations + excessive distress. Not deliberate. Key distinction: factitious = fabricated, malingering = fabricated for gain.
Munchausen = deliberate symptom fabrication + sick role motivation + peregrination + pseudologia fantastica. Distinguish from malingering (external gain) and somatisation (genuine symptoms).
Illness anxiety = fear of having a serious disease with minimal/no actual symptoms. Key difference from somatisation: anxiety about disease vs experience of symptoms. CBT first-line.
Severe Cutaneous Adverse Reactions
3 high-yield facts
TEN (>30% BSA detachment) has a 30-50% mortality - stop the culprit drug, manage in a burns unit/ICU, and calculate the SCORTEN score early to guide prognosis.
Stop drug immediately; burns unit; ophthalmology urgent; SCORTEN predicts mortality; allopurinol commonest cause UK.
HLA-B*5801 screening before allopurinol in Han Chinese/Thai/Korean; 80-fold SJS risk; stop immediately; never rechallenge.
Skin Malignancy
3 high-yield facts
Lip SCC is a high-risk site (~10-15% metastatic risk); BAD guidelines mandate wider margins and Mohs for high-risk lesions; cemiplimab is first-line for advanced disease.
Breslow thickness in mm is the single most important prognostic factor in cutaneous melanoma (NICE NG14); ulceration and mitotic rate also independently worsen prognosis; SLNB if Breslow >0.8 mm or any ulceration; adjuvant anti-PD-1 or BRAF/MEK for resected stage III/high-risk II disease.
BCC is locally invasive but metastasises in <0.1% - pearly rolled-edge nodule with telangiectasia on sun-exposed skin; 4 mm excision per BAD (2021) is first-line, with Mohs for facial H-zone, morphoeic, and recurrent lesions.
Urine pH >5.5 despite acidosis = Type 1 RTA - the "distal" defect prevents urine acidification.
Lithium + polyuria + no desmopressin response = nephrogenic DI - kidney unresponsive to ADH.
Inflammatory Myopathy
3 high-yield facts
In exam questions, new dermatomyositis in an older patient = “hunt for cancer” - malignancy screening is as important as immunosuppressive treatment of the myositis itself.
PM = proximal weakness + no rash + high CK + endomysial CD8+; IBM = distal + poor steroid response.
Bone Disease
3 high-yield facts
“Soft bones, sore muscles, low D” = osteomalacia - unlike osteoporosis, it presents with myopathy, pain, and clear biochemical abnormalities.
In older patients on prolonged steroids, “think bisphosphonate from day one” - combine with calcium/vitamin D, lifestyle advice, and fall-prevention strategies to reduce fracture risk.
Older patient, raised ALP, thickened, expanded bones = Paget’s; treat with IV bisphosphonate, especially if symptomatic or at risk of complications such as fracture, deformity, or nerve compression.
Drug-Induced Dermatological Reactions
3 high-yield facts
Doxycycline photosensitivity = phototoxic (non-immune, rapid sunburn-like); counsel sun protection or switch to lymecycline.
Tetracyclines - direct phototoxic reaction (not immune-mediated) causes sunburn-like rash in sun-exposed areas; dose-dependent; stop drug + sun protection + topical steroids; minocycline safer alternative.
SJS/TEN = T-cell mediated; allopurinol/carbamazepine commonest; stop drug + burns unit; mortality TEN 25-35%.
Cardiac Masses
3 high-yield facts
Young myxoma patient + lentigines + family history = Carney complex - genetic testing + endocrine screening + annual echo!
LA mass + positional symptoms + tumour plop + emboli = myxoma - urgent surgery prevents stroke!
Left atrial myxoma plus embolic stroke means urgent surgical excision once the patient is stabilised - it is curative and prevents the high risk of recurrent embolisation.
Coagulation
3 high-yield facts
DIC labs = “everything low except D-dimer” - platelets and fibrinogen low, PT/APTT prolonged, D-dimer very high in the classic full-blown picture.
Major warfarin bleed = “PCC + IV vitamin K now” - PCC for immediate factor replacement and vitamin K for sustained reversal.
For DOAC emergencies, think “dabigatran = idarucizumab; Xa inhibitors = andexanet or PCC”, not vitamin K or protamine.
Geriatric Medicine
3 high-yield facts
In a falls assessment, always review medications - alpha-blockers, antihypertensives, and sedatives (especially anything prescribed in error) are key reversible contributors (NICE CG161).
NICE CG161 recommends strength and balance exercise as core falls prevention - Otago programme is evidence-based; offer multifactorial assessment; address vision and home hazards alongside exercise.
In an older adult with new confusion plus dry mouth, constipation and urinary retention, add up the anticholinergic burden (e.g. ACB Scale) and deprescribe - oxybutynin and tricyclics are common culprits (NICE NG56).
posterior
3 high-yield facts
PCA = visual/visuospatial deficits (simultanagnosia, optic ataxia, alexia) before memory loss + parieto-occipital atrophy + AD biomarkers; younger onset; 8-12yr course.
PRES = severe HTN + headache + visual disturbance + seizures + bilateral parieto-occipital vasogenic oedema (no restricted diffusion); urgent BP control; reversible if prompt.
(BTS/SIGN 2024): SpO₂ <92%, PEF <33% or a silent chest = life-threatening asthma - escalate to ITU; treat with oxygen, nebulised salbutamol/ipratropium, steroids and IV magnesium sulphate.
ABPA = asthma + brown plugs + total IgE >1000 + Aspergillus IgE + central bronchiectasis; prednisolone + itraconazole; monitor IgE.
Hypoactive delirium = quiet, withdrawn, sleepy - accounts for 50% of cases but most commonly missed. Worse prognosis than hyperactive. Screen with 4AT. Acute change from baseline is the key clue.
Delirium management: non-pharmacological FIRST (reorientation, lighting, familiar objects). Medication only if dangerous. Avoid benzodiazepines. Avoid physical restraints.
Delirium = acute onset + fluctuating + inattention + precipitant. Hypoactive (quiet) is commonest and most missed. Treat the cause, not the confusion.
Neuro-Ophthalmology
3 high-yield facts
IIH (obese young woman + papilledema + LP pressure 38 cmH₂O + normal imaging) = acetazolamide + weight loss - prevents blindness, surgery if refractory.
Bitemporal hemianopia localises to the optic chiasm - when combined with hyperprolactinaemia and amenorrhoea, a pituitary prolactinoma is the diagnosis; treat with cabergoline, not surgery.
Miosis, partial ptosis, and anhidrosis in a smoker with an apical lung lesion is Horner syndrome due to a Pancoast tumour until proven otherwise.
Metabolic Emergencies
3 high-yield facts
DKA cerebral edema (declining GCS + headache + bradycardia 4-12h into treatment + child) = reduce IV fluids + mannitol/hypertonic saline immediately - 20-40% mortality, overzealous rehydration main risk, DO NOT delay treatment for imaging.
High-risk TLS (Burkitt lymphoma, bulky disease, high LDH/uric acid) = rasburicase 0.2 mg/kg IV + aggressive IV hydration before chemotherapy (BSH/NICE TA63) - rasburicase rapidly lowers urate (superior to allopurinol); avoid bicarbonate; check G6PD; renal replacement if refractory.
HHS (extreme hyperglycemia >30 + hyperosmolality >320 + NO ketosis + type 2 diabetes + elderly) = 0.9% saline FIRST (1L/h initially, then slower) - more severe dehydration than DKA, LOW-dose insulin AFTER fluids, thromboprophylaxis essential, mortality 10-20%.
Autonomic Disorders
3 high-yield facts
POTS = HR rise ≥30 bpm within 10 minutes standing + orthostatic symptoms + no drop in BP; start with fluid, salt, compression stockings and graded exercise; add ivabradine/β-blocker, midodrine or fludrocortisone only if first-line measures fail.
Diabetic autonomic neuropathy (gastroparesis + OH + erectile dysfunction + bladder symptoms + long diabetes duration) = optimize glycemic control + metoclopramide/domperidone + small frequent meals; manage OH separately.
Neurogenic OH (BP drop ≥20/10 mmHg standing + symptoms + autonomic disorder) = non-pharmacological measures first then midodrine TDS (avoid evening - supine hypertension).
Trauma and Stress-Related Disorders
3 high-yield facts
Symptoms persisting beyond 4 weeks after trauma with re-experiencing, avoidance, and hyperarousal = PTSD; trauma-focused CBT or EMDR is first-line (NICE NG116).
Adjustment disorder = identifiable stressor + disproportionate distress + functional impairment + doesn't meet criteria for another disorder. Within 3 months of stressor, resolves within 6 months.
Acute stress = <4 weeks post-trauma. PTSD = >4 weeks. Do NOT debrief. Watchful waiting if improving. Trauma-focused CBT or EMDR if symptoms persist beyond 1 month.
Syncope and Postural Hypotension
3 high-yield facts
In postural hypotension, always review and stop the culprit drugs (alpha-blockers, calcium-channel blockers, diuretics) before starting fludrocortisone or midodrine. NICE CKS (Blackouts and syncope / orthostatic hypotension) supports a drug review as the first-line intervention.
Unexplained syncope/falls in elderly + head turning triggers = consider carotid sinus hypersensitivity. Carotid sinus massage is diagnostic (≥3s asystole or ≥50mmHg BP drop). Cardioinhibitory type → pacemaker.
Orthostatic hypotension = ≥20 systolic or ≥10 diastolic drop within 3 minutes of standing. Review medications first. Minimal HR rise suggests autonomic failure (Parkinson's, diabetes).
FH = tendon xanthomata + LDL >6.5 mmol/L - start maximum statin immediately and refer for specialist management. Early treatment can prevent premature MI and death.
QRISK3 threshold is 10% - below this, focus on non-pharmacological risk reduction.
QRISK3 ≥10% = offer atorvastatin 20 mg for primary prevention; 80 mg is for secondary prevention post-CVD event.
"Falls = FRIDS first!" Review meds BEFORE adding interventions. Benzodiazepines = highest fall risk - stop if possible!
FRIDs (Fall-Risk-Increasing Drugs) = sedatives, anticholinergics, antihypertensives, alpha-blockers - review per NICE CG161 and STOPP/START in every recurrent faller; risk is multiplicative with multiple FRIDs.
Recurrent falls → multifactorial assessment (NICE CG161): gait/balance, cardiovascular, medications, vision, environment. Strength and balance exercise = most effective single intervention.
Panniculitis
3 high-yield facts
Lofgren = EN + BHL + arthralgia = acute sarcoidosis (>90% resolution); EN never ulcerates; commonest cause UK = sarcoidosis; commonest infectious = streptococcal.
EN + BHL + arthralgia = Lofgren (>90% resolution); EN never ulcerates; commonest UK cause = sarcoidosis.
Erythema nodosum - tender bilateral pretibial nodules; commonest causes are streptococcal infection and sarcoidosis (Löfgren's); investigate with CXR, ASOT and Mantoux/IGRA; treat the cause and use NSAIDs symptomatically (BAD/NICE CKS).
anterior
3 high-yield facts
ACA = leg > arm (medial homunculus) + incontinence + abulia; vs MCA = arm/face > leg.
AIN syndrome = pure motor + cannot make OK sign + weak FPL/FDP index + NO sensory loss. ~70% recover spontaneously over 6-12 months.
AION = sudden painless vision loss + altitudinal defect + pale disc; NAION (normal ESR) vs AAION (↑ESR → urgent steroids).
Neuroinfections
3 high-yield facts
Suspected bacterial meningitis = IV ceftriaxone 2g BD + dexamethasone 10mg QDS IMMEDIATELY. Don't wait for LP/CT. Dexamethasone reduces death/disability!
Viral meningitis CSF = lymphocytes + normal/borderline glucose + mildly elevated protein + negative Gram stain. Bacterial = neutrophils + low glucose + very high protein!
PML = JC virus + immunosuppressed + asymmetric white matter (no enhancement) + CSF JC PCR; immune reconstitution (ART/stop natalizumab); no antiviral.
Postpartum psychosis = psychiatric emergency, days 3-14 postpartum. Admit to MBU. Strong link to bipolar disorder. 50% recurrence in future pregnancies.
Baby blues = days 3-5, 50-80% of mothers, tearful but functioning, self-limiting within 2 weeks. No treatment needed. If symptoms persist >2 weeks → suspect postnatal depression.
DM = malignancy screening MANDATORY (25-30%, within 3yr); CT CAP + mammography + colonoscopy at diagnosis + annually ×3yr.
Frailty
3 high-yield facts
"Frailty = ≥3 of WEEWS!" Weight loss, Exhaustion, wEakness, Walking slow, low phySical activity. Reversible with multicomponent interventions!
Sarcopenia = low muscle strength + low muscle mass +/- low physical performance (EWGSOP2). Resistance exercise + protein (1.0-1.2 g/kg/day) = mainstay of treatment. Major cause of frailty and falls.
CFS 4 (Vulnerable) = independent but slowing down and symptomatic. Always assess CFS based on BASELINE status (pre-illness), not acute presentation.
Supportive Oncology
3 high-yield facts
Brain metastases with oedema = high-dose dexamethasone immediately. Do not give prophylactic anticonvulsants. LP is contraindicated with posterior fossa lesions.
Cancer-associated VTE = DOAC or LMWH for ≥6 months. Avoid DOACs in GI/urological cancers due to mucosal bleeding risk. Continue anticoagulation while cancer active.
Bone metastases require zoledronic acid or denosumab to reduce skeletal-related events. Check dental health before starting (ONJ risk).
Opportunistic Infections
3 high-yield facts
HIV + CD4 <200 + bilateral infiltrates + high LDH = PCP; treat with co-trimoxazole + prednisolone.
Steroids within 72 hours save lives in moderate-severe PJP.
HIV + CD4 <200 + subacute dyspnoea + exertional desaturation + raised LDH = PCP - co-trimoxazole 21 days, add corticosteroids if PaO₂ <9.3 kPa, start ART within 2 weeks (BHIVA OI 2018, ACTG A5164).
Diabetes Pharmacotherapy
3 high-yield facts
Metformin = AMPK activation → ↓hepatic glucose output; no hypoglycaemia; stop if eGFR <30; first-line T2DM.
SGLT2i + low glucose + high ketones = euDKA; stop drug permanently.
GLP-1 agonist pancreatitis (0.5-1%) = stop permanently; contraindicate entire class (switch to insulin/SGLT2).
Drug-Induced Metabolic Effects
3 high-yield facts
Steroids plus symptomatic glucose above 15 mmol/L = start basal insulin; expect an afternoon and evening glucose peak with once-daily prednisolone.
β-blockers mask hypo symptoms + impair recovery; sulfonylureas high risk elderly; switch to metformin/DPP-4i/SGLT2i.
Thiazides → hyperuricaemia 20-30%; acute gout = NSAIDs/colchicine; start allopurinol after acute settles; switch to losartan.
Drug-Induced Neurological Toxicity
3 high-yield facts
Ciprofloxacin + epilepsy = contraindicated (GABA antagonism); use beta-lactams instead.
Isoniazid = B6 depletion → neuropathy 10-20%; prevent with pyridoxine 10-25mg daily; treat with 50mg daily.
Drug-induced AIN (classically PPIs, NSAIDs, and antibiotics) presents with AKI, sterile pyuria, and eosinophiluria - stop the offending drug first and consider steroids if there is no recovery (NICE NG148 on AKI emphasises medication review).
PNES = prolonged thrashing + eyes closed + retained awareness + no post-ictal confusion + normal ictal video-EEG → explain diagnosis positively, CBT, withdraw AEDs; not epilepsy, not malingering.
FND (inconsistent weakness + Hoover sign + non-anatomical sensory loss + normal imaging) = explain diagnosis positively using examination signs + physiotherapy + CBT; avoid dismissing as "psychological."
FND is diagnosed by positive signs (Hoover sign, distractibility), not by exclusion; explain the diagnosis positively, avoid implying feigning, and treat with FND-informed physiotherapy with or without CBT (UK consensus guidance, Stone et al; Association of British Neurologists).
Genetic Endocrine Disorders
3 high-yield facts
Klinefelter syndrome (tall + small firm testes <4ml + gynecomastia + azoospermia + elevated LH/FSH) = karyotype shows 47,XXY - TRT improves symptoms, TESE + ICSI for fertility (50% success).
Turner syndrome (45,X) = short stature + primary ovarian insufficiency - give growth hormone to optimise height, then oestrogen for pubertal induction and bone protection, and screen the heart and kidneys.
Carcinoid syndrome - flushing + diarrhea + ↑5-HIAA + liver mets, octreotide LAR monthly (70-80% symptom control), PRRT if progressive, IV octreotide peri-op (prevent crisis).
Carcinoid crisis - refractory hypotension + bronchospasm during surgery, IV octreotide 50 μg/h 2h pre-op (prevents crisis), bolus 100 μg if crisis occurs, avoid morphine/suxamethonium (use fentanyl/rocuronium).
Glucagonoma - necrolytic migratory erythema (pathognomonic) + diabetes + weight loss + DVT, glucagon >500, surgery if localised, octreotide improves rash 80%.
Rheumatology
3 high-yield facts
Thrombotic APS - anticoagulate long term with warfarin (INR 2.0-3.0); avoid DOACs, particularly in triple-positive disease (TRAPS trial).
Early RA (seropositive, erosive) → methotrexate plus folic acid within 3 months (NICE NG100; BSR); bridge with steroids while awaiting effect; escalate via cDMARD combinations then biologics after failing ≥2 cDMARDs including methotrexate.
Acute gout with CKD - oral prednisolone when NSAIDs and colchicine are contraindicated; do not start urate-lowering therapy during a flare.
Colonic Disease
3 high-yield facts
microscopic colitis = watery diarrhoea + normal colonoscopy + diagnostic biopsy; PPIs/NSAIDs/SSRIs are classic triggers; stop offending drugs + budesonide 9 mg (80-90% remission); benign - no cancer surveillance required (BSG 2022).
Hinchey Ib (≥4cm abscess) → IV antibiotics + CT drainage (80-90%); III-IV → Hartmann's; colonoscopy 6-8w; elective colectomy if recurrent.
Ogilvie's = post-op + caecal dilatation; correct electrolytes first; neostigmine 2mg IV if >10-12cm (80-90%, cardiac monitoring); colonoscopy if fails; surgery if perforation.
Haematological Oncology
3 high-yield facts
DLBCL = R-CHOP first-line (rituximab + CHOP). ABVD is for Hodgkin lymphoma. DLBCL is aggressive and requires prompt treatment.
CLL diagnosis = flow cytometry showing CD5+/CD19+/CD23+ B-cells with persistent lymphocytosis ≥5 × 10⁹/L. Smear cells are the classic blood film finding.
Young, dry cough, x-ray worse than exam = Mycoplasma! No cell wall means penicillin will not work - reach for macrolides or doxycycline.
Hotel + hyponatraemia + heavy pneumonia = Legionella! The urinary antigen test stays positive for weeks, so do not worry about delaying it - unlike blood cultures.
Cancer Screening
2 high-yield facts
Positive screening FIT (≥10 µg Hb/g) = urgent colonoscopy within 2 weeks per NICE NG12 / BCSP; CT colonography only when colonoscopy is contraindicated or incomplete.
NHS cervical screening uses HPV primary testing from age 25 - every 3 years (25-49) and every 5 years (50-64).
Cancer Genetics
2 high-yield facts
In a BRCA1 carrier, discuss BOTH risk-reducing mastectomy AND risk-reducing salpingo-oophorectomy - RRSO (by age 40 in BRCA1) lowers both ovarian and breast cancer risk (NICE CG164).
Lynch syndrome = MMR gene mutation = colonoscopy every 2 years from age 25. Right-sided colon cancers are common - full colonoscopy is essential.
Urological Malignancy
2 high-yield facts
Metastatic prostate cancer = ADT + intensification (abiraterone/docetaxel/apalutamide)! Combination therapy now standard - improves survival by 15-18 months vs ADT alone. Monitor for castration-resistance (rising PSA despite castrate testosterone).
RCC is chemo- and radio-resistant - adjuvant pembrolizumab (KEYNOTE-564) is the systemic option after resection of high-risk clear cell RCC, whereas surveillance is reserved for low-risk disease.
Haematological Malignancy
2 high-yield facts
Advanced classical Hodgkin lymphoma → ABVD × 6 cycles, PET-adapted after cycle 2 per RATHL; R-CHOP is for DLBCL, not HL.
Remove the line, don't just treat through it - MRSA bacteraemia mortality doubles without source control.
MRSA catheter-related bacteraemia = IV vancomycin 15-20 mg/kg BD with TDM + prompt line removal + repeat cultures to document clearance + TOE if persistent or prosthetic material present.
central
2 high-yield facts
Central cord = upper limbs weaker than lower + sacral sparing + hyperextension in spondylosis; 50-70% ambulatory; lower limbs recover better.
CPM = rapid Na⁺ correction (>10-12mmol/L/24h) → delayed 2-6d → dysarthria/dysphagia/quadriparesis/locked-in; pons T2 signal; prevention (correct slowly); no specific treatment.
Interventional Cardiology
2 high-yield facts
High CIN risk (CKD + diabetes)? IV saline 1 mL/kg/hr 12 hours pre/post contrast - only proven prevention!
High-risk patient + contrast = IV saline 1ml/kg/hr 12h pre/post - only proven prevention!
Oncology Drugs
2 high-yield facts
Ondansetron max 16mg/d (QT risk); add dexamethasone/olanzapine for refractory nausea; check electrolytes.
High-risk tumor lysis syndrome - use rasburicase (rapid urate reduction), not allopurinol (too slow).
Genetic
2 high-yield facts
Turner syndrome = growth hormone for short stature plus staged oestrogen (then add a progestogen) for pubertal induction and bone protection; provide lifelong surveillance for aortic dilatation/bicuspid valve, autoimmune thyroid disease, coeliac disease, and hearing loss (BSPED / international Turner syndrome consensus guidance).
PLS = pure UMN (spasticity, NO fasciculations/wasting) + slow progression >4yr + normal EMG; baclofen; better than ALS (>10yr); 30% develop LMN → ALS.
Paraneoplastic Syndromes
2 high-yield facts
New digital clubbing with painful periostitis in a smoker = HPOA secondary to lung cancer; treat the tumour (NICE NG122) - NSAIDs and bisphosphonates only relieve pain while definitive oncological management proceeds.
PCD = subacute severe ataxia + anti-Yo (ovarian/breast) or anti-Hu (SCLC); urgent cancer screen; treat tumour + immunotherapy; poor prognosis (irreversible).
Autoimmune Blistering Disorders
2 high-yield facts
Dermatitis herpetiformis is the skin sign of coeliac disease - confirm with granular IgA on direct immunofluorescence, treat with a lifelong gluten-free diet, and use dapsone for rapid itch control.
Bullous pemphigoid (BP) requires linear IgG/C3 deposition. Always consider the clinical context and guideline-directed management.
carotid
2 high-yield facts
Carotid endarterectomy: symptomatic stenosis ≥50% (TIA/stroke <6 months) + urgent surgery within 2 weeks (early better) + reduces stroke 70% (NNT 6); CEA preferred over stenting.
Young patient + neck pain + Horner syndrome + stroke = carotid dissection; treat with antiplatelet or anticoagulation for 3-6 months (CADISS: no difference) and avoid thrombolysis once the dissection is confirmed.
Genetic Renal Disorders
2 high-yield facts
Isolated haematuria + thin GBM + family history = TBMN - benign, reassure and monitor.
COL4A5 mutation + hearing loss + renal disease = X-linked Alport syndrome - males more severely affected.
Bone and Joint Infections
2 high-yield facts
Aspirate urgently, don't wait - hours matter for joint salvage in septic arthritis.
Vertebral osteomyelitis = 6-12 weeks total antibiotics (start IV 2-4 weeks, switch oral); flucloxacillin for MSSA; monitor CRP weekly - short courses inadequate.
Palliative Treatments
2 high-yield facts
Palliative radiotherapy = symptom relief (pain, bleeding, obstruction), not cure. Single fraction 8 Gy for bone mets. 60-80% achieve pain relief within 2-4 weeks.
Denosumab 120 mg SC monthly for bone metastases - superior to zoledronic acid, no renal adjustment needed. Monitor calcium (risk of hypocalcaemia) and dental health (ONJ risk).
(BNF): SCD = spastic paraparesis + extensor plantars + dorsal-column signs + low B12 → IM hydroxocobalamin 1 mg alternate days, then every 2 months for life if neurological involvement; never give folate first.
Pharmacogenetics
2 high-yield facts
CYP2C19 poor metabolizers have reduced clopidogrel efficacy - switch to ticagrelor or prasugrel post-ACS.
CYP2D6 poor metabolisers = codeine ineffective; ultra-rapid = toxicity risk; avoid codeine in children post-tonsillectomy.
Bioterrorism Agents
2 high-yield facts
Painless black eschar + marked oedema + animal exposure = cutaneous anthrax; ciprofloxacin/doxycycline, do NOT debride, notify public health.
Pityriasis rosea is a self-limiting viral exanthem (herald patch then Christmas-tree eruption) that resolves in 6-12 weeks; exclude secondary syphilis in the sexually active and reassure rather than treat with antivirals.
Myocardial Disease
2 high-yield facts
Myocarditis = viral prodrome + chest pain + troponin elevation + normal coronaries + global LV dysfunction. Cardiac MRI with LGE is diagnostic!
New-onset HF + shock + normal coronaries = biopsy to diagnose giant cell myocarditis - needs urgent immunosuppression!
Psychiatry
2 high-yield facts
In refeeding syndrome the killer electrolyte is phosphate - start low (5-10 kcal/kg/day), give thiamine first, and monitor phosphate, potassium and magnesium daily (NICE NG69/CG32; RCPsych MARSIPAN).
For moderate to severe depression, NICE NG222 supports an SSRI (e.g. sertraline 50 mg daily) first-line; reserve SNRIs and tricyclics for later steps and review the response at 4-6 weeks.
Cranial Nerve Disorders
2 high-yield facts
Trigeminal neuralgia (unilateral lancinating facial pain + trigger zones + normal exam) = carbamazepine 100 mg BD titrate - 60-80% control, surgery if refractory.
Bell's = LMN VII + forehead involved + no rash; pred 60mg <72h + eye care; 85% recovery.
Acne and Rosacea
2 high-yield facts
First-line = topical metronidazole/azelaic acid; no comedones (distinguishes from acne); AVOID topical steroids; rhinophyma = CO2 laser.
Moderate acne = topical retinoid + antibiotic; never antibiotic monotherapy; isotretinoin for severe (teratogenic, monthly monitoring).
Structural Heart Disease
2 high-yield facts
Cryptogenic stroke + PFO + high-risk features (large shunt/ASA) in patient <60? Percutaneous closure prevents recurrence!
Young stroke + DVT + PFO with right-to-left shunt = paradoxical embolism. Consider PFO closure for secondary prevention.
Vaccine Pharmacology
2 high-yield facts
Live vaccines + immunosuppression = absolute contraindication; wait 3-12 months after stopping.
Live vaccines contraindicated on biologics (anti-TNF, rituximab) and high-dose immunosuppression; use inactivated alternatives (injectable typhoid, not oral); yellow fever vaccine particularly dangerous.
Critical Care
2 high-yield facts
PaO2/FiO2 <300 plus bilateral infiltrates plus non-cardiac equals ARDS - lung-protective ventilation (6 mL/kg, PEEP, plateau <30) reduces mortality 25%.
Berlin ARDS = Bilateral infiltrates + P/F ratio (Mild 200-300, Moderate 100-200, Severe <100); Low tidal volume 6ml/kg proven mortality benefit; PEEP optimization; Prone positioning if P/F <150; Conservative fluids; ECMO if refractory.
Heart Failure Pharmacotherapy
2 high-yield facts
Ivabradine = selective If-current (HCN4) blocker at the SA node → pure heart-rate reduction; indicated in HFrEF in sinus rhythm with HR ≥75 bpm despite maximum beta-blocker (NICE TA267/SHIFT); phosphenes in ~15% are characteristic.
ARNI = 36h ACEi washout (angioedema risk); PARADIGM-HF 20% mortality ↓; never combine with ACEi; titrate to 97/103mg BD.
Cough
2 high-yield facts
Chronic dry cough + ACE inhibitor + normal CXR/spirometry = stop ACE inhibitor (switch to ARB); cough resolves 1-4 weeks; ARBs don't cause cough.
Benign fasciculations = widespread twitching + NO weakness + NO wasting + EMG no denervation; reassure; does NOT become MND.
Nutritional Neurology
2 high-yield facts
Wernicke's = confusion + ophthalmoplegia + ataxia. Suspect ANY confused alcohol-dependent patient. Treat IMMEDIATELY with IV Pabrinex 2-3 pairs TDS x 3-5 days. NEVER give glucose without thiamine. 80% untreated → irreversible Korsakoff!
Carcinoid syndrome = flushing + diarrhoea + right heart valvular disease. Diagnose with 24-hour urinary 5-HIAA. Treat with octreotide.
Carcinoid syndrome = flushing + diarrhoea + right heart disease; diagnose with 24-hour urine 5-HIAA.
Diagnostic Procedures
2 high-yield facts
Bronchoscopy contraindications = Recent MI <4-6 weeks (absolute if unstable), severe hypoxemia; Relative: coagulopathy (INR >1.5), severe COPD; Complications: pneumothorax (biopsy 5%), bleeding; Correct INR <1.5; Platelet >50; HIV not contraindication.
Adult nephrotic = biopsy always; children = empiric steroids; guides specific treatment.
autonomic
2 high-yield facts
AD = SCI ≥T6 + severe HTN + bradycardia + headache; sit upright and remove the noxious trigger first; GTN if BP persistent (MASCIP 2019).
Postural hypotension: BP drop ≥20mmHg systolic or ≥10mmHg diastolic within 3 minutes standing; non-pharmacological first-line (fluid/salt, compression stockings, head-up tilt sleeping); fludrocortisone/midodrine if needed; common Parkinson/diabetes.
Gynaecological Oncology
2 high-yield facts
Postmenopausal woman + raised CA-125 + complex ovarian mass = high RMI - proceed to CT staging before surgical planning.
Endometrial cancer is driven by unopposed oestrogen - obesity and tamoxifen are the two key modifiable risk factors in this scenario.
Acne
2 high-yield facts
Severe nodulocystic or scarring acne, or acne with major psychological impact that has failed antibiotics, warrants oral isotretinoin under specialist care, with the Pregnancy Prevention Programme mandatory for women of childbearing potential.
Isotretinoin is indicated for severe scarring nodulocystic acne after failed conventional therapy - enrol females in the MHRA pregnancy prevention programme before starting.
Trauma
2 high-yield facts
Flail chest = ≥3 ribs fractured ≥2 places + Paradoxical movement; Often with pulmonary contusion; Epidural analgesia gold standard; Chest physiotherapy essential; NIV or intubation if respiratory failure; Mortality 10-20%.
Pulmonary barotrauma = Breath-holding during rapid ascent + Pneumothorax/pneumomediastinum/surgical emphysema; 100% oxygen; Chest drain if indicated; Assess for AGE (neurological); Hyperbaric oxygen if AGE; Never hold breath ascending; Avoid air travel.
Urinary Incontinence
2 high-yield facts
Overflow incontinence = continuous dribbling + palpable bladder + high PVR. Anticholinergics worsen retention in BPH. Always check PVR before prescribing antimuscarinics. Stop the offending drug + catheterise.
Urge incontinence first-line = bladder training for ≥6 weeks. Avoid oxybutynin in elderly (cognitive harm). If medication needed: solifenacin, tolterodine, or mirabegron preferred.
Tick-Borne Infections
2 high-yield facts
Babesiosis = tick bite + haemolytic anaemia + intraerythrocytic parasites + Maltese cross; atovaquone + azithromycin; severe in asplenic patients.
Erythema migrans = clinical diagnosis (treat without serology) - doxycycline 100 mg BD for 21 days (NICE NG95); IV ceftriaxone reserved for neuroborreliosis or carditis with high-grade AV block.
myotonic
2 high-yield facts
DM1 = grip myotonia + distal weakness + frontal balding + cataracts + AV block + CTG repeat + maternal anticipation; annual cardiac surveillance is essential; avoid suxamethonium (Muscular Dystrophy UK / ABN guidance).
Cirrhosis + arterial enhancement + portal venous washout = HCC on imaging - biopsy is not required. BCLC staging guides treatment.
Painless jaundice + weight loss + new diabetes + Courvoisier's sign = pancreatic head cancer until proven otherwise.
Infestations
2 high-yield facts
Crusted scabies = permethrin 5% plus oral ivermectin and contact/environmental treatment; topical steroids, antifungals and antibiotics alone do not clear the mite.
Permethrin 5% first-line (repeat 1wk); treat ALL contacts simultaneously; post-scabetic itch 2-4wk normal; ivermectin for crusted scabies.
Infection
2 high-yield facts
Elderly + "off legs" / new confusion / functional decline = assume infection until proven otherwise. Fever is often ABSENT in elderly sepsis. Full septic screen mandatory. CRP is more reliable than temperature.
In oncology exams, “fever + neutrophils <0.5 = IV antibiotics now” - treat first, refine later based on cultures and clinical response.
IIH = young obese woman + visual obscurations + papilloedema + LP >25 + normal MRI/CSF; weight loss + acetazolamide; monitor fields; surgery if vision threatened.
Drug-Induced Cardiovascular Effects
2 high-yield facts
QT prolongation = hERG blockade; >500ms = torsades risk; IV MgSO₄ first-line; correct K⁺; avoid drug combinations.
NSAIDs ↑BP 5-10mmHg (prostaglandin inhibition); blunt ACEi/diuretics; use paracetamol instead; BP normalises 1-2wk.
Inflammatory Skin Disorders
2 high-yield facts
First-line atopic eczema management is liberal emollients plus a mild topical corticosteroid for flares; step up potency or to calcineurin inhibitors if inadequate, and watch for secondary bacterial or herpetic infection.
First-line = vitamin D analogue + topical steroid; treatment ladder mild/moderate/severe; biologics for refractory; psoriatic arthritis 10-30%.
Comprehensive Geriatric Assessment
2 high-yield facts
CGA = MDT-led multidimensional assessment with individualised care plan; Level 1 (Cochrane) evidence for ↓nursing-home placement and ↑independent living at home; endorsed by BGS and NICE NG56; delivered on acute frailty units and hospital-at-home services.
CGA = multidimensional (medical, functional, psychological, social) + MDT + coordinated care plan. Gold standard of geriatric care. Proven to reduce mortality and institutionalisation (NNT 13).
Leukaemia
2 high-yield facts
“Philadelphia + BCR-ABL = CML = imatinib” in exam shorthand - linking the cytogenetic abnormality with its targeted therapy.
Exam red flags for acute leukaemia are short history, cytopenias + blasts and systemic “B” symptoms - always a haematological emergency.
Vancomycin trough 15-20μg/mL serious infections; nephrotoxic if >20; infuse ≥60min/g to prevent RMS.
Drug-Induced GI Effects
2 high-yield facts
Amlodipine causes constipation in 10-25% (smooth muscle relaxation); switch to ACE inhibitor/ARB for resolution.
Opioid constipation = μ-receptor GI (40-80%, no tolerance); senna + macrogol from day 1; naloxegol if refractory. Anticholinergic = switch lower burden drug.
Antidotes and Overdose Management
2 high-yield facts
Dabigatran = idarucizumab 5g IV (immediate reversal); Factor Xa inhibitors = andexanet alfa/PCC; vitamin K/protamine/FFP ineffective for DOACs.
Insulinoma = Whipple's triad + raised insulin/C-peptide + suppressed ketones during hypoglycaemia; supervised 72-hour fast is diagnostic; surgical resection is curative in 85-95%; diazoxide for pre-operative symptom control.
Insulinoma = Whipple's triad + inappropriately elevated insulin/C-peptide during hypoglycaemia with a negative sulfonylurea screen - surgical excision (enucleation/distal pancreatectomy) cures ~90%; diazoxide pre-operatively; intra-operative ultrasound essential; screen for MEN-1 if <40, multifocal or familial.
Pregnancy and Heart Disease
2 high-yield facts
Pregnancy HF? Hydralazine + nitrates substitute for ACE-i (teratogenic)!
Well-repaired ToF + NYHA I + good RV = WHO class II (intermediate risk); pregnancy safe with cardiology follow-up.
Long-segment Barrett without dysplasia = 3-5 year endoscopic surveillance.
Urological Oncology
2 high-yield facts
High-grade NMIBC = intravesical BCG (induction + maintenance). Single mitomycin C is for intermediate-risk. Cystectomy is for muscle-invasive or BCG failure.
AFP elevation excludes pure seminoma - always classify as NSGCT. Key testicular markers: AFP (yolk sac), bHCG (choriocarcinoma), LDH (burden).
Vascular Renal Disease
2 high-yield facts
Nutcracker syndrome = LRV compression between aorta and SMA; haematuria + left flank pain; observation or surgical.
Atheroembolic = post-angiography + subacute AKI (weeks) + eosinophilia + blue toes; supportive only; 60% ESRD; stop anticoagulation.
Endocrine Oncology
2 high-yield facts
Phaeochromocytoma surgery preparation = alpha-blockade first (phenoxybenzamine), then beta-blockade. Never give beta-blockers without prior alpha-blockade.
Elevated calcitonin + RET mutation = medullary thyroid carcinoma. Screen for phaeochromocytoma (MEN2) before surgery.
IgM paraprotein plus hyperviscosity features (visual disturbance, mucosal bleeding, retinopathy) equals Waldenström macroglobulinaemia - give urgent plasmapheresis first, then rituximab-based chemoimmunotherapy (BSH guideline on the management of Waldenström macroglobulinaemia).
Metabolism
2 high-yield facts
Metabolic syndrome - ≥3 of central obesity/HTN/↑TG/↓HDL/↑glucose, lifestyle cornerstone (weight loss 5-10%, diet, exercise 150 min/week), prevents diabetes 58%, screen annually.
Refeeding syndrome - severe hypoPO4 + hypoK + hypoMg days 2-5, STOP/reduce feeding, IV PO4/K/Mg, thiamine 300 mg TDS, start LOW 5-10 kcal/kg/day.
NSF = Gd + eGFR <30; woody skin + contractures; no treatment; PREVENT by avoiding Gd.
Neonatal Respiratory Disease
2 high-yield facts
BPD = Prematurity + Oxygen at 36 weeks postmenstrual; Pulmonary hypertension 25-40%; Most improve 2 years.
BPD = preterm + O₂ at 36wk PMA; home O₂ + diuretics + caffeine + palivizumab; avoid systemic steroids.
Eczema
2 high-yield facts
Stasis dermatitis = compression + emollients + moderate topical steroid for flares; check ABPI before compression; treat the underlying varicose veins to prevent ulceration.
Geometric eczema at a contact site equals allergic contact dermatitis - confirm with patch testing (nickel sulphate + standard series) and treat by avoidance plus topical corticosteroids.
Gastric Disorders
2 high-yield facts
Diabetic gastroparesis = hyperglycaemia-driven delayed emptying + low-fat/low-fibre + metoclopramide (MHRA ≤5 days routine) or domperidone with ECG; optimise glycaemia first.
Gas gangrene = trauma + rapid onset + bronze skin + crepitus + systemic toxicity; immediate surgery + penicillin G + clindamycin - delay is fatal.
Necrotizing fasciitis = disproportionate pain + rapid progression + systemic toxicity; urgent surgery within hours + piperacillin-tazobactam/meropenem + clindamycin - don't delay for imaging.
Upper GI Disease
2 high-yield facts
Benign GOO (post-prandial vomiting + succussion splash + pyloric stenosis + benign biopsy) is treated first-line with endoscopic balloon dilation, in line with British Society of Gastroenterology endoscopy guidance, after correcting the classic hypochloraemic hypokalaemic metabolic alkalosis.
LA mass + embolic stroke + pedunculated + fossa ovalis attachment = atrial myxoma - urgent surgery to prevent further embolisation!
Mobile pedunculated mass on the interatrial septum + tumour plop + constitutional symptoms = cardiac myxoma - urgent surgical excision because of embolic and obstructive risk (BCS / ESC cardiac tumour pathway).
Intensive Care Cardiology
2 high-yield facts
VA-ECMO = temporary full cardiopulmonary support for refractory cardiogenic shock; bridge to recovery/LVAD/transplant; survival 40-50%.
Sepsis + new global LV dysfunction + mild troponin = septic cardiomyopathy - treat sepsis, inotropes if needed, LVEF recovers 7-10 days!
MEN2A - MTC 95% + pheo 50% + hyperparathyroidism 20-30%, RET codon 634 (autosomal dominant 95% penetrance), calcitonin 80 ↑ (early MTC), metanephrines normal (MUST exclude pheo BEFORE thyroidectomy - crisis risk), if pheo adrenalectomy FIRST (α-blockade then β-blockade), prophylactic total thyroidectomy + node dissection (curative pre-malignant), parathyroidectomy if symptomatic, metanephrines annually, calcitonin 6-monthly, genetic counseling 50% offspring risk screen age 5, prognosis curative if early.
MEN2A = RET mutation (codon 634 high-risk); triad of MTC (>90%), phaeochromocytoma (~50%), primary hyperparathyroidism (20-30%); total thyroidectomy is the cornerstone - but always screen for phaeochromocytoma with metanephrines before surgery (BTA 2014 / ATA 2015).
Calcium
2 high-yield facts
Hypercalcaemia of malignancy = suppressed PTH + raised PTHrP → IV 0.9% saline 3-4 L/24 h then IV zoledronic acid 4 mg per SfE Emergency Endocrine Guidance; denosumab if eGFR <30; treat underlying cancer.
Bisphosphonate-refractory hypercalcemia - Ca >3.0 despite zoledronic acid 5-7d, denosumab 120 mg SC (RANKL inhibitor, effective 60-70%, safe in renal impairment), ensure vitamin D replete.
Hypoglycemia
2 high-yield facts
Congenital hyperinsulinism - high insulin + suppressed ketones + GIR >8, diazoxide trial (50% respond), FluoroDOPA PET: focal (limited resection, no diabetes) vs diffuse (95% pancreatectomy, diabetes 90%), ABCC8/KCNJ11.
Factitious hypoglycemia - high insulin + LOW C-peptide (diagnostic exogenous), 70% healthcare workers, psychiatric referral mandatory, remove insulin access, vs insulinoma has high insulin + HIGH C-peptide.
HE = lactulose first-line (2-3 stools/day) + treat precipitants; inadequate → add rifaximin 550mg BD (↓ HE 58%); maintain protein (do NOT restrict); transplant if recurrent.
Cervical dystonia = sustained head turn + sensory tricks (geste antagoniste) worsened by stress; botulinum toxin A every 12 weeks is first-line per ABN/EFNS guidance; consider DBS if refractory.
median
2 high-yield facts
Median medullary = tongue toward lesion + contralateral hemiparesis + contralateral proprioception loss + pain/temp preserved; anterior spinal artery; vs Wallenberg (no hemiparesis).
Pronator syndrome = proximal forearm pain + median distribution including thenar + Tinel/Phalen negative at wrist; vs CTS (wrist, spares thenar, Tinel/Phalen positive).
Upper GI Oncology
2 high-yield facts
Leather-bottle stomach + signet-ring cells = linitis plastica (diffuse-type gastric cancer). Associated with CDH1 mutations and poor prognosis.
Lower oesophageal cancer + GORD history = adenocarcinoma (Barrett's pathway). Upper/middle oesophagus + smoking/alcohol = squamous cell carcinoma.
Oncology Complications
2 high-yield facts
Grade 3+ irAE colitis = hold immunotherapy + high-dose steroids. Add infliximab only if steroid-refractory.
Anthracycline cardiotoxicity is dose-dependent and irreversible; trastuzumab cardiotoxicity is dose-independent and reversible.
Infections
2 high-yield facts
Positive IGRA plus normal CXR plus asymptomatic equals latent TB - treat with isoniazid 6 months or rifampicin 4 months, prevents active disease 90%.
HIV plus CD4 <200 plus exertional desaturation plus bilateral infiltrates equals PCP - co-trimoxazole plus steroids if pO2 <9.3 kPa, start empirically without delay.
Pediatric Respiratory
2 high-yield facts
Plastic bronchitis = expectoration of branching casts; Type I (Fontan/lymphatic); bronchoscopy + tPA; high-fat diet reduces lymphatic flow.
SCLC uses limited vs extensive staging. Limited = one hemithorax = chemoradiotherapy + PCI. Surgery plays almost no role.
Asbestos exposure + unilateral pleural thickening/effusion + long latency = mesothelioma. Diagnosis requires tissue biopsy, not cytology alone.
Pulmonary hypertension treatment
1 high-yield facts
Vaso-reactor = CCB victor! Only 10% of PAH patients respond to acute vasoreactivity testing. If they do (mPAP drops ≥10mmHg to ≤40mmHg), they get high-dose CCBs and have >95% 5-year survival!
Nausea and vomiting
1 high-yield facts
Malignant bowel obstruction → cyclizine first-line; avoid all prokinetics (metoclopramide, domperidone); add hyoscine butylbromide for colic and octreotide for high-volume vomiting; specialist palliative care referral.
Opioid-induced constipation
1 high-yield facts
Opioids = constipation! Senna + docusate = combination! Start laxatives PROPHYLACTICALLY when starting opioids. Do not wait! Stimulant (senna) pushes it out, softener (docusate) eases passage.
Capacity and consent
1 high-yield facts
Unwise decision ≠ lack of capacity! If they understand, retain, weigh, and communicate - they have capacity. You MUST respect their autonomous refusal, even if it kills them. That is the law.
Central retinal artery occlusion
1 high-yield facts
Cherry-red spot at macula = CRAO (retinal stroke)! Pale ischaemic retina everywhere except fovea (choroidal blood shows through). Emergency: ocular massage + paracentesis within 90 minutes. But prognosis awful despite heroics.
Medical ethics in palliative care
1 high-yield facts
Capacity trumps family and clinician opinion; the MCA 2005 plus Re B (2002) establish the right to refuse life-sustaining treatment; withdrawal of PEG at a capacitous patient's request is lawful, ethical, and distinct from assisted suicide.
Opioid conversion
1 high-yield facts
Oral to SC morphine = divide by 2! Simple conversion: 180mg oral ÷ 2 = 90mg SC. And oral to SC diamorphine? Divide by 3 (even more potent)!
Papilloedema and raised ICP
1 high-yield facts
Young obese woman + headaches + bilateral disc swelling = IIH! Transient visual obscurations (<30 sec) are the giveaway. MRI + MRV to LP (opening pressure >25cmH2O). Treat with weight loss + acetazolamide!
Cancer pain management
1 high-yield facts
Breakthrough morphine = 1/6 the daily total! Simple math: total daily dose ÷ 6 = PRN dose. Using >4 PRNs/day for 2 days? Time to increase the background dose!
Chemotherapy Complications
1 high-yield facts
Febrile neutropenia = door-to-antibiotic within 1 hour (piperacillin-tazobactam IV) per NICE CG151; blood cultures first but never delay antibiotics; G-CSF is prophylaxis, not rescue.
Occupational lung disease
1 high-yield facts
"Shipyard worker + pleural plaques + basal fibrosis = asbest-osis!" The pleural plaques are the smoking gun for asbestos exposure. Smoking multiplies lung cancer risk 50-fold!
Lung cancer
1 high-yield facts
Central mass? Bronchoscopy is best! Bronchoscopy for central lesions gets you tissue AND staging (EBUS for nodes). Do not forget molecular testing - it is not just about confirming cancer, it is about finding targetable mutations!
Giant cell arteritis
1 high-yield facts
Jaw claudication + visual loss = GCA! Steroids first, biopsy later! Do not wait for biopsy - treat the diagnosis with high-dose pred (60-80mg) IMMEDIATELY. You have 7 days to biopsy. Once vision is gone, it is gone forever!
Diabetic retinopathy
1 high-yield facts
4-2-1 rule for severe NPDR! Haemorrhages in 4 quadrants, venous beading in 2 quadrants, OR IRMA in 1 quadrant = severe NPDR. 50% progress to proliferative within a year - refer within 4 weeks!
Interstitial lung disease
1 high-yield facts
IPF = grim prognosis with median survival 3-5 years. Honeycombing at the bases with NO ground-glass is the HRCT signature. And NEVER give steroids - they make it worse!
Pulmonary vasculitis
1 high-yield facts
c-ANCA + cavitating pulmonary nodules + glomerulonephritis = GPA; treat with rituximab or cyclophosphamide plus steroids.
Anterior uveitis
1 high-yield facts
HLA-B27 + red eye + photophobia = anterior uveitis! Young male with axial symptoms (ankylosing spondylitis)? Classic! Unilateral, recurrent, alternates eyes. Treat with steroids hourly + cycloplegics (prevent posterior synechiae)!
Connective tissue disease-associated ILD
1 high-yield facts
NSIP = Not So Immediately Poor prognosis - 70% 5-year survival vs IPF's 50%. Subpleural sparing is the key HRCT clue distinguishing it from UIP/IPF.
Optic neuritis
1 high-yield facts
Pain on movement + RAPD + normal disc = retrobulbar optic neuritis! Patient sees nothing, doctor sees nothing. Get MRI - abnormal brain MRI = 50% MS risk within 15 years!
Palliative Oncology
1 high-yield facts
Malignant jaundice with good performance status and prognosis >3 months = decompress, don't just palliate - ERCP with a metal stent is first-line; reserve PTBD for failed or proximal obstruction.
Terminal agitation and delirium
1 high-yield facts
Terminal agitation? Levomepromazine = sedation solution! Broad-spectrum: sedates AND treats delirium. Benzos alone may worsen confusion. Comfort is the goal, not hastening death.
End of life care priorities
1 high-yield facts
Last days of life - stop prognostic drugs (statins, antihypertensives, antiplatelets), continue only those with symptomatic benefit such as furosemide for dyspnoea, and start the NICE NG31 anticipatory kit (morphine, midazolam, antiemetic, antisecretory).
Malignant pleural effusion
1 high-yield facts
Trapped lung? Talc will not stick - put in a catheter quick! If the lung will not re-expand (no relief despite drainage), pleurodesis will fail. IPC lets patients drain at home.
Aspirin-exacerbated respiratory disease
1 high-yield facts
Samter triad = Asthma, Aspirin, nAsal polyps (the three As!). It is pharmacological NOT allergic, so skin testing is useless. Safe alternatives: COX-2 inhibitors and paracetamol.
Bacterial pneumonia
1 high-yield facts
Alcoholic + red-currant jelly sputum + bulging fissure = Klebsiella kills! This is not your garden-variety pneumonia - it is a necrotizing beast with 50% mortality.
Occupational asthma
1 high-yield facts
Monday morning wheeze, weekend ease = occupational asthma until proven otherwise. If symptoms improve on holidays/weekends, think workplace exposure!
Acute angle-closure glaucoma
1 high-yield facts
Fixed mid-dilated pupil + rock-hard eye + nausea = AACG! Multi-drug attack! IV acetazolamide + topical timolol + apraclonidine + pilocarpine. Then laser iridotomy when IOP controlled. Hours count!
Gastrointestinal Malignancy
1 high-yield facts
Stage III colon cancer = adjuvant FOLFOX or CAPOX; 6 months if high-risk features (LVI, pT4, N2), consider 3 months CAPOX for low-risk; pembrolizumab reserved for MSI-H metastatic CRC; chemoradiotherapy is for rectal cancer, not colon.
Lung cancer paraneoplastic syndromes
1 high-yield facts
SCLC: Small Cell = SIADH Central! 10-15% of SCLC patients get SIADH. Concentrated urine + dilute blood = SIADH. Correct slowly or risk pontine myelinolysis!
Acute Coronary Syndromes
1 high-yield facts
Inferior MI = ST elevation II, III, aVF; RCA territory (85%).
Obstructive sleep apnoea
1 high-yield facts
Severe OSA (AHI >=30) -> CPAP first-line per NICE NG202; adjuncts (weight loss, alcohol avoidance) are additive; advise DVLA if excessive daytime sleepiness.
Advance care planning
1 high-yield facts
ADRT = Absolutely Definitive Refusal of Treatment! If written, signed, witnessed, and says even if life at risk - it is LEGALLY BINDING. Treat against it = battery. Not a suggestion - it is the law!
Community-acquired pneumonia
1 high-yield facts
Urea is essential for full CURB-65 - but a patient already scoring ≥3 on the other four variables needs admission and severe-pneumonia management regardless of the urea value.
Cystic lung disease
1 high-yield facts
LAM = Ladies, Angiomyolipomas (kidneys), Multiple cysts! Only affects women of childbearing age. Uniform cysts throughout both lungs + recurrent pneumothoraces + TSC/angiomyolipomas = LAM diagnosis!
Lung cancer treatment
1 high-yield facts
PD-L1 ≥50% = Pembrolizumab monotherapy wins! If it lights up like a Christmas tree on PD-L1 staining, skip chemotherapy and go straight to immunotherapy.
Hypersensitivity pneumonitis
1 high-yield facts
Love birds? They might not love you back! Bird fancier's lung needs one treatment: rehoming the birds. Serum precipitins help but do not confirm (40% of healthy pigeon keepers have them too).
Pneumothorax
1 high-yield facts
Tall thin man + sudden chest pain = PSP! Size >2cm = Aspirate! Primary pneumothorax loves young tall males. Try suction before drain. And tell them: NO DIVING without bilateral pleurodesis!
Breathlessness management
1 high-yield facts
Refractory palliative dyspnoea - start oral morphine 2.5 mg QDS (NICE CG140/NG142), add a handheld fan, reserve lorazepam for anxiety-predominant breathlessness; opioids at these doses do NOT cause respiratory depression.
Pregnant PE pathway: Legs first, lungs second! Start with leg USS - if positive, you have confirmed VTE and saved both mum and baby from radiation. D-dimer is useless in pregnancy.
Lung cancer resistance mechanisms
1 high-yield facts
"MET amplification = bypass the blockade!" Cancer is smart - block EGFR, it activates MET instead. Think combo therapy (EGFR + MET inhibitors) when TKIs fail.
Central sleep apnoea
1 high-yield facts
Opiates = Central apnoea! Do not give CPAP, it will not save you! Opiates knock out respiratory drive. Use ASV (adaptive servo-ventilation), NOT CPAP. And reducing opiates is key!
Alpha-1 antitrypsin deficiency
1 high-yield facts
Young, never-smoked, lower-lobe emphysema = check AAT! Think alpha-1 when COPD does not fit the typical old smoker pattern. The liver + lung involvement is the giveaway.
Thyroid eye disease
1 high-yield facts
Active moderate-severe TED (CAS ≥3 + diplopia) → urgent ophthalmology + IV methylprednisolone (EUGOGO 2021); decompression for compressive optic neuropathy; stop smoking.
Patent Ductus Arteriosus
1 high-yield facts
A continuous machinery murmur with wide pulse pressure and left heart dilatation indicates a significant PDA - close with a transcatheter device unless Eisenmenger physiology is present (NICE NG168; ESC adult congenital heart disease guidance).
Pulmonary embolism - extended anticoagulation
1 high-yield facts
Men with unprovoked clots = lifelong anticoagulation (unless high bleeding risk). Women can use HERDOO2, but men? No trigger = no stopping!
Pulmonary hypertension
1 high-yield facts
mPAP >20, PCWP ≤15, PVR >2 = Group 1 PAH! Right heart cath is gold standard. Low wedge pressure rules out left heart disease (Group 2). Systemic sclerosis = classic Group 1 cause.
Retinal vein occlusion
1 high-yield facts
Blood and thunder fundus = CRVO! Widespread haemorrhages + dilated tortuous veins in all 4 quadrants. Watch out for rubeosis iridis (neovascular glaucoma) at 2-4 months - the 100-day glaucoma!
Ocular Trauma
1 high-yield facts
In chemical eye injuries, irrigate first and ask questions later - alkali burns are worse than acid because they penetrate deeper via liquefactive necrosis.
MUST ≥2 = high risk → dietitian referral; functioning gut → oral support first, then enteral, then parenteral; always assess refeeding-syndrome risk in low-BMI patients with prolonged poor intake.
Sleep Apnoea
1 high-yield facts
Severe OSA (AHI >30 + symptoms) = CPAP therapy; weight loss adjunctive.
Constipation
1 high-yield facts
Faecal impaction = high-dose macrogol disimpaction (up to 8 sachets/day for 3 days). Always review constipating medications. Opioids, anticholinergics, and iron are the worst offenders.
Lung Transplantation
1 high-yield facts
IPF transplant criteria = FVC <50% OR DLCO <40% OR progressive decline; Refer early (waitlist mortality high); Absolute contraindications: malignancy, organ failure, infection; Median survival post-transplant ~6 years.
Paraprotein-Related Renal Disease
1 high-yield facts
AKI + dipstick-PCR discrepancy + very high serum free light chains + hypercalcaemia + bone pain = myeloma cast nephropathy - urgent bortezomib-based chemotherapy plus aggressive IV hydration; ~50% renal recovery with prompt treatment.
Aztreonam = safest β-lactam (<0.1%); cephalosporins 1-3%; carbapenems 1%; confirm true allergy before avoiding all β-lactams.
Oral Mucosal
1 high-yield facts
Symptomatic erosive oral lichen planus → potent topical corticosteroid (e.g. betamethasone mouthwash); long-term review for the small malignant transformation risk (BAD / NICE CKS).
Kidney Stones
1 high-yield facts
In recurrent stone questions, “three strikes = 24-hour urine” - comprehensive metabolic collections guide personalised stone prevention rather than one-size-fits-all advice.
Inherited Platelet Disorders
1 high-yield facts
May-Hegglin (giant platelets + Döhle bodies + family history) = no treatment needed - functional large platelets, minimal bleeding risk.
Autoimmune
1 high-yield facts
Non-segmental vitiligo on the face = topical tacrolimus first-line (BAD); reserve potent steroids for body sites and NB-UVB for widespread disease, and screen for thyroid autoimmunity.
Azathioprine pancreatitis is idiosyncratic (not dose-dependent), incidence 3-5%, demands permanent withdrawal with no rechallenge, and requires switch to methotrexate or biologics for ongoing IBD control (NICE NG129; BSG 2019; BNF 2024).
Safeguarding
1 high-yield facts
"Elder abuse = Interview ALONE + Safeguard!" Multiple bruises + carer control = high suspicion. Statutory duty to report!
Thermoregulation
1 high-yield facts
Core temperature around 30°C with J waves = moderate-severe hypothermia - use active rewarming (warmed IV fluids and warm humidified air, plus forced-air blankets) and handle gently to avoid precipitating VF (Resuscitation Council UK).
Functional Assessment
1 high-yield facts
"ADLs = BASIC self-care (wash, dress, feed)!" IADLs = COMPLEX tasks (cook, shop, finances). IADLs lost FIRST in dementia!
Hemoptysis
1 high-yield facts
Massive hemoptysis = >200-300ml/24h or hemodynamic compromise; Bronchiectasis/TB commonest; 90% from bronchial arteries (systemic); BAE first-line (70-90% success); Surgery if BAE fails; Position bleeding side down; Complications: spinal embolization, recurrence 10-20%.
Suspected Ebola = isolate + notify PHE + full PPE + HCID unit; NO routine procedures; RT-PCR diagnostic.
Respiratory Physiology
1 high-yield facts
Type 1 (PaO2 <8, PaCO2 normal/low) = V/Q mismatch; type 2 (PaO2 <8, PaCO2 >6) = hypoventilation.
Medical Ophthalmology
1 high-yield facts
Painful CN III palsy with a fixed dilated pupil - urgent CTA to exclude PComA aneurysm; pupil-sparing palsy favours microvascular (diabetic) cause.
myoclonus
1 high-yield facts
Cortical myoclonus = brief + stimulus-sensitive + EEG time-locked; valproate/levetiracetam; avoid phenytoin; vs subcortical (no EEG correlate).
Drug-Induced Endocrine Disorders
1 high-yield facts
Spironolactone-induced gynecomastia (bilateral tender breast enlargement + normal hormones + spironolactone >25mg) = anti-androgen effect at androgen receptor - dose-related, reversible if stopped early, switch to eplerenone (no anti-androgen effect), most common drug cause.
Gastrointestinal Emergencies
1 high-yield facts
HAE (recurrent angioedema/abdominal pain + family history + low C4) = IV C1-INH concentrate - not antihistamines/steroids, bradykinin-mediated.
Osteoporosis
1 high-yield facts
Fragility fracture in women ≥75 = start bisphosphonate without DEXA. Alendronate first-line. eGFR <35 → switch to denosumab. Fracture Liaison Service for all fragility fractures.
charcot
1 high-yield facts
Pes cavus + foot drop + inverted champagne-bottle legs + dominant family history + slow motor conduction <38 m/s = CMT1A (PMP22 duplication); NHS GMS R79 for genetic confirmation; supportive care only; normal lifespan.
radial
1 high-yield facts
Spiral groove radial palsy = wrist drop + preserved triceps + snuffbox sensory loss → splint + physio; NCS at 6-8 weeks; 70-90% recover (BOA/BSSH guidance).
Variceal Bleeding
1 high-yield facts
Variceal bleed = terlipressin + ceftriaxone BEFORE endoscopy; EVL first-line; transfuse 70-80; TIPSS if refractory.
Hurley stage III hidradenitis suppurativa refractory to antibiotics warrants adalimumab (the licensed biologic) combined with wide surgical excision, plus smoking cessation and weight loss.
Encephalitis
1 high-yield facts
RBCs in CSF + confusion = HSE until proven otherwise - start aciclovir immediately, don't wait for PCR.
Rhabdomyolysis
1 high-yield facts
CK >5000 + dipstick blood-positive/RBC-negative; IV fluids 1-2L/h MOST important (output >300mL/h); avoid diuretics; AKI 30-50%; treat hyperkalaemia.
Bell's = sudden LMN VII + forehead involved + no vesicles; pred 50mg ×10d <72h + eye care; 90% recovery.
Drug-Induced Renal Toxicity
1 high-yield facts
Tenofovir Fanconi syndrome = hypokalaemia, hypophosphataemia and glycosuria with a normal blood glucose; a raised urine pH does not exclude proximal RTA. Per BHIVA, monitor renal function regularly on tenofovir disoproxil and switch early if function declines.
Drug-Induced Muscle Toxicity
1 high-yield facts
Statin + gemfibrozil = contraindicated; fenofibrate is safer alternative.
medial
1 high-yield facts
Medial medullary = tongue toward lesion + contralateral hemiparesis + contralateral proprioception loss + pain/temp spared; vs lateral medullary (no hemiparesis, Horner, pain/temp loss).
Critical Care Infections
1 high-yield facts
Sepsis Six in 1h = O₂ + antibiotics + fluids + cultures + lactate + urine output; noradrenaline if refractory.
suprascapular
1 high-yield facts
Suprascapular neuropathy = weak external rotation + infraspinatus atrophy + no sensory loss + overhead athlete; physio first; MRI exclude ganglion; vs axillary (deltoid, sensory).
vestibular
1 high-yield facts
Vestibular neuronitis = acute severe vertigo + horizontal nystagmus + NO hearing loss; prochlorperazine ≤3d; vestibular rehab; 95% recover 6m; vs labyrinthitis (hearing loss).
Antibiotic Pharmacokinetics
1 high-yield facts
CSF penetration = lipophilic + low protein binding + small size; ceftriaxone excellent; avoid aminoglycosides for CNS infections.
First seizure recurrence risk 40-50%; AED reduces to 20-25% but no long-term prognosis benefit; decision individualized (driving, job); lamotrigine/levetiracetam first-line.
Vascular Malformations
1 high-yield facts
HHT = epistaxis + telangiectasia + family history; screen for PAVMs (30-50%); embolise if ≥3mm; prevent stroke/abscess.
Antibiotic Prophylaxis
1 high-yield facts
NICE = no routine prophylaxis; ESC/AHA = prophylax high-risk (prosthetic valves); amoxicillin 3g PO; oral hygiene most important.
Smoking Cessation
1 high-yield facts
Smoking cessation = Most important COPD intervention; Combination NRT (patch + short-acting) for high dependence; Varenicline most effective single agent; Behavioral support essential; Pharmacotherapy doubles/triples quit rates; 12 weeks minimum.
Rare Inflammatory Disorders
1 high-yield facts
Relapsing polychondritis = red ears (sparing earlobes) + saddle nose + hearing loss + scleritis; airway collapse = leading cause death; prednisolone + immunosuppression.
Autoimmune Disease
1 high-yield facts
Relapsing polychondritis = red ears sparing earlobes + saddle nose + stridor; airway collapse = leading cause death; prednisolone + immunosuppression.
trigeminal
1 high-yield facts
TN = electric shock seconds + V2/V3 + triggers; carbamazepine first-line (NNT 2-3); MVD if refractory (70-80% cure); avoid opioids.
Progressive memory loss plus hippocampal atrophy plus MMSE 10-26 equals Alzheimer - acetylcholinesterase inhibitor provides modest symptomatic benefit.
Diabetic Emergencies
1 high-yield facts
Type 1 diabetes sick day rules (illness + reduced intake + elevated glucose/ketones) = NEVER stop insulin (prevents DKA) - continue basal, increase 10-20%, monitor glucose/ketones 2-4 hourly, seek help if ketones >3 or glucose >20, "not eating" NOT reason to stop insulin.
Transplant Infections
1 high-yield facts
CMV disease post-transplant = IV ganciclovir + reduce mycophenolate; monitor viral load weekly until clearance.
Haemoglobinopathy
1 high-yield facts
In sickle cell disease, “new infiltrate + chest pain/fever = acute chest” - treat aggressively with O2, IV antibiotics, strong analgesia, and early consideration of exchange transfusion.
narcolepsy
1 high-yield facts
Narcolepsy type 1 = sleepiness + cataplexy (emotion-triggered tone loss, conscious) + low hypocretin; modafinil + sodium oxybate; no cure.
Farmer with flu + atypical pneumonia + hepatitis + lambing exposure = Q fever; check phase I/II serology, treat with doxycycline, monitor for endocarditis.
Radiotherapy
1 high-yield facts
Late radiotherapy effects are caused by obliterative endarteritis and fibrosis. Chronic radiation proctitis presents years later with telangiectasia and bleeding.
Hypoglycemia Disorders
1 high-yield facts
Persistent neonatal hypoglycaemia + LGA + high insulin/low ketones → IV dextrose first, then diazoxide; genetic testing and 18F-DOPA PET guide surgery.
Glaucoma
1 high-yield facts
Per NICE NG81, SLT is first-line for POAG; where laser is not used, a topical prostaglandin analogue (latanoprost) is the first-line medical therapy. Laser peripheral iridotomy is for angle-closure, not open-angle glaucoma.
meralgia
1 high-yield facts
Meralgia paraesthetica = anterolateral thigh pain/numbness + pure sensory + obesity/tight clothing; weight loss first-line; 90% resolve; vs radiculopathy (motor + reflex loss).
brown
1 high-yield facts
Brown-Séquard = hemisection: ipsilateral motor + proprioception (don't cross in cord); contralateral pain/temp (crosses in cord); 75-90% walk.
Flashes, floaters, and a visual field curtain in a myopic patient is retinal detachment until proven otherwise - requires same-day ophthalmology referral for surgical repair.
Orbital Disease
1 high-yield facts
Proptosis, painful ophthalmoplegia, and reduced visual acuity with fever distinguish orbital from preseptal cellulitis - this is a medical emergency requiring IV antibiotics and urgent ENT/ophthalmology input.
Asthma-COPD Overlap
1 high-yield facts
ACO (smoking + obstruction + asthma features + reversibility + eosinophils) = ICS/LABA combination first-line, not LAMA alone.
Tropical Medicine
1 high-yield facts
Enteric fever = blood cultures; treat with azithromycin or ceftriaxone, and avoid empirical ciprofloxacin after South Asian travel because of fluoroquinolone resistance.
Pressure Ulcers
1 high-yield facts
High-risk pressure-ulcer patients (high Waterlow, immobile) need a high-specification foam mattress plus regular repositioning and skin checks (NICE CG179).
Device-Related Infections
1 high-yield facts
CIED infection = remove everything (device + all leads) - antibiotics alone fail in >90%.
Dermatomyositis = proximal weakness + heliotrope rash + Gottron papules + raised CK; higher malignancy risk (20-30%) than polymyositis (10-15%); arrange urgent malignancy screening and start high-dose prednisolone plus a steroid-sparing agent.
horner
1 high-yield facts
Horner syndrome: partial ptosis + miosis + anhidrosis (no ophthalmoplegia); apical lung mass = Pancoast tumor; carotid dissection if painful; urgent CT chest/neck.
glossopharyngeal
1 high-yield facts
Glossopharyngeal neuralgia = paroxysmal stabbing throat/tonsillar/ear pain (CN IX) triggered by swallowing/talking/coughing, often from a vascular loop; carbamazepine 100-200 mg BD first-line (70-80% respond); microvascular decompression if refractory; distinguish from trigeminal neuralgia (face pain, not throat).
Pharmaceutical Equivalence
1 high-yield facts
Narrow therapeutic index drugs (antiepileptics, warfarin, levothyroxine) - prescribe by brand; generic substitution acceptable within 80-125% bioequivalence but may cause issues in NTI drugs.
Uveitis
1 high-yield facts
Recurrent oral and genital ulcers with posterior uveitis and retinal vasculitis in a patient from the Silk Road region is Behçet disease - aggressive immunosuppression is required to prevent blindness.
Corneal Disease
1 high-yield facts
A dendritic ulcer with terminal bulbs and reduced corneal sensation is pathognomonic of herpes simplex keratitis - treat with topical aciclovir and never prescribe topical steroids for epithelial disease.
delirium
1 high-yield facts
Delirium = acute fluctuating inattention with altered consciousness (4AT ≥4); identify and treat the cause (NICE CG103); non-pharmacological first; haloperidol 0.5 mg only if severe agitation; avoid antipsychotics in Parkinson's disease/Lewy body dementia.
Cardiac Tamponade
1 high-yield facts
Tamponade = Beck's triad + pulsus paradoxus + diastolic RA collapse on echo (ESC 2015) - pericardiocentesis is life-saving; avoid positive-pressure ventilation.
Rosacea Management
1 high-yield facts
papulopustular rosacea (papules/pustules, NO comedones) → doxycycline 40 mg modified-release + topical metronidazole 0.75% or ivermectin 1% per NICE CKS Rosacea; avoid topical steroids and triggers; long-term maintenance topicals.
Paediatric Endocrinology
1 high-yield facts
Central precocious puberty - age 7, LH 8 + FSH 6 ↑ (central GnRH-dependent), bone age 10 (advanced, ↓ height), GnRH stim LH 25 (confirms), MRI normal (idiopathic 90%), leuprolide 3.75 mg IM monthly (desensitizes pituitary, stops puberty, until age 11-12), preserves height 5-10 cm, puberty resumes 6-12m after stopping.
Inherited
1 high-yield facts
MEN-2A - MTC + pheo + hyperparathyroidism, RET codon 634, ALWAYS screen pheo FIRST (remove before thyroidectomy), screen families.
Surgical Emergencies
1 high-yield facts
Pregnancy + suspected appendicitis = ultrasound first, then MRI if inconclusive.
Microangiopathy
1 high-yield facts
In MAHA with low platelets and normal clotting, always think “TTP - treat now with plasma exchange”; waiting for ADAMTS13 assay results is not acceptable in acute presentations.
Nephrotic Complications
1 high-yield facts
Nephrotic-range membranous nephropathy + flank pain + haematuria = renal vein thrombosis; confirm with Doppler/CT venography; LMWH then warfarin/DOAC continued while albumin <25 g/L (KDIGO 2021; UK Kidney Association).
Time is tissue - deliver Sepsis Six within the golden hour.
Adult Immunization
1 high-yield facts
Immunocompromised + asplenia = PCV13 first (primes), then PPV23 8 weeks later; vaccinate BEFORE chemotherapy for better response.
HIV
1 high-yield facts
PEP = start <72h (ideally <4h); Truvada + raltegravir × 28d; reduces transmission 81%; repeat HIV 4-6w/12w/6m.
Vector-Borne Infections
1 high-yield facts
Lyme = erythema migrans (treat without serology); doxycycline 21d; ceftriaxone IV for neuro/cardiac.
Genetic Kidney Diseases
1 high-yield facts
ADPKD = ACE inhibitor for HTN + tolvaptan if rapidly progressive (NICE TA358); screen for intracranial aneurysm if family history of SAH; PKD1 has worse prognosis (ESRD 50-60 y).
Triad of gait apraxia, incontinence, dementia plus ventriculomegaly equals NPH - positive tap test predicts shunt response, early treatment improves outcomes.
carpal
1 high-yield facts
CTS = median nerve symptoms + worse at night + Phalen/Tinel positive; neutral wrist splint first → carpal tunnel release if refractory (NICE CKS 2024).
Claude = CN III + contralateral ataxia (no tremor vs Benedikt, no hemiplegia vs Weber); superior cerebellar peduncle lesion.
copper
1 high-yield facts
Copper deficiency = myeloneuropathy mimicking B12 + normal B12 + post-bariatric/zinc excess; copper supplementation; reversible if early.
locked
1 high-yield facts
Locked-in = conscious + quadriplegic + can only move eyes vertically/blink; ventral pons (basilar thrombosis); communicate via eye movements; thrombectomy.
medication
1 high-yield facts
Daily headache plus regular acute analgesic overuse = medication overuse headache; withdraw the offending drug (headache worsens for 2-10 days then improves), consider a short naproxen bridge, then optimise migraine prophylaxis.
Neurodegenerative
1 high-yield facts
MND = progressive weakness + UMN+LMN signs + NO sensory loss. ALS = both UMN+LMN. Treat with riluzole (extends survival 2-3 months). Multidisciplinary care. Median survival 3-5 years!
polymyositis
1 high-yield facts
Polymyositis: symmetrical proximal weakness + no rash (vs dermatomyositis with rash) + CK elevated 10-50× + EMG myopathic + anti-Jo-1 (ILD association); high-dose prednisolone + azathioprine/methotrexate; screen malignancy 10-15%.
subclavian
1 high-yield facts
Subclavian steal = vertebrobasilar symptoms with arm exercise + BP difference >20mmHg + weak pulse + bruit; Doppler confirms retrograde flow; angioplasty/stenting if symptomatic.
In transplant questions, “high tacrolimus + rising creatinine + no symptoms” should make you think CNI nephrotoxicity first, whereas tender graft, fever, and systemic features point towards rejection or infection.
binucleated/multinucleated erythroblasts plus a positive acidified serum (Ham) test with a negative DAT = CDA-II (HEMPAS); manage supportively with folic acid and iron-overload surveillance in line with BSH guidance, reserving transfusion and splenectomy for severe or transfusion-dependent disease.
DLE = scarring photosensitive plaques with follicular plugging - manage with sun protection, potent topical steroids and hydroxychloroquine 200-400 mg OD (<=5 mg/kg LBW), with baseline and 5-yearly retinal screening (RCOphth/BAD).
Renal Papillary Necrosis
1 high-yield facts
RPN = sickle cell + NSAIDs; ring sign CT; stop NSAIDs; hydroxyurea for sickle cell.
Plasma Cell Dyscrasia
1 high-yield facts
CRAB = symptomatic myeloma - hyperCalcaemia, Renal impairment, Anaemia, Bone lesions - a favourite exam acronym indicating the need for full myeloma therapy rather than observation alone.
Post-COVID fibrosis = 20-30% severe COVID; Persistent dyspnoea + reticular opacities; Most improve within 12 months; Pulmonary rehabilitation essential; Serial HRCT/PFTs monitor; Antifibrotics only if progressive; 10-15% persistent fibrosis.
Vascular Conditions
1 high-yield facts
Raynaud's = white → blue → red colour change - think triphasic vasospasm, screen for secondary causes.
Oncology Infections
1 high-yield facts
Fever + neutrophils <0.5 = pip-taz within 1h; add vancomycin if line/MRSA; antifungal if persistent fever d4-7.
Chelation therapy - forms metal-ligand complexes for renal/biliary excretion; desferrioxamine for transfusional iron overload (target ferritin <1000); prevents cardiac dysfunction from iron deposition.
Bereavement
1 high-yield facts
Prolonged grief disorder = intense yearning + avoidance + functional impairment persisting >6-12 months after bereavement. Key feature is yearning, distinguishing it from depression.
Congenital Urinary Tract Obstruction
1 high-yield facts
PUV = male neonate + 'keyhole sign' + bilateral hydronephrosis; endoscopic valve ablation is definitive per BAUS/BAPU; 30-50% progress to CKD long-term despite treatment.
CN XI palsy = shoulder droop + weak shrug + lateral winging post-neck surgery; vs long thoracic = medial winging.
communicating
1 high-yield facts
NPH = gait (first) + dementia + incontinence + dilated ventricles + normal pressure; LP tap test predicts VP shunt response (60-90% improve).
transient
1 high-yield facts
TIA: transient deficit (less than 24h, typically less than 1h) + ABCD² ≥6 (high-risk, 10% stroke at 7 days); immediate aspirin 300mg + dual antiplatelet (aspirin + clopidogrel) 21 days.
Neutrophilic Dermatoses
1 high-yield facts
Pyoderma gangrenosum is a neutrophilic dermatosis, not an infection - treat with potent topical steroids or systemic immunosuppression (prednisolone or ciclosporin), avoid surgical debridement (pathergy), screen for IBD and haematological disease, and expect healing with characteristic cribriform (sieve-like) scarring (British Association of Dermatologists guideline on pyoderma gangrenosum, 2018).
Metformin-associated lactic acidosis (high anion gap acidosis + high lactate + AKI/sepsis + metformin) = STOP metformin immediately + treat underlying cause + hemodialysis if severe (pH <7.1, lactate >20) - mortality 30-50%, prevention key (stop in AKI/sepsis).
High Altitude Medicine
1 high-yield facts
HAPE at altitude = descend immediately and give oxygen; descent is the single most effective intervention; avoid diuretics; consider nifedipine or hyperbaric therapy only if descent is delayed.
corticobasal
1 high-yield facts
CBS = asymmetric parkinsonism + alien limb + apraxia + cortical sensory loss + levodopa-resistant. Underlying pathology is most often a 4-repeat tauopathy. Median survival 6-8 years; supportive multidisciplinary care only.
Lung Transplant
1 high-yield facts
CLAD = Chronic rejection (bronchiolitis obliterans); FEV1 decline ≥20% for ≥3 months; Affects 50% by 5 years; Leading cause death post-transplant; No effective treatment (irreversible); Median survival 3-5 years; Retransplant only option; Azithromycin slows decline (some patients).
Vertical Transmission Prevention
1 high-yield facts
HIV in pregnancy = start cART immediately to achieve VL <50 by delivery; vaginal delivery safe if suppressed.
restless
1 high-yield facts
Restless legs syndrome: urge to move legs + uncomfortable sensations + worse rest/evening + relieved by movement; check ferritin (replace if <75); ropinirole/pramipexole first-line; avoid antidopaminergics.
ulnar
1 high-yield facts
Ulnar entrapment = little + medial ½ ring finger (palmar + dorsal) + weak interossei + claw hand + Tinel elbow; pads + splint; surgery if severe.
Meningococcal close contact = ciprofloxacin single dose immediately (within 24h) - don't wait for symptoms.
Notifiable Diseases
1 high-yield facts
Measles = notify UKHSA immediately by phone; trace contacts for MMR/HNIG PEP; exclude 4 days post-rash - it's a statutory notifiable disease.
Pubertal Disorders
1 high-yield facts
CDGP - Tanner 1 age 14, bone age delayed 3y, family history late puberty, normal growth velocity, reassurance (self-limiting), testosterone 50 mg IM ×3-6m if distress.
duchenne
1 high-yield facts
DMD = boys + proximal weakness + Gowers + calf pseudohypertrophy + CK 10,000-20,000 + X-linked; prednisolone; wheelchair ~12; life expectancy 20-30y.
Intermediate care = time-limited rehabilitation (up to 6 weeks) to regain independence. Never assess for permanent placement during acute illness. Explore rehabilitation potential first. Prevents prolonged hospital stay and premature institutionalisation.
Drug-Induced Respiratory Toxicity
1 high-yield facts
Non-selective β-blockers CONTRAINDICATED asthma; use ipratropium (bypasses β-receptors); switch to amlodipine.
conus
1 high-yield facts
CMS = sudden + symmetric + mixed UMN/LMN + early bladder + T12-L1; decompression <24h; vs cauda equina (gradual, asymmetric, pure LMN, late bladder).
Fecal incontinence (obstetric sphincter injury + failed conservative + discrete defect on ultrasound) = surgical sphincteroplasty - success 60-70% initially, sacral nerve stimulation alternative with more durable results.
Cardiovascular Infections
1 high-yield facts
IE = fever + new murmur + positive cultures + vegetation; S. aureus → flucloxacillin 4-6w; IVDU → tricuspid.
opsoclonus
1 high-yield facts
Adult OMS = paraneoplastic until proven otherwise - anti-Ri in breast, anti-Hu in SCLC; treat the tumour plus steroids/IVIg/rituximab; CSF lymphocytic pleocytosis supports the diagnosis.
Gradenigo = otitis media + CN VI palsy + V1 pain; petrous apicitis; prolonged IV antibiotics with antipseudomonal cover; CN VI recovers.
alzheimers
1 high-yield facts
Alzheimer dementia: progressive memory + MMSE 10-26 (mild-moderate) + hippocampal atrophy; donepezil 5-10mg (modest benefit, delays care home); memantine if MMSE less than 20.
Crystal Arthropathies
1 high-yield facts
Acute pseudogout = chondrocalcinosis + rhomboid positively birefringent crystals; treat the acute flare with NSAID, colchicine or intra-articular steroid; allopurinol has no role.
Urinary Tract Infection
1 high-yield facts
Pyelonephritis = loin pain + fever + vomiting; IV ceftriaxone/ciprofloxacin if severe; avoid nitrofurantoin; abscess if no response 72h.
Moderate atopic eczema (widespread, sleep-disrupting, failed emollients alone) is treated with a moderate-potency topical steroid such as betamethasone valerate 0.1% for the body plus continued liberal emollients, per NICE CG57; use a mild steroid (hydrocortisone 1%) on the face and step up to a topical calcineurin inhibitor as a steroid-sparing option.
Ulcers
1 high-yield facts
Pyoderma gangrenosum is a neutrophilic dermatosis (not an infection) that is strongly associated with IBD; first-line treatment of a rapidly progressing ulcer is systemic immunosuppression with oral prednisolone 0.5-1 mg/kg/day (or ciclosporin), escalating to anti-TNF (e.g.
Skin Cancer Differential
1 high-yield facts
A rapidly growing keratin-filled crater = treat as cSCC until proven otherwise - excise with a 4 mm peripheral margin per NICE/BAD guidance; do not observe; field-cancerisation requires ongoing skin surveillance.
Facial Dermatoses
1 high-yield facts
Papulopustular rosacea - topical metronidazole or azelaic acid first-line + trigger avoidance; add low-dose doxycycline 40 mg MR OD for moderate-severe or ocular disease; avoid topical steroids; pulsed-dye laser for persistent telangiectasia; per NICE CKS Rosacea and BAD guidance.
Oral Dermatoses
1 high-yield facts
NICE CKS - angular cheilitis is Candida ± Staphylococcus; miconazole 2% covers both; always fix the denture, or it comes straight back.
TSC = autosomal dominant + seizures (often infantile spasms) + ash-leaf spots + facial angiofibromas + cardiac rhabdomyomas + renal angiomyolipomas. Vigabatrin for infantile spasms; everolimus (NICE TA432/TA537) for SEGA and AML. Lifetime surveillance and genetic counselling.
Surgical Oncology
1 high-yield facts
Colorectal liver metastases can be cured by surgical resection in selected patients - always refer to a hepatobiliary MDT for assessment.
Communication
1 high-yield facts
SPIKES = Setting, Perception, Invitation, Knowledge, Emotions, Strategy. 'P' = Perception - find out what the patient already knows before delivering news.
Prognostication
1 high-yield facts
ECOG 3 = bed/chair >50% of day, limited self-care. Performance status guides prognosis and treatment eligibility.
Drug-Resistant Tuberculosis
1 high-yield facts
MDR-TB = rifampicin + isoniazid resistant; specialist referral; all-oral regimens (bedaquiline, linezolid, fluoroquinolone); never add single drug.
Seborrheic
1 high-yield facts
Ketoconazole shampoo is first-line for scalp seborrhoeic dermatitis - reserve potent steroids for short flare control only.
Thoracic Surgery
1 high-yield facts
When FEV1 or DLCO is <80% predicted, calculate ppo FEV1 and ppoDLCO before surgery per BTS guidelines; VO2 max >15 proceed, 10-15 moderate risk, <10 high risk.
Pigmentation
1 high-yield facts
Melasma = SPF 50+ broad-spectrum sunscreen daily plus trigger review first; hydroquinone/retinoid next; reserve laser and oral tranexamic acid for specialist-led resistant disease.
Multiple Endocrine
1 high-yield facts
APS type 3 overlap (T1DM + hypothyroidism + pernicious anaemia) needs levothyroxine AND hydroxocobalamin; check adrenal function before starting thyroxine if Addison disease is possible.
Pulmonary-Renal Syndromes
1 high-yield facts
Pulmonary-renal syndrome needs urgent serology (ANCA, anti-GBM, ANA, anti-dsDNA, complement); SLE with DAH plus nephritis needs immediate IV methylprednisolone and cyclophosphamide; mortality is high without early immunosuppression.
cerebellar
1 high-yield facts
Cerebellar stroke: ataxia + dysarthria + nystagmus + headache/vomiting + PICA territory; monitor GCS (deterioration = brainstem compression); neurosurgical decompression if large (>3cm) or hydrocephalus; mortality 80% large infarcts untreated.
temporal
1 high-yield facts
TLE = aura (fear/déjà vu/epigastric) + automatisms + post-ictal confusion + hippocampal sclerosis on MRI; lamotrigine or levetiracetam are first-line (NICE NG217); refer for temporal lobectomy if drug-resistant.
lateral
1 high-yield facts
Lateral medullary (Wallenberg) syndrome: PICA stroke; ipsilateral Horner + facial pain/temperature loss + ataxia + dysphagia; contralateral body pain/temperature loss; vertigo prominent; NO weakness (pyramidal spared); crossed sensory loss pathognomonic.
Prion Diseases
1 high-yield facts
Sporadic CJD = rapidly progressive dementia + myoclonus + periodic sharp waves + positive CSF RT-QuIC, with cortical ribboning on DWI (the pulvinar sign indicates variant CJD); there is no treatment, survival is 4-6 months, and prions require special decontamination.
Critical Care Respiratory
1 high-yield facts
ARDS severity by PaO2/FiO2: mild >200, moderate 100-200, severe <100 mmHg.
internuclear
1 high-yield facts
INO = impaired adduction + abducting nystagmus + convergence preserved + MLF lesion; MS if young/bilateral, stroke if elderly/unilateral.
foster
1 high-yield facts
Foster Kennedy syndrome equals ipsilateral optic atrophy (chronic nerve compression) plus contralateral papilloedema (raised ICP) plus anosmia, from a frontal meningioma - arrange urgent MRI and neurosurgical resection, and remember ipsilateral vision loss is often irreversible.
Eisenmenger Syndrome
1 high-yield facts
Eisenmenger syndrome is shunt reversal with cyanosis - management is supportive with pulmonary vasodilators (bosentan, sildenafil) via a specialist ACHD centre; defect closure is contraindicated and pregnancy must be avoided (ESC 2020 adult congenital heart disease guidelines).
Psychosocial Care
1 high-yield facts
Existential distress ≠ depression. Active listening first, then offer chaplaincy/psychology. Don't medicalise normal human suffering at end of life.
Fluid and Electrolyte Disorders
1 high-yield facts
Symptomatic hyponatraemia (Na <125 with neurology) → 150 mL 3% saline boluses targeting a 5 mmol/L rise, then fluid restrict (ESE/ERBP 2014; NICE CKS Hyponatraemia; UK Renal Association).
Aortic Dissection
1 high-yield facts
Dissection involving
ECG Interpretation
1 high-yield facts
Sokolow-Lyon >35mm + lateral T-wave inversion = LVH with strain - regress it with BP control!
Mitral Stenosis
1 high-yield facts
MS + pregnancy - tachycardia worsens; beta-blockers for rate control; BMV if refractory (safe >20wk); warfarin teratogenic first trimester.
Myocarditis
1 high-yield facts
Acute viral myocarditis? Supportive HF therapy + NO exercise for 3-6 months. Avoid NSAIDs and routine immunosuppression!
Severe psoriasis + PsA failing methotrexate → anti-TNF (adalimumab) first-line per NICE TA199 and NG65; screen TB/hepatitis pre-biologic; switch to IL-17 or IL-23 inhibitor if inadequate response.
Hip Fracture
1 high-yield facts
Hip fracture surgery within 36 hours (NICE). Displaced intracapsular in elderly = hemiarthroplasty or THR. Orthogeriatric co-management is standard of care. Fascia iliaca block for pain.
Rehabilitation
1 high-yield facts
Rehabilitation goals = patient-centred SMART goals set collaboratively with MDT. Specific, measurable, achievable, relevant, time-bound. Start discharge planning from day 1.
Immobility
1 high-yield facts
Elderly lose 5% muscle strength per day of bed rest. Early mobilisation within 24 hours is the most important intervention. #EndPJparalysis. 10 days bed rest = 10 years of muscle loss.
Dizziness
1 high-yield facts
BPPV = brief positional vertigo + positive Dix-Hallpike (rotatory nystagmus with latency and fatigue). Epley manoeuvre = treatment (~80% cure rate). Avoid vestibular sedatives in elderly (falls risk).
Fever + ANC <0.5 = neutropenic sepsis; pip-taz 4.5g TDS within 1h; do not wait cultures.
Osteomyelitis
1 high-yield facts
When a diabetic foot ulcer probes to bone with raised inflammatory markers, osteomyelitis is highly likely - bone biopsy is the gold standard to confirm the diagnosis and guide antibiotics (NICE NG19).
Immunization
1 high-yield facts
Live vaccines need 4 weeks lead time before anti-TNF - check VZV immunity and vaccinate if negative.
Environmental Kidney Disease
1 high-yield facts
BEN = aristolochic acid + insidious CKD + small kidneys + NO haematuria + urothelial carcinoma 50× risk; supportive + annual cystoscopy.
Environmental Nephrotoxicity
1 high-yield facts
BEN = aristolochic acid + chronic tubulointerstitial nephritis + urothelial cancer 100× risk; supportive + annual cystoscopy; ESRD 50-60y.
Hypertensive Emergency
1 high-yield facts
HTN emergency = IV labetalol; ↓BP 20-25% first 1-2h; avoid rapid drops.
Unexplained Renal Syndromes
1 high-yield facts
LPHS = exclusion; young women + pain + haematuria + negative workup; conservative first; avoid nephrectomy.
Ataxic hemiparesis = weakness + ataxia OUT OF PROPORTION + lacunar infarct (posterior limb IC/pons); small vessel disease.
axillary
1 high-yield facts
Axillary nerve palsy = deltoid paralysis + regimental-badge sensory loss + recent shoulder dislocation; physiotherapy first, explore at 3-6 months if no recovery (BOA 2015 standards).
Motor Neuron Disease
1 high-yield facts
Combined UMN+LMN signs plus bulbar involvement plus no sensory loss equals ALS - riluzole modestly prolongs survival, multidisciplinary care essential.
Metabolic Encephalopathy
1 high-yield facts
Confusion plus ophthalmoplegia plus ataxia in alcoholic equals Wernicke - IV thiamine immediately before glucose prevents Korsakoff syndrome.
Multiple Sclerosis
1 high-yield facts
MS diagnosis: ≥2 clinical attacks in different CNS sites + MRI showing periventricular/juxtacortical/infratentorial lesions + OCBs = definite MS.
Chronic Diarrhoea
1 high-yield facts
Post-cholecystectomy chronic watery diarrhoea + normal investigations = consider BAM, diagnose with SeHCAT scan, treat with cholestyramine.
brachial
1 high-yield facts
Neuralgic amyotrophy = severe pain → resolves → weakness (upper trunk); EMG multi-nerve denervation; physio; no steroids; 70-90% recover 2-3y.
erbs
1 high-yield facts
Erb's = C5-C6 + waiter's tip (adducted, extended, pronated) + intact hand grasp; 70-80% recover 12-18m; surgery if no recovery 3-6m.
foville
1 high-yield facts
Foville = dorsal pons: gaze palsy toward lesion + ipsilateral VII + contralateral hemiplegia; vs Millard-Gubler (ventral pons: isolated VI not gaze palsy); VOR intact.
(NICE NG97): VaD = stepwise decline + vascular risk factors + focal signs + lacunar / white-matter MRI; treat the vasculature (antiplatelet, statin, BP <130/80); AChE inhibitors / memantine NOT recommended unless mixed disease.
Aspirin Overdose
1 high-yield facts
Aspirin OD = early respiratory alkalosis then late metabolic acidosis; urinary alkalinisation critical; haemodialysis if severe >700.
Digoxin Toxicity
1 high-yield facts
Digoxin toxicity precipitated by hypokalaemia + renal impairment; correct K+; DigiFab for life-threatening arrhythmias.
Drug-Induced Hypersensitivity Reactions
1 high-yield facts
DRESS = fever + rash + eosinophilia + organ involvement 2-8 weeks post-drug; delayed T-cell hypersensitivity with HHV-6 reactivation; stop the drug and start systemic steroids if severe (BAD 2022; MHRA).
Drug-Induced Bone Disease
1 high-yield facts
Prednisolone ≥7.5mg ≥3m = alendronate + calcium + vitD; rapid bone loss 5-15% yr1; minimise steroid dose.
Urinary Tract Infections
1 high-yield facts
Pyelonephritis = fever + loin pain + systemic upset; admit if septic, vomiting or pregnant; cultures BEFORE IV co-amoxiclav or ceftriaxone; switch to oral when improving; total 7-14 days; image at 72 h if not responding.
Lithium Toxicity
1 high-yield facts
Acute = GI prominent, level doesn't correlate; chronic = severe CNS, 10% permanent damage; stop + saline + dialysis if severe.
Antibiotic Allergies
1 high-yield facts
Cross-reactivity <3% (not 10%); 3rd-gen cephalosporins safest (<1%); assess allergy severity; most "allergies" not true.
Major bleeding = PCC + vitamin K immediately; minor/high INR = withhold + oral vitamin K.
End-Stage Renal Disease
1 high-yield facts
Friction rub + pleuritic pain + diffuse concave ST elevation + ESRD with very high urea = uraemic pericarditis - urgent haemodialysis is an absolute (AEIOU) indication; avoid systemic anticoagulation; reserve pericardiocentesis for tamponade.
Bacterial Pneumonia
1 high-yield facts
Lung abscess = Cavity with air-fluid level; Aspiration + anaerobes; Antibiotics 4-6 weeks; Drainage if >6cm or failing 7-10 days; Exclude malignancy.
Aspiration
1 high-yield facts
Aspiration pneumonitis = Immediate (<2h) post-gastric aspiration + Chemical injury; Supportive care first; Antibiotics only if no improvement 48-72h; Co-amoxiclav/clindamycin (anaerobic cover); Aspiration pneumonia develops over days; Prevention: swallow assessment.
Pleural Procedures
1 high-yield facts
All pleural aspirations/drains require ultrasound guidance (real-time or mark immediately before); blind landmark technique obsolete/unsafe.
Cystic Lung Diseases
1 high-yield facts
Young woman + recurrent pneumothoraces + diffuse thin-walled lung cysts = LAM; treat with sirolimus.
DPB = East Asian + chronic sinusitis + centrilobular nodules/tree-in-bud + Pseudomonas; long-term macrolide = 90% 10yr survival.
Oxygen Transport Disorders
1 high-yield facts
Methemoglobinemia = Fe2+→Fe3+ (cannot carry oxygen); Dapsone/nitrites/benzocaine causes; Cyanosis + normal PaO2 + chocolate blood; Methylene blue 1-2mg/kg if >20% or symptomatic; Contraindicated in G6PD deficiency; Response 30-60min.
saturday
1 high-yield facts
Saturday night palsy = wrist drop + finger/thumb extension weakness + triceps intact + first dorsal web space sensory loss; splint + physio; 70-90% recover at 6-12 weeks (neurapraxia) (ABN / British Society of Clinical Neurophysiology).
Large Vessel Vasculitis
1 high-yield facts
Takayasu = young Asian woman + pulseless + BP asymmetry + arm claudication; prednisolone + MTX; surgery only when inactive.
Antiplatelet Pharmacology
1 high-yield facts
Aspirin resistance = exclude pseudo-resistance (compliance, NSAID interaction) first → switch to P2Y12 inhibitor (NICE NG185, ESC 2023); no role for routine platelet function testing; do not escalate aspirin dose (CURRENT-OASIS 7).
Chronic Pain Syndromes
1 high-yield facts
Fibromyalgia = widespread pain + tender points + normal bloods; first-line (EULAR 2017 / NICE CKS) = education + graded exercise ± amitriptyline; steroids, DMARDs and long-term opioids are not indicated.
PRES = seizures + visual loss + severe hypertension + posterior vasogenic oedema on MRI; gradual BP reduction to 140-150/90-100 (rapid drop worsens ischaemia); magnesium sulphate for seizures (Magpie); deliver baby; fully reversible if treated promptly.
giant
1 high-yield facts
GCA + vision loss = IV methylpred 1g ×3d immediately; don't wait for biopsy; prevent second eye; taper steroids 12-18m.
LPHS = exclusion diagnosis; young women + pain + haematuria + normal workup; conservative first; nephrectomy avoid.
Cognitive Impairment
1 high-yield facts
Dementia = must notify DVLA. Mild dementia may still drive (DVLA decides with annual review). Doctor should advise notification, can breach confidentiality if patient refuses. Group 2 licence always revoked.
Electrolyte Emergencies
1 high-yield facts
Ca²⁺ gluconate FIRST (cardioprotection, NOT K⁺ lowering) → insulin-dextrose + salbutamol → dialysis.
Polyposis Syndromes
1 high-yield facts
PJS = AD STK11 + perioral pigmentation + hamartomatous polyps; cancer 93% by 64; multi-organ surveillance; polypectomy >1cm; no colectomy.
Anticholinergic Toxicity
1 high-yield facts
Anticholinergic = mad/dry/red/hot/blind; supportive care; physostigmine if severe (not in TCA); benzodiazepines for agitation.
Head and Neck Oncology
1 high-yield facts
Tobacco + alcohol have a synergistic effect in head and neck SCC. HPV is the key factor specifically in oropharyngeal cancer.
Scleral Disease
1 high-yield facts
Deep boring pain, non-blanching violaceous sclera with phenylephrine, and autoimmune disease point to scleritis - the phenylephrine blanch test reliably differentiates it from benign episcleritis.
Lens Disorders
1 high-yield facts
Cataract surgery is indicated when lens opacity causes visual impairment sufficient to affect daily activities - gradual onset, glare, and nuclear sclerosis on slit-lamp confirm the diagnosis; phacoemulsification is the standard of care.
Sepsis and Septic Shock
1 high-yield facts
Septic shock = sepsis + hypotension + lactate >2; Sepsis Six within 1h; noradrenaline for refractory hypotension.
Post-Infectious Syndromes
1 high-yield facts
ARF = post-strep + carditis + migratory arthritis + erythema marginatum; benzylpenicillin + aspirin/prednisolone; MUST have monthly benzylpenicillin prophylaxis ≥10 years.
Progressive unilateral SNHL + CPA enhancing mass on gadolinium MRI = acoustic neuroma; observe small tumours, surgery for >2 cm or brainstem compression; bilateral = NF2 (ENT UK/BSBS).
Ramsay Hunt = facial palsy + ear vesicles + otalgia (VZV geniculate ganglion); aciclovir + prednisolone within 72h; 50% recover (worse than Bell's); CN VIII → vertigo/hearing loss.
tension
1 high-yield facts
TTH = bilateral pressing + mild-moderate + no nausea/photophobia + no activity worsening; amitriptyline prophylaxis; stop analgesic overuse.
Biologic Drug Classification
1 high-yield facts
Monoclonal antibodies end in -mab; substem indicates source (-xi-=chimeric, -zu-=humanized, -u-=fully human); immunogenicity decreases from mouse → human; screen for TB/hepatitis before starting.
Azathioprine pancreatitis - idiosyncratic reaction in 3-5% within first 4 weeks; stop permanently (never rechallenge - 100% recurrence risk); supportive care + alternative immunosuppression.
Inherited Immunodeficiency with Hematological Features
Fibromyalgia = “pain everywhere but tests are normal” - widespread pain, tenderness, fatigue, and poor sleep, without inflammation, distinguishes it from classical rheumatic diseases in exam scenarios.
Thrombosis and Anticoagulation
1 high-yield facts
Cancer VTE = LMWH first-line (not warfarin); lifelong if active malignancy; pancreatic highest risk; Trousseau = migratory thrombophlebitis.
Gastric Disease
1 high-yield facts
Ménétrier's = giant folds fundus/body (spares antrum) + foveolar hyperplasia + protein-losing gastropathy; H. pylori eradication + octreotide; cancer 10-15%.
hemifacial
1 high-yield facts
Hemifacial spasm = unilateral twitching starting at the eye and spreading, persisting in sleep, due to vascular compression of CN VII; botulinum toxin first-line; microvascular decompression curative in 80-90% (ABN / UK movement disorders guidance).
60-70% of necrobiosis lipoidica patients have diabetes, but only ~0.3-1% of people with diabetes develop NL - screen non-diabetic patients for diabetes, and note that the lesions do not improve with better glycaemic control.
Immunobullous
1 high-yield facts
Dermatitis herpetiformis = cutaneous coeliac disease → strict lifelong gluten-free diet (also reduces small-bowel lymphoma risk) plus dapsone for rapid itch control with G6PD screening (BAD / NICE CKS).
Autoimmune Dermatoses
1 high-yield facts
DH = intensely itchy vesicles on extensor surfaces + granular IgA in dermal papillae; dapsone controls skin within 72 h; gluten-free diet lifelong; always check G6PD before dapsone.
Posterior Pituitary Disorders
1 high-yield facts
Cranial DI - polyuria 10 L + polydipsia 8 L (ADH deficiency), Na 148 ↑ + osm 298 ↑, urine 110 dilute (normal >600), water deprivation (osm 305 + urine 125 dilute confirms DI vs polydipsia >600), desmopressin response (125 → 550 >50% confirms cranial vs nephrogenic <10%), traumatic skull base fracture, MRI loss bright spot, desmopressin 10-20 mcg intranasal BD (OR PO 100-200 mcg TDS), target urine 1.5-2.5 L/day, allow breakthrough polyuria prevents hyponatremia, monitor Na weekly, drink to thirst only, prognosis lifelong 80% (transient 20% recovers 12m).
Drug Toxicity Prevention
1 high-yield facts
Folic acid 5mg weekly (24-48h post-MTX) ↓toxicity 70% without ↓efficacy; folinic acid for acute toxicity only.
Page kidney = trauma + new HTN + subcapsular collection + ↑renin; drain if severe; resolves 80%.
Biliary Disease
1 high-yield facts
SOD Type I (biliary pain + elevated LFTs during attacks + dilated CBD) = ERCP biliary sphincterotomy - 85-95% success, definitive treatment.
Plasma Cell Disorders and Amyloidosis
1 high-yield facts
AL amyloidosis (low-voltage ECG + thick myocardium + abnormal light chains) = endomyocardial biopsy Congo red - confirm before chemotherapy.
Cardiovascular
1 high-yield facts
High CHA2DS2-VASc = anticoagulate (benefit outweighs bleeding risk). DOACs preferred over warfarin in elderly. Aspirin NOT recommended for AF stroke prevention. Address modifiable bleeding risk factors rather than withholding treatment.
CN IV palsy = vertical diplopia worse downgaze/adduction + head tilt away from lesion + Parks-Bielschowsky positive; trauma commonest; 80% improve 6m.
ischemic
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Stroke secondary prevention: clopidogrel 75mg daily (superior to aspirin) + atorvastatin 80mg + BP less than 130/80; dual antiplatelet (aspirin + clopidogrel) only 21 days if minor stroke/high-risk TIA; anticoagulation if AF.
jugular
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Vernet = CN IX + X + XI (gag loss + hoarseness + shoulder weakness); glomus jugulare commonest; neurosurgery/radiotherapy.
lhermitte
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Lhermitte = electric shock with neck flexion + cervical demyelination (posterior columns); MS commonest; benign, transient; reassure.
migraine
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Migraine prophylaxis (indicated if ≥3 attacks/month causing disability OR medication overuse): topiramate 50-100mg BD (reduces frequency 50%, teratogenic) OR propranolol 80mg BD; acute triptans + antiemetic; avoid opioids; trial 2-3 months.
multiple
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MSA = parkinsonism (poor levodopa) + autonomic failure + cerebellar + stridor; hot cross bun sign; 6-10yr survival.
Tabes dorsalis = Argyll Robertson pupils (accommodate, not react) + lightning pains + sensory ataxia + areflexia. CSF VDRL is essential for diagnosis. Treat with IV benzylpenicillin 1.8-2.4 g every 4 hours for 14 days (BASHH 2015).
Metabolic Neurology
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ODS = pseudobulbar palsy + quadriparesis 2-7 days after rapid Na⁺ correction + central-pontine T2 hyperintensity - correct chronic hyponatraemia at ≤10 mmol/L/24 h; if early overshoot, re-lower with 5% dextrose ± desmopressin per UK Renal Association guidance.
ACE inhibitor cough = raised bradykinin stimulating C-fibres; switch to an ARB (cough <3%, equivalent efficacy, resolves 1-4 weeks) per BNF and NICE NG136.
Medication Adherence
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, fewer missed doses, less lifestyle disruption.
Oncology
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Suspected MSCC = whole-spine MRI within 24 hours plus immediate high-dose dexamethasone (16 mg/day); plain films are not adequate, and treatment must never be delayed if irreversible neurological deficit is to be avoided.
ACO = Asthma + COPD features; Significant reversibility + eosinophils/FeNO; Triple therapy (ICS/LABA/LAMA) essential; Biologics if eosinophilic; Better than COPD with ICS.
Fungal Disease
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AFRS = Fungal hypersensitivity limited to sinuses; Allergic mucin + fungal hyphae; High IgE + Aspergillus IgE/IgG; No lung involvement (vs ABPA with central bronchiectasis); Surgery + steroids; May progress to ABPA.
Procainamide and hydralazine are the classic high-risk causes of drug-induced lupus - look for anti-histone antibodies with negative anti-dsDNA, serositis without renal or CNS disease, and resolution on stopping the drug (BNF; MHRA).
Colchicine toxicity in CKD = GI, bone marrow, multi-organ failure (fatal); reduce dose: CKD4-5 use 500 mcg OD/alternate days; old high-dose regimen obsolete; CYP3A4/P-gp inhibitors increase toxicity; NSAIDs first-line acute gout.
TPMT deficiency (0.3%) → severe myelosuppression; test before starting; deficient patients avoid or use 5-10% dose; allopurinol + azathioprine reduce dose 75%; monitor FBC weekly initially.
Amiodarone = pulmonary fibrosis (5-15%), thyroid dysfunction, hepatotoxicity, corneal deposits; APT requires stopping drug + corticosteroids; very long half-life (40-60 days).
NSAIDs + ACE inhibitors = afferent vasoconstriction; "triple whammy" with diuretics; avoid combination in elderly/CKD.
Insulin errors = prescribe generic names not brands; never abbreviate "U" as units; separate storage; highest-risk medication.
MTX pneumonitis = dry cough, dyspnea, fever, bilateral infiltrates; NOT dose-related; stop MTX + steroids; 10-20% mortality; never rechallenge.
Apixaban/rivaroxaban major bleed = andexanet alfa 800 mg IV if <8h since dose; idarucizumab for dabigatran only.
Probiotics ↓AAD ~50% (NNT 13); start with antibiotics; *Lactobacillus* GG and *S. boulardii* have the best evidence; avoid in severely immunocompromised or central-line patients.
PPI use >1 year → hypomagnesaemia via TRPM6/7 inhibition; causes secondary hypocalcaemia, hypokalaemia and QT prolongation; stop the PPI, replace Mg²⁺ and switch to an H2RA such as famotidine (MHRA DSU 2012; BNF).
Bioequivalence = AUC and Cmax 80-125% of reference; establishes therapeutic interchangeability; stricter for narrow TI drugs; chemical equivalence insufficient alone; modified-release needs specific bioequivalence studies.
"LEUCOvorin bypasses the BLOCKED pathway" - it's REDUCED folate ready to use! MTX blocks DHFR? Leucovorin says "I don't need that enzyme anyway!"
MTX inhibits DHFR → folate depletion → pancytopenia/mucositis. Treat with folinic acid (leucovorin), NOT folic acid!
Dabigatran ICH = idarucizumab 5g IV (specific antidote); reverses within 5 minutes; PCC/FFP ineffective; hemodialysis if idarucizumab unavailable.
Clozapine = 0.8% agranulocytosis risk; weekly FBC × 18 weeks then fortnightly lifelong; CPMS registration mandatory; never rechallenge if agranulocytosis develops.
Severe myopathy + CK >10× ULN + myoglobinuria + AKI = rhabdomyolysis - stop statin immediately, give IV fluids; high-dose simvastatin and CYP3A4 inhibitors are the dominant risk factors (BNF; MHRA; NICE NG181).
CYP2C9*3/*3 + VKORC1 AA = warfarin 1-2 mg; vitamin K is reserved for bleeding or INR >8 (BNF).
Carbamazepine plus a standard COCP equals contraceptive failure; choose a Cu-IUD, LNG-IUS or DMPA (not the implant or oral methods); the mechanism is hepatic enzyme induction.
Hydroxychloroquine >5 years = annual OCT screening; toxicity irreversible; keep dose <5 mg/kg actual weight.
Phenytoin = zero-order kinetics (saturable) → small dose changes cause large level changes. Titrate slowly!
ONJ risk highest with IV bisphosphonates + invasive dental work; prevent with good oral hygiene + dental assessment before starting; drug holiday benefit unclear for oral bisphosphonates.
Methotrexate monitoring = FBC + LFTs every 2-3 months; detect myelosuppression (most serious), hepatotoxicity; folinic acid rescue if severe toxicity; weekly dosing, avoid NSAIDs/trimethoprim.
PPI + antibiotics = CDI risk via gastric acid suppression → spore survival; stop PPI if unnecessary; oral vancomycin first-line; soap and water (not alcohol gel).
MALA = Type B lactic acidosis; renal impairment = main risk; haemodialysis = treatment; eGFR <30 = contraindication; stop during acute illness.
Rifampicin = potent inducer - double doses of many drugs; PC BRAS mnemonic.
CYP3A4 inhibition (clarithromycin) + simvastatin → rhabdomyolysis; switch to azithromycin or pravastatin/rosuvastatin.
In paracetamol-induced acute liver failure, an arterial pH <7.30 after fluid resuscitation alone fulfils the King's College Criteria for transplant listing - you do not also need the INR/creatinine/encephalopathy triad.
Salicylate toxicity = mixed respiratory alkalosis + metabolic acidosis; alkalinise the urine, replace potassium and dialyse for severe poisoning. A rising PaCO₂ signals dangerous decompensation.
Metformin causes lactic acidosis by inhibiting mitochondrial complex I and blocking NAD⁺-dependent hepatic lactate clearance; suspect it in any unwell, dehydrated patient with renal impairment, and hold metformin on sick days (MHRA / BNF guidance).
NAC <8h most effective; nomogram at 4h; 150/50/100 protocol; King's criteria for transplant; anaphylactoid reaction = pause + antihistamine.
ACE inhibitor angioedema = "BRADYKININ buildup" NOT allergy! Antihistamines won't help. Stop drug, secure airway, icatibant if severe. Afro-Caribbeans at highest risk!
Benzodiazepine overdose = supportive care; Flumazenil rarely indicated, NEVER in epileptics or chronic users.
ACE inhibitor dry cough - most common ADR (10-20%). Mechanism: ↑bradykinin (ACE normally degrades bradykinin) → bronchial irritation. Persistent dry cough (worse at night), onset weeks-months, not dose-dependent.
Benzodiazepine OD = CNS depression; supportive care sufficient for most; flumazenil 0.2mg IV (onset 1-2min, duration 30-60min); contraindicated if seizure risk (dependent patients, TCA co-ingestion).
Itraconazole inhibits CYP3A4 → simvastatin accumulation → rhabdomyolysis; use pravastatin/rosuvastatin with azoles.
DILE = anti-histone antibodies (not anti-dsDNA), normal complement, no renal/CNS involvement; caused by slow acetylation; resolves after stopping drug.
Amiodarone = 15-20% thyroid dysfunction; TFTs every 6 months mandatory; 37% iodine content; hypothyroid more common (continue drug, add levothyroxine).
Z-drugs NO safer than benzodiazepines; similar falls, dependence, cognitive risks; avoid both in elderly if possible; CBT-I most effective; if needed use lowest dose <2-4 weeks.
Beta-blocker overdose = glucagon bypasses blocked receptors; give 5-10 mg IV.
Methotrexate pneumonitis = exclude infection first - think BAL + HRCT, then steroids if infection excluded.
PaO2 reflects dissolved oxygen and stays normal in CO poisoning; it is oxygen content and tissue delivery that fall - measure carboxyhaemoglobin with CO-oximetry and treat with high-flow oxygen (TOXBASE/NPIS).
UK uses a single nomogram line at 100 mg/L at 4 hours (MHRA 2012, TOXBASE) - above the line OR any staggered overdose = start IV NAC immediately, regardless of how well the patient looks.
NAC anaphylactoid = rate-dependent histamine release, not allergy; stop, give chlorphenamine, restart slower; finish the course; adrenaline only for true anaphylaxis.
Iron overdose → free iron toxicity (>transferrin capacity) → GI bleeding, shock, hepatotoxicity, acidosis; serum iron >500 mcg/dL severe; desferrioxamine chelation (binds iron, pink urine); whole bowel irrigation if tablets visible; avoid activated charcoal (ineffective for iron); 5 clinical stages (initial GI → latent → shock/acidosis).
Iron overdose - >20 mg/kg toxic, >60 mg/kg severe. Stages: (1) GI hemorrhage (0-6h), (2) apparent recovery (6-24h), (3) metabolic acidosis, shock, hepatotoxicity (12-48h). Serum iron >350 toxic, >500 severe.
Beta-blocker overdose = bradycardia + hypotension + hypoglycemia; glucagon first-line (3-10mg); high-dose insulin-glucose if refractory; lipid emulsion last resort.
Salicylate overdose = early respiratory alkalosis + later high anion-gap metabolic acidosis. Treat with urinary alkalinisation (sodium bicarbonate) and haemodialysis if severe (TOXBASE).
Benzodiazepine OD = CNS/respiratory depression; flumazenil = GABA-A antagonist (200µg IV); short t½ → re-sedation; contraindicated in epilepsy, chronic BZD use, TCA co-ingestion; supportive care first-line.
Iron overdose = hemorrhagic gastroenteritis + metabolic acidosis + shock; deferoxamine = iron chelator (forms ferrioxamine); serum iron >500 μg/dL = severe toxicity.
Theophylline toxicity = tremor + tachycardia + vomiting; erythromycin/ciprofloxacin inhibit metabolism; multiple-dose charcoal + haemodialysis for severe cases.
BZD overdose = supportive + flumazenil if no contraindications; flumazenil 200 μg then 100 μg increments; contraindicated with seizure history/TCA/chronic BZD; re-sedation risk (short t½); charcoal ineffective; dialysis ineffective (protein-bound, high Vd).
Salicylate = mixed respiratory alkalosis + HAGMA; early respiratory alkalosis, late metabolic acidosis; urinary alkalinization with NaHCO₃; haemodialysis if severe; avoid intubation (loss of respiratory compensation).
Clarithromycin/erythromycin + simvastatin/atorvastatin = rhabdomyolysis risk; stop both, IV fluids; use azithromycin or pravastatin/rosuvastatin instead.
Linezolid = MAO inhibitor; avoid with SSRIs; serotonin syndrome = stop both, benzodiazepines, cooling; use daptomycin/vancomycin or stop SSRI 5 t½ before linezolid.
FQ + steroids/age → Achilles rupture; stop FQ; avoid FQ in elderly on steroids; use alternatives when possible.
Smoke inhalation + lactate >10 mmol/L + normal SpO₂ → suspect cyanide; give hydroxocobalamin 5 g IV (Cyanokit) first-line per TOXBASE/BNF; avoid nitrites because of concurrent carbon monoxide poisoning.
MALA mortality 30-50%; immediate metformin cessation and bicarbonate therapy are life-saving.
Semiconservative; primase makes RNA primer; leading = continuous, lagging = discontinuous (Okazaki fragments); telomeres shorten with replication; telomerase active in cancer/germ/stem cells.
DNA replication = semiconservative, bidirectional; leading strand (continuous, 5'→3', DNA pol III/ε), lagging strand (discontinuous, Okazaki fragments, DNA pol III/δ); key enzymes: helicase (unwind), primase (RNA primers), DNA pol III (synthesis), DNA pol I (remove primers), ligase (join fragments); DNA pol only 5'→3' direction; eukaryotes: pol ε (leading), pol δ (lagging).
Spliceosome = snRNP complex that removes introns; recognizes GU-AG splice sites; defects cause β-thalassemia, SMA; alternative splicing creates protein isoforms.
DNA methylation = epigenetic (reversible); CpG methylation silences genes; cancer = tumour suppressor hypermethylation + oncogene hypomethylation; 5-azacytidine demethylates.
Semiconservative; helicase unwinds, primase = RNA primer, Pol III = 5' to 3'; leading continuous, lagging = Okazaki fragments + ligase; telomerase in germ/stem cells.
CRISPR-Cas9 = gRNA guides Cas9 nuclease to DNA → DSB → gene knockout/correction; BCL11A disruption ↑HbF for sickle cell.
DNA pol 5'→3' only; leading = continuous; lagging = Okazaki fragments (multiple primers, ligated); helicase unwinds; primase makes primers; pol III = main; ligase joins fragments.
Primase makes RNA primers; leading continuous, lagging = Okazaki fragments; Pol III/I + ligase; fluoroquinolones inhibit topoisomerase.
RNAi therapeutics represent precision medicine - silencing disease-causing genes without genomic editing (cf. CRISPR).
BER = single base; NER = bulky lesions (XP if defective); MMR = mismatches (Lynch if defective → MSI-H → immunotherapy); HR = double-strand breaks (BRCA → PARP inhibitors).
Cancer cells reactivate telomerase to maintain telomeres, bypass Hayflick limit, achieve replicative immortality; 85-95% of cancers show telomerase activity.
miRNAs bind mRNA 3'UTR → block translation/promote degradation → reduce protein; antagomirs silence disease-promoting miRNAs like miR-208 in heart failure.
Alternative splicing = multiple protein isoforms from one gene; selective exon inclusion/exclusion during mRNA processing; increases protein diversity; clinical example = dystrophin isoforms.
Semiconservative; helicase unwinds; leading continuous, lagging = Okazaki fragments; DNA pol 5'→3'; proofreading 3'→5' exonuclease; primase → primers → pol I removes → ligase joins.
miRNAs = ~22 nucleotides, bind mRNA 3' UTR, RISC complex; dysregulation in cancer (tumor suppressor↓, oncogene↑); therapeutic targets.
Tumour suppressors = recessive at the cellular level, two hits needed (Knudson; RB1, TP53, APC). Oncogenes = dominant, one gain-of-function hit suffices (KRAS, MYC, BCR-ABL). NHS familial cancer pathways are built around tumour suppressor germline mutations.
Alternative splicing = single gene → multiple mRNA isoforms via selective exon inclusion/exclusion; creates protein diversity (>100,000 from 20,000 genes); tissue-specific, developmental; Bcl-x (anti- vs pro-apoptotic isoforms); SMA (nusinersen corrects aberrant splicing); differs from gene duplication, post-translational modification.
Apoptosis = programmed cell death (energy-dependent, caspases, cell shrinkage, chromatin condensation, membrane blebbing, apoptotic bodies, NO inflammation, phagocytosed); necrosis = uncontrolled (cell swelling, membrane rupture, inflammation, DAMPs release); intrinsic (mitochondrial, p53, cytochrome c) vs extrinsic (death receptor, Fas); cancer resistance (BCL-2 blocks apoptosis); differs from autophagy (survival).
RNA pol II transcribes mRNA; TATA box promoter; pre-mRNA processing = 5' cap + splicing (introns out) + poly(B) tail; alternative splicing → protein diversity; alpha-amanitin inhibits RNA pol II.
RNA pol II = mRNA; TATA box (TFIID/TBP binds); CTD Ser5-P = capping, Ser2-P = splicing/polyadenylation; co-transcriptional processing.
Histone acetylation = open chromatin = active gene transcription; HDACi reactivate silenced tumor suppressors in cancer.
BER removes oxidatively damaged single bases; MUTYH glycosylase deficiency → MAP colorectal cancer; distinct from MMR (Lynch) and NER (XP).
Same region (15q11-13) → different syndrome by parent-of-origin; PWS = loss of paternal; AS = loss of maternal UBE3A; BWS = biallelic IGF2 → overgrowth; DNA methylation silences one allele.
45,X females; short stature + gonadal dysgenesis + webbed neck; bicuspid aortic valve 30%, coarctation 15%; GH for height, oestrogen age 11-12; horseshoe kidney 30%; egg donation for fertility.
Uniparental disomy = both chromosomes from one parent (normal number, abnormal origin); genomic imprinting → parent-specific expression; Prader-Willi (loss paternal 15q11-13, maternal UPD15, hyperphagia, obesity) vs Angelman (loss maternal 15q11-13, paternal UPD15, happy, ataxia); same region, different parent → different disease; trisomy/monosomy rescue mechanism.
Genomic imprinting = parent-specific expression; PWS = loss paternal; AS = loss maternal (same locus).
Anticipation = worsening across generations from trinucleotide expansion. Huntington (paternal CAG), myotonic dystrophy (maternal CTG), Fragile X (maternal CGG).
Klinefelter (47,XXY) = small firm testes, tall, gynecomastia, azoospermia, ↑FSH/LH, ↓testosterone. Testosterone (not fertility). ↑germ cell tumors, breast cancer.
Fragile X = CGG repeat >200 in FMR1; most common inherited intellectual disability; macroorchidism + long face + large ears + autism; anticipation; premutation → FXTAS (males)/POI (females).
Mosaicism = two genetic populations, post-zygotic mutation; Turner mosaicism (45,X/46,XX) → milder phenotype than 45,X; germline mosaicism (gonadal, transmit to offspring); McCune-Albright (GNAS somatic mosaicism); Blaschko lines (skin mosaicism); differs from chimerism (two zygotes fuse).
FMR1 CGG >200 + methylation = no FMRP; males: ID, macroorchidism, autism, seizures; premutation: FXTAS (males), POI (females); expansion maternal.
Variable expressivity = same mutation, different severity; NF1 classic example (100% penetrant but highly variable); vs incomplete penetrance (not all express disease).
Anticipation = earlier onset/worse severity in successive generations due to trinucleotide repeat expansion; HD shows paternal anticipation with CAG expansion.
PWS from maternal UPD (25%) or paternal deletion (70%); methylation analysis distinguishes from deletion.
HH = HFE C282Y → low hepcidin → uncontrolled iron absorption; screen with transferrin saturation ≥45%; treat with venesection; cascade-test relatives (BSH / EASL).
MSI-H CRC + MLH1/PMS2 loss in a young patient or strong family history → germline MMR testing for Lynch syndrome (NICE DG27).
Turner = 45,X = SHORT + PRIMARY ovarian failure + STREAK ovaries! No follicles = No periods = High FSH! Screen heart (coarctation)!
Somatic mosaicism = post-zygotic mutation in subset of cells; affected parent with mild phenotype + severely affected offspring = classic presentation; differs from germline mosaicism (parent clinically unaffected); NF1 shows marked variable expressivity even without mosaicism.
47,XXY tall male + small firm testes + gynaecomastia + azoospermia; ↑LH/FSH, ↓testosterone; lifelong testosterone replacement from age 11-12; TESE+ICSI for fertility (Society for Endocrinology UK guidance).
Lynch = MMR (MLH1/MSH2); early CRC + endometrial; colonoscopy 1-2 y from 20-25; aspirin 600 mg ×2 y reduces CRC; immunotherapy for MSI-high.
Maternal only; ALL offspring inherit (100%); heteroplasmy = variable severity; MELAS (strokes, lactic acidosis), MERRF (myoclonus, ragged red fibres), LHON (vision loss, young males); ragged red fibres on biopsy; no paternal transmission.
Somatic = body tissues (milder, patchy), gonadal = normal parent, affected children (recurrence 1-4% to 50%).
X-linked recessive: carrier mother → 50% sons affected, 50% daughters carriers; no male-to-male transmission.
Anticipation = earlier onset + worse severity each generation; trinucleotide repeats expand in meiosis; Huntington (CAG, paternal), myotonic dystrophy (CTG, maternal), fragile X (CGG); BNF: tetrabenazine for HD chorea; predictive testing via UK Regional Genetics Services (BSGM standards).
UPD = both copies from one parent; trisomy/monosomy rescue; Prader-Willi = loss paternal 15 (maternal UPD 25%), hypotonia then hyperphagia; Angelman = loss maternal 15 (paternal UPD 2-5%), ataxia, happy demeanor, seizures; isodisomy → recessive risk.
Fabry = acroparesthesias + angiokeratomas + renal/cardiac + X-linked. Low alpha-galactosidase A, treat with ERT!
Alport = hematuria + hearing loss + renal failure + X-linked. GBM splitting on biopsy, ACE-I delay progression!
Fragile X = FMR1 CGG expansion >200 with methylation, X-linked dominant, most common inherited ID; large ears, long face, macroorchidism and autism; premutation causes FXTAS/POI; diagnose by FMR1 DNA testing; no cure - MDT support and genetic counselling.
Gaucher disease = glucocerebrosidase deficiency (most common lysosomal storage disorder), glucocerebroside accumulation, Gaucher cells (wrinkled tissue-paper); Type 1 (90%, non-neuropathic, hepatosplenomegaly, bone crises, thrombocytopenia, Ashkenazi Jews); ERT (imiglucerase, reverses manifestations); Parkinson risk 15×; differs from Niemann-Pick (sphingomyelinase), Fabry (alpha-galactosidase A).
An unaffected sibling of an affected child carries a 2/3 carrier risk; a first cousin linked to the carrier line carries about 1/4 risk here, giving a combined 1/24 (4.2%) - far above the population baseline of roughly 1/1,200.
an affected maternal uncle makes the grandmother - not the mother - the obligate carrier, halving the proband's carrier risk to 25%.
mtDNA shows strict maternal transmission with no male-to-child inheritance; offspring severity depends on heteroplasmy and the mitochondrial bottleneck - HFEA-licensed mitochondrial donation is available in the UK for high-risk women.
X-linked recessive = males affected (XY, hemizygous), females carriers (XX); carrier mother × normal father → 50% sons affected, 50% daughters carriers; DMD (dystrophin deletion, progressive weakness, CK↑, cardiomyopathy); hemophilia, G6PD also XLR; manifesting carriers (skewed lyonization); corticosteroids for DMD.
47,XXY tall male + small firm testes + gynaecomastia + azoospermia; ↑LH/FSH, ↓testosterone; lifelong testosterone replacement from age 11-12; TESE+ICSI for fertility (Society for Endocrinology UK).
XLR = males affected (hemizygous), carrier females, maternal transmission, no male-to-male; haemophilia A (VIII), Duchenne (dystrophin, Gowers), G6PD (favism); carrier mother → 50% sons affected; CK elevated 70% Duchenne carriers.
q2 = affected, q = square root, 2pq = carrier; CF 1 in 25 carriers; assumptions: random mating, no selection; consanguinity violates.
Randomisation prevents confounding (balances known + unknown confounders); stratified balances key prognostic factors; does NOT prevent other biases; needs blinding + concealment + ITT.
Attributable risk = incidence exposed - incidence unexposed (absolute effect); this case: 120 - 10 = 110/10,000 excess lung cancers from smoking; attributable fraction = AR/risk exposed (91.7% here); RR (12) measures association strength; AR + prevalence = population attributable risk (public health impact).
Type I error = false-positive (alpha, typically 0.05); Type II error = false-negative (beta, typically 0.20), most often caused by an underpowered study; power = 1 - beta (target 80-90%), and increasing sample size increases power.
Regression to the mean = extreme values tend toward average on repeat (natural variability, NOT real change); pre-post studies vulnerable (mistaken for treatment effect); RCTs control (both groups regress); prevent: multiple baselines, control group.
Screening = high sensitivity (SnNout - don't miss disease); diagnostic = high specificity (SpPin - confirm disease); low prevalence → PPV ↓.
Overdiagnosis = detecting disease never causing harm (true disease, not false positive); PSA screening → ~50% overdiagnosis (indolent cancers treated unnecessarily, side effects); UK: no routine PSA (shared decision); other examples: thyroid incidentalomas, DCIS.
LR+ = sensitivity/(1-specificity); LR+ >10 rules in disease; convert probability ↔ odds for calculations.
KM curves = survival vs time; median survival = where curve crosses 50%; converging curves = no long-term benefit; log-rank test compares curves but doesn't prove causation; always check number at risk table.
Confounding = Coffee AND smoking → lung cancer! When stratified, association DISAPPEARS = Confounder! Effect modification = Association DIFFERS by strata!
Censored = observation ended without event; log-rank test compares curves; curve above = better survival.
Lead-time = earlier diagnosis ≠ longer life; length-time = slow-growing preferentially detected; overdiagnosis = would never cause harm; Wilson-Jungner criteria guide programmes.
NNH = 1/ARI; higher = safer; NNT < NNH = benefit > harm; CI crossing ∞ = not significant.
Confounder = associated with exposure + risk factor for outcome + not on pathway; randomisation = gold standard; multivariable regression adjusts in analysis; confounding controllable, bias is not.
I2 0-40% = fixed effects; 60-100% = random effects; 75% = high heterogeneity, use random effects, investigate sources.
Cross-sectional studies answer "how much?" (prevalence), not "why?" (causation) - temporal sequence is unknown.
A single positive trial may reflect Type I error; replication in adequately powered, pre-registered RCTs is required before changing UK practice (CONSORT 2010, NICE evidence-review methodology).
ITT = analyse as originally assigned (regardless adherence/crossover); preserves randomisation; PP = completers only (efficacy, risk bias); ITT preferred.
Extreme values → average on repeat (not real change); overestimates treatment without control; solution = randomised control group; true effect = intervention − control improvement.
OR (case-control, rare disease) ≈ RR (cohort); OR overestimates RR when outcome common.
AR (risk difference) = absolute excess incidence in the exposed → public-health prioritisation; RR = strength of association; OR for case-control; HR for survival; PAR scales AR by exposure prevalence.
Type I = false positive (α); Type II = false negative (β); power = 1−β.
NNH = 1/ARI; higher NNH = safer; always compare NNT vs NNH before prescribing; CI crossing infinity means harm is not statistically significant (NICE NG196 / NG238; ASCEND-ARRIVE-ASPREE 2018).
HR = ratio of instantaneous event rates; HR 0.65 = 35% reduction; CI not crossing 1 = significant; assumes proportional hazards.
NNH = 1/ARI; smaller NNH = more harm; compare NNT vs NNH to guide treatment decisions.
Extreme values regress on retest; control group essential; compare groups not baseline→follow-up; multiple baselines reduce regression.
ITT = analyse as randomised; preserves balance; per-protocol is biased; multiple imputation for missing data.
Intention-to-treat (ITT) = analyze all randomized patients in original groups (preserves randomization, prevents selection bias, reflects real-world effectiveness); per-protocol = completers only (selection bias, overestimates effect); ITT is gold standard for RCTs (CONSORT).
Hazard ratio = instantaneous risk ratio over time; HR <1 = reduced risk; from Cox model.
HR = instantaneous risk ratio; HR 0.65 = 35% lower death risk at any time; accounts for time-to-event; median survival 18 vs 12 months.
PPV = probability disease if test positive (TP/[TP+FP]); depends on prevalence (↑prevalence → ↑PPV); low prevalence (1%) → low PPV (~15%) despite high sensitivity (90%) + specificity (95%) due to false positives; NPV = probability no disease if negative; screening low-prevalence → need confirmation; SnNout (high sensitivity rule-out), SpPin (high specificity rule-in).
CI excluding 0 (difference) or 1.0 (ratio) = statistically significant; wide CI = imprecise estimate.
SnNOut (sensitive negative rules out); SpPIn (specific positive rules in); D-dimer high sens rules out PE; prevalence affects PPV/NPV not sens/spec.
A wide CI crossing 1.0 indicates an underpowered study, not equivalence (CONSORT; ICH E9; Altman & Bland, BMJ Statistics Notes).
NPV = TN/(TN+FN); high sensitivity + low prevalence → very high NPV (here 99.9%). Use D-dimer only in low/moderate Wells score (NICE NG158, 2023); SnNOut.
Case-control → OR = (a × d) / (b × c); OR > 1 = risk factor; OR ≈ RR when outcome rare (<10%); CI excluding 1 = statistically significant (Doll & Hill British Doctors Study, BMJ 1950/2004).
Type II = false negative (underpowered study); power = 1−β = 80%; sample size most common cause; power calculation before study essential; ↓α → ↑β trade-off.
Effect modification = treatment effect varies by subgroup; stratified analysis shows different effect sizes; aspirin = men benefit (NOT women pre-menopause); trastuzumab = HER2-positive only; personalized medicine (identify responders); interaction term = statistical test (p <0.05 suggests); contrast confounding (distorts, adjust removes).
Allocation concealment = hiding treatment assignment from investigators enrolling patients → prevents selection bias; different from randomization (creates groups) and blinding (after allocation); sealed opaque envelopes, central randomization best methods; CONSORT requires adequate concealment; selection bias = enrolling different patients into groups.
High sensitivity = good NPV (rules out); High specificity = good PPV (rules in).
Normal anion gap acidosis = diarrhea/RTA; hyperchloremia present; contrast with high anion gap (MUDPILES).
pH then primary then compensation then AG; high AG = MUDPILES; Winter's formula for metabolic acidosis; respiratory compensation fast, metabolic slow.
Hungry bone syndrome = severe post-parathyroidectomy hypocalcemia from rapid skeletal remineralization; low Ca + low PO₄ + suppressed PTH; treat with IV calcium + oral calcium + calcitriol.
PHPT = ↑calcium + inappropriately elevated PTH + ↓phosphate; caused by parathyroid adenoma; treat with parathyroidectomy if symptomatic.
HMBS deficiency; ↑PBG + ALA diagnostic; IV haem arginate first-line; port-wine urine; OCP/fasting/barbiturates trigger; opiates safe.
Mixed DKA + respiratory acidosis = pCO2 high (not low); dangerous pH; assess for CNS depression/exhaustion; may need intubation.
Hyperkalaemia >5.5; peaked T-waves earliest (5.5-6.5); RAAS inhibitors ↓aldosterone; calcium gluconate = cardioprotection (NO effect K⁺); insulin-dextrose + salbutamol = shift K⁺ into cells; dialysis if renal failure/K⁺ >7.0.
HAGMA = AG >12 + unmeasured anions; MUDPILES; delta ratio identifies mixed disorders; treat underlying cause; haemodialysis for severe toxins; NAGMA = normal AG, diarrhoea/RTA.
High calcium + high/normal PTH = PHPT until proven otherwise; High calcium + low PTH = look elsewhere.
Km = [S] at ½Vmax (lower = higher affinity); Vmax = max rate; competitive inhibitors ↑Km; non-competitive ↓Vmax.
Type 1 RTA = "DISTAL = CAN'T make urine acid!" Urine pH >5.5 + low K+ + stones = Type 1. Type 4 = HIGH K+!
Severe hyperkalaemia with ECG changes - give IV calcium first for cardioprotection (works in minutes, does not lower K+), then insulin-glucose ± salbutamol to shift, and dialysis/binders to remove.
High AG metabolic acidosis = MUDPILES; DKA = ketones + hyperglycaemia + AG ~25-35.
Hungry bone = severe hypocalcemia post-parathyroidectomy (severe hyperPTH with bone disease). Bone remineralization avidly uptakes Ca/PO4. Needs massive IV calcium + calcitriol + Mg for weeks.
Acute respiratory alkalosis = ↑pH + ↓PaCO₂ + normal HCO₃⁻; commonest cause is anxiety hyperventilation; perioral tingling and carpopedal spasm reflect ↓ionised Ca²⁺. Always exclude PE, sepsis and salicylates. Per NICE CKS, do not use paper-bag rebreathing - reassurance and breathing retraining.
SIADH = euvolaemic hyponatraemia + urine osm >100 + urine Na⁺ >30 + normal thyroid/adrenal function (Society for Endocrinology UK / NICE CKS); fluid restrict first, correct <10 mmol/L/24 h to avoid osmotic demyelination.
TLS hypocalcaemia is due to calcium-phosphate precipitation driven by hyperphosphataemia, not a PTH or vitamin D problem; rasburicase treats, allopurinol prevents; aggressive hydration; follow BCSH 2015 risk-stratified prophylaxis.
HHS = glucose >30, osmolality >320, NO ketones; fluids priority (0.9% saline 1 L first hour); insulin 0.05 units/kg/h (half DKA); avoid rapid correction (cerebral oedema).
"Conn's" = High BP + Low K+ + Alkalosis + Low renin! Aldosterone says "Keep Na+, dump K+ and H+!" Cure adenomas surgically!
Isolated unconjugated hyperbilirubinaemia + normal Hb/reticulocytes + well patient = Gilbert syndrome (diagnosis of exclusion).
Respiratory acidosis from hypoventilation - acute (HCO3 +1/10 mmHg), chronic (HCO3 +3.5/10 via renal retention). Treat cause, support ventilation.
Winter's formula for met acidosis; compensation never overcompensates; actual ≠ expected = mixed disorder.
Metabolic alkalosis from vomiting = chloride-responsive (urine Cl- <20, volume depletion, hypochloremia); treat: normal saline + KCl (NOT K-citrate); chloride-resistant (urine Cl- >20, hyperaldosteronism); contraction alkalosis (volume depletion → ↑aldosterone); acetazolamide or HCl if refractory; correct hypokalemia (paradoxical aciduria).
Calcium gluconate FIRST if ECG changes (stabilises membrane, doesn't ↓K⁺); insulin-dextrose shifts K⁺ in; dialysis definitive; peaked T earliest sign; renal failure + drugs = most common causes.
Anion gap = Na⁺ − (Cl⁻ + HCO₃⁻); HAGMA + metformin + impaired renal function = MALA - stop metformin, supportive care, and consider urgent haemodialysis if pH <7.0, refractory shock, or lactate >20 per NICE NG28.
TLS hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia; rasburicase 0.2 mg/kg IV (rapid effect, avoid G6PD), dialysis if K+ greater than 6.5.
Type A = tissue hypoxia (shock, ischaemia); Type B = no hypoxia (metformin, liver failure); lactate, pH, anion gap and bicarbonate are abnormal in both and do not distinguish them; treat the underlying cause.
High osmolar gap + high anion gap = toxic alcohol; Osmolar gap >10 = methanol or ethylene glycol; Fomepizole + dialysis save lives.
Symptomatic hypermagnesaemia + ECG changes = IV calcium gluconate first → saline + furosemide → haemodialysis if severe or in renal failure (UK Renal Association).
↑Osmolar gap + HAGMA + visual loss = methanol; fomepizole first-line; haemodialysis if severe; ethylene glycol = renal failure + oxalate; isopropanol = no acidosis.
Osmolar gap >10 = unmeasured osmoles; toxic alcohols (methanol/ethylene glycol), ethanol, mannitol; combined with anion gap acidosis.
Central DI = post-surgery; water deprivation → dilute urine; DDAVP → concentrates urine (>600 mOsm/kg); treat with desmopressin.
Type A = tissue hypoxia (shock - NICE NG51); Type B = no hypoxia (B1 disease, B2 drugs including metformin, B3 inborn errors); metformin contraindicated at eGFR <30 (BNF); D-lactate missed by standard assays.
Grapefruit = irreversible intestinal CYP3A4/P-gp inhibition → simvastatin rhabdomyolysis (swap to pravastatin/rosuvastatin); MAOI + tyramine → hypertensive crisis; warfarin + vitamin K → consistent intake, avoid cranberry juice; chelating cations → separate by 2-4 h (BNF/MHRA).
SIADH = euvolaemic hyponatraemia + inappropriately concentrated urine + urine Na >40; fluid restriction first-line (ESE/ERA/ESICM 2014); hypertonic saline only if severely symptomatic; SCLC is a classic cause.
Type A = tissue hypoxia (shock); Type B = NO hypoxia (metformin, liver disease); sepsis = both types; treat cause; lactate clearance predicts survival; bicarbonate only if pH <7.1.
Osmolar gap = measured - calculated (normal <10). High gap + anion gap acidosis = toxic alcohols (methanol, ethylene glycol). Fomepizole + hemodialysis. Isopropanol = high gap, NO acidosis.
Allopurinol + azathioprine → 6-MP 3-5× accumulation; reduce azathioprine 50-75% and monitor FBC weekly (BNF); febuxostat shares the interaction.
Cimetidine inhibits CYP2C9/2C19/3A4 → warfarin and phenytoin toxicity; substitute a PPI or famotidine (ranitidine was withdrawn in the UK in 2020, MHRA).
Thiazide → Na⁺ depletion → ↑proximal lithium reabsorption → ↑30-50%; stop thiazide + IV saline; use amlodipine for BP (BNF lithium; MHRA Drug Safety Update).
Enzyme inducers → OCP failure (↓levels 40-60%); use copper IUD/IUS/barriers; standard OCP/POP unreliable; persists 4wk post-cessation.
Metronidazole inhibits CYP2C9 → reduced S-warfarin clearance → raised INR and bleeding; recheck INR at 3-5 days and adjust the dose (BNF Appendix 1 interactions).
Clarithromycin + warfarin = CYP inhibition → warfarin accumulation → high INR; Always check interactions before prescribing.
Quinolones + corticosteroids = high tendon rupture risk (especially Achilles); FDA black box warning; stop immediately if tendon pain develops; avoid in elderly on steroids.
Additive - combined effect equals the sum (1+1=2, most drug combinations); synergistic - combined effect exceeds the sum (1+1>2, co-trimoxazole, carbidopa-levodopa); both can allow lower doses through complementary mechanisms.
Rifampicin (and rifabutin) are potent enzyme inducers - switch to Cu-IUD, LNG-IUS or DMPA; COC/POP/implant are unreliable; cover for 28 days after stopping rifampicin (FSRH 2022; BNF Rifampicin).
Grapefruit + simvastatin = irreversible CYP3A4 inhibition → ↑16×; stop both + IV fluids; switch pravastatin (no interaction).
Ibuprofen competitively blocks aspirin's COX-1 access; give aspirin ≥2h before any NSAID, or use paracetamol instead - preserves cardioprotection.
Thiazides reduce lithium excretion causing toxicity; avoid combination; use loops if needed; monitor levels.
Cranberry inhibits CYP2C9 → raised INR/bleeding; INR 5-8 + minor bleed = stop warfarin + vitamin K 1-3 mg; major bleed = IV vitamin K + 4-factor PCC (BNF; BSH 2011; MHRA DSU).
Amiodarone + warfarin - CYP2C9 inhibition; reduce warfarin by 30-50% when starting amiodarone and monitor INR closely for 4-6 weeks.
Rifampicin is the strongest CYP450 inducer - increases metabolism of most drugs.
Grapefruit juice inhibits intestinal CYP3A4 - avoid with simvastatin, felodipine, and immunosuppressants.
Amiodarone inhibits CYP2C9 → ↑warfarin → ↑INR; reduce warfarin 30-50%; monitor weekly ×4wk; major bleeding = vitamin K + PCC; rifampicin = most potent ↓INR.
CYP3A4 inhibition (macrolides, azoles, grapefruit) → ↑statin levels → rhabdomyolysis; simvastatin/lovastatin/atorvastatin are CYP3A4-dependent (high risk); pravastatin/rosuvastatin are safer; clarithromycin + simvastatin 80 mg is a BNF-flagged interaction; manage with drug cessation and IV fluids.
Achilles most common (70%); age >60y + corticosteroids = high risk; stop quinolone immediately; rupture = "pop", cannot plantarflex, Thompson test; avoid quinolones if high-risk.
Warfarin = CYP2C9 substrate; metronidazole/amiodarone/fluconazole inhibit → ↑ INR; rifampicin/carbamazepine induce → ↓ INR; monitor INR closely with any change.
Clarithromycin = potent CYP3A4 inhibitor; simvastatin highest risk; azithromycin safe (no CYP3A4 interaction); switch to pravastatin/rosuvastatin if CYP3A4 inhibitors needed; grapefruit juice also inhibits CYP3A4.
Fluconazole - potent CYP2C9 inhibitor increases warfarin levels (supratherapeutic INR); use terbinafine as safer alternative for fungal infections in anticoagulated patients.
Clarithromycin + simvastatin = rhabdomyolysis - always switch to azithromycin or doxycycline for pneumonia.
Type III = immune complexes, complement activation; serum sickness 7-10 days; low C3/C4; SLE/vasculitis/glomerulonephritis.
Type I = immediate (<1 hour), Type II = cytotoxic (hours-days), Type III = immune complexes (7-14 days) + low complement, Type IV = delayed (48-72 hours).
ACE-i angioedema = bradykinin-mediated, no urticaria, poor response to adrenaline/antihistamines; stop the ACE inhibitor permanently, secure the airway, avoid ARBs where possible, and consider icatibant in severe cases.
Type III = immune complexes + complement; serum sickness = fever/arthralgia/rash 7-21 days; SLE = decreased C3/C4; post-streptococcal GN = decreased C3.
High-titre dsDNA + homogeneous ANA + active nephritis = SLE needing urgent treatment.
Terminal complement (C5-C9) deficiency → cannot form MAC → recurrent Neisseria infections (meningococcus, gonococcus); C3 normal (opsonization intact); MAC essential for Neisseria lysis; meningococcal vaccination crucial; CH50 low, C5-C9 absent; differs from C3 deficiency (broader pyogenic infections), C1-INH (angioedema).
Myasthenia gravis = anti-AChR antibodies (85%), fatigable weakness (worsens with use, improves rest), ocular/bulbar/limb; neuromuscular junction block; pyridostigmine (AChE inhibitor) + immunosuppression (prednisolone); thymectomy if thymoma/<60; myasthenic crisis (IVIg/plasma exchange); differs from LEMS (anti-VGCC, improves with use, paraneoplastic).
"C5-C9 = MAC = Kills Neisseria!" Terminal complement deficiency = ONLY Neisseria infections! Vaccinate and consider prophylaxis!
Farmer's lung = Type III (4-6 h after mouldy hay exposure, IgG precipitins to *Saccharopolyspora rectivirgula*); antigen avoidance is the cornerstone of management (BTS 2017).
Selective IgA deficiency - commonest primary immunodeficiency; isolated low IgA with normal IgG/IgM; anaphylaxis to blood products via anti-IgA antibodies; screen for coeliac disease; avoid IVIG and standard transfusion (UK PIN/BSI).
Early (C1-C4) = SLE; C3 = severe infections; C5-C9 = Neisseria only (vaccinate); Factor H/I = atypical HUS (eculizumab); C1-INH = angio-oedema.
HAE = C1-INH deficiency → bradykinin → angioedema (no urticaria); Low C4 diagnostic; Antihistamines ineffective; Treat acute with C1-INH or icatibant; Prophylaxis with androgens.
HAE = C1-INH deficiency → ↑bradykinin → angioedema; no urticaria; ↓C4; acute = C1-INH concentrate/icatibant; antihistamines/adrenaline ineffective; avoid ACEi/oestrogen.
"Anti-dsDNA = SPECIFIC for SLE + tracks disease!" ANA screens, anti-dsDNA confirms. Rising dsDNA = Flare coming!
Type IV = T-cell, 24-72h, NO antibodies; contact dermatitis = patch testing; tuberculin = induration >=10mm at 48-72h; granulomatous = TB (caseous), sarcoidosis (non-caseating).
Cryoglobulinemia Type II = HCV + immune complexes + vasculitis; Very low C4 diagnostic; Triad = purpura + arthralgia + GN; Treat HCV.
SCID = "Bubble boy disease" - NO T cells, NO thymus, DEAD by 2 without HSCT! PCP in infant = Think SCID!
M-protein >30 g/L plus any CRAB feature (Calcium, Renal, Anaemia, Bone) in a patient with clonal plasma cells = multiple myeloma. NICE NG35 guides urgent referral and the initial work-up (FBC, calcium, renal function, protein electrophoresis, serum free light chains and skeletal imaging).
DiGeorge CATCH-22 (cardiac/facies/thymic hypoplasia/cleft/hypocalcemia/22q11.2), calcium+vitamin D/cardiac surgery/PCP prophylaxis/avoid live vaccines!
Type IV hypersensitivity = T-cell mediated, delayed 48-72 hours (NOT immediate); contact dermatitis (nickel, poison ivy); tuberculin test, granulomas, transplant rejection also Type IV; patch testing diagnostic; avoid allergen + topical steroids; differs from Type I (IgE, immediate) and Type III (immune complexes, hours).
HLA-B27 associated with seronegative spondyloarthropathies (AS, reactive, psoriatic, enteropathic); AS = young male, inflammatory back pain (improves exercise, worse rest, morning stiffness), sacroiliitis, bamboo spine; 90% HLA-B27+; NSAIDs + TNF inhibitors; other HLA: DR4 (RA), DQ2/DQ8 (celiac).
Type III hypersensitivity = immune complex deposition (antigen-antibody), complement activation, 7-21 days onset; serum sickness (antivenom, monoclonals, fever, arthralgia, rash, proteinuria, ↓complement); self-limiting, NSAIDs/steroids; SLE, post-strep GN, Arthus reaction also Type III; differs from Type I (IgE, immediate), Type II (cytotoxic), Type IV (T-cell, 48-72h).
Innate = rapid, non-specific, no memory (PAMPs/PRRs); Adaptive = slow, specific, memory (TCR/BCR); distinguished by specificity and memory.
Type III = immune complexes, 7-14 days; serum sickness = foreign proteins; low complement + fever + arthralgia + rash + proteinuria; self-limiting; corticosteroids if severe.
Type IV = T-cell mediated, delayed 48-72h; contact dermatitis, TB test, granulomas.
Anti-AChR (85%) most common; MuSK (5-10%) → bulbar, rituximab-responsive; pyridostigmine + steroid-sparing immunosuppression; thymectomy if thymoma or AChR+ <65 (MGTX); IVIg/plasma exchange for crisis.
HLA-B27 = seronegative spondyloarthropathies (AS, reactive, psoriatic); HLA-DR3/DR4 = type 1 diabetes, autoimmune; HLA increases risk but doesn't cause/guarantee disease.
CVID = adult-onset low IgG with low IgA and/or IgM, normal lymphocyte counts, and impaired vaccine responses; treat with regular immunoglobulin replacement and screen for bronchiectasis, autoimmunity, and malignancy per UK PIN/ESID guidance.
HAE = C1-INH deficiency, increased bradykinin; NO urticaria; decreased C4 screening; C1-INH concentrate or icatibant acute; acquired = decreased C1q.
Arthus = localized type III, repeated antigen, onset 3-10h (delayed); erythema, induration (injection site); local immune complexes → complement → neutrophils → vasculitis; stop injections, self-limiting (1-2 weeks); contrast allergic (immediate minutes), type IV (24-72h); skin biopsy = leukocytoclastic vasculitis.
Factor V Leiden + prior VTE in pregnancy = therapeutic LMWH throughout + 6 weeks postpartum. Warfarin teratogenic, LMWH safe!
MG = AChR antibodies → reduced receptors → fatigable weakness. The ice pack test works because cooling inhibits acetylcholinesterase. Pyridostigmine + immunosuppression.
C3 = opsonization hub - deficiency = recurrent Neisseria (needs opsonization for clearance, unlike other organisms).
MGUS = <30 g/L + <10% plasma cells + no CRAB = watch and wait.
LEMS = proximal weakness + autonomic symptoms + low reflexes that augment + anti-VGCC = screen for SCLC urgently.
CVID = ↓IgG + ↓IgA/IgM; B cells present (vs absent in XLA); poor vaccine response; IVIg lifelong; autoimmunity 20-30%.
IgA deficiency = most common (1:600), anaphylaxis risk with blood products; XLA = BTK, absent B cells, males; CVID = poor vaccine response, autoimmunity; both XLA/CVID need lifelong IVIg.
FV Leiden = most common, APC resistance; Protein C deficiency = warfarin skin necrosis; antithrombin = highest risk + heparin resistance; APS = acquired, thrombosis + pregnancy loss.
IgA <0.07, most common primary immunodeficiency; 85-90% asymptomatic; coeliac 10-15× ↑risk; anaphylaxis risk with blood products (anti-IgA antibodies) → washed red cells; 5-10% progress to CVID.
Most common PID (1:300-700); IgA <0.07; many asymptomatic; Giardia; coeliac 10-15× risk; CRITICAL anaphylaxis risk blood products → washed RBCs; medical alert bracelet.
CSHT = time to ↓50% after stopping infusion; remifentanil constant ~3min (ideal); fentanyl ↑↑ with duration (avoid long infusions); peripheral accumulation prolongs offset.
LD = Css × Vd / F; independent of clearance; used long t½ drugs (digoxin, phenytoin, amiodarone); maintenance dose depends on clearance.
Non-linear kinetics (phenytoin, alcohol) = enzyme saturation → fixed amount eliminated (zero-order) → disproportionate level rise with small dose increase; phenytoin therapeutic 10-20 mg/L (CYP2C9/2C19 saturates); small dose changes (25-50 mg) → large level changes; TDM essential; differs from first-order (linear, constant proportion eliminated).
Enterohepatic recirculation is the classic exam mechanism, but current FSRH advice is that non-enzyme-inducing antibiotics like amoxicillin do NOT require extra contraceptive precautions - only enzyme inducers such as rifampicin do.
First-pass = oral drug metabolized by liver before systemic; Sublingual/transdermal/inhaled bypass first-pass; GTN sublingual for angina (fast, higher bioavailability); High first-pass drugs need alternative routes or higher oral doses.
Bioavailability = fraction reaching systemic circulation; first-pass = hepatic metabolism after GI absorption; high first-pass = low oral F (propranolol 25%, morphine 30%, GTN <1%); sublingual/IV bypass; liver disease ↑F.
Elderly pharmacokinetics - reduced renal clearance most critical change; use Cockcroft-Gault for dosing; start low, go slow; avoid anticholinergics.
Gentamicin OD = concentration-dependent killing + PAE; trough <1mg/L; ↓nephro/ototoxicity vs multiple daily.
Time to steady-state = 5 × half-life - long t½ drugs need loading doses.
Narrow therapeutic index drugs - prescribe by brand to prevent bioavailability variation.
Weak acids ionize in alkaline urine - trapped and excreted (ion trapping enhances elimination).
Codeine is a CYP2D6-dependent prodrug - PMs get no analgesia, UMs risk fatal morphine toxicity (MHRA Drug Safety Update 2013; BNF). Switch PMs to morphine or oxycodone.
Codeine needs CYP2D6 for morphine; PM = no analgesia, UM = toxicity; tamoxifen PM = worse outcome; avoid fluoxetine/paroxetine with tamoxifen.
Vd >body weight = extensive tissue distribution; amiodarone Vd ~3500L explains long t½ and loading requirement.
Renal dosing for >50% renally eliminated; Cockcroft-Gault for dosing; enoxaparin ↓dose CrCl <30; metformin avoid eGFR <30; aminoglycosides dose post-dialysis.
Lipophilic drugs have a high Vd (≫body size); amiodarone Vd ≈70 L/kg with a long half-life, large loading dose and negligible dialysability - calculate with Vd = Dose / C₀.
Cirrhosis - reduced hepatic metabolism requires dose reduction; choose renally eliminated drugs when possible; Child-Pugh C needs 50-75% reduction.
Renal drug clearance ∝ eGFR; gentamicin 90% renally excreted requires significant dose reduction in CKD.
First-pass = liver metabolism before systemic; high ER (>0.7) = flow-dependent, low bioavailability (propranolol/morphine/GTN); low ER = enzyme-dependent; IV/sublingual bypass; liver disease ↑bioavailability.
Time to steady state = 5 × t½ (independent of dose/interval); accumulation occurs when the dosing interval is shorter than the elimination time; loading dose = Vd × target concentration; long t½ drugs (e.g. amiodarone) take months; use TDM for digoxin, lithium and phenytoin (BNF).
St John's Wort hyperforin = inducer of CYP3A4/2C9/2C19 + P-gp (onset 1-2 weeks); contraceptive failure (additional barrier + 4 weeks after stopping); transplant rejection; ↓INR with warfarin; contraindicated with HIV antiretrovirals; per MHRA/BNF.
Competitive = same site, reversible, right shift, Emax unchanged; non-competitive = different site/irreversible, ↓Emax; phenoxybenzamine + aspirin = irreversible; benzodiazepines = allosteric.
Tolerance = ↓response with continued use; pharmacodynamic (receptor desensitisation) vs pharmacokinetic (enzyme induction); opioid tolerance affects analgesia, respiratory depression and euphoria - rotate opioid with 25-50% dose reduction for cross-tolerance.
Salbutamol = β2-selective agonist → bronchodilation via cAMP; selectivity is dose-dependent (high doses → β1 tachycardia + tremor + hypokalaemia); first-line reliever per BTS/SIGN/NICE NG80.
TI = TD50/ED50 (high TI = safer); narrow TI drugs (warfarin, digoxin, lithium, phenytoin, gentamicin) need TDM.
Inverse agonists suppress constitutive activity (below baseline), neutral antagonists block ligands without baseline effect. Examples: some β-blockers, antihistamines.
Potency = EC₅₀ (lower = more potent); efficacy = Emax (clinically more important); fentanyl more potent than morphine, same efficacy; paracetamol less efficacious; partial agonist = submaximal Emax.
Narrow TI drugs: warfarin, digoxin, lithium, phenytoin (zero-order), aminoglycosides, theophylline; TDM at trough, steady state (4-5 t½); renal/hepatic impairment → ↑levels.
Aspirin - irreversible COX-1 acetylation causes platelet inhibition lasting 7-10 days (platelet lifespan); effect independent of short drug half-life; stop 7-10 days pre-op if high bleeding risk.
Potency = ED50 (left-shift of dose-response curve). Efficacy = E_max (ceiling). Drug A: more potent, less efficacious. Clinically, efficacy > potency. Full vs partial agonists (morphine vs buprenorphine) illustrate the distinction. Reference: Rang & Dale Pharmacology; BNF pharmacodynamics.
Partial agonist = submaximal response despite full receptor occupancy; buprenorphine = ceiling effect for respiratory depression (safer); high affinity → displaces full agonists → withdrawal risk.
Allosteric modulators bind separate site from endogenous ligand; PAMs enhance (benzodiazepines ↑GABA-A frequency, NO intrinsic activity, ceiling effect), NAMs reduce; benzodiazepines at α-γ interface (GABA at α-β); advantages: selectivity, safety (ceiling effect vs barbiturates).
NTI = TI <2; requires TDM (digoxin, lithium, phenytoin, gentamicin, tacrolimus); prescribe by brand.
Tolerance - ↓drug response with repeated use. Tachyphylaxis - rapid tolerance. Beta-agonist tachyphylaxis - receptor desensitization + downregulation (avoid LABA monotherapy, use with ICS). Nitrate tolerance - nitrate-free interval (10-14h/day) prevents tolerance.
Allosteric modulators bind allosteric site (NOT active site), alter response to endogenous ligand; benzodiazepines = GABA-A positive allosteric modulators (↑frequency of Cl⁻ opening, require GABA); safer than direct agonists (ceiling effect); flumazenil antagonist.
Full agonist = maximal response; partial = submaximal + ceiling; partial antagonises full agonist; buprenorphine safer (ceiling); precipitated withdrawal if given too soon after full agonist.
Affinity = Kd (low = high affinity); efficacy = max response; partial agonist = submaximal at full occupancy; competitive antagonist = right shift; non-competitive = ↓max; EC50 = potency measure.
Therapeutic index = TD50/ED50 (toxic/effective dose ratio); high TI (>10) = safe (penicillin TI~100), low TI (<10) = dangerous (warfarin TI~2, phenytoin, digoxin, lithium); narrow TI → require TDM, frequent monitoring, dose adjustments; drug interactions/organ impairment more critical.
Competitive antagonism = same binding site, rightward shift (↑EC50), Emax unchanged (overcome by more agonist); naloxone, atropine, beta-blockers; non-competitive = different site/irreversible, ↓Emax (cannot overcome); aspirin, phenoxybenzamine; partial agonist = submaximal Emax (buprenorphine); Schild plot quantifies competitive.
Partial agonist = submaximal Emax + ceiling effect; buprenorphine = µ partial agonist, safer OD profile, precipitates withdrawal if full agonist present; full agonist = no ceiling, ↑OD risk.
TI = LD50/ED50; narrow TI drugs (warfarin, digoxin, lithium, phenytoin, theophylline, aminoglycosides) need TDM; wide TI (penicillin) = safer; TI determines safety, not potency/efficacy.
Paracetamol ALF King's = pH <7.3 OR (INR >6.5 + Cr >300 + Grade 3-4 HE), IV NAC even beyond 24h, transplant if criteria met (80% mortality without).
Reynolds pentad (Charcot triad + hypotension + confusion) = Grade III severe cholangitis - urgent ERCP within 24 hours + IV antibiotics + resuscitation, surgical exploration only if ERCP fails.
Severe allergic asthma (positive specific IgE, IgE 30-1500) → Omalizumab first-line; Eosinophilic (greater than 300) → mepolizumab/benralizumab; Type 2 → dupilumab; Assess response 16 weeks; 50% exacerbation reduction.
ZES = refractory ulcers + gastrin >1000 + secretin rise >200; gastrinoma duodenum 50-60%; 25% MEN-1; surgery if localised, PPI 60-120mg if metastatic.
Internal hemorrhoids = Above dentate line, painless bleeding + prolapse; Grade 2 = prolapse with spontaneous reduction; Rubber band ligation for Grade 2-3 (success 70-80%); Surgical hemorrhoidectomy for Grade 3-4; Conservative first-line (fiber, fluids).
ICP = third-trimester pruritus of palms/soles without rash + bile acids ≥19 µmol/L (RCOG Green-top 43, 2022); UDCA for maternal pruritus only (PITCHES 2019 - no fetal benefit); deliver 40-99 at 38-39w, ≥100 at 35-36w; recurrence 45-90%.
IBS Rome IV = pain + defecation-related + altered frequency/form, no red flags; general dietary advice → low-FODMAP (50-70%) + antispasmodics; TCA/CBT if refractory (NICE CG61; BSG/BDA 2021).
GBS 0 (Hb, urea, BP, HR all normal; no melaena, syncope, liver or cardiac disease) → safe ED discharge with outpatient OGD within 2 weeks - NPV ≈99% per NICE CG141.
Full Rockall 0-2 = safe for early discharge; ≥8 = mortality >25%; visible vessel (Forrest IIa) = 2 pts; IHD = 2 pts; systolic BP <100 = 2 pts.
DAH + AKI + c-ANCA/PR3 = GPA pulmonary-renal syndrome; induce remission with IV steroids + rituximab or cyclophosphamide; plasma exchange is selective for severe renal failure or DAH, not routine, post-PEXIVAS (KDIGO 2021).
Hepatic adenoma = young women + OCPs + rupture 10-30% + malignancy 5-10%; stop OCPs (30-50% regress); resect if >5cm; avoid pregnancy until resected; β-catenin high malignancy.
Gastric cancer = perioperative chemo (3+3) + gastrectomy + D2 lymphadenectomy (5y 23% → 36%); laparoscopy mandatory; EMR if T1a; palliative if metastatic (12m).
Arterial enhancement + washout in a cirrhotic = HCC; BCLC-A (≤5 cm, CP-A/B, PS 0) → resection / ablation / transplant if Milan; 5-year survival 50-70% (resection) and 70-80% (transplant); BCLC-C requires vascular invasion or extrahepatic spread - this patient does not meet that.
Alteplase 0.9 mg/kg within 4.5 h, BP <185/110 first, aspirin at 24 h (not immediately), thrombectomy if LVO; NICE NG128 and NINDS/ECASS III govern UK practice.
Positive FIT in NHS BCSP → colonoscopy next; PPV ~6-8% for cancer, ~30-40% for significant adenomas (NICE NG151; NHS BCSP).
IIH = obese young woman + papilloedema + LP >25 + normal MRI/CSF; acetazolamide + weight loss (curative 50%); monitor vision; 25% loss if untreated.
SE = seizure >5min; lorazepam 4mg IV (×2) → phenytoin 20mg/kg or levetiracetam 60mg/kg → intubation + GA if refractory; mortality 20-30%.
GCA + vision = IV methylpred immediately; without vision = oral pred 60mg; biopsy <7d; 50% blind if untreated.
NRH = portal HTN + preserved function + nodules WITHOUT fibrosis; autoimmune/drugs (methotrexate); beta-blockers + stop drug; 5y 85%.
BOS = Chronic rejection, FEV₁ decline greater than 20%, greater than 1 year post-transplant; Small airway obliteration; Augment immunosuppression + azithromycin; 50% by 5 years; Survival 3-5 years.
BAM = chronic watery diarrhoea + terminal ileum disease + SeHCAT <15%; colesevelam/cholestyramine with meals (70-80%); Type 1 (ileal), Type 2 (idiopathic), Type 3 (secondary).
Severe EoE with food impaction + normal pH = swallowed topical steroids first-line (BSG 2022); confirm histological remission at 8-12 weeks; long-term maintenance needed.
Occupational asthma = Work-related symptoms + improves away; SIC gold standard (FEV₁ decline greater than 15%, medico-legal); Baker's asthma (wheat, α-amylase); Early removal critical (70% symptomatic if delayed); Compensation requires diagnosis.
PBC = AMA-M2 positive (95%) + cholestatic ALP + middle-aged women; UDCA 13-15mg/kg first-line; Response at 1 year (ALP less than 1.5× ULN); Obeticholic acid second-line; Transplant if bilirubin greater than 100/decompensation.
Lynch = MMR mutation + MSI-high + CRC 50-80% + endometrial 40-60%; Colonoscopy every 1-2 years from age 20-25 (reduces mortality 65%); Upper GI every 2-3 years; Consider prophylactic hysterectomy/BSO.
MS relapse = IV methylpred 1g ×3-5d (NOT oral pred); DMT if ≥2 relapses/2yr; first-line interferon/glatiramer/oral agents.
Haemochromatosis = C282Y + TS >45% + high ferritin; weekly phlebotomy → ferritin <50; MCP arthropathy characteristic; screen relatives; normal life if pre-cirrhosis.
Intestinal TB = Terminal ileum + transverse ulcers + caseating granulomas + mesenteric nodes with central necrosis; 6-month anti-TB (2m RIPE, 4m RH) cure 90%; Surgery if obstruction.
IPMN = cyst communicating with duct; main duct (MPD >5mm) → surgery (malignancy 60-90%); high-risk: mural nodule, >3cm, CA19-9; branch duct → surveillance.
Severe alcoholic hepatitis = Maddrey DF greater than 32 (4.6 × PT prolongation + bilirubin/17); Prednisolone 40mg × 28 days; Mortality 35% → 15-20%; Lille score day 7 (greater than 0.45 = non-responder, stop); AST:ALT greater than 2:1, both less than 500; Contraindications: infection, GI bleed, renal failure; Pentoxifylline NOT effective (STOPAH trial).
Refractory ascites = LVP + 8 g albumin/L removed; TIPSS if recurrent; refer for transplantation (BSG 2020 cirrhosis guidelines; EASL ascites guideline).
Bleeding gastric fundal varices (GOV2/IGV1) = cyanoacrylate glue injection; band ligation is ineffective; rescue with TIPSS; mortality 45-55%, much higher than oesophageal variceal bleeding.
GIST = submucosal mass + CD117/c-KIT positive (~95%); R0 resection + 3 years adjuvant imatinib in intermediate/high-risk (NICE TA86 / ESMO 2022); 5-year survival ~80% in localised disease.
IBS = Rome IV + no red flags + normal bloods/coeliac serology → NICE CG61 dietary advice, soluble fibre, antispasmodics, then a low-FODMAP trial; no further investigation unless red flags emerge.
Acute variceal bleed = IV terlipressin + IV ceftriaxone + endoscopy with band ligation within 12 hours; transfusion target Hb 70-80 g/L (NICE NG141; BSG 2015 / Baveno VII consensus).
Achalasia = dysphagia (solids + liquids) + regurgitation + bird-beak + absent peristalsis + impaired LES (IRP >15); POEM or Heller + fundoplication (success 85-95%) per BSG / NICE IPG463; Chicago Types I/II/III; squamous-cell carcinoma risk up to ~33×.
Mesenteric ischaemia = sudden severe pain disproportionate to exam + AF + lactate ↑, CT angiography SMA occlusion, urgent laparotomy <6h, mortality 60-80%.
AIH = Elevated transaminases + IgG elevated + ANA/SMA positive + interface hepatitis; Prednisolone + azathioprine first-line; Type 1 (ANA/SMA, adults) vs Type 2 (anti-LKM1, children); 80-90% remission; IAIHG score aids diagnosis.
BAM = Chronic watery diarrhea + SeHCAT <15%; Colesevelam 625mg BD first-line (better tolerated); Response 70-80%; Post-cholecystectomy common (Type 3); Take with meals.
RCD = persistent villous atrophy + symptoms after >12 months strict GFD with confirmed adherence - exclude mimics, type by IEL flow cytometry; type I responds to budesonide/prednisolone, type II needs cladribine (BSG coeliac guideline).
Child-Pugh C (10-15 points) = decompensated cirrhosis, 1-year survival ~45%, avoid elective surgery, refer for transplant assessment; five components = bilirubin, albumin, INR, ascites, encephalopathy (BSG / EASL 2018; UKELD for UK transplant listing).
Chronic mesenteric ischemia = Postprandial pain (15-30min after eating) + weight loss from food fear + stenosis >70% in 2+ vessels; Revascularization (80-90% relief); "Intestinal angina".
Oesophageal candidiasis = immunocompromised (CD4 <100) + odynophagia + oral candidiasis 90%; empirical fluconazole 200mg → 100mg daily 14-21d (no endoscopy); endoscopy if no response; 80-90% success.
Forrest: Ia (90%) → Ib (50%) → IIa (50%) → IIb (20-25%) → IIc (5%) → III (<2%); Ia-IIb: adrenaline + thermal/clips + IV PPI 72h; IIc/III: oral PPI only.
Gastroparesis = Delayed gastric emptying without obstruction; Scintigraphy (>10% retention at 4h); Prokinetics: metoclopramide (5 days max, tardive dyskinesia 1%) or domperidone (ECG required); Optimize diabetes control; Dietary: small frequent meals, low-fat.
PPI-refractory GERD + objective reflux on pH study + normal manometry + favourable anatomy = laparoscopic Nissen fundoplication (85-90% success); RFA only for dysplastic Barrett's (NICE NG199, BSG).
GAVE = watermelon stripes antrum + CKD/SSc/cirrhosis + chronic bleeding/IDA; APC first-line (70-90%); differentiate PHG (mosaic/fundus/portal HTN); antrectomy if refractory.
H. pylori = PPI + clarithromycin + amoxicillin 7-14d (if resistance <15%); bismuth quadruple if >15%; UBT 4w post-Rx; prevents recurrence 90% → 5%.
LAM = Young women + diffuse round uniform cysts + recurrent pneumothorax + angiomyolipomas; Sirolimus (mTOR inhibitor) stabilizes; Avoid estrogen; LCH (upper, smokers, bizarre cysts) vs LAM (diffuse, uniform).
Legionella → Hyponatremia common + confusion + severe pneumonia; Urinary antigen diagnostic (sensitivity 80%, serogroup 1); Levofloxacin or clarithromycin (intracellular penetration); Beta-lactams ineffective; Mortality 5-30%; 7-14 days treatment.
PD wearing-off = ↑levodopa frequency or add COMT inhibitor (entacapone)/dopamine agonist/MAO-B inhibitor; dyskinesias → amantadine; DBS if refractory.
GI amyloidosis = diarrhoea + malabsorption + macroglossia (AL) + Congo red birefringence; AL → chemo (bortezomib), AA → treat inflammation; median 1-2y AL.
West Haven = 0 (minimal), I (subtle), II (lethargy/time), III (confusion time + place, somnolent), IV (coma); Grade III → Lactulose + rifaximin; Combination reduces recurrence 50%; Target 2-3 stools; Precipitants: constipation, infection, bleed.
Drug-induced oesophagitis = sudden retrosternal pain + odynophagia after doxycycline/bisphosphonate taken at bedtime without water; mid-oesophageal ulcer; stop the drug + PPI + counsel upright with 200 mL water; heals in 2-4 weeks.
Tumour suppressors require two hits (recessive, loss-of-function) whereas oncogenes need only one (dominant, gain-of-function). Inherited cancer syndromes supply the first hit in the germline.
GPCRs = 7TM, largest family, 40% drug targets; Gs → ↑cAMP (β₁/β₂); Gi → ↓cAMP (α₂, M2, opioid); Gq → IP₃/DAG/Ca²⁺ (α₁, M1/M3, H1); desensitisation via GRK/β-arrestin.
RTKs = ligand binding → dimerization → tyrosine autophosphorylation → adaptor protein recruitment → RAS-MAPK/PI3K-AKT pathways; examples include insulin and growth factor receptors.
Rough ER = ribosomes, synthesizes secretory/membrane/lysosomal proteins, N-glycosylation, ERAD; smooth ER = NO ribosomes, lipid synthesis, CYP450 drug metabolism, calcium storage; plasma cells (abundant RER); hepatocytes (abundant SER); ER stress → apoptosis.
Spindle poisons (vinca alkaloids and taxanes) are M-phase specific - they block microtubule function and arrest cells in mitosis, whereas antimetabolites are S-phase specific.
Intrinsic apoptosis (mitochondrial, cytochrome c, caspase-9) from internal stress; extrinsic (death receptor, caspase-8) from external signals - both activate caspase-3/7 executioners.
RTKs: ligand → dimerization → autophosphorylation → RAS-MAPK + PI3K-AKT; EGFR inhibitors for NSCLC; trastuzumab for HER2+ breast (cardiotoxicity); imatinib for GIST/CML.
CaSR is a GPCR that inhibits PTH via Gq/Gi signaling; loss-of-function causes FHH (hypercalcemia + hypocalciuria).
mtDNA = maternal inheritance; all offspring of affected mothers at risk; males and females equally affected; no paternal transmission; heteroplasmy causes variable severity.
Apoptosis = "cellular suicide" with shrinkage + no inflammation; Necrosis = "cellular murder" with swelling + inflammation.
p53 = guardian of genome - arrests cell cycle or triggers apoptosis; Loss of p53 = damaged cells replicate → cancer; Li-Fraumeni = germline TP53 → multiple early cancers.
Autophagy = lysosomal degradation via double-membrane autophagosomes; starvation/stress trigger; defects cause neurodegeneration/cancer.
mtDNA = maternal-only transmission, all offspring of an affected mother are at risk; heteroplasmy → variable expressivity and tissue-specific thresholds; m.3243A>G is the commonest UK mtDNA mutation (MELAS spectrum); refer to the NHS Highly Specialised Mitochondrial Service and consider HFEA-licensed mitochondrial donation.
Apoptosis = silent, caspase-mediated, DNA laddering, no inflammation; necrosis = swelling, membrane rupture, DAMP release, neutrophil-driven inflammation.
ER = protein folding + quality control; UPR detects ER stress; ERAD removes misfolded proteins; α1-antitrypsin deficiency = ER accumulation → liver disease + emphysema.
Maternal only; fathers NEVER transmit; heteroplasmy = variable expression; threshold >60-90%; MELAS, MERRF, LHON; ragged red fibres; lactic acidosis.
SLE + pregnancy = continue hydroxychloroquine, avoid ACE inhibitors and mycophenolate - plan during quiescence.
NPSLE = CNS symptoms in SLE - think headache + cognitive impairment + seizures, exclude other causes first.
“CREST = anti-Centromere” and usually limited skin involvement, whereas “Scl-70 = Scleroderma with Sclerotic trunk” (diffuse disease and lung fibrosis).
In exam questions, “anti-histone antibodies + lupus symptoms + culprit drug” = drug-induced lupus, usually resolving once the medication is stopped.
Skin induration + groove sign + eosinophilia + no Raynaud's = eosinophilic fasciitis - think fascia, not systemic sclerosis.
High-risk APS with thrombosis = “warfarin for life” (INR 2-3), not DOACs, and certainly not aspirin alone, due to the significant risk of recurrent thrombotic events.
In systemic sclerosis patients with sudden severe hypertension and AKI, “think SRC and start ACEi now” - ACE inhibitors are life-saving and should not be stopped because creatinine rises initially.
Diffuse SSc + anti-Scl-70 = watch for lung and renal complications - worse prognosis than limited disease.
SSc + GI symptoms = smooth muscle atrophy - think dysmotility, not obstruction.
SLE + neurological symptoms + active serology = NPSLE - treat aggressively, don't miss it.
SSc + digital ulcers despite Raynaud's control = add vasodilator - sildenafil or bosentan.
Low C3/C4 = complement consumption = active SLE - think disease activity marker, not deficiency.
Lupus nephritis + steroids started = biopsy within 1-2 weeks - histology not significantly affected.
Class I lupus nephritis = mesangial immune deposits with normal glomeruli on light microscopy; mesangial hypercellularity visible on light microscopy is what defines Class II (per the ISN/RPS classification and EULAR/ERA-EDTA lupus nephritis recommendations).
Scleroderma pattern = dilated capillaries + avascular areas - think secondary Raynaud's, screen for SSc.
In exams, associate “dry eyes + dry mouth + anti-Ro/La” with Sjögren’s and think “lymphoma lurking” - non-Hodgkin’s lymphoma risk is the key long-term concern.
In exam questions, “SLE joints hurt and deform but don’t erode”, whereas RA erodes and destroys joints, reinforcing the non-erosive nature of lupus arthritis on plain radiographs.
In young women, “rash, joints, kidneys, and dsDNA” point strongly towards SLE with renal involvement, warranting prompt specialist assessment.
Rhabdomyolysis with AKI - resuscitate early and aggressively with isotonic IV fluids in line with NICE NG148 acute kidney injury principles, treat hyperkalaemia immediately, and reserve dialysis for refractory metabolic derangement.
Myeloma + high light chains + AKI = cast nephropathy - treat urgently or lose the kidneys.
CA-AKI prevention = IV saline only proven; NAC/bicarb no benefit; eGFR <30 strongest risk.
High-risk TLS → rasburicase (rapid urate reduction) plus aggressive IV hydration; allopurinol suits intermediate risk; avoid urinary alkalinisation and check G6PD before giving rasburicase.
KDIGO AKI - 26, 1.5, or 0.5 for 6 hours; ≥26 µmol/L in 48 h, ≥1.5× baseline in 7 days, or urine output <0.5 mL/kg/h for ≥6 h; NICE CG169.
CKD plus contrast = pre-hydrate with IV 0.9% saline and minimise iso-osmolar/low-osmolar contrast volume; N-acetylcysteine and sodium bicarbonate confer no proven benefit (PRESERVE 2018) - hydration and avoiding further nephrotoxins are the key preventive strategies.
Oral sodium phosphate bowel prep → calcium-phosphate crystal nephropathy; avoid in CKD/ACEi/elderly; use PEG (MHRA 2009; BSG 2019).
Tumour lysis = “everything high except calcium” and AKI from crystals in the tubules - think uric acid and calcium phosphate precipitation as the key mechanism.
Cirrhosis + rapid AKI + low urine Na+ = hepatorenal syndrome - terlipressin + albumin, transplant if eligible.
ATN (intrinsic AKI post-hypotension/nephrotoxin + muddy brown casts + FeNa >2% + urine Na >40 + dilute urine <350) = ischemic/nephrotoxic tubular necrosis - supportive care, dialysis if severe, most recover, oliguric phase 1-2 weeks.
FeNa <1%, urine sodium <20 mmol/L and concentrated urine in a volume-deplete patient point to pre-renal AKI - treat with prompt fluid resuscitation and remove nephrotoxins, as recommended by NICE NG148.
AIN = drug + AKI 2-8w + eosinophiluria >5% (90% specific); STOP drug (recovery 60%); steroids if severe; CKD 30% if delayed.
HRS (AKI + advanced cirrhosis with ascites + urine Na <10 + normal kidneys + no other cause) = terlipressin + IV albumin - splanchnic vasoconstriction, bridge to transplant, 80% mortality untreated, functional renal failure (kidneys structurally normal).
AIN = AKI 1-3w post-drug + triad (10%) + sterile pyuria + WBC casts; STOP drug (80-90% recover); steroids if no improvement 3-7d; NSAIDs commonest cause.
Post-chemotherapy ↑K⁺ + ↑PO₄ + ↓Ca²⁺ + ↑urate + AKI in high-grade lymphoma / ALL = TLS; rasburicase + aggressive hydration + treat hyperkalaemia; screen G6PD; do not alkalinise (BCSH 2015; NICE TA39).
Post-hypotension AKI + muddy brown casts + urine Na >40 + FeNa >2% + isosthenuric urine = ischaemic ATN - supportive care per NICE NG148; self-limiting 7-21 days; RRT for AEIOU; 70-80% full recovery.
Muddy brown granular casts + FENa >2% after hypotension/contrast/gentamicin = ATN - NICE NG148: stop nephrotoxins, maintain euvolaemia, dialyse for the usual indications; expect 7-21 days to recovery.
AIN = PPI/NSAID/antibiotic + AKI 2-8w + eosinophiluria + WBC casts; STOP drug (recovery 60-70%); steroids if no improvement 7d.
KDIGO = worst of Cr or urine; Stage 3 = Cr ≥3× or urine <0.3mL/kg/h ≥24h or dialysis; mortality 30%.
Pre-op AKI prevention = stop ACEi + metformin; IV fluids; avoid nephrotoxins; MAP >65; Cr daily post-op.
Rapidly rising creatinine in cirrhosis post-SBP plus low urine Na+ equals HRS type 1 - terlipressin plus albumin buys time for transplant.
Hyperkalaemia + ECG changes (peaked T-waves) = IV calcium gluconate first for membrane stabilisation within minutes; then insulin-dextrose ± salbutamol; rasburicase for hyperuricaemia; dialysis if refractory (UK Kidney Association 2023).
Hepatorenal syndrome type 1 (cirrhosis + rapidly progressive AKI: creatinine doubling <2 weeks + urine Na <10 + FeNa <1% + no response to fluids) = terlipressin + IV albumin - 40-50% reversal, 80% mortality untreated, transplant is cure.
AIN = AKI + fever + rash + eosinophilia + offending drug (PPI, NSAID, penicillin, rifampicin, allopurinol) + eosinophiluria + sterile pyuria; stop drug + supportive care + steroids if severe/persistent (UK Kidney Association AKI guideline; KDIGO AKI 2012).
CRS-1 = furosemide infusion + thiazide; venous congestion main mechanism; small Cr rise OK if decongesting.
Rhabdomyolysis = ↑↑CK + AKI + hyperK⁺ + dipstick blood without RBCs; aggressive saline (target UO >200 mL/h); urgent fasciotomy if compartment syndrome (BOA).
HRS = functional + urine Na <10; terlipressin + albumin 40-50% reversal; transplant curative.
AKI plus eosinophilia plus sterile pyuria plus recent drug exposure equals AIN - stop drug immediately, consider biopsy and steroids.
Rhabdo = CK >1000 + dipstick blood no RBCs; aggressive saline; alkalinise; avoid diuretics.
CIN = IV saline 1mL/kg/h pre+post (gold standard); hold metformin 48h; minimise contrast; NAC adjunct only.
For CKD patients getting contrast, think “fluids, low-dose, low-osmolar” - IV isotonic saline is the cornerstone of prevention, not fancy pharmacological tricks.
ATN = muddy brown casts + FeNa >2%; supportive only; recovery 90% over 1-3w; dialysis if refractory K+/acidosis/overload.
Saline 1 mL/kg/h for 12 hours pre- and post-contrast is the key CA-AKI prevention per RCR guidance - withhold metformin around contrast in CKD; NAC is not routine.
In AKI questions, “old patient + CKD + NSAID + dehydration” usually implies pre-renal physiology; fix the haemodynamics and stop the culprit drug, and creatinine falls quickly.
KDIGO AKI uses the worst of creatinine or urine output; Cr 2 × = Stage 2 and urine <0.5 mL/kg/h for ≥12 h = Stage 2 → this is AKI Stage 2 per NICE NG148.
Polyuria + rising creatinine = ATN recovery phase - tubules healing but not yet functional.
Drug + AKI + eosinophiluria = AIN - stop the drug first, steroids if severe.
Crush/immobility + dark urine + CK >5,000 + AKI + hyperkalaemia = rhabdomyolysis → IV saline targeting urine >200 mL/h; treat hyperkalaemia urgently; avoid loop diuretics.
Chloroquine cardiomyopathy = hypertrophy + conduction disease after chronic use - STOP drug immediately, reversibility possible if early!
HOCM refractory to beta-blockers? Add disopyramide. Avoid vasodilators - they worsen obstruction!
LVH + low voltage ECG = cardiac amyloidosis (voltage-mass discordance). DPD scan + immunofixation diagnose type - ATTR treatable with tafamidis!
Young DCM + family SCD/heart block = genetic testing (likely LMNA) + family screening - identifies at-risk relatives!
Low voltage ECG + significant LVH on echo + HFpEF = cardiac amyloidosis until proven otherwise; PYP scan for ATTR, immunofixation for AL.
Loffler endocarditis = persistent hypereosinophilia + restrictive cardiomyopathy + mural thrombi - treat with corticosteroids to control the eosinophilia plus anticoagulation to prevent emboli.
Cardiac sarcoidosis + active PET + complete heart block = prednisolone 40-60 mg (taper 6-12 months) - reduces mortality and VT burden.
HOCM murmur louder with Valsalva/standing (less volume = more obstruction), softer with squatting (more volume = less obstruction).
AL cardiac amyloid = chemotherapy (bortezomib-based) to stop light chains - tafamidis ONLY for ATTR!
Apical HCM is a benign variant - "ace of spades" cavity + giant negative T waves pathognomonic, conservative management with beta-blockers usually sufficient.
Giant T-wave inversion + Japanese ethnicity = apical HCM until proven otherwise. MRI to confirm!
Low-voltage ECG plus increased wall thickness is the voltage-mass mismatch of cardiac amyloidosis - bilateral carpal tunnel syndrome in an elderly man with HFpEF should trigger suspicion for ATTR amyloidosis.
Cardiac sarcoid suspected → FDG-PET scan for inflammation assessment; endomyocardial biopsy low yield due to patchy distribution.
Young patient + LBBB-superior-axis VT/PVCs + RV fibrofatty change + family SCD = definite ARVC by 2010 Task Force Criteria → ICD for primary prevention, sports restriction and family screening (ESC 2022).
Trabeculations + NC:C >2.3:1 on cMRI + HF + stroke + PVCs = LVNC - GDMT, anticoagulate (LVEF <35% or prior embolism), assess for primary-prevention ICD; cascade-screen relatives (ESC 2023).
Chagas + apical aneurysm + RBBB/LAFB = treat HF AND give benznidazole - combination therapy improves outcomes.
Prominent trabeculations + NC/C ratio 2.8 + HF + family SCD = LVNC - needs anticoagulation + ICD consideration!
PPCM is heart failure within 5 months postpartum - treat with standard heart failure therapy plus bromocriptine, and stop breastfeeding while giving prophylactic anticoagulation if bromocriptine is used.
STEMI-like + emotional trigger + apical ballooning + normal coronaries = Takotsubo - recovers completely in weeks!
Coagulative necrosis = preserved tissue architecture ("ghost cells"); characteristic of MI and solid organ ischemia; vs liquefactive (brain); neutrophils infiltrate day 1-3.
Fat necrosis: enzymatic (pancreatitis, lipase → saponification + hypocalcaemia) or traumatic (breast, mimics cancer); foamy macrophages; biopsy to exclude malignancy.
Metaplasia = reversible swap of one adult cell type for another; Barrett's oesophagus (squamous to intestinal columnar with goblet cells) is the classic example and predisposes to adenocarcinoma. BSG (2014) and NICE guidance recommend PPI therapy and endoscopic surveillance for Barrett's oesophagus.
Phase II = conjugation (glucuronidation, sulfation, acetylation) adds polar groups → increase water solubility for excretion; UGT, SULT, NAT enzymes; usually detoxifies.
Phase II sulfation conjugates paracetamol with sulfate for safe renal excretion; major detox pathway alongside glucuronidation.
Sulfation predominates in neonates (UGT immature); paracetamol safe if dosed correctly; overdose → NAPQI toxicity → N-acetylcysteine antidote.
CYP2D6 PM = no codeine analgesia; UM = morphine toxicity (fatal in children/breastfeeding). Codeine contraindicated <12 y, in UMs, and in breastfeeding (MHRA/BNF). Fluoxetine/paroxetine inhibit CYP2D6 (phenocopy PM).
CI crossing zero = non-significant; Study 1 significant (8-16), Study 2 not (-2 to +26); CIs show precision and significance.
NNT = 1/ARR; lower NNT = more efficient. This case ARR 3% → NNT 33. Compare with NNH; quote alongside ARR for shared decision-making (NICE TA; GMC 2020).
Regression to mean = extreme values naturally less extreme on repeat (random variation). Not real change. Common in trials selecting extremes. Control group + multiple baselines essential.
LR+ = sensitivity/(1−specificity); post-test odds = pre-test odds × LR; LR >10 rules in, LR <0.1 rules out; independent of prevalence.
ITT = analyze all patients in original groups (regardless of adherence); preserves randomization; reflects real-world effectiveness.
Type II error = false negative (missed true effect); β = probability of Type II error; power = 1-β; small sample size = most common cause; always perform power calculation before trial.
PPV = TP / (TP + FP); strongly prevalence-dependent; high prevalence gives high PPV, low prevalence gives low PPV; PPV is not the same as sensitivity.
Type I (α, false positive) = reject true null. α = 0.05 (5%). Type II (β, false negative) = fail to reject false null. Power = 1 - β (80%). ↑sample size → ↑power → ↓Type II. Multiple comparisons → Bonferroni.
NNT = 1 / ARR. Lower = more effective. Aspirin post-MI ~50, statins primary ~100. Compare NNT vs NNH. RRR misleading, ARR/NNT more clinically meaningful.
Publication bias = selective reporting of positive results; funnel plot asymmetry indicates bias; search trial registries for unpublished studies.
ITT = all randomized patients analyzed as allocated; preserves randomization; conservative estimate; gold standard for superiority trials; per-protocol for non-inferiority.
PPV varies with prevalence; low prevalence = more false positives = lower PPV; sensitivity/specificity are fixed test properties.
Type II error = false negative; low power → miss real effects; this trial underpowered (60% not 80%); meta-analysis detected true benefit; Type I (α=0.05) = false positive; power = 1-β; increase power by ↑sample size (most practical).
NNT = 1/ARR; lower NNT = more effective; statin NNT for stroke ~50 in high-risk patients; compare NNT vs NNH.
LR- <0.1 excellent for ruling out; D-dimer LR- = 0.1 makes negative result highly useful for excluding PE.
HR = instantaneous risk ratio over time (accounts for censoring); HR 0.75 = 25% risk reduction; CI not crossing 1 = significant.
Power = 1 - β (typically 80-90%). Sample size ↑ with smaller effect, higher variability, stricter α, higher power. Underpowered → Type II error (false negative).
95% CI = effect range + precision; not crossing null = significant; statistical significance ≠ clinical significance; narrow CI + small effect = precisely small.
NNH = 1/ARI; lower = more harmful; balance NNT (benefit) vs NNH (harm); ideal = low NNT + high NNH.
Forest plot diamond not crossing 1.0 = significant; OR 0.75 = 25% reduction; I² indicates heterogeneity (low <25%, high >50%).
Forest plot displays meta-analysis; diamond = pooled effect; I² measures heterogeneity (>50% = high → random effects); fixed effects if I² low; funnel plot detects publication bias.
Type II error = false negative (insufficient power); Type I error = false positive (alpha error).
Selection bias = non-representative sample; Berkson's (hospital), survival, healthy volunteer; prevent with random sampling; differs from information bias (measurement) and confounding (third variable).
Type II error = false negative, failing to detect true effect; often due to underpowered study (small sample); power = 1-β.
NNH = 1/ARI; lower NNH = more harmful; compare NNT vs NNH to assess benefit-harm balance; NSAID NNH for GI bleed ~100.
ACEi cough = ↑bradykinin; switch to ARB (equivalent efficacy, cough <3%); resolves 1-4wk; class effect - don't switch between ACEi.
AHS = SCAR + mortality 20-25%; HLA-B*5801 screen in Chinese/Thai/Korean; stop immediately + never rechallenge; febuxostat alternative (caution cross-reactivity).
Red man syndrome - non-allergic, rate-related histamine release; slow infusion prevents it; safe to continue vancomycin with antihistamine premedication.
Paroxetine = highest discontinuation risk; FINISH symptoms within days; reinstate and taper hyperbolically over months - never stop SSRIs abruptly (NICE NG222 2022; Maudsley).
Allopurinol DRESS = severe hypersensitivity; HLA-B*5801 risk; screen before prescribing in high-risk groups.
Acute severe thrombocytopenia + new drug = DITP - stop drug immediately.
Hydroxychloroquine maculopathy - baseline screen then annual checks from year 5, keep the dose at or below 5 mg/kg actual body weight, and OCT is the most sensitive test (RCOphth Hydroxychloroquine and Chloroquine Retinopathy guidance, 2018).
Carbamazepine SIADH = euvolaemic hyponatraemia with concentrated urine; switch to lamotrigine; avoid oxcarbazepine (higher risk); per BNF and NICE NG217.
Codeine + breastfeeding = CONTRAINDICATED; CYP2D6 ultra-rapid → excessive morphine → fatal infant toxicity; use paracetamol/ibuprofen or morphine instead.
Rhabdomyolysis = stop statin + IV fluids 200-300mL/h (UO >200mL/h); monitor CK/K⁺/creatinine; dialysis if K⁺ >6.5.
Serotonin syndrome = clonus + autonomic hyperactivity + altered mental status - stop drugs, supportive + benzodiazepines, cyproheptadine if severe.
HCQ retinopathy irreversible; annual screening after 5yr (OCT most sensitive); stop immediately if detected; dose <5mg/kg actual weight.
DRESS = fever + rash + eosinophilia + organ involvement 2-8 weeks post-drug - stop drug, give steroids, prolonged taper.
QT prolongation → correct K⁺ >4.5 + Mg²⁺ >2; MgSO₄ IV for torsades; stop offending drug; avoid QT-drug combinations.
ACE-I first-dose hypotension in high renin states; start low, monitor BP, withhold diuretics pre-dose.
Aspirin OD = tinnitus + mixed respiratory alkalosis/metabolic acidosis; urinary alkalinisation (NaHCO₃); dialysis if >700/pH <7.1.
Domperidone contraindicated QTc >470ms/QT-prolonging drugs/cardiac disease; use metoclopramide/prucalopride instead.
Pioglitazone bladder cancer risk is duration-dependent (highest >5 years; RR ~1.2-1.4); MHRA - contraindicated in bladder cancer history or uninvestigated haematuria, annual urinalysis during long-term use; review alternatives (SGLT2i / GLP-1 RA per NICE NG28); also contraindicated in heart failure.
Mucocutaneous ADRs >90% = expected; manage with emollients; stop only for psychiatric/raised ICP/hepatotoxicity/pancreatitis.
GCA + visual loss = IV methylprednisolone (or 60-80 mg prednisolone if IV unavailable) before biopsy + aspirin 75 mg; biopsy within 1 week; tocilizumab for relapse (BSR 2020; NICE TA518).
Takayasu = young woman + absent pulses + BP difference + large-vessel stenosis; prednisolone + methotrexate; surgery only when inflammation controlled.
GPA = saddle-nose + cavitating nodules + AKI + c-ANCA/PR3; rituximab or cyclophosphamide + steroids; 90% remission.
GCA + visual symptoms = high-dose steroids NOW - don't wait for biopsy, vision loss is permanent.
Young Asian woman + pulseless + arm claudication = Takayasu arteritis - think large-vessel vasculitis, not GCA.
HSP = palpable purpura + abdominal pain + arthritis + haematuria in children - think IgA vasculitis.
“MPO = MPA” in exams - p-ANCA/anti-MPO points towards microscopic polyangiitis, whereas c-ANCA/anti-PR3 suggests GPA with ENT involvement.
In children, “palpable purpura + tummy pain + joints + kidneys after infection” = IgA vasculitis/HSP, the most common vasculitis of childhood.
In rapidly deteriorating renal function with suspected vasculitis, “biopsy is best” - it secures the diagnosis and directs aggressive but appropriate immunosuppression.
MPO-ANCA + pauci-immune GN + no granulomas = microscopic polyangiitis - different from GPA.
MPA = RPGN + pulmonary haemorrhage + p-ANCA/MPO + no upper airway - think small-vessel vasculitis without granulomas.
MPA (pulmonary-renal syndrome + p-ANCA/MPO+ + necrotizing GN with crescents + NO granulomas) = cyclophosphamide/rituximab + high-dose steroids + plasma exchange if severe - 80% mortality untreated, vs GPA (c-ANCA/PR3+, granulomas), vs Goodpasture (anti-GBM+).
GCA + vision loss = pred 60mg (or IV methylpred) immediately; don't wait for biopsy; prevent contralateral blindness; biopsy <7d; taper 12-24m.
Young woman + absent pulse + inter-arm BP gap + raised ESR/CRP = Takayasu arteritis - induce remission with prednisolone 1 mg/kg, add a steroid-sparing agent (methotrexate or tocilizumab) early, and delay revascularisation until inflammation has settled (EULAR 2018, BSR/BHPR).
Takayasu = young woman + pulseless + large-vessel stenosis; prednisolone + methotrexate; tocilizumab if refractory; surgery only when inactive.
EGPA = asthma + eosinophilia + mononeuritis multiplex + p-ANCA/MPO; prednisolone ± cyclophosphamide (if cardiac/renal); cardiac = main cause death.
GCA + aortitis → high-dose prednisolone immediately; tocilizumab for steroid-sparing; monitor for aortic aneurysm.
GCA + vision loss = IV methylprednisolone 1 g × 3 days immediately (don't wait for biopsy); prevents second-eye blindness; temporal artery biopsy within 7 days.
Goodpasture syndrome (pulmonary-renal + anti-GBM+ + linear IgG on GBM + smoker + ANCA negative) = plasma exchange + cyclophosphamide + prednisolone URGENTLY - 90% mortality untreated, 70% dialysis-dependent if delayed, lung recovers faster than kidney.
PAN = medium-vessel + ANCA negative + microaneurysms + no GN; HBV 30% → antivirals; non-HBV → steroids + cyclophosphamide.
GCA = prednisolone 40-60mg immediately; biopsy <7d (positive up to 14d on steroids); negative doesn't exclude (28%); prevent blindness.
Cryoglobulinaemic vasculitis = HCV + purpura + GN + neuropathy + ↓↓C4; treat HCV (DAAs) + rituximab if severe.
GCA + visual loss = IV methylprednisolone 500-1000 mg for 3 days then oral prednisolone 60 mg (BSR 2020); do NOT delay for biopsy; biopsy within 7 days; aspirin 75 mg; tocilizumab (NICE TA518) for refractory disease.
PAN = ANCA neg + medium vessel + spares lungs; testicular pain + microaneurysms; cyclophosphamide + steroids.
EGPA = asthma + eosinophilia + mononeuritis multiplex; cardiac = leading death cause; prednisolone ± cyclophosphamide; mepolizumab if relapsing.
Behçet disease = recurrent oral + genital ulcers + uveitis ± positive pathergy/HLA-B51 - colchicine first-line for mucocutaneous (EULAR); biologics for uveitis or vascular/neuro disease.
Suspected GCA with visual symptoms needs immediate high-dose steroids (consider IV methylprednisolone) - never wait for biopsy results, because vision already lost rarely recovers.
Cryoglobulinaemia = purpura + peripheral neuropathy + renal impairment + cryoglobulins; screen for hepatitis C (commonest Type II cause); EULAR/CryoVas - DAAs for HCV + rituximab + corticosteroids for vasculitis.
Massive hemoptysis + bronchiectasis → Stabilize then BAE (85-90% success); Emergency surgery mortality 18-50% vs 5% elective; BAE bridges to planned resection; Recurrence 10-55% at 1 year.
Methemoglobinemia = Cyanosis unresponsive to oxygen + high PaO₂; Chocolate-brown blood diagnostic; Methylene blue 1-2mg/kg first-line for MetHb greater than 20%; Response within 30-60 minutes; Contraindicated G6PD deficiency.
PJP with PaO₂ <9.3kPa → Co-trimoxazole 120mg/kg/day IV PLUS prednisolone 40mg BD; Steroids reduce mortality 35%→15%; Non-HIV PJP more severe; 21-day treatment.
Post-intubation stenosis (1-5%, risk after 7 days) → Present 2-8 weeks with stridor; Stenosis >50% needs intervention; Stenting bridges to surgery (definitive).
SIADH (SCLC common) → Fluid restriction 500-800ml/24h first-line; Correct maximum 8-10mmol/L/day (osmotic demyelination risk); Hypertonic saline only if severe symptoms; Treat underlying cancer.
In COPD with ongoing exacerbations and eosinophils ≥300 cells/µL, escalate to LABA + LAMA + ICS triple therapy (NICE NG115); below 300 with no asthmatic features, prefer LABA + LAMA.
CURB-65 = Confusion, Urea >7, RR ≥30, BP low, Age ≥65; Score 0-1 home, 2 consider admission (especially if hypoxia), 3+ admit; SpO₂ <94% additional criterion for admission.
Chronic pulmonary aspergillosis → Post-TB cavities + aspergilloma + chronic symptoms; Oral azoles (itraconazole/voriconazole) first-line, 6 months minimum; Bronchial artery embolization for severe hemoptysis; Surgery high-risk.
Severe COPD → LVRS if upper lobe predominant + low exercise (NETT trial: mortality benefit); High-risk: FEV₁ <20% + DLCO <20%; Endobronchial valves alternative; Must be ex-smoker.
GPA = Upper + lower airway + kidneys + c-ANCA/PR3; Cyclophosphamide or rituximab plus steroids immediately; Plasma exchange if severe DAH/renal; Untreated mortality 90%, treated remission 80-90%.
Lung cancer staging → PET-positive mediastinal nodes need histology (PET alone insufficient); EBUS-TBNA first-line (sensitivity 90%, access stations 2/4/7/10/11); Mediastinoscopy if EBUS fails/inaccessible; N2/N3 alters management.
HAP without MRSA/Pseudomonas risk → co-amoxiclav first-line (NICE NG139); reserve vancomycin for MRSA risk and anti-pseudomonal agents for severe disease; de-escalate at 48-72 hours per cultures.
IPF diagnosis → Definite UIP HRCT (honeycombing + basal/subpleural reticulation) sufficient without biopsy; Probable UIP needs biopsy; Antifibrotics (nintedanib/pirfenidone) slow decline 50%; Median survival 3-5 years.
Long COVID dyspnoea + normal PFTs/imaging → Functional limitation not structural; Graded exercise rehabilitation 60-70% effective; Normal tests exclude complications; Avoid over-investigation or steroids.
CPAP non-adherence → Troubleshoot systematically (mask refit, humidification, nasal steroids); Intensive support increases adherence 40% to 70-80%; First 3 months critical; Target greater than 4h/night use.
Unprovoked VTE → Indefinite anticoagulation (recurrence 10%/year off vs 1-2% on); Reduced-dose rivaroxaban 10mg or apixaban 2.5mg BD option; Annual bleeding risk review; Aspirin inferior (30% vs 90% reduction).
PCD (Kartagener if + situs inversus) → Chronic sinopulmonary disease + subfertility + low nasal NO; TEM ciliary ultrastructure gold standard (defects in 70-90%); Middle/lower lobe bronchiectasis typical; Screening: nasal NO less than 77nL/min.
New PAH diagnosis intermediate/high risk → Dual (ERA+PDE5i) or triple combination upfront; Improves outcomes 50% vs monotherapy; CCB only if vasoreactive (10%); Risk stratify (WHO FC, 6MWD, cardiac index).
EGFR-mutant NSCLC → Osimertinib first-line (PFS 18.9 months); Superior CNS control (60-70% response); Exon 19 deletion and L858R most common; Chemotherapy/immunotherapy ineffective.
AECOPD with pH less than 7.35 + hypercapnia despite treatment → NIV immediately (BiPAP); Reduces intubation 65%, mortality 50%; Target SpO₂ 88-92% not higher; Intubate if NIV fails or contraindicated.
SCLC limited stage → Disease within single RT port; Concurrent chemoRT (platinum-etoposide + 45Gy); 5-year survival 20-25%; PCI if response; Extensive stage: chemo + immunotherapy, survival 2-5%.
Pregnancy PE workup → Leg Doppler FIRST (positive in 15-30%, avoids thoracic imaging); CTPA higher yield (96%) but breast radiation; V/Q lower maternal dose; Both fetus-safe (<50mGy); LMWH treatment.
IPF (UIP pattern + FVC 50-80%) → pirfenidone or nintedanib per NICE NG228; never give the PANTHER triple therapy of prednisolone + azathioprine + NAC.
BTS 2023 PSP - conservative first-line for minimally symptomatic patients regardless of size; intervene only if unsuitable for conservative management or if it fails.
Stable PE = DOAC (apixaban or rivaroxaban) first-line per NICE NG158; thrombolysis reserved for massive PE with haemodynamic instability; treat for ≥3 months.
HP acute vs chronic → Reversibility with avoidance distinguishes; Acute: hours post-exposure, ground-glass, fully reversible; Chronic: insidious, fibrotic, irreversible; Early avoidance prevents progression.
Varenicline = Highest cessation rates (23-33% at 12 months); Best for highly dependent smokers; Combination with behavioral support essential; Safe in COPD/cardiovascular disease; Nausea most common side effect (30%, mild).
Unprovoked PE = high recurrence risk → long-term anticoagulation per NICE NG158, ideally a reduced-dose DOAC (rivaroxaban 10 mg OD or apixaban 2.5 mg BD per EINSTEIN-CHOICE/AMPLIFY-EXT) with annual reassessment of bleeding risk. Aspirin is inferior to anticoagulation.
Thymoma + MG → Optimize medically before surgery (pyridostigmine + immunosuppression); Decremental FVC + bulbar symptoms = high-risk; Staged thymectomy after 4-8 weeks; Reduces perioperative crisis 30% to less than 5%.
BOS = FEV₁ fall >20% + obstructive pattern + air trapping; Leading cause late post-transplant mortality (50% at 5 years); Azithromycin 250mg thrice weekly stabilizes 30-40%; Median survival 2-4 years.
Recurrent aspiration despite NG + positioning → PEG-J (jejunal extension) not standard PEG; Post-pyloric feeding bypasses reflux; Reduces pneumonia 40-60%; Standard PEG no better than NG.
Class IV = full-house IF + >50% glomeruli; MMF or cyclophosphamide + steroids; maintenance ≥3y.
In exams, “nephritic child + recent sore throat + low C3, normal C4” = post-strep GN; management is largely supportive with monitoring of blood pressure and renal function.
IgA nephropathy = synpharyngitic haematuria + mesangial IgA on biopsy → ACE inhibitor/ARB first-line per KDIGO 2021; add SGLT2 inhibitor; consider Nefecon (NICE TA906) for progressive disease.
aHUS = TMA + no diarrhoea + ADAMTS13 >10%; urgent eculizumab with mandatory meningococcal vaccination is the definitive treatment - plasma exchange is only a bridge.
TBMD = isolated haematuria + no proteinuria + GBM thinning on EM; reassure and monitor annually; ESRD risk <1%.
Class IV lupus nephritis = MMF or cyclophosphamide plus high-dose steroids for induction; MMF preferred per ALMS trial; hydroxychloroquine in all SLE; 20-30% progress to ESRD at 10 years without adequate treatment.
Nephrotic syndrome + normal light microscopy + diffuse foot process effacement + negative immunofluorescence = minimal change disease; treat with prednisolone 1 mg/kg/day (KDIGO 2021 Glomerular Diseases guideline), expecting around 90% remission.
Childhood MCD = empirical prednisolone 60 mg/m²/day (max 60 mg) for 4 weeks then alternate-day taper; biopsy not required if typical (age 1-10, no atypical features); >90% steroid-responsive; relapses common but long-term renal prognosis excellent.
IgA = synpharyngitic haematuria + normal complement + mesangial IgA; ACEi first-line; 20-40% ESRD 20y.
Sudden nephrotic syndrome plus normal creatinine plus NSAID exposure equals MCD - excellent prognosis with steroids.
IgA nephropathy (synpharyngitic macroscopic haematuria + persistent microscopic haematuria + hypertension + mesangial IgA deposition) = ACE inhibitor/ARB first (target BP <130/80, proteinuria <1g/day) - corticosteroids ONLY if high-risk, 20-40% ESRD over 20 years.
AS + age 82 + STS 4.5% + suitable anatomy = TAVI or SAVR both options, TAVI increasingly preferred at this age/risk!
Low-flow low-gradient AS - dobutamine stress differentiates true severe (AVA stays <1, gradient rises >=40) from pseudo-severe (AVA opens >1); true severe = AVR/TAVI.
'Asymptomatic' severe AS? Exercise test to unmask symptoms/assess BP response before deciding AVR vs surveillance!
Modified Duke = 2 major (blood cultures + echo vegetation) = DEFINITE IE. Right-sided IE = IVDU + S. aureus + tricuspid valve!
Acute severe AR + premature mitral valve closure + narrow pulse pressure + heart failure = urgent surgery within 24-48 hours; do not wait to finish antibiotics (ESC 2023 guidelines on infective endocarditis and the 2021 ESC/EACTS valvular heart disease guidelines).
Post-AVR symptoms + high gradients + small indexed EOA + normal prosthesis = PPM - should have implanted larger valve!
Severe PS (gradient >64) → balloon valvuloplasty even if asymptomatic; 90-95% success; prevents RV failure.
Severe symptomatic TR requires surgical referral - isolated tricuspid surgery is challenging but necessary when medical therapy fails. Don't delay until irreversible RV dysfunction and end-organ damage occur.
Fixed split S2 = ASD (equalised atrial pressures prevent respiratory variation) - look for this sign to clinch the diagnosis.
PVT = increased gradients + low INR → thrombolysis if unstable/high surgical risk; surgery if stable/large thrombus; heparin for small non-obstructive.
Asymptomatic severe primary MR + new AF or PASP >50 mmHg = early surgical repair at an experienced centre (ESC 2021; ACC/AHA 2020; NICE IPG653).
MVP + ectopy + T-wave inversion + MAD → CMR/Holter; ICD if sustained VT or multiple high-risk features + fibrosis.
Prosthetic valve thrombosis? Thrombolysis if symptomatic obstructive left-sided PVT (NYHA I-III), surgery if shock/critical!
Symptomatic MS + Wilkins 7 + no MR/thrombus = PMBC ideal - >95% success, first-line!
Symptomatic severe AS + age ≥75 + STS ~6% + frailty + favourable anatomy = TAVI (ESC/EACTS 2021, NICE) - medical therapy alone gives ~50% 1-year mortality and is unacceptable.
Severe functional MR + heart failure + high surgical risk + good anatomy = MitraClip - proven mortality benefit in COAPT trial.
Severe TR - repair during any left-sided valve surgery (Class I), consider isolated repair if symptomatic + RV dilatation before irreversible RV dysfunction.
AVA 0.8 + gradient 28 + LVEF 62% + low SVI = paradoxical LF-LG severe AS - needs AVR if symptomatic!
Severe symptomatic TR + RV dilatation? Operate now - don't wait for irreversible RV failure!
Always confirm hypotonic hyponatraemia with serum osmolality first, then use volume status plus urine osmolality and urine sodium to identify the cause (European Hyponatraemia Guideline, 2014).
Hyperkalaemia with ECG changes (peaked T + widened QRS) → IV calcium gluconate FIRST for cardiac protection → insulin-dextrose + salbutamol to shift K⁺ in → dialysis to remove K⁺ (UK Renal Association / RCUK 2023).
Salicylate = urinary alkalisation (bicarb) + correct K⁺ first; dialysis if >700 or severe acidosis; avoid intubation.
Severe hypokalemia (K <2.5 + ECG changes: U waves + ventricular ectopics + hypomagnesemia) = IV potassium (max 10mmol/h via large vein) + IV magnesium ESSENTIAL - hypomagnesemia prevents K retention, correct Mg first/simultaneously, furosemide common cause.
Severe symptomatic SIADH (confusion, seizures, GCS drop) = 3% hypertonic saline 150 mL boluses per ESE/ERA/ESICM 2014; correct Na by ≤10 mmol/L in the first 24 h to avoid central pontine myelinolysis; fluid restriction is reserved for mild disease.
Primary polydipsia → gradual fluid restriction + psychological support + review SSRIs; NEVER give desmopressin.
ODS = rapid Na⁺ correction with delayed neurological deterioration on day 2-6 (trident sign on MRI); supportive management only - prevention by limiting correction to ≤10 mmol/L/24h is essential (UK Renal Association/European hyponatraemia guidelines).
Hypercalcaemia of malignancy = raised calcium with suppressed PTH (low PTH distinguishes it from primary hyperparathyroidism); PTHrP is the dominant mechanism in squamous tumours - treat with IV saline plus zoledronate.
Euvolaemic hyponatraemia + concentrated urine + urine Na >40 + normal endocrine/renal function = SIADH - fluid restriction is first-line; reserve hypertonic 3% saline for severe symptomatic hyponatraemia and correct slowly (max ~8-10 mmol/L/24 h).
Lithium NDI → reduce/switch lithium where psychiatrically feasible + amiloride 5-10 mg BD + thiazide + low-salt diet; desmopressin is ineffective; monitor lithium carefully when a thiazide is added.
Hypercalcaemia malignancy = suppressed PTH + Ca²+ >3.0; IV saline then zoledronic acid; PTHrP 80%; poor prognosis.
Milk-alkali = hypercalcaemia + AKI + alkalosis + suppressed PTH + excess calcium carbonate; stop calcium and rehydrate with IV saline (Society for Endocrinology 2023).
Central diabetes insipidus (polyuria + dilute urine + high serum osmolality + responds to desmopressin + absent pituitary bright spot) = desmopressin (synthetic ADH) - excellent response, nephrogenic DI does not respond to desmopressin.
Osmotic demyelination/central pontine myelinolysis (locked-in syndrome 2-6 days after rapid Na correction in chronic severe hyponatremia + alcohol use) = OVERCORRECTION >10-12 mmol/L/24h - prevent by slow correction, re-lower Na if overcorrection, irreversible devastation.
Hyperkalaemia + ECG changes = calcium gluconate FIRST → insulin-dextrose + nebulised salbutamol → urgent dialysis if refractory; identify and stop offending drugs (UK Kidney Association 2023).
Urine K⁺ <20 = GI; >20 = renal; assess BP + acid-base to diagnose.
Over-rapid correction (>10 mmol/L/24h) risks ODS/central pontine myelinolysis - re-lower with desmopressin + 5% dextrose; chronic hyponatraemia must be corrected by ≤8-10 mmol/L/24h.
CSW = hypovolaemic (IV saline); SIADH = euvolaemic (fluid restrict); volume status is key differentiator.
Hyperkalaemia ECG = “tall T, long PR, wide QRS, sine wave” - once you see QRS widening, treat as an emergency and be ready for cardiac arrest unless potassium is rapidly corrected.
Symptomatic paroxysmal AF + failed flecainide = CATHETER ABLATION Class I - 70-80% success, no need to fail multiple drugs!
Brugada = RBBB + coved ST elevation V1-V3 + syncope/sudden death + family history. Type 1 ECG + symptoms = ICD!
Mobitz I = progressive PR + narrow QRS = benign, no pacing. Mobitz II = fixed PR + dropped beats + wide QRS = PACING!
Atrial flutter >48 hours = same anticoagulation rules as AF (3 weeks before cardioversion OR TOE). Ablation is curative but still needs anticoagulation first!
LQT1 + competitive swimmer + family sudden death = beta-blockers (nadolol) plus swimming/sport restriction - reserve the ICD for high-risk features or beta-blocker failure.
Torsades + long QT? Magnesium 2g IV - stop QT drugs, correct K+/Mg2+, pace if needed!
Stable SVT after failed vagal manoeuvres? Adenosine 6-12-12 mg - it's fast, diagnostic, and highly effective!
Recurrent VT with ≥2 ICD shocks despite antiarrhythmics = refer for VT ablation. Ablation reduces shock burden and improves quality of life.
Symptomatic WPW = catheter ablation (curative). Don't use AV-nodal blockers if AF develops in WPW!
Asymptomatic Brugada with a spontaneous Type 1 pattern and family history does not mandate an ICD - reserve ICDs for survivors of cardiac arrest or those with arrhythmic syncope (ESC 2022).
Symptomatic typical atrial flutter → CTI catheter ablation (Class I, ESC 2020 - ~95% acute success, 85-90% symptom-free at 5 years) and lifelong anticoagulation if CHA₂DS₂-VASc ≥2 because of the high downstream risk of AF.
Early HCC (single ≤5 cm or ≤3 ≤3 cm in Child-Pugh A) → curative resection, ablation or transplant per BCLC; 5-year survival 50-70% (NICE NG50, EASL).
PBC = woman + fatigue + pruritus + ↑ALP + AMA+; UDCA 13-15mg/kg; cholestyramine for pruritus; transplant if decompensated.
Hepatorenal syndrome type 1 (rapid AKI in cirrhosis, no other cause) = terlipressin plus IV albumin - improves renal function 40-50%, bridge to liver transplant.
NAFLD with advanced fibrosis (FIB-4 >2.67, FibroScan >9.6 kPa) = lifestyle modification targeting 7-10% weight loss plus optimize diabetes/lipids - most effective intervention.
Alpha-1 antitrypsin deficiency (PiZZ + liver disease) = supportive care and monitor for cirrhosis - AAT augmentation treats lungs but NOT liver; transplant curative.
VOD/SOS post-HSCT (jaundice + hepatomegaly + ascites + weight gain within 21 days) = defibrotide 25 mg/kg/day - specific treatment, improves survival 40-60%.
Large volume paracentesis >5 liters = give IV albumin 8g per liter removed - prevents post-paracentesis circulatory dysfunction and improves outcomes.
Crigler-Najjar Type I (severe unconjugated hyperbilirubinemia >340, phenobarbital non-responsive) = liver transplantation curative - prevents fatal kernicterus.
Amoxicillin-clavulanate DILI causes prolonged cholestatic injury - stop drug and monitor, it will resolve (may take months).
Hereditary hemochromatosis (homozygous C282Y + iron overload) = weekly phlebotomy until ferritin 50-100, then maintenance - prevents organ damage if started early.
PoPH (cirrhosis + mPAP >45 mmHg + normal PCWP) = pulmonary vasodilators first - reduce to <35 mmHg before transplant, untreated 50% peri-op mortality.
SBP (ascitic polymorphs ≥250/µL) = immediate IV cefotaxime/ceftriaxone PLUS albumin (1.5 g/kg then 1 g/kg) - albumin reduces mortality.
Platypnea-orthodeoxia in cirrhotic patient = hepatopulmonary syndrome - confirm with contrast bubble echo showing delayed intrapulmonary shunting.
Alcoholic hepatitis - AST:ALT >2, AST <500; Maddrey ≥32 = severe → prednisolone 40mg 28d, Lille day 7 (<0.45 continue, ≥0.45 stop), abstinence + nutrition.
Gilbert syndrome (unconjugated hyperbilirubinemia, normal LFTs, triggers) = reassurance only - completely benign, no treatment needed.
Primary biliary cholangitis (AMA-positive + cholestatic LFTs) = start ursodeoxycholic acid 13-15 mg/kg daily - improves outcomes when started early.
A1AT (PiZZ) = young lower-lobe emphysema + liver disease, PAS-positive globules, NO liver treatment (augmentation for lungs only), transplant if cirrhosis.
Paracetamol ALF with pH <7.3 = absolute indication for urgent transplant referral - continue NAC (improves outcome even late), do not stop after protocol complete.
Severe AH (MDF ≥32) = prednisolone 40mg 28d, Lille day 7, abstinence + nutrition, AST:ALT >2 typical.
Hepatopulmonary syndrome (cirrhosis + hypoxemia + intrapulmonary shunting on contrast echo) = liver transplantation - only cure, resolves in 80-85%.
HRS diagnosis requires excluding other AKI causes and demonstrating failure to respond to albumin expansion (1g/kg) - vasopressors are the definitive therapy.
PSC = male + cholestatic + IBD + pANCA + MRCP beading; CCA risk 10-15% - annual MRCP/CA 19-9 + annual colonoscopy; transplantation only cure.
PSC = cholestatic + IBD (UC) + MRCP beading; no autoantibodies; CCA 10-15%; transplant only cure.
Tacrolimus - narrow therapeutic index requires TDM; toxicity >15 ng/mL causes nephrotoxicity/tremor; reduce dose and check drug interactions.
Lithium has a narrow therapeutic index and is renally cleared - thiazides, NSAIDs, ACE inhibitors and dehydration reduce clearance and cause accumulation; check a 12-hour level urgently and stop the precipitant.
Vancomycin trough 15-20 for serious MRSA; <15 subtherapeutic; >20 nephrotoxic; AUC/MIC >400 best predictor; newer guidelines favour AUC-guided dosing.
Clozapine FBC (UK CPMS/BNF) = weekly ×18 weeks → fortnightly to week 52 → 4-weekly if stable; stop permanently if neutrophils <1.5; agranulocytosis risk 0.5-1% (peak 6-18 weeks); patients must report fever/sore throat immediately.
Severe lithium toxicity (high level plus neurological features or AKI) = urgent haemodialysis + IV 0.9% saline; charcoal, urinary alkalinisation and forced diuresis do not work (BNF/NPIS).
Aminoglycosides - narrow index, nephro/ototoxic. Once-daily preferred. Monitor: random level 6-14h (Hartford nomogram) or trough <1 mg/L. Adjust for renal impairment.
10-20mg/L therapeutic; seizures most serious (>40); CYP1A2 (ciprofloxacin ↑50%, smoking ↓); benzodiazepines for seizures; avoid phenytoin; MDAC; haemodialysis >100.
Gentamicin trough >1 mg/L on once-daily dosing → withhold and extend the interval / reduce the dose (BNF 2024 / local Hartford nomogram); never simply continue or increase.
Phenobarbital auto-induces CYP450 metabolism over 2-4 weeks; monitor levels at 2 weeks and 6-8 weeks, adjusting dose upward as needed.
Digoxin toxicity = xanthopsia, bidirectional VT, hyperkalemia; Digibind for severe cases; avoid calcium/cardioversion.
Aminoglycoside ototoxicity = irreversible; trough <1mg/L; limit ≤7d; stop if tinnitus; OD dosing safer than TDS.
Phenytoin = zero-order (saturated enzymes), small dose increase = large level increase; adjust 25-50mg; 10-20 range; measure free if hypoalbuminaemia; ethanol = 1 unit/h.
Gentamicin OD = single level 6-14h post-dose (Hartford nomogram); target <1mg/L; creatinine daily; limit 3-5d.
In digoxin toxicity with hypokalemia, replace potassium before considering Digibind.
Once-daily gentamicin monitoring uses trough levels only at 6-14 hours post-dose.
Thiazides = commonest lithium toxicity precipitant (↑30-50%); stop both + IV saline; haemodialysis if severe.
Warfarin = vitamin K antagonist; INR target 2-3 (AF/VTE); reversal: INR 5-8 + minor bleeding = oral vitamin K 1-2mg; major bleeding = PCC + IV vitamin K.
Graves ophthalmopathy (proptosis + diplopia + CAS ≥3 + smoking) = IV methylprednisolone for moderate-to-severe active disease - smoking cessation ESSENTIAL (worsens 8-fold), selenium for mild, avoid radioiodine in active disease, maintain euthyroidism.
Subacute thyroiditis (painful tender thyroid + post-viral + elevated ESR + low uptake scan + thyrotoxicosis) = NSAIDs/prednisolone for pain + beta-blockers - self-limiting 95% by 6 months, do NOT give antithyroid drugs.
Treat subclinical hypothyroidism if TSH >10, OR TSH 5.5-10 with symptoms / positive TPO / dyslipidaemia (NICE NG145); start levothyroxine 50 micrograms daily (25 micrograms if ≥65 or cardiac), retest TSH at 6-8 weeks, target 0.5-2.5 mU/L.
Congenital hypothyroidism (elevated TSH + low T4 + prolonged jaundice + hypotonia + macroglossia + newborn screening) = START levothyroxine immediately 10-15 μg/kg - do NOT delay, first 2 weeks critical for preventing irreversible neurodevelopmental damage (cretinism).
Myxedema coma (hypothermia + hypercapnia + coma + TSH >100 + T4 <5) = IV levothyroxine + IV liothyronine + IV hydrocortisone - mortality 30-40%, always give hydrocortisone BEFORE thyroid hormone.
Myxedema coma (hypothermia + altered consciousness + bradycardia + severe hypothyroidism) = IV liothyronine + levothyroxine + hydrocortisone FIRST (prevents Addisonian crisis) + ICU + passive rewarming - 30-60% mortality, do NOT give thyroid hormone before steroids.
Thyroid storm (hyperthyroidism + fever + AF + confusion + precipitant) = propylthiouracil + propranolol + hydrocortisone, then iodine 1 hour later - multi-drug approach essential, mortality 10-30%.
Mucolytics (carbocisteine) = NOT routine COPD therapy; Only if chronic productive cough + exacerbations; Trial 3-6 months; Continue only if reduced exacerbations; Reduces exacerbations 20-30% (selected patients); Carbocisteine 750mg TDS initially; Discontinue if no benefit; Not for all COPD patients.
Pulmonary rehabilitation = Exercise + education; Most effective non-pharmacological COPD intervention; Offer to all mMRC ≥1; Improves dyspnoea, capacity, QOL, reduces hospitalizations; 6-8 weeks minimum; Post-exacerbation PR within 4 weeks.
Post-exacerbation PR = refer within 4 weeks (reduces readmissions 50%); NOT contraindicated after exacerbation.
Triple therapy (ICS/LABA/LAMA) = Eosinophils ≥300 + ≥2 exacerbations/year on LABA/LAMA; IMPACT trial: reduces exacerbations 25%, reduces mortality; Pneumonia risk increased 1.5x; Withdraw if no benefit.
Post-exacerbation PR = Within 4 weeks discharge (optimally 1-3 weeks); Reduces readmissions 50%; Greater benefits than standard PR; High motivation 'teachable moment'; Don't wait for full recovery; 6-8 weeks programme; Maintenance exercise essential.
Pulmonary rehabilitation = Not just COPD (bronchiectasis, ILD, PH all benefit); mMRC ≥2 + exercise-limited = eligible; 6-8 weeks minimum; Improves exercise, QOL, reduces exacerbations/admissions; Maintenance exercise essential; Even oxygen-dependent benefit.
Early COPD + basal emphysema + low AAT = confirm with phenotype/genotype; augmentation if PiZZ.
High dependence + failed NRT = varenicline (30-35% quit rate); combine with behavioural support; most effective COPD intervention.
COPD advance care planning = Discuss honestly (prognosis, 50% mortality 3-year if NIV); Explore preferences (DNACPR, place of death); Document decisions; Opioids for breathlessness; Early palliative care involvement; Respect autonomy; Review regularly; Improves end-of-life quality; Severe COPD (FEV1 <30%, LTOT, NIV) = trigger for ACP.
Adrenal incidentaloma = ALWAYS screen for subclinical Cushing's (1mg DST) and pheochromocytoma (metanephrines). <10 HU on CT = benign adenoma. >4cm or suspicious = surgery!
Salt-wasting CAH = crisis at 2-4 weeks (low Na, high K, hypoglycaemia) + ambiguous 46,XX; ↑17-OHP >200; IV fluids + IV hydrocortisone + fludrocortisone (BSPED 2023).
Metanephrines MANDATORY all incidentalomas (phaeochromocytoma fatal if missed); overnight dex for Cushing's; ARR if hypertensive; <4cm + <10 HU = benign observe; 5% develop function.
Addisonian crisis - known Addison's omitted doses (gastroenteritis precipitant), hypotension 80/50 (shock), hyponatremia 125, hyperkalemia 6.5 (arrhythmia risk), hypoglycemia 3.2, dehydration, hyperpigmentation (ACTH ↑ primary), confused GCS 13, IV hydrocortisone 100 mg stat (life-saving, do NOT delay, 6-hourly) + IV saline 1 L/hour (deficit 5-8L) + IV dextrose if glucose <4, treat precipitant, taper → maintenance, fludrocortisone once eating, sick day rules (double/triple dose, IM kit, medic-alert), mortality 5-10% delayed.
Adrenal incidentaloma - 2.5 cm, HU <10 (benign lipid-rich), suppresses dex (excludes Cushing), metanephrines normal (excludes pheo), K normal (excludes Conn), observation, repeat imaging 6-12m, biochemical annually 5y (5-10% develop autonomous cortisol), adrenalectomy if >4 cm/HU >20/growing/functioning, 99% remain benign.
Adrenal crisis - shock + hyponatraemia + hyperkalaemia + hypoglycaemia + hyperpigmentation, IV hydrocortisone 100 mg stat (do NOT delay), IV saline, treat precipitant. Mortality high if untreated.
Cushing disease (high cortisol + elevated ACTH + NO low-dose suppression + >50% high-dose suppression + pituitary adenoma) = pituitary retains partial feedback - transsphenoidal surgery curative, distinguish ectopic ACTH (very high ACTH, NO high-dose suppression).
Ectopic ACTH (rapid onset + severe hypokalemia + hyperpigmentation + weight loss + very high ACTH/cortisol + lung mass + smoker) = SCLC most common - metyrapone urgently lowers cortisol, distinguish from Cushing disease (slow, mild K loss, weight gain).
Primary aldosteronism (resistant hypertension + hypokalemia + high aldosterone + low renin + ARR >70) = confirmatory test ESSENTIAL (saline suppression) before imaging - distinguish adenoma (surgery) vs bilateral hyperplasia (spironolactone), false positive ARR common.
Hypertension + hypokalaemia + virilisation + raised 11-deoxycortisol with only mildly raised 17-OHP = 11β-hydroxylase CAH - glucocorticoid (dexamethasone in adults) suppresses ACTH/DOC and androgens; this distinguishes it from classical 21-hydroxylase deficiency.
Alpha-blockade FIRST (phenoxybenzamine 10-14d); NEVER beta-block before alpha; metanephrines diagnostic; surgery curative 90%.
Pheo - metanephrines/normetanephrines ↑↑ (>3× diagnostic), paroxysmal HTN triad, adrenal 4 cm, phenoxybenzamine FIRST (alpha-blocker 7-14d) THEN propranolol (NEVER beta first), fluids, adrenalectomy, cure confirmed metanephrines 2w post-op.
Primary aldosteronism with unilateral adenoma (elevated ARR + adrenal nodule + lateralization on AVS) = laparoscopic adrenalectomy - cures hypokalemia 100%, cures hypertension 50-60%, spironolactone if bilateral.
ACTH-dependent Cushing (normal/elevated ACTH + suppression with high-dose dexamethasone >50%) = Cushing disease (pituitary adenoma) - accounts for 70% endogenous Cushing, transsphenoidal surgery first-line.
Recurrent GI bleeding + normal upper/lower endoscopy = video capsule endoscopy to examine small bowel - highest diagnostic yield.
Pneumatosis intestinalis (bowel wall gas on CT) = conservative if stable/no peritonitis/normal lactate (benign), emergency surgery if peritonitis/shock/elevated lactate (ischemia).
Carcinoid syndrome patient requiring surgery = prophylactic IV octreotide before/during/after procedure - prevents life-threatening carcinoid crisis from massive mediator release.
GI amyloidosis (Congo red apple-green birefringence + multiple myeloma) = treat underlying AL amyloidosis (chemotherapy) + supportive GI care (nutrition, anti-diarrheal) - no specific GI therapy for deposits.
HAE abdominal attack (recurrent pain + bowel wall edema + low C4/C1-INH) = C1-INH concentrate or icatibant - specific therapy, antihistamines/steroids/epinephrine ineffective.
Pernicious anemia diagnosis requires low B12 PLUS positive intrinsic factor antibodies - most specific test available.
Chronic radiation enteritis (pelvic RT history + telangiectasias + bleeding) = endoscopic APC - reduces transfusions 70-80%, hyperbaric oxygen if available, avoid surgery unless complications.
Celiac patient deteriorating despite strict GFD = refractory celiac disease - urgently exclude EATL, especially if lymphadenopathy or weight loss present.
PN-dependent short bowel syndrome with intact colon - trial teduglutide (GLP-2) to promote adaptation and reduce PN needs.
Whipple disease needs IV ceftriaxone 2 weeks THEN co-trimoxazole for 12 months minimum - short courses lead to CNS relapses.
Strongyloides hyperinfection in immunosuppressed patient = urgent ivermectin + stop steroids + gram-negative antibiotics - delay is fatal.
RCD type II (aberrant clonal T-cells CD3+ CD8- despite gluten-free diet) = urgent oncology referral - 50-80% progress to EATL within 5 years.
Suspected coeliac = tTG-IgA positive → upper GI endoscopy with duodenal biopsies (gold standard). Must be eating gluten! Don't start gluten-free diet until diagnosis confirmed!
Abetalipoproteinemia (steatorrhea + ataxia + retinitis pigmentosa + acanthocytes + undetectable LDL) = high-dose vitamin E 100-200mg/kg plus vitamins A/D/K - prevents neurological progression if started early.
Hypoalbuminemia with normal liver/renal function + GI symptoms = measure fecal alpha-1 antitrypsin clearance - >24 mL/24hr confirms protein-losing enteropathy.
Sclerosing mesenteritis (misty mesentery + mesenteric mass + preserved fat) = corticosteroids ± colchicine/tamoxifen - surgery only for complications.
SIBO (bloating + diarrhea + low B12/high folate + early breath test rise) = rifaximin 14 days - response 60-70%, address underlying cause.
Pituitary apoplexy (sudden headache + visual loss/ophthalmoplegia + reduced GCS + hypotension + pituitary hemorrhage) = IV hydrocortisone 100mg immediately (life-threatening ACTH deficiency) + urgent neurosurgery if deteriorating - endocrine/neurosurgical emergency, do NOT delay steroids, early surgery improves visual recovery.
Macroprolactinoma (prolactin >5000 + visual field defects + large pituitary mass) = cabergoline first-line EVEN with mass effects - shrinks tumor 80-90% and restores vision, surgery reserved for drug-resistant, unique among pituitary adenomas.
Nelson syndrome (severe hyperpigmentation + very high ACTH >1000 + pituitary macroadenoma + years post-bilateral adrenalectomy for Cushing) = pituitary corticotroph adenoma unopposed growth - surgery/radiotherapy, now rare (better initial pituitary surgery).
Acromegaly (elevated IGF-1 + GH fails to suppress with OGTT + pituitary adenoma) = transsphenoidal surgery first-line - cure 70% for macroadenomas, somatostatin analogues if surgery unsuccessful.
Sheehan syndrome → panhypopituitarism: replace cortisol BEFORE levothyroxine to avoid adrenal crisis; lifelong replacement plus steroid sick-day rules and emergency hydrocortisone (Society for Endocrinology UK).
Sheehan → start hydrocortisone FIRST, then levothyroxine, then sex-steroid (and GH) replacement; counsel on sick-day rules and emergency injection.
Empty sella syndrome (CSF-filled sella + flattened pituitary + incidental finding) = assess pituitary function and visual fields - most asymptomatic with normal function (primary), exclude secondary causes (surgery/Sheehan).
Lymphocytic hypophysitis - autoimmune pituitary inflammation postpartum (6 weeks, normal delivery differentiates Sheehan PPH >1L, pregnancy/postpartum 70%), hypopituitarism (cortisol 95 low, TSH 1.5 + T4 8 low central hypothyroidism, prolactin 65 low agalactia, LH 1.5 + FSH 2 low), MRI enlarged pituitary 1.5 cm (homogeneous enhancement differentiates adenoma, thickened stalk pathognomonic, no mass), headaches, normal visual fields, hydrocortisone 15-25 mg/day (ESSENTIAL FIRST → adrenal crisis) PLUS levothyroxine 50-100 mcg daily (AFTER hydrocortisone), consider prednisolone 1 mg/kg 4-6w taper (↓ inflammation 50%, controversial), surgery only if vision threatened, MRI 3-6m (50% resolve, 50% persistent → lifelong), prognosis lifelong replacement 50%.
Acromegaly with a macroadenoma and visual field defects warrants first-line transsphenoidal surgery to decompress the chiasm - reserve somatostatin analogues for incomplete resection or when surgery is not feasible.
Central DI = polyuria + dilute urine + hypernatraemia; desmopressin concentrates urine (confirms central); DDAVP 10-20μg intranasal BD; allow free water; craniopharyngioma commonest cause in young adults.
Acromegaly = high IGF-1 + failed GH suppression on OGTT; transsphenoidal surgery first-line (Endocrine Society/BNF); octreotide/pegvisomant for residual disease; lifelong colonoscopy and cardiovascular surveillance.
Prolactinoma = medical therapy FIRST (cabergoline preferred). Surgery only if dopamine agonist fails or acute visual threat. 70-90% shrink with cabergoline!
GRACE score >140 = high risk = invasive strategy within 24 hours. GRACE guides timing - don't delay high-risk patients.
Recent stroke makes PCI the only option for STEMI reperfusion - transfer time <120 minutes is acceptable.
Cardiogenic shock with CI <2.2, high filling pressures, vasopressor-dependent → Impella CP for LV unloading; IABP insufficient for severe shock.
Inferior STEMI + hypotension + raised JVP + clear lungs = RV infarction - give fluids first, avoid nitrates and diuretics, and arrange urgent revascularisation.
Young woman + postpartum + LAD dissection + stable = conservative management - PCI risks extension, most heal spontaneously!
Cocaine chest pain = benzodiazepines first, then aspirin and IV nitrates with early angiography per AHA/TOXBASE - never reach for a β-blocker first.
Deep symmetrical T inversions V2-V4 + recent chest pain = Wellens' syndrome - urgent angiography to prevent massive MI.
Type 2 MI = troponin rise from supply-demand mismatch (sepsis, anemia, tachycardia) - treat underlying cause, NOT ACS protocols (DAPT/PCI), prognosis depends on precipitant.
MINOCA requires systematic investigation (MRI first-line) to identify treatable underlying cause - not a benign diagnosis.
Takotsubo = emotional trigger + chest pain + ST changes + apical ballooning + normal coronaries. Mostly recovers fully within 3 months.
In CKD, high-sensitivity troponin often chronically elevated; acute MI requires significant delta (>20%) plus clinical/ECG/imaging evidence.
Cocaine-associated chest pain - benzodiazepines, aspirin and nitrates first-line; never give pure beta-blockers because unopposed alpha stimulation worsens coronary vasospasm.
Post-MI sudden tamponade in a previously recovering patient = free wall rupture - around 90% fatal; pericardiocentesis temporises, emergency surgery is the only chance of survival.
Low ferritin + low TSAT = iron deficiency - treat iron first, then ESA if needed.
In CKD stage 3b with sepsis, stop metformin (lactic acidosis risk), reduce and monitor lithium, dose-adjust and monitor gentamicin, and continue ramipril with electrolyte monitoring (BNF; NICE NG203 chronic kidney disease).
CKD G3bA3 = optimise everything, refer if eGFR <30 or declining rapidly.
In exam scenarios, “diabetes + typical renal picture = no biopsy; atypical or aggressive features = biopsy” to look for superimposed glomerular disease.
CKD G4-5 + high phosphate + low vitamin D + high PTH = CKD-MBD; phosphate binders FIRST, then cholecalciferol, then active vitamin D, then cinacalcet if refractory (KDIGO 2017; NICE TA448).
Hypertensive nephrosclerosis = chronic HTN + small kidneys + mild proteinuria; African ancestry highest risk (APOL1); aggressive BP control most important.
CKD 3b = stop metformin; ACEi if albuminuria; BP <130/80; very high CV risk.
Uraemic pericarditis = friction rub + widespread ST elevation + ESRD + high urea; intensify dialysis daily for ~2 weeks (UK Kidney Association); avoid NSAIDs and steroids; monitor for tamponade.
Uraemic pericarditis (CKD5 + pericarditic pain + friction rub + widespread ST elevation + effusion) = urgent intensive daily dialysis; AVOID NSAIDs, avoid early heparin (haemorrhagic risk), pericardiocentesis only for tamponade (ESC 2015 Pericardial Diseases; UK Kidney Association).
Hypertension + arm-leg BP gradient + radio-femoral delay + rib notching = aortic coarctation - repair if gradient >20 mmHg!
Hypertension + arm-leg BP gradient + radio-femoral delay + interscapular murmur = coarctation - confirm anatomy with CT/MR angiography and repair if the gradient is >20 mmHg.
Ebstein's anomaly plus pre-excitation and palpitations - arrange an EP study and accessory pathway ablation; reserve tricuspid surgery (cone repair) for advanced symptoms or progressive RV dysfunction.
Palliative breathlessness = Opioids (morphine) first-line (2.5-5mg 4-hourly regular); Reduces dyspnoea sensation; Safe - does NOT hasten death; Oxygen if SpO2 <90%; Fan + non-pharmacological adjunct; Anxiolytics if anxiety; Titrate to control; Improves quality.
SPN >10 mm + high-risk features (irregular, smoking, PET-positive) = biopsy (CT-guided or surgical) for diagnosis before treatment.
Malignant SVCO = elevate head + dexamethasone + urgent oncology; SCLC → chemotherapy; SVC stenting if life-threatening (NICE NG122 lung cancer; UK Oncological Emergencies guidance).
Extensive-stage SCLC (distant metastases) = palliative chemo-immunotherapy; surgery not indicated.
Stage IIIA NSCLC with adequate lung function = surgical candidate - lobectomy plus adjuvant chemotherapy improves survival, EGFR-positive may benefit from adjuvant TKI.
Carcinoid = Neuroendocrine + Non-smoker; Typical (<2 mitoses, no necrosis) vs Atypical; Surgery curative; NO chemo for typical; Carcinoid syndrome rare 5%.
SVCS = SVC obstruction (malignancy 90%, lung cancer 70%); Facial/arm swelling, plethora, distended veins, Pemberton's sign; NOT immediate emergency (unless stridor/cerebral edema); Tissue diagnosis FIRST if stable; Treat cause (chemo/radiotherapy); Stenting if severe/refractory; Supportive: elevation, steroids.
In HFE haemochromatosis, weekly venesection to deplete iron (target ferritin 50-100 µg/L) is first-line; chelation is second-line, and first-degree relatives should be offered HFE genetic screening.
Grade III cholangitis (Charcot triad + septic shock + bacteremia) = urgent ERCP within 24 hours + IV antibiotics + resuscitation - biliary drainage is the definitive treatment, antibiotics alone are insufficient.
NASH with significant fibrosis (steatohepatitis + F2-F3 on biopsy) = weight loss 7-10% plus pioglitazone or vitamin E - improve histology and prevent progression.
PSC with new dominant stricture + elevated CA19-9 = ERCP with brush cytology, biopsies, and FISH - combined approach maximizes cholangiocarcinoma detection.
SOD type II (post-cholecystectomy pain + transient enzyme elevation + dilated CBD) = ERCP with manometry and sphincterotomy - effective 60-90% in type I/II.
DILI (hepatitis pattern + temporal relation to drug + negative workup) = stop offending drug immediately + supportive care - most resolve with withdrawal, amoxicillin-clavulanate commonest antibiotic cause.
IgA = synpharyngitic haematuria + mesangial IgA; ACEi first-line; steroids if ≥1g/d proteinuria persists.
Ogilvie with cecum >10cm needs urgent decompression - neostigmine with cardiac monitoring is safest initial approach.
Chronic anal fissure failing conservative therapy = topical GTN 0.4% for 6-8 weeks - medical sphincterotomy before considering surgery.
Colonoscopy with high-risk adenoma (≥10mm, high-grade dysplasia, villous, or ≥3 total) = repeat in 3 years - balances cancer prevention with procedural risks.
Ogilvie syndrome (post-op colonic dilation, cecum >10-12cm, no obstruction) = IV neostigmine - reverses atony in 80-90%, prevents perforation.
Fulminant CDI (shock + organ failure + megacolon) failing medical therapy = urgent subtotal colectomy with end ileostomy. Earlier surgery improves survival - do not delay.
Severe CDI (WCC >15 + creatinine rise + fever) = oral vancomycin 125mg QDS or fidaxomicin; Bezlotoxumab prevents recurrence; FMT after 2nd recurrence (85-90% cure).
Diverticulitis with pelvic abscess >4cm (Hinchey II) = IV antibiotics PLUS CT-guided drainage - avoids emergency surgery in 70-80%.
ACPO with a stable patient and caecum <12 cm - treat conservatively first (NBM, NG tube, correct electrolytes, stop opioids); reserve intravenous neostigmine for failure of conservative therapy or caecum ≥12 cm.
CRT golden criteria = LVEF ≤35% + LBBB + QRS ≥150 ms + NYHA II-IV despite optimal medical therapy - this is a Class I indication with Level A evidence.
SGLT2i are 'quadruple therapy' for HFrEF alongside ACE-i/ARB, beta-blocker, and MRA - proven to reduce mortality in diabetic AND non-diabetic patients. Consider as standard of care in all HFrEF patients with eGFR ≥20.
Ivabradine for HFrEF = LVEF ≤35% + SR + HR ≥70 despite beta-blocker; pure HR reduction, add to GDMT.
Heart failure with a high cardiac output and a wide pulse pressure in a dialysis patient points to AV fistula-related high-output failure; treat by reducing shunt flow (banding) rather than with inotropes (ESC 2021 Heart Failure guidelines).
Amiodarone + progressive dyspnoea + interstitial infiltrates = pulmonary toxicity - stop drug immediately and give steroids.
Cor pulmonale = RV failure from lung disease - echo distinguishes it from left heart failure.
HFpEF = treat hypertension + diuretics for congestion. Unlike HFrEF, no proven mortality-reducing drugs yet!
Postural hypotension in HF on GDMT → reduce diuretics first (check for overdiuresis); don't stop beta-blockers/ACE inhibitors unless absolutely necessary.
Ulnar at elbow = claw hand + medial 1.5 fingers (including dorsum) + Tinel at elbow; conservative then surgery if progressive.
CTS (nocturnal hand numbness lateral 3.5 fingers sparing palm + thenar wasting + positive Phalen) = wrist splint at night + steroid injection; surgery if severe/refractory.
RLS (urge to move legs + worse at rest + relieved by movement + evening worsening) + ferritin <75 = oral iron supplementation first; dopamine agonists if inadequate response.
HD = chorea + dementia + psychiatric + AD FHx + caudate atrophy; CAG ≥40 confirms; tetrabenazine for chorea.
Essential tremor = bilateral postural/action + absent at rest + family history + alcohol improves; propranolol first-line (50-60% reduction); DBS if refractory.
Chorea plus dementia plus family history equals Huntington disease - CAG repeats ≥40 diagnostic, anticipation causes earlier onset in offspring.
Sydenham chorea = penicillin prophylaxis ≥5yr (longer if carditis); chorea self-limiting but cardiac damage progressive; serial echo monitoring.
MSA (parkinsonism + early severe autonomic failure + poor levodopa response + rapid progression) vs PD (asymmetric, tremor, good levodopa response, slower progression).
Parkinson's wearing off (predictable end-of-dose deterioration after years levodopa) = add dopamine agonist - smooths fluctuations, avoid increasing levodopa alone (dyskinesia risk).
achalasia needs mechanical disruption of the LES - Heller myotomy with partial fundoplication or POEM for fit patients (BSG / NICE IPG463); balloon dilatation for older/less fit patients; botulinum toxin is palliative only.
ABPA = Asthma + IgE markedly raised + Central bronchiectasis; Prednisolone + itraconazole; Monitor IgE for response.
Inhaler technique = Check at EVERY visit; Up to 70% patients incorrect technique; Correct technique before escalating therapy; Common errors: not exhaling first, not holding breath 10s; Consider spacer/different device; Dramatically improves control.
EIB = Symptoms 5-15 min post-exercise, resolve 30-60 min; Exercise challenge ≥10% fall diagnostic; SABA pre-exercise first-line; LTRA if inadequate; Isolated EIB ≠ asthma.
Uncontrolled asthma on low-dose ICS = switch to low-dose ICS-formoterol MART (NICE/BTS/SIGN NG244, 2024); combination delivery preferred over a separate LABA inhaler; SABA-only treatment is no longer recommended.
Acute severe asthma = Peak flow 33-50%, speaking phrases, HR >110; IV magnesium 2g if inadequate response to initial treatment; Single dose over 20 min; Reduces admissions 30%; Aminophylline if magnesium fails; Life-threatening <33% peak flow, SpO2 <92%, silent chest.
Palindromic rheumatism = recurrent, fully resolving inflammatory attacks with no erosions; treat acute attacks with NSAIDs and monitor for progression to RA (refer via NICE NG100 if persistent synovitis develops).
RA = symmetrical MCP/PIP/MTP + stiffness >1hr + RF/anti-CCP+; methotrexate within 3mo (critical window); biologics if refractory.
PsA = dactylitis + DIP + nail pitting + RF/anti-CCP negative + erosions with periostitis (CASPAR); methotrexate first-line (NICE NG200 / BSR 2022); biologics if refractory; avoid systemic steroids.
In RA, think “sore joints, sore hearts” - it is both a joint and cardiovascular disease, so statins and BP control are as crucial as DMARDs in long-term management.
Valproate = most teratogenic psychiatric drug (30-40% neurodevelopmental harm). MUST switch before pregnancy. Lamotrigine or quetiapine = safer alternatives.
"Acute dystonia = Muscle spasm within HOURS/DAYS!" IM procyclidine = rapid reversal. Tardive dyskinesia = late, irreversible.
Serotonin syndrome = rapid onset + hyperreflexia + clonus + serotonergic drug combination (Hunter criteria). NMS = slow onset + lead-pipe rigidity after antipsychotics. Stop drugs, give benzodiazepines, consider cyproheptadine.
"SSRI nausea = EARLY and TRANSIENT!" Sexual dysfunction = persistent. Serotonin syndrome = triad (neuromuscular + autonomic + mental state).
FINISH mnemonic for SSRI withdrawal. Paroxetine and venlafaxine = highest risk. Fluoxetine = lowest risk (long half-life). Always taper gradually.
Depot/LAI antipsychotic = first choice when non-adherence causes relapse. Ensures medication delivery. Paliperidone palmitate (monthly/3-monthly) and aripiprazole LAI commonly used.
Primary pneumothorax ≥2 cm = try needle aspiration first; drain if fails.
Light’s criteria - protein ratio >0.5, LDH ratio >0.6, pleural LDH >2/3 ULN; any one positive = exudate; empyema (pH <7.2) mandates urgent chest drain per BTS 2023.
Diabetic osteomyelitis - probe-to-bone+ + ↑CRP, MRI best investigation (90% sensitivity, differentiates Charcot), bone culture-guided antibiotics 6-12w, offloading essential, MDT.
Type 2 diabetes with established CVD (on metformin + HbA1c >58) = add SGLT2 inhibitor or GLP-1 RA - proven CV outcome benefit (reduce CV death, HF hospitalization), not just glycemic control.
Frail elderly + recurrent hypoglycaemia = relax HbA1c target (58-70). Stop/reduce sulfonylureas. Avoiding hypos is more important than tight control. Metformin contraindicated if eGFR <30.
Acute stroke <4.5 hours + no hemorrhage on CT + BP <185/110 = IV alteplase immediately; avoid antiplatelets 24 hours post-thrombolysis.
Thunderclap + normal CT = mandatory LP at 12+h for xanthochromia; CT sensitivity declines with time.
Acute ICH + BP >140 mmHg = intensive lowering to <140 within 1 hour (safe, reduces expansion); avoid ultra-intensive <120.
CVST with hemorrhagic infarction = still anticoagulate with therapeutic LMWH (counterintuitive but evidence-based); hemorrhage is venous congestion, not contraindication.
Stroke <4.5 hours + no haemorrhage + BP reducible <185/110 = IV alteplase immediately; door-to-needle <60 minutes.
PCOS = Rotterdam 2/3; weight loss + metformin; clomifene/letrozole for fertility; OCP if not trying; screen OGTT annually; acanthosis = insulin resistance.
45,X = short stature + streak gonads + cardiac (bicuspid 30%); GH from age 4-6; oestrogen from 11-12; lifelong HRT until 51; cardiac screening.
Klinefelter 47,XXY - primary hypogonadism (testosterone 6 low, LH 28 + FSH 35 ↑ vs secondary low), small firm testes 4 mL (pathognomonic), azoospermia (infertility 95%), gynecomastia (50%), tall eunuchoid (arm span >height 5 cm), delayed puberty, 1:500-1,000 males, testosterone undecanoate 1000 mg IM (initial, 6w, 12-weekly lifelong, OR gel 50 mg), improves libido 70-80%, ↑ bone/muscle, does NOT restore fertility (micro-TESE 50% if <35y, ICSI 30%), monitor testosterone (target 10-30), screen T2DM (metabolic syndrome 30-40%), lifelong replacement normal lifespan.
Primary hypogonadism (low testosterone + high LH/FSH + small testes) → testosterone replacement (gel or Nebido) per BSSM 2022; monitor haematocrit, PSA and lipids; fertility is not restored - refer to assisted conception.
In AF with HFrEF, beta-blocker + digoxin for rate control; never use diltiazem/verapamil (negative inotropes contraindicated).
Post-op AF after CABG → beta-blocker for rate control first; most converts spontaneously; anticoagulate only if persists >48 hours.
Silicosis = Sandblasting/quarrying + Upper zone nodules + Eggshell calcification (highly characteristic); TB risk 3x; No specific treatment; Remove from exposure; PMF progressive; vs CWP (coal mining, lower zones, no eggshell calcification).
Rounded atelectasis = asbestos + pleural-based mass + comet tail sign; benign; observation only; mimics cancer but stable + low PET.
Gallstone pancreatitis = amylase/lipase >3× ULN + gallstones + ALT >150 (95% PPV); IV fluids + early enteral 24-48h + ERCP if cholangitis + cholecystectomy same admission; Glasgow ≥3 severe.
Hereditary pancreatitis (PRSS1 mutation + recurrent pancreatitis + family history) = annual MRI/MRCP cancer surveillance from age 40 - lifetime pancreatic cancer risk 40-55% (50-75x general population).
Severe pancreatitis = persistent organ failure >48h; Glasgow ≥3/CRP >150; aggressive fluids + early enteral + antibiotics only infected necrosis.
Basilar artery occlusion (vertigo, ataxia, crossed signs, CTA basilar clot) - mechanical thrombectomy up to 24 hours is first-line per NICE NG128 and RCP National Clinical Guideline for Stroke 2023; IV alteplase only as a bridge; mortality 80% untreated falls to around 40% with intervention.
Symptomatic primary pneumothorax in a stable patient - BTS 2023 supports needle aspiration, ambulatory Heimlich-valve drainage, or conservative care; large-bore drainage is no longer the default for PSP (RAMPP and PSP trials).
Loculated empyema + failed drainage → alteplase 10mg + DNase 5mg BD ×3d (MIST2); reduces surgery 50%; VATS if fails.
REPE = Unilateral edema ipsilateral to drained side; Occurs 1-2h post-rapid drainage large chronic effusion; Pink frothy sputum; Prevent: limit drainage <1.5L at once; Supportive care; Self-limiting 48-72h; Mortality 20% if severe.
Chest drain removal = Lung expanded + no bubbling 24h + <50ml/24h + stable; Clamping trial NOT routine (BTS); Remove during Valsalva/exhale; Post-removal CXR 2-4h (check recurrence 5%); Persistent leak >5-7 days = surgery; Empyema drains need longer.
Light's = 0.5 protein, 0.6 LDH, 2/3 ULN; ANY ONE positive = exudate.
Scabies = night itch + web spaces + burrows; permethrin 5% ×2 (day 1 & 8); treat ALL contacts; itch persists 2-4w.
Onchocerciasis = river exposure + nodules + pruritus + visual loss; treat with ivermectin every 6-12 months (per WHO guidance); never give DEC as it worsens ocular disease.
Commotio cordis = VF from chest impact in youth sports - prevent with chest protectors + AEDs at venues, immediate defibrillation essential for survival.
Sinus bradycardia ≥30 bpm, first-degree AV block PR <400 ms, and incomplete RBBB are benign training-related changes - no investigation needed if asymptomatic.
PH + PAWP 24 mmHg + HFrEF = Group 2 - optimise HF therapy, NO PAH-specific drugs (harmful).
Ischemic colitis without peritonitis = conservative management first - surgery only if perforation/gangrene or clinical deterioration.
Episodic anxiety + paroxysmal severe hypertension (>200 systolic) = exclude phaeochromocytoma. 24-hour urinary metanephrines. Family history → consider MEN 2. Alpha-block before beta-block.
Localised non-bullous impetigo = hydrogen peroxide 1% or short-course topical fusidic acid; reserve oral flucloxacillin for widespread, bullous or systemic disease.
Seizure >5 minutes equals status epilepticus - IV benzodiazepine immediately, then phenytoin if continues, then ICU/anesthesia if refractory.
Myasthenic crisis (MG + FVC <1L + bulbar weakness) = intubate + PLEX or IVIg immediately (equal efficacy); hold pyridostigmine; treat precipitant; introduce steroids after PLEX/IVIg.
Pheo - paroxysmal HTN + triad + metanephrines >2× ULN, alpha-blockade FIRST 2-3w (phenoxybenzamine) THEN beta, NEVER beta first, adrenalectomy curative 90%.
No capacity + no ADRT/LPA = best interests decision (MCA 2005). Consult family about patient's wishes (they don't decide). Ceiling of treatment is a clinical decision informed by patient values. IMCA if no one to consult.
alendronic acid 70 mg weekly
calcium 1g + vitamin D 800 daily
severe hypercalcaemia of malignancy - IV 0.9% saline first, then IV zoledronic acid; calcitonin as a bridging adjunct; denosumab if bisphosphonate-refractory or renal failure; cinacalcet has no role in PTHrP-mediated HHM.
Paget's = elevated ALP (normal Ca/PO₄); blade of grass + cotton wool pathognomonic; zoledronic acid 5mg IV (single dose, effective 5yr); calcium + vitD; deafness irreversible.
Hypercalcemia malignancy - Ca 3.8, PTH 1.2 suppressed, PTHrP 12 ↑ (humoral 80%), squamous lung, IV saline 4-6 L + zoledronic acid 4 mg (48-72h) + calcitonin if severe (rapid 4-6h bridge), treat malignancy, median survival 3m.