Quesmed wrong answers Flashcards

Question

What is eczema?

Answer 1

Eczema is a chronic inflammatory disorder of the skin characterised by dermal inflammation (dermatitis) with resultant spongiotic change in the epidermis histologically, with chronic features including epidermal acanthosis, hyperkeratosis, and parakeratosis.

Answer 2

Dermatitis triggers the disease process. The normal dermis has a small amount of lymphocytes and other immune cells but in skin with eczema there is a vast infiltrate visible. Keratinocytes in the epidermis start detaching from one another, becoming rounder and the intercellular spaces widening between them. If the eczema has come on acutely, this separation may be so severe that vesicles form. Under the microscope, this makes the epidermis look like a sponge, hence 'spongiotic' change. With chronic inflammation, histology shows: - Epidermal acanthosis: thickening of the epidermis due to hyperplasia. - Hyperkeratosis: thickening specifically of the stratum corneum. - Parakeratosis: retained nuclei in the stratum corneum indicating problems with the usual differentiation process. In many cases, atopic dermatitis is associated with an IgE-mediated allergic response to environmental allergens. Sensitisation to allergens such as house dust mites, pet dander, pollen, and certain foods can lead to the production of specific IgE antibodies. Upon re-exposure to these allergens, IgE-mediated immune responses are triggered, resulting in skin inflammation and pruritus. This plays a significant role in exacerbations of atopic dermatitis. Often, the terms eczema and dermatitis are used interchangeably as the two are so closely linked. However, there are other instances where there is dermal inflammation without eczematous changes. Therefore, the two terms are not entirely the same.

Answer 3

- Atopic eczema - Allergic contact dermatitis - Irritant contact dermatitis - Seborrheic dermatitis - Venous eczema (stasis dermatitis) - Asteatotic dermatitis (eczema craquele) - Erythrodermic eczema - Pompholyx eczema

Answer 4

Childhood predominance: symptoms tend to become less severe with age. Associated with atopic phenotype: asthma, hayfever, raised eosinophils. In infants, the face is a common site. In older children/adults, the antecubital fossa and posterior knee (flexor surfaces) are affected. The skin is itchy, erythematous, and oozing. There may be vesicles, which may have crusted over. Eventually, the skin becomes dry and flaky. Repeated scratching causes lichenification (thick, leathery skin, also called lichen simplex et chronicus.)

Answer 5

This is a dermatological emergency and may complicate atopic eczema. It is syndrome characterised by widespread redness (>90%) There is often skin exfoliation too, which leads to exfoliative dermatitis.

Answer 6

This common condition is thought to happen due to Malassezia Furfur, a commensal organism on the skin. A predisposed individual due to genetic and environmental factors may develop an inflammatory response to the organism. The skin is flakey with a fine scale, oily, and erythematous. There is usually minimal pain or stinging or itch. The scale may coalesce into thicker plaques. It tends to affect the face (especially hairline, nasolabial fold, and brow area) in adults. Risk factors for the development include: - Family history - Oily skin - Immunosuppression (such as HIV) - Neurological and psychiatric diseases (such as Parkinson's Disease or Depression) - Stress Dandruff is the common term used to describe a mild, non-inflamed form of seborrheic dermatitis Managed with anti-fungal agents, such as ketoconazole shampoo. Infantile seborrheic dermatitis (cradle cap) is asymptomatic. It appears as a diffuse, yellow, greasy scale, coalescing into plaqaues on the scalp/groin/armpit. Emollients (such as olive oil) loosen the scales, which can then be brushed off. Antifungal shampoos may be used if the issue persists.

Answer 7

Also known as venous eczema. This is eczema associated with chronic venous insufficiency (venous hypertension), usually affecting the gaiter area. There may be associated skin changes therefore, including: venous ulcers, lipodermatosclerosis, and hemasiderosis.

Answer 8

This is a subtype of eczema associated with intensely itchy vesicles that erupt in the hands. It is also referred to as dishydrotic eczema.

Answer 9

Eczema is a clinical diagnosis and investigations aren’t always needed. However, investigations may include: - Tests prior to commencing systemic treatments with traditional DMARDs or biologics. - Bloods: *If concerns regarding superadded infection. *Total IgE and raised eosinophils may confirm atopic phenotype. *Patients with atopic eczema often have concerns about ‘allergies' as triggers (i.e. Type 1 mediated immune reactions) The relationship between eczema and allergy is complicated, and it is not thought that eczema is a direct manifestation of a Type 1 allergic process. However, allergies are common amongst patients with eczema, especially atopic eczema. Therefore, it is often sensible to perform testing if it is a subject of genuine concern. This can be in the form of RAST IgE or skin-prick testing. These have a high sensitivity but low specificity, and as such if negative are useful, but if positive do not necessarily indicate allergy. - Patch test: The allergen is applied to the skin under occlusion for 48 hours to confirm a delayed (type IV) allergic process implicated in allergic contact dermatitis. - Swabs: bacterial and viral swabs if concerns regarding superadded infection. - Skin biopsy: if the diagnosis is uncertain, especially with erythrodermic presentations.

Answer 10

Mild - areas of dry skin, and infrequent itching (with or without small areas of redness) Moderate - areas of dry skin, frequent itching, and erythema (with or without excoriation and localized skin thickening) Severe - widespread areas of dry skin, incessant itching, and erythema (with/without excoriation, extensive skin thickening, bleeding, oozing, cracking, and alteration of pigmentation) Infected - if eczema is weeping, crusted, or there are pustules, with fever or malaise

Answer 11

1. Conservative: - Avoid triggers: soaps, perfumes, biological detergents, or synthetic fabrics. Replace these where possible (soap substitutes, non biological detergents, natural fabrics e.g. cotton.) - Avoid allergens. - Keep the area cool and dry. - Sedating antihistamine can reduce itching and aid sleep. - Liberal emollients should be applied frequently. - Psychological support may be needed. 2. Topical treatment for eczema: - Mild eczema - liberal emollient usage + mild topical corticosteroid (such as hydrocortisone 1%) for areas of red skin. - Moderate eczema - liberal emollient usage + moderate topical corticosteroid (such as clobetasone butyrate 0.5% - Eumovate) for 5 days. Hydrocortisone 1% should be used for the face and flexures. Consider prescribing maintenance topical corticosteroids to control areas of skin prone to frequent flares. - Severe eczema - liberal emollient usage + potent topical corticosteroid (for example betamethasone valerate 0.1% - Betnovate) to be used on inflamed areas. For the face and flexures, use a moderate potency corticosteroid (such as Eumovate). - If there is severe, extensive eczema causing psychological distress, consider prescribing a short course of an oral corticosteroid (refer children under 16 years of age). - Topical calcineurin inhibitors (e.g. tacrolimus) - can be considered as a steroid sparing agent. These are second-line and should be prescribed by a specialist. - Light therapy: aims to suppress dermal inflammation. The most common type used is narrow band UV-B. 3. Systemic therapies: - Oral steroids: if widespread and severe, e.g. erythroderma. - Systemic retinoids: such as alitretinoin may be used for hand eczema recalcitrant to topical therapies. - Traditional DMARDs: *Methotrexate: a dihydrofolate reductase inhibitor. *Ciclosporin: a calcineurin inhibitor. *Azathioprine: inibits purine synthesis. - Biologics: as per the NICE guidelines, reserved for patients with moderate to severe eczema not responding to at least 1 traditional systemic therapy: *Dupilumab: IL-4Rα inhibitor *Baricitinib: JAK inhibitor

Answer 12

- Eczema is severe and has not responded to optimum topical treatment after 1 week (urgent referral; within 2 weeks) - The diagnosis is, or has become, uncertain. - Current management has not controlled eczema satisfactorily (for example the person is having one to two flares per month), or the person is reacting adversely to many emollients. - Facial eczema that is treatment-resistent. - Contact allergic dermatitis is suspected

Answer 13

1. Scratching: - Poor sleep - sedating antihistamines (e.g. chlorphenamine) can be prescribed to aid sleep - Poor mood - Skin breakdown: bacterial infection (take a swab - usually Staphylococcal or Streptococcal), scarring, and post inflammatory hyper/hypopigmentation. -Skin thickening (lichenification) with chronic scratching. 2. Psycho-social: - Insecurities surrounding skin appearance, especially if there are scars/pigment changes/lichenified skin, or changes from long term steroid use. - Normal daily activities may be disrupted due to skin condition e.g. avoiding swimming. - Poor mood and poor sleep from itch. 3. Eczema herpeticum: A dermatological emergency. - This is a disseminated herpes simplex virus in a patient with eczema, usually atopic eczema, and normally occurs when the patient is first infected with HSV. - Vesicles and punched out erosions where the vesicles have deroofed will appear, and may affect large areas of skin, including sites that are apparently not currently eczematous. - There may be multi organ involvement, and the patient is unwell. - Admission is required for intravenous antiviral therapy (aciclovir.) Often given concomitantly with antibiotics as concomitant bacterial infection is common and difficult to exclude clinically. - Diagnosis can be confirmed with a swab & Tzanck test.

Answer 14

Vulvovaginal candidiasis, often referred to as a yeast infection, is an inflammation of the vagina and the vulva due to an overgrowth of the yeast fungus, primarily Candida Albicans. Recurrent vulvovaginal candidiasis is defined as four or more symptomatic episodes in one year, with at least two episodes confirmed by microscopy or culture when symptomatic. Transmission is typically non-sexual.

Answer 15

Key factors that increase the risk of developing a Candida infection include: - Pregnancy - Antibiotic use - Immunosuppression

Answer 16

1. Women - Symptoms: Itching, white curdy or lumpy discharge, sour milk odour, dysuria, superficial dyspareunia, pruritus, tenderness, and a burning sensation. - Examination findings: Redness, fissuring, swelling, intertrigo, thick white discharge. 2. Men - Symptoms: Soreness, pruritus, redness. - Examination findings: Dry, dull, red glazed plaques and papules.

Answer 17

The following conditions can present similarly to vulvovaginal candidiasis and should be considered: 1. Bacterial vaginosis: Characterised by greyish-white discharge, fishy odour, and absence of significant inflammation. 2. Trichomoniasis: Presents with yellow-green, frothy discharge, dysuria, and itching. 3. Chlamydia or Gonorrhoea: These sexually transmitted infections can cause similar symptoms such as discharge, but often also present with pelvic pain or bleeding. 4. Genital herpes: Characterised by painful blisters or open sores in the genital area.

Answer 18

Routine investigations are not typically required for acute, uncomplicated vulvovaginal candidiasis cases. However, in instances where the clinical presentation is unclear or recurrent episodes occur, the following investigations may be necessary: 1. Microscopy: Detection of blastospores, pseudohyphae and neutrophils suggests Candida infection. 2. Culture: Recommended for recurrent vulvovaginal candidiasis cases to identify the Candida species.

Answer 19

Vulvovaginal candidiasis is primarily managed with antifungal treatment: - Oral (-azoles) e.g., fluconazole, itraconazole - Intravaginal e.g., clotrimazole pessary - Vulval e.g., topical clotrimazole cream Common regimens include: - Fluconazole oral capsule 150mg as a single dose. - Clotrimazole intravaginal pessary 500mg as a single dose. - Clotrimazole intravaginal cream (10%) 5g as a single dose. - Clotrimazole intravaginal pessary 200mg at night for 3 consecutive nights. Recurrent vulvovaginal candidiasis is managed with a induction and maintainence regimen: - Induction with Fluconazole oral capsule 150mg every 72 hours for a total of three doses - Maintainence with Fluconazole oral capsule 150mg once weekly for six months - These regimens can be supplemented with topical -azole therapy if vulval symptoms persist. Oral therapies should be avoided in pregnant women, women at risk of pregnancy, and breastfeeding women. Intravaginal and topical treatments may compromise the integrity of latex condoms and diaphragms.

Answer 20

The intra-uterine device (IUD) is a long-term form of contraception that is inserted into the uterus. It operates by releasing copper, which is toxic to both the egg and sperm, thereby preventing fertilization and subsequent implantation.

Answer 21

After IUD insertion, some women may experience spotting and period-like pains. It is important for women to regularly check the position of their device and report any changes to their healthcare provider.

Answer 22

In cases of unexplained bleeding or pain following IUD insertion, differential diagnoses could include: - Displacement or expulsion of the IUD - Uterine perforation - Pelvic inflammatory disease - Pregnancy (including ectopic pregnancy)

Answer 23

It is crucial to conduct follow-up investigations 3-4 weeks post-insertion to confirm absence of pregnancy and discuss future contraception plans. The device is not suitable for women with a current pelvic infection, a distorted uterus, a history of frequent sexually transmitted infections, unexplained bleeding or an abnormal cervix. It can be inserted either 48 hours within giving birth or after four weeks postpartum

Answer 24

1. Car/motorbike licence - one off seizure = reapply in 6 months - more than one seizure = reapply in one year - seizure following change in antiepileptic medications = reapply to drive if seizure was more than 6 months ago or you've been back on previous medication for 6 months 2. Bus/coach/lorry licence - one off seizure - reapply in 5 years or if you haven't taken anti epileptic medications for 5 years - more than one seizure = reapply once you haven't had a seizure for 10 years or you haven't taken any anti-epileptic medication for 10 years The guidelines apply for all categories of license and are more strict for those that are Taxi and HGV drivers.

Answer 25

1. Malignancy: Lung, oesophagus, stomach, urinary tract, kidney and pancreas 2. COPD and asthma 3. Pneumonia 4. Atheromatous disease: Stroke, ischaemic heart disease, peripheral vascular disease, mesenteric ischaemia 5. Peptic ulcers Passive smoking is also associated with increased risk of lung cancer and heart disease as well as asthma, chest infection and otitis media in children.

Answer 26

1. Nicotine replacement therapy (NRT) - Multiple formulations are available including patches and oral preparations and can be used for up to 8 weeks. - Works by reducing cravings caused by nicotine withdrawal. - Should be started on the quit day. - Should not be used with varenicline or bupropion and is contra-indicated in severe cardiovascular disease. - Common side-effects include nausea, dizziness, vivid dreams and palpitations. 2. Bupropion - Originally developed as an anti-depressant it has been shown to be effective in helping smoking cessation. It inhibits reuptake of dopamine, noradrenaline and serotonin in the brain. - Taken as an oral medication and started 7-14 days before the quit date. - Contraindicated in: Epilepsy (decreases seizure threshold), Eating disorders and bipolar disorder, CNS tumours, Those experiencing current benzodiazepine or alcohol withdrawal, Pregnancy and breast-feeding - Important side-effects include seizures and severe hypersensitivity though these are rare. 3. Varenicline (Champix) - Works as a partial nicotinic acetylcholine receptor agonist. - Taken as an oral medication and started 7-14 days before the quit date and is titrated in dose. - Contraindicated in pregnancy. - Important side-effects include increase in suicidal thoughts/behaviours, nausea and abnormal dreams. Using e-cigarettes (vaping) is not currently advocated as a first-line smoking cessation technique and though those who are still vaping can still be referred to smoking cessation services they cannot be prescribed medications. Vaping could be considered for those who have failed to quit using conventional techniques in the past.

Answer 27

Urinary incontinence can be categorised into: 1. Stress incontinence 2. Urge incontinence 3. Overflow incontinence 4. Functional incontinence 5. Mixed incontinence

Answer 28

1. Physical examination An examination will identify features of pelvic organ prolapse as well as the ability to contract pelvic floor muscles. 2. Questionnaires These are recommended in order to quantify the symptoms and assess the severity on patients quality of life which may help when deciding if a patient would benefit from more invasive treatment 3. Bladder diary These are also useful for quantifying symptoms and documenting the number and type of episodes of incontinence. They may potentially show a relationship between causes and symptoms. 4. Urinalysis This will help to rule out infection as an acute cause 5. Cystometry This is an investigation which measures bladder pressure whilst voiding. It is not recommended in patients with clear histories where the diagnosis is clear. 6. Cystogram If a fistula is suspected, contrast is instilled into the bladder and a radiological image is obtained in order to see if the contrast travels anywhere else.

Answer 29

This involves leaking of urine when intra-abdominal pressure is raised, putting pressure on the bladder. The pressure of the urine overcomes the mechanisms designed to maintain continence.

Answer 30

1. Risk factors - Childbirth (especially vaginal).This may be due to a combination of injury to the pelvic floor musculature and connective tissue (for example leading to prolapse), as well as nerve damage as a result of pregnancy and labor. - Hysterectomy Triggers Acts such as coughing, laughing, sneezing or exercising can increase abdominal pressure sufficiently. Causes Any abnormality in the anatomy of the bladder, sphincters and urethra can result in stress incontinence.

Answer 31

1. Conservative management - General lifestyle advice such as avoiding caffeine, fizzy and sugary drinks, as well as avoiding excessive fluid intake, can go far in helping incontinence. - Pelvic floor exercises when done with good technique and consistently strengthen the muscles of the pelvic floor. It can help both stress and urge incontinence and can be more effective than drug treatment. 2. Medical management - Duloxetine can help with stress incontinence, but it's only recommended if conservative measures fail and the patient is not a surgical candidate. 3. Surgical management - Incontinence pessaries are placed transvaginally and apply pressure to the anterior vaginal wall. This helps to support the urethra and sphincters. However, the evidence for them is poor in individuals without prolapse and isn't recommended by NICE. It would be worth trying if there was a clinical prolapse. - Bulking agents are injectable materials placed at the bladder neck to improve continence. This procedure is typically reserved for patients who are poor surgical candidates and isn't as efficacious as other methods - Colposuspension and fascial slings involve suspending the anterior vaginal wall to the iliopectineal ligament of Cooper. - Mid-urethral slings are the gold standard surgical treatment of stress incontinence. It compresses the urethra against a supportive layer and assists in the closure of the urethra during increased intra-abdominal pressures. It's minimally invasive and can be performed in the outpatient setting.

Answer 32

This involves the sudden and involuntary loss of urine associated with urgency.

Answer 33

Risk factors for urgency include: - Recurrent urinary tract infections - High BMI - Advancing age - Smoking - Caffeine

Answer 34

1. Conservative management - General lifestyle advice such as avoiding caffeine, fizzy and sugary drinks as well as avoiding excessive fluid intake can go far in helping incontinence. Chemicals contained in these drinks can irritate the bladder, contributing to urge symptoms. - Pelvic floor exercises when done with good technique and consistently, strengthen the muscles of the pelvic floor. It can help both stress and urge incontinence and can be more effective than drug treatment. In urge incontinence, contraction of the pelvic floor relaxes the detrusor. Bladder training is also helpful. 2. Medical/surgical management - Anticholinergic medications can help reduce the symptoms of urge and overactive bladder by inhibiting the parasympathetic action on the detrusor muscle. Examples include: Oxybutynin, Tolterodine, Fesoterodine, Solifenacin. If one agent has limited impact, it can be combined with another. *Anticholinergics are contraindicated in glaucoma and are best avoided in frail/elderly patients so mirabegron (B3 agonists) are the medication of choice. - Bladder instillation: Intravesical injection of Botox can be used to paralyse the detrusor muscle and reduce the symptoms of urge and overactive bladder. - Sacral neuromodulation: Sacral nerve stimulation has been shown to control symptoms of an overactive bladder. This is only done in tertiary centres for patient who have failed or are unsuitable for all other treatments.

Answer 35

This involves an individual having the urge to pass urine, but for whatever reason they're unable to access the necessary facilities and as a result are incontinent.

Answer 36

Functional incontinence associated with: - Sedating medications - Alcohol - Dementias

Answer 37

This occurs when small amounts of urine leak without warning. When the pressure within the bladder overcomes the pressures of the outlet structures urine leaks.

Answer 38

This occurs either due to underactivity of the detrusor muscle such as from neurological damage, or if the urinary outlet pressures are too high, as in constipation or prostatism.

Answer 39

Tonsillitis is a medical condition that is characterized by the inflammation of the tonsils, which are the masses of lymphoid tissue located at the back of the throat. This inflammation is primarily due to an infection.

Answer 40

The aetiology of tonsillitis is usually due to a viral or bacterial infection. Common viruses include the Epstein-Barr virus, influenza virus, adenovirus, and rhinovirus. Bacterial tonsillitis can be caused by Group A streptococcus, which is also responsible for strep throat.

Answer 41

Patients with tonsillitis typically present with the following symptoms: - Sore throat - Headache - Fever (pyrexia) - Enlarged and tender lymph nodes (lymphadenopathy)

Answer 42

When diagnosing tonsillitis, it's important to differentiate it from other conditions with similar symptoms such as: - Pharyngitis: Symptoms include sore throat, fever, and headache. Unlike tonsillitis, patients do not usually present with lymphadenopathy. - Mononucleosis: Characterized by fatigue, sore throat, fever, and swollen lymph nodes. A key difference is the presence of severe fatigue and splenomegaly.

Answer 43

Investigations for tonsillitis typically involve clinical examination and patient history. Additional tests such as throat swabs and rapid antigen tests are not routinely performed unless bacterial infection is suspected. Blood tests are primarily reserved for those with suspected immunodeficiency.

Answer 44

The Centor Criteria is a set of clinical predictors used to identify patients with Group A streptococcal pharyngitis: - History of fever - Presence of tonsillar exudates - Absence of cough - Tender anterior cervical lymphadenopathy Patients presenting with three or four of these criteria should be considered for antibiotic treatment.

Answer 45

1. Symptomatic treatment with paracetamol and ibuprofen 2. Antibiotic therapy in cases featuring: - Marked systemic upset - Three or more Centor criteria - Four or five on FeverPAIN score - Underlying immunodeficiency - History of rheumatic fever *First choice is phenoxymethypenicillin, alternatives are clarithromycin or erythromycin

Answer 46

Fever, Purulence, Attend within 3 days or less, severely Inflamed tonsils, No cough or coryza

Answer 47

1. Recurrent Tonsillitis: This is the most common complication. The evidence base for tonsillectomies as a treatment is poor, leading to stricter referral criteria. 2. Retropharyngeal Abscess: A rare complication characterized by soft tissue swelling, more common in young children. Symptoms include a stiff and extended neck and refusal to eat or drink. 3. Peritonsillar Abscess (Quinsy): Presents with sore throat, difficulty swallowing, peritonsillar bulge, uvular deviation, trismus, and muffled voice. Treatment has shifted from surgical drainage to antibiotics and aspiration. 4. Lemierre's Syndrome: In this rare complication, inflammation leads to pharyngotonsilitis, inflammation within the internal jugular vein, and septic emboli. Treatment may require high-dose benzylpenicillin and debridement.

Answer 48

- Unilateral throbbing headache, potentially preceded by an aura (visual or sensory) - Headache duration of 4-72 hours - Association with photophobia and phonophobia - Possible triggers such as oral contraceptives or specific foods (e.g., chocolate)

Answer 49

Management strategies include avoiding triggers, prophylaxis with Propranolol (contraindicated in asthma) or Topiramate, and managing acute attacks with oral triptans like Sumatriptan (contraindicated in ischaemic heart disease) in addition to Paracetamol or an NSAID.

Answer 50

Recurrent unilateral periorbital pain of sudden onset Associated symptoms: watery and bloodshot eye, lacrimation, rhinorrhoea, miosis, ptosis, lid swelling, and facial flushing Headache duration of 15 minutes to 3 hours, occurring once or twice daily over 4-12 weeks, followed by a pain-free period of several months

Answer 51

Management strategies involve avoiding triggers, prophylaxis with Verapamil, and treating acute attacks with 100% oxygen via a non-rebreathable mask (contraindicated in COPD) and a subcutaneous or nasal Triptan (contraindicated in ischaemic heart disease).

Answer 52

- Bilateral, non-pulsatile headaches - Tightness sensation, like a band around the head - Scalp muscle tenderness

Answer 53

Management includes analgesia per the WHO pain ladder (typically, Paracetamol or an NSAID), and addressing stress as these headaches are often associated with this factor.

Answer 54

- Association with temporary monocular blindness - Temporal tenderness Management High-dose steroids are the mainstay of treatment.

Answer 55

CAN: -POP CAN'T: - COCP in women <6 weeks postpartum who are breastfeeding due to VTE risk and contamination of breast milk. (After 6 weeks it becomes UKMEC 2)

Answer 56

1. Copper intrauterine device (Cu-IUD) - Gold standard emergency contraception - Can be used 120 hours after the first episode of UPSI in a cycle, or within 120 hours of the earliest expected date of ovulation - Inhibits fertilization by its toxic effect on sperm and ova. - If fertilization does occur, the Cu-IUD has an anti-implantation effect. 2. Ulipristal acetate ("Ella One") - Selective progesterone receptor modulator - Binds to human progesterone receptors, suppressing the LH surge and delays ovulation for at least 5 days, until sperm from the UPSI are no longer viable - It delays ovulation even after the start of the LH surge - Can be used within 120 hours of UPSI - Guidance is to wait 5 days before starting ongoing hormonal contraception - Can only be used once per cycle 3. Levonorgestrel ("Levonelle") - Can be used within 72 hours of UPSI - Inhibits or delays ovulation for a period of approximately 5 days, until sperm from the UPSI are no longer viable - Also thickens cervical mucus - Can quick start hormonal contraception - Can take more than once in the same cycle if further UPSI - Ineffective after the LH surge

Answer 57

- (For oral, subdermal, injectable): exerts negative feedback on GnRH output from the hypothalamus. This leads to decreased FSH and LH levels. Reduced FSH prevents follicular development in the ovaries - Prevents ovulation by inhibiting the LH surge - Thickens cervical mucus, making it more difficult for sperm to enter the uterus - Thins the lining of the endometrium, making it more difficult for implantation to take place

Answer 58

- Breast tenderness, enlargement - Headache - Changes to mood and libido - Nausea and vomiting - Irregular menstrual bleeding, spotting, amenorrhoea - Ovarian cysts

Answer 59

A type of scleroderma sometimes known as Limited scleroderma Calcinosis (white deposits in skin) Raynaud's phenomenon Esophageal dismotility Sclerodactyly (localised thickening and tightness of the skin of the fingers or toes) Telangiectasia

Answer 60

Nonpharmacological management includes smoking cessation, the use of warm gloves and avoiding cold exposure. The first-line pharmacological treatment is dihydropyridine calcium channel blockers, which can reduce both the frequency and severity of attacks. Other options include phosphodiesterase inhibitors and IV prostacyclin. In extreme cases, nerve blocks or digital amputation might be necessary.

Answer 61

Impetigo is a bacterial skin infection that is common in children. It is characterized by vesicles that rupture, forming honey-coloured crusts. It typically starts on the face and spreads to other parts of the body. Impetigo is caused by Staphylococcus aureus or Streptococcus pyogenes and is treated with topical or oral antibiotics.

Answer 62

- Oestrogens -Anti-androgens -5-alpha reductase inhibitors NOTE: Spironolactone is an aldosterone antagonist (K+ sparing diuretic) but presents with both oestrogenic and anti-androgenic properties

Answer 63

A positive Kernig's sign is pain on passive flexion of the hip, a sign of meningeal irritation

Answer 64

Acetic acid spray applied to the affected ear. Acetic acid can limit bacterial and fungal growth. If this is ineffective or there are signs of more severe infection such as discharge or oedema, antibiotic and steroid ear drops can be given. The management of otitis externa depends on the severity: 1. Mild to Moderate Otitis Externa: Can be treated with topical drops including combined antibiotic/steroid drops (e.g. Gentamix), acetic acid and other preparations. Patients should be advised to keep the ear dry for the next 7-10 days. 2. Severe Otitis Externa: Treated using a strip of ribbon gauze known as “Pope” wicks which can be used for the application of topical antibiotics (classically gentamicin) enabling deeper penetration. - Indications to Consider Oral Antibiotics: Cellulitis extending beyond the external ear canal, when the ear canal is occluded by swelling and debris and a wick cannot be inserted, and in people with diabetes or compromised immunity with severe infection or high risk of severe infection.

Answer 65

According to NICE guidelines, the first-line pharmacological treatment for stable angina is a beta-blocker, a calcium channel blocker, or a long-acting nitrate CCB are useful if there is also hypertension. Beta-blockers are preferred in patients with stable angina who have had a previous myocardial infarction or left ventricular systolic dysfunction. Long-acting nitrates are generally reserved for patients in whom beta-blockers and calcium channel blockers are contraindicated or not tolerated.

Answer 66

Trimethoprim or nitrofurantoin for 7 days (not 3!)

Answer 67

Typicals - so called because of the classical rapid onset of symptoms, including high fever and productive cough; Streptococcus pneumoniae (gram +ve cocci found in pairs) Staphylococcus aureus Haemophilus influenzae (gram -ve rod, potent beta-lactamase producer) Moraxella catarrhalis (gram -coccus, potent beta-lactamase producer)

Answer 68

Atypicals: so called because of the more gradual onset of symptoms, which may be non-specific initially (fever, myalgia, dry cough). The organisms are also intracellular; Mycoplasma pneumoniae Chlamydia pneumoniae Legionella pneumophila (Coxiella burnettii Chlamydia psittaci)

Answer 69

Most commonly Influenza A, which can predispose to superadded Staph aureus (or strep pneumoniae) pneumonia. Others: CMV, HSV, VZV

Answer 70

Confusion +/- Urea >7 Respiratory Rate >30 Blood pressure: systolic < 90 or diastolic <60 More than 65 years old Management based on score: 0/1: home-based care, give oral amoxicillin for 5 days (macrolide e.g. clarithromycin, doxycycline or tetracycline if penicillin allergic). 2: hospital-based care, 7-10 day course of dual antibiotic therapy with amoxicillin (IV or oral) and a macrolide 3: Hospital/ITU-based care, 7-10 day course of dual antibiotic therapy with IV co-amoxiclav/ceftriaxone/tazocin and a macrolide.

Answer 71

Gout is a form of arthritis caused by the deposition of monosodium urate crystals in and around the joints leading to an acute inflammatory response.

Answer 72

1. Acute gout – commonly presents with a monoarthritis - The first metatarsophalangeal (MTP) joint and the knee are most frequently affected - Extra-articular attacks can sometimes occur, particularly affecting the olecranon bursae - Acute attacks are characterised by sudden, severe attacks of joint pain, swelling, redness and tenderness - Following acute attacks, symptoms resolve; however, joint damage can occur following recurrent attacks 2. Tophaceous gout – usually occurs on the background of longstanding recurrent acute gout - Tophi are nodular masses of sodium monosulphate crystals that commonly occur on the pinnae or on pressure points, commonly the extensor surfaces 3. Nephrolithiasis is caused by the precipitation of uric acid crystals to form renal stones – these are responsible for 8% of renal calculi and are radiolucent 4. Uric acid nephropathy

Answer 73

- Seafood/protein binges – eating lots of high-protein foods raises levels of uric acid - Chemotherapy – increases cell breakdown - Trauma and surgery – increases cell breakdown - Alcohol excess - Intercurrent illness - Medications that interfere with the handling of uric acid (eg. allopurinol)

Answer 74

1. Joint aspiration – This is the key investigation of an acute monoarthritis - The presence of needle-shaped monosodium urate crystals with negative birefringence confirms gout 2. Serum uric acid level – This is useful for long-term management and levels should be obtained at least 2 weeks after the attack as they may be low or falsely normal during the attack - The British Society of Rheumatology advise giving urate-lowering therapies with target levels <300 micromol/l to reduce the risk of future attacks 3. X-rays of affected joints – radiographs can be useful in the assessment of chronic disease - Punched-out periarticular erosions may be seen 4. Ultrasound of affected joints – the double-contour sign is the most sensitive ultrasound finding of gout (a hyperechoic irregular band over the superficial margin of the articular cartilage) but gouty tophi and erosions may also be seen

Answer 75

1. Nonsteroidal anti-inflammatory drugs (NSAIDs): Naproxen and Etoricoxib - Avoid in renal impairment, cardiac failure and ischaemic heart disease 2. Colchicine (first line): Use with caution in liver or renal disease. Causes diarrhoea when given at high doses 3. Intra-articular corticosteroids: Avoid if any suspicion of septic arthritis 4. Oral corticosteroids eg Prednisolone for 5–7 days

Answer 76

1. Lifestyle changes: Reduction of alcohol consumption, purine-based foods (meat and seafood) 2. Review medications, the following drugs may cause hyperuricaemia: - Thiazides and loop diuretics - Low-dose salicylates - Chemotherapy When possible, antihypertensive drugs can be switched to losartan or amlodipine, which have modest urate-lowering effects. Statins and fibrates are useful adjuncts in patients with hyperlipidaemia. 3. Urate-lowering therapies: should be commenced at least 2 weeks after an attack as they can precipitate further attacks. For this reason, the first few weeks of urate-lowering therapy are often covered with an NSAID or colchicine. If the patient experiences an acute flare while on urate-lowering therapy, they should continue the drug. Criteria for commencing prophylactic urate-lowering therapies: - More than 2/3 attacks per year - Chronic tophaceous gout - X-ray changes showing chronic destructive joint disease - Urate nephrolithiasis - Severe and disabling polyarticular attacks - Inherited syndromes (eg. Lesch–Nyhan syndrome) Gout should be managed using a treat-to-target approach, aiming for a serum urate level <300 µg/l. The following medications can be used in the long-term management of gout: *Xanthine oxidase inhibitors (eg. allopurinol and febuxostat) – these act by reducing the production of uric acid: Allopurinol is the first-line medication in gout prophylaxis, generally well tolerated but can rarely cause severe mucocutaneous reactions including Stevens-Johnson syndrome. Febuxostat can be used in patients who do not respond to allopurinol Note: Xanthine oxidase inhibitors can precipitate azathioprine toxicity so should be avoided in patients on this drug *Uricosuric drugs (eg. probenecid and sulfinpyrazone) – these can be used when patients do not respond to allopurinol, Contraindicated in patients with severe renal or liver disease, should be avoided in patients with nephrolithiasis as they can promote stone formation

Answer 77

When presented with red eye, there are 3 important diagnoses that should be initially ruled out. 1. Acute angle-closure glaucoma 2. Anterior uveitis 3. Scleritis There are 3 key questions to assessing red eye: - Is acuity affected? - Is the eye painful? - Are pupil reflexes affected?

Answer 78

Patients typically present as systemically unwell with nausea and headaches. - In some, but not all, there is severe ocular pain associated with blurred vision and haloes around lights. - The pupil is typically in a fixed-dilated position. - Acute angle-closure glaucoma is an emergency, patients must be referred to ophthalmology immediately to prevent the progression of visual loss.

Answer 79

= Patients typically present with red eye, pain, blurred vision and photophobia. - Patients also commonly note increased lacrimation from the affected eye. - The pupil may be irregular due to adhesions between the lens and iris (termed synechiae). - Typically, conjunctival injection is concentrated around the junction of the cornea but this may not always be the case in practice. - There may be hypopyon - accumulation of pus cells in anterior chamber, with a visible fluid level.

Answer 80

- Severe inflammation of the sclera, patients complain of severe pain in the orbit and pain on eye movement. ~50% of patients are systemically ill with associated rheumatological conditions such as rheumatoid arthritis or granulomatosis with polyangiitis, so look for systemic symptoms.

Answer 81

1. Primary Hyperparathyroidism (PHPT): Commonly caused by a parathyroid gland adenoma, hyperplasia of all four glands, or parathyroid carcinoma. 2. Secondary Hyperparathyroidism (SHPT): Typically due to vitamin D deficiency, loss of extracellular calcium, calcium malabsorption, abnormal parathyroid hormone activity, or inadequate calcium intake. 3. Tertiary Hyperparathyroidism (THPT): Occurs after prolonged secondary hyperparathyroidism due to conditions like chronic kidney disease.

Answer 82

Hyperparathyroidism often results in hypercalcaemia - Painful bones - Renal stones - Gastrointestinal symptoms (nausea, vomiting, constipation, indigestion) - Neurological effects (lethargy, fatigue, memory loss, psychosis, depression)

Answer 83

Primary hyperparathyroidism

Answer 84

Secondary hyperparathyroidism

Answer 85

Tertiary hyperparathyroidism

Answer 86

Vitamin D deficiency

Answer 87

1. Conservative management - Smoking cessation - Glycaemic control, Hypertension, Hyperlipidaemia - Weight loss - Alcohol intake 2. Medical management - Secondary prevention: aspirin and statin. - GTN spray for symptom relief: inform patient of side-effects (headache, flushing, dizziness) and to repeat dose if pain not stopped after 5 minutes. Emergency help should be sought if pain not subsided after 2 doses of GTN as this may indicate acute coronary syndrome. 3. Anti-anginal medications *1st line = beta-blocker (bisoprolol) OR calcium channel blocker (verapamil or diltiazem). Do not combine due to risk of heart block - If neither can be tolerated to consider a long-acting nitrate (ISMN), ivabradine, nicorandil or ranolazine. *2nd line = beta-blocker (bisoprolol) AND long-acting dihydropyridine calcium channel blocker (amlodipine or nifedipine) *3rd line = beta-blocker (bisoprolol) AND long-acting dihydropyridine calcium channel blocker AND long-acting nitrate. A 3rd medication should only be added if the patient is symptomatic despite 2 anti-anginal drugs. At this stage, revascularisation with PCI or CABG must be considered. 4. Revascularisation Revascularisation with coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) must be considered in patients with: - Symptoms which are not controlled by optimal medical management. - Complex 3 vessel disease and/or significant left main stem on CTCA.

Answer 88

1. Nicotine replacement therapy (NRT) Multiple formulations are available including patches and oral preparations and can be used for up to 8 weeks. - Works by reducing cravings caused by nicotine withdrawal. - Should be started on the quit day. - Should not be used with varenicline or bupropion and is contra-indicated in severe cardiovascular disease. Common side-effects include nausea, dizziness, vivid dreams and palpitations. 2. Bupropion Originally developed as an anti-depressant it has been shown to be effective in helping smoking cessation. It inhibits reuptake of dopamine, noradrenaline and serotonin in the brain. - Taken as an oral medication and started 7-14 days before the quit date. - Contraindicated in: Epilepsy (decreases seizure threshold) Eating disorders and bipolar disorder, CNS tumours, Those experiencing current benzodiazepine or alcohol withdrawal, Pregnancy and breast-feeding - Important side-effects include seizures and severe hypersensitivity though these are rare. 3. Varenicline (Champix) - Works as a partial nicotinic acetylcholine receptor agonist. - Taken as an oral medication and started 7-14 days before the quit date and is titrated in dose. - Contraindicated in pregnancy. - Important side-effects include increase in suicidal thoughts/behaviours, nausea and abnormal dreams. 4. Using e-cigarettes (vaping) is not currently advocated as a first-line smoking cessation technique and though those who are still vaping can still be referred to smoking cessation services they cannot be prescribed medications. Vaping could be considered for those who have failed to quit using conventional techniques in the past.

Answer 89

Scleritis is a severe inflammation of the sclera, and episcleritis is an inflammation of the episclera, the layer underneath the conjunctiva. Scleritis - Red eye - Severe pain in the orbit - Pain on eye movement - Bluish tinge to the white of the eye in severe or necrotising scleritis - Systemic symptoms in ~50% of patients Episcleritis - Sectoral redness - Tenderness over the inflamed area - Milder pain compared to scleritis - Episcleral vessels move or blanch when pressed with a cotton bud

Answer 90

- Urine dipstick to identify renal disease - FBC, CRP, U&Es, LFT to identify anaemia of chronic disease, neutrophilia, renal function - Autoimmune serology - Phenylephrine eye drops - these blanch the conjunctival and episcleral vessels but not the scleral vessels. So if there is no blanching this is suggestive of scleritis

Answer 91

Management of episcleritis is mostly supportive with the majority of cases self-resolving within weeks. Artifical tears may be used for symptomatic relief. For Scleritis: - NSAIDs such as fluriprofen PO 100 mg TDS for mild cases - Corticosteroids such as oral prednisolone or pulsed IV methylprednisolone for severe or necrotising cases Steroid-sparing therapies for long-term treatment

Answer 92

Salivary gland tumours are abnormal growths of cells in the glands that produce saliva. These tumours can be benign or malignant and can affect any of the salivary glands including the parotid, submandibular, and sublingual glands. Approximately 80% of salivary gland tumours are located within the parotid gland, and 80% of these tumours are benign. The precise cause of salivary gland tumours is unknown, but it is thought to involve a combination of genetic and environmental factors.

Answer 93

Salivary gland tumours typically present as a lump or swelling in the affected gland. Malignant tumours often invade surrounding structures, leading to symptoms such as facial nerve palsy.

Answer 94

Investigations for suspected salivary gland tumours include: - Biopsy: To determine the type of tumour and whether it is benign or malignant. - Imaging studies: Such as ultrasound, CT, or MRI to assess the size and location of the tumour. Management For salivary gland swellings that have been present for over 1 month with no clear underlying cause, removal is typically recommended. Further management strategies depend on the type and stage of the tumour, and may include radiation therapy or chemotherapy for malignant tumours.

Answer 95

1. Bacterial causes The bacteria most commonly implicated are: - Staphylococcus aureus: usually found in cooked meats and cream products. - Bacillus cereus: mainly found in reheated rice. - Clostridium perfringens: usually found in reheated meat dishes or cooked meats. - Campylobacter - E.coli including E.coli 0157 (which can cause haemolytic uraemic syndrome) - Salmonella - Shigella 2. Viral causes - Rotavirus: most common cause of infantile gastroenteritis - Norovirus: most common cause of viral infectious gastroenteritis in all ages in England and Wales - Adenoviruses: commonly cause infections of the respiratory system but can also cause gastroenteritis, particularly in children. 3. Parasitic causes - Cryptosporidium - Entamoeba histolytica - Giardia intestinalis - Schistosoma

Answer 96

Salmonella and shigella are treated with ciprofloxacin. Campylobacter is treated with a macrolide, such as erythromycin. Cholera is treated with tetracycline, to reduce transmission. Food poisoning is a notifiable disease in the UK.

Answer 97

BMI>26 Weight>70kg

Answer 98

1. Pain precipitated by physical exertion 2. Constricting discomfort in the front of the chest, in the neck, shoulders, jaw or arms 3. Relieved by rest or glyceryl trinitrate (GTN) within about 5 minutes associated symptoms include nausea, vomiting, clamminess or sweating

Answer 99

Class I: no angina with normal physical activity. Strenuous activity may cause symptoms. Class II: angina pain causes slight limitation on normal physical activity. Class III: angina causes marked limitation on normal physical activity. Class IV: angina occurs with any physical activity and may occur at rest.

Answer 100

Once atypical/typical anginal pain is suspected: 1. Routine investigations in primary care: - ECG - to assess for ischaemic changes or previous MI. - Bloods - FBC and TFTs (to exclude anaemia and hyperthyroidism respectively which can exacerbate angina symptoms). - Consider cardivascular risk factors: hypertension, hypercholesterolaemia, diabetes mellitus, smoking. 2. 1st line investigations - CT coronary angiogram (CTCA)- indicated if typical/atypical angina pain or if ECG shows ischaemic changes in chest pain with <2 angina features. 3. 2nd line investigations If CTCA is inconclusive the patient may undergo functional imaging: - Stress echocardiogram - Myocardial perfusion SPECT - Cardiac MRI 4. 3rd line investigations - Invasive coronary angiography can be performed if there are inconclusive results from non-invasive testing.

Answer 101

1. Conservative management Involves the optimisation of cardiovascular risk factors to reduce the atherosclerotic process: Smoking cessation, Glycaemic control, Hypertension, Hyperlipidaemia, Weight loss, Alcohol intake 2. Medical management - Secondary prevention: aspirin 75mg OD and statin 80mg ON. - GTN spray for symptom relief: inform patient of side-effects (headache, flushing, dizziness) and to repeat dose if pain not stopped after 5 minutes. - Emergency help should be sought if pain not subsided after 2 doses of GTN as this may indicate acute coronary syndrome. Anti-anginal medications *1st line = beta-blocker (bisoprolol) OR calcium channel blocker (verapamil or diltiazem). Do not combine due to risk of heart block. If neither can be tolerated to consider a long-acting nitrate (ISMN), ivabradine, nicorandil or ranolazine. *2nd line = beta-blocker (bisoprolol) AND long-acting dihydropyridine calcium channel blocker (amlodipine or nifedipine) *3rd line = beta-blocker (bisoprolol) AND long-acting dihydropyridine calcium channel blocker AND long-acting nitrate. - A 3rd medication should only be added if the patient is symptomatic despite 2 anti-anginal drugs. At this stage, revascularisation with PCI or CABG must be considered. 3. Revascularisation Revascularisation with coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) must be considered in patients with: - Symptoms which are not controlled by optimal medical management. - Complex 3 vessel disease and/or significant left main stem on CTCA.

Answer 102

The pathophysiology of cellulitis involves bacterial entry through breaks in the skin's barrier, leading to infection and inflammation. The bacteria multiply in the subcutaneous tissue, triggering an immune response, which results in the characteristic signs and symptoms of cellulitis. The most common offending organisms are Streptococcus pyogenes or Group A beta-haemolytic streptococci (i.e. Streptococci, these strains are also associated with more severe infection), followed by Staphylococcus aureus.

Answer 103

- Breaks in the skin, such as cuts, abrasions, insect bites, or surgical wounds - Chronic conditions that compromise skin integrity - venous insufficiency or lymphedema, pressure sores, ulcers, recent trauma - Obesity - Diabetes - Immunosuppression - Intravenous drug use - Recent history of cellulitis

Answer 104

Generally caused by Streptococcus and/or Staphylococcus organisms. - Erythema - Calor (heat) - Swelling - Pain - Poorly demarcated margins - Systemic upset: fever, malaise - Lymphadenopathy - Rarely blisters and pustules (severe disease) - Often evidence of breach of skin barrier e.g. trauma, ulcer etc.

Answer 105

Cellulitis can usually be diagnosed and treated clinically, however investigations when patients are systemical unwell include: - Blood tests - FBC (high WCC), CRP, U+E (may be AKI if severe infection), blood cultures - Wound swab if there is an open wound, penetrating injury, drainage, or an obvious portal for microbial entry, exposure to water borne-organisms, an infection acquired outside the UK or in severe cellulitis - Ultrasound scan - for distinguishing nonpurulent cellulitis from cellulitis with underlying abscess and for identifying drainable fluid collection

Answer 106

Class I — there are no signs of systemic toxicity and the person has no uncontrolled comorbidities. Class II — the person is either systemically unwell or systemically well but with a comorbidity (for example peripheral arterial disease, chronic venous insufficiency, or morbid obesity) which may complicate or delay resolution of infection. Class III — the person has significant systemic upset, such as acute confusion, tachycardia, tachypnoea, hypotension, or unstable comorbidities that may interfere with a response to treatment, or a limb-threatening infection due to vascular compromize. Class IV — the person has sepsis or a severe life-threatening infection, such as necrotizing fasciitis.

Answer 107

Indications for admission: - Class III - Class IV cellulitis - Rapidly deteriorating cellulitis - Under 1 year of age or frail - Immunosuppression - Significant lymphoedema - Facial cellulitis (unless very mild) - Suspected orbital or periorbital cellulitis (admit to ophthalmology) - Class II cellulitis (systemically unwell or systemically well but with a comorbidity) General principles that should be followed: - Mark the area of erythema to aid in detection of rapidly spreading cellulitis, and to monitor treatment response - Elevate if possible - Review if wound debridement is required Treatment is according to Eron classification: *Class I - high-dose oral flucloxacillin (clarithromycin/doxycyline if penicillin allergic and erythomycin if pregnant) *Class II - admit systemically unwell patients or those systemically well but with a comorbidity. May be able to ambulate with IV antibiotics. *Class III-IV - admit for IV antibiotics

Answer 108

- Abscess formation - Lymphangitis (infection of lymphatic vessels) - Systemic spread of infection (sepsis) - Recurrence of cellulitis - Chronic or recurrent lymphedema - Scarring and changes in skin texture

Answer 109

Amoxicillin Nitro is CI in 3rd trimester Trim seems to be CI all along cause folate antagonist

Answer 110

T-cell mediated inflammatory autoimmune disease

Answer 111

Type IV Hypersensitivity reactions commonly relate to allergens which cause skin reactions such as contact dermatitis.

Answer 112

Type I hypersensitivity corresponds with allergic reactions, such as anaphylaxis.

Answer 113

There is an increased risk (1.2x) of breast cancer and cervical cancer. The risk reduces to baseline after ten years of stopping the OCP. It has been shown to be protective against ovarian and endometrial cancer, and this protective effect lasts 30 years. It is important to discuss these small, but serious, risks with patients when counselling them on contraceptive methods

Answer 114

Oral prednisolone

Answer 115

Haemorrhoids are a pathological condition where the vascular cushions within the anal canal abnormally expand and can protrude outside the anal canal. They are graded as below: Grade 1 - no prolapse Grade 2 - prolapse on straining which spontaneously reduces Grade 3 - prolapse on straining and require manual reduction Grade 4 - prolapse on straining and can't be manually reduced, external haemorrhoids, or lower grade haemorrhoids failing to respond to less invasive measures

Answer 116

The aetiology of haemorrhoids involves a number of risk factors. These include: - Constipation - Pregnancy - Increased intra-abdominal pressure due to causes like obesity, chronic cough or space-occupying lesions - Portal hypertension, particularly secondary to cirrhosis, due to increased pressure at the rectal porto-systemic anastomosis Signs and Symptoms Patients with haemorrhoids typically present with the following clinical features: - Bright red PR bleeding, often associated with defecation and on wiping - Absence of pain, unless the patient has a thrombosed external haemorrhoid or another condition such as an anal fissure - Anal pruritus - A palpable or protruding mass in the anal region during examination, suggestive of prolapsing haemorrhoids

Answer 117

The management of haemorrhoids varies according to the grade: - Grade 1: Conservative management, including potential use of topical corticosteroids to alleviate pruritus - Grade 2: Management may involve rubber band ligation (preferred), sclerotherapy, or infrared photocoagulation - Grade 3: Rubber band ligation is the treatment of choice - Grade 4: Surgical haemorrhoidectomy may be necessary In all cases, patients should be advised to maintain a diet rich in fibre and fluids to reduce the risk of constipation, thereby limiting exacerbation of haemorrhoids. For thrombosed haemorrhoids, which present as painful, purple protrusions, conservative measures such as ice packs, laxatives, and lidocaine gel are first-line treatments. If these measures fail, haemorrhoidectomy may be required.

Answer 118

There are three main genetic mechanisms responsible for Down syndrome: 1. Gamete non-disjunction: Accounts for ~95% of cases; the incidence increases with maternal age. 2. Robertsonian translocation: Sometimes referred to as familial Down syndrome or translocation Down syndrome; accounts for ~4% of cases. 3. Mosaic Down syndrome: The least common form, accounting for ~1% of cases; this often leads to variable expression of the Down syndrome phenotype.

Answer 119

Malignant melanoma is a skin cancer that arises from the melanocytes, the cells responsible for producing the skin pigment melanin. Malignant melanomas originate from a melanocyte that begins to divide uncontrollably, leading to a localised cluster of melanocytes that may eventually become invasive and metastasise. Most melanomas arise de novo from normal skin, but about a third may develop from pre-existing melanocytic naevi. Risk factors for the development of malignant melanoma include: - Family history or prior personal history of melanoma - Genetic syndromes, such as Familial Atypical Multiple Mole Melanoma Syndrome - Skin type prone to burning and not tanning (Fitzpatrick type I or II) - Fair skin, light hair, and blue or green eyes - Immunosuppression - High levels of sun or UV exposure - Presence of multiple or atypical melanocytic naevi - Smoking - Advanced age and male sex - Presence of certain genetic mutations (e.g. BRAF mutations)

Answer 120

Sinusitis is an inflammation or swelling of the tissue lining the sinuses, often following an acute upper respiratory tract infection. It can be acute or chronic, with acute sinusitis often being painful and chronic sinusitis often painless but causing nasal obstruction due to mucosal hypertrophy. Signs and Symptoms - Bilateral intense pain - Fever - Nasal obstruction - Purulent discharge - In acute exacerbations, the pain is worse when sitting forward - In chronic sinusitis, there is nasal obstruction due to mucosal hypertrophy and purulent discharge

Answer 121

Diagnosis of sinusitis is typically clinical, based on the patient’s history and physical examination. Further investigations may include imaging studies, nasal endoscopy, or microbiological studies. Management Management strategies for sinusitis can include: - Analgesics for pain relief - Nasal sprays to reduce inflammation and relieve congestion - Antibiotics in cases of bacterial sinusitis - Surgery may be considered in severe or recurrent cases

Answer 122

Melanoma often presents with the following features (ABCDE): 1. Asymmetry of the lesion 2. Border irregularity 3. Colour variegation 4. Diameter >6mm 5. Elevation/evolution over time Additional symptoms may include itchiness and bleeding. It is important to check for distant metastases, as this cancer is known to spread, affecting the patient's survival rate.

Answer 123

Evaluation of a suspected melanoma involves: 1. Excisional biopsy of the lesion with a 2mm margin 2. Sentinel lymph node biopsy if the Breslow thickness is >1mm 3. PET or CT scans may be necessary in the presence of clinical suspicion for metastases Management The Breslow thickness is determined histologically, and is the most important prognostic indicator. It is measured in mm, from the top of the granular layer in the epidermis to the deepest point that the tumour extends. 1. Excision with a 2mm margin and further excision depending on the Breslow thickness. - Melanoma in situ: 5 – 10 mm - Melanoma < 1 mm: 10 mm - Melanoma 1–2 mm: 10 – 20 mm - Melanoma > 2 mm: 20 mm 2. Lymph node clearance if lymph nodes involved 3. Radiotherapy in some cases 4. Adjuvant Immunotherapy/chemotherapy in metastatic disease (Stage III/IV), such as pembrolizumab (PD-1 blocking drug) 5. Mole-mapping and lifestyle advice to prevent recurrence in those at risk

Answer 124

Bell's palsy is an idiopathic syndrome that causes damage to the facial nerve. The aetiology of Bell's palsy remains unknown. Viral infections, particularly reactivation of herpes simplex virus type 1 (HSV-1), have been implicated as a possible cause. Other viral pathogens, such as Epstein-Barr virus (EBV) and varicella-zoster virus (VZV), have also been suggested as potential triggers. However, the exact mechanisms by which these viruses lead to facial nerve dysfunction are not fully understood.

Answer 125

The clinical features of Bell's palsy include: - Acute (but not sudden) onset of unilateral lower motor neuron facial weakness (classically affecting the forehead as this area has bilateral nervous supply from both sides of the brain) - Mild to moderate postauricular otalgia, which may precede the paralysis. - Hyperacusis - Nervus intermedius symptoms, such as altered taste and dry eyes/mouth. - Patients may subjectively describe "numbness" or "heaviness" without objective facial somatosensory disturbances.

Answer 126

The diagnosis of Bell's palsy is primarily clinical, based on the characteristic signs and symptoms. However, in some cases, additional investigations may be considered to exclude other potential causes or to assess the severity of nerve dysfunction. These investigations may include: FBC, ESR or CRP, Viral serology (e.g. HSV-1, EBV, VZV), Lyme serology (if suggestive symptoms or exposure). Otoscopy to see if any vesicular lesions in external auditory meatus (Ramsay-hunt-syndrome), EMG, Imaging studies (e.g MRI or CT) Management The management of Bell's palsy includes: 1. Prompt administration of oral steroids: 50mg of oral prednisolone or prednisone once daily for 10 days, followed by a taper. 2. Aciclovir can be considered in select cases 3. Supportive treatments: - Artificial tears and ocular lubricants to manage dry eyes. - Eye patch/tape,especially if protective Bell's phenomenon is absent, to prevent corneal exposure and injury. - The use of aciclovir is controversial. Although the pathophysiology of Bell's palsy has not been definitively linked to active herpes virus infection, empirical treatment with aciclovir may be considered, particularly in cases where the clinical distinction between Bell's palsy and Ramsay-Hunt syndrome is difficult. Patients with Ramsay-Hunt syndrome may benefit from antiviral therapy, such as aciclovir, due to the association with varicella-zoster virus (VZV) reactivation. 4. Pain management with analgesics or anticonvulsants may be necessary in cases of severe otalgia or neuropathic pain. 5. Physical therapy, including facial exercises and massage, may be recommended to maintain muscle tone and prevent contractures during the recovery phase. 6. Psychological support and counseling may be beneficial for patients experiencing emotional distress or body image concerns due to facial weakness.

Answer 127

- Undiagnosed vaginal bleeding - Pregnancy - Breastfeeding - Oestrogen receptor-positive breast cancer - Acute liver disease - Uncontrolled hypertension - History of breast cancer or venous thromboembolism (VTE) - Recent stroke, myocardial infarction or angina

Answer 128

Combined HRT contains an oestrogen to relieve symptoms, alongside a progestogen to protect the endometrium from hyperplasia. Cyclical HRT is used in women who have last menstruated less than 1 year ago Continuous combined HRT is required in women who have a uterus and who have ceased menstruating for over 1 year.

Answer 129

Oestrogen-only HRT increases the risk of endometrial cancer in a woman with a uterus and so can only be used in women who have had a hysterectomy. Combined HRT contains a progestogen that protects the endometrium from excessive proliferation. Cyclical HRT is used in women who last menstruated less than 1 year ago, and is only suitable for women who do not have a uterus. Continuous is for women who have ceased menstruating for over 1 year.

Answer 130

Rheumatic fever occurs 2–6 weeks following infection with group A streptococcus (GAS), such as Streptococcus pyogenes. The Jones criteria can be used to provide a diagnosis: A diagnosis is considered likely if there is: - evidence of recent streptococcal infection (eg. history of scarlet fever, positive throat swab or rising or increased antistreptolysin O titre (ASOT) >200 U/ml or DNase B titre). - plus two major criteria; or - one major and two minor criteria 1. Major criteria (J<3NES) - Joint pain (typically a migratory polyarthritis affecting one joint then others in quick succession; most commonly affected joints are the knees, ankles, elbows and wrists) - Pancarditis (<3)/ myocarditis/ endocarditis/ pericarditis (this may manifest as tachycardia or new murmur) - Nodules (subcutaneous nodules on tendons/joints) - Erythema marginatum (geographical pink/red, nonpruritic rash involving mainly the trunk, thighs and arms; characteristically, the rash has raised, sharp outer edges with a diffuse clear centre, making a ring) - Sydenham's chorea (late sign) 2. Minor criteria (J<3NES) - Joint pain - arthralgia not meeting major criteria <3: prolonged PR interval - Nothing - E: ESR/CRP are raised - S: 'shivering' (fever)

Answer 131

Penicillin V

Answer 132

Escherichia coli Higher incidence in many countries particularly across Africa and Asia

Answer 133

Heart failure (HF), also known as congestive heart failure (CHF) and congestive cardiac failure (CCF), is defined as the failure of the heart to generate sufficient cardiac output to meet the metabolic demands of the body. Classification HF can be classified in different ways. 1. Low-output HF vs. High-output HF Low-output HF is much more common than high-output HF. Low-output HF occurs when cardiac output is reduced due to a primary problem with the heart and the heart is unable to meet the body's needs. Conversely, high-output HF refers to a heart that has a normal cardiac output, but there is an increase in peripheral metabolic demands that the heart is unable to meet. Common causes of high-output HF include: Anaemia, Arteriovenous malformation, Paget's disease, Pregnancy, Thyrotoxicosis, Thiamine deficiency (wet Beri-Beri) 2. Systolic vs. Diastolic HF - Systolic dysfunction refers to an impairment of ventricular contraction. The ventricles are able to fill well, but the heart is unable to pump the blood sufficiently out of the ventricle due to impaired myocardial contraction during systole (reduced ejection fraction). Common causes include: ischaemic heart disease, dilated cardiomyopathy, myocarditis or infiltration (haemochromatosis or sarcoidosis). - Diastolic dysfunction refers to the inability of the ventricles to relax and fill normally, hence the heart is still able to pump well but pumps out less blood per contraction due to reduced diastolic filling (preserved ejection fraction). Common causes include: uncontrolled chronic hypertension (significant left ventricular hypertrophy reduces filling of the left ventricle), hypetrophic cardiomyopathy, cardiac tamponade, and constrictive pericarditis. 3. Acute vs. Chronic HF Acute HF occurs with new-onset of HF symptoms (acute mitral regurgitation following an MI) or an acute deterioration in a patient with known, chronic HF. In comparison, chronic HF progresses more slowly and may take many years to develop. 4. New York Heart Association (NYHA) Classification of HF - Class I - no limitation in physical activity, and activity does not cause undue fatigue, palpitation or dyspnoea. - Class II - slight limitation of physical activity, and comfort at rest. Ordinary physical activity causes fatigue, palpitation and/or dyspnoea. - Class III - marked limitation in physical activity, but comfort at rest. Minimal physical activity causes fatigue (less than ordinary). - Class IV - inability to carry on any physical activity without discomfort, with symptoms occurring at rest. If any activity takes place, discomfort increases.

Answer 134

The clinical features of HF can be considered according to the ventricle most impacted. However, a common presenting complaint for all types of heart failure is fatigue. 1. Clinical features of left heart failure (LHF) LHF, or left ventricular failure (LVF), causes pulmonary congestion (pressure builds up on the LHS of the heart and there is backpressure to the lungs) and there is systemic hypoperfusion. Symptoms: - Shortness of breath on exertion - Orthopnoea - Paroxysmal nocturnal dyspnoea - Nocturnal cough (¬± pink frothy sputum) - fatigue Signs - Tachypnoea - Bibasal fine crackles on auscultation of the lungs - Cyanosis - Prolonged capillary refill time - Hypotension - Less common signs: pulsus alternans (alternating strong and weak pulse), S3 gallop rhythm (produced by large amounts of blood striking compliant left ventricle), features of functional mitral regurgitation. 2. Clinical features of right heart failure Right heart failure causes venous congestion (pressure builds up behind the right heart) and pulmonary hypoperfusion (reduced right heart output). Symptoms: - Ankle swelling - Weight gain - Abdominal swelling and discomfort - Anorexia and nausea Signs: - Raised JVP - Pitting peripheral oedema (ankle to thighs to sacrum) - Tender smooth hepatomegaly - Ascites - Transudative pleural effusions (typically bilaterally) NB. Sometimes left sided heart failure can lead to pulmonary congestion which in turn also pushes the right ventricle into failure. In these cases signs and symptoms of both left and right sided heart failure may be present. This is congestive cardiac failure.

Answer 135

If a stable patient is presenting to the GP with suspected chronic heart failure investigations should be carried out as per NICE guidelines. 1st line = NT-pro-BNP level NT-pro-BNP is released by the ventricles in response to myocardial stretch. It has a high negative predictive value. - 2000ng/L (236pmol/L): refer urgently for specialist assessment and TTE <2 weeks. - 400-2000ng/L (47-236pmol/L): refer for specialist assessment and TTE <6 weeks. - If <400ng/L be aware that diagnosis of heart failure is less likely. 2. Arrange a 12-lead ECG in all patients ECG may be normal or hint at underlying aetiology (ischaemic changes or arrhythmias). 3. Transthoracic echocardiogram (TTE) Echocardiogram will confirm the presence and degree of ventricular dysfunction. Ventricular dysfunction is normally measured by the ejection fraction (EF). EF <40% = HF with reduced ejection fraction (HFrEF, systolic dysfunction). EF >40% but with raised BNP = HF with preserved ejection fraction (HFpEF, diastolic dysfunction). EF 50-70% with normal BNP = normal. 4. Other Investigations: Bloods: U&E (renal function for medication and hyponatraemia), LFTS (deranged LFTs suggest hepatic congestion), FTFs (hyperthyroidism and high-output HF), glucose and lipid profile (modifiable CV risk factors) CXR: CXR findings in heart HF can be remembered by the ABCDEF mnemonic: A: Alveolar oedema (with 'batwing' perihilar shadowing) B: Kerley B lines (caused by interstitial oedema) C: Cardiomegaly (cardiothoracic ratio >0.5) D: upper lobe blood diversion E: Pleural effusions (typically bilateral transudates) F: Fluid in the horizontal fissure

Answer 136

1. Conservative management - Weight loss if BMI >30. - Smoking cessation - Salt and fluid restriction - improves mortality - Supervised exercise-based group rehabilitation programme for people with heart failure. - Offer annual influenza and one-off pneumococcal vaccinations for patients diagnosed with heart failure. 2. Medical management - Symptom management: For fluid overload prescribe loop diuretics (e.g. furosemide or bumetanide). These do not confer mortality benefit. - Mortality benefit: 1st line = ACE-I and beta-blocker Consider ARB if intolerant to ACE-I. Consider hydralazine if intolerant to ACE-I/ARB. If symptoms persist and NYHA Class 3 or 4 consider: *Aldosterone antagonists = spironolactone or eplerenone. *Hydralazine and a nitrate for Afro-Caribbean patients. *Ivabradine if in sinus rhythm and impaired EF. *Digoxin = useful in those with AF. This worsens mortality but improves morbidity. Now, NICE also advices seeking specialist guidance for prescribing SGLT2 inhibitors (dapagliflozin or empagliflozin). These should be given in symptomatic chronic heart failure with preserved or reduced ejection fraction, as an add on for patients already optimised with ACE-i/ARB/sacubitril-valsartan (i.e. combination), beta-blockers and aldosterone antagonists 3. Surgical/Interventional management - Cardiac resynchronisation therapy

Answer 137

Common side effects of statins include muscle pain, abdominal pain, constipation and headache. If a patient is struggling with significant myalgia, this may indeed indicate a myositis. Creatinine Kinase can be measured and if it is 5-10 times the upper limit of normal, the statin should be stopped. Statins can also cause abnormal liver function so this should be monitored with a repeat blood test in 4-6 weeks time. If the transaminases (ALT, AST) are 3 times the upper limit the statin should be stopped.

Answer 138

Stage 1 = FEV1 >80% predicted. Symptoms include chronic cough but no/mild shortness of breath. Stage 2 = moderate COPD: FEV1 = 50–80% predicted. Symptoms include shortness of breath on exertion. Stage 3 = severe COPD: FEV1 = 30–50% predicted. Symptoms include shortness of breath on minimal exertion. Stage 4 = very severe COPD: FEV1 <30% predicted OR FEV1/FVC <50% predicted. Symptoms include shortness of breath at rest.

Answer 139

NRT Bupropion and varenicline are contraindicated

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