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1
Q

Patient with hypercalcaemia + high PTH with normal U&E’s

Is it primary or secondary hyperparathyroidism and why

A

Primary hyperparathyroidism

Why?
Primary is characterised by both elevated PTH and hypercalcaemia (due to abnormally active parathyroid glands e.g. adenoma)

Whereas secondary is characterised by high PTH and hypocalcaemia ( it is because of low calcium that there is a reactive overproduction of PTH)

Normal u+ e excludes tertiary hyperparathyroidism

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2
Q

Patient presenting with painful stiff shoulder with restriction of active and passive range of motion in abdication, internal and external rotation**

A

Adhesive capulitis aka frozen shoulder

  • pts will complain of difficulty dressing / doing up bra + difficulty sleeping on the affected side
  • common in middle aged females
  • episodes can last 6months to 2 years
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3
Q

Management of adhesive capulitis

A

NSAIDs / physiotherapy ,

Oral corticosteroid / infra-articular corticosteroids

*no single intervention exists

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4
Q

Patient presents with

Pins and needles in thumb, index and middle finger
May need to shake hand to obtains relief

Signs: weakness of thumb abduction, Tinels sign

?

A

Carpel tunnel syndrome I.e compression of median nerve

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5
Q

Treatment of carpel tunnel syndrome

A

Wrist splints at night

Corticosteroid injection

*consider surgical decompression

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6
Q

Patient presents with feeling of becoming incontinent

No dysuria or frequency but commonly leaks when she coughs or laughs

Initial management?
+ investigations

A

Pelvic floor muscle training

  • this is known as stress incontinence

RF: advancing age, previous pregnancy/childbirth, high bmi + fhx

Investigations:

1) bladder diary for min 3 days
2) urine dip and culture for infection
3) vaginal exam to exclude pelvic organ prolaps

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7
Q

Initial management for urgen incontinence

A

Bladder retraining

  • trains you to hold more urine for longer periods of time
  • lasts for a minimum 6 weeks
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8
Q

55 yo man started fitting around 5 mins ago
Admitted for ACS
PMH: tonic clinic epilepsy which is generally well controlled

Says normal but pulse 97 - has iv access in situ

Next step? And what is it

A

Give IV LORAZEPAM

patient has status epilepticus

  • medical emergency
  • priority is to terminal seizure as it can lead to irreversible brain damage

If ineffective after 10 mins
2nd line: (phenytoin or sodium val)

If ineffective after 30 mins
3rd line: (general anaesthesia )

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9
Q

CSF flows from the 3rd to the 4th ventricle via ?

A

Aqueduct of sylvuis

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10
Q

Patient 53 YO complains of cough after starting lisinopril? what would you change her meds to?

A

Angiotensin 2 receptor blocker (ARB) e.g. Losartan

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11
Q

Which of the following site do TB commonly reactivate in?

  1. Apex of lung
  2. Base of Lung
A

Apex of lung

why? site is better oxygenated than elsewhere allowing the mycobacteria to multiply more rapidly and then spread both locally and distantly.

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12
Q

Mechanism of resistance of penicillins by E.coli?

A

It produces beta-lactamase which cleaves the beta-lactam ring of the antibiotic

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13
Q

Presentation of bacterial vaginosis

A

Need 3/4
1 ) Grey discharge with a fishy odour (asymptomatic in 50% of patients)
2) Vaginal pH > 4.5 (raised vaginal pH) - urine dip
3) Clue cells on microscopy
4) Positive whiff test (addition of potassium hydroxide results in fishy odour)

Extra

  • almost exclusively seen in sexually active women
  • Management: oral metronidazole for 5-7 days (has > 50% chance of coming back
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14
Q

Most common cause of AKI (in someone fallen + remained laying for on floor all night)

A

Rhabdomyolysis
* Damaged muscles release myoglobin which is nephrotoxic and causes renal ischaemia, the pathology of acute tubular necrosis.

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15
Q

What stimulates platelet production

A

Thrombopoietin

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16
Q

Mallory weiss tear commonly occurs after …

A

severe bouts of vomiting

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17
Q

Safest blood group for transfusion if unable to cross match a patient

A

Type O (universal donor)

*has no anti-A or anti-B antibodies

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18
Q

Symptoms of hypocalcemia

A
  1. tingling of lips
  2. convulsions
  3. tentany (intermittent muscular spasms)
  4. Cramps
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19
Q

Mechanism of action of Aspirin

A

it suppresses production of thromboxane A2 and prostaglandin (cox -1/2 inhibitor)
> reduces the ability of platelets to aggregate

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20
Q

Mechanism of action of clopidogrel

A

Inhibits ADP receptors on platelets

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21
Q

Acute phase response includes

A 
Acute phase proteins (ESR/CRP)
Reduction of transport proteins (albumin, transferrin)
Hepatic sequestration cations
Pyrexia
Neutrophil leucocytosis
Increased muscle proteolysis
Changes in vascular permeability
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22
Q

A middle-aged man presents with unilateral facial weakness and asymmetry, and ptosis. The doctor suspects either Bell’s palsy or an upper motor lesion. Upon clinical investigation, which of the following would be the most indicative of Bell’s palsy?

  1. postive fhx
  2. loss of tast in anterior 2/3 of tongue, ear pain and hyperacusis (heightened sensitivity to certain sounds)
  3. loss of taste in posterior 2/3 tongue, ear pain and deafness
A

2* due to damage to the facial nerve
Features include
1) Lower motor neuron facial nerve palsy - forehead affected*
2) Patients may also notice post-auricular pain (may precede paralysis), altered taste (anterior 2/3rds of tongue), dry eyes, hyperacusis

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23
Q

Erythromycin MOA

A

Targets protein synthesis in bacteria

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24
Q

What is ERCP (Endoscopic Retrograde Cholangio-Pancreatography ?

A

Type of x-ray and camera examination that enables your doctor to examine and/or treat conditions of the biliary system (liver, gall bladder, pancreas, pancreatic and bile ducts)

  • enters from mouth
  • can insert stent or remove stones
  • Used to investigate jaundice/ stones
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25
Clinical features of Cholangitis
Charcots triad: Fever, RUQ pain and jaundice
26
A 57-year-old gentleman presents to his GP with an acute onset back pain, causing sharp shooting pains to radiate down his buttocks and the back of his legs. He describes doing some heavy lifting in his garden just before the onset. You perform a full physical examination and find that the ankle jerk reflex is delayed. You suspect an intervertebral disk prolapse. What level is disc prolapse likely to occur? L5/S1 L3/L4 S2-S3
L5 -S1 Ankle reflex is typically delayed in L5/S1 disc prolapse. L5 may also compress the nerve route leading to sciatica
27
An 18-year-old male presents to casualty with a depressed skull fracture. This is managed surgically. Over the next few days he complains of double vision on walking down stairs and reading. On testing ocular convergence, the left eye faces downwards and medially, but the right side does not do so. Which nerve is responsible?
Trochlear nerve Features include : 1. Vertical diplopia (diplopia on descending the stairs) 2. Unable to look down and in
28
Management of SVC obstruction
Emergency: oxygen + dexamethasone 16 po IV | + low dose morphine
29
Most common bacterial cause of meningitis
strep pneumonia
30
Leg is x rotated with posterior hip dislocation (accounts for 90%) and x with anterior hip dislocation
internally | externally
31
Murmur that radiates to carotids
Aortic stenosis *radiation occurs in the direction of blood flow Think about (SCRIPT) Site, Characteristic: Crescendo (getting louder) or decrescendo (quieter), Radiation (if over left axilla = mitral regurgitation), Intensity (what grade out of 6 Pitch Timing (i.e. systolic or diastolic)
32
Grading of murmurs
Murmurs are recorded in six gradations: 1/6 murmur is just audible by an expert in optimal conditions 2/6 is quiet 3/6 is moderately loud 4/6 is markedly loud } are accompanied by 5/6 is very loud } a thrill 6/6 is audible without a stethoscope
33
What is sound 1 and 2
S1: is the closure of mitral and tricuspid valve (beginning of systole) S2: closure of aortic + pulmonary valves (beggining of diastole and end of systole)
34
Patient presenting with possible ACS i.e. angina chest pain, radiating to jaw. What test should you request
1. ECG - if there is ST elevation then = STEMI If no ST elevation then 2. Check troponin levels - if raised = NSTEMI (if normal the diagnosis maybe be unstable angina or another cause)
35
Diabetes diagnosis
HBA1C > 48 Fasting glucose > 11 / Random glucose > 7 Impaired GTT = 75g of glucose drink then measure after 2 hours > 11
36
Pre-diabetes diagnosis
HBA1C 42-47 IGTT 7.8 - 11 Fasting glucose 6.1 - 6.9 (impaired fasting glucose)
37
A 44 year old lady presents complaining of chronic fatigue and general tiredness. She has also noticed her hair and skin becoming more dry and is worried she might be loosing her hair. On examination her thyroid gland is barely palpable Her blood tests reveal a TSH of 13 (normal range 0.5 – 4.0 mIU/L) and free T4 of 1.1 (normal range 4.5 to 11.2 mcg/dL). What is her most likely diagnosis? Hashimotos Graves Addisons disease
Hashimotos disease (common cause of hypothyroidism in developed world) * iodine deficiency in developing world * TSH secreted by Anterior pituitary
38
common Diabetic medication causing hypoglycaemia
1) Insulin | 2) Sulphonylureas e.g. Gliclazide
39
A 41 year old man is diagnosed with acromegaly secondary to a large pituitary adenoma. What visual field defect would you expect he might have? Upper altitudinal hemianopia Central scotoma Bitemporal hemianopia Homonymous hemianopia
Bitemporal hemianopia * pituitary gland sits right beneath the optic chiasm - any enlargement of it will irritate the optic chiasm * Acromegaly = overproduction of growth hormone
40
what is the Addisonian Crisis (AKA Adrenal Crisis)? and treatment?
The inability of the adrenal gland to produce enough cortisol > leads to hypoglycaemia, hyponatraemia, hypotension and hyperkalaemia > present with reduced consciousness, drowsy + faint * initially oxygen + correct glucose + IV hydrocortisone
41
43 year old alcoholic is admitted with right upper quadrant pain. Eight hours after his admission you are called to see him because he has become anxious and confused. He has started having visual hallucinations and is quite distressed. ``` What medication is the most appropriate to help with the symptoms this patient is experiencing? Haloperidol Midazolam Clonazepam Lorazepam Chlordiazepoxide ```
Chlordiazepoxide (sedative/hypnotic drug used for alcohol withdrawl) * pt is going through alcohol withdrawal
42
Haemochromatosis is & how to diagnose
is a disorder where too much iron builds up in your body. Symptoms include - bronze skin, tiredness, arthiritis (muscle and joint pain), early menapause and sexual/liver dysfunction * diagnosis via serum ferritin
43
Treatment of H pylori infection following +ve urea breath test is.....
2 antibiotics + PPI for BID for 1 week Amoxicillin, and either clarithromycin or metronidazole (if allergic to penicillin the C & M).
44
At what point during menustral cycle can an IUD Be inserted
Anytime *it can also be inserted immediately after 1st or 2nd trimester abortion and from 4 weeks postpartum
45
IUD mode of action and effectiveness?
Prevents fertilisation by decreasing sperm motility and survival 2) immediately
46
IUS (levonorgestrel releasing intrauterine systems / Mirena) 1) MOA 2) when is it effective?
It prevents endometrial proliferation and cervical mucous thickening 2) upon 7 days after fitting
47
As well as being used for contraception, x is also used in the management of menorrhagia
IUS
48
Effects of IUD on period?
Heavy, painful and longer
49
What form of contraception is affective for both heavy bleeding and anti-epileptic meds
IUS (mirena)
50
All methods of combined hormonal contraception including the pill, ring and patch are contraindicated in..
Women >35 who smoke 15 or more cigarettes per day* ``` UKMEC 3 (relative) >35 + < 15 cig/day *also fhx of thromboembolic disease Bmi > 35 Immobility Controlled hypertension ``` Unacceptable health risk (UKMEC 4/ absolute)* Breast cancer migraine with aura ( due to increased risk of ischaemic stroke) Breast feeding < 6 week post part I’m Hx of stoke or IHD / DVT or PE Uncontrolled hypertension
51
Primary mode of action contraception implant
Inhibition of ovulation *as well as COC
52
Which contraceptive methods classified by UKMEC has no caution/CI in a patient with migraine + aura
IUD
53
Main adverse effect of implantable contraceptive (nexplanon - progesterone releasing)
Irregular menustral bleeding
54
COCP is Protective against? Increases risk of?
1. Ovarian and endometrial cancer | 2 breast and cervical cancer
55
Which mode of contraception is an indication to all forms of contraception?
All Hormonal forms
56
Which method of contraception has been proven to cause weight gain
Injectable contraceptive (depo provers)
57
What is premature ovarian failure
Onset of menopausal symtptoms and elevated gonadotrophin levels before the age of 40 * causes: idiopathic/ chemo / radiotherapy / fhx * common symptoms include: hot flushes, vaginal dryness/atrophy or sleep disturbance
58
Most suitable initial blood test with 20 yo presenting with menorrhagia
FBC - look for anaemia If symptoms suggest a structural or histological abnormality i.e inter menustral or post coital bleeding, pelvic pain = perform a routing transvaginal ultrasound *hypo can lead to heavier and longer periods but in the absence of other symptom it becomes unlikely
59
A 17-year-old girl presents due to painful periods. These have been present for the past three years and are associated with a normal amount of blood loss. Her periods are regular and there is no abnormal bleeding. She is not yet sexually active. What is the most appropriate first-line treatment? ``` Tranexamic acid Referral for relaxation therapy Paracetamol Combined oral contraceptive pill Ibuprofen ```
Ibuprofen | *NSAIDs are first-line treatment (inhibits prostaglandin synthesis followed by COC pill
60
A 53-year-old woman presents with urgency and frequency. Two weeks ago she consulted with a colleague as she felt 'dry' during intercourse. She has been treated for urinary tract infections on multiple occasions in the past but urine culture is always negative. Her only medication is continuous hormone replacement therapy. A vaginal examination is performed which shows no evidence of vaginal atrophy and no masses are felt. An ultrasound is requested: Both kidneys, spleen and liver are normal size. Outline of the bladder normal. 5 cm complex ovarian cyst noted on left ovary. Right ovary and uterus normal What is the most appropriate next step? ``` Refer for urodynamics Pelvic floor muscle training Trial topical oestrogen Urgent referral to gynaecology Refer for bladder retraining ```
Urgent referral to gynae - any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment ( as it is physiologically unlikely)
61
A 17-year-old comes to your clinic, concerned that she has not yet started her periods although most of her friends have. She is 150 cm tall and 45 kg in weight. She reports the development of pubic hair since the age of 14 and has normal breast development. On speculum examination, you are unable to visualise the cervix and the patient finds the examination too uncomfortable to tolerate further. Serum hormone screening reveals no gross abnormality. What management would you suggest? ``` Refer to a gynaecologist Reassess in one year Advise her to increase her calorie intake, check her hormone levels and reassess in two months. Serum hormone screening Refer to endocrinologist ```
Refer to gynae - In this case, the young woman in question has developed apparently normal secondary sexual characteristics but no periods (primary amenorrhea) This raises the question of mechanical obstruction to menstruation rather than an endocrine/ hormonal cause.
62
Actinic keratosis is a common pre-malignant skin lesion that develops as a consequence of
Chronic sun exposure * Features include: small crusty or scaly lesions which may be pink, brown or skin colour Typically on sun exposed areas *management = sun avoidance/cream Flouracil cream - 2 to 3 week course or topical diclofenac (mild amp)
63
Systemic lupus erythmetus SLE is what type of hypersensitivity reaction..
Type 3 *characterized by antigen- antibody complexes SLE is thought to be caused by IS dysregulation leading to immune complex formation F>M (9:1) and onset 20-40 years
64
A 47-year-old lady is referred to migraine clinic with shooting pains across the left side of her face. The shooting pains occur randomly, and only last a few seconds. They occur across her left cheek and jaw, and do not affect her forehead or eye. They occur three or four times per day. ``` What would be the most appropriate first-line medication to start to help prevent her symptoms? Sumatriptan Verapamil Carbamazepine Propranolol Gabapentin ```
Carbamazepine * nice recommends carbamazepine for first-line treatment in those who have symptoms of trigeminal neuralgia & titrating up
65
A 32-year-old man presents with headaches, which he has had for several years. They seem to be triggered by stressful situations and skipping meals. They after often proceeded by sparks across his vision, after which a generalized severe headache occurs associated with mild photophobia. When he has these headaches he finds that resting in a dark room and having a short nap helps to relieve the symptoms. He has tried simple analgesia, which does not seem to help. Neurological examination and fundoscopy is normal. What is the next most appropriate step in management? ``` 100% Oxygen Codeine Diclofenac Sumatriptan Referral for CT head ```
Sumatriptan Patients have symptoms of migraine Treatment involves: 1. Offer simple analgesia such as: Ibuprofen (400mg) — if ineffective, consider increasing to 600 mg or Aspirin (900 mg) or Paracetamol (1000mg). 2. Triptans (5HT receptor agonists causing vasoconstriction) (sumatriptan 50mg PRN) - These can be offered alone or in combination with NSAIDs 3. Antiemetic (metoclopramide/domperidone) 4. Migraine clinics
66
A 78 year old lady presents to her GP with left sided temporal headache associated with left sided jaw pain when chewing and left sided tenderness when brushing her hair. She rates the pain at 4/10. She has had no visual changes. What is her diagnosis?
Giant cell arteritis/ Temporal arteritis Management 1. Refer for urgent blood tests and specialist review * High EST, CRP * Fbc high platelets , low hb and ihigh in ALP 2. Whilst awaiting these, she should be started on 60mg prednisolone, aspirin 75mg and a PPI (e.g. omeprazole) * co- prescribe ADcal for osteoporosis prevention or bisphosphonates while on steroid 3. Simple analgesia (such as paracetamol and possibly 10-30mg of codeine as required) would be adequate to control pain that is 4/10.
67
When trying to exclude subarachnoid haemorrhage and you have done a lumbar puncture. Other than normal cell microscopy, what else would it be important for you to send the samples for?
Xanthochromia i.e. Yellow discoloration of the CSF caused by bilirubin released from the breakdown of red blood cells.
68
Management of subarachnoid haemorrhage
if suspected: 1. CT head 2. Lumbar puncture for RBC & Xanthochromia 3. Angiography to locate source if confirmed
69
Cluster headache management
Rescue medications (taken as soon as headache starts) 1. Triptans – sumatriptan 6mg subcutaneously 2. High flow pure (100%) oxygen (can be given at home) Prophylaxis options: Verapamil Lithium Prednisolone
70
A 29 year old man who has suffered with on and off headaches for a few years. They are unilateral, and focused mainly over one eye. During he headache this eye goes red and waters. The pain is the most severe pain he can imagine, lasts about 30 minutes then eases off. He tends to get several attacks a day for a month, after which he doesn't have the headaches for a year or so. They are eased by 100% oxygen given at home.
Cluster headache
71
A 68 year old woman presenting with a severe pain over the left side of her forehead. This is associated with slight blurring of the vision in her left eye and she noticed that it was very tender over the area when brushing her hair this morning.
Giant cell arteritis
72
A 74 year old with severe osteoarthritis in her knees presents with headaches. They are generalised headaches and tend to come on a few hours after she wakes up and fluctuate throughout the day.
Analgesic headache The International Classification of Headache Disorders (ICHD) includes the following diagnostic criteria for medication overuse headache: 1. Headache occurring on 15 or more days per month in a patient with a pre-existing headache disorder and Regular overuse for more than 3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache. For ergotamine, triptans, opioids and combination analgesics intake must be 10 days or more per month to be considered overuse. For simple analgesics such as NSAIDS (including aspirin) and paracetamol intake must be 15 days or more per month to be considered overuse.

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