Cancer, Skin and Infection Flashcards
1
Q
Name the 2 lactogenic hormones
A
- Prolactin - secreted by the anterior pituitary
2. Human placental lactogen (hpL) - secreted by the placenta
2
Q
What are the 3 components of the ‘triple assessment’ diagnostic method for breast cancer?
A
- Clinical assessment
- Imaging assessment
- Needle biopsy
3
Q
What is a common consequence/ side effect of axillary node clearance?
A
Lymphedema of the arm
4
Q
What are the 2 views used in a standard mammogram?
A
- Mediolateral oblique
2. Craniocaudal
5
Q
Define Karyorrhexis
A
Breakdown of the cell nucleus
6
Q
Name the 2 principle groups of lymph nodes that drain the breast
A
- Axillary nodes
2. Internal mammary nodes
7
Q
Define the 3 surgical levels of axillary lymph nodes
A
Level 1 - Inferior to the pectoralis major
Level 2 - Posterior to pectoralis major
Level 3 - Superior to pectoralis major
8
Q
What is the principle reason for the use of the mediolateral oblique view in a standard mammogram?
A
To ensure good visualisation of the axillary tail
9
Q
In what area of the breast to cancers most commonly occur?
A
~ 50 % of cancers are found in the upper out quadrant of the breast
10
Q
What 3 factors are taken in to consideration for a pathological grading of a tumour sample?
A
- Amount of gland formation
- Nuclear features
- Mitotic activity
11
Q
Name an example of anti-oestrogen therapy
A
Tamoxifen
12
Q
Name an example of monoclonal anti-HER2 therapy
A
Trastuzumab (Herceptin)
13
Q
What is the most common form of breast cancer?
A
Invasive ductal carcinoma
14
Q
What is the second most common form of breast cancer?
A
Invasive lobular carcinoma
15
Q
Give 3 clinical indications for mastectomy
A
- Multifocality
- Local recurrence
- DCIS or invasion >4cm
16
Q
Suggest 4 factors to consider when assessing a patient with breast cancer for adjuvant chemotherapy
A
- Stage of tumour
- Tumour phenotype
- Age
- Co-morbidities
17
Q
What is the PREDICT online tool?
A
Decision algorithm used to estimate the breast cancer survival rate of a patient and the potential benefits of hormone therapy, chemotherapy and trastuzumab
18
Q
Give 4 potential side effects of tamoxifen
A
- Endometrial thickening
- Cataracts
- DVT
- Vaginal dryness and other menopausal symptoms
19
Q
How does breast density affect an individuals risk of developing breast cancer?
A
Women with dense breast has a risk of breast cancer ~ 5 times that of women with fatty breasts
20
Q
What is lactational mastitis?
A
A women’s breast become painful, swollen and red - this is most common in the first 3 months of breast feeding
21
Q
Name a complication associated with lactational mastitis
A
Breast abscess
22
Q
What is the primary cause of mastitis in lactating women?
A
Milk stasis
23
Q
What is the most common organism associated with infectious mastitis in lactating women?
A
Staph Aureus
24
Q
Give 5 clinical conditions that have an association with peripheral mastitis
A
- Diabetes
- Rheumatoid arthritis
- Trauma
- Corticosteroid treatment
- Granulomatous lobular mastitis
25
What are the most common organisms associated with infective mastitis in non lactating women? (3)
1. S Aureus
2. Enterococci
3. Anaerobic bacteria
26
What are the 3 principle clinical characteristics associated with mastitis?
1. Painful breast
2. Fever and/or general malaise
3. Tender, red and swollen area of breast (usually witha wedge shaped distribution)
27
What histological changes would you expect to see during pregnancy and lactation? (2)
1. Enlargement of lobules
| 2. Increased luminal distension
28
Name the important differential to always consider when assessing a patient with apparent mastitis
Inflammatory breast cancer
29
Give 4 risk factors for the development of a breast abscess in a non lactating women
1. Smoking
2. Diabetes
3. Nipple piercings
4. Immunocompromised
30
Define a fibroadenoma histologically
Benign fibroepithelial lesion of the breast that is composed of both stromal and epithelial components
31
What is the follow up regime for a women treated for DCIS?
Annual mammogram and clinical examination for 5 years
32
What is the normal function of the BRCA genes?
Produce tumour suppressor proteins which help repair damaged DNA
33
Which gene mutation is associated with Li-Fraumeni syndrome?
TP53 mutation
34
BRCA mutations show what form of inheritance pattern?
Autosomal dominant
35
Where are the BRCA genes located?
BRCA 1 - Long arm of chromosome 17
| BRCA 2 - Long arm of chromosome 13
36
Prophylactic mastectomy for a BRCA gene carrier has what affect on the individuals lifetime breast cancer risk?
Reduces the risk of breast cancer by 90%
37
Which agent may be used for chemoprevention in women with BRCA gene mutations?
Tamoxifen
38
What does the term 'over-diagnosis' refer to with regards to the breast cancer screening program
The detection of cancers on screening which would not have become clinically apparent in a women's lifetime in the absence of screening
39
What are the 5 main categories of chemotherapy agents?
1. Alkylating agents
2. Anti-metabolites
3. Mitotic inhibitors
4. Antibiotics
5. Others
40
Which category of chemotherapy agents specifically targets the DNA synthesis section of the cell cycle?
Anti-metabolites
41
Which category of chemotherapy agents specifically targets the mitosis section of the cell cycle
Mitotic inhibitors
42
What is the mechanism of action of alkylating agents in chemotherapy?
Directly bind DNA leading to DNA cross-linking. Resultant abnormal base pairing prevents further cell division
43
What is the mechanism of action of Anthracycline antibiotics as chemotherapy agents?
Intercalation of base pairs leads to free radical formation which in turn inibits the enzyme topoisomerase
44
Which enzyme is targeted by anthracycline antibiotics?
Topoisomerase
45
What is the function of the enzyme topoisomerase?
Catalyses the unwinding of DNA which is required for both replication and repair
46
Name 2 non-anthracycline antibiotics
1. Bleomycin
| 2. Actinomycin D
47
Name an antimetabolite chemotherapy agent
Methotrexate
48
Name 3 Topoisomerase inhibitors
1. Doxorubicin
2. Irinotecan
3. Etoposide
49
Name 2 taxanes used as chemotherapy agents
1. Paclitaxel
| 2. Docetaxel
50
Name 3 vinca alkaloids that are used as chemotherapy agents
1. Vincristine
2. Vinblastine
3. Vinorelbine
51
What are the 4 principle roles of chemotherapy in clinical practise?
1. Curative
2. Adjuvant
3. Radio-sensitise
4. Palliation
52
What are the 3 main chemotherapy emergencies?
1. Febrile neutropenia/ neutropenic sepsis
2. Thrombocytopnenic haemorrhage
3. Tumour lysis syndrome
53
Rituximab is a monoclonal antibody used to treat what form of cancer?
Lymphoma
54
Trastuzumab is a monoclonal antibody agent used to treat what form of cancer
Breast cancer - Trastuzumab is otherwise known as Herceptin
55
Recall the ECOG scale of performance status used in the assessment of oncology patients
0 - Fully active and able to carry out all pre-disease performance without restriction
1 - Restricted in physically strenuous activity but ambulatory and able to carry out light work
2 - Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about > 50 % waking hours
3 - Capable of only limited self care. Confined to bed/chair > 50% waking hours
4 - Completely disabled and confined to bed/ chair. No self care
5 - Deceased
56
Recall the red flags for back pain used the mneumonic 'REDFLAGS'
R - Referred pain that is mulitsegmental or band like
E - Escalating pain that is poorly responsive to treatment
D - Different character or site to previous symptoms
F - 'Funny' sensations / heavy legs
L - Lying flat increases pain (also worse on coughing)
A - Agonising pain
G - Gait disturbance or unsteadiness - particularly on stairs
S - Sleep grossly disturbed due to pain being worse at night
57
What is the most common area of the back for metastatic spinal cord compression to occur?
Thoracic spine - unusual site for any other form of back pain
58
What is the pharmacological management of metastatic spinal cord compression?
High dose steroids - Dexamethasone 16 mg stat followed by 8 mg BD
59
If a patient with hypercalcaemia is found to be refractory to treatment with bisphosphonates what alternative medication can be used?
Denosumab
60
What are the 3 main mechanisms by which hypercalcemia may occur in patients with malignancy?
1. Tumour osteolytic effect on bone
2. Humoral PTHrP
3. Overproduction of vitamin D
61
What are the 3 principle gene types that contribute to cancer formation?
1. Proto-oncogenes
2. Tumour suppressor genes
3. DNA repair genes
62
Recall the 8 red flag symptoms associated with lung cancer
1. Persistent cough (dry/productive)
2. Haemoptysis
3. Dyspnoea
4. Hoarse voice
5. Chest pain
6. Fatigue
7. Appetite loss
8. Weight loss
63
An urgent CXR should be performed on any patient aged > 40 presenting with any of which 5 symptoms in order to rule out lung cancer?
1. Persistent or recurrent chest infections
2. Finger clubbing
3. Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
4. Chest signs consistent with lung cancer
5. Thrombocytosis
64
What is the most common type of mesothelioma diagnosed in the UK?
Pleural mesothelioma
65
Outline the 'T' stages of TNM staging for lung cancer (4)
T1 - < 3cm
T2 - 3-5 cm or involves main bronchus (but not the carina)
T3 - 5-7cm or invades the chest wall or separate nodule in the same lobe
T4 - >7cm or invading local structures e.g. mediastinum/heart/trachea. (Inoperable)
66
What is the 1 year survival rate for patients diagnosed with lung cancer in the UK?
~30%
67
Classify the drug Letrozole
Aromatase inhibitor used in the treatment of hormone responsive breast cancers
68
Name a potential adverse affect of Letrozole
Osteoporosis
69
Give an example of a bisphosphonate used in the treatment of hypercalcemia
Zoledronic acid
70
Classify the drug Denosumab
RANK ligand inhibitor
71
What is the current first line treatment regime for metastatic Her2 positive breast cancer? (3)
1. Trastuzumab
2. Pertuzumab
3. Docetaxel (chemotherapy)
72
What is the mechanism of action of Trastuzumab?
Interacts with the Her2 receptor and prevents its stimulation by growth factors
73
What is the mechanism of action of Pertuzumab?
Prevents dimerisation of HER2 receptors with other receptors in the group
74
What is a MUGA scan?
Multiple gated acquisition scan - radionucleotide scan used to assess ventricular output. Used as an alternative test to an echocardiogram in such instances
75
What is the dose of Denosumab used in the treatment of cancer compared to osteoporosis?
Cancer - 120 mg once every 4 weeks by subcutaneous injection
Osteoporosis - 60 mg once every 6 months
76
Give 2 important side effects associated with Denosumab
1. Hypocalcaemia
| 2. Ostenecrosis of the jaw
77
With regards to potential side effects, give 2 advantages of Denosumab over Zoledronic acid
1. Less likely to induce renal toxic effects
| 2. Less likely to induce acute phase reactions
78
What is Bicalutamide?
Anti-androgen commonly used in the treatment of prostate cancer
79
What are the most common side effects associated with CTLA-4 inhibitors? (2)
1. Skin symptoms e.g. rashes and itching
| 2. GI symptoms e.g. diarrhoea
80
What are the most common side effects associated with PD-1/PD-L1 inhibitors? (3)
1. Skin symptoms e.g. rashes and itching
2. Lung symptoms
3. Thyroid dysfunction
81
Give an example of a CTLA-4 inhibitor
Ipilumumab
82
Give 2 examples of a PD-1 inhibitor
1. Nivolumab
| 2. Pembrolizumab
83
Give 2 examples of PD-l1 inhibitors
1. Atelolizumab
| 2. Avelumab
84
Give 7 possible immune related toxicities which may occur as a result of immunotherapy
1. Exacerbation of existing autoimmune conditions
2. Diarrhoea
3. Endocrinopathies
4. Pneumonitis
5. Nephritis
6. Uveitis
7. Paraesthesia and neuropathy
85
Recall the toxicity gradings of immunotherapy side effects according to ' Common Terminology Criteria' CTC for adverse events
Grade 1 - Asymptomatic or mild symptoms
Grade 2 - Moderate symptoms limiting age appropriate instrumental ADL
Grade 3 - Severe or medically significant but not immediately life threatening. Usually requires hospital admission
Grade 4 - Life threatening consequences - urgent intervention required
Grade 5 - Death caused by treatment toxicity
86
Give an example of a targeted immunotherapy agent that can be used in the treatment of some forms of melanoma
BRAF inhibitors e.g. Vemurafenib or Dabrafenib
87
What is the mechanism of action of the monoclonal antibody Ipilimumab?
Blocks the checkpoint inhibitor: CTLA-4 . This prevents T cells from being 'switched off' thereby ensuring they attack local cancer cells
88
What is the mechanism of action of the monoclonal antibody Nivolumab?
Prevents the interaction of PD-L1 and PD-1 thus preventing T cell apoptosis
89
What is the overall mechanism of action of checkpoint inhibitors in immunotherapy?
They target signalling proteins that allow cancer cells to otherwise 'hide' from the immune system
90
Give 4 toxicities associated with cisplatin therapy
1. Hearing impairment
2. Bone marrow suppression
3. Peripheral neuropathy
4. Renal impairment
91
The HPV vaccine Gardasil protects against which 4 types of HPV?
1. 18
2. 16
3. 6
4. 11
92
Chemotherapy is typically dosed according to which body metric?
Body surface area
93
What is the classical presentation of Hodgkin's lymphoma?
Painless cervical and/or supraclavicular lymphadenopathy in a young adult
94
Name 3 complications associated with Hodgkin's lymphoma
1. Secondary malignancies
2. Heart disease
3. Decreased pulmonary function
95
The presence of which 2 cell types is characteristic of Hodgkin's lymphoma?
1. Hodgkin cells
| 2. Reed - Sternberg cells
96
What is the appropriate form of lymph node biopsy for the investigation of lymphoma?
Excisional lymph node biopsy
97
Describe the Lugano classification for PET-CT reporting of lymphoma
I - One node or group of adjacent nodes
II - Two or more nodal groups on the same side of the diaphragm
III - Nodes on both sides of the diaphragm or nodes above the diaphragm + spleen involvement
IV - Additional non contagious extra-nodal involvement
A Suffix if no B symptoms present. B suffix in the present of B symptoms
98
What 2 components make up the NICE definition of neutropenic sepsis?
1. Temperature > 38
| 2. Neutrophil count < 0.5 *10^9/L
99
Which chemotherapy agents are involved in the ABVD regime for the treatment of lymphoma?
A - Doxorubicin
B - Bleomycin
V - Vinblastine
D - Dacarbazine
100
What is the name given to the thin protective outer layer of the skin?
Stratum Corneum
101
Which protein deficiency is noted in ~ 56% of people with moderate to severe eczema
Filaggrin deficiency
102
Which organisms are associated with adult seborrhoeic dermatitis?
Species of Malassezia yeasts
103
Name the 2 subtypes of contact dermatitis
1. Irritant
| 2. Allergic
104
Define the term 'macule'
An area of skin with a distinct change in colour without any elevation above the surface of the surrounding skin
105
What is another term for a vascular papule?
Haemangioma
106
Define the term 'papule'
Circumscribed, raised lesion of epidermal or dermal origin that is 0.5 - 1cm in diameter
107
Define the term 'nodule'
Circumscribed, raised lesion of epidermal or dermal origin that is >1 cm in diameter
108
Define the term 'plaque'
Circumscribed, superficial elevated plateau area 1 - 2 cm in diameter
109
Define the term 'vesicle' in reference to a dermatological examination
Raised lesion that contains clear fluid (blisters)
110
Define the term 'bullae'
Vesicle that is larger than 0.5cm
111
What is Lichenification?
Hard thickening of the skin with accentuated skin markings commonly as a result of chronic inflammation or rubbing of the skin
112
What is a discoid lesion?
Coin shaped skin lesion
113
Name 4 endogenous types of eczema
1. Discoid
2. Atopic
3. Varicose
4. Seborrhoeic dermatitis
114
Suggest 5 signs of atopic eczema that has become complicated by bacterial infection
1. Weeping/ pustules
2. Failure to respond to therapy
3. Rapidly worsening eczema
4. Crusting
5. Fever and malaise
115
Give 4 clinical signs associated with eczema herpeticum
1. Area of rapidly worsening painful eczema
2. Clustered blisters consistent with early stage cold sores
3. Punched out erosions usually 1-3mm that are uniform in appearance
4. Possibly fever, lethargy or distress
116
What is the first line antibiotic treatment for S.aureus and streptococcal infections?
Flucloxacillin
117
What are the 2 most common infective organisms known to complicate atopic eczema?
1. S. Aureus
| 2. Streptococcal species
118
What is eczema herpeticum?
Atopic eczema that has been infected by Herpes simplex virus
119
Name 3 potential complications associated with eczema herpeticum
1. Encephalitis
2. Hepatitis
3. Pneumonitis
120
Recall 3 factors implicated in the pathogenesis of atopic eczema
1. Breakdown of skin barrier function
2. Inflammatory cascade that has predominantly Th2 cells
3. Decreased expression of fillagrin in the epidermis
121
Name a class of drugs that can be used as alternatives to topical corticosteroids in the treatment of asthma
Topical calcineurin inhibitors
122
Give 2 examples of topical calcineurin inhibitors
1. Tacrolimus
| 2. Primecrolimus
123
What is Dupilimab?
Human monoclonal antibody which inhibits signalling of cytokines IL4 and IL13
124
Suggest 4 possible causes of an erythrodermic eczema flare
1. Withdrawal of systemic steroids
2. Secondary bacterial infection (or viral)
3. Psychological stress
4. Development of contact dermatitis
125
In dermatology, what is the Kobner phenomenon?
Psoriasis lesion that develops following damage (i.e. cut or scratch) to a section of skin
126
Name a vitamin A analogue that can be used in the treatment of psoriasis
Tazarotene
127
Give 4 clinical features of Psoriatic nails
1. Periungal erythema
2. Pitting
3. Subungal keratosis
4. Onycholysis
128
What is the most common form of psoriasis seen?
Chronic plaque psoriasis
129
Which form of psoriasis can be triggered by the withdrawal of systemic corticosteroid therapy/ inappropriate use of superpotent topical steroids of a large body area?
Generalised Pustula psoriasis
130
Recall the 5 distinct patterns of Psoriatic Arthropathy
1. Distal interphalangeal alone
2. Symmetrical polyarthritis (most common)
3. Asymetrical oligoarthritis
4. Arthritis mutilans
5. Spondyloarthropathy
131
Where are the 3 classical areas in which Psoriatic plaques may be found?
1. Elbows
2. Knees
3. Scalp
132
Guttate psoriasis has an association with which illness in adolescence?
Sore throat with associated group B-haemolytic streptococcus
133
Name 6 potential triggers for the development of medically emergent erythrodermic psoriasis
1. Withdrawal of systemic steroids
2. Infections
3. Excessive alcohol intake
4. Antimalarials
5. Lithium
6. Hypocalcemia
134
Outline the genetic characteristics of type 1 and type 2 psoriasis
Type 1 - Initial presentation <40 yrs. Genetically linked to HLA- CW6 mutation
Type 2 - Initial presentation between 55-60 yrs. No association with HLA-CW6
135
Which 2 forms of psoriasis warrant direct secondary referral to dermatology ?
1. Acute guttate psoriasis
| 2. Nail psoriasis with significant effect on quality of life
136
What 2 red flags warrant emergency referral to on call dermatologist when assessing a patient with psoriasis?
1. Erythrodermic patients
| 2. Generalised pustular psoriasis
137
Outline the 4 first line treatments for localised stable psoriatic plaques
1. Tar preparations
2. Vitamin D analogues
3. Salicylic acid preparations
4. Topical steroids
138
Give 4 advantages associated with topical treatments for dermatological conditions
1. Local effects only
2. Self-application
3. Safe for long term use
4. Relatively cheap
139
Give 5 disadvantages associated with topical treatments for dermatological conditions
1. Time consuming in cases of extensive disease
2. Poor compliance
3. Messy and may affect clothing/bedding/hair
4. No benefit for associated joint disease
5. Tachyphylaxis - i.e. treatment may become less effective with prolonged use
140
Give 4 examples of photosensitive diseases
1. Lupus
2. Porphyria
3. Albinism
4. Xeroderma pigmentosum
141
What is the function of the PASI scoring system?
Psoriasis Area Severity Index - objective clinical measure of the severity of the patient's disease state
142
Recall the categories of the Psoriasis Area Severity Index
Mild: 0-5 PASI
Moderate: 5-12 PASI
Severe: 12-20 PASI
Very Severe: >20 PASI
143
What is the function of the DLQI scoring system in dermatology?
Dermatology of Life Index - subjective patient measure of the impact of the disease state on the patient's quality of life
144
Name 5 systemic agents sometimes used in the management of severe psoriasis
1. Ciclosporin
2. Methotrexate
3. Acitretin
4. Fumaric acids
5. Apremilast
145
Give 3 examples of TNF inhibitors
1. Infliximab
2. Etanercept
3. Adalimumab
146
Name an IL12/23 inhibitor
Ustekinumab
147
Give an example of an IL-17 inhibitor
Ixekiaumab
148
Name 3 types of biologics that can be used in the treatment of severe psoriasis
1. TNF inhibitors
2. IL 12/23 inhibitors
3. IL-17 inhibitors
149
Erythrodermic psoriasis is defined as erythema covering what proportion of total body area?
> 90%
150
Name 4 medical conditions for which a patient with psoriasis is at a greater risk of developing as a result of their condition
1. Myocardial infarction
2. Type 2 diabetes
3. Hyperlipidaemia
4. Metabolic syndrome
151
What treatment would you prescribe for stable plaque psoriasis of the trunk
Dovobet gel every 24 hrs for 4 weeks
152
What is the principle clinical feature that helps distinguish between acne Vulgaris and Rosacae?
Absense of comedones (black heads) in Acne Rosacae
153
What is the first line medical treatment for Acne Rosacae?
Topical metronidazole 0.75% applied twice daily
154
Name a system used to grade the severity of acne vulgaris on clinical assessment
The Leeds scoring system - counting + categorisation of inflammatory and non inflammatory lesions
155
Recall the 5 indications for the prescription of oral retinoids (e.g. isotretinoin) for acne vulgaris
1. Moderate acne - unresponsive to conventional therapy or relapsing after conventional therapy
2. Severe acne
3. Acne scarring
4. Psychological effects resulting from acne and/or scarring
5. Unusual form of acne
156
What is the standard dose of isotretinoin used in the treatment of severe acne vulgaris?
Once daily (0.5mg/kg to 1mg/kg) for 4 months
157
Name 2 drug categories that can be utilised to inhibit sebaceous gland function for the treatment of acne
1. Anti-androgens (e.g. spironolactone = androgen receptor blocker)
2. Oestrogens
158
What is the mechanism of action of oral retinoids e.g. isotretinoin?
Normalise the pattern of follicular keratinisation. They are also indirectly antibacterial.
159
What is the most common form of skin cancer?
Basal cell carcinoma
160
What is Gorlin Syndrome?
Autosomal dominant syndrome associated with a higher incidence (and multiple) basal cell carcinomas alongside other clinical sequelae e.g. craniofacial abnormalities and neoplasms
161
What is a Marjolin's ulcer?
An aggressive form ulcerating of squamous cell carcinoma that develops in an area of previous skin trauma, chronic inflammation or scarring
162
Smoking is a risk factor specific to which form of skin cancer?
Squamous cell carcinoma
163
Name a genetic syndrome associated with squamous cell carcinoma
Xeroderma Pigmentosum
164
Which form of keratinocyte cancers is associated with chronic ulcers?
Squamous cell carcinoma
165
Gorlin's syndrome is associated with which gene mutation?
Mutation of the tumour suppressor gene: PTCH 1
166
A 'rodent ulcer' refers to what form of skin cancer?
Basal cell carcinoma
167
When performing a full dermatological examination, it is important to examine which 2 additional areas for completion if a malignant lesion is suspected?
1. Draining lymph nodes
| 2. Abdominal examination for hepatomegaly
168
Recall the 6 categories of the Fitzpatrick skin type classification system
I - Pale white skin, blue/green eyes, blonde/red hair --> Always burns, does not tan
II - Fair skin, blue eyes --> Burns easily, tans poorly
III - Darker white skin --> Tans after initial burn
IV - Light brown skin --> Burns minimally, tans easily
V - Brown skin --> Rarely burns, tans darkly easily
VI - Dark brown/ black skin --> Never burns, always tans darkly
169
What is the scientific word for a mole?
Melanocytic naevus
170
For a lesion that is suspicious for malignant melanoma what is the immediate treatment?
Excision with a narrow margin at the earliest opportunity - ideally same day as positive examination
171
What is considered to be a large number of moles (and therefore a risk factor for melanoma) in young and old people respectively?
Young - More than 100
| Old - More than 50
172
Name 3 major clinical signs associated with malignant melanoma
1. Existing or new mole that is changing rapidly over a period of weeks/ months
2. Mole with an irregular outline
3. Mole with a mixture of different shades of black and brown
173
Give 2 medical conditions that have an associated with melanoma
1. Inflammatory bowel disease
| 2. Immunosuppression for any reason e.g. viral or iatrogenic
174
The 'Breslow thickness' of a melanoma measures the distance between which sections of the skin?
Distance in mm from the granular layer in the epidermis to the deepest level of invasion of the dermis
175
Which 5 characteristics define the TNM staging of a melanoma?
1. Breslow Thickness
2. Evidence of mitosis
3. Ulceration
4. Lymph node involvement
5. Evidence of distant metastases
176
Give 4 recognised risk factors for the development of melanoma
1. >100 melanocytic naevi
2. UV A radiation
3. Family Hx of melanoma in a first degree relative
4. Immunosuppresion
177
What is the most common site for a women to develop a melanoma?
Lower limb
178
Define pruritus
Itching without a rash
179
Define Prurigo
Intensely itchy papules and nodules
180
Define chronic pruritus
Itching that lasts > 6 weeks
181
Give 3 characteristic secondary skin lesions that are often seen in a presentation of chronic pruritus
1. Excoriations
2. Lichenification
3. Hyper/ hypo pigmentation
182
Acanthosis nigrans can be associated with what form of internal malignancy?
Gastric adenocarcinoma
183
Figurate erythemas can be associated with what form of internal malignancy?
Bronchial/oesophageal/ breast carcinoma
184
Pruritus can be associated with what form of internal malignancy?
Lymphoma
185
Dermatomyositis has associations with which 4 carcinomas?
1. Lung
2. Breast
3. Ovarian
4. Testicular
186
Acquired ichthyosis can be associated with which 3 types of internal malignancy?
1. Hodgkin's disease
2. Sarcoma
3. Lymphoma
187
What are the 2 requirements prior to performing a HIV test on a patient?
1. Assessment of patients capacity
| 2. Attain verbal informed consent for the procedure
188
Give 3 neurological causes of a persistent itch
1. Peripheral neuropathy
2. Post-herpetic neuropathy
3. Multiple sclerosis
189
Give 3 psychogenic causes of persistent itch
1. Parasitophobia
2. Obsessive compulsive disorder
3. Depression/ Anxiety
190
Suggest 3 metabolic causes of persistent itch
1. Hyperthyroidism
2. Chronic kidney disease
3. Diabetes
191
What are the 2 means by which chronic kidney disease may cause a persistent itch in a patient?
1. Secondary hyperparathyroidism
| 2. Uraemic pruritus
192
Give 2 haematological causes of a persistent itch
1. Polycythaemia rubra vera
| 2. Myeloid dysplasia
193
Candidiasis of the submammary fold can be a systemic indication of which medical condition?
Diabetes Mellitus
194
Give 3 cutaneous signs associated with tuberous sclerosis
1. Periugal fibroma
2. Adenoma sebaceum
3. Ash leaf 'spots'
195
What is the most appropriate test for the initial investigation of Erythema Nodosum ?
ASOT titre for potential streptococcal throat infection
196
Which 5 diseases account for the vast majority of invasive fungal infections?
1. Aspergillosis
2. Candidiasis
3. Cryptococcosis
4. Mucormycosis
5. Pneumocytosis
197
Name the 4 main truly pathogenic (dimorphic) fungal diseases
1. Blastomycosis
2. Coccidioidomycosis
3. Histoplasmosis
4. Paracoccidioidomycosis
198
Which candida species has increasing prevelence worldwide and is often seen in the intensive care setting?
Candida Auris
199
ABPA (Allergic bronchopulmonary aspergillosis) is caused by what 2 types of hypersensitivity reaction?
Type II and III hypersensitivity reaction to aspergillus antigens
200
Suggest 5 previous disease states which may leave residual lung cavities after resolution
1. Tuberculosis
2. Sarcoidosis
3. Bronchiectasis
4. Pneumoconiosis
5. Ankylosing spondylitis
201
What is the most common symptoms associated with chronic pulmonary aspergillosis?
Haemoptysis - occurs in ~ 50% of cases
202
Suggest 2 patient cohorts in which Tracheobronchitis may be seen in
1. HIV positive patients
| 2. Lung transplant recipients
203
Acute invasive sinusitis is most commonly associated with which aspergillosis species?
Aspergillus flavus
204
What is the treatment of choice for chronic pulmonary aspergillosis?
Long term itraconazole or Voriconazole therapy
205
What is the treatment regime for Cryptococcal meningitis?
Amphotericin B + Flucytosine 25mg/kg every 6 hrs for 2 weeks followed by Fluconazole 400 mg/day for a minimum of 8 weeks
206
What are the 2 classical clinical features associated with a Mucormycosis infection?
Rapid onset necrosis accompanied by fever
207
What is the most common form of pneumonia seen in patients with AIDS?
Pneumocystis Jiroveci pneumonia
208
Define the term prion
Infectious particles composed entirely of proteins
209
What is the mechanism of action of metronidazole?
Inhibits/ interferes with nucleic acid synthesis
210
Name 2 antibiotics that function by interrupting folic acid metabolism in the bacterial cells
1. Trimethoprim
| 2. Sulphonamides
211
Quinolones target which bacterial intracellular organelle?
DNA gyrase
212
Macrolides target which bacterial intracellular organelle?
Ribosome 50S inhibitors
213
Give 4 organisms that are associated with hospital acquired infections
1. MRSA
2. Carbapenem resistant E.Coli
3. Norovirus
4. C. Difficile
214
Give 3 infections that can be acquired through the injection of illegal drugs
1. Candida endopthalmitis
2. Infective endocarditis
3. Hepatitis C
215
What are the 5 stages of the gram staining process?
1. Fixation
2. Crystal violet
3. Iodine treatment
4. Decolouration
5. Counter stain - Safranin
216
Name a stain appropriate for Mycobacteria analysis
Ziehl-Neelson staining
217
Give 2 examples of 'spiral' shaped bacteria as well as the disease states that they cause
1. Treponema Pallidum - Syphilis
| 2. Borrelia Burgdorferi - Lyme disease
218
Which antibiotic class has the broadest species cover for a gram positive infection?
IV Glycopeptides
219
Name 2 glycopeptide antibiotics
1. Vancomycin
| 2. Teicoplanin
220
Which macrolide antibiotic offers a degree of cover to some anaerobic bacteria?
Clindamycin
221
What is the most common source for candidaemia ?
Gut flora
222
What are the 3 broad classification categories for clinically significant fungal infections?
1. Superficial
2. Subcutaneous
3. Deep mycoses
223
Which blood test has a high sensitivity for fungal infection?
Beta D-glucan test (a fungal cell wall antigen).
224
Name 4 risk factors for the development of varicella pneumonitis
1. Smoking
2. Pregnancy
3. Immuno-compromise
4. Chronic lung disease
225
Name 3 types of Herpes virus known to infect humans
1. Herpes simplex virus (1 and 2)
2. Epstein -Barr Virus
3. Cytomegalovirus
226
Koplik spots on the buccal mucosa are indicative of which pathogen?
Measles
227
Name 3 clinical complications associated with Measles
1. Bacterial pneumonia
2. Otitis media
3. Acute encephalitis
228
What are the 3 clinical components of the syndrome associated with glandular fever?
1. Fever
2. Sore throat
3. Lymphadenopathy
229
What is the most common cause for a raised eosinophil count seen in general practise in the UK?
Atopic diseases e.g. asthma and hayfever
230
Suggest 4 possible causes of an eosinophilia
1. Atopic disease e.g. asthma or eczema
2. Haematological malignancy
3. Parasites
4. Drug allergies
231
Define the 2 subdivisions of endoparasites
1. Helminths - Worm like parasites that are mostly visible to the naked eye
2. Protozoan parasites - Single celled, eukaryotic organisms that are usually motile
232
What is the 'definitive' host of a parasite?
The animal that hosts the adult stage of the parasite
233
What is the recommend agent for malarial chemoprophylaxis?
Doxycycline
234
Name the parasite that is thought to be responsible for 'elephantiasis'
Filariasis
235
What is the most common causative pathogen for bacterial endocarditis?
Strep Viridans
236
Which pathogen is associated with infective endocarditis following a dental procedure?
Strep Mitis
237
What is Libman-Sacks endocarditis?
A form of non-bacterial thrombotic endocarditis caused by systemic lupus erythematosus
238
Recall the organisms referred to in the HACEK mnemonic that are recognised to cause culture negative infective endocarditis
```
H - Haemophilus aphrophilus
A - Actinobacillus Actinomycetemitans
C - Cardiobacterium hominis
E - Eikenella Corrodens
K - Kingella kingae
```
239
What is the first line antibiotic choice for the empirical treatment of septic arthritis?
IV Flucloxacillin
240
What is the first line treatment for uncomplicated cellulitis in a patient with no allergies?
Flucloxacillin
241
Give 2 reasons why it is best practise to give an antibiotic that is targeted to the sensitivity of the bacteria as much as possible ( i.e. targeted narrow spectrum antibiotic where possible)
1. Reduce the chance of developing resistance
| 2. Reduce the incidence antibiotic related diarrhoea
242
Which topical treatment is often used in the treatment of impetigo?
Fusidic acid ointment
243
Name the mammals in the UK that carry the rabies virus
Bats are the only mammals in the UK that carry the rabies virus
244
What is the antibiotic of choice for the treatment of uncomplicated cellulitis in a patient with a Penicillin allergy?
Clarithromycin
245
What is the first line antibiotic treatment for mammal bites in the UK?
Co-Amoxiclav
246
Name 4 antibiotics that are active against MRSA
1. Doxycycline
2. Vancomycin
3. Linezolid
4. Teicoplanin
247
What are the 2 most common bacteria implicated in skin and soft tissue infections?
1. Staph Aureus
| 2. Strep Pygogenes
248
How would Staph. Aureus typically appear on gram staining?
Gram positive cocci in clusters
249
What is the typical appearance of streptococcal species on gram staining?
Gram positive cocci in chains
250
Which bacteria is commonly associated with chronic wounds e.g. chronic leg ulcers or diabetic foot ulcers?
Pseudomonas aeruginosa
251
Give 4 clinical differentials for cellulitis
1. DVT
2. Lymphedema
3. Venous insufficiency
4. Venous eczema
252
Recall the two modalities by which the influenza virus family is capable of mutating
1, Antigenic shift
| 2. Antigenic drift
253
Define antigenic drift
Gradual accumulation of mutations that change the surface antigens and make the virus less susceptible to the antibodies produced during previous infections
254
Define antigenic shift
Two or more strains combine to form a new subtype with surface antigens that humans have not encountered previously
255
Suggest 6 risk factors associated with complicated influenza infection i.e. severe influenza requiring hospital admission
1. Neurological, renal, hepatic, pulmonary and chronic cardiac disease
2. Diabetes
3. Immunocompromise
4. Age > 65
5. Pregnancy (including 2 weeks post partum)
6. Morbid obesity
256
Give 4 clinical complications associated with severe influenza
1. Primary viral pneumonia
2. Secondary bacterial pneumonia
3. Myositis and Rhabdomyolysis
4. CNS complications including: GBS, encephalitis and transverse myelitis
257
Name the 3 organisms most commonly implicated in superimposed bacterial infections of the lungs
1. Strep pneumoniae
2. Staph Aureus
3. Haemophilus influenza
258
What is the mean incubation period of COVID-19?
5 days (2-14 day range)
259
What are the 3 most commonly reported symptoms associated with COVID-19 infection?
1. Persistent cough
2. Loss of smell and taste
3. Fever
260
Define Neyman Bias
Tendency of initial reports of a novel infectious disease to overestimate prevalence and severity of symptoms
261
Name 2 Neuraminidase inhibitors
1. Oseltamivir
| 2. Zanamivir
262
What are the 3 most common causes of diarrhoea in transplant recipients?
Infection due to immunosuppression. Causative organisms:
1. C. Diff
2. Cytomegalovirus
3. Norovirus
263
Suggest 3 potential consequences of diarrhoea in a transplant recipient
1. Severe dehydration
2. Medication toxicity
3. Transplant organ rejection
264
What is the incubation period for acute hepatitis infection?
Ranges from 2 weeks to 6 months
265
What is the causative pathogen of Amebic liver abscesses?
Entamoeba Histolytica
266
Amebic liver lesions are most commonly found in which lobe of the liver?
Right lobe
267
What is the typical treatment regime for Amebic liver cysts?
Tissue agent - Metronidazole : 500-750mg IV/PO every 8 hours for 7-10 days
Luminal agent - Paromycin : 25-30 mg/kg PO per day in 3 divided doses over the course of 7 days
268
A serological test showing antibodies to Hepatitis B surface antigens (anti-HBs) indicates what?
Immunity to hepatitis B virus
269
A serological test showing antibodies to Hepatitis B core antigens (anti-HBc) indicates what?
Exposure to hepatitis B virus
270
Suggest 4 causes of increased bilirubin production
1. Haemolysis
2. Ineffective erythropoiesis
3. Blood transfusion
4. Resorption of haematoma
271
Name a drug that reduces the hepatic uptake of bilirubin
Rifampicin
272
Name the 2 characteristic biomarkers associated with type 1 autoimmune hepatitis
1. Antinuclear antibody
| 2. Smooth muscle (actin) antibodies
273
Name the biomarker associated with type 2 autoimmune hepatitis
Anti-LKM1
274
Which genetic mutation is associated with the majority of the cases of haemochromatosis seen?
HFE mutation on the short arm of chromosome 6
275
What are the 2 most common strains of hepatitis C found in the UK?
Genotypes 1 and 3
276
Outline the pathogenesis of an infection with E .Histolytica
Once ingested, trophozoites colonise the small intestine and invade the colonic mucosa. These can then spread via the portal circulation to the liver, the most common extra-intestinal site, or other sites
277
Which form of hepatitis infection has an association with hepatocellular carcinoma?
Hepatitis C
278
Define a 'late' diagnosis of HIV
Patient has a CD4 count < 350 cells/mm3 within 3 months of diagnosis
279
PCP infections occur in the HIV patient population below what CD4 count?
< 200 cells/mm3
280
What is the first line treatment for PCP prophylaxis in HIV patients with a CD4 count < 200 cells/mm3?
Co-trimozazole 96mg OD
281
Recall the 6 main classes of drugs used to treat HIV
1. NRTIs - Nucleotide reverse transcriptase inhibitors
2. NNRTIs - Non-nucleotide reverse transcriptase inhibitors
3. Protease inhibitors
4. Integrase inhibitors
5. CCR5 inhibitors
6. Fusion inhibitors
282
Give 3 examples of Protease inhibitors
1. Indinavir
2. Ritonavir
3. Saquinavir
283
Give 2 examples of NNRTIs
1. Nevirapine
| 2. Efavirenez
284
What resource should be used when checking potential interactions between new medications and a patient's HAART?
Liverpool University HIV drug interaction website - BNF only has limited information on antiretroviral therapy interactions
285
Which 2 medications are used in combination to provide Pre-exposure prophylaxis to individuals identified as being at a high risk of contracting HIV?
1. Tenofovir
| 2. Emtricitabine
286
Name 4 types of viral haemorrhagic fever
1. Lassa fever
2. Crimean -Congo haemorrhagic fever
3. Marburg
4. Ebola
287
Suggest 4 risk factors for the development of invasive amoebiasis
1. Malnutrition
2. Vitamin deficiency
3. Alcoholism
4. Immunosuppression
288
What is the most common infectious diagnoses made in febrile returning travellers to the UK?
Malaria
289
How is the malarial parasite tested for in clinical practise?
Peripheral blood smear
290
Give 6 clinical presentations in which it would be necessary to observe contact infection control precautions when treating a febrile patient
1. Diarrhoea and/or vomiting
2. Acute respiratory symptoms
3. Rash
4. Wound or skin infections
5. Travel to a region where viral haemorrhagic fever is endemic in the last 21 days
6. Recent hospitalisation overseas
291
Define brachytherapy
A form of internal radiotherapy e.g. in the treatment of prostate cancer or cervical cancer
292
Suggest 4 indications for the use of palliative radiotherapy
1. Pain management
2. Breathlessness
3. Bleeding
4. Obstruction
293
What is the starting dose for palliative pain management for a patient with no comorbidities according to NICE?
23-30mg oral modified release morphine (two divided doses) with 5 mg morphine for breakout pain
