Rapid-recall takeaways distilled from the UKMLA AKT question bank, grouped by specialty. One pearl per high-frequency concept. Use it for last-pass revision alongside questions, not as a replacement for them.
1,907 pearls · 25 specialties · Generated 6 November 2026
Cardiovascular
80 high-yield facts
Critical limb ischaemia requires urgent revascularisation - rest pain, ulceration, or gangrene with ABPI <0.5 carries 25% amputation risk without intervention per BASIL trial evidence.
Hyperkalaemia with ECG changes requires IV calcium gluconate first for cardiac protection, then insulin-dextrose to shift potassium, and definitive removal via haemodialysis.
Intermittent claudication first-line is supervised exercise plus best medical therapy - clopidogrel, statin, smoking cessation per NICE NG168, with revascularisation only for refractory symptoms.
Symptomatic severe primary MR requires surgical referral - repair is preferred over replacement, and intervention should occur before LVEF drops below 60% or LVESD exceeds 40mm.
Constrictive pericarditis shows raised JVP with prominent y-descent, Kussmaul sign, and pericardial calcification - pericardiectomy is curative, and TB is the commonest cause worldwide.
IE diagnosis uses modified Duke criteria - S. aureus is commonest in IVDU (tricuspid valve), IV flucloxacillin for 4-6 weeks is standard, and endocarditis MDT guides surgical decisions.
Beta-blocker overdose - IV glucagon is the specific antidote bypassing blocked receptors, high-dose insulin-euglycaemic therapy is second-line, and propranolol is most dangerous due to membrane-stabilising effect.
Acute myocarditis shows non-coronary LGE on cardiac MRI - supportive care and activity restriction are mainstay, and endomyocardial biopsy is reserved for rapidly deteriorating or giant cell myocarditis.
Torsades de pointes requires IV magnesium first-line - stop the causative drug, avoid amiodarone (which prolongs QT further), and consider overdrive pacing if refractory.
Acute heart failure requires IV loop diuretics as first-line - sit upright, give oxygen if hypoxic, and add IV GTN if BP permits per NICE NG106.
Uncomplicated type B dissection is managed medically - IV beta-blocker targeting HR <60 and SBP 100-120, with TEVAR reserved for complicated cases with malperfusion or rupture.
Pharmacology & Therapeutics
80 high-yield facts
Suxamethonium = depolarising, ultra-short acting, fasciculations, RSI use; rocuronium = non-depolarising, competitive, reversible with sugammadex - know the key side effects of each.
Always complete the allergy box on every drug chart - document unknown reactions as 'unknown,' apply a red wristband, and avoid the drug until formal assessment clarifies the allergy status.
MHRA Drug Safety Updates require active review and action for affected patients - treat them as urgent clinical communications, not optional advisories.
ACE inhibitor cough is bradykinin-mediated - switch to an ARB which provides equivalent RAAS blockade and renal protection without affecting bradykinin metabolism.
C. difficile = stop the precipitating antibiotic + oral vancomycin 125mg QDS for 10 days - loperamide is contraindicated, and alcohol gel does not kill C. difficile spores.
Gentamicin in renal impairment = extend the dosing interval (not reduce the dose), with mandatory TDM - trough <1mg/L, and courses should not exceed 7 days without senior review.
Paracetamol max 4g/day for adults >50kg, reduce to 3g/day with hepatotoxicity risk factors - always check weight, liver function, and compound preparations to prevent duplicate dosing.
ACE inhibitor angioedema is bradykinin-mediated and can present without urticaria - manage with an ABCDE airway-focused approach, IM adrenaline if the airway is threatened, and permanent withdrawal of the ACE inhibitor.
Non-purulent cellulitis = flucloxacillin 500mg QDS for 5 days first-line per NICE - mark the border, elevate the limb, and consider prophylaxis for recurrent episodes.
Methotrexate toxicity = folinic acid rescue (NOT folic acid) - daily dosing errors are common and potentially fatal, and NPSA alerts mandate specific weekly prescribing safeguards.
Maintenance fluids per NICE CG174 = 25-30mL/kg/day water + 1mmol/kg/day Na⁺/K⁺/Cl⁻ + glucose - avoid excessive normal saline, and monitor U&Es daily.
Paediatrics
80 high-yield facts
Acanthosis nigricans in an obese child = insulin resistance - screen for type 2 diabetes, dyslipidaemia, hypertension, and NAFLD as part of metabolic syndrome assessment.
First febrile UTI in infants <6 months needs renal ultrasound per NICE CG54 - DMSA and MCUG are added for atypical or recurrent UTIs, and treatment response guides investigation intensity.
TTN is the most common cause of neonatal tachypnoea after elective caesarean - it is self-limiting and caused by delayed lung fluid clearance.
High-grade VUR requires antibiotic prophylaxis and surveillance - surgical reimplantation is indicated for breakthrough infections or progressive scarring, and reflux nephropathy can cause hypertension and CKD.
Kawasaki disease = fever ≥5 days + 4/5 principal features - IVIG plus aspirin within 10 days reduces coronary aneurysm risk from 25% to <5%, and echocardiography is essential.
Paediatric inguinal hernias never resolve spontaneously - refer urgently for early surgical repair due to high incarceration risk in infancy.
Elfin facies plus supravalvular aortic stenosis plus hypercalcaemia plus overfriendly personality = Williams syndrome - microdeletion of elastin gene on chromosome 7.
FII should be suspected when symptoms only occur with one carer and investigations are repeatedly normal - it is child abuse requiring safeguarding procedures, and the child's welfare is paramount.
Sodium valproate in females - MHRA Pregnancy Prevention Programme (two-specialist sign-off in <55s from 2024). Ethosuximide is first-line for absence epilepsy per NICE NG217; carbamazepine worsens absences; always weigh future reproductive potential at the time of any prescribing decision.
CDH - do not bag-mask ventilate; intubate and ventilate gently with low pressures, decompress the stomach with an NG tube, and stabilise before surgery; HFOV/iNO/ECMO are rescue therapies, and pulmonary hypoplasia determines outcome (CDH EURO Consortium consensus; BAPM neonatal guidance).
Respiratory
80 high-yield facts
OHS is daytime hypercapnia in obesity without alternative explanation - NIV is the primary treatment, and weight management (including bariatric surgery consideration) is essential for long-term improvement.
IPF requires antifibrotic therapy - immunosuppression is contraindicated (PANTHER-IPF), FVC is the key monitoring parameter, and early transplant assessment is recommended for eligible patients.
DOACs are first-line for PE per NICE NG158 - sPESI score 0 with normal RV function allows ambulatory management, and apixaban/rivaroxaban can be started without parenteral bridging.
Light criteria distinguish exudates from transudates - any ONE criterion being met classifies the effusion as exudative, and the underlying cause dictates management.
Bronchiectasis management - airway clearance physiotherapy is the cornerstone, sputum cultures guide antibiotics, and underlying causes must be investigated per BTS guidelines.
First Pseudomonas isolate in bronchiectasis - attempt eradication with ciprofloxacin then nebulised colistin per BTS/ERS guidelines, as chronic colonisation worsens outcomes.
NHS lung cancer screening uses LDCT for high-risk individuals aged 55-74 - the NELSON trial showed 24% mortality reduction, and chest X-ray screening is not effective.
Primary spontaneous pneumothorax - needle aspiration is first-line for symptomatic or >2cm, small-bore drain if aspiration fails, and flying is contraindicated until resolution.
Empyema requires chest drain plus prolonged antibiotics - intrapleural tPA/DNase combination per MIST-2 trial is used for loculated collections, and VATS is the surgical rescue option.
CPAP is first-line for moderate-severe OSA per NICE TA139 - weight loss is an essential adjunct, and DVLA must be notified for commercial drivers with confirmed sleep-related symptoms.
Kaftrio (elexacaftor/tezacaftor/ivacaftor) is transformative for CF patients with F508del - improving FEV1 by ~14%, and it is used alongside conventional airway clearance and antimicrobial therapies.
Neurological
80 high-yield facts
Korsakoff = anterograde amnesia + confabulation + mammillary body atrophy - only ~20% recover significantly; prevention by treating Wernicke early is essential.
CIDP develops over >8 weeks distinguishing it from GBS - IVIg, steroids, and plasma exchange are all first-line, and long-term maintenance therapy is usually required.
Third nerve palsy with pupil involvement is a PComA aneurysm until proven otherwise - urgent CT angiography is essential, and pupil-sparing palsies are typically microvascular.
Cluster headache acute treatment = high-flow oxygen (12-15L/min) + subcutaneous sumatriptan; NOT oral triptans or paracetamol; verapamil for prophylaxis.
GBM treatment follows the Stupp protocol - surgery, radiotherapy, and temozolomide - with median survival of 14-16 months, and MGMT methylation predicts better response.
bvFTD presents with personality change and disinhibition with preserved memory - AChEIs are not helpful, SSRIs may reduce compulsive behaviours, and C9orf72 is the commonest genetic cause.
NEAD features: prolonged, eyes closed, asynchronous movements, pelvic thrusting, immediate recovery - diagnose with video-EEG; treat with psychological therapy.
Bell's palsy affects the entire half of the face (LMN) - prednisolone within 72 hours improves recovery, and forehead-sparing facial weakness suggests stroke (UMN).
Viral meningitis shows CSF lymphocytosis with normal glucose - enterovirus is the commonest cause, management is supportive, and CSF PCR identifies the specific virus.
PRES shows posterior white matter oedema on MRI - eclampsia is treated with IV magnesium sulphate, urgent BP control, and delivery, and the changes are reversible with prompt treatment.
ICU + sepsis + flaccid weakness + axonal NCS (low CMAPs AND SNAPs) = CIP; normal SNAPs = CIM; both = CINM.
General Practice
80 high-yield facts
infective conjunctivitis is usually self-limiting - start with self-care and offer topical chloramphenicol if not improving within 48 hours.
FeverPAIN ≥4 means offer antibiotics - use penicillin V not amoxicillin to avoid EBV rash risk.
Supervised PFMT for at least 3 months is first-line for stress incontinence - surgery is reserved for those who fail conservative management per NICE NG123.
Offer atorvastatin 20mg for primary prevention when QRISK3 is 10% or above - aim for a greater than 40% non-HDL cholesterol reduction at 3 months per NICE CG181.
LNG-IUS is first-line for HMB - it reduces blood loss more effectively than any oral treatment and provides contraception.
ADHD is a specialist diagnosis - the GP gathers evidence and refers; symptoms must be in two settings with functional impairment before age 12.
Any unexplained breast lump in a woman aged 30 or over requires a 2-week wait referral - do not delay with imaging requests or watchful waiting per NICE NG12.
ABPM is the gold standard for confirming hypertension in the UK (NICE NG136) - never diagnose on clinic readings alone.
NSAIDs are first-line for primary dysmenorrhoea - start at onset of menses, and consider the combined pill if analgesia alone is insufficient or contraception is desired.
bruising in a non-mobile baby is non-accidental until proven otherwise - refer to paediatrics and safeguarding immediately; never delay.
sertraline is first-line for GAD alongside CBT - avoid benzodiazepines beyond very short-term crisis use.
treat the acute flare first, then start low-dose allopurinol with anti-inflammatory cover once settled - always titrate to target urate.
Infectious Diseases
80 high-yield facts
Dexamethasone 6mg for 10 days reduces mortality in COVID-19 patients requiring oxygen - the RECOVERY trial transformed pandemic management, and benefit is limited to those needing respiratory support.
Latent TB is treated with isoniazid for 6 months plus pyridoxine - always check baseline LFTs and monitor monthly, especially in those over 35 years of age.
Rising haematocrit with falling platelets in dengue signals plasma leakage and imminent severe disease - this critical phase around days 3-7 requires close monitoring and careful fluid management.
Incision and drainage is the treatment for fluctuant abscesses - antibiotics alone are insufficient without drainage, and are only added for cellulitis, systemic infection, or immunosuppression.
Late-onset HAP (>5 days) requires IV broad-spectrum antibiotics covering Gram-negatives - de-escalate based on culture results per NICE NG139.
Hepatitis A vaccine provides rapid protection within 2 weeks - give at least 2 weeks before travel, with a booster at 6-12 months for long-term immunity up to 25 years.
The painless black eschar with surrounding oedema in someone with animal product exposure is pathognomonic for cutaneous anthrax - treat with ciprofloxacin and never excise the eschar.
Sepsis-6 within 1 hour saves lives - blood cultures, lactate, oxygen, IV fluids, IV antibiotics, and urine output monitoring per NICE NG51.
Nitrofurantoin is first-line for uncomplicated lower UTI per NICE NG109 - 3 days in women, and it is ineffective for upper UTI due to low tissue penetration.
HIV PEP must be started within 72 hours (ideally 1-2 hours) and continued for 28 days - three-drug ART is standard, and the risk from needlestick is ~0.3%.
De-escalate antibiotics based on clinical improvement and culture results - IV-to-oral switch reduces complications and supports antimicrobial stewardship per NICE NG138.
Haematological & Immunological
80 high-yield facts
Urticaria pigmentosa + Darier sign + raised tryptase + CD25+ marrow mast cell aggregates + KIT D816V = systemic mastocytosis; counsel on triggers, prescribe adrenaline auto-injector, and refer to haematology.
Auer rods with DIC suggest APL - start ATRA immediately without waiting for genetic confirmation, as early death from DIC is the major risk.
Periventricular enhancing brain mass + DLBCL on biopsy + immunocompetent = PCNSL - high-dose methotrexate is the backbone of treatment; withhold steroids before biopsy if possible.
Mixed cryoglobulinaemia + low C4 + hepatitis C + purpura/neuropathy/glomerulonephritis = treat with direct-acting antivirals first - HCV eradication resolves the cryoglobulinaemia in most cases.
Heparin resistance (high dose UFH with subtherapeutic APTT) + low antithrombin level = antithrombin deficiency - give antithrombin concentrate to restore heparin efficacy, or use a direct thrombin inhibitor.
APS + rapid multi-organ thrombosis + small-vessel involvement = catastrophic APS - triple therapy (anticoagulation + steroids + plasma exchange/IVIG) is the standard of care; mortality remains 30-50%.
Prophylactic platelet threshold = <10×10⁹/L in stable patients (raised to <20×10⁹/L if septic/DIC); therapeutic target >50×10⁹/L for active bleeding - never transfuse in TTP or HIT unless life-threatening haemorrhage.
Pregnant women + transfusion = CMV-negative leucodepleted blood regardless of maternal CMV status - protecting the fetus from congenital CMV infection is the priority.
Life-threatening haemorrhage + no time for crossmatch = emergency O-negative blood immediately - never delay transfusion to wait for compatibility testing in extremis.
Falling Hb + jaundice + new positive DAT 3-14 days post-transfusion + anti-Kidd antibody = delayed haemolytic transfusion reaction - Kidd antibodies are notorious for being undetectable at crossmatch then rapidly rising (evanescent antibodies).
Psychiatric & Mental Health
80 high-yield facts
Family-based treatment empowers parents to lead re-feeding and externalises the eating disorder from the child - it explicitly does not blame parents and is the most evidence-based treatment for adolescent anorexia nervosa.
Dissociative fugue involves unexpected travel with amnesia for personal identity - always exclude organic causes first, then consider the psychological trauma driving the dissociative response.
Depersonalisation-derealisation disorder is distinguished from psychosis by preserved reality testing - the patient knows the experience is subjective, and management focuses on CBT and treating comorbid anxiety or depression.
Elevated insulin with suppressed C-peptide indicates exogenous insulin - factitious disorder is distinguished from malingering by the motivation to assume the sick role rather than for material external gain.
Perimenopausal depression is treated with SSRIs as first-line, not HRT - HRT treats vasomotor symptoms and may be added as an adjunct, but NICE explicitly advises against using it as sole treatment for depressive episodes.
Late-onset psychosis mandates organic exclusion before psychiatric diagnosis - MRI brain, comprehensive bloods, and targeted investigations are essential, as treatable organic causes are more common than in younger patients.
Very-late-onset schizophrenia-like psychosis (onset >60) characteristically features partition delusions, preserved cognition, and sensory impairment - use low-dose antipsychotics and address social isolation and hearing loss.
Pathological intoxication causes severe behavioural disturbance from minimal alcohol with subsequent amnesia - strict alcohol avoidance is the only effective management, and it has significant medicolegal implications.
Korsakoff syndrome features profound amnesia with confabulation but preserved IQ - only 20% recover fully, making prevention with early IV thiamine for Wernicke encephalopathy essential.
Reproductive
80 high-yield facts
Screen for GDM with OGTT at 24-28 weeks in women with risk factors per NICE NG3 - fasting ≥5.6 or 2-hour ≥7.8 is diagnostic, and GDM confers 50% lifetime risk of type 2 diabetes.
Complete mole = snowstorm on USS, no fetal parts, very high hCG, diploid paternal origin - suction evacuation then mandatory hCG surveillance through UK GTD centres.
Obstetric cholestasis = pruritus (palms/soles) + raised bile acids; UDCA for symptom relief only (PITCHES negative for perinatal outcomes); plan birth by bile acid level - 35-36 weeks if ≥100 µmol/L.
Retained placenta after 30 minutes of active management - empty bladder, IV oxytocin, reattempt CCT before proceeding to manual removal in theatre.
Category 1 = immediate threat to life - target delivery within 30 minutes; Category 2 = compromise but not immediately life-threatening - within 75 minutes.
Obstetric APS = aspirin + prophylactic LMWH from positive pregnancy test; warfarin is teratogenic in first trimester - hydroxychloroquine may add benefit.
Spiramycin first to reduce placental transmission; if fetal infection confirmed on amniocentesis, switch to pyrimethamine + sulfadiazine + folinic acid.
PPROM at 30 weeks = expectant management with erythromycin + steroids + infection monitoring; deliver at 37 weeks or sooner if infection develops.
Short cervix (≤25mm) + previous spontaneous preterm birth = vaginal progesterone 200mg nightly; cervical cerclage is an alternative, with history-indicated cerclage usually reserved for three or more previous losses.
Amniocentesis from 15 weeks with ~0.5-1% procedure-related miscarriage risk - NIPT reduces the need but definitive diagnosis still requires invasive testing.
NIPT = highly sensitive screening test using cell-free fetal DNA - NOT diagnostic; positive results must be confirmed with invasive testing (CVS/amniocentesis).
Emergency Medicine
80 high-yield facts
Neutropenic sepsis = IV piperacillin-tazobactam within 1 hour per NICE CG151 - do not wait for culture results, and always culture from the line and periphery.
APLS weight formula for age 1-5 is (age+4)×2; adrenaline in paediatric arrest is 10 micrograms/kg IV using 1:10,000 solution.
Effective cough = encourage coughing; ineffective cough = back blows then thrusts; never use abdominal thrusts in infants <1 year.
Widened mediastinum plus haemorrhagic pleural effusions in a cluster = inhalational anthrax until proven otherwise; ciprofloxacin-based combination therapy; 60-day PEP for contacts.
Lymphocyte count at 48 hours is the best prognostic indicator in radiation injury; early vomiting (<1 hour) suggests high-dose exposure; management is mainly supportive.
Neurogenic shock = hypotension + bradycardia + warm peripheries; distinguish from spinal shock (reflex loss); noradrenaline is the vasopressor of choice.
Positive FAST + haemodynamic instability = emergency laparotomy; CT is only for stable patients; left lower rib fractures raise suspicion for splenic injury.
Testicular torsion is a clinical diagnosis - do not wait for imaging; explore surgically within 6 hours; always perform bilateral orchidopexy.
Ruptured ectopic = surgical emergency; haemodynamic instability mandates emergency laparoscopy/laparotomy; methotrexate is only for stable unruptured ectopics with low beta-hCG.
Adrenal crisis = IV hydrocortisone 100 mg stat + IV saline; do not wait for cortisol results; sick day rules prevent crisis; all steroid-dependent patients need an emergency injection kit.
De-escalation - safe distance, calm voice, open body language, acknowledge feelings, offer choices; physical intervention is always last resort; NICE NG10 mandates de-escalation training for all ED staff.
Musculoskeletal
80 high-yield facts
ANA-positive young girl with oligoarticular JIA must have regular slit-lamp screening for asymptomatic anterior uveitis - this is the most sight-threatening complication.
Ottawa ankle rules identify patients needing X-ray - bony tenderness over posterior malleolar edges or inability to weight-bear 4 steps; always check for Maisonneuve injury.
ACL rupture - pop, rapid haemarthrosis, positive Lachman - MRI confirms and assesses for associated meniscal injuries. Surgical reconstruction for active patients with instability.
Bone metastases need multimodal management - bone-targeted therapy, palliative radiotherapy, analgesia, hypercalcaemia correction, and watch for cord compression as an emergency.
Frozen shoulder causes global restriction of active and passive ROM - external rotation is most affected, diabetes is the major risk factor, and it is self-limiting over 1-3 years.
Plantar fasciitis causes first-step morning heel pain - conservative management (stretching, footwear, weight loss) resolves >80% of cases, and heel spurs are incidental findings.
Dupuytren contracture - refer when MCP contracture ≥30° or positive tabletop test. Fasciectomy has lowest recurrence, and Dupuytren's diathesis indicates aggressive fibroproliferative tendency.
Rickets presents with bowing legs, rachitic rosary, and widened wrists - vitamin D supplementation is recommended for all UK children under 5, and treatment is high-dose vitamin D with calcium.
Neurogenic claudication - bilateral leg symptoms relieved by flexion, normal pulses, able to cycle. Distinguished from vascular claudication by relief with flexion and normal peripheral circulation.
AVN of the femoral head - corticosteroids are the commonest non-traumatic cause, MRI is the best investigation, and always check the contralateral hip (bilateral in 40-80%).
Limited SSc - CREST features, anti-centromere antibodies, main risk is PAH. Diffuse SSc - anti-Scl-70, main risks are ILD and renal crisis. Annual echocardiography and DLCO screen for PAH.
Endocrine & Metabolic
80 high-yield facts
Addison's disease causes hyperpigmentation, hyponatraemia, hyperkalaemia, and hypotension - short synacthen test confirms diagnosis, and lifelong hydrocortisone plus fludrocortisone replacement is required.
Type 1 diabetes requires lifelong insulin - basal-bolus is first-line per NICE NG17, and oral agents cannot replace insulin in absolute deficiency.
DKA management is fluids first, then fixed-rate insulin - monitor ketones hourly and replace potassium aggressively per JBDS protocol.
Levothyroxine is first-line for hypothyroidism per NICE NG145 - start 50-100mcg in fit adults, titrate every 6-8 weeks, and recheck lipids once euthyroid before treating secondary hypercholesterolaemia.
Cushing's disease requires transsphenoidal surgery as first-line - IPSS confirms pituitary source, and bilateral adrenalectomy is reserved for refractory cases with risk of Nelson syndrome.
Conn syndrome requires ARR screening, confirmatory testing, and AVS before adrenalectomy - spironolactone is first-line medical therapy for bilateral disease per Endocrine Society guidelines.
Prolactinomas are treated with dopamine agonists first-line - cabergoline is preferred, surgery is reserved for resistant cases, and prolactin level correlates with tumour size.
PHPT shows elevated PTH and calcium with low phosphate - parathyroidectomy is indicated for symptomatic disease or meeting NICE criteria, and cinacalcet is reserved for surgical refusal or unfitness.
Post-thyroidectomy hypocalcaemia requires IV calcium gluconate if symptomatic - long-term treatment is oral calcium plus active vitamin D (alfacalcidol), as standard vitamin D requires PTH for activation.
Paget's disease shows isolated elevated ALP with mixed lytic-sclerotic bone lesions - bisphosphonates are first-line, and sarcomatous transformation is the most feared complication.
Surgical
80 high-yield facts
EVAR requires lifelong surveillance for endoleaks - Type I and III need urgent treatment, Type II is observed unless sac expands, and CT angiography or duplex ultrasound is used for monitoring.
Intermittent claudication is managed with supervised exercise, best medical therapy, and smoking cessation - naftidrofuryl is second-line, and intervention is reserved for those failing conservative management.
Acute limb ischaemia with motor loss is Rutherford IIb - emergency embolectomy is required, heparin prevents propagation, and long-term anticoagulation addresses the embolic source.
Venous ulcers require compression bandaging as first-line - always check ABPI first (≥0.8 for full compression), and lifelong compression hosiery prevents recurrence after healing.
A hard, fixed, irregular breast lump with skin tethering requires urgent two-week wait referral per NICE NG12 - triple assessment is performed at the breast clinic, and core biopsy provides histological diagnosis.
SLNB avoids axillary clearance when negative - dual tracer technique with radiocolloid and blue dye gives >97% identification, and the AMAROS trial supports axillary radiotherapy as an alternative to ALND for positive nodes.
Thy5 confirms malignancy on FNA - U5 ultrasound features include microcalcifications and irregular margins, papillary carcinoma is the commonest thyroid malignancy, and total thyroidectomy plus radioiodine is standard treatment.
PHPT with calcium >2.85mmol/L or osteoporosis requires parathyroidectomy - sestamibi localises the adenoma, minimally invasive surgery has >95% cure rate, and intraoperative PTH confirms successful excision.
Post-operative PE with high Wells score requires CTPA - D-dimer is unreliable post-surgery, commence anticoagulation immediately, and S1Q3T3 is the classic but uncommon ECG finding.
PADSS score ≥9/10 indicates safe discharge from day surgery - vital signs, ambulation, pain, nausea, and bleeding are assessed, and a responsible adult escort is mandatory.
Clinical Sciences
80 high-yield facts
Horseshoe kidney = lower pole fusion = trapped below IMA = low position = associated with Turner syndrome = usually asymptomatic.
Warfarin = vitamin K epoxide reductase inhibitor = factors II, VII, IX, X = delayed onset = reversed by vitamin K.
SCD = GAG to GTG = valine for glutamic acid = HbS polymerisation under hypoxia = vaso-occlusive crisis = hydroxycarbamide increases HbF.
Iron deficiency = falsely HIGH HbA1c (longer RBC life = more glycation); haemolysis = falsely LOW HbA1c (shorter RBC life = less glycation).
CD4+ = helper T cells = coordinate immunity = HIV target = AIDS when <200 = Th1/Th2/Th17/Treg subsets have distinct functions.
Live attenuated vaccines = MMR, BCG, rotavirus, varicella, yellow fever = replicate in host = contraindicated in immunosuppression and pregnancy.
MHC II = APCs only (dendritic cells, macrophages, B cells) = extracellular antigens = CD4+ T cells; MHC I = all nucleated cells = intracellular antigens = CD8+ T cells.
pRB controls the G1/S checkpoint by sequestering E2F - its loss permits uncontrolled S phase entry; CDK4/6 inhibitors therapeutically restore this checkpoint in pRB-proficient cancers.
Oncogenes = gain of function, dominant (one hit needed); tumour suppressors = loss of function, recessive (two hits needed); cancer requires multiple genetic alterations.
PARP inhibitors exploit synthetic lethality in BRCA-deficient cancers - inhibiting SSB repair forces reliance on defective HR, causing catastrophic DNA damage and tumour cell death.
HLA-A, -B, -DR matching matters most in kidney transplantation; HLA-DR has the greatest individual impact; negative crossmatch is essential before transplant.
Public Health & Epidemiology
80 high-yield facts
Low prevalence dramatically reduces PPV even with excellent sensitivity and specificity = most positive screening results are false positives.
Confounding = third variable associated with both exposure and outcome = distorts the true association = controlled by randomisation, stratification, or regression.
RR = incidence exposed / incidence unexposed = cohort study measure = RR of 10 means 10x the risk = cannot be calculated from case-control studies.
NHS cervical screening = HPV primary test with cytology triage for HPV-positive samples = HPV-negative recall now every 5 years across the UK = colposcopy if triage cytology is abnormal.
NHS Bowel Screening = FIT (faecal immunochemical test) = every 2 years = age 50-74 = detects human haemoglobin specifically = replaced guaiac FOBt in 2019.
Ottawa Charter 1986 = 5 action areas = healthy policy, supportive environments, community action, personal skills, reorient services = advocate, enable, mediate.
Stages of Change = precontemplation, contemplation, preparation, action, maintenance = this patient is contemplating = thinking about change but not yet acting.
Audit = measuring practice against standards + implementing change + re-auditing = closing the loop is essential = no ethics approval needed = different from research.
8 Caldicott Principles = justify + minimise + need-to-know + responsibility + lawful + duty to share + inform patients = every NHS organisation needs a Caldicott Guardian.
P-value = probability of observing the data if null hypothesis is true = NOT probability the null is true = statistical significance ≠ clinical significance = always report confidence intervals.
Chi-squared = categorical vs categorical = 2x2 table = compare observed vs expected frequencies = use Fisher exact test if expected cell count <5.
Ethics, Law & Professionalism
80 high-yield facts
Gillick competence is decision-specific, not age-specific - assess understanding for each individual decision.
capacity is presumed until proven otherwise - an unwise decision does not equal an incapacitous one.
financial LPA and health and welfare LPA are entirely separate - always check which type the attorney holds.
DNACPR is a clinical decision; patient involvement is required (Tracey ruling), family consent is not.
the child's welfare is paramount - suspected non-accidental injury must be escalated to the safeguarding team regardless of parental wishes.
the four domains cover knowledge, safety, communication, and trust - Good Medical Practice is the foundation of all GMC regulation.
self-referral to the GMC and occupational health is a professional duty - the GMC health process aims to support, not punish.
the statutory Duty of Candour requires notification, a truthful account, an apology, and support - it applies to incidents causing moderate harm or worse.
Article 3 prohibits inhuman or degrading treatment absolutely - seclusion must be regularly reviewed and used for the shortest time possible.
research consent must include the right to withdraw at any time without affecting care - this is a non-negotiable ethical requirement.
the Bolam test assesses whether treatment met the standard of a responsible body of opinion - a known complication is not proof of negligence.
Montgomery replaced Bolam for consent - disclose risks that a reasonable patient in that position would consider significant.
the Equality Act 2010 protects gender identity - address discriminatory behaviour directly and ensure all patients receive dignified, respectful care.
Gastrointestinal
80 high-yield facts
Zenker diverticulum presents with dysphagia, regurgitation, halitosis, and a gurgling neck mass - diagnose with barium swallow (not endoscopy first), and treatment is endoscopic or surgical cricopharyngeal myotomy.
Tropical sprue presents after prolonged tropical travel with folate and B12 deficiency and villous atrophy - treat with folic acid and tetracycline for 3-6 months; negative coeliac serology distinguishes from coeliac disease.
Pseudomyxoma peritonei ('jelly belly') usually arises from the appendix - cytoreductive surgery with HIPEC at a specialist centre is the gold standard, achieving 70-80% 10-year survival for low-grade disease.
PoPH is defined by mPAP >20mmHg, PCWP ≤15mmHg, and raised PVR in portal hypertension - severe PoPH contraindicates liver transplant until PAP is reduced with pulmonary vasodilators.
Amoebic liver abscess responds to metronidazole followed by diloxanide furoate for luminal cysts - percutaneous drainage is only needed for large abscesses (>10cm) or failure of medical therapy.
Indeterminate FIB-4 (1.3-2.67) requires ELF test or Fibroscan for further fibrosis stratification - 10% weight loss improves NASH fibrosis, and pioglitazone has anti-fibrotic benefit per NICE NG49.
Liver biopsy is indicated for unexplained persistent LFT elevation when non-invasive workup is inconclusive - transjugular route is preferred for coagulopathy or ascites, and check coagulation and platelets beforehand.
King's College Criteria for paracetamol ALF - pH <7.3 after resuscitation alone qualifies, OR all three of INR >6.5, creatinine >300, and grade III/IV HE; contact the transplant centre early.
Liver transplant for ARLD requires 6 months supervised abstinence in the UK - UKELD ≥49 qualifies for listing, and contraindications include active substance abuse and extrahepatic malignancy.
Incidental T2 gallbladder cancer at cholecystectomy requires radical re-resection with liver bed and lymph node dissection - capecitabine adjuvant chemotherapy per BILCAP trial improves survival.
Renal & Urological
80 high-yield facts
Thin basement membrane disease is the most common cause of benign familial haematuria - biopsy shows uniformly thin GBM without splitting or immune deposits.
Cryoglobulinaemic GN with hepatitis C - treat the virus first with DAAs; very low C4 with positive rheumatoid factor is the serological hallmark.
Apple-green birefringence on Congo red staining is pathognomonic for amyloidosis - abnormal free light chains point to AL type requiring chemotherapy.
SGLT2 inhibitors are now standard of care in diabetic CKD alongside RAAS blockade - expect an initial eGFR dip reflecting reduced hyperfiltration.
Small echogenic kidneys + longstanding hypertension + moderate proteinuria without active sediment = hypertensive nephrosclerosis - Afro-Caribbean ethnicity is a major risk factor.
Terlipressin + albumin is first-line for HRS-AKI - it causes splanchnic vasoconstriction to restore effective circulating volume and improve renal perfusion.
ANCA vasculitis renal = pauci-immune crescentic GN - induce with rituximab or cyclophosphamide plus steroids, maintain with rituximab.
Class IV lupus nephritis = diffuse, ≥50% glomeruli affected, full-house IF - induce with mycophenolate or cyclophosphamide plus steroids.
Medullary sponge kidney = paintbrush appearance on CT urogram with ectatic collecting ducts - benign condition managed conservatively with hydration and metabolic stone prevention.
Retroperitoneal fibrosis with medial ureteric deviation - think IgG4-related disease, treat with glucocorticoids first, and decompress ureters if obstructed.
Adult pathological phimosis with white scarring = lichen sclerosus - trial of topical steroids, then circumcision if refractory, with histology to exclude dysplasia.
ENT
78 high-yield facts
Most AOM resolves in 3 days without antibiotics - offer a back-up prescription per NICE NG91. Immediate antibiotics for bilateral AOM in under-2s, otorrhoea, or systemically unwell children.
Epiglottitis presents with drooling, tripod position, muffled voice, and NO barking cough - do not examine the throat. Secure the airway first, then IV ceftriaxone.
Bilateral nasal polyps in an asthmatic with NSAID sensitivity is Samter triad - intranasal steroids are first-line, and FESS for refractory disease. Unilateral polyps need biopsy to exclude malignancy.
Glue ear requires 3 months of watchful waiting before intervention per NICE CG60 - grommets are offered for persistent bilateral OME with hearing loss. It is the commonest cause of childhood hearing loss.
Pleomorphic adenoma is the commonest parotid tumour - superficial parotidectomy with facial nerve preservation is standard treatment due to recurrence and malignant transformation risks. Facial nerve palsy in a parotid mass suggests malignancy.
Inhaled foreign body causes unilateral wheeze and hyperinflation - peanuts are the commonest aspirated object. Rigid bronchoscopy is the definitive investigation and treatment.
Tinnitus management = CBT + sound enrichment + hearing aids if hearing loss; no drug treatment is proven effective; MRI for unilateral tinnitus to exclude schwannoma.
Small vestibular schwannoma = active surveillance with serial MRI; many do not grow significantly; intervention for growth, brainstem compression, or symptomatic progression.
Tinnitus during aminoglycoside therapy = urgent audiometry and drug level review; ototoxicity is irreversible and cumulative - high frequencies affected first; cisplatin also highly ototoxic.
Geriatric Medicine
77 high-yield facts
Every older person presenting with falls needs a structured multifactorial assessment - treat the cause, not just the consequence.
Exercise is the single most effective intervention for preventing falls - aim for programmes specifically designed to challenge balance.
Orthogeriatric shared care is the evidence-based model for hip fracture management - it improves mortality and functional outcomes.
Falls risk alone should never be the reason to withhold anticoagulation in AF - the stroke risk almost always outweighs the bleeding risk.
Structured medication review in frail elderly focuses on what matters to the patient - quality of life takes precedence over guideline-driven targets.
Review PPIs at every medication review - step down gradually if no ongoing indication, especially in patients with osteoporosis risk factors.
In frail elderly with falls, always check standing BP - the standing blood pressure guides treatment decisions, not the lying value.
Haloperidol for delirium is a last resort at the lowest dose for the shortest time - always maximise non-pharmacological measures first.
The quiet, withdrawn patient may be the most at-risk - always screen for hypoactive delirium using the 4AT, especially in post-surgical elderly patients.
Delirium is acute and fluctuating; dementia is chronic and progressive - the 4AT helps differentiate at the bedside.
Visual hallucinations + fluctuating cognition + parkinsonism = Lewy body dementia - and never give antipsychotics.
Category II = partial-thickness with a shallow, clean wound bed - no slough, no exposed deeper structures.
In Parkinson's hallucinations - reduce medications before adding antipsychotics, and never use typical antipsychotics.
Oncology
69 high-yield facts
TLS = high K⁺, high PO₄³⁻, high urate, low Ca²⁺ - Burkitt lymphoma is the highest-risk tumour. Treat with rasburicase, not just allopurinol.
A suspicious CXR finding mandates immediate 2-week wait referral - never wait for a repeat film when malignancy is suspected.
Over 60 with 6+ weeks of changed bowel habit = automatic 2-week wait referral, regardless of other factors.
Grade 1-2 radiation skin reactions are expected - manage with emollients and continue treatment. Only grade 3-4 reactions may warrant treatment breaks.
Palliative chemotherapy aims to control disease and improve quality of life - it is neither curative nor a sign of giving up. Clear communication of treatment intent is essential.
Locally advanced NSCLC (stage III, N2) = concurrent chemoradiotherapy followed by durvalumab consolidation - this is the evidence-based standard of care.
Haematuria investigation = flexible cystoscopy + CT urogram - you need to see the bladder directly and image the upper tracts.
IGCCCG classification determines treatment intensity and prognosis - always check AFP, hCG, and LDH levels alongside imaging for staging.
Breslow ≥0.8 mm with ulceration or ≥1 mm = offer sentinel lymph node biopsy for staging - it guides adjuvant therapy decisions but CLND is no longer routine.
A rapidly growing keratotic or ulcerated lesion on the skin, especially the lip, requires urgent 2-week wait referral - never treat without tissue diagnosis.
Lynch syndrome = MMR gene mutations → MSI-H tumours → early CRC (right-sided) + endometrial cancer - test all colorectal cancers for MMR status per NICE.
Dermatology
63 high-yield facts
TEN (>30% BSA) requires immediate drug cessation and burns unit transfer - SCORTEN predicts mortality, and ciclosporin may reduce mortality based on observational evidence.
Emollients are the foundation of eczema management - prescribe liberally (250g/week for children) as both a moisturiser and soap substitute per NICE CG57.
Guttate psoriasis follows streptococcal infection by 2-3 weeks - two-thirds resolve spontaneously but one-third progress to chronic plaque psoriasis, and ASOT titre confirms recent streptococcal exposure.
Generalised pustular psoriasis is a dermatological emergency - admit for IV fluids, electrolyte correction, and urgent systemic therapy with ciclosporin. Oral steroids should be avoided in psoriasis.
Papulopustular rosacea is treated with topical metronidazole or ivermectin first-line - distinguish from acne by the absence of comedones, and never use topical steroids on rosacea.
Melanoma WLE margins depend on Breslow thickness - 2cm for 2.1-4mm per NICE NG14, with SLNB offered for tumours ≥1mm for staging purposes.
Flucloxacillin is first-line for cellulitis per NICE NG141 - mark erythema borders, assess Eron class for IV escalation, and consider prophylactic penicillin for recurrent episodes.
Non-bullous impetigo presents with honey-coloured crusts - hydrogen peroxide 1% cream is first-line for localised disease, and school exclusion for 48 hours after starting antibiotics is advised.
Tinea capitis always needs oral antifungals - terbinafine for Trichophyton, griseofulvin for Microsporum. Black dot alopecia with lymphadenopathy is typical of T. tonsurans infection.
Permethrin 5% cream applied twice (one week apart) to the whole body is standard treatment - all household contacts must be treated simultaneously, and itch may persist for 2-4 weeks after eradication.
Non-sedating antihistamines up to four-fold dose are first-line for urticaria - individual wheals lasting >24 hours suggest urticarial vasculitis, and omalizumab is second-line for refractory chronic urticaria.
Palliative Care
55 high-yield facts
Oral tranexamic acid 1g TDS is first-line for haemoptysis in palliative care - always prepare dark towels and anticipatory midazolam in case of catastrophic bleed.
Never use prokinetics or laxatives in complete bowel obstruction - use antisecretory agents (hyoscine butylbromide/octreotide), analgesia, and anti-emetics.
Opioid-induced constipation requires a stimulant laxative (senna) - softeners alone are insufficient as opioids primarily reduce peristalsis.
For anticipated catastrophic haemorrhage, prepare dark towels and stat midazolam at the bedside - the goal is comfort and dignity, not haemostasis.
Refer to palliative care early at diagnosis of incurable disease - early integration alongside oncology improves quality of life, reduces depression, and may even extend survival.
Use a ReSPECT form (Resuscitation Council UK) to record an individualised emergency care plan and ceiling of treatment - a DNACPR form covers resuscitation status only.
Children's palliative care integrates from diagnosis alongside active treatment - it is not reserved for the final days of life.
Always involve the SNOD collaboratively - deemed consent applies in England but families are still approached sensitively, and their views are respected in practice.
Haloperidol 0.5-1mg SC is first-line for delirium in dying patients - always check for reversible causes but keep investigation proportionate to the stage of illness.
Myoclonic jerks, hallucinations, and drowsiness in a patient with declining renal function on morphine indicate M6G accumulation - rotate to a renally safer opioid.
Oral morphine to oral oxycodone conversion is 2:1 - divide the morphine dose by two to get the oxycodone dose.
MSCC is an emergency - give dexamethasone 16mg immediately and refer urgently; outcome depends on neurology at time of treatment, not time of diagnosis.
Ophthalmology
45 high-yield facts
CRAO presents with sudden painless vision loss and a cherry-red spot - it is a stroke equivalent requiring urgent carotid and cardiac investigation. AF without anticoagulation is a common embolic source.
CRVO shows 'stormy disc' with flame haemorrhages in all quadrants - intravitreal anti-VEGF is first-line for macular oedema. Hypertension is the most important risk factor.
R1 background retinopathy requires annual screening and risk factor optimisation - HbA1c and BP control are the most important modifiable factors per UKPDS evidence.
Papilloedema in a young obese woman suggests IIH - LP shows raised opening pressure with normal CSF. Weight loss and acetazolamide are first-line treatment.
Bacterial conjunctivitis is self-limiting - topical chloramphenicol hastens resolution. Red flags (pain, photophobia, reduced VA, corneal involvement) require urgent ophthalmology referral.
Anterior uveitis presents with pain, photophobia, cells and flare - topical steroids and cycloplegics are the treatment. HLA-B27 association with ankylosing spondylitis is the commonest systemic link.
GCA with visual loss requires immediate IV methylprednisolone - never delay for biopsy. Jaw claudication is the most specific symptom, and bilateral blindness can be prevented by urgent treatment.
HSK presents with a dendritic ulcer and reduced corneal sensation - topical aciclovir is first-line. Topical steroids are contraindicated for epithelial disease but used with antiviral cover for stromal HSK.
CRAO with cherry-red spot is a stroke equivalent - urgent carotid and cardiac investigation is essential. Always exclude GCA in patients >50 with raised inflammatory markers.
Circumcorneal injection with a small pupil and photophobia indicates anterior uveitis - this requires ophthalmology referral. Always check visual acuity in any red eye presentation.
Typical atrial flutter shows sawtooth waves at 150bpm (2:1 block) - CTI ablation is curative with >95% success, and anticoagulation is guided by CHA₂DS₂-VASc as for AF.
Tachy-brady syndrome requires pacemaker first, then rate/rhythm control medications - treating AF without addressing the bradycardia risks asystole.
Cardioversion is appropriate within 48 hours of AF onset for symptomatic patients - flecainide is used without structural disease, amiodarone with structural disease, per NICE NG196.
LQTS type 1 is triggered by exercise and swimming - non-selective beta-blockers are first-line, competitive sport is restricted, and ICD is reserved for beta-blocker failures or cardiac arrest survivors.
Post-MI requires atorvastatin 80mg per NICE CG181 - aim for >40% non-HDL reduction, add ezetimibe if target not met, and consider PCSK9 inhibitors for refractory hypercholesterolaemia.
AIT type 1 (pre-existing thyroid disease) shows increased vascularity and is treated with carbimazole - type 2 (destructive thyroiditis) shows reduced vascularity and responds to corticosteroids.
Cardiac rehabilitation reduces mortality by 20-25% post-MI - it should start within 10 days of discharge, and driving can resume 1 week after successful PCI per DVLA guidance.
Unstable angina is troponin-negative ACS with ischaemic symptoms and ECG changes - it requires the same initial treatment pathway as NSTEMI per NICE NG185.
Acute pericarditis requires NSAIDs plus colchicine first-line - corticosteroids increase recurrence, and the saddle-shaped ST elevation with PR depression distinguishes it from STEMI.
Secundum ASD with Qp:Qs ≥1.5 and RV dilatation requires closure - percutaneous device closure is first-line, and fixed split S2 is the classic auscultatory finding.
Submassive PE requires anticoagulation and monitoring - thrombolysis is reserved for haemodynamic deterioration, and elevated troponin/BNP identifies intermediate-high risk patients per ESC guidelines.
STEMI requires immediate reperfusion - primary PCI within 120 minutes is the target, and waiting for troponin delays life-saving treatment.
HFrEF requires four pillars - ACEi/ARNI, beta-blocker, MRA, and SGLT2i - all reduce mortality, and MRA should be added when ACEi and beta-blocker are established.
HFpEF requires LVEF ≥50% with elevated natriuretic peptides and structural/functional cardiac abnormalities - SGLT2 inhibitors are now recommended to reduce hospitalisations per DELIVER and EMPEROR-Preserved.
AVNRT is treated with vagal manoeuvres first, then IV adenosine - 6mg, 12mg, 12mg escalating doses, and catheter ablation is curative for recurrent episodes.
Acute severe AR is a surgical emergency - premature mitral valve closure is pathognomonic, IABP is contraindicated, and emergency valve replacement is required.
MVP is usually benign - the mid-systolic click moves earlier with standing and later with squatting, and endocarditis prophylaxis is no longer routinely recommended per NICE CG64.
Wells score >4 means PE likely - proceed directly to CTPA without D-dimer, and start anticoagulation empirically while awaiting imaging per NICE NG158.
Shockable arrest - shock first, adrenaline and amiodarone after the third shock, and always address the 4Hs and 4Ts per Resuscitation Council UK ALS.
Type A aortic dissection is a surgical emergency - IV beta-blocker controls BP and heart rate while arranging emergency ascending aortic repair, and thrombolysis is absolutely contraindicated.
NICE CG64 does not routinely recommend IE prophylaxis for dental procedures - but discuss risks and benefits with high-risk patients, especially those with previous endocarditis.
LMNA mutations in DCM carry high arrhythmic risk - ICD threshold is lower, first-degree relatives need cascade genetic testing and periodic clinical screening every 2-3 years.
Most small VSDs close spontaneously - moderate-large VSDs need monitoring for heart failure symptoms, and surgical closure is indicated for significant shunts with failure to thrive.
Post-MI secondary prevention requires five drug classes - ACE inhibitor reduces mortality by 20%, and eplerenone is added for LVEF ≤40% with HF symptoms or diabetes per EPHESUS trial.
Functional TR is treated by addressing the underlying pulmonary hypertension - diuretics manage fluid overload, PAH-specific drugs are contraindicated in Group 3 PH, and Carvallo sign is the classic examination finding.
Rate control is first-line for AF per NICE NG196 - beta-blockers are preferred, target heart rate <110bpm, and always calculate CHA₂DS₂-VASc for anticoagulation decision.
First-degree heart block is benign in asymptomatic patients - every P wave is conducted with a prolonged but constant PR interval, and pacing is not required.
Postural hypotension requires medication review first - alpha-blockers are the commonest culprit, and non-pharmacological measures precede fludrocortisone or midodrine.
Hypertensive emergency requires controlled IV BP reduction of MAP by ≤25% in 1-2 hours - sublingual nifedipine is dangerous due to unpredictable rapid drops.
Mobitz type II requires permanent pacing regardless of symptoms - the infra-nodal block carries high risk of progression to complete heart block, unlike benign Mobitz type I.
NSTEMI is risk-stratified using the GRACE score - high-risk patients need angiography within 72 hours, and thrombolysis is never indicated for NSTEMI.
Resistant hypertension at step 4 requires spironolactone per NICE NG136 - the PATHWAY-2 trial demonstrated its superiority over bisoprolol and doxazosin for BP reduction.
Mobitz type I (Wenckebach) shows progressive PR prolongation before a dropped beat - it is benign in young/athletic patients, unlike Mobitz type II which requires pacing.
Symptomatic severe aortic stenosis mandates valve intervention - SAVR or TAVI based on surgical risk assessment, and medical therapy alone carries 50% 2-year mortality.
LVH is diagnosed by Sokolow-Lyon criteria (SV1 + RV5 ≥35mm) - the lateral strain pattern indicates pressure overload, and echocardiography is more accurate than ECG for LV mass assessment.
Digoxin toxicity is potentiated by hypokalaemia - correct potassium urgently, stop digoxin, and use DigiFab for life-threatening arrhythmias. IV calcium is contraindicated.
Pre-excited AF in WPW requires DC cardioversion if unstable - AV nodal blockers (adenosine, verapamil, digoxin) are contraindicated as they may precipitate VF.
Complete heart block with haemodynamic compromise requires IV atropine, isoprenaline, and emergency temporary pacing - permanent pacemaker is the definitive treatment for degenerative complete heart block.
Reflex (vasovagal) syncope = prodrome + clear trigger + rapid full recovery + normal ECG; first-line management is education, hydration, and counter-pressure manoeuvres, with tilt testing only if recurrent or uncertain (NICE NG128).
Broad-complex tachycardia in ischaemic heart disease is VT until proven otherwise - IV amiodarone for stable VT, DC cardioversion if unstable, and IV verapamil is contraindicated.
DOACs are first-line for non-valvular AF anticoagulation per NICE NG196 - aspirin is not recommended for AF stroke prevention, and HAS-BLED guides risk factor modification, not withholding treatment.
Massive PE with haemodynamic instability requires immediate systemic thrombolysis - alteplase is first-line, and surgical embolectomy is the rescue option if thrombolysis fails.
Early PVE with perivalvular abscess requires IV vancomycin/rifampicin/gentamicin and urgent surgical referral - rifampicin is added only after blood cultures clear to avoid resistance.
Percutaneous balloon mitral valvotomy is first-line for symptomatic mitral stenosis with favourable valve morphology (Wilkins score ≤8) - anticoagulate with warfarin (not DOACs) for AF in mitral stenosis.
Brugada syndrome shows coved ST elevation in V1-V3 - ICD is indicated for syncope or cardiac arrest with spontaneous type 1 pattern, and fever must be treated promptly to prevent arrhythmias.
CCB is first-line for hypertension in patients ≥55 or of African/Caribbean origin per NICE NG136 - ACEi/ARB is first-line for younger patients or those with diabetes/CKD.
Cardiac tamponade requires urgent pericardiocentesis - Beck's triad, pulsus paradoxus, and electrical alternans are classic findings, and diuretics and positive pressure ventilation are contraindicated.
HCM sudden death risk is stratified using the ESC calculator - ICD for 5-year risk ≥6%, and competitive sports should be restricted per ESC guidelines.
CRT-D is indicated for HFrEF with LBBB ≥150ms and NYHA II-IV on optimal therapy - LBBB morphology predicts the best response, per CARE-HF and COMPANION trial evidence.
DAPT is continued for 12 months post-ACS per NICE - ticagrelor is preferred post-ACS per PLATO, and PPI co-prescription reduces GI bleeding risk.
Large pericardial effusion without tamponade physiology requires monitoring, not emergency drainage - treat the underlying cause and watch for echocardiographic signs of developing tamponade.
PDA in premature infants is treated with IV ibuprofen or indomethacin to inhibit prostaglandin-mediated ductal patency - surgical ligation is reserved for failed medical closure.
Prinzmetal angina causes transient ST elevation at rest from coronary vasospasm - CCBs are first-line prophylaxis, and beta-blockers are contraindicated as they worsen spasm.
Stable angina first-line is beta-blocker or CCB plus GTN spray - combine both classes as second-line, and always prescribe secondary prevention per NICE CG126.
Low-risk PE (PESI I-II, normal RV and troponin) can be managed with DOAC anticoagulation and early outpatient discharge - thrombolysis is only for massive PE with haemodynamic instability.
Vasovagal syncope is diagnosed clinically in most cases - tilt table testing confirms the diagnosis when there is diagnostic uncertainty, but typical history with normal cardiac workup is often sufficient.
Bicuspid aortic valve requires lifelong echocardiographic surveillance of both valve function and ascending aortic dimensions - aortopathy is the silent danger.
Refer symptomatic varicose veins (or those with bleeding, skin changes, or healed/active ulceration) to vascular services per NICE NG147 - compression is reserved for when intervention is unsuitable, and good evidence-based options include endothermal ablation and foam sclerotherapy.
Beck's triad (hypotension + raised JVP + muffled heart sounds) + pulsus paradoxus = cardiac tamponade - perform urgent echo-guided pericardiocentesis; do NOT give diuretics.
HEART score 0-3 = low risk (early discharge), 4-6 = moderate (admit/observe), 7-10 = high (early invasive strategy) - it is a validated tool for chest pain risk stratification in the ED.
Acute limb ischaemia with motor deficit (Rutherford IIb) = emergency - give IV heparin and arrange surgical embolectomy within 6 hours; the 6 Ps help grade severity.
Commotio cordis = VF from chest wall impact during the T-wave vulnerable period in a structurally normal heart - rapid defibrillation is life-saving; predominantly affects young athletes.
Long-term oxygen therapy ≥15 hours/day is the cornerstone of cor pulmonale management in COPD - pulmonary vasodilators are contraindicated in Group 3 pulmonary hypertension.
DOACs are contraindicated for mechanical heart valves - warfarin is mandatory with target INR 2.5-3.5 for mitral mechanical valves, and 2.0-3.0 for low-risk aortic mechanical valves.
High-sensitivity troponin below the 99th centile at 0 and 3 hours with low delta rules out MI - but not unstable angina; use the HEART score for overall risk stratification.
NICE does not recommend routine antibiotic prophylaxis for dental procedures, even for prosthetic valves - this differs from ESC/AHA guidance; good oral hygiene is emphasised instead.
VO2 max <14mL/kg/min (or <12 on beta-blocker) indicates transplant consideration - assess for contraindications; LVAD provides bridge to transplant when donors are unavailable.
Positive in lead I + negative in aVF = left axis deviation (0° to -90°); use lead II to differentiate normal axis (-30° to 0°) from pathological LAD (-30° to -90°).
Brugada syndrome with spontaneous type 1 ECG + syncope = high risk - refer for ICD; flecainide is contraindicated; episodes typically occur during rest/sleep.
IL-17 inhibitors can unmask or worsen IBD - always screen for GI symptoms before and during treatment; they are contraindicated in active IBD.
Volume of distribution reflects the theoretical volume needed to contain the total drug amount at the measured plasma concentration - it is not a real physiological volume.
Grapefruit inhibits intestinal CYP3A4 - felodipine, simvastatin, and ciclosporin are the most clinically significant interactions, and the effect lasts 24-72 hours after consumption.
Sublingual, transdermal, rectal, and parenteral routes all bypass first-pass metabolism to varying degrees.
Always check statin-antibiotic interactions - erythromycin and clarithromycin with simvastatin is a potentially fatal combination causing rhabdomyolysis.
Clarithromycin + warfarin = dangerous CYP3A4 inhibition causing elevated INR - always check BNF interactions before co-prescribing with warfarin, and consider azithromycin as a safer alternative.
Narrow therapeutic index drugs require careful monitoring - small changes in dose, drug interactions, or renal function can precipitate toxicity.
The suffix tells you the antibody's origin: -omab (mouse), -ximab (chimeric), -zumab (humanised), -umab (fully human) - more human = less immunogenic.
Allopurinol inhibits xanthine oxidase, reducing uric acid production - start low, go slow, and provide anti-inflammatory cover during initiation to prevent flares.
Protamine dose is based on recent heparin exposure (last 2-3 hours) at roughly 1mg per 100 units - give slowly to avoid hypotension, and remember it only partially reverses LMWH.
Rituximab depletes CD20+ B cells - vaccine responses are impaired for 6-12 months; vaccinate before treatment where possible and avoid live vaccines during B-cell depletion.
Loading dose depends on Vd while maintenance dose depends on clearance - these are fundamentally different pharmacokinetic parameters.
Grapefruit juice irreversibly inhibits intestinal CYP3A4 - the interaction affects oral but not intravenous drug administration.
Partial agonists have high affinity but low efficacy - they block full agonists from the receptor, reducing their therapeutic effect.
For serious ESBL infections, carbapenems remain the gold standard - but use carbapenem-sparing alternatives where appropriate to protect this vital antibiotic class.
Carbapenemase-producing organisms need specialist microbiology input - ceftazidime-avibactam covers KPC but not NDM; always request carbapenemase typing to guide therapy per UKHSA guidance.
Biosimilars are highly similar - not identical - to originator biologics, with no clinically meaningful differences; they are rigorously regulated and safe to switch to.
Never combine verapamil or diltiazem with beta-blockers - the additive AV node and myocardial depression can be life-threatening; amlodipine + beta-blocker is safe.
Bisoprolol is the beta-blocker of choice when heart failure coexists with asthma - it is cardioselective with strong HF evidence and the lowest bronchospasm risk.
Idarucizumab reverses dabigatran; andexanet alfa (or PCC if unavailable) reverses apixaban/rivaroxaban - never confuse the two specific reversal agents.
Post-ACS DAPT = aspirin + ticagrelor (or prasugrel) for 12 months - ticagrelor is preferred over clopidogrel; aspirin continues lifelong afterwards.
Hypokalaemia potentiates digoxin toxicity - always check and correct potassium urgently; digoxin-specific antibodies are the definitive treatment for life-threatening toxicity.
review PPIs at every medication review and deprescribe when the original indication has resolved (NICE CKS Dyspepsia) - taper gradually over 4-8 weeks to avoid rebound acid hypersecretion.
Carbamazepine auto-induces CYP3A4 - expect levels to fall in weeks 2-6; always monitor levels and anticipate dose increases during the induction period.
Tocilizumab blocks IL-6, which suppresses CRP production - never rely on CRP to exclude infection in patients on IL-6 inhibitors; clinical assessment is paramount.
Always check TPMT before starting azathioprine - absent activity causes fatal myelosuppression from 6-TGN accumulation; intermediate activity requires dose reduction.
Always prescribe a laxative with regular opioids - tolerance to constipation never develops, senna ± docusate is first-line, and loperamide worsens the problem.
COPD with hypercapnic risk = target SpO₂ 88-92% via Venturi mask - high-flow oxygen causes CO₂ narcosis and respiratory arrest, and always obtain an ABG to guide treatment.
Nitrofurantoin and cefalexin are safe for UTI in breastfeeding - avoid fluoroquinolones, tetracyclines, and codeine, and always check BNF/LactMed for specific drug safety in lactation.
Always wait approximately five half-lives before assessing whether a maintenance dose is achieving the desired steady-state concentration.
Sepsis resuscitation = at least 30mL/kg crystalloid in first 3 hours given as assessed boluses - if hypotension persists, start noradrenaline and escalate to critical care.
LASA drugs are a recognised cause of medication errors - tall man lettering, separate storage, barcode scanning, and prescriber awareness reduce the risk of administering the wrong drug.
Methotrexate + trimethoprim = CONTRAINDICATED (dual antifolate toxicity causing fatal pancytopenia) - use nitrofurantoin or cefalexin for UTI in methotrexate patients instead.
Maximum 40mmol KCl/L at 10mmol/hr peripherally on a general ward - concentrated KCl must never be on general wards, and bolus IV potassium is never given outside cardiac arrest.
Carbamazepine causes SIADH with euvolaemic hyponatraemia - check sodium regularly (especially in elderly), correct Na⁺ slowly (<8-10mmol/L/24h), and consider gabapentin as an alternative.
Long-term steroids + major surgery = IV hydrocortisone 100mg at induction then 50mg TDS for 48 hours - the steroid emergency card is a life-saving document, and adrenal crisis is fatal without treatment.
Labetalol is first-line for hypertension in pregnancy per NICE NG133 - ACE inhibitors, ARBs, and atenolol are contraindicated, and always exclude pre-eclampsia with proteinuria and bloods.
Black triangle (▼) = intensive monitoring and report ALL suspected ADRs - it does not mean the drug is inherently more dangerous than non-triangle medicines.
Start Smart Then Focus - review at 48 hours, narrow spectrum based on cultures, and switch IV to oral when clinically improving and tolerating oral intake.
Flumazenil is contraindicated in mixed overdoses (especially with TCAs) - it precipitates seizures by removing benzodiazepine protection, and is only safe for iatrogenic benzodiazepine reversal.
Gastroparesis is a common cause of erratic oral drug absorption - always consider gastric motility in patients with variable drug responses.
INR >5 without bleeding = stop warfarin + oral vitamin K 1-2mg - PCC is only for major bleeding, and always investigate the cause of over-anticoagulation.
Potency is about the dose needed (position on x-axis), efficacy is about the maximum response achievable (height on y-axis) - they are independent properties.
Choose UFH for haemodynamically unstable patients - its short half-life and full protamine reversibility provide critical flexibility in emergency anticoagulation management.
Amiodarone monitoring = thyroid + liver (6-monthly) + lungs (annually) + eyes if symptomatic - the long half-life means toxicity can persist for months after discontinuation.
Always observe for at least 2 hours post-naloxone - heroin and most opioids outlast naloxone; premature discharge risks fatal re-narcotisation.
Paracetamol overdose may be asymptomatic initially - always use the treatment nomogram; NAC replenishes glutathione and is most effective within 8 hours of ingestion.
When starting amiodarone in a patient on digoxin - halve the digoxin dose and check levels after one week.
Prednisolone 5mg ≈ dexamethasone 0.75mg ≈ hydrocortisone 20mg - dexamethasone is ~6x more potent than prednisolone; always use equivalent dose tables for safe conversion.
NK1 antagonists (aprepitant) block substance P - they are the key agent for delayed CINV; 5-HT3 antagonists cover the acute phase; combine with dexamethasone for optimal control.
Methotrexate = once weekly ONLY; monitor FBC/LFTs/U&Es regularly; always co-prescribe folic acid; daily dosing is a potentially fatal prescribing error.
Basal-bolus = long-acting once/twice daily (peakless basal) + rapid-acting before meals (sharp peak covering food) - this most closely mimics normal pancreatic insulin secretion.
Sulfonylurea hypoglycaemia can be prolonged and recurrent, especially in elderly patients with CKD - reduce the gliclazide dose, monitor for many hours, and avoid glibenclamide (NICE NG28; BNF).
ACE inhibitor cough = switch to ARB for equivalent benefit without cough - the cough is bradykinin-mediated and resolves within weeks of stopping the ACE inhibitor.
Leading zeros (0.5mg), no trailing zeros (5mg not 5.0mg), write micrograms and units in full - these simple rules prevent fatal 10-fold dosing errors.
Digoxin toxicity = stop digoxin, treat hyperkalaemia (but avoid IV calcium), and give DigiFab for life-threatening features - renal impairment and hypokalaemia are the commonest precipitants.
Hip replacement = 28-35 days extended thromboprophylaxis per NICE NG89 - LMWH or DOAC, not aspirin alone, and knee replacement is 14 days.
Always check the wristband for three identifiers before prescribing - wrong-patient errors are preventable and potentially fatal.
UTI in pregnancy = nitrofurantoin (avoid at term) or cefalexin for 7 days - trimethoprim is avoided in the first trimester, and asymptomatic bacteriuria must also be treated.
Metformin must be stopped at eGFR <30 and reduced at eGFR 30-44 per BNF - lactic acidosis is rare but potentially fatal, and SGLT2 inhibitors offer cardiorenal benefit as alternatives.
Vancomycin trough 15-20mg/L for serious MRSA - subtherapeutic levels require dose increase, oral vancomycin has no systemic absorption, and AUC-guided dosing is replacing trough-only monitoring.
Paracetamol at reduced doses (2-3g/day) is the safest analgesic in liver disease - NSAIDs are contraindicated (hepatorenal syndrome, GI bleeding), and opioids accumulate dangerously.
CYP2D6 poor metabolisers cannot activate codeine - always consider alternative analgesics in patients with no response to codeine.
In patients on phenytoin and valproate - always request free phenytoin levels as total levels are unreliable due to protein binding displacement.
Black triangle drugs require reporting of ALL suspected ADRs - do not wait for confirmed causality; early signal detection saves lives.
Pre-marketing trials detect common ADRs but lack power for rare events - pharmacovigilance after licensing is essential for population-level drug safety.
Clavulanic acid is a suicide inhibitor of beta-lactamase - it protects amoxicillin from enzymatic destruction but has no significant antibacterial activity itself.
UK first-line ART = 2 NRTIs (TAF/FTC) + 1 INSTI (dolutegravir) - start ART in all patients regardless of CD4 count to achieve an undetectable viral load.
JAK inhibitors carry increased risks of VTE, MACE, and malignancy - use with caution and only after other options are exhausted, especially in patients with cardiovascular or thrombotic risk factors.
Bloody diarrhoea → anaemia, thrombocytopenia, AKI = STEC-HUS; management is supportive; avoid antibiotics and platelet transfusions.
MCADD - avoid fasting, provide emergency carbohydrate during illness, and carry an emergency protocol letter at all times.
Pertussis causes paroxysmal cough with whoop and marked lymphocytosis - macrolide antibiotics reduce transmission, young infants need admission for apnoea monitoring, and maternal vaccination is key.
Septated pleural effusion in a child with pneumonia = empyema; treat with chest drain plus intrapleural urokinase; VATS only if fibrinolytic therapy fails.
Infantile spasms + developmental regression + hypsarrhythmia = West syndrome; vigabatrin first-line for tuberous sclerosis, prednisolone/ACTH for other causes per NICE NG217 and the ICISS trial - treat urgently.
Wilms tumour = smooth abdominal mass not crossing midline + hypertension in a 3-5 year old - ultrasound is the first investigation, and the SIOP protocol gives >90% survival for localised disease.
Femoral fractures in pre-mobile infants are NAI until proven otherwise - admit, document meticulously, refer to safeguarding lead and social care, and arrange skeletal survey.
Failed AOAE → repeat AOAE → AABR - do not skip straight to audiology referral after one failed test.
Chromosomal microarray is the first-line genetic test for unexplained global developmental delay - it has a 15-20% diagnostic yield and has replaced standard karyotyping.
Floppy infant with tongue fasciculations, absent reflexes, and preserved cognition - think SMA type 1; genetic testing for SMN1 deletion confirms diagnosis.
Anaphylaxis = IM adrenaline first - 150 micrograms for age 1-5, 300 micrograms for 6-11, 500 micrograms for ≥12 years; always into the anterolateral thigh.
Vitamin D deficiency rickets - treat with high-dose colecalciferol for 8-12 weeks; standard 400 IU is for prevention, not treatment.
Young girl with oligoarthritis, ANA positive, and uveitis = oligoarticular JIA - regular slit-lamp screening is essential as uveitis is often silent.
Single-dose oral dexamethasone is first-line for all croup severities - nebulised adrenaline is added for severe cases, and a drooling toxic child suggests epiglottitis, not croup.
Buccal midazolam is first-line for prolonged seizures >5 minutes - follow the APLS escalation algorithm, do not cold-sponge febrile children, and antipyretics do not prevent febrile seizure recurrence.
Incomplete Kawasaki occurs with <4 classic features - use supplementary lab criteria and echocardiography to guide IVIG treatment, and maintain high suspicion in infants who are at greatest coronary artery risk.
Metaphyseal corner fractures and posterior rib fractures in infants are highly specific for NAI - exclude OI and metabolic bone disease, but the fracture pattern itself is virtually diagnostic of inflicted injury.
Short stature plus pulmonary stenosis (dysplastic valve) plus typical facies with normal karyotype = Noonan syndrome - the most common RASopathy.
Turner syndrome = short stature + absent puberty + elevated FSH in a phenotypic female - karyotype confirms 45,X, cardiac MRI is essential for bicuspid aortic valve and coarctation, and growth hormone improves adult height.
Inability to pass NGT plus gas in the stomach = OA with distal TOF (type C) - the most common variant; always screen for VACTERL anomalies.
Exchange transfusion is required when bilirubin reaches the exchange threshold or ABE signs appear - ABO incompatibility is the commonest immune haemolytic cause, and kernicterus causes irreversible neurological damage.
Prolonged jaundice with pale stools = conjugated hyperbilirubinaemia until proven otherwise - urgently exclude biliary atresia as Kasai procedure must be performed before 60 days.
Incomplete Kawasaki - fever ≥5 days with <4 classic features but supportive labs/echo should still receive IVIG and aspirin; do not wait for full criteria.
Start levothyroxine immediately on confirmation - do not delay treatment waiting for imaging or specialist input; early treatment prevents intellectual disability.
No meconium at 24 hours plus abdominal distension - suspect Hirschsprung disease; confirm with rectal biopsy showing absent ganglion cells.
CF screening uses IRT on the heel prick test - sweat chloride ≥60mmol/L confirms the diagnosis, early treatment improves outcomes, and CFTR modulators are revolutionising care for eligible genotypes.
Suspected early-onset neonatal sepsis - take blood cultures then start IV benzylpenicillin and gentamicin within 1 hour (NICE NG195). Never delay antibiotics awaiting culture results, and avoid ceftriaxone in neonates.
Bacterial meningitis CSF = cloudy, polymorphs, high protein, low glucose - IV ceftriaxone plus dexamethasone per NICE CG102, and hearing loss is the commonest long-term complication.
Simple febrile convulsions are benign - reassure parents, no routine investigations needed, and the recurrence risk is ~30% but the epilepsy risk remains low at 2-4%.
HSP is self-limiting - the key is monitoring urine for at least 12 months for nephritis; normal platelets with palpable purpura distinguishes it from ITP.
Transient synovitis is the commonest cause of irritable hip - use Kocher criteria to distinguish from septic arthritis, low CRP and ESR support the diagnosis, and symptoms should resolve within 7-10 days.
VSD is the commonest CHD - pansystolic murmur at left lower sternal edge, small ones often close spontaneously, and large ones require surgical closure to prevent Eisenmenger syndrome.
Steroid-resistant nephrotic syndrome requires renal biopsy - FSGS is the commonest finding, calcineurin inhibitors are first-line treatment, and genetic testing guides whether immunosuppression is likely to be effective.
Morning headaches, vomiting, and ataxia in a child - think posterior fossa tumour; urgent MRI is mandatory; sixth nerve palsy is a false localising sign of raised ICP.
Conjugated jaundice >14 days with pale stools - think biliary atresia and refer urgently; Kasai must be done before 60 days for best outcomes.
Active TB in children = four drugs for 2 months then two drugs for 4 months; do not wait for culture confirmation; always perform contact tracing.
Non-vigorous baby through meconium - clear the airway and ventilate with air first; do not delay ventilation for routine tracheal suctioning (NLS/RCUK 2021).
Tet spells = knee-to-chest position + oxygen + morphine + IV fluids + phenylephrine if refractory - the murmur becomes quieter during spells as less blood crosses the RVOT.
Coeliac disease presents with faltering growth, diarrhoea, and abdominal distension after gluten introduction - screen with IgA-tTG, confirm with duodenal biopsy, and treat with lifelong gluten-free diet per NICE NG20.
Scarlet fever = sandpaper rash + strawberry tongue + Pastia lines from GAS - treat with penicillin V for 10 days, it is notifiable, and complications include rheumatic fever.
Non-blanching purpuric rash with fever = give benzylpenicillin IM/IV immediately and call 999 - meningococcal disease kills within hours, and pre-hospital antibiotics save lives.
Complex febrile seizures are focal, prolonged >15 minutes, or recurrent - they require investigation including LP consideration, carry higher epilepsy risk, and rescue buccal midazolam may be indicated.
Severe acute asthma in children = SpO2 <92%, PEF 33-50%, unable to complete sentences - oxygen, nebulised salbutamol, ipratropium, and oral prednisolone per BTS/SIGN.
Milestone assessment uses the four domains - gross motor, fine motor, language, and social - with red flags including no sitting by 9 months, no walking by 18 months, and no words by 18 months.
NICE traffic light categorises paediatric fever risk - green features allow home management with safety-netting, and all under-3-months with fever need urgent assessment.
Amber traffic light features require blood tests, urine, and possible CXR - decision to admit or discharge is based on investigation results and clinical trajectory per NICE CG160.
Neonatal resuscitation centres on effective ventilation - 5 inflation breaths is the key intervention, chest compressions only if HR <60bpm after effective breathing, and maintain temperature throughout.
Coarctation presents with weak femoral pulses and upper-lower limb BP difference - IV prostaglandin reopens the ductus as an emergency measure, and it is associated with bicuspid aortic valve and Turner syndrome.
Intussusception = episodic pain + sausage mass + redcurrant jelly stools - air enema reduction is first-line (75-80% success), with surgical back-up for failed reduction or perforation.
HSP = palpable purpura on buttocks/legs + abdominal pain + arthralgia + renal involvement - normal platelets distinguish it from ITP, and long-term prognosis depends on renal involvement.
Paediatric DKA = slow 48-hour rehydration + low-dose IV insulin (no bolus) per BSPED - cerebral oedema is the most dangerous complication, and rapid fluid correction increases risk.
First Pseudomonas isolate in CF requires eradication therapy - nebulised colistin plus oral ciprofloxacin for 3 months per UK CF Trust, as chronic colonisation accelerates lung function decline.
Oligoarticular JIA is the commonest childhood arthritis - ANA-positive cases need regular ophthalmological screening for asymptomatic uveitis, and intra-articular steroids are first-line treatment.
Emollients are the foundation of eczema management per NICE CG57 - use liberally and frequently, apply topical steroids to active areas only, and avoid potent steroids on the face.
Uncomplicated infant reflux is normal - reassure parents, no treatment per NICE NG1, and investigate only if red flags (bile-staining, projectile vomiting, failure to thrive) are present.
Still murmur is innocent - vibratory/musical quality, varies with posture, no associated symptoms, and no investigation needed if all innocent murmur criteria are met.
Bruising in pre-mobile infants is always concerning - 'those who don't cruise rarely bruise', facial bruising in any infant is a red flag, and safeguarding procedures must be followed regardless of the explanation.
DMD = Gower sign + calf pseudohypertrophy + massively elevated CK in a young boy - X-linked recessive dystrophinopathy, corticosteroids prolong ambulation, and multidisciplinary care is essential.
Tongue-tie causing breastfeeding difficulty can be treated with frenulotomy per NICE IPG149 - assess the functional impact on feeding, >10% weight loss is a red flag, and frenulotomy is a safe, simple neonatal procedure.
Screen babies <32 weeks or <1501g - timing is 30-36 weeks PMA depending on gestation, not a fixed postnatal age.
FS pattern = sickle cell disease - refer to specialist centre, start penicillin V by 3 months, and educate parents on fever and splenic sequestration emergencies.
Painless abdominal mass in a child aged 3-4 years = Wilms tumour until proven otherwise; ultrasound is the first investigation, and never biopsy percutaneously.
Absent red reflex in a child = urgent ophthalmology referral - retinoblastoma must be excluded; use MRI not CT for imaging.
All babies with Down syndrome need echocardiography regardless of clinical findings - 40-50% have congenital heart disease; also screen thyroid, FBC, hearing, and vision.
Smooth philtrum, thin upper lip, and short palpebral fissures - these three sentinel facial features plus prenatal alcohol exposure and neurodevelopmental impairment define fetal alcohol syndrome.
No remission after 4 weeks of prednisolone = steroid-resistant nephrotic syndrome - renal biopsy is essential to guide treatment; calcineurin inhibitors are first-line for SRNS.
Recurrent wheeze with interval symptoms and atopy in under-5s - trial low-dose ICS with spacer and mask; if no response, consider montelukast; reassess and confirm diagnosis when spirometry is possible.
Oral amoxicillin is first-line for community-acquired pneumonia in children - add a macrolide if no improvement at 48 hours or Mycoplasma is suspected.
Use the NICE gestational age-specific threshold chart to guide phototherapy - encourage breastfeeding, recheck bilirubin at 4-6 hours, and monitor for rebound after stopping per NICE CG98.
Speech delay with reduced social communication and repetitive behaviours requires urgent ASD assessment - hearing test is the first investigation, no words by 18 months is a red flag, and early diagnosis improves outcomes.
Secondary pneumothorax requires a lower threshold for intervention than primary - chest drain for >2cm or significant breathlessness, and all patients should be admitted per BTS guidelines.
HAP requires broader-spectrum antibiotics than CAP - co-amoxiclav or piperacillin-tazobactam per NICE NG139, and treatment is guided by local antibiograms and onset timing.
Tension pneumothorax is a clinical diagnosis - immediate needle decompression (4th/5th ICS anterior axillary line per ATLS, or 2nd ICS mid-clavicular line) followed by formal chest drain in the safe triangle (BTS 2023). Never wait for a chest X-ray.
VTE in pregnancy requires treatment-dose LMWH - DOACs and warfarin are contraindicated, and treatment continues for at least 6 weeks postpartum with a minimum 3-month total duration.
Type 1 respiratory failure is hypoxaemia without hypercapnia - ARDS is classified by PaO₂/FiO₂ ratio using Berlin criteria, and lung-protective ventilation with low tidal volumes is the cornerstone of management.
PJP requires high-dose co-trimoxazole for 21 days - add prednisolone if PaO₂ <9.3kPa, and prophylaxis is indicated for all patients with CD4 <200 cells/µL.
Extensive-stage SCLC is treated with platinum-etoposide plus atezolizumab per IMpower133 - PCI is offered to responders, and paraneoplastic syndromes (SIADH, Lambert-Eaton) are associated features.
For asthma uncontrolled on regular low-dose ICS plus SABA, step up to a low-dose ICS/formoterol combination as MART per the 2024 BTS/NICE/SIGN guideline (NG245) - always check technique and adherence first, and add a LABA rather than relying on increasing the ICS dose alone.
Latent TB is treated with 3HR or 6H per NICE NG33 - IGRA is preferred over Mantoux in BCG-vaccinated individuals, and active TB must be excluded before starting LTBI treatment.
MDR-TB requires specialist referral for individualised regimens with ≥4 effective drugs - fluoroquinolones and bedaquiline are the backbone, and treatment is extended to 9-20 months per WHO guidelines.
Mesothelioma has a 30-40 year latency from asbestos exposure - cisplatin/pemetrexed or nivolumab/ipilimumab are first-line, and patients are entitled to industrial compensation.
Occupational asthma requires serial PEF monitoring over work and rest periods - early removal from exposure is key, and RIDDOR reporting is a legal obligation.
COPD without asthmatic features and low eosinophils follows the LAMA → LAMA/LABA pathway - ICS increases pneumonia risk without benefit in this phenotype per NICE NG115 and the FLAME trial.
Provoked PE with a resolved transient risk factor - stop anticoagulation at 3 months. Unprovoked PE - consider extended anticoagulation with a reduced-dose DOAC per NICE NG158.
Aspiration pneumonia requires anaerobic and Gram-negative coverage - IV co-amoxiclav is first-line, SALT assessment is mandatory, and the right lower lobe is the commonest location.
Malignant pleural effusion requires definitive management - IPC and talc pleurodesis are equally effective per TIME-2, with IPC preferred for trapped lung or to minimise hospital visits.
TB treatment is RIPE for 2 months then RI for 4 months per NICE NG33 - pyridoxine prevents isoniazid neuropathy, and contact tracing is mandatory for smear-positive cases.
COPD patients require controlled oxygen targeting SpO₂ 88-92% via Venturi mask - high-flow oxygen worsens hypercapnia, and ABG must be rechecked at 30-60 minutes per BTS guidelines.
CURB-65 ≥3 indicates severe CAP requiring IV antibiotics and ICU consideration - always obtain blood and sputum cultures and check Legionella urinary antigen per BTS/NICE NG138 guidelines.
Legionella pneumonia causes hyponatraemia and multi-organ dysfunction - macrolides or fluoroquinolones are first-line (beta-lactams are ineffective), and it is a notifiable disease in the UK.
Treat symptomatic stage II/III pulmonary sarcoidosis (declining lung function, significant symptoms, or hypercalcaemia) with oral corticosteroids first-line; hypercalcaemia reflects macrophage 1-alpha-hydroxylase activity and responds to steroids.
Hypersensitivity pneumonitis - complete antigen avoidance is the most important step, BAL lymphocytosis and centrilobular nodules are characteristic, and serum precipitins confirm exposure not disease.
Acute severe asthma requires oxygen, nebulised salbutamol, ipratropium, and oral prednisolone - a normal PaCO₂ in acute asthma is a life-threatening sign indicating respiratory muscle fatigue.
Stage IIIA NSCLC with N2 nodes and good performance status → concurrent chemoradiotherapy followed by consolidation durvalumab (PACIFIC); all advanced NSCLC requires full molecular profiling (EGFR, ALK, ROS1, BRAF, PD-L1) per NICE NG122.
Near-drowning requires observation for at least 24 hours due to risk of delayed pulmonary oedema - prophylactic antibiotics and steroids are not indicated, and hypothermia should be corrected gradually.
Recurrent right-sided pneumothorax coinciding with menstruation = catamenial pneumothorax from thoracic endometriosis - treat with hormonal suppression and VATS repair; >90% are right-sided.
Bilateral peripheral consolidation ('photographic negative of pulmonary oedema') + blood and BAL eosinophilia + middle-aged woman = chronic eosinophilic pneumonia - dramatic steroid response but frequent relapses.
Upper airway disease + cavitating lung nodules + rapidly progressive GN + c-ANCA/anti-PR3 = GPA - treat with cyclophosphamide or rituximab plus steroids; plasma exchange for severe renal disease.
OHS = obesity + daytime hypercapnia + sleep-disordered breathing - start CPAP if OSA is predominant; switch to BiPAP if hypercapnia persists after 3 months; weight loss is essential.
Crescendo-decrescendo breathing with central apnoeas = Cheyne-Stokes respiration - primarily associated with severe heart failure; it is a poor prognostic marker; optimise heart failure therapy first.
Post-COVID fibrosis requires serial PFT and CT monitoring - if progressive, treat as progressive pulmonary fibrosis with antifibrotics; pulmonary rehabilitation improves functional outcomes.
Chest drain tip in the lung parenchyma with haemodynamic instability = iatrogenic lung laceration/haemothorax - do NOT remove the drain; urgent surgical review; insert drains in the triangle of safety using blunt dissection.
CT-guided biopsy is the technique of choice for peripheral pulmonary lesions not reachable by bronchoscopy - pneumothorax rate 15-25% (drain needed in 5-10%); >90% diagnostic accuracy.
≥2 segmental mismatched perfusion defects on V/Q scan = high probability of PE - V/Q is preferred when CTPA is contraindicated; it is also the screening test for CTEPH.
In pregnancy, CTPA = higher breast dose/lower fetal dose; V/Q = lower breast dose/higher fetal dose - discuss with the patient; V/Q preferred if CXR is normal; CTPA if CXR is abnormal or alternative diagnosis is sought.
Mepolizumab targets IL-5 for eosinophilic asthma; omalizumab targets IgE for allergic asthma - phenotyping guides biologic selection at the MDT.
Lower-lobe panacinar emphysema in a young non-smoker with liver disease suggests alpha-1 antitrypsin deficiency - check serum AAT level and genotype.
Refer IPF patients for transplant when DLCO <40%, FVC declining >10% in 6 months, or resting oxygen dependence develops - early referral improves outcomes.
Eggshell hilar calcification with upper-zone rounded opacities is classic for silicosis - silica increases TB risk, and the condition is compensable as an industrial disease.
CWP with PMF shows large upper-zone opacities on a background of small rounded opacities - Caplan syndrome is the association with rheumatoid arthritis, and compensation is available.
Symptomatic endobronchial tumour obstruction requires interventional bronchoscopy for rapid debulking and/or stenting - systemic therapy and radiotherapy act too slowly for acute airway compromise.
Flail chest requires ≥3 ribs fractured in ≥2 places - the underlying pulmonary contusion drives respiratory failure, and adequate analgesia (epidural) is critical to prevent splinting.
Pulmonary contusion may not appear on initial CXR - changes develop over 24-48 hours post-trauma, peaking at 72 hours; supportive care and avoiding fluid overload are the management priorities.
Oxygen toxicity from prolonged FiO₂ >0.6 causes absorption atelectasis and diffuse alveolar damage - target the lowest FiO₂ maintaining adequate oxygenation, and use lung-protective ventilation strategies.
Cough syncope is a vagally-mediated reflex syncope from prolonged coughing - treat the underlying chronic cough, exclude cardiac causes, and reassure that it is benign.
CPAP non-adherence - address nasal congestion with topical steroids and humidification, refit the mask, and provide early follow-up; mandibular devices are alternatives for CPAP-intolerant patients per NICE.
Chronic cough - always stop ACE inhibitors first, then systematically address postnasal drip, GORD, and cough-variant asthma as the three commonest causes per BTS guidelines.
LTOT criteria - PaO₂ ≤7.3kPa stable, or 7.3-8.0 with cor pulmonale/polycythaemia; must use ≥15 hours/day for survival benefit per BTS/MRC trial evidence.
Palliative oxygen does not benefit non-hypoxaemic breathlessness - a handheld fan and low-dose morphine are evidence-based alternatives per BTS and NICE NG31 guidelines.
LTOT criteria = PaO₂ ≤7.3kPa (or 7.3-8.0 with polycythaemia/cor pulmonale) when stable - must use ≥15 hours/day for survival benefit; confirmed by two ABGs ≥3 weeks apart.
Lung cancer staging uses TNM 8th edition - any distant metastasis = Stage IV; all patients require MDT discussion per NICE NG122; PET-CT is essential for assessing mediastinal nodes and distant metastases before treatment planning.
Raised anion gap metabolic acidosis with ketonaemia and hyperglycaemia confirms DKA - Kussmaul breathing is respiratory compensation, and potassium will fall rapidly once insulin is started.
Insert the needle above the upper border of the rib below - the neurovascular bundle runs along the inferior border of each rib; always use ultrasound guidance; limit drainage to 1.5L to prevent re-expansion pulmonary oedema.
Diaphragmatic paralysis causes orthopnoea with >25% supine FVC drop - the sniff test shows paradoxical diaphragm movement, and phrenic nerve injury from cardiac surgery is the commonest cause.
Bronchial carcinoid = young non-smoker + haemoptysis + vascular endobronchial mass + salt-and-pepper chromatin + chromogranin A positive - surgical resection is curative; carcinoid syndrome is rare with bronchial carcinoids.
Adult epiglottitis = rapid sore throat + drooling + muffled voice + thumbprint sign - priority is airway security with senior anaesthetic support; do not agitate the patient or perform direct laryngoscopy in the ED.
Radial ABG technique = modified Allen test → 30-45 degree angle, bevel up → pulsatile blood return (no aspiration) → firm pressure ≥5 min → analyse within 15 min; always record FiO₂.
High-flow oxygen in COPD causes dangerous hypercapnia - switch to Venturi mask targeting SpO₂ 88-92%, never remove oxygen completely, and recheck ABG after 30-60 minutes per BTS guidelines.
LTOT when PaO₂ ≤7.3 kPa, or 7.3-8.0 kPa with complications; ≥15 hours/day for survival benefit; must not smoke; flow titrated to PaO₂ ≥8 kPa; NICE NG115, BTS 2015, and MRC/NOTT trials.
Dislodged tracheostomy = NTSP algorithm: oxygen to face AND stoma → attempt reinsertion (or smaller tube/ET tube) → if fails, cover stoma and ventilate via face; every tracheostomy bedspace needs an emergency algorithm and equipment.
Anterior mediastinal masses - the 4 Ts (thymoma, teratoma, thyroid, terrible lymphoma); thymoma is the commonest anterior mediastinal tumour in adults and is associated with myasthenia gravis.
Asbestosis causes basal UIP-pattern fibrosis with pleural plaques on HRCT - occupational history is the key diagnostic factor, and patients are entitled to industrial compensation.
Pre-exercise SABA inhaler 15-30 minutes before activity is first-line for exercise-induced bronchospasm - a warm-up period can also reduce symptoms; ≥10% FEV1 fall on exercise challenge confirms diagnosis.
NIV for COPD exacerbation is indicated when pH <7.35 despite 1 hour of optimal medical therapy - start BiPAP with IPAP 12-15 and EPAP 4-5 cmH₂O; if pH <7.25 consider ICU for invasive ventilation.
Pulmonary rehabilitation should be offered to all COPD patients with MRC grade ≥3 breathlessness - it improves exercise capacity, quality of life, and reduces hospital admissions; 6-8 weeks supervised, twice weekly.
Mycoplasma pneumoniae = young adult + dry cough + CXR worse than clinical signs + cold agglutinins + extrapulmonary features (rash, haemolysis, encephalitis); treat with macrolide or doxycycline.
Lung abscess = foul sputum + cavity with air-fluid level + aspiration risk factors - treat with prolonged IV antibiotics with anaerobic cover (co-amoxiclav/clindamycin) for 4-6 weeks plus postural drainage.
Secondary pneumothorax >2cm or with breathlessness → chest drain (not aspiration); all SSP patients require hospital admission; high-flow oxygen aids reabsorption by increasing the nitrogen gradient.
Brown-Séquard shows ipsilateral motor and dorsal column loss with contralateral spinothalamic loss - it has the best prognosis among incomplete cord syndromes.
Elderly male + finger flexor + quadriceps weakness + steroid-resistant + rimmed vacuoles on biopsy = IBM - no effective immunotherapy; supportive management only.
NPH presents with gait disturbance, incontinence, and dementia - CSF tap test improvement predicts VP shunt response, and it is a treatable cause of dementia.
Myasthenic crisis requires intubation when FVC <1 L - IVIg or plasma exchange provides rapid improvement, and distinguish from cholinergic crisis before increasing anticholinesterase medications.
ADEM = child + post-infectious encephalopathy + widespread bilateral white matter lesions - monophasic; check MOG antibodies; treat with IV steroids.
Trigeminal neuralgia = carbamazepine first-line; MRI to exclude secondary cause; microvascular decompression if medical therapy fails - electric shock-like pain + triggers is the key history.
CES = asymmetric LMN + radicular pain + late bladder; conus = symmetric + early bladder + less pain - both are surgical emergencies requiring urgent MRI.
Triphasic waves + frontal predominance + encephalopathy = metabolic cause (hepatic, uraemic) - distinguish from NCSE; treat the metabolic cause, not with antiepileptics.
Breakthrough MS on first-line DMT requires escalation to high-efficacy therapy - natalizumab needs JC virus monitoring for PML risk, and ocrelizumab is also licensed for primary progressive MS.
CES presents with saddle anaesthesia, bladder dysfunction, and bilateral leg symptoms - emergency MRI and surgical decompression within 48 hours are essential for optimal recovery.
DMD = absent dystrophin + Gower sign + calf pseudohypertrophy + very high CK - X-linked; steroids slow progression; cardiac and respiratory monitoring essential.
HIV + low CD4 + homogeneous periventricular enhancing mass + CSF EBV = PCNSL - biopsy to confirm; high-dose methotrexate + ART.
Thunderclap headache needs urgent non-contrast CT; if the CT is normal, perform lumbar puncture at 12 hours or more after onset to look for xanthochromia before excluding SAH (RCEM and NICE CKS headache guidance).
Pes cavus + distal wasting + family history + uniform NCS slowing <38m/s = CMT1 - genetic testing (PMP22) confirms; no immunotherapy benefit.
CT first for emergencies (haemorrhage, trauma, hyperacute stroke); MRI for subacute/chronic presentations, posterior fossa, tumours, demyelination - MRI with gadolinium contrast if tumour, infection, or unexplained first seizure aetiology suspected (NICE NG217).
CVST is treated with anticoagulation even with haemorrhagic infarction - stop the combined pill, screen for thrombophilia, and anticoagulate for 3-12 months.
Thunderclap headache requires CT head then LP if CT-negative - xanthochromia at ≥12 hours confirms SAH, and nimodipine reduces vasospasm-related delayed cerebral ischaemia.
Anti-Yo cerebellar degeneration = find and treat the cancer first (usually ovarian or breast); immunotherapy alone rarely helps, and observation allows relentless, often irreversible, neurological worsening.
Neutrophils + low glucose + high protein = bacterial; lymphocytes + normal glucose = viral; lymphocytes + very low glucose = TB/fungal.
POCI = brainstem/cerebellar/occipital signs - CT often misses posterior fossa strokes; MRI DWI is essential; same thrombolysis criteria apply.
HSE targets the temporal lobes - start IV aciclovir immediately without waiting for PCR, treat for 14-21 days, and MRI shows temporal lobe high signal on T2/FLAIR.
TBM presents subacutely with very low CSF glucose and high protein - treat with RIPE plus dexamethasone for 12 months, and GeneXpert provides rapid diagnosis.
Sialorrhoea in MND is treated with anticholinergics (hyoscine, glycopyrronium) - PEG should be placed while FVC is adequate, and advance care planning is essential.
ALWAYS give IV thiamine (Pabrinex) BEFORE glucose in suspected Wernicke - glucose without thiamine can be fatal; oral thiamine is insufficient acutely.
Valproate carries 10% major malformation risk and must be avoided in pregnancy - switch to levetiracetam or lamotrigine before conception, prescribe folic acid 5 mg, and enrol in the Pregnancy Register.
Syringomyelia causes dissociated sensory loss (pain/temperature lost, touch/proprioception preserved) - it is associated with Chiari I malformation, and posterior fossa decompression is the primary surgical treatment.
Wilson = KF rings + low caeruloplasmin + high urinary copper → D-penicillamine + pyridoxine first-line; screen all first-degree relatives.
Optic neuritis + abnormal MRI brain = ~50% 5-year MS risk; normal MRI = much lower risk - check AQP4/MOG antibodies to exclude alternatives.
Moyamoya = bilateral ICA stenosis + 'puff of smoke' collaterals - surgical revascularisation (bypass) is definitive treatment; antiplatelets as adjunct.
LEMS shows proximal weakness with areflexia improving after use - anti-VGCC antibodies are diagnostic, always screen for SCLC, and 3,4-diaminopyridine is first-line treatment.
MSA-C = cerebellar ataxia + severe autonomic failure + hot cross bun sign; MSA-P = symmetrical parkinsonism + autonomic failure - both have poor levodopa response.
sCJD = rapidly progressive dementia + myoclonus + cortical ribboning on DWI + periodic sharp waves - RT-QuIC is the most specific CSF test; CJD is notifiable.
NPH triad = gait + incontinence + dementia - large-volume tap test predicts shunt response; gait improves most.
Brain death preconditions = exclude hypothermia (<34°C), drugs, metabolic derangement - two sets of tests by two senior doctors; death recorded at first test time.
Wrist drop + weak finger extension + preserved triceps + arm compression = Saturday night palsy at spiral groove; preserved triceps localises the lesion.
Medial hand wasting + cervical rib + overhead aggravation + positive Adson/Roos = neurogenic TOS - lower trunk compression; distinguish from ulnar neuropathy.
Stiff person syndrome = truncal stiffness + spasms + very high anti-GAD + continuous EMG activity - diazepam first-line; IVIg for refractory disease.
Anti-Jo1 + myositis + ILD + Raynaud + mechanic's hands = anti-synthetase syndrome - ILD is the major prognostic factor; treat with steroids + immunosuppression.
Exercise intolerance + second wind + no lactate rise on forearm test + absent myophosphorylase = McArdle disease - avoid intense exercise; pre-exercise glucose helps.
Episodic paralysis + low K+ + carbohydrate trigger + family history = hypokalaemic periodic paralysis - acetazolamide for prevention; always exclude thyrotoxicosis.
Group 1 epilepsy = 12 months seizure-free; first seizure = 6 months; Group 2 = 10 years off medication - always document driving advice given.
Donepezil is first-line for mild-to-moderate Alzheimer's - memantine is for moderate-to-severe disease, and cognitive stimulation therapy is an essential non-pharmacological intervention.
BPPV is diagnosed by Dix-Hallpike and treated with Epley manoeuvre - vestibular suppressants are not recommended, and atypical nystagmus should prompt investigation for central causes.
Levodopa is the most effective treatment for Parkinson's motor symptoms - start when function is affected, and dopamine agonists carry impulse control disorder risk.
Do not delay antibiotics for LP or CT in suspected meningitis - IV ceftriaxone plus dexamethasone immediately, and contacts need ciprofloxacin prophylaxis.
New headache with hypertension, proteinuria and HELLP bloods in pregnancy means pre-eclampsia/HELLP - give IV magnesium sulphate, control blood pressure and plan delivery.
Symptomatic carotid stenosis ≥50% requires CEA within 2 weeks - benefit is greatest for severe stenosis treated early, and CAS is reserved for patients unfit for surgery.
first-line for diabetic neuropathic pain = amitriptyline, duloxetine, gabapentin or pregabalin (NICE CG173); paracetamol and NSAIDs are ineffective; optimise HbA1c and review feet annually (NICE NG28).
Raised ICP triad is headache, vomiting, papilloedema - urgent CT head first, LP is contraindicated with mass lesion, and dexamethasone reduces oedema around tumours.
Cluster headache requires high-flow oxygen and SC sumatriptan acutely - verapamil is first-line prophylaxis during the cluster bout, and oral triptans are too slow to be effective.
Hemiplegic migraine = motor weakness as part of aura - triptans and ergotamines are contraindicated; use NSAIDs acutely; verapamil or lamotrigine for prophylaxis.
Acute transverse myelitis = IV methylprednisolone first-line; plasma exchange if steroid-refractory - always check AQP4 and MOG antibodies for long segments.
PSP Richardson = vertical gaze palsy + early backward falls + axial rigidity + poor levodopa response - 'hummingbird sign' on MRI is pathognomonic.
CBD = alien limb + asymmetric apraxia + rigidity + myoclonus + cortical sensory loss - always asymmetric with contralateral cortical atrophy on MRI.
Asymmetric motor weakness + conduction block + no sensory loss + anti-GM1 = MMN - IVIg is first-line; steroids and plasma exchange do NOT work (unlike CIDP).
Triptans are first-line acute treatment for migraine when simple analgesics fail - combine with NSAIDs for added efficacy, and combined oral contraceptives are contraindicated in migraine with aura.
Epilepsy requires 12 months seizure-free for Group 1 driving - a single seizure requires 6 months, Group 2 requires 10 years seizure-free off medication, and patients must notify the DVLA.
Ethosuximide is first-line for childhood absence epilepsy - 3 Hz spike-and-wave on EEG is diagnostic, and carbamazepine/phenytoin are contraindicated as they worsen absences.
GCA with visual symptoms is a medical emergency - start prednisolone immediately before biopsy, and tocilizumab is the NICE-approved steroid-sparing agent for relapsing disease.
Wearing-off is managed by adding COMT or MAO-B inhibitors - amantadine treats dyskinesias, and DBS is considered for refractory fluctuations in cognitively intact patients under 70.
CTS causes nocturnal median nerve symptoms relieved by shaking - NCS confirms the diagnosis, thenar wasting indicates surgical decompression is needed, and nocturnal splinting is first-line conservative treatment.
Sixth nerve palsy is a classic false localising sign of raised ICP - its long intracranial course makes it vulnerable to stretch, and bilateral sixth nerve palsies should always prompt investigation for raised ICP.
Unilateral sensorineural hearing loss requires MRI IAM to exclude vestibular schwannoma - small stable tumours are observed, and bilateral schwannomas indicate NF2.
Bell's palsy requires prednisolone within 72 hours and eye care - antivirals are not needed unless vesicles suggest Ramsay Hunt syndrome, and investigate if no recovery by 3 months.
Bacterial meningitis CSF shows turbid fluid with neutrophils, high protein, and low glucose - antibiotics must never be delayed for LP, and CT before LP is only needed for specific contraindications.
opioid dependence without benefit means gradual reduction with support - never stop abruptly and never escalate.
aqueous cream is a soap substitute, not a leave-on emollient - use appropriate emollients liberally and match steroid potency to body site.
Patients must self-notify the DVLA for epilepsy - Group 1 requires 12 months seizure-free, and the GP should document the advice given per DVLA and GMC guidance.
most acute sinusitis is viral and self-limiting - offer back-up antibiotics if symptoms persist beyond 10 days, not immediate antibiotics.
Rotator cuff tendinopathy presents with a painful arc and positive impingement tests - physiotherapy is first-line, with imaging reserved for persistent or atypical cases.
COPD requires post-bronchodilator FEV1/FVC below 0.7 - classify severity by FEV1 percentage predicted and always consider alpha-1 antitrypsin testing per NICE NG115.
no asthmatic features in COPD means the non-ICS pathway - start LABA or LAMA and step up to LABA plus LAMA if needed.
Most infective conjunctivitis is self-limiting - offer self-care first, with chloramphenicol drops or ointment if not improving in 48-72 hours per NICE CKS.
Always confirm suspected hypertension with ABPM or HBPM before initiating treatment - clinic readings alone are insufficient per NICE NG136.
Target clinic BP is below 140/90mmHg for adults under 80 and below 150/90mmHg for those over 80 per NICE NG136.
Annual diabetes review must include the nine key care processes - HbA1c, BP, cholesterol, feet, eyes, kidneys, BMI, smoking, and mental health per NICE NG28.
Low-dose ICS is the first step-up for uncontrolled asthma - add LTRA then LABA in the NICE NG80 stepwise pathway.
Screen for AF with pulse palpation in over-65s - DOACs are first-line anticoagulation, and aspirin has no role in AF stroke prevention per NICE NG196.
Classify CKD by both eGFR and ACR - stage 3b A2 requires 6-monthly monitoring, ACEi optimisation, and consider SGLT2i per NICE NG203.
Pharmacotherapy for obesity (orlistat, GLP-1 RAs) should be considered alongside lifestyle changes when BMI is 28 or above with comorbidities - bariatric surgery for BMI 40 or above per NICE.
Moderate-severe depression (PHQ-9 15 or above) requires SSRI plus high-intensity psychological therapy - follow the NICE CG90 stepped care model.
CBT-I is first-line for insomnia - hypnotics should be limited to 2-4 weeks if non-pharmacological measures fail per NICE CG191.
NHS breast screening is every 3 years from age 50-71 - enhanced surveillance requires moderate or high familial risk per NICE CG164.
AAA screening is a one-off ultrasound for men at age 65 - surveillance intervals depend on diameter, and repair is considered at 5.5cm or above.
8-week vaccines are 6-in-1, oral rotavirus, and meningococcal B - give paracetamol prophylactically with meningococcal B to reduce fever.
East Africa requires chemoprophylaxis - atovaquone-proguanil, doxycycline, or mefloquine are options, and chloroquine is not effective due to resistance per ACMP guidelines.
The fit note has two options - 'not fit for work' or 'may be fit for work' with adaptations - encouraging supported return to work per DWP guidance.
Nitrofurantoin for 3 days is first-line for uncomplicated lower UTI in women - avoid fluoroquinolones for simple infections per NICE NG109.
FeverPAIN score 4-5 supports antibiotics for sore throat - penicillin V is first-line, and avoid amoxicillin due to EBV rash risk per NICE NG84.
Classify cellulitis severity using the Eron system - flucloxacillin is first-line, and mark the erythema border to monitor progression per NICE NG141.
Back pain red flags - cancer history, night pain, weight loss, neurological deficit - require urgent investigation with MRI, not routine management per NICE NG59.
Postmenopausal women with a uterus need continuous combined HRT - transdermal oestrogen with micronised progesterone is the preferred combination per NICE NG23.
Investigate both partners after 12 months of trying - semen analysis for him, mid-luteal progesterone for her, and offer lifestyle advice per NICE CG156.
Booking bloods include FBC, blood group with antibody screen, haemoglobinopathy screen, and infection screen for HIV, hepatitis B, syphilis, and rubella per NICE NG201.
The 6-8 week check must include heart, hips, eyes (red reflex), and testes - also screen for parental mental health and discuss immunisations.
Independent walking typically develops between 9-18 months - cruising at 12 months is normal, but not walking by 18 months requires assessment.
Movicol Paediatric Plain is first-line for childhood constipation - disimpact first, then maintain with ongoing laxatives and behavioural support per NICE CG99.
In polypharmacy, deprescribe the highest-risk medications first - zopiclone and codeine increase falls risk in frail elderly, and changes should be gradual per NICE NG56.
Suspected dementia requires cognitive assessment, blood tests for reversible causes, and referral to a memory service - do not diagnose or treat empirically in primary care per NICE NG97.
Alpha-blockers are first-line for moderate-severe LUTS in BPH - finasteride is added for significantly enlarged prostates, and PSA must be interpreted considering the 50% reduction effect per NICE CG97.
Start allopurinol at 100mg daily, titrate to target uric acid below 360micromol/L, and cover with colchicine for 6 months to prevent initiation flares per BSR guidelines.
Fibromyalgia requires a multimodal approach - graded exercise plus CBT plus low-dose amitriptyline, duloxetine, or pregabalin, and avoid opioids per EULAR guidelines.
Iron deficiency anaemia in men and postmenopausal women requires upper and lower GI investigation to exclude malignancy - prescribe iron replacement concurrently per BSG guidelines.
Treat vitamin D deficiency with oral colecalciferol loading then maintenance - high-risk groups should supplement year-round per NICE CKS and SACN guidance.
Potent topical corticosteroid or vitamin D analogue is first-line for plaque psoriasis on the trunk and limbs - use for up to 4 weeks then switch or add maintenance per NICE CG153.
Treat all contacts simultaneously with permethrin 5% cream applied twice one week apart - post-treatment itch lasting up to 4 weeks is normal and does not indicate failure per NICE CKS.
Most warts resolve within 2 years - salicylic acid is first-line if treatment is desired, and cryotherapy is an alternative per NICE CKS.
Chronic non-cancer pain requires a biopsychosocial approach - avoid initiating strong opioids, offer exercise, psychology, and consider amitriptyline or duloxetine per NICE NG193.
Multimorbidity management requires a patient-centred approach - explore priorities, reduce treatment burden, rationalise medications, and coordinate care per NICE NG56.
Intra-articular corticosteroid injection - short-term OA flare relief per NICE NG226. Always exclude septic arthritis first; limit to three to four injections per joint per year. Hyaluronic acid not recommended for knee OA; PRP lacks evidence.
Raised ALT with obesity suggests NAFLD - calculate FIB-4, arrange liver ultrasound, and address metabolic risk factors per NICE NG49. Confirm eGFR on repeat testing per NICE NG203.
metformin is always first-line for T2DM - start low and go slow to minimise GI adverse effects.
the annual diabetes review covers the nine key care processes - HbA1c, BP, cholesterol, feet, eyes, kidneys, BMI, smoking, and mental health.
under NG245 the adult pathway starts with blood eosinophils or FeNO (FeNO positive at 50 ppb or more), then BDR spirometry, then PEF variability, then bronchial challenge - in that order.
QRISK3 ≥10% means offer atorvastatin 20 mg for primary prevention - the threshold is 10%, not 20%.
pharmacotherapy for obesity requires BMI ≥35 with comorbidities, failure of lifestyle measures, and continued monitoring with discontinuation if targets are not met.
HPV primary screening means test for HPV first - cytology is the triage test, not the primary test.
'may be fit for work' with adjustments is preferred over 'not fit for work' where possible - support return to work.
the three core OA treatments are exercise, weight management, and education - topical NSAIDs are first-line analgesia, while paracetamol and opioids are no longer routinely recommended (NICE NG226).
plantar fasciitis improves in 80% within 12 months - stretching is the cornerstone, not imaging or injections.
the 6-8 week NIPE covers eyes, heart, hips, and testes - hearing is screened separately by the NHS Newborn Hearing Screening Programme.
independent walking is expected by 18 months not 12 - pulling to stand, cruising, pincer grip, first words, and pointing are all normal at 12 months.
the enuresis alarm is first-line if the family is motivated - desmopressin is the alternative, particularly useful for short-term cover.
STOPP sedative-hypnotics in older adults with falls - zopiclone and amitriptyline are high-risk medications in the elderly.
use a validated cognitive screening tool in the GP surgery - GPCOG or 6-CIT are practical choices; also exclude reversible causes with blood tests.
IBS is a positive clinical diagnosis - use faecal calprotectin to exclude IBD; colonoscopy is not needed without red flags.
test tTG-IgA while eating gluten - always check total IgA to exclude deficiency that can cause false negatives.
pernicious anaemia requires lifelong IM B12 - never give folate alone as it can mask B12 deficiency and worsen neuropathy.
vitamin D below 25 nmol/L needs a loading dose then maintenance - advise at-risk groups to supplement 400 IU daily year-round.
NICE says no to escalating medications for chronic primary pain - exercise, psychology, and supported medication reduction are the evidence-based approach.
Varenicline has the highest cessation rates - offer alongside behavioural support from NHS Stop Smoking Services per NICE NG209.
HbA1c of 48mmol/mol or above with symptoms diagnoses diabetes on a single test - without symptoms, a repeat HbA1c is needed per NICE NG28.
AUDIT-C of 5 or above triggers the full AUDIT - brief intervention for scores 8-15, and specialist referral for scores 20 or above per NICE CG115.
Dengue management is supportive - avoid aspirin and NSAIDs due to bleeding risk, monitor haematocrit closely during the critical phase, and the NS1 antigen is the early diagnostic test.
MDR-TB means resistance to rifampicin and isoniazid - specialist treatment with second-line agents for 9-20 months, and GeneXpert detects rifampicin resistance within hours.
D+/R− serostatus mismatch carries the highest risk of CMV disease - always check donor and recipient CMV status before transplantation.
The amoxicillin rash in glandular fever is not a penicillin allergy - always advise avoiding contact sports for at least 4 weeks due to splenic rupture risk.
Multiple ring-enhancing lesions in HIV with positive toxoplasma IgG should be treated empirically - biopsy only if no improvement after 2 weeks of therapy.
Repeat therapeutic lumbar punctures are essential in cryptococcal meningitis - raised ICP is the leading cause of early mortality.
Always perform baseline visual acuity and Ishihara colour testing before starting ethambutol - stop immediately if any visual deterioration occurs, as early cessation allows recovery.
BCG is offered to UK infants from high-incidence countries (≥40/100,000) - it can be given without prior Mantoux testing if the child is under 6 years old.
Atovaquone-proguanil has the shortest post-travel course (7 days) - mefloquine is contraindicated in pilots and those with neuropsychiatric side effects.
Diphtheria antitoxin must be given immediately - do not wait for culture results, as antitoxin only neutralises free (unbound) toxin and delays worsen outcomes from myocarditis and neuropathy.
Always screen for chronic Q fever in patients with prosthetic valves or valvular disease - chronic Q fever endocarditis requires 18 months of doxycycline plus hydroxychloroquine and is fatal if untreated.
Doxycycline is the universal first-line treatment for all rickettsial diseases - look for the pathognomonic tache noire eschar and a rash involving palms and soles.
Tularaemia from rabbit exposure presents as a painful ulcer with regional lymphadenopathy - alert the laboratory immediately as Francisella tularensis is highly infectious and requires BSL-3 containment.
Hepatitis E can become chronic in immunosuppressed patients - first reduce immunosuppression, then use ribavirin if viraemia persists beyond 3 months.
Always perform genotypic resistance testing while the patient is still on the failing ART regimen - stopping treatment allows wild-type virus to mask resistant mutations.
Over 90% of reported penicillin allergies are not true allergies - formal testing and delabelling allows access to first-line beta-lactams, and desensitisation is possible when penicillin is clinically essential.
Aminoglycoside trough levels must remain below 1 mg/L - elevated troughs indicate accumulation requiring interval extension, and renal function must be monitored every 48 hours.
Voriconazole is first-line for invasive aspergillosis - fluconazole has zero Aspergillus activity, and therapeutic drug monitoring of voriconazole is essential to ensure efficacy and avoid toxicity.
Differential time to positivity ≥2 hours between central and peripheral cultures confirms CRBSI - S. aureus and Candida always mandate line removal, while coagulase-negative staphylococci may allow retention with lock therapy.
Three sputum samples for AFB smear, culture, and NAAT are the first-line diagnostic investigations for pulmonary TB - Mantoux and IGRA cannot diagnose active disease per NICE NG33.
Oral vancomycin is first-line for C. difficile - stop the causative antibiotic, avoid loperamide, and implement strict infection control with chlorine-based cleaning.
Suspected HSE requires immediate IV aciclovir - temporal lobe changes on MRI are characteristic, and treatment must not be delayed for PCR results as mortality without treatment exceeds 70%.
EBV causes the amoxicillin rash in glandular fever - management is supportive, avoid contact sports for 6-8 weeks due to spleen risk, and Monospot confirms diagnosis.
Tetanus-prone wounds with uncertain vaccination history need both vaccine and immunoglobulin - thorough wound debridement is essential, and 5 doses of tetanus vaccine provide long-term protection.
CURB-65 ≥3 indicates severe CAP requiring IV antibiotics and ICU consideration - always send blood cultures and urinary antigens in severe disease per BTS/NICE NG138.
Kaposi sarcoma is driven by HHV-8 in the context of immunosuppression - starting ART is the single most important treatment, with chemotherapy reserved for advanced or refractory disease.
MAC prophylaxis starts at CD4 below 50 - treatment requires at least clarithromycin plus ethambutol, never monotherapy which promotes resistance.
NTM pulmonary disease requires the triad of symptoms, compatible radiology, and repeated positive cultures - a single isolate may represent contamination rather than true disease.
Parasitaemia above 2% defines severe falciparum malaria requiring IV artesunate - always request urgent malaria films in any febrile traveller returning from an endemic area.
Zika virus in pregnancy causes microcephaly and congenital brain abnormalities - first-trimester infection carries the highest risk, and no vaccine or antiviral is available.
Severe symmetrical polyarthralgia persisting for months is the hallmark of chikungunya - always test for both dengue and chikungunya in febrile returned travellers from endemic regions.
Most traveller's diarrhoea is self-limiting - oral rehydration plus loperamide for mild cases, reserving azithromycin for severe or bloody diarrhoea.
Returned traveller + RUQ pain + single right-lobe liver abscess + positive amoebic serology = amoebic liver abscess - metronidazole followed by a luminal amoebicide (diloxanide furoate) to prevent relapse; aspirate only if large, threatening rupture or non-responding.
Giardiasis causes steatorrhoea and bloating rather than bloody diarrhoea - metronidazole for 5 days is first-line, and post-infectious lactose intolerance may persist after treatment.
No antimicrobial reliably cures cryptosporidiosis in advanced HIV - immune reconstitution with ART is the definitive treatment, and oocysts resist standard water chlorination.
Always screen for Strongyloides before starting corticosteroids in patients from tropical endemic areas - hyperinfection carries over 70% mortality and is preventable with pre-treatment ivermectin.
Never aspirate a hydatid cyst without scolicidal agent and albendazole cover - rupture causes anaphylaxis and peritoneal seeding, and management depends on WHO cyst staging.
Always start anticonvulsants and corticosteroids before antihelminthic therapy in neurocysticercosis - treating cysts without steroid cover worsens cerebral oedema and can be fatal.
Massive splenomegaly with pancytopenia and reversed albumin-globulin ratio in a returned traveller from East Africa or South Asia is visceral leishmaniasis until proven otherwise.
Lumbar puncture is mandatory in all trypanosomiasis cases - CSF white cells above 5/μL or trypanosomes in CSF define stage 2 disease requiring CNS-penetrant treatment.
Tetanus-prone wounds in incompletely vaccinated patients require both a vaccine booster and human tetanus immunoglobulin - 3 doses alone without boosters do not confer long-term protection.
Brucellosis requires prolonged dual therapy (doxycycline plus streptomycin or rifampicin) for at least 6 weeks - monotherapy leads to unacceptable relapse rates exceeding 30%.
Any febrile patient with haemorrhagic features returning from a VHF-endemic area must trigger immediate HCID isolation - contact PHE Imported Fever Service urgently and do not wait for test results before implementing containment.
Oseltamivir should be started within 48 hours of symptom onset in at-risk patients - vaccination does not negate the benefit of antiviral treatment during confirmed influenza.
Ritonavir in Paxlovid is a potent CYP3A4 inhibitor - always check drug interactions before prescribing, especially with tacrolimus, ciclosporin, and other narrow therapeutic index drugs.
A single dose of hepatitis A vaccine provides protection within 2 weeks - give a booster at 6-12 months for long-term immunity lasting 25 years or more.
Prosthetic joint infection needs surgery plus prolonged antibiotics - oral therapy alone cannot eradicate biofilm on the implant.
Moderate-to-severe diabetic foot infections are polymicrobial - use broad-spectrum IV antibiotics covering Gram-positives, Gram-negatives, and anaerobes, and always involve the multidisciplinary diabetic foot team.
Nocturnal cough with marked eosinophilia and very high IgE in a patient from the Indian subcontinent is tropical pulmonary eosinophilia - microfilariae are absent from blood, and diethylcarbamazine produces dramatic improvement.
Legionella shows hyponatraemia and diarrhoea with pneumonia - urinary antigen is the rapid diagnostic test, and macrolides or fluoroquinolones are first-line (beta-lactams are ineffective).
Fourth-generation HIV tests are reliable from 45 days post-exposure - they detect p24 antigen and antibodies, enabling earlier diagnosis than antibody-only tests.
MRSA decolonisation uses nasal mupirocin plus chlorhexidine wash for 5 days before elective surgery - systemic antibiotics are not needed for colonisation, but surgical prophylaxis must cover MRSA.
Doxycycline 7 days is first-line for chlamydia (not azithromycin single dose) - partner notification is essential, and untreated infection in women risks PID and infertility.
Known hepatitis B vaccine responders (anti-HBs ≥10) need a booster but not HBIG after exposure - non-responders and unvaccinated require HBIG within 48 hours plus vaccination.
Scarlet fever shows sandpaper rash with strawberry tongue - penicillin V for 10 days is first-line, it is notifiable, and post-streptococcal complications include glomerulonephritis and rheumatic fever.
CMV disease requires IV ganciclovir - pre-emptive monitoring with CMV PCR guides treatment, 'owl-eye' inclusions are pathognomonic, and aciclovir is ineffective against CMV.
Blood cultures are most sensitive in week 1-2 of typhoid - relative bradycardia and rose spots are classical features, and azithromycin is first-line due to fluoroquinolone resistance.
Rabies PEP includes wound washing, immunoglobulin into the wound, and a 5-dose vaccine course - once symptoms develop, rabies is almost 100% fatal, making PEP urgently life-saving.
Norovirus outbreaks need ward closure, chlorine-based cleaning, and soap and water hand hygiene (alcohol gel is ineffective) - staff must stay away for 48 hours after symptoms resolve.
PrEP with tenofovir/emtricitabine reduces HIV acquisition by >85% - it is available on the NHS for high-risk individuals, with 3-monthly HIV testing and renal monitoring required.
Prosthetic valve endocarditis requires ≥6 weeks of combination antibiotics - add rifampicin after bacteraemia clears for biofilm activity, and surgical intervention is needed for complications.
IM ceftriaxone 1g single dose is first-line for gonorrhoea - treat concurrent chlamydia with doxycycline, and always perform test of cure at 2 weeks per BASHH.
Disseminated zoster in immunocompromised patients requires IV aciclovir and isolation - visceral dissemination carries significant mortality, and exposed non-immune contacts may need VZIG.
Young infants with pertussis need hospital admission - azithromycin is first-line, marked lymphocytosis is characteristic, and maternal vaccination is the key preventive strategy.
Noradrenaline is first-line for septic shock targeting MAP ≥65mmHg - escalate to critical care, and consider hydrocortisone for vasopressor-refractory shock.
Primary syphilis requires IM benzathine penicillin single dose - the painless chancre heals spontaneously but infection persists without treatment, and RPR titre monitors treatment response.
Co-trimoxazole PCP prophylaxis is started when CD4 <200 cells/µL - it can be stopped after CD4 >200 for ≥3 months on ART, and it also covers toxoplasmosis.
Fever in a returning traveller - exclude malaria with urgent blood films within 1 hour, thrombocytopenia makes malaria the most likely diagnosis, and three films are needed to exclude it.
Measles requires urgent public health notification - Koplik spots are pathognomonic, MMR within 72 hours protects exposed contacts, and pneumonia is the leading cause of measles mortality.
Transfusion-dependent thalassaemia + ferritin >1000 + cardiac T2* <20ms = aggressive iron chelation - deferasirox is first-line oral therapy; cardiac T2* <10ms requires intensified or combination chelation.
CAR T-cell therapy + fever + hypotension within days = cytokine release syndrome - tocilizumab (anti-IL-6R) is the specific treatment; CRS occurs in most patients and requires vigilant monitoring.
Massive splenomegaly + leukoerythroblastic film with dacrocytes + dry tap + reticulin fibrosis + JAK2/CALR/MPL mutation = primary myelofibrosis - ruxolitinib reduces splenomegaly and symptoms; allo-HSCT is the only cure.
Neonatal severe thrombocytopenia + normal maternal platelets + anti-HPA-1a = NAIT - IVIG and HPA-compatible platelets; ICH risk is 10-20%; unlike HDN, can occur in first pregnancy.
Wells score ≥2 (likely DVT) goes directly to ultrasound - D-dimer is used to exclude DVT in low-probability patients only per NICE NG158.
MGUS has ~1% annual progression risk to myeloma - regular monitoring of paraprotein, FBC, calcium, and renal function is essential, with treatment reserved for progression.
Sickle cell VOC requires opioid analgesia within 30 minutes per NICE CG143 - always assess for acute chest syndrome and avoid pethidine.
ALL is the commonest childhood malignancy peaking at age 2-5 - bone pain with pancytopenia and blast cells should prompt urgent haematology referral.
Sideroblastic anaemia shows ring sideroblasts with microcytosis but iron overload - the dimorphic film is characteristic, and MDS-RS is the commonest acquired cause in the elderly.
AL amyloidosis with cardiac involvement is treated by targeting the plasma cell clone (bortezomib-based, e.g. Dara-CyBorD per the ANDROMEDA trial), with autologous transplant only in selected fit patients - not supportive care alone.
Persistent fever + pancytopenia + hyperferritinaemia (>10,000) + hepatosplenomegaly + haemophagocytosis = HLH - etoposide + dexamethasone is the standard induction protocol; EBV is the most common infectious trigger.
ABO incompatibility causes AHTR within minutes - stop the transfusion immediately, investigate, and report to SHOT - most cases result from identification errors.
FNHTR is the commonest transfusion reaction - stop the transfusion, give paracetamol, and always exclude acute haemolytic reaction or bacterial contamination before restarting.
>25% elliptocytes on blood film + autosomal dominant inheritance + mild compensated haemolysis = hereditary elliptocytosis - most patients are asymptomatic and need no treatment.
Isolated severe anaemia + absent reticulocytes + absent erythroid precursors + thymoma = autoimmune PRCA - corticosteroids ± ciclosporin is first-line; for parvovirus B19, use IVIG.
CD5+ CD23− B-cell lymphoma + cyclin D1+ + t(11;14) = mantle cell lymphoma - aggressive treatment with cytarabine-based regimen and auto-SCT consolidation for fit patients.
Asymptomatic follicular lymphoma + low tumour burden + advanced stage = watch-and-wait - no survival benefit from immediate treatment; initiate therapy only when clinically indicated.
Burkitt + bulky disease + high LDH/urate = high-risk TLS - start IV fluids and rasburicase before chemotherapy; avoid surgery; >90% cure with intensive paediatric protocols (BSH 2015 TLS guidance, CCLG).
Nodular glomerulosclerosis + linear kappa light chain deposition + Congo red negative = LCDD - distinguished from AL amyloidosis by negative Congo red and kappa (not lambda) predominance.
DAT C3d positive + IgG negative + high cold agglutinin titre + acrocyanosis = cold agglutinin disease - rituximab is first-line (not steroids or splenectomy); sutimlimab is a new complement-targeted option.
Aortic stenosis + GI bleeding from angiodysplasia + loss of HMW VWF multimers = Heyde syndrome (acquired VWS) - aortic valve replacement is the definitive treatment.
Prolonged APTT + does not correct on mixing + confirmed by phospholipid neutralisation = lupus anticoagulant - warfarin (not DOACs) is the anticoagulant of choice for APS-related thrombosis.
Unprovoked VTE + prothrombin G20210A = consider extended anticoagulation - the decision is individualised based on recurrence risk vs bleeding risk assessment.
Critical hypofibrinogenaemia (fibrinogen <1.5g/L in major haemorrhage, <2.0g/L in obstetric haemorrhage) = cryoprecipitate (2 pools) - it contains concentrated fibrinogen, factor VIII, XIII, and VWF.
Granulocyte transfusion is reserved for life-threatening infections failing antimicrobials + prolonged severe neutropenia + no imminent marrow recovery - not for routine neutropenic fever.
Acute respiratory distress within 6 hours of transfusion + bilateral infiltrates + hypotension + normal BNP = TRALI - supportive care (oxygen, ventilation); diuretics are ineffective unlike in TACO.
Fever + rash + diarrhoea + liver dysfunction + pancytopenia 8-30 days post-transfusion = TA-GvHD - >90% fatal; prevention with irradiated blood products is essential; Hodgkin lymphoma patients always need irradiated products.
Severe or deteriorating acute chest syndrome (hypoxia, falling Hb, high HbS%) warrants urgent exchange transfusion to bring HbS below 30% (BSH/NHSBT guidance).
Pre-splenectomy = vaccinate ≥2 weeks before surgery (pneumococcal PCV13/PPV23, MenACWY/B, Hib, annual influenza); post-splenectomy = lifelong penicillin V + alert card + patient education; OPSI is the most important preventable complication.
TACO is the leading cause of transfusion death in the UK - elevated BNP distinguishes it from TRALI, and single-unit transfusion with diuretics prevents it in at-risk patients.
Continue oral iron for 3 months after Hb normalises to replenish stores - a reticulocyte peak at 7-10 days confirms response to therapy.
Beta-thalassaemia major presents at 6-12 months with severe anaemia and absent HbA - lifelong transfusions require iron chelation to prevent organ damage.
Alpha-thalassaemia trait shows microcytosis with normal Hb electrophoresis - DNA testing confirms diagnosis, and partner screening is vital in pregnancy.
TTP requires emergency plasma exchange - platelet transfusion is contraindicated, and normal coagulation distinguishes TTP from DIC.
Cast nephropathy is the commonest renal complication of myeloma - urine dipstick misses light chains, and aggressive hydration with rapid chemotherapy initiation is key.
Minor bleeding with high INR - stop warfarin and give oral vitamin K; major bleeding - IV vitamin K plus prothrombin complex concentrate for immediate reversal.
Neutropenic sepsis requires IV broad-spectrum antibiotics within 60 minutes per NICE CG151 - piperacillin-tazobactam is first-line empirical monotherapy.
TRALI shows non-cardiogenic pulmonary oedema within 6 hours of transfusion - normal BNP and no fluid overload distinguish it from TACO, and male-only plasma policies have reduced incidence.
Hydroxycarbamide is teratogenic - stop immediately in pregnancy, continue high-dose folic acid and penicillin, and manage in a specialist multidisciplinary setting per RCOG guidelines.
Irradiated blood products prevent fatal TA-GvHD - Hodgkin lymphoma requires irradiated products lifelong, and purine analogue recipients need them during and after treatment.
Acute chest syndrome requires exchange transfusion, IV antibiotics, and oxygen - it is the leading cause of death in adult sickle cell disease.
Childhood ITP is usually self-limiting - treat bleeding symptoms, not the platelet count, and 70-80% resolve spontaneously within 6 months.
CML is driven by BCR-ABL1 from t(9;22) - imatinib TKI is first-line, transforming prognosis from fatal to chronic disease with near-normal life expectancy.
Type 1 vWD responds to DDAVP which releases endothelial vWF stores - always perform a trial dose, and use vWF-containing concentrates for major surgery or DDAVP failure.
DHTR occurs 5-14 days post-transfusion from anamnestic alloantibodies - Kidd system antibodies are the classic culprits, and maintaining antibody records prevents recurrence.
Pernicious anaemia requires lifelong IM B12 replacement - anti-intrinsic factor antibodies are highly specific, and atrophic gastritis carries increased gastric cancer risk.
Cryoprecipitate targets fibrinogen >1.5g/L in DIC - fibrinogen is the first factor depleted and the best predictor of haemorrhagic progression.
DIC shows prolonged PT/APTT, low fibrinogen, very elevated D-dimer, and low platelets - treat the cause and replace consumed components.
Typical HUS in children follows E. coli O157 - management is supportive, antibiotics worsen toxin release, and plasma exchange is not indicated unlike in TTP.
Severe renal impairment (eGFR <30) limits DOAC options - warfarin remains a safe choice, apixaban is the most renal-friendly DOAC, and regular renal monitoring is essential.
Hydroxycarbamide increases HbF and reduces sickle crises by ~50% - it is first-line disease modification for recurrent crises, with mandatory FBC monitoring and contraception.
DAT positive for IgG at 37°C = warm AIHA - prednisolone 1mg/kg is first-line; never withhold transfusion in life-threatening anaemia despite difficult cross-matching.
Gastric MALT lymphoma + H. pylori positive + localised stage = eradicate H. pylori first - 60-80% achieve lymphoma remission with antibiotics alone.
Emergency with DOAC - calibrated anti-Xa assay for Xa inhibitors, dTT for dabigatran; andexanet alfa reverses Xa inhibitors, idarucizumab reverses dabigatran; always check renal function and drug interactions.
DAT-positive haemolytic anaemia + immune thrombocytopenia + no schistocytes + normal ADAMTS13 = Evans syndrome - rituximab is the most effective second-line treatment after corticosteroids.
History of HIT + needs parenteral anticoagulation = fondaparinux (negligible HIT antibody cross-reactivity) or argatroban - never re-expose to any heparin including LMWH.
Transfusion-dependent thalassaemia needs annual cardiac MRI T2* and endocrine surveillance (growth, thyroid, glucose) to detect iron overload - cardiac iron is the leading cause of mortality (UK Thalassaemia Society standards).
Relapsed chemosensitive DLBCL in remission = autologous SCT; allogeneic SCT is reserved for conditions requiring graft-versus-malignancy effect (AML, MDS, aplastic anaemia) or post-autologous relapse.
Cytopenias + dysplastic morphology + increased blasts + complex cytogenetics = high/very high-risk MDS - azacitidine improves survival; allogeneic HSCT is the only cure.
Morning haemoglobinuria + pancytopenia + unusual site thrombosis + absent CD55/CD59 = PNH - eculizumab is the treatment of choice; vaccinate against meningococcus first.
Schistocytes + thrombocytopenia + normal coagulation + ADAMTS13 <10% = TTP - plasma exchange is the emergency treatment; platelet transfusion is contraindicated.
Painful purpuric skin necrosis on days 3-5 of warfarin + protein C deficiency = warfarin-induced skin necrosis - stop warfarin, give heparin and protein C concentrate; always bridge with heparin when starting warfarin.
IgM paraprotein + hyperviscosity symptoms + MYD88 L265P = Waldenström macroglobulinaemia - plasma exchange urgently for hyperviscosity; do not give rituximab without addressing hyperviscosity first (risk of IgM flare).
Basophilic stippling + microcytic anaemia + abdominal colic + elevated blood lead + elevated FEP = lead poisoning - chelation with DMSA is first-line for blood lead ≥45µg/dL in children.
Infant <1 year + macrocytic anaemia + absent reticulocytes + physical anomalies + elevated eADA = Diamond-Blackfan anaemia - elevated eADA distinguishes it from transient erythroblastopenia of childhood.
MAHA + renal failure + normal ADAMTS13 + low C3 + anti-factor H antibodies = atypical HUS (complement-mediated TMA) - eculizumab is the treatment of choice.
Massive PE with haemodynamic compromise = systemic thrombolysis with alteplase - do not delay; in cardiac arrest with suspected PE, give 50mg alteplase bolus and continue CPR.
Myelofibrosis shows tear-drop cells, dry tap, and leukoerythroblastic film - ruxolitinib improves symptoms and splenomegaly (COMFORT trials), but only allogeneic transplant is curative.
Always check B12 before treating folate deficiency - giving folate without B12 risks precipitating subacute combined degeneration of the cord.
Gambling disorder requires CBT, self-exclusion tools, and financial counselling - always assess suicide risk, as it is significantly elevated, and treat comorbid depression alongside the gambling-specific interventions.
Moderate intellectual disability (IQ 35-49) allows basic communication and self-care with support - always provide annual health checks, reasonable adjustments, and person-centred care planning.
Tic disorders are classified by type (motor/vocal) and duration (less or more than 1 year) - most childhood tics are transient, and reassurance with monitoring is appropriate before diagnosing Tourette syndrome.
Selective mutism is an anxiety disorder, not defiance - children want to speak but cannot due to overwhelming anxiety; graded exposure with stimulus fading is the core treatment approach.
Separation anxiety disorder involves excessive anxiety about separation from attachment figures causing functional impairment - it is distinct from school phobia (fear of school itself) and truancy (non-anxious absence).
School refusal is anxiety-driven (child stays home with parental knowledge and shows distress) - truancy is conduct-driven (child's whereabouts unknown, no anxiety); early multiagency intervention with graded reintegration is essential.
Conduct disorder involves serious rule violations including aggression, destruction, and theft - distinguish from ODD which is defiant but less severe; callous-unemotional traits predict poorer outcomes.
EMDR uses bilateral stimulation during trauma memory processing - it does not require detailed verbal trauma narrative and is equally recommended alongside trauma-focused CBT by NICE for PTSD treatment.
Motivational interviewing uses empathy, discrepancy, and autonomy support to resolve ambivalence - direct confrontation increases resistance, while MI elicits the patient's own motivation for change through reflective listening.
Group therapy for social anxiety provides a natural, safe environment for in-vivo exposure and interpersonal learning - therapeutic factors including universality and cohesiveness offer unique benefits beyond individual treatment.
Unexplained tachycardia with raised troponin and CRP in the first 6 weeks of clozapine suggests myocarditis - stop clozapine immediately, as this complication is potentially fatal if unrecognised.
Fluoxetine's active metabolite (norfluoxetine) has a half-life of up to 16 days - always allow an adequate washout (1-2 weeks minimum) before starting another serotonergic drug to prevent serotonin syndrome.
Section 17 leave is granted solely by the responsible clinician with conditions - the patient remains detained and recallable; for restricted patients (s37/41), Ministry of Justice approval is additionally required.
The AMHP makes the application for detention using independent professional judgement - they are not bound by doctors' recommendations and must consider the least restrictive alternative before applying for compulsory admission.
A CTO can only be made from an existing Section 3 (or equivalent qualifying detention) - it cannot be applied to informal patients.
DBT is the evidence-based treatment for emotionally unstable personality disorder per NICE CG78 - medication has a limited role, avoid polypharmacy, and long-term inpatient stays are generally unhelpful.
Section 3 is for treatment when diagnosis is known (up to 6 months, renewable) - it requires established diagnosis, treatment plan, SOAD review at 3 months, and entitles patients to Section 117 aftercare.
Section 117 aftercare is free and cannot be charged for - it applies to patients detained under Section 3, is jointly funded by NHS and local authority, and continues until formally discharged at review.
Postnatal depression is screened with EPDS - CBT/guided self-help is first-line, sertraline is preferred if breastfeeding, and distinguish from 'baby blues' (self-limiting within 2 weeks) per NICE CG192.
Psychodynamic therapy uses transference interpretation to bring unconscious relational patterns into awareness - it is indicated for treatment-resistant depression and personality difficulties where early relational experiences are central to the formulation.
Valproate causes 10% major malformations and 30-40% neurodevelopmental disorders - all women of childbearing potential must be on the PREVENT programme with effective contraception and annual specialist review.
ASD requires deficits in both social communication AND restricted/repetitive behaviours from early development - multidisciplinary assessment is recommended per NICE CG128, and hearing must be tested.
Trauma-focused CBT or EMDR is first-line for PTSD per NICE NG116 - SSRIs are second-line, psychological debriefing is harmful, and alcohol misuse must be addressed concurrently.
NMS = hyperthermia + rigidity + altered consciousness + CK elevation - stop the antipsychotic, ICU care, dantrolene/bromocriptine, and IV fluids to prevent myoglobinuric renal failure.
Health anxiety is maintained by a cycle of misinterpretation, anxiety, checking, and temporary reassurance - CBT breaks this cycle, while repeated investigations paradoxically worsen the condition.
Prolonged grief disorder is diagnosed when grief persists beyond 12 months with intense yearning and significant functional impairment - it is distinct from normal bereavement and responsive to grief-focused psychological therapy.
The nearest relative is determined by statutory hierarchy with spouse/civil partner at the top - they have the right to be consulted, to object to Section 3, and to apply for discharge, making this a powerful legal role under the MHA.
Alcohol withdrawal requires a reducing chlordiazepoxide regimen plus IV Pabrinex per NICE CG115 - monitor with CIWA-Ar, and delirium tremens peaks at 48-72 hours with significant mortality risk.
Acute dystonia (oculogyric crisis, torticollis) from antipsychotics is treated with IV/IM procyclidine - it occurs within 72 hours, is commoner with high-potency typical antipsychotics in young males.
Alcohol hallucinosis features hallucinations with clear consciousness - delirium tremens involves clouded consciousness with autonomic instability; the key differentiator is preserved orientation and sensorium in hallucinosis.
rTMS is a non-invasive, non-seizure-inducing brain stimulation technique for treatment-resistant depression - it targets the left DLPFC and is an outpatient procedure with a mild side-effect profile.
Lithium carries a small risk of Ebstein anomaly (1 in 1000) - stopping in severe bipolar may be riskier than continuing; always offer fetal echocardiography and increase monitoring frequency during pregnancy.
Fluoxetine is the only first-line antidepressant for under-18s - always try psychological therapy first, start at a low dose, and monitor weekly for the first 4 weeks for emergent suicidal ideation.
Do not offer debriefing or routine early therapy after trauma per NICE NG116 - provide practical support, normalise the response, and review at 1 month to identify those who need treatment.
All self-harm presentations require a psychosocial assessment by a mental health professional before discharge per NICE NG225 - never discharge without formal assessment regardless of apparent severity, and do not rely on risk-stratification scales.
Acamprosate or naltrexone are first-line for alcohol relapse prevention per NICE CG115 - combine with psychosocial intervention, and disulfiram is an alternative requiring supervised administration.
Venlafaxine causes dose-dependent hypertension - monitor blood pressure at baseline and regularly, especially above 200mg, and the drug has greater toxicity in overdose than SSRIs.
CBT is first-line for panic disorder per NICE CG113 - SSRI is the pharmacological alternative, and benzodiazepines are not recommended as they impair exposure therapy outcomes.
First-episode psychosis requires an oral atypical antipsychotic at low dose per NICE CG178 - refer to EIP services, and clozapine is only for treatment-resistant cases.
Negative symptoms require psychosocial rehabilitation as the mainstay - consider aripiprazole, exclude secondary causes (depression, over-medication), and do not simply increase antipsychotic dose.
Severe anorexia nervosa with medical instability requires MARSIPAN-guided admission - assess BMI, bradycardia, electrolytes, and temperature, and no medication treats the core eating disorder.
Wernicke encephalopathy requires IV Pabrinex BEFORE glucose - the classic triad (confusion, ophthalmoplegia, ataxia) is present in only 10-16%, and untreated cases progress to irreversible Korsakoff syndrome.
CTOs allow conditional community discharge from Section 3 - conditions include medication and engagement, patients can be recalled for 72 hours, and the OCTET trial questioned their effectiveness.
Serotonin syndrome (clonus, hyperreflexia, agitation, hyperthermia) results from serotonergic drug interactions - stop the drugs, give cyproheptadine for severe cases, and tramadol + SSRI is a common culprit combination.
Mirtazapine is ideal for depression with insomnia and poor appetite - sedation and appetite stimulation are greater at 15mg than higher doses, and it has antiemetic properties via 5-HT3 antagonism.
Olanzapine carries the highest metabolic risk - monitor weight, glucose, and lipids per NICE CG178, consider switching to aripiprazole, and treat each cardiovascular risk factor proactively.
Benzodiazepine withdrawal requires gradual reduction over weeks to months - convert to diazepam (long half-life), reduce by ~10% every 1-2 weeks, and never stop abruptly due to seizure risk.
Graded exposure therapy is first-line for specific phobias with >80% response rates - medications are generally unnecessary, and avoidance reinforces the phobia.
Individual CBT (Clark and Wells model) is first-line for social anxiety disorder per NICE CG159 - SSRI is second-line, and beta-blockers address only peripheral symptoms.
Section 5(2) is a 72-hour doctor's holding power for voluntary inpatients - any doctor can apply it, it does not authorise treatment, and formal MHA assessment must be arranged promptly.
Persistent physical symptoms require empathic acknowledgement, collaborative explanation, regular scheduled GP visits, and CBT - avoid dismissing symptoms or ordering unnecessary investigations.
TCA overdose with QRS >100ms requires IV sodium bicarbonate - the R wave in aVR >3mm is a specific toxicity marker, and TCAs are one of the most lethal drugs in overdose.
Clozapine is indicated after failure of two adequate antipsychotic trials per NICE CG178 - mandatory blood monitoring for agranulocytosis, and allow 6-9 months at therapeutic plasma levels.
Bulimia nervosa treatment follows NICE NG69 - guided self-help first, then CBT-ED, with fluoxetine 60mg as adjunctive pharmacotherapy if needed.
Refeeding syndrome is characterised by acute hypophosphataemia - replace electrolytes urgently, reduce caloric intake, monitor ECG, and start refeeding slowly in malnourished patients per NICE CG32.
NICE recommends trauma-focused CBT or EMDR as first-line for PTSD - single-session psychological debriefing is harmful and should not be offered.
HoNOS is a clinician-rated 12-item outcome measure covering behaviour, symptoms, impairment, and social functioning - it is mandated in NHS mental health services for routine outcome measurement and service evaluation.
Non-pharmacological interventions are first-line for delirium - review deliriogenic medications (opioids, anticholinergics, benzodiazepines), and use haloperidol only as a last resort per NICE CG103.
NSAIDs precipitate lithium toxicity by reducing renal clearance - stop lithium, IV fluids, and consider haemodialysis for levels >3.0mmol/L or severe neurotoxicity.
Clozapine neutrophil monitoring uses traffic-light thresholds (BNF/CPMS) - green ≥2.0, amber 1.5-2.0 (continue with twice-weekly FBC), red <1.5 (stop and do not rechallenge); benign ethnic neutropenia needs modified thresholds.
Lithium monitoring requires renal, thyroid, and calcium checks - target 0.6-0.8mmol/L measured 12 hours post-dose, NSAIDs increase lithium levels, and long-term risks include CKD and hypothyroidism.
BDD is treated with CBT adapted for BDD and high-dose SSRIs - cosmetic surgery is contraindicated as it almost never resolves the underlying psychological disturbance.
FND is diagnosed by positive signs of internal inconsistency (Hoover sign, give-way weakness) - it is not a diagnosis of exclusion, and patients are genuinely distressed by their symptoms.
Eyes tightly closed during a seizure-like event strongly suggests PNES - video-EEG is the diagnostic gold standard, and anti-epileptic drugs should be withdrawn as they are ineffective and carry unnecessary side effects.
Malingering is distinguished by clear external motivation (financial, legal) - factitious disorder is for the sick role, and FND involves genuinely experienced symptoms with internal inconsistency.
Adjustment disorder fills the diagnostic gap between normal stress responses and full psychiatric disorders - symptoms are linked to a stressor and usually resolve within 6 months of the stressor ending.
Impaired mother-infant bonding requires specific intervention beyond treating maternal depression - video interaction guidance and parent-infant psychotherapy directly target the relationship and improve outcomes for both mother and child.
Delusional disorder features isolated non-bizarre delusions with preserved functioning - the jealous subtype (Othello syndrome) carries a high risk of violence towards the partner and requires thorough risk assessment.
CAT uses reformulation letters and diagrams to map reciprocal role patterns from childhood relationships - it is time-limited (16-24 sessions) and integrates cognitive and psychoanalytic approaches.
FII is child abuse - initiate safeguarding procedures immediately when suspected, do not confront the carer before ensuring the child's safety, and follow local safeguarding protocols and statutory duties.
Antenatal anxiety requires active identification and treatment, not deferral - NICE recommends specialist perinatal mental health referral, CBT as first-line, and sertraline as the preferred SSRI if medication is needed in pregnancy.
Isolated choroid plexus cysts with low-risk screening = benign, reassure; they are associated with trisomy 18 only when multiple other abnormalities coexist.
Macrosomia with GDM = increased shoulder dystocia risk - individualised delivery discussion including vaginal delivery, induction, or caesarean; EFW >4.5kg in diabetes is high risk.
Bartholin abscess - marsupialisation or Word catheter for drainage and recurrence prevention; simple I&D has high recurrence; consider biopsy/excision in women >40.
Vulval SCC >1mm depth = wide local excision + sentinel lymph node biopsy; GROINSS-V supports SLNB over full lymphadenectomy to reduce morbidity.
Primary vaginal SCC - chemoradiotherapy is the standard treatment; surgery only for early superficial upper vaginal lesions; must exclude secondary spread from cervix or endometrium.
POP-Q staging by distance from hymen: Stage II = within 1cm of hymen; Stage III = >1cm below but not fully everted; Stage IV = complete eversion.
Since 2005, UK donor-conceived individuals can access identifying donor information at age 18 - early disclosure to children is strongly recommended but not legally required.
Suspected trafficking - see the patient alone with a professional interpreter; never use the accompanying person; refer via the National Referral Mechanism; treat regardless of immigration status.
Unfavourable cervix (Bishop <6) = cervical ripening with prostaglandin E2 or oral misoprostol first; oxytocin after amniotomy; avoid prostaglandins in previous caesarean.
PPH uterotonic escalation: oxytocin → ergometrine → carboprost → misoprostol, plus early tranexamic acid; then mechanical/surgical options; hysterectomy is last resort.
Methotrexate for ectopic: hCG <5000, no fetal heartbeat, mass <35mm, stable patient, able to follow up - hCG must fall ≥15% between days 4-7 post-treatment.
Placental abruption presents with constant pain and a woody-hard uterus - fibrinogen <2g/L indicates developing DIC, and emergency delivery is required for fetal compromise.
Combined test risk ≥1:150 is higher risk - offer NIPT or diagnostic testing (CVS/amniocentesis) with counselling, and NIPT requires diagnostic confirmation if positive as it remains a screening test.
PCOS requires ≥2 of 3 Rotterdam criteria after excluding other causes - always screen for metabolic complications including insulin resistance and diabetes, and exclude congenital adrenal hyperplasia with 17-hydroxyprogesterone.
Congenital CMV = most common congenital infection - sensorineural hearing loss is the most common sequela, may be late-onset; low IgG avidity confirms primary infection.
Double-bubble sign + polyhydramnios = duodenal atresia - associated with trisomy 21 in 30%, so offer karyotyping; neonatal surgical repair is curative.
Absent end-diastolic flow = admit, steroids, close monitoring; deliver if reversed end-diastolic flow or abnormal ductus venosus/CTG; TRUFFLE guides timing.
APS is the most important treatable cause of recurrent miscarriage - test for lupus anticoagulant, anticardiolipin, and anti-beta-2 GP1; treatment with aspirin + LMWH dramatically improves outcomes.
pathological CTG (reduced variability + recurrent late decelerations) → consider FBS lactate per NICE NG229; lactate ≥4.9 mmol/L means deliver; expedite immediately if acute compromise or FBS not feasible.
Sudden collapse + seizure + DIC during labour/amniotomy = amniotic fluid embolism - supportive management with aggressive resuscitation and blood products; no specific treatment exists.
IM ceftriaxone 1g is first-line for gonorrhoea per BASHH - ciprofloxacin resistance exceeds 30% in the UK, test of cure is mandatory at 2 weeks, and emerging cephalosporin resistance is a global concern.
Peripartum cardiomyopathy = new heart failure in the last month of pregnancy to 5 months postpartum with LVEF <45% - avoid ACE inhibitors during pregnancy; ~50% recover LV function.
Domestic abuse = document, risk assess, safety plan, signpost to IDVA/MARAC; respect patient autonomy regarding police; never confront the abuser or see them together.
TTTS = polyhydramnios in recipient + oligohydramnios in donor in monochorionic twins - fetoscopic laser ablation is the definitive treatment for Stage II-IV.
ECV at 36-37 weeks with tocolysis is first-line for breech - ~50% success in nulliparous; if it fails, counsel about caesarean vs vaginal breech delivery.
RAADP at 28 weeks (single or two-dose) for Rh-negative women with Rh-positive fetus - cell-free fetal DNA now guides who needs prophylaxis.
Female sterilisation failure rate ~1 in 200 - actually LESS effective than LNG-IUS or implant; always counsel about LARC alternatives and ectopic pregnancy risk.
Give anti-D within 72 hours of any sensitising event in RhD-negative women - RAADP at 28 weeks is routine, and a Kleihauer test is required after 20 weeks to quantify feto-maternal haemorrhage.
APS is the key treatable cause of recurrent miscarriage - aspirin plus LMWH from early pregnancy improves live birth rates to 70-80%, and warfarin is contraindicated in pregnancy due to teratogenicity.
Severe pre-eclampsia requires IV labetalol for BP, IV magnesium sulphate for seizure prophylaxis per MAGPIE trial, corticosteroids if preterm, and planned delivery - aspirin 150mg from 12 weeks prevents pre-eclampsia in high-risk women.
IV magnesium sulphate is first-line for eclampsia per the MAGPIE trial - calcium gluconate is the antidote for magnesium toxicity, and delivery should be expedited after maternal stabilisation.
GDM targets are fasting <5.3 and 1-hour <7.8 - metformin is first-line pharmacotherapy per NICE NG3, and delivery timing depends on treatment escalation level.
PPH from uterine atony is managed stepwise - rubbing up the fundus, oxytocin, ergometrine, carboprost, then surgical options - the WOMAN trial showed IV tranexamic acid reduces mortality.
Desogestrel POP is preferred for women with migraine with aura or during breastfeeding - it has a 12-hour missed pill window and inhibits ovulation, unlike traditional levonorgestrel POPs.
The copper IUD is the most effective emergency contraception and provides immediate long-term contraception - it can be inserted up to 5 days after estimated ovulation, and the levonorgestrel IUS is not approved for emergency use.
Primary genital herpes in the third trimester requires caesarean delivery due to 40% neonatal transmission risk - suppressive aciclovir from 36 weeks is recommended, and recurrent herpes carries much lower risk (<3%).
Letrozole is increasingly first-line for PCOS ovulation induction - it has higher live birth rates and lower multiple pregnancy rates than clomifene, and 5-10% weight loss can restore ovulation.
CVS from 11 weeks vs amniocentesis from 15 weeks - earlier diagnosis is the key advantage; watch for confined placental mosaicism as a potential false positive.
Ectopic pregnancy shows an adnexal mass with empty uterus on TVS - risk factors include previous STIs and IUD, and management depends on beta-hCG level and clinical stability per NICE NG126.
The PRISM trial supports vaginal progesterone for threatened miscarriage in women with previous miscarriage - NNT is 10 for those with ≥3 previous losses, and bed rest has no proven benefit.
Category 1 caesarean targets delivery within 30 minutes for immediate life threat - prolonged fetal bradycardia >3 minutes without recovery mandates urgent delivery, and instrumental delivery requires full dilatation with vertex at/below spines.
Diagnose menopause clinically in women ≥45 with typical symptoms - FSH is unreliable and unnecessary per NICE NG23, and FSH is only needed for women under 45 or after hysterectomy.
PPROM is managed with erythromycin for 10 days (NOT co-amoxiclav per ORACLE trial), corticosteroids, and expectant management - digital vaginal examination is contraindicated, and chorioamnionitis mandates delivery.
IVF steps = stimulate → collect → fertilise → transfer → support; single embryo transfer to reduce multiples; ~30-35% success rate per cycle under 35.
Major placenta praevia requires caesarean at 36-37 weeks - assess for placenta accreta in women with prior caesarean sections, and always have cross-matched blood available.
Endometriosis presents with the triad of dysmenorrhoea, deep dyspareunia, and dyschezia - ultrasound detects endometriomas, MRI maps deep disease, and laparoscopy is no longer mandatory for diagnosis per NICE NG73.
HELPERR = Help, Episiotomy, Legs McRoberts, Pressure suprapubic, Enter rotate, Remove arm, Roll - NEVER apply fundal pressure in shoulder dystocia.
Non-immune pregnant woman exposed to varicella = VZIG within 10 days; if rash develops ≥20 weeks, aciclovir within 24 hours; vaccine is contraindicated in pregnancy.
BPP 8/10 is usually reassuring EXCEPT when oligohydramnios is the abnormal parameter - this indicates chronic compromise and requires further evaluation or delivery.
Post-mortem + placental histology are the most valuable investigations for stillbirth - offer sensitively; Kleihauer test for fetomaternal haemorrhage is an important often-missed cause.
Cervical ectropion = columnar epithelium on ectocervix - benign, common with COCP; treat with cryotherapy if symptomatic; always ensure screening is up to date.
Urodynamics before surgery - involuntary detrusor contractions = detrusor overactivity; treat OAB first if no urodynamic stress incontinence is confirmed on testing.
Shoulder dystocia requires McRoberts position and suprapubic pressure first - NEVER apply fundal pressure, and the HELPERR mnemonic guides the sequence of escalating manoeuvres.
POI requires FSH >25 on two occasions ≥4 weeks apart before age 40 - HRT until age 51 is essential for bone and cardiovascular protection, and autoimmune screening is recommended.
Vasectomy - semen analysis at 12 weeks or after 20 ejaculations; azoospermia confirms success; continue contraception until clearance received.
Absent fundus abdominally + mass at introitus + shock = uterine inversion - Johnson manoeuvre for manual reduction; do NOT remove placenta before reducing.
Sudden pain + ceased contractions + easily palpable fetal parts + fetal bradycardia during VBAC = uterine rupture - immediate laparotomy is life-saving.
Postpartum sepsis with foul lochia + uterine tenderness = endometritis - Sepsis Six within 1 hour; Group A strep is the most dangerous cause.
Parvovirus B19 in pregnancy = fetal anaemia and hydrops risk from red cell aplasia - monitor with MCA Doppler; treat with intrauterine transfusion if severe.
≥3 second-trimester losses or ≥1 with short cervix = history-indicated cerclage at 12-14 weeks; this patient has 2 losses plus short cervix, meeting criteria.
Pessary review every 4-6 months - inspect for erosion/ulceration, co-prescribe topical oestrogen; self-management is an option for suitable patients.
In UK surrogacy, the surrogate is the legal mother at birth - intended parents need a parental order within 6 months; surrogacy agreements are not enforceable; only altruistic surrogacy is legal.
Sexual assault - patient's safety, wellbeing, and consent are paramount; police reporting is NOT mandatory for adults; SARCs provide integrated forensic and medical care.
Face presentation - mento-anterior can deliver vaginally; mento-posterior requires caesarean section; ventouse is contraindicated in face presentation.
VBAC success ~72-75% with ~0.5% rupture risk for one previous LSCS - previous vaginal delivery is the best predictor of success; prostaglandin induction increases rupture risk.
Maternal cardiac arrest - perimortem caesarean within 5 minutes if no ROSC, performed at the site of arrest to relieve aortocaval compression and aid maternal resuscitation.
Bereavement care = time with baby, memory-making, specialist support services, structured follow-up - Sands provides national support; the National Bereavement Care Pathway guides standards.
Stress incontinence first-line = supervised pelvic floor exercises for ≥3 months; weight loss if BMI >30; mid-urethral tapes under restricted use following Cumberlege review.
Ethylene glycol - high anion gap acidosis + high osmolar gap + calcium oxalate crystals; fomepizole is first-line; dialysis for severe cases; blocks alcohol dehydrogenase.
Methanol poisoning - visual loss from formic acid optic nerve toxicity; fomepizole first-line; dialysis for severe cases; folinic acid is adjunctive; can cause irreversible blindness.
Button battery in oesophagus = emergency endoscopic removal within 2 hours; halo sign on X-ray confirms battery; give honey every 10 minutes while awaiting endoscopy; aorto-oesophageal fistula is the fatal complication.
ACE inhibitor angioedema - no urticaria, bradykinin-mediated, antihistamines/steroids less effective; stop ACE inhibitor; consider icatibant or C1-INH concentrate; airway management is the priority.
Acute severe asthma not responding to nebulisers and steroids - IV magnesium sulphate 1.2-2 g over 20 minutes is the next step; aminophylline is an alternative; intubation only if failing all medical therapy.
Triage sieve - walking = Green (P3); not walking → breathing? → RR → CRT; takes 30 seconds per patient; triage sort is the secondary tool at the clearing station.
After the third shock - give both adrenaline 1mg and amiodarone 300mg together, then adrenaline every alternate cycle per the ALS shockable algorithm.
Parkland formula = 4mL × kg × %TBSA, half in first 8 hours from time of burn - titrate to urine output 0.5-1mL/kg/hr and avoid fluid creep.
Severe hyperkalaemia with ECG changes = IV calcium gluconate FIRST for cardioprotection, then insulin-glucose and salbutamol to shift potassium, then remove it from the body.
Beck's triad (hypotension, raised JVP, muffled hearts) = tamponade - emergency pericardiocentesis is life-saving, diuretics are contraindicated, and IV fluid augments preload as a bridge.
Start chest compressions immediately at 30:2 - early high-quality CPR is the single most important intervention before defibrillation arrives.
Status epilepticus at 5 minutes = IV lorazepam 4mg (or buccal midazolam if no IV access) - escalate to phenytoin/levetiracetam if refractory, and to RSI if seizure continues beyond 45 minutes.
Staggered overdose = NAC automatically - the nomogram cannot be used, and any staggered ingestion of ≥75mg/kg over 24 hours warrants treatment regardless of paracetamol level.
Crush injury - start aggressive IV fluids BEFORE releasing the crush; reperfusion causes lethal hyperkalaemia; monitor ECG and target high urine output to prevent myoglobin-induced AKI.
Thyroid storm - beta-blocker + PTU + iodine (1 hour after PTU) + hydrocortisone; PTU is preferred over carbimazole; never give iodine before antithyroid drug.
Anticholinergic toxidrome - hot, dry, dilated pupils, confused, urinary retention; DRY skin distinguishes from serotonergic/sympathomimetic; physostigmine is the specific but risky antidote.
Parkland formula - 4 mL × kg × %TBSA; half in first 8 hours FROM TIME OF BURN; Hartmann's is the fluid of choice; titrate to urine output 0.5-1 mL/kg/hr.
Paracetamol level above the 100 mg/L at 4 hours treatment line = start NAC immediately; TOXBASE is the first resource to consult; NAC is most effective within 8 hours.
Isolated PIPJ flexion loss = FDS; DIPJ flexion loss = FDP; sensation excludes digital nerves; zone 2 flexor injuries need specialist repair.
A normal or rising PaCO₂ in acute asthma is ominous - silent chest + rising CO₂ + exhaustion = near-fatal asthma; involve ICU/anaesthetics immediately for intubation.
Massive haemothorax >1500 mL initial or >200 mL/hr ongoing = thoracotomy indication; flail chest - manage the underlying lung contusion and pain; never clamp a chest drain.
Electrical injury with LOC and entry/exit burns = cardiac monitoring for at least 24 hours; AC at domestic voltage (240V) can cause fatal arrhythmias; watch for deep tissue injury and rhabdomyolysis.
Penetrating cardiac tamponade = surgical emergency; pericardiocentesis is temporising only; EDT or theatre thoracotomy is definitive; stab wounds have better outcomes than gunshot wounds.
Sepsis Six within 1 hour - antibiotics and IV fluids are the priorities; 500 mL bolus then reassess; noradrenaline if fluid-refractory hypotension.
Ulnar nerve at the wrist - sensory loss little finger and ulnar ring finger, weak finger abduction/adduction, positive Froment's sign; claw hand develops later.
Acute limb ischaemia with motor deficit = emergency embolectomy within 6 hours; heparin immediately; AF is the most common embolic source; the six P's guide assessment.
Soft boggy uterus = uterine atony (70% of PPH); rub up the uterus + oxytocin first; tranexamic acid within 3 hours; escalate through pharmacological and surgical options.
Myxoedema coma - give IV hydrocortisone BEFORE levothyroxine to prevent adrenal crisis; passive rewarming only; IV levothyroxine ± T3; mortality remains very high.
Rapid tranquillisation - IM lorazepam first-line; if more needed, add IM haloperidol; never combine IM olanzapine with benzodiazepines; continuous monitoring post-RT is mandatory.
Clonus + hyperreflexia + agitation + hyperthermia after serotonergic drug = serotonin syndrome; stop the drug; cyproheptadine is the specific antidote; Hunter criteria for diagnosis.
Refractory anaphylaxis (failed 2 IM doses) - IV adrenaline infusion; glucagon for beta-blocked patients; observe 6-12 hours for biphasic reactions; prescribe two auto-injectors on discharge.
Persistent acidosis and hypercapnia after 60 minutes of optimal medical therapy in acute COPD - commence NIV per NICE NG115 before considering intubation.
CO poisoning - pulse oximetry is unreliable; measure COHb on ABG; 100% oxygen via NRB mask is first-line; half-life drops from 4-6 hours to 60-90 minutes on high-flow O2.
Pain out of proportion + tense compartment + pain on passive stretch = compartment syndrome - remove all dressings, urgent fasciotomy within 6 hours, and preserved pulses do not exclude the diagnosis.
Observe at least 6-12 hours post-anaphylaxis for biphasic reactions - always discharge with two auto-injectors, an action plan, and allergy clinic referral.
NICE CG176 guides CT head timing - GCS <13 or focal neurology needs CT within 1 hour; LOC or amnesia with risk factors needs CT within 8 hours.
Salicylate poisoning = urinary alkalinisation with IV bicarbonate targeting urinary pH >7.5 - avoid intubation as loss of compensatory hyperventilation is catastrophic.
Variceal bleed = terlipressin + antibiotics + emergency band ligation within 12 hours - over-transfusion worsens portal pressure, and Sengstaken tube is a bridge to TIPSS.
High clinical suspicion for PE (Wells >4) = start therapeutic LMWH immediately while awaiting CTPA - never delay anticoagulation for imaging, and D-dimer is not useful in post-surgical patients.
Chemical burns = irrigate immediately and copiously for at least 20 minutes (60 minutes for alkali) - never neutralise, and alkali burns are deeper than they initially appear.
Opioid overdose = naloxone titrated to respiratory rate not consciousness - its short duration means repeat dosing or infusion is often needed, especially with long-acting opioids.
ICH = target systolic BP 130-140mmHg within 1 hour to limit haematoma expansion per INTERACT2 - sublingual nifedipine causes uncontrolled drops and is avoided.
Bilateral leg symptoms + saddle anaesthesia + bladder dysfunction = cauda equina syndrome - emergency MRI and surgical decompression within 48 hours, as delay causes permanent damage.
Anaphylaxis = IM adrenaline first - 500mcg into the anterolateral thigh, repeat every 5 minutes if no response, and never delay for antihistamines or steroids.
Post-ROSC - targeted temperature management 32-36°C for 24 hours plus emergency PCI for STEMI, with neurological prognostication deferred to at least 72 hours.
Major haemorrhage = 1:1:1 ratio of RBCs:FFP:platelets plus tranexamic acid within 3 hours - minimise crystalloid and target permissive hypotension until surgical control.
Acute subdural = crescent-shaped collection crossing sutures from bridging vein rupture - urgently reverse anticoagulation with PCC and IV vitamin K, and evacuate if significant midline shift.
Inhalation injury + stridor = immediate intubation before oedema progresses - do not wait for complete obstruction, and remember SpO₂ is unreliable with CO poisoning.
Drowning = five rescue breaths first as it is a hypoxic arrest - never attempt abdominal thrusts to drain water, and hypothermic patients receive CPR until rewarmed.
Benzodiazepine overdose is rarely fatal alone - supportive care is mainstay, flumazenil risks seizures and is reserved for iatrogenic oversedation, and always suspect co-ingestion.
Sudden epigastric pain + peritonism + free gas under diaphragm = perforated ulcer requiring emergency surgery - NSAID use and H. pylori are key risk factors.
Unstable open-book pelvic fracture with shock = apply pelvic binder at greater trochanters immediately, activate massive transfusion, and escalate to definitive haemorrhage control (fixation, embolisation, or packing) without delay.
Status epilepticus >45 minutes despite benzodiazepines and phenytoin = RSI and ICU for general anaesthesia with continuous EEG - investigate for underlying cause and target burst suppression.
NLS - five inflation breaths first; chest compressions only if HR <60 bpm despite effective ventilation; start with air, not 100% oxygen.
Heat stroke = cool first - ice packs to axillae, groin, and neck; target <39°C within 30 minutes; paracetamol is useless; multi-organ failure is the major complication.
Damage control surgery = stop the bleeding, stop the contamination, close temporarily, resuscitate in ICU, then return for definitive repair; avoid the lethal triad.
Eclampsia = magnesium sulphate 4 g IV loading then 1 g/hour; Magpie trial evidence; monitor reflexes, RR, and urine output; calcium gluconate is the antidote for toxicity.
Seizures or coma with hyponatraemia mandate immediate 3% hypertonic saline (150 mL over 20 minutes, repeated as needed), not fluid restriction - but cap correction at about 8-10 mmol/L per 24 hours.
Paracetamol on or above the treatment line at 4 hours = start NAC immediately - it is nearly 100% effective within 8 hours, and normal ALT/INR at presentation does not exclude developing hepatotoxicity.
UK adder bite with systemic envenomation - give European viper venom antivenom (ViperaTAb) IV; indications include hypotension, significant swelling, leucocytosis, coagulopathy; never incise, suck, or apply a tourniquet.
Open pneumothorax = three-sided dressing (not four-sided) to prevent tension - a fully occlusive seal risks converting to tension pneumothorax, and a chest drain is the definitive treatment.
Lightning cardiac arrest - resuscitate aggressively; fixed dilated pupils are unreliable; reverse triage in mass casualty; Lichtenberg figures are pathognomonic.
Blast lung - low tidal volume, low pressure ventilation to prevent air embolism; bilateral TM rupture indicates significant blast exposure; treat like ARDS but be extra cautious with airway pressures.
Cardiogenic shock post-MI - noradrenaline is first-line vasopressor (SOAP II); add dobutamine for inotropy if needed; consider mechanical support for refractory cases.
Severe midface fractures - never attempt nasal intubation; surgical airway (cricothyroidotomy) may be the safest primary approach; always have FONA equipment ready in maxillofacial trauma.
Heavy bleeding + open os + haemodynamic compromise = emergency surgical evacuation; stable patients can choose expectant, medical, or surgical management per NICE NG126.
Severe hypercalcaemia - rehydrate aggressively with IV saline FIRST, then bisphosphonate; do not give furosemide before rehydration; calcitonin for rapid temporary effect.
Every self-harm presentation needs a psychosocial assessment before discharge (NICE NG225); treat with compassion, do not rely on risk-stratification tools alone, and arrange a safety plan with follow-up.
Moderate hypothermia - active external rewarming with Bair Hugger and warm IV fluids; avoid hot baths (afterdrop risk); Osborn waves are the ECG hallmark; handle gently to avoid VF.
Sjögren's - dry eyes and mouth, anti-Ro/SSA antibodies, salivary gland biopsy confirms. Pilocarpine stimulates secretions, and 5-10% risk of B-cell lymphoma requires vigilance.
Fracture non-union at 9 months - smoking is the strongest modifiable risk factor. Atrophic non-union needs bone grafting; hypertrophic needs better fixation. Smoking cessation counselling is essential.
An isolated falling DLCO in SSc should prompt urgent investigation for pulmonary arterial hypertension.
Anti-Jo-1 positive myositis should prompt HRCT screening for interstitial lung disease as part of antisynthetase syndrome.
pANCA/MPO + no granulomas + no upper airway disease = MPA; cANCA/PR3 + granulomas + upper airway disease = GPA.
ANCA-negative vasculitis + microaneurysms on angiography + hepatitis B association = polyarteritis nodosa - always check hepatitis B serology.
Young woman + absent pulses + interarm BP discrepancy + raised inflammatory markers = Takayasu arteritis - image the entire aorta and its major branches with CTA or MRA per EULAR/BSR guidelines.
Shoulder calcific periarthritis + no birefringent crystals on polarised light + alizarin red positive = hydroxyapatite crystal deposition - always exclude septic arthritis first.
Diabetic neuropathy + warm swollen foot + disproportionately little pain + midfoot destruction = Charcot joint - urgent offloading is the priority.
Boy aged 4-8 + insidious hip pain and limp + sclerotic flattened femoral epiphysis on X-ray = Perthes disease - referred knee pain is a common trap.
Positive Barlow/Ortolani plus risk factors = urgent hip ultrasound and orthopaedic referral; X-ray is unreliable in neonates; the Pavlik harness is first-line if <6 months (NIPE screening programme; Public Health England NIPE Standards).
Adolescent boy + enthesitis + sacroiliitis + HLA-B27 positive = enthesitis-related arthritis - MRI detects sacroiliitis years before X-ray changes appear.
Inflammatory back pain + normal or equivocal X-ray + clinical suspicion of axial SpA = MRI sacroiliac joints - bone marrow oedema is the earliest detectable sign.
Bilateral leg symptoms + worse on walking/extension + better on flexion/sitting + normal pulses/ABPI = neurogenic claudication from spinal stenosis, not vascular claudication.
Low-grade spondylolisthesis (Grade I-II) is managed conservatively with activity modification and physiotherapy - surgery is reserved for high-grade or progressive slips.
Severe back pain + fever + raised inflammatory markers + disc/vertebral destruction on MRI = spondylodiscitis - minimum 6 weeks of antibiotics with S. aureus as the most common cause.
Lateral epicondyle tenderness + positive Cozen test = tennis elbow - eccentric exercises are the cornerstone of treatment; avoid repeated steroid injections due to higher recurrence rates.
Lateral hip point tenderness + full painless hip ROM + worse lying on side = GTPS - physiotherapy with gluteal strengthening is superior to corticosteroid injection long-term.
Warm erythematous olecranon swelling + skin break + fever + positive Gram stain = septic bursitis - flucloxacillin and repeated aspiration; never inject steroids into a septic bursa.
Dorsal wrist + smooth transilluminable swelling + fluctuating size = ganglion cyst - reassurance that most resolve spontaneously is appropriate first-line management.
Radial wrist pain + positive Finkelstein test + new mother = de Quervain tenosynovitis - thumb spica splint and corticosteroid injection are the mainstay of treatment.
GCA with visual symptoms requires immediate high-dose steroids - never delay for biopsy, as permanent blindness can occur within hours. Arrange TAB within 2 weeks of starting treatment.
CTS with thenar wasting is severe and requires NCS and surgical referral - nocturnal splints for mild disease, steroid injection for moderate, and carpal tunnel decompression for severe or failed conservative treatment.
Stress fractures - normal initial X-ray, MRI is best early investigation, march fracture (2nd metatarsal) is commonest. Relative rest and gradual return to activity; high-risk sites may need surgery.
Back pain red flags demand urgent investigation - cancer history with night pain and weight loss requires urgent MRI spine to exclude metastases, and cord compression is a neurological emergency.
PMR responds dramatically to prednisolone 15mg - pain without weakness, elevated ESR/CRP, and normal CK. Always screen for concurrent GCA symptoms at every review.
SUFE - obese adolescent with groin pain and externally rotated leg. Frog-leg lateral X-ray confirms. Urgent in situ pinning without slip reduction, and always X-ray both hips.
Per NICE NG226, OA management starts with core treatments (therapeutic exercise and weight loss), then topical NSAIDs for knee OA, with oral NSAIDs plus gastroprotection if needed, and joint replacement for refractory disease.
Anterior knee swelling + preserved joint ROM + kneeling occupation + non-septic aspirate = prepatellar bursitis - avoidance of kneeling and kneeling pads are the key preventive measures.
RA requires early DMARD therapy (methotrexate first-line) per NICE NG100 - the window of opportunity within 3 months is critical for preventing joint damage.
Acute gout is treated with NSAIDs, colchicine, or steroids - never start allopurinol during an acute attack, and negatively birefringent needle-shaped crystals confirm the diagnosis.
Allopurinol is first-line ULT - start low (100mg) and titrate to target urate <360µmol/L, with colchicine prophylaxis cover for 6 months per BSR guidelines.
Displaced intracapsular NOF fractures need arthroplasty (not fixation) in elderly patients - surgery within 36 hours, and total hip replacement is offered to fit, mobile, cognitively intact patients per NICE NG111.
Colles fracture (dorsal displacement) requires closed reduction if significantly displaced - backslab (not circumferential cast), post-reduction X-ray, and bone health assessment for fragility fractures.
Clinical scaphoid fracture with normal X-ray must be immobilised in a thumb spica - repeat X-ray at 10-14 days or MRI; proximal pole fractures carry highest AVN risk due to retrograde blood supply.
Thigh pain on bisphosphonates suggests atypical femoral fracture - X-ray both femurs, stop bisphosphonate, and refer orthopaedics. Drug holidays after 5 years reduce this risk per MHRA guidance.
SLE management starts with hydroxychloroquine for all patients - anti-dsDNA and complement levels monitor disease activity, and lupus nephritis requires renal biopsy and immunosuppression.
Anterior shoulder dislocation requires closed reduction with pre/post neurovascular assessment - axillary nerve (regimental badge area) is most commonly injured, and young patients have high recurrence risk.
Posterior hip dislocation requires emergency reduction within 6 hours - the limb is flexed, adducted, and internally rotated, and delayed reduction increases AVN risk dramatically.
Meniscal tears with mechanical symptoms need arthroscopic assessment - repair is preferred for peripheral tears (red zone) to preserve the meniscus, while degenerative tears may respond to conservative management.
Psoriatic arthritis requires early DMARD therapy (methotrexate first-line) - DIP involvement, dactylitis, enthesitis, and nail changes are characteristic, and pencil-in-cup deformity on X-ray is pathognomonic.
Achilles tendinopathy - eccentric exercises are first-line, never inject corticosteroid into the tendon, and Thompson test negative excludes complete rupture.
GPA - upper/lower respiratory disease plus glomerulonephritis with cANCA/anti-PR3. Cyclophosphamide or rituximab for induction, then azathioprine for maintenance per BSR guidelines.
ANA-positive oligoarticular JIA - highest risk of asymptomatic chronic anterior uveitis requiring regular slit-lamp screening every 2-3 months. Uveitis can cause permanent blindness if undetected.
CRPS - pain disproportionate to injury with sensory, vasomotor, sudomotor, and motor/trophic changes. Budapest criteria guide diagnosis, multidisciplinary management is essential, and early treatment improves outcomes.
Blue sclerae + recurrent low-trauma fractures + family history + COL1A1 mutation = osteogenesis imperfecta - always consider OI before non-accidental injury in children with fractures.
Dermatomyositis in patients over 40 years mandates thorough malignancy screening - ovarian cancer is the most strongly associated malignancy.
Finger flexor weakness + quadriceps weakness + rimmed vacuoles on biopsy + steroid resistance = inclusion body myositis, not polymyositis.
cANCA/PR3 = GPA; pANCA/MPO = MPA - first-line induction is cyclophosphamide or rituximab combined with high-dose corticosteroids, never monotherapy.
Adult-onset asthma + eosinophilia + mononeuritis multiplex = think EGPA (Churg-Strauss) - cardiac involvement is the leading cause of mortality.
Quotidian fever + salmon-pink rash + ferritin >1000 with low glycosylated fraction + negative ANA/RF = adult-onset Still disease - always exclude infection and lymphoma first.
Bilateral hilar lymphadenopathy + erythema nodosum + ankle arthritis = Löfgren syndrome - this has an excellent prognosis and often resolves without immunosuppression.
Young patient + corticosteroid/alcohol use + hip pain + normal X-ray = request MRI for AVN - the double line sign is diagnostic.
Bone metastases management combines antiresorptive therapy (zoledronic acid/denosumab) + radiotherapy for pain + systemic anticancer treatment - always assess fracture risk in long bones.
Beighton score ≥5 + symptomatic joint hypermobility + not meeting hEDS criteria = hypermobility spectrum disorder - physiotherapy focusing on strengthening (not stretching) is key.
Spontaneous arterial/bowel rupture + thin translucent skin + visible veins + COL3A1 mutation = vascular EDS (type IV) - celiprolol is the only drug shown to reduce vascular events.
Burning forefoot pain in 3rd web space + Mulder click + walking-on-a-pebble sensation = Morton neuroma - wider shoes and metatarsal padding are first-line management.
Sudden calf swelling in a patient with knee osteoarthritis = consider ruptured Baker cyst mimicking DVT - always perform duplex ultrasound to exclude concurrent DVT.
Marfan syndrome - FBN1 mutation, aortic root dilatation is the main concern. Beta-blockers for all, annual echo, and prophylactic surgery at 5.0cm (or 4.5cm with risk factors).
the crystal characteristics.
T-score ≤-2.5 = osteoporosis, warranting bisphosphonate therapy - treat with alendronic acid plus calcium/vitamin D, review at 5 years, and investigate secondary causes if Z-score <-2.0.
Sarcomatous transformation is the most feared Paget's complication - sudden pain increase with rising ALP warrants urgent investigation. ALP monitors disease activity and treatment response.
Axial spondyloarthritis first-line is continuous NSAIDs plus exercise - conventional DMARDs are ineffective for axial disease, and biologics (anti-TNF, anti-IL-17) are second-line per NICE NG65.
Trigger finger is treated with corticosteroid injection first-line (60-90% success) - diabetes is the major risk factor, and A1 pulley surgical release is for refractory cases.
Cauda equina syndrome presents with saddle anaesthesia, urinary retention, and bilateral leg symptoms - emergency MRI and surgical decompression within 24-48 hours are essential.
Rotator cuff pathology - painful arc 60-120°, ultrasound first-line investigation, physiotherapy for partial tears, and surgical repair for full-thickness tears in active patients.
Phaeochromocytoma requires alpha-blockade before beta-blockade preoperatively - phenoxybenzamine for ≥2 weeks, and genetic testing is recommended for all patients.
FH requires high-intensity statin from diagnosis, specialist referral, and cascade family screening per NICE CG71 - QRISK3 is unreliable in FH as it underestimates lifetime risk.
MEN1 is the '3 Ps' - Parathyroid, Pancreatic, Pituitary - caused by MEN1 gene mutation. MEN2 involves medullary thyroid cancer and phaeochromocytoma caused by RET mutations.
Stop metformin when eGFR <30mL/min or during acute illness - sick-day rules are essential education for all metformin-treated patients to prevent lactic acidosis.
GLP-1 RAs provide cardiovascular benefit, weight loss, and HbA1c reduction - consider first for T2DM with established CVD or obesity per NICE NG28.
For antipsychotic-induced hyperprolactinaemia with a normal pituitary MRI, liaise with psychiatry to switch to a prolactin-sparing agent (aripiprazole, quetiapine) rather than adding a dopamine agonist - see the Maudsley Prescribing Guidelines and BNF.
Morning prednisolone = afternoon hyperglycaemia - morning NPH insulin is ideal as its action profile mirrors the steroid's glycaemic effect.
Acromegaly = transsphenoidal surgery first-line; somatostatin analogues second-line if surgery fails - visual field loss is an urgent surgical indication.
Post-bilateral adrenalectomy + very high ACTH + hyperpigmentation + growing pituitary tumour = Nelson syndrome - prevent with pituitary radiotherapy.
Pituitary apoplexy = IV hydrocortisone FIRST (life-saving) + fluid resuscitation + urgent neurosurgical review - do not delay steroids for investigations.
Gold standard for AGHD = insulin tolerance test (peak GH <3 µg/L confirms deficiency); use the glucagon stimulation test if the ITT is contraindicated.
Young male + small firm testes + elevated FSH + azoospermia + tall stature = Klinefelter (47,XXY) - diagnose with karyotype; testosterone replacement is standard.
Mild hypercalcaemia + family history + CCCR <0.01 = FHH - do NOT operate; parathyroidectomy causes harm without correcting calcium.
Low TSH with low free T4 = secondary hypothyroidism - TSH is unreliable for monitoring, replace cortisol before thyroxine, and investigate for pituitary pathology.
Subacute thyroiditis shows painful thyroid, raised ESR, thyrotoxicosis, and reduced isotope uptake - antithyroid drugs are NOT indicated, NSAIDs and propranolol manage symptoms, and >90% recover fully.
Neuropathic pain first-line is amitriptyline, duloxetine, gabapentin, or pregabalin per NICE CG173 - optimise glucose control, exclude B12 deficiency with metformin, and avoid opioids as first-line.
Turner syndrome = start low-dose oestrogen at 11-12 to induce puberty - gradually increase; GH for height should not delay pubertal induction.
Alendronic acid is first-line for osteoporosis per NICE - always co-prescribe calcium and vitamin D, take on empty stomach sitting upright, and review treatment at 5 years.
Life-threatening hyperkalaemia with ECG changes requires IV calcium gluconate first for cardioprotection, then insulin-dextrose for potassium shifting - stop offending drugs immediately.
Metformin is first-line for T2DM per NICE NG28 - start low, titrate slowly, and add a second agent if HbA1c target is not met.
Carbimazole is first-line for hyperthyroidism per NICE - warn about agranulocytosis, add propranolol for symptoms, and course duration is 12-18 months.
Thyroid storm requires PTU, Lugol's iodine (1 hour after PTU), propranolol, hydrocortisone, and ITU - mortality is 10-30% without aggressive treatment.
In suspected adrenal crisis, give IV/IM hydrocortisone 100 mg plus isotonic fluids immediately - treat first and confirm the diagnosis later (Society for Endocrinology Emergency Guidance; BNF).
Cushing's diagnosis requires confirmation with two screening tests, then ACTH level for localisation - exclude exogenous steroids first, and confirm before imaging.
Cranial DI concentrates urine after desmopressin while nephrogenic DI does not - desmopressin is first-line for cranial DI, and the water deprivation test distinguishes the two forms.
PCOS management starts with lifestyle modifications - COCP for menstrual regulation in non-pregnant women, and letrozole or clomifene for ovulation induction when pregnancy is desired per NICE guidelines.
Carcinoid syndrome requires octreotide for symptom control - 5-HIAA is the diagnostic test, and IV octreotide prevents carcinoid crisis during procedures.
Hypernatraemia must be corrected slowly (≤10mmol/L per 24 hours) - volume resuscitate with 0.9% NaCl first, then give free water with 5% dextrose, and rapid correction causes cerebral oedema.
High fasting glucose in basal-bolus regimens indicates insufficient basal insulin - increase by 2 units every 3 days, exclude Somogyi effect, and consider the dawn phenomenon.
New vessels (proliferative retinopathy) require urgent ophthalmology referral for PRP or anti-VEGF - optimise glycaemic and blood pressure control to slow progression.
Insulinoma shows elevated insulin and C-peptide during fasting hypoglycaemia with negative sulphonylurea screen - surgical enucleation is curative, and screen for MEN1.
Hypermagnesaemia in renal failure requires IV calcium gluconate for cardioprotection, stopping magnesium sources, and dialysis - magnesium-containing antacids must be avoided in CKD.
Refractory hypokalaemia and hypocalcaemia should prompt magnesium checking - correct magnesium first as both electrolytes depend on adequate magnesium for homeostasis.
Pregnancy + hypothyroidism = increase levothyroxine 25-50%, target TSH <2.5 in first trimester - check TFTs every 4 weeks.
Fasting hypoglycaemia + high insulin + high C-peptide + negative drug screen = insulinoma - 72-hour fast is the gold standard diagnostic test.
Steroid-induced diabetes peaks in the afternoon with morning prednisolone - gliclazide or insulin matched to steroid timing is appropriate, and reduce diabetes treatment as steroids are tapered.
The NICE NG3 GDM thresholds are fasting ≥5.6 or 2-hour ≥7.8mmol/L on a 75g OGTT - these are higher than the WHO/IADPSG fasting cut-off of 5.1.
Impaired hypo awareness + recurrent severe hypos = real-time CGM with alarms - flash monitoring is insufficient without proactive alerts.
In DKA, ketone clearance guides management - target ≥0.5mmol/L/hour fall; increase FRIII by 1u/hr if targets not met.
SGLT2i + acidosis + raised ketones + near-normal glucose = euglycaemic DKA - stop the SGLT2i immediately and treat as standard DKA.
HHS = slow rehydration over 48 hours with 0.9% NaCl - target osmolality fall 3-8mOsm/kg/hr; avoid rapid correction.
Low T3 + low/normal T4 + normal/low TSH + high rT3 in critical illness = sick euthyroid - no treatment needed; recheck TFTs after recovery.
MEN1 = 3 Ps: Parathyroid + Pituitary + Pancreas - suspect in young hyperparathyroidism; MEN2 = MTC + phaeochromocytoma.
Post-neurosurgical hyponatraemia + volume depletion = cerebral salt wasting (give fluids); euvolaemic = SIADH (restrict fluids) - getting the volume status right is critical.
Water deprivation: dilute urine → DDAVP → concentrated urine = central DI; dilute urine → DDAVP → still dilute = nephrogenic DI.
Primary hypogonadism = low T + high FSH/LH → testosterone replacement; counsel about fertility impact - monitor haematocrit and PSA.
POI = HRT until age 51 is essential, not optional - prevents osteoporosis and cardiovascular disease; screen for autoimmune associations.
Profuse watery diarrhoea + hypokalaemia + acidosis + pancreatic mass = VIPoma (WDHA syndrome) - treat with octreotide and surgery.
Phaeochromocytoma = alpha-blockade FIRST for 10-14 days before surgery - never start beta-blocker before alpha-blocker; liberal fluids to expand intravascular volume.
Heavy drinking + vomiting/fasting + ketoacidosis + low/normal glucose = alcoholic ketoacidosis - give thiamine BEFORE glucose, then IV dextrose and fluids.
Papillary thyroid cancer requires total thyroidectomy for higher-risk disease, RAI ablation, and levothyroxine with TSH suppression - lobectomy alone is an option for low-risk small tumours per BTA guidelines.
Acromegaly requires transsphenoidal surgery first-line - IGF-1 and OGTT GH suppression confirm diagnosis, and somatostatin analogues are first-line medical therapy for persistent disease.
Hypopituitarism replacement order is hydrocortisone first, then levothyroxine - fludrocortisone is NOT needed in secondary adrenal insufficiency as aldosterone is RAAS-dependent.
Severe hypertriglyceridaemia (>10mmol/L) risks pancreatitis - fibrates are first-line, fenofibrate is preferred with statins, and lifestyle modification is essential.
SGLT2 inhibitors can cause euglycaemic DKA - always check ketones even with near-normal glucose in unwell SGLT2-treated patients, and apply sick-day rules during illness.
Myxoedema coma requires IV thyroxine plus IV hydrocortisone in ITU - passive rewarming only, and never give thyroxine without glucocorticoid cover.
In DKA, potassium drops as treatment corrects acidosis - replace at 40mmol/L of fluid when K+ 3.5-5.5, hold insulin if K+ <3.5, and monitor hourly per JBDS protocol.
Vitamin D deficiency requires colecalciferol loading then maintenance - alfacalcidol is reserved for CKD and hypoparathyroidism, and elevated ALP with PTH suggests secondary hyperparathyroidism.
Hashimoto's presents with firm painless goitre, high anti-TPO antibodies, and progressive hypothyroidism - treat with levothyroxine and be vigilant for thyroid lymphoma if rapid enlargement occurs.
Hypercalcaemia requires IV saline rehydration first, then IV bisphosphonate - check PTH to distinguish primary hyperparathyroidism (high PTH) from malignancy (suppressed PTH).
Severe hypokalaemia requires IV potassium with cardiac monitoring - always correct hypomagnesaemia simultaneously, as potassium replacement is ineffective without adequate magnesium.
ACE inhibitors are indicated for any degree of persistent albuminuria in diabetes per NICE NG28 - start regardless of BP, monitor creatinine and potassium, and never combine ACEi with ARB.
Anion gap = Na − (Cl + HCO3) - a gap >12 indicates unmeasured anions; MUDPILES lists the causes, and DKA is confirmed by ketones with high anion gap acidosis.
HbA1c is affected by red cell turnover - iron deficiency falsely elevates it. Always consider the clinical picture including hypoglycaemia frequency and glycaemic variability alongside HbA1c.
The Lee Index predicts perioperative cardiac risk using six variables - ≥3 points indicates highest risk, functional capacity ≥4 METs is reassuring, and CPET provides objective fitness assessment for major surgery.
Class III shock (30-40% loss) presents with tachycardia >120 and hypotension - activate massive haemorrhage protocol, give tranexamic acid within 3 hours, and FAST-positive instability requires emergency laparotomy.
Optimise before repairing incisional hernias - address BMI, smoking, and diabetes; use mesh not primary suture for defects >4cm to minimise recurrence.
Colorectal liver metastases can be cured with surgery - resectability depends on margins, liver remnant, and fitness, not the number of metastases.
Free gas under the diaphragm on erect CXR confirms perforation - but a negative CXR does not exclude it; CT is more sensitive for small perforations.
Ogilvie syndrome = pseudo-obstruction in hospitalised patients; correct electrolytes and stop opioids first, then neostigmine if conservative measures fail; caecal diameter >12cm = perforation risk.
Low rectal cancer <5cm from verge usually needs APER with permanent stoma; mid/upper rectal cancers can have anterior resection with sphincter preservation; TME is the oncological standard.
Courvoisier's sign + head of pancreas mass = consider Whipple procedure if resectable; only 15-20% present with resectable disease; adjuvant chemotherapy is standard.
Post-splenectomy care = vaccinate (pneumococcal, Hib, meningococcal), lifelong penicillin V, patient education and alert card - OPSI is the most important preventable complication.
Charcot's triad = ascending cholangitis; emergency ERCP for biliary decompression; follow with cholecystectomy during same admission or within 2 weeks.
Post-thyroidectomy neck haematoma with stridor = open the wound immediately at the bedside - do not delay; this is a bedside emergency, not a theatre emergency initially.
Phaeochromocytoma = alpha-blockade FIRST (phenoxybenzamine ≥2 weeks), then beta-blocker if needed; NEVER beta-block before alpha-block; volume expand preoperatively.
Intercostobrachial nerve injury (medial arm numbness) is the most common nerve complication of ALND; long thoracic nerve injury causes winged scapula - both should be identified during surgery.
All mastectomy patients should be offered reconstruction; immediate reconstruction gives the best cosmetic outcomes; autologous tissue reconstruction (DIEP flap) is more radiation-tolerant than implant-based approaches.
Free flaps involve complete tissue transfer with microvascular anastomosis - they allow reconstruction of complex composite defects where simpler options are insufficient.
Elective hip replacement = LMWH for 28-35 days + mechanical prophylaxis; knee replacement = 14 days; always perform VTE risk assessment on admission and balance bleeding risk.
Cystic duct stump bile leak = ERCP with sphincterotomy and stent first; surgical repair only needed for major duct injuries - always involve a specialist HPB centre for complex cases.
Infected pancreatic necrosis = step-up approach (drain first, operate if needed); delay intervention ≥4 weeks if possible; avoid primary open necrosectomy - minimally invasive approaches have better outcomes.
Wound dehiscence with evisceration = cover with saline-soaked dressings and emergency theatre; the pink fluid sign often precedes dehiscence - be vigilant in high-risk patients.
Classic RIF pain with migration from the umbilicus, raised WCC and CRP - laparoscopic appendicectomy is the gold standard, and an Alvarado score ≥7 supports the clinical diagnosis.
Testicular torsion requires exploration within 6 hours - absent cremasteric reflex is the most sensitive sign, do not delay for imaging, and always fix the contralateral testis.
Tachycardia and rising CRP on days 3-7 post-colorectal surgery - think anastomotic leak until proven otherwise, urgent CT with contrast is the investigation, and free leaks require emergency laparotomy.
Poorly controlled diabetes is a major modifiable SSI risk factor - perioperative glucose should be 6-10mmol/L, antibiotics within 60 minutes of incision, and the SSI bundle includes normothermia, chlorhexidine prep, and glycaemic control.
Femoral hernias are below and lateral to the pubic tubercle - 40% strangulation risk mandates repair at diagnosis, and strangulated hernias require emergency surgery without attempted reduction.
Ruptured AAA with the classic triad requires immediate surgery - permissive hypotension targets systolic 80-100mmHg, and aggressive fluid resuscitation worsens outcomes by disrupting tamponade.
CLI is Fontaine stage III (rest pain) or IV (tissue loss) - ABPI <0.5, rest pain worse at night and relieved by dependency, and urgent revascularisation is needed to prevent amputation.
Cancer surgery requires 28 days of LMWH prophylaxis per NICE NG89 - combined pharmacological and mechanical prophylaxis is standard, and the ENOXACAN II trial supports extended duration in cancer patients.
Sigmoid volvulus = endoscopic decompression first, then elective resection; caecal volvulus = surgery required as endoscopic decompression is ineffective.
Pre-operative fasting follows the 2-4-6 rule - clear fluids 2 hours, breast milk 4 hours, solids 6 hours before anaesthesia, and prolonged fasting is harmful and should be actively avoided.
Wrong site surgery is a Never Event wholly preventable by site marking, WHO checklist, and team communication - all Never Events require Duty of Candour disclosure and root cause analysis investigation.
ATLS primary survey follows ABCDE strictly - airway kills fastest, GCS ≤8 requires definitive airway, and cervical spine protection is maintained throughout with manual in-line stabilisation.
Wallace Rule of Nines - anterior trunk 18%, each arm 9%, each leg 18% (anterior 9%) - burns >15% TBSA require fluid resuscitation, and full-thickness burns are painless, white, and waxy.
Copious water irrigation for 20-30 minutes is the immediate priority for chemical burns - never use neutralising agents (exothermic risk), alkali burns penetrate deeper than acid burns, and HF acid requires calcium gluconate after irrigation.
Perianal abscesses require surgical drainage - antibiotics alone are insufficient, 30-50% develop a fistula, and recurrent perianal sepsis warrants investigation for Crohn's disease.
Off-midline closure (Karydakis or Bascom cleft lift) is the preferred elective procedure for pilonidal sinus - it flattens the natal cleft, reduces recurrence to 1-5%, and midline closure should be avoided due to high recurrence rates.
Pilonidal abscess requires incision and drainage - use a lateral off-midline incision, avoid primary closure, 40-50% will recur requiring elective surgery, and advise hair removal to reduce recurrence risk.
Single adenoma causing PHPT = focused minimally invasive parathyroidectomy with intraoperative PTH monitoring; four-gland hyperplasia (MEN) requires subtotal parathyroidectomy.
CEAP C5 indicates a healed venous ulcer - post-thrombotic syndrome affects 20-50% after DVT, and lifelong compression therapy is the cornerstone of management.
Acute cholecystitis requires early laparoscopic cholecystectomy within 72 hours per NICE NG104 - early surgery is superior to delayed surgery for reducing complications and hospital stay.
Fibroadenomas are the commonest benign breast lump in young women - 'breast mouse' mobility is characteristic, conservative management is appropriate after triple assessment, and excision is reserved for large, symptomatic, or growing lesions.
Breast abscess is managed with ultrasound-guided aspiration as first-line - breastfeeding should continue from both sides, flucloxacillin covers S. aureus, and incision and drainage is reserved for failed aspiration or large abscesses.
Necrotising fasciitis presents with pain disproportionate to findings and crepitus - emergency surgical debridement is life-saving, clindamycin inhibits toxin production, and delayed surgery dramatically increases mortality.
Compartment syndrome is diagnosed clinically by pain on passive stretch - pulses are a late sign, delta pressure <30mmHg confirms the diagnosis, and emergency four-compartment fasciotomy within 6 hours prevents irreversible muscle damage.
In pregnancy, the appendix migrates superiorly - MRI without gadolinium is the imaging of choice when ultrasound is inconclusive, and surgical delay increases perforation and fetal loss rates.
Appendix mass without abscess is managed conservatively with IV antibiotics - interval appendicectomy at 6-8 weeks is considered, and patients over 40 need colonoscopy to exclude caecal malignancy.
Adhesions are the commonest cause of SBO - initial management is conservative with 'drip and suck,' and Gastrografin follow-through at 24 hours guides the need for surgery.
Charcot's triad with shock indicates severe ascending cholangitis - urgent ERCP within 24 hours for biliary drainage is life-saving, and antibiotics alone are insufficient without biliary decompression.
Surgical site infection is the strongest risk factor for incisional hernia - the STITCH trial showed small bites continuous technique with 4:1 suture-to-wound ratio reduces incidence.
Total thyroidectomy is recommended for papillary carcinomas >1cm - it enables radioiodine ablation and thyroglobulin surveillance, papillary carcinoma is multifocal in 30%, and 10-year survival exceeds 95%.
Hungry bone syndrome causes hypocalcaemia with hypophosphataemia after parathyroidectomy - low phosphate distinguishes it from hypoparathyroidism, urgent IV calcium is needed, and symptoms may persist for weeks.
Port site hernias most commonly occur at the umbilical port - fascial closure of all ports ≥10mm prevents occurrence, symptomatic hernias containing bowel require surgical repair with mesh, and obesity is the major risk factor.
Montgomery (2015) requires disclosure of material risks - those a reasonable patient would want to know, regardless of statistical rarity - replacing the paternalistic Bolam approach to consent.
Reactionary haemorrhage within 24 hours requires urgent resuscitation and return to theatre - tachycardia is the earliest sign, activate the major haemorrhage protocol, and clopidogrel should be stopped 7 days preoperatively.
The WHO Surgical Safety Checklist has three phases - Sign In, Time Out, and Sign Out - reducing complications by 36% and mortality by 47%, and is mandatory in all NHS theatres.
Large bowel obstruction with caecal diameter >9cm requires urgent surgery - Hartmann's procedure is standard for obstructing left-sided cancers, and caecal perforation risk increases significantly above 12cm.
Biliary colic is episodic pain without inflammation markers or Murphy sign - elective laparoscopic cholecystectomy is definitive treatment, and NSAIDs are first-line analgesia.
Triple assessment (clinical + imaging + tissue sampling) achieves >99.6% accuracy - core biopsy is preferred over FNA for histological diagnosis, and ultrasound is first-line imaging for women under 40.
Bile duct injury occurs in 0.3-0.5% of laparoscopic cholecystectomies - the critical view of safety prevents misidentification, bile-stained drainage and rising LFTs require urgent MRCP/ERCP, and major injuries need hepaticojejunostomy.
Mechanical heart valves require bridging anticoagulation - stop warfarin 5 days before, bridge with therapeutic LMWH, and DOACs generally do not need bridging.
ERAS reduces hospital stay by 30-50% through multimodal evidence-based interventions - early feeding, early mobilisation, opioid-sparing analgesia, and avoidance of routine NG tubes and drains are cornerstones.
Pain out of proportion to examination + AF + raised lactate = acute mesenteric ischaemia until proven otherwise - CT angiography is the diagnostic investigation of choice.
NICE criteria for bariatric surgery = BMI ≥40 (or ≥35 with comorbidities); RYGB and sleeve gastrectomy are the current mainstay procedures with excellent metabolic outcomes.
Dumping syndrome = early (osmotic, 15-30 min) + late (reactive hypoglycaemia, 1-3 hours); dietary modification is first-line - small meals, avoid sugar, separate fluids from solids.
Fever + tachycardia + peritonism + rising CRP on day 3-7 post-colorectal anastomosis = suspect leak until proven otherwise; CT is the investigation of choice; major leaks need emergency laparotomy.
Direct inguinal hernias emerge medial to the inferior epigastric vessels through Hesselbach triangle - they rarely descend into the scrotum and are associated with posterior wall weakness in older patients.
Unilateral RLN injury causes hoarseness - 60-70% recover spontaneously within 6-12 months, speech therapy is first-line, and bilateral injury is an airway emergency requiring urgent intervention.
Day surgery suitability requires ASA 1-3 with stable comorbidity, a responsible adult for 24 hours, and appropriate distance from hospital - >80% of elective surgery is now day-case per BADS guidelines.
Post-operative ileus resolves in 3-5 days - correct hypokalaemia, minimise opioids, encourage mobilisation, and investigate if prolonged beyond 5 days for underlying causes including anastomotic leak.
NHS AAA screening at 65 (men); <3 cm discharge, 3.0-4.4 cm annual US, 4.5-5.4 cm three-monthly US, ≥5.5 cm or >1 cm/year or symptomatic = repair; per NICE NG156; smoking cessation single most important intervention.
A tender, irreducible hernia with signs of obstruction and systemic toxicity = strangulation until proven otherwise - emergency surgery is required without delay.
Negative selection = elimination of self-reactive T cells in the thymus; AIRE ensures peripheral antigen expression in thymus; peripheral tolerance (Tregs, anergy) provides additional protection.
Molecular mimicry = microbial antigens resemble self-antigens → cross-reactive immune response; rheumatic fever (streptococcal M protein → cardiac tissue) is the classic example.
Baroreceptors in the carotid sinus (CN IX) and aortic arch (CN X) detect BP changes; falling BP → decreased firing → increased sympathetic + decreased vagal tone; impaired reflex causes orthostatic hypotension.
ACEi in bilateral renal artery stenosis = AKI from loss of efferent arteriolar tone; always check renal function 1-2 weeks after starting ACEi/ARB; the efferent arteriole is the key to understanding this physiology.
Gate control theory - Aβ fibre stimulation closes the spinal gate to pain (C/Aδ fibre) transmission via inhibitory interneurons; this underpins TENS, rubbing injuries, and some aspects of acupuncture.
EMT enables metastasis through E-cadherin downregulation - loss of cell adhesion is the critical first step; E-cadherin loss is a hallmark of invasive and metastatic potential.
PD-L1 on tumours binds PD-1 on T cells causing exhaustion - checkpoint inhibitors block this, reactivating anti-tumour immunity; PD-L1 expression often predicts response.
PDC = pyruvate to acetyl-CoA = gateway to TCA cycle = 5 cofactors (B1, B2, B3, B5, lipoic acid) = lactic acidosis with normal L:P ratio.
PE causes V/Q mismatch = dead space in occluded areas + low V/Q in perfused areas = type 1 respiratory failure with compensatory hyperventilation.
Erb's palsy = upper trunk C5-C6 = waiter's tip = shoulder dystocia in macrosomic babies.
Bohr effect = acidosis/CO2 = right shift = more O2 released to tissues = beneficial in exercise and metabolically active states.
DIC = widespread coagulation activation = consumption of platelets + factors = thrombosis AND bleeding simultaneously = treat the cause.
vWD type 1 = most common inherited bleeding disorder = autosomal dominant = mucocutaneous bleeding + mildly prolonged APTT + low vWF and VIII = desmopressin first-line.
SCID = absent T cells ± B cells in infancy with severe infections; fatal without HSCT; newborn SCID screening (TREC assay) enables early diagnosis.
Acute on chronic = acidotic pH + raised pCO2 above baseline + raised HCO3 (but not enough to compensate for the acute rise); always compare with previous/baseline ABGs.
Gilbert syndrome = mild unconjugated jaundice, worse with fasting/stress, normal LFTs, benign; always consider it in young patients with unexplained isolated unconjugated hyperbilirubinaemia.
Intrinsic pathway = mitochondrial (cytochrome c → apoptosome → caspase-9); extrinsic = death receptor (FasL/TNF → DISC → caspase-8); both converge on executioner caspases.
Promoter CpG island methylation silences genes without mutation - MLH1 methylation causes MSI-high CRC; epigenetic changes are potentially reversible, offering therapeutic opportunities.
Right shift (CADET - CO2, Acid, 2,3-DPG, Exercise, Temperature increase) promotes oxygen unloading to tissues; left shift is the opposite - impairs tissue oxygen delivery.
Exogenous steroids ≥3 weeks suppress the HPA axis - taper gradually to prevent adrenal crisis; patients need steroid sick-day rules and emergency cards.
Recurrent neisserial infections = check terminal complement (CH50); deficiency of C5-C9 impairs MAC formation; vaccinate and provide antibiotic prophylaxis.
Hepcidin degrades ferroportin, blocking iron export; low hepcidin (haemochromatosis) = iron overload; high hepcidin (inflammation) = iron sequestration and anaemia of chronic disease.
T10 = umbilicus is the most commonly examined dermatome landmark in clinical examinations and emergency assessments.
H+/K+ ATPase = proton pump = final common pathway for acid secretion = irreversibly inhibited by PPIs.
Histamine = mast cell degranulation = immediate vasodilation + permeability = swelling and redness = the earliest mediator of acute inflammation.
E. coli = 80% of community UTIs = gram-negative rod = nitrite-positive = treat with nitrofurantoin first-line per NICE.
Free trisomy 21 = 94% of Down syndrome = nondisjunction = risk increases with maternal age = combined screening at 11-14 weeks.
CYP2D6 = codeine to morphine conversion = 6-10% are poor metabolisers = pharmacogenomics determines analgesic response.
CDH = failure of pleuroperitoneal canal closure (usually left posterolateral Bochdalek) = scaphoid abdomen plus bowel in the chest; intubate and pass an orogastric tube, avoid bag-mask ventilation, and treat the pulmonary hypoplasia and pulmonary hypertension that drive prognosis.
Pupil-involving CN III palsy = PComA aneurysm until proven otherwise = neurosurgical emergency.
GSD type I = glucose-6-phosphatase deficiency = cannot release free glucose from liver = fasting hypoglycaemia + hepatomegaly + lactic acidosis + hyperuricaemia.
OTC deficiency = X-linked = most common urea cycle defect = elevated orotic acid in urine = neonatal hyperammonaemia = liver transplant is curative.
APTT = intrinsic pathway = XII, XI, IX, VIII; PT = extrinsic = VII; both = common pathway = X, V, II, fibrinogen.
Power = 1 - beta = probability of detecting a true difference = 80% standard = Type II error is the risk of missing a real effect = sample size calculation is essential before starting an RCT.
Bacillus cereus emetic = fried rice = preformed heat-stable toxin = vomiting in 1-6 hours = self-limiting = prevention by rapid cooling and proper refrigeration.
BCG = targeted selective programme since 2005 = neonates with parent/grandparent from country with TB incidence ≥40/100,000 = protects against severe childhood TB = live vaccine.
NICE threshold = £20,000-£30,000 per QALY = below £20k usually approved = above £30k needs strong justification = special frameworks for rare diseases and end-of-life = ICER = incremental cost/incremental QALY.
CEA/CUA = compare costs and QALYs = NICE preferred method = enables cross-disease comparison = produces ICER for decision-making.
Opportunity cost = value of the best alternative foregone = fundamental to health economics = scarcity means choices have trade-offs = NICE threshold reflects opportunity cost of NHS spending.
Ecological fallacy = assuming group-level associations apply to individuals; ecological studies generate hypotheses but cannot establish individual-level causation due to inability to control individual confounders.
Funnel plot asymmetry = suspect publication bias (small negative studies missing); check with Egger's test; GRADE downgrades evidence if publication bias is likely.
I² >75% = considerable heterogeneity; explore with subgroup analysis/meta-regression; use random-effects model; the pooled estimate may be unreliable if heterogeneity is unexplained.
AUC measures overall discriminatory ability - higher is better; 0.88 = good performance; the optimal threshold depends on the clinical context (rule-in vs rule-out); ROC analysis helps select the best threshold.
ICER = ΔCost/ΔQALYs; compare to the NICE threshold (£20,000-£30,000/QALY); QALYs capture both quantity and quality of life in a single metric.
HNA identifies population health needs using epidemiological, comparative, and corporate approaches; it informs commissioning and resource allocation to reduce health inequalities.
HIA evaluates health effects of non-health policies; it considers equity and vulnerable populations; the process = screening → scoping → appraisal → recommendations → monitoring.
Crossing Kaplan-Meier curves suggest non-proportional hazards - the standard log-rank test may be unreliable; consider alternative analytical methods; always interpret p-values correctly.
HR 0.58 = 42% lower hazard of the event in the treatment group; HR <1 favours treatment; check that the 95% CI excludes 1.0 for significance; assume proportional hazards.
LR+ = sensitivity/(1-specificity); LR- = (1-sensitivity)/specificity; LR+ >10 is a strong rule-in test; use pre-test probability × LR to calculate post-test probability via the odds form.
Low prevalence → low PPV even with excellent tests because false positives overwhelm true positives; this is why screening criteria (Wilson-Jungner) require the condition to be sufficiently prevalent.
NICE threshold = £20,000-£30,000/QALY; end-of-life criteria allow higher thresholds; the CDF provides managed access for promising cancer drugs pending further evidence.
NHS Breast Screening = mammography every 3 years = women aged 50-71 = two-view mammography = reduces mortality by ~20% but causes some overdiagnosis.
Flu vaccine eligibility = all pregnant women + age 50+ + clinical at-risk groups + carers + healthcare workers + care home residents = annual vaccination = Green Book guidance.
Sensitivity = TP/(TP+FN) = how good at detecting disease = SnNOut; Specificity = TN/(TN+FP) = how good at excluding disease = SpPIn.
I-squared = percentage of variability due to heterogeneity not chance = >50% is substantial = use random-effects model when heterogeneity is high.
First step = confirm outbreak exists + verify diagnosis + establish case definition = then descriptive epidemiology (person, place, time) before analytical study.
NICE TA = mandatory funding within 3 months = evaluates specific technologies = clinical effectiveness + cost-effectiveness + wider impact = ICER against £20-30k/QALY threshold.
QALY = years × quality weight; QALY gain = difference between treatment QALYs; this captures both longevity and quality improvements in a single metric for economic evaluation.
Double-blind = participants + investigators blinded; allocation concealment prevents selection bias at recruitment; both reduce different types of bias - they are separate but complementary design features.
Current UK antenatal infectious screening = HIV + hepatitis B + syphilis at booking (opt-out) = rubella susceptibility screening stopped in 2016 = early treatment reduces vertical transmission.
Cohort study = classify by exposure, follow for outcome; primary measure = relative risk; establishes temporal sequence; prospective design minimises recall bias.
Bayesian reasoning = pre-test probability × LR = post-test probability; high sensitivity (low LR-) is valuable for ruling out; D-dimer is a rule-out test only - it cannot rule in PE.
Outbreak investigation starts with confirming the outbreak exists - verify diagnosis and compare with expected baseline; the epidemic curve is the most informative descriptive tool for identifying the source.
Primary prevention = prevent disease occurring = healthy population = vaccination, health promotion, risk factor reduction = population-wide approach.
NHS Health Check = secondary prevention = screening asymptomatic adults 40-74 = every 5 years = QRISK3 risk assessment = detect and manage undiagnosed conditions early.
SEA = structured review of significant events = primary care quality improvement = blame-free analysis = required for GP appraisal = system learning to prevent recurrence.
Marmot Review 2010 = social gradient in health = 7 years life expectancy gap = 17 years disability-free gap = six policy objectives = inequalities worsened by 2020.
Measles HIT = 93-95% = highest of common infections = R0 of 12-18 = HIT = 1 - 1/R0 = small drops in MMR uptake cause outbreaks.
MMR = first dose at 1 year + second dose at 3 years 4 months = pre-school booster appointment = no link with autism = Wakefield struck off = live vaccine.
Lead time bias = earlier diagnosis = longer apparent survival = no true life extension = must use mortality rates not survival times to evaluate screening.
ITT = analyse as randomised = preserves randomisation = conservative estimate = real-world effectiveness = CONSORT requirement = per-protocol may overestimate effect.
Social determinants = conditions in which people live and work = account for 30-55% of health outcomes = Dahlgren-Whitehead model = addressing SDH is key to reducing health inequalities.
CBA = all outcomes in monetary terms = controversial in health = allows cross-sector comparison = CUA (QALYs) is NICE preferred = CBA used more in transport/environment economics.
RCT = randomisation + control + blinding = gold standard for treatment efficacy = minimises bias = Level 1b evidence.
Selection bias = study participants not representative = hospital controls = Berkson bias = controls should come from the same source population as cases.
Wilson-Jungner = 10 criteria for screening = important condition + latent stage + suitable test + accepted treatment + cost-effective = UK NSC applies these for NHS programmes.
OR = odds of exposure in cases / odds of exposure in controls = case-control study measure = cross-product ratio (ad/bc) = approximates RR when disease is rare.
AAA screening = one-off ultrasound = men aged 65 = <3cm normal = ≥5.5cm surgical referral = not offered to women routinely.
ICBs replaced CCGs from July 2022 = statutory NHS commissioning bodies = 42 ICSs across England = Health and Care Act 2022 = integrated planning across NHS and local authorities.
Duty of candour = tell patient when things go wrong + apologise + document = statutory (Regulation 20) + professional (GMC) requirement = Francis Report recommendation.
NNT = 1/ARR = most clinically meaningful measure of treatment effect = lower NNT = better treatment = always report alongside RRR for context.
Inverse care law = Julian Tudor Hart 1971 = healthcare availability inversely related to need = worse in market-based systems = deprived areas have poorest GP access.
TB contact tracing = stone-in-the-pond = household contacts first = expand if high infection rate = Mantoux/IGRA for latent TB = smear-positive is most infectious.
UK HPV programme = Gardasil 9 (nonavalent) = 9 HPV types = boys AND girls from 2019 = Year 8 (age 12-13) = one dose since 2023 = 87% cervical cancer reduction.
QALY = 1 year in perfect health = quality x quantity of life = EQ-5D measures utility = NICE threshold £20-30k per QALY = allows comparison across different disease areas.
95% CI = if repeated many times, 95% of intervals contain the true value = does NOT cross 1.0 for RR means significant = width reflects precision = preferred over p-values for reporting.
TB contact tracing = stone-in-pond approach; start with household/close contacts; expand outward if infection rates warrant it; screen with IGRA/Mantoux + CXR; treat latent TB to prevent progression.
Health Protection (Notification) Regulations 2010 = legal duty to notify = clinical suspicion sufficient = notify proper officer of local authority = measles is notifiable (HIV is not) = contact tracing follows.
8 weeks = 6-in-1 + MenB + rotavirus (oral) = PCV13 now given at 16 weeks (not at 8 weeks) = MMR at 1 year = HPV single dose at 12-13 years.
IMD = 7 domains = income, employment, education, health, crime, housing, environment = ranks LSOAs in England = area-level not individual = used for resource allocation and needs assessment.
DALY = YLL + YLD = one lost year of healthy life = Global Burden of Disease measure = used by WHO and IHME = higher DALYs = greater disease burden.
Forest plot: diamond not crossing the null line = significant; RR <1 = reduced risk; I² <25% = low heterogeneity; always check both statistical significance and clinical significance.
Always calculate the ARR and NNT from trial data - relative risk reduction can be misleading, particularly with low baseline event rates; 25% RRR sounds dramatic but NNT 100 reveals modest absolute benefit.
UK AMR strategy = stewardship + infection prevention + surveillance + research + international collaboration; reducing unnecessary prescribing is the most immediately impactful intervention.
Case-control = start with disease status, look back at exposure; efficient for rare diseases; measure = odds ratio; major bias = recall bias.
Cross-sectional = snapshot in time; measures prevalence; cannot establish temporal sequence or causation; useful for health needs assessment and generating hypotheses.
Systematic review + meta-analysis = gold standard of evidence synthesis; increases precision and power; cannot overcome biases in primary studies; always assess for publication bias and heterogeneity.
NNH = 1/absolute risk increase; it contextualises harm in absolute terms; always compare NNH with NNT to assess overall treatment benefit-harm balance.
never post patient-identifiable information on social media - always anonymise and obtain consent where possible for educational sharing.
always offer a chaperone for intimate examinations - this protects both patient and doctor, and the offer and patient's response should be documented.
never release records directly to a solicitor by phone - all requests must go through the trust's information governance or medical records department.
emergency life-saving treatment for an incapacitous patient is lawful under necessity and the MCA 2005 - never delay to seek formal consent.
respect the autonomous refusal of a capacitous Jehovah's Witness - optimise alternatives and document everything meticulously.
since December 2003, unmarried fathers named on the birth certificate automatically have parental responsibility - always check the date of birth and birth certificate status.
16-17 year olds can consent like adults, but unlike adults, their refusal can be overridden by parents or the court - this asymmetry is unique to minors.
the treating clinician is the decision-maker, but must consult widely - a best interests meeting is not a democratic vote but a structured consultative process.
restraint under the MCA requires both necessity to prevent harm AND proportionality - always try the least restrictive option first.
ACP is a voluntary, ongoing process of discussing future care wishes - it is broader than an ADRT and is not legally binding in itself.
PPC documents guide but do not legally bind - they are valuable communication tools that record patient wishes for use when capacity is lost.
palliative sedation is justified by the doctrine of double effect - the intention is symptom relief, not hastening death, and it is distinct from euthanasia.
assisted dying is illegal throughout the UK under the Suicide Act 1961 - respond to such requests with compassion, explore the underlying concerns, and offer palliative care support.
use the BTS algorithm - SpO2 >95% usually fine, 92-95% needs HCT, <92% likely needs in-flight oxygen - always assess individually.
an expert witness serves the court, not the instructing party - provide honest, impartial, evidence-based opinions within your competence.
for unbefriended patients lacking capacity, an IMCA provides essential independent advocacy - doctors also have a duty to advocate for their patients within the system.
Phase II is about efficacy in the target population and dose optimisation - Phase I is safety, Phase III is confirmation in large trials, Phase IV is post-marketing surveillance.
placebo-controlled trials are ethically questionable when effective treatments exist - the Declaration of Helsinki requires active comparator designs unless there are compelling methodological reasons for placebo use.
if you believe a referral is clinically necessary and it is refused, escalate - patient safety takes priority over hierarchical deference, and clear documentation is essential.
SBAR provides structure for safe handover - verbal communication for sick patients is essential, not optional, and written notes alone are insufficient.
safeguarding referrals cannot wait - any healthcare professional can refer directly to children's social care when abuse is suspected.
report immediately on Datix, manage the clinical risk, inform the patient under Duty of Candour, and support the staff member - never conceal a patient safety incident.
consent is a process of shared decision-making, not merely a signed form.
a valid advance decision refusing life-sustaining treatment must be written, signed, and witnessed - it has no automatic expiry date.
deaths with uncertain cause or that may relate to surgery or anaesthesia must be referred to the coroner - do not issue an MCCD without coroner approval.
where there is disagreement about withdrawing CANH, refer to the Court of Protection - withdrawal is lawful when treatment no longer serves the patient's best interests.
a competent adult's informed refusal is legally binding - even when the consequence is death, and family wishes cannot override patient autonomy.
IMCA instruction is mandatory for serious medical treatment decisions involving unbefriended patients who lack capacity - it is a legal duty, not optional.
supervision must match competence and risk - the delegating clinician retains responsibility and must ensure they can intervene if needed.
a health and welfare LPA holder has legal authority to refuse treatment - disputes should be referred to the Court of Protection.
confidentiality is owed to the patient - being a spouse confers no legal right to access another person's medical records.
raising concerns is a professional duty for all doctors - start locally with your supervisor and escalate if needed.
the professional duty of candour applies to individual doctors for all adverse events - be open, apologise, and explain what happened.
Section 2 is for assessment of unknown conditions lasting up to 28 days - it needs two doctors and an AMHP.
the audit cycle is only complete when changes are implemented and re-audit confirms improvement - always close the loop.
all interventional research involving NHS patients requires REC approval through the HRA - never start recruiting without it.
professional boundaries persist beyond discharge - the power imbalance from the doctor-patient relationship means extra caution is needed with recent patients.
exhaust all efforts to persuade the patient first, then disclose to the DVLA directly - this is a lawful breach of confidentiality to protect public safety.
RIDDOR reporting is the employer's responsibility, not the doctor's - maintain patient confidentiality and do not disclose medical information to employers without consent.
an inquest determines who, how, when, and where - not blame - but always seek medical defence organisation support when called to attend.
subject access requests require careful review for third-party data, potential harm, and exemptions - redact where necessary but default to disclosure of the patient's own data.
NICE uses cost per QALY analysis with a threshold of approximately £20,000-£30,000 - this framework aims to maximise population health benefit from finite NHS resources.
detained patients have a right to tribunal review - for Section 3, they can apply within the first six months and are entitled to free legal representation.
Section 117 aftercare is a joint statutory duty that must be provided free of charge with no means testing - it is not time-limited and covers a broad range of mental health services.
Section 135(1) requires an AMHP application to a magistrate for a warrant - police can then enter premises with the AMHP and a doctor to remove the person for assessment.
written consent is required, the patient has the right to see the report first, disclose only relevant information, and send it to occupational health - not directly to the employer.
always anonymise patient data for presentations and teaching - UK GDPR requires data minimisation and purpose limitation for special category health data.
the Fraser guidelines have five specific criteria - understanding, inability to persuade parental involvement, likely intercourse, health risk, and best interests.
Section 3 is for treatment of a known condition lasting up to six months and is renewable - unlike Section 2 which cannot be renewed.
England operates an opt-out organ donation system since 2020 - adults are deemed to have consented unless they actively opted out.
implied consent through voluntary actions is legally valid, but always ensure the patient understands what will happen and has the opportunity to ask questions or decline.
lawful abortion requires two doctors to certify statutory grounds on HSA1 - under 24 weeks, Ground C (risk to mental/physical health) is most commonly applied.
notifiable disease reporting is a statutory duty - the doctor must notify regardless of whether the patient consents.
the most important indicator of non-accidental injury is inconsistency between the history given and the pattern of injury observed.
the Cheshire West acid test determines deprivation of liberty - continuous supervision and not free to leave requires DoLS authorisation.
SPIKES starts with Setting up - ensure privacy, rapport, and a supportive environment before delivering difficult news.
the Caldicott Principles require using the minimum necessary identifiable information - always ask whether the purpose can be achieved without patient identifiers.
under a care order, the local authority shares parental responsibility and can consent to routine treatment - foster carers often have delegated authority for day-to-day medical care.
euthanasia is illegal throughout the UK - always distinguish it from lawful withdrawal of futile treatment and palliative sedation under double effect.
FGM in under-18s triggers a mandatory police report AND a safeguarding referral - this is a legal duty regardless of where the FGM occurred.
statutory Duty of Candour applies to moderate harm or above, but near-misses must still be reported for learning - transparency and honest reflection are hallmarks of good medical practice.
controlled drugs require rigorous prescribing, storage, and administration procedures including dual-nurse checking - these safeguards protect patients and prevent diversion or misuse.
guardianship provides three limited community powers (residence, attendance, access) - it does NOT authorise compulsory treatment or detention in hospital.
best interests decisions require consulting those who know the patient - appoint an IMCA if nobody is available.
one parent with parental responsibility can consent, but for controversial or non-urgent treatments, consider seeking agreement from both parents.
always try to persuade the patient first, but if they refuse and the public is at serious risk, disclose to the DVLA after informing the patient. Group 2 epilepsy requires 10 years seizure-free off anti-epileptic medication, not 5 years.
CTOs allow supervised community treatment after Section 3 with recall powers - they do not authorise forced medication in the community.
Rectal diclofenac or indomethacin before/after ERCP reduces post-ERCP pancreatitis by 50-60% - it is recommended for all ERCPs, and high-risk patients may additionally benefit from prophylactic pancreatic duct stenting.
Faecal elastase-1 below 100 µg/g indicates severe exocrine pancreatic insufficiency and warrants PERT with meals (NICE NG104, pancreatitis).
High-output ileostomy (>1500mL/day) causes dehydration and AKI - manage with IV fluids, loperamide, restrict hypotonic drinks, and isotonic oral rehydration; magnesium often needs IV replacement.
Type 1 = acute self-limiting; type 2 = prolonged, potentially reversible, often inpatient; type 3 = chronic, home parenteral nutrition dependent (ESPEN/BAPEN classification).
Full-thickness rectal prolapse shows concentric rings (mucosal prolapse shows radial folds) - laparoscopic ventral mesh rectopexy is the preferred surgical approach in fit patients; perineal procedures are for frail patients.
Trans-sphincteric fistulae require sphincter-preserving approaches (seton, LIFT) to avoid incontinence - fistulotomy is safe for simple intersphincteric fistulae only, and MRI maps the tract anatomy per Goodsall's rule.
Acute pilonidal abscess = incision and drainage first; reserve definitive excision or off-midline/cleft-lift surgery for elective treatment of the chronic sinus once infection has settled (ACPGBI).
Fulminant C. difficile requires oral vancomycin 500mg QDS plus IV metronidazole - IV vancomycin does NOT reach the colon; early surgical review is essential, and FMT is indicated for recurrent disease.
Peptic oesophageal stricture is managed with endoscopic dilatation plus long-term PPI - benign strictures are smooth and concentric, and biopsies must exclude malignancy.
Appendicitis is a clinical diagnosis - laparoscopic appendicectomy within 24 hours is standard, and CT is reserved for diagnostic uncertainty, especially in older adults.
EoE presents as dysphagia and food bolus impaction in young atopic males - ≥15 eosinophils/HPF on biopsy, treat with swallowed topical steroids or PPI, and dupilumab for refractory cases.
Chronic anal fissures are treated with GTN ointment plus stool softeners first-line - lateral sphincterotomy is reserved for medical treatment failures, and atypical fissures warrant investigation for Crohn's disease.
Mesenteric lymphadenitis presents as RIF pain in children after URTI - ultrasound showing enlarged mesenteric nodes with normal appendix distinguishes it from appendicitis; management is conservative.
Ascending cholangitis is Charcot's triad - emergency ERCP within 24-48 hours is the gold-standard drainage, and Reynolds' pentad indicates life-threatening septic cholangitis.
Tenofovir or entecavir are first-line for chronic hepatitis B - treatment criteria require elevated ALT plus significant fibrosis, and cirrhotic patients need lifelong HCC surveillance.
HRS is functional renal failure in cirrhosis - terlipressin plus albumin is first-line, liver transplantation is definitive, and the diagnosis requires exclusion of other AKI causes.
GISTs are CD117/DOG1-positive mesenchymal tumours - surgical resection is primary treatment, and adjuvant imatinib is given for intermediate/high-risk tumours based on size and mitotic rate.
FAP carries virtually 100% CRC risk - prophylactic colectomy is mandatory, and upper GI surveillance for duodenal adenomas is essential from age 25.
Proctalgia fugax causes brief, severe episodic rectal pain with normal examination - it is self-limiting and treated with reassurance; distinguish from levator ani syndrome which causes chronic constant rectal discomfort.
Chronic radiation enteritis develops months to years after pelvic radiotherapy with stricturing, fistulae, and malabsorption - radiation proctitis is treated with APC for telangiectasia, and surgery is high-risk in irradiated tissue.
SIBO causes low B12 and high folate - glucose hydrogen breath test is the pragmatic diagnostic test, and rifaximin is first-line treatment; address underlying structural or motility causes.
TIPSS is indicated for refractory ascites and refractory variceal bleeding - it reduces portal pressure but increases hepatic encephalopathy risk (~30%); contraindicated in severe HE or advanced liver failure.
Plummer-Vinson syndrome is the triad of oesophageal web, iron deficiency anaemia, and dysphagia - it is pre-malignant for postcricoid carcinoma, and iron replacement with endoscopic dilatation is the treatment.
Flucloxacillin causes delayed-onset cholestatic DILI weeks after the course - stop the drug and monitor; RUCAM score assesses causality, and Hy's law identifies high-mortality hepatocellular DILI.
DES causes intermittent dysphagia and chest pain with corkscrew oesophagus on barium - manometry shows premature contractions with normal LOS relaxation, distinguishing it from achalasia.
Whipple disease presents with diarrhoea, arthralgia, lymphadenopathy, and PAS-positive macrophages on duodenal biopsy - treat with ceftriaxone then co-trimoxazole for 12 months; oculomasticatory myorhythmia is pathognomonic.
Abdominal TB affects the ileocaecal region and mimics Crohn's - central necrotic lymph nodes and elevated ascitic ADA >40 distinguish it; treat with standard anti-TB therapy for 6-9 months.
Budd-Chiari presents with hepatomegaly, ascites, and pain - always screen for myeloproliferative disorders (JAK2 mutation); management is anticoagulation → TIPSS → transplant in a stepwise approach.
Acute portal vein thrombosis with SMV extension risks intestinal ischaemia - elevated lactate and bloody diarrhoea are red flags requiring urgent anticoagulation and surgical review for possible bowel infarction.
Pyogenic liver abscess >3-5cm requires percutaneous drainage plus IV antibiotics - identify and treat the biliary source, and distinguish from amoebic abscess in travellers.
SOD Type I (pain + abnormal LFTs + dilated CBD) responds to endoscopic sphincterotomy in around 90%; Type III (pain only) does NOT benefit from sphincterotomy per the EPISOD trial.
Insulinoma is diagnosed by the 72-hour fast showing elevated insulin and C-peptide during hypoglycaemia - most are small, benign, and cured by surgical enucleation; consider MEN1 screening.
Capsule endoscopy is first-line for obscure GI bleeding after negative OGD and colonoscopy - angiodysplasia is the commonest small bowel source in elderly patients, and device-assisted enteroscopy enables targeted therapy.
Angiodysplasia presents as cherry-red right colon lesions in the elderly - APC is first-line treatment, and Heyde syndrome links aortic stenosis with GI angiodysplasia via acquired von Willebrand disease.
Meckel diverticulum causes painless rectal bleeding in children from ectopic gastric mucosa - technetium-99m pertechnetate scan detects the ectopic tissue, and surgical resection is the definitive treatment.
GISTs are KIT-positive (CD117) mesenchymal tumours arising from muscularis propria - surgical resection plus adjuvant imatinib for intermediate-high risk; conventional chemo and radiotherapy are ineffective.
SRUS presents with rectal bleeding and straining - histology shows fibromuscular obliteration of the lamina propria; biofeedback and avoidance of straining are the mainstays of treatment.
Classical FAP (APC mutation) with established polyposis requires prophylactic colectomy (IPAA or IRA), not surveillance or chemoprevention alone; stage duodenal adenomas with Spigelman and watch for desmoid tumours.
Adhesive SBO without strangulation is managed conservatively ('drip and suck') for 48-72 hours - Gastrografin predicts resolution; surgery is indicated for strangulation, deterioration, or failure to resolve.
SBP is diagnosed by ascitic neutrophils ≥250/mm³ - treat immediately with IV cefotaxime plus IV albumin (day 1 and 3); prophylaxis with norfloxacin prevents recurrence.
HPS presents with platypnoea and orthodeoxia in cirrhosis - bubble echo confirms intrapulmonary shunting, and liver transplantation is the only definitive treatment.
Branch-duct IPMN without high-risk stigmata is managed with MRI surveillance - main-duct IPMN has high malignancy risk and usually warrants resection; high-risk stigmata include mural nodule ≥5mm, MPD ≥10mm, or jaundice.
Chronic pancreatitis causes both exocrine (low faecal elastase, steatorrhoea - treat with Creon) and endocrine (type 3c diabetes - brittle with hypoglycaemia risk) insufficiency; calcifications on CT are pathognomonic.
HRS is diagnosed after excluding other causes and failure of albumin challenge - terlipressin plus albumin is first-line treatment for HRS-AKI per NICE; liver transplantation is the definitive cure.
Locally advanced rectal cancer requires neoadjuvant chemoradiotherapy before TME surgery - MRI pelvis guides treatment decisions, and clear CRM is the critical prognostic factor.
tTG IgA is first-line for coeliac diagnosis - patients must be eating gluten during testing, and duodenal biopsies confirm the diagnosis with Marsh classification histology.
Sigmoid volvulus shows the coffee bean sign - endoscopic decompression with flatus tube is first-line, followed by elective sigmoid colectomy to prevent the high recurrence rate.
Boerhaave syndrome presents with Mackler's triad - CT with water-soluble contrast confirms the diagnosis, and early surgical repair within 24 hours offers the best outcomes.
Refeeding syndrome causes life-threatening hypophosphataemia - start at 5 kcal/kg/day for BMI <14, give IV Pabrinex before feeding, and monitor phosphate 12-hourly.
Dyspepsia plus alarm features requires urgent 2WW endoscopy per NICE NG12 - perioperative FLOT chemotherapy with gastrectomy is standard for resectable disease.
Ogilvie syndrome is colonic pseudo-obstruction in hospitalised patients - correct the cause first, and IV neostigmine is effective in 80-90% when conservative management fails.
SBS with jejunostomy has the highest PN requirements - intestinal adaptation occurs over 1-2 years, and teduglutide may reduce PN dependence by promoting mucosal growth.
Total gastrectomy causes inevitable B12 deficiency within 2-4 years - lifelong IM hydroxocobalamin is required, and monitor for iron, calcium, vitamin D, and folate deficiencies.
BAM causes chronic watery diarrhoea - SeHCAT retention <15% confirms the diagnosis, and bile acid sequestrants (colestyramine, colesevelam) are the treatment; up to 30% of IBS-D may actually be BAM.
H. pylori triple therapy is PPI plus amoxicillin plus clarithromycin for 7 days - confirm eradication after complicated ulcers, and stop PPIs 2 weeks before testing.
Lynch syndrome causes MSI-H tumours from MMR gene mutations - 2-yearly colonoscopy from age 25 and gynaecological surveillance for endometrial cancer are essential.
Flucloxacillin is the commonest cause of cholestatic DILI in the UK - diagnosis requires exclusion of other causes, and recovery is typically spontaneous over weeks to months.
CT abdomen is gold-standard for acute diverticulitis - the Hinchey classification guides management, and colonoscopy at 6-8 weeks excludes underlying malignancy.
CT angiography is first-line for haemodynamically unstable lower GI bleeding - mesenteric embolisation achieves haemostasis in 80-90%, and antiplatelet decisions require cardiology MDT input.
Inguinal hernias lie above and medial to the pubic tubercle - elective mesh repair prevents strangulation, and laparoscopic TEP/TAPP is preferred for bilateral or recurrent hernias.
Femoral hernias lie below and lateral to the pubic tubercle - they carry high strangulation risk, always require repair, and manual reduction of strangulated hernias is contraindicated.
Mallory-Weiss tears are self-limiting in 90% of cases - GBS 0 allows outpatient management, and Boerhaave syndrome must be excluded when pain is prominent.
PBC presents with pruritus, raised ALP, and positive AMA in middle-aged women - UDCA is first-line treatment, and obeticholic acid is second-line for non-responders.
Perianal abscesses require surgical drainage - antibiotics alone are insufficient, and 30-50% develop a fistula requiring MRI assessment and potential further surgery.
GBS is the pre-endoscopy risk tool for upper GI bleeding - a score of 0 allows safe outpatient management, and urgent endoscopy within 24 hours is standard for admitted patients.
Terlipressin plus prophylactic antibiotics should be started immediately in suspected variceal bleeding - band ligation within 12 hours is the endoscopic treatment of choice.
Empirical PPI for 4-8 weeks is first-line for GORD under 55 without alarms - use the lowest effective dose long-term, and review PPI prescriptions annually.
Caustic ingestion - no emesis, no charcoal, no neutralisation, and no blind NG tube. Resuscitate, keep nil by mouth, and arrange grading upper GI endoscopy within 24 hours (NPIS/TOXBASE; ESGE caustic injury guidance).
IBS is a positive diagnosis using Rome IV criteria - normal faecal calprotectin excludes IBD, and a low-FODMAP diet supervised by a dietitian is an effective dietary intervention.
FIB-4 is the first-line non-invasive fibrosis test for NAFLD - weight loss ≥10% improves fibrosis, and cardiovascular disease is the leading cause of death in NAFLD patients.
OAB first-line drug therapy = antimuscarinic or mirabegron after failed bladder training - avoid immediate-release oxybutynin in the elderly due to cognitive effects.
Bladder pain improving with voiding + frequency + negative cultures + glomerulations on cystoscopy = interstitial cystitis - multimodal stepwise management starting conservative.
Acquired bladder diverticulum from BPH causing stasis - diverticulectomy plus TURP to treat both the diverticulum and underlying obstruction simultaneously.
BK nephropathy = reduce immunosuppression, not increase it - SV40 staining distinguishes it from rejection; no proven antiviral therapy exists.
PTLD - reduce immunosuppression first; EBV D+/R− is highest risk; rituximab ± CHOP for monomorphic disease not responding to RI; antivirals do not treat established PTLD because the virus is latent.
Post-thyroidectomy hypocalcaemia requires IV calcium gluconate urgently - long-term management needs alfacalcidol (active vitamin D) because absent PTH prevents renal 1-alpha hydroxylation of cholecalciferol.
ADPKD management includes BP <130/80 with ACE inhibitor - tolvaptan slows progression in rapidly enlarging kidneys per TEMPO 3:4, and screen for cerebral aneurysms if family history is positive.
Gentamicin trough levels must be <1mg/L for once-daily dosing - nephrotoxicity is usually reversible but ototoxicity may be permanent, so withhold immediately if tinnitus or vestibular symptoms develop.
Testicular torsion is a clinical diagnosis requiring emergency surgery within 6 hours - do not delay for imaging, always perform bilateral orchidopexy, and the absent cremasteric reflex is the most sensitive clinical sign.
Supratherapeutic tacrolimus levels cause nephrotoxicity with hyperkalaemia and hypomagnesaemia - reduce the dose, recheck levels, and be aware of CYP3A4 drug interactions that increase CNI levels.
Drug-induced AIN presents with AKI, rash, eosinophilia, and white cell casts - PPIs are now the commonest cause, and corticosteroids are considered if no improvement after stopping the offending drug.
IV normal saline is the only proven preventive measure for contrast-induced AKI - N-acetylcysteine and bicarbonate have no proven benefit.
Paraphimosis requires urgent manual reduction - apply sustained pressure to express oedema then slide the foreskin forward, and perform a dorsal slit if manual reduction fails to prevent ischaemic injury.
CKD staging uses both eGFR and ACR - SGLT2 inhibitors provide renoprotection beyond glucose lowering per DAPA-CKD, and the blood pressure target in CKD is <130/80mmHg.
Recurrent UTI (≥3 in 12 months) can be managed with low-dose antibiotic prophylaxis or self-start strategies - methenamine hippurate is a non-antibiotic alternative per the ALTAR trial.
AUR requires immediate urethral catheterisation - start tamsulosin before TWOC to improve success rates, and monitor for post-obstructive diuresis which may require IV fluid replacement.
PD peritonitis is treated with intraperitoneal antibiotics (not IV) covering Gram-positive and Gram-negative organisms - catheter removal is reserved for refractory, relapsing, or fungal peritonitis per ISPD guidelines.
CMV treatment = valganciclovir 900mg BD or IV ganciclovir - not prophylactic dosing; D+/R− is the highest-risk combination for CMV disease post-transplant.
Cold, painful hand during dialysis with a strong thrill = arterial steal syndrome - DRIL procedure is the definitive surgical treatment preserving access function.
Severe hypokalaemia with ECG changes requires IV replacement at ≤20mmol/hr peripherally - always correct concurrent hypomagnesaemia, as hypokalaemia is refractory to treatment if magnesium is not replete.
Primary hyperaldosteronism requires adrenal venous sampling to confirm lateralisation before adrenalectomy - spironolactone is first-line medical therapy for bilateral disease, and the ARR is the screening test.
NSAIDs are contraindicated in CKD with heart failure - they inhibit prostaglandin-mediated afferent arteriolar dilatation, causing AKI, and the 'triple whammy' (ACE inhibitor + diuretic + NSAID) is particularly dangerous.
Pre-renal AKI has low urine sodium and high urea:creatinine ratio - withhold nephrotoxic drugs and resuscitate with IV 0.9% sodium chloride before considering dialysis.
Alport syndrome = nephritis + sensorineural deafness + anterior lenticonus, with basket-weave GBM on electron microscopy - ACE inhibitors slow progression.
C3 glomerulopathy = dominant C3 on IF with no immunoglobulins, low C3 with normal C4, and positive C3 nephritic factor - think alternative complement pathway.
Finerenone adds cardiorenal protection on top of RAAS blockade and SGLT2 inhibitors in diabetic CKD - monitor potassium before and after starting.
POSTCARDS mnemonic for papillary necrosis - a ring-shaped filling defect in the renal pelvis is a sloughed papilla until proven otherwise.
Chronic combination analgesic use + small kidneys with papillary calcifications + sterile pyuria = analgesic nephropathy - screen for urothelial malignancy.
Metolazone + loop diuretic = sequential nephron blockade - the first-line approach to diuretic resistance in cardiorenal syndrome with close electrolyte monitoring.
Glomerular endotheliosis is pathognomonic for pre-eclampsia - driven by anti-angiogenic factors (sFlt-1) from the ischaemic placenta causing endothelial swelling.
In IgA nephropathy, S (segmental sclerosis) and T (tubular atrophy/fibrosis) on Oxford classification are the strongest predictors of CKD progression - reflecting irreversible scarring.
Anti-GBM disease = linear IgG on biopsy - emergency plasmapheresis + cyclophosphamide + steroids to remove antibodies and suppress production.
Penile SCC - MRI penis for local staging, CT for nodal/metastatic disease; palpable inguinal nodes may be reactive, so antibiotics trial before biopsy.
Peyronie disease - conservative management during the active phase; surgery only after curvature has stabilised for ≥6 months and prevents intercourse.
Hydrocele = transilluminating scrotal swelling - ultrasound to exclude underlying pathology; surgery (Lord/Jaboulay) if symptomatic, aspiration is not definitive.
Candidal balanitis with white curd-like discharge in a middle-aged man - always screen for diabetes mellitus; also consider SGLT2 inhibitor as a cause.
Tacrolimus is the most important drug cause of PTDM - dose reduction is the key modifiable step, combined with lifestyle measures and standard diabetes treatment.
Kt/V target ≥1.2 for thrice-weekly HD - increasing session time is the most effective way to improve adequacy; also check access function.
PD peritonitis = intraperitoneal antibiotics covering Gram-positive and Gram-negative organisms; catheter removal for refractory, fungal, or relapsing peritonitis.
Low-risk prostate cancer (Gleason 6) is best managed with active surveillance per NICE NG131 and the ProtecT trial - radical treatment is reserved for disease reclassification or patient preference.
SGLT2 inhibitors are now standard renoprotection in CKD with significant albuminuria - an initial eGFR dip is expected and acceptable, and dual RAAS blockade is contraindicated.
Membranous nephropathy requires 6 months of supportive therapy first - anti-PLA2R antibodies confirm primary disease, and rituximab is now first-line immunosuppression per the MENTOR trial.
Anti-GBM disease shows linear IgG on IF and requires plasma exchange + cyclophosphamide + corticosteroids per UK Kidney Association/KDIGO 2021 - smoking increases pulmonary haemorrhage risk, and renal prognosis correlates with creatinine and crescent burden at presentation.
IM diclofenac is first-line analgesia for renal colic per NICE - tamsulosin aids passage of 5-10mm distal ureteric stones, and infected obstructed systems require emergency decompression.
Staghorn calculi are typically struvite stones caused by urease-producing bacteria - PCNL is first-line surgical treatment, and complete removal is essential to prevent recurrence and renal damage.
High-pressure chronic retention with bilateral hydronephrosis and renal impairment is an emergency - catheterise urgently, monitor for massive post-obstructive diuresis, and replace fluids aggressively.
MPGN with hepatitis C and cryoglobulinaemia is treated primarily with direct-acting antivirals - curing HCV resolves the cryoglobulinaemia, and rituximab is reserved for severe disease refractory to antiviral therapy.
mpMRI is the first-line investigation for elevated PSA per NICE NG131 and the PROMIS trial - targeted biopsy is performed only for PI-RADS ≥3 lesions, and transperineal biopsy has a lower infection risk than transrectal.
AV fistula is the preferred dialysis access with lowest infection and mortality - create at least 6 months before anticipated dialysis, and start HD based on symptoms rather than a fixed eGFR cut-off per NICE NG107.
Dialysis disequilibrium occurs with rapid urea clearance in new dialysis patients - prevent with short, low-efficiency initial sessions and consider IV mannitol for high-risk patients with severely elevated urea.
Type 1 RTA causes normal anion gap acidosis with urine pH >5.3, hypokalaemia, and nephrocalcinosis - treat with oral bicarbonate or potassium citrate, and screen for Sjögren syndrome as a secondary cause.
Lithium causes nephrogenic DI by downregulating aquaporin-2 - amiloride is the preferred treatment as it blocks lithium entry into collecting duct cells, and NDI shows no urine concentration after desmopressin.
Class IV lupus nephritis requires induction with cyclophosphamide or mycophenolate - the Euro-Lupus protocol reduces cyclophosphamide toxicity, and hydroxychloroquine should be continued in all patients.
Combination therapy (alpha-blocker plus 5-ARI) is recommended for BPH with prostate >30g and bothersome/severe symptoms per NICE CG97 - remember to double PSA values in men taking finasteride for accurate cancer screening.
PHPT shows elevated calcium with non-suppressed PTH and low phosphate - parathyroidectomy is indicated when complications are present, and FHH is excluded by calcium:creatinine clearance ratio.
Cranial DI shows dilute urine that concentrates after desmopressin - treatment with DDAVP requires sodium monitoring to prevent hyponatraemia, and post-surgical cases may follow a triphasic pattern.
A creatinine rise up to 30% after ACE inhibitor initiation is acceptable and expected - investigate for renal artery stenosis if the rise exceeds 30%, and never combine ACE inhibitor with ARB.
Diabetic nephropathy requires ACE inhibitor plus SGLT2 inhibitor for renoprotection - screen annually with urine ACR, and finerenone is an emerging additional agent per FIDELIO-DKD trial.
Supratherapeutic tacrolimus + bland urine + arteriolar hyalinosis on biopsy = CNI nephrotoxicity - reduce the dose rather than intensify immunosuppression.
Scleroderma renal crisis = ACE inhibitor first-line - do not substitute with other antihypertensives, and corticosteroids are a precipitating risk factor.
PSGN in children = low C3, normal C4, raised ASOT, 1-3 weeks after pharyngitis - >95% make a full recovery with supportive management.
Smooth, transilluminating, posterior to and separate from testis = epididymal cyst - reassure; surgery only if symptomatic, with fertility counselling.
Conservative kidney management = active supportive care without dialysis - not abandoning treatment, but focusing on quality of life, symptom management, and advance care planning.
Typical HUS = MAHA + thrombocytopenia + AKI after bloody diarrhoea; supportive management only; antibiotics contraindicated; atypical HUS = eculizumab (NICE HST1).
FSGS collapsing variant in HIV is primarily treated with antiretrovirals - secondary FSGS does not respond to immunosuppression, and the focus is on treating the underlying cause and reducing proteinuria.
PPI-induced hypomagnesaemia causes refractory hypokalaemia and hypocalcaemia - correct all three electrolytes concurrently, review PPI necessity, switch to famotidine if needed, and be aware of increased digoxin toxicity risk.
Retropharyngeal abscess in children - neck extension, drooling, widened prevertebral shadow; risk of rupture into airway and mediastinal spread via the danger space.
Ranula = blue translucent cyst in the floor of mouth from sublingual gland - excision of the sublingual gland is definitive; plunging ranula extends below mylohyoid into the neck.
Secondary post-tonsillectomy haemorrhage at days 5-10 requires admission, IV access, cross-match, IV antibiotics, and theatre preparation - never discharge a child with active post-tonsillectomy bleeding.
Anterior epistaxis from Little's area is managed with co-phenylcaine spray followed by silver nitrate cauterisation - only cauterise one side of the septum. Assess anticoagulation and blood pressure.
Presbycusis causes bilateral symmetrical high-frequency SNHL - hearing aids are first-line, and cochlear implants are considered for severe bilateral loss per NICE TA566.
Vestibular migraine causes episodic vertigo with migrainous features and normal audiometry - differentiate from Ménière by the absence of hearing loss. Migraine prophylaxis (propranolol, amitriptyline) is the mainstay of prevention.
Blocked tracheostomy - remove the inner cannula first (NTSP algorithm). For laryngectomy patients, the stoma is the only airway. Regular inner cannula care and humidification prevent blockage.
Severe ear pain in a diabetic patient + granulation tissue at bony-cartilaginous junction + cranial nerve palsy = necrotising otitis externa - Pseudomonas, prolonged IV antibiotics needed.
T1 glottic cancer (normal cord mobility) = radiotherapy or TLM with 85-95% cure rate and voice preservation; true cords have minimal lymphatic drainage, so nodal disease is rare.
Postauricular swelling + pinna displacement + loss of postauricular sulcus in a child with AOM = acute mastoiditis - IV antibiotics, myringotomy, CT, and cortical mastoidectomy if abscess.
Iatrogenic (post-septoplasty) is the most common cause of septal perforation - always exclude cocaine use and GPA; septal buttons provide non-surgical symptom relief.
Ramsay Hunt syndrome is VZV reactivation in the geniculate ganglion - triad of facial palsy, auricular vesicles, and audiovestibular symptoms. Treat with valaciclovir + prednisolone, and prognosis is worse than Bell's palsy.
Ménière disease presents with episodic vertigo lasting hours, fluctuating low-frequency hearing loss, and tinnitus - salt restriction and betahistine are first-line preventive measures.
Centor score ≥3 warrants antibiotics - phenoxymethylpenicillin is first-line per NICE NG84. Avoid amoxicillin if glandular fever suspected (EBV rash), and refer if peritonsillar swelling suggests quinsy.
Persistent hoarseness >3 weeks in a smoker requires urgent 2-week-wait referral - HNSCC risk is multiplicative with combined smoking and alcohol. Panendoscopy excludes synchronous primary tumours.
Cholesteatoma presents with foul-smelling otorrhoea and attic retraction with white keratin debris - surgery (mastoidectomy) is always required due to destructive potential including facial nerve palsy and intracranial complications.
NIHL shows a 4kHz audiometric notch with 8kHz recovery - distinguish from presbycusis by the notch pattern. Hearing protection above 85dB(A) is mandatory per UK noise regulations.
Vestibular neuritis causes persistent vertigo without hearing loss - positive head impulse test indicates peripheral pathology. HINTS test differentiates from posterior circulation stroke.
Ear foreign body removal should only be attempted once or twice by a skilled clinician - failed attempts worsen the situation. Button batteries are an emergency, and syringing is contraindicated for organic foreign bodies.
CPAP is first-line for moderate-to-severe OSA per NICE TA139 - AHI ≥30 is severe. Patients must notify DVLA if excessive sleepiness impairs driving ability.
HINTS differentiates central from peripheral vertigo - negative HIT, direction-changing nystagmus, and skew deviation indicate central pathology. Cerebellar stroke can mimic vestibular neuritis.
Unilateral OME in an adult mandates flexible nasendoscopy to exclude nasopharyngeal carcinoma - NPC obstructs the Eustachian tube and is strongly associated with EBV. This is a key clinical red flag.
Bell's palsy is a LMN facial palsy affecting the forehead - prednisolone within 72 hours improves recovery. Eye care is essential, and 85% recover fully. Always exclude Ramsay Hunt (vesicles) and UMN causes (forehead sparing).
Septal haematoma after nasal trauma requires urgent drainage - untreated it causes cartilage necrosis and permanent saddle-nose deformity. Always examine the septum with a speculum after nasal injury.
Button battery in the nose requires emergency removal within hours - liquefactive necrosis causes septal perforation rapidly. Never irrigate, and do not delay removal for investigations or specialist availability.
Chronic rhinosinusitis failing maximum medical therapy requires FESS to restore sinus drainage - continue intranasal steroids post-operatively to prevent recurrence per EPOS guidelines.
Submandibular stones = 80% of all salivary stones - distal palpable stone can be removed transorally; sialendoscopy for proximal stones; gland excision for recurrent/chronic disease.
Intranasal corticosteroids are the most effective single treatment for allergic rhinitis - superior to antihistamines for nasal congestion; avoid prolonged intranasal decongestant use (rhinitis medicamentosa).
Post-viral/post-COVID anosmia = olfactory training (4 scents, twice daily, ≥12 weeks) as primary evidence-based treatment; most recover but 10-15% have prolonged loss.
Sudden sensorineural hearing loss = ENT emergency - high-dose oral steroids within 72 hours; intratympanic steroids as rescue; MRI to exclude schwannoma but do not delay treatment.
Tullio phenomenon + autophony + air-bone gap with intact reflexes + CT showing bony defect = SSCD - the third window effect; surgery for debilitating symptoms.
Deep neck space abscess = surgical drainage + IV broad-spectrum antibiotics; watch for mediastinal spread (danger space) and airway compromise; dental infections are a common cause.
BAHA = bone conduction directly to cochlea - ideal for conductive loss with aural atresia or chronic discharge; softband first in young children, surgical implant from age 5.
Midline neck lump that does NOT move on tongue protrusion = think dermoid cyst; thyroglossal cyst moves upward on tongue protrusion - this is the key clinical distinction.
Parapharyngeal space post-styloid compartment contains the internal carotid artery, IJV, and cranial nerves IX-XII - major vessel injury is the key surgical risk during drainage.
Thyroglossal cyst = midline neck lump moving on tongue protrusion - Sistrunk procedure (cyst + tract + central hyoid body); ultrasound first to confirm normal thyroid exists.
Quinsy presents with unilateral peritonsillar swelling, trismus, uvular deviation, and hot potato voice - needle aspiration or I&D with IV antibiotics is the standard treatment.
Intranasal corticosteroids are first-line for moderate-to-severe allergic rhinitis - use regularly, not as needed. Avoid topical decongestants >7 days (rhinitis medicamentosa). Immunotherapy is for refractory disease.
Paradise criteria for tonsillectomy - ≥7/1yr, ≥5/yr for 2yrs, or ≥3/yr for 3yrs. Secondary haemorrhage at days 5-10 is the key complication. Each episode should be properly documented.
Laryngomalacia causes inspiratory stridor in neonates that resolves by 12-18 months - reassure parents and monitor growth. Supraglottoplasty is reserved for severe cases with feeding difficulties or apnoea.
Otitis externa is characterised by tragal tenderness - aural toilet plus topical antibiotic/steroid drops are first-line. Keep ears dry, and avoid aminoglycoside drops if the TM is perforated.
Asymmetric SNHL requires MRI IAMs to exclude vestibular schwannoma - it is the commonest CPA tumour. Bilateral VS indicates NF2. Management options include observation, radiosurgery, or microsurgery.
Ethmoid sinus adenocarcinoma in a woodworker = hardwood dust exposure - prescribed industrial disease in the UK; unilateral nasal symptoms are red flags for sinonasal malignancy.
Pleomorphic adenoma = most common salivary tumour - mixed histology, superficial parotidectomy (not enucleation); ~5% malignant transformation risk if left untreated long-term.
Nasal crusting + septal perforation + saddle nose + lung nodules + c-ANCA (PR3) = GPA - ENT manifestations often present first; induction with rituximab/cyclophosphamide.
CSF rhinorrhoea = beta-2 transferrin positive - main risk is meningitis; endoscopic surgical repair has >90% success; prophylactic antibiotics are NOT recommended.
Cochlear implant criteria - severe-to-profound SNHL (≥80dB) with inadequate hearing aid benefit (BKB ≤50%); BAHA is for conductive loss, not SNHL.
Pulsatile tinnitus + red/blue mass behind TM blanching on pneumatic otoscopy = glomus tympanicum - surgical excision for small tumours; check catecholamines preoperatively.
Nasopharyngeal carcinoma = EBV-associated, endemic in Southern China - concurrent chemoradiotherapy is standard; EBV DNA is a useful tumour marker; surgery is rarely primary treatment.
Most acute sinusitis is viral and self-limiting - antibiotics only if symptoms worsen after 10 days per NICE CG69. Orbital swelling complicating sinusitis requires urgent referral.
Cocaine is a common cause of anterior septal perforation in young adults - cessation, saline irrigation, and nasal emollients are first-line. Always exclude GPA with ANCA testing for unexplained perforations.
Ludwig angina = bilateral floor-of-mouth cellulitis with airway compromise risk - airway management is the first priority; caused by dental infections below the mylohyoid.
Displaced fresh tracheostomy (<7 days) - if replacement fails, cover stoma and ventilate orally; do NOT make repeated blind insertion attempts; NTSP algorithm at every bedside.
Pyriform fossa SCC = poor prognosis, presents late with dysphagia and neck mass; 5-year survival ~25-35%; referred otalgia via Arnold nerve is a red flag for hypopharyngeal malignancy.
Branchial cyst = anterior triangle, anterior to SCM, junction of upper/middle thirds - cholesterol crystals on FNA; in patients >40, ALWAYS exclude cystic nodal metastasis before assuming benign.
Globus pharyngeus = functional lump sensation without dysphagia or organic pathology - diagnosis of exclusion after nasendoscopy; reassurance is the mainstay of management.
Quinsy = needle aspiration or I&D plus IV antibiotics - trismus + unilateral peritonsillar swelling + uvula deviation is the classic triad; CT only if deep space infection suspected.
Zenker diverticulum = regurgitation of undigested food + halitosis + aspiration in an elderly patient - barium swallow diagnostic; endoscopic stapling is the preferred modern treatment.
Otosclerosis causes conductive hearing loss with a normal TM - Weber lateralises to the affected ear, and Rinne is negative. Stapedotomy offers 90% success and Carhart notch at 2kHz is characteristic.
Submandibular stones cause meal-related gland swelling - 80-90% of salivary stones occur in the submandibular gland. Conservative management first, with sialendoscopy or surgery for persistent stones.
Viral croup causes barking cough and stridor in toddlers - a single dose of oral dexamethasone is the treatment for all severities. Nebulised adrenaline for moderate-to-severe cases provides temporary relief.
Unilateral RLN palsy causes breathy voice and aspiration - post-thyroidectomy is the commonest surgical cause (left > right). Allow 9-12 months for recovery before surgical voice rehabilitation.
Mastoiditis presents with post-auricular swelling and pinna displacement - CT confirms the diagnosis. IV antibiotics and mastoidectomy if abscess present or failed medical management.
Sudden SNHL is an emergency - high-dose oral prednisolone within 72 hours improves outcomes. MRI IAMs is mandatory to exclude acoustic neuroma. Weber lateralises to the unaffected ear in SNHL.
LPR causes throat clearing, globus, and hoarseness without heartburn - lifestyle changes and twice-daily PPI for 2-3 months is the standard empirical trial. Nasendoscopy shows posterior laryngeal changes.
Malignant otitis externa presents with severe ear pain and granulation tissue at the bony-cartilaginous junction in a diabetic patient - Pseudomonas osteomyelitis requires prolonged IV antipseudomonal antibiotics.
Cisplatin causes irreversible high-frequency hearing loss in up to 80% - always perform baseline audiometry before starting. Concurrent aminoglycosides multiply ototoxic risk. Gentamicin is more vestibulotoxic; amikacin is more cochleotoxic.
Labyrinthitis = vertigo + hearing loss (cochlear + vestibular); vestibular neuritis = vertigo without hearing loss (vestibular only); HINTS exam helps exclude stroke.
PEG feeding in advanced dementia - the evidence says it does not help and may harm. Focus on comfort-oriented hand feeding and holistic care.
Intermediate care fills the gap between hospital and home - it prevents both prolonged hospital stays and premature care home placement.
In advanced frailty and dementia, ask 'is this medication helping the patient feel better today?' - if not, consider stopping it.
If you suspect elder abuse - ask, document, and refer. The Care Act 2014 places a duty on all professionals to safeguard adults at risk.
Parkinson's medication is time-critical - treat it like insulin. Late or missed doses can be catastrophic.
Always correct vitamin D deficiency before starting bisphosphonates - failure to do so risks symptomatic hypocalcaemia.
NSAIDs are the most commonly identified inappropriate medication in older adults - they worsen heart failure, kidneys, and bleeding risk simultaneously.
CFS 5 (mildly frail) = independent in basic ADLs but needing help with some instrumental ADLs - this guides treatment intensity and discharge planning.
Stress incontinence = leakage on exertion - pelvic floor exercises are first-line for at least 3 months before considering surgery.
If the bladder works normally but the patient cannot get to the toilet - it is functional incontinence. Fix the barriers, not the bladder.
Mixed incontinence = address both components simultaneously with conservative measures first, prioritising whichever symptom bothers the patient most.
ONS between meals, not instead of meals - supplement the diet, enhance food intake, and aim for high-protein high-calorie formulations.
Vasovagal syncope = prodrome + situational trigger + rapid recovery + normal ECG - focus on risk stratification to exclude cardiac causes.
The 4AT is quick, does not require training, and can be used even in drowsy patients - make it your go-to delirium screen.
Alpha-blockers are the most common medication cause of postural hypotension in older adults - always review before adding new drugs.
FRAX first, then DEXA if the result falls in the intermediate risk category - this is the NOGG recommended pathway.
Denosumab is the go-to second-line agent when bisphosphonates fail - and it is safe in renal impairment unlike zoledronic acid.
Statins for primary prevention can be safely stopped in frail elderly with limited life expectancy - the benefit takes years to materialise.
Think delirium first in any older person with acute confusion - it is always secondary to an underlying cause that must be identified and treated.
In delirium, always look for and fix the cause first - medications are the most treatable precipitant.
Progressive episodic memory loss with preserved personality = think Alzheimer's disease first.
BPSD management always starts with non-pharmacological approaches - antipsychotics are a last resort carrying serious risks in dementia patients.
The Frailty Index counts accumulated deficits - the more things wrong, the more frail the person, reflecting biological rather than chronological ageing.
Urge incontinence = bladder retraining first, then anticholinergics or mirabegron - but use anticholinergics cautiously in elderly men with prostatic enlargement.
MUST ≥2 = high risk - act immediately with dietary referral and nutritional supplements. Don't wait for the patient to deteriorate further.
Sarcopenia = low muscle strength + low muscle mass - exercise and protein are the evidence-based treatments, not medications.
Discharge planning starts on admission day - coordinate the MDT, assess the home environment, and provide reablement to maximise independence.
GSF helps identify patients approaching end of life early - proactive planning prevents crisis admissions and ensures patient preferences are respected.
All medical inpatients should be VTE risk-assessed on admission - enoxaparin 40 mg SC daily is standard prophylaxis for those at increased risk.
Constipation in elderly patients - always ask about opioids, fluids, and mobility before reaching for laxatives.
A day in bed is a day of decline - early mobilisation is a treatment, not a luxury. The 'End PJ Paralysis' campaign aims to get patients dressed and moving.
SMART goals transform vague aspirations into measurable targets - they are Specific, Measurable, Achievable, Relevant, and Time-bound.
CGA is the gold standard in geriatric medicine - it is the process that makes geriatric care distinct from general medicine.
When the MMSE seems normal but you suspect dementia - use the ACE-III, which better detects executive and language dysfunction.
Donepezil for mild-moderate Alzheimer's, memantine for moderate-severe - always check an ECG before starting cholinesterase inhibitors.
If in doubt about swallowing safety - keep nil by mouth and await SLT. The risk of aspiration pneumonia far outweighs the risk of short-term fasting.
Rewarm hypothermic patients gradually and gently - rapid warming kills. Monitor the heart continuously and treat the underlying cause.
A wound cannot heal without adequate protein - always check nutritional status when a pressure ulcer fails to improve.
Dementia diagnosis = must inform DVLA, but does not automatically mean stop driving - the DVLA makes the final decision after assessment.
Day 1 postoperative mobilisation is the standard of care for hip fracture patients - early movement saves lives and preserves independence.
Delirium prevention is non-pharmacological - the best medicine is good basic care: orientation, hydration, mobilisation, and sleep protection.
The MMSE is a screening tool, not a diagnostic test - a declining trajectory is more important than a single score.
Reablement is 'help to help yourself' - it is time-limited, goal-oriented, and focused on maximising independence rather than providing ongoing support.
Safeguarding is everyone's business - you must refer even if the patient initially declines, while continuing to respect their dignity and involvement.
Continence assessment is systematic - history, examination, dipstick, post-void residual, and bladder diary. Never assume incontinence is normal or untreatable.
Fragility fracture in women ≥75 = start bisphosphonate without waiting for DEXA - but always correct vitamin D first.
Alcohol withdrawal in hospital is a medical emergency - always screen for alcohol on admission and prescribe prophylactic reducing-regimen benzodiazepines for at-risk patients.
Heat stroke = temperature ≥40°C + confusion - cool aggressively, hydrate, and stop anticholinergic and diuretic medications immediately.
A cumulative ACB score ≥3 significantly increases delirium and cognitive impairment risk - always calculate the anticholinergic burden in confused elderly patients.
Displaced intracapsular fracture + mobile + cognitively intact = total hip replacement per NICE NG177.
Aim for surgery within 36 hours - reverse anticoagulation actively rather than waiting for it to wear off naturally.
Oxybutynin is the most anticholinergic bladder drug - avoid it in elderly patients. Mirabegron is the safer alternative for overactive bladder in older adults.
Delirium is usually multifactorial - think of it as a glass that overflows when multiple small insults accumulate.
Moderate-severe Alzheimer's = add memantine to the existing cholinesterase inhibitor - do not stop donepezil without good reason.
Constant dribbling + palpable bladder + high post-void residual = overflow incontinence - catheterise first, then investigate the cause.
Liquid stool in an elderly patient with constipation = think overflow, not diarrhoea - treat the impaction, not the symptom.
Postural instability in Parkinson's responds poorly to medication - physiotherapy and postural hypotension management are the mainstays of treatment.
ADRT = legally binding refusal of specific treatment; LPA = appoints a decision-maker; advance statement = wishes to be considered but not legally binding.
Osteoporosis diagnosis is based on the lowest T-score ≤ -2.5 at any measured site - always check both spine and hip values.
A pressure ulcer will not heal if the patient is malnourished - optimising nutrition is as important as optimising the wound dressing.
Falls-related medication review should consider the 'pharmacological cascade' - every drug that causes sedation, hypotension, or anticholinergic effects increases falls risk.
If a patient with revoked licence threatens to continue driving - you must inform the DVLA and document everything. Public safety overrides confidentiality in this situation.
Exercise is the single most effective intervention for preventing frailty - it is never too late to start, and osteoarthritis is not a reason to avoid it.
Clinical trial participation is always voluntary - patients can withdraw at any time without affecting their care. This is the cornerstone of ethical research.
Chemotherapy decisions must balance benefit, harm, performance status, and - above all - the patient's informed wishes. ECOG 3 + the patient's own preferences = best supportive care.
Dysphagia at any age is an automatic 2-week wait referral - it is one of the highest-yield alarm symptoms for upper GI malignancy.
CLL Binet stage A = watch and wait - never treat asymptomatic early-stage CLL as early treatment does not improve survival.
Painless jaundice + palpable gallbladder + weight loss + pancreatic head mass = pancreatic cancer - Courvoisier sign points away from gallstones.
Testicular GCTs = seminoma vs non-seminomatous - the classification determines treatment, markers, and prognosis.
Unexplained lymphadenopathy >4 weeks with B symptoms requires urgent 2-week wait referral - lymph node biopsy is diagnostic, not blood tests.
Brain metastases with raised ICP need immediate dexamethasone - treat the oedema before planning definitive management.
Persistent bloating in a postmenopausal woman + raised CA125 + complex adnexal mass = ovarian cancer until proven otherwise.
Post-orchidectomy tumour markers must fall according to their half-lives - failure to normalise or subsequent rise indicates residual disease needing treatment.
NICE does not recommend routine CA15-3 monitoring in breast cancer surveillance - clinical assessment and annual mammography are the standard approach.
Malignant hypercalcaemia = rehydrate aggressively first, then IV zoledronic acid - never give thiazides, which worsen hypercalcaemia.
Grade 3-4 immune-mediated colitis = withhold checkpoint inhibitor + IV corticosteroids immediately - escalate to infliximab if no response within 72 hours.
Low-dose CT is the screening tool for lung cancer - the NHS TLHC programme targets high-risk individuals and saves lives through early detection.
NHS bowel screening = FIT every 2 years from age 50-74 - a positive FIT leads to colonoscopy.
HPV vaccination is now a single dose of Gardasil 9 for all children aged 12-13 - gender-neutral vaccination maximises population protection against HPV-related cancers.
RMI ≥250 = specialist gynaecological cancer centre referral - calculate it for every postmenopausal woman with an adnexal mass.
Painless jaundice + palpable gallbladder = Courvoisier sign - think pancreatic head cancer, not gallstones.
U4-U5 thyroid nodules on ultrasound = always perform FNA cytology - microcalcifications in a solid hypoechoic nodule are highly suspicious for papillary thyroid cancer.
Breslow thickness determines the excision margin - for 2.01-4 mm, the margin is 2 cm. Breslow is also the most important prognostic factor in melanoma.
Ann Arbor staging = I, II, III, IV based on extent + A/B suffix for B symptoms - all lymph nodes above the diaphragm = Stage II, regardless of how many regions are involved.
Auer rods + DIC = think APL immediately - start ATRA without delay. APL is curable but DIC kills early if untreated.
CRAB = Calcium, Renal, Anaemia, Bone disease - the four cardinal features of myeloma. An ESR >100 with lytic lesions and paraprotein is virtually diagnostic.
Moderate-severe cancer pain = go straight to step 3 strong opioid (oral morphine first-line) - don't waste time with weak opioids when pain is significant.
BRCA1 = 60-80% lifetime breast cancer risk and 40-60% ovarian cancer risk - offer enhanced surveillance, risk-reducing surgery, and chemoprevention.
Painless visible haematuria in anyone aged ≥45 demands urgent 2-week wait referral - always assume malignancy until proven otherwise.
Hoarseness persisting ≥3 weeks requires urgent 2-week wait referral - always visualise the larynx before attributing voice change to a benign cause.
T = tumour size and local invasion, N = regional lymph node involvement, M = distant metastases - knowing the N stage is critical for surgical decision-making.
Oxaliplatin neuropathy is cumulative and may be irreversible - always warn patients before starting FOLFOX and consider dose modification early if symptoms develop.
A rising CEA after curative colorectal surgery demands further investigation with PET-CT - early detection of recurrence can enable curative re-intervention.
Postmenopausal bleeding is endometrial cancer until proven otherwise - always refer urgently via the 2-week wait pathway.
PI-RADS 4-5 on MRI prostate warrants MRI-targeted biopsy - the era of random biopsies as first-line is over per NICE NG131.
Back pain + progressive weakness + upper motor neuron signs in a cancer patient = MSCC - give dexamethasone immediately and arrange emergency MRI whole spine.
Facial swelling + distended non-pulsatile neck veins + upper limb oedema in a lung cancer patient = SVC obstruction - arrange urgent contrast CT and discuss with oncology/respiratory within the lung cancer pathway (NICE NG122). Stenting offers the fastest relief in severe cases.
Oral mucositis = good mouth care + adequate analgesia + nutritional support - exclude infection but do not empirically treat without evidence.
Day 10-14 pancytopenia after chemotherapy is the expected nadir - monitor closely, support the patient through it, and be vigilant for neutropenic sepsis.
Triple assessment = clinical + imaging + core biopsy - it is the standard of care for all breast lumps referred to specialist clinics.
SCLC is chemosensitive - platinum-etoposide is the backbone of treatment. Always consider immunotherapy (atezolizumab) and prophylactic cranial irradiation.
Trastuzumab requires LVEF monitoring every 3-4 months - cardiotoxicity is usually reversible if caught early, unlike anthracycline damage.
GnRH agonists cause testosterone flare for 1-2 weeks - always co-prescribe an anti-androgen to prevent flare, or use a GnRH antagonist instead.
Resectable gastric cancer = perioperative chemotherapy + surgery, decided by the upper GI MDT - the FLOT regimen is now the standard.
B symptoms = Fever + Night sweats + Weight loss >10% - pruritus and fatigue are NOT B symptoms despite being common in lymphoma.
Any unexplained breast lump in a patient aged ≥30 requires urgent 2-week wait referral - do not delay with routine investigations.
ECOG 0 fully active, 1 light work, 2 self-care no work (>50% up), 3 limited self-care (>50% bed/chair), 4 fully disabled, 5 dead; required for chemotherapy eligibility; document at every visit.
Neutropenic sepsis = IV antibiotics within one hour - this is a time-critical emergency where delays directly increase mortality.
Brain metastases with raised ICP = immediate dexamethasone to buy time, then MDT discussion for definitive treatment - never delay steroids.
Cisplatin = highly emetogenic = triple antiemetic prophylaxis with 5-HT3 antagonist + dexamethasone + NK1 antagonist as an absolute minimum.
Premenopausal ER-positive breast cancer = tamoxifen first-line for 5-10 years; postmenopausal = aromatase inhibitor. Never give AIs alone to premenopausal women.
Dukes C = any positive lymph nodes, regardless of T stage - this group benefits from adjuvant chemotherapy.
RCC produces EPO (polycythaemia), PTHrP (hypercalcaemia), and IL-6 (Stauffer syndrome) - the classic triad is rare but the paraneoplastic features are high-yield exam topics.
AFP elevation in a testicular mass = non-seminomatous germ cell tumour until proven otherwise - pure seminomas never produce AFP.
Gleason 3+3 = active surveillance first - avoid the side effects of radical treatment unless the disease progresses on monitoring.
HPV primary testing is now first-line in cervical screening - it is more sensitive than cytology and identifies women who need closer monitoring or colposcopy.
Barrett's oesophagus is THE key premalignant condition for oesophageal adenocarcinoma - surveillance endoscopy can detect dysplasia before cancer develops.
Phase III = large RCT comparing new treatment vs standard of care - this is the pivotal trial for regulatory drug approval.
If in doubt about any changing pigmented lesion, refer urgently - melanoma prognosis is strongly linked to early detection and Breslow thickness.
Nodular BCC = surgical excision with 4-5 mm margins as first-line - reserve Mohs surgery for recurrent, incompletely excised, or high-risk-site BCCs.
Bullous pemphigoid shows linear IgG/C3 at the basement membrane - tense blisters in the elderly with negative Nikolsky sign. Superpotent topical steroids or doxycycline are key management options.
Vitiligo is treated with potent topical steroids or calcineurin inhibitors first-line - screen for autoimmune thyroid disease, and narrowband UVB is used for widespread disease.
Venous leg ulcers require multi-layer compression bandaging (ABPI ≥0.8) as the primary treatment - healing occurs in 70% within 12 weeks per NICE CG168.
Arterial ulcers are deep, painful, and distal with ABPI <0.5 - compression is contraindicated. Urgent vascular referral for revascularisation and smoking cessation are priorities.
Use mild steroids or calcineurin inhibitors on the face - prolonged potent steroids cause atrophy and steroid rosacea. The fingertip unit guides quantity, and weekend therapy prevents flares.
Erythema nodosum with bilateral hilar lymphadenopathy and arthralgia is Löfgren syndrome (sarcoidosis) - EN is self-limiting and treated with NSAIDs and rest.
Seborrhoeic dermatitis affects sebum-rich areas with greasy scale - ketoconazole shampoo/cream is first-line. Severe disease in young adults should prompt HIV testing.
Irritant contact dermatitis is the commonest occupational hand eczema - negative patch testing distinguishes from allergic. Emollients after every hand wash and soap substitutes are the cornerstone of management.
Psoriatic arthropathy features DIP involvement, dactylitis, enthesitis, and nail changes - nail pitting in >80% correlates with joint disease. Methotrexate treats both skin and joints.
Erythroderma is a dermatological emergency with ≥90% BSA involvement - admit for temperature regulation, fluid/nutrition support, and systemic immunosuppression. Abrupt methotrexate withdrawal can precipitate it.
ACE inhibitor angioedema is bradykinin-mediated without urticaria - antihistamines are ineffective. Stop ACE inhibitor permanently, secure the airway, and never re-prescribe. Higher risk in Afro-Caribbean patients.
Tacrolimus 0.03% for children ≥2 years is a steroid-sparing option for facial eczema - no atrophy risk, ideal for sensitive sites per NICE TA82. Proactive twice-weekly application prevents flares.
Dermatomyositis presents with heliotrope rash and Gottron papules - mandatory malignancy screening is required as 10-25% have an underlying cancer within 3 years.
Hyperglycaemia impairs all wound healing phases - glycaemic optimisation is the priority. Wound healing requires adequate perfusion, nutrition (albumin >30g/L), and smoking cessation.
Seborrhoeic keratoses are benign 'stuck-on' lesions with horn cysts - no malignant potential. Sudden eruption of multiple lesions (Leser-Trélat sign) may warrant malignancy investigation.
Step up steroid potency when mild steroids fail - moderate potency for body, mild for face per NICE CG57. Emollients remain the foundation at every step of the treatment ladder.
Benign stable naevi require reassurance - advise sun protection and self-monitoring with ABCDE criteria. Prophylactic removal is not recommended for typical benign moles.
Vulval lichen sclerosus presents with porcelain-white patches in a figure-of-eight - ultrapotent topical steroid is first-line. Long-term follow-up is essential due to 4-5% SCC risk.
DLE presents with scarring disc-shaped plaques, follicular plugging, and permanent alopecia - hydroxychloroquine is first-line systemic therapy. Only 5-10% progress to SLE.
Bowen disease is SCC in situ - a well-defined scaly plaque with 3-5% risk of invasive SCC. Cryotherapy, 5-FU, or PDT are effective treatments depending on site and size.
Fixed drug eruption recurs at exactly the same site upon re-exposure - trimethoprim is one of the commonest causes. Residual hyperpigmentation between episodes is characteristic.
Localised tinea corporis is treated with topical terbinafine or clotrimazole first-line - avoid topical steroids alone which cause 'tinea incognito', and send skin scrapings for mycology confirmation.
Alopecia areata shows exclamation mark hairs with normal scalp skin - 80% regrow within 1 year for limited patches. Baricitinib (JAK inhibitor) is now approved for severe refractory disease.
Erythema multiforme presents with three-zone target lesions on acral sites - HSV is the commonest trigger. Suppressive aciclovir prevents recurrent HSV-associated EM.
FPHL shows crown thinning with preserved frontal hairline - topical minoxidil 5% is first-line. Treatment must be continued indefinitely as hair loss recurs on cessation.
Lichen planus presents with the 5 Ps and Wickham striae - oral involvement occurs in 50-70% and requires monitoring for malignant transformation (1-2% SCC risk).
Morphoea presents with a lilac ring border and ivory centre - it is distinct from systemic sclerosis. Active disease (lilac ring) responds to topical steroids, and morphoea does not progress to systemic disease.
Very potent steroids on the face cause steroid rosacea and dependency - gradual withdrawal with transition to calcineurin inhibitors is necessary. Striae and telangiectasia may be permanent.
Pityriasis rosea has a herald patch followed by Christmas tree distribution along cleavage lines - always exclude secondary syphilis with serology in sexually active patients.
Pemphigus vulgaris presents with oral erosions then flaccid blisters; suprabasal acantholysis with 'chicken wire' IgG pattern is diagnostic; rituximab is increasingly used early in management per NICE TA853 and BAD guidelines.
Suspected melanoma requires 2-week-wait referral per NICE NG12 - never shave biopsy, punch biopsy, or cryotherapy. The 7-point checklist guides referral urgency.
Molluscum contagiosum is self-limiting in immunocompetent children (12-18 months) - treatment is generally unnecessary. Extensive molluscum in adults should prompt HIV testing.
Most warts resolve spontaneously within 2 years - salicylic acid and cryotherapy are first-line treatments if intervention is desired. HPV vaccination prevents both genital warts and cervical cancer.
Mild plaque psoriasis is treated with a potent topical steroid plus vitamin D analogue first-line per NICE CG153 - escalate to phototherapy or systemics if topical therapy fails.
Lip SCC has higher metastatic risk - excise with minimum 5mm margins, assess palpable lymphadenopathy with imaging and biopsy, and smoking is a key risk factor for mucosal SCC.
DRESS presents 2-8 weeks post-drug with fever, facial oedema, eosinophilia, and hepatitis - allopurinol is a common cause. Systemic steroids with slow taper and monitoring for autoimmune sequelae are essential.
Actinic keratoses have a 5-10% risk of SCC transformation - treat with cryotherapy for single lesions or topical 5-FU/imiquimod for field treatment. Sun protection is essential.
Allergic contact dermatitis requires patch testing (type IV hypersensitivity) - not skin prick testing (type I). PPD in hair dye is the commonest cause in hairdressers.
Toenail onychomycosis requires oral terbinafine 250mg daily for 3 months - always confirm with mycology before systemic treatment, and check LFTs at baseline.
Eczema herpeticum presents with monomorphic punched-out erosions on eczematous skin - treat urgently with IV aciclovir. Temporarily stop topical immunosuppressants on infected areas.
Hidradenitis suppurativa involves recurrent nodules, abscesses, and sinus tracts in flexural sites - smoking cessation is the most important lifestyle intervention. Adalimumab is licensed for moderate-to-severe HS per NICE TA424.
Oral aciclovir within 72 hours of shingles rash onset reduces pain and complications - post-herpetic neuralgia is treated with amitriptyline or gabapentin, and Shingrix vaccine is offered at age 70-79.
Dermatitis herpetiformis is coeliac disease of the skin - granular IgA at dermal papillae is diagnostic. Dapsone gives rapid relief, but a lifelong gluten-free diet is the definitive treatment.
Pyoderma gangrenosum has violaceous undermined borders with pathergy - surgery is contraindicated due to pathergy risk. Associated with IBD and treated with immunosuppression, not antibiotics.
Drug-induced phototoxicity causes exaggerated sunburn on exposed skin - doxycycline is a common cause. It is dose-dependent and non-immunological, unlike photoallergy.
Linear IgA bullous dermatosis presents with 'cluster of jewels' blistering - vancomycin is the commonest drug cause. Linear IgA (not IgG) at the basement membrane confirms the diagnosis.
CSU refractory to four-fold antihistamines requires omalizumab per NICE TA339 - ciclosporin is third-line. CSU is self-limiting in ~50% within 5 years.
Nodular BCC presents with pearly rolled borders and telangiectasia - surgical excision with 4mm margins is standard treatment, and Mohs surgery is preferred for high-risk facial sites.
Pityriasis versicolor shows 'spaghetti and meatballs' on microscopy - treat with ketoconazole shampoo, and warn patients that pigment normalisation takes months after successful treatment.
Moderate acne requires combination topical therapy - adapalene/benzoyl peroxide plus topical antibiotic per NICE NG198. Never use topical antibiotics alone.
SJS requires immediate drug withdrawal - admit for IV fluids, wound care, and ophthalmology review. SCORTEN predicts mortality, and HLA-B*1502 screening is recommended before carbamazepine in at-risk populations.
SSSS causes superficial epidermal splitting from exfoliative toxins - mucous membranes are spared (unlike TEN). IV flucloxacillin is the treatment, and prognosis in children is excellent.
Always start low and titrate - immediate-release morphine 5mg every 4 hours is the standard opioid-naïve starting dose.
Always co-prescribe a stimulant laxative when starting opioids - constipation is the one opioid side effect that does not develop tolerance.
Calculate breakthrough morphine as one-sixth of the total daily dose - for this patient on 180mg daily, the breakthrough dose is 30mg immediate-release morphine.
Match the anti-emetic to the mechanism - gastric stasis responds to prokinetics like metoclopramide, chemical causes to haloperidol, and vestibular causes to cyclizine.
Low-dose morphine and a handheld fan are the first-line combination for refractory breathlessness in advanced disease - oxygen is not beneficial if SpO2 is adequate.
Glycopyrronium is first-line for death rattle - it reduces new secretion production and does not cause sedation, unlike hyoscine hydrobromide.
IV normal saline rehydration first, then IV zoledronic acid - this is the standard two-step treatment for hypercalcaemia of malignancy.
In advanced cancer cachexia, prioritise comfort and family communication; consider a short trial of dexamethasone or megestrol for appetite, and avoid PEG feeding or TPN, which do not reverse cachexia (NICE NG31).
Graded exercise is the most evidence-based intervention for cancer-related fatigue - bed rest worsens it, and pharmacological options are limited.
ADRTs refusing life-sustaining treatment must be written, signed, and witnessed - combine with a ReSPECT form for broader emergency care preferences.
In the last days of life, deprescribe non-essential drugs and prescribe anticipatory subcutaneous PRNs (morphine, midazolam, levomepromazine/haloperidol, hyoscine butylbromide) per NICE NG31.
Always refer to the coroner when death follows an accident, fall, or surgery - even if there is an underlying malignancy, the coroner decides whether to investigate.
Prolonged grief disorder is characterised by persistent yearning and functional impairment beyond 6 months - it is distinct from normal grief and major depression, and requires specialist bereavement support.
Terminal agitation (restlessness, picking at bedclothes) in the dying patient should be treated with midazolam SC - distinguish this from pain (localised, with guarding) which requires an opioid.
Fungating wound malodour - think anaerobes and reach for topical metronidazole plus odour-absorbing dressings, in line with NICE CKS palliative care guidance.
Pathological long bone fractures need surgical fixation (IM nail) plus postoperative radiotherapy - conservative management leads to unnecessary immobility and poor outcomes.
A single 8 Gy fraction is the standard palliative radiotherapy dose for uncomplicated painful bone metastases - it is as effective as longer fractionated courses for pain relief (Royal College of Radiologists palliative radiotherapy guidance; NICE QS reference for supportive and palliative care).
Cholestatic pruritus is not histamine-mediated - cholestyramine is first-line, and antihistamines are ineffective; escalate to rifampicin or ondansetron if needed.
treat insomnia in palliative care by tackling reversible causes and offering CBT-I first - use hypnotics only short term and avoid long-term benzodiazepines or Z-drugs.
Spiritual care is for all patients, not just religious ones - acknowledge existential distress and offer chaplaincy or psychological support regardless of faith background.
In collusion, acknowledge the family's fears, explain your duty to the patient's autonomy, and explore the patient's own wishes about information - never agree to withhold a diagnosis from a competent patient.
Auscultate for absent heart sounds for a minimum of 5 minutes when verifying death - this is the AoMRC standard to confirm irreversible cardiorespiratory arrest.
SVC stent provides the fastest symptom relief in SVC obstruction - it can be placed before histology is available and buys time for definitive oncological treatment.
Midazolam SC is first-line for terminal agitation - give a stat dose then add to the syringe driver for continuous infusion.
Lymphoedema management centres on compression and manual lymphatic drainage - diuretics are ineffective as the oedema is protein-rich, not fluid-overload.
Pressure care in dying patients should be proportionate - use pressure-redistributing mattresses and gentle repositioning for comfort, but avoid rigid protocols that cause distress.
Neuropathic pain requires adjuvant analgesics (amitriptyline or gabapentin) alongside opioids - opioids alone are insufficient, and NICE recommends tricyclics or gabapentinoids as first-line.
In a patient lacking capacity, life-sustaining treatment is governed by best interests under the Mental Capacity Act 2005 - relatives are consulted but cannot veto, and a court order is needed only when disagreement cannot be resolved by other means.
For symptomatic or extensive oral candidiasis in an immunosuppressed palliative patient, give systemic fluconazole; reserve topical nystatin for mild, localised disease.
Indwelling peritoneal catheters are the preferred option for recurrent symptomatic malignant ascites - they allow home drainage and reduce hospital visits.
Talc pleurodesis is definitive management for recurrent malignant pleural effusion with expandable lung - an IPC is the alternative if the lung is trapped.
SVCO with weight loss in a smoker is malignancy until proven otherwise - chest X-ray plus contrast-enhanced CT thorax is the key initial investigation, and histology should ideally be secured before definitive treatment (NICE NG122, lung cancer diagnosis and management).
DNAR is a medical decision but families must be informed and consulted - following Tracey v Cambridge, failure to discuss is unlawful unless doing so would cause serious harm.
Always start at the appropriate step of the WHO ladder - do not skip steps unless pain severity warrants it.
In SPIKES, always assess Perception before Knowledge - ask what the patient already knows before delivering the diagnosis to calibrate your communication.
Cyclizine is the most common cause of precipitation in syringe drivers - always check compatibility charts and consider alternatives.
Fast-track NHS Continuing Healthcare funding enables rapid discharge home for patients approaching end of life - it can be arranged within 48 hours.
The four anticipatory medications for dying at home are morphine, haloperidol, glycopyrronium, and midazolam - all prescribed subcutaneously PRN and kept in the home before they are needed.
In a dying patient with IV access and a prolonged seizure, give IV lorazepam 4 mg first; reserve buccal or subcutaneous midazolam for when there is no IV access, and continue background anticonvulsant cover subcutaneously (NICE NG217; SPICT/palliative care emergency guidance).
Bone metastases pain + NSAIDs contraindicated → dexamethasone adjuvant (4-8 mg OD with PPI); consider palliative radiotherapy and bisphosphonates/denosumab; gabapentinoids/TCAs for neuropathic component; ketamine specialist-only (NICE; SIGN 106).
A capacitous patient may refuse life-prolonging treatment - disagreement with the decision does not mean lack of capacity.
Diamorphine, haloperidol, and glycopyrronium is a classic compatible three-drug syringe driver combination for pain, nausea, and secretions in the dying patient.
Oral morphine to SC diamorphine ratio is 3:1 - divide the total daily oral morphine by three to get the 24-hour SC diamorphine dose.
Acute symptomatic PVD requires urgent dilated fundoscopy within 24 hours - 10-15% have an associated retinal tear. Visual field loss or shower of floaters suggests retinal detachment.
Episcleritis is benign and blanches with phenylephrine - scleritis causes severe pain, does not blanch, and requires investigation for systemic autoimmune disease.
Chalazion is a painless meibomian cyst - warm compresses for 6-8 weeks are first-line. Recurrent chalazia in the same location in older patients should prompt biopsy to exclude sebaceous carcinoma.
TED causes proptosis and lid retraction - compressive optic neuropathy is the sight-threatening complication. Smoking cessation is the single most important modifiable factor. IV methylprednisolone for active moderate-to-severe disease.
Full-thickness macular hole is treated with vitrectomy, ILM peel, and gas tamponade - >90% anatomical closure rate. Face-down positioning post-op is required, and early surgery gives better visual outcomes.
Acute dacryocystitis causes painful swelling inferomedial to the medial canthus - treat acutely with co-amoxiclav, then DCR once infection resolves to prevent recurrence.
BRVO causes sectoral haemorrhages at an AV crossing - hypertension is the most important risk factor. Investigate cardiovascular risk factors and consider thrombophilia screen if age <50.
Marfan syndrome causes superotemporal lens subluxation - homocystinuria causes inferonasal subluxation. Aortic root surveillance is essential due to the risk of aortic dissection.
Keratoconus presents with progressive irregular astigmatism in young patients - RGP lenses correct vision, and collagen cross-linking halts progression. Eye rubbing is the most important modifiable risk factor.
Hydroxychloroquine retinal screening with OCT annually from 5 years - renal impairment and high dose increase toxicity risk. Early OCT changes may be reversible if HCQ is stopped before bull's eye maculopathy develops.
Screen for ROP in infants <32 weeks or <1501g - first examination at 30-31 weeks PMA. Plus disease indicates treatment-requiring ROP, managed with laser or anti-VEGF.
Flashes, floaters, and a field defect 'curtain' indicate retinal detachment - this is an emergency requiring same-day referral. Macula-on detachments have the best visual prognosis with prompt surgery.
Leukocoria in a child requires urgent 2-week-wait referral to exclude retinoblastoma - the commonest primary intraocular malignancy of childhood. Bilateral cases indicate heritable RB1 germline mutation.
Post-operative endophthalmitis presents 1-7 days after cataract surgery with pain and hypopyon - intravitreal vancomycin and ceftazidime is the emergency treatment per the EVS protocol.
Childhood strabismus requires prompt ophthalmology referral to prevent amblyopia - patching or atropine penalisation of the dominant eye during the critical period is the treatment. Surgery corrects alignment but not amblyopia.
Prostaglandin drops cause iris hyperpigmentation (irreversible), eyelash growth, and periorbital fat atrophy - these are cosmetic side effects. Latanoprost remains first-line for POAG despite these effects.
AACG requires pilocarpine, timolol, and acetazolamide urgently - definitive treatment is laser peripheral iridotomy. Never use atropine (mydriatic) as it worsens angle closure.
Wet AMD presents with metamorphopsia and subretinal fluid - intravitreal anti-VEGF is first-line and must be started urgently. Smoking is the most important modifiable risk factor for AMD.
Toxoplasma retinochoroiditis presents as active retinitis adjacent to an old scar - the headlight in the fog appearance is classic. Treat sight-threatening lesions with pyrimethamine/sulfadiazine or co-trimoxazole.
Preseptal cellulitis has normal vision, full eye movements, and no proptosis - oral co-amoxiclav with close monitoring is appropriate. Any orbital signs require CT and IV antibiotics.
Chemical eye injury - irrigate immediately for at least 20-30 minutes until pH normalises. Alkali burns are worse than acid due to liquefactive necrosis and deep penetration.
Allergic conjunctivitis causes bilateral itch as the predominant symptom - topical olopatadine (dual-action antihistamine/mast cell stabiliser) is first-line. Topical steroids require specialist supervision.
A-AION from GCA requires immediate IV methylprednisolone to protect the fellow eye - jaw claudication is the most specific symptom. Biopsy within 2 weeks confirms the diagnosis.
Cataract surgery is based on functional impact, not a VA threshold per NICE NG77 - phacoemulsification is the standard technique. Endophthalmitis is the most serious complication, and posterior capsule opacification is the commonest.
Viral conjunctivitis has watery discharge and pre-auricular lymphadenopathy - it is self-limiting in 2-3 weeks. Antibiotics are not indicated, and strict hygiene prevents epidemic spread.
Right homonymous hemianopia localises to the left post-chiasmal pathway - DVLA prohibits driving unless visual field criteria are met. Meyer's loop (temporal lobe) causes 'pie in the sky' quadrantanopia.
Optic neuritis presents with painful visual loss and RAPD - 50% with abnormal MRI develop MS within 15 years (ONTT). IV methylprednisolone hastens recovery but does not change final outcome.
Per updated NICE NG81 (2022), offer 360° SLT first-line for newly diagnosed chronic open-angle glaucoma; a topical prostaglandin analogue (e.g. latanoprost once daily at night, 25-35% IOP reduction) is the first-line pharmacological agent when laser is unsuitable or declined.
Dry AMD with intermediate drusen benefits from AREDS2 supplements; smoking cessation is the single most important modifiable intervention, and Amsler grid monitoring detects conversion to wet AMD.
Proliferative diabetic retinopathy with NVD/NVE requires urgent PRP - DRS trial showed >50% reduction in severe visual loss. Pre-proliferative features (R2) predict imminent PDR and need ophthalmology referral.
Orbital cellulitis features proptosis, ophthalmoplegia, and reduced vision - distinguishing it from preseptal cellulitis. IV antibiotics and surgical drainage of abscesses are required. Sinusitis is the commonest cause.
Microbial keratitis in a contact lens wearer requires corneal scrape and intensive hourly topical antibiotics - Pseudomonas is the most aggressive organism. Never prescribe steroids without culture results.
Centre-involving diabetic macular oedema is treated with intravitreal anti-VEGF first-line - aflibercept and ranibizumab are NICE-approved. Intravitreal steroids are alternatives for pseudophakic patients.
Amaurosis fugax is a TIA equivalent - urgent carotid Doppler and cardiovascular assessment are mandatory. Hollenhorst plaque confirms embolic aetiology, and AF requires anticoagulation.
Congenital nasolacrimal duct obstruction resolves spontaneously in 95% by 12 months - lacrimal sac massage (Crigler technique) is the key conservative treatment. Probing is reserved for persistent cases beyond 12 months.