2022 paper Flashcards
74 y/o patient on an assortment of medications for the past 10 years, presents with a #NOF low impact (think she kicks a football to her grandson and has a fracture) subtrochanteric femur #. Which drug is the most likely cause?
- Omeprazole
- Alendronic acid
- Bendroflumethiazide
- Atorvastatin
Alendronic Acid or omeprazole
This seems like a buzzwordy question and the mention of a low imapct and a subtrochanteric femur fracture which is atypical seems to be suggesting that the answer should be alendronic acid.
Bisphosphonates used for over 8 years is associated with atypical fractures….
HOWEVER Omeprazole use over one year is associated with fractures and according to the BNF, Omeprazole and fractures is uncommon, whereas alendronic acid and atypical fractures are rare or very rare.
so pick one of those 2, the buzzword style makes me lean towards alendronic acid.
Patient has hyperkeratosis suggesting Tinea pedis, what is the causative organism?
In between toes…
- Candida albicans
- Trichophyton rubreum
- Bacteria
- Bacteria
- Bacteria
Trichiphytum Rubreum
The Tinea Pedis is another name for athletes foot. The causative organism of tinea pedis is trichophytum rubreum.
SVC symptoms with lung mass in right upper lung. What is diagnostic investigation?
- CT chest
- Venography
- CT head
- Subclavian artery doppler
CT chest
Superior vena cava syndrome is the description of symptoms caused bu the obstruction of the superior vena cava.
This presents as
* oedema of the face
* Facial plethora
* distended veins
* Cough and or shortness of breath
The investigations are
* CXR
* CT Chest with contrast
* MRI
Venography may be considered
Prostate metastases to the spine, sclerotic, back pain, no nerve impingement, no fractures, PO morphine is not working.
- Tramadol
- Bisphosphonate
- IV zolendronate
- Radiotherapy
- Surgery
IV Zolendronate or bisohosphonate
This is a bisphosphonate. It is reccomended that for metastatic disease of the prostate, breast cancer or in multiple myeloma that is causing spinal metastatic bone pain, bisphosphonates should be used in the management of pain.
WITH PROSTATE CANCER ONLY AFTER OTHER TRADITIONAL METHODS HAVE BEEN ATTEMPTED… Hence the PO morphine in this case.
Overdose, dilated pupils with widened QRS. Patient refuses to disclose what medication was overdosed. What was the agent?
- Amitriptyline
- Diazepam
- Gabapentin
- Tramadol
- Codeine
Amitriptyline is a TCA. This leads to a dilation of pupils and can cause a prolonged QRS
Tramadol and codeine are both opiates and so will cause pinpoint pupils…
Diazapam is a benzo and an overdose in this would cause sedative symptoms. Drosimess, slurred speech etc.
History of atopy, with pollen being the trigger. Now spring and both eyes are watery, red and sore.
* Antihistamine eye drop
* Steroid eye drops
* Steroid orale
Anti-histamine eye drops if option for hypermellose I would go for that over this…
This is describing hay fever or allergic conjunctivivtis.
Allergic conjunctivitis is one of the causes of acute conjunctivitis… This presents with red eyes that is watery. If the symptoms are mild the management is artificial tears, with avoidance of trigger such as wearing glasses. For moderate disease the management is topical antihistamines that can be escalated to the use of topical steroids use.
Mild allergic conjunctivitis refers to itchy, watery, red eyes occurring seasonally and responding to supportive measures, including artificial tears and cool compresses.
Main DMARD for rheumatoid arthritis
- NSAID
- Methotrexate
- Hydroxychloroquine
- Azathioprine
Describe presentation of Rheumatoid arthritis
Methotrexate
Correct statin target 3 months after starting treatment:
- > 25% reduction in total cholesterol
- > 40% reduction in non-HDL cholesterol
- Total cholesterol <5.0
40% reduction in non-HDL cholesterol
Bilateral resting tremor, falls, shuffling (small stepping) gait, no bradykinesia, bilateral cogwheel rigidity, increase tone at the wrists. Taking chlorpromazine, statin and antihypertensive.
- Parkinson’s
- Drug induced
- Supranuclear palsy
- Essential tremor
Drug induced parkinsonism
These symptoms are parkinsonism but they are also bilateral and parkinsons is normally unilateral
Parkinson’s
* Bradykinesia => Short shuffling and smaller swing… Difficulty initiaing movements
* Tremor => improves with initiating a mvement aka better when doing something, PILL ROLLING
* Rigidity => cog wheel or lead pipe
* Mask like facies, flexed posture, drooling saliva sometimes depression or dementia is seen.
* Postural hypotension
Drug induced
* Antipsychotics and Metoclopramide are common causes of this.
* The onset will be faster + BILATERAL
* rigidity and rest tremor is uncommonin drug induced
Essential tremor
* postural tremor it is worse when the arm is stretched
* Improves with alcohol and at rest
* MANAGMEENT Propanolol
Supranuclear palsy
* There would be an upward gaze palsy
* Again the findings would be symmetrical
* Is associated with falls
123I‑FP‑CIT single photon emission computed tomography (SPECT). -> Investigation of choice if not sure between essential tremor and Parkinsons
A female patient woke up with leg weakness at 0700, daughter saw them last at 2300 and she was normal. Now 0800 she has progressive aphasia. 0830 CT scan shows infarct and no haemorrhage. She has a past history of AF.
* Give alteplase
* Give aspirin
* Give clopidogrel
* Give warfarin
Give Aspirin
The first treatment is Aspirin this is changed to a DOAC after 2 weeks.
the DOAC woould be started if the diagnosis of TIA is done.
A man who works as a painter and has lateral epicondylitis, what muscle group is responsible for his pain?
* Wrist flexors
* Wrist extensors
* Elbow flexors
* Elbow extensors
* Elbow pronator
Wrist extensor
Wrist extensor attach to the lateral epicondylitis.
The muscles from the medial epicondyle are the pronator muscles of the arm. this is likely group to be responsible of the pain.
Breastfeeding female patient with 2cm breast abscess for 48 hours. Normal observations. Patient was told to keep feeding as normal. Abscess was drained with needle and sent for MC&S. What to do now?
* Incision and drainage
* Flucloxacillin
* Amoxicillin
* Co-amoxiclav
* Encourage breastfeeding only
Give Flucloxacillin
< 5cm aspirate
> 5cm I and D
NEEDS Abx as well
Parkinson’s patient with recurrent pneumonia, on multiple medications for 10 years, which HCP to refer to
* Speech and language therapy
* Physiotherapy
* Occupational therapy
* Palliative care nurse
Speech and language therapy
Parkinsons can increase the risk of aspiration pneumonia so there is a need to reduce this with a potential of a speech and language therapist.
Pleural effusion with cancer – palliative female patient who had mesothelioma and was only going to live for a few more weeks.
* Aspiration
* Benzodiazepine (SC midazolam)
* IV morphine
* Furosemide
* Chest drain
Aspiration
. What management. Now using emollients
* Vit d analogue and topical potent steroids
* UV treatment
* Oral steroids
* Topical calcineurin inhibitor
* Mild topical steroids + antifungal
Vitamin D analogue + Topical potent steroids
Patient has Multiple sclerosis, is complaining of spasticity.
* Baclofen
* Carbamazepine
Baclofen
38 yo patient with bilateral conductive hearing loss, worsened during pregnancy. Especially at 2000 Hz
* Otosclerosis
* Presbycusis
* Neurofibromatosis type 1
* Meniere’s
Otosclerosis
This can get worse in pregnancy. It describes a conductive hearing loss, it happens with the stapes gets fixated on the oval window,
Menieres disease would have other symptoms of vertigo ear fullness tinnitus and sensoneural hearing loss
Patient comes to GP with vaginal discharge, fishy odour. She is going away on a wine tasting weekend tomorrow. What treatment?
* 7 days metronidazole
* Azithromycin
* Topical clindamycin
* Single dose Fluconazole
Topical Clindamycin
LADIES AND GENTLEMEN GIULIA IS A PSA GODD WITH IMMENSE KNOWLEDGE….
As you can see the first line in treating bacterial vaginosis is 7 days of metrondiazole, but the alcohol weekend means that the metrondiazole needs to be avoided. This means that it is likely that this patient needs the alternative which is topical clindamycin as a pessary.
Can be found if you check interactions with metrondiazole and alcohol….
NOTE: Stems of qs rarely give information for no reason…
Paracetamol overdose. Patient took it 18 hours ago, took 32 500mg tablets. 80kg male. What is your next step?
* IV N-acetylcysteine immediately
* Oral acetylcysteine
* Wait for paracetamol level to come back
* No action required
* Activated charcoal
IV N-acetylcysteine immediately
IV acetyltcystiene needs to be given if:
* the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity
* there is a staggered overdose or there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration; or
* patients who present 8-24 hours after ingestion of an acute overdose of more than 150 mg/kg of paracetamol even if the plasma-paracetamol concentration is not yet available
* patients who present > 24 hours if they are clearly jaundiced or have hepatic tenderness, their ALT is above the upper limit of normal
* acetylcysteine should be continued if the paracetamol concentration or ALT remains elevated whilst seeking specialist advice
Shoulder and hip stiffness and pain. Hard to get out of chair. Can’t remember if CK normal or high. (was normal)
* Polymyalgia rheumatica
* Polymyositis
* Fibromyalgia
Polymyalgia rheumatica
Creatinine kinase is raised in Polymyositis and fibromyalgia
Man returned from India with meningism. LP showed low opening pressure, normal glucose, high protein, lymphocyte predominant cells 90%.
* Bacterial
* Tuberculosis
* Viral
* Streptococcal
* Malaria
Tuberculosis
Patient with #NOF with pain uncontrolled pain. Was on IV paracetamol but it did not relieve pain. What is the next analgesia to offer?
* Repeated IV bolus morphine
* Diclofenac IM
* Femoral Nerve block
* Pethidine PCA
Repeated IV bolus morphine
After Paracetamol the next best management option is opioids.
NSAIDS are not reccomended
BETWEEN PETHADINE AND IV MORPHINE HONESTLY NOT SURE»> CHECK
Patient with typical SLE features, 3 year history of Raynauds, photosensitivity, positive ANA, clear chest and heart sounds normal, which investigation would you do next?
- Urine dipstick
- CXR
- Echocardiogram
- Spirometry
Urine dipstick
SOAPBRAIN MD
Seositis
Oral Ulcer
Arthritis
Photosensative
Blood disorder
Renal (Protien)
ANA +ve
Immunological (DsDNA, ANA etc)
Neurlogical (psych, seizure)
Malar Rash
Discoid rash
Ix
* ESR -> Disease activity
* dsDNA -> Changes with disease activity
* C3 and C4 decrease with activity
* ANA and ENA do not correlate with disease activity.
Managmeent
* Hydroxychloroquine
* Azathiopurine or mycophenolate mofetil
A 60 year old male with B symptoms with lymphadenopathy, anaemia raised neutrophils but no raised lymphocytes, raised LDH
- AML
- CLL
- Lymphoma
- Sarcoidosis
- Tuberculosis
Lymphoma
Delirium and usually well, patient wandering the wards at night and refuses to go to bed
- Lorazepam
- Haloperidol
- Orientation techniques
- Zopiclone
Orientation techniques
The above is an example of de escalation techniques which include verbal and non-verbal and this should be attempted before the use of Haloperidol or drug managmeent.
82 year old female had stroke, found to have AF, currently taking aspirin 75mg for previous MI.
- Change aspirin to apixaban
- Add clopidogrel
- Add warfarin
- Do nothing
Add warfarin
The aspirin needs to continue for lifelong with regards to the MI…
A DOAC or Vit K antagonist should be added so it has to be A or C
Change Aspirin to Apixaban
Warfarin is basically only used in patients with mechanical valve.
With PAtients with AF there is a need for the patient to be on a DOAC…
Stroke -> confirm ischaemic -> Aspirin wait 14days on aspirin still….
IF AF then DOAC (if chadsVASC score deems it necessary)
IF thrombotic then Clopidegrel
IF TIA and AF then DOAC straight away
A male and young patient in his 20s presents with sudden and painful vision loss however notes that this has happened before a few weeks ago and recovered after four weeks.
* Optic neuritis
* Anterior ischaemic optic neuropathy
Optic Neuritis
The other option is we think a permenant cause of loss of vision.
the case vignette we think is describing MS and that is associated with optic neuronitis.
Old man had a 3/7 hx of a fall, since then unable to weight bear. Physiotherapist unable to assess him due to patient being in pain when touched, but x-ray only showed minor degenerative changes only. What do you do?
* CT hip and pelvis
* Encourage him to weight bear
* Refer to old age psychiatry
* IV morphine
CT hip and Pelvis
The X-ray may miss out on the fracture and so because the findings are suggestive of a fracture we think that rescanning would be approapriate.
House fire inhaled. Patient needs increased ventilatory pressures, what is the reason?
- Abnormal alveolar capillary osmosis
- Surfactant insufficiency
- Accelerated pulmonary fibrosis
- Bronchospasm
Abnormal Alveolar Capillary osmosis
Essentially smoke inhalations makes patients dry because the water is lost into the lungs “oedema”. This then results in an abnormal gaseous exchange in the alveolar to the capillary blood.
A man who works as a painter and has lateral epicondylitis, what muscle group is responsible for his pain?
- Wrist flexors
- Wrist extensors
- Elbow flexors
- Elbow extensors
- Elbow pronator
Wrist Extensors
Breastfeeding female patient with 2cm breast abscess for 48 hours. Normal observations. Patient was told to keep feeding as normal. Abscess was drained with needle and sent for MC&S. What to do now?
- Incision and drainage
- Flucloxacillin
- Amoxicillin
- Co-amoxiclav
- Encourage breastfeeding only
Flucloxacillin
Breast Abscess < 5cm can be aspirated and drained.
This is then treated with Abx….
Breast Abscess > 5cm is treated with Incision and drainage.
Patients with MAstitis with no abscess get ecourged breastfeeding with abx being prescribed if the sysmptoms persist after this.
A 40 year old patient worried about getting cancer. Mum received a diagnosis of unilateral breast cancer at 67, brother has metastatic melanoma 5 years ago, uncle with lung cancer at XX age, grandparent with colorectal cancer at 82
- Send for BRCA1
- Reassure patient they do not have increased risk of breast cancer
- Sent to breast clinic
- Sent to mammography
Reassure patient they do not have an increased risk of breast cancer
The ages of these patients are all too old except the brother.
We dont think melanoma is associated with BRCA 1.
They may have been referred for testing if the patient had a 1st degree relative with breast or ovarian cancer and presented at a young age or the breast cancer was triple negative,
Parkinson’s patient with recurrent pneumonia, on multiple medications for 10 years, which HCP to refer to
- Speech and language therapy
- Physiotherapy
- Occupational therapy
- Palliative care nurse
Speech and language therapy
The recurrent infection we think is elluding to a poor swallow with aspiration pneumonia. as such we think that most likely this patient needs a SALT assessment as it is their role to be able to manage these patients.
T1DM patient and Graves, treated with carbimazole, now presenting with mouth ulcers
FBC
ANA
FBC
Not sure but we know carbimazole is associated with agranulocytosis, so we thought the question was probably trying to test whether we knew this… The ANA seems to be hinting at something like SLE whcich this person doesnt seem like she has.
Therefore we thought FBC would male sense.
A middle-aged man with headache, intermittent left-sided claudication, history of a TIA. He has 220/80 BP and has AKI. Biochemistry (presumably U&E) is normal. Ultrasound showing one kidney is 10cm and the other is 7cm. A scan also showed no obstruction in the ureters.
- MR urography
- Renin:aldosterone ratio
- MR angiography
- Urine catecholamines
- Renal biopsy
MR angiography
We think this patient has Renal artery stenosis. One of the findings of renal artery stenosis is a smaller kidney on one side. – for renal artery stenosis - decreased kidney size on side of ischaemia can be seen if chronic (asymmetrical kidneys)
In terms of investigation of RAS there is initial which would include renin:aldosterone ration and there is diagnostic which would be MR angiography -> patients with RAS would have a raised Renin to aldosterone ratio as opposed to Conn’s syndrome which would show the oppposite.
Additionally the intermittent left sided claudication and the history of TIA I think may also be hinting at Takayasu arterutis and that is associated with RAS
Fluid replacement for a female patient 62kg. How much maintenance potassium to add to their fluids in a day?
- 40mmol
- 60mmol
- 100mmol
- 20mmol
- 80mmol
60 mmol
1mmol / kg is the required maintenance…
This is then rounded to the closest figure hence the 60mmol value
Male and young patient with painful left testes pain all through with swelling. Cremasteric reflex is present.
* Epididymo-orchitis
* Torsion
Epididymo-orchitis
As the reflex is preserved this is not torsion but infact epididymo-orchitis.
Parotid gland swelling 6 months, not tethered to skin, face weakness and numbness, dribbling fluids.
- Adenoid cystic carcinoma
- Pleomorphic adenoma
- Warthin’s tumour
- Suppurative parotitis
Adenoid Cystic Carcinoma
The facial nerve palsy is associated with malignant tumours involving the parotid glands.
Pleomorphic Adenoma is a slow growing tumour of the parotid gland and it is the most common tumour.
Patient had SBP with shifting dullness and was treated. Patient currently on furosemide and spironolactone. What other medication should be given?
- Drain
- Bendroflumethiazide
- Ciprofloxacin
- Propranolol
- Prednisolone
Ciprofloxaxin
This patient is suffereing from SBP, this is diagnosed when there is an ascitic neutrophil count above 250 cells/mm3 (technically above 500 but between 250 and 500 its to dangerous to miss this diagnosis)
the management of this is with emperical antibiotics
* cefotaxime or ceftriaxone is normally first line
* Alternatives include ciprofloxacin
The Drainage of the fluid is a potentially considered management plan.
A COPD patient is breathless with 86% oxygen saturations, what should be given initially?
* 15L/minute via non-rebreathe
* Venturi 24% - shit question; NICE says either 24 or 28%
* Venturi 28%
* Continue on room air until ABG comes back
Venturi 28%
Honsetly not sure because NICE says that it should be between 24 and 28% with the target being between 88-92%. At this point you will do ABGs and then reassess if this patient is a CO2 retainer if they are not you can target higher o2 sats 92-96% and also give more O2.
Painless end-of-stream haematuria in a 68 year old patient. Normal observations. Where is the pathology?
- Renal cell carcinoma
- Bladder cancer
- Pyelonephritis
- BPH
- Renal calculus
Bladder cancer
End of stream haematuria is common with prostate of bladder sources of bleeds. The fact that this is painless also rules out the renal calculus as well as pyelonephritis.
Bladder cancer is more likely to cause haematuria than BPH as it is not a common presentation for the condition making Bladder cancer we think more likely.
What management. Now using emollients
- Vit d analogue and topical potent steroids
- UV treatment
- Oral steroids
- Topical calcineurin inhibitor
- Mild topical steroids + antifungal
Vit D analogue and topical potent steroids
This is the first line management of psoriasis.
followed by Vit D analogue
Followed by coal tar prepartation
Scalp involvment
* Topical steroids
* If not working try another potent steroid
Face, flexural or genital psorisis
* again mildly potent steroid topically
If there is joint involvment -> Methotrexate
Phototherapy is also a potential option
Patient had splenectomy, on long-term penicillin now. What infection are they most susceptible to?
- Haemophilus influenza
- Strep pneumoniae
- Staph aureus
- E coli
- Mycobacteria
Strep pneumonia or Haemophilus influenza
NHS is more likely due to the splenectomy (Nisseria meningitis, Haemophilus influenza and strep pneumonia)
Strep pneumonia is more common so we were leaning towards that however there is a case for H.influenza as the long term penecillin is normally protective against Gram +ve bacteria and h.influ is gram negative….
We are still unsure about which one currently leaning towards Strep. Pneumonia.
MAXIM PUTIN LAT MAN FROM ROMANIA: haem influe develops beta lactamases against penicillin V so I think that is not covered by penicillin as well
Shoulder and hip stiffness and pain. Hard to get out of chair. Can’t remember if CK normal (was normal)
* Polymyalgia rheumatica
* Polymyositis
* Fibromyalgia
Polymyalgia Rheumatica
PMR will present with pain and stiffness of the hip and shoulder, additionally there is often rapid improvement with steroids.
ESR + CRP will likely be raised
Firstly polymyalgia rheumatica is often painful compared to polymyositis which is often painless weakness.
BOTH fibromyalgia and Polymyositis are associated with a raised Creatinine Kinase whereas in polymyalgia rheumatica it is normal.
Fibromyalgia is a clinical diagnosis of -> presence of chronic (>3 months), widespread body pain and associated symptoms such as fatigue and sleep disturbance
18 yo female walked into A&E and feels unwell. Definitely no mention of an IV port. Known diabetic, BM 1.9. What do you give her?
- 100-200ml orange juice
- 20% glucose 150ml
- 50% glucose
- IM glucagon
- A slice of toast
100-200ml Orange juice
Patient due for colonic resection surgery, when do you give prophylactic antibiotics?
* 8-12 hours before
* At time of incision only
* At the time of incision and 6 hours + 8 hours after
* 4-8 hours before
* 1 hour before incision
1 Hour before incision
“The Center for Disease Control and Prevention (CDC) guidelines recommend administering the chosen antibiotic within 60 minutes prior to incision.”
Went on holiday and swam in the ocean, now pain when pressing on tragus and canal looks macerated. Nothing wrong with tympanic membrane. What’s the treatment?
* Olive oil drops
* Bicarb drops
* Steroid and abx drops
* Steroid drops only
* Oral steroids
Steroid and abx drops
This is describing otitis externa… The management would nvolve abx drops on its own or a mixture of Abx drops with topical steroids …. making C the answer
Patient with #NOF with pain uncontrolled pain. Was on IV paracetamol but it did not relieve pain. What is the next analgesia to offer?
Repeated IV bolus morphine
Diclofenac IM
Femoral Nerve block
Pethidine PCA
Repeated IV bolus morphine
The Pethidine PCA we think would be indicated in a case where the patient is post op. as this is not the case we would give a bolus of morphine.
Pt had colorectal surgery w primary anastamosis, after has normal obs but rebound tenderness, fever and dull lung bases, what next? – anastomotic leak
- Call for senior help
- Erect CXR
- Lying abdo X-ray
- CT abdo with contrast
Call for senior help
This is either call seniors to let them know followed by a CT abdo with contrast as a way to best investigate post surgical complications,
Old lady on several medications with confusion or something? Which medication caused it?
- Furosemide
- Prochlorperazine
- Amitryptiline
Prochlorperazine
This was associated with confusion, that was more common than amitryptiline.
76 F ate fish and chips. Now has throat pain and pain on swallowing. All of her observations and examination were stable. What are your next steps?
* Laryngoscope
* Lateral soft tissue neck x-ray
* No further investigations
* MRI
* Neck ultrasound
Lateral soft tissue neck X-ray
A guess from the teaching we had in placement… I think you would try and look for it and remove in intially otherwise there is a lateral soft tissue neck X-ray
RE: Throat Foreign body / fishbone
Yes first part of assessment is direct visualisation with tongue depressor and head torch.
If you can’t see it on direct visualisation - next would be lateral neck XR. If you know the type of fish and know that the bones are radiolucent (cannot be seen on XR) then this becomes less useful (in practice I usually still get the XR as you can sometimes see soft tissue disruption around where the bone is - however I expect in an exam they would say don’t get an XR if the bone is radiolucent).
The next investigation would be flexible nasoendoscopy - which is usually fairly definitive. The only fishbones we can’t see on this investigation are those that have already got buried into the soft tissue which is fairly rare (but more likely in patients that have a longer history, and/or have been pushing their fingers around in the back of the throat).
With a short history, if I cannot see a bone on flexible nasoendoscopy I would usually assume they just have a scratch and have swallowed the bone, so would discharge them with safety netting to come back if they are still getting symptoms.
If someone has a very convincing history that there is something present and has factors like a longer history of symptoms etc, then the next investigation is a CT neck.
In terms of a laryngoscope - you can use this to try and visualise the foreign body but you would have to give the patient anaesthetic spray (e.g. xylocaine) before doing so. It is not very comfortable for the patient, and the situations in which I’ve seen this being used, is when the foreign body has been identified on flexible nasoendoscopy, and we use the laryngoscope to get a good view to take it out whilst patient is awake (as it gives a better view, and hopefully avoids need for taking to theatres / general anaesthetic).
I don’t know what the exam questions are, but I think it is unlikely that they would ask you anything more than about lateral XR / flexible nasoendoscopy
Lights criteria. Pleural protein 10. Pleural LDH 80. Total protein 50, Serum LDH 400?
- Cirrhosis
- Pulmonary embolism
- Malignancy
- Pneumonia
- Pancreatitis
Cirrhosis
This patient had a transudative Pleural effusion… The cause of this from the options shown is cirrhosis
if pleural protein > 30 exudative
If < 30 transudative
Lights criteria is used to determine whether a effusion is exudative when the pleural proteine is between 25-35 g/L then the following criteria is useful:
- ratio of pleural fluid protein:serum protein (>=0.5)
- ratio of pleural fluid LDH:serum LDH (>=0.6)
- pleural fluid LDH (> ⅔ the upper limit of normal serum LDH)
Psuedomonas aeruginosa cellulitis. What abx?
* Ciprofloxacin
* Coamoxiclav
* Doxycycline
* Vancomycin
* Clindamycin
Ciprofloxacin
Woman with sudden onset 3 week itchiness. Has well circumscribed (ranging in sizes from 1cm-3m), red, scaly, mildly itchy rash on her abdomen and back. No nail or joint involvement. What is the diagnosis? (no image given)
- Psoriasis
- Discoid eczema
Psoriasis
FOR NOW Psoriasis
Both present with well demarcated lesions that are often 1cm to 3 cm in size. They are itchy red scaly and have a similar distribution as well…
Eczema would be common in a younder female or a 50-60 yr old male.
the lack of mentions of the nail and joint involvment also leads me more towards the discoid eczema diagnosis but the main reason for me not chosing discoid eczema is because that is meant to be really itchy not mild.
2 weeks ago went on holiday to Ibiza. 4 days ago a large rash appeared on his chest. In the next few days smaller patches appeared on his chest and back. What’s the most likely diagnosis? (was also an image of darker skin pls can someone find?)
Pityriasis rosea
Guttate psoriasis
Urticaria?
Tinea corporis
Pityrisasis rosea
This is a self limiting rash that resolves in 6-10 weeks.
Presentation:
* Initially with aherald path in the centre of the chest
* FOLLOWED by small scaly smaller oval shaped patches (mainly on the back)
We also think the holiday to ibiza may be suggesting an HHV infection (I know HSV 1 and 2 are not the ones associated but instead 6 or 7 but still)
Tinea corporis -> is very clear circular lesion.
40 yo F, face rash around the nose and cheeks with pustules, with red eyes and had a gritty feeling. Telangiectasia under the eyelid. No blackheads. What long term management?
Chloramphenicol eyedrops
Oral oxytetracycline
Metronidazole gel
Topical tacrolimus
Ivermectin cream
Ivermectin cream
This is Roscea Acne
This often presents with a rash involving the nose cheeks and forehead. Telangiectasia is COMMON.
This is often pustular in long term as the condition develops.
The treatment of this condition is:
CONSERVATIVE
* sunscreen
For the redness and flushing rash
* topical brimondine gel (but little teleanctasia)
mild to moderate papules or pustules
* Topical ivermectin -> alternatives inc topical metrodiaozle or topical azliac acid
Moderate to severe disease
* topical ivermectin and oral doxycycline,
Patient presenting with hoarseness of the neck. Referred to ENT. Laryngeal involvement, what is the next ?
- MRI neck
- Ultrasound neck
- CT chest
- laryngoscopy
CT chest
ENT reg confirmed this…
Flexible nose endoscopy then CT chest then MRI.
RE: Voice hoarseness
Do you mean in the context of a fishbone or just separately?
In the context of a fishbone, at a stretch it might be that the fishbone is lying directly over the vocal cords, which I think is very unlikely to be honest - but you would proceed with investigations/ management as above. You would have to be very careful as it would be at higher risk of slipping into the airway.
In the context of a patient presenting with voice hoarseness, this depends again on whether its an acute or chronic presentation.
Acute hoarse voice could be laryngitis (what we would say is a sore throat - likely secondary to viral infection), but if accompanied by other more worrying signs it could be due to supraglottitis or deep neck space abscess. Laryngitis would not need any investigation and can be discharged. For both supraglottitis and deep neck space abscess you would need to start airway compromise management, and for suspected abscess get a CT neck with contrast if patient is stable enough.
In chronic presentation
What you are looking for is if they have a ‘persistent unexplained hoarse voice’ in age >45yrs - then they need to be referred on 2 week wait pathway to head & neck team (as per nice guidelines).
Persistent generally means >3 weeks. In exam questions look out for those head and neck cancer risk factors like smoking that would make you more suspicious.
In head and neck clinic they would first get flexible nasoendoscopy, and depending on both the history and what they saw, next would be CT neck with contrast. MRI neck would usually be after CT neck if they want to characterise further. The BMJ best practice page is quite useful for stuff on laryngeal cancer.
https://cks.nice.org.uk/topics/head-neck-cancers-recognition-referral/diagnosis/symptoms-suggestive-of-head-neck-cancers/
https://bestpractice.bmj.com/topics/en-gb/1115/investigations
Man hit his knee on a table. 2 weeks later has swelling and pain in knee. Knee is hot and tender. Systemically well, afebrile.
* Septic arthritis
* Pseudogout
* RA
* Gout
* Osteoarthritis
Pseudogout
Can’t really tell the difference between the 2 withoud more information…
That being said often the first presentation of gout is in the 1st toe and then further presentation involve things like the knee, therfore if this is not the first episode i think it is pseudogout.
Both can be precipitated with trauma.
Gout flareup. Patient was previously treated with colchicine and had diarrhoea. CKD stage 3. (colchicine was not an option)
* Allopurinol
* Ibuprofen
* Prednisolone
* Paracetamol
prednisololne
Intermittent urinary incontinence post-surgery throughout the night. Able to mobilise with the help of the physiotherapist. Doesn’t know she has symptoms. Best long-term management?
* Urinary catheter
* Suprapubic catheter
* Keep reminding her to empty her bladder
* Intermittent self-catheterise
* Oral solifenacin
Urinary catheter
NOT SURE ASKING SISTER TO SEE IF SHE HAS A CLUE
Thikning, we think this is a loss of involuntary control of the sphincter and so when she is not awake there is a voiding of the bladder. ??? Therfore in order to stop this try long term managment with suprapubic catheter.
Patient had winging of the scapula. Long thoracic nerve innervates which muscle?
* Serratus anterior
* Infraspinatus
* Supraspinatus
* Subscapularis
* Latissimus dorsi
Serratus Anterior
An elderly lady had a fall, has tenderness in the right hip and cannot bear weight. Which finding will confirm diagnosis?
- Right leg lengthened and internally rotated
- Right leg lengthened and externally rotated
- Right leg shortened and internally rotated
- Right leg shortened and externally rotated
- Flexed
Right leg shortened and externally rotated
is suggestive of a NOF fracture
Posterior hip dislocation
* Flexed adducted and internally rotated and shortened
Anterior Hip dislocation
* Forced abduction, with external rotation and normal length or maybe exteneded
Hypothyroid patient, had some sort of trigger for Addisonian crisis (surgery? Recent illness?). Bloods showed hyponatraemia, hyperkalaemia, BP 75/45, HR 95. Immediate management?
* Hydrocortisone
* IV liothyrine
* IV saline 0.9%
IV saline 0.9%
Approapriates is Hydrocortisone….
CONFIRMED WITH MEERAN
Blood tests of lady with FHx thyroid issues and cholesterolaemia. TFTs subclinical hypothyroidism,
total cholesterol 5.9 (< 5.0)
LDL 2.9 (< 3.0)
HDL 1.8 (>1.2).
What to do next?
- Start statins
- Start levothyroxine
- Repeat bloods in 6 months
- Test for T3
Repeat bloods in 6 months
NOT SURE DONT KNOW WHERE TO FIND OUT,,,
Start statins if total Cholesterol > 7.5
Surgeon cut himself and has a ruptured extensor tendon his DIP. How do you manage?
- Fix with K wires
- Regular physio
- Plaster cast
- Spica thumb cast
- Tendon repair surgery
Tendon repain surgery
NOT SUREEEE
K wires is to manage small bone fractures, type of temp fixations
Plaster Cast is for after 1 week
Spica thumb cast is also for after 1 week
Rugby player with a Bennett’s fracture, 2 X rays shown. AP showed a small displacement at the proximal 1st metacarpal. How do you manage? - there was no dislocation, not a bennett’s # might have looked something like this, pseudo bennett????
- K wires
- Reduce and plaster cast
- Spica thumb cast
- Rest for 1 week in sling and review
NO CLUEEEEEEEEEE
A 23 year old male with mumps (parotid and submandibular salivary glands) and stable obs. What’s the treatment?
* Oseltamivir
* Amoxicillin
* Paracetamol
Paracetamol
Lowkey unfair half our year had this… so they would know it is supportive but BMJ was helpful in letting us know that it is supportive
Patient with campylobacter jejuni. Bloody diarrhoea 6 times a day and has a fever. Treatment?
* Supportive care
* Ciprofloxacin
* Doxycycline
* Cefuroxime
* Azithromycin
Supportive care
Indications for antimicrobial therapy (in Campylobacter infection):
* include high fever
* systemic infection with suspected or sustained bacteraemia
* grossly bloody diarrhoea (I remember something about > 8 stools a day, but not sure where)
* Persistence of symptoms for >1 week.
* Antibiotics are also indicated in immunocompromised patients.
* IF ABX then Clarithromycin or erythromycon or ciprofloxacin
Patient with myalgia, supraclavicular lymph nodes, jaundice(?) and oral ulcers. Went to South Africa and was taking antimalarials for 2 days, but stopped for the rest of the 2 weeks?
EBV
HIV
Malaria
Yellow Fever
HIV
No fever mentioned for malaria
The Oral ulcers dont really fit with the EBV
So thinking HIV ???
Covid typical xray presentation. Pt desaturates on exertion, what’s seen on CXR?
* Bilateral honeycombing
* Bilateral lower lobe consolidation
* Unilateral lower lobe consolidation
* Bilateral Upper lobe
Bilateral lower lobe consolidations
Pt had pleuritic chest pain, was a mechanic. Had weight loss, night sweats (I think?) Xray what is this?
- Mesothelioma
- Lung cancer
Mesothelioma
A 62 year old man known to A&E for previous visits due to alcohol intoxication. Has been found on street unconscious. GCS 3, blood pH ~7.29, blood glucose 5.3, high anion gap, breath smells of alcohol. What’s the most likely diagnosis?
* Methanol
* Uraemia
* Ketoacidosis
* HHS
* Lactic
Methanol
Alcohol history -> Methanol was the thinking
Raised Anion gap and Acidosis
MUDPILES
Tension pneumothorax with trachea deviated to left, hyperresonance on the right, unilateral expansion (on the left)
- Large bore cannula in 2nd intercostal space on the left
- Large bore cannula in Safety triangle
- Chest drain in the 5th intercostal space anterior axillary line on the right
- Chest drain in the 5th intercostal space anterior axillary line on the left
- Urgent portable chest x-ray
Large bore cannula in safety triangle
This is the treatment of Tension pneumothorax according to new guidelines…. The qs options have been changed to reflect the change in guidelines
Difficulty getting erections for the past year, BPH taking ramipril and other drugs, BP 130, pt is otherwise well (worsening over a long time = organic cause, acute onset = psychological)
* Give penile pump
* Give sildenafil
* Change antihypertensive medication
* Send to psychosexual counselling
* Intraurethral prostaglandin?
Change antihypertensive or Sildenafil
ACEi gives you erective dysfunction (uncommon SE)
CHANGE HYPERTENSIVE IF THE PROBLEM STARTED AROUND THE TIME THAT THE RAMIPRIL WAS STARTED IF NOT CONSIDER GIVING SILDENAFIL
Bilateral and progressive conductive hearing loss 3/12 and had haematuria with raised creatinine. Did it definitely say conductive? Alport’s is sensorineural? I think this may be GPA (ANCA) as is associated with conductive HL secondary to effusions in the inner ear
Anti-GBM
Anti-ANA
Anti-CCP
ANCA
ANCA
If conductive hearing loss pick ANCA as apparaently Granulamtosis with polyangitis is associated with hearing loss…
Anti GBM
If sensineural hearing loss then pick Anti GBM as Alport is associated with goodpastures disease apparently
A post-op patient suddenly develops jaundice, breathlessness and dark brown urine but no change in stool colour given 4 units – can someone remember the answers
* Delayed haemolytic transfusion reaction
* Anaesthetic-induced cholestasis
Delayed haemolytic transfusion reaction
The surgery needs to have happened at least more than 24 hours before.
A 33 year old male who is systemically well with a painless swelling in his left testicle. On examination the left testicle is larger than the right, firm on palpation, and it is impossible to palpate the testicular appendages contents of the scrotum. What’s the most likely diagnosis?
* Scrotal hernia
* Testicular cancer
* Varicocele
* Hydrocele
* Orchitis
testicular cancer
not being able to feel the appendages is suggestive of the mass being with the testicles and that it is not separate… Scrotal hernia you cant get above…
Orchitis would be painful…
VAricocele and hydrocele are not firm…
Cerebral metastases with oedema, patient has nausea. What’s first-line for patient’s nausea?
Cyclizine
Ondansetron
Domperidone
Metoclopramide
Dexamethasone
Cyclizine
this is first line to treat nausea
The Dexamethasone would treat the cerebral oedema
Severe COPD, on maximum inhaled medication but PaO2 6.9, CO2 4.9, PH 7.36, what is the next step in management?
Add theophylline
Long term oxygen
Monteleukast
Long term o2 therapy
Pain ladder was on paracetamol
* Codeine
* Tramadol
* Diclofenac
* Morphine
codiene
But Tramadol is also in the second step dont know how to chose between the 2
CLARIFY WITH END OF LIFE LECTURERER
Elderly man, dysphagia with solids but not liquids, what is the initial investigation?
* Endoscopy
* Barium meal swallow
* CT/MRI
* Neck USS?
Endoscopy
- New-onset dysphagia is a red flag symptom that requires urgent endoscopy, regardless of age or other symptoms.
I really dont know what barium swallow is used for
Old lady in care home + staff started getting these lesions. Can see track marks. Mx
* Isolate patient and staff
* Insecticide for whole care home
* Wash everything at 90c
** Insecticide for whole care home **
Simultaneous empirical treatment of all significant contacts - household, close contacts, sexual contacts – this is scabies
Extra precautions when seeing a patient with multidrug-resistant TB and they are coughing (productive).
* FFP3
* Long sleeved gowns
* Apron
* Surgical mask
* Eye protection
Eye protection
Confirming with another doctor but Giulia found this in tust guidelines
Confirmed with Brother in Law… Apparently most trust guidelines say apron not gown…FFP3 is for succeptible TB and the productive points to Eye protection
Patient with chronic sinusitis. Congested. On examination had oedematous? inferior turbinates. Mx?
Nasal decongestant
Nasal corticosteroid
Oral antibiotics??
Oral steroids
**Nasal Corticosteroids **
This is chronic sinusitis…
The presentaiton of this conditions
They tend to have a history of atopy maybe facial ain and nasal discharge.
Patient with small stepping gait + urinary incontinenece and confusion or poor mememory
What is the diagnosis?
- Parkinson’s
- Alzehiemiers
- Normal Pressure hydrocephalus
Normal Pressure hydrocephalus
This is the classic triad of:
* urinary incontinence
* Demetia / bradyphrenia
* gait abnormality (similar to parkinsons)
Difficult to control epistaxis in a patient with recent chemotherapy. Hb 79 platelets 2, low BP
- Cauterise
- Transfusion 2 units packed red cell with 6 units platelets
- Platelets only
Platelets only
there is low platelets
Indications for blood transfusion -> <70 or <80 if ACS
Guillain barre syndrome (have to deduce condition based on pattern of weakness), patient is bedbound, what is the best way to monitor respiratory function?
* FVC
* ABG
* O2 sats
* Peak flow
* Spirometry
FVC
Spirometry will also say FVC but the spirometry wont really be done at the bedside but FVC can be done….
Additionally FVC is the more specific thing that you will do to test the respiratory function?
