Past paper questions Flashcards
1
Q
What will blood results show in a patient with DKA
A
- High blood ketones, acidosis (ph <7.3), hyperglycaemia
- Low bicarbonate - bicarbonate is used up to buffer high amounts of ketone acid (and try keep normal pH).
- Hyperkalaemia prior to tx (as no insulin to drive into cells). When tx of insulin occurs, pt.s can develop severe hypokalaemia quickly.
- Dehydration - high glucose causes polyuria -> loss of water. Creatinine and Urea levels increase (high urea:creatinine ratio), sodium may increase.
2
Q
Drugs known to cause Stephen-Johnson syndrome
A
- Antiepileptics
- NSAIDs
- Antibiotics
- Allopurinol
3
Q
Juvenile myoclonic epilepsy vs benign rolandic epilepsy vs West syndrome
A
A) Teenage years, more common in girls. MYOCLONIC jerks, often in MORNING/SLEEP DEPRIVED. DAYTIME ABSENCES. Tx: Sodium valproate
B) Tonic clonic SEIZURES in SLEEP, or focal seizures with abnormal sensation in
TONGUE/FACE. Childhood.
C) Around 6 MONTHS. CLUSTERS of full body SPASMS. POOR PROGNOSIS. Tx: Prednisolone
4
Q
Complications of chicken pox
A
- Bacterial superinfection
- Dehydration
- Conjunctival lesions
- Pneumonia
- Encephalitis or Cerebellitis
- DIC
5
Q
CSF of bacterial vs viral meningitis
A
Bacterial: Turbid/cloudy, raised neutrophils (a polymorph leukocyte), raised protein, low glucose
Viral: Clear appearance, raised lymphocytes, raised protein, normal glucose
6
Q
Chicken pox rash + Mx
A
- Raised pink or red bumps (papules) in clusters
- Fluid-filled blisters (vesicles)
- Crusts/scabs
Tx: calamine solution. School excl. until all crusted over. immunocompromised patients and newborns with peripartum exposure should receive varicella zoster immunoglobulin (VZIG). If chickenpox develops then IV aciclovir should be considered
7
Q
What is Urticaria + Mx
A
= hives.
- small itchy lumps on the skin -> WHEALS
- caused by MAST CELL degranulation
- ANGIOEDEMA
- antihistamines, prednisolone
8
Q
Cut-offs for GAD and PHQ-9 score
A
- GAD: Scores of 5, 10, and 15 are taken as the cut-off points for mild, moderate and severe anxiety
- PHQ-9: 5, 10, 15, and 20 represent cut-off points for mild (avoid antidep), moderate, moderately severe and severe depression
9
Q
What are the 4 features of a mental capacity assessment
A
A capacity assessment regarding a specific decision involves four features - the ability to understand, weigh-up, retain and communicate the decision made
10
Q
Tests to assess cognition
A
10CS, 6CIT, MIS
11
Q
Monitoring of clozapine vs lithium
A
CLOZAPINE
- Any patient commenced on Clozapine needs to have a minimum of 1 blood test per week for the first 18 weeks.
- This is reduced to fortnightly until 1 year.
- After this monthly blood tests are needed.
LITHIUM
- when checking lithium levels, the sample should be taken 12 hours post-dose
- after starting lithium levels should be performed weekly and after each dose change until concentrations are stable
- once established, lithium blood level should ‘normally’ be checked every 3 months
- thyroid and RENAL FUNCTION (U+E’s, eGFR) should be checked every 6 months
12
Q
Mx if at colposcopy have a low grade or high grade CIN
A
Low grade/1: do not treat -> discharge and screen again in 12 months
High grade: treat (LLETZ) and screen again in 6 months to test for cure
13
Q
RF/Px of Cervical cancer
A
- post-coital/intermenstrual bleeding - brown, foul smelling
- RF: 35-50 years old, smoker, multiple partners
14
Q
Epidemiology of vaginal cancer
A
- Very rare to get primary
- Most common is secondary/metastatic cancer spread from cervix or endometrium
15
Q
What is the order of fetus progression through the birth canal
A
Every Darn Fool In Egypt Eats Raw Eggs
Engagement, Descent, Flexion, Internal rotation, Extension, External rotation, Expulsion
16
Q
Investigations for asymptomatic bateriuria in pregnancy
A
- Dipstick testing is not sufficient. Instead urine culture is 1st line.
- Pregnant women are tested for asymptomatic bacteriuria at booking and routinely throughout pregnancy.
- In contrast with symptomatic bacteriuria, the presence of asymptomatic bacteriuria should be confirmed by two consecutive urine samples
- Treat with a 7-DAY course of ABX in line with sensitivity results. Alternative
antibiotics should be used in women who are allergic to Penicillin: Amoxicillin, Nitrofurontin, Trimethoprim, Cefalexin
17
Q
Diagnostics of polyhydramnios vs oligohydramnios
A
Polyhydramnios is usually diagnosed at an AFI of >24cm (or 2000ml+). Oligohydramnios is usually
diagnosed with an AFI of <5cm (or under 200ml).
18
Q
Horners syndrome + causes
A
- triad of ptosis (drooping eyelid), anhidrosis (lack of sweating) and miosis (constricted pupil) on the ipsilateral side
- Lesion of sympathetic chain: multiple sclerosis, brain tumours, trauma, Pancoast tumours (apical lung cancer), thyroid/goitre
19
Q
Triggers of migraine
A
- CHOCOLATE- Chocolate, hangover, orgasm, cheese, oral
contraceptive, lie in, alcohol, tumult, exercise. - Other triggers include periods, injury, certain sensory triggers (e.g. bright lights, loud noises, certain smells, etc.), being hungry, smoking,
20
Q
Mechanism of action of parkinson’s drugs + Tx (QOL!!)
A
- Levodopa (if QOL affected): replaces dopamine in brain
- Dopamine agonist (QOL not affected): mimic action of dopamine
- MAOB inhibitors
21
Q
Role of metformin in PCOS
A
- Appetite reduction
- Decreases androgen production
- Increases sex-hormone binding globulin in the liver
- Decreases serum lipids
22
Q
RF’s for oral candidasis
A
- Inhaled corticosteroids (particularly with poor technique, not USING A SPACER and not RINSING WITH WATER AFTERWARDS)
- Antibiotics (disrupt the normal bacterial flora giving candida a chance to thrive)
- Diabetes
- Immunodeficiency (consider HIV)
- Smoking
23
Q
How to calculate maintenance fluid paeds
A
100 ml/kg/day for the first 10kg of weight
50 ml/kg/day for the next 10kg of weight
20 ml/kg/day for weight over 20kg
- Then /24 to get hourly infusion rate.
24
Q
Calculate replacement fluids (dehydration) paeds
A
Fluid deficit = % dehydration x weight (kg) x 10
e.g. 5 x 20kg x 10 = 1000ml deficit.
(subtract bolus if is one)
25
Signs of cushings syndrome and causes
Px: Round in the middle with thin limbs: Round “moon” face, Central Obesity, Abdominal striae, Buffalo Hump (fat pad on upper back), Proximal limb muscle wasting
Causes:
- Exogenous steroids (in patients on long term high dose steroid medications)
- Cushing’s Disease (a pituitary adenoma - + acth + cortisol)
- Adrenal Adenoma (a hormone secreting adrenal tumour)
- Paraneoplastic Cushing’s - ectopic ACTH -> small cell lung cancer
Dx: Dexamethosone suppression test - dexamethasone suppresses release of cortisol (via hypothalamus + pituitary = if ACTH and cortisol suppressed = Cushings/Pituitary adenoma)
26
Features, causes, Mx of hyperaldosteronism
- hypertension
- Muscle weakness
- hypokalaemia + hypernatremia
- metabolic alkalosis
- Causes: Bilateral adrenal hyperplasia (most common). An adrenal adenoma secreting aldosterone (known as Conn’s Syndrome)
- Tx: Spironolactone (aldosterone antagonist), Treat the underlying cause - Surgical removal of adenoma.
27
Ix for hyperaldosteronism
High aldosterone and low renin indicates primary hyperaldosteronism
High aldosterone and high renin indicates secondary hyperaldosteronism
28
Diagnosis of AKI and drugs known to worsen
Diagnostic criteria:
Stage 1 = 1.5x Creatinine OR Urine output <0.5ml 6hrs
Stage 2 = 2x Creatinine OR Urine output " 12 hrs
Stage 3 = 3x Creatinine OR Urine output <0.3ml for 24+hrs
Drugs known to worsen:
* NSAIDs (except if aspirin at cardiac dose e.g. 75mg od)
* Aminoglycosides
* ACE inhibitors
* Angiotensin II receptor antagonists
* Diuretics
29
Peptic ulcer px and Mx
- gastric ulcer: pain IMMEDIATELY after eating
- duodenal ulcers: relieved by food, pain a short while after eating
- Causes: Medications (e.g. steroids or NSAIDs), Helicobacter pylori
- Tx: PPI + 2 antibiotics. Lifestyle - stop smoking, caffeine, alcohol
30
Staging of CKD
G1 = eGFR >90
G2 = eGFR 60-89
G3a = eGFR 45-59
G3b = eGFR 30-44
G4 = eGFR 15-29
G5 = eGFR <15 (known as “end-stage renal failure”)
31
Ix/Tx of status epilecticus
ABC - airway adjunct, oxygen, CHECK BLOOD GLUCOSE - rule out hypoxia/hypoglycaemia
- First-line drugs are IV benzodiazepines such as diazepam or lorazepam
-> in the prehospital setting PR diazepam or buccal midazolam may be given
-> in hospital IV lorazepam is generally used. This may be repeated once after 10-20 minutes
- If ongoing: phenytoin or phenobarbital infusion
- If no response ('refractory status') within 45 minutes from onset, then the best way to achieve rapid control of seizure activity is induction of general anaesthesia.
32
Tx of COPD
Features of steroid responsive (asthmatic features/atopic illness/variation in FEV1):
● Step 1: SABA (salbutamol) or SAMA (ipratropium)
● Step 2: SABA + LABA (salmetarol) + ICS (beclametasone) (if they were originally on SAMA, discontinue and start SABA)
● Step 3: SABA + LABA + ICS + LAMA
No features of steroid responsiveness (no asthmatic features/no atopic illness/no variation in FEV1)
● Step 1: SABA or SAMA
● Step 2: SABA + LABA + LAMA (if they were originally on SAMA, discontinue and start SABA)
33
What is congenital adrenal hyperplasia caused by and what are the presentations and tx?
- congenital deficiency of the 21-hydroxylase enzyme. This causes underproduction of cortisol and aldosterone and overproduction of androgens from birth.
Severe cases:
- hyponatremia, hyperkalaemia, metabolic acidosis, hypoglycaemia shortly after birth (salt losing adrenal crisis) -> vomiting, dehydration, loss of conscious
- virilised/ambigious genitalia and an enlarged clitoris
Mild cases:
during childhood or after puberty. Their symptoms tend to be related to high androgen levels.
- Female patients: tall, facial hair, amenorrhea, early puberty
- Male: tall, large penis, small testicles, early puberty
- SKIN HYPERPIGMENTATION
Tx: Cortisol replacement, usually with hydrocortisone, similar to treatment for adrenal insufficiency
Aldosterone replacement, usually with fludrocortisone
34
Lymphoma: Causes, Presentation, Ix, Dx
-RF: HIV, EBV, AI, FH
- Px: Lymphadenopathy - non-tender, “rubbery”. Pain with alcohol.
B symptoms: Fever, Weight loss, Night sweats
- Ix: LDH raised, Lymph node biopsy: diagnostic test -> Reed Sternberg = Hodgkins Lymphoma. CT, MRI and PET scans
35
Staging of Lymphoma
Stage 1: Confined to one region of lymph nodes.
Stage 2: In more than one region but on the same side of the diaphragm (either above or below).
Stage 3: Affects lymph nodes both above and below the diaphragm.
Stage 4: Widespread involvement including non-lymphatic organs such as the lungs or liver.
36
What is pericarditis px and mx
chest pain: may be pleuritic. Is often relieved by sitting forwards
pericardial rub
tachypnoea
tachycardia
Tx: NSAIDs. Colchichine may be given
37
Features of hyperthyroidism + thyroid storm
- Sweating/heat intolerance
- Weight loss
- Exophthalmos/bulging eyes (graves)
- Anxiety
- Tremor
- Increased heart rate
- Need toilet (diarrhoea)
- Goitre (graves - diffuse w/out nodules)
- Tx: carbimazole, propylthiouracil
Thyroid storm -> severe tachycardia, pyrexia, agitation + confusion, delirium. Tx: beta blockers
38
Gout vs Pseudogout
Gout -> high purine intake (meat and seafood), alcohol
-> big toe, base of thumb
-> Negative birefringent crystals
Tx: Allopurinol/Febuxostate. Colchichine - acute attacks.
Pseudogout - calcium pyrophosphate crystals
-> hot, swollen, painful knee
-> positive birefringent crystals
39
Px, Mx, Complications of Nephrotic syndrome
- Proteinuria, Low serum albumin, Oedema -> most commonly caused by MCD
- Mx: High dose steroid/prednisolone
- Complications: Frequent relapses, Hypovolemia - oedema, pleural effusion, Infection (leak Immunoglob), Thrombosis (factors that usually prevent clotting lost), acute or chronic renal failure, hyperlipidaemia
40
Tx of GORD
- Small, frequent meals, Burping regularly to help milk settle, Not over-feeding, Keep the baby upright after feeding (i.e. not lying flat)
- Gaviscon mixed with feeds
- Thickened milk or formula (specific anti-reflux formulas are available)
- Proton pump inhibitors (e.g., omeprazole)
- Ranitidine (H2 receptor antagonist)
41
Mx of tonsilitis
FEVERPAIN (1 point for each)
Fever during previous 24 hours
P – Purulence (pus on tonsils)
A – Attended within 3 days of the onset of symptoms
I – Inflamed tonsils (severely inflamed)
N – No cough or coryza
CENTOR SCORE (1 point for each)
Fever over 38ºC
Tonsillar exudates
Absence of cough
Tender anterior cervical lymph nodes (lymphadenopathy)
Mx:
- Abx if Centor score ≥ 3 or FeverPAIN score ≥ 4 OR young infants, immunocompromised patients, significant co-morbidity, or rheumatic fever.
- Consider delayed prescription if 2/3 FeverPAIN score
- Penicillin V (phenoxymethylpenicillin) for a 10 day course
42
Birth abnormalities
- Port wine stain (naevus flammeus): present from birth and usually grows with the infant. Vascular malformation of the capillaries in the dermis. Tx: laser therapy
- Strawberry naevus (cavernous haemangioma): Often not present at birth, but appear in first month of life. No tx indicated unless interferes with vision or airway.
- Mongolian blue spots: blue/black macular discoloration at base of spine and on buttocks. More common in Afrocaribbean or Asian infants. Can be misdiagnosed as bruises.
- Positional talipes: feet remain in their inutero position. Unlike true talipes equinovarus, the foot can be fully dorsiflexed to touch the front of the lower leg
43
Mx of constipation
If faecal impaction: Escalating dose
Macrogol laxative -> Movicol (polyethylene glycol)
+ Stimulant/Senna
+ Lactulose/Osmotic
If no faecal impaction:
Same but adjustments to starting dose
44
Px, Mx of Otitis media
- Otalgia, bulging + erythematous tympanic membrane (loss of light reflex),
+/- perforated ear drum
- Mx: Does not require Abx, unless: younger than 2 with bilateral, otitis media w/perforation, Sx 4+ days, Immunocompromise, systemically unwell
= amoxicillin 5-7 days
45
Px, Mx of Glue ear (Otitis media with effusion)
- Reduction in hearing
- Dull tympanic membrane with air bubbles
- Mx: audiometry, usually resolves w/out tx within 3 months. Grommets if co-morbidities or chronic.
46
Tx of alcohol withdrawal
- If have withdrawal sx/delirium tremens -> chlordiazepoxide
- IV thiamine - to prevent/if have wernicke's enchelopathy
47
Withdrawal Sx of cocaine
- Increased hunger and cravings
- Anxiety
- Fatigue
- Irritability
- Lack of motivation
48
What is Kleinhauer test used for
- Used to detect amt of fetal haemoglobin in the mothers bloodstream. In Rh- mothers to determine the correct amount of anti-D has been given following a potentially sensitising event.
49
How long is contraception required in premenopausal women
- Use contraception for 2 years after last period if under 50
- 1 year after last period if over 50
- Still need contraception when taking hRT - cant use COCP. Use IUS/IUD/Progesterone implant/POP
50
Causes of hydrops fetalis
- fluid in fetal serous cavities e.g. ascites, pleural and pericardial effusions
- Severe anaemia: b19 infection, alpha thalassaemia major, massive materno-feto haemorrhage
- Immune: blood group incompatibility
- Chorioangioma
- Trisomy 13, 18, 21, or Turners
- Infection - CMV, toxoplasm, rubella
- Twin-twin trasnfusion syndrome
- Cardiac abnormalities
51
RF's for obstetric cholestasis
- Hepatitis C
- Multiple pregnancy
- Prev.
- Presence of gallstones
52
When is ECV indicated
- 36 weeks in nulliparous women
- 37 weeks in multiparous women
53
What are static risk factors vs dynamic risk factors for suicide
- Static -> not something can intervene
e.g. race, history of childhood abuse, previous attempt of self harm
- Dynamic -> use of illicit substances, financial problems, relationship problems
54
What is a QRISK score
Risk of developing a heart attack or stroke in next 10 years
55
Error of inheriting thinking vs
error due to failure to consider alternative vs
error of bravado vs
error of ignorance vs
error of overattachment
- 1. working diagnosis is handed over and accepted w/out pause for consideration
- 2. one abnormality is found that fits a particular diagnosis so stop looking for alternatives
- 3. working above competence in a show of overconfidence that is not safe
- 4. Unconscious incompetence
- 5. Conducting tests to confirm what we expect or want to and ruling out other causes
56
Seedhouse's ethical grid
Core rationale - core principles of health care (autonomy/equality), deontological layer - duties or moral obligations (beneficence, minimise harm), consequential layer, external considerations
57
four quadrants ethical framework
1. Medical indications (beneficience) - dx/tx options
2. Patient preferences (respect for autonomy)
3. QOL - improve or address QOL
4. Contextual features - loyalty and fairness
58
Ix and Tx for Guillain Barre and Myasthenia Gravis
Guillain Barre
Ix: LP -> rise in protein with a normal white blood cell count, Nerve conduction studies (decreased motor nerve conduction velocity)
Tx: IV immunoglobulins to block autoantibody action and stop progression of weakness and sensory loss. Plasma exchange if Sx rapidly progressing.
Myasthenia Gravis:
Ix: Electromyography, antibodies to acetylcholine receptors
Tx: Pyridostigmine (acetylcholinesterase inhibitors) (1st)
Immunosupresion, thymectomy (if thymoma causing)
59
Types of paediatric squint and causes
- Squint = Strabismus = Misalignment of eyes - double vision
- Esotropia/Convergent squint = inward positioned squint. Most common squint. (e.g. hypermetropia/longsightedness).
- Exotropia/Divergent squint = outward positioned squint
- Hypertropia/Hypotropia = upward moving affected eye/downward moving affecting eye
60
What is hyperparathyroidism
- Sx: renal stones, painful bones, abdominal groans (constipation, n+v) and psychiatric moans (fatigue, depression and psychosis)
- Primary -> pth produced by parathyroid gland tumour. Leads to hypercalcaemia - surgery.
- Secondary -> low/normal calcium, pth high. (chronic renal failure or insufficient vit.D
61
Rheumatoid vs Osteoarthritis
Rheumatoid arthritis
Presentation:
- symmetrical distal polyarthropathy: pain + stiffness in small joints of hands and feet, knees, shoulders + elbows.
- Pain is worse after rest/in morning but improves with activity.
Signs:
- Z shaped deformity of thumb, swan neck deformity, boutonnieres, ulnar deviation
XRAY: Loss of joint space, Erosions, Soft tissue swelling, Soft bones (osteopenia)
Tx: NSAIDs (+PPI), DMARD (methotrexate), Biologics (TNFi - infliximab)
Osteoarthritis
Px:
- asymmetrical Joint pain and stiffness affecting hips, knees, DIPs, PIPs, wrists.
- Stiffness worse in morning but wears off within 30 minutes of getting up. P+S worsened by activity throughout the day.
Signs:
- Heberden nodes (in DIP joints), Bouchards nodes (in PIP joints)
XRAY: Loss of joints space, Osteophytes, Subchondral sclerosis, Subchondral cysts
Tx: Paracetamol/NSAIDs (+PPI), Opiates, Steroid injections, Joint replacement
62
Extra renal manifestations of Polycystic Kidney disease
MLB
Mitral Valve prolapse, Mid systolic click
Liver polycystic disease
Berry aneursyms/SAH
and Colonic Diverticula
63
First rank Sx of schizophrenia
A= Auditory hallucinations: second or third person
B= Broadcasting, insertion, withdrawal of thoughts (delusions of thought interfereance)
C= Controlled feelings, actions or impulse passivity phenomenon or delusion of control
D= Delusional perception
64
Tx of types of epilepsy
Generalised tonic-clonic seizures
males: sodium valproate
females: lamotrigine or levetiracetam
girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children or women who are unable to have children may be offered sodium valproate first-line
Focal seizures
first line: lamotrigine or levetiracetam
second line: carbamazepine, oxcarbazepine or zonisamide
Absence seizures (Petit mal)
first line: ethosuximide
second line:
male: sodium valproate
female: lamotrigine or levetiracetam
carbamazepine may exacerbate absence seizures
Myoclonic seizures
males: sodium valproate
females: levetiracetam
Tonic or atonic seizures
males: sodium valproate
females: lamotrigine
65
Features and Mx of ADHD
- Methylphenidate/Lisdexamfetamine
(metal fence at music festival, Queen Lis on the decks)
- 1) Answers questions prematurely, interrupts
2) Always on the go
3) Losing important things, forgetful
4) Cannot play quietly
5) Reluctant to engage in mentally-intense tasks
66
Mx of paediatric inguinal hernia
- If strangulated need operate urgently
- children presenting in first few months of life at high risk, urgent operation
- Children presenting over 1 at lower risk and surgery may be performed electively.
67
Life threatening signs of asthma and Mx of acute attacks
- PEF <33, SpO2 <92%, Cyanosis, Hypertension, Exhaustion, Silent chest, Tachycardia
- OSHITME
1st: Oxygen, inhaled or nebulised SABA, Hydrocortisone/prednisolone, Ipratropium bromide
2nd: Theophylline, Magnesium Sulphate, Escalate
68
Mx of asthma in Children + adults
SABA
SABA + ICS
SABA + ICS + LTRA (montelukast)
SABA + ICS + LABA (stop LTRA - in adults keep LTRA)
(reference: COPD
SABA or SAMA
SABA + LABA + ICS
SABA + LABA + ICS + LAMA.
If steroid unresponsive - no asthmatic features/FEV stable - omit ICS)
69
Mx of undescended testis + complications
- Unilateral -> If 3+ months then refer baby to see urological surgeon before 6 months.
-> Usually Orchidopexy performed at 1 year of age
- Bilateral -> reviewed within 24hrs as child may need urgent genetic or endocrine investigation
- Compl: infertility, torsion, testicular cancer, psychological
70
Mx of paediatric gastroenteritis
- Main concern is dehydration and potential for shock
- Dry mucous membranes, thirsty, lightheaded = dehydration
- If no signs of shock (lowered conscious, mottle skin, capil refill) then oral rehydration solution sachets
- If signs of shock then hospital IV fluids
71
Mx of delirium
- Underlying cause
ALWAYS START LEAST RESTRICTIVE
- Verbal de-escalation techniques
- orientation, reassurance and quiet environment
- Haloperidol PO
- Haloperidol IV
- If parkinson's/lewy body: Lorazepam
72
Assisted withdrawal from alcohol
- Inpatient assisted withdrawal with chlordiazepoxide
- parenteral thiamine -> oral thiamine (to prevent wenicke-korsakoff)
73
Main type of hallucination in Delirium tremens
- Visual hallucinations of frightening things
- Auditory hallucinations
74
Types of perineal tear
- First degree tear – perineal skin only
- Second degree tear – fascia and muscles of perineum
- Third degree (A) tear – fascia and muscles of perineum, and <50% of external anal sphincter involved
- Third degree (B) tear – fascia and muscles of perineum, and >50% of external anal sphincter involved
- Third degree (C) tear – fascia and muscles of perineum, and both external and internal anal sphincters
involved
- Fourth degree tear – both external and internal anal sphincters completely torn, and anal epithelium
involved
75
Diagnosis of preterm labour: cervical length and tx options
- A cervical length of less than 25cm before 24 weeks indicates preterm labour:
Use prophylaxis:
- vaginal progesterone -> prevents labour by stopping cervix remodelling
- Cervical cerclage -> stitch in the cervix to add support and keep it closed. This involves a spinal or general anaesthetic. The stitch is removed when the woman goes into labour or reaches term. Used if previous premature birth or cervical trauma (e.g. colposcopy and cone biopsy).
Dx:
< 30 weeks gestation = clinical assessment
> 30 weeks gestation = TVUS can be used to assess the cervical length. A cervical length of less than 15mm indicates preterm labour is likely.
- Fetal fibronectin is alternative. Positive result indicates preterm labour is likely
Tx:
- Tocolysis - Nifedipine/Atosiban can be used between 24 and 33 + 6 weeks gestation in preterm labour to delay delivery and buy time for further fetal development, administration of maternal steroids or transfer to a more specialist unit. Used only short term (<48hrs)
- Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality
- IV magnesium sulphate: can be given before 34 weeks gestation and helps protect the baby’s brain
76
When should take a blood test for infertility
progesterone - 7 days post ovulation
Investigations for infertility are not usually recommended until the couple has been unable to conceive after 1 year of regular unprotected sexual intercourse
77
Causes of Secondary amenorrhea: blood results in hypothalamic/pituitary pathology
Panhypopituitarism:
- Low LH, FSH, Oestradiol (low oestrogen should cause increase in LH/FSH)
- Low T4, Low/normal TSH (low T4 should cause increase in TSH)
78
Causes of Secondary amenorrhea: blood results in hyper/hypothyroidism
- Raise TSH and low T3 and T4 indicate hypothyroidism
- Low TSH and raised T3 and T4 indicate hyperthyroidism
79
Causes of Secondary amenorrhea: blood results in PCOS and Premature menopause
- High LH, or LH:FSH ratio, raised testosterone suggests polycystic ovarian syndrome (+ acne, hirsutism, overweight)
- High FSH, low oestradiol indicates primary ovarian failure
80
Likely diagnosis of a 15 year-old school girl presenting with cyclical pelvic pain, who hasnt started menstruating
- Haematocolpos -> – an accumulation of the blood in the vagina, usually due
to an imperforate hymen.
- Menses sealed in vagina -> Tx surgical incision
- complication: retrograde menstruation could occur leading to endometriosis.
81
Investigations of heart failure in GP setting and in hospital
- NT-proBNP in General Practice
High (2000+): urgent specialist referral for echocardiogram (within 2 weeks)
Raised (400+): specialist referral for echocardiogram within 6 weeks
Normal: consider alternative diagnoses
- 12-lead ECG or Troponin measurement can be performed to exclude other cardiac conditions if there is
an atypical presentation
- Echocardiogram diagnosis in hospital - ejection fraction below 40%
82
Man presents to GP with low mood and fatigue - what is the management
1/ Ask him to fill out PHQ-9 questionnaire (screening tool for depression in primary care)
- OR Fill out Hospital Anxiety and Depression scale (HADS) - in both community and hospital settings
2/ An FBC and thyroid function tests would be useful to explore alternaitve diagnoses if patient scored low on PHQ-9
83
Man presents to GP with history of nausea and severe anxiety, sweating and tremor. Partner threatened to leave him if doesnt sort out drinking problem. What is management?
1/ Assess his AUDIT score or CAGE score - help decide whether he has been abusing alcohol and whether he can managed in community or admitted to hospital
2/ medication:
oral thiamine if their diet may be deficient
benzodiazepines for acute withdrawal
disulfiram promotes abstinence
acamprosate reduces craving
84
ICP headache - 3rd and 4th ventricles are normal in size. Dilatation of both lateral ventricles. Her condition is most likely due to a occlusion of which structures?
- CSF flows: Lateral ventricles -> foramina of monro -> third ventricle -> cerebral aqueduct -> fourth ventricle -> foramina of Luschka + Magendie -> subarachnoid space
- Arachnoid granulations are specialised valves that absorb the CSF into venous sinuses and not involved in such pathology.
(LIQUID INSIDE THE CEREBRUM FLOWS AROUND SUBARACHNOID SPACE
Lateral ventricles -> interventricular foarmina (Monro) -> Third -> Cerebral aqueduct -> Fourth -> Apertures (Luschka + Magendie) -> Subarachnoid -> Sinuses (Dural venous))
85
What is the GCS
E4
Eyes - spontaneously, verbal command, pain, none
V05
Verbal - orientated, confused, inapprop words, sounds, none
M6
Motor -
6 - obeys commands,
5- localises pain (grabbing hand away),
4- withdraws from pain/flexes (trying to localise but failing - doesnt cross midline),
3- abnormal flexion to pain (decorticate posturing - flex arms like a trex), 2- extends to pain,
1- no response
86
PBC vs PSC
PBC - WOMEN
- Px: Fatigue, Pruritis, Jaundice, Xanthoma (yellow fat lesions)
- Other AI conditions e.g. thyroid, coeliac
- Dx: ALP, Anti-mitochondrial Ab, Anti nuclear antibodies
- Tx: Ursodeoxycholic aacid
PSC - More MEN
- Px:Fatigue, Pruritus, Jaundice, RUQ pain, Hepatomegaly
- Link with Ulcerative Colitis
- Dx: M/ERCP (MRI)
87
Ulcerative Colitis vs Crohns
Ulcerative Colitis (CLOSEUP)
Contin., Limited to colon and rectum, Only superficial mucosa, Smoking protective, Excrete blood+mucus, Use aminosalicylates, PSC
Tx: Flare-ups -> Severe (steroids), Mild (aminosa)
Maintaining remission -> Aminosa e.g.
mesalazine
Crohns (NEST)
No blood or mucus, Entire GI tract, Skip lesions, Terminal ileum/transmural, Smoking RF. Strictures+Fistulas
Tx: Flare-ups -> Steroids.
Maintaining remission -> Azathioprine
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Acrogmegaly
Px: Large nose, hands and feet, jaw, bitemporal hemianopia
Ix: Oral glucose tolerance test is diagnostic
Insulin-like growth factor 1 is inital screening
Tx: Trans-sphenoidal removal of pituitary tumour
89
Order of puberty in females and males
Females: Boobs-11, Pubes, Grow-12, Flow-13
Boys: Grapes- 12(testicles), drapes (hair), grow- 14, blow (ejaculation)
90
Screening for DDH factors and Imaging used
- multi pregnancy, breech after 36 weeks, first degree relatives
- <4.5 months = US
- >4.5 months = XRAY
91
Thyroglossal cyst vs thyroid goitre
Thyroglossal cysts move with the movements of the tongue, whereas swellings that represent thyroid gland enlargement move with swallowing.
92
Contraindications to vaginal birth after caesarean
- Absolute contraindication in patients with previous vertical (classical) caesarean scars,
previous episodes of uterine trauma,
patients with other contraindications to vaginal birth (e.g. placenta praevia)
93
A 9-year-old boy is brought in accompanied by his parents due to concerns about knee pain and a limp.
On examination, there is a marked reduction in internal rotation on the right side when the leg is flexed. There is no tenderness over the knee.
SUFE -> hip, thigh, knee pain. LOSS OF INTERNAL ROTATION OF THE LEG IN FLEXION.
94
First line agents for neuropathic pain
Dont Get Pain Again
Duloxetine, Gabapentin, Pregabalin, Amitryptiline
95
Alzheimers drug classifications
- Donepezil, Rivastigmine, galantamine = acetylcholinesterase inhibitors
- Memantine = NMDA receptor antagonist
96
Px and Tx of transient tachypnoea of the newborn
- Following caesarean sections
- CXR: hyperinflation of lungs
- Mx: Observation, supportive care
-> supplementary O2 if O2 sats low
97
Causes of recurrent miscarriage
- antiphospholipid syndrome
- endocrine disorders
- uterine abnormality
- smoking
- parental chromosomal abnormalities
98
Fetal alcohol syndrome
- Microcephaly
- Short palpebral fissure
- cardiac malformations
- epicanthic folds
- thin upper lip
99
Conditions associated with hypospadias
cryptorchidism + inguinal hernia
100
Schizophrenia 1st rank symptoms
Auditory hallucinations, Broadcasting/Insertion/Withdrawal
Controlled by someone else
Delsional perceptions
101
Mx of DKA in children
- IV fluid replacement
- IV insulin infusion
- Potassium
- Oral fluids
- children/young adults are particularly vulnerable to cerebral oedema following fluid resuscitation in DKA
- DO NOT GIVE SODIUM BICARBONATE ROUTINELY
102
Common side effects of topical corticosteroids
- Acne -> sebaceuos gland susceptible to inflammation and infection
- Striae
- Telangiectasia (dilated/broken blood vessels near surface of skin)
- Thinning of skin
103
Histological appearance of coeliac vs IBD
- Coeliac: villous atrophy, crypt hyperplasia, intraepithelial lymphocytes
- Crohns: granulomas, cobblestone appearance on endoscopy, fistula
- Ulcerative Colitis: pseudopolyps, crypt absecces
104
What is failure to thrive
= Less than expected growth over time during the first three years of life
1) Inadequate intake -> e.g. maternal depression + socio-economic background, IDA
2) Inadequate retention/difficulty feeding -> vomiting or severe GORD, cerebral palsy (poor suck), cleft lip
3) Malabsorption -> e.g. Coeliac, CF, cows milk
4) Increased requirements -> hyperthyroidism, congenital heart failure, malignancy
105
What is toddlers diarrhoea
- most children will ‘grow out’ of their
symptoms by age 5. - The loose stools are likely due to increased intestinal motility and not related to
malabsorption.
- Therefore, children with toddler’s diarrhoea tend to have normal growth and
development.
- Tx: diet -> fat, little fruit juice/squash, normal fibre
106
Gastroschisis vs Omphalocele
Gastroschisis describes a congenital defect in the anterior abdominal wall just lateral to the umbilical cord.
Mx:
- vaginal delivery may be attempted
- newborns should go to theatre as soon as possible after delivery, e.g. within 4 hours
Exomphalos/omphalocoele
- the abdominal contents protrude through the anterior abdominal wall but are covered in an amniotic sac formed by amniotic membrane and peritoneum.
Mx:
C-section
Staged repair
107
Mx of alcohol problem drinking
- benzodiazepines for acute withdrawal
- disulfram: promotes abstinence - alcohol intake causes severe reaction due to inhibition of acetaldehyde dehydrogenase. Contraindications include ischaemic heart disease and psychosis
- acamprosate: reduces craving, known to be a weak antagonist of NMDA receptors, improves abstinence in placebo controlled trials
108
Use of Mirtazapine
- Mirtazapine has fewer side effects and interactions than many other antidepressants and so is useful in older people who may be affected more or be taking other medications.
- Two side effects of mirtazapine, sedation and an increased appetite, can be beneficial in older people that are suffering from insomnia and poor appetite.
109
Absolute contraindication + indications for ECT
- Only 1 absolute -> raised ICP
- Indications: severe depression refractory to medication, catatonia, psychotic symptoms
110
Types of Catatonia and causes
- Akinetic: not responding to environment. Sit or lie in unusual position.
- Excited catatonia: Moves around but movement pointless and impulsive. Agitate, combative or delirious, mimic movements
- Malignant catatonia: Sx lead to other health problems like changes in blood pressure, body temp.
Causes: mood disorders, psychotic disorders, depression, bipolar disorder, schizophrenia
Tx: Benzo's, ECT
111
Cause/features of Neuroleptic malignant syndrome
- Antipyschotics -> most commonly typical but also clozapine
- FEVER
-> fever, encephalopathy, vital signs (increased HR, Temp, RR), elevated enzymes (creatinine kinase), Rigidity (lead pipe)
112
Thyroid function tests in hyperemesis + Mx
- Hyperthyroidism, obesity, multiple pregnancy, trophoblastic disease, nulliparity all associated with disease.
- TFTs not helpful for diagnosis often abnormal in women with condition -> shouldnt be treated for it
- Mx: Cyclizine/Promethazine,
2nd: Ondanestron (small risk of cleft lip, Metroclopramide (dont use for 5+ days as it has EPSE's)
113
Sodium valproate effects on pregnancy
- 1) hypospadias
- 2)Spina bifida
- 3) ASD
- 4) Cleft palate
- 5) Polydactyl
114
What is Marfan syndrome
- Autosomal dominant condition -> gene responsible for creating fibrillin
-> tall, hypermobility, long fingers
- Associated with mitral valve prolapse or aortic valve prolapse
115
When to consider medical or surgical Mx of miscarriage
- If after 14+ days of expectant
- woman at increased risk of haemorrhage e.g. late in first trimester
- had previous trauma in preg e.g. stillbirth, miscarriage, APH
- Increased risk of effects of haemorrhage (coagulopathies)
- evidence of infection
116
Mx pathway for ovarian cancer
- measure CA125
- If raised -> pelvic abdo US
- If RMI: CA125, US and Menopausal status indicates -> CT abdo pelvis
117
Pt w/ dysuria and purulent discharge -> treat before test results are availble. Use what?
Azithromycin -> used for both tx of gonorrhoea and chlamydia.
(Dox. used after positive NAAT for chlamydia)
118
Scoring tests for dementia
- GP/Non-specialist: 10-CS (8+ normal) , 6CIT (0-7 normal)
- Abbreviated mental test (8+), MMSE (25+/30 normal)
119
Guidelines regarding taking alendronic acid
- Bisphosphate taken PO
- Must be taken while standing/sitting upright for atleast 30 minutes
- SHould be taken before breakfast and on an empty stomach
120
Mx of gallstones
- Asymptom: conservatively
- Symtom: cholecystectomy
121
LFT's
- Increased AST, ALT, AST/ALT ratio of 2:1 = sign of alcoholic liver disease
- Predominant increased ALP = cholestatic
- Isolated increase in bilirubin = gilberts
122
Px of acute bacterial prostatitis
- E.coli
- DRE: tender, boggy, prostate gland
- Obstructive voiding symptoms
- Tx: 14 day course of quinolone
123
Common patterns of inheritance conditions
- Autosomal dominant: huntington, marfan
- Autosomal recessive: cystic fibrosis, sickle cell, Thalassaemia
- X-linked dominant: fragile X -> If affected dad (X'Y) = Cant have affected son (XY), has to have affected daughter (X'X). Affected Mum = 50/50
- X-linked recessive: Haemophilia -> affected dad (X'Y) = cant have affected son or daughter (XX'). Affected/carrier mother -> can give it to son or daughter (carrier/affected)
124
Drugs used in HTN
- ACEi = ramipril
- Ca2+ = amlodopine
- Thiazide-like diuretic = Indapamide or Metalozone
- Potassium sparing (<4.5) = Spironolactone
- >4.5 = Alpha-blocker = Doxazosin OR Beta blocker
125
Causes of otitis externa and Px
- infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal
- seborrhoeic dermatitis (scalp)
- contact dermatitis (allergic and irritant)
- recent swimming is a common trigger of otitis externa
Px: ear pain, itch, discharge
otoscopy: red, swollen, or eczematous canal
Mx: topical antibiotic or a combined topical antibiotic with a steroid
126
How to work out units
= Strength (ABV) x Volume (ml) / 1000
e.g. 9% x 750 (ml) / 1000 = 6.75 units
127
Types of Hypothyroidism
Primary hypothyroidism (thyroid gland) - TSH high, T3/4 low
- Hashimoto's thyroiditis -> anti-TPO and antithyroglobulin
-> most common cause in developed
- Iodine deficiency -> most common cause in developing
- LITHIUM
Secondary hypothyroidism (pituitary gland) - TSH low, T3/4 low
-> tumours, infection, vascular (Sheehan)
tx: levothyroxine
128
Metabolic alkalosis with full compensation vs partial compensation
- pH raised (alkalosis), bicarb raised (metabolic)
- carbon dioxide elevated (compensating but pH still alkalotic so not fully, if pH normal = fully compensated)
129
Length of UTI tx in men and women
- Men - 7 days abx
- Women - 3 days abx, pregnant women - 7 days
- Children 3 days abx
130
What is definition of sensitivity and specificity
- Sensitivity = number of people test correctly identifies as having the disease
- Specificity = relates to the test's ability to correctly reject/exclude healthy patients without a condition.
131
What is Hoover's sign
When examining the patient lying down, place hand under their right leg and ask them to raise their left leg and feel pressure against hand.
132
Features of fronto-temporal dementia
- Onset before 65
- Insidious onset
- Relatively preserved memory and visuospatial skills
- Personality change and social conduct problems
133
A 30-year-old male has been referred for
a home visit. He has no previous psychiatric history. He has not been eating or drinking for days
now. During the consultation, he is apathetic and describes the sensation of feeling as if his internal organs are rotting away. He is not actively against seeking help.
Which section would be most appropriate in this patient?
Section 2 -> no psychiatric history so a section for assessment would be most appropriate, he is in the community and is NOT RESISTANT so the POLICE SECTIONS would not be appropriate
134
Rate control in AF
1. Beta blocker
2. CCB
3. Digoxin
135
Maxwell's 6 dimensions of quality in health care
Accessibility, Equity, Appropriateness, Effectiveness, Efficiency and Social acceptability
136
What type of prevention is breast cancer screening classed as?
Secondary prevention -> (already got the disease) screening catches early before chronic effects
137
Mx of a 78 year old female on prednisolone (steroids)
Start alendronic acid with a 65+ year old on long term steroids even without a DEXA scan
138
Mx of SAH
- Surgical intervention - coiling, clipping
- NIMODIPINE (CCB) used to prevent VASOSPASM. (complication that can result in brain ischaemia following a SAH).
139
What is Rhabdomyolysis
- Skeletal muscle tissue breaks down and releases breakdown products into blood.
-> prolonged immobility, in elderly particularly
- Px: confusion, red-brown urine, muscle aches, oedema
- Ix: CK
- Mx: IV fluids
140
Lithium in pregnancy
- Association between lithium and increase in ebsteins anomaly -> right ventricular outflow tract (tricuspid) obstruction defect = cyanosis in neonate
141
Cut offs for diabetes diagnosis
HbA1c > 48 mmol/mol (T2DM)
Random glucose > 11 mmol (BOTH)
Fasting glucose > 7 (BOTH)
OGTT 2 hour > 11 (T2DM)
142
A 22-year-old male who is known to mental health services presents to A&E
concerned that the government has poisoned him.. He is well known to mental health services for his schizophrenia.
Which section would be most appropriate in this patient?
- Section 3 - A&E still technically counts as the community so section 5s do not apply and he is known to mental health services so section 3 is appropriate
143
mx of bacterial meningitis
Community: benzylpenicillin
Post exposure prophylaxis: ciprofloxacin
<3 months: cefotaxime + amoxicillin
>3 months: ceftriaxone + dexamethosone (reduce neurological damage/hearing loss)
144
Mx of biliary atresia
- Rectal washouts (bowel irrigation)
- Anorectal pullthrough
145
Imaging of DDH
- US (<4m)
- XRAY (>4m)
146
Types of hyperthyroidism
- Graves' disease; most common cause of thyrotoxicosis
-> diffuse goitre (w/out nodules), eye/exopthalmos, pretibilal myoxedema
-> TSH antibodies (TRAb), Low TSH/high T3+4
