c

Question 1

Angina pectoris: drug management

Answer 1

aspirin and a statin in the absence of any contraindication

sublingual glyceryl trinitrate to abort angina attacks

beta-blocker or a calcium channel blocker then both if uncontrolled

Question 2

symptoms and signs of ACS/MI

Answer 2

chest pain.
typically central/left-sided
may radiate to the jaw or the left arm
dyspnoea
sweating
nausea and vomiting
appear pale and clammy

Question 3

The two most important investigations when assessing a patient with chest pain are:

Answer 3

ECG

cardiac markers e.g. troponin

Question 4

Anterior V1-V4

Answer 4

Left anterior descending

Question 5

Inferior II, III, aVF

Answer 5

Right coronary

Question 6

Lateral I, V5-6

Answer 6

Left circumflex

Question 7

Treatment of ACS

Answer 7

MONA
Morphine
Oxygen 94%>
Nitrates
Aspirin

second antiplatelet - clopidogrel, prasugrel and ticagrelor
GRACE in NSTEMI

Question 8

investigations for aortic dissection

Answer 8

Chest x-ray
widened mediastinum

CT angiography of the chest, abdomen and pelvis is the investigation of choice
suitable for stable patients and for planning surgery
a false lumen is a key finding in diagnosing aortic dissection

Transoesophageal echocardiography (TOE)
more suitable for unstable patients who are too risky to take to CT scanner

Question 9

Management of Type A aortic dissection

Answer 9

surgical management, but blood pressure should be controlled to a target systolic of 100-120 mmHg whilst awaiting intervention

Question 10

management of Type B aortic dissection

Answer 10

conservative management
bed rest
reduce blood pressure IV labetalol to prevent progression

Question 11

classify a type A aortic dissection

Answer 11

ascending aorta, 2/3 of cases

Question 12

classify a type B aortic dissection

Answer 12

descending aorta, distal to left subclavian origin, 1/3 of cases

Question 13

tear in the tunica intima of the wall of the aorta

Answer 13

aortic dissection

Question 14

Patients may require inotropic support and/or an intra-aortic balloon pump.

Answer 14

cardiogenic shock

Question 15

treatment for chronic heart failure

Answer 15

Loop diuretics such as furosemide will decrease fluid overload. Both ACE-inhibitors and beta-blockers have been shown to improve the long-term prognosis of patients with chronic heart failure.

Question 16

most common cause of death following a MI

Answer 16

ventricular fibrillation

Question 17

Pericarditis in the first _____ hours following a transmural MI is common

Answer 17

48

Question 18

an autoimmune reaction against antigenic proteins formed as the myocardium recovers. It is characterised by a combination of fever, pleuritic pain, pericardial effusion and a raised ESR. It is treated with NSAIDs.

Answer 18

dresslers syndrome

Question 19

Dressler’s syndrome tends to occur around ______ weeks following a MI.

Answer 19

2-6 weeks

Question 20

This is seen in around 3% of MIs and occurs around 1-2 weeks afterwards. Patients present with acute heart failure secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds). Urgent pericardiocentesis and thoracotomy are required.

Answer 20

Left ventricular free wall rupture

Question 21

what is the first line treatment for acute heart failure?

Answer 21

IV Loop diuretics

Question 22

associated with colorectal cancer

Answer 22

Streptococcus bovis

Question 23

So which features make pulmonary embolism more likely?

Answer 23

The relative frequency of common clinical signs is shown below:
Tachypnea (respiratory rate >16/min) - 96%
Crackles - 58%
Tachycardia (heart rate >100/min) - 44%
Fever (temperature >37.8°C) - 43%

Question 24

Accounts for 80% of cases of pneumonia

Particularly associated with high fever, rapid onset and herpes labialis

Answer 24

Streptococcus pneumoniae (pneumococcus)

Question 25

Particularly common in patients with COPD

Answer 25

Haemophilus influenzae

Question 26

Often occurs in patient following influenza infection

Answer 26

Staphylococcus aureus

Question 27

One of the atypical pneumonias, which often present a dry cough and atypical chest signs/x-ray findings Autoimmune haemolytic anaemia and erythema multiforme may be seen

Answer 27

Mycoplasma pneumoniae

Question 28

Classically seen in alcoholics

Answer 28

Klebsiella pneumoniae

Question 29

Typically seen in patients with HIV | Presents with a dry cough, exercise-induced desaturations and the absence of chest signs

Answer 29

Pneumocystis jiroveci

Question 30

Symptoms and signs of pneumonia

Answer 30

``` Symptoms cough sputum dyspnoea chest pain: may be pleuritic fever ``` ``` Signs signs of systemic inflammatory response fever tachycardia reduced oxygen saturations auscultation: reduced breath sounds bronchial breathing ```

Question 31

the classical x-ray finding in pneumonia is _____

Answer 31

consolidation

Question 32

pneumonia management

Answer 32

antibiotics: to treat the underlying infection supportive care, for example: oxygen therapy if the patient is hypoxaemic intravenous fluids if the patient is hypotensive or shows signs of dehydration

Question 33

symptoms of pneumothorax

Answer 33

``` dyspnoea chest pain: often pleuritic sweating tachypnoea tachycardia ```

Question 34

what differentiates a primary to secondary pneumothorax?

Answer 34

Primary- no underlying lung disease secondary- underlying lung disease

Question 35

recommendations for primary pneumothorax

Answer 35

if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered otherwise, aspiration should be attempted if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted

Question 36

when should a chest drain be inserted in pneumothorax

Answer 36

if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.

Question 37

how long do patients with secondary pneumothorax have to be admitted for?

Answer 37

At least 24 hours

Question 38

management of acute asthma

Answer 38

admission - all patients with life threatening asthma and patients with severe asthma that are not responding to initial treatment. Oxygen - 15L rebreather mask target 94-98% high-dose inhaled SABA e.g. salbutamol, terbutaline oral corticosteroid all patients should be given 40-50mg of prednisolone orally (PO) daily, which should be continued for at least five days or until the patient recovers from the attack ipratropium bromide IV magnesium sulphate

Question 39

Beclometasone dipropionate | Fluticasone propionate

Answer 39

Inhaled corticosteroids (ICS)

Question 40

Salmeterol

Answer 40

Long-acting beta-agonists (LABA)

Question 41

patients on a SABA + ICS whose asthma is not well controlled should be offered a ______

Answer 41

leukotriene receptor antagonist, not a LABA

Question 42

what is classified as a transudate pleural effusion and give examples

Answer 42

Transudate (< 30g/L protein) heart failure (most common transudate cause) hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption) hypothyroidism Meigs' syndrome

Question 43

what is classified as an exudate pleural effusion and give examples

Answer 43

``` Exudate (> 30g/L protein) infection: pneumonia (most common exudate cause), TB, subphrenic abscess connective tissue disease: RA, SLE neoplasia: lung cancer, mesothelioma, metastases pancreatitis pulmonary embolism Dressler's syndrome yellow nail syndrome ```

Question 44

where the volume of fluid in the pleural space is substantially greater than normal

Answer 44

pleural effusion

Question 45

give signs/symptoms of upper GI bleed

Answer 45

haematemesis often bright red but may sometimes be described as 'coffee gound' melena the passage of altered blood per rectum typically black and 'tarry'

Question 46

Dysphagia may be associated with weight loss, anorexia or vomiting during eating Past history may include Barrett's oesophagus, GORD, excessive smoking or alcohol use

Answer 46

Oesophageal cancer

Question 47

There may be a history of heartburn | Odynophagia but no weight loss and systemically well

Answer 47

oesophagitis

Question 48

There may be a history of HIV or other risk factors such as steroid inhaler use

Answer 48

Oesophageal candidiasis

Question 49

Dysphagia of both liquids and solids from the start Heartburn Regurgitation of food - may lead to cough, aspiration pneumonia etc

Answer 49

achalasia

Question 50

More common in older men Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles Usually not seen but if large then a midline lump in the neck that gurgles on palpation Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough. Halitosis may occasionally be seen

Answer 50

pharyngeal pouch

Question 51

Other symptoms may include extraocular muscle weakness or ptosis Dysphagia with liquids as well as solids

Answer 51

Myasthenia gravis

Question 52

steady worsening of dyshpagia over a few weeks in an older patient suggests _______

Answer 52

malignancy

Question 53

give management of crohn's

Answer 53

SG5A/M stop smoking! glucocorticoids (oral, topical or intravenous) eg. beclomethasone, betamethasone, budesonide. 5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective azathioprine or mercaptopurine* metronidazole is often used for isolated peri-anal disease

Question 54

what is used first line to maintain remission of crohn's disease

Answer 54

azathioprine or mercaptopurine is used first-line to maintain remission

Question 55

what classifies ulcerative colitis as mild, moderate and severe?

Answer 55

mild: < 4 stools/day, only a small amount of blood moderate: 4-6 stools/day, varying amounts of blood, no systemic upset severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)

Question 56

give treatment for mild to moderate UC

Answer 56

aminosalicylate eg . balsalazide, mesalazine, olsalazine and sulfasalazine oral aminosalicylate if remission still not achieved stop topical treatments and offer an oral aminosalicylate and an oral corticosteroid

Question 57

should be treated in hospital intravenous steroids are usually given first-line intravenous ciclosporin may be used if steroid are contraindicated if after 72 hours there has been no improvement, consider adding intravenous ciclosporin to intravenous corticosteroids or consider surgery

Answer 57

severe UC

Question 58

mechanism of beta blockers

Answer 58

β1 receptor antagonist

Question 59

mechanism of spironolactone

Answer 59

c) Aldosterone receptor antagonist

Question 60

mechanism of atropine

Answer 60

M2 muscarinic antagonist

Question 61

Pulmonary valve

Answer 61

Left second intercostal space, at the upper sternal border

Question 62

Aortic valve

Answer 62

Right second intercostal space, at the upper sternal border

Question 63

Mitral valve

Answer 63

Left fifth intercostal space, just medial to mid clavicular line

Question 64

Tricuspid valve

Answer 64

Left fourth intercostal space, at the lower left sternal border