Foundation week 2

Question 1

Type 1 hypersensitivity

Answer 1

Antigen +TH2 -> TH2 releases IL-4 so Bcells produce IgE. IgE sensitises mast cells and basophils by joining.

Antigen reinfection + IgE complex -> histamines, leukotrienes and prostaglandins.

Eg anaphylaxis, asthma, atopic dermatitis, food and drug allergies.

Question 2

Type 2 hypersensitivity

Answer 2

Cell-bound antibodies bind to foreign/abnormal cell -> activates compliment -> neutrophil degranulation, O2 radicals and MAC.

Eg Acute transfusion reaction, Goodpasture’s, Grave’s, myasthenia gravis, ITTP, Autoimmune haemolytic anaemia.

Question 3

Type 3 hypersensitivity

Answer 3

Soluble antigens + free antibodies -> complex wedges in basement membranes of blood filtration eg Kidney, synovial joints -> activates compliment.
Eg Rheumatoid Arthritis, T1 diabetes, SLE, post strep glomerulonephritis

Question 4

Type 4 hypersensitivity

Answer 4

Antigen processed by antigen presenting cells. Antigen+ TH1 -> THelper releases chemokines to attract macrophages -> release lysozymes and IF alpha for more. CD8 Tcells involved in organ rejection -> cell mediated cytotoxicity.

Eg contact dermatitis, drug allergies, multiple sclerosis,

Question 5

Chostochondritis

Answer 5

Chest wall pain syndrome- inflammation of costochondal and sternocostal joints. Usually affecting multiple ribs (commonly 2-5th) on same side. Often microtrauma or infection. No swelling.

Those with persisting discomfort may have local nerve blocking corticosteroid injections. Affects teen and 50+ and more likely women.

Question 6

Tietze syndrome

Answer 6

Chest pain and swelling of costochondral and sternocostal areas of ribs 1-4. Firm spindle swelling within the cartilage. An aching, gripping pain. Sometimes radiates to shoulders, arms and neck. Redness and warmth can happen. Pain goes after weeks but swelling stays longer. Mostly affects teenagers and younger adults.

Question 7

Precordial catch syndrome

Answer 7

Nerve based stabbing pain in a small area of the chest. Can be psychological. Children- tweens most commonly affected.

Question 8

Papillary thyroid cancer

Answer 8

70% of thyroid cancer. Presents 35-40. Commonly ,1cm with good prognosis. Tends to spread locally, compressing trachea and recurrent laryngeal nerve. Most metastases= lungs , bone, mediastinal nodes, pelvis, brain, liver.

Question 9

Follicular thyroid cancer

Answer 9

10%. Occurs in areas of low iodine. Women 30-60. More likely to metastasise to lungs and bones.

Question 10

Hurthle cell thyroid cancer/tumours

Answer 10

Up to 10%, most commonly at 50-60 years. More aggressive.

Question 11

Medullary thyroid cancer

Answer 11

From parafollicular calcitonin producing c cells of the thyroid. 75% of cases occur sporadically. Most commonly in 20-30s then 50-60s. In men and women. Produces carcinoembryonic antigen/CEA and calcitonin.

Question 12

Anaplastic thyroid cancer

Answer 12

Most aggressive. From the follicular cells but no resemblance. Most commonly 55-65. Is often a transformation of a well-differentiated tumour. Large mass- often has compression signs:

Dyspnoea, cough, vocal cord paralysis, dysphagia and hoarseness. %05 have distant metastases, commonly in the bones, liver and brain. Mean survival is 6 months.

Question 13

Thyroid lymphomas

Answer 13

Almost always NHL, up to 10% of all thyroid malignancies. More common in areas of thyroiditis. Females have it 4:1. Rapidly growing neck mass that can obstruct. Much worse if disseminated.
Risk = cowden’s syndrome or familial adenomatous polyposis.

Question 14

PSA test fast track referral

Answer 14

if 40-49 yrs- >2.5
50-59- >3.5
60-60- >4.5
70+ is >6.5

Question 15

Prostate cancer hormone therapy

Answer 15

LHRH agonists- eg goserelin, leuprorelin, triptorelin. Lowers testosterone via anterior pituitary.

Anti-androgens inhibit androgen receptors to inhibit cancer growth. Can be steroidal = cyproterone acetate or non-steroidal = bicalutamide, nilutamide, flutamide.

Chemo would be docetaxel or cabazitaxel with prednisone or prednisolone.

Question 16

Small cell lung cancers vs Non-small cell lung cancers

Answer 16

SCLC (15%) also called oat-cell carcinoma. Arises from kulchitsky cells. Part of the endocrine system. Rapidly growing and poor prognosis.

NSCLC- squamous is 42% of lung cancers. Most present as obstructive lesions of the bronchus leading to infection. More likely to have a local spread.

Adenocarcinoma- 39%. From mucous cells in bronchial epithelium. It is the most common bronchial carcinoma associated with asbestos and is more common in non-smokers. Invasion of pleura and mediastinal nodes= common. Often metastasises to brain and bones.

Other types include large cell (undifferentiated), bronchioalveolar and carcinoid.

2 wk referral for 40+ w/ smoked, cough, fatigue, sob, dec weight or appetite.

Question 17

Rifampin side effects

Answer 17

Upset stomach, itching, flu symptoms, headache, dizziness, menstrual changes, temporary colour change of skin, teeth, saliva, urine, stool, sweat and tears to yellow, red or brown.

Question 18

NIPE

Answer 18

eyes, heart and hips (+testes)

Question 19

Exercise induced bronchospasm

Answer 19

Occurs 5-20 minutes after- trouble breathing, cough, chest pain, tightness, wheezing.

Other exercise pain- costochondritis, tietze’s, precordial catch syndrome.

Question 20

Hypothermia changes

Answer 20

dec bicarb and potassium, inc sugar then dec after, increased urea and calcium.

Question 21

Perioperative complications

Answer 21

DVT, PE, intracranial bleeding, sepsis, implant failure, anastomotic leak, ileus, postoperative haemorrhage, fistula.

Question 22

V flutter

Answer 22

is extreme of ventricular tachycardia. Turns to vfib, shows no p, qrs nor t. Rate over 200. x give verapamil to svt bc leads to vfib. this requires cardioversion.

Question 23

Otosclerosis

Answer 23

Bone based hearing loss more likely in women. Develops 15-35. Speaking softly, hears better when noisy, hears body sounds, can be dizzy and ataxic.

Question 24

Doctrine of double effect

Answer 24

If doing something morally good = morally bad outcome, is ethically ok if side effect was not intended.

Question 25

Ethical equipoise

Answer 25

When there is uncertainty or conflicting opinion on best diagnosis, treatment etc. It’s ok to allocate interventions to patients as to figure it out.

Question 26

Thromboangiitis obliterans

Answer 26

Smoking related condition that results in thrombosis in small-medium arteries, commonly in hands and feet.

Pain, general claudication, cold sensitivity, diminished pulses, blue-red digit change, skin becomes thin and shiny, reduced hair growth, might complicate to ulcerations and gangrene.

Question 27

Signs of PAD

Answer 27

leg pain whilst walking that stops at rest, skin ulcers, blue skin, cold skin, statins, ace, cilostazol. Better is dangle feet off bed.

Question 28

Multiple endocrine neoplasia

Answer 28

Autosomal dominant. Tumours in at least 2 endocrine glands and doesn’t have to be cancerous. Types 1 (MEN1) 2 (RET) and 4 (CDKN1B).

Type 1 = parathyroid, pituitary, pancreas, hyperparathyroidism is major sign. Disrupts calcium + gives osteoporosis, vomiting, htn, weakness.

Type 2 is associated with medullary thyroid cancer. can also have pheochromocytoma with htn. Type 2B x have hyperparathyroidism.

Type 4 is like 2 but onset by different genes,

Question 29

Acetylcysteine

Answer 29

To treat paracetamol overdose and loosen thick mucous.

Question 30

STI backdating time frame

Answer 30

men = 1 month before symptoms. Women + asymptomatic men= 6 months before onset.

Question 31

Hepatitis A

Answer 31

Only transmitted fecal-orally. Self-resolving within 2 months. Prodromal phase- flu and GI symptoms, RUQ pain, headache, cough, pharyngitis, itch, urticaria.

Icteric phase includes jaundice, pale stools and dark urine if there is cholestasis. Symptoms improve once jaundice appears.

Convalescent phase includes malaise and hepatic tenderness.

Diagnosis is from presentation, igM + igG or have HAV RNA, or have antiHAV igM with a confirmed hep A link.

No longer contagious after 7 days onset of jaundice or symptoms.

Question 32

Spinal claudication

Answer 32

Narrowed spinal canal-> pressurises cauda equina. Pain, tingling, tiredness, numb or heavy legs, butt and lower back. Caused by stenosis, osteoarthritis, spondylitis, Rha, Paget’s, tumour, disc issues, scoliosis, achondroplasia.

Question 33

Indications of low specific gravity

Answer 33

Diabetes insipidus. High would show mild dehydration or DM.

Question 34

Vocal cord polyps

Answer 34

More red than nodules +larger. Looks like blisters with a scratchy voice. Occurs from overuse. Same with vocal nodules.

Question 35

Reinke’s Oedema

Answer 35

Fold under the vocal cord space is swollen. It’s bilateral and symmetrical. Often from acid, smoking**! or hypothyroidism. Has a sac-like appearance to the vocal cords. Deep hoarse voice like in pharyngitis. Often dyspnoea.

Question 36

Associations of perianal skin tags

Answer 36

External haemorrhoids (will be painful if they have a clot). Or fissures and crohns. Fissures can itch, bleed and hurt when passing stool.

Question 37

Management of diabetes in palliative care

Answer 37

If > 15mmol/L only treat the symptomatic. eg 5 units/novorapid and check in an hour. Monitor twice a day.

If terminal- give if they have spiked 2 days on.

If asymptomatic and BM >4 stop monitoring or once a day at 1/3-2/3 previous normal dose.

If tablets- check up BM twice a week. Should ideally be glicazide. If control is slipping give insulin.

Terminal phase and declining- stop dietary restriction, monitoring and medication.

Question 38

Nimodipine

Answer 38

With subarachnoid haemorrhage is good because improves neurological deficits due to spasm.

Question 39

Acute fatty liver of pregnancy

Answer 39

3rd trimester issue. Vomiting, pain, polydipsia/urea, encephalopathy, >14micromol/L billirubin, <4mmol/L hypoglycaemia. > 340 micromol/L urea. Inc leukocytes, inc transaminases, inc ammonia, creatinine > 150micromol/L, inc PTT or APTT.

Question 40

Coombs test

Answer 40

Also AGT test. Detects antibodies against surface of RBCs. Coomb’s positive babies= risk of hyperbilirubinemia. Could be positive in autoimmune haemolytic anaemia, chronic lymphocytic leukaemia, SLE, drug haemolysis. Tests Rh antibody in pregnancy.

Question 41

Adrenaline dosing

Answer 41

For cardiopulmonary resus- 10micrograms/Kg per 3-5 mins. Max dose 1mg. Eg 100 microgram/Ml for a child. Adult is 1mg per 3-5 mins as 100micrograms/Ml solution as max dose.

For acute hypertension- neonate is 100nanograms/kg/minute, then up to 1.5 micrograms. Same for a child.

For emergency anaphylaxis- in micrograms every 5 minutes:
100 for 6m or younger, 150 for under 5 yrs, 300 for under 12 years, over 12 and under 18 is 300-500 depending on size, 500 for 18+.

Question 42

Testicular seminomas

Answer 42

Germ cell tumour most commonly in anterior mediastinum, 45% of all testicular tumours. Most common non-haematological malignancy in males 15-49.

Risk factors = undescended testis, family history, HIV, mumps, orchitis, trauma, immunosuppression.

Shows painless-uncomfortable yellow-grey nodular testicular mass. Not associated with alpha fetoprotein.

3 types of seminomas- classic (85%) characterised by sheets of cells, lots of cytoplasm, round hyperchromatic nuclei and infrequent mitosis. Anaplastic- (10%) > mitotic figures per high power field. Spermatocytic (5%) males older than 60, rarely metastasises, well differentiated and appears like secondary spermatids.

Ultrasound diagnoses and CT stages it.

Question 43

Non-seminoma testicular tumours

Answer 43

Choriocarcinoma(rare), embryological carcinoma, teratoma, yolk sac tumours.

Stromal tumours are benign tumours of leydig or sertoli cells and usually occurs in childhood.

Stage 1 has not spread, 2 is to nodes and 3 is beyond.

Question 44

Blind loop syndrome

Answer 44

When food bypasses a section of the intestine, often from surgery. Can be as digested food slows or stops moving-? overgrowth of bacteria + issue absorbing nutrients. Affects bile use and vitamin B12 lvels.

Symptoms = diarrhoea, fatty stool, early saeity, loss of appetite, nausea, unintentional weight loss.

Question 45

Giardiasis

Answer 45

Parasite from poor water sanitation. Gives smelly diarrhoea, egg burps, stomach pain and vomitign. Give metronidazole.

Question 46

Lyme disease

Answer 46

Borrelia burgdorferi. Erythema migrans rash only occurs in lyme disease. If doesn’t have that- give an elisa test. Treat with doxycycline.

Question 47

Post operative anuria

Answer 47

May be delayed or reduced due to fluid + blood loss, as well as inc aldosterone + ADH in 24hrs after surgery, comes with salt and water retention. Insufficient analgesia after surgery can precipitate retention or anuria. If anuric or -500ml after 24hrs, could be acute renal failure or urinary retention.

Question 48

Acute cerebellar ataxia of childhood

Answer 48

Unsteady gait, slurred speech, ataxia, nystagmus but afebrile. Cause by drugs, infection or paraneoplastic syndrome. Most common infections are chickenpox and epstein barr. Between 2-7 commonly.