CPS Flashcards

Question

Kantor's string sign

Answer 1

Crohn's disease

Answer 2

nephrotoxicity hepatotoxicity fluid retention hypertension hyperkalaemia hypertrichosis gingival hyperplasia tremor impaired glucose tolerance hyperlipidaemia increased susceptibility to severe infection Interestingly for an immunosuppressant, ciclosporin is noted by the BNF to be 'virtually non-myelotoxic'.

Answer 3

Give aspirin 300mg + fondaparinux

Answer 4

corticosteroids

Answer 5

Crohn's disease

Answer 6

ulcerative colitis

Answer 7

The correct answer is A. Copy a cross A child learns to copy a -circle by 3 years of age, -cross at 4, -square at 4 ½ and -triangle by 5 years. Transferring around 6 months Tell age at 3 years. At 2 year old uses 2 or more words to make simple phrases. At 18-24 months children enjoy symbolic play when playing with dolls, brush, spoon. By 3 years they enjoy interactive play.

Answer 8

Febrile convulsions are common, -Occur in around 3% of children aged 6 months to 3 years. -Peak incidence is at around 18 months -Episodes are commonly associated with --viral infections, --tonsillitis and --otitis media. Convulsions are described as complex if.. -they last more than 15 minutes, -are repeated within 24 hours or -if they are focal at the onset or during the convulsion. The risk of subsequent epilepsy is about 2%. Convulsions associated with low fever are associated with a higher risk of recurrence.

Answer 9

- Age of patient: 0-5 year DDH 5-10 years Perthes' disease 10-15 years SUFE - Pain: Painless (DDH), Slow developing chronic pain (Perthes' disease), Acutely painful (septic arthritis, transient synovitis). - Body habitus: SCFE: obese pubertal children, Osgood-Schlatter disease (knee pain due to repeated traction at the tibial tubercle): active, sporty early teenagers. - Systemic features: f Fevers (septic arthritis, JIA), Blanching rash (JIA), Malaise and tiredness (JIA, ALL), Bruising (ALL). - Sex: more common in boys: Perthes' disease, SCFE, Osgood-Schlatter; more common in girls: DDH.

Answer 10

Persistent atrial fibrillation

Answer 11

Permanent atrial fibrillation

Answer 12

rheumatoid arthritis

Answer 13

osteoarthritis

Answer 14

Rheumatoid arthritis

Answer 15

Osteoarthritis

Answer 16

Rheumatoid arthritis

Answer 17

Osteoarthritis

Answer 18

thiazides loop diuretics

Answer 19

hyperkalaemia

Answer 20

1st line Aspirin (lifelong) & ticagrelor (12 months) 2nd line If aspirin contraindicated, clopidogrel (lifelong)

Answer 21

1st line Aspirin (lifelong) & prasurgrel or ticagrelor (12 months) 2nd line If aspirin contraindicated, clopidogrel (lifelong)

Answer 22

1st line Clopidogrel (lifelong) 2nd line If aspirin contraindicated, clopidogrel (lifelong)

Answer 23

1st line Clopidogrel (lifelong) 2nd line If aspirin contraindicated, clopidogrel (lifelong)

Answer 24

1st line Clopidogrel (lifelong) 2nd line Asprin (lifelong)

Answer 25

Argyll-Robertson pupil

Answer 26

Horner's syndrome

Answer 27

Pulsus paradoxus

Answer 28

Slow-rising/plateau

Answer 29

Collapsing

Answer 30

Pulsus alternans

Answer 31

Bisferiens pulse

Answer 32

'Jerky' pulse

Answer 33

thiazides loop diuretics verapamil diltiazem amiodarone ciclosporin quinidine

Answer 34

loop diuretics aminoglycosides

Answer 35

antibiotics: penicillins, cephalosporins, trimethoprim endocrine: glucocorticoids (avoid high doses), levothyroxine* epilepsy: sodium valproate, carbamazepine asthma: salbutamol, theophyllines psychiatric drugs: tricyclic antidepressants, antipsychotics** hypertension: beta-blockers, hydralazine anticoagulants: warfarin, heparin digoxin

Answer 36

antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides psychiatric drugs: lithium, benzodiazepines aspirin carbimazole methotrexate sulfonylureas cytotoxic drugs amiodarone

Answer 37

HONK Dehydration Diabetes insipidus Excess IV saline

Answer 38

FBC, LFT, U&E

Answer 39

Lithium level, TFT, U&E

Answer 40

breast cancer endometrial cancer ovarian cancer

Answer 41

endometrial cancer

Answer 42

BRCA1, BRCA2 genes 1st degree premenopausal relative with breast cancer (e.g. mother) Past breast cancer Nulliparity, 1st pregnancy > 30 yrs (twice risk of women having 1st child < 25 yrs) Not breastfeeding Early menarche, Late menopause CHR/COCP - Combined hormone replacement therapy, combined oral contraceptive use ionising radiation p53 gene mutations obesity previous surgery for benign disease (?more follow-up, scar hides lump)

Answer 43

Tamoxifen (SERM) -menstrual disturbance: vaginal bleeding, amenorrhoea -hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects -venous thromboembolism -endometrial cancer Anastrozole (Aromatase inhibitors) -osteoporosis -hot flushes -arthralgia, myalgia -insomnia

Answer 44

trastuzumab

Answer 45

After 2 days

Answer 46

After 7 days

Answer 47

Immediately

Answer 48

Adverse effects hypotension hyponatraemia hypokalaemia, hypomagnesaemia hypochloraemic alkalosis ototoxicity hypocalcaemia renal impairment (from dehydration + direct toxic effect) hyperglycaemia (less common than with thiazides) gout

Answer 49

measles virus

Answer 50

Wilson's disease

Answer 51

conservative management - give ticagrelor

Answer 52

low-dose ICS/formoterol combination inhaler as required

Answer 53

Left anterior descending

Answer 54

Right coronary

Answer 55

Proximal left anterior descending

Answer 56

Left circumflex

Answer 57

Usually left circumflex, also right coronary

Answer 58

males: sodium valproate females: lamotrigine or levetiracetam

Answer 59

first line: lamotrigine or levetiracetam second line: carbamazepine, oxcarbazepine or zonisamide

Answer 60

first line: ethosuximide second line: male: sodium valproate female: lamotrigine or levetiracetam carbamazepine may exacerbate absence seizures

Answer 61

males: sodium valproate females: levetiracetam

Answer 62

males: sodium valproate females: lamotrigine

Answer 63

Heart failure, constipation, hypotension, bradycardia, flushing

Answer 64

Heart failure, constipation, hypotension, ankle swelling

Answer 65

Flushing, headache, ankle swelling

Answer 66

Left ventricular free wall rupture

Answer 67

roseola infantum

Answer 68

regular low-dose ICS/formoterol combination inhaler and as required (MART)

Answer 69

A long QT interval

Answer 70

U waves long QT interval prolonged PR interval ST depression

Answer 71

subacute thyroiditis

Answer 72

Klinefelter's syndrome

Answer 73

Androgen insensitivity syndrome

Answer 74

A. Aspirin 300mg and urgent assessment (within 24 hours) NICE Guidelines state that where someone has had a suspected TIA you should give aspirin 300 mg immediately (unless contraindicated) and arrange urgent assessment (within 24 hours) by a specialist stroke physician. If the patient has a bleeding disorder then immediate admission is necessary. Immediate admission may also be necessary if the patient has had more than one TIA or lacks a reliable observer at home.

Answer 75

In conductive hearing loss BC > AC and Weber's lateralises to the affected ear.

Answer 76

In sensorineural hearing loss AC>BC in both ears and with Weber's test lateralisation occurs to the unaffected ear (right) i.e. away from the affected ear (left)

Answer 77

Transient synovitis

Answer 78

Staphylococcus aureus Pseudomonas aeruginosa Burkholderia cepacia* Aspergillus

Answer 79

Turner's syndrome

Answer 80

instant: IUD 2 days: POP 7 days: COC, injection, implant, IUS

Answer 81

Absolute CIs -more than 35 years more than 15 ciggs/day -migraine with aura -H/O thromboembolic disease or thrombogenic mutation -H/O stroke or ischaemic heart disease -breast feeding < 6 weeks post-partum -uncontrolled hypertension -current breast cancer -major surgery with prolonged immobilisation -positive antiphospholipid antibodies (e.g. in SLE) Relative CIs -more than 35 years old and smoking less than 15 cigarettes/day -BMI > 35 kg/m^2* -family history of thromboembolic disease in first degree relatives < 45 years -controlled hypertension -immobility e.g. wheel chair use -carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2) -current gallbladder disease

Answer 82

prone sleeping parental smoking bed sharing hyperthermia and head covering prematurity

Answer 83

BMI of > 30 kg/m² previous macrosomic baby weighing 4.5 kg or above previous gestational diabetes first-degree relative with diabetes family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)

Answer 84

fasting glucose is >= 5.6 mmol/L 2-hour glucose is >= 7.8 mmol/L

Answer 85

Fasting 5.3 mmol/l 1 hour after meals 7.8 mmol/l, or: 2 hour after meals 6.4 mmol/l

Answer 86

At the moment, there is no screening test that reliably detects ovarian cancer at an early stage. Ovarian cancer should be suspected and further tests should be carried out in any woman (particularly those over 50 years of age), who persistently have any of the following symptoms: Abdominal distension/bloating Feeling full (early satiety) or loss of appetite Pelvic or abdominal pain. Increased urinary urgency or frequency

Answer 87

Bony tenderness over the malleoli zones OR an Inability to walk four weight-bearing step Ankle injury: Ottawa rules Pain, Tenderness, Walk The Ottawa Rules for ankle x-rays have a sensitivity approaching 100% An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings: -Bony tenderness at the lateral malleolar zone -Bony tenderness at the medial malleolar zone -Inability to walk four weight-bearing steps immediately after the injury and in the emergency department

Answer 88

majority of children achieve day and night time urinary continence? 3-4 years old Children under the age of 5 years who have nocturnal enuresis can be managed with reassurance and advice

Answer 89

Whooping cough - azithromycin or clarithromycin if the onset of cough is within the previous 21 days Women who are between 16-32 weeks pregnant will be offered the vaccine.

Answer 90

The Mental Health Act overrides the Mental Capacity Act and enables people with capacity to be given treatment against their will

Answer 91

Premature menopause is associated with increased all cause mortality including increased risk of osteoporosis and cardiovascular disease

Answer 92

Meconium aspiration syndrome -Respiratory distress in the newborn as a result of meconium in the trachea. -In immediate neonatal period. -More common in post-term deliveries, with rates of up to 44% reported in babies born after 42 weeks. -It causes respiratory distress, which can be severe. -Higher rates occur where there is a history of maternal hypertension, pre-eclampsia, chorioamnionitis, smoking or substance abuse.

Answer 93

Cushing reflex is a physiological nervous system response to increased intracranial pressure (ICP) that results in -Hypertension -Bradycardia -Wide pulse pressure

Answer 94

A patient must be placed on a DOLS if they are to be treated in hospital and they do not have capacity to consent for this He must be placed on a deprivation of liberty safeguard (DOLS) regardless of his compliance with treatment as he lacks capacity to consent for treatment

Answer 95

A patent ductus arteriosis can be kept open with prostaglandins. This may be useful in duct dependent cardiac lesions

Answer 96

androgen insensitivity syndrome

Answer 97

Aortic stenosis accounts for 5% of congenital heart disease Associations include: William's syndrome (causes supravalvular aortic stenosis) coarctation of the aorta Turner's syndrome Management aim is to avoid or delay valve replacement if possible if gradient across valve is > 60 mmHg then balloon valvotomy may be indicated

Answer 98

any death in pregnancy and labour as well as up to six weeks post partum

Answer 99

*If a person with an asbestos related condition dies, regardless of the cause of their death, the coroner should be notified Patients who have developed certain complications following exposure to asbestos are entitled to compensation. Patients can claim if they develop the following conditions: mesothelioma asbestosis pleural thickening causing disability lung cancer caused by asbestos Under current law patients who have developed pleural plaques are not entitled to compensation. The coroner should be notified when a patient who had an asbestos-related condition dies.

Answer 100

Gestational diabetes Gestational diabetes is the second most common medical disorder complicating pregnancy (after hypertension), affecting around 4% of pregnancies. Risk factors for gestational diabetes BMI of > 30 kg/m² previous macrosomic baby weighing 4.5 kg or above previous gestational diabetes first-degree relative with diabetes family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern) Screening for gestational diabetes the oral glucose tolerance test (OGTT) is the test of choice women who've previously had gestational diabetes: OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal. NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs women with any of the other risk factors should be offered an OGTT at 24-28 weeks Diagnostic thresholds for gestational diabetes these have recently been updated by NICE, gestational diabetes is diagnosed if either: fasting glucose is >= 5.6 mmol/L 2-hour glucose is >= 7.8 mmol/L Management of gestational diabetes newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week women should be taught about self-monitoring of blood glucose advice about diet (including eating foods with a low glycaemic index) and exercise should be given if the fasting plasma glucose level is < 7 mmol/l a trial of diet and exercise should be offered if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started if glucose targets are still not met insulin should be added to diet/exercise/metformin gestational diabetes is treated with short-acting, not long-acting, insulin if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started if the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment Management of pre-existing diabetes weight loss for women with BMI of > 27 kg/m^2 stop oral hypoglycaemic agents, apart from metformin, and commence insulin folic acid 5 mg/day from pre-conception to 12 weeks gestation detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts tight glycaemic control reduces complication rates treat retinopathy as can worsen during pregnancy Targets for self monitoring of pregnant women (pre-existing and gestational diabetes) Time Target Fasting 5.3 mmol/l 1 hour after meals 7.8 mmol/l, or: 2 hour after meals 6.4 mmol/l

Answer 101

Acute epiglottitis is caused by Haemophilus influenzae type B (Hib). Since 1992 Hib has been included in the childhood vaccination programme and is now thankfully rare. It can also cause other serious infections including meningitis and septicaemia etc. Haemophilus influenzae type A is a rare disease. Staphylococcus aureuscommonly causes skin infections including abscesses, respiratory infections such as sinusitis, and food poisoning. Streptococcus pneumoniae commonly causes bronchitis, otitis media ans sinusitis. Meningococcal type B is the most common cause meningococcal disease in the UK and is routinely vaccinated against in the national childhood vaccination programme.

Answer 102

caused by -insufficient surfactant production and -structural immaturity of the lungs *Other risk factors for SDLD include male sex diabetic mothers Caesarean section second born of premature twins Clinical features are those common to respiratory distress in the newborn, i.e. -tachypnoea, -intercostal recession, -expiratory grunting and cyanosis Chest x-ray characteristically shows 'ground-glass' appearance with an indistinct heart border

Answer 103

In younger children secondary hypertension is the most common cause, with renal parenchymal disease accounting for up to 80% Causes of hypertension in children renal parenchymal disease renal vascular disease coarctation of the aorta phaeochromocytoma congenital adrenal hyperplasia essential or primary hypertension (becomes more common as children become older)

Answer 104

Steroid therapy should be given to all children who have an asthma attack

Answer 105

The answer here is the copper intrauterine device. According to the Faculty of Reproductive and Sexual health guidelines, breast cancer is a contraindication to all hormonal forms of contraception, rated as a Category 4- an unacceptable health risk to the patient.

Answer 106

High risk of strangulation: femoral hernia Passes lateral to the inferior epigastric artery: indirect inguinal hernia

Answer 107

Cancers of the bladder, kidney and prostate Stones Benign prostatic hyperplasia Renal causes: such as IgA nephropathy, thin basement membrane disease Infections: such as Prostatitis and Urethritis e.g. Chlamydia

Answer 108

infertility, torsion and testicular cancer

Answer 109

oxytocin, ergometrine, carboprost and misoprostol In addition to the usual steps taken in an episode of PPH (including an ABC approach if the patient is unstable), the following management should be initiated in sequence: bimanual uterine compression to manually stimulate contraction intravenous oxytocin and/or ergometrine intramuscular carboprost intramyometrial carboprost rectal misoprostol surgical intervention such as balloon tamponade

Answer 110

Reversible complications Cardiomyopathy Skin pigmentation Irreversible complications Liver cirrhosis** Diabetes mellitus Hypogonadotrophic hypogonadism Arthropathy

Answer 111

Radial access, give unfractionated heparin, use drug-eluting stent STEMI identified, aspirin given, having PCI, prasugrel given NSTEMI identified, aspirin given, intermediate/high risk, ticagrelor given, having PCI Give ticagrelor STEMI identified, aspirin given, has had fibrinolysis + antithrombin given

Answer 112

Beta-blockers psoriasis glycaemic control in diabetes Tricyclic antidepressants urinary retention

Answer 113

P-ANCA primary sclerosing cholangitis ulcerative colitis Churg-Strauss syndrome Rheumatoid factor Sjogren's syndrome

Answer 114

Any location, flush to skin loop colostomy Right iliac fossa, spouted end ileostomy loop ileostomy

Answer 115

initial empirical therapy of meningitis (aged > 50 years) initial empirical therapy of meningitis (aged < 3 months)

Answer 116

Causes vitamin D deficiency (osteomalacia) chronic kidney disease hypoparathyroidism (e.g. post thyroid/parathyroid surgery) pseudohypoparathyroidism (target cells insensitive to PTH) rhabdomyolysis (initial stages) magnesium deficiency (due to end organ PTH resistance) massive blood transfusion acute pancreatitis Contamination of blood samples with EDTA may also give falsely low calcium levels. Management severe hypocalcaemia (e.g. carpopedal spasm, tetany, seizures or prolonged QT interval) requires IV calcium replacement the preferred method is with intravenous calcium gluconate, 10ml of 10% solution over 10 minutes intravenous calcium chloride is more likely to cause local irritation ECG monitoring is recommended further management depends on the underlying cause

Answer 117

< 6 months 100 - 150 micrograms (0.1 - 0.15 ml 1 in 1,000) 6 months - 6 years 150 micrograms (0.15 ml 1 in 1,000) 6-12 years 300 micrograms (0.3ml 1 in 1,000) Adult and child > 12 years 500 micrograms (0.5ml 1 in 1,000)

Answer 118

Pregnant with rash: Pregnant women ≥ 20 weeks who develop chickenpox are generally treated with oral aciclovir if they present within 24 hours of the rash

Answer 119

Edinburgh Scale

Answer 120

Risk factors for cord prolapse include: -*Artificial amniotomy: Around 50% of cord prolapse occurs after artificial rupture of membranes -prematurity -multiparity -polyhydramnios -twin pregnancy -cephalopelvic disproportion -abnormal presentations e.g. Breech, transverse lie Cephalic presentation, nulliparity and prolonged pregnancy all reduce the likelihood of umbilical cord prolapse Umbilical cord prolapse involves the umbilical cord descending ahead of the presenting part of the fetus.

Answer 121

-Treat with LMWH first then investigate to rule in/out -Thrombolysis is contraindicated in pregnancy as it can cause catastrophic haemorrhage of the placenta and the foetus. For patients with a suspected deep vein thrombosis (DVT): Compression duplex ultrasound should be undertaken where there is clinical suspicion of DVT For patients with a suspected pulmonary embolism (PE): ECG and chest x-ray should be performed in all patients In women who also have symptoms and signs of DVT, compression duplex ultrasound should be performed. If compression ultrasonography confirms the presence of DVT, no further investigation is necessary and treatment for VTE should continue the decision to perform a V/Q or CTPA should be taken at a local level after discussion with the patient and radiologist CTPA CTPA slightly increases the lifetime risk of maternal breast cancer V/Q scanning V/Q scanning carries a slightly increased risk of childhood cancer compared with CTPA D-dimer is of limited use in the investigation of thromboembolism as it often raised in pregnancy.

Answer 122

A patient having a lacunar stroke would present with either a purely motor, a purely sensory or a mixed motor and sensory deficit

Answer 123

The transfusion threshold for patients with ACS is 80 g/L without ACS with ACS Transfusion threshold 70 g/L 80 g/L Target after transfusion 70-90 g/L 80-100 g/L

Answer 124

keratoconjunctivitis sicca (most common) episcleritis (erythema) scleritis (erythema and pain) corneal ulceration keratitis

Answer 125

keratoconjunctivitis sicca (most common)

Answer 126

Acute pancreatitis Gallstones and alcohol are the two most common causes of acute pancreatitis. The site of pain and absence of fever point away from a diagnosis of acute cholecystitis.

Answer 127

Prostaglandin analogues (e.g. latanoprost) -Increases uveoscleral outflow -Brown pigmentation of the iris, increased eyelash length Beta-blockers (e.g. timolol, betaxolol) -Reduces aqueous production -Should be avoided in asthmatics and patients with heart block Sympathomimetics (e.g. brimonidine, an alpha2-adrenoceptor agonist) -Reduces aqueous production and increases outflow -Avoid if taking MAOI or tricyclic antidepressants --Adverse effects include hyperaemia Carbonic anhydrase inhibitors (e.g. Dorzolamide) -Reduces aqueous production -Systemic absorption may cause sulphonamide-like reactions Miotics (e.g. pilocarpine, a muscarinic receptor agonist) -Increases uveoscleral outflow -Adverse effects included a constricted pupil, headache and blurred vision

Answer 128

Tamsulosin: Alpha blockers can cause first dose hypotension Finasteride: Oligospermia Tamsulosin is an alpha adrenergic blocker which preferentially acts on receptors in the prostate. This causes improved urine flow in benign prostatic hypertrophy. Alpha blockers can cause first dose hypotension - a reduction in blood pressure following the first dose, causing a vasovagal faint. Finasteride: Oligospermia Finasteride inhibits the enzyme 5 ɑ-redutase, reducing conversion of testosterone to dihydrotesterone. Dihydrotestosterone promotes prostate growth. Finasteride is licensed for benign prostatic hypertrophy, and can be used off-license in chronic prostatitis. It can cause infertility, sexual dysfunction, and abnormal breast growth

Answer 129

Quick comparison: Hepatitis viruses Hepatitis E: is spread by the faecal-oral route has a particularly high mortality rate in pregnant women Hepatitis C: may cause chronic hepatitis cannot be vaccinated against causes the most morbidity in IVDUs is spread by the parenteral, sexual and vertical transmission route may cause cryoglobulinaemia increases the risk of hepatocellular cancer

Answer 130

HNPCC: endometrial cancer Smoking: cervical cancer

Answer 131

Risk factors excess oestrogen -nulliparity -early menarche -late menopause -unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT) metabolic syndrome -obesity -diabetes mellitus -polycystic ovarian syndrome --tamoxifen --hereditary non-polyposis colorectal carcinoma Protective factors -multiparity -combined oral contraceptive pill -smoking (the reasons for this are unclear)

Answer 132

Small cell -ADH -ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc -Lambert-Eaton syndrome Squamous cell -parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia -clubbing -hypertrophic pulmonary osteoarthropathy (HPOA) -hyperthyroidism due to ectopic TSH

Answer 133

SVC obstruction

Answer 134

'a' wave = atrial contraction large if atrial pressure e.g. tricuspid stenosis, pulmonary stenosis, pulmonary hypertension absent if in atrial fibrillation Cannon 'a' waves caused by atrial contractions against a closed tricuspid valve are seen in complete heart block, ventricular tachycardia/ectopics, nodal rhythm, single chamber ventricular pacing 'c' wave closure of tricuspid valve not normally visible 'v' wave due to passive filling of blood into the atrium against a closed tricuspid valve giant v waves in tricuspid regurgitation 'x' descent = fall in atrial pressure during ventricular systole 'y' descent = opening of tricuspid valve

Answer 135

Non-haemolytic febrile reaction Fever, chills Minor allergic reaction Pruritus, urticaria Anaphylaxis Hypotension, dyspnoea, wheezing, angioedema. Acute haemolytic reaction Fever, abdominal pain, hypotension Transfusion-associated circulatory overload (TACO) Pulmonary oedema, hypertension Transfusion-related acute lung injury (TRALI) Hypoxia, pulmonary infiltrates on chest x-ray, fever, hypotension

Answer 136

HLA antigens are encoded for by genes on chromosome 6. HLA A, B and C are class I antigens whilst DP, DQ, DR are class II antigens. Questions are often based around which diseases have strong HLA associations. The most important associations are listed below: HLA-A3 haemochromatosis HLA-B51 Behcet's disease HLA-B27 ankylosing spondylitis reactive arthritis acute anterior uveitis psoriatic arthritis HLA-DQ2/DQ8 coeliac disease HLA-DR2 narcolepsy Goodpasture's HLA-DR3 dermatitis herpetiformis Sjogren's syndrome primary biliary cirrhosis HLA-DR4 type 1 diabetes mellitus* rheumatoid arthritis - in particular the DRB1 gene (DRB1*04:01 and DRB1*04:04 hence the association with DR4)

Answer 137

Target cells: -Sickle-cell/thalassaemia -Iron-deficiency anaemia -Hyposplenism -Liver disease 'Tear-drop' poikilocytes: Myelofibrosis Spherocytes: Hereditary spherocytosis Autoimmune hemolytic anaemia Basophilic stippling: Lead poisoning Thalassaemia Sideroblastic anaemia Myelodysplasia Howell-Jolly bodies: Hyposplenism Heinz bodies: G6PD deficiency Alpha-thalassaemia Schistocytes ('helmet cells'): Intravascular haemolysis Mechanical heart valve Disseminated intravascular coagulation 'Pencil' poikilocytes: Iron deficency anaemia Burr cells (echinocytes): Uraemia Pyruvate kinase deficiency Acanthocytes: Abetalipoproteinemia Other blood film abnormalities: hypersegmented neutrophils: megaloblastic anaemia

Answer 138

Androgen insensitivity syndrome: High LH Normal/high Testosterone Testosterone-secreting tumour: Low LH High Testosterone Primary hypogonadism (Klinefelter's syndrome) High LH Low Testosterone Hypogonadotrophic hypogonadism (Kallman's syndrome) Low LH Low Testosterone

Answer 139

Unfractionated heparin activates antithrombin III. Forms a complex that inhibits thrombin, factors Xa, IXa, Xia and XIIa low molecular weight heparin Activates antithrombin III. Forms a complex that inhibits factor ONLY Xa

Answer 140

Type I - Anaphylactic Antigen reacts with IgE bound to mast cells * Anaphylaxis * Atopy (e.g. asthma, eczema and hayfever) Type II - Cell bound IgG or IgM binds to antigen on cell surface * Autoimmune haemolytic anaemia * ITP * Goodpasture's syndrome * Pernicious anaemia * Acute haemolytic transfusion reactions * Rheumatic fever * Pemphigus vulgaris / bullous pemphigoid Type III - Immune complex Free antigen and antibody (IgG, IgA) combine * Serum sickness * Systemic lupus erythematosus * Post-streptococcal glomerulonephritis * Extrinsic allergic alveolitis (especially acute phase) Type IV - Delayed hypersensitivity T-cell mediated * Tuberculosis / tuberculin skin reaction * Graft versus host disease * Allergic contact dermatitis * Scabies * Extrinsic allergic alveolitis (especially chronic phase) * Multiple sclerosis * Guillain-Barre syndrome Type V Antibodies that recognise and bind to the cell surface receptors. This either stimulating them or blocking ligand binding * Graves' disease * Myasthenia gravis

Answer 141

short course of oral corticosteroids and oral antibiotics to keep at home

Answer 142

Opioid side-effects: Usually transient Nausea Drowsiness Usually persistent: Constipation Conversion between opioids: Oral codeine - Oral morphine Divide by 10 Oral tramadol - Oral morphine Divide by 10** Oral morphine - Oral oxycodone Divide by 1.5-2 Oral morphine - S/C morphine Divide by 2 Oral morphine - S/C diamorphine Divide by 3 Oral oxycodone - S/C diamorphine Divide by 1.5

Answer 143

Reassurance + topical treatment if lesions are symptomatic -'evidence does not support a therapeutic benefit from antibiotic therapy'. Management most cases resolve spontaneously within 2-3 months there is no firm evidence to support the use of antibiotics to eradicate streptococcal infection topical agents as per psoriasis UVB phototherapy tonsillectomy may be necessary with recurrent episodes

Answer 144

Guttate psoriasis: Classically preceded by a streptococcal sore throat 2-4 weeks Tear drop', scaly papules on the trunk and limbs Most cases resolve spontaneously within 2-3 months Topical agents as per psoriasis UVB phototherapy Pityriasis rosea: Many patients report recent respiratory tract infections but this is not common in questions Herald patch followed 1-2 weeks later by multiple erythematous, slightly raised oval lesions with a fine scale confined to the outer aspects of the lesions. May follow a characteristic distribution with the longitudinal diameters of the oval lesions running parallel to the line of Langer. This may produce a 'fir-tree' appearance Self-limiting, resolves after around 6 weeks

Answer 145

HBsAg negative, anti-HBs positive, IgG anti-HBc positive - previous infection, not a carrier HBsAg = ongoing infection, either acute or chronic if present > 6 months anti-HBc = caught, i.e. negative if immunized It is important to remember a few key facts: -HBsAg-surface antigen implies DISEASE *first marker to appear *causes the production of anti-HBs *HBsAg normally implies acute disease (present for 1-6 months) *if HBsAg is present for > 6 months then this implies chronic disease (i.e. Infective) -Anti-HBs implies IMMUNITY (either exposure or immunisation). *negative in chronic disease -Anti-HBc implies previous (or current) infection. *IgM anti-HBc appears during acute or recent hepatitis B infection and is present for about 6 months. *IgG anti-HBc persists -HbeAg results from *breakdown of core antigen from infected liver cells as is, therefore, *a marker of infectivity. *Marker of HBV replication and infectivity Example results previous immunisation: anti-HBs positive, all others negative previous hepatitis B (> 6 months ago), not a carrier: anti-HBc positive, HBsAg negative previous hepatitis B, now a carrier: anti-HBc positive, HBsAg positive

Answer 146

clopidogrel and atorvastatin

Answer 147

-supporting evidence to accompany eGFR -such as urinalysis or renal ultrasound are abnormal -*i.e. normal U&Es and no proteinuria

Answer 148

C. difficile

Answer 149

First episode of C. difficile infection: first-line therapy is oral vancomycin for 10 days second-line therapy: oral fidaxomicin third-line therapy: oral vancomycin +/- IV metronidazole Recurrent episode: within 12 weeks of symptom resolution: oral fidaxomicin after 12 weeks of symptom resolution: oral vancomycin OR fidaxomicin Life-threatening C. difficile infection: oral vancomycin AND IV metronidazole specialist advice - surgery may be considered Other therapies: bezlotoxumab is a monoclonal antibody which targets C. difficile toxin B NICE do not currently support its use to prevent recurrences as it is not cost-effective faecal microbiota transplant may be considered for patients who've had 2 or more previous episodes

Answer 150

angina attacks

Answer 151

>= 75 years following a fragility fracture, without waiting for a DEXA scan

Answer 152

pregnancy prolactinoma physiological polycystic ovarian syndrome primary hypothyroidism phenothiazines, metoclopramide, domperidone

Answer 153

-cavitating pneumonia in the upper lobes, mainly in -diabetics and -alcoholics

Answer 154

idiopathic intracranial hypertension

Answer 155

Somatisation = Symptoms hypoChondria = Cancer

Answer 156

acute: triptan + NSAID or triptan + paracetamol prophylaxis: topiramate or propranolol

Answer 157

Oral aciclovir -Steroids not recommended

Answer 158

Eye opening 4. Spontaneous 3. To speech 2. To pain 1. None Verbal response 5. Orientated 4. Confused 3. Words 2. Sounds 1. None Motor response 6. Obeys commands 5. Localises to pain 4. Withdraws from pain 3. Abnormal flexion to pain (decorticate posture) 2. Extending to pain 1. None

Answer 159

Thoracic pain Age <20 or >55 years Non-mechanical pain Pain worse when supine Night pain Weight loss Pain associated with systemic illness Presence of neurological signs Past medical history of cancer or HIV Immunosuppression or steroid use IV drug use Structural deformity

Answer 160

SSRIs are the first-line pharmacological therapy for generalised anxiety disorder

Answer 161

Rotator cuff injuries are the most common cause of shoulder problems. A spectrum of disease is recognised: 1. Subacromial impingement (also known as impingement syndrome, painful arc syndrome) 2. Calcific tendonitis 3. Rotator cuff tears 4. Rotator cuff arthropathy Symptoms shoulder pain worse on abduction Subacromial impingement -painful arc of abduction. -typically between 60 and 120 degrees (rotator cuff tears in the first 60 degrees)

Answer 162

Eyelid problems commonly encountered include: blepharitis: inflammation of the eyelid margins typically leading to a red eye stye: infection of the glands of the eyelids chalazion (Meibomian cyst) entropion: in-turning of the eyelids ectropion: out-turning of the eyelids Stye Different types of stye are recognised: external (hordeolum externum): infection (usually staphylococcal) of the glands of Zeis (sebum producing) or glands of Moll (sweat glands). internal (hordeolum internum): infection of the Meibomian glands. May leave a residual chalazion (Meibomian cyst) management includes hot compresses and analgesia. CKS only recommend topical antibiotics if there is an associated conjunctivitis A chalazion (Meibomian cyst) is a retention cyst of the Meibomian gland. It presents as a firm painless lump in the eyelid. The majority of cases resolve spontaneously but some require surgical drainage

Answer 163

methotrexate

Answer 164

Exercise regimes and NSAIDs are the 1st line management for ankylosing spondylitis

Answer 165

Campylobacter jejuni infection may cause marked right iliac fossa pain mimicking appendicitis

Answer 166

Incubation period 1-6 hrs: Staphylococcus aureus, Bacillus cereus* 12-48 hrs: Salmonella, Escherichia coli 48-72 hrs: Shigella, Campylobacter > 7 days: Giardiasis, Amoebiasis Escherichia coli Common amongst travellers Watery stools Abdominal cramps and nausea Giardiasis Prolonged, non-bloody diarrhea Cholera Profuse, watery diarrhoea Severe dehydration resulting in weight loss Not common amongst travelers Shigella Bloody diarrhoea Vomiting and abdominal pain Staphylococcus aureus Severe vomiting Short incubation period Campylobacter A flu-like prodrome is usually followed by crampy abdominal pains, fever and diarrhoea which may be bloody May mimic appendicitis Complications include Guillain-Barre syndrome Bacillus cereus Two types of illness are seen vomiting within 6 hours, stereotypically due to rice diarrhoeal illness occurring after 6 hours Amoebiasis Gradual onset bloody diarrhoea, abdominal pain and tenderness which may last for several weeks

Answer 167

If a patient is on warfarin/a DOAC/ or has a bleeding disorder and they are suspected of having a TIA, they should be admitted immediately for imaging to exclude a haemorrhage

Answer 168

watchful waiting for a month

Answer 169

Meconium ileus Necrotising enterocolitis usually presents after the second week of life & preterm usually

Answer 170

Subacute thyroiditis can be distinguished from Hashimoto's as a cause of hypothyroid by tenderness of the thyroid gland

Answer 171

less than 3cm on imaging: watchful waiting without biopsy If >3cm: surgical excision is usual

Answer 172

Any critically ill patient (including CO2 retainers) should initially be treated with high flow oxygen which is then titrated to achieve target sats. Hypoxia kills

Answer 173

NICE now recommend doing Faecal Immunochemical Test (FIT) testing before deciding whether to refer people of the urgent suspected colorectal cancer pathway for a colonoscopy.

Answer 174

two weeks after the event

Answer 175

Atrial fibrillation is one of the key risk factors for ischaemic stroke. It is therefore very important to recognise and treat atrial fibrillation if it's identified in a patient following a stroke or transient ischaemic attack (TIA). Management following a stroke or TIA it is obviously important to exclude a haemorrhage before starting any anticoagulation or antiplatelet therapy for longer-term stroke prevention, NICE recommend warfarin or a direct thrombin or factor Xa inhibitor the timing of when to start depends on whether it is a TIA or stroke following a TIA, anticoagulation for AF should start immediately once imaging has excluded haemorrhage in acute stroke patients, in the absence of haemorrhage, anticoagulation therapy should be commenced after 2 weeks. Antiplatelet therapy should be given in the intervening period. If imaging shows a very large cerebral infarction then the initiation of anticoagulation should be delayed

Answer 176

oral corticosteroids are added

Answer 177

Treatment can be divided into inducing and maintaining remission. NICE updated their guidelines on the management of ulcerative colitis in 2019. The severity of UC is usually classified as being mild, moderate or severe: 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) Inducing remission Treating mild-to-moderate ulcerative colitis proctitis topical (rectal) aminosalicylate: for distal colitis rectal mesalazine has been shown to be superior to rectal steroids and oral aminosalicylates if remission is not achieved within 4 weeks, add an oral aminosalicylate if remission still not achieved add topical or oral corticosteroid proctosigmoiditis and left-sided ulcerative colitis topical (rectal) aminosalicylate if remission is not achieved within 4 weeks, add a high-dose oral aminosalicylate OR switch to a high-dose oral aminosalicylate and a topical corticosteroid if remission still not achieved stop topical treatments and offer an oral aminosalicylate and an oral corticosteroid extensive disease topical (rectal) aminosalicylate and a high-dose oral aminosalicylate: if remission is not achieved within 4 weeks, stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid Severe colitis should be treated in hospital IV steroids are usually given first-line IV ciclosporin may be used if steroids are contraindicated if after 72 hours there has been no improvement, consider adding IV ciclosporin to IV corticosteroids or consider surgery Maintaining remission Following a mild-to-moderate ulcerative colitis flare proctitis and proctosigmoiditis topical (rectal) aminosalicylate alone (daily or intermittent) or an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or an oral aminosalicylate by itself: this may not be effective as the other two options left-sided and extensive ulcerative colitis low maintenance dose of an oral aminosalicylate Following a severe relapse or >=2 exacerbations in the past year oral azathioprine or oral mercaptopurine Other points methotrexate is not recommended for the management of UC (in contrast to Crohn's disease) there is some evidence that probiotics may prevent relapse in patients with mild to moderate disease

Answer 178

The definition of a TIA is now tissue-based, not time-based: a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction The fact that Mary's symptoms lasted 22 hours would fit with the old definition of a TIA- a sudden onset of a focal neurologic symptom and/or sign lasting less than 24 hours, however this is not mentioned in the new guidance. The presence of a new infarct on MRI attributable to this episode means that this cannot be defined as a TIA according to new guidance. A transient ischaemic attack (TIA), as the name suggests, is a brief period of neurological deficit due to a vascular cause, typically lasting less than an hour. The National Clinical Guideline for Stroke was published in 2023 and made a number of updated recommendations, including the use of dual antiplatelet therapy (DAPT). It should be noted that DAPT is not currently recommended for 'major' ischaemic stroke as the risk of haemorrhagic transformation is too high. The original definition of a TIA was time-based: a sudden onset of a focal neurologic symptom and/or sign lasting less than 24 hours, brought on by a transient decrease in blood flow. However, this has now changed as it is recognised that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new 'tissue-based' definition is now used: a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction. REF Patients often use the term 'mini-stroke' for TIAs.

Answer 179

Intramuscular steroids such as methylprednisolone

Answer 180

Oral ciprofloxacin or rifampicin

Answer 181

DRD: -dehydration -renal failure -drugs: damn --diuretics (especially thiazides), --ACEIs/ARBs --NSAIDs and --metronidazole.

Answer 182

The British Thoracic Society (BTS) published updated guidelines for the management of spontaneous pneumothorax in 2023. The updated guidelines put less emphasis on the size of the pneumothorax and more emphasis on whether the patient is symptomatic and the presence of high-risk characteristics. Decision algorithm The first step is assessing whether the patient is symptomatic -minimal symptoms defined as 'no significant pain or breathlessness and no physiological compromise' -(Negative) or minimal symptoms → conservative care, regardless of pneumothorax size -(Positive) symptomatic → assess for high-risk characteristics If a pneumothorax is symptomatic, the next step is assessment for high-risk characteristics -high-risk characteristics are as follows: --haemodynamic compromise (suggesting a tension pneumothorax) --significant hypoxia --bilateral pneumothorax --underlying lung disease --≥ 50 years of age with significant smoking history --haemothorax (Negative) no high-risk characteristics are present, and it is safe to intervene, then there is a choice of intervention: --conservative care --ambulatory device --needle aspiration (Positive) high-risk characteristics are present, and it is safe to intervene → chest drain How is safety or intervention determined? -before a needle aspiration/chest drain insertion, the safety of intervention should be assessed -this depends on the clinical context, but is usually: --2cm laterally or apically on chest x-ray, or --any size on CT scan which can be safely accessed with radiological support Management options Conservative care -patients with a primary spontaneous pneumothorax that is managed conservatively should be reviewed every 2-4 days as an outpatient -patients with a secondary spontaneous pneumothorax that is managed conservatively should be monitored as an inpatient -if stable, follow-up in the outpatients department in 2-4 weeks Ambulatory care -an example of an ambulatory device is the Rocketµ Pleural Vent„ -it includes an 8FG catheter mounted on an 18G needle and a pigtail catheter to minimize the risk of occlusion -ambulatory devices typically have a one-way valve and vent to prevent air and fluid return to the pleural space while allowing for controlled escape of air and drainage of fluid -many devices also have an indication diaphragm that signals when the catheter tip enters the pleural space and continues to fluctuate with respiration, aiding in the assessment of pneumothorax resolution Needle aspiration -a chest drain should be inserted if needle aspiration of a pneumothorax is unsuccessful -if resolved, discharge and follow-up in the outpatients department in 2-4 weeks Chest drain insertion -daily review as an inpatient -remove drain when resolved -discharge and follow-up in the outpatients department in 2-4 weeks Persistentent / recurrent pneumothorax If a patient has a persistent air leak or insufficient lung reexpansion despite chest drain insertion, or the patient has recurrent pneumothoraces, then video-assisted thoracoscopic surgery (VATS) should be considered to allow for mechanical/chemical pleurodesis +/- bullectomy. Discharge advice Smoking patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men Fitness to fly absolute contraindication, the CAA suggest patients may travel 2 weeks after successful drainage if there is no residual air. The British Thoracic Society used to recommend not travelling by air for a period of 6 weeks but this has now been changed to 1 week post check x-ray Scuba diving the BTS guidelines state: 'Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.'

Answer 183

IgM anti-Mitochondrial antibodies, M2 subtype Middle aged females

Answer 184

Hepatitis A

Answer 185

Expectant management is not suitable if evidence of infection or increased risk of haemorrhage

Answer 186

Fluids and analgesia Antibiotics should not be offered routinely to patients with acute pancreatitis

Answer 187

<6m: 100 - 150 micrograms (0.1 - 0.15 ml 1 in 1,000) 6 m - 6 y: 150 micrograms (0.15 ml 1 in 1,000) 6-12 y: 300 micrograms (0.3ml 1 in 1,000) Adult and child > 12 y: 500 micrograms (0.5ml 1 in 1,000) In the treatment of anaphylaxis, you can repeat adrenaline every 5 minutes

Answer 188

NICE recommend offering a short course of oral Corticosteroids and Oral antibiotics (Azithromycin prophylaxis) to keep at home Azithromycin prophylaxis is recommended in COPD patients who meet certain criteria and who continue to have exacerbations In the 2010 NICE guidelines, there is a recommendation that patients who have frequent exacerbations of COPD should be given a home supply of corticosteroids and antibiotics ->3 exacerbations requiring steroid therapy and -at least one exacerbation requiring hospital admission in the previous year

Answer 189

Section 2 admission for assessment for up to 28 days, not renewable treatment can be given against a patient's wishes Section 3 admission for treatment for up to 6 months, can be renewed treatment can be given against a patient's wishes Section 4 72 hour assessment order used as an emergency, when a section 2 would involve an unacceptable delay often changed to a section 2 upon arrival at hospital Section 5(2) voluntary in-patient in hospital can be legally detained by a doctor for 72 hours Section 5(4) voluntary in-patient in hospital, allows a nurse to detain a patient for 6 hours Section 17a Supervised Community Treatment (Community Treatment Order) can be used to recall a patient to hospital for treatment if they do not comply with conditions of the order in the community, such as complying with medication Section 135 court order can be obtained to allow the police to break into a property to remove a person to a Place of Safety Section 136 someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety can only be used for up to 24 hours, whilst a Mental Health Act assessment is arranged

Answer 190

In 2024 NICE, the British Thoracic Society and SIGN produced joint guidelines on the management of asthma following many years of conflicting guidelines. The new guidelines represent a major step change in the management of asthma is both diagnosed and treated. For many years patients with asthma were started on a short-acting beta-2 agonist (SABA) inhaler before 'stepping up' to a regular inhaled corticosteroid with a SABA as required. The new guidelines now advocate the use of combined inhalers (ICS + long-acting beta-2 agonist) as reliever therapy or regularly, depending on the severity of asthma. Given the prevalence of asthma, it is likely that doctors will have to deal with patients on 'conventional' asthma treatments for many years to come. The joint guidelines therefore include guidance on how to manage these patients if their current treatment is controlling their symptoms sufficiently. Management of adult patients aged children aged ≥ 12 years with newly diagnosed asthma Step 1 NICE a low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler to be taken as needed for symptom relief this is termed anti-inflammatory reliever (AIR) therapy if the patient presents highly symptomatic (for example, regular nocturnal waking) or with a severe exacerbation: start treatment with low-dose MART (maintenance and reliever therapy, see below) treat the acute symptoms as appropriate (e.g. a course of oral corticosteroids may be indicated) Step 2 NICE a low-dose MART MART describes using an inhaled corticosteroid (ICS)/formoterol combination inhaler for daily maintenance therapy and the relief of symptoms as needed, i.e. regularly and as required Step 3 a moderate-dose MART Step 4 check the fractional exhaled nitric oxide (FeNO) level if available, and the blood eosinophil count NICE if either of these is raised, refer to a specialist in asthma care if neither FeNO nor eosinophil count is raised, consider a trial of either a leukotriene receptor antagonist (LTRA) or a long-acting muscarinic receptor antagonist (LAMA) used in addition to moderate-dose MART if control has not improved, stop the LTRA or LAMA and start a trial of the alternative medicine (LTRA or LAMA) Step 5 refer people to a specialist in asthma care when asthma is not controlled despite treatment with moderate-dose MART, and trials of an LTRA and a LAMA Transferring people aged 12 and over from other treatment pathways There will be many people whose asthma was managed according to the previous guidelines that present with uncontrolled asthmatic symptoms. The guidelines give advice on how these people should be switched: NICE Existing asthma treatment New asthma treatment SABA as required only Low-dose ICS/formoterol combination inhaler used as needed (as-needed AIR therapy) SABA as required + regular low-dose ICS SABA as required + regular low-dose ICS/LABA SABA as required + regular low-dose ICS + LTRA SABA as required + regular low-dose ICS/LABA + LTRA Regular low-dose regular ICS/formoterol combination inhaler (MART therapy) SABA as required + regular moderate-dose ICS SABA as required + regular moderate-dose ICS/LABA SABA as required + regular moderate-dose ICS + LTRA or LAMA SABA as required + regular moderate-dose ICS/LABA + LTRA or LAMA Regular moderate-dose MART therapy Treatment regime containing a high-dose ICS Refer to a respiratory specialist

Answer 191

Circumstantiality is the inability to answer a question without giving excessive, unnecessary detail. However, this differs from tangentiality in that the person does eventually return to the original point. Tangentiality refers to wandering from a topic without returning to it. Neologisms are new word formations, which might include the combining of two words. Clang associations are when ideas are related to each other only by the fact they sound similar or rhyme. Word salad describes completely incoherent speech where real words are strung together into nonsense sentences. Knight's move thinking is a severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another. It is a feature of schizophrenia. Flight of ideas, a feature of mania, is a thought disorder where there are leaps from one topic to another but with discernible links between them. Perseveration is the repetition of ideas or words despite an attempt to change the topic. Echolalia is the repetition of someone else's speech, including the question that was asked.

Answer 192

Fluoxetine is predicted to decrease the effectiveness of tamoxifen, and the manufacturer advises avoidance.

Answer 193

C. Colchicine

Answer 194

A. Allopurinol It’s typically recommended that allopurinol be restarted gradually, and that medications like colchicine or NSAIDs (e.g., ibuprofen) be used simultaneously for the first few months to prevent flare-ups when starting urate-lowering therapy.

Answer 195

Penicillamine (causing nephrotic syndrome)

Answer 196

A. Adalimumab

Answer 197

F. Propranolol

Answer 198

A. Diazepam BZDs cause paradoxical & hostility as side effect

Answer 199

Beta-blockers are well known to cause drug-induced psoriasis

Answer 200

E. Lactose-free formula

Answer 201

Infectious mononucleosis

Answer 202

Complications WHAT anaemia hypogammaglobulinaemia leading to recurrent infections warm autoimmune haemolytic anaemia in 10-15% of patients transformation to high-grade lymphoma (Richter's transformation) Richter's transformation Ritcher's transformation occurs when leukaemia cells enter the lymph node and change into a high-grade, fast-growing non-Hodgkin's lymphoma. Patients often become unwell very suddenly. Ritcher's transformation is indicated by one of the following symptoms: lymph node swelling fever without infection weight loss night sweats nausea abdominal pain

Answer 203

↓ pH - ↓ CO2 - ↓ HCO3- metabolic acidosis with respiratory compensation ↓ pH - Normal CO2 - ↓ HCO3- metabolic acidosis

Answer 204

ROME Respiratory = Opposite low pH + high PaCO2 i.e. acidosis, or high pH + low PaCO2 i.e. alkalosis Metabolic = Equal low pH + low bicarbonate i.e. acidosis, or high pH + high bicarbonate i.e. akalosis

Answer 205

Quick comparison: Stereotypical histories (bone disorders) Pott's disease (TB) a 35-year-old man who has recently emigrated to the country presents with back pain associated with night sweats. He has also lost 5kg in weight over the past month Osteomalacia a female immigrant from the Indian subcontinent presents with 'bone pain', muscle weakness and anorexia. Bloods show a decreased calcium and phosphate level

Answer 206

Ejection systolic -louder on expiration --aortic stenosis --hypertrophic obstructive cardiomyopathy -louder on inspiration --pulmonary stenosis --atrial septal defect also: tetralogy of Fallot Holosystolic (pansystolic) -mitral/tricuspid regurgitation (high-pitched and 'blowing' in character) -tricuspid regurgitation becomes louder during inspiration, unlike mitral reguritation during inspiration, the venous blood flow into the right atrium and ventricle are increased → increases the stroke volume of the right ventricle during systole -ventricular septal defect ('harsh' in character) Late systolic -mitral valve prolapse -coarctation of aorta Early diastolic -aortic regurgitation (high-pitched and 'blowing' in character) -Graham-Steel murmur (pulmonary regurgitation, again high-pitched and 'blowing' in character) Mid-late diastolic -mitral stenosis ('rumbling' in character) -Austin-Flint murmur (severe aortic regurgitation, again is 'rumbling' in character) Continuous machine-like murmur -patent ductus arteriosus RILE Right-sided murmur → heard best on Inspiration Left-sided murmur → heard best on Expiration

Answer 207

Quick comparison: Stereotypical histories (respiratory infections) Mycoplasma pneumonia a 20-year-old man presents in summer with gradually worsening flu-like symptoms and a dry cough. On examination he is noted to have erythema multiforme Legionnaires' disease a 60-year-old man presents with flu-like symptoms and a dry cough. On examination he has a relative bradycardia and appears slightly confused. His blood tests show a low sodium

Answer 208

The number of stillbirths and early neonatal deaths (less than 7 days) per 1000 live births and stillbirths The UK perinatal mortality rate includes all deaths that occur after 24 weeks gestation and 7 days of life. This differs from the World Health Organisation (WHO) definition, which also includes late miscarriages between 22 and 23+6 weeks gestation. The total number of neonatal deaths per 100 live births' as described in option C is the Neonatal Mortality Rate.

Answer 209

Enlargement of tonsils is not in itself an indication for tonsillectomy. The indications are: - Airway obstruction with persistent noisy breathing and suspected or proven sleep apnea - Suspicion of lymphoma - Recurrent attacks of tonsillitis (7 in a year / 5 per year for 2 years/ 3 per year for 3 years) - 2 or more attacks of peritonsillar abscess.

Answer 210

Flushing sildenafil adenosine amlodipine verapamil nicorandil isosorbide mononitrate tamoxifen nicotinic acid Hypotension diltiazem verapamil levodopa isosorbide mononitrate bromocriptine

Answer 211

Thalassaemia target cells Heinz bodies basophilic stippling Sickle-cell anaemia target cells

Answer 212

Thrombophlebitis and deep vein thrombosis Behcet's syndrome An association with heavy smoking Buerger's disease

Answer 213

Primary features chancre - painless ulcer at the site of sexual contact local non-tender lymphadenopathy often not seen in women (the lesion may be on the cervix) Secondary features - occurs 6-10 weeks after primary infection systemic symptoms: fevers, lymphadenopathy rash on trunk, palms and soles buccal 'snail track' ulcers (30%) condylomata lata (painless, warty lesions on the genitalia ) Tertiary features gummas (granulomatous lesions of the skin and bones) ascending aortic aneurysms general paralysis of the insane tabes dorsalis Argyll-Robertson pupil Features of congenital syphilis blunted upper incisor teeth (Hutchinson's teeth), 'mulberry' molars rhagades (linear scars at the angle of the mouth) keratitis saber shins saddle nose deafness

Answer 214

Adverse effects of heparins include: bleeding thrombocytopenia - see below osteoporosis and an increased risk of fractures hyperkalaemia - this is thought to be caused by inhibition of aldosterone secretion

Answer 215

Graves' disease: features Graves' disease is an autoimmune thyroid disease in which the body produces IgG antibodies to the thyroid-stimulating hormone (TSH) receptor. It is the most common cause of thyrotoxicosis and is typically seen in women aged 30-50 years. Features typical features of thyrotoxicosis specific signs limited to Grave's (see below) Features seen in Graves' but not in other causes of thyrotoxicosis eye signs (30% of patients) exophthalmos ophthalmoplegia pretibial myxoedema thyroid acropachy, a triad of: digital clubbing soft tissue swelling of the hands and feet periosteal new bone formation Autoantibodies TSH receptor stimulating antibodies (90%) anti-thyroid peroxidase antibodies (75%) Thyroid scintigraphy diffuse, homogenous, increased uptake of radioactive iodine

Answer 216

The table below lists the more common respiratory pathogens: -Bronchiolitis: Respiratory syncytial virus -Croup: Parainfluenza virus -Common cold: Rhinovirus -Flu: Influenza virus Pneumonias: Streptococcus pneumoniae: most common cause of community-acquired pneumonia Haemophilus influenzae: -Community-acquired pneumonia -Most common cause of bronchiectasis exacerbations -Acute epiglottitis Staphylococcus aureus Pneumonia, particularly following influenza Atypical pneumonias: Legionella & Mycoplasma Mycoplasma pneumoniae: Atypical pneumonia -Flu-like symptoms classically precede a dry cough. -Complications include haemolytic anaemia and erythema multiforme Legionella pneumophilia: Atypical pneumonia -spread by air-conditioning systems, causes dry cough. -Lymphopenia, deranged liver function tests and hyponatraemia may be seen Pneumocystis jiroveci: -Common cause of pneumonia in HIV patients. -Typically patients have few chest signs and develop exertional dyspnea Mycobacterium tuberculosis: Causes tuberculosis. -Cough, night sweats and weight loss may be seen

Answer 217

UC & Ca endometrium Lung Ca not associated with smoking: non-small cell lung cancer (NSCLC), particularly adenocarcinoma, which is the most common type of lung cancer in non-smokers.

Answer 218

When a patient dies it is the statutory duty of the doctor who has attended in the last illness to issue the MCCD (medical certificate of cause of death). There is no clear legal definition of “attended”, but it is generally accepted to mean a doctor who has cared for the patient during the illness that led to death and so is familiar with the patient’s medical history, investigations and treatment. The certifying doctor should also have access to relevant medical records and the results of investigations. There is no provision under current legislation to delegate this statutory duty to any non-medical staff. If the attending doctor has not seen the patient within the 14 days preceding death, and has not seen the body after death either, the registrar is obliged to refer the death to the coroner before it can be registered. In these circumstances, the coroner may instruct the registrar to accept the attending doctor’s MCCD for registration, despite the prolonged interval. In contrast, a doctor who has not been directly involved in the patient’s care at any time during the illness from which they died cannot certify under current legislation, but he should provide the coroner with any information that may help to determine the cause of death. The coroner may then provide this information to the registrar of deaths. It will be used for mortality statistics, but the death will be legally “uncertified” if the coroner does not investigate through an autopsy, an inquest, or both.

Answer 219

Screening tests are offered, with various combinations of tests and scans, eg -Combined test with blood tests and nucal scan, or -Quadruple test if booking later. These give more specific screening results to identify those at higher risk, and if a risk then diagnostic test is offered. The two diagnostic tests are -Chorionic villus sampling (CVS) (performed before 13 weeks) -Amniocentesis (performed after 15 weeks)

Answer 220

Chickenpox: Initially Fever Itchy, rash starting on head/trunk before spreading. Initially macular then papular then vesicular Systemic upset is usually mild Measles Prodrome: irritable, conjunctivitis, fever Koplik spots: white spots ('grain of salt') on buccal mucosa Rash: starts behind ears then to whole body, discrete maculopapular rash becoming blotchy & confluent Mumps Fever, malaise, muscular pain Parotitis ('earache', 'pain on eating'): unilateral initially then becomes bilateral in 70% Rubella Rash: pink maculopapular, initially on face before spreading to whole body, usually fades by the 3-5 day Lymphadenopathy: suboccipital and postauricular Erythema infectiosum: parvovirus B19-5th or slapped cheek Also known as fifth disease or 'slapped-cheek syndrome' Caused by parvovirus B19 Lethargy, fever, headache 'Slapped-cheek' rash spreading to proximal arms and extensor surfaces Scarlet fever: Group A hemolytic streptococci Reaction to erythrogenic toxins produced by Group A hemolytic streptococci Fever, malaise, tonsillitis Strawberry' tongue Rash - fine punctate erythema sparing the area around the mouth (circumoral pallor) Hand, foot and mouth disease: coxsackie A16 virus Caused by the coxsackie A16 virus Mild systemic upset: sore throat, fever Vesicles in the mouth and on the palms and soles of the feet

Answer 221

>For autosomal recessive conditions, if both parents are carriers (heterozygote) there is a 25% chance of having an affected (homozygote) child In autosomal recessive inheritance only homozygotes are affected males and females are equally likely to be affected not manifest in every generation - may 'skip a generation' If two heterozygote parents 25% chance of having an affected (homozygote) child 25% chance of having an unaffected (i.e. genotypical) child 50% chance of having a carrier (heterozygote) child If one affected parent (i.e. homozygote for gene) and one unaffected (i.e. not a carrier or affected) all the children will be carriers Autosomal recessive disorders are often metabolic in nature and are generally more life-threatening compared to autosomal dominant conditions >Autosomal dominant In autosomal dominant diseases: no carrier state, only disease state both homozygotes and heterozygotes manifest disease (there is no carrier state) both males and females affected only affected individuals can pass on disease disease is passed on to 50% of children normally appears in every generation (although see below) risk remains same for each successive pregnancy Complicating factors: non-penetrance: lack of clinical signs and symptoms (normal phenotype) despite abnormal gene. E.g. 40% otosclerosis spontaneous mutation: new mutation in one of gametes e.g. 80% of individuals with achondroplasia have unaffected parents >X-linked recessive In X-linked recessive inheritance only males are affected. An exception to this seen in examinations are patients with Turner's syndrome, who are affected due to only having one X chromosome. X-linked recessive disorders are transmitted by heterozygote females (carriers) and male-to-male transmission is not seen. Affected males can only have unaffected sons and carrier daughters. Each male child of a heterozygous female carrier has a 50% chance of being affected whilst each female child of a heterozygous female carrier has a 50% chance of being a carrier. The following conditions are autosomal dominant: Achondroplasia Acute intermittent porphyria Adult polycystic disease Antithrombin III deficiency Ehlers-Danlos syndrome Familial adenomatous polyposis Hereditary haemorrhagic telangiectasia Hereditary spherocytosis Hereditary non-polyposis colorectal carcinoma Huntington's disease Hyperlipidaemia type II Hypokalaemic periodic paralysis Malignant hyperthermia Marfan's syndromes Myotonic dystrophy Neurofibromatosis Noonan syndrome Osteogenesis imperfecta Peutz-Jeghers syndrome Retinoblastoma Romano-Ward syndrome tuberous sclerosis Von Hippel-Lindau syndrome Von Willebrand's disease*

Answer 222

The CHA₂DS₂-VASc score C - Congestive heart failure 1 point H - Hypertension 1 point A - Age 75 years or older 2 points D - Diabetes mellitus 1 point S - Stroke 2 points V - Vascular disease 1 point A - Age 65-74 years 1 point Sc - Sex category (female) 1 point The maximum score is 9

Answer 223

The modified Duke criteria are used for diagnostic classification of infective endocarditis (IE). Major criteria: Positive blood culture Endocardium involved Minor Criteria: Predisposition (cardiac lesion, IVDU) Fever >38°C Vascular phenomena (emboli, Janeway's lesions etc) Immunological phenomena (glomerulonephritis, Osler's nodes etc.) Positive blood culture that does not meet major criteria Diagnosis of definite IE: 2 major or 1 major and 3 minor or all 5 minor criteria. IE of the tricuspid valve (more frequent in IVDU) can lead to regurgitation and the presence of a pansystolic murmur.

Answer 224

Rheumatic fever can develop following an immunological reaction secondary to a Streptococcus pyogenes infection. Diagnosis is made on evidence of recent streptococcal infection with either 2 major criteria or 1 major with 2 minor criteria (Revised Jones criteria). Major criteria include: CASES Carditis (clinical and/or subclinical) Arthritis (polyarthritis) Sydenham's chorea Erythema marginatum Subcutaneous nodules Minor criteria include: Raised ESR/CRP Fever Olyarthralgia Prolonged PR interval (unless carditis is a major criterion)

Answer 225

Plummer-Vinson syndrome: Triad of: DIG -dysphagia (secondary to oesophageal webs) -iron-deficiency anaemia -glossitis Treatment includes iron supplementation and dilation of the webs Mallory-Weiss syndrome: Severe vomiting → painful mucosal lacerations at the gastroesophageal junction resulting in haematemesis. Common in alcoholics Boerhaave syndrome Severe vomiting → oesophageal rupture

Answer 226

The main points for the exam are: -left homonymous hemianopia means visual field defect to the left, i.e. Lesion of right optic tract -homonymous quadrantanopias: PITS (Parietal-Inferior, Temporal-Superior) -incongruous defects = optic tract lesion; congruous defects = optic radiation lesion or occipital cortex A congruous defect simply means complete or symmetrical visual field loss and conversely an incongruous defect is incomplete or asymmetric. Please see the link for an excellent diagram. Homonymous hemianopia: incongruous defects: lesion of optic tract congruous defects: lesion of optic radiation or occipital cortex macula sparing: lesion of occipital cortex Homonymous quadrantanopias* superior: lesion of the inferior optic radiations in the temporal lobe (Meyer's loop) inferior: lesion of the superior optic radiations in the parietal lobe mnemonic = PITS (Parietal-Inferior, Temporal-Superior) Bitemporal hemianopia lesion of optic chiasm upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma *this is very much the 'exam answer'. Actual studies suggest that the majority of quadrantanopias are caused by occipital lobe lesions. Please see the link for more details.

Answer 227

dry skin, eyes and lips/mouth -the most common side-effect of isotretinoin

Answer 228

Quick comparison: Risk factors: female cancers Combined oral contraceptive pill use -cervical cancer -breast cancer Mutations of the BRCA2 gene -ovarian cancer -breast cancer

Answer 229

Exudative: protein level greater than 35g/L is an exudate -MIS-malignancy, inflammation & sepsis tend to be exudative -produced as a result of fluid leakage through abnormally permeable pleural capillaries. Transudative: protein level of less than 25g/L is a transudate -heart failure, liver cirrhosis and renal failure -disruption of hydrostatic and oncotic pressures across pleural membranes

Answer 230

Whilst LTOT is indicated in chronic hypoxaemia, the British Thoracic Society (BTS) guidelines advise that that patient should have a PaO2 that is -consistently below 7.3kPa OR -stable between 7.3 and 8.0kPa in addition to --secondary polycythaemia or --clinical/echocardiographic signs of pulmonary hypertension. All of the other conditions are indications for LTOT as needed along with conditions such as severe chronic asthma, cystic fibrosis, bronchiectasis, pulmonary vascular disease and pulmonary malignancy.

Answer 231

The correct answer is A. Ultrasound scan of the breast Breast lumps should be investigated using the triple assessment approach which comprises -History, -Examination and -Radiological assessment. Young (less than 30): -Ultrasound -Mammogram would not be helpful as the patient is young and therefore it would be difficult to interpret. -A fine needle aspiration or core biopsy would be the next step if a suspicious lump was seen on ultrasound/mammogram -A CT scan would expose the patient to radiation unnecessarily and would not provide as useful results as an ultrasound scan.

Answer 232

Choriocarcinoma is a rare malignant germ cell tumour. It secretes HCG and is extremely responsive to methotrexate-based combination chemotherapy.

Answer 233

Keratomalacia is an eye condition which occurs as a results of Vitamin A deficiency. Symptoms include nightblindness, tunnel vision, dry conjunctiva and decreased visual acuity. Kwashiorkor is a form of severe protein and energy malnutrition. Symptoms include oedema, irritability and anorexia. It occurs when there is sufficient calorie intake but insufficient protein. It is rare in the developed world.

Answer 234

Pleomorphic adenoma -Approximately 80% of all salivary gland tumours occur in the parotid gland -Of these approximately 80% are benign tumours. -Benign parotid tumours have a higher incidence in females. Involvement of the facial nerve can occur with pleomorphic adenomas but generally cranial nerve signs raise the suspicion of a malignant tumour. Parotidectomy can be performed. This operation requires careful dissection around the facial nerve to avoid damage. Salivary duct stones are more common in the submandibular salivary glands. The blockage causes painful swelling of the gland which, crucially, is exacerbated on eating. Sialadenitis can cause swelling of a salivary gland but it is usually painful with associated swelling.

Answer 235

Anaplastic Carcinoma is a rare but deadly form of thyroid cancer. Typically the disease is aggressive with early spread to lymph nodes and infiltration of local structures leading to symptoms of stridor and hoarseness. Papillary Adenocarcinoma tends to affect younger patients and generally has a good prognosis. Medullary Carcinoma may produce calcitonin which can lead to symptoms of hypocalcaemia.