Passmedicine Flashcards

Question

What does Porphyromonas gingivalis cause?

Answer 1

Severe periodontal disease

Answer 2

Associated with necrobacillosis: a severe tonsilitits with septicaemia and metastatic abscesses

Answer 3

Spironolactone Cimetidine Digoxin Anti-testosterone drugs (LHRH analogues used in prostate cancer)

Answer 4

Testicular tumours (seminomas/teratomas) Bronchial carcinoma Klinefelter's syndrome Hepatic cirrhosis

Answer 5

Iron deficiency anaemia Syphilis IBD Vit B12 deficiency Behcet's disease

Answer 6

Resistance develops very quickly Usually its one of the first line agents

Answer 7

Nucleotide inhibitor (Non-nucleoside reverse transcriptase inhibitor) Contraindicated in renal failure

Answer 8

If patients who had an adverse reaction to abacavir are reexposed to the drug, they may have a severe, potentially fatal hypersensitivity reaction, so they should not be given the drug again. Risk of an adverse reaction to abacavir is 100-fold higher in patients with HLA-B*57:01, which can be detected by genetic testing.

Answer 9

4th Generation combination immunoassay (detects antibodies to both HIV-1 and HIV-2 as well as the p24 HIV antigen) RT-PCR can be used to detect virus levels before antibodies have developed during seroconversion

Answer 10

Suxamethonium | increases risk of hyperkalaemia

Answer 11

Haven't had a seizure in over 2 years Drugs stopped usually over 2-3 months

Answer 12

Non-typhi salmonella (NTS)

Answer 13

Clear cell carcinoma Differentiated from simple cyst by variegated, septated interior

Answer 14

Unfractionated Heparin This is prefered to LMWH in patients with eGFR <30

Answer 15

``` <7.35 = NIV <7.25 = invasive ```

Answer 16

Factor VIII Factor XIII vWF Fibrinogen

Answer 17

Thyroid Lymphoma

Answer 18

Pts with a FHx of HS, typical clinical features and laboratory investigations do not require additional tests: - Spherocytes - Raised MCHC - Increased reticulocytes Otherwise diagnosis made by cryohaemolysis test and EMA binding test.

Answer 19

sBP <90 mmHg Bradycardia (<50) Phosphodiesterase 5 inhibitor use in last 24-48 hours

Answer 20

Appearance (skin colour): - Blue/pale centrally = 0 - Blue extremities = 1 - Pink = 2 Pulse - Absent = 0 - <100 = 1 - >100 = 2 Grimace (reflex to stimulation) - No response = 0 - Little response = 1 - Good response = 2 Activity (muscle tone) - Floppy = 0 - Flexed arms and legs = 1 - Active = 2 Respiration: - Absent = 0 - Slow/ irregular = 1 - Strong/ crying = 2

Answer 21

Pneumonic = CHARTS Coal workers pneumoconiosis Histiocytosis/ hypersensitivity pneumonitis Ankylosing spondylitis Radiation Tuberculosis Silicosis/ Sarcoidosis

Answer 22

Idiopathic pulmonary fibrosis SLE, RA etc Drugs: amioderone, bleomycin, methotrexate Asbestosis

Answer 23

First line is non-selective alpha blocker (e.g. phenoxybenzamine) Then add beta-blocker once alpha blocker has worked (if you add first then you cause hypertensive crisis) Second line is a CCB if blood pressure cannot be controlled

Answer 24

Glucose > 11mmol/L or known DM pH <7.3 Bicarbonate <15mmol/L Ketones >3mmol/l or urine ketones ++ on dipstick

Answer 25

Every 2 hours (senior review if low) Fluid balance, blood ketones and glucose every hour

Answer 26

rhesus haemolytic disease ABO haemolytic disease hereditary spherocytosis G6PD

Answer 27

If there are signs of jaundice over 14 days (2-14 days is physiological) Involves: - conjugated and unconjugated bilirubin - Direct Coombs' Test - TFTs - FBC and blood film - Urine (MC+S and reducing sugars) - U+Es and LFTs

Answer 28

Biliary atresia (raised conjugated bilirubin) ``` Hypothyroidism Galactosaemia UTI Breast milk jaundice Congenital infections (CMV, toxoplasmosis ```

Answer 29

All of the following must be met: <35mm unruptured ectopic No visible heartbeat serum B-HCG <1500 IU/L No intrauterine pregnancy No pain Willing to attend for follow up

Answer 30

Can cause hypovolaemia and electrolyte disturbance BEFORE N+V becomes apparent Examination sees abdominal distension, absolute constipation and blood tests keeping with fluid and electrolyte loss Treatment with wide bore NG tube and replacement with IV fluids until bowel becomes motile again.

Answer 31

Mitral valve obstruction Systemic embolisation Constitutional symptoms: - breathlessness - weight loss - fever

Answer 32

Check LFTs at: - Baseline - 3 months - 12 months Stop statins if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range.

Answer 33

FBC in all women with menorrhagia Routine TV USS if: - intermenstrual or postcoital bleeding - Pelvic pain and/or pressure symptoms - Abnormal pelvic exam finding

Answer 34

Requires contraception: - Mirena coil (1st line) - COCP - Long acting progestogens Does not require contraception: - Either mefenamic acid 500mg tds (particularly if dysmenorrhoea as well) OR Tranexamic Acid 1 g tds - If no improvement try other drug while waiting for referral (both started on 1st day of period)

Answer 35

Nodular sclerosing - Most common (70%) - good prognosis - More common in women - Associated with lacunar cells Mixed cellularity - Around 20% - Good prognosis - Associated with large number of Reed-Sternberg Cells Lymphocyte predominant - Around 5% - Best prognosis Lymphocyte deplete - Rare - Worst prognosis

Answer 36

ST depression Long QT Long PR U Waves

Answer 37

Epstein Barr Virus

Answer 38

Consider: - Uterus or not - Perimenopausal or menopausal - Systemic or local effect required Menopausal = no bleed for 12 months -> continuous HRT Perimenopausal -> cyclical HRT (produces predictable bleeding where continuous is unpredictable) Uterus -No systemic oestrogen only (endometrial cancer) Local effect: -cream or pessary for vaginal dryness or dyspareunia

Answer 39

Corrected QT interval prolongation Rare: - AF or Torsade de pointes

Answer 40

Bed wetters go to BED Behavioural and lifestyle Enuresis alarms Desmopressin

Answer 41

Ampulla (70% of tubal and 65% of all extopics) Isthmal only 11% of all ectopics but largest risk of rupture.

Answer 42

Children -> metaphysis Adults -> epiphysis

Answer 43

Stool microscopy for trophozoite and cysts are classically negative Therefore: - duodenal fluid aspirates - "string test"

Answer 44

* An exhaled FeNO of 40 parts per billion or greater * A post-bronchodilator improvement in lung volume of 200 ml * A post-bronchodilator improvement in FEV1 of 12% or more * A peak expiratory flow rate variability of 20% or more * An FEV1/FVC ratio <70% (it is an obstructive lung disease)

Answer 45

``` Skin scarring Microphthalmia Limb hypoplasia Microcephaly Learning disabilities ```

Answer 46

Rare complication and usually affects those who have recently started renal replacement therapy. It is caused by cerebral oedema, but the exact mechanism is unclear. Therefore this is a diagnosis of exclusion.

Answer 47

Sulphonureas (e.g. gliclazide)

Answer 48

Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) Scoring system that determines severity of withdrawal by collating scores of symptom severity

Answer 49

IV 0.9% saline at 1mL/kg/hour for 12 hours pre and post procedure Stop potentially nephrotoxic medications like NSAIDS Consider stoping ACEi if eGFR <40

Answer 50

Sx <4 weeks = watchful waiting (unless severe, or child) Sx <3 months = trauma related CBT +/- hypnotics Sx >3 months = trauma-related CBT or Eye Movement Desensitisation Therapy

Answer 51

If primary (<24 hours post off) then return to theatre If secondary (>24 hours) more likely infection so antibiotics.

Answer 52

Active internal bleeding Recent haemorrhage, trauma or surgery (including dental extraction) Coagulation and bleeding disorders intracranial neoplasm Stroke <3 months Aortic dissection Recent head injury Pregnancy Severe hypertension

Answer 53

Distal radius fracture (Colle's/ Smith's) with associated radiocarpal dislocation Fall onto extended and pronated wrist

Answer 54

Bimalleolar ankle fracture Forced foot eversion

Answer 55

Fracture of the base of the first metacarpal that extends into the carpometacarpal joint

Answer 56

Ceftriaxone and other cephalosporins Co-amoxiclav Clindamycin Ciprofloxacin and other quinolones

Answer 57

Occurs when irrigation fluid enters circulation during TURP Triad of: - Hyponatraemia: dilutional - Fluid overload - Glycine toxicity Management: -Fluid restriction and treatment of hyponatraemia complications

Answer 58

RMI Based on: - CA125 levels - Menopausal status - Ultrasound score

Answer 59

5-HIAA acid assay of the urine

Answer 60

>1.5L blood drained initially OR losses of >200ml per hour for 2 hours

Answer 61

Raised intracranial hypertension

Answer 62

All patients with a pleural effusion in association with sepsis or a pneumonic illness require diagnostic pleural fluid sampling * if the fluid is purulent or turbid/cloudy a chest tube should be placed to allow drainage * if the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection a chest tube should be placed

Answer 63

an unruptured embryo <30mm in size No heartbeat Asymptomatic B-HCG level of <200IU/L and declining

Answer 64

Calcitonin Malignancy of parafollicular cells (C cells) which release calcitonnin

Answer 65

Gurd criteria

Answer 66

Any progression to complete heart block transiently or permanently Any episodes of cardiac syncope

Answer 67

Insertive anal or receptive vaginal sex with known HIV partner.

Answer 68

``` A - albumin B - bilirubin C - clotting D - distention (ascites) E - encephalopathy ```

Answer 69

5 Ts - Truncus arteriosus - Transposition of the great arteries - Tricuspid atresia - Tetralogy of Fallot - Total anomalous pulmonary venous return

Answer 70

Oral corticosteroids (usually 3 weeks then tapered off) Other first lines: - IVIG - IV anti-D (rhesus +ve non-splenectomised people) Splenectomy is second line Small print: - Thrombopoietin receptor agonists (e.g. Eltrombopag) - Rituximab (anti-CD20) - Azathioprine

Answer 71

Ewing sarcoma = onion skin pattern Osteosarcoma = sunburst lesion

Answer 72

Mycoplasma lacks a cell wall. Penicillins inhibit cell wall synthesis so dont work Erythromycin

Answer 73

2 out of 3 of: Oligoamenorrhoea Elevated total/free testosterone (or clinical features of hyperandrogenism) Polycystic ovaries on ultrasound

Answer 74

indicates dorsal column loss, which conveys touch, vibration and proprioception. It may be due to tabes dorsalis (syphilis infection) or subacute combined degeneration of the cord (B12 deficiency).

Answer 75

Rigler triad: - Pneumobilia - Small bowel obstruction - Ectopic gallstone, usually in the right iliac fossa

Answer 76

Extrapyramidal side-effects - Parkinsonism - acute dystonia (e.g. torticollis, oculogyric crisis) - akathisia (severe restlessness) - tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw) The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients: - increased risk of stroke - increased risk of venous thromboembolism Other side-effects - antimuscarinic: dry mouth, blurred vision, urinary retention, constipation - sedation, weight gain - raised prolactin: galactorrhoea, impaired glucose tolerance - neuroleptic malignant syndrome: pyrexia, muscle stiffness - reduced seizure threshold (greater with atypicals) - prolonged QT interval (particularly haloperidol)

Answer 77

COCP Also thicken cervical mucus: - Desogestrel only pill - Injectable (medroxyprogesterone acetate) - Implantable contraceptive (etonogestrel)

Answer 78

Metabolic alkalosis

Answer 79

right bundle branch block increased P wave amplitude right axis deviation

Answer 80

The three acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) as options for managing mild to moderate Alzheimer's disease memantine (an NMDA receptor antagonist) is in simple terms the 'second-line' treatment for Alzheimer's, NICE recommend it is used in the following situation reserved for patients with: → moderate Alzheimer's who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors → as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer's → monotherapy in severe Alzheimer's

Answer 81

short stature shield chest, widely spaced nipples webbed neck bicuspid aortic valve (15%), coarctation of the aorta (5-10%) primary amenorrhoea cystic hygroma (often diagnosed prenatally) high-arched palate short fourth metacarpal multiple pigmented naevi lymphoedema in neonates (especially feet) gonadotrophin levels will be elevated hypothyroidism is much more common in Turner's

Answer 82

metformin is still first-line and should be offered if the HbA1c rises to 48 mmol/mol (6.5%)* on lifestyle interventions ``` if the HbA1c has risen to 58 mmol/mol (7.5%) then a second drug should be added from the following list: → sulfonylurea → gliptin → pioglitazone → SGLT-2 inhibitor ``` if despite this the HbA1c rises to, or remains above 58 mmol/mol (7.5%) then triple therapy with one of the following combinations should be offered: → metformin + gliptin + sulfonylurea → metformin + pioglitazone + sulfonylurea → metformin + sulfonylurea + SGLT-2 inhibitor → metformin + pioglitazone + SGLT-2 inhibitor → OR insulin therapy should be considered

Answer 83

if the HbA1c rises to 48 mmol/mol (6.5%)* on lifestyle interventions, consider one of the following: → sulfonylurea → gliptin → pioglitazone if the HbA1c has risen to 58 mmol/mol (7.5%) then a one of the following combinations should be used: → gliptin + pioglitazone → gliptin + sulfonylurea → pioglitazone + sulfonylurea if despite this the HbA1c rises to, or remains above 58 mmol/mol (7.5%) then consider insulin therapy

Answer 84

if triple therapy is not effective, not tolerated or contraindicated then NICE advise that we consider combination therapy with metformin, a sulfonylurea and a glucagonlike peptide1 (GLP1) mimetic if: → BMI >= 35 kg/m² and specific psychological or other medical problems associated with obesity or → BMI < 35 kg/m² and for whom insulin therapy would have significant occupational implications or

Answer 85

Ketokonazole shampoo

Answer 86

Score <5 (unlikely for labour to start without induction) | Score >9 (likely labour will start spontaneously)

Answer 87

Currently it is recommended that all women who are planning to become pregnant should take a supplement of 400 micrograms of folic acid per day whilst trying to conceive and once pregnancy, they should continue taking this dose until the 12th week of pregnancy. In cases where there has been a previous pregnancy affected by neural tube defects or if there is a family history, this dose should be increased to 5 milligrams and it should be started BEFORE conception.

Answer 88

women are considered higher risk if any of the following apply: → either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD → the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait. → the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).

Answer 89

SIADH | Hypothyroidism

Answer 90

The next important assessment would be the osmolality of the urine. If this was > 100 mmol/kg, this would suggest the syndrome of inappropriate ADH secretion (SIADH).

Answer 91

Use sterile saline for wound cleansing up to 48 hours after surgery. Advise patients that they may shower safely 48 hours after surgery. Use tap water for wound cleansing after 48 hours if the surgical wound has separated or has been surgically opened to drain pus.

Answer 92

Prevention: acetazolamide Treatment: Oxygen, dexamethasone, and decent

Answer 93

Side-effects of erythropoietin accelerated hypertension potentially leading to encephalopathy and seizures (blood pressure increases in 25% of patients) bone aches flu-like symptoms skin rashes, urticaria pure red cell aplasia* (due to antibodies against erythropoietin) raised PCV increases risk of thrombosis (e.g. Fistula) iron deficiency 2nd to increased erythropoiesis

Answer 94

No Immune attack of blood vessels causes purpura Not thrombocytopenia

Answer 95

Plain x-ray Technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist Surgical repair of Perthes' disease is only indicated in children age >6. In those age <6, the prognosis is good with no intervention

Answer 96

CN III (oculomotor) CN IV (trochlear CN VI (abducens) CN V (opthamic and maxillary nerve (V1 and V2))

Answer 97

General term given to describe the consellation of eyelid and orbital changes that accompany the administration of topical prostaglandin analogue eye drops ``` Eyelid ptosis Deepening of upper lid sulcus Periorbital fat atrophy Mild enophthalmos Inferior scleral show Increased prominence of lid vessels Longer eyelashes ```

Answer 98

Low levels of C4a and C4b ANA +ve (99%) RF +ve (20%) anti-dsDNA - highly specific (>99%) - less sensitive (70%) anti-smith - most specific (>99%) - sensitivity 30% anti-U1 RNP SS-A (anti-Ro) SS-B (anti-La)

Answer 99

``` ESR CRP (characteristically normal so if raised may be underlying infection) ``` Complement (low during active disease) anti-dsDNA can be used for disease monitoring in some patients

Answer 100

Anterior colporrhaphy

Answer 101

Sacrocolpoplexy

Answer 102

normocytic anaemia leukopenia thrombocytopenia

Answer 103

Affects 2 eyes, 2 ears, and 2 parts of brain - acoustic neuroma - juvenile cataracts - meningioma - ependymoma

Answer 104

Prostaglandins like alprostadil

Answer 105

GI common - diarrhoea - vomiting - exacerbation of colitis Pancreatitis occasionally (particularly mesalazine)

Answer 106

PCP Legionella Staphylococcus

Answer 107

lung cavitation/ empyema

Answer 108

Paget's usually unilateral, pruritis absent and nipple always involved Eczema usually bilateral, pruritic and spares the nipples

Answer 109

Most common: -TB and sarcoidosis other causes: - lymphoma/ other malignancy - pneumoconiosis (e.g. berylliosis) - fungi (e.g. histoplasmosis, coccidioidomycosis)

Answer 110

urgent referal to specialist centre for evacuation Effective contraception to avoid pregnancy for next 12 months

Answer 111

Multiple, non-keritinised warts = topical podophyllum Solitary, keratinised warts = cryotherapy

Answer 112

From 10 weeks + 0 days to 14 weeks + 1 day Maternal serum hCG PAPP-A Nuchal translucency scan (NT and crown rump length can only be measured from 11 weeks and 2 days to 14 weeks and 1 day.)

Answer 113

14 weeks + 2 days to 20 weeks + 0 days Maternal serum hCG AFP uE3 inhibin A For those presenting later and those morbidly obese who USS wouldnt work

Answer 114

The subthalamic nucleus

Answer 115

Potassium = 1mmol/kg/day Sodium = 2mmol/kg/day Glucose = 50-100g/day Fluid = 20-30ml/kg/day

Answer 116

``` Renal failure Alcohol poisoning Hypoxia Shock DKA Salicylate poisoning ```

Answer 117

Diarrhoea Addison's disease Renal tubular acidosis

Answer 118

Opioid analgesics -sub cut is the friendliest delivery method) - One tenth to one sixth of 24 hour dose of any regular opioid - If not on regular opioid then morphine or diamorphine 2mg SC Anxiolytic sedative -midazolam 2-5mg SC hourly Antisecretory medication -hyoscine butylbromide 20mg SC hourly -Need to give this as soon as nurses alert you to a change in breathing Anti emetic - levopromazine 2.5mg-5mg SC 8 hourly - prochlopromazine commonly used in inverness but above meds taken from palliative care guidelines

Answer 119

Rectal suction biopsy

Answer 120

Risk factor for PID so insertion should be avoided in known infection

Answer 121

EllaOne is effective for up to 5 days (120 hours) Levonelle can be taken up to 72 hours (being most effective in the first 24 hours)

Answer 122

Carbamazepine

Answer 123

Aplastic anaemia (leucopenia and agranulocytosis) SJS Erythema multiforme Arrhythmias Hepatitis P450 enzyme inducer Dizziness and ataxia drowsiness headache visual disturbances (especially diplopia) hyponatraemia secondary to syndrome of inappropriate ADH secretion

Answer 124

bladder exstrophy

Answer 125

Urethral stricture Causes - iatrogenic e.g. traumatic placement of indwelling urinary -catheters - sexually transmitted infections - hypospadias - lichen sclerosus Usually just a bit of dribbling not related to coughing or sneezing. No urgency etc.

Answer 126

Before the induction of anaesthesia, the following must have been checked: Patient has confirmed: Site, identity, procedure, consent Site is marked Anaesthesia safety check completed Pulse oximeter is on patient and functioning Does the patient have a known allergy? Is there a difficult airway/aspiration risk? Is there a risk of > 500ml blood loss (7ml/kg in children)?

Answer 127

PR depression

Answer 128

The mnemonic CHOCOLATE is useful for remembering the common precipitants. ``` Chocolate Hangovers Orgasms Cheese Caffeine The oral contraceptive pill Lie-ins Alcohol Travel Exercise ```

Answer 129

Three doses are now given at: 2 months 4 months 12-13 months

Answer 130

Anti-Jo1 antibody "Antisynthetase syndrome", which is characterised by a combination of myositis and interstitial lung disease

Answer 131

Establishing the diagnosis of autoimmune myositis requires as many as possible of the following 5 criteria: Proximal muscle weakness Characteristic rash Elevated serum muscle enzymes (if CK is not elevated, aminotransferases or aldolase [which are less specific than CK]) Characteristic electromyographic or MRI muscle abnormalities Muscle biopsy changes (the definitive test)

Answer 132

7.5mg per day for 3 months This is anticipatory so if you know they are on steroids for this long at this dose start bisphosphonates STRAIGHT AWAY. e.g. PMR you know they will be on steroids for months at high dose so need to prescribe bone protection also

Answer 133

The RCP guidelines essentially divide patients into two groups. 1. Patients over the age of 65 years or those who've previously had a fragility fracture should be offered bone protection. 2. Patients under the age of 65 years should be offered a bone density scan, with further management dependent: T score >0 = reassure T score 0-1.5 = Repeat bone density scan in 1-3 years T score <1.5 = offer bone protection Bone protection = alendronate plus calcium and vitamin D supplementation

Answer 134

Stable patients with diverticulitis flares can be managed with oral antibiotics at home. If they do not improve within 72 hours, admission to hospital for broad-spectrum antibiotic therapy (eg. IV ceftriaxone + metronidazole) is indicated.

Answer 135

Individuals with type 1 diabetes who do not have established cardiovascular disease (CVD) risk factors should be offered atorvastatin 20 mg for primary prevention of CVD if they are: - Older than 40 years of age - Have had diabetes for more than 10 years - Have established nephropathy - Have other CVD risk factors (such as obesity and hypertension)

Answer 136

Neonatal resuscitation guidelines Birth: Dry the baby, remove any wet towels and cover and start the clock or note the time. Within 30 seconds: Assess tone, breathing and heart rate. Within 60 seconds: If gasping or not breathing - open the airway and give 5 inflation breaths Re-assess: If no increase in heart rate look for chest movement If chest not moving: Recheck head position, consider 2-person airway control and other airway manoeuvres, repeat inflation breaths and look for a response. If no increase in heart rate look for chest movement When the chest is moving: If heart rate is not detectable or slow (< 60 min-1) - start chest compressions with 3 compressions to each breath. Reassess heart rate every 30 seconds. If heart rate is not detectable or slow (<60 beats per minute) consider venous access and drugs

Answer 137

Hodgekin's lymphoma

Answer 138

Even if post menopausal shouldn't stop using contraception until over 50 "Women using non-hormonal methods of contraception can be advised to stop contraception after 1 year of amenorrhoea if aged over 50 years, 2 years if the woman is aged under 50 years"

Answer 139

You should usually share information about sexual activity involving children under 13, who are considered in law to be unable to consent

Answer 140

The ulnar nerve supplies the palmer and dorsal interossei muscles and therefore finger abduction and adduction. Therefore this is an ulnar nerve lesion. When the ulnar nerve is damaged at the wrist, the medial two lumbrical muscles are affected (the lateral two being supplied by the median nerve). Denervation of the lumbricals, which flex the metacarpal phalangeal joints (MCPJ) and extend the interphalangeal joints (IPJ), causes unopposed extension of the MCPJ by extensor digitorum longus and flexion of the IPJ by flexor digitorum profundus and superficialis. This gives the hand a claw like appearance. When the ulnar nerve is damaged at the elbow, the ulnar half of flexor digitorum profundus is also affected resulting in a less marked clawing due to reduced unopposed flexion at the IPJ. As the patient recovers, the deformity will get worse, as flexor digitorum is reinnervated, before getting better. This is known as the ulnar paradox, as one would expect a more proximal lesion (and hence a larger section of ulnar nerve affected) to produce a more deformed appearance.

Answer 141

Spider naevi can be differentiated from telangiectasia by pressing on them and watching them fill. Spider naevi fill from the centre, telangiectasia from the edge

Answer 142

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. Levels should be taken 12 hours post-dose thyroid and renal function should be checked every 6 months patients should be issued with an information booklet, alert card and record book

Answer 143

``` BCG MMR oral polio yellow fever oral typhoid ```

Answer 144

Glaucoma has a strong hereditary component, and so those with a first-degree relative, are generally advised to have annual glaucoma screening form the age of 40.

Answer 145

Craniopharyngioma = bilateral inferior quadrantanopia Pituitary adenoma = bilateral superior quadrantanopia

Answer 146

Cerebral oedema IV 5% dextrose can be used slowly, especially if the patient is replete, but does risk correction of sodium too fast. If sodium >170 mmol/l or haemodynamically unstable then IV 0.9% NaCl can be used and this would correct the sodium more slowly and prevent cerebral oedema. There is debate about which fluid type is most suitable and so local guidelines should be consulted. It is important to note that very acute hypernatraemia can be corrected quicker without worrying about large fluid shifts and resultant cerebral oedema.

Answer 147

ACR > 2.5 = microalbuminuria

Answer 148

NICE guidelines suggest that if admission is not needed, you should prescribe an antibiotic if the onset of the cough is within the last 21 days. In children over 1-month-old, the first line antibiotics are macrolides (specifically azithromycin or clarithromycin for children aged 1 month or older, and non-pregnant adults). Admit if: - Younger than 6 months of age, - Have significant breathing difficulties (for example apnoea episodes, severe paroxysms, or cyanosis) - Have a significant complication (for example seizures or pneumonia).

Answer 149

NSAIDS close | Prostaglandins keep Patent

Answer 150

ABC including two peripheral cannulae, 14 gauge bimanual uterine compression to manually stimulate contraction IV syntocinon (oxytocin) 5 units OR IM ergometrine 500 micrograms (syntometrine IM contains both) IM carboprost 250 micrograms at 15 min intervals (maximum 8 doses (2mg)) Rectal misoprostol Tranexamic acid surgical intervention such as balloon tamponade if medical options failure to control the bleeding then surgical options will need to be urgently considered the RCOG state that the intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure

Answer 151

IV verapamil | adenosine is contraindicated in asthma

Answer 152

Right posterior hip dislocation | NOF -> externally rotated and shortened

Answer 153

Babies who were born prematurely should receive their routine vaccinations according to chronological age; there should be no correcting for gestational age. Babies who were born prior to 28 weeks gestation should receive their first set of immunisations at hospital due to risk of apnoea.

Answer 154

High plasma osmolality (dehydrated) Low urine osmolality (dilute urine)

Answer 155

NICE advise the use of faecal calprotectin to help differentiate between IBS and IBD in primary care. It is released in the bowel in the presence of inflammation and is not degraded so can be detected in a stool sample. It can reduce the need for referral of patients with typical IBS symptoms and the use of invasive diagnostic testing e.g. Colonoscopy. A positive result does not indicate definite IBD but patients should be referred on to secondary care for further investigation.

Answer 156

hypertensive disease during previous pregnancies chronic kidney disease autoimmune disorders such as SLE or antiphospholipid syndrome type 1 or 2 diabetes mellitus

Answer 157

Very fine layer of soft un-pigmented hair that covers her entire body, apart from her palmar and plantar surfaces. Sign of chronic malnutrition Can be differentiated from hair in PCOS which wont be as fine and all over the body

Answer 158

Characteristically very high opening pressure

Answer 159

CT abdomen | AXR is usually done first line because quick and cheap but is not the gold standard

Answer 160

All patients should receive aspirin and a statin in the absence of any contraindication sublingual glyceryl trinitrate to abort angina attacks Beta-blocker or a calcium channel blocker first-line based on 'comorbidities, contraindications and the person's preference' if a calcium channel blocker is used as monotherapy a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker then use a long-acting dihydropyridine calcium-channel blocker (e.g. modified-release nifedipine). Remember that beta-blockers should not be prescribed concurrently with verapamil (risk of complete heart block) if there is a poor response to initial treatment then medication should be increased to the maximum tolerated dose (e.g. for atenolol 100mg od) if a patient is still symptomatic after monotherapy with a beta-blocker add a calcium channel blocker and vice versa if a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then consider one of the following drugs: a long-acting nitrate, ivabradine, nicorandil or ranolazine if a patient is taking both a beta-blocker and a calcium-channel blocker then only add a third drug whilst a patient is awaiting assessment for PCI or CABG

Answer 161

- Symptoms lasting more than 4 days or not improving - Systemically unwell but not requiring admission - Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease - Younger than 2 years with bilateral otitis media - Otitis media with perforation and/or discharge in the canal If an antibiotic is given, a 5-day course of amoxicillin is first-line. In patients with penicillin allergy, erythromycin or clarithromycin should be given.

Answer 162

laxative abuse

Answer 163

'allergic' type picture consisting usually of raised urinary WCC, IgE, and eosinophils, alongside impaired renal function

Answer 164

Abdominal CT | Abdominal X-ray commonly used because quick and cheap and will show thumbprinting

Answer 165

- Smoker or ex-smoker, - Over 35, - Symptomatic (exertional breathlessness, chronic cough or regular sputum production) - with FEV1/FVC <0.7 The severity of COPD is based upon FEV1 readings. If FEV1 is normal (>80%), therefore disease is mild. Moderate is FEV1 50-79%, severe is 30-49%, and very severe is <30%.

Answer 166

External rotation and abduction of the upper limb.

Answer 167

The most common causative organism is Escherichia coli. However, particularly in younger men, a significant minority can be caused by sexually transmitted organisms, such as Chlamydia trachomatis and Neisseria gonorrhoea.

Answer 168

Post-void volumes of <50 ml are considered physiological in patients aged < 65 years old. Post-void volumes of < 100ml are considered physiological in patients aged > 65 years old.

Answer 169

Chronic urinary retention is defined by the presence of >500ml within the bladder after voiding.

Answer 170

Post-catheterisation urine volume of >800ml

Answer 171

NICE states 'Offer carbamazepine or lamotrigine as first-line treatment to children, young people and adults with newly diagnosed focal seizures.' Second line: -levetiracetam, oxcarbazepine or sodium valproate

Answer 172

Sodium valproate Lamotrigine in any woman of childbearing age Second line: lamotrigine, carbamazepine

Answer 173

NICE states 'Offer ethosuximide or sodium valproate as first-line treatment to children, young people and adults with absence seizures.'

Answer 174

Adverse effects of ciclosporin (note how everything is increased - fluid, BP, K+, hair, gums, glucose) ``` nephrotoxicity hepatotoxicity fluid retention hypertension hyperkalaemia hypertrichosis gingival hyperplasia tremor impaired glucose tolerance hyperlipidaemia increased susceptibility to severe infection ```

Answer 175

Diagnosis: - Nuclear acid amplification tests (NAATs) are now rapidly emerging as the investigation of choice - Urine (first void urine sample), vulvovaginal swab or cervical swab may be tested using the NAAT technique Treatment: -azythomycin 1g stat is first line (doxycycline can be used but not recommended by SIGN because over 7 days) -Erythromycin and amoxicillin can also be used (doxycycline not safe in pregnancy remember!)

Answer 176

- Patients diagnosed with Chlamydia should be offered a choice of provider for initial partner notification - either trained practice nurses with support from GUM, or referral to GUM - For men with urethral symptoms: all contacts since, and in the four weeks prior to, the onset of symptoms - For women and asymptomatic men all partners from the last six months or the most recent sexual partner should be contacted - Contacts of confirmed Chlamydia cases should be offered treatment prior to the results of their investigations being known (treat then test)

Answer 177

4ml * % body surface area * weight (kg) = ml of Hartmann's to be given in first 24 hours 50% given over first 8 hrs then 50% over next 16hrs 4 * 25 * 70 = 7000ml. Half of this should be given in the first 8 hours from the burn, so the answer is 3.5 L

Answer 178

After 24 hours Colloid infusion is begun at a rate of 0.5 ml x(total burn surface area (%))x(body weight (kg)) Maintenance crystalloid (usually dextrose-saline) is continued at a rate of 1.5 ml x(burn area)x(body weight) Colloids used include albumin and FFP Antioxidants, such as vitamin C, can be used to minimize oxidant-mediated contributions to the inflammatory cascade in burns High tension electrical injuries and inhalation injuries require more fluid Monitor: packed cell volume, plasma sodium, base excess, and lactate

Answer 179

Raynaud's may be first sign scleroderma affects face and distal limbs predominately associated with anti-centromere antibodies a subtype of limited systemic sclerosis is CREST syndrome: Calcinosis, Raynaud's phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia

Answer 180

scleroderma affects trunk and proximal limbs predominately associated with scl-70 antibodies the most common cause of death is now respiratory involvement, which is seen in around 80%: interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH) other complications include renal disease and hypertension poor prognosis

Answer 181

``` A useful mnemonic to remember the features of Wernicke's encephalopathy is CAN OPEN Confusion Ataxia Nystagmus Ophthamoplegia PEripheral Neuropathy ```

Answer 182

Mild -Hydrocortisone 0.5-2.5% Moderate - Betamethasone valerate 0.025% (Betnovate RD) - Clobetasone butyrate 0.05% (Eumovate) Potent - Fluticasone propionate 0.05% (Cutivate) - Betamethasone valerate 0.1% (Betnovate) Very potent -Clobetasol propionate 0.05% (Dermovate)

Answer 183

More than half of cord prolapse occurs after artificial rupture of membranes (artificial amniotomy)

Answer 184

Escherichia coli is the most common causative organism in adults >35, especially with a prior diagnosis of BPH. Neisseria gonorrhoea and Chlamydia trachomatis are the most likely cause in younger men. Klebsiella pneumoniae and Enterococcus faecalis are enteric organisms that rarely cause epididymitis.

Answer 185

if the organism is unknown BASHH recommend: ceftriaxone 500mg intramuscularly single dose, plus doxycycline 100mg by mouth twice daily for 10-14 days

Answer 186

First-line treatment for neuropathic pain is amitriptyline, duloxetine, gabapentin or pregabalin. If one of these agents don't work next line is to try one of the other remaining three drugs tramadol may be used as 'rescue therapy' for exacerbations of neuropathic pain topical capsaicin may be used for localised neuropathic pain (e.g. post-herpetic neuralgia) pain management clinics may be useful in patients with resistant problems

Answer 187

Type 1 - Anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA) - Affects both adults and children Type 2 - Anti-liver/kidney microsomal type 1 antibodies (LKM1) - Affects children only Type 3 - Soluble liver-kidney antigen - Affects adults in middle-age

Answer 188

Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) = 3 An alternative diagnosis is less likely than PE = 3 Heart rate > 100 beats per minute = 1.5 Immobilisation for more than 3 days or surgery in the previous 4 weeks = 1.5 Previous DVT/PE = 1.5 Haemoptysis = 1 Malignancy (on treatment, treated in the last 6 months, or palliative) = 1 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 give low-molecular-weight heparin until the scan is performed. If a PE is 'unlikely' (4 points or less) arranged a D-dimer test. If this is positive arrange an immediate computed tomography pulmonary angiogram (CTPA). If there is a delay in getting the CTPA then give low-molecular-weight heparin until the scan is performed. If the patient has an allergy to contrast media or renal impairment a V/Q scan should be used instead of a CTPA.

Answer 189

Normocytic anaemia Hyperkalamia Hyponatraemia (hypovolaemic)

Answer 190

For elective total hip replacement surgery NICE recommend commencing a low molecular weight heparin 6-12 hours after surgery. LMWH for 10 days followed by aspirin (75 or 150 mg) for a further 28 days or LMWH for 28 days combined with anti-embolism stockings until discharge or Rivaroxaban

Answer 191

Hep B = 20-30% Hep C = 0.5-2% HIV = 0.3%

Answer 192

Chlorpromazine is licensed for the treatment of intractable hiccups haloperidol, gabapentin are also used dexamethasone is also used, particularly if there are hepatic lesions

Answer 193

Naproxen is preferred first-line treatment for acute pericarditis. Other NSAIDs such as ibuprofen and indomethacin may be used. NSAIDs are used to reduce the inflammation at the pericardium.

Answer 194

ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension) treat if < 80 years of age AND any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 20% or greater ABPM/HBPM >= 150/95 mmHg (i.e. stage 2 hypertension) offer drug treatment regardless of age

Answer 195

An iron chelator is only recommended to be used if phlebotomy cannot be tolerated if, for instance, the patient is very anaemic.

Answer 196

It is advised that chest drains are placed in the 'safe triangle'. The triangle is located in the mid axillary line of the 5th intercostal space. It is bordered by: Anterior edge latissimus dorsi, the lateral border of pectoralis major, a line superior to the horizontal level of the nipple, and the apex below the axilla. Another triangle is situated behind the scapula. It is bounded above by the trapezius, below by the latissimus dorsi, and laterally by the vertebral border of the scapula; the floor is partly formed by the rhomboid major. If the scapula is drawn forward by folding the arms across the chest, and the trunk bent forward, parts of the sixth and seventh ribs and the interspace between them become subcutaneous and available for auscultation. The space is therefore known as the triangle of auscultation.

Answer 197

Local anaesthetic toxicity occurs due to accidental injection intravascularly and can result initially in an excitation phase of circumoral numbness, restlessness, tinnitus, shivering, muscular twitching and convulsions followed by a depression phase of LOC and apnoea

Answer 198

Pontine haemorrhage is a life-threatening condition. It often occurs as a complication secondary to chronic hypertension. Patients often present with reduces Glasgow coma score, quadriplegia, miosis, and absent horizontal eye movements.

Answer 199

White 'curdy' vaginal discharge with pH <4.5 is likely to be candidiasis Options include local or oral treatment Local treatments include clotrimazole pessary (e.g. clotrimazole 500mg PV stat) Oral treatments include itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat If pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated

Answer 200

Nontuberculous mycobacteria (NTM) are mycobacteria which do not cause tuberculosis or leprosy, they can however still cause respiratory (as well as a wide range of other) disease. For the purposes of diagnosis and treatment of mycobacterial disease, mycobacteria can be classified into 3 main groups: Those mycobacteria that can cause tuberculosis: M. tuberculosis, M. bovis, M. africanum, M. africanum, M. microti and M. canetti. Those mycobacteria that can cause leprosy: M. leprae and M. lepromatosis NTM are all the other mycobacteria which can cause pulmonary disease resembling tuberculosis, lymphadenitis, skin disease, or disseminated disease

Answer 201

Mycobacterium avium complex, which consists of comprising Mycobacterium intracellulare and Mycobacterium avium. This is by far the most common NTM and causes pulmonary disease resembling TB.

Answer 202

Mycobacterium marinum, can cause a skin condition called an aquarium granuloma and typically affects people whom have home aquariums or work with fish.

Answer 203

Mycobacterium ulcerans is a slow-growing mycobacterium that classically infects the skin and subcutaneous tissues, giving rise to indolent non-ulcerated (nodules, plaques) and ulcerated lesions.

Answer 204

Treatment depends on the type: - Simple - Complex - Simple atypical - Complex atypical Simple endometrial hyperplasia without atypia: -High dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used Atypia: -A total hysterectomy is advisable for all women, due to the risk of malignant progression, with bilateral salpingo-oophorectomy in addition for postmenopausal women.

Answer 205

The presence of erythema migrans is sufficient to begin treating a patient without laboratory investigations. Lyme disease without focal symptoms is treated with oral doxycycline. IV ceftriaxone or cefotaxime is recommended for Lyme disease associated with cardiac or neurological complications

Answer 206

For a private vehicle, patients do not need to notify the DVLA following PCI and may resume driving after 4 weeks providing they don't have any other disqualifying condition. For a Group 2 vehicle (bus or lorry), patients must notify the DVLA, and may not drive for at least 6 weeks. After 6 weeks the DVLA will assess to determine if the requirements for exercise or other functional tests are met and to ensure there is no disqualifying condition. Only then will the license to drive a Group 2 vehicle be reinstated.

Answer 207

Although the source of gallstones is removed by performing a cholecystectomy, it is possible that a stone can migrate into the distal end of the cystic duct during surgery and not be removed as it is not seen. Subsequently this can enter the common bile duct and cause obstruction and result in pain and jaundice and may even cause ascending cholangitis if not treated early enough. For this reason it is becoming common practice to perform an on-table cholangiogram after gallbladder removal to allow removal of stones from the ducts if present although this is not always the case, especially with elective cholecystectomies.

Answer 208

Due to an increased risk of venous thromboembolism it is advisable to stop the combined oral contraceptive pill 4 weeks prior to her operation.

Answer 209

Domperidone - doesn't cross the blood brain barrier so doesn't cause extrapyramidal side effects - useful if you get nausea on levodopa

Answer 210

Metformin should be stopped following a myocardial infarction due to the risk of lactic acidosis. It may be introduced at a later date. Diabetic control may be achieved through the use of a insulin/dextrose infusion

Answer 211

On a 12-lead ECG ST-elevation would not be noticeable and so only reciprocal changes are visible in leads V1-V3. The changes associated with these leads include: ST depression Tall, broad R-waves Upright T-waves

Answer 212

In this patient, the most appropriate treatment option is sitagliptin, an example of a dipeptidyl peptidase 4 (DPP-4) inhibitor. This is due to his eGFR being <30ml/minute, meaning that metformin is contraindicated.

Answer 213

Crohn's disease can result in terminal ileitis, this is the section of the bowel where bile salts are reabsorbed. When this area is inflamed and the bile salts are not absorbed and people are prone to development of gallstones. Other risk factors for the development of gallstones include; - Increasing age - Family history. - Sudden weight loss - eg, after obesity surgery. - Loss of bile salts - eg, ileal resection, terminal ileitis. - Diabetes - as part of the metabolic syndrome. - Oral contraception - particularly in young women

Answer 214

The triad of joint pain, spiking fevers, and a pink bumpy rash is very characteristic of adult-onset Still’s disease. Additionally, it is also associated with high serum ferritin and leucocytosis. Adult-onset Still’s disease is a diagnosis of exclusion and can only be diagnosed if rheumatoid factor and anti-nuclear antibody are negative (means its not RA or SLE)

Answer 215

Factor 8 acquired disorder. The elderly, pregnancy, malignancy and autoimmune conditions are associated with acquired haemophilia. Prolonged APTT is key to the diagnosis. Management involves steroids.

Answer 216

Sit without support (usually 7-8 months) = refer at 12 months Walk without support (usually 13-15 months) = refer at 18 months

Answer 217

Entry inhibitors (CCR5 receptor antagonists) maraviroc, enfuvirtide prevent HIV-1 from entering and infecting immune cells by blocking CCR5 cell-surface receptor

Answer 218

Nucleoside analogue reverse transcriptase inhibitors (NRTI) examples: zidovudine (AZT), abacavir, emtricitabine, didanosine, lamivudine, stavudine, zalcitabine, tenofovir general NRTI side-effects: peripheral neuropathy zidovudine: anaemia, myopathy, black nails didanosine: pancreatitis

Answer 219

examples: indinavir, nelfinavir, ritonavir, saquinavir side-effects: diabetes, hyperlipidaemia, buffalo hump, central obesity, P450 enzyme inhibition indinavir: renal stones, asymptomatic hyperbilirubinaemia ritonavir: a potent inhibitor of the P450 system

Answer 220

Integrase inhibitors | examples: raltegravir, elvitegravir, dolutegravir

Answer 221

Non-nucleoside reverse transcriptase inhibitors (NNRTI) examples: nevirapine, efavirenz side-effects: P450 enzyme interaction (nevirapine induces), rashes

Answer 222

amiodarone, sotalol, class 1a antiarrhythmic drugs tricyclic antidepressants, selective serotonin reuptake inhibitors (especially citalopram) ``` methadone chloroquine terfenadine** erythromycin haloperidol ondanestron ```

Answer 223

NICE guidelines state that patients who have had emergency treatment for anaphylaxis should be observed for 6–12 hours from the onset of symptoms. After this they can be discharged

Answer 224

Hepatitis D terminology: Co-infection: Hepatitis B and Hepatitis D infection at the same time. Superinfection: A hepatitis B surface antigen positive patient subsequently develops a hepatitis D infection. Superinfection is associated with high risk of fulminant hepatitis, chronic hepatitis status and cirrhosis. Diagnosis is made via reverse polymerase chain reaction of hepatitis D RNA. Interferon is currently used as treatment, but with a poor evidence base.

Answer 225

Painless bleeding after 20 weeks pregnancy Placenta praevia should be considered in all cases of vaginal bleeding occurring after 20 weeks gestation. Features that increase suspicion of this condition include painless bleeding, high presenting part and abnormal fetal lie. Definitive diagnosis generally requires ultrasound examination to identify the position of the placenta.

Answer 226

``` Confusion Urea >7 RR >30 BP <90 systolic or <60 diastolic 65 or older ``` NICE recommend, in conjunction with clinical judgement: - 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)

Answer 227

NICE also mention point-of-care CRP test. This is currently not widely available but they make the following recommendation with reference to the use of antibiotic therapy: CRP < 20 mg/L - do not routinely offer antibiotic therapy CRP 20 - 100 mg/L - consider a delayed antibiotic prescription CRP > 100 mg/L - offer antibiotic therapy

Answer 228

Management of low-severity community acquired pneumonia - amoxicillin is first-line - if penicillin allergic then use a macrolide 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

Answer 229

Cutaneous leishmaniasis - caused by Leishmania tropica or Leishmania mexicana - crusted lesion at site of bite - may be underlying ulcer Mucocutaneous leishmaniasis - caused by Leishmania braziliensis - skin lesions may spread to involve mucosae of nose, pharynx etc (ulcerating lesions) Visceral leishmaniasis (kala-azar) - mostly caused by Leishmania donovani - occurs in the Mediterranean, Asia, South America, Africa - fever, sweats, rigors - massive splenomegaly. hepatomegaly - poor appetite*, weight loss - grey skin - 'kala-azar' means black sickness - pancytopaenia secondary to hypersplenism

Answer 230

Features - abdominal pain - peripheral neuropathy (mainly motor) - fatigue - constipation - blue lines on gum margin (only 20% of adult patients, very rare in children)

Answer 231

The blood lead level is usually used for diagnosis. Levels greater than 10 mcg/dl are considered significant full blood count: microcytic anaemia. Blood film shows red cell abnormalities including basophilic stippling and clover-leaf morphology Raised serum and urine levels of delta aminolaevulinic acid may be seen making it sometimes difficult to differentiate from acute intermittent porphyria Urinary coproporphyrin is also increased (urinary porphobilinogen and uroporphyrin levels are normal to slightly increased)

Answer 232

various chelating agents are currently used: - dimercaptosuccinic acid (DMSA) - D-penicillamine - EDTA - dimercaprol

Answer 233

For babies who are born to mothers who are hepatitis B surface antigen positive, or are known to be high risk of hepatitis B, should receive the first dose of hepatitis B vaccine soon after birth and those born to mother's who are surface antigen positive should also receive 0.5 millilitres of hepatitis B immunoglobulin within 12 hours of birth. The baby should then further receive a second dose of hepatitis B vaccine at 1-2 months and at 6 months.

Answer 234

ASA I - healthy, non-smoker, minimal or no alcohol use ASA II - Including, but not limited to, well-controlled diabetes, hypertension. Social drinker. Smoker ASA III - Including, but not limited to: poorly control diabetes, hypertension. BMI > 40. Previous MI > 6m ago. ASA IV - Including, but not limited to: recent MI (<3m), severe reduction in ejection fraction ASA V - Including, but not limited to: ruptured AAA, massive trauma

Answer 235

Insertion of ICP monitoring device ICP monitoring is appropriate in those who have GCS 3-8 and normal CT scan. ICP monitoring is mandatory in those who have GCS 3-8 and abnormal CT scan.

Answer 236

Alcohol units = volume (ml) * ABV / 1,000

Answer 237

epilepsy, pregnancy and breast feeding. Having an eating disorder is a relative contraindication

Answer 238

Foetal distress | consider C-section

Answer 239

The NICE Clinical Knowledge summary suggests that inflammation is more likely to be severe if there is: - a red, oedematous ear canal which is narrowed and obscured by debris - conductive hearing loss - discharge - regional lymphadenopathy - cellulitis spreading beyond the ear - fever NICE recommend that for mild cases (mild discomfort and/or pruritus; no deafness or discharge), consider prescribing topical acetic acid 2% spray. When features of more severe inflammation are present, such as in this case, they advise 7 days of a topical antibiotic with or without a topical steroid.

Answer 240

<6 months = 150 micrograms (0.15ml 1 in 1,000) 6 months to 6 years = 150 micrograms (0.15ml 1 in 1,000) 6-12 years = 300 micrograms (0.3ml 1 in 1,000) >12 years and adults = 500 micrograms (0.5ml 1 in 1,000)

Answer 241

ADPKD often presents with abdominal pain and early satiety as the kidneys occupy a large volume of the abdomen. Traction on the kidney pedicle can also cause pain. The presence of hypertension, bilateral flank masses and a systolic apical murmur (suggesting mitral valve disease) also point towards this diagnosis. ``` Extra-renal features of ADPKD include: Hepatic cysts which manifest as hepatomegaly Diverticulosis Intracranial aneurysms Ovarian cysts ```

Answer 242

External rotation (first movement to show impairment) They will also struggle with active and passive abduction, internal and external rotation

Answer 243

King's College Hospital criteria for liver transplantation (paracetamol liver failure) Arterial pH < 7.3, 24 hours after ingestion or all of the following: prothrombin time > 100 seconds creatinine > 300 µmol/l grade III or IV encephalopathy

Answer 244

Complications increased risk of infection due to urinary immunoglobulin loss increased risk of thromboembolism related to loss of antithrombin III and plasminogen in the urine. This may result in a renal vein thrombosis, resulting in a sudden deterioration in renal function hyperlipidaemia hypocalcaemia (vitamin D and binding protein lost in urine) acute renal failure

Answer 245

IM Diclofenac

Answer 246

In medicine, Meigs' syndrome, also Meigs syndrome or Demons-Meigs syndrome, is the triad of ascites, pleural effusion, and benign ovarian tumor (ovarian fibroma, fibrothecoma, Brenner tumour, and occasionally granulosa cell tumour). Meigs' syndrome resolves after the resection of the tumor.

Answer 247

Pseudomyxoma peritonei (PMP) is a clinical condition caused by cancerous cells (mucinous adenocarcinoma) that produce abundant mucin or gelatinous ascites.[1] The tumors cause fibrosis of tissues and impede digestion or organ function, and if left untreated, the tumors and mucin they produce will fill the abdominal cavity. This will result in compression of organs and will destroy the function of colon, small intestine, stomach, or other organs.

Answer 248

``` 'Some Arabs Fly Planes' Silver wiring - grade I AV nipping - grade II Flame haemorrhages - grade III Papilloedema - grade IV ```

Answer 249

The Royal College of Obstetricians and Gynaecologists states that women with GBS bacteriuria should therefore be offered intrapartum antibiotics in addition to appropriate treatment at the time of diagnosis. For non-penicillin-allergic patients intrapartum antibiotics will consist of intravenous benzylpenicillin given as soon as possible after the start of labour, then at 4-hourly intervals until delivery.

Answer 250

Furthermore, the characteristic hallmarks of intussusception on physical examination of a sausage-shaped mass in the right hypochondrium and emptiness in the right lower quadrant (Dance's sign)

Answer 251

Patient lies on their left side and the clinician extends the right hip with the knee fully extended. Abdominal pain on this movement indicates irritation of iliopsoas and possible appendicitis. This test usually indicates an appendix that lies in the retrocaecal position

Answer 252

For the exam, remember: - cANCA - granulomatosis with polyangiitis (Wegener's granulomatosis) - pANCA - Churg-Strauss syndrome + others (see below) cANCA most common target serine proteinase 3 (PR3) some correlation between cANCA levels and disease activity granulomatosis with polyangiitis, positive in > 90% microscopic polyangiitis, positive in 40% pANCA most common target is myeloperoxidase (MPO) cannot use level of pANCA to monitor disease activity associated with immune crescentic glomerulonephritis (positive in c. 80% of patients) microscopic polyangiitis, positive in 50-75% Churg-Strauss syndrome, positive in 60% primary sclerosing cholangitis, positive in 60-80% granulomatosis with polyangiitis, positive in 25% Other causes of positive ANCA (usually pANCA) inflammatory bowel disease (UC > Crohn's) connective tissue disorders: RA, SLE, Sjogren's autoimmune hepatitis

Answer 253

Patau - trisomy 13 - odd number gives odd number of fingers (polydactyly), cleft lip and palate (3 on its side could be, in an artistic mind, a symbol of cleft lip), scalp lesions and microcephaly + small eyes

Answer 254

Edward's syndrome - trisomy 18 - imagine Edward, a little boy with Micrognathia+ Low-set ears and Overlapping of fingers sitting in his rocking chair (rocker bottom feet)

Answer 255

Fragile X - everything is big here --> macrocephaly, long face, large ears, large 'orchids' + learning difficulties as with most syndromes

Answer 256

Noonan syndrome - somehow I think of some odd looking bird - webbed neck, pec excavated, short, pul stenosis

Answer 257

Prader-Willi syndrome - we've all seen this one - cant stop eating, raider of the fridge syndrome --> so again large body = small gonads, and cant move arms and legs easily so hypotonia

Answer 258

William's syndrome - prince william is tall but those with william's syndrome are short, more out going. Additionally, learning difficulties, Transient neonatal hypercalcaemia, Supravalvular aortic stenosis

Answer 259

Pierre-Robin syndrome - I think of a small tiny man called Pierre with micrognathia. additionally things in the mouth aren't formed well --> so cleft palate and tongue abnormalities

Answer 260

Proximal aortic dissection An inferior myocardial infarction and AR murmur should raise suspicions of an ascending aorta dissection rather than an inferior myocardial infarction alone. Also the history is more suggestive of a dissection. Other features may include pericardial effusion, carotid dissection and absent subclavian pulse.

Answer 261

CT head immediately GCS < 13 on initial assessment GCS < 15 at 2 hours post-injury suspected open or depressed skull fracture. any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign). post-traumatic seizure. focal neurological deficit. more than 1 episode of vomiting

Answer 262

CT head scan within 8 hours of the head injury - for adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury: age 65 years or older any history of bleeding or clotting disorders dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs) more than 30 minutes' retrograde amnesia of events immediately before the head injury If a patient is on warfarin who have sustained a head injury with no other indications for a CT head scan, perform a CT head scan within 8 hours of the injury.

Answer 263

Nelson's syndrome occurs due to rapid enlargement of a pituitary corticotroph adenoma (ACTH producing adenoma) that occurs after the removal of both adrenal glands (bilateral adrenalectomy) which is an operation used for Cushing's syndrome. Removal of both adrenal glands eliminates the production of cortisol, and the lack of cortisol's negative feedback can allow any pre-existing pituitary adenoma to grow unchecked. Continued growth can cause mass effects due to physical compression of brain tissue. Increased production of adrenocorticotrophic hormone (ACTH) can result in increased melanocyte stimulating hormone (MSH) which can result in hyperpigmentation. Nelson's syndrome is now rare because bilateral adrenalectomy is now only used in extreme circumstances. After bilateral adrenalectom follow-up should include awareness of Nelson's syndrome. Monitoring of ACTH level and pituitary MRI are recommended 3-6 months after surgery and regularly thereafter.

Answer 264

Focal segmental glomerulonephritis

Answer 265

B12/folate: macrocytic anaemias, B12/folate deficiency worsen confusion TFTs: confusion is more commonly seen in hypothyroidism Glucose: hypoglycaemia can commonly cause confusion Bone Profile (Calcium): hypercalcaemia can cause confusion

Answer 266

stop warfarin, give intravenous vitamin K 5mg, prothrombin complex concentrate PCC is a solution containing coagulation factors II, VII, IX and X and is designed to reverse warfarin.

Answer 267

Ebstein's anomaly is a congenital heart defect characterised by low insertion of the tricuspid valve resulting in a large atrium and small ventricle. It is sometimes referred to as 'atrialisation' of the right ventricle. Associations tricuspid incompetence (pan-systolic murmur, giant V waves in JVP) Wolff-Parkinson White syndrome Ebstein's anomaly may be caused by exposure to lithium in-utero

Answer 268

Pellagra is a deficiency of vitamin B3, niacin. Pellagra: Dermatitis, diarrhoea, dementia/delusions, leading to death

Answer 269

raised blood pressure above 160/100 mmHg combined with the significant proteinuria.

Answer 270

A key point for the exam is to appreciate that antiphospholipid syndrome causes a paradoxical rise in the APTT. This is due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with phospholipids involved in the coagulation cascade

Answer 271

The third stage of labour is measured from the birth of the baby to the expulsion of the placenta and membranes. Active management of this stage is recommended in order to reduce post-partum haemorrhage (PPH) and the need for blood transfusion post delivery. Active management lasts less than 30 minutes and involves the following: Uterotonic drugs Deferred clamping and cutting of cord, over 1 minute after delivery but less then 5 minutes Controlled cord traction after signs of placental separation Guidelines suggest the use of 10 IU oxytocin by IM injection to reduce the risk of PPH and for active management of the third stage of labour. This is given after delivery of the anterior shoulder. Ergometrine should not be given in the presence of hypertension. Also oxytocin causes less nausea and vomiting.

Answer 272

According to NICE, the only recommended test for H. pylori post-eradication therapy, is urea breath test. The others are either too invasive, remain positive, or are not sensitive and specific enough.

Answer 273

Cytomegalovirus (CMV) infection is important to consider in renal transplant patients. The 'mixture of cotton-wool spots, infiltrates and haemorrhages' is referring to the characteristic 'pizza-pie' appearance on fundoscopy.

Answer 274

Following a pneumonia, some patients develop a free-flowing exudate (parapneumonic effusion) that may become infected when there is bacterial invasion across the damaged lung epithelium. In the presence of pus, this effusion is termed an empyema, and is characterised as having a pH <7.2, a low glucose (<3.4 mmol/L), and a high LDH (>200 IU/L or 2-3 times above upper limit of normal range for serum).

Answer 275

Following Wells' scoring, if a DVT is 'likely' (> 2 points) then arrange a proximal leg vein ultrasound scan within 4 hours If a scan cannot be arranged within 4 hours she should be given low-molecular weight heparin to 'cover her' until the scan.