Medicine Flashcards

Question

What is the Jarisch-Herxheimer reaction?

Answer 1

Fever, rash, chills and headache occurs following antibiotic administration for syphilis Management - antipyretics and supportive treatment

Answer 2

AR iron absorption and metabolism disorder caused by HFE gene mutation Common features - Liver failure - type 2 diabetes - arthritis 2nd and 3rd MCP joints - bronze, greying of the skin - erectile dysfunction - hypogonadotrophic hypogonadism Diagnosis: - raised ferritin and transferrin saturation levels - reduced total iron binding capacity - molecular genetic testing for C282Y and H63D mutations complications: hepatocellular carcinoma Management: venesection > monitoring: ferritin and transferrin saturation

Answer 3

Reduced FVC Increased FEV1/FVC ratio reduced transfer factor for carbon monoxide (TLCO), reflecting impaired gas exchange caused by pulmonary fibrosis

Answer 4

occurs secondary to two main factors: neuropathy: resulting in loss of protective sensation, Charcot's arthropathy, dry skin peripheral arterial disease Presentations - neuropathy: loss of sensation - ischaemia: absent foot pulses, reduced ankle-brachial pressure index (ABPI), intermittent claudication complications: calluses, ulceration, Charcot's arthropathy, cellulitis, osteomyelitis, gangrene screening on at least an annual basis - ischaemia: palpating dorsalis pedis and posterial tibial artery pulse - neuropathy: a 10 g monofilament is used on various parts of the sole of the foot All patients who are moderate or high risk (I.e. any problems other than simple calluses) should be followed up regularly by the local diabetic foot centre

Answer 5

4L via 28% Venturi aiming for 88-92% Salbutamol and ipratropium bromide nebuliser Oral prednisolone / IV hydrocortisone Antibiotics: doxycycline, clarithromycin or amoxicillin IF purulent sputum / clinical signs of pneumonia e.g. focal consolidation > if poor response, IV theophylline if unsuccessful start NIV (BiPAP) - pH 7.25-7.35 despite best medical treatment for 1h - if pH <7.25 consider invasive ventilation Contraindications to non-invasive ventilation include an inability to protect the airway, impaired consciousness, life-threatening acidosis and aspiration risk

Answer 6

First-line > regular emollients: reduce scale loss and reduce pruritus > topical potent steroid + vitamin D analogue e.g. topical betamethasone and calcipotriol > aim for 4 week break in between courses of topical steroids > Coal tar shampoo - scalp > dithranol > facial psoriasis: calcineurin inhibitors e.g. tacrolimus Phototherapy: narrowband ultraviolet B light Systemic therapy: oral methotrexate, ciclosporin, systemic retinoids (acitretin), apremilast, biologics (adalimumab, infliximab, ustekinumab)

Answer 7

- rehydration with normal saline, 3-4 litres/day - Following rehydration bisphosphonates may be used. (take 2-3 days to work, maximal effect 7 days) > use IV bisphosphonate if Ca >3 Other options include: calcitonin - quicker effect than bisphosphonates steroids in sarcoidosis Loop diuretics e.g. furosemide can sometimes be used

Answer 8

painless jaundice and a palpable mass in the right upper quadrant (RUQ) Steatorrhoea due to loss of exocrine function weight loss

Answer 9

Decreasing kidney function results in kidneys not being able to convert enough vitamin D to its active form Kidneys are also not able to adequately excrete phosphate - HYPERPHOSPHATAEMIA Due to this. insoluble calcium phosphate forms, removing calcium from the circulation, which results in HYPOCALCAEMIA The parathyroid glands detect this and secrete parathyroid hormone to try and raise serum calcium levels. Treatment - addressing the underlying cause of hypocalcaemia

Answer 10

Prerenal (renal hypoperfusion) > urinary sodium <20 mmol/L > raised urea:creatinine ratio > good response to fluid challenge - hypovolaemia secondary to diarrhoea/vomiting - shock e.g. sepsis or blood loss - renal artery stenosis - heart failure Renal (intrinsic disease in the kidney) - toxins (drugs, contrast etc) - immune-mediated glomuleronephritis. - acute tubular necrosis (ATN) > urinary sodium >40 mmol/L > normal urea:creatinine ratio > poor response to fluid challenge - acute interstitial nephritis (AIN), respectively rhabdomyolysis (CK<10,000) - tumour lysis syndrome - haemolytic uraemic syndrome Postrenal - obstruction - unilateral ureteric stone - bilateral hydronephrosis secondary to acute urinary retention caused by benign prostatic hyperplasia - gynaecological malignancy - urethral strictures - retroperitoneal fibrosis

Answer 11

Predisposing factors - obesity - macroglossia: acromegaly, hypothyroidism, amyloidosis - large tonsils - Marfan's syndrome clinical features - daytime somnolence - compensated respiratory acidosis - hypertension - partners report excessive snoring or periods of apnoea Assessment of sleepiness - Epworth Sleepiness Scale - Multiple Sleep Latency Test (MSLT) Diagnostic tests - sleep studies (polysomnography) Management - weight loss - CPAP is first line for moderate or severe OSA - intra-oral devices (e.g. mandibular advancement) may be used if CPAP is not tolerated or for patients with mild OSA - DVLA should be informed if OSA is causing excessive daytime sleepiness

Answer 12

Haemophilia is an X-linked recessive disorder of coagulation. Haemophilia A - deficiency of factor VIII Haemophilia B (Christmas disease) - lack of factor IX Features haemoarthroses haematomas prolonged bleeding after surgery or trauma Blood tests - prolonged APTT - bleeding time, thrombin time, prothrombin time normal

Answer 13

Drug-induced thrombocytopenia (probable immune-mediated) quinine abciximab NSAIDs diuretics: furosemide antibiotics: penicillins, sulphonamides, rifampicin anticonvulsants: carbamazepine, valproate heparin: HIT is a prothrombotic condition

Answer 14

PE is 'likely' (more than 4 points) > CTPA > interim therapeutic anticoagulation if delay in scanning (DOAC e.g. apixaban / rivaroxaban) > CTPA is positive - PE is diagnosed (offer/continue DOAC) > CTPA is negative - proximal leg vein ultrasound scan if DVT is suspected PE is 'unlikely' (4 points or less) > arranged a D-dimer test > if positive arrange CTPA (If there is a delay in getting the CTPA then give interim DOAC) > if negative then PE is unlikely - stop anticoagulation and repeat proximal leg vein ultrasound in 6-8 days In severe renal impairment (<15/min): unfractionated heparin, direct thrombin inhibitor e.g. argatroban second-line - provoked VTE: anticoagulation for 3 months - unprovoked VTE: anticoagulation 6 months > cancer patients with VTE: 6 months if PE with haemodynamic instability - thrombolysis consider IVC filter for patients with recurrent PE despite adequate anticoagulation V/Q scan if renal impairment

Answer 15

inhibits the Na-K-Cl cotransporter in the thick ascending limb of the loop of Henle

Answer 16

Exogenous causes of Cushing's syndrome (e.g. glucocorticoid therapy) are far more common than endogenous ones. ACTH dependent causes > Cushing's disease (80%): pituitary tumour secreting ACTH producing adrenal hyperplasia > ectopic ACTH production (5-10%): e.g. small cell lung cancer is the most common causes ACTH independent causes > iatrogenic: steroids > adrenal adenoma (5-10%) > adrenal carcinoma (rare) > Carney complex: syndrome including cardiac myxoma > micronodular adrenal dysplasia (very rare) Pseudo-Cushing's - mimics Cushing's > often due to alcohol excess or severe depression > causes false positive dexamethasone suppression test or 24 hr urinary free cortisol > insulin stress test may be used to differentiate

Answer 17

Metformin first-line (+lifestyle advice) > target HbA1C of 48 mmol/mol > If this is not met, titrate up metformin (1 week interval between titration) > contraindicated in eGFR <30 > a second drug should only be added if HbA1C rises to 58 mmol/mol > SGLT2i should be used in addition to metformin in patients with CVD, high-risk CVD or chronic heart failure (but metformin should be started and titrated up first) > if metformin is contraindicated + patient has CVD risk/chronic heart failure: SGLT2 monotherapy OR sulfonylurea e.g. gliclazide > HbA1C target on sulfonylurea is 53 > best second-line intensification in non-obese patients OR pioglitazone OR DPP-4 inhibitor e.g. sitagliptin OR GLP1- agonist e.g. semaglutide > failure of triple combination of drugs: switching one to GLP-1 > or if BMI >35 Consider insulin

Answer 18

commonest red blood cell enzyme defect, X-linked recessive inheritance > more common in people from the Mediterranean and Africa factors which can precipitate a crisis - infections - broad (fava) beans - drugs: anti-malarials e.g. primaquine, ciprofloxacin, sulph-group drugs: sulphonamides, sulphasalazine, sulfonylureas, co-trimoxazole Features - neonatal jaundice - intravascular haemolysis - gallstones - splenomegaly blood film: Heinz bodies, bite and blister cells Diagnosis - G6PD enzyme assay levels should be checked at time of presentation and around 3 months after an acute episode of hemolysis

Answer 19

most commonly seen in young females Associated with > Anti-nuclear antibodies (ANA) > anti-smooth muscle antibodies (SMA) > raised IgG levels > biopsy: inflammation extending beyond limiting plate, "piecemeal necrosis", bridging necrosis Features > chronic liver disease > acute hepatitis: fever, jaundice etc > amenorrhoea (common) Management steroids other immunosuppressants e.g. azathioprine liver transplantation

Answer 20

subacute (De Quervain's) thyroiditis clinical features - following a viral illness - raised ESR/CRP - tender goitre - initial hyperthyroid phase, then euthyroid then hypothyroid - usually self-limiting investigations > thyroid scintigraphy: globally reduced uptake of iodine-131 management - simple analgesia e.g. ibuprofen, naproxen - if severe: steroids

Answer 21

Resp > Exacerbations of chronic bronchitis: amoxicillin / doxycycline / clarithromycin > Uncomplicated CAP: amoxicillin > pneumonia secondary to influenza: flucloxacillin >> associated with cavitating lesions > Atypical pneumonia: clarithromycin > HAP: >> within 5 days of admission: co-amoxiclav / cefuroxime >> more than 5 days after admission: piperacillin/tazobactam OR ceftazidime OR ciprofloxacin

Answer 22

Lower UTI - trimethoprim / nitrofurantoin Acute pyelonephritis - gentamicin / ciprofloxacin Acute prostatitis: quinolone or trimethoprim

Answer 23

Cellulitis - flucloxacillin Impetigo: topical hydrogen peroxide, oral flucloxacillin / erythromycin if widespread Erysipelas: flucloxacillin > raised well-defined border, most common cause is Strep pyogenes Animal / human bites: co-amoxiclav Mastitis: flucloxacillin

Answer 24

Throat infections - phenoxymethylpenicillin Sinusitis - phenoxymethylpenicillin Otitis media - amoxicillin Otitis externa - flucloxacillin Periapical / periodontal abscess: amoxicillin Gingivitis: metronidazole

Answer 25

C. diff: oral vancomycin (first episode), oral fidaxomicin if second episode Campylobacter: clarithromycin Salmonella (non-typhoid): ciprofloxacin Shigellosis: ciprofloxacin

Answer 26

TSH is > 10mU/L & T4 level is normal: consider offering levothyroxine if the TSH level is > 10 mU/L on 2 separate occasions 3 months apart and positive anti-TPO antibodies TSH is between 5.5 - 10mU/L and T4 is normal if < 65 years consider offering a 6-month trial of levothyroxine if: the TSH level is 5.5 - 10mU/L on 2 separate occasions 3 months apart,and there are symptoms of hypothyroidism in older people - 'watch and wait' asymptomatic - observe and repeat thyroid function in 6 months

Answer 27

Cushing's disease > cortisol & ACTH suppressed by high dose dexamethasone suppression testing Non-ACTH-dependent e.g. adrenal adenoma > cortisol not suppressed by high dose dexamethasone suppression testing > ACTH suppressed by high dose dexamethasone suppression testing Ectopic ACTH e.g. Small cell lung cancer > cortisol and ACTH not suppressed by high dose dexamethasone suppression testing

Answer 28

endocrine: impaired glucose regulation, increased appetite/weight gain, hirsutism, hyperlipidaemia Cushing's syndrome: moon face, buffalo hump, striae musculoskeletal: osteoporosis, proximal myopathy, avascular necrosis of the femoral head (crescent sign on X-ray) immunosuppression: increased susceptibility to severe infection, reactivation of tuberculosis psychiatric: insomnia, mania, depression, psychosis gastrointestinal: peptic ulceration, acute pancreatitis ophthalmic: glaucoma, cataracts dermatological: acne suppression of growth in children intracranial hypertension neutrophilia

Answer 29

causes - BPH - Urethral obstructions e.g. strictures, calculi, constipation, masses - Medications e.g. anticholinergics, TCAs, antihistamines, opioids - UTI - post-op or post-partum diagnosis >300mL on bladder scan > inability to pass urine > palpable distended urinary bladder > lower abdominal tenderness manage via catheterisation and treatment of underlying cause acceptable post-void volumes <50ml if <65 years old <100ml if >65 years old chronic urinary retention if >500ml in bladder after catheterisation post-catheterisation urinary volume of >800ml in bladder suggests acute on chronic retention complications - post-obstructive diuresis

Answer 30

STI caused by the spirochaete Treponema pallidum Primary syphilis > chancre - painless ulcer at the site of sexual contact > local non-tender lymphadenopathy Secondary syphilis > systemic symptoms: fevers, lymphadenopathy > rash on trunk, palms and soles > buccal 'snail track' ulcers > condylomata lata (painless, warty lesions on the genitalia ) Tertiary syphilis > gummas (granulomatous lesions of the skin and bones) > ascending aortic aneurysms > general paralysis > insane tabes dorsalis > Argyll-Robertson pupil Congenital syphilis > blunted upper incisor teeth (Hutchinson's teeth), 'mulberry' molars > rhagades (linear scars at the angle of the mouth) > keratitis > saber shins > saddle nose > deafness diagnosis: NAAT testing management: single IM dose benzathine benzylpenicillin

Answer 31

Localised prostate cancer (T1/T2) > conservative: watchful waiting > radical prostatectomy > radiotherapy: external beam and brachytherapy Localised advanced prostate cancer (T3/T4) - hormonal therapy > GnRH agonists e.g. goserelin (zoladex) >> give with cyproterone acetate - radical prostatectomy - radiotherapy - external beam and brachytherapy Metastatic prostate cancer disease - hormonal therapy - GnRH agonists: e.g. Goserelin (Zoladex) - bicalutamide: non-steroidal anti-androgen - abiraterone: androgen synthesis inhibitor bilateral orchidectomy Chemotherapy with docetaxel

Answer 32

Moderate - PEFR 50-75% of best - speech normal - RR <25 - Pulse <110 Severe - PEFR 33-50% of best - can't complete sentences - RR >25 - Pulse >110 Life-threatening - PEFR <33% - O2 sats <92% (perform an ABG) - Silent chest, cyanosis or feeble respiratory effort - Bradycardia, dysrhythmia or hypotension - Exhaustion, confusion or coma - Normal PCO2 Respiratory acidosis indicates near fatal asthma

Answer 33

Constipation - ispaghula husk is first-line - lactulose not recommended - linaclotide if other drugs are unsuccessful

Answer 34

Lansoprazole Omeprazole & esomeprazole decrease the efficacy of clopidogrel

Answer 35

Permanent dilatation of the airways secondary to chronic infection or inflammation Management - chest physiotherapy e.g. inspiratory muscle training, postural drainage is first-line - antibiotics for exacerbations + long-term rotating antibiotics in severe cases - bronchodilators - immunisations - surgery if localised disease Haemophilus influenzae is the most common organism causing infection in bronchiectasis

Answer 36

Localised scleroderma. single or multiple hard plaques on the skin, initially erythematous or violaceous then yellowish or ivory

Answer 37

clinical features - purple, pruritic, papular, polygonal rash - flexor surfaces - Wickham's striae "white lines" over surface - oral involvement common - Can occur at site of previous skin injury - Koebner's phenomenon drug causes - gold - thiazides - quinine management - potent topical steroids e.g. clobetasone butyrate - benzydamine mouthwash for oral lichen planus - extensive lichen planus may require oral steroids or immunosuppression

Answer 38

benign self-limiting disease transmission via faecal-oral spread (including anal-oral sex) > men who have sex with men should be offered immunisation - risk factors: > consuming undercooked meat / unclean water in developing countries features - flu-like prodrome - RUQ abdo pain - tender hepatomegaly - jaundice - deranged LFTs Treated supportively, no increased risk of hepatocellular carcinoma

Answer 39

- Tendinopathy - lower seizure threshold

Answer 40

- Macrolide antibiotics e.g. erythromycin – risk of Torsades de Pointes - Specific SSRIs e.g. citalopram/escitalopram - Tricyclic antidepressants - Antipsychotics e.g. chlorpromazine - Antiemetics - Quinines - Antiarrhythmics

Answer 41

Severe primary infection of the skin caused by HSV1 or 2, uncommonly coxsackie virus More commonly seen in children with atopic eczema Presentation - rapidly progressing painful rash - monomorphic punched out erosions (circular, depressed, ulcerated lesions) Management - Hospital admission - IV aciclovir

Answer 42

Type 1 hypersensitivity: antigen reacts with IgE bound to mast cells e.g. anaphylaxis, asthma > can repeat adrenaline every 5 minutes in anaphylaxis Type 2: IgG/IgM binds to antigen on cell surface e.g. autoimmune haemolytic anaemia Type 3: immune-complex mediated e.g. lupus Type 4; delayed hypersensitivity. E.g. allergic contact dermatitis, TB, MS, GBS Type 5: autoantibodies e.g. Graves' disease, myasthenia gravis

Answer 43

Caused by HHV-8, usually underlying HIV infection Features - Raised purple lesions (papules/plaques) on skin or mucosa e.g. GI/ respiratory tract - respiratory involvement: massive haemoptysis and pleural effusion - children: generalised lymphadenopathy suggestive of lymphoma treatment: radiotherapy + resection

Answer 44

- trauma - alcohol, smoking, stress - discontinuing steroids - initiating NSAIDs (including aspirin) - lithium - antimalarials - beta-blockers - ramipril - infliximab streptococcal infections precipitate guttate psoriasis

Answer 45

Cytomegalovirus Features - arthralgia - jaundice - lymphadenopathy - hepatomegaly Treatment - ganciclovir

Answer 46

Widespread clotting leading to bleeding Causes - Sepsis - Trauma - obstetric complications e.g. HELLP syndrome - malignancy Diagnosis -Low platelet count, low fibrinogen - Prolonged PT & APTT - raised fibrin degradation products - schistocytes due to microangiopathic haemolytic anaemia management - treat underlying cause - give fresh frozen plasma (FFC)

Answer 47

inhibition of sodium reabsorption at the DCT by blocking the Na/Cl symporter Common adverse effects - dehydration - postural hypotension - hypokalaemia - hyponatraemia - hypercalcaemia and hypocalciuria

Answer 48

Rosacea features in nose, cheeks and forehead Flushing, erythema and telangiectasia Papules and pustules Treatment - Sunscreen - Erythema/flushing: topical brimonidine - mild/moderate papules/pustules: topical ivermectin - moderate/severe papules or pustules: topical ivermectin + oral doxycycline (first-line) - laser therapy for prominent telangiectasia

Answer 49

- Infection (SBP) - GI bleeding - Alcoholic hepatitis - Constipation - Dehydration - Acute portal vein thrombosis - Hepatocellular carcinoma - Drugs (alcohol, opiates, NSAIDs) - Ischaemic liver injury (sepsis, hypotension)

Answer 50

features - confusion, altered GCS - asterixis - constructional apraxia (inability to draw 5 pointed star) - triphasic slow waves on EEG - raised ammonia level precipitating factors - infection e.g. SBP - GI bleed - TIPS procedure - Constipation - Drugs: sedatives, diuretics - Hypokalaemia - Renal failure - Increased dietary protein stages - I: irritability - II: confusion, inappropriate behaviour - III: incoherent, restless - IV: coma Management - treat trigger - lactulose is first-line - secondary proophylaxis: lactulose, rifaximin

Answer 51

ascitic tap: WCC > 500 OR neutrophils >250 most commonly due to E. coli management - IV co- trimoxazole or IV tazocin - IV albumin on day 1 and day 3 to reduce risk of renal dysfunction prophylaxis: PO ciprofloxacin

Answer 52

VTE prophylaxis

Answer 53

in all patients with clinical ascites within <6h admission

Answer 54

- Delirium - Vivid dreams / nightmares - Persistent sedation - Myoclonus - Peripheral shadows / hallucinations - Hyperalgesia

Answer 55

- Morphine - Midazolam - Levomepromazine - Hyoscine butylbromide

Answer 56

Stage 1: ambulatory BP >= 135/85 or clinic BP >=140/90 > start antihypertensives if less than 80 and cardiovascular risk Stage 2: (>= 150/95 ambulatory B[ or 160/100 clinic BP) start hypertensives regardless of age Patients <40 - referral to exclude secondary causes Lifestyle advice > low salt diet ideally 3g/day > reduce caffeine, alcohol, weight > stop smoking > improve diet and exercise Choice of antihypertensives - If <55 or T2DM: > 1st line ACEi / ARB > 2nd line ACEi/ARB + CCB or ACEi/ARB + thiazide-like diuretic e.g. indapamide > 3rd line: ACEi/ARB + CCB + thiazide-like diuretic > 4th line add beta blocker if K >4.5, spironolactone if K<=4.5 - If >55 and no T2DM or Black African or African-Caribbean ethnicity > 1st line CCB > 2nd line ACEi/ARB (preferably ARB in black African/African-Caribbean) + CCB or CCB + thiazide-like diuretic > 3rd line: ACEi/ARB + CCB + thiazide-like diuretic > 4th line add beta blocker if K >4.5, spironolactone if K<=4.5 ACEi/ARB contraindicated in renovascular disease

Answer 57

Age <80y: clinic BP <140/90 mmHg, ABPM <135/85 mmHg Age >80y: <150/90 mmHg clinic BP or <145/86 ABPM T1DM: <135/85 mmHg T2DM: same as everyone else T2DM with nephropathy: <130/80 mmHg

Answer 58

- Perioral numbness / tingling (paraesthesia) - Muscle twitching, cramping and spasms - Carpopedal spasm - Tetany - if chronic: depression, cataracts Trousseau's sign: carpal spasm if brachial artery occluded by inflating blood pressure cuff: wrist flexion and fingers drawn together Chvostek's sign: tapping over parotid causes facial muscles to twitch can be caused by end-stage renal failure

Answer 59

40 mmol/L over 4h

Answer 60

- Breast - Prostate - Kidneys - Lung - Multiple myeloma - Lymphoma - thyroid cancer

Answer 61

advanced and progressive disease: regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain if no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain. When increasing the dose of opioids the next dose should be increased by 30-50%. Selected points > breakthrough dose of morphine: one-sixth daily dose of morphine > converting oral to parenteral morphine: half the dose > oxycodone is preferred in mild-moderate renal impairment > alfentanil, fentanyl and buprenorphine are preferred in severe renal impairment metastatic bone pain may respond to strong opioids, bisphosphonates or radiotherapy. also denosumab

Answer 62

All types are associated with hyperchloraemic metabolic acidosis (normal anion gap). Type 1 (distal): inability to generate acid urine (secrete H+) in distal tubule > causes hypokalaemia > complications: nephrocalcinosis, renal stones causes: idiopathic, rheumatoid arthritis, SLE, Sjogren's, amphotericin B toxicity, analgesic nephropathy Type 2 (proximal): decreased HCO3- reabsorption in proximal tubule > causes hypokalaemia > complications: osteomalacia causes: idiopathic, Fanconi syndrome, Wilson's disease, cystinosis, outdated tetracyclines, carbonic anhydrase inhibitors (acetazolamide, topiramate) Type 3 (mixed): extremely rare caused by carbonic anhydrase II deficiency results in hypokalaemia Type 4 (hyperkalaemic): > reduction in aldosterone leads in turn to a reduction in proximal tubular ammonium excretion > causes hyperkalaemia : causes hypoaldosteronism, diabetes

Answer 63

Macrocytic anaemia and thrombocytopaenia high ferritin high GGT

Answer 64

Features lungs: panacinar emphysema (lower lobes) liver: cirrhosis and hepatocellular carcinoma in adults, cholestasis in children Management: no smoking supportive: bronchodilators, physiotherapy intravenous alpha1-antitrypsin protein concentrates surgery: lung volume reduction surgery, lung transplantation

Answer 65

Presents with nephrotic syndrome or proteinuria (most common cause in adults) investigations > 24h urinary protein excretion >3g >Renal biopsy: >> electron microscopy: thickened basement membrane with 'spike and dome' appearance Causes > idiopathic: anti-phospholipase A2 antibodies > infections: hepatitis B, malaria, syphilis > malignancy: prostate, lung (spiculated mass), lymphoma, leukaemia > drugs: gold, penicillamine, NSAIDs autoimmune diseases: SLE, thyroiditis, rheumatoid Management > ACEi / ARB > corticosteroid + another agent e.g. cyclophosphamide > consider anticoagulation for high-risk patients >> increased risk of thrombus due to loss of antithrombin III via kidneys

Answer 66

both terlipressin and prophylactic antibiotics should be given before endoscopy in patients with suspected variceal haemorrhage endoscopy: endoscopic variceal band ligation Sengstaken-Blakemore tube if uncontrolled haemorrhage Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail > connects the hepatic vein to the portal vein > exacerbation of hepatic encephalopathy is a common complication

Answer 67

mild to moderate acne: > 12-week course of topical combination therapy (first-line): - topical adapalene with topical benzoyl peroxide - topical tretinoin with topical clindamycin moderate to severe acne: > a 12-week course of a fixed combination of topical adapalene with topical benzoyl peroxide + either oral lymecycline or oral doxycycline Topical and oral antibiotics should not be used in combination Gram-negative folliculitis may occur as a complication of long-term antibiotic use - high-dose oral trimethoprim is effective if this occurs COCP are an alternative to oral antibiotics in women > levonorgestrel first-line > co-cyprindiol (Dianette) second-line oral isotretinoin: only under specialist supervision

Answer 68

Inducers: CRAP GPs (decrease in INR) - carbamazepine - rifampicin - alcohol (chronic) - phenytoin - griseofulvin - phenobarbitone - sulphonylureas Inhibitors: SICKFACES.COM (increase in INR) - sodium valproate - isoniazid - cimetidine - ketoconazole - fluconazole - alcohol (acute) and grapefruit juice - chloramphenicol - erythromycin - sulphonamides - ciprofloxacin - omeprazole - metronidazole

Answer 69

Glucose: >11 OR Known diabetes Acidosis: pH <7.3 or Bicarb <15 Ketones: >3 mmol/l or ++ on urine dip. Management 1. Fluid replacement - 1L IV 0.9% NaCl over one hour 2. Insulin therapy > fixed rate IV insulin initially at 8 units/h OR 0.1 units/kg/h within 30 minutes of admission or diagnosis. When the patient’s blood glucose drops below 14 the rate is reduced to 3 units/hour. aiming to keep blood glucose between 9-14 mmol/L continue patient's long acting insulin but stop short acting 3. IV Glucose therapy > IV 10% dextrose is not used until blood glucose has fallen to <14 > continue until patient eating and drinking 4. Electrolyte replacement > Potassium (KCl) can be added to 0.9% NaCl if K levels are <5 mmol/L 5. Treatment of underlying triggers if ketonaemia / acidosis is not improving after 24h review by senior endocrinologist

Answer 70

Give 20% of their total daily dose of insulin as fast acting bolus VRII if fasting

Answer 71

In order to safely discontinue the DKA pathway the patient must be: 1. Eating and drinking 2. Bicarbonate >15 and pH >7.3 3. Ketones <0.6 4. Restarted on normal insulin regime Discontinue IV insulin and IV fluids 30 mins after SC fast acting insulin Long acting insulin should be continued while on DKA pathway > if above criteria are met and the patient is eating and drinking, switch to subcutaneous insulin > review by diabetes specialist nurse prior to discharge

Answer 72

Determine and optimise iron status before starting erythropoiesis-stimulating agents i.e. correct iron deficiency ESAs: erythropoietin, darbepoietin Oral iron if not on ESA or haemodialysis Switch to IV iron if target Hb levels (100-120) are not reached within 3 months patients on ESAs or haemodialysis generally require IV iron

Answer 73

Laboratory glucose >30 mmol/L H+ <50 mmol/L Bicarb >15 mmol/L Capillary ketones <3mmol/L Serum osmolality >320 mosmol/kg Management - IV 0.9% sodium chloride > switch to 0.45% nacl if osmolality not declining (<3mOsm/kg/hour) despite adequate positive fluid balance - rate of fall of plasma sodium should not exceed 10 mmol/L in 24 hours. - fall in blood glucose should be no more than 5 mmol/L/hour (so that serum osmolality doesn’t fall too quickly) - Low dose IV insulin should only be commenced EITHER once the blood glucose level plateaus with IV fluids alone OR immediately if there is significant ketosis (blood ketones > 1.5 or urine ketones greater than ‘+’ “

Answer 74

Intercurrent or coexisting illness - Infection - MI, stroke/TIA Drug-induced - Metformin - Diuretics - alcohol, cocaine Diabetes-related - first presentation - poor glycaemic control

Answer 75

Richter transformation: into high-grade non-Hodgkin's lymphoma > lymph node swelling > fever without infection > night sweats > nausea > abdominal pain Other complications - warm autoimmune haemolytic anaemia (Coombs +ve) - anaemia - hypogammaglobulinaemia investigations - lymphocytosis - anaemia: due to bone marrow replacement or AIHA - blood film: smear/smudge cells - immunophenotyping: key investigation

Answer 76

aka Conn's syndrome Most commonly caused by bilateral idiopathic adrenal hyperplasia > also adrenal adenoma, unilateral hyperplasia, familial hyperaldosteronism and adrenal carcinoma Features > hypernatraemia and hypokalaemia e.g. muscle weakness > hypertension > metabolic alkalosis Investigations: > plasma renin:aldosterone ratio is first-line: should show high aldosterone and low renin > high resolution CT abdomen and adrenal venous sampling Management > adrenal adenoma: surgery (laparoscopic adrenalectomy) > bilateral adrenocortical hyperplasia: aldosterone antagonist e.g. spironolactone

Answer 77

- hepatocellular: AFP - Testicular: bHCG, LDH, AFP - Pancreatic: CA19-9 (also cholangiocarcinoma) - Colon: CEA - Breast: CA 15-3 - Ovarian: CA-125 - Prostate: PSA

Answer 78

- galactorrhoea: response to emotional events, drugs like histamine receptor antagonists - hyperprolactinaemia: prolactinomas are the commonest type of pituitary tumour, drugs like metoclopramide, haloperidol, domperidone... - mammary duct ectasia: menopausal women, smokers, thick green discharge - carcinoma: often blood-stained, may be underlying mass or axillary lymphadenopathy - intraductal papilloma: blood-stained discharge, can be painful, usually no palpable lump

Answer 79

Presentation - Weight loss - Fatigue - Polyuria / nocturia / polydipsia - Osmotic diuresis / dehydration - Muscle wasting - DKA - Other autoimmune diseases Diagnosis - Random blood glucose >11.1 OR fasting blood glucose >7.0 - HbA1C >48 - low C-peptide (insulin production) - Autoantibodies > Anti-GAD65 > Islet cell antibodies (ICA) > Insulin autoantibodies (IAA) > IA-2A > Anti-ZnT8

Answer 80

- nephropathy > enlarged kidneys on USS (early stages) > mesangial expansion > biopsy: fibrosis, Kimmelstiel-Wilson nodules > annual review with early morning albumin:creatinine ratio (ACR) - retinopathy - neuropathy > autonomic: gastroparesis, postural hypotension - acute: DKA, HHS - cardiovascular disease - associated endocrine diseases: thyroid disease, coeliac disease, addison's - diabetic foot disease: peripheral neuropathy + PVD

Answer 81

Clostridioides difficile - Gram positive rod Risk factors - 4Cs: clindamycin, coamoxiclav, cephalosporins, ciprofloxacin - proton pump inhibitor Features - diarrhoea - abdominal pain - raised white blood cell count (WCC) Complications - pseudomembranous colitis - toxic megacolon Diagnosis - C. difficile toxin (CDT) in the stool - C. difficile antigen shows colonisation / exposure to bacteria, not current infection Management - First episode: oral vancomycin for 10 days (first-line) > second-line: oral fidaxomicin > third-line therapy: oral vancomycin +/- IV metronidazole Recurrent episode > within 12 weeks of symptom resolution: oral fidaxomicin > after 12 weeks of symptom resolution: oral vancomycin OR fidaxomicin Life-threatening: > indications: failure of oral vancomycin, hypotension, ileus, toxic megacolon > oral vancomycin AND IV metronidazole > faecal microbiota transplant: 2 or more previous episodes bezlotoxumab is a monoclonal antibody which targets C difficile toxin B

Answer 82

Factor V Leiden (activated protein C resistance) is the most common inherited thrombophilia Mis-sense mutation resulting in activated factor V (clotting factor) being inactivated 10 times more slowly by activated protein C than normal results in prothrombotic state > more likely to experience VTE

Answer 83

Major bleeding - stop warfarin - IV Vitamin K 5mg - Prothrombin complex concentrate or FFP if unavailable INR >8 and minor bleeding - stop warfarin - IV vitamin K 1-3mg, repeat IV Vitamin K if INR too high after 24h - repeat warfarin when INR <5 INR >8, no bleeding - stop warfarin - vitamin K 1-5mg by mouth INR 5-8, minor bleeding - stop warfarin - IV vitamin K 1-3mg INR 5-8 no bleeding - withhold 1-2 doses of warfarin and monitor INR - reduce maintenace dose

Answer 84

2 main forms of protozoal disease > African trypanosomiasis (sleeping sickness) > American trypanosomiasis (Chagas' disease). spread by the tsetse fly Clinical features of African trypanosomiasis: > Trypanosoma chancre - painless subcutaneous nodule at site of infection > intermittent fever > enlargement of posterior cervical lymph nodes > later: central nervous system involvement e.g. somnolence, headaches, mood changes, meningoencephalitis Management > early disease: IV pentamidine or suramin > later disease or central nervous system involvement: IV melarsoprol American trypanosomiasis, > acute infection is asymptomatic but the following can be seen - chagoma (an erythematous nodule at site of infection) - periorbital oedema > Chronic Chagas' - myocarditis may lead to dilated cardiomyopathy (with apical atrophy) and arrhythmias > gastrointestinal features includes megaoesophagus and megacolon causing dysphagia and constipation Management - acute phase: benznidazole or nifurtimox - chronic disease management involves treating the complications e.g., heart failure

Answer 85

- Infection - Alcohol - MI - First presentation of diabetes - Missed / insufficient insulin doses

Answer 86

- Polydipsia, polyuria - Acetone breath - Kussmaul breathing - Abdominal pain - Nausea and vomiting - Tachycardia, hypotension - confusion, drowsiness - Dehydration, dry mucous membranes - Ketonuria, glycosuria Severe DKA - Severe acidosis (pH <7.1, H+ >80, HCO3 <5) - reduced GCS - Cerebral oedema - Hypokalaemia (K <3.5)

Answer 87

- VTE - Arrhythmias - Cerebral oedema - ARDS - AKI - hypophosphataemia

Answer 88

Hypochloraemia, hypokalaemia

Answer 89

failure of GnRH secreting neurons to migrate to hypothalamus Lack of GnRH leads to hypogonadotrophic hypogonadism > failure to start puberty > anosmia > hypogonadism, cryptorchidism > low LH/FSH levels, low testosterone > cleft lip and palate seen in some patients management - testosterone supplementation - gonadotrophin supplementation

Answer 90

clinical features - prominent forehead (frontal bossing) - large nose, large hands, large feet - arthritis - large tongue (macroglossia) - protruding jaw (prognathism) investigations - serum IGF-1 levels first-line - oral glucose tolerance test and serial growth hormone measurements if IGF-1 is raised to confirm - pituitary MRI complications - hypertension - diabetes - cardiomyopathy - colorectal cancer management - transsphenoidal surgery to remove pituitary adenoma - - medical options > pegvisomant: GH receptor antagonist > octreotide: somatostatin analogue > bromocriptine: dopamine agonist

Answer 91

osteoporosis: all normal osteomalacia - low calcium, low phosphate, high ALP, high PTH primary hyperparathyroidism - high calcium, low phosphate, high ALP, high PTH > parathyroidectomy is definitive management > nephrolithiasis secondary to hyperparathyroidism is an indication for parathyroidectomy CKD - low calcium, high phosphate, high ALP, high PTH Paget's - all normal except increased ALP - X-ray shows mixed sclerotic and lytic lesions - treat with risedronate Osteopetrosis - all normal

Answer 92

SCC developing at site of chronic inflammation e.g. burns or osteomyelitis after 10-20 years

Answer 93

brown pigmentation (haemosiderin), lipodermatosclerosis, venous eczema,venous ulcers

Answer 94

X-linked dominant inheritance due to a defect type IV collagen resulting in an abnormal glomerular-basement membrane (GBM) clinical features: > microscopic haematuria > progressive renal failure > bilateral sensorineural deafness > lenticonus: protrusion of the lens surface into the anterior chamber > retinitis pigmentosa > renal biopsy: splitting of lamina densa seen on electron microscopy Diagnosis - molecular genetic testing - renal biopsy - electron microscopy: longitudinal splitting of the lamina densa of the glomerular basement membrane, resulting in a 'basket-weave' appearance

Answer 95

caused by protozoan parasite Giardia lamblia endemic areas include india incubation period 1-2 weeks Giardia causes fat malabsorption so greasy stool can occur (floating in water) resistant to chlorination so can be transferred in swimming pools features - water diarrhoea - abdominal cramping - bloating - flatulence - apyrexia and non-tender abdomen

Answer 96

- Isoniazid > peripheral neuropathy (prevent with pyridoxine aka vitamin B6) > hepatitis > agranulocytosis - Rifampicin > hepatitis, orange secretions - Ethambutol > optic neuritis - Pyrazinamide > hyperuricaemia causing gout > arthralgia, myalgia > hepatitis

Answer 97

Bisphosphonates inhibit osteoclasts by reducing recruitment and promoting apoptosis Clinical uses - prevention and treatment of osteoporosis - hypercalcaemia - Paget's disease - pain from bone metastases Adverse effects - oesophageal reactions: oesophagitis, oesophageal ulcers (especially alendronate) - osteonecrosis of the jaw - atypical stress fractures of the proximal femoral shaft in patients taking alendronate - acute phase response: fever, myalgia and arthralgia may occur following administration - hypocalcaemia: due to reduced calcium efflux from bone. Usually clinically unimportant > Hypocalcemia/vitamin D deficiency should be corrected before giving bisphosphonates

Answer 98

Laryngeal mask if patient is not fasted, there is a risk of aspiration of gastric contents during induction of anaesthesia. A laryngeal mask is, therefore, contraindicated as this cannot protect the trachea and bronchial tree from aspirate.

Answer 99

Gingival hyperplasia: phenytoin, ciclosporin, calcium channel blockers e.g. amlodipine and AML

Answer 100

gluten-free diet Immunisation > Patients with coeliac disease often have a degree of functional hyposplenism > offer pneumococcal vaccine, as well as Haemophilus type B, meningococcus type C

Answer 101

Triad of: dysphagia (secondary to oesophageal webs) glossitis iron-deficiency anaemia Treatment includes iron supplementation and dilation of the webs

Answer 102

Silicosis is a fibrosing lung disease caused by the inhalation of fine particles of crystalline silicon dioxide (silica). It is a risk factor for developing tuberculosis (silica is toxic to macrophages). Occupations at risk of silicosis mining slate works foundries potteries Features upper zone fibrosing lung disease 'egg-shell' calcification of the hilar lymph nodes

Answer 103

Pneumoconiosis occupations at risk are classically firefighters, dockyard workers, and construction workers rather than miners. crocidolite (blue) asbestos is the most dangerous form Radiological findings > pleural plaques (benign) > lower lobe fibrosis > pleural thickening complications - lung cancer (most common) - mesothelioma > diagnosis on histology following thoracoscopic biopsy

Answer 104

age > 55 years hypocalcaemia hyperglycaemia hypoxia neutrophilia elevated LDH and AST serum amylase is diagnostic but NOT prognostic

Answer 105

type 2 diabetes mellitus gastric adenocarcinoma obesity polycystic ovarian syndrome acromegaly Cushing's disease hypothyroidism familial Prader-Willi syndrome drugs combined oral contraceptive pill nicotinic acid insulin resistance → hyperinsulinemia → stimulation of keratinocytes and dermal fibroblast proliferation via interaction with insulin-like growth factor receptor-1 (IGFR1)

Answer 106

associated with H. pylori infection in 95% of cases good prognosis if low grade then 80% respond to H. pylori eradication

Answer 107

nephrotoxicity ototoxicity thrombophlebitis red man syndrome; occurs on rapid infusion of vancomycin >> if this occurs stop vancomycin infusion and re-start at slower rate

Answer 108

GCS < 13 on initial assessment GCS < 15 at 2 hours post-injury suspected open or depressed skull fracture any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign). post-traumatic seizure. focal neurological deficit. more than 1 episode of vomiting

Answer 109

thiopurine methyltransferase (TPMT) test may be needed to identify individuals prone to azathioprine toxicity adverse effects: bone marrow depression nausea/vomiting pancreatitis increased risk of non-melanoma skin cancer A significant interaction may occur with allopurinol and hence lower doses of azathioprine should be used. Azathioprine is generally considered safe to use in pregnancy.

Answer 110

Features sun-exposed sites, especially the head and neck initially a pearly, flesh-coloured papule with telangiectasia may later ulcerate leaving a central 'crater' Management options: surgical removal curettage cryotherapy topical cream: imiquimod, fluorouracil radiotherapy

Answer 111

Clinical features - weight loss - haemoptysis - fever - productive cough - fatigue - erythema nodosum - CXR: bilateral hilar lymphadenopathy, upper lobe cavitation Diagnosis - Mantoux test: latent TB - nucleic acid amplification test (NAAT) - Interferon gamma release assay - Acid-fast bacilli staining (Ziehl-Neelsen stain) - sputum culture: determine drug sensitivities - gold standardli - all patients should receive HIV test False negative tests may be caused by: miliary TB sarcoidosis HIV lymphoma very young age (e.g. < 6 months)

Answer 112

infection: streptococci, tuberculosis, brucellosis sarcoidosis inflammatory bowel disease Behcet's malignancy/lymphoma drugs: penicillins, sulphonamides, combined oral contraceptive pill pregnancy

Answer 113

normal anion gap: 10-14 mmol/L Causes of a normal anion gap or hyperchloraemic metabolic acidosis > gastrointestinal bicarbonate loss: diarrhoea (w/ hypokalaemia), ureterosigmoidostomy, fistula > renal tubular acidosis > drugs: e.g. acetazolamide > ammonium chloride injection > Addison's disease > large volumes of 0.9% NaCl Causes of a raised anion gap metabolic acidosis > lactate: shock, hypoxia > ketones: diabetic ketoacidosis, alcohol > urate: renal failure > acid poisoning: salicylates, methanol > 5-oxoproline: chronic paracetamol use

Answer 114

Autonomic - Trembling - Sweating - Anxiety - Palpitations - Hunger - Nausea - Tingling Neuroglycopaenic - Confusion - Weakness - Drowsiness - Visual change - Difficulty speaking - Headache - Dizziness - Tiredness impaired hypoglycaemia awareness occurs due to neuropathy of parts of the autonomous nervous system

Answer 115

Mild: conscious, orientated and able to swallow - 15-20g of quick-acting carbohydrate e.g. > 4-5 glucotabs > 150-200ml pure fruit juice >> repeat up to 3 times Moderate: conscious and able to swallow but confused, disorientated or aggressive - capable and cooperative: treat as mild - uncooperative but able to swallow > 2 tubes 40% glucose gel >> repeat up to 3 times Severe: unconscious, fitting, very aggressive or NBM - IV glucose over 15 mins > 100ml 20% dextrose OR 200ml 10% dextrose - if no IV access: 1mg IM glucagon repeat blood glucose measurement in 10-15 minutes; if ineffective after 3 times treat as severe

Answer 116

Causes - drugs: the most common cause, particularly > antibiotics: penicillin, rifampicin > NSAIDs > allopurinol > furosemide - systemic disease: SLE, sarcoidosis, and Sjögren's syndrome - infection: Hanta virus , staphylococci histology: marked interstitial oedema and interstitial infiltrate in the connective tissue between renal tubules Features > raised urinary WCC and eosinophils > fever, rash, arthralgia > eosinophilia > mild renal impairment > hypertension Investigations: sterile pyuria, white cell casts

Answer 117

Lyme disease is caused by the spirochaete Borrelia burgdorferi and is spread by ticks. Early features (within 30 days) > erythema migrans - 'bulls-eye' rash > systemic features >> headache >> lethargy >> fever >> arthralgia - Later features: > cardiovascular: heart block, peri/myocarditis > neurological: facial nerve palsy, radicular pain, meningitis Investigation > enzyme-linked immunosorbent assay (ELISA) antibodies to Borrelia burgdorferi > immunoblot test Management - doxycycline if early disease - ceftriaxone if disseminated disease - Jarisch-Herxheimer reaction is sometimes seen after initiating therapy: fever, rash, tachycardia after first dose of antibiotic (more commonly seen in syphilis, another spirochaetal disease)

Answer 118

Metabolic alkalosis may be caused by a loss of hydrogen ions or a gain of bicarbonate Causes > vomiting / aspiration > diuretics > liquorice, carbenoxolone > hypokalaemia > primary hyperaldosteronism > Cushing's syndrome > Bartter's syndrome

Answer 119

If the patient is symptomatic: > fasting glucose greater than or equal to 7 mmol/L > random glucose greater than or equal to 11 mmol/L (or after 75g oral glucose tolerance test) > If the patient is asymptomatic the above criteria apply but must be demonstrated on two separate occasions. HbA1c: greater than or equal to 48 mmol/mol > not recommended in diagnosis of T1DM > in patients without symptoms, the test must be repeated to confirm the diagnosis > 42-47 mmol/mol - prediabetes (discuss diet & exercise) > misleading HbA1c results can be caused by increased red cell turnover (see below) higher than expected HbA1C (increased RBC life span): > splenectomy > IDA > Vitamin B12/folate deficiency lower than expected HbA1C (reduced RBC life span): > sickle cell anaemia > G6PD deficiency > hereditary spherocytosis > haemodialysis

Answer 120

Ebola spreads through human-to-human transmission via direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people Incubation period: 2 to 21 days > patients are not infectious until they develop symptoms Clinical features > fever > fatigue > muscle pain > headache > sore throat > followed by vomiting, diarrhoea, rash, symptoms of impaired kidney and liver function > internal and external bleeding

Answer 121

AR condition caused by mutation in chromosome 11 leading to defective beta globin chains most commonly seen in mediterranean, african and southeast asian populations split into 3 types - thalassaemia minor > aka beta thalassaemia trait > one abnormal and one normal gene > mild microcytic anaemia, microcytosis is disproportionate to the anaemia > HbA2 raised (>3.5%) > absent HbA, raised HbF > monitor, no active treatment - thalassaemia intermedia > two abnormal copies of gene > more significant anaemia > may require occasional blood transfusions - thalassaemia major > no functioning beta globin genes (homozygous for deletion genes) > severe microcytic anaemia and failure to thrive in early childhood > splenomegaly and bone abnormalities > manage with regular transfusions, iron chelation (desferrioxamine) and splenectomy > bone marrow transplant can be curative

Answer 122

commonest, and most severe, type of malaria. fever on alternating days, think malaria Feature of severe malaria > schizonts, trophozoites on a blood film > parasitaemia > 2% > hypoglycaemia > acidosis > temperature > 39 °C > severe anaemia Complications > cerebral malaria: seizures, coma > acute renal failure: blackwater fever, secondary to intravascular haemolysis, mechanism unknown > acute respiratory distress syndrome (ARDS) > disseminated intravascular coagulation (DIC) Management > artemisinin-based combination therapies (ACTs) as first-line therapy >> artemether plus lumefantrine >> artesunate plus amodiaquine >> malarone (atovaquone/proguanil) >> quinine sulphate tablets >> OR chloroquine if low resistance > primaquine >> used in non-falciparum malaria to destroy liver hypnozoites and prevent relapse Severe falciparum malaria > intravenous artesunate > if parasite count > 10% consider exchange transfusion > shock may indicate coexistent bacterial septicaemia - malaria rarely causes haemodynamic collapse

Answer 123

- patients taking liver enzyme-inducing drugs > rifampicin, phenytoin, carbamazepine, chronic alcohol excess, St John's Wort > malnourished patients (e.g. anorexia nervosa) or patients who have not eaten for a few days acute alcohol intake, as opposed to chronic alcohol excess, is not associated with an increased risk of developing hepatotoxicity and may actually be protective

Answer 124

Hyposplenism e.g. post-splenectomy, coeliac disease target cells Howell-Jolly bodies Pappenheimer bodies siderotic granules acanthocytes Iron-deficiency anaemia target cells 'pencil' poikilocytes if combined with B12/folate deficiency a 'dimorphic' film occurs with mixed microcytic and macrocytic cells low transferrin, low ferritin, high TIBC Myelofibrosis 'tear-drop' poikilocytes Intravascular haemolysis schistocytes Megaloblastic anaemia hypersegmented neutrophils

Answer 125

Causes of gynaecomastia - physiological: normal in puberty - syndromes with androgen deficiency: Kallman's, Klinefelter's - testicular failure: e.g. mumps - liver disease - testicular cancer e.g. teratoma secreting hCG - ectopic tumour secretion - adenocarcinoma of the lung - hyperthyroidism - haemodialysis Drug causes of gynaecomastia - spironolactone (most common drug cause) - ketoconazole - cimetidine - digoxin - cannabis - finasteride - GnRH agonists e.g. goserelin, buserelin oestrogens, anabolic steroids

Answer 126

Size (with measuring tape), shape Colour Associated secondary change Margins, morphology Morphology of rashes > erythematous > maculopapular > vesiculobullous > petechial / purpuric Pattern of rashes > discrete / confluent > demarcated / indistinct > linear > target > annular > discoid Pigmented skin lesion Asymmetry Borders (irregular) Colour (2 or more) Diameter >6mm, distribution

Answer 127

psoriasis eczema pityriasis rubra pilaris cutaneous adverse drug reaction e.g. vancomycin causing red man syndrome cutaneous lymphoma

Answer 128

rare, cutaneous, inflammatory papulosquamous disorder - classically characterized by follicular, hyperkeratotic papules - waxy, yellow palmoplantar keratoderma - erythroderma with islands of sparing

Answer 129

Nail changes: pitting, onycholysis, leukonychia, subungal hyperkeratosis, oil spot sign, Beau's lines (transverse ridging) Types of psoriasis: - Plaque psoriasis > well-demarcated raised salmon pink plaques with silvery white scales on extensor surfaces (also scalp) - Guttate psoriasis: tear-drop shape > often triggered by streptococcal throat infection, lesions on the trunk - Pustular psoriasis: sterile pus-filled pustules, not infectious - Palmoplantar psoriasis: can cause painful fissures in palms / soles - Erythrodermic psoriasis: serious, involves heat, fever, systemic upset - Inverse psoriasis (flexural): can affect submammary, axillary and anogenital folds Association with psoriatic arthritis (often before skin changes)

Answer 130

Common drug causes: > penicillin > sulphonamides > NSAIDs > allopurinol > carbamazepine, lamotrigine, phenytoin > COCP infectious causes - HSV, Mycoplasma pneumoniae, CMV, HIV occurs days up to 2 months after initiation of medication Skin features of TEN/SJS include: > Diffuse erythema > Maculopapular rash with target lesions > Skin detachment, erosions and flaccid blisters (vesicles/bullae) > mucosal involvement > fever, arthralgia FBC - neutropaenia, leukopaenia, anaemia U&Es - AKI due to fluid loss from skin LFTs - transaminitis, hepatitis SJS if <10% skin involvement TEN if >30% Severity scoring system - SCORTEN Nikolsky sign - blisters and erosions appearing when the skin is rubbed gently Management - Identify and stop culprit drug - Fluid balance +/- catheterisation - Temperature and glycaemic control - Barrier nursing - Skin care: regular skin care with greasy emollients, anti-shear sheets and non-adherent dressings. - Mouth and eye care - Analgesia - Identification and treatment of infection - Regular skin swabs

Answer 131

- erythema multiforme major > infectious trigger e.g. EBV, HSV, mycoplasma > target lesions on extremities + mucosal involvement > Nicolsky sign negative staphylococcal scalded skin syndrome > usually in children, mucous membranes spared > Nicolsky sign may be positive

Answer 132

Pemphigus vulgaris > Autoimmune intra-epidermal blistering condition > presents with mucosal ulceration over weeks – months > Skin involvement - flaccid blisters Bullous pemphigoid > Autoimmune subepidermal blistering condition > intact bullae on erythematous base > no mucosal involvement > usually in older patients. > managements: oral steroids

Answer 133

Basics - AD defect of red blood cell cytoskeleton - red blood cell survival reduced as destroyed by the spleen Presentation > failure to thrive > jaundice, gallstones > splenomegaly > aplastic crisis precipitated by parvovirus infection > degree of haemolysis variable > MCHC elevated Diagnosis - spherocytes on blood film - raised mean corpuscular haemoglobin concentration [MCHC] - increase in reticulocytes - EMA ( electrophoresis analysis of erythrocyte membranes) binding test and the cryohaemolysis test for atypical presentations Management acute haemolytic crisis: > treatment is generally supportive > transfusion if necessary longer term treatment: > folate replacement > splenectomy

Answer 134

Side-effects - bronchospasm - cold peripheries - fatigue - sleep disturbances, including nightmares - erectile dysfunction Contraindications - uncontrolled heart failure - asthma - sick sinus syndrome - concurrent verapamil use: may precipitate severe bradycardia

Answer 135

viral infection that can progress to viral haemorrhagic fever dengue virus is a RNA virus of the genus Flavivirus transmitted by the Aedes aegypti mosquito incubation period of 7 days Clinical features - fever - headache (often retro-orbital) - myalgia, bone pain and arthralgia ('break-bone fever') - pleuritic pain - facial flushing (dengue) - maculopapular rash - haemorrhagic manifestations e.g. positive tourniquet test, petechiae, purpura/ecchymosis, epistaxis - 'warning signs' include: > abdominal pain, hepatomegaly, persistent vomiting, clinical fluid accumulation (ascites, pleural effusion) Severe dengue (dengue haemorrhagic fever) a form of disseminated intravascular coagulation (DIC) resulting in thrombocytopenia, spontaneous bleeding, can go on to develop dengue shock syndrome (DSS) Investigations > leukopenia, thrombocytopenia, raised aminotransferases > diagnostic tests: serology, nucleic acid amplification tests for viral RNA > NS1 antigen test Treatment > entirely symptomatic e.g. fluid resuscitation, blood transfusion etc > no antivirals are currently available

Answer 136

Risk factors - exposure to sunlight or psoralen UVA therapy - actinic keratoses and Bowen's disease (SCC in situ) - immunosuppression e.g. following renal transplant, HIV - smoking - genetic conditions: xeroderma pigmentosum, oculocutaneous albinism features - sun-exposed sites - rapidly expanding painless, ulcerate nodules - cauliflower-like appearance and areas of bleeding - non-healing painless ulcer associated with chronic scar treatment - surgical excision with 4mm margins if lesion <20mm diameter - surgical excision with 6mm margins if lesion >20mm > Mohs micrographic surgery in high-risk patients and cosmetically important sites

Answer 137

causes - sexually active young adults > chlamydia trachomatis > neisseria gonorrhoeae - older adults with low-risk sexual history > E. coli (more common) > Enterococcus faecalis Features - unilateral testicular pain and swelling - pain eased by elevating testicle - cremasteric reflex present - urethral discharge - rule out testicular torsion Investigations - STI screen (high risk sexual history) - MSU (low risk sexual history) - microscopy and culture Management - STI likely: IM ceftriaxone 500mg single dose + doxycycline 100mg BD for 10-14 days - Enteric organisms likely: oral quinolone

Answer 138

Non-pregnant women - trimethoprim or nitrofurantoin 3 days - send urine culture of aged >65, haematuria Pregnant women > symptomatic: nitrofurantoin (avoid near term) >> second-line: amoxicillin or cefalexin - avoid trimethoprim - teratogenic > asymptomatic bacteriuria: 7 dayas of nitrofurantoin / amoxicillin / cefalexin Men > nitrofurantoin or trimethoprim for 7 days Catheter-related > do not treat asymptomatic bacteria - symptomatic: 7 day course of antibiotics, change catheter Acute pyelonephritis: broad-spectrum cephalosporin or quinolone for 10-14 days do not use urine dipsticks in women >65, men and catheterised patients

Answer 139

Generally asymptomatic, flat, slightly scaly, pink or brown rash found in the groin / axillae Caused by overgrowth of diphtheroid Corynebacterium minutissimum Examination with Wood's light reveals a coral-red fluorescence Treatment - Topical miconazole or antibacteriall - Oral erythromycin for extensive infection

Answer 140

Rare catecholamine secreting tumour > associated with MEN type II, neurofibromatosis and Von Hippel-Lindau syndrome Features (episodic) - hypertension, may be sustained - headaches - palpitations - sweating - anxiety Tests - 24h urinary collection of metanephrines Management - first-line: phenoxybenzamine (alpha-blocker) BEFORE beta-blocker e.g. propranolol/labetalol - surgery

Answer 141

parasitic flatworm infections 3 main species - S. mansoni, S. japonicum, S. haematobium Clinical features - swimmers' itch - acute schistosomiasis syndrome (Katayama fever) > fever > urticaria/angioedema > arthralgia / myalgia > cough > diarrhoea > eosinophilia Chronic infections - schistosoma haematobium: deposition of egg clusters in bladder leading to frequency, haematuria and bladder calcification - schistosoma mansoni/japonicum: hepatomegaly, splenomegaly Investigation - serum schistosome antibodies (Asymptomatic) - urine/stool microscopy looking for eggs (symptomatic) Management - single dose oral praziquantel complication: squamous cell carcinoma of the bladder

Answer 142

1. oxygen if saturations <94% 2. bronchodilation with salbutamol nebulisers 3. ipratropium bromide nebulisers 4. IV hydrocortisone or oral prednisolone 40-50mg PO for at least 5 days 5. magnesium sulfate IV 6. IV aminophylline / IV salbutamol Criteria for discharge - stable on discharge medication for 12-24h - inhaler techique checked and recorded - PEF >75% of best or predicted

Answer 143

- epididymal cyst > single or multiple painless cysts > may contain clear fluid (spermatocoele) > usually occur over 40 years of age > lie above and behind the testis > can "get above it" on examination > associated conditions: PKD, CF, VHL - varicocoele > varicosities of the pampiniform plexus > may be presenting feature of RCC > affected testis may be smaller, bag of worms appearance - testicular cancer > discrete testicular nodule (may have associated hydrocoele) > hard, fixed, does not transilluminate - inguinal hernia > inguinoscrotal swelling > cough impulse may be present, may be reducible > cannnot "get above it" on examination

Answer 144

causes > haematogenous spread of bacteria (primary), usually staph aureus secondary - Crohn's - diverticulitis, CRC - UTI, GU cancers - vertebral osteomyelitis - femoral catheter, lithotripsy - endocarditis - IVDU Clinical features - back/flank pain - fever - limp - weight loss investigations: clinical examinatino + CT abdomen management - antibiotics - percutaneous drainage - surgery if failure of percutaneous drainage

Answer 145

B or T cell malignancy associated with t(14;18) translocation increased risk with increasing age, 1/2 of cases >75 symptoms - painless lymphadenopathy (non-tender, rubbery. asymmetrical) - B symptoms - fever, weight loss, night sweats important subtypes - MALT lymphoma - Burkitt lymphoma (associated with EBV, C-myc gene translocation) - diffuse large B cell lymphoma Biopsy - some subtypes have classic appearance e.g. Burkitt's lymphoma - starry sky appearance. > CT CAP Staging - Ann Arbor classification Management - dependent on subtype - radiotherapy, chemotherapy - rituximab + CHOP (R-CHOP) for a variety of types of NHL Complications - bone marrow infiltration: anaemia, neutropaenia, thrombocytopaenia - SVC obstruction - metastasis - spinal cord compression

Answer 146

aka black lung disease causes upper zone fibrosis 2 types - simple pneumoconiosis > often asymptomatic > increases risk of lung diseases e.g. COPD > may lead to progressive massive fibrosis (PMF) - progressive massive fibrosis > round fibrotic masses in upper lobes > symptoms: breathlessness on exertion, cough, black sputum PFTs show mixed obstructive/restrictive picture Investigations > CXR: upper zone fibrosis > Spirometry: reduced FEV1, reduced FVC management - avoid exposure to coal dust and other respiratory irritants e.g. smoking - manage symptoms of chronic bronchitis

Answer 147

CHARTS - Coal workers' pneumoconiosis - Histiocytosis / hypersensitivity pneumonitis - Ankylosing spondylitis, allergic bronchopulmonary aspergillosis - Radiation - Tuberculosis - Silicosis, sarcoidosis

Answer 148

Caused by tetanospasmin exotoxin released from Clostridium tetani. tetanus spores are present in soil and may be introduced into the body from a wound. may be seen in IVDU using unclean needles features - prodrome fever, lethargy, headache - trismus (lockjaw) - risus sardonicus: facial spasms - opisthotonus: arched back, hyperextended neck - spasms e.g. dysphagia management - supportive therapy including ventilatory support and muscle relaxants - IM human tetanus immunoglobulin for high-risk wounds - antibiotic treatment with metronidazole

Answer 149

occurs in patients with Graves' disease features - exophthalmos - conjunctival oedema - optic disc swelling - ophthalmoplegia - sore dry eyes which can lead to exposure keratopathy management - topical lubricants - steroids - radiotherapy - surgery urgent review by ophthalmologist if changes in vision with thyroid eye disease contraindications - radioiodine treatment

Answer 150

causes of low magnesium - drugs e.g. diuretics, PPIs - total parenteral nutrition (TPN) - diarrhoea - alcohol - hypokalaemia - hypercalcaemia - metabolic disorders e.g. Gitleman's, Bartter's features may be similar to hypocalcaemia - paraesthesia - tetany - seizures - arrhythmias - ECG features similar to hypocalcaemia - exacerbates digoxin toxicity management <0.4mmol/L or tetany, arrhythmias or seizures: - IV magnesium replacement e.g. 40 mmol magnesium sulphate over 24h >0.4 mmol/L: oral magnesium salts (10-20 mmol orally per day in divided doses). side-effects may include diarrhoea

Answer 151

management of proteinuric CKD - ACEi or ARB: first-line in hypertension + CKD if ACR > 30mg/mmo > if >70mg/mmol then start ACEi regardless of BP - SGLT2i: all regardless of diabetes mineral bone disease - reduce phosphate and PTH levels > reduce dietary intake > phosphate binders e.g. calcichew, sevelamer > give alendronate if osteoporosis - vitamin D supplementation: calcitriol - erythropoietic stimulating agent: anaemia + renal insufficiency (if iron levels normal)

Answer 152

Features - closed and open comedones - papules - pustules - seborrhoea - nodules medications which exacerbate acne - steroids - lithium - ciclosporin - progesterone only contraceptives associated conditions: PCOS Management - topical: benzoyl peroxide, topical antibiotics, adapalene (topical retinoid) - systemic: oral antibiotics e.g. lymecycline / doxycycline / erythromycin / clindamycin - isotretinoin (Roaccutane) - COCP in some patients

Answer 153

highly concentrated vitamin A - dry mucous membranes, can cause nosebleeds - headache - deranged LFTs (avoid alcohol due to risk of transaminitis) - highly teratogenic, patients must be on pregnancy prevention programme - low mood - photosensitivity: caution patients to avoid direct sunlight

Answer 154

mild steroid - hydrocortisone intermediate steroid - eumovate (clobetasone butyrate) potent steroid - betamethasone valerate (betnovate) very potent steroid - dermovate (clobetasol propionate)

Answer 155

rapid enlargement of a pituitary corticotroph adenoma that occurs after bilateral adrenalectomy for Cushing's syndrome removal of both adrenal glands eliminates cortisol production which ceases to exert its negative feedback on ACTH, allowing unchecked growth of adenoma Adenoma causes mass effect on brain and increased melanocyte stimulating hormone leading to hyperpigmentation therefore, following bilateral adrenalectomy monitor ACTH levels and perform pituitary MRI every 3-6 months.

Answer 156

Medical therapy - prolactinoma: dopamine agonists e.g. cabergoline, bromocriptine - acromegaly / GH secreting adenomas > somatostatin analogues: octreotide, lanreotide > GH receptor antagonists: pegvisomant - ACTH-secreting adenomas > cortisol synthesis inhibitors: ketoconazole, metyrapone > neuromodulators; pasireotide Transsphenoidal surgery Radiotherapy: recurrent or residual tumours

Answer 157

Transudate (<30g/L protein) - heart failure - hypoalbuminaemia > liver failure > nephrotic syndrome > malabsorption - hypothyroidism - Meig's syndrome: transudative pleural effusion and ascites in the presence of a benign ovarian tumour (usually fibroma) Exudate (>30g/L protein) - infection: pneumonia, TB, subphrenic abscess > turbid effusion with pH <7.2, low glucose, high LDH - PE - malignancy; lung cancer, mesothelioma, metastases - connective tissue disease: RA, SLE - pancreatitis - Dressler's syndrome - yellow nail syndrome Presentation - dyspnoea, pleuritic chest pain - non-productive cough - signs: dull percussion, reduced breath sounds, reduced chest expansion

Answer 158

metabolic abnormalities associated with feeding a person after a period of starvation Lab features - hypophosphataemia (can lead to heart and respiratory failure, neurological complications, haemolysis, rhabdomyolysis) - hypokalaemia patients are high risk if they have a low BMI, little nutritional intake >10 days, unintentional weight loss if a patient hasn't eaten for >5 days, aim to re-feed at no more than 50% of requirements for 2 days - hypomagnesaemia features - abnormal fluid balance - arrhythmia

Answer 159

Obstructive FEV1 - significantly reduced FVC - reduced/ normal FEV1/FVC - reduced (<0.7) e.g. COPD, asthma Restrictive FEV1 - reduced FVC - significantly reduced FEV1/FVC - normal or increased e.g. pulmonary fibrosis, asbestosis

Answer 160

benign epidermal skin lesions seen in older people features - large variation in colour from flesh to light brown to black - keratotic plugs may be seen on surface Management - removal of patient wishes - curettage, cryosurgery, shave biopsy

Answer 161

Classification - bone sarcoma > osteosarcoma > chondrosarcoma > Ewing's sarcoma - soft tissue sarcoma > liposarcoma > rhabdomyosarcoma > leiomyosasrcoma > synovial sarcoma > fibrosarcoma > angiosarcoma presentation - pain - swelling or palpable mass - impaired function - pathological fracture - systemic symptoms: fatigue, weight loss, fever investigations > imaging: X-rays, CT, MRI, PET scan > biopsy: FNA, core needle biopsy, incisional biopsy Management - surgery - radiation - chemotherapy - targeted therapy e.g. TKIs - immunotherapy: immune checkpoint inhibitors

Answer 162

caused by salmonella typhi and paratyphi Symptoms - fever - headache - arthralgia - relative bradycardia - abdominal pain, distension - diarrhoea or constipation - splenomegaly - rose spots: erythematous maculopapular lesions often on torso - complications > osteomyelitis > GI bleed/perforation > meningitis > cholecystitis > chronic carriage management - ciprofloxacin

Answer 163

shingles (herpes zoster infection) is an acute, unilateral, painful blistering rash caused by reactivation of the varicella zoster virus following primary infection with VZV (chickenpox) the virus lies dormant in the dorsal root or cranial nerve ganglia risk factors - increasing age - immunosuppression features - prodromal period: severe burning pain over affected dermatome 2-3 days - fever, headache, lethargy - rash: initially erythematous macular rash over the affected dermatome and quickly becomes vesicular diagnosis is clinical

Answer 164

clinical features - translucent looking skin and hypermobility of small joints - sigmoid colon perforation at young age of unknown cause - aortic dissection

Answer 165

Most common is adenocarcinoma > most common histological subtype is clear cell carcinoma > also papillary and chromophobe Features - classical triad: haematuria, loin pain and abdominal mass - pyrexia of unknown origin - endocrine effects > may secrete erythropoietin leading to polycythaemia > PTHrP (hypercalcaemia), renin > ACTH - paraneoplastic hepatic dysfunction syndrome - varicocoele - Stauffer syndrome: cholestasis / hepatosplenomegaly - transitional cell carcinoma: textile, plastic and rubber industry management - if confined disease: partial or total nephrectomy depending on tumour size e.g. T1, partial nephrectomy - alpha-interferon and IL-2 to reduce tumour size - receptor tyrosine kinase inhibitors e.g. sorafenib, sunitinib

Answer 166

Complications following venous outflow obstruction and venous insufficiency result in chronic venous hypertension. Clinical features: - painful, heavy calves - pruritus - swelling - varicose veins - venous ulceration management - compression stockings, leg elevation

Answer 167

Benign - thyroid adenoma > Simple – iodine deficiency > Toxic – Grave's / solitary nodule / multinodular goitre: patchy uptake on thyroid scintigraphy - Thyroiditis – Hashimoto's, Riedel's, De Quervain's - Amyloid / Bacterial infection (TB, syphilis) - Thyroglossal duct cyst - Thyroglossal fistula - Ectopic/lingual thyroid Malignant - papillary carcinoma > excellent prognosis despite tendency to spread to cervical lymph nodes early - follicular carcinoma - medullary carcinoma > serum calcitonin to assess recurrence - anaplastic carcinoma - lymphoma > thyroglobulin antibodies to detect recurrence investigation - ultrasonography (first-line) - TFTs

Answer 168

chronic liver disorder typically seen in middle aged females clinical features - asymptomatic e.g. raised ALP on routine LFTs - fatigue, pruritus - cholestatic jaundice - hyperpigmentation (especially over pressure points) - RUQ pain - xanthelasma, xanthomata Investigations - raised IgM - Positive antimitochondrial M2 antibody - smooth muscle antibody present in some patients - imaging > required before diagnosis to exclude extrahepatic biliary obstruction (RUQ ultrasound or magnetic resonance cholangiopancreatography (MRCP)) Management - first-line: ursodeoxycholic acid - pruritus: cholestyramine - fat-soluble vitamin supplementation - liver transplantation Complications - cirrhosis > portal hypertension > ascites, variceal haemorrhage - osteomalacia, osteoporosis - increased risk of hepatocellular carcinoma

Answer 169

excessive sweat production management - topical aluminium chloride (first-line) > side-effect: irritation - iontophoresis - botulinum toxin - surgery: endoscopic transthoracic sympathectomy > risk of compensatory sweating

Answer 170

Severe and permanent retinopathy clinical features > reduced colour differentiation > reduced central visual acuity > floaters Bull's eye maculopathy > appearance on ophthalmoscopy: red spot on the macula surrounded by a ring of retinal epithelial pigment loss

Answer 171

viral disease caused by an RNA rhabdovirus that causes an acute encephalitis tranmission: dog bites, bat, raccoon and skunk bites features > prodrome: headache, fever, agitation > hydrophobia > hypersalivation > Negri bodies: cytoplasmic inclusion bodies found in infected neurons management - vaccination - if bitten and previously vaccinated: 2 further vaccines - if bitten and not vaccinated: human rabies immunoglobulin + full course vaccination

Answer 172

- smoking cessation - annual influenza vaccination + one-off pneumococcal vaccination - pulmonary rehabilitation Bronchodilators - SABA or SAMA first-line - Second line > steroid-responsive: >> add LABA + ICS >> if still unresponsive: LABA/LAMA/ICS >> if no benefit after 3 months with ICS, switch to LABA/LAMA > non-steroid-responsive: >> LABA + LAMA >> if taking a SAMA, discontinue and switch to SABA Consider oral theophylline oral prophylactic antibiotic therapy + home supply of prednisolone > azithromycin mucolytics e.g. carbocysteine - if >=2 exacerbations on triple therapy and FEV1 <50%: > PDE-4 inhibitors e.g. roflumilast

Answer 173

Features - gingivostomatitis - cold sores - painful genital ulceration management - gingivostomatitis > oral aciclovir, chlorhexidine mouthwash - cold sores > topical aciclovir - painful genital ulceration > oral aciclovir pregnancy > delivery by caesarean section and oral aciclovir 400mg TDS until delivery if first presentation

Answer 174

persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance organic cause > gradual onset > lack of tumescence > normal libido psychogenic cause > sudden onset > reduced libido > good quality spontaneous or self-stimulated erections risk factors for organic cause: obesity, diabetes, smoking, hypertension, alcohol, SSRIs, beta-blockers investigations - free testosterone: first-line > if low, measure FSH, LH and prolactin - 10-year cardiovascular risk - nocturnal penile tumescence test Management - lifestyle: weight loss, regular exercise, smoking cessation - counselling if psychological factors - PDE-5 inhibitors e.g. sildenafil > can cause blue vision - vacuum erection devices - intracavernosal injections - young men who have always had difficulty achieving erection - urology referral

Answer 175

peripheral neuropathy > glove and stocking sensory loss > painful neuropathy treatment - first-line: amitriptyline, duloxetine, gabapentin, pregabalin - tramadol (rescue therapy) - topical capsaicin for localised neuropathic pain GI autonomic neuropathy - gastroparesis > erratic blood glucose control, bloating, vomiting - management: metoclopramide, domperidone or erythromycin (prokinetic) - chronic diarrhoea (at night) - GORD

Answer 176

Hypokalaemic metabolic alkalosis

Answer 177

divide oral dose by two when converting from oral to subcutaneous morphine divide by 10 when converting from codeine to morphine starting treatment: if no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain > 1/6 of daily dose for breakthrough laxatives should be prescribed with strong opioids > nausea is often transient but if it persists patient should be offered antiemetic drowsiness is usually transient - if not, adjust dose oxycodone is prescribed in preference to morphine in mild-moderate renal impairment > if renal impairment is more severe, alfentanil, buprenorphine and fentanyl are preferred when increasing the dose of opioids the next dose should be increased by 30-50% metastatic bone pain: strong opioids, bisphosphonates, radiotherapy, denosumab

Answer 178

chronic, painful, inflammatory skin disorder characterised by nodules, pustules, sinus tracts and scars in intertriginous areas axilla is the most common site nodules may rupture releasing purulent, malodorous discharge coalescence of nodules can result in plaques, sinus tracts and rope-like scarring diagnoses is clinical management - good hygiene and loose-fitting clothing - smoking cessation - weight loss in obese - topical (clindamycin) or oral (lymecycline, clindamycin) antibiotics - lumps that persist may be excised surgically complications - sinus tracts, fistulas - comedones - scarring - contractures - lymphatic obstruction

Answer 179

typically seen in patients aged 50-70 years and is twice as common in men features - progressive exertional dyspnoea - bibasal fine end-inspiratory crepitations on auscultation - dry cough - clubbing diagnosis - spirometry - restrictive - impaired gas exchange: reduced transfer factor (TLCO) - imaging: HR-CT > bilateral interstitial shadowing; ground glass progressing to honeycombing management > pulmonary rehabilitation > pirfenidone - antifibrotic > supplementary oxygen > lung transplant

Answer 180

aka primary ciliary dyskinesia pathogenesis - dynein arm defect results in immotile cilia features - dextrocardia or complete situs inversus - bronchiectasis - recurrent sinusitis - subfertility

Answer 181

rare but life-threatening complications of thyrotoxicosis precipitating event: surgery, trauma, infection, acute iodine load e.g. CT contrast clinical features - fever >38.5 - tachycardia - confusion and agitation - nausea and vomiting - hypertension - heart failure - abnormal liver function; jaundice management - symptomatic treatment: paracetamol - beta-blockers e.g. IV propranolol - hydrocortisone / dexamethasone - anti-thyroid drugs (thionamides): propylthiouracil, methimazole - Lugol's iodine

Answer 182

do not stop insulin due to risk of DKA continue normal insulin regime but ensure they are checking their blood sugars frequently (1-2 hourly) normal blood sugar checks in diabetics are at least 4 times a day, including before each meal and before bed blood glucose targets - waking: 5-7 mmol/l - before meals and other times of day: 4-7 mmol/l

Answer 183

aka golfer's elbow features - pain and tenderness localised to the medial epicondyle - pain is aggravated by wrist flexion and pronation - symptoms accompanied by numbness/tingling in 4th and 5th finger due to nerve involvement

Answer 184

- cranial DI: decreased secretion of ADH - nephrogenic DI: insensitivity to ADH Causes of cranial DI - idiopathic - post head injury - pituitary surgery - craniopharyngioma - infiltrative: histiocytosis X, sarcoidosis - haemochromatosis Causes of nephrogenic DI - genetic - hypercalcaemia, hypokalaemia - lithium - demeclocycline - tubulo-interstitial disease: obstruction, sickle cell, pyelonephritis features: polyuria, polydipsia investigation - high plasma osmolality, low urine osmolality - water deprivation test management - nephrogenic: thiazides e.g. chlorothiazide, low salt/protein diet - cranial: desmopressin (vasopressin V2 receptor agonist)

Answer 185

functional kidney impairment due to advanced liver disease clinical features - ascites - low urine output - significant increase in serum creatinine Management - terlipressin - volume expansion with 20% albumin - transjugular intrahepatic portosystemic shunt - liver transplant > type 1 HRS >> Rapidly progressive >> doubling of serum creatinine or halving of creatinine clearance > type 2 HRS >> slowly progressive >> poor prognosis

Answer 186

- focal seizures > start in a specific area on one side of the brain > level of awareness can vary >> focal aware >> focal impaired awareness > other features >> motor e.g. Jacksonian march, automatism >> non-motor e.g. deja vu, jamais vu >> aura - generalised seizures > involves networks on both sides of the brain > all patients lose consciousness immediately > specific types >> tonic-clonic (grand mal) >> tonic >> clonic >> typical absence (petit mal) >> atonic - unknown onset - focal to bilateral seizure > starts on one side of the brain in a specific area before spreading to both lobes

Answer 187

aka alopecia areata autoimmune condition which results in the loss of melanocytes and consequent depigmentation of skin clinical features > well-demarcated patches of depigmented skin > peripheries tend to be most affected > trauma may precipitate new lesions (Koebner phenomenon) management - sunblock for affected areas - camouflage makeup - topical steroids - topical tacrolimus, phototherapy

Answer 188

- hepatocellular > paracetamol > sodium valproate, phenytoin > MAOIs > halothane > anti-TB meds > statins > alcohol > amiodarone > methyldopa > nitrofurantoin - cholestasis > COCP > abx: flucloxacillin, co-amoxiclav, erythromycin > anabolic steroids, testosterone > phenothiazines: chlorpromazine, prochlorperazine > sulphonylureas > fibrates > nifedipine

Answer 189

potassium citrate

Answer 190

to diagnose pseudohyponatraemia > Calculate osmolarity = 2*Na + urea + blood glucose > calculate osmolar gap = measured serum osmolality - calculated osmolality. > normal osmolar gap <10 mmol/l. this rules out pseudohyponatraemia. causes of pseudohyponatraemia - hyperlipidaemia - taking blood from a drip arm

Answer 191

exclude pseudohyponatraemia and determine fluid status clinically - hypovolaemic > urine sodium <20 >> vomiting >> diarrhoea >> 3rd space losses > cerebral salt wasting syndrome > urine sodium >20 >> diuretics >> Addison's - euvolaemic > urine osmolality > 100 mOsm/kg >> SIADH >> Hypothyroidism >> ACTH deficiency > urine osmolality <100 mOsm/kg >> Primary polydipsia >> Beer potomania - hypervolaemic > urine sodium <20 >> heart failure >> cirrhosis >> nephrotic syndrome >> hypoalbuminaemia > urine sodium >20 >> renal failure

Answer 192

haematological malignancy characterised by plasma cell proliferation Features - 70 year olds - CRABBI: > Calcium (hypercalcaemia) > Renal >> monoclonal production of immunoglobulins results in light chain deposition within the renal tubules >> amyloidosis, nephrocalcinosis, nephrolithiasis > Anaemia > Bones bone marrow infiltration by plasma cells creates lytic bone lesions > back pain, pathological fractures > Infection Investigations - Bloods > FBC: anaemia > peripheral blood film: rouleaux formation > urea and electrolytes: renal failure > bone profile: hypercalcaemia - Protein electrophoresis > Bence-Jones proteins - Bone marrow aspiration: plasma cells raised (plasmacytoma) Imaging > whole-body MRI > X-rays: 'rain-drop skull'

Answer 193

features - lethargy, weakness, anorexia - nausea and vomiting - weight loss - salt craving - hyperpigmentation - vitiligo - loss of pubic hair in women - hypotension - hypoglycaemia - hyponatraemia and hyperkalaemia - crisis: collapse, shock, pyrexia management > hydrocortisone 20-30mg daily >> split dose with majority given in first half of day e.g. 20mg 8am and 10mg 5pm > fludrocortisone Give patients a hydrocortisone injection kit for adrenal crises intercurrent illness: double glucocorticoid dose

Answer 194

tinea pedis usually caused by fungi in the genus Trichophyton features - scaling - flaking - itching between toes management - first-line: topical imidazole, undecenoate - second-line: oral terbinafine

Answer 195

- heparin: protamine sulphate - ethylene glycol (anti-freeze): fomepizole, ethanol - methanol: fomepizole, ethanol - benzodiazepines: flumazenil - beta-blockers: atropine if bradycardic, glucagon if resistant - digoxin: digoxin-specific antibody fragments (digibind) - iron: desferrioxamine - lead: dimercaprol, calcium edetate - carbon monoxide: 100% O2, hyperbaric oxygen - cyanide: hydroxycobalamin - methotrexate: folinic acid

Answer 196

inflammation and fibrosis of intra and extrahepatic bile ducts associated with UC Features - cholestasis: jaundice, pruritus, raised bilirubin and ALP - RUQ pain - fatigue - hepatosplenomegaly Investigations - US: bile duct dilatation - MRCP/ERCP: beaded appearance of multiple biliary structures - p-ANCA may be positive - liver biopsy: fibrous, obliterative cholangitis with appearance of onion skin complications: cholangiocarcinoma, colon cancer management - ERCP for dominant strictures +/- stenting - liver transplant in advanced disease

Answer 197

- bradycardia - irregular breathing - hypertension with wide pulse pressure

Answer 198

found in immunocompromised individuals, mostly diabetics most commonly caused by Pseudomonas aeruginosa can progress to temporal bone osteomyelitis features - severe, unrelenting, deep-seated otalgia - temporal headaches - purulent otorrhoea - possibly dysphagia, hoarseness, facial nerve dysfunction diagnosis - CT scan management - ciprofloxacin, ENT referral

Answer 199

riboflavin - vitamin B2

Answer 200

causes - viral: coxsackie, HIV - bacteria: diphtheria, clostridia - spirochetes: Lyme disease - protozoa: Chagas disease, toxoplasmosis - autoimmune - drugs: doxorubicin presentation - usually young with acute history - chest pain - dyspnoea - arrhythmias Troponin - raised ECG - ST elevation, T wave inversion Management - treatment of underlying cause - supportive treatment complications - heart failure - arrhythmia - dilated cardiomyopathy

Answer 201

features - back pain - neuropathic pain - sitting is better than standing - symptoms mimic claudication > patients find it easier to walk uphill than downhill diagnosis - MRI treatment - laminectomy

Answer 202

1. Blood eosinophils or FeNO (>=50 ppb is positive) 2. Bronchodilator reversibility with spirometry >> FEV1/FVC < 0.7 >> Reversibility of >=200ml or 12% or more 3. Peak expiratory flow variability is 20% or more 4. Bronchial challenge test: bronchial hyperresponsiveness occupational asthma: serial peak flow measurements at work and at home > most common cause is isocyanates

Answer 203

myeloproliferative disorder caused by hyperplasia of abnormal megakaryocytes haematopoiesis develops in the liver and spleen features - elderly person presenting with anaemia or fatigue - massive splenomegaly - hypermetabolic symptoms: weight loss, night sweats lab findings - anaemia - high WBC and platelet count - tear drop poikilocytes on blood film - unobtainable bone marrow biopsy - dry tap - so trephine biopsy needed - high urate and LDH due to increased cell turnover

Answer 204

fine layer of soft unpigmented hair that covers the body aside from palmar and plantar surfaces caused by malnutrition can be found in newborn babies, chronic malnutrition or anorexia nervosa

Answer 205

signs and symptoms caused by a tumour arising from neuroendocrine cells releasing serotonin, bradykinin and histamine features - flushing - diarrhoea - wheeze due to bronchospasm - hypotension - right heart valvular stenosis: tricuspid insufficiency, pulmonary stenosis - Cushing's syndrome if ACTH is secreted - pellagra rarely investigation - urinary 5-hydroxyindoleacetic acid (5-HIAA) > collected as 24h urine sample in bottle with acid to maintain pH <3 - niacin (vitamin B3) deficiency - plasma chromogranin A test management - somatostatin analogues e.g. octreotide - diarrhoea: cyproheptadine

Answer 206

6-12h: symptoms like tremor, sweating, tachycardia, anxiety 36h: seizures 48-72h: delirium tremens, confusion, hallucinations management - long-acting benzodiazepines e.g. chlordiazepoxide, diazepam (lorazepam in hepatic failure) - carbamazepine also effective - IV Pabrinex

Answer 207

X-linked dominant trinucleotide repeat disorder - learning difficulties - large low set ears, long thin face, high arched palate - mitral valve prolapse - pes planus - autism - memory problems - speech disorders - macroorchidism - hypotonia features in females range from normal to mild diagnosis - antenatally by chorionic villus sampling or amniocentesis - analysis of the number of CGG repeats using restriction endonuclease digestion and Southern blot sampling

Answer 208

characteristics - hyperuricaemia - hyperkalaemia - hyperphosphataemia - hypocalcaemia - increased serum creatinine - seizure - cardiac arrhythmia or sudden death can occur within 3 days before or 7 days after chemotherapy complications management - give IV fluids, allopurinol or rasburicase prior to chemotherapy to reduce the risk of developing tumour lysis syndrome

Answer 209

all patients must not drive and must inform the DVLA - first unprovoked / isolated seizure: 6 months off if no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG > if these conditions are not met it is increased to 12 months - established epilepsy or those with multiple unprovoked seizures > may qualify for driving licence if free from seizures for 12 months

Answer 210

large vessel vasculitis typically causing occlusion of the aorta leading to absent limb pulses features - systemic features e.g. malaise, headache - unequal blood pressure in upper limbs - carotid bruit and tenderness - aortic regurgitation - intermittent upper and lower limb claudication - absent or weak peripheral pulses - young females, Asian people associations - renal artery stenosis investigations - magnetic resonance angiography or CT angiography management: steroids

Answer 211

features - venous and arterial thrombosis - recurrent foetal loss - thrombocytopaenia - livedo reticularis - pre-eclampsia - pulmonary hypertension can occur as a primary disorder or secondary to SLE , lymphoproliferative disorders, phenothiazines lab investigations - paradoxical rise in APTT - low platelets - antibodies > anticardiolipin antibodies > anti-beta2 glycoprotein I antibodies > lupus anticoagulant - thrombocytopaenia management - primary thromboprophylaxis with low-dose aspirin - secondary thromboprophylaxis > lifelong warfarin with target INR 2-3

Answer 212

hyponatraemia

Answer 213

- immunosuppression > miliary TB, AIDS, steroid therapy - sarcoidosis - lymphoma - extremes of age - fever - hypoalbuminaemia, anaemia

Answer 214

HBsAg - acute or chronic disease Anti-HbS - immunity (exposure or immunisation) > negative in chronic disease Anti-HbC - previous or current infection > negative in immunisation HbeAg - marker of replication and infectivity microscopy: chronic hepatitis B infection leads to ground glass hepatocytes

Answer 215

typically presents in the elderly with T2DM Precipitating factors: intercurrent illness, dementia, sedative drugs clinical features - insidious onset - clinical signs of dehydration - polyuria, polydipsia - lethargy - nausea and vomiting - altered level of consciousness, focal neurological deficits - haematological: hyperviscosity > can result in MI, stroke, peripheral arterial thrombosis diagnostic criteria - hypovolaemia - marked hyperglycaemia (>30 mmol/L) - significantly raised serum osmolarity (>320 mosmol/kg) > calculated by 2* Na + glucose + urea - no significant hyperketonaemia (<3 mmol/L) - no significant acidosis (HCO3 >15, pH >7.3) management - IV 0.9% NaCl given at 0.5-1L/h - monitor potassium - insulin if necessary - VTE prophylaxis

Answer 216

intravascular causes - mismatched blood transfusion - G6PD deficiency - red cell fragmentation: heart valves, TTP, DIC, HUS - paroxysmal nocturnal haemoglobinuria - cold autoimmune haemolytic anaemia extravascular causes - haemoglobinopathies: sickle cell, thalassaemia - hereditary spherocytosis - haemolytic disease of the newborn - warm autoimmune haemolytic anaemia lab - low haptoglobin (binds to free haemoglobin)

Answer 217

allopurinol

Answer 218

group of disorders characterised by dysfunctional blood cell production in the bone marrow risk of progression to acute myeloid leukaemia > associated with Auer rods causes pancytopaenia risk factors - previous radiation and chemotherapy features - fatigue - shortness of breath - weakness - pallor - splenomegaly - easy bruising/bleeding - petechiae treatment - supportive care e.g. blood transfusions, growth factors - disease modifying therapy e.g. hypomethylating agents, lenalidomide - immunosuppressive therapy - haematopoietic stem cell transplant

Answer 219

- check airway and apply oxygen - place patient in recovery position - if seizure is prolonged give benzodiazepines adult: 10-20mg (max 30mg) > rectal diazepam after 5 minutes > repeated once after 10-15 mins if necessary midazolam oromucosal solution may also be used > adult 10mg

Answer 220

aspirin + LMWH

Answer 221

most common genetic bleeding disorder (AD) features - mucocutaneous bleeding after mild injury e.g. nose bleeds, bruising - menorrhagia in women - haemarthroses and muscle haematomas are rare Lab features - prolonged bleeding time - normal platelet count - prolonged APTT management - tranexamic acid for mild bleeding - desmopressin - factor VIII concentrate

Answer 222

intracellular protozoa most commonly Cryptosporidium parvum or Cryptosporidium hominis most common cause of diarrhoea in patients with HIV features - watery diarrhoea - abdominal cramps - fever - if severe immunocompromise: sclerosing cholangitis, pancreatitis modified Ziehl-Neelsen stain of stool may reveal the characteristic red cysts of cryptosporidium management - supportive therapy if immunocompetent - immunocompromised patients: nitazoxanide or rifaximin

Answer 223

secondary hyperaldosteronism - renin levels are high > higher than in primary hyperaldosteronism - aldosterone levels are high > mostly due to atherosclerosis but can be due to fibromuscular dysplasia features > often presents in younger patients with refractory hypertension > flash pulmonary oedema > ACE inhibitors can worsen stenosis resulting in drop in eGFR

Answer 224

causes - idiopathic - iatrogenic e.g. traumatic placement of indwelling urinary catheters - sexually transmitted infections e.g. gonorrhoea - penile fractures - hypospadias - lichen sclerosus features - decreased urinary stream - incomplete bladder emptying - spraying of urine stream, dysuria investigations - uroflowmetry - ultrasound postvoid residual measurement management - dilation - endoscopic urethrotomy

Answer 225

FEV1 >80%: stage 1 - mild FEV1 50-79%: stage 2 - moderate FEV1 30-49%: stage 3 - severe FEV1 <30%: stage 4 - very severe

Answer 226

AD disorder caused by mutation in LDL receptor gene Clinical diagnosis are based on the Simon Broome criteria: - adults total cholesterol (TC) > 7.5 mmol/l and LDL-C > 4.9 mmol/l - children TC > 6.7 mmol/l and LDL-C > 4.0 mmol/l, plus: - tendon xanthoma or DNA-based evidence of FH - family history of myocardial infarction below age 50 years Management - high-dose statins - first-line - screening for first-degree relatives

Answer 227

features - vomiting - agitation - dilated pupils - tachycardia - hyperglycaemia - hypokalaemia management - measure acute levels - activated charcoal - supportive management > antiemetics > IV fluids > correct hypokalaemia > benzodiazepines for seizures > IV beta-blockers for SVTs definitive treatment - haemodialysis

Answer 228

lab features of alcoholic liver disease - elevated gamma GT - ratio of AST:ALT is normally >2, a ratio of >3 is strongly suggestive of acute alcoholic hepatitis management - glucocorticoids e.g. prednisolone during acute episodes - pentoxyphylline can be used

Answer 229

should not fly if flight is >2h duration until 48h after cast applied unless bivalved

Answer 230

aka onychomycosis causative organisms - dermatophytes: 90% of cases > mainly Trichophyton rubrum - yeasts: 5-10% of cases > e.g. Candida - non-dermatophyte moulds features - unsightly nails - thickened, rough, opaque nails investigations - nail clippings / scrapings management - do not need to treat if asymptomatic / unbothered by appearance - if dermatophyte or candida infection > limited involvement (<50% nail affected, <=2 nails): topical treatment with amorolfine 5% nail lacquer, 9-12 months > more extensive involvement due to dermatophyte (Trichophytion rubrum) infection: oral terbinafine 3-6 months > more extensive involvement due to Candida infection: oral itraconazole

Answer 231

Primary - tuberculosis - metastases - meningococcal septicaemia (Waterhouse-Friedrichsen syndrome) - HIV - antiphospholipid syndrome Secondary - pituitary disorders e.g. tumours, irradiation, infiltrationa exogenous glucocorticoid therapy

Answer 232

if suspecting a hypovolaemic cause > 0.9% NaCl > if serum sodium rises this supports hypovolaemic hyponatraemia > if serum sodium falls an alternative diagnosis such as SIADH is more likely euvolaemic cause > fluid restrict to 500-1000ml / day > consider medications > demeclocycline > vaptans hypervolaemic cause > fluid restrict 500-1000ml/day > consider loop diuretics acute hyponatraemia (<120 mmol/L) with severe symptoms > hypertonic 3% saline may be used

Answer 233

- posterior triangle lymph node biopsy: accessory nerve - Lloyd Davies stirrups; common peroneal nerve - thyroidectomy: laryngeal nerve - anterior resection of the rectum: hypogastric autonomic nerves - axillary node clearance: long thoracic nerve, thoracodorsal nerve, intercostobrachial nerve - inguinal hernia surgery; ilioinguinal nerve - varicose vein surgery: sural and saphenous nerves - posterior approach to the hip: sciatic nerve - carotid endarterectomy: hypoglossal nerve

Answer 234

venous ulcers - oedema - brown pigmentation - lipodermatosclerosis - eczema - location above the ankle - painless - management: 4 layer compression banding after exclusion of arterial disease or surgery arterial ulcers - occur on the toes and heel - typically have a deep, punched out appearance - painful - there may be areas of gangrene - cold with no palpable pulses - low ABPI measurements

Answer 235

caused by Toxoplasma gondii, an obligate intracellular protozoan animal reservoir: cats, rats immunocompetent patients - asymptomatic self-limiting infection - symptomatic: clinical features mimic infectious mononucleosis - rare: meningoencephalitis, myocarditis investigations: serology HIV/immunocompromised - cerebral toxoplasmosis in 50% > constitutional symptoms, drowsiness, headache - chorioretinitis - CT: single or multiple ring-enhancing lesions, mass effect may be seen > thallium SPECT negative management: pyrimethamine plus sulphadiazine for at least 6 weeks (if immunosuppressed, immunocompetent individuals require no treatment)

Answer 236

thrombocytopaenia

Answer 237

AD disorder presenting as hypermetabolic crisis with > increased end-tidal CO2 > tachycardia > muscle rigidity > rhabdomyolysis > hyperthermia > arrhythmia commonly associated with volatile inhalational anaesthetic agents e.g. sevoflurane and the muscle relaxant succinylcholine (suxamethonium) > suxamethonium can cause hyperkalaemia > suxamethonium can also increase IOP, contraindicated in penetrating eye injury / acute glaucoma management - IV dantrolene

Answer 238

Untreated thyrotoxicosis increases the risk of fetal loss, maternal heart failure and premature labour Graves' disease is the most common cause of thyrotoxicosis in pregnancy > activation of TSH receptor by HCG may occur - transient gestational hyperthyroidism > HCG levels will fall in the second and third trimester Management > propylthiouracil 1st trimester > carbimazole for remainder of pregnancy Hypothyroidism > maternal free thyroxine levels should be kept in the upper third of the normal reference range to avoid fetal hypothyroidism > women require an increased dose of thyroxine during pregnancy by up to 50% as early as 4-6 weeks of pregnancy

Answer 239

rare AD condition caused by a defect in porphobilinogen deaminase, (enzyme involved in biosynthesis of haem), usually presents in 20-40 year olds > results in toxic accumulation of delta aminolaevulinic acid and porphobilinogen features > abdominal symptoms >> abdominal pain, vomiting > neuropsychiatric symptoms >> depression > neurological: motor neuropathy > hypertension, tachycardia Diagnosis > urine turns deep red on standing > raised urinary porphobilinogen (elevated between attacks and to a greater extent during acute attacks) > assay of red cells for porphobilinogen deaminase > raised serum levels of delta aminolaevulinic acid and porphobilinogen Management > avoiding triggers > acute attacks >> IV haematin/haem arginate >> IV glucose should be used if haematin/haem arginate is not immediately available

Answer 240

Scabies is caused by the mite Sarcoptes scabiei and is spread by prolonged skin contact > affects children and young adults Features > widespread intense pruritus worsening at night > linear silver burrows on the side of fingers, interdigital webs and flexor aspects of the wrist > in infants, the face and scalp may also be affected Management > permethrin 5% is first-line > malathion 0.5% is second-line pruritus persists for up to 4-6 weeks post eradication Patient guidance > avoid close physical contact with others until treatment is complete > all household and close physical contacts should be treated at the same time, even if asymptomatic > launder, iron or tumble dry clothing, bedding, towels, etc., on the first day of treatment to kill off mites. > patient treated twice, applications one week apart Crusted (Norwegian) scabies > immunocompromise e.g. HIV > management with ivermectin and isolation

Answer 241

myeloproliferative disorder caused by clonal proliferation of a marrow stem cell leading to an increase in red cell volume, overproduction of neutrophils and platelets peak incidence in the sixth decade features > hyperviscosity > pruritus (particularly after warm bath) > splenomegaly > positive JAK2 mutation > gout > ruddy complexion > peptic ulcer disease Management - aspirin first-line: reduces the risk of thrombotic events - venesection - chemotherapy - hydroxyurea - slight increased risk of secondary leukaemia - phosphorus-32 therapy 5-15% progress to myelofibrosis or AML

Answer 242

may occur in females or males with thrombophilic tendencies Risk factors - dehydration - malignancy - oral contraceptive pill (OCP) - thrombocytosis - congenital coagulopathies: antiphospholipid syndrome, factor V Leiden deficiency, protein C and S deficiency and antithrombin III deficiency features - sudden severe headache radiating across top of head investigations - Fundoscopy: papilloedema - CT head with contrast - positive delta sign

Answer 243

largely caused by obesity spectrum of disease ranging from - steatosis - steatohepatitis - fibrosis and liver cirrhosis features - usually asymptomatic - hepatomegaly - ALT > AST - increased echogenicity on ultrasound investigations - enhanced liver fibrosis (ELF) test to check for advanced fibrosis > hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1 - calculate FIB4 score or NAFLD fibrosis score - liver biopsy to stage disease management - weight loss - monitoring - ? gastric banding and insulin-sensitising drugs e.g. metformin

Answer 244

AD type I collagen disorder characterised by - multiple fractures in childhood - dental caries - deafness (otosclerosis) - blue sclera investigations - adjusted calcium, phosphate, PTH and ALP - normal

Answer 245

aka chronic mesenteric ischaemia characteristics - triad of severe colicky post-prandial abdominal pain, weight loss and abdominal bruit most common cause is atherosclerotic disease in arteries supplying GI tract

Answer 246

AR disorder which causes renal tubular disease characterised by hypokalaemia, hypochloraemia renal stones and metabolic alkalosis are commonly seen in this condition

Answer 247

- domperidone: dopamine receptor antagonist - ondansetron: 5HT3 antagonist > first-line for chemotherapy induced nausea and vomiting - prochlorperazine: phenothiazine - metoclopramide: dopamine receptor antagonist

Answer 248

norepinephrine and dopamine reuptake inhibitor, nicotinic antagonist

Answer 249

typically caused by gram negative bacteria entering prostate via urethra risk factors - recent UTI - urogenital instrumentation - intermittent bladder catheterisation - recent prostate biopsy features - pain may be referred to perineum, penis, rectum or back - obstructive voiding symptoms - fever and rigors - digital rectal examination: tender, boggy prostate gland management - 14 day course of quinolone - consider STI screening

Answer 250

keloid scars are tumour-like lesions that arise from the connective tissue of a scar and extend beyond the dimensions of the original wound most common in black men treatment - intra-lesional steroids e.g. triamcinolone in early stages - excision

Answer 251

pH <7.3 more than 24h after ingestion

Answer 252

negative sputum culture, normal CXR positive interferon gamma release assay, positive mantoux test cannot pass the disease onto others treatment - 3 months of isoniazid (with pyridoxine) and rifampicin - 6 months of isoniazid (with pyridoxine)

Answer 253

uncertain tetanus vaccination history > booster vaccine + immunoglobulin, unless wound is very minor and <6h old, in which case just booster patient has had a full course (5 doses) of tetanus vaccines with the last dose <10 years ago > no intervention needed patient has had a full course of tetanus vaccines with the last dose >10 years ago > tetanus prone wound: booster > high risk wound: booster + tetanus immunoglobulin

Answer 254

ECG changes > sinus tachycardia > QRS widening > prolongation of PR and QTc intervals features - similar to aspirin overdose - hypotension - metabolic acidosis - hypoglycaemia - tinnitus - flushing - visual disturbances (delayed blindness) - flash pulmonary oedema may occur check salicylate levels to exclude aspirin overdose management - supportive: fluids, inotropes, bicarbonate

Answer 255

aka glandular fever causes - EBV, aka human herpesvirus 4 (90%) - cytomegalovirus - HHV-6 clinical features - sore throat, lymphadenopathy, pyrexia - palatal petechiae - splenomegaly (avoid contact sports for 4 weeks after) - hepatitis - maculopapular pruritic rash in patients who take ampicillin/amoxicillin during illness transmission - salivary exchange e.g. kissing investigations > FBC - lymphocytosis with at least 10% atypical activated lymphocytes - haemolytic anaemia secondary to cold agglutinins (IgM) - thrombocytopaenia > Heterophile antibody test (Monospot test) management - supportive > symptoms resolve after 2-4 weeks complications - post-viral chronic fatigue syndrome - splenic rupture (especially if contact sports) - Guillain-Barre syndrome - meningitis / encephalitis - severe upper airway obstruction

Answer 256

if DVT is likely (2 points or more): arrange proximal leg vein ultrasound scan within 4h > positive scan: start treatment with DOAC or LMWH if eGFR<15 > negative scan: D dimer test if DVT is unlikely (1 point or less): perform D dimer test > positive D dimer: arrange proximal leg vein ultrasound >> negative proximal leg vein ultrasound scan and positive D dimer: stop anticoagulation and repeat scan in 1 week > negative D dimer and negative proximal leg vein ultrasound scan: consider alternative diagnosis

Answer 257

- dabigatran: idarucizumab - apixaban / rivaroxaban: andexanet alfa - warfarin: vitamin K (phytomenadione)

Answer 258

most common cause of AKI 2 main causes - ischaemia > shock > sepsis - nephrotoxins > aminoglycosides > myoglobin secondary to rhabdomyolysis > radiocontrast agents > lead features > raised urea, creatinine, potassium > Granular muddy brown casts in urine

Answer 259

pancreatic lipase inhibitor

Answer 260

high output cardiac failure atrial fibrillation

Answer 261

age, gender, ethnicity

Answer 262

patients at risk of pressure sores

Answer 263

entamoeba histolytica (amoeboid protozoan) may cause - dysentery: profuse, bloody diarrhoea - liver abscesses: anchovy sauce appearance - colonic abscesses - inflammatory masses in colon long incubation period stool microscopy - trophozoites treatment - oral metronidazole - a luminal agent e.g. diloxanide furoate

Answer 264

Wallace's Rule of Nine: Each of the following is 9% of the body when calculating surface area % if a burn: Head + neck each arm each anterior part of leg each posterior part of leg anterior chest posterior chest anterior abdomen posterior abdomen

Answer 265

features > chronic constipation and straining > passing small amounts of blood > examination: indurated area proximal to anal verge investigations - biopsy - exclude malignancy - endoscopy - defecating proctogram - ano-rectal manometry studies

Answer 266

classes - painful or vaso-occlusive crises - acute chest syndrome > dyspnoea, chest pain, cough, hypoxia and new pulmonary infiltrates on chest x-ray - anaemic: aplastic or sequestration - infection management: - painful crisis: IV fluids + oxygen + opiates > consider antibiotics if evidence of infection > hydroxyurea as prophylaxis due to increase in HbF levels acute chest syndrome: > IV fluids + oxygen + opiates + antibiotics + transfusion - aplastic crisis: infection with parvovirus > blood transfusion if Hb is low > exchange transfusion if: acute chest syndrome, stroke, multiorgan failure, splenic sequestration crisis

Answer 267

idiopathic thrombocytopaenic purpura (ITP) - Isolated thrombocytopaenia in a relatively well person Thrombotoic thrombocytopaenic purpura (TTP) - Thrombocytopaenia in a very unwell person Haemolytic uraemic syndrome (HUS) - Thrombocytopaenia, schistocytes, renal failure, post-dysentery Henoch Schonlein Purpura (HSP) - Abdo pain, joint pain, haematuria, purpura. Kids. Haemorrhagic Haemolytic Telangiectasis (HHT) - Epistaxis, GI bleeds, telangiectasia.

Answer 268

agents which slow peristalsis e.g. opioids, loperamide > can predispose to toxic megacolon by slowing clearance of C diff toxin

Answer 269

Vitamin C (ascorbic acid) - citrus fruits - tomatoes - potatoes - Brussel sprouts - cauliflower, broccoli, cabbage and spinach associated with severe malnutrition as well as drug and alcohol abuse, and those living in poverty with limited access to fruits and vegetables. features - Follicular hyperkeratosis and perifollicular haemorrhage - Ecchymosis, easy bruising - Poor wound healing - Gingivitis with bleeding and receding gums - Sjogren's syndrome - Arthralgia - Oedema - weakness, malaise, anorexia and depression

Answer 270

gram positive anaerobic bacillus produces botulinum toxin, a neurotoxin which irreversibly blocks the release of acetylcholine neurotoxin often affects bulbar muscles and autonomic nervous system features - patient usually fully conscious with no sensory disturbance - descending flaccid paralysis - diplopia - ataxia - bulbar palsy risk factor: IVDU, home canning Treatment - botulism antitoxin and supportive care - antitoxin is only effective if given early - once toxin has bound its actions cannot be reversed

Answer 271

Direct Coombs test

Answer 272

patients without ACS: Hb 70 g/L patients with ACS: Hb 80 g/L

Answer 273

- amoxicillin: rash with infectious mononucleosis - co-amoxiclav: cholestasis - flucloxacillin: cholestasis (several weeks after use) - erythromycin: GI upset, QTc prolongation - ciprofloxacin: lower seizure threshold, tendonitis - metronidazole: reaction following alcohol ingestion - doxycycline: photosensitivity - trimethoprim: rashes (photosensitivity), pruritus, suppression of haemotopoiesis

Answer 274

features - macrocytic anaemia - reticulocytosis - low haptoglobin - raised LDH and bilirubin - positive direct antiglobulin test (Coombs' test) - spherocytes 2 types > warm AIHA - most common, IgG mediated - causes: > idiopathic > autoimmune e.g. SLE > neoplasia: lymphoma, CLL > drugs e.g. methyldopa - management: treat underlying disorder, steroids +/- rituximab > cold AIHA - IgM mediated, worse in cold - symptoms of Raynaud's and acrocyanosis - causes: > neoplasia e.g. lymphoma > infections e.g. mycoplasma, EBV - treat underlying cause, respond less well to steroids

Answer 275

check BM before driving and every 2 hours whilst driving regardless of whether they have eaten or not

Answer 276

haemodynamically unstable - immediate vascular review with a view to emergency surgical repair - palliative if patient is frail with multiple comorbidities haemodynamically stable - CT angiogram - assess suitability of repair

Answer 277

- send a blood test for varicella antibodies - give varicella zoster immunoglobulin immediately (antibody testing should not delay post-exposure prophylaxis past 7 days after initial contact)

Answer 278

features - confusion - bradycardia - hypothermia - profoundly hypothyroid Management - IV thyroid replacement (T3 + T4) - IV hydrocortisone (until coexisting adrenal insufficiency has been excluded) - IV fluids - Electrolyte imbalance correction - Sometimes rewarming

Answer 279

Cause of atypical pneumonia classically spread by air conditioning systems clinical features > dry cough > fever > relative bradycardia > confusion > lymphopaenia > deranged LFTs > hyponatraemia > pleural effusion > bilateral mid-lower zone consolidation investigations > urinary Legionella antigen treatment - clarithromycin

Answer 280

- midline > structures divided: linea alba, transversalis fascia, extraperitoneal fat, peritoneum - paramedian > parallel to midline > structures divided: anterior rectus sheath, rectus (retracted), posterior rectus sheath, transversalis fascia, extraperitoneal fat, peritoneum - Gable (rooftop): good access to upper abdomen e.g. pancreatectomy - battle > similar location to paramedian but rectus displaced medially (seldom used) - Kocher's > incision under right subcostal margin: open cholecystectomy - Lanz > incision in RIF: appendicectomy - Gridiron > oblique incision over McBurney's point (appendicectomy) but less cosmetically acceptable than Lanz - Pfannenstiel's: transverse suprapubic, C-section - McEvedy's: groin incision e.g. emergency repair strangulated femoral hernia - Rutherford Morrison: extraperitoneal approach to left or right lower quadrants: renal transplantation

Answer 281

presents with similar features to DKA but BM might be normal or low

Answer 282

assess airway and consider early intubation if deep burns to face or neck, blisters/oedema of oropharynx, stridor conservative management - superficial burns and mixed superficial burns that will heal in 2 weeks - complex burns: excision and skin grafting IV fluids if >15% burn area > Parkland formula says volume of fluid = TBSA % x weight (kg) x 4 > half of the fluid is administered within first 8h no evidence for antimicrobial prophylaxis or topical antibiotics transfer burns involving hand, perineum and face to burns unit escharotomies - indicated in circumferential full thickness burns to torso or limbs - can improve ventilation or relieve compartment syndrome/oedema

Answer 283

pelvic fractures may cause laceration of the urethra features - urinary retention - blood at urethral meatus - high riding prostate on DRE

Answer 284

triad of jaundice, encephalopathy and coagulopathy most accurate marker for assessing liver function acutely - prothrombin time

Answer 285

AD condition MEN I - 3 Ps > parathyroid (hyperparathyroidism) > pituitary e.g. prolactinoma > pancreas e.g. insulinoma, gastrinoma also adrenal and thyroid, MEN1 gene MEN IIa - 2 Ps: hyperparathyroidism, phaeochromocytoma - medullary thyroid cancer > originates from parafollicular cells, produces calcitonin - RET oncogene MEN IIb - medullary thyroid cancer - 1 P: phaeochromocytoma - marfanoid body habitus - neuromas - RET oncogene

Answer 286

condition seen in women 20-45 topical and inhaled steroids are involved in the development of this condition features - clustered erythematous papules, papulovesicles and papulopustules - most commonly in perioral region but also perinasal and periocular region management - steroids may worsen symptoms - treat with topical or oral antibiotics e.g. doxycycline

Answer 287

features - headache - nausea and vomiting - vertigo - confusion - subjective weakness - severe toxicity: pink mucosa and skin, hyperpyrexia, arrhythmias, extrapyramidal features, coma, death investigations - pulse oximetry not reliable - do VBG or ABG Management - 100% O2 via non-rebreather mask - hyperbaric oxygen in severe cases e.g. CO >25%

Answer 288

aim for reduction of 25-50% in ICS dose keep LABA the same

Answer 289

SAAG >11 indicates portal hypertension - liver disorders are the most common cause e.g. cirrhosis, acute liver failure management: - paracentesis if tense ascites - reduce dietary sodium - aldosterone antagonist e.g. spironolactone - prophylactic antibiotics against SBP: ciprofloxacin, norfloxacin - TIPS in some patients - cardiac causes: right heart failure, constrictive pericarditis - other causes: budd chiari syndrome, myxoedema SAAG <11 - hypoalbuminaemia e.g. nephrotic syndrome, severe malnutrition - malignancy e.g. peritoneal carcinomatosis - other causes e.g. pancreatitis, bowel obstruction, biliary ascites

Answer 290

benign ethnic neutropaenia

Answer 291

cranial DI > urine osmolality after fluid deprivation: low > urine osmolality after desmopressin: high healthy individual / primary polydipsia > urine osmolality after fluid deprivation: high > urine osmolality after fluid deprivation: high nephrogenic DI > urine osmolality after fluid deprivation: low > urine osmolality after desmopressin: low

Answer 292

central line as it is strongly phlebitic

Answer 293

sudden and transient episode of muscle weakness > can result in fall/collapse triggers > strong emotions e.g. laughter, anger, surprise often associated with narcolepsy (excessive daytime sleepiness and fragmented nighttime sleep)

Answer 294

intensely pruritic chronic autoimmune skin condition caused by formation of IgA antibodies features - papules and vesicles - affects extensor surfaces such as elbows, knees and buttocks associated with gluten sensitivity and coeliac disease

Answer 295

potassium-sparing diuretics may interact with K+ supplemented or ACEi to cause dangerous hyperkalaemia

Answer 296

aka histiocytoma fibrous solitary slow-growing papules caused by abnormal growth of dermal dendritic histiocyte cells features - raised - brown in colour - may be itchy - rarely painful - dimple sign: applying lateral pressure produces central depression can occur anywhere but most commonly arms and legs often precipitated by injury such as insect bite or thorn prick

Answer 297

- oral hairy leukoplakia > white patches on lateral borders of tongue > painless / mild discomfort > cannot be removed with light pressure - Burkitt's lymphoma - Hodgkin's lymphoma - nasopharyngeal carcinoma - HIV-associated CNS lymphomas

Answer 298

aka giant cell arteritis inflammatory disease of large blood vessels commonly in patients >50 with symptoms such as - temporal headache - scalp tenderness - jaw claudication - lethargy - visual disturbances e.g. sudden visual loss fundoscopy - optic disc appears pale and oedematous due to anterior optic ischaemic neuropathy > secondary to inflammation of posterior ciliary arteries

Answer 299

chlorthalidone > thiazide-like diuretic which increases tubular calcium reabsorption, lowering its concentration in the urine

Answer 300

- anaemia: iron, folate or B12 deficiency > mixed anaemia may lead to normocytic anaemia: low/normal ferritin, wide distribution of red blood cell volume - hyposplenism - osteoporosis, osteomalacia - lactose intolerance - enteropathy-associated T cell lymphoma of small intestine - subfertility - rare: oesophageal cancer, other malignancies

Answer 301

hyoscine is most effective cyclizine is second most effective promethazine is third most effective

Answer 302

rare small vessel vasculitis associated with - pulmonary haemorrhage - rapidly progressive glomerulonephritis > rapid onset AKI >nephritis: proteinuria + haematuria caused by anti-GBM antibodies against type IV collagen associated with HLA DR2 investigations: > renal biopsy: linear IgG deposits along basement membrane > raised TLCO secondary to pulmonary haemorrhage Management - plasma exchange: plasmapheresis - steroids - cyclophosphamide

Answer 303

features - extremely high PTH - moderately raised calcium occurs almost exclusively in patients with CKD ongoing hyperplasia of parathyroid glands leads to excess PTH causing > accelerated bone breakdown > bone pain > fractures > kidney stones

Answer 304

conservative - small subcapsular haematoma - minimal intra-abdominal blood - no hilar distribution laparotomy with conservation - increased amounts of intra-abdominal blood - moderate haemodynamic compromise - tears/lacerations affecting <50% resection - hilar injuries - major haemorrhage - major associated injuries

Answer 305

cryptococcus neoformans - encapsulated yeast usually in the lungs but can cause fungal meningitis/encephalitis in immunocompromised patients staining - India ink

Answer 306

- propofol > GABA receptor agonist > mild antiemetic properties > rapid onset of anaesthesia > pain on IV injection > moderate myocardial depression - sodium thiopentone > extremely rapid onset of action for RSI > marked myocardial depression > unsuitable for maintenance infusion > few analgesic effects - ketamine > NMDA receptor antagonist > moderate to strong analgesic properties > produces little myocardial depression > can lead to dissociate anaesthesia and induce nightmares - etomidate > favourable cardiac safety profile > no analgesic properties > can lead to adrenal suppression so not suitable for prolonged use > can cause post-op vomiting - halothane: hepatotoxic

Answer 307

features - back pain > earliest and most common symptom > may be worse on lying down and coughing/straining - lower limb weakness - sensory changes: sensory loss and numbness - neurological signs depend on level of lesion investigation - urgent MRI whole spine management - high-dose oral dexamethasone - urgent oncological assessment for consideration of radiotherapy or surgery

Answer 308

infection of IVD space features - back pain - pyrexia, rigors - changing lower limb neurology causes - bacterial: most commonly staph aureus - viral - TB - aseptic diagnosis - MRI - CT-guided biopsy complications - sepsis - epidural abscess management - 6-8 weeks of IV Abx - assess for endocarditis with echocardiogram

Answer 309

aspirin is a common cause first-line: non-sedating oral antihistamine - loratadine - cetirizine sedating antihistamine e.g. chlorphenamine for nighttime use severe urticaria (>24h) > short course of oral prednisolone + oral loratadine

Answer 310

common skin infection caused by molluscum contagiosum virus (MCV), a DNA poxvirus. features - pinkish or pearly white papules with a central umbilication - lesions appear in clusters in areas anywhere on the body (except the palms and soles) - children: lesions on trunk and in flexures; anogenital lesions may also occur - adults: sexual contact may lead to lesions developing on the genitalia, pubis, thighs, and lower abdomen. Treatment - not usually recommended, self-resolves - If lesions are troublesome: simple trauma or cryotherapy treatment may be required if > problematic itching: emollient and mild topical corticosteroid (e.g. hydrocortisone 1%) > infections: topical antibiotic (e.g. fusidic acid 2%) Referral: > HIV-positive with extensive lesions > eyelid-margin or ocular lesions and associated red eye > Adults with anogenital lesions

Answer 311

chest physiotherapy and deep breathing exercises

Answer 312

Treponemal tests > T. pallidum enzyme immunoassay (TP-EIA) test - acute IgM antibody to syphilis > may be negative in reinfection > T-pallidum particle agglutination (TPPA) test (treponemal test) > often remains positive in patients who have been previously infected Non-treponemal tests: The rapid plasma reagin (RPR) test OR venereal disease research laboratory (VDRL) > useful to monitor disease activity and reinfection > A rise by 4-fold or more in a previously infected patient either indicates no treatment response or reinfection > false positives: SLE, TB, malaria, HIV, pregnancy, leprosy test results - positive non-treponemal + positive treponemal = active syphilis infection - positive non-treponemal test + negative treponemal test = false positive syphilis result - negative non-treponemal test + positive treponemal test: successfully treated syphilis

Answer 313

IV lipid emulsion

Answer 314

loop diuretics

Answer 315

staphylococcus epidermis (CoNS)

Answer 316

acute transient compromise in blood flow to large bowel can lead to inflammation, ulceration and haemorrhage most commonly in splenic flexure investigations > thumbprinting on AXR due to mucosal oedema / haemorrhage management - supportive - surgery if generalised peritonitis, perforation or ongoing haemorrhage

Answer 317

implant rupture

Answer 318

alpha haemolytic streptococci - streptococcus pneumoniae: pneumonia, meningitis, otitis media - streptococcus viridans beta haemolytic streptococci - only groups A, B & D are important in humans - group A > Streptococcus pyogenes: erysipelas, cellulitis, impetigo, type 2 necrotising fasciitis, pharyngitis / tonsillitis > immunological reactions can cause rheumatic fever or post-strep glomerulonephritis > erythrogenic toxins cause scarlet fever - group B > streptococcus agalactiae: neonatal meningitis, septicaemia - group D > enterococcus

Answer 319

oral codeine to oral morphine: divide by 10 oral tramadol to oral morphine: divide by 10 oral morphine to oral oxycodone: divide by 2 oral morphine to oral diamorphine: divide by 3 oral morphine to SC morphine: divide by 2 oral morphine to SC diamorphine: divide by 2 oral oxycodone to SC diamorphine: divide by 1.5

Answer 320

aka buerger's disease small and medium vessel vasculitis strongly associated with smoking characterised by raynaud's phenomenon with extremity ischaemia > intermittent claudication > ischaemic ulcers also superficial thrombophlebitis

Answer 321

benign epithelial tumour features - said to look like a volcano or crater - initially a smooth dome-shaped papule - rapidly grows to become a crater centrally-filled with keratin spontaneous regression within 3 months is common, often resulting in a scar however, lesions should be removed urgently > difficult to exclude SCC > can prevent scarring

Answer 322

alkylating agents - cyclophosphamide: haemorrhagic cystitis, myelosuppression, transitional cell carcinoma cytotoxic antibiotics - bleomycin: lung fibrosis anthracyclines e.g. doxorubicin: cardiomyopathy antimetabolites - methotrexate: myelosuppression, mucositis, liver fibrosis, lung fibrosis - fluorouracil: myelosuppression, mucositis, dermatitis - cytarabine: myelosuppression, ataxia act on microtubules - vincristine, vinblastine: peripheral neuropathy, paralytic ileus, myelosuppression - docetaxel: neutropaenia cisplatin: ototoxicity, peripheral neuropathy, hypomagnesaemia

Answer 323

- headaches - amenorrhoea - visual field defects (bitemporal hemianopia)

Answer 324

caused by yellow fever virus, a member of Flaviviridae group, transmitted by Aedes mosquito clinical features - flu-like illness followed by brief remission > high fever, malaise, nausea, myalgia, headache, bradycardia - some patients recover completely - some patients progress > hepatitis with jaundice > haematemesis > fever > nausea and vomiting > AKI with oliguria > haemorrhage Councilman bodies may be seen in hepatocytes

Answer 325

IM benzylpenicillin, IV ceftriaxone

Answer 326

eGFR 15-50: DOAC eGFR <15: unfractionated heparin or dose-adjusted LMWH

Answer 327

Stage I - rise in serum creatinine 1.5-1.9x baseline - urine output <0.5ml/kg/h for 6h Stage II - rise in serum creatinine 2.0-2.9x baseline - urine output <0.5ml/kg/h for 12h Stage III - rise in serum creatinine >=3x baseline - urine output <0.3ml/kg/h for 24h

Answer 328

syndrome of spontaneous, continuous lower limb movements that may be associated with paraesthesia Clinical features - uncontrollable urge to move legs (akathisia) > Symptoms initially at night but as condition progresses may occur during the day - worse at rest - paraesthesias e.g. 'crawling' or 'throbbing' sensations - periodic limb movements during sleep associations iron deficiency anaemia uraemia diabetes mellitus pregnancy Management simple measures: walking, stretching, massaging affected limbs dopamine agonists are first-line treatment (e.g. Pramipexole, ropinirole) benzodiazepines gabapentin

Answer 329

features - failure to thrive in young children - bloating - diarrhoea - fatigue - weight loss - mouth ulcers - dermatitis herpetiformis diagnosis - HLA DQ2/8 - anti-TTG antibodies (tissue transglutaminase) - anti-endomysial antibodies > Both are IgA antibodies so must test for total immunoglobulin A levels before interpretation > must eat gluten for 6 weeks before testing duodenal biopsy features - crypt hyperplasia - villous atrophy - lymphocytic infiltration associations: T1DM, thyroid disease, autoimmune hepatitis...

Answer 330

clostridium perfringens

Answer 331

most common in young females type I - ANA - anti smooth muscle antibody - adults and children type II - anti liver/kidney microsomal type 1 antibodies (LKM1) - children type III - soluble liver-kidney antigen - middle-aged adults features - acute hepatitis: fever, jaundice... - signs of chronic liver disease - amenorrhoea - raised IgG - liver biopsy: piecemeal necrosis, bridging necrosis management - steroids - other immunosuppressants e.g. azathioprine - liver transplantation

Answer 332

features - abdominal pain - constipation - blue lines on gum margin - neuropsychiatric features - peripheral neuropathy (mainly motor) - fatigue blood film: basophilic stippling, clover leaf morphology bloods - lead levels >10 mcg/dl are significant - microcytic anaemia raised serum and urine levels of delta aminolaevulinic acid (difficult to differentiate from acute intermittent porphyria) urinary coproporphyrin also increased management - dimercaptosuccinic acid (DMSA) - D-penicillamine - EDTA - dimercaprol

Answer 333

causes - primary: excessive production of bile acid - secondary: underlying GI disorder causing malabsorption > cholecystectomy > coeliac disease > Crohn's > SIBO features - steatorrhoea - vitamin A,D,E,K malabsorption investigations - SeHCAT management - bile acid sequestration with cholestyramine

Answer 334

- autosomal recessive disorder more common in african and asian populations - due to defects in alpha globin genes causes a hypochromic microcytic anaemia with target cells > 1 defective gene: silent carrier > 2 defective genes: alpha thalassaemia minor > 3 defective genes: HbH disease > 4 defective genes: Hb Bart's hydrops fetalis - incompatible with life diagnosis - haemoglobin electrophoresis, genetic testing

Answer 335

areas commonly scanned are femoral neck and lumbar spine DEXA scan involves two X-ray beams aimed at bones bone mineral density is calculated by subtracting X-ray absorbed by soft tissue from total X-ray absorbed, which gives the amount of X-ray absorbed by bones

Answer 336

severe systemic reaction to staphylococcal exotoxins features - fever - hypotension - diffuse erythematous rash - desquamation of rash, especially of the palms and soles - involvement of three or more organ systems: e.g. gastrointestinal (diarrhoea and vomiting), mucous membrane erythema, renal failure, hepatitis, thrombocytopenia, CNS involvement (e.g. confusion) Management - speculum examination: removal of infection focus (e.g. retained tampon) - IV fluids - IV antibiotics

Answer 337

- non-saphrophytic (non-invasive) - leads to colonisation of pre-existing cavities > TB, sarcoidosis, bullous emphysema, bronchiectasis lesion can impinge on a major vessel or airway leading to haemoptysis presents as a fungus ball CXR - partially filled cavity with crescent of air

Answer 338

zoon's balanitis - benign idiopathic condition in uncircumcised men - may be secondary to lichen planus or erythroplasia of Queyrat - features: orange-red lesions with pinpoint redder spots on glans and adjacent areas of foreskin circinate balanitis - chronic balanitis in men with Reiter's syndrome / in isolation - features: well-demarcated erythematous plaque with ragged white border erythroplasia of queyrat - in-situ squamous cell carcinoma - features: single or multiple plaques with red, velvety appearance, often asymptomatic

Answer 339

benign condition characterised by the presence of pigment-laden macrophages in the lamina propria of the colon most commonly associated with chronic laxative abuse particularly anthraquinone-containing laxatives such as cascara or senna

Answer 340

caused by spirochaete Leptospira interrogans spread by contact with infected rat urine, more common in tropics/sewers features - flu-like illness, fever - conjunctival haemorrhage - hepatitis: jaundice, hepatomegaly - AKI - aseptic meningitis investigations - serology (antibodies may not be present until after 7 days) - PCR is less commonly used - culture: blood and CSF samples positive for 10 days, urine cultures become positive during second week management - high dose benzylpenicillin or doxycycline

Answer 341

benign masses made up of fat alone clinical diagnosis - lump is smooth, mobile and painless features suggestive of sarcomatous change (becoming a liposarcoma) - size >5cm - increasing size - pain - deep anatomical location management - reassurance and no need to review if <5cm - can be removed surgically if causing symptoms such as pain or affecting nearby structures - ultrasound if suspicious or >5cm

Answer 342

disorder involving compression of brachial plexus, subclavian artery or vein at the site of thoracic outlet

Answer 343

- aplastic crisis > often triggered by parvovirus B19 infection > features: significant pancytopenia, most notably a severe drop in haemoglobin - acute chest syndrome > features: chest pain, cough, wheeze, dyspnoea and tachypnoea > Imaging: pulmonary infiltrates - haemolytic crisis > features: severe anaemia and jaundice due to sudden haemolysis - Sequestration crisis > features: abdominal pain, signs of haemodynamic compromise and hepatomegaly/splenomegaly > Pooling of blood in the spleen occurs, leading to severe anaemia and haemodynamic collapse. - Vaso-occlusive crisis > could affect different organs, but would present with acute pain due to microvascular occlusion > Other presentations: dactylitis, cerebral infarction, mesenteric ischaemia, avascular necrosis of the femoral head or priapism.

Answer 344

- LADA > late onset type 1DM > progression of autoimmune -cell failure is slow > patients are younger than in T2DM without increased body habitus > do not require insulin early in stages of disease > diagnosis: autoantibody testing - MODY > early onset type 2 DM > inherited genetic disorder affecting insulin production > symptoms similar to T2DM e.g. asymptomatic hyperglycaemia but can progress to DKA

Answer 345

- alopecia - photosensitivity - butterfly rash - discoid lupus - livedo reticularis

Answer 346

increased uncontrolled bone turnover - disorder of osteoclasts, with excessive osteoclastic resorption followed by increased osteoblastic activity Predisposing factors: increasing age, male sex, northern latitude, family history Clinical features - bone pain (e.g. pelvis, lumbar spine, femur) - classical, untreated features: bowing of tibia, bossing of skull Investigations - bloods: isolated raised ALP - calcium and phosphate are typically normal but hypercalcaemia can occur - raised alkaline phosphatase (ALP) x-rays - osteolysis in early disease → mixed lytic/sclerotic lesions later - skull x-ray: thickened vault, osteoporosis circumscripta - bone scintigraphy: increased uptake is seen focally at the sites of active bone lesions Management (if symptomatic) - bisphosphonate (either oral risedronate or IV zoledronate) - calcitonin is less commonly used now Complications - deafness (cranial nerve entrapment) - bone sarcoma - fractures - high-output cardiac failure

Answer 347

- Occur distally: toes or dorsum of foot - associated with peripheral arterial disease > absent pulses, pallor and intermittent claudication - smaller and deeper than venous ulcers - well defined borders - “punched-out” appearance - pale colour due to poor blood supply, less likely to bleed - painful: worse at night (when lying horizontally) and on elevation management same as peripheral arterial disease, >urgent referral for surgical revascularisation. If the underlying arterial disease is effectively treated, the ulcer should heal rapidly. Debridement and compression are not used in arterial ulcers.

Answer 348

clinical features - location: gaiter area (between the top of the foot and bottom of the calf muscle) - associated with chronic venous changes > hyperpigmentation, venous eczema and lipodermatosclerosis - after a minor injury to the leg - larger and more superficial than arterial ulcers - irregular, gently sloping border - more likely to bleed, less painful than arterial ulcers - pain relieved by elevation and worse on lowering the leg management - good wound care > cleaning the wound > debridement (removing dead tissue) > dressing the wound - compression bandaging - pentoxifylline (taken orally) - analgesia is used to manage pain (avoid NSAIDs as they can worsen the condition).

Answer 349

Varicose veins: distended superficial veins >3mm in diameter, usually in legs due to incompetent valves in perforating veins, so blood flows from the deep veins back into superficial veins and overloads them presentation - asymptomatic - Heavy or dragging sensation in the legs - Aching - Itching - Burning - Oedema - Muscle cramps - Restless legs special tests - Tap test - Cough test - Trendelenburg’s test - Perthes test - Duplex venous ultrasound

Answer 350

conservative - Weight loss - Staying physically active - Keeping the leg elevated when possible to help drainage - Compression stockings (exclude arterial disease first with an ankle-brachial pressure index) Surgical options: - Endothermal ablation – inserting a catheter into the vein to apply radiofrequency ablation - Sclerotherapy – injecting the vein with an irritant foam that causes closure of the vein - Stripping – the veins are ligated and pulled out of the leg Complications - Prolonged and heavy bleeding after trauma - Superficial thrombophlebitis - DVT

Answer 351

neutropaenic sepsis - neutrophil count <0.5 x 10^9 /L (don't wait for FBC to start treatment) - OR temperature >38 most often associated with anti-cancer treatment but can be caused by - clozapine - hydroxycholorquine - methotrexate - carbimazole - infliximab - others most common cause: coagulase negative gram positive bacteria (CoNS) such as Staphylococcus epidermis treatment - piperacillin/tazobactam > if penicillin allergic: amikacin / vancomycin / ciprofloxacin - granulocyte colony stimulating factor (G-CSF) is sometimes given

Answer 352

due to chronic urinary retention features - dribbling - intermittent stream - straining - frequent voiding small amounts - feel sincomplete after emptying caused by blockage e.g. BPH or inefficient contraction e.g. spinal cord injury management - treat underlying cause - intermittent self-catheterisation - indwelling catheter only if recurrent UTIs or high pressure retention - devices: urosheaths - percutaneous sacral nerve stimulation (PTNS)

Answer 353

Functional - know they need to go but physically can't get there e.g. reduced mobility Passive - physically can control bladder but cognitive impairment so don't go to toilet

Answer 354

- nausea and vomiting - headache - confusion - drowsiness, fatigue - restlessness, irritability - muscle weakness, cramps or spasms - severe: seizures, coma

Answer 355

- clinical signs of DVT: 3 points - alternative diagnosis is less likely than PE: 3 points - heart rate >100 bpm: 1.5 points - immobilisation >3 days or surgery previous 4 weeks: 1.5 points - previous DVT/PE: 1.5 points - haemoptysis: 1 point - malignancy: 1 point

Answer 356

Pityriasis versicolor is a superficial fungal infection features - flaky rash - predominantly affects trunk - white, red and brown variants - can be pruritic management - ketoconazole shampoo - if ineffective, send scrapings to confirm diagnosis and start oral itraconazole.

Answer 357

rare non-infectious neutrophilic dermatosis clinical features - initially small painful red nodule/pustule - progresses to a deep necrotic ulcer with violaceous borders 50% idiopathic but can be associated with > IBD > Connective tissue disorders e.g. RA, SLE > Myeloproliferative disorders e.g. AML, lymphoma > granulomatosis with polyangiitis > primary biliary cirrhosis management - oral prednisolone first-line - other immunosuppressants if resistant

Answer 358

rare skin disorder commonly seen in people with diabetes usually presents on shins clinical features - shiny red-brown patches - develop into plaques with atrophic centres and raised borders - associated with telangiectasia

Answer 359

local infiltration of phentolamine > alpha-adrenoceptor antagonist

Answer 360

long saphenous vein (anterior to medial malleolus)

Answer 361

3 monthly FBC, U&Es, LFTs

Answer 362

More than one episode of severe hypoglycaemia - requiring assistance - in the past 12 months must inform DVLA and surrender their license

Answer 363

features - jaundice - ascites - RUQ pain - splenomegaly - hepatomegaly screening: ultrasound +/- alpha fetoprotein management - early: resection - liver transplantation - radiofrequency ablation - metastatic HCC: sorafenib (multikinase inhibitor)

Answer 364

RNA hepevirus spread by the faecal-oral route; incubation period: 3-8 weeks common in Central and South-East Asia, North and West Africa, and in Mexico similar disease to hepatitis A but significant mortality during pregnancy does not cause chronic disease or increased risk of HCC

Answer 365

features - headaches - hypogonadism - hypothyroidism - mildly elevated prolactin (stalk compression effect)

Answer 366

failure of anterior and posterior pituitary features - adrenal insufficiency - diabetes insipidus - hypogonadism - hypothyroidism

Answer 367

CKD 1 - eGFR >=90 AND symptoms CKD 2: eGFR 60-89 AND symptoms CKD 3a: eGFR 45-59 CKD 3b: eGFR 30-44 CKD 4: eGFR 15-29 CKD 5: eGFR <15

Answer 368

Causes - infection: sepsis, pneumonia - massive blood transfusion, trauma - smoke inhalation - acute pancreatitis - cardio-pulmonary bypass Clinical features (acute onset and severe): - dyspnoea, tachypnoea - bilateral lung crackles - low oxygen saturations Investigations pulmonary oedema: bilateral infiltrates on chest x-ray non-cardiogenic (pulmonary artery wedge pressure to confirm) pO2/FiO2 < 40kPa Management - oxygenation/ventilation: hypoxaemia - general organ support - treatment of underlying cause e.g. antibiotics for sepsis

Answer 369

aka suxamethonium apnoea - rare abnormality in the production of plasma cholinesterases - leads to increased duration of action of muscle relaxants e.g. suxamethonium - results in respiratory arrest - patient requires mechanical ventilation while the circulating muscle relaxants degrade

Answer 370

- haemoglobin <130g/L for males, <120g/L for females: 2 points - age >74: 1 point - bleeding history (GI bleeds, haemorrhagic stroke): 2 points renal impairment (GFR<60): 1 point - treatment with antiplatelets: 1 point

Answer 371

volume expansion with 0.9% NaCl prior to scan

Answer 372

scoring system to assess need for anticoagulation in AF Congestive heart failure: 1 point Hypertension: 1 point Age >75: 2 points Diabetes: 1 point S: stroke, TIA, VTE: 2 points Vascular disease: 1 point Age 65-74: 1 point Sex category (female): 1 point need for anticoagulation - males >=1 points - females >=2 points if no anticoagulation required, perform echocardiogram to exclude valvular heart disease

Answer 373

gastric ulcer - worsened by eating - associated with weight loss duodenal ulcer - improved by eating - associated with weight gain - gastroduodenal artery most at risk

Answer 374

clinical features > non-painful, soft, fluctuant swelling > contains clear fluid which transilluminates > may be presenting feature of testicular cancer in young men > can "get above it" on examination management - infants > common in newborn males due to patent processus vaginalis > usually resolve within first months of life > repaired if do not resolve by 1-2 years of age - adults > conservative approach > ultrasound to exclude malignancy

Answer 375

e.g. ancylostoma braziliense, strongyloides stercoralis, toxocara canis clinical features - anaemia (visceral larva migrans) - eosinophilia - rash (cutaneous larva migrans) - abdo pain - diarrhoea - pneumonitis - can have liver involvement - pruritus hookworms aka nematodes are acquired from skin contact with contaminated soil or ingestion of eggs from soil contaminated by dog faeces endemic in areas e.g Asia, Africa, South America diagnosis - stool culture: ova management - thiabendazole, albendazole - ivermectin in chronic infection

Answer 376

atypical mycobacteria seen in HIV when CD4 count is below 50 features - fever - sweats - abdominal pain - diarrhoea - hepatomegaly - deranged LFTs diagnosis - blood culture - bone marrow examination management - rifabutin - ethambutol - clarithromycin

Answer 377

erectile dysfunction

Answer 378

features - headache - ataxia - papilloedema Management - descent - dexamethasone - prevention: acetazolamide

Answer 379

acute mountain sickness develops after 6-12 hours at >2500-3500m > features: nausea, headache, fatigue can progress to HACE and HAPE Management of HAPE - descent - nifedipine - dexamethasone - acetazolamide - phosphodiesterase type V inhibitors - oxygen if available

Answer 380

vitamin B3 (niacin) deficiency 4 D's - diarrhoea - dermatitis (brown scaly rash on sun-exposed sites) > Casal's necklace if around the neck - dementia, depression - death causes - isoniazid (prevents dietary tryptophan conversion to vitamin B3) - alcoholics

Answer 381

management - advise patients they are infectious until lesions have crusted over, 5-7 days following onset - analgesia: paracetamol, NSAIDS, amitriptyline - oral steroids if severe refractory pain - antivirals within 72h for most patients > first-line: oral famciclovir or valacyclovir > second-line: oral aciclovir complications - post-herpetic neuralgia (most common complication, antivirals reduce risk) - herpes zoster ophthalmicus - herpes zoster oticus (Ramsay Hunt syndrome): may result in ear lesions and facial paralysis

Answer 382

features - dry rough skin cheeks (keratosis pilaris) - subtle hypopigmentation - more common in Asian skin - often atopic management - emollients - sunscreen

Answer 383

more common in Black African populations organisms - trichophyton tonsurans, trichophyton violaceum features - diffuse scale - patchy alopecia - black dots (broken hairs) - pustules - post-auricular lymphadenopathy - boggy swelling (kerion) diagnosis: > scrape from affected site > rub with moist swab > sterile tooth brush management - ketoconazole shampoo / topical terbinafine if head shaved to prevent spread - oral griseofulvin / terbinafine / fluconazole

Answer 384

self-limiting rash, viral origin > initial presentation: single pink or red "herald patch" > then smaller similar lesions develop along skin cleavage lines in christmas tree pattern on the trunk management: none, self-resolves

Answer 385

mammogram every 3 years in women 50-70

Answer 386

skin prick test - most commonly used - food allergies, pollen radioallergosorbent test (RAST) - determines amount of IgE reacting to suspected/known allergens like IgE to egg protein - food allergies, inhaled allergens (e.g. pollen), wasp/bee venom skin patch testing - contact dermatitis

Answer 387

metformin - GI upset e.g. diarrhoea > improved with modified release preparations > risk of lactic acidosis during intercurrent illness / AKI > contraindicated in eGFR <30 sulfonylurea e.g. gliclazide - risk of hypoglycaemia - hyponatraemia - weight gain - avoid when breastfeeding - contraindicated in renal failure thiazolidinedione e.g. pioglitazone - contraindicated in heart failure, bladder cancer DPP-4 inhibitor e.g. sitagliptin GLP-1 agonists e.g. semaglutide > weight loss SGLT2 inhibitor e.g. dapagliflozin - risk of euglycaemic DKA - risk of recurrent thrush / UTI due to glycosuria - risk of leg ulcers and amputation

Answer 388

AEIOU - acidosis (pH <7.1) - electrolytes: refractory hyperkalaemia - ingestion or overdose - overload (refractory to diuretics) - uraemia (uraemic pericarditis / encephalopathy)

Answer 389

infectious thrombophlebitis of internal jugular vein following anaerobic oropharyngeal infection usually secondary to bacterial pharyngitis caused by Fusobacterium necrophorum leading to peritonsillar abscess clinical features - bacterial sore throat - neck pain and stiffness - systemic involvement: fevers, rigors may cause thrombus formation with subsequent septic emboli going to lung, liver and other areas

Answer 390

Whipple's triad - hypoglycaemia with fasting/exercise - reversal of symptoms with glucose - recorded low BMs at the time of symptoms C-peptide does not fall on exogenous insulin injection in patients with an insulinoma

Answer 391

fluid bolus: 500ml STAT (over 10-15 mins) > if still hypotensive after 2L resuscitation fluids, d/w senior/ICU maintenance fluids - 25-30 mls/kg/24h of water - 1mmol/kg/24h of sodium, potassium respectively - 50-100g glucose daily - types: > 0.9%NaCl (upper GI losses, DKA resuscitation) > Hartmanns, plasmalyte > 0.18%NaCl/4%glucose/KCl - underlying cardiac disease / frailty / renal disease: 20-25ml/kg/24h

Answer 392

- mild LVF: > dilated upper lobe pulmonary veins - moderate LVF: > pleural effusion (may not be present if lying down) > perihilar interstitial oedema: increased opacification of hilar structures > Kerley B lines: interstitial oedema (peripheral, horizontal, 2-3cm, mid-lower zones) > peribronchial cuffing - severe LVF: > bats' wing alveolar oedema

Answer 393

infection caused by Chlamydia psittaci usually causing atypical pneumonia history of bird contact especially parrot owners features - respiratory: dyspnoea, dry cough, chest pain - flu-like symptom: headache, myalgia, fever - hepatosplenomegaly - failure to respond to penicillin-based antibiotics investigations - inflammatory markers, CXR - serology management - first-line: tetracyclines e.g. doxycycline - macrolides e.g. erythromycin

Answer 394

aka non-thyroidal illness syndrome (NTIS) commonly seen in critically ill patients labs - TSH normal/low - thyroxine low - T3 low

Answer 395

delayed reaction occuring 2-6 weeks after transfusion clinical features - diarrhoea - liver damage - rash - pancytopaenia skin biopsy: abundant necrotic keratinocytes bone marrow biopsy: marked hypocellularity with macrophage infiltration management - no treatment - prevention: gamma-irradiated blood products

Answer 396

crusted lesions found on sun-exposed sites such as balding scalps management - fluorouracil cream - topical imiquimod - cryotherapy

Answer 397

hyponatraemia correction: osmotic demyelination syndrome aka central pontine myelinolysis hypernatraemia correction: cerebral oedema "from high to low, your brain will blow. from low to high, your pons will die"

Answer 398

aka osmotic demyelination syndrome caused by rapid correction of hyponatraemia clinical features - brainstem damage - spastic quadriparesis - pseudobulbar palsy: dysarthria, dysphagia - emotional lability (pseudobulbar affect) - seizures, confusion, coma - locked in syndrome

Answer 399

protein ratio (pleural / serum): >0.5 LDH ratio (pleural / serum): >0.6 or >2/3 upper limit of normal

Answer 400

caused by subclavian artery steno-occlusive disease proximal to the origin of the vertebral artery > leads to flow reversal in vertebral artery clinical features - dizziness and vertigo during exertion of an arm management - percutaneous transluminal angioplasty or a stent

Answer 401

Autoimmune disease > autoantibodies >> TSH receptor stimulating antibodies (most common) >> anti-thyroid peroxidase antibodies Thyroid enlarged and increased vascularity (may be audible bruit) Usually young females Symptoms of hyperthyroidism and thyroid eye disease > Proptosis > Lid retraction and lid lag > Oedema > pretibial myxoedema > thyroid acropachy thyroid scintigraphy > diffuse, homogeneous, increased uptake of radioactive iodine

Answer 402

autoimmune disease leading to hypothyroidism > initial hyperthyroid phase, then euthyroid, then hypothyroid associated with anti-TPO antibodies initially goitre, then atrophy of thyroid gland management: levothyroxine associated with development of MALT lymphoma

Answer 403

Symptoms > Tiredness > Weight gain > Anorexia > Cold intolerance > Depression > Poor libido > Dry brittle hair and dry coarse skin > Constipation > Menorrhagia Signs > Ataxia > Deafness > Hypertension > Bradycardia > Cold peripheries > Anaemia euvolaemic hyponatraemia

Answer 404

Features - Palpitations - Tachycardia - Cardiac arrhythmias - Sweating - Tremor - Lethargy - Heat intolerance - Diarrhoea TFTs – low TSH, high T4 management - antithyroid drugs – carbimazole, prophylthiouracil - propranolol - radioactive iodine - surgery

Answer 405

Primary – disorder of parathyroid gland > High PTH, high calcium > Causes: adenoma, hyperplasia, cancer clinical features - fatigue, aches, low mood PTH may be normal

Answer 406

normal variants of glans 1-2mm in size distributed around corona of penis benign and do not require intervention

Answer 407

rare but serious complication of haemodialysis causes cerebral oedema, usually in those who have recently started RRT diagnosis of exclusion

Answer 408

measure urinary albumin-creatinine ratio on a spot urine sample if results abnormal, repeat with a first-pass morning urine specimen

Answer 409

management - conservative: diet, exercise - medical: orlistat, liraglutide - surgical orlistat: pancreatic lipase inhibitor - side-effects: flatulence, faecal urgency/incontinence - prescribe if BMI>28 with risk factors or BMI>30 liraglutide: GLP-1 agonist - prescribe if BMI at least 35 and prediabetic hyperglycaemia (HbA1c 42-47 mmol/mol) BMI >50 - first-line: bariatric surgery

Answer 410

parathyroid hormone related protein secretion

Answer 411

inflammation associated with thrombosis of one of the superficial veins, usually long saphenous vein usually non-infective but secondary bacterial infection may lead to septic thrombophlebitis management - NSAIDs > topical for limited/mild disease > oral if severee.g. naproxen - US if long saphenous to exclude DVT - compression stockings

Answer 412

seminoma > commonest subtype > average age at diagnosis is 40 > AFP normal, HCG and LDH elevated in 10-20% non-seminomatous germ cell tumours > including teratomas, yolk sac tumours, choriocarcinomas... > younger age at presentation (20-30s) > AFP and HCG usually elevated

Answer 413

no vaccine available diagnosis: > HCV antibodies > viral load (used in monitoring response to treatment) management - direct acting antivirals

Answer 414

aka hypersensitivity pneumonitis e.g. - bird fanciers' lung - farmers lung - malt workers' lung - mushroom workers' lung presentation - acute (4-8h after exposure) > dyspnoea > dry cough > fever - chronic (weeks-months after exposure) > lethargy > dyspnoea > productive cough > anorexia and weight loss investigations - imaging: upper/mid-zone fibrosis - bronchoalveolar lavage: lymphocytosis - serologic assays fpr IgG antibodies - blood: NO eosinophilia management - avoid precipitating factors - oral glucocorticoids

Answer 415

salmonella enteritidis

Answer 416

staphylococcus epidermis

Answer 417

platelet concentrate as they are stored at room temperature

Answer 418

causes nephrotic syndrome causes - idiopathic - secondary - HIV - heroin - Alport's syndrome - sickle cell investigations - renal biopsy: focal and segmental sclerosis and hyalinosis on light microscopy management - steroids +/- immunosuppressants

Answer 419

malignant tumour of melanocytes variants - superficial spreading - acral lentiginous - lentigo maligna - nodular

Answer 420

lymphoplasmacytoid malignancy characterised by secretion of monoclonal IgM paraprotein features - weight loss, lethargy - hyperviscosity syndrome e.g. visual disturbance - hepatosplenomegaly - lymphadenopathy - cryoglobulinaemia e.g. Raynaud's investigations - monoclonal IgM paraproteinaemia - bone marrow biopsy is diagnostic management - rituximab-based combination chemotherapy

Answer 421

infection of oligodendrocytes by JC virus or BK virus leads to widespread demyelination features - subacute onset - behavioural changes - speech, motor or visual impairment CT: single or multiple non-enhancing lesions, no mass effect

Answer 422

step 1 - low dose ICS + formoterol combination inhaler prn > anti-inflammatory reliever (AIR) - if highly symptomatic > start treatment with low-dose MART step 2 - low dose MART (maintenance and reliever therapy) > ICS + formoterol (LABA) regularly step 3 - moderate dose MART step 4 - check feNO and eosinophil count > if elevated referral to asthma specialist > if neither is raised consider leukotriene receptor antagonist (LTRA) or LAMA in addition to MART step 5 - specialist referral

Answer 423

Features - acrodermatitis: red, crusted lesions > acral distribution > peri-orificial > perianal - alopecia - short stature - hypogonadism - hepatosplenomegaly - geophagia (ingesting clay/soil) - cognitive impairment

Answer 424

bacterial infection caused by Corynebacterium diphtheriae travel from Eastern Europe/Russia/Asia clinical features - dyspnoea - dysphagia - grey pseudomembrane on posterior pharyngeal wall - fever - bulky cervical lymphadenopathy - "bull neck" - neuritis e.g. cranial nerves - heart block investigations: throat culture with tellurite agar or Loeffler's media management - IM penicillin - diphtheria antitoxin

Answer 425

chlorpromazine, haloperidol or gabapentin dexamethasone if hepatic lesions

Answer 426

acute tubular necrosis of graft - first few weeks after transplant - more common in cadaver transplants vascular thrombosis - rare - presentation: abdominal pain, reduced urinary output, pyrexia acute graft failure - around 6 months post-transplant - investigations > urinalysis: pyuria, proteinuria > U&Es: rising creatinine - management: IV steroids, T cell depletion post-transplant urinary leak - common early post-op complications - high drain output and reduced urinary catheter output - low volume leaks may present later with abdominal tenderness and pyrexia

Answer 427

associated with low levels of orexin (hypocretin), protein responsible for controlling appetite and sleep patterns features - onset in teenage years - hypersomnolence - cataplexy - sleep paralysis - vivid hallucinations on going to sleep or waking up - early onset REM sleep investigations: multiple sleep latency EEG management: daytime stimulants (modafinil) and nighttime sodium oxybate

Answer 428

unintentional weight loss >10% within the last 3-6 months

Answer 429

caused by tapeworm parasite Echinococcus granulosus outer fibrous capsule containing multiple small daughter cysts > cysts are allergens, precipitate a type 1 hypersensitivity reaction endemic in Mediterranean and Middle Eastern countries Clinical features - cysts in liver and lungs - asymptomatic or symptomatic if cysts > 5cm Complications: cyst bursting, infection and organ dysfunction Investigations - ultrasound first-line - CT abdomen gold standard - serology Management: surgery

Answer 430

aka vesicular palmar eczema > can affect hands and feet sweating is a common precipitant > condition is associated with hot, humid environments clinical features - small blisters on palms and soles - pruritic, burning sensation - once blisters burst skin may become dry and crack management - cool compresses - emollients - topical steroids

Answer 431

- pulmonary fibrosis - hypothyroidism - corneal opacities - optic neuritis

Answer 432

aka hepatic vein thrombosis causes - polycythaemia rubra vera - thrombophilia - pregnancy - COCP classic triad - sudden onset severe abdominal pain - ascites: abdominal distension - tender hepatomegaly investigations - US with doppler flow studies

Answer 433

granulomatous disease caused by Mycobacterium leprae features - patches of hypopigmented skin affecting buttocks, face, extensor surfaces of limbs - sensory loss - hair loss management: rifampicin, dapsone and clofazimine

Answer 434

associated with EBV in HIV patients CT: single lesion, solid (homogeneous) enhancement - Thallium SPECT positive treatment - steroids - chemoradiotherapy

Answer 435

persistent penile erection >4 hours not associated with sexual stimulation 2 types: ischaemic and non-ischaemic Causes - idiopathic - sickle cell disease or other haemoglobinopathies - erectile dysfunction medication - other drugs - trauma clinical features - persistent erection - pain localised to the penis - rarely, non-painful erection or erection that is not fully rigid: suggestive of non-ischaemic priapism. Investigations: - cavernosal blood gas analysis: > ischaemic: pO2 and pH reduced, pCO2 increased - doppler or duplex ultrasonography - FBC, toxicology Management - ischaemic priapism: medical > >4 hours: aspiration of blood from cavernosa + injection of saline flush > intracavernosal injection of a vasoconstrictive agent e.g. phenylephrine > surgery - non-ischaemic priapism: not a medical emergency, observation first-line

Answer 436

Haemoglobin electrophoresis

Answer 437

atherosclerosis of abdominal aorta and/or iliac arteries triad of features in men - claudication in buttocks / thighs - impotence - atrophy of leg musculature investigations: angiography management - correct underlying factors e.g. smoking - endovascular angioplasty and stent insertion

Brainscape's Knowledge GenomeTM

Medicine Flashcards

Brainscape's Knowledge Genome^TM