GP3 Flashcards
1
Q
Which general areas does eczema commonly present in adults? [1]
Name three areas
A
In adults, eczematous lesions commonly involve flexural areas
- antecubital fossae (inner elbows), popliteal fossae (behind knees), wrists, ankles, neck folds, axillae, and inguinal folds. However, eczema can also involve other sites such as the face, hands, feet, and trunk.
2
Q
Name this complication of chronic ezcema [1]
What is it characterised by? [3]
A
Lichen Simplex Chronicus:
- may develop secondary to chronic scratching or rubbing in response to pruritus
- characterized by well-demarcated plaques with lichenification, hyperpigmentation, and scaling.
3
Q
Name this complication of ezcema [1]
Why does it occur? [1]
A
Prurigo nodularis
- Characterized by multiple firm, itchy nodules that result from repeated scratching or picking at eczematous lesions.
4
Q
What are the requirements for diagnosis of ezcema?
A
An itchy skin condition in the last 12 months
Plus three or more of
* Onset below age 2 years (not used if below 4)
* History of flexural involvement
* History of generally dry skin
* Personal history of other atopic disease
* Visible flexural dermatitis
5
Q
Describe the conservative and medication used to treat eczema [+]
A
Conservative:
- Education to prevent remission / relapsing and complications
- Explanation medications do not cure but majority of children will grow out of it
- simple measures: cotton clothing / bedding, keep cool, avoid pets, rinse clothes adequately, moisturizer at school, avoid all soaps, house dust mite avoidance
Topical Preparations:
- Emollients - varies from water based to oil based; use all the time even when skin is clear
- bath oils/soap substitutes
Topical steroids - e.g. hydrocortisone 1%
- acute - strong steroid for 5-7 days
- chronic - use lowest appropraite potency, 10-14 days
- USE WITH EMOLLIENT
Phototherapy:
- Narrowband ultraviolet B (NB-UVB) phototherapy can be considered for patients with moderate-to-severe eczema who have not responded adequately to topical therapies
Topical immunomodulators
- calcineurin inhibitors - tacrolimus & pimecrolimus
.
6
Q
Describe the NICE CG 57 (2021 update) describes the following stepped apprach to management of eczema [+]
A
Mild:
* Emollients
* Mild potency topical corticosteroids
Moderate:
* Emollients
* Moderate potency topical corticosteroids
* Topical calcineurin inhibitors
* Bandages
Severe:
* Emollients
* Potent topical corticosteroids
* Topical calcineurin inhibitors
* Bandages
* Phototherapy
* Systemic therapy
7
Q
Which drugs can be used to manage itch in eczema? [2]
A
The use of sedating antihistamines, such as hydroxyzine or chlorphenamine, can be considered for short-term relief of itch and sleep disturbance
8
Q
Describe the stepwise ladder for treating eczema using steroids [4]
A
Mild:
- Hydrocortisone 0.5%, 1% and 2.5%
Moderate
- : Eumovate (clobetasone butyrate 0.05%)
Potent:
- Betnovate (betamethasone 0.1%)
Very potent:
- Dermovate (clobetasol propionate 0.05%)
9
Q
Which steroids might be used to treat areas such as face and genitals eczema [1]
Which steroids might be used to treat the rest of the body for eczema [1]
A
Face and genitals:
- hydrocortisone 1%
Rest of body:
- betamethasone valerate 0.1% - if severe or thicker skin
10
Q
How do emollients work to treat eczema? [1]
How often should patients apply it? [1]
A
They provide symptomatic relief by hydrating the skin, reducing transepidermal water loss and restoring the skin barrier function
Patients should be advised to apply emollients liberally and frequently (at least twice daily) even when their skin appears clear. Emollient choice should be tailored to individual preferences (e.g., creams, ointments or lotions) to improve adherence.
11
Q
A
eczema herpeticum
- Eczema herpeticum is a viral skin infection in patients with eczema caused by the herpes simplex virus (HSV) or varicella zoster virus (VZV). Patients can be very unwell.
12
Q
A
Wiskott-Aldrich syndrome causes primary immunodeficiency due to a combined B- and T-cell dysfunction. It is inherited in a X-linked recessive fashion and is thought to be caused by mutation in the WASP gene.
13
Q
A
PKU
14
Q
What condition is shown? [1]
Where can / does eczema present differently in black ethnicities compared to white skin? [1]
A
Eczema
Those of black ethnicity may demonstrate a different distribution with rashes affecting the extensor surfaces. Affected skin can develop patches of both hypo and hyperpigmentation.
15
Q
Infection to which pathogen often occurs in eczema? [1]
How do you treat? [1]
A
Secondary S.aureus: patients present with crusty, oozing rash with associated erythema. Disease is often mild and antibiotics may be avoided in those who are systemically well. New supplies of emollients and topical corticosteroids should be given and regular review organised.
Treatment is with oral antibiotics, particularly flucloxacillin.
16
Q
Describe what is meant by psoriasis [2]
A
Psoriasis is a common, chronic, inflammatory papulosquamous disorder typically characterised by well-demarcated, scaly plaques and a relapsing-remitting course.
It is frequently associated with systemic diseases (e.g. psoriatic arthritis) and can also impact **individuals’ self-esteem and mental wellbeing. **
17
Q
Describe the pathophysiology of psoriasis [1]
A
Psoriasis is an immune-mediated disease featuring hyperproliferation of the epidermis.
The pathophysiology of psoriasis is complex and incompletely understood. It has been demonstrated that the immune system plays a key role - becoming activated and resulting in inflammatory plaques on the skin.
18
Q
It is estimated that a third of patients with psoriasis will develop psoriatic []
A
It is estimated that a third of patients with psoriasis will develop psoriatic arthritis.
19
Q
Describe the following subtypes of psoriasis:
- Psoriatic nail disease [6]
A
Psoriatic nail disease
- Fingernails are involved in around 50% of cases and toenails in 35%. In patients with psoriatic arthritis, nail changes are very common affecting 90%.
- Subungual hyperkeratosis
- Nail pitting
* Oil drop discolouration (yellow/pink patches)
* Leukonychia (white discolouration)
* Onycholysis (detachment of the nail from the nail bed)
* Splinter haemorrhages
20
Q
Describe the the subtypes of psoriasis:
- chronic plaque psoriasis
A
- raised, scaly, well-demarcated plaques
- symmetrically distributed
- scalp, extensor surfaces, trunk, gluteal cleft and knees.
- Lesions are typically itchy and may become fissured and painful over joint lines, on the palms of the hand or soles of the feet.
21
Q
What is Auspitz’s sign in psoriasis? [1]
A
If the scale is removed, a red membrane with pinpoint bleeding points may be seen (Auspitz’s sign)
22
Q
Describe what is meant by Guttate psoriasis [1]
A
Also termed raindrop psoriasis:
- it presents as a sudden eruption of small circular plaques classically 2 weeks following a streptococcal sore throat.
- It can also occur as a flare of disease in patients with pre-existing psoriasis.
It is generally self-limiting resolving over 3-4 weeks but around a third will develop classic plaque psoriasis.
23
Q
Localised pustular psoriasis effects which parts of the body? [1]
What is a strongly associated RF? [1]
A
Localised pustular psoriasis:
- Localised (palmoplantar) psoriasis generally affects the hand and feet
- . Pustules develop along with plaques. It is strongly associated with smoking.
24
Q
Describe how you treat psoriasis
A
Regular emollients may help to reduce scale loss and reduce pruritus
1st line:
- topical potent corticosteroid OD AND vitamin D analogue (e.g., calcipotriol)
- should be applied separately, one in the morning and the other in the evening
- for up to 4 weeks as initial treatment
- - if no improvement by 8 weeks go to…
2nd line:
- vitamin D analogue BD
- if no improvement by 8-12 weeks go to…
3rd line:
- potent vitamin D BD for up to 4 weeks, tar, short-acting dithranol
25
Describe the secondary care management of psoriasis
**Phototherapy**
* **narrowband ultraviolet B light** is now the treatment of choice. If possible this should be given **3 times a week**
* **photochemotherapy** is also used - **psoralen + ultraviolet A light (PUVA)**
adverse effects: skin ageing, squamous cell cancer (not melanoma)
**Systemic therapy**
* * oral **methotrexate** is used first-line. It is particularly useful if there is associated joint disease
* **ciclosporin**
* **systemic retinoids**
* biological agents: **infliximab**, **etanercept** and **adalimumab**
* **ustekinumab** (IL-12 and IL-23 blocker) is showing promise in early trials
26
How do you treat **Scalp Psoriasis** [2] and **Face, Flexural and Genital Psoriasis**? [2]
**Scalp Psoriasis Management:**
- 1st line **topical potent corticosteroids (OD, 4 weeks**), no improvement different formation, different topical agent
**Face, Flexural and Genital Psoriasis Management:**
- mild or moderate potency corticosteroid corticosteroid applied once or twice daily for a maximum of 2 weeks
27
What is important to note about calipotriol (vit d analagoues) treatment for psoriasis? [3]
they tend to reduce the scale and thickness of plaques but not the erythema
they should be avoided in pregnancy
the maximum weekly amount for adults is 100g
28
The following factors may exacerbate psoriasis [5]
* trauma
* alcohol
* drugs: beta blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors, infliximab
* withdrawal of systemic steroids
29
What does
30
What are the key types of depression?
**Major depressive disorder** (which we typically refer to as depression)
**Persistent depressive disorder** - ⩾ 2 years of a depressed mood for most of the day, for most days.
**Premenstrual dysphoric disorder** - low mood +/- anxiety and irritability in the luteal phase that impacts daily function.
31
Which features are core to a depression diagnosis? [3]
Which other emotional, cognitive, physical and behavioural symptoms might be present? [4]
**Depression is typically characterised (core features) by...**
* Decreased interest or pleasure (anhedonia) in most activities.
* Fatigue
* Depressed or irritable mood
AND:
**Change in...**
* Weight (↑/↓)
* Sleep (↑/↓)
* Activity (agitated/slowed)
* Concentration (low/more indecisiveness)
**Suicidality**
**Guilt/worthlessness**
32
Traditionally, depression severity has been grouped under 4 categories (subthreshold, mild, moderate and severe).
The updated NICE guideline uses a simpler 2 category definition of depression: [2]
Describe which levels of depression fall into^
Traditionally, depression severity has been grouped under 4 categories (subthreshold, mild, moderate and severe).
The updated NICE guideline uses a simpler 2 category definition of depression: **less severe or more severe depression.**
- **Less severe depression** encompasses **subthreshold** and mild **depression**
- **More severe depression** encompasses **moderate** and **severe** **depression**
33
Thresholds on validated scales were used in this guideline as an indicator of severity
a score < **[]** on the PHQ-9: less severe depression
a score of ≥ **[]** on the PHQ-9: severe depression
Thresholds on validated scales were used in this guideline as an indicator of severity
a score **< 16** on the PHQ-9: **less severe depression**
a score of **≥ 16** on the PHQ-9: **severe depression**
34
Which symptoms, and how long do they need to last for, for a diagnosis of clinical depression?
Typically, a clinical diagnosis: **≥5 of the below symptoms, present for ≥2 weeks**
35
How do you treat the following levels of depression
- Mild [2]
- Moderate [2]
- Severe [3]
| GP notes
**Mild**:
- **guided self-help**
- **CBT**
**Moderate**:
- **interpersonal therapy**
- **medication**: first line - **SSRIs** are first line (**sertraline** in adults, **fluoxetine** in paediatrics).
**Severe**:
- **interpersonal therapy, medication +/- admission or antipsychotics.**
36
Treatment options, listed in order of preference by NICE for depression are [++]
Treatment options, listed in order of preference by NICE
* **a combination of individual cognitive behavioural therapy (CBT) and an antidepressant**
* individual CBT
* individual behavioural activation (BA)
* antidepressant medication
selective serotonin reuptake inhibitor (SSRI), or
serotonin-norepinephrine reuptake inhibitor (SNRI), or
another antidepressant if indicated based on previous clinical and treatment history
* individual problem-solving
* counselling
* short-term psychodynamic psychotherapy (STPP)
* interpersonal psychotherapy (IPT)
* guided self-help
* group exercise
37
What are side effects of SSRIs such as sertraline? [4]
Side effects: GI bleeding, GI discomfort, sexual dysfunction, nausea.
Very high doses or use of other medication that increases serotonin levels (e.g., tramadol) can lead to serotonergic syndrome (emergency).
38
Define General Anxiety Disorder [GAD]
GAD is defined as **chronic, excessive worry** for **at least 6 months** that causes **distress or impairment.**
*Remember anxiety is a broad term encompassing GAD alongside other conditions such as obsessive-compulsive disorder, panic disorder and social anxiety disorder. These other conditions are 🧠Differentials for GAD*
39
Describe the treatment for mild [3] and moderate-severe GAD [3]
**Mild**:
- guided self-help, CBT, mindfulness
**Moderate-severe:**
- **CBT, relaxation therapy, medication**
💊Typically, SSRIs or SNRIs (serotonin-noradrenaline reuptake inhibitor) are first line
- **SSRIs**: **duloxetine** or **escitalopram** in adults
- **SNRIs**: **venlafaxine** in adults
40
41
Osteophytes are a hallmark of
Osteomalacia
Osteopenia
Osteosarcoma
Osteoarthiritis
Osteoporosis
Osteophytes are a hallmark of
Osteomalacia
Osteopenia
Osteosarcoma
**Osteoarthiritis**
Osteoporosis
42
This CT is suggestive of a patient with
Osteomalacia
Osteopenia
Osteosarcoma
Osteoarthiritis
Osteoporosis
**Osteoporosis** - kyphosis present
43
Which of the following is associated with RA?
* Heberden's nodes
* Boutonniere deformity
* Bouchard's nodes
* Sadness
**Boutonniere deformity**
44
Name this RA symptom [1]
Boutonniere deformity
45
Label A-D of RA symptoms
A: ulnar deviation
B: z-deformity
C: swan neck
D: Boutonniere deformity
46
# RA
Label A & B
A: swan neck deformity
B: Boutonniere deformity
47
Which of these joints would you least likely see swollen & painful joints in RA?
metacarpophalangeal (MCP)
Metatarsophalangeal (MTP)
proximal interphalangeal (PIP)
distal interphalangeal (DIP)
**distal interphalangeal (DIP)**
48
Rheumatoid factor is found on which Ig
IgG
IgA
IgM
IgD
IgE
**IgM**
49
A 58 year old woman is seen by her GP after a left wrist fracture. She was standing on a chair to change a lightbulb, lost her balance and feel off onto her outstretched hand. She was seen in A&E, where a cast was applied. She was followed up in the fracture clinic, where the cast was removed and she was discharged. The discharge letter requested that her GP review her risk of future fractures. She says she leads a healthy lifestyle, with a balanced diet and regular exercise. She does not smoke or drink alcohol and has no significant ongoing medical problems.
A DEXA scan is arranged, which shows a T-Score at the hip of -2.1.
What term best describes her bone mineral density?
Osteopenia
Osteosclerosis
Normal
Osteoporosis
Osteomalacia
**Osteopenia**
50
A 58-year-old male presents with severe pain in his left knee. This came on suddenly this morning and is not relieved by paracetamol. He is systemically well and has no significant past medical history, except for a BMI of 31. He was assessed by colleagues in the emergency department, with joint aspiration showing positively birefringent, rhomboid-shaped crystals.
What is the most likely diagnosis?
Osteomyelitis
Septic arthritis
Gout
Psoriatic arthritis
Pseudogout
**Pseudogout**
Pseudogout presents with positively birefringent crystals, often described as "rhomboid" in shape. In comparison, gout crystals are negatively birefringent crystals, often described as "needle" in shape.
51
A 58-year-old woman goes to see her GP complaining of enlarging nodules around the olecranon processes of both elbows. She originally noticed them a year ago, but has attended today as they have been getting slowly larger, more unsightly and tender. She reports no longer being able to rest on her elbows.
She is known to be under a Rheumatologist for a chronic inflammatory arthropathy and has been taking Methotrexate for the last eight months.
An image of her elbow is provided below.
What disease is her rheumatologist treating her for?
Source: Dr J.Atkins
Ankylosing Spondylitis
Gout
Psoriatic Arthritis
Seropositive Rheumatoid Arthritis
Seronegative Rheumatoid Arthritis
**Seropositive Rheumatoid Arthritis**
This is a typical **rheumatoid nodule**. They can occur in any tissue, but the commonest sites where they are clinically apparent are the olecranon area of the elbow and the extensor surfaces of the fingers/wrists. **They are only found in seropositive rheumatoid arthritis**.
52
A 40-year-old man presents to the emergency department with an acutely swollen and extremely painful left knee. This started suddenly and woke him from sleep. He has no past medical history and takes no regular medication. The man is overweight and admits to having at least 4 pints of beer a night for as long as he can remember.
On examination, he has a temperature of 37.6°C, but observations are otherwise normal. He is systemically well. The left knee appears erythematous and tender to touch. Urine dipstick is normal.
Synovial fluid is aspirated from the left knee, and microscopy is performed and demonstrated below.
Euthman. License [CC BY 2.0].
What is the most likely diagnosis?
Gout
Osteoarthritis (OA)
Hydroxyapatite deposition disease (HADD)
Septic arthritis
Pseudo-gout
**Gout**
53
Platelet rich plasma (PRP) is a novel treatment process for
Osteoporosis
Osteomalacia
Osteoarthritis
Rheumatoid arthritis
**Osteoarthritis**
54
# OA
Red arrow highlights
- Loss of joint space
- Osteophytes
- Subarticular sclerosis
- Subchondral cysts
**symmetric joint space narrowing (because it is harder to see what is not there, this is best appreciated by mentally contrasting with the NORMAL joint space, shown by red arrow on the figure to the left)**,
55
# OA
Orange arrow highlights
- Loss of joint space
- Osteophytes
- Subarticular sclerosis
- Subchondral cysts
**Osteophytes**
56
# OA
Blue arrow highlights
- Loss of joint space
- Osteophytes
- Subarticular sclerosis
- Subchondral cysts
Subchondral cysts
57
Green arrow highlights
- Loss of joint space
- Osteophytes
- Subarticular sclerosis
- Subchondral cysts
subchondral sclerosis (the white line at the surface green arrow),
58
Erosive OA typically has erosion of cartilage in
Thumb DIP
Index finger PIP
Middle finger DIP
4th finger PIP
Little finger DIP
**Middle finger DIP**
59
This is a patient with OA. The arrow points to
- Loss of joint space
- Osteophytes
- Subarticular sclerosis
- Subchondral cysts
**Subchondral cysts**
60
Name this symptom of gout [1]
Gout **tophi**
61
Name this symptom of gout [1]
Podagra
62
Rat bite erosions would suggest a patient is suffering from
Gout
Osteoarthritis (OA)
Hydroxyapatite deposition disease (HADD)
Septic arthritis
Pseudo-gout
**Gout**
63
This histological slide is suggestive of
Gout
Osteoarthritis (OA)
Hydroxyapatite deposition disease (HADD)
Septic arthritis
Pseudo-gout
Gout
Figure 1. Typical granuloma in gout. The central part is formed by urate crystals. The inflammatory cells surrounding the area of crystals typical include macrophages, lymphocytes, plasma cells and giant cells. This is typical morphology within tophi. No histologic morphology of a coexisting rheumatoid arthritis was present. Fixation: formalin. H&E: amplification, × 20.
64
Name the molecule that would be elevated in this patient
Monosodium urate crystal
(patient has gout)
65
A patient has synovial fluid extracted and it looks like this. What is the patient most likely suffering from
Gout
Osteoarthritis (OA)
Hydroxyapatite deposition disease (HADD)
Septic arthritis
Pseudo-gout
**Gout**
66
Gout is a disorder in which deposits of uric acid crystals accumulate in the joints because of high blood levels of uric acid. Which of the following is the most common cause of high blood levels of uric acid?
Consumption of too much alcohol
Inadequate elimination of uric acid via the kidneys
Infection causing build-up of uric acid
Production of too much uric acid in the body
**Inadequate elimination of uric acid via the kidneys**
67
Which of the following joints is most commonly affected by uric acid crystal accumulation and gout attacks?
A.
Big toe
B.
Fingers
C.
Hip
D.
Shoulder
**Big toe**
68
Sudden gout flare-ups (attacks) can occur without warning. Which of the following is NOT a known trigger of a sudden gout flare-up?
Illness
.
Injury
Use of certain antidepressant medications
Use of certain blood pressure medications
**Use of certain antidepressant medications**
69
What type of hypersensitivity reaction is rheumatoid arthritis?
It isn't a hypersensitivity reaction
Type 2
Type 1
Type 3
Type 4
Type 3
70
You are assessing a referral report for one of your patients which mentions that the HLA DR1 gene has been identified.
What disease is this indicative of?
Sjogrens
SLE
Rheumatoid arthritis
Scleroderma
Polymyositis
**Rheumatoid arthritis**
Rheumatoid arthritis is associated with the following antibodies: HLA DR1, HLA DR4, Anti CCP, ACPA (can be positive or negative).
71
A patient with diagnosed osteoarthritis visits his GP about some swellings that have developed in his hands. The GP explains that the swellings the patient is concerned about are called Bouchard's nodes.
Where are Bouchard's nodes located?
Metacarpophalangeal (MCP) joints
Proximal interphalangeal (PIP) joints
Carpometacarpal (CMC) joints
Distal interphalangeal (DIP) joints
Base of the thumb
**Proximal interphalangeal (PIP) joints**
72
Which one of the following is used in the management of acute gout?
Allopurinol
Febuxostat
Probenecid
Colchicine
**Colchicine**: inhibits microtubule polymerisation by binding tubulin. This impairs neutrophil chemotaxis and degranulation
73
High uric acid levels are common. Above what level uric acid would indicate gout & therefore should be treated ?
9 mg/dL
10 mg/dL
11mg/dL
12mg/dL
13 mg/dL
**11mg/dL**
74
Colchicine is first line treatment for
Acute Gout
Chronic gout
Septic arthritis
Acute pseudo-gout
Chronic pseudo-gout
**Acute Gout**
75
Which of the following treatments for chronic gout blocks xanthine oxidase [2]
Rasburicase
Allopurinol
Probenecid
Uricosuric
Febuxostat
Allopurinol; Febuxostat
76
Which of the following treatments for chronic gout catalyses conversion of uric acid to allantoin
Rasburicase
Allopurinol
Probenecid
Uricosuric
Febuxostat
Rasburicase
77
Which is the most commonly affected joint in pseudogout?
Elbow
Hip
Wrist
Knee
Knee
78
Cholesterol crystals are associated with
Pseudogout
Gout
RA
OA
**RA**: cholesterol crystals
79
Deposition of which type of crystal is characteristic of gout?
Calcium pyrophosphate
Monosodium urate
Monosodium phosphate
Calcium urate
Monosodium pyrophosphate
**Monosodium urate**
80
A 55-year-old man presents to the emergency department with acute knee pain. There is no history of fever or trauma. He has a past medical history of hypertension.
On examination, he is afebrile. His left knee looks swollen and erythematous; there is a positive patellar tap and restricted passive and active joint movement.
His left-knee X-ray is normal, with no acute pathology seen.
The results of his joint aspiration are shown below.
What is the most likely diagnosis?
Pseudogout
Psoriatic arthritis
Gout
Rheumatoid arthritis
Septic arthritis
Gout
81
Which of the following statements does not fit with a diagnosis of rheumatoid arthritis?
There are radiographic changes that show erosion of the affected joints
The arthritis is symmetrical in nature
The patient has no morning stiffness
The small joints of the hands/feet are affected
The patient has no morning stiffness
82
A 53-year-old male is diagnosed with a first episode of acute gout.
His past medical history is significant for peptic ulcer disease, essential hypertension and type 2 diabetes mellitus. He takes esomeprazole 40 mg daily PO, ramipril 5 mg daily PO, and metformin 1 g BD PO. He has no allergies.
Based on the above, which of the following would be the most appropriate treatment option?
Prednisolone
Allopurinol
Febuxostat
cA 53-year-old male is diagnosed with a first episode of acute gout.
His past medical history is significant for peptic ulcer disease, essential hypertension and type 2 diabetes mellitus. He takes esomeprazole 40 mg daily PO, ramipril 5 mg daily PO, and metformin 1 g BD PO. He has no allergies.
Based on the above, which of the following would be the most appropriate treatment option?
Prednisolone
Allopurinol
Febuxostat
Colchine
Naproxen
**Colchicine**
83
Synovial fluid analysis:
Colour: Yellow
Clarity: Cloudy
Viscosity: Decreased
WBC: 5000 cells/mm3 (Reference range: < 200 cells/mm3)
Neutrophils: 55 % (Reference range: < 25%)
Gram stain: Negative
Crystals: Needle-shaped, negatively birefringent crystals
Given the likely diagnosis, the recent introduction of which medication may have precipitated this pathology?
Atenolol
Bisoprolol
Furosemide
Amlodipine
Lisinopril
**Furosemide**
84
Which of the following joints are most commonly affected by rheumatoid arthritis?
Sacroiliac joint
Gleno-humeral
Knee and elbow joints
Small joints of the hands and/or feet
Sterno-clavicular
Small joints of the hands and/or feet
85
A 67-year-old female was recently discharged from the coronary care unit with a diagnosis of heart failure. She arrives at her outpatient appointment and complains she has developed severe pain and swelling in the base of her right big toe. The doctor reviews her medication and decides to remove one of her regular medications.
Which of the following was most likely stopped?
Amlodipine
Nitrates
Bendroflumethiazide
Atorvastatin
Rosuvastatin
**Bendroflumethiazide**: Ptx has gout; Thiazide diuretics, low-dose aspirin **block uric acid secretion**, hence increases its blood level.
86
A 65-year-old presents to the emergency department with a very painful right wrist.
This started 12 hours ago, there is no history of trauma and he has been well recently. He experienced something similar in his left big toe last month but did not seek medical attention and it resolved over a few days.
On assessment, his heart rate is 95 beats per minute but other observations are within normal limits. His right wrist is red and swollen and a joint aspiration is performed.
What is most likely to be found on analysis of the joint aspiration?
Multiple gram-negative cocci
Multiple gram-positive cocci
Needle-shaped crystals negatively birefringent under polarised light
Needle-shaped crystals positively birefringent under polarised light
Rhomboid-shaped crystals positively birefringent under polarised light
Needle-shaped crystals **negatively** birefringent under polarised light
87
Name this sign of RA [1]
**Bakers cyst**: cyst in the popliteal fossa
88
Name this complication of RA [1]
scleromalacia perforans
89
Name this complication of RA [1]
Keratoconjunctivitis sicca
90
State the complication of RA depicted
scleritis
keratoconjunctivitis sicca
episcleritis
scleromalacia perforans
**episcleritis**
91
State the complication of RA depicted
scleritis
keratoconjunctivitis sicca
episcleritis
scleromalacia perforans
**scleritis**
92
State the complication of RA depicted
scleritis
keratoconjunctivitis sicca
episcleritis
scleromalacia perforans
**keratoconjunctivitis sicca**
93
State the complication of RA depicted
scleritis
keratoconjunctivitis sicca
episcleritis
scleromalacia perforans
scleromalacia perforans
94
Reactive arthritis has a triad of which 3 symptoms? [3]
Classic triad of **urethritis**, **conjunctivitis** and **arthritis**
'Can't see, pee or climb a tree'
95
# OA
What change has undertaken at A [1]?
**Eburnation** of cartilage: complete loss of cartilage, exposing bone
96
# OA
What change has undergone at the A? [1]
**Eburnation** of cartilage: complete loss of cartilage, exposing bone
97
# OA
Name the change that the arrow is pointing to [1]
**Fibrillation**: saw tooth surface irregularity of cartilage
98
During a head-to-toe assessment of a patient with osteoarthritis, you note bony outgrowths on the distal interphalangeal joints. You document these findings as:
A. Bouchard's Nodes
B. Heberden's Nodes
C. Neurofibromatosis
D. Dermatofibromas
**B. Heberden's Nodes**
99
You receive your patient back from radiology. The patient had an x-ray of the hips and knees for the evaluation of possible osteoarthritis. What findings would appear on the x-ray if osteoarthritis was present? Select-all-that-apply
A. Increased joint space
B. Osteophytes
C. Sclerosis of the bone
D. Abnormal sites of hyaline cartilage
B. Osteophytes
C. Sclerosis of the bone
100
Which area of articular cartilage does OA initiate in?
A: tangenitial layer
B: transitional layer
C: radial layer
D: calcified cartilage
E: bone
Which area of articular cartilage does OA initiate in?
**A: tangenitial layer** / superifical layer
B: transitional layer
C: radial layer
D: calcified cartilage
E: bone
101
where do each of the following arrive from?
- Muscularcutaneous
- axillary
- median
- radial
- ulnar nerve
where do each of the following arrive from?
- Muscularcutaneous: **C5-C7**
- axillary: **C5-C6**
- median: **C5-T1**
- radial: **C5-T1**
- ulnar nerve; **C8-T1**
102
A patient is found to have the following results: low serum calcium, low serum phosphate, raised ALP and raised PTH. Which condition are these findings most consistent with?
Paget's disease
Chronic kidney disease
Primary hyperparathyroidism
Osteoporosis
Osteomalacia
**Osteomalacia**
103
Which of the following commonly affects the DIP and PIP joints?
Paget's disease
Osteoathritis
Osteoporosis
Osteomalacia
Rheumatoid arthritis
**Osteoathritis**
104
Which of the following commonly affects the MCP and PIP joints?
Paget's disease
Osteoathritis
Osteoporosis
Osteomalacia
Rheumatoid arthritis
Rheumatoid arthritis
105
X-ray findings include osteophytes forming at joint margins
Paget's disease
Osteoathritis
Osteoporosis
Osteomalacia
Rheumatoid arthritis
Osteoathritis
106
State which disease causes A-C
A: RA
B: OA
C: gout
107
Saw tooth erosion is associated with which type of OA? [1]
**Erosive OA**
108
An 84-year-old gentleman presents to GP with stiffness and swelling of the joints on his right hand. On inspection, you see uniform swellings predominantly affecting the distal interphalangeal (DIP) joints, which are non-tender and hard on palpation. He is otherwise systemically well and no other joints are affected. There is no relevant past medical history.
What is the most likely clinical sign described?
Boutonniere deformity
Bouchard's nodes
Rheumatoid nodules
Heberden's nodes
Calcinosis cutis
Heberden's nodes
109
# RA
Methotrexate and Rituximab would be
First line treatment
Second line treatment
Third line treatment
Fourth line treatment
**Third line treatment**
110
# RA
Methotrexate and a 2nd line DMARD would be
First line treatment
Second line treatment
Third line treatment
Fourth line treatment
**First line treatment**
111
# RA
Methotrexate & a TNF-inhibitor would be
First line treatment
Second line treatment
Third line treatment
Fourth line treatment
**Second line treatment**
112
Methotrexate inhibits which enzyme? [1]
**dihydrofolate reductase**
113
Which is the staple treatment for RA?
Methotrexate
Sulfasalazine
Hydroxychloroquine
Leflunomide
Infliximab
Which is the staple treatment for RA?
**Methotrexate**
Sulfasalazine
Hydroxychloroquine
Leflunomide
Infliximab
114
Which treatment for RA inhibits dihydrofolate reductase?
Methotrexate
Sulfasalazine
Hydroxychloroquine
Leflunomide
Infliximab
Which treatment for RA inhibits dihydrofolate reductase?
**Methotrexate**
Sulfasalazine
Hydroxychloroquine
Leflunomide
Infliximab
115
Which treatment for RA reduces purine synthesis?
Methotrexate
Sulfasalazine
Hydroxychloroquine
Leflunomide
Infliximab
**Methotrexate**
116
Which treatment for RA reduces pyrimidine synthesis?
Methotrexate
Sulfasalazine
Hydroxychloroquine
Leflunomide
Infliximab
**Leflunomide**
117
# RA
Methotrexate and Rituximab would be
First line treatment
Second line treatment
Third line treatment
Fourth line treatment
**Third line treatment**
118
# RA
Methotrexate and a 2nd line DMARD would be
First line treatment
Second line treatment
Third line treatment
Fourth line treatment
**First line treatment**
119
# RA
Methotrexate & a TNF-inhibitor would be
First line treatment
Second line treatment
Third line treatment
Fourth line treatment
**Second line treatment**
120
Name the condition for pain at the tendon at the arrow [1]
**De Quervain’s tenosynovitis**
121
Name the condition for this tendon condition [1]
**Trigger finger**
122
What pathology is depicted here? [1]
**Trigger finger**
Superficial and deep flexor tendons with **local tenosynovitis** at the **metacarpal head subsequently develop localised nodal formation on the tendon,** distal to the pulley (Fig. 1). The **A1 pulley** is the most frequently involved ligament in trigger finger.
123
124
You require the emergency pill.
What pill would be prescribed? [1]
Up to what time point? [1]
Levonorgestrel 1.5 mg as a single dose as soon as possible, up to 72 hours after unprotected intercourse
125
A 24 year old female presents to her GP with dysuria which has been ongoing for 7 days. She had already visited her GP 3 days previously who prescribed her a course of amoxicillin based on a previous urine culture. A new culture was taken at that appointment, which has since grown E. coli producing extended spectrum beta-lactamases.
What drug should you prescribe? [1]
**Extended spectrum beta-lactamases (ESBL)** are enzymes produced by bacteria that confer resistance to both penicillin and cephalosporin based antibiotics. One of the few antibiotics these bacteria are susceptible is **nitrofurantoin**, with fosfomycin the other viable treatment option
| NB: if she was systemically unwell could give meropenum
126
She would like the most effective contraception at reducing the risk of pregnancy.
She has no past medical history.
What is the most appropriate contraception to advise her?
Contraceptive patch
Contraceptive implant
Fertility awareness method (cycle tracking)
Progestogen-only contraceptive pill
Combined oral contraceptive pill
**Contraceptive implant**
127
She is started on the combined oral contraceptive pill to help regulate her periods. What advice is appropriate to give regarding how to take these pills for the desired effect?
Take a pill every day for 14 days, followed by a 7-day pill-free interval
Take a pill every day for 3 months, followed by a 4-day pill-free interval
Take a pill every day for 28 days, followed by a 7-day pill-free interval
Continue taking pills back to back until a period is desired, then take a 7-day pill-free interval
Take a pill every day until a breakthrough bleed occurs, followed by a 7-day pill-free interval
**Take a pill every day for 3 months, followed by a 4-day pill-free interval**
128
Which contraception is the only emergency option 5 days after UPSI? [1]
**Ulipristal acetate (ellaOne)** is the only oral emergency contraception that can be given up to 5 days after UPSI
129
A 28-year-old woman presents with vulval pruritus and discharge. Erythematous plaques with satellite lesions are noted on examination.
She has presented with similar symptoms 3 times over the last 12 months.
What is the most appropriate treatment for this woman's condition?
Ciprofloxacin
Fluconazole
Azithromycin
Clotrimazole
Metronidazole
This presentation is suggestive of vulvovaginal candidiasis, which is typically caused by **Candida albicans**.
**Fluconazole** is the preferred treatment for uncomplicated vulvovaginal candidiasis.
130
A 25 year old woman attends the sexual health clinic requesting emergency contraception after having unprotected sexual intercourse (UPSI) four days ago.
The first day of her last menstrual period was 14 days ago. She has a regular 28 day cycle.
She has a past medical history of asthma and acne. Her medications include Salbutamol, Seretide, Montelukast, Prednisolone and topical Benzoyl peroxide.
What is the best management option? [1]
**Copper intrauterine device (IUD)**
The IUD is the most effective form of emergency contraception and should always be offered first-line in the absence of contraindications. Additionally, The Faculty of Sexual and Reproductive Health states that ellaOne is not recommended for women who have severe asthma, as this patient appears to have ('severe asthma' is defined here as requiring oral steroids)
131
What is the ABDCE approach to assessing moles? [5]
**A**: Asymmetry
**B**: Border irregularity (melanoma often has a 'scalloped' border)
**C:** Colour variation (a variegated lesion is one that consists of many colours)
**D:** Diameter > 6mm
**E:** Evolves over time
132
The OCP needs to be taken for [] days in a row to be effective
2
3
5
7
9
**7**
133
**[Pathogen]**, also known as traveller's diarrhoea, usually presents within **[]**–**[]** h of exposure to the pathogen and presents with crampy abdominal pain and profuse watery diarrhoea.
**Enterotoxigenic E. Coli**, also known as traveller's diarrhoea, usually presents within **12–24 h** of exposure to the pathogen and presents with crampy abdominal pain and profuse watery diarrhoea.
134
First-line pharmacological treatment in severe depression is with a **[]** such as **[]**.
First-line pharmacological treatment in severe depression is with a **selective serotonin-reuptake inhibitor (SSRI)** such as **citalopram**.
135
Which type of coil:
- Is effective for heavy periods & don't cause weight gain
- Causes periods to become heavier and longer
**Mirena coil** - Is effective for heavy periods & don't cause weight gain
**Copper intra-uterine device** - Causes periods to become heavier and longer
136
A 30-year-old female presents to your GP clinic with a headache that has been present for 2 days. She describes it as a **"throbbing" sensation** located on the right side of her head. She has no past medical history of migraines and is not currently taking any medications.
What is the most likely diagnosis?
Migraine headache
Cluster headache
Sinus headache
Temporal arteritis
Tension headache
**Migraine headache**
137
*Recurrent unilateral periorbital pain of sudden onset*
*Headache duration of 15 minutes to 3 hours, occurring once or twice daily over 4-12 weeks, followed by a pain-free period of several months*
(recurrent attacks 'always' affect same side)
Migraine headache
Cluster headache
Sinus headache
Temporal arteritis
Tension headache
**Cluster headache**
138
*Bilateral, non-pulsatile headaches
Tightness sensation, like a band around the head
Scalp muscle tenderness*
Migraine headache
Cluster headache
Sinus headache
Temporal arteritis
Tension headache
**Tension headache**
139
*Unilateral throbbing headache, potentially preceded by an aura (visual or sensory)
Headache duration of 4-72 hours
Association with photophobia and phonophobia
Possible triggers such as oral contraceptives or specific foods (e.g., chocolate)*
Migraine headache
Cluster headache
Sinus headache
Temporal arteritis
Tension headache
**Migraine headache**
140
Which of the following aspects in her history is an absolute contraindication to the combined oral contraceptive pill?
Cervical ectropion
1
Varicose veins
2
A first-degree relative with a history of venous thromboembolism
3
Smoking greater than 15 cigarettes per day
4
BMI 30 kg/m2
5
UKMEC grades any woman aged 35 years or older who smokes greater than or equal to 15 cigarettes per day a UKMEC 4 for the use of combined hormonal contraception
141
Which of the following is true regarding the OCP and its association with cancers?
Increases risk of ovarian and endometrial cancer, decreases risk of breast and cervical cancer
Increases the risk of breast, endometrial, and colorectal cancer
It is protective against breast cancer
Reduces risk of ovarian and endometrial cancer, increases risk of breast and cervical cancer
The OCP has no associations with cancer
Reduces risk of ovarian and endometrial cancer, increases risk of breast and cervical cancer
142
Which type of contranception is best for a patient with PCOS? [1]
Why? [1]
**Combined oral contraceptive pill**
it helps control period regularity, as well as other manifestations of the condition like acne
143
POP is Which one of the following statements is correct regarding the side effects of women taking the progesterone only pill?
Pelvic inflammatory disease
Increased risk of depression
Acne improves
Reduction in breast pain or discomfort
Breast discomfort is a side effect of the progesterone only pill.
Regular vaginal bleeding
**Depression** is a common or very common side effect of progesterone only pills.
144
A 7 year old girl has been diagnosed with coeliac disease. Her parents would like to know more about how coeliac disease works.
What is the pathophysiology behind the inflammatory response in coeliac disease?
T-Cell Mediated
1
Iron accumulation
2
Type IV Hypersensitivity
3
IgA Mediated
4
Type I Hypersensitivity
A 7 year old girl has been diagnosed with coeliac disease. Her parents would like to know more about how coeliac disease works.
What is the pathophysiology behind the inflammatory response in coeliac disease?
**T-Cell Mediated**
1
Iron accumulation
2
Type IV Hypersensitivity
3
IgA Mediated
4
Type I Hypersensitivity
145
Antidepressant therapy should be continued for at least [] months following remission to reduce the risk of relapse.
1 month
2 months
4 months
6 months
1 yr
**6 months**
146
Describe how you take the POP is you miss one pill:
- < 3hrs from normal time
- > 3hrs
LESS than 3 hours late: Take the missed pill. No further action required.
MORE than 3 hours late: Take the missed pill as soon as possible. If more than one pill is missed - just take one pill. Take the next pill at its usual time even if it means taking two pills in the same day.
| **Missing ONE pill for POP causes chance of preg; COPC does not**
147
What treatment do you give for empirical meningitis for these age groups:
- < 3months
- 3months - 50 years
- > 50 years
What treatment do you give for empirical meningitis for these age groups:
- < 3months: **IV cefotaxime (or ceftriaxone) & amoxicillin**
- 3months - 50 years: **IV cefotaxime (or ceftriaxone)**
- > 50 years: **IV cefotaxime (or ceftriaxone) & amoxicillin**
148
What do you give for these causes of meningitis:
- Streptococcus pneumonia
- Haemophilus influenzae
- Listeria
- Neisseria meningitidis
What do you give for these causes of meningitis:
- Streptococcus pneumonia: **IV cefotaxime**
- Haemophilus influenzae: **IV cefotaxime**
- Listeria: **Amoxicillin and gentamicin**
- Neisseria meningitidis: **IV Benpen**
