El Panico Flashcards

Question

What is low birth weight?

Answer 1

Less than 2500 g

Answer 2

Less than 1500 g

Answer 3

Less than 1000g

Answer 4

less than 750g

Answer 5

0.5 x age in months plus 4

Answer 6

2 x age + 8

Answer 7

3 x age plus 7

Answer 8

0.5-1ml/kg/hour

Answer 9

20ml/kg/day

Answer 10

4ml/kg for the first 10 kg 2ml/kg for the next 10 kg 1ml/kilo for the next 10kg (0.9% NaCl / 5% dextrose +/- 0.15%KCL)

Answer 11

inhibiting **sodium** reabsorption at the beginning of the **distal** convoluted tubule (DCT) by blocking the thiazide-sensitive Na+-Cl− symporter. Since more sodium reaches the collecting duct then more potassium lost

Answer 12

* dehydration * postural hypotension * hyponatraemia, hypokalaemia, hypercalcaemia\* * gout * impaired glucose tolerance * impotence **_Rare adverse effects_** * thrombocytopaenia * agranulocytosis * photosensitivity rash * pancreatitis

Answer 13

Clinic BP = 140/90 ABPM = 135/85

Answer 14

160/100 150/95

Answer 15

Clinic values over 180 110

Answer 16

140/90 135/85

Answer 17

150/90 145/85 (these are just 10 values more than the targets for people less than 80)

Answer 18

IM benzylpenicillin

Answer 19

IV cefotaxime

Answer 20

Under 3 months or over 50 years we give IV cefotaxime plus amoxicillin If meningococcal we give IV benzylpenicillin or IV cefotaxime If listeria we give IV amoxicillin + gent

Answer 21

Resp rate over 22 Altered mentition Systolic BP less than 100

Answer 22

overall mortality risk of approximately 10% in a general hospital population with suspected infection

Answer 23

Group B strep (strep agalacticae) E.Coli Late-onset sepsis usually occurs via the transmission of pathogens from the environment post-delivery, coagulase-negative staphylococcal species such as Staphylococcus epidermidis, Gram-negative bacteria such as Pseudomonas aeruginosa, Klebsiella and Enterobacter, and fungal species

Answer 24

Benzylpenicillin and gent are first line

Answer 25

Tazocin if patients are still febrile and unwell after 48 hours an alternative antibiotic such as meropenem is often prescribed +/- vancomycin

Answer 26

Patients with a CURB-65 score of 0 should be managed in the community. Patients with a CURB-65 score of 1 should have their Sa02 assessed which should be \>92% to be safely managed in the community and a CXR performed. If the CXR shows bilateral/multilobar shadowing hospital admission is advised. Patients with a CURB-65 score of 2 or more should be managed in hospital as this represents a severe community acquired pneumonia.

Answer 27

Management of low-severity community acquired pneumonia ## Footnote **amoxicillin** is first-line if penicillin allergic then use a macrolide or tetracycline NICE now recommend a 5 day course of antibiotics for patients with low severity community acquired pneumonia Management of moderate and high-severity community acquired pneumonia dual antibiotic therapy is recommended with **amoxicillin** and a **macrolide** a 7-10 day course is recommended NICE recommend considering a beta-lactamase stable penicillin such as **co-amoxiclav, ceftriaxone or piperacillin with tazobactam** and a macrolide in high-severity community acquired pneumonia

Answer 28

Community acquired pneumonia (CAP) may be caused by the following infectious agents: Streptococcus pneumoniae (accounts for around 80% of cases) Haemophilus influenzae = COPD patients Staphylococcus aureus: commonly after influenza infection atypical pneumonias (e.g. Due to Mycoplasma pneumoniae) viruses Klebsiella pneumoniae is classically in alcoholics

Answer 29

Trimethoprim or nitrofurantoin. Alternative: amoxicillin or cephalosporin

Answer 30

Broad-spectrum cephalosporin or quinolone

Answer 31

Quinolone or trimethoprim

Answer 32

Topical hydrogen peroxide, topical fusidic acid oral flucloxacillin or erythromycin if widespread

Answer 33

Flucloxacillin (clarithromycin, erythromycin or doxycycline if penicillin-allergic)

Answer 34

Co-amoxiclav (doxycycline + metronidazole if penicillin-allergic)

Answer 35

Flucloxacillin

Answer 36

Phenoxymethylpenicillin

Answer 37

Amoxicillin Erythromycin if allergic

Answer 38

Flucloxicillin | (plus steroid)

Answer 39

Amoxicillin

Answer 40

Metronidazole

Answer 41

IM ceftriaxone

Answer 42

doxycycline (7 days) or azithromycin (1g od for one day, then 500mg od for two days)

Answer 43

Oral ofloxacin + oral metronidazole OR intramuscular ceftriaxone + oral doxycycline + oral metronidazole

Answer 44

Oral or topical metro or topical clindamycin

Answer 45

First episode: metronidazole Second or subsequent episode of infection: vancomycin

Answer 46

for life-threatening infections a combination of oral vancomycin and intravenous metronidazole should be used

Answer 47

V1-V4 Left-anterior descending

Answer 48

2,3, aVF Right coronary artery

Answer 49

1, AVL V4-6 LAD Left circumflex

Answer 50

1, AVL, +/- V5-V6

Answer 51

Tall R waves V1-V2 Usually left circumflex, also right coronary artery

Answer 52

louder on expiration * aortic stenosis * hypertrophic obstructive cardiomyopathy louder on inspiration * pulmonary stenosis * atrial septal defect also: tetralogy of Fallot

Answer 53

Holosystolic (pansystolic) mitral/tricuspid regurgitation (high-pitched and 'blowing' in character) * tricuspid regurgitation becomes louder during inspiration, unlike mitral stenosis * 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)

Answer 54

Late systolic mitral valve prolapse coarctation of aorta

Answer 55

Aortic regurgitation Graham steel murmur (pulmonary regurgitation)

Answer 56

Mitral stenosis Austin flint murmur (severe aortic regurgitation 'rumbling in character'

Answer 57

Continous hum below clavicles

Answer 58

Low-pitched sound heard at lower left sternal edge

Answer 59

No murmur Loud S2 Prominent right ventricular impulse

Answer 60

Ejection systolic Upper left sternal edge (above stills murmur) Radiates to axilla

Answer 61

Left upper sternal edge (same place as tetralogy, above stills) Prominent apical pulse

Answer 62

Closure of mitral and tricuspid valves

Answer 63

Long PR or mitral regurgitation

Answer 64

Mitral stenosis

Answer 65

Closure of the aortic and pulmonary valves

Answer 66

Aortic stenosis

Answer 67

Inspiration

Answer 68

Diastolic filling of the ventricle

Answer 69

If under 30 May persist in women up to 50 years old

Answer 70

Left ventricular failure (dilated cardiomyopathy) Constrictive pericarditis Mitral regurgitation

Answer 71

Aortic stenosis HOCM Hypertension

Answer 72

Atrial contraction against stiff ventrical (P wave)

Answer 73

Double apical impulse

Answer 74

= beta blocker or calcium channel blocker first line. If CCB monotherapy, use **verapamil** or **diltiazem**. If using beta blocker and want to add ccb, add nifedipine/amlodipine/felodipine. If you can't tolerate these two drugs and want to better control add an adjunct. So prescribe 1 Then add another to make combination of beta blocker and nifedipine. If this combo isn't tolerated, try adding; long-acting **nitrate, ivabradine, nicorandil or ranolazine** Nicorandil is associated with ulcers that can occur anywhere along the gastrointestinal tract Nitrates require a nitrate-free interval each day to prevent tolerance

Answer 75

Satan playing double bass Statin Dual antiplatelet therapy Beta blocker Ace inhibitor

Answer 76

Beta blockers CCBs Digoxin (useful if coexistant heart failure)

Answer 77

Sotalol Amiodarone Flecainide

Answer 78

Over 65 History of IHD

Answer 79

Under 65 Symptomatic First presentation Lone AF or AF secondary to corrected precipitant (e.g alcohol) Congestive heart failure

Answer 80

echo to exclude valvular heart disease

Answer 81

Ace inhibitor and Beta blocker Spironolactone Third-line treatment should be initiated by a specialist. Options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy

Answer 82

If systolic BP is less than 90

Answer 83

Amiodarone Lidocaine Procainamide **VERAPAMIL SHOULD NOT BE USED**

Answer 84

300mg IV over 20-60minutes 900mg over 24 hours

Answer 85

AF with bundle branch block Pre-excited AF Polymorphic VT (torsades de pointes)

Answer 86

Vagal manouvres Adenosine 6mg, 12mg, 12mg

Answer 87

Probably AF Control rate with beta blocker or diltiazem Consider digoxin or amiodarone

Answer 88

Ventricular fibrillation

Answer 89

Within the first 48 hours

Answer 90

2-6 weeks after

Answer 91

Fever Pleuritic pain Pericardial effusion Raised ESR

Answer 92

Left verntricular aneurysm

Answer 93

Occurs 1-2 weeks after MI Acute heart failure Cardiac tamponade Raised JVP Pulsus paridoxus Diminished heart sounds

Answer 94

VSD Also has features of acute heart failure

Answer 95

Acute mitral regurgitation More common in infero=posterior infarction. May be due to ischaemia or rupture of papillary muscle

Answer 96

**_Native valve_** amoxicillin, consider adding low-dose gentamicin **_If penicillin allergic, MRSA or severe sepsis_** vancomycin + low-dose gentamicin **_If prosthetic valve_** vancomycin + rifampicin + low-dose gentamicin

Answer 97

* severe valvular incompetence * aortic abscess (often indicated by a lengthening PR interval) * infections resistant to antibiotics/fungal infections * cardiac failure refractory to standard medical treatment * recurrent emboli after antibiotic therapy

Answer 98

If staph use flucloxacillin If strep use benzylpenicillin If prosthetic valve use rifampicin Back up always involves vancomycin and usually low-dose gent

Answer 99

Stop warfarin Give intravenous vitamin K 5mg Prothrombin complex concentrate - if not available then FFP\*

Answer 100

Stop warfarin Give intravenous vitamin K 1-3mg Repeat dose of vitamin K if INR still too high after 24 hours Restart warfarin when INR \< 5.0

Answer 101

Stop warfarin Give vitamin K 1-5mg by mouth, using the intravenous preparation orally Repeat dose of vitamin K if INR still too high after 24 hours Restart when INR \< 5.0

Answer 102

Stop warfarin Give intravenous vitamin K 1-3mg Restart when INR \< 5.0

Answer 103

Withhold 1 or 2 doses of warfarin Reduce subsequent maintenance dose

Answer 104

Prothrombin complex concentrate only used when there is major bleeding If bleeding the vitamin K will be IV You always stop warfarin unless INR is 5-8 and no bleeding (in this case you withold 1-2 doses) Restart warfarin when INR less less than 5 Standard dose of vit K is 1-3mg (major bleeding dose is 5mg, oral dose is 1-5mg)

Answer 105

Essentially the patient will be on SABA and LABA if no steroid responsive features then add LAMA If steroid responsive then give inhjaled corticosteroids Then all of these medications as last line therapy

Answer 106

PEFR 33 - 50% best or predicted Can't complete sentences RR \> 25/min Pulse \> 110 bpm

Answer 107

* PEFR \< 33% best or predicted * Oxygen sats \< 92% * Silent chest, cyanosis or feeble respiratory effort * Bradycardia, dysrhythmia or hypotension * Exhaustion, confusion or coma Normal PCO2

Answer 108

In child under 5 SABA Then 8 week trial of moderate dose ICS Then final line therapy is SABA low dose ICS and LTRA - after that you refer to specialist In child 5-12 SABA Plus low dose ICS Plus LTRA Plus LABA (stop LTRA) Then increase steroids Then add theophyline

Answer 109

bronchiectasis and eosinophilia bronchoconstriction: wheeze, cough, dyspnoea. Patients may have a previous label of asthma

Answer 110

* eosinophilia * flitting CXR changes * positive radioallergosorbent (RAST) test to Aspergillus * positive IgG precipitins (not as positive as in aspergilloma) * raised IgE

Answer 111

Aspergillus spores

Answer 112

oral glucocorticoids itraconazole is sometimes introduced as a second-line agent

Answer 113

Extrinsic allergic alveolitis

Answer 114

Type 3 and type 4

Answer 115

* bird fanciers' lung: avian proteins from bird droppings * farmers lung: spores of Saccharopolyspora rectivirgula from wet hay (formerly Micropolyspora faeni) * malt workers' lung: Aspergillus clavatus * mushroom workers' lung: thermophilic actinomycetes\*

Answer 116

acute (occurs 4-8 hrs after exposure) * dyspnoea * dry cough * fever chronic (occurs weeks-months after exposure) * lethargy * dyspnoea * productive cough * anorexia and weight loss

Answer 117

Investigation ## Footnote imaging: upper/mid-zone fibrosis bronchoalveolar lavage: lymphocytosis serologic assays for specific IgG antibodies blood: NO eosinophilia (this is in contrast to allergic bronchopulmonary aspergillosis) (additionally, imaging shows bronchiectasis on bronchopulmonary aspergillosis)

Answer 118

avoid precipitating factors oral glucocorticoids

Answer 119

Fibrosis of upper lobes: C- Coal worker's pneumoconiosis H - Histiocytosis/ hypersensitivity pneumonitis A - Ankylosing spondylitis R - Radiation T - Tuberculosis S - Silicosis/sarcoidosis

Answer 120

Assess patients if any of the following: * very severe airflow obstruction (FEV1 \< 30% predicted). Assessment should be 'considered' for patients with severe airflow obstruction (FEV1 30-49% predicted) * cyanosis * polycythaemia * peripheral oedema * raised jugular venous pressure * oxygen saturations less than or equal to 92% on room air Assessment is done by measuring arterial blood gases on 2 occasions at least 3 weeks apart in patients with stable COPD on optimal management. Offer LTOT to patients with a pO2 of \< 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following: * secondary polycythaemia * peripheral oedema * pulmonary hypertension Cannot be given to people who smoke Risk assessment should include falls assessment and risk of burns/fires

Answer 121

virilisation of female genitalia precocious puberty in males 60-70% of patients have a salt-losing crisis at 1-3 wks of age

Answer 122

virilisation of female genitalia precocious puberty in males hypertension hypokalaemia

Answer 123

non-virilising in females inter-sex in boys hypertension

Answer 124

Androgen insensitivity syndrome is an X-linked recessive condition due to end-organ resistance to testosterone causing genotypically male children (46XY) to have a female phenotype. Complete androgen insensitivity syndrome is the new term for testicular feminisation syndrome Features 'primary amennorhoea' undescended testes causing groin swellings breast development may occur as a result of conversion of testosterone to oestradiol

Answer 125

Management ## Footnote counselling - raise child as female bilateral orchidectomy (increased risk of testicular cancer due to undescended testes) oestrogen therapy

Answer 126

X-linked Hypogonadotrophic hypogonadism

Answer 127

* 'delayed puberty' * hypogonadism, cryptorchidism * anosmia * sex hormone levels are low * LH, FSH levels are inappropriately low/normal * patients are typically of normal or above average height

Answer 128

Primary ciliary dyskinesia Features * dextrocardia or complete situs inversus * bronchiectasis * recurrent sinusitis * subfertility (secondary to diminished sperm motility and defective ciliary action in the fallopian tubes)

Answer 129

elevated gonadotrophin levels but low testosterone

Answer 130

* often taller than average * lack of secondary sexual characteristics * small, firm testes * infertile * gynaecomastia - increased incidence of breast cancer * elevated gonadotrophin levels but low testosterone

Answer 131

A fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l implies impaired fasting glucose (IFG)

Answer 132

Secondary hyperthyroidism = high phosphate, Calcium is porportionatel MUCH lower than PTH Tertiary hyperthyroidism = high ALP Remember that secondary hyperparathyroidism is due to CKD. In response to PTH kidney should REABSORB calcium, EXCRETE phosphate and Start making vitamin D. However in CKD the kidneys suck, so it can't do these things. Hence, low calcium, high phosphate and low vit D.

Answer 133

* Exogenous drugs such alcohol, aspirin poisoning, pentamidine, quinine sulfate, ACE-inhibitor * Pituitary insufficiency * Liver failure * Addison's disease * Islet cell tumours eg insulinoma * Non-pancreatic neoplasms

Answer 134

genital infections, diabetic ketoacidosis, fourniers gangrene

Answer 135

GI upset Lactic acidosis

Answer 136

Nause Vomitting Pancreatitis

Answer 137

weight gain, hypoglycaemia, lipodystrophy

Answer 138

* weight gain * liver impairment: monitor LFTs * fluid retention - therefore contraindicated in heart failure. The risk of fluid retention is increased if the patient also takes insulin * recent studies have indicated an increased risk of fractures * bladder cancer: recent studies have shown an increased risk of bladder cancer in patients taking pioglitazone (hazard ratio 2.64)

Answer 139

Try lifestyle, if above 48 add metformin. If above 58 after adding metformin then add another drug. If still above 58 with two drugs then add a third (insulin therapy can be considered instead of adding a third drug) Target is 48 mmol with metformin If two drugs the target is now 53 _Small tips:_ * Drugs that cause weight gain = sulphonylureas and thiazolidinones * Weight neutral = DPPIV * Weight loss = GLP-1 anologues and SGLT2 inhibitors * If heart failure then don't use thiazolidenones * Only ones really used in pregnancy is metformin and insulin * Gliptin in triple therapy can only be used with sulfonylurea * GLP-1's are last line if metformin tolerated * SGLT-1's are not used if metformin is not tolerated

Answer 140

Criteria for glucagon-like peptide1 (GLP1) mimetic (e.g. exenatide) ## Footnote if triple therapy is not effective, not tolerated or contraindicated then NICE advise that we consider combination therapy with metformin, a sulfonylurea and a glucagon-like peptide1 (GLP1) mimetic if: BMI \>= 35 kg/m² and specific psychological or other medical problems associated with obesity or BMI \< 35 kg/m² and for whom insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity-related comorbidities **(basically people who need to lose weight and people who can't take insulin)** only continue if there is a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in 6 months. **Probably because they are very expensive! - Need to make sure they are working to justify using them.**

Answer 141

Maturity-onset diabetes of the young

Answer 142

development of type 2 diabetes mellitus in patients \< 25 years old ## Footnote typically develops in patients \< 25 years a family history of early onset diabetes is often present ketosis is not a feature at presentation patients with the most common form are very sensitive to sulfonylureas, insulin is not usually necessary

Answer 143

* hyperthyroidism: due to over treatment * reduced bone mineral density * worsening of angina * atrial fibrillation

Answer 144

Papillary 65%, generally young females. Metastasis to cervical lymph nodes. Thyroglobulin can be used as a tumour marker. Characteristic Orphan Annie eyes on light microscopy. Good prognosis

Answer 145

Follicular adenoma

Answer 146

Capsular invasion Follicular carcinoma = 20%, generally women \>50 years old. Metastasis to lung and bones. Thyroglobulin can be used as a tumour marker. Moderate prognosis

Answer 147

Medullary thyroid

Answer 148

Anaplastic carcinoma Not responsive to treatment, can cause pressure symptoms

Answer 149

Solitary adenoma Hyperplasia Multiple adenoma Carcinoma

Answer 150

Sickle-cell anaemia GP6D deficiency Hereditary spherocytosis

Answer 151

Vitamin B12/folic acid deficiency Iron-deficiency anaemia Splenectomy

Answer 152

* asthma * pulmonary haemorrhage (Wegener's, Goodpasture's) * left-to-right cardiac shunts * polycythaemia * hyperkinetic states * male gender, exercise

Answer 153

* pulmonary fibrosis * pneumonia * pulmonary emboli * pulmonary oedema * emphysema * anaemia * low cardiac output

Answer 154

* pneumonectomy/lobectomy * scoliosis/kyphosis * neuromuscular weakness * ankylosis of costovertebral joints e.g. ankylosing spondylitis

Answer 155

Graves = TSH receptor stimulating antibodies and anti thyroid peroxidase antibodies Hashimotos = Anti-thyroid peroxidase and anti thyroglobulin antibodies

Answer 156

There are typically 4 phases; phase 1 (lasts 3-6 weeks): hyperthyroidism, **painful goitre**, **raised ESR** phase 2 (1-3 weeks): euthyroid phase 3 (weeks - months): hypothyroidism phase 4: thyroid structure and function goes back to normal Investigations **thyroid scintigraphy: globally reduced uptake of iodine-131**

Answer 157

* Autoimmune * tuberculosis * metastases (e.g. bronchial carcinoma) * meningococcal septicaemia (Waterhouse-Friderichsen syndrome) * HIV * antiphospholipid syndrome

Answer 158

* physiological: normal in puberty * syndromes with androgen deficiency: Kallman's, Klinefelter's * testicular failure: e.g. mumps * liver disease * testicular cancer e.g. seminoma secreting hCG * ectopic tumour secretion * hyperthyroidism * haemodialysis * drugs: see below * spironolactone (most common drug cause) * cimetidine * digoxin * cannabis * finasteride * GnRH agonists e.g. goserelin, buserelin * oestrogens, anabolic steroids

Answer 159

Hypokalaemic metabolic alkalosis

Answer 160

Neuroblastoma is one of the top five causes of cancer in children, accounting for around 7-8% of childhood malignancies. The tumour arises from neural crest tissue of the adrenal medulla (the most common site) and sympathetic nervous system.

Answer 161

* abdominal mass * pallor, weight loss * bone pain, limp * hepatomegaly * paraplegia * proptosis

Answer 162

* raised urinary vanillylmandelic acid (VMA) and homovanillic acid (HVA) levels * calcification may be seen on abdominal x-ray * biopsy

Answer 163

Patchy uptake Treatment is radioiodine therapy

Answer 164

increase in serum creatinine by 26.5 mol/l within 48 hours, increase in serum creatinine to 1.5 times baseline, or urine volume \< 0.5 ml/kg/h for 6 hours.

Answer 165

* anticoagulation should be given for at least 3 weeks prior to cardioversion. * An alternative strategy is to perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus. If excluded patients may be heparinised and cardioverted immediately * If there is a high risk of cardioversion failure (e.g. Previous failure or AF recurrence) then it is recommend to have at least 4 weeks amiodarone or sotalol prior to electrical cardioversion * Following electrical cardioversion patients should be anticoagulated for at least 4 weeks. After this time decisions about anticoagulation should be taken on an individual basis depending on the risk of recurrence

Answer 166

Triad of: ## Footnote 1. Proteinuria (\> 3g/24hr) causing 2. Hypoalbuminaemia (\< 30g/L) and 3. Oedema

Answer 167

Loss of antithrombin-III, proteins C and S and an associated rise in fibrinogen levels predispose to thrombosis. Loss of thyroxine-binding globulin lowers the total, but not free, thyroxine levels.

Answer 168

Goodpasture's syndrome Wegener's granulomatosis others: SLE, microscopic polyarteritis

Answer 169

* nephritic syndrome: haematuria with red cell casts, proteinuria, hypertension, oliguria * features specific to underlying cause (e.g. haemoptysis with Goodpasture's, vasculitic rash or sinusitis with Wegener's)

Answer 170

macroscopic haematuria in young people following an upper respiratory tract infection.

Answer 171

Differentiating between IgA nephropathy and post-streptococcal glomerulonephritis * post-streptococcal glomerulonephritis is associated with low complement levels * main symptom in post-streptococcal glomerulonephritis is proteinuria (although haematuria can occur) * there is typically an interval between URTI and the onset of renal problems in post-streptococcal glomerulonephritis

Answer 172

histology: mesangial hypercellularity, positive immunofluorescence for IgA & C3

Answer 173

Type 1 ## Footnote accounts for 90% of cases cause: **cryoglobulinaemia, hepatitis C** renal biopsy electron microscopy: subendothelial and mesangium immune deposits of electron-dense material resulting in a 'tram-track' appearance

Answer 174

electron microscopy: intramembranous immune complex deposits with 'dense deposits'

Answer 175

Post-streptococcal glomerulonephritis typically occurs 7-14 days following a group A beta-haemolytic Streptococcus infection (usually Streptococcus pyogenes). It is caused by immune complex (IgG, IgM and C3) deposition in the glomeruli. Young children are most commonly affected. C3 deposited hence low C3

Answer 176

* post-streptococcal glomerulonephritis causes acute, diffuse proliferative glomerulonephritis * endothelial proliferation with neutrophils * electron microscopy: subepithelial 'humps' caused by lumpy immune complex deposits * immunofluorescence: granular or 'starry sky' appearance

Answer 177

The majority of cases are idiopathic, but in around 10-20% a cause is found: drugs: NSAIDs, rifampicin Hodgkin's lymphoma, thymoma infectious mononucleosis

Answer 178

normal glomeruli on light microscopy electron microscopy shows fusion of podocytes and effacement of foot processes

Answer 179

normotension - hypertension is rare

Answer 180

Membranous glomerulonephritis

Answer 181

electron microscopy: the basement membrane is thickened with subepithelial electron dense deposits. This creates a 'spike and dome' appearance

Answer 182

* idiopathic: **due to anti-phospholipase A2 antibodies** * infections: hepatitis B, malaria, syphilis * malignancy (in 5-20%): prostate, lung, lymphoma, leukaemia * drugs: gold, penicillamine, NSAIDs * autoimmune diseases: systemic lupus erythematosus (class V disease), thyroiditis, rheumatoid

Answer 183

Management * all patients should receive an ACE inhibitor or an angiotensin II receptor blocker (ARB): * these have been shown to reduce proteinuria and improve prognosis * immunosuppression * as many patients spontaneously improve only patient with severe or progressive disease require immunosuppression * corticosteroids alone have not been shown to be effective. A combination of corticosteroid + another agent such as cyclophosphamide is often used * consider anticoagulation for high-risk patients

Answer 184

* focal and segmental sclerosis and hyalinosis on light microscopy * effacement of foot processes on electron microscopy

Answer 185

Indications for dialysis in acute kidney injury: Acute renal dialysis indications- HAVEPEE * H- hyperkalaemia (refractory) * A-acidosis (refractory) * V- volume overload * E- elevated urea * P- pericarditis * E- encephalopathy * E- (o)Edema (pulmonary)

Answer 186

Rhabdomyolysis

Answer 187

Penicillin

Answer 188

Urine osmolality is low, urine sodium is high (because kidneys try to retain sodium)

Answer 189

Features ## Footnote asthma blood eosinophilia (e.g. \> 10%) paranasal sinusitis mononeuritis multiplex pANCA positive in 60%

Answer 190

Features * upper respiratory tract: epistaxis, sinusitis, nasal crusting * lower respiratory tract: dyspnoea, haemoptysis * rapidly progressive glomerulonephritis ('pauci-immune', 80% of patients) * saddle-shape nose deformity * also: vasculitic rash, eye involvement (e.g. proptosis), cranial nerve lesions

Answer 191

eGFR variables - CAGE - Creatinine, Age, Gender, Ethnicity

Answer 192

* idiopathic * post head injury * pituitary surgery * craniopharyngiomas * histiocytosis X * DIDMOAD is the association of cranial Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness (also known as Wolfram's syndrome) * haemochromatosis

Answer 193

* genetic: the more common form affects the vasopression (ADH) receptor, the less common form results from a mutation in the gene that encodes the aquaporin 2 channel * electrolytes: hypercalcaemia, hypokalaemia * lithium * lithium desensitizes the kidney's ability to respond to ADH in the collecting ducts * demeclocycline * tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis

Answer 194

Driving Post-MI * For a car/motorcycle licence, you do not need to tell the DVLA * Can recommence driving after 1 week if successfully treated with coronary angioplasty * If not successfully treated with coronary angioplasty, can commence driving after 4 weeks * For a bus, coach or lorry licence - must tell DVLA and stop driving for 6 weeks. Assessment with doctor after 6 weeks to see if meet medical standard to start driving again.

Answer 195

* Must not drive if arrythmia has caused or is likely to cause incapacity * Drive 4 weeks after underlying cause of arrythmia has been found and the arrythmia has been controlled * If they drive a bus, coach or lorry, licence will be revoked and only be reinstated after an underlying cause has been identified, the arrythmia has been controlled for 3 months, and they have an LV ejection fraction of \>40%. So cars = drive after 1 month of control Buses = drive after 3 months of control

Answer 196

Neurological problems may manifest as dementia, tremor or dyskinesias. - Wilson’s disease

Answer 197

Features result from excessive copper deposition in the tissues, especially the brain, liver and cornea: ## Footnote liver: hepatitis, cirrhosis neurological: basal ganglia degeneration: in the brain, most copper is deposited in the basal ganglia, particularly in the putamen and globus pallidus speech, behavioural and psychiatric problems are often the first manifestations also: asterixis, chorea, dementia, parkinsonism Kayser-Fleischer rings green-brown rings in the periphery of the iris due to copper accumulation in Descemet membrane present in around 50% of patients with isolated hepatic Wilson's disease and 90% who have neurological involvement renal tubular acidosis (esp. Fanconi syndrome) haemolysis blue nails

Answer 198

* reduced serum caeruloplasmin * reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin) * free (non-ceruloplasmin-bound) serum copper is increased * increased 24hr urinary copper excretion

Answer 199

low potassium, low magnesium and low phosphate and fluid shifts

Answer 200

a proton pump inhibitor + amoxicillin + (clarithromycin OR metronidazole)

Answer 201

portal hypertension that has caused the ascites

Answer 202

Liver disorders are the most common cause * cirrhosis/alcoholic liver disease * acute liver failure * liver metastases Cardiac * right heart failure * constrictive pericarditis Other causes * Budd-Chiari syndrome * portal vein thrombosis * veno-occlusive disease * myxoedema

Answer 203

Hypoalbuminaemia * nephrotic syndrome * severe malnutrition (e.g. Kwashiorkor) Malignancy * peritoneal carcinomatosis Infections * tuberculous peritonitis Other causes * pancreatitisis * bowel obstruction * biliary ascites * postoperative lymphatic leak * serositis in connective tissue diseases

Answer 204

involves middle and anterior cerebral arteries all 3 of the criteria are present 1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg 2. homonymous hemianopia 3. higher cognitive dysfunction e.g. dysphasia

Answer 205

involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery 2 of the criteria are present 1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg 2. homonymous hemianopia 3. higher cognitive dysfunction e.g. dysphasia

Answer 206

involves perforating arteries around the internal capsule, thalamus and basal ganglia presents with 1 of the following: 1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three. 2. pure sensory stroke. 3. ataxic hemiparesis

Answer 207

involves vertebrobasilar arteries presents with 1 of the following: 1. cerebellar or brainstem syndromes 2. loss of consciousness 3. isolated homonymous hemianopia

Answer 208

Contralateral hemiparesis and sensory loss, **lower extremity \> upper**

Answer 209

Contralateral hemiparesis and sensory loss, upper extremity \> lower Contralateral homonymous hemianopia Aphasia

Answer 210

Contralateral homonymous hemianopia with macular sparing Visual agnosia (Notice pure visual)

Answer 211

Ipsilateral CN III palsy Contralateral weakness of upper and lower extremity

Answer 212

Ipsilateral: facial pain and temperature loss Contralateral: limb/torso pain and temperature loss Ataxia, nystagmus

Answer 213

Symptoms are similar to Wallenberg's (see above), but: Ipsilateral: facial paralysis and deafness

Answer 214

Amaurosis fugax

Answer 215

Basilar artery

Answer 216

1. Lateral medullary syndrome 1. Lateral pontine syndrome

Answer 217

Heller cardiomyotomty

Answer 218

Nissen fundoplication

Answer 219

A Whipple procedure is a surgical procedure used for the treatment of pancreatic cancers. It removes the head of the pancreas, the duodenum, the gallbladder and the bile duct.

Answer 220

Sister Mary Joseph node is a palpable nodule in the umbilicus due to metastasis of malignant cancer within the pelvis or abdomen

Answer 221

'Multiple factors, including splenic sequestration, reduced activity of the hematopoietic growth factor thrombopoietin, bone marrow suppression by chronic hepatitis C virus infection and anti-cancer agents, and antiviral treatment with interferon-based therapy, can contribute to the development of thrombocytopenia in cirrhotic patients'.

Answer 222

High Res CT

Answer 223

Isphagula husk

Answer 224

Gastric adenocarcinoma - signet ring cells

Answer 225

usually occurs when metastases are present in the liver and release serotonin into the systemic circulation may also occur with lung carcinoid as mediators are not 'cleared' by the liver

Answer 226

* flushing (often earliest symptom) * diarrhoea * bronchospasm * hypotension * right heart valvular stenosis (left heart can be affected in bronchial carcinoid) * other molecules such as ACTH and GHRH may also be secreted resulting in, for example, Cushing's syndrome * pellagra can rarely develop as dietary tryptophan is diverted to serotonin by the tumour Carcinoid syndrome can affect the right side of the heart. The valvular effects are tricuspid insufficiency and pulmonary stenosis

Answer 227

Grade I: Irritability Grade II: Confusion, inappropriate behaviour Grade III: Incoherent, restless Grade IV: Coma

Answer 228

It leads to a high potassium and high phosphate level in the presence of a low calcium

Answer 229

Complications of tumour lysis syndrome: * hyperkalaemia * hyperphosphataemia * hypocalcaemia * hyperuricaemia * acute renal failure

Answer 230

Wells of 2 or more * Skip D-Dimer * Do doppler - if positive then start DOAC, if negative do D-dimer * If D-dimer comes back positive (scan negative) stop any DOACs, repeat doppler 6-8 days later * If doppler is going to take a 4 hours or more - do D-dimer and start DOAC Wells of 1 or less * Do D-dimer * DOAC if D-dimer is going to take more than 4 hours * if D-dimer is positive then do doppler * If doppler is going to take more than 4 hours then DOAC should be started

Answer 231

DOAC LMWH followed by VKA (warfarin) for Severe renal impairment and antiphospholipid syndrome. 3 months of anticoagulation for provoked 6 months of anticoagulation for unprovoked

Answer 232

Waldenstorm's macroglubulinaemia

Answer 233

1. Parvovirus 2. Acute sequestration and haemolysis

Answer 234

**one major and one minor criteria or three minor criteria in an individual who has signs or symptoms of multiple myeloma.** **_Major criteria_** Plasmacytoma (as demonstrated on evaluation of biopsy specimen) 30% plasma cells in a bone marrow sample Elevated levels of M protein in the blood or urine **_Minor criteria_** 10% to 30% plasma cells in a bone marrow sample. Minor elevations in the level of M protein in the blood or urine. Osteolytic lesions (as demonstrated on imaging studies). Low levels of antibodies (not produced by the cancer cells) in the blood.

Answer 235

normocytic anaemia, leukopenia and thrombocytopenia is the definition of aplastic anaemia

Answer 236

Rivaroxaban is a direct factor Xa inhibitor. Apixaban is also a direct factor Xa inhibitor. Dabigatran is a direct thrombin inhibitor. Heparin activates antithrombin III.

Answer 237

Mild anaemia with big reduction in MCV = beta thalassaemia

Answer 238

Reed-sternberg cell Bimodal age distribution (3rd and 7th decades) * lymphadenopathy (75%) - painless, non-tender, asymmetrical * systemic (25%): weight loss, pruritus, night sweats, fever (Pel-Ebstein) * alcohol pain in HL * normocytic anaemia, eosinophilia * LDH raised B-symptoms with blood findings and alcohol pain

Answer 239

Reed-sterberg cell: either multinucleated or have a bilobed nucleus with prominent eosinophilic inclusion-like nucleoli (thus resembling an "owl's eye" appearance).

Answer 240

30 with clinically significant bleeding 100 for severe bleeding or bleeding at critical sites such as the CNS Platelet transfusion for thrombocytopenia before surgery/ an invasive procedure. Aim for plt levels of: * \> 50×109/L for most patients * 50-75×109/L if high risk of bleeding * \>100×109/L if surgery at critical site A threshold of 10 x 109 except where platelet transfusion is contradindicated or there are alternative treatments for their condition For example, do not perform platelet transfusion for any of the following conditions: * Chronic bone marrow failure * Autoimmune thrombocytopenia * Heparin-induced thrombocytopenia, or * Thrombotic thrombocytopenic purpura.

Answer 241

BCG MMR Influenza (intranasal) Oral rotavirus Oral Polio Yellow Fever Oral typhoid

Answer 242

Rabies Hepatitis A Influenza (IM)

Answer 243

Tetanus Diptheria Pertussis

Answer 244

1-6 hrs: Staphylococcus aureus, Bacillus cereus\* 12-48 hrs: Salmonella, Escherichia coli 48-72 hrs: Shigella, Campylobacter \> 7 days: Giardiasis, Amoebiasis

Answer 245

Genital warts, They are caused by the many varieties of the human papillomavirus HPV, especially types **6 & 11**. It is now well established that HPV (primarily types 16,18 & 33) predisposes to cervical cancer.

Answer 246

1. Herpes = painful ulcers 2. Syphillis = Painless ulcer (chancre). Local non-tender lymphadenopathy. 3. Chancroid = Painful ulcer, unilateral painful inguinal lymphadenopathy 4. LGV = Painless ulcer, painful inguinal lymphadenopathy

Answer 247

Primary = chancre, non-tender lymphadenopathy Secondary = Fever, rash, buccal snail track ulcers, condylomata lata (painless warty lesions on the genitalia) Tertiary = Gummas, ascending aortic aneurysms, generaly paralysis of the insane, tabes dorsales, Argyll - Robertson Pupil

Answer 248

* 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 249

This is a fungal infection which classically affects patients with HIV. It classically presents with a dry cough, exercise-induced desaturations and the absence of chest signs.

Answer 250

* heavy contamination with material likely to contain tetanus spores e.g. soil, manure * wounds or burns that show extensive devitalised tissue * wounds or burns that require surgical intervention

Answer 251

Patient has had a full course of tetanus vaccines, with the last dose \< 10 years ago * no vaccine nor tetanus immunoglobulin is required, regardless of the wound severity Patient has had a full course of tetanus vaccines, with the last dose \> 10 years ago * if tetanus prone wound: reinforcing dose of vaccine * high-risk wounds (e.g. compound fractures, delayed surgical intervention, significant degree of devitalised tissue): reinforcing dose of vaccine + tetanus immunoglobulin If vaccination history is incomplete or unknown * reinforcing dose of vaccine, regardless of the wound severity * for tetanus prone and high-risk wounds: reinforcing dose of vaccine + tetanus immunoglobulin In short. Grade 2 wound = tetanus booster. Grade 3 wound = Add Immunoglobulin If vaccination history is unknown then your threshold is lowered by 1. Grade 1 wound = tetanus booster Grade 2 wound = add Immunogloblin I you have had vaccine in the last 10 years then you need no extra intervention.

Answer 252

caused by HHV-8 (human herpes virus 8)

Answer 253

Leptospirosis - conjunctival suffusion plus muscle tenderness (localised in the calves and possibly the paraspinal muscles)

Answer 254

* initially systemic upset as above (fever, headache, arthralgia) * relative bradycardia * abdominal pain, distension * constipation: although Salmonella is a recognised cause of diarrhoea, constipation is more common in typhoid * rose spots: present on the trunk in 40% of patients, and are more common in paratyphoid

Answer 255

Features * flu-like symptoms including fever (present in \> 95% of patients) * dry cough * relative bradycardia * confusion * lymphopaenia * hyponatraemia * deranged liver function tests * pleural effusion: seen in around 30% of patients

Answer 256

Haemolytic anaemia and thrombocytopenia Erythema multiforme Ecephalitis / GBS Peri/myocarditis Bullous myringitis

Answer 257

Invasive diarrhoea (bloody diarrhoea + fever) then give ciprofloxacin, otherwise give clairithromycin

Answer 258

clarithromycin, erythromycin (in pregnancy) or doxycyline

Answer 259

* cold agglutins (IgM): may cause an haemolytic anaemia, thrombocytopenia * erythema multiforme, erythema nodosum * meningoencephalitis, Guillain-Barre syndrome and other immune-mediated neurological diseases * bullous myringitis: painful vesicles on the tympanic membrane * pericarditis/myocarditis * gastrointestinal: hepatitis, pancreatitis * renal: acute glomerulonephritis

Answer 260

Herpes simplex virus

Answer 261

Iron deficiency anaemia Eosinophilia

Answer 262

Macrolides (clari)

Answer 263

Trimethoprim can cause tubular dysfunction, leading to hyperkalaemia and increased serum creatinine

Answer 264

Erythromycin

Answer 265

10-20 days

Answer 266

Nitro Amoxicillin or cefalexin if near term

Answer 267

Mirizzi syndrome described common hepatic duct obstruction by an impacted gallstone.

Answer 268

Calcium oxalate Cystine Uric acid Calcium phosphate Struvite (staghorn calculi) Xanthine

Answer 269

Hypercalciuria Hyperoxaluria Hypocitraturia

Answer 270

urinary pH low Extensive tissue breakdown

Answer 271

Renal tubular acidosis (1 and 3) High pH

Answer 272

Urease producing bacteria

Answer 273

Opague: * Calcium oxalate * Calcium phosphate Lucent: * Uric Acid Others: Struvite = slightly radiolucent Cystine = radiodense

Answer 274

Hyponatraemia Fluid overload GLycine toxicity

Answer 275

Haemangioma = hyperechoic Liver abscess = hyperechoic Liver cell adnoma = mixed echoity and heterogeneous texture Cystadenoma = anechoic Amoebic abscess = fluid filled structure with poorly defined boundaries Hyatid cysts = septa, hyatid sand or daughter cysts

Answer 276

Incidental finding Hyperechoic

Answer 277

3-5th decade Women Link with OCP

Answer 278

fever, right upper quadrant pain. Jaundice may be seen in 50% Ultrasound will usually show a fluid filled cavity, hyperechoic walls may be seen in chronic abscesses

Answer 279

Fever RUQ (this is a mimic of cholecystitis) FLuid filled structure with poorly defined borders Anchovy paste consistency Metronidazole

Answer 280

Echinococcus infection Malaise and RUQ Eosinophilia Do not aspirate Mebendazole followed by surgical resection

Answer 281

Mesenteric ischaemia

Answer 282

1. 6 weeks of a prostate biopsy 2. 4 weeks following a proven UTI 3. 1 week after DRE 4. 48 hours after vigorous exercise 5. 48 hours after ejaculation

Answer 283

Acute epididymo-orchitis is most commonly caused by Chlamydia E. coli is the most common cause of epididymo-orchitis in men over 35 years of age.

Answer 284

Cholestasis Hepatosplenomegaly in response to increased levels of IL-6

Answer 285

**alpha-interferon** and **interleukin-2** have been used to reduce tumour size and also treat patients with metatases receptor **tyrosine kinase inhibitors** (e.g. sorafenib, sunitinib) have been shown to have superior efficacy compared to interferon-alpha

Answer 286

The Parkland formula for fluid resuscitation in burns is: * Volume of fluid = total body surface area of the burn % x weight (Kg) x 4ml * 50% given in first 8 hours * 50% given in next 16 hours

Answer 287

periumbilical discolouration (Cullen's sign) and flank discolouration (Grey-Turner's sign) is described but rare - acute pancreatitis.

Answer 288

ischaemic (Purtscher) retinopathy - may cause temporary or permanent blindness

Answer 289

Acute = can usually be made clinically (raised amylase, lipase) Ultrasound may be used to determeine cause Contrast enhanced CT is another option Chronic = Abdo CT showing pancreatic calcification Faecal elastase may be used to determine exocrine function

Answer 290

Sedation agents

Answer 291

Depolarising muscle relaxant. Short lasting Rapid action

Answer 292

Non-depolarizing muscle relaxant

Answer 293

Side effects. Side effects include malignant hyperthermia, muscle pains, acute rhabdomyolysis with high blood levels of potassium, transient ocular hypertension, constipation and changes in cardiac rhythm, including slow heart rate, and cardiac arrest.

Answer 294

Neostigmine

Answer 295

20% lipid emulsion

Answer 296

Ileoanal pouch with defunctioning ileostomy Subtotal colectomy

Answer 297

Complications of SAH: * Re-bleeding * happens in around 10% of cases and most common in the first 12 hours * if rebleeding is suspected (e.g. sudden worsening of neurological symptoms) then a repeat CT should be arranged * associated with a high mortality (up to 70%) * Vasospasm (also termed delayed cerebral ischaemia), typically 7-14 days after onset * Hyponatraemia (most typically due to syndrome inappropriate anti-diuretic hormone (SIADH)) * Seizures * Hydrocephalus * Death

Answer 298

Nimodipine

Answer 299

Fat necrosis

Answer 300

Mid/high rectal tumours can be managed with anterior resection. Hartmann's procedure is generally for sigmoid tumours, and abdominoperineal excision of rectum is for low rectal or anal tumours.

Answer 301

Cholecystitis Hyperaesthesia between 9th and 11th ribs on posterior right side

Answer 302

Metformin Sulfonylureas SGLT-2 inhibitors

Answer 303

Lantus/levemir = 20/20/20 Novomix / Humilin M3 = 0/halve/halve

Answer 304

HPV infection

Answer 305

Hypertension, haematuria, polycythaemia and renal mass = renal adenocarcinoma

Answer 306

Displacement of the cingulate gyrus under the falx ceribri

Answer 307

Downwards displacement of the brain

Answer 308

Displacement of the uncus of the temporal lobe under the tentorium cerebelli. Clinical consequences include an ipsilateral fixed, dilated pupil (due to parasympathetic compression of the third cranial nerve) and contralateral paralysis (due to compression of the cerebral peduncle)

Answer 309

Displacement of the cerebellar tonsils through the foramen magnum. This is called ‘coning’. In raised ICP this causes compression of the cardiorespiratory centre. In Chiari 1 malformation, tonsillar herniation is seen without raised ICP

Answer 310

Occurs when brain is displaced through a defect in the skull (e.g. a fracture or craniotomy site)

Answer 311

Burning over anterior thigh which worsens on walking, positive tinel sign over inguinal ligament

Answer 312

Sciatic nerve injury

Answer 313

Pfannelstein incision + pain over inguinal ligament, and tenderness when inguinal nerve is compressed

Answer 314

Weak hip flexion, weak knee extension, impaired quadriceps reflex, sensory deficit over anterior-medial aspect of thigh.

Answer 315

* Fixed pupils which do not respond to sharp changes in the intensity of incident light * No corneal reflex * Absent oculo-vestibular reflexes - no eye movements following the slow injection of at least 50ml of ice-cold water into each ear in turn (the caloric test) * No response to supraorbital pressure * No cough reflex to bronchial stimulation or gagging response to pharyngeal stimulation * No observed respiratory effort in response to disconnection of the ventilator for long enough (typically 5 minutes) to ensure elevation of the arterial partial pressure of carbon dioxide to at least 6.0 kPa (6.5 kPa in patients with chronic carbon dioxide retention). Adequate oxygenation is ensured by pre-oxygenation and diffusion oxygenation during the disconnection (so the brain stem respiratory centre is not challenged by the ultimate, anoxic, drive stimulus)

Answer 316

If their last menstrual period was less than 1 year ago

Answer 317

if they have: * taken cyclical combined for at least 1 year or * it has been at least 1 year since their LMP or * it has been at least 2 years since their LMP, if they had premature menopause (menopause below the age of 40)

Answer 318

Paradoxical rise

Answer 319

Triad of tenosynovitis, migratory polyarthritis and dermatitis Whereas reactive arthritis is urethritis, arthritis and conjunctivitis. Can’t see, pee or climb a tree

Answer 320

Pagets disease

Answer 321

Gout- monosodium urate crystals that are needle-shaped that are **negatively** birefringent under polarised light Pseudogout- calcium pyrophosphate crystals are rhombic/brick shaped that are **positively** birefringent under polarised light

Answer 322

Leriche syndrome Also has atrophy of the legs

Answer 323

Behcet's disease is an autoimmune small vessel vasculitis that targets venules. It is a type 3 hypersensitivity reaction induced by immune complex deposition in small vessels. Its main clinical presentation is with recurrent **oral and genital ulcers**, **anterior uveitis**, and skin lesions (such as **erythema nodosum**). It is most commonly seen in people of East Mediterranean descent. Flares may be precipitated by parvovirus or herpes simplex virus.

Answer 324

Grades hip facture severity Type I: Stable fracture with impaction in valgus Type II: Complete fracture but undisplaced Type III: Displaced fracture, usually rotated and angulated, but still has boney contact Type IV: Complete boney disruption Just remember that 3 is displaced but with bony contact

Answer 325

Internal fixation Hemiarthroplasty if unfit

Answer 326

Total hip replacement Hemiarthroplasty if unfit

Answer 327

Dynamic hip screw

Answer 328

Intramedullary device

Answer 329

1. Calcium - decreased 2. Phosphate - decreased 3. ALP - increased 4. PTH - increased

Answer 330

All normal

Answer 331

1. Calcium = High 2. Phosphate = Low 3. ALP = High 4. PTH = High

Answer 332

1. Calcium = Low 2. Phosphate = High 3. ALP = High 4. PTH = High

Answer 333

Ophthalmic examination

Answer 334

Pseudogout Chondrocalcinosis

Answer 335

De Quervain's tenosynovitis is a common condition in which the sheath containing the **extensor pollicis brevis and abductor pollicis** longus tendons is inflamed

Answer 336

More proximal

Answer 337

present very similarly with pain over the anterior aspect of the thigh. However, with meralgia paraesthetica you can also get numbness/paraesthesia. Meralgia paraesthetic is the same is lateral cutaneous nerve of thigh lesion (Burning over anterior thigh which worsens on walking, positive tinel sign over inguinal ligament)

Answer 338

Physis = 1 point Metaphysis = 1 point Epiphysis = 2 points 5 = crush

Answer 339

1. Femoral = hip flexion and knee extension 2. Obturator = thigh adduction 3. Lateral cutaneous nerve of thigh = Lateral and posterior surfaces of the thigh 4. Tibial - Plantarflexion and inversion 5. Common peroneal = dorsiflexion and eversion (and extensor hallucis longus) 6. Superior gluteal = Hip abduction 7. Inferior gluteal nerve = Hip extension and lateral rotation

Answer 340

Obturator nerve

Answer 341

Tibial nerve

Answer 342

Injury often occurs at the neck of the fibula Tightly applied lower limb plaster cast Injury causes foot drop

Answer 343

Misplaced intramuscular injection Hip surgery Pelvic fracture Posterior hip dislocation

Answer 344

Superior gluteal nerve

Answer 345

Sciatic nerve

Answer 346

Injury results in difficulty rising from seated position. Can't jump, can't climb stairs

Answer 347

External rotation and abduction

Answer 348

Greater tuberosity fracture Bankart lesion Hill-Sachs deformity

Answer 349

Rim's sign, light bulb sign. Associated with Trough sign

Answer 350

Hill-Sachs = Compression fracture of posterolateral humeral head due to compression against glenoid Bankart lesion = labral tear on anterior inferior glenoid

Answer 351

Anterior dislocation description: On examination, the right arm is abducted and externally rotated, and she resists all movement. The acromion appears prominent. The humeral head is seen in a subcoracoid position in anteroposterior view on X-ray Posterior dislocation = arm held in internal rotation

Answer 352

* Osteoarthritis- **calcium phosphate** crystals associated with degeneration of cartilage, coffin-lid shaped with no birefringence * Rheumatoid arthritis- **cholesterol crystals**, these are rhombic/brick-shaped with a negative birefringence

Answer 353

Phenytoin adverse effects: P= p450 interactions H = hirsutism E= enlarged gums N = nystagmus Y= yellow skin ie jaundice T = teratogen O = osteomalacia I = intereference with b12 metabolism - causing megaloblastic anaemia N = neuropathies Can also cause DUPYTREN's

Answer 354

Degenerative cervical myelopathy

Answer 355

a. A drop in systolic BP of 20mmHg or more (with or without symptoms) b. A drop to below 90mmHg on standing even if the drop is less than 20mmHg (with or without symptoms) c. A drop in diastolic BP of 10mmHg with symptoms (although clinically much less significant than a drop in systolic BP).

Answer 356

NMDA receptor antagonist

Answer 357

B12/folate: macrocytic anaemias, B12/folate deficiency worsen confusion TFTs: confusion is more commonly seen in hypothyroidism Glucose: hypoglycaemia can commonly cause confusion Bone Profile (Calcium): hypercalcaemia can cause confusion

Answer 358

Frontotemporal

Answer 359

Hypocalcaemia can be seen secondary to respiratory alkalosis as the higher pH lowers the amount of ionised calcium seen in the blood

Answer 360

Baclofen Gabapentin

Answer 361

Syringe drivers: respiratory secretions & bowel colic may be treated by hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide. If bowel colic, assume it’s an obstruction - use hyoscine butyl bromide. Metoclopramide is contraindicated in bowel obstruction.

Answer 362

Niacin deficiency Vitamin B3 * Pellagra * dermatitis * diarrhoea * dementia

Answer 363

Anaemia, irritability, seizures B6 is called pyridoxine

Answer 364

Dermatitis Seborrhoea B7 is called biotin

Answer 365

Folic acid Megaloblastic anaemia, deficiency during pregnancy - neural tube defects

Answer 366

Cyanocobalamin Megaloblastic anaemia, peripheral neuropathy

Answer 367

Vitamin C Scurvy gingivitis bleeding

Answer 368

Tocopherol, tocotrienol Mild haemolytic anaemia in newborn infants, ataxia, peripheral neuropathy

Answer 369

Naphthoquinone

Answer 370

Abruption previously; Blood pressure (i.e. hypertension or pre-eclampsia); Ruptured membranes, either premature or prolonged; Uterine injury (i.e. trauma to the abdomen); Polyhydramnios; Twins or multiple gestation; Infection in the uterus, especially chorioamnionitis; Older age (i.e. aged over 35 years old); Narcotic use (i.e. cocaine and amphetamines, as well as smoking)

Answer 371

* obesity * nulliparity * early menarche * late menopause * unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously * diabetes mellitus * tamoxifen * polycystic ovarian syndrome * hereditary non-polyposis colorectal carcinoma

Answer 372

* female sex: 6 times greater risk * breech presentation * positive family history * firstborn children * oligohydramnios * birth weight \> 5 kg * congenital calcaneovalgus foot deformity

Answer 373

planus: purple, pruritic, papular, polygonal rash on flexor surfaces. Wickham's striae over surface. Oral involvement common sclerosus: itchy white spots typically seen on the vulva of elderly women

Answer 374

Hypoechoic mass

Answer 375

Chronic salpingitis

Answer 376

Whirlpool sign

Answer 377

an infected nipple fissure, symptoms not improving after 12-24 hours despite effective milk removal and/or breast milk culture positive. If antibiotics are indicated, first line would be flucloxacillin for 10-14 days or erythromycin or clarithromycin if penicillin allergic.

Answer 378

* previous PPH * prolonged labour * pre-eclampsia * increased maternal age * polyhydramnios * emergency Caesarean section * placenta praevia, placenta accreta * macrosomia * ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis)

Answer 379

1st line (physical method) - bimanual uterine massage - empty bladder (catheter) 2nd line - oxytocin/syncitocin - carboprost - ergimetrine (not in hypertension) 3rd line (surgical) - balloon tamponade (do this first in surgical method) - B-Lynch suture - ligation of the uterine arteries or internal iliac arteries Last option hysterectomy

Answer 380

* recurrent acute otitis media * otitis media with effusion in both ears 3 months or one ear for 6 months * In patients with speech delays

Answer 381

whilst viral upper respiratory tract infections (URTIs) typically precede otitis media, most infections are secondary to bacteria, particularly Streptococcus pneumonaie, Haemophilus influenzae and Moraxella catarrhalis

Answer 382

Antibiotics should be prescribed immediately if: * Symptoms lasting more than 4 days or not improving * Systemically unwell but not requiring admission * Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease * Younger than 2 years with bilateral otitis media * Otitis media with perforation and/or discharge in the canal

Answer 383

trauma alcohol drugs: beta blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors, infliximab withdrawal of systemic steroids

Answer 384

* no mucosal involvement (in exams at least\*): bullous pemphigoid * mucosal involvement: pemphigus vulgaris

Answer 385

* increased mood change * restlessness * difficulty sleeping * unsteadiness * sweating * gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting * paraesthesia

Answer 386

aminoglycosides (e.g. Gentamicin), furosemide, aspirin and a number of cytotoxic agents

Answer 387

1,5,10 minutes

Answer 388

Decreasing vision over months with metamorphopsia and central scotoma should cause high suspicion of wet age-related macular degeneration

Answer 389

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

Answer 390

as soon as possible after booking and at 24-28 weeks

Answer 391

If fasting glucose is less than 7 try exercise - add metformin if needed - add insulin if needed If over 7 go immediately to insulin

Answer 392

* 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 Also having diabetes (type 1 or 2) is a high risk factor for pre-eclampsia, therefore women should take aspirin 75-150mg daily from 12 weeks gestation until the birth.

Answer 393

Precipitated by humidity and temperature Pompholyx eczema is a subtype of eczema characterised by an intensely pruritic rash on the palms and soles (basically, if the diagnosis seems like hand foot and mouth but it’s an adult.

Answer 394

Newborns with a positive heel prick for CF, i.e. they have a raised immunoreactive trypsinogen (IRT) result, get a sweat test, which will be high if they have CF

Answer 395

Sacrocolpoplexy

Answer 396

anterior colporrhaphy, colposuspension

Answer 397

Hysterectomy Sacrohysteropexy

Answer 398

Posterior colporrhaphy

Answer 399

**_PEP_** Woman less than 20 weeks pregnant and has EXPOSURE - Check immunity status - Give VZIG IMMEDIATELY Women over 20 weeks pregnant - Check iommunity status - Give VZIG or Aciclovir 7-14 days after the exposure **_Signs of varicella infection:_** Give oral aciclovir

Answer 400

Annual cervical cytology

Answer 401

Eczema herpeticum is a primary infection of the skin caused by herpes simplex virus (HSV) and uncommonly coxsackievirus

Answer 402

Oral aciclovir Oral steroids

Answer 403

After articficial rupture of membranes

Answer 404

Corynebacterium minutissimum Treated with erythromycin

Answer 405

asthma + aspirin sensitivity + nasal polyposis

Answer 406

Skin features * photosensitive * macular rash over back and shoulder * heliotrope rash in the periorbital region * Gottron's papules - roughened red papules over extensor surfaces of fingers * 'mechanic's hands': extremely dry and scaly hands with linear 'cracks' on the palmar and lateral aspects of the fingers * nail fold capillary dilatation Other features * proximal muscle weakness +/- tenderness * Raynaud's * respiratory muscle weakness * interstitial lung disease: e.g. Fibrosing alveolitis or organising pneumonia * dysphagia, dysphonia

Answer 407

* the majority of patients (around 80%) are **ANA** positive * around 30% of patients have antibodies to aminoacyl-tRNA synthetases (**anti-synthetase** antibodies), including: * antibodies against histidine-tRNA ligase (also called Jo-1) * antibodies to signal recognition particle (SRP) * anti-Mi-2 antibodies

Answer 408

* proximal muscle weakness +/- tenderness * Raynaud's * respiratory muscle weakness * interstitial lung disease: e.g. fibrosing alveolitis or organising pneumonia * dysphagia, dysphonia

Answer 409

* elevated **creatine kinase - this helps distinguish the condition from PMR** * other muscle enzymes (lactate dehydrogenase (LDH), aldolase, AST and ALT) are also elevated in 85-95% of patients * EMG * muscle biopsy * anti-synthetase antibodies * anti-Jo-1 antibodies are seen in pattern of disease associated with lung involvement, Raynaud's and fever

Answer 410

RIM JOB Reynauds Interstitial lung disease Myositis (or mechanics hands with gottrons papules for dermatomyositis) JOB = jo-1 antibodies

Answer 411

ANA positive in 100%, dsDNA negative anti-histone

Answer 412

**_Most common causes_** procainamide hydralazine **_Less common causes_** **isoniazid** minocycline phenytoin

Answer 413

99% are **ANA** positive this high **sensitivity** makes it a useful rule out test, but it has low specificity 20% are rheumatoid factor positive **anti-dsDNA: highly specific (\> 99%), but less sensitive (70%)** **anti-Smith: highly specific** (\> 99%), sensitivity (30%) also: anti-U1 RNP, SS-A (anti-Ro) and SS-B (anti-La)

Answer 414

Abdominal CT

Answer 415

**The dorsal carpal branch of the radial artery** is the main neurovascular structure that is compromised in a scaphoid fracture

Answer 416

1- Abrupt onset of moderate to severe hypertension that is typically associated with an increase in plasma renin activity 2- Acute kidney injury (AKI) 3- Urinalysis that is normal or reveals only mild proteinuria with few cells or casts

Answer 417

Ace inhibitors

Answer 418

Behcet's syndrome is associated with various dermatological symptoms including aphthous ulcers, genital ulcers, acne-like lesions and erythema nodosum.

Answer 419

2nd metatarsal

Answer 420

Age Gender Ethnic factors

Answer 421

Osteomyelitis=MRI Septic arthritis = joint aspiration/bloodcultures/joint imaging

Answer 422

CK normal ESR raised

Answer 423

Schirmers test

Answer 424

Polyarteritis nodoa

Answer 425

Thelassey's test weight bearing at 20 degrees of knee flexion, patient supported by doctor, postive if pain on twisting knee (for meniscal tear)

Answer 426

* long-term steroid use * chemotherapy * alcohol excess * trauma

Answer 427

MRI X-ray may show crescent sign

Answer 428

OA of the hand: Usually bilateral: Usually one joint at a time is affected over a period of several years. The carpometacarpal joints (CMCs), distal interphalangeal joints (DIPJs) are affected more than the proximal interphalangeal joints (PIPJs). Squaring of thumb

Answer 429

ANA positive in 90% RF positive in 30% anti-scl-70 antibodies associated with diffuse cutaneous systemic sclerosis anti-centromere antibodies associated with limited cutaneous systemic sclerosis

Answer 430

Low complement = active disease

Answer 431

Osteochondritis dissecans: = Pain after exercise, swelling, locking, giving way, clunking Chondromalacia patellae = Softening of the cartilage of the patella Common in teenage girls Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting Usually responds to physiotherapy

Answer 432

Look for TB Biologics can cause re-activation of TB

Answer 433

Features of the injury 1. Transverse fracture of the radius 2. 1 inch proximal to the radio-carpal joint 3. Dorsal displacement and angulation

Answer 434

Volar angulation of distal radius fragment (Garden spade deformity) Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed

Answer 435

* Intra-articular fracture at the base of the thumb metacarpal * Impact on flexed metacarpal, caused by fist fights * X-ray: triangular fragment at the base of metacarpal

Answer 436

* Dislocation of the proximal radioulnar joint in association with an ulna fracture * Fall on outstretched hand with forced pronation * Needs prompt diagnosis to avoid disability

Answer 437

* Radial shaft fracture with associated dislocation of the distal radioulnar joint * Occur after a fall on the hand with a rotational force superimposed on it. * On examination, there is bruising, swelling and tenderness over the lower end of the forearm. * X Rays reveal the displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint.

Answer 438

* Distal radius fracture (Colles'/Smith's) with associated radiocarpal dislocation * Fall onto extended and pronated wrist

Answer 439

* Fracture of the radial head is common in young adults. * It is usually caused by a fall on the outstretched hand. * On examination, there is **marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).**

Answer 440

Infective endocarditis

Answer 441

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 (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular) * bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia) * inability to walk four weight bearing steps immediately after the injury and in the emergency department

Answer 442

Bimalleolar ankle fracture Forced foot eversion

Answer 443

Related to the level of the fibular fracture. ## Footnote Type A is below the syndesmosis Type B fractures start at the level of the tibial plafond and may extend proximally to involve the syndesmosis Type C is above the syndesmosis which may itself be damaged

Answer 444

1. Weber a / minimally displaced = cam boot 2. Displaced = casted 3. Unstable / weber c = ORIF 4. Management prior to scan = reduction **All ankle fractures should be promptly reduced to remove pressure on the overlying skin and subsequent necrosis**

Answer 445

NSAIDS Steroid DMARDS

Answer 446

Steroids for flares (IM methylprednisolone, intra-articular steroids, oral prednisolone) NSAIDs for symptom relief DMARDs (methotrexate, sulfasalazine, hydroxychloroquine, leflunomide) Biologics: TNF = infliximab, etanercept, adalimumab Anti-CD20 - rituximab Anakinra = IL-1 IL-6 = Toclizumab

Answer 447

Pneumonitis Oral ulcers Heoatotoxicity

Answer 448

Initially monthly then every three months

Answer 449

* oligospermia * Stevens-Johnson syndrome * pneumonitis / lung fibrosis * myelosuppression, Heinz body anaemia, megaloblastic anaemia * may colour tears → stained contact lenses

Answer 450

Irreversible retinopathy

Answer 451

Increased BP Oral ulcers Hepatotoxicity Diarrhoea Male and female teratogenicity

Answer 452

**Methotrexate** women should avoid pregnancy for at least 6 months after treatment has stopped the BNF also advises that men using methotrexate need to use effective contraception for at least 6 months after treatment) **Leflunomide**

Answer 453

Sulfasalazine Hydroxychloroquine

Answer 454

* avoid prescribing trimethoprim or co-trimoxazole concurrently - increases risk of marrow aplasia * high-dose aspirin increases the risk of methotrexate toxicity secondary to reduced excretion

Answer 455

Folic acid folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after methotrexate dose

Answer 456

* Haemorrhagic cystitis * myelosuppression * transitional cell carcinoma

Answer 457

Lung fibrosis

Answer 458

Cardiomyopathy

Answer 459

Myelosuppression, mucositis, dermatitis

Answer 460

Peripheral neuropathy (reversible) , paralytic ileus

Answer 461

Neutropenia

Answer 462

Ototoxicity, peripheral neuropathy, hypomagnesaemia

Answer 463

Third nerve palsy: Eye will be abducted and depressed Ptosis Dilated pupil and absent light reflex - there will be intact consensual constriction

Answer 464

* diabetes mellitus * vasculitis e.g. temporal arteritis, SLE * Uncal herniation * posterior communicating artery aneurysm (often associated pain) * cavernous sinus thrombosis * Weber's syndrome: ipsilateral third nerve palsy with contralateral hemiplegia -caused by midbrain strokes * amyloid, multiple sclerosis

Answer 465

This clinical syndrome occurs in patients who have had a spinal cord injury at, or above T6 spinal level. Briefly, afferent signals, most commonly triggered by faecal impaction or urinary retention (but many other triggers have been reported) cause a sympathetic spinal reflex via thoracolumbar outflow. The usual, centrally mediated, parasympathetic response however is prevented by the cord lesion. The result is an unbalanced physiological response, characterised by extreme hypertension, flushing and sweating above the level of the cord lesion, agitation, and in untreated cases severe consequences of extreme hypertension have been reported, e.g. haemorrhagic stroke. Management of autonomic dysreflexia involves removal/control of the stimulus and treatment of any life-threatening hypertension and/or bradycardia.

Answer 466

Amytrophic lateral sclerosis Primary lateral sclerosis Progressive muscular atrophy Progressive bulbar palsy

Answer 467

* typically LMN signs in arms and UMN signs in legs * in familial cases the gene responsible lies on chromosome 21 and codes for superoxide dismutase

Answer 468

UMN signs only

Answer 469

LMN signs only affects distal muscles before proximal carries best prognosis

Answer 470

* palsy of the tongue, muscles of chewing/swallowing and facial muscles due to loss of function of brainstem motor nuclei * carries worst prognosis

Answer 471

* teratogenic * P450 inhibitor * gastrointestinal: nausea * increased appetite and weight gain * alopecia: regrowth may be curly * ataxia * tremor * hepatotoxicity * pancreatitis * thrombocytopaenia * hyponatraemia * hyperammonemic encephalopathy: L-carnitine may be used as treatment if this develops

Answer 472

Adverse effects * P450 enzyme inducer * dizziness and ataxia * drowsiness * headache * visual disturbances (especially diplopia) * Steven-Johnson syndrome * leucopenia and agranulocytosis * hyponatraemia secondary to syndrome of inappropriate ADH secretion

Answer 473

Antibodies associated with diabetes. (Anti-GAD, islet cell antibodies, insulin autoantibodies)

Answer 474

* Driving advice for type 1 diabetes: * If you have had more than 1 hypo in the last 12 months you must not drive and inform the DVLA * If you have had a hypo in the last 12 months you must not drive a lorry and you must notify the DVLA of every severe episode of hypoglycaemia * If severe hypoglycaemia occurs whilst driving - stop driving and inform the DVLA * Keep glucose treatments in car * Check blood glucose before driving and every two hours * Blood glucose should be more than 5 in order for you to drive

Answer 475

* Brocas is inferior frontal gyrus. It is typically supplied by the superior division of the left MCA. * Wernickes = Due to a lesion of the superior temporal gyrus. It is typically supplied by the inferior division of the left MCA

Answer 476

Acute = hyperdense Chronic = hypodense

Answer 477

Diagnosis of acromegaly = measure serum IGF1 levels (raised), then do glucose tolerance test - measuring GH (normal patients GH is suppressed to less than 1 microgram/L. Levels higher than this conform acromegaly. MRI of sella turcica needed as well. Remember to screen for other secretory effects of the tumour: They include thyroid stimulating hormone (TSH), gonadotropic hormones (FSH, LH), adrenocorticotropic hormone, and prolactin.

Answer 478

1. Rapid correction of hyponatraemia can cause **osmotic demyelination syndrome** 2. Correction of chronic hypernatraemia too fast predisposes to **cerebral oedema**

Answer 479

Benzylpenizillin, to cover for BGS Vanc if penicillin allergic Erythromycin is given for premature rupture of membranes

Answer 480

ciclosporin, oral contraceptives, mineralocorticoids, amiodarone, antibiotics (tetracyclines, sulphonamides), retinoic acid

Answer 481

Glioblastoma multiforme

Answer 482

Imaging: Central necrotic area, with enhanced rim Histology: Pleomorphic tumour cells border necrotic areas

Answer 483

Dura matter

Answer 484

Spindle cells in concentric whorls and calcified psammoma bodies

Answer 485

Antoni A or B patterns are seen. Verocay bodies (acellular areas surrounded by nuclear palisades)

Answer 486

Pilocytic astrocytoma

Answer 487

Rosenthal fibres (corkscrew eosinophilic bundle)

Answer 488

Small, blue cells. Rosette pattern of cells with many mitotic figures

Answer 489

4th ventricle

Answer 490

perivascular pseudorosettes

Answer 491

Calcifications with 'fried-egg' appearance

Answer 492

foam cells and high vascularity

Answer 493

Derived from remnants of Rathke pouch

Answer 494

raised CK and leukocytosis

Answer 495

Squamous = central Adenocarcinoma = peripheral

Answer 496

calcitonin

Answer 497

Analgesia Bisphosphonates Radiotherapy

Answer 498

Hypertonic saline

Answer 499

**_If a hypovolemic cause is suspected_** ## Footnote normal, i.e. isotonic, saline (0.9% NaCl) this may sometimes be given as a trial if the serum sodium rises this supports a diagnosis of hypovolemic hyponatraemia if the serum sodium falls an alternative diagnosis such as SIADH is likely **_If a euvolemic cause is suspected_** fluid restrict to 500–1000 mL/day consider medications: demeclocycline vaptans (see below) **_If a hypervolemic cause is suspected_** fluid restrict to 500–1000 mL/day consider loop diuretics consider vaptans

Answer 500

Lewy body dimentia

Answer 501

Parkinson’s plus falls plus vertical gaze palsy

Answer 502

Carbemazepine Sulfonylureas SSRIs Tricyclics

Answer 503

Chlorpromazine or haloperidol

Answer 504

The intercostobrachial nerves are frequently injured during axillary dissection. These nerves traverse the axilla and supply cutaneous sensation.

Answer 505

dorsal columns and lateral corticospinal tracts are affected. joint position and vibration sense lost first then distal paraesthesia.

Answer 506

Todds paresis

Answer 507

The following drugs may exacerbate myasthenia: * penicillamine * quinidine, procainamide * **beta-blockers** * lithium * phenytoin * antibiotics: gentamicin, macrolides, quinolones, tetracyclines

Answer 508

gastrointestinal disturbance (nausea, vomiting, abdominal pain) dizziness confusion blurry or yellow vision arrhythmias.

Answer 509

Carbemazepine

Answer 510

Intracranial hypotension

Answer 511

dyskinesia dry mouth anorexia palpitations postural hypotension psychosis drowsiness.

Answer 512

pulmonary, retroperitoneal and cardiac fibrosis.

Answer 513

* acute kidney injury * drugs\*: potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers, spironolactone, ciclosporin, heparin\*\* * metabolic acidosis * Addison's disease * rhabdomyolysis * massive blood transfusion

Answer 514

Calcium gluconate

Answer 515

Following referral to ENT, patients with sudden-onset sensorineural hearing loss are treated with high-dose oral corticosteroids

Answer 516

depo-provera

Answer 517

Constipation in children = movicol then add stimulant (Senna), then add osmotic such as lactulose

Answer 518

Indomethacin or ibuprofen

Answer 519

Asthma Breastfeeding - have to stop for one week after taking ulipristal

Answer 520

Penicillins Quinolones Sulfonamides Corticosteroids NSAIDs

Answer 521

U and E SSRI may invoke hyponatraemia, if patient is on a drug like omeprazole which also causes hyponatraemia you need to check U and E before starting SSRI

Answer 522

Caused by trichopghyton tonsurans or Microsporum Canis (associated with cats and dogs, and fluoresce under woods lamp). Treatment for trichophyton tonsurans = oral terbinafine. Treatment for microsporum Canis = griseofulvin. Topical ketoconazole shampoo for first two weeks to reduce transmission.

Answer 523

Tinea corporis = trichophyton rubrum and trichophyton verrucosum. Treated with oral fluconazole. (BMJ says that this is treated with topical terbinafine adjunct is aluminium acetate topical. 2nd line is topical ‘azoles’. 3rd line is oral terbinafine/ oral itraconazole)

Answer 524

oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole