GP

Question 1

what is the pathophys of acne vulgaris 3

Answer 1

formation of acne lesions due to three contributing factors:
1. follicular hyperkeratinization: formation of keratinous plug due to an abnormal keratinization process= skin cells do not shed as normal leading to the proliferation of P. acnes
2. increased sebum production: sebum acts as a nutrient for P.acne and forms a favourable anaerobic environment
3. Propionibacterium acnes colonization: this bacteria contributes to inflammation by releasing pro inflammatory mediators eg chemokines, cytokines and reactive oxygen species

Question 2

Where does acne act? 1

Answer 2

on pilosebaceous unit

Question 3

What are the different types of acne lesions seen in acne vulgaris pts 4

Answer 3

comedones= dilated sebaceous follicle (whitehead is closed and blackhead is open)
inflammatory lesions= papules and pustules
due to excessive inflammatory response= nodules and cysts
scars: ice-pick scars and hypertrophic scars

Question 4

How is acne vulgaris classified 3

Answer 4

mild: open and closed comedones with or without sparse inflammatory lesions
moderate acne: mild + numerous papules and pustules
severe acne: extensive inflammatory lesions, which may include and scarring

Question 5

How is acne vulgaris treated?

Answer 5

Mild/ moderate:
12 week topical combination therapy: any 2 of the following in combination:
Topical benzoyl peroxide.
Topical antibiotics (clindamycin)
Topical retinoids (tretinoin/adapalene)

Mod/ severe:
12 week course of one of the following:
-> a fixed combination of topical adapalene with topical benzoyl peroxide + either oral lymecycline or oral doxycycline
-> a topical azelaic acid + either oral lymecycline or oral doxycycline

Question 6

When can patients be referred with acne? 6

Answer 6

1. Acne fulminans.
2. Mild-moderate acne not responding to two 12 week courses of treatment as above.
3. Moderate-severe acne not responding to one 12 week course of treatment as above, including an oral antibiotic.
4. Psychological distress/mental health disorder contributed to by acne.
5. Acne with persistent pigmentary changes.
6. Acne with scarring.

Question 7

What is a specific complication of long term abx use in acne, causes and what treatment can be given?

Answer 7

Gram-negative folliculitis (caused by e.coli/ kleb/ proteus/ pseudomonas)
high dose oral trimethoprim

Question 8

What is acute bronchitis and timeline

Answer 8

inflammation of bronchi which is mainly virally caused (common cold eg rhino/ coronavirus)
resolves in 3 week but can have persistant cough

Question 9

Presentation of acute bronchitis 3

Answer 9

1. cough
2. wheeze
3. sore throat

inflammation in bronchi= increased mucus production= cough to clear it

Question 10

How can acute bronchitis be differentiated from pneumonia 2

Answer 10

no focal chest signs apart from wheeze in acute bronchitis
systemic features are more indicative of pneumonia

Question 11

What is the management of acute bronchitis 2

Answer 11

1. supportive (fluids and analgesia at home)
2. only consider abx (doxycyline) if systemic unwell, co-morbidities or CRP of over 100
   -> cannot use doxycycline in children/ pregnant so use amoxicillin instead

Question 12

What is acute stress reaction and features 4

Answer 12

occurs in first 4 weeks after a traumatic event
features: sleep disturbance, hypervigilance, flashbacks, dissociation

(imagine a person sleeping then suddenly waking with hypervigilance, looking around the rooms- they dissociate whilst looking at the drawers in the room and get flashbacks looking at the floor)

Question 13

What is the mangement for acute stress reaction 3

Answer 13

1st line: CBT
2. benzodiazipines: ONLY for acute anxiety, not recommended by WHO
3. encourage sleep hygeine and relaxation techniques

Question 14

What is an anal fissure, 3 causes and classification

Answer 14

a tear in the mucosal lining of the distal anal canal
main cause= trauma from defecation of hard stool (constipation and dehydration), alternatively IBD or rectal cancer
acute= present for less than 6 weeks
chronic= present for over 6 weeks

Question 15

What are the features of anal fissures 3

Answer 15

1. intense pain post defecation, which is out of proportion to the size of the fissure
2. bright red rectal bleeds
3. itching typically post defecation

Question 16

How are anal fissures investigated and diagnosed

Answer 16

In the likely event of a DRE being declined due to pain, an EUA and proctoscopy can be done to identify the fissure

EUA= examination under anaesthesia

Question 17

how to differentiate between anal fissures and haemorrhoids 2

Answer 17

fissures are more more painful during bowel movements and bleed more than haemorrhoids

Question 18

What is the management of acute and chronic anal fissures (5,3)

Answer 18

acute:
1. high fibre diet and high fluid intake
2. bulk forming laxatives (isphagula husk)
3. lubricants eg petroleum jelly before defecation
4. using simple analgesia eg paracetomol
5. topical anaesthetic eg lidocaine gel/ ointment

chronic:
1. topical GTN
2. diltiazem cream (CCB), second line to GTN
3. botox injections into internal anal sphincter (to encourage relaxation and healing
3. referral for lateral sphincterotomy (division of the internal anal sphincter muscle to release tension in anal sphincter muscle)

GTN + CCB relaxes internal anal sphincter= reduced anal pressure= increases blood circulation= allows for for healing and reduced pain

Question 19

What is the pathophys of bacterial vaginosis, is it an STI?

Answer 19

overgrowth of anaerobic organisms eg gardnerella vaginalis (normally found in the flora), leading to the increase of vaginal pH
not an STI, but seen mostly in sexually active women

Question 20

What is the diagnosis criteria of bacterial vaginosis and what is this criteria called

Answer 20

Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present
-> thin, white homogenous discharge
-> clue cells on microscopy: stippled vaginal epithelial cells (from high vaginal swab)
-> vaginal pH > 4.5 (swab on pH paper)
-> positive whiff test (addition of potassium hydroxide results in fishy odour)

Question 21

What is the management for bacterial vaginosis 2

Answer 21

1. asymptomatic= no tx required
2. symptomatic= oral metronidazole for 5-7 days

Question 22

What are the main risk factors of benign prostatic hyperplasia 2

Answer 22

1. age: around 80% of 80-year-old men have evidence of BPH
2. ethnicity: black > white > Asian

Question 23

What is the presentation of BPH 8

Answer 23

LUTS symptoms:
issues with both storage and voiding (voiding is more common)
storage: frequency, urgency, nocturne, incontinence
voiding: poor stream, hesitancy, incomplete emptying, dribbling

Question 24

What are the Ix for BPH 5

Answer 24

1. DRE (rectal exam)- smooth enlarged- prostatic cancer is hard and irregular
2. PSA (for ruling out prostate cancer but can be raised in both)
3. urine dipstick
4. international prostate symptom score (IPSS) to assess impact of LUTSon QOL-
   Score 20-35: severely symptomatic
   Score 8-19: moderately symptomatic
   Score 0-7: mildly symptomatic
5. transrectal ultrasound to determine size (can determine tx options)

Question 25

What is the management for BPH 5

Answer 25

1. lifestyle changes and watchful waiting: decrease caffeine intake 2. 1st line- alpha 1 antagonist eg tamsulosin which relaxes bladder neck 3. 2nd line- 5 alpha reductase inhibitor eg finasteride which decreases testosterones production and therefore decreases prostate size 4. combination therapy of 2 & 3 5. surgery (last resort): transurethral resection of prostate (main complication= retrograde ejaculation)

Question 26

What is vaginal candidiasis, cause 2 and risk factors 4

Answer 26

'vaginal thrush' mostly candida albicans and rest by other candida species long term abx/ steroids, diabetes mellitus, immunocompromised

Question 27

What is the normal vaginal flora compromised of and how does this maintain a healthy environment. What happens when this is lacking?

Answer 27

lactobacillus- releases lactic acid to maintain low ph= prevents growth of bacteria

Question 28

What is the presentation of vaginal candidiasis 2

Answer 28

cottage cheese but non-offensive discharge vulvitis- itching and vulval erythema

Question 29

What are the investigations for vaginal candidiasis

Answer 29

swab not indicated if consistent clinical features with candidiasis | otherwise black charcoal swab

Question 30

What is the management of recurrent vaginal candidiasis 4 and what is classed as recurrent

Answer 30

classified as 4+ episodes a year 1. check compliance with treatment 2. confirm candidiasis with high vaginal swab for microscopy and culture 3. glucose test to exclude diabetes 4. induction-maintenance regime -> induction: oral fluconazole every 3 days for 3 doses -> maintenance: oral fluconazole weekly for 6 months

Question 31

What is the management vaginal candidiasis 3

Answer 31

1. first line: oral fluconazole 150 mg as a single dose 2. if allergy/ pregnant: clotrimazole 500 mg intravaginal pessary 3. if vulval sx then add topical imidazole in combination with oral/ intravaginal antifungal

Question 32

What is the cause of Chlamydia and why is it relevant in the UK

Answer 32

Chlamydia trachomatis the most prevalent sexually transmitted infection in the UK

Question 33

What is the presentation of chlamydia 3

Answer 33

1. asymptomatic in around 70% of women and 50% of men 2. women: cervicitis (discharge, bleeding), dysuria 3. men: urethral discharge, dysuria

Question 34

How is chlamydia diagnosed 4

Answer 34

test done 2 weeks after exposure women: low vaginal swab is first-line men: the urine test is first-line (first morning void urine sample) both of these samples are tested via NAATs

Question 35

What is the screening for chlamydia

Answer 35

National Chlamydia Screening Programme for 15-24 years, open to all sexually active pts

Question 36

What is the Mx for chlamydia 3

Answer 36

1. 7 days doxycycline 100mg BD 2. if CI or pregnant, then azithromycin 3. all contacts (men in 4 weeks before sx and women in 6 months before) can be offered support/ referral with GUM- if pt has confirmed chlamydia case then treat their contacts with doxycycline before testing them

Question 37

What are the complications of chlamydia? 4

Answer 37

infertility (both) PID (f) epididymo-orchitis (m) reactive arthritis (both)

Question 38

What is chronic fatigue syndrome

Answer 38

3 months of disabling fatigue affecting mental and physical function more than 50% of the time with no other diseases causing this

Question 39

What are the features of chronic fatigue syndrome 5

Answer 39

1. fatigue (main one) 2. sleep problems 3. muscle/ joint pains 4. headaches 5. cognitive dysfunction (inability to concentrate, difficulty with thinking and word-finding) | (Feeling Sleepy, Might Just Head (c)Out)

Question 40

What is the ix for chronic fatigue syndrome and diagnostic criteria?

Answer 40

1. bloods to exclude pathology: FBC, U&E, LFT, TFT, CRP, ESR, ferratin, coeliac, calcium, CK, glucose 2. nice criteria to diagnose- fatigue not caused by any other condition, post-exertional malaise that is disproportionate to activity and with a prolonged recovery time, sleep disturbance, cognitive dysfunction for more than 3 months

Question 41

What is the Mx for chronic fatigue syndrome 4

Answer 41

1. refer to specialist chronic fatigue syndrome service 2. energy management to stay within energy limit (strategy supported by CFS specialist) 3. cognitive behavioral therapy 4. do not encourage exercise unless part of programme with CFC specialist team

Question 42

What are the two types of conjunctivitis

Answer 42

allergic infective (split into bacterial and viral)

Question 43

What are the features 2 and mx of allergic conjunctivitis 2

Answer 43

features: ->bilateral conjunctival erythema and swelling -> itching Mx: first line: topical/ oral antihistamines eg cetirizine 2nd line: topical mast cell stabilisers eg sodium cromoglicate

Question 44

Compare the sx of bacterial and viral conjunctivitis

Answer 44

bacterial: purulent discharge, eyes stuck together in morning viral: serous discharge, recent URTI

Question 45

How is infective conjunctivitis managed 2

Answer 45

1. topical abc chloramphenicol eye drops, 2/3 hourly 2. topical fusidic acid eye drops or pregnant women BD

Question 46

What classifies as constipation

Answer 46

unsatisfactory defecation due to : infrequent stools (<3 times weekly) difficult stool passage (with straining or discomfort) seemingly incomplete defecation

Question 47

What is the management of constipation 5

Answer 47

1 month of increased fibre, fluids and exercise 2 months of bulk forming laxative eg isphagula husk 2 months of osmotic laxartive eg lactulose/ macrogol 2 months of stimulant laxative eg senna/ sodium picosulfate if still constipated, stop all laxatives and take prucalopride 1mg

Question 48

What is contact dermatitis types, which is more common, locations of each

Answer 48

irritant contact dermatitis: inflammation of skin due to direct contact with irritants (more common) -> on hands/ where contact was with irritant allergic contact dermatitis: inflammation of skin due to a type 4 hypersensitivity reaction (less common) -> expands to area past contact with trigger

Question 49

what r the best readings to quantify CKD 2

Answer 49

eGFR and albumin: creatinine ratio

Question 50

what is CKD

Answer 50

eGFR of <60mL/min/1.73m2 for 3 or more months

Question 51

what are the stages of CKD 5 and their values

Answer 51

stage 1: >90mL/min eGFR stage 2: 60-89 mL/min eGFR stage 3A: 45-59mL/min eGFR stage 3B: 30-44mL/min eGFR stage 4: 15-29mL/min eGFR stage 5: less than 15mL/min eGFR (end stage CKD)

Question 52

what is the pathophys of CKD 4 and explain why proteins and blood can get into urine

Answer 52

low GFR= lots to damaged nephrons this increases burden on remaining nephrons this also increases RAAS activation to increase GFR but this increases pressure this causes loss of basement membranes selective permeability= blood and protein in urine

Question 53

what are the 2 most common risk factors for CKD

Answer 53

diabetes mellitus hypertension

Question 54

why is CKD initially asymptomatic 1 and why does CKD become symptomatic 1

Answer 54

asymptomatic- lots of nephrons as a reserve symptomatic- due to substance accumulation

Question 55

What are the Ix for CKD 3

Answer 55

1. FBC (CKD= kidnyes produce less EPO= less RBC made= anaemia) and U&Es 2. Urinalysis - haematuria, proteinuria, glycosuria, albumin: creatine ratio 3. Renal ultrasound: shows bilateral small atrophied kidneys

Question 56

treatment for CKD 4 (what is the aim of treatment, example, when to refer and last resort treatment)

Answer 56

Irreversible so treat to prevent progression of disease and symptom control: eg Oedema - fluid and sodium restriction furosemide Referral to nephrology if eGFR < 30 (stage 4) or A:CR>70 last resort- renal replacement therapy

Question 57

what is gout’s pathophysiology 3

Answer 57

1. uric acid build up 2. leads to monosodium urate monohydrate crystal deposition along joints 3. =joints symtoms in gout

Question 58

risk factors for gout 2

Answer 58

1. purine rich food: high meat, seafood, alcohol diet 2. middle aged overweight man

Question 59

What are the medicines that increase risk of gout

Answer 59

1. low dose aspirin eg 75mg 2. thiazide like diuretics

Question 60

presentation of gout 2 and what joint is usually affected 1

Answer 60

1. sudden onset 2. painful swollen red joint 3. usually big toe (metatarsophalangeal joint)

Question 61

investigations for gout 2 and result

Answer 61

1. joint aspiration and polorised light microscopy showed needle shaped negatively birefringent crystals 2. bloods: high uric acid

Question 62

treatment for acute gout 3

Answer 62

1st line NSAIDs eg diclonefac PLUS PPI 2nd line colchicine (alternative to NSAIDs for patients on anticoagulants) 3rd line IM corticosteroid injection

Question 63

prophylactic treatment for gout 2

Answer 63

1. allopurinol 2. lifestyle changes: decrease meat, seafood and alcohol

Question 64

how does allopurinol prevent gout 2

Answer 64

it is a xanthine oxidase inhibitor which reduces uric acid production

Question 65

what is the crystal composition for gout and pseudogout?

Answer 65

gout= monosodium urate monohydrate crystals pseudogout= calcium pyrophosphate crystals

Question 66

What is pseudogout

Answer 66

calcium pyrophosphate crystals deposits along joint capsule

Question 67

risk factors for pseudogout 3

Answer 67

1. hypercalcaemia 2. hyperparathyroidism 3. hyperthyroidism

Question 68

investigations for pseudogout 3

Answer 68

1. joint aspiration and polarised light microscopy shows positively birefringent, rhomboid shaped crystals 2. bloods show high calcium 3. joint x-ray to differentiate from rheumatoid/ osteoathritis

Question 69

presentation of pseudogout 2

Answer 69

1. swollen red hot joint 2. multiple widespread joints affected (MC is the knee)

Question 70

treatment for pseudogout 2

Answer 70

1. same acute management as gout- NSAIDs, colchicine and corticosteroids 2. joint aspiration in severe cases

Question 71

What is the prophylactic treatment for pseudogout 1

Answer 71

daily low dose colchicine if no SE

Question 72

what type of disease is type 1 diabetes mellitus, what does it cause destruction of and what is the consequence of this (3)

Answer 72

autoimmune disease causes destruction of beta cells in pancreas causes absolute insulin deficiency

Question 73

what type of reaction is T1DM

Answer 73

type 4 hypersensitivity

Question 74

what are the causes of T1DM 2

Answer 74

combination of genetics and environmental triggers

Question 75

what are the consequences of the body not making insulin in T1DM (4 steps), start with body being unable to produce insulin to digest carbohydrates

Answer 75

2. cells cannot take in glucose so the body thinks it is being fasted 3. gluconeogenesis occurs in liver 4. causing more hyperglycaemia

Question 76

when does T1DM usually manifest and what does it present in the form of

Answer 76

in childhood diabetes ketoacidosis

Question 77

what are 5 symptoms of T1DM

Answer 77

polyuria, polydipsia, lethargy, thursh, sudden weight loss (thirst, toilet, tired, thrush, weight loss)

Question 78

explain polyuria in diabetes 1 reason only explain polydipsia in diabetes

Answer 78

glucose excretion in urine draws water with it because glucose is osmotically active extreme thirst due to fluid loss via urine

Question 79

explain sudden weight loss in T1DM

Answer 79

due to breakdown of adipose and muscle tissue as an alternative energy source to glucose

Question 80

Explain recurrent thrush in diabetics

Answer 80

due to high sugar levels which is an optimal environment for candida

Question 81

what is the max reabsorption value for glucose in the kidneys

Answer 81

10mmol/L

Question 82

what is required for a diagnosis of T1DM 2

Answer 82

one abnormal glucose value and symptoms or two abnormal glucose values in asymptomatic

Question 83

what is fasting glucose value determines diabetes mellitus and units

Answer 83

> =7mmol/L

Question 84

what is fasting glucose value determines pre diabetes and units

Answer 84

> 6mmol/L

Question 85

what HbA1c value determines diabetes mellitus and units

Answer 85

> =48mmol/mol

Question 86

what HbA1c value determines pre diabetes and units

Answer 86

> 41mmol/mol

Question 87

what is the gold standard investigation test for diabetes mellitus

Answer 87

HbA1c test

Question 88

what random glucose value/ glucose tolerance test value determines diabetes mellitus and units

Answer 88

> =11.1mmol/L

Question 89

what is the GS treatment for T1DM (2)

Answer 89

combination of long lasting 12-24 hour basal insulin dose and a short acting bolus injected 30 mins before meals

Question 90

what is vital for treating T1DM patients 2

Answer 90

patient education- to monitor dietary glucose intake TREATMENT IS LIFELONG

Question 91

what can diabetic ketoacidosis be classed as

Answer 91

a life threatening medical emergency

Question 92

explain the pathophysiology of DKA starting with insulin deficiency

Answer 92

glucose not able to be absorbed alternative sources of energy is to break down free fatty acids from adipose tissue this is oxidised to acetyl coA to produce ketones ketones are acidic and cause blood acidosis

Question 93

what is the compensation for DKA and what is this due to/ countering

Answer 93

respiratory compensation due to metabolic acidosis

Question 94

symptoms of DKA (3) signs of DKA (2)

Answer 94

nausea, vomiting, dehydration, acetone-smelling breath, Kaussmal’s breathing

Question 95

what 3 things are required for a DKA diagnosis (not specific values)

Answer 95

1. symptoms 2. hyperglycaemia 3. blood gas sample showing metabolic acidosis with respiratory compensation

Question 96

what value dictates acidosis in the blood

Answer 96

pH <7.3

Question 97

what test can be done to identify ketone levels and what value is DKA

Answer 97

blood ketone test >3mmol/L

Question 98

what is treatment for DKA (4 steps)

Answer 98

1. ABC 2. 0.9% NaCl infusion 3. give insulin and glucose simultaneously 4. correct hypokalaemia if this occurs

Question 99

what are the three complications of DKA treatment

Answer 99

1. cerebral oedema 2. hypokalaemia (insulin treatment for DKA causes intracellular shift of K+ which can cause muscle weakness) 3. hypoglycaemia (insulin treatment can cause glucose levels to drop rapidly into hypoglycaemia)

Question 100

Name 4 non modifiable and 4 modifiable risk factors for T2DM

Answer 100

Non: age, family history, male, ethnicity modifiable: obesity, hypertension, sedentary lifestyle, high carb diet

Question 101

what is T2DM’s insulin deficiency and how does T2 cause hyperglycaemia

Answer 101

relative insulin deficiency insulin resistance in liver and muscle cells causes hyperglycaemia

Question 102

what are the diagnosis and investigations for T2DM

Answer 102

exactly the same as T1DM

Question 103

explain the pathophysiology of T2DM starting with hyperglycaemia, including the role of the pancreas

Answer 103

hyperglycaemia causes increased insulin resistance in cells pancreas compensates by producing large volumes of insulin but is damaged by overworking and toxic glucose levels

Question 104

what are the 4 lines of treatment for T2DM (1,1,4,1)

Answer 104

1st: lifestyle modifications eg lose weight 2nd: metformin 3rd: add sulfonylurea, PIOGLITAZONE, DPP-4 inhibitor or SGLT-2 inhibitor 4th: insulin

Question 105

What is the second line medication for T2DM after metformin

Answer 105

ifno co-morbidiites= solfonylurea-gliciazide if CV co-morbidiity= SGLT2- dapagloflozin as it is cardioprotective

Question 106

how does the SGLT2 inhibitor work? and name examples

Answer 106

inhibits reabsorption of glucose in the proximal tubule via the sodium-glucose transporter, resulting in more glucose to be excreted eg empagliflozen/ dapagliflozen

Question 107

how does the DPP4 inhibitor work? and name an example

Answer 107

DPP4 inhibitor blocks DPP4 enzyme which prevents inhibition of GLP1. Overall effect= increased insulin production in response to a meal being sensed by the body (eg chewing) eg sitagliptin

Question 108

how do sulfonylureas work and give an example

Answer 108

sulfonylurea binds to bind to K+ channels on beta pancreatic cells, reducing K+ efflux which causes depolarisation of the cell. There is a Ca2+ influx due to the action potential which stimulates insulin release from vesicles in the cell eg Gliciazide

Question 109

how does metformin work

Answer 109

inhibits the AMPK enzyme in the liver which inhibits gluconeogensis, decreases intestinal glucose absorption and increases insulin sensitivity

Question 110

what are the 3 microvascular complications of DM

Answer 110

retinopathy peripheral neuropathy nephropathy

Question 111

what are the 4 macrovascular complications of DM

Answer 111

stroke hypertension peripheral artery disease coronary artery disease

Question 112

explain retinopathy associated with diabetes and what can this lead to

Answer 112

high blood pressure and glucose levels damages retina= blindness/ cotton wool spots

Question 113

explain peripheral neuropathy associated with diabetes and what can this lead to

Answer 113

high glucose levels damage blood vessels supplying nerves= pain/ numbness can lead to HTN as more likely to get atherosclerosis which can narrow blood vessels and cause hypertension

Question 114

explain coronary artery disease associated with diabetic hypertension

Answer 114

hypertension caused by diabetes causes increased force exerted on artery walls which can damage them= atherosclerosis and embolism

Question 115

what can hyperosmolar hyperglycaemic state be classed as and who typically presents with hyperosmolar hyperglycaemic state 2

Answer 115

a life threatening medical emergency elderly with T2DM

Question 116

explain the pathophysiology of hyperosmolar hyperglycaemic state starting with hyperglycaemia and ending with what this does to the blood

Answer 116

hyperglycaemia causes osmotic diuresis and the volume depletion in the body increases the serum osmolarity causing hyperviscosity of blood

Question 117

how can you diagnose hyperosmolar hyperglycaemic state (3)

Answer 117

1. severe hyperglycaemia (>30mmol/L) 2. hyperosmolarity (>320mosmol/kg) 3. no acidosis or ketosis

Question 118

what is the presentation of hyperosmolar hyperglycaemic state (6) 2 signs and 3 symptoms

Answer 118

nausea, vomiting, dehydration, HYPOTENSION, TACHYCARDIA

Question 119

what is osmotic diuresis and how does it cause electrolyte imbalances

Answer 119

increased urination in response to hyperglycaemia: excreted glucose in urine takes water with it so sodium and potassium follow the water and are excreted in the urine

Question 120

what are the 3 haematological complications of hyperviscosity of blood and what condition does this occur in

Answer 120

MI, stroke, peripheral arterial thrombosis hyperosmolar hyperglycaemic state

Question 121

what is the treatment for hyperosmolar hyperglycaemic state (4)

Answer 121

1. fluid replacement with saline 2. venous thromboembolism prophylaxis eg LWMH like enoxaparin 3. give insulin if glucose levels do not decrease 4. give K+ if K+ levels aren’t naturally corrected SLIK

Question 122

what are the two complications related to treatment of hyperosmolar hyperglycaemic state

Answer 122

1. insulin related hypoglycaemia (due to excessive high-dose insulin therapy) 2. treatment related hypokalaemia (due to high-dose insulin therapy)

Question 123

what is fibromyalgia and two risk factors

Answer 123

chronic widespread MSK pain for 3+ months 1. females 2. stress

Question 124

presentation of fibromyalgia 3

Answer 124

widespread pain fatigue sleep difficulties

Question 125

investigations of fibromyalgia 2 and how is it diagnosed

Answer 125

pain or tenderness in 11 or more out of 18 sites palpated bloods for exclusion: FBC, UE, LFT, TSH, CRP, calcium, glucose, B12 folate, urine dip (all normal in fibromyalgia) Diagnosis criteria: 1. more than 3 months 2. generalised pain 3. fibromyalgia pain of 12+/31 (consists of widespread pain index and symptom severity score)

Question 126

treatment for fibromyalgia 2

Answer 126

1. encourage exercise, CBT 2. tricyclic antidepressants for severe pain

Question 127

what is GORD and what does it stand for what causes the reflux

Answer 127

LOS relaxation causes reflux of gastric contents into the oesophagus Gastro-Oesophageal Reflux Disease

Question 128

risk factors for GORD 3 and which sex is more likely to get this by how much and why

Answer 128

1. increased abdo pressure eg obesity & pregnancy 2. Sliding Hiatus hernia (LOS slides up into chest) 3. LOS relaxants: Caffeine Alcohol Males x2 risk than females (eostrogen is protective)

Question 129

signs and symptoms 2 of GORD including 3 red flags and 3 extra-oesophageal signs GORD

Answer 129

1. Heartburn (main symptom) which is exacerbated when lying down as reflux more easily occurs 2. Dyspepsia (indigestion) 3. Extra-oseophageal signs: cough, asthma, dental erosion (due to acid eroding teeth) 4. Red flags: dysphagia, weight loss, haematemesis

Question 130

investigations for GORD 2

Answer 130

1. GS and diagnostic: 24 hour pH monitoring (abnormal if pH <4 more than 4% of the time) 2. Endoscopy to look for Barrett’s, especially in those with chronic heartburn symptoms

Question 131

treatment for GORD 2

Answer 131

1st line: PPI Lifestyle changes: smaller meals, avoid food from 3 hours before bed

Question 132

1 complication for GORD and show the disease pathway

Answer 132

Gastric adenocarcinoma GORD-> barretts-> oesophageal adenocarcinoma

Question 133

what is barretts oesophagus and where does this occur, Ix 1 and Mx 2

Answer 133

Metaplasia from stratified squamous to simple columnar epithelium (has to occur within 1cm of the gastro-oesophageal junction) Ix: Endoscopy with biopsy which should show metaplasia within 1cm of the GOJ Tx: PPI + regular endoscopic surveillance

Question 134

what is diverticular disease and where do they usually form

Answer 134

multiple outpouches of the colon wall with symptom sigmoid colon

Question 135

explain the pathophysiology of diverticulitis 2 steps

Answer 135

1. high pressure in colon/ weak wall= diverticula formed 2. inflammation if bacteria/ faecal matter gathers in diverticula (diverticular disease with infection)

Question 136

signs and symptoms of diverticular disease 3

Answer 136

divertiCuLaR constipation, lower left quadrant pain, rectal bleeding (haematochezia)

Question 137

investigation for diverticular disease (GS)

Answer 137

CT abdomen and pelvis with contract GS

Question 138

treatment for diverticular disease (2, GS)

Answer 138

bulk forming laxative eg isphagula husk and antibiotics (if signs of infection) GS= surgery

Question 139

what value is defined to be hypertension and define malignant HTN and value

Answer 139

140/90+ very high blood pressure that develops quickly and causes organ damage 180/110+

Question 140

what are the categories of hypertension and how many cases are in each category and describe the difference between the two

Answer 140

primary 90% secondary 10% primary has no known cause and secondary has known causes

Question 141

what are the causes of secondary hypertension (6) 3 Cs, 2Ps, 1R

Answer 141

renal disease (MC) pregnancy phaechromocytoma cushings conns coarctation of the aorta (congenital narrowing of the aorta)

Question 142

what are the 4 main areas that malignant hypertension has symptoms in and how can this be assessed

Answer 142

brain (cerebral oedema, stroke), eye (papilloedema/ cotton wool spots), heart (HF, MI) and kidneys (AKI) fundoscopy= for papilloedema urinalysis= for renal function Echo/ECG= assesses left ventricular hypertrophy

Question 143

if the bp is measured at GP and is 140/90 then what is the next step

Answer 143

check ambulatory blood pressure at home

Question 144

how is hypertension staged and what are the actions for each stage (3)

Answer 144

stage 1: 135/85 (assess risks- including assessing organ damage) stage 2: 150/95 (lifestyle changes + medications) stage 3: 180/110 (malignant- same day admission and start antihypertensive medication ASAP)

Question 145

what is the treatment approach for stage 1 hypertension 1

Answer 145

BP monitored every 5 years

Question 146

what two things are offered to a person who has been diagnosed with hypertension

Answer 146

assessment of Cv risk investigation for secondary hypertension

Question 147

what is the treatment for under 55s and not of African/ Caribbean origin (2)

Answer 147

ace inhibitor or angiotensin receptor blocker

Question 148

what is the treatment for over 55s and of African/ Caribbean origin (1)

Answer 148

calcium channel blocker

Question 149

what is the 2nd step if one drug is not controlling hypertension for the two categories of people to treat

Answer 149

<55 not A/C origin= CCB or thiazide like diuretic eg indapamide can be added >55 of A/C origin= ACEi or ARB or thiazide like diuretic eg indapamide can be added

Question 150

if a patient is on ACEi and CCB and indapamide already but still symptomatic what should be given to them 1 (and normal potassium levels)

Answer 150

low dose spironolactone

Question 151

what is a side effect of ACEi and what can be given instead

Answer 151

dry long term cough ARB- losartan

Question 152

give an example of an ARB, ACEI, beta blocker, calcium channel blocker

Answer 152

losartan, ramipril, bisoprolol, amlodipine

Question 153

what is ACEi contradicted in 3

Answer 153

asthma and pregnancy and renal stenosis

Question 154

side effect of beta blockers 1 and what can this cause 1

Answer 154

postural hypotension which cause cause loss of consciousness

Question 155

SE of CCB

Answer 155

ankle swelling

Question 156

what is the first line medication for diabetics with hypertension

Answer 156

ACEi

Question 157

what happens when hypertension persists even when multiple medications are prescribed (2)

Answer 157

1. talk about adherence 2. add a beta blocker (potassium above 4.5) or spironolactone (potassium below 4.5)

Question 158

what are haemorrhoids

Answer 158

enlarged veins around anus

Question 159

3 causes of haemorrhoids and main cause

Answer 159

MC: constipation obesity pregnancy

Question 160

What are the two types of haemorrhoid

Answer 160

External originate below the dentate line prone to thrombosis, may be painful Internal originate above the dentate line do not generally cause pain

Question 161

grades of haemorrhoids 4

Answer 161

1. No prolapse 2. Prolapse when straining and return on relaxation 3. Prolapse when straining and can be manually pushed back in 4. Prolapse permanently

Question 162

signs and symptoms of haemorrhoids 2

Answer 162

painless haematachezia (fresh bleeding from rectum) Puritis anus

Question 163

What is the mx of haemorrhoids 3, 2

Answer 163

symptom mx: 1. high fibre diet and high fluid intake 2. bulk forming laxatives (isphagula husk) 3. topical treatment eg hydrocortisone cream (anusol) escalation: 1. rubber band ligation (outpt tx) for internal only 2. haemorrhoidectomy (for large symptomatic haemorrhoids that do not respond to outpt tx)

Question 164

what are rolling hiatal hernias

Answer 164

where the lower gastro-osophageal junction remains the the abdomen but a bulge of stomach (typically fundus) herniates up into the chest via the oesophageal hiatus

Question 165

what is a hiatal hernia and what r the two types of hiatal hernias and which is MC

Answer 165

stomach hernia through diaphragm aperture sliding (MC) and rolling

Question 166

what r sliding hiatal hernias and what is a consequence of this

Answer 166

where the lower gastro-osophageal junction slides up into the chest, above the diaphragm acid reflux

Question 167

investigations for hiatal hernia

Answer 167

barium swallow + x-ray for diagnosis

Question 168

Mx for hiatal hernia 3

Answer 168

1. conservatives: encourage weight loss, treat heartburn with gaviscon 2. PPI 3. laproscopic hiatal hernia repair

Question 169

what is hypothyroidism and what does is generally cause

Answer 169

thyroid hormone deficiency generalised slowing of processes

Question 170

what are the two types of hypothyroidism and how do they each cause hypothyroidism

Answer 170

primary- issue with thryoid gland, lack of T3/4 (one i in thyroid= 1) secondary- issue with pituitary, lack of TSH (two i in pituitary= 2)

Question 171

what are the causes of primary hypothyroidism (4) and secondary (1)

Answer 171

Hashimotos thyroiditis, De Quervain’s thyroiditis, dietary iodine deficiency, carbimazole pituitary adenoma

Question 172

6 symptoms of hypothyroidism

Answer 172

weight gain, lethargy, cold intolernace, loss of lateral aspect of eyebrow, constipation, fluid retention

Question 173

what three diseases are associated with hypothyrodism

Answer 173

downs and turners syndrome and coeliac disease (DOWN the stairs, TURN the corner and you’ll SEE it)

Question 174

what are the investigations for hypothyroidism (3)

Answer 174

1st line: thyroid function test 2. antithyroid peroxidase antibody levels for autoimmune causes 3. fasting blood glucose in patients with non-specific fatigue and weight gain due to association with T1DM

Question 175

what are the thyroid function test results for primary and secondary hypothyroidism

Answer 175

primary: low T3, high TSH secondary: low T3, low TSH

Question 176

treatment for hypothyroidism and how does this work

Answer 176

levothyroxine synthetic T4

Question 177

what is hashimotos thyroiditis, what does it lead to and what type of hypothyroidism does it cause

Answer 177

thyroid gland is attacked by immune system via antithyroid antibodies and leads to loss of function primary hypothyroidism

Question 178

what is the presentation of hashimotos like 2 and what does this progress to

Answer 178

same as hypothyroidism plus goitre of thyroid gland which progresses to atrophy

Question 179

what is the gold standard investigation for hashimotos

Answer 179

antithyroid peroxidase antibodies test should be positive (anti-TPO)

Question 180

What are the two strain of herpes simplex virus that affects humans, how does each spread and what is particular to note about herpes virus?

Answer 180

HSV-1, HSV-2 1= orally (more likely to be responsible for cold sores) 2= sexual contact (more likely to be responsible for genital ulceration) can be latent and reinfect body

Question 181

What are the features of HSV infection.

Answer 181

1. cold sores 2. painful genital ulceration (can happen repeatedly but **first is worst**) 3. severe gingivostomatitis

Question 182

What is the ix for a HSV genital ulcer

Answer 182

swab + NAAT test

Question 183

What is the mx for herpes simplex virus?

Answer 183

1. for gingivostomatitis: oral aciclovir, chlorhexidine mouthwash 2. for cold sores: topical aciclovir 3. for genital herpes: oral aciclovir, especially if multiple episodes

Question 184

What is the appearance of HSV on a pap smear? 3

Answer 184

3 Ms Multinucleated giant cells Margination of the chromatin Molding of the nuclei

Question 185

What is the cause and acute infection location of gonorrhoea

Answer 185

Gram-negative diplococcus Neisseria gonorrhoeae on any mucous membrane surface, typically genitourinary but also rectum and pharynx

Question 186

Features of gonorrhoea

Answer 186

males: urethral discharge, dysuria females: cervicitis e.g. leading to vaginal discharge rectal and pharyngeal infection is usually asymptomatic

Question 187

Why can we not immunise or prevent reinfections of gonorrhoea

Answer 187

due to antigen variation of type IV pili (proteins which adhere to surfaces) and Opa proteins (surface proteins which bind to receptors on immune cells)

Question 188

What is the Mx of gonorrhoea

Answer 188

1st line single dose 1g ceftrioxone IM

Question 189

What is Blepharitis, features, progression and mx

Answer 189

inflammation of the eyelid margins with lots of crusting at the base of eyelids features: dry and itchy eyes this can lead to styes and chalazions mx: warm compresses and gentle cleaning of eyelid margins

Question 190

What are styes, pathophys and mx

Answer 190

infection of sweat glands on eyelid, mc staph aureas mx: warm compresses and analgesia, chloramphenicol if conjunctivitis sx/ persist

Question 191

What is a chalazion and difference to styes. Mx

Answer 191

blocked and swollen meibomian gland typically on inside of eyelid mx: warm compresses and gentle massaging towards eyelashes

Question 192

What is entropian and mx

Answer 192

when eyelid turns inwards, causing lashes to press against the eye Mx: taping eyelid down, lubricating eye drops and surgical resolvement

Question 193

What is Ectropion

Answer 193

when the eyelid turns outwards, exposing the conjunctiva and means the eyeball is not adequately lubricated and protected

Question 194

What is the mx for any benign eyelid disorders that cause a risk to sight

Answer 194

same-day referral to ophthalmology

Question 195

What is thrichiasis and Mx

Answer 195

inward growth of eyelashes which causes corneal damage and ulceration mX; remove affected eyelashes

Question 196

What is periorbital cellulitis, features and mx

Answer 196

infection in front of the orbital septum (in front of the eye) features: swollen, red, hot skin around the eyelid and eye Mx: urgent referral to opthamology, CT to distinguish from orbital cellulitis, systemic oral abx

Question 197

What is orbital cellulitis

Answer 197

infection of tissues behind the orbital septum features: pain with eye movement, reduced eye movements, vision changes, abnormal pupil reactions, and proptosis (bulging forward of the eyeball) Mx: emergency opthamology admission, IV abx LIFE THREATENING

Question 198

What is atrophic vaginitis, who does it affect 1, features, tx 3

Answer 198

atrophy (thinning, drying and inflammation of vaginal walls) post-menopausal women vaginal dryness, dyspareunia and occasional spotting Tx: vaginal lubricants and moisturisers, if these do not help then topical oestrogen cream can be used

Question 199

define IBS 3

Answer 199

Chronic functional bowel disorder characterised by abdominal pain and change in bowel habits

Question 200

3 risk factors for IBS

Answer 200

Stress/ anxiety Female Younger age (peak at 20-30 year olds)

Question 201

5 investigations for IBS and what is the general investigation aim for IBS

Answer 201

Exclude coeliacs with serology (anti-tTG or anti-EMA) Exclude IBD with faecal calprotectin Exclude infections with ESR/CRP/ blood cultures Exclude colorectal cancer with FIT test Exclude hyperthyroidism with tfts Process of exclusion of other conditions

Question 202

diagnosis checklist for IBS 3

Answer 202

Diagnosis checklist= 1. recurrent abdominal pain for at least 1 day weekly for past 3 months 2. symptoms from 6 months ago 3. one of the following -Symptoms relieved by defecation -Change in bowel appearance -Change in bowel frequency

Question 203

conservative treatment for IBS 2

Answer 203

Reassure patient Advise to avoid trigger foods eg caffeine/ alcohol and short chain carbohydrate

Question 204

mild treatment of IBS 2

Answer 204

Anti mobility eg Loperamide for diarrhoea Laxatives eg Senna for constipation

Question 205

severe treatment of IBS 3

Answer 205

Tricyclic antidepressants eg amitriptyline CBT GI referral

Question 206

what is osteoarthritis 1 and what happens 1

Answer 206

degenerative disease of joint due to mechanical erosion of the cartilage in the joint

Question 207

symptoms of osteoarthritis 2

Answer 207

1. painful joints (typically high usage joints- worse towards end of day/ after usage) 2. morning stiffness for less than 30 mins

Question 208

state and explain two clinical signs of osteoarthritis

Answer 208

Bouchards nodes (bony growths on PIP joints= proximal) Heberdens nodes (bony growths on DIP joints=distal)

Question 209

2 investigations into osteoarthritis and results

Answer 209

bloods= normal x-ray of joint (LOSS- loss of joint space, osteophytes (bony growths on joints), subchondral sclerosis (increased density bone along joint line), subchondral cysts (fluid filled holes in bone)

Question 210

what is the treatment of osteoarthritis 3

Answer 210

lifestyle changes: physio, weight bearing pain relief: NSAIDs last resort: joint replacement

Question 211

what is rheumatoid arthritis and what happens

Answer 211

inflammatory disease autoimmune destruction of synovium (soft tissue of the joints)

Question 212

compare the symmetry and number of joints affected for rheumatoid arthritis and osteoarthritis

Answer 212

osteoarthritis= asymmetrical, affects few joints rheumatoid= symmetrical, affects many joints

Question 213

risk factors of rheumatoid arthritis 2

Answer 213

HLADR4/1 women

Question 214

symptoms of rheumatoid arthritis 2 and clinical signs of RA 4

Answer 214

painful swollen joints morning stiffness lasting more than 30 mins rheumatoid skin nodules boutinniere deformity swan neck thumb ulnar deviation

Question 215

treatment for R arthritis 3

Answer 215

1. Disease modifying anti rheumatic drugs- methotrexate/ hydroxychloroquine/ sulfsalazine 2. analgesia- NSAIDs/ steroid injections 3. biologics -> 1st line: TNF alpha inhibitor infliximab (given with methotrexate) -> 2nd line: B cell inhibitor (CD20 target)- rituximab RADAB

Question 216

What is a differential for fibromyalgia

Answer 216

polymalgia rheumatica

Question 217

investigations for R arthritis 4 and results

Answer 217

1. bloods: high ESR/CRP 2. serology: positive rheumatoid factor, positive anti-CCP antibodies 3. genetic test for HLA DR1/4 4. X-ray (LESS- lost joint spaces, bony erosion, soft tissue swelling, periarticular osteopenia)

Question 218

compare polymyalgia rheumatica anad fibromyalgia 3

Answer 218

fibromyalgia at any age but PR over 50 Y/O PR= concentrates pain in shoulder and hips, onsest over a few days with joint stiffness PR resolves within 2 years, fibromyalgia is chronic and lifelong

Question 219

What is syphillis and cause

Answer 219

STI caused by the gram negative bacteria Treponema pallidum

Question 220

What is the disease progression for syphyilis

Answer 220

primary stage: chancre (painless ulcer at site of sexual contact/ where direct contact occured) secondary stage: 1 week after primary > systemic symptoms: fevers, lymphadenopathy > non itchy maculopapular rash on trunk, palms and soles > buccal 'snail track' ulcers (30%) > condyloma lata (painless, white lesions on the genitalia) tertiary features: type 4 hypersensitivity reaction (severe immune response) and organ damage > gummas (granulomatous lesions formed from WBC) > ascending aortic aneurysms due to aortitis > weakness and paralysis and loss of sensation (T. pallidum affects anterior spinal cord) > tabes dorsalis (T.pallidum damages dorsal column-medial lemniscus nerve pathway= loss of vibration and proprioception) > Argyll-Robertson pupil (pupil loses light reflex but does have accomodation reflex)

Question 221

Explain the latent stage of syphillis

Answer 221

Latent phase happens after secondary phase of syphillis infection (basically an asymptomatic stage) early latent phase: within a year of infection- T. pallidum mostly found in capillaries of organs/ tissues finds its way back into bloodstream= secondary symptoms again late latent phase: after a year of infection- T. pallidum stays in capillaries of organs/ tissues finds its way back into bloodstream

Question 222

What are the Ix for syphilis 3

Answer 222

1. Dark-field microscopy from swab of chancre/ secondary lesions (+ is presence of T. pallidum) 2. serology testing: treponemal eg florescent treponemal antibody (more specific and sensitive so used for diagnosis) and non-treponemal tests eg Rapid Plama Reagin blood test (screening and monitoring tx response) 3. CSF examination: Should be considered in tertiary syphilis to evaluate for CNS involvement.

Question 223

Explain serology test results for syphilis 4 and action for 1

Answer 223

both positive= active/ recent syphilis infection Positive non-treponemal test + negative treponemal test= no syphilis, false positive due to other causes eg SLE/ pregnancy Negative non-treponemal test + positive treponemal test = primary/ latent syphillis/ previously having treated or untreated syphilis both negative= no syphilis or incubating syphilis (should repeat after 3 months, as syphilis has an incubating time period of 3 months)

Question 224

What is the mx for syphilis 5

Answer 224

1. 1st line IM benzathine penicillin once confirmed 2. needs referral to GUM, with follow up at 3,6, and 12 months 2. if CI then doxycycline (14 days if early syphillis, 28 dys if late) 3. should monitor nentroponemal titres to assess response (fourfold decline in titres seen as an adequate response to treatment) 4. avoid sex until fully treated **IBANG (ive been a nasty girl)** (C)**I** then doxycycline- 14 for early, 28 dys for late **b**enpen IM injection once + results **a**void sex until fully treated **N**on treponemal titres to assess response (fourfold decline in titres= adequete response) **G**UM referral with 3,6,12 month follow up

Question 225

What is a SE of syphilis mx and mx of this

Answer 225

Jarisch- Herxheimer reaction: fever, rash and tachycardia several hours after treatment no treatment apart from antipyretics

Question 226

What are the causes of otitis externa and features

Answer 226

causes: recent swimming, staph aureaus, p.aerginosa, dermatitis features: ear pain, itch, discharge

Question 227

Mx of otitis externa 3

Answer 227

1. topical antimicrobial (acetic acid) plus with steroid (eg ciprofloxacin and dexamethasone combined-otomize spray) 2. oral flucox if cellulitis expanding past ear or immunocompromised/ diabetes 3. refer to ENT if do not respond to topical abx

Question 228

What is Trichomonas vaginalis and cause

Answer 228

STI caused by Trichomonas vaginalis: a highly motile, flagellated protozoan parasite

Question 229

What are the features of Trichomonas vaginalis 5

Answer 229

1. vaginal discharge: offensive, yellow/green, frothy 2. vulvovaginitis 3. strawberry cervix 4. pH > 4.5 5. in men is usually asymptomatic but may cause urethritis | 4 Vs (1-4)

Question 230

What is the Ix for Trichomonas vaginalis 2

Answer 230

NAAT swab (same as chlamydia + g) microscopy of a wet mount shows motile trophozoites

Question 231

What is the mx of microscopy of Trichomonas vaginalis 1

Answer 231

oral metronidazole 5-7 days

Question 232

What is Sinusitis

Answer 232

inflammatory disorder of paranasal sinuses and linings of the nasal passages

Question 233

What are the features of sinusitis 4

Answer 233

1. facial pain: typically frontal pressure pain which is worse on bending forward 2. nasal discharge: usually clear if allergic or vasomotor. Thicker, purulent discharge suggests secondary infection 3. nasal obstruction: e.g. 'mouth breathing' 4. post-nasal drip: may produce chronic cough

Question 234

What are the red flags for sinitis 3 and action for these

Answer 234

unilateral symptoms persistent symptoms despite compliance with 3 months of treatment epistaxis referral to ENT

Question 235

How is acute and chronic sinusitis managed 2 and what is the timeline for this

Answer 235

acute: supportive as it is self limiting, NICE avoids antibiotics chronic: 3+ months 1. intranasal corticosteroids 2. nasal irrigation with saline solution

Question 236

risk factors for prostate cancer 4

Answer 236

genetic BRCA1/2 and HOXB13 and lynch syndrome elderly family history A/C origin

Question 237

what is prostate cancer

Answer 237

proliferation of outer peripheral zone of prostate (adenocarcinoma)

Question 238

presentation of prostate cancer 2

Answer 238

LUTS like BPH (voiding and storage issues) but with systemic cancer symptoms eg weight loss, fatigue, night pain and bone pain

Question 239

investigations for prostate cancer 3

Answer 239

DRE is hard and irregular PSA in community multiparametric MRI-influenced prostate biopsy

Question 240

where does prostate cancer typically metastasise to and what is the effect of this

Answer 240

typically metastasises to bone= sclerotic lesions, typical lumbar back pain also metastasises to liver, lung and brain

Question 241

what determines if multiparametric MRI is offered to someone with suspected prostate cancer?

Answer 241

If the Likert scale is >=3 a multiparametric MRI-influenced prostate biopsy is offered If the Likert scale is 1-2 then NICE recommend discussing with the patient the pros and cons of having a biopsy.

Question 242

3 treatment approaches for prostate cancer

Answer 242

radical prostatectomy radiotherapy hormone therapy: only for T3/T4 and metastatic malignancy

Question 243

explain hormone therapy treatment for prostate cancer (example name, how does it work and 2 side effects)

Answer 243

GnRH agonist eg goserelin increases LH and FSH but results in suppression of HPG axis= less testosterone side effects= libido loss, erectile dysfunction

Question 244

What is vasovagal syncope and fully explain a vasovagal syncopal episode

Answer 244

transient loss of consciousness due to global cerebral hypoperfusion with rapid onset, short duration and spontaneous recovery trigerred by emotion, pain or stress EPISODE: prodrome: lightheadedness, visual disturbances, muffled hearing, nausea, pallor event: loss of postural tone and consciousness up to a minute recovery: may show signs of confusion, weakness and can recollect prodromal period but has amnesia for actual syncopal event

Question 245

What are the ix for vasovagal syncope

Answer 245

1. BP readings: fall BP >20 mmHg is diagnostic for postural hypotension 2. ECG

Question 246

What are the other types of syncope apart from vasovagal and explain each

Answer 246

REFLEX SYNCOPE: carotid sinus + vasovagal + situational situational: specifically associated with certain situations eg coughing, defecation, post-exercise carotid sinus: hypersensitivity of carotid sinus baroreceptors which stimulate bradycardia/ vasodilation when stimulated eg turning head/ tight collars. Mostly affects elderly OTHER SYNCOPE TYPES: orthostatic: due to postural BP drop eg Parkinsons and Lewy body (nervous system unable to regulate BP changes well), diarrhoea/ diuretics/ vasodilators (volume deplation) cardiac: bradycardias and arrythmias

Question 247

What is lyme disease caused by and how does it spread?

Answer 247

caused by the spirochaete Borrelia burgdorferi and is spread by ticks

Question 248

How does lyme disease present?

Answer 248

1. early features within 30 days - 'bulls-eye' rash is typically at the site of the tick bite which slowly increases in size -systemic features eg lethargy and fever 2. later features after 30 days - myocarditis/ heart block (CV) - facial nerve palsy, radicular pain, meningitis (Neuro)

Question 249

What is the mx of lyme disease 3

Answer 249

1. if asymptomatic tick bite just ensure you remove tick if still present with tweezers and wash area thoroughly after. no other tx 2. suspected/ confirmed lyme disease- doxycycline if early disease and ceftrioxone if disseminated disease

Question 250

What are the Ix for lyme disease

Answer 250

1st line ELISA for Borrelia burgdorferi if negative, repeat after 1 month if positive, do a immunoblot test for lyme disease

Question 251

What is infectious mononucleosis caused by and what is its alternative name

Answer 251

Epstein-Barr virus glandular fever

Question 252

What are the features of infectious mononucleosis 7

Answer 252

triade: pharyngitis (with exudative tonsils), lymphadenopathy, sore throat other: palatal petechiae, maculopapular pruritic rash when being treated with amoxicillin/ penicillins (although this is not part of mx when it is known to be infectious mono, hepatitis (high ALT) LISTENING TO PEALSH FM pharyngitis (struggling to swallow) Exudate on tonsils antibiotics cause MP rash Lymphadenopathy (cervical) Sore throat Hepatitis (high ALT) FBC (haemolytic anaemia) Monospot test (2 weeks in) if pt treated for tonsillitis with abs and gets a rash, then its infectious mononucleosis

Question 253

How is infectious mononucleosis dx 3

Answer 253

NICE guidelines suggest FBC (can show haemolytic anaemia) and Monospot test in the 2nd week of the illness to confirm a diagnosis of glandular fever, otherwise clinical

Question 254

What is the mx for infectious mononucleosis 2

Answer 254

1. rest, analgesia, drink fluids 2. avoid contact sports for 4 weeks after symptoms to reduce risk of splenic rupture

Question 255

What is folliculitis

Answer 255

infection from a single hair follicle, causing pustule/ papule formation (pimples) which can form anywhere on the body except for hands and feet

Question 256

Causes of folliculitis 4

Answer 256

bacterial: staph aureus MC or hot tub folliculitis (caused by pseudo. aeruginosa) or any gram neg bacteria after a long course of abx (eg after acne tx) yeast: malassezia (yeast from skins normal flora infecting hair follicles)

Question 257

What is the mx of folliculitis 2

Answer 257

1. topical antimicrobial (benzyl peroxide) + antibacterial soaps (Hibiscrub) 2. Oral antibiotics (trimethoprim for gram neg due to long term abx use for acne mx) may also be required in more severe cases or cases that don't respond to topical treatments

Question 258

What is another name for atopic dermatitis and features

Answer 258

eczema pruritic, dry, erythemous patches on skin, in a typical distribution pattern in fleuxural areas (inner elbows, behind knees, armpits)

Question 259

What can cause exacerbation of atopic dermatitis 3

Answer 259

stress, irritants, allergens

Question 260

How is atopic dermatitis diagnosed

Answer 260

1. An itchy skin condition in the last 12 months Plus three or more of Onset of some sx below 2 years* (not used for kids under 4) History of flexural involvement History of generally dry skin Personal history of other atopic disease Visible flexural dermatitis

Question 261

How is atopic dermatitis managed 6, 3 community, 3 specialist

Answer 261

1. emollients to be liberally applied 2. topical corticosteroids for acute flares/ severe eczema (hydrocortisone 1 for face/ genitals, betamethasone valerate 0.1 for thicker areas like palms/ soles or in severe cases) 3. chloramphenamine (sedating antihistamine) to short term releive itch adn help with sleep disturbance, otherwise cetirizine if non sedating more appropriate SPECIALIST MX: 4. immunosuppressants eg tacrolimus by a specialist dermatologist 5. phototherapy in unresponsive cases 6. biologics eg dupilomab for severe unresponsive cases

Question 262

what is the MC arrythmia

Answer 262

atrial fibrillation

Question 263

what is the atrial firing rhythm of atrial fibrillation

Answer 263

irregular irregular atrial firing rhythm

Question 264

causes of atrial fibrillation (4)

Answer 264

heart failure hypertension secondary to mitral stenosis sometimes idiopathic

Question 265

explain the pathophysiology of atrial fibrillation and how it increases the risk of thromboembolic events (3)

Answer 265

1. rapid firing rate 300-600 bpm causes atrial spasm (not co-ordinated contraction like normal) 2. blood is not efficiently pumped to ventricles 3. this decreases cardiac output and increases the risk of thromboembolic events

Question 266

symptoms of A fib (6)

Answer 266

palpitations irregularly irregular pulse thromboemboli eg ischaemic stroke chest pain SYNCOPE HYPOTENSION 6 Ps- palpitations, pulse, pain in chest, (hy)potension, (P)FAINTING and thromPoemboli

Question 267

what are the 3 types of atrial fibrillation and what are their patterns

Answer 267

paroxysmal (episodic) persistant (longer than 7 days) permanent (sinus rhythm unrestorable)

Question 268

diagnostic investigation for atrial fibrillation (1, 3)

Answer 268

ECG is diagnostic: irregularly irregular pulse narrow QRS (less than 120ms no p waves (fibrillatory squiggles instead) acronym= PIQ

Question 269

acute treatment for atrial fibrillation

Answer 269

synchronised cardioversion DC (shock heart back into normal rhythm)

Question 270

long term treatment for atrial fibrillation 4

Answer 270

1. start anticoagulant (justify with ChadsVasc stroke risk score and ORBIT bleeding risk score) 2. offer rate control first line: eg beta blocker/ CCB (only first line if not causing HF/ new onset). Can also give digoxin for non paroxysmal, not exercising person when other rate drugs ruled out) 3. offer rhythm control: eg amiodarone (when pts have worse symptoms and HF) 4. surgical: radio frequency ablation which intends to prevent future episodes

Question 271

what is atrial flutter firing rhythm (2) and compare it for atrial fibrillation (2)

Answer 271

regularly irregular atrial firing less common and less severe than atrial fibrillation

Question 272

pathophysiology of atrial flutter 2

Answer 272

1. fast atrial ectopic firing 120-350 bpm 2. this causes atrial spasm

Question 273

symptoms of atrial flutter (2)

Answer 273

shortness of breath palpitations

Question 274

investigation for atrial flutter (1) and results (2)

Answer 274

ECG diagnostic: f wave ‘saw tooth’ pattern, often with a 2:1 blocker (2 p waves for every QRS)

Question 275

what is the wolff parkinson white AVRT and explain the pathophysiology and inheritence

Answer 275

accessory pathways for conduction= bundle of Kent pre-excitation syndrome (excite ventricle faster than typical pathwa) autosomal dominant

Question 276

treatment for atrial flutter that is acutely unstable treatment for atrial flutter that is stable (2) and what is the purpose of these treatments

Answer 276

acute: DC synchronised cardioversion stable: 1. rhythm/ rate control with beta blocker and oral anticoagulation 2. radio frequency ablation to prevent future episodes

Question 277

what are the symptoms of wolff parkinson white (3)

Answer 277

palpitations dizziness dyspnoea

Question 278

what are the ECG changes seen in Wolff parkinson white (3)

Answer 278

slurred delta waves short PR interval wide QRS complex acronym= QuPiD

Question 279

what is the treatment for wolff parkinson white (3)

Answer 279

1. valsalva manoeuvre and carotid massage 2. IV adenosine (temporarily ceases conduction- warn patient it feels like dying)- 6mg then 12mg, then 12 mg and additional doses if unsuccessful 3. radiofrequency ablation of bundle of Kent

Question 280

what is long QT syndrome and what type of arrythmia does this lead to? What is the interval

Answer 280

congenital channelopathy disorder where mutation affects cardiac ion channels =ventricular taachycardia QT interval is 480ms +

Question 281

what are the 4 causes of long QT syndrome

Answer 281

1. Romano Ward syndrome (autosomal dominant) 2. Jerrell Lange Nelson syndrom (autosomal recessive) 3. hypokalaemia and hypocalcaemia (not inherited) 4. drugs eg amiodarone

Question 282

what are two examples of long QT syndrome

Answer 282

torsades de pointes ventricular fibrillation

Question 283

what is torsades de pointes, what does this look like on an ECG, what can this progress to

Answer 283

polymorphic ventricular tachycardia in patients with prolong QT rapid irregular QRS completes which ‘twist’ around baseline ventricular fibrillation

Question 284

what does ventricular fibrillation look like on ECG and what can happen with ventricular fibrillation

Answer 284

shapeless rapid oscillations on ECG patient becomes pulseless and goes into cardiac arrest (no effective cardiac output)


Question 285

what is the first line of treatment for ventricular fibrillation

Answer 285

electrical defibrillation

Question 286

what is primary AV block

Answer 286

PR interval prolongation (200ms +) and every P followed by QRS

Question 287

what is the treatment for asymptomatic and symptomatic primary AV block (1, 3)

Answer 287

if asymptotic then no treatment symptomatic treatment= beta blocker eg atenolol, CCB eg verapamil, digoxin to block AVN conduction

Question 288

what are the two types of secondary AV block and explain what each are

Answer 288

Mobitz type 1 and 2 1: PR prolongation until a QRS is dropped (PR progressively elongates) 2: PR interval is consistently prolonged at the same length with random dropped QRS

Question 289

What is the tx for 2 AV block

Answer 289

pacemaker

Question 290

what is a tertiary AV block and explain pathophys

Answer 290

AV dissociation (complete heart block so atria and ventricles beat independantly of each other) ventricular escape rhythm is sustaining the heartbeat (ventricle pacemakers take over which is bad (firing rate= 20-40bpm))

Question 291

tx for tertiary AV block

Answer 291

IV atropine and permanent pacemaker

Question 292

what is a bundle branch block and what are the two types and explain each

Answer 292

blocked bundles of His RBBB: right ventricle is activated later than left ventricle LBBB: left ventricle is activated later than right ventricle

Question 293

what is the heart sound and ECG pattern in RBBB

Answer 293

wide physiological S2 splitting heart sound MARROW: M in V1 (R wave), W in V6 (S wave)

Question 294

what is the heart sound and ECG pattern in LBBB

Answer 294

WILLIAM: W in V1 (r wave), M in V6 (s wave)

Question 295

What is MART, its use and example

Answer 295

combined ICS and LABA treatment in one inhaler and this inhaler is used both for daily maintenance and to relieve symptoms eg formoterol

Question 296

How much is a low and high dose of inhaled corticosteroids?

Answer 296

<= 400 micrograms budesonide or equivalent = low dose 400 micrograms - 800 micrograms budesonide or equivalent = moderate dose > 800 micrograms budesonide or equivalent= high dose

Question 297

How is asthma diagnosed in adults 3

Answer 297

1. FeNO test (40+ ppb is positive, 35+ in kids) PLUS 2. spirometry + bronchodilator reversibility test (positive if improvement of FEV1 by 12+% **and** increase in volume of 200ml+ (childrne just need 12% improvement in FEV1) 3. spirometry (FEV1:FVC less than 0.7= obstructive)

Question 298

What is balanitis and most common causes 3

Answer 298

inflammation of glans penis 1. candidiasis (candida albicans) 2. contact/ allergic/ eczema (look for hx of eczema elsewhere on body)/ psoriasis dermatitis 3. bacterial (staph)

Question 299

What are the clinical features of balanitis? 3

Answer 299

itching white/ clear non-urethral discharge if bacterial: painful, itchy and yellow non-urethral discharge

Question 300

What is the mx for balanitis?

Answer 300

1. gentle and thorough saline washes 2. 1% hydrocortisone for irritation and dermatitis causes 3. topical clotrimzole 2 weeks if candiasis 4. if bacterial then oral flucoxacillin

Question 301

What is Chancroid and symptoms 2

Answer 301

tropical disease caused by Haemophilus ducreyi -> painful genital ulcers -> unilateral painful inguinal lymph node enlargement

Question 302

What are the classifications of heart failure? Explain each

Answer 302

systolic (heart unable to pump properly = reduced ejection fraction) diastolic (heart unable to relax properly= preserved ejection fraction) acute HF (new onset or acute deterioration of chronic HF) chronic HF= gradual progression and takes years to develop

Question 303

Explain the classification for HF

Answer 303

New York Heart Association (NYHA) Classification of HF 1. Class 1 - no limitation in physical activity, and activity does not cause undue fatigue, palpitations or dyspnoea. 2. Class 2 - slight limitation of physical activity, and comfort at rest. Ordinary physical activity causes fatigue, palpitations and/or dyspnoea. 3. Class 3 - marked limitation in physical activity, but comfort at rest. Minimal physical activity causes fatigue (less than ordinary). 4. Class 4 - inability to carry on any physical activity without discomfort, with symptoms occurring at rest. If any activity takes place, discomfort increases.

Question 304

What are two clinical signs of HF 2

Answer 304

1. orthopnoea (SOB when lying flat, releived by sitting/ standing up) 2. paroxysmal nocturnal dysponoea (sudden onset SOB whilst a person is sleeping, causing them to wake up from sleep)

Question 305

symptoms of left sided HF (8)

Answer 305

respiratory crackles (due to bilateral pleural effusions) pink-tinged sputum tachycardia fatigue CYANOSIS EXERTION DYSPNOEA cough PULMONARY oedema due to vessel backflow lungs: 4 cough, pulmonary oedema, resp crackles, cyanosis systemic: 2 tachy, fatigue, exertional dyspnoea specific: 1 pink tinged sputum

Question 306

symptoms of right sided HF (5)

Answer 306

ASCITES hepatosplenomegaly WEIGHT GAIN raised JVP (due to increased pressure in right atrium) PERIPHERAL OEDEMA due to systemic venous backflow

Question 307

What are the ix for HF

Answer 307

1. first line is NT-pro-BNP ->400-2000 refer to cardio and TTE within 6 weeks -> 2000+ urgent referral to cardio and TTE within 2 weeks -> TTE (echo) confirms ventricular dysfunction= dx 2. 12 lead ECG 3. CXR: A: Alveolar oedema (with 'batwing' perihilar shadowing) B: Kerley B lines (caused by interstitial oedema) C: Cardiomegaly (cardiothoracic ratio >0.5) D: dilated upper lobe vessels E: Pleural effusions (typically bilateral transudates) F: Fluid in the horizontal fissure

Question 308

What are the causes of HF? 5

Answer 308

uncontrolled HTN MI coronary heart disease valve abnormalities Arrythmias eg AF

Question 309

What is the conservative advice for HF 5

Answer 309

1. Weight loss if BMI >30. 2. Smoking cessation 3. Salt and fluid restriction (improves mortality) 4. Supervised exercise-based group rehabilitation programme for people with heart failure. 5. Offer annual influenza and one-off pneumococcal vaccinations for patients diagnosed with heart failure.

Question 310

What is the main symptom management for HF?

Answer 310

loop diuretic for fluid overload eg furosemide

Question 311

How is ventricular dysfucntion measured + classified in HF and how

Answer 311

Transthoracic echocardiogram (TTE) EF <40% = HF with reduced ejection fraction (systolic dysfunction) EF >40% but with raised BNP = HF with preserved ejection fraction (diastolic dysfunction)

Question 312

What are the surgical managements for HF 1

Answer 312

1. Cardiac resynchronisation therapy if wide QRS and above NYHA class 3 (aims to improve QoL)

Question 313

What is the mx for reduced ejection fraction HF? 6?

Answer 313

1st line = ACE-I (if CI then ARB) and beta-blocker (bisoprolol) if sx persist or NYHA class 3/4 then: -> add aldosterone agonist (spironolactone) -> Afro-Caribbean patients add hydralazine and a nitrate -> IvAbradine if in sinus rhythm and impaired EF. -> AF/ not sinus rhythm add digoxin -> ACEi replacement with sacubitril valsartan once pt is stable on ACE and if ejection fraction is less than 35 (stop ACEi 36 hours beforehand before starting SV due to risk of angioedema- facial oedema)

Question 314

what are the two methods the body uses to compensate for heart failure (2) and why is this only effective short term?

Answer 314

RAAS system activation (increased salt and water reabsorption to increase bp) sympathetic system activation (increases inotrophy and chronotrophy) short term as high RAAS and SNS activation exacerbates fluid overload

Question 315

What is the mx for preserved ejection fraction HF? and class of drug

Answer 315

SGLT2 inhibitors dapagliflozin

Question 316

acute heart failure treatment (4)

Answer 316

oxygen, morphine, furosemide, GTN spray OMFG

Question 317

What are the causes 2 and features 3 of innocent murmurs

Answer 317

causes: due to increased cardiac output in febrile illness/ anaemia features: soft systolic murmur, asymptomatic, loudest left sternal edge

Question 319

What are the 3 foetal circulation shunts?

Answer 319

Ductus venosus: shunts oxygenated blood from placenta in umbilical vein towards the fetal heart (placenta to umbilical vein to ductus venosus to skip liver straight to heart via inferior vena cava then to right atria then to left atria via foramen ovale) Foramel ovale: shunts oxygenated bloods from R to L atria to bypass lungs Ductus arteriosus: connects pulmonary artery with aorta to shunt blood away from lungs into the aorta

Question 322

what is the tetralogy of fallots pathophysiology and is it cyanotic

Answer 322

congenital condition with four different heart problems cyanotic due to ventricular systolic defect causes right ventricle outflow obstruction (deoxygenated blood is shunted to the systemic circulation)

Question 323

investigations for tetralogy of fallot and what do they show (2,1)

Answer 323

echo, chest x-ray shows a boot shaped heart

Question 324

what is a behavior of infants with tetralogy of fallot and why do they do this

Answer 324

infants often seen in knee to chest squatting position which increases preload and after load and improves cyanosis get tet spells where they turn blue for short periods of time

Question 325

What are the features of tetralogy of fallot

Answer 325

PROVe P for pulmonary stenosis R for Right ventricular hypertrophy O for overriding aorta V for Ventricular Septal Defect

Question 326

treatment for tetralogy of fallot 2

Answer 326

treatment: full surgical repair within 2 years of life (this gives a good prognosis if done) encourage knees to chest for tet spells and can give beta blockers to help with tet spells egp propanalol/ o2 in hospital

Question 328

what is coarctation of the aorta 1 and what is the pathophysiology of this

Answer 328

congenital narrowing of aorta blood is diverted through proximal aortic arch branches= increased perfusion to upper body vs lower body

Question 329

symptoms/ signs of coarctation of aorta (5)

Answer 329

1. upper body hypertension 2. radio-femoral delay 3. diminished femoral pulses but strong UL pulses 4. systolic murmur, loudest between scapulae 5. leg claudication during physical activities in children

Question 330

diagnostic investigation for coarctation of aorta

Answer 330

echocardiogram

Question 331

treatment for coarctation of the aorta

Answer 331

baloon angioplasty + stent insertion

Question 332

what are the cardinal signs of heart failure 3

Answer 332

orthopnea (difficulty breathing whilst lying down) ankle oedema fatigue

Question 333

if a patient is on ACEi and BB already for HF but still symptomatic what should be given to them 1

Answer 333

spironolactone

Question 334

what is the 1st line ix for IE and what is the GS

Answer 334

1- TTE 2- TOE

Question 335

what is a side effect of amlodipine and what alternative can be given to prevent this side effect 2

Answer 335

peripheral/ ankle oedema ace inhibitor (if not already given) and indapamide

Question 336

what ecg leads look at the lateral aspect of the heart, anterior, inferior and septal

Answer 336

I, aVL, V5, V6 V3-4 II, III, aVF V1-2 see mneumonic online when drawing up the ecg graph (like in iceland, like in spain, some amazing ass anal lois lane)

Question 337

what ecg leads looks at the LAD, RCA, Lcx. diagonal of LAD

Answer 337

V1-4 II, III, aVF I, aVL, V5-6

Question 338

What is the cause of mumps and method of transmission

Answer 338

RNA paramyxovirus resp droplets

Question 339

What are the features of mumps? 3

Answer 339

1. fever 2. malaise, muscular pain 3. parotitis (= earache/pain on eating: unilateral initially then becomes bilateral in 70%

Question 340

What are the features of influenza? 6

Answer 340

1. fever >38 2. myalgia 3. headache 4. sore throat 5. cough 6. lethargy

Question 341

is mumps a notifiable disease?

Answer 341

yes

Question 342

What is the mx for influenza?

Answer 342

only give antivirals if high risk pt presents within 48 hours from onset of sx during a flu outbreak -> antiviral= oseltamivir (zanamivir for renal impairment/ immunocompromised)

Question 343

What are the features of acute tonsillitis? 5

Answer 343

1. sore throat 2. fever >38 3. dysphagia 4. cough, headache (indicates viral) OR cervical lymphadenopathy (indicates bacterial) 5. white pathes on tonsils

Question 344

What is acute tonsillitis? Causes?

Answer 344

acute infection of the palatine tonsils MC viral: MC rhinovirus, coronavirus and parainfluenza virus (MC to LC) bacterial: group A strep MC

Question 345

How is acute tonsillitis dx?

Answer 345

1. physical exam: inflamed tonsils, purulent tonsils (suggests bacterial), painful and large cervical lymph nodes

Question 346

What tool is used to predict likelihood of bacterial cause of tonsillitis? Explain

Answer 346

CENTOR criteria: score 1 point for each (maximum score of 4) presence of tonsillar exudate tender anterior cervical lymphadenopathy or lymphadenitis history of fever absence of cough 3/4 points= more likely to be bacterial (32 to 56% chance of isolating strep in swab) CENTor Cough absent Enlarged lymph nofes Not normal temp (fever) Tonsillar pus

Question 347

What is the mx for tonsillitis 2

Answer 347

1. conservative: fluids and painkillers 2. if 3+ on centor criteria or immunosuppressed or feverPAIN score is 4+, give abx: -> 1st line: Phenoxymethylpenicillin for 10 days -> Clarithromycin if allergy

Question 349

What is a viral exanthma and name some causes 4

Answer 349

widespread rash due to virus eg: 1. chickenpox 2. hand foot and mouth disease

Question 350

Why do people get arterial and venous ulcers

Answer 350

arterial: peripheral arterial disease (atherosclerosis= inadequate blood supply) venous: chronic venous insufficiency (poor venous return= HTN in lower limbs)

Question 351

Compare arterial and venous ulcers

Answer 351

arterial: small, deep 'punched out' ulcers that do not bleed or ooze, at heel/ above foot, PAINFUL, cold, no palpable pulses venous: large and shallow, with sloping edges, and bleed or ooze, on medial side, PAINLESS

Question 352

What are the ix for ulcers 2

Answer 352

1. doppler US for venous ulcers 2. ABPI for arterial

Question 353

What is the mx for arterial and venous ulcers? 3 2

Answer 353

arterial: need to improve arterial circulation 1. lifestyle changes 2. antiplatelets, statins 3. surgery: angioplasty/ peripheral bypass grafting venous: need to compress veins to increase venous return 1. 4 layer band compression stockings 2. If fail to heal after 12 weeks or >10cm2 skin grafting may be needed

Question 354

What are varicose veins?

Answer 354

dilated superficial veins that are formed due to incompetent venous valves

Question 355

What are the rfx of varicose veins? 4

Answer 355

elderly pregnancy (uterus compresses pelvic veins) obesity inactivity

Question 356

What is the ix for varicose veins + result? 1

Answer 356

venous duplex ultrasound: this will demonstrate retrograde venous flow

Question 357

What are the complications of varicose veins? 5

Answer 357

1. varicose eczema (also known as venous stasis) 2. haemosiderin deposition → hyperpigmentation 3. lipodermatosclerosis → hard/tight skin 4. DVT 5. venous ulcers

Question 358

What is the mx for varicose veins? 4

Answer 358

1. conservative: weight loss, elevation, graduated compression stockings 2. referral to 2' care if skin changes (eg eczema), ulcers or significant sx (pain/ swelling) 3. endothermal ablation 4. surgery: ligation of vein

Question 359

what is reactive arthritis

Answer 359

sterile inflammation of synovial membranes and tendons

Question 360

what causes reactive arthritis 3

Answer 360

reaction to a distant GI/GU infection normally by chlamydia trachomatis or campylobacter jejuni

Question 361

presentation of reactive arthritis 2

Answer 361

1. Reiters triad: can’t see, can’t pee, can’t climb a tree= uveitis, urethritis and arthritis 2. occurs a month after intiial infection onset

Question 362

investigations of reactive arthritis 1

Answer 362

joint aspirate: plane polarised light microscopy is negative for crystalarthropathy

Question 363

treatment for reactive arthritis 3

Answer 363

1. symptomatic relief: NSAIDs/ steroid injection 2. give antibiotics until septic arthritis is ruled out 3. methotrexate for chronic

Question 364

what is Psoariatic arthritis

Answer 364

inflammatory arthritis that 1/5 with Psoriasis get

Question 365

presentation of Psoariatic arthritis 4

Answer 365

1. psoriatic rash on skin: hidden sites eg behind ears, scalp 2. enthesitis (inflammation of entheses) 3. dactylitis (sausage fingers) 4. oncholysis (nail separation from nail bed)

Question 366

Describe the psoriasis rashes

Answer 366

well-demarcated red, scaly patches affecting the extensor surfaces and scalp

Question 367

investigations of psoariatic arthritis 1,3

Answer 367

x ray -> osteolysis -> dactylitis -> pencil in cup appearance

Question 368

complication of psoriatic arthritis 1

Answer 368

arthritis mutilans

Question 369

What is guttate psoriasis cause and appearance

Answer 369

psoriatic rash frequently triggered by a streptococcal infection. Multiple red, teardrop lesions appear on the body

Question 370

What is the mx for psoriasis? 6

Answer 370

1. regular emollients 2. hydrocortisone OD 3. vit D analogue (calcitriol) OD and if it doesn't work then vit D BD 4. short-acting dithranol (slows down the production of new skin cells) SECONDARY CARE REFERRAL 5. phototherapy UVB light 6. if associated joint disease, then NSAIDS and then if unresponsive: oral methotrexate

Question 371

what is peripheral arterial/ vascular disease

Answer 371

ischaemia of lower limb arteries

Question 372

general symptoms of PVD 2 and test and positive result for it 1

Answer 372

skin changes: pale colour, cold and ulcers pulses: weak/ absent buerger test positive: elevate leg 45 degrees for 1 min= pallor, pt to sit up with legs hanging off on the coach= blue then reactive hyperaemia (red)

Question 373

why does chronic ischaemic pain occur at night (2) and what can this lead to (2)

Answer 373

due to elevation of limb which can further reduce blood supply to the distal part of the limb which can cause ulcers and gangrene

Question 374

intermittent claudification: when is there pain, how occluded is the lumen and what is the cause of the occlusion

Answer 374

intermittent claudification pain on exertion, relieved by rest partial lumen occlusion atherosclerotic

Question 375

critical limb ischaemia: when is there pain, and what is there a risk of getting 2

Answer 375

pain at rest gangrene and infection

Question 376

ix for PVD 3

Answer 376

1. ABPI 2. colour duplex ultrasound imaging- assesses degree of stenosis 3. CT angiography if surgery is considered

Question 377

what does ABPI stand for, what is it what is classed as normal and explain what the value for results means

Answer 377

ankle brachial pressure index compares blood pressure in upper and lower limbs as a ratio 0.5-0.9= intermittent claudication less than 0.5= critical limb ischaemia absent/0= risk of acute limb threatening ischaemia

Question 378

treatment for intermittent claudification (5)

Answer 378

1. reduce risk factors eg stop smoking 2. exercise programme for intermittent which trains through the pain to stimulate collateral blood supply growth 3. meds: 80mg highest dose statin, clopidogrel is 1st line for PAD 4. according to NICE, can give naftidrofuryl oxalate: vasodilator (for pt with poor QOL) 5. if severe: percutaenous transluminal angioplasty +/- stent placement

Question 379

treatment for critical limb ischaemia (1)

Answer 379

surgical emergency requires revascularisation within 4-6 hours otherwise there is an increase amputation risk via percutaenous transluminal angioplasty +/- stent

Question 380

what are the 6 Ps and how can they assess the severity of the acute limb ischaemia

Answer 380

6 Ps: pulselessness, pallor, pain, persistently cold, paralysis, parasthesia ->the more of these 6 Ps that you have, the more severe the ischaemia

Question 381

How is BMI calculated and state the classifications

Answer 381

BMI = weight (kg) / height (m) squared Underweight < 18.49 Normal 18.5 - 25 Overweight 25 - 30 Obese class 1 30 - 35 Obese class 2 35 - 40 Obese class 3 > 40

Question 382

What is the mx for obesity 4

Answer 382

1. conservative: diet, exercise 2. orlistat -> pancreatic lipase inhibitor 3. liraglutide injections -> GLP1 4. types of bariatric surgery: -> laparoscopic-adjustable gastric banding -> sleeve gastrectomy -> Roux-en-Y gastric bypass surgery

Question 383

What are the NICE guideline criteria for medical mx of obesity

Answer 383

orlistat: -> BMI of 28 kg/m^2 or more with associated risk factors, or -> BMI of 30 kg/m^2 or more -> continued weight loss e.g. 5% at 3 months ->orlistat is normally used for < 1 year liraglutide (SC daily injection) -> person has a BMI of at least 35 kg/m² -> prediabetic hyperglycaemia (e.g. HbA1c 42 - 47 mmol/mol)

Question 384

What is classed as obesity in pregnancy

Answer 384

BMI >= 30 kg/m² at the first antenatal visit

Question 385

What is the mx for obesity in pregnancy?

Answer 385

1. obese women should take 5mg of folic acid, rather than 400mcg 2. screened for gestational diabetes with an oral glucose tolerance test (OGTT) at 24-28 weeks 3. if the BMI >= 35 kg/m² women should give birth in a consultant-led obstetric unit (as obesity increases risk of complications at birth and fetal complications) 4. if the BMI >= 40 kg/m² should have an antenatal consultation with an obstetric anaesthetist and a plan made (" ") | 543O

Question 386

What is the ix 1 and mx 4 for bursitis?

Answer 386

ix: joint aspiration for when septic bursitis/ crystal arthropathy is suspected 1. modify activities to ensure not putting pressure on affected joint 2. conservative: ice and elevation 3. NSAIDs 4. corticoid injections for chronic bursitis

Question 387

What is bursitis? What are the symptoms of bursitis? 3

Answer 387

Inflammation of the bursa (fluid filled sacs in joints) that become inflammed due to repetitive trauma 1. dull achy pain 2. swelling over area 3. redness

Question 388

What are the five types of bursitis?

Answer 388

1. prepatellar (knee) 2. olecranon (elbow) 3. trochanteric (hip) 4. subacromial (shoulder) 4. retrocalcaneal bursitis (back of heel) only one joint is affected usually on presentation

Question 389

Explain screening for AAA

Answer 389

all men aged 65 offered US screening for asymptomatic AAA -> women only screened 70+ with existing co-morbidities eg fhx or CV disease -> done via abdo US -> if aorta diameter 3cm+ then refer to vascular team (urgent referral if 5.5+)

Question 390

Explain screening for bowel cancer

Answer 390

FIT tests sent every 2 years for people between 60-74 -> if FIT is postiive then sent for colonoscopy -> people with rfx eg FAP, HNPCC or IBD are offered a colonoscopy at regular intervals to screen for bowel cancer

Question 391

Explain screening for diabetic eyes and results

Answer 391

yearly eye checks, if last 2 tests were clear then in 2 years -> tropicamide put into eyes to make pupils large so photo can be taken of back of eye results: STAGE : background retinopathy means small changes but vision unaffected, non-proliferative STAGE 2: pre-proliferative retinopathy means widespread changes in the retina, including bleeding= more frequent screening STAGE 3: proliferative retinopathy= retinal detachment, risk of vision loss, needs referral for treatment DIABETIC MACULOPATHY: leaky/ blocked blood vessels supplying macula, risk of vision, needs more frequent testing and treatment

Question 392

What are the different types of diabetic eye disease 4

Answer 392

1. diabetic retinopathy (haemorrhages, cotton wool spots, aneurysm) 2. diabetic macular odema (leaky BV cause fluid build up in macula= blurry vision) 3. cataracts (high sugar levels over time damage the eye lens= less flexible and less transparent= cloudy vision and sensitivity to light/ glares) 4. glaucoma (damaged retina BV= abnormal collaterals= block fluid from draining out of eye= increased eye pressure= blurry vision)

Question 393

What is the care after newborn birth 5

Answer 393

1. clamp the umbilical cord 2. skin to skin, keeping baby warm 3. vitamin K injection (baby's have deficiency so this prevents bleeds and stimulates baby to cry to open up lungs) 4. measure baby's weight and length 5. screening: -> NIPE within 72 hours -> blood spot test -> newborn hearing test

Question 394

Expain the newborn spot test

Answer 394

-> test on day 5 with parental conset screenign for 9 congenital conditions: eg sickle cell disease, cystic fibrosis, congenital hypothyroidism, Maple syrup urine disease | 4 Ss: (S for Spot) SIckle, Systic, Slow (cong hypothyroid), Syrup

Question 395

Explain screening done in NIPE

Answer 395

1. oxygen sats (should be 94+) 2. head: circumference, fontanelle, red reflex, cleft lip/ palate, suckling reflex, tone 3. shoulder/ hand: shoulder symmetry for clavicle fracture, check all digits are present 4. chest: heart and breath sounds 5. abdo: check umbilicus for healing, check for hernias 6. genitals: descended testes, patent anus, check it is being cleaned well, ask if baby opened bowel yet 7. legs: check digits, symmetry of legs, Barlows (to dislocate (Dr Barlow= bad)- involves addution and putting pressure down) and Ortolani manouveres, femoral pulse 8. back: spina bifida 9. reflexes: Moro (startle), rooting (turning head towards the direction where something touched their mouth), grasp, stepping 10. any abnormalities, refer (undescended testes) or US (hip clicking)

Question 396

What are the MC causes of COPD 2

Answer 396

smoking alpha 1 antitrypsin deficiency

Question 397

What are COPD CXR signs 3

Answer 397

barrel chest flat hemidiaphragm hyperinflation bullae (big fat heart- meaning chest)

Question 398

What are the sx of an acute exacerbation of COPD 3

Answer 398

1. increased green sputum 2. increase in cough 3. increase inSOB

Question 399

What are the causes of acute exacerbation of COPD 2

Answer 399

1. haemophilus influenza (MC) 2. strep pneumoniae

Question 400

What is the tx for acute exacerbation of COPD 3

Answer 400

1. pred 30mg for 5 days 2. abx only if sputum is purulent or clinical signs of pneumonia (amoxicillin) 3. admisison if severe SOB, O2 sats less than 90: give 02 with venturi mask at 4L/min with target sats of 88-92

Question 401

What is the risk for patients with acute exacerbation of COPD and how is this risk managed?

Answer 401

risk of developing type 2 resp failure non invasive ventilation

Question 402

What are the ix for COPD diagnosis and how does the severity scale work?

Answer 402

spirometry to demonstrate airflow obstruction: FEV1/FVC ratio less than 70% FEV1 is used to rank severity: >80= stage 1 mild (symptoms need to be present to diagnosed COPD in these patients) 50-79= stage 2 moderate 30-49= stage 3 severe <30= stage 4 very severe

Question 403

What is the mx for stable COPD? 5

Answer 403

1. lifestyle: stop smoking 2. vaccinations: annual influenza, one off- pneumococcal vaccine 3. first line SABA 4. if asthmatic features/ features that suggest steroid responsiveness then add regular LABA + ICS, otherwise LABA + LAMA 5. prophylactic azithromycin (ECG needs to be done as azithromycin can prolong QT interval) 6. pulmonary rehabilitation for MRC 3+ individuals

Question 404

What are the extra tests for COPD? 5

Answer 404

1. FBC to exclude polycythaemia, anaemia and infection 2. CXR to exclude lung cancer 3. BMI (weight loss can occur in severe disease) 4. sputum culture (for recurrent infections) 5. Serum alpha-1 antitrypsin to look for alpha-1 antitrypsin deficiency

Question 405

What are the MRC scale grades

Answer 405

Grade 1: Breathless on strenuous exercise Grade 2: Breathless on walking uphill Grade 3: Breathlessness that slows walking on the flat Grade 4: Breathlessness stops them from walking more than 100 meters on the flat Grade 5: Unable to leave the house due to breathlessness

Question 406

SABA, LAMA, LABA, ICS, LRA: what does each stand for and examples for each

Answer 406

SABA: short acting brochodilator agonist, salbutamol SAMA: short acting muscarinic agonist, ipratropium bromide LAMA: long acting muscarinic agonist, tiotropium bromide LABA: long acting brochodilator agonist, salmetorol ICS: inhaled corticosteroids, beclomethasone dipropionate LRA: leukotriene receptor antagonist, montelukast

Question 407

What is infa