Pass med Questions Flashcards
A 23-year-old male presents to you in neurology clinic complaining of excessive daytime somnolence. He describes episodes of sudden onset sleep during the day, and at night often wakes with episodes where he is unable to move his arms or legs and describes seeing figures in the far corner of his bedroom.
Given the likely diagnosis, what is the most appropriate first-line investigation?
Multiple sleep latency EEG:
This patient is likely suffering from narcolepsy, which is associated with episodes of sleep paralysis. Here, patients experience episodes of paralysis, sometimes associated with hallucinations (e.g. figures in the corner of the bedroom) upon waking at night.
ECG and echocardiography is not indicated for the diagnosis of narcolepsy.
This patients symptoms are more consistent with narcolepsy over organic pathology, hence and MRI head would not be indicated in this case.
Multiple sleep latency EEG, along with polysomnography are the investigations of choice for narcolepsy.
This patients symptoms are most likely associated with narcolepsy over psychiatric disturbance, hence a psychiatric assessment is not necessary.
24 hour telemetry is typically used to investigate epilepsy over narcolepsy.
When is Abx used for SBP prophylaxis?
- patients who have had an episode of SBP
- patients with fluid protein <15 g/l and either Child Pugh score of at least 9 or hepatorenal syndrome
NICE recommend: ‘Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less until the ascites has resolved’
A 47-year-old female presents to her general practitioner with eczematous lesions with flakes on the ears and nose. The lesions began appearing 3 months ago, however, she is now growing increasingly anxious as she can no longer hide them with make-up due to increased dryness. She is otherwise healthy and never experienced anything similar before.
Which one of the following is the most appropriate management?
The correct answer is ketoconazole. This patient is suffering from seborrhoeic dermatitis, a very common chronic dermatitis, caused by an inflammatory reaction to a proliferation of a normal skin inhabitant, a fungus called Malassezia furfur. The classic symptoms are dandruff and eczematous lesions with flakes on the periorbital, auricular and nasolabial folds. The first-line management for the face and body lesions is ketoconazole, an antifungal, used to decrease the presence of Malassezia furfur.
A 56-year-old lady is referred to rheumatology clinic due to severe Raynaud’s phenomenon associated with arthralgia of the fingers. On examination you note shiny and tight skin of the fingers with a number of telangiectasia on the upper torso and face. She is also currently awaiting a gastroscopy to investigate heartburn. Which one of the following antibodies is most specific for the underlying condition?
Limited (central) systemic sclerosis = anti-centromere antibodies.
Important for meLess important
This lady has some features of CREST syndrome. Although ANA is positive in 90% of patients with systemic sclerosis, anti-centromere antibodies are the most specific test for limited cutaneous systemic sclerosis.
A 5-year-old girl is seen in the emergency department following her first seizure. This lasted 5 minutes. Her parents describe her falling to the floor suddenly and jerking her arms. She now feels well in herself and does not remember the incident. She is otherwise well.
Neurological examination is normal. General examination reveals four de-pigmented patches of skin over her torso and areas of thickened leathery skin over her lumbar region.
What is the most likely diagnosis?
Tuberous sclerosis
Ash leaf spots and shagreen patches, although not pathognomonic, are often seen in cases of tuberous sclerosis. Most of the manifestations of this disease are neurocutaneous, similarly in the neurofibromatous diseases.
All of the options above may have a seizure component but do not features the skin manifestations described in this case.§
A 28-year-old woman, who is 8 weeks pregnant, recently presented for her booking appointment. A mid-stream urine sample sent to the laboratory has now shown positive cultures. On questioning, she has no urinary symptoms, such as increased frequency, dysuria or haematuria. She is generally well, with no past medical or family history.
Which of the following is the most appropriate next step in the management?
Treat with Abx immediately due to a risk of progression to Acute pyelonephritis
It is offered at booking clinic.
Factors that worsen psoriasis?
There are multiple triggers for worsening psoriasis including alcohol, smoking, stress, discontinuing steroids or initiating NSAIDs, lithium, antimalarials and beta-blockers such as this patient’s propranolol.
A 55-year-old man with a background of Barrett’s oesophagus is seen in the gastroenterology clinic with the results of his routine surveillance endoscopy. He is still experiencing symptoms of dyspepsia despite regular treatment with high-dose omeprazole. He denies dysphagia or weight loss.
Endoscopy and biopsy results: Columnar epithelium is seen in the distal 5cm of the oesophagus. Dysplastic cells are seen on biopsy in keeping with high-grade dysplasia.
What is the recommended next step in this patient’s management?
Management
endoscopic surveillance with biopsies
high-dose proton pump inhibitor: whilst this is commonly used in patients with Barrett’s the evidence base that this reduces the change of progression to dysplasia or induces regression of the lesion is limited
Endoscopic surveillance
for patients with metaplasia (but not dysplasia) endoscopy is recommended every 3-5 years
If dysplasia of any grade is identified endoscopic intervention is offered. Options include:
endoscopic mucosal resection
radiofrequency ablation
A 36-year-old male presents to the general practitioner with a 2-month history of generalised weakness and headaches.
Observations show:
Respiratory rate 16 breaths/min Heart rate 63 beats/min Blood pressure 168/132mmHg Temperature 37.2ºC Oxygen saturations 98% on room air
Blood results include:
Na+ 169 mmol/L (135 - 145) K+ 2.9 mmol/L (3.5 - 5.0) Bicarbonate 34 mmol/L (22 - 29) Urea 4.2 mmol/L (2.0 - 7.0) Creatinine 74 µmol/L (55 - 120)
A plasma aldosterone/renin ratio is subsequently performed which suggests a peripheral cause of the patient’s presentation.
What is investigation could be used to further differentiate the likely underlying diagnosis?
This patient is presenting with symptoms of lethargy and headache, accompanied by hypertension, hypokalaemia, hypernatraemia and high serum bicarbonate (caused by metabolic alkalosis). This is a classical presentation of primary hyperaldosteronism, otherwise known as Conn syndrome. The first-line investigation of this condition is with an aldosterone/renin ratio, which in this case indicates a peripheral source of excess aldosterone secretion, suggesting an underlying aetiology of either unilateral adrenal adenoma or bilateral adrenal hyperplasia. These two peripheral causes of hyperaldosteronism can be distinguished with adrenal venous sampling. An adrenal adenoma will show excess aldosterone in only one adrenal vein, whereas levels will be raised in both adrenal veins in cases of bilateral adrenal hyperplasia.
A 41-year-old man develops itchy, polygonal, violaceous papules on the flexor aspect of his forearms. Some of these papules have coalesced to form plaques. What is the most likely diagnosis?
Lichen
planus: purple, pruritic, papular, polygonal rash on flexor surfaces. Wickham’s striae over surface. Oral involvement common
sclerosus: itchy white spots typically seen on the vulva of elderly women
A 52-year-old male is referred to urology clinic with impotence. He is known to have hypertension. He does not have any morning erections. On further questioning the patient reports pain in his buttocks, this worsens on mobilising. On examination there is some muscle atrophy. The penis and scrotum are normal. What is the most likely diagnosis?
Leriche syndrome
Classically, it is described in male patients as a triad of symptoms:
- Claudication of the buttocks and thighs
- Atrophy of the musculature of the legs
- Impotence (due to paralysis of the L1 nerve
What are the circumstances in which rythm control would be first line in AF management?
- New onset AF (<48 hrs)
- AF with reversible cause
- AF leading to HF
- AF remaining symptomatic despite adequate rate control
What is the QRISK score?
QRISK 3 gives the risk of a stroke or MI for a patient in the next 10 years if it is over 10% then a low dose statin should be started
All patients with CKD or T1DM for more then 10 years should be offered what?
A statin
What monitoring is needed after initiating a statin?
Check lipid levels at 3 months and increase the dose to aim for a 40% reduction in the HDL cholesterol. (always check adherence before increasing dose)
Also check LFTs within 3 months of starting the statin and at 12 months to make sure that they are normal- they can cause a mild transient rise in ALT/AST in the first few weeks, only needing stopping if they hit abnormal ranges.
Stages of HTN and their blood readings?
Stage 1: >140/90 or >135/85
Stage 2: >160/100 or >150/95
Stage 3: >180/120
Give 5 Contraindications to the Combined oral contraceptive pill?
more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
current breast cancer
major surgery with prolonged immobilisation
positive antiphospholipid antibodies (e.g. in SLE)
Give 5 situations in which the risks of taking the COCP would outweigh the benefits?
more than 35 years old and smoking less than 15 cigarettes/day
BMI > 35 kg/m^2*
family history of thromboembolic disease in first degree relatives < 45 years
controlled hypertension
immobility e.g. wheel chair use
carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
current gallbladder disease
ALARMS symptoms?
RF for dyspepsia:
Anaemia (IDA), Loss of weight, Anorexia, Recent onset, Maleana, Swallowing issues.
What drug is given alongside isoniazide to prevent Peripheral neuropathy?
Pyridoxine
What are the ECG changes in hyperkalaemia
- Tall tented T waves
- Prolonged PR interval (>200 ms)
- Widened QRS complex (>120 ms)
- Small/absent P waves
- SINE WAVE PATTERN
GnRH analogue, GnRH antagonist
Goserelin goserelin (Zoladex) or leuprorelin (Prostap), use for short periods in fibroids. Relugolix
What are the triad needed for endocarditis?
Endothelial damage, platelet adhesion, Microbial Adherence.
Dukes modified criteria?
• For diagnosis: o 2 major or o 1 major 3 minor or o 5 minor • Major: o Positive blood culture for endocarditis (from 2 separate cultures) o Evidence of endocardial involvement: Postive ECHO suggestive of IE • Minor: o Predisposition (CHD, surgery) o Fever o Vascular phenomena (Emboli, infarcts…) o Immunologic phenomena (Glomerulonephritis, Oslers nodes, Roth spots, RF) o Microbiological evidence o Echo findings
What are the four components of tetralogy of fallot?
- VSD
- Overriding aorta
- Pulmonary valve stenosis
- Right ventricular hypertrophy
Which bacteria is important in acne?
Propionibacterium acnes
Mild moderate and severe acne?
- Mild: Open and closed comedones with/without sparse inflammatory markers
- Moderate: Widespread non-inflammatory lesions and numerous papules and pustules
- Severe: Extensive inflammatory lesions, may include nodules, pitting and scarring.
Steroid ladder for exczema?
Hydrocortisone (0.5,1.0, 2.5%)
Eumovate (clobetasone butyrate 0.05%)
Betnovate (Beclamethasone 0.1%)
Dermovate (clobetasone propranoate 0.05%)
• Two products with a potent steroid and a vit D analogue that are commonly prescribed and need to know about:
o Dovobet
o Enstilar
When would you admit a child with bronchiolitis?
o Apnoea o Persistent sat of <92% on air o Clinical dehydration o 50-75 % usual fluid intake! o Severe resp distress signs: Recession Grunting RR over 70 B/M
What scoring system is used for croup?
Westley croup score
What are the 3 cardinal pahtophysiological features of asthma?
Chronic airway inflammation
Airway hyperresponsiveness
Reversible airway obstruction
What are the structural changes in asthma?
o Thickening of the epithelial reticular basement membrane (collagen deposition)
o Hypertrophy and airway smooth muscle hyperplasia
o Extracellular matrix deposition
o Hypertrophy of mucus secreting glands
Prehn sign positive
Elevation of the testes relieves pain in epididymitis
Which cells produce surfactant?
Type II pneumocytes
Di george
22q11- deletion causes cardiac defects, facial issues, absent thymus and hypocalcaemia.
Lack of thymus leads to underdeveloped T cells.
CATCH 22
C- Congenital HD A- Abnormal faces T- Thymus gland missing C- cleft palate H- Hypoparathyroidism leading to hypocalcaemia
22nd chromosome effected
Wiskott aldrich?
• Wiskott-Aldrich syndrome is an X-linked recessive condition with a mutation of the WAS gene. It causes abnormal functioning of the T cells. • Other features: o Thrombocytopenia o Neutropenia o Eczema o Recurrent infections o Chronic bloody diarrhoea.
Ataxic Telangiesctasia:
• Ataxic telangiaectasia is an AR condition affecting the gene that codes for the ATM serine/threonine kinase protein on chromosome 11.
• This is key for several functions of DNA coding, meaning that the single mutation can lead to issues with this gene leads to issues with the coding of many other genes.
• There are various features associated with this condition:
o Low numbers of T-cells and immunoglobulins, causing immunodeficiency and recurrent infections.
o Ataxia: Issues with coordination, due to cerebellar impairment
o Telangiectasia, particularly in the sclera and damaged areas of the skin.
o Predisposition to cancers: particularly haem
o Slow growth and delayed puberty
o Accelerated aging
o Liver failure.
C1 Esterase Inhibitor Deficiency (HEA):
- Bradykinin is part of the inflammatory response.
- It is responsible for causing BV dilation and increased permeability, leading to angioedema.
- Part of the action of C1 esterase is to inhibit bradykinin.
- An absence of C1 esterase leads to intermittent angioedema in response to minor triggers, such as viral infection or stress, or without any clear trigger at all.
- Angioedema often affects the lips or face but can occur anywhere in the body, including the resp and GI tracts.
- The swelling can last a few days before self resolving.
- Angioedema can occur in the airway and compromise the patients airways
- Patients can be treated with IV C-1 esterase inhibitor before dental appointments/surgical procedures or in response to acute attacks of HAE.
Key point- test C4 levels in recurrent angioedema
Kawasaki disease findings?
• A key feature that should lead to you considering Kawasaki disease is a PERSITENT high fever (>39) for OVER 5 DAYS.
• Children will be unhappy and unwell
• The key skin findings are:
o Widespread maculopapular rash
o Desquamation of the palms and soles (2-5 days after onset)
• Other features include:
o Strawberry tongue (red with large papillae)
o Cracked lips
o Cervical lymphadenopathy
o Bilateral conjunctivitis (2-4 days after onset)
• May also have inflammation of their BCG vaccine scar
Measels features
• Prodrome: o Irritable child o Fever o Conjunctivitis • Koplik spots (before the rash): white spots “grains of salt” rash on the buccal mucosa PATHOGENOMIC • Rash: o Starting behind the ears o Then spreads to the whole body o Discrete maculopapular rash which becomes blotchy and confluent.
CI to lumbar puncture?
o Focal neuro signs o Papilledema o Sig. bulge of the fontanelle o DIC o Signs of cerebral herniation
What test on CSF?
o Bacterial culture o Viral PCR o Cell count o Protein o Glucose
HIV transmission at birth?
• Mode of delivery is determined by the mothers viral load:
o Normal < 50 copies/ml
o C section >50 copies /ml and in all over 400 copies/ml
o IV Zidovudine should be given with C-section if the viral load is unknown or there are >1000 copies/ml
• Prophylaxis treatment may be given to the baby depending on the mothers V.load:
o Low risk babies, where mums viral load is <50 copies per ml, should be given Zidovudine for 4 weeks
o High risk babies, where the mum’s viral load is >50 copies per ml, should be given zidovudine, Lamivudine and nevirapine for 4 weeks.
