msra Flashcards
Unilateral nasal polyps are a red flag and require ENT referral, True or False?
True
Rhinosinusitis is typically bilateral, if unilateral then refer.
What is the treatment for bilateral nasal polyps?
Saline nasal douch + Intranasal steroids (effective in 80% of cases at shrinking the polyp)
What is Samter’s triad?
Association of nasal polyps with aspirin sensitivity + asthma.
What percentage of dementia is Lewy Body Dementia? What are the early signs?
~20%
Visual hallucinations
Attention / Executive function deficits
Cognitive then motor deficit
What are the features of Vertebrobasilar ischaemia?
Elderly person
Dizziness on extension of neck
What are the features of Meniere’s?
Hearing loss
Tinnitus
Fullness in one/both ears
What are the features of acoustic neuroma? What condition is it associated with?
Hearing loss
Tinnitus
Absent corneal reflex
Associated with neurofibromatosis T2
What are the features of BPPV? What is the first line treatment?
Gradual onset
Associated with change in head position
Vertigo lasting 10-20 seconds
Epley Maneuver
What is the difference in presentation between Vestibular neuritis and Viral Labyrinthitis?
Both associated with recent viral infection, however viral labyrinthitis is associated with nausea/vomiting and may have hearing loss. There is no hearing impairment in vestibular neuronitis and less common to have nausea/vomiting.
Give a risk associated with Gentamicinglycoside)
Ototoxicity
Avoid giving in otitis externa/media if ear drum has ruptured!
Define vertigo
False sense that body or environment is moving
If a patient is on cardiac monitoring in CCU and enters Ventricular Fibrillation, what is the initial treatment?
3 successive stacked shocks then CPR.
Normally in VF or Pulseless VT you give one shock, but if on monitoring (witnessed) then give 3.
What are the shockable and non-shockable rhythms? When do you give adrenaline for each?
Shockable: VF / Pulseless VT
- Adrenaline 1mg IV/IO 1 in 10,000 post 3rd shock + 300mg amiodarone then adrenaline every 3-5 minutes. Consider amiodarone 150mg IV post 5th shock.
Non-shockable: PEA, Asystole
- Immediately 1mg adrenaline
- Every 3-5 minutes.
NB: 30:2 ratio compressions
What are the 4 Hs and 4 Ts in cardiac arrest?
Hypoxia
Hypovolaemia
Hyper/Hypokalaemia
Hypothermia
Thrombus
Tension Pneumothorax
Tamponade
Toxins
What is the test for anaphylaxis?
Serum Tryptase (raised for 12 hrs)
When is it safe to discharge a patient post anaphylaxis?
> 2hrs if responded well to 1 dose adrenaline (500mcg; 0.5ml 1 in 1000) ant lat middle 1/3rd thigh.
> 6hrs if 2 doses adrenaline required or if previous biphasic reaction
> 12hrs if on-going symptoms or if severe reaction or if severe asthma, or presenting late at night.
Give a non-drowsy antihistamine you could give someone in recovery from anaphylaxis?
Cetirizine
Fexofenadine
Loratadine
NB:
What operation would you perform for caecal, ascending colon, or proximal 1/3rd transverse colon cancer?
Right hemicolectomy
What is a Hartmann’s procedure?
Complete resection of the rectum and sigmoid + formation of end colostomy (emergency bowel obstruction or perforation)
What surgery would you use for upper rectal tumours?
High anterior resection
Lower anterior resection is for low rectal tumours (<5cm from anus).
What surgical procedure would you use for a cancer of the distal 2/3rds of the transverse colon, or the descending colon?
Left hemicolectomy
True or false, all anaphylaxis cases should be referred to specialist allergy clinic?
True
What is Sialadenitis?
Inflammation of the salivary gland due to an obstruction e.g. malignancy or stone
Which salivary gland is most commonly affected by cancer?
Parotid - 80% of cases
Pleomorphic adenoma (benign) = 80% of these
What are the management steps for asthma treatment?
1) SABA
2) SABA + Low Dose ICS
3) SABA + Low Dose ICS + Leukotriene receptor Antagonist (LTRA) e.g. Montelukast
4) SABA + Low Dose ICS + LABA +/- LTRA
5) SABA +/- LTRA + MART (Maintenance + Reliever) + ICS
6) SABA +/- LTRA + Moderate dose ICS MART
7) SABA +/- LTRA + High dose ICS +/- Theophylline (musc rec antagonist)
What is Ludwig’s angina?
Cellulitis of the mouth/neck due to a blocked salivary duct. Typically red, swollen under mandible. Urgent referral to ENT + antibiotics.
With inhaled corticosteroids, what constitutes low, moder and high dose?
E.g. Budesonide
Low: <400mg
Moderate: 400 - 800mg
High: >800mg
What is Warthin’s tumour?
Benign neoplasm of salivary gland
Tends to be softer and fluctuant
What is the treatment for otitis externa (‘swimmer’s ear’)?
Topical antibiotic drops + steroid drops
Avoid aminoglycosides e.g. gentamicin if rupture of ear drum
If treatment fails then ENT referral
Which drugs for congestive heart failure increase long-term survival rate?
ACE inhibitors
Beta Blockers
ARBs
Aldosterone antagonist e.g. spironolactone
What are the 1st, 2nd and 3rd line treatments for CHF? What vaccinations should they be given?
1st: ACEi + Beta blocker (start one at a time).
- BB e.g. Bisoprolol, Carvediolol, Nebivolol.
2nd: Aldosterone antagonist e.g. spironolactone or eplerenone
+/- SGLT-2 Inhibitor e.g. dapagliflocin or empagliflocin.
3rd: Sacubatril Valsartan, Hydralazine.
Remember to give annual influenza and pneumococcal vaccines.
What is the triad of symptoms for Optic Neuritis?
What pupil sign would you look for?
Visual loss (hours/days) - Central scotoma (key feature!)
Periocular pain (worse on eye movement)
Dyschromatopsia (change in colour perception e.g. red desaturation.
Look for Relative Afferent Pupillary Defect (RAPD) aka Marcus Gunn Pupil - lack of constriction in affected and non-affected pupil when light is swung to affected eye.
Give two common causes of optic neuritis. What investigation would you order if discovered?
Multiple Sclerosis
Diabetes
Syphylis
Bloods/Sexual health screen
MRI: if >3 white matter lesions then 50% get MS in 5 years!
What is the treatment for optic neuritis?
High dose steroids. IV methylprednisolone 30mg/kg for 3-5 days.
Expect resolution in 4-6 weeks.
What is the test for Addison’s?
Short Synacthen Test:
Measures serum cortisol levels after ACTH stimulation is administered (Synacthen).
What are the key signs of addison’s? What is the treatment?
Hypotension
Hyperpigmentation
Vitiligo
Hyponatraemia
Hyperkalaemia
Treat with IV hydrocortisone
A 70 year old, heavy smoker presents with painless, loss of vision in one eye. Fundoscopy shows pale, swollen optical disc, cotton wool spots and peripapillary haemorrhages. What is the most likely diagnosis?
Ischaemic Optic Neuropathy
Give two risk factors for vitreous detachemnt. What are the key features?
HTN
Diabetes
Floaters/Flashes
Loss of vision ‘curtain fall’ / peripheral
Painless
What are the common features of macular degeneration?
Distortion of vision e.g. straight lines appearing curved
Blurring
Central loss of vision
Drusen (yellow spots) on the retina (in Dry Macular Degeneration)
Dry MD is more common and less severe than Wet MD. In wet MD blood vessels are leaky and vision loss is more severe.
MD is the most common cause of blindness
What are the features of Temporal Arteritis? How is it managed?
AKA Giant Cell Arteritis
Rapid onset, headache, jaw claudication, blurred/loss of vision, tenderness around temporal nerve.
Oral Prednisolone 40-60mg/day with temporal artery biopsy within a week.
What is the best prevention for contrast induced nephropathy?
Saline IV 0.9% pre and post administration of contrast
(1ml/kg/hr 12hrs pre and post)
Contrast nephrotoxicity = 25% increase in creatinine within 3 days of contrast
What is the most common cause of diarrhoea in HIV?
Cryptosporidium
What vitamin supplement is given to alcoholics with dietary insufficiency?
Thiamine
Which visual pathology is associated with a cherry red spot on fundoscopy?
Central Retinal Artery Occlusion
What is the treatment for BPPV?
Dix Hallpike
What is the treatment of choice for:
1) Alcohol withdrawal acute
2) Antabuse
3) Reducing cravings
1) Benzodiazepines (chlordiazepoxide)
2) Disulfiram (inhibits acetaldehyde dehydrogenase enzyme)
3) Acamprosate NMDA receptor antagonist
How quickly are IUD, POP and [COCP, Implant, IUS,] effective?
IUD Instant
POP 2 days
COCP, Implant, IUS 7 days.
A patient has bacterial meningitis and is started on ceftriaxone. What other drug would you give and why?
Dexamethasone as it reduces the risk of neurological sequelae e.g. deafness
What vaccines do you not give to patients with HIV?
Live attenuated vaccines e.g.
BCG
Yellow Fever
Oral polio
Intranasal influenza
Varicella
MMR
What are relative and absolute contraindications to COCP?
Relative:
- BMI >35
- FHx VTE in 1st deg <45yrs
- Immobility e.g. wheelchair
- BRCA1/2
- Controlled HTN
- > 35 and smokes <15 /day
Absolute:
- >35 and smokes > 15/day
- Migraine with aura
- CVA hx
- Breast feeding <6 weeks
- Uncontrolled HTN
- Major surgery
- SLE
- Active breast ca
A patient presents with painful, monomorphic, punched out erosions on face. They are diagnosed with Eczema Herpeticum, what is the causative pathogen and what is the treatment?
Herpes 1/2
IV Aciclovir
How do you investigate ectopic pregnancy?
Pregnancy Test
Transvaginal US
A patient who previously had TB presents with a mass within a lung cavity and haemoptysis, what is the most likely diagnosis?
Aspergilloma
A fungal mass in a lung cavity commonly secondary to TB, lung cancer or cystic fibrosis.
Does Growth Hormone increase or decrease in annorexia nervosa?
Increases
Gs and Cs increase. Everything else decreases
Growth hormone
Glucose
Salivary Glands
Cortisol
Cholesterol
Carotinaemia
Which of the following is associated with decreased fertility in men? Epididymitis, hydrocoele, varicocoele.
Varicocoele
Dilatations of the pampiniform plexus. Most common on left side (80% of cases). “Bag of worms”.
US Doppler and conservative management in most cases.
What is the best treatment for vaginal thrush in pregnancy?
Clotrimazole pressary 500mg
Oral antifungals are contraindicated
What is the best treatment for vaginal candidiasis?
Oral fluconazole 150mg single dose.
If pregnant then clotrimazole pessary 500mg.
Give two risk fators for vaginal candidiasis
Diabetes
Pregnancy
Steroids
Antibiotics
Is sickle cell disease associated with higher or lower Hba1c and why?
Lower. Faster turnover of RBC which means reduced glycation time.
Before starting a patient on aromatase inhibitors for ER+ve breast ca, what scan should you arrange?
DEXA
Aromatase inhibitors e.g. anastrazole may cause osteoporosis by reducing peripheral oestrogen activity.
What is conversion disorder?
Loss of motor or sensory function caused by stress
What is the difference between somatisation and conversion?
Somatisation affects multiple physical systems, whereas conversion is typically one complaint with no explanation.
What is the difference between Malingering and Munchausen (Factitious disorder)?
Malingering is to falsely claim to have a condition or complaint for gain.
Munchausen’s is to deliberately induce a symptom to adopt a sick role.
A 43yr old 3cm dilation at 27 weeks presents. How do you manage?
Admit
Tocolytics (delay labour)
- Atosiban (oxytocin antagonist)
- Magnesium Sulfate
- Ca blockers e.g. nifedipine
- Betamimetics e.g. Terbutaline
- Prostaglandin inhibitors e.g. ketoralac.
- Nitroglycerine
Steroids (matures foetus’ lungs in case pregnancy cannot be avoided) as premature.
What does syntocinon do in labour?
Strengthens contractions
What muscle is overactive in Urge incontinence? How do you treat it?
Detrusor muscle
Muscarinic antagonist e.g. oxybutynin, solifenacin, tolteradine.
Investigate with bladder diary for >3 days, vaginal examination to exclude prolapse, urine dip and culture, urodynamic studies.
Give two antimuscarinic side effects
Blurred vision (cant see)
Urinary retention (cant pee)
Dry mouth (cant spit)
Constipation (cant shit)
In bacterial meningitis, what is the antimicrobial treatment of choice for:
- Neonates (<3months)
- 3months - 50 years
- >50 years
- Community meningococcal
- Hospital meningococcal
- Listeria
- Pneumococcal
- Haemophilus influenzae
- Prophylaxis
- Neonates (<3months) - Cefotaxime + Amoxicillin
- 3months - 50 years Cefotaxime/Ceftriaxone
- > 50 years Cefotaxime/Ceftriaxone + Amoxicillin
- Community meningococcal Benzylpenicillin
- Hospital meningococcal Cefotaxime/Ceftriaxone
- Listeria Amoxicillin
- Pneumococcal Cefotaxime/Ceftriaxone
- Haemophilus influenzae Cefotaxime/Ceftriaxone
- Prophylaxis Ciprofloxacin / Rifampicin (close contact within 7 days e.g. in same house hold).
If a mother has previously had Group B Strep infection and is pregnant again but is otherwise well, should you give antibiotic treatment?
Yes. Prophylactic Benzylpenicillin
What is the best treatment for cluster headaches?
100% O2
Triptan Subcutaneous
Verapamil and tapered prednisolone can be effective prophylaxis.
What is the 1st line test for Lyme disease?
ELISA for antibodies to Borrelia burdoferi
Repeat this 4-6 weeks after
When should you commence antibiotic therapy for Lyme disease?
If erythema migrans is present (clinical diagnosis) or systemically unwell following a tick bite.
Skin lesions e.g. bull’s eye lesion usually show 1-4 weeks post bite.
Treat with Doxycycline unless contraindicated e.g. pregnancy, then use Amoxicillin.
If patient is asymptomatic, you dont treat tick bites.
What is Jarisch Hexheimer reaction?
Tachycardia, and fever following commencement of antibiotics for certain infections e.g. syphilis or lyme’s disease.
What is the difference in how you manage asthma in <5yr olds vs over 5 years old?
If SABA doesn’t work, then <5yrs you trial 8 weeks of MODERATE ICS. In 5yrs and over you treat with LOW dose ICS.
A smoker presents with a white patch on his oral mucosa which cannot be rubbed off. A biopsy rules out squamous cell carcinoma, give another differential, what is the diagnosis of exclusion?
Oral Candidiasis
Lichen Planus
Dx of exclusion is Leukoplakia
- premalignant condition. 1% will transform into malignancy. Therefore this requires monitoring.
What blood test must you review before starting an ACE i?
U&Es
What blood test must you review before starting methotrexate?
FBC
LFT
U&E
What blood test must you review when starting Lithium?
Lithium levels (weekly until stable then 3 monthly, then 6 monthly)
TFT
U&E
What blood test must you review before starting Sodium Valproate?
LFT
What blood test must you review before starting Gliclazide?
LFT
What blood test must you review before starting Azathioprine?
FBC
LFT
What is the first line treatment for lichen planus?
Corticosteroids
What is the difference between Erbs palsy and Klumpke’s palsy?
Erbs palsy = inward rotation of arm, with extended elbow ‘waiters tip’. Upper brachial plexus injury (C5, C6).
Klumpke’s palsy = flexed IP joints and extended MCPJs. Often caused by hyperextension of arm e.g. holding onto a rail when falling. Lower brachial plexus injury (C8, T1)
Following shoulder dystocia, a child has an inwardly rotated right arm with an extended right elbow? What is the name for this palsy?
Erb-Duchenne Palsy
Upper brachial plexus injury (C5, C6)
Which nerve is most commonly affected by a mid shaft humeral fracture?
Radial nerve
Which nerve is commonly injured with proximal humerus injuries e.g. dislocation?
Axillary nerve
What is the function of the following nerves?
- Musculocutaneous
- Axillary
- Radial
- Median
- Ulnar
- Long Thoracic
Musculocutaneous
Elbow flexion (C5-7)
Axillary
Shoulder abduction (C5, C6)
Radial
Wrist extension (C5-8)
Median
LOAF muscles of hand (C6, C8, T1)
Ulnar
Intrinsic muscles of hand (C8, T1)
Long Thoracic
Serratus anterior
What are the LOAF muscles of the hand? Which nerve innervates them?
Lateral two umbricals
Opponens Pollis
Abductor policis brevis
Flexor policis brevis
Median nerve
Which nerve is tested when you trigger the triceps tendon?
Radial nerve
An, obese, moderate drinker (17 units a week) presents with mildly abnormal LFTs and increased hepatic echogenicity on US. What is the most likely diagnosis?
Non-alcoholic Fatty Liver Disease
(NAFLD)
Obesity with deranged LFTs suggests NAFLD. 17 units of alcohol is not significantly high
What blood tests are suggestive of active Hepatitis B infection?
HBsAg (surface antigen) positive suggests infection. First marker to appear. Appears as early as 1 week.
Anti HB positive suggests previous vaccination.
What is the best treatment of improving survival in COPD?
Long term oxygen therapy
What is the first line treatment for diabetic neuropathy pain?
Duloxetine
Inhibits reuptake of serotonin and noradrenaline which increases their pain suppression
What is the treatment approach for COPD?
1st line SABA or SAMA
2nd line add LABA + LAMA if non asthmatic features
If asthmatic features add LABA + ICS.
Theophylline, Mucolytics, Azithromicin, and PDE-4 inhibitors (reduce exacerbations) can also be added.
Annual flu vaccination
One off pneumococcal vaccination
A patient with cellulitis has a penicillin allergy, what would you treat him with?
Typically flucloxacillin is first line.
If penicillin allergy then Clarithromycin, Erythromycin, Doxycycline are good alternatives.
80% of vulval carcinomas are what type of cancer?
Squamous Cell Carcinoma
How do you differentiate strangulated and incarcerated femoral hernia?
Inferolateral to pubic tubercle = femoral hernia.
Incarcerated is non-reducible but patient is well
Strangulated is when the blood supply is compromised and the patient is sick with it.
What is the pathway of direct vs indirect inguinal hernias? Which is more common?
Direct goes directly through the posterior wall and out the superficial ring of the inguinal canal.
INdirect goes IN the deep ring and through the superficial ring of the inguinal canal. 2/3rds of inguinal hernias are indirect.
What feature of migrain is more common in children than in adults?
Gastrointestinal disturbance
What is the antibiotic treatment for GBS in pregnancy?
Intrapartum Benzylpenicillin
Clindamycin is an alternative.
True or false, vincristine (chemotherapy agent) is associated with peripheral neuropathy (tingling in peripheries) as well as urinary retention due to bladder atony?
True
Give a serious side effect of methotrexate
Myelosuppression
Liver / Lung fibrosis
Define menopause. How long does it last on average? What is the management?
Permanent cessation of menstruation for 12+ months. Symptoms last 2-5 years.
HRT - Combination therapy if still has a uterus (unopposed oestrogen increases risk of endometrial cancer).
If no uterus then oestrogen only therapy is fine.
How might you treat a woman going through menopause with flushes (vasomotor symptoms) if she does not want HRT?
SSRI e.g. fluoxetine
Weight loss, regular exercise and reduced stress are also advised.
What is the best test for asymptomatic H pylori?
13C Urea Breath Test
CLO test if symptomatic and doing a gastroscopy
Give two risks associated with HRT
Coronary Heart Disease
VTE risk
Stroke
Breast ca
Ovarian ca
Give two contraindications for HRT
Current/Prev breast ca
Oestrogen sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
How do you treat Hashimoto’s thyroiditis? What do you monitor to determine treatment success?
Autoimmune vs thyroid gland
Treat with Levothyroxine
Monitor TSH levels to ensure they are in normal range. This determines when the levothyroxine is at appropriate levels.
What is the treatment for Premature Ovarian Insufficiency?
Hormone Replacement Therapy / COCP until 51 (age of menopause).
Combined hormone therapy if has uterus as unopposed oestrogen increases risk of endometrial cancer.
Look for raised gonadotrophins e.g. FSH and low oestrogen on bloods. Bloods should be checked again 4-6 weeks apart.
If occus <40 years then the ovarian failure is “premature”. This occurs in 1% of women, and is mostly idiopathic.
How would you manage urge incontinence?
Bladder retraining for 6 weeks (aim is to increase time between voids).
Kegel exercises
Anti-muscarinics e.g. Oxybutynin, or Tolterodine
If elderly and concerned about ant-muscarinic side effects then Mirabegron (Beta-3 agonist).
What is the best prophylactic for cluster headaches?
Verapamil
True or false, antibiotic prophylaxis should be given for dental extractions in patients at risk of infective endocarditis?
False. No prophylaxis is given
What happends to body temperature during menstruation?
It is lower in the first stages of menstruation and rises following ovulation (due to rising progesterone levels).
What are the four stages of the menstrual cycle?
Mentruation 1-4
Follicular phae (proliferation) 5-13
Ovulation 14
Luteal (secretory phase) 15-28
What hormone spikes just before ovulation?
LH spike
(FHS rises modestly)
What happens to Oestrogen and Progesterone levels during the menstrual cycle?
Oestrogen (oestradiol) rises gradually up to ovulation which triggers the leutenising hormone spike and then oestrogen levels decrease.
Following ovulation progesterone is released by the corpus luteum (this causes increased body temperature and makes cervical mucus thick and tacky.
A well, 16 year old complains of knee pain, with locking and swelling at rest. What is the most likely diagnosis?
Why is it not Juvenile Idiopathic Arthritis, Osgood Schlatter, Osteosarcoma, or Chondromalacia patellae?
Osteochondritis dissecans
- Loose bone fragment in knee due to poor blood supply. Moves around under cartilage causing joint to lock, swell and be painful. Common in young active people. Mostly heals with rest.
JIA: Typically affects multiple joints, with morning stiffness which improves and systemic signs e.g. rash.
Osgood Schlatter: Inflammation at tibial tuberosity where patellar tendon attaches. No pain at rest. Sporty teenagers.
Osteosarcoma: Severe bone pain typically at night time. Associated with B symptoms/Red flags.
Chondromalacia patellae: ‘Grinding/clicking’ in the knee with quadriceps weakness. No locking or swelling.
True or false, patients with Fragile X syndrome tend to have smaller heads?
False. They tend to have larger heads.
What is microcephaly? Give 2 causes
Occipito-frontal head circumference <2nd percentile.
Congenital infection
Patau
Fetal alcohol syndrome
Family inheritance
Craniosynostosis (early fusion of bones of skull)
If a patient is not tolerating metformin due to gastrointestinal upset, what should you do?
Switch to modified release Metformin first before considering second line treatments.
Why are sulphonylureas like gliclazide and tolbutamide not first line treatments for T2DM?
Risk of Hypoglycemia and Weight gain
What is the mechanism of Metformin? What effect does it have on insulin sensivity, liver gluconeogenesis, and GI absorption of carbohydrate?
AMP-activated protein kinase (AMPK) activation
Increases insulin sensitivity
Decreases liver gluconeogenesis
Decreases GI absoption of carbohydrates
What renal function would lead you to change metformin dose?
EGFR <45 - Reduce
EGFR <30 - Stop
NB: GI side effects are common with metformin which is why you titrate the dose up. Lactic acidosis is a less common side effect.
True or false, gestational diabetes is treated with insulin in most cases?
False. Lifestyle change is the first line treatment in most cases.
True or false, gestational diabetes is associated with small babies?
False. It is associated with macrosomia (large for gestational age). Indeed, previous macrosomia is a risk factor for gestational diabetes.
True or false, certain ethnicities are more likely to develop gestational diabetes?
True. Afro-Caribbean and South asian are at higher risk.
What is the best test for gestational diabetes? What are the diagnostic levels?
Oral Glucose Tolerance Test (OGTT)
Fasted: > 5.6
2hr glucose: > 7.8
Drusen are associated with Dry or Wet macular degeneration?
Drusen = Dry (aka atrophic)
Drusen are yellow retinal deposits in Bruch’s membrane.
Optic disc cupping on fundoscopy is associated with which condition?
Glaucoma
A 70 year old patient complains of gradually worsening vision with flickering/glare around lights and worsening night vision (dark adaptation). What is this suggestive of?
Macular degeneration
fluctuating, gradually deteriorating vision, with poor dark adaptation. Can also present with Charles Bonnet hallucinations and photopsia (flickering lights).
A woman with cold sores, presents with a watery (epiphora), red eye and photophobia. You see a dendritic ulcer on examination. What is the probable diagnosis and treatment?
Herpes Simplex Keratitis
Topical Aciclovir Drops
Refer to ophthalmology urgently
Which cancers does the COCP increase and decrease the risk of?
Increases risk of:
Breast and Cervical cancer
Decreases risk of:
Ovarian and Endometrial cancer
What is Hoover’s sign?
A test for organic vs in-organic paresis.
If a patient claims right leg paresis. Perform a straight leg raise on the left leg with your hand under the heel of the right leg. If you feel pressure then it suggest the muscles of the right leg are operative and counterbalancing. This suggests a non-organic cause e.g. conversion.
What is Brudzinski’s sign?
When flexion of the neck induces flexion of the hips. This is suggestive of meningitis, encephalitis or Subarachnoid Haemorrhage .
What is the Meyerson’s sign aka Glabellar tap sign?
A test for Parkinsons.
Tap the glabellar region (between eye brows). Healthy individuals will blink for the first few times. If they are unable to resist blinking after this then it is suggestive of PD.
What is the Babinski sign?
UML test
Over 2yrs. Plantar stimulation should cause plantarflexion and curling of toes. If it causes dorsiflexion and extension of toes [Positive Babinski] it is suggestive of UML e.g. stroke.
In <2yr old Babinski is normally +Ve.
What is the Lasegue sign?
Test for disc herniation and radiculopathy.
If radiating leg pain can be induced by a straight leg raise then this suggests disc herniation as the cause.
A 75 year old attends your clinic with multiple, pink/brown, small crusty, skin lesions on his bald scalp, which have been there for over a year. What is the most likely diagnosis and treatment?
Actinic keratosis
AKA solar keratosis
Florouacil cream +-/ hydrocortisone cream for inflammation.
Topical imiquimod
Curettage / Cautery
How would you treat a UTI in a pregnant woman during the first trimester? What antibiotic should you avoid?
Nitrofurantoin (avoid at term) 7 days
Trimethoprim is contraindicated due to teratogenicity / neural tube defects.
When would you send a urine culture in a UTI case?
Pregnancy
Male
Haematuria
>65 years old
How long do you treat uncomplicated UTI in women and in men?
Women 3 days
Men 7 days
What is the treatment for acute pyelonephritis?
Cefalexin 7-10 days PO
If unable to tolerate e.g. vomiting or severe illness then IV Cefuroxime
Co-amoxiclav is only advised if you have culture results.
True or false, you should treat all cases of asymptomatic bacteruria in catherised patients?
False. Don’t treat it if they are asymptomatic.
How would you investigate Grave’s thyrotoxicosis? What would you see on the results?
TSH Low
T4 / T4 Raised
TSH receptor Autoantibodies +Ve
What is De Quervain’s Thyroiditis?
Subacute thyroiditis commonly caused by certain infections. Lasts for several weeks.
Triphasic - Presents with temporarily rasied thyroid levels then low levels then they normalise.
What is Courvoisier’s sign?
Painless, Palpable gall bladder with jaundice.
Unlikely to be gall stones. Likely to be pancreatic or biliary tree cancer.
What are normal and abnormal fasting glucose levels?
Normal = < 5.6
Pre-diabetic = 5.6 - 6.9
Diabetic = > 7
What is Whipple’s resection?
Removal of pancreas and duodenum. Mostly often due to pancreatic cancer. 80% of which affect the head of the pancreas.
What is the gold standard diagnostic test for coeliacs?
Intestinal Tissue Biopsy
Following a positive Anti Tissue Transglutaminase (Anti TTG) and IgA serology.
What skin condition is associated with coeliacs? How is it investigated and treated?
Dermatitis Herpetiformis - caused by IgA deposition in the dermis. Extensor surfaces e.g. knees, elbows. Vesicular, itchy.
Skin biopsy
Gluten free diet
Dapsone
A patient presents with flakey, scaley kin lesions around his eyes, nasolabial folds and on his scalp. What is the most likely diagnosis?
Seborrhoeic Dermatitis
Caused by a fungus (Malassezia furfur)
Treated with Head and Shoulders or Neutrogena shampoos [1st line].
Second line is topical ketoconazole
Risk factors associated HIV and Parkinsons.
What pathogen causes Hand Foot and Mouth disease?
How does it typically present?
Coxsackie A16
Sore throat, fever, vesicular rash on palms and soles.
What pathogen causes Slapped Cheek or Fifth’s disease?
Parvovirus B19
What causes scarlet fever? What is the treatment?
Group A Haemolytic Strep
Strawberry tongue and rash
Penicillin 10 days.
A child presents with watery, red eyes, fever and white spots on the buccal mucosa and a rash which starts behind the ears and progresses to the body. What is the likely diagnosis?
Measles
Koplik spots are a key feature
What is the order of lesion evolution for chicken pox?
Macular –> Paupular –> Vesicles
Incubation is around 2 weeks.
A patient presents with discoid rash, fatigue, arthralgia, malar rash, photosensitivity. They have normal CRP and raised ESR. What is the likely diagnosis?
SLE
What is Dupuytren’s Contracture? How does it present? how is it treated?
Thickening of the palmar aponeurosis. Causes moderate flexion of the medial digits. No sensory or motor component.
Consider surgical management if hand cannot be extended fully e.g. placed flat on a table.
A well 34yo male presents with left flank pain radiating to groin. Systemically well but appears sweaty. What is the diagnosis? How do you investigate? What is the management?
Renal colic
Non-contrast CT KUB within 14hrs.
Diclofenac 75mg IM
Stone <5mm expectant will pass in 4 weeks
Stone >5mm Lithotripsy
If pregnant then Ureteroscopy
If staghorn calculi or complex renal calculi then Percutaneous Nephrolithotomy.
What constitutes blindness on the Snellen chart?
<3/60 while wearing prescribed glasses.
What spirometry results indicate COPD? What are the stages?
FEV1/FVC ratio <0.70
FEV1 >80 = Mild (Stage 1)
FEV1 50 - 79 = Moderate (Stage 2)
FEV1 30 - 49 = Severe (Stage 3)
FEV1 <30 = Very Severe (Stage 4)
True or false, pulomonary fibrosis is an obstructive condition? What would you expect to see on Spirometry?
False. It i restrictive.
Expect FEV1/FVC >0.7
But FEV1 and FVC to be <0.80 of predicted
Give two examples of Obstructive and Restrictive lung disease?
Obstructive:
- COPD
- Bronchiectasis
- Emphysema
- Asthma
Restrictive
- Pulmonary Fibrosis
- Pulmonary Oedema
- Pneumoconiosis
How do you test reversibility for asthma?
400mcg Salbutamol with a repeat 15minutes later. If 12% improvement in FEV1 or FVC.
What would you expect to see on an ECG of a patient with pericarditis? How would you exclude myocarditis? What is the treatment?
Global ST and PR changes across ECG
Saddle ST elevation
PR depression (most specific sign)
Troponin should be normal in pericarditis and raised in Myocarditits.
Treatment for pericarditis is NSAID + Colchicine.
What is the most common viral cause of pericarditis? Give another cause
Coxsackie
Radiotherapy
Trauma
SLE
TB
MI (Dressler Syndrome)
What is Dressler Syndrome?
Pericarditis 1-3 days post MI
True or false, alcohol is a commom trigger of cluster headaches?
True
NB: They are more common in men and smokers.
True or false, aspirin is contraindicated in breast feeding?
True. Risk of Reye’s syndrome.
Other contraindications:
ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
lithium,
benzodiazepines
Clozapine
carbimazole
methotrexate
sulfonylureas
cytotoxic drugs
amiodarone
True or false, vision and hearing problems are common in Down’s Syndrome?
True.
Cataracts
Glaucoma
Blepharitis
Strabismus
Otitis media
Glue ear (otitis media + effusion)
What is Chancroid?
Tropical disease. Genital ulcer with ragged border. Caused by Haemophilus ducreyi. Treated with azithromycin, ceftriaxone, ciprofloxacin etc.
A woman presents with foul smelling vaginal discharge (yellow green) after intercourse 1 week earlier. What is the likely diagnosis?
What is the treatment?
Trichomonas vaginalis, a sexually-transmitted disease classically causing offensive vaginal discharge, dysuria and vulval itching. Speculum examination may reveal a ‘strawberry cervix’ caused by multiple punctate haemorrhages of the cervix.
Treatment is metronidazole 5-7 days.
A young boy is noted to have learning difficulties, macrocephaly, large ears and macro-orchidism - what is the diagnosis?
Fragile X
A child presents with severe congenital malformations including microcephaly, cleft lip/palate, polydactyly, cardiac defects and severe intellectual disability. What is the likely genetic disorder?
Patau (Trisomy 13)
A child presents with a triad of micrognathia (small lower jaw), glossoptosis (downward displacement or retraction of the tongue) and airway obstruction, what is the likely genetic disorder?
Pierre Robin Syndrome
A child presents with growth retardation, severe intellectual disability, microcephaly, overlapping fingers, rocker-bottom feet, congenital heart disease and other anomalies. What is the likely genetic disorder?
Edward’s Syndrome (Trisomy 18)
A child presents with,
Webbed neck
Pectus excavatum
Short stature
Pulmonary stenosis.
What is the likely genetic condition?
Noonan Syndrome
A child presents with
Short stature
Learning difficulties
Friendly, extrovert personality
Transient neonatal hypercalcaemia
Supravalvular aortic stenosis
What is the likely genetic condition?
William’s Syndrome
Which heart murmus is associated with Turner’s syndrome? (45XO)
Ejection systolic murmur
Due to bicuspid aortic valve
Female with missing second sex chromosome.
A child presents with strange cry due to larynx and neurological problems
Feeding difficulties and poor weight gain
Learning difficulties
Microcephaly and micrognathism
Hypertelorism (increased distance between body parts e.g. eyes).
What is the likely genetic condition?
Cri du chat
(Chromosome 5p deletion)
True or false, SSRIs are associated with hyponatraemia?
True
True or false, antidepressants should be continued for 6 months after symptom resolution to reduce risk of relapse?
True
True or false, SSRIs can increase the risk of congenital heart defects if used during pregnancy?
True. In the first trimester. However, SSRIs are still used in pregnancy with caution.
What is the most common cause of sudden, painless loss of vision in patient’s with Marfan’s syndrome?
Lens dislocation
A patient requires emergency contraception. They have asthma. She doesnt want a coil. Which of Levonorgestrel or Ullipristal (EllaOne) should she be given?
Levonorgestrel is better (must be taken within 3 days (72hrs)
EllaOne can exacerbate asthma.
Must be taken within 5 days (120hrs).
The IUD can also be used. Must be given within 5 days or 5 days after the likely ovulation date.
In a child 5-16yo with asthma. If SABA, LTRA and Low dose ICS arent working, what do you do?
Stop LTRA and trial LABA e.g. salmeterol.
If that doesnt work, swap the (ICS+LABA) for MART (maintenenace and reliever e.g. Fostair, or Symbicort).
If that doesnt work then switch the MART to moderate steroid MART and then high dose steroid MART.
An 8-year-old boy who is known to have asthma is reviewed. His current treatment is a salbutamol inhaler as required and beclometasone inhaler 100mcg bd. Despite this, he regularly requires salbutamol for exacerbations and suffers with a night time cough.
Following NICE guidance, what is the most appropriate next step in management?
Trial LTRA
True or false, rheumatoid factor is associated with a worse prognosis and more severe form of rheumatoid arthritis?
True
What is a serious complication of Kawasaki disease? What investigation must you therefore do?
Coronary Artery Aneurysm
Echocardiogram
How do you treat hypoglycemia in the conscious and unconscious patient?
Conscious and alert then oral glucogel.
Unconscious or not able to tolerate oral medication. Then IM glucagon or IV 20% Glucose.
What is Kawasaki disease? How is it managed?
Vasculitis presenting with:
High-grade fever which lasts for > 5 days. Fever is characteristically resistant to antipyretics
conjunctival injection
bright red, cracked lips
strawberry tongue
cervical lymphadenopathy
red palms of the hands and the soles of the feet which later peel
Treatment is high dose aspirin (one of the few indications for use of aspirin in children <16)
IV immunoglobulin.
It is importantto do an echocardiogram to rule out coronary artery aneurysm!
How do you manage SVT?
Vagal maneuvers
IV bolus Adenosine 6mg then 12mg then 18mg.
SVT characterised by sudden onset narrow complex tachycardia.
Which virus causes shingles? What is the treatment? What time-frame should it be treated?
Varicella Zoster
Oral antiviral e.g. oral famciclovir within 72hrs of start.
Remain infective until crusted over. Typically in 5 days.
A 5 year old presents with a limp. An Xray shows widening of the joint space, and flattening of the femoral head. What is the most likely diagnosis?
Perthes disease
Common 4-8 years old
Avascular necrosis of the femoral head, resulting in widening of the joint space and flattening of the femoral head on X-Ray.
It is 5x more common in boys.
A 5 year old child, has had a recent viral infection and is now complaining of unilateral hip pain. What is the most likely diagnosis?
Transient Synovitis
The most common hip problem in children. Common ages 2-10.
Typically presents after a viral infection.
An obese 10 year old presents with unilateral hip pain and reduced internal rotation of the hip in flexion. What is the most likely diagnosis?
Slipped Upper Femoral Epiphysis
A 15 year old presents with 3 joint pains which have lasted 5 months. What is the likely diagnosis?
Juvenile Idiopathic Arthritis
Typically multiple joints affected.
Must be <16 years old
JIA is associated with anterior uveitis
What secondary prevention treatment would you give a patient who has had a stroke (ischaemic)?
Aspirin 300mg
Clopidogrel
Statin (if Cholesterol >3.5)
Thrombolysis if within 4.5hrs and not contraindicated.
What is the difference between Bouchard’s and Heberden’s nodes? What condition are they associated with?
Osteoarthritis
Bouchard’s affect proximal IPJs
Heberden’s affect distal IPJs
What is the time window for thrombolysis for stroke?
Give two contraindications
4.5 hrs from onset give Alteplase or Tenecteplase
Pregnancy
Active bleeding
LP in last 7 days
Prev ICH
Seizure at onset of stroke
Intracranial Neoplasm
Uncontrolled HTN >200
Oesophageal varices
Stroke in prev 3 months
Traumatic brain injury in prev 3 months
What are the treatment doses for suspected meningococcal rash in children?
<1yr 300 mg Benzylpenicillin IM
1-10 600 mg Benzylpenicillin IM
>10 yrs 1.2 g Benzylpenicillin IM
True or false, morning stiffness which improves through the day is associated with Osteoarthritis?
False. Morning stiffness which improves is typical of rheumatoid arthritis.
How long should a patient be put on anticoagulants following a provoked or unprovoked VTE?
DOAC (Apixaban or Rivaroxaban) for 3 months if provoked.
3-6 months if provoked by cancer.
6 months if unprovoked. Then reassessed as to whether to continue for life.
When is it appropriate to use rapid tranquilisation?
If restraint is required for more than 10 minutes and the patient is a risk to themselves or others.
When would it be appropriate to refer a patient with T2DM for bariatric surgery?
If their BMI is >35 kg/m2
If a patient is not responding to metformin or gliclazide, what is the next step?
Pioglitazone
DPP-4 Inhibitor
SGLT-2 Inhibitor
You start with metformin + lifestyle. At this point the target is Hba1c of <48 mmol/mol (<6.5%)
Only add a second drug e.g. gliclazide (sulfonylurea) if Hba1c rises above 58 (7.5%). Then the target is 53mmol/mol (7.0%) as there is an increased risk of rebound hypoglycemia.
Hba1c should be reviewed every 3-6 months until stable then every 6 months.
A patient with T2DM who is on metformin has a QRisk of 15%. What is the best additional antidiabetic medication to add?
SGLT-2 inhibitor e.g. Dapagliflozin.
These are the best choice if the patient has a raised risk of CVD or existing CVD history. QRisk >10% would indicate this.
True or false, metofrmin should be titrated?
True. To reduce risk of GI distubance.
A patient has a Qrisk of 15%, what would be your initial treatment?
Artovastatin 20mg ON
How do you manage TIA/Stroke?
Thrombolysis within 4.5hrs if CT rules out haemorrhagic stroke.
If low risk ABCD 3 or less.
Aspirin 300mg OD 14days
Atorvastatin 40mg OD on-going
Clopidogrel 75mg OD to replace aspirin after 14 days and given life-long.
If high risk ABCS 4-7.
Immediate Clopidogrel 600mg + Aspirin 300mg.
Dual Antiplatelet Therapy (DAPT) of Clopidogrel 75mg and Aspirin 75mg OD for 21 days. Then Clopidogrel only 75mg OD on-going.
Atorvastatin 40mg OD on-going.
ACEi +/- Thiazide diuretic to lower blood pressureto < 130/80
What is the first line antihypertensive used in T2DM?
ACEi
ARB if Black/Afrocaribbean
Target:
140/90 (<80yrs)
150/90 (>80yrs)
What is the treatment for listerosis in pregnancy?
Ampicillin or penicillin G and gentamicin.
Listerosis is 20x more common in pregnancy
How do you diagnose listeria in pregnancy?
Bloods test for listeria IgM
NB Listeria is Gram +ve
Differentiate the following:
Gallstone ileus
Ascending Cholangitis
Biliary Colic
Acute Cholecystitis
Acute Pancreatitis
Pancreatic Cancer
Ascending cholangitis typically triad of RUQ pain, Jaundice and Fever (Charcot’s Triad)
Gallstone ileus typically presents with abdominal distension as it is an obstruction.
Pancreatic cancer presents as a painless jaundice typically.
Acute pancreatitis presents as severe epigastric pain with vomiting.
Biliary Colic presents as on/off RUQ pain related to eating.
Acute Cholecystitis is similar to biliary colic but is more persistent and often radiates to shoulder.
How do you differentiate cephalohaematoma from subgaleal bleeds or caput succedaneum?
Cephalohaematoma is a bleed/swelling on a baby’s head secondary to labour/extraction with forceps. Typically on the parietal bone. Unlike the others, it does not cross suture lines. It can take months to resolve.
What cancer is common in patients who have had renal transplant and why?
Squamous Cell Carcinoma
Immunosuppression and sun exposure.
True or false, cushing’s is associated with Hyperkalaemic, metabolic acidosis?
False.
HypOkalaemic, metabolic acidosis.
What is the gold standard test for Cushing’s?
Low-Dose Dexamethasone Suppression test.
In patients with Cushing’s their Cortisol spike in the morning is not suppressed by Dexamethasone.
A woman has a +ve HPV smear result and shows dyskariosis on examination? What is the next step?
Colposcopy referral
Any woman with an abnormal cytology and +ve HPV should be referred.
If the smear was inconclusive then a repeat should be offered in 3 months.
If the smear was +ve but cytology is normal then repeat screen in 12 months.
True or false, infertility is the most common complication of PID or Gonorrhoea infection
True
What pathogen causes Gonorrhoea? What is the investigation? What is the treatment?
Gram-negative diplococcus Neisseria gonorrhoeae.
Nucleic Acid Amplification Test (NAAT) or by Culture (swab/MSU)
IM Ceftriaxone (due to increased resistance)
PO Cefixime or Azithromicin if needle-phobic.
Which antibody test is done for Sjogren’s? What is a treatment?
Anti-Ro
Artificial tears
Pilocapine (may increase saliva)
What is the treatment for CIN? When should a follow up test of cure (TOC) screen be done?
Cervical Intraepithelial Neoplasia
CIN1 - <1/3 thickness of epithelium
CIN2 - 1/3 to 2/3rd thickness
CIN3 - >2/3rd thickness
Large LoopExcision of Transformational Zone (LLETZ) is the standard treatment.
TOC review 6 months after.
What is the test for scleroderma?
ANA (Antinuclear Antibody) Test
What is Schirmer’s test?
Test in Sjogren’s (lymphocytic infiltration of exocrine glands)
Dry mouth
Dry eyes
Arthralgia
Vaginal dryness
Filter paper to conjunctiva to assess tear production
What would you expect to see on blood screening for sarcoidosis?
Elevated ACE
Elevated Calcium
Low WCC
SOB and persistently dry cough
Bilateral hilar lymphadenopathy is most common XR finding.
When is cervical smear screening done?
6 months before turn 25
25 - 49 every 3 years
50 - 64 every 5 years
65+ only if recently abnormal test
What is the risk of unopposed oestrogen in HRT?
Endometrial cancer
Differentiate these strokes:
Lacunar
Posterior Circulation
Total Anterior Circulation
Partial Anterior Circulation
Lacunar: Pure sensory, Pure motor or mixed sensory/motor only.
Posterior Circulation: LOC, Cerebellar/Brain stem signs, isolated Hononymous Hemianopia.
Total Anterior: Unilateral weakness of face, arm, legs, Homonymous Hemianopia, higher cerebral signs.
Partial Anterior: 2 of the above for Total.
NB: Higher cortical signs e.g. aphasia, agnosia, neglect, apraxia, or hemianopsia
What is homonymous hemianopia?
Loss of the same hemifield of vision in each eye.
Which pituitary hormone increases signalling menopause?
FSH
What is Argyll-Robertson Pupil response? What is the most common cause in the UK? What is a serious alternative cause?
Accommodation reflex present e.g. constricts on near vision.
Pupil reflec to light not present i.e. no change with light exposure.
Most common in Diabetes
Classically found in Neurosyphylis!
What nerve is affected in Bell’s palsy? What is the treatment? What is the recovery time?
7th cranial nerve
Prednisolone
4 months
NB: 15% have residual weakness if not treated.
If no improvement after 3 weeks of treatment then refer to ENT
Cause unknown. ? Herpes simplex
How does bacterial vaginosis present? What is the treatment?
Amsel’s criteria:
Thin, white discharge
Clue cells on microscopy: stippled Vaginal epithelial cells
pH > 4.5
Positive whiff test (addition of potassium hydroxide results in fishy odour)
PO Metronidazole
If aspirin and clopidogrel are contraindicated, what antiplatelet could you give for a stroke patient?
Modified Release Dipyridamole
What vaginal infection is associated with Clue cells on mincroscopy?
Bacterial Vaginosis
Green vaginal discharge with ‘strawberry cervix’ suggests what diagnosis? What is the treatment?
Trichomonas vaginalis
Oral metronidazole
What is the treatmentfor gonorrhoea?
IM ceftriaxone 1g single dose
A pregnant woman develops an itchy rash and stretch marks over her abdomen during her third trimester. What is the likely diagnosis?
Polymorphic eruption of pregnancy. No treatment is needed.
A woman presents with cottage cheese discharge, vulvitis, and itch? What is the likely diagnosis and treatment?
Vaginal candidiasis
Oral Fluconazole
True or false, all oral antiglycemics should be continued around surgery?
True
Surgical patients may consume clear fluids up to 2 hrs prior to the operation. True or false, the following count as clear fluids: water, fruit juice without pulp, coffee or tea without milk and ice lollies?
True
True or false, depression is the most common mental health disorder associated with Parkinsons?
True. Occurs in ~40%
A 3 yr old with known eczema attends GP clinic with worsening rash spreading around his body (monomorphic punched-out erosions (circular, depressed, ulcerated lesions) usually 1–3 mm in diameter), is not himself and has a temperatureof 39. What do you do?
Refer to hospital.
Sounds like Eczema herpeticum which is potentially life threatening and requires IV aciclovir. This is an HSV 1 or 2 infection which can take hold in patients with eczema.
A patient presents with fever, confusion, headache, vomiting and seizure. CSF shows raised lymphocytes, raised protein and normal glucose. What is the likely diagnosis? What treatment should be started?
Viral encephalitis
95% of encephalitis is caused by Herpes Simplex Virus
IV aciclovir
What is the triad of Parkinson’s features?
Bradykinesia
Rigidity (Lead pipe rigidity or Cogwheel rigidity)
Resting Tremor (pill-rolling; 3-5 Hz)
True or false, quinine can cause tinnitus?
True
What is the first line treatment for Parkinsons? How is it diagnosed?
What would you see in the substantia nigra?
Levodopa
Diagnosed clinically. However, if unclear then SPECT can be done.
Lewy Bodies (made of alpha synuclein)
What is pyoderma gangrenosum?
A rare skin ulceration on the lower legs associated with Ulcerative Colitis. Oral steroids is first line or other immune suppression.
What is the difference between Lichen planus and lichen sclerosis?
Lichen planus is a purpuric, polygonal rash on flexor surfaces, genitals and oral mucosa.
Liceh sclerosis affects older women and men and involves white patches on the vulva or penis.
A 34-year-old man presents with an itchy rash on his genitals and palms. He has also noticed the rash around the site of a recent scar on his forearm. Examination reveals papules with a white-lace pattern on the surface. What is the diagnosis? How is it treated
Lichen Planus
Planus: purple, pruritic, papular, polygonal rash on flexor surfaces. Wickham’s striae (white lines) over surface. Oral involvement common
Koebner’s phenomenon is a rash caused by skin injury.
Oral steroids
True or fale, scabies is most itchy at night time? What is the treatment
True.
Sarcoptes scabiei
Trail burrows often inbetween webbed spaces of hands.
Permethrin cream
A self-limiting rash thought to be viral in origin. The initial presentation is often a single pink or red oval ‘herald patch’, followed by the development of smaller similar lesions arranged along skin cleavage lines creating a ‘Christmas tree’ pattern on the trunk. What does this describe?
Pityriasis rosea
Of Anti HBs and HBsAg which implies seroconversion i.e immunity and which implies active infection
Anti HBs = immunity
HBsAg = active infection
‘HBs what a breeze, HBSag what a drag!’
Teue or false, back pain in <20 year old is a red flag?
True
Back pain Red Flags :
<20 or >50
Previous malignancy
Systemically unwell
Trauma
Night pain
A 30 year old presents with back pain described as ‘aching/crawling’ which affects both legs and is made worse by walking and better by crouching or sitting down. Clinical examination is otherwise normal. What does this suggest?
Spinal stenosis
Needs an MRI
How do hormonal contraceptives work?
COCP / Oestrogen inhibit oulation
Progesterone thickens cervical mucus
What is the gold standard test for renal colic?
Non-contrast CT KUB
What are the centor criteria?
Tonsillar exudate
No cough
Fever
Tender anterior lymph nodes
Indicate likelihood of Strep throat
How do you manage acute and chronic anal fissures?
Acute <1wk:
- Stool softener e.g. lactulose
- Topical numbing agent
Chronic >1wk:
Topical GTN
If no improvement in 8 weeks refer to secondary care
True or false, whooping cough is worse at night? What is the treatment?
True.
(Bordatella pertussis)
Inspiratory whoop
Coughing fits +/- cyanosis
Post-tussis vomits
PO Azithromycin
What vitamins are supplemented for pregnant women?
Daily
Folic acid 400mcg
VitD 10 mcg
Which nerve impairment commonly causes foot drop?
Common peroneal nerve
Which hepatobiliary disorder is associated with Ulcerative Colitis?
Primary Sclerosing Cholangitis
Give two differences between Ulcerative Colitis and Crohn’s.True
UC:
Bloody Diarrhoea
Ileocecal - Anus
LLQ pain
Tenesmus
Assoc. Primary Sclerosing Cholangitis
Crypt abscesses
Decreased Goblet cells
Crohn’s:
Non bloody diarrhoea
Mouth - Anus
RLQ mass
Assoc. Gallstones
Cobblestone appearance
Skip lesions
Full thickness mucosa - serosa
True or false, splenectomy extends the lifespan of RBCs and gives and artificially high Hba1c reading as a consequence?
True
Iron Deficiency Anaemia
B12/Folate deficiency
Also do the same.
The following decrease RBC life span and decrease Hba1c:
- Sickle-cell anaemia
- GP6D deficiency
- Hereditary spherocytosis
- Haemodialysis
What is acanthosis nigrans? What is it associated with?
Velvety dark patches typically under the arms and neck.
Associated with diabetes, cushing’s but can also suggest internal malignancy especially gastric cancer.
What is the first line treatment for Grave’s? What is the major concern with this drug?
Carbimazole 40mg which is reduced gradually over time
Propranolol canalso begiven for symptom control e.g. anxiety
The major concern with Carbimazole is agranulocytosis.
True or false, omeprazole reduces the efficacy of clopidogrel?
True. Both use the same metabolic pathway in the liver.
What is the treatment for community acquired pneumonia, atypical pneumonia, hospital acquired pneumonia?
CAP: Amoxicillin (/Doxycycline)
Atypical: Clarithromycin
HAP: <5d of admission Co-amox
>5d of admission Pip/Taz
An acutely unwell patient with pancreatitis has deranged clotting suddenly and low platelets.You find Schistocytes on his blood film. What is the diagnosis?
Disseminated Intravascular Coagulopathy (DIC)
A procoagulation state secondary to acute stress on the body e.g. severe illness. Schistocytes are formed due to the microangiopathic haemolytic anaemia.
Treatment is fix the cause e.g. antibiotics for infection. Clotting factor/platelet replacement.
What is the test for C difficile? What is the treatment?
GDH antigen stool test
If antigen +ve and toxin +ve then confirms c diff.
If antigen +ve but toxin -ve then c diff is unlikely to be the cause
First case = Oral Vancomycin 125mg QDS for mild moderate and severe cases 10 days.
Repeat case then Fidaxomycin
What is the antibiotic treatment for Acute pyelonephritis?
Cephalosporins
What is theantibiotic treatment for dental abscess and gingervitis?
Dental abscess Amoxicillin
Gingervitis Metronidazole
What is the antibiotic treatment for most skin infections? Give an exception
Flucloxacillin
Animal bites: co-amoxiclav
Cellulitis near eyes/nose: Coamoxiclav
What is the antibiotic of choice for throat or sinus infections?
Phenoxymethylpenicillin (erythromycin if allergic)
What is thetreatmentfor bacterial vaginosis?
Metronidazole
What is the antibiotic treatment for Gonorrhoea or Chlamydia?
Gonorrhoea IM ceftriaxone
Chlamydia Doxycycline or Azithromycin
What is theantibiotic treatment for PID?
Ofloxacin + metronidazole
What is theantibiotic treatmnet for prostatitis?
Quinolone or Trimethoprim
What is the treatmentfor Syphilis if the patient is allergic to penicillin?
Normally benzathine benzylpenicillin
But as penicillin allergic, doxycycline or erythromycin.
True or false, erythema migrans - the bull’s eye rash associated with lyme’s disease is itchy?
False. It is non-itchy.
A patient presents with progressive night blindness and tunnel vision. Fundoscopy shows black bone spicule-shaped pigmentation in the peripheral retina, and mottling of the retinal pigment epithelium. What is the diagnosis?
Retinitis pigmentosa
Typically presents with night blindness first then tunneling of vision.
Glaucoma can present with tunnel vision but is not associated with night blindness.
True or false, furosemide can increase the risk of gout?
True
True or false, carbimazole is associated with erythema multiforme?
Tue.
Erythema multiforme is a hypersensitivity reaction associated with infection and some drugs. It causes a pruritic rash over the body + palms. Starts on the back of the hands typically and then spreads to the body.
True or false, William’s syndrome is associated with which valvular defect?
Aortic Stenosis
Which bacterium is associated with severe vomiting after ingestion of contaminated food and can come on as quickly as 30 minutes?
Staphylococcus aureus
Very short incubation
Severe vomits
Resolves in 1-2 days
No diarrhoea typically
What is a neurological complication associated with campylobacter infection?
Guillaine Barre Syndrome
NB: Campylobacter presents typically with a flu-like prodrome and can mimic appendicitis
Which two bacterial gastroenteritis infections are the fastest incubation?
Bacillus cerrus (associated with rice; 1-6 hrs)
Staph aureus (30mins - 6hrs)
Severe vomiting.
When do you give fibrinolysis in STEMI?
Within 12 hrs of onset if PCI cannot be done within 120 minutes.
What is ACS management?
Morphine
GTN
Oxygen if <94%
Aspirin 300mg
Dual antiplatelet with Clopidogrel if on anticoagulant or prasugrel if not.
PCI within 2 hours (120mins)
Fibrinolysis e.g. alteplase if PCI not possible in 2hrs and within 12hrs of start.
Fondaparinux if no bleeding risk
What is the GRACE score?
6 month mortality following ACS
<3% Low risk
>3% High risk
What is the first line antihypertensive in patients over 55yrs or black/afrocaribbean?
Calcium Channel Blockers
or Thiazide diuretics
When would you treat hypertension?
> 135BP ABPM / >140clinical
<80 years old
> 150 systolic in any age
1st line ACEi/ARB if <55 and not Afrocaribbean
If >55 or Afrocaribbean then CCB or Thiazide diuretic
What is Sheehan’s syndrome?
Post partum hypopituitarism
Amenorrhoea
Hypothyroidism
Milk production issues
What are the stages of hypertension?
Stage 1 - 140 - 160
Stage 2 - 160 - 180
Crisis 180+
A patient with MS is experiencing muscle spasms and cramps. What is the firstline treatmnet?
Baclofen (+/- gabapentin)
Dantrolene can be used for MS spasticity if Baclofen fails. Dantrolene is hepatotoxic so it is avoided as a first line.
Gabapentin is great for oscillopsia in MS
A patient presents with bone weakness, low Vit D, low phosphate and raised ALP. What does this suggest?
Osteomalacia
You may also see transverse bands called Looser’s bands on XR
What is Section 17a?
Community Treatment Order
Under mentalhealth act, gives the power to treat in community or recall to hospital for up to 72 hours for treatment if the patient is not complying with medication.
What is the CURB score?
Confusion
Urea >7mmol/L
Resp Rate >30/min
BP <90 systolic
>65 years old
1-2 moderate risk,consider hospital
3-4 high risk; hospital assessment
What is the treatment for heart failure?
First line: (start one at a time)
ACEi (1st; regardless of age)
Beta Blocker Nebivolol, carvediolol, bisoprolol
Second line:
Spironolactone or eplerenone.
SGLT-2 inhibitors e.g. empagliflozin
Third line:
Sacubatril valsartan
Digoxin
Hydralazine
True or false, a patient who is on long-term prednisolone should be on Hydrocortisone during surgery?
True.
Local procedure: none required.
Moderate procedure: 50mg hydrocortisone before induction and 25mg every 8h for 24h
Major surgery: 100mg hydrocortisone before induction and 50mg every 8h for 24h, thereafter halving dose every 24h until maintenance dose reached.
Why is eplerenone preferred to spironolactone in heart failure treatment?
Selective mineral corticoid receptor antagonist which has less hormonal effects (gynecomastia, mastodynia etc) than spironolactone.
Whatis sick euthyroid syndrome?
Non-thyroidal illness. Unwell patients, or elderly patients may present with low/normal TSH, or low T4, T3. This typically recovers on its own. Repeat tests in 6 weeks are advised. No treatment is given typically.
True or false, in X-linked recessive conditions only males are affected?
True.
There can be no male to male transmission.
True or false, first degree heart block is a normal ECG finding in an athlete?
True. Prolonged PR intervals can be normal.
Which nerve is affected by meralgia paraesthetica?
Lateral cutaneous nerve
A patient presents with a long-term dry cough with erythema nodosum (erythemaous pretibial nodules) on his shin. What is the likely diagnosis?
Sarcoidosis
Ho do you treat Gout?
Colchicine + NSAID cover e.g. diclofenac.
Commence allopurinol (urate lowering medication) after the first attack. Don’t start it for 14 days / 2 weeks or until pain has settled as it can precipitate another attack! The patient then continues on allopurinol.
True or false, pleural plaques are a benign feature of asbestosis affected lungs and do not require monitoring or follow up?
True.
A patient presents with syncope, angina, and dyspnoea on exertion. They have a crescendo-decrescendo, ejection systolic murmur in the 2nd intercostal space. They have a narrow pulse pressure. What is the condition?
Aortic stenosis
‘SAD’
Syncope
Angina
Dyspnoea on exertion
What is the treatment fo acne rosacea?
Normally conservative but ivermectin can be applied to pustules if bothersome.
No known cause of acne rosacea. Typically affects nose and cheeks.
What is Corrigan’s sign?
Aortic Regurgitation
Sharp upstroke with slow collapsing downstroke
True or false, steroids increase risk of cataracts?
True
What is Cataplexy?
Sudden loss of muscular tone in response to high emotion e.g. laughing or stress. Ranges from buckling knees to full collapse.
2/3rd of narcoleptics have cataplexy.
True or false, amiodarone increases risk of corneal opacities and optic neuritis?
True
True or false, patients over 75 years old who have sustained a fragility fracture (e.g. a fall at home), should be commenced on alendronic acid.
True.
Don’t need a DEXA scan for this.
If they are under 75 then a DEXA scan is needed.
True or false, BRCA2 gene increases risk of ovarian cancer?
True. Increases risk of breast and ovarian cancer.
When would you give Varicella Zoster Immunoglobulin (VZIG)?
Immunocompromised, neonates, pregnant women exposed to chickenpox who have no immunity. Serology checks should be done to check for immunity.
VZIG should be given within 10 days.
Close contact is direct contact or +15mins contact time.
What is the treatment for acute dystonic reaction?
Procyclidine
What is the treatment for serotonin syndrome?
Benzodizepines or cyproheptadine
A 29-year-old female patient presents to the GP surgery with a 3-day history of left eye redness and a sensation of grittiness and the feeling of a foreign body in the left eye. She also admits to having significant photophobia and watering eye. She has a history of contact lens use. What is the likely diagnosis?
Keratitis
Typically presents with grittiness, red, watery eye and photophobia.
Typically bacterial infection with staph aureus, but can be viral e.g. herpes simplex
If contact lens wearer then refer to eye specialist
What is the difference between primary and secondary dysmenorrhoea?
Primary = no underlying pelvic pathology. Just pain associated with periods. Typically due to excessive endometrial prostaglandins. NSAID (1st line) / COCP (2nd line)
Secondary: Underlying pelvic pathology e.g. endometriosis, adenomyosis, PID, Fibroids, IUD.
Whatis adenomyosis?
Invasion of endometrial tissue into the myometrium. Can be a cause of secondary dysmenorrhoea.
A 66yo patient presents with pain in her neck and loss of dexterity in her hands. What is the likely diagnosis and next step?
Refer to spinal surgical team + MRI
? Degenerative Cervical Myelopathy (DCM)
A diabetic patient presents with signs of sepsis and bilateral lower limb neurological findings. What is the likely diagnosis?
Lumbar Epidural Abscess
More common in diabetes. Presents as a septic patient with lower limb neurological issues. Inflammation of the spinal cord causes cada equina presentation. This can also be a complication of discitis (infection of vertebral discs).
What qualifies as premature menopause?
Irregular menstrual cycle
<45yrs
Raised FSH/LH
Low oestradiol
What is the most common cause of cyanotic congenital heart disease in neonates? What are its core features?
Tetralogy of Fallot
Overriding aorta
Pulmonary stenosis
Right ventricular hypertrophy
VSD
Causes right to left shunt, cyanosis and tet spells (suddenly turn blue or faint).
Transposition of the great arteries is another cyanotic congenital heart disease
What is the treatment for patent ductus arteriosus?
NSAID or cardiac catheterisation
Which HPV viruses are most linked to cancer? Who is offered vaccination and when?
12 & 13 year old girls and boys
(year 8)
Which medication is used to induce remission and then to maintain remission in crohn’s?
Induce remission:
Glucocorticoids e.g. budesonide.
Mesalazine (second line)
Maintain remission:
1st: Azathioprine or mercaptopurine
2nd: Methotrexate
80% of Crohn’s patients will have surgical resection of bowel. They are at increased risk of bowel cancer.
True or false, in testes torsion, both testicles should be fixed during surgery?
True
How do you manage AF that has persisted for >48hrs?
Rate control with bisoprolol
Anticoagulation with apixaban for at least 3 weeks before cardioversion
What is the investigation for idiopathic pulmonary fibrosis?
High resolution CT
What is refractory anaphylaxis? How is it managed?
Respiratory or cardiovascular impairment despite two doses of adrenaline IM. At this point switch to IV adrenaline infusion.
How much adrenaline do you give based on age? How often can adrenalinebe given?
<6months 100mcg
6m - 6 yrs 150mcg
6-12yrs 300mcg
>12 500mcg
Every 5 minutes. Anterolateral middlethird of thigh (remember to change sites)
A 59-year-old male presents with a three-month history of progressive slurring of speech and difficulty swallowing. The patient finds swallowing liquids more difficult than solids, experiencing multiple episodes of choking when drinking water. On examination, there is facial weakness and hypophonic speech. The ocular examination reveals no ptosis or ophthalmoplegia.
What is the most likely cause of this patient’s symptoms?
Motor Neuron Disease or ALS
Eye movements are typically spared in MND
True or false, nucturnal pain is a key featureof ankylosing spondylitis?
True
What condition is associted with HLA-B27?
Ankylosing spondylitis
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?
Spironolactone
Primary hyperaldosteronism due to hyperplasia is managed with spironolactone.
If due to adrenal cancerthen adrenaletomy would be the best option.
What is the treatment for trigemnial neuralgia?
Carbamazepine
True or false, radioiodinetherapy is commonly associated with hypothyroidism?
True
How would you distinguish the metabolic acidosis of sepsis vs diarrhoea on blood gas?
Anion gap
Sepsis the anion gap will be increased (anything over 14) due to increased acid
In diarrhoea the anion gap is normal as there is no increased acid but rather loss of base (bicarbonate in diarrhoea).
What is a normal anion gap?
Howis it calculated?
8-14
(Na + K) - (bicarbonate + chloride)
How do you manage a low and high risk NSTEMI?
Low risk = GRACE <3%
High risk = GRACE>3%
Low risk:
Aspirin, Ticagrelor, Fondaparinux (clopidogrel if high bleeding risk)
High risk: Coronary angiography within 72hrs + above medications.
PCI is for STEMI
In cardiac tamponade, what is Beck’s triad? What is the treatment of cardiac tamponade?
Beck’s triad:
hypotension
raised JVP
muffled heart sounds
You might also see pulsus paradoxus - a drop in BP on inspiration of >10mm/hg and low amplitude QRS on ECG.
Pericardiocentesis.
True or false, hyptertension in diabetics, ACEi is the first line?
True
When do post-partum women need to start contraception?
After 21 days
IUD can be inserted within 48hrs of birth or after 4 weeks.
COCP is contraindicated for 6 weeks w breast feeding.
Which skin rash is associated with antiphospholipid syndrome?
Livedo reticularis
Flashes and floaters in vision suggests what?
Posterior vitreous detachment
What is the first sign of puberty in boys and girls?
Boys testicular growth ~12yrs
Girls breast growth ~12yrs
What is the carrier rate for cystic fibrosis in the UK?
1 in 25
What is Geographic tongue?
AKA benign migratory glossitis.
Squiggly, white, raised lines over the tongue. Unknown cause. Asymptomatic. No need to treat.
True or false, hydroxychloroquine is associated with retinopathy?
True
True or false, methotrexate is associated with pneumonitis?
True
What is the treatment if you suspect temporal arteritis aka Giant Cell Arteritis? Why is this important?
High dose glucocorticoids
To prevent ocular complications
NB: GCA affects medium/large vessels
True or false, branchial cysts typically occur with respiratory tract infections?
True.
Oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx. Fluctuant, doesnt move with swallowing. Does not transilluminate.
A 17-year-old girl presents with a painless swelling in the neck. She is currently well. A midline, cystic swelling is noted in the region of the hyoid bone. It moves upwards when she swallows or sticks her tongue out. What is the diagnosis?
Thyroglossal cyst
Treatment is surgical removal
Which antibiotic is prescribed to reduce recurrence of exacerbations of COPD?
Azithromycin
How do you manage vitiligo?
Tacrolimus
Sun block
Topical corticosteroids
Phototherapy
What is the difference between a straweberry naevus and a port wine stain?
Port wine stain doesn’t resolve
What is the treatment for haemodynamically unstable bradycardia?
Atropine IV
What test must you do if a patient had chorioretinitis?
HIV
Cystomegalovirus causes chorioretinitis which is an infection associated with HIV
What is the treatment for bacterial vaginosis?
Metronidazole 400mg BD 5 days
Clue cells and fishy smell (Whiff test) are key signs
A woman who is 36 weeks pregnant is reviewed. This is her first pregnancy. Her baby is known to currently lie in a breech presentation. What is the most appropriate management?
External Cephalic Version
Women at 36 weeks or more in breech (feet first) should be referred for this procedure to convert from breech to cephalic presentation (head first). Has a success rate of ~60%
NB: While 25% at 28 weeks are in breech position, only 3% are near term
You are preparing cases for the morbidity and mortality meeting. What is the time frame that defines maternal mortality?
Any death in pregnancy, labour, or up to 6 weeks post partum
In palliative medicine how is breakthrough analgesia calculated?
1/6th the daily dose
What are the key features of Meniere’s?
Recurrent episodes of vertigo, fluctuating sensorineural hearing loss, and a sensation of fullness or pressure in the affected ear
True or false, if you suspect a spinal epidural abscess you must do a lumbar MRI?
False. Whole spine MRI is needed to look for skip lesions.
True or false, patients with Meniere’s are required to inform the DVLA?
True. They are advised to refrain from driving until their symptoms have resolved.
What drug could you give to help with vertigo associated with Menier’s ?
Prochlorperazine aka Stematil
What is primary postpartum haemorrhage and how is it initially managed?>
Loss of >500ml within 24hrs of delivery. Most commonly caused by uterine atony.
Mechanical:
Palpation of the uterine fundus and bladder catheterisation may help to stimulate uterine contractions.
Medical:
IV oxytocin
Carboprost IM
Ergometrine IV/IM
Tranexamic acid
Surgery may be required if the above doesnot work
NB: Secondary Postpartum Haemorrhage is from 24hrs to 6 weeks. Most commonly caused by uterine infection.
What are the four Ts of primary postpartum haemorrhage?
Tone (uterine atony): the vast majority of cases
Trauma (e.g. perineal tear)
Tissue (retained placenta)
Thrombin (e.g. clotting/bleeding disorder)
Which medication is given for fibroids to try and shrink them?
GnRH agonists e.g. leupromide
Which contraceptive is the only one known to cause weight gaine?
DepoProvera (progesterone injection)
NB: Medroxyprogesterone acetate 150mg, given every 12 weeks.
A patient presents with a venous ulcer. What is the initial investigation and treatment?
They need compression dressings
They therefore need an Ankle Brachial Pressure Index to ensure sufficient circulation
AKBI is 0.9 - 1.2 in healthy people
True or false, hypocalcaemia is an idication that kidney disease is chronic as opposed to acute?
True
Chronic kidney disease affects vitamin D metabolism which in turn affects calcium levels
How does management of fast AF differ dependingon whether AMiodaroneit hasbeen going for <48hrs or >48hrs?
If <48hrs then they should be admitted, heparinised and converted.
If >48hrs then they needto be on anticoagulation for 3 weeks before they can be converted. A transoesophageal echo to look for left atrial appendage in the heart is also advised.
What is the drug of choice for chemical cardioversion of AF?
Amiodarone
True or false, methotrexate can cause folate deficiency?
True
What is the dose of folic acid in pregnancy?
400mcg OD until 12th week
unless high risk (obeses, on antiepileptic drugs, history of NTD e.g. partner, self, family) of neural tube defect in which case it is 5mg OD until the 12th week.
In paediatric life support, how many rescue breaths do you give initially?
5 breaths even beforechecking fora pulse
Respiratory arrest is most common in children whereas cardiac arrest is more common in adults
True or false, blood and bone infections caused by non-typhi salmonella (NTS) are typically associated with malaria and homozygous sickle cell disease, especially in children?
True
Normally staph aureus is most common but not in homozygous SCD
How do you manage osteomyelitis?
6 weeks of flucloxacillin
Clindamycin if allergic to penicilllin
Which antiobiotics are associated with weakening of the tendons / tendonitis?
Fluoroquinolones
Ciprofloxacin, levofloxacin
Clindamycin and azithromycin also can cause tendonitis
How much atropine do you give in bradycardia if there are signs of shock e.g. cool peripheries, hypotension, confusion?
500mcg up to a max of 3mg.
If this is not succuessful then transcutaneous pacing is required. until more permanent treatment can be put in place e.g. permanent pacemaker.
Give a cuase of pre, renal and post renal causesof kidney injury.
Pre Renal: Sepsis, dehydration, HF
Renal: Acute Tubular Necrosis (most common) - look for raised urinary sodium, Glomerulonephritis.
Post Renal: Obstruction. Look for hydronephrosis on US.
Which bacterial infection is associated with glomerulonephritis?
Post streptococcal Glomerulonephritis is associated with Strep pyogenes. Antibiotics such as penicillin can be given.
What is the ratio of chest compressionsto rescue breaths in adults vs children?
Adults 30:2
Children 15:2
What is the most common cause of renal injury? (vs pre or post)
Acute Tubular Necrosis
Caused by ischaemia to kidney e.g. stroke or MI
A patient with lupus presents with a purplish, non-blanching, reticulated rash on her legs. What is the likely diagnosis?
Livedo reticularis
Caused by obstruction of capillaries. Most often this is idiopathic.
A 2 year old presents with foul-smelling diarrhoea for 3 weeks and failure to thrive. What is the likely diagnosis and screening?
Coeliacs
Causes villous atrophy in the bowel which causes malabsorption and failure to thrive.
Anti TTG screen
Jejunal biopsy showing subtotal villous atrophy
True or false, transposition of the great arteries is a cyanotic heart condition?
True
Tetralogy of Fallot and Tricuspid atresia are two other examples
Whatis the treatment for polymyalgia rheumatica?
15mg OD prednisolone for 1 week then review.
PMR most common in >60s presents with bilateral shoulder pain, stiffness and raised ESR. It responds very well to steroids and is associated with temporal arteritis (unknown why).
How do you convert codeine to morphine?
Codeine dose /10 give morphine dose.
Tramadol is the same conversion
Howdo you convert morphine to oxycodone?
Divide morphine dose by 1.5 or 2
(Oxycodone is 1.5 - 2 x stronger)
How do you convert oral morphine to subcut?
Divide by 2
How much stronger is diamorphine vs morphine?
2x stronger
Differentiate polymorphic erption of pregnancy from pemphigoid gestationis.
Polymorphic eruption of pregnancy is themost common skin complaint in pregnancy and presents as an itchy rash over the abdomen and abdominal striae.
Pemphigoid gestationis is a similar presentation however it involves blistering lesions. Oral corticosteroids are usually required.
How does tardive dyskinesia present? What is the treatment?
Choreathoid movements, tongue protrusion, grimacing, rapid blinking.
Tetrabenazine
Give an example of a typical antipsychotic and an atypical antipsychotic. What are thecommon side-effects associated?
Typical: Haloperidol, chlorperazine, prochlorperazine.
Extra-pyramidal side effects:
- Akathisia
- Parkinsonism
- Acute dystonia
- Tardive dyskinesia
Atypical: Clozapine, Olanzapine.
- Agranulocytosis (low neutrophil count)
- Prolactinaemia
- Weight gain
- QT prolongation
What is glue ear?
Otitis media + effusion
Typically a grommet can be inserted which allowsair to pass through the ear drum much like a eustachian tube
Which bacteria is associated with GBS?
Campylobacter jejuni
Progressive, ascending, symmetrical lower limb weakness is the typical sign
Immune mediated demyelination of the PNS
What is the most common cause of viral meningitis in adults?
Coxsackie virus
What is MillerTrue -fischer syndrome?
A variant of GBS wherethe eyes areaffectedfirst e.g ophthalmoplegia, areflexia and ataxia. Usually presents with descending paralysis (not ascending as in GBS) AntiQB1g antibodies are present in 90% of cases.
True or false, beta thalassemia trait presents with microcytic anaemia?
True
If a COPD patient is still breathless after SABA/LABA what do you add?
Depends if asthmatic featuresr notIf no asthmaticfeatures i.e. notlikely to respondto steroids then LABA + LAMA
If asthmatic features:
Any previous, secure diagnosis of asthma or of atopy
Higher blood eosinophil count
Substantial variation in FEV1 over time (at least 400 ml)
Substantial diurnal variation in peak expiratory flow (at least 20%)
Then LABA + ICS
What type of drugs are the following?
Salbutamol
Salmeterol
Tiotropium
Ipratropium
Salbutamol SABA
Salmeterol LABA
Tiotropium LAMA
Ipratropium SAMA
What is the Chadsvasc score?
Stroke risk in AF
Score 0 no treatment
1 in males consider anticoag
1 in femalesno treatment
2+ treat with anticoagulant
(Score 1 for being female)
Rivaroxaban 20mg OD
NB: Age >75 counts for 2 points
What is the most common congenital cardiac anomaly in Down’s syndrome?
Atrioventricular septal defect
What are some of the physiological features of Dwon’s syndrome?
Upslanting palpebral fissures, Epicanthic folds,
Brushfield spots in iris
Protruding tongue
Small low-set ears
Round/flat face
Flat occiput
Single palmar crease
Pronounced ‘sandal gap’ between big and first toe
Hypotonia
Congenital heart defects (40-50%)
Duodenal atresia
Hirschsprung’s disease
What is duodenal atresia?
Narrowingof the duodenum in neonates –> bilious vomits. No bowel movements after the firstfew meconium movements. Requires surgical correction.
A 3 year old presents with a squnit (strabismus). How do you test for this? What is the next step?
Corneal light reflection test
Refer to ophthalmology
Eye patches may help
Strabismus (cross eyed) can progress to amblyopia (lazy eye) where the brain deprioritises one eye in favour of the other.
True or false,patients with stable CVD and AF usually have their antiplatelet stopped and are just put on anticoagulation?
True
Why might a patient with PMR have a transient lossof vision?
Associated with temporal arteritis
ESR should be raised
Needs prednisolone 15mg OD
True or false, PPIs like omeprazole should be stopped 2 weeks prior to endoscopy asthey can mask signs of cancer?
True
True or false, nexplanon (implant) can be inserted immediately post-partum?
True
What contraception can you use immediately post-partum?
Injection
POP
Impant
Condom (male/female)
IUS/IUD (within 48hrs)
NB: IUS/IUD mustbeafter4 weeks if not within 48hrs.
3 weeks (if not breast feeding):
COCP
Patch / Ring
6 weeks (if breast feeding)
How long does the implant last?
3 years
What is the main side effect of the hormonal implant?
Irregular / Heavy periods
How is the pill taken>
One a day for 21 days then 7 days break during which time you have a bleed.
True or false, the COCP causes weight gain?
False. There is no evidence of this.
DepoProvera is the only contraceptive linked to weight gain.
When are you protected when taking the pill?
If you take it day 1-5 of the cycle i.e. while on your period then you are protected straight away. If after this then you are not protected for 7 days.
True or false, if you vomit after takinga COCP you should take another one and then continue as before?
True.
If you continue to vomit then you must use another safer form of contraception e.g. condoms until you have taken the pill for 7 days without vomiting.
True or false, diarrhoea can reduce the efficacy of the COCP?
True. You must use another form of contraception until you have stabilised on COCP without diarrhoae for 7 days.
Give two contraindications for the COCP
Migraine (especially with aura)
35+ and smoker
Obese
Pregnant
VTE (+ in family <45yo)
Breast ca
What do you do if you miss one COCP?
Take another (even if it means taking 2 in one day) and continue as normal
What do you do if you miss two COCP pills?
Depends on the week.
Week one of pack
- Emergency contraception may be needed if you have had sex
- Condoms 7 days and continue
- Take the last pill you missed (even if means 2 in one day)
Week 2 or 3:
- No emergency contraception needed.
- Condoms 7 days.
- Take the last pill missed.
NB: 7 missed pills you have to start again. Emergency contraception may be required. Contact health professionals.
True or false, thortaccic back pain is a red flag?
True
Especially if uncontrolled by analgesia, if >50 years old, or <20 years old
What is the triad of shaken baby syndrome?
Retinal haemorrhages
Subdural haematoma
Encephalopathy
What is the first line treatment for urge incontinence and stress incontinence?
Urge = Bladder retraining (6 weeks). If fails then antimuscarinics e.g. oxybutynin or tolterodine.
Stress = Pelvic floor training 8 contractions TDS for 3 months.
If fails then retropubic midurethral tape. Duloxetine if refuse surgery.
Why are fibroadenomas nicknamed “breast mice”?
They are mobile and slip away when you grab them. They typically occur in 16-24yo women. Aberration of development. Benign.
If a woman presents with a firm lump following breast trauma to that area, what is the likely diagnosis?
Fat necrosis
If a woman who is breastfeeding presents with a hot, swollen breast. What is the likely diagnosis?
Breast abscess
True or false, if suppressive therapy is given to women with Herpez simplex infection, risk of transmission to the baby is low?
True
True or false, if a mother has an active herpez infection after 28weeks, C-section is advised?
True
What is the most common cause of scrotal swellin seen in primary care?
Epididymal cyst
A non-tender, lump at the posterior testicle which feels separate fromthe testicle itself.
What is the most common type of testicular cancer?
Germ cell tumours (>90%)
What is a hydrocele?
Collection of fluid in the tunica vaginalis - layer iof tissue surroundingthe testicle. Treated surgically
How do you manage sciatica?
4-6 weeks of NSAID/Analgesia and physio. 90% of cases settle in 3 months.
If no improvement then refer to secondary care.
What is Still’s disease?
Idiopathic juvenile arthritis
Characterised by high spiking fevers, an evanescent salmon-pink rash, and arthritis.
If a patient cannot take metformin and has Hba1c of 58, and Qrisk of 25%. What do you treat them with?
SGLT-2 inhibitor monotherapy
e.g. dapagliflozin.
If raised CVD risk and cannot take metformin this is the choice
If raised CVD risk and can tolerate metformin then take both. Start metformin first then add SGLT-2 inhibitor
A patient presents with BPH. What is the treatment?
Alpha 1 antagonist e.g. tamsulosin or alfuzocin. Decreases the smooth muscle tone of the prostate and bladder
A 5 alpha reductase inhibitor would be second line e.g. finasteride
What contraception would be safe for a woman on carbamazepine for epilepsy?
IUS
IUD
DepoProvera
The only ones safe to use with enzyme inducing drugs such as carbamazepine
True or false, women with a BMI above 30 are considered high risk of having children with neural tube defects?
True
True or false, jaundice in the first 24hrs is always pathological? Whatis the treatment>
True. Should measure Bilirubin levels immediately.
Possible causes of pathological jaundice:
- Rhesus haemolytic disease
- ABO haemolytic disease
- hereditary spherocytosis
- glucose-6-phosphodehydrogenase
2-14 days is common (40%) - Physiological jaundice.
14 days + = Prolonged jaundice
Phototherapy is the first line treatment
True or false, in glaucoma you lose the central vision?
False. You lose the peripheral vision first
What type of visiual field defect would you expect with a pituitary tumour?
Bitemporal hemianopia + upper quadrant defect
Optic chiasm lesion + inferior compression
(lower quadrant = superior compression)
How do you test for acromegaly?
Glucose challenge - measure growth hormone following glucose.
IGF-1 levels will also be testedasthey will be raised in acromegaly.
A lesion to the right optic tract causes what visual field defect?
Left (contralateral) homonymous hemianopia
What lesions cause homonymous quadrantanopias (superior or inferior)?
Superior = Inferior radiation Temporal lobe (Meyer’s loop) lesion. Defect is contralateral
Inferior = Superior radiation Parietal lobe. Defect is contralateral
PITS
Parietal Inferior Temporal Superior
What lesion causes homonymous hemianopia with macular sparing?
Occipital cortex lesion
What condition typically causes a central scotoma?
Macular degeneration
Why is sildenafil used in neonates?
Reduces risk of pulmoanry hypertension
True or false, with Bell’s palsy you should prescribe artificial tears and advise eye tapping to encourage tear formation?
True
What is the Short Synacthen test for?
Addison’s
True or false, sodium valproate is associated with pancreatitis?
True
What are Gottron’s papules?
Rough, red papules over the extensor surfaces associated with dermatomyositis. Often over the knuckles.
Dermatomyositis involves symmetrical proximal muscle weakness and papular rash over extensor surfaces. May be associated with malignancy or idiopathic.
How do you calculate the fluid maintenance for paediatrics?
100 ml/kg/day for the first 10kg of weight
50 ml/kg/day for the next 10kg of weight
20 ml/kg/day for weight over 20kg
What is normal fluid output for an adult?
0.5ml/kg/hr
If less than this, consider bolus IV 0.9% saline over 15 minutes.
What is the bolus fluid amount for paediatrics?
10 ml/kg over 20 minutes
When would you use amiodarone or adenosine for tachycardia?
If unstable arrythmia e.g. shock, syncope, MI, heart failure then 3x shocks DC cardioversion + amiodarone loading + 24hr infusion.
If stable, then depends if regular and on QRS.
Regular Narrow Complex = Adenosine.
Irregular then maybe A Flutter (consider beta blocker)
Regular Broad Complex = Amiodarone (loading dose followed by 24hr infusion) aslikely VT. If irregular then consider rate control as ? AF
NB: Amiodarone is a broader word than Adenosine
True or false, metoclopramide is contraindicated in Parkinson’s? What is the best choice of antisickness in Parkinson’s?
True. It is a DA antagonist and can make parkinson’s worse!
Domperidone targets DA receptios but doesnt cross the BBB!
True or false, hypokalaemia disposes patients to Digoxin toxicity?
True
They compete for the same binding sites on Na/K ATPase pump and therefore if K is low, moire digoxin binds increasing its toxic effect.
Digibind is the treatment for digoxin toxicity
If angina is not controlled with a beta blocker, then what should be added?
A longer-acting dihydropyridine calcium channel blocker e.g. amlodipine should be added.
If this cannot be tolerated then a long-acting nitrate e.g. ivabradine or nicorandil should be employed.
If medical management fails then referral for revascularisation e.g. PCI is the next step
How do you differentiate scleritis from episcleritis?
Scleritis is a red and PAINFUl eye
Episcleritis is not painful just red
How does Campylobacter present?
Prodrome of feeling unwell for a few days then bloody diarrhoea and abdominal pain. Campylobacter is the most common gastroenteritis in the UK
What is the first line treatmentfor mild-severe c.diff?
Vancomycin: 125 mg orally four times a day for 10 days
Second line: Fidaxomicin: 200 mg orally twice a day for 10 days if Vancomycin is ineffective.
True or false, a peak expiratory flow rate (PEFR) of less than 33% of the patient’s best or predicted is considered as a sign of a life-threatening asthma attack?
True
<33% Life threatening
33-50% Severe
50-75% Moderate
How do you manage life threatening asthma?
[Peak flow <33% predicted = life threatening
O2 15L Non-rebreather mask
SABA: Salbutamol high dose neb
SAMA: Ipratropiumbromide
IV Magnesium Sulfate
Oral prednisolone (continue for 5 days after)
Consider IV aminophylline
If fails to respond then ICU for possible ECMO - Extracorporeal membrane oxygenation.
A 17-year-old female presents for review. Four days ago she presented to her doctor with a severe sore throat, lethargy and headache. Her doctor prescribed a course of amoxicillin to treat an upper respiratory tract infection. Two days ago she developed a widespread, pruritic maculopapular rash. Her original symptoms have also not improved. What is the most likely diagnosis?
Infectious Mononucleosis
(Epstein Barr Virus / Glandular fever) caused by Herpes 4.
Amoxicillin + EBV causes a macular papular rash in 99% of people!
What is the test for glandular fever?
Heterophil antibody test (Monospot test)
True or false, complete surgical excision is needed for sebaceous cysts?
True. To prevent recurrence.
True or false, following DC cardioversion for AF, life-long anticoagulationis rerquired?
True
What is the treatment for whooping cough in adults?
Macrolides if within 21 days of infection e.g. Azithromycin.
If pregnant then erythromycin.
True or false, headache triggered by cough or valsalva is a red flag?
True
True or false, optic neuritis is associated with RAPD?
True
Inferolateral deviation of the eye is associated with which palsy?
Occulomotor 3rd nerve palsy
What second antiglycemic drug would you a dd fora patient already on metformin whose Hba1c is 58 and has no significant CVD risk?
Gliclazide (sulfonylurea) would bea good choice.
Alternative second lines:
- DPP-4 inhibitor
- Pioglitazone
SGLT-2 inhibitor e.g.empagliflozin if CVD risk.
Trueor false, pioglitazone increases the risk of bladder cancer?
True
What T score suggests osteoporosis?
-2.5 or less
-1 to -2.5 = Osteopenia
0 to -1 = Normal
Trueorfalse, a Tscoreof-0.8 is osteopenia?
False.
0 to -1 = Normal
-1 to -2.5 = Osteopenia
Less than -2.5 = Osteoporosis
What is the usual dose for alendronic acid for osteoporosis?
70mg once weekly
What is the first line treatment for Rheumatoid Arthritis?
Methotrexate + DMARD + Corticosteroids.
Folate should also be supplemented
Why is nitrofurantoin contraindicated near term? What is the best alternative in pregnancy?
Risk of neonatal haemolysis
Best alternative is cefalexin or amoxicillin
True or false, Anti-CCP is more specific for Rheumatoid Arthritis than Rheumatoid factor?
True
Whatis the gold standard for diagnosing contactdermatitis?
Skin patch test
Which scrotal mass transilluminates with a pen torch?
Hydrocele
What is the first line anti-emetic for intracranial cause nausea?
Cyclizine
True or false, aloecia areata regrows in 50% of cases in 1 year and in 90% of cases eventually?
True
True or false, asirin is safe in breast feeding?
False. It is not safe
True or false, ciprofloxacin is unsafe in breastfeeding?
True
True or false, Trimethoprim is considered safe in breast feeding?
True
True or false, there is no cure for dry macular degeneration?
True
What is re-eclampsia and what is the preventative treatment given to women at risk of it?
High blood pressure in pregnancy.
New-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
Proteinuria
Other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
Asirin 75-150mg daily from 12 weeks until delivery.
Oral labetalol is the first line for treating acutely
If a patient with COPD has failed to recover on SABA, SAMA, ICS and IV antibiotics, what is the next step
BIPAP
If this fails then ITU
When is it safe for a child with chicken pox to return to school?
When all lesions have crusted over
When can a child with measles return to school?
4 days after onset of rash
Rubella is 5 days
When can a child with mumps return to school?
5 days from onset of swollen glands.
How long should a child be off school with diarrhoea/vomiting?
48hrs with no symptoms
If a patient does not respond to oralvancomycin or fidaxomicin for c. diff what is the next step?
Oral vancomycin + IV Metronidazole
What are the Kocher criteria?
Identifying Septic Arthritis
fever >38.5 degrees C
non-weight bearing
raised ESR
raised WCC
If a child presents with a hot joint (particularly after an infection) then transient synovitis is most likely.
True or false, sulfasalazine can cause lung fibrosis?
True.
Amiodarone, methotrexate,nitrofurantoin can also be causes.
What is the most common cause of infective exacerbations of COPD?
Haemophilus influenzae
What is the treatment for impetigo?
1st Hydrogen peroxide 1% cream
2nd Topical antibiotic e.g. fusidic acid
If extensive then oral flucloxacillin
Give a common side effect of calcium channel blockers?cris
Headache, flushing, peripheral oedema.
What is Toxic Epidermal Necrolysis (TEN)? How is it treated?
A life threatening skin reaction to a drug where the epidermis detatches and the patient is systemically unwell.
Typical causes:
phenytoin
sulphonamides
allopurinol
penicillins
carbamazepine
NSAIDs
Treatment: IV Ig and often ITU
How do you manage sickle cell crisis
Analgesia, O2 and IV fluids
How does a central retinal vein occusion presernt?
Sudden painless loss of vision, severe retinal haemorrhages on fundoscopy
What is the treatment for labial adhesions?
Oestreogen pessary
Labial adhesions are usually caused by low oestrogen and typically occur in girls 3months to 3 years.
True or false, loop diuretics can cause ototoxicity?
True
Tue or false, patients who have had PCI for STEMI need to stop driving for 1 week but do not need to inform the DVLA?
True
CABG would be 4 weeks off driving
Which eicondylitis is worse on extension of the wrist and supination?
Lateral eicondylitis
What is the mechanism of action of bupropion?
Norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
What is Post Thrombotic Syndrome?
Syndrome after a DVT.
Painful, heavy calves
Pruritus
Swelling
Varicose veins
Venous ulceration
True or false, paternal breast cancer history in a patient warrants secondary care referral regardless of age?
True
When can emergency contraception be used up to ?
5 Days EllaOne (ullipristal)
3 Days Levonelle
5 days Copper Coil or within 5 days of expected start of ovulation (typically day 14 of 28 day regular cycle is start of ovulation).
How would you differentiate Buerger’s from Peripheral vascular disease?
PVD - numbness and claudication (pain in thigh, calf, buttock) typically occurs in older patients.
Buerger’s is a medium vessel vasculitis which presents similarly but in young smokers most often.
True or false, magnesium is indicated in severe pre-eclapsia?
True. It is to prevent seizure.
What do you give in pre-eclampsia if the patient is asthmatic?
Can’t give labetolol
Nifedipine is the choice. Hydralazine is another option.
True or false, TCAs such as amitriptyline should be stopped in Dementia as they can worsen cognitive symptoms?
True
True or false, hypothyroidism is a reversible cause of dementia?
True
Other reversible causes:
Depression, B1 and B12 deficiency, sleep deprivation, ICH, brain tumour.
True or false, in bacterial vaginosis, you can still use metronidazole during pregnancy?
True
True or false, in infants atopic eczema presents on extensor surfaces e.g. knees and elbows and not flexor surfaces as in older children and adults?
True
How soon after ingestion of a toxin should activated charcoal be used?
<1hr of ingestion
How do you manage aspirin (salicylate) poisoning?
Urinary alkalisation with IV bicarbonate
Haemodialysis if severe!
What is the antidote for benzodiazepine toxicity? What is the risk associated with this treatment?
Flumazenil
Only used in extreme cases as Flumazenil carries the high risk of seizures! Most benzo overdoses are managed with supportive care only.
What is the treatment for TCA overdose?
IV bicarbonate to reduce the risk of seizures and arrhythmias
What is the atidote for beat blocker overdose?
Atropine if bradycardic
Glucagon if severe
What is the antidote for ethylene glycol overdose?
Fomepizol (1st line) - inhibits alcohol dehydrogenase
Haemodialysis in extreme cases
Alcohol used to be used to out compete ethylene glycol for alcohol dehydrogenase.
Methanol poisoning is the same management
What is the antidote for organophosphate poisoning?
Atropine
What is the treatment for CO poisoning?
100% oxygen
Hyperbaric oxygen
What is the treatment for cyanide?
Hydroxocobalamin
What is the treatment for iron toxicity?
Desmoferoxamine
What is the treatmentfor lead poisoning?
Dimercaprol
What is the treatment for lithium overdose?
IV saline
haemodialysis if severe
When will a child be able to say mama or dada and understand no?
9 monhts
When will a child learn to respond to its own name?
12 months
When should a child understandsimple commands e.g. give it to me?
12-15 months
True or false, group A blood types are more likely to develop gastric cancer?
True
What is the mechanism of Pernicious anaemia?
Autoimmune vs intrinsic factor / parietal cells aka oxyntic cells at the gastric body/fundus which impairs B12 absorption.
True or false, H pylori is a risk factor for gastric cancer?
True
What are the stages of AKI?
Stage 1:
Cr 1.5-1.9 x baseline, (~26.5umol increase), <0.5ml/kg/hr urine output for >6hrs.
Stage 2:
Cr 2-2.9 x baseline, <0.5ml/kg/hr urine output for >12hrs
Stage 3:
Cr 3+ x baseline, <0.3ml/kg/hr urine output for >24hrs.
What is the treatment for psoriasis?
Strong corticosteroid e.g. betamethasone + topical Vit D e.g. calcipotriol.
A patient presents with a ‘volcano-like’ eruption on her arm witha keratin filled crater. What is the likely diagnosis and what is the next step?
Keratoacanthoma. Benign skin lesion.
Urgent referral to dermatology as
cannot exclude malignancy e.g. squamous cell carcinoma.
A woman presents with a tender goitre, sweating and raised TSH + low T4. What is the diagnosis?
De Quervain’s subacute thyroiditis.
TENDER goitre + thyrotoxicosis = De Quervains which is inflammation of the thyroid gland comonly due to recent viral infection. Tenderness is key. Thyroid issues or thyroid cancer would be painless!!
Which is the most common type of thyroid cancer, paillary or follicular?
Papillary
NB: Thyroid cancer is not associated with derranged thyroid levels.
When is clozapine indicated for treating psychosis?
When 2 other antipsychotics have failed
True or false, statins are contraindicated in pregnancy?
True
What is the Atorvastain dose for primary prevention and secondary prevention?
Primary 20mg ON
Secondary 80mg ON
Primary if QRisk >10%
Secondary if Ischaemic heart disease, peripheral vascular disease or CVD.
When should women stop taking contraceptive pill / HRT prior to surgery?
Stop 4 weeks prior as may increase risk of clotting
What is the difference between sick euthyroid syndrome and De Quervain’s?
De Quervains TSH is raised.
Sick euthyroid TSH is normal (T3/4 is low). AKa non-thyroidal illness
What is the key difference between a genital ulcer of syphylis and a chancroid?
Pain. Cahancroid ulcers are painful (caused by Haemophilus ducreyi - tropicalillness).
Syphylis ulcers are non-tender.
What type of incontinence do TCAs like amitriptyline cause?
Overflow urinary incontinence i.e. leaking. Anticholinergic effect.
What is the first line treatment of men with acute prostatitis?
Ciprofloxacin 500mg BD (Quinolone)
A young man who recently had a throat infection and was treated with antibiotics, presents with a rash with ‘teradrop scaly papules’ over his trunk. What is the diagnosos?
Guttate psoriasis
Tear drop papules is the giveaway. Typically inducedby strep infection
‘Gutta’ is latin for tear drop
Resolves in about 6 weeks
True or false, otitis externa and blepharitis are associated with seborrhoeic dermatritis?
True
How often doyou measure LFTs for statins?
Baseline, 3 months and 12 monhts.
How do you manage a child with glue ear?
Observe for 6-12 weeks as usually self limiting. No antibiotics needed in most cases. Refer for hearing test if problem persists.
True or false, macrolides such as azithromycin can cause torsardes de pointes?
True
What is the treatment for torsades de pointes?
IV Magnesium sulfate
A patient with crohns has an anal fistula, what is the best investigation to confirm?
MRI pelvis
Trueor false, patients with crohn’s should be advised to stop smoking?
True
A mother is 11wks pregnant and has no immunity to rubella. What do you do?
Advise her to avoid contact with infective persons.
MMR vaccine can be offered post natally.
True or false, ceftriaxone is safe to use in breast feeding?
True
How do you treat immune thrombocytopenic purpura (ITP)?
ITP typically presents with petechiae, purpura, epistaxis, thrombocytopenia and often follows a respiratory infection.
Autoimmune vs platelets
Treatmentis oral steroids first line
True or false, doxycycline is safe in pregnancy?
False. It can affect tooth and bone development
True or false, surfactant deficient respiratory disease is more common in mothers with diabetes?
True
True or false, acoustic neuroma is associated with loss of corneal reflex?
True
Acoustic neuroma aka vestibular schwanoma
True or false, organophosphate poisoningis associated with bradycardia?
True
How do you differentiate spider naevi from telangiectasia?
Press them. Spider naevi (Liver impairment, pregnancy) fill from the centre, telangiectasia from the edge
True or false, COCP is associated with spider naevi?
True
A 52 year old man on ACEi still has HTN, what is the next treatment?
CCB e.g. amlodipine or thiazide diuretic indapamide.
Spironolactone or beta blocker after this if both CCB + Diuretic fails.
You are asked to attend a preterm delivery. The neonate is born at 36 weeks gestation via emergency Caesarean section. The neonate has difficulty initiating breathing and requires resuscitation. They are dyspnoeic and tachypnoeic at a rate of 85 breaths/min. On auscultation of the chest, there is reduced breath sounds bilaterally. Heart sounds are displaced medially. The abdominal wall appears concave. What is the most likely diagnosis?
Congenital diaphragmatic hernia presents with scaphoid abdomen, due to herniation of the abdominal contents into the cleft
What is a safe SSRI in a breast feeding mother with post-partum depression?
Paroxetine
True or false, sulfonylureas e.g. gliclazide are associated with hypoglycemic episodes?
True
True or false, gliptins are associated with pancreatitis?
True
What is the first line treatment for a child who is bed wetting?
Enuresis alarm
Wakes the child up when it detects urine is passing i.e. moisture
High success rate
What are the BMI weight categroies?
<18.5 Underweight
18.5 - 24.9 Normal
25 - 29.9 Overweight
30 - 34.9 Obese I
35 - 39.9 Obese II
40+ Morbidly obese
What is thelarche?
Breast development in puberty
When is puberty delayed?
If no thelarche (breast development) by 13 or no menarche by 15
True or false, short stature and primary amenorrhoea are associated with Turner’s syndrome
True
Girls 45XO or 45X
What is the treatment for life threatening c diff infection?
Oral vancomycin + IV metronidazole
What would you expect to see in primary hyperaldosteronism?
Hypokalaemia
Hypernatremia
HTN
Aldosterone antagonist e.g. spironolactone
What type of fungal infection tends to occur in immunocompromised patients?
Aspergilloma
NB: Often will have past history of TB
How much folic acid in pregnancy do you give if the patient has epilepsy?
5mg OD
In patients with AS what is the key indication for valve replacement?
Symptomatic
True or false, breast cancer family history if a contraindication for COCP?
Yes and no, only BRCA associated breast cancer is a contraindication
<45yrs VTE in first degree relative is however a contraindication
When do you treat otitis media with amoxicillin (cefuroxime if pen allergic)?
Symptoms lasting more than 4 days or not improving
Systemically unwell but not requiring admission
Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
Younger than 2 years with bilateral otitis media
Otitis media with perforation and/or discharge in the canal
In a patient with cauda equina secondary to spinal malignancy what is the immediate medical treatment?
High dose oral dexamethasone
How do you treat,chroic (>6 weeks) anal fissures?
Topical GTN
Relaxes the anal sphincter
What antibody is associated with drug induced lupus?
Anti histone antibodies
What is used for migraine prophylaxis?
Propranolol or Topiramate (not in pregnancy/women of child bearing age)
A women in third trimester experiences groin pain and difficulty mobilising the hip. ESR is raised. What is the likely diagnosis?
Transient idiopathic osteoporosis
A woman in pregnancy experiences pain over the pubis and a waddling gait, what is the diagnosis?
Pubic symphysis dysfunction
An obese man presents with burning sensation of the anterolateral thigh, what is the likely diagnosis>?
Meralgia paraesthetica
How would you differentiate greater trochanteric hip pain from osteoarthritis?
Pain can be ilicited by palpation if its Greater trochangteric pain whereas it cannot if its osteoarthritis.
True or false, club foot is mostly idiopathic? How is it treated?
True
Club foot aka Talipes equinovarus is normally picked up at the first baby check.
Ponseti method is favoured which is non-surgical gradual correction of foot position with braces.
WHen is the first baby check done?
Within 72 hours of being born
What happens at the 12 and 20 week antenatal scans?
12 week (10-14 wk) - US ‘Dating scan’ - check how far along in pregnancy, development and whether Down’s, Edward’s, Patau, sceening is needed.
If after 14 weeks then a Quadruple test is done to look for Down’s.
20 week (18 - 21 wk scan): A more detailed US checking development and for other conditions such as Patau’s.
What part of the anatomy is affected by amaurosis fugax?
Retinal/ophthalmic artery
What are the two sampling methods for establishing risk of Down’s in pregnancy? Which has a higher risk of miscarriage?
Chorionic Villous Sampling 11-14 weeks. Higher risk of miscarriage 1 in 200.
Amniocentesis 15-20 weeks. Slightly lower risk of miscarriage but roughtly 1 in 200 still.
If you suspect SMD how quickly should you refer to opthalmology?
Within 1 week
What is the safest rapid tranquilsation?
IM lorazepam
In antipsychotic naieve patients with unknown cardiovascular background, Lorazepam is the safest choice. IM Haloperidol is second line but less safe.
Diabetic patients who have any foot problems other than simple calluses should be followed up regularly by the local diabetic foot centre
True
True or false, codeine is a common cause of urinary retention?
True
What type of MI is most likely to cause a LBBB?
A large downwards V1 QRS suggests LBBB.
Anterolateral / Septal MI is the most likely cause
You are speaking to a 24-year-old man who is known to have haemophilia A. His wife has had genetic testing and was found not to be a carrier of haemophilia. He asks you what the chances are of his future children developing haemophilia. What is the correct answer?
0%
X-linked conditions cannot be passed male to male.
He can only have carrier female children. Males will not be affected.
A patient has a family history of breast cancer and ovarian cancer in a second degree relative, should you refer them to breast cancer clinic?
Yes
If FHX of breast cancer AND ovarian in1st or 2nd degree relative
How often is breast cancer screening done?
50 -70 yo
Every 3 years mammography
True or false, a person with Addisons who is on oral hydrocortisone should take IM hydrocortisone until their vomiting stops?
True
What is the quick SOFA score?
Assessment of sepsis risk.
If 2 ormore of the following then assume sepsis
qSOFA score
Respiratory rate > 22/min
Altered mentation
Systolic blood pressure < 100
How does meconium ileus present? How does it differ from duodenal atresia?
Meconium ileus: presents in the first 24-48 hours of life with abdominal distension and bilious vomiting, more common in cystic fibrosis.
NB Dueodenal atresia would be present within a few hours ofbirth and would show on antenatal scans
Pyloric stenosis would present 2-12 weeks and would be projectile vomiting.
What is the first line investigation for malrotation? How is it treated?
US Abdo
Ladd’s procedure
3-7 days after birth
Sick patient
Volvulus
What is posseting?
Posseting - posseting is the act of bringing up small quantities of milk without any pain or discomfort.
What is necrotising enterocolitis?
Usually 2nd week of life
Associated with prematurity
Dilated bowel loops on AXR
High risk perforation
What do the following hepatitis screening results suggest?
HBsAg Negative
HBcAg Negative
Anti-HBs IgG Positive
Anti-HBc IgG Positive
Previously infected with Hep B virus
HBsAg (surface antigen) and cAg (core antigen) are negative suggestingno active infection.
Anti-HBs (surface) and Anti-HBc (core) antibodies are present suggesting previous infection which has resolved.
If the patient was immunised then AntiHBs would be positive but Anti-HGc would be negative.
What are the types of heart block?
First degree: Prolonged PR interval >0.2 seconds. No treatment if asymptomatic.
Second degree:
Mobitz 1 (Wenkebach): progressively longer PR until QRS dropped. Transcutanous pacing symptomatic until pacemaker can be provided.
Mobitz 2: Prolonged PR (fixed) with a dropped QRS atintervals. (2:1 block is 2 P waves then 1 QRS)
Third degree:
No association between P waves and QRS waves.
What is the most common type of Necrotising fasciitis? What is the treatment? Where is the most common site?
Type 1: mixed anaerobe and aerobe bacteria. Most common.
Type 2: Strep pyogenes
Fournier’s gangrene (perineum) is the mostcommon site. Appears like cellulitis.
Treatment is surgical debridement andbroad spectrum antibiotics e.g. Tazocin + Vancomycin
NB: Mortality ~20%
What is the most common route for orbital cellulitis in children?
Ethmoidal sinus (due to thin medial wall of orbit) following a cold
How do you differentiate orbital cellulitis from preseptal cellulitis?
Orbital celluliitis there is:
Proptosis
Pain on eye movement
Reduced visual acuity
This is not the case in preseptal
What is the most common cause of hypothyroidism in children in the UK?
Hashimoto’s (autoimmune thyroiditis)
Iodine deficiency is the most common cause in the developing world
True or false, asymptomatic bacteriuira should be treated with antibiotics?
True
Nitrofurantoin (1st line) but avoided near term
Amox or cefalexin 2nd line
At what age are children urinary continent?
3-4yrs
True or false, Dupuytren’s contracture is associated with phenytoin?
Ture
How do you treat endometriosis?
Analgesia: NSAID / Paracetamol
COCP or progeserone
GnRH analogues (pseudomenopause)
NB: Medical treatment does not hel with infertility
Surgical laparoscopic excision or ablation can improve chances of conception
What is the gold standard investigation for endometriosis?
Laparoscopy
NB: US is of little value
Why would you use clomifene citrate in endometriosis?
It induces ovulation and may help counteract subfertility in endometriosis.
Clomifene is typically used for anovulatory oroligo-ovulatory infertility
What are the levels for diabetes?
Fasting > 7 (Key diagnostic!)
Random > 11
Hba1c > 6.5 (48)
Prediabetic:
Fasting 5.5 - 6.9
2hrs Post Prandial: 7.8 - 11%
Hba1c:
Normal <42 (6%)
Pre 42 - 47 (6 - 6.4%)
Diabeteic 48+ (6.5%)
What are the following tumour markers for?
CA19-9
CEA
CA153
CA 125
Alpha Feto Protein
CA19-9 - Pancreatic
CEA - Colon
CA 153 - Breast cancer
CA 125 - Ovarian cancer
Alpha Feto Protein - Hepatocellular
