Past papers Flashcards
If person on lithium develops polyuria, what is first investigation do
Serum calcium
Do not rush to do water deprivation assuming is diabetes insipidus
What can do to prevent contrast nephropathy prior to a CT if history of kidney disease
IV fluids infusion can protect kidney
What causes episodes where feel heart skips a beat in a young person
Ectopics- either ventricular or supraventricular
What is initial investigation for PSC post USS
MRCP
Proctitis and tender lymphadenopathy in MSM
LGV
What artery causes bleeding in peptic ucer disease posterior to the first and second parts of the duodenum
Gastroduodenum
Best management option for mets in the spine causing compression of cord
Radiotherapy
Inflammatory back pain features
Improvement with activity
Not relieved by rest
Younger population
Management of restlessness in a palliative patient in terminal stages
Midazolam via subcut infuser
What is first choice post operative analgesia
Opiods
What do for postoperative analgesia if a severe respiratory disease
Epidural as want to avoid opiods
A 78 year old man has type 2 diabetes. His clinician does not invite him to join
an internet-based self-monitoring programme because she considers him to be too old to engage with it effectively. What is this an example of?
Discrimination
Man attends for ramipril review, U&Es show hyperkalaemia, what do?
Repeat as likely spurious
If have cerebral symptoms in malaria, what is most likely cause
Falciparum
How is resp function monitored in myasthenia
FVC
Man has twitching that starts in left hand then spreads up arm, arm feels weak for an hour after
Focal seizure
If conscious how decide what form of glucose to give
If swallow appears to be intact then oral glucose
If not then glucogel
Post abdominal procedure, patient develops low grade fever and reduced breath sounds at lung bases
Atelectasis
How does atelectasis present post operatively
Low grade fever
SOB
Reduced air entry at both lung bases
If in pain then shallower breathing which means distal airway not receiving air
What makes lumbar spinal stenosis easier
Leaning forward and riding bike
When intubating someone what is cricoid pressure
Placing fingers over cricoid ring to prevent aspiration of gastric contents to airway
Man falls downstairs and brought into hospital, what is first thing do
Cervical spine immobilisation
If have confusion what is most likely type of pathogen causing meningitis
Bacterial
What are 2 types of metaplasia in barretts oesophagus
Intestinal- goblet and paneth cells seen
Squamous- none of these cells seen
How long keep patients in a sideroom for with C diff
Need to be in a sideroom for 48 hours with no diarrhoea
Below what creatinine clearance give warfarin for DVT/PE
15
If treating DVT/PE with warfarin, what is regime
Give LMWH for first 5 days then warfarin for 3 months
Management options for HCC
Surgery
Sorafenib
What is sorafenib
Multikinase inhibitor used in HCC management
How oftens should SCD patients receive pneumococcal vaccine
Every 5 years
What type of hypogonadism does haemochromatosis cause
Secondary as causes pituitary dysfunction
Lymphoma translocations
Follicular- 14;18
Mantle- 11;14
Burkitts- 8;14
If someone falls soon after parkinsons diagnosis what need to consider
Parkinsons plus syndromes
Which anti-epileptic most associated with weight gain
Sodium valproate
How long can’t drive if diagnosis of epilepsy
1 year
What do if patient with MI has AF and haem unstable
Following ALS pathway ABCDE would cardiovert
Vitreal vs retinal detachment
Vitreal= floaters
Retinal= loss of vision
If patient develops third nerve palsy after traumatic headinjury what is cause
Brain herniation
When is only time repair aortic abdominal aneurysm as urgent (not rupture)
If symptomatic
What is urgency of endovascular repair for AAA
Elective if above 5.5cm, growing by 1 cm
Urgent if rupture or symptomatic
Which type of bowel defunctioning is easiest to reverse
Loop ileostomy
Management of post transfusion purpura
IVIG
Presentation of post transfusion purprua
Purpura a week after transfusion
Liver failure triad
Jaundice
Encephalopathy
Coagulopathy
If recurrent sinusitis how can prevent it
Intranasal corticosteroids
What do if have any type of back pain but PMH of cancer
Refer to ortho
If suspected colorectal cancer what is first thing do
FIT test avoid urgent colonoscopy referral
Most specific sign on examination for comaprtment syndrome
Pain on passive movement
Most common complication from oesophagectomy
Anastamotic leak leading to mediastinitis
Second line laxative for acute constipation
Osmotic laxative like macrogol
Investigation of choice for lymphoma
Excisional node biopsy
What are orange peel lesion on shins bilaterally
Pretibial myxoedema
Process after getting a needlestick injury
Ask someone else to complete risk assessment and take the patient blood
Go immediately to ED or occ health
What need to do for all ARDS patients
Prone the patients
What use to determine if PE patient should be treated as inpatient
Pulmonary Embolism Severity Index score
If after chest drain develop cough and SOB what has caused
Re expansion pumonary oedema
What causes re expansion pulmonary oedema post chest drain
Rapid drainage of the pneumothorax
What give for gout if on warfarin
Colchicine- avoid NSAIDS due to risk of GI bleeding
Indications for external pacing
Unstable bradycardua which did not respond to atropine
Type 2 or complete HB post anterior MI
Trifasicular block before surgery
Difference in heart block caused by anterior vs inferior MI
Anterior- more long lasting and may need external pacing
Inferior- often transient and will not require pacing
Management of intermittent and recurrent testicular torsion
Urgent testicular fixation
Serotonin syndrome presentation
Sweating
Tremor
Confusion
Hyperreflexia
Ebola presentation
Incubation period up to 21 days
Initially flu like then develop diarrhoea, rash and kidney/liver dysfunction
Bleeding late stage
If have hoarse voice post thyroidectomy what is cause and how investigate
Laryngeal nerve damage
Laryngoscopy
If post thyroidectomy develop stridor what worried about
Haematoma development
Management if develop haematoma post thyroidectomy
Immediate removal of skin clips on ward to relieve pressure
Systolic murmur in takayasus
Aortic regurg
What is steroid regime for sensorineural hearing loss
Oral pred for 7 days
What are at risk of if ocular trauma and susbsequent hyphema
Glaucoma
When is only time do loop colostomies
Obstructing cancers
Patient has renal stone causing hydronephrosis but no infection, what do
Nephrostomy
Patient with nephrotic syndrome develops abdo pain and haematuria, what is cause
Renal vein thrombosis due to hypercoagulable state
Severe pain when exposed to cold conditions
SCD
Arthrocentesis findings reactive arthritis
Yellow colour
No crystals
Arhtrocentesis colour difference, normal vs infection vs inflammatory
Normal= clear, straw, yellow
Infection= cloudy, turbid grey
Inflammatory= yellow
If post op fever, what are 2 things need to rule out
Infection
Thrombous
Management of diverticulitis
Assess for complicated disease
- sepsis
- obstruction
- acute abdomen
If uncomplicated offer oral abx (co amox) and analgesia
If complicated admit for IV cef and metro plus possible surgical intervention if indicated
Management of uncomplicated diverticulitis
Can be managed in primary care
- oral co-amox
- analgesia
- if no improvement in 72 hours admit
What abx in primary care for diverticulitis
Oral co amox
If CI
- oral cefalexin + metro
- oral metro +trimethoprin
Abx for diverticulitis in hospital
IV ceftriaxone and metronidazole
Complications of diverticulitis
Strictures
Abscess
Perforation
Fistula
Obstruction
Purpose of giving albumin alongisde paracentesis for ascites
Reduce post paracentesis circulatory dysfunction
What give alongside paracentesis for ascites
IV albumin
How check if NG tube in place
Aspirate looking for pH <5.5
What do if NG tube aspirate over 5.5
Do CXR
What do if unable to obtain NG tube aspirate
Turn patient on left side
Withdraw or advance the tube 10-20 cm
If still no luck do CXR
What assesses prognosis in pancreatitis
Glasgow IMRIE- done 48 hours post admission
What is included in glasgow imrie
Remember as PANCREAS
P - PaO2
A - Age
N - Neutrophilia
C - Calcium
R - Renal function
E - Enzymes
A - Albumin
S - Sugar: blood glucose
Indications to give sodium bicarb for TCA overdose
Widened QRS
Arrythmia
What indicates septic arthritis over flare of RA
Erythematous
Hot
Raised WCC
Most common mechanism of injury for ankle sprain
Inversion
Vision worse when going down stairs
Trochlear nerve injury
Skin squamous cell carcinoma management
If cosmetically important area or high risk then mohs micrographic surgery
Under 20mm in diameter= 4mm margins excision
Over 20mm= 6mm margins excision
Most common malignancy on lip
Skin SCC
Management of SCC on lip
Moh micrographic surgery as cosmetically significant area
If going to have surgery and anaemic what is preferred option for increasing Hb
Transfusion- if refused consider other options
What can offer as alternative to transfusion if jehovahs witness
EPO
Why give steroids in meningitis
To reduce neurological complications
Difference in vision affected ARMD vs POAG
Glaucoma= peripheral
ARMD= central as macula
What veins should amiodarone be given into
Ideally central as causes thrombophlebitis
Why give aciclovir in shingles
Reduce incidence of post herpetic neuralgia
Which CCB are able to give if HF
Amlodipine for HTN
Differentiating sequestration from aplastic crisis
Reticulocytes raised in sequestration
Management of periductal mastitis
Co amoxiclav or metro plus erythro
What is periductal mastitis
Infection of ducts underlying the skin
Tropical infection with bradycardia
Typhoid
What does positive femoral stretch test indicate about hip pain
Referred from lumbar spine
When consider ventilation for asthma
Acidotic
Refractory to medical tx
OA in knee presentation
Knee locking
Obese
Exercise induced pain
With regards to varicella and healthcare workers, what must have
If natural immunity is good, if none then vaccinate
What syndrome associated with bicuspid aortic valve
Turners
Most likely location for gallstone not causing jaundice
Cystic duct
What does not being able to view retina in patient with acute vision loss indicate
Vitreous haemorrhage
Differentials for acute pain in thigh
DVT
Superfical thrombophlebitis
Which vein if suspected for thrombophlebitis should be investigated in secondary care
Long saphenous
Hardened vein in leg that is painful and erythematous
Thrombophlebitis
Management of meningococcal sepsis in GP if penicillin allergy
If rash give IM benzylpenicillin or IM cefotaxime
If anaphylaxis history send straight to hospital for IV chloramphenicol
Acute glaucoma management in GP
Pilocarpine eye drops and oral acetazolamide
Lie down and send to hospital
If have non-healing otitis externa in diabetic what need to do
Refer urgently to ENT for IV ciprofloxacin
How often measure glucose if T1DM
At least 4 times including before each meal and before bed
What is dosulepin
TCA
After transfusion patient develops numbness in legs and palpitations
Hypocalcaemia
Hypocalcaemia presentation
CATS go numb
Convulsions
Arrythmias
Tetanny
Numbness
What electrolyte abnormalities common post transfusion
Hypocalcaemia- contain citrate which binds to endogenous calcium
Hyperkalaemia
If have addisons and not able to take normal steroids due to nausea what give
IM or IV hydrocortisone
What can give for meningococcus in primary care if pen allergic
IM cefotaxime
If neuropathic pain and unable to take oral medications what use
Lidocaine patch
Alongside restarting at lower rate, what also do for anaphylactoid reaction
Causes bronchoconstriction so give salbutamol
Most significant rf for aspiration pneumonia
Recent intubation
What do if patient comes in with strangulated hernia
DO NOT ATTEMPT TO MANUALLY REDUCE
Straight to theatre for open repair
Pus in the anterior chamber
Anterior uveitis
How do metastases appear on x ray
Sclerotic
Painless vs painful ulcers on genitals
Painful- herpes, chancroid
Painless- LGV, syphillis
Allergic conjunctivitis management
Topical antihistmines
How investigate unexplained IDA
Refer to gastroenterology if Hb under 110 in men and 100 in non-menstruating women
OF ANY AGE
IDA management at GP
Investigate if dietary or coeliac
If unexplained refer to gastro if Hb under 110 in men and under 100 in non-menstruating women
Which drugs may cause glaucoma
Antimuscarinc- TCA
Nebulised ipatropium
Contents of inguinal canal
Inferior epigastric vein and artery
What do if persistent haemorrhoid symptoms
Investigate further
Young = flexi sigmoidoscopy
Old= colonoscopy
What nerve damaged in mid humeral fracture
Radial
What is housemaids knee
Prepatellar bursa- look up more
What do if AF secondary to something like sepsis
Do not treat AF straightaway- treat cause first and see if responds to that
First line for suspected neck malignany
Endoscopy
Apple core stricture on barium
Cancer
Staging investigation for colorectal cancer
CT CAP
If need a CT for bowel obstruction but have CKD what do
Oral contrast like gastrograffin- avoid IV contrast which would normally use
When give bipap for COPD
After medical treatment with oxygen for an hour and still acidotic
Which lymph nodes do breast cancers metastasise to
Medial part of breast- internal thoracic
Lateral part of breast- axillary
CURB65 interpretation
0-1 outpatient
2 inpatient
3< consider ITU
First aid for drowning patients
5 rescue breaths
INR target for warfarin if recurrent DVT
3.5
What is most common AIDS presenting condition
PJP
What does inguinal lymphadenopathy with a sinus which expresses pus indicate
Chancroid
How often are colonoscopies performed in UC
Every 5 years
Management of mallory weiss tear
If heam stable and Hb normal then can observe and discharge
What has an increased osmotic gap in stool
Lactose intolerance
Birds beak on barium
Achalasia
If come back from india with chronic diarrhoea, what could be cause
Tropical sprue
Parasitic infection like giardia or cryptosporidium
If come back from india with chronic diarrhoea, what investigation need to do
Small intestine biopsy to look for villous atrophy indicative of tropical sprue or being able to identify a parasite
Blood findings of PSC
pANCA
Anti-smooth muscle
Typically seen by isolated ALP
Most common site for renal stones
Vesicoureteric junction
What causes ischaemia distal to an AV fistula
Distal hypoperfusion ischaemic syndrome where get shunting of blood
When suspect gastrinoma as cause of ulcers
Multiple
Bleeding
Refractory to treatment
Hpylori negative
What do if patient has treatment refractory upper GI symptoms
Refer for upper GI endoscopy if over 55
NICE recommend referral for over 55s with treatment refractory upper GI sx
What do for haemodynamically unstable PE patients if post op
Unfractionated heparin as thrombolysis would cause bleeding and not able to reverse
If patient in shock post trauma, what give
Packed red cells
For bleeding post trauma what use
Red blood cells
Tranexamic acid IV may be considered
What must do before relocating shoulder dislocation
Check for axillary nerve function
What must be with acute onset liver pain and hepatomegaly
Budd chiari
What do as second line for suspected hip fracture
MRI if still clinical question
In occupation asthma what does weeks peak flow diary show
During the week it gets worse
Management of occupational asthma
Redeployment to other area
What is bowel cancer screening programme in the UK
FIT kit offered to everyone 60-74 to carry out every 2 years
How differentiate between atelectasis and PE as cause of post op fever and SOB
Atelectasis 1-2 days post op
PE typically at least a week after
What do if recurrent DVTs whilst on warfarin
Change target INR to 3.5
Shigella management
Uncomplicated- nothing
Blood in stool- cipro
Notifiable disease
How do myeloma bony lesions appear on x ray
Lytic (well punched out)
Hereditary angioedema presentation
Attacks of pain or tingling around mouth
Often precipitated by dental anaesthetic
Occurs in late teens
What are carbuncles vs furuncles
Furuncle- root hair abscess
Carbuncle- root hair abscess with mutliple sinuses with puscoming out of
What diabetic drug can precipitate gastroparesis
GLP-1 agonists
What do if start GLP1 agonist and develop gastroparesis
Stop GLP1 agonist
Tender pea sized lump on superior pole which has developed over last 24 hours
Testicular appendage torsion
What do if patient comes in aggressively vomiting as side effect of chemo
IV ondensatron
IV fluid resus if necessary
If multiple nosebleeds within a short period of time what use to manage
Cautery
Which nodes do testes drain to
Para aortic
Lung disease following work in ceramics factory
Silicosis
When use furosemide for ascites
If refractory to spironolactone
Potassium rises as result of spironolactone
What nerve responsible for tears
Facial
If have chronic diarrhoea and high folate what could be cause
Small bowel overgrowth
Patient becomes feverish, hypotensive, oral ulcers, diarrhoea and generalised oedema following nasal packing
Toxic shock syndrome
Toxic shock syndrome presentation
Multiorgan failure
- diarrhoea
- septic
- generalised oedema
- rash
- ulcers in mouth
How diagnose toxic shock syndrome
Swab from area of infection source
What is most important part of treating DIC in sepsis
Treat underlying sepsis
If pelvic fracture what do to investigate urethral injuries
Retrograde urethrograthy- do before suprapubic catheter
Management of optic neuritis
If vision impaired then IV methylprednisolone
How view fractures of the mandible and what do if unclear from first investigation
X ray
May need CT
Presentation of diffuse oesophageal spasm
Young person
Dysphagia to both food and drink
Intermittent symptoms
Retro sternal pain
What gives corkscrew appearance on barium swallow
Diffuse oesophageal spasm
First line investigation for diffuse oesophageal spasm
Oesophageal manometry
Differentials for dysphagia in young
Achalasia
Diffuse oesophageal spasm
PCKD patient presents with flank pain and fever, what is most likely cause
Infected cyst
How diagnose infected cyst in PCKD
Blood culture
Imaging for rib fractures
Only do CXR if resp compromise otherwise delays getting CT
What do if about to do elective cystoscopy and find patient has murmur with symptoms
Delay procedure refer to cardio
How investigate a new onset suspected bulbar palsy
MRI
Syphylis serology
LP
What is name given to lymphoedema treatment
Decongestive therapy which incorporates
- massaging
- compression bandaging
What is organism for hydatid
Echinococcus
Risk factor in UK for hydatid
Sheep farmer
Bone cotton wool spot calcification
Chondrosarcoma
Treatment options for PSC
Ursodeoxycholic acid
Definitive is liver transplant
What is tinea incognito
If treat a tinea infection with a steroid and then it becomes worse
If have been trekking in a tropical country and come back with lesions on foot what is likely cause
Cutaneous larva migrans
Cutaneous larva migrans presentation
Recent tropical travel
Erythematous rash over feet
Vesicles present- erythematous trails from each vesicle
How differentiate bleeding artery in stomach
Lesser curvature= left gastric
Greater curvature= gastroduodenal
What do for treatment refractory severe c diff
Faecal transplant
Causes of pulsatile tinnitus
Intracranial pathologies- MS
Vascular
Investigating pulsatile tinnitus
Suspected MS- CT of temporal bone
Vascular- MR angio
Most common side effect of ciclosporin
Nephrotoxicity
Which medication can make you present with cerebellar syndrome appearing drunk
Phenytoin
What organism shows air crescent sign on CT
Aspergillus
What does 24Fr catheter mean
External circumfrence is 24mm
What is proctitis syndrome
Can get STI infected rectum leading to proctitis symptoms
- incontinence
- blood in stool
- constant feeling of needing to go
Presentation of proctitis syndrome
Incontinence
Blood in stool
Feeling of needing toilet all the time
What do if discover an undescended testis in an adult
Remove it to eliminate cancer risk
When can you give DOAC before CTPA
If very high clinical suspicion- ie risk factors, classic presentation etc
What give for malaria prophylaxis
Combination therapy- atovaquone+proguanil
What is conus medullaris
Get acute onset neurological symptoms from compression of spine at L2. Symptoms include
- inability to walk
- urinary control lost
- loss of anal tone
Management of conus medullaris
Urgent decompressive laminectomy
Lung complications of RA
Fibrosis
Pleuritis
Bronchiectasis
Extra GI features of yersinia
Erythema nodosum
Mesenteric lymphadenitis
Management if parvovirus in SCD
Admit
Transfusions
What do if open up for appendecectomy and appendix appears absolutely normal
Still remove as reduces risk of cancer
Causes of renal AV fistula
Previous biopsy or other cause of trauma
Presentation of renal AV fistula
Haematuria
Hypertension
After bone marrow transplant patient becomes SOB with diffuse crackles- spirometry shows obstructed picture
Bronchiolitis obliterans
In trauma if bleeding internally in abdomen what do to reduce bleeding
Apply a pelvic splint
What can use to medically treat a gastrinoma
Somatostatin which can reduce gastrin production
Management of cryptococcal meningitis
IV amphotericin B
Gold standard for small bowel overgrowth
Small bowel fluid culture
If patient has hypotension and confusion post abdominal op what is next investigation
Bloods- X match etc
Taking back to theatre will take time to arrange
Colonoscopy shows abnormal vessels in wall of colon
Angiodysplasia
Angiodysplasia presentation
IDA
Blood on FIT
Can present with acute haemodynamic instability
Angiodysplasia in bowel management
Ablation of vessels endoscopically
Renal angiography shows string of beads appearance in young patient with HTN
Fibromuscular dysplasia
What can use in dementia to treat insomnia
Trazodone
Can CXRs rule out lung cancers
No
On CXR what does calcification within the heart indicate
Myxoma
In supracondylar humeral fractures which structure most at risk
Brachial artery
What causes vertebral fractures above vs below T4
Above T4= cancer
Below = osteoporosis
Skin peeling when having breast radiotherapy
Radiation dermatitis- give emollients
If you are worried about adherance in chlamydia treatment what give
2 days worth of azithromycin
When can stop variable insulin infusion post operatively
1 hour after can eat and drink
Has recommended short acting insulin
What do if notice blood in ejaculate
Nothing- only consider referral if over 3x
When refer if blood in ejaculate
If over 3x
When give infliximab for RA, what is given alongside
Methotrexate
What indicates severe autoimmune hepatitis
AST 5x upper limit
Evidence of necrosis on biopsy
If is bundle branch block, what is likely MI vessel
LAD
What can give for SOB in palliative patients
Opioids
Interstitial pneumonia causes
Mycoplasma- most common
PJP
CMV
RSV
What is when cough up tubular gelatinous materials
Plastic bronchitis
If are electrocuted what is main risk to patient
Cause rhabdomyolysis and subsequent severe hyperkalaemia
When changing a long term catheter what do
Give stat aminoglycoside unless renal impairment
Patient lives alone in campervan collapses now feels faint and nauseous with headache
CO poisoning
Best investigation for CO poisoning
Multi wavelength pulse oximetry
If axillary nerve compromise how manage shoulder dislocation
Still do reduction in resus bay
What do if reduction in ED fails for shoulder dislocation
Reduction under general GA in theatre
Benign oesophageal stricture managemen
Endoscopic dilation and aggressive GORD management
Causes of secondary restless leg syndrome
IDA
DM
Pregnant
If patient comes in with acute IBD what is first imaging do
AXR
Stepwise approach to buddchari
Anticoagulation
Angioplasty
Liver transplant
Management of severe budd chiari
Liver transplant esp when liver enzymes in thousands
What often precipitates salt losing nephropathy
Obstructive cause of kidney injury like a stone
How can prevent relapses of guttate psoriasis
Tonsillectomy
If patient has stroke signs in context of aortic dissection what do with regards to imaging
Is a complicated dissection so immediate vascular referral for echo
First line investigation for boerhaves
CXR
Whipples disease management
Co trimoxazole
If have poor defaecation from pelvic floor weakness what use to investigate
MR defecography
What are vocal chord nodules
Seen in singers, are hard growths on the larynx which can affect voice
TMJ dysfunction presentation
Hearing loss
Clicking in jaw
Which TB drugs can cause Vit D defic
Rifampicin
Isoniazid
Most common cause of rhinitis, cough and sneezing
Rhinovirus
Causes of renal papillary necrosis
SCD
Paracetamol chronic use
Pyelonephritis
Management of viral warts
Salicylic acid
Can use cryo if a small number but avoid if large numbers
Cluster of lesions on hands after starting etanecerpt
Viral warts
If have cushingoid appearance then suddenly develop addisons symptoms what is cause
Abrupt withdrawal of steroid therapy
Pre calyceal calcifications of kidney with bunch of grapes appearance
Medullary sponge kidney
Management options for fistula
First line antibiotics
Surgical measures may be required- draining seton or fistulectomy
Can also consider infliximab to help seal
Which drugs can increase risk of gallstones
Fibrates
What white marks in mouth can be easily scraped off with minimal bleeding
Candida
Management of paraphimosis
Soak foreskin in hypertonic saline and attempt to manually retract the foreskin
Neurosarcoidosis presentation
Cranial diabetes insipidus
If patient requires emergency surgery on warfarin what give
Prothrombin complex
Which valvular disease is seen in pulmonary HTN
Pulmonary regurg
Pulmonary HTN presentation
Peripheral oedema
Fatigue
Weakness
Pulmonary regurg sometimes seen
Pulmonary HTN management
Oxygen
Diuretics
Bosentan
What is bosentan
Endothelial receptor antagonist used in pulmonary HTN
Asteatotic eczema presentation
Seen in elerderly in winter
Dry skin in weird pattern on legs
Unilateral vs bilateral tinnitus referral
URgent for unilateral
Bilateral very common and does not require referral most of time
In palliative patients what is best management of a bowel obstruction
Loperamide
If have vitreal haemorrhage, what use to visualise retina for detachments
Ultrasound B scan of eye
What counts as mild hyperkalaemia that would not be worried about in community
5-5.9 plus asymptomatic with no ECG changes
Long term effect of cushings on calcium metabolism
Leads to secondary hyperparathyroidism
First line for verrucas
Topical salicylic acid
What is meibomiam cyst
Chalazion
Chalazion management
Apply heat and massage daily
What makes diabetic retinopathy pre proliferative as opposed to backgorund
IRMA
Cotton wool spots (soft exudates)
Blot haemorrahges
TTP management
Exchange transfusion
72 year old woman develops severe back pain after a coughing fit
Wedge fracture- note caused by minimal trauma
Management of low grade small cell lung cancer
Chemoradiation
Side effect of penicillamine
Membranous nephropathy
Ruptured aortic aneurysm VBG
Raised anion gap metabolic acidosis from lactate
Causes of coronary artery vasospasm
Cocaine
Some chemo agents
Methadone side effects
Suppression of hypothalamic gonadal pathway which leads to reduced libido etc
What do if someome has reduced libido but part of detoxification programme
Come back once done as methadone suppresses HPG pathway
If morphine CI what use instead post op
Oxycodone
First line for cervical spondylosis
NSAIDS then physio
Malignant hyperthermia from anaesthetic management
Stop agent
Give dantrolene and cool patient
What indicates general as opposed to localised peritonitis
Absent bowel sounds
Best antibiotic for klebsiella
Meropenem
2-3 months after starting drug get itchy violaceous rash
Lichenoid reaction
Side effects of testosterone
Infertility
Acne
BPH
Breast tenderness
Achilles tendon rupture management
Main intervention preferred nowadays is below knee plaster cast
Surgery for sports person or recurrent injuries
What is reactive airway dysfunction
When exposed to irritant gas or fumes get asthma like symptoms 24 hours later
What investigation used for reactive airway dysfunction syndrome
Metacholine challenge test
BP 178/95, intracranial HTN headache 2 years after lung cancer resection
Cerebral metastases
management of short duration acute low back pain in fit person
continue usual activity and provide safety netting
first thing to do in oncology patient with neutropenic sepsis (A&E)
IV broad spectrum abx
(even before discussing with onc team / starting fluids)
Anticoagulant choice for sub-massive pulmonary embolism in patient at risk of haemorrhage (previous peptic ulcer bleed in history)
IV unfractionated heparin, can be stopped and reversed in event of recurrent bleeding
<30% increase in serum creatinine after starting anti-HTN medication, what do next?
repeat renal function in 2-4 weeks
what to bear in mind if septic arthritis picture but no organisms seen on joint aspiration gram staining?
gram stain positive in only 50% of cases, so IV abx should be started regardless and cultures sent
what investigation done following unilateral sensorineural hearing loss
MRI scan of internal acoustic meatus to exclude vestibular schwannoma/neoplasm
What is the investigation of choice for an acute abdomen following abdominal surgery
CT (with contrast)
what is the method for confirming norovirus
stool PCR
Patients catheter output drops to 0 with associated haematuria what is likely cause and how manage
Blocked with clots
Flush with 50ml saline
Patient working from hard metals industry has interstitial fibrosis bilaterally what is cause
Giant cell interstitial pneumonitis from cobalt exposure
If had stroke due to high WCC from CML, what is immediate management
Leukapharesis
What does milky joint aspirate suggest
Gout or pseudogout
If knock elbow then becomes swollen over next few days what is cause
Olecranon bursitis
What are 2 types of olecranon bursitis
Septic- indicated by unwell, fever etc
Non-septic
Management of septic vs non-septic olecranon bursitis
Septic- aspirate and flucloxacillin
Aseptic- conservative, aspirate if very uncomfortable and large
If mild hypernatraemia what do
Oral water
Best drug for reducing triglycerides
Fibrates
When do balloon valulotomy for MS
Under 1.5cm2 and valve intact
If valve poor then do replacement
What do if strep bovis (group D strep identified as cause of IE)
Colonoscopy
How does ambulatory blood pressure maangements work
Take 2 per hour all day and take average
If have adenomas removed at colonoscopy how are followed
All undergo surveillance with colonoscopy for cancer either in 1, 3 or 5 years
Above 10mm is high risk
What is main cause of mortality after a pneumectomy
Pulmonary oedema which often requires ECMO
How should manage someone with borderline HTN measures with CVD rfx
Review in 1 year
Effect of grapefruit juice on CYP450
Inhibits
Hit by cricket ball and now distal phalynx is flexed
Mallet finger
Management of mallet finger
Minor- Place finger in splint for 6 weeks
Severe- surgery
Psoriasis patient has painful and itchy ear with discharge. On examination a scaly red lesion is seen in the ear. What is management?
Topical abx as psoriasis lesion has caused break in skin leading to infection
What suggests mesenteric ischaemia on CT
Air in bowel wall
Air in portal vein
What hypersensitivity is erythema multiforme
4
What causes fracture of 5th metacarpal
Punching
Patient on CCB for HTN discontinues due to side effects but has history of osteoporosis what give as 2nd line
Thiazides as increases calclium absorption
How treat all non lactational mastitis
Co amox
Mass in GI tract with spindle cells
GI stromal tumour
What is phacoemulsification
Name for cataracts surgery
What use as screening investigation for renovascular causes of HTN
USS can identify RAS or PCKD
If one of these comes back positive then can do MRA or CTA
When consider prophylactic abx for UTIs
Over 1 a month
What are options for prophylactic abx for recurrent UTIs
Trimethoprin or nitrofurantoin
If poor renal function then use trimethoprin
What do for background, pre proliferative and proliferative diabetic retinopathy identified on fundoscopy at GP
Background- annual screening
Pre-proliferative- Routine referral to opthal
Proliferative- urgent referral
Management of reactive airway dysfunction
Inhaled bronchodilators
Patient hears hissing in ears what is management
Example of tinnitus- not always ringing
CBT if associated depression
Sound generators can help symptoms
Trauma to chest and then RBBB
Myocardial- contusion
Think that RV is at front of chest so most likely to be affected
Most urgent investigation for intraocular foreign body in metal welder
Fluoroscein angiography
Cholangitis management options
ERCP
- stone removal
- sphincterectomy to allow stone to pass
- stent insertion if stricture or malignancy
If unfit for ERCP then can insert stent percutaneously
Cholecystitis complications
Perforation
Gangrenous gall bladder
Abscess
Mirizzi
Fistula to bowel- get air in gallbladder
When do CT in acute pancreatitis
If getting more unwell- look for complications ie abscess, haemorrhage
Drug causes of priapism
Trazodone
SSRI
Heparin
Clozapine
When give mannitol for a brain bleed
If any signs of raised ICP
- papilloedema
- cushings triad
- low GCS
If evidence of sinusitis on imaging causing orbital cellulitis, what is management
First line= drain sinuses
IV tazocin
You are assessing a 90-year-old female with advanced dementia who is bed-bound and has a grade two pressure ulcer. Her carer thinks she feels pain when being moved into bed. The patient takes no pain medication at present. The patient has severe nausea, vomiting and has severely impaired mental status.
Rectal paracetamol
During anaesthesia which investigations are necessary
Capnography, pulse oximetry, ECG monitoring, non-invasive blood pressure monitoring, airway pressure alarms
Normal cardiac axis
-30 to 90
Trigeminal neuralgia on turning neck
Paroxysmal hemicrania
Drug causes staining of teeth
Tetracycline
A 58-year-old male with a fractured intracapsular neck of femur is scheduled for a hemiarthroplasty. He is on warfarin but has received vitamin K to normalise his INR before surgery. He has multiple comorbidities, including atrial fibrillation, previous TIAs, and type II diabetes, with a long list of medications. The senior house officer is reviewing his medications prior to tomorrow’s surgery. The patient is currently stable with normal vital signs.
Which medication is safe to take on the day of surgery?
Ramipril
Metformin
Digoxin
Aspirin
Gliclazide
Digoxin
What can really affect wound healing for abdominal cancer resections and lead to complications such as sinus formation
Adjuvant radiotherapy
What do with DVLA if diagnosed with MS
Inform DVLA but can continue to drive
A 28-year-old male is referred to the Respiratory Outpatient clinic with a chronic non-productive cough. He is a non-smoker and has no other symptoms. Initial investigations reveal normal full blood count, C-reactive protein, chest X-ray, and spirometry. Next investigation?
Bronchial provocation test as next investigation for cough variant asthma
Management of transient hypocalcaemia after parathyroid surgery
If mild symptoms or above 1.9 then observe
If severe tetany or below 1.9 then bolus of calcium gluconate
Difference in morphology of heart between HTN and HOCM
HTN- uniformly hypertrophied
HOCM- enlarged in septa and apex
Condition where penis becomes overly curved
Peyronies disease
How manage recurrent seizures in short period of time
Give 2 doses of benzos
Can give phenytoin first line for a recurrent seizure if already given 2 doses of benzo
What do for any new diagnosis of T1DM, hashimotos or coeliac
Screen for others
What is a stokes adam attack
Where collapse because of cardiac problem (aka cardiac syncope)
What give for fluids refractory sepsis
Noradrenaline
Murmur in biscuspid aortic valve
Early systolic click
Pneumonia signs in alcoholic who is covered in vomit
Aspiration pneumonia- mixed anaerobes
Colorectal cancer 2WW guidelines
Over 40 years with abdominal pain and unexplained weight loss
Over 50 years with unexplained rectal bleeding
Over 60 years with a change in bowel habit or iron deficiency anaemia
First line for if suspect colorectal cancer in GP
FIT
If above 10 refer
What is blue sclera seen in
Ehlers danlos
Osteogenesis imperfecta
What is astigmatism
Abnormal corneal curvature leading to inability to see both close and far
Management of astigmatism
Cylindrical lenses
If develop gingivitis on phenytoin what do
Refer to neurologist for medication review
Where measure central venous pressure from
Insert through right internal jugular vein or right braciocephalic to superior vena cava which measures preload
A 19-year-old, asymptomatic male presents to his General Practitioner. He is concerned since his father died of colorectal cancer at the age of 35 years. He is concerned that he may develop the condition himself. What would be the most appropriate management of this patient?
Colonoscopy
Normally do around age of 20 for those with family history of colorectal cancer death/diagnosis in 30s
If polyps found to panproctocolectomy
What muscle and nerve contribute to winging of scapula
Long thoracic
Serratus anterior
What does macula on mean
That central vision or overall acuity has not been affected
If have inferonasal retinal visual loss then where is retinal tear
Superotemporal retinal tear
If history of liver disease what would be best opiate choice
Fentanyl
What is stomach complication of primary hyperparathyroidism
High Ca can lead to peptic ulceration
Carpet layer presents with severe anterior knee pain and swelling over patellar
Pre patellar bursitis
Repetitive trauma over area from kneeling is responsible
Bursitis management
Determine if septic from aspirate
If aseptic NSAIDs with or without steroid injection
If septic then antibiotics with therapeutic aspirate
How position knee for aspiration
Knee fully extended
Teenager has bitemp hemianopia and delayed growth, what is most likely cause
Craniopharyngioma most common in younger years as cause of panhypopituitarism compared to pituitary adenoma
Lymphoedema presentation in leg
Painless unilateral swelling in leg
Worse towards end of day
How diagnose lymphoedema
Clinically but can do lymphoscintigram
When can stop drinking carbohydrate rich drinks before surgery
2 hours
What are 2 best indicators of acute limb ischaemia compared to critical limb ischaemia
Parasthesia
Paralysis
Management of HB in MI
Temporary pacing until after primary PCI/attempts at revascularisation
Tropical sprue management
Folate supplementation
Tetracycline
What does positive head impulse test show
That cause of vertigo is peripheral
Which electrolyte if abnormal will lead to hypokalaemia
Hypomagnesaemia
What do if T2DM on metformin during ramadan
Take 1/3 dose before sunrise
Take 2/3 after sunset
In tension pneumothorax what is the type of shock
Obstructive
When give IV paracetamol for renal stones
If IM diclofenac CI orif IM diclofenac has not worked in touching the pain
Key distinguishing feature of lateral medullary syndrome
Dysphagia
Vertical diplopia CN cause
Trochlear
What is seen in the miller fischer variant of GBS
Opthalmoplegia
Ataxia
Areflexia
Descending paralysis
If bleed on right side of brain leading to right to left shift, which cranial nerves will be affected
Right
Efferent nerve for light reflex
3rd
If propranolol CI for essential tremor what use
Primodine- barbiturate
If measure urate during attack how interpret
Over 360= supports diagnosis
Under 360= remeasure at least 2 weeks after inflammation dies
What do if bite from HIV +ve human
Let bleed
No need for PEP
What is management of T1DM if HbA1c comes back as over 48
Increase doses
If patient is on PCA and requests extra painkillers what do
Add paracetamol
Can not be on concomitant opioids
Patient has pruritus, pale stools and positive smooth muscle abs, what is next step?
Bone marrow biopsy
Fecal calprotectin
MRCP
Ursodeoxycholic acid
Vitamin K
MRCP
Exclude duct obstructions, also note anti smooth muscle seen in some PBC patients
Gold standard for typohoid
Can use blood cultures or widal test but BM aspirate the gold standard
Curved rods causing gastroenteritis
Campylobacter
New vessels on the iris in T1DM what do next
Measure intraocular pressure as is rubeosis iridis, a complication of proliferative T1DM which can lead to glaucoma
What causes burr cells/echinocytes
Uraemia from CKD
Patient comes in with recent knee replacement which is probably infected, what do
Urgent ortho referral as likely needs to be aspirated in theatre
MOA of dipyramidole
Phosphodiesterase inhibitor
ACEi effect on bowel
Constipation
How differentiate between chylothorax and empyema
Centrifue pleural aspirate
In chylothorax will remain opaque
Patient with UTI develops bilateral bibasal creps, what is cause
ARDS
Max magnesium replacement rate per hour
36mmol
Arterial spasm vs venous occlusion priapism
Venous (ischaemic)- painful and rigid. seen in SCD and malignancy
Arterial (noniscahemic)- painless and semirigid, caused by trauma
On TB meds- develop microcytic anaemia with high ferritin
Isoniaxid causes sideroblastic anaemia
Morphine to fentanyl
0.42
Patient has memory loss and means forgetting to take daily morphine, what do
Switch to fentanyl patch with immediate release morphine for pain relief
Palliative patient describes spasmodic pain, what use
Diazepam
Which condition most associated with MG
Thymic hyperlasia
How manage MG if thymoma
THymectomy
How manage NPH
If fit for surgery- ventriculoperitoneal shunting
If not then conservative with repeated CSF taps
Grade 3 HTN management in A&E
If symptomatic then- IV labetalol ASAP
If not then can consider oral agent
Mesenteric adenitis cause
Yersinia enterocolitica
Which anaesthetic use for perianal abscesses
Local unless suspect infiltration of sphincter
Pyogenic granuloma
How give adenosine
Initially give IV then start oral regime
If awaiting surgery for achalasia what can give
Nifedipine
How manage dermatitis herpetiformis
Dapsone- sulph antibiotic
What do with fludrocortisone perioperatively
Stop
IV hydrocortisone will have enough mineralocorticoid effects
If starting TPN, what need to monitor
Hypomagnesaemia
When start TB meds
As soon as suspect TB
Cholera antibiotic
Doxycycline
What do if triple vessel disease noted at PCI
CABG
How best assess small bowel disease in crohns
MRI
Patient has had recent MI with drug eluting stent insertion, due for surgery. What do with current medications
Speak to cardiology as risk of stent stenosis
If had MI or stroke in last 3 months what does this make ASA
4
Triggers of lichenoid reaction
beta-blockers, thiazides, gold, quinine, quinidine, penicillamine, and ACEi
If have infected surgical wound site with pus, how manage
Remove sutures to release pus
Hep C patient develops leg oedema, what is cause
Membranoproliferative GN
Patient with history of lung cancer presents with addisons, what is next investigation
CT abdomen as likely mets
Treated with DKA and met resolution criteria but still confused
Cerebral oedema- do head CT
If on long term steroids and develop high BM’s, what do
Give gliclazide for steroid induced diabetes if glucose above 10 twice 24 hours apart
Acute mesenteric ischaemia management
If evidence of peritonitis, infarction or perforation then do urgent laparotomy
If not then do CTangio
Investigation for chronic mesenteric ischaemia
CTangio
If have DVT on a DOAC what do to manage
Increase dose of DOAC
Change to warfarin
Patient with abdominal cancer has become anuric with abdominal pain, what do
USS of bladder
USS of renal tract and kidney to assess for obstruction and hydronephrosis from cancer obstruction
Treatment of TED
Steroids
If visual acuity affected then consider surgical decompression if optic nerve indicated
Difference in most common site of prostate adenocarcinoma vs BPH
BPH- transitional zone
Peripheral zone- cancer
Candida presentation in men
Itching and redness
Dry plaques and papules
Other than elbows and knees where can dermatitis herpetiformis affect
Shoulders
Where is V1 chest lead placed
Right sternal border
4th ICS
Blisters on back of hand and hypertichosis on cheek
Porphyria cutaneous tarda
Best investigation for gastrinoma
Secretin stimulaiton test
Gastrin levels are good screening test
Long term catheter can cause what in bladder
Squamous cell carcinoma
Small breast lump which grows very rapidly after initially being mobile
Phyllodes
Causes of lymphocytic picture on pleural tap
Cancer
TB
How manage contacts of TB patients
Do mantoux test
If negative give BCG
What is hemispatial neglect
Although can see an area you do not process its presence
Counts as higher dyfunction in stroke criteria
If have AKI with renal stone what do
Insert JJ stent as suggests is obstructed
Problem with trimethoprin in assessing eGFR
Increases creatinine secretion
How does cryoglobulinaemia present
Hep C
Then vasculitis
How manage hypertensive emergency with ACS
IV GTN
Patient with T2DM on ward becomes hyperglycaemic with random glucose 20 what do
SC insulin or VRII
Hyperglycaemia common occurence in people with T2DM on ward
How investigate renal TB
Early morning urine samples
What defines stage 3 AKI
Over 3x baseline
Over 355
Under 0.3ml/kg/hour for 24 hours
How diagnose PNH
Flow cytometry for CD55 and CD59
Skin changes in PAN
Ulcers with palpable purpura
Use biopsy to diagnose
Lots of white spots on glans of penis and management
Penile papules
Do nothing
Quinsy management
Aspiration and abx
Avoid incision as proximity to carotid
Patient with testicular cancer had orchidectomy. CT showed enlarged para-aortic lymph nodes. What will the MDT likely advise?
Radiotherapy
