Questions Flashcards
What is nominal aphasia? Where in the brain is affected?
Unable to name familiar objects but language is otherwise preserved - it can occur as part of other aphasic syndromes
When it occurs on its own, it suggests an inferior parietal lesion - angular gyrus
Woman on COCP missed 1 pill previous night on the 19th pill of packet - recommendation?
Take forgotten pill now ad next one at usual time - additional precautions only required if 2 or more pills missed
What is an Advance Statement?
When a person is well, they can specify what treatment they would want in the event of mental health deteriorating again and lacking capacity to make decisions
Pt in acute psychosis intending to commit suicide attends psychiatry out-patient clinic. What law can be used?
Short term detention can be used as it is a psychiatrist who is available
Supplements women should take daily during pregnancy?
Folic acid 400mcg
VitD 10mcg
If at risk of neural tube defect e.g. maternal diabetes, give 5mg folic acid
Premalignant change with discoloured growth?
Neoplasia
What is used to identify treponema pallidum?
Aerobic/anareobic?
Dark field microscopy - difficult to perform gram stain as thin membrane
Aerobic/microaerophilic
First line treatment for Iron deficiency anaemia Hb 8.8g/L
PO Fe supplements
What is toxic granulation?
How is a neutrophil identified?
A neutrophil has granules containing anti-microbial enzymes - when activated these are particularly prominent (neutrophil count normally also raised in this context)
Usually colours purple - nucleus has 3-5 lobes
Blood supply to intercostal spaces
Anterior - internal thoracic artery/internal thoracic vein
Posterior - thoracic aorta and azygous vein
80 y/o woman with 3 month Hx of falls. Has CKD, mild dementia and is awaiting R knee replacement for OA. Struggles to climb stairs due to knee pain. Takes paracetamol and 2 weeks ago started on codeine. What do you do?
Strength and balance training before knee replacement - improve quadriceps strength and inc joint stability, helps improve outcomes
Codeine can cause confusion and falls in the elderly, but her falls precede codeine and codeine has not exacerbated them
NSAIDs in elderly?
Risk of GI bleed and renal impairment
Blood pressure during pregnancy?
Decreases 2nd trimester due to expansion of uteroplacental circulation and decreased TPR, and increases back to normal 3rd trimester
GFR in pregnancy?
Increases 30-50%
Cardiac output in pregnancy?
Increases 30-50%
Erythropoeisis during pregnancy?
Increases 25%
Vital capacity in pregnancy?
Remains unchanged
tidal volume and minute volume increase
Requirements for diagnosis of delirium?
Acute onset
Inattention with fluctuating course
Disorganised thinking; OR
altered level of consciousness
40y/o woman who smokes 20 cig/day has green nipple discharge and a non-tender lump below the nipple?
Duct ectasia
Assoc with smoking and green/cream nipple discharge. A lump (thickened duct) can be felt under the nipple
70y/o woman who develops hot tender breast with overlying cellulitis - recently had 2 courses of antibiotics which have not helped?
Inflammatory breast cancer
Elderly patient with inflammatory breast changes and no resolution despite antibiotics - suspect inflammatory breast cancer
Wilson’s disease inheritance?
Symptoms?
Autosomal recessive
Neuro, psych and hepatic conditions due to copper deposition - kayser-fleischer rings in eyes from copper deposits around iris
Becker’s muscular dystrophy inheritance?
Gene?
Can it be de novo?
X-linked recessive
Dystrophin gene
Some are de novo
What is myoclonic epilepsy with ragged red fibres?
Features?
Inheritance?
Mitochondrial disease - clumps of mitochondria accumulate in muscle fibres giving ragged, red appearance.
Other features include progressive myoclonic epilepsy, short stature, hearing loss, lactic acidosis, exercise intolerance and poor night vision.
Mitochondrial inheritance
What should be measured before commencing COCP on healthy 17 y/o?
BMI and BP - uncontrolled hypertension and obesity both CI
Inheritance of Huntington’s?
Autosomal Dominant
Blood test pattern for autoimmune haemolytic anaemia?
Low Hb
High MCV
Very high reticulocytes
Normal WCC and PLT
Film shoes spherocytes and polychromasia
Direct Antiglobulin Test will be positive
Hormone used to assess ovarian reserve prior to IVF?
anti-mullerian hormone
Also useful to predict response to supra-ovulation in IVF treatment
First area affected in Alzheimer’s?
Nucleus Basalis of Meyert
This is the main source of cholinergic projections to the rest of the brain - thought to be one of the mechanisms by which Alzheimers causes cognitive impairment (however the fact cholinesterase inhibitors only delay symptoms shoes there are other mechanisms at work)
Which law allows detention of pt in hospital for 6 months in first instance?
Compulsory treatment order
What is a compulsion order?
Similar to a compulsory treatment order, but used to enable patients subject to criminal proceedings to receive treatment for mental disorder under Criminal Procedure (Scotland) Act 1995
What is dystonia?
Name of cervical dystonia?
Sustained abnormal posture caused by persistent contraction of large trunk or limb muscle. Aetiology and pathology unknown.
Spasmodic Torticollis - head turning to one side due to sternocleidomastoid contraction.
Treatment of dystonia?
anticholinergics (promethazine, atropine, tolterodine are antimuscarinic, burpropion is anti-nicotinic)
Phenothiazines (prochlorperazine)
Botulinum toxin injection
What is blepharospasm
Uncontrolled spasm/twitch of eyelid
What form of hepatitis is faeco-oral transmission
Hep A and E
Most people in UK over 60 now immune. Still most common type.
Visual defect from lateral optic nerve lesion immediately anterior to chiasma?
Junctional scotoma
central scotoma of one eye and temporal hemianopia/quadrantopia of other eye
Acutely manic 29y/o woman who may be pregnant?
Olanzapine
Treatment of hyperactive delirium?
Haloperidol or Aripiprazole
Benzos prolong delirium
85y/o woman, has to rush to toilet any time she thinks of urinating, often incontinent. Type?
Urge
Stimulus causes OAB leading to sudden voiding
Is early neonatal jaundice normal?
> 24hrs yes
Is neonatal polycythaemia normal?
Yes
Is neonatal peripheral cyanosis normal?
Yes
Is neonatal splitting of 2nd heart sound normal?
Yes
Is neonatal delay in femoral pulse normal?
No - suggestive of coarctation of aorta
Moderately severe continuous frontal headache, worse in evenings?
Acute tension headache
Features of benign intracranial hypertension?
generalised throbbing headache assoc w nausea and vomiting, made worse by activity that increased ICP e.g. coughing to sneezing. Commonly in obesity or taking COCP
Is smoking a CI for HRT?
No
Is well controlled angina a CI for HRT?
Yes - any active or recent thromboembolic disease (MI or angina) is a CI
Is obesity with BMI 37 a CI for HRT?
No
Is FHx of breast cancer CI for HRT?
No
Is osteoporosis CI for HRT?
No
Function of proximal tubule
Involved in regulation of pH and reabsorbs 100% of filtered glucose and amino acids
Are H+ ions reabsorbed in proximal tubule?
No they are excreted
Is urea reabsorbed in proximal tubule?
No it is filtered in glomerulus, and reabsorbed at the collecting duct (and loop of henle), reabsorption controlled by ADH to create a high-osmolar concentration gradient
65 y/o male has cervical, axillary and inguinal lymphadenopathy measuring 2cm. FBC shows Hb 123, WCC 231x10^9, Lymphocytes 223x10^9, PLT 332
Chronic Lymphoid Leukaemia - Lymphocytosis also seen in non-Hodgkin’s and acute viral (but never more than 20x10^9) - Lymphocytes only ever this high in CLL
What is seen on blood film of EBV?
Atypical lymphocytes
What can occur after EBV?
Many have chronic fatigue - immune-mediated cytopenias (e.g. neutropaenia, thrombocytopenia or autoimmune haemolytic anaemia)
What should trigger HIV suspicion, even in low risk individuals?
Unexplained cytopaenia (even lymphopenia or thrombocytopenia), or unexplained lymphadenopathy
What is used to dose unfractioned heparin?
APTT
All others (PT, INR, PV and bleeding time insensitive to heparin)
What happens to phosphate in CKD?
How is it managed?
It usually rises, but not until late stage, and it isn’t efficiently removed by dialysis either
Phosphate binders often used to maintain phosphate within reference range
Why do CKD patients often have hyperparathyroidism?
Management?
Low Ca as impaired reabsorption, and low vitD due to reduced activation, causes hyperparathyroidism
Treatment is recommended even if asymptomatic due to increased risk of fractures and vascular calcification
CSF pattern in bacterial meningitis
Cloudy Glucose <50% serum Protein increased Predominantly neutrophils Oligoclonal bands -ve
When are lymphocytes raised in CSF
Viral meningitis
TB meningitis
Multiple Sclerosis
When are protein levels raised in CSF
In most conditions, but severely increased in bacterial meningitis
When are oligoclonal bands seen in CSF
MS
>90% of patients
First line for simple partial (focal aware) seizures?
Carbamazepine or Lamotrigine
How does Lamotrigine work?
Blockade (antagonist) of voltage-sensitive Na+ channels, which reduces glutamate release
What is red cell fragmentation and thrombocytopenia seen in?
Intravascular destruction of RBC due to over activation of complement system - e.g. haemolytic uraemic syndrome after E Coli 0157 infection
Features of Haemolytic Uraemic Syndrome post-E Coli O157?
Few days Hx of diarrhoea Purpura develops Low Hb High WCC (due to infection) Low PLT Very high creatinine
Is fluid removed from the patient by osmosis in dialysis?
No
Are dialysis patients given EPO?
Yes - to stimulate RBC production and prevent anaemia
Induction of Labour at 42 weeks gestation - following artificial ROM there is prolonged foetal bradycardia at 50bpm, and fresh vaginal bleeding is noted. On exam uterus is soft and non-tender
Vasa Praevia
Condition where cord vessels cross the foetal membranes
Assoc w severe foetal distress and relatively small intrapartum bleed following ROM
CN responsible for pain across posterior triangle of neck?
CNVII
neurotransmitter responsible for suspected epileptic fit in 21y/o known IVDU
GABA - withdrawal from sedative-hypnotic drugs causes reduced GABA
Features of acute dystonic reaction?
Extrapyramidal SE which occurs within hours of taking antipsychotic medication
Patient cannot move affected body part and it is extremely painful
Features of metabolic syndrome?
Central obesity
Hypertension
Hypercholesterolaemia
Insulin resistance
Can lead to serious problems e.g. MI
Lung disease assoc w RA
Fibrosing Alveolitis secondary to Rheumatoud Disease (DPLD/ILD)
Causes breathlessness, finger clubbing, CXR shows shrunken lungs and bilateral infiltrates
Spirometry of interstitial lung disease
Low FEV1
Low FVC
Normal FEV1/FVC ratio
When does to urge to urinate come?
When bladder volume reaches 250ml
What is upper limit of urine production?
2.8L daily
Control of urethral sphincter?
Both voluntary (striated muscle) and involuntary (smooth muscle) control
What does parasympathetic stimulation of bladder cause?
Contraction of detrusor muscle
Artery most likely to be injured during insertion go abdominal port for female laparoscopic sterilisation?
Inferior epigastric artery
Branch of external iliac that runs on posterior surface of lower half of rectus abdominis
Artery most likely to be injured by bartholin’s abscess removal?
Branches from internal pudendal artery
Supply the labia and clitoris
Artery most likely to be damaged during dissection of lower ureter?
Uterine artery
Lower ureter passes under the uterine artery as it passes through the base of the broad ligament beside the cervix, before entering the trigone of the bladder
25 y/o primigravida has 2 hour second stage of labour and is exhausted after 1 hour. CTG is reassuring. On exam there is cephalic presentation in direct OP position with station +2cm. Most appropriate intervention?
Mid-cavity non-rotational forceps delivery (e.g. Haig Ferguson, Neville-Barnes, Simpson’s)
Appropriate as the saggital suture is in AP diameter and presenting part below ischial spine
Best test for definitive diagnosis of sickle cell anaemia?
Hb high performance liquid chromatography of whole blood lysate (HPLC)
Confirms presence of HbS
What is a sickle solubility test
Test for presence of sickle cells, but not specific as also present in carriers of disease
What is the function of the appetitive and approach systems?
Mediate seeking and approach behaviours including pleasure. They involve ascending dopamine systems which project to the mesolimbic areas of the cortex, as well as the striatum, amygdalae, anterior cingulate and orbitofrontal cortex
What is Rouleaux?
When does it occur?
When RBC’s are stacked like ‘coins’ under film
Occurs when the charge on the cell surface alters as a consequence of being labelled with proteins (e.g. acute phase proteins in infection or paraproteins (intact immunoglobulin) found in plasma cell dycrasias)
Bacterium which is intracellular, that produces elementary bodies and reticulate bodies during its reproductive cycle, and is diagnosed by PCR?
Chlamydia trachomatis
35 y/o with severe dysmenorrhoea and dyspareunia caused by known endometriosis - Rx?
COCP, or any treatment which reduces menstruation
25 y/o woman who presents to A&E suffering from smoke inhalation, from a fire which killed her 14 day old baby. She is tearful and distracted by loud voices stating “they told me to start the fire”. Diagnosis?
Peurperial psychosis
This is an extreme presentation
Consent required from 14 y/o girl who wants TOP and fully understands procedure?
Written consent, as it is a surgical procedure
Consent required for a 77y/o unconscious man requiring emergency repair to fractured hip. Wife accompanies him.
Nil required.
As it is an emergency, a procedure can be performed if it is not possible to obtain consent and treatment is immediately required to save life or prevent serious deterioration
Consent required for 40y/o severely brain damaged woman with menorrhagia, whose husband is requesting total abdominal hysterectomy to improve personal hygiene?
Court of law decide, overriding need for consent
In a non-emergency situation when pt cannot provide consent and is unlikely to gain capacity in future, it is appropriate to seek legal action
What type of organism is trichomonas vaginalis?
flagellated protozoa
What type of organism is Gardnerella vaginalis?
‘Clue cells’ seen in bacterial vaginosis
Is warfarin CI in breastfeeding?
No
Is Labetalol CI in breastfeeding?
No
Is Tetracycline CI in breastfeeding?
Yes - can discolour infant’s teeth
Is amoxicillin CI in breastfeeding?
No
Is Amitriptyline CI in breastfeeding?
No
With ageing, does a serum creatinine within normal range always an indicator of normal renal function?
No, Muscle is a source of creatinine and low muscle mass may mean serum creatinine is normal despite poor renal function
Compare cardiac output of an 80y/o to a 20y/o?
CO about 50%
Bone mass loss in men and women with ageing?
Around 5-10% per decade for women
Around 5% per decade for men
How can older people get weaker despite remaining constant weight
Sarcopenic obesity
Muscle mass loss and converted to fat
Does methyldopa affect COCP?
No
Does Phenytoin affect COCP?
Yes - it is a CYP450 enzyme inducer, as is Carbamazepine
Does mefanamic acid affect COCP?
No
Does Amoxicillin affect COCP?
No
Does Codeine affect COCP?
No
30y/o woman with borderline personality disorder has episodes where she loses consciousness and appears to have tonic-clonic seizure, however EEG is normal?
Non-epileptic seizure
Childhood trauma/abuse is risk factor for both
However, beware of malingering
4 problems which may happen in life of premature infant born at 29 weeks gestation?
Sepsis
ARDS
Intraventricular haemorrhage
Patent ductus arteriosus
1 long-term issue which a preterm infant born at 29 weeks gestation may face
Chronic lung disease (broncho-pulmonary dysplasia)
What does decreased CO2 do to oxyhemoglobin dissociation curve?
Shifts to left
decreased oxygen release
What does decreased pH do to oxyhemoglobin dissociation curve?
shifts right
increased oxygen release
What does decreased temperature do to oxyhaemoglobin dissociation curve?
shifts to left
decreased oxygen release
What does decreased 2,3-DPG do to oxyhemoglobin dissociation curve?
Shifts to left
decreased oxygen release
What does decreased H+ ions do to oxyhemoglobin dissociation curve?
shifts to left
decreased oxygen release
Monitoring for patient on Dalteparin (LMWH) for PE she had 3 weeks ago?
Anti-Xa assay
APTT useful for unfractioned heparin but is often normal in LMWH.
LMWH inhibits Xa.
Timing of sample very important and should be done 3-4 hours after dose
Monitoring for 75 y/o patient on Dabigatran (direct thrombin inhibitor) for AF and Hx of TIA. Renal function normal.
No routine monitoring required
(licensed for AF to prevent stroke - just as good as warfarin with less intracranial effects)
It is mostly excreted renally and CI if GFR <30ml/min
Therefore, only monitor if renal function deteriorates
4 signs of multiple myeloma?
Focal back pain (over vertebra)
Anaemia
Hypercalcaemia
Renal failure (proteinuria, microscopic haematuria, high urea and creatinine)
(can affect ribs, femur or hip as well as spine)
Inheritance of hereditary spherocytosis?
Autosomal dominant
very very rarely autosomal recessive, not one of they typical proteins involved
What is hereditary spherocytosis?
Umbrella term for a mutation in one of several RBC membrane proteins, causing spherical RBC’s.
Pts can require splenectomy or cholecystectomy (from pigment gall stones) due to chronic haemolysis
Function of aversive system?
Neurotransmitters/anatomy?
Promote survival in event of a threat
endogenous opioids (kappa)
ascending serotonin
Noradrenaline
Involves central amygdala, hippocampus and peri-acqueductal grey
