Lecture Random Points

Question 1

Otalgia

Secondary Causes

Answer 1

C2/3 – arthritis/cervical spondylosis, soft tissue injury
CN V – Dental, TMJ dysfunction, nasopharyngeal
CN IX – Oropharyngeal infection, tongue malignancy
CN X – laryngeal/pharyngeal malignancy

Question 2

Vitamin A

Answer 2

Vision by maintaining a clear cornea
Component of rhodopsin

Xerophthalmia is a progressive eye disease which begins with night blindness.

Question 3

Vitamin D

Answer 3

Calcium

Question 4

Thyroid bruit

Carotid bruit

Answer 4

(Grave’s thyroiditis)

carotid stenosis

Question 5

Head & Neck Investigations

Answer 5

FNAC - Fine Needle Aspiration Cytology
CT/MRI/PET scan
US scan
Plain X-ray
Contrast Swallow
Endoscopy

Question 6

Neck Lump Examination

Answer 6

How long?
Fluctuates?
Site, Size, Shape, Sore, Soft, Skin, Stuck
Symptoms?

Question 7

Reactive lymph node appearance

Can Turn to Non Hodgkins Lymphoma
+night sweats and loss of apetite

Answer 7

*Oval
Soft
Smooth
*Mobile
*Tender

Question 8

Malignant neck node appearance

Squamous Carcinoma Commonest

Answer 8

*Round
Firm
Irregular
*Fixed
*Non-tender

Question 9

Bacterial Tonsillitis – Offer Tonsillectomy if?

Answer 9

Pus covering neck nodes, fever, no cough

6-7 attacks in 1 year
(5 per year over two years, 3 per year over three years)
Disrupting daily activities
More than 1 quinsy

Question 10

Necrotising otitis externa common causative organism?

Answer 10

Pseudomonas Aeruginosa

Question 11

Post thyroidectomy patient presents with a hoarse voice and is found to have a paralysed right vocal cord. Which nerve has been damaged?

Answer 11

Reccurent Laryngeal Nerve

Question 12

Family history of MEN (multiple endocrine neoplasia) Presents with an anterior neck swelling and WL.
She is found to have a high calcitonin on blood tests.

Answer 12

Medullary thyroid cancer

Question 13

A 5 year old girl presents with a 3 week history of foul smelling unilateral nasal discharge. She is afebrile and otherwise asymptomatic. What is the likely diagnosis?

Answer 13

Retained foreign body

Question 14

Anterior 2/3rd of Tongue

Posterior 1/3rd of Tongue

Answer 14

From 1st branchial arch
Sensation by lingual nerve (branch of CN V3)
Taste by chorda tympani (branch of CN VII)

From 3rd branchial arch
Supplied by CN IX

Question 15

A 30 year old woman presents with episodes of severe pain above the left eye, associated with photophobia and visual disturbance and not improved by a nasal steroid spray. Treatment?

Answer 15

Amitriptiline - tricyclic antidepressant.

Lower doses are also widely used to block the long-term (chronic) pain of some rheumatic conditions

Question 16

Thyroid gland produces Calcitonin which?

Answer 16

Calcitonin acts to lower calcium and raise phosphate

Question 17

Thyroglossal cyst

Answer 17

Dilatation of thyroglossal duct remnant
Moves on tongue protrusion
Need ultrasound scan prior to removal

Question 18

THYROID LOBECTOMY

Answer 18

tissue required for histological diagnosis

FNAC cannot distinguish bw Follicular Adenoma/Carcin

Question 19

Thyroid cancer

Answer 19

Papillary - Lymphatic metastasis

Follicular - Haematogenous metastasis

Medullary - 10% familial, arise from *Parafollicular C cells

Anaplastic - aggressive, local spread, old, poor progn.

Question 20

Colloid goitre

Answer 20

Gland hyperplasia
Iodine deficiency
Puberty, pregnancy, lactation

Question 21

Multi-nodular goitre

Answer 21

GRAVES
Middle aged Women
Over activity→hyperthyroidism
Pre-tibial myxoedema

TOXIC GOITRE
Older, No eye signs,
Atrial fibrillation

Question 22

Stridor

Clinical sign of airway obstruction and Treatment

Answer 22

Inspiratory - laryngeal
Expiratory - tracheobronchial
Biphasic – glottic/subglottic

O2, Nebulised Adrenaline, IV Dexamethasone

Question 23

Branchial cyst

Answer 23

Remnant of fusion failure of branchial arches
OR lymph node cystic degeneration

Transilluminates

Anterior to sternocleidomastoid at Junction bw U+M 3rd

Question 24

Pharyngeal pouch

Answer 24

Herniation of pharyngeal mucosa between
thyropharyngeus and cricopharyngeus muscles of the
inferior constrictor of the pharynx

Voice hoarseness Regurgitation
Dysphagia Weight loss
Aspiration pneumonia Neoplasia 1%

Barium swallow;
Excision (endoscopic or open)

Question 25

Epidermis Layers

Answer 25

Stratum Croneum
Lucidium
Granulosum 
Spinosum
Basale

Question 26

Acne Vulgaris Medication

Answer 26

Mild Acne - Salicylic Acid, Benzoyl Peroxidase
Moderate - Tetracycline Abx, Spironolactone
Severe - Isotretinoin (Vit A derivative, impacts sebum secretion)

Question 27

Pyoderma Gangrenosum

Answer 27

IBD, Myeloma

Question 28

Acanthosis Nigricans

Answer 28

Malignancy,
Acromegaly,
Scleroderma,
Wilson’s Disease (excess copper - genetic)

Question 29

Erethyma Nodosum

Answer 29

Infection: Streptococcus, TB
Sarcoidosis
IBD
Sulfonamides - Furosemide (loop diuretic)

Question 30

Dermatitis Herpetiformis

Answer 30

Coeliac Disease

Question 31

Psoriasis

Symptoms

Management Index

Risk Factors

Answer 31

Chronic, Autoimmune, Non Contagious
Polygenic Prodisposition + Environmental triggers (Infection, Drugs, Trauma, Sunlight)

*Sharply defined erythematous plaque (Salmon colour)
Inflamed red from blood vessels - angiogenesis
Numerous small, widely disseminated papules, plaques
Scalp and Behind the ear

*Nails - Onycholysis, pitting, oil spots

Koebner Phenomenon - Occur over trauma sites

Psoriasis Area Severity Index (PASI)
Surface area, plaque colour, thickness, scale
Dermatology Life Quality Index (DLQI)

Question 32

Types of Psoriasis

Answer 32

Chronic Plaque Psoriasis - symmetric, extensor surfaces
Scaly plaques on both *elbows, Hypertension
Large salmon coloured plaques on his arms, legs and back with thick scale.

Guttate psoriasis - Children, adolescents.
Can be *triggered by viral or bacterial infections.

Pustular Psoriasis - Sterile pustules, sometimes systemic symptoms - Pregnancy, rapid taper/stop steroids, hypocalcaemia, infection

Erythrodermi Psoriasis - Fire-red scales

Question 33

Psoriasis Treatment

Answer 33

Emollients - Creams vs Ointments, Soap substitutes
(clear plaques and minimise itchiness)

Vitamin D3 analogues: inhibit epidermal proliferation
Coal Tar creams
Topical Steroid
Salicylic acid (keratolytic)
UV Phototherapy (damage karatynocytes DNA)

Systemic
Retinoid - Acitretin (Teratogenic, LFTs, lipids)
Immunosuppression - Ciclosporin (Renal cancer risk)
Biologic Therapies - Anti-TNF (Infliximab)

Question 34

Aetiology Mechanism of Psoriasis

Answer 34

T cells (epidermal: CD8, dermal CD4&8)
Stressed keratinocytes
Activation of dermal dendritic cells (dDCs)
by interleukins, TNF alpha (cause Inflammation)
Differentiation into Th (T helper)

Associated with cardiovascular disease, smoking, alcohol, the metabolic syndrome, depression

Question 35

Eczema - Atopic Dermatitis

Answer 35

Allergic Skin Inflammation - Type 1 Hypersensitivity

Inherited *Atopy related (Asthma, Allergic Rhinitis)

Itchy, il-defined erethymatous scaly patches on flexor surfaces, oedema, vesicles

Emollients, Frequent Moisturising
Oral Antihistamines

Question 36

Leukocoria

Answer 36

Physical exam finding of a white pupillary reflex.

Retinoblastoma and cataract formation are the most common causes in children.

Question 37

DM and COPD - difficulty with driving at night.
He sees halos around lights and has difficulty with the glare. He is far-sighted and reports that over the last year, his vision initially seemed to be improving as he no longer required his glasses for distance vision. However, his vision has since deteriorated.

Answer 37

Cataracts can result from high levels of galactitol in the lens, due to a deficiency in galactokinase.

Question 38

Eczema Aetiology

Answer 38

Filaggrin gene
Atopic family history 
Epidermal barrier dysfunction
Environmental factors
Immune system dysregulation

Spongiosis (intercellular oedema) within the epidermis.
Acanthosis (thickening of the epidermis).

Inflammation
- Superficial perivascular lymphohistiocytic infiltrate

Question 39

Embryology of Head and Neck

Answer 39

Skull = mesenchyma
Face = mesenchymal process
Neck, Thyroid, Parathyroid Tongue
= Branchial + Pharyngeal arches

1st Arch - V3, Anterior Digastric, Maxillary Process
2nd - VII and all the muscles supplied by it
3rd - Cr.N IX
4th - Superior Laryngeal Nerve - part of vagus
6th - Recurrent Laryngeal Nerve

Question 40

Benign Tumour

Answer 40

Face Lump, Painless
No change in size/colour
commonest is PSA (Pleiomorphic Salivary Adenoma)

Ix: FNAC, Rx: Lumpectomy, Partial Parotidectomy

Question 41

A 56 year lady with 1 year history of type 2 diabetes, 7 month history of hypertension, complains of increasing central obesity and tiredness. (normal ranges in parentheses)

Urinary free cortisol markedly elevated
(5 X normal upper limit)

Early morning cortisol 2000 nmol/l (138- 690)
Midnight cortisol 1500 nmol/l (138- 690)

Early morning ACTH 0.4 pmol/l (1.3 to 16.7)
Midnight ACTH 0.2 pmol/l (1.3 to 16.7)

Answer 41

Adrenal Carcinoma (ACTH Independent)

Question 42

Nephron

Renal corpuscles (blood-filtering component of the nephron of the kidney)

Answer 42

Renal corpuscles + renal tubules

Glomerulus + bowmen’s capsule

Question 43

Nephrotic syndrome

Answer 43

Minimal change disease

Membranous nephropathy

Question 44

Nephritic state

Answer 44

Anti-neutrophil cytoplasmic antibody (ANCA) associated

Post-infection glomerlunephritis

Question 45

Post-infective glomerulonephritis: Treatment

Answer 45

Loop diuretics such as frusemide for oedema
Vasodilator drugs (e.g. amlodipine) for hypertension

Question 46

IgA nephropathy

Answer 46

IgA deposition in mesangium + mesangial proliferation

Most common in 2nd and 3rd decade in males

Question 47

Nephrotic syndrome-management

Answer 47

Treat oedema: salt, fluid restriction and loop diuretics.
Hypertension: Renin-Angiotensin-Aldosterone-blocker
Reduce risk of thrombosis: Heparin or Warfarin.
Reduce risk of infection e.g. pneumococcal vaccine.
Treat dyslipidemia e.g. statins.

Question 48

Minimal Change Nephrotic Syndrome

Answer 48

Commonest form in children
Sudden onset of oedema - days

Complete loss of proteinuria with steroids (Prednisolone)

Subsequent relapses treated with
Cyclophosphamide
Cyclosporin
Tacrolimus

Question 49

Transplanted kidney is placed into?

Indications for native nephrectomy

Answer 49

Iliac fossa and anastomosed to the iliac vessels

Size (polycystic kidneys) and infection (chronic pyelonephritis)

Question 50

Types of hormonal therapy for prostate cancer

Answer 50

Surgical castration (i.e. bilateral orchidectomy)

Chemical castration (LHRH analogue – goserelin) 
Down regulates androgen receptors by -VE feedback

Oestrogens (i.e. diethylstilboestrol)
Inhibits LHRH and testosterone secretion and has direct cytotoxic effect on prostatic epithelial cells

Anti-androgens - inhibits androgen receptors

Question 51

Acute Kidney Injury (AKI) (ARF)

Answer 51

Risk - Increase in serum creatinine level (1.5x) or decrease in GFR by 25%, or UO <0.5 mL/kg/h for 6 hours

Injury - Increase in serum creatinine level (2.0x) or decrease in GFR by 50%, or UO <0.5 mL/kg/h for 12 hours

Failure - Increase in serum creatinine level (3.0x), or decrease in GFR by 75%, or serum creatinine level >355μmol/L with acute increase of >44μmol/L; or UO <0.3 mL/kg/h for 24 hours, or anuria for 12 hours

Loss - Persistent ARF or complete loss of kidney function >4 weeks

End-stage kidney disease - complete loss of kidney function >3 months

Question 52

Chronic urinary retention

Acute urinary retention

Answer 52

Defined as ‘painless, palpable and percussible bladder after voiding. Mainly due to detrusor underactivity

Defined as ‘painful inability to void with a palpable and percussible bladder’ RF is Benign Prostatic Obstruction

Question 53

Types of renal replacement therapy

Answer 53

Renal transplant

Haemodialysis

Peritoneal dialysis

• Continuous ambulatory peritoneal dialysis (CAPD)
• Intermittent peritoneal dialysis (IPD)

Conservative Kidney Management

Question 54

Dialysis

Answer 54

Solute composition of a solution, A, is altered by exposing solution A to a second solution, B, through a semipermeable membrane

Diffusion and Ultrafiltration

Question 55

Types of renal replacement therapy

Answer 55

Renal transplant

Haemodialysis

Peritoneal dialysis

• Continuous ambulatory peritoneal dialysis (CAPD)
• Intermittent peritoneal dialysis (IPD)

Conservative Kidney Management

Question 56

Haemodialysis Access

Answer 56

Permanent (Arteriovenous fistula, AV prosthetic graft)

Temporary (Tunnelled / Temporary venous catheter)

Question 57

Restrictions for dialysis patients

Answer 57

Fluid restriction

• Dictated by residual urine output
• Interdialytic WG

Dietary restriction - Potassium, Sodium, Phosphate

Question 58

Peritoneal dialysis fluids

Answer 58

The dialysate contains a balanced concentration of electrolytes

Glucose is the most common osmotic agent for ultrafiltration of fluid

Question 59

Indications for dialysis in ESRD

Answer 59

Advanced uraemia, (GFR 5-10 ml/min)
Severe acidosis (bicarbonate <10 mmol/l)
Treatment resistant hyperkalaemia (K >6.5 mmol/l)
Treatment resistant fluid overload

Question 60

Dialysis Related Drugs

Answer 60

Anaemia
Erythropoietin injections
IV iron supplements 
Renal Bone Disease
Activated Vitamin D (eg calcitriol)
Phosphate binders with meals (CaCo3)
Heparin
Water soluble vitamins 
Antihypertensives

Question 61

Complications of haemodialysis

Answer 61

Cardiovasular problems
Intra-dialytic hypotension and cramps
Arrythmias

Coagulation
Clotting of vascular access
Heparin related problems

Allergic reactions to dialysers and tubing

Question 62

When to suspect a systemic disease with renal involvement?

Answer 62

CVS - Hypertension, murmur
Chest - Crepitations, haemoptysis
Locomotor - Joint swelling, tenderness
CNS - Stroke, encephalopathy