Rapid-recall takeaways distilled from the MRCP Part 2 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.
1,282 pearls · 18 specialties · Generated 6 November 2026
Gastroenterology & Hepatology
80 high-yield facts
Gallstone pancreatitis WITHOUT cholangitis - do NOT perform early ERCP (APEC trial, Lancet 2020). Falling LFTs suggest spontaneous stone passage; same-admission cholecystectomy per PONCHO. ERCP only if concurrent cholangitis or persistent obstruction.
PBC diagnosis = AMA positive + cholestatic biochemistry (biopsy not needed). First-line = UDCA 13-15mg/kg/day. Assess response at 12 months (Paris criteria); add OCA or bezafibrate if inadequate response.
Rumination syndrome - effortless regurgitation within minutes of eating, not during sleep, normal investigations. Treatment is diaphragmatic breathing retraining, not PPI or prokinetics.
Always check total IgA when anti-tTG IgA is negative in suspected coeliac disease - IgA deficiency causes false negatives, and IgG-based tests should be used instead.
HEV in transplant patients - first reduce immunosuppression (stop mycophenolate, reduce tacrolimus). If HEV RNA persists >3 months, add ribavirin. Interferon is contraindicated in transplant recipients.
SMA syndrome - lost mesenteric fat pad; first-line is nutritional rehabilitation with NJ feeding and weight restoration per MEED/MARSIPAN and NICE CG32; surgery (duodenojejunostomy) only if conservative care fails.
Stricture in long-standing UC = malignancy until proven otherwise (25-30% harbour cancer/dysplasia). Unlike Crohn's, UC strictures are uncommon and warrant surgical resection for definitive histology.
SRUS - anterior rectal ulcer, fibromuscular obliteration on biopsy, colitis cystica profunda. Caused by straining/prolapse. Manage with behavioural modification and biofeedback. Not malignant, not IBD.
Chronic radiation proctitis with bleeding - first-line = APC (80-90% improvement). Second-line = topical formalin or hyperbaric oxygen. Surgery is last resort due to high morbidity in irradiated tissue.
In (day 3 Travis criteria), escalate to - do not continue ineffective IV steroids beyond day 5. Multidisciplinary medical-surgical involvement from day 1.
Endocrinology & Diabetes
80 high-yield facts
Thyroid storm requires PTU (not carbimazole) for its additional peripheral T4-to-T3 blockade, Lugol's iodine given 1 hour after PTU, IV beta-blocker, IV hydrocortisone, and active cooling.
IV sodium bicarbonate is generally not recommended in DKA, even when pH <7.0, because it can worsen intracellular acidosis and hypokalaemia and delay ketone clearance - treat with fluids and insulin per the JBDS guideline (consider only by a senior clinician if pH <6.9 with life-threatening compromise).
HHS has higher mortality than DKA - key complications are VTE (give full-dose LMWH prophylaxis), cerebral oedema (avoid rapid osmolality correction), and hypokalaemia (replace K+ aggressively as it falls with treatment).
Thyroid storm treatment follows the order: Beta-blocker → PTU → Hydrocortisone → Iodine (1 hour after PTU). The sequence matters - Lugol's iodine must come AFTER antithyroid drug to prevent worsening hormone synthesis.
LADA should be treated as autoimmune (type 1) diabetes - maintain insulin therapy, avoid sulphonylureas which may accelerate beta-cell loss, and screen for associated autoimmune conditions (thyroid, coeliac, pernicious anaemia).
In a woman with current or previous Graves' disease, a markedly positive TRAb (>3x ULN) crosses the placenta and can cause fetal/neonatal thyrotoxicosis even when the mother is euthyroid - arrange fetal monitoring, neonatal TFTs, and neonatal paediatric review.
Treat subclinical hyperthyroidism when TSH is persistently <0.1 or in patients >65 with AF, osteoporosis, or cardiovascular disease - low-dose carbimazole or radioactive iodine are treatment options.
Cardiology
80 high-yield facts
Iron deficiency in HF (ferritin <100 or ferritin 100-299 with TSAT <20%) requires IV iron - oral iron is ineffective due to impaired absorption in heart failure.
Anticoagulation must continue for at least 4 weeks post-cardioversion due to atrial stunning - stopping immediately risks thromboembolism even if sinus rhythm is maintained.
Aortic root abscess, large vegetation (>10mm), and severe valvular regurgitation are class I indications for surgery in IE - S. gallolyticus mandates colonoscopy to exclude colorectal cancer.
SGLT2 inhibitors are one of the four pillars of HFrEF therapy and should be prescribed regardless of diabetes status - DAPA-HF showed a 26% reduction in CV death/HF hospitalisation.
Electrical storm requires IV amiodarone, IV beta-blocker (esmolol), and deep sedation - breaking the catecholamine-arrhythmia cycle is as important as the antiarrhythmic drugs.
Symptomatic severe aortic stenosis (AVA <1.0cm², mean gradient >40mmHg) mandates intervention - SAVR for low-risk patients <75, TAVI for higher-risk or older patients.
statin-associated muscle symptoms (SAMS) requires ezetimibe. Always consider the clinical context and guideline-directed management.
Digoxin is an excellent rate control agent in AF with HF when beta-blockers are not tolerated - the RATE-AF trial showed comparable efficacy with fewer side effects.
Left-sided obstructive prosthetic valve thrombosis with thrombus >10mm requires urgent surgery - DOACs are contraindicated with mechanical valves (RE-ALIGN trial).
Asymptomatic severe primary MR should be referred for repair at a centre of excellence when anatomy is favourable - waiting for symptoms risks irreversible LV dysfunction.
Declining TAPSE, new pericardial effusion, falling 6MWD, and rising NT-proBNP in PAH indicate treatment failure requiring escalation - parenteral prostanoid should be considered.
Renal Medicine
80 high-yield facts
Potassium citrate is the ideal treatment for type 1 RTA - it corrects acidosis, replaces potassium, and provides urinary citrate to prevent nephrolithiasis in a single agent.
ACE inhibitor-induced AKI with bilateral RAS - stop the ACE inhibitor and spironolactone; creatinine typically recovers.
A single elevated uACR needs confirmation on 2 further samples before diagnosis and treatment changes - transient albuminuria is common.
Gitelman = hypokalaemia + metabolic alkalosis + hypomagnesaemia + hypocalciuria (thiazide-like); Bartter = similar but normal/high urinary calcium + normal magnesium (loop diuretic-like).
Gentamicin trough levels >1 mg/L require immediate drug cessation - toxicity risk increases dramatically with duration of supra-therapeutic trough levels.
In infection-related glomerulonephritis, treat the infection, not the glomerulonephritis - immunosuppression is harmful in the context of active bacterial endocarditis.
SGLT2 inhibitors are now a cornerstone of proteinuric CKD management - add to RAAS blockade when urine ACR >25 mg/mmol regardless of diabetes status.
Stop metformin once eGFR falls below 30 ml/min/1.73m² per MHRA/BNF - reduce to a maximum of 1 g/day at eGFR 30-45, and always apply sick day rules during acute illness.
Always exclude infection before starting immunosuppression for GN - infection-related glomerulonephritis resolves with adequate antimicrobial therapy and surgical source control.
Recurrent FSGS post-transplant is caused by a circulating permeability factor - plasma exchange is the mainstay of treatment, often combined with rituximab.
When potassium is unexpectedly elevated with a normal ECG, always repeat using a lithium-heparin plasma sample to exclude pseudohyperkalaemia, especially in haematological malignancies.
Neurology
80 high-yield facts
Meningitis: give IV ceftriaxone immediately - never delay for LP or CT. Add dexamethasone before/with antibiotics. Add amoxicillin if >60 or immunosuppressed (Listeria). Petechial rash + meningism = meningococcal until proven otherwise.
MuSK-MG: bulbar predominant (dysphagia >> limbs), facial/tongue ATROPHY (unusual for MG), pyridostigmine worsens, NO thymic pathology (no thymectomy), IgG4 antibodies (no complement activation). Rituximab: dramatic response (may be first-line). No eculizumab (IgG4 doesn't fix complement).
AD: amyloid plaques + neurofibrillary tangles (tau) + cholinergic loss. CSF: low Aβ42, high p-tau, high t-tau. ChEIs first-line (donepezil - mild-moderate). Memantine for moderate-severe (NMDA antagonist).
Meniere's: episodic vertigo (hours) + fluctuating SNHL + tinnitus + aural fullness. Betahistine + salt restriction for prevention. Prochlorperazine for acute attacks. Intratympanic gentamicin for refractory cases. Hearing loss is progressive.
Focal epilepsy first-line per NICE NG217: lamotrigine or levetiracetam. Generalised: sodium valproate (avoid in females of childbearing potential - MHRA PPP). Carbamazepine - avoid in generalised epilepsy.
Basal ganglia encephalitis with somnolence + oculogyric crises + movement disorder post-infection. MRI: basal ganglia signal changes (NOT temporal lobe). Consider autoimmune aetiology. Treat with immunotherapy. Anti-D2R antibodies emerging as important marker.
SCD = absent ankle jerks + extensor plantars (LMN + UMN combined), sensory ataxia and positive Romberg from posterior column loss. B12 deficiency may occur without anaemia (~25%). Urgent IM hydroxocobalamin per BNF - delayed treatment risks irreversible damage.
Dermatomyositis in adults >40: 25-30% cancer risk - screen with CT CAP, mammography, ovarian screening. Anti-TIF1-γ = high cancer risk. Anti-MDA5 = ILD risk. Anti-Mi-2 = good prognosis. Annual screening for 3 years.
Infectious Diseases
80 high-yield facts
Chronic Chagas disease causes dilated cardiomyopathy with apical aneurysm AND gastrointestinal megadisease - screen for megaoesophagus and megacolon alongside cardiac management.
TDF-associated Fanconi syndrome presents with rising creatinine + hypophosphataemia + glycosuria (normal glucose) + proteinuria - switch to TAF or abacavir immediately; monitor renal function in all patients on TDF.
HIV PEP should start within 1 hour using TDF/FTC plus dolutegravir for 28 days - never delay PEP to wait for source patient results.
De-escalate antibiotics when culture results confirm a susceptible pathogen - switch from IV broad-spectrum to oral narrow-spectrum once clinically stable (afebrile, eating, improving CRP).
Add vancomycin in neutropenic sepsis when there is catheter site infection, skin involvement, or haemodynamic instability - port pocket infections usually require device removal.
Fluid-refractory septic shock (MAP <65 mmHg after 30mL/kg crystalloid) requires IV noradrenaline as the first-line vasopressor - target MAP ≥65 mmHg to maintain organ perfusion.
Multiple ring-enhancing brain lesions in advanced HIV with positive Toxoplasma IgG should be treated empirically with sulfadiazine/pyrimethamine - biopsy is reserved for treatment non-responders at 2 weeks.
DTP ≥2 hours confirms CRBSI - for CoNS in stable patients with essential long-term lines, antibiotic lock therapy allows line salvage.
P. knowlesi from Southeast Asian forests causes quotidian fever and can mimic P. malariae on microscopy - but unlike P. malariae, it can cause rapidly progressive severe disease requiring IV artesunate.
90-95% of reported penicillin allergies are not confirmed on formal testing - penicillin allergy delabelling is a key stewardship intervention; low-risk histories (childhood rash, no anaphylaxis) should prompt allergy assessment.
Pharmacology & Therapeutics
80 high-yield facts
Antimicrobial stewardship: review at 48 hours, IV-to-oral switch when improving, de-escalate to targeted therapy based on cultures - CAP typically requires only 5 days of antibiotics.
Rasburicase converts uric acid to allantoin - rapid uric acid reduction for TLS. Contraindicated in G6PD deficiency (haemolysis). Blood samples must go on ice to prevent ex-vivo breakdown.
Amiodarone doubles digoxin levels via P-glycoprotein inhibition. Halve digoxin dose when co-prescribing. Hypokalaemia potentiates toxicity. DigiFab for severe toxicity.
True penicillin-cephalosporin cross-reactivity is 1-2%, not the historical 10%. Side chain structure determines cross-reactivity. Aztreonam is safe in penicillin allergy. Carbapenems can usually be given safely with observation.
Deferasirox is once-daily oral iron chelator - comparable to deferoxamine but much better tolerated. Monitor renal function and LFTs. Deferiprone is best for cardiac iron but risk of agranulocytosis. Target ferritin <1000.
Febuxostat is second-line after allopurinol intolerance - hepatically metabolised (no CKD dose adjustment). CARES trial raised CV mortality concern, but FAST trial was reassuring. Co-prescribe colchicine prophylaxis when starting ULT.
Alteplase 0.9mg/kg (max 90mg) within 4.5 hours for acute ischaemic stroke - 10% bolus, 90% over 60 minutes. Must exclude haemorrhage on CT. Consider thrombectomy for large vessel occlusion.
Levetiracetam's key advantages: renal excretion, no drug interactions, no enzyme effects, low teratogenicity, broad spectrum. Main drawback: psychiatric side effects (irritability, aggression).
GBS is treated with IVIg 2g/kg over 5 days or plasma exchange - corticosteroids are ineffective. Screen IgA levels before first IVIg dose; IgA-deficient patients risk anaphylaxis.
Statins: cornerstone of CV prevention. Secondary prevention: atorvastatin 80mg (NNT ~15 over 5 years). SAMS: most common reason for discontinuation but ~50% is nocebo (SAMSON trial). CK <5× ULN with tolerable symptoms → continue with reassurance.
Haematology
80 high-yield facts
Don't test during acute thrombosis or on anticoagulants. Test 6 weeks after stopping treatment. Antithrombin deficiency is the highest-risk inherited thrombophilia. Always test for antiphospholipid syndrome.
TTP: MAHA + thrombocytopenia + NORMAL PT/APTT/fibrinogen (key differentiator from DIC). ADAMTS13 <10% = TTP. >90% mortality if untreated. Treatment: plasma exchange (start within 4-8 hours - do NOT wait for ADAMTS13 result) + steroids + caplacizumab (NICE).
IDA in male/post-menopausal female = GI malignancy until proven otherwise → OGD + colonoscopy + coeliac serology. Ferritin is the best single test (but is an acute phase reactant). Blood film: microcytic hypochromic + pencil cells.
ACD = low iron, raised ferritin, low TIBC; hepcidin is the key mediator; ferritin is an acute-phase reactant and can mask concurrent iron deficiency - use sTfR or IV iron trial (BSH 2021; NICE TA323).
Chronic GVHD resembles autoimmune disease (sicca, lichenoid, sclerosis, cholestasis). Bronchiolitis obliterans is the most serious lung complication. Ibrutinib is approved for steroid-refractory cGVHD. Some GVH activity protects against relapse (GVL effect).
Fever, loin pain, hypotension and haemoglobinuria soon after starting red cells = AHTR from an ABO/identification error - stop the transfusion immediately, give IV fluids, recheck identity and report to the laboratory and SHOT (BSH/JPAC transfusion guidelines).
DAT+ IgG with spherocytes = warm AIHA → prednisolone 1 mg/kg/day; DAT+ C3d only = cold AIHA → keep warm + rituximab; schistocytes = MAHA; haptoglobin is the most sensitive haemolysis marker.
Unprovoked PE - offer extended anticoagulation with reduced-dose DOAC (apixaban 2.5mg BD) for long-term secondary prevention; this is superior to aspirin with low bleeding risk.
secondary spontaneous pneumothorax (SSP) requires chest drain insertion. Always consider the clinical context and guideline-directed management.
NIV is first-line for AECOPD with persistent respiratory acidosis (pH 7.25-7.35) despite optimal medical therapy - start BiPAP before considering intubation.
Advanced COPD with high symptom burden and failing therapy = early integration of palliative care; low-dose oral morphine for refractory breathlessness, ACP and community palliative support per NICE NG115, BTS and GOLD 2024.
Suspect Legionella in pneumonia with travel/hotel history, confusion, diarrhoea, hyponatraemia, lymphopenia and beta-lactam non-response.
Post-influenza cavitating pneumonia should raise suspicion of Staphylococcus aureus, including PVL-SA - treat with IV flucloxacillin and consider adding linezolid for toxin suppression.
First isolation of Pseudomonas aeruginosa in bronchiectasis should trigger an eradication attempt (oral ciprofloxacin for 2 weeks, with or without 3 months of nebulised colistin or tobramycin) per BTS guidelines - reserve long-term nebulised anti-pseudomonal therapy for when eradication fails and infection becomes chronic.
Pleural fluid pH <7.2 in the context of pneumonia indicates complicated parapneumonic effusion requiring chest drain insertion - do not delay drainage.
Thunderstorm asthma requires low-dose ICS preventer. Always consider the clinical context and guideline-directed management.
Legionella - think hyponatraemia, elevated CK, deranged LFTs, diarrhoea, confusion, and water-system exposure; confirm with the urinary antigen test, treat with a macrolide or fluoroquinolone, and notify public health (UKHSA) as a notifiable disease.
Rheumatology
80 high-yield facts
MRI detects active sacroiliitis (bone marrow oedema) before X-ray changes develop. Normal X-ray does not exclude sacroiliitis. ASAS criteria recognise non-radiographic axial SpA using MRI. Average diagnostic delay for AS is 8-10 years - MRI can shorten this significantly.
Lupus ITP results from antiplatelet antibodies. Glucocorticoids are first-line. Rituximab is preferred second-line for refractory cases. IVIG provides temporary platelet boost for acute bleeding or pre-procedure. Splenectomy is less favoured in SLE patients.
IBP = onset <40, insidious, improves with exercise, no improvement with rest, nocturnal pain. Morning stiffness >30 minutes and alternating buttock pain are key features. MRI SIJ detects early sacroiliitis before X-ray changes. Family history and HLA-B27 increase clinical suspicion.
Calcinosis in SSc is dystrophic (normal serum calcium). More common in limited cutaneous SSc (CREST). Deposits are calcium hydroxyapatite. Treatment is challenging - diltiazem, colchicine, and surgical excision are options. Distinguish from tophi, xanthomata, and rheumatoid nodules.
Primary Raynaud - young women, symmetrical, normal capillaroscopy, negative ANA: conservative measures first, nifedipine if needed. Red flags warrant nailfold capillaroscopy and autoantibody testing for connective tissue disease, especially systemic sclerosis.
Nailfold capillaroscopy is the best predictor of CTD in Raynaud patients. Normal pattern = primary Raynaud (reassuring). Giant capillaries + avascular areas = SSc spectrum. Combined with specific autoantibodies, it has >90% PPV for SSc. Simple bedside test with a dermatoscope.
Type 1 enteropathic arthritis parallels IBD activity - treat the bowel. Type 2 is independent of IBD activity - treat the joints. NSAIDs may worsen IBD. Anti-TNF treats both bowel and joints. Sacroiliitis is common but often asymptomatic.
Behcet = recurrent oral/genital ulcers + uveitis + skin lesions + pathergy. HLA-B51 associated. Silk Road distribution. Pulmonary artery aneurysm can be fatal. Treat vascular disease with immunosuppression, not just anticoagulation.
Dermatology
80 high-yield facts
ACD: type IV hypersensitivity (T-cell mediated). Patch testing gold standard (read at 48h AND 96h). Nickel: most common allergen. PPD: hair dye. Occupational: improves on holiday. Allergen avoidance is key treatment. Distinguish from ICD (non-immunological; patch test negative).
CSU: wheals ≥6 weeks, no trigger. Step 1: standard antihistamine → Step 2: updose to 4x → Step 3: add omalizumab → Step 4: ciclosporin. NEVER allergy test for CSU. Omalizumab: anti-IgE, NICE approved, very effective. Anti-TPO positive in ~40% (autoimmune marker, not causative).
Eczema herpeticum: monomorphic punched-out erosions + haemorrhagic crusting + fever in patient with eczema. Dermatological emergency. HSV PCR confirms. Stop topical immunosuppressants. IV aciclovir if severe, oral if mild. Screen for secondary bacterial infection (flucloxacillin).
Psoriatic nails = irregular pitting and oil-drop/salmon patch (pathognomonic) plus onycholysis and subungual hyperkeratosis; send clippings for mycology to exclude co-existing onychomycosis.
In psoriasis, pitting is the most common nail sign but the oil-drop (salmon patch) sign is the most specific; psoriatic nail disease is a strong predictor of psoriatic arthritis (per BAD and NICE NG65 guidance), warranting joint assessment.
Melanoma: Breslow thickness is the single most important prognostic factor. Excision margins are determined by Breslow (1cm for ≤1mm; 2cm for 1-2mm; 2-3cm for 2-4mm; 3cm for >4mm). SLNB for ≥1mm (prognostic, not therapeutic). BRAF V600 mutation in ~50% → targeted therapy.
KA: rapidly growing crateriform nodule + central keratin plug. Sun-exposed sites, elderly. Grows in weeks (unlike SCC which usually grows slower). May regress spontaneously (3-6 months) but SCC cannot be excluded → excise. Needs full excision biopsy (not punch - architecture needed for diagnosis).
Isotretinoin: only drug targeting all 4 acne pathogenic factors. Cumulative dose 120-150mg/kg. Pregnancy Prevention Programme mandatory (Category X teratogen). Dry lips/skin universal. Monitor lipids + LFTs. Never combine with tetracyclines (intracranial hypertension). 85-90% clearance rate.
Geriatric Medicine
80 high-yield facts
Insomnia in elderly: very common (30-50%). Sleep hygiene: regular wake time (most important), avoid naps, avoid caffeine after 2pm, avoid alcohol. CBT-I: NICE first-line for chronic insomnia (more effective than drugs long-term).
Discharge planning starts on admission. D2A pathways: 0 (simple), 1 (home with support - reablement), 2 (rehabilitation bed), 3 (long-term care - CHC assessment). Reablement: intensive 6-week home rehab - 60-70% independence rate. OT home assessment essential.
AKI is staged by the worst of the creatinine and urine-output criteria - a creatinine of 2.0-2.9× baseline is stage 2 (stage 3 needs ≥3× baseline, creatinine ≥354 μmol/L, or RRT).
Drusen plus central vision loss with preserved peripheral vision = AMD; new metamorphopsia is a red flag for conversion to wet AMD and needs urgent anti-VEGF referral. (NICE NG82; Royal College of Ophthalmologists AMD guidance.)
Urinary incontinence: common in elderly women (30-40%); NOT normal ageing. Mixed type common. Conservative FIRST: PFMT (supervised, 3 months), bladder training, weight loss, reduce caffeine. AVOID oxybutynin in elderly (cognitive impairment).
MSCC: oncological emergency. Back pain + cancer = MSCC until proven otherwise. Dexamethasone 16mg IMMEDIATELY (before MRI). MRI whole spine within 24h (4h if severe). Ambulant at treatment → 80% stay ambulant. Paraplegic >48h → virtually no recovery. Surgery + RT > RT alone (Patchell).
Chronic pain in elderly with CKD/PUD: first-line for OA (NICE NG226). Avoid oral NSAIDs (CKD/PUD/HF) and morphine (M6G accumulation). Duloxetine is useful; is the safest opioid in CKD. Non-pharmacological care is essential.
Ophthalmology
80 high-yield facts
In diabetic vitreous haemorrhage without retinal detachment, anti-VEGF is the bridge - if the view does not clear for PRP within 1-3 months, vitrectomy with endolaser becomes necessary.
IV methylprednisolone hastens visual recovery in optic neuritis - oral prednisolone alone is contraindicated. The key long-term action is neurology referral for disease-modifying therapy in confirmed MS.
Acanthamoeba keratitis requires at least 3-6 months of intensive dual anti-amoebic therapy with PHMB and propamidine - premature cessation risks relapse from encysted organisms that are resistant to short treatment courses.
Hydroxychloroquine retinal toxicity is irreversible - stop the drug immediately when screening detects early changes. Keep dose ≤5 mg/kg/day actual body weight. Annual screening from 5 years per RCOphth guidelines.
interferon-associated retinopathy requires multidisciplinary discussion. Always consider the clinical context and guideline-directed management.
Septic cavernous sinus thrombosis - bilateral orbital signs after midface infection. Start IV antibiotics immediately. CT/MR venography confirms diagnosis. Consider anticoagulation. The 'dangerous triangle' drains to the cavernous sinus.
The Khodadoust line is pathognomonic of endothelial rejection - treatment with hourly topical steroids must begin immediately, as every hour of delay risks permanent endothelial cell loss.
Oral prednisolone monotherapy is specifically contraindicated in optic neuritis based on the ONTT - always use IV methylprednisolone first when treatment is indicated.
Rifabutin-induced uveitis is dose-related and commonly precipitated by CYP3A4 inhibitors including protease inhibitors - reduce rifabutin to 150 mg daily and treat with topical steroids rather than stopping antimycobacterial therapy.
Papilloedema requires urgent neuroimaging before lumbar puncture - CT then MRI with MR venography to exclude mass lesions and venous sinus thrombosis before measuring opening pressure.
Oncology
80 high-yield facts
Aromatase inhibitors are superior to tamoxifen in postmenopausal ER-positive breast cancer but accelerate bone loss - sequential therapy with bone-protective agents is recommended for patients with existing osteoporosis.
Leukostasis presents with respiratory and neurological symptoms in hyperleukocytosis - urgent leukapheresis and hydroxyurea are required, with red cell transfusion strictly avoided until the blast count is adequately reduced.
Azacitidine is first-line for higher-risk MDS in transplant-ineligible patients - at least six cycles are needed before assessing response, as epigenetic reprogramming requires sustained treatment exposure.
Lynch syndrome requires lifelong surveillance - colonoscopy every two years from age 25 and gynaecological screening, with cascade germline testing offered to all at-risk family members.
Cancer survivors require structured follow-up addressing cardiovascular, pulmonary, endocrine, and psychosocial late effects - anthracycline cardiotoxicity and radiation-related breast cancer risk are critical long-term concerns requiring ongoing surveillance.
Prognostic tools like PPI guide honest end-of-life discussions - early palliative care integration improves quality of life, and chemotherapy should be avoided when performance status is ECOG 3 or above.
Radiation pneumonitis presents 4-12 weeks post-radiotherapy with cough, dyspnoea, and ground-glass changes confined to the radiation field. Treat with oral prednisolone and taper slowly over 6-12 weeks. Rapid steroid withdrawal causes relapse.
Metastatic castration-sensitive prostate cancer now requires treatment intensification beyond ADT alone - add docetaxel, abiraterone, or enzalutamide based on current trial evidence and NICE guidelines.
HNSCC - smoking and alcohol are synergistic risk factors. Test oropharyngeal cancers for HPV/p16. Concurrent cisplatin-chemoradiotherapy for organ preservation. Pembrolizumab is first-line for recurrent or metastatic PD-L1-positive disease.
Palliative Care
80 high-yield facts
Intrathecal drug delivery is preferred over epidural for refractory cancer pain with prognosis exceeding four weeks - combination diamorphine, bupivacaine, and clonidine provides synergistic spinal analgesia at a fraction of systemic doses.
Talc pleurodesis is first-line for recurrent malignant pleural effusion with good lung expansion - indwelling pleural catheters are preferred for trapped lung, very short prognosis, or failed pleurodesis.
An LPA attorney must act in the patient's best interests - when disagreement with clinicians persists despite discussion, refer to the Court of Protection rather than overriding or automatically accepting the attorney's decision.
Mirtazapine 15mg at night is the antidepressant of choice in palliative care when appetite loss, insomnia, and low mood coexist - its antihistaminic and 5-HT3 antagonist properties provide appetite stimulation, sedation, and antiemetic effects.
For cholestatic pruritus refractory to cholestyramine, rifampicin is the preferred second-line agent - start at low dose with LFT monitoring, and reserve opioid antagonists as third-line with cautious dose titration.
DBD occurs after confirmed brain stem death with ventilatory support maintained - the specialist nurse for organ donation facilitates consent and coordinates allocation through NHSBT; deemed consent applies in England but families can still decline.
Haloperidol 1-2mg SC stat then 5-10mg/24hr via syringe driver is first-line for terminal delirium - it is compatible with most syringe driver medications; use levomepromazine as second-line if insufficient.
Enabling home deaths requires rapid response community nursing for night cover and crises - anticipatory medications, EPaCCS coordination, and carer support are the pillars that prevent unplanned hospital admission in the dying phase.
Humidification with HME devices and nebulised saline is the cornerstone of tracheostomy care - regular inner cannula changes and suctioning technique review prevent blockages; anticholinergics worsen viscous secretions and must be avoided.
Psychiatry
80 high-yield facts
In renal impairment, start SSRIs at reduced doses and monitor sodium for SIADH - avoid lithium (renally excreted, nephrotoxic), sulpiride, amisulpride, and duloxetine in advanced CKD. Sertraline and mirtazapine are generally safer choices with appropriate dose adjustment.
Dissociative disorders are linked to trauma and managed with phased trauma-focused psychological therapy - stabilisation with grounding techniques first, then trauma processing. There is no specific pharmacological treatment; SSRIs address comorbidity only.
In Lewy body dementia, antipsychotics are extremely dangerous - neuroleptic sensitivity affects 50% of patients. If essential, use the lowest possible dose of quetiapine with vigilant monitoring, and always optimise the cholinesterase inhibitor first.
In behavioural variant FTD, avoid cholinesterase inhibitors and memantine - these are Alzheimer's-specific treatments. SSRIs are the preferred pharmacological option for behavioural symptoms alongside structured non-pharmacological management and robust carer support.
Refeeding syndrome is characterised by a precipitous fall in phosphate when malnourished patients are refed - start low and go slow with caloric reintroduction, replace phosphate urgently, give prophylactic thiamine, and monitor electrolytes and cardiac rhythm closely.
Use Section 3 when the diagnosis is established and treatment needs are clear (up to 6 months, renewable); use Section 2 for assessment when the diagnosis is uncertain (up to 28 days).
Delirium tremens requires immediate IV Pabrinex before glucose, intravenous benzodiazepines for acute symptom control, and a CIWA-guided symptom-triggered protocol - oral chlordiazepoxide is insufficient for this severity, and haloperidol lowers the seizure threshold.
Vascular dementia management centres on secondary stroke prevention and cardiovascular risk factor optimisation - AChEIs and memantine are not recommended unless mixed Alzheimer's pathology is suspected. Anticoagulation for atrial fibrillation is a critical priority.
Stage IIIA NSCLC with bulky N2 = unresectable; concurrent chemoradiotherapy with platinum doublet plus 12 months of consolidation durvalumab (PACIFIC trial, NICE NG122/TA798) is the standard of care for PS 0-1; surgery only for selected single-station N2 after MDT.
steroid-refractory ASUC
ciclosporin or infliximab
Lynch syndrome (MLH1 mutation) - colonoscopy every 1-2 years, gynaecological surveillance for female carriers, offer predictive genetic testing to relatives. MSI-high status affects adjuvant chemotherapy decisions.
Continue infliximab and azathioprine through pregnancy - active disease is a greater risk than medications. Avoid live vaccines in infants exposed to biologics in utero for 6 months.
Post-operative Crohn's - high-risk patients (smoking, prior surgery, penetrating disease) need anti-TNF prophylaxis. POCER trial for risk stratification. Ileocolonoscopy at 6-12 months (Rutgeerts score). Smoking cessation is critical.
D-penicillamine with pyridoxine is first-line for symptomatic Wilson's disease - key diagnostic clues are low ALP, Coombs-negative haemolysis, low caeruloplasmin, and Kayser-Fleischer rings.
ACLF is graded by number of organ failures (CLIF-SOFA): Grade 3 (≥3 organ failures) carries 75% 28-day mortality - consider emergency transplantation.
Caroli syndrome - saccular intrahepatic bile duct dilatation + congenital hepatic fibrosis + renal cysts (ARPKD association). 'Central dot sign' is pathognomonic. Cholangiocarcinoma risk 7-14%.
Sarcopenia in cirrhosis - protein 1.2-1.5g/kg/day (NOT restricted), late evening snack, 25-35 kcal/kg/day, supervised exercise. Protein restriction is outdated and harmful. CT L3 SMI is the gold standard.
In decompensated cirrhosis, use NS5A/NS5B combinations (sofosbuvir/velpatasvir) - never protease inhibitors (glecaprevir/pibrentasvir are contraindicated in Child-Pugh B/C).
Rectal cancer with threatened CRM - long-course neoadjuvant chemoradiotherapy followed by TME. CRM is the key determinant of local recurrence and treatment approach.
SIBO - low B12 + HIGH folate is a classic clue. Predisposing factors: blind loops, dysmotility, achlorhydria. Treat with rifaximin 14 days. Glucose hydrogen breath test is diagnostic (≥20 ppm rise).
Single HCC ≤5cm with Child-Pugh A and no portal hypertension - surgical resection is first-line. Transplantation for CSPH or multifocal within Milan criteria. RFA for ≤3cm tumours.
HRS-AKI = terlipressin + albumin (CONFIRM trial). Always exclude other causes of AKI first. Liver transplantation is the only definitive cure.
Functional dysphagia (Rome IV) - dysphagia with normal endoscopy and manometry. Gut-brain interaction disorder. Treat with neuromodulators (amitriptyline) and psychological therapies. Differentiate from globus (between meals, not swallow-related).
Dermatitis herpetiformis is the skin manifestation of coeliac disease - manage with GFD plus dapsone for initial symptom control, and always perform duodenal biopsies.
Caustic ingestion - OGD within 12-24 hours for Zargar grading. Never induce vomiting or give activated charcoal. Corticosteroids do not prevent strictures. Grade IIb+ carries high stricture risk.
Severe alcoholic hepatitis (mDF >32) - prednisolone 40mg for 28 days after excluding infection. Lille score at day 7 to assess response. STOPAH trial: prednisolone marginally effective; pentoxifylline ineffective.
For chronic constipation failing lifestyle and osmotic laxatives, prucalopride is the NICE-recommended next step - linaclotide is better positioned for IBS-C with pain.
Boerhaave syndrome - Mackler triad (vomiting, chest pain, subcutaneous emphysema). Emergency surgical repair within 24 hours is critical; mortality rises steeply with delay.
H. pylori-positive localised gastric MALT lymphoma is treated with H. pylori eradication first - this achieves lymphoma regression in the majority of cases (BSG; ESMO).
In HBeAg-positive chronic hepatitis B with normal ALT and no fibrosis (immune tolerant phase), monitor every 3-6 months - treat when ALT rises indicating immune-active disease.
SBEM - infection of hepatic hydrothorax (PMN >250/mm³). Treat as SBP (IV cephalosporin + albumin). Avoid chest drains in hepatic hydrothorax. Can occur without concurrent SBP in 40% of cases.
FNH = hepatobiliary phase uptake + central scar on gadoxetic acid MRI (98% accuracy). No treatment needed, OCP is safe. Adenoma = no hepatobiliary uptake, capsule, fat - stop OCP, consider resection if >5cm.
Large sessile colorectal polyps (≥20mm) with a positive lift sign should be referred for specialist EMR - the lift sign indicates endoscopic resectability and predicts absence of deep invasion.
B12 deficiency with neurological signs - IM hydroxocobalamin loading on alternate days until no further improvement, then every 2 months lifelong. Never give folate alone without B12.
Borderline resectable pancreatic cancer should receive neoadjuvant chemotherapy before surgical reassessment - this improves R0 resection rates and identifies unfavourable tumour biology.
Toxic megacolon with systemic toxicity requires urgent subtotal colectomy - rescue medical therapy is inappropriate once megacolon has developed.
Hy's Law - hepatocellular injury + jaundice without obstruction = 10-50% mortality. Stop the drug immediately. Refer urgently for transplant assessment if synthetic function deteriorates.
In IBD pregnancy, continue azathioprine and anti-TNF to maintain remission - disease flares are more dangerous than medication exposure. Methotrexate is absolutely contraindicated.
Jackhammer oesophagus = ≥20% swallows with DCI >8,000, normal IRP, normal DL. Exclude opioid use and GORD first. Normal IRP differentiates from achalasia; normal DL differentiates from DES.
SBP is diagnosed by ascitic PMN ≥250/mm³ - treat immediately with IV cefotaxime plus IV albumin to prevent hepatorenal syndrome.
Tofacitinib - assess cardiovascular, VTE, malignancy risk before starting (ORAL Surveillance). Check varicella immunity, lipids at 8 weeks, regular FBC. Use lowest effective maintenance dose (5mg BD).
Distal oesophageal spasm = normal IRP + ≥20% premature contractions (DL <4.5s). Normal IRP distinguishes DES from achalasia. First-line: calcium channel blockers or PDE5 inhibitors.
Acute SMA embolism - 'pain out of proportion', AF source, CTA diagnosis. Emergency revascularisation (embolectomy or IR thrombolysis) + laparotomy for bowel assessment. Mortality >60% without intervention.
Congestive hepatopathy - dilated hepatic veins with flow reversal on Doppler, pulsatile hepatomegaly, cholestatic LFTs. Treat the cardiac cause. Long-standing = cardiac cirrhosis ('nutmeg liver').
Opioid-induced constipation refractory to conventional laxatives - naloxegol (PAMORA) reverses GI opioid effects without affecting central analgesia.
Intermediate probability of CBD stones requires MRCP (or EUS) before deciding on ERCP - avoid unnecessary ERCP based on indirect evidence alone.
After negative OGD and colonoscopy in iron deficiency anaemia, video capsule endoscopy is the investigation of choice to evaluate the small bowel - diagnostic yield is 50-70%.
PSC-IBD requires annual colonoscopy with chromoendoscopy from diagnosis due to markedly elevated colorectal cancer risk - this is more intensive than standard IBD surveillance.
Wilsonian acute liver failure requires super-urgent liver transplantation - use the revised King's Wilson Index (score ≥11) to identify patients who will not survive with medical therapy alone.
Extreme refeeding risk - start at 5 kcal/kg/day, supplement electrolytes, give IV thiamine before feeding, and monitor phosphate twice daily.
In suspected ZES, the secretin stimulation test is the confirmatory investigation of choice - always stop PPIs if safely possible before gastrin measurement, and investigate for MEN1.
All gastric ulcers require repeat OGD with biopsies at 6-8 weeks to exclude malignancy - this applies regardless of initial biopsy results. Duodenal ulcers do not need routine follow-up OGD.
IgG4-SC - distinguished from PSC by elevated IgG4, multi-organ involvement, no IBD association, negative pANCA, and dramatic steroid response (>95% remission). Always consider IgG4-SC before diagnosing PSC.
A1ATD liver disease - PAS-positive diastase-resistant globules in hepatocytes. No medical therapy - only liver transplant is curative. IV augmentation therapy treats lungs, NOT liver.
Type 3c diabetes - impaired glucagon = high hypoglycaemia risk. Avoid sulfonylureas. Insulin if needed but titrate carefully. Often misclassified as type 2 diabetes.
SOS/VOD - painful hepatomegaly + weight gain + jaundice within 21 days of HSCT. Patent hepatic veins distinguish from Budd-Chiari. Defibrotide is the specific treatment.
For biologic-naïve moderate-severe UC, infliximab + azathioprine combination therapy is first-line (UC SUCCESS trial) - superior to monotherapy for steroid-free remission.
PSC-UC requires annual colonoscopy with chromoendoscopy (5x CRC risk) AND annual biliary imaging + CA 19-9 for cholangiocarcinoma surveillance.
King's College criteria for paracetamol ALF - pH <7.3 after resuscitation, OR (INR >6.5 + creatinine >300 + grade III/IV encephalopathy) - list for super-urgent transplant immediately.
Anastomotic Crohn's stricture ≤5cm - endoscopic balloon dilatation is first-line (CREOLE criteria). Preserve bowel length by avoiding repeated resections. Metal stents are contraindicated.
Solitary rectal ulcer syndrome - first-line treatment is behavioural therapy and biofeedback. It is caused by mechanical trauma from straining, not inflammatory disease.
Common precipitants of hepatic encephalopathy include infection (SBP), GI bleeding, constipation, electrolyte disturbance (especially hypokalaemia), dehydration, and sedative drugs - always identify and treat the precipitant alongside lactulose.
ASUC requires IV hydrocortisone, VTE prophylaxis, and daily Truelove and Witts reassessment - assess response at day 3 with Travis criteria before escalating to rescue therapy.
Insulinoma diagnosis: Whipple's triad + elevated insulin/C-peptide/proinsulin with fasting hypoglycaemia. Surgery is curative in >95% (most are benign, solitary). Always screen for MEN1.
Dieulafoy lesion - large artery protruding through tiny mucosal defect, normal surrounding mucosa. Treat with haemoclips + adrenaline injection. Commonly missed on OGD between bleeding episodes.
SBP prophylaxis - secondary (after first SBP, lifelong), primary (low ascitic protein + liver/renal impairment), and during GI bleeding. Norfloxacin 400mg OD is standard. 1-year SBP recurrence is 70% without prophylaxis.
Enterovesical fistula in Crohn's - pneumaturia + faecaluria + recurrent UTIs. Surgical resection + bladder repair is definitive (unlike perianal fistulae where biologics are first-line). Medical therapy alone rarely achieves closure.
Non-responsive coeliac disease - always re-evaluate dietary compliance first; inadvertent gluten exposure accounts for ~50% of cases. True refractory coeliac disease requires normalised serology with persistent villous atrophy.
GAVE (watermelon stomach) is treated with APC - distinguish from portal hypertensive gastropathy, which has different treatment. TIPS and beta-blockers do not help GAVE.
For high-risk peptic ulcer bleeding (Forrest Ia, Ib, IIa), dual endoscopic therapy followed by IV PPI infusion (80mg bolus + 8mg/hour for 72 hours) is the standard of care - always stop the causative NSAID.
In Crohn's disease refractory to thiopurines, infliximab plus azathioprine combination therapy (supported by the SONIC trial) is first-line - combination therapy reduces immunogenicity and improves remission rates.
Chronic pancreatitis pain with dilated duct and obstructing stone - ERCP with stone extraction (± ESWL) is first-line. Surgery is second-line if endoscopic management fails.
Colonic angioectasias - treat with APC and IV iron. Associated with aortic stenosis (Heyde syndrome). Right colon is the most common location.
In young, HBeAg-positive, non-cirrhotic hepatitis B with elevated ALT, pegylated interferon offers a finite treatment course with potential for functional cure.
Type 3 intestinal failure is chronic and requires long-term HPN - colon in continuity improves prognosis through SCFA absorption but 50cm jejunum alone rarely achieves nutritional autonomy.
HELLP syndrome = haemolysis + elevated liver enzymes + low platelets. Definitive treatment is delivery. IV magnesium sulfate for seizure prophylaxis. Risk of hepatic rupture and DIC.
Non-gangrenous ischaemic colitis is managed conservatively - surgical intervention is only needed for gangrenous colitis, perforation, or clinical deterioration.
Recurrent pyogenic cholangitis localised to one hepatic lobe - hepatic resection offers the best long-term outcome. Repeated ERCP alone has high recurrence rates.
Gallstone ileus - Rigler's triad (SBO + ectopic gallstone + pneumobilia). Enterolithotomy alone is the preferred emergency procedure in elderly patients. Defer cholecystectomy/fistula repair.
CIPO is diagnosed by recurrent obstructive episodes without mechanical cause, confirmed by absent phase III MMC on manometry - identify and treat the underlying cause (diabetes, connective tissue disease).
Non-functioning pituitary macroadenomas without visual field defects are managed conservatively with hormone replacement, serial MRI, and visual field monitoring - surgery is indicated for visual compromise or significant growth.
Low TSH + low fT4 = central hypothyroidism - always assess all anterior pituitary axes and consider Sheehan's syndrome in women with history of post-partum haemorrhage.
Ectopic ACTH presents with rapid onset, very high ACTH/cortisol, no suppression on high-dose dexamethasone, hypokalaemia, hyperpigmentation, and weight loss - small cell lung cancer is the most common malignant cause, bronchial carcinoid the most common overall.
When metformin is contraindicated (eGFR <30, lactic acidosis history), consider SGLT2 inhibitors as first-line in patients with heart failure or CKD - they provide cardio-renal benefits independent of glycaemic effect. Pioglitazone is contraindicated in heart failure.
The insulin tolerance test is the gold standard for adult GH deficiency diagnosis - GH peak <3 μg/L during adequate hypoglycaemia confirms the diagnosis.
Triglycerides >10 mmol/L = pancreatitis risk - treat urgently with fibrate, very low fat diet, alcohol cessation, and optimise diabetes. Insulin infusion can rapidly lower triglycerides in emergencies. Statins are NOT first-line for severe hypertriglyceridaemia.
For occult insulinoma localisation, EUS is the most sensitive non-invasive investigation (90-95%) - if negative, consider selective arterial calcium stimulation or 68Ga-DOTATATE PET-CT.
The key CGM targets are TIR >70%, time below range <4%, and time above range <25% - when TIR is low with acceptable hypoglycaemia, focus on optimising mealtime insulin dosing.
In T1DM patients, unexpectedly falling insulin requirements should prompt investigation for adrenal insufficiency (APS-2). The combination of Addison's + autoimmune thyroiditis ± T1DM defines APS-2/Schmidt's syndrome.
In Addisonian crisis, give IV hydrocortisone 100mg stat immediately - never delay treatment for investigations, and aggressive fluid resuscitation with 0.9% NaCl is essential alongside glucocorticoid replacement.
ICI-induced hypophysitis (especially with ipilimumab) - give hydrocortisone BEFORE levothyroxine. ACTH recovery is rare (lifelong steroids needed in >90%). Pituitary enlargement on MRI distinguishes from metastasis.
Post-bariatric reactive hypoglycaemia is caused by exaggerated incretin-mediated insulin secretion - first-line treatment is dietary modification (small meals, low GI carbohydrate, combine with protein). A normal 72-hour fast distinguishes this from insulinoma.
APS-2 = Addison's + autoimmune thyroid disease ± T1DM - screen all Addison's patients for thyroid disease, diabetes, B12, coeliac disease, and gonadal function.
Alendronate is first-line for post-menopausal osteoporosis with fragility fractures - always co-prescribe calcium and vitamin D and review medications contributing to bone loss (PPIs, glucocorticoids).
In GDM with fasting glucose <7.0 mmol/L, trial dietary modification for 1-2 weeks first - if fasting glucose is ≥7.0 mmol/L at diagnosis, start insulin immediately alongside diet.
Before surgery on carcinoid syndrome patients, give IV octreotide infusion (50-100μg/hour) to prevent carcinoid crisis - avoid catecholamines and morphine peri-operatively.
SGLT2 inhibitors can now be started at eGFR ≥20 mL/min for renoprotection in diabetic kidney disease - always combine with RAS blockade for maximum benefit in proteinuric CKD.
For severe hypercalcaemia: rehydrate first (IV NaCl 3-4L/24h), then IV zoledronic acid - consider calcitonin for rapid initial reduction while awaiting bisphosphonate effect.
Postpartum thyroiditis follows a biphasic course (thyrotoxic → hypothyroid → recovery) - 20-30% develop permanent hypothyroidism. Anti-TPO-positive women should be screened postpartum. Carbimazole is NOT effective for the thyrotoxic phase.
Transsphenoidal surgery is first-line for acromegaly - somatostatin analogues are second-line (or used pre-operatively). Achievement of biochemical remission (normal IGF-1, GH <1 µg/L) improves survival to that of the general population.
Jod-Basedow phenomenon = iodine-induced thyrotoxicosis in patients with autonomous thyroid tissue exposed to iodinated contrast - treat with antithyroid drugs ± potassium perchlorate.
Lithium causes hypothyroidism in 20-30% of patients - treat with levothyroxine while continuing lithium if psychiatrically stable. Monitor TFTs every 6 months on lithium.
AVS lateralisation index >4:1 confirms unilateral aldosterone source - treat with laparoscopic adrenalectomy. AVS is essential because CT alone cannot reliably distinguish adenoma from hyperplasia.
Total thyroidectomy is recommended for papillary thyroid carcinoma >1cm - this enables radioiodine ablation and thyroglobulin surveillance. Lobectomy may suffice for low-risk microcarcinomas <1cm.
Calcium, iron, and PPIs all reduce levothyroxine absorption - separate calcium and iron by ≥4 hours from levothyroxine and review PPI necessity.
Dental assessment and treatment BEFORE starting IV bisphosphonates is the most important prevention strategy for BRONJ - all patients should have dental review, and invasive dental procedures should be avoided during treatment wherever possible.
Post-thyroidectomy hypocalcaemia with symptoms requires IV calcium gluconate urgently - long-term, use alfacalcidol/calcitriol (active vitamin D) as PTH-dependent activation is lost.
Gestational thyrotoxicosis = hCG-mediated, negative TRAb, self-limiting by 14-16 weeks. No antithyroid drugs needed - supportive treatment only. Distinguish from Graves' by negative TRAb, absent goitre, and association with hyperemesis.
Low testosterone with low or normal gonadotrophins = secondary hypogonadism - always perform MRI pituitary and full anterior pituitary function assessment to identify the cause.
In T2DM with ASCVD, HF, and obesity - the combination of SGLT2i + GLP-1 RA + metformin provides optimal cardiometabolic protection. Never use pioglitazone in heart failure.
For T2DM with established ASCVD, the evidence-based combination is SGLT2i + GLP-1 RA - they reduce cardiovascular events through complementary mechanisms and should be prescribed regardless of HbA1c.
Post-partum thyroiditis = negative TRAb, positive TPO - biphasic course. Thyrotoxic phase treated with propranolol only (antithyroid drugs ineffective). Monitor for subsequent hypothyroid phase.
In myxoedema coma, always give IV hydrocortisone before or with thyroid replacement to prevent adrenal crisis - IV T3 acts faster than T4 and is preferred in this emergency.
Low thyroid scintigraphy uptake during thyrotoxicosis indicates destructive thyroiditis (De Quervain's, postpartum, or AIT-2) - antithyroid drugs are ineffective; treat with NSAIDs/steroids and beta-blockers.
The NHS DPP provides structured lifestyle intervention reducing diabetes risk by 58% - refer all patients with HbA1c 42-47 or fasting glucose 5.5-6.9, especially those with additional risk factors.
hCG-mediated TSH suppression is normal in early pregnancy - use pregnancy-specific reference ranges. A low TSH with mildly elevated free T4 and negative TRAb in an asymptomatic first-trimester woman does NOT require antithyroid treatment.
When a large pituitary macroadenoma has only mildly elevated prolactin, always request serial dilution to exclude the hook effect - the true level may be vastly higher, indicating a prolactinoma requiring medical rather than surgical treatment.
Acromegaly complications screening includes colonoscopy (polyps/cancer), echocardiogram (cardiomyopathy), sleep study (OSA), OGTT (diabetes), and visual fields - colonoscopy screening continues long-term.
Distinguish AIT-1 (increased Doppler vascularity, treat with carbimazole) from AIT-2 (absent vascularity, elevated IL-6, treat with prednisolone) - colour-flow Doppler is the key differentiating investigation.
Cabergoline is first-line for all prolactinomas, including large macroprolactinomas with visual field loss - it shrinks tumours effectively and visual improvement often occurs within days. Surgery is reserved for resistant or intolerant cases.
Consider levothyroxine for subclinical hypothyroidism when TSH is persistently elevated with positive TPO antibodies and symptoms - start low and titrate, rechecking TFTs at 6-8 weeks.
A positive aldosterone:renin ratio is a screening test only - always perform a confirmatory suppression test before imaging to avoid false-positive diagnoses and unnecessary surgery.
For prolonged aerobic exercise in T1DM, reduce basal insulin by 20%, reduce pre-exercise bolus by 50%, consume 15-30g carbs per hour during exercise, and have a bedtime snack.
SGLT2 inhibitors are recommended in all patients with HFrEF irrespective of diabetes - pioglitazone and saxagliptin are contraindicated or best avoided in heart failure.
All adrenal incidentalomas require hormonal assessment - overnight dexamethasone suppression test and plasma metanephrines are mandatory; aldosterone:renin ratio if hypertensive.
Adult GH deficiency is diagnosed by peak GH <3 µg/L on ITT - NICE recommends GH replacement when quality of life is impaired, titrating dose to normalise IGF-1.
In HHS, the priority is cautious fluid resuscitation - not insulin. Aim for slow osmolality correction (3-8 mOsm/kg/hour) to avoid neurological complications. Start insulin only if glucose not falling with fluids alone.
Letrozole is now first-line for ovulation induction in PCOS (PCOS guideline 2023), replacing clomifene - it achieves higher live birth rates with lower multiple pregnancy risk. Weight loss of 5-10% should be attempted first.
In PCOS with infertility, lifestyle modification and weight loss are first-line - metformin is added for BMI ≥30; letrozole has replaced clomifene as first-line ovulation induction agent.
When escalating from a DPP-4 inhibitor, switch (don't combine) to a GLP-1 RA - NICE NG28 requires BMI ≥35 with obesity-related complications (or BMI <35 with occupational insulin issues); check the 6-month response criteria (HbA1c fall ≥11 mmol/mol plus weight loss ≥3%).
Diabulimia - insulin omission for weight loss in T1DM - affects up to 40% of young women with T1DM and carries 3× increased mortality. Requires specialist eating disorder + diabetes psychology input.
Biotin supplements cause assay interference mimicking thyrotoxicosis (low TSH, high fT4/fT3) - if clinical picture is discordant, stop biotin for 48-72 hours and repeat TFTs before treating.
De Quervain's thyroiditis shows painful thyroid, raised ESR, and low uptake scan - treat with NSAIDs/steroids for pain and propranolol for symptoms. Antithyroid drugs are ineffective.
GLP-1 RA GI side effects are transient (2-4 weeks per dose level) - slow titration, small low-fat meals, and reassurance, not premature discontinuation or escalation.
Carbimazole is first-line for Graves' disease - give for 12-18 months in the first instance, with propranolol for symptom control while awaiting euthyroidism.
Persistent TRAb, smoking, large goitre, severe biochemistry, and young age predict Graves' relapse - counsel high-risk patients about likely need for definitive treatment.
Switch carbimazole to PTU in the first trimester of pregnancy (up to 16 weeks) to avoid embryopathy - monitor TFTs 4-weekly and check TRAb at 28-32 weeks for fetal risk assessment.
Toxic multinodular goitre does not remit with antithyroid drugs alone - radioiodine is preferred definitive treatment in elderly or comorbid patients; surgery is reserved for significant compressive symptoms or suspicion of malignancy.
IGF-1 is the first-line screening test for acromegaly - if elevated, confirm with an oral glucose tolerance test (GH should suppress to <0.4 µg/L). Only request MRI after biochemical confirmation.
After failed or incomplete surgery in acromegaly, first-line medical therapy is a somatostatin analogue - pegvisomant is reserved for SSA-resistant or intolerant patients.
Echocardiography and sleep study are priority investigations in newly diagnosed acromegaly - cardiac disease and OSA are the most important perioperative risks. Arrange colonoscopy at diagnosis for colorectal polyp/cancer screening.
Acromegaly patients need colonoscopy at diagnosis and follow-up every 3 years if polyps found (5-10 years if clear). The polyp risk is independent of IGF-1 control and reflects cumulative GH exposure. Full colonoscopy (not sigmoidoscopy) is needed due to right-sided predominance.
After confirming Cushing's syndrome biochemically, the next step is always plasma ACTH to differentiate ACTH-dependent from ACTH-independent causes before any imaging.
Biotin supplements cause false TFT results mimicking hyperthyroidism - always ask about supplements before starting antithyroid treatment. Stop biotin for ≥2 days and repeat tests. The MHRA has highlighted this as a significant patient safety concern.
AVS is essential before adrenalectomy for Conn's syndrome - CT alone incorrectly lateralises in up to 38% of cases. Unilateral → surgery; bilateral → spironolactone/eplerenone.
When initiating insulin in T2DM, start with once-daily basal insulin and continue background therapies - metformin, SGLT2 inhibitors, and GLP-1 RAs all provide additive benefits alongside insulin.
After total pancreatectomy, patients lose both insulin and glucagon - anticipate lower insulin requirements but high hypoglycaemia risk due to absent glucagon counter-regulation. CGM and careful dose titration are essential.
During recovery from illness, TSH may transiently overshoot above normal - this is physiological recovery, NOT hypothyroidism. Always wait 6-8 weeks after recovery before diagnosing and treating hypothyroidism based on in-hospital TFTs.
Prolactinomas are treated with dopamine agonists (cabergoline) first, even with chiasmal compression - always assess and replace cortisol before other hormones, and reassess visual fields within 2-4 weeks.
In phaeochromocytoma, alpha-blockade first (phenoxybenzamine or doxazosin) for 10-14 days - never start beta-blockers before alpha-blockade to avoid hypertensive crisis.
Post-neurosurgical diabetes insipidus requires prompt desmopressin treatment - monitor sodium closely and be aware of the triphasic response pattern; never perform water deprivation when diagnosis is clinically obvious.
atypical femoral fracture (AFF) requires teriparatide. Always consider the clinical context and guideline-directed management.
TSH is the most sensitive single test for primary thyroid disease because of its log-linear amplification of small fT4 changes - but it is unreliable in suspected pituitary/hypothalamic disease, where fT4 must also be measured.
In Killip IV cardiogenic shock complicating STEMI, immediate primary PCI is the most important intervention - the SHOCK trial proved early revascularisation saves lives.
Symptomatic persistent AF with LV dysfunction should be considered for rhythm control (cardioversion plus maintenance) - EAST-AFNET 4 supports early rhythm control within 12 months of diagnosis.
Type 2 MI is treated by addressing the underlying trigger (infection, tachycardia, anaemia) - not with invasive coronary strategies used for type 1 MI.
Takotsubo cardiomyopathy is managed supportively with ACEI and beta-blockers - LV function typically recovers within weeks but monitor for LVOT obstruction and apical thrombus.
Primary PCI is preferred over fibrinolysis for STEMI if deliverable within 120 minutes of first medical contact, regardless of symptom duration up to 12 hours.
IVDU endocarditis is predominantly S. aureus - flucloxacillin is the empirical choice for native valve disease. Cavitating pulmonary nodules are pathognomonic for right-sided septic emboli.
Bicuspid aortic valve aortopathy requires surgery at ≥50mm (vs ≥55mm for tricuspid valves and ≥45mm for Marfan syndrome).
Cardiac tamponade requires emergency pericardiocentesis - absent y-descent on JVP and electrical alternans on ECG are key diagnostic features.
Post-MI VSD requires urgent surgical repair with bridging IABP support - delay significantly increases mortality in haemodynamically compromised patients.
Ongoing ischaemic chest pain refractory to medical therapy mandates immediate invasive angiography within 2 hours, regardless of GRACE score.
CRT-D is indicated for symptomatic HFrEF (LVEF ≤35%) with LBBB and QRS ≥150ms despite optimal medical therapy - this population has the strongest evidence of benefit.
SGLT2 inhibitors (empagliflozin, dapagliflozin) are the first class proven to improve outcomes in HFpEF - the EMPEROR-Preserved and DELIVER trials transformed HFpEF management.
CTI ablation is the treatment of choice for typical atrial flutter with >95% success - flecainide risks 1:1 conduction and is relatively contraindicated without a rate-limiting agent.
Antibiotic prophylaxis (amoxicillin 3g orally) is recommended for high-risk patients (prosthetic valves, previous IE) before invasive dental procedures - this reflects current ESC guidance and UK practice.
Mitral stenosis with AF requires warfarin (not DOACs) for anticoagulation - PBMC is the intervention of choice when Wilkins score ≤8 with favourable anatomy.
Tachy-brady syndrome requires a dual-chamber pacemaker to enable safe addition of rate-controlling drugs - always anticoagulate for the AF component based on CHA2DS2-VASc score.
In young patients with suspected renovascular hypertension, MR angiography is preferred to avoid radiation, and FMD is more likely than atherosclerotic disease.
In hypertensive acute pulmonary oedema, IV GTN is the priority alongside diuretics - morphine is no longer recommended and may worsen outcomes.
Eplerenone should be started within 3-14 days post-MI in patients with LVEF ≤40% - the EPHESUS trial showed a 15% relative mortality reduction.
De Winter T waves (J-point ST depression with tall peaked T waves in V1-V6) are a STEMI equivalent requiring immediate primary PCI - do not wait for ST elevation to develop.
Type II endoleak post-EVAR requires intervention only if the aneurysm sac is expanding - most Type II endoleaks are benign and self-limiting.
Resuscitation Council UK / ERC ALS algorithm requires amiodarone 300mg IV. Always consider the clinical context and guideline-directed management.
Start with an ACE inhibitor and beta-blocker as the foundation of HFrEF treatment, then rapidly optimise with MRA, SGLT2i, and consider switching ACEI to sacubitril/valsartan.
Urgent surgery should not be delayed for aortic valve intervention - proceed with invasive monitoring and expert anaesthetic care in severe AS.
CRT-D is indicated for HFrEF (LVEF ≤35%) with LBBB, QRS ≥150ms, and NYHA II-III symptoms despite optimal medical therapy - LBBB with wide QRS predicts the best response.
Cardiac MRI is the essential investigation in MINOCA - the pattern of late gadolinium enhancement distinguishes myocarditis from true MI and guides appropriate treatment.
Myocardial bridging causes systolic compression (milking) of the mid-LAD - treat with beta-blockers to prolong diastole; nitrates are relatively contraindicated as they worsen compression.
LQTS1 (KCNQ1) is triggered by exercise, especially swimming - nadolol is first-line and competitive swimming must be restricted due to the specific adrenergic trigger.
CRT non-response requires systematic optimisation - assess lead position, optimise AV/VV timing, ensure >98% biventricular pacing, and consider lead repositioning.
In cocaine-associated chest pain, benzodiazepines and GTN are first-line - beta-blockers are contraindicated due to risk of unopposed alpha stimulation.
In Afro-Caribbean patients without diabetes, a calcium channel blocker is first-line per NICE due to the low-renin hypertension phenotype.
Suspected PE causing cardiac arrest is an indication for systemic thrombolysis during CPR - continue resuscitation for 60-90 minutes after thrombolysis.
Andexanet alfa specifically reverses factor Xa inhibitors (apixaban/rivaroxaban) - idarucizumab reverses dabigatran only. PCC is an effective alternative when andexanet alfa is unavailable.
Acute limb ischaemia with motor deficit (Rutherford IIb) = emergency surgical embolectomy plus IV heparin - thrombolysis is too slow when motor function is threatened.
In Marfan syndrome, refer for prophylactic aortic root surgery at ≥50 mm, or ≥45 mm with risk factors such as a family history of dissection, rapid growth (>3 mm/year), severe regurgitation, or planned pregnancy - and individualise lower when there is a family history of dissection at a small aortic diameter.
Cardiogenic shock management: vasopressor (noradrenaline) plus inotrope (dobutamine) first, then escalate to mechanical circulatory support if refractory.
GRACE score >140 in NSTE-ACS indicates high risk - early invasive strategy with coronary angiography within 24 hours is recommended.
FFR ≤0.80 (or iFR ≤0.89) indicates haemodynamically significant stenosis requiring PCI - FFR 0.82 means deferral with medical therapy is safe.
Routine complete revascularisation of non-culprit lesions in stable STEMI patients reduces cardiovascular death and MI - COMPLETE trial, but not in cardiogenic shock (CULPRIT-SHOCK).
Hypertensive urgency (severe BP without end-organ damage) is managed with oral medication reinstatement and outpatient follow-up - IV treatment is reserved for emergencies.
SCAD is managed conservatively when haemodynamically stable - PCI has high complication rates and most dissections heal spontaneously.
Stop metformin on the day of contrast procedures and withhold for 48 hours post-procedure - restart only after confirming stable renal function.
In cardiogenic shock with ongoing instability after culprit PCI, consider immediate multivessel PCI to address haemodynamically significant non-culprit lesions.
SCAD in stable patients with preserved flow is managed conservatively - PCI risks propagating the dissection and worsening outcomes.
In severe AR, LVEF <55% or LVESD >50mm mandates surgical referral even in asymptomatic patients - a falling EF indicates decompensation before symptoms appear.
Acute MR from papillary muscle rupture post-MI is a surgical emergency - IABP bridging followed by emergency mitral valve surgery is life-saving.
Both dronedarone (ANDROMEDA trial) and flecainide (CAST trial) are contraindicated in heart failure - amiodarone is the only safe antiarrhythmic in structural heart disease.
Transient creatinine rises during successful HF decongestion are acceptable - continue diuresis with dose adjustment if the patient is improving and still congested.
Takotsubo cardiomyopathy typically shows complete LV recovery within weeks - supportive care with heart failure medications is the mainstay, not ICD or catecholamine inotropes.
AV dissociation, capture beats, and fusion beats in a broad complex tachycardia are diagnostic of VT - always assume VT in patients with structural heart disease.
de Winter T-wave pattern requires primary PCI pathway. Always consider the clinical context and guideline-directed management.
Effusive-constrictive pericarditis is diagnosed when elevated filling pressures persist after complete pericardiocentesis - TB is the most common cause worldwide.
MRI-conditional pacemakers can safely undergo MRI with proper precautions - reprogramming, monitoring during scan, and post-scan device check are essential.
Type 4a periprocedural MI (troponin >5× URL post-PCI) without new ischaemic features is managed conservatively - it does not mandate urgent re-angiography.
Do not implant ICD within 40 days of MI - reassess LVEF after 6-12 weeks of optimised heart failure therapy, as stunned myocardium may recover.
Amiodarone is the only antiarrhythmic safe for AF rhythm control in structural heart disease with reduced LVEF - flecainide, propafenone, and dronedarone are all contraindicated.
Post-cardiac arrest STEMI requires immediate coronary angiography - TTM2 trial showed targeting 36°C is equivalent to 33°C, but prevent hyperthermia.
Post-pericardiotomy syndrome is treated with NSAIDs plus colchicine - low procalcitonin helps distinguish it from post-surgical infection.
After GI bleeding on a DOAC, restart at the same dose once haemostasis is achieved - co-prescribe PPI and treat the bleeding cause. Dose reduction without meeting criteria increases stroke risk.
AAA repair threshold is ≥5.5cm - aneurysms 4.5-5.4cm require three-monthly surveillance, and below 4.5cm annual surveillance suffices.
DPD bone scintigraphy can non-invasively diagnose ATTR cardiac amyloidosis when light chain disease is excluded - endomyocardial biopsy is no longer always necessary.
CT-FFR provides non-invasive functional assessment of coronary stenoses from existing CTCA data - it reduces unnecessary invasive angiography by identifying haemodynamically insignificant lesions.
Epicardial and mid-wall LGE not following a coronary territory is characteristic of myocarditis - subendocardial LGE indicates ischaemic injury.
Severe symptomatic tricuspid regurgitation refractory to medical therapy should be referred to a specialist valve centre - transcatheter and surgical options are expanding rapidly.
NICE recommends atorvastatin 20mg for primary prevention when QRISK3 ≥10% - aim for >40% reduction in non-HDL cholesterol at 3-month review.
In ADHF, give IV furosemide at least equivalent to the total daily oral dose - the DOSE trial supports a high-dose strategy for better decongestion.
Tension pneumothorax is a clinical diagnosis requiring immediate needle decompression - never delay for imaging confirmation.
Leadless pacemakers (Micra) are ideal for patients needing VVI pacing with limited venous access or high infection risk - deployed via the femoral vein without leads or a pocket.
ADPKD cyst infection = use fluoroquinolones (cyst-penetrating); beta-lactams have poor cyst penetration; consider percutaneous drainage if no response; treat for 4-6 weeks.
Adult minimal change disease requires a longer trial of steroids (minimum 16 weeks) compared to children before concluding steroid resistance.
Assisted APD is an excellent option for frail elderly patients who wish to remain at home but cannot manage unassisted self-care dialysis.
In post-neurosurgical hyponatraemia, volume status is the key to distinguishing CSW (hypovolaemic, treat with saline) from SIADH (euvolaemic, treat with fluid restriction).
HELLP syndrome requires urgent delivery - the placenta drives the disease through anti-angiogenic factor production, and maternal complications resolve rapidly post-delivery.
In hyperkalaemia with ECG changes, always give calcium FIRST for cardiac protection, then insulin-dextrose - and identify all contributing medications, including trimethoprim, which is a commonly overlooked cause.
Cool dialysate at 35.5°C is the most effective single intervention for intradialytic hypotension.
STEC-HUS management is supportive only - antibiotics are contraindicated as they increase toxin release and may worsen the thrombotic microangiopathy.
ADPKD USS diagnosis at age 15-39 = ≥3 cysts total; at 40-59 = ≥2 per kidney; genetic testing if USS equivocal.
Anti-PLA2R antibody is highly specific for primary membranous nephropathy - always consider non-diabetic causes of proteinuria, especially with atypical features.
Bilateral ureteric obstruction causing anuria is a urological emergency - stabilise hyperkalaemia first, then arrange urgent nephrostomy drainage.
PSGN in children = self-limiting (>90% recovery); low C3/normal C4; present 1-3 weeks AFTER pharyngitis (vs IgA which is concurrent); supportive care only.
Hypertensive nephrosclerosis in Afro-Caribbean patients - optimise RAAS blockade and target BP <130/80 mmHg (or <120 systolic per SPRINT).
ASTRAL and CORAL show medical therapy equals revascularisation for atherosclerotic renal artery stenosis; reserve intervention for flash pulmonary oedema or refractory decline, and review the ACE inhibitor dose (rather than automatically stopping it in unilateral disease) when creatinine rises by more than ~30%.
Novel AKI biomarkers (NGAL, TIMP-2/IGFBP-7) detect tubular injury 12-48 hours before creatinine rises; they enable early intervention but are not yet universally adopted.
Bartter = childhood onset, hypercalciuria, nephrocalcinosis, normal Mg²+; Gitelman = adult onset, hypocalciuria, hypomagnesaemia - both cause hypokalaemic metabolic alkalosis.
Morphine and codeine are contraindicated in severe CKD - fentanyl and alfentanil are safe alternatives as they produce no active renally excreted metabolites.
Primary membranous nephropathy - rituximab is now first-line (MENTOR trial); anti-PLA2R titre guides treatment decisions and monitors response; 6-month trial of supportive care before immunosuppression for moderate-risk disease.
Access recirculation >10% suggests AVF stenosis - investigate with Doppler before modifying the dialysis prescription.
Vaccinate CKD patients early in stage 4-5 - immune responses decline with worsening renal function and immunosuppression post-transplant prohibits live vaccines.
KDIGO AKI staging uses the higher stage from creatinine or urine output criteria; Stage 2 = 2.0-2.9× baseline creatinine.
High transporters on PET do best with APD (short, frequent cycles) - CAPD with long dwells leads to ultrafiltration failure.
Type 1 RTA = urine pH >5.5 in the presence of systemic acidosis + nephrocalcinosis + hypokalaemia; treat with potassium citrate.
Offer atorvastatin 20 mg to all CKD patients for primary prevention regardless of cholesterol or QRISK3 - the NICE general-population threshold is ≥10%, and CKD is itself a cardiovascular risk equivalent.
New hypertension + declining graft function + bruit + elevated PSV on Doppler = transplant renal artery stenosis; treat with angioplasty and stenting.
In DKD with autonomic neuropathy, use maximum tolerated (not maximum) RAAS blockade plus SGLT2 inhibitor, and actively manage postural hypotension with non-pharmacological measures.
Always check osmolality in hyponatraemia - hypertonic hyponatraemia (from glucose, mannitol) is not true hyponatraemia; correct sodium for glucose: add 2.4 mmol/L Na+ for every 5.5 mmol/L glucose above normal.
Low-molecular-weight proteinuria + hypercalciuria + nephrocalcinosis in a boy = Dent disease (X-linked); check the urine albumin:total protein ratio to distinguish tubular from glomerular proteinuria.
Reset osmostat shows stable mild hyponatraemia with preserved ability to dilute urine after a water load - no treatment is needed if the patient remains asymptomatic.
Bilateral obstructive AKI with hyperkalaemia = treat K+ first (cardiac protection), then urgent nephrostomy; anticipate and manage post-obstructive diuresis.
Non-visible haematuria in patients >45 with risk factors (smoking, male) = CT urogram + cystoscopy to exclude malignancy; dysmorphic RBCs or casts redirect towards nephrology.
Lithium-induced NDI = poor DDAVP response; manage with amiloride (blocks lithium entry via ENaC) and ensure free water access.
In primary hyperaldosteronism, always confirm biochemically and perform adrenal vein sampling before surgery - CT alone is insufficient for lateralisation.
The KDIGO heat map combines GFR category and albuminuria category to determine risk level and monitoring frequency - G3b + A3 = very high risk (red), requiring specialist referral.
In RPGN with negative serology, urgent renal biopsy is mandatory - approximately 10-15% of ANCA vasculitis is seronegative and treatment should not be delayed.
Cholesterol embolisation presents weeks after vascular procedures with the triad of renal impairment, eosinophilia, and livedo reticularis - anticoagulation is stopped, not started.
Hungry bone syndrome after parathyroidectomy requires continuous IV calcium infusion plus magnesium, alfacalcidol, and oral calcium - high pre-operative ALP predicts the severity.
Refractory hypocalcaemia with inappropriately low PTH should always prompt magnesium measurement - hypomagnesaemia causes functional hypoparathyroidism that only responds to magnesium replacement.
S. aureus dialysis catheter infection = remove the catheter and treat with 4+ weeks of targeted IV antibiotics.
rehydrate with IV 0.9% saline first, then give an IV bisphosphonate (zoledronic acid) once euvolaemic - this follows the Society for Endocrinology emergency guidance on acute hypercalcaemia; avoid loop diuretics for calciuresis.
Scleroderma renal crisis = start captopril immediately and taper steroids; ACE inhibitors are disease-modifying, not just antihypertensive.
Vancomycin in AKI - monitor levels closely, adjust doses to prevent accumulation; troughs >20 mg/L increase nephrotoxicity risk; AUC-guided dosing is now preferred over trough-only monitoring.
In pregnancy, creatinine and urea FALL (hyperfiltration), sodium falls by 4-5 mmol/L (reset osmostat), mild proteinuria is normal, and bilateral hydronephrosis is physiological.
Prolonged anuria after obstetric emergency with DIC + non-enhancing renal cortex on CT = cortical necrosis; prognosis is much worse than ATN.
Trimethoprim acts like a potassium-sparing diuretic by blocking ENaC - check potassium early when prescribing alongside ACE inhibitors or in CKD patients.
Gitelman syndrome = hypokalaemia + hypomagnesaemia + hypocalciuria + metabolic alkalosis - the low urinary calcium distinguishes it from Bartter syndrome.
In severe hypercalcaemia of malignancy, rehydrate first then give IV zoledronic acid - loop diuretics are no longer recommended as routine calciuresis therapy.
Bosniak IV in dialysis patients = nephrectomy; the patient can remain on the transplant list with appropriate cancer-free waiting period.
Gentamicin in CKD - use synergistic low-dose regimen for endocarditis, extend intervals, target trough <1 mg/L, monitor levels and renal function closely.
Vaccinate CKD patients EARLY (better responses pre-dialysis); hepatitis B requires double-dose; live vaccines must be given pre-transplant.
In a well patient with a normal ECG and normal renal function, an isolated high potassium is usually pseudohyperkalaemia from haemolysis, prolonged tourniquet use, or delayed processing - repeat the sample before treating.
Type 4 RTA shows hyperkalaemia with low renin and low aldosterone - check urine pH to distinguish from Type 1 RTA, which has inappropriately alkaline urine.
Refer for AVF creation at least 6 months before anticipated dialysis - a functioning fistula significantly reduces morbidity and mortality compared to central venous catheter access.
Synpharyngitic haematuria (concurrent with URTI) with glomerular red cells = IgA nephropathy until proven otherwise; biopsy for confirmation and prognostication.
Gabapentin is entirely renally cleared - in dialysis patients, prescribe 100-300 mg after each session only, never three times daily.
FGF23 rises early in CKD to maintain normal phosphate but simultaneously suppresses calcitriol production - this trade-off initiates the cascade of CKD-mineral bone disease.
ADPKD + family history of intracranial aneurysm/SAH = screen with MRA; repeat every 5-10 years if negative.
In CKD start allopurinol low (100mg daily, 50mg if eGFR <20) and titrate by 100mg every 4 weeks to a target urate <360 µmol/L (<300 if tophi), with colchicine cover for at least 6 months.
The initial eGFR dip with SGLT2 inhibitors is expected and protective - do not discontinue; it reflects beneficial reduction in intraglomerular pressure.
HRS-1 is diagnosed when AKI in cirrhosis fails to respond to 48 hours of albumin - terlipressin is the first-line pharmacological treatment.
Use potassium binders like patiromer to enable continued RAAS blockade in CKD - always check for dietary potassium sources including salt substitutes, which are a commonly overlooked cause.
Membranous nephropathy carries the highest thrombotic risk in nephrotic syndrome - RVT requires systemic anticoagulation with LMWH bridging to warfarin as first-line therapy.
Tumoral calcinosis requires aggressive phosphate reduction - always use non-calcium binders when the calcium-phosphate product is elevated, and optimise dialysis clearance.
HIT = stop ALL heparin (including LMWH), use argatroban, and NEVER start warfarin during the acute thrombocytopenic phase.
Air embolism during dialysis - clamp line, Durant's manoeuvre (left lateral head down), 100% oxygen.
Adynamic bone disease = over-suppressed PTH from excessive calcium/active vitamin D; reduce treatment and allow PTH to rise; avoid calcium-based binders.
Finerenone is the preferred MRA for diabetic kidney disease - it reduces renal progression on top of RAAS blockade and SGLT2 inhibition with an acceptable safety profile.
Primary membranous nephropathy requires 6 months of supportive care first - serial anti-PLA2R titre monitoring guides whether immunosuppression with rituximab is needed.
Polyneuropathy workup: HbA1c, B12, TFTs, SPE + immunofixation, ESR, FBC, U&E, LFTs as minimum. Paraprotein and diabetes are the most common treatable "idiopathic" causes. Always do immunofixation (not just SPE). OGTT may reveal pre-diabetes missed by HbA1c. 25-30% remain truly idiopathic.
for wearing off, add a COMT inhibitor, MAO-B inhibitor, or dopamine agonist per NICE NG71; for peak-dose dyskinesia use amantadine and reduce individual doses. Never give haloperidol or metoclopramide, and never stop levodopa suddenly.
SCAs: autosomal dominant progressive cerebellar ataxias. SCA3 (Machado-Joseph) most common worldwide. Most are CAG polyglutamine expansions (like Huntington).
HINTS > MRI in first 48 hours for posterior circulation stroke detection. Any ONE dangerous sign (normal HIT, direction-changing nystagmus, skew deviation) = central. CT misses >80% of posterior fossa strokes - do NOT rely on CT alone. Teach all emergency physicians HINTS.
Narcolepsy type 1: EDS + cataplexy (triggered by emotions) + sleep paralysis + hypnagogic hallucinations. CSF hypocretin <110 pg/mL diagnostic. MSLT: mean latency <8 min + ≥2 SOREMPs. HLA-DQB1*06:02 associated. Autoimmune loss of orexin neurons. Sodium oxybate treats both EDS and cataplexy.
Cerebellar haemorrhage >3cm or with hydrocephalus = neurosurgical emergency. Risk of brainstem compression and rapid death. LP contraindicated. HINTS exam distinguishes central from peripheral vertigo.
AL amyloid neuropathy: painful sensory + autonomic neuropathy + carpal tunnel + paraprotein + multi-organ involvement. Congo red → apple-green birefringence. Urgent haematology referral - median survival 12-18 months untreated.
Friedreich's ataxia - autosomal recessive, GAA repeat in FXN, frataxin deficiency; progressive ataxia + absent reflexes + upgoing plantars + pes cavus + scoliosis + hypertrophic cardiomyopathy + diabetes; cardiomyopathy is the leading cause of death so annual echocardiography is essential; most common inherited ataxia (Ataxia UK guidance).
AMAN: pure motor, axonal NCS pattern (low CMAP, normal velocity), anti-GM1/GD1a antibodies, strongly linked to Campylobacter. Treatment: IVIg or PLEX (same as AIDP). Steroids don't help. Miller Fisher: ophthalmoplegia + ataxia + areflexia + anti-GQ1b.
Syringomyelia: dissociated sensory loss (pain/temp lost, touch/proprioception preserved) in cape distribution + LMN signs at level + UMN below. Associated with Chiari I malformation. Painless burns are classic. Posterior fossa decompression is definitive treatment.
Locked-in syndrome: bilateral ventral pontine lesion → tetraplegia and anarthria with PRESERVED consciousness and vertical eye movements. Usually basilar artery occlusion. Must test for purposeful eye movements - do NOT mistake for vegetative state. EEG is normal. Communicate via eye blinks.
Cluster headache acute treatment: high-flow O₂ 12-15 L/min + SC sumatriptan 6mg. Oral triptans are too slow. Verapamil is first-line prevention (monitor ECG). Patients are agitated (not still) during attacks.
Spinal epidural abscess: back pain + fever + neurological deficit = emergency. MRI whole spine urgently. S. aureus most common organism. Emergency laminectomy if ANY neurological deficit. Delay >24-48 hours = worse outcome. Blood cultures + IV antibiotics 4-6 weeks.
NF2: bilateral vestibular schwannomas (pathognomonic) + meningiomas + spinal ependymomas. NF2 gene (chromosome 22), merlin protein. Distinguished from NF1 by: fewer skin features, schwannomas not neurofibromas, juvenile cataracts, no Lisch nodules. Bevacizumab may reduce tumour size.
Tardive dyskinesia: orofacial choreiform movements after prolonged antipsychotic use. Do NOT increase dose (worsens long-term). Switch to clozapine/quetiapine. VMAT2 inhibitors (valbenazine) are first-line treatment. Prevention: regular AIMS screening, lowest effective dose, prefer atypicals.
Young stroke: dissection (CTA neck), PFO (bubble echo), APS (lupus anticoagulant), vasculitis (ANA/ANCA), drugs (toxicology). Stop COCP if migraine with aura. APS requires anticoagulation (warfarin, not DOAC). PFO closure for cryptogenic stroke with high-risk features.
SPS: axial rigidity + painful spasms + exaggerated lordosis + very high anti-GAD antibodies. Associated with type 1 diabetes and other autoimmune conditions. Diazepam first-line symptomatic; IVIg for disease modification. Anti-amphiphysin = paraneoplastic (screen for breast cancer).
SE: >5 minutes convulsive seizure = treat. Step 1: benzodiazepine (IV lorazepam in hospital; buccal midazolam pre-hospital). Step 2: IV levetiracetam/phenytoin/valproate (if 2 benzo doses fail). Step 3: RSI + ICU + propofol/thiopental infusion. Phenytoin needs cardiac monitoring; never IM.
FND = positive signs (Hoover's, inconsistency) - not exclusion, not malingering (involuntary); explain positively + specialist physio + CBT; second commonest neurology outpatient diagnosis.
Highly active RRMS (relapses despite DMT + new MRI activity + disability progression) = escalate to natalizumab, ocrelizumab, or alemtuzumab. Check JCV antibody before natalizumab (PML risk). Growing evidence supports early intensive treatment.
Trigeminal neuralgia: electric-shock pain in V2/V3, triggered by touch/eating, seconds duration. Carbamazepine first-line (NNT ~2). MRI to exclude secondary causes. MVD for refractory cases. Normal neuro exam expected in classical TN.
ODS: overly rapid sodium correction → pontine demyelination → quadriplegia/locked-in syndrome. Safe rate: ≤10-12 mmol/L in 24 hours (aim ≤8). Monitor sodium every 2-4 hours. Use desmopressin if overcorrecting. Risk factors: alcoholism, malnutrition, liver disease.
Malignant MCA infarction carries up to 80% mortality - decompressive hemicraniectomy within 48 hours (DECIMAL, DESTINY, HAMLET) is life-saving and most beneficial in patients aged 60 or under.
UK brainstem death: 2 doctors (1 consultant), 2 independent sets of tests, all brainstem reflexes absent, apnoea test (PaCO₂ >6.65 kPa with no respiratory effort). Exclude hypothermia (<34°C), drugs, metabolic causes. Time of death = first set of tests. EEG NOT required (UK).
bilateral sciatica plus saddle anaesthesia plus bladder or bowel dysfunction equals cauda equina syndrome until proven otherwise - arrange emergency MRI and urgent surgical decompression, because every hour of delay worsens the prognosis and these cases are heavily litigated.
Wilson's: low caeruloplasmin + high urinary copper + Kayser-Fleischer rings. ATP7B gene. Wing-beating tremor + liver disease in young adult. D-penicillamine is first-line chelator. Screen siblings. Treatable if caught early.
Diabetic autonomic neuropathy = resting tachycardia + loss of heart rate variability (earliest) + orthostatic hypotension + gastroparesis + erectile dysfunction + gustatory sweating; parasympathetic fibres fail first, and cardiovascular autonomic neuropathy predicts silent MI and increased mortality.
Pituitary apoplexy: sudden headache + visual loss + ophthalmoplegia + hypotension. IV hydrocortisone 100mg IMMEDIATELY (acute hypoadrenalism is the immediate killer). Urgent neurosurgery if vision deteriorating. Replace cortisol BEFORE thyroxine. Lifelong hormone monitoring.
In acute ICH, target systolic BP 130-140 mmHg within 1 hour (INTERACT2; NICE NG128), maintain it, avoid <110 mmHg, use IV labetalol first-line, and reverse any anticoagulation promptly.
FND is diagnosed on positive signs (Hoover's sign for weakness, entrainment for tremor) - it is a genuine disorder, not malingering; explain the diagnosis clearly and refer for physiotherapy (Physio4FMD).
CVST: young woman + COCP + progressive headache + seizures + haemorrhagic infarct NOT in arterial territory → CT/MR venography. Anticoagulate with LMWH EVEN IF HAEMORRHAGE (haemorrhage is venous congestion, not contraindication). Stop COCP. Screen for thrombophilia.
Severe asymmetric thigh pain + proximal weakness + weight loss + absent knee jerk in a diabetic = diabetic amyotrophy (lumbosacral radiculoplexus neuropathy); immune-mediated, usually self-limiting; exclude structural causes with MRI; treat pain per NICE CG173.
Wearing off → add COMT inhibitor or MAO-B inhibitor and fractionate levodopa doses. Peak-dose dyskinesia → reduce individual doses, increase frequency. Advanced therapies for refractory fluctuations.
PD non-motor symptoms: hyposmia, REM sleep behaviour disorder, constipation, depression, autonomic dysfunction, hallucinations. Often more disabling than tremor. May precede motor diagnosis by years (prodromal PD). Visual hallucinations: reduce dopaminergic drugs → quetiapine → clozapine.
HSP: progressive spastic paraparesis + family history + normal MRI. SPG4 (spastin) most common. Pure vs complex forms. Longest axons degenerate first (legs >> arms). No LMN signs (vs MND). Physiotherapy + baclofen for spasticity. Genetic counselling.
Thiamine deficiency post-bariatric surgery: painful polyneuropathy (dry beriberi) ± Wernicke's (confusion, nystagmus, ataxia). IV Pabrinex urgently. Oral absorption unreliable. Increasingly common cause - must screen post-bariatric patients. Give thiamine BEFORE glucose.
JME - morning myoclonus plus GTCS on waking, onset in adolescence, sleep deprivation a key trigger; generalised 4-6 Hz polyspike-and-wave on EEG; avoid carbamazepine, and avoid valproate in women of childbearing potential (NICE NG217).
CTTH: bilateral, pressing, mild-moderate, ≥15 days/month, no migraine features. Amitriptyline first-line prophylaxis. Limit analgesics to prevent MOH. Non-pharmacological treatments important (stress management, CBT, exercise). Most common headache type globally.
AD biomarkers: AT(N) framework. A: low CSF Aβ42 or positive amyloid PET. T: elevated CSF p-tau. N: hippocampal atrophy, FDG-PET hypometabolism, elevated t-tau. Plasma p-tau217 emerging as screening blood test. APOE ε4 is risk factor not diagnostic.
Optic neuritis = painful visual loss + RAPD + red colour desaturation; IV methylprednisolone speeds recovery but does not change final outcome; never give oral steroids alone (increased relapse rate, ONTT); around 90% recover good vision; brain MRI determines MS risk; check AQP4/MOG if bilateral or severe.
Malignant MCA infarction ( >50% territory, massive oedema, herniation) carries >80% mortality without surgery. Decompressive hemicraniectomy within 48 hours (DECIMAL/DESTINY/HAMLET pooled analysis) reduces death, with greatest benefit in those under 60; medical management is only a bridge.
LEMS: proximal weakness that improves with use, absent reflexes that augment, autonomic symptoms, anti-VGCC antibodies. 60% have SCLC - CT chest essential. 3,4-diaminopyridine is first-line treatment. Opposite to MG in most features.
GCA with visual loss = emergency: IV methylprednisolone immediately (don't wait for biopsy). Jaw claudication is most specific symptom. Biopsy within 2 weeks (skip lesions → may be negative). Tocilizumab for steroid-sparing. Bilateral blindness if untreated. PMR coexists in ~50%.
Subcortical VaD: executive dysfunction + psychomotor slowing + gait disturbance + apathy in patient with vascular risk factors. MRI: extensive WMH + lacunar infarcts. Manage vascular risk factors aggressively. Memory relatively preserved initially (unlike Alzheimer's). Most common VaD subtype.
High-risk TIA or minor ischaemic stroke (non-AF) = aspirin + clopidogrel for 21 days, then clopidogrel monotherapy (National Clinical Guideline for Stroke 2023; CHANCE and POINT trials). Anticoagulate only if AF is identified.
Central HINTS pattern - NEGATIVE (normal) head impulse, OR direction-changing/vertical nystagmus, OR positive test of skew = stroke until proven otherwise. Only valid in acute continuous vertigo >24 hours with nystagmus. Vascular risk factors raise suspicion.
HD: autosomal dominant, CAG repeat ≥40 in HTT gene. Chorea + psychiatric symptoms + cognitive decline. Caudate atrophy on MRI. Tetrabenazine for chorea (depletes dopamine). Depression common - SSRIs + suicide monitoring. Anticipation (especially paternal).
Hemiplegic migraine: motor weakness as part of aura. FHM is autosomal dominant (CACNA1A most common gene). Triptans and ergots are contraindicated and the COCP should be avoided (SIGN 155 headache guideline; ICHD-3 classification). Must exclude stroke each time. Normal MRI between episodes.
Alteplase 0.9mg/kg (10% bolus, 90% over 60 min) within 4.5 hours. BP <185/110 before dosing. No antiplatelets for 24 hours post-thrombolysis.
Wernicke's: fluent but meaningless speech + poor comprehension + unaware of deficit = temporal lobe. Broca's: non-fluent but good comprehension + aware and frustrated = frontal lobe. Repetition impaired in both (intact in transcortical types). Global aphasia = large MCA territory infarct.
Acute ischaemic stroke: CT → exclude haemorrhage → alteplase within 4.5 hours + thrombectomy for LVO within 6-24 hours (perfusion-guided). Thrombectomy NNT 3-5 (most effective stroke treatment). Tenecteplase emerging as simpler alternative. BP <185/110 before thrombolysis.
CVST in pregnancy: anticoagulate with LMWH even if haemorrhagic infarct. Warfarin and DOACs contraindicated in pregnancy. Convert to UFH around delivery. Continue anticoagulation for ≥6 months. Screen for thrombophilia postpartum.
Vestibular schwannoma: unilateral SNHL + tinnitus + imbalance. Most common CPA tumour. MRI gadolinium diagnostic. Bilateral = NF2. Treatment: watch (small) vs Gamma Knife (medium) vs surgery (large). Not acoustic neuroma - arises from vestibular nerve.
IIH: obese young woman + headache + papilloedema + raised LP pressure + normal MRI. Acetazolamide + weight loss. Monitor visual fields closely. Surgical options if vision threatened.
TBM: subacute meningitis (weeks), cranial nerve palsies, very low CSF glucose + very high protein, lymphocytic, basal meningeal enhancement. RIPE for 12 months + adjunctive dexamethasone (reduces mortality by 30%). GeneXpert CSF has moderate sensitivity (~60-70%).
Advanced PD therapies: DBS (strongest evidence; STN or GPi), apomorphine infusion (non-surgical; SC pump), LCIG/Duodopa (jejunal infusion via PEG-J). All reduce off-time ~50-60%. DBS: requires preserved cognition, good levodopa response. Apomorphine: pre-treat nausea with domperidone, skin nodules.
NPH: gait apraxia (earliest + most responsive) → urinary incontinence → dementia (subcortical). "Wet, wobbly, wacky" - but gait comes first. Evans index >0.3. DESH sign. Opening pressure NORMAL. CSF tap test/ELD predicts shunt response. VP shunt with programmable valve. Gait responds best (~80%).
Acute transverse myelitis: IV methylprednisolone immediately - don't wait for antibody results. Plasma exchange if steroid-refractory. Investigate underlying cause (MS, NMOSD, MOGAD, sarcoidosis, infection). Short-segment favours MS; LETM ≥3 segments favours NMOSD/MOGAD.
Miller Fisher: ophthalmoplegia + ataxia + areflexia (NO weakness). Anti-GQ1b antibodies (~90%). Self-limiting in most cases. IVIg if severe or overlap with GBS. Distinguished from MG (no ataxia/areflexia), Wernicke's (no areflexia, has confusion), botulism (descending).
Brown-Séquard = ipsilateral motor weakness + ipsilateral proprioception/vibration loss + contralateral pain/temperature loss. The dissociation of sensory modalities (proprioception on one side, pain and temperature on the other) is the key diagnostic clue.
sCJD: rapidly progressive dementia (months) + myoclonus + ataxia. MRI DWI: cortical ribboning + basal ganglia signal. CSF RT-QuIC is most specific test. 14-3-3 and periodic EEG are supportive. Fatal - no treatment. vCJD: younger, psychiatric onset, pulvinar sign.
Mild-moderate AD: donepezil (or rivastigmine/galantamine). Moderate-severe: add memantine. Avoid antipsychotics unless essential. Non-pharmacological interventions are important. Monitor for bradycardia with AChEi.
sCJD: rapidly progressive dementia over weeks-months + myoclonus + ataxia in elderly. MRI DWI: cortical ribboning + caudate/putamen. EEG: PSWCs. CSF RT-QuIC is gold standard (>99% specificity). vCJD: young + psychiatric onset + pulvinar sign + tonsil biopsy positive. Fatal, no treatment. Notifiable.
JME: adolescent onset + morning myoclonic jerks + GTCS + absences. EEG: generalised polyspike-and-wave. Sodium valproate most effective but teratogenic (lamotrigine/levetiracetam for WCBP). AVOID carbamazepine/phenytoin (worsen myoclonus). Sleep deprivation is the main trigger.
Chronic migraine after failing ≥3 preventives: anti-CGRP antibodies (erenumab/fremanezumab/galcanezumab) OR Botox (onabotulinumtoxinA). NICE approved pathway. ~50% achieve ≥50% migraine reduction with CGRP antibodies. Stop if <30% improvement at 12 weeks. Reassess annually.
ADEM vs CIS/MS: encephalopathy is the key differentiator (required for ADEM, absent in CIS). ADEM: large lesions + deep grey matter + polyfocal + monophasic. MS: periventricular + well-defined + no encephalopathy + relapsing. Test MOG and AQP4 antibodies.
VP shunt infections require complete hardware removal, external ventricular drainage, and IV plus intrathecal vancomycin - biofilm on the shunt cannot be sterilised with antibiotics alone.
Zika in pregnancy requires serial fetal ultrasound monitoring for microcephaly - there is no antiviral treatment, and male partners should use barrier contraception for 3 months due to seminal persistence.
PrEP with daily TDF/FTC requires 3-monthly HIV testing and regular renal monitoring - prescribing PrEP without frequent HIV testing risks selecting for drug-resistant HIV.
Reactive arthritis is managed with NSAIDs first-line and intra-articular corticosteroids for monoarthritis - prolonged antibiotics do not alter the course once the triggering infection is treated.
Pseudomonas aeruginosa bacteraemia with sepsis warrants initial combination therapy (anti-pseudomonal beta-lactam plus aminoglycoside) for 3-5 days - de-escalate to monotherapy once the patient improves.
HIV-positive women require annual cervical screening from diagnosis - the increased HPV-related cancer risk persists even with successful ART, and screening intervals should not be relaxed.
Prosthetic valve staphylococcal endocarditis requires triple therapy (vancomycin + rifampicin + gentamicin) - rifampicin is essential for biofilm penetration on prosthetic material.
IV-to-oral switch should occur as soon as clinical criteria are met - afebrile for 24 hours, clinical improvement, falling CRP, functioning GI tract, and no indication for continued IV therapy.
Sterile pyuria in a patient from a TB-endemic country = consider genitourinary TB - send 3 early morning urines for mycobacterial culture; calyceal erosion, ureteric strictures, and contracted kidney are characteristic imaging findings.
MSSA native valve endocarditis is treated with IV flucloxacillin monotherapy for 6 weeks - gentamicin adjunct is no longer recommended due to nephrotoxicity without benefit.
Herpes zoster is an HIV indicator condition - offer HIV testing to all patients with indicator conditions regardless of perceived risk factors; late diagnosis remains a major UK public health challenge.
Melioidosis requires IV meropenem/ceftazidime (minimum 2 weeks) then oral co-trimoxazole (minimum 3 months) - without prolonged eradication therapy, relapse rates exceed 20%; prostatic abscess is nearly pathognomonic in endemic areas.
Oral valganciclovir is first-line for non-sight-threatening CMV retinitis - secondary prophylaxis can stop when CD4 >100 for ≥3-6 months on effective ART.
Asymptomatic bacteriuria in catheterised patients should NOT be treated - bacteriuria is universal with long-term catheters and treatment only drives resistance without clinical benefit.
Chronic osteomyelitis requires MRI plus deep surgical bone biopsy for culture - superficial wound swabs are unreliable; management requires debridement, sequestrum removal, and prolonged targeted antibiotics.
Isoniazid-induced peripheral neuropathy is prevented by pyridoxine supplementation - high-risk patients (diabetes, CKD, alcohol, malnutrition, HIV) must receive pyridoxine 10-25mg OD throughout treatment.
HIV/HCV coinfection should be treated with DAAs (sofosbuvir/velpatasvir is pangenotypic) - cure rates >95% are achievable; check drug interactions with ART before starting.
TB meningitis requires 12 months of treatment (2+10) plus adjunctive dexamethasone for 6-8 weeks - steroids reduce mortality by ~30% and should never be omitted.
Erysipelas (well-demarcated, raised edge) is caused by Group A Streptococcus - recurrent episodes (≥2/year) warrant prophylactic penicillin V alongside treatment of predisposing factors.
Severe/fulminant CDI requires high-dose oral vancomycin (500mg QDS) plus IV metronidazole - always stop the offending antibiotic and consider surgical review if there are signs of complications.
Mycotic aneurysm with Salmonella requires urgent vascular surgery plus prolonged IV antibiotics - Salmonella has a tropism for diseased aortic tissue, and infected aneurysms carry a very high rupture risk.
HIV/HBV coinfection mandates TDF/FTC (or TAF/FTC) in the backbone to treat both viruses - stopping these agents risks severe HBV flare from immune reconstitution.
Zika virus requires no specific antiviral treatment. Always consider the clinical context and guideline-directed management.
Amoebic liver abscess requires metronidazole (tissue amoebicide) followed by diloxanide furoate (luminal amoebicide) - the luminal agent is essential to prevent relapse from intestinal cysts.
MAC lung disease requires clarithromycin + ethambutol + rifampicin for 12 months beyond culture conversion - never use macrolide monotherapy (promotes resistance); standard TB drugs are ineffective against NTM.
In candidaemia, CVC removal within 24 hours is the single most important intervention alongside antifungal therapy - delay increases mortality significantly.
Eschar + regional lymphadenopathy + maculopapular rash (including palms/soles) after African travel = African tick bite fever - treat with doxycycline 100mg BD for 5-7 days.
Whipple disease requires IV ceftriaxone for 2 weeks then oral co-trimoxazole for ≥12 months - PAS-positive foamy macrophages in duodenal biopsies are pathognomonic, and anti-TNF therapy is contraindicated.
PML has no specific antiviral - immediate ART to restore immune function is the only life-prolonging treatment, but carries a risk of PML-IRIS.
Right-sided (tricuspid) infective endocarditis requires good clinical response within 72 hours. Always consider the clinical context and guideline-directed management.
Cryptosporidiosis in advanced HIV is primarily treated with ART for immune reconstitution - no antimicrobial is reliably effective with CD4 <100, and aggressive rehydration is essential.
Severe falciparum malaria is treated with IV artesunate (not quinine) - the SEAQUAMAT/AQUAMAT trials showed 35% mortality reduction compared to quinine.
Standard TB treatment is 2RHZE/4RH (total 6 months) - monitor visual acuity for ethambutol toxicity and LFTs for hepatotoxicity, particularly in the first 2 months.
90% of 'penicillin-allergic' patients are not truly allergic - childhood rashes during infections are usually viral, and cephalosporin tolerance strongly suggests safe penicillin use.
Active IV drug use is a contraindication to OPAT due to risks of line misuse - ideal OPAT candidates are clinically stable with good social support, compliance, and once-daily antibiotic regimens.
Typhoid from South Asia should be treated with IV ceftriaxone first-line, not ciprofloxacin - fluoroquinolone resistance is widespread even when in vitro sensitivity is reported.
Delayed prescribing is appropriate for intermediate FeverPAIN/Centor scores - it reduces antibiotic use by 30-50% while maintaining safety, and is a key primary care stewardship strategy.
possible viral haemorrhagic fever (VHF) requires strict isolation with enhanced personal protective equipment (PPE). Always consider the clinical context and guideline-directed management.
Sterile pyuria in a patient from a TB-endemic country is genitourinary TB until proven otherwise - send three early morning urine samples for AFB culture and TB PCR.
K103N confers NNRTI class resistance - switch to an integrase inhibitor-based regimen, and consider TAF over TDF if there is declining renal function.
Abacavir hypersensitivity syndrome requires immediate and permanent discontinuation - rechallenge is NEVER permitted as it can cause fatal anaphylaxis, even in HLA-B*5701-negative patients.
Sight-threatening CMV retinitis with macular involvement requires IV ganciclovir plus intravitreal injections for rapid local drug delivery - oral valganciclovir alone is insufficient for zone 1 disease.
ART should be started within 2 weeks for advanced HIV - exceptions are active TB (delay 2-8 weeks) and cryptococcal meningitis (delay 4-6 weeks) to reduce IRIS risk.
NICE guidelines do not recommend routine antibiotic prophylaxis for endocarditis prevention - however, ESC guidelines still recommend it for high-risk patients, and shared decision-making is appropriate.
Latent TB must be treated before starting anti-TNF therapy - NICE recommends 3 months of isoniazid plus rifampicin, started at least 1-2 months before biologic therapy.
Pre-XDR-TB = MDR + fluoroquinolone resistance; XDR-TB = MDR + fluoroquinolone + bedaquiline or linezolid resistance (2021 WHO definition) - these require specialist management with individualised regimens.
Occupational PEP (TDF/FTC + dolutegravir for 28 days) should be offered for significant needlestick exposures even if the source has an undetectable viral load - start within 1 hour.
Multiple ring-enhancing lesions with positive Toxoplasma IgG in advanced HIV should be treated empirically - brain biopsy is reserved for non-responders at 2 weeks.
Acute schistosomiasis (Katayama syndrome) presents with eosinophilia, urticaria, and pulmonary infiltrates after freshwater exposure - treat with praziquantel; stool microscopy may be negative early.
Spinal epidural abscess (fever + back pain + neurological deficit) requires urgent whole-spine MRI - delays in diagnosis and surgical decompression lead to irreversible paralysis.
Brain abscess requires empirical ceftriaxone plus metronidazole and urgent neurosurgical referral for aspiration/excision - LP is contraindicated with mass effect.
PORN is a VZV-related retinal emergency in advanced HIV requiring IV aciclovir plus intravitreal foscarnet - it progresses rapidly to blindness and has a much worse prognosis than CMV retinitis.
Severe leptospirosis (Weil disease) requires IV benzylpenicillin or ceftriaxone - conjunctival suffusion plus jaundice with AKI and relatively low transaminases is the characteristic diagnostic pattern.
Most 'penicillin allergies' are not true IgE-mediated reactions - delayed rashes, cephalosporin tolerance, and remote history suggest safe rechallenge, and de-labelling allows use of the most effective agents.
Disseminated MAC occurs at CD4 <50 with fever, wasting, hepatosplenomegaly, anaemia, and very elevated ALP - treat with clarithromycin + ethambutol + rifabutin; start primary prophylaxis with azithromycin when CD4 <50.
Continue integrase inhibitor-based ART during chemotherapy - avoid boosted PIs (interaction with vincristine) and zidovudine (additive myelosuppression).
Severe DILI during TB treatment (ALT >5× ULN + symptoms) requires stopping RHZ, maintaining ethambutol + fluoroquinolone, then sequential re-introduction once LFTs normalise.
A single viral load blip (<200 copies/mL) requires adherence reinforcement and repeat testing - do not perform resistance testing or change ART without confirmed virological failure (two consecutive VL >200).
Persistent fever during endocarditis treatment with negative cultures should prompt imaging for embolic complications - splenic abscess requires drainage for source control.
sepsis requires emergency response. Always consider the clinical context and guideline-directed management.
DAIR is appropriate for early PJI (<4 weeks) with a well-fixed implant and susceptible organism - success depends on immature biofilm; late chronic PJI requires staged revision.
Yellow fever vaccine is live attenuated - give ≥10 days before travel; single dose provides lifelong protection (no boosters needed since 2016); contraindicated in severe immunosuppression and egg allergy.
Bullous impetigo (large flaccid bullae from S. aureus exfoliative toxin) requires oral flucloxacillin per NICE NG153 - topical antibiotics are insufficient because the toxin-mediated, multifocal pathology demands systemic therapy.
Japanese encephalitis presents with extrapyramidal signs + bilateral thalamic MRI lesions - no antiviral exists; prevention with JE vaccine (Ixiaro) is essential for rural Asian travel.
Cystoisospora belli responds to co-trimoxazole (unlike Cryptosporidium) - distinguish by larger oocyst size and uniform acid-fast staining, and maintain secondary prophylaxis until immune reconstitution.
Fournier gangrene requires emergency surgical debridement within hours - every hour of delay increases mortality, and imaging should never delay operative management.
Neurosyphilis requires IV benzylpenicillin (NOT IM benzathine penicillin) for 14 days - IM benzathine penicillin does not achieve adequate CSF levels; Argyll Robertson pupils are pathognomonic.
When blood cultures are negative in suspected discitis, CT-guided biopsy is essential before starting antibiotics - empirical treatment without a microbiological diagnosis risks inadequate therapy and culture sterilisation.
Children under 5 with latent TB are at high risk of progression to active disease - treat with 3 months of isoniazid and rifampicin; a positive IGRA confirms infection regardless of BCG status.
Basal-bolus is standard for T1DM: detemir/glargine/degludec (basal) + lispro/aspart (bolus). Never stop basal insulin. Transition from IV: give SC basal 30-60 min before stopping infusion.
IV ceftriaxone is first-line for bacterial meningitis (3 months-50 years). Add amoxicillin for Listeria cover in neonates and >50 years. Give dexamethasone before/with first antibiotic dose. Pre-hospital: IM benzylpenicillin.
Idarucizumab 5g IV specifically reverses dabigatran within minutes - andexanet alfa reverses factor Xa inhibitors. Dabigatran is the only DOAC removable by haemodialysis.
EMPEROR-Reduced showed empagliflozin benefits HFrEF regardless of diabetes. DAPA-HF showed the same for dapagliflozin. SGLT2 inhibitors are now the fourth pillar of HFrEF treatment.
Restrict the 4Cs (Clindamycin, Cephalosporins, Co-amoxiclav, Ciprofloxacin/fluoroquinolones). Start Smart Then Focus - review at 48-72h. Soap and water for *C. diff*. Vancomycin/fidaxomicin first-line per NICE NG199.
Ticagrelor dyspnoea affects ~14% - adenosine-mediated (ENT1 inhibition), not pulmonary pathology. Normal CXR and oxygen saturations. Usually mild and self-limiting. Switch to clopidogrel if intolerable.
Grapefruit juice irreversibly inhibits intestinal CYP3A4, dramatically increasing simvastatin levels - switch to rosuvastatin or pravastatin (not CYP3A4 substrates) if patients cannot avoid grapefruit.
Once-daily gentamicin requires trough level monitoring (<1 mg/L) to prevent nephrotoxicity and ototoxicity - renal function should be checked every 48-72 hours.
Flumazenil is contraindicated in mixed overdose (especially with TCAs/tramadol) - unmasks seizures. Also contraindicated in benzodiazepine-dependent patients. Only safe for isolated iatrogenic benzodiazepine over-sedation.
Tacrolimus: more diabetes and tremor, less cosmetic effects. Ciclosporin: more hypertension, hirsutism, gingival hypertrophy. Tacrolimus is generally preferred (lower rejection rates).
Drug-induced lupus is characterised by positive anti-histone antibodies with negative anti-dsDNA and normal complement - it resolves on stopping the drug. Hydralazine and procainamide are the most common causes.
Clozapine requires mandatory FBC monitoring (weekly for 18 weeks, then fortnightly, then monthly) for agranulocytosis risk - never re-challenge after confirmed agranulocytosis.
LAMA (tiotropium) is first-line maintenance in COPD without asthmatic features. Add LABA if still symptomatic. ICS only if asthmatic features or eosinophilia present.
INR 2-3 for AF and VTE; INR 2.5-3.5 for mechanical valves. Major bleeding: IV vitamin K + 4-factor PCC (not FFP). Warfarin still required for mechanical valves.
Baricitinib reduces COVID-19 mortality when added to dexamethasone in hospitalised patients requiring oxygen. COV-BARRIER showed 38% mortality reduction. Alternative: tocilizumab (if baricitinib unavailable).
Semaglutide 2.4mg achieves 15-17% weight loss with 20% MACE reduction even without diabetes (SELECT trial). Multiple formulations available. Main side effect is nausea.
EMPA-REG OUTCOME showed empagliflozin reduces cardiovascular death by 38% in T2DM with CVD - this benefit is independent of glucose lowering and appears within months.
Dobutamine (beta-1 agonist) is first-line for cardiogenic shock - increases contractility. Combine with noradrenaline if hypotensive. Avoid dopamine (more arrhythmogenic). Consider mechanical support early if refractory.
DAAs cure HCV in >95% with 8-12 weeks oral treatment. Sofosbuvir inhibits NS5B polymerase. Always screen for HBV before starting. Avoid amiodarone combination (bradycardia). Continue HCC surveillance in cirrhosis.
Anticholinergic burden causes confusion, urinary retention, constipation, and visual blurring in elderly patients - amitriptyline is a common high-burden offender with safer alternatives available.
Rivaroxaban VTE: 15mg BD for 21 days then 20mg OD - no LMWH lead-in needed. Provoked VTE = 3 months; unprovoked = consider indefinite. Extended low-dose reduces recurrence.
Rifampicin is the most potent CYP inducer - renders OCP ineffective and dramatically reduces warfarin levels. Use alternative contraception. Monitor INR frequently. Effects persist 2-4 weeks after stopping.
Tacrolimus is metabolised by CYP3A4 - azole antifungals inhibit this, causing toxic accumulation. Reduce tacrolimus dose when starting azoles. Rifampicin causes the opposite (dangerously low levels). Monitor levels closely with any new medication.
Dopamine agonists cause impulse control disorders in up to 17% of patients - gambling, shopping, hypersexuality. Screen before starting, warn patients and carers. Reduce/stop the agonist; symptoms usually resolve.
Before reducing long-term steroids, ensure bone protection (bisphosphonate) and a steroid-sparing agent are in place - never stop abruptly after >3 weeks due to adrenal suppression risk.
Hydroxocobalamin 5g IV is first-line for cyanide poisoning (fire smoke inhalation) - chelates cyanide to cyanocobalamin. Also treat concurrent CO poisoning with high-flow O2. Normal PaO2 + lactic acidosis = suspect cyanide.
Apremilast is an oral PDE4 inhibitor - increases cAMP, reduces inflammatory cytokines. No blood monitoring needed. Main side effects: GI (diarrhoea), weight loss. Less effective than biologics but oral and convenient.
G6PD testing is mandatory before primaquine - severe oxidative haemolysis can occur. Weekly dosing is safer than daily if primaquine is essential in G6PD-deficient patients.
Sugammadex encapsulates rocuronium (cyclodextrin wrapping) - rapid, complete reversal without muscarinic effects. Only for aminosteroid NMBAs. 16mg/kg for emergency "can't intubate" reversal.
Olaparib (PARP inhibitor) exploits synthetic lethality in BRCA-mutated cancers - blocking single-strand repair in cells that cannot perform homologous recombination. Main toxicity: myelosuppression. Rare risk of secondary MDS/AML.
Trimethoprim is a folate antagonist and increases NTD risk in the first trimester - use nitrofurantoin or cefalexin instead. Nitrofurantoin should be avoided at term due to neonatal haemolysis risk.
Aminoglycosides, macrolides, beta-blockers, and magnesium are the most important drugs to avoid in myasthenia gravis. Safe antibiotics: penicillins and cephalosporins. Always check before prescribing anything new in MG.
Serotonin syndrome is characterised by clonus, hyperreflexia, and agitation - distinguishing it from NMS which causes rigidity and bradyreflexia. Stop the serotonergic agent and give cyproheptadine.
Erythromycin = motilin receptor agonist; effective short-term prokinetic for gastroparesis; tachyphylaxis after 1-2 weeks; prolongs QT; potent CYP3A4 inhibitor.
HLA-B*5701 testing is mandatory before abacavir - positive result contraindicates use (fatal rechallenge risk). PREDICT-1 trial validated screening. Never rechallenge after hypersensitivity.
IV magnesium 2g is first-line for Torsades de Pointes - effective regardless of Mg²⁺ level. Do NOT give amiodarone (worsens it). Stop offending drug, correct K⁺/Mg²⁺, consider isoprenaline or pacing to increase heart rate.
Mechanical valve = high risk → bridge with therapeutic LMWH. Stop warfarin 5 days pre-op, start LMWH when INR <2.0, stop LMWH 24h pre-op. BRIDGE trial: don't bridge low-risk AF patients.
GLP-1 agonists have a possible pancreatitis association - stop immediately if pancreatitis occurs, never restart. Contraindicated in history of pancreatitis and medullary thyroid cancer/MEN2. Counsel about severe abdominal pain.
Terlipressin plus albumin is first-line for hepatorenal syndrome type 1 - monitor closely for respiratory complications. Definitive treatment is liver transplantation.
Adenosine 6 → 12 → 12 mg rapid IV push followed by a 20 mL saline flush via large proximal vein; half-life <10 s; contraindicated in asthma (use verapamil).
budesonide's ~90% first-pass metabolism gives gut-targeted anti-inflammatory action with fewer systemic effects than prednisolone, making it first-line for mild-to-moderate ileocaecal Crohn's (NICE NG129) - but it is less effective in severe/extensive disease and does not maintain remission.
Carbimazole causes agranulocytosis in 0.1-0.5% - warn patients to report sore throat/fever urgently. Cannot be predicted by routine FBC. Stop permanently if occurs. PTU has hepatotoxicity risk instead.
Minoxidil (K⁺ channel opener) for severe resistant hypertension - must co-prescribe loop diuretic (fluid retention) and beta-blocker (reflex tachycardia). Causes hypertrichosis in 80%.
Tea (tannins), PPIs (raised pH), and calcium all reduce iron absorption. Take on empty stomach with vitamin C. Avoid tea/coffee within 2 hours. Alternate-day dosing may optimise absorption via hepcidin kinetics.
Hydroxycarbamide increases HbF, reducing sickling and crises by ~50%. Monitor FBC regularly (myelosuppression). Teratogenic. 40% mortality reduction in long-term studies.
Naltrexone (opioid antagonist) and acamprosate (glutamate/GABA modulator) are first-line for alcohol relapse prevention. Naltrexone suits controlled drinking goals; acamprosate suits abstinence goals.
DAPT for 12 months post-ACS. Never stop both agents. Defer elective surgery until DAPT complete. Stop ticagrelor 5 days pre-op; continue aspirin throughout.
Brivaracetam is a higher-affinity SV2A ligand than levetiracetam - similar efficacy with fewer psychiatric side effects (irritability, aggression). Can switch directly from levetiracetam. For focal epilepsy.
Rasburicase is first-line for high-risk TLS prevention - it rapidly reduces existing uric acid, unlike allopurinol which only prevents new formation. Aggressive hydration is the cornerstone.
Valproate inhibits lamotrigine metabolism (doubles half-life) - must titrate lamotrigine twice as slowly to prevent SJS/TEN. Start at half dose. This is one of the most important AED interactions.
ACEi cough is caused by bradykinin accumulation - switch to an ARB (bradykinin not affected). Prior ACEi cough is not a contraindication to ARBs, but prior angioedema is.
Oseltamivir 75mg BD for 5 days for influenza in at-risk patients - start within 48 hours. Amantadine is obsolete due to resistance. Zanamivir is contraindicated in severe airways disease.
GI procedure within 21 days is a relative contraindication to IV thrombolysis - weigh bleeding risk against stroke severity. Alteplase window is 4.5 hours; mechanical thrombectomy extends to 24 hours for large vessel occlusion.
Colchicine 500mcg BD-TDS (max 6mg/course) - never hourly until diarrhoea. Reduce in renal impairment. Avoid with macrolide antibiotics (fatal interaction). No antidote for toxicity.
Trimethoprim blocks ENaC (like amiloride) - additive hyperkalaemia with ACE inhibitors and spironolactone. Check K⁺ before and during trimethoprim in at-risk patients. Consider alternative antibiotics.
Serotonin syndrome = clonus + hyperreflexia + agitation (rapid onset). Distinguish from NMS by clonus vs rigidity. Stop serotonergic drugs, give benzodiazepines and cyproheptadine.
MALA is precipitated by AKI in metformin users - stop metformin, consider haemodialysis for severe acidosis. Contraindicated when eGFR <30 mL/min.
Apixaban AF dose reduction (2.5 mg BD) requires ≥2 of: age ≥80, weight ≤60 kg, creatinine ≥133 μmol/L. Use serum creatinine (not eGFR). Dose-reduction criteria differ between DOACs.
Flumazenil reverses benzodiazepine sedation but has a shorter half-life than most benzodiazepines - monitor for re-sedation. Contraindicated in chronic benzodiazepine use (seizure risk) and mixed TCA overdose.
Naloxone for opioid overdose: titrate IV 400mcg every 2-3 minutes to respiratory rate, not consciousness - monitor for re-sedation as naloxone's duration is shorter than most opioids.
Mycophenolate is teratogenic (ear malformations, cleft palate) - stop 6 weeks before conception, switch to azathioprine. Ensure disease stability before pregnancy. Hydroxychloroquine should be continued (reduces flares).
Sulfasalazine causes reversible oligospermia (80% of men) - switch to mesalazine 3 months before conception. Also causes folate deficiency (co-prescribe folic acid) and turns urine orange.
Loperamide is contraindicated in bloody/inflammatory diarrhoea - it slows pathogen clearance and risks toxic megacolon. Safe for watery non-inflammatory diarrhoea only.
First-dose hypotension with ACE inhibitors is commonest in patients on high-dose diuretics - withhold/reduce diuretic first. Start low, go slow. Expect up to 30% creatinine rise (stop if >50%).
Iron overdose is treated with IV desferrioxamine - activated charcoal is ineffective. The "latent phase" of apparent recovery is deceptive; systemic toxicity follows 12-48 hours later.
HIET is the definitive treatment for severe CCB overdose - insulin acts as a positive inotrope by restoring myocardial glucose utilisation. IV calcium is a temporising first-line measure.
ESA target Hb is 100-120 g/L - overcorrection increases cardiovascular events and hypertension. Monitor BP closely during ESA therapy and maintain adequate iron stores for optimal response.
Valproate causes NTDs (6-7%), major malformations (10%), and neurodevelopmental disorders (30-40%) - the Pregnancy Prevention Programme mandates effective contraception and annual specialist review for all women of childbearing potential.
Anaphylaxis: adrenaline 500mcg IM (1:1000) into the anterolateral thigh - repeat every 5 minutes. IV adrenaline requires 1:10,000 dilution in much smaller doses by experienced clinicians only.
Avoid opioids, NSAIDs, and sedatives in severe liver disease - all accumulate and can precipitate encephalopathy or bleeding. Paracetamol ≤2g/day is the safest analgesic in cirrhosis.
In thrombotic APS, use warfarin with a target INR of 2.0-3.0 for life - DOACs are contraindicated, especially in triple-positive disease (TRAPS trial), and a strongly positive lupus anticoagulant can spuriously affect point-of-care INR monitoring, so laboratory INR or chromogenic factor X may be needed.
LMWH is the only safe anticoagulant in pregnancy. Warfarin causes embryopathy. DOACs are contraindicated. Treat for remainder of pregnancy plus 6 weeks postpartum (minimum 3 months total).
MetHb = Fe3+ cannot carry oxygen. Cyanosis unresponsive to O2 with SpO2 ~85%. Chocolate-brown blood. Treat with IV methylene blue. Contraindicated in G6PD deficiency.
T315I = gatekeeper mutation resistant to all TKIs except ponatinib. Rising BCR-ABL transcripts mandate mutation analysis. Ponatinib effective but carries arterial thrombotic risk. Asciminib is a novel alternative.
Factor XIII deficiency = all clotting tests normal + delayed bleeding. Umbilical stump bleeding is classic. High ICH risk. Diagnose with urea clot solubility test. Factor XIII cross-links fibrin AFTER clot formation.
ITP: diagnosis of exclusion; isolated thrombocytopenia + normal coagulation + large platelets on film. No splenomegaly. Check: HIV, HCV, H. pylori, ANA. Bone marrow: not routine (consider if >60 or atypical). Treatment: only if platelets <30 or bleeding.
FIP1L1-PDGFRA fusion = clonal eosinophilic neoplasm. Low-dose imatinib is curative. Cardiac involvement (Loeffler endocarditis) is the major cause of morbidity/mortality. Always check for PDGFRA before starting steroids.
Unicentric CD = single site, hyaline vascular type, cured by excision. Multicentric CD = systemic, IL-6 driven, associated with HHV-8/HIV. Siltuximab (anti-IL-6) for idiopathic MCD.
Cold agglutinins = IgM antibodies, DAT positive for C3d only. Steroids and splenectomy do not work. Rituximab is first-line. Distinguish from warm AIHA (IgG, responds to steroids).
Lymphocytosis ≥5 × 10⁹/L + CD5+/CD19+/CD23+/CD20-weak + smear cells = CLL (iwCLL 2018); Binet A → watch and wait, treat only when symptomatic or marrow failure; check TP53/IGHV before therapy (NICE TA689, BSH).
5-10% of AIHA is DAT-negative. Causes include low-density IgG, IgA antibodies, and low-affinity antibodies. If clinical features are compelling, treat empirically. Flow cytometric DAT is most sensitive. Always exclude PNH and HS.
UFH needs APTT monitoring (4-6 hourly, target 1.5-2.5x). LMWH doesn't usually need monitoring except in renal failure, extremes of weight, or pregnancy (use anti-Xa). UFH preferred when rapid reversal needed.
Ring sideroblasts = iron trapped in mitochondria. MDS-RS is the most common acquired cause. SF3B1 mutation in >80% (favourable prognosis). Iron overload despite anaemia. Luspatercept for transfusion-dependent disease.
Haemophilia A = factor VIII deficiency, X-linked, with a prolonged APTT and normal PT - treat bleeds and give prophylaxis with factor VIII or emicizumab via a haemophilia centre, and reserve DDAVP for mild disease (UKHCDO guidance).
Leukaemoid reaction = reactive WCC >50 with identifiable cause. High LAP score, toxic granulation, no basophilia, BCR-ABL negative. CML has low LAP, basophilia, and is BCR-ABL positive.
Massive splenomegaly = myelofibrosis, CML, hairy cell leukaemia, visceral leishmaniasis, Gaucher disease. Myelofibrosis is the top haematological cause. Multiple myeloma and aplastic anaemia do NOT cause splenomegaly.
VOC management: analgesia within 30 min (morphine - avoid pethidine), IV fluids (euvolaemia - avoid overhydration), O2 only if SpO2 <95%, fever workup + empirical antibiotics (functional asplenia), monitor for ACS (leading cause of death). Exchange transfusion for ACS/stroke/MOF.
NEVER give folate without excluding B12 deficiency first. Folate corrects anaemia but allows irreversible neurological damage from B12 deficiency to progress. B12 stores last 3-5 years; folate stores only 4 months.
Hodgkin lymphoma: Reed-Sternberg cells (CD15+, CD30+, 'owl eyes'). Bimodal age distribution. Painless lymphadenopathy (cervical). Mediastinal mass in 60-70%. B symptoms: fever, night sweats, weight loss. Alcohol-induced pain: classic for HL. PET-CT for staging (Deauville score). Ann Arbor staging.
MDS = cytopenias + dysplasia + <20% marrow blasts. Pseudo-Pelger-Huët neutrophils and ring sideroblasts are classic. IPSS-R drives therapy; allo-HSCT is the only cure (BSH MDS guideline 2021; ELN 2022).
TPO-RAs stimulate platelet production via c-Mpl receptor. Romiplostim (SC weekly) and eltrombopag (oral daily). Watch for thrombosis and marrow fibrosis. Used in refractory ITP, aplastic anaemia, and hepatitis C thrombocytopenia.
Type II mixed cryoglobulinaemia = monoclonal IgM-RF + polyclonal IgG, strongly linked to hepatitis C. Low C4, normal C3. Treat HCV first. Rituximab for severe vasculitis.
Richter = CLL transforming to aggressive DLBCL. Suspect with rapid LN growth + B symptoms + high LDH. PET-CT shows intense FDG uptake. Excisional biopsy required. Poor prognosis (~6-12 months). Occurs in 5-10% of CLL.
Beta-thalassaemia: reduced/absent β-globin → excess α-chains → ineffective erythropoiesis. Major: presents 6-12 months; HbF 90%+, HbA absent; transfusion-dependent. Trait: microcytosis with mild anaemia; HbA₂ raised (>3.5%); DO NOT treat with iron (unless also iron-deficient).
FNHTR = fever >=1 degree C rise during transfusion. Most common reaction. Always exclude haemolysis and sepsis first. Give paracetamol. Leucodepletion has reduced incidence.
Prothrombin G20210A = elevated factor II levels. 2-3 fold VTE risk (heterozygous). Second most common inherited thrombophilia. Synergistic risk with OCP and Factor V Leiden. Recurrent unprovoked VTE usually warrants lifelong anticoagulation.
LA prolongs APTT in vitro (phospholipid interference) but is prothrombotic in vivo (paradox). Mixing study doesn't correct. Confirm with excess phospholipid. Part of antiphospholipid syndrome. DOACs cause false-positive LA.
Mixing study corrects = factor deficiency. Does not correct = inhibitor. Factor XII deficiency causes prolonged APTT with NO bleeding risk. Always correlate with clinical bleeding history before acting on isolated APTT prolongation.
SOS/VOD = sinusoidal endothelial damage post-conditioning. Triad: tender hepatomegaly + jaundice + weight gain within 21 days of SCT. Defibrotide for severe disease. Busulfan is a key risk factor.
Evans syndrome = AIHA + ITP (± autoimmune neutropenia). DAT positive with thrombocytopenia. More refractory than either alone. Screen for SLE, CLL, CVID. Rituximab is effective second-line.
Adult ALL = TdT+ lymphoblasts. Ph+ ALL (~25% of adults) needs TKI plus chemo. CNS prophylaxis is mandatory. Testicular involvement is a sanctuary site.
MAHA = schistocytes from mechanical fragmentation. Causes: TTP, HUS, DIC, malignant hypertension, HELLP, prosthetic valves. AIHA causes spherocytes (immune-mediated), not schistocytes.
MCL = CD5+/CD23- (CLL is CD5+/CD23+). t(11;14) cyclin D1 overexpression is pathognomonic. Generally aggressive. Check for GI involvement. Ibrutinib for relapsed disease.
Heyde syndrome = severe AS + acquired vWD + GI angiodysplasia. Shear stress destroys HMW vWF multimers. Resolves post-AVR. No family history distinguishes from inherited vWD.
Fondaparinux = synthetic pentasaccharide, selective anti-Xa via antithrombin. Safe in HIT (doesn't bind PF4). Once-daily SC. No reversal agent. Renally cleared.
Low EPO = think PV (primary). Raised EPO = secondary (hypoxia or EPO-secreting tumour). Smoking causes both direct CO-mediated erythrocytosis and COPD-related hypoxic drive.
Sheets of large CD20+ B-cells with a high Ki-67 and rapidly progressive nodal disease point to DLBCL - the most common aggressive NHL - treated first-line with R-CHOP (British Society for Haematology DLBCL guidelines).
Four alpha genes exist. Four deleted = Hb Bart's hydrops fetalis (lethal). Three deleted = HbH disease. Cis configuration (SE Asian) carries risk of hydrops in offspring. Trans (African) does not.
Excisional biopsy is gold standard for suspected lymphoma - preserves architecture. FNAC is inadequate for lymphoma diagnosis. Core biopsy acceptable if excision not feasible. Investigate persistent nodes >6 weeks unresponsive to antibiotics.
vWD - most common inherited bleeding disorder; normal platelets, normal PT, variable APTT. A vWF:RCo/vWF:Ag ratio <0.6 suggests a qualitative (type 2) defect; DDAVP is contraindicated in type 2B.
Aplastic anaemia = pancytopenia + hypocellular marrow + low reticulocytes. Severe if neutrophils <0.5. Allo-SCT if young with sibling donor; otherwise ATG + ciclosporin.
HS = DAT-negative spherocytosis + family history. EMA binding test is first-line diagnosis. Splenectomy cures anaemia. Watch for parvovirus B19 aplastic crises.
Acquired haemophilia = elderly + sudden severe bleeding + prolonged APTT + failure to correct on mixing. Bypass agents for bleeding, immunosuppression to eradicate inhibitor. 20% mortality.
T-LGL leukaemia = CD8+ cytotoxic T-cell clonal expansion. Associated with RA (overlaps Felty syndrome). Causes neutropenia via Fas/FasL-mediated killing. Treat with methotrexate. Indolent course.
Glanzmann = GPIIb/IIIa deficiency. Absent aggregation to ALL agonists EXCEPT ristocetin. Normal platelet count. Bernard-Soulier = GPIb deficiency, absent ristocetin aggregation, giant platelets.
Neutropenic sepsis: medical emergency. Antibiotics within 60 MINUTES (door-to-needle). Piperacillin-tazobactam (Tazocin): NICE first-line. Anti-pseudomonal cover essential. Blood cultures BEFORE antibiotics (but don't delay). Signs of infection may be absent in neutropenia.
Sickle cell trait is usually benign but carries risks of renal medullary carcinoma, hyposthenuria, splenic infarction at altitude, and exertional rhabdomyolysis. Safe for anaesthesia with standard precautions. Genetic counselling for reproduction.
Venetoclax inhibits BCL-2 → rapid CLL apoptosis → high TLS risk. Mandatory 5-week ramp-up. Hydration and allopurinol essential. Monitor bloods intensively during initiation.
Burkitt lymphoma is highest TLS risk. Rasburicase for high-risk (converts uric acid to allantoin). Avoid in G6PD deficiency. Aggressive hydration essential. Do NOT alkalinise urine.
AL amyloid = light chain deposition. Congo red with apple-green birefringence. Cardiac involvement determines prognosis. Low-voltage ECG with thick walls is classic. Treat the plasma cell clone.
HH: C282Y homozygosity (HFE gene); most common genetic disorder in Northern Europeans. Transferrin saturation: best screening test (>45%). Ferritin reflects total body iron.
Anti-Xa level (drug-calibrated) measures apixaban/rivaroxaban. Standard PT/APTT unreliable. Stop apixaban 24-48 hours pre-surgery. PCC or andexanet alfa for urgent reversal.
CKD anaemia = EPO deficiency. Optimise iron first (IV iron, ferritin >200, TSAT >20%). ESA target Hb 100-120 (NOT higher). Avoid over-correction - increased CV risk.
HCL = hairy cells + monocytopenia + massive splenomegaly without lymphadenopathy. BRAF V600E in 100%. Cladribine single course achieves CR in >80%. One of the most treatment-responsive haematological malignancies.
Hydroxyurea increases HbF, reduces crises by 50%, and improves survival in sickle cell disease. Monitor FBC for neutropenia. Macrocytosis confirms adherence. Teratogenic.
Schistocytes = mechanical fragmentation (TTP, HUS, DIC, MAHA). Always correlate blood film with clinical context. TTP = schistocytes + thrombocytopenia + normal PT/APTT. DIC = schistocytes + prolonged PT/APTT.
HbSC = HbS + HbC compound heterozygote. Milder haemolysis than HbSS but more retinopathy and AVN. Spleen persists into adulthood. Target cells and HbC crystals on film. Not benign - all sickle complications can occur.
HIT Type II: immune-mediated (anti-PF4/heparin IgG). PROTHROMBOTIC (not a bleeding disorder). Timing: 5-14 days. Platelet drop >50%. Thrombosis in 30-50%. 4Ts score: pre-test probability. STOP ALL HEPARIN. Start alternative anticoagulant (argatroban, fondaparinux).
Macrocytic anaemia + hypersegmented neutrophils + low B12 + anti-IF antibodies = pernicious anaemia; treat with lifelong IM hydroxocobalamin per BNF/BSH and never give folate alone if B12 is low.
Ibrutinib inhibits BTK, disrupting CLL cell homing. Redistribution lymphocytosis is expected (rising blood count with shrinking nodes = response, not failure). Watch for AF and bleeding.
TRALI = non-cardiogenic pulmonary oedema within 6 hours. Hypotension and normal BNP distinguish from TACO. Leading cause of transfusion death in UK. Supportive care; no diuretics.
DIC: consumptive coagulopathy with simultaneous thrombosis AND bleeding. Diagnosis: low platelets + prolonged PT/APTT + low fibrinogen + very high D-dimer + schistocytes on film. Most common cause: sepsis. Treat the underlying cause (MOST IMPORTANT).
TTP = MAHA + thrombocytopenia + NORMAL coagulation; ADAMTS13 <10%; treat empirically with urgent plasma exchange + steroids + caplacizumab (BSH 2023); rituximab reduces relapse; AVOID platelet transfusion.
DAT with IgG = warm AIHA (37 degrees C, extravascular, spleen). C3d only = cold AIHA (IgM-mediated). IgG + C3d = warm AIHA with complement activation (more severe). Spherocytes on film are from partial macrophage phagocytosis.
Reed-Sternberg cells ('owl-eye' nuclei) in a mixed inflammatory background = classical Hodgkin lymphoma; confirm with an excisional lymph node biopsy.
Dysfibrinogenaemia = normal fibrinogen antigen but low functional fibrinogen (Clauss). Prolonged thrombin time. Can cause bleeding OR thrombosis (or be asymptomatic). Discrepancy between functional and antigenic levels is the key diagnostic clue.
Gastric MALToma = H. pylori driven. Eradicate H. pylori first - 60-80% lymphoma regression. t(11;18) predicts eradication failure. Serial endoscopy monitoring. Antibiotics can cure a cancer.
Waldenstrom = IgM paraprotein + lymphoplasmacytic marrow infiltrate + MYD88 L265P. Hyperviscosity treated with urgent plasmapheresis. IgM is the culprit - large pentameric molecule.
Typical HUS = STEC (E. coli O157) in children. Do NOT give antibiotics (increases toxin release). Supportive care. Atypical HUS = complement-mediated, treat with eculizumab.
Major bleeding on warfarin = stop warfarin, give IV vitamin K 5 mg and four-factor PCC (25-50 IU/kg); reserve FFP for when PCC is unavailable.
G6PD deficiency = bite cells + Heinz bodies after oxidant exposure. DAT negative. G6PD assay may be falsely normal during crisis - retest at 3 months. Avoid sulphonamides, primaquine, dapsone.
Non-resolving pneumonia in smokers requires urgent CT and 2-week wait cancer referral - always arrange 6-week follow-up CXR for all pneumonias to exclude underlying malignancy.
Low-risk PE (sPESI 0, normal RV, normal biomarkers) can be managed as an outpatient with a DOAC - rivaroxaban or apixaban are first-line per NICE NG158.
BTS 2015: ambulatory O₂ requires desaturation to <90% on exertion AND demonstrable benefit on a comparative walk test (≥30 m increase or ≥1-point Borg fall). AMBOX trial: desaturation alone does not predict benefit.
In confirmed occupational asthma, early and complete removal from the causative allergen is the single most important intervention - respiratory protective equipment alone is inadequate, and the BTS/SIGN asthma guideline recommends specialist occupational respiratory referral with reporting via SWORD.
Submassive PE (haemodynamically stable with RV dysfunction + elevated troponin) - anticoagulate with UFH in HDU, ready for rescue thrombolysis if deterioration occurs.
BTS 2015 pulmonary nodule guidelines requires Herder model. Always consider the clinical context and guideline-directed management.
in pregnancy, treat asthma as you would in any adult - inhaled corticosteroids are far safer than uncontrolled disease.
Light's criteria can misclassify a cardiac transudate as an exudate in patients on diuretics - use the serum-to-pleural albumin gradient (>12 g/L) or pleural fluid NT-proBNP (>1500 pg/mL) to confirm a transudative, cardiac cause.
Wells score ≤4 (PE unlikely) - check D-dimer first; if negative, PE is excluded; if positive, proceed to CTPA.
Suspected MSCC = IV dexamethasone 16 mg + whole-spine MRI within 24 hours + urgent MSCC coordinator referral (NICE CG75). Ambulatory status at the time of treatment is the strongest predictor of post-treatment function.
In suspected PE in pregnancy - start with leg Doppler, then CTPA; D-dimer is unreliable in pregnancy; fetal radiation from CTPA is negligible.
In HIT - stop ALL heparin AND warfarin; start argatroban; never transfuse platelets; only restart warfarin when platelets >150 × 10⁹/L.
Varenicline is the most effective single pharmacotherapy for smoking cessation - always offer with behavioural support; it is the cornerstone of COPD management.
Antibiotics are indicated in COPD exacerbations when purulent sputum is present - amoxicillin 500mg TDS for 5 days is first-line per NICE guidelines.
BTS LTOT guidelines requires ≥15 hours/day. Always consider the clinical context and guideline-directed management.
Solid pulmonary nodules >8mm with growth should be assessed with PET-CT and discussed at MDT - use Brock and Herder models to stratify malignancy risk.
Always confirm AATD with phenotyping/genotyping before starting augmentation therapy - test all COPD patients diagnosed before age 45 or with a family history.
Apixaban is the preferred DOAC in severe renal impairment due to lowest renal clearance (~27%) - it can be used down to eGFR 15 ml/min without routine dose adjustment for renal function alone.
Offer elexacaftor/tezacaftor/ivacaftor (Kaftrio) to CF patients aged >=6 years with at least one F508del allele; monitoring includes baseline and periodic LFTs, ophthalmic (cataract) screening, and mental health review for depression or suicidal ideation.
coal workers' pneumoconiosis (CWP) requires IIDB. Always consider the clinical context and guideline-directed management.
Legionella pneumophila requires IV macrolide (azithromycin). Always consider the clinical context and guideline-directed management.
In severe COPD with a chronic bronchitic phenotype and frequent exacerbations despite optimised triple therapy, add roflumilast (a PDE4 inhibitor) - monitor for weight loss, GI upset, and mood disturbance, and avoid it in significant hepatic impairment.
Severe hypercalcaemia of malignancy - rehydrate first with IV saline, then give IV zoledronic acid; furosemide is no longer recommended for calciuresis.
Refer COPD patients to pulmonary rehabilitation within 4 weeks of hospital discharge (NICE NG115 / QS10) - halves readmission risk (NNT ≈4) and improves exercise capacity and quality of life; standard course is 6-8 weeks of supervised exercise twice weekly.
Cough syncope is a situational reflex syncope - forceful coughing raises intrathoracic pressure, drops venous return and causes transient cerebral hypoperfusion.
In AECOPD with type 2 respiratory failure, NIV should be initiated if pH remains <7.35 after 1 hour of optimal medical therapy - do not escalate prematurely if the patient is improving.
Unexplained haemoptysis in a smoker aged ≥40 mandates an urgent 2-week-wait suspected lung cancer referral with CT thorax ± flexible bronchoscopy - up to 5-10% of lung cancers have a normal CXR (NICE NG12; BTS Lung Cancer Guideline; NICE NG122).
Respiratory bronchiolitis-associated ILD (RB-ILD) requires smoking cessation. Always consider the clinical context and guideline-directed management.
lymphocytic interstitial pneumonia (LIP) requires corticosteroids ± azathioprine or mycophenolate. Always consider the clinical context and guideline-directed management.
Cancer-associated VTE - DOACs (edoxaban/rivaroxaban) are alternatives to LMWH; avoid DOACs in GI tract cancers due to increased bleeding risk; anticoagulate for at least 6 months.
Extensive-stage SCLC is now treated with immunochemotherapy (atezolizumab/durvalumab plus carboplatin-etoposide) based on IMpower133/CASPIAN trial data.
tezepelumab (anti-TSLP) is the only asthma biologic with proven efficacy across all inflammatory phenotypes, making it the biologic of choice in non-eosinophilic, low-FeNO severe asthma (NAVIGATOR trial; NICE TA880).
When anticoagulation is absolutely contraindicated in acute PE (e.g., recent ICH), insert a retrievable IVC filter - plan removal when anticoagulation becomes safe.
MSCC requires immediate IV dexamethasone 16mg and urgent whole-spine MRI - the patient's ambulatory status at treatment onset is the strongest predictor of outcome.
When NIV fails to improve pH/PaCO2, increase IPAP in 2-5 cmH2O increments to augment tidal volume - optimise settings before considering intubation.
Consider home NIV in stable COPD patients with persistent hypercapnia (PaCO2 >7 kPa) after recurrent acute NIV - the HOT-HMV trial showed improved survival.
Incidental segmental PE in cancer patients should be treated with therapeutic anticoagulation - same as symptomatic PE; do not delay cancer treatment.
In COPD patients with frequent exacerbations and blood eosinophils ≥300 cells/µL, escalate to triple therapy (LABA/LAMA/ICS) - eosinophil count guides ICS use.
Tezepelumab (anti-TSLP) acts upstream at the airway epithelium, so it is the biologic to consider in severe asthma that is pauci-inflammatory or has failed eosinophil-directed therapy (NICE TA880; NAVIGATOR trial).
MDR-TB needs an individualised DST-guided regimen (now often a shorter all-oral BPaL/BPaLM course) under a specialist service, with negative-pressure isolation, notification and contact tracing - never standard or higher-dose RIPE. (WHO 2022; NICE NG33.)
COPD with FEV1 >40% predicted and no hypercapnia generally indicates acceptable risk for non-cardiothoracic surgery - optimise inhalers, favour the laparoscopic approach, and avoid unnecessary cancellation.
CURB-65 score 0-1 = mild CAP managed in the community with oral amoxicillin 500mg TDS for 5 days - always arrange 6-week follow-up CXR.
CURB-65 ≥3 indicates severe CAP requiring hospital admission; a score of 4-5 warrants ITU/HDU consideration with IV dual antibiotic therapy covering typical and atypical organisms.
DOACs are contraindicated in antiphospholipid syndrome - warfarin is the anticoagulant of choice; the TRAPS trial showed increased thrombosis with rivaroxaban in APS.
Lobectomy is standard of care for Stage I NSCLC - assess fitness using ppoFEV1, ppoDLCO, and VO2 max; SABR is reserved for medically inoperable patients.
In moderate-severe PJP (PaO2 <9.3 kPa), adjunctive corticosteroids with co-trimoxazole improve survival - delay ART for 2 weeks to reduce IRIS risk.
Refer for pulmonary rehabilitation per NICE NG115 in COPD if MRC ≥3 - current smoking, stable cardiac disease, MRC 4-5, and recent exacerbation are NOT contraindications. Commence post-exacerbation PR within 4 weeks of discharge to reduce readmission.
Dupilumab (anti-IL-4Rα) blocks IL-4/IL-13 signalling and uniquely treats severe eosinophilic asthma, chronic rhinosinusitis with nasal polyps, and atopic dermatitis together - the preferred biologic when several type 2 conditions coexist (NICE TA751 for severe asthma).
Tension pneumothorax is a clinical diagnosis - perform immediate needle decompression; NIV is contraindicated in pneumothorax.
Small airways disease - normal FEV1/FVC but reduced FEF25-75, mildly raised RV, and elevated R5-R20 on impulse oscillometry; the 'silent zone' of the lungs; in smokers represents early COPD - smoking cessation is the most important intervention per NICE NG115.
ABPA = asthma/CF + total IgE >1000 + Aspergillus-specific IgE/IgG + central bronchiectasis + eosinophilia.
Cardiac sarcoidosis requires ICD implantation. Always consider the clinical context and guideline-directed management.
CTEPH is a curable form of pulmonary hypertension - refer all patients for pulmonary endarterectomy assessment; V/Q scan is the screening investigation of choice.
Osimertinib is first-line for EGFR-mutant NSCLC (FLAURA trial) - always request molecular testing in adenocarcinoma; EGFR-mutant tumours respond poorly to immunotherapy.
ATS/ERS 2019 acceptable spirometry - good start (BEV <5% FVC or <150 mL), no cough in the first second, exhalation ≥6 seconds or plateau; minimum three acceptable efforts with the two largest FVCs and two largest FEV1s within 150 mL; report the largest FVC and the largest FEV1 (may be from different efforts).
PD-L1 TPS ≥50% requires KEYNOTE-024 trial. Always consider the clinical context and guideline-directed management.
EBVs for severe heterogeneous emphysema with absent collateral ventilation (confirm by Chartis or CT fissure analysis). NICE IPG712 / BTS 2019. LIBERATE & EMPROVE: ~+15-29% FEV1. Pneumothorax in ~25% - main complication; observe for 72 h.
Around 98% of males with CF have obstructive azoospermia from CBAVD - biological children are achievable via surgical sperm retrieval plus IVF/ICSI, and the partner should undergo CFTR carrier testing before conception (NICE NG78; UK CF Trust standards of care).
Symptomatic nocturnal hypoventilation in neuromuscular disease is treated with nocturnal non-invasive ventilation, not oxygen alone (which suppresses respiratory drive and worsens CO2 retention); a supine FVC fall >25% indicates diaphragmatic weakness (BTS guideline on respiratory management of patients with neuromuscular weakness).
Before labelling a patient as severe asthma and starting biologics, confirm adherence (objective measures), inhaler technique, diagnosis and treat comorbidities (obesity, GORD, vocal cord dysfunction, OSA, rhinitis).
Cor pulmonale in COPD = WHO Group 3 PH. Optimise LTOT ≥15 h/day (MRC/NOTT) - only proven survival benefit. Cautious low-dose diuretics. Consider home NIV if hypercapnic despite LTOT (HOT-HMV trial). Avoid PAH-targeted drugs in Group 3.
Severe osteoporosis with fragility fractures + COPD on high-dose ICS + recurrent oral steroids → IV zoledronate + calcium/vitamin D + ICS dose review + falls assessment + smoking cessation, per NOGG 2021 and NICE TA464. Teriparatide (TA161) if bisphosphonate failure.
In cor pulmonale secondary to COPD, LTOT ≥15 hours/day is the only treatment shown to improve survival - avoid pulmonary vasodilators in WHO Group 3 pulmonary hypertension.
TNM 8 - separate nodule in a different ipsilateral lobe = T4 (not M1a). Mediastinal-organ invasion = T4. Stage IIIB unresectable NSCLC → chemoradiotherapy + adjuvant durvalumab (NICE NG122, PACIFIC).
LTOT assessment is indicated when resting PaO2 ≤7.3 kPa - confirm with two stable measurements 3 weeks apart; pulmonary rehabilitation should be offered to all COPD patients with MRC ≥3.
inducible laryngeal obstruction (ILO) requires continuous laryngoscopy during exercise (CLE). Always consider the clinical context and guideline-directed management.
Chronic fibrotic HP - upper-lobe fibrosis with ongoing antigen exposure; manage with strict antigen avoidance, corticosteroids for inflammatory component, and nintedanib if progressive (INBUILD trial, NICE TA747); pirfenidone is IPF-only; transplant for end-stage disease.
Nintedanib is a tyrosine kinase inhibitor (VEGFR/FGFR/PDGFR) that slows FVC decline in IPF; manage diarrhoea with loperamide, monitor LFTs, and dose-reduce to 100mg BD if diarrhoea or transaminitis persists rather than stopping at the first side effect.
Secondary polycythaemia in COPD is treated by correcting hypoxia with LTOT - venesection is only a temporary measure for acute symptomatic hyperviscosity.
After two negative pleural fluid cytologies in a suspected malignant exudate, the next step is medical (LAT) thoracoscopy - high diagnostic yield, allows simultaneous talc pleurodesis, performed under local anaesthetic (BTS pleural disease guidelines 2023).
Sjogren = anti-Ro/anti-La + dry eyes/mouth. 5-10% lifetime lymphoma risk (MALT lymphoma). Watch for persistent parotid swelling and falling immunoglobulins. Pilocarpine for dry mouth. Hydroxychloroquine for fatigue.
EAMs are commonest in seropositive, erosive, nodular RA. RA-ILD (UIP pattern) is a major cause of mortality. Felty syndrome = RA + splenomegaly + neutropenia. Secondary Sjögren occurs in ~30%. RA doubles cardiovascular mortality risk.
RV = longstanding seropositive RA + digital infarcts + mononeuritis multiplex + scleritis + purpura. High RF, male, smoker, nodules are risk factors. Treat with cyclophosphamide + glucocorticoids. Declining incidence with modern RA management.
Bone loss is fastest in the first 3-6 months of steroid therapy. Start bisphosphonate and calcium/vitamin D at the same time as glucocorticoids for at-risk patients. Do not wait for osteoporotic T-scores. Postmenopausal women on high-dose steroids need treatment.
Class IV lupus nephritis requires induction with MMF or cyclophosphamide plus glucocorticoids. MMF is preferred in Afro-Caribbean patients. Hydroxychloroquine should never be stopped. Azathioprine is for maintenance, not induction.
hEDS = joint hypermobility + recurrent dislocations + skin hyperextensibility + chronic pain + autonomic dysfunction. Beighton score >=5/9. Physiotherapy is the cornerstone of management. Screen for PoTS. Distinguish from vascular EDS (life-threatening).
PsA = dactylitis + enthesitis + DIP involvement + nail changes. Five clinical patterns. Methotrexate first-line for peripheral disease. Avoid hydroxychloroquine. Anti-TNF, anti-IL-17, or JAK inhibitors for refractory disease.
Felty syndrome = RA + neutropenia + splenomegaly. Treat the underlying RA - methotrexate first-line. Rituximab for refractory cases. G-CSF for acute severe infection. Exclude LGL leukaemia. Splenectomy is last resort.
Osteomalacia = low Ca, low PO₄, raised ALP, raised PTH, Looser zones. Myeloma = raised Ca, normal ALP, lytic punched-out lesions. Paget = normal Ca, very raised ALP, mixed lytic/sclerotic changes.
Febuxostat is preferred ULT in significant CKD as it does not require renal dose adjustment. Target urate <300 micromol/L in tophaceous gout. Probenecid is ineffective at eGFR <30. Avoid NSAIDs in CKD. Corticosteroids are safest for acute flares.
Corticosteroids are the most common non-traumatic cause of AVN. MRI is gold standard - X-rays are often normal early. Double-line sign on T2 MRI is pathognomonic. Core decompression for early disease. THR for post-collapse.
AAU in SpA is HLA-B27 associated. Monoclonal anti-TNF antibodies (adalimumab, infliximab) are superior to etanercept for uveitis prevention. Switch from etanercept to adalimumab for recurrent uveitis. IL-17 inhibitors do not prevent uveitis. Urgent ophthalmology for acute episodes.
Septic arthritis = WCC >50,000/microL with >90% neutrophils, positive Gram stain, low glucose, and raised LDH - joint washout plus IV flucloxacillin (vancomycin if MRSA risk) per BSR/BNF guidance, and culture all suspected crystal arthropathies before steroid injection.
Inactivated vaccines (influenza, pneumococcal, COVID-19, Shingrix, hepatitis B) are safe and recommended on immunosuppression. Live vaccines (yellow fever, MMR, BCG, live varicella, LAIV, oral typhoid) are contraindicated. Provide a yellow fever exemption letter for travellers.
DM in adults >40 = screen for malignancy (15-30% within 3 years). Anti-TIF1-gamma = highest malignancy risk. Anti-MDA5 = rapidly progressive ILD. Anti-Jo-1 = antisynthetase syndrome.
Rituximab is superior to azathioprine for AAV maintenance (MAINRITSAN). PR3-ANCA/GPA patients have the highest relapse risk and benefit most. Monitor immunoglobulins. Maintenance duration should be at least 24-48 months.
T2T aims for remission (DAS28 <2.6) or low disease activity (≤3.2). Assess every 1-3 months until target reached. Escalate csDMARDs before biologics. Biologics require failure of ≥2 csDMARD strategies and DAS28 ≥3.2 on two occasions.
AA amyloidosis results from chronic inflammation driving SAA overproduction. Renal involvement (nephrotic syndrome) is the most common presentation. Congo red with apple-green birefringence is diagnostic. Target SAA <10 mg/L through aggressive inflammatory disease control.
Vertebral fractures require full osteoporosis assessment including DEXA and a secondary cause screen. Initiate a bisphosphonate without waiting for DEXA in patients >=75 with a fragility fracture. Multiple vertebral fractures indicate severe osteoporosis. Early mobilisation improves outcomes.
SSc-ILD: anti-Scl-70 is the strongest risk factor. Mycophenolate is first-line (SLS II trial). Nintedanib slows FVC decline (SENSCIS trial). Avoid high-dose steroids in dcSSc. Combination MMF + nintedanib for progressive disease.
DISH = flowing anterior ossification >=4 contiguous vertebrae + preserved discs + no sacroiliitis (Resnick and Niwayama criteria). Associated with metabolic syndrome and type 2 diabetes. Right-sided thoracic predominance (aorta protects left). Dysphagia from cervical osteophytes.
TPMT testing is mandatory before azathioprine. Absent TPMT = absolute contraindication (fatal myelosuppression risk). Intermediate TPMT = reduced dose. Allopurinol inhibits xanthine oxidase and dramatically increases toxicity. Monitor FBC closely after initiation.
HRCT is the gold standard for characterising ILD pattern. NSIP is the most common CTD-ILD pattern. Screen high-risk CTDs with baseline HRCT and PFTs. Declining FVC or DLCO indicates progression. Mycophenolate is first-line for SSc-ILD.
GI involvement affects 90% of SSc patients. Oesophageal dysmotility with reduced LOS pressure is most common. SIBO causes malabsorption. Wide-mouth colonic diverticula are characteristic. Aggressive PPI and nutritional support are key management priorities.
Alendronate 70mg weekly is first-line. Take upright, empty stomach, plain water. Add calcium + vitamin D. Denosumab or IV zoledronate if intolerant. Teriparatide for severe cases only.
IgG4-RD = tumour-like masses + storiform fibrosis + IgG4+ plasma cells + obliterative phlebitis. Mimics cancer (pancreatic, biliary). Responds to steroids but often relapses. Rituximab for refractory disease.
Jaccoud arthropathy = deforming but reducible and non-erosive. Passively correctable deformities distinguish it from RA. Hook-like osteophytes on metacarpal heads are characteristic radiologically. Caused by capsular/ligamentous laxity from recurrent synovitis. No bony erosions on X-ray.
Tocilizumab is first-line steroid-sparing therapy in GCA (GiACTA trial). It suppresses CRP, so this marker becomes unreliable. Monitor for infection, GI perforation, and lipids. BSR/EULAR recommend it for relapsing or steroid-dependent GCA.
MPA = p-ANCA/anti-MPO + pulmonary-renal syndrome without granulomata or ENT disease. Pauci-immune crescentic GN on biopsy. Treatment identical to GPA. Distinguished from anti-GBM by pauci-immune pattern.
Negatively birefringent needle crystals = gout. Colchicine low-dose is preferred to high-dose. Avoid NSAIDs in CKD. Prednisolone is a safe alternative. Start ULT after acute attack resolves. Target urate <360.
Methotrexate is first-line DMARD in RA. Give with folic acid. Monitor FBC/LFTs. Anti-CCP is highly specific for RA. Treat-to-target strategy aims for remission or low disease activity.
APS with thrombosis = lifelong warfarin (INR 2-3). DOACs are inferior (TRAPS trial). Obstetric APS = aspirin + LMWH. Lupus anticoagulant is the strongest predictor of thrombosis. Triple positivity = highest risk.
PET-CT detects active vessel-wall inflammation before structural damage; image before steroids (BSR 2020, EULAR 2018); up to 50-80% of GCA has extra-cranial LVV; key cause of FUO; not for temporal/intracranial arteries.
TNF inhibitors can cause or unmask CNS demyelination. TNF-alpha is paradoxically protective in the CNS. Stop the anti-TNF permanently - do not switch to another anti-TNF agent. Urgent neurology referral. Use non-TNF biologics for ongoing RA management (rituximab, tocilizumab, abatacept).
MTX pneumonitis is a hypersensitivity reaction - not dose-related. Stop MTX permanently. Treat with high-dose steroids. Never rechallenge. Distinguish from infection (PCP) and RA-ILD.
Secondary anti-TNF failure with anti-drug antibodies warrants switching mechanism of action, not cycling anti-TNFs. Rituximab is preferred in seropositive RA. Concomitant methotrexate reduces immunogenicity. JAK inhibitors offer oral alternatives to injectable biologics.
Rheumatoid nodules occur in seropositive RA over pressure points. Histology shows palisading granulomata with fibrinoid necrosis. Methotrexate may accelerate nodulosis. Distinguish from tophi (raised urate) and xanthomata (raised cholesterol). Normal urate and lipids point to RA nodules.
Active RA (DAS28 of 5.1 or above) that has failed two csDMARDs warrants a TNF-alpha inhibitor plus methotrexate as first-line biologic therapy under NICE NG100/TA375.
Charcot joint = painless destruction in a neuropathic joint. Diabetes is the commonest cause. Acute Charcot foot mimics infection - hot, swollen, red. Total contact casting is the key treatment. Distinguish from osteomyelitis. Rocker-bottom foot deformity is characteristic.
CPPD = positively birefringent rhomboid crystals. Chondrocalcinosis on X-ray. Knee is most common joint. Screen young patients for metabolic causes (PTH, ferritin, magnesium). No long-term crystal-dissolving therapy exists.
20-30% of RA is seronegative. Erosions in typical RA distribution confirm diagnosis regardless of serology. 2010 ACR/EULAR criteria allow RA classification without positive serology. Treat identically to seropositive RA - do not delay DMARDs. Ultrasound aids early diagnosis.
NPSLE = inflammatory (treat with immunosuppression) vs thrombotic (treat with anticoagulation). Anti-ribosomal P associated with NPSLE psychosis. IV methylprednisolone + cyclophosphamide for severe cerebritis. Always exclude infection.
Test HLA-B*5801 before starting allopurinol in Southeast Asian, Korean, African American, and Thai patients. Positive result = absolute contraindication. AHS presents 2-8 weeks after starting with fever, rash, eosinophilia, and organ involvement.
Paget = elevated ALP with normal calcium. IV zoledronic acid is first-line treatment. Osteosarcoma is the most feared complication. Deafness from skull involvement. High-output cardiac failure with extensive disease.
Asymptomatic hyperuricaemia does not require ULT - only symptomatic gout or urate complications warrant pharmacological treatment. Address reversible causes (thiazides, alcohol, diet, obesity). Only ~5% of hyperuricaemic individuals develop gout per year.
Denosumab cessation causes rebound bone loss and vertebral fracture risk. Effects reverse within 12-18 months. Transition to bisphosphonate is mandatory. Never stop abruptly. Highest risk in those with prior vertebral fractures.
Nifedipine is first-line for Raynaud. Secondary Raynaud requires full autoimmune and capillaroscopy workup. Digital ulcers in SSc may need IV iloprost or bosentan. Avoid beta-blockers. Non-pharmacological measures are foundational.
AAS occurs in up to 50% of longstanding RA. Assess cervical spine before GA in all RA patients. AADI >3mm is abnormal. MRI for cord compression. Neurosurgical referral if myelopathy or cord signal change. Fibreoptic intubation required.
RA-ILD with a UIP pattern has the worst prognosis; rheumatoid pleural effusions have characteristically low glucose; pulmonary nodules may cavitate; Caplan syndrome = RA + pneumoconiosis; always distinguish chronic RA-ILD from acute methotrexate pneumonitis.
Palindromic rheumatism = recurrent episodic arthritis with complete resolution and no joint damage; anti-CCP positive cases carry a 50-60% risk of progressing to RA; hydroxychloroquine reduces attack frequency and may prevent progression.
HCQ retinopathy is irreversible - stop immediately if detected. Dose should be <=5mg/kg/day. Annual OCT screening from 5 years. Risk increases with duration, dose, and renal impairment. Bull's-eye maculopathy is a late finding.
Rising anti-dsDNA + falling complement = lupus flare. Low procalcitonin favours flare over infection. CRP is relatively suppressed in SLE flare (ESR > CRP). Active urinary sediment indicates nephritis. Always consider coexistent infection and send cultures.
AOSD = quotidian fever + salmon-pink rash + arthritis + ferritin >1000 + neutrophilia + negative ANA/RF. Glycosylated ferritin <20% supports diagnosis. Watch for MAS (falling WCC/ESR with rising ferritin). Anakinra (anti-IL-1) for refractory disease.
Early classical pathway deficiency (C1q > C4 > C2) strongly predisposes to SLE. C1q deficiency has >90% SLE penetrance. Mechanism involves impaired immune complex and apoptotic cell clearance. CH50 is zero. Terminal complement deficiency predisposes to Neisseria infections.
Anti-GBM = linear IgG on renal biopsy. Smokers get pulmonary haemorrhage. Triple therapy: plasma exchange + cyclophosphamide + steroids. Treatment is urgent - renal outcome depends on presentation severity. Check for dual ANCA positivity (~30%).
Continue hydroxychloroquine in pregnancy (safe, reduces flares). Stop mycophenolate >=6 weeks before conception, replace with azathioprine. Anti-Ro positive mothers need foetal cardiac monitoring. Plan pregnancies during disease remission. Certolizumab is the safest anti-TNF.
OA core treatments are education, exercise, and weight loss. Topical NSAIDs first-line pharmacological. NICE does not recommend glucosamine or hyaluronic acid. Brief morning stiffness <30 min distinguishes from inflammatory arthritis.
Never stop hydroxychloroquine in pregnancy - it reduces flares and improves outcomes. Azathioprine, prednisolone, and calcineurin inhibitors are pregnancy-safe. Mycophenolate, cyclophosphamide, and methotrexate are teratogenic. Anti-Ro positivity requires foetal cardiac monitoring from 16 weeks.
Chapel Hill classifies by vessel size - large, medium, small, variable. ANCA-associated vasculitis is small-vessel and pauci-immune. PAN is medium-vessel and ANCA-negative. Behcet is variable-vessel. Understanding classification guides investigation and treatment.
Reactive arthritis = sterile arthritis 1-4 weeks post-GU/GI infection. Triad: arthritis + urethritis + conjunctivitis. Keratoderma blennorrhagica and circinate balanitis are characteristic. NSAIDs first-line. Self-limiting in ~50%.
Lofgren syndrome = BHL + erythema nodosum + ankle arthritis. Excellent prognosis - >90% resolve spontaneously. NSAIDs are first-line. Sarcoidosis causes hypercalcaemia via excess vitamin D activation. Non-caseating granulomata on biopsy.
Fibromyalgia = widespread pain + fatigue + sleep disturbance + cognitive dysfunction with normal investigations. Graded exercise and CBT are core management. Amitriptyline, duloxetine, or pregabalin for adjunctive pharmacotherapy. Avoid opioids.
GCA with visual symptoms = IV methylprednisolone immediately. Do not wait for biopsy. Biopsy valid for 2 weeks post-steroids. Tocilizumab for steroid-sparing. Aspirin reduces ischaemic events. Screen for aortic aneurysm.
Homogeneous ANA pattern reflects anti-dsDNA/histone antibodies - most commonly SLE. Speckled = ENAs (Sm, RNP, Ro, La). Centromere = limited SSc. Nucleolar = diffuse SSc. ANA is a screening test - always request specific antibodies for clinical relevance.
HPOA = clubbing + periostitis + synovitis. Most commonly caused by non-small cell lung cancer. Symmetrical periosteal new bone formation on X-ray is characteristic. Treatment is directed at the underlying cause. Resolution after tumour resection confirms the diagnosis.
Screen ALL patients for latent TB before anti-TNF therapy. IGRA + chest X-ray mandatory. Treat LTBI before starting biologic. Screen for hepatitis B/C and HIV. No live vaccines on biologics. Anti-TNF contraindicated in severe heart failure and demyelination.
PAN = ANCA-negative medium-vessel vasculitis. Microaneurysms on angiography. Spares lungs and glomeruli. Testicular pain is characteristic. Screen for hepatitis B. Treat HBV-PAN with antivirals.
Anti-synthetase syndrome = anti-Jo-1 + myositis + ILD + arthritis + mechanic's hands + Raynaud. ILD determines prognosis. NSIP is the most common lung pattern. Treat with corticosteroids + mycophenolate. Rituximab for refractory disease.
CAPS = >=3 organ systems involved within one week with confirmed aPL antibodies. Triple therapy: anticoagulation + steroids + plasma exchange ± IVIG. Infection is the most common trigger. Mortality 30-50%. Triple-positive aPL patients are at highest risk.
JAK inhibitors carry increased MACE, VTE, and malignancy risk (ORAL Surveillance). MHRA restricts use in patients >=65 or with CV/VTE risk factors. Herpes zoster risk - consider vaccination. Monitor FBC, LFTs, and lipids.
RP = recurrent auricular chondritis sparing ear lobes + saddle-nose + airway involvement. Laryngotracheal stenosis is the leading cause of death. No specific autoantibody. High-dose steroids + immunosuppression for severe disease.
Leflunomide inhibits DHODH (pyrimidine synthesis). Teriflunomide persists for up to 2 years without washout. Cholestyramine 8g TDS for 11 days eliminates it. Confirm levels <0.02 mg/L twice before conception. Methotrexate is also teratogenic - not a substitute.
SCC: keratinising nodule + rapid growth + sun-exposed sites. Can metastasise (2-5% overall; higher in immunosuppressed, perineural invasion, poorly differentiated). Transplant recipients: 65-250× risk; SCC is their most common cancer. Switch to sirolimus (mTOR).
Dermatofibroma: firm, brown papule on legs (women). Dimple sign pathognomonic. Dermoscopy: central white patch + peripheral pigment network. Benign - no treatment needed. Multiple (>15) → consider SLE or immunosuppression.
HHT (Osler-Weber-Rendu): AD; endoglin/ALK1 mutations. Curaçao criteria: epistaxis + telangiectasiae + visceral AVMs + family history. Pulmonary AVMs: paradoxical emboli → stroke/brain abscess; screen with bubble echo; treat with embolisation. GI bleeding → iron deficiency anaemia.
PR: herald patch → 1-2 weeks → secondary eruption of oval patches with collarette scale. Christmas tree pattern on back. Self-limiting 6-8 weeks. HHV-6/7 reactivation. ALWAYS exclude secondary syphilis (palms/soles involvement, RPR/TPHA testing). No treatment usually needed.
Onychomycosis: ALWAYS confirm before treating (only 50% of dystrophic nails are fungal). Nail clippings for KOH + culture. Terbinafine first-line oral (6 weeks fingers / 12 weeks toes). Itraconazole for Candida/moulds. PSO pattern → consider HIV. T. rubrum most common cause (90%).
PG: rapidly enlarging painful ulcer + violaceous undermined border + sterile. Pathergy positive (DO NOT debride). Neutrophilic dermatosis. Diagnosis of exclusion. Associated with IBD (UC > Crohn's), haematological disease, RA. Treat: prednisolone + ciclosporin or infliximab.
Telogen effluvium (TE) - recognise the key clinical and investigative features to guide appropriate management.
EBA: anti-collagen VII (anchoring fibrils). Mechanobullous: trauma-prone sites, scarring, milia (like hereditary dystrophic EB). DIF: linear IgG at BMZ; salt-split skin: DERMAL side (vs BP = epidermal side). Associated with Crohn's disease. Often refractory to treatment. Rituximab for refractory.
AKs: premalignant; 5-10% lifetime SCC risk per lesion. Field cancerisation concept. Rough, scaly patches on sun-exposed sites. Cryotherapy for individual lesions.
IBD skin manifestations: EN (most common; correlates with activity; Crohn's > UC), PG (doesn't correlate; UC > Crohn's; peristomal common), aphthous ulcers (Crohn's), metastatic Crohn's (granulomatous skin disease away from GI). Perianal disease in 30-50% of Crohn's.
DH = pruritic herpetiform vesicles on extensors + granular IgA at dermal papillae on DIF + coeliac disease; lifelong gluten-free diet is the only definitive treatment; add dapsone for rapid symptom control after checking G6PD.
Discoid eczema: coin-shaped, well-defined, exudative/crusted plaques. Lower legs, forearms. Intensely pruritic. No central clearing (vs tinea). Potent topical steroids needed (moderate often insufficient). Emollients essential. Secondary infection common (flucloxacillin if needed). Winter worsening.
AGA: most common alopecia. DHT-driven follicular miniaturisation. Male: frontal recession + vertex thinning; occipital spared. Female: diffuse vertex thinning, hairline preserved. Finasteride (5α-reductase inhibitor): first-line for men. Minoxidil: first-line topical for both sexes.
Steroid potency: mild (hydrocortisone) → moderate (Eumovate) → potent (Betnovate) → superpotent (Dermovate). Face: mild-moderate only (short courses); calcineurin inhibitors for long-term. Thin skin = more absorption = more side effects. FTU = 0.5g for dosing. Ointments > creams for efficacy.
Impetigo: S. aureus (most common now) ± GAS. Non-bullous (70%): honey crusts, perioral. Bullous (30%): S. aureus exfoliative toxins cleave Dsg1 → flaccid blisters. Highly contagious → school exclusion 48h. Topical fusidic acid/mupirocin for localised. Oral flucloxacillin for widespread/bullous.
AA: autoimmune non-scarring alopecia. Exclamation mark hairs pathognomonic. 80% spontaneous remission for limited patches. Poor prognosis: AT/AU, ophiasis, childhood onset. Intralesional triamcinolone for limited patches. DPCP contact immunotherapy for extensive.
- common exam question):
Guttate psoriasis = drop-shaped scaly papules on the trunk, triggered by streptococcal pharyngitis 1-3 weeks earlier; check ASOT/anti-DNase B. Often self-limiting (3-4 months) but around one third develop chronic plaque psoriasis. NB-UVB is effective.
Perioral dermatitis: papulopustular eruption around mouth + nose + eyes. Spares vermilion margin (characteristic). No comedones. Caused/worsened by topical steroids on face. Treatment: STOP steroid (warn of rebound) + oral doxycycline/lymecycline 6-8 weeks + topical metronidazole.
Pityriasis versicolor: Malassezia yeast; hypo- or hyperpigmented scaly macules on trunk; KOH: spaghetti and meatballs; Wood's lamp: yellow-gold; topical ketoconazole shampoo or selenium sulfide first-line; itraconazole oral for extensive; NOT terbinafine (ineffective for Malassezia).
NL: bilateral pretibial yellow-brown waxy plaques + telangiectasiae + atrophy + violaceous border. 60-70% have diabetes (but NL does NOT correlate with glycaemic control). Ulceration in 35% (difficult to heal). Histology: full-thickness dermal necrobiosis + layered palisading granulomas.
Stepwise eczema management per NICE CG57: emollients always; mild → hydrocortisone 1%; moderate → moderate-potency TCS (clobetasone); severe → potent TCS short courses. Tacrolimus for face/flexures. Step down once controlled. Refer for systemic therapy (ciclosporin, dupilumab) if refractory.
PEP: most common pregnancy dermatosis. Starts in striae. Spares periumbilical (vs PG which involves it). Primigravida. No fetal risk. DIF negative. Self-limiting postpartum. Topical steroids + emollients. Pemphigoid gestationis: periumbilical blisters, anti-BP180, DIF+, fetal risk, recurs.
PCT: most common porphyria. Dorsal hand blisters + milia + hypertrichosis + hyperpigmentation. UROD deficiency. Triggers: iron overload, alcohol, HCV, oestrogen. Urine: elevated uroporphyrin (pink fluorescence).
HAE: recurrent angioedema WITHOUT urticaria. Bradykinin-mediated (NOT histamine). C4 low at all times (best screening test). Antihistamines/steroids/adrenaline INEFFECTIVE. Acute: C1-INH concentrate or icatibant. Prophylaxis: lanadelumab (anti-kallikrein mAb).
HS is a follicular occlusion disorder, not sweat gland disease. Painful nodules, sinuses and scarring in axillae/groin, with smoking and obesity as major modifiable risks.
Tendon xanthomas = pathognomonic for FH. Xanthelasma: 50% have normal lipids (still check). Eruptive xanthomas = severe hypertriglyceridaemia (pancreatitis risk). Palmar crease xanthomas = pathognomonic for type III. FH: AD; LDL receptor mutation; high-intensity statin + ezetimibe + PCSK9 inhibitor.
Adult DM → comprehensive malignancy screen (CT CAP, mammography, pelvic USS ± Ca-125) at diagnosis and annually for 3-5 years (BSR 2022); anti-TIF1-γ confers the highest cancer risk; juvenile DM does not require malignancy screening.
DM: Gottron papules (over knuckles - pathognomonic; vs SLE between knuckles), heliotrope rash (upper eyelids), V-sign, shawl sign. 15-25% have cancer → CT CAP + mammography + pelvic USS + NPC screen. Anti-TIF1-γ: highest cancer risk. Anti-MDA5: RPILD (amyopathic).
Behçet = recurrent oral ulcers (mandatory) + genital ulcers (scarring) + uveitis + pathergy + Silk Road / HLA-B51. Treat eyes early with azathioprine; anti-TNF for refractory disease.
lcSSc (CREST): anti-centromere; skin limited to distal extremities + face; PAH is major complication. dcSSc: anti-Scl-70; widespread skin involvement; ILD and renal crisis main complications. Raynaud's: often first feature. Nailfold capillaroscopy abnormal in SSc (not primary Raynaud's).
Tinea capitis: ALWAYS needs oral antifungal (topical alone insufficient). T. tonsurans now most common in UK (endothrix, black dots, no fluorescence). M. canis: ectothrix, green fluorescence, from cats/dogs. Terbinafine for Trichophyton (4 weeks). Griseofulvin for Microsporum (6-8 weeks).
Bowen disease - recognise the key clinical and investigative features to guide appropriate management.
Molluscum: MCV (poxvirus). Flesh-coloured umbilicated papules. Self-limiting (6-18 months) in immunocompetent. NO treatment usually needed (watchful waiting - NICE). Henderson-Patterson bodies on histology. HIV: giant/widespread/facial → ART needed.
EM: classic 3-zone target lesions (pathognomonic). HSV most common cause (90% of recurrent EM). Acral distribution (palms, hands). NOT on SJS/TEN spectrum (separate condition). EM minor = skin only; EM major = +mucosal. Self-limiting 2-4 weeks. Recurrent EM: prophylactic aciclovir.
NF: surgical emergency. Red flags: disproportionate pain, crepitus, haemorrhagic bullae, dusky/grey skin, systemic toxicity, rapid progression. Type 1 (polymicrobial; diabetes), Type 2 (GAS; healthy individuals). Immediate surgery - every hour delay increases mortality.
UK impetigo - *S. aureus* dominant cause; honey-coloured crusts on face. NICE NG153: hydrogen peroxide first-line for localised disease; topical fusidic acid/mupirocin alternatives; oral flucloxacillin if widespread or bullous. School exclusion until crusted or 48 h on antibiotics.
BCC: most common cancer. Pearly, telangiectasia, rolled border, rodent ulcer. Almost never metastasises. Nodular (face), superficial (trunk), morphoeic (aggressive). 4mm excision margin. Mohs for high-risk/facial. Imiquimod for superficial. Vismodegib for advanced (Hedgehog pathway).
PDT uses a topical photosensitiser (MAL or ALA) that is converted to protoporphyrin IX and activated by red light/daylight to selectively destroy dysplastic cells - excellent cosmesis for actinic keratoses, Bowen's disease, and superficial BCC, but not for invasive SCC.
AD systemic therapy: dupilumab (anti-IL-4Rα; blocks IL-4+IL-13; conjunctivitis side effect; excellent safety; no monitoring needed) and JAK inhibitors (baricitinib, upadacitinib, abrocitinib; oral; rapid onset; VTE/CV/malignancy monitoring needed). Ciclosporin: only licensed conventional systemic.
IV: most common ichthyosis (1:250). FLG mutations. Fine white scales, extensor, SPARES flexures. Hyperlinear palms (pathognomonic). Keratosis pilaris. Strong atopic eczema association. Absent granular layer on histology. Autosomal semi-dominant. Improves with age.
NF: surgical emergency. Pain out of proportion = KEY early sign. Rapid progression (hours). Haemorrhagic bullae, crepitus (gas), skin necrosis. Type I: polymicrobial (diabetic); Type II: GAS (healthy patients). IMMEDIATE surgical debridement + meropenem + clindamycin (toxin inhibition) + ICU.
MF: most common CTCL. Patch → plaque → tumour stages over years. Bathing trunk distribution. Epidermotropism + Pautrier microabscesses + cerebriform nuclei. CD4+; CD7 loss. Misdiagnosed for years. Early stage: excellent prognosis (topical steroids, phototherapy, nitrogen mustard).
AK: most common premalignant lesion. UV-induced keratinocyte dysplasia (intraepidermal). Sandpaper texture. Individual transformation risk low (~0.1%/year) but cumulative risk significant. Field cancerisation → treat the field, not just individual lesions. 5-FU cream: best evidence (4 weeks).
XP: AR; defective NER of UV-induced DNA damage. Severe photosensitivity from infancy. Multiple skin cancers from childhood (BCC, SCC, melanoma). >1000-fold cancer risk increase. Freckling in first year of life. Strict total UV avoidance essential. Neurodegeneration in some subtypes (XPA, XPD).
EB: inherited mechanobullous disease. EBS: keratin 5/14 (intraepidermal; mildest; AD). JEB: laminin-332 (lamina lucida; severe Herlitz lethal in infancy). DEB: collagen VII (sublamina densa; RDEB: mitten deformities, oesophageal strictures, 70% SCC risk). IF antigen mapping for diagnosis.
Mandatory recurrent oral ulcers + genital ulcers + uveitis + skin lesions + pathergy = Behçet (ISG); HLA-B51; pulmonary artery aneurysms pathognomonic; colchicine for mucocutaneous and azathioprine/biologics for ocular per BSR/EULAR.
Morbilliform eruption is the most common drug reaction (>90%); onset 5-14 days; symmetrical maculopapular rash; no systemic features (vs DRESS); no blistering or mucosal involvement (vs SJS/TEN); self-limiting. Amoxicillin plus EBV gives a rash that is NOT a true allergy.
OTR: SCC risk 65-250x (most dramatically increased skin cancer). SCC:BCC ratio REVERSED (4:1 SCC:BCC vs 4:1 BCC:SCC in GP). Azathioprine: UVA-mutagenesis via 6-TG. mTOR inhibitors: anti-tumour. Acitretin: chemoprevention for multiple SCCs. Regular dermatology surveillance mandatory.
PLE is the commonest photodermatosis - an itchy papulovesicular rash on sun-exposed skin with delayed onset, worse in spring with summer hardening; exclude lupus (ANA, anti-Ro) and porphyria, then manage with sun protection, topical steroids and pre-season narrowband UVB.
Breslow drives margin (>2mm → 2cm) and SLNB threshold (≥0.8-1mm). BRAF testing all melanomas. Adjuvant anti-PD-1 for stage IIB+. Per NICE NG14 and BAD melanoma guideline.
Pemphigoid gestationis is a pregnancy-specific autoimmune blistering disease (anti-BP180) with characteristic periumbilical onset and linear C3 at the basement membrane zone on DIF; fetal risks are prematurity, SGA and transient neonatal blistering, not malformation.
PF: anti-Dsg1 only → subcorneal split → superficial erosions + crusting. NO oral involvement (Dsg3 compensates in mucosa). Seborrhoeic distribution. Less severe than PV. Nikolsky positive. DIF: chicken wire IgG (same as PV). Dapsone may help. Fogo selvagem: endemic PF in Brazil. Sun can exacerbate.
Drug photosensitivity: phototoxicity (common, dose-dependent, sunburn-like) vs photoallergy (rare, immunological, eczematous). Amiodarone: up to 75% phototoxicity + blue-grey pigmentation. Doxycycline, thiazides, fluoroquinolones, NSAIDs: common phototoxic drugs.
BP: most common autoimmune blister disease. Elderly (>70). Anti-BP180 (NC16A) + anti-BP230. TENSE blisters (subepidermal). Nikolsky NEGATIVE. Pre-blistering urticarial phase (often misdiagnosed). DIF: linear IgG/C3 at BMZ. Salt-split: epidermal side.
Isotretinoin - most effective acne treatment; 0.5-1 mg/kg/day for ~6 months (cumulative 120-150 mg/kg). PPP mandatory (absolute teratogen); monthly pregnancy test, LFTs, fasting lipids; mental health review each visit; avoid tetracyclines (raised ICP).
Carpet-tack sign + follicular plugging + scarring alopecia = DLE. Biopsy the active edge for H&E AND DIF (lupus band). Hydroxychloroquine is the first-line systemic agent (BAD 2017). Hair will NOT regrow in scarred areas - treat early.
Vitiligo = autoimmune melanocyte loss - first-line topical steroid (body) or tacrolimus (face/flexures); ruxolitinib cream is a newer option (NICE TA980); NB-UVB for widespread disease; repigmentation is perifollicular and takes 6-12 months; screen for thyroid and other autoimmune disease (BAD 2021).
LAD: linear IgA at BMZ (vs granular IgA in DH). String of pearls pattern (children). Most common autoimmune blistering disease of childhood (CBDC). Perioral + perineal distribution in children. Drug-induced: vancomycin most common. Dapsone first-line (check G6PD). No coeliac association (unlike DH).
AA = smooth, non-scarring patches + exclamation mark hairs + preserved follicular ostia (potentially reversible). First-line: intralesional steroids; severe disease - baricitinib (NICE TA1029). Always check thyroid function.
DLE = discoid plaques + adherent scale + carpet-tack/follicular plugging + central scarring + ANA usually negative; treat early to prevent scarring alopecia; hydroxychloroquine first-line systemic (BAD 2021).
KS: HHV-8-driven vascular neoplasm. Four types (classic, endemic, iatrogenic, AIDS-associated). Violaceous non-blanching papules/nodules. Spindle cells + slit-like vessels. AIDS-KS: ART is primary treatment. Advanced: liposomal doxorubicin. Transplant-KS: switch to sirolimus (anti-KS activity).
CSDH: common in elderly (brain atrophy + anticoagulation + falls). Weeks after trivial/no recalled head injury. Gradual confusion, focal neurology, gait disturbance. CT: crescent-shaped collection (hypodense if chronic). Reverse anticoagulation urgently. Burr hole drainage: first-line surgery.
NEVER stop PD medications abruptly → parkinsonism-hyperpyrexia syndrome (life-threatening). NG levodopa or rotigotine patch if NBM. AVOID metoclopramide, prochlorperazine, haloperidol in PD (dopamine antagonists → worsen parkinsonism). Safe antiemetics: domperidone, ondansetron.
NICE CG109 - every elderly patient with syncope needs history + witness account + lying/standing BP + 12-lead ECG. High-risk features (exertional, no prodrome, abnormal ECG, structural heart disease, FH SCD) → admit. Recurrent unexplained → implantable loop recorder.
Hypothyroidism in elderly: common (5-10%); often missed (symptoms mimic ageing). Hashimoto's: most common cause (anti-TPO positive). START LOW, GO SLOW with levothyroxine (25mcg in IHD; 25-50mcg otherwise). Increase 25mcg every 4-6 weeks. Rapid treatment → angina/MI risk.
Polypharmacy: ≥5 medications; hyperpolypharmacy ≥10. STOPP/START: systematic screening for PIPs and PPOs. Key STOPP: aspirin without CV indication, long-term benzodiazepines, long-term PPIs without indication, TCAs in elderly, anticholinergics in cognitive impairment, NSAIDs long-term.
AF in elderly: very common (10-15% >75). CHA₂DS₂-VASc for stroke risk. DOACs first-line (NICE). Apixaban: preferred in elderly (lowest bleeding). Aspirin: NO LONGER recommended for AF. Age is NOT a contraindication to anticoagulation. Falls are NOT a contraindication.
DVLA notification: patient's legal obligation (not the doctor's - but doctor can breach confidentiality if patient refuses and poses risk). Dementia: must notify; may get 1-year licence if mild; Group 2 revoked permanently. Stroke: 1 month off driving (Group 1).
Severe hypophosphataemia + hypokalaemia + hypomagnesaemia after refeeding a malnourished patient = refeeding syndrome; prevent per NICE CG32 (thiamine first, start 5-10 kcal/kg/day, prophylactic electrolytes); treat by slowing the feed and aggressive IV electrolyte correction.
Displaced intracapsular NOF + independently mobile + AMT ≥ 7 → THR (NICE CG124); surgery within 36 h; fascia iliaca block; orthogeriatric MDT; VTE prophylaxis 28-35 d; bone protection before discharge.
DLB vs PDD: 1-year rule (dementia before/concurrent with motor = DLB; motor ≥1 year before dementia = PDD). Same pathology (alpha-synuclein Lewy bodies). Both: ChEIs (rivastigmine), avoid antipsychotics, visual hallucinations, fluctuations, RBD. DLB: more prominent hallucinations and fluctuations.
CAUTI: most common hospital-acquired infection. Change catheter BEFORE antibiotics. Cloudy/smelly urine ≠ infection (do NOT treat). ASB in catheterised patients: do NOT treat. Daily review: does the patient still need this catheter? TWOC for BPH (tamsulosin first). Prevention: avoid catheterisation.
Dehydration in elderly: very common (20-30% of care home residents). Reduced thirst is the key problem (age-related). Test skin turgor over sternum (not hands). Urea:creatinine >100:1 = pre-renal. Hypernatraemia = water-loss dehydration.
Low-dose morphine + fan first-line for refractory breathlessness (NICE NG31). Anticipatory prescribing: morphine, midazolam, hyoscine butylbromide, levomepromazine. ReSPECT/DNACPR. Oral to SC morphine: divide by 2. Breakthrough = 1/6th of 24h dose.
Prevent delirium with a multicomponent bundle (NICE CG103; HELP programme) - orientation, sleep, early mobilisation, sensory aids, medication review, pain control and hydration. No drug is recommended for prevention, and prevention is far more effective than treatment.
eGFR overestimates GFR in elderly with low muscle mass (sarcopenia → low creatinine production → falsely normal creatinine → falsely high eGFR). For drug dosing of narrow-therapeutic-index drugs: use Cockcroft-Gault CrCl (incorporates weight).
Severely low 25(OH)D + low Ca²⁺ + low PO₄³⁻ + raised ALP + raised PTH = osteomalacia from vitamin D deficiency; load colecalciferol then maintenance; correct vitamin D and calcium BEFORE any bisphosphonate (NICE CKS, NOS guideline).
Older adult vaccines per UKHSA Green Book = annual influenza (adjuvanted in ≥65), PPV23 at 65 (once), Shingrix 2 doses from 65 (>90% efficacy, safe in immunosuppression), and seasonal COVID-19 boosters; immunosenescence reduces responses but vaccination remains one of the most cost-effective interventions in geriatric medicine.
In frail older adults, non-pharmacological measures and topical NSAIDs come first (NICE NG226); avoid long-term oral NSAIDs (GI, renal, CV risk) and minimise opioids for chronic non-malignant pain (NICE NG193) - deprescribe the drugs that are causing falls, constipation, and drowsiness.
Conservative management of ESKD is active, holistic care. In frail elderly >80 with multimorbidity, survival is comparable to dialysis with better quality of life and more time at home (NICE NG107; UK Kidney Association).
Fried phenotype: ≥3 of weight loss, exhaustion, slow walking, weak grip, low activity = frail - not simply old age or multimorbidity.
Anticholinergic burden: cumulative effect of multiple anticholinergic drugs. ACB scale: score each drug 1-3; total ≥3 → cognitive harm, falls, mortality. Worst offenders: oxybutynin, amitriptyline, chlorphenamine (all ACB 3). Effects: dry mouth, constipation, retention, confusion, delirium, falls.
DLB: fluctuating cognition, visual hallucinations, RBD, parkinsonism. NEVER give haloperidol/typical antipsychotics (NMS, death). Neuroleptic sensitivity: up to 50%. DaTSCAN: abnormal (differentiates from Alzheimer's).
MUST ≥2 = high risk → dietitian referral + food-first plan (NICE CG32). Refeeding syndrome risk if BMI <18.5 or >10% weight loss - start low, give thiamine, monitor electrolytes daily.
Presbycusis: most common sensory deficit in elderly. Bilateral, symmetric, high-frequency SNHL. Difficulty in noise (cardinal feature). Largest modifiable risk factor for dementia (Lancet 2020). ACHIEVE trial: hearing aids reduced cognitive decline 48%. NHS hearing aids free.
The eFI is the automated primary-care frailty screen built from GP record data - identifying moderate or severe frailty triggers medication review and comprehensive geriatric assessment, in line with NHS England's GP contract frailty identification requirement.
GCA: medical emergency if visual symptoms. Immediate steroids (IV methylpred if visual loss; oral pred 40-60mg if not). Temporal artery biopsy within 2 weeks (don't delay treatment). Jaw claudication: highly specific. ESR/CRP markedly raised (but normal ESR doesn't exclude).
OH: ≥20mmHg systolic drop within 3 minutes of standing. Medication review FIRST (alpha-blockers are the worst - doxazosin, tamsulosin). Non-pharmacological: rise slowly, hydration, compression stockings, salt, head-of-bed elevation, small meals.
No upper age limit for thrombolysis/thrombectomy; alteplase ≤4.5 h, thrombectomy ≤24 h with imaging selection; clopidogrel + atorvastatin + BP control are the NICE NG128 secondary-prevention triad.
MoCA: more sensitive than MMSE for MCI (90% vs 18% sensitivity). ACE-III: most detailed screening tool (100 points; 5 domains). AMTS: quick bedside screen (10 points; <7 = abnormal). 4AT: delirium screening (not dementia). Clock drawing: visuospatial/executive function.
STOPP/START + ACB scoring guide deprescribing in frail elderly with falls. Stop anticholinergics, aspirin without CV indication, PPIs without indication, and consider stopping sulfonylureas/high-dose statins in advanced dementia. Per NICE NG56.
PD non-motor symptoms: affect 100% of patients; often MORE disabling than motor symptoms. Constipation, anosmia, RBD may PREDATE motor diagnosis by years (prodromal). Autonomic: constipation, OH, urinary urgency, ED.
NEVER stop/omit/delay PD medications in hospital (Get It On Time). If NBM: dispersible Madopar via NG, rotigotine patch, or apomorphine SC. PHS: rigidity + hyperthermia + confusion + high CK from medication withdrawal → life-threatening; restart dopaminergics immediately + supportive care + ICU.
Stroke unit MDT care reduces mortality and dependency (Cochrane). NICE NG128 - admit to acute stroke unit within 4 h; SLT swallow assessment before oral intake; early mobilisation 24-48 h; screen and treat post-stroke depression; secondary prevention plus structured rehabilitation goals.
Older surgical patient = CGA + Clinical Frailty Scale + prehabilitation + medication review + delirium prevention; age alone is not a contraindication (CPOC 2021 / RCoA).
Hypothyroidism in elderly: commonly missed (symptoms attributed to ageing). Check TFTs in: cognitive impairment, depression, constipation, fatigue, dyslipidaemia, anaemia, hyponatraemia.
BPPV: most common vertigo. Brief (<60s) positional episodes. Dix-Hallpike: latency + upbeat torsional nystagmus + fatigable = positive for posterior canal. Epley manoeuvre: treatment of choice (~80-95% cure rate). NO betahistine (doesn't work for BPPV).
DNACPR is a clinical decision (no patient consent required, but discussion required - Tracey). Does NOT stop other treatment. ReSPECT documents holistic emergency plan. Family is consulted, not consenting.
Delirium prevention - multicomponent non-pharmacological bundle (NICE CG103, HELP programme) reduces incidence by ~40%: orientation, hydration, sleep, mobilisation, sensory aids, medication review, pain control, constipation prevention; prophylactic haloperidol and benzodiazepines do NOT prevent delirium and may worsen it.
Delirium prevention: multicomponent non-pharmacological interventions reduce delirium by 30-40%.
Vascular dementia: second most common dementia. Stepwise decline (multi-infarct) or insidious (SVD). Executive dysfunction prominent (memory relatively preserved early). Gait disturbance early. Emotional lability. MRI: infarcts + white matter disease.
Dysphagia: screen ALL stroke patients within 4 hours (NICE). SALT referral for formal assessment. IDDSI framework for diet/fluid modification (Levels 0-7). VFS: gold standard imaging. FEES: portable bedside alternative. NG tube for short-term (<4 weeks); PEG for long-term (>4 weeks).
Alzheimer's treatment: ChEI first-line for mild-moderate (donepezil most common; rivastigmine patch avoids GI side effects; rivastigmine preferred in DLB). Memantine: for moderate-severe (alone or combination with ChEI - DOMINO trial).
Infections in elderly: often NO fever (up to 50% afebrile). Confusion/delirium is often the FIRST sign. Tachypnoea is the most reliable sign of pneumonia. Do NOT over-diagnose UTI from dipstick alone (ASB is common - 50% of care home residents). Any acute functional decline = consider infection.
Anaemia in elderly: NEVER normal. IDA + male/postmenopausal female → GI investigation mandatory (exclude cancer - 2WW referral). Ferritin: most useful test (but acute phase reactant - may be falsely normal in inflammation). OGD + colonoscopy. Angiodysplasia: common in elderly.
Overflow incontinence from faecal impaction is treated with disimpaction and laxatives, never anti-diarrhoeals - always review constipating drugs such as opioids and antimuscarinics in older patients (NICE CKS Constipation).
Syncope in elderly: OH is the most common cause (20-30% prevalence). Lying and standing BP: essential test. Medications: most common modifiable cause (review ALL medications - alpha-blockers, diuretics, antihypertensives).
AD: most common dementia (60-70%). Progressive episodic memory loss (hippocampal). MRI: medial temporal lobe/hippocampal atrophy. CSF: low Aβ42, high tau. Cholinesterase inhibitors for mild-moderate (donepezil, rivastigmine, galantamine). Memantine for moderate-severe. ApoE4 is risk allele.
Bed rest in older adults loses 1-3% muscle/day; ~30-40% of older inpatients suffer hospital-acquired functional decline (only ~50% fully recover); prevent with early mobilisation, deprescribing and CGA (NICE NG114, BGS End PJ Paralysis).
Elderly T2DM - individualise and relax HbA1c target in frailty/cognitive impairment. Stop sulphonylureas if hypoglycaemia (especially glibenclamide). Metformin: dose-reduce eGFR 30-45, stop <30. Linagliptin needs no renal adjustment.
In a patient aged 75 or over with a fragility fracture, start bone protection (alendronate plus calcium and vitamin D) without waiting for DXA. Switch to denosumab if eGFR is below 35 mL/min.
Moderate-severe depression in elderly: SSRI (sertraline) + CBT/IPT per NICE NG222. Citalopram max 20mg >65. Mirtazapine if insomnia/weight loss. Avoid TCAs and benzodiazepines. Check sodium. Always assess suicide risk.
Paget's disease = isolated markedly raised ALP with normal calcium and phosphate; X-ray shows cortical thickening, disorganised trabeculae and bowing; IV zoledronate 5 mg is first-line for symptomatic disease (PRISM: no benefit from treating asymptomatic disease).
STOPP/START is a validated deprescribing tool - in older adults watch for anticholinergics (oxybutynin, tricyclics), long-term PPIs without indication, and aspirin used for primary prevention; review, deprescribe and taper where needed.
ChEI (donepezil) is first-line for mild-moderate AD per NICE TA217; add memantine for moderate-severe disease (DOMINO-AD); avoid antipsychotics in BPSD where possible.
Osteoporosis: 1 in 2 women, 1 in 5 men over 50 get fragility fracture. Previous fracture = strongest clinical risk factor. FRAX + NOGG: determines treatment threshold. Alendronate 70mg weekly first-line (fasting, upright 30 min, water). IV zoledronate: annual; if oral not tolerated (eGFR >35).
Sundowning = evening BPSD; follow NICE NG97 - treat reversible causes, then non-pharmacological measures, then short-term risperidone as last resort (mortality and stroke risk per MHRA).
Delirium: ACUTE onset, FLUCTUATING course, IMPAIRED ATTENTION, ALTERED CONSCIOUSNESS, REVERSIBLE. Dementia: INSIDIOUS onset, PROGRESSIVE course, PRESERVED attention (early), NORMAL consciousness, IRREVERSIBLE. Delirium superimposed on dementia is very common - look for ACUTE CHANGE from baseline.
PD diagnosis: bradykinesia + rest tremor and/or rigidity. Asymmetric onset. Excellent levodopa response. DaTSCAN: differentiates PD from essential tremor. In elderly: levodopa preferred first-line (most effective, best tolerated).
HFpEF = EF ≥50% with raised natriuretic peptides and diastolic dysfunction, typically an older hypertensive or diabetic woman. SGLT2 inhibitors are the key evidence-based therapy (EMPEROR-Preserved, DELIVER, NICE TA902); use diuretics for congestion and treat comorbidities aggressively.
Accidental hypothermia - mild 32-35°C, moderate 28-32°C, severe below 28°C. Handle gently (ventricular fibrillation risk), rewarm slowly at 0.5-1°C/h, monitor continuously, and always look for an underlying cause and for complications of a long lie (rhabdomyolysis, AKI).
AKI in elderly: very common (pre-renal most common cause). Medications: ACEi + diuretics + NSAIDs = 'triple whammy'. Sick-day rules: STOP SADMAN drugs during acute illness (ACEi/ARB, diuretics, metformin, NSAIDs, SGLT2i). IV fluids for pre-renal (careful in HF).
Hip fracture in elderly = established osteoporosis. Surgery within 36 h + orthogeriatric care + IV zoledronic acid post-op (HORIZON-RFT) or oral alendronate (NICE TA464/NOGG) + calcium and vitamin D. Bone protection mandatory if prednisolone ≥7.5 mg for ≥3 months.
Presbycusis = bilateral, symmetrical, high-frequency sensorineural hearing loss (Rinne positive bilaterally, Weber central). Exclude wax, refer for audiology and hearing aids (NICE NG98); treating hearing loss is a key modifiable dementia risk factor.
AF in elderly: CHA₂DS₂-VASc guides anticoagulation decision. DOACs preferred over warfarin (NICE). Apixaban: safest in elderly (lowest ICH, GI bleeding; dose reduce 2.5mg BD if ≥2 of: age≥80, weight≤60, Cr≥133). Aspirin NOT recommended for AF.
CGA: gold standard for frail elderly care. Cochrane evidence: increases likelihood of being alive and at home at 12 months (NNT 13).
Hyponatraemia: most common electrolyte abnormality in elderly. Thiazides: most common drug cause (especially elderly women; within 2-4 weeks). SIADH: most common cause of euvolaemic hyponatraemia. SSRIs also cause hyponatraemia (common in elderly).
CGA is the gold-standard, evidence-based approach for complex older inpatients - it reduces mortality and institutionalisation; combine it with orthogeriatric hip-fracture care (surgery <36 h, early mobilisation, bone protection).
LHON follows strict maternal inheritance - all children of affected females carry the mutation, but no children of affected males will inherit it, making genetic counselling essential.
xerophthalmia requires high-dose oral vitamin A. Always consider the clinical context and guideline-directed management.
The ice-pack test and Cogan lid twitch sign are bedside indicators of myasthenia - AChR antibodies are positive in only 50-70% of ocular myasthenia, so negative serology does not exclude the diagnosis.
CRVO with macular oedema - intravitreal anti-VEGF is first-line treatment. Monitor for ischaemic conversion and neovascular complications. Aggressively manage cardiovascular risk factors. PRP only if neovascularisation develops.
Eales disease requires scatter laser photocoagulation. Always consider the clinical context and guideline-directed management.
In neovascular glaucoma, anti-VEGF is the bridge to definitive treatment with PRP - always treat the ischaemic drive, not just the pressure.
Chemical eye injury - irrigate immediately and copiously until pH 7.0-7.5, regardless of the chemical involved. Alkali is worse than acid. Classify severity with Roper-Hall. Never attempt neutralisation.
Kayser-Fleischer rings are present in nearly 100% of Wilson disease patients with neurological involvement - their absence in a patient with isolated hepatic disease does not exclude the diagnosis.
Congenital rubella syndrome requires lensectomy. Always consider the clinical context and guideline-directed management.
Ethambutol optic neuropathy presents with bilateral visual loss and dyschromatopsia - stop ethambutol immediately. Baseline visual acuity and colour vision are mandatory before starting treatment. Recovery is usual if detected early.
Screen all UK infants born before 32 weeks or under 1501 g; the first examination is at 30-31 weeks' postmenstrual age (or 4-5 weeks postnatal, whichever is later), and type 1 ROP requires treatment within 72 hours.
INO in a young patient - suspect multiple sclerosis with a demyelinating lesion in the medial longitudinal fasciculus. MRI brain with gadolinium is first-line investigation. In elderly patients, consider brainstem vascular disease instead.
Vigabatrin retinal toxicity is irreversible and affects up to 40% of adults - once confirmed, drug withdrawal should be discussed, though visual field loss will not recover after stopping treatment.
Amiodarone corneal deposits occur in nearly all patients and are rarely visually significant - the genuinely concerning ocular complication is optic neuropathy, which requires urgent assessment and drug cessation.
Dense vitreous haemorrhage - perform B-scan ultrasound to exclude retinal detachment. In diabetic patients, treat the fellow eye PDR with panretinal photocoagulation urgently. Vitrectomy if haemorrhage fails to clear or detachment is present.
Orbital cellulitis = proptosis + ophthalmoplegia + pain on eye movement ± reduced vision. Urgent CT orbits with contrast plus IV antibiotics. Surgical drainage if abscess present or failure to respond within 48 hours.
In ocular toxocariasis, always commence corticosteroids before or with albendazole - antihelminthic therapy alone can provoke a severe inflammatory flare from larval death that worsens vitreous traction.
Once hydroxychloroquine retinal toxicity is detected on screening, the drug must be stopped immediately - damage is irreversible and can progress even after cessation due to prolonged tissue binding.
Horner syndrome with arm pain in a smoker - urgently exclude Pancoast tumour with CT chest. Apraclonidine confirms Horner syndrome. Anhidrosis indicates a central or preganglionic lesion. Localisation determines the investigation pathway.
Behçet posterior uveitis requires combined systemic corticosteroids and steroid-sparing immunosuppression - anti-TNF therapy is increasingly first-line for sight-threatening ocular disease per EULAR guidelines.
multifocal choroiditis with panuveitis requires mycophenolate mofetil. Always consider the clinical context and guideline-directed management.
Down syndrome requires proactive ophthalmological screening - correct refractive errors early, treat amblyopia within the sensitive period, and monitor for keratoconus and early cataracts throughout childhood and adolescence.
GCA with visual symptoms demands immediate IV methylprednisolone - oral steroids alone are insufficient, and delaying treatment for biopsy risks permanent bilateral blindness.
Solar retinopathy is managed conservatively - most recover to 6/6-6/9 over 3-6 months, no drug treatment helps, avoid laser and anti-VEGF, and prevent with ISO 12312-2 eclipse glasses.
PDR requires panretinal photocoagulation; centre-involving DMO requires intravitreal anti-VEGF - different pathologies in the same disease demand different treatments guided by NICE NG28.
Acute anterior uveitis requires intensive topical steroids plus cycloplegia - always investigate for systemic associations, particularly HLA-B27-related spondyloarthropathies, in young men with recurrent episodes.
Ocular MG - test AChR antibodies first, then MuSK if negative. CT chest for thymoma is mandatory. Ice pack test is a safe bedside alternative to edrophonium. 50% progress to generalised MG within 2 years.
Bilateral disc swelling requires urgent MRI with MR venography before lumbar puncture - exclude mass lesions and CVST first. IIH is a diagnosis of exclusion. Monitor visual fields closely as vision loss is the main morbidity.
BRVO management combines intravitreal anti-VEGF for macular oedema with aggressive cardiovascular risk factor modification - blood pressure control is paramount. Anticoagulation is not indicated. Monitor for ischaemic neovascular complications.
Ocular sarcoidosis with bilateral sight-threatening uveitis requires topical and systemic corticosteroids plus early steroid-sparing immunosuppression. Methotrexate is first-line steroid-sparing agent. Monitor for glaucoma, cataract, and CMO as complications.
IIH management - discontinue offending medications, acetazolamide plus structured weight loss (≥5% body weight), and regular visual field monitoring. Surgical options for sight-threatening or refractory cases. Weight loss is the most effective long-term treatment.
Recurrent sarcoid uveitis failing topical therapy mandates systemic corticosteroids with methotrexate as the preferred steroid-sparing agent - always check for and manage raised IOP, which is common in sarcoid uveitis.
idiopathic intracranial hypertension requires lumbar puncture. Always consider the clinical context and guideline-directed management.
Macula-on retinal detachment is a surgical emergency - refer to a vitreoretinal surgeon within 24 hours to prevent macular involvement and preserve central vision.
Bilateral temporal disc pallor with centrocaecal scotomata in a young patient without compressive or inflammatory cause should prompt genetic testing for OPA1 mutations and LHON as the priority investigation.
Sjögren-related dry eye - preservative-free artificial tears first-line, topical ciclosporin for moderate-to-severe disease, punctal plugs if refractory. Monitor for MALT lymphoma risk. Oral pilocarpine addresses both ocular and oral sicca symptoms.
Steroid-induced ocular hypertension is managed by tapering the steroid, not simply adding IOP-lowering drops. Switch to lower-potency agents or steroid-sparing immunosuppression. Monitor IOP at every visit in patients on topical steroids.
Painful pupil-involving third nerve palsy = posterior communicating artery aneurysm until proven otherwise. Urgent CTA of the circle of Willis. Pupil-sparing palsy in a diabetic is typically microvascular and self-limiting, but still warrants imaging.
CMV retinitis at CD4 <50 - IV ganciclovir induction plus intravitreal injection for macular threat, then oral valganciclovir maintenance. Delay ART by 2 weeks to reduce IRIS risk. Continue maintenance until CD4 >100 for 6 months.
Bilateral sixth nerve palsy with papilloedema is raised ICP until proven otherwise - the sixth nerve palsy is a false localising sign. In children, urgently exclude a posterior fossa tumour with MRI. Never perform LP before imaging when raised ICP is suspected.
HZO with Hutchinson's sign requires oral valaciclovir within 72 hours plus urgent ophthalmology assessment - topical steroids are appropriate for zoster uveitis and keratitis, unlike in herpes simplex where steroids require specialist supervision.
Relapsing organ-threatening GPA (including orbital disease with rising PR3-ANCA) requires remission RE-INDUCTION with rituximab (preferred, RAVE trial) or cyclophosphamide plus high-dose corticosteroids - NOT radiotherapy, and not corticosteroid escalation alone (EULAR/BSR ANCA-associated vasculitis guidance).
Adult orbital floor fractures with entrapment should be repaired within 1-2 weeks - but paediatric white-eyed trapdoor fractures require emergency repair within 24 hours due to rapid muscle ischaemia.
Cataract surgery is indicated when visual impairment affects quality of life - there is no minimum acuity threshold. Phacoemulsification with IOL implantation has >95% success rate. Assess for coexisting retinal disease pre-operatively.
Posterior uveitis requires a broad infective and inflammatory workup - toxoplasma, syphilis, TB, HIV, and sarcoidosis are the key differentials. Never immunosuppress without excluding infection first.
NAION has no proven acute treatment - focus on cardiovascular risk modification and protecting the fellow eye, especially ensuring CPAP compliance and avoiding nocturnal hypotension.
Necrotising scleritis with PUK in rheumatoid arthritis signals active systemic vasculitis - this is a medical emergency requiring urgent escalation to cyclophosphamide or rituximab, not just increased methotrexate.
AACG requires immediate multi-agent IOP reduction - IV acetazolamide, topical pilocarpine, timolol, and apraclonidine - followed by definitive laser peripheral iridotomy to both eyes.
Tamoxifen retinopathy is characterised by perifoveal crystalline deposits and cystoid macular changes - cessation should be discussed with oncology when retinopathy is symptomatic, particularly when alternative endocrine therapies are available.
Centre-involving DMO requires intravitreal anti-VEGF; non-centre-involving DMO is managed with focal macular laser. OCT determines the treatment pathway. Systemic glycaemic and blood pressure optimisation are essential adjuncts.
Anti-VEGF is first-line for BRVO-related macular oedema - but always address systemic cardiovascular risk factors concurrently, as BRVO is a marker of vascular disease.
Phacomorphic glaucoma requires cataract extraction as definitive treatment - medical IOP reduction is the bridge to surgery, and pilocarpine should be avoided.
Topiramate-induced angle closure is NOT pupil-block mediated - laser iridotomy is ineffective and pilocarpine is contraindicated; stop the drug and use atropine to pull the lens-iris diaphragm posteriorly.
In POAG escalation, add a drug from a different class to the prostaglandin analogue - but avoid non-selective beta-blockers (timolol) in asthma and choose a topical carbonic anhydrase inhibitor instead (NICE NG81).
JIA-associated uveitis is typically chronic, bilateral and asymptomatic (white eye) - screen high-risk children (oligoarticular, ANA-positive, onset under 6) by slit-lamp within 6 weeks of diagnosis, then every 3-4 months.
Once sympathetic ophthalmia is established bilaterally, enucleation of the exciting eye offers no benefit - systemic immunosuppression is the cornerstone of management.
Scleritis causes severe boring pain, deep scleral injection unresponsive to phenylephrine, and is associated with systemic autoimmune disease in 50% - investigate with RF, anti-CCP, ANCA, ANA and treat with oral NSAIDs or systemic immunosuppression.
Ocular ischaemic syndrome reflects severe ipsilateral internal carotid stenosis - investigate first with carotid duplex ultrasonography; the asymmetrically low IOP and prolonged arteriovenous transit time help distinguish it from CRVO and diabetic retinopathy.
A complete homonymous hemianopia fails the Group 1 standard of at least 120 degrees horizontal field - the patient must notify the DVLA and stop driving until formal Esterman assessment; normal visual acuity alone does not permit driving.
In the ONTT, IV methylprednisolone (then oral taper) accelerated visual recovery but did not change final acuity, while standard-dose oral prednisolone alone increased the rate of recurrent optic neuritis and should be avoided.
Amaurosis fugax is a TIA equivalent - urgent carotid Doppler within 24 hours. Carotid endarterectomy within 2 weeks if stenosis ≥50% (NASCET). Immediate clopidogrel, statin, and cardiovascular risk factor management.
Bilateral retinoblastoma is always germline - siblings of affected children should undergo RB1 genetic testing, and mutation-positive infants require retinal screening from birth at 3-4 weekly intervals.
Retinitis pigmentosa - no curative treatment exists. Genetic counselling and testing are essential for inheritance pattern determination and gene therapy eligibility.
Homonymous hemianopia indicates a post-chiasmal lesion - urgent MRI brain with DWI. Sudden onset in AF suggests posterior circulation stroke. Localise by congruity and associated features. Macular sparing suggests an occipital cortex lesion.
Botulinum toxin is first-line for blepharospasm with 90% response rates - myectomy is reserved for toxin-refractory cases, and oral medications play only a secondary role.
Asymptomatic NF1-associated optic pathway gliomas with preserved vision are managed by active surveillance; reserve carboplatin-vincristine chemotherapy for progressive visual decline or radiological progression, and avoid radiotherapy in NF1.
Toxoplasmosis retinochoroiditis in immunocompromised patients - treat with pyrimethamine plus sulfadiazine plus folinic acid. Steroids only with anti-parasitic cover. Commence ART and continue maintenance prophylaxis until immune reconstitution (CD4 >200).
The EVS threshold for vitrectomy is light perception vision - above this, intravitreal tap-and-inject achieves equivalent outcomes with less surgical risk.
All myasthenia patients with thymoma require thymectomy regardless of symptom severity - thymoma is a neoplasm that requires excision independently of its association with myasthenia.
The COMS trial showed equivalent survival with brachytherapy versus enucleation for medium choroidal melanomas - always refer to ocular oncology for eye-conserving options before considering enucleation.
Cancer-associated VTE - LMWH or DOACs (edoxaban, rivaroxaban) are first-line per NICE. Avoid DOACs in GI or urothelial cancers due to bleeding risk. Continue anticoagulation whilst cancer is active. Warfarin is inferior in cancer-associated VTE.
Li-Fraumeni syndrome from TP53 mutations causes early-onset sarcomas, breast cancer, brain tumours, adrenocortical carcinoma, and leukaemia - minimise radiation and implement comprehensive whole-body MRI surveillance.
FAP carries near-certain colorectal cancer risk - prophylactic colectomy is mandatory, with lifelong surveillance for duodenal adenomas, desmoid tumours, and other extracolonic manifestations.
CML monitoring uses BCR-ABL1 PCR milestones - failure to reach ≤10% IS at three months warrants switching to a second-generation TKI after mutation analysis.
Primary CNS lymphoma in immunosuppressed patients is EBV-driven - negative toxoplasma serology and positive CSF EBV PCR strongly support the diagnosis over toxoplasmosis, with high-dose methotrexate as the chemotherapy backbone.
Neutropenic sepsis - IV antibiotics within one hour, typically piperacillin-tazobactam. Do not delay for culture results. MASCC score stratifies risk. Persistent fever beyond 48 hours warrants antifungal consideration.
T315I is the gatekeeper mutation conferring pan-TKI resistance in CML - ponatinib is the only standard TKI effective against it, though cardiovascular toxicity requires careful ongoing risk-benefit assessment.
EGFR-mutant NSCLC should receive osimertinib first-line regardless of PD-L1 status - molecular testing is mandatory before starting systemic treatment in all advanced lung adenocarcinomas.
Adult-onset dermatomyositis carries a 15-30% malignancy risk - comprehensive cancer screening including CT imaging and age-appropriate investigations is mandatory, particularly with anti-TIF1-gamma antibody positivity.
BRCA1/2 carriers require annual MRI breast screening from age 30, with risk-reducing mastectomy and salpingo-oophorectomy discussed - PARP inhibitors exploit homologous recombination deficiency therapeutically.
MRONJ requires pre-treatment dental assessment before starting bisphosphonates or denosumab - dental extraction is the major precipitant, and prevention through dental optimisation is the most effective management strategy.
MEN1 - parathyroid, pancreas, pituitary (menin gene, chromosome 11). MEN2 - medullary thyroid cancer, phaeochromocytoma, hyperparathyroidism (RET proto-oncogene). Genetic testing guides screening and prophylactic surgery in families.
Anthracycline cardiotoxicity is cumulative, dose-dependent, and irreversible (type I). Trastuzumab cardiotoxicity is reversible with treatment interruption (type II). Hold trastuzumab if LVEF drops below 50%. Commence ACE inhibitor and beta-blocker, reassess and consider rechallenge.
RCC - classic triad is rare; most diagnosed incidentally. Non-decompressing left varicocele suggests renal vein invasion. Radical nephrectomy for localised disease. Resistant to chemotherapy. Immunotherapy-based combinations for metastatic disease.
Gorlin syndrome results from PTCH1 mutations causing constitutive hedgehog pathway activation - radiotherapy must be avoided as it induces further BCCs, and vismodegib offers targeted therapy for advanced disease.
Peutz-Jeghers syndrome carries approximately 85-90% lifetime cancer risk - comprehensive surveillance of gastrointestinal, breast, gynaecological, and pancreatic sites must commence from age 25.
Hereditary retinoblastoma follows Knudson's two-hit model - one inherited germline RB1 mutation plus one somatic hit causes bilateral disease, with lifelong risk of secondary malignancies requiring ongoing surveillance.
SJS-TEN is classified by BSA detachment - immediately stop the causative drug, calculate SCORTEN, transfer to burns unit, and arrange urgent ophthalmology review to prevent long-term ocular complications.
Symptomatic SIADH (Na <125 mmol/L with neurological features) → 3% hypertonic saline 150 mL boluses targeting a 4-6 mmol/L rise; fluid restriction is for asymptomatic disease; never correct >10 mmol/L in 24 hours (Society for Endocrinology UK / European hyponatraemia guideline).
Post-splenectomy patients require pneumococcal, meningococcal, and Hib vaccinations with lifelong penicillin prophylaxis - overwhelming post-splenectomy infection is rapidly fatal and prevention through vaccination and antibiotics is essential.
FDG PET-CT has false positives from inflammation and false negatives for small or low-grade lesions - pathological confirmation of stage-altering findings is mandatory before determining treatment intent.
ALK-rearranged NSCLC requires alectinib as first-line treatment for superior efficacy and CNS penetration - sequential ALK inhibitor therapy provides sustained disease control in this molecularly favourable subtype.
Solitary pulmonary nodules require Brock model risk stratification - spiculated margins, part-solid morphology, and upper lobe location indicate high malignancy risk warranting PET-CT and tissue diagnosis.
Phaeochromocytoma - diagnose with plasma or urinary metanephrines. Alpha-blockade before beta-blockade is critical. Genetic testing for all patients (40% hereditary). Never give beta-blockers without prior alpha-blockade.
Ovarian cancer - CA-125 and ultrasound for risk assessment. Primary debulking surgery with complete cytoreduction followed by carboplatin-paclitaxel. BRCA testing for all epithelial ovarian cancers guides PARP inhibitor use.
Gastric cancer - Virchow's node indicates advanced disease. Staging laparoscopy essential to exclude occult peritoneal disease. Perioperative FLOT chemotherapy is standard for locally advanced resectable disease. H. pylori is a Group 1 carcinogen.
MDT discussion is mandatory for all cancer patients under NICE guidance - multidisciplinary consensus improves diagnostic accuracy, treatment quality, and outcomes compared with individual clinician decision-making.
CUP - systematic immunohistochemistry panel and PET-CT to identify the occult primary. Molecular profiling increasingly guides treatment selection. Always identify favourable subsets requiring specific site-directed therapy.
WHO analgesic ladder - step up to strong opioids when pain is uncontrolled. Oral morphine is first-line. Always co-prescribe laxatives. Add gabapentin or pregabalin for neuropathic pain. Palliative radiotherapy effectively treats painful bone metastases.
MASCC score 21 or above identifies low-risk febrile neutropenia suitable for oral antibiotics. Key components: symptom burden, haemodynamic stability, tumour type, age, and outpatient status. High-risk patients require inpatient IV antibiotics.
VHL disease requires lifelong multimodal surveillance from age 16 - annual renal imaging, ophthalmological review, and catecholamine screening are essential for early detection of treatable tumours.
Bevacizumab (anti-VEGF) causes gastrointestinal perforation, hypertension, impaired wound healing, and thromboembolism - withhold perioperatively and monitor blood pressure and proteinuria regularly throughout treatment.
Brain metastases - stereotactic radiosurgery for limited lesions preserves cognition better than whole brain radiotherapy. Dexamethasone reduces oedema. Consider systemic therapy blood-brain barrier penetrance. Surgery for large symptomatic lesions.
IPSS-R guides MDS management - higher-risk patients require azacitidine first-line, while allogeneic transplantation offers the only potential cure for eligible candidates.
Leptomeningeal disease presents with multifocal neurological deficits - gadolinium-enhanced MRI and CSF cytology confirm diagnosis, with intrathecal chemotherapy and systemic therapy forming the multimodal treatment backbone.
Wilms tumour is an intrarenal mass with normal catecholamines presenting at age 3-4 years - neuroblastoma crosses the midline with elevated urinary VMA and HVA, arising from neural crest tissue.
All myasthenia gravis patients require CT thorax to exclude thymoma - complete surgical resection is the primary treatment, with adjuvant radiotherapy indicated for incompletely resected or advanced-stage disease.
Highly emetogenic chemotherapy - triple antiemetic prophylaxis: 5-HT3 antagonist plus dexamethasone plus NK1 antagonist. Consider adding olanzapine as fourth agent. Cisplatin is the most emetogenic chemotherapy agent. Anticipatory nausea responds to benzodiazepines.
Blast phase transformation of MPN carries poor prognosis - allogeneic transplant is the only curative option, with azacitidine as bridging therapy for suitable candidates awaiting transplantation.
Melanoma - Breslow thickness determines excision margins and prognosis. SLNB for lesions 0.8mm or thicker. Stage III - adjuvant anti-PD-1 immunotherapy or dabrafenib-trametinib for BRAF-mutant. BRAF testing is essential for all melanomas.
Oesophageal cancer - endoscopic ultrasound is essential for accurate locoregional staging (T and N stage). Barrett's oesophagus is the key risk factor for adenocarcinoma. Neoadjuvant FLOT or CROSS protocol before surgery for locally advanced disease.
GBM - ring-enhancing lesion with central necrosis on MRI. Stupp protocol: maximal resection plus concurrent temozolomide-radiotherapy then adjuvant temozolomide. MGMT methylation predicts temozolomide benefit. Median survival approximately 14-16 months.
Malignant ascites is managed with paracentesis and indwelling peritoneal catheters for recurrent drainage - diuretics are generally ineffective as the mechanism is VEGF-driven peritoneal permeability rather than portal hypertension.
Unresectable stage III NSCLC - concurrent chemoradiotherapy followed by durvalumab consolidation (PACIFIC trial). Molecular profiling is mandatory for all advanced NSCLC to identify actionable mutations.
Symptomatic hyperviscosity in Waldenström requires urgent plasmapheresis before chemotherapy - avoid rituximab monotherapy initially due to the IgM flare phenomenon worsening viscosity.
irAEs - grade severity determines management. Grade 3-4 toxicity requires immunotherapy cessation and high-dose IV corticosteroids. Infliximab for corticosteroid-refractory colitis. Endocrinopathies require hormone replacement. Combination immunotherapy carries highest toxicity risk.
Fertility preservation must be discussed before gonadotoxic treatment - oocyte cryopreservation using random-start protocols is feasible within two weeks and is the standard approach for female patients of reproductive age.
Pancreatic cancer - painless jaundice with palpable gallbladder (Courvoisier's sign). Double duct sign on CT. New-onset diabetes may be an early feature. Whipple procedure if resectable, followed by adjuvant gemcitabine-capecitabine.
Adrenal incidentalomas require systematic hormonal assessment for phaeochromocytoma, cortisol excess, and aldosteronism - always exclude phaeochromocytoma before any invasive procedure to prevent hypertensive crisis.
Merkel cell carcinoma presents as a rapidly growing violaceous nodule in elderly immunosuppressed patients - CK20-positive and TTF-1-negative immunohistochemistry is diagnostic, with management combining surgery and adjuvant radiotherapy.
Prostate cancer - mpMRI before biopsy per NICE. Gleason 4+3 is more aggressive than 3+4. High-risk localised disease requires radical prostatectomy or radiotherapy with ADT. Active surveillance is for low-risk disease only.
Three UK national cancer screening programmes exist - breast (mammography, 50-71), bowel (FIT, 50-74), and cervical (HPV primary testing, 25-64) - know the eligible ages, intervals, and modalities for each.
Mesothelioma requires histological confirmation as pleural cytology is insensitive - all patients must be informed about compensation rights including industrial injuries benefit and civil claims within statutory time limits.
Painless visible haematuria over 45 years - urgent 2-week wait referral for cystoscopy and CT urogram. Smoking and occupational chemical exposure are major risk factors. TURBT with intravesical BCG for high-risk non-muscle-invasive disease.
Anterior mediastinal masses in young men require urgent tumour marker assessment - elevated AFP excludes pure seminoma, and BEP chemotherapy is the standard first-line treatment for extragonadal germ cell tumours.
CRS from CAR-T therapy presents with fever, hypotension, and markedly elevated IL-6 - tocilizumab is first-line for grade 3-4 CRS, with corticosteroids reserved for refractory cases.
LEMS - anti-VGCC antibodies, strongly associated with SCLC. Weakness improves with repetition, opposite to myasthenia gravis. Autonomic features are prominent. Incremental response on high-frequency repetitive nerve stimulation is diagnostic.
Limited-stage SCLC - concurrent chemoradiotherapy with cisplatin-etoposide plus prophylactic cranial irradiation if responding. Extensive-stage - add checkpoint immunotherapy to platinum-etoposide.
Thyroid nodules - ultrasound U-classification guides FNA. Thy5 is diagnostic of malignancy. Papillary carcinoma is the commonest thyroid cancer with excellent prognosis. Total thyroidectomy with radioactive iodine for intermediate-high risk disease.
TLS - hyperkalaemia, hyperphosphataemia, hyperuricaemia, and hypocalcaemia. Aggressive hydration is the cornerstone of prevention. Rasburicase for high-risk patients. Only treat symptomatic hypocalcaemia.
Cervical screening uses HPV primary testing. HPV-positive with abnormal cytology - refer to colposcopy. HPV-positive with normal cytology - repeat at 12 months. HPV vaccination has near-eliminated cervical cancer in vaccinated populations.
Stage III colorectal cancer - adjuvant CAPOX or FOLFOX chemotherapy. IDEA trial supports 3 months for low-risk, 6 months for high-risk stage III. Test microsatellite instability status. Right-sided tumours present with anaemia.
Testicular GCTs - AFP elevated in NSGCT but never pure seminoma. Radical inguinal orchidectomy is diagnostic and therapeutic. Stage I NSGCT - surveillance is preferred. BEP chemotherapy for advanced disease with excellent cure rates.
Rituximab targets CD20 on B-cells - first-infusion reactions are cytokine-mediated and not anaphylactic, managed by slowing the infusion rate with premedication rather than permanent discontinuation.
Mesothelioma - 20-50 year latency after asbestos exposure. Pleural biopsy is essential as cytology has low sensitivity. Pemetrexed-cisplatin or nivolumab-ipilimumab for systemic treatment. Industrial compensation may be available.
Migratory thrombophlebitis mandates urgent investigation for occult malignancy, particularly pancreatic cancer - LMWH is preferred over warfarin for cancer-associated thrombosis due to superior efficacy.
TKI toxicity - hypertension (ACE inhibitor/ARB), hypothyroidism (levothyroxine), hand-foot syndrome (emollients and dose reduction), diarrhoea (loperamide). Side effects are generally manageable. Dose modification preferred over permanent discontinuation.
Denosumab is preferred over bisphosphonates in renal impairment for metastatic bone disease - dental assessment before starting is essential to minimise osteonecrosis of the jaw risk.
Gestational trophoblastic neoplasia is treated according to the FIGO score - low-risk disease (0-6) receives single-agent methotrexate whilst high-risk disease (>=7) with metastases requires multi-agent EMA-CO (RCOG Green-top Guideline No. 38).
HCC - 6-monthly ultrasound surveillance in cirrhosis. Non-invasive diagnosis by characteristic arterial enhancement and washout. BCLC staging guides treatment. Resection, transplantation, or ablation for early-stage disease.
When stimulant laxatives fail in opioid-induced constipation, escalate to a peripherally-acting mu-opioid receptor antagonist such as naloxegol - this targets the mechanism without compromising pain relief.
Graded exercise is the best evidence-based intervention for cancer-related fatigue - exclude reversible causes, refer to specialist fatigue management, and reserve pharmacological agents for refractory cases in the palliative setting.
Treat hypercalcaemia of malignancy with aggressive IV saline rehydration followed by zoledronic acid 4mg - avoid routine furosemide, and recognise that corticosteroids are only effective in haematological malignancies.
For refractory breathlessness in advanced COPD, start low-dose immediate-release oral morphine (1-2mg PRN), titrate carefully, and convert to modified-release once stable - evidence supports safety without increased mortality risk.
Capacity is decision-specific and time-specific under the Mental Capacity Act - assess using the four functional criteria (understand, retain, weigh, communicate) and never assume incapacity based on diagnosis alone.
Dexamethasone 16mg daily is first-line for raised intracranial pressure from brain metastases - it reduces vasogenic oedema within 24-48 hours; always co-prescribe a PPI and taper to the minimum effective dose.
The Liverpool Care Pathway was replaced by individualised care plans under NICE NG31 following the Neuberger Review - assess each dying patient individually, communicate sensitively, rationalise medications, and prescribe anticipatory drugs.
Lorazepam sublingual is first-line for acute episodic anxiety in palliative care - it has no active metabolites, reliable sublingual absorption, and intermediate duration; reserve midazolam for subcutaneous use when oral routes fail.
Reasonable adjustments under the Equality Act are mandatory for patients with learning disabilities - use adapted pain tools like DisDAT, communicate through preferred methods including Makaton, and involve familiar carers as essential partners in care.
Culturally sensitive end-of-life care actively accommodates religious practices - facilitate Qibla positioning, continuous prayer, ritual washing facilities, and rapid body release; the Equality Act 2010 requires reasonable adjustments for religious observance.
Long-term indwelling peritoneal catheters enable home drainage of recurrent malignant ascites - they reduce hospital visits and improve quality of life; diuretics are largely ineffective in malignant ascites unlike cirrhotic ascites.
Distinguish spiritual distress from depression in palliative care - chaplaincy referral and psychological support address existential suffering, meaning, and faith-related distress more appropriately than pharmacological approaches alone.
Cancer-related sweating is prostaglandin-mediated - NSAIDs (naproxen) are first-line treatment; thalidomide and anticholinergics are second-line options; distinguish paraneoplastic sweating from infection, medications, and hormonal causes before treatment.
Convert oral morphine to transdermal fentanyl using the ratio of 90mg oral morphine per 24 hours to 25 microgram/hour patch - allow 12-24 hours for onset, prescribe parenteral breakthrough, and avoid in opioid-naive patients.
Comprehensive advance care planning requires three tools - a legally binding ADRT for specific treatment refusals, an LPA for welfare registered with the OPG, and an advance statement for broader preferences; next of kin has no automatic legal authority.
Safeguarding concerns must be raised under the Care Act 2014 regardless of the patient's wishes regarding intervention - speak with the patient alone, document factual observations, report to adult safeguarding, and address missing controlled drugs separately.
Catastrophic terminal haemorrhage management focuses on comfort - prescribe anticipatory midazolam, prepare dark towels to reduce visual impact, counsel the family, and document a clear protocol emphasising rapid sedation over futile resuscitation.
Steroid-induced diabetes causes predominantly postprandial hyperglycaemia requiring insulin - always aim for the minimum effective corticosteroid dose, monitor for proximal myopathy, and plan gradual taper to avoid adrenal crisis.
Honest age-appropriate communication about parental terminal illness protects children psychologically - use the word "cancer," acknowledge what children already perceive, and refer to specialist services like Winston's Wish for family support.
Clinically assisted nutrition and hydration are medical treatments requiring best interests assessment - families cannot demand treatment deemed clinically inappropriate; resolve disagreements through discussion, second opinion, and ethics review before court application.
Alfentanil is the safest opioid in end-stage renal failure - it is hepatically metabolised to inactive metabolites with a short half-life allowing safe titration via subcutaneous syringe driver.
No legal timeframe mandates when a GP must attend an expected home death - attend reasonably promptly by agreement with the family, verify death with five-minute examination, issue the MCCD if seen within 28 days, and provide bereavement support.
Pregabalin is preferred over gabapentin in palliative care for its linear pharmacokinetics, twice-daily dosing, and anxiolytic benefit - always reduce the dose in renal impairment and warn patients about drowsiness and driving.
For opioid-naïve patients, start oral morphine immediate-release at low doses with four-hourly dosing - titrate to effect before converting to modified-release, always co-prescribing laxatives from the outset.
Hypodermoclysis using 0.9% saline via a butterfly needle is a practical, safe method of hydration in palliative care - administer up to 1L over 8-12 hours, avoid dextrose solutions, and rotate sites regularly.
Refer to specialist palliative care based on complexity of need, not proximity to death - the Temel trial showed early integration improves quality of life, reduces depression, and may even extend survival in advanced lung cancer.
Ketamine is a specialist-supervised adjuvant for refractory neuropathic cancer pain - start low at 50-100mg/24 hours subcutaneously, titrate gradually, and co-prescribe a benzodiazepine or haloperidol to manage psychomimetic effects.
Topical metronidazole is first-line for fungating wound odour targeting anaerobic bacteria - combine with charcoal dressings for absorption, use non-adherent dressings to prevent bleeding, and address the significant psychosocial impact.
In palliative care, dilute naloxone and titrate in small increments to restore safe respiration without full reversal - aim for respiratory rate above 8, not full alertness.
Glycopyrronium is first-line for death rattle as it lacks central sedative effects - administer early to prevent secretion accumulation, and always reassure families that the noise does not indicate patient distress.
Before starting methadone, correct electrolytes, review and stop QTc-prolonging drugs, and obtain a baseline ECG - methadone conversion is non-linear and unpredictable, requiring specialist supervision throughout.
Regular mouth care with moistening agents is essential comfort care in dying patients - treat oral candidiasis with topical nystatin when swallowing is impaired, and address anticholinergic-induced xerostomia with frequent oral moistening.
Always co-prescribe a stimulant laxative with opioids - for established constipation, combine oral stimulant plus softener with rectal interventions, and avoid lactulose which causes bloating without addressing opioid-mediated dysmotility.
For sialorrhoea in MND refractory to oral anticholinergics, use hyoscine patches for continuous anticholinergic effect and consider botulinum toxin injection to salivary glands - NICE recommends this stepwise approach for progressive bulbar disease.
For insomnia in palliative care, address modifiable factors first - eliminate daytime napping, optimise corticosteroid timing before 2pm, and use sleep restriction therapy before considering short-term hypnotics.
For cholestatic pruritus refractory to cholestyramine, consider rifampicin (second-line) then sertraline or naltrexone (third-line) - antihistamines are ineffective as cholestatic itch is not histamine-mediated.
Low-dose oral morphine is first-line pharmacotherapy for refractory breathlessness in ILD - start at 5mg modified-release twice daily, titrate gradually, and combine with handheld fan therapy and oxygen for multimodal symptom relief.
DNACPR is a clinical decision, not a family consent process - the Tracey judgment requires patient consultation but families cannot override clinical futility judgements or the patient's own expressed wishes.
Hypoactive delirium is frequently missed - always screen for reversible causes including hypercalcaemia, infection, opioid toxicity, and metabolic derangement before starting antipsychotics or assuming terminal decline.
Malignant pericardial tamponade requires urgent echocardiography-guided pericardiocentesis - diuretics are contraindicated; consider pericardial window or indwelling catheter to prevent recurrence, which occurs in 40-70% after simple aspiration alone.
Pathological long bone fractures require surgical fixation for pain control and functional restoration - conservative management fails because tumour prevents healing; follow surgery with postoperative radiotherapy and systemic bone-protective agents.
Cancer cachexia is metabolically driven and not reversed by feeding alone - offer short-term dexamethasone for appetite, counsel families about the nature of cachexia, and avoid artificial nutrition in the last weeks of life.
Trained nurses can verify death, but only a registered medical practitioner who attended the patient in life can certify it - since 9 September 2024 (England and Wales) the 28-day attendance rule no longer applies and all non-coronial deaths undergo independent medical examiner scrutiny before registration.
A valid ADRT refusing life-sustaining treatment must be written, signed, witnessed, and include a life-at-risk statement - it is legally binding and cannot be overridden by family members unless there is clear evidence of withdrawal.
BRONJ presents as exposed jaw bone persisting beyond eight weeks in bisphosphonate-treated patients - manage conservatively with antibiotics, chlorhexidine, and withholding the bisphosphonate; prevention through pre-treatment dental assessment is essential.
Refer to hospice palliative care early when the surprise question answer is "no" - hospice services support all life-limiting conditions alongside active treatment, improving symptoms and quality of life without requiring treatment withdrawal.
Since 9 Sept 2024 all non-coronial deaths in England and Wales undergo Medical Examiner scrutiny and the 28-day rule has been replaced.
Never use modes of death (cardiac arrest, respiratory failure) on the MCCD - construct a logical causal sequence from immediate cause (1a) through underlying disease (1c), and include contributing conditions in Part 2.
Acute malignant stridor requires dexamethasone IV, heliox, and titrated low-dose opioids and anxiolytics - respect the patient's wish for consciousness by using proportionate dosing initially, with palliative sedation available for escalation.
Since the 2018 Supreme Court ruling in Y, court authorisation is not mandatory for CANH withdrawal if the clinical team and family agree on best interests - but any disagreement should still be referred to the Court of Protection.
Assisted dying is illegal under the Suicide Act 1961 in England and Wales - respond to requests with empathy, explore underlying fears, and offer comprehensive palliative care including advance planning and palliative sedation for refractory symptoms.
MSCC requires immediate dexamethasone 16mg IV and urgent whole-spine MRI - functional outcome depends on neurological status at treatment, so do not delay steroids while awaiting imaging.
Octreotide via syringe driver is essential for inoperable malignant bowel obstruction - it reduces secretions and vomiting, enabling nasogastric tube removal; metoclopramide is absolutely contraindicated in complete obstruction.
When dying patients cannot take oral anticonvulsants, add midazolam 20-30mg/24hr to the syringe driver for continuous seizure prophylaxis - prescribe 5-10mg SC PRN for breakthrough, and consider phenobarbital as second-line.
Single-fraction palliative radiotherapy (8 Gy) is first-line for localised painful bone metastases - it is as effective as multi-fraction schedules, more convenient, and achieves pain relief in approximately two-thirds of patients.
Neuropathic cancer pain requires adjuvant analgesics alongside opioids - pregabalin or gabapentin are first-line, with pregabalin preferred in palliative care for its predictable pharmacokinetics and faster dose titration.
EUS-guided coeliac plexus neurolysis with absolute alcohol is the gold-standard interventional procedure for refractory visceral pain in pancreatic cancer - it reduces pain in 70-90% of patients and substantially lowers opioid requirements.
Palliative emergencies require bedside anticipatory medications - midazolam for catastrophic haemorrhage sedation and seizures, tranexamic acid for wound bleeding, dexamethasone and heliox for malignant stridor.
For persistent generalised anxiety in palliative care, sertraline combined with psychological therapy is first-line - use short-term benzodiazepines only as bridging while SSRIs reach efficacy, and address specific fears about dying through adapted CBT.
The Gold Standards Framework identifies patients in the last year of life using the surprise question and clinical indicators - add to the palliative care register, initiate advance care planning, and ensure MDT review regardless of diagnosis.
In MND, initiate NIV when respiratory symptoms emerge with declining FVC, and arrange gastrostomy while FVC exceeds 50% - early intervention for both improves outcomes and procedural safety significantly.
Pelvic tenesmus requires multimodal management targeting neuropathic and nociceptive components - dexamethasone for nerve root oedema, topical rectal treatments for local inflammation, and early referral for interventional nerve blocks in refractory cases.
Medical management of inoperable malignant bowel obstruction combines hyoscine butylbromide for antisecretory and antispasmodic effect, dexamethasone to reduce oedema, and an antiemetic - avoid prokinetics and oral laxatives in complete obstruction.
Cyclizine is the most commonly incompatible drug in syringe drivers - it precipitates with many combinations; levomepromazine is a safer antiemetic alternative when multiple drugs are co-administered.
Oral-to-subcutaneous conversion is divide by 2 for morphine and divide by 3 for diamorphine - diamorphine is preferred in UK syringe drivers due to superior solubility and compatibility with co-administered drugs.
Anticipatory medications cover four symptoms - pain, agitation, nausea, and secretions - prescribed as subcutaneous as-needed injections with clear indications, ensuring availability in the home before the patient deteriorates.
SPIKES provides a structured approach to breaking bad news - Setting, Perception, Invitation, Knowledge, Emotions, Strategy - always use a warning shot, deliver information in portions, and respond to emotions with empathy before discussing plans.
Prolonged grief disorder is a distinct diagnosis characterised by persistent yearning and functional impairment beyond six months - specialist bereavement counselling with grief-focused CBT is first-line, not antidepressants alone.
Offer ICD deactivation (shock function only) to heart failure patients approaching end of life to prevent distressing shocks - low-dose morphine is effective for refractory breathlessness, and palliative care should be integrated alongside continued disease-modifying therapy.
Baclofen 5mg TDS is first-line for persistent hiccups in palliative care via GABA-B mediated phrenic nerve inhibition - gabapentin is an effective alternative; avoid chlorpromazine due to significant adverse effects.
Self-expanding metal stents provide rapid dysphagia relief within 24-48 hours for malignant oesophageal obstruction - covered stents reduce tumour ingrowth; counsel patients on soft diet and upright positioning to prevent complications.
NMS demands immediate cessation of the offending antipsychotic, aggressive fluid resuscitation, and active cooling - dantrolene sodium and bromocriptine are the key pharmacological interventions for persistent hyperthermia and rigidity in this medical emergency.
Recovery is a personal journey emphasising hope, identity, meaning, empowerment, and connectedness (CHIME) - it complements clinical treatment and is implemented through co-production, supported employment, peer support, and shared decision-making.
Benzodiazepine tapering uses diazepam as the preferred agent due to its long half-life - reduce by one-eighth every two weeks, slow the taper in the final stages below 5mg, and never stop abruptly after prolonged use as withdrawal seizures can be fatal.
Ganser syndrome is a dissociative disorder characterised by approximate answers in the context of severe stress - distinguish from malingering (unconscious versus conscious), exclude organic causes, adopt a supportive non-confrontational approach, and address underlying psychosocial stressors.
rTMS is a NICE-endorsed non-invasive neuromodulation for treatment-resistant depression - it targets the left DLPFC without anaesthesia or cognitive side effects. Less efficacious than ECT for severe depression but offers a favourable risk-benefit profile for moderate treatment-resistant cases.
Perinatal depression requires specialist perinatal mental health involvement and shared decision-making - sertraline is the preferred SSRI if medication is needed. Untreated depression poses significant risks; paroxetine should be avoided in the first trimester due to cardiac teratogenicity.
Structured professional judgement using tools like HCR-20v3 is the gold standard for violence risk assessment; it combines historical, clinical, and risk management factors in a formulation-based approach, avoiding the pitfalls of unstructured clinical opinion or purely actuarial prediction.
Personality disorder crisis management requires compassionate care, structured risk assessment, and collaborative safety planning - avoid routine admission (which may be counterproductive) and routine pharmacotherapy. Every crisis presentation deserves proper assessment regardless of frequency.
Depression with reduced libido, visual field defects, and raised prolactin requires urgent pituitary imaging - macroprolactinomas are treated with cabergoline, and hypopituitarism must be managed with cortisol replacement before thyroxine.
Confidentiality may be breached when necessary to protect identifiable individuals from serious harm - GMC guidance supports disclosure where the public interest outweighs the patient's right to privacy.
In TCA overdose, QRS widening above 100ms demands immediate intravenous sodium bicarbonate targeting a pH of 7.45-7.55 - this overcomes sodium channel blockade and is the single most important intervention. Flumazenil is absolutely contraindicated.
NICE rapid tranquillisation follows oral-first then IM if refused - intramuscular lorazepam 1-2mg is the preferred parenteral agent. Continuous vital sign monitoring every 15 minutes is mandatory, and resuscitation equipment including flumazenil must be immediately available.
Section 5(2) detains voluntary inpatients for up to 72 hours pending formal MHA assessment - it is a doctor's holding power, not a treatment order. Section 5(4) is the nurse's equivalent lasting six hours, used only when a doctor is not immediately available.
Factitious disorder requires compassionate non-confrontational engagement, psychiatric liaison, cross-hospital care coordination, and safeguarding assessment - avoid accusatory confrontation which drives disengagement, and always consider safeguarding implications for any dependants.
When switching serotonergic antidepressants, cross-taper gradually over two to four weeks - reduce the first agent whilst introducing the second at low dose. Monitor for discontinuation symptoms and serotonin syndrome. A two-week washout is only mandatory for MAOI switches.
Subacute memory loss with seizures, personality change, and weight loss in a smoker should prompt urgent investigation for paraneoplastic limbic encephalitis with antibody testing and malignancy screening.
The Mental Capacity Act requires a structured best interests decision when patients lack capacity - consult family as information providers not decision-makers, consider past wishes and values, choose the least restrictive option, and document the process thoroughly.
PTSD first-line treatment is trauma-focused psychological therapy - either TF-CBT or EMDR. SSRIs are second-line when psychological therapy is unavailable, declined, or ineffective. Psychological debriefing is not recommended and may cause harm.
In moderate-to-severe Alzheimer's, add memantine to the existing cholinesterase inhibitor rather than switching - the DOMINO trial showed combination therapy is superior, and NICE recommends continuing beneficial AChEIs throughout the disease course.
For acute mania on an existing mood stabiliser, add an antipsychotic - NICE recommends haloperidol, olanzapine, quetiapine, or risperidone. Never prescribe antidepressants in mania. Consider Mental Health Act assessment when severity, financial risk, and loss of insight preclude voluntary admission.
Bipolar depression - never antidepressant monotherapy. Stop the fluoxetine, then add quetiapine or lamotrigine to the existing lithium per NICE CG185. Venlafaxine and tricyclics carry the highest manic-switch risk.
Wernicke encephalopathy demands IV Pabrinex before glucose - glucose metabolism depletes thiamine stores and can precipitate neurological crisis. Give two pairs of Pabrinex three times daily for at least five days; oral thiamine is inadequate due to impaired absorption.
In cocaine-associated chest pain, beta-blockers are absolutely contraindicated due to unopposed alpha stimulation - use benzodiazepines first-line to reduce sympathomimetic drive, GTN for coronary vasospasm, and aspirin for antiplatelet effect. Urgent cardiology input is essential.
An AUDIT score above 20 with evidence of liver disease requires a structured brief intervention, non-invasive liver fibrosis assessment with FibroScan, and referral to specialist alcohol services - brief interventions have an NNT of approximately 8 and are the cornerstone of early alcohol harm reduction.
Puerperal psychosis is a psychiatric emergency presenting within days of delivery with rapidly fluctuating psychosis, mood lability, and confusion - admit urgently to a mother and baby unit to maintain bonding, commence antipsychotic treatment, and plan for the 25-50% recurrence risk in future pregnancies.
Autistic patients in hospital require reasonable adjustments under the Equality Act 2010 - environmental modification, sensory accommodation, carer presence, dietary flexibility, and clear communication. Address the environment first before considering pharmacological approaches to distress.
Dementia of any severity requires mandatory DVLA notification - early-stage patients may retain their licence following formal assessment. If a patient refuses to notify, GMC guidance allows the clinician to contact the DVLA directly to protect public safety.
BDD requires high-dose SSRIs (comparable to OCD dosing) combined with specialist CBT-BDD - cosmetic procedures are contraindicated as they do not resolve the underlying preoccupation. Treat for at least 12 weeks before assessing SSRI response.
Always check thyroid function in new psychiatric presentations - thyrotoxicosis closely mimics anxiety disorders, and failure to respond to psychiatric treatment should prompt investigation for organic causes including thyroid disease.
Delirium is distinguished from dementia by acute onset, fluctuating consciousness, and identifiable precipitants - use the 4AT for rapid screening, systematically address reversible causes using PINCH ME, and stop all anticholinergic medications immediately.
Visual hallucinations with preserved insight and visual impairment suggest Charles Bonnet syndrome - reassurance and psychoeducation are therapeutic, antipsychotics are not indicated, and optimising remaining vision may reduce hallucination frequency.
Focus on modifiable risk factors - alcohol misuse, undertreated depression, social isolation, and access to means are all addressable. Removing access to firearms is an urgent safety priority. NICE recommends comprehensive psychosocial assessment rather than reliance on risk prediction tools.
GAD follows NICE stepped care - start with low-intensity CBT-based interventions for moderate symptoms before escalating to SSRIs or high-intensity individual CBT. Benzodiazepines should not be used beyond very short-term crisis management due to dependence risk.
Acute dystonia requires immediate intramuscular procyclidine 5mg - response occurs within 20 minutes. Young males on high-potency typical antipsychotics are at greatest risk. Switch to an atypical antipsychotic and prescribe short-term oral anticholinergics to prevent recurrence.
Panic disorder first-line is CBT addressing catastrophic misinterpretation of bodily sensations - add an SSRI at low starting dose if CBT is insufficient. Avoid benzodiazepines as they cause dependence and undermine psychological therapy effectiveness through safety behaviour reinforcement.
Bulimia nervosa management follows NICE stepped care - guided self-help first, then CBT-ED if insufficient. Fluoxetine at 60mg daily (not 20mg) is the pharmacological treatment of choice and can be offered alongside or sequentially with psychological therapy.
Safeguarding children of mentally ill parents is a statutory duty - refer to children's social services, ensure multi-agency assessment, and always prioritise the child's welfare as paramount under the Children Act 1989.
MAOI plus tyramine-rich food causes a potentially fatal hypertensive crisis through uninhibited catecholamine release - treat urgently with intravenous phentolamine. Patients on MAOIs must strictly avoid mature cheese, cured meats, fermented foods, and red wine.
DoLS must be applied whenever a person lacking capacity is under continuous supervision and control and not free to leave (Cheshire West test) - hospitals can grant urgent authorisation for seven days whilst the local authority processes the standard application.
New-onset Capgras delusion in middle age with cognitive impairment and frontal signs demands urgent investigation for organic pathology - Lewy body dementia is the most common neurodegenerative association, and comprehensive neuroimaging and blood screening must precede empirical treatment.
QTc above 500ms is a medical emergency - urgently correct potassium and magnesium, stop all non-essential QT-prolonging drugs, switch to safer alternatives, and ensure continuous cardiac monitoring until the QTc normalises below 470ms.
Synthetic cannabinoids are full CB1 agonists causing far more severe toxicity than natural cannabis - standard drug screens are negative.
Cotard delusion presenting with nihilistic beliefs in severe psychotic depression requires urgent inpatient management - ECT is first-line given treatment resistance and life-threatening complications, alongside combination antidepressant-antipsychotic therapy.
Young patients presenting with personality change, movement disorder, and liver dysfunction should be investigated for Wilson disease - Kayser-Fleischer rings and low caeruloplasmin are key diagnostic clues, and early penicillamine treatment can reverse neuropsychiatric symptoms.
Psychiatric symptoms in SLE patients with serological evidence of active disease should prompt consideration of neuropsychiatric lupus - management requires immunosuppression for inflammatory mechanisms and anticoagulation for antiphospholipid-related thrombotic disease.
Cognitive decline in HIV patients with poor viral control should prompt urgent ART optimisation - viral suppression is the most important intervention for HAND, alongside neuropsychological assessment and adherence support.
Postoperative delirium management prioritises identifying and treating precipitating factors - opioid review, electrolyte correction, and infection exclusion precede pharmacological intervention, which should be low-dose haloperidol only when patient safety is at risk.
An amber neutrophil count (1.0-1.499×10⁹/L) requires immediate clozapine cessation - always investigate new cardiac symptoms in the first six weeks with troponin, CRP, and echocardiography to exclude potentially fatal clozapine-associated myocarditis.
Capacity assessment requires a two-stage test (diagnostic then functional) - it is decision-specific, time-specific, and must follow the five statutory principles of the Mental Capacity Act 2005 before any best interests decision is made.
Catatonia demands a lorazepam challenge (1-2mg IV/IM) as both diagnostic test and initial treatment - reduce or stop antipsychotics as they can worsen the condition. ECT is the definitive treatment if benzodiazepines fail within 3-5 days, with response rates exceeding 80%.
Psychotic depression requires combined antidepressant plus antipsychotic therapy - antidepressant monotherapy is insufficient.
Bipolar disorder on a Group 2 licence - patient must notify the DVLA; do not advise continuing vocational driving until formally relicensed.
Section 136 allows police to remove a person appearing mentally disordered to a health-based place of safety for assessment within 24 hours - police stations should no longer be used.
Antipsychotic metabolic syndrome requires proactive multimodal management - lifestyle intervention, consider switching to a metabolically neutral agent, add metformin if switching is inappropriate, and actively treat hypertension and dyslipidaemia.
CTOs require Section 3 detention, agreement of both responsible clinician and AMHP, and allow recall to hospital but not forced community treatment - the OCTET trial found no significant benefit in reducing readmissions, making their use clinically controversial.
Serotonin syndrome is distinguished from NMS by rapid onset, clonus, hyperreflexia, and myoclonus - stop all serotonergic agents, use benzodiazepines for symptom control, and consider cyproheptadine as a specific 5-HT₂A antagonist for refractory cases.
NICE (NG225) mandates psychosocial assessment for every self-harm presentation regardless of frequency - avoid pejorative labelling, develop collaborative safety plans, and consider dialectical behaviour therapy for emotionally unstable personality disorder.
Behavioural change with asterixis and constructional apraxia in a patient with liver disease indicates hepatic encephalopathy - treat with lactulose and rifaximin, not antipsychotics or sedatives.
Malingering involves symptom fabrication for identifiable external gain (financial, legal, drugs) - distinguishing it from factitious disorder where motivation is psychological.
Pathological jealousy carries the highest violence risk of any psychiatric presentation - urgent risk assessment, partner safeguarding, addressing alcohol dependence, and antipsychotic treatment for delusional intensity are the management priorities.
Clozapine rechallenge after neutropenia is not absolutely contraindicated - it requires haematology supervision, prophylactic G-CSF, enhanced monitoring, informed consent, and re-registration with CPMS; consider when no viable alternative exists and prior response was exceptional.
Repeated relapse due to oral medication non-adherence is the primary indication for long-acting injectable antipsychotics - offer collaboratively alongside psychoeducation, and choose formulation based on individual tolerability and dosing convenience.
Social anxiety disorder requires disorder-specific individual CBT as first-line - generic CBT is insufficient. SSRIs (escitalopram, sertraline) are the pharmacological option if CBT is inadequate. Propranolol only addresses autonomic symptoms in performance anxiety, not generalised social anxiety.
CIWA-Ar scores guide management intensity - moderate scores (10-18) require symptom-triggered benzodiazepines, severe scores (>20) indicate high complication risk. Postpone elective procedures during active withdrawal and always commence IV Pabrinex prophylactically.
Severe lithium toxicity requires immediate cessation, aggressive saline resuscitation, and urgent haemodialysis when levels exceed 2.0mmol/L with neurological features or renal impairment - NSAIDs, ACE inhibitors, and thiazides are the commonest drug precipitants.
For SSRI-resistant OCD, augment with low-dose aripiprazole or risperidone before switching medications - ensure the SSRI has been trialled at maximum dose for at least 12 weeks with concurrent ERP therapy before concluding resistance.
NICE recommends against routine pharmacotherapy for personality disorder - gradually rationalise accumulated polypharmacy and prioritise psychological therapies (DBT, MBT). Medication should only target specific comorbid diagnoses, not core personality disorder features.
The triad of gait disturbance, dementia, and urinary incontinence with disproportionate ventriculomegaly on imaging suggests NPH - a potentially reversible dementia diagnosed by large-volume LP drainage trial and treated with VP shunt insertion.
Clozapine is indicated after two failed antipsychotic trials - initiate at 12.5mg with slow titration, mandatory weekly blood counts for 18 weeks via CPMS, and intensive cardiac monitoring for myocarditis in the first six weeks with weekly CRP and troponin measurements.
First-episode psychosis requires EIP referral, a low-dose atypical antipsychotic chosen through shared decision-making, and CBTp - clozapine is reserved for treatment-resistant cases after two adequate antipsychotic trials, and building therapeutic alliance takes priority over rapid symptom suppression.
Psychiatric symptoms in Cushing syndrome are secondary to hypercortisolism and typically resolve with successful treatment of the underlying cause - prioritise endocrine management over long-term psychiatric medication.
Dual diagnosis requires integrated treatment of both mental illness and substance misuse within one team - consider depot antipsychotics for non-adherence, use assertive outreach for engagement, and address social determinants of health including housing as a treatment priority.