Rapid-recall takeaways distilled from the PLAB 1 question bank, grouped by specialty. One pearl per high-frequency concept. Use it for last-pass revision alongside questions, not as a replacement for them.
800 pearls · 10 specialties · Generated 6 November 2026
Renal & Urology
80 high-yield facts
Weekly Kt/V target 1.7 or above; creatinine clearance 50 L or above; PET classifies membrane transport; high transporters suit APD; residual renal function important; ISPD 2020 guidelines; clinical plus biochemical adequacy; preserve RRF; icodextrin for long dwell; clinical symptoms matter alongside numbers.
Blue dot sign = torsion of appendix testis - preserved cremasteric reflex, normal Doppler, localised upper pole tenderness; managed conservatively; if ANY doubt, explore surgically to exclude testicular torsion; peak age 7-12 years.
Acute urinary retention needs urgent urethral catheterisation - monitor for post-obstructive diuresis, start tamsulosin for TWOC preparation, and check renal function daily as obstructive AKI is common.
XGP mimics renal carcinoma - suspect it when a non-functioning kidney contains a staghorn calculus with chronic infection in a diabetic patient; nephrectomy is definitive treatment.
ATN shows muddy brown casts and FeNa >2% distinguishing it from pre-renal AKI - it follows ischaemia or nephrotoxins and typically recovers with supportive management over 2-4 weeks.
GPA presents with upper/lower respiratory involvement plus RPGN - c-ANCA/PR3-ANCA positive with normal complement and pauci-immune crescents; induce remission with rituximab or cyclophosphamide plus steroids.
Post-transplant triple therapy is tacrolimus + MMF + prednisolone - tacrolimus causes tremor, diabetes, and nephrotoxicity; lifelong immunosuppression is mandatory with trough level-guided dosing.
Severe hypokalaemia with ECG changes requires IV KCl via central line (max 20 mmol/hr) with cardiac monitoring - always correct concurrent hypomagnesaemia as potassium replacement is refractory without it.
Anion gap = Na - (Cl + HCO3); HAGMA causes remembered by MUDPILES - in DKA, use delta-delta ratio to exclude mixed disorders and Winter's formula to confirm respiratory compensation.
Suspected massive PE causing cardiac arrest is an indication for IV alteplase 50mg during CPR - continue resuscitation for at least 60 minutes after thrombolysis to allow time for clot resolution.
Life-threatening asthma features include silent chest, rising PaCO2, and confusion - IV magnesium sulphate is the key escalation step, and ICU must be alerted early for potential ventilatory support.
Rate control with a beta-blocker is first-line for haemodynamically stable AF - DC cardioversion is reserved for instability, and digoxin is no longer first-line monotherapy.
NSTEMI requires dual antiplatelet therapy plus fondaparinux, with timing of angiography guided by the GRACE risk score - thrombolysis is never appropriate for NSTEMI.
Acute heart failure management follows the 'sit up, oxygen, IV furosemide, GTN' approach - avoid IV morphine as it worsens outcomes despite historical use.
Anticoagulate with a DOAC for CHA₂DS₂-VASc score of 2 or above - aspirin has no role in stroke prevention in AF according to current NICE guidelines.
Stage 3 hypertension without end-organ damage requires same-day treatment initiation and early review - hospital admission is only for hypertensive emergencies with papilloedema or acute organ damage.
In COPD exacerbations, target SpO2 88-92% with controlled oxygen - NIV is indicated for persistent hypercapnic acidosis (pH <7.35) and should be started early with ABG reassessment at 1 hour.
Always confirm phaeochromocytoma biochemically with plasma metanephrines before imaging - and never start beta-blockers before adequate alpha-blockade is established.
HFrEF first-line treatment is ACE inhibitor plus beta-blocker titrated to maximum tolerated doses - loop diuretics treat symptoms but do not improve survival.
Pleural fluid pH <7.2 with infection indicates empyema requiring chest drain - intrapleural fibrinolytics (alteplase plus DNase) improve drainage in multiloculated collections.
Endocrine, Metabolic & Haematology
80 high-yield facts
Thyroid storm requires the treatment triad of propranolol, propylthiouracil (not carbimazole), and hydrocortisone - always identify and treat the precipitating cause.
TRALI causes bilateral infiltrates and hypoxia within 6 hours of transfusion without fluid overload - stop the transfusion, provide respiratory support, and avoid diuretics as they will not help.
HHS treatment is slow and cautious - fluids first with 0.9% saline, insulin only if glucose isn't falling with fluids, and aim to normalise osmolality over 48 hours to avoid neurological complications.
Start levothyroxine at 50-100mcg in healthy adults under 65, or 25mcg in elderly or cardiac patients - recheck TSH at 6-8 weeks and titrate to normalise TSH.
Iron deficiency anaemia needs oral ferrous sulphate and investigation of the underlying cause - in premenopausal women with menorrhagia, gynaecological assessment takes priority over GI endoscopy.
Warm AIHA is IgG-mediated with spherocytes on film and positive DAT - treat with prednisolone 1mg/kg/day as first-line and avoid transfusion unless life-threatening.
Sickle cell vaso-occlusive crisis demands strong opioid analgesia within 30 minutes - do not wait or give weak analgesics first, and always investigate for precipitating infection.
Addisonian crisis needs IV hydrocortisone 100mg immediately - never delay for investigations, and ensure all Addison's patients carry a steroid emergency card and injection kit.
Primary hyperparathyroidism with calcium >2.85mmol/L, renal stones, or osteoporosis requires parathyroidectomy - cinacalcet is only for patients unfit for surgery.
Metformin is always first-line for type 2 diabetes - start low, titrate slowly, and consider modified-release if standard formulation causes GI side effects.
Carbimazole is first-line for Graves' disease - always warn patients about agranulocytosis and advise urgent FBC if they develop a sore throat or fever.
Gastrointestinal
80 high-yield facts
HBsAg positive + HBeAg positive + high HBV DNA + raised ALT = immune active chronic hepatitis B requiring treatment. Anti-HBs positivity alone indicates vaccination. Anti-HBc IgG + anti-HBs positive indicates past infection with immunity.
Classic appendicitis with migratory pain to the right iliac fossa, raised inflammatory markers, and peritonism warrants urgent laparoscopic appendicectomy - do not delay for unnecessary imaging when the diagnosis is clinically clear.
Sudden severe epigastric pain with board-like rigidity and shoulder-tip pain in an NSAID user - think perforated peptic ulcer, request an erect chest X-ray for pneumoperitoneum, and prepare for urgent surgical repair.
Painless jaundice with a palpable gallbladder - Courvoisier's law points to pancreatic head malignancy rather than gallstones. Obstructive LFTs show raised ALP and GGT with dark urine and pale stools.
Acute severe UC (Truelove and Witts criteria) - IV hydrocortisone is first-line, assess response at day 3 with Travis criteria, and always give VTE prophylaxis as flares carry high thrombotic risk.
Always test for coeliac disease while the patient is eating gluten - IgA tTG is the first-line test per NICE guidelines, and check total IgA to exclude IgA deficiency causing false negatives.
Dyspepsia with weight loss in patients aged 55 and over - always refer for urgent two-week-wait endoscopy per NICE NG12. Never empirically treat alarm symptoms with a PPI trial.
Confirmed erosive oesophagitis - full-dose PPI for 8 weeks is first-line. Weight loss is the most effective lifestyle intervention. Always review long-term PPI use annually and aim for the lowest effective dose.
Change in bowel habit with rectal bleeding, weight loss, and iron deficiency anaemia in patients over 50 - do not delay with empirical treatment. Refer urgently via the two-week-wait pathway per NICE NG12 for suspected colorectal cancer.
Acute pancreatitis - aggressive IV fluid resuscitation is the single most important initial treatment. Use the modified Glasgow criteria to assess severity. Prophylactic antibiotics are not indicated.
Child & Adolescent Health
80 high-yield facts
The 8-week immunisations are the 6-in-1 vaccine, oral rotavirus, and MenB - advise prophylactic paracetamol specifically after MenB-containing visits and reassure parents that simultaneous vaccination is safe.
Kawasaki disease requires IVIG 2g/kg within 10 days of fever onset plus high-dose aspirin - without treatment, 25% develop coronary artery aneurysms, making early recognition essential.
Absence of pointing by 18 months combined with poor eye contact and lack of pretend play are red flags for autism spectrum disorder - refer urgently rather than adopting a 'wait and see' approach.
Clinical dehydration in children is managed with ORS 50mL/kg over 4 hours as frequent small sips - reserve IV fluids for severe dehydration with shock, and never use loperamide in children under 12.
Replace aqueous cream with a proper emollient applied 3-4 times daily, and step up to moderate-potency topical corticosteroids for moderate eczema - emollients remain the treatment cornerstone and should be continued generously even between flares.
Suspected epiglottitis is a 'do not disturb' emergency - keep the child calm and upright, avoid throat examination, and summon senior anaesthetics and ENT for controlled intubation in theatre with surgical airway backup.
Severe childhood asthma requires immediate oxygen, back-to-back nebulised salbutamol with ipratropium bromide, and early oral prednisolone - escalate to IV salbutamol or IV magnesium sulphate if there is poor response.
Use the NICE gestational age-specific bilirubin charts to determine phototherapy thresholds - continue breastfeeding during treatment, recheck bilirubin at 4-6 hours, and investigate prolonged jaundice beyond 14 days to exclude biliary atresia.
Always use BNFc for paediatric dosing - prescribe in mg not mL; weight-based calculation essential; pharmacokinetics differ from adults; review at 48 hours; IV-to-oral switch when improving; document weight on every prescription.
Reproductive Health
80 high-yield facts
Heavy bleeding with haemodynamic compromise in incomplete miscarriage requires urgent surgical evacuation - always administer anti-D to rhesus-negative women and send tissue for histology.
Ovarian torsion requires emergency laparoscopy for detorsion - always attempt to conserve the ovary even if it appears ischaemic, as most recover function. Dermoid cysts are the commonest cause of torsion in young women.
PID demands immediate empirical antibiotics - ceftriaxone IM stat plus 14 days of doxycycline and metronidazole covers gonorrhoea, chlamydia, and anaerobes. Never delay treatment awaiting swab results, and always arrange partner notification.
Migraine with aura = UKMEC 4 for the COCP because of ischaemic stroke risk; smoking <15/day under 35 is UKMEC 2 on its own; a grandmother with breast cancer at 72 is not a contraindication; offer a progestogen-only method, with the LNG-IUS also treating menorrhagia.
NICE diagnoses gestational diabetes at fasting glucose ≥5.6mmol/L or 2-hour ≥7.8mmol/L - start with diet and exercise, add metformin if targets unmet in 1-2 weeks, and escalate to insulin if still uncontrolled.
The Mirena IUS is NICE first-line for heavy menstrual bleeding, reducing blood loss by 90% - always check and treat iron deficiency anaemia, and consider endometrial biopsy in women over 45 or with red-flag features.
Uterine atony causing PPH requires bimanual compression plus stepwise uterotonics - oxytocin first, then ergometrine, carboprost, and misoprostol, with early tranexamic acid as per the WOMAN trial.
Endometriosis with subfertility and endometrioma requires specialist referral - do not prescribe hormonal suppression in women actively trying to conceive, and mildly elevated CA-125 is common in endometriosis and does not indicate malignancy.
Asymptomatic bacteriuria in pregnancy must always be treated - untreated, it carries a 20-40% risk of pyelonephritis. Cefalexin is first-line; avoid trimethoprim in the first trimester and nitrofurantoin at term.
Neurosciences & Senses
80 high-yield facts
Thrombolysis with alteplase within 4.5 hours is the cornerstone of acute ischaemic stroke management - CT to exclude haemorrhage is all that is needed before treatment.
GBS requires urgent IVIg and regular FVC monitoring every 4 hours - corticosteroids are ineffective, and ICU referral is needed if FVC falls below 20mL/kg or one-third of predicted.
Valproate most teratogenic AED - 10% malformation rate, 30-40% neurodevelopmental risk; MHRA Pregnancy Prevention Programme mandatory; switch before conception to lamotrigine or levetiracetam; 5mg folic acid daily; annual specialist review with signed consent.
Post-infectious demyelination in children; encephalopathy required; large bilateral asymmetric lesions; similar age lesions; MOG antibodies 30-50%; oligoclonal bands absent; IV methylprednisolone; monophasic with good recovery; molecular mimicry mechanism; distinguish from MS.
Friedreich ataxia = FXN GAA expansion + ataxia + areflexia + extensor plantars + cardiomyopathy; cardiac disease is the leading killer; omaveloxolone is the first approved therapy.
Remove infected shunt entirely; S. epidermidis commonest with biofilm; EVD for temporary drainage; vancomycin IV and intrathecal; reinsert after 48-72 hours sterile cultures; antibiotics alone 80 percent failure; IDSA 2017; biofilm 1000-fold resistance; antibiotic-impregnated catheters preventive.
Riluzole only disease-modifying MND drug - glutamate excitotoxicity; 2-3 months survival benefit; start at diagnosis; monthly LFTs for 3 months then quarterly; Bensimon and Lacomblez trials; NICE NG42; does not halt progression; 50mg BD; hepatotoxicity risk.
PML = JC virus + immunosuppression + multifocal non-enhancing white matter lesions; start ART for HIV-associated PML - no specific antiviral exists; monitor for IRIS.
Chlordiazepoxide first-line for alcohol withdrawal - fixed-dose reducing over 7-10 days; prevent seizures and delirium tremens; always co-prescribe Pabrinex; CIWA-Ar guides symptom-triggered dosing inpatient.
Bupropion for smoking cessation - NDRI mechanism; seizure risk is the critical concern; contraindicated in epilepsy and eating disorders; start one to two weeks before quit date; no sexual dysfunction or weight gain; can combine with SSRIs cautiously.
the AMHP is the applicant and decision-maker - they apply for detention, not the doctors who provide medical recommendations.
Charles Bonnet syndrome causes visual hallucinations with preserved insight in visually impaired patients - reassurance and vision optimisation are first-line, not antipsychotics.
Dissociative amnesia selectively erases autobiographical memory while preserving procedural skills - organic amnesia does the opposite, making this distinction diagnostically crucial.
CBT is first-line for depression, anxiety, OCD, PTSD, and bulimia - it targets cognitive distortions through restructuring and behavioural experiments; match therapy to condition per NICE guidance.
EMDR is equally effective as TF-CBT for PTSD - uses bilateral stimulation during trauma memory processing; requires less verbal recounting; eight-phase protocol; suitable for patients who find prolonged reliving overwhelming.
PNES are diagnosed by video-EEG showing no epileptiform activity during an event - treat with CBT, not antiepileptics, and validate the patient's experience.
Hoarding disorder requires specialist CBT and multiagency support - forced clearance without therapy leads to re-accumulation and psychological harm.
Pregabalin for GAD - Schedule 3 controlled drug since 2019; faster anxiolytic onset than SSRIs; alpha-2-delta calcium channel mechanism; prescriptions limited to 30 days; monitor for misuse; dual benefit in comorbid neuropathic pain.
Musculoskeletal
80 high-yield facts
EGPA is asthma + eosinophilia + vasculitis - cardiac involvement is the leading cause of death; MPO/p-ANCA positive in only ~40% (PR3/c-ANCA is a negative classification item); mepolizumab is approved for relapsing disease.
Denosumab - anti-RANKL antibody every 6 months; NEVER stop abruptly (rebound vertebral fractures); transition to bisphosphonate before stopping; correct hypocalcaemia and vitamin D first; dental check for ONJ risk; NICE TA204 second-line.
Boutonniere - flexed PIP, hyperextended DIP, central slip rupture; swan neck - hyperextended PIP, flexed DIP, volar plate laxity; ulnar deviation at MCPs; chronic synovitis damages tendons and ligaments; functional assessment guides surgery; passively correctable vs fixed determines options.
WCC 50,000+ traditionally suggests septic joint - but not absolute; immunosuppressed patients have lower counts; prosthetic joints have much lower thresholds; neutrophil percentage over 90% important; crystals can cause very high WCC; clinical context guides management; early or treated infection may have lower counts.
Treat-to-target - urate below 360µmol/L standard or below 300µmol/L for tophaceous or severe gout; crystals dissolve below saturation point; monitor every 3-6 months; lifelong therapy; crystal dissolution takes 12-24 months; normal lab range is irrelevant for gout targets.
Septic olecranon bursitis is usually caused by S. aureus - flucloxacillin with serial aspiration is first-line; never inject corticosteroid into a potentially infected bursa.
Osteoarthritis management follows NICE core principles - exercise, weight loss, and education first, then topical NSAIDs before oral. Joint replacement is the last resort when conservative measures have been optimised.
Allopurinol - start 100mg, titrate by 100mg every 4 weeks to target urate; prophylactic colchicine for 6 months; start 2-4 weeks after acute flare resolves; reduce starting dose in CKD; HLA-B*5801 screening in high-risk groups.
Oral PDE4 inhibitor; increases cAMP; no TB screening; no blood monitoring; lower infection risk; GI side effects settle over weeks; weight loss monitor; MHRA depression warning; moderate efficacy ACR20 40%; titrate over 5 days; NICE TA433; suitable for biologic-averse patients.
Ethics & Others
80 high-yield facts
ADRTs are legally binding to refuse specific treatments - must be written, signed, and witnessed if refusing life-sustaining treatment; ReSPECT covers all emergency treatment preferences (not just CPR); LPA provides a decision-maker if capacity is lost; review regularly.
Never Events are wholly preventable serious incidents with established national systemic barriers (e.g. WHO Surgical Safety Checklist for wrong-site surgery) - report via LFPSE, investigate under PSIRF, and discharge the statutory duty of candour with the patient and family.
Groups of GP practices; 30,000-50,000 patients; established 2019; ARRS additional roles; clinical pharmacists social prescribers physiotherapists; GP Clinical Director; network DES contract; building blocks of ICS; extended access; Long Term Plan; tackling health inequalities.
Quadruple test at 14+2-20+0 weeks - 4 serum markers, no ultrasound; 80% detection rate (lower than combined test); AFP and uE3 LOW, beta-hCG and inhibin-A HIGH in Down syndrome; same risk thresholds; raised AFP alone may indicate neural tube defect; NIPT available as contingent test.
Anaphylaxis - adrenaline IM first and immediately; anterolateral thigh; 0.5mg over 12 years; repeat at 5 minutes; lie flat with legs up unless breathing difficulty; antihistamines adjunct not replacement; biphasic reaction risk; 999 ambulance; Resuscitation Council UK algorithm.
The fit note allows 'may be fit for work' with adjustments - prolonged absence worsens outcomes; a phased return with modified duties supports recovery and sustained employment.
Medical confidentiality applies equally to prisoners - dual loyalty must always resolve in favour of the patient unless overriding public interest exists; institutional convenience does not justify disclosure.
Emergency treatment must never be withheld or delayed because the original procedure was performed abroad - treat the acute presentation fully, then address administrative and commissioning questions later.
PPE selection - risk assessment based; FFP3 for airborne TB, measles, varicella; surgical mask for droplet; fit testing required for FFP3; hierarchy of controls PPE is last; donning and doffing sequence critical; gloves for body fluids; apron for splashes; UKHSA and HSE; contamination during removal; eye protection for splash-generating procedures.
AML - benign with fat, smooth muscle, vessels; macroscopic fat on CT diagnostic; four-centimetre threshold for intervention; TSC-associated bilateral multifocal; everolimus EXIST-2 trial; embolisation for haemorrhage; nephron-sparing approach; Wunderlich syndrome; NICE TA318; EAU guidance.
TLS causes hyperkalaemia, hyperuricaemia, hyperphosphataemia, and hypocalcaemia - treat hyperkalaemia urgently, use rasburicase for uric acid, and do not correct asymptomatic hypocalcaemia.
Lupus nephritis requires renal biopsy for ISN/RPS classification - Class III/IV needs corticosteroids plus mycophenolate or cyclophosphamide, and hydroxychloroquine should be continued in all SLE patients.
HRS-1 - functional renal failure, no structural damage; splanchnic vasodilation mechanism; terlipressin plus albumin first-line; urine sodium below 10; no response to albumin challenge; liver transplant definitive treatment; median survival weeks untreated; EASL criteria; rapid creatinine doubling.
A persistent penile ulcer or mass requires urgent two-week wait referral - phimosis and lichen sclerosus are risk factors; specialist penile cancer centres manage all cases.
Oxybutynin - highest CNS penetration among OAB drugs; avoid in elderly; cumulative anticholinergic burden increases dementia risk dose-dependently; use ACB scale to assess total burden; switch to mirabegron; systematic deprescribing in polypharmacy reviews.
Vasectomy reversal success depends on time interval - best within 3 years; female partner age equally important; microsurgical technique; vasoepididymostomy if no sperm in vasal fluid; not NHS-funded in most areas; ICSI is an alternative pathway.
PD peritonitis - two of three criteria; intraperitoneal antibiotics empirically; cover Gram-positive and negative; culture before antibiotics; fungal peritonitis remove catheter immediately; refractory at five days remove catheter; ISPD guidelines; Gram-positive commonest; fourteen to twenty-one days treatment; prevention through technique training.
alemtuzumab depletes all CD52+ lymphocytes enabling maintenance minimisation - key risks are infections and autoimmune thyroid disease (up to 30%).
CKD anaemia management follows iron first, then ESA - target Hb 100-120 g/L (not normal); IV iron is preferred in advanced CKD; avoid transfusion in potential transplant recipients.
SPC tract matures 4-6 weeks - insert replacement immediately; tract closes within minutes; false passage risk if forced; same size or one up; red flags need medical review; lower CAUTI than urethral; aseptic technique; 8-12 weekly changes routine.
Fanconi syndrome presents with multiple proximal tubular losses (glucose, phosphate, amino acids, bicarbonate) - tenofovir is a key drug cause; switch to TAF and replace electrolytes.
NHSBT allocation balances HLA matching, waiting time, age matching, proximity, and sensitisation level; highly sensitised patients get priority; paediatric patients get national priority; opt-out donation law since 2020; DR matching has greatest impact on graft survival.
Robotic vs laparoscopic - robotic has better articulation and shorter ischaemia time; warm ischaemia under twenty-five minutes; faster learning curve; higher cost; da Vinci system; both superior to open for morbidity; EAU recommends minimally invasive; open for complex cases; wristed instruments key advantage; nephron preservation priority.
Bosniak III - forty to sixty percent malignant; partial nephrectomy for fit patients; surveillance for comorbid or elderly; forty percent excised prove benign; MDT decision-making; serial imaging three to six months; growth triggers intervention; shared decision-making; ablation emerging; EAU guidance; comorbidity influences risk-benefit.
High-pressure chronic retention causes painless bilateral hydronephrosis with AKI - catheterise urgently; monitor for massive post-obstructive diuresis; differentiate from low-pressure retention which lacks renal compromise; renal recovery depends on obstruction duration.
Royal Marsden staging - Stage II = infradiaphragmatic nodes; AFP from yolk sac, hCG from syncytiotrophoblast, LDH = burden; BEP chemotherapy for advanced disease; >90% cure rate even in metastatic testicular cancer.
PC-RPLND for NSGCT residual masses >1cm - teratoma in 35-40% is chemoresistant; growing teratoma syndrome requires urgent resection; nerve-sparing preserves ejaculatory function; specialist centre surgery; seminoma residual masses are monitored with PET-CT instead.
Home haemodialysis - NICE NG107 recommends offering to all suitable; better quality of life and blood pressure; flexible scheduling; six to twelve weeks training; home modifications may be needed; carer trained as backup; 24/7 telephone support; more frequent dialysis possible; reduced dietary restriction; improved survival observed.
Dialysis adequacy - Kt/V minimum 1.2; URR minimum sixty-five percent; K times t divided by V; access problems commonest modifiable cause; increase time, flow, dialyser size; inadequate dialysis increases mortality; UK Renal Association targets; recirculation reduces clearance; patient compliance with session duration critical.
MEST-C five components; T score strongest prognostic predictor; mesangial IgA deposition; synpharyngitic haematuria; ACEi/ARB first-line; SGLT2 inhibitors additive; corticosteroids if proteinuria persists; targeted budesonide NEFIGAN trial; KDIGO 2021; commonest primary GN.
TMA triad MAHA thrombocytopenia organ damage; ADAMTS13 below 10% equals TTP; Shiga toxin typical HUS children; complement-mediated atypical HUS eculizumab; secondary causes hypertension pre-eclampsia; empirical plasma exchange; fragmented red cells on film; LDH elevated haptoglobin low.
Renal amyloidosis - kidney most affected organ; AL from light chains treat plasma cell; AA from SAA treat inflammation; Congo red apple-green birefringence; mass spectrometry typing essential; SAP scintigraphy maps burden; tocilizumab reduces SAA; colchicine for FMF; KDIGO BSH guidelines.
50-80% mortality at 1 year; sepsis main cause of death; stop warfarin inhibits matrix Gla protein; sodium thiosulphate IV after dialysis; obesity strongest modifiable risk; trunk lesions worse prognosis; non-calcium phosphate binders; cinacalcet for PTH; pain management essential; meticulous wound care.
Mirabegron - beta-3 agonist with no anticholinergic effects; ideal when antimuscarinics are contraindicated especially with cholinesterase inhibitors; monitor blood pressure; avoid in severe uncontrolled hypertension; NICE NG123 recommended alternative.
AIN presents with AKI, fever, rash, and eosinophilia 1-2 weeks after drug exposure - withdraw the offending agent immediately and consider corticosteroids if recovery is delayed.
Anti-C5 monoclonal blocking MAC; Factor H mutation commonest genetic cause; mandatory meningococcal ACWY+B vaccination and antibiotic prophylaxis before initiation; NICE HST1; lifelong treatment often required; preserves C3 opsonisation; high relapse risk if Factor H mutation; ravulizumab longer-acting alternative.
Hyperkalaemia with ECG changes requires IV calcium gluconate first (10 mL of 10% in UK practice), then insulin-dextrose and salbutamol to shift potassium - always stop contributing medications and escalate to dialysis if refractory.
Anti-GBM disease - alpha-3 type IV collagen; linear IgG pathognomonic; daily plasma exchange fourteen days; cyclophosphamide and steroids; smoking increases lung disease; self-limiting low recurrence; futile if dialysis-dependent with fibrosis; transplant after six months antibody-free; KDIGO Renal Association.
CI-AKI prevention - PRESERVE trial NAC ineffective; saline hydration for high-risk; modern contrast low risk; metformin hold if eGFR below 30; never withhold life-saving imaging; intra-arterial higher risk than IV; oral hydration adequate for eGFR above 30; KDIGO 2024; RCR guidelines.
Elderly AKI - triple whammy ACEi plus NSAID plus dehydration; reduced renal reserve with age; atypical presentation as confusion or falls; cautious fluid management; permanent NSAID cessation; polypharmacy review; NICE NG148; cardiac assessment before aggressive fluids.
CNI nephrotoxicity shows isometric vacuolisation on biopsy - acute form is reversible with dose reduction; chronic form causes irreversible arteriolar hyalinosis; always check trough levels before biopsy.
Reduced thrill plus rising venous pressure suggests AVF stenosis - investigate with flow studies and angioplasty before thrombosis; do not wait for complete occlusion.
sham-controlled SPYRAL and RADIANCE trials rehabilitated renal denervation evidence - 5-9 mmHg systolic reduction - NICE permits with special governance arrangements.
WHO 2021 - concentration 16 million, total motility 42%, morphology 4%; two samples needed 3 months apart; OAT syndrome is commonest pattern; 2-7 days abstinence; deliver within 1 hour; investigate with hormones and scrotal USS.
20-30% of dialysis patients; correct iron first ferritin above 100; gabapentin first-line not dopamine agonists; augmentation risk with dopamine agonists; iron cofactor for dopamine synthesis; worse at rest evening; relieved by movement; avoid antihistamines and metoclopramide; dose-adjust for CKD; optimise dialysis adequacy.
Medullary nephrocalcinosis with hypercalcaemia and elevated PTH points to primary hyperparathyroidism - parathyroidectomy is indicated when nephrocalcinosis or recurrent stones are present.
intensify dialysis to >36 hours/week for best outcomes - target pre-dialysis urea <12.5 mmol/L - increase dialysate potassium to prevent fetal hypokalaemia.
Distal ureteric injuries are best repaired by reimplantation into the bladder - recall 'water under the bridge' for the ureter's vulnerability during hysterectomy.
KDIGO heat map combines eGFR + albuminuria for risk stratification - G3b/A3 is very high risk ('red') requiring 3-monthly monitoring and nephrology care; albuminuria independently predicts outcomes; applies to all CKD causes.
Post-nephrectomy surveillance - risk-stratified follow-up; CT at six months then annually for low-risk; RCC metastasises late beyond ten years; lung seventy-five percent commonest site; monitor renal function; Leibovich score; local recurrence two to five percent; EAU and BAUS; bone liver brain metastases; contralateral tumour risk.
Oncocytoma - benign; three to seven percent of renal tumours; central stellate scar; cannot distinguish from RCC on imaging alone; CK7 negative versus chromophobe RCC positive; biopsy ninety to ninety-five percent accurate; active surveillance appropriate; does not metastasise; EAU guidance; percutaneous biopsy increasingly used.
Gas in the kidney on CT with diabetic sepsis means emphysematous pyelonephritis - mortality is high without urgent source control; percutaneous drainage or nephrectomy is essential.
LPHS is a diagnosis of exclusion causing chronic flank pain with haematuria and C3 arteriolar deposits - structured multidisciplinary pain management is key, as no curative treatment exists.
the four medication classes to temporarily stop during acute illness: diuretics, ACE inhibitors, NSAIDs, and metformin. These medications either reduce renal perfusion or accumulate in renal impairment.
Triple therapy - tacrolimus + MMF + prednisolone; basiliximab induction; tacrolimus trough monitoring (narrow therapeutic index); CMV and BK virus surveillance; post-transplant diabetes and cancer are major long-term complications.
PTDM affects 15-30% - tacrolimus is the primary driver (beta-cell toxicity); minimise diabetogenic immunosuppression; metformin first-line if eGFR allows; increases cardiovascular mortality and graft loss; screen at every clinic visit; lifestyle modification is essential.
Bladder diary minimum 3 days - record times, volumes, intake, leakage, pads; normal frequency 4-7 daily; nocturia 0-1; functional capacity 300-500mL; nocturnal polyuria over 33%; identifies modifiable factors; NICE NG123; objective data guides treatment.
Pad testing quantifies leakage objectively - 1-hour ICS protocol: 500mL water then provocative activities; over 1g abnormal; 24-hour home test over 8g abnormal; pre and post-operative comparison; poor reproducibility is a limitation; complements clinical assessment and urodynamics.
Renal biopsy contraindications include uncontrolled hypertension, coagulopathy, active infection, and uncooperative patient - always check BP, platelets, and INR before proceeding; monitor for 6-8 hours post-biopsy.
Varicoceles - 90% left-sided; left testicular vein drains into renal vein; found in 35-40% of subfertile men; Grade I-III classification; new right-sided varicocele warrants renal imaging; ultrasound with Doppler confirms; treatment may improve fertility.
CAUTI commonest HAI - 40% of hospital infections; 5% risk per day; do NOT treat asymptomatic bacteriuria; treat only systemic symptoms; change catheter when treating CAUTI; review necessity daily; NICE QS90; closed drainage system; aseptic technique.
NSAID AKI - afferent arteriole prostaglandin mechanism; significant only when perfusion compromised; haemodynamic AKI most common and reversible; interstitial nephritis immune-mediated; papillary necrosis chronic use; sodium retention and hyperkalaemia; stop NSAID and rehydrate; avoid in CKD, heart failure, dehydration.
FSGS is the commonest cause of steroid-resistant nephrotic syndrome - calcineurin inhibitors are second-line, ACE inhibitors reduce proteinuria, and recurrence post-transplant occurs in up to 30%.
Anti-alpha-3 type IV collagen; linear IgG on biopsy; plasma exchange urgently; cyclophosphamide and steroids; smoking increases lung involvement; creatinine above 500 poor renal prognosis; treat anyway for lungs; relapse rare below 5%; 30% also ANCA positive; serial antibody monitoring.
Congo red negative fibrils 16-24nm; DNAJB9 specific biomarker; poor prognosis 50% ESKD in 2-4 years; rituximab most promising; 50% transplant recurrence; distinguish from amyloid Congo red positive 8-12nm; polyclonal IgG kappa and lambda; screen for monoclonal gammopathy; rare 0.5-1% of biopsies.
ESWL is first-line for renal stones <20 mm - stone-free rate 60-80%; contraindicated in pregnancy, coagulopathy, and active UTI; hard stones (HU >1000) and lower pole location predict poor outcomes; Steinstrasse is a complication after treating large stones.
Active planned approach not withdrawal; symptom management anaemia BP calcium phosphate; advance care planning; palliative care integration; frail elderly may have similar survival to dialysis; NICE NG107; UK Kidney Association; quality of life prioritised; maintained independence; not doing nothing.
Dutasteride - dual type 1 and 2 inhibitor with greater DHT suppression than finasteride; 5-week half-life; Combodart combines with tamsulosin; halves PSA like finasteride; effects persist months after stopping; both teratogenic.
RRT modalities - transplant best survival; pre-emptive transplant optimal; haemodialysis and peritoneal dialysis comparable survival; conservative management valid choice; NICE NG107; patient-led shared decision-making; pre-dialysis education; living donor best graft outcomes; informed choice mandatory.
CAPD vs APD - CAPD four manual exchanges daily; APD automated overnight; APD ideal for working patients; CAPD machine-free; peritoneal transport characteristics guide choice; APD fewer connections less peritonitis risk; NICE NG107; ISPD; icodextrin for daytime dwell; patient preference paramount.
Nocturnal haemodialysis - six to eight hours overnight; phosphate clearance allows stopping binders; blood pressure improves reducing medications; LVH regression; gentle ultrafiltration; sleep adaptation two to four weeks; wetness detectors for safety; fertility may improve; UK Renal Association; daytime freedom; superior quality of life.
Dialysis disequilibrium - cerebral oedema from osmotic gradient; first session two hours maximum; blood flow 150-200 mL/min; target thirty to forty percent urea reduction; very high urea greatest risk; gradual escalation over sessions; IV mannitol for extreme cases; reverse urea effect; idiogenic osmoles; UK Renal Association prevention protocols.
APD overnight machine CAPD daytime manual; high transporters suit APD short dwells; low transporters suit CAPD long dwells; no survival difference; lifestyle guides choice; fewer connections lower peritonitis risk APD; wet day adds daytime dwell; ISPD guidelines; 4 exchanges CAPD typical; 8-10 hours overnight APD.
Advance care planning throughout ESKD journey; dialysis withdrawal legitimate not suicide; 15-20% of UK dialysis deaths; median survival 7-10 days; ReSPECT form; patient autonomy precedence; symptom control after withdrawal; family support and bereavement care; capacity assessment if doubt; early not late discussions.
Flexible ureteroscopy is ideal for 10-20 mm renal stones, hard stones, and obese patients - holmium laser fragments all stone compositions; stone-free rates 65-90%; day-case with no percutaneous puncture; a JJ stent is commonly placed post-procedure.
High Wells score means proceed directly to CTPA - D-dimer is only useful when clinical probability is low, as it cannot reliably exclude PE in high-probability patients.
Recurrent malignant pleural effusion needs definitive management with either an IPC for home drainage or talc pleurodesis - the choice depends on patient preference, as both offer equivalent symptom control.
Tension pneumothorax is a clinical diagnosis - perform immediate needle decompression in the second intercostal space midclavicular line, never wait for a chest X-ray as this delay can be fatal.
Acute severe asthma needs the triad of oxygen, nebulised bronchodilators (salbutamol plus ipratropium), and systemic steroids - measure PEF before and after treatment to guide escalation.
COPD without asthmatic features follows the LABA + LAMA pathway - ICS is only added if there are eosinophilic features or recurrent exacerbations despite optimal bronchodilation.
Symptomatic carotid stenosis ≥50% requires CEA within 2 weeks - early surgery delivers the greatest stroke prevention benefit per NASCET and ECST trials.
STEMI demands primary PCI within 120 minutes of first medical contact - thrombolysis is the fallback only when PCI is not available in time.
HAP developing ≥5 days after admission needs IV co-amoxiclav as first-line - always send cultures before starting antibiotics and review at 48-72 hours for de-escalation.
CURB-65 score of 2 needs dual therapy with amoxicillin plus clarithromycin and consideration for hospital admission - score each component: Confusion, Urea >7, Respiratory rate ≥30, Blood pressure low, and age ≥65.
Light's criteria differentiate exudative from transudative effusions - an exudative effusion with weight loss in an older patient mandates CT thorax and pleural fluid cytology to exclude malignancy.
Large primary spontaneous pneumothorax (≥2cm rim) is treated first with needle aspiration - chest drain insertion is the second step only if aspiration fails after two attempts.
NICE CG168 recommends endothermal ablation as first-line for symptomatic varicose veins - compression stockings alone are not an acceptable alternative to intervention referral.
MINOCA - 5-10% of MI; cardiac MRI key investigation; LGE pattern distinguishes cause; not benign at 5% annual MACE; more common in women; OCT for plaque disruption; vasospasm testing; Takotsubo diagnosis; ESC 2023 guidelines.
RV failure - afterload-sensitive thin-walled chamber; careful diuresis; maintain systemic BP for RV perfusion; reduce PVR; pulmonary vasodilators; avoid hypoxia; maintain sinus rhythm; dobutamine or milrinone; pulmonary endarterectomy for CTEPH; ESC 2022.
Beck's triad with penetrating chest injury - call trauma team and prepare for resuscitative thoracotomy; pericardiocentesis only temporises; cardiac box marks highest-risk zone but injury can occur outside it; FAST detects pericardial blood; 100-200 mL is enough to cause acute tamponade.
Apixaban is preferred in renal impairment with dosing to eGFR 15mL/min and the lowest GI bleeding risk - dose reduction requires ≥2 of 3 criteria, and dabigatran exposure increases 50% with concurrent verapamil.
Dobutamine stress echo - pharmacological alternative when exercise impossible; dose escalation 5 to 40mcg/kg/min; atropine augmentation if needed; biphasic response identifies viable hibernating myocardium; contraindicated in acute MI and severe aortic stenosis; stop infusion for significant complications.
DDD for AV block in sinus rhythm; VVI for permanent AF; pacemaker syndrome 20-25%; atrial kick 15-25%; UKPACE no survival difference; leadless Micra; NICE TA938.
Upper-lobe-predominant emphysema with low exercise capacity benefits most from LVR per NETT trial - endobronchial valves require absent collateral ventilation, pulmonary rehabilitation must precede any LVR procedure, and DLCO >20% predicted is required.
COVID-19 requiring oxygen needs dexamethasone 6mg daily per RECOVERY trial evidence - oseltamivir treats influenza only, and dexamethasone should not be given to patients who do not require supplemental oxygen.
White coat hypertension - do not treat per NICE NG136 but not benign: 15-30% progress within 5 years, so annual review and lifestyle advice are essential. Masked hypertension (opposite pattern) carries higher CV risk and requires ABPM to detect.
TTM2 - no benefit of hypothermia over normothermia with fever prevention; prevent fever below 37.7 degrees for 72 hours; cooling optional for selected patients; slow rewarming 0.25 degrees per hour; HACA and TTM trials evolution; Resuscitation Council UK.
Isolated DLCO reduction with normal spirometry suggests pulmonary vascular disease or early ILD - always correct DLCO for haemoglobin, and raised KCO with reduced DLCO points to extrapulmonary restriction.
UACS is a leading cause of chronic cough - intranasal corticosteroids with saline irrigation are first-line, therapeutic trial for 2-4 weeks is both diagnostic and therapeutic, and persistent symptoms warrant CT sinuses and ENT referral.
Four phases of cardiac rehab - Phase 3 supervised exercise is the core component; 20-25% cardiovascular mortality reduction; screen for post-MI depression; driving typically 4 weeks for cars per DVLA; individualised return to activity.
TPO - cartilaginous nodules sparing posterior wall; incidental finding; benign prognosis; distinguishes from amyloidosis; no treatment if asymptomatic; bronchoscopic debulking if obstructive.
CTCA first-line per NICE CG95 - high NPV over 97%; beta-blocker pretreatment for heart rate control; cannot assess functional significance; heavy calcium causes blooming artefact; iodinated contrast required; replaced functional testing as initial investigation since 2016.
Absent prosthetic click suggests valve thrombosis from subtherapeutic anticoagulation - lifelong warfarin is mandatory for mechanical valves, and INR must never be stopped without bridging.
Eosinophilic COPD is a treatable trait - mepolizumab NICE-approved for severe cases; dupilumab shows strong BOREAS data; biologics are for maximal-therapy-failure patients; persistent eosinophils above 300 identify responders.
PPF - non-IPF fibrosing ILD progressing despite treatment; NICE NG227; nintedanib per INBUILD trial; two of three criteria in 12 months; optimise underlying management first; pulmonary rehabilitation; transplant assessment; palliative care integration.
BAV aortopathy triggers prophylactic surgery at ≥55mm (≥50mm with risk factors) - Marfan syndrome has lower thresholds at ≥50mm, and annual surveillance with strict BP control is essential for intermediate dilatation.
Serial PEFR diary with work-rest pattern is essential for occupational asthma diagnosis - >20% diurnal variability with workplace deterioration supports the diagnosis, and specific inhalation challenge is the gold standard.
ABPA is diagnosed by elevated total IgE, Aspergillus-specific antibodies, and central bronchiectasis - prednisolone is first-line, with itraconazole as a steroid-sparing adjunct.
Pulmonary valve disease - TOF repair commonest cause; CMR gold standard for RV volumes; RVEDVI over 160mL/m2 intervene; RVEF below 47% intervene; transcatheter option; ESC 2021 congenital guidelines.
NT-proBNP >2,000pg/mL triggers urgent 2-week echocardiography per NICE NG106 - obesity falsely lowers values, renal impairment falsely elevates them, and serial measurements guide treatment response assessment.
NHS AAA screening refers men at 5.5cm for elective repair - 3-monthly surveillance for medium aneurysms (4.5-5.4cm), and smoking cessation is the key modifiable risk factor.
Hypothermic arrest - warm before declaring dead; withhold drugs below 30 degrees; limit to 3 shocks; ECMO gold standard; gentle handling; Resuscitation Council UK 2021.
EMPEROR-Preserved - first positive HFpEF trial; empagliflozin 21% RR reduction; benefit regardless of diabetes; Class I ESC 2023; natriuresis plus cardiac energetics; NICE TA929.
Noradrenaline - first-line vasopressor; alpha-1 vasoconstriction; SOAP II fewer arrhythmias than dopamine; MAP target 65mmHg; central access; vasopressin second-line; Surviving Sepsis 2021.
Head tilt-chin lift - non-trauma first-line; jaw thrust - cervical spine precaution; genioglossus tone loss; mandibular advancement; adjuncts supplement; Resuscitation Council UK.
ESC 0/1h algorithm - rule-out with very low value or minimal delta; rule-in with high value or significant rise; observe zone needs 3h testing; hs-cTnT sensitivity far exceeds conventional assays; NPV over 99% for rule-out; always integrate clinical context.
Yellow nail syndrome - two of three features for diagnosis; impaired lymphatic drainage; exudative lymphocytic effusions; talc pleurodesis for recurrence; 30% spontaneous remission; exclude malignancy.
BOS = chronic rejection (50-60% by 5 years); obstructive defect with mosaic/air trapping; azithromycin helps 30-40%; treat reflux; ISHLT grading by FEV1 decline; re-transplant for end-stage disease per BTS/ISHLT.
Omit aminophylline loading dose if on oral theophylline - cardiac monitoring mandatory; limited evidence of benefit in acute asthma; 5mg/kg over 20-30 minutes; check level at 4-6 hours; last resort before intubation.
Airway stents - silicone for benign (removable); metallic for malignant; covered prevents ingrowth; combined with debulking; mucus plugging common; rigid bronchoscopy for silicone; BTS guidelines.
Berlin criteria - acute (≤1 week); bilateral opacities; not cardiac failure; P/F on PEEP ≥5. Mild 201-300; moderate 101-200; severe ≤100. Mortality rises with severity.
In shockable arrest, adrenaline and amiodarone 300mg are given after the third shock - adrenaline then every 3-5 minutes and a further amiodarone 150mg after the fifth shock if VF/pVT persists.
Chest drains go in the safe triangle (5th intercostal space, mid-axillary line) - never insert below the nipple line, always go above the rib, and always confirm position with a post-procedure chest X-ray.
CEP shows the photographic negative of pulmonary oedema with peripheral eosinophilia - dramatic steroid response is expected, but relapse is common during taper.
Spontaneous pneumomediastinum presents with Hamman's sign and surgical emphysema - management is conservative, but always exclude oesophageal perforation.
Hyponatraemia plus atypical pneumonia with travel history suggests Legionella - urinary antigen provides rapid diagnosis, and the condition is notifiable in the UK.
NIV is indicated for COPD exacerbation with pH 7.25-7.35 after optimal therapy - recheck ABG at 1-2 hours, and escalate to intubation if pH worsens below 7.25.
CPVT - RyR2 mutations; normal resting ECG; bidirectional VT pathognomonic; exercise stress test diagnostic; nadolol first-line; flecainide add-on; exercise restriction; left cardiac sympathetic denervation for refractory; ESC 2022.
Bifascicular block plus syncope - investigate for intermittent complete heart block; RBBB with LAD commonest; implantable loop recorder for monitoring; pacemaker if documented progression; asymptomatic cases have low annual progression rate.
Bradycardia-tachycardia needs pacemaker before rate-control drugs - commonest pacemaker indication; dual-chamber with mode-switch preferred; anticoagulate for AF per CHA2DS2-VASc; rate-control drugs unsafe without pacing backup.
Agatston score from non-contrast CT - zero is reassuring; above 400 extensive disease; does not measure stenosis or detect non-calcified plaque; MESA data for percentile interpretation; refines intermediate risk; no contrast required; not a population screening tool.
TAVI complications - PVL most specific; pacemaker 10-20%; self-expanding higher PPM rate; stroke 2-5%; AKI from contrast; coronary obstruction rare but fatal; CT sizing reduces PVL; VARC-3 definitions; ESC/EACTS 2021.
Fabry disease - alpha-galactosidase A deficiency; X-linked; LVH with short PR; inferolateral LGE on MRI; 1-4% of HCM; ERT with agalsidase; migalastat per NICE HST4; early treatment before fibrosis; GLA gene mutations.
Wellens syndrome - pain-free T-wave inversions in V2-V3; critical proximal LAD stenosis; preserved R-waves; no stress testing; urgent angiography; Type B commonest; window for intervention before anterior STEMI; admit to CCU.
BAV - commonest congenital cardiac anomaly; 1-2% prevalence; premature AS; independent aortopathy; ascending aorta surveillance; surgery at 55mm or 50mm with risk factors; coarctation association; family screening; ESC/EACTS 2021.
Pre-flight assessment - SpO2 above 95% low risk; below 92% needs oxygen; hypoxic challenge test for borderline; 15% FiO2 for 20 minutes; PaO2 below 6.6 kPa needs oxygen; increase LTOT by 2 L/min; pneumothorax wait 1-6 weeks; BTS 2022 air travel guidelines.
Mechanical valve pregnancy - warfarin throughout if dose 5mg or less; LMWH first trimester alternative; anti-Xa monitoring 0.8-1.2; switch heparin at 36 weeks; safe in breastfeeding; ESC 2018.
SIADH is diagnosed by euvolaemic hyponatraemia with concentrated urine and high urine sodium - correct sodium slowly (no more than 10mmol/L in 24 hours) to avoid osmotic demyelination syndrome.
DKA treatment is fluids first, then fixed-rate insulin at 0.1 units/kg/hour - never give an IV insulin bolus, and continue the patient's basal insulin throughout.
Always confirm Cushing's biochemically before imaging - the overnight dexamethasone suppression test or 24-hour urinary free cortisol are the two recommended first-line screening tests.
Pernicious anaemia needs lifelong IM hydroxocobalamin - never give folate alone in B12 deficiency as it can worsen neurological damage.
INR above 8.0 without bleeding needs warfarin stopped plus oral vitamin K 1-5mg - IV vitamin K and PCC are reserved for life-threatening haemorrhage.
DIC treatment is treat the cause plus replace what's consumed - FFP for clotting factors, cryoprecipitate for fibrinogen, and platelets if bleeding, while aggressively managing the underlying trigger.
Microcytic anaemia + normal iron + target cells = think thalassaemia trait; confirm with HbA2 on electrophoresis and urgently screen the partner in pregnancy.
Mechanical mitral valve = high thromboembolic risk = therapeutic LMWH bridging; stop warfarin 5 days pre-op; restart anticoagulation when haemostasis secured postoperatively.
Screen for acromegaly with IGF-1 first, then confirm with an oral glucose tolerance test showing failure to suppress GH - never rely on random GH levels due to pulsatile secretion.
All adults with type 1 diabetes should be offered DAFNE or equivalent structured education - basal-bolus with carbohydrate counting is the standard of care, and exercise should be encouraged with appropriate insulin adjustment.
ITP is a diagnosis of exclusion - treat with prednisolone when platelets are below 30×10⁹/L, and platelet transfusions are ineffective as they are rapidly destroyed.
Definitive cure for refractory Cushing's; lifelong hydrocortisone and fludrocortisone; Nelson syndrome 15-25 percent; prophylactic pituitary radiotherapy; laparoscopic approach; immediate cortisol elimination; sick day rules essential; Endocrine Society guidelines; last resort after pituitary surgery.
ARR screens; confirmatory test required; saline suppression gold standard; AVS for lateralisation; CT only 50-60 percent accurate; unilateral adrenalectomy curative; bilateral spironolactone; commonest secondary hypertension; Endocrine Society 2016; stop interfering medications.
CREDENCE was the landmark SGLT2 renal outcomes trial - canagliflozin 100mg in diabetic CKD with proteinuria; monitor amputation risk factors especially with PVD; Fournier's gangrene is rare but reportable.
Postpartum painless thyroiditis; anti-TPO positive; low radioiodine uptake; triphasic course; beta-blockers only for thyrotoxic phase; 20-30 percent permanent hypothyroidism; 70 percent recurrence; may mimic postnatal depression; BTA guidelines; annual monitoring.
UFC >3× ULN is virtually diagnostic of Cushing - ACTH determines dependent (pituitary/ectopic) vs independent (adrenal); pituitary MRI first; IPSS with CRH for equivocal cases; Cushing disease (pituitary) accounts for 70%.
Empty sella with normal pituitary function = reassure and monitor; always check baseline hormones and distinguish primary (incidental) from secondary (post-pathology) causes.
GSD type I = severe fasting hypoglycaemia + lactic acidosis + hyperlipidaemia + hepatomegaly; managed with frequent feeding and uncooked cornstarch - not enzyme replacement.
MGUS = paraprotein <30g/L + plasma cells <10% + no CRAB - monitor annually at 1% per year progression risk to myeloma.
GLP-1 RAs - cardiovascular benefit + weight loss; caution with pancreatitis history; SGLT2 inhibitors are the cardiorenal alternative; always consider MTC/MEN2 as absolute contraindications.
Cardiac T2* <20ms = myocardial iron overload; combine chelators for severe loading - iron cardiomyopathy is preventable and reversible with intensive chelation.
HIT type 2 - stop all heparin, start argatroban, no warfarin until platelets >150, no platelet transfusion; prothrombotic not bleeding; 4Ts score; day 5-14 onset (BSH 2012).
Resistant hypertension + hypokalaemia = screen with aldosterone-to-renin ratio; adrenal vein sampling distinguishes adenoma (surgery) from hyperplasia (spironolactone).
Acute haemolysis + bite cells/Heinz bodies + negative DAT + oxidant drug exposure = G6PD deficiency; test after the acute episode, not during it.
LMWH or DOAC for cancer VTE per NICE NG158 - caution with DOACs in GI/urothelial cancers due to bleeding; apixaban (CARAVAGGIO) showed less GI bleeding; treat for ≥6 months, longer if cancer active; LMWH remains preferred for GI tract malignancies.
Richter transformation - CLL to DLBCL in 2-10%; rapidly enlarging nodes and B symptoms; LDH elevated; PET-CT SUVmax above 5; excisional biopsy required; median survival 6-12 months; R-CHOP treatment; allograft in responders; BSH guidelines.
Hashimoto's 60-80 fold risk increase; DLBCL commonest subtype; rapidly enlarging mass; R-CHOP for DLBCL; core biopsy not FNA; urgent dexamethasone for airway; steroid-sensitive; MALT may respond to radiotherapy alone; BTA and NICE guidelines.
PTMC under 10mm; active surveillance valid option; 5-10 percent grow over 10 years; Japanese evidence base; 6-monthly then annual ultrasound; intervene if growth over 3mm; lobectomy sufficient; BTA 2023 and ATA 2015; avoid unnecessary thyroidectomy; zero disease-specific mortality.
Thiamine BEFORE glucose always - pyruvate dehydrogenase needs thiamine; complete triad only 10%; Wernicke's to Korsakoff's in 80% untreated; Pabrinex IV 2 pairs TDS; at-risk: alcohol, malnutrition, hyperemesis; mammillary body damage irreversible; low threshold for empirical treatment.
CLL autoimmune cytopenias - AIHA commonest at 5-10%; positive DAT with haemolysis markers; corticosteroids first-line 70-80% response; rituximab second-line; not automatic CLL progression; avoid fludarabine; bendamustine or targeted therapy if CLL treatment needed; BSH and NICE NG225.
Goal-directed replaces empirical transfusion; FIBTEM below 9mm give fibrinogen; fibrinogen target 2g/L in obstetrics; prolonged CT give FFP; low MA give platelets; lysis give tranexamic acid; NICE DG13; reduces unnecessary products; fibrinogen drops first; BSH and OAA guidance.
Refeeding syndrome - thiamine BEFORE glucose; start 5kcal/kg/day if BMI under 14; monitor phosphate, potassium, magnesium twice daily; hypophosphataemia causes cardiac arrest; NICE CG32 risk criteria; insulin drives intracellular electrolyte shift; correct electrolytes before and during feeding.
Platelets highest contamination risk - stored at room temperature; septic shock presentation; stop transfusion, IV antibiotics, resuscitate; culture patient and product; Staph epidermidis commonest; Gram-negatives most dangerous; visual inspection before administration.
JBDS protocol - 0.9% NaCl first; no potassium in bag one; approximately 6L over 12-14 hours; 10% glucose when blood glucose falls below 14; potassium replacement guided by hourly levels.
Edoxaban - any single criterion triggers dose reduction to 30mg; requires 5 days parenteral anticoagulation before VTE use; ciclosporin is a key P-gp inhibitor interaction; avoid if eGFR above 95 due to reduced efficacy.
TSH first then ultrasound; BTA U-classification; FNA for U3-U5; Thy cytology guides management; ultrasound features more important than size; microcalcifications suspicious; 5-15 percent malignant; BTA 2014 and NICE NG145.
Hungry bone syndrome - severe hypocalcaemia post-parathyroidectomy; skeletal calcium uptake; high ALP strongest predictor; IV calcium gluconate infusion; calcitriol not cholecalciferol; magnesium replacement; hypophosphataemia; weeks to months duration; preoperative vitamin D repletion; specialist guidelines.
Acquired VWF deficiency; late onset no family history; MPN, lymphoproliferative, aortic stenosis; Heyde syndrome; loss of large multimers; treat underlying cause; DDAVP, VWF concentrates, IVIG; BSH guidelines; resolves with valve replacement in Heyde syndrome.
C-cell origin; calcitonin and CEA markers; exclude phaeochromocytoma before surgery; total thyroidectomy with central dissection; no radioiodine; calcitonin doubling time prognostic; RET testing for familial; vandetanib cabozantinib for advanced; BTA and ATA 2015.
HIT presents as thrombocytopenia plus thrombosis on heparin - stop all heparin immediately, never switch to LMWH, start a non-heparin anticoagulant, and do not give warfarin until platelets recover.
Ropeginterferon NICE-approved for PV; targets malignant clone; reduces JAK2 allele burden; safe in pregnancy; fortnightly injection; PROUD-PV trial; screen for depression; autoimmune thyroiditis risk; unlike hydroxyurea which is teratogenic; BSH and ELN guidelines.
Massive haemorrhage demands a 1:1:1 ratio of red cells, FFP, and platelets - give O-negative blood immediately, administer tranexamic acid within 3 hours, and avoid excessive crystalloid which worsens the lethal triad.
Sodium bicarbonate for pH <7.1 not responding to definitive treatment - specific indications include uraemic acidosis, RTA, salicylate and TCA poisoning; avoid in DKA and lactic acidosis; 1.26% peripherally, 8.4% centrally only; watch for hypokalaemia and fluid overload.
Gestational thyrotoxicosis is hCG-mediated and self-limiting - distinguish from Graves' by negative TRAb and association with hyperemesis; no antithyroid drugs needed; recheck TFTs after first trimester as hCG declines.
t(9;22) reciprocal translocation; BCR-ABL fusion tyrosine kinase; karyotyping, FISH, RT-PCR increasing sensitivity; RT-PCR for monitoring; International Scale; p210 in CML, p190 in ALL; diagnostic for CML; 20-30 percent adult ALL; BSH and WHO 2022.
Addisonian crisis - IV hydrocortisone 100mg IMMEDIATELY; IV saline; IV dextrose; never delay treatment for tests; sick-day rules and IM injection kits prevent crises.
FRII at 0.1 units/kg/hour - target ketone clearance not glucose; continue basal insulin alongside FRII; ketones should fall ≥0.5mmol/L/hour; resolution is ketones below 0.6 with pH above 7.3 and bicarbonate above 15.
Calcium gluconate first for ECG changes - stabilises myocardium in 1-3 minutes; does NOT lower potassium; 30mL of 10% over 5-10 minutes; repeat once if needed; calcium chloride via central line only; slow infusion if on digoxin.
FFP 12-15mL/kg - thaw 30 minutes, infuse within 4 hours; INR in cirrhosis reflects balanced haemostasis not bleeding risk; TEG/ROTEM guide management better; TACO risk high in liver disease; ABO-compatible required.
Sickle cell preoperative - TAPS trial supports simple transfusion to Hb 100; avoid hypothermia, hypoxia, dehydration, acidosis; incentive spirometry prevents ACS; extended phenotype matching; first on list; exchange for high-risk surgery only; BSH guidelines.
RLN injury - 1-2% incidence; unilateral causes hoarseness; bilateral causes stridor; paramedian cord position; IONM for identification; medialisation for persistent unilateral; tracheostomy for bilateral obstruction; non-recurrent variant 0.5-1%; BTA/BAETS.
RAI ablation - TSH above 30 by withdrawal or Thyrogen; low-iodine diet; 1.1GBq for remnant ablation; intermediate and high-risk cancers; post-RAI scan; radiation isolation; sialadenitis side effect; sodium-iodide symporter dependent; BTA and ATA guidelines.
AVS - gold standard for lateralisation; CT only fifty to sixty percent accurate; cortisol confirms cannulation; lateralisation ratio above 4:1 unilateral; cosyntropin infusion; experienced centres eighty to ninety-five percent success; Endocrine Society 2016; all surgical candidates should have AVS.
TSHoma - rarest functioning pituitary tumour; non-suppressed TSH with elevated T4/T3; alpha-subunit elevated; distinguish from RTH; transsphenoidal surgery first-line; somatostatin analogues; avoid antithyroid drugs alone; Endocrine Society 2018.
GPIIb/IIIa fibrinogen receptor; autosomal recessive; absent aggregation to all agonists; ristocetin normal; normal platelet count; absent clot retraction; alloantibody risk; recombinant FVIIa; tranexamic acid; BSH guidelines.
CRH stimulates pituitary adenomas; ectopic tumours non-responsive; ACTH rise above 35-50 percent suggests pituitary; 90 percent sensitivity; bronchial carcinoids may respond; IPSS gold standard when discordant; Endocrine Society guidelines; concordance with MRI strengthens diagnosis.
Feeding jejunostomy = direct jejunal access for upper GI surgery (oesophagogastrectomy, gastrectomy, Whipple's); continuous pump feeds only - no boluses; flush regularly to prevent blockage; lower aspiration risk than gastric feeding per ESPEN/BAPEN.
Autosplenectomy - repeated splenic infarction in HbSS; complete by age 5-8; Howell-Jolly bodies confirm asplenia; identical infection risk to surgical splenectomy; lifelong penicillin and vaccinations; HbSC preserves splenic function; acute sequestration before autosplenectomy completes.
MCL = t(11;14) + cyclin D1 + CD5+/CD23−; distinguish from CLL by CD23 negativity; intensive chemo + ASCT for fit patients; ibrutinib for relapsed disease.
Markedly prolonged TT on dabigatran confirms significant anticoagulation; normal TT excludes it - use idarucizumab before urgent surgery when TT is prolonged; BSH recommends TT as the optimal rapid screen.
Howell-Jolly bodies = hyposplenism; in SCD, lifelong penicillin V + encapsulated organism vaccines; blood film morphology is a vital diagnostic tool - always correlate with clinical context.
Periorbital oedema characteristic; muscle cramps common; take with food; weekly FBC initially; neutropenia commonest haematological; hold if neutrophils below 1.0; LFTs monthly initially; CYP3A4 interactions; avoid grapefruit and St John's wort; BSH and ELN 2020.
TTP is schistocytes plus thrombocytopenia with normal clotting - arrange urgent plasma exchange and never transfuse platelets as it may be fatal.
Post-thyroidectomy hypocalcaemia - IV calcium gluconate urgently, then lifelong oral calcium and alfacalcidol; monitor for hypercalciuria.
Waldenström = IgM paraprotein + lymphoplasmacytic marrow infiltration; plasmapheresis for hyperviscosity, then rituximab-based chemoimmunotherapy - avoid rituximab monotherapy initially.
Persistent eosinophilia + end-organ damage = HES; test for FIP1L1-PDGFRA - if positive, imatinib is first-line; if negative, corticosteroids first-line.
APS-2 = Addison's + autoimmune thyroid disease and/or T1DM, adult-onset, HLA-DR3/DR4. No mucocutaneous candidiasis or hypoparathyroidism (those features point to APS-1, AIRE mutation). Always screen for additional autoimmune endocrinopathies once one diagnosis is made.
H. pylori test-and-treat for uninvestigated dyspepsia in under-55s without alarm features - use urea breath test or stool antigen, and stop PPIs at least 2 weeks before testing to avoid false negatives.
Previous abdominal surgery is the most common cause of small bowel obstruction - manage conservatively with drip and suck, but operate urgently if signs of strangulation or peritonitis develop.
Acute cholecystitis - Murphy's sign positive, fever, raised WCC/CRP, and pain lasting more than 6 hours. Early laparoscopic cholecystectomy within 1 week is now recommended over delayed surgery.
IBS is a positive diagnosis using Rome IV criteria, not just exclusion. A normal faecal calprotectin (<50 µg/g) is very reassuring for excluding IBD. Always check coeliac serology before diagnosing IBS.
Alcoholic hepatitis with Maddrey DF ≥32 - prednisolone 40 mg daily for 28 days, reassess response at day 7 with the Lille score. AST:ALT ratio >2 is the characteristic biochemical clue.
Variceal bleeding requires the triad of IV terlipressin, prophylactic antibiotics, and urgent endoscopic band ligation within 12 hours - do not delay terlipressin for endoscopic confirmation.
Ascites in cirrhosis - first-line is sodium restriction plus spironolactone. Calculate the SAAG (≥11 confirms portal hypertension). Always perform diagnostic paracentesis to exclude spontaneous bacterial peritonitis.
Crohn's disease - think right iliac fossa pain, non-bloody diarrhoea, weight loss, mouth ulcers, and perianal disease in a young patient with raised faecal calprotectin indicating intestinal inflammation.
Acute diverticulitis - CT abdomen confirms diagnosis and identifies complications. Treat uncomplicated disease with antibiotics, and always arrange colonoscopy 6-8 weeks later to exclude underlying colorectal cancer.
In stable lower GI bleeding, flexible sigmoidoscopy is first-line investigation - reserve CT angiography for haemodynamically unstable patients with massive haemorrhage requiring urgent localisation.
Biliary colic - transient constant RUQ pain after fatty food, normal bloods, negative Murphy's sign. Distinguish from cholecystitis by absence of fever, normal inflammatory markers, and self-resolving pain within 6 hours.
In acute upper GI bleeding, resuscitate first with an ABCDE approach, use the Glasgow-Blatchford score to stratify risk, and arrange endoscopy within 24 hours per NICE guidelines.
Charcot's triad (pain, jaundice, fever) = acute cholangitis. Reynolds' pentad adds confusion and hypotension, indicating severe disease. IV antibiotics immediately and urgent ERCP for biliary decompression within 24-72 hours.
Two-stage treatment - metronidazole for tissue invasion then diloxanide furoate for luminal cysts; trophozoites with ingested red cells are pathognomonic; flask-shaped ulcers in right colon; luminal agent prevents 40% relapse rate.
SMA syndrome causes duodenal obstruction from aortomesenteric compression in severely underweight patients - weight restoration is curative, and nasojejunal feeding bypasses the obstruction.
TIPSS for refractory variceal bleeding and ascites - hepatic encephalopathy in 30-50%; Doppler surveillance for shunt patency; contraindicated in Child-Pugh above 13; early TIPSS in high-risk bleeding per Baveno VII; covered stents preferred.
0.1-0.5% therapeutic; immediate endoscopic closure over 90% success; OTSC for larger defects; conservative for small sealed; surgery for large or delayed; laparoscopic repair within 12-24 hours; sigmoid highest risk; BSG ESGE guidelines.
BAM causes chronic watery diarrhoea diagnosed by SeHCAT <15% - bile acid sequestrants (colestyramine/colesevelam) are first-line, and up to 30% of IBS-D patients have undiagnosed primary BAM.
DCI 5,000-8,000 with normal peristalsis; exclude cardiac causes first; HRM diagnostic; calcium channel blockers and TCAs; PPI trial for GORD; distinguish from jackhammer above 8,000; Chicago Classification v4.0; POEM for refractory cases.
Medium or large varices without prior bleeding - non-selective beta-blocker (carvedilol preferred) is first-line primary prophylaxis. Band ligation is the alternative if beta-blockers are contraindicated or not tolerated.
ADPKD 80% have liver cysts; liver function preserved; biliary epithelium origin; oestrogen promotes growth; somatostatin analogues reduce volume; aspiration-sclerotherapy for dominant cysts; transplant for refractory; PRKCSH/SEC63 in isolated PLD.
Defunctioning loop ileostomy protects low anastomosis - leak rates 10-15% for low rectal; converts catastrophic leak to manageable event; ileostomy preferred over colostomy; reversal at 8-12 weeks; confirm integrity with contrast study; high-output stoma causes dehydration and electrolyte loss.
Reheated rice food poisoning is caused by Bacillus cereus emetic toxin - self-limiting within 24 hours, and multiple linked cases require notification.
GORD is managed stepwise - full-dose PPI for 4-8 weeks then step down, with endoscopy reserved for alarm features per NICE.
Maddrey ≥32 warrants prednisolone for alcoholic hepatitis - assess response with the Lille score at day 7, and always exclude infection before starting steroids.
Laparoscopic colectomy (NICE NG151; CLASICC/COLOR/COST trials) gives equivalent oncological outcomes with shorter stay and fewer wound complications; combine with ERAS, and accept a 10-20% conversion rate.
Bronze skin, diabetes, arthralgia, and raised transferrin saturation in a Northern European patient - hereditary haemochromatosis. Confirm with HFE gene testing. Venesection is the cornerstone of treatment to reduce iron stores.
Mature symptomatic pancreatic pseudocysts are best drained via EUS-guided cystogastrostomy - distinguish from walled-off necrosis and cystic neoplasms.
NAFLD with a raised ELF score (≥10.51) requires hepatology referral for fibrosis staging - weight loss of ≥10% is the most effective treatment. Cardiovascular risk is the leading cause of mortality, not liver failure.
Loop stomas defunction with two lumens - easier reversal; end stomas single lumen from divided bowel; loop ileostomy protects anastomosis; end colostomy for Hartmann's; ileostomy output liquid and corrosive; spouted appliance for ileostomy; stoma nurse education essential.
Commonest benign liver tumour; hyperechoic on ultrasound; MRI centripetal fill-in diagnostic; no biopsy needed; observe asymptomatic; enucleation for symptomatic giant; Kasabach-Merritt consumptive coagulopathy; oestrogen responsive; 5-7% prevalence.
Hartmann's reversal is major surgery - only 40-60% reversed; timing 3-6 months; CT and sigmoidoscopy preoperatively; adhesiolysis challenging; anastomotic leak 5-10%; laparoscopic approach improving outcomes; overall morbidity 20-40%; careful patient selection essential.
R-value ALP-predominant below 2; co-amoxiclav commonest UK cause; flucloxacillin highest per-prescription risk; HLA-B*5701; stop offending drug; UDCA for cholestasis; resolves 1-3 months; may persist 6-12 months; Yellow Card reporting; vanishing bile duct syndrome.
Lead point 70-90% in adults; colonic 50-60% malignant; target sign and sausage shape on CT; resect colonic without reduction; air enema not for adults; small bowel often benign; intermittent symptoms; adenocarcinoma commonest malignant cause; fundamentally different from paediatric.
Intestinal lymphangiectasia causes protein-losing enteropathy with hypoalbuminaemia and lymphopenia - white-tipped villi are pathognomonic, and a low-fat diet with MCT supplementation is the cornerstone of treatment.
Mural calcification from chronic cholecystitis; 2-7% cancer risk revised downward; incomplete mucosal calcification higher risk; cholecystectomy even if asymptomatic; open approach if cancer suspected; histology mandatory; curvilinear RUQ calcification on X-ray; longstanding cholelithiasis cause.
Antimesenteric border only; bowel lumen remains patent; no obstruction initially; strangulation risk despite absence of obstruction; femoral hernia commonest association; delayed diagnosis is the danger; emergency surgery always; assess viability; resect if gangrenous.
10-15% of laparotomies; wound infection strongest risk; sublay retromuscular preferred; mesh essential; 5 cm overlap minimum; component separation for large; Rives-Stoppa gold standard; suture only 40-50% recurrence; mesh below 10%; laparoscopic for smaller defects.
EoE is diagnosed by ≥15 eosinophils per HPF on oesophageal biopsy - recurrent food bolus impaction in a young atopic patient is the classic presentation.
Six variables including BMI and diabetes; below -1.455 low risk; above 0.676 high risk; 90% NPV; NICE NG49; specifically for NAFLD; 25-30% indeterminate; sequential testing pathway; ELF or FibroScan second-line; liver biopsy gold standard.
High-output ileostomy requires hypotonic fluid restriction and iso-osmolar rehydration - loperamide and omeprazole reduce output, and excessive water intake paradoxically worsens sodium depletion.
Tropical sprue causes villous atrophy with negative coeliac serology after tropical residence - folic acid plus prolonged tetracycline is the standard treatment.
Middle-aged woman with pruritus, fatigue, raised ALP, and positive anti-mitochondrial antibody - primary biliary cholangitis. Ursodeoxycholic acid is first-line treatment and improves long-term outcomes.
Chronic radiation proctitis causes telangiectasia and bleeding months to years after radiotherapy - argon plasma coagulation is first-line for recurrent rectal bleeding.
IBS is a clinical diagnosis after excluding alarm features - low-FODMAP diet and antispasmodics are first-line, with neuromodulators for refractory symptoms.
PSC is the strongest risk factor for cholangiocarcinoma - Klatskin tumours at the hepatic duct confluence are most common, and only 20-30% are surgically resectable.
NG tube placement requires pH ≤5.5 or chest X-ray confirmation - the whoosh test is unreliable and prohibited, and misplacement is classified as a Never Event.
SIBO causes low B12 with elevated folate - hydrogen breath testing diagnoses it, and rifaximin is the preferred first-line antibiotic treatment.
Terlipressin before endoscopy for suspected variceal bleed - prophylactic antibiotics reduce mortality; restrictive transfusion (Hb 70-80g/L); band ligation within 12 hours; Sengstaken-Blakemore tube as temporary rescue.
Five variables - Bilirubin, Albumin, INR, Ascites, Encephalopathy; class A 5-6 (compensated), B 7-9 (significant compromise), C 10-15 (decompensated); one-year survival approximately 100%, 80%, 45% respectively; MELD preferred for transplant allocation.
NAC benefits early non-paracetamol acute liver failure - Lee trial showed improved transplant-free survival in grade I-II encephalopathy; same infusion protocol as paracetamol; stop the offending drug immediately; flucloxacillin is a common UK cause of DILI.
HELLP syndrome - haemolysis, elevated liver enzymes, low platelets; definitive treatment is delivery; IV magnesium for seizure prophylaxis; hepatic rupture is catastrophic complication; maternal stabilisation before delivery; NICE NG133 guidance.
SMV thrombosis - insidious onset over days; pain-examination discrepancy; CT with contrast diagnostic; anticoagulation cornerstone; surgery only for peritonitis; thrombophilia screening mandatory; 5-15% of mesenteric ischaemia cases; long-term anticoagulation.
PVT - acute versus chronic; cavernous transformation indicates chronicity; anticoagulate even in cirrhosis per BAVENO VII; JAK2 screening in non-cirrhotic; distinguish bland from tumour thrombus; recanalisation 80% with anticoagulation; important for transplant candidacy.
SBP neutrophils 250 or above - E. coli commonest; IV ceftriaxone plus IV albumin; Sort trial proved albumin benefit; monomicrobial distinguishes from secondary peritonitis; norfloxacin prophylaxis; ascitic protein below 15 increases risk.
Watermelon stripes in antrum; APC first-line; multiple sessions 3-6; TIPSS ineffective; distinguish from PHG; fibrin thrombi diagnostic; autoimmune associations; cirrhosis in 30%; RFA emerging alternative; antrectomy for refractory; not primarily portal hypertension driven.
Second commonest benign colonic tumour; submucosa 90%; pillow sign positive; CT fatty density -70 to -120 HU; right colon commonest; no malignant potential; asymptomatic under 2cm observe; large can cause intussusception; naked fat sign; no surveillance needed.
Candida CRBSI requires mandatory catheter removal and systemic antifungal therapy - catheter salvage is only appropriate for coagulase-negative staphylococci and other low-virulence organisms.
Clinical complete response required; DRE endoscopy MRI concordance; surveillance every 3-4 months for 2 years; 15-30% regrowth; over 95% salvageable; comparable oncological outcomes; quality of life benefit; organ preservation; avoids TME and stoma; UK OnCoRe data.
Cerebral oedema is the leading killer in acute liver failure - hyperammonaemia drives astrocyte swelling, and mannitol or hypertonic saline manages acute intracranial hypertension.
Microscopic colitis - normal colonoscopy, biopsy both sides; collagen band ≥10 micrometres = collagenous colitis; budesonide first-line ~80% response; common drug triggers PPIs, SSRIs, NSAIDs; BSG 2023 guidelines.
Barrett's oesophagus requires lifelong PPI therapy and endoscopic surveillance with the Seattle biopsy protocol - the interval depends on segment length and dysplasia status per BSG guidelines.
Ascitic neutrophils ≥250 cells/mm³ = SBP - start IV cephalosporin immediately without waiting for cultures. IV albumin on days 1 and 3 reduces hepatorenal syndrome risk and improves survival.
NHS bowel cancer screening uses the FIT test every 2 years for people aged 56-74 (expanding to 50+). A positive FIT leads to colonoscopy. Population screening reduces colorectal cancer mortality by approximately 15-25%.
Acute PVT requires anticoagulation to prevent mesenteric extension - always screen for myeloproliferative neoplasms, particularly JAK2 V617F mutation.
Bronchiolitis management is purely supportive - admit if SpO2 is below 92% or feeding is under 50%, and never prescribe bronchodilators, steroids, or antibiotics as they have no proven benefit.
Oral dexamethasone is first-line treatment for croup at all severities - reserve nebulised adrenaline for severe cases, and never attempt direct laryngoscopy as it risks worsening airway obstruction.
Amber features on the NICE traffic light system - pallor, poor social responsiveness, dry mucous membranes, and tachycardia - require urgent paediatric assessment and must not be managed solely in primary care.
Weak femoral pulses with an upper-to-lower limb blood pressure gradient in a neonate strongly suggest coarctation - start IV prostaglandin E1 immediately to reopen the ductus arteriosus before cardiovascular collapse occurs.
Pyloric stenosis presents with non-bilious projectile vomiting in a first-born male at 3-6 weeks - diagnose with ultrasound, fully correct the metabolic alkalosis before surgery, and definitive treatment is Ramstedt pyloromyotomy.
First UTI in infants aged 3 months to 3 years requires 7-10 days of oral antibiotics and renal ultrasound within 6 weeks - DMSA and MCUG are reserved for atypical or recurrent UTIs per NICE CG54.
Non-blanching purpuric rash with fever demands immediate IV ceftriaxone and fluid resuscitation - never delay antibiotics for investigations, and lumbar puncture is contraindicated in shock or reduced GCS.
Simple febrile convulsions require no investigation, prophylaxis, or admission - reassure parents, treat the underlying fever source, provide seizure first aid advice, and arrange routine GP follow-up.
Fractures or bruises in a pre-mobile infant must be considered non-accidental until proven otherwise - 'those who don't cruise rarely bruise'. Follow safeguarding procedures immediately and never discharge without a completed safety assessment.
Pertussis in young infants requires hospital admission for apnoea monitoring - marked lymphocytosis is a diagnostic clue. Treat with azithromycin, notify Public Health England, and offer contacts prophylaxis. Maternal vaccination in pregnancy is the key preventive strategy.
Intussusception presents with episodic colicky pain, redcurrant jelly stool, and a sausage-shaped mass - diagnose with ultrasound showing the target sign and treat with air or hydrostatic enema reduction, keeping surgical backup available.
Paediatric DKA requires cautious fluid replacement over 48 hours with insulin delayed until at least 1 hour after starting fluids - cerebral oedema is the most dangerous complication and is precipitated by overly rapid correction.
V1 port wine stain - 10-20% Sturge-Weber risk; leptomeningeal angiomatosis on MRI; seizures earliest feature; glaucoma 30-70%; GNAQ somatic mutation; pulsed-dye laser for PWS; aspirin for stroke prevention; bilateral V1 increases risk; MDT approach.
Marfan - FBN1 mutation, aortic root dilatation, and superotemporal lens subluxation. Beta-blocker or losartan for aortic protection. Surgery at 50mm. No contact sports.
Neonatal hepatitis - giant cell transformation; non-specific response to multiple causes; diagnosis of exclusion; CMV commonest infectious cause; idiopathic 60% resolve; fat-soluble vitamins A, D, E, K essential; MCT formula for fat absorption; 25% of neonatal cholestasis.
Nasal cannulae first-line for mild hypoxia in children - HFNC increasingly used for bronchiolitis (PARIS trial); target SpO2 ≥92% per NICE NG9; device selection by severity; face masks poorly tolerated in young children; HFNC provides CPAP effect.
trauma-informed care - 6 SAMHSA principles: safety, trustworthiness, peer support, collaboration, empowerment, cultural responsiveness. 'What happened to you?' not 'what's wrong with you?' Does NOT require detailed trauma questioning. Recognise behaviour as communication.
Continuous machinery murmur; left infraclavicular second intercostal space; bounding pulses from aortic run-off; wide pulse pressure; prematurity main risk; ductus closes 24-48 hours; rising PaO2 and falling prostaglandins; echocardiography confirms; ibuprofen or paracetamol for closure per BNF for Children.
HUS triad - MAHA, thrombocytopenia, AKI; E. coli O157 cause; antibiotics worsen outcome; supportive management; KDIGO stage 3 if anuric; schistocytes on film; most children recover; atypical HUS needs eculizumab; commonest paediatric AKI cause.
Periventricular watershed zone; pre-oligodendrocyte vulnerability; cystic PVL 60-80% cerebral palsy; spastic diplegia from corticospinal tract location; antenatal magnesium neuroprotective; serial cranial ultrasound screening; MRI at term-equivalent most sensitive; sepsis and hypotension compound injury; prevention key.
Deficit = percentage × weight × 10 - replace over 24 hours plus maintenance; reassess 4-hourly; 20mL/kg bolus for shock; oral rehydration preferred; isotonic fluids IV; monitor electrolytes; classify as no dehydration, clinical dehydration, or shock.
Turner syndrome - growth hormone for height, oestrogen for puberty, and screen for cardiac (bicuspid aortic valve, coarctation), renal, and thyroid abnormalities.
Two AAIs prescribed - 0.15mg for 15-30kg, 0.3mg for >30kg; train patient, parents, and school; personalised action plan; inject outer mid-thigh through clothing; second dose after 5 minutes if needed; biphasic reactions in up to 20%.
CRAFFT screening for adolescent substance misuse (score ≥2 = problematic). Cannabis: 2-4x psychosis risk (dose-dependent). Nitrous oxide: B12 depletion, subacute combined degeneration. Brief intervention with motivational interviewing first-line. Refer to young people's substance misuse service.
Offer IM phytomenadione 1 mg at birth (NICE NG194 / BNFc); the oral regimen requires three doses and is less reliable; late VKDB at 2-12 weeks causes fatal intracranial haemorrhage; breast milk is low in vitamin K.
undescended testis - if not descended by 6 months, refer for orchidopexy by 12 months. Preserves fertility and facilitates cancer surveillance. 4-8 fold cancer risk. Hormonal treatment no longer recommended. Impalpable testis needs laparoscopy. Bilateral impalpable testes - investigate for DSD.
congenital CMV - periventricular calcifications, SNHL, and petechiae. Diagnose with urine PCR within 21 days. Valganciclovir for 6 months for symptomatic disease; monitor FBC for neutropenia.
CSII delivers rapid-acting insulin continuously - basal rates replace long-acting insulin; bolus for meals; NICE TA151; DKA risk within 4-6 hours if pump fails; site changes every 2-3 days; bolus calculator assists dosing; approximately 40-50% UK paediatric T1DM use pumps.
RDS equals surfactant deficiency - ground-glass chest X-ray with air bronchograms in a preterm infant demands surfactant replacement and respiratory support.
pneumatosis intestinalis on abdominal X-ray in a preterm infant with abdominal distension and bloody stools is NEC - stop feeds, start IV antibiotics, and involve paediatric surgery.
delayed meconium with abdominal distension and explosive decompression on rectal examination suggests Hirschsprung disease - suction rectal biopsy confirms absent ganglion cells.
nephritic syndrome with low C3 and elevated ASOT 1-3 weeks post-streptococcal infection is PSGN - management is supportive, and prognosis in children is excellent.
febrile neutropenia in an oncology patient - IV antibiotics within 60 minutes, blood cultures before (but not delaying) antibiotics. This is a time-critical emergency.
Supportive care only; oxygen if sats below 92%; no bronchodilators; no steroids; no antibiotics; feeding support essential; NICE NG9; RSV commonest cause; HFNC if standard oxygen fails; palivizumab for high-risk prevention; winter seasonality; apnoea risk in young infants.
Exchange transfusion - threshold 100µmol/L above phototherapy line; double-volume exchange removes 85% of blood; group O Rh-negative irradiated blood; encephalopathy mandates exchange regardless of level; hypocalcaemia from citrate; umbilical venous access; NICE CG98.
Choledochal cyst - Todani type I commonest; complete excision mandatory; malignancy risk 10-30% if retained; Roux-en-Y hepaticojejunostomy; anomalous pancreaticobiliary junction pathogenesis; classical triad in under 20%; East Asian and female predominance; Caroli disease is type V.
Organic acidaemias - high anion gap acidosis plus hyperammonaemia; stop protein; IV calories; correct acidosis; carnitine supplementation; B12 trial in MMA; monitor cardiomyopathy in PA and renal failure in MMA; neonatal emergency; liver transplant for severe cases.
Laryngomalacia - commonest cause of infantile stridor; worse supine, feeding, crying; peaks 6-8 months; resolves by 12-24 months in 90%; flexible laryngoscopy confirms; supraglottoplasty for severe cases with FTT or desaturations.
Giant aneurysm z-score 10 or above 8 mm; lifelong warfarin plus aspirin; serial imaging echocardiography CT MRI; stenosis from intimal proliferation; small aneurysms often regress; leading acquired heart disease in developed world; AHA guidelines.
Single trunk with obligate VSD; single loud S2; mild cyanosis with heart failure; DiGeorge 22q11.2 association; early surgery within weeks; RV-to-PA conduit; irreversible PVD if delayed; Collett and Edwards classification.
UK newborn screening 9 conditions at day 5 - positive result needs confirmation; PKU early diet prevents intellectual disability; phenylalanine restriction lifelong; false positives occur; contact family within 24 hours; metabolic team referral; calm communication; NHS Screening programme.
Graves in adolescents - carbimazole first-line 0.5-1mg/kg/day; agranulocytosis warning (sore throat = urgent FBC); propranolol for symptoms; 2-year treatment course; 25-30% remission; PTU not first-line due to hepatotoxicity; TRAb confirms diagnosis; block-and-replace or titration regimen.
Iron deficiency commonest nutritional deficiency in infants - breast milk insufficient from 6 months; oral iron for 3 months post-Hb normalisation; sodium feredetate well-tolerated; limit cow's milk <500mL/day; vitamin C enhances absorption; recheck FBC at 4 weeks; ferritin confirms depleted stores.
3-5% of term neonates; most descend by 3 months; refer at 6 months; orchidopexy by 12 months; retractile testes normal variant; fertility and malignancy implications; bilateral non-palpable needs karyotype; NIPE screening; BAPS guidelines.
NICE CG98 threshold charts - plot bilirubin against age in hours; gestational age determines which chart; preterm lower thresholds; check response at 4-6 hours; stop when 50µmol/L below threshold; rebound check at 12-18 hours; lower albumin in preterm increases risk.
Pre-emptive transplant preferred - living donor from parent best outcomes; peritoneal dialysis for younger children; haemodialysis for older; minimum 10kg for adult kidney; transition planning to adult services; multidisciplinary team essential; home PD preserves school attendance.
Neonatal gentamicin = 5mg/kg with extended intervals - TDM trough <1mg/L is mandatory; altered neonatal pharmacokinetics require different dosing from adults; nephrotoxicity and ototoxicity require monitoring; always double-check calculations in neonatal prescribing.
Appears first weeks; proliferates 3-6 months; involutes 3-7 years; 90% resolved by age 9; observation for most; propranolol first-line if complicated; periocular risks amblyopia; beard distribution screen airway; PHACE with large facial lesions.
C5-C6 upper plexus; waiter's tip posture; absent Moro, preserved grasp; shoulder dystocia cause; 80-90% recover spontaneously; physiotherapy for contracture prevention; surgery if no recovery by 3-6 months; RCOG guidelines; biceps function prognostic indicator.
Most tall children are familial - investigate if velocity is accelerated or features are atypical; bone age, thyroid, pubertal hormones, IGF-1; karyotype boys for Klinefelter (47,XXY); Marfan syndrome if marfanoid habitus; precocious puberty causes tall-then-short pattern; GH excess is rare.
Hyponatraemic seizures - 3% saline 2-3mL/kg over 10-15 minutes; raise sodium 4-6mmol/L to stop seizures; max 10-12mmol/L in 24 hours; iatrogenic from hypotonic fluids; NICE NG29 warns against hypotonic maintenance; switch to isotonic immediately.
Plot bilirubin against hours not days - use correct gestational age chart; rate over 8.5µmol/L/hour suggests haemolysis; reassess at 4-6 hours; phototherapy and exchange threshold lines; rebound check at 12-18 hours; NICE CG98; preterm lower thresholds; rising on phototherapy needs investigation.
Commonest innocent murmur ages 2-7; musical vibratory quality; lower left sternal edge; disappears standing; resolves by puberty; false tendons possible mechanism; no investigation if classic; reassurance only.
Right-sided 70%; direct IVC drainage; large vascular neonatal adrenals; birth trauma risk; ultrasound shows shrinking mass; distinguish from neuroblastoma; urinary catecholamines if uncertain; jaundice from haemoglobin reabsorption; bilateral may cause adrenal insufficiency; serial imaging essential.
Bicuspid aortic valve is the commonest congenital cardiac anomaly (1-2 percent); a right upper sternal edge ejection systolic murmur with an ejection click radiating to the carotids plus exertional syncope signals critical aortic stenosis - arrange urgent echocardiography, refer to paediatric cardiology, and restrict competitive sport.
developmental red flags - no sitting by 9 months, no pincer grip by 12 months, no babble by 12 months, no walking by 18 months, no words by 18 months. Absent joint attention is an early autism red flag. Always check hearing with speech delay. Global delay (≥2 domains) needs urgent referral.
ALL - most common childhood cancer (25-30%). Peak age 2-5 years. Presents with marrow failure (anaemia, thrombocytopenia, neutropenia) + organ infiltration. Blasts on blood film. 90% cure rate. NICE recommends urgent FBC for unexplained petechiae or hepatosplenomegaly.
Anti-Ro/anti-La cross placenta; 2% risk in anti-Ro positive; 18-24 weeks critical window; AV node fibrosis irreversible; 60-70% need pacemaker; non-cardiac features transient; echocardiography from 16 weeks; hydroxychloroquine may reduce risk; 15-20% recurrence; PATCH trial.
meconium aspiration - patchy opacification with hyperinflation on X-ray. No routine suctioning; supportive ventilation, consider surfactant and inhaled nitric oxide for PPHN.
JIA - arthritis >6 weeks in a child under 16. ANA-positive oligoarticular JIA requires regular slit-lamp screening for uveitis, the most important extra-articular complication.
Prader-Willi - floppy baby who won't feed becomes a child who won't stop eating. Paternal 15q11-13 deletion. Growth hormone therapy and strict caloric restriction are cornerstones of management.
childhood obesity - NICE tiered approach. Multicomponent family-based lifestyle intervention is first-line. 60 minutes activity daily, <2 hours screen time. Acanthosis nigricans = insulin resistance. Orlistat and surgery are last resort.
Step 3 = add LABA to ICS in children ≥5 years per BTS/SIGN - assess response to guide further steps; always check adherence, technique, and triggers before stepping up; LTRA is an alternative add-on; combination inhalers improve adherence; reliever use >3 times/week indicates poor control.
craniopharyngioma - Rathke's pouch remnant, suprasellar. Calcified cystic-solid mass. Panhypopituitarism + diabetes insipidus + bitemporal hemianopia. Adamantinomatous type in children. High recurrence (30-50%). Hypothalamic obesity is a devastating complication. Lifelong hormone replacement.
nine conditions on blood spot - sickle cell, CF, hypothyroidism, PKU, MCADD, MSUD, IVA, GA1, HCU. Day 5 timing allows metabolite accumulation from feeding. SMA is being added.
beta-thalassaemia major - presents at 3-6 months as HbF declines. Absent HbA on electrophoresis. Regular transfusions to maintain Hb >95g/L plus iron chelation. UK antenatal screening identifies carrier couples. HSCT is curative.
Alagille syndrome - JAG1 mutation; autosomal dominant; 5 features: cholestasis, cardiac, vertebrae, eyes, face; need 3 plus bile duct paucity; peripheral pulmonary stenosis 90%; posterior embryotoxon 80%; 15-20% need liver transplant; Notch signalling pathway.
Nitrofurantoin for lower UTI ONLY - no tissue penetration, only urine concentration; contraindicated in renal impairment and G6PD deficiency; very low resistance rates; 750mcg/kg QDS for 3 days in children; not for pyelonephritis or urosepsis.
Montelukast 5mg at bedtime for ages 6-14 - LTRA blocking CysLT1 receptors; add-on to ICS at step 3; good for exercise-induced symptoms and allergic rhinitis; assess response at 4-8 weeks; monitor for neuropsychiatric side effects; FDA black box warning.
Fluid restriction includes ALL sources - IV, oral, medications, flushes; divide across nursing shifts; sodium monitoring 6-8 hourly; document on fluid balance chart; family education essential; caloric intake must be maintained; adjust restriction based on sodium response.
Hyperemesis gravidarum with ketonuria, >5% weight loss, or electrolyte disturbance requires admission for IV fluids, antiemetics, potassium correction, and thiamine supplementation - the suppressed TSH is gestational thyrotoxicosis, not true hyperthyroidism.
Women with a uterus need combined HRT (oestrogen + progestogen) - NICE NG23 confirms benefits outweigh risks when started under 60 or within 10 years of menopause. Transdermal oestrogen avoids VTE risk.
Major placenta praevia with suspected accreta spectrum requires delivery at 36-37 weeks in a specialist centre - counsel about possible hysterectomy, ensure cross-matched blood and multidisciplinary team availability.
PCOS requires two of three Rotterdam criteria - for women not seeking pregnancy, the COCP is first-line for cycle regulation and hyperandrogenism, combined with lifestyle modification targeting 5-10% weight loss.
Severe pre-eclampsia requires labetalol for blood pressure control, magnesium sulphate for seizure prophylaxis, and planned delivery - NICE NG133 guides stepwise management with a BP target of <150/80-100mmHg.
HPV positive with any cytological abnormality requires colposcopy referral - HPV positive with normal cytology gets 12-month recall. HPV vaccination reduces but does not eliminate cervical cancer risk, so screening remains essential.
Methotrexate for ectopic pregnancy requires an unruptured mass <35mm, no fetal heartbeat, beta-hCG <5,000 IU/L, and normal bloods - always check eligibility criteria before offering medical management.
Large fibroids distorting the uterine cavity with menorrhagia and fertility desire require gynaecology referral for myomectomy - GnRH agonists can shrink fibroids pre-operatively, and UAE is generally avoided when future pregnancy is planned.
Delay in the first stage (less than 2cm dilatation in 4 hours) is managed with amniotomy first, then reassessment - oxytocin augmentation follows if amniotomy alone is insufficient. Always amniotomy before oxytocin.
Major placental abruption with fetal bradycardia demands category 1 caesarean section within 30 minutes - the triad of bleeding, woody-hard tender uterus, and fetal compromise is diagnostic without the need for imaging confirmation.
FBS pH ≥7.25 = normal, 7.21-7.24 = borderline (repeat in 30 minutes), ≤7.20 = deliver; lactate is an alternative measure; contraindicated in maternal HIV; provides objective data to guide delivery decisions when CTG is non-reassuring.
emergency contraception - Cu-IUD most effective (>99%), up to 120 hours. Ulipristal effective to 120 hours, works post-LH surge, no weight effect. Levonorgestrel to 72 hours, reduced efficacy if ≥70kg. Cu-IUD also provides ongoing contraception. Not abortifacient.
Aspirin 150mg from 12-36 weeks per NICE NG133 - one high-risk or two moderate-risk factors; ASPRE trial showed 62% reduction in preterm pre-eclampsia; take at bedtime; start before 16 weeks for maximum benefit; 150mg replaced the previous 75mg dose.
Ergometrine contraindicated in hypertension - causes systemic vasoconstriction and hypertensive crisis; Syntometrine contains ergometrine so is also contraindicated; use oxytocin infusion then carboprost or misoprostol instead; ergometrine safe only in normotensive patients; always check blood pressure before prescribing.
chronic pelvic pain - multifactorial, often negative laparoscopy. Treat with amitriptyline or gabapentin, pelvic floor physiotherapy, and CBT. Avoid repeated opioids and unnecessary investigations.
eclampsia - magnesium sulphate is first-line (not diazepam or phenytoin). 4g loading then 1g/hour. Monitor reflexes and urine output. Antidote is calcium gluconate.
ECV from 36 weeks in nulliparous, 37 weeks in multiparous - use tocolysis, give anti-D to Rh-negative women, and success is approximately 40-60%.
persistent intermenstrual bleeding - transvaginal ultrasound first-line, endometrial biopsy if age ≥40 or endometrium thickened. Exclude polyps, hyperplasia, and STIs. NICE NG88 guides the pathway.
Postnatal VTE scoring - caesarean section plus any factor equals LMWH; two or more factors for 10 days; persistent factors for 6 weeks; low-risk vaginal delivery no LMWH; mobilise and hydrate all women; RCOG 37a; reassess at each clinical change; standardised assessment tool.
PMRT for every perinatal death - post-mortem identifies cause in 40%; placental histology in 60%; Kleihauer for feto-maternal haemorrhage; MBRRACE-UK national surveillance; parental consent for post-mortem; follow-up appointment at 6-8 weeks.
hepatitis B in pregnancy - vaccine within 24 hours for all exposed neonates, add HBIG if HBeAg positive or high viral load. Consider maternal tenofovir from 28 weeks. Breastfeeding is safe. Caesarean section is not protective.
PMS diagnosis requires a prospective symptom diary showing luteal-phase-only symptoms - first-line treatment is lifestyle measures, COCP with drospirenone, or luteal-phase SSRIs.
Nexplanon - most effective reversible contraceptive (>99.9%). UKMEC 3 with enzyme-inducing drugs (carbamazepine, phenytoin, rifampicin). IUD/IUS unaffected by enzyme inducers. Unpredictable bleeding is the main side effect. Must be palpable post-insertion. Lasts 3 years.
cervicitis - chlamydia and gonorrhoea are the main causes. Mucopurulent discharge, friable cervix, contact bleeding. Empirical dual therapy (doxycycline + ceftriaxone) in high-risk patients. Mycoplasma genitalium if treatment fails. Untreated cervicitis can progress to PID.
HIV and breastfeeding in UK - formula feeding is safest (zero risk). BHIVA supports managed breastfeeding if viral load undetectable, with monthly monitoring. Exclusive breastfeeding only (mixed feeding increases risk). Non-judgemental, informed choice.
60-70% intrauterine pregnancy rate after salpingectomy - 10-15% recurrent ectopic risk; early USS in all future pregnancies; no mandatory waiting period; transperitoneal migration enables conception; refer after 12 months of trying; IVF if remaining tube compromised.
lamotrigine clearance increases 50-100% in pregnancy - monitor levels monthly and increase dose accordingly. Reduce dose within 1-2 weeks postpartum to avoid toxicity. Breakthrough seizures are common without dose adjustment.
150 minutes moderate exercise weekly per RCOG/NICE - reduces GDM risk by 25-30%; avoid contact sports, scuba diving, and hot environments; pelvic floor exercises specifically recommended; previously active women can continue modified activity.
septate uterus - normal external contour with an internal septum. Most common anomaly linked to miscarriage. Hysteroscopic septoplasty evidence is being re-evaluated by ESHRE.
fFN - high NPV (95-99%), modest PPV (15-30%); take before digital examination; invalid with blood/semen/liquor; valid 22-34+6 weeks; negative result enables safe discharge per NICE NG25.
primary vaginal cancer - rare (1-2% of gynaecological cancers), diagnosis of exclusion. SCC most common subtype. DES exposure linked to clear cell adenocarcinoma. Chemoradiation is the primary treatment. FIGO staging determines management. HPV infection is a key risk factor.
Shoulder dystocia requires McRoberts position plus suprapubic pressure as the first-line response - never apply fundal pressure as it worsens impaction, and document all manoeuvres, timings, and outcomes meticulously.
Antenatal colostrum harvesting from 36-37 weeks - particularly for diabetic mothers; DAME trial confirmed safety; frozen in syringes; provides breast milk for neonatal hypoglycaemia; does not increase preterm birth risk; teaches hand expression technique.
vigorous baby through meconium - dry, stimulate, observe. Do NOT routinely suction the trachea. Only intubate and suction if the baby is non-vigorous. Monitor for meconium aspiration syndrome for 24 hours.
Modifiable stillbirth risk factors - obesity, smoking, undetected FGR, uninvestigated reduced movements, supine sleeping; Saving Babies' Lives care bundle; left lateral sleeping position after 28 weeks; MBRRACE-UK data drives quality improvement.
Explore reasons; offer perinatal mental health support; discuss risks including future pregnancies; respect informed request; refer if unwilling to perform; not before 39 weeks; document discussion; NICE CG132; tokophobia is recognised.
CO monitoring at booking (≥4ppm triggers referral) per NICE PH26 - behavioural support first-line; NRT safer than smoking; smoking doubles miscarriage risk; quitting at any gestation improves outcomes.
At least one antenatal appointment without the partner per NICE - never ask about DV in front of partner; pregnancy escalates risk in 30%; MARAC referral for high-risk cases; domestic violence is a leading cause of maternal death.
Meigs syndrome - ovarian fibroma plus ascites plus pleural effusion, all resolving after tumour removal. Negative cytology and absent peritoneal deposits distinguish it from ovarian cancer.
two doses of betamethasone 12mg IM 24 hours apart - give between 24 and 34 weeks whenever preterm delivery is anticipated within 7 days, including PPROM.
Surrogate is legal mother at birth - parental order transfers parenthood; not legally binding contract; consent at 6 weeks-plus; one intended parent genetically related; commercial surrogacy unenforceable; Law Commission recommends reform; reasonable expenses only.
deep dyspareunia with cyclical pain and subfertility - think endometriosis. Superficial dyspareunia is introital (vulvodynia, atrophy). Pouch of Douglas nodularity and fixed uterus on examination are key signs.
HCV in pregnancy - 5-10% vertical transmission; vaginal delivery safe; caesarean does not reduce transmission; breastfeeding permitted; DAAs post-delivery; avoid invasive fetal procedures; test neonate at 18 months or PCR at 6 weeks; no neonatal prophylaxis available.
SFH above 90th customised centile needs ultrasound assessment - consider GDM, polyhydramnios, and macrosomia; customised charts are superior to the 'SFH = gestational weeks' rule; LGA carries shoulder dystocia risk.
Salpingectomy first-line if other tube healthy per NICE NG126 - ESEP trial confirms equivalent fertility; salpingotomy when contralateral tube compromised; 5-20% persistent trophoblast after salpingotomy needing hCG surveillance; laparoscopic approach standard; laparotomy for instability.
Cornual ectopic has 2-2.5% mortality from rupture - rich myometrial blood supply; interstitial line sign on USS; methotrexate possible if criteria met; laparoscopic cornuostomy or wedge resection for surgical cases; future pregnancy surveillance for uterine rupture risk; senior input essential.
Puerperal endometritis - commonest after emergency caesarean; IV clindamycin plus gentamicin; exclude retained products; prophylactic antibiotics reduce risk 60-70%; polymicrobial infection; VTE prophylaxis; afebrile 24-48h before oral switch; NICE CG132.
DVT history = UKMEC 4 for all CHC; progesterone-only methods are safe; POP and implant can start immediately postpartum; IUD from 4 weeks post-delivery; breastfeeding adds further CHC restriction in first 6 weeks.
FGM - mandatory reporting for under-18s, specialist referral for pregnant women, and de-infibulation enables vaginal delivery. Re-infibulation is illegal in the UK.
OHSS is managed with IV fluids and LMWH - never give diuretics as the problem is intravascular depletion despite extravascular fluid overload.
FSH >25 IU/L on two occasions with low oestradiol before age 40 is premature ovarian insufficiency - offer HRT until age 51 for bone and cardiovascular protection.
POI requires HRT until age 51, not the COCP - screen for associated autoimmune conditions and counsel that donor oocyte IVF is the most reliable fertility pathway.
Sheehan syndrome - failure to lactate after massive PPH is the cardinal early sign. Always replace hydrocortisone before levothyroxine to avoid adrenal crisis.
CSP incidence rising with caesarean rates - implants in scar defect; risks placenta accreta spectrum and rupture; thin myometrium <2mm is high-risk; multiple treatment modalities available; tertiary referral essential; systemic or local methotrexate for early cases.
RIF investigation - hysteroscopy, thrombophilia, karyotype, ERA; endometrial scratching no longer supported after SWAT trial; HFEA traffic lights for add-ons; PGT-A for translocation carriers; evidence base for many treatments is limited; systematic approach essential.
First infant formula from birth to 12 months - water must be ≥70°C to kill Cronobacter; make fresh each time; responsive paced feeding reduces overfeeding; sterilise until 12 months; support maternal choice without judgement.
endometrial hyperplasia - without atypia: LNG-IUS first-line (>95% regression), re-biopsy at 6 months, low cancer risk (<5%). Atypical hyperplasia: hysterectomy recommended (28-30% cancer risk). Address underlying cause (obesity, anovulation). WHO 2014 two-tier classification.
NICE prefers diamorphine over pethidine; norpethidine half-life 14-21 hours; diamorphine has better analgesia and less nausea; naloxone available at delivery; co-prescribe antiemetic; both delay gastric emptying; avoid within 2-4 hours of delivery.
Cervical ectopic is a rare emergency - cervix cannot contract to stop bleeding; Foley balloon tamponade for acute haemorrhage; methotrexate systemic or local injection; uterine artery embolisation before evacuation; hysterectomy if uncontrollable; multidisciplinary management essential.
IUI places washed sperm into the uterus at ovulation - 10-15% per cycle unstimulated; sperm preparation removes seminal plasma; NICE CG156 recommends up to 6 cycles; not effective if motile count <5 million; donor sperm is a key indication; stimulated cycles increase success but also multiple pregnancy risk.
6-week check covers mental health (EPDS if concerns), contraception from 21 days, perineal healing, BP, and continence screening; baby blues resolve by 2 weeks; symptoms beyond 2 weeks need assessment; LARC recommended for contraception.
Reduced fetal movements require same-day assessment with CTG and fetal heart auscultation - if CTG is reassuring, arrange ultrasound within 24 hours. Never dismiss RFM as normal in late pregnancy.
HRT - most effective for vasomotor symptoms. Combined (oestrogen + progestogen) if uterus intact. Transdermal oestradiol avoids VTE risk. Micronised progesterone safer than synthetic. Breast cancer risk small and contextualised. Greatest benefit when started <60 or within 10 years of menopause.
Spinal preferred for caesarean; onset 5-10 minutes; T4 block target; phenylephrine infusion standard; left lateral tilt essential; co-loading fluids; faster onset and more reliable than epidural; fixed duration limitation; pencil-point needles reduce PDPH.
Maintain uteroplacental circulation; partial delivery only; deep volatile anaesthesia for tocolysis; 30-60 minutes on placental support; secure airway before cord clamping; tracheostomy if intubation fails; haemorrhage risk from atony; multidisciplinary team essential; 85-90% survival.
Golden hour - skin-to-skin and breastfeed within 1 hour; correct attachment is key (wide gape, flanged lip, chin to breast); colostrum provides immunity; 8-12 feeds per day is normal; UNICEF Baby Friendly standards guide practice.
Gold standard for uterine cavity; outpatient without GA for diagnosis; operative under GA for resection; saline distension safer than glycine; perforation 1-2% operative; fluid balance monitoring; NICE NG88; submucous fibroid and polyp treatment.
Vacuum aspiration for first-trimester surgical TOP - cervical preparation reduces trauma; prophylactic antibiotics essential; metronidazole or doxycycline; <1% major complication rate; inspect tissue for completeness; screen or treat for Chlamydia.
Letrozole 2.5mg days 2-6 - aromatase inhibitor with superior live birth rates to clomifene per Legro NEJM 2014; mono-follicular response; no endometrial thinning; off-label in UK; short half-life; first-line per 2023 international PCOS guideline.
Prosopagnosia - selective face recognition deficit; right fusiform face area; acquired (stroke, encephalitis) or developmental (2% of population); compensatory strategies using voice and non-facial cues; distinct from general visual agnosia.
MND MDT improves survival - neurologist, specialist nurse, respiratory, SLT, dietitian, physiotherapy, OT, palliative care, psychology, social work; 2-3 monthly clinics; early palliative care; 15% FTD overlap; communication aids; NICE NG42.
SLT first-line per NICE NG81 and LiGHT trial - 74% drop-free at 3 years; selective targeting of pigmented meshwork cells; repeatable unlike ALT; 20-30% IOP reduction; 5-10 minute outpatient procedure; lasts 3-5 years; cost-effective; transient IOP spike risk.
Fibular head compression; foot drop with preserved inversion and plantarflexion; lateral calf and foot dorsum sensory loss; preserved ankle jerk; distinguish from L5 by inversion strength; AFO for walking; bed rest and leg crossing causes; most recover spontaneously; specialist guidelines.
MND end-of-life - early advance care planning; opioids for breathlessness; anticholinergics for secretions; benzodiazepines for anxiety; death usually peaceful from CO2 retention; reassure patients; pain often underrecognised; NICE NG42; palliative care from diagnosis.
DN4 score 4 or above identifies neuropathic pain; burning, shooting, electric shock descriptors; allodynia and hyperalgesia are positive phenomena; assess function, sleep, and mood; NICE CG173 guides management; diabetic neuropathy commonest cause.
Carbamazepine first-line (start 100 mg BD; 70-80% response supports diagnosis); monitor FBC/Na/LFTs; HLA-B*1502 in SE Asian patients (SJS/TEN); CYP3A4 induction reduces COC efficacy; oxcarbazepine second-line per NICE CKS and ABN.
Ceftriaxone plus dexamethasone empirically; dexamethasone before or with antibiotics; amoxicillin for Listeria cover over 50; never delay antibiotics for LP; notify Public Health; ciprofloxacin prophylaxis for contacts; NICE CG102.
Flavivirus transmitted by Culex mosquitoes; rural Asia near rice paddies and pigs; bilateral thalamic lesions; extrapyramidal features; supportive treatment only; Ixiaro vaccine; case fatality 20-30 percent; PHE Green Book; neurological sequelae in survivors.
Biphasic - severe pain then patchy weakness; immune-mediated after infection; long thoracic and suprascapular commonly affected; scapular winging; 80-90 percent recover over 1-3 years; SEPT9 hereditary form; physiotherapy during recovery; EMG patchy denervation; specialist guidelines.
Phenytoin zero-order kinetics - narrow therapeutic index 10-20 mg/L; nystagmus is the first sign of toxicity; correct the total level for albumin using Sheiner-Tozer; potent enzyme inducer; adjust in small increments only; gingival hyperplasia and osteomalacia are long-term effects.
Brivaracetam next-generation SV2A ligand - 15-30x higher affinity; fewer psychiatric side effects; focal epilepsy adjunctive; start at therapeutic dose; IV available; CYP2C19 metabolism; logical switch from levetiracetam when psychiatric effects limit use.
Carbamazepine causes SIADH-like hyponatraemia in 20% - enhances ADH action; correct sodium slowly (max 10mmol/L per 24 hours); osmotic demyelination risk with rapid correction; oxcarbazepine has higher risk; fluid restriction for mild cases; monitor sodium regularly.
Flavivirus from Ixodes ticks; biphasic illness with afebrile interval; supportive treatment only; TBE vaccine for travellers; European subtype 1-2 percent fatality; ataxia and tremor characteristic; also via unpasteurised dairy; PHE Green Book; neurological sequelae in 10-20 percent.
vCJD - young patients psychiatric onset; pulvinar sign on MRI; tonsil biopsy positive; linked to BSE; sporadic CJD - elderly rapid dementia cortical ribboning; RT-QuIC for sporadic; notify CJD Surveillance Unit; prion resistant to standard decontamination; NICE guidelines.
Intact surgical removal essential; Dowling-Orlando hydrodissection; rupture causes anaphylaxis and recurrence; perioperative albendazole; large spherical cyst without enhancement; children in endemic areas; hypertonic saline scolicidal; treat hepatic cysts concurrently; specialist guidelines.
Spiral groove compression; wrist and finger drop; triceps intact; dorsal first web space sensory loss; Saturday night palsy; neurapraxia recovers 6-12 weeks; extension splint; brachioradialis reflex absent; distinguish from axillary lesion by triceps function.
Autoimmune microvasculitis not hyperglycaemia; acute thigh pain and quadriceps wasting; weight loss; occurs with good control; EMG widespread denervation; elevated CSF protein; self-limiting 12-24 months; pain management priority; type 2 diabetes predominantly; specialist guidelines.
Posterior columns plus lateral corticospinal tracts; absent ankle jerks with brisk knees; pernicious anaemia commonest cause; IM hydroxocobalamin urgent; inverted V sign on MRI; methylmalonic acid elevated; Romberg positive; treatment prevents irreversibility; BSH guidelines; lifelong injections.
NEAD = prolonged episodes, eyes closed, asynchronous movements, no post-ictal phase - diagnose with video-EEG and treat with psychological therapy, not AEDs.
Optic neuritis - IV methylprednisolone speeds recovery; oral prednisolone alone is harmful; MRI brain determines MS risk.
Unidirectional horizontal-torsional nystagmus following Alexander's law = peripheral; direction-changing gaze-evoked = central (cerebellar); purely vertical (upbeat/downbeat) = central; peripheral nystagmus is suppressed by fixation.
HAND persists despite ART - subcortical pattern with psychomotor slowing and executive dysfunction; optimise ART for CNS penetration; always exclude treatable causes.
Papilloedema = disc swelling FROM raised ICP; bilateral, preserved acuity early; papillitis = optic neuritis with reduced acuity; always image to exclude mass lesion; AION = sudden painless loss in elderly; drusen mimic swelling.
GCS ≤8 = coma requiring airway protection - motor response is the most prognostically significant component; abnormal flexion (M3) indicates damage above the red nucleus; decerebrate extension (M2) indicates brainstem damage.
Demyelinating NCS pattern = slow velocities + conduction block + prolonged latencies; axonal = reduced amplitudes + preserved velocities; CIDP and GBS show demyelinating patterns and are treatable immune-mediated conditions.
Thrombectomy + alteplase for proximal LVO - NNT 3-5 for independence; 6-hour standard window, up to 24 hours with perfusion imaging; drip and ship or mothership models; NICE NG128 mandates thrombectomy access for eligible patients.
MSA - early severe autonomic failure plus parkinsonism plus or minus cerebellar ataxia; hot cross bun sign on MRI; alpha-synucleinopathy; levodopa response wanes; postural hypotension ≥30mmHg systolic is a key diagnostic criterion.
NICE NG217 - discuss withdrawal after ≥2 years seizure-free; relapse risk ~30-50%; taper over 2-3 months; DVLA off-licence during taper plus 6 months; levetiracetam pregnancy-safe; valproate contraindicated under MHRA PPP.
SNRI enhancing descending inhibition; first-line per NICE CG173; dual benefit for pain and depression; start 60 mg or 30 mg if cautious; avoid with MAOIs; taper on withdrawal; nausea commonest side effect; hepatic metabolism.
10-75 mg at night for pain; anticholinergic effects limit use in BPH and glaucoma; unlicensed but NICE-recommended; dual mechanism reuptake inhibition plus sodium channel; lethal in overdose; ECG if cardiac risk; 6-8 weeks to assess.
Neurosurgical emergency; Staph aureus 60-70%; back pain to paralysis progression; emergency laminectomy if deficit present; pre-op neurology predicts outcome; MRI with gadolinium; 6-8 weeks IV antibiotics; diabetes and IVDU major risk factors; window to surgery critical.
Commonest spinal vascular malformation; venous congestion causes congestive myelopathy; men 50-70; ascending weakness and bladder dysfunction; serpentine flow voids on MRI; spinal angiography gold standard; surgical disconnection or embolisation; early treatment improves outcome.
PHN persists beyond 90 days; NICE CG173; amitriptyline, duloxetine, gabapentin, pregabalin first-line; capsaicin 8 percent patch second-line; Shingrix vaccine prevention; age over 60 strongest risk; peripheral and central sensitisation; early antiviral reduces risk.
MS bladder - 75% affected; detrusor overactivity commonest; check post-void residual before anticholinergics; ISC for incomplete emptying; botulinum toxin for refractory overactivity; UTIs trigger pseudo-relapses; urodynamics guide treatment; bladder diary first step.
Taenia solium eggs cause NCC not eating pork; vesicular-colloidal-calcified stages; albendazole for viable cysts; steroids before antiparasitic; calcified needs anticonvulsants only; scolex pathognomonic; leading cause of epilepsy in endemic areas; specialist guidelines.
Rapid correction of chronic hyponatraemia causes ODS; maximum 10 mmol/L in 24 hours; 6-8 for high-risk patients; desmopressin rescue for overcorrection; pontine demyelination; locked-in syndrome; MRI T2 hyperintensity in pons; variable recovery.
Malignant otitis externa should be suspected in any diabetic patient with severe ear pain unresponsive to topical treatment and cranial nerve involvement - urgent IV anti-pseudomonal antibiotics and ENT referral are essential.
Melanocyte-targeting autoimmune disease; four stages - prodromal, uveitic, convalescent, chronic; bilateral panuveitis with serous detachments; poliosis, vitiligo, alopecia; no penetrating trauma history; darkly pigmented populations; early aggressive steroids; sunset-glow fundus.
NMOSD = AQP4 antibodies + longitudinally extensive myelitis + severe optic neuritis; MS drugs are contraindicated; rituximab or eculizumab for relapse prevention.
Rapid sodium correction → ODS 2-6 days later; limit correction to ≤10-12mmol/L per 24 hours; if overcorrected, re-lower with desmopressin urgently.
Locked-in syndrome = conscious but paralysed; vertical eye movements and blinking are preserved; ventral pons destroyed, dorsal pons intact; EEG is normal - never mistake for brain death.
Severe boring eye pain + deep violaceous injection + non-blanching with phenylephrine + RA = scleritis; needs systemic treatment, not just topical; check for underlying autoimmune disease.
dAVF acquired (not congenital); Cognard classification guides treatment; cortical venous reflux raises haemorrhage risk to 8-10% per year; pulsatile tinnitus is earliest symptom; endovascular embolisation first-line per BSNR.
Botox for chronic migraine after 3 failed preventives; 155-195 units across 31-39 sites every 12 weeks; PREEMPT protocol; stop if <30% improvement after 2 cycles; anti-CGRP antibodies are alternatives.
EDS + cataplexy + MSLT ≤8 min with ≥2 SOREMPs = narcolepsy type 1; modafinil for sleepiness, sodium oxybate for cataplexy; check CSF hypocretin-1.
PSP is supportive care only - withdraw ineffective levodopa; falls prevention is the priority; SLT for progressive dysphagia; pseudobulbar affect responds to low-dose amitriptyline; early advance care planning and palliative care involvement.
DMD adult care - cardiomyopathy leading cause of death; ACE inhibitor early; annual echo and ECG; NIV extends survival; cough assist when peak flow below 270; continue corticosteroids; scoliosis surgery; bone health; psychosocial support; transition planning.
Two doctors, two sets of tests; preconditions - known cause, exclude hypothermia, drugs, metabolic; six clinical tests plus apnoea; PaCO2 above 6.65 kPa; death at second test completion; no mandatory EEG in UK; spinal reflexes may persist.
Argyll Robertson pupils - accommodate but do not react; general paresis 10-25 years; tabes dorsalis posterior columns; CSF VDRL specific but 50-70% sensitive; IV benzylpenicillin 14 days; BASHH guidelines; repeat CSF at 3-6 months; IM benzathine penicillin insufficient.
Siponimod for active SPMS per NICE TA656 - CYP2C9 genotyping mandatory (*3/*3 contraindicated), 5-day titration with cardiac monitoring, OCT screening for macular oedema, EXPAND trial evidence base.
Parkinsonian gait = shuffling, festination, freezing, reduced arm swing - distinguish from NPH (magnetic gait without tremor); cerebellar = wide-based ataxia; sensory ataxia = high-stepping with positive Romberg.
Pars plana entry 3.5-4 mm from limbus; vitreous haemorrhage wait 1-3 months then surgery; gas tamponade requires face-down positioning; no air travel until gas absorbs; cataract commonest long-term complication; NICE NG28.
CSW hypovolaemic, SIADH euvolaemic; same biochemistry, different volume status; CSW needs saline, SIADH needs fluid restriction; SAH commonest cause of CSW; fludrocortisone for sodium retention; opposite treatments make distinction critical.
Screen with MRA if two or more first-degree relatives with SAH; screen all ADPKD; repeat every 5 years; PHASES score for rupture risk; coiling per ISAT trial; stop smoking strongest modifiable factor; 2-3% population prevalence; MRA non-invasive screening modality.
Bilateral panuveitis after penetrating injury; exciting and sympathising eyes; immune privilege broken; mutton-fat KPs and Dalen-Fuchs nodules; systemic steroids then immunosuppression; preventive enucleation within 2 weeks; established SO - enucleation doesn't help; T-cell mediated autoimmune.
Frontal lobe syndrome - orbitofrontal = disinhibition; dorsolateral = executive dysfunction; bvFTD presents with personality change not memory loss; distinguish from Alzheimer's; executive tests include verbal fluency, WCST, and Stroop.
Dry eye = preservative-free artificial tears first; review medications; ciclosporin drops for moderate-severe; punctal plugs retain tears; Sjögren's is the main autoimmune cause; paradoxical watering is reflex tearing.
Therapeutic DOAC with measurable anti-Xa contraindicates IV alteplase - thrombectomy remains an option for large vessel occlusion; thrombolysis window is 4.5 hours; thrombectomy window extends to 24 hours with perfusion imaging selection.
Progressive headache + papilloedema + cranial nerve palsy = raised ICP - image urgently; CN VI palsy is a false localising sign; contrast-enhanced imaging is essential (NICE NG12).
EEG classifies epilepsy syndromes but does not diagnose or exclude epilepsy per NICE NG217 - about 50% of epilepsy patients have a normal single routine EEG; 3 Hz spike-and-wave indicates absence epilepsy; video-EEG telemetry distinguishes epileptic from non-epileptic events.
MAO-B inhibitors - NICE NG71 first-line option for early PD; caution with SSRIs (serotonin syndrome) per BNF; no tyramine diet needed at recommended doses.
ICDs in 15-20% on dopamine agonists per NICE NG71 - gambling, hypersexuality, shopping, binge eating; patients lack insight; gradually reduce agonist to avoid DAWS.
Donepezil 5mg at bedtime, increase to 10mg after 4-6 weeks - check ECG for conduction abnormalities; caution with beta-blockers and rate-limiting drugs; nausea and diarrhoea are commonest side effects; NICE NG97 for mild-to-moderate Alzheimer.
Levodopa is first-line per NICE NG71 - always combine with carbidopa or benserazide; start low, titrate slow; motor complications develop in 50% by 5 years; protein competes for absorption; most effective symptomatic therapy available.
Tenecteplase 0.25mg/kg single IV bolus (max 25mg) - non-inferior to alteplase per AcT trial; simpler logistics for thrombectomy transfers; higher fibrin specificity; same contraindications and monitoring as alteplase; increasingly adopted in UK stroke guidelines.
Hydroxyzine - H1 antihistamine licensed for short-term anxiety; rapid onset within thirty to sixty minutes; no dependence potential; MHRA warning about QTc prolongation; useful bridge while awaiting SSRI effect; anticholinergic side effects and drowsiness.
Methadone induction - highest risk in first 2 weeks; start 10-30mg; increase maximum 5-10mg every 3-5 days; supervised consumption 3 months minimum; QTc monitoring mandatory; Orange Book guidance; accumulation risk from long half-life.
Abbey Pain Scale - observational for non-verbal dementia patients; 6 domains scored 0-3; behavioural change always prompts pain assessment; pain underdiagnosed in dementia; empirical analgesia trial appropriate; common sources include UTI, constipation, arthritis; score 14+ indicates severe pain.
rTMS - left DLPFC, high-frequency, outpatient, no anaesthesia, no memory loss; 30-50% response in TRD; NICE IPG542; theta-burst protocols last 3-10 minutes; ECT remains more efficacious for severe or rapidly deteriorating cases.
Section 136 - police power, public places only, up to 24 hours, assessment by a doctor and AMHP at a health-based place of safety. Section 135(1) is needed for private homes.
Erotomania involves the fixed delusion that someone of higher status is in love with the patient - assess stalking and violence risk; treat with antipsychotics; engagement is difficult due to poor insight.
Alcohol withdrawal requires chlordiazepoxide reducing regimen plus IV Pabrinex - always assess for Wernicke's encephalopathy and monitor with the CIWA-Ar scale, as delirium tremens carries significant mortality if untreated.
Antipsychotics in dementia increase mortality and stroke risk - risperidone is the only licensed option for BPSD aggression; use the lowest dose for the shortest time; absolutely avoid in Lewy body dementia.
ASPD - group CBT interventions; NICE CG77; no medication for ASPD itself; treat substance misuse priority; multiagency working; preceded by conduct disorder; screen for ADHD; staff supervision essential; do not discharge for non-attendance; early intervention prevents development.
Adjustment disorder is distinguished from depression by preserved mood reactivity, identifiable stressor, and not meeting full depressive criteria - supportive counselling is first-line, not antidepressants.
Somatic symptom disorder management requires validation, continuity of care with one GP, limiting unnecessary investigations, and CBT - never dismiss symptoms as imaginary, and avoid reinforcing the sick role.
work is therapeutic - 'may be fit for work' with adjustments is almost always preferable to prolonged sickness absence.
Section 2 = 28 days assessment - AMHP application + 2 doctors (one Section 12 approved); non-renewable; appeal within 14 days to tribunal; Section 3 for longer treatment; IMHA must be offered.
Trazodone - SARI with dose-dependent sedation at low doses; lower dependence risk than benzodiazepines; warn males about priapism risk; orthostatic hypotension in elderly; off-label for insomnia but widely used.
Promethazine OTC - short-term only (≤7-14 nights, BNF); long half-life causes morning drowsiness; anticholinergic burden in elderly; avoid alcohol/CNS depressants; not for children under 2; refer if insomnia >2 weeks per NICE CKS Insomnia.
Forensic PD - OPD pathway joint NHS and HMPPS; PIPEs therapeutic environments; MHA 1983 allows detention; high-secure Broadmoor, Rampton, Ashworth; adapted DBT and schema therapy; long-term engagement; progression through security levels; specialist staff training; Parole Board assessment; personality disorder is mental disorder under MHA.
PFA - practical assistance first; do not debrief; NICE advises against single-session debriefing; normalise acute reactions; sixty to eighty percent recover naturally; screen at four to six weeks; anyone can deliver; connect with social support; WHO endorsed; trauma-focused CBT for persistent PTSD.
Refugee mental health - professional interpreters; three-phase trauma enquiry; PTSD twenty to forty percent; cultural idioms of distress; social determinants critical; torture screening; Freedom from Torture referral; narrative exposure therapy; NICE and UNHCR; trust and confidentiality essential.
GAD management follows NICE stepped care - SSRIs are first-line pharmacotherapy after psychological interventions, and benzodiazepines must only be used short-term for acute crisis situations.
Section 5(2) is the emergency holding power for inpatients - it lasts up to 72 hours, can be applied by the doctor in charge or deputy, and buys time for a formal MHA assessment.
IPS uses 'place then train' - rapid competitive job search with integrated employment specialists; 2-3 times higher employment rates than traditional approaches; NICE-recommended for psychosis; ongoing in-work support; employment improves clinical outcomes.
MBCT prevents depressive relapse in patients with 3+ episodes - 8-week group programme; reduces relapse by 40-50%; especially effective with childhood adversity; NICE-recommended alternative to long-term antidepressants.
PST is a NICE-recommended low-intensity treatment for mild-moderate depression - seven-step structured approach; delivered by PWPs at IAPT Step 2; particularly suited to depression triggered by identifiable life stressors; 6-8 sessions.
Secondary traumatic stress plus burnout; indirect trauma through empathy; ProQOL assessment tool; compassion satisfaction is protective; Figley described concept; high empathy is risk factor; reflective supervision essential; palliative and trauma work highest risk; self-care strategies; organisational responsibility.
Concordance explores patient beliefs about medication rather than enforcing compliance - non-adherence to lithium affects 50% of patients; address side effects and relapse risk collaboratively; abrupt discontinuation risks rebound mania.
Post-ICU morbidity - PICS; PTSD ten to twenty-five percent; depression twenty-five to thirty-five percent; cognitive impairment common; ICU diaries reduce PTSD; NICE CG83 follow-up at two to three months; screen with PHQ-9 GAD-7 IES-R; delusional memories key risk; trauma-focused CBT.
MAOIs require strict tyramine-restricted diet to prevent hypertensive crisis - mature cheese is the classic trigger; treat with IV phentolamine; never combine MAOIs with serotonergic drugs; 2-week washout minimum when switching.
Gaming disorder is recognised in ICD-11 - always screen for underlying depression, anxiety, and ADHD; use motivational interviewing for engagement; family therapy and CBT are the mainstays of treatment.
Supported living separates housing from care - own tenancy with personalised support; greater autonomy and legal rights than residential care; retains housing benefit; promotes recovery and independence; part of the stepped rehabilitation pathway.
AUDIT-C - 3 questions for rapid screening; score 5+ needs further assessment; NICE PH24 recommends brief interventions; 5-15 minutes; NNT of 8; AUDIT 20+ requires specialist referral; most cost-effective public health intervention for alcohol.
PD comorbidity - seventy-five to eighty-five percent have comorbid disorders; depression sixty to eighty percent; distinguish trait-related from independent; biological features indicate depression; treat with SSRIs; comorbidity increases suicide risk multiplicatively; PTSD thirty to fifty percent; screen substance misuse; NICE CG78; do not withhold treatment.
Conversion disorder requires positive signs of internal inconsistency (Hoover sign) - not just normal investigations - and is treated with physiotherapy and psychology, not investigation escalation.
NICE TA854 does NOT recommend esketamine for treatment-resistant depression on the NHS; it is an NMDA antagonist with rapid onset given under supervision with 2-hour observation, but is not routinely NHS-funded for TRD.
TCA overdose causes lethal cardiac sodium channel blockade - IV sodium bicarbonate narrows QRS and is the specific antidote; target pH 7.45-7.55; avoid class Ia/Ic agents and physostigmine; QRS >160 ms predicts arrhythmia.
PD employment - fifty to eighty percent unemployed; IPS model evidence-based; rapid job search; integrated with mental health treatment; Equality Act 2010 reasonable adjustments; Access to Work scheme; volunteering as stepping-stone; occupational therapy assessment; rejection sensitivity barrier; NICE CG78; employment supports recovery.
Agoraphobia is now classified independently from panic disorder - pervasive situational avoidance disproportionate to panic attack frequency distinguishes primary agoraphobia; treat with CBT and graded exposure.
ODD features defiance without serious conduct violations - parent training programmes are first-line for under 12s, and always screen for comorbid ADHD.
Section 4 = 72-hour emergency detention with one doctor + AMHP - used when a second doctor would cause undesirable delay; convert to Section 2 ASAP.
IMHAs are statutory, independent advocates for MHA-detained patients - must be offered to all qualifying patients; independent of the treating team and do not make clinical decisions.
Delirium prevention - multicomponent non-pharmacological bundle; NICE CG103; HELP programme thirty to forty percent reduction; orientation sleep mobilisation hydration; no prophylactic antipsychotics; medication review; sensory optimisation; twenty to thirty percent of elderly inpatients affected.
Quetiapine dose-dependent effects - low dose = H1 sedation (off-label insomnia, not NICE-recommended); moderate dose = 5-HT2A mood stabilisation; high dose = D2 antipsychotic; metabolic risks exist even at low doses; norquetiapine provides antidepressant properties.
Propranolol - blocks peripheral somatic anxiety symptoms only; take 30-60 minutes before event; absolutely contraindicated in asthma; no dependence; does not treat cognitive worry; useful for performance anxiety with palpitations and tremor.
Delirium tremens - medical emergency; five to fifteen percent mortality; forty-eight to ninety-six hours onset; ICU with high-dose IV benzodiazepines; refractory cases need phenobarbital or propofol; aggressive fluids; correct magnesium and potassium; Pabrinex IV; no haloperidol monotherapy; visual hallucinations characteristic.
Synthetic cathinones cause sympathomimetic toxicity and serotonin syndrome risk with SSRIs - treat with cooling, benzodiazepines, and IV fluids; standard drug screens may miss NPS.
Take-home naloxone saves lives - supplied without prescription since 2015; IM or intranasal; duration shorter than most opioids so repeat doses needed; train users to recognise overdose, call 999, give naloxone, and provide rescue breaths.
AUDIT 10 questions scored 0-40 - 20+ suggests dependence; AUDIT-C is 3-question screen; NICE CG115 for management; SADQ for dependence severity; scores 8-15 brief intervention; specialist referral for 20+; chlordiazepoxide for assisted withdrawal.
Guilt shame anger not fear; violates moral beliefs; distinct from PTSD and burnout; COVID-19 healthcare prominence; triage decisions resource scarcity; institutional betrayal; peer support valued; organisational acknowledgement needed; existential crisis; military origin concept.
Duloxetine - SNRI licensed for GAD per NICE CG113; start 30mg then increase to 60mg; nausea is commonest early side effect; analgesic benefit for comorbid pain; taper gradually to avoid discontinuation syndrome.
NAS Finnegan scoring - twenty-one items; four-hourly assessment; three scores at eight or above triggers treatment; oral morphine first-line; onset twenty-four to seventy-two hours; methadone delayed up to seven days; non-pharmacological measures essential; swaddling and rooming-in; NICE CG110; BAPM guidance; affects fifty-five to ninety-four percent of exposed neonates.
ACE-III 100-point tool - 5 domains; impaired fluency with preserved memory suggests frontotemporal or vascular; Alzheimer's shows early memory loss; VLOM ratio for subtyping; 88 and 82 cut-offs; 15-20 minutes; widely used in UK memory clinics; domain scores guide diagnosis.
PD risk assessment - dynamic not static; structured professional judgement; HCR-20 for violence; BPD suicide eight to ten percent; formulation-based approach; protective factors important; MAPPA for offenders; triggers include relationship breakdown; multiagency management; crisis contingency planning; RCPsych guidance.
BPSD in 90% of dementia - treat underlying causes first; non-pharmacological interventions first-line; risperidone only licensed antipsychotic for BPSD; 3× stroke risk; lowest dose shortest time; review at 6-12 weeks; document risk-benefit discussion; NICE NG97.
Lifelong neurodevelopmental condition; childhood developmental history essential; ADOS-2 and ADI-R gold standard; women underdiagnosed masking; high comorbidity anxiety depression ADHD; sensory differences DSM-5; NICE CG142; Equality Act reasonable adjustments; post-diagnostic psychoeducation; peer support valuable.
Promethazine as adjunct reduces haloperidol dose and side effects - TREC trial supports the combination; H1 antagonist with sedation, not an antipsychotic; >90% sedated within 20 minutes; reduces dystonia and QTc prolongation risk; never give IV promethazine.
Fabricated or induced illness is child abuse requiring immediate safeguarding - never confront the carer directly; refer through the designated safeguarding lead and involve police.
Selective mutism is an anxiety disorder, not defiance - children speak normally at home but are unable to speak in specific social settings; treat with graded exposure CBT.
SAD features atypical depression recurring every winter - light therapy (10,000 lux morning use) and CBT-SAD are first-line; SSRIs are the pharmacological alternative.
Always give IV Pabrinex before glucose in at-risk patients - Wernicke's triad is present in only 10-16%; untreated Wernicke's progresses to irreversible Korsakoff syndrome in 80% of cases.
In elderly prescribing, start at half the adult dose and titrate slowly - citalopram is restricted to 20 mg maximum; avoid anticholinergics (STOPP criteria); sertraline is preferred in dementia with depression.
First-episode psychosis requires EIP referral within 2 weeks - shorter DUP predicts better outcomes; EIP provides a comprehensive package including low-dose antipsychotic, CBTp, family intervention, and vocational support.
Art therapy is NICE-recommended for psychosis - provides non-verbal expression for patients unable to engage in verbal therapy; music therapy also NICE-recommended; both require HCPC-registered therapists; useful in trauma where verbal processing triggers dissociation.
Pabrinex before glucose - always; 2 pairs TDS for suspected Wernicke's; classic triad present in only 10-16%; high index of suspicion in malnourished patients; untreated Wernicke's becomes irreversible Korsakoff's.
MMSE limitations - poor MCI sensitivity; misses executive dysfunction; ceiling effect in educated; cultural and educational bias; copyright restrictions; does not subtype dementia; MoCA and ACE-III preferred alternatives; still useful for moderate-severe staging.
4AT - Alertness, AMT4, Attention, Acute change; under 2 minutes; no training needed; score 4+ possible delirium; 0 makes delirium unlikely; 1-3 suggests cognitive impairment; validated in ED and acute settings; universal screening tool for elderly admissions.
Biopsychosocial - biological, psychological, social; formulation using 4 Ps: predisposing, precipitating, perpetuating, protective; mental state examination is cross-sectional; why this person, this problem, this time; comprehensive not reductionist; Royal College standards; ACEs increase vulnerability.
AUDIT - ten questions scoring zero to forty; three domains: hazardous, dependence, harmful; AUDIT-C abbreviated three questions; superior to CAGE for hazardous drinking; NICE CG115 thresholds guide intervention; 8-15 increasing risk; 20 or above possible dependence; WHO-developed validated tool.
Alcoholic hallucinosis - clear consciousness distinguishes from DT; auditory not visual hallucinations; intact orientation; minimal autonomic signs; onset twelve to twenty-four hours; chronic in ten to twenty percent; antipsychotics appropriate; abstinence prevents recurrence; differentiate from schizophrenia; ICD-11 alcohol-induced psychotic disorder.
MBT - restores mentalisation during emotional arousal; not-knowing stance; individual plus group therapy; eighteen months; Bateman and Fonagy RCT; maintained gains at eight years; NICE CG78; attachment theory basis; adapted for adolescents and families; present-moment focus; reduced self-harm and admissions.
Alfredson eccentric heel drops for 12 weeks - never inject corticosteroid into the Achilles tendon - exercise into pain is therapeutic.
OCD of the medial femoral condyle causes knee pain with mechanical symptoms in adolescents - skeletally immature patients with stable lesions often heal conservatively; unstable lesions need surgery.
hEDS presents with joint hypermobility, recurrent dislocations, chronic pain, and multisystem features - physiotherapy for joint stabilisation is the cornerstone of management.
OI presents with recurrent fractures, blue sclerae, and dentinogenesis imperfecta - differentiate carefully from non-accidental injury before making safeguarding assumptions.
Achilles rupture is diagnosed clinically with a positive Simmonds-Thompson test - both surgical repair and accelerated functional rehabilitation are acceptable; fluoroquinolones are a recognised risk factor.
Ultrasound-guided injection - 95%+ accuracy vs 30-70% blind; improved outcomes; real-time needle visualisation; diagnostic capability; BSR guidance; especially for deep joints, obese patients, and failed blind injection; training and competency essential; standard of care evolving.
Ultrasound dynamic and real-time - MRI comprehensive and standardised; ultrasound comparable to MRI for full-thickness rotator cuff tears; MRI for labrum, bone marrow, and surgical planning; operator dependence is ultrasound's main limitation; modality selection depends on clinical question and treatment plan.
Anatomical snuffbox tenderness after a FOOSH injury - treat as a scaphoid fracture until proven otherwise. Normal initial X-rays do not exclude the diagnosis. MRI at 10-14 days is the gold standard for occult fractures.
APS - triple positive highest risk; warfarin INR two to three lifelong; DOACs inferior per TRAPS trial; pregnancy LMWH plus aspirin; warfarin teratogenic; hydroxychloroquine protective; twelve weeks between positive antibodies; catastrophic APS multiorgan; BSR and EULAR; INR three to four for recurrent events.
Orthopaedic prophylaxis - cefuroxime 1.5g IV within 60 minutes; cross-reactivity below 2% for non-severe penicillin allergy; teicoplanin for anaphylactic allergy; maximum 24 hours; re-dose if surgery over 4 hours; add glycopeptide for MRSA; de-label unconfirmed allergy; NICE NG125.
FLS - closes treatment gap; systematic identification of fragility fractures; DEXA and FRAX assessment; alendronate first-line; calcium and vitamin D; multifactorial falls assessment; Otago exercise programme; medication review; less than 50% currently treated; Capture the Fracture; NICE NG177.
AHSCT SSc - immune system reset; ASTIS and SCOT trials improved survival; five to ten percent treatment-related mortality; early diffuse SSc under four years; contraindicated in severe PAH and cardiac dysfunction; EBMT EULAR guidance; specialist centres only; cyclophosphamide conditioning; short-term risk for long-term benefit; FVC and skin score improvement.
Mallet finger requires continuous DIP extension splinting for 6-8 weeks - ANY flexion restarts the clock; Stack splint or equivalent; leave PIP free; surgery only for large bony mallet or volar subluxation; untreated leads to swan-neck deformity.
Haemarthrosis in haemophilia requires immediate factor replacement within 2 hours - avoid NSAIDs; prophylactic replacement prevents haemophilic arthropathy; emicizumab offers subcutaneous prophylaxis for haemophilia A.
Periarticular osteopenia - earliest RA radiological sign; cytokine-driven osteoclast activation; precedes erosions; window for early DMARD therapy; localised not generalised; OA shows sclerosis not osteopenia; NICE NG100; 2010 ACR/EULAR criteria; TNF-alpha and RANKL driven.
SSc calcinosis - hydroxyapatite deposits; twenty to forty percent of SSc; more common limited than diffuse; no reliable medical therapy; diltiazem minocycline colchicine tried; surgical excision high recurrence; ulceration and infection risk; fingers commonest location; normal calcium levels; dystrophic mechanism; EULAR guidance; significant functional impact.
NOF fracture requires surgery within 36 hours - displaced intracapsular in elderly = hemiarthroplasty (cemented); THR if independently mobile and cognitively intact; orthogeriatric co-management reduces mortality; 1-year mortality is 25-30%.
TKR rehab - full extension critical, flexion contracture impairs gait; golden period first 6 weeks; target 110-120° flexion; 90° minimum for function; same-day mobilisation; quads reactivation priority; CPM machine; cryotherapy; BOA standards; most improvement in first 3 months.
Rapidly progressive ILD high mortality; amyopathic or minimal CK; palmar ulcers pathognomonic; ferritin predicts severity; aggressive combination immunosuppression; tacrolimus key agent; 40-70% mortality untreated; early treatment improves survival; MDA5 antibody testing urgent; lung transplant referral if refractory.
Pathological fractures from low-energy trauma require malignancy investigation - myeloma causes purely lytic lesions with CRAB features; metastases are the most common bone malignancy overall; always perform protein electrophoresis and free light chains.
Fibromyalgia is diagnosed clinically with widespread pain, fatigue, sleep disturbance, and cognitive dysfunction - management centres on exercise, CBT, and amitriptyline/duloxetine. Opioids are not recommended and should be avoided.
Methotrexate toxicity - pancytopenia, macrocytosis, raised LFTs, mouth ulcers. Stop immediately, check folate, assess for infection. Regular FBC and LFT monitoring plus folic acid supplementation are essential. Sore throat with low WCC is an emergency.
QFracture - UK tool incorporating falls, dementia, Parkinson's, medications; addresses FRAX gaps; no BMD input; not linked to NOGG thresholds; better for patients where falls risk predominates; both tools NICE-recognised; complementary use recommended.
Facet pain - extension-aggravated, flexion-relieved; paramedian not midline; medial branch block is diagnostic gold standard; radiofrequency denervation for treatment; imaging findings don't always correlate; 15-40% of chronic LBP; no radicular component below knee.
VTE prophylaxis orthopaedic - NICE NG89; hip 28-35 days; knee 14 days; LMWH, DOACs, or aspirin; mechanical compression; early mobilisation; 15-30% DVT without prophylaxis; RECORD trials rivaroxaban; EPCAT-II aspirin; start post-op once haemostasis achieved.
CASPAR criteria - inflammatory arthritis plus three points; current psoriasis scores two; nail pitting, negative RF, dactylitis, periostitis each score one; ninety-one percent sensitive, ninety-nine percent specific; five clinical patterns; dactylitis is hallmark; NICE NG65; GRAPPA; asymmetric oligoarthritis commonest pattern.
A hot swollen joint is septic arthritis until proven otherwise - aspirate urgently for Gram stain, crystals, and culture, then start IV flucloxacillin immediately without waiting for results.
IV iloprost - prostacyclin analogue; six hours daily for three to five days; effects last weeks to months; headache and flushing common; titrate to tolerance; severe Raynaud's and digital ulcers; cardiac monitoring required; repeat at six to eight weeks; vascular remodelling mechanism; BSR EULAR; Cochrane evidence; starting dose 0.5 ng/kg/min.
Tennis elbow - lateral epicondyle tenderness with positive Cozen's test. Conservative management with eccentric exercises and activity modification is first-line. Corticosteroid injection gives short-term relief but worsens long-term outcomes.
Rebound vertebral fractures on discontinuation; does not accumulate in bone; RANKL reactivation; bone turnover overshoots baseline; transition to bisphosphonate essential; MHRA safety advice; 6 months after last dose; monitor bone markers; on-time dosing critical; informed consent at initiation.
Distal radius fragility fractures require FLS referral - review osteoporosis treatment if fracturing on therapy; consider treatment escalation to denosumab or zolendronic acid; assess falls risk; fragility fractures predict future hip fractures within 10 years.
Gabapentinoids are Schedule 3 controlled drugs since April 2019 - 30-day prescriptions only; substance misuse history is a risk factor for gabapentinoid misuse; potentiate opioid respiratory depression; amitriptyline or duloxetine are safer first-line alternatives in at-risk patients (NICE CG173).
Hydroxychloroquine retinal toxicity risk increases after 5 years and at doses >5 mg/kg/day - annual OCT screening from year 5 per RCOphth guidelines; reduce dose based on actual body weight.
Neurogenic claudication improves with flexion and worsens with extension - the shopping trolley sign and ability to cycle distinguish it from vascular claudication; normal ABPI confirms spinal rather than vascular aetiology.
Cervical myelopathy shows UMN signs in legs with mixed UMN/LMN at compression level - T2 cord signal change on MRI indicates myelomalacia; urgent surgical decompression prevents irreversible cord damage.
Bilateral leg symptoms, urinary retention, saddle anaesthesia, and reduced anal tone - cauda equina syndrome is a surgical emergency requiring emergency MRI and decompression within 48 hours to prevent permanent disability.
Aspirate before antibiotics in suspected septic arthritis - aseptic technique essential; send for microscopy, culture, and crystals; superolateral knee approach; blood culture bottles improve yield; do not aspirate through cellulitis; BSR guidelines; both diagnostic and therapeutic.
Baricitinib - JAK1/JAK2; dose reduce in CKD to 2mg; seventy-five percent renal clearance; herpes reactivation elevated; Shingrix before starting; RA-BEAM trial; NICE TA466; MHRA class warnings; not recommended eGFR below 30; BSR guidance.
Psoriatic arthritis - look for dactylitis, enthesitis, DIP involvement, nail changes, and seronegative status. Methotrexate is first-line DMARD. Avoid hydroxychloroquine (may worsen skin) and high-dose steroids (rebound flares).
APS requires persistent antiphospholipid antibodies with thrombosis or pregnancy loss - warfarin, not DOACs, is the anticoagulant of choice; aspirin plus LMWH improves pregnancy outcomes.
Febuxostat - non-purine xanthine oxidase inhibitor; second-line after allopurinol intolerance; no renal dose adjustment; MHRA warning about cardiovascular mortality from CARES trial; avoid in pre-existing cardiovascular disease; flare prophylaxis still needed.
Takayasu arteritis affects young women with pulseless disease and BP discrepancy - CT/MR angiography shows aortic wall thickening and stenosis; treat with steroids and steroid-sparing agents; tocilizumab for refractory disease.
PAN is a medium-vessel vasculitis with microaneurysms on angiography - ANCA-negative and does NOT cause glomerulonephritis; testicular pain is near-pathognomonic; always check hepatitis B serology.
AOSD shows quotidian fever, salmon rash, and ferritin >1000 with low glycosylated fraction - ESR is paradoxically low; IL-1 inhibitors (anakinra) are effective for refractory disease; watch for macrophage activation syndrome.
Belimumab - anti-BLyS/BAFF; BLISS-LN trial renal response; NICE TA752 add-on therapy; reduces autoreactive B-cell survival; depression monitoring; IV or SC administration; BLISS-52 and BLISS-76 for non-renal SLE; steroid sparing; specialist lupus guidance.
Morton neuroma causes burning forefoot pain with Mulder click between the 3rd and 4th metatarsal heads - wide shoes and metatarsal pads first; corticosteroid injection or neurectomy for refractory cases.
Displaced midshaft clavicle fractures with >2 cm shortening have 15% nonunion risk - discuss surgical fixation; broad arm sling (not figure-of-eight) for non-operative management; skin tenting, open fracture, and floating shoulder indicate surgery; plate fixation is most common.
Denosumab rebound - no residual bone effect; RANKL surge on stopping; rapid bone loss below baseline; multiple vertebral fractures; transition to bisphosphonate mandatory; zoledronate at six months; MHRA safety alert; monitor CTX; never stop without transition; five to ten percent fracture risk.
DAS28 >5.1 on two occasions = eligible for biologic per NICE; incorporates tender/swollen joints, ESR, and patient global assessment; target is remission (<2.6); must fail 2 csDMARDs including methotrexate; TNF inhibitors are commonest first-line biologic.
PMR is treated with prednisolone 15 mg - a dramatic response within 1 week is diagnostic; always screen for GCA symptoms; plan a slow taper over 12-24 months with bone protection.
Cryoglobulinaemic vasculitis shows low C4 with preserved C3, positive RF, and Meltzer's triad - 80-90% is HCV-associated; treat with DAA antiviral therapy; blood must be transported at 37°C for cryoglobulin testing.
Bucket-handle tears causing locking require arthroscopic surgery - repair is preferred over meniscectomy to prevent OA; degenerative tears in older patients respond to physiotherapy alone; McMurray test and joint line tenderness are key clinical signs.
Behçet disease requires recurrent oral ulcers plus genital ulcers, uveitis, or skin lesions - posterior uveitis is sight-threatening and requires aggressive immunosuppression; pathergy is a useful diagnostic sign.
Commonest acquired myopathy over 50; finger flexors and quadriceps selectively; asymmetric; rimmed vacuoles pathognomonic; treatment resistant; exercise is mainstay; mildly elevated CK; anti-cN1A antibody; inflammatory plus degenerative; dysphagia 30-50%; male predominance; wheelchair 10-15 years.
Limited systemic sclerosis has anti-centromere antibodies and risks PAH - screen annually with echocardiography and TLCO; diffuse SSc has anti-Scl-70 and risks lung fibrosis and renal crisis.
Perthes disease presents as painless limp in a 4-8 year old boy with femoral head changes on X-ray - prognosis depends on age and femoral head involvement; younger children remodel better.
SUFE presents with obligatory external rotation on hip flexion in an obese adolescent - fix in situ with a screw; never attempt forced reduction, which risks avascular necrosis.
zone 2 Jones fracture = watershed blood supply = high non-union risk - athletes benefit from primary surgical fixation with intramedullary screw.
Intra-articular steroid - aseptic technique mandatory; relief lasts 4-12 weeks; post-injection flare in 2-5%; septic arthritis rare but serious; maximum 3-4 per joint per year; aspirate if effusion present; NICE NG226 for OA.
Teriparatide - anabolic PTH fragment stimulating bone formation; 24-month lifetime maximum; NICE TA161 for severe osteoporosis with fractures despite bisphosphonates; must follow with anti-resorptive therapy; contraindicated in Paget's and skeletal malignancy.
Cytokine storm in systemic JIA; falling ESR with rising ferritin pathognomonic; ferritin often above 10,000; low fibrinogen from DIC; high triglycerides; IV methylprednisolone and ciclosporin; anakinra increasingly used; mortality 8-20%; secondary HLH; pancytopenia; treat infection triggers.
BASDAI - six domains scoring zero to ten; four or above is active disease; key criterion for biologics; response is two-unit or fifty percent improvement; NICE TA383; patient-reported; two NSAIDs must fail first; BASFI for function; twelve-week response assessment; complementary ASDAS includes CRP.
Lupus nephritis - biopsy essential; ISN/RPS Class IV most common and severe; induce with MMF or cyclophosphamide + steroids; maintain with MMF or azathioprine; monitor anti-dsDNA and C3/C4; rituximab/voclosporin for refractory cases (EULAR/ERA-EDTA, BSR, ALMS trial).
Neonatal lupus - anti-Ro and anti-La mediated; complete heart block two to five percent; irreversible needs pacemaker; rash self-limiting by six to eight months; fetal echocardiography from sixteen weeks; hydroxychloroquine may protect; recurrence fifteen to twenty percent; screen all SLE and Sjögren's pregnancies; BSR and RCOG guidance; haematological features transient.
Colchicine - 500mcg two to four times daily (low-dose regimen); diarrhoea is the dose-limiting side effect; dose-reduce in renal impairment; dangerous with macrolides; narrow therapeutic index; most effective within 12-24 hours of onset.
5 years oral or 3 years IV zoledronate; bone reservoir provides ongoing effect; eligible if T-score better than minus 2.5; no fractures during treatment; reassess after 2-3 years; FLEX trial evidence; reduce atypical fracture and ONJ risk; restart if risk increases; NOGG and NICE guidance; not eligible if T-score minus 2.5 or worse.
Health inequalities are avoidable and driven by social determinants - the Marmot Review demonstrated a social gradient in health. Addressing inequalities requires both individual patient care and population-level public health interventions through proportionate universalism.
Always use professional interpreters for medical consultations - never rely on family members (especially children). Telephone interpreting is available 24/7. Speak to the patient directly, not the interpreter, and pause regularly.
Bolitho - modifies Bolam; logical analysis requirement; court can reject illogical opinion; 1998 House of Lords; child respiratory arrest case; experts must justify reasoning; comparative risk-benefit; rarely invoked in practice; strengthens court oversight; Bolam not automatic defence.
Bolam - responsible body of medical opinion; 1957 ECT case; standard of care for negligence; still applies to diagnosis and treatment; replaced by Montgomery for consent; modified by Bolitho; minority practice can be acceptable; protects reasonable clinical judgment; English law foundation.
Duty of candour - Regulation 20; moderate harm threshold; notify promptly; truthful account; apology not liability; verbal and written; GMC individual duty broader; CQC prosecution for failure; Compensation Act protects apology; keep records; reasonable support; statutory requirement.
FOIA 2000 - right of access; twenty working days; exemptions for personal data, confidence, health and safety; public interest test for qualified exemptions; anonymised data provided; publication scheme proactive; ICO oversight; any person can request; no reason needed; NHS fully covered.
three tryptase samples (immediate, 1-2 h, ≥24 h baseline); rise ≥[1.2 × baseline + 2 μg/L] confirms anaphylaxis; normal tryptase does not exclude (especially food); baseline >11.4 μg/L → investigate mastocytosis (RCUK 2021; NICE CG134; NAP6).
Caldicott Principles - eight principles; justify purpose; minimum necessary; need-to-know; duty to share seventh principle; inform patients eighth principle; Caldicott Guardian mandatory; UK GDPR compliance; balance protection and sharing; senior clinician role; NHS England guidance.
Asthma on regular ICS qualifies for NHS flu vaccination - all adults ≥65, pregnant women, chronic conditions, carers, and healthcare workers are eligible; children receive nasal spray; the programme runs September-March annually.
SARCs are 24/7 one-stop centres - self-referral available; three options including anonymous evidence storage for 7 years; free and confidential; STI screening at baseline, 2 weeks, and 3 months; HIV PEP within 72 hours; commissioned by NHS England and police; multiple referral routes.
Opioid prescribing - not for chronic primary pain; short-term trial four to eight weeks; review and taper if no functional gain; 120mg morphine equivalent ceiling; no concurrent benzodiazepines; regular three-monthly review; NICE NG193; FPM guidance; naloxone for high-risk; driving impairment; hyperalgesia risk; lowest dose shortest time.
Opioid tapering - ten percent every one to four weeks; gradual individualised; withdrawal unpleasant not dangerous; switch to long-acting first; fortnightly GP review; pain programme before tapering; no gabapentinoid substitution; liquid preparations for final reductions; FPM and PHE guidance; relapse plan; psychological support essential.
Standard precautions - all patients all settings; hand hygiene most effective; PPE based on anticipated exposure; never recap needles; respiratory hygiene; equipment decontamination; waste segregation; spillage management; NICE and UKHSA; universal application regardless of diagnosis; ten components comprehensive protection.
Strong opioid initiation - immediate-release morphine five to ten milligrams four-hourly; rescue doses same dose every one to two hours; convert to modified-release at twenty-four to forty-eight hours; laxatives from day one; antiemetic first week; NICE CG140; titrate thirty to fifty percent; breakthrough dose one-sixth of daily; elderly start lower; regular review.
Methotrexate daily instead of weekly is a well-known fatal prescribing error - stop the drug, inform the patient (duty of candour), check bloods urgently, report through Datix, and consider folinic acid rescue. Always specify the day of the week.
Suspect trafficking when a controlling companion prevents private consultation - separate the patient, use a professional interpreter, and refer to the National Referral Mechanism under the Modern Slavery Act 2015.
NEWS2 - six parameters plus consciousness; seven or above is red trigger; single parameter three is red trigger; primary care means emergency transfer; NICE NG51; NHS England standard; do not delay for investigations; confusion scores three; Scale 2 for COPD patients; tracks deterioration trends.
that 'private' social media accounts are never truly private. Using hashtags like #NHSlife increases the visibility and reach of posts, amplifying any breach.
EM features typical three-zone target lesions on acral surfaces - HSV is the trigger in >70%; distinguish from SJS (atypical targets, drug-triggered, mucosal involvement); EM minor is self-limiting; recurrent EM warrants long-term aciclovir prophylaxis; EM major involves mucosae but is distinct from SJS.
Medical Examiners independently scrutinise all non-coronial MCCDs - statutory since 2024 post-Shipman and Francis; they contact bereaved families, check MCCD accuracy, and identify coroner referrals; they are senior doctors independent of the clinical team.
Five key questions safe effective caring responsive well-led; four rating levels; independent regulator; Health and Social Care Act 2008; special measures for inadequate; routine and focused inspections; GP practices hospitals all providers; ICS assessment from 2023; enforcement action possible.
Pneumococcal meningitis - commonest adult bacterial meningitis; 20-30% mortality; dexamethasone strongest benefit; ceftriaxone 10-14 days; hearing loss commonest sequela so arrange audiology; acute meningitis IS notifiable to UKHSA but contacts do not need prophylaxis.
Allergy action plan - written personalised plan; BSACI and NICE CG134; mild vs anaphylaxis actions; photograph included; accessible to all carers; annual review; adrenaline first for anaphylaxis; specify medication location; allergen avoidance information; emergency contacts; signed by doctor and parent.
Chain of evidence - continuous tracking from collection to court; tamper-evident sealed packaging; documentation of every handler and transfer; body maps with measurements; photographs with scale and consent; notes are disclosable; any break may render evidence inadmissible; expert witness testimony expected.
Rape Crisis - free confidential specialist support regardless of timing or reporting; ISVA services for advocacy; NICE NG116 for PTSD treatment; trauma-focused CBT or EMDR first-line; no obligation to report in competent adults; GP validates and refers; SSRIs for PTSD.
PSIRF 2022 - replaced Serious Incident Framework; proportionate investigation; patient safety incident response plans; PSII for significant incidents; just culture; systems not blame; duty of candour statutory; patient involvement; LFPSE reporting; swarm huddles and after action reviews; staff support.
Tinea corporis - annular lesion with advancing scaly edge; scrape from the edge not centre; topical terbinafine 1% first-line for 1-2 weeks; Microsporum canis from cats; avoid topical steroids (creates tinea incognito); oral treatment for extensive disease only.
Blistering sunburn in youth increases melanoma risk; SPF 30+ broad-spectrum sunscreen; avoid peak UV hours; sunbeds are IARC Group 1 carcinogens; ABCDE criteria for self-examination; consider dermatology referral for high-risk patients; NICE NG14 guidance.
Deaths during or after surgery or anaesthesia must always be referred to the coroner - even if the complication is recognised and prophylaxis was appropriate. The coroner decides on post-mortem and inquest, not the clinical team or family.
Adapalene/benzoyl peroxide combination is first-line for moderate acne - add oral tetracycline for 3 months if inadequate; never use topical antibiotics alone; limit oral antibiotics to 3 months; refer for isotretinoin if failing 2 oral courses or nodulocystic disease.
The Public Interest Disclosure Act 1998 protects whistleblowers from retaliation - raise concerns through the Freedom to Speak Up Guardian, formal trust policy, or external regulators. Failing to raise genuine patient safety concerns breaches GMC duties.
Bolitho refines Bolam; expert opinion must have logical basis; court can reject illogical opinions; prevents hired gun experts; risk-benefit analysis required; rarely used to reject genuine opinion; combined Bolam-Bolitho standard; House of Lords 1998; reasoning must be articulated; judicial safeguard retained.
Professional boundaries prohibit personal relationships with current patients - transfer care, seek mentor support, and reflect; the power imbalance means patient-initiated contact does not constitute valid consent.
Gillick competence is assessed individually - not all under-16s lack capacity, and not all possess it. The Fraser guidelines provide the specific framework for contraceptive advice. Always encourage parental involvement but respect the competent young person's confidentiality.
Emollients are the foundation of eczema management (250-500g weekly) - aqueous cream is no longer recommended as a leave-on; step up corticosteroid potency by site and severity; proactive weekend therapy prevents relapse; tacrolimus for steroid-sensitive areas; dupilumab for severe disease.
Unknown vaccination + tetanus-prone wound = TIG + vaccine; 5 UK schedule doses provide long-term protection; tetanus-prone = puncture, soil-contaminated, devitalised tissue, >6h old; thorough wound cleaning is essential; fully vaccinated individuals need no additional treatment.
Tetanus-prone wound with uncertain vaccination - give both immunoglobulin AND vaccine; Green Book Chapter 30 algorithm; clean and debride wound; metronidazole for anaerobic cover; fully vaccinated with 5 doses only need booster if more than 10 years; immunoglobulin provides immediate but temporary protection.
Dog bites - irrigate thoroughly; co-amoxiclav prophylaxis; do NOT close puncture bites primarily (except face); hand bites are high risk for deep infection; watch for tenosynovitis and septic arthritis; 5-25% infection rate.
MASH co-located multi-agency team - single referral point; rapid information sharing; reduces silos; threshold decisions: universal, early help, Section 17, Section 47; Working Together 2023; addresses failures from serious case reviews; Children Act 2004 Section 11; health, police, social care, education, probation.
Yellow Card - MHRA pharmacovigilance; established after thalidomide; Black Triangle intensive monitoring; report all ADRs for new drugs; serious or unexpected for established; suspicion sufficient; patients can report; online app or paper; detects rare ADRs; BNF guidance; post-marketing surveillance.
EBM integrates best evidence + clinical expertise + patient values - use the 5 As (Ask, Acquire, Appraise, Apply, Assess); systematic reviews top the evidence hierarchy; always critically appraise rather than accept promotional material.
WHO ladder - three steps for cancer pain; non-opioid then weak then strong opioid; by the mouth, clock, ladder; Step 2 increasingly questioned; CYP2D6 codeine variability; not for chronic non-cancer pain; neuropathic pain needs adjuvants; 1986 original; regular not as-needed dosing; individual titration.
FIT replaced gFOBt - quantitative, specific for human haemoglobin, single sample; ≥120µg threshold; ages 50-74 every 2 years; positive → colonoscopy; polypectomy prevents cancer; 10% cancer detection rate among those scoped.
ACT chronic pain - six core processes; acceptance not resignation; cognitive defusion observing thoughts; values clarification; committed action despite pain; NICE NG193 recommended; psychological flexibility model; changes relationship with pain; does not target pain reduction; systematic review evidence; BPS guidance; Hayes; improves functioning and mood; meaningful living focus.
Universal NHSP - AOAE first (cochlear function), then AABR if not passed (auditory pathway); screen by 4 weeks, diagnose by 8 weeks, aids by 12 weeks; 1 in 1,000 prevalence; early detection optimises language development; performed while baby sleeps.
GP partnership = self-employed contractors with joint and several liability; written BMA-template agreement covering profit-share, premises, restrictive covenants and notice period; CNSGP indemnity for NHS work since 2019; salaried/locum/portfolio GP roles are alternatives.
PDSA cycles test small changes iteratively - Plan, Do, Study, Act with rapid cycles before wider spread; QI differs from audit (standards-based) and research (new knowledge); use SPC charts to monitor improvement over time.
Hepatitis B PEP - HBIG within forty-eight hours for unvaccinated; accelerated vaccination; known responders need booster only; non-responders need HBIG plus revaccination; PHE Green Book; anti-HBs ten or above is protective; super-accelerated schedule; follow-up at six months; source HBsAg status determines management; combination most effective.
Norovirus outbreak - ward closure most effective; soap and water not alcohol gel; staff excluded 48 hours after last symptoms; chlorine-based environmental cleaning; notify UKHSA; restrict visitors; symptomatic treatment only per UKHSA outbreak guidance.
Vitiligo - autoimmune melanocyte destruction; potent topical steroids first-line (max 2 months); tacrolimus for facial vitiligo; narrowband UVB for widespread disease; 20-30% thyroid association; repigmentation is perifollicular; camouflage cosmetics and sunscreen supportive.
MARAC monthly multi-agency for high-risk DA - share information without consent if needed; police, health, social care, housing, IDVA; coordinated safety plan; Crime and Disorder Act 1998; GP shares health information; not criminal prosecution; IDVA links victim to safety plan; review actions monthly.
NRM for modern slavery victims - Modern Slavery Act 2015; see patient alone; professional interpreter only; refer to police or local authority as first responders; indicators: malnourishment, restricted movement, no documents, fear; 45-day recovery period; do not use accompanying person as interpreter.
Food labels - 14 major allergens declared by law; emphasised in ingredients; Natasha's Law 2021 for PPDS; may contain is voluntary; avoid may contain if severe allergy; 14 allergens include nuts, peanuts, milk, egg, sesame; hidden names exist; Food Standards Agency guidance; individualised risk discussion.
HAE - C1-INH deficiency; bradykinin-mediated not histamine; antihistamines and steroids ineffective; low C4 screening; C1-INH concentrate or icatibant for acute attacks; lanadelumab for prophylaxis; avoid ACE inhibitors and oestrogen; no urticaria; family history; BSACI; laryngeal attacks can be fatal; early treatment critical.
WHO 5 Moments - before patient, before procedure, after fluid exposure, after patient, after surroundings; alcohol rub routine; soap and water for C.
Patient-centred materiality test; replaced Bolam for consent; reasonable patient standard; material risks and alternatives; consent is a conversation; tailored to individual; therapeutic exception narrow; applies all specialties; Supreme Court 2015; respect for autonomy.
Opioid conversion - codeine to morphine 10:1; morphine to oxycodone 2:1; morphine 120mg to fentanyl 50mcg/hr; reduce twenty-five to fifty percent for cross-tolerance; BNF and PCF; rescue dose one-sixth to one-tenth; fentanyl twelve to twenty-four hours onset; oral to SC 2:1; oral to IV 3:1; use conversion tables.
TENS - gate control theory; endogenous opioid release; not recommended for chronic primary pain or low back pain per NICE; consider for osteoarthritis; widely used in labour; pacemaker contraindication; home use devices; minimal side effects; high-frequency and low-frequency types; NG193 NG59 CG177; self-management tool.
Neuropathic pain - burning shooting allodynia hyperalgesia; DN4 screening tool; NICE CG173 four first-line drugs; switch or combine if partial response; specialist referral after two failures; diabetic neuropathy optimise glycaemic control; duloxetine specific evidence; capsaicin for localised pain; foot care essential; tramadol acute rescue only.
Chronic pain and work - work is therapeutic; six weeks critical threshold; fit note enables modifications; yellow flags psychological barriers; fear-avoidance and catastrophising predict disability; Equality Act reasonable adjustments; phased return; NICE NG59; FPM guidance; blue and black flags systemic barriers; occupational health assessment.
Double medical school places to 15,000; 50% more GP training places; 92% more nursing places; train retain reform pillars; 15-year plan; 2.4 billion funding; 112,000 vacancies context; community training expansion; new roles development; 2023 publication.
Montgomery - patient-centred consent; material risk disclosure; reasonable person and particular patient tests; replaced Bolam for consent; includes alternatives; therapeutic exception narrow; Supreme Court 2015; GMC guidance; applies to all treatment; doctor-centred consent abolished.
MHRA pharmacovigilance; all ADRs for black triangle drugs; serious or unusual for established drugs; suspected association sufficient; healthcare professionals and patients can report; online app or BNF paper form; pre-marketing trials miss rare ADRs; signal detection from aggregate reports; Yellow Card app accessible.
Three roles referrer practitioner operator; individual justification mandatory; ALARA optimisation; pregnancy screening essential; adequate clinical information from referrer; CQC enforcement; diagnostic reference levels; employer written procedures; benefits must outweigh risks; IRMER 2017.
Core curriculum requirement; human factors essential; Swiss cheese model systems thinking; SBAR structured handover; Just Culture; incident reporting LFPSE; medication safety; duty of candour; simulation-based learning; GMC graduate requirement; HEE National Patient Safety Syllabus.
Cool running water for 20 minutes minimum - effective up to 3 hours; not ice; do not burst blisters; no butter or home remedies; cling film as temporary dressing; remove jewellery early; refer per British Burns Association criteria; paracetamol/ibuprofen for analgesia.
The fit note offers 'not fit for work' or 'may be fit for work' with adaptations (phased return, amended duties, altered hours, workplace modifications) - always consider whether modified work is feasible before signing someone off completely.
Schedule 2 CD prescriptions require quantity in words and figures, are valid for 28 days only, and cannot be amended by pharmacists - any error requires a new prescription.
Detained patients can self-refer to the Mental Health Tribunal - this independent panel of judge, psychiatrist, and lay member can discharge if detention criteria are no longer met; legal aid is available.
Report ALL patient safety incidents including near-misses via LFPSE/Datix - near-misses reveal system vulnerabilities; a just culture focuses on system improvement, not individual blame.
A complete audit cycle requires re-audit to close the loop - five stages from standard selection through re-measurement; audit measures against existing standards (no ethics approval needed) while research creates new knowledge.