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Y4 > General Medicine Block > Flashcards

General Medicine Block Flashcards

1
Q

MFE - what does the term “deconditioning” mean?

A

When a patient loses the strength in their muscles

Wasting of the muscle bulk

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2
Q

How can you test if a patient has deconditioning in their legs (quads)?

A

Stand up from chair with arms folded

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3
Q

Define sarcopenia

A

Loss of muscle mass and muscle function with ageing (pathological, more than the normal amount of mass and function lost)

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4
Q

With age, the following normal changes happen:
Muscle mass - increase/decrease ?
Body fat - increase/decrease ?
Cerebral blood flow - increase/decrease ?
Cardiac output - increase/decrease?

A

Muscle mass - decreases
Body fat - increases
cerebral blood flow - decreases
Cardiac output - decreases

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5
Q

Postural hypotension is defined in a drop in ___ mmHg or more in the systolic OR a drop in ___ mmHg or more in the diastolic?

A

20mmHg or more systolic

10mmHg or more diastolic

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6
Q

What is the largest weight bearing joint and therefore the joint most likely to be affected by OA ?

A

Knee

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7
Q

Name features suggestive of metabolic syndrome?

A

Overweight
High blood glucose
Lipid profile off (Lots of LDL, low HDL)
Sedentary lifestyle

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8
Q

Constipation increases/decreases with age?

A

Increases

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9
Q

Older patients with constipation should always get a laxitive?

A

True

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10
Q

Patient admitted to hospital and at night he/she asks for a sleeping tablet. Should you prescribe and justify your answer?

A

No!! Try to avoid as much as possible

  • highly addictive
  • can increase likelihood of falls
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11
Q

Which type of medications are sleeping tablets?

A

Benzodiazepines

- diazepam etc

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12
Q

What should you do for patients instead of giving them sleeping tablets?

A

Sleep hygine

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13
Q

Define frailty

A

When normal ageing has become pathological.

Loss of biological reserves (ie homeostasis is not as good as it should be) across multiple body systems resulting in increased vulnerability to relatively minor events and leading to adverse outcomes

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14
Q

What is dyspepsia?

A

Indigestion
Epigastric pain
Associated with eating

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15
Q

Differential diagnoses of dyspepsia?

A

GORD
Peptic ulcer disease (gastritis, gastric erosions)
Malignancy
Angina

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16
Q

Upper GI red flag symptoms

A

Weight loss
Dysphagia
Recurrent vomiting

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17
Q

2 main causes of peptic ulcer disease?

A

H. Pylori (most common)

NSAIDs

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18
Q

Investigations for H. Pylori include

A

Urease breath test
Stool antigen test
H. Pylori antibody serology

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19
Q

Urease breath test and stool antigen test for H. Pylori - are often done. What do you need to remember medication wise before carrying out these investigations?

A

Off antibiotics for previous month

Not on PPI for 2 weeks beforehand

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20
Q

Patients getting tested for H. Pylori should stop their PPI medication for __ weeks before the investigation?

A

2 weeks

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21
Q

Management of H. Pylori infection

A

PPI + amoxicillin + metronidazole (total 7 days)

use clarithromycin in penicillin allergic pt

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22
Q

If patient has had treatment of H. Pylori but experiences recurring symptoms, what should you do?

A

Re-check H. Pylori test

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23
Q

Patient presents with symptoms of GORD. What should you do?

A

No need for investigations.

Trial of PPI and if symptoms settle, continue PPI

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24
Q

Curative Tx for oesophageal cancer

A 
Oesophagectomy 
Radical radiotherapy (Squamous cell carcinoma)
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25
Q

Palliative treatment for oesophageal cancer?

A

Stent

Ablation (lasers)

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26
Q

Name some causes of dysphagia

A 
Stricture 
- benign (GORD) 
- malignant (cancer) 
Motility disorder 
- achalasia
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27
Q

Which is a helpful investigation to visualise achalasia and what does it show

A

Barrium swallow

  • shows bird beak appearance
  • widened oesophagus. muscles above the LOS don’t work and the LOS doesn’t relax
  • floppy oesophagus
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28
Q

What is the diagnostic investigation for achalasia?

A

Oesophageal manometry

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29
Q

Name the 2 types of oesophageal cancer

A

Adenocarcinoma

Squamous cell carcinoma

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30
Q

What is the first line MEDICATION treatment in delirium?

A

Halloperidol

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31
Q

If a patient with parkinsons disease has delirium and needs pharmacological treatment, which drug is commonly used?

A

Lorazepam

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32
Q

In which condition is halloperidol use contraindicated?

A

Parkinsons disease

- halloperidol blocks dopamine receptors

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33
Q

What is the best anti-emetic to use in parkinsons patient?

A

Odansetron

- don’t use metochlopromide since this blocks dopamine receptors

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34
Q

Which dose of halloperidol should be used to treat delirium in an old patient?

A

500 micrograms

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35
Q

In terms of endocrine imaging, which imaging modality is best for assessing the adrenals?

A

CT scan

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36
Q

In terms of endocrine imaging, which imaging modality is best to see the pituitary gland?

A

MRI scan

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37
Q

What is the only organ in the body which likes iodine?

A

Thyroid gland

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38
Q

What is the role of osteoclasts (with bone)

A

Bone resorption - ie they break down bone

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39
Q

Which hormone is important in the regulation of calcium

A

PTH (parathyroid hormone)

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40
Q

What does a raised calcium suggest?

A

Problem in the parathyroid gland or elsewhere

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41
Q

If a patient has raised calcium level, what should you test for?

A

PTH level

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42
Q

If patient has a raised calcium and a raised PTH, what is the likely diagnosis

A

Primary hyperparathyroidism

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43
Q

If a patient has a raised calcium but a normal PTH, what does this suggest?

A

The raised calcium is coming from somewhere else (ie not the parathyroid gland). It could be an indicator of malignancy

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44
Q

Name 3 things which could make calcium levels raised/

A

Hyperparathyroidism
Malignancy
Granulomatous disease (TB, sarcoidosis)

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45
Q

What is a pack year (smoking)

A

20 cigarettes in a pack

How many packs per year?

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46
Q

Which condition (asthma or COPD) responds better to bronchodilators?

A

Asthma

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47
Q

If a patient presents with obstructive spirometry results but you can’t tell whether they are asthmatic or have COPD, what do you do?

A

Post bronchodilator spirometry test

- If asthmatic, patient will respond better to bronchodilators

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48
Q

Peak flow curve in obstructive airway disease.

Angle is shallower/steeper and why is this?

A

Angle is shallower, air can’t get out quickly

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49
Q

Spirometry results in obstructive disease:
FEV1 - normal/high/reduced
FVC - normal/high/reduced
FEV1/FVC - normal/high/reduced

A

FEV1 - reduced
FVC - normal
FEV1/FVC - reduced

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50
Q

Spirometry results in restrictive disease:
FEV1 - normal/high/reduced
FVC - normal/high/reduced
FEV1/FVC - normal/high/reduced

A

FEV1 - reduced
FVC - reduced
FEV1/FVC - normal

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51
Q

Which 3 disease processes cause obstructive spirometry results?

A

Asthma
COPD
Bronchiectasis

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52
Q

How do you confirm a diagnosis of COPD?

A

Spirometry

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53
Q

How do you confirm the severity of COPD?

A

Combination of breathlessness and number of exacerbations

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54
Q

Why might the FVC be disproportionately high in COPD?

A

If the patient has hyperinflated lungs

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55
Q

Emphysema is most common at the top/bottom of the lungs?

A

Top of the lungs

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56
Q

What is the best imaging modality for emphysema?

A

CT scan

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57
Q

Patient wakes up in the middle of the night gasping for breath. What is this?

A

PND

- paroxysmal nocturnal dyspnoea

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58
Q

If a patient is quite well in himself but nurse notices an irregular pulse and orders an ECG. ECG shows AF, what should you counsel the patient about?

A

Consider stroke risk

Starting tablets

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59
Q

Stroke due to AF is worse/better prognosis than a stroke minus AF?

A

Worse prognosis if patient has AF, clot is affecting a bigger part of the brain.

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60
Q

What is the main risk factor for developing AF

A

Hypertension

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61
Q

How do you tell when a patient in AF gets complete heart block?

A

No P waves
Slow rate
regular rhythm

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62
Q

What do electrical spikes on an ECG suggest?

A

Pacemaker

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63
Q

If patient has AF where in the heart to clots tend to form?

A

Left atrial appendage

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64
Q

For AF what is the first line rate control drug?

A

Beta blocker

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65
Q

Patient with AF who is also asthmatic. What is the first line rate control drug in THIS patient?

A

CCB

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66
Q

For AF, what is the second line rate control drug?

A

CCB

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67
Q

For AF, what is the third line rate control drug?

A

Digoxin

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68
Q

What does digoxin block?

A

AV node

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69
Q

What is the treatment of pre-excited AF?

A

DO NOT give AV node blocking drugs (eg digoxin, CCB) as this will make the patient go fast.

Cardiovert the patient early.

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70
Q

Why should you be wary of AF with fast ventricular rate (over 220bpm) ?

A

May not be conducting through the AV node. May be an accessory pathway.

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71
Q

It is common to have a raised troponin in patients with AF. True or false?

A

True

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72
Q

You should check troponin levels in AF patients?

A

NO

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73
Q

Default treatment for AF is rate or rhythm control?

A

Rate control

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74
Q

What is the definition of a haemarthrosis? and what is the most common cause?

A

Bleeding into the joint (usually knee)

common cause - traumatic injury

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75
Q

If a patient has poor renal function but is in severe pain, which medication should be used?

A

Use oxycodone instead of morphine

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76
Q

What adverse effect can tramadol have?

A

Causes delirium

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77
Q

Co-trimoxazole causes hyper/hypo -kalaemia?

A

Hyperkalaemia

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78
Q

What is the treatment of pemphigus vulgaris?

A

Steroids

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79
Q

Which is most common to affect mucosal surfaces: Pemphigoid or pemphigus?

A

Pemphigus

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80
Q

If a patient has a pinpoint pupil in one eye and a normal pupil in the other eye, what does this make you think is going on?

A

CN lesion (CN 3)

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81
Q

Pemphigus is more fragile/tense than pemphigoid?

A

Pemphigus - fragile, superficial

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82
Q

Furosemide can cause hyper/hypo -kalaemia?

A

Hypokalaemia

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83
Q

Normal volume of resuscitation fluids is 500ml. If a patient has severe heart failure, which volume of resuscitation fluids should be given and why?

A

Give 250ml resuscitation fluids instead.

Concern is fluid overload

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84
Q

What are the 3 R’s of fluid replacement

A

Resuscitation
Replacement
Routine maintenance

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85
Q

When should you do daily weights on a patient?

A

If on IV furosemide

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86
Q

Patient with increased calcium levels and also increased parathyroid hormone. Where is the problem likely to be?

A

Parathyroid gland

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87
Q

Patient with increased calcium levels and normal parathyroid hormone levels. Where is the problem likely to be?

A

Not in the parathyroid gland, elsewhere

bones (malignancy
Sardoid
TB

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88
Q

Prolonged QT interval is associated with which condition?

A

Ventricular Tachycardia

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89
Q

If patient has a PE, acutely what is the risk in the first 7 days?

A

Death

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90
Q

If a patient has a PE, what is the long term risk?

A

pulmonary hypertension

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91
Q

5% dextrose = ??mg/ml ?

A

50mg/ml

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92
Q

1% lidocane = ??mg/ml

A

10mg/ml

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93
Q

What is xanthochromia?

A

Yellow appearance of CSF which occurs hours after a bleed into the subarachnoid space

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94
Q

Where is xanthochromia measured?

A

LP

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95
Q

What is the maximum score on a 4AT

A

12

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96
Q

What does a pacemaker ECG look like?

A

no P waves

line on ECG

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97
Q

What would you expect to see on an echo if a patient has had an MI

A

Regional wall motion abnormality

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98
Q

For murmur classification, how many grades are there?

A 
6 grades 
1 - experienced cardiologist 
2 - experienced cardiologist 
3 - student 
4 - student + thrill 
5 - student + thrill + hear without stethescope 
6 - very very loud (never get this)
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99
Q

When looking at the JVP, what are you actually looking at?

A

Right atrium

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100
Q

JVP in tricuspid regurgitation?

A

CV wave

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101
Q

If you measure the LH and FSH of a post-menopausal woman, what would you expect to find? and why?

A

LH and FSH should be very high.
The ovaries have decided to pack in, the pituitary doesnt know that and the pituitary gland is therefore trying to drive the ovaries harder.

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102
Q

What is the most common cause of pituitary hormone excess?

A

pituitary adenoma

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103
Q

What is the commonest cause of cortisol excess (cushing’s syndrome) ?

A

Exogenous steroids

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104
Q

Ectopic ACTH from which cancer can give a cushing’s syndrome picture?

A

Small cell lung cancer

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105
Q

From simple blood tests, how can you tell if cortisol excess is due to a pituitary tumour or an adrenal tumour?

A

Pituitary tumour - high cortisol, high ACTH

Adrenal tumour - high cortisol, low ACTH (pituitary is still working, sees a high cortisol and wants to correct it by lowering the ACTH)

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106
Q

How does ACTH arise?

A

Pro-hormone (POMC) is chopped up by enzymes into ACTH and melanocyte stimulating hormone (MSH)

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107
Q

Why does excess ACTH and hyper pigmented skin go hand in hand?

A

ACTH and Melanocyte stimulating hormone (MSH) arise together in the anterior pituitary gland

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108
Q

Any disease that results in ACTH excess will result in a pigmented patient. True or false?

A

True

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109
Q

High ACTH + High Cortisol - where is the problem (2)

A 
Pituitary gland 
Ectopic ACTH (SCLC)
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110
Q

Low ACTH + High Cortisol - where is the problem (1)

A

Adrenal gland

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111
Q

What is the normal function of prolactin?

A

Initiation and maintenance of lactation

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112
Q

What is the most common pituitary tumour?

A

Prolactinoma

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113
Q

If someone has galactorrhoea and amenorrhoea, what is the best investigation?

A

Measure prolactin

- if raised and the patient is not pregnant or breast feeding, request MRI pituitary (thinking prolactinoma)

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114
Q

What is the most effective treatment of a prolactinoma?

A

Dopamine agonist (cabergoline)

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115
Q

What is the gold standard investigation for acromegaly?

A

Glucose tolerance test

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116
Q

Why do we do a glucose tolerance test to look for excess GH (acromegaly) ?

A

GH is an insulin antagonist

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117
Q

What is the function of oxytocin?

A

For lactating woman

  • prolactin makes the milk
  • oxytocin squeezes the milk out of the milk ducts
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118
Q

What is the function of ADH ?

A

Stops the body from losing too much water

Conserves water

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119
Q

Diabetes insipidus - main clinical feature

A

Pee out lots of dilute urine

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120
Q

Diabetes insipidus
urine osmolality - low/normal/high
plasma osmolality - low/normal/high

A

urine osmolality - low

plasma osmolality - high

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121
Q

When you think a patient may have diabetes insipidus, what should you check?

A

If hypokalaemia
If hypercalcaemia
If taking lithium
these can all cause people to pee out lots of dilute urine

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122
Q

What is the best diagnostic test for diabetes insipidus?

A

water deprivation test

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123
Q

Which hormone abnormalities can cause a picture which looks like SIADH?

A

Hypothyroidism

Low cortisol

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124
Q

If elderly patient has fallen and has been lying on the floor for a while, what enzyme will go up?

A

Creatinine Kinase

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125
Q

What does romberg’s test test for?

A

Proprioception

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126
Q

Active vitamin D increases absorption of which two things?

A

Increased calcium absorption

Increased phosphate absorption

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127
Q

increased PTH results in

  • increased/normal/decreased calcium
  • increased/normal/decreased phosphate
A 
Increased calcium
Decreased phosphate (but increased urinary phosphate)
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128
Q

If a patient has ?coeliac disease, what initial investigation should you do and what is the definitive diagnostic investigation

A

Do anti-TTG test. If this is positive then do a duodenal biopsy

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129
Q

What is a very important side effect you MUST counsel patients on when starting bisphosphonate therapy?

A

Osteonecrosis of the jaw

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130
Q

Why should patients get dental work before starting bisphosphonates

A

To reduce the likelihood of developing bisphosphonate-related osteonecrosis of the jaw

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131
Q

What is the only way of differentiating between ischaemic and haemorrhagic stroke?

A

Imaging - usually CT scan

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132
Q

Which type of stroke is most common: ischaemic or haemorrhagic stroke?

A

Ischaemic (around 80%)

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133
Q

What do the vertebral arteries arise from?

A

The first branch of the subclavian artery

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134
Q

What does the external carotid artery supply?

A

Face and scalp

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135
Q

The circle of willis is able to save strokes. True or false?

A

True

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136
Q

How is the PR interval measured? and what is a normal PR interval?

A

From the start of the P wave to the start of the QRS complex

Normal PR interval = 3-5 small squares (0.12-0.2s)

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137
Q

What does a prolonged PR interval suggest?

A

Some form of AV node block (heart block)

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138
Q

How would you identify a Q wave on an ECG?

A

If the first deflection after the P wave is negative, this is a q wave

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139
Q

As soon as you hear ‘irregularly irregular’ think

A

AF

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140
Q

The magic number 150bpm suggests which arrhythmia?

A

Atrial flutter

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141
Q

ECG with retrograde P wave, around 150bpm, narrow QRS complex makes you think of?

A

AVNRT

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142
Q

How do you work out a persons maximum heart rate?

A

220 - age

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143
Q

What are we trying to achieve by doing vagal manouvres?

A

CNX carries parasympathetics to the heart. It sends a supply to the SA and AV node to SLOW CONDUCTION.

therefore, CNX slows the heart rate

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144
Q

Name 2 vagal manouvres

A

carotid sinus massage

valsalva

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145
Q

Vagal manouvres can cure atrial flutter. True or false?

A

False

- they are not curative

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146
Q

Why are vagal manouvres helpful in atrial flutter?

A

They unmask the saw tooth baseline and get rid of the QRS complex

  • diagnostic tool which can be used
  • not curative
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147
Q

What is the mainstay of treatment in AVNRT?

A

Vagal manourves

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148
Q

Why is adenosine given in some arrhythmias?

A

adenosine stops conduction through the AV node

- must be given in very small doses

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149
Q

SE of adenosine?

A

Sense of impending doom

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150
Q

Half way through a bedside teaching session, a student collapses. What is the most likely cause of this?

A

Vasovagal collapse

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151
Q

How do you treat a vasovagal collapse?

A

Leave them lying there for a while

Sit on a chair with feet up

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152
Q

When do benign palpitations tend to happen? At rest or during activity ?

A

At rest

- when you are more hyperaware of own heartbeat

153
Q

When would you do an exercise ECG?

A

For people who have experienced syncope during exercise

154
Q

What does an ECHO investigation look at?

A

Structure of the heart
Looks at heart valve
Looks at function of the heart

155
Q

What is worse: getting vasovagal syncope standing up or sitting down?

A

Sitting down is worse

156
Q

If a patient gets vasovagal syncope whilst sitting down, what should happen in terms of driving?

A

No driving for at least 1 month and must notify the DVLA

157
Q

In haematology, why is vitamin B 12 important?

A

It is required to allow the red cells to develop normally

158
Q

Why is doing a reticulocyte count useful

A

lots of reticulocytes - think spurious anaemia -> think haemolysis

lack of reticulocytes - think bone marrow is not able to produce red cells, marrow struggling to keep up

159
Q

Main cause of iron deficiency anaemia in young people

A

Menorrhagia

160
Q

What is the INR

A

A measure of how long it takes for blood to clot

161
Q

Why do you not tend to give young women warfarin?

A

Terratogenic

162
Q

Which drugs can commonly interfere with warfarin

A

Antibiotics
Aspirin
St Johns wart

163
Q

If patient is on warfarin and is bleeding excessively, how do you reverse the effects of the warfarin?

A

Vitamin K injection

164
Q

For a young patient who is on warfarin but they wwant to have a baby, what is the alternative treatment?

A

Fragmin injections

165
Q

When would you do an exercise ECG?

A

If the patient has exertional symptoms

166
Q

What does the left bundle branch divide into?

A

Fascicles

167
Q

What would you be more worried about - narrow or wide QRS complex?

A

Wide

= worrying, wentricles

168
Q

What is the most common heart rhythm disturbance?

A

Ectopy

169
Q

“my heart skips a beat and this is followed by a hard/forceful beat” - what does this Hx make you automatically think of?

A

Ectopy

170
Q

Features of ventricular ectopy

A

Wide QRS complex
for the ectopic (extra) beat, there is less time of the ventricles to fill as the extra beat comes prematurely…therefore this is the sensation of heart skipping a heat
the next beat will be normal but will seem like a thud because the previous beat was so weak

171
Q

AVNRT - findings on an ECG
QRS - wide or narrow?
Rate?

A

Narrow QRS

Rate: around 150 bpm

172
Q

Which arrhythmia is commonly associated with a retrograde P wave?

A

AVNRT

173
Q

In most patients, what is the treatment of AVNRT?

A

Vagal manouvres

174
Q

CNX carries the sympathetics/parasympathetics to the heart and tells the heart speed to increase/decrease?

A

Parasympathetics

Decrease heart rate

175
Q

Atrial flutter: what is the atrial rate and what is the ventricular rate (commonly)

A

Atrial rate: 300 bpm
Ventricular rate: 150 bpm
(2:1 conduction)

176
Q

Vagal manouvres are the curative treatment for atrial flutter. True or flse?

A

False

- they are not curative

177
Q

In what sense are vagal manouvres useful in atrial flutter?

A

Vagal manouvres are diagnostic of atrial flutter as it will unmask the saw tooth base line

178
Q

Name 2 instances where radiofrequency ablation is used commonly to treat

A

SVT

Atrial flutter

179
Q

Define syncope

A

Transient loss of consciousness caused by a sudden drop in blood pressure

180
Q

Vasovagal syncope - what are the 3 P’s

A

Posture - prolonged period of standing
Prodromal symptoms - vision closing in, nauseous, dizzy, tinnitus
Provoking factor - procedure/pain

181
Q

Describe situational syncope

A

clearly and consistently provoked by a trigger

  • straining during micturation
  • coughing
182
Q

What are the top 3 differentials for sudden chest pain

A

MI (ACS)
PE
Aortic dissection

183
Q

Why would you die having an MI?

And why should the patient with suspected MI come into the hospital via ambulance?

A

Incase the patient goes into Ventricular Fibrillation

184
Q

Describe stable angina

A

STABLE narrowing of the coronary arteries caused by plaque build up
Predictable symptoms

185
Q

Describe NSTEMI

A

UNSTABLE symptoms
the plaques from the stable angina rupture and the artery becomes unstable
Artery is still open but there is severe/critical narrowing

186
Q

Describe STEMI

A

UNSTABLE symptoms

plaques rupture and completely occlude (block) the artery so there is no flow

187
Q

If you have a patient with AF, what are they at increased risk of?

A

Stroke

188
Q

Why should you be very wary of AF with a ventricular rate above 220bpm?

A

May not be conducting through the AV node, may be an accessory pathway. If you use rate control drugs on these patients, it will make the AF worse and the patient will go into VF

189
Q

Which is most common: ischaemic or haemorrhagic stroke?

A

Ischaemic

190
Q

What are the first arteries to come off of the aorta?

A

Coronary arteries

191
Q

Where is a clot most likely to lodge out of the 3 branches of the aorta?

  • brachiocephalic trunk
  • left common carotid
  • left subclavian
A

Left common carotid

192
Q

What do we use to help determine whether a patient should get anticoagulation or not?

A

CHA2DS2VASc score

193
Q

What are the components of the CHA2DS2VASc score?

A 
Congestive heart failure 
Hypertension
Age (1 pt if between 65-74, 2 pt if over 75) 
Diabetes
Stroke/tia 
Vascular disease 
Sexual category (female)
194
Q

CHA2DS2VASc score of X or more means you must anticoagulate the patient?

A

2 or more

195
Q

What is the main side effect to be aware of with amiodarone?

A

Extravasation

- it is deposited in the skin

196
Q

What is the pro-arrhythmic affect of beta blockers

A

Bradycardia

197
Q

In which type of AF should digoxin NOT be used

  • paroxysmal
  • permanent
A

Paroxysmal

198
Q

Why must rate control drugs NOT be used in the treatment of pre-excited AF

A

They act by blocking the AV node, so will make the patient’s heart go faster (through the accessory pathway) and can trigger ventricular fibrillation

199
Q

What is pre-excited AF

A

Accessory pathway AF - not going through the AV node - ventricular rate can get very high

200
Q

Where medications are necessary, what is the first line pharmacological intervention for delerium?

A

Haloperidol

201
Q

Where medications are necessary, what is the first line pharmacological intervention for a patient with parkinsons who has delirium?

A

Lorazepam

202
Q

Name 2 cortical signs of the dominant hemisphere of the brain

A 
Dysphasia 
- receptive
- expressive 
Agnosia 
- failure to recognise objects
203
Q

Name 1 cortical signs of the non-dominant hemisphere of the brain

A

Neglect

204
Q

What is the only way to differentiate between embolic vs thrombotic strokes?

A

Presence or absence of cortical signs

  • presence = embolic, large vessel occlusion
  • absence = thrombotic, small vessel occlusion
205
Q

Lacunar strokes are thrombotic or embolic infarcts?

A

Thrombotic infarcts

- deep in the brain

206
Q

What is the difference between intracerebral and intracranial haemorrhage ?

A

Intracerebral haemorrhage - haemorrhagic stroke, brain damage

intracranial haemorrhage - any type of bleeding within the skull

207
Q

Causes of haemorrhagic strokes

A

Due to blood
- ie being on anti-platelet or anti-coagulant (increases bleeding risk)

Due to vessel walls

  • Hypertension
  • Vasculitis
  • Vessel wall abnormalities (aneurysm, AVM)
208
Q

Overall, waht is the most common causative factor of stroke?

A

Hypertension

209
Q

What layer of the artery does atherosclerosis affect?

A

Inner layer (endothelium)

210
Q

What layer of the artery does arteriosclerosis affect?

A

Middle layer of the artery

- hardening of the arteries, loss of elasticity

211
Q

When would a carotid endartectomy be carried out?

A

If a patient has had a TIA or minor stroke

If there is over 70% stenosis noted on the carotid US scan
If the patient is within 14 days of TIA/minor stroke

212
Q

What are the 3 arms of virchow’s triad

A

Hypercoagulability (too much clotting)
Endothelial injury (damage to the vessel wall)
Haemostasis

213
Q

Venous clots are treated with antiplatelets/anticoagulants?

A

Anti-coagulants

- venous clots are formed by coagulation factors

214
Q

Arterial clots are treated with antiplatelets/anticoagulants?

A

Anti-platelets

- arterial clots are platelet rich

215
Q

AF related strokes cause arterial/venous clots?

A

Venous

216
Q

What are the 3 components of secondary prevention for a stroke?

A

Anti-coagulant / Anti-platelet
Anti-hypertensive
Statin

217
Q

Anti-platelets to be used post ischeamic stroke

  • for first 2 weeks
  • thereafter
A

300mg Aspirin for first 2 weeks

Switch to 75mg clopidogrel

218
Q

It is important to give a combination of aspirin + clopidigrel in the management of stroke. True or false?

A

False

- don’t use them both together as it increases the bleeding risk

219
Q

When would you give aspirin and clopidogrel at the same time?

A

MI

220
Q

What is the target range for INR?

A

2-3

- takes 2-3 times longer to clot

221
Q

Which imaging modality (CT/MRI) is best for visualising acute haemorrhage?

A

CT scan

222
Q

Which imaging modality (CT/MRI) is best for visualising acute infarct?

A

MRI scan

223
Q

Increased ALT / AST LFT makes you think?

A

Pathology is in the liver

- ?hepatitis

224
Q

Increase in which LFT makes you think of excess alcohol useage?

  • ALT
  • AST
  • GGT
  • Alk phos
A

GGT

225
Q

Increased Alk phos LFT makes you think of what clinical picture?

A

Obstruction

- gallstones?

226
Q

What do you give to reverse the effects of opioids and benzodiazepines?

A

Naloxone

227
Q

Cauda equina compression causes flaccid/spastic paralysis with loss of/brisk reflexes.

Spinal cord compression usually causes flaccid/spastic paralysis with loss of/brisk reflexes.

A

Cauda equina compression

  • flaccid paralysis
  • loss of reflexes

Cord compression

  • spastic compression
  • brisk reflexes
228
Q

Which 3 medications are used for prophylaxis of migraine?

  • propranolol
  • diclofenac
  • amitryptiline
  • topiramate
  • rizatriptan
A

Propranolol
Amitryptiline
Topiramate

229
Q

Why should amoxicillin be avoided in the treatment of glandular fever?

A

Cause a rash in glandular fever

230
Q

What is the treatment of choice for scarlet fever?

A

Penicillin V

231
Q

IVOST - when can you consider discharge after you switch to oral therapy for treatment of severe pneumonia

A

After 24 hours

232
Q

If someone is an inpatient for treatment of pneumonia, upon discharge who should get a follow up CXR at 6/52 ?

A

Patients that are at risk of lung cancer

  • smokers
  • over 50 years old
233
Q

Empyema is one of the most common complications of pneumonia. True or false?

A

True

234
Q

Patient with persisting/swinging pyrexia, new chest pain. Patient had previously been treated for pneumonia but despite adequate treatment with antibiotics, symptoms are persisting and the CRP is climbing. What is the likely problem and what investigations should be done?

A

Likely that this is empyema

CXR initially - if fluid present then do US

235
Q

Which imaging investigation is best for clarifying the presence of pleural fluid?

A

US scan

236
Q

How do you diagnose an empyema?

A

Pleural tap

Check the pH. if <7.2 then infection is present

237
Q

What is the treatment (including dosage) for an infective exacerbation of COPD

A 
Ipratropium bromide nebuliser (500mcg QDS) 
Salbutamol nebuliser (2.5mg QDS) 
Oxygen (if required) 
Amoxicillin 
Prednisolone (30mg OD)
238
Q

What are the target O2 sats in patients with COPD?

A

88-92% usually

- CO2 retainers

239
Q

Which pattern of ABG’s would make you think type 2 respiratory failure?

A

Decreased PO2

Increased PCO2

240
Q

What is the treatment of decompensated type 2 respiratory failure secondary to a COPD exacerbation?

A

ISOAP (as for normal exacerbation of COPD)
+ BIPAP
Call for help
Do hourly ABGs

241
Q

Name a situation (other than PE) when D-dimers might be raised?

A

Post surgery

- open wound -> degradation of fibrin

242
Q

What is the treatment of moderate asthma attack

A

Oxygen
Salbutamol nebuliser (5mg QDS)
Steroid (hydrocortisone or prednisolone)

243
Q

Why do surgeons not like to give patient’s steroids?

A

It decreases wound healing

244
Q

What is the treatment of life threatening asthma attack

A 
Oxygen 
Salbutamol nebuliser
Steroid: oral prednisolone or IV hydrocortisone 
Ipratropium bromide nebuliser
Magnesium sulphate 
Theophyline/aminophyline
245
Q

How do you diagnose pneumonia ?

A

Must have CXR showing new changes

246
Q

How do you know if a patient is rotated on a CXR?

A

Look at the spinous processes and the distance of this from the clavicles

247
Q

In radiology, “sail sign” is associated with

A

Left lower lobe collapse - will be found in the region where the heart normally is

248
Q

Trachea is displaced to the right on a CXR suggests that there is overall reduced volume on the right/left hand side?

A

Reduced volume on the right side

249
Q

Which is most common in the elderly:
subdural haemorrhage
extradural haemorrhage

A

Subdural haemorrhage

250
Q

What is a contrecoup (contra-coo) brain injury typically associated with?

A

High speed injury (deceleration injury)

251
Q

Palliative care - when an individual’s pain is not being managed effectively with paracetamol, the WHO analgesic ladder suggests what?

A

Moving to an opioid

252
Q

What is a modified release opioid good for?

A

Controlling background pain over 24 hours

253
Q

What are the signs of opioid toxicity

A

Pin point pupils
Respiratory depression
unconsciousness
cold peripheries, cyanosis

254
Q

How do you convert oral morphine sulphate dose -> subcutaneous morphine sulpate dose?

A

Divide oral dose by 2 to get subcutaneous dose

255
Q

Patient getting 30mg subcutaneous morphine / 24hours through syringe driver. What is the breakthrough dose the patient will get?

A

1/6th of the total dose

therefore, 1/6th of 30 –> 5mg

256
Q

In ABG interpretation, if the BE is low (minus figures) then its more likely to be an acidosis or an alkalosis?

A

An acidosis

257
Q

Comparison of DKA and HHS:

  • age:
  • diabetes type (1 or 2)
A

DKA age: younger
HHS Age: older

DKA diabetes: mainly type 1
HHS diabetes: mainly type 2

258
Q

Mainstay of treatment for DKA

A

Insulin

Fluids

259
Q

What is IV pabrinex

A

High dose vitamins

260
Q

What is the triad of Kartaganers syndrome?

A

Dextrocardia + sinus invertus
Chronic sinusitis
Bronchiectasis

261
Q

2 potential causes of air under the diaphragm

A

perforated bowel

post op

262
Q

What is surgical emphysema

A

air/gas under the skin

- can be caused by pneumothorax

263
Q

What can cause a complete white-out of lung?

A 
Pleural effusion (trachea and mediastinum push away)
Complete lung collapse (trachea and mediastinum pull toward)
264
Q

Acute asthma attack, what treatment should everyone get?

What treatment is only for the deteriorating patient if normal treatment fails?

A 
Everyone should get: 
Oxygen - if required 
Salbutamol (nebs)
Prednisolone Oral (IV hydrocortisone if patient can't swallow)
Ipatropium bromide (neb)

Deteriorating patients should get:
IV magnesium sulphate
IV aminophyline / theophyline (oral)

265
Q

What is the treatment for acute on chronic type 2 respiratory failure?

A

Non invasive ventilation

266
Q

What is the best volume expander - colloid or crystalloid fluids?

A

Colloids

267
Q

Do they struggle with fine finger movements.
Do they drop things.
Do they ever fall over when their eyes are shut.
Do their legs twitch at night.

These four questions are important to consider when thinking about which diagnosis?

A

Cervical Myelopathy

268
Q

Blow to the head -> initial loss of consciousness -> lucid interval -> deterioration
this describes extradural / subdural haematoma?

A

Extradural haematoma

269
Q

Blow to the head -> immediately symptomatic -> continued decreasing consciousness
this describes extradural/subdural haematoma ?

A

Subdural haematoma

270
Q

Which medication may be used in patients with stress incontinence who don’t respond to pelvic floor muscle exercises and decline surgical intervention?

  • oxybutynin
  • duloxetine
  • mirabegron
  • tolterodine
A

Duloxetine

271
Q

A chest x-ray which shows widening of the mediastinum suggests ?

A

Lymphoma

272
Q

Which thyroid cancer is most common in young females

  • follicular carcinoma
  • papillary carcinoma
  • anaplastic carcinoma
  • medullary carcinoma
A

Papillary carcinoma

273
Q

A lady has thyrotoxicosis (low TSH) and a hot solitary nodule. What does this indicate?

A

Toxic adenoma

274
Q

Hypertension + hypokalaemia makes you think

A

Primary hyperaldosteronism

275
Q

What is the first line investigation for suspected primary hyperaldosteronism

A

plasma aldosterone/renin ratio
- should show high aldosterone levels alongside low renin levels (negative feedback due to sodium retention from aldosterone)

276
Q

The combination of frontal headache with tenderness/pain on palpation/brushing over the temporal regions, combined with jaw claudication on eating is highly suggestive of which condition?

A

Giant Cell Arteritis

277
Q

how to best distinguish between giant cell arteritis and trigeminal neuralgia?

A

Trigeminal neuralgia is severe and episodic, giant cell arteritis is constant.

278
Q

First line management of acute pericarditis involves combination which 2 medications

A

NSAID

Colchicine

279
Q

Woman with hypothyroidism is pregnant. What changes should be made to her levothyroxine medication>

A

Increase the dose of levothyroxine

280
Q

what is the preferred antiplatelet for secondary prevention following stroke

A

Clopidogrel

281
Q

What is the key drug to use in anaphylaxis?

A

Adrenaline

282
Q

Wilson’s disease symptom onset is in early life or later life?

A

Early life - the onset of symptoms is usually between 10 - 25 years

283
Q

change in bowel habit, rectal bleeding and abdominal pain but malignancy is excluded. What is therefore most likely and where is this most likely to be found?

A

Diverticular disease

Sigmoid colon

284
Q

Which drug is used in pregnancy induced pregnancy?

  • Doxazosin
  • Methyldopa
  • Amlodipine
  • Ramipril
A

Methyldopa

285
Q

raised transferrin saturation and ferritin, but a low total iron binding capacity…what condition does this suggest?

A

Haemachromatosis

286
Q

combination of vertigo, hearing loss, tinnitus and an absent corneal reflex. What does this suggest?

A

Acoustic neuroma (vestibular schwannoma)

287
Q

Howel jolly bodies in which condition?

A

Hereditory spherocytosis

288
Q

Bones, moans, stones, groans makes you think

A

Hypercalcaemia

289
Q

Patient with increased serum calcium.

Subsequent tests: 
PTH (high) 
Phosphate (low)
Urine calcium excretion (high)
Alk phos (normal)
A

Primary hyperparathyroidism

290
Q

Patient with increased serum calcium.

Subsequent tests: 
PTH (normal) 
Phosphate (high) 
Urine calcium excretion (normal)
Alk phos (high)
A

Bony metastasis

291
Q

What is the management of malignant hypercalcaemia

A 
Lots of fluid intake (4L 0.9% NaCl over 24 hours)
IV bisphosphonates (zolendronic acid) 
Furosemide
292
Q

Thiazide / loop diuretics cause hypercalcaemia?

A

Thiazide diuretics cause hypercalcaemia

293
Q

Main cause of secondary hypoparathyroidism

A

CKD

Vit D deficiency

294
Q

Patient presents with transient visual disturbance in right eye, describes it as a curtain coming down.
What is this condition called?
What internal carotid artery is affected (R or L) ?

A 
Amaurosis Fugax 
Right side (symptoms on ipsilateral side as carotid artery stenosis)
295
Q

Patient has 6 hour Hx right sided arm weakness. ?TIA

What internal carotid artery is affected (R or L)?

A

Left internal carotid artery affected (contralateral to symptoms)

296
Q

First line investigation in carotid artery disease?

A

carotid artery duplex US

297
Q

Which patients with carotid artery disease are considered for surgery and what is the surgery called?

A

Patients with large stenosis in carotid artery

Procedure called: carotid endarectomy

298
Q

Immediate medical management of a patient with carotid artery disease

A

Discuss risk factors
Dual antiplatelet therapy aspirin and clopidogrel
Statin
Manage hypertension

299
Q

When should carotid endarectomy be carried out?

A

WITHIN 2 WEEKS of carotid artery disease event

300
Q

Why is a carotid endarectomy done?

A

To reduce the risk of further stroke/TIA

301
Q

Rusty coloured sputum is common in which type of pneumonia?

A

Strep pneumonia

302
Q

IVDU pneumonia

A

Staph aureus - due to the introduction of bacteria into the bloodstream from dirty needles

303
Q

Which pneumonia affects young people living in close proximity?

A

Mycoplasma pneumonia

304
Q

First line treatment for SVT

what to do if this fails

A

Carotid sinus massage or valsalva manouvre

Adenosine if this fails

305
Q

NICE recommend that all heart failure patients should take which 2 medications since they both reduce mortality in heart failure?

A

Beta blocker

ACE inhibitor

306
Q

The most common organism causing infective exacerbations of COPD is

A

haemophilus influenzae

307
Q

DVLA advice post MI

A

Can’t drive for 4 weeks

308
Q

Patient on warfarin but has major intracerebral bleed. What should be done?

A

Stop warfarin
Administer IV vit K 5mg
Administer IV prothrombin complex concentrate

309
Q

A patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination. Whats the diagnosis

A

Ventriculr septal defect

310
Q

What is the management if patient has fast AF but is haemodynamically unstable

A

DC cardioversion

311
Q

What is the management if patient has fast AF but is haemodynamically stable

A

B-blocker

312
Q

Patients with a suspected pulmonary embolism should be initially managed with

A

DOAC (rivaroxaban)

313
Q 
Patients with COPD exacerbations which are not responsive to optimal medical management should be started on
BiPAP
CPAP
Nebulised adrenaline 
Intubation and manual ventilation
A

BiPAP

314
Q

If blood pressure target is not reached within 3 months, a second antihypertensive drug from a different pharmacological class at a low-moderate dose should be initiated OR increase the dose of the first drug?

A

Add a second drug

315
Q

Which medication is used first line to prevent angina attacks?

A

Beta blocker

CCB

316
Q

Hypertension + hypernatraemia + hypokalaemia

A

Conns syndrome

317
Q

What is the treatment of choice for ventricular tachycardia?

A

emergency DCCV

318
Q

Elevated serum ACTH, supressed by high dose dexamethasone. Where is pathology?

A

Pituitary gland

319
Q

Elevated serum ACTH, not suppressed by high dose dexamethasone. Where is the pathology?

A

Ectopic ACTH

- small cell lung cancer

320
Q

Low serum ACTH where is the pathology?

A

Adrenals

321
Q

What is the commonest cause of viral encephalitis in adults?

A

HSV

322
Q

Cushing’s triad is a set of three clinical signs. What are they?

A

irregular respirations, bradycardia and systolic hypertension resulting from raised intracranial pressure.

323
Q

pituitary tumour secreting ACTH producing adrenal hyperplasia
is this cushings disease or cushings syndrome?

A

Disease

324
Q

In gestational diabetes, if blood glucose targets are not met with diet/metformin, what should be added?

A

Insulin

325
Q

What are some symptoms of hyponatraemia?

A

headache
dehydration
confusion

326
Q

What is paroxetine licensed for?

A

Major depressive episode

327
Q

Woman presents with acute confusion, hypothermia. On examination, she is overweight, there is non-pitting oedema affecting the eyes and legs, and she has dry skin and coarse hair. What is the likely diagnosis?

A

Myxeodema coma

- potentially fatal complication of longstanding undertreated hypothyroidism

328
Q

In the context of an acute illness, a normal TSH and low T3 and T4 levels are diagnostic of

A

sick euthyroid syndrome

329
Q

Conn’s syndrome is associated with hypo/hyper kaleamia?

A

Hypokalaemia

330
Q

Low/high urine osmolality is seen in diabetes insipidus

A

Low

331
Q

What is NOW the first line test for acromegaly?

A

IGF1 levels

- these have now overtaken the OGTT

332
Q

suspected primary hyperaldosteronism - what is first line investigation?

A

aldosterone/renin ratio

333
Q

Secondary hyperparathyroidism

  • PTH (low/normal/high)
  • calcium (low/normal/high)
A

PTH - high

Calcium - normal or low

334
Q

What would a blood gas look like in a cushing’s patient?

A

Metabolic aLKalosis

335
Q

What is an important complication of fluid resuscitation in DKA, especially in young patients

A

cerebral oedema

336
Q

In graves disease, can the goitre be tender?

A

nO

- this would be subacute thyroiditis

337
Q

How to differentiate between cranial and nephrogenic diabetes insipidus?

A

Cranial

  • urine osmolality LOW
  • plasma osmolality HIGH

Nephrogenic

  • urine osmolality LOW
  • plasma osmolality LOW
338
Q

A 57 year old man presents with fluctuating symptoms of intense anxiety, sweating, palpitations and headache. These can last half and hour and happen several times a day. They have been getting worse over the last 2 months. What is likely diagnosis and first line management?

A

Phaeochromocytoma

24 hr urinary cateholamines or serum metanephrines

Tx: alpha blocker -> beta blocker -> surgery

339
Q

You suspect cushings syndrome in a patient and arrange a dexamethasone suppression test. The patient has no suppression of cortisol with 1mg of dexamethasone, and 8mg of dexamethasone is unable to suppress his cortisol but does suppress ACTH levels.

A

adrenal adenoma

340
Q

How to treat SIADH

A 
Fluid restriction
then vaptans (tolvaptan)
341
Q

Sick day rules for addison’s disease

A

double dose of steroids

342
Q

Hypoglycaemia, hyponatraemia, hyperkaemia - makes you think

A

Addison’s disease

343
Q

What is the most appropriate first line medication to start for trigeminal neuralgia

A

Carbemazapine

344
Q

Which diabetic medication causes weight gain and hypoglycaemia?

A

Sulphonylurea

345
Q

What is gliclazide?

A

Sulphonylurea

346
Q

Which medication is used to stimulate ovulation in women conceiving by IVF?

A

Clomifene

347
Q

Which type of thyroid cancer carries the poorest prognosis?

A

Anaplastic carcinoma

348
Q

What is the treatment of phaeochromocytoma

A

Alpha blocker
Beta blocker
Surgery

349
Q

What is the treatment of conn’s syndrome

A

Spironolactone

350
Q

Spironolactone causes hypo/hyper-kalaemia

A

Hyperkalaemia

351
Q

Secondary hyperparathyroidism occurs due to

A

RENAL DISEASE

352
Q

Secondary hyperparathyroidism

  • PTH level
  • calcium level
A

PTH level increased

Calcium level decreased

353
Q

When does tertiary hyperparathyroidism occur

A

After prolonged secondary hyperparathyroidism

354
Q

Patient with spontaneous episodes of hypoglycaemia which are relieved by administering glucose. What is the likely diagnosis?

A

Insulinoma

355
Q

What is the treatment of cranial diabetes insipidus?

A

Desmopressin

356
Q

In acromegaly, there is increased/decreased glucose?

A

Increased

357
Q

In addison’s disease there is increased/decreased glucose?

A

Decreased

358
Q

Adrenalectomy is a cause of addison’s disease. True or false ?

A

True

359
Q

What is first line analgesia (in a hospital setting) for renal colic

A

IM diclofenac

360
Q

If anal fissures don’t respond to conservative measures, what do you do?

A

Sphincterotomy

361
Q

Reduced chest expansion
Dulness to percussion
Increased tactile vocal ressonance

Suggests

A

Consolidation - most common cause being pneumonia

362
Q

Atypical pneumonias should be treated with

A

macrolides (eg clarithromycin)

363
Q

Which type of pneumonia has an association with autoimmune haemolytic anaemia (cold agglutinins)

A

Mycoplasma pneumonia

364
Q

Granulomatosis with polyangitis typically presents with

A

Nasal symptoms

chest pathology

365
Q

Pulmonary oedema is associated with

  • left ventricular failure
  • right ventricular failure
A

Left ventricular failure

366
Q

Patient with COPD, severe exacerbaton. Has been treated with oxygen, nebulised bronchodilators and oral prednisolone. An hour later his ABG reveals T2 resp failure. What is the best treatment?

A

Non-invasive positive pressure ventilation (BiPap)

367
Q

Frank haematuria lasts for 3-4 days after recent URTI. What is likely diagnosis

  • Goodpastures syndrome
  • Alports syndrome
  • IgA nephropathy
A

IgA nephropathy

368
Q

18 year old patient, has reflux symptoms, tried antacids but they’re not working. Otherwise well and no other findings. What is next best step?

  • refer for endoscopy
  • PPI
  • test for helicobacter pylori
  • prescribe mucosal protective agent
A

Prescribe PPI

369
Q

25, female, fatigue. 3 months ago she developed a sore throat with cervical lymphadenopathy. What investigation will be most diagnostic?

  • HIV serology
  • EBV serology
  • throat swab
  • endoscopy
A

EBV serology

370
Q

Man with pulse 72bpm, BP 210/110. Radiofemoral delay, notching on CXR. What does this suggest?

A

Coarctation of the aorta

371
Q

Man 2/52 Hx coughing up blood, fatiuge, joint pains (ankles and wrists swollen and tender) . Mid zone crepitations in chest, purpuric rash on lower legs. Urinalysis: Protein 3+, blood 2+.
Which antibodies are likely to be found in high titres?
- anti-endomesial antibodies
- ANCA
- ANA
- AMA
- anti glomerular basement membrane antibodies

A

ANCA

- this is GPA

372
Q

Patient with breathlessness 3 days after STEMI. Pan systolic murmur with radiation to the axilla. Bibasal inspiratory creps. What is the likely diagnosis?

  • ventricular septal rupture
  • papillary muscle rupture
  • chordae tendinae rupture
  • pericarditis
  • PE
A

Papillary muscle rupture

373
Q

Man had a stroke. Unable to understand how to put on his shirt, often attempting to put it on backwards and doesn’t know how to work the buttons. Which brain lobe was the stroke in?

  • cerebellum
  • frontal lobe
  • parietal lobe
  • temporal lobe
A

Parietal lobe

- dressing apraxia is a feature of parietal lobe lesion

374
Q

COPD patient with evidence of hypercapnia and respirateoy acidosis with hypoxia despite controlled oxygen therapy. What is next line management?

A

NIV (BiPAP)

375
Q

Male, visible haematuria, R loin pain. Masses are palpable in both flanks. What is likely diagnosis? what is initial imaging investigation?

A

PKD

US renal tract

376
Q 
middle aged woman, fatigue, itch. 
AST 60 (10-50) 
ALP 920 ( 25-115)
What is likely diagnosis? 
Which autoantibodies will be raised?
A

PBC

Raised AMA

377
Q

A 48-year-old man who chronically abuses alcohol has presented with abdominal pain. He has not eaten for the week prior to admission to hospital.

While in hospital he resumes eating normal meals. He initially complains of dysphagia and weakness. Following this he becomes increasingly confused.

What does this suggest?
What abnormalities on bloods?

A

Refeeding syndrome

Hypophosphataemia
Hypomagnesiuma
Hypokalaemia

378
Q

Post thyroidectomy you may have which abnormal finding?

A

Hypocalcaemia

379
Q

This young woman has a normal thyroxine (T4) yet elevated thyroid-stimulating hormone (TSH) and has been taking medication for approximately one year. The most likely explanation for this result is….

A

Non compliance with treatment

Y4 (23 decks)

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