finals qs Flashcards
1
Q
Give 4 risk factors for ischaemic heart disease
A
DM, smoking, high BMI (obesity), FH, hypercholesterolaemia, HTN, increasing age, sedentary lifestyle
2
Q
Which artery supplies the anterior territory of the myocardium?
A
Left anterior descending artery
3
Q
Give 3 aspects in immediate management of anterior STEMI
A
ABCDE approach|Oxygen|Morphine|Aspirin 300mg|GTN spray|Contact cardiology|LMWH
4
Q
What 3 management options are available to treat STEMI?
A
Primary PCI|Thrombolysis
5
Q
Give 4 medications that must be started prior to discharge post STEMI
A
Statin|Beta blocker|Aspirin|ACE inhibitor|PRN GTN spray
6
Q
What are the lateral leads in a 12 lead ECG? What vessel could be affected if there is ST elevation in these leads?
A
I, aVL, V5, V6|Circumflex
7
Q
Give two cardiac enzymes that commonly rise following cardiac damage
A
Troponin (T/I), creatine kinase, CK-MB, AST, LDH
8
Q
What driving advice would you offer a patient post MI?
A
Not allowed to drive for 4 weeks|Can drive from then on so long as not otherwise disqualified|DVLA do not need to be informed
9
Q
Give 3 possible complications of coronary angiography
A
Bleeding|Rupture of vessel needing further intervention|Infection|Further MI|Stroke|Allergy to contrast|Death
10
Q
What ECG changes may develop following STEMI?
A
Hyperacute T waves and then ST elevation (or new onset LBBB)|T wave inversion and pathological Q waves develop over the next few days
11
Q
Give 2 possible triggers of angina
A
Exertion, cold weather, emotion, heavy meals, lying down, vivid dreams
12
Q
Give 2 symptoms a patient may experience during an episode of angina
A
Heavy central chest pain|Shortness of breath|Sweating|Feeling faint/lightheaded
13
Q
What blood tests would you request in a patient with new onset angina?
A
FBC - to check for anaemia as this can precipitate angina|TFTs - for thyrotoxicosis|Lipid profile for hypercholesterolaemia|U+E - for renal vessel disease/if considering ACEi
14
Q
Name 3 tests (not bloods) that may be used to investigate angina
A
12 lead ECG|Exercise tolerance test|Echocardiogram|Coronary angiography
15
Q
How does aspirin reduce the risk of coronary events?
A
Irreversibly inhibits cyclooxygenase, which prevents further production of TxA2 from platelets as they do not have a nucleus, shifting the balance of PGI2:TxA2 towards inhibiting platelet aggregation
16
Q
Give 3 signs of acute pulmonary oedema you would look for on examination
A
Bibasal fine crepitations|Tachypnoea|Tachycardia|Raised JVP|Wheeze|Additional heart sounds/gallop rhythm|Dull percussion of bases|Cyanosis
17
Q
Give 4 investigations you would request in a patient who you suspect has had an MI and acute pulmonary oedema
A
12 lead ECG|CXR|FBC|Cardiac enzymes|Coronary angiography
18
Q
Name 1 drug that may have been used to treat acute MI with pulmonary oedema that could cause hypokalaemia
A
Furosemide
19
Q
Name 2 drugs used in the treatment of acute pulmonary oedema
A
Furosemide, GTN/nitrates, morphine, oxygen
20
Q
Give 2 ways in which you can replace potassium
A
Oral (sando-k)|KCl added into IVI
21
Q
Which territory of the myocardium do leads II, III and aVF represent? Which vessel is responsible for this territory?
A
Inferior, RCA
22
Q
What is the normal QRS interval?
A
<120ms
23
Q
What is a capture beat?
A
Normal QRS complex between VT complexes
24
Q
Give two drugs that may be used during an arrest
A
Adrenaline|Amiodarone|O2|Lignocaine/lidocaine
25
A patient on your ward arrests. His ECG shows a regular rhythm at a rate of approx 140, broad QRS complexes and an occasional capture beat. He has no palpable pulse. What is this rhythm and is it shockable?
Ventricular tachycardia, yes
26
What system is used to classify the severity of heart failure?
New York Heart Association
27
Give 3 symptoms of LVF
Dyspnoea, cough, production of pink frothy sputum, PND, decreased exercise tolerance, fatigue, wheeze
28
Give 3 signs of heart failure on a chest radiograph
Alveolar oedema in bat wing distribution|Kerley B lines|Cardiomegaly|Upper lobe diversion|Pleural effusion
29
Specifically, how and where does furosemide act?
Ascending loop of Henle in the nephron|Competitively inhibits the Na-K-2Cl co transporter, diminishing the osmotic gradient for water reabsorption
30
A patient is admitted to hospital with worsening confusion and is treated for a UTI. His admission ECG reveals a reverse tick pattern, ST depression and T wave inversion. What drug often used in heart failure causes this?
Digoxin
31
Give two side effects you would make a patient aware of before starting them on an ACEi
Dry cough|Renal impairment|Hypotension|Hyperkalaemia|Angioedema/urticaria
32
Give two signs that may be visible on the retina of someone with hypertensive retinopathy
Cotton wool spots|Flame haemorrhages|Papilloedema|Silver/copper wiring|A-V nipping
33
Give 3 complications of essential hypertension
Hypertensive nephropathy|Hypertensive retinopathy|Stroke|Ischaemic heart disease|Heart failure|Aneurysmal disease|PVD
34
What is the mechanism of action of simvastatin?
Inhibits HMG-CoA reductase, the rate-limiting step in cholesterol synthesis
35
What signs of hypercholesterolaemia may you find on examination?
Xanthelasmata, tendon xanthoma, corneal arcus
36
Name 3 common causes of AF
Pneumonia|Alcohol excess|MI/ACS|PE|Hyperthyroidism|Heart failure|Endocarditis
37
Name 2 features you would see on an ECG in AF
Irregularly irregular rhythm|Absent P waves
38
Name 2 symptoms of AF
Palpitations|Shortness of breath|Feeling dizzy/faint/syncope
39
Name 2 methods that could be used to cardiovert a patient with AF
Electrical - DC cardioversion|Chemical - flecainide
40
Name two drugs that may be used in a patient with AF
Propanolol|CCB|Digoxin|Warfarin
41
Name two complications of AF
Embolic events i.e. stroke, TIA, MI
42
Which organism is commonly responsible for infective endocarditis?
Strep viridans
43
Why might you ask for a urine dip in suspected infective endocarditis?
Microscopic haematuria
44
You examine the fundi of a patient with infective endocarditis and see a boat-shaped retinal haemorrhage with a pale centre. What is this called?
Roth spot
45
What criteria are used to make a diagnosis of infective endocarditis?
Duke criteria
46
Other than an early diastolic murmur, give 3 signs of aortic regurgitation
Collapsing pulse|Wide pulse pressure|Displaced apex beat|Quincke's sign (nail-bed capillary pulsation)|De Musset's sign|Austin Flint murmur
47
What organism is likely to cause IE in IVDUs?
Staph aureus
48
How should blood cultures be taken in a patient with suspected IE?
3 sets|3 sites|3 times
49
What Ix would you request in suspected IE?
BCs|Echo|ECG|CXR|Urine dip
50
Give two examples of pre-existing cardiac disease that increases the risk of patients developing endocarditis. What can preve
IVDU|Prosthetic valves|PDA|VSD|Coarctation|Mitral valve disease|Aortic valve disease
51
How can endocarditis be prevented in at-risk patients?
Prophylactic ABx prior to invasive procedures
52
Give 4 common triggers of asthma
House dust mite exposure|Cold air |Exercise|Emotional stress|Allergens e.g. household pets|Infections|Pollen|Cigarette smoke|Drugs e.g. NSAIDs, BB
53
What pattern is seen on spirometry in asthmatics?
Obstructive pattern (reduced FEV1:FVC ratio)
54
How can asthma be diagnosed using spirometry?
Improvement in FEV1 by \>15% following administration of bronchodilator
55
Specifically, how does salbutamol improve symptoms in asthmatics?
Stimulates B2 receptors of respiratory tract, which increases sympathetic activity and relaxes bronchial smooth muscle
56
What pattern of spirometry do you see in COPD?
Obstructive
57
What physiological measurement is used to determine the severity of COPD?
FEV1
58
How should you manage an infective exacerbation of COPD?
Oxygen (88-92%)|ABG|ABx|Steroids|Salbutamol/ipratropium nebs|Chest physio|Consider NIV|Inform seniors
59
Give 2 signs on examination of consolidation
Reduced chest expansion|Dull percussion note|Bronchial breathing|Increased tactile vocal fremitus and vocal resonance
60
Give the 3 most likely organisms to cause CAP
S. pneumoniae|Haemophilus influenzae|Mycoplasma pneumoniae
61
Give 2 possible complications of pneumonia
Pleural effusion|Respiratory failure|Empyema|Lung abscess|Sepsis|AF|Shock|Pericarditis/myocarditis|Cholestatic jaundice
62
What signs on examination would you expect in pleural effusion?
Reduced chest expansion|Stony dull percussion|Diminished breath sounds
63
What signs on examination would you expect in pneumothorax?
Reduced chest expansion|Hyperresonant percussion|Diminished breath sounds
64
Give 2 reasons why cases of TB may be on the rise
HIV/AIDS prevalence|Use of immunosuppressive drugs|Poor socio-economic conditions, overcrowding|Increased immigration from areas of high prevalence of TB|Multidrug resistance
65
What antibiotics are used to treat active TB and for how long is each one taken?
Rifampicin (6mo)|Isoniazid (6mo)|Pyrazinamide (2mo)|Ethambutol (2mo)
66
Why are 4 antibiotics used in TB?
To combat multidrug resistance
67
A 26-y/o lady with TB presents with painful, purple nodules over her shins - what are these? Name 2 other causes of this
Erythema nodosum|Idiopathic, Crohn's, UC, sarcoidosis, drugs (OCP, sulphonamides)|Strep infections|Chlamydia|Leprosy
68
What is the incidence of CF in the UK?
1 in 2500 live births
69
What is bronchiectasis?
Chronic infection of the large airways, causing their abnormal, permanent dilatation
70
Name two organisms that commonly colonise the lungs of CF
S pneumoniae|H influenzae|P aeruginosa|Burkholderia cepacia
71
Give 4 causes of bronchiectasis
Idiopathic|Post-infective (inadequately treated necrotising infections e.g. staph aureus, mycoplasma pneumoniae, pertussis, measles, TB, klebsiella)|Post-obstructive (FB, tumour, hilar lymphadenopathy, broncholithiasis)|Congenital (primary ciliary dyskinesia, Kartagener's syndrome)|Immunodeficiency|Allergic bronchopulmonary aspergillosis|A1-antitrypsin deficiency|RA|UC
72
Give 2 complications of bronchiectasis
Pneumonia|Sepsis|Recurrent pneumonia/LRTIs|Haemoptysis|Resp failure|Cor pulmonale|PTX
73
Give 2 risk factors for PE
Known malignancy|Immobility|Pregnancy|COCP/HRT|Thrombophilia|Known DVT, prev DVT/PE|FH DVT/PE|Major trauma|Inflammatory disease|Nephrotic syndrome|Dehydration|Current infection
74
Name 2 investigations that may be required to confirm a diagnosis of PE
V/Q scan, CTPA
75
A patient is admitted with a PE and is started on LMWH and warfarin. What will her target INR be? She has no past Hx of VTE - how long should she be on warfarin for?
2-3|6 months
76
What measures can be taken to reduce the risk of VTE in a TKR patient?
Prophylactic LMWH, TED stocking, early mobilisation, intermittent pneumatic compression devices
77
Give 4 symptoms someone with lung Ca may present with
Cough|Haemoptysis|Dyspnoea|Chest pain|Hoarse voice|Weight loss|Anorexia|Horner's syndrome
78
Name 3 imaging modalities that may be used to determine the extent of disease in lung Ca
CXR, CT, PET scan, bone scan
79
What staging system is used for SCC of the lung?
TNM
80
What is the test for SVC obstruction?
Pemberton's test - lift arms above head and keep them there for a minute, see if it gets worse
81
Give 3 sites that lung Ca commonly metastasises to
Brain|Bone|Liver|Adrenals|Other parts of lung
82
What are the clinical features of SVC obstruction?
Dyspnoea|Headache|Swelling of arms, legs, face|Non-pulsatile dilated neck veins|Dilated collateral vessels of arms and chest|Blue face|Raised JVP|Stridor
83
52 y/o is diagnosed with IPF. What may you see on her CXR?
Reduced lung volume|Reticulonodular shadowing|Honeycomb lung
84
What are the spirometry findings in IPF?
FVC:Low|FEV1:Low|FEV1:FVC ratio: High/Normal
85
Extrinsic allergic alveolitis is a cause of pulmonary fibrosis. Give 2 causes of this
Farmer's lung|Bird fancier's lung|Maltworker's lung|Humidifier fever|Mushroom worker's lung|Cheese washer's lung|Winemaker's lung
86
Name 2 non-respiratory causes of pulmonary fibrosis
Systemic sclerosis|RA|Drugs (MTX, amiodarone, nitrofurantoin, bleomycin)|SLE|Sjogren's|UC|Tuberous sclerosis|Neurofibromatosis
87
Give 3 respiratory causes of clubbing
Bronchial Ca|Mesothelioma|Bronchiectasis|Cryptogenic organising pneumonia |Chronic empyema|Chronic lung abscess
88
54 y/o man presents with fatigue, wife says he snores and has recently stopped breathing in night. He is obese with a large neck circumference. You ask him to complete a questionnaire. What is the diagnosis and what questionnaire is this?
Obstructive sleep apnoea|Epworth sleepiness scale
89
Give 3 risk factors for OSA
Obesity|Acromegaly|Enlarged tonsils|Enlarged adenoids|Nasal polyps|Alcohol
90
How is OSA diagnosed?
Sleep studies
91
Give 2 aspects in the management of OSA?
Weight loss|Avoid alcohol|Sleep upright|Mandibular advancement device|CPAP|Surgery e.g. tonsillectomy, adenoidectomy
92
What is cor pulmonale?
Right heart failure secondary to chronic pulmonary HTN
93
What CXR and ECG abnormalities may you see in a patient with cor pulmonale?
CXR: dilated right atrium, enlarged right ventricle, prominent pulmonary arteries |ECG: right axis deviation, P pulmonale, dominant R wave in V1, inverted T waves in the chest leads
94
Give 3 causes of bilateral hilar lymphadenopathy
Sarcoidosis|Lymphoma|Bronchial carcinoma|TB|Mycoplasma|Extrinsic allergic alveolitis
95
What will be seen in a trans bronchial biopsy of a patient with sarcoidosis?
Non-caseating granulomatous inflammation
96
Give 4 extrapulmonary manifestations of sarcoidosis
Skin - erythema nodosum|Eye - anterior uveitis, posterior uveitis, keratoconjunctivitis sicca|MSK - arthralgia, bone cysts|CNS - neuropathy, CN palsies|Cardiac - cardiomyopathy, ventricular dysrhythmias|Other - lymphadenopathy, hepatosplenomegaly, hypercalcaemia
97
What advice would you give a patient before starting long term corticosteroids?
Don't stop taking them suddenly|Doses should be reduced gradually|Carry a steroid card at all times|Doses need to be increased at times of inter current illness|Always inform doctors and dentists prior to start of treatment or surgery|Inform of side effects
98
Give 6 side effects of long term corticosteroids
Endocrine - adrenal suppression, hyperglycaemia|Change in fat distribution - central obesity, buffalo hump, moon face|Skin - easy bruising, skin thinning|Eyes - cataracts|MSK - muscle wasting, osteoporosis, AVN of femoral head|Psych - psychosis, euphoria, emotional lability|HTN|Increased susceptibility to infection|Peptic ulceration
99
What signs on examination would you expect in pleural effusion?
Reduced chest expansion on affected side|Stony dull percussion
100
Where should you insert the needle in a pleural tap and why?
Above the rib|To avoid the neurovascular bundle that is located immediately below the ribs
101
If the protein content is high (\<30 d/L) in a pleural tap sample, is it an exudate or transudate?
Exudate
102
If the LDH is high (\>200IU/L) in a pleural tap sample, is it an exudate or transudate?
Exudate
103
What test would you ask the lab to carry out on a pleural tap sample from a pleural effusion?
Protein content|LDH|MC+S|Cytology|Glucose|Amylase|pH|Ziehl-Neelsen staining for acid-fast bacilli
104
A lady comes in with recurrent pleural effusion. Your consultant explains that you will drain the infusion then instil a chemical to "plug the gap". What procedure is this and what chemical is used?
Pleurodesis with talc, bleomycin, tetracycline
105
A man has an eGFR of 52. What stage CKD is this?
CKD 3
106
Give 4 common causes of CKD
Diabetes|HTN|Glomerulonephritis|PKD|Renovascular disease|Pyelonephritis|Obstructive uropathy
107
A renal USS is arranged for a man with CKD - give 2 reasons why this has been arranged
Exclude obstruction|Assess renal size|Exclude PKD
108
Give 2 common side effects of ACEi
Dry cough|First-dose hypotension|Hyperkalaemia|Acute renal failure|Urticaria
109
Give 4 blood tests it is important to monitor in patients with diabetic nephropathy
U+E|Diabetic control|Ca2+|PO4|Alk phos|PTH|FBC
110
A 75 y/o lady is being readied by the renal team for RRT. Her eGFR is 14. What stage of CKD does she have?
CKD 5
111
Give 3 signs of end stage CKD you may see on examination
Pallor|Uraemic tinge|Purpura|Bruising|Brown discolouration of nails|Evidence of excoriation|Peripheral oedema|HTN|Pericardial rub|Evidence of pleural effusion|Proximal myopathy|Evidence of preparation for RRT
112
Explain the basic principles of haemodialysis
Blood and dialysis fluid flow either side of a semipermeable membrane|Molecules diffuse down their concentration gradients|Plasma biochemistry changes to become more like the dialysis fluid
113
Give 2 complications of peritoneal dialysis
Bacterial peritonitis|Local infection at catheter site|Constipation|Failure|Sclerosing peritonitis
114
What time period determines whether renal rejection is acute or chronic?
Six months
115
Why might renal transplant patients on immunosuppression see a dermatologist?
Increased risk of SCC due to long-term immunosuppression
116
A 74 y/o man has CKD 4 and recent bloods have shown a low calcium and high PTH. What form of hyperparathyroidism is this?
Secondary hyperparathyroidism
117
Give 2 actions of PTH
Increased osteoclast activity leads to increased Ca and PO4 release from bone|Increased Ca and PO4 reabsorption via kidney|Increased hydroxylation of vit D
118
At what 2 sites does hydroxylation of vitamin D occur?
Liver, kidney
119
What is the term given to bone disease in patients with renal failure? Give 2 aspects of the management of this condition
Renal osteodystrophy|Phosphate restricted diet|Phosphate binders|Vit D analogues|Calcium supplements
120
What blood results would you get in tertiary hyperparathyroidism? Why has this developed in a patient with CKD4 who previously had secondary hyperparathyroidism?
High PTH, high Ca|Prolonged secondary hyperparathyroidism causing the parathyroid glands to act autonomously
121
How can AKI be sub-classified? Give 2 causes of each
Pre renal - hypovolaemia, sepsis, renal artery stenosis, ACEi, NSAIDs, CCF, cirrhosis|Renal - ATN, nephrotoxins, vasculitis, glomerulonephritis, HUS, malignant HTN, TTP, acute tubulointerstitial nephritis, pre-eclampsia|Post renal - renal caliculi, renal tumours, ureteric tumours, BPH, prostate cancer
122
Name 2 potentially life-threatening complications of AKI
Pulmonary oedema|Hyperkalaemia|Haemorrhage
123
Give 2 indications for dialysis in AKI
Refractory pulmonary oedema|Persistent hyperkalaemia|Severe metabolic acidosis|Uraemic encephalopathy|Uraemic pericarditis
124
Other than bloods, how would you investigate AKI?
ECG|CXR|Renal USS|ABG|Urinalysis
125
What is acromegaly?
Hypersecretion of GH by a tumour in the anterior pituitary
126
State 6 signs or symptoms you may find in acromegaly
Thick spade like hands|Frontal bossing|Macroglossia|Bitemporal hemianopia|Headache|Sweats|Wide spaced teeth|Prognathism|Voice changes|Sleep disturbance due to OSA|CTS|HTN
127
Why do people with acromegaly become clumsy?
Bitemporal hemianopia due to pituitary tumour pressing on optic chiasm
128
What serum blood test do you use to screen for acromegaly?
Serum IGF-1
129
How does an OGTT aid diagnosis of acromegaly?
Rapid increase in blood glucose should suppress GH secretion|This will not happen in a patient with acromegaly
130
What other endocrine disorder would you screen for in a patient newly diagnosed with acromegaly? What is the main cause of death in these patients?
DM|GH is anti-insulin and this leads to a state of insulin resisitance and eventually DM|CV disease
131
What surgery can cure acromegaly?
Trans-sphenoidal resection of pituitary tumour
132
Name some causes of hypothyroidism
Amiodarone|Radiotherapy|Autoimmune|Iodine deficiency|Cancer|Infection|Hypopituitarism
133
What might an FBC show in a patient with hypothyroidism?
Macrocytic anaemia
134
What will the TSH and T4 be in a patient with hypothyroidism?
TSH high |T4 low
135
What anatomical structure represents the site at which the thyroid gland originated before embryological descent?
Foramen caecum
136
What is Grave's disease?
Autoimmune disease caused by TSH receptor antibodies
137
Name 3 signs you might look for on examination in Grave's disease. Name 2 which are specific to Grave's
Tachycardia, tachycardia|AF|Warm peripheries|Goitre|Thinning of hair|Brisk reflexes|Palmar erythema|High-output cardiac failure signs|Specific: pretibial myxoedema, eye disease (ophthalmoplegia, exopthalmos), thyroid acropachy
138
What would the TFTs show in Grave's disease?
Low TSH|High T4
139
What drugs can be used to control tremor in Grave's disease?
Beta blockers
140
Name 2 drugs that "block the thyroid"
Carbimazole|Propythiouracil
141
A 25-y/o lady comes in with symptoms of excessive thirst, weight loss, increase in urine production. Urine dip negative for glucose. What is the likely diagnosis?
Diabetes insipidus
142
Where is ADH secreted from?
Posterior pituitary
143
With the use of low, high and normal, what do you expect the urine and plasma osmolality to be in diabetes insipidus?
Urine - low|Plasma - high
144
What is the difference between the nephrogenic and cranial types of this condition?
Nephrogenic - lack of response to ADH in the kidney|Cranial - lack of production of ADH
145
How is the water deprivation test used to diagnose DI?
Patient is starved of any fluid intake|Normal response would be to concentrate urine and decrease urine output; however in DI there is continued large volume urine production with low osmolality
146
Name the drug used to treat cranial DI
Desmopressin
147
What is the syndrome of DI after massive post-partum haemorrhage called?
Sheehan's syndrome
148
Give 2 ways of raising the blood glucose of an unconscious patient with a hypo
IM glucagon|IV glucose
149
Name 3 symptoms of neuroglycopenia
Coma|Confusion|Drowsiness|Seizures|Hemiparesis
150
What can repeated episodes of hypoglycaemia lead to?
A lack of awareness of hypoglycaemia
151
What advice would you give to avoid hypos?
Regular finger-prick monitoring|Never miss a meal|Keep emergency supply of glucose in pocket e.g. energy tablets|Adjust insulin in response to changes in diet, activity, illness
152
Name a cause of hypoglycaemia in non-diabetics
Alcohol binging|Liver failure|Addison's|Insulin-secreting tumours|Pituitary insufficiency
153
Explain the OGTT
Patient fasts overnight|Drinks 75g of glucose in 300ml water|BM measured prior to drink then at 120 mins|DM diagnosed if BM at 120 min \>11.1mmol/L|DM diagnosed if fasting \>7mmol/L|Patient advised not to drink coffee or smoke in fasting period
154
Name 2 macrovascular and 2 microvascular complications of T2DM
Macro: CVA, MI/IHD, PVD|Micro: nephropathy, neuropathy, retinopathy
155
Name 3 different agents that could be used to treat T2DM
Metformin (biguanides), pioglitazone (thiazolidinedione), tolbutamide (sulfonylurea), insulin
156
What lifestyle advice would you give to a patient with newly diagnosed T2DM?
Lose weight, eat healthy, stop smoking
157
How do you confirm a DKA on bedside testing?
Urine dip - presence of ketonuria
158
Name 2 venous blood tests you would perform in a DKA
U+E - electrolyte abnormality, renal failure|FBC - may indicate infection
159
What is the initial management of a DKA?
Fluid replacement (aggressive)|Insulin sliding scale|Potassium replacement
160
Explain the pathophysiology of a DKA
Insulin deficiency produces glucose production in the liver|Lipolysis occurs|Fatty acids broken down to form ketone bodies which produce a metabolic acidosis
161
A 40 y/o man comes to you complaining of feeling tired all the time and loss of appetite. Has PMH of vitiligo. Examination unremarkable except for tanning of skin and buccal pigmentation.|What do you suspect the diagnosis and pathogenesis is?
Addison's disease|Autoimmune (because of the vitiligo)
162
Name 2 tests you would perform to aid diagnosis of Addison's
U+E|Short synacthen test
163
What would you expect the serum sodium and potassium to be in Addison's?
Low sodium|High potassium
164
What drugs would you prescribe to a patient with Addison's?
Glucocorticoids|Mineralocorticoids
165
What advice do you give to a patient with Addison's regarding their steroid use?
Carry a steroid card and medic alert bracelet|Know how to change dose of medication in intercurrent illness|Carry an emergency ampoule of hydrocortisone in case you can't ingest orally
166
What is the commonest cause of pathological hyperprolactinaemia?
Prolactinoma
167
Name 4 signs and symptoms of prolactinoma
Amenorrhoea|Bitemporal hemianopia|Galactorrhoea|Subfertility|Headache|Decreased libido
168
What imaging would you request in suspected prolactinoma?
MRI head
169
Why would you order visual field testing in suspected prolactinoma?
Prolactinoma may grow and press upon the optic chiasm|Causing a bitemporal hemianopia
170
What is the medical management of hyperprolactinaemia and what is its MoA? What other non-surgical treatment is available?
Cabergoline/bromocriptine|Dopamine agonist|Radiotherapy
171
A gentleman with longstanding T2DM presents with diminished sensation in his hands and feet. You diagnose a symmetrical polyneuropathy secondary to poor diabetic control. What term is used to describe the distribution of his dimished sensation?
Glove and stocking distribution
172
In diabetic sensory neuropathy, what is the first type of sense to diminish?
Vibration sense
173
What might you find on examination of a foot in a person with diabetic neuropathy?
Blunted sensation|Charcot's joint|Painless ulcer|Diminished reflexes|High arched foot with clawing of the toes
174
Name 3 types of neuropathy that can occur in diabetic patients
Peripheral sensory neuropathy|Autonomic neuropathy|Diabetic amyotrophy|Mononeuropathy/mononeuritis multiplex|Acute painful neuropathy
175
How can you prevent progression of polyneuropathy in diabetic neuropathy?
Good glycaemic control
176
You discover a patient has diabetic neuropathy of the feet. What two other areas of the body must now be investigated?
Eyes - ophthalmology review|Kidneys - renal function tests
177
A man with diabetic neuropathy comes to you with intractable vomiting. What has caused this?
Autonomic gastroparesis
178
A 25 y/o man presents with a 3 month history of diarrhoea. List 4 differential diagnoses for chronic diarrhoea in this age group.|Name a basic and an invasive test you might do
IBD, IBS, infective, coeliac, colorectal Ca, medications, chronic pancreatitis, thyrotoxicosis|Basic: FBC (anaemia, raised WCC), raised CRP, B12 deficiency, stool MC+S, coeliac screen, amylase, TFT|Invasive: sigmoidoscopy and rectal biopsy, colonoscopy, barium enema, capsule endoscopy for small bowel disease
179
List 2 histological features of Crohn's disease
Granuloma formation|Transmural inflammation|Lymphocytic infiltration
180
Contract Crohn's and UC in the following domains: endoscopic appearance and distribution
Endo:|Crohn's: skip lesions, cobblestone appearance|UC: uniform inflammation, thin walls, loss of vascular pattern|Distribution:|Crohn's: mouth to anus, commonly terminal ileum|UC: rectum always affected, affects large bowel only
181
List 2 extraintestinal features of Crohn's
Erythema nodosum|Pyoderma gangrenosum|Iritis/episcleritis|Enteropathic arthritis|Ank spond|Apthous ulceration
182
Why are steroid-sparing agents useful in the management of Crohn's?
Avoids long-term side effects of steroids in frequent relapses
183
List 2 complications from long term Crohn's disease
Malnutrition|Colonic carcinoma|Perianal abscess and fistula|Small bowel obstruction|Bowel perforation
184
Infliximab is a monoclonal antibody that can reduce Crohn's disease activity. How does it work?
Anti-TNF|TNF is important in establishing inflammation and granuloma formation
185
List 4 causes of UGI bleed
Oesophagitis|Mallory-Weiss tear|Oesophageal varices|Peptic ulcers|Gastritis/duodenitis|Malignancy|Bleeding disorders|Aortic enteric fistula
186
What 3 medications can contribute to an UGI bleed?
NSAIDs|Aspirin|Anticoagulants|Corticosteroids
187
Why might you perform a PR in a patient with UGI bleed?
Presence of melaena is evidence of large blood loss
188
What diagnostic investigation is recommended in an UGI bleed?
Urgent OGD
189
What class of medication is given in an UGI bleed?
PPIs
190
What disease is oesophageal varices commonly associated with? How does this disease lead to varices?
Liver cirrhosis|Venous portal hypertension
191
Name a site of portosystemic anastamoses and the symptom it would cause
Superior rectal vein shunts cause haemorrhoids|Paraumbilical vein shunts cause caput medusae
192
Name an endoscopic treatment of oesophageal varices
Adrenaline|Sclerotherapy|Banding of varices|Argon plasma coagulation
193
Name 3 differentials for dyspepsia
PUD|GORD|Gastritis|Oesophagitis|Duodenitis|Malignancy
194
Name 2 symptoms that would alert you to the possibility of UGI malignancy in a patient with dyspepsia
Symptoms of anaemia|WL|Anorexia|Recently worsening symptoms|Dysphagia|Melaena|Haematemesis
195
List 2 risk factors for PUD
H.pylori infection|NSAIDs/steroids|Smoking|Delayed gastric emptying|Physiological stress e.g. ITU patients|Hypercalcaemia|Chronic renal failure
196
Explain the urease breath test for H.pylori
H.pylori bacteria produces urease to break down urea into ammonia and CO2|A radio isotope of carbon (C13 or 14) in the form of urea is ingested|If urease is present it breaks down urea and radioisotope CO2 can be measured
197
What is H.pylori eradication therapy?
PPI plus|Clarithromycin, and either amoxicillin or metronidazole for at least 2 weeks
198
What radiological investigation can you use for suspected perforation of peptic ulcer? What sign would you look for?
Erect CXR|Free air under diaphragm (pneumoperitoneum)
199
Abnormally high gastrin levels are associated with extensive and atypical ulceration. What condition causes this?
Zollinger-Ellison syndrome
200
What is the definition of GORD?
Excessive entry of gastric contents into the oesophagus through the gastro-oesophageal junction
201
List 2 exacerbating factors of GORD
Lying flat|Stooping, straining|Drugs|Alcohol|Obesity|Food|Hiatus hernia
202
What could cause night time wheeze in a patient with GORD with no history of asthma?
Inhalation of small amounts of gastric contents
203
What lifestyle advice would you give to a patient with GORD?
Weight loss|Smoking cessation|Reduce alcohol consumption|Avoid large meals|Avoid eating before bedtime|Sleep sat up
204
A patient with GORD presents with worsening GORD symptoms despite PPI and difficulty swallowing. Name 2 causes of dysphagia in this case
Benign stricture secondary to GORD|Malignant stricture|Extrinsic pressure from lung Ca|Mediastinal LNs|Retrosternal goitre|Pharyngeal pouch|Oesophagitis|Bulbar palsy|Myasthenia gravis
205
Explain the term "oesophageal metaplasia" and its cause
Change of lower oesophageal squamous epithelium into columnar epithelium, caused by recurrent damage from gastric contents refluxing into the oesophagus
206
What is the gold-standard test for proving reflux?
Oesophageal pH manometry
207
What is the surgical option for GORD treatment and how does it help reflux?
Nissen fundoplication - fundus is wrapped around oesophagus|Augments the high pressure zone, giving more strength to the GOJ
208
Name a possible side effect to fundoplication
Dysphagia from compression of the GOJ|Dumping syndrome|Achalasia
209
Give 3 symptoms of acute appendicitis
Anorexia|Nausea|Vomiting|Fever|Constipation|Diarrhoea
210
Why is pain first felt in the periumbilical region in appendicitis? Why does it then migrate to the RIF?
Irritation of the visceral peritoneum by the inflamed appendix is felt in the T10 dermatome which corresponds to the periumbilical region|This is because the visceral peritoneum has no somatic inner action, so the brain perceives visceral signals as being from the same dermatome as where the visceral signals enter the spinal cord|As the appendix is found in the midgut the corresponding dermatome is T10|As the disease progresses, the parietal peritoneum becomes affected|As this receives somatic innervations, the pain is well localised to the area of inflammation
211
What is Rosving's sign?
Pain felt in the RIF when the LIF is palpated
212
Give 2 differentials of appendicitis
Ectopic pregnancy, torsion/rupture of ovarian cyst, salpingitis|UTI, renal stone, testicular torsion|GI obstruction, constipation, strangulated hernia, Crohn's, gastroenteritis, mesenteric adenitis, Meckel's diverticulum, intussusception
213
What is the definitive treatment of appendicitis?
Appendicectomy
214
Give 2 possible complications of appendicitis
Perforation|Appendix mass (omentum and small bowel adhere to appendix)|Abscess|Sepsis|Paralytic ileus |Intestinal obstruction
215
What is a diverticulum?
An outpouching of mucosa through the muscle wall
216
Which section of the colon are diverticula commoner in?
Sigmoid|In this section the majority of water has been reabsorbed from the faeces, leading to high intraluminal pressures
217
Define diverticulosis, diverticular disease and diverticulitis
The presence of diverticula in GIT|Symptomatic diverticula|Inflammation of diverticula
218
Give 2 investigations that may be performed in acute diverticulitis
FBC|CRP|Blood cultures|CXR|AXR|CT|USS
219
Give one mainstay of the conservative management of diverticulitis
Analgesia|ABx|Adequate hydration
220
What are two possible complications of diverticulitis?
Perforation|Bleeding |Abscess|Strictures|Fistulas
221
What is the definition of a hernia?
The protrusion of a structure through the wall of a cavity in which it is usually contained
222
With relation to the pubic tubercle, how do you differentiate between an inguinal and femoral hernia?
The neck of an inguinal hernia appears superior and medial to the pubic tubercle|The neck of a femoral hernia appears inferior and lateral to it
223
With relation to the inferior epigastric vessels, how do you differentiate between direct and indirect hernias?
Indirect inguinal hernias occur lateral to the inferior epigastric vessels|Direct inguinal hernias occur medial to these vessels
224
Using embryology, explain how indirect inguinal hernias occur
Testes descend from posterior abdo wall into the scrotum following the processus vaginalis via an attachment called the gubernaculum|If the connection to the peritoneal cavity fails to close, then a patent processus vaginalis is present through which indirect inguinal hernias can occur
225
Give 2 risk factors for inguinal hernias
Prematurity|Male sex|Chronic cough|Constipation|Obesity|Heavy lifting|Physical activity
226
What is the difference between an obstructed and a strangulated inguinal hernia?
Obstructed - contents of GIT cannot pass through|Strangulated - ischaemia of the portion of bowel
227
Give 2 complications following inguinal herniotomy surgery
Recurrence|Wound site infection|Mesh infection|Hydrocele|Intestinal damage|Bladder damage|Spermatic cord damage
228
What line divides internal and external haemorrhoids?
Dentate line
229
Give 3 symptoms of haemorrhoids
PR bleed|Pruritus ani|Mucous|Rectal fullness|Pain |Soiling
230
Give 2 conservative management options and 2 procedures used to manage haemorrhoids
Increase fluid intake, increase fibre intake, analgesia, bed rest, topical therapies (anaesthetics/corticosteroids)|Rubber band ligation, sclerotherapy, cryotherapy, photocoagulation, haemorrhoidectomy
231
Name 1 complication of haemorrhoids
Ulceration|Stricture|Thrombosis|Infection|Anaemia|Skin tags
232
What investigations may be performed for haemorrhoids?
FBC, proctoscopy, sigmoidoscopy
233
Name the arterial supply to the foregut, midgut and hindgut
Foregut - celiac trunk|Midgut - sup mesenteric artery|Hindgut - inf mesenteric artery
234
What acid-base disturbance is typically seen in acute mesenteric ischaemia? What other disturbances may you see on blood tests?
Metabolic acidosis|Raised WCC, lactate, Hb, amylase
235
What is the gold standard for imaging in acute mesenteric ischaemia?
Angiography
236
Give one essential component of the initial management prior to surgery for acute mesenteric ischaemia. What are the aims of surgery
Aggressive fluid resuscitation, ABx, heparin, analgesia|Resection of necrotic bowel, revascularisation
237
What is the function of the red and white pulps of the spleen?
Red pulp - filter, destroys defunct red blood cells|White pulp - lymphoid tissue which acts as part of immune system
238
Give 3 indications for splenectomy
Trauma|Spontaneous rupture|Hyper splendid|Neoplasia|Cysts|Splenic abscess
239
What type of organisms are people susceptible to following splenectomy? How might you prevent infection?
Encapsulated bacteria|Lifelong prophylactic penicillin V|Vaccination - pneumococcal, meningococcal, influenza, HiB
240
What are Howell-Jolly bodies?
Red blood cells where the nuclear remnant is still seen
241
Name 5 causes of acute pancreatitis
Gallstones, alcohol, idiopathic, ERCP, trauma, steroids, mumps, scorpion stings, hyperlipidaemia, hypercalcaemia, drugs, hypothermia
242
What blood test confirms acute pancreatitis?
Serum amylase|Can also do lipase
243
Name 2 early and 2 late complications of acute pancreatitis
Shock, ARDS, sepsis, DIC, renal failure|Pancreatic pseudo cyst, pancreatic necrosis, abscess, thrombosis of splenic/duodenal arteries, chronic pancreatitis
244
Describe the basis of management of acute pancreatitis
Fluids, analgesia, NGT, ICU
245
What are the 4 main features of bowel obstruction?
Constipation|Vomiting|Colicky abdominal pain|Distension
246
What features in a history would make you think small bowel over large bowel obstruction?
In small bowel obstruction pain is higher in abdomen, vomiting occurs earlier and abdo distension is less
247
Give 4 common causes of bowel obstruction
Constipation|Adhesions|Hernias|Tumour|Diverticulitis
248
What clinical sign would distinguish between an ileus and a mechanical obstruction?
Absence of BS = ileus|Tinkling BS = obstruction
249
What investigation would help you to distinguish between a small- and large- bowel obstruction?
AXR
250
What immediate management would you start in small bowel obstruction?
Bowel rest - drip and suck|NBM, NGT, IV fluids
251
What is contained within bile?
Bile salts|Bile pigments|Cholesterol|Phospholipid|Electrolytes|Water
252
Name 2 types of gallstones based on composition
Pigment stones|Cholesterol stones|Mixed stones
253
What are the risk factors for developing gallstones?
Fair (Caucasian)|Fat|Forty|Fertile|Female
254
What is Murphy's sign?
2 fingers laid in RUQ and patient breathes in - causes pain and stops patient breathing in fully|It is positive if the when repeated in LUQ there is no pain
255
What imaging would confirm a diagnosis of acute cholecystitis?
Biliary USS
256
What is the initial management for acute cholecystitis?
NBM|IV fluids|Analgesia|ABx
257
Name the 4 lobes of the liver
Right|Left|Caudate|Quadrate
258
Which ligament divides the anterior of the liver into the anterior lobes?
Falciform ligament
259
Name 3 common origins of secondary tumour to the liver
Breast|Lung|GIT|Uterus
260
Name 3 causes of HCC
Viral hepatitis|Cirrhosis (alcoholic, PBC, haemochromatosis)|Parasites|Steroids|COCP
261
What tumour marker is commonly raised in HCC?
Alpha-fetoprotein
262
Give one example for each of the following causes of jaundice: prehepatic, intrahepatic/hepatocellular, cholestatic/obstructive
Prehepatic: anything that causes haemolysis (malaria, sickle cell, thalassaemia, G6PD deficiency, spherocytosis, Gilbert's, Crigler-Najjar)|Intrahepatic: viral hepatitis, paracetamol OD, drugs, alcoholic hepatitis, liver tumour, sepsis, A1 antitrypsin, Budd-Chiari, autoimmune hepatitis, haemochromatosis|Obstructive: CBD bile stones, pancreatic cancer, PBS, PSC, fluclox, COCP, anabolic steroids
263
What is bilirubin the breakdown product of?
Haemoglobin
264
A patient complains of dark urine and pale stools. What is the cause of their jaundice likely to be?
Obstructive
265
Why does conjugated bilirubin appear in the urine and unconjugated bilirubin doesn't?
Conjugated bilirubin is water-soluble, so dissolves in urine making it dark
266
What is the commonest histological type of pancreatic carcinoma?
Adenocarcinoma -\> mutinous cystic adenoma -\> islet cell tumours
267
Name 3 signs and symptoms of pancreatic carcinoma
Jaundice|Epigastric pain|Back pain|WL|Epigastric mass|Dyspepsia|Fatigue|Hepatomegaly from mets
268
What tumour marker can be used to monitor response to pancreatic cancer treatment?
Ca 19-9
269
Name a complication of persistent jaundice
Pruritus|Liver dysfunction|ARF|Susceptibility to infection|Nutritional dysfunction
270
What are the routes of spread of Hep A and Hep B?
Hep A - FO|Hep B - blood bourne
271
List 2 at risk groups for Hep B
IVDU and their sexual partners|Sex workers|Healthcare workers|Haemophiliacs
272
What does having antibodies to Hep B core antigen (anti-HBC) in the serum signify?
Past infection
273
Name 2 long-term complications of Hep B
Fulminant hepatic failure|HCC|Chronic hepatitis|Cirrhosis|Glomerulonephritis|Cryoglobulinaemia
274
What is the definition of an arterial aneurysm?
Abnormal dilatation to more than 150% of the original diameter of a blood vessel due to weakness in the vessel wall
275
What is the difference between a true and a false aneurysm?
A true aneurysm is an abnormal dilatation of a blood vessel
A false aneurysm is a collection of blood around a blood vessel wall that communicates with the lumen
276
A patient is found to have a 6cm AAA on screening. What should the next step in the management be?
Refer for surgical intervention if \>5.5cm
277
Name 2 causes of an AAA
Atheromatous degeneration
CTDs - Ehlers-Danlos, Marfan's
Mycotic aneurysms from infection
278
Name 4 complications of open AAA repair
Bleeding
Infection
VTE
MI
Spinal ischaemia
Renal failure
Mesenteric ischaemia
Distal thrombus causing limb ischaemia
Death
279
When would you use EVAR instead of open AAA repair? What are the disadvantages of EVAR?
Would use if many comorbidities making open surgery too risky, morphology of AAA makes it amenable for EVAR, position of renal arteries, torturosisty of artery
Disadvantages include: not suitable for every type of aneurysm, long term f/u needed, high reintervention rate
280
What is the diagnostic investigation in ruptured AAA?
Abdo CT with contrast
281
Name the 4 layers of an arterial vessel wall, from inner to outer
Intima
Tunica media
Tunica externa
Adventitia
282
Name a cell type that may be present in an anuerysmal wall
Lymphocytes
Macrophages
Fibroblasts
283
Name 6 symptoms of acute limb ischaemia
Pallor
Pulseless
Pale
Perishingly cold
Paraesthesia
Paralysis
284
What are 2 common causes of acute limb ischaemia?
Acute thrombosis and emboli
Aortic dissection, trauma, iatrogenic, peripheral aneurysm
285
A patient needs to be transferred to a vascular unit for treatment of an ischaemic leg. What treatments can you initiate in the meantime?
Oxygen, analgaesia, heparin infusion, IV fluids
286
Name 2 definitive treatments for acute ischaemic limb
Thrombolysis
Angioplasty
Embolectomy
Arterial bypass
287
A patient with intermittent claudication now has pain at rest and has to hang his leg out of bed at night to relieve his pain. What are these symptoms a sign of?
Critical limb ischaemia
288
What radiological investigations would you do in a TIA?
CT/MRI head
Carotid artery duplex scan
Echocardiogram
289
What criteria make up the ABCD2 score?
Age
BP
Clinical features (weakness = 2, just speech = 1)
Duration (10-59m = 1, \>60m = 2)
Diabetes
290
List 4 vascular complications of DM
Nephropathy
Retinopathy
Peripheral neuropathy
Increased risk of MI and stroke
PVD
291
List 4 causes of skin ulceration
Venous disease
Arterial disease
Neuropathy
Vasculitis
Infection
Malignancy
292
How can you prevent a diabetic getting ulcers?
Improve glycaemic control
Regular chiropody for callus removal and pressure area care
Orthotics
Education
Re-vascularise
293
What are the principles of managing an infected ulcer?
Broad spectrum ABx
Investigate for osteomyelitis
Debridement
Revascularisation
Amputation if all else fails
294
What is the difference between primary and secondary intention in wound healing?
Primary: wound edges approximated, small scar
Secondary: wound left open, granulates from bottom up, large scar and slower
295
What is the commonest cause of epistaxis?
What is the name of the area on the anterior nasal septum where epistaxis commonly originates?
Trauma
Little's area/Kiesselbach's plexus
296
List 2 initial management steps in epistaxis
List 2 methods by which epistaxis may be stopped
Sit pt upright and lean forwards
Squeeze bottom part of nose
Apply ice pack to bridge of nose
Monitor pulse and BP, IV access, fluid resus if necessary
Cauterisation, packing, balloon/foley catheter, ligation of sphenopalatine/other artery
297
What LN is commonly affected in tonsillitis?
Jugulodigastric LN
298
What is Barrett's oesophagus and what does it predispose you to?
Metaplasia of squamous to columnar epithelium in lower oesophagus
Adenocarcinoma of oesophagus
299
Name 2 risk factors for oesophageal carcinoma
Barrett's oesophagus, smoking, alcohol, obesity, achalasia, increasing age, male, FH
300
How is oesophageal cancer staged? What are the treatment options?
TNM system
Surgery, chemoradio, palliation
301
Which cranial nerve is the recurrent laryngeal nerve a branch of? Which side is recurrent laryngeal nerve palsy commoner on and why?
Vagus
L - nerve follows a longer course than on the right so it is more susceptible to damage
302
What is the only laryngeal muscle not supplied by the recurrent laryngeal nerve, and what nerve is it supplied by?
Cricothyroid
Superior laryngeal nerve
303
Give 3 symptoms of vocal cord palsy
Hoarseness
Vocal fatigue and reduced vocal volume
SOB
Cough
304
Give 2 causes of recurrent laryngeal nerve palsy
Tumours
Surgery
Aortic arch aneurysm
Bulbar/pseudobulbar palsy
Idiopathic
305
List 5 causes of unilateral facial weakness
Stroke/TIA
Bell's palsy
Tumours
Acoustic neuromas
Otitis media
MS
Ramsay Hunt syndrome
Parotid tumours
Trauma
GBS
306
In the face, how can you discriminate between an UMN lesion and LMN lesion?
UMN lesions forehead sparing - as the forehead is bilaterally innervated
LMN (lesions that affect facial nerve) will also affect forehead
307
What is the most likely cause of septic arthritis?
Staphylococcus aureus
308
What fluids will you send for culture in septic arthritis?
Joint aspirate
Blood cultures
309
What is your management plan in septic arthritis?
Joint aspirate and culture
IV ABx
Refer ortho for ?washout
310
Name 2 risk factors for septic arthritis
Intra-articular injections
RA
DM
Immunosuppression
Penetrating injury
Gonoccocal infection
311
What organism would you worry about in a septic arthritis of an artificial joint?
Staph epidermis
312
Name the rotator cuff muscles
Teres minor
Supraspinatus
Infraspinatus
Subscapularis
313
Where does the supraspinatus attach to the humerus?
Greater trochanter
314
What muscle takes over abduction of the arm after the supraspinatus initiates movement (the first 10-15 degrees)?
Deltoid
315
What two muscles are innervated by the accessory nerve?
Teres minor
Deltoid
316
What 2 imaging methods are used to visualise the supraspinatus and to assess whether any labral tears are present?
MRI and USS
317
What tests are used to test the ACL and PCL?
Anterior draw test and posterior draw/sag test
318
How do you test the collateral ligaments of the knee?
Flex the knee to 20 degrees
One hand holds the ankle, the other stabilises the femur
The knee joint is then stressed in abduction to test the medial collateral ligament
And in adduction to test the lateral collateral ligament
If the knee "opens up" suggests a complete tear
319
In the knee, what is the "unhappy triad"?
ACL tear
Medial collateral ligament tear
Medial meniscal damage
320
What test is used to test for a meniscal tear?
McMurray's
321
What tendon may be transplanted to repair the ACL?
Patellar
Hamstring
Quadriceps
322
An old lady has a fall. XR confirms a R displaced intracapsular #NOF.
What position would you expect to see on inspection of her R leg?
Shortened, externally rotated
323
What system is used to classify intracapsular #NOF?
Garden system
324
What complication may occur if the blood supply to the head of femur is disrupted by an displaced intracapsular fracture?
Avascular necrosis
325
What operation is performed for a displaced intracapsular #NOF where there are concerns that the blood supply has been disrupted?
Arthroplasty (hemi/total)
326
What procedure will be performed for an undisplaced intracapsular #NOF (therefore blood supply intact)?
Internal fixation
327
What is a Colles' fracture?
What displacement and angulation would be present?
How long will it take to heal?
Fracture of distal metaphysis of radius
Dorsal displacement and angulation
6-8w
328
Define an open fracture
Communication between the fracture and the outside world
329
Give 4 components of managing an open fracture
Analgesia
Fluid resuscitation
Assess neurovascular status and soft tissue damage
Sterile cover, splint
Broad spectrum ABx
Tetanus prophylaxis
Urgent theatre for debridement, surgical fracture stabilisation, wound closure
330
What is the surgical management of compartment syndrome?
Urgent decompression via open fasciotomy
331
What are the complications of open fractures?
Wound infection, tetanus infection, osteomyelitis, nerve damage, vascular damage, malunion, sepsis, DVT, death
332
333
Give 3 causes of secondary HTN
Coarctation of aorta
Phaeochromocytoma
Conn's
Cushing's
RAS
Acromegaly
334
Why do you get different BP readings on different arms in coarctation of aorta? Which arm has higher BP?
Narrowing of aorta proximal to L subclavian artery
Right
335
What signs might you see in hypertensive retinopathy?
AV nipping
Flame haemorrhages
Hard exudates
Cotton wool spots
Papilloedema
336
Give 3 risk factors for NAI
Maternal depression
Domestic abuse
SCBU baby - delayed emotional attachment
Financial difficulty
337
What are the differentials for red eye?
Keratitis
Acute angle-closure glaucoma
Anterior uveitis
Conjunctivitis
338
What 3 findings on a slit lamp would support a diagnosis of anterior uveitis?
Cell and flare
Hypopyon
Keratic precipitates
Posterior synechiae
339
Name 2 treatments for anterior uveitis
Prednisolone drops
Oral prednisolone
Atropine drops
340
Name 2 infective causes of anterior uveitis
Herpes simplex
TB
VZV
341
Name 6 clinical findings in SLE
Malar rash
Arthritis
Psychosis
Pericarditis
Fatigue, malaise
Nail fold infarcts
Photosensitivity
Raynaud's
Renal failure
342
What type of anaemia would you see in a patient with SLE?
Normocytic normochromic anaemia
343
What is the histological reason for renal impairment in SLE?
Immune complex deposition on basement membrane
344
Name 3 treatments used in SLE
Steroids - prednisolone
NSAIDs - ibuprofen
Immunosuppressants - MTX
345
What are the core symptoms of depression?
Low mood
Anhedonia
Anergia
346
What are the non-core symptoms of depression?
Sleep disturbance - EMW
Decreased libido
Decreased appetite
Thoughts of suicide or self harm
Poor concentration
347
What drugs can cause low mood?
Beta-blockers
Corticosteroids
BDZs
Levodopa
348
Name 2 signs on examination of ascites
Shifting dullness
Fluid thrill
349
Name 3 signs in the hands in chronic liver disease
Clubbing
Dupuytren's
Jaundice
Liver flap
Palmar erythema
350
Name 2 investigations you could use to establish the cause of ascites
Abdo USS
Diagnostic paracentesis
LFTs
351
Name 3 complications of chronic liver disease
Oesophageal varices
Coagulopathy
SBP
Hepatorenal syndrome
Hepatic encephalopathy
HCC
352
What 4 investigations would confirm a diagnosis of TB?
Sputum culture - Lowenstein Jensen media, Ziehl Neelsen stain
Pleural fluid MC+S
HIV test
CXR
Quantiferon test
353
Name 2 ECG signs of hyperkalaemia
Tall tented T waves
Broad QRS
Prolonged PR interval
354
What 4 actions would you take in a patient with a potassium of 7.5
IV fluid bolus
High flow O2
Calcium gluconate
Insulin/dextrose
Salbutamol nebs
355
What is the characteristic cell in Hodgkin's lymphoma?
Reed-Sternberg cell
356
Name 3 B symptoms in Hodgkin's lymphoma
Weight loss
Night sweats
Fever
357
What are the 3 defining features of a health economic evaluation?
Cost of both services
Benefits of both services
Comparing the cost and benefit of service and alternative service
358
What are the 2 features comprising a QALY?
Number of years
Quality of life i.e. utility
359
What system do health economists use to evaluate disabilty?
DALYs
360
Define healthcare economic "efficiency"
Getting the maximum cost/health benefit outcomes from a service
361
What is the term for when treatment if given elsewhere and benefit foregone for other patients?
Opportunity cost - money spent elsewhere because it gives better benefit
362
What is an SAH?
Bleeding into the subarachnoid space (area between arachnoid membrane and pia mater)
363
Why does SAH cause coma?
Raised ICP
364
Name 4 common causes of coma
Hypoglycaemia
Hyperuricaemia
Miningococcal septicaemia
Trauma
Hypoxaemia
Seizures
365
Why do you get a fixed dilated pupil in SAH?
parasympathetic nerves are in the superficial parts of the nerve, so tend to be more
vulnerable to compressive lesions and spared by vascular lesions- 3 rd nerve palsy
occulomotor
366
Name 4 features of brainstem death
No resp effort in reaction to turning off ventilator
Fixed pupils unreactive to light
No corneal reflex
No cough reflex
No response to supra orbital pressure
367
What screening should GPs do for microvascular damage in DM?
Retinal screening
U+E - urine albumin and serum creatinine
Foot care - monofilament to assess sensation
ABPI - autonomic damage
368
2 causes of increasing floaters
diabetic retinopathy
retinal detachment
posterior vitreous detachment
369
What is the most common type of bladder cancer?
Where else are these cells found?
Transitional cell carcinoma
Ureters
Urethra
370
Name 4 risk factors for bladder cancer (TCC)
FH
Smoking
Frequent bladder infections
Working in rubber dye factory
371
What LNs should be removed when removing bladder and prostate?
initial lymphatic drainage from the bladder is primarily into the external iliac,
obturator, internal iliac (hypogastric), and common iliac nodes
372
Give 2 symptoms of cauda equina at each of the following sites
Perianal skin
Lower limb
Anal and urethral sphincters
Perianal skin: decreased sensation and tone
Lower limb: upgoing plantars, pain, altered reflexes
Anal and urethral sphincters: decreased tone, incontinence
373
What heart sound would you hear in pericarditis?
Pericardial rub
374
Name 4 investigations for pericarditis
Echo
CXR
CRP, WCC, ESR
ECG
375
What ECG changes would you see in acute pericarditis?
Diffuse ST elevation
PR depression
376
Name 2 treatments for pericarditis?
NSAIDS
Colchicine
Steroids if immune mediated
377
A patient with pericarditits becomes hypotensive, tachycardic, with low BP. What has happened?
Cardiac tamponade
378
Name 2 causes of pericarditis
Recent viral infection
Bacterial infection e.g. TB
Recent MI (Dressler syndrome)
Chest trauma
AI disorders
Cancer
Uraemic pericarditis
379
A patient is found to have a suspicious lung lesion on CXR and you are concerned he may have lung Ca with cerebral mets. Name 3 investigations you might do and why
HR CT chest to get more detailed image of lesion
PET scan for staging
Brain MRI to image cerebral mets
Lung lesion biopsy - for histological subtyping
380
What is your immediate management of a fracture?
Pain relief
Immobilisation
381
What are the important things to assess in a fracture?
Neurovascular status
Open vs closed
Displacement
Stable vs non stable
382
What are the ECG findings in AF?
Irregularly irregular rhythm
Absent P waves
383
What 3 medications can you use for rate control in AF? What is 1st line?
Beta blockers 1st line - propanolol
CCB - verapamil
Digoxin
384
What anticoagulants could you consider in AF? How do they work?
Warfarin - inhibits clotting factors 2, 7, 9 and 10, vit K antagonist
Rivaroxaban - inhibits factor 10a
385
Name 4 causes of facial nerve palsy
Ramsay Hunt syndrome
Bell's palsy
Stroke
Acoustic neuroma
GBS
Congenital
386
What causes Ramsay Hunt syndrome?
Where does this virus reside?
How would you treat it?
Varicella zoster
Geniculate ganglion
Aciclovir and prednisolone
387
What are the symptoms of Ramsay Hunt syndrome?
Sensorineural deafness
Vertigo
Facial pain
Facial palsy
Vesicular rash
388
A 55 year old lady presents with constipation and fatigue. Bloods show high Ca and PTH. What is the diagnosis? What would it be if PTH was low?
Primary hyperparathyroidism
Bone mets or malignancy
389
What are the 3 actions of parathyroid hormone?
Stimulates osteoclasts to reabsorb bone mineral increasing serum Ca
Enhances absorption of Ca from small intestine
Suppresses Ca loss in urine
Increases converstion of inactive D into active vitamin D
390
What are the symptoms of primary hyperparathyroidism?
Bone pain, osteoporosis
Depression, fatigue
Myalgia
Kidney stones
391
What are the complications of untreated hyperparathyroidism?
Cardiac arrhythmias - short QT interval
Renal tubular damage - hypokalaemia, dehydration, acute kidney injury
392
What is the treatment for severe hypercalcaemia?
IV fluids
Loop diuretic eg furosemide
Bisphosphonates
Calcitonin
393
A 40 year old man presents with L sided flank pain, nausea and vomiting. Differentials?
Ureteric colic
MSK pain
Diverticulitis
Constipation
Pyelonephritis
394
What is the investigation of choice in renal colic?
CT KUB
395
A man with a hx of renal stones comes in with fever and flank pain. What has happened and how would you sort?
Pyelonephritis - ABx as per local guidance eg gentamycin
Consider stenting if obstructed
396
How would you diagnose B thalassaemia?
FBC, blood film (microcytic hypochromic anaemia)
Hb electrophoresis
DNA testing
397
How do you treat B thalassaemia major?
Regular transfusions
BM transplant
398
Giving blood transfusions in B thalassaemia major has complications. Which organs may be affected and how? How could this be prevented?
Liver, heart, brain may be affected by iron induced oxidative stress
Iron chelation therapy
399
Alpha thalassaemia major is never seen in primary care - why, and what is the pathophysiology?
Severe intrauterine haemolytic anaemia - babies die before/shortly after birth
400
Name 4 risk factors for oropharyngeal cancer
Excessive alcohol, smoking, FH, HPV, asbestos exposure, diet low in fruit and veg
401
A man come in with rectal bleeding, mixed in with the stool. Differentials?
Haemorrhoids
Anal fissure
Trauma
Fistula
IBD
Gastroenteritis
Bowel Ca
402
What things would you want to examine in a patient with rectal bleeding?
Abdo palpation for masses
PR - for blood, masses
Inspect perianal area
Assess anaemic status
403
What investigations would you organise in a patient with PR bleed and microcytic anaemia?
Colonoscopy and biopsy
Faecal calprotectin
IgA anti TTG, antiendomysial antibodies
404
What are 3 treatments in conventional eczema regime?
Emollients
Steroid cream
Antihistamines oral
ABx if infected
405
What factors may make eczema worse?
Stress, hot weather, washing powder or washing products, infection
406
Describe the pathophysiology of anaphylaxis
Type 1 hypersensitivity
Degranulation of mast cells causes histamine release
407
Name 4 methods of preventing VTE
TED stockings
Pneumatic compression stockings
Heparin/warfarin
Early mobilisation
Stopping meds e.g. OCP
IVC filters
408
What 4 things must be measured before giving LMWH?
U+E
FBC (platelet count)
LFT
Weight
409
What are some RFs for PE? Link them to Virchow's triad
Active cancer, OCP, pregnancy, obesity - hypercoagulability
Immobility - stasis
Surgery/trauma - endothelial damage
410
What are the ABCDE of examining a skin lesion?
Asymmetry
Border irregularity
Colour
Diameter
Evolving
411
Name 4 RFs for melanoma
Pale skin (Causasian)
Sunlight exposure
Moles
FH
Lack of suncream
Increasing age
Immunosuppression
412
What staging system is used in melanoma?
Breslow staging
413
What tumour marker is used in melanoma?
s-100
414
Name 2 risk factors for vitamin d deficiency
Institutionalised
Dark skin tone (black/asian)
Wearing clothing that covers large amounts of skin or lots of sunscreen
CKD
Malabsorption, poor diet
415
How is vitamin d metabolised in the body?
Vit D3 made in skin, found in fish and eggs
Vit D2 found in salmon, mushroom, eggs
Liver convers vit D2 and D3 to 25(OH)D
25(OH)D converted to calcitriol (active form) by kidneys
416
What does lack of vitamin D do to the bone?
lack of Vit D reduces calcitriol and therefore calcium level in the
blood, and increasing PTH which increases osteoclastic activity and bones become undermineralised- i.e osteomalacia
417
Name 4 risk factors for gout
Diet - spinach, red meat
Alcohol
Smoking
Male
HTN
CKD
Myeloma
418
Name 4 triggers of gout
Dehydration
Prolonged fasting
Alcohol
Aspirin
Starting allopurinol
Thiazide diuretics
419
Name 2 acute treatments for gout
NSAIDs - diclofenac
Colchicine - natural product
420
Why does gout favour smaller more distal joints?
Distal blood supply is cooler so crystals more likely to precipitate
421
How does allopurinol act and how does it reduce chances of gout?
Xanthine oxidase inhibitor
Reduces serum uric acid levels
422
What are the histological features of coeliac disease?
Crypt hyperplasia
Subtotal villous atrophy
Lymphocytic infiltration
423
Name 4 fat soluble vitamins and their deficient state
A: night blindness
D: osteomalacia
E: ataxia
K: bleeding, bruising
424
What skin rash may be present in coeliac disease?
Dermatitis herpetiformis
425
What malignancy is associated with coeliac disease?
T cell lymphoma of small bowel - if non compliant with diet
426
Name an antimalarial prophylaxis
Proguanil + chloroquine
Doxycycline
Malarone
427
Why might malarial prophylaxis fail?
Poor compliance
Resistance
Not 100% effective
428
Name 2 non-drug measures to prevent malaria
Cover up with long sleeves and trousers
Use DEET repellant
Mosquito nets
429
What are the complications of cerebral malaria?
Confusion
Coma
Encephalopathy
Cerebral oedema
Covulsions
430
What drugs can treat malaria?
Artemisinin combination therapy
Atovaquone-proguanil
Chloroquine
Quinine
431
What 2 things would you test before starting lithium?
TFTs, U+E
432
Name 3 neuro signs of lithium toxicity
Coarse tremor
Hyperreflexia
Coma
Ataxia
Nystagmus
433
What are the 3 features of Horner's syndrome?
Miosis
Ptosis
Anhydrosis
434
Name 6 signs of MND
Hyperreflexia
Fasciculations
Muscle wasting
Spasticity
Dysarthria
Dysphagia
435
Give 4 symptoms of bulbar palsy
Dysarthria
Dysphagia
Weak/wasted tongue
Fasciculating tongue
Disturbed emotional state
436
What is an advanced directive?
A document where a patient makes provision for future healthcare decisions in the event that they become unable to make those decisions
437
What malignant cell is involved in multiple myeloma?
Plasma cells
438
What is present in the urine in multiple myeloma?
BJP
439
Which is better for investigating bone lesions in MM: technicium bone scan or full skeletal X-ray survey? Provide rationale.
Full skeletal x-ray as technicium scan as technicium looks at osteoblastic activity.
Plasma cells secrete IL-6 which inhibits osteoblast and stimulates osteoclastic activity
440
Name 2 methods in which patient could get funding for cancer treatments not recommended by NICE in the NHS
Individual funding through PCT
Cancer drug fund from charity
Private funding
441
Give 4 classic clinical features of plaque psoriasis skin lesions
Well-demarcated
Silver scaly plaque
Erythematous rash
Hyperproliferation (thickening of skin)
442
Give 2 clinical signs that distinguish between psoriatic arthritis and RA
DIPS affected in psoriatic
Nail changes in psoriasis
443
What class of drug is diclofenac? Which enzyme does diclofenac inhibit? What 2 substances does it prevent from forming?
NSAID
COX
Prostaglandin, thromboxin A2
444
What is the mechanism of action of steroids in the nucleus and cytoplasm?
1) nucleus – lipid soluble molecules pass through the cell membrane – bind with nuclear receptors in cytoplasm, translocation to nucleus binds to nuclear DNA, leading to increase transcription of the relevant gene product.
2) cytoplasm – binds with steroid receptors in the cytoplasm. In combination enters the nucleus where it controls protein synthesis and enzymes that regulate vital cell activities.
445
Name 2 side effects of MTX and how a patient might prevent them
Teratogenic - use contraception
Anaemia (BM suppression) - take folate
446
What are the features of Conn's syndrome?
Hypertension
Lethargy
Muscle weakness
Polyuria and polydipsia
Persistent hypokalaemia
447
What hormone level is elevated in Conn's and what organ is it from?
What hormone level is low in Conn's and what organ is it from?
Aldosterone - adrenal glands
Renin - kidneys
448
Name 2 clinical signs of Korsakoff syndrome
Confabulation
Anterograde amnesia
Personality changes
449
What is the first line rx for DT?
Diazepam, haloperidol
450
Name 2 organisms commonly found in COPD exacerbation related pneumonia
H influenzae
Strep pneumoniae
451
How is COPD diagnosed on spirometry?
FEV1/FVC ratio 0.7 or les
FEV1 \<80% predicted
452
Name 3 drug treatments of one lifestyle intervention important in COPD
SABA
LABA
LAMA
Stop smoking
453
Draw an image describing the HPT axis
454
How does a goitre form in hypothyroidism?
TSH stimulates the thyroid to produce T3 and T4 when the pituitary realises T3 and T4 is too low
This causes thyroid hyperplasia
455
How long does it take for a patient to feel the effects of thyroxine?
3 months
456
Give 6 risk factors for osteoporosis
Steroid use
Hyperparathyroidism
Alcohol
Low testosterone
Low BMI
Early menopause
Renal failure
Female sex
Increasing age
Smoking
457
What drug treatment would you give in an acute attack of IBD?
IV hydrocortisone
458
How might you manage erythema nodosum?
Analgesia
Raise leg
Compression stockings
Steroids
459
How do you differentiate between lower and upper motor neurone lesions causing facial nerve palsy?
UMN = forehead sparing
460
A patient with an acoustic neuroma has hearing loss and facial weakness. Where is the acoustic neuroma located?
Cerebellopontine angle
461
What are the symptoms of acoustic neuroma?
Hearing loss
Facial nerve palsy
Tinnitus
Signs of raised ICP
Vertigo
Nystagmus
462
What amount of proteinuria signifies nephrotic syndrome?
\>3.5g/24h
463
What are the biochemical abormalities in nephrotic syndrome?
Hypoalbuminaemia
Hyperlipidaemia
Proteinuria
464
Describe the body's response to nephrotic syndrome, and how does that worsen the condition
Hyperlipidaemia is a consequence of increased synthesis of lipoproteins as a direct consequence of low plasma albumin
Reduced clearance of triglycerides
465
Name 3 pharmacological and 1 lifestyle treatment for nephrotic syndrome
Fluid and salt restriction
Furosemide
Bendroflumethiazide
ACEi for proteinuria
LMWH for thrombosis risk
Statin
466
What pathological change would you see in the glomerular basement membrane in someone who has diabetic nephropathy?
Basement membrane thickening followed by mesangioexpansion and modular sclerosis
467
What is the most likely cause of mitral stenosis?
Rheumatic fever
468
State the pathophysiology behind the following in relation to how they occur due to mitral stenosis:
AF - pressure buildup causes enlargement of left atrium
RV heave - increased flow across narrow valve
Raised JVP - pulm htn and right heart failure
469
With reference to Starling's law, explain how mitral stenosis causes dyspnoea
Increased pressure in atrium due to stenosis
Backlog to pulmonary criculation leads to fluid overload
This causes increased hydrostatic pressure causing fluid to shift from vascular to interstitium causing oedema and shortness of breath
470
What features in a history would make you think of COPD rather than asthma?
Middle age
Smoking Hx
No diurnal variation
Sputum production
Lack of fx of atopy
Chronic dyspnoea
Progressive
471
Name 2 methods to help patients stop smoking
NRT
Buproprion
Champix (nicotine receptor partial agonist, reduces craving and makes smoking less pleasurable)
472
What treatments may be suitable for end stage/severe COPD?
Theophylline
Mucolytics
CPAP
LTOT
Lung volume reduction, bullectomy
473
Name 4 risk factors for acute pancreatitis
Alcohol
Gallstones
Prev ERCP
Scorpion stings
Mumps
Trauma, tumour
Autoimmune
Hypercalcaemia
Hyperlipidaemi
474
Why do patients with acute pancreatitis become hyperglycaemic?
Beta cells in islets of langerhans damaged by inflammation and calcification
This reduces insulin production
Insulin drives glucose into cells so a lack of this would mean that serum glucose is increase
There is an endocrine insufficiency
475
What is a normal Allen's test? Why do you perform it before an ABG?
It means both arteries (radial and ulnar) are patent and the palmar arches are functioning
It is important before ABG to ensure that the hand will have an adequate blood supply in case one of the arteries is damaged
476
Name 4 features you may find on examination in Parkinson's disease
Pill rolling resting tremor (improves with movement)
Cogwheel rigidity
Bradykinesia
Shuffling festinant gait
Micrographic handwriting that tails off
477
State 2 classes of drugs used in Parkinson's and give examples
Dopamine agonist - ropinirole
Dopamine - levodopa
Peripheral decarboxylase inhibitor - carbidopa
MAO-B inhibitor - selegiline
478
State 2 histological hallmarks of Parkinson's disease
Decrease in dopaminergic neurons in the substantia nigra
Lewy bodies
479
What would you find in a CT head in Parkinson's?
Nothing!
480
Name 4 symptoms of hypercalcaemia
Polyuria, polydipsia
Renal stones
Bone pain
Abdominal pain, constipation
Depression
Reduced QT interval
Nausea, vomiting
481
Name 1 drug treatment of hypercalcaemia and its pharmacology
Bisphosphonates - decrease action of osteoclasts
482
What electrolyte abnormalities would you expect in a patient with Addison's disease?
Low sodium
High potassium, urea, creatinine
483
What test would you perform to diagnose Addison's disease?
Short Synacthen test
Failure of exogenous ACTH to increase serum cortisol is diagnostic
484
Name 2 treatments for Addison's disease
Hydrocortisone
Fludrocortisone
485
Name 2 signs or symptoms of an Addisonian crisis
Nausea, vomiting, diarrhoea
Dehydration
Muscle aches
Shock
486
What chromosomal abnormality is associated with CML? Can this be passed on to family?
Philadelphia chromosome t9;22
No, spontaneous mutation
487
Where would you do a bone marrow biopsy in ?CML?
Trephine biopsy - posterior superior iliac spine
488
Name a treatment that may be used in CML
Imatinib - tyrosine kinase inhibitor
489
Name 2 signs you may find on examination of the genitals in an STI
Urethral discharge
Ulcers
Warts
Lymphadenopathy
490
A patient with chlamydia develops knee pain and sore eyes. What complication has occured?
Reiter's syndrome
491
Name 4 sexual behaviours that increase the risk of contracting HIV
Anal sex
Unprotected sex
MSM
Multiple partners, promiscuous behaviour
492
A patient has burns with no blistering but reduced pin-prick sensation - what level of burns is this? What complication might they develop?
3rd degree
Hyperkalaemia due to lysis of cells
493
Give 4 signs of inhalation injury
Tachypnoea
Facial burns
Hoarse voice
Respiratory distress
Harsh cough
Stridor
Soot in saliva
Inflamed oropharynx
494
Define hospital-acquired infection
Acquired after 48h of admission
495
How can you manage a patient with diarrhoea from an infection control perspective on the ward?
Side room (quarentine)
Barrier nursing, use of PPE
Hand washing
Involve infection control nurses
496
Name 4 viral causes of pharyngitis and cervical lymphadenopathy
EBV
Measles
Adenovirus
Rhinovirus
HSV
Influenza
HIV
497
What features would you find on examination of the mouth and pharynx in glandular fever?
Erythema
Palatal petechiae
Tonsillar enlargement
Uvular oedema
Lymphadenopathy
498
What tests can be used to confirm glandular fever?
Monospot
Heterophil antibody
499
Why would a patient with glandular fever get splenomegaly and deranged LFTs?
Mild hepatitis is common
500
What may be used in severe EBV?
Steroids and aciclovir
501
What may you find in an FBC of a man with OSA?
Raised Hb (polycythaemia)
502
