Exam topics from feedback Flashcards

Question

dermoid

Answer 1

dermoid is composed only of dermal and epidermal elements (which are both ectodermal in origin),

Answer 2

``` Rarely greater than 8 cm Glistening membrane Thin walled Unilocular or multilocular Clear or serous fluid contents No solid component ```

Answer 3

most common ovarian neoplasm, unilocular (or at times multilocular) cysts filled with clear watery fluid. The cysts measure 10 cm in average diameter but may be extremely large.

Answer 4

benign cystic tumor lined by a mucinous epithelium. | multilocular cyst with smooth outer and inner surfaces. It tends to be huge in size.

Answer 5

A pelvic ultrasound is the single most effective way of evaluating an ovarian mass with transvaginal ultrasonography being preferable due to its increased sensitivity over transabdominal ultrasound. Women with small (less than 50 mm diameter) simple ovarian cysts generally do not require follow-up as these cysts are very likely to be physiological and almost always resolve within 3 menstrual cycles. Women with simple ovarian cysts of 50–70 mm in diameter should have yearly ultrasound follow-up and those with larger simple cysts should be considered for either further imaging (MRI) or surgical intervention.

Answer 6

multiplying the total volume of a drink (in ml) by its ABV (measured as a percentage) and dividing the result by 1,000

Answer 7

Pulmonary hypertension is an increase of blood pressure in the pulmonary artery, pulmonary vein, or pulmonary capillaries, together known as the lung vasculature, leading to shortness of breath, dizziness, fainting, leg swelling and other symptoms.

Answer 8

= mean pulmonary arterial pressure that is greater than 25 mmHg. causes by heart failure, chronic lung disease chronic thromboembolic pulmonary hypertension

Answer 9

``` Presentation Symptoms exertional dyspnea, chest pain, and syncope fatigue and lethargy Physical examination loud P2 on auscultation right ventricular heave right-sided 4th heart sound murmurs holosystolic murmur of tricuspid regurgitation systolic ejection murmur diastolic pulmonic regurgitation (in severe cases) ```

Answer 10

Treatment Conservative continuous long-term oxygen therapy indication to maintain adequate oxygenation Medical note that there are a myriad of causes of pulmonary hypertension treatment should be aimed at treating and optimizing the underlying condition (e.g., anticoagulation in patients with recurrent pulmonary embolisms) vasoactive agents indication pulmonary hypertension targeted therapy medication options calcium channel blockers prostacyclin pathway agonists (e.g., epoprostenol, treprostinil, and iloprost) endothelin receptor antagonists (e.g., bosentan, macitentan, and ambrisentan) nitric oxide-cyclic GMP enhancer (e.g., sildenafil and tadalafil)

Answer 11

The median age at presentation is 70-years-old. Use the mnemonicCRABBI: Calcium - Hypercalcaemia occurs as a result of increased osteoclast activity within the bones This leads to constipation, nausea, anorexia and confusion Renal Monoclonal production of immunoglobulins results in light chain deposition within the renal tubules This causes renal damage which presents as dehydration and increasing thirst Other causes of renal impairment in myeloma include amyloidosis, nephrocalcinosis, nephrolithiasis Anaemia Bone marrow crowding suppresses erythropoiesis leading to anaemia This causes fatigue and pallor Bleeding bone marrow crowding also results in thrombocytopenia which puts patients at increased risk of bleeding and bruising Bones Bone marrow infiltration by plasma cells and cytokine-mediated osteoclast overactivity creates lytic bone lesions This may present as pain (especially in the back) and increases the risk of fragility fractures Infection a reduction in the production of normal immunoglobulins results in increased susceptibility to infection

Answer 12

Investigations Bloods will show anaemia (FBC) and thrombocytopenia (FBC); raised urea and creatinine (U&E) and raised calcium Peripheral blood film: rouleaux formation Serum or urine protein electrophoresis: raised concentrations of monoclonal IgA/IgG proteins will be present in the serum. In the urine, they are known as Bence Jones proteins Bone marrow aspiration and trephine biopsy: confirms the diagnosis if the number of plasma cells is significantly raised Whole-body MRI (or CT if MRI is not suitable) is used to survey the skeleton for bone lesions

Answer 13

Symptomatic multiple myeloma is defined at diagnosis by the presence of the following three factors: Monoclonal plasma cells in the bone marrow >10% Monoclonal protein within the serum or the urine (as determined by electrophoresis) Evidence of end-organ damage e.g. hypercalcaemia, elevated creatinine, anaemia or lytic bone lesions/fractures

Answer 14

For patients who are suitable for autologous stem cell transplantation* induction therapy consists of Bortezomib + Dexamethasone For patients who are unsuitable for autologous stem cell transplantation*, induction therapy consists of Thalidomide + an Alkylating agent + Dexamethasone Pain: treat with analgesia (using the WHO analgesic ladder) Pathological fracture: Zoledronic acid is given to prevent and manage osteoporosis and fragility fractures as these are a large cause of morbidity and mortality, particularly in the elderly. Infection: patients receive annual influenza vaccinations. They may also receive Immunoglobulin replacement therapy. VTE prophylaxis Fatigue: treat all possible underlying causes. If symptoms persist consider an erythropoietin analogue.

Answer 15

abnormal creatinine and urea point towards reduced kidney function most likely due a nephrotoxic drug. NSAIDs (ibuprofen, naproxen) are known to precipitate renal failure in patients with multiple myeloma (MM)

Answer 16

leak of luminal contents from a surgical join' most important complication in GI surgery Causes Emergent surgery or prolonged operative time Decreased perfusion of the anastomosed bowel segments Increased pressure within the anastomosis Clinical features Postoperative fever, tachycardia (usually 5–7 days following surgery) Abdominal distention, pain, and peritoneal signs Tender incision wound, purulent (or feculent) drainage

Answer 17

Diagnostics Elevated inflammatory parameters X-ray /CT scan: contrast medium leakage in a barium meal or rectal filling; fluid collections and/or gas collections Complications: abscess formation, peritonitis, SIRS, sepsis Treatment Revision surgery Treating complications (e.g., by giving broad-spectrum antibiotics in the case of infection) Endoluminal vacuum-assisted closure therapy

Answer 18

the BAUS recommend an NSAID as the analgesia of choice for renal colic whilst diclofenac has been traditionally used the increased risk of cardiovascular events with certain NSAIDs (e.g. diclofenac, ibuprofen) should be considered when prescribing the CKS guidelines suggest for patients who require admission: 'Administer a parenteral analgesic (such as intramuscular diclofenac) for rapid relief of severe pain' BAUS no longer endorse the use of alpha-adrenergic blockers to aid ureteric stone passage routinely. They do however acknowledge a recently published meta-analysis advocates the use of α-blockers for patients amenable to conservative management, with greatest benefit amongst those with larger stones

Answer 19

Risk factors include known renal impairment (especially diabetic nephropathy) age > 70 years dehydration cardiac failure the use of nephrotoxic drugs such as NSAIDs

Answer 20

Features widespread pruritus linear burrows on the side of fingers, interdigital webs and flexor aspects of the wrist in infants, the face and scalp may also be affected secondary features are seen due to scratching: excoriation, infection

Answer 21

Management permethrin 5% is first-line malathion 0.5% is second-line give appropriate guidance on use (see below) pruritus persists for up to 4-6 weeks post eradication

Answer 22

cvd increase the risk of major cardiovascular events (such as atrial fibrillation, ischaemic stroke, heart failure and myocardial infarction) in comparison to other painkillers such as paracetamol.

Answer 23

here are 3 main frameworks that are used in this scenario: common law: used to treat patients in emergency scenarios Mental Capacity Act: (MCA) used in patients who require treatment for physical disorders that affect brain function. Remember this may be delirium secondary to sepsis or a primary brain disorder such as dementia Mental Health Act (MHA): used in patients who require treatment for mental disorders. For patients already admitted to hospital, a section 5(2) is used if there is not the time for a more formal section 2 or 3. A typical scenario would be a patient who has a mental health disorder attempting to discharge themselves, when it is thought this may result in harm

Answer 24

Immediate antithrombotic therapy: give aspirin 300 mg immediately, unless 1. the patient has a bleeding disorder or is taking an anticoagulant (needs immediate admission for imaging to exclude a haemorrhage) 2. the patient is already taking low-dose aspirin regularly: continue the current dose of aspirin until reviewed by a specialist 3. Aspirin is contraindicated: discuss management urgently with the specialist team

Answer 25

A simple step-up management scheme often used in the treatment of acne is as follows: single topical therapy (topical retinoids, benzoyl peroxide) topical combination therapy (topical antibiotic, benzoyl peroxide, topical retinoid) oral antibiotics: a topical retinoid (if not contraindicated) or benzoyl peroxide should always be co-prescribed with oral antibiotics to reduce the risk of antibiotic resistance developing. Topical and oral antibiotics should not be used in combination Gram-negative folliculitis may occur as a complication of long-term antibiotic use - high-dose oral trimethoprim is effective if this occurs

Answer 26

Features red eye classically not painful (in comparison to scleritis), but mild pain may be present watering and mild photophobia may be present in episcleritis, the injected vessels are mobile when gentle pressure is applied on the sclera. In scleritis, vessels are deeper, hence do not move phenylephrine drops may be used to differentiate between episcleritis and scleritis. Phenylephrine blanches the conjunctival and episcleral vessels but not the scleral vessels. If the eye redness improves after phenylephrine a diagnosis of episcleritis can be made

Answer 27

Oral glucocorticoids

Answer 28

The recommended initial management of otitis externa is: topical antibiotic or a combined topical antibiotic with a steroid if the tympanic membrane is perforated aminoglycosides are traditionally not used* if there is canal debris then consider removal if the canal is extensively swollen then an ear wick is sometimes inserted

Answer 29

= bisphosphate

Answer 30

Consider assessment of fracture risk in all women aged 65 years and over and all men aged 75 years and over. Use either FRAX (without a BMD value if a DXA scan has not previously been undertaken) or QFracture

Answer 31

``` Oral bisphosphonates (alendronic acid, ibandronic acid and risedronate sodium) are recommended as options for treating osteoporosis in adults only if: the person is eligible for risk assessment as defined in when to assess a person depending on age and sex and the 10-year probability of osteoporotic fragility fracture is at least 1%. ```

Answer 32

``` Delirium tremens (DTs) is a rapid onset of confusion usually caused by withdrawal from alcohol. peak 72 hours offer oral lorazepam1 as first-line treatment. If symptoms persist or oral medication is declined, offer parenteral lorazepam1 or haloperidol. ```

Answer 33

``` Reduced FEV1 (<80% of the predicted normal) Reduced FVC (but to a lesser extent than FEV1) FEV1/FVC ratio reduced (<0.7) ```

Answer 34

Typical spirometry findings in restrictive lung disease include: ``` Reduced FEV1 (<80% of the predicted normal) Reduced FVC (<80% of the predicted normal) FEV1/FVC ratio normal (>0.7) ```

Answer 35

do an ECG (to rule out prolonged QT interval) and baseline liver function tests

Answer 36

1. morbidity 2. losses: relationships, independence, work and income, self-worth, mobility andflexibility 3. social isolation and lack of social support

Answer 37

ymptoms and signs include: Follicular hyperkeratosis and perifollicular haemorrhage Ecchymosis, easy bruising Poor wound healing Gingivitis with bleeding and receding gums Sjogren's syndrome Arthralgia Oedema Impaired wound healing Generalised symptoms such as weakness, malaise, anorexia and depression

Answer 38

Linked the HLA-B38/B39 (peripheral PsA) and HLA-B27 (spondylitis PsA) Inflammatory arthritis- i.e. painful, hot, swollen, erythematous joints NB joints are usually less painful/tender than in rheumatoid Joints are also more likely to present in a ‘ray’ distribution i.e. all the joints of one digits affected rather than the same joints of both hands (more typical of RA) However, like RA, symptoms do worsen at rest/night and improve with movement Pencil-in-cup deformity is the description given to one of the appearances on plain radiograph in psoriatic arthritis.

Answer 39

``` Anterior uveitis SAPHO syndrome synovitis acne pustulosis hyperostosis osteitis ```

Answer 40

Management NSAIDs are recommended for symptomatic treatment Intra-articular steroids may be used second line. NB Oral corticosteroids should be avoided as psoriasis rash may rebound upon treatment withdrawal. DMARDS Early treatment with DMARDS should be considered for peripheral arthritis and enthesitis, +/- skin/nail disease. Ideally treat both the skin and musculoskeletal symptoms (if both are present) Methotrexate is often the best treatment for this reason

Answer 41

differtating factor - high ACE levels

Answer 42

hot joint + waxy yellow rash time course typically develops within 4 weeks of initial infection - symptoms generally last around 4-6 months around 25% of patients have recurrent episodes whilst 10% of patients develop chronic disease arthritis is typically an asymmetrical oligoarthritis of lower limbs dactylitis symptoms of urethritis eye conjunctivitis (seen in 10-30%) anterior uveitis skin circinate balanitis (painless vesicles on the coronal margin of the prepuce) keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)

Answer 43

Heberden's nodes and thumb symptoms is highly suggestive of osteoarthritis.

Answer 44

common peroneal nerve

Answer 45

Osteoarthritis - paracetamol + topical NSAIDs (if knee/hand) first-line

Answer 46

Morning stiffness lasting > 2 hours may be an indication of inflammatory arthritis. This would warrant further investigations.

Answer 47

Anti mitocondrial antibodies middle-aged females (female:male ratio of 9:1). with itch Clinical features early: may be asymptomatic (e.g. raised ALP on routine LFTs) or fatigue, pruritus cholestatic jaundice hyperpigmentation, especially over pressure points around 10% of patients have right upper quadrant pain xanthelasmas, xanthomata also: clubbing, hepatosplenomegaly late: may progress to liver failure

Answer 48

p-ANCA ass/w UC ``` Presents with cholestasis jaundice, pruritus raised bilirubin + ALP right upper quadrant pain fatigue ```

Answer 49

nvestigation (MRCP prefered) endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) are the standard diagnostic investigations, showing multiple biliary strictures giving a 'beaded' appearance p-ANCA may be positive there is a limited role for liver biopsy, which may show fibrous, obliterative cholangitis often described as 'onion skin' Cholangiocarcinoma develops in around 10% of primary sclerosing cholangitis patients

Answer 50

is the most common malignancy in men aged 20-30 years. Around 95% of cases of testicular cancer are germ-cell tumours.

Answer 51

``` Commonest subtype (50%) Average age at diagnosis = 40 Even advanced disease associated with 5 year survival of 73% ``` AFP usually normal HCG elevated in 10% seminomas Lactate dehydrogenase; elevated in 10-20% seminomas (but also in many other conditions)

Answer 52

Sheet like lobular patterns of cells with substantial fibrous component. Fibrous septa contain lymphocytic inclusions and granulomas may be seen.

Answer 53

Younger age at presentation =20-30 years Advanced disease carries worse prognosis (48% at 5 years) Retroperitoneal lymph node dissection may be needed for residual disease after chemotherapy AFP elevated in up to 70% of cases HCG elevated in up to 40% of cases Other markers rarely helpful

Answer 54

Diagnosis Ultrasound is first-line!! CT scanning of the chest/ abdomen and pelvis is used for staging Tumour markers (see above) should be measured Management Orchidectomy (Inguinal approach) Chemotherapy and radiotherapy may be given depending on staging Abdominal lesions >1cm following chemotherapy may require retroperitoneal lymph node dissection.

Answer 55

Leptospirosis is caused by the spirochaete Leptospira interrogans (serogroup L. icterohaemorrhagiae), classically being spread by contact with infected rat urine. Epidemiology leptospirosis is commonly seen in questions referring to sewage workers, farmers, vets or people who work in an abattoir however, on an international level, leptospirosis is far more common in the tropics so should be considered in the returning traveller

Answer 56

Features 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

Answer 57

Investigation serology: antibodies to Leptospira develop after about 7 days PCR culture growth may take several weeks so limits usefulness in diagnosis blood and CSF samples are generally positive for the first 10 days urine cultures become positive during the second week of illness Management high-dose benzylpenicillin or doxycycline

Answer 58

``` Clinical features of symptomatic disease chest pain dyspnoea syncope murmur an ejection systolic murmur (ESM) is classically seen in aortic stenosis classically radiates to the carotids this is decreased following the Valsalva manoeuvre ``` ``` Features of severe aortic stenosis narrow pulse pressure slow rising pulse delayed ESM soft/absent S2 S4 thrill duration of murmur left ventricular hypertrophy or failure ```

Answer 59

Contraindications chronic kidney disease: NICE recommend that the dose should be reviewed if the creatinine is > 130 µmol/l (or eGFR < 45 ml/min) and stopped if the creatinine is > 150 µmol/l (or eGFR < 30 ml/min) metformin may cause lactic acidosis if taken during a period where there is tissue hypoxia. Examples include a recent myocardial infarction, sepsis, acute kidney injury and severe dehydration iodine-containing x-ray contrast media: examples include peripheral arterial angiography, coronary angiography, intravenous pyelography (IVP); there is an increasing risk of provoking renal impairment due to contrast nephropathy; metformin should be discontinued on the day of the procedure and for 48 hours thereafter alcohol abuse is a relative contraindication

Answer 60

Usually contain a mixture of papillary and colloidal filled follicles Histologically tumour has papillary projections and pale empty nuclei Seldom encapsulated Lymph node metastasis predominate Haematogenous metastasis rare

Answer 61

Usually present as a solitary thyroid nodule | Malignancy can only be excluded on formal histological assessment

Answer 62

May appear macroscopically encapsulated, microscopically capsular invasion is seen. Without this finding the lesion is a follicular adenoma. Vascular invasion predominates Multifocal disease raree

Answer 63

C cells derived from neural crest and not thyroid tissue Serum calcitonin levels often raised Familial genetic disease accounts for up to 20% cases Both lymphatic and haematogenous metastasis are recognised, nodal disease is associated with a very poor prognosis.

Answer 64

Most common in elderly females Local invasion is a common feature Treatment is by resection where possible, palliation may be achieved through isthmusectomy and radiotherapy. Chemotherapy is ineffective

Answer 65

Supplementary oxygen should be given to all hypoxaemic patients with severe acute asthma to maintain an SpO2 level between 94–98%. Do not delay if pulse oximetry is unavailable. First-line treatment for acute asthma is a high-dose inhaled short-acting beta2 agonist (salbutamol or terbutaline sulfate) given as soon as possible. If response poor - consider continuous nebulisation with an appropriate nebuliser adequate dose of oral prednisolone. Nebulised ipratropium bromide may be combined with a nebulised beta2 agonist in patients with severe or life-threatening acute asthma, . A single intravenous dose of magnesium sulfate may be considered in patients with severe acute asthma (peak flow

Answer 66

Monitoring • ECG – Cardiac side effects include: Arrhythmias, Hypotension, Tachycardia • Neurology – if convulsions are seen call a ‘MET call’ • U+E’s – Hypokalaemia Therapeutic Drug monitoring • Take levels 4- 6 hours after starting infusion then daily thereafter • Therapeutic range 10 - 20mg/L

Answer 67

``` patient must be monitored every  15mins for at least 1 hour  1 hourly for 4 hours 2 hourly thereafter  If stable commence 4 hourly observations (or as per NEWS frequency) ```

Answer 68

Respiratory depression- Inform Anaesthetist/ DR have Naloxone ready. Nausea and vomiting - Give anti emetic. Hallucinations Pruritis Urinary retention

Answer 69

1) Stop epidural infusion if patient is symptomatic 2) Place patient supine or in the lateral recovery position if there is any concern about the patient's airway or level of consciousness is depressed. 3) Rapidly infuse 250-500mls of colloid? 4) Give 100% O2 by face mask 5) Have EPHEDRINE at patient's bedside (with 10 mls water for injection) 6) Get Medical Assistance, i.e. ward doctor and/or on-call anaesthetist Bleep 1130 7) Monitor the following: blood pressure, pulse, respiratory rate, AVPU (conscious level) every 5 minutes until there is sustained improvement in blood pressure and level of consciousness.

Answer 70

Symptoms ``` Frequently asymptomatic in early stages Anorexia & nausea Fatigue & weakness Muscle cramps Pruritus Dyspnoea Oedema Signs ``` ``` Pallor (secondary to anaemia) Hypertension Fluid overload (e.g. raised JVP, peripheral & pulmonary oedema) Skin pigmentation Excoriation marks Peripheral neuropathy ```

Answer 71

Urine ``` Urine dipstick Urine microscopy ACR (spot test) ACR (24-hour collection) Electrophoresis (e.g. myeloma) Bloods ``` ``` FBC U&Es (inc. eGFR) Bone profile PTH Bicarbonate LFTs Lipid profile Autoimmune screen (e.g. ANCA, ANA) Myeloma screen Imaging ``` Renal ultrasound Magnetic resonance angiography Echocardiogram ECG (high risk of CVS disease)

Answer 72

normocytic normochromic anaemia is typical of CKD (decreased erythropoietin) Hyperkalaemia ypocalcaemia, hyperphosphataemia and hyperparathyroidism = bony pathology adynamic bone disease, osteomalacia, osteoporosis and osteitis fibrosa cystica hypervolaemia and patients may have evidence of peripheral oedema, ascites, raised JVP, gallop rhythm and bilateral pleural effusions. low bicarbonate levels

Answer 73

Hypocalcaemia: dietary supplements and calcitriol. Hyperphosphataemia: dietary restriction and phosphate binders. Hyperparathyroidism: calcimimetics or surgery. fluid restriction reduced sodium intake and the use of oral diuretics (e.g. furosemide) oral sodium bicarbonate therapy. .