Past Papers Flashcards
Shoulder and hip girdle pain
Raised inflammatory markers
Not responding to steroids
Possible diagnosis?
Rheumatoid arthritis - can present as polymyalgia syndrome before articular features
Non convulsive status epilepticus
- investigation findings
Usually signs link rapid blinking, twitching, may be confused but will be responsive
Must last more than 30 minutes
Need EEG to confirm, normal lactate usually (nil tonic clonic activity)
What do you need to do prior to starting RCHOP?
Hepatitis B serology
Rituximab can reactivate
Atrial fibrillation
Unable to rate control with beta blocker
Diltiazem or digoxin if possible
Remember other agents e.g. amiodarone will cardiovert patient
Diagnosis of sleeping sickness
Can use serology/lymph node biopsy, ideally LP
Any neurological involvement will need treatment
Autoimmune hepatitis
Raised IgG
Type 1 Autoimmune Hepatitis
Determining salicylate overdose
Management
> 450 - moderate overdose, treat IV bicarbonate
> 700 or resistant acidosis/neurological sequale, consider haemodialysis
Indication for hyperbaric oxygen in CO poisoning
Carboxyhaemoglobin levels >25%
Nerve palsy CN III, IV, V
How to determine location of lesion
Use which branches of CN V are involved, remember V1 superior orbital fissure, V2 foramen rotundum
If multiple branches involved = cavernous sinus
Uniform capillary wall deposits IgG and C3
Membranous glomerulonephritis
Management of membranous nephropathy
BP control with ACE inhibitor
Immunosuppression e.g. oral prednisolone
Management of necrobiosis lipodica
Topical corticosteroids
Secondary prevention in CKD
No need for QRISK
Start statin straight away
Eccentric
Social isolation
Inappropriate affect
- personality disorder?
Schizotypal
What do you need to diagnose someone with an insulinoma/begin further investigation?
Hypoglycaemic symptoms which coincide with hypoglycaemia
Symptoms improve with raising blood sugar
How to differentiate between 1y hyperparathyroidism and familial hypocalciuric hypercalcaemia
PTH levels?
PO4- level
1y = low (XS PTH promotes phosphate excretion by the kidneys)
Familial hypocalciruic = normal PO4-, may have normal/high PTH
What do you need on renal biopsy of Alport’s syndrome?
Electron microscopy
CSF results in cryptococcal meningitis
Low glucose
Elevated protein
Raised opening pressure
Management of gastroparesis
Domperidone
Can also use metoclopramide
How to manage cisplatin related nephrotoxicity
Switch to platinum alternative e.g. carboplatin
Management of Takaysau’s arteritis
Prednisolone
Differentiating between pseudo-Cushing’s and Cushing’s
Pseudo = retain diurnal variation of cortisol, check a midnight level
Cushing’s = loss of diurnal, persistently high
Management of thyroid eye disease
Consider the severity
Mild = nil optic nerve involvement
Artificial tears and smoking cessation
Moderate/severe = steroids
When would you use SGLT2 as second line?
CVD disease e.g. hypertension
ACR >30
Lower limb weakness
Painful paraesthesia
Reduced sensation distally
Absent ankle jerks
Fasciculations
Diabetic Amyotrophy
How often should those with cirrhosis be screened for HCC?
Every 6 months
Option for xanthelasma management
Topical trichloroacetic acid
Likely diagnosis HIT - test you can use to confirm
Serotonin release assay
Initial management of diabetes
- metformin contraindicated
If CVD disease - SGLT2 monotherapy
Management of Flu A
- immunocompromised
Zanamivir
Indication of severe AS - heart sounds
Soft S2
What type of amyloidosis is associated with inflammatory conditions?
AA amyloidosis
Treatment associated with increased risk of delayed bleeding
Plasma exchange
- depleted of clotting factors etc
First presentation of uncal herniation
Ipsilateral CN III palsy
What is moraxella seen in association with?
COPD
How can you avoid post-LP headache?
By re-inserting the stylet when removing the needle
Volume of CSF removed largely doesn’t make a difference
How do you manage bone and joint TB?
Same - 2 months RIPE and 4 months rifampicin and isoniazid
Biopsy findings in anti-GBM disease
Linear IgG and C3 deposits in the membrane with crescenteric glomerulonephritis
Lung nodule follow up
<5mm - no further follow up
5-8mm - CT in three months
>8mm - Brock risk stratification, likely to have PET CT
Cardiac arrest
P waves only on monitor
Management?
Consider ventricular standstill - consider pacing
Management of small bowel obstruction 2y to metastatic cancer
Dexamethasone
Investigations in acute GBS
Nerve conduction studies may be normal
Will see elevated CSF protein
CT findings in normal pressure hydrocephalus
Ventriculomegaly
Normal sized sulci/gyrus
What pre-excitation disorders are there?
Wolff Parkinson White - short PR, delta wave
Lown-Ganong-Levine - short PR, no delta wave
Features of pseudogout on XR
Calcification of meniscus
Knee - may see calcification of the patellar/quadriceps tendon
What can you use in HUS?
Eculizumab
Reduces complement activation which drives the haemolytic process
Investigation of choice in MND
Electromyography
Investigation of choice in sarcoidosis
Pulmonary function tests
Management of lytic bone lesions in myeloma
- isolated
- risk of fracture
Single = denosumab
Fracture risk = radiotherapy
Management of Lambert Eaton Syndrome
Amifampridine
= blocks K+ channels to extend action potential, allows Ca2+ channels to be open for a longer duration, more ACh release
Management of urinary schistomiasis
Praziquantel
Differentiating pituitary tumours
Microadenoma = no visual field defects
Macroadenoma = very high prolactin, often visual field defect
Non-functioning = often see hypopituitarism as a result of compression
What can be used to manage delirium in Parkinson’s disease?
Lorazepam
Multiple transfusions
Hypoxia
Pyrexia
Hypotension
- diagnosis
Transfusion associated lung injury
The pyrexia helps differentiate
Management options for remission of membranous nephropathy
Rituximab
Prednisolone + cyclophosphamide (obviously avoid in young people)
Management option in IBD resistant to TNFa inhibitor/not suitable for TBFa I
- mechanism of action
Vedolizumab
= integrin antagonist, blocks white cell movement across the intestinal epithelium
What renal stones are associated with small bowel overgrowth?
Calcium oxolate
= fat malabsorption associated with increased oxolate absorption
What is associated with the best prognosis in cardiac arrest?
Ventricular Tachycardia
Multi-infarct dementia - presentation
Various steps in altered cognition
e.g. memory around cooking, then names then items to do
Cardiac risk factors
Causes of axonal neuropathy (10)
Diabetes
HIV
B12 deficiency
Hypothyroidism
Uraemia
Chemotherapy
Paraneoplastic
Paraproteinaemia
Tropical spastic paraparesis
Cryoglobulinaemia vasculitis
Nerve conduction studies
- reduced amplitude of signals
= axonal neuropathy
Number of axons are less due to damage, results in weaker signal
Nerve conduction studies
- decreased signal velocity
= demyelinating neuropathy
Pattern of loss in axonal neuopathies
Sensory loss first, distal then proximal
- this is because longer fibres are affected first
Hands affected only when at level of knees
Motor involvement is later
Deep tendon reflexes lost
Pattern of loss in demyelinating neuropathies
Motor loss first with motor weakness a prominent feature
Remember some sensory nerves are myelinated - these can be affected by demyelination in multiple sclerosis giving sensory symptoms
Reflexes
- UMN lesion
- LMN lesion
Upper = hyper reflexic deep tendon reflexes, absent superficial reflexes
Lower = absent deep tendon reflexes
Paraparesis
- UMN lesion
- LMN lesion
Upper = spastic
Lower = flaccid
Features of erythroderma
Systemic upset
Bright red
Often associated with recent cessation of PO steroid
Contraindication to use of ciclosporin
Chronic kidney disease
Differentiating between essential tremor and parkinson’s diagnosis
SPECT imaging
When would you use rifaximin?
In the prophylaxis of hepatic encephalopathy
No role in acute management
Key feature of accelerated idioventricular rhythm
No p waves present
Prolonged APTT
What can you use to determine cause?
Results?
Mixing study
If factor deficiency = APTT improves with mixing
If factor inhibitor = nil improvement with mixing, likely acquired Haem A
What is a cause of acquired haem A?
Clopidogrel
Distinguish between Familial Mediterranean Fever and Behcet’s Disease
Both may present with pyrexia, abdominal pain, arthralgia
FMF = NO ulcers, high fever and high CRP
MEFV mutation
Behcet’s = ulcers, normal CRP
Pathergy test
Low dose dexamethasone suppression test (1mg overnight or two day test)
Result = Cortisol high at end of test
= Cushing’s syndrome
Further test to localise - either insulin stress test or high dose dexamethasone test
High dose dexamethasone suppression test
- results and diagnosis
Suppress cortisol = Cushing’s disease (adenoma)
No suppression of cortisol = ACTH ectopic source
Insulin tolerance test - what does it aim to do?
Induce hypoglycaemia to see whether there is a ACTH/cortisol response
Insulin tolerance test
Result: hypoglycaemia + high ACTH/cortisol
Pseudo-Cushing’s
What is a metallo beta-lactamase?
CPE
Antibiotic options for CPE?
Colistin
Tigecycline
Fosfomycin
Gentamicin
What anti-emetic is of use in delayed phase emesis?
Dexamethasone
Shortness of breath
Purulent cough
Macular rash on face
Atypical pneumonia
Psittacosis
How does methylene blue work?
Reduction of Fe3+ to Fe2+
Option for nausea in long QT syndrome
Aprepitant
What is the chance of focal segmental glomerulosclerosis going into spontaneous remission?
<10% chance
Livedo reticularis - associations (3)
Anti-phospholipid syndrome
Cholesterol embolism
Polyarteritis nodosa
Management of chicken pox
- immunocompromised
IV aciclovir
- can use oral if nil systemic upset
- if symptomatic too late for immunoglobulin
Modest CK elevation
Muscle weakness
Anti-TPO antibodies
Hypothyroidism
- can be associated with CK elevation in untreated disease
Acute hepatitis - associated with HIV seroconversion?
NO
Hypertension
Hypokalaemia
Raised renin and aldosterone
- diagnosis?
Fibromuscular dysplasia
= reduced renal perfusion, activates RAAS system
Hypertension
Hypokalaemia
Low renin and raised aldosterone
- diagnosis
Conn’s syndrome
Management of T2 N1 NSCLC (ipsilateral hilar node)
Pneumonectomy if well
Distinguish between Becker and Myotonic
Largely age - myotonic longer life expectancy
+VE edrophonium test
Myaesthenia gravis
What are the stages of treatment of prostate cancer?
Bicalutamide - androgen antagonist, blocks receptors in tumour and prevents tumour flare with use of GnRH agonist (Gosrelin)
Polymyositis - extra-muscular mainfestations
ILD
Can you use warfarin in pregnancy?
No - contraindicated
Management of BPH
Finasteride - good option, takes a while to get to therapeutic effect
Doxazosin - gives immediate improvement to symptoms, relaxes the smooth muscle
Electrical management of HF + EF low and broad QRS
Usually CRT-P
CRT-D if there has been evidence of ventricular arrhythmia
Management of malaria
Uncomplicated = artemether + lumefantine
Complicated
e.g. significant parasetaemia
= IV artesunate, bolus initially
VT vs SVT
All complexes in the chest leads should be uniform (i.e. not a mixture of broad and narrow) in VT
If V1-V3 broad consider SVT with RBBB
Achalasia - weight?
Can remain stable
Management of hepatorenal syndrome
Type 1 = rapid decline of renal function
1st - terlipressin to promote splanchnic vasoconstriction, increase circulating volume
2nd - TIPSS
Initiation of NIV
- nil improvement after 1 hour
Consider elective intubation and ventilation
1st line investigation of hypoadrenalism
Short synacthen test
How many PVCs are you allowed a day?
<10%
= approx 10’000 per day
Management option in digoxin toxicity
Digoxin immune Fab
= fragments of antibodies
What is CLL associated with? Increased risk?
Autoimmune haemolytic anaemia
Increased risk with fludarabine
What is the mechanism behind hyperchloraemic metabolic acidosis following DKA correction?
Plasma volume expansion
(not excessive replacement)
Confused
Nausea
Initial dialysis
- diagnosis
- management?
Dialysis dysequilibrium syndrome
Sodium modelling - can use a button on the machine to change the sodium content of the dialysate
Option for behavioural issues in Alzheimer’s Disease
Atypical antipsychotic
e.g. risperidone
Management of histoplasmosis
Itraconazole
Confirmation of brain stem death
Apnoea testing
Hoarding and self-neglect
- diagnosis
- management
Diogenes syndrome
CBT
Management of VTE
- what do you need to consider?
Renal impairment - then LMWH not suitable
Use unfractionated instead
Vertebral dissection
- investigation of choice
MRI head + MRA
What can you see high levels of post seizure?
Hyperprolactinaemia
The epileptic activity propagates to the hypothalamus and triggers excessive prolactin release from the pituitary gland
Management of chronic paroxysmal hemicrania
Indomethacin
Can be used to aid diagnosis - should have excellent response
What is a cause of transient conjugated hyperbilirubinaemia?
Dubin-Johnson Syndrome
- all other causes are unconjugated
Management of cystinuria
Pencillamine
What can interact with diltiazem?
Ciclosporin
HIV medication + renal complication
Atazanvir
Associated with crystal nephropathy
Manage with hydration
Eosinophilia
Penicillin based antibiotics
Proteinuria
Haematuria
Acute tubular necrosis
What is the mechanism of action of dobutamine?
Increased inotropic action
Diagnosis of obesity hypoventilation syndrome
Raised BMI
Day pCO2 >6
Nil alternative cause identified
Remember OSA not a clinical diagnosis
Assessment of ?airway obstruction
Flow volume loop
Management of legionella
Levofloxacin
Bilateral PERIPHERAL infiltrates
Hard to control asthma
Raised IgG and ESR
Chronic eosinophilic pneumonia
Melanosis coli
Laxative abuse - specifically SENNA
Management of relapsing/remitting MS
Dimethyl fumarate
Progressive visual loss
Hypertension
Central vein occlusion
Test to confirm medullary thyroid cancer
Pentagastrin stimulation
What can insulin trigger?
Ventricular failure - promotes salt and water retention
Contraindication for furosemide
Pregnancy
= reduced placental perfusion
Management of cholera
Erythromcyin
Fibrate
How to manage in line with renal function?
Need to reduce dose in eGFR <60
Jaundice
Hepatomegaly
Abnormal LFTs
Liver transplant
- diagnosis
- management
Acute graft VS host disease
Hepatic US/doppler US
Pupil in Horner’s syndrome
Constricted pupil
Will NOT respond to atropine
Cause of hyperprolactinaemia
CKD
Urea reduces dopamine release
= increased release of prolactin
Risk of immune checkpoint inhibitors
Colitis
Treat with IV steroids
Mechanism behind GORD in systemic sclerosis
Oesophageal dysmotility
CCB and prokinetics superior to PPI
How often should people with Peutz-Jegher’s get a colonoscopy?
Every 3 years
Management of Familial Mediterranean Fever
Colchicine
Wrist dorsiflexion =
Wrist extension
Foreign travel
Transient non-erythematous swellings
Loa Loa
Management of latent TB
3 months RIP
or
6 months IP
What can reduce iron absorption?
Calcium/zinc/magnesium supplements
Management of Kawasaki’s Disease
IVIg and aspirin
Management of asbestosis
Nil specialist management, conservative
CSF in HSV encephalitis
Raised protein
Raised WCC - lymphocyte predominant
Normal glucose
What types of malaria are prone to relapsing?
Vivax
Ovale
Indications for CMV negative blood
Neonates
Pregnant women
Intrauterine transfusions
Serum electrophoresis VS serum free light chains
Different things
Sometimes serum free light chains can detect what electrophoresis cannot
Differentiating between 11 and 21 hydroxylase deficiency
11 = hypertension
21 = normotension
What does disulfiram do?
Unpleasant side effects when continue to drink
Nausea, vomiting, flushing, arrhythmias
Large volume of stool in spite of fasting
= secretory diarrhoea
e.g. VIPoma
Management of Mobitz II and third degree heart block
DDD pacemaker - need to pace atria and ventricles
Absence seizures - management
Levetiracetam or lamotrigine
MS management - what to consider?
Don’t need IV steroids if not having a flare
Likely need to refer to MDT for decision about drug modifying treatment
VTE
Pancytopaenia
Urine Hb not haematuria
- diagnosis
Paroxysmal nocturnal haemoglobulinuria
TB drugs - drug-induced lupus?
Isoniazid
Management of body dysmorphia
Exposure and response prevention therapy
Meningitis
Immunsuppressed
Ependymal enhancement
CSF = increased protein, decreased glucose, mild rise in opening pressure
CMV meningoencephalitis
Cause of low HDL and raised trigylcerides
Diabetes
Mucocutaneous lesions
Breast cancer
FH colon cancer
- diagnosis
- genetics
Peutz Jegher’s syndrome
STK11
Dark pink lesions on shin with orange peel appearance
Pretibial myxoedema
Features of Grave’s Disease
Pretibial myxoedema
Acropachy
Can you have Grave’s Eye Disease with normal TFTs?
Yes
What suggests increasing severity in mitral stenosis?
Increased duration of murmur
Digoxin toxicity and VT
IV lidocaine/lignocaine
Diagnostic test of Lambert Eaton Syndrome
NCS and EMG
What is the mechanism of action of oseltamivir
Neuroaminidase inhibitor
