questions

Question 1

Requirements for maintenance fluids.

Answer 1

In the 2013 guidelines NICE recommend the following requirements for maintenance fluids:
25-30 ml/kg/day of water and
approximately 1 mmol/kg/day of potassium, sodium and chloride and
approximately 50-100 g/day of glucose to limit starvation ketosis

Question 2

Routine maintenance IV fluids

Answer 2

Body weight Fluid requirement/24 h

First 10 kg 100 ml/kg
Second 10 kg 50 ml/kg
Subsequent kg 20 ml/kg

Question 3

How to test for diabetic kidney disease

Answer 3

Microalbuminuria is the first indicator of diabetic nephropathy. Albumin/creatinine ratio should be used to screen for diabetic kidney disease. If results are abnormal then repeat with first-pass morning urine specimen.

ACR has a higher sensitivity than PCR for low levels of proteinuria. If abnormal then monitor BP and control it, tight glycemic control, control dyslipidemia.

Question 4

Hypoglycaemics for breastfeeding

Answer 4

Sulfonlyureas/gliclazide should be avoided when breastfeeding due to theoretical risk of neonatal hypoglycaemia.
Metformin is safe.

Question 5

Trigeminal neuralgia

Answer 5

Severe unilateral pain. Pain brought on by light tough, including washing, shaving, smoking, talking and brush the teeth. Pain occurs spontaneously.

Management is carbamazepine.

Red flag symptoms: sensory changes, deafness, optic neuritis, FH of MS, <40yrs

Question 6

Normal pressure hydrocephalus

Answer 6

Triad: ataxia, urinary incontinence, and dementia.

reversible cause of dementia seen in elderly patients. Secondary to reduced CSF absorption at arachnoid villi.

Managed with ventriculoperitoneal shunting - around 10% of patients may experience complications such as seizures, infections and ICH

Question 7

Huntington’s - dominant or recessive?

Answer 7

autosomal dominant

Question 8

VWD von willebrand

Answer 8

Prolonged bleeding time, normal platelet count, prolonged APTT.

Autosomal dominant.

Factor VIII may be moderately reduced.

Managed with tranexamic acid for mild bleeding, desmopressin, factor VIII concentrate

Question 9

Chest X-Ray - white shadowing

Answer 9

trachea towards white out: pneumonectomy, complete lung collapse, pulmonary hypoplasia

trachea central: consolidatorn, bilateral pulmonary odemea, mesothelioma

trachea pushed away: pleural effusion, diaphragmatic hernia, large thoracic mass

Question 10

Carbimazole

Answer 10

Used to treat hyperthyroidism. Carbimazole is a pro-drug as after absorption it is converted to the active form, methimazole. Methimazole prevents thyroid peroxidase enzyme from coupling and iodinating the tyrosine residues on thyroglobulin, hence reducing the production of the thyroid hormones T3 and T4.

Question 11

Hypothyroidism Management

Answer 11

SE of thyroxine therapy: hyperthyroidism, reduced bone mineral density, worsening of angina, AF

Interacts with iron given at least 2 hrs apart.

Question 12

SE of SGLT2 inhibitors

Answer 12

genital infections, diabetic ketoacidosis

Question 13

SE biguanides e.g. metformin

Answer 13

GI upset, lactic acidosis

Question 14

SE of GLP-1 mimetics

Answer 14

nausea, vomiting, pancreatitis

Question 15

SE of insulin

Answer 15

weight gain, hypoglycaemia, lipodystrophy

Question 16

SE of thizolidinediones

Answer 16

weight gain, liver impairment, fluid retention, bladder cancer, increased risk of fractures

Question 17

gentamycin complication

Answer 17

nephrotoxicity and ototoxisity

Question 18

Complications of Transurethral Resection:

Answer 18

T ur syndrome
U rethral stricture/UTI
R etrograde ejaculation
P erforation of the prostate

Question 19

NEONATE SEPSIS

Answer 19

Sepsis in the neonate can broadly be divided into early-onset (<48 hours since birth) and late-onset (>48 hours from birth). Early-onset sepsis is associated with acquisition of micro-organisms from the mothers birth canal. Late-onset sepsis normally occurs due to hospital acquired pathogens such as Staphylococcus epidermidis and Staphylococcus aureus.

The neonate in this question has early onset sepsis. The most likely pathogen is Group B Strep which is a common commensal of the female genital tract.

Question 20

NEONATE SEPSIS

Answer 20

Sepsis in the neonate can broadly be divided into early-onset (<48 hours since birth) and late-onset (>48 hours from birth). Early-onset sepsis is associated with acquisition of micro-organisms from the mothers birth canal. Late-onset sepsis normally occurs due to hospital acquired pathogens such as Staphylococcus epidermidis and Staphylococcus aureus.

The neonate in this question has early onset sepsis. The most likely pathogen is Group B Strep which is a common commensal of the female genital tract.

Question 21

Henoch-Schonlein purpura

Answer 21

Henoch-Schonlein purpura (HSP) is an IgA mediated small vessel vasculitis. There is a degree of overlap with IgA nephropathy (Berger’s disease). HSP is usually seen in children following an infection.

Features
palpable purpuric rash (with localized oedema) over buttocks and extensor surfaces of arms and legs
abdominal pain
polyarthritis
features of IgA nephropathy may occur e.g. haematuria, renal failure

Treatment
analgesia for arthralgia
treatment of nephropathy is generally supportive. There is inconsistent evidence for the use of steroids and immunosuppressants

Question 22

Pulmonary function tests

obstructive

Answer 22

FEV1 - significantly reduced
FVC - reduced or normal
FEV1% (FEV1/FVC) - reduced

asthma
COPD
bronchiectasis

Question 23

Pulmonary function tests

restrictive

Answer 23

FEV1 - reduced
FVC - significantly reduced
FEV1% (FEV1/FVC) - normal or increased

pulmonary fibrosis
asbestosis
sarcoidosis

Question 24

Hashimoto’s thyroiditis

Answer 24

hypothyroidism
goitre
anti-TPO

Question 25

Phenytoin

Answer 25

cause of aplastic anaemia.

characterised by decreased RBC, WBC and platelets and a hypoplastic bone marrow

Question 26

subarachnoid haemorrhage

Answer 26

CT scan. if negative then LP should be performed no earlier than 12 hrs following onset of symptoms. Performing a LP before this may fail to detect xanthochromia within the CSF

Question 27

Hypophophataemia

Answer 27

Can be caused by DKA. increasing the dosage of insulin is not an answer.
insulin therapy should not be stopped in a patient with DKA.

causes
alcohol excess
acute liver failure
diabetic ketoacidosis
refeeding syndrome
primary hyperparathyroidism
osteomalacia

Consequences
red blood cell haemolysis
white blood cell and platelet dysfunction
muscle weakness and rhabdomyolysis
central nervous system dysfunction

replacement therapy is rarely required unless very severe

Question 28

prescribing in renal failure

Answer 28

Drugs to avoid in renal failure
antibiotics: tetracycline, nitrofurantoin
NSAIDs
lithium
metformin

Drugs likely to accumulate in chronic kidney disease - need dose adjustment
most antibiotics including penicillins, cephalosporins, vancomycin, gentamicin, streptomycin
digoxin, atenolol
methotrexate
sulphonylureas
furosemide
opioids

Drugs relatively safe - can sometimes use normal dose depending on the degree of chronic kidney disease
antibiotics: erythromycin, rifampicin
diazepam
warfarin

Question 29

management of primary open angle glaucoma

Answer 29

Beta blockers act by reducing aqueous secretion by the ciliary body.

Prostaglandin analogues act by increasing aqueous outflow via the uveoscleral route.

Sympathomimetics act by reducing aqueous secretion and increasing aqueous outflow.

Miotics act by opening the aqueous drainage channels in the trabecular meshwork.

Diode laser cycloablation destroys part of the secretory component of the ciliary body, thereby reducing aqueous secretion.