Passmed knowledge Flashcards
1
Q
antibiotic for syphallis
A
benzathine benzylpenicillin
2
Q
how to manage migraine ?
A
Migraine
acute: triptan + NSAID or triptan + paracetamol
prophylaxis: topiramate or propranolol
(be careful no beta blocker for asthma patient)
3
Q
Why can’t asthmatics have propanolol?
A
propanolol = beta blockers
The β2 receptors in the lungs help relax the smooth muscle of the airways, promoting bronchodilation.
Therefore, beta blockers conversely promote bronchoconstriction and also bronchospasm.
They also act in opposition to drugs like salbutemol (short-acting β2-adrenergic receptor agonist (SABA))
4
Q
why do COPD patients have lower target o2 sats?
A
COPD patients are chronic CO2 retainers.
Physiologically, breathing is driven by CO2 levels picked up in the brains central chemoreceptors.
But these patients the body becomes less sensitive to CO2 over time. They loose their hypercapnic drive.
Instead these patients rely on hypoxia to influence their breathing rate (hypoxic drive).
Giving these patients high levels of oxygen can reduce their stimulus to breath.
The goal is to provide just enough oxygen to maintain adequate tissue oxygenation without suppressing the hypoxic drive or causing excessive CO2 retention.
5
Q
If about to have OGD what should happen with PPI meds?
A
Proton pump inhibitors should be stopped 2 weeks before an upper GI endoscopy
6
Q
what is a normal LVEF?
A
Normal LVEF is 45%-60%
therefore reduced is less than 45
7
Q
first line for heart failure management ?
A
The first-line treatment for all patients is both an ACE-inhibitor and a beta-blocker
generally, one drug should be started at a time. NICE advise that clinical judgement is used when determining which one to start first
beta-blockers licensed to treat heart failure in the UK include bisoprolol, carvedilol, and nebivolol.
ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction
8
Q
double duct sign?
A
pancreatic cancer
dilation of common bile duct and and pancreatic duct
9
Q
which med for secondary prevention of iscaemic stroke ?
A
clopidogrel 75mg OD
10
Q
which med for secondary prevention of TIA ?
A
clopidogrel 75mg OD
11
Q
which valve is affected in infective endocarditis ?
A
In infective endocarditis, the mitral valve is most commonly affected
12
Q
which valve in IE for IV drug users?
A
tricuspid valve
13
Q
preceding influenza predisposes to which organism for pneumonia ?
A
S aureus
14
Q
how to calc alcohol lunits ? 1
A
Alcohol units = volume (ml) * ABV / 1,000
15
Q
why ACE-i bad for AKI but reno-protective in CKD?
A
RAAS
IN AKI, there is often hypoperfusion of kidney. Therefore RAAS activated -> vasocontriction of efferent arteriole. maintains filtrations despite low renal blood flow. ACE-i blocks this system and doesn’t allow kidney to be well perfused.
In CKD, RAAS contributes to glomerular hypertension, fibrosis, and proteinuria. Therefore, blocking this is good.
16
Q
what acid base in cushings?
A
Cushing’s syndrome - hypokalaemic metabolic alkalosis
17
Q
scoring system to assess bleeding risk ?
A
ORBIT scoring system
18
Q
apixaban mechanism (what does it iniibibt?
A
factor Xa inhibitor
19
Q
when to send a urine culture in UTI (MSU)?
A
non-pregnant women = over 65, visible or non visible haemturia
pregannt women = alwsys
men = always
20
Q
tool for preidtcing chance of getting cardiovascular disease ?
A
QRISK
this is 10 year risk. given as a percentage. 10% is cut off for statin therapy and also SGLT-2 tx in t2dm
21
Q
pneumonia + traget lesion ? also what is target lesion?
A
mycoplasma pneumoniae
target lesion = erythema multiforme
22
Q
bacterial vaginosis organism ?
A
Bacterial vaginosis - overgrowth of predominately Gardnerella vaginalis
23
Q
breast cancer marker
A
ca 15-3
CA125 = ovarian
CA19-9 = pacnreatic cancer
24
Q
how long are tthe clusters of cluster headacehs
A
Clusters’ of cluster headaches typically last from 4 to 12 weeks
25
extra dural vs subdural haematoma on CT
exdural = bi-convex = lemon shaped, midline shift, brainstem herniation. this is arterial
The majority are caused by rupture of the middle meningeal artery
subdural = Crescent “banana-shaped” mass
An acute SDH will have a hyperdense (bright white) appearance
A chronic SDH will have a hypodense (black/grey) appearance
rupture of the bridging cranial veins after a blow to the temporal side of the head
26
management for GCA
urgent high-dose glucocorticoids should be given as soon as the diagnosis is suspected and before the temporal artery biopsy
if there is no visual loss then high-dose prednisolone is used
if there is evolving visual loss IV methylprednisolone is usually given prior to starting high-dose prednisolone
27
cluster headaches management ?
NICE recommend seeking specialist advice from a neurologist if a patient develops cluster headaches
acute
100% oxygen (80% response rate within 15 minutes)
subcutaneous triptan (75% response rate within 15 minutes)
prophylaxis
verapamil is the drug of choice
there is also some evidence to support a tapering dose of prednisolone
28
ix for bladder cancer ?
Gold standard for bladder cancer diagnosis is cystoscopy
29
what to do with insulin in DKA for a known type 1 ?
In the acute management of DKA, insulin should be fixed rate whilst continuing regular injected long-acting insulin but stopping short actin injected insulin
This patient has diabetic ketoacidosis (DKA). The management of DKA involves starting fixed-rate insulin, continuing regular long-acting insulin, and stopping regular short-acting insulin. Fixed-rate insulin is safer than variable-rate insulin in patients with DKA as a fixed, smaller dose of insulin is less likely to result in hypoglycaemia and hypokalaemia. The patient's regular long-acting insulin is continued to prevent rebound hyperglycaemia when intravenous treatment is stopped. Short-acting insulin is not necessary in addition to the fixed-rate insulin and would risk causing hypoglycaemia.
30
lung cancer and paraneoplastic syndromes
Small cell = ADH / ACTH
Squamous cell = PTH-rp (hypercaclaemia)
31
PCR vs ACR
ACR is more specific to detecting early kidney damage, particularly in diabetes or hypertension, where microalbuminuria is a concern.
PCR is broader and used when significant proteinuria is suspected, often for more advanced kidney disease or systemic conditions (glomerular or tubular kidney disease)
32
cavitating pnuemonia in upper lobes?
Klebsiella most commonly causes a cavitating pneumonia in the upper lobes, mainly in diabetics and alcoholics
33
most common type of lung cancer in non smokers ?
adenocarcinoma
34
glue ear
otitis media with effusion
Glue ear describes otitis media with an effusion (other terms include serous otitis media). It is common with the majority of children having at least one episode during childhood
Treatment options include:
active observation: the management for a child with a first presentation of otitis media with effusion is active observation for 3 months - no intervention is required
grommet insertion - to allow air to pass through into the middle ear and hence do the job normally done by the Eustachian tube. The majority stop functioning after about 10 months
adenoidectomy
35
Otitis media with perforation and/or discharge in the canal - what do you do ?
give amoxicillin 5-7 days
36
risk factors for ovarian cancer?
many ovulations*: early menarche, late menopause, nulliparity
37
abdominal aortic aneurysm size what do you do ?
< 3 cm Normal No further action
3 - 4.4 cm Small aneurysm Rescan every 12 months
4.5 - 5.4 cm Medium aneurysm Rescan every 3 months
≥ 5.5cm Large aneurysm Refer within 2 weeks to vascular surgery for probable intervention
Only found in 1 per 1,000 screened patients
38
how often breast cacner screening ?
Breast cancer screening is offered to all women aged 50-70 years (mammogram every 3 years)
39
fibromyalgia outline
Fibromyalgia is a syndrome characterised by widespread pain throughout the body with tender points at specific anatomical sites. The cause of fibromyalgia is unknown.
Epidemiology
women are around 5 times more likely to be affected
typically presents between 30-50 years old
Features
chronic pain: at multiple site, sometimes 'pain all over'
lethargy
cognitive impairment: 'fibro fog'
sleep disturbance, headaches, dizziness are common
mx =
explanation
aerobic exercise: has the strongest evidence base
cognitive behavioural therapy
medication: pregabalin, duloxetine, amitriptyline
40
scleritis vs episcleritis
Scleritis is painful, episcleritis is not painful
41
acute interstitial nephritis
Acute interstitial nephritis accounts for 25% of drug-induced acute kidney injury.
Causes
drugs: the most common cause, particularly antibiotics
penicillin
rifampicin
NSAIDs
allopurinol
furosemide
systemic disease: SLE, sarcoidosis, and Sjogren's syndrome
infection: Hanta virus , staphylococci
Pathophysiology
histology: marked interstitial oedema and interstitial infiltrate in the connective tissue between renal tubules
Features
fever, rash, arthralgia
eosinophilia
mild renal impairment
hypertension
Investigations
sterile pyuria
white cell casts
42
when should you do a lumbar puncture if suspecting subarachoid hameorrhage ?
if CT head not confirms
lumbar puncture to test for xanthochromia should be performed 12 hours after the onset of symptoms
43
gliclazide mechanism
Sulfonylureas work by closing ATP-sensitive potassium channels in pancreatic beta cells, leading to membrane depolarization, calcium influx, and increased insulin release. Their efficacy depends on residual beta-cell function and carries a risk of hypoglycemia and weight gain.
44
new-onset flashes or floaters
what does it mean and what do you do ?
This patient has new-onset floaters which could be caused by a retinal detachment and thus needs an ophthalmologist review within 24 hours. The ophthalmology team may need to urgently perform an operation to prevent loss of sight if a detachment is detected.
45
estrogen receptor +ve breast cancer (progestogen -ve/HER2 -ve) - what do you do?
anastrozole (aromatase inhibitor) if post menopausal. this reduces peripheral oestrogen synthesis since for these women ostrogen is now produced in adipose tissues and not in ovaries.
tamoxifen (oestrogen receptor antagonist) if pre menopausal
46
c diff infection first line?
first-line therapy is oral vancomycin for 10 days
47
normal qrs complex
0.08-0.1s
48
broad complex tachycardia no adverse features- what do you do ?
IV amiodarone is the first-line treatment for regular broad complex tachycardias without adverse features
normal qrs = 0.08-0.1s
49
PHQ 9 score - what does it mean ? what does it mean for treatment as well ?
Her PHQ-9 score is over 15, indicating 'more severe' depression
NICE recommend a combination of a combination of individual cognitive behavioural therapy (CBT) and an antidepressant for patients who present with 'more severe' depression
50
features of acute interstitial nephritis?
Features
fever, rash, arthralgia
eosinophilia
mild renal impairment
hypertension
51
features of reactive arthritis ?
cant see, cant pee, cant climb a tree
typical triad of urethritis, conjunctivitis and arthritis
52
alcohol withdrawal features at specific time frames ?
Alcohol withdrawal
symptoms: 6-12 hours
seizures: 36 hours
delirium tremens: 72 hours
53
types of aortic dissection and give management options
type A (which affects the ascending aorta) and type B (affects descending aorta only). Management of type A consists of hypertension control with intravenous (IV) labetalol and surgical repair, which is usually thoracic endovascular aortic repair.
Type B dissections require management of hypertension with IV labetalol only.
uncomplicated dissection of descending aorta can be managed medically
54
stroke
Contralateral hemiparesis and sensory loss, lower extremity > upper
anterior cerebral artery
55
stroke
Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia
middle cerebral artery
56
stroke
Contralateral homonymous hemianopia with macular sparing
Visual agnosia
POSTERIOR CEREBRAL ARTERY
57
stroke
'Locked-in' syndrome
basilar artery
58
diagnostic test for mycoplasma pneumonia ?
mycoplasma serology
59
marker of severity of pancreatitis ?
hypocalcaemia
Hypocalcaemia occurs in pancreatitis due to the saponification of fats. As lipase leaks out of the damaged pancreas, it breakdown fat into triglycerides and fatty acids. Fatty acids combine with calcium to produce soap. Therefore, reduced serum calcium can be used as a surrogate marker for the level of enzymatic damage in pancreatitis.
60
initial treatment for anal fissure
conservative mx= soften stool, deitry fibre, analgesia, topical anaetshetic
name = ispagula husk
61
gold standard ix for ank spond
Diagnosis of ankylosing spondylitis can be best supported by sacro-ilitis on a pelvic X-ray
62
first line for diabetic neuropathy
first-line treatment: amitriptyline, duloxetine, gabapentin or pregabalin
63
severe pneumonia, hyponatraemia, and deranged liver function tests + recent travel - which organism ? and how to test?
legionella
urinary antigen test
64
what type of cancer do renal transplant patient get ?
Renal transplant patients - skin cancer (particularly squamous cell) is the most common malignancy secondary to immunosuppression
65
how to manage patient with both b12 / folate deficiency
In patients with both vitamin B12 and folate deficiencies, the vitamin B12 deficiency must be treated first to avoid subacute combined degeneration of spinal cord
give 1mg cyanocobalamin IM injection 3x per week
66
all patients with CKD should be started on what medication?
statin
67
patient with gastro side effects to metformin what do you do ?
switch to modfied release metforminn
68
when would you do thrombolysis stroke
The standard criteria for thrombolysis with alteplase or tenecteplase are as follows:
it is administered within 4.5 hours of onset of stroke symptoms
haemorrhage has been definitively excluded (i.e. Imaging has been performed)
69
when would you do thrombectomy in stroke
Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have:
acute ischaemic stroke and
confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)
Offer thrombectomy as soon as possible to people who were last known to be well between 6 hours and 24 hours previously (including wake-up strokes):
confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and
70
which nerve routes for ankle reflex ?
s1&s2
s1/s2 i tie my shoe
71
which nerve routes for knee jerk relfex
L3/L4
L3/L4 KICK THE DOOR
72
features of motor neurone disease
There are a number of clues which point towards a diagnosis of motor neuron disease:
asymmetric limb weakness is the most common presentation of ALS
the mixture of lower motor neuron and upper motor neuron signs
wasting of the small hand muscles/tibialis anterior is common
fasciculations
the absence of sensory signs/symptoms
vague sensory symptoms may occur early in the disease (e.g. limb pain) but 'never' sensory signs
Other features
doesn't affect external ocular muscles
no cerebellar signs
abdominal reflexes are usually preserved and sphincter dysfunction if present is a late feature
Patients often have more difficulty swallowing liquids than solids in the early stages. Facial weakness, hypophonic speech, fasciculations and reduced jaw jerk reflex (LMN sign) are all features. Eye movements are typically spared.
73
crypt absesses vs crypt hyperplasia
ca = UC
ch = coeliac
74
acid base picture with salicyclate overdose
Salicylate overdoses typically presents with a respiratory alkalosis initially due to hyperventilation, followed by a metabolic acidosis due to lactic acid accumulation. Therefore whilst options 1 and 3 are also possible, the most likely option is 4.
75
HSV1 vs HSV2 - which does it affect in herpes ?
HSV1- oral herpes
HSV2- genital herpes
76
large bowel obstruction vs small bowel osbtruction
Large bowel obstruction would present with lack of passage of flatus and faeces, distended abdomen and generalised abdominal pain. But in ti case the patient has vomited as well, making a diagnosis of small bowel cancer more likely. Additionally, previous abdominal surgery is the most common cause of small bowel obstruction, whilst malignancy is the most common cause of large bowel obstruction.
77
most prognostic factor for skin cancer ?
As a general rule in Breslow depth, the deeper the tumour, the greater the mortality.
invasion depth
78
79
vomiting & constipation & diarhheaa sx - what does this mean in a diabetic with poor glycaemic control ?
Gastrointestinal autonomic neuropathy
Gastroparesis
occurs secondary to autonomic neuropathy
symptoms include erratic blood glucose control, bloating and vomiting
management options include metoclopramide, domperidone or erythromycin (prokinetic agents)
80
in AKI, how to differentiate between prerenal uraemia (dehydration) vs acute tubular necrosis
in ATN, urine Na+ > 40.
in pre renal uraemia, urine Na+ < 20.
High urinary sodium levels in Acute Tubular Necrosis (ATN) occur because the damaged tubular cells in the kidney lose their ability to reabsorb sodium effectively.
In dehydration, kidneys are still working fine so Na can be reabsorbed. So kidneys hold onto sodium in an attempt to hold onto water. therefore Na low in dehydration.
81
how does acute interstitial nephritis present ?
It presents with fever, rash, and arthralgia. On blood tests, eosinophilia would be expected
82
most common cause of neutropenic sepsis (organism)
Aetiology
coagulase-negative, Gram-positive bacteria are the most common cause, particularly Staphylococcus epidermidis
this is probably due to the use of indwelling lines in patients with cancer
83
Organisms causing post splenectomy sepsis:
Streptococcus pneumoniae
Haemophilus influenzae
Meningococci
84
pleural fluid cut off for exudate/transudate ?
Pleural fluid with a protein level >30g/L is indicative of an exudate
85
b12 or folate first when you have to replace both ?
Vitamin B12 replacement should always occur prior to folate replacement as folate replacement prior to B12 can precipitate subacute combined degeneration of the spinal cord
The reason:
High-dose folate supplementation can exacerbate the neurological symptoms of B12 deficiency. This occurs because folate drives DNA synthesis without addressing the underlying myelin damage caused by B12 deficiency.
86
drug exacerbates plaque psoriasis
Beta-blockers are known to exacerbate plaque psoriasis
87
brocke's vs wernicke's dysphasia - where is the lesion ?
Broca's dysphasia: speech non-fluent, comprehension normal, repetition impaired = frontal lobe
Wernicke's dysphasia: present with fluent speech but no comprehension. = temporal lobe
88
severe diarrhoea + loads of IV fluid - what do you expect to see on ABG ?
hyperchloraemic metabolic acidosis
This patient has had severe diarrhoea and excess normal saline. Severe diarrhoea can cause excess bicarbonate loss. 0.9% Sodium chloride contains 154mmol/L of sodium and 154mmol/L chloride. Large volume resuscitation with normal saline leads to an overload of chloride ions into the blood. The increased chloride ions, force bicarbonate into the cells and in doing so reduce the available bicarbonate for the pH buffering system.The result is a hyperchloraemic metabolic acidosis.
89
where does alzeihmers disease affect in the brain ?
Alzheimer's disease causes widespread cerebral atrophy mainly involving the cortex and hippocampus
90
what meds do sickle cell patients need to be on ?
Hydroxycarbamide reduces the frequency of painful episodes and the risk of life-threatening illness or death. However, it can also increase your risk of infections. It is advised not to be taken in pregnancy.
91
mechanism of alzehimers drugs
Donepezil is an acetylcholinesterase inhibitor, which along with with galantamine and rivastigmine, are first line for management of mild to moderate Alzheimer's dementia.
Memantine is an NMDA receptor antagonist, used as a 2nd line or 'add on' treatment for mild-moderate Alzheimer's dementia. It may be used 1st line in severe Alzheimer's.
92
analgesia for palliative patients with renal impairment ?
oxycodone for mild /moderate renal impairment
Buprenorphine or fentanyl are the opioids of choice for pain relief in palliative care patients with severe renal impairment. not renally excreted so can't build up as much.
These are preferred over morphine sulphate
93
what to give for a palliative patient with secretions ? and how do you give it ?
Hyoscine hydrobromide or hyoscine butylbromide is generally used first-line to manage secretions in a palliative care setting
give subcut (or IV)
94
women with bone mets - where is most likely original cancer ?
Woman with bone metastases- most likely to originate in the breast
95
tool for patients with multiple morbidities, especially elderly patients, to decide whether the introduction of a new medication will be beneficial
START tool
96
who gets a mechanical vs prosthetic heart valve ?
prosthetic > 65 since it doesn't last as long as a metallic one
97
what meds should someone be on after a stroke ?
AF = 2 weeks aspirin followed by DOAC/Warfrin
non AF = 2 weeks aspirin followed by lifelong clopidogrel
98
causes of a 3rd heart sound ?
caused by diastolic filling of the ventricle considered normal if < 30 years old (may persist in women up to 50 years old)
heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis (called a pericardial knock) and mitral regurgitation
99
causes of a 4th heart sound ?
may be heard in aortic stenosis, HOCM, hypertension
caused by atrial contraction against a stiff ventricle therefore coincides with the P wave on ECG in HOCM a double apical impulse may be felt as a result of a palpable S4
100
when would you want to use cardiac resynchronisation therapy (CRT)?
cardiac resynchronisation therapy indications include a widened QRS (e.g. left bundle branch block) complex on ECG
101
if atropine fails in symptomatic bradycardia what do you do ?
atropine is given 6 times in total - but if this fails
immediate external pacing
then refer to transvenous pacing
102
lesion on R side of brain causing 3rd nerve palsy which eye will this affect ?
R eye
cranial nerves do not cross over apart from 4th nerve
103
mx for idiopathic intracranial hypertension
Acetazolamide is a carbonic anhydrase inhibitor that is used to treat idiopathic intracranial hypertension
104
what is Amaurosis fugax
Amaurosis fugax is a form of stroke that affects the retinal/ophthalmic artery
105
mx for sarcoidosis ?
Oral prednisolone is incorrect. This is first-line in patients with stage 2/3 sarcoidosis who are also symptomatic, in patients with hypercalcaemia, or in patients with eye, heart, or neuro involvement. However, this patient has none of these features and thus does not require treatment.
106
what to look out for on a blood gas of someone with acute asthma attack - this can trip you up ?
normal co2
co2 should be low. normal co2 means that the patient is getting tired -
107
what gives you upper zone pulmonary fibrosis ?
CHARTS
C - Coal worker's pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
108
trachea in a total white out lung what does it mean ?
trachea pulled towards the side of the white out:
pneuonectomy
complete lung collapse
trachea pushed away from white out:
pleural effusion
109
vestibular neuronitis vs labrinthitis ?
labrinthitis has hearing symptoms
vestibular neuronitis - no hearing sx
both present with vertigo
110
Hiccups in palliative care mx
- chlorpromazine or haloperidol
111
patient with DNA CPR choking what do you do ?
This question focuses on some of the nuances of DNACPR orders. DNACPRs are contextual to the anticipated cause of death and choking is not a common cause of death in terminal breast cancer. This is referred to as a, 'not envisaged arrest' and the guidance is that you should resuscitate. Choking and being hit by a bus are the two most commonly used examples to illustrate this question.
112
patient taking prednislone what do you need to do prior to surgery ?
make sure you prescribe hydrocortisone
prednisolone can suppress the hypothalamic-pituitary-adrenal axis, meaning that in times of stress (such as surgery), the adrenal glands are not able to respond appropriately. Hydrocortisone should therefore be given preoperatively to patients taking regular prednisolone for moderate to major surgery.
113
how to manage acute flares of RA ?
Intramuscular steroids such as methylprednisolone are used to manage the acute flares of rheumatoid arthritis
114
Management of placental abruption when the fetus is alive, <36 weeks and not showing signs of distress is ...
admit and administer steroids
115
which anasthetic induction agent is useful in a trauma setting ?
Ketamine doesn't cause a drop in blood pressure so useful in trauma
116
COCP and surgery ? good ?
Advise women to stop taking their COCP/HRT 4 weeks before surgery
117
length of time after time of last unprotected sexual intercourse ?
Ulipristal acetate is the correct option, and is effective up to 120 hours post-unprotected sexual intercourse (UPSI). Its primary mechanism of action is thought to be the inhibition of ovulation.
Levonorgestrel must be used within 72 hours post-UPSI to ensure effectiveness and is therefore not appropriate in this patient. Its mechanism of action is thought to be a combination of inhibition of ovulation and prevention of implantation.
118
size of fibroadenoma where you would think of excising it ?
Breast fibroadenoma: surgical excision is usual if >3cm
119
mx for thyroid storm ?
symptomatic treatment
e.g. paracetamol
treatment of underlying precipitating event
beta-blockers: typically IV propranolol
anti-thyroid drugs: e.g. methimazole or propylthiouracil
Lugol's iodine
dexamethasone/ hydrocortisone - e.g. 4mg IV qds - blocks the conversion of T4 to T3
120
4 key imaging findings in RA ?
uniform joint space loss
periartiuclar osteopenia
marginal erosions
soft tissue swelling
121
patient with SIADH and hyponatraemia
Hypertonic saline (typically 3% NaCl) is usually indicated in patients with acute, severe, symptomatic hyponatraemia (< 120 mmol/L)
otherwise you would fluid restrict
122
bronchiectasis + raised eosinophils ?
allergic bronchopulmoaru aspergillosis
123
allergic bronchopulmoary aspergillosis treatment ?
oral corticosteroids
124
what is the link between magneisum and potassium metabolically - and give implications of this ?
Replace magnesium before correcting hypokalaemia. Hypomagnesemia prevents potassium absorption
125
role of pyridoxine in TB mx ?
prevents peripheral neuropathy
126
mx SLE ?
Hydroxychloroquine
the treatment of choice for SLE
126
outline dresslers syndrome what is it ?
Dressler's syndrome tends to occur around 2-6 weeks following a MI. The underlying pathophysiology is thought to be an autoimmune reaction against antigenic proteins formed as the myocardium recovers. It is characterised by a combination of fever, pleuritic pain, pericardial effusion and a raised ESR. It is treated with NSAIDs.
126
hyposplenism blood film
Target cells and Howell-Jolly bodies
127
Unstable angina or NSTEMI?
Elevation in troponin points towards NSTEMI
128
ix for patients with AAA
A ruptured AAA is a surgical emergency - patients with a suspected ruptured AAA require an immediate vascular review with a view to emergency surgical repair.
In haemodynamically unstable patients the diagnosis is clinical, these patients are not stable enough for a CT scan etc to confirm the diagnosis and should be taken straight to theatre. For frail patients with multiple comorbidities, this may represent a terminal event and consideration should be given to a palliative approach.
Patients who are haemodynamically stable may be sent for a CT angiogram where the diagnosis is in doubt - this may also assess the suitability of endovascular repair.
129
metochlopromide mechanism and side effects
Metoclopramide is a dopamine antagonist and it works by blocking dopamine receptors in the chemoreceptor trigger zone of the central nervous system.
This action prevents nausea and vomiting triggered by most stimuli. However, its antagonistic effect on dopamine can also lead to extrapyramidal side-effects such as acute dystonic reactions, akathisia, and parkinsonism.
These side effects are more common in young people and females.
130
how often should young people / children monitor their sugars in t2dm
According to NICE guidelines, children and young people with type 1 diabetes should monitor their capillary blood glucose at least 5 times per day, when they are well.
Monitoring helps guide insulin dosing and allows for tight control of blood glucose levels to prevent both hypoglycaemia and
hyperglycaemia. More frequent testing may be necessary during periods of physical activity, illness,
or when adjusting insulin doses. Additionally, individuals with type 1 diabetes should be aware of symptoms of hypoglycaemia and hyperglycaemia and respond appropriately with blood glucose
testing.
131
pinpoint pupils ?
opioid overdose
132
name of lithium you prescribe
lithium citrate = priadel
lithium carbonate = camcolit
133
anti emetic for hyperemisis gradvidrarum ?
first line =
antihistamines: oral cyclizine or promethazine
phenothiazines: oral prochlorperazine or chlorpromazine
second line = ondansetron
134
chemotherapy related nausea which anti-emetic ?
1. ondansetron
5-HT3 antagonists are antiemetics used mainly in the management of chemotherapy-related nausea. They mainly act in the chemoreceptor trigger zone area of the medulla oblongata.
The 5HT3-receptor antagonists, granisetron, ondansetron, and palonosetron, are used in the management of nausea and vomiting in patients receiving cytotoxics
135
anti emetic for motion sickness (e.g. from vestibular neuronitis)
a short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine) may be used to alleviate less severe cases
136
post op nausea and vomiting - which anti emetic ?
Drugs used include 5HT3-receptor antagonists
(e.g. granisetron, ondansetron),
dexamethasone, droperidol and haloperidol.
Cyclizine is licensed for the prevention and treatment of postoperative nausea and vomiting caused by opioids and general anaesthetics.
Prochlorperazine is licensed for the prevention and treatment of nausea and vomiting.
137
how to treat agitation and confusion in pallliative care ?
first choice: haloperidol
other options: chlorpromazine, levomepromazine
In the terminal phase of the illness then agitation or restlessness is best treated with midazolam
138
managment of hiccups in palliative care presrcibig ?
Management of hiccups
chlorpromazine is licensed for the treatment of intractable hiccups
139
what does present / absense of lymphadenopathy in the axilla mean for a woman who needs to have breast cancer surgery?
Prior to surgery, the presence/absence of axillary lymphadenopathy determines management:
women with no palpable axillary lymphadenopathy at presentation should have a pre-operative axillary ultrasound before their primary surgery
if negative then they should have a sentinel node biopsy to assess the nodal burden
in patients with breast cancer who present with clinically palpable lymphadenopathy, axillary node clearance is indicated at primary surgery
this may lead to arm lymphedema and functional arm impairment
140
which types of breast cancer for mastectomy vs wide local exicsion ?
mastectomy:
- multifocal tumour
- central tumour
- large lesion in small breast
- DCIS > 4cm
wide local exicsion
- solitary lesion
- peripheral tumour
- small lesion in large breast
- DCIS < 4cm
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who gets radiotherapy after breast cancer surgery ?
Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds.
For women who've had a mastectomy radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes
142
what to prescribe for infective exscacerbation of COPD ?
IECOPD in the first instance are amoxicillin, doxycycline, or clarithromycin
143
what medication should you give after variceal bleed for prophylaxis of subsequent further bleeds?
propanolol
144
normal serum osmoliaty and hyponatraema - what does this mean ?
This is a pseudohyponatremia as the serum osmolality is normal. All the other options cause a genuine hyponatraemia.
Other causes of a similar picture could be hyperglycaemia or the presence of paraproteins in the plasma (such as in myeloma).
Hyperlipidaemia causes psuedohyponatremia as sodium is dissolved in plasma and in extreme hyperlipidemia the plasma is displaced by lipids, leading to an inaccurate measurement of sodium
145
thinking about pain relief for an eldery person - what should you be thinking ?
NSAIDS are generally not tolerated well with elderly with comorbidities due to gastro side effects and renal side effects
codeine increases risk of sedation --> falls / increases risk of constipation
Therefore, often safer to go for paracetamol (always check the weight cause patients under 50 kg get 500g instead of 1g qts)
146
how long after an op does atelectasis present ?
Features
it should be suspected in the presentation of dyspnoea and hypoxaemia around 72 hours postoperatively
147
dry cough and exercise desaturation in immunocompromised patients - what should you be thinking and give mx
Pneumocystis jiroveci pneumonia
(common in HIV)
mx = co-trimoxazole
148
how to manage acute severe flare of UC?
IV corticosteroids
149
differentials for sudden onset painless vision loss
vitreous haemorrhage - think this is associated with proliferative diabetic retinopathy. mx --> vitrectomy
central retinal artery occlusion
central retinal vein occlusion
retinal detachment - think flashes floaters / black curtain coming down
also can include GCA causing arteritic anterior iscaemic optic neuropathy
150
name of rash in mycoplasma pneumoniae?
erythema multiformae
151
ix for mycoplasma pneumoniae
serology
152
patient with metastatic spinal cord compression what do you do ?
give dexamethasone
afterwards you will need to get a spinal MRI - but give the dex first
153
carcinoid tumours / carcinoid sndrome mx ?
Octreotide
154
types of hiatus hernia - what is the different + how do you manage ?
sliding: accounts for 95% of hiatus hernias, the gastroesophageal junction moves above the diaphragm
(think of sliding in the the DMs - this is so regular, this hernia comes straight through so ofc is most common)
rolling (paraoesophageal): the gastroesophageal junctions remains below the diaphragm but a separate part of the stomach herniates through the oesophageal hiatus
management:
manage sliding hiatus hernia conservatively most often...
medical management: proton pump inhibitor therapy
surgical management: only really has a role in symptomatic paraesophageal hernias
155
manage low severity CAP vs high ?
low = amoxicillin
high = dual antibiotic therapy --> amoxicillin + clarithromycin
156
when to give abx in a sore throat ?
when centor score >=3
1. absence of cough
2. exudative tonsils
3. tender anterior cervical lymphadenopathy or lymphadenitis
4. history of fever
157
heberden's nodes?
OA
158
3rd nerve palsy - 2 types and explain ?
Surgical 3rd nerve palsy: oculomotor nerve palsy + pupillary dilation. Due to parasympathetic fibres that are on the surface of the nerve, (usually cause constriction) being compressed by something external. This needs urgent brain imaging and referral.
Medical 3rd nerve palsy: just oculomotor nerve palsy, no dilation. This is because medical causes affect the core, which is where the main parts of the oculomotor nerve are. No effect on the surface, so doesn't affect the parasympathetic fibres
(Features
eye is deviated 'down and out'
ptosis
pupil may be dilated (sometimes called a 'surgical' third nerve palsy))
159
mx for phaeochromocytoma ?
PHaeochromocytoma - give PHenoxybenzamine before beta-blockers
1. is a non-selective alpha blocker, in this case, phenoxybenzamine
2. beta blocker
160
after receiving blood how can you tell the different between acute haemolytic transfusion reaction and anaphylaxis ?
acute haemolytic transfusion reaction is due to ABO incompatilibility. you get fever, abdo pain, chest pain
anaphylaxis - wheeze, stridor, shortness of breath
161
ix for GBS ?
LP
nerve conduction studies
162
Otitis media with perforation and/or discharge in the canal
abx - yes or no?
yes give amoxiillin
163
pregnant woman is +ve for Group B strep on MSU - what do you do ?
IV Benzyl penicillin
164
Neuroleptic malignant syndrome vs serotonin syndrome
Both NMS and serotonin syndrome can bring about hypertension, tachycardia and hyperthermia. However, NMS is different from serotonin syndrome in that it is associated with hyporeflexia, normal pupillary sizes and a gradual onset while serotonin syndrom is characterised by hyperreflexia, myadriasis and a rapid onset
165
staggered vs non-staggered overdose of paracetemol ?
This is not a staggered overdose, as the patient reports taking the tablets over 30 minutes, and a staggered overdose is defined as taking paracetamol over more than a 1 hour period
for a staggered overdose - you ignore the treatment line thingy and just give them N-acetylcysteine
166
An elevated TSH with normal T4 indicates ...
subclinical hypothyroidism
167
how does vitreous haemorrhage present ?
Vitreous haemorrhage
causes:
- diabetes,
- bleeding disorders,
- anticoagulants
features may include sudden visual loss, dark spots
168
good way to differentiate migraine and cluster headache?
want to lie still in migraine
restless during cluster headahce
169
features of cholesteatoma
It is most common in patients aged 10-20 years
Main features
foul-smelling, non-resolving discharge
hearing loss
170
how does age related macular degneration present ?
The patient's symptoms of blurry vision, distortion of straight lines (metamorphopsia), and a central scotoma in the right eye are classic features of age-related macular degeneration.
This condition typically affects individuals over the age of 60 and is characterized by damage to the macula, which is responsible for central vision.
There are two types: dry and wet, with dry being more common.
171
2 belly rashes in pregnancy and how to differentiate
The skin rash in pemphigoid gestationis usually starts in the periumbilical area and can cause blisters.
One of the main features of polymorphic eruption in pregnancy is periumbilical sparing.
The condition is more common in nulliparous women and it usually starts in the third trimester with erythematosus, itchy papules located typically in the abdominal striae.
172
what are the mechanisms of sight loss in proliferative diabetic retinopathy
The mechanisms of sight loss in proliferative diabetic retinopathy are retinal detachment and vitreous haemorrhage
173
ix for patient with stable cardiac chest pain ?
most likely angina
therefore:
For patients in whom stable angina cannot be excluded by clinical assessment alone NICE recommend the following (e.g. symptoms consistent with typical/atypical angina OR ECG changes):
1st line: CT coronary angiography
2nd line: non-invasive functional imaging (looking for reversible myocardial ischaemia)
3rd line: invasive coronary angiography
Examples of non-invasive functional imaging:
myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT) or
stress echocardiography or
first-pass contrast-enhanced magnetic resonance (MR) perfusion or
MR imaging for stress-induced wall motion abnormalities
174
depending on CRB-65 score - what do you do ?
consider home-based care for patients with a CURB65 score of 0 or 1 - low risk (less than 3% mortality risk)
consider hospital-based care for patients with a CURB65 score of 2 or more - intermediate risk (3-15% mortality risk)
consider intensive care assessment for patients with a CURB65 score of 3 or more - high risk (more than 15% mortality risk)
Management of low-severity community acquired pneumonia
amoxicillin is first-line
if penicillin allergic then use a macrolide (clarithromycin) or tetracycline
NICE now recommend a 5 day course of antibiotics for patients with low severity community acquired pneumonia
Management of moderate and high-severity community acquired pneumonia
dual antibiotic therapy is recommended with amoxicillin and a macrolide
a 7-10 day course is recommended
NICE recommend considering a beta-lactamase stable penicillin such as co-amoxiclav, ceftriaxone or piperacillin with tazobactam and a macrolide in high-severity community acquired pneumonia
175
anaemia associated with pneumonia what is it ?
mycoplasma pneumoniae
cold autoimmune haemolytic anaemia
176
chronic HF mx ?
1. ACE or beta blocker
2. spironolactone
3. SGLT-2 i
then other random shit
177
definitive mx for acute cholecystsitis ?
cholecystectomy
NICE now recommend early laparoscopic cholecystectomy, within 1 week of diagnosis
make sure you give abx as well
178
abx for meningitis at GP vs at the hospital ?
hospital
3 months - 50 years: BNF recommends cefotaxime (or ceftriaxone)
> 50 years: BNF recommends cefotaxime (or ceftriaxone) + amoxicillin (or ampicillin) for adults
GP:
benzylpenicillin
179
white out of lung - what could it be and how do you tell ?
pleural effusion = trachea deviated away from opacified side
collapsed lung = trachea pulled towards the opacified side
180
which side of lung for aspiration pneumonia ?
The right middle and lower lung lobes are the most common sites affected, due to the larger calibre and more vertical orientation of the right main bronchus.
181
liver disease + resp symptoms ?
alpha 1 anti trypsin deficiency
182
mx for emergency spinal cord compression (ie malignancy ?)
Immobilise the patient and administer 16mg of dexamethasone
This is correct. The patient is presenting with signs and symptoms of metastatic spinal cord compression, an emergency which requires immobilisation, urgent high-dose steroids to limit oedema and urgent spinal imaging to characterise the level and nature of compression.
183
lumbar disc herniatiion vs common peroneal nerve compression ?
Both:
- weakness in dorsiflexion
- sensory deficits over the dorsum of the foot
However,
lumbar disc herniation usually presents with additional symptoms such as lower back pain and radicular pain along the distribution of the affected nerve root (e.g. sciatica)
You wouldn;t get foot drop as this is quite specific to peroneal nerve
184
GOLD standard graft for CABG?
The internal thoracic artery (also known as the internal mammary artery) is considered the gold standard for CABG due to its superior long-term patency rate, with up to 90% patency at ten years. The left internal thoracic artery is typically used to bypass the left anterior descending artery, as it provides the best outcomes in terms of survival and freedom from myocardial infarction and revascularisation.
can use saphenous vein as well but its not as good
185
suburst appearance on bone xray what is it ?
osteosarcoma
186
mx for phaeochromocytoma ?
Surgery is the definitive management. The patient must first however be stabilized with medical management:
alpha-blocker (e.g. phenoxybenzamine), given before a
beta-blocker (e.g. propranolol)
187
acute haemolytic transfusion reaction vs febrile non-haemolytic transfusion reaction
Febrile non-haemolytic transfusion reactions are the most common type of transfusion reaction and are caused by recipient antibodies reacting with donor leukocytes. These reactions typically present with fever, chills and sometimes pain during or shortly after the transfusion. The patient’s physical examination findings, including the absence of signs of fluid overload, further support this diagnosis.
An acute haemolytic transfusion reaction occurs when the recipient’s immune system attacks the donor’s red blood cells, leading to rapid haemolysis. It is typically caused by ABO incompatibility and can cause fever, chills and back pain.
However, it usually presents with additional symptoms such as hypotension, tachycardia and haemoglobinuria.
188
what do you do if patient already on anticoagulants and they have elective surgery ?
In patients with atrial fibrillation who are already on therapeutic anticoagulation with a direct oral anticoagulant (apixaban) and on an antiplatelet (aspirin) for a previous MI, the risk of DVT following knee replacement surgery is sufficiently covered without the need for additional prophylaxis.
189
menieres bilateral or unilateral
typically unilateral
190
aural fullness
think menieres
191
menieres vs acoustic neuroma
menieres come in attacks
cancer is constant
192
adrenaline dose cardiac arrest vs anaphylaxis
Recommend Adult Life Support (ALS) adrenaline doses
anaphylaxis: 0.5ml 1:1,000 IM
cardiac arrest: 10ml 1:10,000 IV or 1ml of 1:1000 IV
193
good way to tell difference between VF and VT ?
As the patient is conscious ventricular fibrillation (VF) can be excluded - the nature of VF means that it is not compatible with a cardiac output. The diagnosis is ventricular tachycardia. Given the peri-arrest nature of the presentation the patient should be immediately cardioverted.
194
first line for parkinsons ?
this is the most important info
In early stages of Parkinson's disease, patients whose motor symptoms decrease their quality of life should be offered levodopa combined with carbidopa (co-careldopa) or benserazide (co-beneldopa).
Parkinson's disease patients whose motor symptoms do not affect their quality of life, could be prescribed a choice of levodopa, non-ergot-derived dopamine-receptor agonists (pramipexole, ropinirole or rotigotine) or monoamine-oxidase-B inhibitors (rasagiline or selegiline hydrochloride).
#
Prescribing levodopa/carbidopa is the most appropriate initial management for Parkinson’s disease.
commercial names ==> carbidopa (co-careldopa) or benserazide (co-beneldopa).
Levodopa, a precursor of dopamine, effectively replenishes dopamine levels in the brain, thereby improving motor symptoms such as tremors, rigidity and bradykinesia.
Carbidopa is added to the formulation to prevent peripheral conversion of levodopa to dopamine before it reaches the brain.
This combination reduces side-effects, such as nausea and vomiting, which occur due to an increase in peripheral dopamine levels. .
Levodopa/carbidopa has been shown to provide the greatest improvement in motor symptoms and functionality in patients with Parkinson’s disease, making it the gold standard for initial pharmacological management, especially in older patients or those with significant functional impairment.
195
first line diagnostic test for TB (and give the names of the other tests as well)
Sputum acid-fast bacilli (AFB) smear microscopy is the first-line diagnostic test for suspected cases of pulmonary tuberculosis (TB), according to guidelines from the National Institute for Health and Care Excellence (NICE).
other tests:
- PCR - too long
- sputum culture too long
- interferon gamma assay (cannot tell difference between active and latent)
- tuberculin skin test
196
mx of fibroids
2 mainstays:
sort out menorrhagia:
1. levonorgestrel intrauterine system (LNG-IUS)
useful if the woman also requires contraception
cannot be used if there is distortion of the uterine cavity
2. NSAIDs e.g. mefenamic acid
3. tranexamic acid
4. combined oral contraceptive pill
5. oral progestogen
6. injectable progestogen
shrink fibroid:
1. GnRH agonists
2. surgical
myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically
hysteroscopic endometrial ablation
hysterectomy
3. uterine artery embolization
197
thin, greyish-white
vs
thick white cottage cheese
thin, greyish-white = BV
other one is candidiasis
198
199
why should you do a diagnostic tap before draining a pleural effusion ?
Whilst this is a relatively large pleural effusion, a diagnostic tap should be performed prior to any symptomatic drainage.
This will help determine whether there are any absolute indications for drainage, such as an empyema. Please see the British Thoracic Society Pleural Disease guidelines for more information.
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