1 Flashcards
Farmer has 24 hour symptoms. Vital signs very bad hypotensive tachycardic and high resps, painful lymphadenopathy up right arm and paronchia of right thumb.
Orf, staphylococcal toxic shock syndrome, brucellosis
Orf
Man has 4 month sx of pain in heel which has stopped him walking. An XR demonstrates a Calcaneal spur.
Plantar fasciitis Calcaneal spur (or heel spur) is a bony outgrowth from the calcaneal tuberosity (heel bone) Plantar fasciitis is a common cause of calcaneal spurs. People who are obese, have flat feet, or who often wear high-heeled shoes are most susceptible to heel spurs.
According to NICE guidelines, a patient has a Qrisk of 20%. What Rx?
Atrovastatin 20mg OD: 10 year mortality Qrisk score > 10% -> Give statins
Statins should be taken at night as this is when the majority of cholesterol synthesis takes place.
A pt is informed that as per qrisk2 score, reduces risk heart disease 20%. How many patients like this would need a rx to save one person the bad CV event?
20
true positives
/
true positives + false negatives
sensitivity: ability to detect those with the disease
Specificity: ability to correctly identify those without the disease
TN/(TN+FP)
ECG with ST depression in v2-4. Which part of heart has been damaged
Posterior MI: usually left circumflex, also right coronary
Patient has sudden onset L facial weakness and R arm weakness. They have diplopia on L lateral gaze.
Answers: L cerebral, L brainstem, R cerebral, R brainstem, MLF.
L brainstem (Lateral medullary syndrome= L Brainstem)
Long chat about a guy with bradycardia. His ECG shows broad QRS complexes 40bpm regular and p waves at a rate of 75bpm. Is this 1st degree, 2nd or complete heart block.
Complete heart block
Pancreatitis guy gets v unwell with bibasal crackles his CXR is shown. What is dx
ARDS
CSF Glucose was 4.4 (2-4.4), opening pressure 80cm H20 (normal), lots of white cells.
Viral
HIV guy has brain MRI shows multiple ring enhancing lesions
Toxoplasma: 1st line prophylactic pyrimethamine + sulfadiazine + calcium folinate
AIDS pt has disseminated infection with chest, abdominal pain, diarheoa, vomiting etc. He is then treated with multiple drugs, which is most likely organism.
Mycobacterium avium-intracellulare
Patient with hypokalemia and hyponatremia. What is best Ix
Aldosterone and Plasma Renin Activity.
Cluster headache acute rx: triptans, O2, verapamil
O2
Description woman with dry eyes (Sjogen) what is rx?
Answers: Prednisolone, hypromellose artificial tears,
Rx - Artificial tears, Saliva replacement solutions, NSAIDs and hydroxychloroquine for arthralgia, Immunosuppression for severe systemic disease
Black guy lower 7th same pic as 5th year. Pic shows its lower coz eyebrow also weak. Next test
Examine ear – Infectious causes of facial nerve palsy -> VZV reactivation (RH syndrome), Otitis Media, Malignant otitis externa
Menieres description ie dizzy deaf and vertigo with ear fullness next Ix?
MRI inner ear, Audiometry
Audiometry
Weber lateralises to L ear, Rinne’s positive on the R (AC>BC)
Acoustic neuroma
Hearing loss, has FHx, worsen in preg
Otosclerosis
Ghanian girl 20yo collapses during badminton. O/E has pansystolic murmur mitral region (MR) and ejection systolic murmur (AS) and father had sudden death
HOCM
Patient with HF has found hypokalameia 2, what is cause
Metolazone
Patient has coarse crackles lower lobe. Describes CAP Whats commonest
Strep pneumo
Classic patient has pink urine. He had a URTI 3 days ago.
IgA nephropathy, Post strep
IgA nephropathy,
Heavy smoker has cavitating lesion at L hilum. Bronchoscopy reveals a lesion with Keratin pearl.
Squamous Cell Carcinoma, Adenocarcinoma, small cell carcinoma
Squamous Cell Carcinoma
Squamous Cell Carcinoma what is next tx
Surgery – unless mets -> Chemo/Radiotherapy
Old person has post prandial pain and pr clear
mesenteric ischemia
Classic stable angina but asthma
Calcium Channel Blocker,
Prolong survival HF
Spironolactone
Calcified heart on CXR kussmaul sign.
Tamponade, constrictive pericarditis, TB pericarditis
constrictive pericarditis
Woman has had headache and been at home a week. Is found unresponsive by neighbour. Her pulse 56, BP 166/86 and fast followed by slow breathing. Cause?
raised ICP
Supports a diagnosis of shy dragger? (type of MSA)
Orthostatic hypotension, atypical tremor, aphasia
Orthostatic hypotension
Pt has nonspecific sx nausea malaise etc and yellow tinge on white objects (Xanthochromia)
Digoxin
Pt has yellow tinge to scan after treated for infection why?
Coamoxiclav
long description of obvious pancreatic cancer first ix
Endoscopic Us, CT, AXR, Abdominal US
Abdominal US (also would do pancreas specific CT and LFTs 1st line
CT scan demonstrated huge renal cancer on R side. Biopsy shows which most likely histology?
Clear cell
Patient has huge ortho op and medullary nail for hip fracture. Next day comes in hugely unwell
fat embolism - Hypoxia + Neuro impairment + Petechai
GCS c. 5 What do you do?
Cuffed tracheal tube, laryngeal mask, tracheostomy
Cuffed tracheal tube
Pt has fit and you as doctor are told by patient he adamant will not tell DVLA. 1) Professional duty not legal to breach confidentiality, 2) legal duty to breach if in pts best interests
Professional duty not legal to breach confidentiality
Hypercalcaemia of malignancy 2 qns one in each paper. First was whats most important initial IV rx?
9% saline, Bisphosphonates
9% saline
what drug to use in hypercalcaemia: IV zoledronate (bisphosphonates), Furosemide
IV zoledronate
Neutropenic sepsis whats most likely org
e coli (previously -> now gram +ve cocci eg Staph, Strep)
Unknown Overdose during argument in a guy recently prescribed antidepressants- which drug. PT was 48, ast 64 (would expect in 1000s and think was an OD after 24 hours). no info pupils:
flumazenil, tricyclic, fluoxetine, paracetamol, Aspirin
Aspirin
2 years ago displaced fracture talus in accident. Now 2 yr later pain - xr shows sclerotic area middle of bone
AVN
Diabetic with ascending weakness. Weird power of how 4/5 and 3/5 mostly in arms and legs. can’t close eyelids properly, reflexes gone planters absent but sensation fine –
Gullian barre, DM, MG, MS.
Gullian barre (variant of GBS -> Miller Fisher syndrome… Ascending weakness + ATAXIA + OPHTHALMOPLEGIA + AREFLEXIA)
Pt has diplopia on R gaze
R abducent palsy
Disseminated renal cell. Progressive pitting oedema legs and distended abdo veins
Hypoalbuminaemia, inginal lymph nodes blocked, IVCO
IVCO
Guy has lots lesions with rough skin on bald forehead. This lesion predisposes to what?
SCC
Guy on clozapine for schizophrenia and ivdu comes in. o/e neck stiffness, moving all limbs, t39.8 13/15 gcs.
bact mening, abscesses, NMS, SS
NMS
Common to both:
- drug reaction - often young patients
- tachycardia, raised BP
- pyrexia, diaphoresis
- rigidity
- IV fluids and benzos tx
Serotonin syndrome:
- Caused by SSRIs, MAOIs, ecstasy/novel psychoactve stimulants
- faster onset (hours0
- increased reflexes, clonus, dilate dpupils
- mx severe cases: cyproheptadine, chlopromazine
NMS:
- Caused by antipsychotics
- slower onset (hours-days)
- decreased reflexes, ‘lead-pipe’ rigidity
- normal pupils
- Mx of severe cases: dantrolene
Diabetic with bad kidney function gfr low, creatinine>150. What drug to start after diet?
metformin, gliclazide
Glicazide
Guy painful retention and u+e off - USs shows vv distended bladder.
Uro referral, catheter
catheter
Single marker prognosis in Hodgkin?
crp esr albumin
albumin
Hoarse voice weak cough post thyroidectomy
neurpraxia of recurrent largyneal, laryngeal oedema, heamatoma
Neurpraxia of recurrent largyneal
Patient with papules pustules, telangiectasia, red flushing on face
Rosacea
In a new trial, why does orally administered drug have lower area under curve than iv?
First pass hep metabolism: The drug is absorbed from the GI tract and passes via the portal vein into the liver where some drugs are metabolised. Sometimes the result of first pass metabolism means that only a proportion of the drug reaches the circulation Alternative routes of administration like suppository, intravenous, intramuscular, inhalational aerosol, transdermal, buccal and sublingual avoid the first-pass effect because they allow drugs to be absorbed directly into the systemic circulation.
In RCT, if there is a large nocebo effect, what does this mean?
unblinding has occurred: Nocebo effect = negative expectations of the patient regarding a treatment cause the treatment to have a more negative effect than it otherwise would have. Eg anticipating side effects of a medication -> ptn suffers that effect even if the “medication” is actually an inert substance
Woman has breast lump removed for which the pathologist provides their standard report. For which of these in further investigation needed?
Grade, stage, ER status, completeness of excision.
completeness of excision
Death certificate easy pt has RLL crackles after being admitted. Rx but dies next day whats 1a?
Part 1 = Cause of death
Part 2 = Conditions that contributed to death/made patient weaker eg. IHD (2) -> Pneumonia (1a)
Anxious banker worried about work palpitations at night. What u do as GP
arrange ecg, confident it’s not arrhythmia but can’t be sure
proteinuria and oedema. what’s most likely cause
Focal segmental now more common than membranous in adults
CML treatment
Imatinib
inhibitor of the tyrosine kinase associated with the BCR-ABL defect
very high response rate in chronic phase CML
Guy hit from behind car accident, immediate pain shoulder neck and spasm muscles. Ix and exam all normal at first, but still pain at 4 weeks despite normal XR and exam , next ix?
Mri or refer neuro
MRI - check for other injuries
Man has pickled beetroot he made few days ago and some weakness in face (non specific, would expect multiple palsies):
clostridium botulinum
Kid has muscular hypertrophy amd struggling to run with kids 3 years. He has huge calves. Where is the problem?
Anterior horns cells, peripheral, striated muscle
striated muscle - muscular dystrophy - problem in dystrophin a protein in the cytoskeleton
A young guy has just come back from a 3 month trip in the south of Africa and has had 2 weeks of frank hematuria. A urine dipstick demonstrates 3+ myoglobin. Which is likely cause?
Schistosomiasis, strongyloides.
Schistosomiasis
Schistosomiasis next investigation
Terminal urine microscopy
Patient has treatment for RA and then gets extensive and widespread TB, what is likely cause?
Infliximab – immunosuppression reactivates TB… Primary -> Latent -> (Reactivated) Secondar
Pt has had injury to leg and had morphine but in anguish, what next rx? Increase morphine, ignore because patient is druggie, refer to surgeons for fasciotomy
refer to surgeons for fasciotomy
Teratoma tumour marker
AFP (also markers for HCC)
Lady with 1 episode of PMB, O/e atrophic vaginitis (common cause of PMB) description of pink raw genital skin, her TV USS shows endometrial thickness 3mm. rx?
AV Mx: Vaginal lubricants, Topical oestrogen cream
PMB -> 2ww TVUS to assess endometrial thickness
If endometrial thickness >4mm -> pipelle biopsy to assess for endometrial hyperplasia or cancer
- Pt after RTA 1g IV paractemeol but still in pain, next rx?
Para -> NSAID -> Weak opioid (codeine) -> strong opioid (morphine or pethidine – caution in RF)
Neuropthic pain: National Institute of Clinical Excellence (UK) guidelines:
- First line: Amitriptyline (Imipramine if cannot tolerate) or pregabalin
- Second line: Amitriptyline AND pregabalin
- Third line: refer to pain specialist. Give tramadol in the interim (avoid morphine)
- If diabetic neuropathic pain: Duloxetin
Woman 30yo who has been in UK 8 years , originally from brazil. Has pain, tingling, sensory loss all limbs v weird no obvious pattern. Has thickened ulnar and peroneal nerves. Answer likely Leprosy therefore rx is
dapsone, rifampicin, and clofazimine.
Description of diabetic gastroparesis (vagus neuropathy -> gastroparesis slows) young T1DM ha dyspepsia and nausea after meals what is best rx -
Stimulate stomach muscles: Metoclopramide, Domperidone and Erythromycin (other anti-emetics to control nausea
25yo from Bangladesh 2 week ago gram negative rods were grown in aerobic and anaerobic bottles, had rash buttocks thighs (rose spots – patchy red macules). which organism?
salmonella typhi/paratyphi – also look for a relative bradycardia
Post splenectomy most likely strep pneumo. One person told me that qn said pt was on prophylactic penicillin V, which is most likely org. If it says that then answer is
haemophilus influenza
Contrast CT showing focal bilateral temporal involvement:
This patient had prolonged seizure then died
HSV encephalitis
Guy has transjugular shunt, and next day noted to be solmnent. Why?
TIPS predisposes to hepatic encephalopathy because ammonia can reach brain and cause osmotic change, damaging astrocytes
Wasted small muscles hand, abduction adduction and thumb adduction all weak. Loss of sensation of medial aspect of forearm . Triceps biceps reflexes and finger flex normal. L arm normal
T1 or c8 lesion
Guy who plays golf with pain at lateral epicondyle (of humerus) what muscles weak?
Radial nerve affected - extensors wrist (ie muscles on ventral aspect of forearm)
Description of asthma lady who has exacerbations despite SABA LABA and ICS at maximum dose, what next?
PO pred, or leukotriene receptor antagonist,
leukotriene receptor antagonist:
1) SABA
2) +ICS
3) LABA +ICS or trial or LTRA/theophilline/LAMA
4) high dose ICS or trials above adding 4th drug
5) oral steroid
Lady with UC, has been well controlled for 3 years with mesalazine, now admitted with severe 8 bloody stools/d ,
- increase po mesalazaine, give po pred or iv hydrocortisone
iv hydrocortisone
Guy dysuria for 4 days and 4 raised painful lesions on corona of penis
herpes simplex
How does sildanefil cause postural hypotension
PDEV inhibitor resulting in vasodilation
Ground glass hepatocytes: aa1 low levels, Wilsons, hepatitis B
hepatitis B
A man has polycythaemia which is well treated. He then moves practice area and represents 2 years later with distended abdomen and dilated abdominal veins. Portal vein, splenic vein thrombosis
Polycythaemia Rubra Vera which causes Budd Chiari = HEPATIC vein thrombosis
- Primary BCS: PRV, Pregnancy, OCP, HCC, Lupus anticoagulants
- Secondary BCS: Compression by external structure eg. tumour
painful knee t 38.5. Start empirical abx or urgent aspirate and ix fluid?
urgent aspirate
Guy tired all time normal t4 7, tsh <0.01, testosterone also low 0.02
hypopituitarism
Man has painful face and headache with no cause found. He represents a few days later with a few red bumps which extend past the orbit to midline, what is like nerve affected?
Trigeminal opthalmic branch: herpes zoster ophthalmicus
Guy with HIV has culture with silver stain which is positive, organism?
Aspergillus, Pseudomonas, Legionella, Pneumocystis, Cryptococcus, Candida all silver +ve
Ix for pulseless cold R leg?
Ix = Doppler US (both limbs) +/- CT angiography (esp if limb salvageable, gather more info)
profound paralysis with complete lack of sensation or fixed mottling = unsalavagable
guy punched someone 3 days ago. Oe cut on 3rd knuckle and exquisitely tender on palmar aspect and can’t move passively.
surgical debridement and iv abx w
LMN 7 palsy presents at 48hr, what rx is indicated
Tx LMN CNVII with prednisolone within 72hrs, + Valaciclovir if VZV
Guy during flexible cystoscopy becomes unresponsive and HR 38 bradycardic. 1st rx?
atropine
Guy has COPD, which spirometer value high will be high?
Hyperexpanded: HIGH TLC and Residual Vol
FEV1 <80%
FEV1:FVC <0.7
V myopic (near-sighted) person sudden loss vision curtain in eye
Retinal detachment (NB myopia major rf for development of RD)
Someone addisonian. Descrption was electrolytes show low Na, high K, has postural drop in BP of like 20/10, and looks unwell. What is best rx?
100mg hydrocortisone
9am cortisol low what’s best dx for addisons?
24 hr cortisol urine (used in Cushings – see loss of diurnal variation with increased midnight cortisol) or Addisons Ix: 9am cortisol (LOW), 9am ACTH (HIGH) Synacthen test (cortisol doesn’t rise
Guy had UTI and was treated with Abx. At review appointment, cr 430 and k high most likely dx?
ckd likely undetected – Trimethoprim in CKD ptn -> Raised Cr and K
Pt is pen allergic, what drug can u give?
Teicoplanin, cephalosporin, meropenem, tazocin and co-amoxiclav
Teicoplanin (glycopeptide - same as vancomycin)
Person has CAP and has sugar 8. Checked 6 weeks later 5 fasting and 7 ogtt why was it higher during the CAP?
Stress hyperglycaemia
Old woman with osteoporosis has severe pain trying to lift shopping bag first ix?
Plain xr
Pt having a GI bleed is peripherally ‘shut down’ and it is decided to cannulate his subclavian vein, what is the most likely complication?
subclavian artery damage
Carotid artery damage is actually more common if answer
Pt admitted who is alcoholic, given 2 pictures of bad teeth and another of hair follicles with parafollicular haemorrhage, what is the likely deficiency?
vitamin C (Scurvy)
What to give with tb drugs?
Pyridoxine (vitamin B6, otherwise will be depleted by isoniazid causing peripheral neuropathy)
Metallica valve warfarinised but has taken erythromycin and INR now 9.1, presents with nosebleed. 10mg or 1mg vit k IV?
Major bleeding: 5mg IV
Minor bleeding: 1-3mg IV
No bleeding and INR>8 = 1-
Pt on rchop chemo, why hyperglcaemia?
Prednisolone
Young Pt on chemo, why’d he develop heart failure
Doxirubicin
Pt rxed chemo obs on wr normal. 30 mins later fucked and after 3l resus doesn’t help her sats, what is likely pathogen?
staph aureus -> major cause of Neutropenic Sepsis (used to be EColi; more likely endogenous pathogen)
Pt ra and spleen. Whats most likely finding on blood?
Neutropenia - Feltys
Obv description of pt has UC. What is most likely histology?
Villous atrophy, intraepithelial lymphocytes, superficial ulceration, crypt abscesses.
superficial ulceration
Pt to be discharged. Their previous FBCs from past 3 days show a slowly correcting hyponatraemia, what do u recommend?
Hold fruseomide and see what happens
Pt severe resp infection has na 119 and urinary na 70. Rx?
SIADH Mx: IV hypertonic saline (if severe) + Fluid restriction + Tx underlying cause + Furosemid (if acute) + Vasopressin-R antagonist (if chronic)
Pic of vf loss right superior quadrantopia which lobe is lesion
Temporal – UPPER Quadrantanopia
Parietal – LOWER Quadrantanopia
Rheumatic fever crp 300. Admitted. Whats cause, ie?
Streptococcus pyogenes
Question about patient on medications for stress incontinence, what is likely cause of their confusion and retention?
Oxybutynin
Patient has continuous urine leakage needed pads for 1 year, hx includes radiotherapy for cervical cancer, cause?
Vesicovaginal fitsula
Woman 4 episodes hemoptysis all tests normal but cxr still shows this rounded peripheral lesion? Dx?
Cancer
Guy has collapsed in football. Had undescended testis fixed at 4. Given CT chest with so many mets, most likely histology?
non-seminoma germ cell tumour
Which of following is most specific sign of LVF?
S3 gallop, S4, ejection systolic murmur
S3 gallop
