OSCE Flashcards

Question

Pressure sores Management

Answer 1

Ix: Assess cause, location, grade, size, infection, odor, exudate Waterlow risk assessment Grade based on appearance and depth Tx: Pressure redistribution, nutrition, analgesia, dressing (-ve pressure) Rotate position, address incontinence, malnutrition, regular skin assessment Debridement 6w fluclox if osteomyelitis Plastic surgery

Answer 2

Can present with gradual onset of fluctuating pain, headaches, blurred vision and halos appearing around lights, particularly at nighttime Ix: Fundoscopy - cupping of optic disc (>0.4), notching, retinal haemorrhage Vision assessment - scotoma, loss of peripheral vision (Humphrey visual field) Tonometry (>21mmhg) Goniometry - exclude AACG Slit lamp MRI scan of orbit if suspect graves or orbital cellulitis Tx: 1st line - latanoprost (prostaglandin analogue) or timolol (beta blocker) 2nd line - switch, combine or add pilocarpine, acetazolamide, bimonidine Laser trabeculoplasty, trabeculotomy, aqueous shunt Monitor yearly for rest of life -

Answer 3

If >50 and smoke or evidence of lung disease -> secondary Primary <2cm AND no breathlessness = discharge with outpatient x-ray Primary, >2cm OR breathless = percutaneous aspiration and oxygen then 2nd x ray to confirm gone Secondary <1cm = oxygen and admit for 24 hours Secondary 1-2cm = aspiration (if fails then chest drain) Secondary >2cm OR breathless = chest drain (if fails then discuss with thoracic surgeon) Tension = needle decompression in 2nd IC space MC line, oxygen then chest drain in triangle of safety Refer for pleurodesis if recurrence or surgery for open thoracotomy and pleurectomy or video-assisted thoracoscopic surgery with pleurectomy and pleural abrasion (better tolerated than open surgery)

Answer 4

Ix Investigate cause of fall - syncope, CV, neuro, mechanical Assess for risk factors: vision impairment, cognitive impairment, fear, arthritis, alcohol, urinary incontinence, tinnitus, vertigo etc fragility fracture - fracture from standing height Assess mobility with timed get up and go test - (>12-15s = high risk) or turn 180 test (>4 steps high risk) QFracture - risk of fragility fracture DEXA scan if fracture ( -1to-2.5 = osteopenia, >-2.5 = osteoporosis) If >2 falls in past 12 mo or needed medical attention post fall do multifactorial falls risk assessment ``` Mx Lifestyle - exercise, stop smoking/alcohol, increased vit D and calcium Exercise - weight bearing, muscle strengthening, balance exercises, back care Adjust medication PT, OT Walking aids Home adjustment and support Treat osteoporosis Vision correction Footwear ```

Answer 5

``` Causes: Pain Infection Nutrition Constipation Head injury, hypoxia Endocrine + electrolyte - altered pH, hypo/hyper Na+ Ca++, acute liver or renal failure, hypoglycaemia Stroke Medication and alcohol Environment ``` Ix: Take a Hx from person and third party Baseline Cognitive assessment based on DSM-V criteria or a 4AT or CAM, AMT10 Admit for further investigations and treatment U+E, ABG, HbA1c/BM, Infection screen (CXR, urinalysis, FBC), LFT (encephalopathy), neuro exam, medication review, home hazard review confusion screen: FBC, LFT, CRP, U+E, ABG, Coag, TFT, Bone profile, Mg, b12, folate, ferritin Mx: Treat cause Optimise treatment of Comorbs, medications Reorientation strategies Quiet side room, normalise sleep/wake cycle Home comforts PT/OT assessment Home hazard assessment Give haloperidol or benzodiazepines as sedation may be used if very agitated Explain diagnosis to carers

Answer 6

Ix: Do a dermatological exam - ABCDE, determine classification (superficial, nodular) Use Glasgow 7 point checklist Dematoscopy Biopsy - excisional with 2mm margins Breslow, Clarkes (not part of staging), ulceration, mitotic index give indicator of prognosis Do CT if suspect metastatic spread, assess for BRAF mutation ``` Mx: Wide local excision with margin based on breslow thickness insitu - 5mm <1mm - 10mm 1-2 - 10-20 2-4 - 20-30 >4 - 30mm +/- lymphadenectomy/ sentinel LN biopsy Can also do electrochemotherapy ``` If metastatic - BRAF inhib, immunotherapy e.g. ipilimumab, chemo, interferon alpha

Answer 7

Ix: Do neurological examination Do routine obs, perform a GCS, listen to carotids for bruit Can use FAST screening tool in primary care Refer to specialist centre for appointment within a day FBC, ESR, U+E, LFTs (including PT, INR), TFT, ECG Do CT head if suspect haemorrhage Carotid doppler to look for stenosis Assess risk of stroke using ABCD2 score Mx: 300mg aspirin loading dose immediately Discuss lifestyle: diet, exercise, smoking, alcohol Treat CV risk factors e.g. BP, cholesterol Give 300mg clopidogrel loading dose then continue on 75mg a day long term If >70% stenosis - carotid endarterectomy

Answer 8

Ix: Take history and perform cardiac examination Do an ECG to look for ST elevation or LBBB Take serial troponins Do routine bloods: FBC, U+E, LFT, CRP, CK, myoglobin, lipids, TSH CXR, echo Consider exercise stress test, CT angiogram or Coronary angiogram to investigate angina Sx and degree of CAD ``` Mx: O2 if sats less than 94% Morphine, metoclopramide 10mg of each Nitrates Aspirin 300mg Ticagrelor according to Chadvas/hasbled Heparin if going for PCI Resuscitate Glycoprotein inhibs if PCI ``` Use grace score to decide the risk of MI and need for PCI Discuss lifestyle risk factors e.g. diet, exercise, smoking, alcohol Evaluate CV risk factors and start on statins, Acei, Beta blockers 12m Ticagrelor and aspirin For stable angina: 1st line - rest +GTN 2nd line - Beta blocker or CCB (verapamil/diltiazem) 3rd line - Beta blocker + CCB (bisoprolol and nifedipine) 4th line - Add in long acting nitrate (isosorbide mononitrate), nicorandil, ivabradine, ranolazine + Secondary prevention: 3A’s: aspirin (75mg OD), atorvastatin (80mg OD), ACEi (e.g. ramipril, titrated up to max dose)

Answer 9

Ix: Do surgery reading, if raised then do ambulatory home blood pressure monitoring for 7 days If >140/90 - stage 1 If >160/100 - stage 2 If >180/110 - stage 3 Tx: Lifestyle advice and education: - exercise, low salt diet, weight loss, smoking, alcohol, reduce caffeine - educate about the risks of hypertension including renal disease, eye disease, CV disease and metabolic disease If <55 or diabetes- ACEi If >55 or black - CCB e.g. amlodipine Step 2 - add each other or thiazide diuretic Step 3 - all 3

Answer 10

``` Ix: Respiratory exam Blood + sputum culture CXR FBC, U+E, LFT, CRP, ABG Lung function test Sepsis 6 is suspect systemic infection, dropping vitals Procalcitonin to monitor ``` Do CURB 65 - who needs admission Confusion, Urea >7, RR >30, BP <90/60, >65 home: 0-1, hosp >2, ITU >3 ``` Tx: Educate, stop smoking Fluids Oxygen if hypoxic Analgesics for pleuritic pain Start on antibiotics - low severity: amoxicillin - Mod: amoxicillin +/- clarithro - severe: co-amox + clarithro ``` If suspect aspiration -> metronidazole

Answer 11

Ix: Do a GI exam - look for jaundice FBC, U+E, CRP, LFT (ALP/GGT/billirubin), amylase/lipase (pancreatitis) ABG, culture if suspect sepsis US gallbladder ECRP, MRCP or HIDA cholescintigraphy if US -ve Contrast CT for cholangitis or if suspect complication e.g. perforation Mx: Acute cholecystitis: Monitor BP, pulse urine output Analgesics - diclofenac or opioid IV abx - trust guideline (cefuroxime and metro) Laparoscopic cholecystectomy - Nil by mouth, IV fluid, analgesia, ondasteron Cholangitis Monitor BP, pulse urine output Analgesics - diclofenac or opioid IV abx - trust guideline (cefuroxime and metro) ERCP to remove stone or can stent/lithotripsy Cholecystectomy

Answer 12

Ix: Comprehensive history Visual assessment, fundoscopy if eye signs Neuro exam/CN exam if neurological symptoms Take drug history to identify if medication overuse Mx: Educate, do headache diary to understand triggers and avoid them. Limit standard analgesics Optimise Comorbs e.g. OSA, insomnia, depression Take off oral contraceptive pill 1st - Ibuprofen, aspirin, paracetamol + metoclopramide + sumatriptan - take at start of headache not aura Prevention: Propanalol (1st line in women of childbearing age), Topiramate, amytriptalline - start if 2 or more attacks a month that last 3 or more days Consider mindfulness, acupuncture, riboflavin

Answer 13

Ix: CN exam Examine face and dental cavity MRI if diagnostic uncertainty, young, suspect malignancy or MS, not improve with treatment Tx: Educate patient, get to understand their triggers e.g. shaving, cold air to face etc Carbamazepine 1st line - titrate up to effective dose, explain not work immediately alternatives - baclofen, lamotrigine Can give botulinum, perform decompression

Answer 14

Tx: Avoid triggers such as alcohol and smoking Acute: 100% O2 via non rebreathe and sumatriptan, metoclopramide if nausea Prevention: verapamil, lithium or prednisolone

Answer 15

Ix: Routine observations Medication history - blood thinners FBC, U+E, LFT, CRP, Coagulation profile (INR, PT), Group and save Mx: Immediate management includes pinching the soft cartilage at the base of the nose for 15 mins, leaning forward and placing a cold compress on bridge of nose or back of neck In hosp: AtoE Wide bore cannula - blood/fluid Stop warfarin, reverse with vit K, reverse doac If stop with pinching give naseptin If not stop visualise with thidicum to locate a bleeding point If present cauterise with silver nitrate If not present then pack nose - rapid rhino Admit to hosp for review and remove after 24 hours, then reattempt cauterisation If still bleeding - ligate artery under GA Avoid blowing or picking the nose, heavy lifting, strenuous exercise, lying flat, drinking alcohol or hot drinks, avoid hot showers, 2w naceptin

Answer 16

Otitis media Sx: Earache, fullness, hearing loss, fever Ix: Otoscopy to look for bulging, redness of TM, fluid level or perforation, impedance audiometry to measure pressure in middle ear, do nasal endoscopy to check the openings of eustachian tubes, audiometry if hearing loss Mx: Analgesics, warm compress, most self limiting. If severe, <2yo, bilateral: oral amoxicillin Consequences include mastoiditis, facial nerve palsy, meningitis, cerebral abscess. If mastoiditis - IV abx, consider CT (if consider surgery or abscess, have headache, lethargy etc) and mastoid air cell clearance. Otitis media with effusion - due to closure of Eustachian tube. Get negative pressure in middle ear, draws fluid in from middle ear. hearing loss, poor speech development, ear popping, imbalance If effusion - fullness, hearing loss persists after infection treated. Observe for 6-12 weeks for spont resolution, if ongoing, limiting development, bilateral consider grommets, adenoidectomy If perforation persists (Chronic otitis media) - antibiotics and surgery to fix eardrum Otitis externa Sx: Ear pain, itch, discharge often post water based activity. If unrelenting pain that interferes with sleep, hearing loss, FN involvement, fever think necrotising otitis externa (do CT, CRP, ESR) Ix: otoscopy - red swollen external auditory canal, ear swab if recurrent, if necrotising do CT/ MRI Mx: Clean ear, analgesic, often self limiting - if severe: ear wick, acetic acid or topical antibiotic (aminoglycoside e.g. gent or ciprofloxacin) +/- hydrocortisone drops, keep ears dry. For necrotising, same day referral to ENT, 6w oral ciprofloxacin Cholesteatoma Sx: Non resolving unilateral offensive discharge thats unresponsive to antibiotics Ix: Retraction of pars flaccida on otoscopy, if facial nerve involvement or planned surgery do an MRI Tx: Surgical removal often required - canal wall up mastoidectomy Also want to rule out CSF if base of skull fracture - test for glucose and beta 2 - transferrin

Answer 17

L side: bleeding, altered bowel habit R side: anaemia, weight loss, abdo pain Ix: Abdominal and PR exam looking specifically form mass Routine observations FBC (anaemia), U+E, LFT (mets), CRP, CEA, CA19-9, BRAF ``` 2ww: 1st line: Colonoscopy with biopsy 2nd line: Barium enema CT TAP - staging and metastatic identification Liver Ultrasound PET scan ``` Screening: Faecal immunochemical testing - every 2 years from age of 60-74. If +ve have colonoscopy 2ww: Aged 40 and over with unexplained weight loss and abdominal pain Or if they are aged over 50 with unexplained rectal bleeding Or if they are over 60 with IDA or changes in their bowel habit Mx: Remove polyp on colonoscopy and send for histology Segmental resections with anastomosis or stoma Radiotherapy Chemo: FOLFOX, anti-VEGF

Answer 18

Causes: HF, CKD, Cirrhosis, Cellulitis, venous insufficiency, DVT, obesity, immobility, protein loss in IBD/ coeliac, pregnancy, lymphedema, hypothyroid ``` Ix: Urinalysis to look for high protein in nephrotic syndrome FBC, U+E, LFT, CRP, BNP, TFT Abdo/pelvic US look for ascites, tumour, liver mets CXR for HF, lung malignancy ECG D-Dimer/ Doppler for DVT Pregnancy test ``` Mx: Dependant on cause Epirical management with diuretics not appropriate without clear cause

Answer 19

Ix Blood, pressure, pulse, saturations FBC (WCC), ESR/CRP (Inflammatory markers for septic arthritis), blood cultures Xray to exclude fracture and tumour US to see if there is an effusion within the hip Aspirate hip for microscopy and culture Tx if septic arthritis: Sepsis 6 Escalate Surgery: incision and drainage - perform a washout - need to do asap as otherwise can get avascular necrosis Infection in joint replacement is grumbling, low grade, aspirate, ESR/CRP, take to theatre, remove metalwork, insert antibiotic spacer, give IV abx then replace metalwork

Answer 20

Ix Assess level of pain and limitations of activity Assess psychological impact Do examination of joint and one above/below Calculate BMI Bloods: FBC (WCC), U+E (before starting on NSAID), LFT as baseline, CRP/ESR (identify inflammation) Do Xray of the joint Consider joint aspiration to rule out gout, septic arthritis Mx Educate, weight loss, physio, hot/cold compress, stop smoking, foot wear, psych, TENS WHO pain ladder Surgical opinion of refractory to conservative

Answer 21

Ix Examination and history - systems review FBC, U+E, LFT, CRP/ESR, RF, Anti-CCP, ANA Xray - bony erosions, joint space narrowing, soft tissue swelling, juxta-articular osteoporosis US - look for effusion and thickening/blood flow in synovial membrane Joint aspiration if suspect septic Assess disease activity with DAS28 Mx Educate, lifestyle, psych Assess psych wellbeing NSAID for pain relief Corticosteroid if flare - up to 3x a year 1st Line: cDMARD e.g. methotrexate, if palindromic hydroxychloroquine. Bridge with glucocorticoid. 2nd Line: bDMARD (if 2x above ineffective) e.g. TNF inhibit adalimumab, Anti CD20 rituximab 3rd line: surgery Drug SE Steroids - Infection, osteoporosis, DM, cushings Methotrexate – liver toxicity, pneumonitis, oral ulcers

Answer 22

Ix: Qfracture risk assessment tool: if >10% in 10 years then perform a DEXA scan DEXA of -2.5 or more is diagnostic Investigate for vit D, calcium deficiency, do U+E, LFT (high ALP, low Ca, PO4 in osteomalacia, all normal in osteoporosis) Do xray if suspect fracture Do a falls risk assessment and assess fragility with a timed get up and go test (comprehensive geriatric assessment) Investigate cause (steroids, DM, hypogonadism, hyperthyroid, GI, RA) Mx: Education, fall prevention programmed, exercise, balance training, diet, smoking, alcohol 1st line bisphosphonate e.g. alendronate 2nd line: raloxifene, strontium ranalate, zoledronic acid Replace vit D, calcium as needed HRT if premature menopause

Answer 23

Schizophrenia = overactivity of dopamine in mesolimbic pathway Decreased dopamine in mesocortical leads to negative sx d2 blockage in nigrostriatal pathway leads to parkinsonian, dystonia, akathisia sx Tuberoinfundibular pathway blockade leads to hyperprolactinaemia 2 types: Typical = D2 antagonist Atypical = D2 + 5HT2a SE: typical - extrapyramidal (Parkinsonism, acute dystonia, akathisia, tardive dyskinesia), sedation (histamine), anticholinergic (constipation, dry mouth, urinary retention, confusion), postural hypotension, impotence Atypical - Weight gain, hyperprolactinaemia, sedation, QTC prolongation, postural hypotension, anticholinergic, reduce seizure threshold, agranulocytosis To reduce: Reduce qqt of drug, switch to atypical or procyclidine can be used EPS (anticholinergic) Parkinsonism, akathisia, acute dystonia To improve compliance - depot NMS: - fever, tachy, fluctuating BP - due to muscle contraction - Raised CK/Myoglobin, MI - muscle rigidity, tremor - altered mental status - autonomic dysfunction Protect airways, stop antipsychotic, cool, dialysis for AKI/rhabdo, benzo if agitated, Bromocriptine, amantadine, dantrolene in sever cases

Answer 24

>3 or more of - withdrawal, lack of control over qqt, impulse, difficulty controlling when start/stop, tolerance, affecting other activities, persisting despite negative effects Alcohol limit is <14 units a week spread over 3 days CAGE (>2)/AUDIT (>16) score - screen for heavy alcohol use SADQ score - measure dependence & tolerance ``` Brief intervention: FRAMES F - feedback (risks) Dependance can lead to: - Alcoholic liver disease, cirrhosis, liver failure - pancreatitis - cause high blood pressure - Cancer incl head/neck, bowel - Wernickes, Korsakoff - Peripheral neuropathy - Sexual dysfunction ``` ``` R - responsibility to change A- advise the need to cut down M - menu of alternative options - (non drinking days, different alcohol, low alcohol drinks, alternative activities E - empathetic interviewing S - self efficacy ``` Mx: - CBT - Alcoholics Anonymous - Family, social behaviour therapy - Rehabilitation - Advice of social drinking, keeping an alcohol diary Meds - Antabuse (drinking brings on nasty SE), Naltrexone/Nalmefene (reduce pleasurable effects), Acamprosate (reduces cravings) For withdrawal (delirium tremens) - reducing dose of chlordiazepoxide over 5-7 days and thiamine (pabrinex)

Answer 25

Hyperlipidaemia, proteinuria, hypoalbuminuria, peripheral oedema

Answer 26

``` Ix: Take plasma paracetamol lvl 4 hours post ingestion U+E, LFT as baseline Regular BM for hypoglycaemia Clotting screen, INR ABG for Acidosis ``` Mx: If within an hour give activated charcoal If >4 hrs but <10-12 hours, >100mg/L then give 3 bags of IV N-acetylcysteine infusion over 21 hours If doubt about timing or staggered give irrespective If >150mg/kg give prior to bloods Stop when level <10, bloods normalise If pH <7.3, Lactate or INR high, high grade encephalopathy consider transplant

Answer 27

Ix: Hx - ask about onset of jaundice and encephalitis Asses consciousness/ mental state and do abdo exam for asterixis/ ascites Raised PT, low Albumin Do routine bloods (FBC, LFT, U+E, glucose, INR, ammonia) and liver screen (hep b/c AI etc) High ammonia -> encephalopathy Do G+S, blood culture if suspect infection ABG for lactate Liver US + doppler for Budd chiari CT - Assess for cerebral oedema, raised ICP, EMG Investigate for cause - caeruloplasmin (low), alpha 1 antitrypsin, ferritin (haemochomatosis), ANCA, AI screen, Alcohol, viral Mx: Treat cause Fluid resus - fix distributive shock with: Fluids, monitoring urine output, BP Encephalopathy -Lactulose with neomyciny, mannitol can reduce ICP IV glucose Coagulopathy - clotting factors, plasma, platelets, PPI to stop bleeding AKI - Correct electrolytes, dialysis Abx prophylaxis Consider transplant based on kings college criteria if high INR, quick onset encephalopathy, high bilirubin

Answer 28

Truvada OD + Raltegravir BD for 28 days Works by inhibiting viral replication stopping the virus from entering the blood and reaching the LN Can do if present within 72 hours of event Screen for STI, do HIV, check baseline U+E, LFT prior to starting Give emergency contraception if needed, ensure woman avoids getting pregnant whilst on treatment Consider Hep B vaccine Side effects include: tiredness, diarrhoea, nausea, vomiting, feeling generally unwell HIV test at 8-12 weeks post exposure Advise to attend future regular sexual health checks Pre-exposure prophylaxis is just Truvada OD

Answer 29

- Oesophagitis and oesophageal ulcers - Osteonecrosis of the jaw - Atypical fractures of the proximal femoral shaft - Acute phase reaction: arthralgia, myalgia and fever - Hypocalcaemia - Alopecia - Allopecia Take 30 mins before a meal and sit upright for 30 mins after

Answer 30

``` WIPE Ask about any recent symptoms, anything they want to discuss about their medication Take a brief PMHx, Social Hx, allergies Ask about prescribed medication - indication, when start, dose, dose regimen, when do you take, how do you take OTC meds Extras - inhalers, creams ICE Summary, advice, med changes, plan ```

Answer 31

``` GORD Peptic ulcer Hiatus hernia Gastroparesis - DM Malignancy Drugs lactose intolerance Coeliac ``` Lifestyle - smaller more regular meals, lift head in bed, eat meals earlier, weight loss, avoid trigger foods, smoking, stress/anxiety GORD: Ix - PPI trial, OGD if any alarm symptoms (anorexia, anaemia, loss of weight, IDA, melaena) Mx Consider a month trial of PPI to help the oesophagus heal, if severe 2months. If recurrent put on lowest effective dose long term If ineffective consider laparoscopic fundoplication Peptic ulcer: Ix - Hpylori breath test or stool antigen test (not have taken PPI for 2w or Abx for 4), OGD with biopsy, FBC for anaemia due to blood loss, Mx Review meds (aspirin, bisphosphonates, corticosteroids, potassium supplements, SSRIs, cocaine) Ask about prev Abx that could affect H pylori tx 7d - Omeprazole, clarithro and amoxicillin Retest breath or stool test as TOC Hiatus hernia/ malignancy - Barium swallow or endoscopy

Answer 32

Diabetes is diagnosed as a HbA1c > 48, Fasting >7 or random glucose >11.1 1 +ve result with sx, 2x if no symptoms First line management is lifestyle, education (DESMOND, X-pert programmes) - exercise, reduce intake of sugar, low GI foods, reduce alcohol, stop smoking, weight loss, screening If HbA1c > 48 start metformin 500mg OD, each week increase by 500 to max of 2g If HbA1c >53 then start then add DPP4, SGLT2, pioglitazone, SU If still >53 - triple therapy SU - hypo, gain weight SGLT2 - (gliclazide) Improve weight, cardio and renal protective (not work if eGFR <60 TZT - contraindicated with haematuria DPP4 - (-gliptin) not improve weight, use in liver or renal failure GLP-1 - (-tide) third line, only use if already on triple therapy If insulin/ SU - aim 53 If others aim 48 Consequences Microvascular - neuro, nephropathy (peripheral, autonomic e.g. gastroparesis, erectile dysfunction), retinopathy Microvascular - ischaemic heart disease, stroke, PVD Annual review Take a hx, ask about how managing, sx, SE of tablets Depression and anxiety Qrisk to look for CV disease - cholesterol, BP, BMI Do a blood glucose measurement - HbA1c Diabetic retinopathy screen Foot exam - check sensation, for ulcers, do ABPI Ask about autonomic SE including erectile dysfunction, gastroparesis Nephropathy - early morning first pass urine specimen for ACR, also do creatinine level for eGFR

Answer 33

Localised: DVT, cellulitis, rheumatoid arthritis, lymphedema, malignancy Systemic: Heart failure, liver failure, nephrotic syndrome calcium antagonists, NSAIDS, hypothyroid Have neuropathy, greater than 2 degrees difference in temp between two feet Charcot Mx: Xray and screen for infection and ulcers: involves MDT, nurses, podiatry, diabetes drs, orthopaedics Immobilisation of the joint in a cast (or with orthopaedic stabilisation), which will usually remain in place for 3 – 6 months (monthly X-Rays are used to assess progress) - takes weight off of foot to allow healing Surgery is required if foot deformity puts the patient at risk of ulcers or protective footwear (custom braces and orthotic footwear) is not effective. Also if is unstable fractures or dislocations. Longer term management is with optimisation of diabetic control, including BP and lipids, as well as specialised footwear and education Important to regularly check the feet for ulcers May require amputation if not healing and infection The total process of healing usually takes 1 – 2 years Give antibiotics as needed,

Answer 34

Caused by normal ageing, trauma, steroids, DM Clouding, loss of vision, washed out colours, glare, defect in red reflex ``` Ix: Check visual acuity with snellen, colour vision and peripheral vision with Humphrey's Dilated fundoscopy Slit lamp exam Tonometry - assess IOP Wild field fundoscope images OCT for macula degen and oedema ``` Mx Conservative - watchful waiting, optimisation of glasses If visual impairment refer for phacoemulsification +/- intra-ocular lens implant To drive: need to be able to read a number plate from 20m away and need to see at least 6/12 on snellen ``` Phacoemulsification - LA - Incise into cornea - remove anterior lense capsule - Using US break up and aspirate lens - remove cortex - Insert post chamber IOL into capsule (decide lens using biometry which includes measurement of the eye) - postop given topical steroids and antibiotics ``` Complications - rupture of posterior capsule leading to a dropped nucleus. Post operative can get infection called endopthalmitis (staph epidermidis). Can also get post op raised IOP, macular oedema, retinal detachment

Answer 35

CP leads to death of retinal pigment epithelium geographic atrophy and neovascularisation Loss of central vision and distortion of vision (straight lines appear crooked, fluctuates from day to day ``` Ix: Slit lamp Dilated fundoscopy Visual acuity Retinal wide field imaging OCT can identify drusen Amsler grid Fluorescein angiography ``` Mx: Educate, stop smoking, exercise, diet rich in leafy green veg and fruit, antioxidant and mineral supplements e.g. AREDS2, register as sight impaired Dry - give an amsler grid, say to self monitor at home In early stages observe, visual rehab, safety net If neovascularisation - anti-VEGF (bevacizumab), injection monthly for 3m - other options - laser photocoag, photodynamic therapy with verteprofin and implantable miniature telescope (focuses central visual field onto healthy portion of retina)

Answer 36

LFT, U+E, FBC, CRP, coag Viral serology including hep B/C antibody antigen tests HCV RNA, HBV DNA Hep B - acute Hep C - more chronic Treat with: Avoid unprotected sexual intercourse Contract tracing, inform local health protection team Regular monitoring of INR, PT and LFTs Avoid alcohol and stop non essential meds Supportive treatment with fluids, antiemetics, rest Treat itching with chlorphenamine Consider antiviral agents if fulminant hepatitis or chronic

Answer 37

Ask about joints (polymyalgia rheumatica), scalp, vision, jaw, resp tract sx ``` Ix: Exam, bloods: FBC (normochromic normocytic anaemia and an elevated platelet count) , U+E, LFT (raised ALP), ESR, CRP Fundoscopy (CRAO), RAPD Biopsy Duplex US PET ``` ``` Mx: If strong clinical suspicion start high dose corticosteroids immediately prior to confirmation with biopsy - IV Methylpred if eye - 60mg pred if jaw, 40mg if no jaw - Assess response after 48 hrs - Taper and continue for 1-2 years Start aspirin 75mg daily unless contraindications + PPI If recurrent tocilizumab ```

Answer 38

``` Ix: CV, neuro, MSE - identify injuries Routine obs FBC, U+E, LFT, CRP, BM (hypoglycaemia), Raised prolactin and CK ECG MRI - look for structural cause EEG ``` Mx: Advise on water safety (shower not bath, buddy system), leave bathroom door unlocked, fire safety and cooking, environment and work safety. Care with heights, high risk activities and consider contraception for certain meds. Advise family and carers. 1st seizure - 6months for car 5 years for HGV epileptic seizure 1 year for car >1 seizure - 10 years for HGV Focal - carbamazepine Tonic-clonic seizures: sodium valproate or lamotrigine. Absence seizures: ethosuximide or sodium valproate Myoclonic seizures: sodium valproate or topiramate. Status epilepticus = seizure >30 mins or recurrent without regaining consciousness (treat at >5mins) AtoE Lorazepam 4 mg IV, if unavailable; Diazepam 10 mg PR, if unavailable; Midazolam 10 mg buccal if 2 doses of above 10 mins apart, if not work give phenytoin If phenytoin not work transfer to ITU for GA

Answer 39

``` Ix: Bedside - urinalysis and culture Bloods - urate and calcium levels, FBC, U+E, LFT, CRP, Ca, PTH (exclude high ca as cause), uric acid Imaging - US for hydronephrosis, CT KUB Stone analysis ``` Struvite stones - stag horn calculi Mx: Advice to increase fluids, loose weight, reduce salt/urate/oxalate/protein in diet At home, (<5mm) - fluids, pain relief (PR diclofenac), antiemetic - most pass within 3w. Refer all to urology within 7 days. can help passage with CCB (nifedipine) or alpha blocker (tamsulosin) ``` In hosp - AtoE give IV fluids If hydronephrosis - stent, nephrostomy, catheterise Treat infection Shock wave lithotripsy Percutaneous removal Uretero-renoscopy ``` Prevention - potassium citrate, thiazide diuretics

Answer 40

Ix: Regular bloods, Clotting, albumin, ascitic tap, liver screen, US, MRI/CT Perform ascitic tap if suspect SBP - raised WCC and neutrophils. Treat with abx (cefotaxime/ ceftriaxone) and human albumin solution Put on a low salt diet - in some this will be enough to resolve 1st line fluid restrict and spironolactone 2nd line furosemide Aim for no more than 1kg loss a day If large, refractory or causing resp compromise paracentesis followed by plasma expansion If persistent - TIPS Cholestyramine for pruritis

Answer 41

1 yearly checkups - 2 x digital fundus photographs ``` Ix: Presence of micro aneurysms, haemorrhages, cotton wool spots, hard exudates on fundoscopy OCT can show macula oedema Fleuroscein angiography B scan US to look for detachment Examine cranial nerves Check red reflex for cataracts ``` ``` R0 - no changes R1 - just haemorrhage or microaneurysm R2 - extensive above or cotton wool spot R3 - neovascularisation M0 - no maculopathy M1 - maculopathy present ``` Tx: Optimise glucose, BP, lipids Stop smoking, healthy diet, observe Macular oedema - focal laser, intravitreal steroids proliferative retinopathy - pan retinal photocoag, anti-VEGF (bevacizumab) Vitrectomy if virtual bleed

Answer 42

Periorbital oedema, intraocular muscle swelling, redness, photophobia, eyelid retraction, proptosis Ix: TFTs and MRI of orbits, anti-TSH receptor antibodies Management: Conservative first line - lubricating/ NSAID eye drops, stop smoking, avoid dmg to eyes with sunglasses when out, taping shut at night. Prism glasses. To reduce inflammation use corticosteroids Surgery if raised IOP (decompression), if scar tissue pulls eye out of alignment

Answer 43

Ix: Visual acuity, slit lamp exam, gonioscopy Acute angle closure - acetazolamide and pilocarpine + laser iridotomy Keratitis - corneal ulcer, red, painful, photophobia, corneal infiltrate (staph a, pseudomonas, herpes). Diagnose by presence of lesion on slit lamp. Manage with corneal scraping, intensive topical antibiotics (broad spectrum at first e.g. gentamicin), cyclopentolate for pain relief See acanthamoeba in contact lense wearers Avoid steroids in keratitis, herpes keratitis as would dampen immune system Uveitis - pain, photophobia, flashers, floaters, blurring Aqueous flare, synechiae, HLA B27 Treat cause: non infectious - corticosteroid eye drops, cyclopentolate for pain and systemic immunosuppressants e.g. methotrexate

Answer 44

Defined as BMI below 17.5 kg/m2 Ask about binge eating, purging, vomiting, perceptions towards appearance, typical food consumption in a day, how often weigh self or look in mirror, make excuses not to eat. Ask about excessive exercise, any tablets used to loose weight. Lack of insight into own weight loss. Ask about menstrual irregularities, sexual dysfunction, weakness, fainting, fatigue, constipation, changes in skin or hair, seizures? SCOFF questionnaire do you make yourself Sick have you lost Control over how much you ear lost > One stone in last 3m Do you believe you are Fat when others say you are thin would you say Food dominates your life Routine obs + blood glucose Sit-up, Squat–stand test - rank difficulty BMI, FBC, U+E, LFT, CRP, ESR, TFT, Bone profile, Mg ECG Pregnancy test Consider DEXA if <18, >1year Assess risk with marsipan document Immediate referral to CAHMs, community mental health team or eating disorder specialist If high risk, risk of referring syndrome admit <18 - anorexia focussed family therapy or individual CBT/ psychotherapy second line >18 - eating disorder based CBT, group therapy If refuse to eat - NG tube and TPN, consider sedation if refusing, emergency crash team General monitor food consumption + U+Es Avoid QT prolonging drugs e.g. citalopram If vomiting - dental checkup, rinse mouth with mouthwash after rather than cleaning Stop excessive exercise/laxatives Dexa scan, refer to diabetes if insulin misuse Advise against conception until weight improves, give contraception even if amenorrhoea

Answer 45

Low potassium, magnesium, phosphate and thiamine Fluid retention leads to peripheral oedema Can get fluid overload, HF and arrhythmias

Answer 46

Hypotension, fatigue, weight loss, GI/MSK sx, hyperpigmentation, hair loss in women, salt craving Ix: Early morning serum cortisol Synacthen test Test ACTH level to differentiate primary and secondary Electrolytes - low sodium, high potassium Mx: Educate that it is a chronic condition, will need to take medication for the rest of their life. Is important they take the medication every day, not suddenly stop. Ensure they know how to recognise an adrenal crisis (hypotension, hypovolaemic shock, low blood glucose, N+V, abdo pain, low grade fever) Treatment involves a combination of hydrocortisone taken 3x daily 10mg on waking, 5mg at noon and 5mg in the evening and fludrocortisone Can get all their medications for free Wear a medic alert bracelet Educate on sick rules - mild to mod (fever, Abx) - 2x dose for 2 days - severe - 2x dose, cont until better - vomit - if vomit within 30 mins, double dose again immediately, if again then 100mg hydrocortisone inject - maj surgery - cont infusion If go abroad take enough for double doses + injection kit Addisonian crisis - hypotension, high K, low NA, vomiting, weight loss AtoE Identify cause, screen for infection Iv hydrocortisone 100mg-200mg IV fluid rehydration

Answer 47

Central obesity, HTN, insulin resistance, facial redness, purple striae, easy bruising, premature osteoporosis, facial rounding, menstrual abnormality, acne, mood changes Ix: 1st 24hr urine free cortisol or 1mg overnight dex suppression test - 3.5-4.5 norm for urine, <2 norm for suppression test 2nd - repeat (2mg instead) to confirm +ve 3rd - ACTH lvl (differentiate if primary or secondary) 4th - High dose (8mg) dex suppression test (differentiate between secondary causes of pituitary or ectopic small cell lung cancer CT adrenals, MRI pituitary, CT chest if ectopic Mx: Surgical removal of adrenal tumour, pituitary adenoma or cause of ectopic ACTH Transsphenoidal pituitary adenomectomy Radio or bilateral adrenal removal second line Metyrapone, ketoconazole - can block production or function of cortisol

Answer 48

Ix: CKD is defined by albumin:creatinine ratio (taken early morning) and the creatinine (GFR) Other investigations need to do include U+E, BP, BM, ca, PO4, Hb, PTH (high ca, high PTH, low PO4) Also CT KUB, US kidneys, ANCA/ANA, urinalysis, culture, biopsy if glomerulonephritis Mx: Treat cause - immunosuppressants for glomerulonephritis, diabetic drugs, antiHTN Stop nephrotoxics, monitor, lifestyle changes Give statins, aspirin (if high risk CVD) Keep blood pressure below 130/80 - ACEi Correct any fluid overload with diuretics Correct any electrolyte imbalances (K+ high) Replace EPO if anaemia Vit D, Ca supplements, PO4 binder If acidosis give bicarb End stage - renal replacement therapy or transplant (5-7 or <10 w. sx)

Answer 49

Changes - High K+ - High PO4 - High uric acid - Low Ca Lab TLS - if 2 or more of above are abnormal or change by >25% within 3d before, 7d after chemo Do ECG Clinical TLS = Lab + symptoms (raised creatinine, seizure, dysrhythmia) Large tumour burden haematological malignancies with recent chemo most common cause ``` Management: General - prechemo fluids Low risk - just fluid Mod risk - allopurinol 7 days High risk - 1 dose rasburicase 3mg ``` Acute: Uric acid - Rasburicase PO4 - give phosphate binders e.g. aluminium hydroxide K+ - calcium gluconate, insulin/dextrose solution Ca - calcium gluconate Renal failure - fluids and haemodialysis if needed

Answer 50

Screening - every 3 years from 50-70 earlier if gene mutation, have MRI Investigations: breast exam, US, cancer markers (CEA, CA 15-3) 2ww: > 30 + unexplained breast lump or >50 + nipple discharge, retraction. ``` Triple assessment: Hx and exam, imaging, Biopsy/FNA Hormone receptor status CXR, routine bloods US of LN CT if suspect mets ``` Nottingham prognostic index predicts survival/ relapse Treatment - wide local excision - breast conserving - Mastectomy with reconstruction - +/- LN biopsy/clearance - +/- chemo with anthrocycline - alternative is radiotherapy Hormone therapy - cause infertility If ER positive - Tamoxifen if premenopausal or Anastrozole if post menopausal If HER2 positive - Herceptin

Answer 51

Open consultation - Acknowledge difficult topic say if want to stop and have a break at any time please say How long been going on for, any triggers? How much been affecting life - appetite, sleep, exercise, social life, hobbies, mood, libido How changed over time Anything your worrying about Anything pre-occupying your mind When is it at its worst What do you feel is getting you through Hows your concentration, how feel about self, how feel about future Have you ever thought about harming yourself or others Have you ever felt the opposite to how you are now, particularly high? What do you think is causing this, anything you're worried about? Have you ever felt like this before? Have you ever suffered with mental health conditions before or been on any medication How are you otherwise, fit and healthy Any family history of mental health conditions? ``` Do you drink, smoke, take drugs? Live alone, with family? Able to look after self? Relationships? Support network? ```

Answer 52

Normal valve - staph A Abnormal valve - strep viridens Prosthetic valve - staph epidermis Investigate with DUKE criteria 2 major (+ve blood culture, evidence of endocardial involvement) 1 major, 3 minor 5 minor

Answer 53

Ix: Hx, Exam Serial troponin, CK-MB, myoglobin if recent MI ECG - look for ST elevation, new LBBB, Q wave ECHO/ CXR Bloods - FBC look for anaemia, U+E to check renal function for contrast, BNP O2 sats ``` Mx Morphine +metoclopramide O2 if sats <94% Nitrates - GTN infusion Aspirin 300 Relocate to cardiac intensive unit Ticagrelor 180 Unfractionated heparin - give for max of 5 days, stop post PCI ``` PCI with stent (or CABG if multi vessel disease) within 90 mins, if not possible within 120 give thrombolysis w. alteplase or streptokinase If low CO consider ionotrope e.g. dobutamine Post MI discuss lifestyle - smoking, alcohol (<14), exercise (150 mins a week, weight training at least 2days), cardio protective diet (reduced salt and fat, more fruit, seeds and nuts, more fish). ``` Start on ACEi Beta blocker Antiplatelet - aspirin + ticagrelor - 12m, after this cont aspirin, stop ticagrelor Rehab Statin ``` Antianginals - give ranolazine if low BP

Answer 54

Raised JVP, low BP, muffled heart sounds Lie with feet up Treat cause (infection, malignancy, aortic dissection, AI), most resolve on own IV fluids, O2 Ionotropes e.g. dobutamine Pericardiocentesis, pericardial fenestration

Answer 55

Manage with Vagal manoeuvre. If not work try adenosine to slow heart rate (see cause) then verapamil, then DC cardioversion, then amiodarone Long term ablation, beta blocker, Stop driving until sx controlled for 4w

Answer 56

Alcohol - history Hep B/C - history and serology NAFLD - hx, exclusion Hered haemochromatosis - ferritin, transferrin Alpha-1-antitrypsin deficiency - A1-AT lvl Wilsons - caeruloplasmin AI - Hepatitis, PBC, PSC - AI screen complications - anaemia - clotting issues, low platelets - encephalopathy - varices - HCC - Low albumin and ascites - SBP - altered drug metabolism

Answer 57

Hyperkalaemia Pulmonary oedema Uraemic encephalitis or pericarditis Metabolic acidosis

Answer 58

On exam looking for stony dullness, reduced breath sounds, reduced chest expansion, reduced vocal resonance Take detailed history to elucidate cause Do CXR, bloods to differentiate causes, ABG, CT if suspect malignancy, ECG/echo for HF Important take a sample of pleural fluid using US to differentiate cause - look at protein, LDH. Not needed if bilateral effusion typical of transudate if asymptomatic - 50ml, if symptomatic aspirate till sx improve Send for biochem (pH, protein, LDH, glucose), cytology (blood), microbiology (gram stain and culture) If >35 = exudate (unilateral) - cancer, infection, PE, AI, pancreatitis If <25 = transudate (bilateral) - HF, LF, RF, hypo-albumin, peritoneal dialysis Can also be haemothorax, chylothorax, empyema (pH <7.2) If between the two use lights criteria - is exudate if Protein pleural: blood >0.5 LDH pleural:blood >0.6 LDH pleural >2/3 upper limit of normal for serum Also send aspirate for cytology, pH, glucose, gram stain, culture and sensitivity, acid fast bacilli Treatment If transudate - treat underlying failure - diuretics etc If exudate - small - observe - infection - Abx - Large - therapeutic aspiration (no >1.5L), chest drain - If recurrent - long term chest drain or pleurodesis

Answer 59

Prev LRTI, TB Asthma/COPD CTD - SLE, RA CF, kartagners On exam: Clubbing, coarse crackles, rhonchi, high pitch squeaks and pops Ix O2 sats, sputum culture FBC, U+E, LFT, CRP, ANCA, ANA, RF, ant-CCP, genetic for CF, specific IgE for ABPA Bronchoscopy if single area, suspect aspiration High resolution CT shows signet ring, dilation without thickening Tram track on xray Mx Stop smoking, annual vaccines, physio for sputum clearance, acapella/flutter devices Humidification Mucoactive agent - saline neb, DNAase, carbocisteine If >3 exacerbations a year azithromycin prophylaxis Bronchodilators - SABA/LABA Treat cause e.g. CF LTOT if sats <88% or PO2 < 7.3 Surgical - lung resection if localised, transplant if <65

Answer 60

Symmetrical erythematous patches, papules and plaques with overlying silver scale Differentials - dermatitis, lichen planus, cutaneous lymphoma Recent alcohol binge -> rash = psoriasis Ix: Clinical diagnosis, skin biopsy only if doubt Auspitz sign - removal of scales causes capillary bleeding IBD, assess CV risk Ask about nails (pitting and onycholysis), joints, dactylics (swelling of digit) Dermatology quality of life index score Use psoriasis area and severity index (PASI) to assess severity, also assess body surface area affected Tx: Educate, is chronic condition, help sx not cure Identify + avoid precipitants, stop smoking, alcohol, healthy lifestyle diet and exercise Emollient, salicylic acid for scale/itch 1st line - vit D analogue OD + topical corticosteroid OD If after 4-8 weeks not gone stop steroid and try vit d analogue BD for 12 w. If still not better consider corticosteroid BD or coal tar If ongoing treatment resistant consider referral and dithranol Dermatology - topical calcineurin inhib, ciclosporin, acitretin, narrow band UVB. If UVB ineffective consider methotrexate, ciclosporin or TNF alpha inhibitors e.g. adalimumab For joint - do xray (central erosions), bloods, joint aspiration. Treat with NSAID first line, 2nd line corticosteroid injection and if active disease methotrexate, if dactylitis or entheses - adalimumab, NSAID Guttate psoriasis - rain drop lesions, commonly post strep throat, treat with phototherapy Pustular psoriasis - acute withdrawal of psoriasis meds - treat with supportive care and systemic management

Answer 61

Red itchy rash in skin folds Erythema, scaling, papules, scratching lead to excoriation, lichenification If round, scaly = discoid eczema Ask about hx of atopy Ix - clinical - consider allergy testing - swab if suspect infection - eczema area and severity index Mx - educate patient is a chronic condition that will come and go, requires treatment all the time, can become infected (red, hot swollen) if so see the doctor, usually grow out of it, avoid exacerbating agents - avoid allergens, tight clothing, soap substitutes, keep house cold, cut finger nails and avoid animals Mild - emollient + mild topical steroid (put steroid on 30 mins post emollient) Mod - emollient + moderate topical steroid + non sedating antihistamines if itch (maintain on steroid or calcineurin inhib) Severe - emollient + potent topical steroid + antihistamine (sedating if itch affecting sleep) or oral steroid. Can also use calcineurin inhib e.g. tacrolimus Mild - hydrocortisone Mod - bethametasone - 0.025% Severe - bethametasone - 0.1% Refer to derm - phototherapy, immunosuppressants e.g. methotrexate, biologics, Treat 2ndry infection with fluclox if develop blisters - think eczema herpeticum

Answer 62

Ix: MRI/CT - look at size of ventricles (normal) LP - assess pressure Visual field mapping ``` Mx: Loose weight, lifestyle Acetazolamide, serial LP can drop ICP Prednisolone for papilloedema Surgery - bariatric, CSF shunt ```

Answer 63

Ix: CT head - extradural lemon, subdural banana If small, no sx watch and wait If large, causing symptoms then consider surgical decompression with burr hole Manage fall holistically

Answer 64

Often first sign is drooping of eyelid and diplopia, then get muscle weakness that is worse with exertion. Worse at end of day. Myopathy, eye trauma, third nerve palsy, cyst or swelling - differentials for MG eye symptoms Ix: Do a full neuro exam, assess vision and muscle weakness Crushed ice on eye for 3 mins, improves ptosis Ask to count to 50 and see if they tire Anti-Acetylcholine receptor antibodies Repetitive nerve stimulation test CT/MRI of thymus to look for thymoma Tensilon test - rarely done as can cause bradycardia Mx: Myasthenic crisis - intubation, mechanical ventilation + immunoglobulins, plasma exchange and steroids Treat with acetylcholinesterase inhibitor e.g. pyridostigmine, add steroids or azathioprine if not sufficient. Is also rituximab, biologics TPMT before start azathioprine, not combine with allopurinol Oral atropine for muscarinic SE If thymoma present - thymectomy

Answer 65

``` Ix Clinical diagnosis of ascending weakness, parasthesia and hyporeflexia occurring post infection Do NCS, EMG Look for antibodies Do LP - protein in CSF Spirometry if suspect resp involvement Routine bloods ``` Mx: Immunoglobulins and plasma exchange Supportive care - treat resp failure, monitor heart, give analgesics and DVT prophylaxis Improves over time

Answer 66

``` Ix sx worse when hot (uhthoffs) Routine bloods, vit B12, HIV MRI LP - oligoclonal bands Antibody testing EDSS to assess disability ``` Mcdonald criteria - inflammatory cause - no other cause - lesions at different locations at different times (>2) If just one lesion = clinically isolated syndrome Differential - neuromyelitis optica ``` Mx Education and general care Oxybutynin for bladder dysfunction Laxatives for constipation SSRI for depression PT/OT for mobility neuropathic pain killers amantadine for fatigue baclofen for spasticity ``` acute relapse - steroids +ppi long term - beta interferon glatiramer

Answer 67

Present with dry cough, worse at night, haemoptysis, SOB, chest pain, weight loss Can present with SVC obstrusctuction - facial venous engorgement Pancoast: Sympathetic chain, subclavian vein, brachial plexus -> horners (anhidrosis, ptosis and miosis), pain, weakness, atrophy, oedema in upper limb Also get laryngeal nerve involvement -> hoarse voice Differential = lung abscess, cervical disc prolapse with concurrent TB, Lung mets 2ww if evidence of cancer on CXR or >40 with haemoptysis Ix: Obs, FBC (anaemia), LFT (ALP high in bone mets), U+E, bone profile (Ca may be raised due to PTH or bony mets, Na may be low if SIADH) CXR, CT TAP, Bronchoscopy with biopsy or percutaneous biopsy Paraneoplastic Squamous - PTH Small cell - ACTH, SIADH, Lambert eaton (antibodies to voltage-gated calcium channels, prox and ocular weakness better with exercise) Mx: Stage fitness with ECOG Early disease consider surgery (lobectomy) Consider adjuvant or neoadjuvant chemotherapy (platinum based) Radiotherapy often used in palliative cases

Answer 68

Support head and control airway during movements Warming - prevent coagulopathy, periop cardiac events, reduce risk of postop infection - Anaesthesia cause vasodilation Fluid balance for perfusion Positioning – avoid nerve and pressure injury Prevent awareness, maintain appropriate level of anaesthesia – unplanned recall of events Muscle relaxants as and when needed by the surgeon Manage haemorrhage with blood transfusion or fluids CV manipulation Increase HR with anti-muscarinic (atropine or glycopyrrolate) or mixed beta-adrenoceptor agonist e.g. ephedrine Reduce HR with Beta blocker Increase BP with alpha 1 adrenoceptor agonist e.g. metaraminol Reduce BP with alpha antagonist e.g. phentolamine

Answer 69

Haemorrhage, basal atelectasis, shock, sepsis, DVT/PE Compression stockings, enoxaparin pre and post op Obs for shock: Low BP, tachycardia, tachypnoea, low O2 sats, reduced urine output Sepsis 6 Basal atelectasis - deep breathing exercises and physio Anaesthesia anaphylaxis: IM adrenaline, chlorphenamine, hydrocortisone, fluid challenge On intubation or removal of ET tube: Bronchospasm: IV salbutamol +/- aminophylline Laryngospasm: Check airway clear, 100% oxygen (CPAP), may need suxamethonium to relax muscles or propofol to deepen anaesthesia and re-intubate Clonidine used to treat shivering as muscle contraction increases O2 consumption Malignant hyperthermia – Autosomal dominant Caused by volatile anaesthetic/ suxamethonium Increased O2 consumption, hypercapnia, raised HR/RR, acidotic, hyperthermia See rhabdomyolysis – raised myoglobin, creatinine kinase, potassium Stop current anaesthesia (volatile) and start propofol Give dantrolene + 100% O2, cool via cold IV saline, NG lavage, give bicarb if acidosis, treat high K+, treat dysrhythmias

Answer 70

Ask: how long for? Tinnitus, hearing loss, what makes better, what makes worse, headaches, visual changes? If seconds to minutes, comes on when turning head, no tinnitus or hearing loss: BPPV - diagnose with dicks hall pike manoeuvre (rotary nystagmus) - treat with epley manoeuvre - educate, advise against sudden head movements and sit/lie down in stages If >20 mins to hours, fullness in ear, sensorineural hearing loss, tinnitus, N+V = Menieres - inform DVLA - limit salt, alcohol, caffeine as can trigger - avoid dangerous activities - prochlorperazine for vertigo and nausea - beta-histone as prophylaxis, diuretics in 2dry care - hearing aid for hearing loss If spont vertigo lasting days = acute labyrinthitis (hearing loss) or vestibular neuritis (no hearing loss). Often post viral infection. - resolves on own in few weeks - start moving as soon as possible - not drive when dizzy - if severe consider antihistamine/ antiemetic e.g. prochlorperazine - give antiemetics, hydration, vestibular rehab If central (also sx of dysphagia, dysarthria, diplopia, dysmetria) - brainstem lesion or acoustic neuroma

Answer 71

If suspected septal haematoma – same day 5-7 days for first ENT OPD follow up from date of injury (allows for bruising/swelling to settle) 7-21 days for MUA (manipulation under anaesthetic) – callous formation occurs after this 3-6 months if thinking of operation (rhinoseptoplasty) – await full healing

Answer 72

Examine throat with tongue depressor (not use if stridor due to epiglottitis) Common causes: cold, influenza, strep, infection mononucleosis, herpetic pharyngitis, smoking, acid reflux, hay fever, leukaemia Splenomegaly, cervical lymphadenopathy, mono-spot test can be used to identify IM 2 main causes are tonsillitis and infectious mononucleosis Tonsillitis can be viral or due to strep pyogenes IM is caused by EBV To differentiate the two look at LN - if only anterior chain involved most likely strep if widespread lymphadenopathy most likely IM Use feverPAIN and Centor criteria to identify strep throat - fever, lymphadenopathy, exudate, no cough Advise general measures to make more comfortable - Regular use of ibuprofen and paracetamol - Adequate fluid intake - saltwater gargle, local anaesthetic lozenges/ spray In mild cases usually get better by self, help sx with above May prescribe back-up prescription - Phenoxymethylpenicillin first line for 10 days In severe - if dysphagia and high fever consider IV fluids, Abx and steroids. If sx of severe sore throat, dysphagia, trismus or stridor consider epiglottitis (AtoE) Main complications are quinsy (needle drainage), otitis media, sinusitis, acute rheumatic fever, acute glomerulonephritis If >7 in one year, 5 per year over 2 or 3 per year over 3 refer for tonsillectomy - major complication is primary haemorrhage within 48hrs, return to theatre ``` If IM: Avoid contact sport for 3 weeks Avoid alcohol Paracetamol + NSAID No antivirals Avoid ampicillin/amoxacillin as can cause rash ```

Answer 73

AIDS = CD4 <200 or HIV + indicator disease HAART - 2 nucleoside reverse transcriptase inhibitors + one of integrase strand transfer inhibitor, non-nucleoside reverse transcriptase inhibitor, protease inhibitor E.g. Truvada + Raltegravir (integrase) or Etravirine (NNRTI), Indinavir (PI) Early stages - seborrheic dermatitis, varicella zoster, herpes reactivation, oral or genital candidiasis Later on - karposi sarcoma (tumour caused by herpes, presents as purple lesions in mouth or on the skin) Pneumocystis jirovecii - pneumonia, also TB, Mycobacterium avium CMV, Cryptosporidiosis -> diarrhoea, CMV also cause retinitis Toxoplasmosis, cerebral lymphoma -> neuro Sx Cryptococcal meningitis

Answer 74

First catch urine/ vulvovaginal swab NAAT test - 2w window period Gonorrhoea can also be examined by microscopy and culture - gram-negative diplococci Transvaginal US, cervical motion tenderness - can be used to identify endometritis and salpingitis of PID Chlamydia - 7d 100mg doxycycline or 1g azithromycin oral - also treat partner - avoid sex until completed course - partner notification - 1 month or last partner for symptomatic males, 6 months for others - if under 25 retest in 3-6 months Gonorrhoea - 1g Ceftriaxone IM - also treat partner - abstain from sex until completed treatment - partner notification - 2w or last partner if symptomatic male, 3m for all else - Follow up after 1 week to ensure treatment successful, test of cure 2w after

Answer 75

Meningitis, Encephalitis, SAH

Answer 76

Look for steatosis on US Enhanced liver fibrosis blood test Fibroscan

Answer 77

total: hemiplegia, higher cortical dysfunction, homonymous hemianopia Partial 2 of 3

Answer 78

Oesophageal cancer Achalasia Pharyngeal pouch Scleroderma (crest) Ask about type of food can eat, ask about blood, ask about constitutional sx, ask about swelling in neck, ask about aspiration, lung infection 1st line refer via 2ww for upper GI endoscopy Do barium swallow CT TAP CXR/AXR

Answer 79

1st line drug is Levodopa - this is a precursor to dopamine that can ended BBB The decarboxylase inhibitor carbidopa is always given alongside to prevent metabolism Some of the issues with levodopa are its wearing off effect and propensity to dyskinesia To prevent dyskinesia can delay use of L-DOPA at first until symptoms progress or to use a dopamine agonist such as apomorphine either alone or alongside To prevent wearing off effect can use MAOB inhib (selegiline) and COMT inhib (entacapone) which slow degradation of dopamine. Can also give long acting L-dopa, give smaller doses more regularly SE - dopamine agonists can cause hallucinations and impulse control disorders. The medication can cause daytime sleepiness, should not drive if so. Can also cause orthostatic hypertension (review meds, midodrine), is also a risk of neuroleptic malignant syndrome. Glycopyrronium bromide for drooling

Answer 80

MSA - hypotension PSP - Vertical gaze palsy Lewi body - dementia Drug induced - antipsychotics

Answer 81

Can be viral, bacterial (STI) or allergic If infectious - gritty, foreign body sensation, watering of eye lead to blurring Viral - watery discharge Bacterial - sticky yellow/green discharge crusting and sticking together of eyelids on waking Allergic - itchy eye with watery discharge and associated nasal congestion, sneezing, eyelid swelling Wear gloves, examine eye, visual acuity, fundoscopy Consider swab if cause not clear, red flags (herpes) Viral - usually resolves within 7 days, advise cleaning eyelids, cool compress, lubricating drops. Avoid contact lenses, hand hygiene, different towels to stop spread, safety net Bacterial - same as above, if severe can treat with topical chloramphenicol drops or fusidic acid drops. Safety net - reduced visual acuity, photophobia/ headache etc. Allergic - identify and avoid allergens, avoid eye rubbing, apply cold compress to relieve sx, ocular lubricants - Topical antihistamine or oral antihistamine - Mast cell stabiliser (sodium cromoglycate) - topical steroids if very severe

Answer 82

AD: early impairment of memory. Manifests as short-term memory loss and difficulty learning new information. VD: typically a ‘stepwise’ decline in function. Predominant gait, attention and personality changes. May have focal neurological signs (e.g. previous stroke) DLB: parkinsonism (tremor, rigidity, bradykinesia, postural instability). Fall, syncope and hallucinations predominant feature FTD: marked personality change and behavioural disturbances. Memory and perception relatively preserved. ``` Investigate with cognitive tests - Abbreviated mental test score - Mini mental state exam Refer to memory clinic then: - MOCA (26/30) - Addenbrookes ``` DSM-V Diagnosis - functional impairment, affect >2 cognitive domains, no other cause (depression, delirium) Do Brain MRI Mx: Advanced planning, capacity, care plan, end of life care Supportive care Physical and mental health Inform DVLA Exercise, group cognitive stimulation programmes Mild to moderate - acetylcholinesterase inhibitors e.g. rivastigmine or donepezil Moderate to severe - NMDA antagonist e.g. memantine

Answer 83

Impingement syndrome - pain on raising arm above head, pain lying on arm at night, loss of internal rotation, +ve neers and Hawkins test. Clinical diagnosis may be confirmed with MRI. Analgesia, rest, physio, steroid injection. Surgery to decompress acromium or remove bursa Rotator cuff tear - Acute weakness and pain, test individual muscles. Xray to exclude fracture, can look for tear using MRI/US. Rest, analgesics, physio, steroids. If complete tear consider surgical repair. Frozen shoulder - Deep, constant pain, stiffness of all movements. Freezing (pain+stiffness), frozen (stiffness), thawing (improves). Common in diabetics, test. Treat with analgesics, reassurance, steroid injection. May consider hydroxylation, capsular release or manipulation under anaesthesia Dislocation of ACJ - pinpoint pain over joint following fall onto shoulder. Rest, put in sling for 3w and review. Most improve with conservative treatment for 3m, may need stabilisation

Answer 84

OA - Elderly, chronic stiffness, locking/ instability, prev trauma. Do Xray if unsure. Physio, joint support, walking aids, analgesics, steroid injections. Consider arthroplasty Meniscal tear - Twisting around a flexed knee. Knee pain (worse on extension), swelling a few hours after injury (if immediate may be ACL or peripheral tear), giving way/catching/locking. Joint line tenderness, mcmurrays +ve. To differentiate from MCL do MRI. RICE, physio. Surgery if large tears or persistent symptoms. ACL - Hyperextension or change in direction with foot fixed. Acute pain and audible pop, immediate swelling, joint stability and unable to weight bear. +ve anterior draw and lachmans test. Xray to exclude avulsion fracture, MRI to confirm. RICE, if not highly active knee brace and physio. Not heal on own so all others ligament reconstruction with tendon grafting PCL - dashboard injury, posterior draw and post sag sign. MRI to confirm. Respond well to conservative. Immobilise in extension for few weeks, crutches, physio.

Answer 85

Mechanical back pain - spasm of vertebral muscles, soft tissue dmg. Pain worse on movement. START back tool to assess risk, can do CT/MRI if chronic or red flag. Return to normal, lat bending exercises, warm compress, analgesics. If med risk - physio, high risk MDT approach If chronic lower back pain in a young male with associated stiffness that is worse in the mornings and better throughout the day = ankylosing spondylitis. Do a lumbar spinal Xray. 1st step is NSAIDs and physio. 2nd line biologic e.g. adalimumab exclude metastasis, AAA Prolapsed disc - middle aged, sudden onset when heavy lifting, hx of repetitive movements. Have low back pain, radicular pain worse on bending, better on standing, shooting pain into leg and sensation loss. Can have cauda equina if low and large. +ve straight leg raise, Trendelenburg gait. MRI if pain persist >6w or bilateral. Rest, NSAID, neuropathic pain killers, physio. Corticosteroid injection second line, microdiscectomy 3rd line. Spinal stenosis - Gradual onset of back pain, unilateral or bilateral leg pain and weakness. Neurogenic claudication (pain, tingling in back and leg when walking as pain worse when standing, better when sitting forward). May be bladder or bowel involvement. -ve leg raise, MRI lumbar spine. NSAID, physio, steroid injection, back brace. If persistent pain or neuro sx - decompression laminectomy Cauda equina - prolapsed disc below L1/L2 - bilateral leg pain, bowel/bladder dysfunction, saddle anaesthesia, sensorimotor changes, poor anal tone on PR. Investigate immediately with MRI and refer for urgent surgical decompression If old, sudden onset severe pain exacerbated by movement consider osteoporotic fracture. Do xray, rule out cancer. Observe, brace, give calcitonin and bisphosphonate. Vertebroplasty or kyphoplasty

Answer 86

UMN - forehead sparing LMN - non forehead sparing Assess facial movements against resistance, ask about changes in taste (ant 2/3) and intolerance to load noises Can grade degree of paralysis by House-Brackmann LMN causes - Idiopathic bells palsy, parotid tumour, base of skull fracture, cholesteatoma, acoustic neuroma, herpes (Ramsey hunt), GB UMN causes - brainstem stroke, MS, tumour, HIV, syphilis Refer if suspected cause or red flag features (cancer, UMN, ENT sx etc) Mx: Eye care - Refer to ophthalmology: lubricating eye drops, patches, taping, eye weights, botulinum, surgery Give steroids if present within 72 hours, cont for 10 days. Most resolve spontaneously. If refractory consider facial nerve decompression surgery or reanimation surgery

Answer 87

``` Ix: IPSS PR Dipstick - Diabetes, UTI Blood tests including PSA Flow rate <10mls = obstruction (or neuro/DM) Bladder, kidney US to look for chronic retention (recurrent UTI, CKD, hydronephrosis, stones, overflow incontinence) May do MRI, CT KUB in secondary care ``` Mx: If mild - reassure and reduce alcohol/caffeine, incontinence pads, bladder training, follow up If moderate - Alpha blockers (tamsulosin), 5-alpha reductase inhibs (finasteride), catheters If severe (recurrent UTI, haematuria, acute retention) - surgery Transurethral resection of prostate If acute urinary retention catheterise

Answer 88

Transitional cell cancer Ix: Urine dipstick + microscopy Routine bloods (PSA) 2ww to hosp for: Flexible cystoscopy + biopsy Upper urinary tract imaging with CT/US Mx: If clots - need to catheterise to avoid clot retention Transurethral resection of bladder tumour - assess grade and staging If not invade muscle, consider either active surveillance, intravesical BCG or mitomycin or radical cystectomy If muscle invasive - radical radio or cystectomy + chemo In bladder removal - ureters plugged into bowel, bowel brought to surface as a stoma

Answer 89

``` Ix: Ask about previous stones Urine dipstick + culture (blood, infection) Routine bloods Non contrast CT US for hydronephrosis Pregnancy test ``` Mx: Analgesia, IV fluids, antiemetics Nifedipine or tamsulosin can help stone passage If small (<10mm) - pass within 4w, follow up imaging, get to catch stone for analysis if 1st. Safety net. If >10mm - extracorporeal shock wave lithotripsy or percutaneous. If obstruction - nephrostomy or stent Advise to increase fluid, reduce salt, protein, oxalate, rate rich foods

Answer 90

Ix: Do urine dip to exclude infection and haematuria Bladder diary Explore red flags for cancer, infection, neuro disease Stress incontinence: Reduce caffeine, weight loss, stop smoking to reduce cough, pelvic floor muscle training (12w), pads, restrict fluid intake Surgical - colposuspension Medical (2nd line) – duloxetine (SNRI) Urge incontinence Reduce caffeine, monitor fluid intake, bladder training (6w) Medical – antimuscarinic e.g. oxybutynin, 2nd line mirabegron. If fail botulinum toxin injection, sacral nerve stimulation, augmentation cystoplasty (increase size of bladder) Overflow incontinence: Refer to urologist or nephrologist Further investigations of cause, may need catheterisation, nephrostomy

Answer 91

Differentials - DVT, Gastroc/ soleus sprain, claudication, ankle sprain, achilles tendinopathy, achilles tendon rupture, nerve entrapment, fracture Achilles tendinopathy, plantar fasciitis - pain in back of heal, base of foot worse in the morning and with movement - stiffness better on movement, tender, crepitus - due to overuse, repetitive trauma, inflammation - obesity is a RF - tender to touch and painful on dorsiflexion Usually takes 12w to resolve. Treat with initial rest period, restart exercise as pain allows. NSAID/ paracetamol. Refer to physio if not improving or suspect misalignment or muscle weakness to be contributing For fasciitis Can give foot orthotics e.g. heel inserts, splints. Shock wave treatment if last >6mo, surgical release with fasciotomy at >9mo Achilles tendon rupture - Hx of repetitive strenuous activity - Forced plantar flexion or violent dorsiflexion - hear a pop, weakness, pain in heel - struggle to stand on tip toes - palpable gap, Simmons test +ve Do US to locate and stage tear, Xray if suspect fracture. Only do MRI if diagnostic uncertainty Treat with analgesia, physiotherapy. If complete rupture put in a boot for 6-8w. No steroid injections. If high risk of re-rupture then consider operative management (open end to end or percutaneous) Tarsal tunnel syndrome = tibial nerve entrapment under flexor retinaculum - paraesthesia, pain, and swelling of the feet - NSAID, rest, orthotics, steroid injection - surgical decompression if not respond

Answer 92

Ix confirm individual eaten gluten twice a day over last 6 weeks - IgA Ttg and Total IgA, (2nd line IgG ttg/ IgA EMA) - If +ve send to GI for endoscopy and duodenal biopsy - stool culture, MC+S - FBC, U+E, LFT, CRP, ESR - Skin biopsy if rash Mx Avoid gluten - dietary counselling, referral to dietician No wheat, barley, rye Vit D, Ca supplements if insufficient in diet Assess and manage osteoporosis risk Yearly follow up, assess sx, BMI, diet adherence, blood tests If refractory - refer to dietician, specialist and consider short term prednisolone Complications are dermatitis herpetiformis and Enteropathy-associated T-cell lymphoma (EATCL)

Answer 93

DM, acromegaly, pregnancy, Idiopathic, neoplasm, oedema, trauma, RA Presents with pain, numbness, parasthesia over the palmar aspect of the lateral 3 1/2 digits. Also have wasting of thenar eminence, difficulty making a fist. Pain worse at night, have to hang hand off of bed or shake. Differentials = C6 radiculopathy (also have neck pain), pronator teres syndrome, Flexor carpi radialis tenosynovitis (pain at base of thumb) Supplies LOAF - Lateral lumbricals - Opponens pollicis - Adductor pollicis brevis - Flexor pollicis brevis Phalens and tunnels test +ve If diagnostic uncertainty consider NCS or MRI Mx: Analgesia, activity modification, physio, corticosteroid injections. Splinting at night If failure of non-operative treatment consider carpal tunnel release

Answer 94

Scaphoid fracture Tenderness in anatomical snuffbox Pain, swelling in wrist, difficulty gripping Xray in AP, lateral and R/L oblique views Scaphoid plaster/splint and place in cast If complicated fracture do ORIF or percutaneous crew fixation Colles fracture Dinnerfork deformity Closed reduction, splint and cast If grossly displaced do MUA, put in backslab and sling

Answer 95

History of acute attack of pain, swelling, redness and warmth. Commonly 1st metatarsophalangeal joint May have tophi on extensor surfaces of limbs, ears and achilles tendon Ix: Hx - ask about prev attacks, diet, alcohol Often clinical diagnosis Do joint aspiration to confirm (urate crystals) Do uric acid lvl 4-6w post attack Xray to exclude other causes Screen for CV and renal disease Mx: Discuss lifestyle changes - loose weight, reduce purine in diet (red meat, seafood), reduce alcohol consumption Rest, ice, elevate 1st line: NSAID (naproxen + PPI) or colchicine 2nd line: oral or corticosteroid injections Prevention - once acute attack resolved - allopurinol - titrate dose to reduce uric acid <300. Give colchicine alongside for first 6 months. Can cause rash/fever, if renal impairment monitor U+E - 2nd line febuxostat

Answer 96

Ix: Hx (recent instrumentation), abdo/PR/genital exam Urine dipstick PSA AI screen if nephritic FBC (anaemia), U+E, LFT, CRP, Coag (clotting disorder) Mid stream urine - send for culture, microscopy, cytology Refer based on 2ww >45 and haematuria not linked to or post UTI >60 and non visible + either dysuria or raised WCC Flexible cystoscopy +/- biopsy Upper urinary tract imaging - US KUB, CT urogram

Answer 97

Ix: Routine obs + bloods CXR - look for air under diaphragm (perforation) CT of abdomen Barium enema Sigmoid/colonoscopy - not do in diverticulitis due to risk of perforation Mx: If asymptomatic diverticulosis - reassure, suggest lifestyle changes and increase fibre in diet Diverticular disease - 30g fibre a day, bulk forming laxatives 2nd line, give paracetamol and antispasmodics. Avoid NSAIDS and opioids (increase risk of perforation) Diverticulitis - Co-amoxiclav, if complications admit for IV fluids, Abx, analgesia. Consider surgery if peritonitis or sepsis, percutaneous drainage if abscess.

Answer 98

Ix: Urine dipstick Mid stream urine sample - MC&S Bloods, US/CT if complicated or renal function affected Mx: Trimethoprim (not if pregnant) Nitrofurantoin (not if renal F) (3 days in women, 7-14 in men) Pyelonephritis urine dipstick and culture Bloods - FBC, U+E, CRP, Lactate USSKUB, CTKUB (gold standard) AtoE, sepsis 6, resuscitate Treat obstruction Treat hydronephrosis with nephrostomy Ciprofloxacin 500mg for 14 days If severe or urosepsis give co-amox or ceftriaxone

Answer 99

Assess with GAD2, GAD7 Screen for organic causes e.g. hyperthyroid, SVT, anaemia, hypoglycaemia etc. Step 1 - educate, sleep hygiene, exercise, Beta blocker Step 2 - Low intensity psychological interventions based on CBT (individual) Step 3 - CBT or drug therapy with SSRI Step 4 - Refer for specialist care, medication

Answer 100

Yale-brown OCD scale low severity - relaxation techniques, low intensity CBT with exposure and response prevention (exposed to a situation causing anxiety and prevented from performing repetitive actions) More severe - high intensity CBT or SSRI

Answer 101

Must last longer than 4w Trauma based CBT first line Eye movement desensitization and reprocessing SSRI If no response consider antipsychotic

Answer 102

Last at least 2w, no hypo or mania Core symptoms are low mood, fatigue and reduced energy, loss of interest in activities that are normally pleasurable Can do routine bloods to screen for organic causes ``` Mx: Assess suicide risk PHQ-9 >5 – mild >10 – moderate >15 – moderately severe >20 – severe ``` Sleep hygiene, exercise Crisis team if suicidal If mild Discuss concerns, sleep hygiene, regular sleep/wake times Exercise programmes Provide information Active monitoring Follow up in 2 weeks, make contact if not attend Mild - mod low intensity self guided or computerised CBT, second line is group CBT Mod to severe High intensity individualised CBT SSRI first line - continue for 6m post remission ECT can be considered for fast short term improvement

Answer 103

Increased intake: dietary, IV fluids, blood transfusion, Decreased excretion: K+ sparing diuretic, ACEi, spironolactone, Addisons, AKI Extracellular shift: Acidosis, TLS, Rhabdo ``` Presents with Fatigue Generalised weakness Chest pain Palpitations ``` ``` Ix: Full set of bloods ABG - see electrolyte levels Urinalysis ECG ``` ``` Mx: ABCDE Cardiac monitoring Protect myocardium - calcium gluconate Reduce K+ with insulin/dextrose solution Nebulised salbutamol ```

Answer 104

Aspirate joint + send for culture - Cloudy yellow/green, raised WCC, low viscosity, low glucose, raised neutrophils, gram stain +ve, crystal negative Do 2x blood cultures, routine bloods + urate and obs Consider urine dip, STI screen to look for causative infection Imaging - CT/MRI, US, Xray Do sepsis 6 - take blood culture, lactate level, measure urine output. Give fluids, IV abx, O2 Treatment Liaise with microbiology, fluclox often 1st line - IV for 2w, continue for total of 6w, Vanc for MRSA Aspirate joint to dryness, consider arthroscopic drainage, washout

Answer 105

Presents with fever, arthralgia, butterfly rash

Answer 106

Diagnosed if have facial discomfort/pain, nasal obstruction or purulent discharge, loss of sense of smell May consider nasal endoscopy to look for polyps, inflammation, oedema, purulent discharge Mx Reassure, most resolve within 3 weeks Anti-pyretic, nasal decongestant max a week, nasal irrigation with saline, fluid + rest, warm face mask If >10 days consider 14 days of high dose intranasal corticosteroid If prolonged beyond this or very severe may consider Abx, first line = phenoxymethylpenicillin

Answer 107

Can be caused by meningitis, small cell lung cancer, SSRI, carbamazepine Present with fluid overload, sx of hyponatraemia (N+V, headache, muscle cramp, confusion) Differential if K+ raised = Addisons Ix: U+E Plasma and urine osmolality (high in urine, low in blood) TFT, cortisol ``` Mx: Treat cause Fluid restrict Demeclocycline Vaptans ```

Answer 108

Intermenstrual, post sex, post menopausal bleeding. Malodorous discharge, pelvic pain, pain on sex. Refer via 2ww for cervical screening if abnormal looking cervix or unexplained symptoms, post or premenopausal bleeding Cervical screening - first invited at age 25, 25-49 every 3 years and 50-65 every 5 years. Only screen over 65 if not had a test since 50 or if recent abnormal test Insert speculum, use brush and rotate 5 times against squamocolumnar junction = liquid based cytology Results are Negative - return to screening Inadequate - repeat Borderline - some changes, very unlikely to progress Mild dyskaryosis - Cancer very unlikely, most revert to normal smears For borderline or mild - do HPV test and if +ve do colposcopy Moderate dyskaryosis - Intermediate probability of developing into cancer Severe dyskaryosis - high risk of cancer, some may show changes suggestive of cancer Glandular neoplasia - adenocarcinoma Microinvasive - large loop excision or cone biopsy Early stage - radical hysterectomy + lymphadenectomy In locally advanced/ metastatic consider chemoradiation

Answer 109

Main causes are gallstones, alcohol, steroids ``` Ix: Serum lipase/amylase (also high Obs Blood sugar, ECG, pregnancy test Routine bloods + bone profile + LDH Do blood gas for grading Do US, if negative MRCP for gallstones ``` ``` Go Glasgow score in first 48hrs to assess severity >3 = severe PaO2 Age Neutrophils Calcium Renal function Enzymes Albumin Sugar ``` Mx: Cut down on alcohol, review meds IV fluids, analgesia (morphine or buprenorphine), nutritional support Manage gallstones, Abx if infected If suspect pancreatic necrosis - aspirate and culture

Answer 110

Essential - bilateral, symmetrical, intention tremor. Better with alcohol, beta blocker Parkinsons - unilateral, asymmetrical, resting tremor. Additional rigidity, bradykinesia, postural instability

Answer 111

``` A-E, CV exam Same investigations as ischaemic stroke FAST rapid assessment Assess GCS, blood glucose, nutrition screen (MUST), bloods, CT - haemorrhage = white If suspect SAH do a lumbar puncture ``` ``` Mx A to E oxygen BP control swallow assessment Early mobilisation Falls risk assessment Decompressive hemicraniectomy ```

Answer 112

Temperature >38 or features of sepsis in a person with a neutrophil level <0.5. Occurs within 6w of chemo Peak risk at 7-14 days ``` Ix: Routine obs - rr, hr, sats, bp, bm Infection screen (FBC, U+E, CRP, Lactate, coag) - look at neutrophil lvl Relevant stool, sputum, urine culture ``` Sepsis 6 Take blood culture, lactate and urine output Give O2, iV fluids and empirical IV Abx (start immediately) MASCC index to assess risk Mx: Prevention - neutropenic diet (uncooked vegetables and most fruits, raw or rare meat, fish, uncooked or undercooked eggs, soft blue cheeses, food from salad bars), can give prophylactic G-CSF if high risk IV Abx started immediately Give G-CSF if prolonged neutropenia or hypovolaemic shock Consider transfer to ITU Manage subsequent chemotherapy

Answer 113

10ml 10% calcium gluconate over 10 mins to stabilise myocardium 10 units of short acting insulin alongside dextrose 50ml 50% Back to back 5mg salbutamol nebs If refractory - Dialysis Do repeated ECGs and check U+Es every 4-6 hours Do medication review Can offer calcium resonium

Answer 114

Presents with delirium, hallucinations and tremor 24-72 hours post cessation of alcohol Do ABCDE Correct dehydration and electrolyte abnormalities Treat with chlordiazepoxide or diazepam, can add barbiturates if refractory. Give pabrinex - 2 ampoules 3x day for 3 days Magnesium can protect against seizures/arrhythmias

Answer 115

Adenocarcinoma ``` Ix: DRE, PSA (>3, abnormal DRE refer for 2ww) Multi-parametric MRI Transrectal ultrasound guided biopsy Bone isotope scan/ CT ``` PSA, TNM and Gleason score for used for risk stratification and prognosis Mx: For localised prostate cancer consider active surveillance, radical prostatectomy and radical radiotherapy. Add in anti-androgen therapy for 6 months Can also give docetaxel chemo if metastatic castrate resistance. Androgen deprivation - orchidectomy or LHRH agonist e.g. Goserelin. Can cause SE if flushes, gynaecomastia, sexual dysfunction, osteoporosis

Answer 116

Herpes: swab from base of ulcer, NAAT If 1st episode oral acyclovir within 5 days Self care e.g. clean, Vaseline, increase fluid, pain relief, avoid tight clothing, urinate in bath, not share towels.

Answer 117

Single, round, painless, indurated lesion 2ndry have rash on palms and soles Tertiary have neuro, cardiac and gummate Ix: Dark ground microscopy - gram -ve motile spiral bacteria PCR Treponemal and non treponemal test Mx: Benzathine benzylpenicillin - one off IM if early, weekly for 3 weeks if late If cardio give steroids alongside

Answer 118

podophyllotoxin, immiquimod, TCA, cryotherapy, excision

Answer 119

Uterine, cervical motion tenderness Lower abdo pain, pain on urination and sex Uterine bleeding (inter-menstual or post coital) Abnormal cervical or vaginal discharge Fever, nausea and vomiting Ask about recent termination of pregnancy or IUD ``` Ix: Bimanual + obs Vulvovaginal swab Urinalysis + culture Bloods Pregnancy test Transvaginal US ``` Tx: Pain relief Empirical antibiotics: Ceftriaxone IM, doxy 100mg BD and metro 400 mg BD for 14 days Consider removing IUD Contract trace all partners in last 6 months, give 7 days doxycycline to all partners

Answer 120

Frothy yellow discharge, vulval itching and soreness, cherry red cervix, offensive odour, superficial dysuria/dyspareunia Ix: High vaginal swab from post fornix Motile protozoa on light microscopy Treat with metronidazole Screen and treat all partners in last 4 weeks

Answer 121

Amsels criteria - clue cells on microscopy - thin grey discharge - pH >4.5 - +ve amine test (fishy smell with KOH) Grade with Hay Ison score Treat symptomatic with oral or intravaginal metronidazole gel. Avoid vaginal douching, use of shower gel, and use of antiseptic agents or shampoo in the bath. Inform is often recurrent

Answer 122

Pre-renal Aminoglycosides, chemo MM Rhabdomyolysis

Answer 123

Diamorphine, furosemide and nitrate | Or dialysis

Answer 124

Prerenal - hypo perfusion due to haemorrhage, low blood pressure, sepsis, renal artery occlusion (embolus, infarct, stenosis), reduced cardiac output (HF, MI, PE Intrinsic - rhabdomyolysis (+ve blood on dipstick), myeloma, ATN, glomerulonephritis tubular interstitial nerphritis - abx (penicillin), ppi, chemo, nasi Post renal - bilateral renal stone, lymphoma, bladder outflow obstruction (tumour, stricture, stone), tumours, BPH, neurogenic bladder Stage 1 - Creatinine >26.5, 1.5-1.9x baseline, urine <0.5 ml/kg/hr for 6-12 hrs Stage 2 - Creatinine 2.0-2.9x baseline <0.5ml/kg/h for >12 hours Stage 3 - Creatinine >3x baseline <0.3ml/kg/h for >24 hours OR anuria for >12 hours hospital acquired AKI - after 48 hours post admission Ix: Observe urine output Do lying/standing BP urine dip (looking for raised protein, blood), MSU, PCR, PSA U+E, bicarb, inflam markers, nephritic/MM screen ABG (pH) USS KUB Correct high K+ If hypovolaemic - fluid challenge and maintenance, stop BP meds If hypervolaemic - furosemide, diamorphine and nitrate plus fluid restrict If acidosis - sodium bicarbonate Relieve obstruction, remove stones etc If sepsis - sepsis 6 Stop DAAAMN- Aminoglycosides, NSAID, ACEi, Metformin, Amphoteracin, Diuretics, Lithium, Digoxin Insulin renally cleared - if develop AKI reduce dose by 10-20% ATN - prerenal or post renal cause to an extreme TIN - sensitivity reaction to Abx, NSAID - give steroids

Answer 125

Nephritic - Haematuria, HTN and hardly any urine | Nephrotic - Hyperlipidaemia, oedema, proteinuria and hypoalbuminaemia

Answer 126

Presents with fever, SOB, cough, fatigue and loss of smell Can develop tachypnoea, hypoxia and worsening SOB Ix Diagnose with NAAT, also lat flow tests, antibody testing Obs including BP, HR, RR, Sats, temp Bloods, coag Sputum culture, ABG CXR - bilateral patchy infiltrates suggesting acute respiratory distress syndrome, ground glass Screen for sepsis D-dimer, trops ``` Mx: Self isolate for a full 10 days from time of symptoms onset and conservative management Call 111 if worsening symptoms Increase fluid intake Take antipyretics May need to monitor O2 sats ``` ``` O2, ventilation Dexamethasone (6mg for 7-10 days)/ hydrocortisone for severe or critical (sats <90, RR >30) Remdesivir Tocilizumab Anticoag if hospitalised ```

Answer 127

Lie flat - 4% pilocarpine in brown eyes and 2% in blue, give 500mg acetazolamide oral. Refer to 2ndry care. Do laser iridotomy. Treat unaffected eye as prophylaxis Follow up for 2 years - visual field, pressures

Answer 128

NSAID Prednisolone Methotrexate

Answer 129

Orbital - posterior to orbital septum (Sinus infection) - CT orbit, bloods, blood culture - co-amoxiclav Peri-orbital - anterior to orbital septum

Answer 130

GCA, Embolus, atherosclerosis of carotid artery - important to ask about headache etc to rule out GCA Sudden acute painless loss of vision RAPD, cherry red spot + pale retina If transient, complete black out that comes back after time = amaurosis fugax - treat as TIA Occular massage Acetazolamide, paracentesis to reduce pressure Hyperbaric O2/ isosorbide dinitrate Rebreath into a bag Thrombolysis recombinant tissue plasminogen activator Laser embolectomy, vitrectomy Refer to stroke team Give aspirin to protect against TIA CV risk factors

Answer 131

Ask about location (what ear) onset, freq, what sound like, how often, anything relieve. Ask about hearing loss, dizziness, vertigo, jaw pain, facial weakness. Ask about impact on life (sleep, mental health), current meds. History of noise exposure, ear disease or surgery Unilateral with sensorineural hearing loss - menieres and acoustic neuroma Unilateral/ bilat with conductive hearing loss - wax, middle ear effusion, cholesteatoma, otosclerosis Bilateral with sensorineural - noise induced, presbycusis, drug induced Treat cause, reassure most improves with time If refractory consider sound enrichment therapy, tinnitus based CBT, hearing aid Subjective - only they can hear Objective - you can hear

Answer 132

Unilateral tinnitus, hearing loss, facial/trigeminal nerve involvement Do audiogram and MRI with contrast, consider biopsy Stereotactic radiotherapy or surgery

Answer 133

Balloon insertion to stretch LOS or surgery to loosen it.

Answer 134

``` Skin infections Lipoma Reactive or malignant lymphadenopathy Salivary, thyroid or parathyroid gland tumour Thyroid lump e.g. thyroglossal cyst (midline near hyoid, moves on swallowing), goitre Parotid lumps Lateral neck, smooth = brachial cyst Laryngocele - more prominent on valsava ```

Answer 135

Presents with pain post fall, leg shortened and externally rotated. Not able to weight bear. Stage with garden classification On xray see loss of continuity of shentons line Investigate cause of the fall Do Bloods and CK to rule out rhabdomyolysis Urine dip, CXR, ECG AtoE Give paracetamol, opioid, nerve block as needed If intracapsular - hemiarthroplasty or can do cannulated hip screw if non displaced If extra capsular - dynamic hip screw If subtrochanteric do intramedullary nail Physiotherapy - mobilise asap

Answer 136

Mania - symptoms of increased mood and energy lasting at least 7 days and interfering with social or occupational functioning, requiring hospital admission or causing psychotic symptoms Hypomania - symptoms lasting >4 days but not severe enough to fit above Depressive episode - at least 2 weeks of depressed mood, reduced energy, reduced interest Bipolar I - mania +/- depression Bipolar II - hypomania + depression Mixed episode - where occurring together Rapid cycling - 4 episodes of depression/mania within 12m Refer to bipolar disorder service, early intervention in psychosis or CAMHS. Urgent if risk to self or others If manic episode - stop antidepressant, offer antipsychotic e.g. onlanzapine, quetiapine. 2nd line is different antipsychotic and 3rd line add sodium valproate or lithium. Get them to stop driving during manic episode For depression give quetiapine or lamotrigine or onlanzapine alone Long term - discuss care plan 4 weeks post resolution of acute episode. Consider Lithium first line for prevention of relapses. Consider psychological therapies. Get lasting power of attorney to control spending. Yearly review - assess sx, warning signs Encouraging compliance Sleep Avoidance of shift work, night flying and flying across time zones, or routinely working excessively long hours Regular morning routine Self-monitoring and coping strategies Avoiding caffeinated drinks such as tea, coffee, or cola. Stop smoking, correct alcohol and drug misuse

Answer 137

Baselines when initiate treatment BMI weekly for first 6 weeks, then at 3 months, then every 12 months U&E, eGFR, HbA1c, LFT every 12 months BP/BMI/lipids/glucose at 3 months Prolactin– at 6 months then every 12 months if risperidone ECG at start if cardiovascular risk factors, also when changing doses Creatinine kinase if neuroleptic malignant syndrome is suspected FBC for clozapine - agranulocytosis

Answer 138

Seminoma or non seminoma - painless testicular mass that is irregular, firm, fixed, not transilluminate - Do US, alpha fetoprotein, LDH, beta HCG, CT TAP - also do urinalysis to exclude other causes - Marsden staging - Radical orchidectomy - chemo with cisplatin or radio if high risk - Offer sperm storage Testicular torsion - very painful, sudden, hot, red, swollen testicle. Absent cremasteric, one higher than other, lifting not relieve pain - US, emergency referral to urology, fix both Tender, red, hot, swollen - pain relieved on lifting - epididymis-orchitis - identify cause with first catch urine (NAAT), MSU, bloods - Doxy, Cef, Ciprofloxacin Epididymal cyst - Upper pole of testes, separate from testes, smooth/ fluctuant nodule that transilluminates - Do US, aspirate if large or symptomatic Varicocele - bag of worms, painless - dragging sensation, disappear when flat - red flag if right side - embolize or ligate if symptomatic or affecting fertility Hydrocele - painless, fluctuates, transluminates - US to rule out trauma, malignancy - conservative in adults, may fix in babies Hernia - cant get above, worse when cough,

Answer 139

increased vagal tone, inferior MI, myocarditis, cardiac surgery,

Answer 140

Present with central tearing chest pain radiating to the back Aortic regurg murmur

Answer 141

If unstable, adverse features - DC cardiovert | If stable - magnesium sulphate

Answer 142

atropine and/or temporary pacemaker insertion. Treatment by insertion of a permanent cardiac pacemaker may be required, particularly for Mobitz type II and complete

Answer 143

Dementia - not aware of memory loss, confusion, mood normal, slow onset and deteriorating, activities of daily living normal initially, suicide and guilt rare - worse late in day Depression - aware and worried about memory loss, poor attention, low mood, more sudden onset, neglect of self care, loss of interest, lots of don't know answers, can remember if cued. - worse early in day

Answer 144

dizziness, chest pain, SOB, cough Slow rising - AS Collapsing - AR

Answer 145

Ataxia, ophthalmoplegia and confusion

Answer 146

Think thyroid cancer, cyst, adenoma Do US, FNA Excise and radioactive iodine

Answer 147

Frailty - Loss of in built reserves: weakness, weight loss, exhaustion, reduced mobility and reduced walking speed Sarcopenia - loss of muscle mass and strength as a result of ageing risk factors for frailty - comorbidities and chronic diseases, physiologic impairment e.g. electrolyte imbalances, anaemia, infection, inflammation, and environment Diagnose frailty following a cognitive geriatric assessment - prisma7 - age, male, health conditions that limit activity, need help on regular basis, need to stay at home, have someone can count on, use walking aids. - electronic frailty index - edmonton frail score - rockwood clinical frailty score - fried frailty index Do timed get up and go test, grip strength, turn 180 degrees test ``` Mx comprehensive geriatric assessment Refer to geriatric ward Review meds with Stopp Start Manage Comorbs Personalised care plan exercise, nutrition ```

Answer 148

MM (light chains, plasma electrophoresis), complement, ds-DNA, ANA, ANCA

Answer 149

Abdominal distension, Early satiety, weight loss, change in bowel habit, abnormal bleeding, pelvic pain, urinary symptoms, pelvic mass Do CA 125, USS - calculate risk of malignancy score Then do CT Can do image guided percutaneous biopsy or take sample as part of laparoscopic surgery Stage 1 - within ovary Stage 2 - within pelvis, spread to uterus, Fallopian tube Stage 3 - Spread outside pelvis Stage 4 - metastasised to liver or lungs Treatment = surgery, adjuvant chemotherapy

Answer 150

Erysipelas is raised, red | Cellulitis is flat to the skin

Answer 151

Furosemide and acetazolamide to lower intracranial pressure | decompressive craniotomy, CSF shunt

Answer 152

Oral -> subcut divide by 2 | Oral -> IV divide by 3

Answer 153

Causes bradycardia, sinoatrial pauses, blocks, and arrest Treat acutely with atropine first line, second line pacemaker Can treat long term with pacemaker but if asymptomatic no need to treat

Answer 154

``` COCP, HRT - stop 4 weeks before Herbal meds - 2 weeks before Clopidogril/aspirin - 7days Warfarin 6 days before, bridge with LMWH DOAC - 48 hours before Metformin - day of surgery ACEi/ARB on the day, all others cont Bisphosphonates - stop on day of surgery Insulin - reduce dose by 20%, stop short acting ``` Consider stopping TCAs, Lithium

Answer 155

Biguanide - metformin SU - gliclazide - weight gain, hypo Thiazolidine - Pioglitazone - weight gain no hypo SGLT2 - dapagliflozin - weight loss, no hypo DPP4 - Linagliptin - weight neutral, no hypo GLP-1 - Exenatide - weight loss, no hypo

Answer 156

Fluid restrict, reduce K+ and PO4 intake Do HD - 4hours 3x a week Continuous ambulatory PD - 4x 30 mins a day Autonomous PD HD better for those that cannot carry out PD themselves, such as visually impaired, dementia, or in poor state or health - You have to restrict yourself from certain foods and fluid needs to be restricted - Fewer restrictions on diet and fluid intake of PD - One of the main disadvantages of PD is that it needs to be carried out every day, which people can find very disruptive - People may also find it upsetting to have a catheter left permanently in their abdomen - Risk of peritonitis with PD - Another drawback of peritoneal dialysis is that the dialysis fluid used can cause a reduction in protein levels, which can lead to a lack of energy – weight gain is also a possible SE - For haemodialysis are in hospital for 4 hours, 3 times a week. Generally feel very unwell after treatment so are ill at home t

Answer 157

Prodrome for 18m before Symptoms of auditory hallucinations, thought insertion, broadcasting, withdrawal, delusions of control and delusions of perception First thing do - assess risk, refer to early intervention service Consider treatment in community or admission to hospital under MHA section 2. In emergency can do section 4 for 72 hours, needs just one Dr and AMHP. Start on antipsychotic - typical (EPSE, Cholinergic), atypical (high prolactin, metabolic se, QT, cholinergic, agranulocytosis, sedation) Initiate a care plan for both primary and secondary care - crisis plan - advance statement (how prefer to be treated in future) - contacts in case of crisis Need to be stable under secondary care for 3 years before discharge

Answer 158

SJS - <10% TEN - >30% Due to detachment of epidermis from papillary dermis Dusky erythematous skin rash with formation of blisters and skin detachment Nikolsky sign - epidermis sloughs off when pressure applied Most cases caused by drugs - Abx, anticonvulsants, SLE, HIV Fever, painful skin rash, mucosal ulceration Take a skin biopsy SCORTEN scoring to assess mortality Stop causative drug Supportive care, assess resp status

Answer 159

Refer 2ww anyone with dysphagia or abdo mass Refer 2ww if weight loss + dyspepsia, reflux Refer routinely if haematemesis

Answer 160

Ix: Caeruloplasmin low Free copper high 24hr urine copper high Management penicillinamine Monitoring

Answer 161

ANA, ds-DNA Raised ESR, low CRP hydroxychloroquine 1st line NSAID/steroid for flares May require methotrexate long term

Answer 162

Crest ANA, Anti-ro/la Treat raynauds with nifedipine Treat sclerodactyly with emollients and pain killers PPI for oesophageal problems Consider immunosuppressants if organ involvement

Answer 163

dry eyes and dry mouth Associated with RA, SLE, Scleroderma Tear/saliva substitutes NSAID/paracetamol DMARD, steroids

Answer 164

Proximal muscle weakness, heliotrope rash, periorbital oedema Do EMG, biopsy, ANA +ve, CK high Acute: IV steroids/ Immunoglobulins In chronic: DMARD and steroids

Answer 165

Abnormally enlarged vascular mucosal cushions in the anal canal Grade: 1 – not prolapse 2 – prolapse on straining and reduce spontaneously 3 – prolapse on straining and can be reduced manually 4 – permanently prolapsed RF: Constipation, prolonged straining, increased abdo pressure (ascites, cough, pregnancy) can cause Presentation: - Internal = painless, External = painful and itchy - Bright red bleeding with + after defecation, rectal fullness, impaired continence, lump at anal verge - Can become thrombosed, very painful Ix - Exam – ask to strain to see if visible - Proctoscopy - Flexible sigmoidoscopy/ colonoscopy to exclude malignancy/ diverticular - FBC for anaemia if high blood loss Mx - Prevent constipation with fibre, fluids, methylcellulose/ lactulose - Analgesia - Lignocaine gel, topical steroids (up to 7d) Non surgical – grade 1/2 - Rubber band ligation, infrared coag, injection sclerotherapy, bipolar diathermy Surgical - Haemorrhoidectomy (3 or 4) or haemorrhoidal artery ligation (2 or 3)

Answer 166

Primary (no cause) or secondary (constipation, IBD, STI, malignancy) Mx Primary care - Soften stool – fluid, fibre, laxative (bulk forming e.g. fybogel) - petroleum jelly - Analgesia (paracetamol/NSAID), warm bath - GTN ointment if no improvement over week, topical lignocaine if extreme pain (max 14 days) - Refer if not resolved within 6-8w Secondary care - Topical diltiazem or nifedipine - Botulinum toxin - Sphincterotomy