past paper questions 2 Flashcards
32 y/o female EPAU
pc: 6 weeks amennorrhoea, positive pregnancy test, LIF pain, small vaginal bleed 1 day ago.
possible gynae causes?
- ectopic pregnancy
- ovarian cyst
- miscarriage
onset of pain 1 week prior to bleeding classically suggests ecotpic pregnancy
complications of copper coil
- pain
- irregular bleding
- infection
psuedomonas aureginosa gram stain and shape
- gram negative
- rod
non-invasive method to confirm diagnosis of MS
MRI of brain
- high signal lesions (plaques) on white matter tract
36 y/o female
pc: 3 week hx of sensory symptoms in left arm, started with tingling in her hand, spread over 3 days up her arm.
pmh: 7 years ago painful loss of vision in left eye which resolved in 2 weeks
OE: loss of light touch and pinprick sensation in left upper limb, otherwise normal
most likely diagnosis?
Multiple sclerosis
36 y/o patient with diagnosis of MS confirmed by MRI.
symptoms resolve, but one year later she presents with numbness, ascending to umbilicus and weakness in both limbs.
what treatment could be offered?
- relapse
- IV Methyl prednisolone
- high dose oral steroids
49 y/o patient
pmh: diagnosed with MS aged 36
has had progressive deterioration.
main symptoms now are:
- painful spasms in legs
- urinary frequency
- urgency
- occasional incontinence
what treatments may help her symptoms?
Pharmacological
- anti-cholingeric drugs
Non-pharmacological
- self-catheterisation / intermittent catheterisation
57 y/o
pc: 9 month hx shaking in right hand, writing getting smaller as he writes
OE: resting remor, R hand abolished on purposeful movements, mild cogwheel rigidity at right wrist , slowness in snapping
gait normal, but right arm significantly flexed at elbow, doesn’t swing properly as he walks
most likely diagnosis?
Parkinsons
pathophysiology of Parkinsons?
- loss of dopaminergic neurones from this substantia nigra
most appropriate management for:
31 y/o female, 15cm fundal fibroid, pelvic adhesions and severe menorrhagia.
has completed family
options:
a) anterior repair (colporrhaphy)
b) bilateral oophorectomy
c) bilateral tubal ligation
d) left ovarian cystectomy
e) left oophorectomy
f) total abdominal hysterectomy with bilateral salpingo-oophorectomy and omentectomy
g) total abdominal hysterectomy with ovarian conservation
h) transvaginal tape (TVT) urethral sling
i) vaginal hysterectomy
j) Wertheim’s (radical) hysterectomy
total abdominal hysterectomy with bilateral salpingo-oophorectomy and omentectomy
most appropriate intervention for 65 y/o female with bilateral mixed solid/cystic ovarian masses, ascites and raised Ca 125.
a) anterior repair (colporrhaphy)
b) bilateral oophorectomy
c) bilateral tubal ligation
d) left ovarian cystectomy
e) left oophorectomy
f) total abdominal hysterectomy with bilateral salpingo-oophorectomy and omentectomy
g) total abdominal hysterectomy with ovarian conservation
h) transvaginal tape (TVT) urethral sling
i) vaginal hysterectomy
j) Wertheim’s (radical) hysterectomy
f) total abdominal hysterectomy with bilateral salpingo-oophorectomy and omentectomy
28 y/o nulliparous woman with infertility
- marked cyclical pain
- occurs ten days preceding onset of heavy periods
- negative pregnancy test
- US shows 4cm echogenic ovarian cyst
endometriosis
a 42 yr old woman presents to her GP with severe right iliac fossa pain, feeling faint, and shoulder tip pain. She has no vaginal bleeding, but she has a positive pregnancy test. There is no pregnancy seen on transvaginal ultrasound.
ectopic pregnancy
45 y/o
- regular heavy periods
- haemoglobin level of 8g/dl
Abdo examination
- irregular, hard mass arising from pelvis
- size of 20 week pregnancy
most likely
uterine fibroids
a 58 year old woman with type 2 diabetes. She has had no periods for 9 years, but presents with a sudden heavy painless bleed.
most likely:
a) appendicitis
b) constipation
c) dysmenorrhoea
d) ectopic pregnancy
e) endometrial carcinoma
f) endometriosis
g) follicular cyst
h) incomplete miscarriage
endometrial carcinoma
a 35 year old woman who finds that she has been unable to pass urine normally since the forceps delivery of her 4.2 kg baby a week ago. She now loses a dribble of urine intermittently throughout the day, and feels constantly as if she wants to pass urine. She also has lower abdominal discomfort and a central pelvic mass.
overflow incontinence
a 48 year old multiparous woman who has noticed that she loses a dribble of urine when she coughs. She feels a fullness in the vagina. On examination, there is a ‘lump’ protruding from the anterior aspect of the vagina.
cystocele
A cystocele is when the wall between the bladder and the vagina weakens. This can cause the bladder to drop or sag into the vagina. It may be caused by things that increase pressure on the pelvic muscles.
a 38 year old woman who needs to dash to the toilet when she has the urge to pass urine. Sometimes she leaks when she is unable to reach the toilet in time. She now has stopped going out unless she knows there is a toilet nearby.
detrusor instability
a woman who presents to antenatal clinic feeling uncomfortable at 34 weeks. Her uterus measures ‘large for dates’ and it is difficult to palpate fetal parts.
most appropriate test to help make diagnosis?
ultrasound assessment of liquor volume
is produced by the ovary in the first trimester, but by the placenta in the second and third trimesters. Synthetic forms of it are given in the ‘mini-pill’.
progesterone
is produced in large amounts by the growing follicle in the ovary
oestradiol
is produced by the posterior lobe of the pituitary gland. A synthetic form of it may be given to women to treat slow progress in labour.
oxytocin
what is nephrotic syndrome?
- condition that causes kidneys
- to leak large amounts of protein into urine
- may cause sweling of body tissues, greater chance of catching infection
what should be looked for in a blood result for nephrotic syndrome?
serum albumin
what should be looked for in a blood result for acute renal failure?
serum urea
what should be looked at in a blood result for gilbert’s syndrome?
serum bilirubin
gilberts syndrome:
In a newborn infant, this is associated with:
1. pitting oedema of the lower limbs and a short neck.
Turner’s syndrome (genotype XO)
In a newborn infant, this is associated with:
an increased respiratory rate for 24 hours in an otherwise well infant
transient tachypnoea of the newborn
In a newborn infant, this is associated with:
overwhelming neonatal infection presenting 24-48 hours after birth.
maternal vaginal group B streptococcal carriage
in a new born infant, this is associated with:
marked cyanosis but not dyspnoea
transposition of great arteries
7 y/o well female
pc:
- rash all over back, buttocks, spreading down back of legs
- numerous discrete raised lesions with white centres
- not itchy
- creamy white stuff exuded from the centre
indicative of:
molluscum contagiosum
7 y/o girl
pc:
- lesion on face
- spread all over cheek
- discrete
- inflamed edges
- covered in a golden, crusty but weeping, scab
indicative of:
impetigo
7 y/o girl
pc: unwell for 3 days
- off her food, feverish, red eyes
- had spot behind her ear
- now covered with spots
- all over trunk and face
- spots are discrete and intensely itchy
- some on her abdomen look like blisters
indicative of:
chicken pox
7 y/o girl
well in morning but sent home after vomiting her lunch.
looks pale and unwell.
OE: discrete purple spots on her chest, do not blanch under pressure.
dr gives injection, urgently take her to hospital.
indicative of:
meningococcal septicaemia
a 7 year old girl is seen by the school nurse because she is constantly scratching in class. She has a generalised red rash on her arms and neck and is sore from the scratching. She says her elder brother is scratching too. The school nurse notices that she has several raised tracks between the fingers on her left hand.
scabies
a 74 year old man complaining of gradually worsening vision, particularly when reading. The printed lines look wavy and distorted. Ophthalmoscopy reveals drusen (lipid and protein deposits under the retina).
indicative of:
age related macular degeneration
episodic attacks of vertigo, tinnitus and hearing loss and gradually progressive deafness between attacks.
menieres disease
conductive hearing loss due to hardening of the stapes (or stirrup) in the middle ear.
otosclerosis
common side effects of metformin
GI symptoms
notabily diarrhoea
most likely to occur from long term oral steroid use?
osteoporosis
This is most likely to occur in patients taking:
ferrous sulphate
constipation
common antibiotic used for urinary tract infections?
trimethoprim
which drug is the most appropriate antidote for the following
a) warfarin
b) paracetamol
c) ethylene glycol
d) dihydrocodeine
e) iron
a) warfarin - vitamin K
b) paracetamol - N-acetylcysteine
c) ethylene glycol - ethanol
d) dihydrocodeine - naloxone
e) iron - desferrioxamine
what condition should respond to treatment with a corticosteroid?
a) angina pectoris
b) asthma
c) cholera
d) dental caries
e) diabetes insipidus
f) diabetes mellitus
g) halitosis
h) hypoglycaemia
i) oral candidiasis (thrush)
j) peptic ulcer
k) polydipsia
l) transient ischaemic attack (TIA)
m water-brash
asthma
name four risk factors that might put you at risk of cervical carcinoma?
- early sexual activity
- increased number of sexual partners
- not using condoms
- multiparity
- HPV
most common cause of cervical cancer is?
- infection with human papillomavirus (HPV)
80% of cervical cancers are squamous cell carcinoma, then adenocarcinoma.
what four presenting symptoms would make you consider a diagnosis of cervical cancer as a differential?
- abnormal vaginal bleeding (intermenstrual, post-coital or post-menopausal bleeding)
- vaginal discharge
- pelvic pain
- dyspareunia
what is the next line when you suspect cervical cancer?
- speculum
- if abnormal cervical appearance, then urgent cancer referral for colposcopy
four appears on colposcopy which may suggest cervical cancer?
- ulceration
- inflammation
- bleeding
- visible tumour
grading system used for level of dysplasia in cells of the cervix?
CIN = cervical intraepithelial neoplasia
CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
CIN III: severe dysplasia, very likely to progress to cancer if untreated
what is dyskaryosis?
- examination of fluid containing collection of cells from cervix
- precancerous changes in this fluid are known as dyskaryosis.
It is decided that the CIN = cervical intraepithelial neoplasia area is going to be excised. what procedures may be performed?
list two complications
- large loop excision of the transformation zone (LLETZ)
- cold knife cone biopsy
- laser cone biopsy
complications:
- bleeding, infection, cervical scarring, cervical incompetence
On otoscopy, what clinical picture is likely to be found in acute otitis media.
erythema and bulging of the tympanic membrane
1st choice of antibiotic for otitis media would be?
amoxycillin
Which of the following would be a contra-indication to administering adenosine?
a) COPD
b) Asthma
c) Heart failure
d) IHD
e) treatment with adenosine
asthma
name a side effect of adenosine administration ?
shortness of breath
feeling of impending doom
name three anti-arrythmic drugs?
- amiodarone
- digoxin
- adenosine
four key x-ray changes seen in osteoarthritis?
L- loss of joint space
O -osteophytes
S - subchondral sclerosis
S - subchondral cysts
is osteoarthritis worse or better with movement?
osteoarthritis presents with joint pain and stiffness
- worsened by activity
- leads to deformity, instability and reduced function in joint
NICE (2014) suggest that a diagnosis can be made without any investigations if the patient is over 45, has typical activity related pain and has no morning stiffness or stiffness lasting less than 30 minutes.
signs of osteoarthritis in hands?
- herbeden’s nodes (in DIP)
- bouchards nodes (in PIP)
- weak grip
- squaring at base of thumb at carpo-metacarap joint
- reduced rage of motion
herbedens nodes affect
dip joints
bouchards nodes affect
pip joints
management of osteoarthritis in a patient?
- lifestyle: weight loss, physio
- analgesia
- oral paracetamol, topical NSAID or tropical capsaicin - oral NSAID, PPI
- Opiates (codeine and morphine)
- intra-articular steroid injections
- joint replacement
what is rheumatoid arthritis?
- autoimmune
- causes chronic inflammation
- of synovial lining of joints, tendon sheaths and bursa
- tends to be symmetrical, affecting multiple joints
genetic associations with rheumatoid arthritis
HLA DR4 (RF positive patients)
HLA DR1 (gene occasionally present in RA patients)
which antibodies are associated with rheumatoid arthritis?
- Rheumatoid factor
- anti-CCP antibodies
commonly affected joints of Rheumatoid arthritis?
- Proximal Interphalangeal Joints (PIP) joints
- Metacarpophalangeal (MCP) joints
- Wrist and ankle
- Metatarsophalangeal joints
- Cervical spine
- Large joints can also be affected such as the knee, hips and shoulders
TOM TIP: The distal interphalangeal joints are almost never affected by rheumatoid arthritis. If you come across enlarged painful distal interphalangeal joints this is most likely to be Heberden’s nodes due to osteoarthritis.
signs of rheumatoid arthritis in hands?
- Z shaped deformity to the thumb
- swan neck deformity (hyperextended PIP with flexed DIP)
- boutonnieres deformity (hyperextended DIP with flexed PIP)
- Ulnar deviation at knuckles
investigations for possible rheumatoid arthritis?
- check rheumatoid actor
- if RF negative check anti-CCP
- inflammatory markers: CRP and ESR
- X-ray of hands and feet
NICE guidelines for disease modifying anti-rheumatic drugs?
1st line: methotrexate, leflunomide or sulfsalazine. hydroxychloroquine
2nd line: two of the above together
3rd line: biological therapy, TNF inhibitor
4th line: rituximab
how does methotrexate work?
- interferes with metabolism of folate
notable side effects
- mouth ulcers and mucositis
- liver toxicity
- pulmonary fibrosis
- bone marrow suppression and leukopenia
- is teratogenic
There are a lot of side effects to remember for your exams. Many of them are shared between medications. Try to remember the unique ones as these are more likely to be tested:
Methotrexate: pulmonary fibrosis
Leflunomide: Hypertension and peripheral neuropathy
Sulfasalazine: Male infertility (reduces sperm count)
Hydroxychloroquine: Nightmares and reduced visual acuity
Anti-TNF medications: Reactivation of TB or hepatitis B
Rituximab: Night sweats and thrombocytopenia
Methotrexate: pulmonary fibrosis
Leflunomide: Hypertension and peripheral neuropathy
Sulfasalazine: Male infertility (reduces sperm count)
Hydroxychloroquine: Nightmares and reduced visual acuity
Anti-TNF medications: Reactivation of TB or hepatitis B
Rituximab: Night sweats and thrombocytopenia
