Final Flashcards
If an enteric organism (e.g. E.coli), or UTI is the most likely cause of epididymo-orchitis treat with [] (10 days) or [] (14 days).
If an enteric organism (e.g. E.coli), or UTI is the most likely cause - treat with levofloxacin (10 days) or ofloxacin (14 days).
How can PDR lead to blindness? [4]
- New blood vessels are very fragile; easily break and leak
- Retinal haemorrhage can lead to acute blindness
- If repeated; leads to fibrosis & scarring
- Can lead to: tractional retinal detachment: when scar tissue or other tissue grows on your retina and pulls it away from the layer underneath
What is the management of diabetic retinopathy? [5]
Laser photocoagulation
Anti-VEGF medications such as ranibizumab, bevacizumab & Aflibercept
Vitreoretinal surgery (keyhole surgery on the eye) may be required in severe disease or a vitrectomy may be necessary to clear severe vitreous hemorrhage or to relieve tractional retinal detachment.
Corticosteroids: (triamcinolone, dexamethasone implant) can also be used, particularly in refractory DME.
Pan-retinal photocoagulation (PRP): laser used to make small burns evenly across the peripheral retina - should make blood vessels shrink and dissapear
What is the most common cause of visual loss in patients with diabetes? [1]
Describe this [1]
Diabetic macular oedema (DMO)
DMO is the commonest cause of visual loss in patients with diabetes
DMO is characterised by oedematous changes in or around the macula. As the macula is responsible for central vision, affected patients tend to complain of blurred vision when reading or difficulty recognising faces in front of them. DMO is the commonest cause of visual loss in patients with diabetes.9
Treatment of mild [2], moderate [2] and severe [4] hypoglycaemia?
Mild:
Sugary drink, e.g. lucozade, ordinary coke, orange juice
5-7 glucose tablets, or 3-4 heaped teaspoons of sugar in water
Moderate:
Glucogel® – 1-2 tubes buccally (into cheek), or jam, honey, treacle massaged into the cheek.
Intramuscular glucagon if needed
Severe (unconscious)
Do not put anything in the mouth
Place the person in the recovery position Administer 0.5-1mg glucagon IM
If carer is unable to administer glucagon, call 999
In hospital, administer iv glucose:
- Ideally 75mls of 20% glucose or 150mls 10% glucose over 15 mins
- 50mls 50% glucose can be given, but take care with veins – extravasation can cause chemical burns
A patient with DMT2 is presenting with symptoms of gastroparesis.
What drug could you rec. to resolve this? [1]
First line treatment for this condition as recommended by NICE is with Domperidone, a dopamine receptor antagonist
Diagnosis of prediabetes involves specific criteria:
Impaired Fasting Glucose (IFG): Fasting blood glucose levels between [] mmol/L
Impaired Glucose Tolerance (IGT): Two-hour oral glucose tolerance test (OGTT) values between [] mmol/L
Diagnosis of prediabetes involves specific criteria:
Impaired Fasting Glucose (IFG): Fasting blood glucose levels between 6.1-6.9 mmol/L
Impaired Glucose Tolerance (IGT): Two-hour oral glucose tolerance test (OGTT) values between 7.8-11.1 mmol/L
One or more of which parameters would warrant referral to a high-dependency unit (level 2 care)? [7]
- Blood ketone > 6 mmol/L
- Bicarbonate level < 5 mmol/L
- pH < 7.0
- GCS ≤ 12
- Systolic BP < 90 mmHg
- Hypokalaemia on admission < 3.5 mmol/L
State 5 causes of drug induced diabetes [5]
Glucocorticoids
b-blockers
Thiazide diuretics
Tacrolimus (used in transplantation – may cause “New Onset Diabetes after Transplantation” [NODAT])
Atypical anti-psychotics – eg. olanzapine, risperidone, clozapine
Which drugs are contraindicated for patients with DMT2 who might also be suffering from:
Heart Failure [2]
CKD [1]
Frail / elderly [3]
Obesity [2]
Heart Failure:
- Pioglitazone: causes oedema as an AE
- Saxagliptin: increase risk of HF
CKD [2]
- Caution with SUs
Frail / elderly [3]
- SGLT2i (hypoglycaemia risk)
- GLPs (hypoglycaemia risk)
- Caution with SUs (hypoglycaemia risk)
Obesity
- SUs (weight gain)
- Pioglitzaone (weight gain)
Name three anti-VEGF medications used to treat diabetic retinopathy [3]
ranibizumab, bevacizumab & Aflibercept
What is the arrow pointing to? [1]
Cotton wool spot
Cotton wool spots appear as grayish/whitish spots with soft, fuzzy edges, giving them a resemblance to a ball of cotton wool. They do not usually appear in clusters like hard exudate.
Name this complication of diabetic retinopathy [1]
Diabetic retinopathy is one of several causes of neovascular glaucoma: a type of secondary glaucoma.
Neovascularization can occur within the iris and its trabecular meshwork (rubeosis) causing a narrowing and closure of the drainage angle and therefore increased intraocular pressure.
Describe basic overview on how you determine AF tx? [+]
First question: is patient haemodinamically stable?
* if no then DC
If yes, Two questions to ask:
* i. is patient >65 y/o?
* ii. Does patient has history of ischaemic heart disease?
If yes to ANY of the two questions then:
* first line Beta Blockers, second line digoxin
If no to BOTH then
* First line is fleccanide, second line ameodarone
Congenital adrenal hyperplasia is caused by a congenital deficiency of the which enzyme? (In most cases) [1]
21-hydroxylase
- In a small number of cases it is caused by a deficiency of 11-beta-hydroxylase rather than 21-hydroxylase.
What is the role of 21-hydroxylase? [1]
21-hydroxylase is the enzyme responsible for converting progesterone into aldosterone and cortisol.
Autoantibodies directed at the adrenal cortex to the autoantigens [] and [] can be seen in 70% of patients with idiopathic or primary Addison’s disease
Autoantibodies directed at the adrenal cortex to the autoantigens 21-hydroxylase and 17 alpha hydroxylase can be seen in 70% of patients with idiopathic or primary Addison’s disease
Which enzyme being suppressed / mutated causes syndrome of apparent mineralocorticoid excess? [1]
Why does that create symptoms of hyperaldosternism? [1]
When 11BHSD-2 enzyme is supressed/mutated - cortisol is NOT deactivated and will binds to MR.
symptoms of hyperaldosteronism
Name three causes of adrenal insufficiency caused infections [3]
Pseudomonas aeruginosa
Meningococcal infection
TB
A patient has recently started a new medication that has caused them to have decreased free T3/4 levels.
What medication could it be?
- Interaction with calcium carbonate
- Interaction with amlodipine
- Iodine deficiency
- Interaction with aspirin
- Poor adherence to levothyroxine
A patient has recently started a new medication that has caused them to have decreased free T3/4 levels.
What medication could it be?
Interaction with calcium carbonate
- Interaction with amlodipine
- Iodine deficiency
- Interaction with aspirin
- Poor adherence to levothyroxine
What is the most common endogenous cause of this Cushings?
Adrenal adenoma
Adrenal carcinoma
Glucocorticoid therapy
Micronodular adrenal dysplasia
Pituitary adenoma
What is the most common endogenous cause of this Cushings?
Adrenal adenoma
- adrenal adenoma (5-10%)
Adrenal carcinoma
Glucocorticoid therapy
Micronodular adrenal dysplasia
Pituitary adenoma
Describe the results from high-dose dexomethasone testing for Cushings syndrome, Cushing disease and ectopic ACTH [3]
State which pathologies MEN1 [3], MEN2A [3] AND MEN2B [3] relate to
MEN1: 3Ps-
* Pituitary
* Pancreas
* Parathyroid
MEN2a- 3Cs
* Calcitonin- medullary thyroid
* Calcium- parathyroid
* Catecholamines- phaeochromocytoma
MEN2b- big and belly (the big ones and in the tummy)
* Medullary thyroid
* Phaeochromocytoma
* Mucosal tumours- eg GI tract
How can you figure out if a patient has bilateral adrenal hyperplasia or renal artery stenosis causing Na++++ and K —-? [1]
Renal artery stenosis will have a raised renin
Give differential diagnosis of primary hyperparathyroidism [3]
Thiazide like diuretics [1]
Lithium [1]
Tertiary hyperparathyroidism [1]
How do you treat hyperparathyroidism?
- Surgically? [1]
- Therapeutically? [1]
Parathyroidectomy
Cinacalcet directly lowers parathyroid hormone levels by increasing the sensitivity of the calcium sensing receptors to activation by extracellular calcium, resulting in the inhibition of PTH secretion. Indicated in patients with:
- Chronic renal failure
- Tertiary hyperparathyroidism
How do you treat ptx with hypocalcaemia:
With < 1.9 Ca2+, no symptoms? [2]
With < 1.9 Ca2+, symptoms? [2]
< 1.9 with no symptoms
- Oral calcium supplements
- If due to severe vitamin D def, treat with high dose vit D (Calcitriol)
< 1.9 with symptoms
- IV calcium gluconate
How does renal artery stenosis cause HTN? [2]
- Atherosclerosis or fibromuscular dysplasia most causes narrowing of the renal arteries
- The chronic ischemia produced by the obstruction of renal blood flow leads to adaptive changes in the kidney which include the formation of collateral blood vessels and secretion of renin by juxtaglomerular apparatus
TOM TIP: The MHRA issued a warning in 2019 about the risk of [] in patients taking carbimazole.
In your exams, look out for a patient on carbimazole presenting with symptoms of []
NB - not agranulocytosis
TOM TIP: The MHRA issued a warning in 2019 about the risk of acute pancreatitis in patients taking carbimazole.
In your exams, look out for a patient on carbimazole presenting with symptoms of pancreatitis (e.g., severe epigastric pain radiating to the back).
Describe the treatment for HBV [3]
Nucleoside analogues:
- Entecavir
- Tenofovir
AND
PEG-IFN (peginterferon alfa 2a)
If cirrhosis - just E & T
Describe HCV treatment:
- Length? [1]
- Therapies? [3]
8-12 weeks
Therapies:
- ARVs: aim sustained virological response (SVR; undetectable serum HCV RNA six months after the end of therapy)
- Combination dependent on genotype and stage of fibrosis
- currently a combination of protease inhibitors (e.g. daclatasvir + sofosbuvir or sofosbuvir + simeprevir) with or without ribavirin are used
Which drugs are used if seizures [1] and pyschotic symptoms [1] develop from AWS?
Seizures: IV Lorazepam
Pyschotic symptoms: Haloperidol (blocks D2 receptors)
Describe and explain treatment plan for hepatic encephalopathy [3]
1. Lactulose:
- Increases faecal bulk & peristalsis
- Also reduces colonic pH: reduces absorption of NH3
- dose varies from 15-50ml TDS
2. Phosphate enemas:
- fast acting osmotic laxative
- STAT if Ptx encephalopathic; after passing stools PRN BD
3. Rifaximin
- antibiotic: diminishes deaminating enteric bacteria to decrease production of nitrogenous compounds
- 550mg BD
Describe IV NAC infusion regime in paracetamol OD [3]
First infusion:
- 150mg/kg: one hour
Second infusion:
- 50mg/kg: 4 hours
Third infusion (can repeat if need)
- 100mg/kg: 16 hours
Tx for Hep B? [2]
Which is safe in pregnancy? [1]
Tenofocir
- competitive inhibition: replaces the deoxyribonucleitde substrate in HBV DNA
- faster acting than entecavir
- safe in pregancy
Entecavir
- inhibits RT of Hep B DNA
- toxicity in pregnancy
Explain specific change in blood flow from portal hypertension contributes to hepatic encephalopathy [1]
Collaterals between splenic and renal veins: spleno-renal shunts: allow blood from bowel to bypass the liver and leak into systemic circulation, ammonia included (instead of being converted to urea and excreted). Goes to brain
How does portal hypertension lead to ascites? [5]
- Increased pressure in portal system causes fluid to leak out of the capillaries in the liver and into peritoneal cavity. Increase in pressure also causes release of splachnic vasodilators.
- Drop in circulating volume due to vasodilators on splachnic vessels and fluid forced out causes reduced pressure in kidneys
- Renin is released
- Aldosterone is secreted via RAAS
- Increased aldosterone increase Na+ and therefore fluid reabsorption
- Cirrhosis is causes low albumin levels, which decreases oncotic pressure
How is spontaneous bacterial peritonitis diagnosed? [2]
Ascitic tap:
- WCC > 250 mm3 (neutrophils 80%)
- Gram -ve often
Tx of SBP? [2]
IV antibiotics: IV cefotaxime
Human albumin solution
Which immunoglobulins are specifically screened for in a liver screen? [3]
Which diseases do they indicate may be more likely?
IgA: ALD
IgM: Primary biliary cholangitis (PBC)
IgG: Autoimmune hepatitis
Describe the process of TIPS [2]
- shunt inserted into portal vein & into hepatic circulation
- reduces portal pressure
How do you manage Ptx with ALF? [6]
- Monitor for encephalopathy and conscious state.
- Administer N-acetylcysteine in all patients with acute liver failure, regardless of aetiology
- Insert a urinary catheter and monitor urine output hourly
- Blood glucose should be monitored by nursing staff every 2 hours for hypoglycaemia.
- Baseline tests depend on the history ie paracetamol levels following an overdose
- Arrange USS abdomen with Doppler of hepatic veins
What is dialysis dysequilibrium syndrome? [1]
As urea doesn’t leave the BBB as quick so you have excess urea in the brain but lower in circulation so there is a shift of water into the brain causing cerebral oedema
What MCV results are seen in SCA? [1]
Sickle cell disease causes a normocytic anaemia with raised reticulocyte count - due to haemolysis
What is the treatment of nephrogenic DI? [1]
Thiazide like diuretic:
- In simple terms DI leads to the production of vast amounts of dilute urine which is dehydrating and raises the plasma osmolarity, stimulating thirst. The effect of the thiazide causes more sodium to be released into the urine. This lowers the serum osmolarity which helps to break the polyuria-polydipsia cycl
Which pathologies make up Men1, 2a & 3a [+]
WPW is associated with which cardiac disease? [1]
HOCM
? abscess of colon should be investigated by..
Acutely unwell surgical patients should be investigated in a systematic way. Plain abdominal films and an erect chest x-ray will identify perforation. An abdominal CT scan (not a CT cologram) with oral and intravenous contrast will help to identify whether acute inflammation is present but also the presence of local complications such as abscess formation.
Coagulase-negative, Gram-positive bacteria such as [] are the most common cause of neutropenic sepsis
Coagulase-negative, Gram-positive bacteria such as Staphylococcus epidermidis are the most common cause of neutropenic sepsis
What change is seen in this kidney biopsy? [1]
Glomeruli are full of crescents.
What does this CT show? [1]
Background of XS alcohol
Pancreatic pseudocyst
A mild jaundice, raised WCC and dense fluid-filled mass on CT are classic findings. Note fluid is less dense than the surrounding tissues and will therefore appear darker on CT
If symptomatic, one of the following results is sufficient for diagnosis for DMT2
Random blood glucose ≥ [] mmol/l
Fasting plasma glucose ≥ [] mmol/l
2-hour glucose tolerance ≥ [] mmol/l
HbA1C ≥ [] mmol/mol (6.5%)
If symptomatic, one of the following results is sufficient for diagnosis:
Random blood glucose ≥ 11.1mmol/l
Fasting plasma glucose ≥ 7mmol/l
2-hour glucose tolerance ≥ 11.1mmol/l
HbA1C ≥ 48mmol/mol (6.5%)
In life-threatening bleeds what should you give a haemophiliac A patient? [1]
Haemophilia A affects factor VIII levels, and in major or life-threatening bleeds, recombinant factor VIII is the most appropriate treatment.
Desmopressin raises factor VIII levels and is used in minor bleeding in haemophilia A; it is not used in major bleeds.
How do you differentiate between a sickle cell patient having a splenic sequestration crisis and an aplastic crisis? [1]
Sequestration crisis and aplastic crisis can present similarly, however the reticulocyte count will typically be high in a sequestration crisis and low in an aplastic crisis.
How can you distinguish between a fibroadenoma and phyllodes tumour? [2]
They can be difficult to distinguish from a fibro-adenoma, as both present as a firm, non-tender, mobile lump in the breast.
However, phyllodes tumours are typically much faster growing and most commonly affect women in their 40s and 50s
A patient has A 65 year old man presents to the district nurse clinic with acute urinary retention secondary to an enlarged prostate. An immediate urinary catheterisation is attempted and the volume post-catheterisation is recorded as 1200ml.
Explain what the next appropriate management is [1]
This patient has a large retention volume of >1000ml. He should be admitted to monitor for post-obstructive diuresis
- Patients will be at risk for dehydration and should be monitored closely for their urine output in the hospital and if >200ml/hr urine is being produced, they should be replaced with intravenous fluids to avoid acute kidney injury.
How do you differentiate between ASD and VSD based off their murmurs? [2]
Atrial septal defect
- ejection systolic murmur louder on inspiration
VSD
- would give a pansystolic murmur and is therefore incorrect.
Which conditions are DOACs contraindicated in? [1]
In renal failure: if egfr < 15
If a patient has AF and structural heart disease - what do you give them? [1]
Amiodarone
What are the 4 stages to testicular tumour spreaD? [4
A patient is fat and presents with this symptom. What does it specifically suggest? [1]
eruptive xanthomas - hypertriglyceridemia
What are the rules about anticoagulating post-stroke / or TIA for a patient with AF? [2]
AF post stroke:
- following TIA - start immediately and after excluding haemorrhage
- following stroke - after 2 weeks. give antiplatelet in intervening period
What are two rules need to consider with regards to AF treatment and DOACs [1] and Amiodarone treatment? [2]
DOACs are contraindicated in valvular AF
If structural heart disease - amiodarone for rhythm control
Describe the murmur heard in coarctation of the aorta [1]
Systolic machinery murmur
Describe the (very) general management of umbilical and inguinal hernias [2]
remember it using the mnemonic:
Inguinal hernia - get then IN for surgery
Umbilical hernia - um don’t need to operate
How much ml of blood is determined as life-threatening haemoptysis? [1]
more than 120mls of frank blood in 24 hrs
Which drug should be avoided when giving levothyroxine as it reduces the effectiveness? [1]
How do you alter dosing timing to alleviate this? [1]
Ferrous sulphate should not be taken at the same time as Levothyroxine as the iron interferes with levothyroxine absorption.
The two medications should be taken about 2-4 hours apart with the Levothyroxine taken first.
Explain the change in JVP waveform you see in tricuspid regurgitation
Big v waves
- Tricuspid regurg happens during ATRIAL DIASTOLE, and means some blood moves from the ventricle to the atria filling it even more, and sending more of an equal and opposite force upwards to the internal jugular vein hence why we see prominent v waves.
Describe these changes seen in CXR [1]
What disease does this indicate? [1]
Ring shadows in the left lower zone are consistent with bronchiectasis.
A 25-year-old female presents with a 2-week history of bloating, abdominal cramps, and foul-smelling diarrhoea. Stool studies revealGiardia lamblia.
What is the first-line treatment for this patient’s infection?
metronidazole
How do you treat sigmoid volvulus [1]
How
- sigmoid volvulus: rigid sigmoidoscopy with rectal tube insertion
- caecal volvulus: management is usually operative. Right hemicolectomy is often needed
Sputum for TB? [3]
One straight away
One morning after
One morning after
Which type of polyp is associated with colorectal caner? [1]
What electrolyte change would this cause? [1]
Villous polyp - causes hypokalaemia
How do you calculate absolute risk?
E.g. The study recruited 3000 patients. 1700 received the new drug of which 170 patients developed carpal tunnel syndrome. The remaining patients received a placebo of which 300 developed carpal tunnel syndrome.
What is the absolute risk reduction of developing carpal tunnel syndrome by taking the new drug?
The absolute risk of the exposure group is 10% (170/1700). The absolute risk of the control group is 23% (300/1300). Therefore, the absolute risk reduction is 13% (23-10).
The presence of PR prolongation in infective endocarditis is suspicious for []
The presence of PR prolongation in infective endocarditis is suspicious for aortic root abscess
What can you give to prevent calcium stones? [3]
Ask patients to add lemon juice to water
Potassium citrate should be considered for the prevention of calcium stones
limit salt
avoid carbonated drinkd
Name two things can give to reduce the chance of oxalate stones [2]
cholestyramine reduces urinary oxalate secretion
pyridoxine reduces urinary oxalate secretion
What is BCG vaccine good at protecting agaisnt? [1]
TB meningitis in children
[] is the most common complication of mumps in post-pubertal males.
NB: symptoms of mumps - bilateral pain and swelling at the angle of the jaw, which is made worse by talking or chewing. On examination his pulse is 90/min, temperature 38.4ºC and bilateral palpable, tender parotid glands are noted.
Orchitis is the most common complication of mumps in post-pubertal males.
Name what the arrow is pointing at [1]
What drug class might you expect to see them in? [1]
Hyaline casts may be seen in the urine of patients taking loop diuretics
What is the difference in murmur between pulmonary and tricuspid stenosis? [2]
Pulmonary stenosis: ejection systolic
tricuspid stenosis: diastolic
Desribe the early presentation [2] and late presentation [5]of TURP syndrome [2
TURP syndrome typically presents with CNS, respiratory and systemic symptoms:
Early features
* mild cases may go unrecognised
* restlessness, headache, and tachypnoea, or a burning sensation in the face and hands
Features of greater severity
* respiratory distress, hypoxia, pulmonary oedema
* nausea, vomiting
* visual disturbance (e.g. blindness, fixed pupils)
* confusion, convulsions, and coma
* haemolysis
* acute renal failure
* reflex bradycardia from fluid absorption
Which of the following treatments for prostate cancer works as an non-steroidal anti-androgen?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works as an non-steroidal anti-androgen?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an steroidal anti-androgen?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an steroidal anti-androgen?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an androgen synthesis inhibitor?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an androgen synthesis inhibitor?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an GnRH antagonist?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an GnRH antagonist?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an GnRH agonist?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an GnRH agonist?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Name this form of taking prostate biopsies [1]
Why is it better than trans rectal biopsy? [1]
Template / transperineal biopsy (BP)
Less infections; more biopsies can be taken
A guided biopsy is offered to patients with a Likert score of [] or greater
A guided biopsy is offered to patients with a Likert score of 3 or greater
3 = Chance of clinically significant cancer is equivocal
4 = Clinically significant cancer is likely to be present
5 = Clinically significant cancer is highly likely to be present
Describe the treatment types for localised prostate cancer [4]
Radical prostatectomy (if < 75 and fit): can be open, laparoscopic or robotic surgery
Focal therapy:
- Brachytherapy (radioactive seeds)
- Cryotherapy
- HIFU (High frequency focused ultrasound)
Radiotherapy
Radiotherapy & androgen deprivation (stops stimulating the cancer to grow):
- Androgen-receptor blockers such as bicalutamide
- GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
A 70-year-old patient with prostate cancer is commenced on goserelin therapy. A week after starting treatment, he attends a local emergency department complaining of worsened lower urinary tract symptoms and new onset back pain.
Which treatment may have helped avoid this deterioration? [1]
Flutamide, a synthetic antiandrogen, can be used preemptively to attenuate the tumour flare through its antagonistic effects at androgen receptors.
Which of the following treatments for prostate cancer works by preventing DHT binding from intracytoplasmic protein complexes?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works by preventing DHT binding from intracytoplasmic protein complexes?
Cytoproterone acetate - steroidal anti-androgen
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer is normally the option for the treatment of hormone-relapsed metastatic prostate cancer in patients who have no or mild symptoms after androgen deprivation therapy has failed, and before chemotherapy is indicated?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer is normally the option for the treatment of hormone-relapsed metastatic prostate cancer in patients who have no or mild symptoms after androgen deprivation therapy has failed, and before chemotherapy is indicated?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
How do you decide when to use mirabegron or oxybutynin? [2]
Oxybutynin
- is an immediate-release antimuscarinic drug, often used for urge incontinence.
- However it can lead worsening of dementia and postural hypotension in older patients
Mirabegron
- beta-3 receptor agonist
- it is used in frail elderly patients as it has fewer anticholinergic side-effects so will not worsen dementia.
How do you treat unilateral and bilateral undescended testes in newborns? [2]
unilateral undescended testis:
- Arrange a review at 6-8 weeks
bilateral undescended testes:
- Refer to a senior paediatrician for endocrine or genetic investigation
- the presence of bilateral undescended testes should prompt the clinician to consider the possibility of an underlying pathology (commonly congenital adrenal hyperplasia (CAH).
A patient has BPH and concurrent DMT2 peripheral neuropathy. Which treatment for the peripheral neuropathy is CI because of his BPH? [1]
Amitriptyline due to the risk of urinary retention.
amyDRIPtyline - don’t prescribe to BPH patients with terminal dribbling
Describe the GI side effects of bisphosphonates like alendronic acid [3]
How do you instruct patients to take this medication to reduced the risks? [1]
Alendronic acid, a bisphosphonate used in the treatment of osteoporosis, can cause gastrointestinal side effects, including dyspepsia, oesophagitis and gastric ulcers.
It is important for patients to take alendronic acid correctly (with a full glass of water, without lying down for 30 minutes afterwards) to reduce these risks.
Name some CI for sildenafil use for ED? [5]
Individuals taking nitrates
Hypertension/hypotension
Arrhythmias
Unstable angina
Stroke
Recent myocardial infarction.
What is the difference in renal cancer staging between 1-4? [4]
Stage 1: < 7cm; no spread
Stage 2: > 7cm; no spread
Stage 3: > 7cm; spread locally
Stage 4: Spread to abdomen; adrenal glands; lymph nodes
Treatment for localised renal cancer?: T1 [2] & T2 [1]
T1 tumours:
- < 3 cm: ablative therapies
- up to 7 cm: partial nephrectomy
T2:
Radical nephrectomy (open, laporoscopic, open)
Name 4 differential diagnosises of cannonball metastasis
- renal
- choriocarcinoma
less commonly, with prostate, bladder and endometrial cancer.
Describe what is meant by Stauffer syndrome
Stauffer syndrome: RCC paraneoplastic syndrome
Hepatosplenomegaly
+
Cholestatic LFTs (elevated bilirubin; ALP and GGT)
Describe NICE guidelines regarding haematuria that determines investigating for bladder cancer [2]
Painless haematuria:
Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI. 2/3 samples positive for blood require investigation
Aged over 60 with microscopic haematuria (not visible but positive on a urine dipstick) PLUS:
Dysuria or;
Raised white blood cells on a full blood count
Describe the treatment for Mild [2], Intermediate [2] & High [3] risk patients of Non-Muscle Invasive Bladder Cancer (NMIBC)
Mild:
- Transurethral resection of bladder tumor (TURBT): provides diagnosis, staging, and initial treatment of diathermy
- Post TURBT - Intravesical chemotherapy (mitomycin or gemcitabine) given using a catheter: reduces risk of relapse
Moderate:
- Transurethral resection of bladder tumor (TURBT): provides diagnosis, staging, and initial treatment
- Post TURBT - Intravesical chemotherapy (mitomycin) given using a catheter; 6 doses - liquid place directly in bladder
High:
- Transurethral resection of bladder tumor (TURBT): X2
- BCG vaccine
- Cystectomy – totally remove the bladder
Describe treatment for Muscle Invasive Bladder Cancer (MIBC) [3]
Radical cystectomy: - gold standatd
- Complete surgical removal of the bladder, prostate or uterus, and regional lymph nodes
- Requires urinary diversion
Radiotherapy:
- organ sparing
(Adjuvant &/OR) Chemotherapy:
- Cisplatin before radical cystectomy
Describe the treatment for metastatic bladder cancer [3]
First-line therapy:
- platinum-based combination chemotherapy, such as gemcitabine-cisplatin or dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC).
Immune checkpoint inhibitors:
- For patients ineligible for cisplatin or after progression on first-line chemotherapy, pembrolizumab, atezolizumab, or nivolumab are options.
Targeted therapy:
- For patients with specific molecular alterations (e.g., FGFR3), targeted therapies like erdafitinib may be considered.
Describe the therapy options provided post-radical cystectomy [4]
Ileal conduit:
- A section of the ileum (15 – 20cm) is removed, and end-to-end anastomosis is created so that the bowel is continuous.
- The ends of the ureters are anastomosed to the separated section of the ileum.
- The other end of this section of the ileum forms a stoma on the skin, draining urine into a urostomy bag
Continent urinary diversion:
- Create a pouch inside the abdomen from a section of the ileum, with the ureters connected and fills with urine
- A thin tube is connected between a stoma on the skin and the internal pouch
- Urine does not drain from the stoma (unlike a urostomy), and the patient needs to intermittently insert a catheter into the stoma to drain urine from the pouch.
Neobladder formation:
- Formed from ileum; connected to both ureters and urethra
- Functions as normal bladder
Ureterosigmoidostomy (rare)
- Attaching the ureters directly to the sigmoid colon.
- The rectum may be expanded to create a recto sigmoid pouch (called a Mainz II procedure) to create a larger space for urine to collect.
- The patient can then drain the urine by relaxing the anal sphincter in the same way they open their bowels.
What is the name for this operation? [1]
Continent urinary diversion
Name this operation [1]
Ileal conduit
Describe the treatment for metastatic testicular cancer [3]
Chemotherapy:
- Cisplatin & Etoposide (cornerstone)
- Bleomycin (added)
Describe which parameters of varicoceles determine if treatment is given [2]
Grade II or III varicocoele Management:
* Asymptomatic AND normal semen parameters Semen analysis every 1-2yrs
* Symptomatic OR abnormal semen parameters: Surgery
Label the tumour marker for each type of testicular cancer [4]
A: hCG & AFP
B: AFP
C: hCG
D: no rise
Describe the difference in percutaneous nephrostomy and percutaneous nephrolithotomy [1]
nephrostomy - focuses on draining urine to relieve obstruction
- e.g A 23-year-old male is admitted with left sided loin pain and fever. His investigations demonstrate a left sided ureteric calculi that measures 0.7cm in diameter and associated hydronephrosis.
nephrolithotomy - focuses on removing kidney stones
- e.g. A 30-year-old male presents with left sided loin pain. His investigations demonstrate a large left sided staghorn calculus that measures 2.3cm in diameter.
What is the management of lower UTIs causing uncomplicated cystitis: (include length of time)
First line? [2]
Second line? [3]
Length of treatment? [1]
3-5 day course of standard antibiotics to local guidance:
First line:
* Nitrofurantoin
* Trimethoprim
Second line:
* co-amoxiclav
* cephalosporin
* ciprofloxacin
NICE guidelines (2018) recommend the which first-line antibiotics for 7-10 days when treating pyelonephritis in the community? [5]
Cefalexin
Co-amoxiclav (oral or IV if more serious; if culture results are available)
Trimethoprim (if culture results are available)
Ciprofloxacin (keep tendon damage and lower seizure threshold in mind)
IV Gentamicin (if severe)
How do you manage UTIs in men:
- If lower UTI [2]
- If suspected prostatic involvement [1]
If lower UTI:
* 7 day course of trimethoprim or nitrofurantoin
If suspected prostatic involvement:
- Ciprofloxacin
- Cefalexin (the typical choice)
Name [1] and describe the classification used for PAD [4]
Fontaine classification
What is the scar called? [1]
Whats the indication? [1]
Rutherford Morison
Describe the process of AVN ablation to treat AF [3]
Atrioventricular node ablation involves destroying the connection between the atria and ventricles (the atrioventricular node)
After the procedure, the irregular electrical activity in the atria cannot pass through to the ventricles
A permanent pacemaker is required to control ventricular contraction
Anticoagulation is still needed to prevent strokes.
Name five side effect of amiodarone use [5]
- Pneumonitis
- Bradycardia and Heart Block
- Hepatitis
- Photosensitivty and grey discolouration
- Thyroid abnormalties (hyper & hypo): amIODarone - iodine in the drug
What is meant by Prinzmetal’s or variant angina? [1]
When you get transient ST elevation due to coronary vasopasm (artery isn’t blocked, but muscle is in spasm)
Describe the treatment regimes for difference IE valves / pathogens
Decompensated heart failure accounts for most cases of AHF.
What are the most common precipitating causes of acute AHF? [4]
- Acute coronary syndrome
- Hypertensive crisis: e.g. bilateral renal artery stenosis
- Acute arrhythmia
- Valvular disease
There is generally a history of pre-existing cardiomyopathy. It usually presents with signs of fluid congestion, weight gain, orthopnoea and breathlessness.
CHAMP
Acute coronary syndrome (ACS)
Hypertensive crisis
Arrhythmias, e.g. atrial fibrillation, ventricular tachycardia, bradyarrhythmia
Mechanical problems, e.g. myocardial rupture as a complication of ACS, valve dysfunction
Pulmonary embolism
Explan your answer [1]
Left ventricular aneurysm
The ischaemic damage sustained may weaken the myocardium resulting in aneurysm formation. This is typically associated with persistent ST elevation and left ventricular failure. Thrombus may form within the aneurysm increasing the risk of stroke. Patients are therefore anticoagulated.
A patient has chronic heart failure. You trial and ACEI but the patient is intolerant.
You then trial an ARB, but the patient is still intolerant.
What treatment should you consider nexr? [1]
Hydralazine and nitrate
A patient has chronic heart failure.
You iniate an ACEin and a BB as first line treatment. This does not resolve their EF.
You next trial and aldosterone antagonist. This does also not help.
They are Afro-Carribean.
What is the appropriate third line treatment?
- Ivabradine
- sacubitril-valsartan
- digoxin
- hydralazine in combination with nitrate
- cardiac resynchronisation therapy
- hydralazine in combination with nitrate
State the different risk stratifications based of GRACE scores [5]
MI complications:
What would cause persistent ST elevation without chest pain? [1]
Ventricular aneurysm
Left ventricular free wall rupture
This is seen in around 3% of MIs and occurs around 1-2 weeks afterwards. Patients present with acute heart failure secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds). Urgent pericardiocentesis and thoracotomy are required.
How do you differentiate between a posterior and anterior MI on an ECG?
Anterior MI
- ST-segment elevation in the precordial leads V1-V4
Posterior MI
- tall R waves V1-3 PosteRioR contains 2 tall Rs
- Horizontal ST depression in V1-3
You believe he has Balanitis Xerotica Obliterans. What can be associated with this condition?
Protection from cancer
Phimosis
Protection from infection
Prostate hyperplasia
Basal cell carcinoma
You believe he has Balanitis Xerotica Obliterans. What can be associated with this condition?
Protection from cancer
Phimosis
Protection from infection
Prostate hyperplasia
Basal cell carcinoma
What are the symptoms of digoxin toxicity? [+]
dizziness, nausea and vomiting, palpitations, bradycardia, visual disturbances, confusion, and hyperkalaemia.
What is the MoA of digoxin? [1]
Inhibiting the Na+ K+ ATPase enzyme, also known as the sodium-potassium pump. This causes sodium to build up inside the heart cells, decreasing the ability of the sodium-calcium exchanger to push calcium out of the cells, consequently causing calcium to build up in the sarcoplasmic reticulum.
Increased intracellular calcium results in a positive inotropic effect, which in turn has the effect of increasing the force of the heart’s contractions.
Describe the clinical features of amyloidosis
Give 5 causes of falsely increased HbA1C [5].
Describe why this occurs [1]
B12 deficiency
IDA deficiency
Chronic alcoholism
Splenectomy
Pregnancy
All increase the lifespan of Hb
A patient presents with lipomas, supernumerary teeth, osteomas, and epidermoid cysts.
A 25 year old male patient presents to the general practitioner with a 1 month history of constipation, PR bleeding, and weight loss. He reports a family history of gastrointestinal problems.
What is the most likely diagnosis? [1]
Gardner’s variant of familial adenomatous polyposis (FAP): lipomas, supernumerary teeth, osteomas, and epidermoid cysts. FAP is caused by mutation of 1 allele in the APC gene A tumour suppressor gene)
A patient presents with the following, alongside respiratory symptoms.
Which infective organism is most likely to have caused this?
Mycoplasma pneumonia
A patient presents with the following, alongside respiratory symptoms.
Which infective organism is most likely to have caused this?
Streptococcus pneumonia
Herpes labialis
What causes this change? [1]
What FBC would you expect to see with this? [2]
Sideroblastic anaemia is a condition where red cells fail to completely form haem, whose biosynthesis takes place partly in the mitochondrion:
- hypochromic microcytic anaemia
- high ferritin iron & transferrin saturation
When do you give irradiated components? [4]
When plalelet concentrates indicated for transfusion? [4]
When are fresh frozen plasma transfusions indicated? [4]
Label the side effects
How d you treat a thrombotic and embolic acute limb ischaemia? [2]
For thrombotic causes:
- Angiography for incomplete ischaemia. This helps map the occlusion site and plan for intervention. Potential endovascular procedures include angioplasty, thrombectomy, or intra-arterial thrombolysis.
- Urgent bypass surgery for complete ischaemia.
For embolic causes:
- the leg is typically threatened, and immediate embolectomy is required. If embolectomy fails, on-table thrombolysis may be considered.
Describe what is meant by Immune Thrombocytopenic Purpura [3]
(AKA autoimmune thrombocytopenic purpura, idiopathic thrombocytopenic purpura and primary thrombocytopenic purpura)
- antibodies are created against platelets, leading to their destruction
- antibodies are produced of IgG and target the platelet membrane glycoproteins GPIIb/IIIa
- the bone marrow compensates by making more megakaryocytes
Desribe the treatment plan for ITP
First line treatment:
- Oral prednisone at 1mg/kg daily with proton pump inhibitors
- Over 2 - 4 weeks and weaned off a few weeks after
AND
- Pooled normal human immunoglobulin (IVIG)
Second line:
- Mycophenolate mofetil- mmunosuppressive agent
AND
- thrombopoietin receptor agonist (e.g romiplostim)
AND
- Rituximab
AND
- Fostamatinib spleen tyrosine kinase (Syk) inhibitor
AND
- Splenectomy
Describe the phenomona of Heparin-Induced Thrombocytopenia [2]
Development of antibodies against platelets in response to heparin (usually unfractionated heparin, but it can occur with low-molecular-weight heparin).
Heparin-induced antibodies target a protein on platelets called platelet factor 4 (PF4).
The HIT antibodies activate the clotting system, causing a hypercoagulable state and thrombosis (e.g., deep vein thrombosis)
They also break down platelets and cause thrombocytopenia
What are the symptomatic or palliative treatment options for myelofibrosis? [4]
Ruxolitinib:
- a JAK2 inhibitor
- effective regardless of JAK2 mutation status.
Hydroxyurea / (hydroxycarbamide)
interferon-alpha
Describe how you would investigate for CLL [4]
FBC:
- Presence of excess lymphocytes on full blood count that are found to be clonal
PBS:
- indicated to confirm lymphocytosis
- presence of smudge cells artefacts from lymphocytes damaged during the slide preparation because of the fragile nature of these cells.
Immunophenotyping:
- shows the characteristic clonal B lymphocytes expressing CD5 and CD23 antigens.
- detect deletion of TP53 gene
Which of the following is most associated with smudge cells
Acute myeloid leukaemia
Acute lymphoblastic leukaemia
Chronic myeloid leukaemia
Chronic lymphocytic leukaemia
Chronic lymphocytic leukaemia
Which cytogenetic abnomarlities in AML have a really poor prognsosis (3% to 10yrs)? [1]
inversion 3
