PASS MED

Question 1

A 27-year-old female presents with weakness of both hands. On examination you note wasting and weakness of the small muscles of the hands and loss of pain and temperature sensation over the trunk and arms. Vibration sense is intact.

What is the most likely diagnosis?

Answer 1

Syringomyelia - yringomyelia is a condition whereby fluid filled cavities develop within the spinal cord. Pressure can increase resulting in compression of the spinal cord tracts. The syrinx can extend to and damage the anterior horn cells, thereby resulting in lower motor neurone features. The spinothalamic tract axons decussate to the other side of the spinal cord via the anterior white commissure, and they are particularly susceptible to damage from the syrinx. Pain and temperature sensation are lost due to spinothalamic tract damage, and one side may be affected more than the other. Classically, the sensation loss is experienced in a shawl-like distribution over the arms, shoulders and upper body. Light touch, vibration and proprioception may also be affected as the syrinx enlarges into the dorsal columns.

Question 2

Complications of aneurysmal SAH:

Answer 2

Re-bleeding
happens in around 10% of cases and most common in the first 12 hours
if rebleeding is suspected (e.g. sudden worsening of neurological symptoms) then a repeat CT should be arranged
associated with a high mortality (up to 70%)
Vasospasm (also termed delayed cerebral ischaemia), typically 7-14 days after onset
Hyponatraemia (most typically due to syndrome inappropriate anti-diuretic hormone (SIADH))
Seizures
Hydrocephalus
Death

Question 3

window for thrombolysis stroke

Answer 3

A combination of thrombolysis AND thrombectomy is recommend for patients with an acute ischaemic stroke who present within 4.5 hours

NICE have also made recommendations to use a modified Rankin score of less than 3 and a National Institutes of Health Stroke Scale (NIHSS) score of more than 5 when considering the selection of patients for mechanical thrombectomy.

Question 4

Contraindications to thrombolysis:

Answer 4

Absolute

• Previous intracranial haemorrhage
• Seizure at onset of stroke
• Intracranial neoplasm
• Suspected subarachnoid haemorrhage
• Stroke or traumatic brain injury in preceding 3 months
• Lumbar puncture in preceding 7 days
• Gastrointestinal haemorrhage in preceding 3 weeks
• Active bleeding
• Pregnancy
• Oesophageal varices
• Uncontrolled hypertension >200/120mmHg

relative
Concurrent anticoagulation (INR >1.7)
- Haemorrhagic diathesis
- Active diabetic haemorrhagic retinopathy
- Suspected intracardiac thrombus
- Major surgery / trauma in the preceding 2 weeks

Question 5

A 68-year-old gentleman was diagnosed with glaucoma and commenced on treatment. He returned in one month for review, his eye pressures had improved but he complains his eyelashes have increased in length. What medicine is likely to have caused his eyelashes to grow in length?

Answer 5

Lantanprost - treatment for glaucoma

Question 6

preferred antiplatelet for secondary prevention following stroke

Answer 6

Clopidogrel is the preferred antiplatelet for secondary prevention following stroke

Question 7

In baby (neonate) feeding intolerance, abdominal distension and bloody stools, which can quickly progress to abdominal discolouration, perforation and peritonitis.  
Xray - pneumatosis intestinalis (intramural gas)

Answer 7

Necrotising enterocolitis

Question 8

Bone protection for patients who are going to take long-term steroids

Answer 8

should start immediately= start vitamin D and calcium supplements

Question 9

tetanus vaccination - unsure history - management?

Answer 9

Patients with an uncertain tetanus vaccination history should be given a booster vaccine + immunoglobulin, unless the wound is very minor and < 6 hours old

Question 10

Infective exacerbation of COPD antibiotics

Answer 10

Infective exacerbation of COPD: first-line antibiotics are amoxicillin or clarithromycin or doxycycline

Question 11

Laryngomalacia

Answer 11

Congenital abnormality of the larynx.

Infants typical present at 4 weeks of age with:
stridor

Question 12

Bacterial endocarditis - causative organism

Answer 12

he vast majority of cases of bacterial endocarditis are caused by gram positive cocci.

Common causes:
Streptococcus viridans
Staphylococcus aureus (in intravenous drugs uses or prosthetic valves)
Staphylococcus epidermidis (in prosthetic valves)

Question 13

HBA1c diagnostic of diabetes.

Answer 13

A HbA1c of 48mmol/mol is diagnostic of diabetes.

Over 58 = 2nd medication

Question 14

A 17-year-old male presents to the Ear Nose and Throat clinic to discuss the results from the fine needle aspirate taken from a smooth, fluctuant, non-tender, non-translucent mass located anterior to his left sternocleidomastoid muscle. It does not move on tongue protrusion. The aspirate reveals an acellular fluid with cholesterol crystals.

Answer 14

A branchial cyst is typically a benign, lateral, unilateral neck mass

Question 15

VTE post warfarin length

Answer 15

Venous thromoboembolism - length of warfarin treatment
provoked (e.g. recent surgery): 3 months
unprovoked: 6 months

Question 16

Pyloric stenosis

Answer 16

Pyloric stenosis typically presents in the second to fourth weeks of life with vomiting, although rarely may present later at up to four months. It is caused by hypertrophy of the circular muscles of the pylorus.

Epidemiology
incidence of 4 per 1,000 live births
4 times more common in males
10-15% of infants have a positive family history
first-borns are more commonly affected

Features
‘projectile’ vomiting, typically 30 minutes after a feed
constipation and dehydration may also be present
a palpable mass may be present in the upper abdomen
hypochloraemic, hypokalaemic alkalosis due to persistent vomiting

Diagnosis is most commonly made by ultrasound.

Management is with Ramstedt pyloromyotomy.

Question 17

Myocardial infarction: secondary prevention

Answer 17

NICE produced guidelines on the management of patients following a myocardial infarction (MI) in 2013. Some key points are listed below

All patients should be offered the following drugs:
dual antiplatelet therapy (aspirin plus a second antiplatelet agent)
ACE inhibitor
beta-blocker
statin

Question 18

Parotid gland mass - Benign pleomorphic adenoma or benign mixed tumor

Answer 18

Most common parotid neoplasm (80%)
Proliferation of epithelial and myoepithelial cells of the ducts and an increase in stromal components
Slow growing, lobular, and not well encapsulated
Recurrence rate of 1-5% with appropriate excision (parotidectomy)
Recurrence possibly secondary to capsular disruption during surgery
Malignant degeneration occurring in 2-10% of adenomas observed for long periods, with carcinoma ex-pleomorphic adenoma occurring most frequently as adenocarcinoma

Question 19

Paranoid gland mass

Answer 19

Second most common benign parotid tumor (5%)
Most common bilateral benign neoplasm of the parotid
Marked male as compared to female predominance
Occurs later in life (sixth and seventh decades)
Presents as a lymphocytic infiltrate and cystic epithelial proliferation
May represent heterotopic salivary gland epithelial tissue trapped within intraparotid lymph nodes
Incidence of bilaterality and multicentricity of 10%
Malignant transformation rare (almost unheard of)

Question 20

COPD management

Answer 20

General management
>smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion
annual influenza vaccination
one-off pneumococcal vaccination
pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above)

Question 21

synchronised DC cardioversion indications

Answer 21

Unstable atrial fibrillation, atrial flutter, atrial tachycardia, and supraventricular tachycardias

Question 22

Klebsiella pneumonia

Answer 22

Features of Klebsiella pneumonia
more common in alcoholic and diabetics
may occur following aspiration
'red-currant jelly' sputum
often affects upper lobes

Question 23

Progressive multifocal leukoencephalopathy

Answer 23

Caused by JC or BK virus

Question 24

superior vena cava obstruction presentation?

Answer 24

Features
dyspnoea is the most common symptom
swelling of the face, neck and arms - conjunctival and periorbital oedema may be seen
headache: often worse in the mornings
visual disturbance
pulseless jugular venous distension

Question 25

superior vena Cava obstruction causes and management

Answer 25

Causes common malignancies: small cell lung cancer, lymphoma other malignancies: metastatic seminoma, Kaposi's sarcoma, breast cancer aortic aneurysm mediastinal fibrosis goitre SVC thrombosis Management general: dexamethasone, balloon venoplasty, stenting small cell: chemotherapy + radiotherapy non-small cell: radiotherapy

Question 26

ECG: hypokalaemia

Answer 26

``` ECG features of hypokalaemia U waves small or absent T waves (occasionally inversion) prolong PR interval ST depression long QT ```

Question 27

Palliative care prescribing: pain

Answer 27

when starting treatment, offer patients with advanced and progressive disease regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain oral modified-release morphine should be used in preference to transdermal patches laxatives should be prescribed for all patients initiating strong opioids patients should be advised that nausea is often transient. If it persists then an antiemetic should be offered drowsiness is usually transient - if it does not settle then adjustment of the dose should be considered

Question 28

Palliative care prescribing: pain SIGN

Answer 28

the breakthrough dose of morphine is one-sixth the daily dose of morphine all patients who receive opioids should be prescribed a laxative opioids should be used with caution in patients with chronic kidney disease oxycodone is preferred to morphine in palliative patients with mild-moderate renal impairment if renal impairment is more severe, alfentanil, buprenorphine and fentanyl are preferred

Question 29

Palliative care prescribing: pain - increasing dose

Answer 29

When increasing the dose of opioids the next dose should be increased by 30-50%.

Question 30

``` Conversion between opioids Codine -> morphine = tramadol -> morphine Morphine -> oxy Oral morphine -> Subcutaneous morphine Oral morphine -> Subcutaneous dimorphine Oral oxycodone ->Subcutaneous dimorphine ```

Answer 30

Codine -> morphine = Divide by 10 tramadol -> morphne = Divide by 10 Morphine -> oxy = Divide by 1.5-2 Oral morphine -> Subcutaneous morphine = divide by 2 Oral morphine -> Subcutaneous dimorphine = divide by 3 Oral oxycodone ->Subcutaneous dimorphine = divide by 1.5

Question 31

Small bowel bacterial overgrowth syndrome Diagnosis Management

Answer 31

Diagnosis hydrogen breath test small bowel aspiration and culture: this is used less often as invasive and results are often difficult to reproduce clinicians may sometimes give a course of antibiotics as a diagnostic trial Management correction of underlying disorder antibiotic therapy: rifaximin is now the treatment of choice due to relatively low resistance. Co-amoxiclav or metronidazole are also effective in the majority of patients.

Question 32

Undescended testes

Answer 32

A congenital undescended testis is one that has failed to reach the bottom of the scrotum by 3 months of age consider age - may watch and wait Treatment Orchidopexy at 6- 18 months of age. The operation usually consists of inguinal exploration, mobilisation of the testis and implantation into a dartos pouch. Intra-abdominal testis should be evaluated laparoscopically and mobilised. Whether this is a single stage or two stage procedure depends upon the exact location. After the age of 2 years in untreated individuals the Sertoli cells will degrade and those presenting late in teenage years may be better served by orchidectomy than to try and salvage a non functioning testis with an increased risk of malignancy.

Question 33

epigastric ulcers

Answer 33

Features epigastric pain nausea duodenal ulcers -more common than gastric ulcers epigastric pain when hungry, relieved by eating gastric ulcers- epigastric pain worsened by eating

Question 34

non-invasive ventilation indications

Answer 34

Non-invasive ventilation - key indications COPD with respiratory acidosis pH 7.25-7.35* type II respiratory failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea cardiogenic pulmonary oedema unresponsive to CPAP weaning from tracheal intubation

Question 35

Keratoacanthoma

Answer 35

Features - said to look like a volcano or crater initially a smooth dome-shaped papule rapidly grows to become a crater centrally-filled with keratin Spontaneous regression of keratoacanthoma within 3 months is common, often resulting in a scar. Such lesions should however be urgently excised as it is difficult clinically to exclude squamous cell carcinoma. Removal also may prevent scarring.

Question 36

Osteoporosis: assessing risk

Answer 36

They advise that all women aged >= 65 years and all men aged >= 75 years should be assessed. Younger patients should be assessed in the presence of risk factors, such as: previous fragility fracture current use or frequent recent use of oral or systemic glucocorticoid history of falls family history of hip fracture other causes of secondary osteoporosis low body mass index (BMI) (less than 18.5 kg/m²) smoking alcohol intake of more than 14 units per week for women and more than 14 units per week for men. Use FRAX

Question 37

neuroleptic malignant syndrome management

Answer 37

Management stop antipsychotic patients should be transferred to a medical ward if they are on a psychiatric ward and often they are nursed in intensive care units IV fluids to prevent renal failure dantrolene may be useful in selected cases thought to work by decreasing excitation-contraction coupling in skeletal muscle by binding to the ryanodine receptor, and decreasing the release of calcium from the sarcoplasmic reticulum bromocriptine, dopamine agonist, may also be used

Question 38

Gastro-oesophageal reflux disease presentation

Answer 38

oesophagitis secondary to refluxed gastric contents

Question 39

Gastro-oesophageal reflux disease: management

Answer 39

Endoscopically proven oesophagitis full dose proton pump inhibitor (PPI) for 1-2 months if response then low dose treatment as required if no response then double-dose PPI for 1 month Endoscopically negative reflux disease full dose PPI for 1 month if response then offer low dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions if no response then H2RA or prokinetic for one month

Question 40

otitis externa Features and management

Answer 40

Features ear pain, itch, discharge otoscopy: red, swollen, or eczematous canal Give Topical combination steroid and antibiotic drops s Swab may need referral for micro-suction. If a patient fails to respond to topical antibiotics then the patient should be referred to ENT.

Question 41

Anterior uveitis presentation

Answer 41

Features acute onset ocular discomfort & pain (may increase with use) pupil may be irregular and small photophobia (often intense) blurred vision red eye lacrimation ciliary flush hypopyon; describes pus and inflammatory cells in the anterior chamber, often resulting in a visible fluid level visual acuity initially normal → impaired ``` Associated conditions ankylosing spondylitis reactive arthritis ulcerative colitis, Crohn's disease Behcet's disease sarcoidosis: bilateral disease may be seen ```

Question 42

Anterior uveitis management

Answer 42

Management urgent review by ophthalmology cycloplegics (dilates the pupil which helps to relieve pain and photophobia) e.g. Atropine, cyclopentolate steroid eye drops

Question 43

Subacute thyroiditis

Answer 43

occur following viral infection and typically presents with hyperthyroidism. ``` There are typically 4 phases; phase 1 (lasts 3-6 weeks): hyperthyroidism, painful goitre, raised ESR phase 2 (1-3 weeks): euthyroid phase 3 (weeks - months): hypothyroidism phase 4: thyroid structure and function goes back to normal ``` Investigations thyroid scintigraphy: globally reduced uptake of iodine-131 Management usually self-limiting - most patients do not require treatment thyroid pain may respond to aspirin or other NSAIDs in more severe cases steroids are used, particularly if hypothyroidism develops

Question 44

Pulsus paradoxus

Answer 44

greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration - severe asthma, cardiac tamponade

Question 45

Slow-rising/plateau

Answer 45

aortic stenosis

Question 46

Pulsus alternans

Answer 46

regular alternation of the force of the arterial pulse | severe LVF

Question 47

Bisferiens pulse

Answer 47

'double pulse' - two systolic peaks | mixed aortic valve disease

Question 48

'Jerky' pulse

Answer 48

hypertrophic obstructive cardiomyopathy*

Question 49

Legionnaire's disease

Answer 49

Legionella pneumophilia. It typically colonizes water tanks and hence questions may hint at air-conditioning systems or foreign holidays. Person-to-person transmission is not seen ``` Features flu-like symptoms including fever (present in > 95% of patients) dry cough relative bradycardia confusion lymphopaenia hyponatraemia deranged liver function tests pleural effusion: seen in around 30% of patients ``` iagnosis urinary antigen Management treat with erythromycin/clarithromycin

Question 50

Superficial spreading melanoma

Answer 50

70% of cases Arms, legs, back and chest, young people A growing moles flat patch of pigmented skin which grows slowly, often taking months or years to be recognised. It can be recognised by an ABCDE approach (asymmetry, border irregularity, colour variation, diameter >6mm and evolving)

Question 51

routine manintance fluids adult

Answer 51

NICE guidelines from 2013 state for routine maintenance fluids the water requirement is approximately 25-30 ml/kg/day.

Question 52

Osteogenesis imperfecta Features Investigations

Answer 52

Overview autosomal dominant abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides ``` Features presents in childhood fractures following minor trauma blue sclera deafness secondary to otosclerosis dental imperfections are common ``` Investigations adjusted calcium, phosphate, parathyroid hormone and ALP results are usually normal in osteogenesis imperfecta

Question 53

Smudge or smear cells

Answer 53

CLL

Question 54

Reed-Sternberg cells

Answer 54

Hodgkin's lymphoma.

Question 55

Rouleaux formation

Answer 55

multiple myeloma.

Question 56

Auer rods

Answer 56

a feature of AML.

Question 57

Pseudo Pelger-Huet cells

Answer 57

CML

Question 58

Hypothermia on ECG

Answer 58

J Wave

Question 59

reverse tick sign ECG

Answer 59

dioxin

Question 60

PE management

Answer 60

the use of direct oral anticoagulants (DOACs) as first-line treatment for most people with VTE the use of DOACs in patients with active cancer, as opposed to low-molecular weight heparin as was the previous recommendation outpatient treatment in low-risk pulmonary embolism (PE) patients routine cancer screening is no longer recommended following a VTE diagnosis if neither apixaban or rivaroxaban are suitable then either LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin) if the patient has active cancer previously LMWH was recommended the new guidelines now recommend using a DOAC, unless this is contraindicated Anticoag for at least three months if provoked Thrombolysis thrombolysis is now recommended as the first-line treatment for massive PE where there is circulatory failure (e.g. hypotension) other invasive approaches should be considered where appropriate facilities exist

Question 61

Toxic epidermal necrolysis

Answer 61

``` Drugs known to induce TEN phenytoin sulphonamides allopurinol penicillins carbamazepine NSAIDs ```

Question 62

Pericarditis Features

Answer 62

Features chest pain: may be pleuritic. Is often relieved by sitting forwards other symptoms include non-productive cough, dyspnoea and flu-like symptoms pericardial rub tachypnoea tachycardia

Question 63

Pericarditis causes

Answer 63

``` Causes viral infections (Coxsackie) tuberculosis uraemia (causes 'fibrinous' pericarditis) trauma post-myocardial infarction, Dressler's syndrome connective tissue disease hypothyroidism malignancy ```

Question 64

Pericarditis Investigations & Management

Answer 64

Investigations ECG changes the changes in pericarditis are often global/widespread, as opposed to the 'territories' seen in ischaemic events 'saddle-shaped' ST elevation PR depression: most specific ECG marker for pericarditis all patients with suspected acute pericarditis should have transthoracic echocardiography Management treat the underlying cause a combination of NSAIDs and colchicine is now generally used for first-line for patients with acute idiopathic or viral pericarditis

Question 65

Type 1 RTA

Answer 65

distal) inability to generate acid urine (secrete H+) in distal tubule causes hypokalaemia complications include nephrocalcinosis and renal stones causes include idiopathic, rheumatoid arthritis, SLE, Sjogren's, amphotericin B toxicity, analgesic nephropathy

Question 66

absolute contraindication to the use of regional anaesthesia such as spinal, epidural or plexus block?

Answer 66

Therapeutic anticoagulation is an absolute contraindication to the use of regional anaesthesia due to the risk of bleeding and the severity of a hematoma within the rigid space of the central nervous system.

Question 67

Ankylosing spondylitis

Answer 67

Features typically a young man who presents with lower back pain and stiffness of insidious onset stiffness is usually worse in the morning and improves with exercise the patient may experience pain at night which improves on getting up Clinical examination reduced lateral flexion reduced forward flexion - Schober's test - a line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible reduced chest expansion

Question 68

lithium toxciity precipitated by

Answer 68

Toxicity may be precipitated by: dehydration renal failure drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.

Question 69

Diclofenac NSAID - contraindications

Answer 69

Diclofenac is now contraindicated with any form of cardiovascular disease

Question 70

Degenerative cervical myelopathy

Answer 70

DCM symptoms can include any combination of [1]: Pain (affecting the neck, upper or lower limbs) Loss of motor function (loss of digital dexterity, preventing simple tasks such as holding a fork or doing up their shirt buttons, arm or leg weakness/stiffness leading to impaired gait and imbalance Loss of sensory function causing numbness Loss of autonomic function (urinary or faecal incontinence and/or impotence) - these can occur and do not necessarily suggest cauda equina syndrome in the absence of other hallmarks of that condition Hoffman's sign: is a reflex test to assess for cervical myelopathy. It is performed by gently flicking one finger on a patient's hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick. (GOLD Standard - MRI of cervical spine if cervical suspected )

Question 71

primary hyperparathyroidism | features

Answer 71

Features - 'bones, stones, abdominal groans and psychic moans' polydipsia, polyuria peptic ulceration/constipation/pancreatitis bone pain/fracture renal stones depression hypertension

Question 72

primary hyperparathyroidism investigations

Answer 72

Investigations raised calcium, low phosphate PTH may be raised or (inappropriately, given the raised calcium) normal technetium-MIBI subtraction scan pepperpot skull is a characteristic X-ray finding of hyperparathyroidism Treatment the definitive management is total parathyroidectomy conservative management may be offered if the calcium level is less than 0.25 mmol/L above the upper limit of normal AND the patient is > 50 years AND there is no evidence of end-organ damage calcimimetic agents such as cinacalcet are sometimes used in patients who are unsuitable for surgery

Question 73

Ottawa Rules with for ankle x-rays

Answer 73

The Ottawa Rules with for ankle x-rays have a sensitivity approaching 100% An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings: bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular) bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia) inability to walk four weight bearing steps immediately after the injury and in the emergency department

Question 74

New York Heart Association (NYHA) classification

Answer 74

NYHA Class I no symptoms no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations NYHA Class II mild symptoms slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea NYHA Class III moderate symptoms marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms NYHA Class IV severe symptoms unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity

Question 75

DDX breathing difficulty in children

Answer 75

``` Infection (ie croup, URTI) If stridor present - Larynomalcia, asthma Allergy Cardiac (malformation in young children) ```

Question 76

croup | presentation

Answer 76

Parainfluenza viruses ``` Features stridor barking cough (worse at night) fever coryzal symptoms ```

Question 77

croup | when to admit

Answer 77

CKS suggest admitting any child with moderate or severe croup. Other features which should prompt admission include: < 6 months of age known upper airway abnormalities (e.g. Laryngomalacia, Down's syndrome) uncertainty about diagnosis (important differentials include acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)

Question 78

croup investigations

Answer 78

the vast majority of children are diagnosed clinically however, if a chest x-ray is done: a posterior-anterior view will show subglottic narrowing, commonly called the 'steeple sign' in contrast, a lateral view in acute epiglottis will show swelling of the epiglottis - the 'thumb sign'

Question 79

croup management

Answer 79

Management CKS recommend giving a single dose of oral dexamethasone (0.15mg/kg) to all children regardless of severity prednisolone is an alternative if dexamethasone is not available Emergency treatment high-flow oxygen nebulised adrenaline

Question 80

Acute epiglottitis

Answer 80

Haemophilus influenzae type B. Prompt recognition and treatment is essential as airway obstruction may develop. Epiglottitis generally occurs in children between the ages of 2 and 6 years. The incidence of epiglottitis has decreased since the introduction of the Hib vaccine ``` Features rapid onset unwell, toxic child stridor drooling of saliva ```

Question 81

Acute epiglottitis | management

Answer 81

Management immediate senior involvement, including those able to provide emergency airway support (e.g. anaesthetics, ENT) endotracheal intubation may be necessary to protect the airway if suspected do NOT examine the throat due to the risk of acute airway obstruction the diagnosis is made by direct visualisation but this should only be done by senior staff who are able to intubate if necessary oxygen intravenous antibiotics

Question 82

Parainfluenza virus

Answer 82

croup

Question 83

Rhinovirus

Answer 83

cold

Question 84

Streptococcus pneumoniae

Answer 84

he most common cause of community-acquired pneumonia

Question 85

Haemophilus influenzae

Answer 85

Community-acquired pneumonia Most common cause of bronchiectasis exacerbations Acute epiglottitis

Question 86

Staphylococcus aureus

Answer 86

Pneumonia, particularly following influenza

Question 87

Mycoplasma pneumoniae

Answer 87

Atypical pneumonia Flu-like symptoms classically precede a dry cough. Complications include haemolytic anaemia and erythema multiforme

Question 88

Pneumocystis jiroveci

Answer 88

Common cause of pneumonia in HIV patients. Typically patients have few chest signs and develop exertional dyspnoea

Question 89

Mycobacterium tuberculosis

Answer 89

Causes tuberculosis. A wide range of presentations from asymptomatic to disseminated disease are possible. Cough, night sweats and weight loss may be seen

Question 90

Wheeze questions

Answer 90

- Infection - systemic illness - Associated symptoms -Associated with excersies Associated with environment (pet, dust, smoking, mould, damp, _ Imms

Question 91

Ddx Cyanosis

Answer 91

- Illness and infection - cardiac (TOF, ebsteins, tricuspid atresia, transposition) Medications (quinones) Resp - choanal atresia, Pierre Robin Sequence, airway hemangioma, vascular rings/slings, cystic hygroma, and micrognathia Blood related disorders - Polycythemia, Methemoglobinemia

Question 92

pansystolic murmur at his lower left sternal edge and a loud P2.

Answer 92

Ventricular septal defect

Question 93

typical features of heart failure in child

Answer 93

breathlessness, difficulty feeding, poor growth at an early age

Question 94

VSD presentation | associations

Answer 94

classically a pan-systolic murmur which is louder in smaller defects chromosomal disorders (e.g. Down's syndrome, Edward's syndrome, Patau syndrome) and single gene disorders such as Non-congenital causes include post myocardial infarction

Question 95

VSD complications

Answer 95

``` Complications aortic regurgitation* infective endocarditis Eisenmenger's complex right heart failure pulmonary hypertension: pregnancy is contraindicated in women with pulmonary hypertension as it carries a 30-50% risk of mortality ```

Question 96

ostium secundum

Answer 96

stium secundum (70% of ASDs) associated with Holt-Oram syndrome (tri-phalangeal thumbs) ECG: RBBB with RAD

Question 97

Ostium primum

Answer 97

present earlier than ostium secundum defects associated with abnormal AV valves ECG: RBBB with LAD, prolonged PR interval

Question 98

Coarctation of the aorta presentation

Answer 98

infancy: heart failure adult: hypertension radio-femoral delay mid systolic murmur, maximal over back apical click from the aortic valve notching of the inferior border of the ribs (due to collateral vessels) is not seen in young children

Question 99

Coarctation of the aorta associations

Answer 99

``` Associations Turner's syndrome bicuspid aortic valve berry aneurysms neurofibromatosis ```

Question 100

hypertrophic obstructive cardiomyopathy associated pulse

Answer 100

bisferiens pulse (double pulse).

Question 101

Aortic stenosis management

Answer 101

VR if symptomatic, otherwise cut-off is gradient of 40 mmHg

Question 102

Features of severe aortic stenosis

Answer 102

``` narrow pulse pressure slow rising pulse delayed ESM soft/absent S2 S4 thrill duration of murmur left ventricular hypertrophy or failure ```

Question 103

Aortic regurgitation features

Answer 103

ifficulty breathing at night, occasional palpitations and tight chest pain. On examination, he has a collapsing pulse and a laterally shifted apex beat murmur = early diastolic

Question 104

Abdominal pain ddx in children

Answer 104

- infection (Gastroenteritis) -Constipation _ Appendcitis Merkles adentisi - Hernia Intussception Allergery Hischsprung IBS coalic -

Question 105

Attention Deficit Hyperactivity Disorder presentaion

Answer 105

- inattentiveness hyperactivity and impulsiveness associated mood or behaviour disorders

Question 106

Attention Deficit Hyperactivity Disorder management

Answer 106

watch and wait (CAMHS ref needed) Drug therapy should be seen as a last resort and is only available to those aged 5 years or more Methylphenidate is first line in children f there is inadequate response, switch to lisdexamfetamine;

Question 107

Methylphenidate side effects

Answer 107

ide-effects include abdominal pain, nausea and dyspepsia. In children, weight and height should be monitored every 6 months

Question 108

Features Bronchiolitis

Answer 108

eatures coryzal symptoms (including mild fever) precede: dry cough increasing breathlessness wheezing, fine inspiratory crackles (not always present) feeding difficulties associated with increasing dyspnoea are often the reason for hospital admission

Question 109

Bronchiolitis - NICE recommend immediate referral (usually by 999 ambulance) if they have any of the following:

Answer 109

apnoea (observed or reported) child looks seriously unwell to a healthcare professional severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute central cyanosis persistent oxygen saturation of less than 92% when breathing air.

Question 110

Bronchiolitis- management

Answer 110

Management is largely supportive humidified oxygen is given via a head box and is typically recommended if the oxygen saturations are persistently < 92% nasogastric feeding may be needed if children cannot take enough fluid/feed by mouth suction is sometimes used for excessive upper airway secretions

Question 111

causes Cerebral palsy

Answer 111

Causes antenatal (80%): e.g. cerebral malformation and congenital infection (rubella, toxoplasmosis, CMV) intrapartum (10%): birth asphyxia/trauma postnatal (10%): intraventricular haemorrhage, meningitis, head-trauma

Question 112

presentations Cerebral palsy

Answer 112

``` Possible manifestations include: abnormal tone early infancy delayed motor milestones abnormal gait feeding difficultie. ```

Question 113

Cerebral palsy

Answer 113

Management as with any child with a chronic condition a multidisciplinary approach is needed treatments for spasticity include oral diazepam, oral and intrathecal baclofen, botulinum toxin type A, orthopaedic surgery and selective dorsal rhizotomy anticonvulsants, analgesia as required

Question 114

Exanthems

Answer 114

eruptive skin rashes associated with a fever or other constitutional symptoms

Question 115

Causes of maculopapular eruptions

Answer 115

``` Measles (rubeola) Rubella Erythema infectiosum (slapped cheek) Exanthum subitum (roseola) Lyme disease Pityriasis Drug-related eruptions Erythema multiforme ```

Question 116

Causes of diffuse erythema with desquamation

Answer 116

Scarlet fever Toxic shock syndrome Staphylococcal scaled skin syndrome Kawasaki disease

Question 117

Measles rash

Answer 117

erythematous maculopapular rash beginning on the head, with a cephalocaudad progression. Blue-white Kopliks spots occurring on the buccal mucosa opposite the second molar and lasting around 1-2 day

Question 118

Measles management

Answer 118

Measles is a notifiable illness and notification is required based on clinical suspicion. Children diagnosed with measles should be kept off school until 5 days after the appearance of the rash. The treatment of measles is largely symptomatic and the majority of children will recover uneventfully.

Question 119

Meckel's diverticulum | presentation

Answer 119

Presentation (usually asymptomatic) abdominal pain mimicking appendicitis rectal bleeding Meckel's diverticulum is the most common cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years intestinal obstruction secondary to an omphalomesenteric band (most commonly), volvulus and intussusception

Question 120

Anaphylaxis presentation

Answer 120

Anaphylaxis may be defined as a severe, life-threatening, generalised or systemic hypersensitivity reaction. Common identified causes of anaphylaxis: food (e.g. nuts) - the most common cause in children drugs venom (e.g. wasp sting)

Question 121

Anaphylaxis management

Answer 121

Adrenaline is by far the most important drug in anaphylaxis and should be given as soon as possible. also give Hydrocortisone and Chlorphenamine Adrenaline can be repeated every 5 minutes if necessary. The best site for IM injection is the anterolateral aspect of the middle third of the thigh. Management following stabilisation: patients who have had emergency treatment for anaphylaxis should be observed for 6–12 hours from the onset of symptoms, as it is known that biphasic reactions can occur in up to 20% of patients sometimes it can be difficult to establish whether a patient had a true episode of anaphylaxis. Serum tryptase levels are sometimes taken in such patients as they remain elevated for up to 12 hours following an acute episode of anaphylaxis.v

Question 122

Anaphylaxis test after episode to confirm

Answer 122

serum tryptase levels rise following an acute episode

Question 123

Acute exacerbations of COPD features

Answer 123

Features increase in dyspnoea, cough, wheeze there may be an increase in sputum suggestive of an infective cause patients may be hypoxic and in some cases have acute confusion

Question 124

The most common bacterial organisms that cause infective exacerbations of COPD are:

Answer 124

Haemophilus influenzae (most common cause) Streptococcus pneumoniae Moraxella catarrhalis

Question 125

Infective exacerbations of COPD managements

Answer 125

NICE guidelines from 2010 recommend the following: increase frequency of bronchodilator use and consider giving via a nebuliser give prednisolone 30 mg daily for 5 days it is common practice for all patients with an exacerbation of COPD to receive antibiotics. NICE do not support this approach. They recommend giving oral antibiotics 'if sputum is purulent or there are clinical signs of pneumonia' the BNF recommends one of the following oral antibiotics first-line: amoxicillin or clarithromycin or doxycycline.

Question 126

pneumonia causes

Answer 126

bacterial pneumonia is by far the most common type of pneumonia Streptococcus pneumoniae = most common Haemophilus influenzae = COPD Staphylococcus aureus = occurs in patient following influenza infection Klebsiella pneumoniae = alcoholics

Question 127

Pneumonia Bloods

Answer 127

Bloods full blood count: would usually show a neutrophilia in bacterial infections urea and electrolytes: check for dehydration (remember the 'U' for urea in CURB-65, see below) and also other changes seen with some atypical pneumonias CRP: raised in response to infection

Question 128

Pneumonia management

Answer 128

Patients with pneumonia require the following: antibiotics: to treat the underlying infection supportive care: for example oxygen therapy if the patients is hypoxaemic, intravenous fluids if the patient is hypotensive or shows signs of dehydration CURB- 65 score

Question 129

Pneumonia - Discharge criteria and advice post-discharge

Answer 129

Discharge criteria and advice post-discharge ``` NICE recommend that patients are not routinely discharged if in the past 24 hours they have had 2 or more of the following findings: temperature higher than 37.5°C respiratory rate 24 breaths per minute or more heart rate over 100 beats per minute systolic blood pressure 90 mmHg or less oxygen saturation under 90% on room air abnormal mental status inability to eat without assistance. ``` They also recommend delaying discharge if the temperature is higher than 37.5°C.

Question 130

Pneumothorax risk factors

Answer 130

Risk factors pre-existing lung disease: COPD, asthma, cystic fibrosis, lung cancer, Pneumocystis pneumonia connective tissue disease: Marfan's syndrome, rheumatoid arthritis ventilation, including non-invasive ventilation catamenial pneumothorax is the cause of 3-6% of spontaneous pneumothoraces occurring in menstruating women. It is thought to be caused by endometriosis within the thorax

Question 131

Pneumothorax symptoms

Answer 131

``` Symptoms tend to come on suddenly. Features include: dyspnoea chest pain: often pleuritic sweating tachypnoea tachycardia ```

Question 132

Primary pneumothorax | management

Answer 132

Recommendations include: if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered otherwise, aspiration should be attempted if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men

Question 133

Secondary pneumothorax management

Answer 133

Recommendations include: if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted. otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours regarding scuba diving, the BTS guidelines state: 'Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.'

Question 134

triad of PE | and clinical signs

Answer 134

pleuritic chest pain, dyspnoea and haemoptysis. The relative frequency of common clinical signs is shown below: Tachypnea (respiratory rate >20/min) - 96% Crackles - 58% Tachycardia (heart rate >100/min) - 44% Fever (temperature >37.8°C) - 43%

Question 135

PE suspected

Answer 135

If a PE is suspected a 2-level PE Wells score should be performed: linical probability simplified scores PE likely - more than 4 points PE unlikely - 4 points or less If a PE is 'likely' (more than 4 points) arrange an immediate computed tomography pulmonary angiogram (CTPA). If there is a delay in getting the CTPA then interim therapeutic anticoagulation should be given until the scan is performed. interim therapeutic anticoagulation used to mean giving low-molecular weight heparin NICE updated their guidance in 2020. They now recommend using an anticoagulant that can be continued if the result is positive. this means normally a direct oral anticoagulant (DOAC) such as apixaban or rivaroxaban

Question 136

test in PE

Answer 136

CTPA is now the recommended initial lung-imaging modality for non-massive PE. Advantages compared to V/Q scans include speed, easier to perform out-of-hours, a reduced need for further imaging and the possibility of providing an alternative diagnosis if PE is excluded if the CTPA is negative then patients do not need further investigations or treatment for PE V/Q scanning may be used initially if appropriate facilities exist, the chest x-ray is normal, and there is no significant symptomatic concurrent cardiopulmonary disease. V/Q scanning is also the investigation of choice if there is renal impairment (doesn't require the use of contrast unlike CTPA)

Question 137

Pulmonary embolism and renal impairment →

Answer 137

V/Q scan is the investigation of choice

Question 138

Massive PE + hypotension

Answer 138

- thrombolyse

Question 139

bloods PE

Answer 139

Pulmonary embolism causes hyperventilation, causing a drop in arterial carbonic dioxide partial pressure and thus alkalosis.

Question 140

Features of pulmonary oedema on a chest x-ray may include:

Answer 140

Features of pulmonary oedema on a chest x-ray may include: interstitial oedema bat's wing appearance upper lobe diversion (increased blood flow to the superior parts of the lung) Kerley B lines pleural effusion cardiomegaly may be seen if there is cardiogenic cause

Question 141

Tricuspid regurgitation signs

Answer 141

Pan systolic mumur JVP increase Hepatomegaly Heave

Question 142

Tricuspid regurgitation causes

Answer 142

Right V INFARCT Pulmonary hypertension Rheumatic heart disease Infective endo Ébstekns

Question 143

NSTEMI

Answer 143

All patients should receive aspirin 300mg nitrates or morphine to relieve chest pain if required Clopidogrel

Question 144

optic neuritis causes

Answer 144

Causes multiple sclerosis diabetes syphilis

Question 145

optic neuritis features

Answer 145

Features unilateral decrease in visual acuity over hours or days poor discrimination of colours, 'red desaturation' pain worse on eye movement relative afferent pupillary defect central scotoma

Question 146

optic neuritis management

Answer 146

Management high-dose steroids recovery usually takes 4-6 weeks Prognosis MRI: if > 3 white-matter lesions, 5-year risk of developing multiple sclerosis is c. 50%

Question 147

abdo signs

Answer 147

A number of eponymous abdominal signs are noted. These include: Rovsings sign- appendicitis Boas sign -cholecystitis Murphys sign- cholecystitis Cullens sign- pancreatitis (other intraabdominal haemorrhage) Grey-Turners sign- pancreatitis (or other retroperitoneal haemorrhage)

Question 148

BV causes and treatment

Answer 148

Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis Features vaginal discharge: 'fishy', offensive asymptomatic in 50% Amsel's criteria for diagnosis of BV - 3 of the following 4 points should be present thin, white homogenous discharge clue cells on microscopy: stippled vaginal epithelial cells vaginal pH > 4.5 positive whiff test (addition of potassium hydroxide results in fishy odour) ``` Management oral metronidazole for 5-7 days 70-80% initial cure rate relapse rate > 50% within 3 months the BNF suggests topical metronidazole or topical clindamycin as alternatives. ```

Question 149

BV in pregnancy

Answer 149

Bacterial vaginosis in pregnancy results in an increased risk of preterm labour, low birth weight and chorioamnionitis, late miscarriage it was previously taught that oral metronidazole should be avoided in the first trimester and topical clindamycin used instead. Recent guidelines however recommend that oral metronidazole is used throughout pregnancy. The BNF still advises against the use of high dose metronidazole regimes

Question 150

hypocalcaemia causes

Answer 150

auses vitamin D deficiency (osteomalacia) chronic kidney disease hypoparathyroidism (e.g. post thyroid/parathyroid surgery) pseudohypoparathyroidism (target cells insensitive to PTH) rhabdomyolysis (initial stages) magnesium deficiency (due to end organ PTH resistance) massive blood transfusion acute pancreatitis

Question 151

hypocalcaemia Management

Answer 151

Management acute management of severe hypocalcaemia is with intravenous replacement. The preferred method is with intravenous calcium gluconate, 10ml of 10% solution over 10 minutes intravenous calcium chloride is more likely to cause local irritation ECG monitoring is recommended further management depends on the underlying cause

Question 152

Bells palsy presentation

Answer 152

Features lower motor neuron facial nerve palsy - forehead affected* patients may also notice post-auricular pain (may precede paralysis), altered taste, dry eyes, hyperacusis

Question 153

Bells palsy management

Answer 153

prednisolone 1mg/kg for 10 days should be prescribed for patients within 72 hours of onset of Bell's palsy. Adding in aciclovir gives no additional benefit eye care is important - prescription of artificial tears and eye lubricants should be considered

Question 154

large fluid volumes risk

Answer 154

hyperchloraemic acidosis

Question 155

stroke post coag

Answer 155

Aspirin 300 mg daily for 2 weeks should be given immediately after an ischaemic stroke is confirmed by brain imaging. Following this, clopidogrel 75 mg daily should be given long-term -if it can be tolerated and is not contraindicated. If clopidogrel is contraindicated or not tolerated, then the patient should be given modified-release dipyridamole alongside low dose aspirin.

Question 156

Age-related macular degeneration presentation

Answer 156

Patients typically present with a subacute onset of visual loss with: a reduction in visual acuity, particularly for near field objects difficulties in dark adaptation with an overall deterioration in vision at night fluctuations in visual disturbance which may vary significantly from day to day they may also suffer from photopsia, (a perception of flickering or flashing lights), and glare around objects

Question 157

Age-related macular degeneration treatment

Answer 157

zinc with anti-oxidant vitamins A,C and E reduced progression of the disease by around one third. anti-VEGF agents (wet) - instituted within the first two months of diagnosis of wet ARMD if possible. Laser photocoagulation does slow progression of ARMD where there is new vessel formation, although there is a risk of acute visual loss after treatment, which may be increased in patients with sub-foveal ARMD. For this reason anti-VEGF therapies are usually preferred.

Question 158

Central retinal vein occlusion presentation

Answer 158

Features sudden, painless reduction or loss of visual acuity, usually unilaterally severe retinal haemorrhages are usually seen on fundoscopy

Question 159

Herpes simplex keratitis presentation

Answer 159

``` Features red, painful eye photophobia epiphora visual acuity may be decreased fluorescein staining may show an epithelial ulcer ```

Question 160

Herpes simplex keratitis management

Answer 160

Management immediate referral to an ophthalmologist topical aciclovir

Question 161

Rentral retinal artery occlusion

Answer 161

causes sudden unilateral visual loss due to thromboembolism (from atherosclerosis) or arteritis (e.g. temporal arteritis) features include afferent pupillary defect, 'cherry red' spot on a pale retina

Question 162

retinal detachment presentaition

Answer 162

Peripheral curtain over vision + spider webs + flashing lights in vision (painless loss of vision)

Question 163

amaurosis fugax

Answer 163

Painless, transient monocular blindness together with the description of a 'black curtain coming down'

Question 164

Tunnel vision is the concentric diminution of the visual fields Causes

Answer 164

``` Causes papilloedema glaucoma retinitis pigmentosa choroidoretinitis optic atrophy secondary to tabes dorsalis hysteria ```

Question 165

Acute angle closure glaucoma is associated with ?

Answer 165

hypermetropia,

Question 166

primary open-angle glaucoma is associated with

Answer 166

myopia

Question 167

Acyanotic heart disease

Answer 167

most common causes (blood contains oxygen) ``` ventricular septal defects (VSD) - most common, accounts for 30% atrial septal defect (ASD) patent ductus arteriosus (PDA) coarctation of the aorta aortic valve stenosis ```

Question 168

Cyanotic heart disease

Answer 168

Cyanotic - most common causes tetralogy of Fallot transposition of the great arteries (TGA) tricuspid atresia

Question 169

Anti-dsDNA

Answer 169

SLE

Question 170

Anti-CCP

Answer 170

RA

Question 171

Anti-La

Answer 171

Sjogren's syndrome. It can also be found in patients with SLE, however, it is not very specific.

Question 172

ANCA

Answer 172

ANCA is an antibody targeted against neutrophils. It is seen in patients with autoimmune vasculitis.

Question 173

Anti-centromere

Answer 173

Anti-centromere antibodies are characteristic of the CREST syndrome which is the cutaneous form of systemic sclerosis. CREST stands for calcinosis, Raynaud's, oesophageal dysmotility, sclerodactyly and telangiectasia.

Question 174

metoclopramide avoid when

Answer 174

bowel obstruction | as could cause a perforation in bowel obstruction.

Question 175

Osteochondritis dissecans presentation

Answer 175

Patients typically present with a subacute onset of: Knee pain and swelling, typically after exercise Knee catching, locking and/or giving way - more constant and severe symptoms are associated with the presence of loose bodies Feeling a painful 'clunk' when flexing or extending the knee - indicating the involvement of the lateral femoral condyle

Question 176

Osteochondritis dissecans signs

Answer 176

Joint effusion Full range of movement in the joint without signs of ligamentous instability External tibial rotation when walking - if medial femoral involvement Tenderness on palpation of the articular cartilage of the medial femoral condyle, when the knee is flexed Wilson's sign for detecting medial condyle lesion - with the knee at 90° flexion and tibia internally rotated, the gradual extension of the joint leads to pain at about 30°, external rotation of the tibia at this point relieves the pain

Question 177

Osteochondritis dissecans investigations

Answer 177

Investigations: X-ray (anteroposterior, lateral and tunnel views) - may show the subchondral crescent sign or loose bodies MRI - used to evaluate cartilage, visualise loose bodies, stage and assess the stability of the lesion CT - may be used in preoperative planning and in cases where MRI is not available or contraindicated Scintigraphy - may be used to guide treatment as it may show increased uptake in the fragments - a sign of osteoblastic activity

Question 178

treatments have not been shown to improve mortality in patients with chronic heart failure?

Answer 178

furosemide

Question 179

Heart failure management

Answer 179

The first-line treatment for all patients is both an ACE-inhibitor and a beta-blocker Second-line treatment is an aldosterone antagonist Third-line treatment should be initiated by a specialist. Options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy

Question 180

antibiotics for Exacerbations of chronic bronchitis

Answer 180

Amoxicillin or tetracycline or clarithromycin

Question 181

antibiotics for Uncomplicated community-acquired pneumonia

Answer 181

Amoxicillin (Doxycycline or clarithromycin in penicillin allergic, add flucloxacillin if staphylococci suspected e.g. In influenza)

Question 182

antibiotics for Pneumonia possibly caused by atypical pathogens

Answer 182

Clarithromycin

Question 183

antibiotics for Hospital-acquired pneumonia

Answer 183

Within 5 days of admission: co-amoxiclav or cefuroxime More than 5 days after admission: piperacillin with tazobactam OR a broad-spectrum cephalosporin (e.g. ceftazidime) OR a quinolone (e.g. ciprofloxacin)

Question 184

Impetigo treatment

Answer 184

Topical hydrogen peroxide, oral flucloxacillin or erythromycin if widespread

Question 185

Cellulitis treatment

Answer 185

Flucloxacillin (clarithromycin, erythromycin or doxycycline if penicillin-allergic) Co-amoxiclav (clarithromycin, + metronidazole if penicillin-allergic)

Question 186

Animal or human bite treat

Answer 186

Co-amoxiclav (doxycycline + metronidazole if penicillin-allergic)

Question 187

Salicylate poisoning presentation

Answer 187

present with nausea, vomiting, tinnitus and headache. In more severe overdoses, hyperventilation and a secondary respiratory alkalosis develops. give IV sodium bicarb

Question 188

benzodiazepine overdose.

Answer 188

Flumazenil

Question 189

CLL is associated with

Answer 189

warm autoimmune haemolytic anaemia

Question 190

The Mackler triad for Boerhaave syndrome:

Answer 190

vomiting, thoracic pain, subcutaneous emphysema. It typically presents in middle aged men with a background of alcohol abuse. = oesphgealo perforation

Question 191

Plummer-Vinson syndrome

Answer 191

Triad of: dysphagia (secondary to oesophageal webs) glossitis iron-deficiency anaemia Treatment includes iron supplementation and dilation of the webs

Question 192

Orlistat

Answer 192

weight loss | inhibiting gastric and pancreatic lipase to reduce the digestion of fat

Question 193

Features suggestive of hypernatraemic dehydration:

Answer 193

``` jittery movements increased muscle tone hyperreflexia convulsions drowsiness or coma ```

Question 194

X-linked recessive inheritance

Answer 194

males only effected X-linked recessive disorders are transmitted by heterozygote females (carriers) and male-to-male transmission is not seen. ie haemophilia A

Question 195

life treating asthma attack

Answer 195

``` SpO2 <92% PEF <33% best or predicted Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis ```

Question 196

risk factors for erectile dysfunction

Answer 196

Other than increasing age, risk factors include: cardiovascular disease risk factors: obesity, diabetes mellitus, dyslipidaemia, metabolic syndrome, hypertension, smoking alcohol use drugs: SSRIs, beta-blockers

Question 197

assessment for erectile dysfunction

Answer 197

t all men have their 10-year cardiovascular risk calculated by measuring lipid and fasting glucose serum levels. Free testosterone should also be measured in the morning between 9 and 11am. If free testosterone is low or borderline, it should be repeated along with follicle-stimulating hormone, luteinizing hormone and prolactin levels. If any of these are abnormal refer to endocrinology for further assessment.

Question 198

erectile dysfunction management

Answer 198

PDE-5 inhibitors (such as sildenafil, 'Viagra') Vacuum erection devices are recommended as first-line treatment in those who can't/won't take a PDE-5 inhibitor. Other points for a young man who has always had difficulty achieving an erection, referral to urology is appropriate people with erectile dysfunction who cycle for more than three hours per week should be advised to stop

Question 199

normocytic anaemia with low serum iron, low TIBC but raised ferritin

Answer 199

anaemia of chronic disease

Question 200

Sideroblastic anaemia

Answer 200

a microcytic anaemia with raised serum iron levels.

Question 201

a microcytic anaemia, low ferritin and a raised TIBC, not the current clinical picture.

Answer 201

iron def

Question 202

Subcapsular cataracts may be associated with what medication

Answer 202

steroids (Allopurinol less strong link )

Question 203

) Myotonic dystrophy is associated with what eye problem

Answer 203

dot cataracts

Question 204

Whipple’s triad of symptoms of for insluinoma

Answer 204

) hypoglycaemia with fasting or exercise, 2) reversal of symptoms with glucose, and 3) recorded low BMs at the time of symptoms is hallmark for an insulinoma

Question 205

insluinoma features

Answer 205

Features of hypoglycaemia: typically early in morning or just before meal, e.g. diplopia, weakness etc rapid weight gain may be seen high insulin, raised proinsulin:insulin ratio high C-peptide

Question 206

Rhabdomyolysis causes

Answer 206

Causes seizure collapse/coma (e.g. elderly patients collapses at home, found 8 hours later) ecstasy crush injury McArdle's syndrome drugs: statins (especially if co-prescribed with clarithromycin)

Question 207

Hypothyroidism causes a euvolaemic hyponatraemia | blood results

Answer 207

Plasma osmolality low | NA in urine = high

Question 208

The recommended dose of adrenaline to give during advanced ALS

Answer 208

1mg

Question 209

Hodgkin's lymphoma - best prognosis =

Answer 209

lymphocyte predominant

Question 210

Intramuscular ceftriaxone is the treatment of choice for

Answer 210

gonnorhoae

Question 211

Bifascicular block

Answer 211

combination of RBBB with left anterior or posterior hemiblock e.g. RBBB with left axis deviation

Question 212

Trifascicular block

Answer 212

Trifascicular block | features of bifascicular block as above + 1st-degree heart block

Question 213

metformin not tolerated GI

Answer 213

If metformin is not tolerated due to GI side-effects, try a modified-release formulation before switching to a second-line agent

Question 214

Lithium monitoring

Answer 214

When checking lithium levels, the sample should be taken 12 hours post-dose after starting lithium levels should be performed weekly and after each dose change until concentrations are stable once established, lithium blood level should 'normally' be checked every 3 months after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable.

Question 215

Lithium SE

Answer 215

Adverse effects nausea/vomiting, diarrhoea fine tremor nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus thyroid enlargement, may lead to hypothyroidism ECG: T wave flattening/inversion weight gain idiopathic intracranial hypertension leucocytosis hyperparathyroidism and resultant hypercalcaemia

Question 216

GCS

Answer 216

Motor response 6. Obeys commands 5. Localises to pain 4. Withdraws from pain 3. Abnormal flexion to pain (decorticate posture) 2. Extending to pain 1. None Verbal response 5. Orientated 4. Confused 3. Words 2. Sounds 1. None Eye opening 4. Spontaneous 3. To speech 2. To pain 1. None

Question 217

autoimmune hep - presentation

Answer 217

Features may present with signs of chronic liver disease acute hepatitis: fever, jaundice etc (only 25% present in this way) amenorrhoea (common) ANA/SMA/LKM1 antibodies, raised IgG levels liver biopsy: inflammation extending beyond limiting plate 'piecemeal necrosis', bridging necrosis

Question 218

duloxetine

Answer 218

duloxetine. This acts as a serotonin/norepinephrine reuptake inhibitor and its common side effects include nausea, dizziness and insomnia.

Question 219

Lacunar strokes can present with

Answer 219

unilateral motor disturbance affecting the face, arm or leg or all 3. complete one sided sensory loss. ataxia hemiparesis.

Question 220

patient refuses IM ceftriaxone in gonorrhoea

Answer 220

oral cefixime + oral azithromycin

Question 221

optimal treatment in HNF1A-MODY.

Answer 221

Sulfonylureas (e.g. gliclazide)

Question 222

live attenuated vaccines which should not be given in immunocompromised patients are:

Answer 222

``` Yellow fever Oral polio Intranasal influenza Varicella Measles, mumps and rubella (MMR) BCG ```

Question 223

most frequent malaria

Answer 223

Falciparum malaria is the commonest type of malaria

Question 224

recent parovirus in pregnancy immunology | Rubella

Answer 224

IgG positive & IgM negative - shows immunity to parvovirus. Reassure, no further action. IgG negative & IgM positive - non-immune. Recent parvovirus infection in last 4 weeks. Refer immediately for further tests/fetal medicine. IgG negative & IgM negative - repeat test in 4 weeks. If both tests still negative, this confirms susceptibility, but no recent infection. Reassure, further action required only if subsequent exposure occurs.

Question 225

Dupuytren's contracture

Answer 225

``` Specific causes include: manual labour phenytoin treatment alcoholic liver disease diabetes mellitus trauma to the hand ```

Question 226

Orbital cellulitis présentation

Answer 226

``` Presentation Redness and swelling around the eye Severe ocular pain Visual disturbance Proptosis Ophthalmoplegia/pain with eye movements Eyelid oedema and ptosis Drowsiness +/- Nausea/vomiting in meningeal involvement (Rare) ```

Question 227

Orbital cellulitis investigations

Answer 227

nvestigations Full blood count – WBC elevated, raised inflammatory markers. Clinical examination involving complete ophthalmological assessment – Decreased vision, afferent pupillary defect, proptosis, dysmotility, oedema, erythema. CT with contrast – Inflammation of the orbital tissues deep to the septum, sinusitis. Blood culture and microbiological swab to determine the organism. Most common bacterial causes – Streptococcus, Staphylococcus aureus, Haemophilus influenzae B.

Question 228

Felty's syndrome

Answer 228

RA + splenomegaly + low white cell count)

Question 229

Irradiated blood products when

Answer 229

Irradiated blood products are used to avoid transfusion-associated graft versus host disease Neonates up to 28 days post expected date of delivery Pregnancy: Elective transfusions during pregnancy (not during labour or delivery) Immunocompromised (e.g. chemotherapy or congenital) Patients with/previous Hodgkins Disease HIV

Question 230

Injury to the AC joint - injury

Answer 230

AC joint injuries are graded I to VI depending on the degree of separation. Grade I and II injuries are very common and are typically managed conservatively including resting the joint using a sling. Grade IV, V and VI are rare and require surgical intervention. The management of grade III injuries is a matter of debate and often depends on individual circumstances.

Question 231

sialadenitis

Answer 231

inflammation of the salivary gland likely secondary to obstruction by a stone impacted in the duct. The duct from the submandibular gland drain into the floor of the mouth and purulent discharge from this duct causes a foul taste in the mouth.

Question 232

Oesophageal adenocarcinoma is associated with

Answer 232

GORD or Barrett's

Question 233

Constipation in children history

Answer 233

poor diet and fluid intake history of cerebral palsy learning difficulties, or spinal cord problems; psychological factors (e.g., depression, abuse, ADHD, autism, oppositional disorder), weaning, toilet training, start of schooling or other causes of stress may be present; vague abdominal pain, painful defecation (infants may extend their legs and squeeze anal and buttock muscles to prevent stooling;

Question 234

constipation in children exam

Answer 234

examination findings may be minimal (mild abdominal tenderness, stool in rectum); abdominal distension in severe cases or in small children; faecal mass palpable on abdominal or rectal examination

Question 235

constipation in children management

Answer 235

1. Dietary changes remain a common initial recommendation, particularly increased intake of fluids and dietary fibre. 2. osmotic agents ie lactulose or polyethylene glycol (PEG) (quicker response, over 1) 3. Some children may require the addition of a short-term stimulant laxative (e.g., senna) to achieve regular bowel movements. If impaction present given osmotic lax 1st line

Question 236

Appendicitis history

Answer 236

history of sharp or stabbing periumbilical pain that migrates to the right lower quadrant (RLQ); anorexia, fever, vomiting, and/or diarrhoea may be present; occurs in all age groups but is rare in infants

Question 237

Appendicitis exam

Answer 237

positive McBurney's sign (RLQ pain and tenderness to palpation at a point two-thirds along a line from the umbilicus to the anterior superior iliac spine); positive Rovsing's sign (pain in the RLQ in response to left-sided palpation, suggesting peritoneal irritation); positive psoas sign (pain in the RLQ when child placed on left side and right hip gently hyperextended, suggesting irritation to the psoas fascia and muscle); positive obturator sign (RLQ pain on internal rotation of the flexed right thigh);

Question 238

Appendicitis management

Answer 238

Seek immediate surgical input and consider involving critical care for any patient with suspected appendicitis and signs of shock or sepsis. Think fluids, abx and access - consider if patient is acutely unwell and in shock. Laparoscopic appendicectomy is the first choice for most adults

Question 239

Gastroenteritis history

Answer 239

vague abdominal pain with nausea and vomiting; diarrhoea with or without mucus in stool; recent travel or contact with sick individual(s) or ingestion of suspected food and drink; >10 days suggests parasitic or non-infectious cause; fever, chills, myalgia, rhinorrhoea, upper respiratory symptoms

Question 240

Gastroenteritis on exam

Answer 240

diffuse abdominal pain without evidence of peritonitis (no guarding or rebound tenderness); abdominal distension; hyperactive bowel sounds; mucus in stool (bacterial or parasitic); signs of volume depletion (tachycardia, hypotension, dry mucous membranes, poor capillary refill, sunken fontanelle in infants); low-grade fever, lethargy and/or irritability, reduced response to noxious stimuli, abnormal temperature

Question 241

Gastroenteritis management

Answer 241

access dehydration rehydrate if needed Daily fluid maintenance requirement is 100 mL/kg for the first 10 kg body weight, 50 mL/kg for the next 10 kg, and 20 mL/kg for each subsequent 1 kg over 20 kg. This is usually supplied by the age-appropriate diet. For infants who are breast-fed, breastfeeding should be continued. ondansetron should be considered when vomiting interferes with ORT.

Question 242

UTI in children management

Answer 242

age dependant Neonates under 6 weeks - IV abx infants >6 weeks to <2 years children and adolescents : systemically stable - oral cefixime if unstable - need IV abx

Question 243

Intussuspection presentation / history

Answer 243

usually infant between 3 months and 12 months of age presenting with colicky abdominal pain, flexing of the legs, fever, lethargy, and vomiting; Henoch-Schonlein purpura (HSP) may be initiating factor in an older child (usually <11 years of age); vague abdominal complaints; severe, cramp-like abdominal pain; child may be inconsolable

Question 244

Intussuspection exam

Answer 244

may see gross or occult blood that may be mixed with mucus and have 'red currant jelly ' appearance, abdominal tenderness, and palpable abdominal mass; signs of HSP may be present in older child (rash of palpable purpura, blood in the stools) confirm with USS

Question 245

Intussuspection treatment

Answer 245

1st line - fluid resuscitation Reduction should be first attempted by contrast enema 2nd (when contrast enema is contra ie in peritonitis, perforation, and hypovolaemic shock) - surgical reduction

Question 246

merkles diverticulum history

Answer 246

typically aged <2 years; may present with abdominal pain (may be intermittent or mimic acute appendicitis), and/or painless passage of bright red blood per rectum (haematochezia); often asymptomatic

Question 247

merkles diverticulum exam

Answer 247

dark red, maroon, or 'red currant jelly' stools; abdominal tenderness with guarding and rebound (may suggest diverticulitis);

Question 248

merkles diverticulum investigation

Answer 248

Pertechnetate scan is best | ectopic focus or 'hot spot'; enhancement of diverticulum

Question 249

merkles diverticulum management

Answer 249

symptomatic - surgical excision of the diverticulum

Question 250

crohns disease history

Answer 250

crampy abdominal pain, intermittent diarrhoea, bloody diarrhoea if colitis a feature (blood less common in Crohn's disease than in ulcerative colitis), weight loss, fatigue, family history of inflammatory bowel disease

Question 251

crohns disease exam

Answer 251

ulcers, evidence of weight loss, pallor, abdominal tenderness, abdominal mass, perianal fistula, perirectal abscess, anal fissure, perianal skin tags; extraintestinal manifestations including iritis, arthritis, sacroiliitis, erythema nodosum, pyoderma gangrenosum

Question 252

crohns disease investigation

Answer 252

FBC: leukocytosis, anaemia, thrombocytosis CRP and ESR - raised colonoscopy with biopsy: may demonstrate inflammation, friability, ulcer formation, and oedema

Question 253

crohns disease management

Answer 253

budesonide - a modified-release corticosteroid, which is active particularly at the terminal ileum prednisolone: 0.5 to 0.75 mg/kg/day orally, taper gradually according to response (consider adverse effect profile) immunmodulator therapy ie azathioprine or mercaptopurine: or methotrexate (with folic acid) biological therapy TNF-alpha inhibitors infliximab and adalimumab

Question 254

testicular torsion history

Answer 254

acute-onset testicular pain; nausea, and vomiting; history of recurrent episodes suggests repeated episodes of testicular torsion followed by spontaneous detorsion; history of trauma may be present

Question 255

testicular torsion exam

Answer 255

tender, oedematous testicle; affected testicle may appear higher than unaffected testicle with horizontal lie; associated scrotal erythema and oedema; absent cremasteric reflex; usually no pain relief with elevation of the scrotum

Question 256

testicular torsion investigations

Answer 256

duplex Doppler ultrasound of scrotum: presence of fluid and the whirlpool sign (the swirling appearance of the spermatic cord from torsion as the ultrasound probe scans downwards perpendicular to the spermatic cord); absent or decreased blood flow in the affected testicle

Question 257

giardiasis history

Answer 257

history of travel, contaminated water/food, IgA deficiency, foul-smelling watery/fatty stools, abdominal pain, bloating, or weight loss

Question 258

giardiasis investigation

Answer 258

giardiasis - stool culture - This remains the most definitive investigation. Inexpensive, but requires microscopic expertise and specialised laboratories.

Question 259

giardiasis treatment

Answer 259

metronidazole 1st line Nitroimidazoles (e.g., metronidazole and tinidazole) are first choice for these patients and bind with parasite DNA causing death of the trophozoite. paromomycin in pregnancy (1st Trimenster`0

Question 260

Labyrinthitis history

Answer 260

history of vertigo, dizziness, hearing loss, tinnitus, otalgia, and flu-like symptoms; irritation of the vestibular system can be secondary to trauma, central nervous system or ear infection, or vestibular neuritis

Question 261

Labyrinthitis risk factors

Answer 261

Key risk factors include viral infections, acute or chronic otitis media, meningitis, cholesteatoma, and inner ear malformations.

Question 262

Labyrinthitis treatment

Answer 262

Symptoms of acute vertigo episodes can be treated with vestibular suppressants and anti-emetics ie promethazine:

Question 263

malrotation history

Answer 263

onset <1 month age with bilious vomiting; more concerning symptoms include haematochezia, abdominal distension, and shock; for older children, presents as chronic vomiting and poor weight gain

Question 264

malrotation exam

Answer 264

examination initially normal but may demonstrate rapid progression to acute abdomen secondary to bowel necrosis; there is a high risk of midgut volvulus and intestinal necrosis

Question 265

malroation investigation

Answer 265

plain abdominal x-ray: obstruction: dilatation of the stomach and duodenum needs emergency surgery

Question 266

aaa screening

Answer 266

In England, abdominal aortic aneurysm screening (AAA) is offered to men during the year they turn 65. If normal (<3cm) the patient will require no further future scans as the chances of developing a AAA after 65 years old is small.

Question 267

Carbimazole

Answer 267

hyrotoxicosis. It is typically given in high doses for 6 weeks until the patient becomes euthyroid before being reduced. Mechanism of action blocks thyroid peroxidase from coupling and iodinating the tyrosine residues on thyroglobulin → reducing thyroid hormone production in contrast propylthiouracil as well as this central mechanism of action also has a peripheral action by inhibiting 5'-deiodinase which reduces peripheral conversion of T4 to T3 Adverse effects agranulocytosis crosses the placenta, but may be used in low doses during pregnancy

Question 268

Argyll-Robertson pupil

Answer 268

Argyll-Robertson pupil is one of the classic pupillary syndrome. It is sometimes seen in neurosyphilis. A mnemonic used for the Argyll-Robertson Pupil (ARP) is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA) Features small, irregular pupils no response to light but there is a response to accommodate Causes diabetes mellitus syphilis

Question 269

Orthostatic hypotension

Answer 269

Orthostatic hypotension can be diagnosed when there is: a. A drop in systolic BP of 20mmHg or more (with or without symptoms) b. A drop to below 90mmHg on standing even if the drop is less than 20mmHg (with or without symptoms) c. A drop in diastolic BP of 10mmHg with symptoms (although clinically much less significant than a drop in systolic BP).

Question 270

SSRI + NSAID = =

Answer 270

GI bleeding risk - give a PPI

Question 271

Genital warts

Answer 271

90% are caused by HPV 6 & 11 Management topical podophyllum or cryotherapy are commonly used as first-line treatments depending on the location and type of lesion. Multiple, non-keratinised warts are generally best treated with topical agents whereas solitary, keratinised warts respond better to cryotherapy imiquimod is a topical cream which is generally used second line genital warts are often resistant to treatment and recurrence is common although the majority of anogenital infections with HPV clear without intervention within 1-2 years

Question 272

Venous leg ulcers | presentation

Answer 272

Most due to venous hypertension, secondary to chronic venous insufficiency (other causes include calf pump dysfunction or neuromuscular disorders) Ulcers form due to capillary fibrin cuff or leucocyte sequestration Features of venous insufficiency include oedema, brown pigmentation, lipodermatosclerosis, eczema Location above the ankle, painless Deep venous insufficiency is related to previous DVT and superficial venous insufficiency is associated with varicose veins Doppler ultrasound looks for presence of reflux and duplex ultrasound looks at the anatomy/ flow of the vein Management: 4 layer compression banding after exclusion of arterial disease or surgery If fail to heal after 12 weeks or >10cm2 skin grafting may be needed

Question 273

Marjolin's ulcer presentation

Answer 273

Squamous cell carcinoma Occurring at sites of chronic inflammation e.g; burns, osteomyelitis after 10-20 years Mainly occur on the lower limb

Question 274

Arterial ulcers presentation

Answer 274

``` Occur on the toes and heel Painful There may be areas of gangrene Cold with no palpable pulses Low ABPI measurements ```

Question 275

Neuropathic ulcers presentation

Answer 275

Commonly over plantar surface of metatarsal head and plantar surface of hallux The plantar neuropathic ulcer is the condition that most commonly leads to amputation in diabetic patients Due to pressure Management includes cushioned shoes to reduce callous formation

Question 276

Pyoderma gangrenosum presentation

Answer 276

Associated with inflammatory bowel disease/RA Can occur at stoma sites Erythematous nodules or pustules which ulcerate

Question 277

retractile testis

Answer 277

testis that appears in warm conditions or which can be brought down on clinical examination and does not immediately retract

Question 278

neoplastic spinal cord compression is suspected

Answer 278

high-dose oral dexamethasone should be given whilst awaiting investigations

Question 279

benign prostatic hyperplasia management

Answer 279

Alpha-1 antagonists

Question 280

BPH typically presents with lower urinary tract symptoms (LUTS), which may be categorised into:

Answer 280

``` voiding symptoms (obstructive): weak or intermittent urinary flow, straining, hesitancy, terminal dribbling and incomplete emptying storage symptoms (irritative) urgency, frequency, urgency incontinence and nocturia post-micturition: dribbling complications: urinary tract infection, retention, obstructive uropathy ```

Question 281

prophylaxis for contacts of patients with meningococcal meningitis

Answer 281

``` Oral ciprofloxacin (preferred ) ( or rifampicin) ```

Question 282

most useful prognostic marker in paracetamol overdose?

Answer 282

An elevated prothrombin time signifies liver failure in paracetamol overdose and is a marker of poor prognosis.

Question 283

acute pericarditis management

Answer 283

1. combination of NSAID and colchicine

Question 284

Otosclerosis describes the replacement of normal bone by vascular spongy bone. It causes a progressive conductive deafness due to fixation of the stapes at the oval window. Otosclerosis is autosomal dominant and typically affects young adults features

Answer 284

``` Onset is usually at 20-40 years - features include: conductive deafness tinnitus normal tympanic membrane* positive family history ```

Question 285

Otosclerosis management

Answer 285

hearing aid

Question 286

bstructive urinary calculi and signs of infection

Answer 286

urgent renal decompression and IV antibiotics due to the risk of sepsis

Question 287

Sarcoidosis is a multisystem disorder of unknown aetiology characterised by non-caseating granulomas. It is more common in young adults and in people of African descent Features

Answer 287

acute: erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, polyarthralgia insidious: dyspnoea, non-productive cough, malaise, weight loss skin: lupus pernio hypercalcaemia: macrophages inside the granulomas cause an increased conversion of vitamin D to its active form (1,25-dihydroxycholecalciferol)

Question 288

Lyme disease management

Answer 288

Management of suspected/confirmed Lyme disease doxycycline if early disease. Amoxicillin is an alternative if doxycycline is contraindicated (e.g. pregnancy) people with erythema migrans should be commenced on antibiotic without the need for further tests ceftriaxone if disseminated disease Jarisch-Herxheimer reaction is sometimes seen after initiating therapy: fever, rash, tachycardia after first dose of antibiotic (more commonly seen in syphilis, another spirochaetal disease)

Question 289

OCD management

Answer 289

he most appropriate initial management would be a form of low-intensity psychological therapy. NICE guidelines recommend exposure and response prevention as a beneficial therapy for patients with OCD. The use of selective serotonin re-uptake inhibitors is also recommended by NICE guidelines, but is typically commenced following a stepwise approach where non-pharmacological interventions are recommended first.

Question 290

Chronic insomnia

Answer 290

may be diagnosed after three months, if a person has trouble falling asleep or staying asleep at least three nights per week

Question 291

medication in insomnia

Answer 291

hypnotics: The hypnotics recommended for treating insomnia are short-acting benzodiazepines or non-benzodiazepines (zopiclone, zolpidem and zaleplon). Diazepam is not recommended but can be useful if the insomnia is linked to daytime anxiety. Use the lowest effective dose for the shortest period possible. If there has been no response to the first hypnotic, do not prescribe another. You should make the patient aware that repeat prescriptions are not usually given. It is important to review after 2 weeks and consider referral for cognitive behavioural therapy (CBT).

Question 292

oculogyric crisis

Answer 292

oculogyric" refers to the bilateral elevation of the visual gaze, but several other responses are associated with the crisis. = dsytonia

Question 293

Tricyclic antidepressants (TCAs) ie imipramine side effects

Answer 293

``` Common side-effects drowsiness dry mouth blurred vision constipation urinary retention lengthening of QT interval ``` antimuscarinic side-effects are more common with imipramine than other types of tricyclic antidepressants.

Question 294

Akathisia

Answer 294

sense of inner restlessness and inability to keep still

Question 295

Metformin should be stopped f when

Answer 295

following a myocardial infarction due to the risk of lactic acidosis.

Question 296

typical carboxyhaemoglobin levels

Answer 296

3% non-smokers < 10% smokers 10 - 30% symptomatic: headache, vomiting > 30% severe toxicity

Question 297

Drug-induced thrombocytopenia (probable immune-mediated)

Answer 297

quinine abciximab NSAIDs diuretics: furosemide antibiotics: penicillins, sulphonamides, rifampicin anticonvulsants: carbamazepine, valproate heparin

Question 298

Ethylene glycol toxicity management (antifreeze)

Answer 298

Fomepizole (IV), an inhibitor of alcohol dehydrogenase, is used as the first-line treatment for ethylene glycol toxicity. Fomepizole is superior antidote than ethanol because it is safer and easy to dose and administer.

Question 299

Contraindications of metformin

Answer 299

chronic kidney disease: NICE recommend that the dose should be reviewed if the creatinine is > 130 µmol/l (or eGFR < 45 ml/min) and stopped if the creatinine is > 150 µmol/l (or eGFR < 30 ml/min) metformin may cause lactic acidosis if taken during a period where there is tissue hypoxia. Examples include a recent myocardial infarction, sepsis, acute kidney injury and severe dehydration iodine-containing x-ray contrast media: examples include peripheral arterial angiography, coronary angiography, intravenous pyelography (IVP); there is an increasing risk of provoking renal impairment due to contrast nephropathy; metformin should be discontinued on the day of the procedure and for 48 hours thereafter alcohol abuse is a relative contraindication

Question 300

Drugs to avoid in renal failure

Answer 300

antibiotics: tetracycline, nitrofurantoin NSAIDs lithium metformin

Question 301

Drugs likely to accumulate in chronic kidney disease - need dose adjustment in renal failure

Answer 301

``` most antibiotics including penicillins, cephalosporins, vancomycin, gentamicin, streptomycin digoxin, atenolol methotrexate sulphonylureas furosemide opioids ```

Question 302

Rifampicin tb

Answer 302

mechanism of action: inhibits bacterial DNA dependent RNA polymerase preventing transcription of DNA into mRNA potent liver enzyme inducer hepatitis, orange secretions flu-like symptoms

Question 303

Isoniazid tb

Answer 303

mechanism of action: inhibits mycolic acid synthesis peripheral neuropathy: prevent with pyridoxine (Vitamin B6) hepatitis, agranulocytosis liver enzyme inhibitor

Question 304

Pyrazinamide | tb

Answer 304

mechanism of action: converted by pyrazinamidase into pyrazinoic acid which in turn inhibits fatty acid synthase (FAS) I hyperuricaemia causing gout arthralgia, myalgia hepatitis

Question 305

Ethambutol tb

Answer 305

mechanism of action: inhibits the enzyme arabinosyl transferase which polymerizes arabinose into arabinan optic neuritis: check visual acuity before and during treatment dose needs adjusting in patients with renal impairment

Question 306

Methotrexate monitoring

Answer 306

FBC, LFT, U&E

Question 307

Caution should always be exercised when combining diuretics. However, which one of the following combinations is always contraindicated?

Answer 307

Amiloride and spironolactone a | hyperkalemia

Question 308

Steroid responsiveness COPD

Answer 308

Asthmatic features/features suggesting steroid responsiveness in COPD: previous diagnosis of asthma or atopy a higher blood eosinophil count substantial variation in FEV1 over time (at least 400 ml) substantial diurnal variation in peak expiratory flow (at least 20%)

Question 309

Acromegaly: management

Answer 309

Trans-sphenoidal surgery is the first-line treatment for acromegaly in the majority of patients Dopamine agonists for example bromocriptine the first effective medical treatment for acromegaly, however now superseded by somatostatin analogues effective only in a minority of patients ``` Somatostatin analogue directly inhibits the release of growth hormone for example octreotide effective in 50-70% of patients may be used as an adjunct to surgery ``` Pegvisomant GH receptor antagonist - prevents dimerization of the GH receptor once daily s/c administration very effective - decreases IGF-1 levels in 90% of patients to normal doesn't reduce tumour volume therefore surgery still needed if mass effect

Question 310

Drug-induced urinary retention

Answer 310

The following drugs may cause urinary retention: tricyclic antidepressants e.g. amitriptyline anticholinergics opioids NSAIDs disopyramide

Question 311

Thyrotoxic storm treatment

Answer 311

beta blockers, propylthiouracil and hydrocortisone

Question 312

ACR results

Answer 312

NICE recommendations for referral to a nephrologist: a urinary albumin:creatinine ratio (ACR) of 70 mg/mmol or more, unless known to be caused by diabetes and already appropriately treated a urinary ACR of 30 mg/mmol or more, together with persistent haematuria (two out of three dipstick tests show 1+ or more of blood) after exclusion of a urinary tract infection consider referral to a nephrologist for people with an ACR between 3-29 mg/mmol who have persistent haematuria and other risk factors such as a declining eGFR, or cardiovascular disease Management ACE inhibitors (or angiotensin II receptor blockers) are key in the management of proteinuria they should be used first-line in patients with coexistent hypertension and CKD if the ACR > 70 mg/mmol they are indicated regardless of the patient's blood pressure

Question 313

open angle glaucoma treatment

Answer 313

NICE guidelines: first line: prostaglandin analogue (PGA) eyedrop second line: beta-blocker, carbonic anhydrase inhibitor, or sympathomimetic eyedrop if more advanced: surgery or laser treatment can be tried2

Question 314

open angle glaucoma features

Answer 314

Features severe pain: may be ocular or headache decreased visual acuity symptoms worse with mydriasis (e.g. watching TV in a dark room) hard, red-eye haloes around lights semi-dilated non-reacting pupil corneal oedema results in dull or hazy cornea systemic upset may be seen, such as nausea and vomiting and even abdominal pain

Question 315

Metformin predisposes to lactic acidosis

Answer 315

should therefore be used with caution in patients with acute kidney injury

Question 316

adverse effects if metformin

Answer 316

dverse effects gastrointestinal upsets are common (nausea, anorexia, diarrhoea), intolerable in 20% reduced vitamin B12 absorption - rarely a clinical problem lactic acidosis* with severe liver disease or renal failure

Question 317

Nerve at risk during a total hip replacement

Answer 317

Sciatic nerve

Question 318

MRSA management

Answer 318

uppression of MRSA from a carrier once identified nose: mupirocin 2% in white soft paraffin, tds for 5 days skin: chlorhexidine gluconate, od for 5 days. Apply all over but particularly to the axilla, groin and perineum The following antibiotics are commonly used in the treatment of MRSA infections: vancomycin teicoplanin linezolid

Question 319

Headache: red flags

Answer 319

compromised immunity, caused, for example, by HIV or immunosuppressive drugs age under 20 years and a history of malignancy a history of malignancy known to metastasis to the brain vomiting without other obvious cause worsening headache with fever sudden-onset headache reaching maximum intensity within 5 minutes - 'thunderclap' new-onset neurological deficit new-onset cognitive dysfunction change in personality impaired level of consciousness recent (typically within the past 3 months) head trauma headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked), sneeze or exercise orthostatic headache (headache that changes with posture) symptoms suggestive of giant cell arteritis or acute narrow-angle glaucoma a substantial change in the characteristics of their headache

Question 320

mild to moderate dementia management

Answer 320

Acetylcholinesterase (AChE) inhibitors (donepezil, galantamine, and rivastigmine) [NICE, 2006; NICE, 2011]: These drugs can be used for mild to moderate Alzheimer's disease but must only be prescribed by healthcare professionals with expertise in this area ... Memantine is an option for managing Alzheimer's disease for people with: Moderate Alzheimer's disease who are intolerant of, or have a contraindication to, AChE inhibitors or Severe Alzheimer's disease.

Question 321

tonsilitis criteria

Answer 321

``` The criteria are as follows: • Temperature >38ºC • Tender anterior cervical lymphadenopathy • Absence of a cough • Exudate present on tonsils ```

Question 322

TURP syndrome what is this

Answer 322

TURP syndrome is a rare and life-threatening complication of transurethral resection of the prostate surgery. It is caused by irrigation with large volumes of glycine, which is hypo-osmolar and is systemically absorbed when prostatic venous sinuses are opened up during prostate resection. This results in hyponatremia, and when glycine is broken down by the liver into ammonia, hyper-ammonia and visual disturbances.

Question 323

RF TURP syndrome

Answer 323

``` There are risk factors for developing TURP syndrome are : surgical time > 1 hr height of bag > 70cm resected > 60g large blood loss perforation large amount of fluid used poorly controlled CHF ```

Question 324

Adhesive capsulitis presents

Answer 324

painful stiff shoulder with restriction of active and passive range of motion in abduction, internal and external rotation.

Question 325

Sensineural hearing loss

Answer 325

t has a diverse range of pathologies including common causes such as: Presbycusis (most common) Noise-induced hearing loss Congenital infections (e.g. rubella, CMV) Neonatal complications (e.g. kernicterus or meningitis) Drug induced deafness (aminoglycosides). Vascular pathology (stroke, transient ischaemic attacks)

Question 326

Pharmacodynamic interactions with Methotrexate

Answer 326

Trimethoprim and Methotrexate are anti-folate agents. This means that there is an increased risk of Methotrexate toxicity,

Question 327

AKI following contrast risks

Answer 327

An increased risk of AKI is associated with: chronic kidney disease, diabetes with chronic kidney disease, heart failure, renal transplant, age 75 or over, hypovolaemia, increasing volume of contrast agent, and intra-arterial administration of contrast agent.

Question 328

Pharmacological management of chronic COPD

Answer 328

Step 1 Starting with a Short acting B2 agonist (SABA)/ short acting muscarinic antagonist (SAMA). These are continued as the patient goes up the management steps. Step 2 For patients with persistent exacerbations but no asthmatic features (e.g. asthma/atopy history, raised eosinophils, reduced FEV1 or diurnal variations in peak flow) or evidence of steroid responsiveness then add a long acting B2 agonist (LABA) AND a long acting muscarinic antagonist (LAMA). For patients with persistent exacerbations with asthmatic features or evidence of steroid responsiveness increase management to long acting B2 agonist (LABA) and inhaled corticosteroid in combination (ICS). Step 3 If patients on a LABA + LAMA combination are still getting daily symptoms that affect their activities of daily living then a 3 month trial of LAMA + LABA + ICS should be considered. If this does not work then it should be reverted back to LABA + LAMA. If any patient on Step 2 is getting more than one severe or two moderate exacerbations in a year then LAMA + LABA + ICS should be started. Step 4 If patients are still symptomatic consider specialist referral.

Question 329

drug induced lupus

Answer 329

Drug induced lupus (DIL) typically presents as a less severe form of systemic lupus erythematosus (SLE) which starts while taking an offending medication, and completely resolves after it is discontinued. Although DIL can present with any feature of SLE, the most common features are: Systemic upset (fever / fatigue / myalgia). Arthritis (non-erosive) or arthralgia. Serositis in the form of pleurisy or pericarditis. check for

Question 330

Acquired melanocytic naevus

Answer 330

Acquired melanocytic naevus Occur in childhood and evolve through a number of steps: Junctional: flat + pigmented (due to melanocytes at the basal layer of the epidermis) Compound: raised + pigmented (due to melanocytes at the basal layer of the epidermis + deep in the dermis) Intradermal: raised + pale (due to melanocytes deep in the dermis)

Question 331

Antibodies associated with dermatomyositis

Answer 331

constitutional symptoms, symmetrical muscle weakness and a characteristic rash (heliotrope rash, shawl rash, mechanic's hands). Creatine kinase is markedly raised and Anti-Jo1 antibodies are characteristically raised as well. A muscle biopsy will show evidence of Dermatomyositis.

Question 332

Imatinib

Answer 332

Imatinib is a tyrosine kinase inhibitor treatment of chronic myeloid leukaemia (CML) in 2001. Common side effects include fluid retention, headache, diarrhoea, loss of appetite, weakness, nausea and vomiting, abdominal distension, oedema, rash, dizziness, and muscle cramps. Serious side effects may include myelosuppression, heart failure, and liver function abnormalities.

Question 333

Causes of high output cardiac failure

Answer 333

auses of high output cardiac failure can be remembered by the mnemonic AAPPTT: ``` Anaemia Arteriovenous malformation Paget's disease Pregnancy Thyrotoxicosis Thiamine deficiency (wet Beri-Beri) ```

Question 334

Complications of nephrotic syndrome

Answer 334

lose immunoglobulins in their urine. This is because the damage to the glomerular capillary walls causes increased permeability to proteins. This means that these patients are at an increased susceptibility to infection. In particular they are susceptible to staphylococcal and pneumococcal infections.

Question 335

Peri-operative Management of Insulin Dependent Diabetes

Answer 335

Peri-operative management principles of insulin use are: Put the patient as early on the theatre list as possible minimising the amount of time the patient is nil by mouth. Stop long acting insulin the night before. Stop any other insulin and begin sliding scale insulin infusion from when the patient is placed nil by mouth. Continue infusion until patient is able to eat post-operatively. Switch to normal insulin regimen around their first meal.

Question 336

broad complex tachycardia

Answer 336

A broad complex tachycardia will have a heart rate of more than 100 and widened QRS complexes. These patients can be stable or unstable. Patients with a broad complex tachycardia should be managed according to the ALS algorithm. All patients should be maintained on high flow oxygen and IV access obtained. Adverse signs are: ``` Blood pressure <90mmHg (systolic) Heart rate >150 Chest pain Heart failure If a patient displays adverse signs, the patient should be prepared for DC cardioversion. ``` If the patient is stable, they should be started on 300mg IV amiodarone over 1h followed by an infusion of 900mg amiodarone over 24h. The patient should be urgently reviewed by cardiology and intensive care.

Question 337

Haemofiltration should be considered if the following are present;

Answer 337

``` Pulmonary oedema Refractory hyperkalaemia Severe metabolic acidosis Uraemia Drug overdose e.g. aspirin overdose ```

Question 338

Muscle spasm pain in palliative care

Answer 338

The management of pain in palliative care patients in important but can be challenging, and a history is key to ascertaining the best course of treatment. Simple, conservative measures such as heat, massage and relaxation should always be considered. Transcutaneous electric nerve stimulation can be used if there is a specific trigger point. PO diazepam is the first line treatment for spasmodic pain, titrated to effect. Baclofen is a GABA receptor agonist may also be used as a second line.

Question 339

Torsades de points

Answer 339

orsades de points is a polymorphic ventricular tachycardia, a heart rhythm that may arise in a patient with a prolonged QT interval. Patients present with feeling generally unwell, palpitations, chest pain, dizziness and syncope. Sudden cardiac death may also occur. Causes of torsades de points include; Abnormal electrolytes Drugs - clarithromycin, anti-psychotics, fluoxetine, cimetidine, lithium, sotalol Genetic conditions Treatment of torsades de points is primarily supportive using the ABCDE algorithm. DC cardioversion is indicated if the patient is unstable. Isoprenaline and pacing can be used if the patient is stable, and advice should be sought from a specialist.

Question 340

chronic mesenteric ischaemia

Answer 340

Chronic mesenteric ischaemia typically presents in elderly patients. Patients have risk factors for arterial disease (smoking, diabetes, high cholesterol, previous MI etc.) or embolic disease (such as atrial fibrillation). Patients typically present with diffuse, colicky abdominal pain which is worse after eating. Weight loss is a common feature, as patients avoid eating due to the pain. There may be associated diarrhoea and melaena or haematochezia (secondary to mucosal sloughing). On physical examination there is commonly abdominal tenderness. An epigastric bruits may be present (secondary to turbulent flow in the narrowed vessels).

Question 341

Management of narrow complex tachycardias (regular)

Answer 341

``` ABCDE adverse features (shock, syncope, heart failure, or myocardial ischaemia), emergency synchronised direct current (DC) cardioversion is indicated ``` trial vagal manoeuvres (carotid sinus massage or Valsalva manoeuvre). If vagal manoeuvres fail, adenosine should be administered (initially as a 6 mg intravenous bolus, and if this fails 12 mg followed by a further 12 mg is trialled).

Question 342

Management of narrow complex tachycardias (irregular)

Answer 342

``` ABCDE adverse features (shock, syncope, heart failure, or myocardial ischaemia), emergency synchronised direct current (DC) cardioversion is indicated ``` Atrial fibrillation with onset less than 48 hours is typically managed with rhythm control (LMWH followed by flecainide if there is no structural heart disease, or amiodarone if there is structural heart disease). Atrial fibrillation with onset more than 48 hours is typically managed with rate control (i.e. metoprolol or bisoprolol or verapamil, or digoxin if there are signs of heart failure) and anticoagulation

Question 343

investigation for aortic dissection diagnosis

Answer 343

CT angiogram is used to diagnose dissection

Question 344

Acute causes of AR

Answer 344

Infective endocarditis, with valve destruction and leaflet perforation. It can also cause perivalvular abscesses, which can rupture into the left ventricle Aortic dissection, which can cause regurgitation by primarily impeding valve closure Traumatic rupture of the valve leaflets, caused by blunt chest trauma or deceleration injury Iatrogenic causes include balloon valvotomy or trans catheter aortic valve implantation (TAVI)

Question 345

Chronic causes of AR

Answer 345

Chronic valvular causes of AR include: Calcific aortic valve disease (age related) Myxomatous degeneration Congenital disease e.g. bicuspid aortic valve Rheumatic heart disease - most common cause in the developing world Infective endocarditis Rheumatic causes e.g. rheumatoid arthritis, antiphospholipid syndrome Marfan's syndrome

Question 346

Presentation of Acute AR

Answer 346

``` Sudden cardiovascular collapse Pulmonary oedema Pallor Sweating Peripheral vasoconstriction ``` (Early diastolic murmur)

Question 347

Presentation of Chronic AR

Answer 347

Exertional dyspnoea Orthopnoea Paroxysmal nocturnal dyspnoea Stable angina can also develop in some patients with severe AR, even in the absence of coronary artery disease. This is due to reduction in diastolic coronary perfusion. (Early diastolic murmur)

Question 348

Investigations for AR

Answer 348

Echocardiogram is the definitive investigation for aortic regurgitation (AR).

Question 349

Surgical intervention in aortic regurgitation (AR) is indicated in the following situations

Answer 349

Significant enlargement of the ascending aorta Symptomatic AR Asymptomatic AR with the following parameter findings: Poor left ventricular ejection fraction (<= 50%) Left ventricular end diastolic diameter more than 70mm or left ventricular end systolic diameter mote than 50mm Infective endocarditis refractory to medical therapy

Question 350

Aortic stenosis (AS) is associated with a classic triad of symptoms:

Answer 350

Heart failure Syncope Angina

Question 351

ECG findings for AS

Answer 351

Increased QRS complex voltage Left axis deviation Poor R-wave progression

Question 352

AS can be judged to be severe via the following parameters

Answer 352

Peak gradient > 40 mmHg (note, in severe left ventricular dysfunction, a low peak gradient can be falsely reassuring) Valve area < 1.0 cm^2 Aortic jet velocity >4 m/s

Question 353

ndications for intervention in AS

Answer 353

All patients with symptomatic aortic stenosis Asymptomatic patients with a left ventricular ejection fraction (LVEF) < 50% Asymptomatic patients with an LVEF > 50% who are physically active, and who have symptoms or a fall in blood pressure during exercise testing Aortic valve peak velocity > 5.5 m/s^2 Severe calcification and peak velocity progression >= 0.3 m/s^2 Markedly elevated BNP levels without other explanation Severe pulmonary hypertension (pulmonary artery systolic pressure > 60mmHg)

Question 354

intervention in AS

Answer 354

TAVI is favoured with patients with severe comorbidities, previous heart surgery, frailty, restricted mobility, and those older than 75 years of age. SAVR is favoured for patients who are low risk and less than 75 years of age.

Question 355

CHADS2VASc score components

Answer 355

C: 1 point for congestive cardiac failure. H: 1 point for hypertension. A2: 2 points if the patient is aged 75 or over. D: 1 point if the patient has diabetes mellitus. S2: 2 points if the patient has previously had a stroke or transient ischaemic attack (TIA). V: 1 point if the patient has known vascular disease. A: 1 point if the patient is aged 65-74. Sc: 1 point if the patient is female.

Question 356

Management of VF

Answer 356

Management is according to the Advanced Life Support guidelines: The initial priorities will be as for the Basic Life Support: ensure the airway is patent, check for signs of life (pulse and breathing), and commence CPR. Ventricular fibrillation is a shockable rhythm: the next step is to administer defibrillation (unsynchronised cardioversion using a 200 J biphasic shock). Chest compressions should then be resumed. 1 mg adrenaline (10 ml 1:10 000) plus 300 mg amiodarone should be administered after the 3rd shock. Adrenaline should subsequently be administered every 3-5 mins (after every alternate shock).

Question 357

Management of pulseless Ventricular tachycardia (VT)

Answer 357

If there is no pulse the patient should be managed according to the Advanced Life Support algorithm: VT is a shockable rhythm so a 200 J bi-phasic (unsynchronised) shock should be administered. CPR should be resumed for 2 minutes before re-checking the rhythm. Intravenous adrenaline (1 mg of 10 ml 1:10 000 solution) and amiodarone (300 mg) should be administered after delivery of the 3rd shock. Adrenaline should be administered every 3-5 minutes thereafter (after every alternate shock).

Question 358

Management of Ventricular tachycardia with a pulse with adverse features

Answer 358

If there is a pulse but the patient shows adverse features (shock, syncope, myocardial ischaemia, or heart failure) the patient should be managed according to the Resuscitation Council tachyarrhythmia algorithm: Administer a synchronised DC shock (up to 3 attempts). After seeking expert help amiodarone (300 mg intravenously over 10-20 minutes followed by 900 mg over 24 hours) should be administered.

Question 359

Management of Ventricular tachycardia with a pulse with no adverse feature

Answer 359

Management of Ventricular tachycardia with a pulse with no adverse features Management is with amiodarone (300 mg intravenously over 20-60 minutes followed by 900 mg over 24 hours)

Question 360

Signs of Cardiac Tamponade can be remembered by Beck's Triad.

Answer 360

Signs of Cardiac Tamponade can be remembered by Beck's Triad. Hypotension Quiet heart sounds Raised JVP

Question 361

Bradyarrhythmias requiring pacemakers

Answer 361

Complete heart block (whether asymptomatic or symptomatic) Mobitz type 2 heart block (whether asymptomatic or symptomatic) Symptomatic sick sinus syndrome Permanent bradyarrhythmias caused by a myocardial infarct (typically anterior infarcts - arrhythmias caused by inferior infarcts tend to be temporary)

Question 362

Tachyarrhythmias requiring pacemakers

Answer 362

Tachyarrhythmias requiring permanent pacing are those that are resistant to pharmacological therapy. These forms of permanent pacing are typically dual chamber (with one lead in the right atrium and one lead in the right ventricle). Bi-ventricular pacemaker (in which a 3rd wire is placed in a branch of the coronary sinus, to allow left ventricular pacing and ventricular synchronisation) is an option if the left ventricular ejection fraction is <35%.

Question 363

Hypertrophic cardiomyopathy

Answer 363

Hypertrophic cardiomyopathy is the commonest genetic heart condition. It is often the cause of sudden cardiac death in young people and athletes. (AD) ``` Many patient are asymptomatic Generally presents in young adults Exertional syncope Shortness of breath Chest pain Palpitations Heart failure Double apex pulse Ejection systolic murmur at the lower left sternal edge that may get louder during exercise and reduce if lying supine. ```

Question 364

ECG findings in MR

Answer 364

P-mitrale (a broad notched P wave due to left atrial enlargement) Right ventricular hypertrophy Right axis deviation.m

Question 365

Causes of right heart strain

Answer 365

Right heart strain is caused by pathologies affecting the pulmonary vasculature such as ``` Pulmonary emboli Pulmonary hypertension Chronic lung disease Pulmonary stenosis Pneumothorax ```

Question 366

ECG features of right heart strain

Answer 366

``` Sinus tachycardia (most common) Right ventricular strain pattern (ST depression and T wave inversion in right ventricle and inferior leads) RBBB Right axis deviation P pulmonale S1Q3T3 Atrial arrhythmias ```

Question 367

Managment of AF

Answer 367

1.Aspirin Statin Sublingual GTN Beta blocker or rate limiting calcium channel blocker 2. beta blocker and long-acting dihydropyridine calcium channel blocker. 3. A 3rd medication should only be added if the patient is symptomatic despite 2 anti-anginal drugs. Coronary angiography should be arranged unless contraindicated as PCI may be required.

Question 368

Contraindications in WPW

Answer 368

Digoxin and NDP-CCBs (e.g. verapamil) are contraindicated for long term use because they may precipitate ventricular fibrillation. If the patient is experiencing supraventricular tachycardia the management depends on whether the patient is stable or unstable, and if stable the type of arrhythmia:

Question 369

prevent pathological fractures in bone metastases

Answer 369

Bisphosphonates and denosumab can be used to prevent pathological fractures in bone metastases. If the eGFR < 30, denosumab is preferred

Question 370

Medical management of a miscarriage

Answer 370

vaginal misoprostol alone

Question 371

drugs should be avoided in breast feeding

Answer 371

``` antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides psychiatric drugs: lithium, benzodiazepines aspirin carbimazole methotrexate sulfonylureas cytotoxic drugs amiodarone ```

Question 372

loop diuretic. where do they act

Answer 372

inhibits the Na-K-Cl cotransporter in the thick ascending limb of the loop of Henle

Question 373

Acute angle closure glaucoma and priamry assocaitions

Answer 373

Acute angle closure glaucoma | is associated with hypermetropia, where as primary open-angle glaucoma is associated with myopia

Question 374

Water deprivation test: cranial DI

Answer 374

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

Question 375

Nephrogenic DI water dep

Answer 375

urine osmolality after fluid deprivation: low | urine osmolality after desmopressin: low

Question 376

Symptoms of Hypoalbuminaemia

Answer 376

``` Peripheral oedema (due to reduced oncotic pressure, fluid moves to tissues) - starts in ankles and progresses up the body Ascites ```

Question 377

certain circumstances when the creatine equation may not be accurate. Examples include:

Answer 377

Amputation - reduced muscle mass and body weight Pregnancy Very high or low BMI High protein meals Under 18s - never validated Extremely old patients - never validated and likely to have low muscle mass

Question 378

Hypercalcaemia is defined as correct calcium >2.65mmol/L. Management

Answer 378

Aggressive IV fluids (corrects dehydration, protects the kidneys and increases calcium excretion) Bisphosphonates (inhibits osteoclast activity reducing calcium release) Further management to prevent recurrence (depending on the cause): Chemotherapy (malignancy) Surgical resection (malignancy) Radiotherapy (malignancy) Steroids (sarcoidosis) Calcitonin Furosemide

Question 379

Hypernatraemia is defined as serum sodium concentration >145mmol/L. Clinical Features

Answer 379

Lethargy Weakness Signs; Confusion Agitation Seizures Coma treat with IV fluids

Question 380

Hyperphosphataemia may be treated with

Answer 380

phsophate binders (eg. sevelamer 800mg TDS PO during meals)

Question 381

Clinical features of hypocalcaemia can be remembered by the mnemonic 'SPASMODIC'.

Answer 381

SPASMODIC: ``` S – Spasms (Trousseau's sign) P – Perioral parasthaesia A – Anxiety/Irritability S – Seizures M – Muscle tone increase (colic, dysphagia) O– Orientation impairment (i.e. confusion) D – Dermatitis I – Impetigo herpetiformis C – Chvostek's sign ```

Question 382

Management of severe hypokalaemia

Answer 382

Management of severe hypokalaemia Severe: Continuous cardiac monitoring Check and correct magnesium (low magnesium causes renal potassium wasting) IV infusion of 1L 0.9% saline containing 40mmol potassium chloride. Note that maximum peripheral potassium infusion rate is 10mmol/hour. If faster rates required, a central line will neeed to be inserted Avoid glucose and bicarbonate solutions Treat cause(s)

Question 383

The management of hyponatraemia depends on the cause:

Answer 383

``` Hypovolaemic: IV normal saline Treat underlying cause Euvoleamic: SIADH Fluid restriction ADH receptor antagonists (e.g. tolvaptan, deomeclocycline) Oral sodium and furosemide Hypothyroidism Levothyroxine Hypervolaemic: Fluid restriction Treat underlying cause ```

Question 384

Causes of lactic acidosis

Answer 384

``` Tissue hypoxia (Type A) Shock (e.g. cardiogenic, hypovolaemic, haemorrhagic) Hypoxia Acute mesenteric ischaemia Limb ischaemia Severe anaemia Seizures Vigorous exercise Abnormalities in metabolism of lactate (Type B) Diabetic ketoacidosis Cancer Liver disease Inborn errors in metabolism Drugs: Metformin - impairs liver metabolism of lactate Aspirin ```

Question 385

Normal anion gap acidosis is the result of one of three pathologies:

Answer 385

Increased loss of HCO3-, such as; Diarrhoea High output ileostomy Ureterosigmoidostomy Impaired kidney resorption (e.g. acetazolamide treatment) Renal tubular acidosis type 2 Hypoaldosteronism Adrenal insufficiency Mineralocorticoid receptor block (e.g. spironolactone treatment) ``` Increased production of H+, such as; Toluene poisoning Lysine or arginine administration (found in total parental nutrition) Decreased excretion of H+, such as; Renal tubular acidosis types 1 and 4 ```

Question 386

Management of osteomalcia

Answer 386

A vitamin D level of < 25 nmol/L = deficiency, requires high dose treatment initially followed by maintenance treatment. A vitamin D level of between 25-50 nmol/L = insufficiency, can be treated with long term maintenance therapy alone. Lifestyle advice: Safe sun exposure Dietary intake of vitamin D and calcium Long term maintenance supplements

Question 387

SIADH managment

Answer 387

Management revolves around offloading this excess water: ``` Fluid restriction (up to 750ml/day) and treat underlying cause ADH antagonists (e.g. tolvaptan, deomeclocycline) Oral sodium and furosemide ```

Question 388

vestibular schwannomas which cranial nerves effected

Answer 388

Cranial nerves V, VII and VIII

Question 389

cardiogenic shock | PAP CO and SVR

Answer 389

Pulmonary artery occlusion pressure - high CO - Low Systemic vascular resistance - high

Question 390

Hypovolaemia | PAP CO and SVR

Answer 390

Pulmonary artery occlusion pressure - low CO - Low (decreased preload) Systemic vascular resistance - high

Question 391

Septic shock | PAP CO and SVR

Answer 391

Pulmonary artery occlusion pressure - low CO - high Systemic vascular resistance - low

Question 392

prophylaxis of oesophageal bleeding

Answer 392

A non-cardioselective B-blocker (NSBB) is used for the prophylaxis of oesophageal bleeding ie Propranolol

Question 393

e investigation of choice for reflux nephropathy

Answer 393

Micturating cystography

Question 394

safer opioid to use in patients with moderate to end-stage renal failure

Answer 394

Oxycodone

Question 395

Klinefelter's syndrome is associated with

Answer 395

karyotype 47, XXY. Features often taller than average lack of secondary sexual characteristics small, firm testes infertile gynaecomastia - increased incidence of breast cancer elevated gonadotrophin levels but low testosterone Diagnosis is by karyotype (chromosomal analysis).

Question 396

Oesophageal cancer

Answer 396

Dysphagia may be associated with weight loss, anorexia or vomiting during eating Past history may include Barrett's oesophagus, GORD, excessive smoking or alcohol use

Question 397

Hypertrophic obstructive cardiomyopathy (HOCM) Management

Answer 397

``` Management Amiodarone Beta-blockers or verapamil for symptoms Cardioverter defibrillator Dual chamber pacemaker Endocarditis prophylaxis* ```

Question 398

Drugs to avoid in HOCM

Answer 398

Drugs to avoid nitrates ACE-inhibitors inotropes

Question 399

The British Thoracic Society (BTS) state that the following are the main indications for placing a chest tube in pleural infection:

Answer 399

Patients with frankly purulent or turbid/cloudy pleural fluid on sampling should receive prompt pleural space chest tube drainage. The presence of organisms identified by Gram stain and/or culture from a non-purulent pleural fluid sample indicates that pleural infection is established and should lead to prompt chest tube drainage. Pleural fluid pH < 7.2 in patients with suspected pleural infection indicates a need for chest tube drainage.

Question 400

confirm stone diagnosis imagine (renal colic)

Answer 400

non contrast CT

Question 401

pontaneous bacterial peritonitis: most common organism

Answer 401

E. coli

Question 402

HRT for women at risk of venous thromboembolism

Answer 402

transdermal

Question 403

Bile-acid malabsorption may be treated with c

Answer 403

cholestyramine

Question 404

Hyperemesis gravidarum, diagnostic criteria triad:

Answer 404

5% pre-pregnancy weight loss dehydration electrolyte imbalance

Question 405

Left ventricular hypertrophy and deep ST depression and T-wave inversions

Answer 405

hypertrophic obstructive cardiomyopathy.

Question 406

Charcot's cholangitis triad:

Answer 406

fever, jaundice and right upper quadrant pain

Question 407

Beta-blockers are contraindicated in patients with asthma when managing atrial fibrillation what do you give instead?

Answer 407

CCB ie n. Diltiazem

Question 408

Blepharitis may be associated with

Answer 408

seborrhoeic dermatitis, dry eye syndrome and acne rosacea

Question 409

osmotic diuretic that may be used in patients with raised ICP

Answer 409

IV mannitol

Question 410

otitis media - Indications for antibiotics in children are:

Answer 410

Indications for antibiotics in children are: Perforated eardrum <2 years old and bilateral Present for ≥4 days <3 months old

Question 411

Examples of acyanotic heart disease

Answer 411

Ventricular septal defect Coarctation of the aorta Patent ductus arteriosus

Question 412

Types of brain tumours in children include:

Answer 412

Craniopharyngioma: originates from the pituitary gland and presents with homonymous hemianopia from pressure on the optic chiasm. Astrocytoma: graded from 1 (pilocytic astrocytoma) to 4 (glioblastoma multiforme). Grade 1 tumours have an excellent prognosis (95% 5 year survival). Grade 4 tumours have a poor prognosis (20% 5 year survival). Grade 4 astrocytomas may cross the corpus callosum, giving a characteristic 'butterfly glioma' appearance on CT. Ependymomas (tumours of the cells of the ventricular system) Meningioma (tumours of arachnoid cells of the meninges)

Question 413

bronchiolitis obliterans organism

Answer 413

Whilst bronchiolitis obliterans is a relatively rare complication of bronchiolitis it is most commonly associated with adenovirus infection.

Question 414

complication of RSV

Answer 414

Hyponatraemia is commonly seen as a complication in bronchiolitis caused by respiratory syncytial virus (RSV).

Question 415

Congenital Adrenal Hyperplasia (CAH)

Answer 415

s a genetic defect in an enzyme in the synthesis of steroid hormones. Patients can present within a few weeks of birth, with evidence of vomiting and dehydration - suggests that this is the most common and also most severe of the CAH syndromes: classical “salt-wasting” 21-hydroxylase deficiency.

Question 416

Calculating paediatric doses using WETFLAG

Answer 416

``` Weight: (Age + 4) * 2 Energy: 4J/kg Tube size: (Age/4) + 4 Fluids: 20ml/kg normal saline bolus (10ml/kg if septic, trauma or in heart failure) Lorazepam: 0.1mg/kg Adrenaline: 10 micrograms/kg Glucose: 2ml/kg of 10% dextrose ```

Question 417

Glandular fever

Answer 417

EBV illness worsened by antibiotics Risk of speenic rupture -

Question 418

Meconium ileus is managed with

Answer 418

with 'drip and suck' (stomach drainage with an NG ryles tube, and IV fluids), along with enemas to remove the sticky meconium. In severe cases, surgery may be necessary.