Medicine

Question 1

What is the cushing’s reflex?

Answer 1

Hypertension and Bradycardia (Usually Hypertension and Tachycardia go hand in hand)

Raised ICP

Question 2

Migraine Treatment:

Acute

Prophylaxis

Answer 2

Acute: Triptan + NSAID/ Triptan + Paracetomal (5 HT Agonists)

Prophylaxis: Topiramate or propranolol (5 HT Antagonists)

Propranolol - Avoid if patients are asthmatic or have heart block etc.

Question 3

Treatment resistant Migraine Treatment

Answer 3

5-8 Weeks acupuncture

Gabapentin

Menstrual Migraine - Zolpitriptain and Frovatriptan

Question 4

Hypertension Treatment Pathway

<55 year old

>55 year old / black people

Answer 4

<55 year old

i) ACE-i and ARB
ii) CCB
iii) Thiazides
iv) Spironolactone / High-dose thiazide diuretic
v) Alpha/ Beta Blocker

>55 year old / Black

i) CCB
ii) Thiazides
iii) Spironolactone / High-dose thiazide diuretic
iv) Alpha/ Beta Blocker

Question 5

Stages of hypertension

Answer 5

1) Clinic- 140/90 mmHg

Home - 130/85 mmHg

2) Clinic - 160/100 mmHg

Home - 150/95 mmHg

Severe Hypertension) Clinic - 180 mmHg

BP - 110mmHg

Question 7

Risks of dialysis

Four main ones and ions responsible

Answer 7

Calcium Related (and phosphate)

Circulatory Disease

Cardiovascular Siease

Cerebrovascular disease

Peripheral Vascular Disease

Question 8

Phosphate target in:

Normal Patient

And Renal Patients

What is the risk?

Answer 8

Normal patient: 1.0-1.1

Renal patient: 1.7

Severe promoter of cardiovascular disease

Question 9

Polycystic kidney disease mutations

Disease relation?

Proteins effected?

Predominant types of mutation?

Answer 9

Disease relations -

Berry aneurysms (PKD1 +PKD2)

liver cysts

diverticular disease

Aortic disease

Adrenal Disease

Proteins: Polycystin 1 and Polycistin 2

Mutations:

Most inherited

15% Mutations sporadic / mosaicim

85% Mutations inherited

Question 10

Which mutation confers worse prognostically for PKD?

What type of mutaton confers worse progonstically?

Answer 10

PKD1!! - ESRF by the 40s

PKD2 - ESRF by the 60s

Deletions are worse than point mutations

Question 11

Which drug has shown benefit in reducing growth of polycystc kidneys?

Mechanism?

Side effects?

Answer 11

Tolvaptan

Downregulates cAMP pathway leading to reduction in cyst size.

Side effects: Thirst, Polyuria, Dysuria, Dehydration

Question 12

What phenotypic characteristics of PKD confer worse diagnosis?

Answer 12

Male

Hypertension

Deletion

Urological complications

Multiple Cysts

Question 13

Causes of hypertrichosis? (4)

Answer 13

Drugs - minoxidil, cyclosporin, diazoxide

Congenital hypertrichosis

Porphyria Cutanea Tarda

Anorexea Nervosa

Question 14

Hepatitis E is associated with which food products?

Type of virus?

Particularly at risk group?

Answer 14

Seafood

Pork

Hep E is a RNA hepevirus

20% mortality in pregnant women

Question 15

Ciclosporin

MOA?

Side Effects?

Indications

Answer 15

Calcinuein inhibitor preventing IL2 mediated T Cell proliferation

Side Effects - Everything goes up.

Fluid retention, hyperkaemia, IGT, Gingival hyperplasia, Hypertrichosis, hyperlipidaemia.

Hepatotoxic

Indications - Transplant, RA, psoriasis, UC, pure red cell aplasia

Question 16

Drug causes of hyperkalaemia

Answer 16

Potassium sparing diuretics, Ace-i, ARBs, ciclosporin, heparin

Question 17

Watery eye

Swelling of the medial canthus

Dx

Mx

Answer 17

dacryocystitis - lacrimal sac infection

Mx - systemic abx (not topical),

If accompanied by periorbital cellulitis - Iv Abx too

Question 18

Inflamed breast appearance?

Answer 18

Inflammatory breast cancer

Where cancerous cells block lymph drainage resulting in an inflamed breast appearance

Question 19

Two examples of loop diuretics

Where do they act

On what do they act

SEs

Answer 19

Frusemide, bumetanide

Act on ascending limb

Block the Na, K, Cl transporter

SEs - hypotension, hyponatraemia, hypokalamia, hypocholoraemia alkalosis, hypocalcaemia, ototoxic, gout hyperglygaemia

Question 20

Hyperemesis Gravidarum criteria

Answer 20

5% Pre Pregnancy Weight Loss

AND

Dehydration

AND

Electrolyte Imbalance

Question 21

What is ABCD2?

What are the scoring points?

What is the scoring threshold plus intervention?

Answer 21

ABCD2 is the prognostic scoring algorithm for determining stroke following TIA

ABCD2

A ge - >60 Years 1 point

B - BP >140/90 mmHg 1 point

C - Unilateral weakness - 2 points

Speech disturbance - 1 point

D - Duration of symptoms

>60 minutes - 2 points

10-59 minutes - 1 point

Patient has diabetes - 1 point

Scoring threshold:

3 or less - Specialist assessment within 1 week of symptom onset

>4 - 300mg Aspirin daily

assessment within 24 hours

optimising of risk factors

Question 22

Which antiplatelet therapy for stroke?

Answer 22

CHANCE Study- Shows greatest risk reduction in high risk TIA patients was seen in aspirin + clopidogrel

Then clopidogrel

Then aspirin + dypirimadole

Question 23

Most common organism implicated in dog and cat bites?

Which antibiotic therapy?

If not tolerated?

Answer 23

Pasteurella Multocida

Antibiotic;

Co-Amoxiclav

Doxy + Met

Question 24

What GFR level do you:

review metformin

stop metformin

Contrast studies- what do you do with metformin

Answer 24

Review:

< 45 ml/min

Stop:

<30 ml/min

Metformin should be stopped on day of contrast study and for 48 hours after

Question 25

Hypokalaemic Metabolic Alkalosis = \_\_\_\_\_\_ Syndroem

Answer 25

Cushing's Syondrome:

Question 26

Alendronate Advice?

Answer 26

30 minutes before breakfast with plenty of water and sit up right for at least 30 minutes after

Question 27

First line for trigeminal neuralgia

Answer 27

Carbamezapine

Question 28

Positive tests in asthma: FENO (what is measured and positive test) Spirometry

Answer 28

FENO: all 3 NOs is measured but iNOS rises (produced by inflammatory cells) Adults \>40 parts per billion Children \> 35 parts per billion Spirometry: Reversibility testing Adults - 12% + improvement of FEV1 and 200ml increase in volume Children - 12% + improvement of FEV1

Question 29

Which drug should be given after every other blood unit?

Answer 29

Furosemide

Question 30

Dehydration Osmolality \>320 mosmol/kg Hyperglycaemia \>30 mmol/L

Answer 30

Hyperosmolar Hyperglyacemic State Key differentating factors from DKA : Hyperglycaemia is more pronounced in HHS No acidosis in HHS Ketones are less than 3 in HHS

Question 31

Acetycholine Accumulation: Causes Symptoms Management

Answer 31

**Causes:** Acetylcholinesterase Inhibitors Organophosphate insecticide poisoning **Symptoms:** SLUD - Salivation, lcarimation, urination, diarrhoea Hypotension Bradycardia Miosis Muscle Fasciculations **Mx:** Atropine ?Pralidoxime

Question 32

Which disease warrants pre operative cervical spine radiographs? Why?

Answer 32

**Rheumatoid Arthritis** Atlantoaxial subluxation is a complication and due to airway manipulation can cause SC compression

Question 33

**Rheumatoid Arthritis Extra Ocular:** **ROODII AF**

Answer 33

**Resp:** PF, PE, Pulmonary nodules, Bronchiolotis Oblietrans, Pleurisy **Ocular:** Keratoconjunctivitis, Episcleritis, Scleritis, Ulceration, Keratitis, Chloroquine, retinopathy **Osteoporosis** **Depression** **IHD** **Infections** **Amyloidosis** **Felty's Syndrome ( RA + Splenomegaly + Neutropenia)**

Question 34

**Causes of horner's syndrome?** Central - 5, preganglionic - 4, postganglionic 4

Answer 34

**Central:** **Anhidrosis of face, arm and trunk** **Causes -** Stroke, Syringomyelia, Multiple Sclerosis, Tumour, Encephalitis **Pre-Ganglionic Lesions:** **Anhidrosis of the face** **Causes -** Pancoast's Tumour, Thyroidectomy, Trauma, Cervical Rib **Post-Ganglionic Lesions** **No Anhidrosis** **Causes - carotid artery -** Disseciton, aneurysm, Cluster headache, Cavernous Sinsus thrombosis

Question 35

**Ototoxic Drugs**

Answer 35

Aminoglycosides - Gentamicin Furosemide Aspirin Cisplatin, Carboplatin Chlorhexidine (Direct Contact)

Question 36

Replacement of normal bone by vascular spongy bone ( in the ear )

Answer 36

**Otosclerosis** **Age of onset -** 20-40 yo Features: Conductive deafness, tinnitus, flamingo tinge of Tympanic membrane, FH

Question 37

Metabolic Acidosis Elevated Anion Gap Elevated Serum Ketone Levels Normal/Low Glucose Concentrations **Management?**

Answer 37

**Alcoholic Ketoacidosis** Mx - Saline + Thiamine.

Question 38

**Digoxin:** **MOA** **Indications** **Toxicity + Management**

Answer 38

**MOA** - Cardiac glycoside decreasing conduction through AVN and increases contractility due to Na/K ATPase pump inhibition **Indications** - AF and Atrial flutter (rate control) Symptomatic relief in HF **Toxicity** - \>1.5 mcg/l **Features** - Unwell, lethargic, N&V, yellow - green vision, arrhythmias, gynaecomastia **Toxicity is** incurred due to - **hypokalaemia** and other electrolyte disturbacnes (low Mg, High Ca, high Na), renal failure, hypoalbumin, hypothermia, hypothyroid and **other drugs ( amiodarone, quinidine, verapamil, spironolactone)** **Management -** Digibind, correct arrhythmias, monitor potassium

Question 39

**Treatment of ischaemic stroke**

Answer 39

**Thrombolysis if \<4.5 hours and no contraindications** 300 mg Aspirin Daily for 2 weeks 75 mg daily clopidogrel long term Statin if cholesterol is \>3.5 mmol/l

Question 40

Cavitating pneumonia: Alcoholics and diabetics

Answer 40

**Klebsiella Pneumoniae** - Upper lobe bilateral cavitating opacities, empyema red currant jelly sputum - Gram Negative, non motile, encapsulated, facultative anaerobid, rod shaped, lactose - fermenting

Question 41

Red scaly patches on sun-exposed areas **Dx** **Mx**

Answer 41

**Bowen's Disease or SCC in situ** 5% malginant risk Mx: Topical 5 FUC, Imiquimod Cryotherapy Excision

Question 42

**Therapeutic Drug Monitoring** Lithium Ciclosporin Digoxin Phenytoin

Answer 42

**Lithium** 12 hours post dose. Range 0.4-1.0 mmol/l **Digoxin** 6 hours post dose **Ciclosporin and Phenytoin** Trough doses. Phenytoin - not routinely done

Question 43

**Contraindications to lung cancer surgery?** 7

Answer 43

i) **General health** ## Footnote **ii) IIIb or IV (metastases)** **iii) FEV1 \<1.5 Litres** **iv) Malignant pleural effusion** **v) Tumour in peri-hilar region** **vi) Vocal cord paralysis** **vii) SVC obstruction**

Question 44

**Criteria for HHT Diagnosis** **Inheritance Pattern**

Answer 44

**HHT is an AD condition** **Possible HHT: 2 of 4** **Definite HHT: 3 of 4** **Criteria:** Epistaxis Telangiectases Visceral Lesions - AVMs, GI telangiectasia FH - First degree relative with HHT

Question 45

**Oxford/Bamford Stroke classification system?**

Answer 45

Criteria: 1) Unilateral hemiparesis/hemisensory loss of face, arm or leg 2) homonymous hemianopia 3) Higher Cognitive dysunfction **TACI - All criteria present** **PACI - 2 of 3 criteria present** **LACS - 1 of: Unliateral weakness/ sensory deficit, Pure sensory, Ataxis Hemiparesis** **PCI - Presents with 1 of following - Cerebellar/ brainstem syndrome, loss of consciousness, homonymous hemianopia**

Question 46

**What are the two medullary occlusion snydromes ?** **Describe deficits and differentiating features**

Answer 46

**PICA Infarct** **- Contralteral** loss of pain and temp sensation in **body** - **Ipislateral -** Pain and temp sensory loss in **face** **Ipsilateral -** Cerebellar deficits, Hornery Syndrome Vertigo, nystagmus, hoarseness, trouble swallowinw **Anterior Spinal Artery Infarct** - **Contralateral -** hemiparesis, tactile and kinsethetic defects **Tongue deviates to side of lesion**

Question 47

**PUO** in context of a patient with haematuria, loin pain, abdo mass?

Answer 47

**RCC**

Question 48

Indicatiosn for steroid treatmentin sarcoidosis

Answer 48

**Stage 2 / 3 CXR -** + Moderate, severe or progressive symptoms. ( if asymptomatic then no treatment required) **Hypercalcaemia** **Eye, heart or neuro involvement** **Parenchymal lung disease**

Question 49

**Acute angle closure glaucoma** **Features** **Mx**

Answer 49

Rise in IOP due to impairment of aqueous flow **Fx -** Pain, Reduced vision, Mydriasis causes pain, red eye, haloes, non-recative pupil, corneal oedema, **Mx - Reduce aqueous secretion (**Acetazolamide) and **Induce pupillary constriction (** Pilocarpine)

Question 50

**Two Liver classifiaction systems?** **Try to detail criteria**

Answer 50

Child - Pugh : **BAAPE** - Bilirubin, Albumin, PT, Encephalopathy, Ascites \<7 = A, 7-9 = B, \>9 = C **MELD** - Bilirbuiin, Creatinine, INR - **provides 3 month mortality. \>40 = 71.3% mortality** **Lower the score the better**

Question 51

**Visual Field Defects** Bitemporal Hemianopias - When upper quadrants are worse than lower and vice versa? Homonymous quadrantanopias - Causes? Homonymous Hemianopias - Causes?

Answer 51

**Bitemporal Hemianopias -** If compression is inferior to the optic chiasm then the upper quadrants are more effected **- pituitary tumour** If compression is superior to the optic chiasm then the **lower quadrants** are more effected - **Craniophayingioma** Homonymous quadrantanopias - Mostly caused by Occipital lobe lesions. Also caused by parietal (Inferior quadrantanopias) and temporal (superior quadrantanopias) Homonymous Hemianopias - **Macula sparing - Definitely occipital cortex.** IF the shape of the defect is the same in both eyes then **- posterior defect (Occipital lobe, radiation)** If Different - **anterior defect (optic tract)**

Question 52

**Recurrent Laryngeal nerve palsy vs Superior laryngeal nerve palsy**

Answer 52

**Recurrent -** Innervates all intrinsic larynx muscles except cricothyroid. Causes hoarsesness **Superior -** Cricothyroid. Damage affects pitch of the voice and the projection of the voice Look at the image and you can see the course of the superior laryngeal nerve exposes it to traumatic injury whereas the recurrent can be implicated in cardiac, mediastinal and pulmonary pathology.

Question 53

**AntiDiabetic drug** **Bind to ATP dependent K+ channel on pancreatic B Cells** Side effects?

Answer 53

Sulfonylureas Increase insulin secretion from B Cells. Side effects: Weight gain hypoglycaemic Rare - SIADH, BM Suppression

Question 54

**5 HT DRugs** **Agonists:** **5 HT 1 D** **Partial 5 HT1** **Antagonists:** **5 HT2** **5 HT 3**

Answer 54

5 HT 1 D agonist - Sumitriptan. Acute migraien treatment Partial 5 HT 1 agnoist - ergotamine 5 HT 2 antagonist - pizitogen ( migraine prophylaxis) 5 HT 2 antagonist - cyproheptadine (diarrhoea control in carcinoid pts) 5 HT 3 antagonists - ondansetron

Question 55

What do you do if you hae a hypo while driving?

Answer 55

**Have fast acting glucose.** **Move out of drivers seat** **Wait un til 45 minutes after the BG is \>4.0 mmol/mol**

Question 56

**Burns managmenet** **Wallace rule?** **Parklands formula?**

Answer 56

**Wallace:** 9% - head and neck, anterior chest, posterior chest, arm, posterior leg, anterior leg **Parklands:** Fluid requirement. Fluid needed: Total body SA of burns(%) x weight (kg) x 4 Half fluid in first eight hours

Question 57

**Drugs reducing mortality in LVF?**

Answer 57

ACE-I ARB Hydralazine Nitrates Beta blockers Aldosterone Antagonists

Question 58

What type of visual problem occurs due to open angle glaucoma?

Answer 58

**Visual Field Defects** leading to tunnel vision

Question 59

**Which antihypertensive is safe to give with lithium**

Answer 59

Amlodipine

Question 60

Mixed respiratory alkalosis and metabolic acidosis What overdose?

Answer 60

Salicylate low CO2 and Low pH = Mixed

Question 61

**IV amiodarone vs Synchronised cardioversion** **In VT**

Answer 61

IV amiodarone --\> patient is stable Synchronised cardioversion --\> Unstable patient

Question 62

**Polymorphic VT/ Torsades de Pointes treatment**

Answer 62

IV magnesium If unstable cardioversion

Question 63

Diabetes Insipidus + Visual Field defect. What is the defect? Likely pathology?

Answer 63

Lower bitemporal heminopia Craniophayngioma

Question 64

Itchy vesicular skin lesions on extensor surfaces?

Answer 64

**Dermatitis Herpetiformis** - Note vesicular so not eczema necessarily. Associated with coeliac disease

Question 65

**Dapsone** **Three uses**

Answer 65

Dermatitis herpetiformis (Coeliac's Disease) Leprosy (with rifampicin and clofimazine) Granuloma Annulare

Question 66

**TB Drug Side Effects**

Answer 66

**Rifampicin -** orange bodily fluids, rash, hepatotoxicity, drug interactions **Isoniazid -** peripheral neuropathy, psychosis, hepatotoxicity **Pyrazinamide -** arthralgia, gout, hepatotoxicity, nausea **Ethambutol -** optic neuritis, rash

Question 67

**Ivabradine** **MOA** **Indications** **SEs**

Answer 67

MOA: Inhibits **If channels (Funny channels)** which usually allow a mix of potassium and sodium in and are triggered by hyperpolarisation. **The influx of potassium when they are triggered allows depolarisation and spontaneous activation of cardiac myocytes.** Indications: Symptomatic angina relief **Side effects:** - bright spots in vision (due to iH channels in the retina) - blurred vision - metabolised by the **cyp450 3A4** so inducers and inhibitors alter drug concentration

Question 68

**How long before surgery do you stop the OCP?**

Answer 68

4 weeks In some cases for exampel where LA is given tehre is no need to stop it

Question 69

**Special prep for following surgeries:** Thyroid Parathyroid Sentinal node Thoracic Duct Carcinoid Colorectal Thyrotoxicosis

Answer 69

Thyroid - Vocal cord check Parathyroid - Methylene blue to identify gland Sentinel node - radioactive marker/ dye Thoracic duct - administer cream Carcnioid - Octreotide Colorectal - Bowel perforation Thyrotoxicosis- lugol's iodine/medical therapy

Question 70

**Louis Bar Syndrome?**

Answer 70

**Neurological syndrome** **- severe ataxia** **- telangiectasia** **Otherwise known as ataxia tenlangiectasia** Defective ATM Gene - usually responsible for identifying DNA breaks

Question 71

**Describe the following pulses and conditions they're in:** **i)** Pulsus paradoxus ii) Slow Rising iii) Collapsing iv) Pulsus Alternans v) Bisferiens pulse vi) Jerky pulse

Answer 71

i) **PUlsus paradoxus:** \>10mmHg fall in Systolic BP during expiration. (Severe asthma, Cardiac tamponade) Pulse may be absent during inspiration ii) **Slow rising:** Aortic Stenosis iii) **Collapsing:** Aortic regurgitation, PDA, High output states iv) **Pulsus Alternans:** Regular alternation of the force of the pulse. (LVF) v) **Bisferiens pulse:** Double Pulse (seen in mixed aortic valve disease) **vi) Jerky pulse:** HOCM

Question 72

4 Types of MND: Chromosome association Gene Association Worst and best prognosis

Answer 72

**Chromosome - 21** **Genes -** SOD1, C9orf72, TARDBP, FUS Primary Lateral Sclerosis -Just UMN signs Amyotrophic Lateral sclerosis - 50% of patients. SOD1 Progressive Muscular Atrophy - LMN Signs only. Best prognosis Progressive bulbar palsy - Loss of function of motor brainstem nuclei. Chewing, swallowing, facial muscle dysfunction. Worst prognosis

Question 73

**Drug Name?** Increases GABA Activity Causes Weight Gain and nausea OtherSEs?

Answer 73

**Sodium Valproate (guess you could say alcohol too)** SEs: Alopecia, Pancreatitis, Hepatitis, ataxia, tremor, thrombocytopenia, hyponatraemia teratogenicity

Question 74

Dry mouth and Raised ALP

Answer 74

**Primary Biliary Cholangitis** 70% have sicca symptoms Middel aged women Anti Mitochondrial Antibodies

Question 75

Weber's test localises to the contralateral or ipislateral side in sensorineural hearing loss?

Answer 75

**Localises to the contralateral side because sound**

Question 76

String like narrowed terminal ileum

Answer 76

**Kantor's Sign** **Crohn's Disease**

Question 77

**Best test to identify bowel perforation?**

Answer 77

**CT Scan** Erect chest x ray also useful

Question 78

**Mx for acne rosacea**

Answer 78

Mild - Topical Metronidazole more severe - Oxytetracycline Laser therapy - prominent telangiectasia General principles - high factor UV cream, camouflage to disguise redness

Question 79

**Complications of Subarachnoid Haemorrahge and treatment :** **3**

Answer 79

Rebleeding - ICP management, coiling, surgery Obstructive hydrocephalus - Therapuetic lumbar puncture, decompressive craniectomy Vasospasm - nimodipine

Question 80

**Mucosal invovlement:** **Pemphigus** **Pemphigoid**

Answer 80

Pemphigus! Pemphi**gus** involves the muc**ous** Pemphigus - IgG against desmosomal proteins ---\> Intrapeidermal bullous formation Pemphigoid - IgG against hemidesmosal proteins --\> subepidermal bullous formation

Question 81

What GCS level warrants CT head within 1 hour of arrival?

Answer 81

**GCS \<13**

Question 82

**Immediate management of acute urinary clot retention leading to AKI?**

Answer 82

Bladder irrigation with three way urethral catheter Nephrostomies /Suprapubic catheters are second line measures as more invasive

Question 84

**Pain on wrist extension/forearm supination when elbow is extended**

Answer 84

**lateral epicondylitis: Tennis elbow**

Question 85

**Diffuse haemorrhage of adrenal glands**

Answer 85

Waterhouse- Friedrichson syndrome -Patients often septic with profound coaguloapthy

Question 86

**Most common benign (4) and malignant parotid masses (6)** **Other causes of parotid swelling (3)?**

Answer 86

**Benign:** Pleomorphic Adenoma (80% of ALL masses) Warthin's Tumour (adenolymphoma) Monomorphic Adenoma, Hemangioma **malignant:** Mucoepidermoid carcinoma (30%), Adenoid, Mixed, Acinic, Adenocarcinoma, Lymphoma **Other:** HIV, Sjogren, Sarcoid

Question 87

**COPD Management?**

Answer 87

i) SABA/SAMA ii) **FEV1 \>50%** LABA or LAMA **FEV1 \<50%** LABA/LAMA + ICS **Oral theophylline** **Mucolytics - Carbocysteine**

Question 88

**Features of TCA Overdose** **Mx**

Answer 88

**Features:** Anticholinergic features Arrhythmias Seizures Metabolic acidosis coma Broad complexes, Tachycardia, prolonged QT interval Management: **IV bicarbonate -** for metabolic acidosis **IV lipid emulsion -** binds free drugs **Anti arrhythmics not as useful as they prolong depolarisation or prolong QT intervals.** **Lidocaine** may be helpful

Question 89

**What to do if someone taking the COCP does not stop taking this before their surgery?** **What can be offered instead of COCP for these patients?**

Answer 89

Give them thromboprophylaxis. **If they don't want to stop contraception then offer the POP until they are mobilised then they cna be switched to COCP**

Question 90

**Name some occupational materials that are thought to cause occupational asthma (7)**

Answer 90

**Spray painting, foam moulding** (Isocyanates) ## Footnote **Platinum Salts Soldering Flux Resin** **Glutaraldehyde** **Flour** **Epoxy Resins** **Proteolytic Enzymes**

Question 91

**i) Colicky pain and post prandial swelling of sumbandibular gland?** **ii) Pus leaking from ducts associated with submandibular gland - Cx?** **iii) painless slow growing mass in submandibular region** **iv) Parotid duct called? Submanidublar duct called?**

Answer 91

i) Sialolithiasis - 80% occur in the submandibular gland. **Sialography** - investigation of choice. ii) Sialadenitis - submandibular abscess iii) Submandibulat tumour. **CT/MRI** - to timage and **usually FNAd.** Most masses are excised anyway iv) Parotid - Stenton's duct. Submandibular - warthol's duct

Question 92

**List of conditions pyoderma gangrenosum is associated with? (7)** **Mx**

Answer 92

Deep red necrotic ulcers **Causes -** Idiopathic (50%), IBD (UC ,Crohn's), RA, SLE, Myeloproliferative disorders, Lymphoma, Monoclonal Gammopathy, Primary Biliary Cirrhosis **Mx** - oral steroids, ciclosporin, infliximab

Question 93

**Corneal abrasian** **Dx** **Mx**

Answer 93

Dx - Slit lamp investigation with fluorescein shows yellow stained abrasian Mx - topical antibiotic to prevent bacterial superinfeciton

Question 94

**Treatment for:** **i) Massive PE with circulatory failure** **ii) Provoked PE** **iii) Unprovoked PE** **iv) PE in malignancy**

Answer 94

i) Thrombolysis. Use unfranctionated heparin (measure with APTT) ii) Provoked PE - 5 days LMWH + 3 months warfarin iii) Unprovoked PE - 5 days LMWH + 3-6 months Warfarin iv) Malignancy PE - 6 months LMWH

Question 96

**Two most comman causes of bihilar lymphadenopathy** 3 Other rarer

Answer 96

Sarcoidosis Tuberculosis **Rarer Causes:** Malignancy, lymphoma Pneumoconiosis - beryliosis Fungi - histoplastmocytosis, coccidioidmycosis

Question 97

**New classification for Diabetic Retinopathy** **Old classification**

Answer 97

New: **Mild, Moderate, Severe NPDR** **PDR** **Mild - \>1 microaneurysm** **Moderate - microaneurysms, hard exudates, blot haemorrhages, cotton wool spots, venous bleeding, intraretinal microvascular abnormalities** **Severe - blot haemorrahges and microaneurysms in 4 quadrants. Venous bleeding in at least 2 quadrants. IRMA in at least 1 quadrant** **PDR - Neovascularisation** **Old:** Backround - microaneurysms, blot haemorrhages \<3, hard exucates Pre proliferative - cotton wool spots, \> 3 blot haemorrhages, venous bleeding, dark haemorrhages Proliferative - neovascularisation

Question 98

Cocaine MOA Side Effects

Answer 98

**MOA -** Blockes dopamine, NA and serotonin **Cardiovascular effects** myocardial infarction. tachycardia, bradycardia, hypertension, QRS widening and QT prolongation, aortic dissection **Neurological effects -** seizures, mydriasis, hypertonia, hyperreflexia **Psychiatric effects -** agitation, psychosis, hallucinations **Others** ischaemic colitis, hyperthermia, metabolic acidosis, rhabdomyolysis

Question 99

**Clinical features of aynkylosing Spondylitis** Examination - **what is schober's test** Radiologically **7 As and 1 C of ankylosing spondylitis**

Answer 99

**HLA B27 association** Night and morning pain in young man **On examination:** Loss of lumbar lordosis Increased thoracic kyphosis Reduced lateral flexion Reduced forward flexion **Schober's test -** Line drawn 10 cm above + 5 cm below. Distance between lines should increase by more than 5 cm when patient bends as far as possible. Reduces chest expansion **Radiological features** Bamboo spine/ dagger spine Scroilitis - narrowing/ widening of the joints Squaring of the vertebral bodies Enthesopathy, Ossification of ligmaents and tendons **7 As and 1 C of ank spond** Anterior Uveitis Apical Fibrosis Aortic Regurgitation Achilles Tendonitis AV Node Block Amyloidosis Peripheral arthritis **Cauda Equina Syndrome = C**

Question 100

**Reduces IL-2 release causing reduction in clonal expansion of T Cells** **Indications** **Side Effects**

Answer 100

**Ciclosporin** **Indications:** UC, Red Cell Aplasia, psoriasis, RA, Organ transplantation **SE:** Nephrotoxic Hepatotoxic HyperKalaemia Hypertension Hypertension Fluid Retention Gingival hyperplasia Hypertrichosis IGT Hyperlipidaemia Increased chance of severe infection

Question 101

**Binds to sodium channels and increases their refractory period** **Side Effects:** **Acute** **Chronic** **Dose Monitoring**

Answer 101

**Phenytoin** **Side Effects:** Acute - Cerebellar Poisoning ( Dizziness, Diplopia, Ataxia, Nystagmus, Slurred Speech, Confusion, Seizures) Chronic - Gingival Hyerplasia, hirsutism, drowsiness, megaloblasitc anaemia, **peripheral neuropathy,** **increased vitamin d metabolism (osteomalacia),** lymphadenopathy, dyskinesia, drug induced lupus, hepatitis. dupytren's contracture, fever, rashes (**TEN)** **Trough monitoring -** for dose adjustment, suspected toxicity, non-adherence

Question 102

**Patient with Intracerebral Bleed** **Becomes unresponsive** Primary Diagnostic Concern?

Answer 102

**Obstructive hypercephalus -** due to blood in in the ventricles

Question 103

**Antibiotic choice for corneal abrasian in:** **Contact Lens Wearer** **Non-Contact Lens Wearer**

Answer 103

**Contact lens -** Topical Ciprofloxacin **Non contact lens wearer -** Topical Erythromycin, Topical sulfecetamide

Question 104

**Levodopa:** Usually given with? How long does it usually work for? What side effects?

Answer 104

Usually given with - **Carbidopa, Benserazide (DOPA Decarboxylase inhibitors)** **Usually effective for about 2 years** SIde effects - On and off --\> where suddenly there isn't enough dopamine so symptoms resume. Can be treated with interspersed dopamine analogues. Dyskinesia Postural hypotension Cardiac arrhythmias Nausea and vomiting reddish discolouration of urine

Question 105

**Opthalmaplegia, Areflexia, Ataxia**

Answer 105

Miller- Fisher Syndrome

Question 106

Statin + Macrolide

Answer 106

= Raised CK

Question 107

**Blood test for advanced fibrosis?**

Answer 107

**ELF (Enhanced liver fibrosis) -** looks at **Hyaluronic Acid, Procollagen III, Metalloproteinase 1 Inhibitor** **Algorithmic result determined from the finding**

Question 108

**Treatment goals for haemachromatosis**

Answer 108

Transferrin saturation - \<50% Ferritin - \<50 ug/l

Question 109

**Different renal stone treatmetns (5)**

Answer 109

**Extracorporeal shock therapy / Lithotripsy:** \>2 cm stones **Ureteroscopy :** \>2 cms stones in pregnant women **Percutaneous nephrolithotomy:** complex renal calculi/ stone calculi **Expectant Management:** \<5mm ureteric calculi **Open:** Complex cases

Question 110

**Renal stone prevention:** Calcium Stones Oxalate Stones Uric Acid Stones

Answer 110

Calcium Stones - High fluids, low protein, **thiazide diuretics -** increase distal tubular calcium resorption Oxalate Stones - **cholestyramine, pyridoxine -** urinary oxalate secretion Uric Acid Stones - **Allopurinal, Oral bicarbonate**

Question 111

**Hypokalaemia ECG (5)** **Hyperkalaemia ECG**

Answer 111

**Hypokalaemia ECG:** U have no pot and no t, but a long PR and a long QT U Waves Absent T Waves Long PR St Depression Long QT **Hyperkalaemia ECG:** Peaked T Waves (first sign) Absent P Waves Prolonged PR Conduction block Sine waves bradycardia

Question 112

Treatment for symptomatic bradycardia

Answer 112

IV Atropine

Question 113

Drug causes of pancreatitis (8)

Answer 113

azathioprine mesalazine didanosine bendroflumethiazide furosemide pentamidine steroids sodium valproate

Question 114

**Which COPD patients get antibiotics in exacerbation?**

Answer 114

**NICE -** purulent sputum or clinical signs of pneumonia **In reality** - all of them get antibiotics

Question 115

**Heart Failure:** **1st Line** **2nd Line** **3rd Line**

Answer 115

1st Line: **ACE-i + Beta Blocker (**bisoprolol or carvedilol**)** 2nd Line: **Aldosterone Antagonist, ARB or Hydralazine + Nitrate** 3rd Line: **Cardiad resynchronisation, Digoxin (particularly if concurrent AF) or Ivabradine (only if HR \>75 bpm + LVF \<35%)**

Question 116

**Regarding extra-colonic manifestations of IBD:** **Which are disease activity:** **Related** **Unrelated**

Answer 116

**Related:** * Asymmetric arthritis * Episcleritis (**more common in crohn's**) * Erythema nodosum * Osteoporosis **Unrelated:** * Symmetric Arthritis * Uveitis (**more common in UC**) * Pyoderma Gangrenosum (Rx oral/iv intermittent pred/ ciclosporin) * Clubbing * Primary Sclerosing Cholangitis (**UC)**

Question 117

**Lobar Collapse** **X Ray Signs** **Causes**

Answer 117

X Ray signs: * Opacification in distribution of lobe * Pulling up of rest of lung i.e. horizontal fissure * Tracheal deviation to side of collapse * raised hemidiaphragm on side of collapse Causes: * Mucous plug in asthma * Pneumonia * Lung cancer * Foreign body

Question 118

**Pneumothorax intevention guidance:** **Primary** **Secondary**

Answer 118

Primary: - \<2 cm rim of air. Consider discharge - \>2cm rim of air: aspirate then drain if not working Secondary: - \>2 cm rim of air: Chest drain - 1-2 cm rim of air: Aspiration / chest drain - 1 cm : 24 hour oxygen therapy then repeat x ray

Question 119

Amyloid Deposit in Thyroid Cancer

Answer 119

Medullary Thyroid

Question 120

**Statin Dose:** **Primary prevention** **Secondary prevention**

Answer 120

Primary - 20 mg OD Secondar - 80 mg OD

Question 121

**Treatment for acne** **3 - and their rough MOA**

Answer 121

Benzoyl peroxide - **bacteriocidal** Adapalene - topical retinoid inhibiting **keratinocyte differentiation** Lymecycline - is an antibiotic but in acne is an **anti-inflammatory**

Question 122

**Hallmark features of dermatofibroma** 5

Answer 122

Itchy occurs after insect bite benign Well-defined **Dimples inwards when squeezed**

Question 123

**Brown, yellow patches on sun exposed areas.**

Answer 123

**Solar Lentigines** - benign but have malignant potential. Look for brown spots in between them for malignant conversion

Question 124

**Which type of naevus can resemble malignant melanoma**

Answer 124

Dysplastic naevus

Question 125

**Difference between Lentigo Maligna and Solar Lentigenes and SSM**

Answer 125

**Lentigo Maligna** are more darkly pigmented than **solar lentigenes,** - also usually larger and more irregularly shaped **When distinguishign between LM and SSM:** - sun exposed more likely to be LM - Trunk and limbs - SSM - Angiogenesis - SSM -

Question 126

**Pigmented linear line on nail** **(involvement of nail bed)**

Answer 126

Longitudinal Melanicular **(hutchinsons sign)**

Question 127

**Grows faster than BCC, but resembles BCC**

Answer 127

Amelanotic Melanoma - Although these will not be pigmented can be picked up by realising their growth is rapid

Question 128

**Crusted, erythematous, yellow lesion** What does it become

Answer 128

**Actinic Keratoses** **- becomes SCC (1-5% risk over 2 years)** Sun exposed sites , scaly, red, sore, plaque like, keratin

Question 129

**keratocanthoma vs SCC**

Answer 129

**They are similar visually and even histologically** BUT **Keratocanthomas** - originates from follicular infundibulum - appear involuted - spontaneously regress - faster growing than SCC - keratin filled centre - **retinoids** **SCC** - Metastasise, grow fast - firm, flesh toned, sore, painful, bleeds and oozes Excision is management for both, 5 FUC, imiquimod,

Question 130

**Cranial Nerves effected in Accoustic Neuroma** Investigation of choice

Answer 130

**CNVII - facial droop** **CNV - absent corneal reflex** **CNVIII - Deafness, tinnitus** MRI Cerebellopontine angle

Question 131

**cANCA (2)** **pANCA (5)**

Answer 131

**cANCA** - targets serine proteinase 3 **granulomatosis with polyangitis (Wegener's)** **microscopic polyangitis** **pANCA -** targets MPO immune crescenteric glomerulonephritis churg-strauss primary sclerosing cholangitis microscopic polyangitis granulomatosis with polyangitis (wegener's)

Question 132

**Screening test of choice for Adult polycystic kidney disease** **Which gene is associated with worse disease** **Which chromosomes?**

Answer 132

Ultrasound abdomen: **total of 2 cysts from either kidney if \<30 yo** **2 cysts in each kidney if 31-59 yo** **4 cysts in each kidney if \>60 yo** **ADPKD1 (also more common) is associated with worse disease** **ADPKD1- Chr 16** **ADPKD2- Chr 4**

Question 133

**First time tonic clonic AED for:** **Men** **Women**

Answer 133

Men: Valproate Women: Lamotrigine

Question 134

**Palliative care:** **i)Moving from oral morphine to parenteral morphine** **ii)from morphine to diamorphine** **iii)in CKD alternatives to morphine** **iv) codeine/tramadol to morphine** **v) oral morphine to oral oxycodone**

Answer 134

**i)Moving from oral morphine to parenteral morphine** Divide oral morphine dose by 2 **ii)from oral morphine to diamorphine (SC)** Subcutaneous diamorphine. Divide oral dose by 3 **iii)in CKD alternatives to morphine** Buprenorphine, fentanyl, alfentanil **iv) Oral codeine/tramadol to oral morphine** divide by 10 **v) oral morphine to oral oxycodone** divide by 1.5-2

Question 135

**Inducing remission in UC:** **I)** mild to moderate disease **ii)** severe disease **iii)** distal disease vs proximal disease

Answer 135

**i )** mild to moderate disease: **Oral aminosalicylate** **rectal/topical aminosalicylate** **oral beclometasone proprionate** **oral prednisolone -** second line for inducing remission **ii)** severe disease: **IV steroids** **iii)** distal disease vs proximal disease: **distal disease -** rectal medalazine **proximal disease** - oral aminosalicylates

Question 136

**Red Man syndrome?** **i) What drug** **ii) Mechanism** **iii) Mx**

Answer 136

i) Vancomycin ii) Fast infusion causes vancomycin mediated mast cell degranulation. **not anaphylaxis** iii) Stop infusion, wait for resolution, and start again at a slower rate.

Question 137

**Component of CHADS2 VASC scoring**

Answer 137

**C- Congestive Heart Failure** **H - Hypertension** **A - Age \>75 = 2 points, 65-74 = 1 point** **D- Diabetes** **S2 - Stroke/TIA =2 points** **V = Vascular disease** **S = Sex being female** **Consider anticoagulation in MEN at score of 1** **Definitely anticoagulate when score \>2**

Question 138

**Reflexes: Which nerve correlation** Ankle Knee Biceps Triceps Brachioradialis

Answer 138

Ankle - S1-S2 Knee - L3-L4 Biceps - C5-C6 Triceps - C7-C8 Brachioradialis - C5-C6

Question 139

**Bony Metastases:** Common primaries Common sites

Answer 139

**Primaries -** Prostate, breast, lung **Sites -** Spine, pelvis, ribs, skull, long bones

Question 140

**Variceal Haemorrhage:** **Acute treatment (5)** **Prophylactic treatment (2)**

Answer 140

**Acute treatment (5)** ABC + fluid / blood resuss **Clotting-** FFP + VIt K **Terlipressin** **QUinolones** **Invasive -** Endoscopy + rubber band ligation/ Sengstaken-Blakemore if uncontrolled/ **TIPS as a last line** **Prophylactic treatment (2)** Propanolol - reduce rebleeding Endoscopic variceal band ligation - two weekly intervals

Question 141

**Mx of chronic neuropathic pain** **First Line** **Second Line** **Trigeminal Neuralgia**

Answer 141

First **- Amiptryilline, Duloxetine (SSNRI), Pregalab****alin, gabapentin** Second- topical capsaicin, tramadol (rescue therapy), pain management **Trigeminal Neuralgia -** Carbamezapine

Question 142

**UC + Transverse colon diameter \>6 cm =**

Answer 142

Toxic megacolon

Question 143

**Simon Broome Classification**

Answer 143

**Used to diagnose Familial Hypercholesterolaemia**

Question 144

**Eron Classification System**

Answer 144

**For cellulitis** **1-4**

Question 145

**Serum-ascites albumin gradient** Raised in What's normal

Answer 145

**Ascites** caused by **Portal Hypertension** \<11 g/L normal

Question 146

**Significant smoking history increases lung cancer risk by a factor of ....** **Asbestos exposure increases lung cancer ...**

Answer 146

10 - smoking 5 - asbestos

Question 147

**Carbon 13 urea breath test?** **Reduced accuracy of test?**

Answer 147

H Pylori **Reduced accuracy of test?** - Anti secretory drugs within last 2 weeks - Antibiotics within last 4 weeks

Question 148

**Thiazide Diuretics used to treat Hypertension (3)**

Answer 148

Bendroflumethiazide Indapamide (1.5mg MR) Chlorthalidone (12.5-25.0 mg)

Question 149

**Causes of Long QT** **2 syndromic** **5 Drug** **5 other**

Answer 149

2 syndromic: **Jervelle- Lang- Nielsen Syndrome -** (abormal K+ Channel - associated with deafness) **Romano Ward Syndrome -** **5 Drug:** TCAs - Amiodarone Terfenadine Chloraquine Erythromycin **5 other :** Electrolyte- Hypomaganesaeima, Hypokalaemia, Hypocalcaemia Acute MI Myocarditis Hypothermia SAH

Question 150

**Drugs causing haemolysis in G6PDD\>**

Answer 150

**anti-malarials: primaquine** **ciprofloxacin** **sulph- group drugs: sulphonamides, sulphasalazine, sulfonylureas**

Question 151

**Acceptable RF change when ACE-I started?**

Answer 151

25% GFR decrease 30% Creatinine rise Anymore should prompt investigation

Question 152

**What are medicines associated with the development of idiopathic (iatrogenic) intracranial hypertension? (7)**

Answer 152

Tetracycline antibiotics isoretinoin contraceptives steroids levothyroxium cimetidine lithium

Question 153

**Blood investigation in wernicke's encephalopathy?**

Answer 153

**Red Cell Transketolase** **- thiamine dependent enzyme so in those with thiamine defficiecny the activity will be negatively impacted**

Question 154

**Dermatome:** **C6?** **T4?** **T10?** **L1?** **L4?** **L5?** **S1?**

Answer 154

C6 - Put thumb and first finger together to make a 6 with your left hand. **Dorsal thumb and first finger** T4 - Teat Pore. **Nipple** T10 - Belly but- TEN. **Umbilicus** L1 - L for ligamnet (inguinal) 1 for 1nguinal. **Inguinal Ligament** L4 - Down on aall fours. **Knee Cap** L5 - Largest of the five. **DOrsum of big toe** S1 - Smallest one - **Small toe**

Question 155

**CVP Reading of \<18 mmHg implies:**

Answer 155

Pulmonary oedema is excluded

Question 156

**EBV Associated malignancies**

Answer 156

Burkitt's Lymphoma - starry sky Nasopharyngeal carcinoma Hodgkin's lymphoma - HIV associated CNS Lymphoma

Question 157

**Dysplasisa in oesophagus during endoscopy?** **Metaplasia?**

Answer 157

Needs treatment! - Endoscopic resection/ablation - thought to prevent transfromation to **adenocarcinoma** **3-5 yearly surveillance with endsocopy for metaplasia**

Question 158

**IBS Management** **1st line** **2nd line**

Answer 158

1st line drugs often depend on presentation: Constipation - Laxatives, Linaclotide (if constpiation \>12 months and laxatives not working) Pain - anti-spasmodics ( baclofen, mebeverine, dantrolene) Diarrhoea - loperamide 2nd Line: TCA\> SSRIs

Question 159

**Differentiate between SIADH and Salt Wasting**

Answer 159

**Both have:** **\> 500 urine osmolality** **Hyponatraemia** **SIADH - euvolaemic** **Salt wasting - Dehydrated**

Question 160

**RBBB** **Left Axis Deviation** **First Degree heart block** **/** **RBBB** **Left Axis Deviation**

Answer 160

Tri-Fascicular Block / Bi-Fascicular Block

Question 161

**Medication to quit smoking?** **3**

Answer 161

Given in isolation and not as combination treatment **NRT - Lozenges, Gums etc.** - cauase nausea and headaches **Bupropion -** Dopamine + NE reuptake inhibitor/ nicotinic antagonist SEs - Seizures, CI - elipepsy, pregnancy, breast feeding **Varenicline** - Nicotinic receptor partial agonist ?more effective than bupropion SE - suicidalility. Commonly - nauseua, headaches, abnormal dreams CI- mental health issues, pregnancy and breastfeeding **Varenciline**

Question 162

**Screening for zollinger ellison syndrome**

Answer 162

**Fasting gastrin levels!** secretin stimulation test

Question 163

**Strep Bovis** What tests do you do?

Answer 163

**Bloods - usuals + Blood cultures** **Echo - if murmur / ?valve vegitation** **Colonoscopy - ?Colorectal cancer**

Question 164

**Infective endocarditis** Most common Subacute Culture negative

Answer 164

**Most common -** S. Aureus **Subacute -** Viridans, Bovis? **Culutre negative:** - Liebman Sacks (SLE) - Marantic (Malignancy) - 3 Bs - bartonella, Brucella, coxiella burnetti - HACEK -Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)

Question 165

**Anti-Emetics MOA:** Metoclopramide Domperidone Ondansetron Cyclizine Prochlorperazine

Answer 165

Metoclopramide - Dopamine receptor antagonist / 5 HT3 antagonist/ 5 HT4 agonist Domperidone - D2 receptor antagonist Ondansetron - 5 HT3 Antagonist Cyclizine - anti-histamine Prochlorperazine - D2 Receptor antagonist (phenothiazine)

Question 166

**Causes of respiratory alkalosis** **(6)**

Answer 166

Anxiety Salicylate Pulmonary embolism Pregnancy altitude CNS Disorders (Stroke, SAH, encephalitis)

Question 167

**WPW** 5 ECG Features Explain mechanism Types? **Mx?** **Mx if AF?**

Answer 167

**ECG:** Short PR Interval Broad QRS RAD if right accessary LAD if left accessary Delta wave - upstroke of QRS complex **WPW caused by a congenital accessory pathway between the atria and the ventricles** **- can cause AF to rapidly degeneratie into VF** **Three types** **A LAD (left accessory) - dominant r wave in v1** **B RAD (right accessory) - dominant r wave in v6** **C - upright delta waves in v1-4 but negative delta waves in v5-v6** Mx Medical - Sotalol, Fleicanide, Amiodarone Interventional - radiofrequency ablation of accessory **Mx if AF -** Don't give sotalol as this can cause progression to VF. Beta blockers increase the refractory period so slowing down the rate but in WPW this is thought to lead to increased conduction through the accessory pathway

Question 168

**Amiodarone** **MOA** **Monitoring** **SEs**

Answer 168

**MOA -** Potassium channel blocker (CLASS III Anti-arrhythmic) (minor sodium channel blocker) --\> Inhibits repolarisation **Monitoring --\> Prior to starting -** TFT, U+E, LFT, CXR **6 monthly** - TFT, LFT **SEs -** Thyroid, hepatotoxic, pulmonary fibrosis, slate-grey appearance, corneal deposits, peripheral neuropathy + myopathy, photosensitiviy. makes pts bradycardic

Question 169

**Maintenance fluids requirements?** **V important card**

Answer 169

Water - 30 ml/kg/day Sodium, Potassium Chloride - 1mmol/kg/day Glucose - 50-100 g/day

Question 170

**Tumour Antigens:** Ca 125 Ca 19 9 Ca 15 3 PSA AFP CEA S- 100 Bombesin

Answer 170

Ca 125 - ovary Ca 19 9 - pancreatic, cholangiocarcinoma Ca 15 3 - breast PSA - prostate AFP - HCC, Teratoma CEA - CRC S- 100 - Melanoma, Schwannoma Bombesin - SCLS, Gastric cancer, neuroblastoma

Question 171

**Peripheral Neuropathy** Which are predominantly: **i) motor (6)** **ii) sensory (6)di**

Answer 171

**MOTOR CAUSES:** i) CMT - HMSN ii) GBS iii) Poprhyria iv) Lead poisoning vI) CIDP - chronic inflammatory demyelinating polyneuropathy vi) diptheria **Sensory Causes:** i) diabetes ii) uraemia iii) leprosy iv) B12 def. v) alcoholism vi) amyloidosis

Question 172

**Inhaled ICS Doses:** **Low** **Medium** **High**

Answer 172

Low - \<400 Medium - 400-800 High - \>800 doses all in mcgs.

Question 173

**Which artery supplies AV node?** **What is it usually a branch of?**

Answer 173

Posterior Interventricular Artery **usually a branch of the - RIGHT CORONARY ARTERY (** in a minority of patients the left circumflex artery **)** So - clinically: RCA occlusion causes Inferior MI ---\> complication can be heartblock as both the AVN and SAN are supplied by the right coronary usuallly

Question 174

Cerebral oedema after blood transfusion?

Answer 174

**Dialysis Disequilibrium Syndrome** Diagnosis of exclusion

Question 175

**Inhibits sodium absorption at beginning of DCT?** What channel does it block Some examples of the drug (3) SEs

Answer 175

**Thiazides: Blocks the Na+ Cl- symporter** **Drugs: Indapamide, Chlortalidone,** Bendroflumethiazide **SEs:** Electrolytes: Hypokalaemia and natraemia, hypercalcaemia dehydration postural hypotension gout IGT impotence rare- thrombocytopenia, agranulocytosis, **photosensitive rash,** pancreatitis

Question 176

**Ptosis and dilated pupil =?** **Ptosis and constricted pupil =?**

Answer 176

**Ptosis and mydriasis (dilated pupil) =** CN III palsy **Ptosis and meiosis (****Constricted pupil)** = Horner's syndrome

Question 177

**In CURB 65 :** **All of the values**

Answer 177

Confusion: 8/10 or less on AMTS Urea: \>7 mmol/L R: \>30 BPM B: \<60 mmHg **diastolic** Age: \>65

Question 178

**Allergy, Eosinophilia, Medium vessel vasculitis (involvement of renal vessels?)** **Condition** **Antibody implicated** **Drugs that can precipitate disease?**

Answer 178

Churg Strauss- asthma, eosinophils, sinusitis, mononeuritis multiples, **pANCA positive in 70% patients** **- pANCA** **Leukotriene receptor antagonists can precipitate disease**

Question 179

**Erratic blood glucose control** **bloating** **vomiting** **Dx?** **Rx?**

Answer 179

Gastroparesis (in DM) Rx - metoclopramide, domperidone, erythromycin

Question 180

**Investigating frank haematuria in \>45?**

Answer 180

Cystoscopy - Concern is bladder cancer so follows the 2ww pathwya

Question 181

**Chemotherapeutic agents and their SEs?** Cyclophosphamide Bleomycin Doxirubicin MTX 5FUC 6MCU Cytarabine Vincblastine Vincristin Docetaxel Cisplatin Hydroxyurea

Answer 181

Cyclophosphamide - **haemorrhagic cystitis**, myelosuppression, TCC Bleomycin - lung fibrosis Doxirubicin - **cardiomyopathy** MTX - myelosuppresion, mucositis, **liver fibrosis**, lung fibrosis 5FUC - myelosuppression, mucositis, dermatitis 6MCU - myelosuppression Cytarabine, myelosuppression, **ataxia** Vincblastine - myelosuppression Vincristin - peripheral neuropathy, paralytic ileus Docetaxel - **neutropenia** Cisplatin - **ototoxicity, peripheral neuropathy, hypomaganasaemia** Hydroxyurea - myelosuppression

Question 182

**Which murmur is associated with collagen defects - Marfan's, ehler's danlos?**

Answer 182

Mitral regurgitation - pan systolic - soft s1, split s2

Question 183

**Epilepsy and driving** **1 seizure** **formal diagnosis of epilepsy** **withdrawal of AEDs**

Answer 183

1 seizure - tell DVLA and cant drive for six months Formal diagnosis - must be seizure free for \>12 months withdrawal of AEDs - shouldn't drive while withdrawing and until 6 months after final dose

Question 184

**Pointed/ arrowhead t wave inversion in anterior leads?**

Answer 184

Wellen's Syndrome - represents **critical, proximal stenosis** of the **LAD** (symmetrical often deep t wave inversion, \>2mm)

Question 185

**Thyroid nodules + lymphadenopathy?**

Answer 185

Papillary Carcinoma - undergo lymphatic spread more readily than follicular thyroid cancers

Question 186

**Atrial Flutter** What is the atrial rate? What does block refer to? Rx?

Answer 186

Atrial rate is normally 300. So the **block** refers to how many saw tooth p waves versus how many ventricular beats. This dissociation is caused by **AV Block**. 2:1 block = 150 bpm (ventricular beats), 3:1 = 100, 4:1 =75 **Rx:** Medication used to treat AF Cardioversion - lower lectricity required Tricpid valve isthmus ablation

Question 187

**Pericarditis** Signs and symptoms Causes ECG Findings

Answer 187

**Signs and symptoms** Central chest pain, pleuritic Relieved by sitting forwards tachypnoea, tachy cardia pericardial rub **Causes:** Virii (Cox), TB, Uraemia, Post MI, Dresslerr's, CTD, hypothyroidism **ECG Findings - Concave ST elevation.** Most specific- PR depression

Question 188

Epithelioid Histiocytes

Answer 188

**Histological finding in TB**

Question 189

**Common causes of pyogenic liver abscesses** **Hydatid disease vs other liver abscess**

Answer 189

Staph aureus and e coli **hydatid disease -** the cyst is walled off and well circumscribed

Question 190

**Adenosine interactions**

Answer 190

**Enhanced by** - dipyrimadole **Inhibited by -** theophylline

Question 191

**AS** **Asymptomatic patient** **when to treat?**

Answer 191

\>40 mmHg pressure gradient LVF

Question 192

**Trichrome stain.** **Methenamine silver stain .** **Giemsa stain**

Answer 192

Trichrome stain is for giardiasis. Methenamine silver stain is for PCP pneumonia. Giemsa stain is for Cryptococcus neoformans.

Question 193

**Councilman bodies** **Epithelioid histiocytes .** **Herman's sign .** **Winterbottom's sign**

Answer 193

Councilman bodies is something you would see in the liver and is associated with hemorrhagic fevers such as yellow fever. Epithelioid histiocytes are for tuberculosis infection. These are flattened macrophages which resemble epithelium. Herman's sign is a rash found in dengue fever patients. Winterbottom's sign is an enlarged lymph node found in patients suspected of African sleeping sickness.

Question 194

Wegener's renal biopsy finding?

Answer 194

Crescenteric GN **WCC** **Wegeners, cANCA, Crescenteric**

Question 195

**Surgical treatment of ITP?**

Answer 195

platelet count threshold level is **80** **\>80** Nothing , just monitor bleeding **\<80** consider IVIG and corticosteroids

Question 196

**Neuropathies** predominantly sensory and autonomic neuropathy predominantly motor neuropathy predominantly sensory neuropathy

Answer 196

**Type 2 diabetes** causes predominantly sensory and autonomic neuropathy **Botulism and lead poisoning** cause predominantly motor neuropathy **Vitamin B12 deficiency and alcohol** cause predominantly sensory neuropathy

Question 197

Periodic acid schiff positive granules

Answer 197

**Macrophage inclusions seen in Whipple's Disease** **Tropheryma whippelii** **Rx - Co-trimoxazole** malabsorption: diarrhoea, weight loss large-joint arthralgia lymphadenopathy skin: hyperpigmentation and photosensitivity pleurisy, pericarditis neurological symptoms (rare): ophthalmoplegia, dementia, seizures, ataxia, myoclonus

Question 198

Visual field defect in glaucoma?

Answer 198

Peripheral visual field loss

Question 199

**Target INR for valves** **Mitral** **Aortic**

Answer 199

Mitra- 3;5 Aortic - 3.0

Question 200

**Which ECG findings have a risk of potential asystole (4)** **Rx**

Answer 200

complete heart block with broad complex QRS recent asystole Mobitz type II AV block ventricular pause \> 3 seconds Rx - Transvenous pacing (if delay - atropine, adrenaline, transcutaneous pacing)

Question 201

**Common drug decreasing absorption of levothyroxine?**

Answer 201

**IRON**

Question 202

**Nicorandil** MOA Use

Answer 202

Potassion channel activator Used in angina

Question 203

**Angina Algorithm** **1st Line** **2nd Line** **3rd Line** **Definitive**

Answer 203

**Angina Algorithm** All given aspirin, statin + GTN **1st Line -** CCB (Rate limiting - diltiazen / verapamil) / B BLocker **2nd Line -** Both CCB + B Blocker **3rd Line -** Nicorandil (K+ Channel activator), Long acting Nitrate, Ranazoline, Ivabradine (Interacts with If channel in SAN --\> rate limiting) **Definitive -** PCI/ CABG

Question 204

**Why are packed red cells irradiated?**

Answer 204

**Depletes blood of T lymphocytes** **Effort to prevent GVHD**

Question 205

**ADenosine** MOA Use

Answer 205

SVT A1 agonist - reduces cAMP -\> causes hyperpolarisation due to potassium eflux

Question 206

**eGFR variables** **CAGE**

Answer 206

Creatinine Age Gender Ethnicity

Question 207

**ECG Changes for thrombolysis or percutaneous intervention**

Answer 207

ST elevation of **\> 2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6)** OR ST elevation of greater than **1mm (1 small square) in greater than 2 consecutive inferior leads (II, III, avF, avL)** OR New L**eft bundle branch block**

Question 208

**Absent corneal reflex...**

Answer 208

Accoustic neuroma - effect 5,7,8

Question 209

**Hypercalcaemia management?**

Answer 209

**IV NS + Frusemide if patient is fluid intolerant** **followed by bisphosphonates** Calcitonin can be used to quickly rectify and steroids in sarcoid

Question 211

**T1DM** Target BM on: Waking Before meals

Answer 211

Waking: 5-7 Before meals : 4-7

Question 212

**Aortic Coarctation** **Features** **Associations**

Answer 212

Features - RF Delay - Mid Systolic Murmur (listen inbetween clavicles) - Apical click from aortic valve Associations - Turner's - Bicuspid - Berry aneurysms - NF

Question 213

**VF/ pVT** **When do you give drugs** **What drugs?**

Answer 213

1 mg Adrenaline, 300mg Amiodarone - **IV** **Drugs to be given after third shock**

Question 214

**Addisonian Crisis** **Features** **Mx**

Answer 214

Features - hypovolaemia, hyponatraemia, hypokalaemia, abdo pain Mx - 100mg hydrocortisone (6 hourly) Stat IV NS **start oral steroid after 24 hours/ when patient stabilises**

Question 215

**Parkinson's** **TRAP?**

Answer 215

Tremor Rigidity Akinesia Postural instability

Question 216

**Triptan adverse effects?**

Answer 216

Tightness of throat and chest tingling heat heaviness pressure

Question 217

**Why would you have anterior lead and inferior lead ST Elevation?**

Answer 217

Due to complete occlusion of a wrap around **LAD**

Question 218

**Causes of SVT (3)**

Answer 218

AV nodal re entry tachycardia (AVNRT) AV re entry tachycardia (AVRT) Junctional Tachycardia

Question 220

**Subungual Fibromata** **Subungual Hyperkeratosis**

Answer 220

Subungual Fibromata - Tuberous Sclerosis Subungual Hyperkeratosis - Psoriasis

Question 221

**Causes of:** **Increased T4** **Increased TSH**

Answer 221

Grave's De Quervian's Pituitary Adenoma Poor Compliance with Thyroid meds (TSH goes down days to weeks after consumption) Total thyroid resistance -

Question 222

**GLP 1 Mimetics?**

Answer 222

Exanetitde (SC), Liraglutide Good for weight loss Need to have a significant HBA1C reduction Good for people not usitable for insulin therapy

Question 223

**Kallman Vs Kinefelter?**

Answer 223

**Kallmann - X Linked recessive** **Reduced GnrH Secreting neurones in hypothalamus (low SH levels)** **-** sterility, delayed puberty, anosmia ., hypogonadism. - normal/ tall **Kinefelter -** 47 XXY - delayed/ absent puberty Tall limbs, hypotonia , gynaecomastia , Cognitive impairment

Question 224

**Tumour Lysis Syndrome Biochemical markers** **Rx**

Answer 224

2 of : **Raised-** Uric acid, potassium, phosphate **Decreased -** calcium **Clinical diagnosis needs 2 of biochemical markers +** Raised serum creatinine Arrhytmia/ sudden death Seizure **Mx** **- Allopurinol** **- Rasburicase**

Question 225

**Inherited Hyperbilirubinaemias (4)**

Answer 225

**Unconjugated Hyperbilinaemia (Impaired UGT1A1 - bilirubin processor)** - Crigler Najjar (appear jaundiced) - Gilbert **Conjugated Hyperbilinaemia** - Dubin Johnson - Rotor

Question 226

**Causes of:** **Pulsus parodoxus Slow-rising/plateau Collapsing Pulsus alternans** **Bisferins Pulse 'Jerky' pulse**

Answer 226

**Pulsus parodoxus** greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration severe asthma, cardiac tamponade **Slow-rising/plateau** aortic stenosis **Collapsing** aortic regurgitation patent ductus arteriosus hyperkinetic (anaemia, thyrotoxic, fever, exercise/pregnancy) **Pulsus alternans** regular alternation of the force of the arterial pulse severe LVF **Bisferiens pulse** 'double pulse' - two systolic peaks mixed aortic valve disease **'Jerky' pulse** hypertrophic obstructive cardiomyopathy\*

Question 227

**Carcinoid Syndrome** ## Footnote **- Cardiac Features** **- Respiratory Features** **-Others** **- Ix** **-Mx**

Answer 227

**Cardiac Features** - TIPS - Tricuspid Insufficeincy, Pulmonary Stenosis. **Respiratory Features** Bronchospasm **Others -** hypotension, flushing, diarhoea, pellagra, Cuhsing's **Ix -** 5 HIAA, Chromagrin A y **Mx -** Octreotide ( Somatostin Analogues). Diarrhoea (Cyproheptadine)

Question 228

**IgA Deposition on histology of kidney?**

Answer 228

IgA Nephropathy - Berger's Disease (HSP also has IgA positive immunohistochemistry) Ax - Alcoholic cirrhosis, Coelias, HSP Mx - steroids / DMARDs dont help

Question 229

**Prophylaxis for neutropenic sepsis?**

Answer 229

Fluoroquinolones

Question 230

**Eczema** ## Footnote **Immunodeficiecny** **thrombocytopenia**

Answer 230

Wiskott Aldrich Syndrome -X linked recessive (WASP gene) Fx: - Bacterial infections - eczema - thromboycytopenia - **low IgM levels**

Question 231

**Sulfonylurea** **MOA:** **SEs:**

Answer 231

**MOA:** increase insulin secretion by binding to ATP Dependent K+ Channel on beta cells SEs: **Weight gain + Hypos** N+V SIADH cholestasis peripheral neuorpathy hepatic damage BM suppression

Question 233

**Rule for bowel diameter**

Answer 233

**369** \>3 pathological for Small bowel \>6 pathological for large bowel \>9 pathological for caecum

Question 234

**COPD** **using inhalers but not effective at reducing breathlessness** **FEV1 \<50%** **FEV1 \>50%**

Answer 234

FEV1 \> 50%: LABA or LAMA FEV1 \< 50%: LABA + ICS **or** LAMA

Question 235

**Proximal aortic dissection - Mx?** **Descending aortic dissection - Mx?**

Answer 235

Proximal aortic dissection = Aortic root replacement Descending aortic dissection = Endovascular treatment

Question 236

**Heart Sounds?** **S1** **S2** **S3** **S4**

Answer 236

**S1** closure of mitral and tricuspid valves **soft** = long PR or mitral regurgitation **loud=** mitral stenosis **S2** closure of aortic and pulmonary valves **soft** = aortic stenosis **splitting** = during inspiration is normal **S3** caused by **diastolic filling** of the ventricle considered normal if \< 40 years old heard in **left ventricular failure**, **constrictive pericarditis** and **mitral regurgitation** **S4** atrial contraction against a stiff ventricle **aortic stenosis**, **HOCM**, **hypertension**

Question 237

**Splitting of S2** Inspiration Expiration Wide Fixed

Answer 237

Inspiration = can be normal Expiration= aortic stenosis, HOCM, LBBB Wide = pulmonary stenosis, RBBB Fixed = ASD

Question 238

**Sickle Cell Disease** **Low Hb and High Reticulocytes** **Low Hb and Low Reticulocytes**

Answer 238

**Low Hb and High Reticulocytes -** Acute sequestration, haemolysis **Low Hb and Low Reticulocytes -** Parvovirus

Question 239

**Severe hypokalaemia?** **Value?** **Mx?**

Answer 239

Value = \<2.5/ or if symptomatic (cramps and palpitations etc.) **Mx** Cardiac monitoring No more than 20 mmol/hour K If mild Hypokalaemia can give oral potassium

Question 240

**Distinguishing between ATN and Pre Renal AKI** Urinary sodium? Urine: Plasma osmolality? Urine: Plasma urea?

Answer 240

**ATN** Urinary sodium - \>30 mmol/L Urine: Plasma osmolality - \<1.1 Urine: Plasma urea \>10:1 **Pre renal AKI** Urinary sodium - \<20 mmol/L Urine: Plasma osmolality \>1.5 Urine: Plasma urea \<8:1

Question 241

**Investiation of CHoice for Liver Cirrhosis**

Answer 241

Transient Elastography - 50 Mhz Wave looking for stiffness of liver Recommended instead of liver biopsy Indications - Hep C - \>35 units alcohol per week - known alcohol related liver disease

Question 242

**Late onset Type 1 Diabetes + Other Autoimmune**

Answer 242

LADA - Latent Autoimune diabetes of adulthood Anti-GAD antibodies bt just slower process

Question 243

**Gold standard for oesophogeal Ca diagnosis\>**

Answer 243

Endoscopy Not barium anymore

Question 244

**Indications for prophylactic antibiotics in SBP (3)** **Which antibiotic**

Answer 244

**Indications:** - previous SBP - ascitic fluid albumin level \<15 g/L + Child-Pugh Score of \>9/ hepatorenal syndrome - cirrhosis + ascites with albumin level \<15 g/L

Question 245

**Normal QT?** **Drugs prolonging QT?** **Other causes of long QT?** **Congental Causes of QT?**

Answer 245

**Normal QT** \<430 ms in men \<450 ms in women **Drugs prolonging QT** Anti Depressants (TCAs, SSRIs), Anti-arrhythmics (sotalol, amiodarone), Anti Addiction (methadone), Anti malarial (chloroquine), Anti Fungal (terfenadine), Antibiotic (erythromycin), Antipsychotic (Haloperidol) **Other causes of long QT** HypOs - Calcaemia, kalaemia, Magnaesema, MI, Hypothermia, SAH **Congental Causes of QT** Jervell-Lange-Nielsen (deafness), Romano -Ward

Question 246

**Fluid bolus volume?**

Answer 246

500 ml 0.9% saline STAT if no HF 250 ml 0.9% saline STAT if HF

Question 247

**What severity index for UC?** **One of 2** **then one of 4**

Answer 247

Trueove and Witt's **Either:** Passing \>6 stools a day or Blood ins tool and **one of:** \>37.8 degrees c HR \>90 bpm Hb \<105 g/L ESR \>30 mmHour

Question 248

**Which leads is t wave inversion normal in?**

Answer 248

III aVR VI

Question 249

**Degenerative loss of auerbach's plexus**

Answer 249

Achalasia Failure of peristalsis and relaxatio nof the LOS **Middle age people**

Question 250

**Improvement in mortality with Spironalactone?**

Answer 250

Only in patients with: ## Footnote **NYHA Class III/ IV** **Already talking ACE-I**

Question 251

**Digoxin in HF**

Answer 251

- Only improves symptoms due to inotropic effects **But strongle indicated in people with HF + AF**

Question 252

**Statins in T1DM?** **Dose and indications**

Answer 252

Atorvostatin 20mg Indications: \>40 yo Diabetis for \>10 years Nephropathy CVD risk factors - hypertension/ obesity

Question 253

Dyspnoea AF Haemoptysis

Answer 253

Mitral Stenosis ## Footnote **particularly if heart has added sound + diastolic murmur**

Question 254

Valve abnormality in takayasu's arteritis

Answer 254

Aortic Regurgitatiopn (20%)

Question 255

**Target INRs?** **VTE** **AF**

Answer 255

**VTE** Single - 2.5 Recurrent - 3.5 **AF** 2.5

Question 256

**MI Sequalae** Infero Posterior infarction + LHF/Pulmonary Oedema + New Systolic Murmur Acute HF + Pan systolic Murmur Muffled heart sounds, Raised JVP persistent ST Elevation + LVF

Answer 256

**Mitral Regurgitation** Infero Posterior infarction + LHF/Pulmonary Oedema + New Systolic Murmur **Interventricular Septum Rupture** Acute HF + Pan systolic Murmur **Ventricular Free wall rupture** Muffled heart sounds, Raised JVP **Ventricular Aneurysm** persistent ST Elevation + LVF

Question 257

**First line anti hypertensive irrespective of age or ethnicity in diabetics?**

Answer 257

ACE-inhibitors

Question 258

**EPO** **Failure to respond reasons? (5)** **SEs? (7)**

Answer 258

**Failure to respond reasons** Low iron Low Dose Infection/Inflammatory disease Hyperparathyroidism Aluminium **SEs** Hpyertension --\> Enceophalopathy/seizures Bone pain Flue symptoms Cutaneous symptoms **Ab formation against EPO? - red cell aplasia** (Darbepoetin negates the risk) **Low iron - increased RBC production**

Question 259

**Anti Anginal to be avoided in HF?** **First line anti-anginal in patients with known HF?** **Two sets of two drugs not to combine that are used to treat HF/ Angina?**

Answer 259

**Anti Anginal to be avoided in HF?** Verapamil **First line anti-anginal in patients with known HF?** Atenolol (Beta blockers) **Two sets of two drugs not to combine that are used to treat HF/ Angina?** ACE-i + ARB Verapamil + Beta Blocker

Question 260

**Causes of widened mediastinum ( acute) (5)**

Answer 260

Thoracic AAA Lymphoma Retrosternal Goitre Teratoma Thymic tumour

Question 261

**Hypoparathyroidism vs Pseudo HypoPTH vs Pseudo Pseudo HypoPTH** **Test?**

Answer 261

Hypoparathyroidism - PTH deficiency (low PTH, low calcium ,high phosphate) Pseudohypoparathyroidism - GNAS 1 mutation ---\> abnormal G proteins --\> **resistance to PTH everywgere.** (high PTH, low calcium, high phosphate) Pseudopseudohypoparathyrodisim - **imprinting effect** - GNAS1 mutation from father---\> selective expression of mutation in **everywhere EXCEPT kidney. So normal kidney calcium handling but resistance to PTH in the rest of body.** (high PTH, normal calcium, normal phosphate Urinary **- cAMP and phospahte levels used to distinguish between the three (raised in primary hypoPTH. normal in the other 2)**

Question 262

**Metabolic complication from overadministration of NS?**

Answer 262

Hypercholoraemic Acidosis This is because you give them too much chloride relative to sodium ---\> forms more HCL due to the physiological buffering effect

Question 263

**3 Hz oscillations on EEG**

Answer 263

Absence seizures Sleep Narcolepsy

Question 264

**Terbanifine toxic to?**

Answer 264

Liver - Check LFTs before and then 4-6 weeks into treatment

Question 265

**What does TIPS procedure involve?**

Answer 265

Connecting the hepatic vein to the portal vein thus bypassing the cirrhotic liver which is causing the hypertension in the portal system

Question 266

**Causes of dilated cardiomyopathy?** **(3 main)** (**7 others)**

Answer 266

Main causes: Alohol Postpartum Hypertension Other Causes: Viruses (Coxsackie, HIV, DIptheria) Drugs (Doxorubicin) Inherited Endocrine (hyperthyroidism) Infiltrative (Haemachromatosis, Sarcoidosis) Neuromuscular (Duchenne's) Nutritional (Kwashiakor, pellagra (b3), thiamine, selenium)

Question 267

**Gastroenteritis:** **Typical causes of food poisoning (3)** **Gradual (2)**

Answer 267

**Typical - B Cerues, C perfringens, S Aureus** **Gradual - Ameobiasis (painful, bloody), Giardiasis**

Question 268

**Risk factor for?** **Nitrosamines** **Aflatoxin** **Aniline Dyes** **Benzene** **Cadmiun**

Answer 268

**Nitrosamines -** oesophageal and stomach cancer **Aflatoxin -** Liver cancer **Aniline Dyes -** TCC of bladde **Benzene -** leukaemia and lymphoma **Cadmiun -** prostate cancer **Vinyl Chloride -** Hepatic Angiosarcoma

Question 269

**MRSA management** **first line** **second line**

Answer 269

First line - Vancomycin/ Teicoplanin Second line - Linezolid

Question 270

**Proteinuria in inflammatory conditions?** **Supporting diagnosis?**

Answer 270

Amyloidosis Diagnosis: Rectal Biopsy Congo Red stain Serum amyloid precusor scan (SAP Scan)

Question 271

Soil/bird/rat dropping exposure?

Answer 271

Histoplasmosis

Question 272

**Mx of PCP pnuemonia** **Mild/mod** **Severe**

Answer 272

Mild mod - co trimoxazole Severe - IV Pentamidine Steroids reduce risk of RF and death

Question 273

**Rx for metastatic bone pain? (4)**

Answer 273

NSAIDs Opioids Bisphosphonates Radiotherapy

Question 274

Neutropenic Sepsis Prophylaxis Rx

Answer 274

Fluoroqunolone for prophylaxis Rx: Tazocin If no improvement after \>48 hours - meropenem +/- vanc 4-6 days no improvement - Investigated for fungi

Question 275

**Signet Ring Cells**

Answer 275

Gastric Carcinoma - the more signet ring cells, the worse the prognosis Also present in other cancers like prostate, bladder, gallbladder

Question 276

Caveat to diagnosing kidney disease in stage 1 and stage 2?

Answer 276

Normal GFR: \>100 ml/min in adults Stage 1: \> 90 ml/min Stage 2: 60-90 ml/min Stage 1 and stage 2 need signs of CKD other than eGFR being low - Blood tests (Abnormal us and es) - Urinalysis ( proteinuria)

Question 277

**Mx of migraine during pregnancy:**

Answer 277

1: Paracetomal 2: Aspirin/Ibruprofen (first and second trimester still okay)

Question 278

Magnesium deficiency in relation to calcium handling

Answer 278

Hypocalcaemia - due to end organ resistance to PTH

Question 279

DDx for Hypertension with Hypokalaemia

Answer 279

Conn's Cushing's Liddle's (Dysregulation of eNac channels) Renal artery stenosis

Question 280

**When to stop PPI before OGD**

Answer 280

2 weeks before - Masks pathology

Question 281

**Post menopausal lady who has had a fracture**

Answer 281

Bisphopshonates + calcium supplements treat as though they have osteoporosis

Question 282

Mutation associated with MODY Best Rx?

Answer 282

**Glucokinase, HNF1 Alpha - hepatic nuclear factor alpha** Suflonylureas

Question 283

Which antibiotics when combiend with alcohol produce a disulfiram type reaction?

Answer 283

Metronidazole, Cefoperazone ( cephalosporin)

Question 284

Tests for confirming H Pylori Cure?

Answer 284

Urea breath test (wait 4 weeks after antibiotics stopped, 2 weeks after PPI stopped) Stool antigen test Rapid urease test - Biopsy Gastric biopsy +/- culture Not serology - stays positive following eradication

Question 285

Vomiting Thoracic pain Subcut Emphysema

Answer 285

Boerrhave's Mackler triad

Question 286

Monitoring for statins?

Answer 286

LFTs at baseline, 3 months and 12 months

Question 287

**Patho of Anaemia in RF (6/7)**

Answer 287

Reduced erythropoiesis: - Reduced EPO - Uraemic damage to bone marrow Reduced Fe absorption N/V due to uraemia REduced RBC survival Blood loss due to capillary fragility / Poor platelet function Stress ulceration --\> blood loss

Question 288

Wernicke's encephalopathy: CAN OPEN

Answer 288

Confusion Ataxia Nystagmia Ophthalmoplegia Peripheral Neuropathy

Question 289

**Hiccups in palliative care** **Rx**

Answer 289

Chlorpormazine Haloperidol Gabapentin Dexamethasone

Question 290

**Hypothermia ECG findings (5)**

Answer 290

Bradycardia J Wave (hump at end of QRS) 1t degree HB Long QT Arrhythmias

Question 291

Mx of surgical MRSA patient

Answer 291

Nasil - mupirocin Skin - clorhexidine

Question 292

CCB use in angina Monotherapy Combined therapy

Answer 292

Monotherapy - rate limiting like verapimil /diltiazem Combined therapy (with BB) - Long acting dihydropiridine -\> nifedipine

Question 293

**AKI Three stages? Creatining and UO**

Answer 293

1: Cr: 1.5-1.9 x baseling. UO: \<0.5/ml/kgh for \>6 hours 2: 2.0-2.9 x baseline. UO: \<0.5ml/kg/h for \>12 hours 3: \>3.0 x baseline. UO: \<0.3 ml/kh/hour for \>24 hours or anuric for \>12 hours

Question 294

**What is lost in nephrotic syndrome?** **What rises**

Answer 294

**Antithromin-III** **Protein C** **Protein S** Thyroxine binding globulin lost tooo Fibrinogen levels rise

Question 295

Mesenteric Ischaemia ABG?

Answer 295

Metabolic acidosis (low bicarb)

Question 296

**2ww endoscopy guidelines**

Answer 296

**Anyone with:** Dysphagia Upper abdo mass ?Gastric Ca **Over 55 with weight loss ANd:** upper abdo pain reflux dyspepsia

Question 297

**What are the features of child's pugh stage 3?**

Answer 297

**Bilirubin \>50** **Albumiun \<28** **PT \>6** **Marked Encephalopathy** **Marked Ascites**

Question 298

**What are the components of the MELD score?**

Answer 298

**MELD -** Model for end stage liver disease **Bilirubin** **Creatinine** **INR** Used to work out 3 month mortality

Question 299

**5 cutaneous features of TS**

Answer 299

Shagreen Patch Ashleaf spots Subungual Fibroma Adenoma sebaceum - butterfly distribution Cafe au lait spots

Question 300

**MOA** **Carbibamazole** **Propylthiouracil**

Answer 300

**Both:** Block TPO from joining and iodinating TG residues --\> reduces thyroid hormone production **PTU ALSO** - stops peripheral conversion of T4 to T3 (inhibits **5 de iodinase)**

Question 301

**PCI Cut off time?**

Answer 301

120 minutes if not possible them thrombolysis ---\> ECG check 90 minutes later ----\> no resolution then PCI transfer anyway

Question 302

**Type and description of aphasia?** Superior temporal gyrus Arcuate Fasciculus Inferior frontal gyrus

Answer 302

**Wernicke's (receptive) dysphasia -** Superior temporal gyrus. Fluent speach, good repitition but **abnormal comprehension (** sentences dont make sense, neologisms) **Conduction (associative) dysphasia -** Arcuate Fasciculus. Fluent speech, **abnormal comprehension, abnormal repitition.** (poor repititon but know that they are making mistakes) **Broca's (expressive) dysphasia** - Inferior frontal gyrus (MCA). **Non- fluent speech.** normal comprehension, normal reptition. (non fluent, halting, laboured speech) **Global aphasia -- comprises all three and is due to large damage**

Question 303

**Persistent ST ELevation after MI**

Answer 303

Ventricular aneurysm --- thromboembolic stroke risk

Question 304

**Srugical choices for oesophageal carcinoma (Four types)**

Answer 304

**Ivor - Lewis (bi incisional)** Right sided thoracotamy and laparatomy --\> Laparatomy to mobilise stomach and divide oesophageal hiatus Right sided thoracotomy to mobilise oesophagus and create an intrathoracic oesophagogastric anastamoses **Mckeown (tri incisional)** Abdominal incision - mobilise stomach and oesophagus and for LN resection Thoracic incision - remove oesophagus and mediastinal LNs Cervical incision - cervicogastric anastamosis **Transhiatal resection (distal lesions), left thoraco-abdominal resection**

Question 305

**Drugs causing photosensitivity**

Answer 305

APQRST - Amiodarone - phenytoin - Quinidine - Retinoids - Suphonamides - Tetracyclines

Question 306

**Cholesterol threshold follliwing stroke?**

Answer 306

3.5

Question 307

**anti-GM1 (ganglioside)** **anit-GQ1b**

Answer 307

**anti-GM1 (ganglioside)** - GBS **anit-GQ1b -** MFS

Question 308

**Which ECG lead can q waves be normal?**

Answer 308

Lead III

Question 309

**how do you know which is the a and which is the c wave in JVP?**

Answer 309

C coincides with carotid! a is just before

Question 310

INsulin regemin of choice 1 and 2

Answer 310

1 - Basal bolus with twice daily insulin detemir 2 - Basal bolus with once daily glargine or detemir Rapid acting insulin analogues before meals

Question 311

**When to stop AEDs?**

Answer 311

\>2 year seizure free Wean over 2-3 months Wean benzos over longer period of time

Question 312

**Constituents of cryoprecipitate**

Answer 312

Factor VIII Fibrinogen VWf Factor XIII

Question 313

**FEV1 COPD Classification**

Answer 313

80 - \>80% MILD 50 - 79-50 MODERATE 30 - 49 - 30 SEVERE 30 - \<30 VERY SEVERE

Question 314

Most common complication of meninigitis

Answer 314

SNHL

Question 315

1st line treatment for Diabetic Neuropathy

Answer 315

1st Amitriptylline Duloxetine, Gabapentin, pregabalin Tramadol for rescue Amitriptylline contraindicated in people at risk of urinary retention

Question 316

Transfusion threshole

Answer 316

Without ACS . 70g/L with ACS . 80 g/L

Question 318

**WHich opioids can you give to renally impaired?**

Answer 318

Codeine Alfentanil Buprenorphine Fentanyl

Question 319

**What is the QT INterval**

Answer 319

Start of Q ---\> End of T Males : \<430 ms Females: \<450 ms

Question 320

Smoking in IBD

Answer 320

Crohn's - worsens UC - thought to improves **Stopping smoking is UCELESS**

Question 321

**ASD :** **left or right BBB**

Answer 321

ONLY RIGHT

Question 322

**Preventing risk of contrast nephropathy**

Answer 322

Iv fluids for 12 hours pre and post procedure ?Oral N-Acetylcysteine

Question 323

**Transfer factor reduce** **Transfer coefficeint reduced** **Transfer factor reduced** **Transfer coefficient normal**

Answer 323

PULMONARY FIBROSIS **Transfer factor reduce** **Transfer coefficeint reduced** CYSTIC FIBROSIS **Transfer factor reduced** **Transfer coefficient normal** Transfer coefficient corrects for normal alveolar volume

Question 324

**Raised Ferritin** How do you deduce the cause?

Answer 324

**Transferrin saturation** If this is \<45% (females) \<50% (males) **this effectively excludues both primary (HH) and secondary (transfusions) iron overload** **Causes of Normal transferrin saturation + Raised ferritin:** Acute phase response - Inflammation Alcohol excess Liver Disease Renal failure Malignancy

Question 325

**CIx to Sildenafil** **What is sildenafil**

Answer 325

Phosphodiesterae (v) inhibitor **Cix** Taking Nitrates or nicorandil ( due to augmented vasodilatory effects) Hypotension Recent stroke / MI

Question 327

**DDx for shin derm lesiosn**

Answer 327

Erythema nodosum Pyoderma Gangernosum Pretibial Myxoedema Necrobiois Lipioidica Diabeticorum (yellow shiny pale plaques with telangectasia) Ulcers too..

Question 328

**Rx for Acne Rosacea?**

Answer 328

Mild/Mod - topical metronidazole Mod/Sev- Oral Oxytetracycline

Question 329

**Mx for vitiligo?**

Answer 329

Camouflage, Make up Topical steroids - if early Maybe phototherapy/tacrolimus

Question 330

**Drug OD?** Hyperreflexia, myoclonus rigidity Hyperthermia (ANS excitation) Altered mental state

Answer 330

**This is serotonin Syndrome** **Drug causes -** SSRIs, MAOi, Ecstasy, Amphetamines **Mx** Benzos (like with cocaine) Maybe Serotonin antagonist - Cyprohetpadine

Question 331

**Causes of pyoderma gangrenosum**

Answer 331

Pyoderma gangernosum - small papule initially then ebgins to ulcerate Casues include: **HIR** Haematological malignancies **IBD , PBC** **RA**, SLE **Rx -** oral steroids and immunosuppresants ( ciclosporin, infliximab)

Question 332

**ASutin flint murmur?**

Answer 332

Aortic regurg Heard in apex area - mid diastolic murmur The regrugitant jet from the aortic valve hits the mitral valve cusps

Question 334

**Oral morphine to IV/IM/SC Morphine dose**

Answer 334

HALF IT

Question 335

**First ECG sign of MI?**

Answer 335

Hyperacute T Waves

Question 336

**Why give imms to coeliac patients**

Answer 336

Functional hyposlenism -- need PCV +/- Influenza

Question 337

**What other electrolyte may you need to replace in patients with hypocalcaemia?**

Answer 337

Magnesium

Question 338

**Murmur in VSD**

Answer 338

Pansystolic murmur in triscuspid area

Question 339

**What is low in sick euthyroid syndroem**

Answer 339

Everything (sometims TSH can be normal)

Question 340

Drug induced angiodema - most common cause

Answer 340

ACE-I

Question 341

**What comes first in shingles**

Answer 341

**The pain and parasthaesie** **PRECEDES** **the rash**

Question 342

**Palliative care** **Codeine/Tramadol --\> morphine --\> oxycodone --\> diamorphine** **10 -3**

Answer 342

**Codeine/Tramadol --\> morphine** (/10) **morphine--\> oxycodone (/1.5-2)** **morphine--\> diamorphine (/3)** **oxycodone --\> diamorphine (/1.5)** **Codeine/Tramadol --\> morphine --\> diamorphine** **10 - 3**

Question 343

**Cerebellar Lesions:** **Finger nose ataxia** **Ataxia**

Answer 343

Finger nose ataxia - Cerebellar hemisphere ataxia - Cerebellar vermis

Question 344

**CUrrent most common cause of infective endocarditis**

Answer 344

Staph Aureus

Question 345

**Subclinical hypothyroidism:** **Mx?**

Answer 345

\<65 trial of levothyroxine \>65 watch and wait

Question 346

layers of the eosphagus

Answer 346

Question 347

**Structures divided in a midline incision**

Answer 347

linea alba transversalis fascia extraperitoneal fat peritoneum

Question 348

**Incision names:** Under right subcostal margin Incision in right iliac fossa Oblique incision in right iliac fossa Rooftop incision Trasnverse suprapubic insision Groin incision Hockey shape scar

Answer 348

Under right subcostal margin - **Kocher's** Incision in right iliac fossa - **Lanz** Oblique incision in right iliac fossa - **Gridiron** Rooftop incision - **Gable** Trasnverse suprapubic insision **- Pfannestiel** Groin incision - **Mcevedy's** Hockey shape scar - **Rutherford Morrison**

Question 349

**JONEs criteria** **JONES** **CAFE PAL**

Answer 349

2 Major /1 Major2 minor **Major:** **J** - Joint involvement **O -** Carditis **N -** Subcutaneous Nodules **E -** erythema marginatum **S -** Sydenham's Chorea **C** - CRP/ ESR **A -** rthyralgia **F - ever** **E-** ESR **P - Prolonges PR** **A - mnsesia** **L - eukocytosis**

Question 350

**Drugs lowerin BNP**

Answer 350

BAAAD Beta blockers Aldosterone antagonise ACEi ARB Diurtetics

Question 351

**breakthrough dose of morphine?**

Answer 351

1/6th regular dose

Question 352

**Palliative care management:** **respiratory secretion** **Bowel obstruction**

Answer 352

**respiratory secretion - Hyoscine Hydrobromide** **Bowel obstruction -** Hyoscine Butylbromide

Question 354

**Rx for minimal change disease**

Answer 354

Pred (80% will resolve) Cyclophosphamide

Question 355

**Patho for wilson's**

Answer 355

Reduced caeruloplasmin in blood **mutation in ATP7B -** ATP7B usually releases copper into the bile **or** binds it to caeruloplasmin. The function atp7b is impaired ----\> leading to copper deposition aborrhently

Question 356

**Abdo pain + peripheral neuropathy** **Mx**

Answer 356

Lead poisoning Dx - can be confused with Porphyria (Raised ALA, Raised urinary coroporoporphyrinogen) Mx - Chelating (Penicillamine, Dimercaptosuccinic Acid (DMSA)

Question 357

**Diagnosis of Clostridium Difficile**

Answer 357

**Clostridium Difficile Toxin in the stool**

Question 358

**Copper chelating agents: Give 2**

Answer 358

Penicillamine Trientine Hydrochloride

Question 360

**worsening psoriasis** Drugs Infection Others

Answer 360

**Drugs** - Beta blockers, lithium, alochol, NSAIDS, ACE-is, Infliximab **Infection** Strep- guttate psoriasis **Others** Trauma

Question 361

**Bisphosphonaes** **Indications** **SEs** **Advice for taking**

Answer 361

Indications: Osteoporosis, Paget's, Pain form bony met's, hypercalcaemia **SEs:** Oesphogatitis AVN of jaw Atypical stress fractures of femur Hypocalceamia Constitutional Sx **tablet swallowed with plenty of water on an empty stomach/ before breakfast. Patient should stand/sit upright for 30 minutes after administration**

Question 362

**Features of papillodoema**

Answer 362

Venous engorgement Loss of venous pulsation **Loss of optic cup** **Blurring of optic disc margins** Elevation of optic disc Paton's lines - retinal lines cascading from the disc

Question 363

Yellow spots around macula

Answer 363

Dry Age reglated maculopathy (or early as per new classification) **Rx -** Beta caroten, Zinc, Vit C, Vit E (not im smokers due to incr risk of lung cancer)

Question 364

**1st line Rx for psoriasis (three in combo)** **2nd line** **3rd line** Secondary care mx?

Answer 364

Emolient + Vit D topical ( calcipotriol) + topical steroid 2nd line - Oral vit d analogue BD (Reduces epidermal proliferation) 3rd - potent corticosteroid / Coal tar (Interferes with DNA synthesis)/ **Secondary care** Light therapy - narrow band UV light PUVA - psorelan + UV light **Methotrexate, Ciclosporin, systemic retinoids** **Biologics- Infliximab, Adalimumab, Etanercept, Ustekinumab**

Question 365

**Respiratory involement of polymyositis/dermatomypositis**

Answer 365

Respiratory muscle weakness Fibrosing alveolitis/ Organising pneumonia

Question 366

**MOA of the open angle glaucoma treatments** **BC** **PM** **S** **BeCause PMS**

Answer 366

**BC - Reduce aqueous production** Beta blockers (Timolol - CI in HF, ASthma), Carbonic anhydrase inhibitors (Dorzolomide - Sulphonamide like reactions) **PM -** **Increase uveoscleral outflow** Prostacyclin Analogues (latanaprost - pigmentation of iris), Myotics (Pilocarpine - blurring of vision, constriction of iris, headaches) **S -** BOTH Sympathomimetics (a2 adrenergic agonists like brimonidine - Hyperaemia. Avoid with people taking MAOis - hypertensive crisis, TCAs - reduce efficacy of sympathomimemtics)

Question 367

Asprin Aminoglycosides Loop diuretics Quinine **all cuase**

Answer 367

Bilateral tinnitus -.-

Question 368

**Osteomyelitis** **Dx tool of choice**

Answer 368

MRI Scan

Question 370

**DUKE CRITERIA for ?** **Pnemonic** **Bacterial Endocarditis FIVE PM**

Answer 370

**Major:** **B- Blood cultures (2 showing typical orgnaisnms/ 2 +ve 12 hours apart/ one positive with coxiella)** **E- Endocarditis (+ve echo, new murmur)** **Minor:** FIVE PM Fever \>38 Immunological Phenomena - GN, Osler's Nodes, Rothe Spots, RF +ve Vascular Phenomena - Arterial emboli, pulmonary infarcts, ICH, Mycotic aneursyms, Conjuctival haemorrhage, Janeway Lesions Echo - Not definitive but suggestive P - Predisposition ( Heart/Valve disease, IVDU) M - Microbiology (Positive but not fulfilling major criteria)

Question 372

**Chemotherapy Regime** **R-CHOP (R-CVDP)** **BEP**

Answer 372

**R-CHOP** Rituximab Cyclophosphamide Vincristine Doxorubicin Prednisolone **BEP** Bleomycin Etoposide Cisplatin

Question 374

**Principle electrolyte abnormality seen in refeeding syndrome**

Answer 374

Hypophosphataemia - Because in catabolic state there is a depletion of intracellular phosphate stores and also a reduction in insulin secretion Upon the reintroduction of carbohydrates ---\> insulin + increased phosphate influx into cells. Depleting intravascular phosphate levels Cx- rhabdomyolysis , seizures, arrhythmias etc...

Question 375

**The Seven S's for TPN**

Answer 375

Prolonged Ob**S**truction Severe Chron's Severe malnutrition High output fi**S**tula swallowing impairment - Oesopageal Ca, etc. Short gut syndrome Severe pancreatitits

Question 376

**Borders of the inferior lumbar triangle**

Answer 376

Lateral - External oblique medial - Lat Dorsi Inferior - crest of ilium

Question 378

Painful nodule on ear Elderly

Answer 378

Chondrodermatitis nodularis helicis Conservaitive measures - Alleviate pressure on ear Medical mx - cryotherapy - Steroids - collagen Sx - Removal but high recurrence

Question 379

**Achilles tendon rupture** **Which abx?**

Answer 379

Fluroquinolones

Question 380

**RBBB** **LAD** **1st Degree AVN Block**

Answer 380

Incomplete Tri-fascicular block: - In this case the Left anterior fascicle would be blocked (LAD) + the right fascicle (RBBB) Three fascicles in the heart conducting from AVN to Ventricles: Two left side One right side

Question 381

**RBBB** **RAD** **1st degree AVN Block**

Answer 381

Incomplete Trifascicular Block: This case would be the Left Posterior fascicle being blocked (RAD) + Right Fascicle (RBBB)

Question 382

**RBBB** **R/L AD** **Complete Heart Block**

Answer 382

Compelte trifascicular block R (L Posterior fascicular block) / L (L Anterior Fascicle Block) AD

Question 383

Axis deviation when both Anterior/Posterior L fascicles blocked?

Answer 383

No shift

Question 384

**Which parts of the bowel are:** **Intraperitoneal** **Retroperitoneal** **Infraperiotenal**

Answer 384

Question 386

**Treatment for hyperhidrosis**

Answer 386

1st - Ammonium Chloriude 2nd - Iontophoresis 3rd- botulinum injections Can have a thoracic sympathectomy but cx include compensatory sweating

Question 387

Diseases MAllasezia Furfur Causes **Rx?**

Answer 387

Seborrhoeic Dermatitis/ Pitryiasis Versicolor **Rx** Seb Derm: Scalp - T Gel/ H&S. Topical Ketocanazole Skin - Topical ketaconazole, Daktacort (Mild steroid + topical antifungal) Pit Vers Topical ketaconazole , Oral itraconazole

Question 388

Petechial Rash Neuro Symptoms Resp Symptoms

Answer 388

Fat embolism (think about fractures) Petechial Rash + subconjunctival/oral haemorrahge Neuro Symptoms - confusion agitation, retinal haemorrhages, fat globules on fundoscopy Resp Symptoms - temp, tachycardia, dyspnoea

Question 390

**Pityriasis Rosea** Duration of rash

Answer 390

HHV 7 Herald Patch Erythematous, oval scaly patches paralle to lines of langer Disappears after 4-12 weeks

Question 391

**Stroke while on warfarin** **Anticoagulation / antiplatelet?**

Answer 391

Not good idea to co-prescribe antiplatelet + anticoagulant --\> greatly increased risk of bleeding **Conflicting evidence** Some say increase INR to therapeutirc range 2.5-3.5 (if Was 2-3 for AF for example) Passmed says introduce DOAC

Question 392

**Kussmaul's Sign?** **What is it** **Which disease is it present in most often**

Answer 392

Paradoxical rise of the JVP with inspiration Seen more so in Constrictive pericarditis than with Cardiac tamponade. Whereas with tamponade Pulsus paradoxus is more common ( reduction in bp of more than 20 mmHg with inspiration0

Question 393

**Extra skin conditions** **Melasma** **Pitryasis Alba** **Erythrasma**

Answer 393

**Melasma** Dark skin discolouration Pregnant women or those on hormonal therapies **Pityriasis alba** Children and young adults Pink scaly patches ---\> hypopigmentation afterwards Dark skinned people **Erythrasma** - brown scaly skin patches - DM and obese

Question 395

Which antibiotic should be avoided with Statin? Why?

Answer 395

**Macrolide** **P450 inhibitors ---\> lead to increased plasma level of the statin --\> risk of statin related myopathy etc.**

Question 396

**What does the serum-ascites albumin gradient ACTUALLY tell you?**

Answer 396

Tells you whether ascites is caused by portal hypertension or something else: **If \>1.1g/dl** then you're thinking **portal hypertension** --\> Cirrhosis, Budd chiari, Portal vein thrombosis, liver mets, cardiac ascites **If \<1.1g/dl** then it's **something else** (as the albumin level in the ascitic fluid itself is pretty high) - peritoneal carcinomatosis, tuberculous, pancreatic ascites, nephrotic syndrome

Question 397

**Determining pre renal aki/ post renal aki** just based on U and Es

Answer 397

Look at the urea and the creatinine: Multiply urea x 10 If Urea\*10 \> Creatinine **It is likely to be pre renal uraemia**

Question 398

**Type of fluid to avoid in stroke patients**

Answer 398

5% dextrose Increases risk of cerebral oedema Stick to NS or other without sugar in it

Question 399

**In diabetic** When hands in prayer position inability to fully extend the MCP joints?

Answer 399

Cheiloarthropathy Scleroderma like thickening of the hands

Question 401

**Double right heart border in Mitral Stenosis**

Answer 401

The more medial line represents left atrial enlargement in these patients which is secondary to a Tight Stenosis Other CXR Signs - Splaying of the carina - Raised left main bronchus **Both due to the left atrial enlargement** Furthermore will have cardiomegaly

Question 402

**Prokinetic medications**

Answer 402

Domperidone Metoclopramide Erythromycin

Question 403

**CI to ear irrigation**

Answer 403

HO of OM (not OE) in last 6 weeks PSH ENT Current OM or OE Grommets Tympanic Perf Altered mental state Cleft palate

Question 404

**Features of Optic Neuritis**

Answer 404

Reduced red discrimination

Central SCotoma

RAPD

Pain worse on eye movements

Question 405

**DDx of white tongue lesions**

Answer 405

**Oral Candidiasis -** Rub off **Lichen Planus** - White lace pattern on buccal membrane, will rub off **Oral Leukoplakia** - pre-malignant (SCC), need FU, won't rub off

Question 406

**Ophth Option in Open Angle Glaucoma:** **If CVD** **If Asthmatic**

Answer 406

Open angle glaucoma - Raised IOP + reduced peripheral vision First would go for prostacyclin analogue: Latanaprost (brown staining of iris) - Increases Uveoscleral outflow

Question 407

**Brown velvety plaques (neck, axilla, groin)**

Answer 407

Acanthosis Nigricans - Due to hyperinsulaemic states - Most commonly GI Ca (But any high insulin state will do)

Question 408

Blurry vision and haloes around light (Months to develop)

Answer 408

Glaucoma

Question 409

**RFs for Cataract** **Subtypes of Cataract**

Answer 409

**Rfs:** **Systemic -** DM Steroids Cong Rubella Cong - Downs, Myotonic Distrophy Metabolic - hypoclacaemia, galactosaemia, **Occular** trauma uveitis ++myopia (short sightedness where image is focused before the retina) Topical Steroids **Subtypes** Nuclear Polar Subcapsular Dot opacities

Question 410

Koebner phenomeneon seen in..

Answer 410

Psoriasis Lichen Planus

Question 411

**Glaucoma RFs:** **Hypermetropia** **Myopia** **Diff between Open/Closed angle**

Answer 411

Hypermetropia - Acute closed angle glaucoma Myopia - Open angle glaucoma **The angle** : The angle between the iris and the cornea. The trabecular meshwork where the fluid drains through sits near this angle. In closed angle - the lens/ choroid/ lens zonules appear to move in a rostral direction --\> pushing the iris forward with it and obliterate the angle In open angle- there isn't such obliteration. Using drugs to improve drainage and reduce secretion is helpful but drastic measures like causing pupillary constriction aren't necessary So the Rx for Closed angle makes sense: Acetozolamide - reduced secretions Pilocarpine - pupillary constriction and opens up the angle again

Question 412

**What happens to the pupil on closed angle glaucome**

Answer 412

Semi Dilates Non reactive

Question 413

**Monitoring in leflunomide**

Answer 413

LFT, FBC, BP AEs: Diarrhoea Hypertension Pneumonitis Myelosuppresion Weight loss Peripheral neuropathy

Question 414

Which usually effects mouth Pemphigus Pemphigoid

Answer 414

**Pemphigus** - Shear off easily - EFfects mouth - **IgG** against **intra-epidermal** adhesion proteins - Bit more of an emergency than pemphigoid **Pemphigoid** - tense bullae, pruritic - mouth usually spared **- IgG and C3** deposition against **hemidesmosomes** at the dermo-epidermal junction **Dermatitis herpetiformis** - is like pemphigoid in the sense that it is subepidermal in pathophysiology - intensely pruritic **- but it's IgA deposition**

Question 415

Spoon shaped nails

Answer 415

Koilonychia - IDA

Question 417

**Like taking which drug?** **Liddle's** **Bartter's** **Gitelman's**

Answer 417

**Liddle's** - Amiloride. ENaC in the Collecting Duct's **Bartter's -** Loop diuretic. NaKCl in the Ascending loop ofh enle. **Like loop diuretics will cause hypercalciuria (so used to treat gout)** **Gitelman's -** Thiazide Diuretic. NaCl in the Distal convolutred tubule. **Like thiazide diuretics will cause hypocalciuria (so cause gout)** Lidoride, Bartoop, Gitiazide

Question 419

**Periarticular Osteopenia** **Inflammatory Arthritis**

Answer 419

More of a pointer to RA

Question 420

**Extensively swollen ear canal in OE?**

Answer 420

Use an ear wick impregnated with Topical antibiotic +/- steroid

Question 421

**Which organism tends to colonise plastic implants?**

Answer 421

Staphylococcus Epidermidis ---\> usually need to remove the device

Question 422

**Drug causes of TEN? (6 in this list)** **Rx?**

Answer 422

Penicillins Sulphonamides NSAIDs Phenytoin Carbamezapine Allopurinol **Rx?** **-** IVIG (used more now) - Plasmapheresis - Immunosuppresion (cyclosporin, cyclophosphamide)

Question 423

**What is mydriasis** **What causes mydraisis**

Answer 423

Mydriasis is a dilated pupil - Dilated pupil think about sympathetic supply taking control So - CNIII carries with it the parasymtpahtetic fibres ---\> if this is damaged will cause mydriatic pupil as parasympathetic would cuase pupillary constriction Other causes --\> Holme's adie pupil, Traumatic iridoplegia, Phaeo (lots of catecholamines), Congenital, **Drugs -** Sympathomimetics - amphetamines and coke, Anticholinergics - TCAs (reduce PNS effeicacy) , mydriatics (atropine and tropicamide)

Question 424

**Cutaneous features of SLE**

Answer 424

Discoid Rash Malar rash Alopecia Livedo Reticularis

Question 425

**Skin prick test or skin patch test**

Answer 425

Skin prick- Allergens SKin patch - contact dermatitis

Question 426

**Mulder's Click\>?**

Answer 426

Morton's Neuroma One hand tries to hold the neuroma while the other performs metatarsal squeeze Click might be palpated and heard

Question 428

**HCV up to date treatment**

Answer 428

PegIFN alfa-2B + Ribavarin + **newer agents such as** **bocepravir** (protease inhibitor) **sofusbuvir** (example of a nucleotide inhibitor)

Question 430

**What acid base abnormality to gitelman's and barter's cause?**

Answer 430

Metabolic Alkalosis

Question 431

**Which cancers have response to anti-vegf treatment**

Answer 431

Lung Cancer CRC Renal Cell E.g. - Bevacizumab

Question 432

**What is ceftuximab** **What Cancer?**

Answer 432

Anti-EGFR Antibody Useful in Colorectal Cancer

Question 433

**What is the underlying blood ppicture in hyperchloremic metabolic acidosis**

Answer 433

This is so termed a Normal anion gap metabolic acidosis - Essentially caused by a loss of base (rather than an increase in acid - the other way around is more true for high anion gap metabolic acidosis) - There is a saturation of NaCl Channels in the PCT ---\> this leads to an **increased Chloride level in the plasma.** - Loss of base (Bicarb) is often due to GI causes but can also be due to **RTA Type 2 (reduced resorption** bicarb at proximal convoluted tubule) or **RTA type** (failure of H+ secretion at the distal convoluted tubules) --\> essentially there is a **low serum bicarb level** So: Normal anion gap metabolic acidosis: **High Cl-/ Low HCO3-** Ineffective acid buffering ---\> leads to acidosis Causes GI - Base loss ( diarrhoea, fistulae), renal loss ( RTA type 1/2 ) , Drugs like acetazolomide, Addison's (reduced H+ secretion as this is usually coupled with Na+ resorption in the distal convoluted tubule )

Question 434

**What does hepcidin do** **What is TIBC**

Answer 434

Hepcidin is a key regulator of iron management in mammals. It essentially traps iron within cells such as hepatocytes and macrophages. Reduced Hepcidin levels seen in - Hereditary Haemachromatosis ---\> TIBC will be decreased because hepcidin/ transferring already supersaturated ---\> Transferring saturation will be high following this logic Increased hepcidin levels seen in - Inflammatory states ---\> contributes to anaemia of chronic disease **TIBC** Is an indirect measure of the transferrin in blood. Blood is drawn and then it is seen how much iron can be added to it - the more iron that can be added the lower the transferrin saturation (IDA)

Question 435

**Which drugs can preciptate worsening of psoriasis**

Answer 435

Alcohol Beta Blockers Lithium Anti Malarials

Question 436

**Drugs causing pemphigus vulgaris**

Answer 436

ACE-i NSAIDS L-DOpa

Question 437

**Skin blisters:** **Desmosomes** **Hemidesmosome**

Answer 437

Desmosomes - Pemphigus Vulgaris (IgG) Hemidesmokes - Bullous Pemphigoid (IgG +C3) Dermatitis Herpetiformis (IgA)

Question 438

**How and where is bicarb reabsorbed**

Answer 438

Bicarb: HCO3- Reabsorbed in the proximal convoluted tubuel - Due Carbonic Anyhdrase

Question 439

**Types of eruptions (What causes them)**

Answer 439

Maculopapular - Generalies erythematomous macules + papules, fever, +Eosinophils Cause - penicillis, cephalosporins, AEDS Urticarial: Two types. I) IgE mediated - penicillins, cephalosporins ii) Direct mast cell dreganulation - Morphine, NSAIDs, COntrast, Codeine Eythema Multiforme - HSV, Mycoplasma, Drugs

Question 440

**pANCA**

Answer 440

Churg STrauss Microscopic Polyangitis Primary Sclerosing Cholangitis

Question 442

**Weber's test.** **Rinnhe's testW** **Patterns**

Answer 442

Weber - localises to the side **with** conductive hearing loss - or to the **unnafected ear** in SNHL Rinnhe's - positive if there is Conductive hearing loss (if bone conduction (mastoid process) is better than air conduction (just in front of external accoustic meatus) **then there is conductive hearing loss)** SNHL - Webers localises to the **unaffected ear** and rinnhe's **air conduction is better than bone conduction** Conductive hearing loss - Webers localises to the **affected ear** and on rinnhe's **bone conduction is better than air conduction**

Question 443

**Monosodium urate monohydrate**

Answer 443

Gout

Question 444

**A reaction to which other drug precludes the use of sulfasalazine** **SEs of sulfasalazine**

Answer 444

Aspirin SEs: Oligospermia SJS MYelosuppression Pneumonitis/ Lung fibrosis

Question 445

**Options for bradycardia**

Answer 445

IV atropine Transvenous Pacing Alternatives Transcutaneous pacing Adrenaline infusion

Question 446

**What cup to disc ratio signifies cupping**

Answer 446

\>0.7 dup to disc ratio

Question 447

**Fundoscopy features of primary open angle glaucoma**

Answer 447

1. Optic Disc Cupping 2. Optic Disc Pallor 3. Bayonetting of vessels (vessels appear to disappear and reappear) 4. Additional features - Cup notching, disc haemorrahges

Question 448

**WHat is a trefoil pelvis** Classification of the disease this is associated with

Answer 448

Sign of osteogenesis imperfects Where the acetabulum indents the medial aspect of the femur. I-IV Classification I is not enough quantity ----\> IV disordered quality but sufficient quantity.

Question 449

**What type of cataract is associated with these circumstances:** **Elderly** **Commonly inherited** **Steroid Use** **Also present in normal eye**

Answer 449

Elderly - Nuclear Commonly inherited - Polar (in visual axis) Steroid use - Subcapsular (just deep to the capsule of the lens) Dot opacities - Can be present in normal individuals

Question 450

**HLA B5 & Mica 6 allele** **Disease association and features**

Answer 450

Behcet's Syndrome - Young, Male meditarranean - repeated genital, oral ulceration and anterior uveitis Rarer - Thrombophlebitis, arthitits, neuro (asceptic meningitis), GI upset, Erythema nodosum, DVT Positive skin pathergy test --- Needle prick causing ulcer formation

Question 451

**Why do ABPI in patients with obvious venous ulcers** **What drug improves healing rate in venous ulcers**

Answer 451

Treatment is with graded compression stockings however these are contraindicated if the patient has concurrent arterial disease. Venous ulcer - Oral pentoxifylline

Question 452

**Short posterior ciliary artery occlusion ...** **Which arteries supply the choroid**

Answer 452

Anterior ischaemic optic neuropathy (leads to optic neuropathy) -- Temporal arteriries or atherosclerosis Choroid ---\> supplied by posterior and anterior choroidal arteries (from ICA and PCA)

Question 453

**CRP or ESR raised in SLE?**

Answer 453

**ESR** - SL-E-SR

Question 454

**key numbers in terms of body water and ECF/ ICF split**

Answer 454

60% composition is water 2/3 ICF 1/3 ECF (3/14 plasma, 10/14 interstitial, 1/14 transcellular)

Question 455

**Storage vs voiding symptoms**

Answer 455

**Storage** - Urgency Nocturia Frequenzy Incontinence **Voiding** - Hesitancy Poorflow Intermittent flow Straining Incomplete emptying Post micturition Dribbling

Question 456

**Consequences of hypophosphataemia (5)** **RARSS**

Answer 456

Rhabdomyolysis Respiratory Insufficiency Arrhythmias Shock Seizures

Question 457

**Calcium Renal stones** **Loop Diuretics** **Thiazide Diuretics**

Answer 457

Loop diuretics --- cause them as they cause hypercalciuria Thiazide directs --- can prevent them as these increase resorptoion of calcium in the distal convoluted tubule (can cause slight hypercalcaemia)

Question 459

**Serotonin Syndrome** **Features** **Which drugs implicated**

Answer 459

Features - Tachycardia, nause, hypertension, hyperreflexia, Dilated pupils **Drugs** SSRIs, Tramadol MAOis Triptans St John's wart

Question 460

**Opiates in CKD? (3)**

Answer 460

Alfentanil Fentanyl Buprenorphine (AFB)

Question 462

Involves nasolabial folds Cheeks Eyebrows Nasal Bridge Scalp Spares nasolabial folds Telangiectasia pustules

Answer 462

**Seb Derm** Involves nasolabial folds Cheeks Eyebrows Nasal Bridge Scalp **Acne Rosacea** Spares nasolabial folds Telangiectasia pustules

Question 464

**What is RF?**

Answer 464

IgM antibody reacting with Fc portion of patients own IgG - detected using the Rose Waaler test (sheep red cell agglutination) Latex agglutination test

Question 465

Bowing appearance on x ray Child

Answer 465

Greenstick fracture

Question 466

What is the interstitial space What radiological feature si expansion of the interspitial space with fluid often known as\>

Answer 466

In the context of the lung the interstitial space is the space between the alveoli - remember alveoli are extremely thin Thickened in interstitial lung diseases When thi interstitial space becomes oedematous - in pulmonary oedema This is referred to as **Kerley Lines** (usually b) - easily seen just above the costophrenic angles and are usually perpendicular to the lateral pleural surface

Question 467

What does reticular pattern mean on CXR nodular Reticular nodular Alveolar Pattern Vs Interstitial pattern

Answer 467

**Reticular Pattern** - lots of lines **Nodular** - lots of dots **Reticulonodular -** bit of both **Alveolar Pattern** - Fluffy ill defined looking - Can be segmental / lobar - think pneumonia - Air bronchiograms **Interstitial pattern** - Reticulonodular looking pattern With lots of septal lines

Question 468

Mixed stromal and epithelial elements (Biphasic might be keyword) Parotid lesion

Answer 468

Pleomorphic adenoma of the parotic

Question 469

**Meniere's Disease** Treat an acute attack? Prophylaxis

Answer 469

Acute attack - Prochlorperazine Prophylaxis - Betahistine

Question 470

**Penis** **Tight white ring** Orange red lesions - with redder spots on glans and adjacent areas Itchy and non-well demarcated rash Well de-marcated erythematous plaque with a ragged white border

Answer 470

**Lichen Sclerosus - Tight white ring. Topical steroids** Zoon's balanitis - Orange red lesions - with redder spots on glans and adjacent areas. Plaques are shiny. **steroids, circumision, CO2 laser therapy.** Seb Derm - Itchy and non-well demarcated rash. Steroids + antifungals Circinate Balanitis - Well de-marcated erythematous plaque with a ragged white border.

Question 471

**Vascular Surgery/ Fractures** **Common complication/prophylactic measure** **What do you do**

Answer 471

Compartment syndrome (re fractures : tibial shaft, supracondylar humerus fractures) Extensive Deep Fasciotomies + Agress fluids to prevent myoglobin causing an AKI Necrotic muscles should be debrided/?amputation

Question 472

Bowed Bones Large Head Thickened Chostocondral Junctions Cupped/Widened epiphsis Transverse subcostal sulcus

Answer 472

Rickets

Question 473

**Why is inversion spared in common peroneal nerve injury?**

Answer 473

Because: The tibialis posterior nerve is supplied by the tibial nerve and also assists in inverting the foot

Question 474

**Mnemonics for the Vaughan Williams Classifications** **SoBe PoCa** Double Quarter Pounder lettuce, tomato, mayo, pickles more fries please A Big dog is scary

Answer 474

**SoBe PoCa** **I: Sodium** fast channel blockers **II: Beta Blockers** **III: Potassium** Channel Blockers **IV:** Slow **calcium** channel bloker **Class IA** Double Quarter Pounder Disopyramide, Quinine, Procainamide **Class IB** lettuce, tomato, mayo, pickles Lidocaine, Tocainide, Mexilitine, Phenytoin **Class IC** more fries please Moricizide, Fleicanide, Propafenone **Class II: No mnemonic but just beta blockers** **Class III** A Big dog is scary Amiodarone, Bretylium, Dofetilide, Ibutilide, Sotalol **Class IV** Calcium channel blockers not in mnemonic **Class V** Adenosine, Digoxin

Question 476

What common drug can cause GI haemorrahge in pts taking warfarin

Answer 476

NSAIDs

Question 478

**Scleroderma** **Face and distal limbs** **Trunk and proximal limbs**

Answer 478

Faec and distal limb = Limited (centromere) Trunk and proximal limb = Diffuse (SCL-70 (Topoisomerase))

Question 480

**Keratotic Plugs?**

Answer 480

Sebhorreic Keratosis (Stuck - on wart)

Question 481

**Distal fragment:** Posteriorly displaces supracondylar fracture anteriorly dysplaced supracondylar fracture

Answer 481

Posterior - Extension (more common) Gartland classification Anterior - Flexion

Question 482

**Hypopyon:** Normal pupillary reaction Abnormal pupillary reaciton

Answer 482

Normal pupillary reaction - keratitis/ corneal ulcer Abnormal pupillary reaciton - anterior uveitis Both will have hyperaemia and photophobia

Question 483

Nerve roots for anal sphincter control

Answer 483

S2, S3, S4 Stops shit hitting the floor

Question 484

Inflammation of extensor pollicsis brevis and abductor pollicis longus tendon sheath

Answer 484

De quervain's tenosynovitis

Question 485

Viral labyrinthitis vs Vestibular neuronitis

Answer 485

Viral labyrinthitis: Hearing loss, Vertigo, nystagmus and nausea Vestibular neuronitis - spares hearing

Question 486

What colour can pit vers be?

Answer 486

hypo Pink brown

Question 487

What is morphoea?

Answer 487

Localised scleroderma

Question 488

Emergency management for acute angle closeure glaucoma

Answer 488

IV acetazolamide Meiotic - pilocarpine (muscarinc agonist) Beta blocker - timolol Urgent refer to ophth IV mannitol - if can't tolerate other meds Occular massage Peripheral Laser Iridotomy (APLI) Anterior Chamber Parcentesis (ACP)

Question 489

**Subtypes of BCC? (4)**

Answer 489

Nodular Morpheic Superficial Pigmented

Question 490

**Malignant Melanoma Criteria (3 major) (4 minor)**

Answer 490

Major : Change in i) size ii) shape iii) colour Minor: Diameter \>6mm Inflamed Oozing/ Bleeding Paraesthesia

Question 491

**Allergy:** **Type 1? - MOA and Examples** **II** **III** **IV** **V?**

Answer 491

**I -** IgE mediated mast cell degranulation. **Atopy and Anaphylaxis** **II -** Antibody against cell. **HA,** **ITP, Anti GBM, Anti IF, Anti ABO, ASOT, Rheumatic, Pemphigus** **III -** Antibodies combine in circulation. **Serum sickness, SLE, Post strep glomer, EAA** **IV -** Delayed T Cell. **Contact derm, Tuberculosis, GVHD, Scabies, EAA, MS, GBS** **V? - Kind of like II But hte distinction is the ABs bind to the receptor on the cell rather than a random antigen -** MG, Grave's, LEMS,

Question 492

**What is the pupil like Cavernous Sinus Thrombosis**

Answer 492

Semi dilated and non reactive

Question 493

**Cause of proteinuria in patients with RA**

Answer 493

**Treatment - Gold Penicillamine** **AMyloidoisis**

Question 494

**Indication for nalaxone**

Answer 494

Respiratory depressopm

Question 496

**What does hypomagnasaemia cause?**

Answer 496

i) low PTH --\> Hypocalcaemia (Mg needed for PTH secretion ii) PTH resistance (impaired action of calcium at target organs)