MaM mocks Flashcards

Question

Hesselbach’s triangle is an anatomical landmark that demarcates the areas of weakness in the abdominal wall through which abdominal contents could herniate. Which one of the following statements is true with regards to hernias? A) Indirect inguinal hernias occur medial to the inferior epigastric vessels B) Inguinal hernias are typically found superior and lateral to the pubic tubercle C) Direct inguinal hernias typically herniate along the medial border of the rectus abdominis muscle D) The deep inguinal ring is located within Hesselbach’s triangle E) Direct inguinal hernias occur medial to the inferior epigastric vessels

Answer 1

**Direct inguinal hernias ccur medial to the inferior epigastric vessels** Hesselbach’striangle is an anatomical landmark that demarcates the potential areas of weakness in the anterior abdominal wall through which herniation can occur. It has three borders: ● Medial: lateral border of the rectus abdominis ● Lateral: inferior epigastric vessels ● Inferior: inguinal ligament In a direct inguinal hernia, the viscera herniates through Hesselbach’s triangle (medial to the inferior epigastric vessels). In an indirect inguinal hernia, the viscera passes through the deep inguinal ring and along the inguinal canal. It, therefore, arises lateral to the inferior epigastric vessels.

Answer 2

**2 hourly VBGs** There is a worry about raising the sodium too quickle and causing demylination, to prevent this there is a need to take 2 hourly VBFS intially. with a formal U+Es every 4-6 hours. This is so that if the rate is increasing to greatly then a dextrose infusion can be given.

Answer 3

**Right Hemicolectomy** In Caecal or ascending cancers there is a need to do a right hemicolectomy In transverse cancers there is a need to an exttended right hemicolectomy An anterior resection is done i there is a cancer greater than 5 cm from the anal verge. The operation leaves the acus intact. This however requrires a temporary loop ileostomy as a way for the anastamosis to heal. Hartman's is doe in emergencied and is used to manage acute mamanegement of the sigmoid colon aka diverticular obstruction or bowel obstruction. Often results in a endcolostomy and a rectal stump.

Answer 4

**HHS, IV fluids** Serum osmolality = 2(Na) + Ur + Glu Diagnosis of HHS: * BM levels > 30 * Serum osmolality >320 mOsmol/kg * Hypovolaemia

Answer 5

**Acetazolamide** -> They are suffering from a raised ICP. This is the first line pharmacological management The topiramate is the managment of an acute migraine The propanalol is the long term management of this The Lumbar peritoneal shunt would be used if the raised ICP is persisitant after medical managmeent

Answer 6

**Lhermitte sign** So the pain in the eye with reduced visual acuity was suggestive of Multiple sclerosis. This sign is seen that when the patient flexes the neck they get parathersiia in the upper limbs and trunk. Often associated with MS, cervical spondylosis, cervical spinal cord tumour.

Answer 7

**Serum ACE** This patient has sarcoidosis.... The non-pulmonary features of sarcoidodid include -> lethargy, joint pain, neuropathy and erythema nodosum and uveitis. ACE is a surrogate marker for granuloma burden in the body and is elvated in sarcoidosis patients. It is released bu macrophages in the granulomas Vitamin D taht is measured are the precursor levels and as sarcoidosis is activates Vitamin D the precursor levels will not highlight a surplus of activated Vitamin D.

Answer 8

**Dexamethasone only** Remdesvir, Oxygen therapy and dexamethasone are all treatments of COVID 19 pneumonitis HOWEVER Remdesevirs is contraindicated in Renal impairement <30 mL/min or if ALT > x5 upper limit normal

Answer 9

**APTT ratio** Unfractioned heparin has a very short half life compared to low molecular weight heparn so will be given as an infusion. Heparins are anti thrombin III enhancers -> It leads to the ability for anti thrombin III binding and inhibitin factor 2 4 10 and 11. As these factors are involved in the intrinsic pathway the APTT is needed, Anti Xa can be used but to help results to be followed earier often the APTT will be expressed as a ration as a way to better monitor the infusion of unfractioned heparin

Answer 10

**Endometrial cancer** the inheritable cancers include HNPCC and FAP. If you have the gene for HNPCC there is a near garuntee that you will have a cancer... This is also the more common reason for inheritable cancers... HNPCC is also heavily linked with enndometrial cancers.

Answer 11

**Bleep the regitrar about taking patient to the theatre** the diagnosis is Acute appendicitis... this patient is acutely unwell considering his low BP and the relevant team needs to be notified first before starting the invetigations or management,,,, In regards to this case a clinical diagnosis can be made Ultrasound and CT scans can be used to aids diagnosis Ultrasound can't rule out diagnosis CT scan is generally avoided in younger patients due to radiation worries.

Answer 12

**Analgesia and diettary advice** The CT rules out Cancer and there is no need for colonoscopy for this reason as there are also no features of a cancer Therfore as the diverticular disease is not infected or bleeding this can be managed conservatively with analgesia and a high fibre diet

Answer 13

**no more than 24 hours post surg** Guidelines state Physio should be done on the day of the surgery and this rehabilitation includes mobilisation of people who have had knee or hip replacement as errl as advice on managing activities of daily living ot home exercises.

Answer 14

**Metaraminol** Metaraminol is a alpjha 1 agonist and a vasoconstrictor like this is needed. Apparently the metaraminol is better and is great if the patient doesnt not have a central line. Adrenaline would increase both the HR and the BP Dobutamine -> improves the contractility of the heart.

Answer 15

**Serum Urate** This patient has Tumour lysis syndrome. This is associated with chemotherapy of leukaemia and lymphoma. Electrolyte changes seen inc: * Urate > 476 or 25% increase from baseline * K+ > 6 or 25% increase from baseline * PO4 >1.45 or 25% increase from baseline * Ca < 1.75 or 25% increase from baseline It can lead to AKI or suddent death as well as arrythmias

Answer 16

**Percutaneous Nephrolithotripsy** This is a large renal calculus that will require direct removal, Extracorporeal shockwave lithotripsy may be considered for stones smaller than 20mm Percutaneous nephrostomy is an emergency decompress JJ stents are inserted for obstructed ureters, stones tumours or retroperitoneal fobrosis Ureteroscopic lithotripsy is primarily used for lower ureteric stones

Answer 17

**Cardiac arrest** The leakage of fluid suggests that the needle is within the dura and therefore in the subarachnoid space. If the dose was given in the subasrachnoid space then there is achance that the anaesthetic block will extend above the desired level above T4 and result in a a dangerous bradycardia and life thretening hypotension....

Answer 18

**Metoprolol** Bisoprolol is the first line in treating AF with rate control medications such as B eta blockers. BUTTT this persion is nbm and so there is a need to have a medications that can be delivered by a different route and that Beta blockers is metoprolol Another possible option is IV atenolol Other than that labetolol can come in an IV preparation but this is non-cardioselective and is more indicatedd for high blood pressure,

Answer 19

**Premature Ventricular complex** Ventricular because it is wide. Premature becuase it is before the anticipated next heart beat.

Answer 20

**Fractures** Omeprazole is a PPI. There is an increased risk of osteoperosis with omeprazol and increased riisk of fractyres. There is also an increased risk of C.Diff infection and hyponatraeima. It can increase the risk of gastric cancer with long term use. Nizatidine is an alternative to treat gord.

Answer 21

**Serum Gastrin** -> The extensive ulceration with multiple locations is suggestive of zollinger ellison syndrome. This conditions results in an excess production of gastrin and produces gastric acid.

Answer 22

**Non-ciliated Columnar** Barrets oesophagus is the metaplasia of the oesophageal cells to the stomach cells. These cells are columnar and non-cilated. Ciliated columnar cells are found in airways Keratinisisng Squamous is found in the skin Non-keratinising squamous is found in the oesophagus Transitional is found in the urinary tract.

Answer 23

**Smoking** -> This is the risk factor most liked with the progression and the severity of Graves disase. TSH receptor antibody levels -> is somewhat useful in checking to response to treatment and predictiong disease course but not eye disease Family history, radioiodine and some single nucleotide polymorphisms are all associated with higher risk of thyroid eye disease by far the biggest risk factor is smoking.

Answer 24

**SIADH** Urine osmlality > 100 Urinary sodium > 20 there is excess SIADH produced.... with the low sodium in the serum there shoud be an even lower concentration of urine as it would be very diluted. Diabetes insipidus is urine osmolality would be innapproapriately low cpmpared to the raised plasma osmolality

Answer 25

**Right sided facial anhidrosis and righ sided miosis** The description is of sudden onset neck pain is suggestive of carotid dissection. With cases of dissection the symptoms of horner syndrtome present on the ipsilateral side.

Answer 26

**Chest X-ray** Lateralising shoulder girl pain associated with upper limb neurological symptoms should raise suspicion of potential brachial plexus injury. the patient also complains of horners syndrome togethere this is could be explained with a pancoast tumour. this would meand that CXR would be the best investigation The ultrasound of the shoulder could be used to investigate a rotator cuff injury. A: An MRI spine would be useful for investigating potential radiculopathy secondary to cervical vertebra or disc disease D: MRI brain would be useful in delineating parenchymal brain abnormalities like multiple sclerosis. It would not be the most appropriate initial investigation. E: Nerve conduction studies may be carried out to diagnose diseases that affect peripheral nerves (e.g. motor neurone disease).

Answer 27

**Chest X-ray** For a patient of this age with no other PE risk factors a spontaneous Pneumothorax is the most likely cause of this patients symptoms and the best way to investigate that is with the use of Chest X-ray. PE is unlikely in this age group.

Answer 28

**Squamous cell carcinoma** Patient has haemoptysis, dyspnoea and poorly resolcving pneumonia secondary to bronchial obstruction which is suggested by monophasic wheeze. 85% lunc cancers are non-small cell lung cancers of which 40% are squamouce cell carcinoma. which is more common in smokers. Another 40 % of the 85% are adenocarcinoma and these are more associated woth non-smokers. The remaining 20 % are Large cell carcinoma, carcinoid tumours and bronchoalveolar carcinomas NSCLC * 40 % Smokers -> SCC * 40 % Non-smokers -> Adenocarcinoma * 20 % -> large cell carcinoma/ carcinoid / Bronchoalveolar cell carcinoma

Answer 29

**Loperamide and omeprazole** Complications of stoma: * Ileus * Necrosis * High stoma output defined as >1L in 24 hours for 3 or more days This can lead to the development of Electrolyte imbalances. Therefore the first step to manage this is to give loperamide and a PPI which decreases stomach ascid. Fluid restriction is used along side the above

Answer 30

**Rubber band ligation therapy** This is describing a grade 2 haemorrhoid. Diltiazam is used in anal fissure Steroids could be used to ease itching. Surgical removal would be considered in stage 4 disease and if other methods fail. Artery ligation is the third line measure after 1) rubber band ligation and 2) sclerotherapy

Answer 31

**Incentive spirometry** This is atelectasis. This can be avoided with breathing excercises which would be possible with spirometry

Answer 32

**Piloniddal sinus** A pilonidal sinus is a chronic inflammatory condition caused by an ‘ingrown hair’ usually in the natal cleft of the buttocks. The insertion of hair into the skin initiates an inflammatory response which leads to the formation of a sinus tract deep into the tissue. This will usually present as a painful swelling with purulent, foul-smelling discharge. It affects younger men and women and risk factors include hirsutism, metabolic conditions (e.g. diabetes mellitus) and a sedentary lifestyle. It isusually treated surgically with excision of the tract. A: A perianal abscess will present as a red, painful, fluctuant mass in the perianal region. Its overlying skin will be intact, unlike the pilonidal sinus described that is *discharging a purulent substance*. B: An anorectal fistula will similarly present with a mass draining purulent discharge, however, it is usually *found around the anus.*Furthermore, there is likely to be a background of an underlying inflammatory condition (e.g. Crohn’s disease). D: Sacral osteomyelitis would not cause a mass on the surface. E: Hidradenitis suppurativa is a chronic inflammatory condition characterised by the development of recurrent abscesses in the skin. The abscesses tend to arise in areas with lots of hair (e.g. groin, axillae)

Answer 33

**Anteroir Cruciate ligament injury** Segmond fracture is a avulsion fracture of the proximal lateral tibia and is associated with ACL injuries.

Answer 34

**Above knee amputation** Honestly the most BS qs... Essentially they are not mobalising so there is no point for below the knee amputation as this person does not need the below knee to help with prosthesis. Revascuralisation would be useful if the tissue was viable with gangrene the tissue is dead and so it cannot be reversed.

Answer 35

**Refer to urology** Benign prostatic hyperplasia (BPH) is extremely common. This patient has presented with typical symptoms of BPH -frequency, nocturia, terminal dribbling and poor stream. The dysuria and urine dipstick testing positive for nitrites and leucocytes suggest that this patient currently also has a urinary tract infection for which he requires antibiotics. He has had three other urinary tract infections in the last 6 months. These are most likely a complication of his BPH. * * BPH that has led to complications is an indication for referral to urology for surgery*. Surgery can be both minimally invasive or open which will depend on the size of the prostate alongside clinical factors. A: Tamsulosin is an alpha-blocker that is used first-line in the management of uncomplicated BPH. It induces smooth muscle relaxation in the prostate and bladder neck. B: Phenoxybenzamine is an alpha-blocker that is used in the treatment of phaeochromocytomas, not BPH. C: Finasteride is a 5-alpha-reductase inhibitor that is also used first-line in the management of uncomplicated BPH. It inhibits the synthesis of dihydrotestosterone which, in turn, reduces prostate volume E: Watchful waiting is only appropriate for patients who present with mild symptoms and whose symptoms are not bothersome.

Answer 36

**Hydrocele** They are common in newborn boys, especially if preterm. The majority resolve on their own within the first year of life. If the hydrocele has not resolved on its ownby the time the baby is one year old, referral to a paediatric surgeon should be considered. Persistent hydroceles may require surgery (usually laparoscopic) at 12-24 months of age.

Answer 37

**Dantrolene** This is malignant hyperthermia.... This is a a congential problem where when given anesthetic agents they react with a really high temperature. This is treated with dantrolene This would also be managed with hyperventialation

Answer 38

**Ondansetron** Constiapation is a common cause of delerium in patients. It is important to be able to identify the drug causes of constiaption. Common drugs to cause constipation * codiene * CCB * Iron supplelemts * Ondansetron

Answer 39

**Consider alternatives to carbamazepine and omeprazole** SIADH can be precipitated by drugs such as * SSRI * TCAs * Anti epileptics (carbamazepine) * PPIs Therefore the first step in management should be to stop these medications as a way to stop the precipatiatng factors. Then fluid restrict Then Demeclocycline

Answer 40

**Aspirin 900mg PO** The patient has presented with a unilateral severe headache accompanied by a preceding visual and sensory aura, in keeping with migraine. Patients with migraines should be advised to keep a headache diary to identify possible triggers. Acutely, migraines can be treated with high-dose aspirin (900 mg), paracetamol or ibuprofen in the first instance. Triptans (e.g. sumatriptan) may also be used. Other classes of medications, such as antiemetics, may be used to provide symptomatic relief. Patients who experience two or more headaches per month should be considered for migraine prophylaxis (amitriptyline, topiramate or propranolol). A: Codeine does not tend to be effective in migraines. B: PR Diclofenac is highly effective at relieving pain caused by ureteric calculi. C: Propranolol is used for migraine prophylaxis. E: Morphine is a strong opioid that is effective in managing various types of pain, however, opioids are generally not thought to be particularly effective in migraines.

Answer 41

**Percutaneous cholecystomy** This patient has ascending cholangitis. the main aim is to decompress the biliary system. This can be done with all of the above management except the referral, but the least invasive method would be with percutaneous cholecystomy therefore making it the right answer.

Answer 42

**Serum Albumin** Low albumin is associated with multiorgan failure...

Answer 43

**Grade III** Grade I: does not prolapse Grade II: spontaneously reduces Grade III: can be reduced manually Grade IV: irreducible

Answer 44

**Superior gluteal nerve injury** The above nerve innervates the hup abductors, gluteus medius and minimus, this means that injury to this nerve will cause weak hip abduction that presents in the trendelenburg test. This is a common complication of the Total hip replacement surgery. The inferior gluteal nerve which is also at risk in a total hip replacement if the scar was seen posteriorly would present with weakness on hip extension.

Answer 45

**Common peroneal nerve** Common peroneal nerve damage is usually caused by compression of the fibular head as the nerve passes along its fibular neck. Injury leads to foot drop. The common peroneal nerve is a terminal division of the sciatic nerve which divides above the knee joint at the popliteal fossa into the tibial and common peroneal nerves. A: The tibial nerve travels down the posterior compartment of the leg into the foot. It is deep and well protected and thus not commonly injured. C: The femoral nerve supplies the anterior compartment of the thigh and is commonly injured in hip and pelvic fractures. It is responsible for knee extension and provides sensory function to the anterior and medial aspect of the thigh. D: Lateral cutaneous nerve injuries occur due to compression near the ASIS, leading to paraesthesia and pain at the lateral aspect of the thigh (meralgia paraesthetica). E: The sciatic nerve divides into the tibial nerve and the common peroneal nerve. ALSO PRESENTS WITH FOOT DROP

Answer 46

**Pseudogout** the calcification of the cartilage with the acute history is suggestive of pseudogout. Acute flares of pseudogout are usually managed similarly to gout -with NSAIDs and colchicine. A: Osteoarthritis presents with chronic joint pain and radiographic features including loss of joint space, osteophytes, subchondral cysts and subchondral sclerosis. C: Psoriatic arthritis refers to the development of arthritis in patients with psoriasis. It can take five main forms: symmetrical polyarthritis, asymmetrical oligoarthritis, distal interphalangeal joint disease, arthritis mutilans and psoriatic spondylopathy. D: Reactive arthritis is a sterile arthritis that arises several weeks after an infection (e.g. usually gastrointestinal or genitourinary). It classically manifests with a triad of arthritis, urethritis and uveitis. E: Gout presents similarly to pseudogout, with acute-onset joint pain. It has a predilection for affecting the first metatarsophalangeal joint and is caused by the deposition of monosodium urate crystals. It does not cause chondrocalcinosis

Answer 47

**Acute** Hyperacute ● Within seconds of clamp release ● Mediated by preformed antibodies ● Results in immediate loss of graft Accelerate Acute ● First few days ● Cellular and antibody mediators Acute ● Days to weeks ● Cell mediated –usually lymphocytes Chronic ● Most common ● Graft atrophy and atherosclerosis ● Fibrosis is a very late event

Answer 48

**CT scan of head** Raised ICP can present with ECG changes that mimic STEMI. Patients who are driwsy and have ECG changes should have a CT head

Answer 49

** IVC filter** This patient has a DVT and just had a major oesophageal variceal bleed meaning the risk of putting then in anticoags is too great therefore in an attempt to reduce the risk of the clot spreading into the lungs and IVC filter can be used.

Answer 50

**No Action Needed** This patient probably has a diagnosis of IBD. there is a second peak incidence at around 60 years old. However as IBD is a pro inflammatory condition and is associated with a dehydrated state because of blood loss and diarrhoea there is a larger thrombotic risk, when confounded with the being ADMITTED into hospital, meaning they do need prophylaxis. Therefore patients who have symptomatic IBD in hospital and are being admitted do need VTE prophylaxis.

Answer 51

**Nizatidine** GORD that is not treated with PPI should be trialled on a histamine antagonist -> Nizatidine Peroal endocscopic myotomy -> Treatment for Achalasia Nissen Fundoplications -> Surgical treatment of GORD where medical treatment is not effective RANITDIINE is generally avoided because of carcinogen worries.

Answer 52

**Irreversible COX inhibitor** B -> Clopigogrel

Answer 53

**Obesity** Obesity Hypoventilation syndrome -> They develop high CO2 concentration because they are less able to breathe fast or deeply enough to clear the CO2... This is associated with Obstructive sleep apnoea

Answer 54

**Pneumoconiosis** This is a term used to describe a group of interstitial lung diseases that occurs secondary to the inhalation of iatrogenic allegens such as : Aesbestosis, coal dust or silica. This particular presentation is suggestive of asbestosis. Extrinsic allergic alveolitis -> would have exposure to organic allergens such as moulds Hypersensitivity pneumonitis is another term used for extrinsic allergic alveolitis Bronchiectasis is irreversible dilatation of the airways usually secondary to infections or inflammations.

Answer 55

**Pirfenidone** This is a antifibrotic medication that reduces the proliferation of fibroblasts. In turn this reduces the progression of Pulmonary fibrosis. Carbocisteine -> Mucolytic and reduces the viscous secerestions and provides symptmatic relief in COPD, Cystic fibrosis or bronchiectasis Azithromycin -> this is used as prophylaxis in COPD patients Beclomethasone is given as a inhaled steroids wio help in asthma and COPD Prednisolone -> USed in the exacerbation of COPD and Asthma. it is used in interstitial lung disease where the pathophysiology is inflammatory like sarcoidosis.

Answer 56

**Nitrofurantoin** This is associated with both acute and chronic pulmonary reactions with the pulmonary reactions may lead to fibrosis.

Answer 57

**Histamine** This challenge test is done if the reports following spirometry or FeNO is uncertain.

Answer 58

**Anterior Nasal Packing** So initially pinch -> conservative such as adrenalinse soaked gauze, lidocaine solution and silver nitrate cautery If unsuccessful anterioir nasal packing is needed .

Answer 59

**Transitional cell carinoma** Patient is over 55 has haematuria has a smoking history and this is a sterile urine analysis makes it suggestive of bladder cancer,

Answer 60

**Cathertisation** This is acute retention secondary to BPH. This should be managed urgently with cathertisation... If there was signs of hypdronephrosis then there is a need for percutaneous nephrostomy An Abdo Us would only be indicated if an alternative underlying pathology was suspected.

Answer 61

**Application of 0.05% betamethasone ointment** This patient has phimosis. this is whent there is difficulty in retracting the foreskin. Phimosis is common between 2-6. Surgical input is only needed if there is redness soreness or sweeling of the glans as well as difficulty in urinating. Uncomplicated phimosis like in this case requires topical steroids to help soften and make retracting the foreskin easier. PARAPHIMOSIS is when after the foreskin is retracted and does not return to position. This is a urological emergency and needs to be reffered yo urology. 2% lidocaine and phycical manipulation is the first way you would attempt to treat this. INDICATIONS for circumcision * medical management not successful * Complicated by balantis or urethral obstruction

Answer 62

**Spondylysis** Lysis means break. itis inflammation spondylosis -> OA of the vertebrae spondylolisthesis -> Stress facture with vetebra sliding out of position EXAMPLE BELOW FROM PPQ that is Spondylectomy -> Removal of part of the spine

Answer 63

**Pruritis** What are the indications for Dialysis: (AEIOU) **A**cidosis **E**lectrolyte-> Hyperkalaemia that is not treatable Tox**I**ns **O**verload -> Again treatment resistant **U**raemia -> but symptomatic

Answer 64

**Megatively bifringent needle shaped crystals** This is characteristic of gout Positively bifringent rhomboid shaped is charateristic of pseudogout.

Answer 65

**Injection sclerotherapy** This patient had a venous ulcer as a result of the venous insufficiency meaning she hhas quirte severe disease. This meets the threshold of interventional therapy. Compression stockings are deemed suitable if other invasive techniques are deemed not suitable. The saphenofemoral ligation is BETTER as it is the most effective... However this is more of a strenous procedure and takes longer to recover making it less useful... the sclerotherapy therefore is more approapriate as it does not require GA and has quicker recovery.

Answer 66

A) Sciatic Nerve L5-S3 supplies posteroir thigh muscles * posterior approach hip arthroplasties * -> Loss of sensation below the knee, foot drop and inabiliy to evert the ankle as well as a loss of the ankle reflex B) Superior Gluteal Nerve * Anterolateral approach to the hip arthroplasties * -> Trendelenburg positive gait and sigm * -> loss of hip abductors -> Gluteus minimus and medius C) Common Peroneal Nerve L4-S2 * **Knee replacement surgery** * Fibular fractures * Trauma to the knee * -> leads to foot drop and a high steppping gait D) Tibial Nerve . L4 to S3. terminal branches of the sciatic * damaged through direct trauma and compression * -> inability to plantarfex the ankle (patients cannot stand on their tiptoes) * -> loss of sensation on the sole of the foot. It can be damaged E) Femoral Nerve L2 -L4 * trauma * Surgery * Tumours * -> Quadricep wasting * -> Loss of knee jerk * -> numbness along the medial thigh and calf

Answer 67

**ERCP** Patient has RUQ pain, jaundice fever -> Ascending cholangitis GOLD standard treatment / investigation is ERCP... Abdo US -> GOLD standard for Gallstones but not obstructive disease.

Answer 68

**Sigmoid volvulus** -> this is the coffee bean sign Sn ileus will be seen as generalised distension on a radiograph Toxic megacolon is a when there is severe dilataion and the diameter of the colon is >6cm perforation will have pneumoperitoneum signs including riglers as well as hepatic edge sign (gas in the subphrenic area) The loops of bowel that would be dilated would be more central and there will be transverse lines that vwill completely cross the lumen,

Answer 69

**Phlegmasia Cerulea Dolens** -> this is a major block of both the collateral and the deep veins. Critical limb ischaemia -> This is when there is severe vascular disease with rest pain and tissue loss Phlegmasia Alba dolens -> this is just the occlusion of the deep veins but not the collaterals, essentially one step before the Cerulea Leriche syndrome -> this is a peripheral vascular disease it is a arterial disease of the ilac arteries... It presents with butt claudication and ED and weak femoral pulses.

Answer 70

**Wet Gangrene** Gangrene is dead tissue due to ischaemia, then there is wet gangrene when the dead tissue gets infected. This is often needs urgent debridement and IV abx

Answer 71

**Surgical Lobectomy** Squamous cell carcinoma is a type of non small cell carcinoma. This is at Stage 2 disease and if there are no other comorbidities the treatment of choice is Lobectomy. Stage I or II is treated with surgical resection Stage III or IV is treated with Chemotherapy If this was a small cell carcinoma it is treated with Chemo, with surgery + radiotherapy being a consideration B -> Used in adenocarcinoma that is metastatic or recurring C -> This is offered in NSCLC in Stage I-III but without being able to have a surgery

Answer 72

**Transphenoidal Hypophysectomy** Dumbass Cushing disease is the disease of the pituitary gland and so there is a need to remove the pituitary tumour not the adrenals.... Cabergoline -> Dopamine agonist that is used to treat prolactinoma

Answer 73

**Admit and insert 8-14 F chest drain** The British Thoracic Society (BTS) recommends chest drain insertion and admission for all secondary spontaneous pneumothoraces that are > 2 cm or presenting with breathlessness. A: Urgent needle decompression in the 2ndintercostal space, mid-clavicular line is recommended for tension pneumothorax. (I think this has changed to the 4th or 5th intercostal space) B: Patients with asymptomatic primary spontaneous pneumothoraces that are < 2 cm in size may be considered for discharge with outpatient follow-up. C: Aspiration is used in primary spontaneous pneumothoraces that are > 2 cm in size and/or presenting with breathlessness. It may also be considered in cases of asymptomatic secondary spontaneous pneumothoraces which are 1-2 cm in size. D: If a patient is discharged with a small pneumothorax with no shortness of breath, they should have a follow-up chest X-ray to ensure that the pneumothorax has resolved.

Answer 74

**Vestibular Schwannoma** This is the same as an acoustic neuroma This is a slow growing tumour in the brain Presntation: * Unilateral sensorinueral hearing loss (IF THIS IS BILATERAL THEN IT IS NEUROFIBRAMOTOSIS 2) * Dizziness * facial numbness The features mentioned here about Ataxia are features if the Vestibular schwannoma is particularly big. If there is papilloeoedema and obstructiv hydrocephalus. Investigation of choice is MRI... REFER URGENTLY TO ENT . . . Other options to the question and why they werent right... *`meningioma`* is a benign tumour of the meninges. It is less likely to cause a hearing impairment but may lead to features due to the mass effect (e.g. persistent headache). MRI head will show a large angle between the tumour and dura not centred over the internal acoustic meatus, often with a dural tail and without any internal acoustic meatus enlargement. *`Non-functional pituitary adenomas`* are categorised based on size. Macro-adenomas (over 1 cm) present with symptoms secondary to mass effect such as headaches, visual field defects and hypopituitarism. Pituitary MRI is the preferred investigation and will show a sellar mass – which is not present on the MRI in this case. *`Brain metastases`* are the most common type of brain tumour. There are usually multiple small deposits and there are likely to be features suggestive of an underlying malignancy. *`CNS lymphoma`* typically occurs in patients who are immunosuppressed (e.g. poorly-controlled HIV).

Answer 75

**IV unfractioned heparin** So in a PCI there is an introduction of a guide wire into the arterial system and this can cause clot formation. Unfractioned heparin is needed to help counteract this... STEMI managememnt

Answer 76

**Colchicine** This is a diagnosis of pericarditis -> Treatment is with NSAIDS and Colchine.

Answer 77

**Aortic bifurcation** Thiis is Leriche syndrome... The vascular disease is at the bifurcation and causes problems with tje proximal oortic arteries. Presentation with triad: * butt claudication * erectile dysfunction * Absent or weak femoral pulse.

Answer 78

**20 mmHg** The normal range in the pulmonary system is 18-25.

Answer 79

** HbA1c** Chronic pancreatitis can lead to DM and so HbA1c monitorting is indicated They should also have a 2 yearly bone scan CHRONIC PANCREATITIS MONITORING

Answer 80

**Complication of TIPS procedure** There is no detoxification of the blood from the GI tract to the sytemic circulation and this leads to the hepatic ecephelopathy if the bleed was continuing the blood test wont show an increasin Hb level The inflammatory markers are only slightly raised and his observations are otherwise normal this patient does have hepatorenal syndrome,.... but this is mild and the uraemic encephelopathy is less liklely than hepatic encephelopathy.

Answer 81

**Fondaparinux** Fonda should be started in an NSTEMI The unfractioned heparin only needs to be started around the time of the procedure with regards to the PCI. THIS IS because there is a high chance of clots in PCI the procedure

Answer 82

**Cyclical Progesterone** This would mean the patient would know her period would be during the pill free week. Wt loss should be reccomended if the stem mentioned the patient being overweight Metformin is if patients show they are insulin resistant Clomifene is selective oestrogen receptor modulator and is used to stimulate ovilation Levongesteerol IUS makes periods lighter but not more predictable

Answer 83

**Topical GTN** After analgesia and having warm shallow baths and laxatives have been attempted the next step in management is Topical GTN this will help as it relaxes the anal sphiter and allows for healing If Topical GTN was uneffective then you would attempt topical Diltiazem

Answer 84

**Sodium Nitroprusside** HF due to severe HTN give sodium Nitroprusside AVOID beta blockers in the above population MethylDopa can be used in pregnant women Phentolamine is a potential treatment option in pheeochromocytoma.

Answer 85

**Autosomal Dominant** This is an Autosomnal dominant conditions. There is NF1 + NF2 NF1 peripheral disease * Cafe au lait spots * Axillary freckling * Phaecochromocytomas NF2 * Bilateral vestibular schwannomas * Meningiomas * Glioma

Answer 86

**Haemophilus influenza** `S. aureus` is a common skin commensal that can cause severe infections if introduced to the bloodstream. B: `S. pyogenes` can cause pharyngitis, skin infections and necrotising fasciitis. D:` Pneumocystic jiroveciiis` a fungus that causes pneumonia in immunocompromised hosts (e.g. people with HIV). It used to be called Pneumocystis carinii. E: `Pseudomonas aeruginosais` a Gram-negative rod that can cause troublesome infections in people with COPD. It is resistant to a wide variety of antibiotics so requires targeted antibiotic therapy

Answer 87

**Azithromycin** Prophylaxis for COPD.

Answer 88

**Extrinsic allergic alveolitis** Caused by exposure to mould, which is seen in the history as this patient was a farmer The mainstay treatment is avoid the allergen and steroids A: Sarcoidosis can cause interstitial lung disease, however, a more classical imaging finding is bilateral hilar lymphadenopathy. B: Asbestosis is pulmonary fibrosis secondary to asbestos exposure. The main jobs that are historically at risk of asbestos exposure are ship building and construction. D: COPD would present similarly but is very unlikely in a patient who does not smoke. E: Bronchiectasis classically presents with chronic shortness of breath, copious sputum production and recurrent chest infections.

Answer 89

** High flow nasal oxygen therapy** High-flow nasal oxygen therapy is a good option for patients who have high oxygen requirements and are unable to tolerate NIV. The device delivers humidified oxygen which means that patients are able to tolerate very high flow rates. A: Intubation and ventilation may be considered at a later stage, however, this will be dependent on the patients frailty and comorbidities. C: A non-rebreathe mask is unlikely tobe sufficient to meet the oxygen requirements of the patient. D: A 60% Venturi mask is unlikely to be sufficient to meet the oxygen requirements of the patient. E: Heavy sedation would not be recommended for patients having NIV as *reduced consciousness is a contraindication for NIV*

Answer 90

**Abdomen** Often grows in the lungs then the next most common site is the abdomen and then finally the pericardium

Answer 91

**Dunphy's sign** this is a sign associated with appendicitis, pain while coughing Rovsing's sign palpation of the left ilac fossa causes pain in the right iliac fossa Psoas sign For a retrocaecal appendix, when extension of the hip produces abdominal pain Murphy's sign Acute cholecystitis palpation over the right subcostal margin elicits pain on deep inspiration Obturator sign acute appendicitis Pain is produced on flexion and interal rotation of the hip as the inflamed appendic comes into contact with the obturator muscle

Answer 92

**Trastuzumab** This is given to breast cancers that are HER 2 positive Hormone therapy would be given to breast cancer that are hormone receptive to reduce the risk of recurrance. `chemotherapy` This is given as a neo adjuvant when the tumours is > 4cm before the surgery. And after the surgery for younf woman with cancer lymph nodes positive status, high grade histological features and ER negative cancers. `Radiotherapy` This used to reduce the rate of local recurrence, offered to patients with aggressive disease such as lymph node involvement, large tumours, and surgical margins that were not clear of tumour. `Surgery` is the first-line treatment for patients with breast cancer and is offered to everyone who is fit enough to undergo surgery. Mastectomy and wide local excision are the two surgical approaches. The choice of surgery depends on factors such as the size of the tumour compared to the tumour to the breast, location of the tumour. `Tamoxifen` Oestrogen receptor positive cancers are treated with tamoxifen or aromatase inhibitors. Tamoxifen is a selective oestrogen receptor modulator given to women who are pre and *perimenopausal*. Anastrozole is an aromatase inhibitor and is given to *postmenopausal* women as most oestrogen is produced through aromatisation in this age group.

Answer 93

**Fibroadenoma** This fibroadenoma was probably present for many years but became noticable after starting the HRT. HRT can increase the size of fibroadenomas. Contrceptives can also have this effect. `breast abscess` presents with systemic upset (i.e. fever, malaise). On examination, there is a painful breast lump which may be fluctuant and associated erythematous swollen skin. `Intraductal papillomas` are benign growths found within milk ducts. They are often located near the nipple. They may present with a lump but it would not be smooth and highly mobile like the lump described in this patient. Other symptoms may be a *clear* or *bloody nipple* discharge and breast pain or discomfort. `Fibroadenosis,` also called *fibrocystic disease*, is the most common cause of breast lumps in women of reproductive age. Patients present with breast pain, changes in breast size and breast nodularity. It is *unlikely to present with a solitary lump*. `Fat necrosis` occurs after *trauma* to the breast. It may present as one or multiple lumps and there may be some associated skin changes. There is often tenderness on examination.

Answer 94

**Non-urgent referral to breast clinic** According to NICE guidelines, an urgent referral (on the 2-week-wait pathway) is required for * anyone over the age of 30 years presenting with an unexplained breast lump (with or without pain) or * over 50 years with unilateral changes to a nipple including discharge or retraction. * A 2-week-wait referral should also be considered for anyone presenting with skin changes suggestive of breast cancer (i.e. peau d’orange, Paget’s disease of the nipple) or * patients under the age of 30 years presenting with an axillary lump The GP should reassure the patient about these findings. Although it is highly unlikely that this lump is cancerous, NICE guidelines state that any woman under the age of 30 years presenting with an unexplained breast lump should receive a non-urgent referral (within 6 weeks) to a breast clinic.

Answer 95

**Rectal prolapse** Risk Factors: * Pelvic floor dysfunction * Previous abdominal surgery * Chronic constipation Presentation: * lump protruding through the anus (initially only while straining) * this progresses to the lump protruding with activities, leading to a prolapse that will only retracts with manual force. * ASSOCIATED with faecal incontinence, rectal bleeding and mucus and pain * Examinaition -> cocentric rings of bowel `Haemorrhoids`: Often presents with bright painless bleeding and pruritus ani. A `rectal ulcer` would not present with a lump protruding through the anus. Symptoms of a rectal ulcer include rectal bleeding, mucus, pain or discomfort and tenesmus. These ulcers should be biopsied to exclude malignancy.

Answer 96

**BMI of 42 kg/m2 without comorbidities** Indications of bariatric surgery inc: * BMI > 40 * BMI 35-40 and serious combobidities (HTN + T2DM) * All other methods of Wt loss have been attempted * BMI > 50 it is the FIRST LINE treatment * BMI < 35 and diagnosed with T2DM Qualifying for surgery: * Fit for general anaesthesia * agree to long term follow up * Be prepared to make long term changes

Answer 97

**Hemi-arthroplasty** Involves replacement of the femoral head and neck only. A hemi-arthroplasty is indicated in *displaced* intracapsular fractures where the patient is *older than 65 years of age* but is *not* deemed to be* fit enough* to qualify for a total hip replacement. *`Open reduction and internal fixation with an intramedullary nail`* is only indicated in patients with an *extracapsular fracture*. It involves the placement of a titanium rod through the medullary cavity of the bone. *`Open reduction and internal fixation with a plate and cannulated screws`* is indicated in *intracapsular fractures *which are *not displaced*. Given that this patient’s X-ray demonstrates shortening and external rotation of the distal bone fragment, internal fixation with a plate and cannulated screws is inappropriate here *`Open reduction and internal fixation with a plate and dynamic hip screw (DHS)`* is typically reserved for patients with a stable *intertrochanteric fractured neck of femur* (a type of extrcapsular). *`A total hip replacement`* is indicated in patients over the age of 65 years who are independent for their activities of daily living, can walkover a mile per day and have few comorbidities. It involves replacing the femoral neck, head as well as the pelvic acetabulum. **Extra-capsular** - outside the capsule, subdivided into: Inter-trochanteric, which are between the greater trochanter and the lesser trochanter. Sub-tronchanteric, which are from the lesser trochanter to 5cm distal to this point.

Answer 98

**Duplex US scan** this is the next best scan CT angio will be done after as it is a gold standard and will help assist surgeons to plan for surgery...

Answer 99

**Electromyogram** this patient has carpal tunnel syndrome. Tinel's sign is what is being described with the tapping of the flexor retinaculum THIS is mainly a clinical diagnosis but Electromyogram may be used to confirm diagnosis. an US of the wrist can be used to diagnose a ganglionic cyst. MRI wrist is semi useless Hypothyroidism can cause Carpal tunnel syndrome but this patient does not have any of the hypothyroid signs MRI cervical spine would be reccomended if there was any concerns about degenerative cervical myelopathy ot radiculopathy.

Answer 100

**Urea breath test** this is the FIRST test second test is the stool antiged test and the hydrogen breath test is for Small bowel growth,

Answer 101

**MRCP** Ok so the diagnosis of this patient is not pancreatic cancer... Essentially this is painless jaundice but you need to look for the risk factors... In this case there are none for pancreatic cancer but there are signs of atopy with T1DM and Hypothyroidism making PBC more likely. Additionally the patient is a woman, and she is middle aged. This patient has primary biliary cirrhosis and this can be seen in MRCP as there is features on the intrahepatic ducts. `Ultrasound abdomen` is likely to be the first investigation to be performed because it can demonstrate the presence of gallstones (more common cause of biliary tract obstruction), however, it would not be able to diagnose PBC. `ERCP` is more commonly used to investigate and treat biliary tract obstructions caused by gallstones. As this patient has painless jaundice, it is less likely to be due to gallstones. `Endoscopic ultrasound` is rapidly becoming a useful diagnostic and interventional tool. It can be used in a variety of situations including the investigation of mural invasion in oesophageal cancer, and for biliary drainage in ascending cholangitis. `CT Pancreas` is the gold-standard investigation for chronic pancreatitis.

Answer 102

Nephrotic syndrome is defined as a condition in which urinary protein loss exceeds 3.5 g per day. More recently, urine albumin creatinine ratio (ACR) has been used as a spot test to assess proteinuria as it is far more convenient than 24 hr urine collections. An ACR > 220 mg/mmol is suggestive of nephrotic range proteinuria. Minimal change disease is the most common cause of nephrotic syndrome in children. It is described as ‘minimal change’ because a renal biopsy in these patients will reveal little or no abnormalities when viewed under a light microscope. Electron microscopy, however, may reveal effacement of the podocyte foot processes which compromises the barrier that would normally prevent albumin from leaking into the urine. This damage results in many other proteins, in addition to albumin, leaking into the urine. *Patients with nephrotic syndrome lose a considerable amount of antithrombin-III in their urine, which is a major component of the body’s endogenous anticoagulant mechanism. Therefore, patients with nephrotic syndrome are at increased risk of venous thromboembolism. *

Answer 103

**Nephrotic syndrome** The ascites is probably due to the nephrotic syndrome. The static water is likely to be a source of infection.Additionally there is an impaired immune response due to the loss of immunological antibodies in the urine. `Budesonide` is a steroid that is commonly used in the treatment of asthma. It is given in relatively low doses and is unlikely to cause a systemicimmune suppressed state that predisposes patients to serious infections. Given that it is an inhaler, it can cause local immunosuppression within the oral cavity, thereby predisposing patients to the development of oral candidiasis. `Diabetes mellitus` does increase the risk of developing infections (mainly skin and respiratory tract infections). It may increase the risk of peritonitis in patients who have peritoneal dialysis. One of the major side-effects of `clozapine therapy` is the development of *neutropaenia*. This is why clozapine requires close monitoring and patients should be advised to seek medical attention if they start showing any features of infection (e.g. sore throat). This patient is not neutropaenic. Patients on `peritoneal dialysis` for end-stage renal failure are at risk of developing peritonitis. This patient only has CKD Stage 2, so is unlikely to be on dialysis.

Answer 104

**Watchful waiting** HYDROCELE for under the age of 1 the first step is watchful waiting. `Aspiration` is the management of choice in patients with hydroceles which do not respond to watchful waiting. Whilst they are benign, it is important that hydroceles resolve eventually, as they are associated with complications including rupture, infection and testicular atrophy if they persist. Surgical management with aspiration is therefore used in patients with hydroceles which are refractory to conservative management. `Excisionis` a potential treatment option for a *haematocele*, but not a hydrocele. Excision might also be used to obtain a biopsy in patients with suspected testicular cancer.

Answer 105

**Repeat TURBT with intavesical BCG treatment** The described Bladder cancer is a high risk tumour that is quite superficial.... Another TURBT is done to make sure no inasice disease has been missed The use of the BCG is used to stimulate the immune system at the site of the cancer in a way to make the immune system attack the cancer cells that may still be there/

Answer 106

Bag-valve-mask (BVM) ventilation is fundamental in ensuring oxygenation of the apnoeic patient. Sometimes, patients can be difficult to ventilate, regardless of good technique, due to a number of factors such as high BMI, large neck circumference and the presence of facial hair. An `oropharyngeal airway (OPA/Guedel)` can be used to help maintain the airway. When a patient becomes unconscious, the muscles of the jaw relax which allows the tongue to obstruct the airway. The OPA moves the tongue out of the way. It can only be used in unconscious patients, due to the absence of the gag reflex `Pushing the mask down into the face` actually causes the tongue to be forced to the back of the throat, obstructing the airway. Good technique is to thrust the jaw upwards into the mask. `Nasopharyngeal airways` (NPAs) are always used in conscious patients as OPAs would trigger the gag reflex. NPAs are also indicated in unconscious patients however *coagulopathy* is a *relative contraindication*, which is present in this patient. `Hyperventilation` is dangerous as it can result in gastric insufflation, which can lead to regurgitation and aspiration of the stomach contents, as well as gastric rupture.

Answer 107

**EEG** EEG monitoring is the best way of assessing the depth of anaesthesia in patients under TIVA. Anaesthetists use a number called the bispectral index (BIS) on the EEG monitor to titrate the dose of anaesthesia given. The lower the BIS, the less likely the patient is to become aware under anaesthesia

Answer 108

**Endometrial cancer** Womb is exposed to a high amount of uncontested oestrogen and that leads to endometrial hyperplasia and later carcinoma.

Answer 109

**Amoxicillin** Triple therapy is the recommended approach to treating H. pylori infection. It involves a combination of a proton pump inhibitor and two antibiotics (most commonly amoxicillin and either metronidazole or clarithromycin). H. pylori increases the risk of peptic ulcer disease and gastric malignancies, so should be treated if detected

Answer 110

**Constipation** So this is Faecal impaction. The line that is seen on the radiograph is a common feature of faecal impaction on top of constipation. Sigmoid volvulus will have dilated loops originating from the left iliac fossa and the classic coffee bean sign may be seen Rectal tumour may not be seen on AXR, but it can cause bowel obstruction Paralytic ileus affects the small bowel and is hard to diagnose for AXR Hernias normall lead to small bowel obstruction larger than large bowel obstruction.

Answer 111

**Meclel's diverticulum** Meckel’s diverticulum is a congenital gastrointestinal abnormality characterised by the presence of a remnant of the omphalomesenteric duct. It is usually found around the ileum. It is often asymptomatic and may be an incidental finding on imaging, however, it can become infected (Meckel’s diverticulitis) or bleed. It usually contains ectopic gastric mucosa which can ulcerate. Scintigraphy using technetium-99m pertechnetate may be used to identify the presence of a Meckel’s diverticulum. The age makes colorectal cancer and diverticulitis unlikely. Additionally the lack of pain also points away from diverticulitis. Colonic angiodysplasia presents with painless fresh rectal bleeding.

Answer 112

**Spironolactone.** Primary hyperaldosteronsismm is caused bilateral adrenal hyperplasia and it tends to be medically managed with an aldosterone antagonist. Bilateral adrenalectomy is rarely performed and is normally only done in refractory cushing's syndrome with disabling symptoms Fludrocortisone will make the symptoms worse as it is the treatment of addison's disease Cabergoline is used in the treatment of acromegaly and prolactinomas

Answer 113

**Central Hypothyroidism**

Answer 114

**Ethosuxmide** This is a treatment of abscence seizures.

Answer 115

**Anti Viral** -> Used to treat influenza Amantadine is used in the treatment of Parkinson’s disease as it has some agonist activity on central dopamine receptors. It also blocks the M2 proton channel of influenza A which prevents endosomal escape of the virus. It is, therefore, used to treat influenza A.

Answer 116

**Squamous cell lung carcinoma** The normal ALP should have pushed you away from bone metastassis addistionally the large cell lung cancer is very rare cancer within non small cell lung cancer.... Squamous cell lung cancer is a non small cell lung cancer and it is a 2nd most common cause of it. It can sometimes produve PTH related peptide hence the electrolyte abnormality shown. Small cell lung cancer is the most common lung cancer associated with smoker, and is associated with the ACTH and ADH production.

Answer 117

**T wave inversion in V1-3** So right heart strain may show ischaemic changes to the right side of the heart. this would be T wave inversion or ST depression in the leads that represent the right side of the heart aka V1-3 and II and III. With dominant S waves in V5-6.

Answer 118

**Morphine** Removal of the chest drain is painful and so important to provide pain relief for the patient. Glycopyrronium -> palliative care for secretions Paracetamol -> Analgesic and antipyretic but not gonna be helpful when removing the chest drain Carbocisteine is a mucolytic and helps with mucou related redpiratory conditions such as bronchiectasiis Transxeamic acid is an antifibrinolytic and can reduce blood loss in menorrhagia and epixstasis..

Answer 119

**Bariatric surgery** BMI < 35 and NEW diagnosis of DM -> needs to be referred for bariatric surgery. orlistat is indicated BMI >28 + Risk factors or BMI >30, therfore this would have been the answer if the patient did not also have T2DM Has not lost weight despite triallyin lifestyle changes.... Liraglutide is another medical treatment of obesity and would have been approapriate once unsuccessful with lifestyle treatments were not effective.

Answer 120

**Sleeve gastrectomy** Sleeve gastrectomy involves the surgical excision of the majority (about 80%) of the stomach. The remainder of the stomach is closed to create a tube-shaped stomach. The stomach is therefore much smaller so patients feel full much quicker and eat less. This type of bariatric surgery cannot be reversed. A: Gastric band involves the surgeon placing a ring (‘band) around the stomach to create a small stomach pouch. Patients feel full much quicker and they eat less due to the smaller size of the stomach. The band can beadjusted by injecting saline solution to increase or decrease the size of the stomach. B: Gastric bypass is also called Roux-en-Y gastric bypass. The stomach is initially stapled to create a much smaller pouch at the upper end. Patients feel full quicker and they eat less due to the smaller stomach. The small intestine is then divided into two parts and the distal part is attached to the newly created smaller stomach pouch. This results in a significant part of the small intestine being bypassed, and since most nutrients are absorbed in the small intestine, fewer calories are absorbed. The upper part of the divided small intestine is then attached to a later part of the small intestine so that digestive juices from the bypassed stomach and small intestine can enter and help digest food in the remainder of the gastrointestinal tract. This surgery results in significant weight loss as patients eat less (due to feeling satiated much quicker) and less food is absorbed (due to bypassing of a significant portion of the small intestine). D: An intragastric balloon is not a permanent form of bariatric surgery. It involves a gastroscopy (where an endoscopy tube is passed through the oesophagus into the stomach) to place a small balloon into the stomach. This balloon is filled with air or water and reduces the relative size of the stomach. Patients therefore feel full quicker and eat less. E: Biliopancreatic diversion is a form of bariatric surgery that is similar to a gastric bypass. The stomach pouch is connected further along the small intestine (than in gastric bypass surgery) which means more of the small intestine is bypassed so even fewer nutrients are absorbed.

Answer 121

**US-guided Fine needle aspiration** Eventhough generally speaking the next investigation would be an scan normally and in under 35 the scan is an US scan. In the case of a patient that has suspected breast abscess the most important intial test is a fine needle aspiration to send off for an MCS while also treating the problem.

Answer 122

**Gallstone ileus** There are no lumps seen on the examination and so a inguinal hernia or intrabdominal adhesions are unlikely. Cholecystitis would not explain the obstruction that is described here. Pancreatitis usually presents with severe epigastric pain associated with nausea and vomiting. The abdomen will be very tender upon palpation

Answer 123

**Smiths fracture** There is a volar angulation and this is a Smiths fracture if the fracture was displaced dorsally then that would be a colles fracture... Volar is taking about the distal portion of the fracture and where that ends up aka doe the distal end of the radius face palmar side that would be VOLAR If the distal end of the fracture is pointing to the dorsum of the hand that would be a DORSAL and a Colles fracture. **Initial management **involves ensuring the neurovascular function of the limb is intact and providing adequate analgesia. Reduction with analgesia/anaesthetic support is the mainstay of initial management, followed by immobilisation of the joint with a back slab and plaster of Paris. A repeat X-ray is required post reduction to ensure realignment of the joint and displaced fragments. The patient should be reviewed in fracture clinic.

Answer 124

**Enterotomy on emergency surgery list** This patient has a gallstone ileus secondary to a cholecystoduodenal fistula. This often presents with a triad of : * pneumobilia * Bowel obstruction * Calcified gallstones within the bowel The treatment for this is to remove the mechanical obstruction and an enterotomy does this by making an incision in the small bowel to remove the stone.

Answer 125

**Oseophagectomy and chemotherapy** the N1M0 of the TNM stage informs us that the extent of disease in this patient is limited to the oesophagus. Hence, a surgical resection through an oesophagectomy is appropriate. However, at least one nearby lymph node contains malignant cells. Therefore, adjuvant and neoadjuvant chemotherapy are also indicated endoscopic resection is only appropriate in patients a low-grade tumour that is limited to the muscularis mucosa with no lymph node involvement. Oesophagectomy alone is the management of choice in patients who have disease limited to the oesophagus, but with no nearby lymph node involvement. Involvement of any lymph nodes at all would indicate eligibility to adjuvant and/or neoadjuvant chemotherapy Chemotherapy plus radiotherapy is offered to patients with stage IV tumours. This includes tumours which have spread to distant lymph nodes and/or other organs. It may also be used in patients with lower stage tumour who are not fit for surgery. Endoscopic ablation and stenting is a palliative procedure indicated for non-surgical candidates to enable them to continue eating by mouth

Answer 126

**Trimethoprim** Nitrofurantoin is excreted by the kidneys so should be avoided in imparired renal disease with eGFR < 45

Answer 127

**Amyloidosis** Amyloidosis is a condition in which abnormal amyloid proteins accumulate in various tissues across the body. It can accumulate in the kidneys resulting in nephrotic syndrome, in the heart and cause heart failure and within nerves causing peripheral neuropathy and autonomic dysfunction. It is also known to cause carpal tunnel syndrome due to the deposition of amyloid around the tissues of the carpal tunnel. There are two main forms of amyloidosis that are defined based on the type of protein produced. AA amyloidosis arises in patients with chronic inflammatory conditions (e.g. rheumatoid arthritis) as the chronic inflammatory state results in persistently elevated levels of serum amyloid A protein (acute phase protein) which can aggregate to form amyloid. AL amyloidosis arises in patients with **multiple myeloma** (Hence the CRAB symptoms). The excess production of immunoglobulins results in the aggregation of light chains to form amyloid. The two types can be remembered as A for Amyloid A, and Lfor Light chains.

Answer 128

**Post Strepococcal** Haematuria weeks after infection -> Post streptococcal nephropathy. Patients may present with painless haematuria, peripheral oedema, oliguria or incidentally raised blood pressure. Most cases will resolve spontaneously so treatment is mainly supportive. For a passed stone there would be a pain history IgA nephropathy is caused because of IgA causing glomeruli inflammation. it often presents 24-72 hours post infection A cause of haematuria should always be sought as it is pathological RCC would present with constituitional symptoms....

Answer 129

**Giant cell arteritis** (also known as temporal arteritis) is a vasculitis that typically occurs in adults over the age of 50 years and usually involves the branches of the external carotid artery. It is commonly associated with polymyalgia rheumatica, so patients may describe a background of shoulder and pelvic girdle pain. GCA usually presents with a unilateral headache and tenderness over the temporal artery. It may also be associated with scalp tenderness, jaw claudication and, in some cases, visual changes. In patients with suspected GCA, a blood sample should be sent to check the ESR. If elevated or if there is a strong index of suspicion of GCA, patients should be started on high dose steroids. A temporal artery biopsy is the gold-standard diagnostic test for GCA. Takayasu’s arteritis is a large-vessel vasculitis that typically occurs in younger females. A key diagnostic factor is absent or asymmetrical peripheral pulses and multiple bruits on auscultation. Polymyositis is an inflammatory myopathy characterised by proximal muscle weakness and raised muscle-derived enzymes such as creatine kinase. Hypothyroidism can cause myalgias but the TFTs are normal in this case Systemic lupus erythematosus is a chronic multisystem disorder –typically involving the skin and joints –features manifest over a prolonged period and include malar rash, photosensitivity, arthralgia/arthritis –although ESR and CRP may also be elevated, you often find cytopenias and deranged renal function on the blood test results.

Answer 130

**Tuberous Scleroris** Tuberous sclerosis is an inherited disorder characterised by the presence of cutaneous manifestations (e.g. ash leaf hypopigmentation, Shagreen patches, adenoma sebaceum) and neurological manifestations (e.g. epilepsy, developmental delay). Other features include renal angiomyolipomas and retinal hamartomas Neurofibromatosis is another inherited disorder in which patients develop neurological and cutaneous manifestations. `NF1` is characterised by *cafe-au-lait patches, axillary freckling, cutaneous neurofibromas and phaeochromocytoma*. `NF2` is characterised by *bilateral vestibular schwannoma, meningiomas and ependyomas.* `Lennox-Gestaut syndrome` is a seizure disorder in which young children develop seizures in association with* severe learning disability*. It is not associated with cutaneous changes. `Juvenile myoclonic epilepsy` is a common form of epilepsy in which children develop myoclonic jerks, usually in their limbs. It is often precipitated by a lack of sleep, and patients are *often seizure-free by adulthood* Sturge-Weber syndrome is a neurocutaneous disorder characterised by the presence of a port-wine stain on the face, seizures and developmentaldelay. *BABIES*

Answer 131

**Percutaneous Nephrostomy** the CT shows hydronephrosis and this needs to be urgently managed with a nephrostomy, to relieve pressure on the kidney. `Medical expulsive therapy` is considered in patients with *non-obstructive stones* that are less than *10 mm in size*. It involves using alpha-blockers (e.g. tamsulosin) and calcium channel blockers (e.g. nifedipine) to relax the ureteric smooth muscle and facilitate the passage of the stone

Answer 132

**Urgent referral to urology for consideration of bilatera fixation** This patient has signs and features of testicular torsion that cant be differentiated from epididymitis. Therefore this should be treated as such until proven otherwise.

Answer 133

**Sevoflurane** Common agents that trigger malignant hyperthermia are -> Sevoflurane and suxamethonium patients who have this reaction have a mutation on the ryanodine receptor and it leads to increased intracellular Ca concentration and this lead sto excessive muscle contraction.. re storing the Ca causes the use of a lot of ATP and this is what causes the hyperthermia.

Answer 134

**Visual assessment of transient fasciculations** The fascicualtions are because of the depolarising affect of the suxamethonium. This can be seen progressively starting supraorbitally and then travelling down the body.

Answer 135

**Glyceryl trinitrate** In severe AS nitrates are contraindicated. This is because nitrates cause a sudden decrease in preload and the in patients with AS the hear will not be able to compensate by sufficiently increasing the stroke volume and this can lead to myocardial ischaemia.

Answer 136

A) Irreversible COX Inhibitor -> ASPIRIN B) P2Y12 Receptor Antagonist -> CLOPIDOGREL OR TICAGRELOR C) Potentiates Action of Antithrombin-III -> FONDAPARINUX D) Vitamin K Epoxide Reductase Inhibitor -> WARFARIN E) Converts Plasminogen to Plasmin -> ALTEPLASE

Answer 137

**Ursodeoxycholic acid** can improve the prognosis. This is PBC. Primary biliary cholangitis (previously known as primary biliary cirrhosis) is a chronic inflammation disease that is characterised by progressive *intrahepatic bile duct damage*. Features of PBC: ● Associated with other autoimmune diseases ● Associated with anti-mitochondrial antibody (AMA) ● Ursodeoxycholic acid confers a prognostic benefit

Answer 138

**Iodine deficiency** Common in areas where iodine fortified grains are not readily available. This often causes a large goitre.

Answer 139

**BMI Centiles** 98 centile -> obese 91-98 -> overweight

Answer 140

**Donepezil** the above is an *acetylcholinesterase inhibitor* that is used in the treatment of *Alzheimer’s dementia*. Alzheimers is thought to be associated with a deficiency of acetylcholine in the brain. Therefore, acetylcholinesterase inhibitors can bring about an improvement in the symptoms that the patient experiences. Other examples of acetylcholinesterase inhibitors include rivastigmine and galantamine. A: Aspirin is an antiplatelet agent. C: Haloperidol is a typical antipsychotic. D: Risperidone is an atypical antipsychotic that is sometimes used in the treatment of *difficult behaviour* in the context of dementia. E: Memantine is an NMDA receptor antagonist that is used to treat *severe Alzheimer’s disease*.

Answer 141

**NMDA receptor antagonist** In Severe Alzheimer's NMDA receptor antagonists cn be used. Muscarini agonists are not used in Alzheimers disease. Pilocarpine is an example and is used in acute close angle glaucoma Acetycholinesterase inhibitors such as dinzepil is used in the treatment of Alzheimers dementia but in the earlier stages Serotonin reuptake inhibitors are used in the treatment fo depression, OCD and anixiety Dopamine agonits (ropinerole) -> Can be used in parkinson's disease or prolactinomas

Answer 142

**BiPAP** this should be attempted before intubation in patients with type 2 RF

Answer 143

**ECG** There is an irregular pulse and there signs of ischaemic bowel. If there is a irregularly irregular pulse then AF can be assumed, however there are multiple reasons for an irregular pulse. This can be confirmed to be AF with an ECG. The AF would most likely be the cause of the ischaemic of bowel... The VBG may show raised lactate and that is a sign of ischaemic bowel but does not tell us the cause of this.

Answer 144

**Book onto the emergency theatre list.** Acute mesenteric ischaemia, this is a surgical emergency. and so requires urgent booking to the emergency theater list. A is inapproapriate as the patient needs intervention The rest of the options are all possible but the main next initial managment should be the most urgent which is booking into emergency surgery.

Answer 145

**CT abdo and pelvis.** The patient has bowel obstruction and this is seen by the mentioned risk factor -> parkinsons, constipation and multiple previous abdo surgeries. The lack of vomiting suggests the obstruction is in the large bowel. AXR may be preferred there is a history of recurrant sigmoid volvulus otherwise generally speaking a CT abdo is better for obstruction. U+Es and bone profile is causes of paralytic ileus, to check for those but these are less urgent.

Answer 146

**Perforated Peptic ulcer** CLUES : * History of chest pain relieved by gaviscon. AKA GORD, known RF for Peptic Ulcer disease * Peritonitic picture with shallow breaths and generalised abdo pain. * TRIAD : Sudden Abdo pain/Tachycardia/abdominal rigidity. Acute pancreatitis -> Sever pain that radiates to the back and is relieved whil leaning forward and is associated with vomiting Acute cholecystitis -> severe RUQ continous pain that may radiate to the scapula, Murphy's sign maybe positive

Answer 147

**Erect CXR** Lying very still on the examination couch. This is suggestive off perforated peptic ulcer. CT abdo is needed if there is suspected surgery needed, to plan for surgery.

Answer 148

**Laparotomy** This is the most approapriate management option for perforation of a peptic ulcer. NBM and NGT would be initial management of obstruction. h.Pylori treatment -> Omeprazole, Amoxicillin and Clarithromycin/Metrondiazole. Rigid sigmoidoscopy with gas insufflation is the initial management of patients with UNCOMPLICATED sigmoid Volvulus. It may also be used in children presenting with intussusception.

Answer 149

**Open reduction and internal fixation** This is the treatment of choice of a Barton Fracture which is when there is a dorsal displacement of the fracture component. Different to Colles or Smiths fracture where there is a complete fracture and it is extrarticular aka does not break the surface of the articulating point of the joint. Wrist injury -> presents to AE -> Examine and check if neurovasculalary intact -> AP and Lateral CXR of the wrist Polysling is the treatment of choice to support the elbow and the shoulder joint so does not help with the wrist injuries. K wires are indicates in small fractues usually involving the phalanges or metacarpals. External fixation is indicated when there is no definitive stabilisation of a fracture or no immediate wound cover at the time of the first operation. It may be indicated in OPEN fractures or fractues that have significant COMINUTION OR TISSUE LOSS

Answer 150

**Administer antibiotics and tetanus prophylaxis, transfer to theatre within 24 hours** Cleaning and irrigation is no longer indicated, unless htere is gross contamination or there is a need to seal the wound or photograph the wound. Debridement needs to occur within 24 hours.

Answer 151

**Arthroscopic tendon repair** Tears can also be divided by size: up to 1cm, 3 cm, 5 cm or over 5 cm are classified as being small, medium, large or massive, respectively. This patient has a large, acute, full-thickness tear, which is unlikely to heal with conservative management. Surgical intervention is therefore required, which in this scenario would involve an arthroscopic tendon repair. Surgery is also indicated in patients where conservative management has failed, and in those where at least 2 weeks have elapsed since the initial injury. One might also consider an open repair given the size of the tear, but a shorter recovery period and fewer associated complications make an arthroscopic approach a much more appealing option in this younger patient. A: Conservative management including activity modification and analgesia for at least two weeks would usually be considered before surgery. However, this patient has a large, symptomatic tear, which, as previously discussed, is unlikely to heal by itself. Therefore, conservative management is inappropriate. B: Physiotherapy should form part of the management plan regardless of whether or not the patient undergoes surgery. However, it is only an adjunct to treatment, and in this case will not help the patient’s large tear to heal without surgery. C: A steroid injection may also be considered as an adjunct in patients undergoing conservative management where the pain is not improving. E: A shoulder arthroplasty, also known as a shoulder replacement is not indicated in this patient. It would only be considered in patients with massive tears where the quality of the remaining tissue is too poor for a repair to be effective

Answer 152

**Potassium, Phosphate and Protein** The kidney maintains fluids and electrolyte homeostasis. kidney dysfunction often presents with Potassium retention, phosphate retention and impaired abilirt to excrete urea.

Answer 153

**Schirmer's test** This is Sjrogen's disease Schirmer’s test involves placing a strip of filter paper under the patient’s eyelid and monitoring the progress that the tears make through the paper. Progression of less than 10 mm after 5 mins is considered a positive result. A -> BPPV Pathergy test -> Non-specific Skin reaction (BEHCHET's DISEASE) Phalens test -> Carpal tunnel syndrome Schrober test -> Ankylosing Spondylitis, where there is a less than 5 cm increase in range of movment.

Answer 154

**Acute Glaucoma** The history provided by this patient is typical: rapid-onset pain and disturbed vision unilaterally, with no obvious precipitant. The injection of the sclera and conjunctiva seen in this patient are common, as is the sensation of nausea. Further examination findings may include dilation of the pupil in the affected eye, “corneal haze”and a rock-hard eyeball on gentle palpation. `Giant cell arteritis` is also a medical emergency which can lead to blindness, but it presents quite differently to acute glaucoma. Often, the patient has no visual symptoms at all. Instead, the pain experienced by the patient is not located in the eye socket, but instead manifests as a headache, typically worst in the temple area and featuring scalp tenderness. Other associated symptoms include jaw claudication, constitutional upset and features of polymyalgia rheumatica (shoulder and pelvic girdle pain and stiffness). `Orbital cellulitis` is another ophthalmological emergency, this time resulting from an infection of the skin and tissues around the orbit. Unlike periorbital cellulitis, which is a superficial infection of the skin around the eye, orbital cellulitis extends through the orbital septum, and, as a result, requires in-patient treatment. Both feature pain, swelling and erythema in the tissues around the orbit (which this patient does not have). Red flags signs which point to orbital cellulitis as the diagnosis over periorbital cellulitis include pain with extraocular movements, proptosis, visual impairment, ophthalmoplegia and fever. `Episcleritis` is self-limiting inflammation of the episclera, the layer which lies between the conjunctiva and the sclera. It is a common cause of a red eye, however it does not affect vision and pain is minimal, if present at all. Most cases are idiopathic, but around a third are associated with an underlying vasculitis, connective tissue disorder or seronegative spondyloarthropathy. `scleritis` is an emergency which requires immediate intervention with steroids. It presents with pain, redness and sometimes impaired vision in the affected eye. In this patient, however, the presence of nausea and dilatation of the pupil in the affected eye make acute glaucoma a more likely diagnosis.

Answer 155

**Slit lamp Gonioscopy** Slit lamp gonioscopy is the first-line investigation of choice in acute angle closure. It involves using a goniolens in conjunction with a slit-lamp to directly visualise the iridocorneal angle in the patient’s affected eye. This is the angle which is “closed” in acute angle closure. It isa rapid, non-invasive test which can be used by ophthalmologists to quickly reach a diagnosis in the acute setting. A slit lamp examination is often the go-to investigation of choice for diagnosing pathology in the anterior segment of the eye and can evenbe used to facilitate the removal of foreign bodies. `Goldmann tonometry` involves using a tonometer in conjunction with a slit lamp to introduce a probe which contacts the eye. The position of the probe is adjusted using a dial, the reading from which is used to determine the intraocular pressure of the eye. It is the *gold standard for assessing and monitoring open angle glaucoma* but is not used in the diagnosis of acute angle closure.

Answer 156

**Percutaneous lethotripsy** Non contrast CTKUB is the gold standard imaging modality to diagnose ureteric colics. Non obstructive **renal** stone management -> * < 10mm -> analgesia and watch and weight -> if persistent then shockwave * 10-20 mm -> /shockwave or ureterscopic -> percutaneous nephrolithotomy * > 22 mm percutaneous nephrolithotomy Non-obstructive **Ureteric** Stones: * < 10 mm Analgesia and alpha blockers * >10 mm Uretoscopy or shockwave lithotripsy -> If fails then percutaneous nephrolithotripsy All patients willl recieve NSAIDs for oain relief most oftenlly with PR diclofenac.

Answer 157

**TURP** TUIP is the prostate was smaller than 30 g if it doesnt mention the mass go for TURP....

Answer 158

**Endotracheal tube** DEFINITIE AIRWAYS: * Crico * Tracheo * endotracheal tubes

Answer 159

**Digital rectal examination** Cauda equina syndromeis a condition in which the cauda equina becomes compressed. This usually occurs due to a disc prolapse, but can also occur due to bone metastases, abscesses and trauma. It usually presents with severe lower back pain, bilateral lower limb weakness and shooting pains, saddle anaesthesia and bladder and bowel dysfunction. It is, therefore, very important to perform a digital rectal examination in patients with suspected cauda equina to check for saddle anaesthesia and reduced anal tone. It should be investigated urgently with a whole spine MRI scan.

Answer 160

**Neurofibromatosis 1** NF1 -> Cafe au lait sots and axillary and groin freckles and phaeco NF2 -> Bilateral schwanommas, meningiaoma + ependymomas MEN 1 -> 3 ps, pitu, para, pancreatic MEN 2 -> parathyroid hyperplasia, phaeochromocytomas and medullary thyroid cancer. MEN IIb is a subtype of MEN II which is also associated with mucosal neuromas and a Marfanoid body habitus TS -> cutaneous manifestations (e.g. ash leaf hypopigmentation, Shagreen patches, adenoma sebaceum) and neurological manifestations (e.g. epilepsy, developmental delay). Other features include renal angiomyolipomas and retinal hamartomas

Answer 161

**Wernicke's ecncephalopathy** Age makes stroke less likely. Wernicke's -> confusion, ophtalmoplegia (strabismus-> abnormal alignment of the eyes) and ataxia/

Answer 162

**Oxygen use during anaesthesia**

Answer 163

**Excision biopsy** This patient will need the full triple assessment hence the answer. I do think the qs is a bit stupid because considering the most likely diagnosis, would be you do nothing if it is that condition... Anyway...

Answer 164

**carpal Tunnel syndrome** It manifests with numbness in the distribution of the median nerve (first three digits and lateral half of the palm). The median nerve provides motor innervation to the muscles of the thenar eminence and the lateral two lumbricals. Loss of motor function of the median nerve will lead to difficulties with the pinch grip. Lateral epicondylitis or ‘Tennis elbow’ causes forearm and lateral elbow pain due to overuse Medial epicondylitis or ‘Golfer’s elbow’ causes forearm and medial elbow pain due to overuse of the flexor muscles of the forearm. Amyotrophic lateral sclerosis is the most common type of motor neurone disease. It presents with the development of progressive upper and lower motor neuron signs. It does not cause any sensory impairment. Multiple sclerosis can present with a variety of neurological symptoms (e.g. sensory impairment, motor impairment, visual impairment). Diagnosis requires evidence of more than one neurological manifestation separated in time and space.

Answer 165

**Compartment needle manometry** The neuro and passive movement history is suggestive of compartment syndrome. This needs to be ruled out and that can be done quickly with the above investigation. Urgent fasciotomy is needed and this should not be delayed.

Answer 166

**cataracts** In patients where ageing is the main cause, cataracts tend to be bilateral, meaning that both eyes will be abnormal when tested individually (although there is often a discrepancy in visual acuity between the two). Additional symptoms of blurred vision, glare and washed-out colour vision are all typical of cataracts. On examination one might see a straw-coloured lens or an absent red reflex on fundoscopy, but these are not always present or obvious. Age-related macular degeneration (AMD) is caused by damage and atrophy to the cells of the retinal pigment epithelium, which lies between the photoreceptors and choroid of the retina. Unlike age-related cataracts, the symptoms of which come on over a period of months or years as they have in this patient, age-related macular degeneration usually has a relatively quick onset. There is blurring and/or visual loss at the centre of the patient’s visual fields, whilst the patient’s peripheral vision is spared. AMD becomes even more unlikely when one considers that normally, signs would be observed on fundoscopy. These include small yellow spots on theretina (called drusen deposits), atrophy, pigment clumping and occasionally neovascularisation

Answer 167

**Topical Latanoprost** Topical prostaglandin analogues, such as latanoprost, are the first-line treatment for open angle glaucoma and will help to prevent further deterioration in vision. Prostaglandin analogues improve the outflow of aqueous humour through the trabecular meshwork by relaxing the ciliary muscle and stimulating matrix metalloproteinases, which break down the trabecular meshwork. Carbonic anhydrase like B can be used if the above doesnt work C -> is used if medical does not work. and is prefered over D as D is more invasive. E -> This is only for acute angle glaucoma

Answer 168

**Acute tubular necrosis** Intrarenal tubular -> leads to hyponatraemia and increased urinary sodium concentration and low urinary osmolality Pre-renal kidney -> Urine osmolality is raised/ urinary sodium is low Gentamicin is known to be toxic to the tubiular epithelial cells.

Answer 169

T1 -> Transurethral resection of bladder tumour (MEANS NO MUCULAR INVASION) OR B) if the tumour is high riskmight add Intravesical BAcillus calmette Guerin therapy T2 -> In our case, the tumour is T2b meaning that it invades the deep muscle of the bladder. Most cases of muscle-invasive bladder cancer warrant **radical cystectomy** (removal of whole bladder and parts of surrounding structures depending on the sex of the patient). Patients with muscle-invasive disease will also be considered for neo-adjunctive chemotherapywith the aim of reducing the tumour size prior to resection. T3... -> Chemotherapy alone is offered if curative surgical resection cannot be offered. These patients should also have a palliative discussion.

Answer 170

**Arrange Urgent US** In pts 20-40 + hydrocele means should have urgent US. This is done first then referred to Uro.

Answer 171

**NON contrast CT KUB.**

Answer 172

**Gliclazide Overdose** C-peptide is raised Can be caused by insulinoma or gliclazide as it causes increased insulin production.

Answer 173

**Furosemide** -> This patient has hyponatraemia but this is a transfusion complication of TACO and this is treated with Furosemide.

MaM mocks Flashcards

Answers are uptodate and defo correct