extra passmed questions Flashcards
PPIs can increase risk of what…
and why?
increased risk of osteoporosis and fractures
due to malabsorption of calcium and magnesium
long term PPI use can also mask symptoms of gastric cancer
first line anti-hypertensive in pre-eclampsia patiens
labetalol
give nifedipine is patient asthmatic
beta blockers should be avoided in patients with asthma
A 65-year-old man with liver cirrhosis of unknown cause is reviewed in clinic. Which one of the following factors is most likely to indicate a poor prognosis?
- ALT > 200
- caput medusae
- ascites
- gynaecomastia
- splenomegaly
ascites
child pugh classification
the following characteristics indicate:
- sudden onset
- concealed bleeding
- severe pain
- shock greater than visible blood loss
- firm, woody uterus
placental abruption
the following characteristics indicate:
- insidious onset
- visible bleeding
- painless
- shock in proportion to visible blood loss
- uterus relaxed
placenta praevia
management of premature rupture of membranes
IX - speculum + USS
TX- admit, regular obs, oral erythromycin, antenatal corticosteroids to reduce RDS risk, delivery considered at 34 weeks gestation?
70 y/o
pc: sudden onset of central chest pain, radiating to his jaw and left shoulder. The chest pain occurred an hour ago when he was sitting on a chair after his dinner.
pmh: HTN
OE: sweaty, nauseas, SOB, 120bpm, 150/100mmHg
ECG: T wave inversion, ST segment depression in anterior leads
Troponin not elevated.
likely diagnosis?
unstable angina
elevated trop will differ NSTEMI from unstable angina
COPD - still breathless despite using SABA/SAMA and no asthma/steroid responsive
next step:
LABA + LAMA
if patient is still breathless after laba and lama, then you would add ICS : LABA, LAMA + ICS
COPD - still breathless despite using SABA/SAMA and patient has features of asthma / steroid responsiveness
then give:
LABA and ICS
44 y/o female with Addisons
- hypotensive
- low grade fever
- increased urea
what does she have and what is first line management?
Addisonian crisis
give IV hydrocortisone
85 y/o male
ambulatory BP reading of 142/84
no pmh of CHD, Renal disease, or diabetes
dx: lansoprazole
10 year QRISK is 8%
management will include:
stage 1 hypertension : ambulatory reading of 135/85 or higher
HOWEVER only TX only offered if
- aged less than 80
- with either target organ damage, CHD, renal disease, diabetes or QRISK > 10%
so LIFESTYLE ADVICE
if stage 2, then antihypertensive should be started regardless
A 34-year-old woman with longstanding varicose veins is referred to hospital. Over the past few days she has developed a burning pain over one of the veins, with associated tenderness. It is hard to the touch, and the surrounding skin has become red. She is otherwise well, and has not noticed any calf swelling or pain, nor any shortness of breath. She has no other significant past medical history, nor family history, and does not take any regular medications.
On examination, a worm-like mass is felt, corresponding to the physical location of a varicose vein. The surrounding tissue appears erythematous and is hard. There are no ulcers. here is no evidence of deep vein thrombosis. Observations are normal. A couple of investigations are performed:
indicative of:
superficial thromboplebitis
- inflammation of one of the superficial veins
management
- compression stockings
What is target blood pressure for a 56-year-old man with type 2 diabetes mellitus who has no end-organ damage, if using a clinic blood pressure reading?
T2DM blood pressure targets are the same as non-T2DM. If < 80 years:
clinic reading: < 140 / 90
ABPM / HBPM: < 135 / 85
A patient presents to the emergency department with shortness of breath. They undergo an erect chest X-ray. The report states:
The left hemithorax demonstrates blunting of the costophrenic angle and cardiophrenic angle with fluid within the horizontal or oblique fissures.
Pleural fluid analysis demonstrates the following:
pH - 7.55
protein - 36 (10-20)
a) heart failure
b) hepatitis
c) meig’s syndrome
d) nephrotic syndrome
e) pulmonary embolism
EXUDATIVE
- rheumatoid arthritis
- TB
- Pulmonary embolism
Transudative
- Heart failure (most common)
- Meig’s syndrome
- hepatitis
- nephrotic syndrome
in this case: PULMONARY EMBOLISM
what type of effusion does Meig’s syndrome cause?
transudative pleural effusion and ascites
in presence of benign ovarian tumour
Boerhaave’s syndrome is a
spontaneous rupture of oesophagus
resulting in repeated episodes of vomiting
diagnosis: CT contrast swallow
baby boy:
Auscultation of the chest reveals a systolic murmur heard loudest at the left sternal edge and bilateral femoral pulses are weak.
indicative of what abnormality
coarcation of aorta
- narrowing of aorta leading to hypoperfusion of lower body
- babies: cardiac failure, poor feeding, lethargy and SOB
associated with
- turners
- bicuspid aortic valve
- berry aneurysms
- neurofibromastosis
treatment of choice for allergic bronchopulmonary aspergillosis
oral glucocorticoids
- prednisolone
A 65-year-old Caucasian male visits the GP complaining of tiredness, which has been worsening over the past few months. He also reports feeling short of breath on exertion and being more fatigued than usual.
next appropriate step:
URGENT COLORECTAL CANCER 2WW REFFERAL
- 60 years old with new iron deficiency anaemia
classical ‘bird’s beak’ appearance of the lower oesophagus. air fluid level seen.
indicative of:
achalasia
- failure of oesophageal peristalsis and relaxation of lower oesophageal sphincter
due to:
- degenerative loss of ganglia of Auerbach’s plexus
imaging of choice in suspected renal colic
non contrast CT KUB
A 45-year-old man attends the emergency department with acute-onset loin-to-groin pain. He states he has had similar pain before, but never as bad as this. A set of observations are carried out on his arrival:
Blood pressure: 110/85 mmHg Heart rate: 119 bpm Temperature: 38.6ºC Oxygen saturation: 98% on air Respiratory rate: 22/min
Given the most likely diagnosis, what is the definitive management?
obstructive renal calculi
+ signs of infection
ureteric colic from urinary calculi
MX = IV antibiotics, urgent renal decompression
Which of the following therapies is most likely to increase her risk of breast cancer?
a) combined HRT
b) primrose oil
c) oestrogen only HRT
d) SSRI
combined HRT has been shown to increase risk of breast cancer
The Mackler triad :vomiting, thoracic pain, subcutaneous emphysema.
It commonly presents in middle aged men with a background of alcohol abuse.
this is:
Boerhaave syndrome
A 52-year-old male presents with tearing central chest pain. On examination he has an aortic regurgitation murmur. An ECG shows ST elevation in leads II, III and aVF.
indicative of:
proximal aortic dissection
an inferior myocardial infarction and AR murmur should raise suspicions of ascending aorta dissection
A transjugular intrahepatic portosystemic shunt (TIPS) procedure connects the
hepatic vein and portal vein
what is recommended for for the secondary prophylaxis of hepatic encephalopathy?
- lactulose first line
- with addition of rifaximin
lactulose works through promoting excretion of ammoonia and increasing metabolism of ammonia in gut bacteria.
rifaximin given to modulate gut flora - resulting in decreased ammonia production
A 42-year-old woman presents to her GP complaining of symptoms of fatigue, weight gain and constipation. On examination, she has dry skin and hair and you note a firm, non-tender goitre in the neck. She has no significant medical history and isn’t aware of any family history as she was adopted.
Given the likely diagnosis, what is the most likely pathology underlying her condition?
a) autoimmune thryoiditis
b) drug induced hypothyroidism
c) iodine deficiency
d) subacute thyroiditis
e) toxic multinodular goitre
Autoimmune thyroiditis (Hashimoto’s) is the most common cause of hypothyroidism and is associated with other autoimmune diseases
this is generally used to induce remission of Crohn’s disease
prednisolone
note:
Azathioprine is very useful in maintaining remission, once achieved. It can also be used to induce remission on failure of steroids or aminosalicylates.
what drug is first line for reducing remission in ulcerative colitis?
aminosalicylate
such as mesalazine
On examination, there is an ejection systolic murmur heard loudest in inspiration. Chest auscultation is normal, the jugular venous pulse is not elevated and there is no peripheral oedema.
What is the most likely diagnosis of the options listed?
pulmonary stenosis
give 3 examples of things that would lead to:
Lower-than-expected levels of HbA1c (due to reduced red blood cell lifespan)
- sickle cell anaemia
- hereditary spherocytosis
- GP6D deficiency
give 3 examples of things that would lead to:
Higher-than-expected levels of HbA1c (due to increased red blood cell lifespan)
Vitamin B12/folic acid deficiency
Iron-deficiency anaemia
Splenectomy
first-line test for acromegaly
Serum IGF-1 levels
maturity onset diabetes of the young.
What is the inheritance pattern for this condition?
autosomal dominant
`1.) Severe hyperglycaemia
- ) Dehydration and renal failure
- ) Mild/absent ketonuria
indicates diagnosis of:
hyperosmolar hyperglycaemic state
- rehydrate with 0.9% saline
A 63-year-old woman presents to her GP with several years of hand pains. She describes pains initially developing in both wrists several years ago, and more recently pains in several joints of the fingers.
They tend to ache more after use and are relieved by resting. The affected joints feel stiff upon waking, but this lasts just a few minutes. Functionally, she does not describe any problems in completing tasks.
On examination, the patient describes tenderness at the carpometacarpal joints and several distal interphalangeal joints (DIPs) bilaterally. There are painless nodes palpable over several DIPs.
Given the findings, what is the most likely diagnosis?
Carpometacarpal and distal interphalangeal joint involvement is characteristic of hand osteoarthritis
where do loop diuretics act?
ascending loop of henle
44 y/o female
pc: recovering from ERCP 2 days ago for gall stone removal.
now: acutely unwell, abdo pain radiating to back and mild jaundice. vomiting and mild fever.
likely complication of ERCP to occur?
acute pancreatititis
Hypertrophic obstructive cardiomyopathy (HOCM) has what pattern of inheritance?
autosomal dominant
The AST/ALT ratio in alcoholic hepatitis
2:1
THIS is an essential investigation when investigating a PE
CXR
- should occur prior to CTPA or V/Q in suspected PEs
management of benign prostatic hyperplasia
Medication
- alpha 1 antagonist (tamsulosin) decrease smooth muscle tone
- 5 alpha reductase inhibitors (finasteride) reduce prostate volume, takes 6 months to take effect!
35 y/o runner with heal pain
- diffuse tenderness worse on medial aspect of heel bed
- aggravated by being on their feet
- worse on tip toes
typical of plantar fascitis
unlike subcalcaneal bursitis
A 67-year-old man presents to his GP with his wife who has noticed that he appears jaundiced over the past 2 days.
On taking a full history you elicit that his stools have recently become pale and difficult to flush. He has also lost approximately 5kg over the past two weeks. There is no abdominal pain. You note that he was diagnosed with type 1 diabetes 4 months ago.
On examination, you palpate an enlarged gallbladder in the right upper quadrant which is not tender.
Blood tests are as follows:
This scenario describes a patient with painless obstructive jaundice with a palpable gallbladder.
Courvoisier’s law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
PANCREATIC CANCER
1st line for COPD?
a) beclomethasone
b) ipratropium
c) N-acetylecysteine
d) oxygen
e) salmeterol
Ipatropium
- a SABA or SAMA is first line pharma treatment for copd
A 78-year-old man presents to emergency department with sudden onset, severe, diffuse abdominal pain at 7:30pm after finishing his evening meal. It is intermittent and severe in nature. However the abdomen is soft on examination. While in hospital he suffers from 1 episode of non-bloody emesis. Initial imaging does not yield any diagnosis. He has a history of GORD, hernia repair, hypertension, myocardial infarction and atrial fibrillation.
What is the most likely diagnosis?
ishchaemic colitis more likely
- post meal
- intermittent and severe pain
- pain out of proportion
- predisposing factors (MI, AF, HTN)
other DDs;
ruptured ulcer would give
- severe diffuse abdo pain
- more likely to present with epigastric pain first and bloody emesis
Small bowel obstruction
- intermittent pain
- distended abdomen
- obstruction on imaging
Diverticulitis
- PR bleed and bowel symptoms on top of pain
what sign might be seen on Abdo x-ray in a patient with ischaemic colitis
thumb printing - due to mucosal oedema and haemorrhage
IC
- inflammation, ulceration and haemorrhage
management
- usually supportive
this test is diagnostic for obstructive sleep apnoea
polysomnography
The patient is recorded using wires measuring various parameters including rapid eye movements, oxygen saturations and the electrical activity of the brain.
obstructive sleep apnoea
- either narrowing or collapse of pharyngeal airway
Patients with SVT who are haemodynamically stable and who do not respond to vagal manoeuvres, the next step is treating with
adenosine
describe supraventricular tachycardia?
- sudden onset narrow complex tachycardia
- typically atrioventricular nodal re-entry tachycardia
how to prevent episodes of supraventricular tachycardia?
- beta blockers
- radio frequency ablation
3 steps of management of supraventricular tachycardia
- vagal manouver : carotid sinus massage and valsalva
- IV adenosine (NOT IN ASTHMATICS give verapamil instead)
- electrical cardioversion
which drug is contraindicaed in ventricular tachycardia?
ventricular tachycardia
- broad complex tachycardia
verapamil - IV adminstration of calcium channel blocker can precipitate cardiac arrest
57 y/o female
T2DM, BP 141/90mmHg
which anti-hypertensive is recommended?
ACEi or ARB
Newly diagnosed patient with hypertension who has a background of type 2 diabetes mellitus - add an ACE inhibitor or an angiotensin receptor blocker regardless of age
A 67-year-old man with a history of hypertension presents to the emergency department with a 24hr history of dyspnoea and palpitations. He also complains of mild chest discomfort. On examination, you note an irregularly irregular pulse of 115 beats per minute, blood pressure 95 / 70 mmHg and a respiratory rate of 20 breaths/min. He denies any regular medication and insists he has never experienced anything like this before. An ECG shows absent P waves with QRS complexes irregularly irregular intervals.
appropriate management:
think new onset atrial fibrillation
MX = Direct current cardioversion
side effects of GTN spray?
- hypotension
- tachycardia
- headaches
- flushing
Diabetes may cause postural hypotension secondary to autonomic dysfunction
what are other features of autonomic neuropathy?
These are features of autonomic neuropathy:
- Postural hypotension
- Loss of respiratory arrhythmia
- Erectile dysfunction
Poorly controlled hypertension, already taking an ACE inhibitor and a thiazide diuretic -
calcium channel blocker
Persistent ST elevation following recent MI, no chest pain
left ventricular aneurysm
DD
Dressler’s syndrome is a good differential for ST-elevation >2 weeks after an MI. However, you would expect to see widespread ST elevation with PR depression and it would typically present with fever and pleuritic chest pain that is worse on lying supine.
Massive PE + hypotension
MANAGEMENT?
thrombolyse
Has only been demonstrated to improve mortality in patients with NYHA class III or IV heart failure who are already taking an ACE inhibitor
spironolactone
Should be introduced first-line in patients with stable impaired left ventricular function
ACE inhibitor + beta-blocker
how to differentiate between ventricular tachycardia and supraventricular tachycardia?
VT is a broad (QRS) complex tachycardia
whereas SVT is a narrow (QRS) complex tachycardia.
A 30-year-old man presented with difficulty in breathing and fever. He was a known intravenous drug user. On examination, there was a pan-systolic murmur, heard loudest in inspiration over the left lower sternal edge. He had a small degree of pitting oedema bilaterally.
What is the most likely valvular condition?
Tricuspid regurgitation becomes louder during inspiration, unlike mitral stenosis
Tricuspid valve regurgitation is where the valve between the two right heart chambers (right ventricle and right atrium) doesn’t close properly. This causes a pan-systolic murmur best heard at the left lower sternal border and radiates to the right lower sternal border.
Wendy, 48, presents to the Emergency Department after feeling faint earlier that day. She is found to be in atrial fibrillation. She is known to have structural heart disease as a result of an ill-functioning mitral valve, but is otherwise fit and healthy. What is the most appropriate treatment if pharmacological cardioversion is agreed upon?
amiodarone
