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Medicine - Finals > Past Papers > Flashcards

Past Papers Flashcards

1
Q

Explain what an Addisonian Crisis is?

A

aka Adrenal crisis
Potentially fatal condition - acute glucocorticoid (cortisol) deficiency (also aldosterone - less)

Physiological demand for the hormones > ability of the adrenal gland to produce them.

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2
Q

Common causes/precipitants of Addisonian crisis?

A

Abrupt withdrawal of steroids
Infections (commonly GI), Injury, Surgery, Burns
Pregnancy
General anaesthesia
MI
Acute allergic reactions, Acute hypoglycaemia
Adrenal haemorrhage (eg Waterhouse-Friedrichsen syndrome)

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3
Q

What is the biggest RF for Addisonian crisis?

A

Long-term steroid therapy (oral = most common cause)

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4
Q

What symptoms may be seen in Addisonian crisis?

A

Sudden pain in back, abdomen or legs
D+V: dehydration, hypotension, hypovolaemic shock
Loss of consciousness
Fatigue

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5
Q

Addisonian Crisis. Changes seen in:

1) Sodium
2) Potassium
3) Creatinine
4) pH

A

1) Low sodium (not re-absorbed at DCT as aldosterone is not stimulating Na+/K+ pump)
2) High potassium
3) High creatinine (water follows Na in excretion, therefore dehydration and high creatinine)
4) Metabolic acidosis (aldosterone not stimulating excretion of H+ and absorption of bicarb)

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6
Q

What is the Parkland formula for burns?

A

Fluid requirement (mL) = TBSA (%) x body weight (kg) x 4

TBSA = total body surface affected

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7
Q

How is COPD managed?

A

1) SABA/SAMA (eg salbutamol/ipratropium bromide)
2) Assess whether steroid-responsive (?PMH asthma/atopy/raised eosinophils)
3) if YES: LABA + ICS (formoterol + beclamethasone - Fostair)
4) if still not controlled: add LAMA (tiatropium bromide)
5) if not steroid-responsive, LAMA + LABA eg Duaklir

Also: annual influenza vaccine, one-off pneumococcal vaccine, smoking cessation

Acute: SABA + 30mg prednisolone PO 7-10d.

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8
Q

What is Wallace’s rule of 9s in burns?

A 
Estimates TBSA (total body surface area) % affected by burns:
Head = 9
Arm = 9
Torso = 18 (9 front, 9 back)
Abdo = 18 (same)
Leg = 18 (same)
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9
Q

What is the parkland formula for estimating fluid requirements in a burns patient?

A

Fluid requirement (ml) over 24h = TBSA (%) x weight (kg) x 4

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10
Q

What are the different depths of burns? Which has blisters?

A

Superficial (epidermal)
Superficial dermal
Deep dermal (both of these have blisters)
Full thickness

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11
Q

What signs might you see in a patient with mitral regurgitation?

A

Systolic murmur
Soft S1 (due to incomplete closure of valve before start of systole)
Displace apex beat (LVH)

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12
Q

What is Starlings law?

A

Increased SV due to increased EDV as this will increase stretch of LV thus generating stronger contraction of cardiac myocytes

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13
Q

What signs might be seen in CML?

A

Pallor, lethargy (anaemia)
Bruising, petechiae (thrombocytopenia)
Frequent/severe infections (neutropenia)

Bone pain (bone marrow infiltration)
Hepatosplenomegaly
Lymphadenopathy
Testicular swelling
Neurological (CN palsies, meningism)
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14
Q

Chromosome seen in CML?

A 
Philadelphia
Translocation T(9:22)
Tyrosine kinase
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15
Q

What are the two main types of bone marrow test?

A

BM aspiration - sucks liquid bone marrow

BM trephine biopsy - removes 1-2cm core of bone marrow from posterior iliac crest

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16
Q

What is the advantage of bone marrow trephine biopsy as opposed to bone marrow aspiration?

A

Shows structure of bone marrow

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17
Q

What is epilepsy?

A

Continuous tendency to have recurrent unprovoked seizures even if the events are separated over long intervals. Caused by excessive, hypersynchronous neuronal discharges in the brain.

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18
Q

How long must a patient be seizure free for before driving?

A

One year

6 months if first, single non-epileptic seizure

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19
Q

Give 3 types of generalised seizure

A 
Tonic-clonic
Absence (children - 3 Hz spike and wave)
Myoclonic
Tonic
Akinetic
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20
Q

Give 3 types of focal seizure

A

Temporal - deja-vu, vertigo, hallucination
Frontal - strange smells
Parietal - sensory, e.g. skin crawling

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21
Q

How do you treat:

a) generalised tonic-clonic
b) absence seizures
c) myoclonic seizures
d) partial seizures

A

a) sodium valproate or lamotrigine, carbamazepine
b) ethosuximide (avoid carbamazepine)
c) sodium valproate (avoid carbamazepine)
d) lamotrigine or carbamazepine

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22
Q

What are the 3 defining features of a health economic evaluation?

A

Cost of both services
Benefit of both services
Comparison of costs and benefits of the service and alternative service

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23
Q

What are the two features comprising a QALY?

A

Length of life (yrs) x Quality of life (0-1)

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24
Q

How can quality of life be measured? (give an example)

A

PROMs (Patient Reported Outcome Measures)

e. g. EQ-5D-5L (5 domains, 5 levels)
e. g. ePAQ (personal assessment questionnaire)

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25
Q

What are the 5 domains in an EQ-5D-5L?

A 
Mobility
Self-care
Usual activities
Pain/discomfort
Anxiety/depression
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26
Q

What system do health economists use to evaluate disability?

A

DALYS (disability adjusted life years)

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27
Q

Define healthcare economic ‘efficiency’?

A

Getting the maximum cost/health benefit outcomes from a service

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28
Q

What is the term for when treatment is given to one area, meaning sacrifice is made elsewhere?

A

Opportunity cost

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29
Q

Define a subarachnoid haemorrhage

A

Bleeding into the space between the arachnoid and pia mater

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30
Q

Why does SAH cause coma?

A

Due to the raised ICP

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31
Q

Give 4 causes of coma

A

‘COMA’
CO and CO2 excess

Overdose (TCAs, Benzos, EtOH, insulin, paracetamol, etc.)

Metabolic (hypoglycaemia, Na+, K+, Mg2+, urea, ammonia, myxoedema coma (hypothyroid))

Apoplexy (stroke, SAH, extradural, subdural, Ca, meningitis, encephalitis, cerebral abscess, etc)

Seizures, septicaemia (meningococcal), hypoxia, etc

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32
Q

Give some key differentials for a fixed dilated pupil (mydriasis)?

A

Pharmacological (anticholinergics, alpha1-agonists)
Oculomotor nerve (CNIII) palsy
Holmes-Adie pupil
Acute closed angle glaucoma

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33
Q

Immediate management of patient you suspect to have had an SAH?

A

ABCDE assessment - intubate and O2 if needed
CT scan
Nimodipine (3wks, reduce vasospasm)
Refer for surgery to stem bleed - endovascular coiling/clipping

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34
Q

4 features of brainstem death?

A 
Fixed pupils, unreactive to light
Absent cough reflex
Absent corneal reflex
Unresponsive to supraorbital pressure
No respiratory effort in response to turning off ventilator
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35
Q

Give 3 causes of hypoglycaemia in a pt with T1DM

A 
Insulin overdose
Infection
Alcohol
Insufficient carbohydrate intake
Too much exercise
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36
Q

What screening should patients with diabetes receive?

A

Diabetic eye check (retinopathy)
Diabetic foot check (monofilament - peripheral neuropathy)
Renal function tests (diabetic nephropathy)
ABPI (arterial circulation - autonomic damage)

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37
Q

4 features of depression?

A 
Anhedonia
Anergia
Low mood
Decreased cognition
Decreased libido
Feelings of guilt
Suicidal ideation
Struggling to sleep, early morning waking
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38
Q

What would you look for in a patient presenting with breast lump?

A 
Size
Smooth or irregular
Skin changes (colour, texture)
Nipple changes (inverted, discharge, colour)
Whether lump is mobile or tethered
Tender?
Any lymph nodes involved
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39
Q

Young woman presents with +ve pregnancy test, closed os, slightly large uterus, blood in vagina. 3 possible causes?

A 
Threatened/complete miscarriage
Ectopic with fibroids
Molar pregnancy
Cervical ectropion
Trauma to vaginal canal
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40
Q

Young woman presents with +ve pregnancy test, closed os, slightly large uterus, blood in vagina. 3 investigations?

A

TVUS
Abdominal ultrasound
Urine dip
Cervical swab

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41
Q 
Bladder cancer.
Most common cell type involved?
Where else is this found?
4 RFs for bladder cancer
Which artery supplies the vesicle arteries?
A

Transitional cell
Ureters, urethra

FHx, smoking, frequent bladder infections, working in a rubber dye factory

Internal iliac

42
Q

What lymph nodes should the surgeon consider when removing the bladder and prostate?

A

External iliac
Obturator
Internal iliac
Common iliac

43
Q

2 Sx cauda equina at the following sites:

1) Perianal skin
2) Lower limb
3) Anal and urethral sphincters

A

1) Perianal skin - saddle paraesthesia, decreased tone
2) Lower limb - pain, weakness, upgoing planters, altered reflexes
3) Relaxation of anal and constriction of urethral

44
Q

Pericarditis.
What would you hear on auscultation?
4 investigations to confirm?

A

Pericardial rub

ECG (depressed PR, upwardly concave ST)
Serum troponin
ESR/CRP
Pericardiocentesis
CXR (normal, or water-bottle heart)
Echo
45
Q

Two treatments for pericarditis?

A

NSAID (aspirin) + PPI (omeprazole)
Steroids (prednisolone)

If cardiac tamponade/purulent effusion suspected, pericardiocentesis + treat cause!

46
Q

Patient with pericarditis develops raised JVP, hypotension and tachycardia. What is the cause?

A

Cardiac tamponade

47
Q

Two causes of pericarditis?

A 
Post-MI
Recent viral infection
Bacterial infection (eg TB)
Chest trauma
Autoimmune disorders
Cancer
Uraemic pericarditis
48
Q

Male, 75 year old smoker with haemoptysis. CXR shows a suspicious lump and there is concern that he has a cancer with cerebral mets.

3 Ix you would do, and why?

A

FBC (anaemia, pancytopenia - bone marrow infiltration)
Full body CT scan with contrast
PET scan (staging)
CT-guided biopsy

49
Q

What are the 4 types of lung (bronchial) cancer?

A

Small cell
Adenoma
Squamous
Large cell

50
Q

Which type of lung cancer is most seen in non-smokers?

A

Adenocarcinoma

51
Q

What is an apical tumour called?

A

Pancoast’s tumour

52
Q

Treatments available for lung cancer?

A

Chemotherapy (if WHO performance status 0-2)
Surgical excision
Radiotherapy (radical or for symptom relief)

53
Q

80 year old woman with bilateral pain and 2-3hrs morning stiffness in shoulders, hips and thighs. Elevated CRP and ESR.
Suspected diagnosis?
Management?

A

Polymyalgia rheumatica

Prednisolone (+ osteoporosis prophylaxis - bisphosphonates + calcium + vitamin D)

54
Q

What other questions may you want to ask in a person presenting with polymyalgia rheumatica? Why?

A 
Associated with GCA, so ask about:
Headaches
Scalp tenderness
Jaw claudication
Visual disturbance
55
Q

What is the ratio of chest compressions to breaths in ALS CPR?

A

30:2

56
Q

What are the 2 shockable rhythms?

A

VF

Pulseless VT

57
Q

What are the 2 non-shockable rhythms?

A

Pulseless electrical activity

Asystole

58
Q

A 64 year old man has vomiting and severe chest pain, radiating to L arm after eating a large meal. Temp 37.6°C, HR 130, BP 95/50 mmHg, RR 30. There is palpable subcutaneous
emphysema on the left side of his neck.
Suspected diagnosis?

A

Boerhaave’s Syndrome (spontaneous oesophageal rupture)

Occurs due to raised intraoesophageal pressure (ie vomiting, large meal)

59
Q

How would you investigate oesophageal rupture?

A

CXR (infiltrate/effusion)
CT w/contrast
Diagnostic endoscopy

60
Q

How would you manage oesophageal rupture?

A

Contact ICU
Fluid resus
IV antibiotics + antifungals
Refer to specialist oesophago-gastric centre

61
Q

What is Mackler’s triad?

A

Three features of oesphageal rupture:

1) Chest pain
2) Vomiting
3) Subcutaneous emphysema

62
Q

Why is waveform capnography useful in a peri-arrest situation?

A

Can indicate return of spontaneous circulation (ROSC) - increase in end tidal CO2

63
Q

What are the two drugs that are administered during a CPR protocol?

A

Adrenaline 1mg IV (every 2 cycles)

Amiodarone 300mg IV (after 3 shocks)

64
Q

What investigations may you want to do in a patient who has been rescued from a house fire?

A 
Pulse oximetry
ABG
Carboxyhaemoglobin
CXR, ECG
Urine/serum toxicology
65
Q

What anticoagulation would you give to someone with a prosthetic heart valve?

A

Warfarin + aspirin (DOACs are currently C/I in these patients)

66
Q

In which 2 key conditions do you see Koebner phenomenon?

A

Psoriasis

Vitiligo

67
Q

What is Boerhaave’s syndrome?

A

Spontaneous oesophageal rupture due to increased intraoesophageal pressure

68
Q

Patient with polyuria and polydipsia. Normal blood glucose levels. Serum osmolality HIGH and urine osmolality LOW. What is the likely diagnosis? How will you investigate?

A

Diabetes insipidus OR primary polydipsia

Water deprivation test + desmopressin:
8hr fluid deprivation, then measure serum and urine osm. Give desmopressin. 8hr fluid deprivation then measure again.
Nephrogenic: urine osm stays low after desmopressin
Cranial: urine osm increases after desmopressin

69
Q

Briefly describe the difference between nephrogenic and cranial diabetes insipidus

A

Nephrogenic - collecting ducts do not respond to ADH
(causes: lithium, hypercalcaemia, hypokalaemia)

Cranial - hypothalamus does not produce ADH for posterior pituitary to secrete
(causes: idiopathic, SOL, head trauma, meningitis, etc)

70
Q

Woman comes in with oligomenorrhoea, headaches, galactorrhoea. How would you manage a prolactinoma?

A

1) Dopamine agonist, e.g. cabergoline
2) COCP
3) Trans-sphenoidal surgery
4) Sellar radiotherapy

71
Q

What is octreotide?

A

Somatostatin analog. Inhibits GH, glucagon, insulin

72
Q

Patient with raised ALT, very raised ferritin, and raised CRP. Hepatomegaly. T2DM. Drinks 16units EtOH/week.
Suspected diagnosis?
What is the next investigation you would do?

A

Haemochromatosis

Transferrin saturation

73
Q

What type of arthralgia might you see in haemochromatosis?

A

Pseudogout (calcium pyrophosphate crystals deposited)

74
Q

Aside from diabetes and pseudogout, what other problems might someone with haemochromatosis experience?

A 
Cardiomyopathy (dilated/restrictive)
Hypogonadism
Skin discolouration (bronze -> slate grey)
75
Q

What is the first-line investigation of a neck lump? What features would indicate malignancy? What would be the next Ix if malignancy suspected?

A

Cervical ultrasound scan

Large mass, central necrosis, peripheral hypervascularisation, microcalcifications, irregular border

Fine needle aspiration biopsy

76
Q

Which antibody is most sensitive for Rheumatoid Arthritis?

A

anti-cyclic citrullinated peptide (anti-CCP)

77
Q

Give 2 adverse effects of trimethoprim

A
  1. Myelosuppression

2. Rise in creatinine

78
Q

Why should nitrofurantoin be avoided in pregnant women close to full term?

A

Risk of neonatal haemolysis

79
Q

What type of Hep B infection does ‘ground glass hepatocytes’ point towards?

A

Chronic

80
Q

How do you calculate the maintenance fluid requirements for a normal adult?
Electrolytes?
Glucose?

A

25-30ml/kg/day (20-25 if underlying cardiac disease)

+ 1mmol/kg/day Sodium, Potassium, Chloride

+ 50–100 g/day glucose (e.g. glucose 5% contains
5 g/100ml).

81
Q

What is the first line medical treatment for delirium?

A

Low-dose haloperidol

82
Q

Myaesthenia gravis - give 3 signs/symptoms

A 
Increasing muscle fatiguability
Ptosis
Diplopia
Dysphagia
Dysarthria
Proximal limb weakness
May develop SOB
83
Q

What is a common precipitant for Myaesthenic crises?

A

Infections

84
Q

How is a myaesthenic crisis managed?

A

Intubate and ventilate
Plasma exchange/ IVIg
Supportive (DVT prophylaxis, hydration, etc)
?Prednisolone/Rituximab

85
Q

What antibodies are seen in MG?

A

Serum AChR antibodies

MuSK antibodies

86
Q

What respiratory function tests would you do in a myaesthenic crisis?

A

Serial FVC and NIF (negative inspiratory force)

87
Q

Why would you do a CT chest in MG?

A

Check for thymoma - may do thymectomy as 2nd/3rd line treatment

88
Q

What is the first line treatment of mild/mod ongoing MG?

A

Pyridostigmine +/- prednisolone

Mycophenylate or Tacrolimus or Azothioprine

89
Q

What type of drug is pyridostigmine?

What medication can be given with pyridostigmine in the treatment of MG to reduce its muscarinic side effects?

A

Acetylcholinesterase

Glycopyrronium

90
Q

How would you manage a patient with a ureteric stone (causing obstructve uropathy) and signs of sepsis?

A

Analgesia
Nephrostomy (or ureteric stent)
Antibiotics (eg gentamicin)

91
Q

What is the first line treatment for sinus bradycardia (with haemodynamic instability)?

A

1) Atropine IV bolus

or adrenaline/dopamine

Then pacing (transcutaneous/transvenous)

92
Q

Management of an acute episode of gout?

A

1) NSAID (eg naproxen)
2) Colchicine (when NSAID C/I)
3) Prednisolone (if NSAID and colchicine C/I)

93
Q

What is the most common pathogen in leg cellulitis?

A

Strep pyogenes

94
Q

Old person presents with pain, tenderness, induration, warmth, erythema, and palpable cord along the lower leg. Suspected diagnosis? Investigation?

A

Superficial thrombophlebitis (SVT)

Doppler US

95
Q

What is the first line treatment for superficial vein thrombophlebitis (SVT)?

A

NSAID, e.g. naproxen

96
Q

Which regional lymph nodes is ovarian cancer most likely to spread to?

A

Para-aortic

97
Q

What is the management for symptomatic gallstone disease?

A

Laparoscopic cholecystectomy

98
Q

Management of venous leg ulcer (if ABPI within normal ranges)?

A

Compression stockings

99
Q

What is the initial management of SVCO? Why?

A

Dexamethasone

To reduce tumour swelling

100
Q

What drug can be used to reverse heparin overdose?

A

Protamine sulfate

101
Q

High INR. How do you manage major bleeding in a patient on warfarin?

A

1) Stop warfarin
2) IV vitamin K 5mg
3) Prothrombin complex concentrate (if not available then FFP - but slower and assoc with transfusion reactions etc)

102
Q

What is the definitive investigation for nephrotic syndrome in adults?

A

Renal biopsy

Medicine - Finals (13 decks)

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