Mock 2 Flashcards
What is the initial treatment for DKA if the child who presented to A&E with nausea and vomiting, is clinically dehydrated and is now not alert?
IV fluids (0.9% NaCl 10 ml/kg) + SC insulin (0.2units/kg/hr)
Aside from hyperglycaemia, acidosis and ketonaemia, which other abnormality may be seen on blood investigation of DKA prior to treatment?
Mildly raised creatinine
Why does hyperkalaemia occur in DKA ?
Acidosis and lack of insulin means K+ is not moved into cells
Note once insulin and IV fluids have been given K+ levels will fall and should be monitored to avoid hypos
A 9-year-old, has been experiencing a fever, cough and runny nose for the last few days. However, this morning, his dad said that he noticed a rash that started behind his ears and has spread down over his body. He seems very unsettled, and his fever has been getting progressively higher and is now at 39 degrees. What is the likely diagnosis?
Measles
Clinical features of Turner Syndrome
Hypothyroidism
Congenital heart defects
Short statue
Webbed neck
Widely spaced nipples
Which three vaccines should a baby receive at 8 weeks old?
6 in 1 + rotavirus + MenB
Which vaccines should an infant receive at 12 weeks
6 in 1 (again) rotavirus (again), pneumococcal
Which vaccines should an infant receive at 16 weeks
6 in 1 (again) Men B (again)
Which vaccines should an infant receive at 1 year
Men B (again), pneumococcal (again), HiB, Men C and MMR
First line treatment for oligoarticular JIA
Intra-articular steroid injection
Used as a bridging agent when starting methotrexate
When is methotrexate more effective ?
Polyarthritis (useful)
What should be monitored for a child of methotrexate ?
Liver function
Bone marrow suppression
What is chronic anterior uveitis a complication of ?
Junior idiopathic arthritis
Seen in 33% of cases
Child with JIA are screened every 3 months as hard to pick up
What drugs can cause Stephen-Johnson syndrome?
Allopurinol
Lamotrigine
Penicillin
Phenytoin
What is Stephen-Johnson syndrome ?
A rare condition arising from ‘over-reaction’ of the immune system to a trigger such as a mild infection or a medicine, leading to blistering and peeling of the skin and surfaces of the eyes, mouth and throat.
Associated with a red/purple target like rash that spread and forms blisters
The mucous membranes of the mouth may also become blistered and ulcerated
At what age will a baby raise its head to 45 degrees from horizontal, follow moving objects by turning their head and smile responsively?
6 weeks
A 13-year-old male presents to his GP along with his mother. His mother describes her son appearing distant at times and falling behind at school, despite being very bright. She reports his attention as being generally poor. She describes him being clumsy in the morning and often dropping his breakfast. She noticed him jerking this morning and decided to get it checked out. What is the most likely diagnosis?
Juvenile Myoclonic epilepsy
Typical age of onset for juvenile myoclonic epilepsy ?
10–20 years
Typical features of juvenile myoclonic epilepsy
Myoclonic jerks up to 2 hours after waking up
Period of absence which disrupt school but learning is normal
You assess an 8-year-old boy in your paediatrics clinic who was referred by his GP. The referring letter states his mother has described a classic presentation of seizures, having had 3 to date. There is also a family history of epilepsy. You take a history and perform a thorough neurological examination, which is all normal. You agree that he is likely to be having seizures. What is the most appropriate first step?
Request an EEG and follow up when results are back
Complications of chickenpox
Bacterial superinfection
Cerebellitis
Disseminated intravascular coagulation
Progressive disseminated disease
How would the CSF appear in bacterial meningitis
Turbid appearance, raised polymorphs, raised protein and low glucose
How would the CSF appear in viral meningitis
Clear appearance, raised lymphocytes, raised or normal protein, normal/low glucose
How would the CSF appear in encephalitis
Clear appearance, normal/raised lymphocytes, normal/raised protein, normal/low glucose
How would the CSF appear in TB meningitis
Turbid/clear appearance, raised lymphocytes, raised protein, low glucose
What is the causative organism in scarlet fever ?
Group A streptococcus (strep pyogenes)
A 6-year-old male presents after having blood in his urine for 3 days. A urine dip is performed. On examination, there is a palpable mass on his left side. What is the most important diagnosis to exclude?
Wilms tumour
Between what ages does a Wilms tumour usually present ?
5-10 years
What is the classic presentation of a Wilms tumour ?
Abdominal mass
Painless haematuria
What is a Wilms tumour ?
Most common type of kidney cancer in children
Also known as nephroblastoma
A 10-year-old male is seen by his GP. He has severe learning difficulties and global developmental delay. He has characteristic facies of a large head, long face, large everted ears, and a prominent mandible. He also has mitral valve prolapse and poor muscle tone. What is the most likely underlying genetic syndrome?
Fragile X syndrome
Classical presentation of Downs syndrome
Learning difficulty,
Decreased muscle tone
Face-small chin, epicanthic folds, poor
Muscle tone, flat nasal bridge, single palmar crease, protruding tongue.
A 16-year-old male is seen by his GP. He has delayed onset of puberty-small penis, reduced testicle size and no facial or body hair. He also had a reduced sense of smell, poor balance and learning difficulties. What is the most likely underlying diagnosis?
Kallmann syndrome
How could Turner’s syndrome present ?
Female
45XO
Premature ovarian failure
Delayed/absent puberty
Short stature
Learning disability
Congenital heart defects - coarctation of the aorta
Horseshoe kidney
A 2-year-old female presents with multiple itchy lesions mainly on the face and trunk, with some on the limbs. The lesions appeared 3 days ago and are papular with surrounding erythema. Some lesions have been scratched, bled and scabbed over. She has had a mild fever but is largely well. What is the most likely diagnosis?
Chickenpox
Small pustules that develop a honey-coloured crusted plaques usually on the face with no surrounding erythema, often not itchy
Impetigo
A neonate presents with poor feeding, irritability, and fever. They have a purpuric rash appearing. On examination, they have a bulging fontanelle. A lumbar puncture is performed and is found to have raised polymorphs, high protein and low glucose. Given the diagnosis, what is the most likely causative organism
Group B streptococcus
(Could also be E.coli or listeria monocytogenes)
What are RFs for completed suicide ?
Male
Violent method
Care taken to not be found
Leaving a note
Carrying out final acts
First rank symptoms of schizophrenia
3rd person auditory hallucinations
Delusional perceptions
Somatic passivity
Thought alienation
What is somatic passivity ?
The belief that external forces control your actions, thoughts and perceptions
What drug can be used to treat the extrapyramidal side effects of APs ?
Procyclidine
Extra-pyramidal side effects of APs ?
Tardive dyskinesia
Akathisia
Parkinsomia
Dystonia
Features of a hypomanic episode
Flight of ideas
Irritability
Reduced need for sleep
Sexual disinhibition
What is knight’s move thinking ?
When a patient’s thoughts move from one topic to another without any logical connection between them
A feature common in schizophrenia
What differentiates knights move thinking and flight of ideas ?
There is at least some vague connection between subjects in flight of ideas
What blood cell change is associated with lithium ?
Leukocytosis (increased leucocytes)
How often should thyroid and renal function be tested in patients taking lithium ?
Every 6 months
Once therapeutic dose is reached how often should lithium levels be tested ?
Every 3 months
How long should SSRI and exposure and response prevention CBT last for before switching the SSRI for a different SSRI when treating OCD ?
12 weeks
2nd line medication treatment for OCD
TCA - clomipramine
A 17-year-old boy is brought in by his mother, who is concerned about her son. She says, over the last 9 months his performance at school has deteriorated. He’s told his mother on more than one occasion that his headteacher has put a thought in his head that he should drop out of school. He occasionally hears the sound of a bell that he cannot locate the source of. On questioning, he tells you his headteacher is able to control his actions, making him sit in a chair all day and not talk to anyone. He said this was done through a controlling machine in his office, transmitting signals through the bell tower. What best describes this phenomenon?
Delusion of passivity
What is a delusion of passivity ?
When someone experiences their own feelings/impulses/thoughts/actions not as their own but as being imposed on by some external force
What type of hallucination is the feeling of buys crawling under your skin
Tactile hallucinations which are a type of somatic hallucinations
What is thought broadcast?
The fixed idea that other people can read your thoughts
What are the components of a capacity assessment
Ability to understand
Ability to retain
Ability to weigh up
Ability to communicate
What are egodystonic thoughts ?
Thoughts that are very different from a patient’s normal beliefs and values
Common in COD
What are egosyntonic
Thoughts that are similar to a patient’s normal beliefs and values
What is test could be used in primary care to test cognitive function ?
6CIT
The 6 item cognitive impairment test
What is the 6CIT
A brief cognitive function test which takes less than 5 mins and is widely used in primary care settings
What medications are associated with delirium ?
Furosemide
Oxybutynin
Propranolol
Ranitidine
What is the initial monitoring for a patient taking clozapine
Every week for 18 weeks
Then every 2 weeks until 1 year
After that monthly bloods
Typical presentation of placental abruption
Abdominal pain with mild vaginal bleeding (can get a concealed abruption with maternal distress and haemorrhage much greater than vaginal loss).
Uterus is typically tender and if severe can be hard and “woody”.
Typical presentation of placenta praevia
A large amount of painless vagina bleeding.
The fetus often presents with an abnormal lie (breech/ transverse)
Typical presentation of vasa praevia
Onset with rupture of membranes
Usually painless with severe foetal distress
RFs for VTE in pregnancy ?
PMHx
Factor V leiden deficiency
Multiple pregnancy
High BMI
Pre-eclampsia
Miss Sahli, a 29-year-old lady, had a positive urinary pregnancy test 6 weeks ago. She presents to your GP surgery complaining of blood coming from her vagina. You suspect she may be having a threatened or inevitable miscarriage. A transvaginal ultrasound is carried out which shows an intrauterine fetal pole with no fetal heartbeat. The crown rump measurement is less than 7mm. What is the next most appropriate step?
Repeated US in 7 days
Crown rump length are less than 7mm and so it iis too early to tell whether this is a viable but very early pregnancy or a possible miscarriage
A 28-year-old lady is found to be high grade HPV positive and has had an abnormal cervical smear which showed low grade dyskaryosis. She is referred for a colposcopy which shows low grade Cervical Intraepithelial neoplasia 1 at the transformation zone. What is the most appropriate management?
Do not treat - discharge and screen again at 12 months in the community
Individuals with CIN1 have low grade abnormal changes in the transformation zone and are at a lower risk of developing cervical cancer but still need 12 months follow up
When would a screen be done to check on the effect of large loop excision of the transformation zone cure ?
6 months
RFs for Group B Strep Infection
Maternal pyrexia
Prematurity
Sibling with GBS
Prolonged rupture of membranes
Features of RFs that would suggest cervical cancer
Post-coital bleeding
Purulent discharge
Red brown discharge
Aged 45-49
Smoko
Multiple sexual partners
What is the most common cause of vaginal cancer ?
Secondary (metastatic) vaginal cancer - 80%
What is the most common cause of primary vaginal cancer ?
Squamous cell carcinoma (85%)
What is the 6 in 1 vaccine ?
Diphtheria
Hep B
Haemophilus influenzae B
Polio
Tetanus
Whooping cough
When is the 6 in 1 vaccine given ?
8, 12 and 16 weeks
RFs for placenta praevia
Maternal age > 40 years
Twin pregnancy
Previous placenta praevia
Previous uterine surgery
A nulliparous 28-year old lady presents to A&E at 38 week’s gestation in early labour and she is now showing dark-red vaginal bleeding after spontaneous rupture of the placental membranes, and CTG shows acute fetal compromise. What is the most likely cause of this bleeding?
Vasa praevia
Features of endometriosis
Cyclical pelvic pain
Dysmenorrhea
Deep dyspareunia
Subfertility
Describe the correct process of fetal descent through the birth canal
Descent, engagement, flexion, internal rotation, crowning, extension of presenting part, external rotation of head, delivery
A 23-year old lady attends her 20-week booking appointment and undertakes routine asymptomatic bacteriuria screening, the result comes back positive for the presence of bacteriuria. What are the most appropriate next steps?
Confirm presence of bacteriuria with second culture and then begin culture dependent antibiotic
What conditions can develop if asymptomatic bacteriuria in pregnant women is not treated ?
Pyelonephritis
Premature
ROM
At what amniotic fluid index (AFI) would a pregnancy be diagnosed with polyhydramnios?
Polyhydramnios is usually diagnosed at an AFI of >24cm (or 2000ml+). Oligohydramnios is usually diagnosed with an AFI of <5cm (or under 200ml).
What is the most common cause of polyhydramnios?
Idiopathic
An elderly patient presents with progressive confusion, ataxia and hallucinations
Lewy Body Dementia
Common presentations following left-sided middle cerebral artery ischaemic stroke ?
Aphasia
Headache
Right-sided numbness
Right-sided weakness
Ischaemic stroke in which blood vessel is associated with personality of changes
Anterior cerebral artery stroke
What DEXA T score would indicate osteoporosis ?
Less than -2.5
What DEXA T score would indicate osteopenia ?
-1 to -2.5
Useful mnemonic for osteoporosis
SHATTERED
Steroids
Hyperthyroidism
Alcohol/smoko
Thin (BMI < 22)
Testosterone deficiency
Early menopause
Renal/liver failure
Erosive or inflammatory bone disease (RA, Ank spind),
Dietary Ca2+ deficiency
Definition of polypharmacy
Patient taking 5 or more medications daily
Investigations in a confusion screen
Chest X-ray
C-reactive protein
FBC
Urinalysis
Mary is a 54-year-old lady who presents to the GP complaining of urine leakage when she runs. She has had 3 vaginal deliveries, with her youngest child she had retained placenta resulting in a hysterectomy. Her BMI is 28. She does not experience leakage at night or just as she gets to the toilet. What is the most likely diagnosis?
Stress incontinence
Features of a unilateral total anterior circulation stroke
Affects supply from both the anterior cerebral and middle cerebral artery
Presents with unilateral weakness of face, arm and leg
Presents with higher cerebral dysfunction
What is first line treatment of stress incontinence?
Pelvic floor physiotherapy
What medication could be used in stress incontinence ?
Duloxetine
SSRIs
What is a surgical intervention that could be used for stress incontinence ?
Urethral sling surgery
What % of dementia’s are AD ?
62%
Features of delirium ?
Changes in cognition
Disturbances of consciousness
Develops over a short period of time and fluctuates over the course of a day
Underlying medication condition
Features of Horner’s syndrome
Anhidrosis
Enophthalmos
Miosis
Ptosis
Only current medication licensed to treat MND
Riluzole
Mrs Smith, a 50-year-old lady, comes to see you in your GP practice with a week’s history of an electric-shock-like pain in the lower left side of her face that lasts for a few seconds and occurs whenever she touches her face or brushes her teeth. No abnormalities are detected on cranial nerve examination and she has no other significant past medical or family history. Given the likely diagnosis, what is the first line treatment that you should start Mrs Smith on?
Carbamazepine
Red flags in a history of neuropathic pain that would contraindicate carbamazepine
Deafness, sensory changes, bilateral pain, pain only in the ophthalmic division, age of onset before 40,
Family history of MS, optic neuritis, history of skin/oral lesions that could spread perineurally
Triggers for migraines
CHOCOLATE
Chocolate
Hangover
Orgasm
Cheese
Oral contraceptive
Lie in
Alcohol
Tumult
Exercise
Other - injury, bright lights, loud noise, certain smells, being hungry, smoking
How does frontal-temporal dementia present ?
Disinhibition, personality changes, language problems, and apathy-they tend to become quite nasty. You often also see pathological gambling. It is often genetic and is associated with MND.
Sophie is a 30-year-old woman with a past medical history of migraines, asthma and anxiety. She has been controlling her migraines for years with PRN sumatriptan as they were not too frequent. However, over the last few months the migraines have been getting more frequent and her symptoms have been worse. She would like something to prevent her migraines. What would be the first line management option you would offer her?
Topiramate
What would prevent you prescribing propranolol as first line treatment for migraines and prescribing topiramate instead ?
Asthma
(Note topiramate is teratogenic)
Classical triad of Parkinson’s
Rigidity
Bradykinesia
Resting tremor
What is the mechanism of action of ropinirole?
Activates dopamine receptors to mimic the action of dopamine
ACHi used to treat Lewy Body Dementia
Rivastigmine
John is a 72-year-old man who presented to his GP after having an episode of slurred speech and a left sided facial droop yesterday. This lasted for roughly 2 hours before wearing off and he has not had any symptoms since. The GP suspected TIA and refers to you in neurology. Which of the following is the most appropriate initial management to treat TIA?
Give aspirin 300mg OD for 2 weeks before switching to clopidogrel 75mg. Remember to give PPI with aspirin
ABCD2 score
Age > 60
BP > 140/90
Clinical features of TIA
Duration of symptoms
Hx of DM
Lola, a 35-year-old lady presents to the GP clinic with heavy menstrual bleeding that has been ongoing for the last 3 months. Her last menstrual period was 2 weeks ago. She is not on any contraception as she is trying to conceive. On examination you find a large palpable mass in the suprapubic area of the abdomen. Given the most likely diagnosis what is the most appropriate immediate management?
Tranexamic acid
Management of fibroid less than 3 cm
1st line - Mirena coil
Symptomatic management - NSAIDs and tranexamic acid
COCP
Cyclical oral progesterones
Management of fibroid more than 3 cm
Symptomatic management with NSAIDs and tranexamic acid
Mirena coil – depending on the size and shape of the fibroids and uterus
Combined oral contraceptive
Cyclical oral progestogens
Surgical options for < 3cm fibroids
Endometrial ablation
Resection of submucosal fibroids during hysteroscopy
Hysterectomy
Surgical options for > 3cm fibroids
Uterine artery embolisation
Myomectomy
Hysterectomy
Medications used to reduce fibroids before surgery
Goserelin - GnRH agonists
Rotterdam Criteria for diagnosis of PCOS
Polycystic ovaries (either 12 or more follicles or increased ovarian volume [> 10 cm3]
Oligo-ovulation or anovulation
Clinical and/or biochemical signs of hyperandrogenism.
When diagnosing PCOS what needs to be excluded
Thyroid dysfunction
Acromegaly
Hyperprolactinaemia
How does metformin impact PCOS ?
Appetite reduction
Decreases androgen production
Decreases LH and anterior pituitary
Decreases sex-hormone binding globulin in the liver
A 6-year-old (20kg) is brought in to the emergency department by his parents. He weighs 20kg, is clinically dehydrated, tachypneic, but not shocked. His breath smells like pear drops. You carry out some basic investigations and discover that his blood glucose is 20 mmol/l, arterial pH is 7.2 (assume 5% fluid deficit) and there is ketonaemia. After 200ml of bolus, what is the most appropriate fluid resuscitation in this patient’s current state?
0.9% NaCl plus KCl 40mmol/L, at a rate of 79ml/hour
HELLP Syndrome
Haemolysis, elevated liver enzymes, low platelets
A severe variant of pre-eclampsia
A 32-year-old female has an appointment with the gynaecologists regarding recurrent miscarriages. She has no known past medical history, but she has suffered with joint pain in the last few years. On examination you find that she has dysmorphic nail features that are seen below: What is the most likely diagnosis?
SLE
Diagnostic Levels of glucose for GDM
Fasting plasma glucose of > 5.6mmol/L
2 hour plasma glucose level of > 7.8
A 7-day-old premature neonate was delivered at 32 weeks gestation. On routine examination you identify abdominal distension and white-coloured vomit. What is the most important diagnosis to rule out?
Necrotising enterocolitis
A 75-year-old male presents with a 4 month history of fatigue, shortness of breath and a loss of appetite. He is an ex-smoker of 30 per day. You also notice that he has a round face, a hypertrophied interscapular fat pad and lots of bruises on his skin. He also is diagnosed with COPD and takes salbutamol, inhaled budesonide and salmeterol. CT scans of the adrenal glands and head show no pathology. What is the most likely cause for his Cushing syndrome?
Small cell carcinoma
What kind of lung cancer is associated with secretions of ADH or ACTH ?
Small cell carcinoma
What king of lung cancer is associated with parathyroid hormone secretion (and therefore hypercalcaemia) ?
Squamous cell carcinoma
A 45-year-old male presents with increased thirst, nocturia, frequency, a headache and muscle weakness. He is investigated for diabetes. These tests come back normal. It is noticed on his second visit that he has a very high blood pressure. An abdominal CT is performed which shows bilateral hyperplasia of the adrenal glands. What is the condition ?
Conns syndrome
What electrolyte imbalance would you expect, and what is the management of Conns syndrome ?
Primary hyperaldosteronism
Aldosterone acts on the kidneys to increase sodium absorption and as a result causes potassium excretion leading to Hypernatremia and hypokalaemia. The management is a potassium-sparing diuretic like spironolactone.
Investigation of choice for renal colic
Kidney, ureter, bladder CT
The nurse informs you that a 75-year-old female on a COTE ward has not voided for the past 12 hours, has vomited once in the last hour and appears confused. Her creatinine is measured and is more than 3 times higher than her baseline. She has been started on a few medications whilst on the COTE ward: metformin, ramipril, amoxicillin and alendronic acid. What stage AKI is she and what drug
most likely caused it?
Stage 3: ramipril
William is a 60-year-old male smoker with an occupational history of working in a chemicals factory. He presents to the GP with frequency, urgency, nocturia, weight loss and painless haematuria. What is the most appropriate next step?
2 week wait urgent referral for cystoscopy and biopsy
A 50-year-old female smoker comes to the GP with epigastric pain immediately after eating and vomiting. Urea breath test is positive. She is a smoker, drinks lots of caffeine and takes ibuprofen. What is the most appropriate management?
Lifestyle modifications + lansoprazole + clarithromycin + metronidazole
You are reviewing Dorothy, a 70-year-old woman on the renal ward. Her eGFR is 50mL/min/1.73m2 What stage CKD is she?
Stage 3A
You are a GP on route to a home visit to review a patient on long term oxygen therapy. When you arrive at the door the patient rushes to the door asking for your help as their 18 year-old-daughter is just recovering from a seizure which ended about 30 seconds before you arrived. Whilst talking to her, she then starts to have another seizure. What is the most appropriate management?
ABCDE then administer buccal midazolam
You are a GP seeing a 72-year-old male. He is complaining of slowing down of movements, difficulty turning when walking, poor balance and a loss of his sense of smell. On examination you notice a symmetrical pin-rolling tremor in his hands, rigidity in both arms, bradykinesia, a shuffling gait and a lack of facial expressions. His medications include: atorvastatin, aspirin, clopidogrel, ramipril and haloperidol. What is the most likely diagnosis?
Drug-induced Parkinsonism
You are seeing a 60-year-old known COPD sufferer who is still getting short of breath and has a cough despite treatment with salbutamol. There is no past medical history of atopic illness and no variation in his recent FEV1 recordings. He has quit smoking and is up to date on his vaccines. What is the next step in treatment according to NICE?
Add a long acting muscarinic antagonist (LAMA) + a long acting beta agonist (LABA)
Stepwise management of COPD (steroid responsive) - Step 1
SABA or SAMA
Stepwise management of COPD - Step 2
If on a SAMA then switch to SABA
SABA + LABA + ICS
Stepwise management of COPD - Step 2
SABA + LABA + ICS + LAMA
Clinical presentation of misses MC
Variable presentation from no symptoms to light vaginal bleeding
Pregnancy symptoms may be decreased
Cervix and US on missed MC
C- Closed
US - Nonviable fetus
Clinical presentation of inevitable MC
Vaginal bleeding, uterine cramps
Possible intrauterine fetus with heart beat
Cervix and US of inevitable MC
Fetus with possible heartbeat
Clinical features of an incomplete MC
Vaginal bleeding with passage of large clots or tissue
Uterine cramps
Products of conception often visualised in dilated cervical os
Cervix and US for incomplete MC
Open cervix
Products of conception in cervix
Clinical presentation threatened MC
Variable amount of vaginal bleeding
Pregnancy can proceed to viable birth
Cervix and US of threatened MC
Closed
Viable pregnancy
Clinical presentation of septic MC
Fever, malaise, signs of sepsis
Foul smelling discharge
Cervical motion and uterine tenderness
Usually occurs after induced abortions and can be life-threatening
Cervix and US findings of septic MC
Usually open
Usually retained products of conception
