Medicine

Question 1

Crohns vs UC?

Answer 1

Crohns: non-bloody diarrhoea, abdominal pain (often right-sided), weight loss, and extraintestinal manifestations like oral ulcers or skin lesions; pei-anal disease eg skin tags

UC: Tender LLQ, bloody diarrhoea, abdominal pain, and a feeling of incomplete evacuation after defecation (tenesmus), urgency.

Question 2

In a patient on long term hydrocortisone and fludrocortisone who has N+V what should you do re their medications

Answer 2

A person with Addisons’ who vomits should take IM hydrocortisone until vomiting stops
Fludrocortisone is a mineralocorticoid that is used to manage Addison’s. However, it is extra glucocorticoid (hydrocortisone) that is required in this situation

Question 3

What signs are associated with mitral stenosis?

Answer 3

malar flush on cheeks.
regular, low-volume pulse
mid-diastolic murmur loudest with the patient leaning to left-hand side.
Thinks ARMS - atrial regurg early murmur, followed by MS with mid murmur

Question 3

WHat is the most common cause of inherited thrombophilia?

Answer 3

Activated protein C resistance (Factor V Leiden) is the most common inherited thrombophilia

Question 4

At what ages and how often are FITs done as part of the colorectal screening programme?

Answer 4

Faecal immunochemical tests are sent every 2 years to all patients aged 60-74 years in England, 50-74 years in Scotland.

Question 5

ACA vs MCA vs PCA stroke?

Answer 5

ACA:
contralateral sensory and motor loss
Lower> upper

MCA: (most common)
Contralateral sensory and motor loss
Upper> lower
aphasia
contralateral homonymous hemianopia

PCA:
Contralateral homonymous hemianopia with macular sparing
Visual agnosia (can’t recognise objects seen)

Question 6

Webers syndrome vs posterior inferior cerebellar artery stroke vs anterior infectior cerebellar artery stroke vs basilar artery stroke vs lacunar stroke?

Answer 6

Webers:
Affects branches of PCA which supply midbrain
Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity

Posterior inferior cerebellar AKA wallenberg syndrome : Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus

Anterior inferior cerebllar AKA lateral pontine syndrome: Symptoms are similar to Wallenberg’s (see above), but:
Ipsilateral: facial paralysis and deafness

Basilar artery: Locked in syndrome

Lacunar stroke: either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
common sites include the basal ganglia, thalamus and internal capsule

Question 7

Management of ischaemic stroke?

Answer 7

A combination of thrombolysis AND thrombectomy is recommend for patients with an acute ischaemic stroke who present within 4.5 hours
aspirin 300mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded

Question 8

What signs are associated with aortic regurgitation?

Answer 8

early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre
collapsing pulse
wide pulse pressure
Quincke’s sign (nailbed pulsation)
De Musset’s sign (head bobbing)

Question 9

Management of suspected temporal arteritis with visual loss and without visual loss?

Answer 9

1. Steroids: give urgent high dose steroids as soon as suspected, before biopsy.
   If visual loss IV methylprednisolone is given prior to PO steroids as above.
   there should be a dramatic response, if not the diagnosis should be reconsidered
2. urgent ophthalmology review
3. bone protection with bisphosphonates due to high dose steroids

Question 10

What skin changes do you get in dermatomyosis?

Answer 10

Get weakness + skin changes:

photosensitive
macular rash over back and shoulder
heliotrope rash in the periorbital region
Gottron’s papules - roughened red papules over extensor surfaces of fingers
‘mechanic’s hands’: extremely dry and scaly hands with linear ‘cracks’ on the palmar and lateral aspects of the fingers
nail fold capillary dilatation

Question 11

What are the most common types of HPV? which types are linked to cervical cancer?

Answer 11

Most common: Types 6 and 11 are responsible for 90% of genital warts cases

Link to cancer: 16,18 & 33 predisposes to cervical cancer.

Question 12

Cushings disease vs syndrome?

Answer 12

Cushing’s syndrome is a collection of signs and symptoms due to prolonged exposure to cortisol and Cushing’s disease is a specific type of Cushing’s syndrome characterised by increased ACTH production of because of a pituitary adenoma

Question 13

What are all MI patients discharged on?

Answer 13

beta blocker
aspirin
ticagrelor / second line anti-platelet (DAPT - this is stopped at 12 months post MI
ACE inhibitor
statin

Question 14

What is limited vs diffuse cutaneous systemic sclerosis?

Answer 14

Limited cutaneous systemic sclerosis
scleroderma affects face and distal limbs predominately
associated with anti-centromere antibodies
a subtype of limited systemic sclerosis is CREST syndrome: Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia

Diffuse cutaneous systemic sclerosis
scleroderma affects trunk and proximal limbs predominately
associated with anti scl-70 antibodies
the most common cause of death is now respiratory involvement, which is seen in around 80%: interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH)
other complications include renal disease and hypertension
poor prognosis

Question 15

What is hyperaldosteronism

Answer 15

Primary hyperaldosteronism was previously thought to be most commonly caused by an adrenal adenoma, termed Conn’s syndrome. However, recent studies have shown that bilateral idiopathic adrenal hyperplasia is the most common cause. Differentiating between the two is important as this determines treatment.

Causes
bilateral idiopathic adrenal hyperplasia: the cause of around 60-70% of cases
adrenal adenoma: 20-30% of cases
unilateral hyperplasia
familial hyperaldosteronism
adrenal carcinoma

Features
hypertension, hypokalaemia, metabolic alkalosis

Investigations
plasma aldosterone/renin ratio -
should show high aldosterone levels alongside low renin levels (negative feedback due to sodium retention from aldosterone)

following this a high-resolution CT abdomen and adrenal vein sampling is used to differentiate between unilateral and bilateral sources of aldosterone excess
if the CT is normal adrenal venous sampling (AVS) can be used to distinguish between unilateral adenoma and bilateral hyperplasia

Management
adrenal adenoma: surgery (laparoscopic adrenalectomy)
bilateral adrenocortical hyperplasia: aldosterone antagonist e.g. spironolactone

Question 16

What is Pagets disease of the bone? Sx? management and ix (and blds)?

Answer 16

Paget’s disease is a disease of osteoclasts -> increased + uncontrolled bone turnover.

Presentation: typically older male with bone pain and an isolated raised ALP, (e.g. pelvis, lumbar spine, femur), untreated features: Bowing of tibia, Bossing of skull

Investigations: Raised ALP, normal Ca and Phosphate.
x-rays- osteolysis in early disease → mixed lytic/sclerotic lesions later
skull x-ray: thickened vault, osteoporosis circumscripta

Management: only treat if sx/ fracture/ deformity.
bisphosphonate (either oral risedronate or IV zoledronate)

Question 17

Management of UC flare? severe vs mild-mod

Answer 17

definition of severe UC: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)

In mild/moderate: topical (rectal) aminosalicylate. –> PO aminosalicylate (eg Sulfasalazine)–> steroid

Severe: hospital. IV steroids –> IV ciclosporin –> surgery

Question 18

1st, 2nd line and 3rd line mx of HF?

Answer 18

1st - BB (carvedilol or bisoprolol) + ACE-i
2nd - spironolactone (also think of SGLT-2 inhib if diabetic) - in hfref
3rd- initiated by a specialist. Options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy

Question 19

How often are women with HIV meant to have smears?

Answer 19

Annually

Question 20

What is pyoderma gangrenosum?

Answer 20

Inflammatory, not infection. An uncommon cause of very painful skin ulceration.
Associated with IBD.
Starts as pustule then ulcerates
Treat with steroids

Question 21

WHat is used for prevenetion of variceal high risk bleeds?

Answer 21

A non-cardioselective B-blocker (NSBB) is used for the prophylaxis of oesophageal bleeding eg carvedilol, propranolol

Question 22

What raises ALP in relation to bones?

Answer 22

When bones have increased remodelling ALP rises as it is realeased by ostoblasts eg in osteomalacia, hyperparathyrdoisism, bones mets, pagets, bone fracture

Question 23

cubital tunnel syndrome presentation?

Answer 23

Compression of ulnar nerve

Motor to:
medial two lumbricals
aDductor pollicis
interossei
hypothenar muscles: abductor digiti minimi, flexor digiti minimi
flexor carpi ulnaris
‘claw hand’ - hyperextension of the metacarpophalangeal joints and flexion at the distal and proximal interphalangeal joints of the 4th and 5th digits

Sensory to:
medial 1 1/2 fingers (palmar and dorsal aspects)

Question 24

What are the different hypersensivity reactions according to the Gell-Coombs classifications?

Answer 24

Type 1-4, think ACID
A - Anaphlyaxis - IgE mediated
C - Cell bound - cytotoxic antibody-mediated responses involving IgG or IgM antibodies eg hemolytic transfusion reactions, ITP
I - Immune Complex - between antigens and IgG or IgM antibodies eg SLE
D - Delayed hypersensitivity - T lymphocytes eg contact dermatitis, MS, tuberculin skin reaction

Question 25

What type of brain bleeding can present several weeks after head injury?

Answer 25

chronic subdural haematoma

Question 26

Length of tx for unprovoked vs provoked DVT?

Answer 26

provoked - 3 m
unprovked - 6 m

Question 27

What is chancroid?

Answer 27

Tropical disease (Haemophilus ducrey)
Chancroid presents as a deep, painful genital ulcer and is often associated with inguinal lymphadenopathy.

Question 28

What is blood test for sjogrens Vs polymyo/dermatomyositis?

Answer 28

Sjogrens - Anti Ro and anti La

Anti-Jo1 - Polymyo/Dermatomyositis

Question 29

It cardiac arrest is witnessed on a monitor how should ALS be done

Answer 29

Witnessed cardiac arrest while on a monitor - up to three successive shocks before CPR

Question 30

When do patients get fibrinolysis for a STEMI?

Answer 30

should be offered within 12 hours of the onset of symptoms if primary PCI cannot be delivered within 120 minutesof the time when fibrinolysis could have been given. Should be given wtih an antithrombin drug eg fondaparinux

Question 31

What is diptheria?

Answer 31

Diphtheria is a bacterial infection caused by Corynebacterium diphtheriae which primarily infects the throat and upper airways, leading to difficulty in breathing and swallowing. A grey coating surrounding the tonsils, fever, and cervical lymphadenopathy are classic symptoms of this disease

Question 32

What is dengue fever?

Answer 32

Dengue fever is a viral illness transmitted by mosquitoes that commonly causes high fever, severe headache, pain behind the eyes, joint pain, muscle and bone pain, rash, and mild bleeding.

Question 33

What is typhoid/ paratyphoid?

Answer 33

caused by different strains of Salmonella. Typhoid and Paratyphoid fevers present with prolonged high-grade fever associated with relative bradycardia, malaise, headache, cough, constipation, rose spots

Question 34

Wernickes vs brocas area?

Answer 34

Spoken word is heard at the ear. This passes to Wernicke’s area in the temporal lobe (near the ear) to comprehend what was said. Once understood, the signal passes along the arcuate fasciculus, before reaching Broca’s area. The Broca’s area in the frontal lobe (near the mouth) then generates a signal to coordinate the mouth to speak what is thought (fluent speech).

Question 35

Spider naevi vs telangiectasia

Answer 35

Spider naevi can be differentiated from telangiectasia by pressing on them and watching them fill. Spider naevi fill from the centre, telangiectasia from the edge

Question 36

What can you test for to differentiate type 1 vs type 2 diabetiics? What will these levels be like?

Answer 36

c-peptide is low in t1DM as no insulin is being made

Question 37

What is MODY (mature onset diabetes of young)?

Answer 37

Maturity-onset diabetes of the young is an autosomal-dominant disease, and it is characterised by the development of type 2 diabetes mellitus in patients younger than 25 years old. In this condition, C-peptide remains in the normal range and beta-cell antibodies are negative.

Question 38

How do you diagnose diabetes?

Answer 38

If the patient is symptomatic:
fasting glucose greater than or equal to 7.0 mmol/l
random glucose greater than or equal to 11.1 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.

Question 39

What is the most common cause of hyperthryoidism

Answer 39

graves disease

Question 40

dresslers syndrome - what is it?

Answer 40

dresslers syndrome is pericarditis secondary to MI, occurs 3-6 weeks after MI

Question 41

What is Beck’s triad?
What can cause it?

Answer 41

Muffled heart sounds + JVP raised + hypotension indicate Beck’s Triad -> cardiac tamponade
LV free wall rupturet MI

Question 42

What are the indications for an urgent vs less urgent CT head according to NICE guidelines? What timeframe should they be done in?

Answer 42

CT head within 1 hour
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

CT head scan within 8 hours of the head injury - for adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury:
age 65 years or older
any history of bleeding or clotting disorders including anticogulants
dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)
more than 30 minutes’ retrograde amnesia of events immediately before the head injury

Question 43

What is the treatment for genital warts?

Answer 43

multiple, non-keratinised warts: topical podophyllum
solitary, keratinised warts: cryotherapy

Question 44

IgG vs IgM positivity?

Answer 44

IgG positive & IgM negative - shows immunity
IgG negative & IgM positive - shows recent infection

Question 45

Treatment for angina (initial)? 2nd line add in if uncontrolled? 3rd line?

Answer 45

Initial: bisoprolol, GTN, aspirin and statin

2nd: longer-acting dihydropyridine calcium channel blocker should be added eg Nifedipine, amlodipine

3rd: a long-acting nitrate/ ivabradine/ nicorandil/ ranolazine + refer to cardiology for PCI assessment

Question 46

When are topical NSAIDs particularly useful for OA?

Answer 46

Topical NSAIDs may be particualrly beneficial for patients with OA of the knee or hand

Question 47

What can be found on CXRs for bronchiectasis?

Answer 47

Parallel line shadows (often called tram-lines) are common in bronchiectasis and indicate dilated bronchi due to peribronchial inflammation and fibrosis.

Question 48

What is T score on BMD indicates need for treatment?

Answer 48

Less than -1.5

The first-line treatment is alendronate. Patients should also be calcium and vitamin D replete.

Question 49

If a patient is on warfarin/a DOAC/ or has a bleeding disorder and they are suspected of having a TIA, what should you do?

Answer 49

they should be admitted immediately for imaging to exclude a haemorrhage

Question 50

Mx of crohns flare up?

Answer 50

Induce remission:
1st line - steroids
2nd line - 5-ASA (aminosalicylaes) eg mesalazine
3rd line - azathioprine/ mercaptopurine /methotrexte.
4th line - infliximab
Metronidazole is used if fistula present

Maintain remission:
1st line - azathioprine/ mercaptopurine - need to test TPMT
2nd line - methotrexate

Surgery:
ileocoecal resection if stricture, resections, draining seton
around 80% of patients with Crohn’s disease will eventually have surgery
stricturing terminal ileal disease → ileocaecal resection
segmental small bowel resections
stricturoplasty
perianal fistulae
an inflammatory tract or connection between the anal canal and the perianal skin
MRI is the investigation of choice for suspected perianal fistulae - can be used to determine if there (is an abscess and if the fistula is simple (low fistula) or complex (high fistula that passes through or above muscle layers)
patients with symptomatic perianal fistulae are usually given oral metronidazole
anti-TNF agents such as infliximab may also be effective in closing and maintaining closure of perianal fistulas
a draining seton is used for complex fistulae
a seton is a piece of surgical thread that’s left in the fistula for several weeks to keep it open. This is useful because persisting fistula tracks after premature skin closure predispose to abscess formation
perianal abscess
requires incision and drainage combined with antibiotic therapy
a draining seton may also be placed if a tract is identified

Complications of Crohn’s disease

As well as the well-documented complications described above, patients are also at risk of:
small bowel cancer (standard incidence ratio = 40)
colorectal cancer (standard incidence ratio = 2, i.e. less than the risk associated with ulcerative colitis)
osteoporosis

*assess thiopurine methyltransferase () activity before offering azathioprine or mercaptopurin

Question 51

How is SBP diagnosed?

Answer 51

In suspected SBP- diagnosis is by paracentesis. Confirmed by neutrophil count >250 cells/ul

Question 52

How do you interpret Hep B serology?

Answer 52

HBsAg normally implies acute disease (present for 1-6 months)

if HBsAg is present for > 6 months then this implieschronic disease(i.e. Infective)

Anti-HBs implies immunity (either exposure or immunisation). It is negative in chronic disease.

Anti-HBc implies previous (or current) infection. IgM anti-HBc appears during acute or recent hepatitis B infection and is present for about 6 months. IgG anti-HBc persists.

HbeAg results from breakdown of core antigen from infected liver cells as is, therefore, a marker of infectivity. Marker of HBV replication and infectivity

Example results

previous immunisation: anti-HBs positive, all others negative

previous hepatitis B (> 6 months ago), not a carrier: anti-HBc positive, HBsAg negative

previous hepatitis B, now a carrier: anti-HBc positive, HBsAg positive

Question 53

What conditions tend to be AR vs AD?

Answer 53

Autosomal recessive conditions are often thought to be ‘metabolic’ as opposed to autosomal dominant conditions being ‘structural’, notable exceptions:

some ‘metabolic’ conditions such as Hunter’s and G6PD are X-linked recessive whilst others such ashyperlipidaemia type IIandhypokalaemic periodic paralysisare autosomal dominant

some ‘structural’ conditions such as ataxia telangiectasia and Friedreich’s ataxia are autosomal recessive

Question 54

Mx of Ramsay Hunt syndrome

Answer 54

oral aciclovir + corticosteroids + eye protection

Question 55

Achalasia vs oeseophgeal stricture?

In achalasia, the hallmark symptom is a progressive dysphagia to both solids and liquids from the onset due to a failure of relaxation of the lower oesophageal sphincter (LES). This is often accompanied by regurgitation of undigested food, chest pain and weight loss. The diagnosis can be confirmed with a barium swallow test showing ‘bird’s beak’ sign and manometry showing increased LES pressure and lack of peristalsis.

On the other hand, in benign oesophageal stricture, patients typically first experience difficulty swallowing solids followed by liquids as the condition progresses. This is due to mechanical narrowing of the oesophagus often secondary to gastro-oesophageal reflux disease (GORD). Symptoms such as heartburn, acid regurgitation or relief from antacids may also suggest GORD as an underlying cause. Barium swallow or endoscopy would show a narrowed segment in case of stricture.

Answer 55

Achalasia - relaxed lower sphincter.