Miscellaneous Flashcards
What are the biochemical features of Tumour Lysis Syndrome?
Treatment of cancer results in lysis which releases components into bloodstream: raised phosphate raised potassium raised uric acid lowered calcium (chelated by elevated phosphate) raised creatinine (renal failure)
What is the MOA of Rasbirucase?
rh-Urate oxidase which converts uric acid into allantoin. Allantoin is water soluble thus more easily excreted by the kidneys
What is the most common form of Malaria?
M falciparum
What are the features of Malaria falciparum?
Fever >39C
Hypoglycaemia
Acidosis
Severe anaemia: TATT
Schizonts on blood film
What are the complications to be concerned of regarding malaria falciparum?
Cerebral spread: seizures/coma
Acute renal failure: blackwater fever (haemorrhaging of RBCs releasing Hb into urine)
ARDS
Hypoglycaemia
DIC
What is the most common non-falciparum malaria cause?
A. P falciparum
B. P malariae
C. P ovarle
D. P vivax
D
Which forms of malaria is associated with nephrotic syndrome?
A. P vivax
B. P malariae
C. P falciparum only
D. P malariae and P falciparum
D
A 55-year-old man presents with fever, fatigue, and chest pain. The patient was discharged after a successful mitral valve replacement 6 weeks ago. An urgent echo showed the presence of a new valvular lesion. Three sets of blood cultures are taken, and a diagnosis of infective endocarditis is confirmed.
Given the background, what is the most likely causative organism?
S epidermis
A 12-hour old baby girl is noted to have dysmorphic features, including webbing of the neck and wide-spaced nipples. She is also noted to have ‘puffy’ hands and feet. She is in the 10th percentile for length and weight.
There is no family medical history and, other than being small for gestational age, there were no abnormalities noted during pregnancy.
What cardiac condition is commonly associated with the likely underlying diagnosis?
CoA
You review a patient in the respiratory clinic who has a history of recurrent pulmonary embolism despite anticoagulation with warfarin.
What lung-specific, physiological change may be expected?
TLCO reduced
What drugs should be stopped in an AKI as they are nephrotoxic?
Mnemonic: NADA
NSAIDs ACEi Diuretics Aminoglycosides ARBs
A 23-year-old woman presents with dysuria, malaise, vaginal pain, fever, and myalgia. She consents to a vaginal examination which reveals multiple painful ulcerations around the vagina and perineum. Urinalysis reveals trace leukocytes, no nitrites, and microscopic haematuria. Swabs are taken and sent and a urine MCS is also sent.
Given the most likely diagnosis, what is the most appropriate treatment?
This woman has genital herpes. The painful nature rules out lymphogranuloma venereum.
Therefore it is a Genital Herpes caused by HSV-1 which requires an antiviral for 10 days.
Valaciclovir for BDS 10/7
A 27-year-old man presents to his GP feeling generally unwell complaining of joint pain and swelling. He returned from a walking trip in Thailand one month ago and one day after his return he developed severe watery diarrhoea and abdominal cramps that lasted for one week.
On examination he appears unwell and looks fatigued. He has large effusions of the left knee and right ankle along with tender planter fascia bilaterally. He also has tender metatarsophalangeal joints on both feet. On closer inspection of the feet he has a papular rash on the soles of both feet.
For the last week he has been taking regular paracetamol and ibuprofen with minimal improvement in symptoms.
Given the most likely diagnosis what is the most appropriate next step in this patients management?
This man has Reactive Arthritis
Therefore oral steroids required for 4/6/52
A 38-year-old woman presents with a litany of symptoms that have been ongoing for the past four months. These include weight gain, which particularly bothers her around the abdomen, with troubling purplish stretch marks, thin skin and easy bruising. She has been noticing increased swelling in her ankles and poor mood. In the diagnostic work-up, a range of laboratory tests is taken.
What is the expected electrolyte abnormality in this patient?
This woman has Cushing’s Syndrome.
The elevated cortisol is due to ectopic production or exogenous sources.
Cortisol may simulate aldosterone thus increased sodium reabsorption, potassium excretion. At high levels of potassium excretion, bicarbonate is absorbed.
This results in a metabolic alkalosis that is hypokalaemic thus Hypokalaemic metabolic alkalosis.
What are the features of severe acute asthma?
RR >25
HR >110bpm
PEF 33-50% of normal
Cannot complete sentences in one breath
A 68-year-old male presents to the Emergency Department with a two-hour history of crushing left-sided chest pain radiating to the jaw. He has a past medical history of dyslipidaemia and hypertension. You perform an electrocardiogram and serum troponin which confirm an anterior ST-elevated myocardial infarction (STEMI). The nearest primary percutaneous coronary intervention (PCI) centre is three hours away by ambulance and urgent fibrinolysis is therefore given in preference to PCI.
What is the most appropriate management plan regarding myocardial revascularisation of this patient?
Take ECG 60-90 minutes later and if no correction, transfer for PCI
What are the clinical features of Port wine stains?
Do they require treatment?
Unilateral
Deep red/purple (vascular birthmark)
Darken and raise over time
Not symptomatically, but potentially if Sturge-Weber Syndrome or psychosocial implications
Cosmetic camouflage
Laser therapy
What are the clinical features of a dermatofibroma?
Solitary firm papule resulting from trauma
5-10mm in size
Skin dimples on pinching skin
What are the clinical features of Mongolian blue spots?
Flat blue/grey skin markings occurring at birth/after
Base of spine/back
Dermal melanosis with melanocytes remain deep in dermis (red wavelengths of light absorbed and blue wavelengths reflected back from brown melanin pigment deep in dermis) - “Tyndall Effect”
What is Eisenmenger Syndrome?
Give the clinical features.
Reversal of L-to-R shunt in CHD due to pulmonary hypertension.
Murmur may not be heard Cyanosis Clubbing RV failure Haemoptysis/Embolism
What is Transposition of the Great Arteries?
Give the clinical features.
What is the management of this?
Congenital heart defect with failure in embryonic development.
Aorta leaves from RV
Pulmonary artery leaves LV
Cyanosis Tachypnoea Found S2 (ejection systolic murmur) RV impulse prominent CXR: Egg-on-side appearance
Must surgically correct.
Maintain patency of any shunt with PGEs
Surgically correct
Outline what a Stokes-Adams attack is?
Syncopal episodes occurring from cardiac arrhythmia - heart block or sick sinus syndrome
How may Syncope be classified?
Cardiac
- Arrhythmia
- Structural
- Others: e.g. PE; Myocarditis
Neural
- Vasovagal
- Situational
- Carotid sinus
Orthostatic syncope
- Autonomic failure
- Drug-induced
- Volume depletion
What is a femoral aneurysm?
How may it present?
Bulging weakness in wall of femoral artery
Pulsation in groin
Pain in leg/abdomen/back
Claudication symptom
Nerve compression (femoral nerve/obturator nerve)
What is Short Bowel Syndrome?
Give the clinical features.
Absence of functional SI
Fatigue Vomiting Thirst/Dry skin Bloating/Cramping Foul-smelling stool Weakness
When prescribing anti-emetics in palliative care, what should be considered?
Consider the cause of the N/V to be treated
Reduced motility (e.g. secondary to opioids) - Use metoclopramide / domperidone
Chemically mediated (e.g. secondary to hypercalcemia; opioids or chemotherapy)
- Ondansetron
- Levomepromazine
Visceral/serosal (secondary to constipation/oral candidiasis)
- Cyclizine
- Levopromazine
Raised ICP
- Cyclizine
- Dexamethasone (if metastases)
Vestibular (opioid related)
- Cyclizine
Cortical (e.g. anxiety/pain/fear)
- Benzodiazepines
- Cyclizine
When would you avoid oral anti-emetics in palliative care?
NBM Poor swallow Vomiting Malabsorption Gastric stasis
Therefore use IV route
How do you calculate the breakthrough dose of morphine?
1/6 of daily dose
What should be prescribed with opioids?
Laxatives
What opioid should be given in patients with renal impairment?
Moderate impairment: Oxycodone
Severe impairment: Buprenorphine; Fentanyl
What can be used to manage metastatic bone pain?
Opioid analgesia
Bisphosphonates
Radiotherapy
What are the side effects of opioids?
Respiratory depression
Nausea
Drowsiness
Constipation
How do you convert between oral codeine and oral morphine?
Divide by 10
How do you convert between oral tramadol and oral morphine?
Divide by 10
What are the differences in side effects between oxycodone and morphine?
Cf Morphine…
More constipation
Less sedation
Less vomiting
Less pruritus
How do you convert between oral morphine and oral oxycodone?
Divide by 2
How do you convert from oral morphine to subcutaneous morphine?
Divide by 2
How do you convert from oral morphine to subcutaneous diamorphine?
Divide by 3
What is the management for intractable hiccups?
Chlorpromazine
Dexamethasone (if hepatic lesions)
How is confusion managed in palliative care?
Sedatives
Haloperidol
Chlorpromazine
Levomepromazine
How are secretions managed in palliative care?
Hyoscine hydrobromide/Hyoscine butylbromide
Glycopyrronium bromide
When is neutropenic sepsis most likely to occur?
7-14 days following chemotherapy
Neutrophil count <0.5 x 10^9
Fever >38 C
Sepsis features
What is the management of neutropenic sepsis?
ABX: Pip/Taz
+
Specialist assessment
If still unwell after 48 hours - use alternative ABX e.g. Meropenum ± Vancomycin
A patient who is fully active is which WHO performance status?
A. 1
B. 0
C. 2
D. 3
B
A patient who is restricted in physical activity but ambulatory and able to carry out work is which WHO performance status?
A. 1
B. 0
C. 2
D. 3
A
A patient who is able to self care but unable to work, out of bed for 50% of the day is which WHO performance status?
A. 1
B. 0
C. 2
D. 3
C
A patient who is bedridden for >50% of the day is?
A. 1
B. 0
C. 2
D. 3
D
A patient who is completely disabled, unable to carry on self-care or leave chair is given which WHO performance status?
A. 1
B. 4
C. 2
D. 3
B
Which cancers are most commonly associated with hypercalcaemia?
Breast
Kidney
Multiple myeloma
Why might a magnet be placed over an ICD?
In the event that you are unclear whether an ICD has been deactivated, placing a large magnet over the device will temporarily deactivate the defibrillation function for the duration of time the magnet is in place. The magnet should therefore be securely taped over the ICD to prevent it slipping off the patient’s chest. If it turns out the ICD has been deactivated, the magnet will do no harm and can simply be removed once it is confirmed deactivation has taken place.
What are the criteria to certify a patient’s death?
Absence of pupillary response Failed response to pain Absence of central pulse Absence of heart sounds Absence of bowel sounds Check and confirm again at 5 minutes
Give the two predictors of mortality in the palliative patient group?
Deteriorating function
Surprise Question: Would you be surprised if this patient were to die in the next days/weeks/months?
Give two examples of deprivation of liberty.
Restraint being used to admit a patient to a hospital / care home when the patient has resisted admission
Medication being given by force against a patient’s will
Staff taking complete control over a person’s care and movements over a long period
Patients being prevented from seeing family or friends because the care home / hospital had restricted their access to them.
What does the DOLS Mental Capacity Act 2005 aim to do?
Aims to ensure patients in care settings are cared for in accordance to their wishes without restricting their freedom
Why may Glycopyrronium be preferred to Hyoscine hydrobromide?
Hyoscine hydrobromide is an antimuscarinic drug which will also dry secretions, it can cross the blood-brain barrier and cause agitation, so glycopyrronium might be preferable.
A 40-year-old with known rheumatoid arthritis, established on sulfasalazine and regular paracetamol and ibuprofen, is seen by her GP with ongoing low mood. Non-pharmaceutical interventions have been trialled with limited improvement and now the patient reports they feel their depressive symptoms are worsening.
As such the GP decided to commence the patient on an antidepressant.
What agent would increase this patient’s risk of a GI bleed the most, therefore, warranting a protein pump inhibitor as cover?
SSRI in combination with NSAID = increased risk
PPI should be prescribed
A 52-year-old man is admitted to hospital with acute pancreatitis. He drinks 90 units of alcohol per week. When is the peak incidence of delirium tremens following alcohol withdrawal?
72 hours
6-12 hours = symptoms (tremor, tachycardia, anxiety)
36 hours = seizures
72 hours = Fever, confusion, delusions, tremor and hallucinations
A 36-year-old man with a history of asthma and schizophrenia presents to his local GP surgery. He complains of ‘tonsillitis’ and requests an antibiotic. On examination he has bilateral inflammed tonsils, temperature is 37.8ºC and the pulse is 90/min. His current medications include salbutamol inhaler prn, Clenil inhaler 2 puffs bd, co-codamol 30/500 2 tabs qds and clozapine 100mg bd. You decide to prescribe penicillin.
What is the most appropriate further action?
FBC - Clozapine can cause agranolocytosis/neutropenia
A 23-year-old male has been on antipsychotics for the past few months. He has been suffering from a side-effect of this drug, that you grade as severe, which causes repetitive involuntary movements including grimacing and sticking out the tongue. This side-effect is known to arise only in individuals who have been on antipsychotic for a while.
Which medication is therefore most suitable to treat this side-effect?
Tetrabenzene - treats tardive dyskinesia
A 24-year-old woman is brought to the Emergency Department by her friend. The friend states she has been acting differently and can’t seem to concentrate on one thing at a time. He has noticed over the past few days that she hasn’t been sleeping as he can hear her walking around in the early hours of the morning. His main concern is that she has been coming home with multiple bags of very expensive looking shopping every day for the past 3 days.
The patient denies any hallucinations but states she feels great and wants to eat all the time. She has no past medical history and takes no medications.
What is the most likely cause of this patient’s presentation?
Hypomania
What are the clinical features of SSRI discontinuation syndrome?
increased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia
A 36-year-old with a long standing history of schizophrenia presents to the emergency department in status epilepticus. Once he is treated, he tells the doctor he has been having a lot of seizures recently.
Which of the following medications is most likely to be causing the seizures?
A. Sertraline
B. Lithium
C. Clozapine
D. Onlazapine
C - Clozapine reduces the seizure threshold
Which factors give a poor prognosis of Schizophrenia?
strong family history gradual onset low IQ prodromal phase of social withdrawal lack of obvious precipitant
Joseph, a 55-year-old man, goes to his GP describing a lack of energy, low mood and lack of pleasure doing activities he normally enjoys for the past 10 days. According to ICD-10 criteria, how long must Joseph’s symptoms last to be classified as a depressive episode?
2 weeks
A 60-year-old man with chronic schizophrenia presented with nausea and vomiting. He receives metoclopramide for his symptoms. Twenty minutes later he becomes agitated and develops marked oculogyric crises and oromandibular dystonia.
What is the most appropriate drug to prescribe?
Procyclidine
A 27-year-old man presents to his GP with ongoing issues with sleep and admits that he has not been sleeping because of tension in his relationship with his girlfriend. He feels she is somewhat distant with him and is concerned that she is spending time with her former boyfriend who works in the same office as her.
On further questioning, he explains he has had several relationships in the past during which he felt as though they were not interested in him. He feels as though he will never be able to find the perfect partner therefore suffers from mood swings as a result. During the consultation, he reveals that he feels ‘alone in the world’ and that even his friends are ‘out to get him’, risk assessment reveals he does not have any suicidal thoughts but self-harms from time to time. A referral to psychiatry is made and subsequently he is diagnosed with borderline personality disorder.
What is the most appropriate treatment?
DBT
You are on a psychiatric liaison rotation, and have been asked to talk to an admitted patient with known bipolar disorder. Upon trying to take a history from him, you struggle to follow his stream of consciousness, as he keeps saying things like: ‘I went home to feed my cat – so fat I am, I really need to lose weight – I hate the postman, he always speeds in his red van, Dan is my best friend at work -‘. You suspect that his flight of ideas is linked only by rhyme or similar sounding words.
What is the medical term for this psychiatric symptom?
Clang associations
Outline the difference between Somatisation, Hypochondriasis, Conversion disorder, Fatitious disorder and Malingering.
Somatisation = 2+ Sx for 2+ years
Hypochondriasis = belief of disease without accepting medical tests e.g. Cancer
Conversion disorder = motor/sensory loss without consciously knowing
- No malingering
- No factitious
Factitious disorder = Munchausen’s with intentional production (insight)
Malingering = fraudulent simulation of symptoms to gain financially or in another way
A 75-year-old male presents to the acute medical unit with dyspnoea. He has a past medical history of chronic obstructive pulmonary disorder (COPD). On examination the patient has an SpO2 = 85%, blood pressure 100/65 mmHg, temperature = 38.6 C and widespread bilateral expiratory wheeze on auscultation. An arterial blood gas (ABG) sample reveals:
pO2 = 6.8 kPa pCO2 = 7.8 kPa pH = 7.31 HCO3- = 44 mmol/l
Acute on chronic Respiratory Acidosis
A 26-year-old male presents via ambulance to the emergency department of your local hospital following a motor vehicle accident. He was a restrained passenger. The paramedics have secured his c-spine before transporting him. He is complaining of chest pain and shortness of breath. A primary and secondary survey are undertaken and the following pertinent findings are reported:
Young, otherwise healthy looking male in clear pain and respiratory distress.
Glasgow coma scale (GCS) of 14.
Heart rate of 104/min.
Blood pressure of 94/50mmHg.
Respiratory rate of 24/min.
Oxygen saturation: 99% on 15L non-rebreather.
Temperature: 36.8 degrees.
There is a tender contusion on the anterior chest. No abnormal chest movements. JVP can been seen at the level of the earlobe. Auscultation reveals soft heart sounds and bibasal crepitations. There is air entry throughout both lung fields.
An ECG is performed.
Which of the following ECG findings is most likely to be reported in this patient?
Electrical Alternans
A 26-year-old male presents via ambulance to the emergency department of your local hospital following a motor vehicle accident. He was a restrained passenger. The paramedics have secured his c-spine before transporting him. He is complaining of chest pain and shortness of breath. A primary and secondary survey are undertaken and the following pertinent findings are reported:
Young, otherwise healthy looking male in clear pain and respiratory distress.
Glasgow coma scale (GCS) of 14.
Heart rate of 104/min.
Blood pressure of 94/50mmHg.
Respiratory rate of 24/min.
Oxygen saturation: 99% on 15L non-rebreather.
Temperature: 36.8 degrees.
There is a tender contusion on the anterior chest. No abnormal chest movements. JVP can been seen at the level of the earlobe. Auscultation reveals soft heart sounds and bibasal crepitations. There is air entry throughout both lung fields.
An ECG is performed.
Which triad is demonstrated here?
Beck’s Triad = hypotension + raised JVP + muffled heart sounds
A thirty-four-year-old man with ulcerative colitis is recovering on the ward 6 days following a proctocolectomy. During the morning ward round he complains to the team looking after him that he has developed pain in his abdomen. The pain started in the left iliac fossa but is now diffuse. It came on suddenly, overnight, and has gradually been getting worse since. He ranks it an 9/10. He has not opened his bowels or passed flatus since the procedure. He has had no analgesia for this.
On examination:
Blood pressure: 105/68 mmHg; Heart rate: 118/minute, regular; Respiratory rate: 12/minute; Temperature: 38.2 ºC; Oxygen saturations: 98%.
Abdominal exam: abdomen is distended and diffusely tender upon palpation and widespread guarding, indicating peritonism. No organomegaly or palpable abdominal aortic aneurysm. Kidneys are non ballotable. No shifting dullness. Bowel sounds are absent.
There is 250 mL of feculent matter in the abdominal wound drain.
The registrar requests an abdominal CT which demonstrates an anastomotic leak. What is the most appropriate initial management of this patient?
Take to theatre immediately
Jenna is an 18-year-old woman who was initially admitted with a fever and disseminated rash. She had not been previously vaccinated and was in contact with her 2-year-old cousin who had developed a fever and disseminated blisters and vesicles containing clear fluid. She began to have a fever and flu-like symptoms 2 weeks after seeing her cousin. Similar clear-fluid filled vesicles and blisters developed 3 days later and she was admitted for further observation.
After 3 days, she noticed that while most of her skin lesions are healing, one of the lesions on the thigh appears to be red and becoming hot to touch. An area of skin approximately 3x3cm was erythematous. The skin was marked and she was commenced on IV flucloxacillin. Over the coming 12 hours, the erythema around this lesion continued to spread. The pain around her leg increased in intensity, requiring morphine to take the edge off the pain. A blueish discolouration begins to develop around the rash.
Given the likely complication that has developed, what is the likely organism that has caused the complication?
GAS
Jenna is an 18-year-old woman who was initially admitted with a fever and disseminated rash. She had not been previously vaccinated and was in contact with her 2-year-old cousin who had developed a fever and disseminated blisters and vesicles containing clear fluid. She began to have a fever and flu-like symptoms 2 weeks after seeing her cousin. Similar clear-fluid filled vesicles and blisters developed 3 days later and she was admitted for further observation.
After 3 days, she noticed that while most of her skin lesions are healing, one of the lesions on the thigh appears to be red and becoming hot to touch. An area of skin approximately 3x3cm was erythematous. The skin was marked and she was commenced on IV flucloxacillin. Over the coming 12 hours, the erythema around this lesion continued to spread. The pain around her leg increased in intensity, requiring morphine to take the edge off the pain. A blueish discolouration begins to develop around the rash.
Given the likely complication that has developed, what is the likely diagnosis?
Necrotising Fasciitis
Chickenpox can predispose you to Nec Fasc
What is target blood pressure for a 56-year-old man with type 2 diabetes mellitus who has no end-organ damage, if using a clinic blood pressure reading?
<140/90 mmHg
A 32-year-old woman comes to surgery for her blood results. She is 25 weeks pregnant and has had her glucose tolerance test.
The results are as follows:
Fasting glucose = 7.3 mmol/L
2-hour glucose 8.5 mmol/L
What would be the most appropriate next step?
Fasting glucose > 7 thus insulin immediately
If fasting glucose < 7 then 1 week trial of diet and exercise may be given
A 43-year-old man is attending today following a referral from his GP. He has a history of poorly controlled hypertension and has come in today to have his aldosterone: renin ratio performed. The results showed high aldosterone and low renin levels. The patient also has a CT scan which shows bilateral hyperplasia of the adrenal glands.
How should this patient be managed?
This patient has a high aldosterone : renin ratio therefore there is elevated levels of aldosterone which feeds back to suppress renin.
Aldosterone levels increase sodium retention and potassium secretion thus hypertension occurs.
The cause is bilateral thus surgery not indicated, but something to antagonise the effects of aldosterone hence Spironolactone
A 29-year-old woman presents to the GP with her mother. She has been experiencing fatigue for 2 weeks which she says is unusual for her. She has multiple petechiae on her arms and legs and hepatomegaly on examination. Her vital signs are all normal, and she is not aware of having any long-term medical conditions.
Which of the following is the most appropriate management?
Refer to specialist urgently - suspected leukaemia
What are the clinical features of an atrial myxoma?
systemic: dyspnoea, fatigue, weight loss, pyrexia of unknown origin, clubbing
emboli
atrial fibrillation
mid-diastolic murmur, ‘tumour plop’
echo: pedunculated heterogeneous mass typically attached to the fossa ovalis region of the interatrial septum
An 85-year-old man is bought into hospital after developing severe abdominal pain at home. His family report that he has also seemed more confused today and is ‘off his legs’.
On examination, his abdomen is full with a large palpable bladder. A PR examination reveals a smooth, mildly enlarged prostate with an empty rectum. A bladder scan shows 1L of urine in his bladder.
His most recent prescription shows that he takes aspirin, fexofenadine, ramipril, paracetamol, prazosin and insulin.
What medication is most likely to have contributed to this presentation?
Fexofenadine - may cause urinary retention
A 16-year-old girl with cystic fibrosis is being reviewed for her annual check-up. She was diagnosed with cystic fibrosis 15 years ago.
She has a good exercise tolerance, minimal gastrointestinal symptoms and has not been hospitalised in the past year.
Her recent investigations show an iron-deficient anaemia on her blood work, and multiple positive sputum cultures for Burkholderia species. Her latest FEV1 is 650% of her predicted.
What feature of her history confers the greatest increase in mortality?
Chronic Burkholderia infection
A 23-year-old female with severe learning difficulties is brought into the emergency department by her parents following an accidental paracetamol overdose. She was found 40 minutes ago to have mistakenly ingested 16 grams of paracetamol after having been briefly unsupervised.
What is the best initial management of this patient?
Within 1 hour, can give Charcoal
Check serum Paracetamol levels to determine if above treatment line then give n-acetylcysteine
A 77-year-old male presents to the Emergency Department after waking in the morning with lower back pain and an inability to stand unassisted. He has a past medical history of metastatic lung cancer and is currently receiving palliative care for this. Examination of the lower limbs reveals severe neurological deficits of both legs.
Given the likely diagnosis, which of the following would be a late sign in this patient?
Urinary incontinence
A 47-year-old man is admitted to the hospital with severe knee pain, swelling and stiffness which began last night. He is unable to weight bear and is systemically unwell with a temperature of 39.3ºC. He undergoes joint aspiration to confirm the diagnosis.
How long of a course of antibiotics should be prescribed?
4-6 weeks for Septic Arthritis
What are the side effects of glucocorticoids?
Immunosuppression/Neutrophilia
Growth suppression
Psychiatric: Mania/Insomnia/Depression/Psychosis
Ophthalmic: Glaucoma/Cataracts
GI: peptic ulceration/pancreatitis
Dermatological: Acne
Endocrine: IGT/ Increased appetite/ Weight gain/ Hirsutism/ Hyperlipidaemia
Cushing syndorme: moon face; striae; buffalo hump
Why are steroids gradually tapered?
Long-term corticosteroids suppress the glucocorticoid axis therefore sudden withdrawal may lead to an Addisonian crisis
How long does steroid withdrawal symptoms last for?
Up to 2 weeks
What may be a protective factor in a paracetamol overdose?
Acute alcohol intake
Which patients are at increased risk of hepatotoxicity following a paracetamol overdose?
Patients taking enzyme inducing drugs (rifampicin, phenytoin, carbamazepine, chronic alcohol excess, St. John’s Wart)
Malnourished patients
When may charcoal be of benefit in a paracetamol overdose?
<1 hour
When should acetylcysteine be given in a paracetamol OD?
Staggered overdose
Plasma concentration above treatment line
How is acetylcysteine given?
Infuse over 1 hour - reduce risk of anaphylactoid reaction
What are the criteria for a liver transplant following paracetamol overdose?
Arterial pH <7.3 after 24 hours of ingestion
PT >100 seconds
sCr > 300umol/L
Grade III or IV encephalopathy
How may encephalopathy be graded?
I = irritable
II = confusion
III = incoherent/restless
IV = coma
What is the first line management of hepatic encephalopathy?
Lactulose first line ± Rifaximim for secondary prophylaxis
What is the underlying cause of hepatic encephalopathy?
Any liver pathology with excess levels of ammonia and glutamine which cause confusion, asterixis, constructional apraxia and raised ammonia levels with triphasic slow waves on EEG.
What is the first line treatment of Scleroderma associated renal injury?
ACEi
What are the clinical features of Ankylosing Spondylitis?
Back stiffness: morning, improves with activity
Reduced movement
Reduced chest expansion
"The A's..." Amyloidosis Apical fibrosis Anterior uveitis Aortic regurgitation Peripheral arthritis Achilles tendonitis
Give an example of a cluster A personality disorder?
Paranoid
Schizoid
Schizotypal
Give an example of a Cluster B personality type?
Antisocial
Borderline
Histrionic
Narcissistic
Give an example of a cluster C personality type?
Obsessive-Compulsive
Dependent
Avoidant
What are the clinical features of a paranoid personality disorder?
Hypersensitivity Questions loyalty Perceives attacks on character Does not trust Preoccupied with alt beliefs
Give the clinical features of a Schizoid personality disorder.
Indifferent to praise Solo activities Emotional coldness Few interest Few friends or confidants other than family Lack of desire for companionship Lack of interest in sexual interactions
What are the clinical features of Schizotypal personality disorder?
Schizophrenic features BUT insight
Odd beliefs and magical thinking
Ideas of reference
Unusual perceptual disturbances (pseudohallucinations)
Odd, eccentric behaviour
Lack of close friends other than family members
Inappropriate affect
What are the clinical features of antisocial behaviour?
No social norms Deception Impulsiveness Irritable Aggressive Disregard for patient safety
What are the clinical features of Borderline personality disorder?
Unstable interpersonal relationships - alternate between idolisation and devaluation Unstable self image Impulsivity Affective instability Chronic feelings of emptiness Difficulty controlling temper
What are the clinical features of histrionic personality disorder?
Inappropriate sexual seductiveness
Need to be centre of attention
Shallow expression of emotion
Relationships considered to be more intimate than they are
What are the clinical features of narcissistic personality disorder?
Grandiose self importance Preoccupation with unlimited success Sense of entitlement Opportunistic - takes advantage of others Lack of empathy Craves admiration Chronic envy
What are the clinical features of Obsessive-Compulsive personality disorder?
Occupied with details Perfectionism Must act on obsessions Not capable of disposing of worn out possessions Unwilling to pass on tasks Stingy with money and spending
What are the clinical features of avoidant personality disorder?
Avoidance of activity out of fear of rejection
Preoccuied with ideas they are being criticised
Restraint in relationship due to fear of ridicule
Views self a inept and inferior to others
Social isolation whilst craving social contact
What are the clinical features of dependent personality disorder?
Requires assurance from others
Lack of initiative
Efforts to gain support for others
Unrealistic feelings that they cannot care for themselves
Unrealistic fears of being left to care for themselves
When is a phimosis considered treatable?
2 years old
Give 3 RFs for Vulval carcinoma.
HPV
Immunosuppression
Lichen sclerosus
VIN
A 27-year-old woman presents to her general practitioner with a one month history of abdominal pain, bloody diarrhoea and weight loss. She is referred for colonoscopy and biopsy which shows a continuous area on inflammation confined to the mucosa and the presence of crypt abscesses.
Given her likely diagnosis, which of the following antibodies is most specific?
This lady has UC
pANCA may be raised in UC, but not in CD
A 65-year-old man is seen in the rheumatology clinic following an acute monoarthropathy that affected the metatarsophalangeal joint of his left big toe. Analysis of synovial fluid aspirated from the joint showed the presence of negatively birefringent crystals under polarised light. Following acute treatment to settle the inflammation, the rheumatologist decides to initiate prophylactic treatment with allopurinol to prevent recurrence.
What is the most appropriate medication to initiate alongside allopurinol?
Colchicine / NSAID cover for up to 6/12
Which of the following is not a poor prognostic marker for ALL?
A. Age <2 years
B. WBC >20 x 10^9/L at diagnosis
C. T or B cell surface markers
D. Female sex
D - Male sex is a poor prognostic marker
A 32-year-old sewage worker presents with a 3 days history of lower back pain, fever, myalgia, fatigue, jaundice and a subconjunctival haemorrhage. He has no past medical history and has not been abroad in the last 6 months.
Na+ 136 mmol/l
K+ 5.2 mmol/l
Urea 10 mmol/l
Creatinine 180 µmol/l
What is the most likely diagnosis?
Leptospirosis
What distinguishes labyrinthitis from vestibular neuritis?
Hearing - in vestibular neuronitis the patient may have a preceding URTI but no hearing changes
If the D-dimer is positive but nothing is found on US, what should be done?
Stop the DOAC and repeat US in 1 week
How is a Jarisch-Herxheimer reaction different to anaphylaxis?
Fever, rash, tachycardia following ABX due to endotoxin release following bacterial death
However, no wheeze or hypotension
What are cannonball metastases secondary to?
Renal cell cancer
In a premature baby, how do you calculate the corrected age for which a development milestone should be reached?
The corrected age of a premature baby is the age minus the number of weeks he/she was born early from 40 weeks
Which intracranial venous thrombosis is characterised by an empty delta sign seen on venography?
Sagittal sinus thrombosis
What are the clinical features of normal pressure hydrocephalus?
Dementia
Ataxia
Urinary incontinence
What are the complications of M pneumoniae infection?
Cold agglutins (IgM): haemolytic anaemia/thrombocytopenia
Erythema multiforme
Erythema nodosum
Neurological diseases: meningoencephalitis; GBS
Bullous myringitis
Hepatitis
Pancreatitis
Acute glomerulonephritis
What is the recommended dose of adrenaline in ALS in a patient with an arrest?
1mL of 1:1000 IV Adrenaline
What are the features of life-threatening asthma?
PEFR <33%
Normal pCO2
Silent chest
Cyanosis
Bradycardia/Hypotension
Exhaustion, confusion, coma
What are the causes of increased nuchal translucency?
Down’s syndrome
CHD
Abdominal wall defects
A 52-year-old Nigerian woman presents with a 3 month history of menorrhagia and pelvic pain. On examination there is a palpable, firm, non-tender abdominal mass arising from the pelvis. Pelvic ultrasound confirms the presence of a large uterine fibroid. A decision is taken to perform a hysterectomy. Which medication would be most appropriate in preparation for her surgery?
GnRH agonist e.g. Leuprolide as it will shrink the size of the fibroid
what are the clinical features of sick euthyroid syndrome?
Following recent infection in vulnerable e.g. elderly
TSH is low/normal but T3/T4 low
Usually requires no treatment
What is the pterion?
Joining of the temporal, parietal frontal and sphenoid bones
A 13-year-old girl is brought by her mother for a widespread skin eruption. She began itching 2 days ago and has since developed fevers and a skin rash. On examination, there are various stages of lesions including macules, papules, crusted lesions, and vesicles which cover a majority of her body. Her mother has been giving her ibuprofen for the fever and discomfort.
Given the likely diagnosis, why would ibuprofen not be recommended in this scenario?
Risk of necrotising fasciitis
What are the dermatological features of Pernicious Anaemia?
Jaundice = ‘lemon tinge’
What is the threshold to mange subclinical hypothyroidism?
If TSH >10 = treat
If TSH 4-10 = watch and wait
Mnemonic: Ten is treat in hypoT
How is maintenance fluid calculated in children?
Calculated serially by weight
100mL/kg for first 10kg
50mL/kg for next 10kg
20mL/kg for every other kg
Which medications may decrease the quantity of a drug as they are enzyme inducers?
Carbamazepine Phenytoin Phenobarbitone Rifampicin St Johns Wart Chronic alcohol intake Griseofulvin Smoking
Which medications may increase the quantity of a drug as they are enzyme inhibitors?
Ciprofloxacin Erythromycin Isoniazid Cimetidine Omeprazole Amiodarone Allopurinol Ketoconazole Fluconazole SSRs Sodium valproate Acute alcohol intake Quinupristin
A 72-year-old lady with metastatic gastric adenocarcinoma presented with recurrent vomiting and abdominal pain. On examination, she was found to have a painful palpable umbilical node. This metastatic nodule representing advanced malignancy is eponymously referred to as?
Sister Mary Joseph’s Node
Palpable nodule in umbilicus due to metastasis of malignant cancer within pelvis or abdomen
What is the most common infective exacerbation of COPD?
H influenza
When should you initiate treatment for hyperkalaemia?
Severe thus >6.5mmol/L requires IV Calcium Gluconate and Insulin/Dextrose infusion
How are thromboses haemorrhoids managed?
Within 3 days = excision
Outwith 3 days = supportive measures
What are the features of an Argyll-Robertson Pupil?
Mnemonic: ARP, PRA
Accommodation reflex present; Pupil reflex absent
In which conditions may you see an Argyll-Robertson pupil?
Diabetes Mellitus
Syphilis
What are the clinical features of a Holmes-Adie pupil?
Dilated pupil
Slow reactive to accommodation
Association with ankle/knee reflex absence in Holmes-Adie Syndrome
Outline the key differences between Legionella pneumonia and Mycoplasma pneumonia.
Both: Atypical pneumonia Flu-like symptoms Dry cough LFT deranged
Rx with macrolide
Legionella:
Lymphopenia
Hyponatremia
Ix Urinary Antigen
Mycoplasma: Haemolytic anaemia/ITP Erythema multiforme Encephalitis Myocarditis
Ix Serology
What are the clinical features of Dengue fever?
Fever Retro-orbital headache Facial flushing Rash Thrombocytopenia
What are the clinical features of Klebsiella pneumonia?
Prevalence in Diabetics and Alcoholics
Occurs following aspiration
Red currnant jelly
Affects upper lobes
A 7 year-old boy from Sierra Leone presents with a 1 week history of painful left arm. He is homozygous for sickle cell disease. On examination the child is pyrexial at 40.2ºC and there is bony tenderness over the left humeral shaft. Investigations are:
Hb = 7.1 g/dL
Blood culture = Gram negative rods
X-ray left humerus: Osteomyelitis - destruction of bony cortex with periosteal reaction.
What is the most likely responsible pathogen?
Non-typhi Salmonella
Tell me everything you know about malignant hyperthermia
Chromosome 19, gene encoding RyR which controls Ca++ release from SR
Susceptibility following anaesthetic
Hyperthermia
Hypertonicity
Ix shows CK raised
Tx Dantrolene
What are the clinical features of Osler nodes?
Tender
Purple papules
Pale centre
Result of immune complex deposition
Give examples of live vaccines.
Rotavirus MMR Influenza Oral polio Yellow fever BCG
Which vaccines are derived from inactivated toxins?
DTP
What are the clinical features of Behcets Syndrome?
Ulceration: Oral + Genital Anterior uveitis DVT Arthritis Neurological involvement GI: Abdo pain, diarrhoea, colitis Erythema nodosum
Which drugs may exacerbate digoxin toxicity?
Amiodarone Verapamil/Diltiazem Quinidine Spironolactone Diuretics Ciclosporin
Note: Heart meds; Kidney meds
What is contrast media nephropathy?
What can be done to limit this?
25% increase in sCr within 5 days of IV contrast
Give IV NaCl 0.9% at 1mL/kg/hour
Describe ischaemic hepatitis.
Diffuse hepatic injury from acute hypoperfusion following an inciting event e.g. cardiac arrest
Ix shows raise ALT
AKI may be shown
What are the clinical features of antisynthetase syndrome?
Myositis
ILD
Mechanic’s hands
Raynaud’s
This is Abs to anti-Jo1 but also affects other anti-synthetases
In a DEXA score, how do the z and T scores differ?
Z score adjusted for age, gender and ethnicity
T score cf to healthy 30 year old
Why do Azathioprine and allopurinol interact to cause bone marrow suppression?
Allopurine is a XOi thus results in elevated 6-mercaptopurine which is incorporated in the DNA in bone marrow precursors which reduces platelet cell lines and RBC/WBC line productions
Which is the most likely pathogen to cause osteomyelitis in a Sickle Cell disease patient?
S enteritidis
What are Kanavel’s signs of flexor tendon sheath infection?
Fixed flexion
Painful passive extension
Fusiform swelling
What scoring test can be used to assess hypermobility?
Beighton score
Used to assess for Ehler-Danlos Syndrome
Which malignancies is dermatomyositis associated with?
Ovarian
Breast
Lung
Which antibodies are most associated with drug-induced lupus?
Antihistone antibodies
What are the clinical features of Hand, Foot and Mouth disease?
Mnemonic: CRASH and burn
Conjunctivitis Rash Adenopathy Strawberry tongue Hand swelling
Burn: fever > 5 days and high
What is the management of Kawasaki disease?
Aspirin + IVIG
What are the complications of Kawasaki disease?
Coronary artery aneurysm
What are ‘innocent murmurs’?
These are murmurs heard in children which are benign, with no worrisome pathology
Venous Hum = turbulent flow in vein with blowing noise at the infraclavicular region
Still’s murmur = low-pitched sound heard at left sternal edge
Mnemonic: Still = sternal edge
What are the clinical features of an innocent murmur?
Soft blowing noise Asymptomatic Varies with position No added sounds No thrill No heave No other abnormalities
How does the management of sepsis in a child <3 months differ to a standard sepsis case?
Use IV Amoxicillin in conjunction to IV Cephalosporin
What are the clinical features of Fragile X Syndrome?
Mnemonic: Nothing but an L
Low set ears Long thin face Large head Learning difficulties Low tone Low mitral valve (mitral valve prolapse)
What are the causes of cerebral palsy?
Congenital infection
Cerebral malformation
Asphyxia
Trauma
Intraventricular haemorrhage
Meningitis
Head-trauma
What is the MOA of Baclofen?
GABA agonist, therefore encourages relaxation of skeletal muscle
What is the criterion for pauciarticular JIA?
What Abs may be present in JIA?
<4 joints
ANA in an under 16
What pathogen causes roseola infantum?
HHV-6
In what condition would you see Nagayama spots?
Describe these.
Roseola infantolum
Papular enanthem (eruption of mucous membrane) on the uvula and soft palate
If a patient with Addison’s disease falls ill, what should their medications be?
Double the corticosteroids
Keep mineralocorticoids the same
What are the side effects of Thiazolidinediones?
Mnemonic: ELBOW
Elevated Liver enzymes Liquid retained Bladder cancer Osteoporosis Weight gain
What are the clinical features of Noonan Syndrome?
Webbed neck
Pes excavatum
Short
Pulmonary stenosis
What are the clinical features of Pierre-Robin syndrome?
Micrognathia
Posterior displacement of tongue
Cleft palate
What are the clinical features of PWS?
Hypogonadism
Obese
Hypotonia
What are the clinical features of Patau syndrome?
Microcephaly
Cleft palate
Polydactyly
Scalp lesions
What are the clinical features of Edward’s syndrome?
Micrognathia
Low-set ears
Rocker bottom feet
Overlapping fingers
What are the clinical features of Fragile X syndrome?
Learning difficulties Macrocephaly Long face Large ears Macro-orchidism
What are the clinical features of William’s syndrome?
Short stature
Learning difficulties
Friendly/extroverted
Supravalvular aortic stenosis
What are the clinical conditions in MEN 1?
3 Ps
Pituitary
Pancreatic
Parathyroid
What are the clinical features of MEN Type 2a?
Parathyroid
Phaeochromocytoma
What are the clinical features of MEN Type 2b?
Phaeochromocytoma
Marfanoid body habitus (Marfinoid body)
Neuroma
What are the types of shock?
Septic: SIRS + hypotension
Hypovolaemic: Loss of fluid e.g. haemorrhage
Cardiogenic: Reduced CO following cardiac compromise
Neurogenic: SCI causing PSNS > SNS thus reduced TPR with reduced blood pressure
Anaphylactic: trigger results in vasodilation following mast cell and IgE and histamine release with vasodilation and third compartment losses
What is the Cushing’s triad?
Raided ICP causing hypertension, bradycardia and irregular respiration
What common examination findings may suggest Downs Syndrome in a neonate?
Floppy
Poor feed
Epicanthic fold
Sandlewedge gap
Single palmar crease
Brushfield spots of the iris
Outline the VTE prophylaxis in a pregnant woman.
Two forms exist: Mechanical or Pharmacological
Assess at antenatal assessment into high risk, intermediate risk or low risk
3 or more low RFs or 1 high risk = LMWH
Low risk: BMI >30 Age > 35 years Smoker Immobility Pre-eclampsia Parity > 3 Dehydration Multiple pregnancy/ART
Postnatal RFs (different to above): Operation/AVD/PPH >1L
If a suspicion of VTE or diagnosis of VTE - Treat with LMWH
State 5 causes of a low GCS.
Trauma SOL Infection Lupus Toxicity Stroke Seizure Hypoxia Haemorrhage
What is Boas sign?
Tender on palpation of R inferior angle of scapula due to cholecystitis
A patient’s bloods show:
HbsAg - negative
anti-HBc - negative
anti-HBs - negative
IgM anti-HBc - negative
What is their hepatitis B status?
A. Natural immunity
B. Susceptible
C. Acute infection
D. Immune due to vaccination
E. Chronically infected
B
Absence of any Abs
A patient’s bloods show:
HbsAg - negative
anti-HBc - positive
anti-HBs - positive
IgM anti-HBc - negative
What is their hepatitis B status?
A. Natural immunity
B. Susceptible
C. Acute infection
D. Immune due to vaccination
E. Chronically infected
A
A patient’s bloods show:
HbsAg - negative
anti-HBc - negative
anti-HBs - positive
IgM anti-HBc - negative
What is their hepatitis B status?
A. Natural immunity
B. Susceptible
C. Acute infection
D. Immune due to vaccination
E. Chronically infected
D
A patient’s bloods show:
HbsAg - positive
anti-HBc - positive
anti-HBs - negative
IgM anti-HBc - positive
What is their hepatitis B status?
A. Natural immunity
B. Susceptible
C. Acute infection
D. Immune due to vaccination
E. Chronically infected
C
A patient’s bloods show:
HbsAg - positive
anti-HBc - positive
anti-HBs - negative
IgM anti-HBc - negative
What is their hepatitis B status?
A. Natural immunity
B. Susceptible
C. Acute infection
D. Immune due to vaccination
E. Chronically infected
E
What is the definition of priapism?
> 4 hours of an erection not associated with sexual stimulation
Give 5 causes of priapism.
Idiopathic
Hb-opathy
Anticoagulants; blue pills; ecstasy; sildenafil
Trauma
What are the features of Still’s disease?
Arthralgia Maculopapular salmon pink rash Pyrexia Lymphadenopathy RF
Elevated serum ferritin
How is the anion gap calculated?
all cations - all anions
(Na+ + K+) - (Cl- + HCO3-)
Should be between 8-14mmol/L
Give the causes of a normal anion gap.
This would be anything which does not increase anions…
Renal tubular acidosis
Acetazolamide
Addison’s disease
GI bicarb loss - diarrhoea
Give the causes of a raised anion gap metabolic acidosis.
Mnemonic: MUD PILES
Methanol
Uraemia
DKA
Paraldehyde Isoniazid/Iron Lactic acid Ethylene Glycol Salicylate
Which of the following is an intravenous anaesthetic?
A. Isoflurane
B. Desflurane
C. Propofol
D. NO
Propofol
What is the MOA of Propofol?
Potentiates GABAa
Why does propofol cause pain on injection?
Activation of a pain receptor TRPA1
How does desflurane work?
Unsure - speculated to be GABAa, glycine and NMDA receptors
What are the side effects of isoflurane?
Myocardial depression
Malignant hyperthermia
What are the potential side effects of NO?
Diffuse into other gas occupied compartments causing increased pressure - avoid in pneumothorax
When might you consider avoiding NO in a patient?
If gas disequilibrium in other compartments such as Pneumothorax
Which of the following IV anaesthetics works by blocking NMDA receptors?
A. Propofol
B. Thiopental
C. Etomidate
D. Ketamine
D - blocks NMDA receptors
Which of the following IV anaesthetics may cause Laryngospasm?
A. Propofol
B. Thiopental
C. Etomidate
D. Ketamine
B - Thiopental = throat
Which of the following IV anaesthetics would be most useful in trauma?
A. Propofol
B. Thiopental
C. Etomidate
D. Ketamine
D - Ketamine
No BP drop caused and acts as a dissociative anaesthetic
Which of the following drugs has anti-emetic effects?
A. Propofol
B. Thiopental
C. Etomidate
D. Ketamine
A. Propofol
Pain and Prevent sickness
How is pleural aspiration conducted?
21G needle and 50mL syringe
Fluid sent for: pH, lactate, protein and microbiology
Evaluate using Light’s criteria
Outline Light’s Criteria.
Always focus on the pleural fluid
If pleural protein between 25-35g/L… one of the following qualifies for exudative
Protein: Pleural / serum = >0.5
LDH: Pleural / serum = >0.6
LDH: 1.66x upper limit of serum LDH
In what condition might you see cannonball metastases?
Renal cell carcinoma
Prostate cancer
How should you manage wound dehiscence?
Cover with gauze IV ABX IV Fluids Analgesia Arrange to go to surgery
What imaging should you request if suspicious of a SAH?
CT non-contrast
Blood is radio-opaque thus contrast not required
How do you manage severe colitis in UC?
IV Corticosteroids
What are the clinical features of early vs late shock?
Early shock: Normotensive Tachycardia Tachypnoea Oliguria Mottled/pale
Late shock: Hypotensive Tachycardia Kussmaul breathing Anuria Blue
What is the INR if in AF?
2.5
What is the target INR in VTE?
- 5 prevention
3. 5 recurrent §
Which diuretics may cause hypercalcemia and hypocalcuria?
Thiazide diuretics
Outline the Levine scale for a heart murmur.
Grade 1 - Very faint murmur, frequently overlooked
Grade 2 - Slight murmur
Grade 3 - Moderate murmur without palpable thrill
Grade 4 - Loud murmur with palpable thrill
Grade 5 - Very loud murmur with extremely palpable thrill. Can be heard with stethoscope edge
Grade 6 - Extremely loud murmur - can be heard without stethoscope touching the chest wall
What are the features of life-threatening asthma?
Confusion Sats <92% Normal pCO2 (4.6-6kPa) Silent chest Bradycardia, hypotension
What are the cardiac complications of Carcinoid syndrome?
Mnemonic: TIPS
Tricuspid insufficiency
Pulmonary stenosis
How may Hypothyroidism cause hyponatraemia?
Reduced CO causes reduced BP thus baroreceptors trigger increased ADH resulting in SIADH and euvolaemic hyponatraemia
What is the name of the sign when the anterior chest wall demonstrates surgical emphysema, outlining the pec major muscle?
Gingkgo leaf sign
What is the drug of choice for reversing respiratory depression caused by magnesium sulphate?
Calcium gluconate
State 3 p450 enzyme inducers.
Mnemonic: R ABCDS
Rifampicin Anti-epileptics: Carbamazepine, Phenytoin Barbiturates Chronic alcohol use Demon chaser (St Johns Wart) Smoking
When should you consider a liver transplant in a paracetamol OD?
pH <7.3 24 hours post-OD
or ALL of these:
PT >100
sCr > 300
Grade 3/4 hepatic encephalopathy
What is the treatment for Non-Falciparum Malaria?
P vivax malaria treat with ACT or Chloroquine THEN Primaquine
Which cause of gastroenteritis features a short onset and vomiting?
S aureus
With a QRISK of 11% and cholesterol levels of 5.1, what is your management?
Need primary prevention dose of Atorvastatin 20mg
What investigations are required to diagnose postpartum thyroiditis?
TFTs alone
What may precipitate digoxin toxicity?
Renal failure Hypokalemia Hypoalbuminaemia Hypothermia Hypothyroidism Drugs: TZDs; Loop diuretics; Spironolactone; Ciclosporin; Amiodarone; CCBs
What is Corrigan’s sign?
Rapid upstroke and collapse of carotid pulse, seen in Aortic Regurgitation
Which valve is commonly affected in IVDUs?
Tricuspid valve
What is the most common cause of exudative pleural effusion?
Pneumonia
Give 5 causes of low SAAG.
Hypoalbuminaemia Malignancy Infection Pancreatitisis Bowel obstruction Biliary ascites Postoperative lymphatic leak Serositis in connective tissue diseases
What are the clinical features of Ebola?
Fever, Fatigue, Myalgia, Headache, Rash, Sore throat
Liver failure
Kidney failure
Haemorrhagic (potentially)
Infectious once symptomatic
2-21 day incubation
How is diabetic retinopathy classified?
Background (HOME): Haemorrhages Oedema Microaneurysms Exudate
Pre-proliferative:
Cotton wool spots
Venous abnormalities
Proliferative:
New vessel growth on retina, optic disc, iris
What is the classification of Hypertensive Retinopathy?
Keith-Wagener-Barker classification
Grade I: Arteriolar nipping
Grade II: AV nipping
Grade III: Flame haemorrhages
Grade IV: Optic disc swelling and macular oedema
What is the difference between phacoemulsification and extracapsular lens extraction?
Phacoemulsification divides cataract into portions by US cutter and removes diseased lens with intraocular lens implanted in.
Extracapsular extraction involves a large corneal incision, lens removed in one piece and the wound is stitched into the eye
Give 3 causes of a Third Nerve Palsy.
Raised ICP Vasculitis Demyelination Diabetes Dyslipidaemia Hypertension Smoking
What do you see in a Third Nerve palsy?
Why do you see this?
Eye is down and out and ptotic
Weakened elevation (superior rectus and inferior oblique)
WITH
unopposed abduction of lateral recuts and superior oblique
The eye is ptotic as the CN III innervates levator palpebrae superioris which elevates the eyelid.
What is Uhthoff’s phenomenon?
Worsening of vision following rise in body temperature in MS
How would you explore the treatment options in a Cancer patient, broadly-speaking?
Look at intention - is it curative or palliative?
Look at the modes of treatment:
Radio/Chemo
Medical
Surgery
Discuss this at the MDT depending on factors such as age, co-morbidities, functionality, patient wishes.
What is the MOA of a DNA alkylating agent? Give an example.
Forms a DNA cross-link between DNA base pairs thus prevents mitosis
Platinum-based drugs
Busulfan
What is the MOA of antimetabolites?
Give an example.
Inhibits RNA/DNA synthesis thus stops formation of nucleic acids
Fluorouracil
Methotrexate
What is the MOA of plant-derived chemotherapeutics?
Inhibit microtubule formation by binding to tubulin
Vincristine
Vinblastine
What is the MOA of anti-tumour antibiotics?
Intercalates between DNA base pairs thus DNA damage
Bleomycin
Doxorubicin
Epirubicin
Why are bloods monitored prior to and during Radiotherapy?
Keep Hb >100g/L as Oxygen-dependent process which DNA damage generates toxic free radicals.
O2 is determining factor in cell killing
Give 5 complications of radiotherapy.
Alopecia Mucositis Telangiectasia Skin rash N/V Diarrhoea Strictures Secondary cancer Immunosuppression
Why is there a link between Acromegaly and Colon cancer?
GH released binds to liver to produce IGF-1 which can bind to IGF-R or IR on colonic tissue with downstream signalling to increase CRC risk
What is the first-line antidepressant in a post-MI patient?
Sertraline
What are the causes of Erythema Nodosum?
Mnemonic: NODOSUM
NO (idiopathic) Drugs (sulphonamides; penicillin) OCP Sarcoidosis/TB Ulcerative colitis/CD Microbiology (Strep/EBV/Mycoplasma)
What are the additional consequences of Ankylosing Spondylitis?
Amyloidosis and acute cauda equina Anterior uveitis AV node block Aortic regurgitation Achilles tendonitis Arthritis (peripheral)
Following confirmation of S Bovis infection, what investigation/screening should occur? Explain why.
S Boris increases risk of colonic metaplasia thus colonoscopy advised
Give 10 causes of endocarditis.
S viridans
S aureus
S epidermidis
C burnetti
HACEK bacteria
Chlamydia
Candida
SLE (Libman-Sacks endocarditis)
Malignancy
Why do statins and clarithromycin react?
Clarithromycin Is an enzyme inhibitor of P450 enzymes thus increased levels of atorvastatin and reduced metabolism. Leads to increased chance of rhabdomyolysis. Risk is increased if CKD
What are the contraindications to statins?
Macrolides
Pregnancy
What are the indications for primary prevention dose of statins?
Atorvastatin 20mg
10 year risk >10%
eGFR <60ml/min/m2
DM
Which of the following is a P450 enzyme inducer?
A. Isoniazid
B. Sertraline
C. Acute alcohol
D. Chronic alcohol
D
Which of the following is a P450 enzyme inducer?
A. Isoniazid
B. Sertraline
C. Acute alcohol
D. Amiodarone
D
Which of the following is a P450 enzyme inducer?
A. Isoniazid
B. Sertraline
C. Rifampicin
D. Acute alcohol
C
Which of the following is an enzyme inhibitor?
A. St Johns Wort
B. Carbamazepine
C. Sodium valproate
D. Phenytoin
C
Which of the following is an enzyme inhibitor?
A. St Johns Wort
B. Carbamazepine
C. Ritonavir
D. Phenytoin
C
Which of the following is an enzyme inhibitor?
A. St Johns Wort
B. Carbamazepine
C. Omeprazole
D. Phenytoin
C
What is Trade’s sign?
Pistol shot femoral pulses in Aortic regurgitation
What is Quincke’s sign?
Capillary pulses in the nailbed
What murmur is heard in Aortic Regurgitation?
Austin-Flint murmur (mid-diastolic murmur at the apex)
Give 5 causes of clubbing
Cyanotic heart disease
Bacterial endocarditis
Atrial myxoma
Lung Ca
Pyogenic conditions
Asbesosis/Mesothelioma
Alveolitis
CD
Cirrhosis; PBC
Grave’s disease
Whipple’s disease
What type of chemotherapy is Cyclophosphamide?
A. Alkylating agent
B. Cytotoxic antibiotic
C. Antimetabolite
D. Acts on Mt
A
What type of chemotherapy is Bleomycin?
A. Alkylating agent
B. Cytotoxic antibiotic
C. Antimetabolite
D. Acts on Mt
B
What type of chemotherapy is Doxorubicin?
A. Alkylating agent
B. Cytotoxic antibiotic
C. Antimetabolite
D. Acts on Mt
B
What type of chemotherapy is Fluorouracil?
A. Alkylating agent
B. Cytotoxic antibiotic
C. Antimetabolite
D. Acts on Mt
C
What type of chemotherapy is Vincristine?
A. Alkylating agent
B. Cytotoxic antibiotic
C. Antimetabolite
D. Acts on Mt
D
What type of chemotherapy is Methotrexate?
A. Alkylating agent
B. Cytotoxic antibiotic
C. Antimetabolite
D. Acts on Mt
C
What investigation should be undertaken prior to Hydroxychloroquine?
Eye test - can cause retinal damage
What are the risk factors for SIDS?
Sleep in same bed Smoking Prone sleeping Hyperthermia and head covering Prematurity
What are the potential side effects of Loop diuretics?
Headaches Postural hypotension Hypocalcaemia Metabolic alkalosis Hypokalaemia
Ototoxicity
Gout
ATN
What are the potential side effects of Loop diuretics?
Headaches Postural hypotension Hypocalcaemia Metabolic alkalosis Hypokalaemia
Ototoxicity
Gout
ATN
Successful treatment with BenPen for Syphilis would be shown as?
Positive treponema test
Negative non-treponema test
Note: Non-treponemal test detects biomarkers released in cellular damage thus should be negative when no longer present
What is the gold standard for diagnosing schistosomiasis?
Stool and urine microscopy
What is the gold standard for diagnosing schistosomiasis?
Stool and urine microscopy
Name 3 medications which give erectile dysfunction
Beta blockers
SSRIs
What is the main difference between investigations to diagnose asthma in children vs adults?
In those under 17:
BPT
Spirometry
In those above 18:
BPT
Spirometry
FeNO test
A 73-year-old woman is admitted to hospital. After being treated with a broad-spectrum antibiotic for sepsis secondary to a lower respiratory tract infection. After a period of improvement, the patient deteriorates and is discovered to have an MRSA bacteraemia. The patient is documented as having previously had an allergic reaction to vancomycin. With which antibiotic would it be appropriate to treat the patient?
Linezolid
A 67-year-old diabetic patient has been on a surgical ward for one week, for treatment of a necrotic toe. His current medications include metformin and gliclazide. Since admission, he has received paracetamol, morphine, and daily enoxaparin.
His initial bloods showed:
K+ 4.0 mmol/L (3.5 - 5.0)
One week later, his blood results showed:
K+ 5.4 mmol/L (3.5 - 5.0)
Which medication is most likely to have caused the rise in serum potassium?
LMWH can cause hyperkalaemia
Which medications may worsen Myasthenia Gravis?
Beta blockers ABX Penicillamine Procainamide Phenytoin
Why are Loop diuretics not first choice in the management of secondary ascites in liver cirrhosis?
Furosemide causes hypokalaemia and alkalosis which promotes formation of NH3+ compounds which may precipitate a hepatic encephalopathy.
Spironolactone is the first line
What is the most likely pathogen to cause Infective Endocarditis in a patient 3 months post-operation?
S aureus
What is the most common cause of infective endocarditis within the first 2 weeks of a valve replacement?
S epidermidis
Give 5 causes of ST elevation.
Normal variation (take-off) Printzmetals angina Pericarditis Myocarditis LV aneurysm Takutsubo's SAH
What is the upper limit of LFT derangement permissible when starting Statins?
Allowed x3 of the derangement
When should you notify the consultant for communicable disease upon a meningococcal septicaemia patient?
Clinical suspicion
Calculate the osmolarity of blood.
2Na + 2K+ + Glucose + Urea
When should you refer a patient with varicose veins to a vascular surgeon?
Symptoms
Skin changes
Superficial venous thrombosis
Ulceration
Following a sickle cell crisis, how long should a patient wait to travel?
10 days
What are the 3 Ps of Vasovagal syncope?
Posture (upright)
Provocation (warm/cold/stress etc)
Prodromal symptoms (dizziness)
Which cancers are BRCA1 and BRCA2 associated with?
Breast
Ovarian
Prostate
Pancreas
Melanoma
Where do the majority of gastric cancers arise from?
Cardia
What is Lemierre’s syndrome?
Thrombophlebitis of IJV secondary to anaerobic oropharyngeal infection.
Spread via carotid sheath which contains the IJV; thrombus of septic emboli forms
Give 5 examples when a chest drain should be done immediately.
Pneumothorax of >2cm in 50 y/o + COPD or other secondary cause
Failed aspiration in pneumothorax
Pleural fluid pH <7.2 Pleural fluid glucose <2.2mmol/L LDH >1000 IU/L Positive gram culture Empyema (gross pus upon pleural aspirate)
Give 3 examples of pulmonary fibrosis of the upper zones.
Mnemonic: CHARTS
Coal miner's lung Hypersensitivity pneumonitis/Histiocytosis AS Radiation TB Sarcoidosis/Silicosis
What might cause fibrosis of the lower zones?
Drugs: Amiodarone/Nitrofurantoin/Bleomycin/Cyclophosphomide/Methotrexate
Systemic disorders: Wegener’s/Churg-Strauss
CT disorders: SLE/RA/Sjogrens/ Scleroderma/ Polymyositis
EEA
Radiotherapy
Give 3 types of extrinsic allergic alveolitis.
Farmer’s lung (Thermoactinomyces)
Mushroom worker’s lung (Thermoactinomyces)
Malt worker’s lung (A clavatus)
Wine maker’s lung (Botrytis)
List 3 complications of liver cirrhosis.
Malnutrition: Catabolic state/Reduced glycogenolysis/IGT/Increased gluconeogenesis
Vitamin deficiencies: B vitamins
Coagulopathy
Impaired immune system
Varices (portal hypertension >12mmHg)
Oedema/Ascites
Hepatic encephalopathy
Hepatorenal syndrome (hepatic failure results in vasoactive splanchnic mediators which drops systemic vascular resistance causing renal failure)
Why does ascites occur in liver cirrhosis?
Shrunken, cirrhotic liver results in portal hypertension with reduced protein production thus hypoalbuminaemia.
Hypoalbuminaemia with portal hypertension results in increased capillary permeability with transudate into peritoneal cavity resulting in abdominal distension and peripheral oedema.
Give 5 causes of hepatic failure.
Alcoholic Infective (viral, bacteria, parasitic) Drugs Toxins Ischaemic Pregnancy Infiltration (PCKD/VHL/Haemochromatosis/Wilson's disease)
Which drugs may be used in neuropathic pain?
Amitryptiline
Duloxetine
Gabapentin/Pregabalin
Which viruses are associated with Polyarteritis nodosa?
HBV
Hep C
CMV
HIV
What type of ovarian cancer may cause thyrotoxicosis?
Struma ovarii
