Past Papers Flashcards
Explain what an Addisonian Crisis is?
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.
Common causes/precipitants of Addisonian crisis?
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)
What is the biggest RF for Addisonian crisis?
Long-term steroid therapy (oral = most common cause)
What symptoms may be seen in Addisonian crisis?
Sudden pain in back, abdomen or legs
D+V: dehydration, hypotension, hypovolaemic shock
Loss of consciousness
Fatigue
Addisonian Crisis. Changes seen in:
1) Sodium
2) Potassium
3) Creatinine
4) pH
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)
What is the Parkland formula for burns?
Fluid requirement (mL) = TBSA (%) x body weight (kg) x 4
TBSA = total body surface affected
How is COPD managed?
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.
What is Wallace’s rule of 9s in burns?
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)
What is the parkland formula for estimating fluid requirements in a burns patient?
Fluid requirement (ml) over 24h = TBSA (%) x weight (kg) x 4
What are the different depths of burns? Which has blisters?
Superficial (epidermal)
Superficial dermal
Deep dermal (both of these have blisters)
Full thickness
What signs might you see in a patient with mitral regurgitation?
Systolic murmur
Soft S1 (due to incomplete closure of valve before start of systole)
Displace apex beat (LVH)
What is Starlings law?
Increased SV due to increased EDV as this will increase stretch of LV thus generating stronger contraction of cardiac myocytes
What signs might be seen in CML?
Pallor, lethargy (anaemia)
Bruising, petechiae (thrombocytopenia)
Frequent/severe infections (neutropenia)
Bone pain (bone marrow infiltration) Hepatosplenomegaly Lymphadenopathy Testicular swelling Neurological (CN palsies, meningism)
Chromosome seen in CML?
Philadelphia Translocation T(9:22) Tyrosine kinase
What are the two main types of bone marrow test?
BM aspiration - sucks liquid bone marrow
BM trephine biopsy - removes 1-2cm core of bone marrow from posterior iliac crest
What is the advantage of bone marrow trephine biopsy as opposed to bone marrow aspiration?
Shows structure of bone marrow
What is epilepsy?
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.
How long must a patient be seizure free for before driving?
One year
6 months if first, single non-epileptic seizure
Give 3 types of generalised seizure
Tonic-clonic Absence (children - 3 Hz spike and wave) Myoclonic Tonic Akinetic
Give 3 types of focal seizure
Temporal - deja-vu, vertigo, hallucination
Frontal - strange smells
Parietal - sensory, e.g. skin crawling
How do you treat:
a) generalised tonic-clonic
b) absence seizures
c) myoclonic seizures
d) partial seizures
a) sodium valproate or lamotrigine, carbamazepine
b) ethosuximide (avoid carbamazepine)
c) sodium valproate (avoid carbamazepine)
d) lamotrigine or carbamazepine
What are the 3 defining features of a health economic evaluation?
Cost of both services
Benefit of both services
Comparison of costs and benefits of the service and alternative service
What are the two features comprising a QALY?
Length of life (yrs) x Quality of life (0-1)
How can quality of life be measured? (give an example)
PROMs (Patient Reported Outcome Measures)
e. g. EQ-5D-5L (5 domains, 5 levels)
e. g. ePAQ (personal assessment questionnaire)
What are the 5 domains in an EQ-5D-5L?
Mobility Self-care Usual activities Pain/discomfort Anxiety/depression
What system do health economists use to evaluate disability?
DALYS (disability adjusted life years)
Define healthcare economic ‘efficiency’?
Getting the maximum cost/health benefit outcomes from a service
What is the term for when treatment is given to one area, meaning sacrifice is made elsewhere?
Opportunity cost
Define a subarachnoid haemorrhage
Bleeding into the space between the arachnoid and pia mater
Why does SAH cause coma?
Due to the raised ICP
Give 4 causes of coma
‘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
Give some key differentials for a fixed dilated pupil (mydriasis)?
Pharmacological (anticholinergics, alpha1-agonists)
Oculomotor nerve (CNIII) palsy
Holmes-Adie pupil
Acute closed angle glaucoma
Immediate management of patient you suspect to have had an SAH?
ABCDE assessment - intubate and O2 if needed
CT scan
Nimodipine (3wks, reduce vasospasm)
Refer for surgery to stem bleed - endovascular coiling/clipping
4 features of brainstem death?
Fixed pupils, unreactive to light Absent cough reflex Absent corneal reflex Unresponsive to supraorbital pressure No respiratory effort in response to turning off ventilator
Give 3 causes of hypoglycaemia in a pt with T1DM
Insulin overdose Infection Alcohol Insufficient carbohydrate intake Too much exercise
What screening should patients with diabetes receive?
Diabetic eye check (retinopathy)
Diabetic foot check (monofilament - peripheral neuropathy)
Renal function tests (diabetic nephropathy)
ABPI (arterial circulation - autonomic damage)
4 features of depression?
Anhedonia Anergia Low mood Decreased cognition Decreased libido Feelings of guilt Suicidal ideation Struggling to sleep, early morning waking
What would you look for in a patient presenting with breast lump?
Size Smooth or irregular Skin changes (colour, texture) Nipple changes (inverted, discharge, colour) Whether lump is mobile or tethered Tender? Any lymph nodes involved
Young woman presents with +ve pregnancy test, closed os, slightly large uterus, blood in vagina. 3 possible causes?
Threatened/complete miscarriage Ectopic with fibroids Molar pregnancy Cervical ectropion Trauma to vaginal canal
Young woman presents with +ve pregnancy test, closed os, slightly large uterus, blood in vagina. 3 investigations?
TVUS
Abdominal ultrasound
Urine dip
Cervical swab
Bladder cancer. Most common cell type involved? Where else is this found? 4 RFs for bladder cancer Which artery supplies the vesicle arteries?
Transitional cell
Ureters, urethra
FHx, smoking, frequent bladder infections, working in a rubber dye factory
Internal iliac
What lymph nodes should the surgeon consider when removing the bladder and prostate?
External iliac
Obturator
Internal iliac
Common iliac
2 Sx cauda equina at the following sites:
1) Perianal skin
2) Lower limb
3) Anal and urethral sphincters
1) Perianal skin - saddle paraesthesia, decreased tone
2) Lower limb - pain, weakness, upgoing planters, altered reflexes
3) Relaxation of anal and constriction of urethral
Pericarditis.
What would you hear on auscultation?
4 investigations to confirm?
Pericardial rub
ECG (depressed PR, upwardly concave ST) Serum troponin ESR/CRP Pericardiocentesis CXR (normal, or water-bottle heart) Echo
Two treatments for pericarditis?
NSAID (aspirin) + PPI (omeprazole)
Steroids (prednisolone)
If cardiac tamponade/purulent effusion suspected, pericardiocentesis + treat cause!
Patient with pericarditis develops raised JVP, hypotension and tachycardia. What is the cause?
Cardiac tamponade
Two causes of pericarditis?
Post-MI Recent viral infection Bacterial infection (eg TB) Chest trauma Autoimmune disorders Cancer Uraemic pericarditis
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?
FBC (anaemia, pancytopenia - bone marrow infiltration)
Full body CT scan with contrast
PET scan (staging)
CT-guided biopsy
What are the 4 types of lung (bronchial) cancer?
Small cell
Adenoma
Squamous
Large cell
Which type of lung cancer is most seen in non-smokers?
Adenocarcinoma
What is an apical tumour called?
Pancoast’s tumour
Treatments available for lung cancer?
Chemotherapy (if WHO performance status 0-2)
Surgical excision
Radiotherapy (radical or for symptom relief)
80 year old woman with bilateral pain and 2-3hrs morning stiffness in shoulders, hips and thighs. Elevated CRP and ESR.
Suspected diagnosis?
Management?
Polymyalgia rheumatica
Prednisolone (+ osteoporosis prophylaxis - bisphosphonates + calcium + vitamin D)
What other questions may you want to ask in a person presenting with polymyalgia rheumatica? Why?
Associated with GCA, so ask about: Headaches Scalp tenderness Jaw claudication Visual disturbance
What is the ratio of chest compressions to breaths in ALS CPR?
30:2
What are the 2 shockable rhythms?
VF
Pulseless VT
What are the 2 non-shockable rhythms?
Pulseless electrical activity
Asystole
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?
Boerhaave’s Syndrome (spontaneous oesophageal rupture)
Occurs due to raised intraoesophageal pressure (ie vomiting, large meal)
How would you investigate oesophageal rupture?
CXR (infiltrate/effusion)
CT w/contrast
Diagnostic endoscopy
How would you manage oesophageal rupture?
Contact ICU
Fluid resus
IV antibiotics + antifungals
Refer to specialist oesophago-gastric centre
What is Mackler’s triad?
Three features of oesphageal rupture:
1) Chest pain
2) Vomiting
3) Subcutaneous emphysema
Why is waveform capnography useful in a peri-arrest situation?
Can indicate return of spontaneous circulation (ROSC) - increase in end tidal CO2
What are the two drugs that are administered during a CPR protocol?
Adrenaline 1mg IV (every 2 cycles)
Amiodarone 300mg IV (after 3 shocks)
What investigations may you want to do in a patient who has been rescued from a house fire?
Pulse oximetry ABG Carboxyhaemoglobin CXR, ECG Urine/serum toxicology
What anticoagulation would you give to someone with a prosthetic heart valve?
Warfarin + aspirin (DOACs are currently C/I in these patients)
In which 2 key conditions do you see Koebner phenomenon?
Psoriasis
Vitiligo
What is Boerhaave’s syndrome?
Spontaneous oesophageal rupture due to increased intraoesophageal pressure
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?
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
Briefly describe the difference between nephrogenic and cranial diabetes insipidus
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)
Woman comes in with oligomenorrhoea, headaches, galactorrhoea. How would you manage a prolactinoma?
1) Dopamine agonist, e.g. cabergoline
2) COCP
3) Trans-sphenoidal surgery
4) Sellar radiotherapy
What is octreotide?
Somatostatin analog. Inhibits GH, glucagon, insulin
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?
Haemochromatosis
Transferrin saturation
What type of arthralgia might you see in haemochromatosis?
Pseudogout (calcium pyrophosphate crystals deposited)
Aside from diabetes and pseudogout, what other problems might someone with haemochromatosis experience?
Cardiomyopathy (dilated/restrictive) Hypogonadism Skin discolouration (bronze -> slate grey)
What is the first-line investigation of a neck lump? What features would indicate malignancy? What would be the next Ix if malignancy suspected?
Cervical ultrasound scan
Large mass, central necrosis, peripheral hypervascularisation, microcalcifications, irregular border
Fine needle aspiration biopsy
Which antibody is most sensitive for Rheumatoid Arthritis?
anti-cyclic citrullinated peptide (anti-CCP)
Give 2 adverse effects of trimethoprim
- Myelosuppression
2. Rise in creatinine
Why should nitrofurantoin be avoided in pregnant women close to full term?
Risk of neonatal haemolysis
What type of Hep B infection does ‘ground glass hepatocytes’ point towards?
Chronic
How do you calculate the maintenance fluid requirements for a normal adult?
Electrolytes?
Glucose?
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).
What is the first line medical treatment for delirium?
Low-dose haloperidol
Myaesthenia gravis - give 3 signs/symptoms
Increasing muscle fatiguability Ptosis Diplopia Dysphagia Dysarthria Proximal limb weakness May develop SOB
What is a common precipitant for Myaesthenic crises?
Infections
How is a myaesthenic crisis managed?
Intubate and ventilate
Plasma exchange/ IVIg
Supportive (DVT prophylaxis, hydration, etc)
?Prednisolone/Rituximab
What antibodies are seen in MG?
Serum AChR antibodies
MuSK antibodies
What respiratory function tests would you do in a myaesthenic crisis?
Serial FVC and NIF (negative inspiratory force)
Why would you do a CT chest in MG?
Check for thymoma - may do thymectomy as 2nd/3rd line treatment
What is the first line treatment of mild/mod ongoing MG?
Pyridostigmine +/- prednisolone
Mycophenylate or Tacrolimus or Azothioprine
What type of drug is pyridostigmine?
What medication can be given with pyridostigmine in the treatment of MG to reduce its muscarinic side effects?
Acetylcholinesterase
Glycopyrronium
How would you manage a patient with a ureteric stone (causing obstructve uropathy) and signs of sepsis?
Analgesia
Nephrostomy (or ureteric stent)
Antibiotics (eg gentamicin)
What is the first line treatment for sinus bradycardia (with haemodynamic instability)?
1) Atropine IV bolus
or adrenaline/dopamine
Then pacing (transcutaneous/transvenous)
Management of an acute episode of gout?
1) NSAID (eg naproxen)
2) Colchicine (when NSAID C/I)
3) Prednisolone (if NSAID and colchicine C/I)
What is the most common pathogen in leg cellulitis?
Strep pyogenes
Old person presents with pain, tenderness, induration, warmth, erythema, and palpable cord along the lower leg. Suspected diagnosis? Investigation?
Superficial thrombophlebitis (SVT)
Doppler US
What is the first line treatment for superficial vein thrombophlebitis (SVT)?
NSAID, e.g. naproxen
Which regional lymph nodes is ovarian cancer most likely to spread to?
Para-aortic
What is the management for symptomatic gallstone disease?
Laparoscopic cholecystectomy
Management of venous leg ulcer (if ABPI within normal ranges)?
Compression stockings
What is the initial management of SVCO? Why?
Dexamethasone
To reduce tumour swelling
What drug can be used to reverse heparin overdose?
Protamine sulfate
High INR. How do you manage major bleeding in a patient on warfarin?
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)
What is the definitive investigation for nephrotic syndrome in adults?
Renal biopsy
