Medicine

Question 1

Describe the classical triad of symptoms associated with normal pressure hydrocephalus and its diagnosis and treatment

Answer 1

Dementia + gait abnormality + urinary incontinence

Diagnosis
- Lumbar puncture (normal CSF opening pressure)
- head CT or MRI: ventriculomegaly without sulcal enlargement

Treatment is with ventriculo-peritoneal shunting.

Question 2

Describe the laboratory features of haemochromatosis

Answer 2

Low TIBC, high ferritin, high transferrin saturation

Question 3

Describe Peutz-Jeghers syndrome

Answer 3

AD condition

Clinical features
> Hamartomatous polyps in GI tract (causing intussusception)
> can lead to SBO

> Pigmented freckles on the lips, face, palms and soles

Question 4

Describe the use of prolactin in seizures

Answer 4

Rise in serum prolactin can help to differentiate a seizure from a pseudoseizure

pseudoseizures also tend to have a gradual onset while true seizures have sudden onset

Other features suggestive of seizure
> Tongue biting
> Urinary incontinence
> Post-ictal phase
> Memory loss
> Todd’s paresis (post-ictal weakness)

Question 5

Describe the management of BPH

Answer 5

First-line: tamsulosin (alpha 1 antagonist)
> adverse effects: dizziness, postural hypotension

Second-line: finasteride (5 alpha reductase inhibitor) - takes 6 months to see results
> adverse effects: ED, reduced libido, gynaecomastia

anti-muscarinics such as tolterodine or darifenacin may be tried

Transurethral resection of the prostate (TURP) if medical management fails

Question 6

Describe balanitis xerotica obliterans

Answer 6

Causes multiple itchy hyperkeratotic lesions on foreskin and glans

features
- dysuria
- reduction in sensation of glans
- can cause phimosis due to scarring

Question 7

describe the presentation and management of urge incontinence

Answer 7

overactive bladder / urge incontinence

features
- urge
- frequency
- nocturia
- +/- no infection

causes
- idiopathic
- neurological / UMN conditions
- psychological
- bladder irritation e.g. UTI/stones

management
- conservative: bladder retraining, pelvic floor exercises

• pharmacological:
  > antimuscarinics: Oxybutinin, solifenacin, tolterodine
  > beta 3 agonists: mirabegron
• invasive
  > botulin toxin A into bladder wall
  > percutaneous / sacral nerve stimulation (PTNS)

Question 8

List risk factors for subdural haematoma

Answer 8

Old age, alcoholism, anticoagulation

Question 9

When should LP for subarachnoid haemorrhage be performed?

Answer 9

12h after onset of headache, identify xanthochromia

Question 10

Describe the clinical features associated with Hodgkin’s lymphoma

Answer 10

Bimodal age distribution: peaks around 20-25 and 80 years

Usually B cell origin

Associated with history of glandular fever (EBV infection)

Presentation
> Asymmetrical painless lymphadenopathy (usually single rubbery lymph node in cervical, axillary or inguinal region) - may become painful after alcohol ingestion

> B symptoms: weight loss, sweating, fever, pruritis and general lethargy

Diagnosis
> Lymph node biopsy: Reed-Sternberg cells (large malignant B cells).

Spread - Ann Arbor system
I = one node region involved
II = 2+ ipsilateral regions
III = bilateral node involvement
IV = extranodal disease
> Suffix “A” (B symptoms absent) or “B” (B symptoms present).

Management
> Early stage disease: radiotherapy alone
> Advanced: radiotherapy + chemotherapy

Question 11

Describe the clinical features associated with Klinefelter’s syndrome

Answer 11

Karyotype 47XXY

Primary hypogonadism in patients with male external genitalia

Examination
> tall stature, low-volume testes, sparse pubic hair, and gynecomastia

Hypergonadotrophic hypogonadism
> High FSH and LH
> Low testosterone

Semen analysis - azoospermia
> infertility

Question 12

Describe the mechanism of action of DPP-4 inhibitors such as sitagliptin

Answer 12

Reduce peripheral breakdown of incretins e.g. GLP-1

Question 13

Describe allergic bronchopulmonary aspergillosis and its management

Answer 13

Due to allergy to Aspergillus spores

Features of asthma and bronchiectasis

Eosinophilia, raised IgE.

Sputum microscopy - eosinophils and fungal hyphae

CXR - proximal bronchiectasis, consolidation

Treatment
- Oral prednisolone
- Oral itraconazole (second-line)

Question 14

Describe Heberden’s nodes, Bouchard’s nodes and Oslers nodes

Answer 14

Heberden’s: DIP joints, osteoarthritis

Bouchard’s: PIP joints, rheumatoid arthritis

Oslers nodes: tender purple/red raised lesions with pale centre, shows immune complex deposition. Causes: infective endocarditis, SLE, gonorrhoea, typhoid, haemolytic anaemia.

Question 15

Describe Chronic Myeloid Leukaemia (CML)

Answer 15

BCR-ABL - t(9:22) - Philadelphia chromosome

Presentation 60-70 years of age

Anaemia, weight loss, sweating, splenomegaly

Increase in granulocytes, thrombocytosis

May undergo blast transformation - AML in 80%, ALL in 20%

Management
> Tyrosine kinase inhibitor (TKI) - imatinib
> Hydroxyurea
> Interferon-alpha
> Allogeneic bone transplant

Question 16

Describe Wilson’s disease

Answer 16

AR disorder characterised by excessive copper deposition in tissues

Features
- Liver: hepatitis, cirrhosis
- Neurological: speech, behavioural and psychiatric problems
- Kayser-Fleischer rings: green-brown rings in the periphery of the iris
- Renal tubular acidosis
- Haemolysis
- Blue nails

Lab
- Reduced serum caeruloplasmin
- Reduced total serum copper
- Increased 24h urinary copper excretion

Management
- penicillamine (chelates copper)

Question 17

Describe small bowel bacterial overgrowth syndrome

Answer 17

Features
> chronic diarrhoea
> bloating, flatulence
> abdominal pain

Diagnosis
> hydrogen breath test
> small bowel aspiration and culture

Management
> correction of underlying disorder
> antibiotic therapy
» rifaximin
» Co-amoxiclav / metronidazole

Question 18

Which enzyme must be checked before starting azathioprine or mercaptopurine therapy?

Answer 18

TPMT: thiopurine methyltransferase

Question 19

Describe the clinical features of superior vena cava obstruction

Answer 19

Causes
- External pressure (e.g. malignancy, usually lung)
- Thrombus
- Direct tumour invasion

Clinical features
> facial flushing / swelling
> pain worsened leaning forward
> distended neck veins / bulging facial veins
> blurred vision
> papilloedema on fundoscopy
> Pemberton sign: bilateral arm elevation causes facial plethora

Treatment
- Sitting the patient up
- Oxygen
- Stat dose of dexamethasone
- Definitive management: SVC stenting, radiotherapy and chemotherapy

Question 20

What are the antibiotics of choice for contacts of patients with meningococcal meningitis

Answer 20

PO ciprofloxacin or rifampicin

Question 21

Describe the management of migraines

Answer 21

Acute: NSAIDs or paracetamol + triptans

Prophylaxis: topiramate or propranolol

Question 22

Describe the features of organophosphate insecticide poisoning

Answer 22

Salivation
Lacrimation
Urination
Defecation/diarrhoea
cardiovascular: hypotension, bradycardia
also: small pupils, muscle fasciculation

Management - atropine

Question 23

Describe features associated with different gastroenteritis-causing bacteria

Answer 23

Staphylococcus aureus: severe vomiting after a short incubation period (30 minutes - 8 hours)
> Symptoms usually resolve within two days

Escherichia coli: incubation period of 3-4 days. Causes diarrhoea that usually becomes bloody, lasting up to a week. Common amongst travellers.

Giardia: watery diarrhoea at least 5 days after infection.

Salmonella: diarrhoea and fever; symptoms usually occur between 6 hours - 6 days

Shigella: fever and (sometimes bloody) diarrhoea begin1-2 days after infection

Cholera: profuse, watery diarrhoea
> Severe dehydration resulting in weight loss

Campylobacter: flu-like prodrome followed by crampy abdominal pains, fever and diarrhoea which may be bloody
> Complications include Guillain-Barre syndrome

Bacillus cereus: vomiting within 6 hours, stereotypically due to rice.

Amoebiasis: gradual onset bloody diarrhoea, abdominal pain and tenderness which may last for several weeks

Question 24

Describe the differences between pneumonia caused by different bacteria

Answer 24

Community acquired pneumonia (CAP) :

> Streptococcus pneumoniae (80% of cases) - associated with cold sores

> Haemophilus influenzae

> Staphylococcus aureus: commonly after influenza infection

> atypical pneumonia
> Mycoplasma pneumoniae: dry cough, erythema multiforme, reticulo-nodular shadowing on CXR, RBC agglutination (haemolytic anaemia)
> serology is diagnostic

> viruses

Klebsiella pneumoniae: alcoholics, cavitating upper lobe pneumonia, red currant jelly sputum, empyema

Question 25

Describe causes of vertigo

Answer 25

Benign paroxysmal positional vertigo
- triggered by a change in head position which lasts a few seconds before subsiding
- spontaneous rotatory nystagmus
- positive head impulse test
- positive Dix-Hallpike positional test: delayed (few seconds) torsional nystagmus on descent only on one side
- Management: Epley manoeuvre, helps to reposition the dislodged otoconia OR Brandt-Daroff exercises at home

Acute labyrinthitis
> presents following a viral infection
- impaired hearing
- continuous dizziness

Otosclerosis
- genetic condition which causes conductive hearing loss at a young age.
- does not cause vertigo.

Posterior circulation stroke
- new-onset vertigo
- negative head impulse

Vestibular neuronitis
- presents following a viral infection
- causes sudden and severe onset of continuous vertigo that can last for days to weeks

Question 26

Describe the diagnosis and management of IBS

Answer 26

Clinical diagnosis - diarrhoea/constipation, mucus in stool, abdominal discomfort relieved by defaecation, normal blood tests.

First-line - according to predominant symptom

> pain: antispasmodic agents

> constipation: laxatives but avoid lactulose
> if not responding to conventional laxatives try linaclotide

> diarrhoea: loperamide is first-line

Second-line pharmacological treatment
> low-dose tricyclic antidepressants (e.g. amitriptyline)
> sertraline

Psychological interventions - CBT, hypnotherapy

Question 27

List and describe transfusion reactions as well as their management

Answer 27

acute haemolytic
> fever, abdo/lumbar pain, tachycardia, hypotension, tachypnoea
> caused by ABO incompatible blood
- management: stop transfusion, check patient identity/name, send blood for direct Coombs test, repeat typing and cross-matching. Supportive care (fluid resuscitation)

non-haemolytic febrile reaction
> fever and chills but no systemic upset
- management: slow/stop transfusion; paracetamol; monitor

minor allergic reaction
> pruritus, urticaria
- management: temporarily stop transfusion, give antihistamine, monitor

allergic/anaphylaxis
> hypotension, dyspnoea, wheezing, angioedema
- management: stop transfusion, IM adrenaline, oxygen, fluids

infective

transfusion-related acute lung injury (TRALI): hypoxia, pulmonary infiltrates, fever, hypotension, normal/unchanged JVP
- management: stop transfusion. O2, IV fluids & consider escalation of care

transfusion-associated circulatory overload (TACO): pulmonary oedema, hypertension, raised JVP, afebrile, S3 present
- management: slow/stop transfusion, consider IV diuretics and O2

other: hyperkalaemia, iron overload, clotting

First step is stopping transfusion

IgA deficiency increases risk of anaphylactic transfusion reactions

Question 28

Describe autosomal dominant polycystic kidney disease (ADPKD)

Answer 28

Two disease loci have been identified, PKD1 and PKD2, which code for polycystin-1 and polycystin-2 respectively

Screening - renal USS

Clinical features
- Extensive cysts, enlarged kidneys
- Haematuria, abdominal pain, recurrent UTIs, renal failure

• extra-renal manifestations
  > mitral regurgitation
  > cerebral berry aneurysms
  > hepatic, splenic, pancreatic, ovarian and prostatic cysts
  > colonic diverticula

Management
- tolvaptan (vasopressin receptor 2 antagonist)

Question 29

Describe Q fever

Answer 29

Caused by Coxiella burnetti, a rickettsia

Features: farmer, fever, transaminitis

also atypical pneumonia and culture-negative infective endocarditis

contact with sheep, cattle

management - doxycycline

Question 30

Describe sideroblastic anaemia

Answer 30

• Hypochromic microcytic anaemia
• High ferritin iron and transferrin saturation
• Basophilic stippling of red blood cells

Congenital cause: delta-aminolevulinate synthase-2 deficiency

Acquired causes
myelodysplasia
alcohol
lead
anti-TB medications

symptoms of anaemia + hepatosplenomegaly

Management - supportive, treat underlying cause, pyridoxine may help

Question 31

Describe an Addisonian crisis

Answer 31

Lab features: hyponatraemia, hyperkalaemia, hypoglycaemia

clinical features
- circulatory shock with severe hypotension
- unexplained pyrexia
- nausea and vomiting
- abdominal pain
- diarrhoea
- muscle cramps

Can be precipitated by
- sepsis or surgery causing exacerbation of chronic insufficiency
- adrenal haemorrhage e.g. Waterhouse-Friderichsen syndrome (fulminant meningococcaemia)
- steroid withdrawal

Management
- hydrocortisone 100mg IM or IV, no fludrocortisone required as high steroids exert mild mineralocorticoid effect
- 1 litre saline over 30-60 mins or with dextrose if hypoglycaemic

Question 32

Describe the indications for LTOT in COPD patients

Answer 32

COPD - LTOT if pO2 of 7.3 - 8 kPa AND one of the following:
secondary polycythaemia
peripheral oedema
pulmonary hypertension

Question 33

Describe the following skin conditions:
> Seborrhoeic dermatitis
> Actinic keratosis

Answer 33

• Seborrhoeic dermatitis:
  > erythematous, greasy, pruritic lesions affecting the scalp, glabella, nasolabial folds, posterior auricular skin, and anterior chest

> due to over-proliferation of the Malassezia furfur fungus

> complications: otitis externa, blepharitis

> linked to Parkinson’s disease and HIV

• Actinic keratosis
  > crusted lesions found on sun-exposed sites such as balding scalps
  > treat with fluorouracil cream, topical imiquimod, cryotherapy

Question 34

What is the Jarisch-Herxheimer reaction?

Answer 34

Fever, rash, chills and headache occurs following antibiotic administration for syphilis

Management - antipyretics and supportive treatment

Question 35

Describe haemochromatosis, its treatment and how to monitor treatment

Answer 35

Autosomal recessive iron absorption and metabolism disorder caused by HFE gene mutation

Common features
- Liver failure
- type 2 diabetes
- arthritis
- bronze, greying of the skin

Diagnosis: raised ferritin and transferrin saturation levels, molecular genetic testing for C282Y and H63D mutations

Management: venesection
> monitoring: ferritin and transferrin saturation

Question 36

Describe acute chest syndrome

Answer 36

complication of sickle-cell disease and presents with dyspnoea, chest pain, cough, hypoxia and new pulmonary infiltrates seen on chest x-ray

Question 37

Describe a restrictive spirometry pattern

Answer 37

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

caused by pulmonary fibrosis

Question 38

Describe the following breast pathologies

• Duct ectasia
• Periductal mastitis
• Paget’s disease of the nipple
• Mondor’s disease of the breast

Answer 38

Duct ectasia- similar to periductal mastitis

Periductal mastitis
- common in smokers
- women present younger than in duct ectasia
- presents with recurrent infections
-Treatment - co-amoxiclav

Mondor’s disease of the breast
- localised thrombophlebitis of a breast vein.

Question 39

Describe the treatment for gonorrhoea

Answer 39

IM ceftriaxone

or oral azithromycin + cefixime

Question 40

Describe diabetic foot disease

Answer 40

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
screening for ischaemia: palpating for both the dorsalis pedis pulse and posterial tibial artery pulse
screening for 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.

Question 41

Describe the management of an acute exacerbation of COPD

Answer 41

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 <7.35 despite best medical treatment for 1h

Contraindications to non-invasive ventilation include an inability to protect the airway, impaired consciousness, life-threatening acidosis and aspiration risk

Question 42

Describe the treatment for chronic plaque psoriasis

Answer 42

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)

Question 43

Describe the management of hypercalcaemia

Answer 43

• 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

Question 44

Describe the clinical features of pancreatic cancer

Answer 44

painless jaundice and a palpable mass in the right upper quadrant (RUQ)

Steatorrhoea due to loss of exocrine function

weight loss

Question 45

Describe secondary hyperparathyroidism

Answer 45

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

Question 46

List causes of AKI

Answer 46

Prerenal (renal hypoperfusion)
> urinary sodium <20 mmol/L

• 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
• 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

Question 47

Describe the features associated with obstructive sleep apnoea

Answer 47

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

Question 48

Describe haemophilia

Answer 48

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

Question 49

Which medications can cause drug-induced thrombocytopaenia?

Answer 49

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

Question 50

Describe the management of PE

Answer 50

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) then LMWH, unfractionated heparin, or LMWH followed by VKA (especially in antiphospholipid syndrome)

• provoked VTE: anticoagulation for 3 months
• unprovoked VTE: anticoagulation 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

Question 50

Describe the mechanism of action of Loop diuretics

Answer 50

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

Question 51

Describe the causes of Cushing’s syndrome

Answer 51

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

Question 52

describe the management of T2DM

Answer 52

Metformin first-line (+lifestyle advice)
> target HbA1C of 48 mmol/mol
> If this is not met, titrate up metformin
> 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

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
> if a triple combination of drugs has failed to reduce HBA1c then switching one of the drugs to GLP-1 is recommended, especially BMI >35

Consider insulin

Question 53

Describe G6PD deficiency and contraindicated medications

Answer 53

commonest red blood cell enzyme defect
> more common in people from the Mediterranean and Africa
> X-linked recessive inheritance
> Many drugs can precipitate a crisis as well as infections and broad (fava) beans
» drugs: anti-malarials e.g. primaquine, ciprofloxacin, sulph-group drugs: sulphonamides, sulphasalazine, sulfonylureas, co-trimoxazole

Features
neonatal jaundice
intravascular haemolysis
gallstones are common
splenomegaly may be present
Heinz bodies on blood films
Bite and blister cells may also be seen

Diagnosis - G6PD enzyme assay
levels should be checked around 3 months after an acute episode of hemolysis

Question 54

Describe autoimmune hepatitis

Answer 54

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

Question 55

Describe De Quervain’s thyroiditis and its management

Answer 55

subacute (De Quervain’s) thyroiditis

following a viral illness
raised ESR/CRP
tender goitre

initial hyperthyroid phase, then euthyroid then hypothyroid

investigations
> thyroid scintigraphy: globally reduced uptake of iodine-131

this condition is usually self-limiting,
management - simple analgesia e.g. naproxen
- if severe: steroids

Question 56

List antibiotic choices for the following conditions

Resp
> Exacerbations of chronic bronchitis
> Uncomplicated CAP
> pneumonia secondary to influenza
> Atypical pneumonia
> HAP

Answer 56

Resp

> Exacerbations of chronic bronchitis: amoxicillin / doxycycline / clarithromycin

> Uncomplicated CAP: amoxicillin

> pneumonia secondary to influenza: flucloxacillin

> Atypical pneumonia: clarithromycin

> HAP:
> within 5 days of admission: co-amoxiclav / cefuroxime
> more than 5 days after admission: piperacillin/tazobactam OR ceftazidime OR ciprofloxacin

Question 57

List antibiotic choices for the following conditions

Urinary
> Lower UTI
> Acute pyelonephritis
> Acute prostatitis

Answer 57

Lower UTI - trimethoprim / nitrofurantoin

Acute pyelonephritis - gentamicin / ciprofloxacin

Acute prostatitis: quinolone or trimethoprim

Question 58

List antibiotic choices for the following conditions

Skin
> Cellulitis
> Impetigo
> Erysipelas
> Animal / human bite
> Mastitis

Answer 58

Cellulitis - flucloxacillin

Impetigo: topical hydrogen peroxide, oral flucloxacillin / erythromycin if widespread

Erysipelas: flucloxacillin

Animal / human bites: co-amoxiclav

Mastitis: flucloxacillin

Question 59

List antibiotic choices for the following conditions

ENT
> Throat infections
> Sinusitis
> Otitis media
> Otitis externa
> periapical / periodontal abscess
> gingivitis:

Answer 59

Throat infections - phenoxymethylpenicillin

Sinusitis - phenoxymethylpenicillin

Otitis media - amoxicillin

Otitis externa - flucloxacillin

Periapical / periodontal abscess: amoxicillin

Gingivitis: metronidazole

Question 60

List antibiotic choices for the following conditions

Genital system
> gonorrhoea
> chlamydia
> PID
> Syphilis
> Bacterial vaginosis

Answer 60

Gonorrhoea: IM ceftriaxone

Chlamydia: doxycycline / azithromycin

PID: oral ofloxacin + oral metronidazole OR IM ceftriaxone + oral doxycycline + oral metronidazole

Syphilis: benzathine benzylpenicillin

Bacterial vaginosis: metronidazole; topical clindamycin

Question 61

List antibiotic choices for the following conditions

GI
> C. diff
> Campylobacter
> Salmonella (non-typhoid)
> Shigellosis

Answer 61

C. diff: oral vancomycin (first episode), oral fidaxomicin if second episode

Campylobacter: clarithromycin

Salmonella (non-typhoid): ciprofloxacin

Shigellosis: ciprofloxacin

Question 62

Describe the management of ischaemic stroke

Answer 62

aspirin 300mg orally or rectally - once haemorrhagic stroke has been excluded
> continue aspirin 300mg daily for 2 weeks then clopidogrel 75mg daily long-term

If AF - anticoagulants should not be started until 14 days have passed from the onset of an ischaemic stroke

if cholesterol is > 3.5 mmol/l - commence statin
> delay treatment until after 48 hours due to risk of haemorrhagic transformation

Thrombolysis with alteplase for acute ischaemic stroke
> if within 4.5 hours of onset of stroke symptoms and
haemorrhage definitively excluded

Thrombectomy for acute ischaemic stroke
> within 6 hours of symptom onset, PLUS intravenous thrombolysis (if within 4.5 hours)
> consider extended 6-24h if potential to salvage tissue as shown by CT perfusion or diffusion-weighted MRI showing limited infarct core volume

Question 63

List contraindications to thrombolysis

Answer 63

Absolute
- Previous intracranial haemorrhage
- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected subarachnoid haemorrhage
- Stroke / traumatic brain injury in preceding 3 months
- LP in preceding 7 days
- GI bleed in preceding 3 weeks
- Active bleeding
- Pregnancy
- Oesophageal varices
- Uncontrolled hypertension

Relative
- Concurrent anticoagulation
- Active diabetic haemorrhagic retinopathy
- Suspected intracardiac thrombus
- Major surgery / trauma in the preceding 2 weeks

Question 64

Describe the secondary prevention of stroke

Answer 64

clopidogrel (first-line)

aspirin plus MR dipyridamole (if clopidogrel is contraindicated)

Carotid artery endarterectomy if patient has suffered stroke / TIA in the carotid territory and is not severely disabled

Question 65

describe the management of subclinical hypothyroidism

Answer 65

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

Question 66

Describe ocular nerve palsies

Answer 66

oculomotor nerve - down and out position, ptosis, no pupillary constriction

trochlear nerve - vertical diplopia

abducens nerve - horizontal diplopia

Question 67

List causes of subarachnoid haemorrhage and describe its diagnosis and management

Answer 67

Causes
> intracranial aneurysm
> arteriovenous malformation (AVM)
> pituitary apoplexy
> mycotic (infective) aneurysm)

Clinical features
> thunderclap headache
> meningism (photophobia, neck stiffness)
> nausea and vomiting
> coma
> seizures
> ECG changes - ST elevation

Diagnosis
- Non-contrast CT head <6h after onset: if negative, consider alternative diagnosis
- if CT >6h after onset is negative do LP after 12h

• after spontaneous SAH is confirmed
  > CT intracranial angiogram +/- digital subtraction angiogram

Management
> supportive
- bed rest
- analgesia
- VTE prophylaxis
- discontinuation of antithrombotics
> nimodipine for prevention of vasospasm
- neurosurgical referral due to risk of aneurysm rebleeding
> coiling by interventional neuroradiologist
> if severe, clipping or craniotomy

Question 68

List complications of SAH

Answer 68

• Re-bleeding
• hydrocephalus (treated with external ventricular drain or long-term ventriculoperitoneal shunt)
• vasopasm
• hyponatraemia (usually due to SIADH)
• Seizures

Question 69

Describe the management of Parkinson’s

Answer 69

• Levodopa (co-careldopa contains levodopa and carbidopa)

> side-effects of levodopa
> CVS: palpitations, arrhythmias, postural hypotension
> on-off phenomenon
> end-of-dose dyskinesia
> hallucinations

• Carbidopa: DOPA decarboxylase inhibitor
• dopamine receptor agonists e.g. bromocriptine, cabergoline, apomorphine
  > highest chance of inhibition disorders
• COMT inhibitors e.g. entacapone
• MAO-B inhibitors e.g. selegiline
• amantadine

Question 70

List side-effects of levodopa

Answer 70

dry mouth
anorexia
palpitations
postural hypotension
psychosis
on-off phenomenon
dyskinesia

Question 71

Describe the diagnosis of Cushing’s syndrome

Answer 71

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

Question 72

List side-effects of steroids

Answer 72

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

Question 73

Describe the causes and diagnosis of urinary retention, acceptable post-void volumes and complications

Answer 73

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

Question 74

Describe the features, diagnosis and management of syphilis

Answer 74

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

Question 75

Describe the management of prostate cancer

Answer 75

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

Question 76

Describe the classification of acute asthma

Answer 76

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

Question 77

Describe the clinical presentation of subdural haemorrhage

Answer 77

Clinical presentation
- falls
- can be triggered by alcohol excess
- fluctuating consciousness

caused by rupture of bridging veins

Question 78

describe the treatment of IBS

Answer 78

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

Question 79

Which PPI should be prescribed with clopidogrel?

Answer 79

Lansoprazole

Omeprazole & esomeprazole decrease the efficacy of clopidogrel

Question 80

Which antiemetic should be given in patients with migraine?

Answer 80

Metoclopramide

prokinetic agent that helps to relieve gastric stasis that occurs during acute migraine attack.

Should be considered even in cases without nausea.

Question 81

Describe bronchiectasis

Answer 81

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

Question 82

Describe the following dermatological conditions

• Lichen planus
• Lichen sclerosus
• Morphea

Answer 82

• lichen planus: purple, pruritic, papular, polygonal rash on flexor surfaces. Wickham’s striae “white lines” over surface. oral involvement common. Can occur at site of previous skin injury - Koebner’s phenomenon.
• lichen sclerosus: itchy white spots found on vulva of older women, treatment: strong topical steroids e.g. clobetasol propionate. Topical tacrolimus if steroid resistant.

> in men: uncircumcised man with tight white ring around tip of foreskin and phimosis

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

Question 83

List drug causes of lichen planus and describe its management

Answer 83

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

Question 84

Describe neuroleptic malignant syndrome and its treatment

Answer 84

Rare dangerous condition seen in patients taking antipsychotic medication, occurs within hours to days of starting antipsychotics

can also occur with dopaminergic drugs such as levodopa for PD, usually when the drug is suddenly stopped or dose reduced

Features
- pyrexia
- decreased reflexes
- lead pipe muscle rigidity, raised CK
- autonomic lability: hypertension, tachycardia and tachypnoea
- agitated delirium with confusion
- AKI can occur secondary to rhabdomyolysis

diagnosis: increased creatine kinase

Management
- stop antipsychotic
- IV fluids to prevent renal failure
- dantrolene in selected cases
- bromocriptine, dopamine agonist

Question 85

Describe serotonin syndrome and its management

Answer 85

Caused by
> SSRIs (tramadol may precipitate with SSRIs)
> MAOIs
> ecstasy
> amphetamines / novel psychoactive stimulants

Onset within hours

Features
- hyperreflexia, clonus
- tremor
- tachycardia, increased BP
- Pyrexia / hyperthermia, sweating
- Rigidity
- dilated pupils
- altered mental state / confusion

diagnosis: elevated creatine kinase

Management
- IV fluids
- Benzodiazepines
- Severe cases: cryptoheptadine, chlorpromazine

Question 86

Describe hepatitis A and its management

Answer 86

benign self-limiting disease

transmission via faecal-oral spread (including anal-oral sex)

• 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

Question 87

List side-effects of quinolone therapy

Answer 87

• Tendinopathy
• lower seizure threshold

Question 88

List some QTc prolonging medications

Answer 88

• 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

Question 89

Describe eczema herpeticum and its treatment

Answer 89

• Severe primary infection of the skin caused by HSV1 or 2

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

Question 90

Describe the different types of hypersensitivity reactions giving examples

Answer 90

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

Question 91

Describe Kaposi’s sarcoma

Answer 91

Caused by HHV-8, usually underlying HIV infection

Features
- Raised purple lesions (papules/plaques) on skin or mucosa - respiratory involvement may cause massive haemoptysis and pleural effusion

treatment: radiotherapy + resection

Question 92

Which factors exacerbate psoriasis?

Answer 92

• trauma
• alcohol, smoking, stress
• discontinuing steroids
• initiating NSAIDs (including aspirin)
• lithium
• antimalarials
• beta-blockers
• ramipril
• infliximab

streptococcal infections precipitate guttate psoriasis

Question 93

Name the most common viral infection in solid organ transplant patients and its management

Answer 93

Cytomegalovirus

Features
- arthralgia
- jaundice
- lymphadenopathy
- hepatomegaly

Treatment - ganciclovir.

Question 94

Describe spontaneous intracranial hypotension

Answer 94

Low CSF headaches caused by spontaneous intracranial hypotension

> worse on standing, improved lying flat

more common in connective tissue disorder e.g. Marfan’s syndrome

Conservative management. Epidural blood patch if this fails.

Question 95

Describe disseminated intravascular coagulation (DIC)

Answer 95

• 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)

Question 96

Describe HIV testing

Answer 96

Combined HIV antibody/antigen tests (HIV p24 antigen and HIV antibody)
> turn positive approx 4 weeks post-exposure
> repeat test to confirm diagnosis before starting treatment

Question 97

Describe the mechanism of action of thiazide diuretics and common adverse effects

Answer 97

inhibition of sodium reabsorption at the DCT by blocking the Na/Cl symporter

Common adverse effects
- dehydration
- postural hypotension
- hypokalaemia
- hyponatraemia
- hypercalcaemia and hypocalciuria

Question 98

Describe Ramsay Hunt syndrome and its treatment

Answer 98

aka herpes zoster oticus caused by reactivation of the varicella zoster virus in the geniculate ganglion of CN VII.

• Auricular pain
• Facial nerve palsy
• Vesicular rash (ear canal, tongue, soft palate)
• vertigo, tinnitus

Management
- oral aciclovir and prednisolone

Question 99

Describe acne rosacea and its treatment

Answer 99

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
- laser therapy for prominent telangiectasia

Question 100

List causes of decompensation of liver disease

Answer 100

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

Question 101

Describe hepatic encephalopathy and its management

Answer 101

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

Management
- treat trigger
- lactulose is first-line
- secondary proophylaxis: lactulose, rifaximin

Question 102

How to diagnose SBP on ascitic tap? how to treat it?

Answer 102

WCC > 500 OR neutrophils >250

most commonly due to E. coli

treat with co- trimoxazole or IV tazocin

Question 103

how to reduce the risk of renal dysfunction in patients with SBP?

Answer 103

IV albumin on day 1 and day 3

Question 104

Describe hepatorenal syndrome

Answer 104

Renal dysfunction secondary to vasomotor responses to hepatic failure

Ensure strict fluid balance, may need to give fluids

Co-exists with ascites

terlipressin and albumin can improve renal outcomes

Question 105

Why give enoxaparin during an IBD flare?

Answer 105

VTE prophylaxis

Question 106

when should you perform an ascitic tap?

Answer 106

in all patients with clinical ascites within <6h admission

Question 107

Describe the diagnosis of creutzfeldt jakob disease

Answer 107

Rapidly progressive neurodegenerative condition with cognitive decline and myoclonic jerks

Key investigations
- lumbar puncture
- EEG
> bi- or tri-phasic periodic sharp wave complexes appearing with a frequency of around 1-2 per second.

Definitive diagnosis: post-mortem biopsy

Question 108

List signs of opioid toxicity

Answer 108

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

Question 109

List typical palliative medications on a syringe driver aka continuous subcutaneous infusion (CSCI)

Answer 109

• Morphine
• Midazolam
• Levomepromazine
• Hyoscine butylbromide

Question 110

Describe the guidelines on management of hypertension

Answer 110

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

Question 111

List blood pressure targets

Answer 111

Age <80y: clinic BP <140/90 mmHg, ABPM <135/85 mmHg

Age >80y: <150/90 mmHg clinic BP or <145/86 ABPM

Question 112

Describe ECG changes seen in hypocalcaemia

Answer 112

QTc prolongation

Severe: Osborn (J waves)

Rare: AF or Torsades de Pointes

if ECG changes present give urgent IV calcium gluconate

Question 113

Describe features of hypocalcaemia

Answer 113

• 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

Question 114

What is the maximum rate of potassium infusion?

Answer 114

40 mmol/L over 4h

Question 115

Describe the causes and management of sore throat

Answer 115

Causes: pharyngitis, tonsillitis, laryngitis

Management
> paracetamol / ibuprofen for pain relief
> antibiotics not routinely indicated

NICE indications for antibiotics
- features of marked systemic upset
- unilateral peritonsillitis
- history of rheumatic fever
- increased risk from acute infection (child with diabetes, immunodeficiency)
- Centor criteria >=3
- FeverPAIN score 4-5

Centor criteria:
- tonsillar exudate
- tender anterior cervical lymphadenopathy
- fever
- absence of cough

FeverPAIN
- Fever >38
- purulence (pharyngeal / tonsillar exudate)
- attend rapidly (3 days or less)
- severely inflamed tonsils
- no cough/coryza

Management: phenoxymethylpenicillin or clarithromycin if penicillin-allergic (7 or 10 day course)

Question 116

List cancers that commonly metastasise to bone

Answer 116

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

Question 117

Describe the guidelines for prescribing pain medication in palliative care

Answer 117

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

Question 118

Describe renal tubular acidosis

Answer 118

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

Question 119

Describe findings on a full blood count in alcoholic liver disease

Answer 119

Macrocytic anaemia and thrombocytopaenia

Question 120

Describe the features and management of alpha-1 antitrypsin deficiency

Answer 120

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

Question 121

Describe membranous glomerulonephritis

Answer 121

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

Question 122

Describe bifascicular and trifascicular block

Answer 122

Bifascicular block: combination of RBBB with left anterior or posterior hemiblock
e.g. RBBB with left axis deviation

Trifascicular block
features of bifascicular block as above + 1st-degree heart block

Question 123

Describe trigeminal neuralgia

Answer 123

Trigeminal neuralgia: pain syndrome characterised by severe unilateral pain
> brief electric shock-like pains, abrupt in onset and termination

triggers
> light touch, washing, shaving, smoking, talking, and brushing the teeth (trigger factors), and frequently occurs spontaneously

> idiopathic but compression of trigeminal roots by tumours or vascular problems may occur

Management
> carbamazepine is first-line
> failure to respond to treatment or atypical features (e.g. < 50 years old) should prompt referral to neurology

Question 124

Describe the management of variceal haemorrhage

Answer 124

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

Question 125

List causes of hypokalaemia and its ECG features

Answer 125

Hypokalaemia with alkalosis
> vomiting
> thiazide and loop diuretics
> Cushing’s syndrome
> Conn’s syndrome (primary hyperaldosteronism)

Hypokalaemia with acidosis
> diarrhoea
> renal tubular acidosis
> acetazolamide
> partially treated diabetic ketoacidosis

Magnesium deficiency may also cause hypokalaemia. In such cases, normalizing the potassium level may be difficult until the magnesium deficiency has been corrected

ECG features - U waves, small/absent T waves (or inversion), prolonged PR interval, ST depression, long QT

Question 126

Describe the features of Trichomonas vaginalis

Answer 126

Trichomonas vaginalis is a highly motile, flagellated protozoan parasite. Trichomoniasis is a sexually transmitted infection (STI).

Features
vaginal discharge: offensive, yellow/green, frothy
vulvovaginitis
strawberry cervix
pH > 4.5
in men is usually asymptomatic but may cause urethritis

Investigation
microscopy of a wet mount shows motile trophozoites

Management
oral metronidazole for 5-7 days

Question 127

Describe the management of acne vulgaris

Answer 127

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

oral isotretinoin: only under specialist supervision

Question 128

Describe the management of glue ear (otitis media with effusion)

Answer 128

• active observation: the management for a child with a first presentation of otitis media with effusion is active observation for 3 months - no intervention is required
• grommet insertion - to allow air to pass through into the middle ear and hence do the job normally done by the Eustachian tube.
• adenoidectomy

Children with Down’s syndrome or cleft palate require immediate referral to ENT

Question 129

Describe the management of breast cancer

Answer 129

surgery
> Wide local excision if mass <4cm + radiotherapy
> sentinel node biopsy
> mastectomy

hormone therapy
> tamoxifen (selective oestrogen receptor modulator) - pre-menopausal if ER+
> aromatase inhibitors e.g. anastrozole (post-menopausal, can cause osteoporosis)

biological therapy
> herceptin aka trastuzumab if Her2+
» cardiac toxicity is common so echocardiogram prior to treatment

node status
- neoadjuvant FEC-D chemotherapy if node positive
- clinically palpable lymphadenopathy: axillary node clearance

Question 130

Name inducers and inhibitors of warfarin (P450 ENZYME)

Answer 130

Inducers: SCARS (decrease in INR)
- smoking
- chronic alcohol intake
- anti-epileptics: phenytoin, carbamazepine, phenobarbitone
- rifampicin
- St Johns wort

Inhibitors: ASS-ZOLES (increase in INR)
- antibiotics: ciprofloxacin, erythromycin, isoniazid, clarithromycin
- SSRIs: fluoxetine, sertraline
- Sodium valproate
- Zoles: omeprazole, ketoconazole, fluconazole

Question 131

Describe the management of DKA

Answer 131

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

Question 132

Describe the management of hyperkalaemia

Answer 132

severe - sine wave pattern

stabilisation of cardiac membrane: IV 10ml 10% calcium gluconate over 10 minutes

IV insulin dextrose
> 8 units of actrapid in 100ml of 10% dextrose over 30 mins

nebulised salbutamol

removal of potassium from body
- calcium resonium
- sodium zirconium
- loop diuretics
- haemodialysis

Question 133

How would you manage a patient with high ketones who wasn’t acidotic?

Answer 133

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

VRII if fasting

Question 134

List criteria for discontinuing the DKA pathway

Answer 134

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

Further points
> both the ketonaemia and acidosis should have been resolved within 24 hours. If this hasn’t happened the patient requires senior review from an endocrinologist
> if the above criteria are met and the patient is eating and drinking switch to subcutaneous insulin
> Listthe patient should be reviewed by the diabetes specialist nurse prior to discharge

Question 135

Describe the management of anaemia in chronic kidney disease

Answer 135

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

Question 136

Describe a tricyclic overdose and its management

Answer 136

E.g. amitriptyline or dosulepin (dothiepin)

Early features
- Anticholinergic: dry mouth, dilated pupils, agitation, sinus tachycardia, blurred vision
- severe poisoning: arrythmia, seizure, metabolic acidosis, coma

ECG changes: sinus tachycardia, widening QRS, QTc prolongation

Widening of QRS >100 ms is associated with increased risk of seizure whilst QRS>160 is associated with ventricular arrhythmia

Management
- IV bicarbonate: first-line for hypotension or arrhythmias, also widening QRS >100
- other drugs for arrhythmias (not flecainide or amiodarone)
- Intravenous lipid emulsion
- Dialysis is not effective

Question 137

Describe the criteria for HHS and its management

Answer 137

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 ‘+’ “

Question 138

List causes of HHS

Answer 138

Intercurrent or coexisting illness
- Infection
- MI, stroke/TIA

Drug-induced
- Metformin
- Diuretics
- alcohol, cocaine

Diabetes-related
- first presentation
- poor glycaemic control

Question 139

Describe achalasia and its treatment

Answer 139

Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter due to degenerative loss of ganglia from Auerbach’s plexus

Clinical features
- dysphagia of BOTH liquids and solids
- variation in severity of symptoms
- heartburn
- regurgitation of food
- may lead to cough, aspiration pneumonia etc

Investigations
- oesophageal manometry: excessive LOS tone which doesn’t relax on swallowing

• barium swallow: grossly expanded oesophagus, fluid level, ‘bird’s beak’ appearance
  chest x-ray: wide mediastinum, fluid level

Treatment
> pneumatic (balloon) dilation first-line

> surgical intervention: Heller cardiomyotomy

> intra-sphincteric injection of botulinum toxin if high surgical risk

> drug therapy (e.g. nitrates, calcium channel blockers)

complications - squamous cell carcinoma

Question 140

Describe the investigations used in stroke

Answer 140

• ROSIER score: asymmetric weakness, speech disturbance, visual disturbance
• Non-contrast CT head:
  > acute ischaemic strokes
  » areas of low density in the grey and white matter; changes may take time to develop

> > other signs include the ‘hyperdense artery’ sign corresponding with the responsible arterial clot - this tends to visible immediately

> acute haemorrhagic strokes
>hyperdense material (blood) surrounded by low density (oedema)

Question 141

Describe the complications of chronic lymphocytic leukaemia (CLL)

Answer 141

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

Question 142

Describe primary hyperaldosteronism and its management

Answer 142

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

Question 143

List tumour markers for the following cancers:
- hepatocellular
- testicular
- pancreatic
- colon
- breast
- ovarian
- prostate

Answer 143

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

Question 144

Describe the following causes of nipple discharge

• galactorrhoea
• hyperprolactinaemia
• mammary duct ectasia
• carcinoma
• intraductal papilloma

Answer 144

• 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

Question 145

List autoantibodies for T1DM

Answer 145

• Anti-GAD65
• Islet cell antibodies (ICA)
• Insulin autoantibodies (IAA)
• IA-2A
• Anti-ZnT8

Question 146

Describe the presentation and diagnosis of T1DM

Answer 146

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
- C-peptide (insulin production)
- Autoantibodies

Question 147

List complications of diabetes mellitus

Answer 147

• 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

Question 148

Describe small bacterial overgrowth syndrome (SBBOS)

Answer 148

excessive amounts of bacteria in the small bowel resulting in gastrointestinal symptoms

Risk factors for SBBOS
> neonates with congenital gastrointestinal abnormalities
> scleroderma
> diabetes mellitus

clinical features:
- chronic diarrhoea
- bloating, flatulence
- abdominal pain

Diagnosis
- hydrogen breath test
- small bowel aspiration and culture

Management
- correction of the underlying disorder
- antibiotic therapy:rifaximin
> Co-amoxiclav or metronidazole are also effective

Question 149

Describe Clostridium difficile and its management

Answer 149

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:
> oral vancomycin AND IV metronidazole

> faecal microbiota transplant: 2 or more previous episodes

bezlotoxumab is a monoclonal antibody which targets C difficile toxin B

Question 150

Describe the effects of cocaine and the management of cocaine toxicity

Answer 150

cocaine blocks the uptake of dopamine, noradrenaline and serotonin

Adverse effects
- cardiovascular
> coronary artery spasm → myocardial ischaemia/infarction
> both tachycardia and bradycardia may occur
> hypertension
> QRS widening and QT prolongation
> aortic dissection

• neurological
  > seizures
  > mydriasis
  > hypertonia
  > hyperreflexia
• psychiatric effects: agitation, psychosis, hallucinations
• GI: ischaemic colitis, perforated ulcer
• hyperthermia
• metabolic acidosis
• rhabdomyolysis

Management
> benzodiazepines are first-line for most cocaine-related problems

> chest pain: benzodiazepines + glyceryl trinitrate; if myocardial infarction develops then primary percutaneous coronary intervention

> hypertension: benzodiazepines + sodium nitroprusside

Question 151

Describe genital herpes and its management

Answer 151

Features
- painful genital ulceration
- dysuria and pruritus
- systemic features: headache, fever and malaise
- tender inguinal lymphadenopathy
- urinary retention

Investigations
- nucleic acid amplification tests (NAAT) on swab
- HSV serology if recurrent genital ulceration

Management
- saline bathing
- analgesia
- topical anaesthetic agents e.g. lidocaine
- oral aciclovir

Question 152

Describe factor V Leiden

Answer 152

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.

Question 153

Describe the management of a high INR in a patient on warfarin

Answer 153

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

Question 154

Describe trypanosomiasis

Answer 154

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

Question 155

Describe the adult advanced life support algorithm

Answer 155

Adult advanced life support

> ‘shockable’ rhythms: ventricular fibrillation/pulseless ventricular tachycardia (VF/pulseless VT)

> ‘non-shockable’ rhythms: asystole/pulseless-electrical activity (asystole/PEA)

Major points include:
chest compressions
> ratio of chest compressions to ventilation is 30:2

defibrillation
> a single shock for VF/pulseless VT followed by 2 minutes of CPR

> if the cardiac arrested is witnessed in a monitored patient (e.g. in a coronary care unit) then up to three quick successive (stacked) shocks’

> IV access should be attempted and is first-line

> adrenaline 1 mg as soon as possible for non-shockable rhythms

> > during a VF/VT cardiac arrest, adrenaline 1 mg is given once chest compressions have restarted after the third shock
repeat adrenaline 1mg every 3-5 minutes whilst ALS continues

> amiodarone 300 mg in VF/pulseless VT after 3 shocks have been administered
> a further dose of amiodarone 150 mg should be given to patients who are in VF/pulseless VT after 5 shocks have been administered

thrombolytic drugs should be considered if a pulmonary embolus is suspected
> if given, CPR should be continued for an extended period of 60-90 minutes

Question 156

List triggers for DKA

Answer 156

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

Question 157

Describe the presentation of DKA (as well as severe DKA)

Answer 157

• 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)

Question 158

List complications of DKA

Answer 158

• VTE
• Arrhythmias
• Cerebral oedema
• ARDS
• AKI

Question 159

Which electrolyte imbalances occur after prolonged vomiting?

Answer 159

Hypochloraemia, hypokalaemia

Question 160

Describe Kallman syndrome

Answer 160

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

Question 161

Describe the clinical features of acromegaly, investigations and management

Answer 161

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

Question 162

Describe the lab values associated with the following bone disorders

• osteoporosis
• osteomalacia
• primary hyperparathyroidism (osteitis fibrosa cystica)
• secondary hyperparathyroidism (CKD)
• Paget’s disease
• Osteopetrosis

Answer 162

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

Question 163

Describe Bell’s palsy and its management

Answer 163

acute, unilateral, idiopathic, facial nerve paralysis.

risk factors
- age 20-40 years
- pregnant women

Features
> lower motor neuron facial nerve palsy → forehead affected
> post-auricular pain (may precede paralysis)
> altered taste
> dry eyes
> hyperacusis

Management
- oral prednisolone within 72 hours of onset of Bell’s palsy
- eye care to prevent exposure keratopathy: prescribe artificial tears and eye lubricants, taping at night

Question 164

Describe a Marjolin’s ulcer

Answer 164

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

Question 165

Describe features of chronic venous insufficiency on examination

Answer 165

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

Question 166

How does AF with bundle branch block present on ECG?

Answer 166

irregular trace with a QRS complex of > 120 ms, accompanied by a fast heart rate of 150/min. These are defining features of an irregular broad complex tachycardia.

Question 167

Describe Alport’s syndrome

Answer 167

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

Question 168

Describe the symptoms of infection with Giardia lamblia

Answer 168

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

Question 169

Describe the symptoms of stroke depending on the affected vessel

Answer 169

ACA
> contralateral hemiparesis and sensory loss
> lower extremity > upper

MCA
> contralateral hemiparesis and sensory loss
> upper extremity > lower extremity
> aphasia
> contralateral homonymous hemianopia

PCA
> Contralateral homonymous hemianopia with macular sparing
> Visual agnosia

Weber’s syndrome (branches of PCA supplying midbrain)
> contralateral upper and lower limb weakness
> ipsilateral CN III palsy

PICA (lateral medullary syndrome, Wallenberg syndrome)
> ipsilateral facial pain and temperature loss
> contralateral limb/torso pain and temperature loss
> ataxia, nystagmus
> ipsilateral Horner’s syndrome

AICA (lateral pontine syndrome)
> similar to Wallenberg’s but ipsilateral facial paralysis and deafness also
> reduced GCS, paralysis, bilateral pinpoint pupils

Retinal/ophthalmic artery: amaurosis fugax

Basilar artery: locked in syndrome

Lacunar strokes present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
> strong association with hypertension
> common sites include the basal ganglia, thalamus and internal capsule

Question 170

Describe the management of tuberculosis and the associated side-effects

Answer 170

• 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

Question 171

Describe the law regarding advanced care directives

Answer 171

Advance directives are a document written at a time when a person is of sound mind, of that individual’s preferences with respect to medical treatment, should they later become unable to express those wishes directly

> refers to a specific treatment in a specific circumstance rather than a general statement

The Mental Capacity Act 2005 makes clear that such advance directives are binding, unless the following exceptions apply:

> The decision has been subsequently withdrawn

> Power to make such decisions has been conferred to another person by creating a Lasting Power of Attorney

> Since making the will the patient has acted in a way that is clearly inconsistent with the advance decision remaining their fixed decision

> The person is not incapacitated and can decide for themselves

> The treatment in question is not that specified in the advance decision

> Any of the circumstances specified in the advance decision do not exist

> There ‘are reasonable grounds for believing that circumstances exist which the person did not anticipate at the time of the advance decision and which would have affected his decision at the time of the advance decision.’

Question 172

Describe the use of bisphosphonates and adverse effects associated

Answer 172

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

Question 173

What is the transfer factor value in asthma?

Answer 173

Raised

Question 174

What airway is contraindicated in non-fasted patients?

Answer 174

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.

Question 175

List medications and conditions that can cause gingival hyperplasia

Answer 175

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

Question 176

Describe the management of coeliac disease

Answer 176

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

Question 177

Describe Plummer-Vinson syndrome

Answer 177

Triad of:
dysphagia (secondary to oesophageal webs)
glossitis
iron-deficiency anaemia

Treatment includes iron supplementation and dilation of the webs

Question 178

Describe silicosis

Answer 178

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

Question 179

Describe asbestosis

Answer 179

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

can lead to mesothelioma and lung cancer

Question 180

Describe factors which indicate severe acute pancreatitis

Answer 180

age > 55 years
hypocalcaemia
hyperglycaemia
hypoxia
neutrophilia
elevated LDH and AST

serum amylase is diagnostic but NOT prognostic

Question 181

Describe the guidelines for breast cancer referral

Answer 181

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:

aged 30 and over and have an unexplained breast lump with or without pain or

aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people:

with skin changes that suggest breast cancer or
aged 30 and over with an unexplained lump in the axilla

Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain.

Question 182

List causes of acanthosis nigricans

Answer 182

type 2 diabetes mellitus
gastrointestinal cancer
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)

Question 183

Describe gastric MALT lymphoma and its management

Answer 183

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

Question 184

Describe adverse effects of vancomycin

Answer 184

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

Question 185

List indications for CT head within 1 hour in head injury

Answer 185

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

Question 186

Describe adverse effects associated with azathioprine

Answer 186

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.

Question 187

describe basal cell carcinoma and its management

Answer 187

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

Question 188

Describe the diagnosis and clinical features of TB

Answer 188

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

False negative tests may be caused by:
miliary TB
sarcoidosis
HIV
lymphoma
very young age (e.g. < 6 months)

Question 189

list causes of erythema nodosum

Answer 189

infection: streptococci, tuberculosis, brucellosis

sarcoidosis

inflammatory bowel disease

Behcet’s

malignancy/lymphoma

drugs: penicillins, sulphonamides, combined oral contraceptive pill

pregnancy

Question 190

List causes of a normal anion gap metabolic acidosis (hyperchloraemic) and a raised anion gap metabolic acidosis

Answer 190

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

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

Question 191

List symptoms of hypoglycaemia

Answer 191

Autonomic
- Trembling
- Sweating
- Anxiety
- Palpitations
- Hunger
- Nausea
- Tingling

Neuroglycopaenic
- Confusion
- Weakness
- Drowsiness
- Visual change
- Difficulty speaking
- Headache
- Dizziness
- Tiredness

Question 192

Describe the management of hypoglycaemia

Answer 192

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

Question 192

Describe the features of Parkinson’s disease

Answer 192

• Bradykinesia
  > test with finger-tap test and pronation-supination test
• Unilateral pill-rolling tremor
  > asymmetrical, 4-6 Hz, enhanced by anxiety
• shuffling gait with reduced arm swing
• Postural instability
• Leadpipe rigidity or cogwheeling

Neuropsychiatric
- Anxiety, depression
- Hallucinations
- Sleep disorders
- Cognitive impairment

Autonomic
- Altered sense of smell
- Constipation

Genitourinary
- Incontinence
- Nocturia, frequency
- Erectile dysfunction

Myalgia
Hyperhidrosis (sweating)
Hypomimia
Infrequency of eye blinking
Hypophonia

Question 192

List lower motor neurone signs

Answer 192

• Reduced tone
• Hyporeflexia
• Fasciculations
• Paresis
• Weakness in a root innervated pattern
• muscle atrophy

Question 193

Describe medication overuse headaches and their treatment

Answer 193

Features
present for 15 days or more per month
developed or worsened whilst taking regular symptomatic medication
patients using opioids and triptans are at most risk
may be psychiatric co-morbidity

Management (from 2008 SIGN guidelines)
simple analgesics and triptans should be withdrawn abruptly (may initially worsen headaches)
opioid analgesics should be gradually withdrawn

Question 194

Describe acute interstitial nephritis

Answer 194

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

Question 195

Describe Lyme disease and its management

Answer 195

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)

Question 195

Describe cluster headaches and their management

Answer 195

occur in clusters lasting 4-12 weeks
> clusters typically occur once a year

More common in men, smokers and alcohol drinkers

Features
-intense sharp, stabbing pain around one eye
- pain occurs once or twice a day, each episode lasting 15 mins - 2 hours
- restless and agitation during an attack
- clusters typically last 4-12 weeks
- accompanied by redness, lacrimation, lid swelling, nasal stuffiness
- miosis and ptosis

Investigations
- neuroimaging - underlying brain lesions are sometimes found
- MRI with gadolinium contrast: investigation of choice

Management
- acute:
> 100% oxygen (80% response rate within 15 minutes)
> subcutaneous triptan (75% response rate within 15 minutes)
> prophylaxis: verapamil

Question 195

Describe different types of aphasia

Answer 195

Wernicke’s (receptive) aphasia: left MCA lesion.
> Lesions result in sentences that make no sense, word substitution and neologisms but speech remains fluent - ‘word salad’
> impaired comprehension

Broca’s (expressive) aphasia: left MCA lesion.
> Speech is non-fluent, laboured, and halting. Repetition is impaired.
> Comprehension is normal

Conduction aphasia: stroke affecting arcuate fasciculus (connecting Wernicke’s and Broca’s):
> fluent speech but poor repetition.
> Comprehension is normal.

Global aphasia: severe expressive and receptive aphasia

Question 195

Describe Wernicke’s encephalopathy and its management

Answer 195

Wernicke’s encephalopathy is a neuropsychiatric disorder caused by thiamine deficiency which is most commonly seen in alcoholics

Rarer causes; persistent vomiting, stomach cancer, and dietary deficiency

Classic triad: ophthalmoplegia/nystagmus, ataxia and encephalopathy

Features
> oculomotor dysfunction
> nystagmus (the most common ocular sign)
> ophthalmoplegia: lateral rectus palsy, conjugate gaze palsy
> gait ataxia
> encephalopathy: confusion, disorientation, indifference, and inattentiveness
> peripheral sensory neuropathy

Investigations
> decreased red cell transketolase
> MRI

Treatment: urgent replacement of thiamine
> IV Pabrinex (vitamin B/C)

If not treated Korsakoff’s syndrome may develop
> antero- and retrograde amnesia
> confabulation

Question 195

Describe the causes of metabolic alkalosis and its management

Answer 195

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

Question 196

Describe nasopharyngeal carcinoma and its management

Answer 196

More common in individuals from southern China
Associated with EBV

Features
- Cervical lymphadenopathy
- Otalgia
- Unilateral serous otitis media
- Nasal obstruction, discharge or epistaxis
- Cranial nerve palsies e.g. III-VI

Imaging - CT / MRI

Treatment: radiotherapy

Question 197

Describe adverse effects and contraindications of statins

Answer 197

Adverse effects
- myopathy
- liver impairment

contraindications
- macrolides: clarithromycin / erythromycin
- pregnancy

Question 198

Describe myasthenia gravis and its management (as well as exacerbating factors)

Answer 198

autoimmune disorder resulting in insufficient functioning acetylcholine receptors

Features
- muscle fatigability - muscles become progressively weaker during periods of activity and slowly improve after periods of rest
- extraocular muscle weakness: diplopia
- proximal muscle weakness: face, neck, limb girdle
- ptosis
- dysphagia

Associations
> thymomas in 15%
> autoimmune disorders: pernicious anaemia, autoimmune thyroid disorders, rheumatoid, SLE
> thymic hyperplasia in 50-70%

Exacerbating factors
> penicillamine
> beta-blockers
> lithium
> phenytoin
> antibiotics: gentamicin, macrolides, quinolones, tetracyclines
> quinidine, procainamide

Investigations
> single fibre electromyography
> CT thorax - exclude thymoma
> antibodies to acetylcholine receptors

> Tensilon test: IV edrophonium reduces muscle weakness temporarily

Management
> long-acting acetylcholinesterase inhibitors: pyridostigmine is first-line
> immunosuppression: prednisolone initially
> azathioprine, cyclosporine, mycophenolate mofetil
> thymectomy

Question 199

Describe the diagnosis of diabetes mellitus

Answer 199

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

Question 200

Describe the ebola virus and its management

Answer 200

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

Question 201

List the components of the Glasgow Coma Scale

Answer 201

Eye-opening
> eyes open spontaneously (4)
> eyes open to voice (3)
> eyes open to pain (2)
> no eye-opening (1)

Verbal response
> orientated (5)
> confused (4)
> words (3)
> incomprehensible sounds (2)
> no verbal response (1)

Motor resopnse
> obeys commands (6)
> localises pain (5)
> normal flexion (4)
> abnormal flexion (3)
> abnormal extension (2)
> no motor response (1)

Question 202

Describe beta thalassaemia

Answer 202

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
  > 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

Question 203

Describe falciparum malaria and its treatment

Answer 203

commonest, and most severe, type of malaria.

fever on alternating days, think malaria

Feature of severe malaria
> schizonts 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&raquo_space; artemether plus lumefantrine
> artesunate plus amodiaquine
> malarone (atovaquone/proguanil)
> quinine sulphate tablets

Severe falciparum malaria
> intravenous artesunate
> if parasite count > 10% consider exchange transfusion
> shock may indicate coexistent bacterial septicaemia - malaria rarely causes haemodynamic collapse

Question 204

List risk factors for hepatotoxicity in paracetamol overdose

Answer 204

• 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

Question 205

Describe the appearance of the following on blood films

• hyposplenism
• IDA
• myelofibrosis
• intravascular haemolysis
• megaloblastic anaemia

Answer 205

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

Question 206

List causes of gynaecomastia (physiological and drug side-effects)

Answer 206

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. seminoma secreting hCG
- ectopic tumour secretion - adenocarcinoma of the lung
- hyperthyroidism
- haemodialysis

Drug causes of gynaecomastia
- spironolactone (most common drug cause)
- cimetidine
- digoxin
- cannabis
- finasteride
- GnRH agonists e.g. goserelin, buserelin
oestrogens, anabolic steroids

Question 207

Describe acute pericarditis and its treatment

Answer 207

Aetiology
> viral infections (Coxsackie)
> tuberculosis
> uraemia
> post-myocardial infarction
» early (1-3 days): fibrinous pericarditis
» late (weeks to months): autoimmune pericarditis (Dressler’s syndrome)

Features
> chest pain: may be pleuritic. Is often relieved by sitting forwards
> other symptoms include a non-productive cough, dyspnoea and flu-like symptoms
> pericardial rub

Investigations
> ECG changes
» widespread ‘saddle-shaped’ ST elevation
» PR depression: most specific ECG marker for pericarditis

> all patients with suspected acute pericarditis should have transthoracic echocardiography

> bloods
> inflammatory markers
> troponin: around 30% of patients may have an elevated troponin - this indicates possible myopericarditis

Management
> if high-risk features: fever > 38°C or elevated troponin: inpatient care
> treat any underlying cause
> avoid strenuous physical activity
> NSAIDs + colchicine: first-line for patients with acute idiopathic or viral pericarditis

Question 208

Describe the SCAM and ABCD approach to describing a skin lesion as well as the common morphology and pattern of rashes

Answer 208

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

Question 209

List conditions that cause all-over redness (erythroderma)

Answer 209

psoriasis

eczema

pityriasis rubra pilaris

cutaneous adverse drug reaction e.g. vancomycin causing red man syndrome

cutaneous lymphoma

Question 210

Describe pityriasis rubra pilaris

Answer 210

rare, cutaneous, inflammatory papulosquamous disorder

• classically characterized by follicular, hyperkeratotic papules
• waxy, yellow palmoplantar keratoderma
• erythroderma with islands of sparing

Question 211

Describe the clinical features of psoriasis

Answer 211

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)

Question 212

Describe features of Stevens Johnsons syndrome & Toxic Epidermal Necrolysis

Answer 212

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

Question 213

Describe erythema multiforme major and staphylococcal scalded skin syndrome

Answer 213

• 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

Question 214

Describe pemphigus vulgaris and bullous pemphigoid

Answer 214

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
> usually in older patients.
> managements: oral steroids

Question 215

Describe hereditary spherocytosis and its management

Answer 215

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

Question 216

List side-effects and contraindications of beta-blockers

Answer 216

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

Question 217

Describe dengue fever and its management

Answer 217

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

Question 218

Describe squamous cell carcinoma and its management

Answer 218

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

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

Question 219

Describe epididymo-orchitis and its management

Answer 219

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

Question 220

Describe UTI treatment guidelines

Answer 220

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

Question 221

Describe syringomyelia

Answer 221

due to development of syrinx (CSF-filled cyst) in the centre of the spinal cord

Presentation
- cape-like loss of pain and temperature sensation due to compression of spinothalamic tract fibres decussating in centre of spinal cord
- preserved light touch, proprioception and vibration
- spastic weakness
- neuropathic pain
- upgoing plantars
- autonomic features
> Horner’s syndrome due to compression of sympathetic chain
> scoliosis can develop if untreated

causes
- congenital e.g. Arnold-Chiari malformation
- acquired: trauma e.g haemorrhage, tumour
- idiopathic

investigations
- full spine MRI with contrast - exclude tumour / tethered cord
- brain MRI - exclude Chiari malformation

Treatment
- manage underlying cause
- shunt into syrinx

Question 222

Describe erythrasma and its management

Answer 222

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

Question 223

Describe phaeochromocytoma and its management

Answer 223

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
- surgery (previous stabilisation with alpha-blocker e.g. phenoxybenzamine given before a beta-blocker e.g. propranolol/labetalol)

Question 224

Describe bacterial meningitis and its management

Answer 224

Clinical features
- meningism: neck stiffness, photophobia
- nausea / vomiting
- reduced GCS
- non-blanching rash
- fever
- tachycardia, tachypnoea, hypotension
- Brudzinski / kernig’s sign +ve

attempt LP unless
- severe sepsis / rapidly evolving rash
- severe respiratory / cardiac compromise
- significant bleeding risk
- signs of raised ICP (focal neurological signs, papilloedema, continuous/uncontrolled seizures)

Management
- IV antibiotics
> <3 months: IV cefotaxime + amoxicillin
> 3 months-50 years: cefotaxime or ceftriaxone
> >50 years: cefotaxime (or ceftriaxone) + amoxicillin

• IV dexamethasone 0.15mg/kg QDS for 4 days
  > avoid in septic shock, meningococcal septicaemia, immunocompromised or meningitis following surgery
• if allergic to penicillin / cephalosporins, use chloramphenicol
• if Listeria: IV amoxicillin + gentamicin
• CT scan not indicated

Question 225

Describe schistosomiasis and its treatment

Answer 225

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

Question 226

Describe the management of acute asthma and criteria for discharge

Answer 226

• oxygen if saturations <94%
• bronchodilation with SABA (salbutamol) + ipratropium bromide
• Oral prednisolone 40-50mg PO for at least 5 days

Senior medical decision:
- IV magnesium sulphate
- IV aminophylline

Criteria for discharge
- stable on discharge medication for 12-24h
- inhaler techique checked and recorded
- PEF >75% of best or predicted

Question 227

Describe nasal polyps and their management

Answer 227

Associated with
- asthma
- aspirin sensitivity
- infective sinusitis
- cystic fibrosis
- Kartagener’s syndrome
- Churg-Strauss syndrome

Features
- nasal obstruction
- rhinorrhoea, sneezing
- poor sense of taste and smell

Red flags: unilateral symptoms, bleeding

Management
- ENT referral
- topical steroids shrink polyp size in most patients
> intranasal steroid spray or drops e.g. mometasone furoate for 4-6 weeks

Question 228

Describe otitis externa and its management

Answer 228

Causes
- infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal
> pseudomonas aeruginosa: gram negative rod, non-lactose fermenting, oxidase positive
- Seborrhoeic dermatitis
- contact dermatitis
- recent swimming

features
- ear pain, itch, discharge
- otoscopy: red, swollen or eczematous canal

management

• topical acetic acid 2% and antibiotic or combined topical antibiotic with steroid for 1-2 weeks
• if canal debris consider removal, if canal is extensively swollen then insert ear wick

second-line
- consider contact dermatitis secondary to neomycin
- oral antibiotics (flucloxacillin) if infection is spreading
- take a swab inside ear canal
- empirical use of antifungal agent

If the patient fails to respond to topical antibiotics refer to ENT

Malignant otitis externa more common in elderly diabetics - extension of infection into bony ear canal and soft tissues

Question 229

Describe idiopathic intracranial hypertension

Answer 229

classically seen in young overweight females

features
- headache
- blurred vision
- papilloedema
- enlarged blind spot
- sixth nerve palsy

investigations
- lumbar puncture: opening pressure values >25 cmH2O
- CT brain: enlarged arachnoid outpouchings, prominent perivascular spaces

management
- weight loss - semaglutide and topiramate
- carbonic anhydrase inhibitors e.g. acetazolamide
- repeated LP - temporary measure
- surgery:
> optic nerve sheath decompression and fenestration
> lumboperitoneal / ventriculoperitoneal shunt

Question 230

describe allergic rhinitis and its management

Answer 230

inflammatory disorder of the nose where it becomes sensitised due to allergens such as house dust mites, grass and tree pollens.

classification
- seasonal (hay fever)
- perennial
- occupational

features
- sneezing
- bilateral nasal obstruction
- clear nasal discharge
- post-nasal drip
- nasal pruritus

management
- allergen avoidance
- mild symptoms: oral / intranasal antihistamines
- moderate/severe: intranasal steroids
- topical nasal decongestants e.g. oxymetazoline (short courses as rebound hypertrophy may occur after prolonged courses, known as rhinitis medicamentosa)

Question 231

Describe the following testicular lumps
- epididymal cysts
- varicocoele
- testicular cancer
- inguinal hernia

Answer 231

• 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

Question 232

Describe an Arnold-Chiari malformation

Answer 232

downward displacement or herniation of cerebellar tonsils through foramen magnum

malformation may be congenital or acquired through trauma

features
- non-communicating hydrocephalus may occur as a result of obstruction of CSF flow
- headache
- syringomyelia

Question 233

Describe iliopsoas abscesses

Answer 233

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

Question 234

Describe the management of AF

Answer 234

Rate control
- beta-blockers
- calcium channel blockers
- digoxin
> causes scooped ST depression

rhythm control
- beta-blockers
- dronedarone (second-line following cardioversion)
- amiodarone (co-existing HF)

catheter ablation if not responding to medication
> patients should remain on anticoagulation (DOAC) as stroke risk is the same

To determine the need for anticoagulation in AF: CHA2DS2VASc >=2

Question 235

Describe Non-Hodgkin’s lymphoma

Answer 235

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)
- 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

Question 236

Describe coal workers’ pneumoconiosis

Answer 236

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

Question 237

List causes of upper lobe fibrosis

Answer 237

CHARTS

• Coal workers’ pneumoconiosis
• Histiocytosis / hypersensitivity pneumonitis
• Ankylosing spondylitis, allergic bronchopulmonary aspergillosis
• Radiation
• Tuberculosis
• Silicosis, sarcoidosis

Question 238

Describe tetanus and its management

Answer 238

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

Question 239

Describe thyroid eye disease

Answer 239

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

Question 239

Describe HIV and its management

Answer 239

Seroconversion occurs 3-12 weeks after infection
features of seroconversion
- sore throat
- lymphadenopathy
- malaise, myalgia, arthralgia
- diarrhoea
- maculopapular rash
- mouth ulcers
- rarely meningoencephalitis

management

• highly active anti-retroviral therapy

> 2 nucleoside reverse transcriptase inhibitor (NRTI) e.g. tenofovir and emtricitabine + one other agent
integrase inhibitors
protease inhibitors
non-nucleoside reverse transcriptase inhibitor

• if CD4 count <200 give co-trimoxazole as prophylaxis against pneumocystis jiroveci pneumonia
  > often normal CXR with desaturation on exertion

Question 240

describe hypomagnesaemia and its symptoms

Answer 240

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

Question 241

Describe the management of proteinuric CKD and its complications

Answer 241

management of proteinuric CKD
- ACEi or ARB: first-line in hypertension + CKD if ACR > 30mg/mmol, 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

• vitamin D supplementation: calcitriol
• erythropoietic stimulating agent: anaemia + renal insufficiency (if iron levels normal)

Question 242

Describe acne vulgaris and its management

Answer 242

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

Question 243

List side-effects of isotretinoin

Answer 243

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

Question 244

List examples of a mild steroid, intermediate, potent and very potent

Answer 244

mild steroid - hydrocortisone

intermediate steroid - eumovate (clobetasone butyrate)

potent steroid - betamethasone valerate (betnovate)

very potent steroid - dermovate (clobetasol propionate)

Question 245

Describe Nelson’s syndrome

Answer 245

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.

Question 246

Describe the treatment of pituitary adenomas

Answer 246

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

Question 247

Describe the causes and presentation of pleural effusion

Answer 247

Transudate (<30g/L protein)
- HF
- liver failure
- nephrotic syndrome
- hypothyroidism
- Meig’s syndrome: transudative pleural effusion and ascites in the presence of a benign ovarian tumour

Exudate (>30g/L protein)
- infection: pneumonia, TB
> 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

Question 248

Describe refeeding syndrome

Answer 248

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

Question 249

Describe pulmonary function test results for obstructive and restrictive lung pathology using examples

Answer 249

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

Question 250

Describe seborrhoeic keratosis

Answer 250

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

Question 251

Describe sarcomas and their treatment

Answer 251

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

Question 252

Describe enteric fever (typhoid/paratyphoid)

Answer 252

caused by salmonella typhi and paratyphi

Symptoms
- fever
- headache
- arthralgia
- relative bradycardia
- abdominal pain, distension
- diarrhoea or constipation
- rose spots: erythematous maculopapular lesions often on torso

• complications
  > osteomyelitis
  > GI bleed/perforation
  > meningitis
  > cholecystitis
  > chronic carriage

management - ciprofloxacin

Question 253

Describe a post-LP headache and its management

Answer 253

Low pressure headache

can occur up to a week later from when the LP was taken

alleviated by lying down
> if headache lasts more than 3 days, consider subdural haematoma

management
- supportive analgesia - analgesia, rest
- consider blood patch, epidural saline and IV caffeine

Question 254

Describe the diagnostic criteria for migraine

Answer 254

• headache attacks lasting 4-72h
• at least 2 of the following characteristics
  > unilateral location but may be bilateral
  > pulsating quality
  > moderate or severe pain
  > aggravation by routine physical activity
• during headache at least one of the following
  > nausea or vomiting
  > photophobia, phonophobia
• not attributed to another disorder

in children, attacks may be shorter-lasting, headache is bilateral and GI disturbance is more prominent

migraine with aura
> aura is progressive in nature and occurs hours prior to headache
> typical aura includes a transient hemianopic disturbance or a spreading scintillating scotoma (jagged crescent)
> sensory symptoms may occur

auras may occur with/without headache and are fully reversible, develop over at least 5 minutes and last 5-60 minutes

atypical symptoms
> motor weakness
> double vision
> visual symptoms affecting only one eye
> poor balance / decreased GCS

Question 255

Describe a cholesteatoma

Answer 255

non-cancerous growth of squamous epithelium that is trapped within the skull base causing local destruction

most common in patients aged 10-20 years

risk factor: cleft palate

clinical features
- foul-smelling non-resolving discharge
- hearing loss
- vertigo
- facial nerve palsy
- cerebellopontine angle syndrome

otoscopy - attic crust - seen in uppermost part of ear drum

management - ENT referral for consideration of surgical removal

Question 256

Describe the clinical features and diagnosis of shingles

Answer 256

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

Question 257

Describe Ehlers-Danlos syndrome

Answer 257

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

Question 258

Describe renal cell cancer and its management

Answer 258

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

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

Question 259

Describe post-thrombotic syndrome

Answer 259

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

Question 260

Describe different thyroid nodules and appropriate investigations

Answer 260

Benign
- multinodular goitre: patchy uptake on thyroid scintigraphy
- thyroid adenoma
- hashimoto’s thyroiditis
- cysts - colloid, simple or haemorrhagic

Malignant

• papillary carcinoma
• follicular carcinoma
• medullary carcinoma
  > serum calcitonin to assess recurrence
• anaplastic carcinoma
• lymphoma

> thyroglobulin antibodies to detect recurrence

investigation
- ultrasonography (first-line)
- TFTs

Question 261

Describe primary biliary cholangitis and its management

Answer 261

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

Question 262

Describe hyperhidrosis and its management

Answer 262

excessive sweat production

management
- topical aluminium chloride (first-line)
> side-effect: irritation

• iontophoresis
• botulinum toxin
• surgery: endoscopic transthoracic sympathectomy
  > risk of compensatory sweating

Question 263

Describe a major side effect of hydroxychloroquine therapy

Answer 263

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

Question 264

Describe rabies and the management of possible exposure

Answer 264

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

Question 265

describe the management of COPD

Answer 265

• 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 add LAMA as well

> 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

Question 266

Describe herpes simplex virus and its management

Answer 266

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

Question 267

describe erectile dysfunction and its management

Answer 267

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

Question 268

describe diabetic neuropathy and its treatment

Answer 268

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

Question 269

What electrolyte and acid-base disturbance is associated with Cushing’s syndrome?

Answer 269

Hypokalaemic metabolic alkalosis

Question 270

Describe the prescription of morphine in palliative care

Answer 270

divide oral dose by two when converting from oral to subcutaneous 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

Question 271

Describe hidradenitis suppurativa

Answer 271

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

Question 272

describe digoxin toxicity

Answer 272

features
> generally unwell, lethargy
> nausea and vomiting, anorexia
> confusion
> yellow-green vision
> arrhythmias e.g. premature ventricular complexes (PVCs), ventricular tachycardia or ventricular fibrillation, sinus bradycardia
> gynaecomastia

predisposing factors
- hypokalaemia, hypomagnesaemia
- hypercalcaemia
- hypernatraemia
- acidosis
- drugs: amiodarone, quinidine, verapamil, diltiazem, spironolactone, ciclosporin, bendroflumethiazide

management
> digibind
> correct arrhythmias
> monitor potassium

Question 273

Describe idiopathic pulmonary fibrosis

Answer 273

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

Question 274

Describe Kartagener’s syndrome

Answer 274

aka primary ciliary dyskinesia

pathogenesis - dynein arm defect results in immotile cilia

features
- dextrocardia or complete situs inversus
- bronchiectasis
- recurrent sinusitis
- subfertility

Question 275

describe thyroid storm

Answer 275

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): methimazole, propylthiouracil
- Lugol’s iodine

Question 276

describe diabetes sick day rules

Answer 276

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)

Question 276

describe medial epicondylitis

Answer 276

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

Question 276

describe diabetes insipidus and its management

Answer 276

• 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)

Question 277

Describe hepatorenal syndrome

Answer 277

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

Question 277

Describe the classification in epilepsy

Answer 277

• 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

Question 277

Describe vitiligo

Answer 277

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

Question 277

Describe drugs which cause the following changes in the liver

• hepatocellular
• cholestatic

Answer 277

• 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

Question 278

What medication can be given for the prevention of calcium stones?

Answer 278

potassium citrate

Question 278

describe pathology of the salivary glands

Answer 278

3 pairs of salivary glands

• parotid (serous secretions) - most tumours
  > Stensens duct drains the parotid gland

> malignancy
> pleomorphic adenomas
> Warthin’s tumour: benign adenolymphoma
> superficial lobe

> other causes of enlargement
> acute viral infection e.g. mumps
> acute bacterial infection
> sicca syndrome and Sjogren’s

• submandibular (mixed secretions) - most stones

> sialadenitis

> > inflammation of the salivary gland likely secondary to obstruction by a stone impacted in the duct

> > the duct from the submandibular gland drains into the mouth and purulent discharge causes a foul taste

> > clinical features
> recurrent unilateral pain and swelling on eating
> may become infected: Ludwig’s agina

> > investigations: plain X-ray, sialography

> > remove surgically

• sublingual (mucous secretions)

Question 279

describe brain abscesses and their management

Answer 279

causes
- extension of sepsis from middle ear or sinuses
- trauma or surgery to the scalp
- penetrating head injuries
- embolic events from endocarditis

clinical features
- depends on the site of the abscess
- headache (dull, persistent)
- fever
- focal neurology e.g. oculomotor nerve palsy
- other features of raised ICP: nausea, papilloedema, seizures

investigations
- CT head

management
- surgery
> craniotomy and debridement of abscess cavity
- IV Abx: IV 3rd generation cephalosporin + metronidazole
- Intracranial pressure management: e.g. dexamethasone

Question 280

Describe pseudohyponatraemia and its causes

Answer 280

to diagnose pseudohyponatraemia

> Calculate osmolarity = 2Na + 2K + 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

Question 281

Describe hyponatraemia and its causes

Answer 281

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

Question 282

Name the most common cause of
- bacterial meningitis <60
- viral meningitis
- viral encephalitis

Answer 282

bacterial meningitis <60: Neisseria meningitidis, streptococcus pneumoniae

Viral meningitis: enterovirus
> Coxsackie, Echovirus

Viral encephalitis: HSV

Question 283

Describe viral meningitis and its management

Answer 283

Presents similarly to bacterial meningitis
> less likely to have a non-blanching purpuric rash
> less severe than bacterial meningitis

management
- supportive, usually self-limiting course of 7-14 days
- aciclovir if thought to be caused by HSV
- IV aciclovir if concern regarding encephalitis

Question 284

in the context of meningitis, under which circumstances should LP be delayed?

Answer 284

• signs of severe sepsis
• rapidly evolving rash
• severe respiratory / cardiac compromise
• significant bleeding risk
• signs of increased ICP
  > focal neurology
  > GCS <=12
  > Papilloedema
  > seizures

Question 285

describe CSF results depending on the cause of meningitis

Answer 285

bacterial
- appearance: cloudy
- glucose: low (<1/2 plasma)
- protein: high (>1g/l)
- WCC: 10-5000 polymorphs/mm3

viral
- appearance: clear/cloudy
- glucose: 60-80% of plasma glucose
- protein: normal/raised
- WCC: 15-1000 lymphocytes/mm3

TB
- appearance: slight cloudy, fibrin web
- glucose: low (<1/2 plasma)
- protein: high (>1 g/l)
- WCC: 30-300 lymphocytes/mm3

fungal
- appearance: cloudy
- glucose: low
- protein: high
- WCC: 20-200 lymphocytes/mm3

Question 286

describe the management of status epilepticus

Answer 286

• ABCDE assessment
• airway: lateral decubitus, nasal trumpets, O2, suction
• IV access

0-5 mins (give benzos at 5 mins)
> lorazepam 0.1mg/kg IV, max 4mg, repeat once in 4min
> OR midazolam 10mg IM once

10-15 mins
> levetiracetam 60mg/kg IV
> OR fosphenytoin or phenytoin 20mg/kg IV
> OR valproate 40mg/kg IV

> advanced airway management
> RSI
> Preoxygenation
> Induction: propofol or ketofol
> paralytics: rocuronium, succinylcholine

15-20 mins: refractory medications
- propofol
- midazolam
- ketamine
- lacosamide
- phenobarbital

Question 287

Describe multiple myeloma and its diagnosis

Answer 287

haematological malignancy characterised by plasma cell proliferation

Features
- 70 yo

• 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’

Question 288

Describe Addison’s disease and its management

Answer 288

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

Question 289

Describe athlete’s foot and its treatment

Answer 289

tinea pedis

usually caused by fungi in the genus Trichophyton

features
- scaling
- flaking
- itching between toes

management

• first-line: topical imidazole, undecenoate
• second-liine: oral terbinafine

Question 290

Describe the management of the following overdoses

• heparin
• ethylene glycol (anti-freeze)
• methanol
• benzodiazepines
• beta-blockers
• digoxin
• iron
• lead
• carbon monoxide
• cyanide
• methotrexate

Answer 290

• 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

Question 291

Describe primary sclerosing cholangitis and its management

Answer 291

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

Question 292

describe cushing’s triad for increased ICP

Answer 292

• bradycardia
• irregular breathing
• hypertension with wide pulse pressure

Question 293

describe malignant otitis externa

Answer 293

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

Question 294

deficiency of what vitamin causes angular cheilitis

Answer 294

riboflavin - vitamin B2

Question 295

Describe myocarditis and its treatment

Answer 295

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

Question 296

describe spinal stenosis

Answer 296

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

Question 297

describe diagnostic testing for asthma

Answer 297

> spirometry with a bronchodilator reversibility test
> FEV1/FVC < 0.7
> Reversibility of >=200ml or 12%

> FeNO test (>=40 ppb is positive)

test peak flow variability if inconclusive

Question 298

describe atrial flutter and its management

Answer 298

features
- supraventricular tachycardia
- ECG findings
> sawtooth appearance
> flutter waves may be visible following carotid sinus massage or adenosine

management
- similar to AF but medication may be less effective
- atrial flutter is more sensitive to cardioversion so lower energy levels may be used
- radiofrequency ablation of the tricuspid valve isthmus is curative for most patients

Question 299

describe myelofibrosis

Answer 299

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

Question 300

what is lanugo hair?

Answer 300

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

Question 301

describe carcinoid syndrome

Answer 301

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

Question 302

describe the diagnosis of multiple sclerosis

Answer 302

diagnosis requires dissemination of demyelinating lesions in time and space

MRI brain + spinal cord with contrast

+ve Hoffman’s sign

MRI
- high signal T2 lesions
- periventricular plaques
- Dawson fingers

CSF
- oligoclonal bands
- increased intrathecal synthesis of IgG

Visual evoked potentials
- delayed but well-preserved waveform

Question 303

describe alcohol withdrawal

Answer 303

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

Question 304

describe degenerative cervical myelopathy

Answer 304

presentation
- pain (neck, upper or lower limbs)

• loss of motor function (loss of digital dexterity, arm or leg weakness/stiffness leading to impaired gait and balance)
• loss of sensory function causing numbness
• loss of autonomic function (urinary or faecal incontinence / impotence)
• Hoffman’s sign: exaggerated flexion of terminal phalanx of thumb after flicking DIP joint of middle finger
  > UMN sign

MRI - gold standard

management
- urgent referral for assessment by specialist spinal services
- decompressive surgery

Question 305

describe fragile X syndrome

Answer 305

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

Question 306

describe tumour lysis syndrome

Answer 306

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

Question 307

describe driving guidelines for epilepsy

Answer 307

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

Question 308

describe takayasu’s arteritis

Answer 308

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

Question 309

describe antiphospholipid syndrome

Answer 309

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

Question 310

name the most likely electrolyte abnormality in a patient taking a thiazide diuretic

Answer 310

hyponatraemia

Question 311

list causes of a false negative mantoux test

Answer 311

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

Question 312

describe hepatitis B serology interpretation

Answer 312

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

Question 313

describe hyperosmolar hyperglycaemic state (HHS)

Answer 313

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

Question 314

describe haemolytic anaemia

Answer 314

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)

Question 315

describe the clinical features of MS

Answer 315

visual
- optic neuritis
- optic atrophy
- Uhthoff’s phenomenon: worsening of vision following rise in body temperature
- internuclear ophthalmoplegia

sensory
- pins/needles
- numbness
- trigeminal neuralgia
- Lhermitte’s syndrome: paraesthesiae in limbs on neck flexion

motor
- spastic weakness (most commonly in legs)

cerebellar
- ataxia
- tremor

others
- urinary incontinence
- sexual dysfunction
- intellectual deterioration

Question 316

which medication increases the risk of azathioprine toxicity?

Answer 316

allopurinol

Question 317

describe myelodysplastic syndrome

Answer 317

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

Question 318

describe acute management of seizures

Answer 318

• 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

Question 319

what is the management of antiphospholipid syndrome in pregnancy?

Answer 319

aspirin + LMWH

Question 320

describe extradural haematoma

Answer 320

pathophysiology
> mostly trauma, low-impact head injury
> especially over temporal region due to the pterion overlying the middle meningeal artery

patients may experience a lucid interval
> briefly regain consciousness after injury before progressing into coma

imaging
- biconvex or lentiform hyperdense collection limited by suture lines of skull

management
- no neurological deficit: cautious clinical and radiological observation
- definitive treatment: craniotomy and evacuation of haematoma

Question 321

describe von willebrand disease (VWD)

Answer 321

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

Question 322

describe cryptosporidium diarrhoea

Answer 322

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

Question 323

describe renal artery stenosis

Answer 323

secondary hyperaldosteronism
- renin levels are high
- 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

Question 324

describe miller fisher syndrome

Answer 324

subtype of Guillain-Barré syndrome (GBS)

characterised by areflexia, ataxia and ophthalmoplegia

descending weakness is a classic features as opposed to ascending weakness in more common forms of GBS

anti-GQ1b antibodies present in most cases

Question 325

describe urethral strictures

Answer 325

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

Question 326

describe the staging of severity of COPD

Answer 326

FEV1 >80%: stage 1 - mild

FEV1 50-79%: stage 2 - moderate

FEV1 30-49%: stage 3 - severe

FEV1 <30%: stage 4 - very severe

Question 327

describe familial hypercholesterolaemia

Answer 327

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

Question 328

describe theophylline toxicity

Answer 328

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

Question 329

describe alcoholic hepatitis and its management

Answer 329

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

Question 330

how long should patients wait before flying if they have a full plaster cast

Answer 330

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

Question 331

describe the treatment of fungal nail infections

Answer 331

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 infection: oral terbinafine 3-6 months

> more extensive involvement due to Candida infection: oral itraconazole

Question 332

list causes of hypoadrenalism

Answer 332

Primary
- tuberculosis
- metastases
- meningococcal septicaemia (Waterhouse-Friedrichsen syndrome)
- HIV
- antiphospholipid syndrome

Secondary
- pituitary disorders e.g. tumours, irradiation, infiltrationa

exogenous glucocorticoid therapy

Question 333

describe the management of hyponatraemia

Answer 333

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

Question 334

describe osmotic demyelination syndrome

Answer 334

aka central pontine myelinolysis

• can occur due to overcorrection of severe hyponatraemia
• Na levels should only be raised by 4-6 mmol/l in 24h

symptoms usually occur after 2 days and are irreversible
- dysarthria
- dysphagia
- paraparesis or quadriparesis
- seizures
- confusion
- coma

patients are awake but unable to move or verbally communicate - locked-in syndrome

from high to low your brain will blow - cerebral oedema
from low to high your pons will die - central pontine myelinolysis

Question 335

when is rhythm control preferred to rate control in AF?

Answer 335

patients who are young and symptomatic

> anticoagulation for 3 weeks followed by cardioversion when AF >48h in duration

Question 336

list associated nerve lesions for the following operations

• posterior triangle lymph node biopsy
• Lloyd Davies stirrups
• thyroidectomy
• anterior resection of the rectum
• axillary node clearance
• inguinal hernia surgery
• varicose vein surgery
• posterior approach to the hip
• carotid endarterectomy

Answer 336

• 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

Question 337

differentiate between arterial and venous ulcers

Answer 337

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

Question 338

describe toxoplasmosis

Answer 338

caused by Toxoplasma gondii, an obligate intracellular protozoan

animal reservoir: cats, rats

immunocompetent patients
- asymptomatic self-limiting infection
- if symptomatic clinical features mimic infectious mononucleosis
- less common manifestations: meningoencephalitis, myocarditis

serology is the investigation of choice

HIV/immunocompromised
- cerebral toxoplasmosis in 50%
- constitutional symptoms, drowsiness, headache
- chorioretinitis may develop

• CT: single or multiple ring-enhancing lesions, mass effect may be seen

management: pyrimethamine plus sulphadiazine for at least 6 weeks (if immunosuppressed, immunocompetent individuals require no treatment)

Question 339

what is the most sensitive and specific lab finding for diagnosis of liver cirrhosis in those with chronic liver disease?

Answer 339

thrombocytopaenia

Question 340

describe malignant hyperthermia and its treatment

Answer 340

AD disorder presenting as hypermetabolic crisis with
> increased end-tidal CO2
> tachycardia
> muscle rigidity
> rhabdomyolysis
> hyperthermia
> arrhythmia

commonly associated with volatile inhalational anaesthetic agents and the muscle relaxant succinylcholine (suxamethonium)

management - IV dantrolene

Question 341

describe thyroid problems which may arise during pregnancy

Answer 341

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

Question 342

describe Torsades de Pointes

Answer 342

polymorphic VT with long QTc

may deteriorate into VFib

management - IV magnesium sulphate over 10 minutes

may be caused by subarachnoid haemorrhage, SSRIs

Question 343

describe acute intermittent porphyria

Answer 343

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

Question 344

describe scabies and its management

Answer 344

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

Question 345

describe polycythaemia rubra vera

Answer 345

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
- 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

Question 346

describe sagittal sinus thrombosis

Answer 346

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

Question 347

describe non-alcoholic fatty liver disease (NAFLD)

Answer 347

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

Question 348

describe osteogenesis imperfecta

Answer 348

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

Question 349

describe intestinal angina

Answer 349

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

Question 350

describe Bartter syndrome

Answer 350

AR disorder which causes renal tubular disease

characterised by hypokalaemia, hypochloraemia

renal stones and metabolic alkalosis are commonly seen in this condition

Question 351

describe the mechanism of action of the following drugs

• domperidone
• prochlorperazine
• ondansetron
• metoclopramide

Answer 351

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

Question 352

what is the mechanism of action of bupropion?

Answer 352

norepinephrine and dopamine reuptake inhibitor, nicotinic antagonist

Question 353

describe the diagnosis of MND

Answer 353

diagnosis is clinical

• clues
  > asymmetric limb weakness
  > mixture of LMN and UMN signs
  > wasting of small hand muscles / tibialis anterior
  > fasciculations
  > emotional lability
  > absence of sensory signs/symptoms
  > sparing of eye movements

> nerve conduction studies will show normal motor conduction and can exclude a neuropathy

> electromyography shows a reduced number of action potentials with increased amplitude

> MRI - exclude cervical cord compression and myelopathy

Question 354

describe the management of acute confusional state

Answer 354

treat the underlying cause and modify environment

if not working then haloperidol / olanzapine can be used

if Parkinson’s use atypical antipsychotics like quetiapine or clozapine

Question 355

describe acute bacterial prostatitis

Answer 355

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

Question 356

Describe keloid scars and their treatment

Answer 356

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

Question 357

state liver transplantation criteria in paracetamol overdose

Answer 357

pH <7.3 more than 24h after ingestion

Question 358

describe vertebrobasilar ischaemia

Answer 358

features
vertigo upon neck extension (looking up)
exacerbated by changes in head position
falls in elderly patients

risk factors - CVD, atherosclerosis

Question 359

describe latent tuberculosis

Answer 359

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)

Question 360

describe tetanus vaccination

Answer 360

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

Question 361

describe quinine toxicity (cinchonism)

Answer 361

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

Question 362

describe the features and diagnosis of infectious mononucleosis

Answer 362

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

Question 363

how would you check if fluid is truly CSF?

Answer 363

check a glucose level: bedside test

beta-2-transferrin level: gold standard

Question 364

describe the different types of aphasia

Answer 364

Wernicke’s (receptive) aphasia
> lesion of superior temporal gyrus
> usually supplied by inferior division of left MCA

> features
- sentences that make no sense
- word substitution
- neologism
- speech remains fluent
- “word salad”
- comprehension is impaired

Broca’s (expressive) aphasia
> lesion of inferior frontal gyrus
> usually supplied by superior division of left MCA
> speech is non-fluent, laboured and halting
> repetition is impaired
> comprehension is normal

Conduction aphasia
> usually due to stroke affecting arcuate fasciculus
> speech is fluent but repetition is poor
> aware of errors being made
> comprehension is normal

Global aphasia
> severe expressive and receptive aphasia
> may still be able to communicate using gestures

Question 365

What should be done in the investigation of DVT if the scan is negative but D dimer is positive?

Answer 365

stop anticoagulation and repeat scan in 1 week

Question 366

describe chronic fatigue syndrome

Answer 366

aka myalgic encephalomyelitis (ME)

diagnosed after at least 3 months of disabling fatigue affecting mental and physical function >50% of the time in the absence of other disease which can explain symptoms

features
- fatigue
- sleep problems
- muscle/joint pains
- headaches
- painful lymph nodes
- cognitive dysfunction
- physical or mental exertion makes symptoms worse

management
- energy management
- CBT

Question 367

What is the mechanism of controlled hyperventilation in raised ICP?

Answer 367

Reduced blood carbon dioxide to induce cerebral vasoconstriction

Question 368

which blood-thinning medication should be avoided if patients are allergic to sulfasalazine?

Answer 368

aspirin

Question 369

how long is anticoagulation continued in PE

Answer 369

provoked: 3 months

unprovoked: 6 months

Question 370

which medication is used to reverse

• dabigatran
• apixaban / rivaroxaban
• warfarin

Answer 370

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

Question 371

describe acute tubular necrosis

Answer 371

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

Question 372

describe the mechanism of action of orlistat

Answer 372

pancreatic lipase inhibitor

Question 373

what is the most likely cardiac sequela of thyrotoxicosis?

Answer 373

high output cardiac failure

atrial fibrillation

Question 374

what patient factors are required to calculate Z score?

Answer 374

age, gender, ethnicity

Question 375

what is the waterlow score used to identify?

Answer 375

patients at risk of pressure sores

Question 376

describe amoebiasis

Answer 376

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

Question 377

describe epistaxis and its management

Answer 377

split into anterior and posterior bleeds

anterior bleeds often have a visible source of bleeding and occur due to insult to the network of capillaries forming Kiesselbach’s plexus

posterior bleeds tend to be more profuse and originate from deeper structures

causes
- nose picking / nose blowing
- trauma
- insertion of foreign bodies
- bleeding disorders
- juvenile angiofibroma
- cocaine use
- hereditary haemorrhagic telangiectasia
- GPA

Management

• haemodynamically stable:

> first aid
> sit with torso forward and mouth open (breathe through mouth)
> pinch the cartilaginous area of the nose firmly

> topical antiseptic e.g. Naseptin (chlorhexidine, neomycin)

if bleeding does not stop after 10-15 minutes of continuous pressure consider cautery or packing
> cautery if source is visible
> packing if source is not visible

• haemodynamically unstable
  > control with first aid measures, if source is not visible admit to hospital, if fails all emergency management - sphenopalatine ligation in theatre

Question 378

what is the target INR for the following mechanical valve replacements

mitral
aortic

Answer 378

aortic: 3.0
mitral: 3.5

Question 379

how would you calculate % of body surface covered by burns in a patient

Answer 379

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

Question 380

describe solitary rectal ulcer syndrome

Answer 380

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

Question 381

describe the management of sickle cell crisis

Answer 381

classes
- painful or vaso-occlusive crises
- acute chest syndrome
- anaemic: aplastic or sequestration
- infection

management:

• painful crisis:
  IV fluids + oxygen + opiates
  > consider antibiotics if evidence of infection

acute chest syndrome:
> dyspnoea, chest pain, pulmonary infiltrates on CXR, low O2
> 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

Question 382

describe the following conditions

Idiopathic thrombocytopaenic purpura (ITP)

Thrombotoic thrombocytopaenic purpura (TTP)

Haemolytic uraemic syndrome (HUS)

Henoch Schonlein Purpura (HSP)

Haemorrhagic Haemolytic Telangiectasis (HHT)

Answer 382

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.

Question 383

which medications should be held in C diff inspection?

Answer 383

agents which slow peristalsis e.g. opioids, loperamide

> can predispose to toxic megacolon by slowing clearance of C diff toxin

Question 384

describe vitamin C deficiency (scurvy)

Answer 384

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

Question 385

which medication shouldn’t be given in VT?

Answer 385

Verapamil

Question 386

describe infection with clostridium botulinum

Answer 386

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

Question 387

what test can confirm an acute haemolytic transfusion reaction?

Answer 387

Direct Coombs test

Question 388

describe the Barthel index

Answer 388

measure of disability or dependence in activities of daily living in stroke patients

Question 389

list criteria for CT head within 1 hour

Answer 389

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, CSF leakage from ear or nose, Battle’s sign)
post-traumatic seizure
focal neurological deficit
more than 1 episode of vomiting

Question 390

state transfusion threshold for the following conditions

Answer 390

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

Question 391

List side-effects associated with the following antibiotics

• amoxicillin
• co-amoxiclav
• flucloxacillin
• erythromycin
• ciprofloxacin
• metronidazole
• doxycycline
• trimethoprim

Answer 391

• 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

Question 392

Describe autoimmune haemolytic anaemia

Answer 392

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

Question 393

describe driving rules for insulin-dependent diabetics

Answer 393

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

Question 394

describe neurogenic shock

Answer 394

causes
- trauma e.g. spinal cord transection

features
- bradycardia
- hypotension

management
- vasopressors

Question 395

describe the management of a ruptured AAA

Answer 395

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

Question 396

how would you manage an immunosuppressed patient who has been exposed to varicella zoster virus (chickenpox)?

Answer 396

• 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)

Question 397

describe myxoedema coma and its management

Answer 397

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

Question 398

Describe Legionella pneumophila

Answer 398

Cause of atypical pneumonia

• classically spread by air conditioning systems
• features
  > dry cough
  > fever
  > relative bradycardia
  > confusion
  > lymphopaenia
  > deranged LFTs
  > hyponatraemia
  > pleural effusion
  > bilateral mid-lower zone consolidation

investigations
> urinary Legionella antigen

treatment - clarithromycin

Question 399

describe the management of Meniere’s disease

Answer 399

acute attacks - buccal or IM prochlorperazine

prevention - betahistine and vestibular rehabilitation exercises

Question 400

describe the following surgical incisions

• midline incision
• paramedian incision
• Battle
• Kocher’s
• Lanz
• Gridiron
• Gable
• Pfannenstiel’s
• McEvedy’s
• Rutherford Morrison

Answer 400

• 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

Question 401

describe alcoholic ketoacidosis

Answer 401

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

Question 402

describe the management of burns

Answer 402

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

Question 403

list features of urethral injury after trauma

Answer 403

pelvic fractures may cause laceration of the urethra

features
- urinary retention
- blood at urethral meatus
- high riding prostate on DRE

Question 404

what is the most accurate marker for assessing liver function in acute liver failure?

Answer 404

prothrombin time

Question 405

describe multiple endocrine neoplasia

Answer 405

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
- medullary thyroid cancer
- 2 Ps: hyperparathyroidism, phaeochromocytoma
- RET oncogene

MEN IIb
- medullary thyroid cancer
- 1 P: phaeochromocytoma
- marfanoid body habitus
- neuromas
- RET oncogene

Question 406

describe periorificial dermatitis

Answer 406

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

Question 407

describe carbon monoxide poisoning

Answer 407

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%

Question 408

describe a funnel plot and a forest plot

Answer 408

funnel plot: demonstrate existence of publication bias in meta-analyses

forest plot: found in meta-analyses and provide graphical representation of strength of evidence of constituent trials

Question 409

describe step down of asthma treatment

Answer 409

aim for reduction of 25-50% in ICS dose

keep LABA the same

Question 410

describe serum ascites albumin gradient (SAAG)

Answer 410

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 e.g. ciprofloxacin to prevent SBP
> 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

Question 411

What benign haematological finding is common in people of black African and Afro-Caribbean ethnicity

Answer 411

benign ethnic neutropaenia

Question 412

describe water deprivation testing

Answer 412

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

Question 413

describe Meckel’s diverticulum

Question 414

what route of administration is most appropriate for the delivery of total parenteral nutrition

Answer 414

central line as it is strongly phlebitic

Question 415

describe cataplexy

Answer 415

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)

Question 416

describe herpes simplex encephalitis

Answer 416

infection of brain parenchyma

features
- fever
- headache
- psychiatric symptoms
- seizures
- vomiting
- focal features e.g. aphasia, weakness, limping

investigations
- LP
> elevated protein
> lymphocytosis
> PCR for HSV, VZV, enterovirus

• CT head: temporal lobe changes e.g. asymmetrical low density areas
• EEG

management
- start aciclovir promptly in all suspected cases of viral encephalitis
> treats HSV and VZV
> ganciclovir is needed for CMV

Question 417

describe dermatitis herpetiformis

Answer 417

intensely pruritic chronic autoimmune skin condition

features
- papules and vesicles
- affects extensor surfaces such as elbows, knees and buttocks

associated with gluten sensitivity and coeliac disease

Question 418

when co-prescribing spironolactone and ramipril which electrolyte abnormality can occur?

Answer 418

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

Question 419

describe a dermatofibroma

Answer 419

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

Question 420

list EBV associated conditions

Answer 420

• 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

Question 421

Describe temporal arteritis

Answer 421

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

Question 422

which medication can be used for the prophylaxis of calcium renal stones?

Answer 422

chlorthalidone

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

Question 422

list complications of coeliac disease

Answer 422

• anaemia: iron, folate or B12 deficiency
• hyposplenism
• osteoporosis, osteomalacia
• lactose intolerance
• enteropathy-associated T cell lymphoma of small intestine
• subfertility
• rare: oesophageal cancer, other malignancies

Question 423

describe the management of motion sickness

Answer 423

hyoscine is most effective

cyclizine is second most effective

promethazine is third most effective

Question 424

describe anti-glomerular basement membrane disease aka Goodpasture’s syndrome

Answer 424

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

Question 425

describe tertiary hyperparathyroidism

Answer 425

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

Question 426

describe the management of splenic trauma

Answer 426

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

Question 427

which organism stains with India ink?

Answer 427

cryptococcus neoformans

Question 428

which diet is used in children with epilepsy which is unresponsive to treatment?

Answer 428

ketogenic diet

Question 429

describe the following conditions affecting the spinal cord

• Brown-Sequard syndrome
• friedrich’s ataxia
• anterior spinal artery occlusion
• neurosyphilis

Answer 429

Brown-Sequard syndrome
- aka spinal cord hemisection
- ipsilateral spastic paresis below lesion
- ipsilateral loss of proprioception and vibration sensatoin
- contralateral loss of pain and temperatures sensation

friedrich’s ataxia
- same as above + cerebellar ataxia, intention tremor

anterior spinal artery occlusion
- bilateral spastic paresis
- bilateral loss of pain and temperature sensation

neurosyphilis (tabes dorsalis)
- loss of proprioception and vibration sense as dorsal columns are affected

Question 429

describe the following anaesthetic agents

• propofol
• sodium thiopentone
• etomidate
• halothane
• ketamine

Answer 429

• 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

Question 430

describe neoplastic spinal cord compression

Answer 430

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

Question 430

describe discitis

Answer 430

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

Question 431

describe
- atopic eruption of pregnancy
- intrahepatic cholestasis of pregnancy
- pemphigoid gestationis
- polymorphic eruption in pregnancy

Answer 431

atopic eruption of pregnancy
- presents mainly on face, neck and chest and the extensor surfaces of the limbs

intrahepatic cholestasis of pregnancy
- itching
- secondary skin changes due to pruritus

pemphigoid gestationis
- very rare but serious; starts in the periumbilical area
- causes pruritic blistering lesions
- give oral steroids

polymorphic eruption in pregnancy
- periumbilical sparing
- more common in nulliparous women
- usually starts in 3rd trimester with erythematous itchy papules typically located in abdominal striae
- management: emollients, mild potency topical steroids, oral steroids

Question 432

describe the treatment of urticaria

Answer 432

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

Question 433

describe molluscum contagiosum

Answer 433

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

Question 434

in a painful third nerve palsy where would the lesion be located?

Answer 434

posterior communicating artery aneurysm

Question 435

describe the management of atelectasis

Answer 435

chest physiotherapy and deep breathing exercises

Question 436

describe Wolff Parkinson White syndrome

Answer 436

Pre-excitation syndrome where accessory pathway bypasses AV node leading to early depolarisation of ventricles

this is an AV re-entry tachycardia

• wide QRS with slurred upstroke - delta wave
• short PR interval (<120ms)
• left axis deviation if right-sided accessory pathway
• right axis deviation if left-sided accessory pathway

treatment
- radiofrequency ablation of accessory pathway
- medical therapy: sotalol, amiodarone, flecainide

> echocardiogram must be done before use of flecainide to check for signs of structural heart disease

Question 437

explain the interpretation of syphilis testing

Answer 437

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

Question 438

what is the treatment for local anaesthetic toxicity?

Answer 438

IV lipid emulsion

Question 439

which group of drugs is associated with the presence of hyaline casts in urine?

Answer 439

loop diuretics

Question 440

what is the most common cause of peritonitis in patients undergoing peritoneal dialysis?

Answer 440

staphylococcus epidermis (CoNS)

Question 441

describe ischaemic colitis

Answer 441

acute but transient compromise in blood flow to large bowel

can lead to inflammation, ulceration and haemorrhage

most commonly affected site is splenic flexure

investigations
> thumbprinting on AXR due to mucosal oedema / haemorrhage

management
- supportive
- surgery if generalised peritonitis, perforation or ongoing haemorrhage

Question 442

what does the snowstorm sign on ultrasound of axillary lymph nodes indicate?

Answer 442

implant rupture

Question 443

patients with type I DM and BMI >25 should be considered for what treatment in addition to insulin

Answer 443

metformin

Question 444

describe streptococci and their associated infections

Answer 444

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

Question 445

describe conversion rates between different opioids

Answer 445

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 SC morphine: divide by 2

oral morphine to SC diamorphine: divide by 2

oral oxycodone to SC diamorphine: divide by 1.5

Question 446

what is the treatment for Turner’s syndrome

Answer 446

growth hormone

Question 447

what are the complications of parvovirus B19 infection in individuals with sickle cell anaemia?

Answer 447

aka “fifth disease” - typically causes a mild illness with characteristics “slapped cheek” rash

risk of aplastic anaemia

can happen with any background of haemolytic anaemia but especially sickle cell anaemia

features
- fever
- rash
- pancytopaenia

Question 448

describe thromboangiitis obliterans

Answer 448

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

Question 449

what is the most common cause of neutropaenic sepsis?

Answer 449

Coagulase negative gram positive bacteria such as Staphylococcus epidermis

Question 450

describe a keratoacanthoma

Answer 450

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

Question 451

describe side-effects associated with the following chemotherapy drugs:

• alkylating agents
• cytotoxic antibiotics
• anthracyclines
• antimetabolites
• act on microtubules
• cisplatin

Answer 451

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

Question 452

Describe the clinical features of prolactinoma

Answer 452

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

Question 453

describe yellow fever

Answer 453

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

Question 454

what medications can a GP give in a patient with suspected meningitis while an ambulance arrives?

Answer 454

IM benzylpenicillin, IV ceftriaxone

Question 455

describe the treatment of DVT depending on renal function

Answer 455

eGFR 15-50: DOAC

eGFR <15: unfractionated heparin or dose-adjusted LMWH

Question 456

describe the KDIGO criteria for AKI

Answer 456

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

Question 457

describe the management of genital warts

Answer 457

solitary keratinised wart: cryotherapy

multiple non-keratinised warts: topical podophyllum

Question 458

describe restless leg syndrome

Answer 458

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

Question 459

list clinical features of coeliac disease and its diagnosis

Answer 459

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

duodenal biopsy features
- crypt hyperplasia
- villous atrophy
- lymphocytic infiltration

associations: T1DM, thyroid disease, autoimmune hepatitis…

Question 460

what is the most likely organism to be associated with gangrene?

Answer 460

clostridium perfringens

Question 461

describe autoimmune hepatitis

Answer 461

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

Question 462

describe causes of genital ulceration

Answer 462

painful
- HSV
> more common
> multiple painful ulcers, fever, painful inguinal lymphadenopathy
> first attack: 7 days oral vanciclovir
> recurrence: 3 days oral vanciclovir

• chancroid
  > less common
  > caused by haemophilus ducreyi
  > painful ulcers with unilateral painful lymph node enlargement
  > ulcers are typically sharply defined, ragged with undermined border

painless
- syphilis
> more common
> painless ulcer (chancre) is seen in the primary stage

• lymphogranuloma venereum
  > less common
  > caused by Chlamydia trachomatis
  > small painless pustule later forms an ulcer
  > progresses to painful inguinal lymphadenopathy and proctocolitis
  > management: doxycycline

Question 463

describe lead poisoning

Answer 463

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

Question 464

describe bile acid malabsorption

Answer 464

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

Question 465

describe alpha thalassaemia

Answer 465

• 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

Question 466

describe DEXA scans

Answer 466

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

Question 467

describe staphylococcal toxic shock syndrome

Answer 467

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

Question 468

describe an aspergilloma

Answer 468

• 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

Question 469

describe the following conditions
- Zoon’s balanitis
- circinate balanitis
- erythroplasia of Queyrat

Answer 469

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

Question 470

describe melanosis coli

Answer 470

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

Question 471

describe leptospirosis

Answer 471

caused by spirochaete Leptospira interrogans

spread by contact with infected rat urine

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

Question 472

describe lipomas and their investigation

Answer 472

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

Question 473

describe thoracic outlet syndrome

Answer 473

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

Question 474

describe the following complications of sickle cell anaemia

• aplastic crisis
• sequestration crisis
• vaso-occlusive crisis
• acute chest syndrome
• haemolytic crisis

Answer 474

• 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.

Question 475

describe
- latent autoimmune diabetes of adulthood (LADA)
- maturity onset diabetes of the young (MODY)

Answer 475

• 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

Question 476

list circumstances where the procurator fiscal must be informed about an adult death

Answer 476

• sudden death
• deaths related to neglect or complaint
• drug-related death
• food poisoning
• death during administration of GA
• Legionnaire’s

Question 477

which medications can lead to drug-induced parkinsonism?

Answer 477

typical antipsychotics e.g. haloperidol

antiemetics e.g. metoclopramide, prochlorperazine

> symptoms are likely to be bilateral in drug-induced parkinsonism

Question 478

list dermatological manifestations of SLE

Answer 478

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

Question 479

describe paget’s disease

Answer 479

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

Question 480

describe arterial ulcers

Answer 480

• 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.

Question 481

describe venous ulcers

Answer 481

• Occur in 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).

Question 482

describe varicose veins and tests used for their assessment

Answer 482

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

Question 483

describe management options for varicose veins and associated complications

Answer 483

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: manage with NSAIDs e.g. naproxen
- DVT

Question 484

describe neutropaenic sepsis and its management

Answer 484

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

treatment
- piperacillin/tazobactam
> if penicillin allergic: amikacin / vancomycin / ciprofloxacin
- granulocyte colony stimulating factor (G-CSF) is sometimes given

Question 485

describe the presentation and management of stress incontinence

Answer 485

stress incontinence: weak pelvic floor

features
- leaking small amounts when coughing / laughing / jumping

causes
- childbirth
- chronic cough
- constipation
- obesity

management
- non-pharmacological: caffeine reduction, pelvic floor exercises

• duloxetine (SNRI)
• invasive: intramural bulking agents

surgery
- mid-urethral sling
- colposuspension

Question 486

describe overflow incontinence

Answer 486

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)

Question 487

explain the difference between functional and passive urinary incontinence

Answer 487

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

Question 488

list symptoms of hyponatraemia

Answer 488

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

Question 489

list the Wells criteria

Answer 489

• 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

Question 490

describe pityriasis versicolor

Answer 490

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.

Question 490

describe pyoderma gangrenosum

Answer 490

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

Question 491

describe necrobiosis lipoidica diabeticorum

Answer 491

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

Question 492

what is the treatment for adrenaline-induced ischaemia?

Answer 492

local infiltration of phentolamine
> alpha-adrenoceptor antagonist

Question 493

which vein is usually used for venous cutdown

Answer 493

long saphenous vein (anterior to medial malleolus)

Question 494

list monitoring requirements for methotrexate

Answer 494

3 monthly FBC, U&Es, LFTs

Question 495

When should diabetic patients get in contact with the DVLA?

Answer 495

More than one episode of severe hypoglycaemia - requiring assistance - in the past 12 months

must inform DVLA and surrender their license

Question 496

describe hepatocellular carcinoma and its management

Answer 496

features
- jaundice
- ascites
- RUQ pain
- splenomegaly
- hepatomegaly

screening: ultrasound +/- alpha fetoprotein

management
- early: resection
- liver transplantation
- radiofrequency ablation
- metastatic HCC: sorafenib (multikinase inhibitor)

Question 497

describe hepatitis E

Answer 497

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

Question 498

describe a non-functioning pituitary adenoma

Answer 498

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

Question 499

describe hypophysitis

Answer 499

failure of anterior and posterior pituitary

features
- adrenal insufficiency
- diabetes insipidus
- hypogonadism
- hypothyroidism

Question 500

describe the classification of CKD

Answer 500

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

Question 501

how long should you wait between courses of topical steroids

Answer 501

4 weeks

Question 502

describe acute respiratory distress syndrome (ARDS)

Answer 502

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

Question 503

describe pseudocholinesterase deficiency

Answer 503

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

Question 504

describe the ORBIT scoring system for bleeding risk

Answer 504

• 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

Question 505

how can the risk of contrast nephropathy be reduced?

Answer 505

volume expansion with 0.9% NaCl prior to scan

Question 506

list the components of the CHA2DV2ASC scoring system

Answer 506

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

Question 507

differentiate between gastric and duodenal ulcers

Answer 507

gastric ulcer
- worsened by eating
- associated with weight loss

duodenal ulcer
- improved by eating
- associated with weight gain

Question 508

describe a hydrocoele and its management

Answer 508

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

Question 509

describe hookworms

Answer 509

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

Question 510

describe the duration of post-exposure prophylaxis (PEP)

Answer 510

28 days

Question 511

describe Mycobacterium avium intracellulare

Answer 511

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

Question 512

name a common side-effect of indapamide

Answer 512

erectile dysfunction

Question 513

describe tuberous sclerosis

Answer 513

AD condition

cutaneous features
- depigmented ash-leaf spots which fluoresce under UV light
- roughened patches of skin over lumbar spine (Shagreen patches)
- adenoma sebaceum (angiofibromas): butterfly distribution over nose
- subungal fibromata
- cafe-au-lait spots may be seen

neuro features
- developmental delay
- epilepsy (infantile spasms or partial)
- intellectual impairment

also: retinal hamartomas, rhabdomyomas of the heart, gliomatous changes in brain lesions, polycystic kidneys, lymphangioleiomyomatosis

Question 514

describe high altitude cerebral oedema

Answer 514

features
- headache
- ataxia
- papilloedema

Management
- descent
- dexamethasone
- prevention: acetazolamide

Question 515

describe the management of high altitude pulmonary oedema

Answer 515

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

Question 516

describe pellagra

Answer 516

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

Question 517

describe the management and complications associated with shingles

Answer 517

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

Question 518

describe pityriasis alba

Answer 518

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

management
- emollients
- sunscreen

Question 519

describe tinea capitis

Answer 519

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

Question 520

describe scabies

Answer 520

infestation with the mite Sarcoptes scabiei

features
- intense itching that is worse at night along
- erythematous papules and burrows in web spaces of hands, wrists and genitals
- nodules - axilla, umbilicus, groin, penis
- crusted scabies. (immunosuppressed)

treatment
- head, neck and scalp
- treat whole family

Question 521

describe pityriasis rosea

Answer 521

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

Question 522

describe breast screening

Answer 522

mammogram every 3 years in women 50-70

Question 523

describe allergy testing

Answer 523

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

Question 524

list side-effects of diabetic drugs

Answer 524

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

Question 525

list indications for urgent haemodialysis

Answer 525

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

Question 526

describe Lemierre’s syndrome

Answer 526

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

Question 527

describe an insulinoma

Answer 527

Whipple’s triad
- hypoglycaemia with fasting/exercise
- reversal of symptoms with glucose
- recorded low BMs at the time of symptoms

Question 528

describe essential tremor

Answer 528

autosomal dominant condition which usually affects both upper limbs

Features
- postural tremor: worse if arms outstretched
- improved by alcohol and rest
- most common cause of titubation (head tremor)

Management
- propranolol is first-line
- primidone is sometimes used

Question 529

describe fluid prescription in adults

Answer 529

fluid bolus: 500ml STAT (over 10-15 mins)

maintenance fluids
> 25-30 mls/kg/24h of water
> 1mmol/kg/24h of sodium, potassium respectively
> 50-100g glucose daily

• underlying cardiac disease / frailty / renal disease: 20-25ml/kg/24h

Question 530

describe a myasthenic crisis and its management

Answer 530

myasthenic crisis
- acute respiratory failure characterised by FVC <1L
- accessory muscle use

Management
> plasmapheresis
> intravenous immunoglobulins
> ventilatory support: low threshold for intubation