Friday [08/10/2021]

Question 1

How do Lacunar strokes typically present? [2]

Answer 1

Lacunar stroke is a type of stroke that results from occlusion of one of the penetrating arteries that provides blood to the brain’s deep structures. Lacunar strokes most commonly present as a pure motor hemiparesis, pure sensory stroke, sensorimotor stroke, ataxic hemiparesis or dysarthria/clumsy hand syndrome.

Question 2

What is the classification system for strokes? [1]

Answer 2

Oxford Stroke classification

Question 3

Criteria assessed by the Oxford Stroke Classification [3]

Answer 3

1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia

Question 4

How do TACI [c.15%] typically present? Which arteries do they involve? [2]

Answer 4

involves middle and anterior cerebral arteries
all 3 of the above criteria are present

Question 5

Which arteries do PACI [c.25%] typically effect and how do they present? [2]

Answer 5

involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
2 of the above criteria are present

Question 6

Which arteries do lacunar infarcts typically effects [c.25%] and how they present? [4]

Answer 6

involves perforating arteries around the internal capsule, thalamus and basal ganglia
presents with 1 of the following:
1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke.
3. ataxic hemiparesis

Question 7

Which arteries do POCI [c.25%] typically effect and what is the presentation? [4]

Answer 7

involves vertebrobasilar arteries
presents with 1 of the following:
1. cerebellar or brainstem syndromes
2. loss of consciousness
3. isolated homonymous hemianopia

Question 8

What is a lateral medullary stroke? [3]

Answer 8

Lateral medullary syndrome (posterior inferior cerebellar artery)
aka Wallenberg’s syndrome
ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
contralateral: limb sensory loss

Question 9

What is Weber’s syndrome and how does it present? [2]

Answer 9

ipsilateral III palsy
contralateral weakness

Question 10

COPD still breathless despite using SABA/SAMA and a LABA+ICS, what should you add? [1]

Answer 10

A LAMA like inhaled triotropium

Question 11

General Mx of COPD [4]

Answer 11

>smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion
annual influenza vaccination
one-off pneumococcal vaccination
pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above)

Question 12

bronchodilator therapy initially in COPD [2]

Answer 12

a short-acting beta2-agonist (SABA) or short-acting muscarinic antagonist (SAMA) is first-line treatment
for patients who remain breathless or have exacerbations despite using short-acting bronchodilators the next step is determined by whether the patient has ‘asthmatic features/features suggesting steroid responsiveness’

Question 13

Criteria to determine if patient has asthmatic/steroid responsiveness features []4

Answer 13

any previous, secure diagnosis of asthma or of atopy
a higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up
substantial variation in FEV1 over time (at least 400 ml)
substantial diurnal variation in peak expiratory flow (at least 20%)

Question 14

How to Tx patient if no asthmatic features/features suggesting steroid responsiveness? [2]

Answer 14

add a long-acting beta2-agonist (LABA) + long-acting muscarinic antagonist (LAMA)
if already taking a SAMA, discontinue and switch to a SABA

Question 15

How to Tx a patient if they have asthmatic features/features suggesting steroid repsiveness? [3]

Answer 15

LABA + inhaled corticosteroid (ICS)
if patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS
if already taking a SAMA, discontinue and switch to a SABA
NICE recommend the use of combined inhalers where possible

Question 16

When to include oral theophylline in Tx for COPD? []2

Answer 16

NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy
the dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed

Question 17

When to include prophylactic antibiotic therapy for COPD Tx [4]

Answer 17

azithromycin prophylaxis is recommended in select patients
patients should not smoke, have optimised standard treatments and continue to have exacerbations
other prerequisites include a CT thorax (to exclude bronchiectasis) and sputum culture (to exclude atypical infections and tuberculosis)
LFTs and an ECG to exclude QT prolongation should also be done as azithromycin can prolong the QT interval

Question 18

What should be done before giving azithromycin prophylaxis for COPD patients? [2]

Answer 18

LFTs and an ECG to exclude QT prolongation should also be done as azithromycin can prolong the QT interval

Question 19

When should mucolytics be considered in COPD patients? [1]

Answer 19

should be ‘considered’ in patients with a chronic productive cough and continued if symptoms improve

Question 20

Features of Cor pulmonale and how to Tx [3]

Answer 20

features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, loud P2
use a loop diuretic for oedema, consider long-term oxygen therapy
ACE-inhibitors, calcium channel blockers and alpha blockers are not recommended by NICE

Question 21

Factors which may improve survival in patients with stable COPD [3]

Answer 21

smoking cessation - the single most important intervention in patients who are still smoking
long term oxygen therapy in patients who fit criteria
lung volume reduction surgery in selected patients

Question 22

WHen is electroconvulsive therapy considered? [2]

Answer 22

Electroconvulsive therapy is a useful treatment option for patients with severe depression refractory to medication (e.g. catatonia) those with psychotic symptoms. For catatonic schizophrenai and severe mania too.

Question 23

What is the only absolute CI to ECT? [1]

Answer 23

The only absolute contraindications is raised intracranial pressure.

Question 24

Short-term SE of ECT? [5]

Answer 24

headache
nausea
short term memory impairment
memory loss of events prior to ECT
cardiac arrhythmia

Question 25

Long-term SE of ECT [1]

Answer 25

some patients report impaired memory

Question 26

What is done first-line during endoscopy to stop bleeding? [1]

Answer 26

Band ligation

Question 27

Acute Tx of variceal haemorrhage [7]

Answer 27

ABC: patients should ideally be resuscitated prior to endoscopy
correct clotting: FFP, vitamin K
vasoactive agents:
terlipressin is currently the only licensed vasoactive agent and is supported by NICE guidelines. It has been shown to be of benefit in initial haemostasis and preventing rebleeding
octreotide may also be used although there is some evidence that terlipressin has a greater effect on reducing mortality
prophylactic IV antibiotics have been shown to reduce mortality in patients with liver cirrhosis. Quinolones are typically used. NICE support this in their 2016 guidelines: ‘Offer prophylactic intravenous antibiotics for people with cirrhosis who have upper gastrointestinal bleeding.’
both terlipressin and antibiotics should be given before endoscopy in patients with suspected variceal haemorrhage
endoscopy: endoscopic variceal band ligation is superior to endoscopic sclerotherapy. NICE recommend band ligation
Sengstaken-Blakemore tube if uncontrolled haemorrhage
Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail
connects the hepatic vein to the portal vein
exacerbation of hepatic encephalopathy is a common complication

Question 28

What should be given before endoscopy if being given? [2]

Answer 28

both terlipressin and antibiotics should be given before endoscopy in patients with suspected variceal haemorrhage [Abx given those with liver cirrhosis]

Question 29

If endoscopic measures fail to control variceal bleed,what is done next? [2]

Answer 29

Sengstaken-Blakemore tube if uncontrolled haemorrhage
Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail
connects the hepatic vein to the portal vein
exacerbation of hepatic encephalopathy is a common complication

Question 30

What are prophlyactic measures for variceal haemorrhages? [2]

Answer 30

propranolol: reduced rebleeding and mortality compared to placebo
endoscopic variceal band ligation (EVL) is superior to endoscopic sclerotherapy. It should be performed at two-weekly intervals until all varices have been eradicated. Proton pump inhibitor cover is given to prevent EVL-induced ulceration. This is supported by NICE who recommend: ‘Offer endoscopic variceal band ligation for the primary prevention of bleeding for people with cirrhosis who have medium to large oesophageal varices.’

Question 31

third step for asthma Mx in 5-16 y/o

Answer 31

1 - SABA
2 - SABA + paediatric low-dose inhaled ICS
3 - SABA + paediatric low-dose inhaled ICS + LTRA

Question 32

Prophylaxis for migraines [2]

Answer 32

NICE advise either topiramate or propranolol ‘according to the person’s preference, comorbidities and risk of adverse events’. Propranolol should be used in preference to topiramate in women of child bearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives

Question 33

Acute Tx for migraines [2]

Answer 33

first-line: offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol

Question 34

Which cancer are transplant patient at paritcular risk from? [1]

Answer 34

Patients who have received an organ transplant are at risk of skin cancer (particularly squamous cell carcinoma) due to long-term use of immunosuppressants

Question 35

Which renal transplant drugs can cause CVD? [2]

Answer 35

Cardiovascular disease - tacrolimus and ciclosporin can cause hypertension and hyperglycaemia. Tacrolimus can also cause hyperlipidaemia. Patients must be monitored for accelerated cardiovascular disease.

Question 36

Which renal transplant drugs can cause renal failure? [2]

Answer 36

Renal failure - due to nephrotoxic effects of tacrolimus and ciclosporin/graft rejection/recurrence of original disease in transplanted kidney

Question 37

What must be monitored with eryhroderma? [3]

Answer 37

SoB:
- Inpatient treatment for erythroderma must be monitored for complications like dehydration, infection and high-output heart failure

Question 38

What is erythroderma? [1]

Answer 38

When more than 95% of the skin is involved in a rash of any kind

Question 39

Causes of erythroderma [5]

Answer 39

eczema
psoriasis
drugs e.g. gold
lymphomas, leukaemias
idiopathic

Question 40

What is erythrodermic psoriasis and how should it be Mx? [2]

Answer 40

may result from progression of chronic disease to an exfoliative phase with plaques covering most of the body. Associated with mild systemic upset
more serious form is an acute deterioration. This may be triggered by a variety of factors such as withdrawal of systemic steroids. Patients need to be admitted to hospital for management

Question 41

Sx of liver abscesses [2]

Answer 41

Raised inflammatory markers, RUQ pain and fever

Question 42

How are liver abscesses Mx? [2]

Answer 42

Combination of antibiotics and drainage

Question 43

Most common orgnaisms found in pyogenic liver abscesses [2]

Answer 43

The most common organisms found in pyogenic liver abscesses are Staphylococcus aureus in children and Escherichia coli in adults.

Question 44

Which Abx are used in Mx of liver abscesses? [3]

Answer 44

drainage (typically percutaneous) and antibiotics
amoxicillin + ciprofloxacin + metronidazole
if penicillin allergic: ciprofloxacin + clindamycin

Question 45

Target levels for blood glucose in pregnant women [3]

Answer 45

Pregnant women with GDM should be advised to maintain their CBGs below the following target levels:
fasting: 5.3mmol/L
AND
1 hour postprandial: 7.8 mmol/L or
2 hours postprandial: 6.4 mmol/L

Question 46

If blood glucose targets are not met by metformin/lifestyle, what should be done? [2]

Answer 46

If these targets are not met with diet, exercise and metformin, then insulin should be offered as add-on therapy.

Question 47

When do Sx start of alcohol withdrawal? [1]

Answer 47

Between 6-12 hours

Question 48

when do seizures, adn when does delirium tremens begin with alcohol? [2]

Answer 48

Alcohol withdrawal
symptoms: 6-12 hours
seizures: 36 hours
delirium tremens: 72 hours

Question 49

Frist-line Mx of delirium tremens [2]

Answer 49

first-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol

Question 50

Sx of alcohol withdrawal [1]

Answer 50

tremor, sweating, tachycardia, anxiety

Question 51

Which drugs can cause cataracts? [1]

Answer 51

Steroids

Question 52

Which drugs can cause corneal opacities? [2]

Answer 52

amiodarone
indomethacin

Question 53

Which drugs can cause optic neuritis? [3]

Answer 53

ethambutol
amiodarone
metronidazole

Question 54

Which drugs can cause retinopathy? [2]

Answer 54

chloroquine, quinine

Question 55

What type of herpes are genital ulcers caused by? [1]

Answer 55

Genital herpes is most often caused by the herpes simplex virus (HSV) type 2 (cold sores are usually due to HSV type 1)

Question 56

Sx of primary attacks from Herpes [2]

Answer 56

Primary attacks are often severe and associated with fever whilst subsequent attacks are generally less severe and localised to one site. There is typically multiple painful ulcers.

Question 57

What is syphilis caused by and what is the presentation of it? [2]

Answer 57

Syphilis is a sexually transmitted infection caused by the spirochaete Treponema pallidum. Infection is characterised by primary, secondary and tertiary stages. A painless ulcer (chancre) is seen in the primary stage. The incubation period= 9-90 days.

Question 58

What is Chancroid caused by and how does it present? [2]

Answer 58

Chancroid is a tropical disease caused by Haemophilus ducreyi. It causes painful genital ulcers associated with unilateral, painful inguinal lymph node enlargement. The ulcers typically have a sharply defined, ragged, undermined border.

Question 59

What is LGV caused by and how does it present? [2]

Answer 59

Lymphogranuloma venereum (LGV) is caused by Chlamydia trachomatis. Typically infection comprises of three stages
stage 1: small painless pustule which later forms an ulcer
stage 2: painful inguinal lymphadenopathy
stage 3: proctocolitis

Question 60

How is LGV Tx? [1]

Answer 60

Doxycycline

Question 61

Immediate frist aid for burns [4]

Answer 61

airway, breathing, circulation
burns caused by heat: remove the person from the source. Within 20 minutes of the injury irrigate the burn with cool (not iced) water for between 10 and 30 minutes. Cover the burn using cling film, layered, rather than wrapped around a limb
electrical burns: switch off power supply, remove the person from the source
chemical burns: brush any powder off then irrigate with water. Attempts to neutralise the chemical are not recommended

Question 62

How to assess the extent of the burn [3]

Answer 62

Wallace’s Rule of Nines: head + neck = 9%, each arm = 9%, each anterior part of leg = 9%, each posterior part of leg = 9%, anterior chest = 9%, posterior chest = 9%, anterior abdomen = 9%, posterior abdomen = 9%

Lund and Browder chart: the most accurate method

the palmar surface is roughly equivalent to 1% of total body surface area (TBSA). Not accurate for burns > 15% TBSA

Question 63

When to refer to secondary care? [3]

Answer 63

all deep dermal and full-thickness burns.
superficial dermal burns of more than 3% TBSA in adults, or more than 2% TBSA in children
superficial dermal burns involving the face, hands, feet, perineum, genitalia, or any flexure, or circumferential burns of the limbs, torso, or neck
any inhalation injury
any electrical or chemical burn injury
suspicion of non-accidental injury

Question 64

What is the PP of severe burns? [3]

Answer 64

Following the burn, there is a local response with progressive tissue loss and release of inflammatory cytokines. Systemically, there are cardiovascular effects resulting from fluid loss and sequestration of fluid into the third space. There is a marked catabolic response. Immunosupression is common with large burns and bacterial translocation from the gut lumen is a recognised event. Sepsis is a common cause of death following major burns.

Question 65

How to Mx more severe burns [3]

Answer 65

The initial aim is to stop the burning process and resuscitate the patient. Intravenous fluids will be required for children with burns greater than 10% of total body surface area. Adults with burns greater than 15% of total body surface area will also require IV fluids. The fluids are calculated using the Parkland formula which is; volume of fluid= total body surface area of the burn % x weight (Kg) x4. Half of the fluid is administered in the first 8 hours. A urinary catheter should be inserted. Analgesia should be given. Complex burns, burns involving the hand perineum and face and burns >10% in adults and >5% in children should be transferred to a burns unit.

Question 66

When to conservatively manage burns? [2]

Answer 66

Conservative management is appropriate for superficial burns and mixed superficial burns that will heal in 2 weeks. More complex burns may require excision and skin grafting. Excision and primary closure is not generally practised as there is a high risk of infection.

Question 67

What are escharotomies and when are they used? [2]

Answer 67

Indicated in circumferential full thickness burns to the torso or limbs.
Careful division of the encasing band of burn tissue will potentially improve ventilation (if the burn involves the torso), or relieve compartment syndrome and oedema (where a limb is involved)

Question 68

Mx of scabies [4]

Answer 68

Treating the affected person and all household members, close contacts, and sexual contacts with a topical insecticide (e.g. permethrin 5% cream or malathion 0.5% liquid), even in the absence of symptoms.

Question 69

Guidance of Tx for households with scabies [4]

Answer 69

avoid close physical contact with others until treatment is complete
all household and close physical contacts should be treated at the same time, even if asymptomatic
launder, iron or tumble dry clothing, bedding, towels, etc., on the first day of treatment to kill off mites.

Question 70

Features of scabies

Answer 70

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

Question 71

What is obese class 1? [1]

Answer 71

Overweight is 25-30, obese class 1 is 30-35

Question 72

Step-wise approach to managing obesity [3]

Answer 72

conservative: diet, exercise
medical
surgical

Question 73

MoA of Orlistat and adverse effects of the drug [2]

Answer 73

Orlistat is a pancreatic lipase inhibitor used in the management of obesity. Adverse effects include faecal urgency/incontinence and flatulence

Question 74

What is the lower dose version now available [2]

Answer 74

A lower dose version is now available without prescription (‘Alli’).

Question 75

Which adults can be given orlistat? [4]

Answer 75

BMI of 28 kg/m^2 or more with associated risk factors, or
BMI of 30 kg/m^2 or more
continued weight loss e.g. 5% at 3 months
orlistat is normally used for < 1 year

Question 76

When are women covered by the lactational amenorrhoea method? [LAM] [1]

Answer 76

She is having unprotected intercourse and will not be covered by the lactational amenorrhea method (LAM) as the baby is getting less than 85% of its feeds as breast milk (NICE CKS: Contraception - natural family planning)

Question 77

If not covered by LAM, when are women art risk of prognancy from unprototected sex? [2]

Answer 77

If not covered by the LAM, women are at risk of pregnancy from unprotected intercourse from day 21 postpartum

Question 78

When is COCOP CI? [1]

Answer 78

The COCP is absolutely contraindicated (UKMEC 4) for women who are breastfeeding less than 6 weeks post-partum

Question 79

Are women allowed to have the COCP 7w post-partum? [2]

Answer 79

However, this lady is seven weeks postpartum meaning she falls into the 6 weeks - 6 months postpartum guidance, in which the COCP is categorised as UKMEC2 for breastfeeding women. This means that advantages of prescribing the COCP would generally outweigh the disadvantages and based on the FRSH advice regarding the COCP, NICE clinical knowledge summaries recommend

Question 80

WHen can women start the PIP? [3]

Answer 80

the FSRH advise ‘postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.’
after day 21 additional contraception should be used for the first 2 days
a small amount of progestogen enters breast milk but this is not harmful to the infant

Question 81

When can women start the COC? [4]

Answer 81

absolutely contraindicated - UKMEC 4 - if breast feeding < 6 weeks post-partum
UKMEC 2 - if breast feeding 6 weeks - 6 months postpartum*
the COC may reduce breast milk production in lactating mothers
may be started from day 21 - this will provide immediate contraception
after day 21 additional contraception should be used for the first 7 days

Question 82

When can an IUD or IUD be inserted owmne a women post-partum? [1]

Answer 82

The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks.

Question 83

How effective is LAM? [2]

Answer 83

is 98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum

Question 84

Problems with Inter-pregnancy interval being shortened? [2]

Answer 84

An inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birthweight and small for gestational age babies.

Question 85

What is pre-eclampsia defined as? [2]

Answer 85

Pre-eclampsia is defined as new-onset BP ≥ 140/90 mmHg after 20 weeks AND ≥ 1 of proteinuria or organ dysfunction

Question 86

Consequences of pre-eclampsia [4]

Answer 86

eclampsia
other neurological complications include altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
fetal complications
intrauterine growth retardation
prematurity
liver involvement (elevated transaminases)
haemorrhage: placental abruption, intra-abdominal, intra-cerebral
cardiac failure

Question 87

Features of severe pre-eclampsia [4]

Answer 87

hypertension: typically > 160/110 mmHg and proteinuria as above
proteinuria: dipstick ++/+++
headache
visual disturbance
papilloedema
RUQ/epigastric pain
hyperreflexia
platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

Question 88

High RF for pre-eclampsia [5]

Answer 88

hypertensive disease in a previous pregnancy
chronic kidney disease
autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
type 1 or type 2 diabetes
chronic hypertension

Question 89

Moderate RF for pre-eclamspia [4]

Answer 89

first pregnancy
age 40 years or older
pregnancy interval of more than 10 years
body mass index (BMI) of 35 kg/m² or more at first visit
family history of pre-eclampsia
multiple pregnancy

Question 90

What should be given and whom to to reduce the risk of pre-eclampsia in pregnannt women? [2]

Answer 90

Reducing the risk of hypertensive disorders in pregnancy
women with the following should take aspirin 75-150mg daily from 12 weeks gestation until the birth
≥ 1 high risk factors
≥ 2 moderate factors

Question 91

Which women will admitted and observed for risk of pre-eclampsia in pregnancy? [2]

Answer 91

Initial assessment
NICE recommend arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected
women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed

Question 92

First-line, and defintive Mx of pre-eclampsia in pregnancy [2]

Answer 92

oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine (e.g. if asthmatic) and hydralazine may also be used
delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario

Question 93

What can be used for pre-eclampsia if women if asthmatic and can;t have oral labetolol? [1]

Answer 93

Nifedipine

Question 94

Which type of Herpes causes oral lesions? [1]

Answer 94

There are two strains of the herpes simplex virus (HSV) in humans: HSV-1 and HSV-2. Whilst it was previously thought HSV-1 accounted for oral lesions (cold sores) and HSV-2 for genital herpes it is now known there is considerable overlap

Question 95

Features of Herpes Simplex virus [3]

Answer 95

primary infection: may present with a severe gingivostomatitis
cold sores
painful genital ulceration

Question 96

Mx of gingivomastitis vs cold sores vs genital herpes [3]

Answer 96

gingivostomatitis: oral aciclovir, chlorhexidine mouthwash
cold sores: topical aciclovir although the evidence base for this is modest
genital herpes: oral aciclovir. Some patients with frequent exacerbations may benefit from longer term aciclovir

Question 97

How should women with Herpes at pregnancy be Tx? [2]

Answer 97

elective caesarean section at term is advised if a primary attack of herpes occurs during pregnancy at greater than 28 weeks gestation
women with recurrent herpes who are pregnant should be treated with suppressive therapy and be advised that the risk of transmission to their baby is low

Question 98

What are patietns with Addison’s disease given? [2]

Answer 98

Patients who have Addison’s disease are usually given both glucocorticoid and mineralocorticoid replacement therapy.

Question 99

Which drugs does that mean they are given [2]

Answer 99

hydrocortisone: usually given in 2 or 3 divided doses. Patients typically require 20-30 mg per day, with the majority given in the first half of the day
fludrocortisone

Question 100

Which part of patient educatio is important with Addison disease Tx? [3]

Answer 100

emphasise the importance of not missing glucocorticoid doses
consider MedicAlert bracelets and steroid cards
patients should be provided with hydrocortisone for injection with needles and syringes to treat an adrenal crisis
discuss how to adjust the glucocorticoid dose during an intercurrent illness (see below)

Question 101

Mx of intercurrent illness of Addison’s disease [2]

Answer 101

in simple terms the glucocorticoid dose should be doubled, with the fludrocortisone dose staying the same
the Addison’s Clinical Advisory Panel have produced guidelines detailing particular scenarios - please see the CKS link for more details

Question 102

Associations of adhesive capsulitis [1]

Answer 102

diabetes mellitus: up to 20% of diabetics may have an episode of frozen shoulder

Question 103

Features of adhesive capsulitis [4]

Answer 103

external rotation is affected more than internal rotation or abduction
both active and passive movement are affected
patients typically have a painful freezing phase, an adhesive phase and a recovery phase
bilateral in up to 20% of patients
the episode typically lasts between 6 months and 2 years

Question 104

Mx of adhesive capsulitis [2]

Answer 104

no single intervention has been shown to improve outcome in the long-term
treatment options include NSAIDs, physiotherapy, oral corticosteroids and intra-articular corticosteroids

Question 105

What is Trichomonas vaginalis? [1]

Answer 105

Trichomonas vaginalis is a highly motile, flagellated protozoan parasite. Trichomoniasis is a sexually transmitted infection (STI).

Question 106

Features of Trichomonas vaginalis [5]

Answer 106

vaginal discharge: offensive, yellow/green, frothy
vulvovaginitis
strawberry cervix
pH > 4.5
in men is usually asymptomatic but may cause urethritis

Question 107

Microscopy of TV [2]

Answer 107

microscopy of a wet mount shows motile trophozoites

Question 108

Mx of TV [2]

Answer 108

oral metronidazole for 5-7 days, although the BNF also supports the use of a one-off dose of 2g metronidazole

Question 109

Which receptors are attacked at the NMJ in myasthenia gravis? [2]

Answer 109

Myasthenia gravis is an autoimmune condition whereby the patient’s immune system attacks the acetylcholine receptors at the neuromuscular junction. Symptoms include weakness, especially in the evening. Treatment is focused on increasing the concentration of acetylcholine in the synaptic cleft using acetylcholinesterase inhibitors.

Question 110

WEhat would GBS look like on NCS? [2]

Answer 110

Guillan-barre syndrome is an autoimmune condition. It has no known causes but often occurs after an episode of infection or immunization. Both conditions are associated with slowed motor conduction on nerve conduction studies.

Question 111

Does MND present as LMN or UMN? [1]

Answer 111

Motor neuron disease is a neurological condition of unknown cause which can present with both upper and lower motor neuron signs. It rarely presents before 40 years and various patterns of disease are recognised including amyotrophic lateral sclerosis, progressive muscular atrophy and bulbar palsy.

Question 112

Are there sensory signs/Sx in MND? [4]

Answer 112

fasciculations
the absence of sensory signs/symptoms*
the mixture of lower motor neuron and upper motor neuron signs
wasting of the small hand muscles/tibialis anterior is common

Question 113

Are eyes effected in MND? [1]

Answer 113

doesn’t affect external ocular muscles
no cerebellar signs
abdominal reflexes are usually preserved and sphincter dysfunction if present is a late feature

Question 114

What will NCS, electromyography and MRI in MND show? [3]

Answer 114

The diagnosis of motor neuron disease is clinical, but nerve conduction studies will show normal motor conduction and can help exclude a neuropathy. Electromyography shows a reduced number of action potentials with increased amplitude. MRI is usually performed to exclude the differential diagnosis of cervical cord compression and myelopathy

Question 115

Which signs are seen in ALS? [2]

Answer 115

affects both upper (corticospinal tracts) and lower motor neurons
results in a combination of upper and lower motor neuron signs

Question 116

Which neuron signs are seen in poliomyelitis? [1]

Answer 116

affects anterior horns resulting in lower motor neuron signs

Question 117

Which tracts are affected in Brown-Sequard syndrome [spinal cord hemisection? [3]

Answer 117

1. Lateral corticospinal tract
2. Dorsal columns
3. Lateral spinothalamic tract

Question 118

How does Brown-Sequard syndrome present? [3]

Answer 118

1. Ipsilateral spastic paresis below lesion
2. Ipsilateral loss of proprioception and vibration sensation
3. Contralateral loss of pain and temperature sensation

Question 119

Which tracts are affected in Freidrich’s ataxia? [1]

Answer 119

Same as subacute combined degeneration of the spinal cord (see above)

Question 120

How does Friedrich’s ataxia present? [2]

Answer 120

Same as subacute combined degeneration of the spinal cord (see above)

In addition cerebellar ataxia → other features e.g. intention tremor

Question 121

Which tracts are affected in MS? [2]

Answer 121

Asymmetrical, varying spinal tracts involved

Question 122

How does MS present? [2]

Answer 122

Combination of motor, sensory and ataxia symptoms

Question 123

Name a condition that is just a snesory lesion? [3]

Answer 123

Disorder Tracts affected Clinical notes
Neurosyphilis (tabes dorsalis) 1. Dorsal columns 1. Loss of proprioception and vibration sensation

Question 124

What is conveyed by the dorsal column? [3]

Answer 124

The sensation of fine touch, proprioception and vibration are all conveyed in the dorsal column

Question 125

What is conveyed by the lateral spinothalamic tract? [2]

Answer 125

It is primarily responsible for transmitting pain and temperature as well as coarse touch.

Question 126

What is conveyed by the lateral corticospinal tract? [2]

Answer 126

The primary responsibility of the lateral corticospinal tract is to control the voluntary movement of contralateral limbs

Question 127

What is th efunction of the spinocerebellar tract? [2]

Answer 127

The spinocerebellar tracts carry unconscious proprioceptive information gleaned from muscle spindles, Golgi tendon organs, and joint capsules to the cerebellum

Question 128

Asympatomic patient w/o any Sx of gour should be treated how? [1]

Answer 128

No Tx as not recommedned by NICE. Not proven to be beneficial.Lifestyle changes (less red meat, alcohol and sugar) can reduce uric acid levels without drug treatment and so can be advised.

Question 129

What is associated with hyperuricaemia? [2]

Answer 129

Hyperuricaemia may be associated with hyperlipidaemia and hypertension. It may also be seen in conjunction with the metabolic syndrome

Question 130

What causes increased synthesis of uric acid? [3]

Answer 130

Lesch-Nyhan disease
myeloproliferative disorders
diet rich in purines
exercise
psoriasis
cytotoxics

Question 131

What causes decreased excretion of uric acid? [4]

Answer 131

drugs: low-dose aspirin, diuretics, pyrazinamide
pre-eclampsia
alcohol
renal failure
lead

Question 132

What is idiopathic pulmonary fibrosis? [2]

Answer 132

Idiopathic pulmonary fibrosis (IPF, previously termed cryptogenic fibrosing alveolitis) is a chronic lung condition characterised by progressive fibrosis of the interstitium of the lungs. Whilst there are many causes of lung fibrosis (e.g. medications, connective tissue disease, asbestos) the term IPF is reserved when no underlying cause exists.

Question 133

Whom is idiopathic pulmonary firbosis typically seen in? [1]

Answer 133

IPF is typically seen in patients aged 50-70 years and is twice as common in men.

Question 134

Features of idiopathic pulmonary fibrosis [4]

Answer 134

progressive exertional dyspnoea
bibasal fine end-inspiratory crepitations on auscultation
dry cough
clubbing

Question 135

Dx pulmonary fibrosis [4]

Answer 135

spirometry: classically a restrictive picture (FEV1 normal/decreased, FVC decreased, FEV1/FVC increased)
impaired gas exchange: reduced transfer factor (TLCO)
imaging: bilateral interstitial shadowing (typically small, irregular, peripheral opacities - ‘ground-glass’ - later progressing to ‘honeycombing’) may be seen on a chest x-ray but high-resolution CT scanning is the investigation of choice and required to make a diagnosis of IPF
ANA positive in 30%, rheumatoid factor positive in 10% but this does not necessarily mean that the fibrosis is secondary to a connective tissue disease. Titres are usually low

Question 136

What is the investigation of choice and required to make a diagnosis for IPF? [2]

Answer 136

imaging: bilateral interstitial shadowing (typically small, irregular, peripheral opacities - ‘ground-glass’ - later progressing to ‘honeycombing’) may be seen on a chest x-ray but high-resolution CT scanning is the investigation of choice and required to make a diagnosis of IPF

Question 137

Mx of IPF [3]

Answer 137

pulmonary rehabilitation
very few medications have been shown to give any benefit in IPF. There is some evidence that pirfenidone (an antifibrotic agent) may be useful in selected patients (see NICE guidelines)
many patients will require supplementary oxygen and eventually a lung transplant

Question 138

Prognosis of IPF [1]

Answer 138

poor, average life expectancy is around 3-4 years

Question 139

What is a restrictive lung picture in studies? [2]

Answer 139

classically a restrictive picture (FEV1 normal/decreased, FVC decreased, FEV1/FVC increased)

Question 140

What will a CXR show in IPF [2]

Answer 140

A chest x-ray will show interstitial shadowing, and a high resolution CT will show ‘honeycomb’ lungs.

Question 141

WHat is Lynch syndreom [HNPCC] characterised by? [1]

Answer 141

Lynch syndrome (HNPCC) is characterised by development of bowel cancer (among other cancers) with little formation of adenomatous polyps

Question 142

How does familial adenomatous polyposis presetn? [2]

Answer 142

Typically over 100 colonic adenomas
Cancer risk of 100%
20% are new mutations

Question 143

Hoes does MYH associated polyps present? [3]

Answer 143

Multiple colonic polyps
Later onset right sided cancers more common than in FAP
100% cancer risk by age 60

Question 144

How does Puetz-Jeghers syndreom present? [3]

Answer 144

Multiple benign intestinal hamartomas
Episodic obstruction and intussusception
Increased risk of GI cancers (colorectal cancer 20%, gastric 5%)
Increased risk of breast, ovarian, cervical pancreatic and testicular cancers

Question 145

How does Cowden disease develop? [3]

Answer 145

Macrocephaly
Multiple intestinal hamartomas
Multiple trichilemmomas
89% risk of cancer at any site
16% risk of colorectal cancer

Question 146

How does HNPCC disease develop? [3]

Answer 146

Colo rectal cancer 30-70%
Endometrial cancer 30-70%
Gastric cancer 5-10%
Scanty colonic polyps may be present
Colonic tumours likely to be right sided and mucinous

Question 147

What is sick euthyroid syndrome? [2]

Answer 147

In sick euthyroid syndrome (now referred to as non-thyroidal illness) it is often said that everything (TSH, thyroxine and T3) is low. In the majority of cases however the TSH level is within the >normal range (inappropriately normal given the low thyroxine and T3).

Question 148

Mx of sick euthyroid syndrome [1]

Answer 148

In sick euthyroid syndrome (now referred to as non-thyroidal illness) it is often said that everything (TSH, thyroxine and T3) is low. In the majority of cases however the TSH level is within the >normal range (inappropriately normal given the low thyroxine and T3).

Changes are reversible upon recovery from the systemic illness and hence no treatment is usually needed.

Question 149

A 22-year-old male falls of a ladder. He complains of neck pain and cannot feel his legs. His GCS suddenly deteriorates and a CT head confirms an extradural haematoma. What is the best imaging for his neck?

Answer 149

The correct answer is: CT c-spine40%

This man needs a CT scan of his c-spine. A CT scan will give the best resolution of any bony injury.

Question 150

A 25-year-old teacher falls down the stairs. She complains of a headache and has vomited 3 times. She has a GCS of 15/15.

Answer 150

CT head within 1h72%

This lady has a head injury and vomiting > 1, therefore an urgent CT head is indicated.

Question 151

An 18-year-old student is shot in the back of the head.

Answer 151

Urgent neurosurgical review (even before CT head performed)86%

A penetrating injury needs urgent neurosurgical review.

Question 152

Which patients need a CT head immediately? [6]

Answer 152

GCS < 13 on initial assessment
GCS < 15 at 2 hours post-injury
suspected open or depressed skull fracture.
any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
post-traumatic seizure.
focal neurological deficit.
more than 1 episode of vomiting

Question 153

Which patietns need a CT head within 8h? [4]

Answer 153

CT head scan within 8 hours of the head injury - for adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury:
age 65 years or older
any history of bleeding or clotting disorders
dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)
more than 30 minutes’ retrograde amnesia of events immediately before the head injury

Question 154

If a patient is on warfarin who have sustained a head injury with no other indications for a CT head scan, how should they be maanged? [1]

Answer 154

Perform CT head within 8h

Question 155

How should thoracic back pain be maanged? [1]

Answer 155

Red flag if presneting with this, should be rederred to hospital immediately

Question 156

Red flags for lower back pain [5]

Answer 156

age < 20 years or > 50 years
history of previous malignancy
night pain
history of trauma
systemically unwell e.g. weight loss, fever

Question 157

Presentation of spinal stensosis [5]

Answer 157

Usually gradual onset
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as ‘aching’, ‘crawling’.
Relieved by sitting down, leaning forwards and crouching down
Clinical examination is often normal
Requires MRI to confirm diagnosis

Question 158

Presentationr AS [3]

Answer 158

Typically a young man who presents with lower back pain and stiffness
Stiffness is usually worse in morning and improves with activity
Peripheral arthritis (25%, more common if female)

Question 159

Presentation for PAD [3]

Answer 159

Pain on walking, relieved by rest
Absent or weak foot pulses and other signs of limb ischaemia
Past history may include smoking and other vascular diseases

Question 160

Karyotype of Klinfelter’s syndrome [1]

Answer 160

Klinefelter’s syndrome is associated with karyotype 47, XXY

Question 161

Features of Klinefelter’s syndrome [5]

Answer 161

often taller than average
lack of secondary sexual characteristics
small, firm testes
infertile
gynaecomastia - increased incidence of breast cancer
elevated gonadotrophin levels

Question 162

Dx of Klinefelter’s syndrome [1]

Answer 162

Diagnosis is by chromosomal analysis

Question 163

Inheritance and cause of Kallman’s syndrome [2]

Answer 163

Kallman’s syndrome is a recognised cause of delayed puberty secondary to hypogonadotrophic hypogonadism. It is usually inherited as an X-linked recessive trait. Kallman’s syndrome is thought to be caused by failure of GnRH-secreting neurons to migrate to the hypothalamus.

Question 164

Features of Kallman’s syndrome

Answer 164

Features
‘delayed puberty’
hypogonadism, cryptorchidism
anosmia
sex hormone levels are low
LH, FSH levels are inappropriately low/normal
patients are typically of normal or above average height

Cleft lip/palate and visual/hearing defects are also seen in some patients

Question 165

Exam question often of Kallman’s syndrome [1]

Answer 165

The clue given in many questions is lack of smell (anosmia) in a boy with delayed puberty

Question 166

Inheritance of androgen insensitivity syndrome [1]

Answer 166

Androgen insensitivity syndrome is an X-linked recessive condition due to end-organ resistance to testosterone causing genotypically male children (46XY) to have a female phenotype. Complete androgen insensitivity syndrome is the new term for testicular feminisation syndrome

Question 167

Features of androgen insensitvity syndrome [3]

Answer 167

‘primary amenorrhoea’
undescended testes causing groin swellings
breast development may occur as a result of conversion of testosterone to oestradiol

Question 168

Dx of androgen insensitivty syndrome [1]

Answer 168

buccal smear or chromosomal analysis to reveal 46XY genotype

Question 169

Mx of Androgen insensitivty syndrome [3]

Answer 169

counselling - raise child as female 
bilateral orchidectomy (increased risk of testicular cancer due to undescended testes) 
oestrogen therapy

Question 170

What will Lh and testerone be in primary hypogonadism? [1]

Answer 170

Klinefelter’s syndrome

• high LH
• low testerone

Question 171

What will LH and testerone be in hpyogonadotrophic hypogonadism? [1]

Answer 171

Kallman’s

• low LH
• low testerone

Question 172

What will Lh and testerone be in androgen insensitivty syndrome [1]

Answer 172

AIS

• high LH
• normal/high testerone

Question 173

Adverse effects of depolarising NM blocking drugs [3]

Answer 173

Malignant hyperthermia
Hyperkalaemia [normally transient]
May cause fasciculations

Question 174

Why may succinylcholine [or suxamethonium cause fasciculations? [2]]

Answer 174

Binds to nicotinic acetylcholine receptors resulting in persistent depolarization of the motor end plate

Question 175

CI for suxamethonium [2]

Answer 175

Suxamethonium is contraindicated for patients with penetrating eye injuries or acute narrow angle glaucoma, as suxamethonium increases intra-ocular pressure

Question 176

Non-depolarizing NM blocking drugs MoA, examples, adverse effects and reversal of them

Answer 176

Competitive antagonist of nicotinic acetylcholine receptors
Tubcurarine, atracurium, vecuronium, pancuronium
Hypotension
Reversal by Acetylcholinesterase inhibitors (e.g. neostigmine)

Question 177

In aortic dissection, pulse deficit may be seen when? [2]

Answer 177

In aortic dissection, a pulse deficit may be seen:
weak or absent carotid, brachial, or femoral pulse
variation in arm BP

Question 178

Pan-systolic murmur seen when? [1]

Answer 178

MR

Question 179

Slow rising pulse seen when? [1]

Answer 179

AS

Question 180

Splinter haemorrhages seen when? [1]

Answer 180

infective endocarditis

Question 181

RV heave seen when? [1]

Answer 181

RVH such as in cor pulmomale

Question 182

PP of aortic dissection [1]

Answer 182

tear in the tunica intima of the wall of the aorta

Question 183

Associations of aortic dissection [5]

Answer 183

hypertension: the most important risk factor
trauma
bicuspid aortic valve
collagens: Marfan’s syndrome, Ehlers-Danlos syndrome
Turner’s and Noonan’s syndrome
pregnancy
syphilis

Question 184

Features of aortic dissection [5]

Answer 184

chest pain: typically severe, radiates through to the back and ‘tearing’ in nature
pulse deficit
weak or absent carotid, brachial, or femoral pulse
variation (>20 mmHg) in systolic blood pressure between the arms
aortic regurgitation
hypertension
other features may result from the involvement of specific arteries. For example coronary arteries → angina, spinal arteries → paraplegia, distal aorta → limb ischaemia
the majority of patients have no or non-specific ECG changes. In a minority of patients, ST-segment elevation may be seen in the inferior leads

Question 185

Stanford classication of aortic dissection [2]

Answer 185

type A - ascending aorta, 2/3 of cases
type B - descending aorta, distal to left subclavian origin, 1/3 of cases

Question 186

Debakey classification of aortic dissection

Answer 186

type I - originates in ascending aorta, propagates to at least the aortic arch and possibly beyond it distally
type II - originates in and is confined to the ascending aorta
type III - originates in descending aorta, rarely extends proximally but will extend distally

Question 187

Most common trigger of anaphylaxis in children [1]

Answer 187

Food!

Question 188

Define anaphylaxis [2]

Answer 188

Anaphylaxis may be defined as a severe, life-threatening, generalised or systemic hypersensitivity reaction.

Question 189

Common identified triggered of anaphylaxis [3]

Answer 189

food (e.g. nuts) - the most common cause in children
drugs
venom (e.g. wasp sting)

Question 190

How does the Resus Council IUK define anaphyaxis? [2]

Answer 190

The Resus Council UK define anaphylaxis as:
the sudden onset and rapid progression of symptoms
Airway and/or Breathing and/or Circulation problems

Airway problems may include:
swelling of the throat and tongue →hoarse voice and stridor

Breathing problems may include:
respiratory wheeze
dyspnoea

Circulation problems may include:
hypotension
tachycardia

Question 191

What other features will around 80-90% of pts with anaphlyaxius have? [2]

Answer 191

generalised pruritus
widespread erythematous or urticarial rash

Question 192

Recommended adrenaline dose for <6m old compared to adult? [2]

Answer 192

<6m then 100-150mcg
Adult then 500mcg

Question 193

How often can adrenaline be repeated? [1]

Answer 193

Adrenaline can be repeated every 5 minutes if necessary

Question 194

What is the best site for IM injection of adnrealine? [1]

Answer 194

The best site for IM injection is the anterolateral aspect of the middle third of the thigh.

Question 195

What is refractory anaphylaxis and hwo should this be Mx? [3]

Answer 195

defined as respiratory and/or cardiovascular problems persist despite 2 doses of IM adrenaline
IV fluids should be given for shock
expert help should be sought for consideration of an IV adrenaline infusion

Question 196

How should the patient be managed following stabilisation? [5]

Answer 196

non-sedating oral antihistamines, in preference to chlorphenamine, may be given following initial stabilisation especially in patients with persisting skin symptoms (urticaria and/or angioedema)
sometimes it can be difficult to establish whether a patient had a true episode of anaphylaxis. Serum tryptase levels are sometimes taken in such patients as they remain elevated for up to 12 hours following an acute episode of anaphylaxis
all patients with a new diagnosis of anaphylaxis should be referred to a specialist allergy clinic
an adrenaline injector should be givens an interim measure before the
specialist allergy assessment (unless the reaction was drug-induced)
patients should be prescribed 2 adrenaline auto-injectors
training should be provided on how to use it

Question 197

What can happen in around 20% of patients with anaphlaxis? [2]

Answer 197

• a risk-stratified approach to discharge should be taken as biphasic reactions can occur in up to 20% of patients

Question 198

How long should a patient be kept if they needed 2 doses of IM adnrealine? [1]

Answer 198

fast-track discharge (after 2 hours of symptom resolution):
good response to a single dose of adrenaline
complete resolution of symptoms
has been given an adrenaline auto-injector and trained how to use it
adequate supervision following discharge

minimum 6 hours after symptom resolution:
2 doses of IM adrenaline needed, or
previous biphasic reaction

minimum 12 hours after symptom resolution:
severe reaction requiring > 2 doses of IM adrenaline
patient has severe asthma
possibility of an ongoing reaction (e.g. slow-release medication)
patient presents late at night
patient in areas where access to emergency access care may be difficult
observation for at 12 hours following symptom resolution

Question 199

Factors favouring pseudoseizures[5]

Answer 199

pelvic thrusting
family member with epilepsy
much more common in females
crying after seizure
don’t occur when alone
gradual onset

Question 200

Factors favouring true epileptic seizures [2]

Answer 200

Ongue biting
Raised serum prolactin [why is not fully understood]

Question 201

What is a useful tool for differentiating NES from ES [1]

Answer 201

Video telemetry

Question 202

What causes HFM? [1]

Answer 202

Hand, foot and mouth disease is a self-limiting condition affecting children. It is caused by the intestinal viruses of the Picornaviridae family (most commonly coxsackie A16 and enterovirus 71)

Question 203

Can HFM be spread? [1]

Answer 203

It is very contagious and typically occurs in outbreaks at nursery

Question 204

Clinical features of HFM disease [3]

Answer 204

mild systemic upset: sore throat, fever
oral ulcers
followed later by vesicles on the palms and soles of the feet

Question 205

Mx of HFM disease [3]

Answer 205

symptomatic treatment only: general advice about hydration and analgesia
reassurance no link to disease in cattle
children do not need to be excluded from school
the HPA recommends that children who are unwell should be kept off school until they feel better
they also advise that you contact them if you suspect that there may be a large outbreak.

Question 206

A 16-year-old patient presents to the emergency department with shortness of breath and is referred for an x-ray. The scan shows the presence of a bony growth extending from the C7 vertebrae unilaterally. While not immediately concerning, this could cause problems for the patient in future.

Which condition is more likely to develop in this patient?

Answer 206

cervical rib is a common cause of thoracic outlet syndrome [about 10% will develop cervical rib syndrome]

Question 207

What is a Hangman’s fracture? [2]

Answer 207

Hangman’s fracture is another incorrect answer. This is a fracture to the C2 vertebrae commonly as a result of hanging. It is unlikely that this 16-year-old boy has a hangman’s fracture, especially as there is no history of neck pain or suicide attempts.

Question 208

What is thoracic outlet syndrome? [2]

Answer 208

Thoracic outlet syndrome (TOS) is a disorder involving compression of brachial plexus, subclavian artery or vein at the site of the thoracic outlet. TOS can be neurogenic or vascular; the former accounts for 90% of the cases.

Question 209

Epidemiology of thoracic outlet syndrome [3]

Answer 209

given the lack of widely agreed diagnostic criteria, the epidemiology of TOS is not well documented
patients are typically young thin women possessing long neck and drooping shoulders
peak onset occurs in the 4th decade

Question 210

Aetiology of thoracic outlet syndrome [5]

Answer 210

TOS develops when neck trauma occurs to individuals with anatomical predispositions
neck trauma can either be a single acute incident or repeated stresses
anatomical anomalies can either be in the form of soft tissue (70%) or osseous structures (30%)
a well-known osseous anomaly is the presence of cervical rib
examples of soft tissue causes are scalene muscle hypertrophy and anomalous bands
there is usually a history of neck trauma preceding TOS

Question 211

CLinical presentation of neurogenic TOS [3]

Answer 211

painless muscle wasting of hand muscles, with patients complaining of hand weakness e.g. grasping
sensory symptoms such as numbness and tingling may be present
if autonomic nerves are involved, the patient may experience cold hands, blanching or swelling

Question 212

Clinical presentation of vascular TOS [2]

Answer 212

subclavian vein compression leads to painful diffuse arm swelling with distended veins
subclavian artery compression leads to painful arm claudication and in severe cases, ulceration and gangrene

Question 213

Ix for TOS [4]

Answer 213

chest and cervical spine plain radiographs to check for any obvious osseous abnormalities e.g. cervical ribs, exclude malignant tumours or other differentials e.g. cervical spine degenerative changes
other imaging modalities may be helpful e.g. CT or MRI to rule out cervical root lesions
venography or angiography may be helpful in vascular TOS
an anterior scalene block may be used to confirm neurogenic TOS and check the likelihood of successful surgical treatment

Question 214

Tx for TOS [5]

Answer 214

there is a limited evidence base
conservative management with education, rehabilitation, physiotherapy, or taping is typically the first-line management for neurogenic TOS
surgical decompression is warranted where conservative management has failed especially if there is a physical anomaly. Early intervention may prevent brachial plexus degeneration
in vascular TOS, surgical treatment may be preferred
other therapies being investigated include botox injection

Question 215

What should be used for urge incontinence is older frail women? [1]

Answer 215

bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding) 
bladder stabilising drugs: antimuscarinics are first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in 'frail older women' 
mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients

Question 216

First-line stress incontinence Mx [2]

Answer 216

pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
surgical procedures: e.g. retropubic mid-urethral tape procedures
duloxetine may be offered to women if they decline surgical procedures
a combined noradrenaline and serotonin reuptake inhibitor
mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced
contraction

Question 217

What is HL? [2]

Answer 217

Hodgkin’s lymphoma is a malignant proliferation of lymphocytes characterised by the presence of the Reed-Sternberg cell. It has a bimodal age distributions being most common in the third and seventh decades

Question 218

Staging tool of HL [1]

Answer 218

Ann-Arbor

Question 219

Nodes on both sides of diaphragm what is the stage of HL? [4]

Answer 219

I: single lymph node
II: 2 or more lymph nodes/regions on same side of diaphragm
III: nodes on both sides of diaphragm
IV: spread beyond lymph nodes

Question 220

How can each stage of HL be subdivided? [2]

Answer 220

A = no systemic symptoms other than pruritus 
B = weight loss \> 10% in last 6 months, fever \> 38c, night sweats (poor prognosis

Question 221

What is Takotsubo cardiomyopathy associated with?on an echo? [2]

Answer 221

Takotsubo cardiomyopathy is associated with apical ballooning of myocardium (resembling an octopus pot)

Question 222

What is Takotsubo cardiomyopathy? [2]

Answer 222

Takotsubo cardiomyopathy is a type of non-ischaemic cardiomyopathy associated with a transient, apical ballooning of the myocardium. It may be triggered by stress.

Question 223

PP of Takotsubo cardiomyopathy [2]

Answer 223

Takotsubo is a Japanese word that describes an octopus trap
the apical ballooning appearance occurs due to severe hypokinesis of the mid and apical segments with preservation of activity of the basal segments. In simple terms, the bottom of the heart (the apex) does not contract and therefore appears to balloon out. However, the area closer to the top (the base) continues to contract (creating the neck of the octopus trap)

Question 224

Features of Takotsubo cardiomyoapthy [4]

Answer 224

chest pain
features of heart failure
ECG: ST-elevation
normal coronary angiogram

Question 225

Prognosis and Tx of Takutsubo cardiomyoapthy [2]

Answer 225

Treatment is supportive.

Prognosis
the majority of patients improve with supportive treatment

Question 226

An 80-year-old man presents to the emergency department with back pain. He has no documented past medical history. An x-ray spine shows vertebral wedge compression fractures and focal sclerotic bony lesions.

Which of the following diagnoses is most likely?

Answer 226

The most likely diagnosis in this case is metastatic prostate cancer. This disease is the most common cancer to metastasise to bone and patients often present with pathological fractures or bone pain as the first sign of disease. Prostate cancer metastases typically have a sclerotic appearance on x-ray.

Question 227

How does MM and Paget’s disease present? [2]

Answer 227

Multiple myeloma and Paget’s disease are typically associated with osteolytic lesions rather than sclerotic, however.

Question 228

How does osteosarcoma typically present? [2]

Answer 228

Osteosarcoma is a rare cancer most commonly affecting the long bones of children/young adults. It would be highly unusual to be present in the spine of man of this age. It often presents with pathological fractures of long bones such as the femur.

Question 229

What are the most common tumours causing bone mets? [3]

Answer 229

Most common tumour causing bone metastases (in descending order)
prostate
breast
lung

Question 230

Where are the most common sites of bone mets? [5]

Answer 230

Most common site (in descending order)
spine
pelvis
ribs
skull
long bones

Question 231

Features of bone mets

Answer 231

pathological fractures -> sclerotic appearnace, not osteolytic lesions
hypercalcaemia
raised ALP

Question 232

What biopsy results would Crohn’s disease have? [2]

Answer 232

Colonoscopy Deep ulceration affecting terminal ileum and colon, with skip lesions
Biopsy sample from terminal ileum Granulomatous inflammation extending from serosa to mucosa [transmural]

Question 233

What is the first-line for inducing remission in Crohn’s disease? [1]

Answer 233

GLucocorticoids [oral, topical or IV] -> e.g. 300mg of predninsolone

Question 234

Which part of the GI tract does Crohn’s effect? [2]

Answer 234

Crohn’s disease is a form of inflammatory bowel disease. It commonly affects the terminal ileum and colon but may be seen anywhere from the mouth to anus. NICE published guidelines on the management of Crohn’s disease in 2012.

Question 235

What should all patients with Crohn’s stop doing immediately? [1]

Answer 235

Smoking

Question 236

Frist and second line Tx for Crohn’s [2]

Answer 236

First-line = glucocorticoids (oral, topical or intravenous) are generally used to induce remission. Budesonide is an alternative in a subgroup of patients 
Second-line = 5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective

Question 237

What can also be done apart from medication to reduce chacnes of remission? [2]

Answer 237

enteral feeding with an elemental diet may be used in addition to or instead of other measures to induce remission, particularly if there is concern regarding the side-effects of steroids (for example in young children)

Question 238

What can be used as an add-on in Crohn;s? [1]

Answer 238

azathioprine or mercaptopurine* may be used as an add-on medication to induce remission but is not used as monotherapy. Methotrexate is an alternative to azathioprine

Question 239

When is infliximab and metronidazole useful in Crohn’s? [2]

Answer 239

infliximab is useful in refractory disease and fistulating Crohn’s. Patients typically continue on azathioprine or methotrexate
metronidazole is often used for isolated peri-anal disease

Question 240

What is used to maintain remission in Crohn’s? [2]

Answer 240

as above, stopping smoking is a priority (remember: smoking makes Crohn’s worse, but may help ulcerative colitis)
azathioprine or mercaptopurine is used first-line to maintain remission
methotrexate is used second-line
5-ASA drugs (e.g. mesalazine) should be considered if a patient has had previous surgery

Question 241

What should be assessed before starting azathioprine for Crohn’s? [1]

Answer 241

+TMPT activity should be assessed before starting

Question 242

How common is surgery for Crohn’s? [2]

Answer 242

around 80% of patients with Crohn’s disease will eventually have surgery
see below for further detail

Question 243

First-line remission drug for crohns? [1]

Answer 243

Azathioprine or mercaptopurine

Question 244

Commonest disease pattern and Mx for Crohn;s? [2]

Answer 244

The commonest disease pattern in Crohn’s is stricturing terminal ileal disease and this often culminates in an ileocaecal resection

Question 245

Other procedures seen in Crohn’s [2]

Answer 245

Other procedures performed include segmental small bowel resections and stricturoplasty. Colonic involvement in patients with Crohn’s is not common and, where found, distribution is often segmental. However, despite this distribution segmental resections of the colon in patients with Crohn’s disease are generally not advocated because the recurrence rate in the remaining colon is extremely high, as a result, the standard options of colonic surgery in Crohn’s patients are generally; sub total colectomy, panproctocolectomy and staged sub total colectomy and proctectomy. Restorative procedures such as ileoanal pouch have no role in therapy.

Question 246

What is Crohn;s disease notorious for developing [2]

Answer 246

Crohn’s disease is notorious for the developmental of intestinal fistulae; these may form between the rectum and skin (perianal) or the small bowel and skin. Fistulation between loops of bowel may also occur and result in bacterial overgrowth and malabsorption. Management of enterocutaneous fistulae involves controlling sepsis, optimising nutrition, imaging the disease and planning definitive surgical management.

Question 247

What are Crohn;s patietns at an increased risk of? [4]

Answer 247

As well as the well-documented complications described above, patients are also at risk of: 
small bowel cancer (standard incidence ratio = 40) 
colorectal cancer (standard incidence ration = 2, i.e. less than the risk associated with ulcerative colitis) 
osteoporosis

Question 248

How common is each type of diabetes in pregnancy? [3]

Answer 248

87.5% have gestational diabetes
7.5% have type 1 diabetes
5% have type 2 diabetes

Question 249

How common is gestational diabetes? [1]

Answer 249

Gestational diabetes is the second most common medical disorder complicating pregnancy (after hypertension), affecting around 4% of pregnancies.

Question 250

How often should pregnant women with T1DM be tested for their glucose? [2]

Answer 250

Pregnant patients with type 1 diabetes should monitor their blood glucose levels closely. They should test their levels multiple times during the day. NICE NG3

Daily fasting, pre-meal, 1-hour post meal and bedtime tests.

Question 251

Mx of pre-existing DM? [5]

Answer 251

weight loss for women with BMI of > 27 kg/m^2
stop oral hypoglycaemic agents, apart from metformin, and commence insulin
folic acid 5 mg/day from pre-conception to 12 weeks gestation
detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
tight glycaemic control reduces complication rates
treat retinopathy as can worsen during pregnancy

Question 252

A 10-year-old boy is brought to the GP by his mother after two weeks of a productive cough and fevers. The GP who saw him last week sent him away advising to come back in a week if he was still no better. The patient is documented to be allergic to penicillin. Which antibiotic should be used to treat his respiratory infection?

Answer 252

Clarithromycin
-This patient was likely sent away initially due to the high probability he had a self-limiting viral illness. Due to the persistence of his symptoms the GP would be justified in treating the child for a bacterial lower respiratory tract infection. Without penicillin allergy then amoxicillin is the first choice treatment, however in this case this must be avoided, clarithromycin is the antibiotic of choice instead.

Question 253

Inheritance pattern of essential tremor? [1]

Answer 253

Essential tremor (previously called benign essential tremor) is an autosomal dominant condition which usually affects both upper limbs

Question 254

Features of essential tremor? [3]

Answer 254

postural tremor: worse if arms outstretched [6-8Hz]
improved by alcohol and rest
most common cause of titubation (head tremor)

Question 255

Mx of essential tremor

Answer 255

Management
propranolol is first-line
primidone is sometimes used

Question 256

Important risk factors used by major tools like FRAX? [6]

Answer 256

history of glucocorticoid use
rheumatoid arthritis
alcohol excess
history of parental hip fracture
low body mass index
current smoking

Question 257

Other risk factors for osteoporsis [5]

Answer 257

sedentary lifestyle
premature menopause
Caucasians and Asians
endocrine disorders: hyperthyroidism, hypogonadism (e.g. Turner’s, testosterone deficiency), growth hormone deficiency, hyperparathyroidism, diabetes mellitus
multiple myeloma, lymphoma
gastrointestinal disorders: inflammatory bowel disease, malabsorption (e.g. Coeliac’s), gastrectomy, liver disease
chronic kidney disease
osteogenesis imperfecta, homocystinuria

Question 258

Medciations that may worsen OP [5]

Answer 258

SSRIs
antiepileptics
proton pump inhibitors
glitazones
long term heparin therapy
aromatase inhibitors e.g. anastrozole

Question 259

When should a patient with OP have further testing? [4]

Answer 259

If a patient is diagnosed with osteoporosis or has a fragility fracture further investigations may be warranted. NOGG recommend testing for the following reasons:

exclude diseases that mimic osteoporosis (e.g. osteomalacia, myeloma);
identify the cause of osteoporosis and contributory factors;
assess the risk of subsequent fractures;
select the most appropriate form of treatment

Question 260

Ix recommended by NOGG for OP? [4]

Answer 260

History and physical examination
Blood cell count, sedimentation rate or C-reactive protein, serum calcium,
albumin, creatinine, phosphate, alkaline phosphatase and liver transaminases
Thyroid function tests
Bone densitometry ( DXA)

Question 261

Other Ix recommended by NOGG if indicated in OP [3]

Answer 261

Lateral radiographs of lumbar and thoracic spine/DXA-based vertebral imaging
Protein immunoelectrophoresis and urinary Bence-Jones proteins
25OHD
PTH
Serum testosterone, SHBG, FSH, LH (in men),
Serum prolactin
24 hour urinary cortisol/dexamethasone suppression test
Endomysial and/or tissue transglutaminase antibodies (coeliac disease)
Isotope bone scan
Markers of bone turnover, when available
Urinary calcium excretion

Question 262

As such, what should be ordered as a minimum for P{ further Ix? [5]

Answer 262

full blood count
urea and electrolytes
liver function tests
bone profile
CRP
thyroid function tests

Question 263

What malignancy is most associated with the SIADH? [1]

Answer 263

Small cell lung cancer

Question 264

What is SIADH characterised by? [2]

Answer 264

The syndrome of inappropriate ADH secretion (SIADH) is characterised by hyponatraemia secondary to the dilutional effects of excessive water retention.

Question 265

Mx of SIADH [4]

Answer 265

correction must be done slowly to avoid precipitating central pontine myelinolysis
fluid restriction
demeclocycline: reduces the responsiveness of the collecting tubule cells to ADH
ADH (vasopressin) receptor antagonists have been developed

Question 266

A 55-year-old man with end-stage renal failure is due to have a renal transplant. He has read that having a renal transplant will increase his risk of cancer and would like to know more about this.

The risk of which one of the following cancers is he most at risk of following renal transplantation?

Answer 266

Squamous cell carcinoma of the skin [also cervical and lymphoma cancer risk increased]

Research shows that 25% of patients who live for 20 years after a transplant develop some type of cancer. This occurs due to the immunosuppressive effects of the medication given to prevent transplant rejection.

The risk of all skin cancers increases following kidney transplantation, evidence has shown that in particular the risk of squamous cell carcinoma is increased. The risks of lymphoma and cervical cancer are also increased.

Question 267

Which monitoring do patients on long-term immunosuppression need? [3]

Answer 267

CVD, renal disease and malignany monitoring

Question 268

Why should their CVD be monitored for patients with an organ transplant?

Answer 268

Cardiovascular disease - tacrolimus and ciclosporin can cause hypertension and hyperglycaemia. Tacrolimus can also cause hyperlipidaemia. Patients must be monitored for accelerated cardiovascular disease.

Question 269

Why should their renal failure be monitored for patients with an organ transplant?

Answer 269

Renal failure - due to nephrotoxic effects of tacrolimus and ciclosporin/graft rejection/recurrence of original disease in transplanted kidney

Question 270

How should their malignancy be monitored for patients with an organ transplant?

Answer 270

Malignancy - patients should be educated about minimising sun exposure to reduce the risk of squamous cell carcinomas and basal cell carcinomas

Question 271

What is first-line for menorrhagia? [1]

Answer 271

IUS [Mirena]

Question 272

Define menorrhagia [1]

Answer 272

Previously defined as over 80ml blood loss per menses, now has become whatever the women feels is heavy

Question 273

Ix for menorrhagia -important [2]

Answer 273

a full blood count should be performed in all women
NICE recommend arranging a routine transvaginal ultrasound scan if symptoms (for example, intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms) suggest a structural or histological abnormality. Other indications include abnormal pelvic exam findings.

Question 274

Which Rx should be given in women experiencing menorrhagia that does not require contraception? [2]

Answer 274

either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period
if no improvement then try other drug whilst awaiting referral

Question 275

Which Rx should be given if women does require contraception? [3]

Answer 275

intrauterine system (Mirena) should be considered first-line 
combined oral contraceptive pill 
long-acting progestogens

Question 276

What can be used in the short-term to stop HMB? [1]

Answer 276

Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding.

Question 277

An obese 14-year-old boy presents with difficulty running and mild knee and hip pain. There is no antecedent history of trauma. On examination internal rotation is restricted but the knee is normal with full range of passive movement possible and no evidence of effusions. Both the C-reactive protein and white cell count are normal.

Answer 277

Slipped upper femoral epiphysis is the commonest adolescent hip disorder. It occurs most commonly in obese males. It may often present as knee pain which is usually referred from the ipsilateral hip. The knee itself is normal. The hip often limits internal rotation. The diagnosis is easily missed. X-rays will show displacement of the femoral epiphysis and the degree of its displacement may be calculated using the Southwick angle. Treatment is directed at preventing further slippage which may result in avascular necrosis of the femoral head.

Question 278

A 6-year-old boy presents with pain in the hip it is present on activity and has been worsening over the past few weeks. There is no history of trauma. He was born by normal vaginal delivery at 38 weeks gestation On examination he has an antalgic gait and limitation of active and passive movement of the hip joint in all directions. C-reactive protein is mildly elevated at 10 but the white cell count is normal.

Answer 278

Perthes disease78%

This is a typical presentation for Perthes disease. X-ray may show flattening of the femoral head or fragmentation in more advanced cases.

Question 279

A 30-year-old man presents with severe pain in the left hip it has been present on and off for many years. He was born at 39 weeks gestation by emergency caesarean section after a long obstructed breech delivery. He was slow to walk and as a child was noted to have an antalgic gait. He was a frequent attender at the primary care centre and the pains dismissed as growing pains. X-rays show almost complete destruction of the femoral head and a narrow acetabulum.

Answer 279

Developmental dysplasia of the hip63%

Developmental dysplasia of the hip. Usually diagnosed by Barlow and Ortolani tests in early childhood. Most Breech deliveries are also routinely subjected to USS of the hip joint. At this young age an arthrodesis may be preferable to hip replacement.

Question 280

Compare mild, moderately severe and severe pancreatitis [3]

Answer 280

Mild = no organ failure, no local complications
M. severe = no or transient organ failure [<48h], possible local Cx
Severe = persistent [>48h] organ failure, possible local Cx

Question 281

What are the 5 key aspects to Mx pancreatitis? [5]

Answer 281

1. Fluid resus
2. Analgesia
3. Nutrition
4. Abx
5. Surgery

Question 282

Fluid resus for pancreatitis [3]

Answer 282

aggressive early hydration with crystalloids. In severe cases 3-6 litres of third space fluid loss may
occur
aim for a urine output of > 0.5mls/kg/hr
may also help relieve pain by reducing lactic acidosis

Question 283

Analgesia for pancreatitis [2]

Answer 283

pain may be severe so this is a key priority of care
intravenous opioids are normally required to adequately control the pain

Question 284

Nutrition for pancreatitis [3]

Answer 284

patients should not routinely be made ‘nil-by-mouth’ unless there is a clear reason e.g. the patient is vomiting
enteral nutrition should be offered to anyone with moderately severe or severe acute pancreatitis within 72 hours of presentation
parental nutrition should only be used if enteral nurition has failed or is contraindicated

Question 285

Role of Abx in pancreatitis [2]

Answer 285

NICE state the following: ‘Do not offer prophylactic antimicrobials to people with acute pancreatitis’
potential indications include infected pancreatic necrosis

Question 286

Role of surgery in pancreatitis [4]

Answer 286

Patients with acute pancreatitis due to gallstones should undergo early cholecystectomy
Patients with obstructed biliary system due to stones should undergo early ERCP
Patients who fail to settle with necrosis and have worsening organ dysfunction may require debridement, fine needle aspiration is still used by some
Patients with infected necrosis should undergo either radiological drainage or surgical necrosectomy. The choice of procedure depends upon local expertise

Question 287

Which age do febrile convulsions typically occur at? [1]

Answer 287

6m to 5y

Question 288

Clinical features of febrile convulsions [3]

Answer 288

usually occur early in a viral infection as the temperature rises rapidly
seizures are usually brief, lasting less than 5 minutes
are most commonly tonic-clonic

Question 289

Simple febrile convulsion [4]

Answer 289

<15m, generalised seizure, typically no recurrence within 24h, should be complete recovery within an hour

Question 290

Complex febriel convulsions

Answer 290

15-30m, focal seziure, may have repeated seizures

Question 291

Febrile status epilepticus [1]

Answer 291

Time seizure lasts over 30m

Question 292

Mx for febrile seizure [1]

Answer 292

children who have had a first seizure OR any features of a complex seizure should be admitted to paediatrics

Question 293

Do regular antipyreitcs reduce the chance of febriel seizures occuring? [1]

Answer 293

regular antipyretics have not been shown to reduce the chance of a febrile seizure occurring

Question 294

If recurrences of seizures, how should parents be advised to Mx? [2]

Answer 294

if recurrences, try teaching parents how to use rectal diazepam or buccal midazolam. Parents should be advised to phone for an ambulance if the seizure lasts > 5 minutes

Question 295

Prognosis of febrile seizures [3]

Answer 295

the overall risk of further febrile convulsion = 1 in 3. However, this varies widely depending on risk factors for further seizure. These include: age of onset < 18 months, fever < 39ºC, shorter duration of fever before seizure and a family history of febrile convulsions
if recurrences, try teaching parents how to use rectal diazepam or buccal midazolam. Parents should be advised to phone for an ambulance if the seizure lasts > 5 minutes
regular antipyretics have not been shown to reduce the chance of a febrile seizure occurring

Question 296

Link to epilepsy for febrile seziures [3]

Answer 296

risk factors for developing epilepsy include a family history of epilepsy, having complex febrile seizures and a background of neurodevelopmental disorder
children with no risk factors have 2.5% risk of developing epilepsy
if children have all 3 features the risk of developing epilepsy is much higher (e.g. 50%)

Question 297

Meningitis causes 0-3m [3]

Answer 297

Group B Streptococcus (most common cause in neonates)
E. coli
Listeria monocytogenes

Question 298

Meningitis causes 3m-6y [3]

Answer 298

Neisseria meningitidis
Streptococcus pneumoniae
Haemophilus influenzae

Question 299

Meningitis causes 6y-60m [2]

Answer 299

Neisseria meningitidis
Streptococcus pneumoniae

Question 300

Meningitis causes over 60y [3]

Answer 300

Streptococcus pneumoniae
Neisseria meningitidis
Listeria monocytogenes

Question 301

Meningitis cause for the immunosuppressed? [1]

Answer 301

Listera monocytogenes

Question 302

What type of bacteria is N.meninigitis, S. pneumoniae, E.coli, H.influenzae, L.monocytognese [5]

Answer 302

Neisseria meningitis and Streptococcus pneumoniae would be most common in this age group but it is N.meningitis that is a gram negative diplococci.
S. pneumoniae is a gram positive diplococci/chain
E. coli is a gram negative bacilli
H. influenzae is a gram negative coccobacilli
L. monocytogenes is a gram positive rod

Question 303

Mx for DCM [2]

Answer 303

Management of patients with cervical myelopathy should be by specialist spinal services (neurosurgery or orthopaedic spinal surgery). Decompressive surgery is the mainstay of treatment and has been shown to stop disease progression

Question 304

Sx of DCM [5]

Answer 304

Pain (affecting the neck, upper or lower limbs)
Loss of motor function (loss of digital dexterity, preventing simple tasks such as holding a fork or doing up their shirt buttons, arm or leg weakness/stiffness leading to impaired gait and imbalance
Loss of sensory function causing numbness
Loss of autonomic function (urinary or faecal incontinence and/or impotence) - these can occur and do not necessarily suggest cauda equina syndrome in the absence of other hallmarks of that condition
Hoffman’s sign: is a reflex test to assess for cervical myelopathy. It is performed by gently flicking one finger on a patient’s hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick.

Question 305

What is DCM often confuse with? [1]

Answer 305

Carpal tunnel syndrome

Question 306

What Ix is the gold standard for DCM? [1]

Answer 306

An MRI of the cervical spine is the gold standard test where cervical myelopathy is suspected. It may reveal disc degeneration and ligament hypertrophy, with accompanying cord signal change.

Question 307

Why is it important for early Tx with DCM? [2]

Answer 307

All patients with degenerative cervical myelopathy should be urgently referred for assessment by specialist spinal services (neurosurgery or orthopaedic spinal surgery). This is due to the importance of early treatment. The timing of surgery is important, as any existing spinal cord damage can be permanent. Early treatment (within 6 months of diagnosis) offers the best chance of a full recovery but at present, most patients are presenting too late. In one study, patients averaged over 5 appointments before diagnosis, representing >2 years.

Question 308

What is the only Tx currently available for DCM? [2]

Answer 308

Currently, decompressive surgery is the only effective treatment. It has been shown to prevent disease progression. Close observation is an option for mild stable disease, but anything progressive or more severe requires surgery to prevent further deterioration. Physiotherapy should only be initiated by specialist services, as manipulation can cause more spinal cord damage.

Question 309

A 75-year-old man presents with dysphagia and halitosis. On the left side of the neck is a small, fluctuant swelling which gurgles when palpated.

Answer 309

Pharyngeal puch

Question 310

. A 54-year-old woman presents with a neck swelling. She is systemically well apart from some recent weight loss. On examination she is noted to have a midline, non-tender neck swelling which moves upwards when she swallows.

Answer 310

Goitre47%

Patients with a goitre are often euthyroid or have minor symptoms. A thyroglossal cyst would be unusual at this age - they typically present in patients < 20 years old.

Question 311

A newborn baby is noted to have a large swelling on the left-side of the neck. On examination a soft, fluctuant and highly transilluminable lump is noted just beneath the skin.

Answer 311

Cystic hygroma

Question 312

By far the most common cause of neck swellings. There may be a history of local infection or a generalised viral illness

Answer 312

Reactive lyphmadenopathy

Question 313

Rubbery, painless lymphadenopathy
The phenomenon of pain whilst drinking alcohol is very uncommon
There may be associated night sweats and splenomegaly

Answer 313

Lymphoma

Question 314

May be hypo-, eu- or hyperthyroid symptomatically
Moves upwards on swallowing

Answer 314

Thyroid swelling

Question 315

More common in patients < 20 years old
Usually midline, between the isthmus of the thyroid and the hyoid bone
Moves upwards with protrusion of the tongue
May be painful if infected

Answer 315

Thyroglossal cyst

Question 316

More common in older men
Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen but if large then a midline lump in the neck that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough

Answer 316

Pharyngeal pouch

Question 317

A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side
Most are evident at birth, around 90% present before 2 years of age

Answer 317

Cystic hygroma

Question 318

An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx
Develop due to failure of obliteration of the second branchial cleft in embryonic development
Usually present in early adulthood

Answer 318

Brnachial cyst

Question 319

More common in adult females
Around 10% develop thoracic outlet syndrome

Answer 319

Cervical rub

Question 320

Pulsatile lateral neck mass which doesn’t move on swallowing

Answer 320

Carotid aneurysm

Question 321

What can amenorrhoea be divided into? [2]

Answer 321

primary: defined as the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics
secondary: cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea

Question 322

Causes of primary amenorrhoea [5]

Answer 322

gonadal dysgenesis (e.g. Turner’s syndrome) - the most common causes
testicular feminisation
congenital malformations of the genital tract
functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
congenital adrenal hyperplasia
imperforate hymen

Question 323

Causes of secondary amenorrhoea [after excl. pregnancy]

Answer 323

hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis*
Sheehan’s syndrome
Asherman’s syndrome (intrauterine adhesions)

Question 324

What should be excluded first before deciding the cause of secondary amenorrhoea? [1]

Answer 324

Pregnancy

Question 325

Initial Ix for amenorrhoea [6]

Answer 325

exclude pregnancy with urinary or serum bHCG
full blood count, urea & electrolytes, coeliac screen, thyroid function tests
gonadotrophins
raised if gonadal dysgenesis (e.g. Turner’s syndrome)
prolactin
androgen levels
oestradiol

Question 326

What would raised levels of gonadotrophins indicate? [1]

Answer 326

raised if gonadal dysgenesis (e.g. Turner’s syndrome)

Question 327

What would reduced levels of gonadotrophins indicate?[2]

Answer 327

low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)

Question 328

What would raised levels of androgens indicate? [1]

Answer 328

May be seen in PCOS

Question 329

How to Mx primary amenorrhoea [2]

Answer 329

investigate and treat any underlying cause
with primary ovarian insufficiency due to gonadal dysgenesis (e.g. Turner’s syndrome) are likely to benefit from hormone replacement therapy (e.g. to prevent osteoporosis etC)

Question 330

How to Mx secondary amenorrhoea [2]

Answer 330

exclude pregnancy, lactation, and menopause (in women 40 years of age or older)
treat the underlying cause

Question 331

Which endocrine disroder can cause amenorrhoea?[1]

Answer 331

Hypothyroidism

Question 332

How should you alter the sertraline dose given to a patietn that it about to have ECT? [1]

Answer 332

Reducing the sertraline dose is the correct answer. With antidepressants and ECT, you do not suddenly stop them when the patient commences ECT treatment. The recommended regime is to safely reduce them to the minimum dose. You may actually add an increased dose of antidepressant towards the end of the ECT course.

Question 333

Whom is ET given to? [2]

Answer 333

Electroconvulsive therapy is a useful treatment option for patients with severe depression refractory to medication (e.g. catatonia) those with psychotic symptoms.

Question 334

Absolute CI for ECT

Answer 334

The only absolute contraindications is raised intracranial pressure.

Question 335

Short-term SE of ECT [5]

Answer 335

headache
nausea
short term memory impairment
memory loss of events prior to ECT
cardiac arrhythmia

Question 336

Long-term SE of ECT [1]

Answer 336

Some patients report impaired memory

Question 337

When is IV adenosine used? [1]

Answer 337

IV adenosine is incorrect. It is used as a rate lowering drug used to slow supraventricular tachycardias. Since there are QRS abnormalities here, there is an indication of ventricular or conducting system pathology. Adenosine is not always appropriate in these circumstances - and expert help should be sought first.

Question 338

FOllowing ABC assessment, what would indicate that patient is stable/unstable? [4]

Answer 338

shock: hypotension (systolic blood pressure < 90 mmHg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness
syncope
myocardial ischaemia
heart failure

Question 339

If there are signs patient is unstable, then what should be done? [1]

Answer 339

If any of the above adverse signs are present then synchronised DC shocks should be given. Up to 3 shocks can be given; after this expert help should be sought.

Question 340

Mx for regular broad-complex tachycardia [2]

Answer 340

assume ventricular tachycardia (unless previously confirmed SVT with bundle branch block)
loading dose of amiodarone followed by 24 hour infusion

Question 341

Mx for irregular broad-complex tachycardia [1]

Answer 341

Seek expert help

Question 342

Possible causes of irregular broad-complex tachycardia [3]

Answer 342

atrial fibrillation with bundle branch block - the most likely cause in a stable patient
atrial fibrillation with ventricular pre-excitation
torsade de pointes

Question 343

Narrow-complex regular tachycardia Mx [3]

Answer 343

vagal manoeuvres followed by IV adenosine
if above unsuccessful consider diagnosis of atrial flutter and control rate (e.g. beta-blockers)

Question 344

Narrow-complex tachycardia irregular [2]

Answer 344

probable atrial fibrillation
if onset < 48 hr consider electrical or chemical cardioversion
rate control: beta-blockers are usually first-line unless there is a contraindication

Question 345

How would acute interstitial nephritis present? [3]

Answer 345

Acute interstitial nephritis is not the correct answer. This is an interrenal AKI due to inflammation of the nephron interstitium, usually in response to drugs such as penicillin, rifampicin, NSAIDs, allopurinol or furosemide. More systemic symptoms such as joint pain, fever, rashes would be present if this were the case. Investigations will show mild renal impairment but importantly there will be white cell casts and sterile pyuria.

Question 346

Important findings Ix wise for acute interstitial nephritis [2]

Answer 346

White cell clasts and sterile pyuria

Question 347

Important findings for acute tubular necrosis [3]

Answer 347

Acute tubular necrosis is not the correct answer. This is an example of intrarenal AKI, in which the kidney tubules are damaged leading to an inability to reabsorb sodium. This leads to dilute urine (low osmolality) with high amounts of sodium. Acute tubular necrosis is usually due to nephrotoxins such as aminoglycosides and light chains in myeloma- neither of which are indicated in this patient.

Question 348

important finding for ATN in blood Ix? [1]

Answer 348

This is an example of intrarenal AKI, in which the kidney tubules are damaged leading to an inability to reabsorb sodium. This leads to dilute urine (low osmolality) with high amounts of sodium

Question 349

How would haemolytic uraemic syndrome present? [2]

Answer 349

Haemolytic uraemic syndrome is not the correct answer. This is a glomerular intrarenal cause of AKI caused by an infection that is most common in childhood. This would present with the core symptoms of AKI, anaemia and thrombocytopenia. The patient here has normal red blood cell and platelet counts.

Question 350

Give an example of prerenal uraemia [2]

Answer 350

Hypovolaemia is the correct answer. This is an example of prerenal uraemia, a cause of acute kidney injury (AKI) due to renal hypoperfusion, usually caused by shock, haemorrhage or volume depletion

Question 351

How can prereanl uraemia be differentiated? [3]

Answer 351

Prerenal uraemia can also be differentiated from other causes of AKI by the results of the urine analysis in which the kidneys reabsorb water in order to increase circulatory volume. This leads to the production of concentrated urine (high osmolality) urine with low amounts of sodium. Urine osmolality of more than 500 mOsm/kg, with an urine sodium inferior to 20 mol/l is landmark for the diagnosis os pre-renal disease.

Question 352

COmpare urine sodium and urine osmolaity in PTU and ATN

Answer 352

Pre-renal uraemia (‘azotemia’) ATN

Urine sodium < 20 mmol/L > 40 mmol/L
Urine osmolality > 500 mOsm/kg < 350 mOsm/kg

Question 353

Characterisation of BCC [1]

Answer 353

Basal cell carcinoma (BCC) is one of the three main types of skin cancer. Lesions are also known as rodent ulcers and are characterised by slow-growth and local invasion.

Question 354

Features of BCC [4]

Answer 354

many types of BCC are described. The most common type is nodular BCC, which is described here
sun-exposed sites, especially the head and neck account for the majority of lesions
initially a pearly, flesh-coloured papule with telangiectasia
may later ulcerate leaving a central ‘crater’

Question 355

A 78-year-old man asks you to look at a lesion on the right side of nose which has been getting slowly bigger over the past 2-3 months. On examination you observe a round, raised, flesh coloured lesion which is 3mm in diameter and has a central depression. The edges of the lesion appear rolled and contain some telangiectasia.

Answer 355

BCC

Question 356

What are the 3 malignant types of skin cancer? [3]

Answer 356

Basal cell carcinoma, squamous cell carcinoma, malignant meloma

Question 357

Referral for BCC? [1]

Answer 357

generally, if a BCC is suspected, a routine referral should be made

Question 358

Mx of BCC [5]

Answer 358

surgical removal
curettage
cryotherapy
topical cream: imiquimod, fluorouracil
radiotherapy

Question 359

in general, when should warfarin be stopped? [1]

Answer 359

5d before surgery

Question 360

What should INR be before surgery? [1]

Answer 360

below 1.5

Question 361

What happens to warfarin after surgery is complete? [1]

Answer 361

Usually resumed at the normal dose on the evning of the surgery or the next day if haemostasis is adequet

Question 362

MoA of warfarin [4]

Answer 362

Warfarin is an oral anticoagulant which inhibits epoxide reductase preventing the reduction of vitamin K to its active hydroquinone form, which in turn acts as a cofactor in the carboxylation of clotting factor II, VII, IX and X (mnemonic = 1972) and protein C.

Question 363

Indications for warfarin []3

Answer 363

venous thromboembolism: target INR = 2.5, if recurrent 3.5
atrial fibrillation, target INR = 2.5
mechanical heart valves, target INR depends on the valve type and location. Mitral valves generally require a higher INR than aortic valves.

Question 364

What is the INR? [1]

Answer 364

Patients on warfarin are monitored using the INR (international normalised ration), the ratio of the prothrombin time for the patient over the normal prothrombin time

Question 365

How long can it take for the INR to be stablisied? [2]

Answer 365

Warfarin has a long half-life and achieving a stable INR may take several days. There a variety of loading regimes and computer software is now often used to alter the dose.

Question 366

Factors which may potentiate warfarin [5]

Answer 366

liver disease
P450 enzyme inhibitors, e.g.: amiodarone, ciprofloxacin
cranberry juice
drugs which displace warfarin from plasma albumin, e.g. NSAIDs
inhibit platelet function: NSAIDs

Question 367

SE of warfarin [4]

Answer 367

haemorrhage
teratogenic, although can be used in breastfeeding mothers
skin necrosis: when warfarin is first started biosynthesis of protein C is reduced. This results in a temporary procoagulant state after initially starting warfarin, normally avoided by concurrent heparin administration. Thrombosis may occur in venules leading to skin necrosis
purple toes

Question 368

Where should swabs for chlamydia and gonorrhoea be taken? [1]

Answer 368

Should be taken from the vulvo-vaginal area [introitus]

Question 369

What is the most prevalent STI infection in the UK? [1]

Answer 369

Chlamydia

Question 370

Which is the most sensitive Ix for Chlamydia in females? [2]

Answer 370

Nucleic acid amplification tests (NAATs) are currently the most sensitive and specific test for the diagnosis of Chlamydia in females. An endocervical swab can be performed, but it is not as sensitive as a vulvovaginal swab. Vulvovaginal swabs for NAAT is the specimen of choice in females, as recommended by BASHH.

Question 371

Which is the most sensitive Ix for Chlamydia in males? [2]

Answer 371

NAAT with
- for men: the urine test is first-line

Question 372

When should Chlamydia testing be done? [1]

Answer 372

Chlamydiatesting should be carried out two weeks after a possible exposure

Question 373

How many owmen in the Uk have chlamydia? [1]

Answer 373

Approximately 1 in 10 young women in the UK have Chlamydia

Question 374

Incuabtion period for chlamydia [1]

Answer 374

The incubation period is around 7-21 days, although it should be remembered a large percentage of cases are asymptomatic

Question 375

Features of chlamydia [3]

Answer 375

asymptomatic in around 70% of women and 50% of men

women: cervicitis (discharge, bleeding), dysuria
men: urethral discharge, dysuria

Question 376

Potential Cx of Chlamydia

Answer 376

epididymitis
pelvic inflammatory disease
endometritis
increased incidence of ectopic pregnancies
infertility
reactive arthritis
perihepatitis (Fitz-Hugh-Curtis syndrome)

Question 377

Screnning for chlamydia in the UK [3]

Answer 377

in England the National Chlamydia Screening Programme is open to all men and women aged 15-24 years
the 2009 SIGN guidelines support this approach, suggesting screening all sexually active patients aged 15-24 years
relies heavily on opportunistic testing

Question 378

What is first-line Tx for chlamydia in the UK? [2]

Answer 378

doxycycline (7 day course) if first-line
this is now preferred to azithromycin due to concerns about Mycoplasma genitalium. This infection is often coexistant in patients with Chlamydia and there is evidence of rising levels of macrolide resistance, hence why doxycycline is preferred
if doxycycline is contraindicated / not tolerated then either azithromycin (1g od for one day, then 500mg od for two days) should be used

Question 379

If pregnant, how should a patient be maanged with chlamydia? [2]

Answer 379

if pregnant then azithromycin, erythromycin or amoxicillin may be used. The SIGN guidelines suggest azithromycin 1g stat is the drug of choice ‘following discussion of the balance of benefits and risks with the patient’

Question 380

When to contact people with Chlamydia infection? [4]

Answer 380

patients diagnosed with Chlamydia should be offered a choice of provider for initial partner notification - either trained practice nurses with support from GUM, or referral to GUM
for men with urethral symptoms: all contacts since, and in the four weeks prior to, the onset of symptoms
for women and asymptomatic men all partners from the last six months or the most recent sexual partner should be contacted
contacts of confirmed Chlamydia cases should be offered treatment prior to the results of their investigations being known (treat then test)

Question 381

What is acute urinary retention? [2]

Answer 381

Acute urinary retention is when a person suddenly (over a period of hours or less) becomes unable to voluntarily pass urine. It is the most common urological emergency and there are several potential causes that must be investigated for.

Question 382

Epidemiology of acute urinary retention [2]

Answer 382

Whilst acute urinary retention is common in men, it rarely occurs in women (incidence ratio of 13:1). It occurs most frequently in men over 60 years of age and incidence increases with age.
It has been estimated that around a third of men in their 80s will develop acute urinary retention over a five year period.

Question 383

Most common cause of acute urinary retention [1]

Answer 383

In men, acute urinary retention most commonly occurs secondary to benign prostatic hyperplasia; a condition where the prostate becomes enlarged but non-cancerous. The enlarged prostate presses on the urethra which can make the bladder wall thicker and less able to empty.

Question 384

Other causes of acute urinary retention [3]

Answer 384

In men, acute urinary retention most commonly occurs secondary to benign prostatic hyperplasia; a condition where the prostate becomes enlarged but non-cancerous. The enlarged prostate presses on the urethra which can make the bladder wall thicker and less able to empty.
Other urethral obstructions; including urethral strictures, calculi, cystocele, constipation or masses.
Some medications can cause acute urinary retention by affecting nerve signals to the bladder: these include anticholinergics, tricyclic antidepressants, antihistamines, opioids and benzodiazepines.
Less commonly, there may be a neurological cause for the acute urinary retention.
In patients with predisposing causes, a simple urinary tract infection can be enough to cause acute urinary retention
Acute urinary retention often occurs postoperatively and in women postpartum: usually secondary to a combination of the above risk factors.

Question 385

How do patients typically present in AUR [4]

Answer 385

Inability to pass urine
Lower abdominal discomfort
Considerable pain or distress
an acute confusional state may also be present in elderly patients

Question 386

How does chronic urinary retention usually present? [2]

Answer 386

This differs from chronic urinary retention which is typically painless. In a patient with a background of chronic urinary retention, acute urinary retention may present instead with overflow incontinence.

Question 387

Sx of acute urinary retention [3]

Answer 387

Palpable distended urinary bladder either on an abdominal or rectal exam
Lower abdominal tenderness
All men and women should have a rectal and neurological examination to assess for the likely causes above. Women should also have a pelvic examination.

Question 388

Ix for acute urinary retnetion [3]

Answer 388

Patients should all be investigated with a urine sample which should be sent for urinalysis and culture. This might only be possible after urinary catheterisation.
Serum U&Es and creatinine should also be checked to assess for any kidney injury.
A FBC and CRP should also be performed to look for infection
PSA is not appropriate in acute urinary retention as it is typically elevated

Question 389

What should first be done for a patient with AUR? [2]

Answer 389

To confirm the diagnosis of acute urinary retention a bladder ultrasound should be performed. A volume of >300 cc confirms the diagnosis, but if the history and examination are consistent, with an inconsistent bladder scan, there are causes of bladder scan inaccuracies and hence the patient can still have acute urinary retention.

Question 390

Further Mx for AUR [3]

Answer 390

Acute urinary retention is managed by decompressing the bladder via catheterisation
Urinary catheterisation can be performed in patients with suspected acute urinary retention, and the volume of urine drained in 15 minutes measured. A volume of <200 confirms that a patient does not have acute urinary retention, and a volume over 400 cc means the catheter should be left in place. In between these volumes, it depends on the case.
Further investigation should be targeted by the likely cause. In reversible causes such as UTI, resolution with treatment is sufficient and further investigation is not necessary. Men not diagnosed by BPH should be further evaluated by a urologist, Patients with neurological symptoms should be evaluated by a neurologist and women with gynaecological symptoms by a gynaecologist. Where no likely cause is identified, patients should be evaluated by a urologist for anatomical and urodynamic causes.

Question 391

Cx of AUR [3]

Answer 391

post-obstructive diuresis

the kidneys may increase diuresis due to the loss of their medullary concentration gradient. This can take time re-equilibrate
this can lead to volume depletion and worsening of any acute kidney injury
some patients may therefore require IV fluids to correct this temporary over-diuresis

Question 392

A 60-year-old man is admitted with severe central chest pain to the resus department. The admission ECG shows ST elevation in leads V1-V4 with reciprocal changes in the inferior leads. Which one of the following is most likely to account for these findings?

Answer 392

100% ST elevation in the LAD

Widepread ST elevation in this territory implies a complete occlusion of the left anterior descending artery.

Question 393

Causes of ST elevation [5]

Answer 393

myocardial infarction
pericarditis/myocarditis
normal variant - ‘high take-off’
left ventricular aneurysm
Prinzmetal’s angina (coronary artery spasm)
Takotsubo cardiomyopathy
rare: subarachnoid haemorrhage

Question 394

What is it called when neurological Sx are exacerbated by increases in body temperature? [1]

Answer 394

Uhthoff ’s phenomenon where neurological symptoms are exacerbated by increases in body temperature is typically associated with multiple sclerosis

Question 395

What do most pts with MS present with? [1]

Answer 395

Patient’s with multiple sclerosis (MS) may present with non-specific features, for example around 75% of patients have significant lethargy.

Question 396

Dx of MS [2]

Answer 396

Diagnosis can be made on the basis of two or more relapses and either objective clinical evidence of two or more lesions or objective clinical evidence of one lesion together with reasonable historical evidence of a previous relapse

Question 397

Visual Sx of MS [4]

Answer 397

optic neuritis: common presenting feature
optic atrophy
Uhthoff’s phenomenon: worsening of vision following rise in body temperature
internuclear ophthalmoplegia

Question 398

Sensory Sx of MS [4]

Answer 398

pins/needles
numbness
trigeminal neuralgia
paraesthesiae in limbs on neck flexion

Question 399

What is Lhermitte’s syndrome? [1]

Answer 399

Paraesthesiae in limbs on neck flexion

Question 400

Motor and cerebellar Sx of MS [2]

Answer 400

ataxia: more often seen during an acute relapse than as a presenting symptom
tremor

Question 401

Other Sx seen in MS [3]

Answer 401

urinary incontinence
sexual dysfunction
intellectual deterioration

Question 402

If ruptures may cause pseudomyxoma peritonei [1]

Answer 402

Mucinous cystadenoma

Question 403

The most common type of epithelial cell tumour [1]

Answer 403

Serous cystadenoma

Question 404

May contain skin appendages, hair and teeth [1]

Answer 404

Dermoid cyst [teratoma]

Question 405

What can benign cysts be divided into? [3]

Answer 405

Benign ovarian cysts are extremely common. They may be divided into physiological cysts, benign germ cell tumours, benign epithelial tumours and benign sex cord stromal tumours.

Question 406

What should happen to complex ovarian cysts and why? [2]

Answer 406

Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy.

Question 407

Name types of physiological [or functional] cysts [2]

Answer 407

1. Follicular cysts
2. Corpus luteum cysts

Question 408

What is the commonest type of ovarian cyst and what is it due to? [2]

Answer 408

Follicular cysts
commonest type of ovarian cyst
due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
commonly regress after several menstrual cycles

Question 409

How are corpus luteum cysts formed? How can they present? [2]

Answer 409

during the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears. If this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst
more likely to present with intraperitoneal bleeding than follicular cysts

Question 410

Name a benign germ cell tumour that causes an ovarian cyst [1]

Answer 410

Dermoid cyst

Question 411

Why may dermoid cysts contain skin appendages, hair and teeth? [1]

Answer 411

also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth

Question 412

Commonest presentation of dermoid cyst [4]

Answer 412

most common benign ovarian tumour in woman under the age of 30 years
median age of diagnosis is 30 years old
bilateral in 10-20%
usually asymptomatic. Torsion is more likely than with other ovarian tumours

Question 413

Where do benign epithelial tumours arise from? [1]

Answer 413

Arise from the ovarian surface epithelium

Question 414

name types of benign epithelial tumour ovarian cysts [2]

Answer 414

Serous cystadenoma
Mucinous cystadenoma

Question 415

What is the most common type of benign epithelial tumour? what does it resemble? [2]

Answer 415

Serous cystadenoma
the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
bilateral in around 20%

Question 416

Which benign ovarian tumours are typically large? [3]

Answer 416

Mucinous cystadenoma
second most common benign epithelial tumour
they are typically large and may become massive
if ruptures may cause pseudomyxoma peritonei

Question 417

What is given prior to surgery for an appendectomy? [1]

Answer 417

Prophylactic IV Abx

Question 418

When is acute appendicits likely to occur? [2]

Answer 418

Acute appendicitis is the most common acute abdominal condition requiring surgery. It can occur at any age but is most common in young people aged 10-20 years.

Question 419

Pathogenesis of appendicitis [2]

Answer 419

lymphoid hyperplasia or a faecolith → obstruction of appendiceal lumen → gut organisms invading the appendix wall → oedema, ischaemia +/- perforation

Question 420

Which Sx is seen in most pts with acute appendicitis? [4]

Answer 420

Abdominal pain is seen in the vast majority of patients:

peri-umbilical abdominal pain (visceral stretching of appendix lumen and appendix is midgut structure) radiating to the right iliac fossa (RIF) due to localised parietal peritoneal inflammation.
the migration of the pain from the centre to the RIF has been shown to be one of the strongest indicators of appendicitis
patients often report the pain being worse on coughing or going over speed bumps. Children typically can’t hop on the right leg due to the pain.

Question 421

Other features of appendicitis 4]

Answer 421

vomit once or twice but marked and persistent vomiting is unusual
diarrhoea is rare. However, pelvic appendicitis may cause localised rectal irritation of some loose stools. A pelvic abscess may also cause diarrhoea
mild pyrexia is common - temperature is usually 37.5-38oC. Higher temperatures are more typical of conditions like mesenteric adenitis
anorexia is very common. It is very unusual for patients with appendicitis to be hungry
around 50% of patients have the typical symptoms of anorexia, peri-umbilical pain and nausea followed by more localised right lower quadrant pain

Vomiting, diarrhoea, pyrexia, anorexia

Question 422

Examination for appendcitis [4]

Answer 422

generalised peritonitis if perforation has occurred or localised peritonism
rebound and percussion tenderness, guarding and rigidity
retrocaecal appendicitis may have relatively few signs
digital rectal examination may reveal boggy sensation if pelvic abscess is present, or even right-sided tenderness with a pelvic appendix
classical signs: Rovsing’s and psoas

Question 423

What are Rovsing;s and psoas sign and how useful are they? [2]

Answer 423

Rovsing’s sign (palpation in the LIF causes pain in the RIF) is now thought to be of limited value
psoas sign: pain on extending hip if retrocaecal appendix

Question 424

Dx of appendicits [4]

Answer 424

typically raised inflammatory markers coupled with compatible history and examination findings should be enough to justify appendicectomy
a neutrophil-predominant leucocytosis is seen in 80-90%
urine analysis: useful to exclude pregnancy in women, renal colic and urinary tract infection. In patients with appendicitis, urinalysis may show mild leucocytosis but no nitrites
there are no definite rules on the use of imaging and its use is often determined by the patient’s gender, age, body habitus and the likelihood of appendicitis:

• thin, male patients with a high likelihood of appendicitis may be diagnosed clinically
• ultrasound is useful in females where pelvic organ pathology is suspected. Although it is not always possible to visualise the appendix on ultrasound, the presence of free fluid (always pathological in males) should raise suspicion
• CT scans are widely used in patients with suspected appendicitis in the US but this practice has not currently reached the UK, due to the concerns regarding excessive ionising radiation and resource limitations

Question 425

Inflammatory markers in appendicits [2]

Answer 425

Tpyically raised inflammatory markers; neutrophil-predominnnat leucocytosis seen in 80-90%

Question 426

Thin male vs female with pelvic pathology Dx for appendicits [2]

Answer 426

thin, male patients with a high likelihood of appendicitis may be diagnosed clinically
ultrasound is useful in females where pelvic organ pathology is suspected. Although it is not always possible to visualise the appendix on ultrasound, the presence of free fluid (always pathological in males) should raise suspicion

Question 427

Initial Mx of appendicits [2]

Answer 427

appendicectomy
can be performed via either an open or laparoscopic approach
laparoscopic appendicectomy is now the treatment of choice

Question 428

Summarised Mx for appendicits [6]

Answer 428

appendicectomy
- can be performed via either an open or laparoscopic approach
- laparoscopic appendicectomy is now the treatment of choice
administration of prophylactic intravenous antibiotics reduces wound infection rates
patients with perforated appendicitis (typical around 15-20%) require copious abdominal lavage.
patients without peritonitis who have an appendix mass should receive broad-spectrum antibiotics and consideration given to performing an interval appendicectomy
be wary in the older patients who may have either an underlying caecal malignancy or perforated sigmoid diverticular disease.
trials have looked at the use of intravenous antibiotics alone in the treatment of appendicitis. The evidence currently suggests that whilst this is successful in the majority of patients, it is associated with a longer hospital stay and up to 20% of patients go on to have an appendicectomy within 12 months.

Question 429

A 21-year-old man presents to his GP with an itchy rash. This has been coming on for the past three months and is characterised by red, scaly patches of skin, most prominent on the back of his elbows and the front of his knees. He has suffered with dandruff for some time. He has no past medical or family history and is not taking any medication.

Dx?

Answer 429

Chronic plaque psoriasis

Question 430

What is Koebner phenomenon? [2]

Answer 430

This patient is presenting with a history suggestive of chronic plaque psoriasis. The Koebner phenomenon describes the tendency for new skin lesions to form at sites of cutaneous injury. It is not clear why this occurs, but it is observed in chronic plaque psoriasis and vitiligo.

Question 431

Sunlight and psoriasis [2]

Answer 431

Photosensitive rash is primarily associated with SLE and other connective tissue diseases including dermatomyositis. It may rarely be seen in psoriasis, but the majority of psoriasis patients actually experience an improvement in symptoms when exposed to UV light, and so this is not the most likely feature.

Question 432

What is Samter’s triad? [3]

Answer 432

Aspirin sensitivity and nasal polyps are two aspects of Samter’s triad, the third being chronic asthma, not psoriasis. Samter’s triad is seen in aspirin-exacerbated respiratory disease, where hypersensitivity to aspirin results in asthmatic symptoms.

Question 433

What is Apthous ulceration? [2]

Answer 433

Aphthous ulceration is the formation of ulcers on the oral and genital mucous membranes. It may be idiopathic but is also associated with connective tissue diseases including Behcet’s and systemic lupus erythematosus (SLE). It is not a feature associated with psoriasis.

Question 434

Where is Koebner phenomenon also seen in? [5]

Answer 434

The Koebner phenomenon describes skin lesions that appear at the site of injury. It is seen in:
psoriasis
vitiligo
warts
lichen planus
lichen sclerosus
molluscum contagiosum

Question 435

Features of acute pericarditis [5]

Answer 435

chest pain: may be pleuritic. Is often relieved by sitting forwards
other symptoms include non-productive cough, dyspnoea and flu-like symptoms
pericardial rub
tachypnoea
tachycardia

Question 436

What is pericarditis relieved by? [1]

Answer 436

Sitting forwards

Question 437

What can be heard in pericarditis? [1]

Answer 437

Pericardial rub

Question 438

Causes of acute pericarditis [5]

Answer 438

viral infections (Coxsackie)
tuberculosis
uraemia (causes ‘fibrinous’ pericarditis)
trauma
post-myocardial infarction, Dressler’s syndrome
connective tissue disease
hypothyroidism
malignancy

Question 439

What can acute pericarditis arise secondary to in very ill patients? [1] - important!

Answer 439

malignancy!

Question 440

ECG changes seen in acute pericarditis [3] - important

Answer 440

the changes in pericarditis are often global/widespread, as opposed to the ‘territories’ seen in ischaemic events
‘saddle-shaped’ ST elevation
PR depression: most specific ECG marker for pericarditis

Question 441

What should all patients with suspected acute pericarditis have? [2]

Answer 441

all patients with suspected acute pericarditis should have transthoracic echocardiography

Question 442

Mx of acute pericarditis [2] - important

Answer 442

treat the underlying cause
a combination of NSAIDs and colchicine is now generally used for first-line for patients with acute idiopathic or viral pericarditis

Question 443

What is colchicine used for? [4]

Answer 443

Colchicine is an adjuvant therapy which improves the response to medical therapy and reduces the rate of recurrence in acute pericarditis.
Also used for gout, Behcets disease and FMF.

Question 444

A 41-year-old woman presents with palpitations and heat intolerance. On examination her pulse is 90/min and a small, diffuse goitre is noted which is tender to touch. Thyroid function tests show the following:

Free T4 at 24, TSH at 0.05. Dx? [1]

Answer 444

De Quervain’s thyroiditis [subacute thyoiriditis]

Whilst Grave’s disease is the most common cause of thyrotoxicosis it would not cause a tender goitre. In the context of thyrotoxicosis this finding is only really seen in De Quervain’s thyroiditis.

Hashimoto’s thyroiditis is an autoimmune disorder of the thyroid gland. It is typically associated with hypothyroidism although there may be a transient thyrotoxicosis in the acute phase. The goitre is non-tender in Hashimoto’s.

Question 445

WHen does subacute thyoiriditis typically occur? [2]

Answer 445

Subacute thyroiditis (also known as De Quervain’s thyroiditis and subacute granulomatous thyroiditis) is thought to occur following viral infection and typically presents with hyperthyroidism.

Question 446

4 phases of subacute thyroiditis [4]

Answer 446

There are typically 4 phases; 
phase 1 (lasts 3-6 weeks): hyperthyroidism, painful goitre, raised ESR 
phase 2 (1-3 weeks): euthyroid 
phase 3 (weeks - months): hypothyroidism 
phase 4: thyroid structure and function goes back to normal

Question 447

Ix for subacute thyroiditis [1]

Answer 447

thyroid scintigraphy: globally reduced uptake of iodine-131

Question 448

Mx for subacute thyroiditis [3]

Answer 448

usually self-limiting - most patients do not require treatment
thyroid pain may respond to aspirin or other NSAIDs
in more severe cases steroids are used, particularly if hypothyroidism develops

Question 449

Which types of thyroid disroders are solely hypo or hyper? [2]

Answer 449

Hypo = Hashimotos, Riedel's thyroiditis, Iodine def., lithium 
Hyper = Graves', toxic multinodular goitre

Question 450

Initially hyper, then hypo? [2]

Answer 450

Subacute thyroiditis, postpartum thyroiditis

Question 451

Which drug can cause both hypo and hyperthyroidism [2]

Answer 451

Amiodarone

Question 452

Inheritance pattern of Wilson’s disease

Answer 452

Autosomal recessive disorder

Question 453

Characterisation of Wilson’s disease

Answer 453

Wilson’s disease is an autosomal recessive disorder characterised by excessive copper deposition in the tissues.

Question 454

Pathogenesis of Wilson’s disease [2]

Answer 454

Metabolic abnormalities include increased copper absorption from the small intestine and decreased hepatic copper excretion. Wilson’s disease is caused by a defect in the ATP7B gene located on chromosome 13.

Question 455

onset of Sx for WIlson’s disease usually? [2]

Answer 455

The onset of symptoms is usually between 10 - 25 years. Children usually present with liver disease whereas the first sign of disease in young adults is often neurological disease

Question 456

Features of excessive copper deposition [6]

Answer 456

Liver hepatitis
Neurological Sx like basal ganglia degeneration, speech/psychiatric problems, dementia
Kayser-Fleischer rings
Renal tubular acidosis
Haemolysis
Blue nails

Question 457

What is often the first manifestation of Wilson’s disease? [1]

Answer 457

speech, behavioural and psychiatric problems are often the first manifestations

Question 458

What do Kayser-Fleischer rings look like, and how common are they in Wilson’s disease? [3]

Answer 458

green-brown rings in the periphery of the iris
due to copper accumulation in Descemet membrane
present in around 50% of patients with isolated hepatic Wilson’s disease and 90% who have neurological involvemen

Question 459

Summarise features of Wilson’s disease

Answer 459

Features result from excessive copper deposition in the tissues, especially the brain, liver and cornea:

liver: hepatitis, cirrhosis
neurological:
- basal ganglia degeneration: in the brain, most copper is deposited in the basal ganglia, particularly in the putamen and globus pallidus
- speech, behavioural and psychiatric problems are often the first manifestations
- also: asterixis, chorea, dementia, parkinsonism
Kayser-Fleischer rings
- green-brown rings in the periphery of the iris
- due to copper accumulation in Descemet membrane
- present in around 50% of patients with isolated hepatic Wilson’s disease and 90% who have neurological involvement
renal tubular acidosis (esp. Fanconi syndrome)
haemolysis
blue nails

Question 460

Dx of Wilson’s disease

Answer 460

slit lamp examination for Kayser-Fleischer rings
reduced serum caeruloplasmin
reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin)
- free (non-ceruloplasmin-bound) serum copper is increased
increased 24hr urinary copper excretion

Question 461

Is total serum copper raised or reduced in Wilson’s disease [1]

Answer 461

reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin)

Question 462

Traditional first-line Mx for Wilson’s disease [1]

Answer 462

penicillamine (chelates copper) has been the traditional first-line treatment

Question 463

What other mx is done for WIlson’s disease? [3]

Answer 463

penicillamine (chelates copper) has been the traditional first-line treatment
trientine hydrochloride is an alternative chelating agent which may become first-line treatment in the future
tetrathiomolybdate is a newer agent that is currently under investigation

Question 464

What is the role of calcium resonium in the Mx of hyperkalaemia patient? [2]

Answer 464

Calcium resonium results in removal of potassium from the body, rather than shifting potassium between fluid compartments in the short-term

Question 465

Principles of managing hyperkalaemia [2]

Answer 465

Untreated hyperkalaemia may cause life-threatening arrhythmias. Precipitating factors should be addressed (e.g. acute kidney injury) and aggravating drugs stopped (e.g. ACE inhibitors). Management may be categorised by the aims of treatment

Question 466

Three classifications of hyperkalaemia [3]

Answer 466

The European Resuscitation Council classifies hyperkalaemia as:

mild: 5.5 - 5.9 mmol/L
moderate: 6.0 - 6.4 mmol/L
severe: ≥ 6.5 mmol/L

Question 467

What are the ECG changes associated with hyperkalaemia [4]

Answer 467

Remember that the presence of ECG changes is important in determining the management - it should be done in all patients with new hyperkalaemia. The following changes are associated with hyperkalaemia:
peaked or ‘tall-tented’ T waves (occurs first)
loss of P waves
broad QRS complexes
sinusoidal wave pattern

Question 468

How to shift potassium from the ECF to the ICF compartment in hyperkalaemia [2]

Answer 468

Short-term shift in potassium from extracellular (ECF) to intracellular fluid (ICF) compartment

• combined insulin/dextrose infusion
• nebulised salbutamol

Question 469

How to remove potassium from the body in hyperkalaemia [2]

Answer 469

Removal of potassium from the body

• calcium resonium (orally or enema)
• enemas are more effective than oral as potassium is secreted by the rectum
• loop diuretics
• dialysis
• haemofiltration/haemodialysis should be considered for patients with AKI with persistent hyperkalaemia

Question 470

How to stabilise cardiac membrane in hyperkalaemia [2]

Answer 470

Stabilisation of the cardiac membrane

• IV calcium gluconate
• does NOT lower serum potassium levels

Question 471

What are the principles of Tx for hyperkalaemia [3]

Answer 471

Stabilise cardiac membrane, shift potassium from ECF to ICF, remove potassium from the body

Question 472

How to manage patients with severe hyperkalaemia [3]

Answer 472

All patients with severe hyperkalaemia (≥ 6.5 mmol/L) or with ECG changes should have emergency treatment

IV calcium gluconate: to stabilise the myocardium
insulin/dextrose infusion: short-term shift in potassium from ECF to ICF
other treatments such as nebulised salbutamol may be given to temporarily lower the serum potassium

Question 473

Furterh Mx for hyperkalaemia [10]

Answer 473

Further management
stop exacerbating drugs e.g. ACE inhibitors
treat any underlying cause
lower total body potassium
calcium resonium
loop diuretics
dialysis

Question 474

Summarise Mx of hyperkalaemia

Answer 474

Management

Principles of treatment modalities

Stabilisation of the cardiac membrane
IV calcium gluconate
does NOT lower serum potassium levels

Short-term shift in potassium from extracellular (ECF) to intracellular fluid (ICF)
compartment
combined insulin/dextrose infusion
nebulised salbutamol

Removal of potassium from the body
calcium resonium (orally or enema)
enemas are more effective than oral as potassium is secreted by the rectum
loop diuretics
dialysis
haemofiltration/haemodialysis should be considered for patients with AKI with persistent hyperkalaemia

Outline of practical treatment

All patients with severe hyperkalaemia (≥ 6.5 mmol/L) or with ECG changes should have emergency treatment
IV calcium gluconate: to stabilise the myocardium
insulin/dextrose infusion: short-term shift in potassium from ECF to ICF
other treatments such as nebulised salbutamol may be given to temporarily lower the serum potassium

Further management
stop exacerbating drugs e.g. ACE inhibitors
treat any underlying cause
lower total body potassium
calcium resonium
loop diuretics
dialysis

Question 475

First-line Tx for COPD [1]

Answer 475

SABA or LAMA

Question 476

Seocn dline Tx for COPD [1]

Answer 476

+ LAMA or ICS

Question 477

Third-line Tx for COPD

Answer 477

Question 478

First, second and third line for ashtma in 5-16 y/o children [3]

Answer 478

Question 479

4th, 5th, 6th, and 7th line for asthma in 5-16 y/o

Answer 479

Question 480

First, second, third and fourth linne Mx for asthma in children under 5

Answer 480

Question 481

What is maintenance nad reliever therapy in children under 5 with asthma? [2]

Answer 481

Question 482

Answer 482

Erythroderma

Question 484

Answer 484

Extensive exfoliation on patient with erythroderma

Question 485

What is the appearance of a superifical epidermal burn? [1]

Answer 485

Question 486

What is the appearance of a deep dermal burn? [1]

Answer 486

Question 487

Answer 487

Scabies

Question 488

BMI of 32, BMI of 29, BMI of 37 =

Answer 488

Question 489

What Sx overlap between BV and Trichomonas? [3]

Answer 489

Question 490

Which Sx are seperate from BV and tirchomonas?

Answer 490

Question 491

Answer 491

Pulmonary fibrosis I think

Question 492

LH and testerone in androgen insensitivty syndrome vs in praimry hypogonadism

Answer 492

Question 493

Adrenaline dose to give patient if under 6m as compared to 6-12y in anaphyalxis [2]

Answer 493

Question 494

Answer 494

Hand foot mouth disease

Question 495

Which drugs, which malignancies, which neurological causes of SIADH? [3]

Answer 495

Question 496

Summarise causes of SIADH [split into malignancy, neuro, infections, drugs, other]

Answer 496

Question 497

Compare pre-renal uraemia to ATN

Answer 497

Question 498

Urine sodium and urine osmolaity difference in pre-renal uraemia vs acute tubular necrosis

Answer 498

Question 499

Answer 499

BCC

Question 500

Answer 500

ECG showing pericarditis -> note widespread ST elevation anf PR depression

Question 501

Compare which types of thyroid disease fall into hypo, which hyper and which both [3]

Answer 501

Question 502

Answer 502

ECG showing hyperkalaemia -> widening QRS complexes and peaked T waves