PM2 Flashcards
[] is the investigation of choice for suspected Boerhaave’s syndrome
CT contrast swallow is the investigation of choice for suspected Boerhaave’s syndrome
What is the difference in murmur between pulmonary and tricuspid stenosis? [2]
Pulmonary stenosis: ejection systolic
tricuspid stenosis: diastolic
Difference between Cushing disease and syndrome? [2]
Cushing’s syndrome is a collection of signs and symptoms due to prolonged exposure to cortisol and Cushing’s disease is a specific type of Cushing’s syndrome characterised by increased ACTH production of because of a pituitary adenoma (or sometimes due to excess production of hypothalamus CRH).
CI to diclofenac for kidney stones? [2]
CKD; recent upper GI bleeds
to
Describe how you alter paracetamol tx depending on time of ingestion of paracet.
If < 4hrs:
- Wait until 4 hrs and measure paracetamol levels
If > 4hrs:
- NAC immediately
If staggered:
- Give NAC immediately
Surgical emphysema, chest pain & vomiting blood indicates what pathology? [1]
Boerhaave’s syndrome
Which electrolyte disturbances are a RF for VT? [3]
Which is the most important? [1]
Hypokalemia, hypomagnesemia, and hypocalcemia may predispose patients to either monomorphic VT or torsade de pointes.
A deficiency in which immunoglobulin increases the risk of such blood transfusion reaction?
IgA
IgD
IgE
IgG
IgM
A deficiency in which immunoglobulin increases the risk of such blood transfusion reaction?
IgA
IgD
IgE
IgG
IgM
What is dialysis dysequilibrium syndrome? [1]
As urea doesn’t leave the BBB as quick so you have excess urea in the brain but lower in circulation so there is a shift of water into the brain causing cerebral oedema
What are the HbA1c targets for DMT2 patients? [2]
What HbA1c do you add a therapy after titrating up metformin to maximum dose? [1]
The standard HbA1c target in type 2 diabetes mellitus is 48 mmol/mol for those taking a signal drug not associated with hypoglycaemia (in this case metformin).
For those taking more than one medication or a single medication associated with hypoglycemia then the target would be 53 mmol/mol.
Only add a second drug if the HbA1c rises to 58 mmol/mol (7.5%)
DVT investigation: if the scan is negative, but the D-dimer is positive → how do you manage? [1]
DVT investigation: if the scan is negative, but the D-dimer is positive → stop anticoagulation and repeat scan in 1 week
What MCV results are seen in SCA? [1]
Sickle cell disease causes a normocytic anaemia with raised reticulocyte count - due to haemolysis
What is the treatment of nephrogenic DI? [1]
Thiazide like diuretic:
- In simple terms DI leads to the production of vast amounts of dilute urine which is dehydrating and raises the plasma osmolarity, stimulating thirst. The effect of the thiazide causes more sodium to be released into the urine. This lowers the serum osmolarity which helps to break the polyuria-polydipsia cycl
Carcinoid syndrome can affect the [] side of the heart. The valvular effects are [] insufficiency and [] stenosis
Carcinoid syndrome can affect the right side of the heart. The valvular effects are tricuspid insufficiency and pulmonary stenosis
Which pathologies make up Men1, 2a & 3a [+]
What makes a AAA a high risk of rupture? 1[]
The presence of abdominal pain (1) indicates a symptomatic AAA which has a high risk of rupture, and these need surgical intervention rather than watching/medical treatment
How do you differentiate between rhabdomyolysis and other pathologies from blood results? [1]
rhabdomyolysis normally has CK elevations 5x greater than normal
elevations of CK that are ‘only’ 2-4 times that of normal are not supportive of a diagnosis and suggest another underlying pathophysiology
myoglobinuria: dark or reddish-brown colour
Acute limb ischaemia:
- Doppler or duplex? [1]
Doppler
The treatment of biliary colic is [] in the acute phase.
he treatment of biliary colic is analgesia in the acute phase.
Describe the DMT1 sick day rules with regards to:
- Fluid intake
- Checking glucose levels
- Checking ketone levels
- Meal contents
Describe the DMT1 sick day rules with regards to:
Fluid intake:
- Aim 3L water
Checking glucose levels:
- check blood glucose more frequently, for example, every 1-2 hours including through the night
Checking ketone levels:
- consider checking blood or urine ketone levels regularly
Meal contents
- if appetite is reduced meals could be replaced with carbohydrate-containing drinks (such as milk, milkshakes, fruit juices, and sugary drinks)
Describe the DMT2 sick day rules with regards to:
- Medication [1]
Consider stopping oral hypoglycaemics
WPW is associated with which cardiac disease? [1]
HOCM
What are the different stages of CKD? [5]
Investigation for ? colovesical fistula complication of diverticular disease? [1]
abdominal CT scan
? abscess of colon should be investigated by..
Acutely unwell surgical patients should be investigated in a systematic way. Plain abdominal films and an erect chest x-ray will identify perforation. An abdominal CT scan (not a CT cologram) with oral and intravenous contrast will help to identify whether acute inflammation is present but also the presence of local complications such as abscess formation.
Coagulase-negative, Gram-positive bacteria such as [] are the most common cause of neutropenic sepsis
Coagulase-negative, Gram-positive bacteria such as Staphylococcus epidermidis are the most common cause of neutropenic sepsis
A 52-year-old male presents with tearing central chest pain. On examination, he has an aortic regurgitation murmur. An ECG shows ST elevation in leads II, III and aVF. What is the likely explanation? [1]
An inferior myocardial infarction and AR murmur should raise suspicions of an ascending aorta dissection rather than an inferior myocardial infarction alone. Also the history is more suggestive of a dissection.
Other features may include pericardial effusion, carotid dissection and absent subclavian pulse.
distal aorta → limb ischaemia
Complete heart block with broad complex QRS WITH bradycardia treatment? [1]
transvenous pacing
Describe the two types of hepatorenal syndrome [2]
What indicates a patient has HRS? [1]
How do you treat? [3]
functional kidney impairment that occurs in patients with advanced liver disease.
Treatment:
* vasopressin analogues, for example terlipressin, have a growing evidence base supporting their use. They work by causing vasoconstriction of the splanchnic circulation
* volume expansion with 20% albumin
* transjugular intrahepatic portosystemic shunt
A
A patient has acute tubular necrosis. How does their urine urine osmolality and urine sodium change? [2]
Kidneys can no longer concentrate urine or retain sodium - urine osmolality low, urine sodium high
What change is seen in this kidney biopsy? [1]
Glomeruli are full of crescents.
NSTEMI management: unstable patients should have immediate []
NSTEMI management: unstable patients should have immediate coronary angiography
A patient has a UTI and CKD < 45. What is the treatment of choice for the UTI? [1]
Trimethoprim
What is the inheritance of CF? [1]
A woman presents to you for discussion of her recent genetic testing. She is pregnant with a new partner who has cystic fibrosis. Her results show that she is heterozygous for the disease.
What is the probability that their offspring will have this disease? [1]
Autosomal recessive
50
What does this CT show? [1]
Background of XS alcohol
Pancreatic pseudocyst
A mild jaundice, raised WCC and dense fluid-filled mass on CT are classic findings. Note fluid is less dense than the surrounding tissues and will therefore appear darker on CT
If symptomatic, one of the following results is sufficient for diagnosis for DMT2
Random blood glucose ≥ [] mmol/l
Fasting plasma glucose ≥ [] mmol/l
2-hour glucose tolerance ≥ [] mmol/l
HbA1C ≥ [] mmol/mol (6.5%)
If symptomatic, one of the following results is sufficient for diagnosis:
Random blood glucose ≥ 11.1mmol/l
Fasting plasma glucose ≥ 7mmol/l
2-hour glucose tolerance ≥ 11.1mmol/l
HbA1C ≥ 48mmol/mol (6.5%)
The BNF reports high doses or rapid intravenous administration of loop diuretics can cause []
The BNF reports high doses or rapid intravenous administration of loop diuretics can cause tinnitus and deafness.
In life-threatening bleeds what should you give a haemophiliac A patient? [1]
Haemophilia A affects factor VIII levels, and in major or life-threatening bleeds, recombinant factor VIII is the most appropriate treatment.
Desmopressin raises factor VIII levels and is used in minor bleeding in haemophilia A; it is not used in major bleeds.
Which biomarker should be used if you suspect an infarct, but the patient has had an infarct 3 days ago? [1]
Creatine Kinase-MB (CK-MB)
- Troponin levels can be elevated for up to 2 weeks after the initial infarct episode, whilst CK-MB usually clear by 72 hours. A CK-MB level of more than 3 times the upper limit of normal is generally considered to be indicative of one.
How do you treat hiatus hernias? [3]
all patients benefit from conservative management e.g. weight loss
medical management: proton pump inhibitor therapy
surgical management: only really has a role in symptomatic paraesophageal hernias
How do you differentiate between the most likely causes of primary and secondary aldosterinism? [1]
Explain your answer
Primary and secondary aldosteronism can be differentiated by looking at the renin levels. If renin is high then a secondary cause is more likely, i.e renal artery stenosis:
- Because the blood flow through the renal arteries is slow, the kidney interpret the blood pressure to be low. This is sensed by macula densa. A low blood pressure in the renal artery means a lower glomerular filtration rate which means longer time to absorb salts. When salts are low when the tubular fluid reaches the macula densa, the kidneys know their blood pressure is low, and thus interpret that the systemic blood pressure must be low too. Thus they organize renine to fix the problem.
How do you differentiate between a sickle cell patient having a splenic sequestration crisis and an aplastic crisis? [1]
Sequestration crisis and aplastic crisis can present similarly, however the reticulocyte count will typically be high in a sequestration crisis and low in an aplastic crisis.
How can you distinguish between a fibroadenoma and phyllodes tumour? [2]
They can be difficult to distinguish from a fibro-adenoma, as both present as a firm, non-tender, mobile lump in the breast.
However, phyllodes tumours are typically much faster growing and most commonly affect women in their 40s and 50s
A patient has A 65 year old man presents to the district nurse clinic with acute urinary retention secondary to an enlarged prostate. An immediate urinary catheterisation is attempted and the volume post-catheterisation is recorded as 1200ml.
Explain what the next appropriate management is [1]
This patient has a large retention volume of >1000ml. He should be admitted to monitor for post-obstructive diuresis
- Patients will be at risk for dehydration and should be monitored closely for their urine output in the hospital and if >200ml/hr urine is being produced, they should be replaced with intravenous fluids to avoid acute kidney injury.
Which of the following types of renal stones are radio-lucent?
Triple phosphate stones
Cystine stones
Calcium phosphate
Xanthine stones
Calcium oxalate
Which of the following types of renal stones are radio-lucent?
Triple phosphate stones
Cystine stones
Calcium phosphate
Xanthine stones
Calcium oxalate
Renal stones on x-ray
cystine stones: semi-opaque
urate + xanthine stones: radio-lucent
stones at the back of the alphabet are radio-lucent - Urate and Xanthine :) and then cystine being semi-opaque is just a weird one to rote learn
How do you differentiate between ASD and VSD based off their murmurs? [2]
Atrial septal defect
- ejection systolic murmur louder on inspiration
VSD
- would give a pansystolic murmur and is therefore incorrect.
Infective exacerbation of COPD: first-line antibiotics are [] or [] or []
Infective exacerbation of COPD: first-line antibiotics are amoxicillin or clarithromycin or doxycycline
[] is common during the period of breast involution that occurs during the menopausal period.
As the ducts shorten they may contain insipiated material. The discharge will often discharge from several ducts.
Duct ectasia is common during the period of breast involution that occurs during the menopausal period. As the ducts shorten they may contain insipiated material. The discharge will often discharge from several ducts.
A patient presents with findings suggestive of CLL.
What are they at risk of developing? [1]
NHL - Richters Transformation
What are the 6 reasons for increased prolactin? [6]
- pregnancy
- prolactinoma
- physiological
- p
- primary hypothyroidism
- phenothiazines - prochorperazine, metoclopromide, domperidone
NSAIDs are CI in which condition? [1]
Asthma
Which conditions are DOACs contraindicated in? [1]
In renal failure: if egfr < 15
If a patient has AF and structural heart disease - what do you give them? [1]
Amiodarone
Which tumour marker is specific for teratoma? [1]
AFP
LDH - non specific
bHCG is raised in both teratoma and seminoma
What are the 4 stages to testicular tumour spreaD? [4
A patient presents with this sign. What does in indicate? [1]
Blue dot sign - testicular torsion
A patient is fat and presents with this symptom. What does it specifically suggest? [1]
eruptive xanthomas - hypertriglyceridemia
What are the rules about anticoagulating post-stroke / or TIA for a patient with AF? [2]
AF post stroke:
- following TIA - start immediately and after excluding haemorrhage
- following stroke - after 2 weeks. give antiplatelet in intervening period
What are two rules need to consider with regards to AF treatment and DOACs [1] and Amiodarone treatment? [2]
DOACs are contraindicated in valvular AF
If structural heart disease - amiodarone for rhythm control
Describe the murmur heard in coarctation of the aorta [1]
Systolic machinery murmur
Describe the (very) general management of umbilical and inguinal hernias [2]
remember it using the mnemonic:
Inguinal hernia - get then IN for surgery
Umbilical hernia - um don’t need to operate
A patient presents with an elevated prolactin level along with secondary hypothyroidism and hypogonadism is indicative of what pathology? [2]
The presence of an elevated prolactin level along with secondary hypothyroidism and hypogonadism is indicative of stalk compression is consistent with a non-functioning pituitary adenoma
In a secondary pneumothorax < 1cm, what is the management plan? [1]
If the pneumothorax was 1-2cm aspiration should be attempted
In a secondary pneumothorax < 1cm, admit and give oxygen for 24 hours and review
In a secondary pneumothorax 1-2 cm, what is the management plan? [1]
In a secondary pneumothorax >2 cm, what is the management plan? [1]
If the pneumothorax was 1-2cm aspiration should be attempted
> 2cm: a chest drain should be inserted.
The doctor thinks that another medication he is taking might be reducing the effectiveness of clopidogrel.
What medication would that be?
Allopurinol
Amiodarone
Metronidazole
Omeprazole
Trimethoprim
The doctor thinks that another medication he is taking might be reducing the effectiveness of clopidogrel.
What medication would that be?
Allopurinol
Amiodarone
Metronidazole
Omeprazole
Trimethoprim
How much ml of blood is determined as life-threatening haemoptysis? [1]
more than 120mls of frank blood in 24 hrs
Which drug should be avoided when giving levothyroxine as it reduces the effectiveness? [1]
How do you alter dosing timing to alleviate this? [1]
Ferrous sulphate should not be taken at the same time as Levothyroxine as the iron interferes with levothyroxine absorption.
The two medications should be taken about 2-4 hours apart with the Levothyroxine taken first.
What’s an important differential to ask about coughing at night? [to asthma] [1]
GORD - causes nocturnal asthma/cough
Explain the change in JVP waveform you see in tricuspid regurgitation
Big v waves
- Tricuspid regurg happens during ATRIAL DIASTOLE, and means some blood moves from the ventricle to the atria filling it even more, and sending more of an equal and opposite force upwards to the internal jugular vein hence why we see prominent v waves.
CF related to which pancreatic disease? [1]
Diabetes
What are the clinical findings that would suggest massive PE from a cardiac exam? [3]
In a sub-massive PE there may be signs of right heart strain (such as a raised JVP, parasternal heave, and loud P2)
Describe these changes seen in CXR [1]
What disease does this indicate? [1]
Ring shadows in the left lower zone are consistent with bronchiectasis.
A 25-year-old female presents with a 2-week history of bloating, abdominal cramps, and foul-smelling diarrhoea. Stool studies revealGiardia lamblia.
What is the first-line treatment for this patient’s infection?
metronidazole
The gold standard investigation and first line management for ascending cholangitis is []
The gold standard investigation and first line management for ascending cholangitis is ERCP
Symptoms of strangulated herniasinclude [5]
- Pain
- Fever
- Increase in the size of a hernia or erythema of the overlying skin
- Peritonitic features such as guarding and localised tenderness
- Bowel obstruction e.g. distension, nausea, vomiting
- Bowel ischemia e.g. bloody stools
Describe how you would give food to a patient with acute pancreatitis? [1]
Patients with acute pancreatitis should not routinely be made ‘nil-by-mouth’
[] is the diagnostic investigation of choice for pancreatic cancer
High-resolution CT scanning is the diagnostic investigation of choice for pancreatic cancer
How do you treat sigmoid volvulus [1]
How
- sigmoid volvulus: rigid sigmoidoscopy with rectal tube insertion
- caecal volvulus: management is usually operative. Right hemicolectomy is often needed
Sputum for TB? [3]
One straight away
One morning after
One morning after
LOOK UP
smear - stain it to see if have AFB or MTM
If negative - do PCR to see if TB or MTM
How do you differentiate TRALI vs TACO? [1]
hypotension in TRALI
vs
hypertension in TACO
Which drug class, when treating UTIs can cause an isolated raise in creatitine? [1]
Trimethoprim can cause an isolated rise in creatinine by competing with creatinine for secretion into the renal tubules
Which drugs should you stop prior to surgery? (and when)
COCP 2 weeks before (and witheld for 2 weeks after)
Clopidogrel 7 days before
Warfarin 5 days before (switched to LMWH)
ACEin 1 days before
Joja CCWA
Describe the neurotransmitter change in acute alcohol excess cessation []1
Acute alcohol consumption causes an increase in GABA neurotransmission. This is an inhibitory neurotransmitter. However, in those with chronically high alcohol intake, a compensatory decrease in GABA neurotransmission and increase in the excitatory neurotransmitter glutamate occurs.
This means that in cases of acute alcohol cessation, as in cases of delirium tremens, the upregulated glutamate is no longer opposed by GABA. This generates an overall excitatory state.
How do you treat asprin OD? [1]
IV sodium bicarbonate
Which type of polyp is associated with colorectal caner? [1]
What electrolyte change would this cause? [1]
Villous polyp - causes hypokalaemia
How do you calculate absolute risk?
E.g. The study recruited 3000 patients. 1700 received the new drug of which 170 patients developed carpal tunnel syndrome. The remaining patients received a placebo of which 300 developed carpal tunnel syndrome.
What is the absolute risk reduction of developing carpal tunnel syndrome by taking the new drug?
The absolute risk of the exposure group is 10% (170/1700). The absolute risk of the control group is 23% (300/1300). Therefore, the absolute risk reduction is 13% (23-10).
Name 5 causes of drug induced pancreatitis [5]
azathioprine, mesalazine, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate
[] is the key parameter to monitor in patients with hyperosmolar hyperglycaemic state
Serum osmolality is the key parameter to monitor in patients with hyperosmolar hyperglycaemic state
The presence of PR prolongation in infective endocarditis is suspicious for []
The presence of PR prolongation in infective endocarditis is suspicious for aortic root abscess
What is a type 1 error in medical statistics? [1]
A Type 1 error, also known as a false positive or alpha error, occurs when the null hypothesis is incorrectly rejected
he probability of making a Type 1 error is denoted by the significance level (alpha), which is usually set at 0.05 in medical studies.
What are small, regular and large pericardial effusions? [3]
What size would indicate pericardiocentesis? [1]
< 1cm is a small effusion; 1 - 2 cm is moderate; >2 cm is large.
What can you give to prevent calcium stones? [3]
Ask patients to add lemon juice to water
Potassium citrate should be considered for the prevention of calcium stones
limit salt
avoid carbonated drinkd
Name two things can give to reduce the chance of oxalate stones [2]
cholestyramine reduces urinary oxalate secretion
pyridoxine reduces urinary oxalate secretion
Which aspects of HF make patients breathless? [2]
Pulmonary oedema
Pleural effusion
Resp. causes of clubbing? [+]
Lung cancer
ILD / IPF
Bronchiectasis
CF
Lung abscess
When do you use Light’s criteria?
When proteins levels are between 25-35
Does RA/lupus cause transudative or exudative pleural effusion? [1]
Exudative
How can you work out if pre/post bronchodilator changes is greater than 12%?
e.g.
FEV1 pre-salbutamol 2354 mL
FEV1 post-salbutamol 2669 mL
(2669-2354)/2354 = 0.1338 times this by 100 to get 13.4%
Alternatively just times the original amount 2354 by 1.12
If the post bronchodilator is bigger than the answer then it is above 12%
What is BCG vaccine good at protecting agaisnt? [1]
TB meningitis in children
[] is the most common complication of mumps in post-pubertal males.
NB: symptoms of mumps - bilateral pain and swelling at the angle of the jaw, which is made worse by talking or chewing. On examination his pulse is 90/min, temperature 38.4ºC and bilateral palpable, tender parotid glands are noted.
Orchitis is the most common complication of mumps in post-pubertal males.
Name what the arrow is pointing at [1]
What drug class might you expect to see them in? [1]
Hyaline casts may be seen in the urine of patients taking loop diuretics
Why may low BP secondary to blood loss cause deranged LFTs? [1]
Acute hypoperfusion (e.g. low BP secondary to blood loss) may result in ischaemic hepatitis
Suspected epididymo-orchitis tx? [2]
Suspected epididymo-orchitis: If unknown organism: ceftriaxone 500mg intramuscularly single dose, plus oral doxycycline 100mg twice daily for 10-14 days
