2023 paper Flashcards

Question

Young patient with displaced apex beat, systolic murmur related to exercise. Which investigation to diagnose? (HOCM test, Echo/TOE not given as options) a) Cardiac MRI b) CT angiography c) Myocardial perfusion scan

Answer 1

**Cardiac MRI** This will let us know about the structure of the heart aka the valves.

Answer 2

**Package of Care** -> They assess the house and come up with a plan of changes to help with life. This includes adaptations at home to get in and out of the shower etc.

Answer 3

**Oral Naproxen** For renal Colic NSAIDS via any route is first line before trying anything else. IV paracetamol is given if NSAIDS are contraindicated IV morphine only if the previous 2 is not effective

Answer 4

**Coarctation of the Aorta** Turners syndrome is associated with CoA and Bicuspid Aortic valve... The intrascapular area and the murmur is suggestive of CoA The Radiofemoral delay is not always present.. The answer has been confirmed by GIULIAS DADDY, aka Mr or Dr Iacona surgeon at some hospital somewhere

Answer 5

****Hypophosphataemia** We believe the implication from this stem is that the patient has not eated in a while and that we are worried about refeeding syndrome and as such the electrolyte to look out for is phosphate levels. This is because low phosphate can cause weakness of muscles -> Resp failure or cardiac failure (diapghram or heart muscles weakening) However it also causes -> hypo - kal - mag and abnormal fluid babalance NICE produced guidelines in 2006 on nutritional support. Refeeding syndrome may avoided by identifying patients at a high-risk of developing refeeding syndrome: Patients are considered high-risk if one or more of the following: * BMI < 16 kg/m2 * unintentional weight loss >15% over 3-6 months * little nutritional intake > 10 days * hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high) If two or more of the following: (`*THE PATIENT HAS TWO OF THE FOLLOWING*`) * BMI < 18.5 kg/m2 * unintentional weight loss > 10% over 3-6 months * little nutritional intake > 5 days * history of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids

Answer 6

**Hypokalaemia** Features: * Taller P waves * Longer PR interval * ST depression * T wave inversion/flattening * U waves `Hyperkalaemia` Features: * Tall tented T waves * P wave flattening and prolongation * Broad bizarre QRS `Hypomagnesamia` Features: * Prolonged PR * Prolonged QT * Atrial and ventricular ectopy * Predisposition to ventricular tachycardia and ***torsades de pointes***

Answer 7

**HRCT** This is should be done in all patients with IPF. It is required to make a diagnosis. There will be a reduced TLCO. Spirometry will show a restricive pattern and is suggestive of IPF but not the best investigation to diagnose it... FEATURES OF IPF: * Progressve exertional dyspnoea * Bibasal fine end inspiratory crackles * Dry cough * Clubbing Management: * Pulmonary rehabilitation * Pirfenidone (antifibrolytics may be used) * supplementary O2 or ung transplant may be required.

Answer 8

**Fibrodysplasia of renal artery** So the stem would have to be of a young female with hypertension for this diagnosis I thing... 90% are female and this is a cause of RAS in young population. basically this patient has Renal artery stenosis... One of the features of RAS is the fact that there is a difference in the size of the kidneys, which is what we think this is elluding to This can present with * Flash pulmonary oedema * CKD that rapidly progresses * Episodic AKI * Abdominal Bruit `Phaeochromocytoma` * episodic features * Headache * Sweating * Palpiations * Tremor * Anxiety `Rapidly progressing essential HTN` * I am pretty sure this is what Doctors say when they have no clue whats causing this problems "no identified secondary cause." `Primary Hyperaldosteronism` * Mostly asympptomatic * Incidental finding of HTN in a young pt * HYPOKALAEMIA features : muscle weakness, polyuria and polydipsia etc.

Answer 9

**Nephrectomy** Renal Cell Carcinoma: `Features` are shown in the images below `Investigations` * Initial -> USS but does not confirm diagnosis. * Definitive -> CT with contrast `Management:` * Generally speaking it is either partial nephrectomy or complete nephrectomy. (BMJ has < 4cm and passmed >7cm) * If there was metastatic disease or they are elderly with loads of comorbidities -> a more palliative care approach is likely These patients get targeted therapies sounds like immunotherapy options `Referral for RCC:` * >45 + Haematuria ++++ with no infection OR treated infection

Answer 10

**Alendronate** Osteoperosis management: ALL patients -> Vit K and Ca, only not if doctor is convinced there is adequate intake FIRST LINE -> Alendronate SECOND LINE -> risedronate or etidronate

Answer 11

**Lewy body dementia** PArkinosims + dementia -> Lewy body dementia THERE IS NOT REALLY CLEAR INFORMATION TO ANSWER THIS QUESTION Features LWD: * progressive cognitive impairment * in contrast to Alzheimer's, early impairments in attention and executive function rather than just memory loss * cognition may be fluctuating, in contrast to other forms of dementia usually *develops before parkinsonism* * parkinsonism * visual hallucinations (other features such as delusions and non-visual hallucinations may also be seen) `Parkinson's` THIS IS UNILATERAL features, hence why this is not parkinsons Features: * Tremor is *asymmetrical* * Masked facies

Answer 12

**Myocarditis** Myocarditis can have the changes that are described... Clinically will present with Sharp chest pain worse on inspiration, breathlessness and palitation along with a flu like illness. TREATMENT : supportive, if autoimmune then Steroids, if HF then standard treatment, MI -> Central crushing Chest pain, The wide spread ECG could be suggestive of a SEVERE MI with triple vessel disease but that is hard to determine PE will have a similar Hx to the myocarditis except ECG will show tachycardia and maybe also s1q3t1

Answer 13

**Oral Cetirizine** This is Urticaria-> FIRST LINE : Non - sedating antihistamines (*Loratadine + Cetirizine*) -> for 6 weeks SEDATING antihistamine -> for problems of symotoms at night time (*Chlorphenamine*) PREDNISOLONE is for severe and persistent presentations

Answer 14

NEEDS CLARIFICATIONNNNN **Reassure and check in 3 months** We think this is subclinical hypothyroidism. In the case of the above diagnosis there is a need for 2 blood tests before treatment is started. What is subclinical hypothyroidism? This is when there is a raised TSH but the T3/T4 levels are normal. IF TSH > 10 -> 2 tests 3 months apart IF TSH < 10 + < 65 + symptoms + 2 tests 3 months aparts shows raised TSH -> levothyroxine trial IF TSH < 10 + > 65 -> Watch and wait If TSH < 10 + No symptoms -> repeat thyroid function in 6 months. --------------- If there is an option for check in 6 months I would do that

Answer 15

**Sacrum** We just searched it up, and thats what came up... If it isnt saccrum its heel.

Answer 16

**ERCP** Triad represents the charcot triad for ascending cholangitis, the US confirms this with a stone in the common bile duct. The best management option or next step is the removal of the stone and imaging and that is throught the ERCP.

Answer 17

**Charles de bonnet syndrome** This is the association with long term vision impairment and visual hallucinations.

Answer 18

**Barthel** This scoring system is used to measure the extent to which somebody can function independently and has mobility in their activities of daily living. `Rockwood score` This is to summarise the overall fitness or frailty of patients that are elderly. Apparently this is used to assess frailty in dementia.., IF YOU KNOW WHAT THE INDICATIONS OF ANY OF THESE ARE CAN YOU LET ME KNOW `MUST` Malnutrition universal screening tool, This is a way to identify patients who are at risk of malnourishment or obesity `Barlow` Hip stability???? No clue `Waterlow` This is used to assess the risk of a patient developing a pressure ulcer. `PRIMSA-7` This is a general frailty score

Answer 19

**Pneumococcal Conjugate vaccine** Apparently kids get the flu vaccine anyway and so the PCV is the additional vaccine that is needed.

Answer 20

**US abdomen**

Answer 21

**Altered alveolar capillary permeability** Apparently this is bronchospasm So alveolar capillary permeability is how leaky the capillaries are in the alveoli. In cacses of ARDS this is often altered or increased leading to an accumulation of fluids in the alveoli. ARDS is when this the above happens and is known as non-cardiogenic pulmonary oedema... Causes include: * Infections * Blood transfusion * Trauma * Smoke inhalations such as in this case * Acute pacreatitis * Covid 19 * Cardio pulmonary bypass. INVESTIGATIONS: A pulmonary wedge pressure may be needed to ensure the causes is not cardiogenic.

Answer 22

**Separate bathroom facilities**

Answer 23

**Levetiracetam** The reason it isnt lamotrigine is because lamotrigine interacts with the COCP... Epilepsy management? `Generalised` * Male -> sodium Valproate * Female -> Lamotrigine or levietiracetam `Focal` * Lamotrigine or levetiracetam * Carbamzepine, oxcarbazepine or zonisamide `Abscence` -> LOC with posture maintained. * 1st - Ethosuxemide * 2nd - Male - Sodium valproate * 2nd - Female - Lamotrigine or levetiracetam * CARBAMAZEPINE WILL MAKE THESE SEIZURES WORSE `Myoclonic ` * Male - Sodium Valproate * Female - Levetiracetam `Tonic or clonic seizures` * Male - Sodium Valproate * Female - Lamotrigine

Answer 24

**Sodium Valproate**

Answer 25

**high dose dexamethasone** Then radiotherapy

Answer 26

**Chemotherapy** Bas all the options in the BMJ had chemotherapy as an option. If there is a suspected malignant testicular mass a radical orchidectomy is done. BIOPSY is not done but US imaging will be done as well as tumour markers

Answer 27

**Carcinoid** There is a mass and there is diarrhoea. Often presents with diarrhoea, flushing and palpitations Abscess would be a more unwell patient. Lipoma wont really cause these symptoms Faecolith will cause overflow diarrhoea, but I dont think is yellow in colour as it is just essentially compacted stool.

Answer 28

**IV morphine** So there is still pain and it needs to be managed, Step 1 and 2 of the pain ladder have been done. There needs to be excalation to the third step and that is the addition of the IV morphine. NEEDS TO BE NON ORAL as they are NBM.

Answer 29

**Depression** Could be Alzheimers because of the low MMSE but depends on the onset of symptoms... I think the precesnce of the Wt loss is a biologic signs that points me more towards depression...

Answer 30

**Remove with Gent cover** This person has symptomatic UTI, CYstitis with suprapubic pain + a +ve culture this there fore needs to be treated. Additionally the Catheter would need to be changed. Confirmation asked my sister and her husband...

Answer 31

**Fibre supplementation**

Answer 32

**Squamous cell carcinoma** BAS Melanoma would be dark. Actinic keratossi is scaly and not something that will cause lymphadenopathy BCC often does not often metastasise, It presents as a pearl with an umbilicated center and is associated with telegiectasia SCC -> These are often fast growing and are cauliflower like in their appearance.

Answer 33

**Excisional Biopsy**

Answer 34

**Quetiapine** So if this is an acute confusional state and lorazepam was not successful then the next option that can be used is quetiapine. Eventhough it is an antipsychotic and most are contraindicated in Parkinsons disease However if this seems to be describing more a patient, whose parkinsons medication is wearing off then it might be worth thinking about entacapone as apparently this medication is used as it stops the "wearing off affects" of the Levodopa

Answer 35

**Length of time of amnesia** Bascially, there is a scoring system that looks at the cognitive function post a head injury and that scoring system is called GOAT (Galveston Orientation and Amnesia Test ). This as well as Westmead post traumatic amnesia scale are both scales that use post traumatic amnesia to try and predict the cognitive/outcome of patients....

Answer 36

**nothing** Don't really know how to find this out but we a democracy and this lady is not complaining so let her do what she wants

Answer 37

**CT hip and pelvis** Again this is something where we collectively thought this was the answer. There seems to be a high clinical suspicoin something is not right and the way to ivestigate it would be to do a CT hip and pelvis NVM I am a genius found it

Answer 38

**Dyspnoea** We found this in one of the MaM flashcards.

Answer 39

This is bascially pulmonary oedema Diffuse alveolar infiltration If it is ARDS then there needs to be mention of a trigger in the stem and if it is heart failure then that would be the other cause.

Answer 40

**Fluid restrict** Bilateral crackles is suggestive of fluid overload. There is Hyponatraemiam... The causes of hypervolaemic hyponatraemia include polygenic polydipsia and SIADH both are managed with fluid restriction initially.

Answer 41

**Oxybutynin** So oxybutynin can cause confusion and bendroflumethiazide can cause hyponatraemia and so both are causes of confusion.... However Oxybutynin is cautiuoned in the use with elderly patients, so we think that this is should be stopped. With regards to swapping to toterodine that is also meant to be avoided with the elderly population. In the Side effects of both drugs however confusion is only mentioned in Oxybutynin so leaning towards that one... THIS I AM NOT SURE ABOUT ANYONE HAS ANY CLUE>

Answer 42

**Sertralline** Causes hyponatreaemia

Answer 43

**Myoglobin**

Answer 44

**Hartmann's solution** This should not be used in Lactic acidosis. This is because it can make it worse... It has lactate and so makes it worse...

Answer 45

**Doxycyline** or azithryomycin The description is of Cholera and the treatment of cholera is: Supportive + Abx

Answer 46

**Anterior Cruciate ligament** The mechanism of injury sounds like a twisting injury and this is associated with a ACL or meiscus injury. However with the freedom of movement of the knee this makes the ACL more likely as Menisus injury is likely to present with the locking or giving way of the knee. *`ACL `* Sports injury with high rotational force There is a loud crack, rapid pain and RAPID joint swelling Intense physion and or surgery is needed *`Meniscus`* Sports injury with high rotational force The swelling will be delayed unlike above. There is also joint locking on examination *`PCL`* Dshboard injuries -> Direct trauma from the front going backwards Hyperextension injuries will also have this. The tibia lies back on the femur *`Lateral collateral ligament `* ISOLATED injuries with this is uncommon. Caused by trauma from medial aspect of the knee to the lateral aspect of the knee. This will present with locking of the knee

Answer 47

**ECG** This patient has Hyperkalaemia, and patients with a high K+ should have an ECG and a repeat blood test for K+ ions.

Answer 48

**Needs to be seen in ED** (Screen for other injuries CONFIRMED WITH ORTHO REG) Rib fractures are only really X-rayed if there is suspicion of complications that is associated with it. Only indication otherwise would be if they are haemodynamically unstable or is there is a worry of abuse...

Answer 49

**Duct ectasia** Duct ectasia is often green Papilloma -> Presents with bloody or brown dischard

Answer 50

**Prescribe emperical oral Abx** In the case of diabetic ulcers abx are given if there are signs of infections The following is the treatment of a diabetic foot ulcer: * Offloading, in which a plaster cast is used to take pressure off the ulcer and help with healing * treating any foot infection with antibiotics * Making sure the foot has a good blood supply * Clearing away the dead, damaged and infected skin from the ulcer (the medical name for this is debridement) * Using dressings while the ulcer heals.

Answer 51

**Subcutaneous infusion** If the oral route is unsuitable, alternatives include subcutaneous or transdermal opioids; prescribers should be sufficiently experienced and able to closely monitor the patient, otherwise specialist advice should be sought. If palliative patient we try and avoid IV as much as we can and pick subcut as much as possible

Answer 52

**Subcutaneous Emphysema** Look at the right side of the chest the weird translucency and opacifications on the right shoulder is suggestive of air there and this is likely to be air under the skin aka subcutaneous emphysema.

Answer 53

**Staging procedure**

Answer 54

**Prescribe Co-amoxiclav** Honestly this is a dumb question... but essentially deep cat bites need to be treated with Co-amoxiclav Otherwise the question is refering to test the tetanus prophylaxis in which case this wound just needs a dressing... BELOW is the management of Tetanus wounds So this is split based on the vaccination status of the patient. If you are** unsure about their vaccination history (ASSUME NO VACCINATION)** then there is a need to give the patient IG and also give them a reinforcing or intial dose of Tetanus vaccinations, if this a tetanus prone wound or high risk wound. If it is a clean wound then there is a need only for the vaccine. If the patient** was vaccinated more than 10 years ago **a clean wound does not require treatment but a an at risk wound would require a tetanus vaccine with a high risk wound requirinig both IG and a tetnus vaccine. If they have been vaccinated within 10 years then there is no need to do anything...

Answer 55

**Needle Fasciotomy** IF this is Dupuytren’s contracture then the management is Needle Fasciotomy Stenosing tenosynovitis (trigger finger) -> steroid injection -> finger splint -> surgery IF injury then fixesd deformity then it is a finger splint. . . To differentiate between the 2 diagnosis consider the description... Dupetryn contracture is when there is a thickening of the skin on the hand and leads to soft tissue contracture, whereas in stenosing tenosynovitis there is inflammation that leads to trapping of the flexor tendon. `Stenosing tenosynovitis` -> Will present with pain at the base of the affected finger... There will be stiffness of clicking when moving the finger... worse in the morning `Dupuytren's contracture `-> Will often start with nodules and cords as the soft tissue hardens -> This will then progress to reduced functionallity as the affected finger becomes more flexed...

Answer 56

**Prescribe metrondiazole** Remeber if alcohol then there is a need to give topical clindamycin,,,, the diagnosis is BV, with symptoms this should be treated The Amsel criteria for diagnosis: * thin, white homogenous discharge * clue cells on microscopy: stippled vaginal epithelial cells * vaginal pH > 4.5 * positive whiff test (addition of potassium hydroxide results in fishy odour)

Answer 57

**Lumbar puncture** The diagnosis is normal pressure Hydrocephalus. These patients presents with ataxia, diuresis and dementia/bradyphrenia The gold standard treatment is neurosurgery with a ventricular peritoneal shunt. However this is only done after LP as there needs to be evidence that the surgery will actually help manage this patient COULD ASK NEURO CONSULTANT AS THIS COULD BE A CASE LIKE THE STROKE THING WHERE IF LESS THAN 4.5 hrs there is a pathway for them

Answer 58

**Strep Pneumonia** This patient has well controlled HIV, with a lobar pneumonia. The most common cause of a lobar pneumonia is Strep

Answer 59

**Viral meningitis** The ratio between the serum glucose and that off the CSF will be less than 50 % if there is TB meningitis... Therefore eventhought there is a low CSF glucose it should be compared with the serum glucose to see if this is a true negative. If the ratio is greater than 50% then the answer like in this case is Viral menigitis

Answer 60

**Midazolam** There are many potential causes of seizures in advanced disease (such as brain tumours or biochemical abnormalities) and specialist advice should be sought where the diagnosis of seizures, or choice or dose of antiepileptic drug is in doubt. Antiepileptic drugs should not be used prophylactically in the absence of a history of seizures. In palliative care, levetiracetam is generally preferred as a first-line option as the dose can be titrated rapidly and there are fewer drug interactions. In the last days of life, midazolam may be preferred due to benefit in concurrent symptoms and compatibility with other drugs in a CSCI.

Answer 61

**Typhoid** I think this is a travelling fever with a maculopapular rash. I think this is elluding to the rose spots seen in Typhoid, hence my answer.... `typhoid` PRESENTATION: initially systemic upset relative bradycardia abdominal pain, distension constipation (can cause diarrhoea but constipation is more common) rose spots: present on the trunk in 40% of patients, and are more common in paratyphoid `Malaria` PRESENTATION intermittend cyclic Fever chills sweat, headache and myalgia maybe arthralgia `Brucellosis` PRESENTATION -> Around animals, Hx of fever, hepatosplenomegaly and arthralgia

Answer 62

**ESR** PMR >60 with stiffness of shoulder and CK is normal but there will be raised ESR.

Answer 63

**Allergy to band aid** The fact that the wound itself was clean and there was redness around the wound seems to make it more likely to be an allergy to the bandaid.

Answer 64

**Pneumothorax** This is a complication of the central line insertion. WHY NOT LEFT MAIN BRONCHUS INTUBATION? the intubation into the left main bronchus is a rare complication it is more likley to be the right main bronchus... This will present with louder breath sounds in the roght.

Answer 65

**Co-codamol** The next step in the pain ladder is Co-codamol or tramadol. However there is no real way to pick between the 2. HOWEVER in this particular case with regards to back pain an SNRI should not be used in the management of pain and the tramadol is both a weak opioid and a SNRI. This makes it the wrong drug to use. The screenshot does generally say to avoid opioids but in this case it is the only remaining choice

Answer 66

**Administer broad spectrum antibiotics** With regards to the lack of temperature, the screenshot below shows that it cant be used to rule out sepsis in certain pt groups, and with the next step I think you would assume it is sepsis and it is more important to give Abx than it is to place a catheter. CONTROVERSY between above and cathertise Reasoning for abx is because of sepsis becasuse of potentially neurtopenic sepsis if he is having chemo. This will need abx... Cathertise -> this is part of the sepsis 6 and so needs to be done anyway and if the condition is not sepsis but dehydration then there is a need to monitor fluid balance and so the patient needs to be cathertised anyway.

Answer 67

**Ciprofloxacin** Acute prostatitis Presentation: * Fever * Lower back pain * Dysuria * Incomplete voiding or urinary retention * Haematuria * TENDER prostate and warm/ might be boggy Treatment * Ciprofloxacin or levofloxacin * eftriaxone

Answer 68

**Tamsulosin** This patient has Benign prostatic hyperplasia. MANAGEMENT: Patients are symptomatic but it doesnt affect QoL * Lifestyle changes : avoid fluids at night, avoid diuretic (alcohol or coffee) and try double voiding when going to the toilet If it impacts QoL or if the above is not helpful then Medication: * Tamsulosin (causes dizziness, dry mouth hypotension) * Finasteride (if above not working or tolerated) For patients not controlled by medication OR have experienced hydronephrosis or urinary retention then REFERRAL to surgery * TURP or TUIP

Answer 69

**US guided fine needle aspiration** We think this is a ranula... Either way neck lumps normally need to be US and biopsied or aspirated. MAYBE CAN EMAIL KATIE???

Answer 70

**Fine needle aspiration** NOTE that not all patients do need all 3 of the triple assessment. Now with what we are expected to know for this exam I dunno how this exam would work if there are any worrying signs for example an irregular lump... This question becomes more problematic if the lump was regular mobile and then an image found just regular breast tissue, cause then it is a guess between them. The screenshot is from a consultant, honsetly no clue...

Answer 71

**Acetazolamide** the mid dilated pupils and the sudden onset visions changes we think is suggestive of an acute close angle glaucoma. This however would present with pain, which is not mentioned in the stem. They may have a red eye, halos around lights `Investigation for this inc:` * Tanometry * gonioscopy `MAnagment:` * Topical beta blockers, alpha agonist and prostaglandin analogues (latanoprost) may be used * NEXT step is topical carbonic anhydrase -> Acetazolamide or dorzolamide * Systemic hyperospmotic agents (IV mannitol) `SURGERY` * DEFINITIVE MANAGEMENT -> Laser peripheral iridotomy IF MORE OF AN ACUTE SCENARIO LOOK AT THE IMAGE,

Answer 72

**L4-S1** Muscle and nerver roots * Hip flexion L2 * Hip Extentsion L5 * Knee extension L34 * Knee flexion S1 * Ankle dorsiflexion L4 * Ankle plantarflexion S1 * Great toe flexor L5 Reflexes * Knee jerk -> L3+4 * Achilies reflex -> S1 * Babinski reflex -> L5 + S1 Dermatome The booty is ze S1

Answer 73

**Haemophilia** This is X linked so more common in males. Presents with haemoarthroses * Prolonged APTT * Bleeding time, thrombin time and prothrombin time normal are normal `Von willebrands disease` AD disease Presentation * Epixstasis and menorrhagia * RARELY presents with haemoarthrosis Ix * Prolonged bleeding time * APTT may be long * factor 8 levels are reduced * Defective platelet aggregation Mx * Tranexamic acid for mild bleeding * Demopressin raises vWF * Factor 8 concentrate `Factor V leiden` This is the most common cause of thrombophilia.. AKA this makes clots.... so would present with DVT and PE Ix * Activated Protein C blood test -> Most people have a resistance to protein C

Answer 74

**Sling only** , I think this is refer to fracture clinic??? `With undisplaced fractures` Analgesia + immobilisation and supportive care The immobilisation is with a sling in an undisplaced clacicular fracture. `With displaces fractures ` -> They need an ortho review, often they end up having a open reduction and internal fixation. ORTHO REG + My sister both say it is sling.... They have passed med you have not chose wisely....

Answer 75

**NOT ENOUGH INFO** But depends on the timings. I think if less than 8 hours and the below criteria have not been met and there is time to get the paracetamol levels within 8 hours then you will check paracetamol levels 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

Answer 76

**amitriptyline** This was the only option so we assume it is right. This seems to be a description of a neuropathic pain. If the question is suggestive of trigeminal neuralgia -> Carbamazepine

Answer 77

**Chemotherapy**

Answer 78

**Aircast** If there is no signs of infection there is no need for abx. The aircast other than being the only other option left we think is used in diabetic foot as a way to ease pressure in high pressure areas as a way to reduce the chance of an ulcer

Answer 79

**Hyoscine** Reduce the secretions.

Answer 80

**Cause of death unknown** Stupid deaths stupid deaths they are funny cause they are true stupid deaths stupid deaths hope next time its not you Notifiable deaths: * Unexpected or sudden death * Doctor has not seen patient in the last 28 days * within 24 hours of hospital admission * Accidents and injuries * Suicide * Indiustrial disease * ill treatment, starvation or neglect * During an operation of before recovering from the anaesthesia * Poisoning inc taking drugs * still births * Prisoners or peiople in polic custody * Serivce disability prisoners.

Answer 81

**Decline as best evidence suggests mobility is best** BELOW IS FROM THE NHS WEBSITE: If you need a fit note, contact the healthcare professional treating you. This should be a doctor, nurse, occupational therapist, pharmacist or physiotherapist. Your healthcare professional will assess you, and if they decide your health affects your fitness for work, they can issue a fit note and advise either that: you are "not fit for work" you "may be fit for work taking into account the following advice" Your healthcare professional will choose the "may be fit for work" option if they think that you are able to do some work, even if it is not your usual job, with support from your employer.

Answer 82

**Urgent referral** This patient has features of cancer so should be referred urgently... Now there is something where breast lump below the age of 30 can have a non urgent refferral and hopfully that question doesnt come up cause the consultant again has said bas everything should be referred urgently... I would say if they are less than 30 and had features of a fibroadenoma then I would do a non-urgent referral.

Answer 83

**Posterior nasal packing** IF haemodynamically unstable transfer to A and E, with a pinch of the soft part of the nose and the pt sat up and leaning forward. If the blood is from both nostrils aka a posterior bleed is suspected needs to be referred to hospital If this continues for 10-15 minutes and the bleeding site can be seen then cautery is attempted if the bleeding site cant be seen then posterior nasal packing is attempted.

Answer 84

We said **on warfarin** but, it doesnt acc fit with the below criteria as none of what is mentioned is a need for immidieate CT... I am not sure if within 8 hours is Urgent.... **Immediate:** * a GCS score of 12 or less on initial assessment in the emergency department * a GCS score of less than 15 at 2 hours after the injury on assessment in the emergency department * suspected open or depressed skull fracture * any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign) * post-traumatic seizure * focal neurological deficit * more than 1 episode of vomiting. **within 8hrs:** * age 65 or over * any current bleeding or clotting disorders * dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of more than 1 m or 5 stairs) * more than 30 minutes' retrograde amnesia of events immediately before the head injury.

Answer 85

**IV PCC** Intracranial bleed is major bleeding and this requires a PCC.

Answer 86

**Tranexamix acid**

Answer 87

**Refer to ENT surgeon** I think this is a chronic presentation of a hoarse voice and needs to be referred with a 2 week wait... 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.

Answer 88

**IV atropine**

Answer 89

**Ramipril**

Answer 90

**Patient needs to tell DVLA that she cant drive** What are the cases when the doctors have a responsibilty to tell the DVLA???

Answer 91

**Radial** ADD FEATURES OF EACHH Ulnar Median Axillary

Answer 92

**SPirometry** Major controversy Basically if there is an option for ECG go for that... If not If there is severe COPD then there is a need to do spirometry If there are signs of Heart failure then an Echo is needed A chest x-ray is not indicated.... If i am not sure between there being severe COPD or HF signs I will probably go for spirometry if ECG is not an option

Answer 93

**Add prednisolone** Add ramipril if it asks to help with protienuria

Answer 94

**Intubate** So Type 2 resp failure the answer would be BiPAP BUT in cases where there may be airway collapse there is a need to be intubated and to secure airway as quickly as possible.

Answer 95

**Naproxen** NSAIDS -> Pracetamol

Answer 96

**Oral azithromycin** This patient has Chlamydia There is a need to treat this.... Doxycycline is contraindicated in pregnanacy and so Oral azithromycin is used

Answer 97

**Physiotherapy** The sore trapezius is a common feature of whiplash. I think this depends if pain is controlled or not.... If not step up pain meds if not then physio?

Answer 98

**Osteoporotic fracture** This patient has androgen deprivation therapy -> This is a risk factor for osteoporotic fractures.... Dunno why it could not be prostate cancer... with bony mets??? We presume its because prostate cancer is quite slow growing,

Answer 99

**ESR** This person has polymyalgia rheumatica Weakness is not a feature of this but stifness and pain is. it has normal CK but raised ESR. When considering the diagnosis of Polymyositis, the features include: * proximal muscle weakness +/- tenderness * Raynaud's * respiratory muscle weakness * interstitial lung disease * e.g. fibrosing alveolitis or organising pneumonia * seen in around 20% of patients and indicates a poor prognosis * dysphagia, dysphonia

Answer 100

**MR angiography** This patient may have renal artery stenosis but due to fibromuscular dysplasia... It is unlikely to occur this early otherwise Phaeochromocytoma would have other features such as sweating or flushing and would be intermittent -> Urinary metanerphrine Conn's needs HRCT for diagnosis Aldosterine : renin ratio only tells if it is a primary hyperaldosteronism. -> I would go for this if the bloods showed an electrolyte abnormality like, Low K+ and High Na

Answer 101

**Syphylis** Investigations Refer to GUM they will -> Dark field microscopy and serology Treatment: * Benzathine penacillin * Doxy * Erythromycin if PREGNANT

Answer 102

**Metronidazole gel** ` rosacea` -> only refer if optimal care in GP has failed / red nose

Answer 103

**IV 500ml Fluid bolus** A-E you would die from C before E so manage the BP first...

Answer 104

**Chemotherapy** Small Cell lung cancer is basically always treated with Chemotherpy

Answer 105

**Pamidronate** Think this is a bisphosphonate

Answer 106

**Oral Fluclox** There is a lump so this neeeds abx

Answer 107

**Acute Dystonia** The neck back is a sustained contraction... This would need to be painful The eye movments is the description of the oculogyric crisis... ADD FEATURES OF OTHERS AS YOU GO

Answer 108

**High fibre diet**

Answer 109

**MR internal meatus** This person has senineoronal heading loss and tinnitus, these are some of the signs of a vestibular schwamonnoma and Prbyscusis is bilateral....

Answer 110

**Behcet's diaseas** Cant see cant pee cant eat spicy there are 2 of the 3 symptoms making this more likely.

Answer 111

**PBC** 1:160 means that for every 1 part of antigen diluted in 160 part of saline the antibody is still detected.... Therfore the higher the number the higher the concentration.... Therefore becuase it is greater than 20 it is +ve.