My common mistakes

Question 1

MDMA (ecstasy) poisoning is associated with…

Answer 1

Hyponatraemia

Question 2

N-Acetylcysteine commonly causes what type of reaction?

Answer 2

Anaphylactoid reaction (non-IgE mediated mast cell release)

Question 3

For DMT2 when is metformin contraindicated?

Answer 3

eGFR <30

Question 4

What is the most highly negatively inotropic CCB? (weakens heart contractions- slows HR)

Answer 4

Verapamil

Question 5

Key investigation for suspected CO poisoning?

Answer 5

ABG- carboxyhaemoglobin

Question 6

Liver transplantation criteria in paracetamol overdose?

Answer 6

pH <7.3 more than 24hrs after ingestion

Question 7

Patient on amiodarone (eg for AF) develops hypothyroidism?

Answer 7

Continue amiodarone and add levothyroxine

Question 8

Double duct sign?

Answer 8

Pancreatic cancer

Question 9

Haemochromatosis iron study profile?

Answer 9

Raised transferrin and ferritin, low TIBC

Question 10

Upper GI bleed or lower GI bleed if high urea?

Answer 10

Upper- blood digested (contains protein) so increase in urea

Question 11

Acute hypophosphataemia management- severe or symptomatic

Answer 11

IV phosphate polyfusor

Question 12

Visual hallucinations with dementia

Answer 12

Lewy body dementia

Question 13

Blood tests that form part of the confusion screen

Answer 13

TSH, B12, Folate & Glucose

Question 14

Memantine drug class

Answer 14

NMDA receptor antagonist

Question 15

Complications of thyroid surgery

Answer 15

• Recurrent laryngeal nerve damage
• Bleeding- laryngeal oedema.
• Damage to the parathyroid glands resulting in hypocalcaemia.

Question 16

Ways to remember causes of nystagmus?

Answer 16

Horizontal nystagmus = peripheral cause (goes in direction of ears)
Vertical nystagmus = central cause (goes in direction of brain)

Question 17

Difference between neuronitis and labrynthitis?

Answer 17

Neuronitis = No loss
Labrynthitis = Loss

Vestibular neuronitis = inflammation of the vestibular nerve, which deals with balance but not hearing

Labyrinthitis = inflammation of labyrinth, which deals with both balance AND hearing

Question 18

FLUID THERAPY IN CHILDREN

Question 19

FLUID THERAPY IN ADULTS

Question 20

Atropine increase or decrease HR?

Answer 20

Increase, if fails then external pacing

Question 21

Amiodarone increase or decrease HR?

Answer 21

Decreases HR (treats fast irregular HR)

Question 22

Cause of infective endocarditis <2m post valve surgery

Answer 22

Staph epidermidis

Question 23

Is a child is choking, why is the foreign object most likely found in right main bronchus?

Answer 23

Shorter, wider and more vertical

Question 24

Severe anaemia is a cause of

Answer 24

high-output heart failure

Question 25

RBBB +left anterior or posterior hemiblock + 1st-degree heart block

Answer 25

trifasicular block

Question 26

Acute heart failure not responding to treatment

Answer 26

consider CPAP

Question 27

Hypothermia is a cause of

Answer 27

Torsades de pointes

Question 28

ACS: Nitrates are contraindicated in patients with

Answer 28

hypotension (< 90 mmHg)

Question 29

'Global' T wave inversion (not fitting a coronary artery territory) - think

Answer 29

non-cardiac cause of abnormal ECG

Question 30

Hypothermia causes what on ECG

Answer 30

J waves

Question 31

Mx if V tachy leads to haemodynamic instability?

Answer 31

synchronised electrical cardioversion; may be followed by an amiodarone infusion when more stable to enhance the probability of achieving sinus rhythm

Question 32

Lichen planus vs scleorsus?

Answer 32

planus: purple, pruritic, papular, polygonal rash on flexor surfaces. Wickham's striae over surface. Oral involvement common sclerosus: itchy white spots typically seen on the vulva of elderly women

Question 33

Toxic epidermal necrolysis (TEN) vs Stevens-Johnson syndrome (SJS)?

Answer 33

Both severe skin reactions, TEN more severe end of spectrum. SJS: Affects less than 10% of the body's surface area TEN: Affects more than 30% of the body's surface area

Question 34

erythema nodosum vs erythema multiforme?

Answer 34

Erythema multiforme is typically target shaped and only slightly raised. It's not typically painful but can be itchy. They can also be on various sites of the body Erythema nodosum is more like a raised nodule that mainly presents on the shins. It looks a bit like a bruise and it is painful.

Question 35

most accurate way to asses the burns area

Answer 35

Lund and Browder chart

Question 36

Wallace's Rule of Nine

Answer 36

Each of the following is 9% of the body when calculating surface area % if a burn: Head + neck, each arm, each anterior part of leg, each posterior part of leg, anterior chest, posterior chest, anterior abdomen, posterior abdomen

Question 37

Psoriasis commonly exhibits what pgenomenon

Answer 37

Koebner phenomenon

Question 38

What clotting factors and other components does the liver make?

Answer 38

1) Clotting factors= I (fibrinogen); II (prothrombin); V; VII; IX; XII; XIII (all for blood coag) 2) Albumin (transport and maintain BP) 3) Transport proteins= ceruloplasmin (transports copper) and transferrin (iron) 4) Bile salts (fat digestion) 5) Bilirubin (from RBC breakdown) 6) Glucose (through gluconeogenesis and glycogen storage/release) 7) Lipids (cholesterol, trigly and lipoproteins) 8) Detoxification products (ammonia to urea & drug metabolism) 9) Hormones= angiotensinogen and thrombopoietin

Question 39

Role of angiotensinogen and thrombopoietin?

Answer 39

A= BP regulation T= platelet production

Question 40

What blood tests would you do to investigate the liver?

Answer 40

1) LFTs (enzymes & proteins): - ALT & AST - ALP - GGT - Bilirubin (total & direct)= direct is conjug and indirect is unconjug - Albumin - Total protein 2) Clotting screen= INR or PT 3) Viral serology= hep A, B, C, E 4) Autoantibodies= AMA, ANA, Anti-SMA 5) Ceruloplasmin 6) Ferritin and transferrin 7) Paracetamol levels 8) Alpha-1 antitrypsin 9) Tissue Transglutaminase antibody 10) Ammonia levels

Question 41

Overall tests to measure kidney function?

Answer 41

1) Bloods= serum creatinine; blood urea nitrogen (BUN); eGFR; serum uric acid 2) Urine= eg. urinalysis; protein, albumin, glucose, blood, bacteria 3) Imaging= USS, CT or MRI

Question 42

What does high serum creatinine indicate about kidney function?

Answer 42

impaired. Creatinine= waste product from muscle metabolism in blood

Question 43

What does elevated uric acid levels indicate about kidney function?

Answer 43

kidney disease or gout

Question 44

What does proteinuria indicate about kidney function?

Answer 44

damage or disease

Question 45

What does high urine albumin indicate about kidney function?

Answer 45

Damage eg. in diabetes or HTN

Question 46

Budd-Chiari Ix- way to remember? (pt presents with abdo pain, tender hepatomegaly and ascites- basically a painful swollen liver)

Answer 46

USS with doppler. basically a 'liver DVT' , being a hepatic vein thrombosis. The 'painful, swollen calf' is essentially just a painful swollen liver (abdo pain, tender hepatomegaly) + ascites due to venous obstruction. They also have exactly the same gold standard investigation in Doppler Ultrasound!

Question 47

Hepatocellular disease LFTs?

Answer 47

ALT= raised at least 2 fold ALP= normal ALT/ALP= 5+

Question 48

Cholestatic disease LFTs?

Answer 48

ALT= normal ALP= raised at least 2-fold ALT/ALP= <2

Question 49

LFTs in mixed disease (hepatocellular + cholestatic)?

Answer 49

ALT= raised at least 2-fold ALP= raised at least 2-fold ALT/ALP= 2-5

Question 50

ALP, AST and ALT produced by what?

Answer 50

AST & ALT produced by hepatocytes; in hepatocellular disease, hepatocytes release these enzymes into blood so get raised ALT. ALP produced by cells lining bile duct so in obstructive disease ALP rises.

Question 51

Summary of liver enzymes in LFTs?

Answer 51

ALT = correspond to hepatocytes AST = correspond to hepatocytes, cardiac cells, and muscle cells ALP = correspond to biliary system (bile ducts) & various tissues in the body eg. bones GGT= more specific version of ALP in terms of biliary system; also indicates pt drinks alcohol

Question 52

deranged LFTs combined with secondary amenorrhoea in a young female

Answer 52

autoimmune hepatitis

Question 53

C.diff Mx

Answer 53

1st: oral vancomycin 2nd: if doesn't work then oral fidazomicin OR IF SEVERE (eg. hypotension, shock) or doesn't respond to above= oral vanc + IV metronidazole

Question 54

Maintain remission in UC if have had a severe relapse or >=2 exacerbations in past yr?

Answer 54

oral azathioprine or oral mercaptopurine

Question 55

Metoclopramide MOA?

Answer 55

antagonism of D2 dopamine receptors

Question 56

Electrolyte disturbances in refeeding syndrome?

Answer 56

hypophosphataemia, hypokalaemia and hypomagnesaemia

Question 57

Receding bleeding gums

Answer 57

think scurvy

Question 58

What electrolyte disturbance can PPIs cause?

Answer 58

hyponatraemia

Question 59

Primary biliary cholangitis- M rule?

Answer 59

IgM anti-Mitochondrial antibodies, M2 subtype Middle aged females

Question 60

How long should pts not eat gluten for before they get endoscopic intestinal biopsy to diagnose coeliac?

Answer 60

6w

Question 61

Most common site affected in Crohn's

Answer 61

ileum

Question 62

How to stop uncontrolled variceal haemorrhage?

Answer 62

Sengstaken-Blakemore tube

Question 63

1st line Ix for acute mesenteric ischaemia?

Answer 63

Lactate= raised

Question 64

Liver + neuro disease?

Answer 64

think Wilson's

Question 65

Mneumonic to remember causes of erythema nodosum?

Answer 65

NO - idiopathic D - drugs (penicillin sulphonamides) O - oral contraceptive/pregnancy S - sarcoidosis/TB U - ulcerative colitis/Crohn's disease/Behçet's disease M - microbiology (streptococcus, mycoplasma, EBV and more)

Question 66

Reversible causes for cardiac arrest?

Answer 66

H.ypothermia H.ypovolaemia H.ypoxia H.yperkalaemia T.hrombus T.oxins T.ension pneumothorax T.amponade

Question 67

ALS for VF/pulseless VT?

Answer 67

single shock followed by CPR

Question 68

ALS if cardiac arrest is witnessed in monitored pt eg. coronary care unit and is in VF/pulseless VT?

Answer 68

Up to 3 quick successive shocks rather than 1, then CPR

Question 69

What is first line drug administration route and should always be attempted in ALS?

Answer 69

IV access if can't achieve then give drugs IO

Question 70

Role of adrenaline in ALS?

Answer 70

1mg given as soon as possible for non-shockable rhythms shockable rhythms= 1mg once restart chest compressions after the third shock repeat adrenaline 1mg every 3-5mins whilst ALS continues

Question 71

Role of amiodarone in ALS?

Answer 71

300mg given to pt in VF/pulseless VT after 3 shocks have been given. then further 150mg given after 5 shocks, then 7 ect. lidocaine can be an alternative

Question 72

When should thrombolytic drugs be given in ALS and how long should CPR continue for?

Answer 72

is PE suspected. continue CPR for extended period of 60-90mins

Question 73

A to E vs DRABC?

Answer 73

DRABC for immediate, on-scene assessments, and A to E for systematic evaluation in a clinical setting.

Question 74

What is a heart attack?

Answer 74

- must have troponin RISE AND FALL - must also have typical CP, ECG changes or new scar (eg. ST depression or elevation; T wave inversion-new; CLINICAL CONTEXT)

Question 75

Standard bloods for chest pain?

Answer 75

FBC, U+E, LFT, Clotting screen, Troponin +/- D dimer, Cholesterol, Glucose/HbA1c

Question 76

Ix for chest pain?

Answer 76

- vital signs - ECG - CXR - Bloods - ABG if hypoxic/PE suspected

Question 77

Criteria for PPCI in STEMI?

Answer 77

- ST elevation >2mm in 2 contiguous chest leads or >1mm in 2 contiguous limb leads (i.e. territorial not randomly distributed) ~Chest pain or other evidence of ischaemia - New or presumed new LBBB was an indication for thrombolysis and is often considered an indication for PPCI in the right clinical context

Question 78

If morphine is given in acute Mx of STEMI, what needs to be given with it?

Answer 78

Metoclopramide as morphine can make pt feel sick (delays absorption of anti platelet drugs)

Question 79

What if pt is already on aspirin but you need to give 300mg stat for STEMI acute Mx?

Answer 79

in theory don't need to give but best to just give anyway as shouldn't do any harm

Question 80

When to measure troponin?

Answer 80

- Depends on assay STH assay – hsTnT: - Measure ASAP - If raised, measure again in 3h – significant rise or fall suggests MI - If not raised, can r/o MI, unless pain was <6 hrs ago, in which case obtain further measurement at that point – significant rise suggests MI - Does NOT rule out ACS (could still be unstable angina) - MI is NOT always due to ACS

Question 81

Follow up post MI?

Answer 81

Clinic 1 month – can consider device therapy if significant LVSD Transthoracic echocardiogram if not had as inpatient Cardiac rehabilitation programme Smoking cessation GP – uptitrate secondary prevention e.g. ramipril and bisoprolol towards 10 mg OD

Question 82

Advise for pt post MI?

Answer 82

Don’t drive for 1 week if PCI, 4 weeks if no PCI (we advise all pts 4 weeks) Gradual return to usual activity levels Typically 6 weeks off work Stop smoking

Question 83

MI- what to write on the TTO?

Answer 83

Big 5 1) Aspirin 75 mg OD 2) Potent P2Y12 inhibitor – ticagrelor 90 mg BD or prasugrel 5-10 mg OD for >=1 year. Can consider a PPI alongside. 3) Cardioselective beta blocker (caution if asthmatic, bradycardic, conduction disease) e.g. bisoprolol 2.5 mg OD 4) ACE inhibitor (ARB if intolerant due to cough) (caution if hypotensive, severe CKD) e.g. ramipril 2.5 mg OD 5) High intensity statin e.g. Atorvastatin 80 mg OD (PRN GTN) Pretty much most pts will go home on these if tolerated

Question 84

What drugs to consider writing on the TTO for MI?

Answer 84

- Consider if poor LV function MRA – eplerenone or spironolactone 12.5 – 25 mg OD - Consider if pericarditic pain Colchicine 500 mcg BD - Consider if clinical heart failure Loop diuretic e.g. Furosemide 40 mg OD SGLT2 inhibitor e.g. Dapagliflozin or Empagliflozin - Consider if non-revascularized significant coronary artery disease Anti-anginals - beta blocker, nitrates, amlodipine etc.

Question 85

Cardiac Resynchronisation Therapy (CRT)

Answer 85

Patients with LVSD + LBBB or needing a PPM or very wide RBBB Dual chamber PPM - RA lead - RV lead - PLUS LV lead (in the CS) - Bi-ventricular PPM - Biventricular PPM = ‘CRT-P’

Question 86

Groups of patients with at significant risk of VT/VF

Answer 86

Severe LVSD Previous VT/VF (but not if assoc with an acute infarct) Inherited cardiac conditions HCM, Brugada etc.

Question 87

Implantable Cardioverter Defibrillator (ICD)

Answer 87

Adds a generator and shock coils to pacing function If added to a single lead or dual chamber PPM = ‘ICD’ If added to a CRT device = ‘CRT-D’

Question 88

What is the tumour marker for pancreatic ca?

Answer 88

CA 19-9

Question 89

What lung ca has the strongest association with smoking?

Answer 89

squamous cell lung ca

Question 90

What drug is used to suppress N&V with intracranial tumours?

Answer 90

dexamethasone

Question 91

What chemo drug is associated with hypomagnesaemia?

Answer 91

cisplatin

Question 92

What chemo drug may cause pulmonary fibrosis?

Answer 92

bleomycin

Question 93

What should be part of the diagnostic work up in a women found to have abdo malignancy of unknown primary?

Answer 93

CA 125

Question 94

What HPV subtypes are carcinogenic and increase risk of cervical ca?

Answer 94

16,18,33

Question 95

What HPV subtypes are NOT carcinogenic and are associated with genital warts?

Answer 95

6, 11

Question 96

Tumour marker in colorectal ca and has a role in monitoring disease activity?

Answer 96

CEA

Question 97

Most common cause of SVCO?

Answer 97

small cell lung ca

Question 98

What chemo drug may cause peripheral neuropathy?

Answer 98

vincristine

Question 99

Tumour marker for breast ca?

Answer 99

CA 15-3

Question 100

Women with bone mets, likely to originate where?

Answer 100

breast ca

Question 101

Tumour marker in medullary thyroid ca?

Answer 101

calcitonin

Question 102

PBC vs PSC?

Answer 102

PBC is middle-aged women, anti-mitochondrial antibodies, assoc with keratoconjunctivitis sicca. PSC is young men, often with Ulcerative colitis, assoc with pruritus and fatigue, anti-mitochondrial antibodies negative. Primary Sclerosing Cholangitis is associated with Ulcerative Colitis (i.e. both 'itis'), which occurs in younger people.

Question 103

Way to remember PBC?

Answer 103

PBC - M Disease - Increased IgM, AMA associated, Middle Aged Women!

Question 104

Melanosis coli is most commonly caused by

Answer 104

prolonged laxative use

Question 105

The oral contraceptive pill and co-amoxiclav is associated with

Answer 105

drug-induced cholestasis

Question 106

Budd-Chiari syndrome presents with the triad of

Answer 106

sudden onset abdominal pain, ascites, and tender hepatomegaly

Question 107

High urea levels can indicate

Answer 107

upper GI bleed versus lower GI bleed

Question 108

Bile-acid malabsorption may be treated with

Answer 108

cholestyramine

Question 109

Antinuclear antibodies, anti-smooth muscle antibodies and raised IgG levels are characteristic of

Answer 109

autoimmune hepatitis

Question 110

Odynophagia is a concerning symptom that may be present in patients with

Answer 110

oesophageal ca

Question 111

first line test for diagnosis of small bowel overgrowth syndrome

Answer 111

hydrogen breath testing

Question 112

All patients with suspected upper GI bleed require

Answer 112

endoscopy within 24 hours of admission

Question 113

key investigation for a suspected perforated peptic ulcer

Answer 113

erect CXR

Question 114

PPIs can increase the risk of

Answer 114

osteoporosis and fractures

Question 115

used in the management of severe alcoholic hepatitis

Answer 115

corticosteroids

Question 116

should be given before endoscopy in patients with suspected variceal haemorrhage

Answer 116

Both terlipressin and antibiotics

Question 117

Autoimmune hepatitis is more likely to show predominantly raised

Answer 117

raised ALT / AST on LFTs than ALP

Question 118

cause of hypogonadotrophic hypogonadism

Answer 118

haemochromatosis

Question 119

generally used to induce remission of Crohn's disease

Answer 119

Glucocorticoids (corticosteroids) (oral, topical or intravenous)

Question 120

used to monitor treatment in haemochromatosis

Answer 120

Ferritin and transferrin saturation

Question 121

first-line in maintain remission in ulcerative colitis patients with proctitis and proctosigmoiditis

Answer 121

A topical (rectal) aminosalicylate +/- an oral aminosalicylate

Question 122

HBsAg negative, anti-HBs positive, IgG anti-HBc positive

Answer 122

previous infection, not a carrier

Question 123

Diarrhoea, fatigue, osteomalacia →

Answer 123

?coeliac

Question 124

diagnostic investigation of choice for pancreatic cancer

Answer 124

High-resolution CT scanning

Question 125

Always examine the what in a young man with RIF pain

Answer 125

testicles

Question 126

In an acute upper GI bleed, what can identify low risk patients who may be discharged

Answer 126

Blatchford score

Question 127

A transjugular intrahepatic portosystemic shunt (TIPS) procedure connects the

Answer 127

hepatic vein to portal vein

Question 128

may be useful for diagnosing and monitoring the severity of liver cirrhosis

Answer 128

Transient elastography

Question 129

characteristic iron study profile in haemochromatosis

Answer 129

Raised transferrin saturation and ferritin, with low TIBC

Question 130

Jaundice following abdominal pain and pruritus during pregnancy think

Answer 130

acute fatty liver of pregnancy

Question 131

somatostatin analogue used to treat the symptoms of carcinoid syndrome

Answer 131

Octreotide

Question 132

develops in around 10% of primary sclerosing cholangitis patients

Answer 132

Cholangiocarcinoma

Question 133

Obesity with abnormal LFTs

Answer 133

? non-alcoholic fatty liver disease

Question 134

Iron defiency anaemia vs. anaemia of chronic disease

Answer 134

TIBC is high in IDA, and low/normal in anaemia of chronic disease

Question 135

C. difficile antigen positivity only shows what?

Answer 135

exposure to the bacteria, rather than current infection toxin=current

Question 136

If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year they should be given what to maintain remission?

Answer 136

oral azathioprine or oral mercaptopurine

Question 137

Small bowel obstruction (often due to intussusception) is a common presenting complaint in what syndrome?

Answer 137

Peutz-Jegher's syndrome

Question 138

Ongoing diarrhoea in Crohn's patient post-resection with normal CRP

Answer 138

cholestyramine

Question 139

Large-volume paracentesis for the treatment of ascites requires albumin 'cover'. Evidence suggests this reduces

Answer 139

paracentesis-induced circulatory dysfunction and mortality

Question 140

best first line management for NAFLD

Answer 140

weight loss

Question 141

prophylaxis of oesophageal bleeding

Answer 141

non-cardioselective B-blocker (NSBB) eg. propanolol

Question 142

Acute mesenteric ischaemia first line Ix?

Answer 142

raised lactate (causes this and is the 1st line Ix)

Question 143

Acute hypoperfusion (e.g. low BP secondary to blood loss) may result in

Answer 143

ischaemic hepatitis

Question 144

Most likely area to be affected by ischaemic colitis

Answer 144

splenic flexure

Question 145

Increased goblet cells

Answer 145

Crohn's

Question 146

Constipation - if symptoms don't respond to a bulk-forming laxative such as isphagula husk, try what?

Answer 146

osmotic laxative such as a macrogol

Question 147

Bile-acid malabsorption may be treated with

Answer 147

cholestyramine

Question 148

The definition of an Upper GI Bleed is a haemorrhage with an origin proximal to the...

Answer 148

ligament of Treitz

Question 149

HBsAg negative, anti-HBs positive, IgG anti-HBc negative

Answer 149

previous immunisation

Question 150

In patients with severe colitis, colonoscopy should be avoided due to the risk of perforation, so what should be used?

Answer 150

flexible sigmoidoscopy

Question 151

Coeliac disease increases the risk of developing what ca?

Answer 151

enteropathy-associated T cell lymphoma

Question 152

Long term proton pump inhibitor therapy can cause what electrolyte disturbances?

Answer 152

hypomagnesaemia hyponatraemia

Question 153

Dermatitis, diarrhoea, dementia/delusions, leading to death

Answer 153

Pellagra

Question 154

First-line pharmacological management of acute constipation

Answer 154

bulk-forming laxative such as isphagula husk mobility, increasing fluid intake and high fibre diet also v important

Question 155

Induce remission in crohn's

Answer 155

glucocorticoids (oral, topical or intravenous) Budesonide is alternative in certain pts metronidazole is often used for isolated peri-anal disease

Question 156

Maintaining remission in crohn's?

Answer 156

azathioprine or mercaptopurine and stop smoking methotrexate is used second-line

Question 157

Useful in refractory disease and fistulating Crohn's to induce remission?

Answer 157

infliximab Patients typically continue on azathioprine or methotrexate.

Question 158

Induce remission in ulcerative colitis?

Answer 158

topical (rectal) aminosalicylate if not achieved in 4w= add an oral aminosalicylate still not achieved= add topical or oral corticosteroid

Question 159

Induce remission in ulcerative colitis in extensive disease?

Answer 159

topical (rectal) aminosalicylate and a high-dose oral aminosalicylate if remission is not achieved within 4w= stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid

Question 160

Induce remission in ulcerative colitis in severe colitis?

Answer 160

should be treated in hospital IV steroids first-line IV ciclosporin may be used if steroids are contraindicated if after 72 hours there has been no improvement, consider adding IV ciclosporin to IV corticosteroids or consider surgery

Question 161

Maintaining remission in UC if mild or moderate eg. proctitis and proctosigmoiditis?

Answer 161

topical (rectal) aminosalicylate alone (daily or intermittent) or an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or an oral aminosalicylate by itself: this may not be effective as the other two options

Question 162

Maintaining remission in UC if left-sided and extensive ulcerative colitis?

Answer 162

low maintenance dose of an oral aminosalicylate

Question 163

Maintaining remission in UC following a severe relapse or >=2 exacerbations in the past year?

Answer 163

oral azathioprine or oral mercaptopurine

Question 164

UC flare severity?

Answer 164

Mild= <4 stools a day, with or without blood Moderate= 4-6; minimal systemic distrubance eg. slight raise in CRP Severe= >6 a day, containing blood; systemic disturbance eg. fever, anaemia, hypoalbuminaemia, tachy, abdo tenderness

Question 165

first line test for diagnosis of small bowel overgrowth syndrome

Answer 165

Hydrogen breath testing

Question 166

You cannot interpret TTG level in coeliac disease without looking at

Answer 166

IgA level (so test this when u test TTG)

Question 167

Patients must eat gluten for at least how long before they are tested for coeliac?

Answer 167

6w

Question 168

What is used for complex perianal fistulae in patients with Crohn's disease?

Answer 168

A draining seton

Question 169

crypt abscesses

Answer 169

UC

Question 170

Dyspepsia: there is no need to check for H. pylori eradication with urea breath test if

Answer 170

symptoms have resolved following test and treat

Question 171

treatment for achalasia

Answer 171

1st= Pneumatic dilatation (less invasive) 2nd if failed= Heller cardiomyotomy (surgery)

Question 172

If a severe flare of UC has not responded to IV steroids after 72 hours, consider adding

Answer 172

IV ciclosporin or surgery

Question 173

In a mild-moderate flare of ulcerative colitis extending past the left-sided colon, how to Mx?

Answer 173

oral aminosalicylates should be added to rectal aminosalicylates, as enemas only reach so far

Question 174

Coeliac disease is associated with what deficiencys?

Answer 174

iron, folate and vitamin B12 deficiency

Question 175

What should be assessed before offering azathioprine or mercaptopurine therapy in Crohn's disease?

Answer 175

TPMT activity

Question 176

Ascites: a high SAAG gradient (> 11g/L) indicates

Answer 176

portal hypertension

Question 177

A combination of liver and neurological disease points towards

Answer 177

Wilson's

Question 178

During infection, ferritin is an unreliable indicator of iron stored in the body as it is an acute phase protein. What should be used instead?

Answer 178

Transferrin saturation

Question 179

Autosomal recessive vs dominant conditions typically....

Answer 179

Autosomal recessive conditions are 'metabolic' - exceptions: inherited ataxias Autosomal dominant conditions are 'structural' - exceptions: Gilbert's, hyperlipidaemia type II

Question 180

Cerebellar disease signs?

Answer 180

D - Dysdiadochokinesia, Dysmetria (past-pointing), patients may appear 'Drunk' A - Ataxia (limb, truncal) N - Nystamus (horizontal = ipsilateral hemisphere) I - Intention tremour S - Slurred staccato speech, Scanning dysarthria H - Hypotonia

Question 181

Unilateral cerebellar lesions cause...

Answer 181

ipsilateral cerebellar signs

Question 182

Ptosis + dilated pupil = ? Ptosis + constricted pupil = ?

Answer 182

Ptosis + dilated pupil = third nerve palsy Ptosis + constricted pupil = Horner's

Question 183

Total anterior circulation infarcts - all 3 of the following:

Answer 183

unilateral hemiparesis and/or hemisensory loss of the face, arm & leg homonymous hemianopia higher cognitive dysfunction e.g. dysphasia

Question 184

left homonymous hemianopia means

Answer 184

visual field defect to the left, i.e. lesion of right optic tract

Question 185

homonymous quadrantanopias

Answer 185

PITS (Parietal-Inferior, Temporal-Superior)

Question 186

Lambert-Eaton Syndrome is a paraneoplastic myasthenic syndrome most commonly associated with

Answer 186

small cell lung cancer. It may precede the cancer diagnosis by a number of years

Question 187

Lateral medullary syndrome - PICA lesion?

Answer 187

cerebellar signs, contralateral sensory loss & ipsilateral Horner's

Question 188

Fever, headache, psychiatric symptoms, seizures, focal features e.g. aphasia

Answer 188

?herpes simplex encephalitis

Question 189

The radial nerve is at risk in a shaft fracture of the

Answer 189

humerus

Question 190

Raised ICP can cause what nerve palsy?

Answer 190

third nerve palsy due to herniation

Question 191

Contralateral hemiparesis and sensory loss with the upper extremity being more affected than the lower, contralateral homonymous hemianopia and aphasia

Answer 191

middle cerebral artery

Question 192

Patients who present 4.5-9 hours after symptom onset, or with 'wake-up stroke' should still be considered for thrombolysis if

Answer 192

they have imaging evidence of potential to salvage brain tissue

Question 193

Progressively worsening headache with higher cognitive function impaired

Answer 193

urgent imaging

Question 194

Contraindication to triptan use

Answer 194

Cardiovascular disease

Question 195

Hoover's sign

Answer 195

differentiates between organic and non-organic lower leg weakness

Question 196

Headache linked to Valsalva manoeuvres =

Answer 196

raised ICP until proven otherwise so LP is contraindicated

Question 197

Partial anterior circulation infarcts - 2 of the following:

Answer 197

unilateral hemiparesis and/or hemisensory loss of the face, arm & leg homonymous hemianopia higher cognitive dysfunction e.g. dysphasia

Question 198

rapid onset dementia and myoclonus

Answer 198

Creutzfeldt-Jakob disease

Question 199

Intubate if the GCS is less than

Answer 199

8

Question 200

Common peroneal nerve lesion can cause

Answer 200

weakness of foot dorsiflexion and foot eversion

Question 201

Pt presents with a fall following a recent diagnosis of Parkinson's, think what?

Answer 201

may be Parkinson's Plus syndrome eg. Progressive supranuclear palsy- so test CN III, IV and VI (common CP of PSP is vertical supranuclear gaze palsy anyone with a fall test CN III, IV and VI

Question 202

Progressive supranuclear palsy

Answer 202

postural instability, impairment of vertical gaze, parkinsonism, frontal lobe dysfunction

Question 203

Progressive supranuclear palsy vs multiple system atrophy?

Answer 203

PSP= vertical gaze impairment MSA= autonomic dysfunction is a more significant feature such as tachycardia, fainting, erectile dysfunction both may present like Parkinsons

Question 204

Pulmonary function test results for obstructive lung disease eg. asthma, COPD, Bronchiectasis, Bronchiolitis obliterans?

Answer 204

FEV1 - significantly reduced FVC - reduced or normal FEV1% (FEV1/FVC) - reduced transfer factor reduced or normal

Question 205

Pulmonary function test results for restrictive lung disease eg: Pulmonary fibrosis Asbestosis Sarcoidosis Acute respiratory distress syndrome Infant respiratory distress syndrome Kyphoscoliosis e.g. ankylosing spondylitis Neuromuscular disorders Severe obesity

Answer 205

FEV1 - reduced FVC - significantly reduced FEV1% (FEV1/FVC) - normal or increased transfer factor reduced or normal

Question 206

Normal FEV1, FVC and FEV1/FVC ratio?

Answer 206

FEV1= >80% predicted FVC= >80% predicted FEV1/FVC= >70% predicted

Question 207

Clubbing may be seen in what?

Answer 207

bronchiectasis

Question 208

What is helpful in ventilated pts with ARDS?

Answer 208

prone positioning

Question 209

Pneumothorax Mx- what are the high-risk characteristics that determine the need for a chest drain?

Answer 209

- Haemodynamic compromise (suggesting a tension pneumothorax) - Significant hypoxia - Bilateral pneumothorax - Underlying lung disease - ≥ 50 years of age with significant smoking history - Haemothorax

Question 210

Over rapid aspiration/drainage of pnuemothorax can result in what?

Answer 210

re-expansion pulmonary oedema

Question 211

When should oral Abx only be given in acute exacerbation of COPD?

Answer 211

presence of purulent sputum or clinical signs of pneumonia

Question 212

Neuromuscular disorders result in what pattern on pulmonary function tests?

Answer 212

restrictive pattern

Question 213

patient get admitted and you don't know their full PMH. If someone is put on 15L of high flow O2 and suddenly go into respiratory acidosis and T2RF

Answer 213

think COPD

Question 214

Causes of upper lobe pulmonary fibrosis?

Answer 214

C - Coal worker's pneumoconiosis H - Histiocytosis/ hypersensitivity pneumonitis A - Ankylosing spondylitis R - Radiation T - Tuberculosis S - Silicosis/sarcoidosis

Question 215

Examples of SABA, SAMA, LABA, LAMA, ICS

Answer 215

SABA - Salbutamol or Terbutaline SAMA - Ipratropium Bromide LABA - Salmeterol or Formoterol LAMA - Tiotropium ICS - Budesonide or Fluticasone

Question 216

Characterising fractures: way to remember the Salter-Harris criteria (type of fracture)?

Answer 216

SALTEr 1 S-Straight 2 A-Above 3 L-Lower 4 T-Through (above and below) 5 Er-Everything (Crush)

Question 217

General Abx for pregnant pt allergic to penicillin?

Answer 217

erythromycin

Question 218

CO2 in asthma exacerbation?

Answer 218

pt hyperventilates so should be high O2 and low CO2 in severe= CO2 normal near-fatal= CO2 >6 (should be low as breathing fast in exacerbations but as it is raised this is really bad)

Question 219

Pregnant women, severe asthma attack and improve with medical Tx?

Answer 219

still need hospital admission if pregnant

Question 220

What causes lower zone pulmonary fibrosis?

Answer 220

A - asbestos. C - connective tissue diseases. I - idiopathic pulmonary fibrosis. D - drugs e.g. methotrexate, nitrofurantoin.

Question 221

Acute asthma Mx?

Answer 221

1. Oxygen 2. Salbutamol nebulisers 3. Ipratropium bromide nebulisers 4. Hydrocortisone IV OR Oral Prednisolone 5. Magnesium Sulfate IV 6. Aminophylline/ IV salbutamol 7. ITU (intubation) Oh Shit, I Hate My Asthma initially salbutamol + ipra together if severe or life-threatening

Question 222

COPD exacerbation, what to do when medical Mx fails?

Answer 222

BiPAP if this fails then intubation and ventillation

Question 223

Target O2 sats in COPD?

Answer 223

if a known type 2 resp failure i.e hypercapnic on blood gas= 88-92% Normal CO2 (not hypercapnic)= 94-98%

Question 224

COPD symptoms in a young person/non-smoker?

Answer 224

think alpha-1 antitrypsin (A1AT) deficiency

Question 225

Painful shin rash + cough

Answer 225

?sarcoidosis

Question 226

Persistent productive cough +/- haemoptysis in a young person with a history of respiratory problems →

Answer 226

?bronchiectasis

Question 227

Bronchiectasis vs pulmonary fibrosis

Answer 227

Bronchiectasis: Primary Problem= Airway damage and dilation Cough= Productive (mucus) Onset= Chronic but not necessarily progressive Main Tx Focus= Infection control, airway clearance Pulmonary Fibrosis: Primary Problem= Lung tissue scarring Cough= Dry Onset= Progressive and worsening Main Tx Focus= Slowing fibrosis, symptom management

Question 228

Sudden deterioration with ventilation suggests

Answer 228

tension pneumothorax

Question 229

Patients diagnosed with pneumonia who have COPD should be given what even if no evidence of the COPD being exacerbated

Answer 229

corticosteroids

Question 230

Although diagnosis is often confirmed on CT imaging, WHAT is raised in approximately 60% of sarcoid patients at diagnosis and is the most specific autoantibody used in diagnosis.

Answer 230

serum ACE raised in sarcoidosis (also hypercalcaemia)

Question 231

Mining occupation, upper zone fibrosis, egg-shell calcification of hilar nodes

Answer 231

silicosis

Question 232

Hypercalcaemia + bilateral hilar lymphadenopathy

Answer 232

?sarcoidosis

Question 233

Light's criteria state that a pleural effusion is an exudate if:

Answer 233

- Effusion lactate dehydrogenase (LDH) level greater than 2/3 the upper limit of serum LDH - Pleural fluid LDH divided by serum LDH >0.6 - Pleural fluid protein divided by serum protein >0.5

Question 234

If a pleural effusion is drained too quickly, a rare but important complication that can develop is

Answer 234

re-expansion pulmonary oedema

Question 235

Gynaecomastia - associated with what lung ca

Answer 235

adenocarcinoma

Question 236

most commonly causes a cavitating pneumonia in the upper lobes, mainly in diabetics and alcoholics

Answer 236

Klebsiella

Question 237

A chest infection failing to improve with antibiotics followed by a deterioration in symptoms with a cough productive of foul, purulent sputum, and rigours suggests

Answer 237

an empyema or abscess CT findings of a smooth-walled fluid collection with air-fluid levels and pleural enhancement, alongside pleural fluid analysis showing a low pH, high LDH, and low glucose, confirm this diagnosis chest tube drainage combined with antibiotics

Question 238

Indications for corticosteroid treatment for sarcoidosis are:

Answer 238

parenchymal lung disease, uveitis, hypercalcaemia and neurological or cardiac involvement

Question 239

treatment of choice for allergic bronchopulmonary aspergillosis

Answer 239

oral glucocorticoids eg. pred

Question 240

Which of the following options confirms that the chest drain is located in the pleural cavity?

Answer 240

The water seal rises on inspiration and falls on expiration

Question 241

COPD - still breathless despite using SABA/SAMA and no asthma/steroid responsive features →

Answer 241

add a LABA + LAMA

Question 242

COPD - still breathless despite using SABA/SAMA and asthma/steroid responsive features →

Answer 242

add a LABA + ICS

Question 243

contraindication for chest drain insertion

Answer 243

INR >1.3

Question 244

The treatment of extrinsic allergic alveolitis is

Answer 244

mainly avoidance of triggers

Question 245

Acute respiratory distress syndrome can only be diagnosed in the absence of

Answer 245

a cardiac cause for pulmonary oedema (i.e. the pulmonary capillary wedge pressure must not be raised)

Question 246

Decrease in pO2/FiO2 in poorly patient with non-cardiorespiratory presentation eg. acute pancreatitis →

Answer 246

?ARDS

Question 247

Obstructive sleep apnoea can cause

Answer 247

HTN

Question 248

first-line for acute bronchitis (unless pregnant/child)

Answer 248

oral doxycycline

Question 249

Fine end-inspiratory crepitations are seen in

Answer 249

idiopathic pulmonary fibrosis

Question 250

Coal workers' pneumoconiosis typically causes

Answer 250

upper zone fibrosis

Question 251

What is recommended in COPD pts who have frequent exacerbations?

Answer 251

Azithromycin prophylaxis

Question 252

Large bullae in COPD can mimic a

Answer 252

pneumothorax

Question 253

Squamous cell carcinoma is associated with

Answer 253

hypertrophic pulmonary osteoarthropathy (HPOA)

Question 254

Asthmatic features/features suggesting steroid responsiveness in COPD:

Answer 254

previous diagnosis of asthma or atopy a higher blood eosinophil count substantial variation in FEV1 over time (at least 400 ml) substantial diurnal variation in peak expiratory flow (at least 20%)

Question 255

Causes of hypoglycaemia

Answer 255

EXPLAIN Exogenous drugs (typically sulfonylureas or insulin) Pituitary insufficiency Liver failure Addison's disease Islet cell tumours (insulinomas) Non-pancreatic neoplasms

Question 256

DKA resolution is defined as:

Answer 256

pH >7.3 and blood ketones < 0.6 mmol/L and bicarbonate > 15.0mmol/L

Question 257

What should happen to patients regular insulin if DMT1 in DKA?

Answer 257

continue long acting insulin and stop short acting

Question 258

Hyponatraemia, hyperkalaemia and weight loss

Answer 258

?Addison's disease. Presentation of adrenal insufficiency can be very non-specific.

Question 259

Cushing's syndrome electrolyte abnormality

Answer 259

hypokalaemic metabolic alkalosis

Question 260

Primary hyperaldosteronism can present with

Answer 260

hypertension, hypernatraemia, and hypokalemia

Question 261

High-dose dexamethasone suppression test with an ectopic source of ACTH

Answer 261

Cortisol: not suppressed ACTH: not suppressed

Question 262

High-dose dexamethasone suppression test with Cushing's syndrome due to other causes (e.g. adrenal adenomas)

Answer 262

Cortisol: not suppressed ACTH: suppressed

Question 263

High-dose dexamethasone suppression test with Cushing's disease (i.e. pituitary adenoma → ACTH secretion)

Answer 263

Cortisol: suppressed ACTH: suppressed

Question 264

'unrecordable' blood sugar measurement with confusion and abdominal pain

Answer 264

DKA 'unrecordable' means it is too high

Question 265

High insulin, High C-peptide = Endogenous insulin production →

Answer 265

Insulinoma or sulfonylurea use/abuse

Question 265

Congenital adrenal hyperplasia has the following biochemical abnormalities

Answer 265

Increased plasma 17-hydroxyprogesterone levels Increased plasma 21-deoxycortisol levels Increased urinary adrenocorticosteroid metabolites

Question 266

PHaeochromocytoma - give what to manage HTN prior to surgical removal

Answer 266

PHenoxybenzamine (non-selective alpha-blocker) before beta-blockers

Question 267

Water deprivation test: primary polydipsia

Answer 267

urine osmolality after fluid deprivation: high urine osmolality after desmopressin: high

Question 268

Endocrine parameters reduced in stress response: eg. following major surgery

Answer 268

Insulin Testosterone Oestrogen

Question 269

SGLT-2 inhibitors examples

Answer 269

canagliflozin, dapagliflozin and empagliflozin.

Question 270

TFTs in critically ill pt eg. ITU with pneumonia?

Answer 270

TSH normal, T3 & T4 low (Sick euthyroid syndrome)

Question 271

How to distinguish between DMT1 and DMT2?

Answer 271

C-peptide levels and diabetes-specific autoantibodies (anti-GAD) normally in type 1= c-peptide low and antibodies present

Question 272

normal stroke - Mx normal TIA - Mx AF causing stroke - Mx AF causing TIA - Mx

Answer 272

normal stroke - aspirin first, then lifelong clopi normal TIA - aspirin first, then lifelong clopi AF causing stroke - aspirin first, then DOAC AF causing TIA - immediate DOAC

Question 273

1st line Mx for HTN?

Answer 273

Do they have diabetes? Yes = ACEi or ARB if Afro-Carribean Are they Afro-Carribean or over 55? Yes = CCB Are they non-Afro-Carribean and under 55? Yes = ACEi

Question 274

Patients with bradycardia and signs of shock require what

Answer 274

500micrograms of atropine (repeated up to max 3mg)

Question 275

New onset AF is considered for electrical cardioversion if it presents within

Answer 275

48 hours of presentation

Question 276

A patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination -

Answer 276

ventricular septal defect

Question 277

Mx of aortic dissection?

Answer 277

type A - ascending aorta - control BP (IV labetalol) + surgery type B - descending aorta - control BP(IV labetalol)

Question 278

ACE inhibitor or ARB in pt who is afro-caribbean (after CCB or 1st line if diabetic)?

Answer 278

ARB preferred

Question 279

A right coronary infarct supplies the AV node so can cause what after MI (infarction)?

Answer 279

arrhythmias

Question 280

Poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a standard-dose thiazide diuretic. K+ > 4.5mmol/l - what should you add?

Answer 280

specialist review add an alpha- eg. carvedilol 58% or beta-blocker

Question 281

Tx if pharmacological cardioversion of AF agreed on?

Answer 281

amiodarone

Question 282

A posterior MI causes what on a 12-lead ECG

Answer 282

ST depression not elevation

Question 283

What drug class is contraindicated in V Tach?

Answer 283

CCB eg. verapamil

Question 284

PR interval over 200ms with an otherwise normal ECG (regular sinus rhythm, no missing QRS complexes) is consistent with

Answer 284

1st-degree atrioventricular block. Isolated 1st degree atrioventricular block is common rarely problematic and a normal variant in athletes

Question 285

Mx of alcohol withdrawl if pt has liver cirrhosis?

Answer 285

long acting benzodiazepines eg. lorazepam chlordiazepoxide C/I in cirrhosis

Question 286

Acute dystonia secondary to antipsychotics is usually managed with

Answer 286

procyclidine

Question 287

After starting an ACE inhibitor, significant renal impairment may occur if the patient has

Answer 287

undiagnosed bilateral renal artery stenosis

Question 288

Beta-blockers combined with verapamil can potentially cause profound

Answer 288

bradycardia and asystole

Question 289

Patients with bradycardia and signs of shock require

Answer 289

500micrograms of atropine (repeated up to max 3mg)

Question 290

Bleeding on dabigatran? Can use what to reverse

Answer 290

idarucizumab

Question 291

What drug might cause cold peripheries?

Answer 291

beta blockers

Question 292

Diabetic ketoacidosis: the IV insulin infusion should be started at what rate?

Answer 292

0.1 unit/kg/hour

Question 293

What is suggested by the tender goitre, hyperthyroidism and raised ESR. The globally reduced uptake on technetium thyroid scan is also typical?

Answer 293

Subacute thyroiditis

Question 294

hypothyroidism + goitre + anti-TPO

Answer 294

Hashimoto's thyroiditis

Question 295

Symptomatic bradycardia is treated with

Answer 295

Atropine (500mcg IV)

Question 296

Hormones in Klinefelter's vs Kallmans vs Turner's?

Answer 296

Klinefelter's syndrome= high LH & FSH and low testosterone (CLIMB felters- can't feel testes too small) Kallman= low LH & FSH and low testosterone (ALL low/FALL) Tuners= high FSH & LH (TURNED UP) and low oestrogen

Question 297

Depression, nausea, constipation, bone pain →

Answer 297

?primary hyperparathyroidism

Question 298

medication of choice in suppressing lactation when breastfeeding cessation is indicated

Answer 298

Cabergoline (dopamine receptor agonist)

Question 299

After 20 weeks, symphysis-fundal height in cm =

Answer 299

gestation in weeks +/- 2cm eg/ 24w= 22-26cm

Question 300

AFP - raised with

Answer 300

fetal abdominal wall defects (e.g. omphalocele)

Question 301

The investigation of choice for ectopic pregnancy is

Answer 301

transvaginal ultrasound

Question 302

HRT: unopposed oestrogen increases risk of

Answer 302

endometrial cancer

Question 303

COCP: If 2 pills are missed in week 1...

Answer 303

consider emergency contraception if she had unprotected sex during the pill-free interval or week 1

Question 304

SSRIs of choice in breastfeeding women

Answer 304

Sertraline or paroxetine

Question 305

The combined oral contraceptive pill CAN be given if requested 6 weeks postpartum even if breastfeeding. BUT they can get pregnant from day

Answer 305

21 postpartum so if they have had unprotected intercourse from day 21 postpartum, a pregnancy test should be performed first

Question 306

The combined oral contraceptive pill CAN be given if requested ... w postpartum even if breastfeeding

Answer 306

6w

Question 307

The most common cause of PPH by far is

Answer 307

uterine atony

Question 308

In patients with urinary incontinence, make sure to rule out

Answer 308

UTI and diabetes mellitus

Question 309

HNPCC/Lynch syndrome is a strong risk factor for

Answer 309

C.olon E.ndometrial O.varian

Question 310

Suspected PE in pregnant women with a confirmed DVT:

Answer 310

treat with LMWH first then investigate to rule in/out

Question 311

most common cause of postmenopausal bleeding

Answer 311

vaginal atrophy

Question 312

Red eye - glaucoma or uveitis?

Answer 312

glaucoma: severe pain, haloes, 'semi-dilated' pupil uveitis: small, fixed oval pupil, ciliary flush

Question 313

Proliferative diabetic retinopathy is the most common underlying cause of a

Answer 313

vitreous haemorrhage

Question 314

scleritis vs episcleritis

Answer 314

scleritis painful episcleritis painless

Question 315

sudden painless loss of vision in diabetic

Answer 315

? Vitreous haemorrhage

Question 316

Anterior uveitis is most likely to be treated with

Answer 316

steroid + cycloplegic (mydriatic) drops

Question 317

red eye, dilated pupil, and a hazy cornea due to increased intraocular pressure

Answer 317

Acute angle closure glaucoma

Question 318

In diabetic retinopathy, cotton wool spots represent areas of

Answer 318

retinal infarction

Question 319

A patient is noted to have persistent ST elevation 4 weeks after sustaining a myocardial infarction. Examination reveals bibasal crackles and the presence of a third and fourth heart sound. No chest pain ???

Answer 319

left ventricular aneurysm

Question 320

AV block can occur following an .... MI

Answer 320

inferior

Question 321

ECG findings of sinus tachycardia and right axis deviation are characteristic features of

Answer 321

PE

Question 322

A third heart sound is one of the possible features of

Answer 322

left-sided HF

Question 323

Complete heart block following a MI? -

Answer 323

right coronary artery lesion

Question 324

Offer a ....... in addition to an ACE inhibitor (or ARB) and beta-blocker, to people who have heart failure with reduced ejection fraction if they continue to have symptoms of heart failure

Answer 324

mineralcorticoid receptor antagonist eg. spirinolactone

Question 325

Way to remember systolic vs diastolic murmur?

Answer 325

MS ARD = Mitral Stenosis (late), Aortic Regurg (early)- Diastolic MR ASS = Mitral regurg (pan), Aortic Stenosis (ejection) - Systolic

Question 326

What electrolyte disturbances could lead to long QT syndrome?

Answer 326

hypocalcaemia, hypokalaemia, hypomagnesaemia

Question 327

For cardioversion of AF: patients must either be

Answer 327

anticoagulated (for 3w) or have had symptoms for < 48 hours to reduce the risk of stroke. eg. Bisoprolol and oral anticoagulant therapy for 3 weeks and then electrical cardioversion

Question 328

What is contraindicated in aortic stenosis?

Answer 328

nitrates eg. GTN spray due to risk of profound hypotension

Question 329

ECG is reported as showing no visible P waves and an irregularly irregular narrow QRS complex?

Answer 329

AF not SVT as AF is irregulary irregular but SVT is regular

Question 330

Narrow complex tachy (<0.12s) vs broad complex tachy (>=0.12s)?

Answer 330

Narrow= AF, SVT, atrial flutter Broad= v tach, v fib (v tach can go into v fib), BBB

Question 331

early diastolic murmur, pulse is collapsing (water-hammer) and has wide pulse pressure

Answer 331

aortic regurg

Question 332

The ECG shows monomorphic ventricular tachycardia. The patient still no pulse. What should be the next step in management?

Answer 332

defib If VF/pVT persists, only after a third shock should adrenaline 1 mg IV and amiodarone 300 mg IV be administered.

Question 333

Aortic dissection can present with

Answer 333

neuro complaints Focal neurological deficits occur due to propagation of the intimal tear to branch arteries, or due to mass effects as the expanding aorta compresses surrounding structures. Eg. man presents with chest pain & with symptoms of Horner's syndrome (classically ptosis, miosis and anhidrosis) due to compression of the sympathetic trunk by the expanding aortic dissection.

Question 334

Tricuspid regurg type of murmur?

Answer 334

pan-systolic murmur as, during systole, the blood is ejected from the ventricles which are contracting. If the tricuspid valve is 'leaky' as in tricuspid regurgitation, the blood will backflow to the right atrium during this process, causing a pansystolic murmur.

Question 335

Expert help should be sought for stable patients with what heart rhythm?

Answer 335

IRREGULAR broad complex tachycardia (rare)

Question 336

What heart condition is most associated with S3?

Answer 336

dilated cardiomyopathy

Question 337

Mx of cardiac tamponade?

Answer 337

Pericardiocentesis if cancer then Percutaneous balloon pericardiotomy (Pericardiocentesis is good for one off drainage, but these patients need intervention to manage recurrence)

Question 338

when are nitrates contraindicated?

Answer 338

hypotension or aortic stenosis

Question 339

Hypertrophic obstructive cardiomyopathy - is classically associated with an

Answer 339

S4

Question 340

S3 vs S4?

Answer 340

An S3 heart sound occurs early in diastole, signifying rapid ventricular filling, while an S4 heart sound happens late in diastole, just before the S1, and indicates the atria forcefully pushing blood into a stiff ventricle S3 (threeee) - hard to breeeeeath (LVF and MR can lead to pulmonary oedema) S4 - hit the floor (HOCM and AS can cause collapse/sudden death) Also if you noticed S3 is normal in under 30 (3 is the number to remember) S4 is normal in over 40 (4 is the number to remember) DCM = S3 (3 letters) HOCM = S4 (4 letters)

Question 341

Most common cause of primary adrenal insufficiency?

Answer 341

autoimmune so test for 21-hydroxylase antibodies (Addisons)

Question 342

3 types of hyponatraemia?

Answer 342

hypervolaemic, hypovolaemic and euvolaemic

Question 343

Causes of hypervolaemic hyponatraemia?

Answer 343

secondary hyperaldosteronism= heart failure, liver cirrhosis nephrotic syndrome IV dextrose psychogenic polydipsia

Question 344

Causes of hypovolaemic hyponatraemia?

Answer 344

Diarrhoea & vomiting Medications eg. thiazides, loop diuretics Addison's disease Diuretic stage of renal failure Burns

Question 345

Causes of euvolaemic hyponatraemia?

Answer 345

SIADH Hypothyroidism

Question 346

How to determine hyponatraemia Mx?

Answer 346

1) Acute (<48hrs) or chronic (>48hrs)= look at the trend 2) Severity= mild (130-134), moderate (120-129) or severe (<120) 3) Fluid status: - hypovolaemic= clinically dehydrated, diuretics, Addisonian crisis, diuretic stage of renal failure - euvolaemic= SIADH, hypothyroidism - hypervolaemic= HF, liver failure, nephrotic syndrome 4) Symptomatic? - early symptoms= headache, lethargy, nausea, vomiting, dizziness, confusion, muscle cramps - late= seizures, coma, resp arrest

Question 347

Ix for hyponatraemia?

Answer 347

serum osmolality; urine osmolality; urine sodium; 9 am cortisol (exclude adrenal insuf- low sodium, high potassium), TSH (?hypothyroidism)

Question 348

Hyponatraemia- check Na how often?

Answer 348

every 2hrs (VBG not very accurate); don't be too aggressive with fluids- just 1L slow then reassess

Question 349

How may hypovolaemic hyponatraemia present?

Answer 349

subtle, may just have low urea and low urine output

Question 350

SIADH?

Answer 350

high urine osmolality and urine sodium >40 causes= ca (esp lung); meds (SSRI, antipsychotics); chest infections (pnuemonia) Mx= fluid restrict (to 1L or 750ml); talk to endo, tolvaptan

Question 351

Mx if hypovolaemic hyponatraemia suspected?

Answer 351

normal, i.e. isotonic, saline (0.9% NaCl) this may sometimes be given as a trial if the serum sodium rises this supports a diagnosis of hypovolemic hyponatraemia if the serum sodium falls an alternative diagnosis such as SIADH is likely

Question 352

Mx if euvolaemic hyponatraemia suspected?

Answer 352

fluid restrict to 500-1000 mL/day consider medications: demeclocycline vaptans

Question 353

Mx if hypovolaemic hyponatraemia suspected?

Answer 353

fluid restrict to 500-1000 mL/day consider loop diuretics consider vaptans

Question 354

Patients with acute, severe (<120 mmol/L) or symptomatic hyponatraemia?

Answer 354

require close monitoring, preferably in an HDU or above setting. Hypertonic saline (typically 3% NaCl) is used to correct the sodium level more quickly than would be done in patients with chronic hyponatraemia.

Question 355

For type 2 diabetics requiring treatment, metformin is contraindicated in those with

Answer 355

eGFR < 30

Question 356

IgA deficiency increases the risk of

Answer 356

anaphylactic blood transfusion reactions

Question 357

The main ECG abnormality seen with hypercalcaemia is

Answer 357

short QT

Question 358

Hypothermia ECG changes?

Answer 358

Jesus Quist It's Bloody Freezing J-Waves QT interval - prolonged Irregular Rhythm Bradycardia First Degree Heart Block

Question 359

Examples of a a long-acting nitrate?

Answer 359

ivabradine nicorandil ranolazine

Question 360

What is characterised by a positive direct antiglobulin test (Coombs' test)?

Answer 360

Autoimmune haemolytic anaemia

Question 361

Warfarin drug interactions?

Answer 361

Inducers: (INR decreases) “SCARS” * S → Smoking * C → Chronic alcohol intake * A → Anti- epileptics: Phenytoin, Carbamazepine, Phenobarbitone (all barbiturates) * R → Rifampicin * S → St John's Wort Inhibitors: (INR increases) “ASS-ZOLES” * A → Antibiotics: Ciprofloxacin, Erythromycin, Isoniazid * S → SSRIs: Fluoxetine, Sertraline * S → Sodium Valproate * - Zoles → Omeprazole, Ketoconazole, Fluconazole

Question 362

Rhabdomyolysis can cause AKI by causing what damage in kidney?

Answer 362

Tubular cell necrosis

Question 363

Myeloma without metastasis is characterised by what electrolyte levels?

Answer 363

high calcium, normal/high phosphate and normal alkaline phosphate

Question 364

How to identify bundle branch block on ECG?

Answer 364

If QRS is broad look at V1: If QRS predominantly negative then its a LBBB If QRS predominantly positive then its a RBBB So much more reliable than William marrow as it doesn't rely on you looking at the shape of the QRS

Question 365

Bifascicular block vs Trifascicular bloc

Answer 365

Bifascicular block= RBBB + Left axis deviation Trifascicular block= RBBB+ Left axis deviation + 1st degree heart block

Question 366

Stokes–Adams syndrome?

Answer 366

episodes of syncope due to intermittent complete heart block or other high-grade arrhythmia which compromise cerebral circulation

Question 367

Half life of adenosine?

Answer 367

Adenosine has a very short half-life of about 8-10 seconds Patients who are given adenosine will experience unpleasant, but short-lived, side-effects.

Question 368

chest pain + neurology, always rule out

Answer 368

aortic dissection

Question 369

Narrow complex tachy?

Answer 369

Regular= SVT but if Mx fails consider flutter Irregular= AF

Question 370

Broad complex tachy?

Answer 370

Regular= V tach or SVT with BBB (if previously diagnosed) Irregular= torsades de pointes or if stable then AF with BBB

Question 371

Mx of SVT?

Answer 371

vagal manoeuvres -> IV adenosine if fails then ?flutter -> beta blocker

Question 372

MX of AF?

Answer 372

BB for rate control or onset <48hrs consider rhythm control -> cardioversion

Question 373

Mx of V tach?

Answer 373

IV amiodarone

Question 374

Mx of torsades de pointes?

Answer 374

IV magnesium sulphate

Question 375

Mx of severe bradycardia (signs of haemodynamic compromise)?

Answer 375

1) IV atropine (500mcg) if no response... 2) atropine, up to a maximum of 3mg 3) transcutaneous pacing 4)isoprenaline/adrenaline infusion titrated to response

Question 376

Mx of narrow or broad complex tachy if unstable?

Answer 376

synchronised DC shock

Question 377

A patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination -

Answer 377

ventricular septal defect

Question 378

What does it mean if patient's cardiac arrest was witnessed?

Answer 378

it was seen in a patient already receiving cardiac monitoring, such as in a coronary care unit

Question 379

Recent sore throat, rash, arthritis, murmur →

Answer 379

?rheumatic fever causes aortic regurg

Question 380

Overview of Mx after having stroke/TIA (after CT ect)?

Answer 380

TIA due to AF: DOAC immediately and continue for life TIA not due to AF: Aspirin 300mg immediately for 2 weeks and then clopidogrel lifelong Stroke due to AF: Aspirin 300mg for 2 weeks and then DOAC lifelong Stroke not due to AF: Aspirin 300mg for 2 weeks and then clopidogrel lifelong

Question 381

Ludwigs angina?

Answer 381

NOT CARDIO RELATED, it is a rare, life-threatening bacterial infection that affects the floor of the mouth and neck.

Question 382

What drug class can cause hyponatraemia, hypokalaemia and hypercalcaemia?

Answer 382

thiazide diuretic eg. Bendroflumethiazide

Question 383

.....should be suspected in patients with continuous dribbling incontinence after prolonged labour and from an area with limited obstetric services.

Answer 383

Vesicovaginal fistulae

Question 384

U waves?

Answer 384

hypokalaemia

Question 385

J waves?

Answer 385

hypothermia or hypercalcaemia

Question 386

Intermittent limb claudication, absent or weak peripheral pulses in a young woman, →

Answer 386

?Takayasu's arteritis

Question 387

A transjugular intrahepatic portosystemic shunt (TIPS) procedure connects

Answer 387

the hepatic vein to the portal vein

Question 388

Hormones in premature ovarian failure vs PCOS?

Answer 388

POF= high FSH PCOS= high LH and testosterone

Question 389

important differential for sudden visual loss in diabetics

Answer 389

Vitreous haemorrhage

Question 390

hyphema

Answer 390

blood collecting in the front (anterior) chamber of your eye usually caused by trauma to the eye, but can also occur after surgery

Question 391

Raised IOP number?

Answer 391

> 21 mmHg

Question 392

Beta blockers such as timolol work in primary open-angle glaucoma by

Answer 392

reducing aqueous production

Question 393

Mx of dry AMD?

Answer 393

There is no curative medical treatment for dry AMD. High dose of beta-carotene, vitamins C and E, and zinc can be given to slow deterioration of visual loss

Question 394

Corneal abrasion Mx?

Answer 394

topical antibiotics should be given to prevent secondary bacterial infection

Question 395

Red eye - glaucoma or uveitis?

Answer 395

glaucoma: severe pain, haloes, 'semi-dilated' pupil uveitis: small, fixed oval pupil, ciliary flush

Question 396

Common eye disorders affecting vision? (2)

Answer 396

Macular degeneration is associated with central field loss Primary open-angle glaucoma is associated with peripheral field loss

Question 397

In diabetic retinopathy, cotton wool spots represent...

Answer 397

areas of retinal infarction

Question 398

Primary open-angle glaucoma Tx?

Answer 398

360° selective laser trabeculoplasty (SLT) is first-line if the IOP is ≥ 24 mmHg

Question 399

If patients treated with PCI for MI are experiencing pain or haemodynamic instability post PCI, what should be done?

Answer 399

urgent coronary artery bypass graft (CABG) is recommended as suggests PCI failed

Question 400

investigation of choice for suspected aortic dissection (depending on stability of patient)

Answer 400

CT aortic angiography of the chest, abdomen and pelvis= a false lumen (NOT a coronary angiogram) Transoesophageal echocardiography (TOE) if unstable (NOT transthoracic)

Question 401

how would you know a type A vs type B aortic dissection?

Answer 401

The presence of the murmur. As the tear in the aorta grows in type A, it can affect the aortic root, where the aortic valve is, leading to acute aortic regurg= new early diastolic murmur

Question 402

Provoked PE?

Answer 402

surgery or immobilisation for 3 days in the last month Or recent long haul flight being started on COCP

Question 403

Following an ACS, all patients should be offered:

Answer 403

dual antiplatelet therapy (aspirin plus a second antiplatelet agent eg. ticagrelor) ACE inhibitor beta-blocker statin

Question 404

Way to remember hypokalaemia ECG findings?

Answer 404

U got no Pot and no T, but a long PR and a long QT.

Question 405

antihypertensive treatment should be offered only if the person is...

Answer 405

aged less than 80 years with stage 1 hypertension with one or more of, target organ damage, established cardiovascular disease, renal disease, diabetes, and/or a 10 year cardiovascular risk of 10% or more. If stage 2 hypertension is diagnosed then antihypertensive medication should be started regardless of age.

Question 406

systolic murmur, loudest in the second intercostal space, along the left sternal border; what sided heart failure would this be?

Answer 406

Right sided as the murmur is in the pulmonary region (pulmonary stenosis)

Question 407

Way to remember where the valves are and which side of the heart they are?

Answer 407

All Prostitutes Take Money A= aortic (R of sternum); left side of heart (heard in the right as loudest as goes towards upper right sternal border) P= pulmonary (L of sternum); right side of heart T= tricuspid (L of sternum); right side of heart M= mitral (L of sternum); left side of heart

Question 408

large, broad R waves in several leads are consistent with ...

Answer 408

posterior MI

Question 409

Which finding on ECG is most likely to prompt investigation for an acute coronary syndrome?

Answer 409

ECG shows new widening QRS complexes and a notched morphology of the QRS complexes in the lateral leads (new LBBB)

Question 410

Pt has renal impairment but needs a CT with contrast?

Answer 410

give IV saline (1mL/kg) before to reduce risk of contrast nephropathy

Question 411

Urge incontinence Mx?

Answer 411

1) Bladder retraining min 6w 2) Oxybutynin immediate release (or tolterodine (immediate release) or darifenacin (once daily preparation)) 3) If elderly give mirabegron (a beta-3 agonist) eg. if concern about anticholinergic side-effects in frail elderly patients

Question 412

Stress incontinence Mx?

Answer 412

1) Pelvic floor exercises min 3m 2) Surgery= retropubic mid-urethral tape procedures 3) Decline surgery= duloxetine (combined noradrenaline and serotonin reuptake inhibitor)

Question 413

HTN but renal impairment eg. CKD?

Answer 413

can still use ACE inhibitor (helps with CKD) but avoid if severe eg. GFR <30 or severe and hyperkalaemia (>5)

Question 414

SOB, sudden right chest pain radiating to right shoulder?

Answer 414

may be pneumothorax

Question 415

Normal JVP?

Answer 415

<=4cm above from sternal angle when at 45 degrees

Question 416

Mx of AF is BB is not an option?

Answer 416

BB, CCB or digoxin

Question 417

Haematuria after tonsillitis?

Answer 417

?IgA nephropathy

Question 418

What to do before deciding whether to prescribe an anticoag (DOAC) in pt with AF?

Answer 418

calculate CHADsVASc (don't just always prescribe to everyone with AF)

Question 419

Parkinson's pt agitated?

Answer 419

give lorazepam

Question 420

Serum osmolality vs urine osmolality?

Answer 420

Conc of solutes in blood vs urine Measurement of serum osmolality is used to evaluate the body's regulation of water and sodium balance, while urine osmolality evaluates the kidney's ability to concentrate urine.

Question 421

Causes of resistant hypertension?

Answer 421

primary aldosteronism (Conns) renal artery stenosis pheochromocytoma cushings hyper/hypothyroidism

Question 422

Carcinoma histology?

Answer 422

nuclei enlarged, hyperchromic and pleomorphic

Question 423

Inflam back pain improves with...

Answer 423

activity and is NOT relieved by rest (mechanical pain is opposite)

Question 424

Septic shock- what if give fluids and BP is still low and signs of hydration or even overload?

Answer 424

give noradrenaline as need vasoconstriction

Question 425

Premature ovarian failure vs PCOS bloods?

Answer 425

premature ovarian failure= raised FSH PCOS= raised LH and testosterone

Question 426

Young pt with intermittent palpitations and ECG showing sinus rhythym?

Answer 426

? supraventricular premature beats

Question 427

Summarise primary sclerosing cholangitis (PSC)?

Answer 427

may have history of UC; bilirubin and albumin at presentation typically normal; cholestatic pattern on LFTs; USS shows bile duct wall thickening an dilation; GOLD Ix= MRCP (cholangiopancreatography) showing beaded appearance of bile duct

Question 428

What is it important to check in a pt on lithium?

Answer 428

serum correctd Ca as risk of developing hyperparathyroidism

Question 429

What could be differentials for kidney injury in elderly pt who had a fall and long lie on floor?

Answer 429

If creatinine in the thousands think rhabdomyolysis If not then ?hypovolaemia eg. due to dehydration

Question 430

GOLD Ix for suspected c-spine fracture?

Answer 430

CT neck (not x-ray) eg. suspected, what is next most appropriate Ix- CT as best detected

Question 431

Analgesia following major abdo surgery with background of resp disease eg. COPD?

Answer 431

AVOID OPIOIDS Give epidural anaesthesia as this can be topped up and titrated but spinal anaesthesia cannot

Question 432

Mx of gout?

Answer 432

NSAIDs or colchicine first line if contraindicated eg. CKD or asthma then oral pred 15mg od

Question 433

MRCP vs ERCP vs liver biopsy indications?

Answer 433

1. Magnetic Resonance Cholangiopancreatography (MRCP)= Non-invasive imaging of the biliary and pancreatic ducts using MRI. Indications: - Suspected biliary obstruction (e.g., gallstones, strictures, tumors). - Evaluation of primary sclerosing cholangitis (PSC). - Ix of congenital biliary anomalies (e.g., choledochal cysts). - Suspected pancreatic ductal abnormalities (e.g., chronic pancreatitis). - Preoperative assessment of biliary anatomy before surgery. 2. Endoscopic Retrograde Cholangiopancreatography (ERCP)= Invasive procedure combining endoscopy and fluoroscopy to examine & treat biliary/pancreatic ducts. Indications: - Therapeutic purposes: Removal of choledocholithiasis (CBD stones). - Stent placement for strictures or malignancies. - Sphincterotomy for sphincter of Oddi dysfunction. - Drainage of bile leaks or pancreatic pseudocysts. - Diagnostic use (less common due to MRCP availability): - When tissue sampling (biopsy, brush cytology) is needed. - Unclear biliary strictures after MRCP. 3. Liver Biopsy= Histopathological assessment of liver tissue. Indications: - Unexplained liver disease (chronic hepatitis, fibrosis staging). - Autoimmune liver disease (e.g., autoimmune hepatitis, PBC, PSC). - Metabolic liver disease (e.g., Wilson’s, hemochromatosis, NAFLD/NASH). - Suspected malignancy (hepatocellular carcinoma, metastases). - Post-transplant rejection monitoring.

Question 434

Ix palpitations?

Answer 434

1) ECG, FBC, U&E, TFTs 2) Holter monitor 3) If no abnormality is found on the Holter monitor, and symptoms continue, other options include: external loop recorder or implantable loop recorder

Question 435

Antihypertensive drugs max doses?

Answer 435

Ramipril= 10mg Amlodipine= 10mg Indapamide= 5mg (normally 2.5) Candesartan= 32mg Spironolactone= 25mg Losartan= 100mg

Question 436

Acute heart failure not responding to treatment consider-

Answer 436

CPAP BiPAP usually in T2RF eg COPD exacerbation

Question 437

Posterior MI ECG?

Answer 437

ST depression and tall R waves

Question 438

Serum osmolality can be estimated using what equation...

Answer 438

2 * Na+ + glucose + urea

Question 439

Anion gap =

Answer 439

(sodium + potassium) - (bicarbonate + chloride)

Question 440

How to help identify cause of meningitis from CSF blood results?

Answer 440

1) Is CSF glucose less than half of serum glucose? Yes = Bacteria No = Viral 2) Are lymphocytes or polymorphs main present? Lymp = TB Poly= Non-TB

Question 441

Rinnes and webers test= what does negative and positive result mean?

Answer 441

unlike other tests, if the result is negative it is abnormal and if it is positive it is normal

Question 442

Affect of cocaine on the heart?

Answer 442

causes coronary artery spasm that induces ACS

Question 443

1st line Mx for bradycardia?

Answer 443

atropine (not fluids) as it DIRECTLY increases heart rate by blocking the parasympathetic (vagal) influence on the sinoatrial (SA) node.

Question 444

Ix if pt has recurrent candidiasis (4 or more in 1yr)?

Answer 444

test for diabetes with glycated haemoglobin (HbA1c)

Question 445

What type of airway Mx is used to prevent reflux of stomach contents into lungs?

Answer 445

tracheal tube (intubation) and NOT igel

Question 446

SVCO Mx?

Answer 446

dexamethasone

Question 447

Live size?

Answer 447

8cm palpable edge if 6cm or less then small 10cm or more then hepatomegaly

Question 448

Test to monitor resp function in myasethenic crisis?

Answer 448

FVC

Question 449

Ureteric stones with severe hydronephrosis?

Answer 449

nephrostomy to decompress renal pelvis

Question 450

1st line Mx for micro & macroprolactinomas?

Answer 450

cabergoline or bromocriptine (dopamine agonists)

Question 451

Mx of asytstole?

Answer 451

adrenaline/epinephrine only Tx alongside chest compressions (NOT FLUIDS)

Question 452

Ix in pt who was in house fire?

Answer 452

carboxyhaemoglobin as CO inhalation likely

Question 453

PE order of most appropriate Ix?

Answer 453

CXR to rule out other causes; Wells score; then either CTPA or V/Q scan

Question 454

Nephrotic syndrome in adults= what is needed to diagnose before starting Tx?

Answer 454

renal biopsy

Question 455

Ovarian ca- 1st lymph node will spread to?

Answer 455

para-aortic nodes

Question 456

Most common cause of cellulitis (incl in diabetics)?

Answer 456

Streptococcus pyogenes then less commonly Staphylcoccus aureus

Question 457

Pathophysiology of SIADH?

Answer 457

Syndrome of inappropriate ADH secretion with hyponatraemia and inappropriately concentrated urine. ADH stimulates synthesis of aquaporin-2 in the apical membrane of the collecting duct which promotes water absorption. This leads to a dilutional hyponatraemia. (Increased water absorption in the collecting duct)

Question 458

Causes of high plasma aldosterone:renin ratio?

Answer 458

primary hyperaldosteronism causes of primary hyperaldosteronism= bilateral idiopathic adrenal hyperplasia (most common) and adrenal adenoma- CONNS

Question 459

Cause of subcutaneous emphysema on side of pts neck?

Answer 459

usually due to an underlying injury to the airway or oesophagus eg. oesophageal rupture where air gets trapped under the skin of the neck, causing a noticeable swelling and a crackling sensation when touched

Question 460

Do all pneumothoraces cause tracheal deviation?

Answer 460

No primary (Simple/spontaneous) pneumothorax: Usually doesn't shift the mediastinum or trachea. tension pneumothorax does

Question 461

Mx of superficial thrombophelbitis?

Answer 461

NSAIDs and compression stockings

Question 462

Fibrocystic breast changes vs fibroadenoma?

Answer 462

fibroadenoma solid but fibrocystic are fluid filled

Question 463

What is the extensor plantar response?

Answer 463

also known as the Babinski reflex, is a reflex that causes the big toe to extend upwards when the sole of the foot is stimulated

Question 464

Does pt with primary sclerosing cholangitis always have fever and jaundice?

Answer 464

No, may be asymptomatic or subtle symptoms like fatigue, abdominal discomfort, or itchy skin (pruritus) and is picked up by abnormal LFTs. Common to present like this in EARLY stages of disease or if pt has ulcerative colitis.

Question 465

ECG in aortic dissection

Answer 465

non-specific changes usually do: - CXR= widened mediastinum - CT angiography chest, abdo and pelvis (GOLD)= false lumen - TOEcho if unstable

Question 466

Rheumatoid arthritis usually affects multiple joints so it pt presents with swelling, pain and stiffness in 1 joint think what?

Answer 466

gout or OA

Question 467

When are compression stockings contraindicated?

Answer 467

PAD

Question 468

Mx of venous ulcers?

Answer 468

compression bandaging, usually four layer= inital Tx, open ulcers, until healed then compression stockings= after healed to prevent recurrence

Question 469

Suspected diabetes insipidus, exclude what before water deprivation test?

Answer 469

exclude hypercalacaemia (with serum corrected calcium) due to hyperparathyroidism before Ix for diabetes insipidus

Question 470

Mx of acute gout in CKD4?

Answer 470

oral pred NOT NSAIDs

Question 471

CK in rhabadomyolysis?

Answer 471

>10,000

Question 472

What artery may be the source of major haemorrhage in peptic ulcer disease?

Answer 472

gastroduodenal artery (runs posterior to 1st and 2nd parts of duodenum)

Question 473

Cord compression Mx?

Answer 473

if elderly, frail and/or multiple lesions then radiotherapy not surgical spinal cord decompression

Question 474

Boerhaave syndrome?

Answer 474

Transmural distal oesophageal rupture caused by sudden increase in intraoesophageal pressure Ix: - CXR= left-sided effusion or pneumomediastinum - Barium swallow= GOLD Tx= surgery

Question 475

Awaiting surgery, fluid to run alongside VR insulin infusion in diabetics?

Answer 475

Sodium chloride 0.45% / glucose 5% / potassium chloride 0.15% 1000mL in 8h

Question 476

Rivaroxaban and apixaban can be reversed by

Answer 476

andexanet alfa

Question 477

Screening for an abdominal aortic aneurysm consists of

Answer 477

single abdominal ultrasound for males aged 65

Question 478

Mining occupation, upper zone fibrosis, egg-shell calcification of hilar nodes → ?

Answer 478

silicosis

Question 479

What test is consistent with successfully treated syphilis?

Answer 479

Negative non-treponemal test + positive treponemal test

Question 480

Hep... is spread by the faecal-oral route and is most commonly spread by undercooked pork

Answer 480

E

Question 481

Organisms causing post splenectomy sepsis: (eg. pt with resp infection with history of splenectomy)?

Answer 481

Streptococcus pneumoniae Haemophilus influenzae Meningococci

Question 481

Stroke initial Mx?

Answer 481

Within 4.5 hours: Thrombolysis with Alteplase, followed 24 hours later by aspirin 300mg After 4.5 hours: No thrombolysis; just give Aspirin 300mg

Question 482

Fever on alternating days, think?

Answer 482

malaria

Question 483

When using an inhaler, for a second dose you should wait for approximately how long before repeating?

Answer 483

30 secs

Question 484

The differentiation between delirium and dementia?

Answer 484

impairment of consciousness eg. lower GCS; fluctuation in symptoms and hallucinations.

Question 485

Men who have sex with men should be offered immunisation against

Answer 485

hep A

Question 486

Examination of the right eye reveals a painful, red eye, with a small and irregularly-shaped pupil- diagnosis and Mx?

Answer 486

Anterior uveitis steroid + cycloplegic (mydriatic) drop

Question 487

All men presenting with erectile dysfunction should have what checked?

Answer 487

morning testosterone HbA1c and lipids

Question 488

What electrolyte abnormalities does vomiting and diarrhoea cause?

Answer 488

Diarrhoea can cause a normal anion gap acidosis because the gastrointestinal loss of bicarbonate causes a reciprocal increase in serum chloride. Vomiting causes alkalosis as gastric secretions (which are very acidic) are lost.

Question 489

management of severe alcoholic hepatitis

Answer 489

1st= corticosteroids to limit inflammation. then also= Lactulose is indicated if hepatic encephalopathy is suspected to avoid constipation, a common precipitant. Do not consider liver transplant if pt is still consuming alcohol.

Question 490

catheterised patient has developed an asymptomatic bacteriuria- what do you do?

Answer 490

No Tx needed. Very common amongst catheterised patients. As this very rarely leads to serious sequelae, it should not be treated with antimicrobials.

Question 491

Any critically ill patient (including CO2 retainers) should initially be treated with? Eg. with COPD presents with suspected CO poisoning and O2 sats 78%, how do you treat the low sats?

Answer 491

Reservoir mask at 15 litres/min high flow oxygen which is then titrated to achieve target sats. Hypoxia kills If was COPD exacerbation- 28% Venturi mask at 4 litres/min is used prior to the results of blood gases in patients with risk factors for hypercapnia aiming for oxygen saturation of 88-92%.

Question 492

BiPAP vs CPAP indications?

Answer 492

BIPAP - COPD / weaning off ventilation CPAP - most T1RF causes (pneumonia, heart failure etc...) + OSA

Question 493

URTI symptoms + amoxicillin → rash ? diagnosis and diagnostic Ix?

Answer 493

Glandular fever Monospot test (blood test that detects the presence of heterophil antibodies made following infection with Ebstein-Barr virus)

Question 494

The ward doctor is asked to prescribe maintenance fluids for a pt. Her body weight is 60kg and her height is 157cm. What following fluid regimes replaces the potassium correctly for this patient?

Answer 494

30mmol K+ per 12 hours as gives a total of 60/24hrs

Question 495

.... is used to prevent vasospasm in aneurysmal subarachnoid haemorrhages?

Answer 495

Nimodipine (NOT nifedipine)

Question 496

Human bites, like animal bites, should be treated with what?

Answer 496

co-amoxiclav High-risk areas include the hands, feet, face, genitals, skin overlying cartilaginous structures or an area of poor circulation. If a bite has broken the skin but not drawn blood, antibiotics should be considered if it is in a high-risk area or if the person is at high risk (immunosuppression, diabetes, asplenia or decompensated liver disease)

Question 497

What drugs may exacerbate psoriasis?

Answer 497

beta blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors, infliximab

Question 498

Areas affected in Wernickes and Brocas dysphasia?

Answer 498

Wernickes (dont understand but normal speech)= Temporal Brocas (broken speech but understand)= Frontal Spoken word is heard at the ear. This passes to Wernicke's area in the temporal lobe (near the ear) to comprehend what was said. Once understood, the signal passes along the arcuate fasciculus, before reaching Broca's area. The Broca's area in the frontal lobe (near the mouth) then generates a signal to coordinate the mouth to speak what is thought (fluent speech).

Question 499

severe headache, left retro-orbital pain, left loss in visual acuity, conjunctiva are red and the cornea looks hazy. Pupillary light reflexes on the right are normal; however, the left pupil is non-reactive?

Answer 499

acute angle-closure glaucoma Initial Mx= Direct parasympathomimetic e.g. pilocarpine and beta-blocker eye drops. Definitive Mx= laser peripheral iridotomy

Question 500

The following drugs may exacerbate myasthenia?

Answer 500

penicillamine quinidine, procainamide beta-blockers lithium phenytoin antibiotics: gentamicin, macrolides, quinolones, tetracyclines

Question 501

Mx should be used in euvolemic and hypervolemic hyponatraemic patients who don't have severe symptoms?

Answer 501

fluid restrict

Question 502

Summarise hyponatraemia Mx simply?

Answer 502

- Euvolaemic or hypervolaemic and >120 = fluid restrict - Hypovolaemic and >120 = IV 0.9 NaCl - <120 or symtomatic= Hypertonic saline (either 1.8% or 3% NaCl)

Question 503

NIV should be considered in all patients with an acute exacerbation of COPD in?

Answer 503

whom a respiratory acidosis (PaCO2>6kPa, pH <7.35 ≥7.26) persists despite immediate maximum standard medical treatment

Question 504

When to consider mirabegron instead of oxybutynin in overactive bladder eg. male?

Answer 504

if 1st line fail (oxybutynin), if antimuscarinics are not tolerated or not effective or if there is concern about anticholinergic side-effects in frail elderly patients (>65yrs)

Question 505

Patients with chronic kidney disease should be started on what?

Answer 505

ACE inhibitor if they have an ACR > 30 mg/mmol

Question 506

CKD: only diagnose stages 1 & 2 if what?

Answer 506

supporting evidence to accompany eGFR eg. patient has an eGFR between 60-90 ml/minute. This would be classified as CKD stage II if there were accompanying evidence of kidney damage e.g. abnormal U&Es or proteinuria. If these are absent we do not classify this as having chronic kidney disease.

Question 507

most common cause of peritonitis secondary to peritoneal dialysis?

Answer 507

Coagulase-negative Staphylococcus eg. staph epidermis

Question 508

Secondary prevention following ACS?

Answer 508

- dual antiplatelet therapy (aspirin plus a second antiplatelet agent eg. ) - ACE inhibitor - beta-blocker - statin GIVE ALL DAPT= Ticagrelor/prasugrel/(clopi less common now) + aspirin

Question 509

Alzheimer's disease causes widespread cerebral atrophy mainly involving what areas of brain?

Answer 509

cortex and hippocampus (in temporal lobe)

Question 510

IgM vs IgG in hep B?

Answer 510

IgM = IMmediate infection (acute) IgG = aGed infection (chronic)

Question 511

What foods to avoid in coeliac disease and what can you eat?

Answer 511

AVOID= barley, wheat, couscous, bread, rye bread (rye-gluten), pasta, cereals Can eat= rice, potatoes, corn (maize), quinoa

Question 512

If a patient has a urine output of < 0.5ml/kg/hr postoperatively the first step is...

Answer 512

consider a fluid challenge, if there are no contraindications or signs of haemorrhage etc do not need to remove catheter

Question 513

Patient with acute asthma who do not respond to full medical treatment and are becoming acidotic should be...

Answer 513

intubated and ventilated, do NOT do BiPAP/CPAP

Question 514

What is the most accurate marker for assessing the function of the liver in acute liver failure vs chronic liver failure?

Answer 514

Acute= Prothrombin time - Prothrombin has a shorter half-life than albumin, making it a better measure of acute liver failure Chronic= Albumin

Question 515

When may you order a DaTscan?

Answer 515

?parkinsons or lewy body dementia MRI for vasulcular, alzheimers ect dementia

Question 516

Finasteride treatment of BPH may take how long before results are seen

Answer 516

6m

Question 517

What should be suspected in the presentation of dyspnoea and hypoxaemia around 72 hours postoperatively?

Answer 517

Atelectasis A common postoperative complication in which basal alveolar collapse can lead to respiratory difficulty. It is caused when airways become obstructed by bronchial secretions. Management positioning the patient upright chest physiotherapy: breathing exercises

Question 518

1st line Mx in any trauma pt?

Answer 518

immobilise c-spine!!!

Question 519

patients will present following trauma within the previous 24-72 hours. The most common presenting features is worsening shortness of breath, however other symptoms include confusion, drowsiness, or the development of a petechial rash (Fig. 2, classically seen in the axilla and conjunctivae). On examination, patients will be tachypnoeic, tachycardic, and hypoxic. Often neurological signs that develop are non-specific, including acute confusion or seizures. A low grade pyrexia can also occur. In late stages of the disease, features of organ dysfunction will develop. what is the diagnosis?

Answer 519

fat embolism RFs= young age, long bone fractures, closed fractures or multiple fractures, and conservative management for long bone fractures

Question 520

What is atelectasis?

Answer 520

the collapse of part or all of a lung, is caused by a blockage of the air passages (bronchus or bronchioles) or by pressure on the lung. Risk factors for atelectasis include anesthesia, prolonged bed rest with few changes in position, shallow breathing and underlying lung disease. Mucus that plugs the airway, foreign objects in the airway (common in children) and tumors that obstruct the airway may lead to atelectasis. Large-scale atelectasis may be life threatening, especially in someone who has another lung disease or illness.

Question 521

Sjogrens?

Answer 521

autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces. It may be primary (PSS) or secondary to rheumatoid arthritis or other connective tissue disorders, where it usually develops around 10 years after the initial onset F>M marked increased risk of lymphoid malignancy

Question 522

dry eyes: keratoconjunctivitis sicca dry mouth vaginal dryness arthralgia Raynaud's, myalgia sensory polyneuropathy recurrent episodes of parotitis renal tubular acidosis (usually subclinical)

Answer 522

Sjogrens

Question 523

Ix for Sjogrens?

Answer 523

rheumatoid factor (RF) positive in nearly 50% of patients ANA positive in 70% anti-Ro (SSA) antibodies in 70% of patients with PSS anti-La (SSB) antibodies in 30% of patients with PSS Schirmer's test: filter paper near conjunctival sac to measure tear formation histology: focal lymphocytic infiltration also: hypergammaglobulinaemia, low C4

Question 524

Mx for Sjogrens?

Answer 524

artificial saliva and tears pilocarpine may be helpful to stimulate saliva production

Question 525

How to know if type 2 resp failure is acute or chronic based on ABG?

Answer 525

Acute= pH low, bicarb normal or slightly increased, base excess may be normal Chronic= pH near normal (due to compensation); bicarb elevated (eg. >28); base excess markedly increased (> +4) Acute: The rise in PaCO₂ happens suddenly, and the kidneys haven’t had time to compensate by increasing HCO₃⁻. So, pH is low, and HCO₃⁻ is normal or slightly elevated. Chronic: The kidneys have compensated by retaining HCO₃⁻ over time, which normalizes pH despite persistently high PaCO₂.

Question 526

Elderly patient dizzy on extending neck

Answer 526

??vertebrobasilar ischaemia BPPV does causes vertigo upon head movement, but the characteristic production of symptoms on neck extension makes this a less likely diagnosis than vertebrobasilar ischaemia.

Question 527

Mnemonic to remember Salter Harris classification: (for fractures)

Answer 527

SALTER S: Type 1; Slipped, # through growth plate only A: Type 2; Above, # 'above' growth plate (metaphysis) and in growth plate L: Type 3; Lower, # below growth plate (epiphysis) and in growth plate TE: Type 4; Through Everything, # through all 3 elements R: Type 5; Rammed, crush # of growth plate I: horizontal line II: backwards L III: upside down L IV: vertical line

Question 528

Use of 0.9% Sodium Chloride for fluid therapy in patients requiring large volumes eg. 6L = risk of...

Answer 528

Hyperchloraemic metabolic acidosis