Everything else - Passmed

Question 1

Risk factors for SBOS (Small bowel bacterial overgrowth syndrome)?

Answer 1

• Neonates with congenital gastrointestinal abnormalities
• Scleroderma
• Diabetes Mellitus

Question 2

Key investigations for SBOS (small bowel bacterial overgrowth syndrome)?

Answer 2

• Hydrogen breath test
• Sometimes give a course of antibiotics as a diagnostic trial
• Small bowel aspiration and culture - this is used less often as invasive and results are often difficult to reproduce

Question 3

What is the management of SBOS (small bowel bacterial overgrowth syndrome)?

Answer 3

Antibiotic therapy - rifaximin

Note co-amox or metronidazole are also effective in most patients

Question 4

Give 2 examples of GLP-1 mimetics

Answer 4

Liraglutide
Exenatide

Question 5

Liraglutide and exenatide belong to which class of diabetes medications?

Answer 5

GLP-1 mimetics

Question 6

What is a good side effect of GLP-1 mimetics?

Answer 6

Weight loss

Question 7

What is a good benefit of Liraglutide over Exenatide?

Answer 7

Liraglutide only needs to be given once a day

Question 8

When patient is already on metformin and a sulfonylurea, in what situations according to NICE can we add on exenatide (GLP-1 mimetic)?

Answer 8

• When BMI > / = 35 kg/m2 in people of european descent and there are problems associated with high weight or
• BMI < 35 kg/m2 and insulin is unacceptable because of occupational implications or weight loss would benefit other comorbidities

Question 9

What targets for HbA1C and weight loss are set by NICE to justify the ongoing prescription of GLP-1 mimetics?

Answer 9

> 11 mmol/mol (1%) reduction in HbA1C and 3% weight loss after 6 months to justify the ongoing prescription of GLP-1 mimetics

Question 10

What is the mechanism of action of DPP-4 inhibitors?

Answer 10

They increase the level of incretins (GLP-1 and GIP) by decreasing their peripheral breakdown

Question 11

When are DPP-4 inhibitors preferable to thiazolidinediones?

Answer 11

If further weight gain would cause significant problems, a thiazolidinedione is contraindicated or the person has a poor response to thiazolidinediones

Question 12

Give two examples of DPP-4 inhibitors?

Answer 12

Sitagliptin
Vildagliptin

Question 13

True or false DPP-4 inhibitors e.g. sitagliptin cause weight gain?

Answer 13

False

Question 14

In heart failure, what are the dinidcations for:
1) Cardiac resynchronisation therapy?
2) Implantable cardiac defibrillator (ICD)?

Answer 14

1) Cardiac resynchronisation therapy
- Heart failure NYHA class III
- Left ventricular dysfunction
- Ejection fraction < 35%
- QRS duration > 120ms

2) Implantable cardiac defibrillator (ICD)
- Symptoms no more than NYHA class III
- Ejection fraction < 35%
- Sustained ventricular tachycardia

Question 15

What type of pacing is done in chronic heart failure?

Answer 15

Biventricular pacing

Question 16

Most common cause of CAP (organism)?

Answer 16

Streptococcus pneumoniae

Question 17

Predisposing influenza predisposes to pneumonia related to which organism?

Answer 17

Staph Aureus

Question 18

Which anticoagulation is absolutely contra-indicated in pregnancy?

Answer 18

Warfarin - as it is teratogenic

Question 19

Which anticoagulant is recommended first line for VTE treatment in pregnancy?

Answer 19

Low molecular weight heparin - it has a preferable safety profile as compared to unfractionated heparin and is equally effective

Question 20

Target INR is higher in atrial or mitral valve metallic replacements?

Answer 20

Higher in mitral valve replacements

Question 21

1) VTE treatment with warfarin what target INR is usually set?

2) What about in AF?

3) What about in metallic heart valves?

Answer 21

1) VTE treatment - usually 2.5 target, if recurrent 3.5

2) Atrial fibrillation target INR = 2.5

3) Mechanical heart valves = 3-3.5

Question 22

List some factors that may potentiate warfarin?

Answer 22

• Liver disease
• P450 enzyme inhibitors e.g. amiodarone, ciprofloxacin
• Cranberry juice
• Drugs which displace warfarin from plasma albumin e.g. NSAIDs
• Inhibit platelet function e.g. NSAIDs

Question 23

Warfarin in pregnancy in breastfeeding - are they contraindicated, can they be used?

Answer 23

Breastfeeding - can be used
Pregnant - cannot be used - teratogenic

Question 24

Side effects of warfarin?

Answer 24

• Haemorrhage
• Teratogenic, although can be used in breastfeeding mothers
• Skin necrosis (due to thrombosis in venules)
• Purple toes

Question 25

In genital wart treatment what is used in the following situations? 1) Multiple, non-keratinised warts? 2) Solitary, keratinised wards?

Answer 25

1) Multiple, non-keratinised warts - topical podophyllum 2) Solitary, keratinised wards - cryotherapy

Question 26

In which situation do you use topical podophyllum and in which do you use cryotherapy for the management of genital wards?

Answer 26

Multiple, non-keratinised warts - topical podophyllum Solitary, keratinised wards - cryotherapy

Question 27

Which strands of HPV cause genital warts? What about cervical cancer?

Answer 27

1) 6&11 - genital warts 2) 16,18,33 - cervical cancer

Question 28

Outline treatment options for salicylate overdose

Answer 28

- Urinary alkalinisation with IV bicarbonate - Haemodialysis - if indicated with severe metabolic acidosis or pulmonary oedema

Question 29

Reversal agent for benzodiazepines?

Answer 29

Flumazenil

Question 30

What is the management of overdose with TCAs?

Answer 30

IV bicarbonate - reduces the risk of seizures and arrythmias in severe toxicity Can consider lignocaine but priority is IV bicarb, and note to avoid class 1a (e.g. Quinidine) and class Ic antiarrhythmics (e.g. Flecainide) are contraindicated as they prolong depolarisation. Class III drugs such as amiodarone should also be avoided as they prolong the QT interval.

Question 31

True or false, dialysis is ineffective in management of TCA overdose?

Answer 31

True

Question 32

What is the management of lithium overdose?

Answer 32

- Mild-moderate toxicity - volume resuscitation with normal saline - Haemodialysis may be needed in severe toxicity - Sodium bicarb sometimes used

Question 33

What are reversal agents for warfarin overdose?

Answer 33

Vit K, prothrombin complex

Question 34

Reversal agent for heparin overdose?

Answer 34

Protamine sulphate

Question 35

Management options for beta-blockers?

Answer 35

- If bradycardic then atropine - In resistant cases, glucagon may be used

Question 36

Management options for ethylene glycol poisoning?

Answer 36

- Fomepizole, an inhibitor of alcohol dehydrogenase - Haemodialysis in refractory cases

Question 37

What is the reversal agent used in treatment of poisoning with organophosphate insecticides?

Answer 37

Atropine N.B the role of pralidoxime is unclear - meta-analyses failed to show any clear benefit

Question 38

What is the reversal agent for digoxin toxicity?

Answer 38

Digoxin-specific antibody fragments

Question 39

What is the reversal agent for iron poisoning?

Answer 39

Desferrioxamine, a chelating agent

Question 40

What are the reversal agents for lead poisoning?

Answer 40

Dimercaprol, calcium edetate

Question 41

What is the management for CO poisoning?

Answer 41

100% oxygen Hyperbaric oxygen

Question 42

What are the management options for cyanide poisoning?

Answer 42

Hydroxycobalamin Any combination of amyl nitrate, sodium nitrite, and sodium thiosulfate

Question 43

How to manage seasonal affective disorder (SAD)?

Answer 43

Treat the same way as depression Begin with psychological therapies and follow up in 2 weeks to ensure no deterioration Following this an SSRI can be given if needed

Question 44

Which antibodies may be positive in idiopathic pulmonary fibrosis?

Answer 44

ANA in 30%, Rheumatoid factor in 10% - however the titres will be low

Question 45

Outline the management of idiopathic pulmonary fibrosis

Answer 45

- Pulmonary rehab - Supplementary oxygen - Eventually will require a lung transplant

Question 46

Prognosis in idiopathic pulmmonary fibrosis?

Answer 46

Poor, average life expectancy is around 3-4 years

Question 47

What will be the TLCO in idiopathic pulmonary fibrosis? Reduced or increased?

Answer 47

Reduced

Question 48

Lung function test pattern in idiopathic pulmonary fibrosis?

Answer 48

FVC reduced < 70% FEV1 reduced FVC and FEV1 will be proportionately reduced so FEV1/FVC will be normal (sometimes slightly inreased)

Question 49

Idiopathic pulmonary fibrosis in what age group commonly and more common in men or women?

Answer 49

50-70yrs 2x as commmon in men

Question 50

Outline how skin prick tests are done

Answer 50

Drops of diluted allergen are placed on the skin after which the skin is pierced using a needle. A large number of allergens can be tested in one session. Normally includes a histamine (positive) and sterile water (negative) control. A wheal will typically develop if a patient has an allergy. Can be interpreted after 15 minutes Useful for food allergies and also pollen

Question 51

Skin prick tests are useful for what allergies?

Answer 51

Food allergies Pollen

Question 52

Which allergy tests useful for food allergies and pollen?

Answer 52

Skin prick test and RAST

Question 53

Which allergy test useful for wasp / bee venom?

Answer 53

RAST

Question 54

IgE RAST test determines the level of IgE to specific allergen or is it non-specific?

Answer 54

Specific

Question 55

Outline how RAST tests are done

Answer 55

Determines the amount of IgE that reacts specifically with suspected or known allergens, for example IgE to egg protein. Results are given in grades from 0 (negative) to 6 (strongly positive)

Question 56

Which allergy test is useful for contact dermatitis?

Answer 56

Skin patch testing

Question 57

How soon are results from skin prick tests read?

Answer 57

After 15 minutes

Question 58

How soon are results from skin patch testing read?

Answer 58

Read by a dermatologist after 48 hours

Question 59

Give some risk factors for degenerative cervical myelopathy

Answer 59

- Smoking - Genetics - Occupations - that expose patients to high axial loading

Question 60

What is the gold standard investigation in suspected degenerative cervical myelopathy (DCM)?

Answer 60

MRI cervical spine

Question 61

Features of DCM (degenerative cervical myelopathy)?

Answer 61

- Pain (affecting the neck, upper or lower limb) - Loss of motor function (loss of digital dexterity, preventing simple tasks such as holding a fork or doing up their shirt buttons, arm or leg weakness/stiffness leading to impaired gait and imbalance) - Loss of sensory function causing numbness - Loss of autonomic function (urinary or faecal incontinence and/or impotence) - these can occur and do not necessarily suggest cauda equina syndrome in the absence of other hallmarks of that condition - Hoffman's sign positive

Question 62

What is Hoffman's sign and in which condition is it positive?

Answer 62

Degenerative cervical myelopathy Gently flicking one finger on a patient's hand Positive test results in reflex twitching of the other fingers on the same hand in response to the flick

Question 63

How to manage suspected degenerative cervical myelopathy?

Answer 63

Urgent referral to specialist spinal services (neurosurgery or orthopaedic spinal surgery) Decompressive surgery Close observation for mild disease, but anything more progressive or severe requires surgery to prevent further deterioration Physiotherapy should ONLY be initiated by specialist services, as manipulation can cause more spinal cord damage

Question 64

Which drug is useful to manage tremor in drug-induced Parkinsonism?

Answer 64

Procyclidine

Question 65

Which drug in Parkinson's is associated with pulmonary fibrosis?

Answer 65

Cabergoline

Question 66

Which medication in Parkinson's management often has a reduced effectiveness with time?

Answer 66

Levodopa

Question 67

Features of Rosacea?

Answer 67

- Typically affects nose, cheeks and forehead - Flushing is often first symptom - Telangiectasia are common - Later develops into persistent erythema with - Papules and pustules - Rhinophyma - Ocular involvement: blepharitis - Sunlight may exacerbate symptoms

Question 68

In rosacea, what are some simple measures that can be used - (i.e. not for specifc treatment of erythema / flushing or papules / pustules)?

Answer 68

Daily application of high-factor sunscreen Camouflage creams may help reduce redness

Question 69

How to manage predominant erythema / flushing in rosacea?

Answer 69

Topical brimonidine gel may be considered for patients with predominant flushing but limited telangiectasia

Question 70

In rosacea, what can be considered for mild-to-moderate papules and / or pustules? What about moderate to severe papules and / or pustules?

Answer 70

Topical ivermectin is first line Alternatives: topical metro or topical azelaic acid Combination of topical ivermectin + oral doxycycline

Question 71

When to consider referral for rosacea?

Answer 71

When symptoms have not improved with optical management in primary care Patients with rhinophyma

Question 72

Predisposing factors for pityriasis versicolor?

Answer 72

Occurs in healthy individuals also Immmunosuppression Malnutrition Cushing's

Question 73

What is the management for pityriasis versicolor, and what if it does not respond to this?

Answer 73

Ketoconazole shampoo If not responding then send scrapings to confirm the diagnosis or consider alternative diagnoses and add oral itraconazole

Question 74

Key feature that distinguishes scleritis from episcleritis?

Answer 74

Pain - pain in scleritis, not in episcleritis Note scleritis is potentially sight threatening so more urgent

Question 75

Risk factors for scleritis?

Answer 75

- Rheumatoid arthritis: the most commonly - Associated condition - Systemic lupus erythematosus - Sarcoidosis - Granulomatosis with polyangiitis

Question 76

Features of scleritis

Answer 76

- Red eye - Painful - Watering and photophobia are common - Gradual decrease in vision

Question 77

Outline management of scleritis

Answer 77

- Same day assessment by an ophthalmologist - Oral NSAIDs typically used first line - Oral glucocorticoids may be used - Immunosuppressive drugs for resistant cases (and also to treat any underlying associated diseases)

Question 78

Causes of dacytlitis?

Answer 78

- Spondyloarthritis: e.g. Psoriatic and reactive arthritis - Sickle-cell disease - Other rare causes include tuberculosis, sarcoidosis and syphilis

Question 79

In imaging in subarachnoid haemorrhage, which imaging is first line and then what other imaging can be done and why?

Answer 79

First-line = non-contrast CT head Then can do CT angiography to identify the causal pathology and to plan definitive treatment Then MRI angiography if CT angiography did not identify the cause of the subarachnoid haemorrhage

Question 80

What to do if metformin is not tolerated due to GI side-effects?

Answer 80

Try a modified release formulation before switching to a second line agent

Question 81

What is cataplexy?

Answer 81

Sudden and transient loss of muscular tone caused by strong emotion (e.g. laughter, being frightened). Features range from buckling knees to collapse

Question 82

Around 2/3rds of patients with narcolepsy have ....

Answer 82

Around 2/3rds of patients with narcolepsy have cataplexy

Question 83

How to differentiate between spider naevi and telangiectasia?

Answer 83

Spider naevi fill from the centre vs telangiectasia fills from the edge

Question 84

Risk factors for spider naevi?

Answer 84

- Liver disease - Pregnancy - COCP

Question 85

Normal variants in ECGs for athletes?

Answer 85

- Sinus bradycardia - 1st degree atrioventricular block - Wenckebach phenomenon (2nd degree - atrioventricular block Mobitz type 1) - Junctional escape rhythm

Question 86

True or false, hydroceles can affect fertility?

Answer 86

False

Question 87

Where are epididymal cysts found in relation to the testicle, and are they separate or attached to the body of the testicle?

Answer 87

Posterior to the testicle, separate from the body of the testicle

Question 88

Give some conditions associated with epididymal cysts

Answer 88

- Polycystic kidney disease - CF - VHL

Question 89

What investigation is used to confirm the diagnosis of epididymal cysts?

Answer 89

Ultrasound

Question 90

What is the management of epididymal cysts?

Answer 90

- Usually supportive - Surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts

Question 91

What are the two types of hydroceles and what are they caused by?

Answer 91

- Communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life - Non-communicating: caused by excessive fluid production within the tunica vaginalis

Question 92

Give 3 things that hydroceles may develop secondary to?

Answer 92

- Epididymo-orchitis - Testicular torsion - Testicular tumours

Question 93

Describe the typical location of hydroceles in relation to the testicle and can you get above the mass or not on palpation?

Answer 93

Usually anterior to and below the testicle You can get 'above' the mass on examination

Question 94

Investigation for suspected hydrocele?

Answer 94

Clinical diagnosis, but ultrasound can be used if clinical uncertainty

Question 95

At what point are hydroceles advised to be corrected in babies?

Answer 95

They usually self-resolve within 1 year of birth, however if they do not resolve spontaneously they are repaired

Question 96

How are hydroceles managed in adults?

Answer 96

Conservative approach Further investigation is usually warranted with ultrasound to exclude any underlying cause such as a tumour

Question 97

True or false varicoceles are associated with infertility?

Answer 97

True

Question 98

Varicoceles more common on right or left?

Answer 98

Left (>80%)

Question 99

Investigation for varicoceles?

Answer 99

Doppler studies

Question 100

Management for varicoceles?

Answer 100

- Usually conservative - Occasionally surgery if patient is troubled by pain. Ongoing debate regarding the effectiveness of surgery to treat infertility

Question 101

Outline the acute treatments for migraine/

Answer 101

First line: offer combo therapy with - Oral triptan + NSAID or... - Oral triptan + paracetamol For young people 12-17 years consider a nasal triptan in preference to oral triptan If above measures not effective or tolerated offer non-oral preparation of metoclopramide or prochlorperazine and consider adding a non-oral NSAID or triptan Beware prescribing metoclopramide to young patients as acute dystonic reactions may develop

Question 102

Which migraine prophylactic should be avoided in women of childbearing age?

Answer 102

Topiramate - it can be teratogenic and can reduce the effectiveness of hormonal contraceptives

Question 103

What are the options for migraine prophylaxis?

Answer 103

- Propranolol - Topiramate - Amitryptiline If these fail advise a course of up to 10 sessions of acupuncture over 5-8 weeks Advise riboflavin 400mg OD may help For women with predictable menstrual migrain consider Frovatriptan 2.5mg BD or Zolmatriptan 2.5mg BD-TDS

Question 104

Patient with AF and is haemodynamically unstable - what do you do?

Answer 104

Electrical cardioversion

Question 105

Patient with new AF, haemodynamically stable. What to do if: 1) < 48 hrs from onset? 2) > 48 hrs from onset or uncertain (e.g. patient not sure when symptoms started)?

Answer 105

1) < 48 hrs - rate or rhythm control 2) > 48 hrs or uncertain - rate control - If considered for long term rhythm control, delay cardioversion until they have been maintained on therapeutic anticoagultion for a minimum of 3 weeks

Question 106

Rate controle should be offered as first line treatment strategy in AF except for (list some criteria)?

Answer 106

- Atrial fibrillation has a reversible cause - Patients who have heart failure thought to be primarily caused by atrial fibrillation - New-onset atrial fibrillation (< 48 hours) - Atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm - Those in whom rhythm-control strategy would be more suitable based on clinical judgement

Question 107

3 rate control drugs / classes?

Answer 107

- Beta-blockers - CCBs - Digoxin (only if very sedentary or other drugs ruled out because of comorbidities, may have a role in coexistent heart failure)

Question 108

Which rhythm control agent is second line in patients following cardioversion?

Answer 108

Dronedarone

Question 109

Which rhythm control agent is useful particularly in coexisting heart failure?

Answer 109

Amiodarone

Question 110

Give 4 rhythm control agents?

Answer 110

Beta blockers Dronedarone Amiodarone Flecainide

Question 111

When is catheter ablation used in AF?

Answer 111

In those who have not responded to, or wish to avoid anti-arrythmic medication

Question 112

How long should anticoagulation be used before and during / after catheter ablation?

Answer 112

4 weeks before and during the procedure, and needs afterwards based on chadvasc score

Question 113

What to do about anticoagulation in patients undergoing catheter ablation after the procedure?

Answer 113

Still require anticoagulation based on the CHADVASC score - If = 0 - 2 months anticoagulation - If > 1 - long-term anticoagulation

Question 114

Give 3 notable complications of catheter ablation for AF?

Answer 114

- Cardiac tamponade - Stroke - Pulmonary vein stenosis

Question 115

Definition of status epilepticus?

Answer 115

- Single siezure lasting > 5 minutes or - > / = 2 seizures within a 5 minute period without the person returning to normal between them

Question 116

Management of status epilepticus?

Answer 116

- ABC Airway adjunct Oxygen Check blood glucose - In prehospital either buccal midazolam or rectal diazepam - In hospital IV lorazepam 4mg - then again after 5-10 minutes If ongoing or established epilepticus - start second-line agent e.g. levetiracetam, phenytoin or sodium valproate If no response within 45 minutes from onset - rapid induction of general anaesthesia or phenobarbital

Question 117

Nail changes that can be seen in psoriasis / psoriatic arthropathy?

Answer 117

- Pitting - Onycholysis (separation of the nail from the nail bed) - Subungual hyperkeratosis - Loss of the nail

Question 118

Which medication is used to help prevent reaccumulation of ascites?

Answer 118

Spironolactone (aldosterone antagonist) N.B. A loop diuretic may need to be added in non-responders

Question 119

MOA of spironolactone and site of action?

Answer 119

Aldosterone antagonist - acts in the collecting ducts

Question 120

Some indications for spironolactone?

Answer 120

- Ascites: patients with cirrhosis develop a - Secondary hyperaldosteronism. Relatively large doses such as 100 or 200mg are often used - Hypertension: used in some patients as a NICE 'step 4' treatment - Heart failure - Nephrotic syndrome - Conn's syndrome

Question 121

Patient on 15mg Mirtazapine is complaining of sedation side effects, what can you do?

Answer 121

Increase the dose to 30mg ON Mirtazapine is paradoxically, generally more sedating at lower BNF doses

Question 122

2 side effects of mirtazapine that can actually be useful?

Answer 122

Sedation Increased appetite

Question 123

List some common causes of CKD

Answer 123

- Diabetic nephropathy - Chronic glomerulonephritis - Chronic pyelonephritis - HTN - Adult PCKD

Question 124

In rotator cuff injuries with the painful arc of abduction at what angles is it painful in subacromial impingement and in which angles is it painful for rotator cuff tears? Also other features of rotator cuff injury - shoulder pain worse on .... and tenderness over what site?

Answer 124

Subacromial impingement - between 60 and 120 degrees Rotator cuff tears - pain in first 60 degrees Shoulder pain worse on abduction Tenderness over anterior acromion

Question 125

List different causes of rotator cuff injurt (different types)

Answer 125

- Subacromial impingement - Calcific tendonitis - Rotator cuff tears - Rotator cuff arthropathy

Question 126

List some conditions associated with vitiligo

Answer 126

- T1DM - Addison's disease - Autoimmune thyroid disorders - Pernicious anaemia - Alopecia areata

Question 127

What is the Koebner phenomenon in relation to vitiligo?

Answer 127

Trauma may precipitate new lesions

Question 128

Outline the management of Vitiligo

Answer 128

- Sunblock for affected areas - Camouflage make-up - Topical corticosteroids may reverse the changes if applied early - Topical tacrolimus and phototherapy but careful with light-skinned patients

Question 129

Jaundice within which time period after birth is always pathological?

Answer 129

Jaundice in the first 24 hours is always pathological and requires immediate paediatric assessment

Question 130

List some causes of jaundice in the first 24 hours

Answer 130

- Rhesus haemolytic disease - ABO haemolytic disease - Hereditary spherocytosis - G6PD

Question 131

After what period in the post-natal period is jaundice considered prolonged?

Answer 131

After 14 days

Question 132

Causes of neonatal jaundice from 2-14 days?

Answer 132

- More red cells - More fragile red cells - Less developed liver function - Commonly in breastfed babies

Question 133

What are the different investigations done in a prolonged jaundice screen in neonates (after 14 days)?

Answer 133

- Conjugated and unconjugated bilirubin - note a raised conjugated bili could indicate biliary atresia which requires urgent surgical intervention - Direct antiglobulin test (Coomb's test) - TFTs - FBC and blood film - Urine for MC&S and reducing sugars - U&Es and LFTs

Question 134

List some causes of prolonged jaundice in the neonate (after 14 days)

Answer 134

- Biliary atresia - Hypothyroidism - Galactosaemia - UTI - Breast milk jaundice - Prematurity - Congenital infections e.g. CMV, toxoplasmosis

Question 135

When to start bone protection (bisphosphonate + calcium + vit D) in patients starting on long-term steroids?

Answer 135

Immediately, no need for DEXA or FRAX first IF > 65 years or previously had fragility fracture OR IF < 65 years - offer bone density scan with further management dependent on T-score > 0 - reassure T-score between 0 - -1.5 - repeat bone density scan in 1-3 years T-score < -1.5 - offer bone protection

Question 136

List 3 most common cyanotic heart disease?

Answer 136

- Tetralogy of fallot - Transposition of the great arteries - Tricuspid atresia

Question 137

What is more common, transposition of the great arteries, or tetralogy of fallot?

Answer 137

Fallot's is more common, however at birth TGA is more apparently common a patients generally present at around 1-2 months

Question 138

List some of the most common causes of acynanotic congenital heart diseases?

Answer 138

- VSD - most common - ~30% - ASD - PDA - Coarctation of the aorta - Aortic valve stenosis

Question 139

Vitamin B6 overdose can lead to what?

Answer 139

Peripheral neuropathy

Question 140

Where to insert nexplanon implant?

Answer 140

Subdermal, non-dominant arm

Question 141

What is the first line treatment for Paget's disease?

Answer 141

Bisphosphonates

Question 142

Features of Paget's disease?

Answer 142

- Typically older males - Bone pain - Isolated raised ALP - Bone pain (e.g. pelvis, lumbar spine, femur) - Untreated features: bowing of tibia, bossing of skull

Question 143

What happens with the serum calcium and phosphate in Paget's disease?

Answer 143

Calcium and phosphate are typically normal

Question 144

X-ray features in Paget's disease?

Answer 144

- Osteolysis in early diseaes - mixed lytic / sclerotic lesions later - Skull x-ray: thickened vault, osteoporosis circumscripta

Question 145

Osteolysis in early diseaes - mixed lytic / sclerotic lesions later Skull x-ray: thickened vault, osteoporosis circumscripta Likely diagnosis?

Answer 145

Paget's

Question 146

What is seen in bone scintigraphy in Paget's disease of the bone?

Answer 146

Increased uptake is seen focally at the sites of active bone lesions

Question 147

What investigations done in Paget's?

Answer 147

Bloods - raised ALP isolated, normal calcium and phosphate usually X-rays - and skull x-rays Bone scintigraphy

Question 148

What is the management for Paget's disease of the bone?

Answer 148

Bisphosphonate (either oral risedronate or IV zoledronate)

Question 149

List some complications of Paget's disease of the bone

Answer 149

- Deafness (cranial nerve entrapment) - Bone sarcoma (1% if affected for > 10 years) - Fractures - Skull thickening - High-output cardiac failure

Question 150

Features in malignant hyperthermia?

Answer 150

Raised end-tidal CO2 Raised temp - may appear diaphoretic, skin mottling

Question 151

Which anaesthetic agents can cause malignant hyperthermia?

Answer 151

Volatile liquid anaesthetics - isoflurane, desflurane, sevoflurane

Question 152

What is another adverse effect related to volatile liquid anaesthetics aside from risk of malignant hyperthermia?

Answer 152

Myocardial depression

Question 153

What is a contra-indication for the use of nitrous oxide as an anaesthetic agent?

Answer 153

Pneumothorax Since it may diffuse into gas-filled body compartments - increase in pressure

Question 154

Key adverse effects related to propofol?

Answer 154

- Hypotension - Pain on injection (due to activation of the pain receptor TRPA1)

Question 155

Aside from its main use for induction / in already ventilated patients in intensive care, what is another beneficial property of propofol?

Answer 155

Has some anti-emetic effects - useful for patients with a high risk of post-operative vomiting

Question 156

What is a key adverse effect of thiopental?

Answer 156

Laryngospasm

Question 157

Adverse effects related to etomidate?

Answer 157

- Primary adrenal suppression (secondary to reversibly inhibiting 11B- hydroxylase) - Myoclonus

Question 158

Key adverse effects with ketamine?

Answer 158

- Disorientation - Hallucinations

Question 159

Why is ketamine useful as a rapid sequence induction agent in trauma situations?

Answer 159

Because it doesn't cause a drop in BP

Question 160

Clinical features in paraproteinaemias?

Answer 160

- Hyperviscosity syndrome - Neuropathy (e.g. sensory, motor or autonomic dysfunction) - Renal dysfunction - Haematological abnormalities (e.g. anaemia, thrombocytopaenia, or leukopaenia) - Bone pain or pathologic fractures (in the context of multiple myeloma)

Question 161

List the causes of benign and malignant paraproteinaemias

Answer 161

BENIGN: - MGUS - Transient paraproteinaemia (e.g. following an infection) MALIGNANT: - Multiple myeloma - Waldenstrom's macroglobulinaemia - Primary amyloidosis (AL) - B-cell lymphoproliferative disorders (e.g. CLL, NHL)

Question 162

What are myxoid cysts?

Answer 162

Benign ganglion cysts usually found on the distal, dorsal aspect of the finger There is usally osteoarthritis in the surrounding joint. More common in middle-aged women

Question 163

50 year old woman presents with swelling just proximal to the nail bed on the left great toe. She has a history of osteoarthritis but is usually well. What is the diagnosis?

Answer 163

Myxoid cyst

Question 164

MS more common in men or women?

Answer 164

3x more common in women

Question 165

What is the most common form of MS?

Answer 165

Relapsing-remitting

Question 166

What is the pattern of disease in relapsing-remitting, primary progressive and secondary progressive forms of MS?

Answer 166

Relapsing-remitting: acute attacks (e.g. lasts 1-2 months) followed by periods of remission Primary progressive: progressive deterioration from onset. More common in older people Secondary progressive: relapsing-remitting patients who have deteriorated and have developed neurological signs and symptoms between relapses. Gait and bladder disorders are generally seen

Question 167

In a patient on metformin, what HbA1C target should you aim for, and at what piont do you add a second drug?

Answer 167

- Aim target HbA1C of 48 mmol/mol (6.5%) - Add second drug if HbA1C rises to 58mmol/mol (7.5%)

Question 168

How often to check HbA1C targets in the type 2 diabetic?

Answer 168

HbA1C should be checked every 3-6 months until stable, then 6 monthly

Question 169

What HbA1C target to set for patient on any drug which may cause hyperglycaemia (e.g. sulfonylurea) + lifestyle modification for management of T2DM?

Answer 169

53 mmol/mol (7.0%)

Question 170

What are the thyroxine and TSH levels in sick euthyroid? Low or normal or high?

Answer 170

Often everything is low - TSH, thyroxine and T3 However mostly TSH is within normal range (inappropriately given the low thyroxine and T3)

Question 171

How to manage sick euthyroid syndrome?

Answer 171

Changes are reversible upon recovery from the systemic illness and hence no treatment is usually needed - ask the GP to repeat TFTs in 6 weeks

Question 172

Give 3 causes of optic neuritis

Answer 172

- Multiple sclerosis - most common - Diabetes - Syphilis

Question 173

Features of optic neuritis

Answer 173

- Unilateral decrease in visual acuity over hours or days - Poor discrimination of colours, 'red desaturation' - Pain worse on eye movement - Relative afferent pupillary defect - Central scotoma

Question 174

What is the key investigation in optic neuritis?

Answer 174

MRI of the brain and orbits with gadolinium contrast

Question 175

What is the management for optic neuritis?

Answer 175

- High-dose steroids - Recovery usually takes 4-6 weeks

Question 176

What is the 5 year risk of developing multiple sclerosis in optic neuritis?

Answer 176

MRI - if > 3 white matter lesions, 5 year risk of developing MS is ~50%

Question 177

What is the guidance for the units of alcohol to drink per week?

Answer 177

No more than 14 units of alcohol per week. If you do drink as much as 14 units per week, spread this evenly over 3 days or more

Question 178

Management of blepharitis?

Answer 178

- Softening of the lid margin using hot compresses twice a day - Lid hygiene - mechanical removal of debris from lid margins - Artificial tears for symptom relief in people with dry eyes or an abnormal tear film

Question 179

What may occur secondary to blepharitis?

Answer 179

Secondary conjunctivitis

Question 180

Blepharitis may be either due to .... or .... / .... Blepharitis is also more common in patients with .....

Answer 180

Blepharitis may be either due to meibomian gland dysfunction (common, posterior blepharitis) or seborrheic dermatitis / staphylococcal infection (less common, anterior blepharitis)

Question 181

Anterior uveitis is associated with which HLA?

Answer 181

HLA-B27

Question 182

Give some conditions associated with anterior uveitis

Answer 182

- Ankylosing spondylitis - Reactive arthritis - UC, Crohn's - Behcet's - Sarcoidosis - bilateral disease may be seen

Question 183

Outline the management of anterior uveitis

Answer 183

- Urgent review by ophthalmology - Cycloplegics e.g. atropine, cyclopentolate (dilates the pupil which helps relieve pain and photophobia) - Steroid eye drops

Question 184

Features of anterior uveitis?

Answer 184

- Acute onset - Ocular discomfort and pain - Pupil may be small +/- irregular due to sphinchter muscle contraction - Photophobia (often intense) - Blurred vision - Red eye - Lacrimation - Ciliary flush - a ring of red spreading outwards - Hypopon - pus and inflammatory cells in the anterior chamber, often resulting in a visible fluid level - Visual acuity initially normal - impaired

Question 185

List some neurological sequelae of meningitis

Answer 185

- Sensorineural hearing loss (most common) - Seizures - Focal neurological deficit - Infective - sepsis, intracerebral abscess - Pressure - brain herniation, hydrocephalus

Question 186

Aside from neurological sequelae, name an endocrine complication of meningitis?

Answer 186

Waterhouse-Friderichsen syndrome (adrenal insufficiency secondary to adrenal haemorrhage)

Question 187

How long does acute pericarditis usually last?

Answer 187

4-6 weeks

Question 188

List some causes of acute pericarditis?

Answer 188

- Viral infections (Coxsackie) - TB - Uraemia - Post-MI - RT - Connective tissue disease - SLE, RhA - Hypothyroidism - Malignancy - lung cancer, breast cancer - Trauma

Question 189

What is the nature of the chest pain in acute pericarditis, and relieved on what position?

Answer 189

Pleuritic Often relieved on sitting forwards

Question 190

Clinical features of acute pericarditis?

Answer 190

- Chest pain - pleuritic, often relieved on sitting forwards - Pericardial rub - Non-productive cough, dyspnoea, flu-like symptoms

Question 191

What is the most specific ECG marker for pericarditis?

Answer 191

PR depression

Question 192

ECG features in acute pericarditis?

Answer 192

- Global / widespread ST elevation (not limited to territories) - 'Saddle shaped' ST elevation - PR depression

Question 193

What investigations in acute pericarditis?

Answer 193

ECG Bloods and trops TTE

Question 194

High risk features that warrant inpatient rather than outpatient management of acute pericarditis?

Answer 194

- Fever > 38C - Elevated troponin

Question 195

Management of acute pericarditis?

Answer 195

Depends on the cause e.g. if viral - often nothing Often managed as outpatient Avoid strenuous physical activity until symptom resolution and normalisation of inflammatory markers NSAIDs + colchicine for acute idiopathic or viral pericarditis - until symptom resolution and normalisation of inflammatory markers (usually 1-2 weeks) followed by tapering of dose

Question 196

What is the recommended antibiotic and duration of therapy for lower UTI in non-pregnant women?

Answer 196

Trimethoprim or nitrofurantoin for 3 days

Question 197

When to send a urine culture in lower UTIs?

Answer 197

- > 65 years - Visible or non-visible haematuria

Question 198

True or false - you need to treat asymptomatic bacteriuria in pregnant women?

Answer 198

True - due to significant risk of progression to acute pyelonephritis

Question 199

How to manage symptomatic UTI in pregnant women?

Answer 199

- Urine culture always send - Abx - nitro (should be avoided near term) second line is amox of cefalexin - Note trimethoprim is teratogenic in the first trimester and should be avoided during pregnancy

Question 200

How to manage asymptomatic bacteruria in pregnant women?

Answer 200

- Urine culture should be performed routinely at the first antenatal visit - Immediate antibiotic prescription (nitro - but avoid near term), amox or cefalexin - 7 day course - Do another culture following completion of treatment as a test of cure

Question 201

How to treat lower UTI in men?

Answer 201

Trimethoprim or nitrofurantoin for 7 days

Question 202

How to treat UTI in catheterised patients?

Answer 202

- Do NOT treat asymptomatic bacteruria in catheterised patients - If the patient is symptomatic they should be treated with 7 day antibiotic course - Remover or change the catheter ASAP if has been in place > 7 days

Question 203

How to treat acute pyelonephritis?

Answer 203

IV fluids, abx - usually broad spectrum cephalosporin or a quinolone (for non-pregnant women) for 10-14 days

Question 204

List some key indications for NIV

Answer 204

- COPD with resp acidosis 7.25-7.35 - T2RF secondary to chest wall deformity, neuromuscular disease or OSA - Cardiogenic pulmonary oedema unresponsive to CPAP - Weaning from tracheal intubation

Question 205

Recommended initial settings for BIPAP in COPD: 1) EPAP 2) IPAP 3) Back up rate 4) Back up I:E ratio

Answer 205

1) 4-5cm H2O 2) IPAP 10cm H2O or 12-15cm H2O 3) Back up rate: 15 breaths per minute 4) Back up I:E ratio : 1:3

Question 206

How soon before urea breath test should antibacterials or antisecretory drug e.g. PPI?

Answer 206

Should not do urea breath test within 4 weeks of treatment with antibacterial or within 2 weeks of an antisecretory drug e.g. PPI

Question 207

Which investigation can be used to test for H pylori eradication?

Answer 207

Urea breath test

Question 208

List some investigations done in suspected H.Pylori infection?

Answer 208

Urea breath test Rapid urease test e.g. CLO test Serum antibody Culture of gastric biopsy Gastric biopsy Stool antigen test

Question 209

What can be seen on the blood film in multiple myeloma?

Answer 209

Rouleaux formation

Question 210

After how long after a stroke can we consider safe initiation of anticoagulation therapy (e.g. apixaban)

Answer 210

2 weeks

Question 211

What to replace ACEis with in people with ACEi related cough?

Answer 211

ARBs

Question 212

List some exacerbating factors for psoriasis

Answer 212

- Trauma - Alcohol - Drugs e.g. beta-blockers, lithium, anti-malarials (chloroquine and hydroxychloroquine), NSAIDs and ACEis, infliximab - Withdrawal of systemic steroids

Question 213

Aside from antibiotics such as clindamycin or third generation cephalosporins, what other drug is a risk factor for c.diff?

Answer 213

PPIs

Question 214

What is the transmission route for c.diff?

Answer 214

Faeco-oral via ingestion of spores

Question 215

Severe c.diff can lead to?

Answer 215

Toxic megacolon

Question 216

How to classify mild, moderate, severe and life threatenning c.diff?

Answer 216

Mild - normal WCC Moderate - Raised WCC ( < 15 x 10^9/L), typically 3-5 loose stools per day Severe - Raised WCC or an acutely raised creatinine (>50% above baseline), temp > 38.5, evidence of colitis (abdo or radiological signs) Life threatening - hypotension, partial or complete ileus, toxic megacolon, CT evidence of severe disease

Question 217

True or false - c.diff antigen positivity means there is active infection?

Answer 217

False - only shows exposure to the bacteria, rather than current infection

Question 218

What is first, second and third line treatment for c.diff?

Answer 218

1. First line - oral vancomycin 10 days 2. Second line - oral fidaxomicin 3. Third-line - oral vancomycin +/- IV metronidazole Consider specialist advice for consideration of surgery in life-threatening cases

Question 219

How to manage recurrent episode of c.diff?

Answer 219

If within 12 weeks of symptom resolution - oral fidaxomicin If after 12 weeks of symptom resolution - oral vancomycin or fidaxomycin Faetal microbiota transplant

Question 220

What are the isolation precautions for c.diff?

Answer 220

Isolation in side room - until there has been no diarrhoea (types 5-7 on the bristol stool chart) for at least 48 hours Gloves and apron, handwashing

Question 221

List some sickle-cell crises

Answer 221

- Thrombotic, 'vaso-occlusive', 'painful crises' - Acute chest syndrome - Anaemic - aplastic, sequestration - Infection

Question 222

What can precipitate thrombotic crises in sickle cell?

Answer 222

Infection, dehydration, deoxygenation (high altitude)

Question 223

Where can infarcts occur in thrombotic crises in sickle cell?

Answer 223

Various areas Bones e.g. avascular necrosis of the hip Hand-foot syndrome in children Lungs, spleen, brain

Question 224

Features of acute chest syndrome in sickle cell disease?

Answer 224

Dyspnoea, chest pain, pulmonary infiltrates on CXR, low pO2

Question 225

What is the classic feature of acute chest syndrome on CXR in sickle cell disease?

Answer 225

Infiltrates

Question 226

What is the most common cause of death after childhood in sickle cell disease?

Answer 226

Acute chest syndrome

Question 227

Outline management for acute chest syndrome

Answer 227

- Pain relief - Respiratory support e.g. oxygen therapy - Antibiotics - infection may precipitate acute chest syndrome, and findings often hard to differentiate from it

Question 228

Aplastic crisis is precipitate by what in sickle cell disease?

Answer 228

Infection with parvovirus

Question 229

Feature in aplastic crises in sickle cell disease

Answer 229

- Sudden fall in haemoglobin - Bone marrow suppression - reduced reticulocyte count

Question 230

Features of sequestration crisis in sickle cell disease?

Answer 230

- Worsening of anaemia - Increased reticulocyte count

Question 231

What is a key difference between aplastic crises and sequestration crises?

Answer 231

Reduced reticulocyte count in aplastic crises vs increased reticulocyte count in sequestration crises

Question 232

How does the TIBC differ in iron deficinecy anaemia versus anaemia of chronic disease?

Answer 232

Raised in IDA vs not in anaemia of chronic disease

Question 233

What is a useful measure to differentiate between IDA and anaemia of chronic disease in iron studies?

Answer 233

TIBC - will be raised in IDA, not in anaemia of chronic disease

Question 234

What can raise the TIBC?

Answer 234

- IDA - Pregnancy - Oestrogen

Question 235

How to calculate the transferrin saturation?

Answer 235

Serum iron / TIBC

Question 236

When will ferritin be raised?

Answer 236

Inflammation

Question 237

When will ferritin be low?

Answer 237

IDA

Question 238

What will happen to the ferritin and TIBC in anaemia of chronic disease?

Answer 238

Ferritin will be normal or raised TIBC will be reduced

Question 239

How to calculate the anion gap, and what is a normal range for the anion gap, in mmol/L?

Answer 239

Anion gap = (Na + K) - (HCO3- + Cl-) 8-14 mmol/L

Question 240

List causes of a raised anion gap metabolic acidosis

Answer 240

- Lactate - shock, hypoxia - Ketones - diabetic ketoacidosis, alcohol - Urate - renal failure - Acid poisoning - salicylates, methanol - 5-oxoproline: chronic paracetamol use

Question 241

List causes of a normal anion gap or hyperchloraemic metabolic acidosis

Answer 241

- GI bicarb loss: diarrhoea, uterosigmoidostomy, fistula - RTA - Drugs e.g. acetazolamide - Ammonium chloride injection - Addison's disease

Question 242

Classical triad in renal cell carcinoma?

Answer 242

- Haematuria - Loin pain - Abdominal pain

Question 243

Features of renal cell carcinoma?

Answer 243

- Classical triad - haematuria, loin pain, abdominal mass - Pyrexia of unknown origin - Left varicocele (due to occlusion of left testicular vein) - Endocrine effects: secrete EPO (polycythaemia), parathyroid hormone (hypercalcaemia), renin, ACTH - 25% have metastases at presentation

Question 244

Which type of urological cancer can cause varicoceles?

Answer 244

Renal cell carcinoma - due to occlusion of left testicular vein

Question 245

Endocrine effects that can occur in renal cell carcinoma?

Answer 245

- EPO secretion - polycythaemia - Parathyroid hormone - hypercalcaemia - Renin - ACTH

Question 246

Features of chlamydia in women? In men?

Answer 246

Asymptomatic in 70% of women, 50% of men 1) Women - cervicitis (discharge, bleeding), dysuria 2) Men - urethral discharge, dysuria

Question 247

Give some transient or spurious causes of non-visible haematuria?

Answer 247

- UTI - Menstruation - Vigorous exercise - Sexual intercourse

Question 248

List some causes of persistent non-visible haematuria?

Answer 248

- Cancer (bladder, renal, prostate) - Stones - BPH - Prostatitis - Urethritis e.g. chlamydia - Renal causes e.g. IgA nephropathy, thin basement membrane disease

Question 249

Give some spurious causes of visible haematuria but negative on dipstick - i.e. urine appears red / orange but no evidence of blood on dipstick

Answer 249

- Foods - beetroot, rhubarb - Drugs - rifampicin, doxorubicin

Question 250

What are the guidelines for 2 week wait referral for haematuria?

Answer 250

Aged > = 45 years AND - Unexplained visible haematuria without UTI or - Visible haematuria that persists or recurs after successful treatment of UTI - Age > = 60 years AND have unexplained nonvisible haematuria and either dysuria or a raised WCC on a blood test

Question 251

What are the criteria for non-urgent referral for haematuria?

Answer 251

Aged > = 60 with reucrrent or persistent unexplained UTI Note patients under 40 with normal renal function, no proteinuria and who are normotensive, do not need to be referred and may be managed in primary care

Question 252

BNP is produced by what part of the heart in response to strain?

Answer 252

Left ventricular myocardium

Question 253

Give one thing that can cause a falsely raised BNP (not heart pathology)?

Answer 253

Reduced excretion in CKD

Question 254

True or false, BNP can be used as a marker of prognosis in patients with chronic heart failure, and as a treatment marker (i.e. effective treatment lowers BNP)?

Answer 254

True

Question 255

True or false, ACEi's and beta-blockers reduce mortality in heart failure with preserved ejection fraction?

Answer 255

False

Question 256

What is the first line treatment for chronic heart failure?

Answer 256

ACEi and beta- blocker But not at the same time - one then the other Beta blockers licenced include: bisoprolol, carvedilol, nebivolol

Question 257

What is second line therapy in chronic heart failure?

Answer 257

Aldosterone antagonists SGLT-2 inhibitors

Question 258

What is third line therapy for chronic heart failure?

Answer 258

- Ivabradine - if sinus rhythm < 75bpm, LVEF < 35% - Salcubitril-valsartan - LVEF < 35%, HFrEF who are symptomatic on ACEi's or ARBs. Should be initiated following ACEi or ARB wash-out period - Digoxin - inotropic, strongly indicated if there is AF - Hydralazine + nitrate - especially in Afro-Caribbean patients - Cardiac resynchronisation therapy - widened QRS e.g. LBBB on ECG

Question 259

What vaccines do people with chronic heart failure need?

Answer 259

- Offer annual influenza vaccine - One off pneumococcal vaccine Adults usually require just one dose but those with asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years

Question 260

What is the most common type of oesophageal cancer, and is more likely to develop in those with a history of GORD or Barret's?

Answer 260

Adenocarcinoma

Question 261

What is the most common type of oesophageal cancer in the developing world?

Answer 261

Squamous cell cancer

Question 262

Where are adenocarcinomas located along the oesophagus?

Answer 262

Lower third - near the gastroesophageal junction

Question 263

Where are squamous cell carcinomas located along the oesophagus?

Answer 263

Upper two thirds of the oesophagus

Question 264

List some risk factors for adenocarcinoma of oesophagus

Answer 264

- GORD - Barret's oesophagus - Smoking - Obesity

Question 265

List some risk factors for squamous cell cancer of oesophagus

Answer 265

- Smoking - Alcohol - Achalasia - Plummer-Vinson syndrome - Nitrosamine rich diet

Question 266

In suspected oesophageal cancer, which investigations are used for the following? 1) Diagnosis? 2) Locoregional staging? 3) Initial staging? 4) To detect occult metastases if not seen on initial staging scans? 5) To detect occult peritoneal disease?

Answer 266

1) Diagnosis = OGD 2) Locoregional staging = Endoscopic u/s 3) Initial staging = CT CAP 4) To detect occult metastases if not seen on initial staging scans = FDG-PET-CT 5) To detect occult peritoneal disease = Laparoscopy

Question 267

What is the treatment for oesophageal cancer?

Answer 267

Operable disease (T1N0M0) - surgical resectin - most commonly Ivor-Lewis type oesophagectomy - N.B risk of anastamotic leak - with intrathoracic anastamosis resulting in mediastinitis Adjuvant chemo

Question 268

What is the inheritance pattern of sickle cell disease?

Answer 268

Autosomal recessive

Question 269

At what age do sickle cell homozygotes tend to develop symptoms, and why?

Answer 269

4-6 months - because abnormal HbSS molecules take over from fetal haemoglobin

Question 270

What is the definitive investigation for sickle cell disease?

Answer 270

Haemoglobin electrophoresis

Question 271

Verapamil or CCBs are contraindicated in which type of arrythmia?

Answer 271

Ventricular tachycardia

Question 272

What is the appropriate medical management for ventricular tachycardia? Non medical?

Answer 272

- Amiodarone - ideally through a central line - Lidocaine - use with caution in severe LV impairment - Procainamide Note if drug therapy fails - Electrophysiological study (EPS) - Implantable cardioverter-defibrillator - especilly in patients with significantly impaired LV function NOTE: If SBP < 90mmHg, chest pain, heart failure, syncope - IMMEDIATE CARDIOVERSION

Question 273

A 65-year-old man is discharged from hospital following a thrombolysed ST-elevation myocardial infarction. Other than a history of depression he has no past medical history of note. Examination of his cardiorespiratory system today was normal. His stay on the coronary care unit was complicated by the development of dyspnoea and an echo show a reduced left ventricular ejection fraction. Other than standard treatment with an ACE inhibitor, beta-blocker, aspirin, clopidogrel and statin, what other type of drug should he be taking?

Answer 273

Aldosterone antagonist as the patient has reduced LVEF. Note: a loop diuretic is not indicated unless there is evidence of fluid overload

Question 274

Describe how to manage the oxygen therapy for a patient with COPD?

Answer 274

- Acutely ill patients - high flow oxygen at 15/L min - At risk of hyercapnia (retainers) who are stable - 88-92% target - Unwell with COPD prior to availability of blood gases, use a 28% venturi mask at 4 L / min and aim for O2 sats of 88-92% for patients with risk factors for hypercapnia byt no prior history of respiratory acidosis - Adjust the target range to 94-98% if the PCO2 is normal

Question 275

What is torsades de pointes?

Answer 275

Torsades de pointes is a form of polymorphic ventricular tachycardia associated with a long QT interval

Question 276

How can Torsades de pointes lead to death?

Answer 276

Torsades de pointes is a polymorphic ventricular tachycardia associated with a long QT interval. It may deteriorate into VF and hence lead to sudden death

Question 277

What is the definitive treatment for Torsades de pointes?

Answer 277

IV Magnesium Sulphate

Question 278

List causes of Torsades de pointes

Answer 278

- Congenital - Jervell-Lange-Nielsen Syndrome, Romano-Ward syndrome - Antiarrythmics: amiodarone, sotalol, class 1a antiarrythmic drugs - Tricyclic antidepressants - Antipsychotics - Chloroquine - Terfenadine - Erythromycin - Electrolyte - hypocalcaemia, hypokalaemia, hypomagnesaemia - Myocarditis - Hypothermia - Subarachnoid haemorrhage

Question 279

Outline the medical management in Alzheimer's

Answer 279

- Acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) - for mild-moderate disease - NMDA receptor antagonist (memantine) - either for severe disease, as add-on therapy or if acetylcholinesterase inhibitors are contra-indicated - Antipsychotics only if patients at risk of harming themselves or others, or when the agitation, hallucinations or delusions are causing them severe distress

Question 280

When is Donepezil contra-indicated?

Answer 280

In patients with bradycardia

Question 281

Common adverse effect with Donepezil?

Answer 281

Insomnia

Question 282

What is the most common cause of nephrotic syndrome in children?

Answer 282

Minimal change disease (75% in children, 25% in adults)

Question 283

Give some causes of minimal change syndrome?

Answer 283

Mostly idiopathic, but in 10-20% a cause can be found e.g. : - Drugs e.g. NSAIDs, Rifampicin - Hodgkin's lymphoma, Thymoma - Infectious mononucleosis

Question 284

Outline the features of minimal change syndrome

Answer 284

- Nephrotic syndrome - Normotension - hypertension is rare - Highly selective proteinuria - intermediate sized proteins such as albumin and transferrin leak through the glomerulus - Renal biopsy features - normal glomeruli on light microscopy, EM - fusion of podocytes and effacement of foot processes

Question 285

What is the prognosis in miimal change syndrome? - tip remember the rule of thirds

Answer 285

1/3 have just one episode 1/3 have infrequent relapses 1/3 have frequent relapses which stop just before adulthood

Question 286

Outline the management for minimal change disease

Answer 286

- Oral corticosteroids - 80% are steroid-responsive - Cyclophosphamide for non-steroid responsive cases

Question 287

What test is best used to assess for acute liver failure?

Answer 287

Prothrombin time LFTs do not always accurately reflect the synthetic function of the liver. This is best assessed by looking at the PT and the albumin level PT has a shorter half-life than albumin, making it a better measure of acute liver failure than albumin

Question 288

List some causes of acute liver failure

Answer 288

- Paracetamol overdose - Alcohol - Viral hepatitis (usually A or B) - Acute fatty liver of pregnancy

Question 289

What are the features of acute liver failure?

Answer 289

- Jaundice - Coagulopathy - raised PT - Hypoalbuminaemia - Hepatic encephalopathy - Renal failure - 'hepatorenal syndrome'

Question 290

Which blood group is associated with higher risk of gastric cancer, and which associated with a higher risk of duodenal cancer?

Answer 290

Blood group A - higher risk of gastric cancer Blood group O - higher risk of duodenal cancer

Question 291

Features of hypocalcaemia?

Answer 291

- Tetany - muscle twitching, cramping and spasm - Perioral paraesthesia - If chronic - depression, cataracts - ECG: prolonged QT interval - Trousseau's sign - Chvostek's sign

Question 292

Which anti-hypertensive useful in diabetics?

Answer 292

ACEi's e.g. Ramipril

Question 293

List drugs which cause a hepatocellular drug induced liver injury picture

Answer 293

- Paracetamol - Sodium valproate, phenytoin - MAOIs - Halothane - Anti-TB - Rifampicin, Isoniazid, Pyrazinamide - Statins - Alcohol - Amiodarone - Methyldopa - Nitrofurantoin

Question 294

List drugs that tend to cause cholestasis (+/- hepatitis)

Answer 294

- COCP - Antibiotics - flucloxacillin, co-amox, erythromycin - Anabolic steroids, testosterones - Phenothiazines: chlorpromazine, prochlorperazine - Sulphonylureas - Fibrates - Rare - nifedipine

Question 295

Give 3 medications that can cause liver cirrhosis

Answer 295

- Methotrexate - Methyldopa - Amiodarone

Question 296

What is the initial phase and continuation phase of TB therapy - which medications and what duration of therapy? What about for latent TB What about for meningeal TB What is directly observed therapy and in whom is it useful?

Answer 296

INITIAL PHASE - for first 2 months: - Rifampicin - Isoniazid - Pyrazinamide - Ethambutol CONTINUATION PHASE - for the next 4 months: - Rifampicin - Isoniazid LATENT TB - 3 months of Isoniazid + Pyridoxine (not pyrazinamide) + Rifampicin OR 6 months of Isoniazid + Pyridoxine (not pyrazinamide) MENINGEAL TB - prolonged period (at least 12 months) with addition of steroids DIRECTLY OBSERVED THERAPY - 3x a week dosing regimen in: - Homeless people with active TB - Patients likely to have poor concordance - All prisoners with active or latent TB

Question 297

What is immune reconstitution disease in TB?

Answer 297

A complication that occurs typically 3-6 weeks after starting treatment for TB that often presents with enlarging lymph nodes

Question 298

Adverse effects associated with rifampicin?

Answer 298

- Potent liver enzyme inducer - Hepatitis - Orange secretions - Flu-like symptoms

Question 299

What is given alongside isoniazid to help prevent peripheral neuropathy?

Answer 299

Pyridoxine (Vitamin B6)

Question 300

Adverse effects associated with isoniazid?

Answer 300

- Peripheral neuropathy - prevented with pyridoxine (vitamin B6) - Hepatitis - Agranulocytosis - Liver enzyme inhibitor

Question 301

Adverse effects associated with pyrazinamide?

Answer 301

- Hyperuricaemia causing gout - Arthralgia - Myalgia - Hepatitis

Question 302

Key adverse effect associated with ethambutol?

Answer 302

- Optic neuritis - therefore check visual acuity before and during treatment

Question 303

In animal bites - often dogs and cats, what is the most common isolated organism?

Answer 303

Pasteurella multocida

Question 304

How to manage animal bites? Which antibiotic is best, and then what if allergic?

Answer 304

- Clean wound - Pucnture wounds should not be sutured closed unless cosmesis is at risk - Abx: Co-amoxiclav - If penicillin allergic: doxycycline + metronidazole

Question 305

What is the treatment for human bites?

Answer 305

Co-amoxiclav, as for animal bites The risk for viral infections e.g. HIV and Hep C should also be considered

Question 306

In whom should adenosine be avoided?

Answer 306

Asthmatics due to bronchospasm

Question 307

Adverse effects with adenosine?

Answer 307

- Chest pain - Bronchospasm - Transient flushing - Can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)

Question 308

How to administer adenosine - large or small cannula?

Answer 308

Large calibre cannula due to its short half-life

Question 309

Over 80% of pancreatic tumours are ..... which typically occur at the .... of the pancreas

Answer 309

Over 80% of pancreatic tumours are adenocarcinomas which typically occur at the head of the pancreas

Question 310

List some associations for pancreatic cancer

Answer 310

- Increasing age - Smoking - Diabetes - Chronic pancreatitis - HNPCC - MEN - BRCA2 gene - KRAS mutation

Question 311

What is Courvoisier's law?

Answer 311

In the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones

Question 312

What is the most common histological subtype in pancreatic cancer?

Answer 312

Adenocarcinomas

Question 313

Features of pancreatic cancer?

Answer 313

- Painless jaundice, may have palpable gallbladder (Courvoisier's sign) - Pale stools, dark urine, pruritis - Cholestatic LFTs - Abdominal masses - hepatomegaly (due to mets), gallbladder, epigastric mass (from the primary tumour) - Loss of exocrine function - e.g. steatorrhea - Loss of endocrine function - e.g. DM - Atypical back pain - Migratory thrombophlebitis (Trousseau's sign) more commonly than in other cancers - Anorexia, weight loss, epigastric pain

Question 313

What is the most common site on the pancreas where pancreatic (adeno-)carcinomas occur?

Answer 313

Head of the pancreas

Question 314

What is the key investigation in suspected pancreatic cancer?

Answer 314

HRCT Note: imaging may demonstrate the double duct sign - presence of simultaneous dilatation of the common bile and pancreatic ducts

Question 315

What is the surgical management for pancreatic cancer?

Answer 315

Whipple's resection (pancreaticoduodonectomy) - for resectable lesions at the head of the pancreas Adjuvant chemo is usually given following the surgery

Question 316

What are 2 key side effects in Whipple's disease?

Answer 316

- Dumping syndrome - PUD

Question 317

What is often done for palliative management in pancreatic cancer?

Answer 317

ERCP with stenting

Question 318

List some adverse effects associated with PPIs

Answer 318

- Hyponatraemia, hypomagnasaemia - Osteoporosis - increased risk of fractures - Microscopic colitis - Increased risk of c.diff infections

Question 319

What organism is predominant in Bacterial Vaginosis?

Answer 319

Gardnerella Vaginalis

Question 320

How does BV affect vaginal pH?

Answer 320

Increases it - because the Gardnerella Vaginalis leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH

Question 321

What are Ansel's criteria for BV?

Answer 321

3 of the 4 points should be present: - Thin, white, homogenous discharge - Clue cells on microscopy: stippled vaginal epithelial cells - Vaginal pH > 4.5 - Positive whiff test (addition of potassium hydroxide results in a fishy odour)

Question 322

What is the management of bacterial vaginosis?

Answer 322

- If incidental asymptomatic - no treatment (unless undergoing termination of pregnancy) - If symptomatic - oral metro for 5-7 days (note a single dose of metro 2g may be used if adherence may be an issue). Topical metro or clindamycin as alternatives - If pregnant asymptomatic - speak to the obstetrician - If pregnant symptomatic - oral metro - but not the higher stat dose of 2g

Question 323

Conditions associated with coeliac's disease?

Answer 323

Dermatitis herpetiformis Autoimmune disorders - T1DM and autoimmune hepatitis

Question 324

What is the key serology done in investigation of Coeliac disease?

Answer 324

- Tissue Transglutaminase TTG antibodies (IgA) is first choice - Enomyseal antibody (IgA)

Question 325

What is the gold standard investigation in Coeliac disease?

Answer 325

Endoscopic intestinal biopsy - often from the duodenum Features: - Villous atrophy - Crypt hyperplasia - Increase in intraepithelial lymphocytes - Lamina propria infiltration with lymphocytes

Question 326

What are the 4 phases in subacute (De Quervain's thyroiditis?

Answer 326

1. Phase 1 (lasts 3-6 weeks) - hyperthyroidism, painful goitre, raised ESR 2. Phase 2 (1-3 weeks) - euthyroid 3. Phase 3 (weeks-months) - hypothyroidism 4. Phase 4: thyroid structure and function goes back to normal

Question 327

What is the key investigation in suspected subacute (De Quervain's) thyroiditis and what will it show?

Answer 327

Thyroid scintigraphy - globally reduced uptake of iodine-131

Question 328

What is the management of subacute (De Quervain's) thyeroiditis?

Answer 328

- Usually self-limiting - most patients do not require treatment - Thyroid pain may respond to aspirin or other NSAIDs - In more severe cases, steroids are used, particularly if hypothyroidism develops

Question 329

What will thyroid scintigraphy show in subacute (De Quervain's) thyroiditis?

Answer 329

Globally reduced uptake of iodine-131

Question 330

What is the inheritance pattern in Huntington's disease, and what is the mechanism, and which chromosome is it on?

Answer 330

- Autosomal dominant - Trinucleotide repeat disorder - repeat expansion of CAG - phenomenon of anticipation occurs where the disease presents at an earlier age in successive generations - Due to defect in hintingtin gene on chromosome 4

Question 331

Features of Huntington's disease?

Answer 331

- Chorea - Personality changes (e.g. irritability, apathy, depression) and intellectual impairment - Dystonia - Saccadic eye movements

Question 332

What is the mechanism of action of statins?

Answer 332

Inhibit the action of HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis

Question 333

Give 3 absolute contraindications for statins, and one other relative contraindication?

Answer 333

Absolute: - Macrolides e.g. erythromycin, clarithromycin - important interaction - Pregnancy - Liver impairment with serum transaminase 3x the upper limit of the referance range Relative: - History of intracerebral haemorrhage - some evidence that it may increase risk of ICH in people with history of stroke

Question 334

Give 3 adverse effects linked to statins?

Answer 334

- Myopathy - including myalgia, myositis, rhabdomyolysis and asymptomatic raised CK - Liver impairment - May increase the risk of intracerebral haemorrhage in patients who've previously had stroke

Question 335

Risk factors for myopathy in statin use? Which type of statins more commonly cause myopathy and which less commmonly?

Answer 335

Risk factors: - Age - Females - Low BMI - Presence of multisystem disease e.g. diabetes More common in lipophilic statins (simvastatin, atorvastatin) than relatively hydrophilic statins (rosuvastatin, pravastatin, fluvastatin)

Question 336

True or false, everyone with type 2 diabetes mellitus must be on statins?

Answer 336

False - they should now be assessed using QRISK 2 like any other patients

Question 337

What are the indications for receiving a statin?

Answer 337

- All people with established cardiovascular disease (stroke, TIA, IHD, PAD) - Anyone with QRISK > 10% - Patients with type 1 diabetes who were either diagnosed > 10 years ago OR are aged > 40 OR have established nephropathy

Question 338

When should statins be taken and why?

Answer 338

At night, as this is when the majority of cholesterol synthesis occurs

Question 339

Outline primary and secondary prevention statin doses

Answer 339

Primary prevention - start at 20mg OD - then if non-HDL has not fallen by > / = 40% then consider titrating up to 80mg Secondary prevention - atorvastatin 80mg OD

Question 340

What are the electrolyte abnormalities in tumour lysis syndrome? What other major bloods abnormality will be found?

Answer 340

- High potassium - High phosphate - High urate - Low calcium AKI

Question 341

What is done for prevention of tumour lysis syndrome?

Answer 341

- IV fluids - Patients at higher risk should receive either allopurinol or rasburicase - Note both should not be co-administered due as this reduces the effect of rasburicase

Question 342

What is the grading system for tumour lysis syndrome?

Answer 342

Cairo-Bishop scoring system Abnormality in two or more of the following, occurring within three days before or seven days after chemotherapy: - Uric acid > 475umol/l or 25% increase - Potassium > 6 mmol/l or 25% increase - Phosphate > 1.125mmol/l or 25% increase - Calcium < 1.75mmol/l or 25% decrease

Question 343

How is clinical tumour lysis syndrome defined?

Answer 343

Laboratory tumour lysis syndrome plus one or more of the following: - Increased serum creatinine (1.5x upper limit of normal) - Cardiac arrythmia or sudden death - Seizure

Question 344

What can trigger tumour lysis syndrome?

Answer 344

Usually related to the treatment of high-grade lymphoma and leukaemias. - Usually triggered by the introduction of combination chemo - Can also occur with steroid treatment alone

Question 345

What are the causes of trigeminal neuralgia?

Answer 345

Idiopathic Compression of the trigeminal roots by: - Tumours - Vascular problems

Question 346

What are some red flags that could suggest a serious underlying cause in trigeminal neuralgia?

Answer 346

- Sensory changes - Deafness or other ear problems - History of skin or oral lesions that could spread perineurally - Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally - Optic neuritis - A family history of multiple sclerosis - Age of onset before 40 years

Question 347

What is the management of trigeminal neuralgia?

Answer 347

- Carbamazepine is first line - Failure to respond to treatment or atypical features (e.g. < 50yrs) - prompt referral to neurology

Question 348

The sciatic nerve divides into which two other nerves?

Answer 348

Tibial and common peroneal nerves

Question 349

Injuries at what site can cause common peroneal nerve lesions?

Answer 349

Injuries at the neck of the fibula

Question 350

The common peroneal nerve branches from which other nerve?

Answer 350

The sciatic nerve - the sciatic nerve divides into the tibial and common peroneal nerves

Question 351

What is the most characteristic feature in common peroneal nerve lesions? List some other features of common peroneal nerve lesions

Answer 351

Foot drop Other features: - Weakness of foot dorsiflexion - Weakness of foot eversion - Weakness of extensor hallucis longus - Sensory loss over the dorsum of the foot and the lower lateral part of the leg - Wasting of the anterior tibial and peroneal muscles

Question 352

Features of encephalitis?

Answer 352

- Fever, headaches, psychiatric symptoms, seizures, vomiting - Focal features e.g. aphasia - N.B peripheral lesions e.g. cold sores have no relation to the presence of HSV encephalitis

Question 353

What is the key cause of encephalitis in most cases in adults?

Answer 353

HSV-1 is responsible for 95% of cases in adults

Question 354

Where does encephalitis typically occur - which lobes?

Answer 354

Temporal and inferior frontal lobes

Question 355

Typical features in neuroimaging in encephalitis?

Answer 355

- Medial temporal and inferior frontal changes (e.g. petechial haemorrhages) - Normal in 1/3 of patients - MRI is better

Question 356

What is the preferred modality of imaging which is best to pick up changes in encephalitis?

Answer 356

MRI

Question 357

What is the classic EEG finding in encephalitis?

Answer 357

Lateralised periodic discharges at 2 Hz

Question 358

What is the management in encephalitis?

Answer 358

IV aciclovir - in ALL cases of suspected encephalitis

Question 359

What organisms typically cause cellulitis?

Answer 359

Strep pyogenes - most common Staph aureus - next most common

Question 360

What are some criteria for admission for IV antibiotics for cellulitis patients?

Answer 360

- Eron class III or IV - Severe or rapidly deteriorating cellulitis (e.g. extensive areas of skin) - Very young (< 1 yr) or frail - Immunocompromised - Significant lymphoedema - Facial cellulitis (unless very mild) or periorbital cellulitis

Question 361

What is the classification system used in cellulitis?

Answer 361

Eron classification system I - no signs of systemic toxicity and the person has no uncontrolled co-morbidities II - the person is either systemically unwell or systemically well but with a co-morbidity (for example peripheral arterial disease, chronic venous insufficiency, or morbid obesity) which may complicate or delay resolution of infection III - significant systemic upset e.g. acute confusion, tachycardia, tachypnoea, hypotension, or unstable co-morbidities that may interfere with a response to treatment IV - sepsis or severe life-threatening infection e.g. necrotizing fasciitis

Question 362

Outline the management of cellulitiis as based on the Eron classification system

Answer 362

Eron class I - Oral antibiotics - oral flucloxacillin is first line treatment for mild-moderate cellulitis - Oral clarithromycin, erythromycin in pregnancy or doxycycline is recommended in patients allergic to penicillin Eron class II - Admissino may not be necessary if have the facilities for giving IV antibiotics in the community Eron class III-IV - Admit - Oral / IV co-amoxiclav, oral / IV clindamycin, IV cefuroxime or IV ceftriaxone

Question 363

Patient on immunosuppresive medications post renal transplant - they are at risk in particular of developing which malignancy?

Answer 363

SCC of the skin

Question 364

When to add steroids in post-renal transplant regimen?

Answer 364

If more than one steroid responsive acute rejection episode

Question 365

What is the mechanism of action of ciclosporin?

Answer 365

Calcineurin inhibitor - a phosphotase involved in T-cell activation

Question 366

Some advantages and disadvantages of tacrolimus over ciclosporin?

Answer 366

Advantages: - Lower incidence of acute rejection - Less hypertension and hyperlipidaemia Disadvantages: - High incidence of impaired glucose tolerance and diabetes

Question 367

What is the mechanism of action of MMF?

Answer 367

Blocks purine synthesis by inhibition of IMPDH - therefore inhibits proliferation of B and T cells

Question 368

2 key side effects of MMF?

Answer 368

- GI side effects - Bone marrow suppression

Question 369

What is the mechanism of action of sirolimus (rapamycin) - a drug used post renal transplant?

Answer 369

Blocks T-cell proliferation by blocking the IL-2 receptor

Question 370

What is a key side effect with sirolimus (rapamycin) - a drug used post renal transplant?

Answer 370

Hyperlipidaemia

Question 371

What is the mechanism of action of monoclonal antibodies used post renal transplant? Give examples of these drugs?

Answer 371

Selective inhibitors of IL-2 receptor Daclizumab, basilximab

Question 372

Patients on long term immunosupression for organ transplantation require regular monitoring for complications such as what?

Answer 372

- Cardiovascular diseaes - tacrolimus and ciclosporin can cause HTN and hyperglycaemia. Tacrolimus can cause hyperlipidaemia - Renal failure - due to nephrotoxic effects of tacrolimus and ciclosporin / graft rejection / recurrence of original disease in transplanted kidney - Malignancy - patients should be counselled to avoid sun exposure to reduce the risk of SCC and BCC of skin

Question 373

What causes secondary hypothyroidism?

Answer 373

The only cause is pituituary failure - note this needs pituitary imaging to rule out an anatomical cause such as a tumour or vascular cause

Question 374

Secondary hypothyroidism - caused by pituitary failure, is also associated with which other conditions?

Answer 374

- Down's syndrome - Turner's syndrome - Coeliac disease

Question 375

List causes of primary hypothyroidism

Answer 375

- Hashimotos thyroidism - Subacute thyroiditis (De Quervain's) - Riedel's thyroiditis - After thyroidectomy or radioiodene treatment - Drug therapy (e.g. lithium, amiodarone or anti-thyroid drugs e.g. carbimazole) - Postpartum thyroiditis - Dietary iodine deficiency

Question 376

Vitamin A deficiency leads to what condition?

Answer 376

Night blindness

Question 377

Which vitamin, if taken in high doses can be dangerous in pregnant women?

Answer 377

Vitamin A Hence why pregnant women are advised not to take multivitamins and not to eat liver

Question 378

How does chancroid typically present? What organism is it caused by?

Answer 378

Painful genital ulcers associated with painful inguinal lymph node enlargement Ulcers typically have a sharply defined, ragged, undermined border

Question 379

What can happen with suddenly stopping use of long term exogenous corticosteroids?

Answer 379

Can precipitate an Addisonian crisis Because it suppresses the HPA axis, leading to reduced endogenous cortisol production, when suddenly withdrawn, adnreal glands cannot produce enough cortisol to meet the body's needs, resulting in an Addisonian crisis

Question 380

Place the following corticosteroids - fludrocortisone,dexamethasone, hydrocortisone, betmethasone, prednisolone, in the following categories below: 1) Minimal glucocorticoid activity, very high mineralocorticoid activity 2) Glucocorticoid activity, high mineralocorticoid activity 3) Predominant glucocorticoid activity, low mineralocorticoid activity 4) Very high glucocorticoid activity, minimal mineralocorticoid activity

Answer 380

1) Minimal glucocorticoid activity, very high mineralocorticoid activity - Fludrocortisone 2) Glucocorticoid activity, high mineralocorticoid activity - Hydrocortisone 3) Predominant glucocorticoid activity, low mineralocorticoid activity - Prednisolone 4) Very high glucocorticoid activity, minimal mineralocorticoid activity - Dexamethasone, Betmethasone

Question 381

What are the mineralocorticoid side effects of corticosteroids?

Answer 381

- Fluid retention - HTN

Question 382

What is the sick day rule for the use of corticosteroids?

Answer 382

Patients on long-term steroids should have thir doses doubled during intercurrent illness

Question 383

What are the criteria for tapering down corticosteroids (not how to but when to taper them - in what scenarios)?

Answer 383

If patients have: - Received > 40mg prednisolone daily for > 1 week - Received > 3 weeks of treatment - Recently received repeated courses

Question 384

What are the contraindications to BCG vaccination?

Answer 384

- Previous BCG vaccination - Past history of TB - HIV - Pregnancy - Positive tuberculin test (Heaf or Mantoux) Note not given to people > 35 yrs old, as there is no evidence it works for people of this age group

Question 384

Outline the side effects of corticosteroids

Answer 384

- Endocrine - impaired glucose regulation, increased appetite / weight gain, hirsutism, hyperlipidaemia - Cushings - MSK - osteoporosis, proximal myopathy, AVN femoral head - Immunosuppression - Pyschiatric - psychosis, insomnia, mania, depressiono - GI - peptic ulceration, acute pancreatitis - Ophthalmic - glaucoma, cataracts - Suppression of growth in children - Intracranial HTN - Neutrophilia MR side effects - fluid retention, hypertension

Question 385

In whom should the BCG vaccine be given?

Answer 385

- All infants 0-12 months in areas of the UK where the annual incidence of TB is 10/100 000 or greater - All infants 0-12 months with a parent or grandparent who was born in a country where the annual incidence of TB is 40 / 100 000 or greater. Also in older children but they require a tuberculin skin test first - Previously unvaccinated tuberculin-negative contacts of cases of respiratory TB - Previously unvaccinated, tuberculin negative new entrants under 16 urs who were born in or have lived for a prolonged period (at least 3 months) in a country with an annual TB incidence of 10 / 100 000 or greater - Healthcare workers - Prison staff - Staff of care home for the elderly - Those who work with homeless people

Question 386

What do you do first before administering the BCG vaccine? What is the exception?

Answer 386

Must first be given the tuberculin skin test. The only exception are children < 6 yrs old who have had no contact with TB

Question 387

Can BCG vaccine be co-administered with other live vaccines?

Answer 387

BCG can be given at the same time as other live vaccines, but if not administered simultaneously there should be a 4 week interval

Question 388

How long should the interval be between giving BCG vaccine after another live vaccine (if not given simultaneously at the time)?

Answer 388

4 week interval

Question 389

A 34-year-old man is diagnosed as being HIV positive. He was born and brought up in the United Kingdom and is currently fit and well with no past medical history. At what point should anti-retroviral therapy be started? A) At the time of diagnosis B) CD4 < 200 x 10^6/L C) CD4 < 250 x 10^6/L D) CD4 < 300 x 10^6/L

Answer 389

A) At the time of diagnosis Anti-retroviral therapy is now started at the time of diagnosis, rather than waiting for the CD4 count to drop to a particular level

Question 390

Outline the management of hypercalcaemia

Answer 390

- Initially rehdyration with normal saline - typically 3-4 litres per day - Following this bisphosphonates - note they typically take 2-3 days to work with maximal effect being seen at 7 days - Other options: Calcitonin - quicker effect than bisphosphonates Steroids in sarcoidosis Loop diuretics e.g. furosemide sometimes used, particularly in those who cannot tolerate aggressive fluid rehydration, however they should be used in caution as they may worsen electrolyte derangement and volume depletion

Question 391

What are the features of vestibular schwannoma? Tip base it on the cranial nerves

Answer 391

CNV: Absent corneal reflex CN VIII: - Vertigo - Hearing loss (unilateral, sensorineural) - Tinnitus (unilateral) CN VII: Facial palsy

Question 392

Bilateral vestibular schwannomas are seen in what condition?

Answer 392

Neurofibromatosis type 2

Question 393

What investigations to carry out in vestibular schwanomma?

Answer 393

MRI of the cerebellopontine angle Audiogram

Question 394

What is the management of vestibular schwannoma?

Answer 394

Refer to ENT Either surgery, radiotherapy or observation

Question 395

Infarction in which coronary territory can cause complication of complete heart block following an MI?

Answer 395

Right coronary artery lesion Since this supplies the AVN in most people (90%). Infarction of the AV node leads to loss of the normal conduction pathway from the atria to the ventricles. Well known complication post-MI

Question 396

Outline the different ways that diabetic foot disease can present?

Answer 396

- Neuropathy - loss of sensation - Ischaemia - absent foot pulses, reduced ABPI, intermittent claudication - Complications: calluses, ulceration, Charcot's arthropathy, cellulitis, osteomyelitis, gangrene

Question 397

All patients with diabetes should be screened with diabetic foot disease on at least an annual basis - what is done in this testing?

Answer 397

- Screening for ischaemia - palpate both the dorsalis pedis pulse and posterior tibial artery pulse - Screening for neuropathy - 10g monofilament on various parts of the sole of the feet

Question 398

Outline the risk stratification for low risk, moderate risk and high risk in diabetic foot disease

Answer 398

Low risk - no risk factors except callus alone Moderate risk - Deformity or .... , neuropathy or.... , non-critical limb ischaemia High risk - previous ulceration or ..., previous amputation... , or on RRT or..., neuropathy and non-critical limb ischaemia together or...., neuropathy in combination with callus and / or deformity or...., criticitcal limb ischaemia in combination with callus and / or deformity Note all patients who are moderate or high risk (i.e. any problems other than simple calluses) should be followed up regularly by the local diabetic foot centre

Question 399

What is the most prevalent STI in the UK?

Answer 399

Chlamydia trachomatis

Question 400

What is the incubation period of chlamydia trachomatis?

Answer 400

7-21 days

Question 401

What are the clinical features of chlamydia?

Answer 401

- Asymptomatic in around 70% of women and 50% of men - Women: cervicitis (discharge, bleeding), dysuria - Men: urethral discharge, dysuria

Question 402

List some complications of chlamydia trachomatis:

Answer 402

- Epididymitis - PID - Endometritis - Increased incidence of ectopic pregnancies - Infertility - Reactive arthritis - Perihepatitis (Fitz-Hugh-Curtis syndrome)

Question 403

When should chlamydia testing be carried out?

Answer 403

Two weeks after a possible exposure

Question 404

What are the investigations carried out in chlamydia trachomatis?

Answer 404

NAATs - urine, vulvovaginal swab or cervical swab For women - vulvovaginal swab NAAT is first line For men - urine NAAT is first line

Question 405

What is the screening programme in Chlamydia in the UK?

Answer 405

Open to all men and women aged 15-24 years

Question 406

1) What is the first line management for chlamydia? 2) What if this is contraindicated or not tolerated? 3) What should be used in pregnant women?

Answer 406

1) Doxycycline - 7 day course 2) If contraindicated / not tolerated - azithromycin - either 1g OD or 500mg OD for two days 3) If pregnant - azithromycin, erythromycin, amoxicillin - 1g azithromycin first line following discussion or risk vs benefit

Question 407

What are the notification protocols in chlamydia?

Answer 407

- For men with urethral symptoms: All contacts since, and in the four weeks prior to the onset of symptoms - For women and asymptomatic men: All partners from the last six months or the most recent sexual partner should be contacted - Contacts of confirmed chlamydia cases should be offered treatment prior to hte results of their investigations being known (treat then test)

Question 408

Outline when blood pressure should be controlled in acute stroke patients Blood pressure should be lowered to what before thrombolysis?

Answer 408

- BP should not be lowered in the acute phase of ischaemic stroke unless there are complications e.g. Hypertensive encephalopathy or being considered for thrombolysis - BP control should be considered for patients who present with an acute ischaemic stroke, if they present within 6 hours and have a systolic BP > 150mmHg BP should be lowered to 185/110 mmHg before thrombolysis

Question 409

What medication and what dose should be given for acute ischaemic stroke?

Answer 409

Aspirin 300mg orally or rectally ASAP if a haemorrhagic stroke has been excluded

Question 410

When can you restart anticoagulants following an ischaemic stroke in patients with AF?

Answer 410

Anticoagulants should not be started until brain imaging has excluded haemorrhage, and usually not until 14 days have passed from the onset of an ischaemic stroke

Question 411

When can patients be started on statin following ischaemic stroke if needed - and in whom is it needed?

Answer 411

If cholesterol is > 3.5 mmol/L then patients should be commenced on a statin Often delay treatment until at least 48 hours due to risk of haemorrhagic transformation

Question 412

What are the criteria for thrombolysis with alteplase or tenecteplase?

Answer 412

- Administered within 4.5 hrs of onset - or if treatment can be started between 4.5 and 9 hrs of known onset, or within 9 hours of midpoint of sleep when they have woken with symptoms AND -The have evidence from CT / MR perfusion (core-perfusion mismatch) or MRI (DWI-FLAIR mismatch) of the potential to salvage brain tissue - This should be irrespective of whether they have a large artery occlusion and require mechanical thrombectomy - Haemorrhage has been definitively excluded (i.e. imaging has been performed)

Question 413

What are the guidelines for overall clinical status of a patient when considering for thrombectomy?

Answer 413

Pre-stroke functional status of < 3 on the modified Rankin scale and a score of > 5 on the NIHSS

Question 414

When to consider thrombectomy +/- IV thrombolysis?

Answer 414

Offer thrombectomy ASAP and within 6 hours of symptom onset, together with IV thrombolysis (if within 4.5 hours), to people who have: Acute ischaemic stroke and - Confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA Offer thrombectomy ASAP to people known to be well between 6-24 hours previously (including wake-up strokes): - Confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and - If there is potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion weighted MRI sequences showing limited infarct core volume Consider thrombectomy with IV thrombolysis (if within 4.5 hours) as soon as possible for people last known to be well up to 24hrs previously (including wake-up strokes) - who have acute ischaemic stroke and confirmed occlusion of the proximal posterior circulation (i.e. basilar or posterior cerebral artery) demonstrated by CTA or MRA and... - if there is potential to salvage brain tissue as shown by CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

Question 415

What is given for lifelong treatment for secondary prevention of stroke? What is given if this is not tolerated?

Answer 415

- Clopidogrel lifelong - Or aspirin + dipyridamole if clopidogrel not tolerated

Question 416

When should carotid endarterectomy given in stroke?

Answer 416

- If suffered stroke or TIA in the carotid territory - Not severely disabled - If stenosis > 50%

Question 417

Outline the medical management of angina pectoris (stable)

Answer 417

- Aspirin + statin in the absence of any contraindication - Sublingual GTN to abort angina attacks - Either a beta-blocker or CCB first-line based on comorbidities, contraindications and the person's preference - If a CCB is used monotherapy use a rate-limiting one e.g. verapamil or diltiazem - If used in combination with beta-blocker then use longer acting dihydropyridine CCB (e.g. amlodipine, modified release nifedipine). Do NOT co-prescribe beta-blockers and verapamil - risk of complete heart block - If poor response to initial therapy increase to max tolerated dose - If still symptomatic after monotherpay with beta-blocker add a CCB and vice versa - If on monotherapy and cannot tolerate a second drug (either CCB or beta-blocker) then consider andy of : long acting nitrate, ivabradine, nicorandil, ranolazine - If a patient is taking both CCB and beta-blocker then only add a third drug when awaiting assessment for PCI or CABG

Question 418

How to manage nitrate tolerance in patients taking isosorbide mononitrate?

Answer 418

NICE advises that patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimise the development of nitrate tolerance this effect is not seen in patients who take once-daily modified-release isosorbide mononitrate

Question 419

Lyme disease is caused by which organism and is spread by what?

Answer 419

Borriela Burgdorferi Spread by ticks

Question 420

Features of lyme disease?

Answer 420

- Erythema migrans - in 80% of patients - Systemic features - headache, lethargy, fever, arthralgia - Cardiovascular - heart block, peri/myo-carditis - Neuro - facial nerve palsy, radicular pain, meningitis

Question 421

Investigations in Lyme disease?

Answer 421

NICE recommend that Lyme disease can be diagnosed clinically if erythema migrans is present Enzyme-linked immunosorbent assay (ELISA) antibodies to Borrelia burgdorferi are the first-line test - If negative and Lyme disease is still suspected in people tested within 4 weeks from symptom onset, repeat the ELISA 4-6 weeks after the first ELISA test - If still suspected in people who have had symptoms for 12 weeks or more then an immunoblot test should be done - If positive or equivocal then an immunoblot test for Lyme disease should be done

Question 422

What is the management of Lyme disease?

Answer 422

- Doxycyline if early disease - Amoxicillin if doxy is contraindicated (e.g. pregnancy) - Ceftriaxone if disseminated disease - Jarisch-Herxheimer reaction is sometimes seen after initiating therapy: fever, rash, tachycardia after first dose of antibiotic (more commonly seen in syphilis, another spirochaetal disease)

Question 423

What reaction can sometimes happen after initiating therapy in Lyme disease? In which other condition can this happen also?

Answer 423

Jarisch-Herxheimer reaction - fever, rash, tachycardia after first dose of antibiotic (more commonly seen in syphilis, another spirochaetal disease)

Question 424

What score system can be used in assessment of considering whether stroke is likely?

Answer 424

ROSIER score Exclude hypoglycaemia first then.... Loss of consciousness - NEGATIVE 1 point Seizure activity - NEGATIVE 1 point New acute onset of: - Asymmetric facial weakness - + 1 point - Asymmetric arm weakness - + 1 point - Asymmetric leg weakness - + 1 point - Speech disturbance - + 1 point - Visual field defect - +1 point Stroke likely if > 0 points

Question 425

What is the most common cause of primary hypoadrenalism in the UK?

Answer 425

Addison's - autoimmune destruction of the adrenal glands 80% of cases

Question 426

Features of Addison's disease Features of Addisonian crisis?

Answer 426

- lethargy, weakness, anorexia, nausea & vomiting, weight loss, 'salt-craving' - hyperpigmentation (especially palmar creases) - vitiligo - loss of pubic hair in women - hypotension - hypoglycaemia - hyponatraemia and hyperkalaemia may be seen Crisis: collapse, shock, pyrexia

Question 427

List causes of primary hypoadrenalism

Answer 427

- Most common - Addisons (autoimmune destruction of adrenals) - TB - Metastases (e.g. bronchial carcinoma) - HIV - Antiphospholipid syndrome

Question 428

List secondary causes of hypoadrenalism

Answer 428

Pituitary disorders - tumours, irradiation, infiltration Exogenous glucocorticoid therapy

Question 429

What type of bacteria is Neisseria Gonorrhae - gram -ve or positive and rod or coccus?

Answer 429

Gram negative diplococcus

Question 430

What is the incubation period of gonorrhoea?

Answer 430

2-5 days

Question 431

Features of gonorrhoea?

Answer 431

- Males - urethral discharge, dysuria - Females - cervicitis e.g. leading to vaginal discharge - Rectal and pharyngeal infection usually asymptomatic

Question 432

True or false, no vaccination exists for gonorrhoea?

Answer 432

True - immunisation is not possible and reinfection is common due to antigen variation of type IV pili (proteins which adhere to surfaces) and Opa proteins (surface proteins which bind to receptors on immune cells)

Question 433

Complications of gonorrhoea?

Answer 433

- Urethral strictures - Epididymitis - Salpingitis (hence may lead to infertility) - Disseminated infection - tenosynovitis, migratory polyarthritis, dermatitis (lesions may be maculopapular or vesicular). Later complications septic arthritis, endocarditis, perihepatitis (Fitz-Hugh-Curtis syndrome)

Question 434

What is first line treatment for gonorrhoea? What if this is not tolerated?

Answer 434

Single dose of IM ceftriaxone 1g If sensitive to cipro - single dose of oral cipro 500mg If ceftriaxone is refused (e.g. needle phobic) then oral cefixime 400mg (single dose) + oral azithromycin 2g (single dose) should be used

Question 435

Pathogen associated with bronchiolitis?

Answer 435

Respiratory syncytial virus

Question 436

Pathogen associated with croup?

Answer 436

Parainfluenza virus

Question 437

Most common pathogen behind CAP?

Answer 437

Strep pneumoniae

Question 438

Pathogen that can cause CAP, is the most common cause of bronchiectasis exacerbations, acute epiglottitis?

Answer 438

Haemophilus influenzae

Question 439

Which pathogen commonly associated with pneumonia following influenza?

Answer 439

Staph aureus

Question 440

Which pathogen in pneumonia can be complicated by haemolytic anaemia and erythema multiforme?

Answer 440

Mycoplasma pneumoniae

Question 441

Which pathogen in pneumonia can be complicated by lymphopaenia, deranged LFTs and hyponatraemia?

Answer 441

Legionella pneumonia

Question 442

What should you advise for renal diet for patients with renal failure? Low what (not just one thing btw)

Answer 442

- Low protein - Low phosphate - Low sodium - Low potassium

Question 443

Outline treatment in acute heart failure?

Answer 443

- IV loop diuretics - e.g. furosemide, bumetanide - Oxygen - aim sats 94-98% (unless COPD?) - Vasodilators - NOT routinely - only if concomitant myocardial ischaemia, severe hypertension, or regurgitant aortic or mitral valve disease - CI in hypotension - Resp failure - CPAP NOT Bipap - HOTN (e.g. < 85mmHg / cardiogenic shock) Inotropic agents e.g. dobutamine - for patients with severe LV dysfunction who have potentially reversible cardiogenic shock, vasopressor agents e.g. norepinephrine - if insufficient response to inotropes and evidence of end-organ hypoperfusion, mechanical circulatory assistance e.g. intra-aortic ballon counterpulsation or ventricular assist devices

Question 444

When should beta-blockers be stopped in patients who take them for heart failure in the acute heart failure scenario?

Answer 444

Beta-blockers should not be stopped if the patient has heart rate < 50 bpm, second or third degree AV block, or shock

Question 445

List causes of vitamin B12 deficiency

Answer 445

- Pernicious anaemia - most common cause - Post gastrectomy - Vegan diet or poor diet - Disorders / surgery of terminal ileum - Crohns either disease activity or following ileocaecal resection - Metformin (rare)

Question 446

List some features of vitamin B12 deficiency

Answer 446

- Macrocytic anaemia - Sore tongue and mouth - Neurological symptoms the dorsal column is usually affected first (joint position, vibration) prior to distal paraesthesia - Neuropsychiatric symptoms: e.g. mood disturbances

Question 447

Outline management of vitamin B12 deficiency

Answer 447

- If no neurological involvement 1 mg of IM hydroxocobalamin 3 times each week for 2 weeks, then once every 3 months - If a patient is also deficient in folic acid then it is important to treat the B12 deficiency first to avoid precipitating subacute combined degeneration of the cord

Question 448

GBS often triggered by infection with which organism?

Answer 448

Campylobacter Jejuni

Question 449

Features of Miller Fisher syndrome?

Answer 449

- Descending paralysis rather than ascending paralysis in GBS - Ophthalmoplegia - Areflexia - Ataxia

Question 450

Which antibodies are present in 90% of cases of GBS?

Answer 450

Anti-GQ1b antibodies

Question 451

Features of trichomonas vaginalis?

Answer 451

vaginal discharge: offensive, yellow/green, frothy vulvovaginitis strawberry cervix pH > 4.5 in men is usually asymptomatic but may cause urethritis

Question 452

Management of Trichomonas Vaginalis?

Answer 452

Oral metronidazole 5-7 days Or one off 2g metronidaole

Question 453

What is the investigation in suspected trichomonas vaginalis?

Answer 453

Microscopy of a wet mount shows motile trophozoites

Question 454

What is Buerger's disease and what are the features of it?

Answer 454

Buerger's disease (also known as thromboangiitis obliterans) is a small and medium vessel vasculitis that is strongly associated with smoking Features: - Extremity ischaemia - Intermittent claudication - Ischaemic ulcers - Superficial thrombophlebitis - Raynaud's phenomenon

Question 455

Buerger's disease is strongly associated with what key risk factor?

Answer 455

Smoking

Question 456

Most common bacterial causes of acute exacerbations of COPD?

Answer 456

- Haemophilus influenzae - MOST COMMON - Streptococcus pneumoniae - Moraxella catarrhalis

Question 457

Which respiratory virus is the most common in acute exacerbation of COPD?

Answer 457

Human rhinovirus

Question 458

Initial management of acute exacerbation of COPD? i.e. not severe, not requiring hospital admission

Answer 458

- Increase the frequency of bronchodilator use and consider giving via a nebuliser - Give prednisolone 30mg OD for 5 days - Only give abx (amoxicillin / clarithromycin / doxycycline) IF sputum is purulent or clinical signs of pneumonia

Question 459

Indications for admission for acute exacerbation of COPD?

Answer 459

- Severe breathlessness - Acute confusion or impaired consciousness - Cyanosis - Oxygen sats < 90% on pulse ox - Social reasons e.g. inability to cope at home (or living alone) - Significant comorbidity (e.g. cardiac disease or insulin-dependent diabetes)

Question 460

How to titrate oxygen therapy in management of COPD?

Answer 460

- Initial targets of 88-92% - Prior to the availability of blood gases, use a 28% Venturi mask at 4L/min and aim for O2 sats of 88-92% for patients with risk factors for hypercapnia but no prior history of respiratory acidosis - Adjust target range to 94-98% if the PCO2 is normal

Question 461

Outline management options for severe COPD

Answer 461

- Oxygen therapy - Nebulised bronchodilator therapy Beta-adrenergic agonist e.g. salbutamol Muscarinic antagonist e.g. ipratropium - Steroid therapy - Oral prednisolone or IV hydrocortisone - IV theophylline - if not responding to nebulised bronchodilators - IF resp aciosis NIV , consider HDU BIPAP EPAP 4-5cm H20 IPAP either 10cm H20 or 12-15cm H20

Question 462

What are the commonest causes of anterior mediastinum mass?

Answer 462

4 T's: Teratoma, Terrible lymphadenopathy, Thymic mass and Thyroid mass

Question 463

What is the management for SVT in shock?

Answer 463

Synchronised DC cardioversion Note when you can feel a measurable pulse its synchronised e.g. SVT in shock but if either VF/VT/pulseless with shock then its unsynchronised

Question 464

What is raised in the FBC in polycythaemia vera?

Answer 464

- Hb main thing but also accompanied by... - Neutrophils - Platelets

Question 465

Incidence of polycythaemia vera is greatest when?

Answer 465

In the sixth decade

Question 466

Features of polycythaemia?

Answer 466

- Pruritus, typically after a hot bath (aquagenic pruritis) - Splenomegaly - Hypertension - Hyperviscosity - Arterial thrombosis / Venous thrombosis - Haemorrhage (secondary to abnormal platelet function) - Low ESR

Question 467

Investigations in suspected polycythaemia vera?

Answer 467

full blood count/film (raised haematocrit; neutrophils, basophils, platelets raised in half of patients) JAK2 mutation serum ferritin renal and liver function tests If the JAK2 mutation is negative and there is no obvious secondary causes the BCSH suggest the following tests: red cell mass arterial oxygen saturation abdominal ultrasound serum erythropoietin level bone marrow aspirate and trephine cytogenetic analysis erythroid burst-forming unit (BFU-E) culture

Question 468

Diagnostic criteria for polycythaemia rubra vera?

Answer 468

Question 469

Main mechanism of action of metoclopramide?

Answer 469

D2 receptor antagonist

Question 470

Uses of metoclopramide?

Answer 470

- Anti-emetic - GORD - Prokinetic action useful in gastroparesis secondary to diabetic neuropathy - Often combined with analgaesics for treatment of migraine (migraine attacks result in gastroparesis, slowing the absorption of analgaesics)

Question 471

Adverse effects associated with metoclopramide?

Answer 471

- Extrapyramidal effects - acute dystonia e.g. oculogyric crisis - especially in children and young adults - Diarrhoea - Hyperprolactinaemia - Tardive dyskinesia - Parkinsonism

Question 472

Metoclopramide should be avoided in .... ....., but may be helpful in paralytic ileus

Answer 472

Metoclopramide should be avoided in bowel obstruction, but may be helpful in paralytic ileus

Question 473

Metoclopramide should be avoided in bowel obstruction, but may be helpful in ..... .....

Answer 473

Metoclopramide should be avoided in bowel obstruction, but may be helpful in paralytic ileus

Question 474

Causes AR - both due to valve disease and aortic root disease and chronic vs acute in these?

Answer 474

Question 475

Features of aortic regurgitation?

Answer 475

- Early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre - Collapsing pulse - Wide pulse pressure - Quincke's sign (nailbed pulsation) - De Musset's sign (head bobbing) mid-diastolic Austin-Flint murmur in severe AR - due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams

Question 476

Indications for surgical management of aortic regurgitation?

Answer 476

- Symptomatic patients with AR - Asymptomatic patients with severe AR who have LV systolic dysfunction

Question 477

Adverse effects associated with nicorandil?

Answer 477

- Headaches - Flushing - Skin, mucosal, eye and anal ulceration

Question 478

Contraindication for nicorandil?

Answer 478

Left ventricular

Question 479

What is the peak incidence of Bell's palsy? In what group of people is it most common?

Answer 479

20-40yrs Pregnant women

Question 480

Features of facial palsy?

Answer 480

- Lower motor neuron facial nerve palsy → forehead affected in contrast, an upper motor neuron lesion 'spares' the upper face Patients may also notice: - post-auricular pain (may precede paralysis) - altered taste - dry eyes - hyperacusis

Question 481

Management for Bell's palsy?

Answer 481

- Oral pred within 72 hours - Aciclovir IF severe facial palsy - Eye care and artificial tears, micropore tape - IF no improvement after 3 weeks - refer to ENT - IF more longstanding weakness e.g. 3 months - refer to plastic surgery

Question 482

Prognosis of Bell's palsy?

Answer 482

Most recover in 3-4 months If untreated around 15% have permanent moderate to severe weakness

Question 483

Typhoid and paratyphoid are caused by which organisms respectively?

Answer 483

Salmonella Typhi and Salmonella Paratyphi

Question 484

Features of enteric fever (typhoid / paratyphoid)?

Answer 484

- Systemic upset - headache, fever, 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

Question 485

Possible complications of enteric fever - typhoid / paratyphoid?

Answer 485

- Osteomyelitis (especially in sickle cell disease where Salmonella is one of the most common pathogens) - GI bleed / perforation - Meningitis - Cholecystitis - Chronic carriage (1% more likely if adult females)

Question 486

What infections can Pseudomonas Aeruginosa cause?

Answer 486

- Chest infections (especially in cystic fibrosis) - Skin: burns, wound infections, 'hot tub' folliculitis - Otitis externa (especially in diabetics who may develope malignant otitis externa) - UTIs

Question 487

Pseudomonas aeruginosa gram -ve or positive and rod or bacillus?

Answer 487

Gram -ve rod

Question 488

Lab features of Pseudomonas Aeruginosa?

Answer 488

- Gram-negative rod - Non-lactose fermenting - Oxidase positive

Question 489

A 31-year-old male presents to his GP complaining of a sudden onset 3 day history of fever, shivers and a sore throat. He has a past medical history of ulcerative colitis, for which he is treated with the aminosalicylate, mesalazine. What is the most important investigation in this patient? A) Blood cultures B) FBC C) LFTs D) U+Es E) Viral throat swab

Answer 489

FBC - Aminosalicylates, such as sulphasalazine or mesalazine have a number of side effects. Mesalazine, in particular, can cause agranulocytosis, which may present with sudden onset rigors, fever and sore throat

Question 490

List differentials for melaena in terms of oesophageal, gastric and duodenal causes

Answer 490

OESOPHAGEAL: - Oesophageal varices - Oesophagitis - Cancer - Mallory-Weiss Tear GASTRIC: - Gastric ulcer - Gastric cancer - Dieulafoy lesion - Diffuse erosive gastritis DUODENAL CAUSES: - Duodenal ulcer - Aorto-enteric fistula

Question 491

What scoring system in upper GI bleeds is used before endoscopy at first assessement and what is used after endoscopy to provide a percentage risk of rebleeding and mortality?

Answer 491

- Glasgow-Blatchford Score - at first assessment - helps decide whether patients can be managed as outpatients or not, and urgency of endoscopy - Rockall Score - after endoscopy - after endoscopy provides a percentage risk of rebleeding and mortality

Question 492

What Glasgow-Blatchford score may be considered for early discharge?

Answer 492

0

Question 493

What blood products are used in management of upper GI bleeds?

Answer 493

Beware transfusing too much RBC due to increase in portal venous pressure - Platelet transfusion if actively bleeding platelet count of less than 50 x 10*9/litre - Fresh frozen plasma to patients who have either a fibrinogen level of less than 1 g/litre, or a prothrombin time (international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal - Prothrombin complex concentrate to patients who are taking warfarin and actively bleeding

Question 494

Outline the management of variceal bleeding in upper GI bleeding?

Answer 494

- Terlipressin and prophylactic antibiotics should be given to patients at presentation (i.e. before endoscopy) - Band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices - Transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures

Question 495

Outline the management of non-variceal upper GI bleeding?

Answer 495

- NICE do not recommend the use of proton pump inhibitors (PPIs) before endoscopy to patients with suspected variceal upper gastrointestinal bleeding although PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy - If further bleeding then options include repeat endoscopy, interventional radiology and surger

Question 496

Name 3 of the most common precipitating factors of DKA?

Answer 496

1. Infection 2. Missed insulin doses 3. MI

Question 497

What are the diagnostic criteria for DKA?

Answer 497

American Diabetes Association: - Glucose > 13.8 mmol/l - pH < 7.30 - Serum bicarbonate <18 mmol/l - Anion gap > 10 - Ketonaemia Joint British Diabetes Societies (2013): - Glucose > 11 mmol/L or known diabetes mellitus - pH < 7.3 - Bicarbonate < 15 mmol/L - Ketones > 3 mmol/L or urine ketones ++ on dipstick

Question 498

DKA resolution is defined as ....?

Answer 498

- pH >7.3 and - blood ketones < 0.6 mmol/L and - bicarbonate > 15.0mmol/L

Question 499

List some complications of DKA

Answer 499

- Gastric stasis - Thromboembolism - Arrhythmias secondary to - Hyperkalaemia/iatrogenic hypokalaemia - Iatrogenic due to incorrect fluid therapy: cerebral oedema*, hypokalaemia, hypoglycaemia - Acute respiratory distress syndrome - Acute kidney injury

Question 500

Which demographic is particular at risk of complications from fluid therapy in DKA, what is the complication, and how to mitigate the risk?

Answer 500

Children / young adults are particularly vulnerable to cerebral oedema following fluid resuscitation in DKA and often need 1:1 nursing to monitor neuro-observations, headache, irritability, visual disturbance, focal neurology etc. It usually occurs 4-12 hours following commencement of treatment but can present at any time. If there is any suspicion a CT head and senior review should be sought

Question 501

Common advserse effects with sulfonylureas e.g. gliclazide? Then list some rarer ones if possible

Answer 501

- Hypoglycaemic episodes (more common with long-acting preparations e.g. chlorpropamide) - Weight gain Rarer: - Hyponatraemia secondary to SIADH - BM suppression - Hepatotoxicity (typically cholestatic) - Peripheral neuropathy

Question 502

True or false, sulfonylureas e.g. gliclazide can be used in breastfeeding and pregnancy?

Answer 502

False - avoid

Question 503

What is the mechanism of action of sulfonylureas and give an eample drug name?

Answer 503

Increase pancreatic insulin secretion and hence only effective if functional pancreatic B cells are present Bind to ATP-dependent K+ channel on the cell membrane of pancreatic beta cells (SUR-1 receptor) - decreasing potassium efflux from the cell leading to depolarisation. This results in calcium ion influx leading to insulin release GLICLAZIDE

Question 504

HbA1C targets in T2DM? In patients in whom you suggest lifetstyle changes or lifestyle + metformin or if any drug that can cause hypoglycaemia (e.g. lifestyle + sulfonylurea)? What if already on one drug but HbA1C has risen to 58 mmol / mol (7.5%)

Answer 504

48 mmol/mol (6.5%), 48 mmol / mol (6.5%) then 53 mmol / mol (7.0%) 53 mmol / mol (7.0%)

Question 505

Outline the causes of gynaecomastia

Answer 505

- Physiological - normal in puberty - Syndromic: Kallman's, Klinefelter's - Testicular failure e.g. mumps - Liver disease - Testicular cancer e.g. seminoma secreting hcg - Ectopic tumour secretion - Hyperthyroidism - Haemodialysis - Drugs: spironolactone, cimetidine, digoxin, cannabis, finasteride, GnRH agonists e.g. goserelin and buserelin, oestrogens, anabolic steroids. Then other rarer drug causes not listed here

Question 506

How to interpret OGTT test?

Answer 506

If patient symptomatic and random glucose tolerance > / = 11.1mmol/L (or after 75g OGTT) = DIABETES Fasting glucose > / = 6.1 but < 7.0 mmol/L implies impaired fasting glucose Impaired glucose tolerance (IGT) = fasting plasma glucose < 7.0mmol/L and OGTT 2 hour value > / = 7.8mmol/L but less than 11.1mmol/L

Question 507

Outline the management of Addison's disease

Answer 507

- Hydrocortisone - usually in 2/3 divided doses. Typically 20-30mg per day, with majority given in first half of the day - Fludrocortisone - Patient education - dont miss doses of hydrocortisone, medicalert bracelets and steroid cards, hydrocortisone for injection for adrenal crisis, sick day rules - Sick day rules - glucocorticoid dose doubled, fludrocortisone dose stays the same

Question 508

What is used for diagnosis of prolactinoma?

Answer 508

MRI

Question 509

Features of prolactinomas in women then men?

Answer 509

Women: - Amenorrhoea - Infertility - Galactorrhoea - Osteoporosis Men: - Impotence - Loss of libido - Galactorrhoea Headache Visual disturbances - bitemporal hemianopia or upper temporal quadrantanopia Hypopituitarism

Question 510

Outline the medical then surgical management for prolactinomas

Answer 510

- Dopamine agonists (e.g. cabergoline, bromocriptine) which inhibit the release of prolactin from the pituitary gland - Surgery - trans-sphenoidal hypophysectomy

Question 511

Outline the management of subclinical hypothyroidism

Answer 511

TSH is > 10mU/L and the free thyroxine level is within the normal range: consider offering levothyroxine if the TSH level is > 10 mU/L on 2 separate occasions 3 months apart TSH is between 5.5 - 10mU/L and the free thyroxine level is within the normal range if < 65 years consider offering a 6-month trial of levothyroxine if: - the TSH level is 5.5 - 10mU/L on 2 separate occasions 3 months apart - there are symptoms of hypothyroidism In older people (especially those aged over 80 years) follow a 'watch and wait' strategy is often used If asymptomatic people, observe and repeat thyroid function in 6 months

Question 512

What are the most common causes of hypercalcaemia? List some other rarer causes

Answer 512

COMMON 1. PRIMARY HYPERPARATHYROIDISM 2. MALIGNANCY - PTHrP from the tumour e.g. SCC of lung, bone mets, Myeloma OTHER CAUSES: - Sarcoidosis - Vit D intoxication - Acromegaly - Thyrotoxicosis - Milk-alkali - Drugs - thiazides, calcium-containing antacids - Dehydration - Addison's disease - Paget's disease of the bone - usually normal in this but may occur with prolonged immobilisation

Question 513

Which test in the iron studies is best to test for iron overload?

Answer 513

Transferrin saturation

Question 514

List some causes of raised ferritin without iron overload?

Answer 514

- Inflammation (as ferritin is an acute phase reactant) - Alcohol excess - Liver disease - CKD - Malignancy

Question 515

List some causes of raised ferritin with iron overload

Answer 515

Primary iron overload (hereditary haemochromatosis) Secondary iron overload (e.g. following repeated transfusions)

Question 516

Reduced ferritin level in ?

Answer 516

Reduced ferritin levels with iron levels - think IDA

Question 517

Secondary prevention of MI, what are the cocktail of drugs that should be offered?

Answer 517

All patients should be offered: - DAPT (aspirin plus a second agent) - ACEis - Beta-blockers - Statin Patients how had acute MI and / or signs of HF and LV systolic dysfunction, treatment with an aldosterone antagonist licenced for post-MI treatment (e.g. eplerenone) should be initiated with 3-14 days of the MI, preferably after ACEi therapy

Question 518

Lifestyle advice to advise after MI in a patient?

Answer 518

- Diet - Mediterranean style diet, swich butter and cheese for plant oil based products. Do not recommend omega 3 supplements or eating oily fish - Exercise - 20-30 mins a day until patients are 'slightly breathless' - Sexual activity may resume 4 weeks after an uncomplicated MI. Reassure patients sex does not increase likelihood of further MI. PDE5 inhibitors e.g. sildenafil may be used 6 months after an MI. However avoid in patients prescribed either nitrates or nicorandil

Question 519

In which sort of post-MI patients should aldosterone antagonists be started e.g. eplerenone?

Answer 519

Post-MI patients who have symptoms and / or signs of HF and LV systolic dysfunction

Question 520

ECG features in hypokalaemia?

Answer 520

- U -waves ( - Small or absent T waves (occasionally inversion) - ST depression - Prolong PR interval - Long QT

Question 521

Outline the management of SVT

Answer 521

ACUTE MANAGEMENT - Vgal maneouvres - valsalva maneouvre -blowing into an empty plastic syringe, carotid sinus massage - IV adenosine - rapid bolus 6mg, 6mg, 12 mg - Contra-indicated in asthmatics - give verapamil instead PREVENTION - Beta-blockers - Radio-frequency ablation

Question 522

List causes of raised ALP

Answer 522

- Liver: cholestasis, hepatitis, fatty liver, neoplasia - Paget's - Osteomalacia - Bone mets - Hyperparathyroidism - Renal failure - Physiological: pregnancy, growing children, healing fractures RAISED ALP AND RAISED CALCIUM - Bone mets - Hyperparathyroidism RAISED ALP AND LOW CALCIUM - Osteomalacia - Renal failure

Question 523

The ACE-3 exam tests the domains of Memory, Attention, Fluency, Language and Visuospatial What is the pattern of deficits in... : 1) Alzheimer's dementia 2) Frontotemporal dementia 3) Vascular dementia 4) Parkinson's dementia?

Answer 523

1) Alzheimer's dementia - Global deficits 2) Frontotemporal dementia - Fluency and language deficits in particular - reflecting primarily damage to the frontal lobe 3) Vascular dementia - often no consistent pattern 4) Parkinson's dementia - Visuospatial and memory and attention deficits

Question 524

Risk factors for Alzheimer's Dementia?

Answer 524

- Age - FHx - 5% of cases inherited as AD trait - mutations in APP (chr 21), Presenilin 1 (chr 14) and Presinilin 2 (chr 1) genes thought to cause the inherited form - Apoprotein E allele E4 - encodes a cholesterol transport protein - Caucasian ethnicity - Down's syndrome

Question 525

Macroscopic pathological changes in Alzheimer's Disease?

Answer 525

Widespread cerebral atrophy, particularly involving the cortex and hippocampus

Question 526

Microscopic findings in Alzheimer's Dementia?

Answer 526

Cortical plaques due to deposition of type A-Beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein Hyperphosphorylation of the tau protein

Question 527

What is the gold standard investigation for Addison's disease?

Answer 527

ACTH stimulation test (short synacthen test) - plasma cortisol is measured before and 30 minutes after giving synacthen 250ug IM

Question 528

Which adrenal antibody may be demonstrated to be raised in Addison's diasease?

Answer 528

Anti-21 hydroxylase

Question 529

If short synacthen test is not readily available, what other precursor test can be done to then prompt further testing in suspected Addison's disease?

Answer 529

- > 500 nmol/L makes Addison's very unlikely - < 100 nmol/L is definitely abnormal - 100-500 nmol/L should prompt an ACTH stimulation test to be performed

Question 530

At what age does MS typically present?

Answer 530

Over 40 yrs - very rarely below this

Question 531

Features of MND?

Answer 531

- Asymmetric limb weakness is the most common presentation of ALS - Mixture of lower motor neuron and upper motor neuron signs - Wasting of the small hand muscles/tibialis anterior is common - Fasciculations - Absence of sensory signs/symptoms vague sensory symptoms may occur early in the disease (e.g. limb pain) but 'never' sensory signs - Doesn't affect external ocular muscles - so is eye sparing - No cerebellar signs - Abdominal reflexes usually preserved and sphinchter dysfunction if present is a late feature

Question 532

Investigations in suspected MND?

Answer 532

CLINICAL DIAGNOSIS NCS - normal motor conduction, and will exclude a neuropathy EMG - reduced number of action potentials with increased amplitude MRI - excludes ddx of DCM and myelopathy

Question 533

Bulbar-onset ALS features?

Answer 533

- Patients often have more difficulty swallowing liquids than solids in the early stages - Facial weakness -Hypophonic speech - Fasciculations - Reduced jaw jerk reflex (LMN sign) - Eye movements spared

Question 534

Parkinsons more common in men or women?

Answer 534

2x more common in men

Question 535

Mean age of diagnosis in Parkinson's?

Answer 535

65

Question 536

How might the presentation of drug-induced parkinsonism differ from that of Parkinson's disease clinically?

Answer 536

- Motor symptoms generally rapid onset and bilateral - Rigidity and rest tremor are uncommon

Question 537

Features of Parkinson's?

Answer 537

BRADYKINESIA - Hypokinesia / poverty of movement - Short, shuffling steps with reduced arm swinging - Difficulty in initiating movement TREMOR - Most marked at rest 3-5 Hz - Worse when stressed or tired, improves with voluntary movement - Typically 'pill-rolling' i.i in the thumn and index finger RIGIDITY - Lead pipe - Cogwheeling due to superimposed tremor OTHER FEATURES - Mask-like facies - Flexed posture - Micrographia - Drooling of saliva - Psychiatric features - depression (40%), dementia, psychosis, sleep disturbances - Impaired olfaction - REM sleep behaviour disorder - Fatigue - Autonomic dysfunction - postural hypotension

Question 538

Causes of primary hyperparathyroidism?

Answer 538

- 85% solitary adenoma - 10% hyperplasia - 4% multiple adenoma - 1% carcinoma

Question 539

Features of hypercalcaemia in primary hyperparathyroidism?

Answer 539

- Polydipsia, Polyuria - Depression - Anorexia, nausea, constipation - Peptic ulceration - Pancreatitis - Bone pain / fracture - Renal stones - Hypertension

Question 540

X-ray findings in primary hyperparathyroidism?

Answer 540

Pepper pot skull Osteitis fibrosa cystica

Question 541

Outline the treatment options in primary hyperparathyroidism?

Answer 541

- Definitive management = TOTAL PARATHYROIDECTOMY - Conservative management may be offered if the calcium level is less than 0.25 mmol/L above the upper limit of normal AND the patient is > 50 years AND there is no evidence of end-organ damage - Patients not suitable for surgery may be treated with cinacalcet, a calcimimetic a calcimimetic 'mimics' the action of calcium on tissues by allosteric activation of the calcium-sensing receptor

Question 542

In which situations can you consider conservative management for primary hyperparathyroidism?

Answer 542

- If the calcium level is less than 0.25 mmol/L above the upper limit of normal - AND the patient is > 50 years - AND there is no evidence of end-organ damage

Question 543

What is the medical management option for primary hyperparathyroidism?

Answer 543

Cinacalcet - calcimimetic

Question 544

Outline the management of syphilis and how it is monitored

Answer 544

- IM Benzathine Penicillin is first-line - Alternatives: Doxycycline (avoid in pregnancy) - Nontreponemal RP or VDRL titres should be monitored after treatment to assess the response - a fourfould decline in titres is often considered adequate response to treatment

Question 545

What is a reaction that occures in response to treatment of syphilis, how does it present and how is it managed?

Answer 545

- Fever, rash and tachycardia after the first dose of antibiotic - In contrast to anaphylaxis, there is no wheeze or hypotension - MANAGEMENT = ANTI-PYRETICS ONLY

Question 546

What is the skin manifestation with mycoplasma pneumoniae?

Answer 546

Erythema multiforme, erythema nodosum

Question 547

What is the haematolical manifestation in mycoplasma pneumoniae?

Answer 547

Cold autoimmune haemolytic anaemia

Question 548

Complications of mycoplasma pneumoniae?

Answer 548

- Cold agglutins (IgM) may cause haemolytic anaemia, thrombocytopaenia - Erythema multiforme, erythema nodosum - Meningoencephalitis, GBS and other immune-mediated neurological diseases - Bullous myringitis - painful vesicles on the tympanic membrane - Pericarditis / Myocarditis - Gastrointestinal: hepatitis, pancreatitis - Renal: Acute glomerulonephritis

Question 549

Investigations in mycoplasma pneumoniae - gold standard and then another investigation that can be done?

Answer 549

- MYCOPLASMA SEROLOGY - Positive cold agglutination test - peripheral blood smear may show RBC agglutination

Question 550

What is the management of mycoplasma pneumoniae?

Answer 550

Doxycycline or a macrolide e.g. erythromycin / clarithromycin

Question 551

Features of hypokalaemia?

Answer 551

- Muscle weakness, hypotonia - Hypokalaemia predisposes patients to digoxin toxicity - care should be taken if patients are also on diuretics

Question 552

ECG features in hypokalaemia?

Answer 552

- U waves - Small or absent T waves - Prolonged PR interval - ST depression

Question 553

Causes of hypokalaemia?

Answer 553

1.) Increased potassium loss: Drugs: thiazides, loop diuretics, laxatives, glucocorticoids, antibiotics GI losses: diarrhoea, vomiting, ileostomy Renal causes: dialysis Endocrine disorders: hyperaldosteronism, Cushing's syndrome 2.) Trans-cellular shift Insulin/glucose therapy Salbutamol Theophylline Metabolic alkalosis 3.) Decreased potassium intake 4.) Magnesium depletion (associated with increased potassium loss)

Question 554

Key 2 side effects of ARBs?

Answer 554

Hypotension Hyperkalaemia

Question 555

If patients cannot tolerate ACEi due to development of cough, what is the alternative?

Answer 555

ARBs

Question 556

How to manage MRSA in MRSA carriers?

Answer 556

- Nose: mupirocin 2% in white soft paraffin, tds for 5 days - Skin: chlorhexidine gluconate, od for 5 days. Apply all over but particularly to the axilla, groin and perineum

Question 557

Which antibiotics are commonly used in treatment of MSRA?

Answer 557

- Vancomycin - Teicoplanin - Linezolid

Question 558

What is a key feature in Lewy Body dementia that is not as common in other forms of dementia (aside from Hallucinations and Parkinsonism)?

Answer 558

Cognition may be fluctuating

Question 559

How is Lewy Body Dementia diagnosed?

Answer 559

- Usually CLINICAL DIAGNOSIS - But SPECT can be used with 90% sensitivity and 100% specificity

Question 560

What is the management for Lewy Body Dementia?

Answer 560

- Acetylcholinesterase inhibitors e.g. donepezil, rivastigmine - Memantine - BEWARE neuroleptics - can cause irreversible parkinsonism in people with LBD

Question 561

Outline the management of Barret's oesophagus

Answer 561

- High dose PPI - Endoscopic surveillance with biopsies - for patietns with metaplasia (but not dysplasia) endoscopy is recommended every 3-5 years - If dysplasia of any grade is identified, endoscopic intervention is offered. Either RFA or endoscopic mucosal resection

Question 562

Risk factors for Barret's oesophagus?

Answer 562

- GORD - Males (7:1) ratio - Smoking - Central obesity

Question 563

Outline the management of Mesothelioma

Answer 563

- Symptomatic - Industrial compensation - Chemotherapy, surgery if operable - Prognosis is poor, median survival is 12 months

Question 564

Outline investigation of mesothelioma

Answer 564

- Suspicion is normally raised by a chest x-ray showing either a pleural effusion or pleural thickening - Next step is normally a pleural CT if a pleural effusion is present fluid should be sent for MC&S, biochemistry and cytology (but cytology is only helpful in 20-30% of cases) - Local anaesthetic thoracoscopy is increasingly used to investigate cytology negative exudative effusions as it has a high diagnostic yield (around 95%) - If an area of pleural nodularity is seen on CT then an image-guided pleural biopsy may be used

Question 565

What is the most common inherited bleeding disorder?

Answer 565

von Willebrand disease?

Question 566

What are the 3 types of vWd?

Answer 566

- Type 1 - partial reduction in vWf (80% of patients) - Type 2 - abnormal form of vWf - Type 3 - total lack of vWf (autosomal recessive)

Question 567

What is the inheritance pattern of vWd usually, what is the exception?

Answer 567

Mostly autosomal dominant, except in type 3 vWd - autosomal recessive

Question 568

What is the management of vWd?

Answer 568

- Tranexamic acid for mild bleeding - Desmopressin (DDAVP) - raises levels of vWF by inducing release of vWF from Weibel-Palade bodies in endothelial cells - Factor VIII concentrate

Question 569

Inheritance pattern of familial hypercholesterolaemia? Mutations in which gene?

Answer 569

Autosomal dominant Mutations in the gene which encodes the LDL-R protein

Question 570

What is the criteria on which diagnosis of familial hypercholesterolaemia is based?

Answer 570

Simon Broome criteria - Adults - Total cholesterol (TC) > 7.5 mmol/L and LDL-C > 4.9 mmol/L OR Children - TC > 6.9 mmol/L and LDL-C > 4.0 mmol/L, plus: - For definite FH: Tendon xanthomata in patients or 1st or 2nd degree relatives or DNA-based evidence of FH - For possible FH: FHx of MI below age of 50 yrs in 2nd degree relative, below age of 60 in 1st degree relative, or a family history of raised cholesterol levels

Question 571

Management of familial hypercholesterolaemia?

Answer 571

- Refer to specialist lipid clinic - High-dose statins usually first line - First-degree relatives have 50% chance of having the disorder - therefore offer screening. Screen children by age 10 if one affected parent and by age 5 if two affected parents - N.B statins should be discontinue in women 3 months before conception due to the risk of congenital defects

Question 572

What is the MOA of Thiazolidinediones and given an example drug in this class?

Answer 572

Agonists to the PPAR-gamma receptor and reduces peripheral insulin resistance E.g. Pioglitazone

Question 573

List some adverse effects of Thiazolidinediones

Answer 573

- Weight gain - Liver impairment - monitor LFTs - Fluid retention - therefore contra-indicated in heart failure. Risk of fluid retention increased if patient also takes insulin - Increased fracture risk - Bladder cancer - increased risk of ballder cancer in patients taking pioglitazone (hazard ratio 2.64)

Question 574

Outline the causes of Cushing's syndrome

Answer 574

ACTH dependent causes: - Cushing's diseaes (80%) - pituitary tumour secreting ACTH producing adrenal hyperplasia - Ectopic ACTH production (5-10%) e.g. small cell lung cancer ACTH independent causes: - Iatrogenic - steroids - Adrenal adenoma - Adrenal carcinoma - Carney complex - syndrome including cardiac myxoma - Micronodular adrenal dysplasia (very rare) Pseudocushing's: - Mimics Cushings - Often due to alcohol excess or severe depression - Causes false positive dex supression test or 24 hr urinary free cortisol - Insulin stress test may be used to differentiate

Question 575

Outline the management of neuroleptic malignant syndrome?

Answer 575

- Stop antipsychotics - Transfer to medical ward, consider ITU - IV fluids to prevent renal failure - Dantrolene in some cases - Bromocriptine can be used also

Question 576

What renal complication can occur in severe cases of neuroleptic malignant syndrome?

Answer 576

AKI secondary to rhabdomyolysis

Question 577

Features of neuroleptic malignant syndrome?

Answer 577

- Pyrexia - Muscle rigidity - Autonomic lability: typical features include hypertension, tachycardia and tachypnoea agitated delirium with confusion

Question 578

What is the inheritance pattern of Peutz-Jegher?

Answer 578

Autosomal Dominant

Question 579

What is the management of Peutz-Jegher syndrome?

Answer 579

Conservative unless complications develop

Question 580

Features of Peutz-Jegher syndrome?

Answer 580

- Hamartomatous polyps in the gastronintestinal tract (mainly small bowel) - Small bowel obstruction is a common presenting complaint, often due to intussusception - Gastrointestinal bleeding - Pigmented lesions on lips, oral mucosa, face, palms and soles

Question 581

What is the management for Peutz-Jegher syndrome?

Answer 581

Conservative unless complications develop

Question 582

True or false, there may be a transient thyrotoxicosis phase in Hashimoto's thyroiditis?

Answer 582

True

Question 583

Hashimoto's is linked with the development of which GI cancer?

Answer 583

MALT lymphoma

Question 584

How is pain in diabetic neuropathy managed?

Answer 584

Same as with other peripheral neuropathies First line: Amitryptiline, Duloxetine, Gabapentin, Pregabalin If one of these don't work, try another of them Tramadol can be used as rescue therapy for exacerbations of neuropathic pain Topical capsaicin may be used for localised neuropathic pain (e.g. post-herpetic neuralgia) Pain management clinics may be useful in patients with resistant problems

Question 585

Features of gastroparesis?

Answer 585

Occurs secondary to autonomic neuropathy Symptoms include erratic blood glucose control, bloating and vomiting Management options include metoclopramide, domperidone or erythromycin (prokinetic agents)

Question 586

Give 3 examples of GI manifestations of autonomic neuropathy

Answer 586

1. Gastroparesis 2. Chronic diarrhoea - often at night 3. GORD

Question 587

How is Leptospirosis spread?

Answer 587

Leptospirosis is caused by the spirochaete Leptospira interrogans (serogroup L. icterohaemorrhagiae), classically being spread by contact with infected rat urine.

Question 588

Features of leptospirosis?

Answer 588

The early phase is due to bacteraemia and lasts around a week - May be mild or subclinical - Fever - Flu-like symptoms - Subconjunctival suffusion (redness)/haemorrhage Second immune phase may lead to more severe disease (Weil's disease) - Acute kidney injury (seen in 50% of patients) - Hepatitis: jaundice, hepatomegaly - Aseptic meningitis

Question 589

How is leptospirosis diagnosed?

Answer 589

- Serology - antibodies to Leptospira develop after about 7 days - PCR - Culture - note growth may take several weeks

Question 590

Outline management for leptospirosis

Answer 590

Management: - Mild-moderate disease - doxycycline or azithromycin - Severe disease - IV benzylpenicillin

Question 591

What is the imaging option of choice in cluster headaches?

Answer 591

MRI with gadolinium contrast

Question 592

What is the management of cluster headaches?

Answer 592

Acute - 100% oxygen (80% response rate within 15 minutes), subcut triptan (75% response rate within 15 minutes) Prophylaxis - verapamil Refer to specialist

Question 593

What is the management of haemochromatosis?

Answer 593

- Venesection is first-line - Desferrioxamine may be used second-line Monitoring - transferrin saturation should be kept < 50% and serum ferritin below 50 ug/L

Question 594

What is first line management for ITP?

Answer 594

First-line treatment is oral prednisolone Poolend normal human immunoglobulin can also be used - raises plt quicker than steroids so may be used if active bleeding or urgent invaisve procedure required Splenectomy - rarely used

Question 595

What is Evan's syndrome?

Answer 595

ITP in association with AIHA

Question 596

What is ITP?

Answer 596

Immune (or idiopathic) thrombocytopenic purpura (ITP) is an immune-mediated reduction in the platelet count. Antibodies are directed against the glycoprotein IIb/IIIa or Ib-V-IX complex. Children with ITP usually have an acute thrombocytopenia that may follow infection or vaccination. In contrast, adults tend to have a more chronic condition.

Question 597

Outline the management of Wolff-Parkinson-White (WPW)

Answer 597

- DEFINITIVE: RFA of the accessory pathway - MEDICAL: Sotalol**, amiodarone, flecainide **Avoid if co-existent AF as prolonging the refractory period at the AVN may increase the rate of transmission through the accessory pathway, increasing the ventricular rate and potentially deteriorating into VF

Question 598

List some association of WPW

Answer 598

HOCM mitral valve prolapse Ebstein's anomaly thyrotoxicosis secundum ASD

Question 599

ECG features of WPW?

Answer 599

Possible ECG features include: short PR interval wide QRS complexes with a slurred upstroke - 'delta wave' left axis deviation if right-sided accessory pathway in the majority of cases, or in a question without qualification, Wolff-Parkinson-White syndrome is associated with left axis deviation right axis deviation if left-sided accessory pathway type A (left-sided pathway): dominant R wave in V1 type B (right-sided pathway): no dominant R wave in V1

Question 600

How to differentiate between type A (left-sided pathway) WPW and type B (right-sided pathway) WPW?

Answer 600

- Type A (left-sided pathway): dominant R wave in V1 - Type B (right-sided pathway): no dominant R wave in V1

Question 601

When to consider starting abx in C. Jejuni infection? What is the treatment?

Answer 601

- Usually self-limiting - BNF advises treatment if severe or the patient is immunocompromised. Antibiotics are recommended if severe symptoms (high fever, bloody diarrhoea, or more than eight stools per day) or symptoms have lasted more than one week - First-line antibiotic is clarithromycin

Question 602

Complications of C. Jejuni infection?

Answer 602

- Guillain-Barre syndrome may follow - Campylobacter jejuni infections - Reactive arthritis - Septicaemia, endocarditis, arthritis

Question 603

Outline bronchiectasis management

Answer 603

- Physical training (e.g. inspiratory muscle training) - has a good evidence base for patients with non-cystic fibrosis bronchiectasis - Postural drainage - Antibiotics for exacerbations + long-term rotating antibiotics in severe cases - Bronchodilators in selected cases - Immunisations - Surgery in selected cases (e.g. Localised disease)

Question 604

Most common organisms isolated from patients with bronchiectasis?

Answer 604

- Haemophilus influenzae (most common) - Pseudomonas aeruginosa - Klebsiella spp. - Streptococcus pneumoniae

Question 605

Causes of LBBB?

Answer 605

- Myocardial infarction diagnosing a myocardial infarction for patients with existing LBBB is difficult, the Sgarbossa criteria can help with this - Hypertension - Aortic stenosis - Cardiomyopathy - Rare: idiopathic fibrosis, digoxin toxicity, hyperkalaemia

Question 606

What is the key investigation for pharyngeal pouch?

Answer 606

Barium swallow combined with dynamic video fluoroscopy

Question 607

What is the management for pharyngeal pouch?

Answer 607

Surgical management

Question 608

Features of pharyngeal pouch?

Answer 608

dysphagia regurgitation aspiration neck swelling which gurgles on palpation halitosis

Question 609

Pharyngeal pouch more common in men or women?

Answer 609

5 x more common in men

Question 610

List some side effects of thyroxine therapy?

Answer 610

- Hyperthyroidism: due to over treatment - Reduced bone mineral density - Worsening of angina - Atrial fibrillation

Question 611

What are some key interactions with levothyroxine and what is done to prevent this?

Answer 611

Absorption of levothyroxine is reduced with iron and calcium carbonate So give at least 4 hrs apart

Question 612

How soon after dose changes in thyroxine should TFTs be checked?

Answer 612

8-12 weeks

Question 613

At what dose to initiate levothyroxine?

Answer 613

initial starting dose of levothyroxine should be lower in elderly patients and those with ischaemic heart disease. The BNF recommends that for patients with cardiac disease, severe hypothyroidism or patients over 50 years the initial starting dose should be 25mcg od with dose slowly titrated. Other patients should be started on a dose of 50-100mcg od women with established hypothyroidism who become pregnant should have their dose increased by at least 25-50 micrograms levothyroxine due to the increased demands of pregnancy. The TSH should be monitored carefully, aiming for a low-normal value

Question 614

What is the target TSH in levothyroxine therapy?

Answer 614

the therapeutic goal is 'normalisation' of the thyroid stimulating hormone (TSH) level. As the majority of unaffected people have a TSH value 0.5-2.5 mU/l it is now thought preferable to aim for a TSH in this range

Question 615

Features in Wernicke's encephalopathy?

Answer 615

- Ophthalmoplegia (lateral rectus palsy, conjugate gaze palsy) / nystagmus (most common ocular sign) - Ataxia - Encephalopathy - Peripheral sensroy neuropathy Note petechial haemorrhages may occur in a variety of structures in the brain including mamillary bodies and ventricle walls

Question 616

Investigations of Wernicke's encephalopathy?

Answer 616

- decreased red cell transketolase - MRI

Question 617

WWhat additional symptoms are there in Korsakoff's syndrome versus Wernicke's syndrome?

Answer 617

Antero- and retrograde amnesia Confabulation

Question 618

Treatment for Wernicke's encephalopathy?

Answer 618

Thiamine replacement

Question 619

What follow up is needed for pleural plaques?

Answer 619

None - they are benign and DO NOT undergo malignant change

Question 620

What is the typical finding in the lungs in asbestosis?

Answer 620

Lower lobe fibrosis

Question 621

Management of asbestosis?

Answer 621

It is treated conservatively - no interventions offer a significant benefit

Question 622

Features of mesothelioma?

Answer 622

Malignant disease of the pleura Features: - Progressive SOB - Chest pain - Pleural effusion

Question 623

Features of asbestosis?

Answer 623

- Dyspnoea and reduced exercise tolerance - Clubbing - Bilateral end-inspiratory crackles - Lung function tests show a restrictive pattern with reduced gas transfer

Question 624

What is the management of mesothelioma? What is the prognosis of mesothelioma?

Answer 624

- Palliative chemo - Limited role for surgery and radiotherapy - Prognosis is very poor with median survival from diagnosis of 8-14 months

Question 625

What is the most common form of cancer associated with asbestos exposure?

Answer 625

Lung cancer actually more than mesothelioma Asbestos exposure and cigarette smoke increase risk synergistically - therefore smoking cessation is v important

Question 626

What is the management of hypocalcamia?

Answer 626

Severe hypocalcaemia (e.g. carpopedal spasm, tetany, seizures or prolonged QT interval) requires IV calcium replacement: - IV calcium gluconate, 10ml of 10% solution over 10 minutes - ECG monitoring is recommended - Further management depends on the underlying cause

Question 627

List the causes of hypocalcaemia?

Answer 627

- 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

Question 628

What is the typical finding on CXR in aortic dissection?

Answer 628

Widened mediastinum

Question 629

What is the gold standard investigation in suspected aortic dissection?

Answer 629

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

Question 630

The gold standard investigation for suspected aortic dissection is CT angiography of chest, abdomen and pelvis. What investigation can be done instead if patients are too risky to take to the CT scanner?

Answer 630

Trans-oesophageal echo (TOE)

Question 631

Management for type A then for type B aortic dissection?

Answer 631

Type A (ascending aorta - 2/3 of cases): - Surgical management, but blood pressure should be controlled to target systolic of 100-120mmHg whilst awaiting intervention Type B (descending aorta, distal to left subclavian origin 1/3 of cases): - Conservative management - Bed rest - Reduce blood pressure IV labetalol to prevent progression

Question 632

Complications of backward tear in aortic dissection? Complications of forward tear in aortic dissection?

Answer 632

BACKWARD TEAR COMPLICATIONS: - Aortic incompetence/regurgitation - MI: inferior pattern is often seen due to right coronary involvement FORWARD TEAR COMPLICATIONS: - Unequal arm pulses and BP - Stroke - Renal failure

Question 633

What is the classic triad in infectious mononucleosis?

Answer 633

- Sore throat - Pyrexia - Lymphadenopathy - note may be present in the anterior and posterior triangles of the neck, in contrast to tonsillitis which typically only results in the upper anterior cervical chain being enlarged

Question 634

Management of infectious mononucleosis?

Answer 634

- rest during the early stages, drink plenty of fluid, avoid alcohol - simple analgesia for any aches or pains - consensus guidance in the UK is to avoid playing contact sports for 4 weeks after having glandular fever to reduce the risk of splenic rupture

Question 635

What is used for the management of hiccups in palliative care prescribing?

Answer 635

- Chlorpromaxine - Haloperidol and gabapentin can also be used - Dex is also used, particularly if there are hepatic lesions

Question 636

What is the MOA of SGLT-2 inhibitors?

Answer 636

Inhibit sodium-glucose co transporter (SGLT-2) in the renal PCT to reduce glucose reabsorption and increase urinary glucose excretion

Question 637

Key side effect of SGLT-2 inhibitors which can actually be a beneficial side effect?

Answer 637

Weight loss

Question 638

List some key adverse effects related to SGLT-2 inhibitors?

Answer 638

- Urinary and genital infection (secondary to glycosuria). Fournier's gangrene - Normoglycaemic ketoacidosis - Increased risk of lower-limb amputation. Feet should be closely monitored

Question 639

Features of essential tremor?

Answer 639

- Postural tremor: worse if arms outstretched - Improved by alcohol and rest - Most common cause of titubation (head tremor)

Question 640

Inheritance pattern of essential tremor?

Answer 640

Autosomal dominant

Question 641

What is the first line management for essential tremor?

Answer 641

Propranolol

Question 642

Treatment for Legionnaire's

Answer 642

Treat with erythromycin / clarithromycin

Question 643

What is the diagnostic test of choice in Legionnaire's?

Answer 643

Urinary antigen

Question 644

Features of Legionella?

Answer 644

- 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

Question 645

Which territory of MI can often cause first degree heart block?

Answer 645

Inferior - right coronary artery - II , III, avF

Question 646

What are negative prognostic factors in Hodgkin's lymphoma?

Answer 646

- The presence of B symptoms (night sweats, weight loss and fever) - Male gender - Being aged >45 years old at diagnosis - High WCC, low Hb, high ESR or low blood albumin

Question 647

Key adverse effects with Rifampicin?

Answer 647

- Potent CYP450 liver enzyme inducer - Hepatitis - Orange secretions - Flu-like symptoms

Question 648

Which valvular pathology causes: 1) Wide pulse pressure? 2) Narrow pulse pressure?

Answer 648

1) Wide - Aortic regurgitation 2) Narrow - Aortic stenosis

Question 649

Raised beta- hcg and raised AFP suggests seminomatous or non-seminomatous testicular cancer?

Answer 649

Non-seminomatous

Question 650

List some associations for coarctation of the aorta

Answer 650

Turner's syndrome bicuspid aortic valve berry aneurysms neurofibromatosis

Question 651

Features of coarctation of the aorta?

Answer 651

infancy: heart failure adult: hypertension radio-femoral delay mid systolic murmur, maximal over the back apical click from the aortic valve notching of the inferior border of the ribs (due to collateral vessels) is not seen in young children

Question 652

Patient has a HbA1C of 45 mmol/mol (6.3%) - new diagnosis of pre-diabetes on testing - what is required as the next step?

Answer 652

Arrange a fasting glucose sample His HbA1c is on the higher side and currently resides in the pre-diabetes range (42-47 mmol/mol). A HbA1c reading cannot however be used to exclude diabetes - a fasting sample should therefore be arranged

Question 653

ECG features of hypokalaemia?

Answer 653

- U waves - Small or absent T waves (occasionally inversion) - Prolong PR interval - ST depression - Long QT

Question 654

After how many weeks of gestation can you start to consider pregnancy induced hypertension?

Answer 654

After 10 weeks only - if earlier than this then consider other causes

Question 655

What is the most common cause of secondary hypertension?

Answer 655

Conn's syndrome

Question 656

List some causes of secondary HTN and split them into renal, endocrine and drug causes then other causes

Answer 656

RENAL: - GN - Pyelonephritis - Adult PCKD - RAS ENDOCRINE: - Phaechromocytoma - Cushing's syndrome - Liddle's syndrome - Congenital adrenal hyperplasia (11-beta hydroxylase deficiency) - Acromegaly DRUG: - Steroids - MOAIs - COCP - NSAIDs - Leflunomide OTHER CAUSES: - Pregnancy - Coarctation of the aorta

Question 657

How to treat asymptomatic bacteriuria in pregnant women?

Answer 657

Prescribe a 7-day course of nitrofurantoin (if in first or second trimester only - contraindicated in the third trimester due to increased risk of neonatal haemolysis) Although asymptomatic, bacteriuria in pregnancy should always be treated to avoid progression to symptomatic urinary tract infection or pyelonephritis

Question 658

Primary and secondary causes of bile-acid malabsorption?

Answer 658

PRIMARY -excessive production of bile acid SECONDARY: - Ileal disease e.g. Crohn's - Cholecystectomy - Coeliac's disease - Small intestinal bacterial overgrowth

Question 659

What is the key investigation for bile-acid malabsorption?

Answer 659

SeHCAT test - scans are done 7 days apart to assess the retention/loss of radiolabelled 75SeHCAT

Question 660

What is the medical management for bile-acid malabsorption?

Answer 660

Cholestyramine

Question 661

Clostridia are gram negative or positive? Aerobic or anaerobic? Rods or bacilli?

Answer 661

Positive Anaerobic Bacillii

Question 662

Features of gas gangrene?

Answer 662

- Begins with pain - Then systemic - fever, dehydration - Then skin changes - tender, oedematous skin with haemorrhagic blebs and bullae. Crepitus may present on palpation

Question 663

What is post-thrombotic syndrome and how does it present?

Answer 663

Complications following a DVT. Venous outflow obstruction and venous insufficiency result in chronic venous hypertension. The resulting clinical syndrome is known as post-thrombotic syndrome The following features maybe seen: - Painful, heavy calves - Pruritus - Swelling - Varicose veins - Venous ulceration

Question 664

What is the management for post-thrombotic syndrome?

Answer 664

Compression stockings Keeping the leg elevated

Question 665

Most common valvular abnormality associated with PCKD?

Answer 665

Mitral valve prolapse Mitral regurgitation is also common but not as much as MV prolapse

Question 666

Associations for phaeochromocytoma?

Answer 666

- MEN type II - NF - VHL syndrome

Question 667

Rule of 10s in phaeochromocytoma?

Answer 667

- Bilateral in 10% - Malignant in 10% - Extra-adrenal in 10%

Question 668

Key investigation in phaeochromocytoma?

Answer 668

24 hr urinary collection of metanephrines (sensitivity 97%*)

Question 669

What is the management for phaeochromocytoma?

Answer 669

- FIRST - alpha blockers e.g. Phenoxybenzamine - Beta-blocker e.g. propranolol - SURGICAL management is definitive

Question 670

Anti-phospholipid syndrome can be primary or secondary to other conditions, which condition is it most commonly secondary to?

Answer 670

SLE

Question 671

Complications that may arise in pregnancy secondary to anti-phospholipid syndrome?

Answer 671

- Recurrent miscarriage - IUGR - Pre-eclampsia - Placental abruption - Pre-term delivery - Venous thromboembolism

Question 672

Outline the management of anti-phospholipid syndrome in pregnancy

Answer 672

- Low-dose aspirin should be commenced once the pregnancy is confirmed on urine testing - Low molecular weight heparin once a fetal heart is seen on ultrasound. This is usually discontinued at 34 weeks gestation

Question 673

Antibiotic options for treatment of chlamydia in pregnancy?

Answer 673

Azithromycin, erythromycin or amoxicillin

Question 674

Management for cardiac tamponade?

Answer 674

Urgent pericardiocentesis

Question 675

ECG feature in cardiac tamponade?

Answer 675

Electrical alternans

Question 676

Classical triad of features in cardiac tamponade?

Answer 676

- Hypotension - Raised JVP - Muffled heart sounds

Question 677

Outline the investigations required to diagnose Acromegaly

Answer 677

- Serum IGF-1 levels - THEN do OGTT to confirm and serial GH levels - Pituitary MRI may demonstrate a pituitary tumour

Question 678

Most common organism in ascitic fluid culture in SBP?

Answer 678

E.Coli

Question 679

Key investigation for SBP?

Answer 679

Paracentesis: neutrophil count > 250 cells/ul

Question 680

Key management for SBP?

Answer 680

Intravenous cefotaxime is usually given

Question 681

When should antibiotic prophylaxis ever be considered to prevent SBP in patients with ascites What is the prophylaxis used?

Answer 681

- Patients who have had an episode of SBP - Patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome Oral ciprofloxacin or norfloxacin

Question 682

How long after MI can you re-prescribe PDE5 inhibitors e.g. Sildenafil in patients who usually take it?

Answer 682

6 months

Question 683

Causes of hyperuricaemia?

Answer 683

INCREASED SYNTHESIS - Lesch-Nyhan syndrome - Myeloproliferative disorders - Purine-rich diet - Exercise - Psoriasis - Cytotoxics DECREASED EXCRETION - Drugs - low-dose aspirin, diuretics, pyrazinamide - Pre-eclampsia - Alcohol - Renal failure - Lead

Question 684

Posterior circulation stroke involves which vessels?

Answer 684

Vertebrobasilar arteries

Question 685

Outline the NYHA classification

Answer 685

NYHA Class I no symptoms no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations NYHA Class II mild symptoms slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea NYHA Class III moderate symptoms marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms NYHA Class IV severe symptoms unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity

Question 686

What is done for prevention of contrast media nephrotoxicity?

Answer 686

Intravenous 0.9% sodium chloride at a rate of 1 mL/kg/hour for 12 hours pre- and post- procedure. There is also evidence to support the use of isotonic sodium bicarbonate

Question 687

Risk factors for contrast induced nephropathy?

Answer 687

Risk factors include - Known renal impairment (especially diabetic nephropathy) - Age > 70 years - Dehydration - Cardiac failure - Use of nephrotoxic drugs such as NSAIDs

Question 688

Management for latent TB?

Answer 688

3 months of isoniazid (with pyridoxine) and rifampicin OR 6 months of isoniazid (with pyridoxine)

Question 689

Risk factors for latent TB becoming active?

Answer 689

- Silicosis - Chronic renal failure - HIV positive - Solid organ transplantation with - Immunosuppression - IVDU - Haematological malignancy - Anti-TNF treatment - Previous gastrectomy

Question 690

Variceal haemorrhage management

Answer 690

Flashcard notes skipped - you know this

Question 691

Grave's disease is an autoimmune thyroid disease in which the body produces .... antibodies to the ... .... ... ...

Answer 691

Grave's disease is an autoimmune thyroid disease in which the body produces IgG antibodies to the thyroid stimulating hormone receptor

Question 692

2 autoantibodies related to Grave's disease?

Answer 692

- TSH receptor stimulating antibodies (90%) - Anti-TPO antibodies (75%)

Question 693

List some features of Grave's that can be seen in Grave's but not in other causes of thyrotoxicosis?

Answer 693

Eye signs: - Exophthalmos - Ophthalmoplgia Pretibial Myxoedema Thyroid acropachy - a triad of: - Digital clubbing - Soft tissue swelling of hands and feet - Periosteal new bone formation

Question 694

How does myxoedema usually present - two key signs / symptoms?

Answer 694

Confusion Hypothermia

Question 695

How to manage myxoedema coma?

Answer 695

- IV thyroid replacement - IV fluid - IV corticosteroids (until the possibility of coexisting - Adrenal insufficiency has been excluded) - Electrolyte imbalance correction - Sometimes rewarming

Question 696

Outline the management of Acromegaly

Answer 696

**Trans-sphenoidal surgery is the first-line treatment for acromegaly in the majority of patients.** If a pituitary tumour is inoperable or surgery unsuccessful then medication may be indicated: **- Somatostatin analogue e.g. octreotide** Directly inhibits the release of growth hormone for example octreotide effective in 50-70% of patients **- GH receptor antagonist e.g. Pegvisomant ** prevents dimerization of the GH receptor once daily s/c administration very effective - decreases IGF-1 levels in 90% of patients to normal doesn't reduce tumour volume therefore surgery still needed if mass effect **- Dopamine agonists e.g. bromocriptine** the first effective medical treatment for acromegaly, however now superseded by somatostatin analogues effective only in a minority of patients **External irradiation is sometimes used for older patients or following failed surgical/medical treatment**

Question 697

How long is carbimazole used for initially until the patient becomes euthyroid before being reduced?

Answer 697

6 weeks

Question 698

Key adverse effect in use of carbimazole and therefore a key investigation to be done when starting on carbimazole?

Answer 698

Agranulocytosis - so check FBC

Question 699

What is the treatment of choice for toxic multinodular goitre?

Answer 699

Radioiodene therapy

Question 700

What key advice should you give when counselling patients starting carbimazole therapy?

Answer 700

Attend for urgent emdical review if developing any symptoms of infection e.g. sore throat or fever

Question 701

2 Key drug interactions that can reduce absorption of levothyroxine?

Answer 701

Iron Calcium Carbonate Advice to take at least 4 hours apart

Question 702

True or false, patients with Bartter's syndrome are often hypertensive as a result?

Answer 702

False - often normotensive

Question 703

Which class of oral hypoglycaemics to avoid in patients with active foot disease e.g. skin ulceration, osteomyelitis or gangrene? Why?

Answer 703

SGLT2-inhibitors should be avoided due to the possible increased risk of lower limb amputation (mainly toes)

Question 704

What is the first line treatment for painful diabetic neuropathy?

Answer 704

Amitriptyline, Duloxetine, Gabapentin or Pregabalin

Question 705

Difference between Cushing's disease and Cushing's syndrome?

Answer 705

This patient is suffering from Cushing's disease which results from increased secretion of adrenocorticotropic hormone (ACTH) from the anterior pituitary, often caused as a result of a pituitary adenoma. Whilst the symptoms should allow you to remove both Addison's disease and acromegaly as answers, confusion often comes from the difference between the different cushing answers. Cushing's syndrome is a collection of signs and symptoms due to prolonged exposure to cortisol and Cushing's disease is a specific type of Cushing's syndrome characterised by increased ACTH production of because of a pituitary adenoma (or sometimes due to excess production of hypothalamus CRH).

Question 706

hyperthyroidism associated with a tender goitre after an upper respiratory tract infection which is the typical presentation of .....?

Answer 706

Hyperthyroidism associated with a tender goitre after an upper respiratory tract infection which is the typical presentation of subacute thyroiditis (de Quervain's thyroiditis).