Imperial past papers Flashcards
Runner with irregular periods, where is problem
Hypothalamus
Features of CF
AR inheritance
Recurrent chest infections
Bronchiectasis
Pancreatic dysfunction
Small and skinny
CXR showing multiple air filled sacs in lungs
Septic emboli
Milky fluid drained from chest drain
Chylothorax- leakage of lymph fluid
Which cell is primarily affected in multiple sclerosis
Oligodendrocytes- myelin producing cells
How diagnose FH
Simon broome criteria
TC > 7.5 mmol/l and LDL-C > 4.9 mmol/l
WITH evidence of
- family member with xanthomas
- early MI
Useful blood investigations for polymyositis
Anti-Jo (anti synthetase)
CK
Management of metastatic spinal cord compression
Dex and urgent MRI
Consideration of radiotherapy or spinal surgery depending on suitability for surgery
How calculate units in alcoholic drink
%*mls divided by 1000
Management of neuropathic ulcer with black crust
Urgent referral as ischaemic
Post partum thyroiditis presentation
Thyrotoxicosis
Hypothyroid
Management of post partum thyroiditis
Thyrotoxicosis- give propanolol
Hypothyroid- thyroxine replacement
Management of graves if breastfeeding
All thionamides safe
Caseating necrosis with langerhans cells in bowel
TB
Differentials for granulomas in bowel
TB- necrotising
Crohns
What diet use for IBS
FODMAP
What is FODMAP diet helpful for
IBS
SBOSS
Sprain ankle- most likely ligament affected
Anterior tabofibular ligament
Types of chemo
- neoadjuvant
- adjuvant
- palliative
- curative
Neo- before main treatment eg surgery
Adjuvant- after main treatment
Palliative- prolong life
Curative- in name
What do if chemical injury to eye
Irrigate for 30 mins with saline then refer to opthal
When refer corneal foreign bodies to opthal
Suspected penetrating eye injury
Significant orbital or peri-ocular trauma has occurred.
Chemical injury
Foreign bodies composed of organic material
Foreign bodies in or near the centre of the cornea
Any red flags e.g. severe pain; irregular, dilated or non-reactive pupils; significant reduction in visual acuity.
Management of high cholesterol
Start on 20mg statin
Review after 3 months and assess if over 40% reduction in non-HDLc
- if not increase dose
Review after 3 months and reassess
- consider alternate agent
Choking BLS
Get to cough
If becomes ineffective or cant do, do 5 back blows
5 abdominal thrusts
If ineffective unresponsive at any point do CPR
Difficulty swallowing relieved by drinking lots of water
Pharyngeal pouch
What causes trifasicular block
Complete HB
If fluid restriction does not work for SIADH what use
Demecycline or tolvaptan
What causes production of ketones in DKA
Increased lipolysis
What monitor in refeeding
Phosphate
Man working on construction site with rats and pigeons, living in caravan nearby. Has abdo pain and nausea. Blood film showed basophilic stippling and sideroblasts. What is cause
Lead poisoning
Notifiable infections
Acute encephalitis
Acute infectious hepatitis
Acute meningitis
Acute poliomyelitis
Anthrax
Botulism
Brucellosis
Cholera
COVID-19
Diphtheria
Enteric fever (typhoid or paratyphoid fever)
Food poisoning
Haemolytic uraemic syndrome (HUS)
Infectious bloody diarrhoea
Invasive group A streptococcal disease
Legionnaires’ disease
Leprosy
Malaria
Measles
Meningococcal septicaemia
Monkeypox
Mumps
Plague
Rabies
Rubella
Scarlet fever
Smallpox
Tetanus
Tuberculosis
Typhus
Viral haemorrhagic fever
Whooping cough
Yellow fever
Pathophysiology of BBPV
Crystals of calcium phosphate in ear- otoconia
Which x ray plane best to do for c spine fracture
Lateral
What do with regards to head CT if on antiplatelets
Within 8 hours
NOT ASPIRIN MONOTHERAPY
What does SMA vs IMA supply
SMA- ampulla of vater onwards to distal 1/3 of transverse colon
IMA- Distal 1/3 of transverse colon onwards
Inheritance of BRCA
AD
How manage candida in catheter
Asymptomatic- change catheter
Symptomatic- oral fluconazole
How manage proteinuria in nephrotic syndrome
Reduce dietary protein
Give ACEi
Patient is brain dead, what determines prognosis
Brainstem reflexes
Patient has chronic RUQ pain with dilatation of intrahepatic ducts, what antibody
ANCA as PSC
Man rescured from house fire is wheezy with soot in mouth and nose what give
100% oxygen (worried about CO poisoning)
How feed a patient with a prolonged postoperative ileus
IV parenteral feeding
Woman with history of radiation for cervical cancer presents with continuous dribbling of urine
Vesicovaginal fistula
First line investigation for suspected laryngeal cancer
Flexi-nasoendoscopy
Which substance is the primary factor facilitating platelet adhesion?
VWB factor
A 50 year old woman has suddenly become short of breath. She has found it painful to swallow for two months, and she has coughed up a small amount of blood. She is distressed and cannot lie flat.
Her temperature is 37.5°C. Her respiratory rate is 40 breaths per minute and her oxygen saturation is 78% using 15L pe minute via a re-breather mask. She has inspiratory stridor.
What is the most appropriate action to take?
Continuous positive airways pressure ventilation
Endotracheal intubation
Nebulised bronchodilators
Oral airway
Tracheostomy
Endotracheal intubation
What scan use to plan surgery on ankle fracture
CT
A 70 year old woman is admitted with a one week history of worsening breathlessness. She looks pale. She has a temperature of 36.2°C, pulse rate 100 bpm, BP of 132/68 mmHg, JVP +8 cm above the sternal angle and oxygen saturation 94% on 40% oxygen via a face mask. She has bilateral inspiratory crepitations to the midzones. She has a pansystolic murmur at the apex.Investigations:
Haemoglobin 52 g/L (115-150)
MCV 120 fL (80-96)
White cell count 3.0 x 109/L (3.8-10.0)
Platelets 87 x 109/L (150-400)
Which is the most likely diagnosis?
Acute myeloid leukaemia
Alcoholic cardiomyopathy
Hypothyroidism
Pernicious anaemia
Viral myocarditis
Pernicious anaemia
Think HF due to anaemia
Mitral regurg can be a result of HF
Pernicious anaemia would give the very high MCV and pancytopenia
First thing do if patient develops signs of transfusion reaction
Stop
ABC
Check details
If develop raised ALT as IVDU what is most likely cause
Hep C- incidence higher in IVDU
A 19 year old man has 3 weeks of diarrhoea. He is a student and has just returned from a gap year in Thailand.
Investigations:
Haemoglobin 96 g/L (130-175)
MCV 76 fL (80-96)
Eosinophils 3.1 x 109/L (0-0.4)
Which is the most likely diagnosis?
Amoebiasis
Campylobacter
Hookworm
Shigellosis
Typhoid fever
Hookworm
Causes IDA and also as parasite will cause eosinophillia
For protozoa like amoeba would not cause eosinophillia
What is trendelenburg manoeuvre
Where position patient lying down with head beneath body
Blood film shows smear cells what is next investigation
Immunophenotyping with flow cytometry
How best diagnose giardia
Stool sample will see parasites
Patient comes in unstable with blood diarrhoea on history of IBD like symptoms, what do next
CT
X rays going out of fashion
What is preferred test nowadays for H pylori
Faecal antigen test
If HBe IgG what does this mean
NOT that necessarily actively replicating, just that previous infection
How diagnose Hep D
Anti Delta IgM
Thyroid cancer of parafollicular (C) cells
Medullary
How investigate RAS
MR/CT angio
How treat RAS
If very problematic then percutaneous renal artery angioplasty
How differentiate inferior vena cava obstruction from portal HTN
Look at vein underneath umbilicus and which direction blood is flowing
IVCO- blood flow upwards
Portal HTN- blood flows towards feet
SNAPP causes
Sulphonamides
NSAIDS
Allopurinol
Penicillin
Phenytoin
Most likely cause of amaurosis fugax
Cholesterol deposit emboli
If LP shows positive SAH what do next
CT angio
When give thiamine for seizures
Alcoholic
Malnutrition
Give straightaway in initial period before benzos
Most likely cause of medical third nerve palsy
DM
If third nerve palsy with dilated pupil only what must ensure do
Urgent imaging
If unstable UC presentation what is first thing do
CT abdomen
X rays not recommended anymore
What give for fluids refractory septic shock
Vasopressors- noradrenaline etc
When say consider stopping in AKI what is reasoning behind this
They are drugs which will accumulate and lead to toxicity if renal function is poor
When monitor CVP
Do on ITU
Helps tailor dose of inoptropes and vasopressors when treating shock
What do for AF incidentally picked up with no symptoms and normal HR
Just give DOAC
What use for AF if valvular disease
Warfarin
If cardiogenic shock from cardiac tamponade what use
Fluids
Inotropes will not work
If pericardiocentesis resistant cardiac tamponade what use to treat
Pericardial window
If someone is completely unable to take any anticoagulation what do for stroke risk in AF
Can insert left atrium appendage occlusion device
Does VT within 1 week of MI require ICD
No as very common then
What investigation do if raised troponin and angiogram normal
Cardiac MRI
Will help give idea of fibrosis/local damage to cardiac tissue
Most common site of AF impulse initiation
Pulmonary veins
What can be seen on CXR of mitral stenosis
Small nodules around lungs from haemosiderin depostion as pulmonary HTN has lead to haemolysis
How differentiate septic, cardiogenic and hypovolaemic shock
Cardiogenic= elevated BP
Septic= warm peripheries
What is seen in background diabetic retinopathy
Hard exudates
Venodilation
Microaneurysms
HTN retinopathy scale keith wagener
1- silver wiring
2- AV nipping
3- flame haemorrhages, cotton wool spots
4- papilloedema
Patient comes in with suspected stroke, what is next most important step
Contact stroke team
Then do CT
Headaches for past few days with painful eye and vomiting
Acute glaucoma
What are different types of optic neuritis
Retrobulbar- involves part of nerve behind the eye
Papillitis- involves portion of optic nerve within the eye
Are differentiated by the presence of papilloedema seen in papillitis
What type of drug is 5 fluoracil
Topical cytotoxic chemotherapy
MSC equation for osmolality
2(Na)+urea+glucose
What is difference between anterior ischaemic optic neuropathy vs central retinal artery occlusion
Anterior ischaemic optic neuropathy occurs from inflammation of vessels supplying optic nerve like in GCA
Central retinal artery occlusion occurs when is “eye stroke”
Fundoscopy differences between anterior ischaemic optic neuropathy and central retinal artery occlusion
Anterior ischaemic optic neuropathy- engorged disc which appears swollen
Retinal artery occlusion- pale retina with cherry red spot in macula
Choice of neuropathic analgesic in DM
Duloxetine or amitryptyline
If renal impairment use amitryptyline
In MSC questions which factor often rules out TB
Absence of fever
Difference in colour of BCC vs SCC
BCC= pale
SCC= red
When are antibiotics with catheter change indicated
Neutrophils 1 x 109/L
Multiple attempts or traumatic insertion,
Post trans-urethral urological surgery
Previous episode of catheter change related sepsis
Frank pus at the urethral meatus
Critical care patients
What is a monitored dosage system
Method of dispensing tablets that enables you to keep track of medications particularly helpful in people with cognitive dysfunction or poor adherance
Causes of headache with visual disturbance
Migraine
SAH
Acute glaucoma
Haemorrhage into pituitary
Cerebral venous sinus thrombosis
Which hormonal contraceptive use for acne
Co-cyprindiol is licensed for acne
Progesterone often exacerbates it
If getting oral candidiasis on inhaled steroids, what do to prevent
Take with a large colume spacer
Wash mouth after taking
Patient sitting on chair all day with area if redness over lower back, what do
At risk of pressure sore so refer to district nurse who can make an assessment and think about - dressing, nutritional assessment and analgesia
What do immediately after puncture from needlestick
Let it bleed, can apply antiseptic like alcohol hand solution
Recent falls in elderly person, BP is 132/80 mmHg sitting and 138/84 mmHg standing, what drug is causing
Unlikely to be antihypertensive as no postural drop therefore consider alternate cause such as benzo or Z drug
If had asthma attack what give long term on top of meds etc
Personalised asthmatic action plan
How monitor if on orlistat or semaglutide
Review in 3 months
If not lost over 5% then STOP
If distal aortic and external iliac stenosis what operation do
Aorto bi femoral bypass graft
What area of congition is most affected in alzheimers
Short term memory
What makes C.diff difficult to treat
Spore formation
55 year old, smoker, has chest pain and SOB, what do as next investigation
CXR to rule out cancer
DCIS management
> 4cm= mastectomy
<4cm= wide local excision
Which cellular feature on biopsy of UC patient would encourage to have colectomy
Epithelial dysplasia
Old man confused and shouting after hip replacement, obs are stable, no pain, Mx?
Stop morphine
Haloperidol
Midazolam
Well-lit room
Well lit room
Woman calls GP about husband with terminal prostate cancer who is breathless?
Call 999
Ask another GP to visit next week
Tell her you will prescribe Abx for LRTI
Visit them in morning and community palliative discussion
Visit them in morning and community palliative discussion
What causes non pulsatile raised JVP
SVCO
Pneumonia with 30 pack year history, background of prostate antigen, blood gas shows low sodium, high urea, blood and sputum cultures already done, next?
Urinary legionella test
How long does OA stifness last in morning
Up to 30 mins
Which investigation diagnoses myositis
Muscle biopsy
Person has very low urinary output with epidural in what need to do
Bladder scan to check not in retention
Man with epidural which fell out, took a long time to get patient controlled analgesia, has a fever 1 day post-op?
Atelectasis- in pain so didnt breathe in properly
Man on motorbike crashes into a car, has an internal rotated and shortened leg, adducted and flexed?
Posterior dislocation of femur
59 y/o female with pruritus, IgM anti-mitochondrial antibodies, what makes PBC likely?
Tendon xanthomas
Hepatomegaly 8cm
Macroglossia
Facial rash
Xanthelasma
Xanthelasma
Pathophysiology of thyroid eye disease
Rectus muscle thickening
Deltoid wasting, weakness of flexion and supination?
Upper brachial plexus injury
Which nerves affected in upper vs lower brachial plexus injury
Upper- axillary or musculocutaneous
Lower- radial and ulnar
Will see lower motor nuerone signs in all brachial plexus injuries
40 year old patient whacked by football 2 days ago, noticed swelling in left groin, diffuse swelling at upper pole of left testis, does not transilluminate, right testis normal?
Seminoma
Testicular tumours often found incidentally after minor trauma to scrotum
Man has footdrop after hip fracture, which nerve was damaged?
Common peroneal
Gluteal
Sciatic
Femoral
Sciatic
Tolvaptan MOA
Vasopressin receptor antagonist
DVT prophylaxis following elective hip vs knee replacement
LMWH and TED for 28 days with hip
LMWH and TED for 14 days with knee
Can use rivaroxaban
What is bronchial breathing and what causes it most likely
Where get equally harsh sounds on both inspiration and expiration
Pneumonia
Displaced fracture NOF in young person vs old
Under 55= Cannulated screws/internal fixation
Over 65= total/hemi arthroplasty depending on morbidity
70 y/o patient has 2cm irregular, mobile lump in outer quadrant of breast, most likely diagnosis?
DCIS
LCIS
Invasive ductal carcinoma
Invasive lobular carcinoma
Medullary carcinoma
DCIS as invasive would not be mobile
Most common breast malignancy
Invasive ductal
Patient had inguinal lymphadenopathy, LN biopsy finds sheets of rapidly growing moderately sized B cells, diagnosis?
Burkitts lymphoma
In a RCT, what is the most likely form of bias?
Attrition
Pathophysiology of dupyutrens contracture
Thickened palmar fascia
Which cell is responsible for uptake of fat in fatty plaque formation?
Macrophages
Causes of pleural rub
PE
Pneumonia
Pleural effusion
Someone has industrial liquid splashed in their eye after workplace accident, eye is now red and painful, what to do next?
Saline washout
If sore throat with pain swallowing but throat appears fine, what is cause
Acute laryngitis
Woman lost 6kg, diplopia in every direction, can see sclera on downward gaze, difficulty with most movements of the eyes, what do you do?
TFTs
Man has posterior hip dislocation, what is he most at risk of?
Sciatic nerve injury
Patient on various meds with hyperkalaemia, ECG changes showing bradycardia with 2:1 block . Cause?
Digoxin toxicity
What electrolyte abnormality does digoxin toxicity lead to
Hyperkalaemia
Cholestasis drug induced causes
Penicillins
Macrolides
COCP
Steroids
Phenothiazines- prochlorperazine, chlorpromazine
Sulphonylureas
Nitrofurantoin
Dry eyes first line eye drop
Hypromellose articial tears
TB chest x ray findings
Latent- calcified gohn focus
Post primary- bilateral hilar lymphadenopathy, cavitating lesion, consolidation in upper lobes
Miliary- if immunocompromised see diffuse infiltrates
Person with HIV but on anti-retrovirals,
however has oral thrush. No symptoms. Has lobar consolidation on CXR. Cause? Strep Pneum, P. jirovecii, TB
TB is asymptomatic and HIV will reactivate the TB
If have spatial neglect after a stroke where is lesion
Parietal lobe
Asthmatic, which indicates severe?
BP 105, RR 30, O2 sats 94%
RR>25
What do for OSA if day time alertness a crucial part of job like lorry driver
Urgent referral and ensure that DVLA aware
After treatment for OSA, what is most likely to improve?
Weight, exercise tolerance, vital capacity, hypertension
HTN
What does spiculated lesion mean
Irregular lines originating from lesion
Spiculated lesion in lung, what is it
Cancer
Patient with lumbar back pain and hypotensive. What investigation do first line in emergency department?
Aortic USS
If patient needs to be on a sliding scale for surgery, when do you start it
The morning of the surgery
Male patient in his 70’s is adamant he wants to be at home instead of hospital and understand this may mean he can’t get all of his treatment. What is the best action to proceed with for this to happen?
Advanced directive
What tests must be done prior to doing dialysis
Screeed for HIV, Hep B and Hep C
HIV- antibodies done prior to starting dialysis
Hep B- HBsAg (every 3 months)
Hep C- HCV antibodies (every 3 months)
If is tetraplegic following neck hyperextension, where is lesion likely to be in spinal cord
Anterior cord
What causes hypotension if epidural in
Interruption of sympathetic supply-> vasodilation
Management of hypotension with epidural infusion
Stop infusion
Lie flat with legs elevated
IV fluids and O2
May require anaesthetics for vasopressors
Patient refuses colonoscopy what offer instead
CT colonography
If elderly person with osteoarthritis and HTN, what use as analgesia
Paracetamol
Patient has back pain with a depression depression felt along spinal cord
Spondylolisthesis- vertebra pushed forward
Spondylolisthesis presentation
Back pain that worsens with exercise
Palpable depression felt along spine
Management of vaginal prolapses in GP
If mild then pelvic floor exercises
If severe or is severe bowel/urinary incontinence then refer to urogynae
What is pagetoid spread
“upward spreading” of abnormal cells in the epidermis
What is transcolemic spread
Spread across the surface which encompasses a cavity- eg ovarian cancer spreads to liver via peritoneal membrane
Painless persistent lymphadenopathy in elderly person
Follicular lymphoma
Patient with chronic sinusitis, when lean forward fluid pours from nose, which sinus is most likely affected
Maxillary sinus- most commonly affected in chronic sinusitis
Pain in shoulder at night with painful abduction between 80 and 120 degrees
Subacromial bursitis
Breathing in palliative patient described as rattly
Excess secretions in mouth
30 year old man unable to straighted DIP following injury- what use
Finger splint
First line for hodgkins lymphoma
Chemo
If patient is admitted to hospital with confusion and metastatic cancer, who makes decision regarding DNR
- oncology team
- admitting team
- wait 24 hours to see if he regains capacity
Admitting team
Man with T1DM for short procedure, HbA1c control is good and needed to be fasted from midnight, what do with usual basal insulin
Keep evening dose
Omit morning dose
What part of inhaler has greatest carbon footprint
Hydrofluorocarbon propellant in MDI
If tumour lysis syndrome, what is most likely to identify cause of deterioration
Urate
What does a CVP of +12 indicate in shock
Adequate hydration
If present with a tender lump in breast during pregnancy what is management
Triple assessment
Hypotension post op and has epidural in
Assess if operation has lead to fluid losses and hypovolaemia is cause
If evidence of dehydration then give fluids
DO NOT ASSUME EPIDURAL IS CAUSE
If on dialysis which painkiller best to use
Tramadol
HIV patient had SOBOE, CXR clear, what do next
BAL- best definitive option for PJP
TB patient develops photosensitive rash after starting meds, what antibody
Anti-histone
Investigations to do prior surgery for COPD
CXR
Spirometry if no idea about severity- risk of bronchoconstriction
Echo may show RHF
If on warfarin, what do prior to surgery
Stop 5 days
If moderate/high risk then give bridging LMWH/UFH until night before
If very recent VTE then consider need for surgery/ put in IVC filter
What do with addisons/long term steroids post op
Minor procedure- oral prednisolone post op
Major- 3 days of IV hydrocortisone
Addisons patient becomes hypotensive in operation
Add fludrocortisone
ATIN causes
antibiotics like β-lactams, cephalosporins, and flouroquinolones, NSAIDs, diuretics, rifampicin, allopurinol, and proton-pump inhibitors
Unable to differentiate between asystole and v fib on ECG in crash call, what do
Continue compressions- will increase amplitude and help differentiate
Vit D defic management
If requires acute rise like if about to go on strong bisphosphonate or symptomatic then loading dose of 300,000 units over 6 weeks
If not then maintenance 800-2000 units daily or up to 4000 if malabsorption
Causes of hypoalbuminaemia (not liver and kidney)
Poor oral intake and sepsis (liver favours production of inflam makers)
Assessment of diabetic foot wound infection
Counts as infection if 2 of
- erythema
- fever
- discharge
- hot
- swelling
Take swab and give abx
If suspect osteomyelitis do X ray then MRI if unclear
When suspect charcot arthropathy in diabetics
If broken or if foot is deformed/warm/redness or swelling in presence of CKD or neuropathy
Management of charcot arthropathy
Refer to foot MDT within 1 working day
X ray then MRI to confirm if needed
Weight bearing support given form moment suspect it
Rheumatic fever management
Stat dose of benzylpenicillin then 10 days pen V
Aspirin for joint pain
Steroids if carditis leading to HF
Carbamazepine for sydenhams chorea
Schistoscomiasis
- presentation
- diagnosis
- management
Bowel involvement and bladder involvement
Itchy rash
Ix- stool or urine culture
Rx- praziquantel ASAP and again in 2 months
Dressler syndrome rx
NSAIDs
Can increase aspirin dose
Post oesophagectomy, drain starts to drain with white fluid
Chylothorax
Let it drain and start TPN
Standard pre abdo surgery antibiotic cover
Co amoxiclav
Patient develops ulnar nerve palsy, then common peroneal then a few weeks later 6th CN
Mononeuritis multiplex
Can be caused by systemic inflam conditions like RA or vasculitis then can be infective like lyme or HIV
For breakthrough pain what is % of total daily dose tend to give
10-25%
How go to oxycodone from morphine
Times by 2
Raised ICP headache management with mets
Cyclizine first line for nausea
Dexamethasone
Radiotherapy can be used
