general Flashcards

Question

pancoast tumour

Answer 1

- hoarseness of voice due to pressing on recurrent laryngeal nerve - apex -

Answer 2

All patients with a pleural effusion in association with sepsis or a pneumonic illness require diagnostic pleural fluid sampling - if the fluid is purulent or turbid/cloudy a chest tube should be placed to allow drainage - if the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection a chest tube should be placed

Answer 3

daytime somnolence compensated respiratory acidosis hypertension

Answer 4

vascular problems: thoracic aortic aneurysm lymphoma retrosternal goitre teratoma tumours of the thymus

Answer 5

right lower and middle lobes

Answer 6

large bullae in COPD

Answer 7

obstructive

Answer 8

prostate cancer

Answer 9

pyridoxine

Answer 10

autoimmune haemolytic anaemia

Answer 11

Ghon complex - latent TB

Answer 12

sputum culture

Answer 13

3 months of isoniazid (with pyridoxine) and rifampicin or 6 months of isoniazid (with pyridoxine)

Answer 14

macrolides

Answer 15

splenic flexure - supplied by superior and inferior mesenteric arteries. thumbprinting on CXR

Answer 16

nimodipine

Answer 17

Generalised tonic-clonic seizures * males: sodium valproate * females: lamotrigine or levetiracetam * girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children or women who are unable to have children may be offered sodium valproate first-line Focal seizures * first line: lamotrigine or levetiracetam * second line: carbamazepine, oxcarbazepine or zonisamide Absence seizures (Petit mal) * first line: ethosuximide * second line: ○ male: sodium valproate ○ female: lamotrigine or levetiracetam * carbamazepine may exacerbate absence seizures Myoclonic seizures * males: sodium valproate * females: levetiracetam Tonic or atonic seizures * males: sodium valproate * females: lamotrigine

Answer 18

If a patient is on warfarin/a DOAC/ or has a bleeding disorder and they are suspected of having a TIA, they should be admitted immediately for imaging to exclude a haemorrhage

Answer 19

radial nerve extend wrist

Answer 20

* Head injury is top cause - traumatic SAH * In the absence of trauma: 'spontaneous SAH' * Intracranial aneuyrsm e.g. saccular 'berry aneurysms' ○ Associated conditions with berry aneurysms: § Polycystic kidney disease § Hypertension § Ehlers-Danlos syndrome Coarctation of the aorta *Atriovenous malformation *Pituitary apoplexy *Mycotic (infective) aneurysms

Answer 21

Pontine haemorrhage commonly presents with reduced GCS, paralysis and bilateral pin point pupils

Answer 22

* Co-beneldopa (levodopa + benserazide) - Madopa Co-careldopa (levodopa + carbidopa) - Sinemet

Answer 23

if stenosis > 70% in internal carotid artery

Answer 24

everyone except: - meningococcal septicaemia - shock - immunocompromised - recently out of surgery

Answer 25

pregabalin usually amitryptiline but to be avoided to prevent urinary retention

Answer 26

* Cannulated screw fixation ○ Non-displaced intracapsular fractures ○ Insertion of screws across fracture line to stabilise * Dynamic hip screw ○ Stable, extracapsular ○ Insertion of single large screw into femoral head, combined with a side plate fixed to femoral shaft § If unstable, intermedullary nail generally preferred * Hemiarthroplasty ○ Replacing femoral head and neck with a prosthesis ○ Displaced intracapsular fractures in older patients with lower activity levels, as these fractures have a high risk of non-union and avascular necrosis * Total hip arthroplasty ○ Replacement of femoral head and acetabulum with prosthetic components ○ Typically for displaced intracapsular fractures in younger, more active patients or older patients with pre-existing osteoarthritis

Answer 27

posterior dislocation

Answer 28

Posterior Reversible Encephalopathy Syndrome (PRES) is a constellation of symptoms that results in oedema of the posterior occipital and parietal lobes. Manifestations include headache, changes in vision, confusion and seizures. It can be caused by severe hypertension, and it should resolve once the blood pressure is under control.

Answer 29

The chest pain in ACS is caused by reduced blood flow to the myocardium resulting from a narrowing of the coronary arteries. Superimposed anaemia will worsen the ischaemia by compromising the ability of the blood to deliver oxygen through the already narrowed coronary arteries. For most indications, the haemoglobin threshold for blood transfusion is 70 g/L, however, in ACS, the threshold rises to 80 g/L.

Answer 30

type 1 - CPAP type 2 - BiPAP

Answer 31

1st line: oral vancomycin for 10 days If ineffective, oral fidaxomicin Last line: faecal transplant

Answer 32

They can be administered via a nasogastric tube or a rotigotine patch could be used.

Answer 33

urine dipstick, urine MC&S, FBC, U&E, Calcium, LFTs, TFTs, Coagulation Screen, Glucose, Vitamin B12 and Folate

Answer 34

able to mobilise outside with no more than the use of a stick not cognitively impaired medically fit for anaesthesia and the procedure.

Answer 35

biliary and urinary systems

Answer 36

should prompt further investigation. It could be the presenting symptom of an underlying renal cell carcinoma that is compressing the venous drainage of the left testicle into the left renal vein

Answer 37

Paradise Criteria ● ≥7 episodes of tonsillitis in the past 12 months ● ≥5 episodes of tonsillitis per year for 2 years ● ≥3 episodes of tonsillitis per year for 3 years ● ≥2 peritonsillar abscesses at any point in the patient’s life (≥1 in children)

Answer 38

A thyroglossal cyst is an embryological remnant of the thyroglossal duct which has incompletely closed in utero. Thyroglossal cysts are benign but may cause difficulty in speaking and swallowing or may become infected. They typically present in children up to adolescence. Thyroglossal cysts are managed by surgical excision, typically with a Sistrunk procedure, which involves complete removal of the cyst and part of the hyoid bone. Any underlying infection of the cyst must be treated with antibiotics prior to surgery.

Answer 39

Non-invasive ventilation is an umbrella term that encompasses CPAP and BiPAP. There are two main measures that are used when describing NIV. Inspiratory positive airways pressure (IPAP) which is the pressure applied during the inspiratory phase of the respiratory cycle, and expiratory positive airway pressure (EPAP) which is the pressure during the expiratory phase. In CPAP, the pressure remains constant throughout inspiration and expiration (IPAP = EPAP). In BiPAP, the pressure during the inspiratory phase is higher than the pressure during the expiratory phase. The EPAP is responsible for splinting open otherwise collapsed airways, thereby increasing alveolar recruitment and, hence, oxygenation of the blood. In other words, an increase in EPAP should bring about an increase in oxygenation. The difference between IPAP and EPAP creates a gradient which facilitates the expiration of carbon dioxide-rich air from the lungs. Therefore, increasing the gap between the IPAP and EPAP will lead to an increase in carbon dioxide excretion. In this scenario, the patient’s pO2 has improved, however, their pCO2 has remained roughly the same. Therefore, an increase in the gap between the IPAP and EPAP would be recommended as it would increase carbon dioxide excretion. Given that the patient is on 60% FiO2 and their oxygenation has only slightly improved, it would not be appropriate to reduce their EPAP at this point in time.

Answer 40

Atelectasis refers to loss of lung volume due to collapse or inadequate ventilation. This may be caused by an obstruction (e.g. mucus plug) which the trapping of air within the airways distal to the obstruction. Over time, this trapped air will be absorbed into the circulation and the airway will collapse. It can also result from inadequate ventilation and is a common post-operative complication. The reduced respiratory effort during anaesthesia and shallow-breathing due to post-operative pain are thought to contribute to the development of atelectasis. It can be prevented by encouraging patients to take regular deep breaths during the post-operative period, and using devices such as incentive spirometers.

Answer 41

A high output stoma is generally defined as having a stoma output of 1.5-2 L or greater and results from the inability of the small bowel to reabsorb fluid and electrolytes efficiently. It usually resolves over time, but it is relatively common for new stomas to develop this complication. It can lead to dehydration and electrolyte imbalance. The management involves administering IV fluids and using loperamide or codeine to increase bowel transit time. In some cases, PPIs and histamine antagonists may also be used. Oral fluids can further increase stoma output in patients with high-output stoma by reducing the osmolarity of the bowel contents and, hence, drawing more fluid into the bowel lumen. Oral fluids should be heavily restricted (500 ml/day) and replaced with IV fluids. Sometimes an electrolyte-rich oral rehydration solution may be used.

Answer 42

Pneumonia is one of the most common complications in post-operative patients. When a patient spikes a temperature in the post-operative period, it is important to try and identify the cause. The time the fever develops after surgery can indicate the likely underlying cause: 1-2 days post op: respiratory or part of physiological inflammatory response to surgery 3-5 days post-op: respiratory or urinary tract 5-7 days: surgical site infection, venous thromboembolism, anastomotic leak It is important to manage pain well in patients who have had major abdominal or thoracic surgery. The pain can limit their ability to breathe deeply and, hence, adequately ventilate their lungs. This can result in atelectasis and the development of hospital-acquired pneumonia.

Answer 43

Anterior Wall: aponeurosis of the external oblique, reinforced laterally by the internal oblique muscle Posterior Wall: transversalis fascia Superior Wall (roof): transversalis fascia, internal oblique and transversus abdominis Inferior Wall (floor): inguinal ligament thickened medially by the lacunar ligament

Answer 44

Duputryen's - digital contracture, ring finger most commonly affected - associated with ALCOHOL Trigger finger - flexion of PIP - associated with DIABETES

Answer 45

Femoral-femoral crossover

Answer 46

occlusion of both iliac vessels

Answer 47

if aorta and right common iliac artery are not patent

Answer 48

Primary haemorrhage occurs within the first 8 hours of the operation and requires immediate return to theatre. Secondary haemorrhage usually occurs as a result of infection and tends to occur 5-10 days after the operation. In some cases, it may require a return to theatre. All cases of post-tonsillectomy haemorrhage require review by ENT.

Answer 49

Hesselbach’s triangle is an anatomical landmark that demarcates the potential areas of weakness in the anterior abdominal wall through which herniation can occur. It has three borders: Medial: lateral border of the rectus abdominis Lateral: inferior epigastric vessels Inferior: inguinal ligament

Answer 50

Legionella pneumophila is one cause of atypical pneumonia, and it tends to be associated with hyponatraemia and confusion. The organism spreads via aerosolised water and common reservoirs for the bacteria include air conditioning units and water tanks. Legionella antigens can be detected in the urine, so a urinary antigens test should be requested in any patient with possible atypical pneumonia.

Answer 51

APTT anti-thrombin III and enhancing its activity. It will result in a dramatic increase in the ability of anti-thrombin III to bind to and inhibit Factors II, IX, X and XI. As these factors are primarily involved in the intrinsic pathway of the clotting cascade, the effect of heparin is monitored using activated partial thromboplastin time

Answer 52

ileo-colic

Answer 53

The femoral canal has four borders: Medial: lacunar ligament Lateral: femoral vein Anterior: inguinal ligament Posterior: pectineal ligament, superior ramus of pubic bone and pectineus muscle

Answer 54

NICE guidelines state that “a physiotherapist or occupational therapist should offer rehabilitation, on the day of surgery if possible and no more than 24 hours after surgery” for those who have had a primary elective knee replacement. This rehabilitation should include: · advice on managing activities of daily living · and home exercise programmes · and mobilisation for people who have had knee or hip replacement

Answer 55

Paraesthesia and Paralysis - amputation

Answer 56

Metaraminol is an alpha-1 agonist that is commonly used to support blood pressure in critically unwell patients. It tends to be the vasopressor of choice for patients who only have peripheral intravenous access (i.e. no central line).

Answer 57

Fontaine I Asymptomatic patients Fontaine II = Intermittent claudication - IIa- walk over 200m before experiencing Sx - IIb Intermittent claudication - walk <200m before experiencing Sx iii - rest/nocturnal pain iv - Most severe form of chronic limb ischaemia - tissue loss e.g. ulcers, gangrene

Answer 58

A “high spinal” occurs when the local anaesthetic block extends above the desired level (in this case, above T4). This will block a greater proportion of the sympathetic output from the sympathetic chain (including the cardiac accelerator fibres to the heart) leading to dangerous bradycardia and life-threatening hypotension. If the local anaesthetic progresses to the intracranial space, total spinal anaesthesia occurs. This can lead rapidly to loss of consciousness, respiratory arrest and cardiac arrest from sudden loss of sympathetic outflow.

Answer 59

Type 1: Caused by ischaemia due to a sudden coronary artery occlusion (e.g. thrombus) Type 2: Caused by ischaemia due to increased oxygen demand or decreased supply without any acute coronary event. Type 3: Referred to cases of sudden death in patients with preceding features suggestive of a myocardial infarction but without available biomarkers. Type 4: Associated with percutaneous coronary intervention or stent thrombosis. Type 5: Associated with cardiac surgery (e.g. CABG).

Answer 60

The first-line management choice for rate control in patients with atrial fibrillation is bisoprolol, however, in patients who are nil by mouth, other alternatives must be considered as bisoprolol does not have an intravenous preparation. IV metoprolol or IV atenolol are good alternatives that are cardioselective and able to rapidly achieve rate control. Labetalol is also available in an IV preparation, however, it is non-cardioselective and, so, tends to mainly be used to manage high blood pressure as opposed to high heart rate.

Answer 61

Zollinger-Ellison syndrome is a disease in which patients develop extensive mucosal ulceration across their oesophagus, stomach and duodenum. It is caused by excessive release of gastrin from a tumour of the enteroendocrine G cells. Gastrin is a hormone that stimulates gastric acid production and gastric motility. The excessive acid production in Zollinger-Ellison syndrome results in mucosal damage and ulceration. This is usually followed by a secretin stimulation test in which secretin is administered and the change in serum gastrin is observed. Normally, secretin will reduce gastrin production, however, in Zollinger-Ellison syndrome it causes a paradoxical increase in gastrin secretion.

Answer 62

A fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l implies impaired fasting glucose (IFG)

Answer 63

fasting plasma glucose less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l

Answer 64

capillary glucose

Answer 65

Patients with type 1 diabetes if a patient is on insulin, they must not stop it due to the risk of diabetic ketoacidosis check blood glucose more frequently, for example, every 1-2 hours including through the night consider checking blood or urine ketone levels regularly maintain normal meal pattern if possible if appetite is reduced meals could be replaced with carbohydrate-containing drinks (such as milk, milkshakes, fruit juices, and sugary drinks) aim to drink at least 3 L of fluid (5 pints) a day to prevent dehydration

Answer 66

advise the patient to temporarily stop some oral hypoglycaemics during an acute illness medication may be restarted once the person is feeling better and eating and drinking for 24-48 hours metformin: stop treatment if there is a risk of dehydration, to reduce the risk of lactic acidosis. sulfonylureas: may increase the risk of hypoglycaemia SGLT-2 inhibitors: check for ketones and stop treatment if acutely unwell and/or at risk of dehydration, due to the risk of euglycaemic DKA GLP-1 receptor agonists: stop treatment if there is a risk of dehydration, to reduce the risk of AKI if on insulin therapy, do not stop treatment, as above monitor blood glucose more frequently as necessary

Answer 67

1/3 before sunrise 2/3 after sunrise

Answer 68

hypocalcaemia associated with cataracts

Answer 69

primary hyperaldosteronism

Answer 70

avulsion fracture of the proximal lateral tibia and is pathognomonic of an anterior cruciate ligament tear. Therefore, the most appropriate management option is an anterior cruciate ligament repair.

Answer 71

referral to urology for surgery

Answer 72

Hydroceles occur when the tunica vaginalis becomes distended and filled with serous fluid. They are common in newborn boys, especially if preterm. The majority resolve on their own within the first year of life. If the hydrocele has not resolved on its own by the time the baby is one year old, referral to a paediatric surgeon should be considered. Persistent hydroceles may require surgery (usually laparoscopic) at 12-24 months of age.

Answer 73

albumin & clotting times international normalised ratio (INR) which is calculated by dividing the patient’s prothrombin time by a fixed reference prothrombin time, is most sensitive as it is affected by the levels of factor VII. Factor VII has the shortest half-life (4-6 hours) of all the clotting factors and, hence, would be first to be deranged in liver failure.

Answer 74

Admit & 5 day course of IV Co-Amoxiclav 1.2 g TDS and Clarithromycin 500 mg BD

Answer 75

otoscopy should be performed to check for the presence of a vesicular rash in the outer ear that would be suggestive of Ramsay-Hunt syndrome

Answer 76

myasthenia: anti-achr on postsynaptic membrane - movements worse with exertion - first line: pyridostigmine lambert eaton: anti-voltage gated calcium channels on presynaptic membrane - movements better with exertion as acetylcholine overpowers - first line: amifampridine

Answer 77

limited scleroderma

Answer 78

pseudogout

Answer 79

para-aortic

Answer 80

Hyperacute ● Within seconds of clamp release ● Mediated by preformed antibodies ● Results in immediate loss of graft Accelerate Acute ● First few days ● Cellular and antibody mediators Acute ● Days to weeks ● Cell mediated – usually lymphocytes Chronic ● Most common ● Graft atrophy and atherosclerosis Fibrosis is a very late event

Answer 81

analgesia, hypnosis and relaxation

Answer 82

Muscle relaxants are also known as neuromuscular blocking agents (NMBAs) NMBAs are divided into depolarising and non-depolarising blockers. Depolarising blockers, such as suxamethonium, are agonists of the acetylcholine receptor (AChR), creating a long-lasting depolarisation which eventually causes desensitisation and thus paralysis. Non-depolarising agents, such as rocuronium, are competitive antagonists of the AChR, preventing ACh from binding to its receptor and causing muscle contraction.

Answer 83

benign ECG pattern that appears as widespread concave ST elevation that is usually seen in leads V2-5. It may be associated with a notched J point and the T waves are usually prominent, such that the ST elevation: T wave ratio is < 0.25. It is usually seen in young people under the age of 50 years.

Answer 84

Raised intracranial pressure (e.g. due to an intracranial bleed) can give rise to a number of ECG changes that could mimic myocardial ischaemia (such as ST elevation or depression and T wave inversion). In patients who are drowsy and have marked ECG changes, an urgent CT head scan should be conducted to check for any intracranial pathology. Given that these changes could be caused by an intracranial bleed (such as a subdural haemorrhage in this patient subset), it is important to conduct a CT head scan prior to starting antiplatelet or anticoagulant therapy that would dramatically worsen any bleed.

Answer 85

Constrictive pericarditis is a condition in which inflammation results in thickening and scarring of the pericardium. This can result in reduced ventricular filling as the heart cannot relax fully as it is constrained by the stiff pericardium. It may present with features of heart failure such as peripheral and pulmonary oedema. As it causes diastolic failure, an echocardiogram is likely to reveal preserved ejection fraction Constrictive pericarditis usually arises following diseases that inflict damage to the pericardium such as viral and non-viral pericarditis Restrictive cardiomyopathy may present similarly, however, it is a disease of the myocardium as opposed to the pericardium. It may be genetic, or caused by infiltrative diseases such as sarcoidosis and amyloidosis.

Answer 86

As this patient is actively bleeding, it is often assumed that they should not be given venous thromboembolism prophylaxis upon admission as it may worsen their bleeding. Inflammatory bowel disease, however, is a systemic inflammatory condition which creates a very pro-thrombotic state. This, coupled with the dehydration due to diarrhoea and immobility due to hospital admission, puts the patient at a very high risk of developing a venous thromboembolism. Therefore, patients with suspected inflammatory bowel disease should be given VTE prophylaxis during a hospital admission (e.g. tinzaparin 4500 units SC OD).

Answer 87

hiatus hernia - elevated gastric bubble

Answer 88

Acute mesenteric ischaemia refers to ischaemia of the bowel resulting from an occlusion of the superior mesenteric artery. It classically manifests with a triad of abdominal pain, shock and normal abdominal examination findings. Risk factors include hypercoagulable states (e.g. multiple myeloma which may have developed from this patient’s previous MGUS). It may be treated interventionally with embolectomy and bypass surgery.

Answer 89

AF with bundle branch block

Answer 90

usually occurs when metastases are present in the liver and release serotonin into the systemic circulation may also occur with lung carcinoid as mediators are not 'cleared' by the liver Features flushing (often the earliest symptom) diarrhoea bronchospasm hypotension right heart valvular stenosis (left heart can be affected in bronchial carcinoid) other molecules such as ACTH and GHRH may also be secreted resulting in, for example, Cushing's syndrome pellagra can rarely develop as dietary tryptophan is diverted to serotonin by the tumour Investigation urinary 5-HIAA plasma chromogranin A y Management somatostatin analogues e.g. octreotide diarrhoea: cyproheptadine may help

Answer 91

S1 closure of mitral and tricuspid valves soft if long PR or mitral regurgitation loud in mitral stenosis

Answer 92

closure of aortic and pulmonary valves soft in aortic stenosis splitting during inspiration is normal

Answer 93

caused by diastolic filling of the ventricle considered normal if < 30 years old (may persist in women up to 50 years old) heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis (called a pericardial knock) and mitral regurgitation associated with rapid ventricular filling

Answer 94

may be heard in aortic stenosis, HOCM, hypertension caused by atrial contraction against a stiff ventricle therefore coincides with the P wave on ECG in HOCM a double apical impulse may be felt as a result of a palpable S4

Answer 95

risk of stroke same, need to remain on apixaban

Answer 96

hypophosphataemia this is the hallmark symptom of refeeding syndrome may result in significant muscle weakness, including myocardial muscle (→ cardiac failure) and the diaphragm (→ respiratory failure) hypokalaemia hypomagnesaemia: may predispose to torsades de pointes abnormal fluid balance

Answer 97

beta blockers, propylthiouracil and hydrocortisone

Answer 98

fever > 38.5ºC tachycardia confusion and agitation nausea and vomiting hypertension heart failure abnormal liver function test - jaundice may be seen clinically

Answer 99

- severe conduction disturbances (unless pacemaker fitted) - sinus node disease (unless pacemaker fitted) - iodine sensitivity - sino-atrial heart block (except in cardiac arrest) - sinus bradycardia (except in cardiac arrest) - thyroid dysfunction

Answer 100

offered PRN nitrofurantoin as post-coital prophylaxis

Answer 101

- conjunctivitis (cant see) - urethrtis (cant pee) - arthritis (cant climb a tree) - cant ski (keraoderma blenorrhagicum) - can't get jizzy (Circinate balanitis -Serpiginous ring-shaped dermatitis on glans penis)

Answer 102

extradural initially loses, briefly regains and then loses again consciousness after a low-impact head injury. The brief regain in consciousness is termed the 'lucid interval' and is lost eventually due to the expanding haematoma and brain herniation. As the haematoma expands the uncus of the temporal lobe herniates around the tentorium cerebelli and the patient develops a fixed and dilated pupil due to the compression of the parasympathetic fibers of the third cranial nerve.

Answer 103

paediatric fractures involving growth plate (ie physis) I: S - straight across (ie only physis) II: A - above (physis and metaphysis) III: L - lower (physis and epiphysis to include joint) IV: T - through (physis, metaphysis, and epiphysis) V: ER - erasure of growth plate (crush injury)

Answer 104

Thrombotic crises * also known as painful crises or vaso-occlusive crises * precipitated by infection, dehydration, deoxygenation (e.g. high altitude) * painful vaso-occlusive crises should be diagnosed clinically - there isn't one test that can confirm them although tests may be done to exclude other complications * infarcts occur in various organs including the bones (e.g. avascular necrosis of hip, hand-foot syndrome in children, lungs, spleen and brain Acute chest syndrome * vaso-occlusion within the pulmonary microvasculature → infarction in the lung parenchyma * dyspnoea, chest pain, pulmonary infiltrates on chest x-ray, low pO2 * management ○ pain relief ○ respiratory support e.g. oxygen therapy ○ antibiotics: infection may precipitate acute chest syndrome and the clinical findings (respiratory symptoms with pulmonary infiltrates) can be difficult to distinguish from pneumonia ○ transfusion: improves oxygenation * the most common cause of death after childhood Aplastic crises * caused by infection with parvovirus * sudden fall in haemoglobin * bone marrow suppression causes a reduced reticulocyte count Sequestration crises * sickling within organs such as the spleen or lungs causes pooling of blood with worsening of the anaemia associated with an increased reticulocyte count

Answer 105

avoid prescribing trimethoprim or co-trimoxazole concurrently - increases risk of marrow aplasia

Answer 106

Overview absence of beta globulin chains chromosome 11 Features presents in the first year of life with failure to thrive and hepatosplenomegaly microcytic anaemia HbA2 & HbF raised HbA absent Management repeated transfusion this leads to iron overload → organ failure iron chelation therapy is therefore important (e.g. desferrioxamine)

Answer 107

papiloedema - venous engorgement - loss of venous pulsation - blurring of optic disc margin - elevation of optic disc - loss of optic cup - Paton's lines: concentric/radial retinal lines cascading from optic cup

Answer 108

ultrasound

Answer 109

inflammation of the myocardium in the absence of ischaemia. Patients are usually under 50 and have a history of recent viral illness, as in this presentation. Common symptoms are chest pain and features of pulmonary oedema. Typically, inflammatory markers and troponin will be raised, and ECG will show non-specific ST segment and T wave changes. Focal ST elevation is a possible finding, as in this patient. Myocarditis can manifest as new-onset congestive heart failure (due to inflammation reducing the contractile strength of the heart), as evidenced by the presence of orthopnea and pulmonary oedema on chest x-ray.

Answer 110

non-pregnant: doxycycline pregnant: azithromycin, erythromycin or amoxicillin

Answer 111

presents with dendritic corneal ulcer: painful red eye + tearing branching linear lesion with terminal bulbs seen on fluorescein staining - immediate referral to ophthal - topical aciclovir

Answer 112

hep b serology

Answer 113

Patients with cystic fibrosis should minimise contact with each other due to the risk of cross-infection

Answer 114

salter harris I - most distal part of radius has moved back on lateral view ie gone through growth plate, making it salter harris I

Answer 115

- no palpable axillary lymphadenopathy -> ultrasound if ultrasound -ve, sentinel node biopsy to assess nodal burden - breast cancer with clinically palpable lymphadenopathy -> axillary node clearance (may lead to arm lymphoedema and functional arm impairment)

Answer 116

mastectomy: - multifocal tumour - central tumour - large lesion in small breast - DCIS > 4 wide local excision - solitary lesion - peripheral tumour - small lesion in large breast - DCIS < 4 everyone offered breast reconstruction

Answer 117

offered after WLE for mastectomy: offered for T3-T4 tumours OR 4+ positive axillary nodes

Answer 118

adjuvant if tumours positive for hormonal receptors pre and peri menopausal: tamoxifen post-menopausal: anastrazole

Answer 119

-increased risk of endometrial cancer - VTE - menopausal sx

Answer 120

HER2 positive tumours - trastuzumab (Herceptin) NOT in patients with history of heart disorders though

Answer 121

neoadjuvant to downstage primary lesion OR adjuvant depending on stage e.g. if axillary node disease, FEC-D used

Answer 122

refer to secondary care

Answer 123

CT angiography TOE if unstable

Answer 124

reducing peripheral synthesis of oestrogen

Answer 125

sacroiliitis: subchondral erosions, sclerosis squaring of lumbar vertebrae 'bamboo spine' (late & uncommon) syndesmophytes: due to ossification of outer fibers of annulus fibrosus chest x-ray: apical fibrosis

Answer 126

last thing in the evening

Answer 127

Early features (within 30 days) * erythema migrans ○ 'bulls-eye' rash is typically at the site of the tick bite ○ typically develops 1-4 weeks after the initial bite but may present sooner ○ usually painless, more than 5 cm in diameter and slowlly increases in size ○ present in around 80% of patients. * systemic features ○ headache ○ lethargy ○ fever ○ arthralgia Later features (after 30 days) * cardiovascular ○ heart block ○ peri/myocarditis * neurological ○ facial nerve palsy ○ radicular pain meningitis

Answer 128

stop anticoag and repeat scan in a week

Answer 129

usually delayed until 3 months post-partum unless missed screening or previous abnormal smears hormonal changes during pregnancy can lead to physiological alterations in cervical cells. For example, increased oestrogen initiates cervical cell proliferation, creating potentially misleading changes on a smear test.

Answer 130

ECG -> can widen QRS complex and increase risk of seizures

Answer 131

activated charcoal

Answer 132

1 hour NOT 15 minutes

Answer 133

commonly causes an anaphylactoid reaction (non-IgE mediated mast cell release). Anaphylactoid reactions to IV acetylcysteine are generally treated by stopping the infusion, then restarting at a slower rate.

Answer 134

the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity there is a staggered overdose* or there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration; or patients who present 8-24 hours after ingestion of an acute overdose of more than 150 mg/kg of paracetamol even if the plasma-paracetamol concentration is not yet available patients who present > 24 hours if they are clearly jaundiced or have hepatic tenderness, their ALT is above the upper limit of normal acetylcysteine should be continued if the paracetamol concentration or ALT remains elevated whilst seeking specialist advice

Answer 135

Arterial pH < 7.3, 24 hours after ingestion or all of the following: prothrombin time > 100 seconds creatinine > 300 µmol/l grade III or IV encephalopathy

Answer 136

meniscal tear

Answer 137

correct vitamin D and calcium deficiency

Answer 138

caused by an inherited mutation in the ranitidine receptor which interferes with calcium regulation in skeletal muscle. Anaesthetic agents known to trigger an episode of malignant hyperpyrexia include all potent inhaled general anaesthetic agents (e.g. halothane, thiopental) and all depolarising muscle relaxants (e.g. suxamethonium). As ketamine is not in either of these classes of drug, it will not cause malignant hyperpyrexia in this patient.

Answer 139

Staph aureus

Answer 140

↑ creatinine > 26µmol/L in 48 hours ↑ creatinine > 50% in 7 days ↓ urine output < 0.5ml/kg/hr for more than 6 hours

Answer 141

anticholinergic e.g. tolterodine or darifenacin

Answer 142

surgical fixation due to risk of development of avascular necrosis

Answer 143

Acute chest syndrome - dyspnoea, chest pain, hypoxia + pulmonary infiltrates not ARDS - same as above however no mention of sepsis, trauma, or pneumonia (causing trauma to lungs causing non-cardiogenic pulmonary oedema due to increase in capillary permeability) and when given O2, hypoxia does not usually respond in ARDS

Answer 144

not recommended by NICE

Answer 145

antibiotics should be prescribed immediately if: Symptoms lasting more than 4 days or not improving Systemically unwell but not requiring admission Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease Younger than 2 years with bilateral otitis media Otitis media with perforation and/or discharge in the canal

Answer 146

genetic condition caused by the defective production of type IV collagen. Features include glomerulonephritis, end-stage kidney disease, and hearing loss, and it is managed using ACE inhibitors and haemodialysis.

Answer 147

no established risk of serotonin syndrome!

Answer 148

tramadol and St John's Wort

Answer 149

Iron / calcium carbonate tablets can reduce the absorption of levothyroxine - should be given 4 hours apart

Answer 150

- give IV bicarbonate

Answer 151

clopidogrel & statin

Answer 152

inducers will decrease INR, inhibitor will increase INR

Answer 153

IV ciprofloxacin to cover pseudomonas aeruginosa

Answer 154

ciprofloxacin to cover pseudomonas

Answer 155

Wet age-related macular degeneration is typified by rapid vision loss (over weeks), and choroidal neovascularisation, which in this case is indicated by subretinal fluid and haemorrhages in the macula. Dry age-related macular degeneration progresses more slowly (over months) and is associated with drusen;

Answer 156

(Na+) - (bicarb + chloride) the normal AG = 0.2 x [albumin] (g/L) + 1.5 x [phosphate] (mmol/L) generally normal: 4-12

Answer 157

gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula renal tubular acidosis drugs: e.g. acetazolamide ammonium chloride injection Addison's disease

Answer 158

lactate: shock, hypoxia ketones: diabetic ketoacidosis, alcohol urate: renal failure acid poisoning: salicylates, methanol 5-oxoproline: chronic paracetamol use CO, CN Alcoholic ketoacidosis and starvation ketoacidosis Toluene Metformin, Methanol Uremia DKA Pyroglutamic acidosis, paracetamol, phenformin, propylene glycol, paraladehyde Iron, Isoniazid Lactic acidosis Ethylene glycol Salicylates

Answer 159

sexually active younger adults: NAAT for STIs older adults with a low-risk sexual history: MSSU

Answer 160

hypokalaemic metabolic alkalosis Cushing's syndrome causes hypokalaemic metabolic alkalosis because when the levels of cortisol are high, the cortisol that is not inactivated by 11β-hydroxysteroid dehydrogenase is free to bind to mineralocorticoid receptors. This causes an increase in water and sodium retention, increased potassium excretion, and increased hydrogen ions excretion. Lower levels of hydrogen ions cause alkalosis and less potassium causes hypokalemia.

Answer 161

amlodipine

Answer 162

condition characterized by splenomegaly and neutropenia in a patient with rheumatoid arthritis.

Answer 163

gastric adenocarcinoma

Answer 164

ureteroscopy

Answer 165

Renal stones watchful waiting if < 5mm and asymptomatic 5-10mm shockwave lithotripsy 10-20 mm shockwave lithotripsy OR ureteroscopy > 20 mm percutaneous nephrolithotomy Uretic stones shockwave lithotripsy +/- alpha blockers>< 10mm shockwave lithotripsy +/- alpha blockers 10-20 mm ureteroscopy

Answer 166

subchondral erosions, sclerosis and squaring of lumbar vertebrae

Answer 167

atypical antipsychotics quetiapine and clozapine are preferred

Answer 168

B12/folate: macrocytic anaemias, B12/folate deficiency worsen confusion TFTs: confusion is more commonly seen in hypothyroidism Glucose: hypoglycaemia can commonly cause confusion Bone Profile (Calcium): hypercalcaemia can cause confusion

Answer 169

hyperchloraemic metabolic acidosis can arise as a complication of substantial intravenous administration of 0.9% sodium chloride. This disorder is typified by an increase in serum chloride and a concurrent decrease in bicarbonate levels, which reduces pH

Answer 170

thyroxine and hydrocortisone

Answer 171

sarcoidoisis can cause cranial DI by depositing granulomas in the pituitary gland

Answer 172

for <65 if the TSH level is 5.5-10 mU/L on 2 separate occasions 3 months apart + symptomatic if TSH > 10 on 2 separate occasions 3 months apart for >65: watch and wait

Answer 173

MM - raindrop PTH - pepperpot

Answer 174

should not be done within at least: 6 weeks of a prostate biopsy 4 weeks following a proven urinary infection 1 week of digital rectal examination 48 hours of vigorous exercise 48 hours of ejaculation

Answer 175

critical > 2 weeks

Answer 176

1) handheld arterial Doppler 2) if doppler signals present, ABPI

Answer 177

Initial management ABC approach analgesia: IV opioids are often used intravenous unfractionated heparin is usually given to prevent thrombus propagation, particularly if the patient is not suitable for immediate surgery vascular review Definitive management: intra-arterial thrombolysis surgical embolectomy angioplasty bypass surgery amputation: for patients with irreversible ischaemia

Answer 178

caecal volvulus: foetal sign

Answer 179

sigmoid volvulus: coffee bean sign

Answer 180

should raise suspicion of compartment syndrome

Answer 181

double the glucocorticoids, keep fluodrocortisone the same

Answer 182

oral macrolide if within 21 days

Answer 183

central retinal artery occlusion

Answer 184

multiple myeloma until proven otherwise

Answer 185

a uric acid level ≥ 360 umol/L is seen as supporting a diagnosis if uric acid level < 360 umol/L during a flare repeat the uric acid level measurement at least 2 weeks after the flare has settled

Answer 186

hypodense (dark), crescentic collection around the convexity of the brain

Answer 187

risedronate or etidronate

Answer 188

tenosynovitis, migratory polyarthritis, dermatitis

Answer 189

proteus mirabilis

Answer 190

Use Simmonds triad (palpation, examining the angle of declination at rest and the calf squeeze test) to assess for evidence of Achilles tendon rupture

Answer 191

CNS lymphoma

Answer 192

Measure the urinary albumin/creatinine ratio (ACR) on a spot urine sample. If results abnormal, repeat with a first-pass morning urine specimen

Answer 193

chondrocalcinosis -> pseudogout

Answer 194

'SomeTimes Mistakes Happen' (SLE, TB, malaria, HIV)

Answer 195

often occurs secondary to pulmonary hypertension as a result of chronic lung disease such as chronic obstructive pulmonary disease (COPD) producing a loud pulmonary component of the second heart sound, raised jugular venous pressure and a pansystolic murmur in the left lower sternal edge.

Answer 196

Nasal mupirocin + chlorhexidine for the skin

Answer 197

idarucizumab dabigatran is a DOAC and direct thrombin inhibitor

Answer 198

andexanet alfa modified Xa protein

Answer 199

protamine sulphate

Answer 200

obesity female sex pregnancy drugs combined oral contraceptive pill steroids tetracyclines retinoids (isotretinoin, tretinoin) / vitamin A lithium

Answer 201

pseudomonas keratitis

Answer 202

iliofascial block

Answer 203

Staphylococcus aureus Staphylococcus epidermidis if < 2 months post valve surgery

Answer 204

urea that is proportionally higher than the rise in creatinine

Answer 205

sigmoid volvulus: rigid sigmoidoscopy with rectal tube insertion - In patients with sigmoid volvulus who have bowel obstruction with symptoms of peritonitis, skip the flexible sigmoidoscopy and treat with urgent midline laparotomy caecal volvulus: management is usually operative. Right hemicolectomy is often needed

Answer 206

supracondylar + tibial shaft

Answer 207

lesion of optic chiasm upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma

Answer 208

prolactin - raised in true epileptiform seizures

Answer 209

due to a lesion in superior temporal gyrus typically supplied by inferior division of left MCA 'forms' the speech before sending it to Broca's area => word salad comprehension impaired

Answer 210

expressive aphasia inferior frontal gyrus -> typically supplied by superior division of left MCA - speech non-fluent, laboured, and halting repetition impaired - comprehension normal

Answer 211

stroke affecting arcuate fasciculus - connection between Wernicke's and Broca's area Speech fluent but repetition poor - aware of errors they are making Comprehension normal

Answer 212

large lesion affecting receptive, expressive, and conductive aphasia -> may still be able to communicate using gestures

Answer 213

pituitary MRI urgent steroid replacement due to loss of ACTH careful fluid balance surgery

Answer 214

diabetes mellitus vasculitis e.g. temporal arteritis, SLE false localizing sign* due to uncal herniation through tentorium if raised ICP posterior communicating artery aneurysm pupil dilated often associated pain cavernous sinus thrombosis Weber's syndrome: ipsilateral third nerve palsy with contralateral hemiplegia -caused by midbrain strokes other possible causes: amyloid, multiple sclerosis

Answer 215

if lesion above t6 cause of a dysreflexia is an discontinuity between the nociceptors on the viscera and the brain stem autonomic centres due to the cord injury. features: the result is an unbalanced physiological response, characterised by extreme hypertension flushing and sweating above the level of the cord lesion agitation in untreated cases, severe consequences of extreme hypertension have been reported, e.g. haemorrhagic stroke. All the pain receptors on smooth muscle on the abdominal and some pelvic viscera are carried by the sympathetics and the specific nerve which extends to the pelvis is the greater splanchnic nerve (which has its lowest innervation at T6 and so this is the lowest level at which autonomic dysreflexia can still occur). management: removal/control of the stimulus and treatment of any life-threatening hypertension and/or bradycardia.

Answer 216

subacute combined degeneration of the spinal cord

Answer 217

Cutaneous features depigmented 'ash-leaf' spots which fluoresce under UV light roughened patches of skin over lumbar spine (Shagreen patches) adenoma sebaceum (angiofibromas): butterfly distribution over nose fibromata beneath nails (subungual fibromata) cafe-au-lait spots* may be seen Neurological features developmental delay epilepsy (infantile spasms or partial) intellectual impairment Also retinal hamartomas: dense white areas on retina (phakomata) rhabdomyomas of the heart gliomatous changes can occur in the brain lesions polycystic kidneys, renal angiomyolipomata lymphangioleiomyomatosis: multiple lung cysts

Answer 218

Common features headache (may be sudden onset) nausea & vomiting reduced consciousness Investigation MRI venography is the gold standard CT venography is an alternative non-contrast CT head is normal in around 70% of patients D-dimer levels may be elevated Management anticoagulation typically with low molecular weight heparin acutely warfarin is still generally used for longer term anticoagulation

Answer 219

may present with seizures and hemiplegia parasagittal biparietal or bifrontal haemorrhagic infarctions are sometimes seen 'empty delta sign' seen on venography

Answer 220

other causes of cavernous sinus syndrome: local infection (e.g. sinusitis), neoplasia, trauma periorbital erythema and oedema ophthalmoplegia: 6th nerve damage typically occurs before 3rd & 4th trigeminal nerve involvement may lead to hyperaesthesia of upper face and eye pain central retinal vein thrombosis

Answer 221

6th and 7th cranial nerve palsies

Answer 222

if pupillary reflexes affected, that's due to pressing on parasympathetic fibres ie surgical cause

Answer 223

W B STIF Wernicke's - superior temporal Brocha's - inferior frontal

Answer 224

- raised CK - AKI secondary to rhabdo - leukocytosis

Answer 225

pirfenidone nintendanib

Answer 226

contrast CT abdo

Answer 227

also known as aortoiliac occlusive disease, is a form of peripheral vascular disease caused by narrowing at the point at which the aorta branches to form the common iliac arteries. It manifests with erectile dysfunction, buttock claudication and weak femoral pulses.

Answer 228

SSRIs, NSAIDs, bisphosphonates

Answer 229

Acute bacterial endocarditis is when previously normal heart valves become damaged by very virulent organisms such as Staphylococcus aureus. Subacute bacterial endocarditis occurs in patients with pre-existing valvular damage (e.g. due to rheumatic heart disease). The abnormal valves provide ground on which less virulent bacteria, such as Streptococcus viridans, can form vegetations.

Answer 230

inferior mesenteric artery

Answer 231

ELF - enhanced liver fibrosis - blood test that measures 3 molecules that are involved in development of liver fibrosis

Answer 232

agranulocytosis (cessation in the production of granulocytes) which can result in patients developing life-threatening infections. Patients should be advised that if they develop any features of an infection (e.g. sore throat, fever) they should seek urgent medical attention.

Answer 233

Blood gas machines only provide a value for the ionised serum calcium concentration. Calcium exists in the blood in two forms - around 50% is free ionised calcium and the remaining 50% is bound to proteins (e.g. albumin) or anions. The total serum calcium concentration, therefore, is roughly double the ionised serum calcium concentration.

Answer 234

a resting pO2 of less than 7.3 kPa. It should also be considered for patients who have a resting pO2 of 7.3-8 kPa with one of secondary polycythaemia, peripheral oedema or pulmonary hypertension. It is important to ensure that the patient is no longer smoking before issuing long-term oxygen therapy.

Answer 235

Malleolar pain * Ankle X-ray only required if pain in the malleolar zone and any of: * Bone tenderness at the posterior edge or tip of lateral malleolus * Bone tenderness at the posterior edge or tip of medial malleolus * Inability to bear weight both immediately and in front of clinician for 4 steps Midfoot pain * Foot X-ray only required if midfoot zone pain and any of the below: * Bone tenderness at base of fifth metatarsal * Bone tenderness at navicular bone * Inability to bear weight both immediately and in front of clinician for 4 steps To note It is important also to use clinical judgement and appreciate this decision aid might not be accurate if: * The patient is intoxicated or has reduced consciousness * The patient has other distracting painful injuries * The patient has evidence of reduced sensation in the lower limb

Answer 236

ECG feature suggestive of left atrial enlargement. Having been generated within the sinoatrial node in the wall of the right atrium, the wave of depolarisation will spread across the right atrium followed by the left atrium. In cases of left atrial enlargement, the second half of the P wave (as it goes across the left atrium) will be enlarged, giving it a bifid appearance. Left atrial enlargement may occur due to pressure overload (e.g. mitral stenosis) or volume overload (e.g. mitral regurgitation).

Answer 237

IV nitrates (e.g. sodium nitroprusside)

Answer 238

The indications for bariatric surgery on the NHS are a BMI of over 40 kg/m2 or a BMI between 35 and 40 kg/m2 and a significant comorbidity like hypertension or type 2 diabetes, when all other weight loss methods have failed (lifestyle and medical). To qualify for the surgery, patients need to be fit enough for general anaesthesia, agree to long-term follow-up and be prepared to make lifelong lifestyle changes. Bariatric surgery is also considered for patients with a BMI of less than 35 kg/m2 if they have recently been diagnosed with type 2 diabetes mellitus. It is the first-line management option for patients with a BMI of over 50 kg/m2 (so other weight loss methods do not need to be trialled first before offering surgery to these patients).

Answer 239

1st line: 5HT3 receptor - ondansetron, risk of QT prolongation and constipation 2nd line: H1 receptor antagonist e.g. cyclizine, avoid in severe heart failure 3rd line: dopamine receptor antagonist e.g. prochlorperazine. risk of extrapyramidal SEs

Answer 240

IV patient controlled analgesia

Answer 241

nasopharyngeal airway - can potentially enter the cranial vault through fractured cribiform plate, causing further injury

Answer 242

D2 D3 antagonist

Answer 243

End-tidal CO2 - measures the partial pressure of CO2 at the end of expiration.

Answer 244

occurs when there's prolonged paralysis and apnoea following administration of suxamethonium, typically due to a deficiency or abnormality of the enzyme pseudocholinesterase - enzyme is responsible for rapid metabolism of suxamethonium

Answer 245

- reduced effort to cough or breathe spontaneously at the end of a procedure

Answer 246

- plasma cholinesterase levels management: - intubate and ventilate - avoid suxamethonium in the future

Answer 247

- D2 receptor antagonist contraindicated in Parkinson's and phaeochromocytoma

Answer 248

suxamethonium and volatile anaesthetics eg. sevoflurane and isoflurane

Answer 249

cooling and dantrolene which prevents calcium release from the sarcoplasmic reticulum

Answer 250

IV hydrocortisone - Addisonian crisis

Answer 251

stop 4 weeks prior to surgery and use barrier contraception

Answer 252

head tilt chin lift - do jaw thrust instead

Answer 253

discuss with cardiology before changing meds usually aspirin and clopidogrel stopped 1 week before surgery due to increased bleeding tisk but may get stent stenosis

Answer 254

rapid sequence induction

Answer 255

- hypotension due to local anaesthesia of sympathetic nerves - epidural haemotoma - low pressure headache

Answer 256

L3-L4 or L4-L5

Answer 257

can be brown! damaged muscles -> myoglobinuria

Answer 258

switch to increased dose of IV hydrocortisone peri-op and temporarily stop fludrocortisone if any associated hypotension, fludrocortisone can be added minor ops: - oral pred can be restarted immediately post-op major op: - hydrocortisone for up to 72 hours post-op

Answer 259

GABA agonist - good for nausea!

Answer 260

avoid! as it is a pro-kinetic

Answer 261

22WW ENT referral for evaluation for a posterior nasal space tumour

Answer 262

not responsed to 2 IM injections of anaphylaxis expert help for IV adrenaline

Answer 263

endometrial - oligo/anovulation => uterus exposed to high levels of unopposed oestrogen it is because of this that patients with PCOS recommended to have a withdrawal bleed at least every 3-4 months

Answer 264

duodenal - food takes time to pass through duodenum

Answer 265

1st line: CT abdo 2nd line: scintigraphy using technetium-99m pertechnetate due to presence of ectopic gastric mucosa

Answer 266

congenital gastrointestinal abnormality characterised by the presence of a remnant of the omphalomesenteric duct. It is usually found around the ileum

Answer 267

small bowel

Answer 268

when they metastasise to the liver

Answer 269

used in the treatment of Parkinson’s disease as it has some agonist activity on central dopamine receptors. It also blocks the M2 proton channel of influenza A which prevents endosomal escape of the virus. It is, therefore, used to treat influenza A.

Answer 270

ECG changes associated with right heart strain include : T wave inversion and ST depression in the leads corresponding to the right ventricle (V1-3, II, III and aVF) - v1-3 and inferior leads. Other features include right bundle branch block, dominant R wave in V1 and dominant S wave in V5-6.

Answer 271

a breast abscess requires incision and drainage of the pus, in addition to antibiotic therapy. Breast cancer should always be excluded in patients with a breast abscess. The most appropriate investigation in this patient is therefore ultrasound-guided fine needle aspiration as this can also simultaneously treat the abscess, alongside prescribing antibiotics.

Answer 272

- pain - swelling - crepitus - deformity - adjacent structure injury: nerves/vessels/ligaments/tendons

Answer 273

acute interstitial nephritis

Answer 274

acute interstitial nephritis

Answer 275

tetracyclines

Answer 276

abdominal ultrasound diagnostic criteria: - 2 cysts, unilateral or bilateral, if aged <30 years - 2 cysts in both kidneys if 30-59 - 4 cysts in both kidneys if > 60

Answer 277

prothrombotic - occurs when molecules of the cytokine Platelet factor 4 (PF4) bind to heparin to form an antigen. This antigen is then recognised by antibodies which in turn activate platelets through their Fc receptors, and thereby initiate a pro-thrombotic cascade.

Answer 278

rescan at 32 weeks to reassess

Answer 279

IV saline + hydrocortisone (don't need fludocortisone as high cortisol exerts weak mineralocorticoid action)

Answer 280

Lymphocyte depleted

Answer 281

nodular sclerosing

Answer 282

lymphocyte predominant

Answer 283

Mycoplasma pneumoniae

Answer 284

the Holliday-Segar formula* First 10 kg 100 ml/kg Second 10 kg 50 ml/kg Subsequent kg 20 ml/kg

Answer 285

When CD4 < 200

Answer 286

urinalysis + BP

Answer 287

patients taking liver enzyme-inducing drugs (rifampicin, phenytoin, carbamazepine, chronic alcohol excess, St John's Wort) malnourished patients (e.g. anorexia nervosa) or patients who have not eaten for a few days

Answer 288

admit + administer steroids

Answer 289

immediate caesarean

Answer 290

immediate caesarean

Answer 291

vaginal delivery

Answer 292

induce vaginal delivery

Answer 293

All patients with ischaemic heart disease should take aspirin if there is no contraindication

Answer 294

give fluids as increases strain on heart by increasing preload

Answer 295

Richter's transformation

Answer 296

direct visualisation performed by senior, airway trained staff

Answer 297

Legionella pneumophila constellation of symptoms including a dry cough, fever, hyponatraemia, relative bradycardia, abnormal liver function tests (LFTs), mid-to-lower zone patchy consolidation on chest X-ray, and pleural effusions

Answer 298

metaphysis

Answer 299

FBC, U+E, LFTs every 3 months

Answer 300

mucositis myelosuppression pneumonitis the most common pulmonary manifestation similar disease pattern to hypersensitivity pneumonitis secondary to inhaled organic antigens typically develops within a year of starting treatment, either acutely or subacutely presents with non-productive cough, dyspnoea, malaise, fever pulmonary fibrosis

Answer 301

testosterone

Answer 302

hip fracture

Answer 303

dislocation

Answer 304

prescription of two nucleoside reverse transcriptase inhibitors (NRTI) and either a protease inhibitor (PI) or a non-nucleoside reverse transcriptase inhibitor (NNRTI).

Answer 305

ooking for fasciculations in the patient. These fasciculations occur due to the depolarisation of the motor end plates of skeletal muscle. They are transient and are first seen supraorbitally, then progress downwards to the chest, then abdomen, and eventually down to the feet. After this, the patient goes into full paralysis.

Answer 306

Critical limb ischaemia is a severe form of peripheral vascular disease which is characterised by the presence of tissue loss (e.g. arterial ulcers), gangrene and pain at rest. This is different from stable angina which is characterised by leg pain upon exertion that is relieved by rest.

Answer 307

nitrates coronary ostia (proximal opening of the coronary arteries) arise from behind the aortic valve leaflets. Nitrates cause a sudden decrease in preload, and patients with severe aortic stenosis will not be able to compensate sufficiently by increasing their stroke volume. This may result in worsening myocardial ischaemia.

Answer 308

Stroke Volume/End Diastolic Volume

Answer 309

The sign in involves checking patient details, the surgical site, procedure and consent. The anaesthetic machine and medication list must be checked, confirm any allergies, discuss any aspiration risks and anticipated blood loss. Time out involves re-checking patient identity, procedure and site, discussing any anticipated critical events from the surgeon, the anaesthetist and the nurse/ODP. The surgical site infection bundle should be checked, check VTE prophylaxis and any essential imaging as appropriate. The sign out involves the ODP confirming the procedure has been recorded, the instrument and swab check is correct, specimens are labelled, any equipment issues identified, and the surgeon, anaesthetist and ODP must discuss any concerns anticipated during recovery. All of these steps must occur while the patient is in theatre.

Answer 310

a condition in which the central canal of the spine becomes narrowed due to tumour or disc prolapse. It usually presents with back and leg pain that is worse when standing or walking downhill. MRI spine

Answer 311

The kidneys of a patient with CKD have an impaired ability to carry out the regulatory involved in maintaining fluid and electrolyte homeostasis. This usually manifests with potassium retention (hyperkalaemia), phosphate retention (hyperphosphataemia) and an impaired ability to excrete uraemic waste products (uraemia). Therefore, a dietician’s plan for a patient with CKD usually focuses on potassium, phosphate and protein.

Answer 312

cholestyramine

Answer 313

Type 1 HRS is characterised by a rapid, progressive impairment in renal function whereas type 2 is more stable and less progressive impairment in renal function.

Answer 314

administering human albumin solution and terlipressin. Human albumin solution (HAS) is a colloid that helps maintain the effective circulating volume in patients who are hypoalbuminemic due to liver disease. Terlipressin is a vasopressin analogue that specifically causes splanchnic vasoconstriction. It is thought, in cirrhosis, blood pools within the splanchnic circulation due to the increased resistance to blood flow within a cirrhotic liver and the inability of the liver to metabolise vasoactive substances. The combination of HAS and terlipressin is therefore able to shift more of the circulating volume into the systemic circulation, thereby improving renal perfusion.

Answer 315

(it is largely a diagnosis of exclusion). ● Cirrhosis with ascites ● Serum creatinine concentration > 133 µmol/L ● Absence of shock ● Absence of hypovolaemia ● No current or recent treatment with nephrotoxic drugs Absence of parenchymal renal disease (defined by the absence of proteinuria, haematuria and structural urinary tract abnormalities)

Answer 316

Vitamin D is activated in two steps by two different enzymes: 25-hydroxylase in the liver, then 1a-hydroxylase in the kidneys. In CKD, the ability of the kidneys to activate Vitamin D via the action of 1a-hydroxylase is compromised, therefore, resulting in vitamin D deficiency and hypocalcaemia. The two most common forms of vitamin D that are used as supplements are vitamin D2 (ergocalciferol) and vitamin D3 (colecalciferol). These, however, require activation and, so, would not be effective in end stage renal failure. These patients should, instead, be given alfacalcidol which is a form of vitamin D that has already undergone 1a-hydroxylation.

Answer 317

Activated charcoal can be given within 1 hour of ingesting more than 125 mg/kg of aspirin. Fluid losses should be replaced and intravenous sodium bicarbonate may be given (ensuring plasma-potassium concentration is within the reference range) to enhance urinary salicylate excretion (optimum urinary pH 7.5–8.5). Plasma-potassium concentration should be corrected before giving sodium bicarbonate as hypokalaemia may complicate alkalinisation of the urine. Haemodialysis is the treatment of choice for severe salicylate poisoning and should be considered when the plasma-salicylate concentration exceeds 700 mg/litre (5.1 mmol/litre) or in the presence of severe metabolic acidosis.

Answer 318

ACE inhibitors (or angiotensin II receptor blockers) are key in the management of proteinuria they should be used first-line in patients with coexistent hypertension and CKD, if the ACR is > 30 mg/mmol if the ACR > 70 mg/mmol they are indicated regardless of the patient's blood pressure SGLT-2 inhibitors patients who have proteinuric CKD (with or without diabetes) may benefit from treatment with SGLT2 inhibitors

Answer 319

the glucose requirement is 50-100 g/day irrespective of the patient's weight

Answer 320

- patient unresponsive - not strongly palpable carotid pulse - take <10s for assessment: feel pulse, feeling for breath sounds, looking for chest wall movements, listening for breath sounds - call for help early!

Answer 321

see what CO2 monitor is doing! capnography will tell you if you are doing it properly

Answer 322

5-7 mmol/l on waking and 4-7 mmol/l before meals at other times of the day

Answer 323

if INR in range, keep warfarin at current dose

Answer 324

we want a short acting benzo so lorazepam and go sublingual

Answer 325

don't give oral as swallowing usually impaired

Answer 326

bulking agents as often reduced bowel motility, especially if on opiates

Answer 327

continuous subcut

Answer 328

- haloperidol - cyclizine - metoclopramide

Answer 329

subcut 'anticipatory' drugs

Answer 330

shock -> ruptured AAA

Answer 331

emergency valve replacement surgery

Answer 332

3rd heart sound

Answer 333

Advice about maintaining good hydration (drinking 3-4 L of fluid per day), provided there are no contraindications (such as severe renal impairment or heart failure). Reassure that a low calcium diet is not necessary, as intestinal absorption of calcium is usually reduced. Advise the person to avoid any drugs or vitamin supplements that could exacerbate the hypercalcaemia. Encourage mobilization where possible to avoid exacerbating the hypercalcaemia. Advise the person to report any symptoms of hypercalcaemia.

Answer 334

Have symptoms that are persistent or do not resolve with antibiotic treatment. Have recurrent UTI (2 episodes in 6 months or 3 in 12 months). Have a urinary catheter in situ or have recently been catheterised. Have risk factors for resistance or complicated UTI such as abnormalities of the genitourinary tract, renal impairment, residence in a long-term care facility, hospitalisation for more than 7 days in the last 6 months, recent travel to a country with increased resistance or previous resistant UTI. Have atypical symptoms. Have visible or non-visible (on urine dipstick) haematuria. Pregnant Age more than 65 years old.

Answer 335

colon cancer

Answer 336

adhesions from previous surgery

Answer 337

Burns > 10 % TBSA in an Adult Burns > 5 % TBSA in a Child Full thickness burns > 5% TBSA Burns of face, hands, feet, perineum, genitalia, and major joints Circumferential burns Chemical or electrical burns Burns in the presence of major trauma or significant co-morbidity Burns in the very young patient, or the elderly patient Burns in a pregnant patient Suspicion of Non-Accidental Injury

Answer 338

First aid for burns such as this would be to hold under cool running water for 20 minutes. Guidelines do not recommend the application of any creams or gels. Ice packs are not recommended as they can cause frostnip/old burns. Burns are painful due to air moving across exposed nerve endings. The burn should be layered in cling film – not wrapped around circumferentially to reduce the risk of vasoconstriction . Cling film stops the nerve endings being exposed the air.

Answer 339

Superficial burns are usually dry, sometimes with minor blistering and erythema. Painful. Often due to sunburn or minor scalds. Involve the epidermis. Partial thickness burns are moist and red, usually with broken blisters and normal capillary refill. Involve the dermis. They are usually painful unless they are deep dermal. Deep dermal burns may also have sluggish capillary refill. Full thickness burns are dry, charred and often white. They are painless and have absent capillary return. They have destroyed the epidermis and dermis and have begun to destroy the underlying subcutaneous tissue.

Answer 340

Anterior - extensor muscles of the foot and lower limb are in the anterior compartment as is the deep peroneal nerve that innervates them Lateral - Nerves - Superficial peroneal nerve, Muscles - Peroneal longus and brevis muscles,Damage here would cause paraesthesia of the dorsum of the foot (except the 1st interweb space) and inability to evert the foot. Posterior - Nerves – Tibial Nerve (L4, L5, S1), Muscles – Flexor Digitorum Longus, Flexor Hallucis Longus, Tibialis Posterior, Popliteus, Vessels - Posterior tibial vein and artery, Damage here causes inability to plantarflex the ankle, flex the digits as well as sole of foot paraesthesia Superficial posterior compartment - Muscles – Gastrocnemius, Plantaris, Soleus, Vessels – Peroneal artery and vein, Damage here also causes impaired ankle plantarflexion

Answer 341

In general, it is recommended that patients under the age of 40 years who are diagnosed with hypertension should be referred for further investigations to identify a secondary cause. This is often due to some form of renal pathology (e.g. renal artery stenosis, polycystic kidney disease). An ultrasound scan of the urinary tract is useful in assessing the size of the kidneys. This can provide useful information about the possible causes of hypertension (e.g. in renal artery stenosis, one kidney will likely be bigger than the other, polycystic kidney appear large and bulky).

Answer 342

Capnography measures the concentration/partial pressure of inhaled and exhaled carbon dioxide (CO2). It is displayed as a waveform, showing how the exhaled CO2 changes between inspiration and expiration. The end-tidal CO2 is the peak measurement taken at the very end of expiration, which reflects the clearance of CO2 from the lungs. This measurement can therefore be used reliably to confirm that the ETT is correctly positioned within the trachea.

Answer 343

Rocuronium is a non-depolarising muscle relaxant, which is able to be reversed through the use of agents such as sugammadex and neostigmine.

Answer 344

Non-sustained ventricular tachycardia (NSVT) is defined as an ectopic ventricular rhythm with all of the following features: ● Wide QRS complex ● Rate > 100 bpm ● Lasts for at least 3 beats ● Spontaneously resolves in 30 seconds NSVT is very common in patients post-PCI. There are many causes of NSVT after an ACS such as: · Ischaemia · Reperfusion after PCI · Electrolyte imbalances (e.g. hypomagnesemia or hypokalaemia) · Underlying myocardial scar · Increased automaticity (ability of heart cells to spontaneously depolarise) in the myocardium adjacent to the infarcted area Hypomagnesemia can precipitate ventricular arrhythmias. Magnesium sulphate can be administered to stabilise the myocardial cell membrane. It works by inhibiting L-type Ca2+ channels and delayed rectifier channels, reducing Ca2+ and K+ concentrations, thereby reducing automaticity and subsequent possible arrhythmias.

Answer 345

ALT or AST more than 3 times the upper limit of normal Serum bilirubin more than 2 times the upper limit of normal No other reason that could explain this abnormality (e.g. alcoholic or viral hepatitis)

Answer 346

The first line treatment for hyponatraemia caused by SIADH is fluid restriction (usually 1-1.5 L per day). If this fails, demeclocycline can be used. Demeclocycline is a tetracycline antibiotic that can be used in SIADH as it causes nephrogenic diabetes insipidus (thereby countering the effect of the excess ADH). Other agents that may be used include tolvaptan (vasopressin receptor antagonist), sodium chloride and furosemide.

Answer 347

- carotid doppler - ambulatory ECG - echocardiogram

Answer 348

ask patient to do valsalva manoeuvre

Answer 349

NMDA receptor antagonist

Answer 350

dexamethasone

Answer 351

30 seconds

Answer 352

hypoglycaemia

Answer 353

lumbar pincture - elevated protein with normal white cell count

Answer 354

beta blocker

Answer 355

coagulase negative staphylococcus epidermidis

Answer 356

acetylcholine receptor agonist => persistent stimulation of acetylcholine receptor which eventually results in desensitisation

Answer 357

transverse lucencies with sclerotic borders that traverse part of the way through a bone and is perpendicular to the cortex. The pubic rami are commonly affected and they are sometimes referred to as ‘pseudofractures’.

Answer 358

pyridoxine

Answer 359

riboflavin

Answer 360

PERC to determine whether PE should be investigated further PESI: assess severity of PE and associated mortality

Answer 361

Adhesions form as part of the body’s healing process following surgery, so surgically accessing the abdomen to relieve an obstruction would increase the risk of further adhesions forming and, in turn, increasing the risk of future obstruction. If there is any concern of bowel strangulation, the patient is likely to require an emergency laparotomy to break down the adhesions and relieve the obstruction. If there is no concern about strangulation, patients should be treated with gastrografin. It is a contrast medium which has a very high osmolality, thereby causing a laxative effect and reducing intestinal oedema. An abdominal X-ray should be taken around 6 hours after the patient is administered gastrografin to check for resolution of the obstruction.

Answer 362

If medical treatment of the underlying cause of VT/VF fails (e.g. electrolyte imbalances) Patients who have survived cardiac arrest due to VT/VF Idiopathic and prolonged VT/VF with either syncope, haemodynamic instability or a reduced ejection fraction < 35% Inherited conditions that increase risk of developing VT/VF such as long QT syndrome, hypertrophic cardiomyopathy and Brugada syndrome. Patients who have developed heart failure with a reduced ejection fraction < 35% secondary to myocardial infarction

Answer 363

● Complete atrioventricular block or third degree heart block. ● Mortbitz type II atrioventricular block. There is a risk of progressing to third degree heart block, and therefore a pacemaker is needed. ● Persistent symptomatic bradycardia.

Answer 364

chronic: superior mesenteric artery ischaemic: inferior mesenteric artery

Answer 365

ABPI - should not apply if there's arterial insufficency (ABPI < 0.8)