Random Knowledge to review

Question 1

Sudden chest pain + neurology important condition?

Answer 1

Rule out aortic dissection

Expanding aorta can compress sympathetic trunk etc- Horner’s syndrome

Question 2

Vomiting/Diarrhoea effects on pH etc?

Answer 2

Vomiting causes alkalosis

Diarrhoea causes acidosis due to bicarbonate loss, also hypokalaemia due to loss of potassium

Question 3

Mesenteric ischaemia triad?

Answer 3

CVD, high lactate, soft but tender abdomen

Question 4

In what condition should adenosine be avoided in?

Answer 4

Bronchospasm

Question 5

Management of major bleeding (eg variceal haemorrhage, intracranial harmorrhage) due to high INR?

Answer 5

Stop warfarin

Give intravenous vitamin K 5mg

Prothrombin complex concentrate
(FFP if not available)

Question 6

Beck’s triad of features for cardiac tamponade?

Answer 6

Beck’s triad-

Hypotension

Raised JVP

Muffled heart sounds

Question 7

What to do if high risk of cardioversion failure in elective AF rhythm control?

Answer 7

Amiodarone for 4 weeks prior to electrical cardioversion

Question 8

How can a brisk upper GI bleed present?

Answer 8

Fresh PR blood rather than malena can happen if quick bleed- variceal (usually malena)

High urea levels indicate an upper GI bleed especially if raised out of proportion to creatinine

Question 9

Which condition is closely related to primary sclerosing cholangitis?

Answer 9

Ulcerative colitis

Question 10

Which liver enzyme is raised in an obstructive picutre?

Answer 10

ALP

Question 11

What is the hallmark symptom of refeeding syndrome?

Answer 11

Hypophosphatemia- may result in significant muscle weakness and cardiac failure

Hypokalaemia

Hypomagnesaemia

Abnormal fluid balance

Question 12

Criteria for patients being high risk of refeeding syndrome?

Answer 12

One or mote of the following:

BMI < 16kg/m2

unintentional weight loss >15% over 3-6 months

little nutritional intake > 10 days

hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high)

Two or more of the following:

BMI < 18.5 kg/m2

unintentional weight loss > 10% over 3-6 months

little nutritional intake > 5 days

history of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids

Question 13

Torsades de pointes treatment?

Answer 13

IV magnesium

Can be precipitated by hypomagnesaemia

Question 14

Is high urea associated with a lower or upper GI bleed?

Answer 14

Upper GI Bleed

Question 15

Smoking cessation?

Answer 15

Patients offered nicotine replacement therapy (NRT), varenicline or bupropion

Varenicline and bupropion CI in pregnancy

Bupropion CI in epilepsy

Question 16

How to calculate pack years?

Answer 16

Number of packs smoked per day x the number of years they smoked for

20 in a pack, if smoking 15 a day example would be
0.75x30 years

Question 17

Statin contrindications?

Answer 17

Pregnancy

Macrolides- erythromycin, clarithromycin

Question 18

CURB65 score criteria?

Answer 18

Confusion

Urea >7

Resp rate >30

Systolic <90 Diastolic <60

> 65 years olf

CRB65 pre hospital

CURB65 in hospital

Question 19

When is infliximab used in Crohn’s disease?

Answer 19

In refractory disease or fistulating Crohn’s

Question 20

What should be assessed before starting azathioprine or mercaptopurine in Crohn’s disease?

Answer 20

+TMPT actvity

Question 21

Spirometery results in idiopathic pulmonary fibrosis?

Answer 21

FEV1:FVC ratio >70%, decreased FVC

Impaired gas exchange (reduced TLCO)

Question 22

Painful shin rash + cough?

Answer 22

?Sarcoidosis

Question 23

Main side effect ACEi?

Answer 23

Dry cough

Question 24

What are the high risk factors for pneumothorax?

Answer 24

Haemodynamic compromise

Significant hypoxia

Bilateral pneumothorax

Underlying lung disease

≥ 50 years of age with significant smoking history

Haemothorax

Question 25

What does polymorphic ventricular tachycardia with oscillatory changes mean?

Answer 25

Torsades de pointes Polymorhpic means different size QRS comples, oscillatory characteristic of torsades up and down in relation tot baseline Give magnesium sulfate

Question 26

Causes of a long QT interval?

Answer 26

Causes of long QT interval Congenital: Jervell-Lange-Nielsen syndrome Romano-Ward syndrome Antiarrhythmics: amiodarone, sotalol, class 1a antiarrhythmic drugs Tricyclic antidepressants Antipsychotics Chloroquine Terfenadine Erythromycin Electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia Myocarditis Hypothermia Subarachnoid haemorrhage

Question 27

Hypercalcaemia features?

Answer 27

Bones, stones, abdo groans and psychiatric moans Corneal calcification Shortened QT interval Hypertension

Question 28

Contraindications for chest drain insertion?

Answer 28

INR>1.3 Platelet count < 75 Pulmonary bullae Pleural adhesions

Question 29

Adverse effects of loop diuretics?

Answer 29

Hypotension Hyponatremia Hypokalaemia, hypomagneaemia Hypochloraemic alkalosis Ototoxicity Renal impairment (from dehydration + direct toxic effect) Hyperglycaemia (less common than wiht thiazides) Gout

Question 30

PPI adverse effects?

Answer 30

Hyponatremia, hypomagnasaemia Osteoporosis--> increased fracture risk Increased risk of C diff

Question 31

Which side is aspiration pneumonia more common?

Answer 31

The right lung

Question 32

Functions of vitamin C?

Answer 32

Antioxidant Collagen synthesis Facilitates iron absorption

Question 33

Vitamin C deficiency? (Scurvey)

Answer 33

Defective synthesis of collagen- capillary fragility (bleeding) and poor wound healing Features: Gingivitis, loose teeth Poor wound healing Bleeding from gums, haematuria, epistaxis General malaise

Question 34

Most commonly affected valves in infective endocarditis?

Answer 34

Mitral in normal people Tricuspid in IVDU

Question 35

Which cancers is Lynch syndrome (HNPCC) associated with?

Answer 35

Female- CEO-P Colon Endometrial Ovarian Pancreatic Male (CP) Colon Pancreatic

Question 36

Primary Biliary Cholangitis Ms?

Answer 36

IgM Anti-mitochondrial antibodies Middle aged females

Question 37

Post-MI complications?

Answer 37

1. Death during/ immediately after MI = V-fib 2. Pleuritic chest pain relieved by sitting forward days after MI = fibrinous pericarditis 2. New pansystolic murmur + SOB days after MI = mitral regurgitation due to papillary muscle rupture 3. Acute severe hypotension, raised JVP, muffled heart sounds days after MI = tamponade due to ventricular free wall rupture 4. Harsh pansystolic murmur heard best in tricuspid area days after MI = ventricular septal rupture 5. Persistent ST elevation weeks-months later + signs of LV dysfunction (poor CO, pulmonary oedema) = LV aneurysm 6. Pleuritic chest pain relieved by sitting forward weeks after MI = Dressler's syndrome

Question 38

What is the cause of mitral stenosis?

Answer 38

Rheumatic fever mainly

Question 39

Causes of upper zone fibrosis?

Answer 39

CHARTS C - Coal worker's pneumoconiosis H - Histiocytosis/ hypersensitivity pneumonitis A - Ankylosing spondylitis R - Radiation T - Tuberculosis S - Silicosis/sarcoidosis

Question 40

Causes of fibrosis affecting the lower zones?

Answer 40

Idiopathic pulmonary fibrosis Most connective tissue disorders- SLE (except ankylosing spondylitis) Drug induced: amiodarone, belomycin, methotrexate Asbestosis

Question 41

Statin doses and CI?

Answer 41

20mg for primary prevention 80mg for secondary prevention (even if cholesterol normal it seems) Contraindications- Macrolides (erythromycin, clarithromycin)- statin stopped until patients complete the course Pregnancy

Question 42

A major ECG change in AF?

Answer 42

Absence of P waves

Question 43

Boerhaave syndrome?

Answer 43

Mackler triad: vomiting, thoracic pain and subcutaneous emphysema Middle aged men with background of alcohol abuse

Question 44

Side effects of ACEi and CI?

Answer 44

Cough Angioedema Hyperkalaemia First-dose hypertension CI: Preganancy/breastfeeding Renovascular disease- renal impairment Aortic stenosis- hypotension

Question 45

Monitoring after starting ACEi?

Answer 45

U+E checked before treatment initiated and after increasing the dose Rise in creatinine and potassium may be expected Up to 30% increase in serum creatinine and potassium increase up to 5.5 mmol/l acceptable Significant renal impairment may occur in patients who have undiagnosed bilateral renal artery stenosis

Question 46

GI bleed key blood result?

Answer 46

Isolated raised urea

Question 47

Indications for surgery in infective endocarditis?

Answer 47

Severe valvular incompetence Aortic abscess Infections resistant to antibiotics/fungal infections Cardiac failure refractory to standard medical treatment Recurrent emboli after antobiotic therapy

Question 48

Which anatomical landmark allows the categorisation of an upper GI or lower GI bleed?

Answer 48

The ligament of Treitz

Question 49

AF + valvular heart disease?

Answer 49

Absolute indication for anticoagulation If CHA2DS2-VASc score suggests no need for anticoagulation ensure transthoracic echocardiogram has been done to exclude valvular heart disease

Question 50

Stepping down treatment in asthma?

Answer 50

Step down treatment every 3 months or so if appropriate. When reducing ICS reduce by 25-50% at a time

Question 51

Murmurs best heard?

Answer 51

RILE Right sided murmurs best heard on inspiration Left sided murmurs best heard on expiration

Question 52

HbA1c target when adding a medication that can cause hypoglycaemia?

Answer 52

53 mmol/mol (7.0%)

Question 53

Hypercalcaemia effect on QT interval on ECG?

Answer 53

Shorterned QT interval

Question 54

HF- which two drugs to monitor potassium?

Answer 54

If they are on both an ACE inhibitor and an aldosterone antagonist both can cause hyperkalaemia- monitor potassium

Question 55

Which artery supplies the AV node?

Answer 55

Right coronary artery (inferior myocardial infarction)

Question 56

Main angina drugs?

Answer 56

Coronaries Need Blood (CNB) CCBs Nicorandil/Nitrates Beta-Blockers

Question 57

Drug induced gynaecomastia?

Answer 57

Spironolactone- most common Cimetidine Digoxin Cannabis Finasteride GnRH agonists- goserelin, buserelin Oestrogens, anabolic steroids

Question 58

Which antibiotics cause C.difficile?

Answer 58

C's for C.Diff- Co-amoxiclav, Ciprofloxacin, Clindamycin, Cephalosporins (ceftriaxone) And PPIs

Question 59

Which drug causes hyperthyroidism?

Answer 59

Amiodarone

Question 60

Which drugs cause hypothyroidism?

Answer 60

Lithium Amiodarone

Question 61

Cushing's syndrome vs Addison's electrolyte disturbances?

Answer 61

Cushing's- too much cortisol- hypernatremia and hypokalaemia Addisons- too little cortisol- hyponatremia and hyperkalaemia

Question 62

PSC malignancy risks?

Answer 62

Cholangiocarcinoma Increased risk of colorectal cancer

Question 63

T1DM initial insulin management?

Answer 63

Daily basal-bolus injection regimes Twice-daily insulin detemir, rapid acting before meals

Question 64

Drugs causing a raised prolactin (galactorrhoea)?

Answer 64

Metoclopramide, domperidone Phenothiazines Haloperidol Very rare: SSRI/ Opioids Dopamine acts as primary prolactin releasing inhibitory factor- domapine agonists such as bromocriptine can be used to control galactorhoea

Question 65

Corticosteroid side effects?

Answer 65

Glucocorticoid side effects- -Endocrine- impaired glucose regulation, increased appetite/weight gain, hirsutism, hyperlipidaemia -Cushing's syndromem MSK- osteoporosis, proximal myopathy, avascular necrosis of the femoral head Immunosuppression- increased susceptibility to severe infection, reactivation of TB Psychiatric- insomnia, mania, depression, psychosis GI- peptic ulceration, acute pancreatitis Opthalmic- glaucoma, caataracts Suppression of growth in children Intracranial hypertension Neutrophillia Mineralcorticoid side-effects- Fluid retention Hypertension

Question 66

Selected points on steroids?

Answer 66

Patients on long term steroids should have their doses doubled during intercurrent illness Longer term systemic corticosteroids suppress endogenous steroids- do not stop abruptly to prevent Addisonian crisis Suggested gradual withdrawal of steroids if 40mg prednisolone daily for more than one week Recieved more than 3 weeks of treatment Recieved repeated courses

Question 67

Major complication of carbimalzole therapy?

Answer 67

Agranulocytosis

Question 68

Distinguish between Graves and De Quervain's?

Answer 68

Pain in Quervain's- painful goitre Goitre not painful in Graves

Question 69

Thiazolidinediones (pioglitazone) side effects?

Answer 69

Weight gain Liver impairment- monitor LFTs Fluid retention- CI in heart failure Increased risk of fractures Bladder cancer Fat Bastards Won't Feel Lighter F- Fracture B- Bladder ca W- Weight gain F- Fluid retention (CI in HF) L- LFT derangement

Question 70

Acute asthma managment adults?

Answer 70

Oh Shit, I Hate My Asthma Oxygen, Salbutamol nebulisers, Ipratropium bromide nebulisers, Hydrocortisone IV or Prednisolone Oral, Magnesium sulfate IV, Aminophylline/IV salbutamol

Question 71

After which MI is bradyarrhythmias more common?

Answer 71

Inferior myocardial infarctions, occlusion of the right coronary artery which supplies the AV node

Question 72

Adverse effects of thiazide diuretics?

Answer 72

Indapamide ad chlortalidone are examples Dehydration Postural hypotension Hypokalaemia Hyponatremia Hypercalcaemia- also hypocalciuria which may be useful in reducing the incidence of renal stones Gout Impaired glucose tolerance Impotence Rare: Thrombocytopenia Agranulocytosis Photosensitivity rash Pancreatitis

Question 73

PTX high risk characteristics?

Answer 73

Haemodynamic compromise Significant hypoxia Bilateral pneumothorax Underlying lung disease ≥ 50 years of age with significant smoking history Haemothroax If any present with symptoms- insert a chest drain

Question 74

Hypertension, HypoK?

Answer 74

Primary hyperaldostronism- with no symptoms of Cushing's eg weight gain, moonface

Question 75

Management of SVT?

Answer 75

1. Vagal manouvres 2. IV adenosine 6mg 3. IV adenosine 12mg 4. IV adenosine 18mg 5. Electrical cardioversion Adenosine CI in asthmatics so use verapamil

Question 76

ACEi side effects?

Answer 76

Cough Angioedema Hyperkalaemia First dose hypotension- more common in patients taking diuretics

Question 77

ACEi cautions and contraindications?

Answer 77

Pregnancy and breastfeeding Renovascular disease- may result in renal impairment Aortic stenosis Hereditary idiopathic angiodema Specialist advice sought before starting ACEi in patients with potassium over 5

Question 78

ACEi monitoring?

Answer 78

U+E checked before treatment initiated and after increasing dose Rise in creatinine and potassium

Question 79

Causes of raised prolactin?

Answer 79

The P's Pregnancy Prolactinoma Physiological Polycystic ovarian syndrome Primary hypothyroidism Phenothiazines, metocloPramide, domPeridone

Question 80

Hypo or hyperkalaemia with a diuretic?

Answer 80

If potassium sparing- hyperkalaemia Any other diuretic- hypokalaemia

Question 81

Can digoxin cause gynaecomastia?

Answer 81

Yes

Question 82

Beck's triad cardiac tamponade?

Answer 82

Raised JVP, muffled heart sounds, hypotension

Question 83

Diastolic murmur + AF?

Answer 83

?Mitral stenosis

Question 84

BB side effects?

Answer 84

Bronchospasm Cold peripheries Fatigue Sleep disturbances, including nightmares Erectile dysfunction

Question 85

Easy way to remember CHA2DS2-VASc?

Answer 85

SADCHAVS Stroke 2 Age >75 2 Diabetes 1 Congestive heart failure 1 HTN 1 Age >65 1 Vascular Hx 1 Sex Female 1

Question 86

Can severe obesity cause restrictive lung disease?

Answer 86

Yes

Question 87

Young adult with severe hypertension and systolic murmur?

Answer 87

Coarctation of the aorta

Question 88

Posterior STEMI ECG?

Answer 88

Changes is V1-3 Tall R waves- V2 paticularly Horizontal ST depressiion Upright T waes

Question 89

Cells in Barrett's oesophagus?

Answer 89

Squamous epithelium replaced with columnar epithelium

Question 90

Wilson's disease, Haemochromatosis and Alpha-1-antitrypsin?

Answer 90

Liver + Brain- Wilson's Liver + Joints/ED- Haemochromatosis Liver + Lungs = Alpha-1-antitrypsin

Question 91

Adrenal insufficiency tanned?

Answer 91

Addison's (primary) is associated with hyperpigmentation wheras secondary adrenal insufficiency is not This is due to it being related to increased ACTH production

Question 92

What are the two most common causes of hypercalcaemia?

Answer 92

Primary hyperparathyroidism Malignancy

Question 93

Unsynchonised vs synchronised shocks?

Answer 93

Unsynchronised shocks used in cardiac arrest- VF/pulselessVT Synchronised shocks used in arryhtmias that are unstable

Question 94

Test used to check for H.Pylori eradication?

Answer 94

Urea breath test Should not be performed within 4 weeks of treatment with an antibacterial or within 2 weeks if an antisecretory drug (PPI)

Question 95

Tricuspid regurgitation vs mitral regurgitation?

Answer 95

Tricuspid louder during inspiration, unlike mitral regurgitation RILE: Right sided murmurs louder on inspiration Left sided murmurs louder on expiration

Question 96

Who should adenosine be avoided in?

Answer 96

Asthmatics due to bronchospasm Adverse effects: Chest pain Bronchospasm Transient flushing

Question 97

Features of hypokalaemia on ECG?

Answer 97

U waves Small or absent T waves (occasionally inversion) Prolong PR interval ST depression Long QT U have no Pot and no T, but a long PR and a long QT

Question 98

Decompensation risk factors?

Answer 98

ABCDI Alcohol, bleeding, constipation, drugs, infection

Question 99

Hepatorenal syndrome triad?

Answer 99

Cirrhosis, ascites, AKI bit attributable to any other cause

Question 100

Inducers and inhibitors INR ways to remember?

Answer 100

Inducers: cause decrease in INR “SCARS” * S → Smoking * C → Chronic alcohol intake * A → Antiepileptics: Phenytoin, Carbamazepine, Phenobarbitone (all barbiturates) * R → Rifampicin * S → St John's Wort Inhibitors: cause increase in INR “ASS-ZOLES” * A → Antibiotics: Ciprofloxacin, Erythromycin, Isoniazid, Clarithromycin * S → SSRIs: Fluoxetine, Sertraline * S → Sodium Valproate * - Zoles → Omeprazole, Ketoconazole, Fluconazole

Question 101

Alcohol withdrawl timeline?

Answer 101

Symptoms- 6-12 hours Seizures- 36 hours Delirium tremens- 72 hours

Question 102

Switching antidespressants?

Answer 102

Direct switch from most (sertraline, citalopram, escitalopram, paroexetine) to SSRI If fluoxetine longer half life so leave a gap of 4-7 days after withdrw before starting new SSRI

Question 103

Choice of SSRI in children and adolescents?

Answer 103

Fluoxetine

Question 104

Other name for obsessive compulsive personality disorder?

Answer 104

Anankastic personality disorder

Question 105

Lithium monitoring after change in dose?

Answer 105

Take levels a week later then weekly until the levels are stable

Question 106

Most effective form of contraception?

Answer 106

Implantable Nexplanon etonogestrel Lasts 3 years No oestrogen so can be used in history of VTE/Migraine Can be inserted straight after a termination Additional contraceptive needed for first 7 days if not inserted on day 1-5 Main issue- irregular/heavy bleeding UKMEC 4 current breast cancer

Question 107

How long after medical termination should a pregnancy test be performed?

Answer 107

2 weeks after a medical termination 3 weeks after a medically managed miscarridge

Question 108

Abortion act?

Answer 108

1967, in 1990 it was adjusted reducing the upper limit from 28 weeks to 24 weeks

Question 109

What is a multi-level pregnancy test?

Answer 109

One that detects the level of hCG not just a positive or negative result

Question 110

When can an intrauterine contraceptive be inserted after surgical termination?

Answer 110

Immediately after evacuation of the uterine cavity

Question 111

Routine recall for HPV screening?

Answer 111

Every 3 years between the ages of 25 and 49 Every 5 years between the ages of 50 and 64

Question 112

Alternative name for methylphenidate?

Answer 112

Ritalin

Question 113

Corticosteroids and meingitis?

Answer 113

Do not use corticosteroids in children younger than 3 months with suspected or confirmed bacteria meningitis

Question 114

N+V in pregnancy?

Answer 114

Natural remedies- ginger/acupuncture Antihistamines should be used first line- promethazine

Question 115

Should all pregnant and breastfeeding women take vit D?

Answer 115

Yes

Question 116

Blood pressure during pregnancy?

Answer 116

Falls in first trimester and until 20-24 weeks then ususally increases to pre-pregnancy levels by term

Question 117

What level is hypertension in pregnancy defined as?

Answer 117

140/90 Or increase about booking of 30/15

Question 118

Types of hypertension in pregnancy?

Answer 118

Pre-existing- elevated over 140/90 before pregnancy- no proteinuria, no oedema If takes an ACEi or ARB for pre-existing hypertension this should be stopped immediately and labetalol started Pregnancy-induced hypertensio- occuring in the second half of the pregnancy Pre-eclampsia- pregnancy induced hypertension in association with proteinuria >0.3/24h Oedema may occur Oral labetalol Oral nifedipine if asthmatic

Question 119

Raised AFP in pregnancy association?

Answer 119

Abdominal foetal wall defects (omphalocele, gastrochisis) Neural tube defects Multiple pregnancy Deacreased in: Down's Trisomy 18 Maternal diabetes mellitus

Question 120

Example of a GnRH agonist?

Answer 120

Goserelin

Question 121

HRT in VTE risk?

Answer 121

Transdermal

Question 122

In HRT what increases the breast cancer risk?

Answer 122

The addition of the progestogen Dual HRT risk- breast ca Oestrogen only risk- endometrial ca

Question 123

Pregnancy of unknown location what points towards an ectopic?

Answer 123

Serum bHCG levels >1500

Question 124

Indications for more folic acid?

Answer 124

MORE M- metabolic- T1DM, Coeliac O- Obesity BMI>30 R- Relative E- Epilepsy- taking antiepileptics +Haem- sickle cell

Question 125

Folic acid supplementation?

Answer 125

All women should take 400mcg of folic acid until 12th week of pregnancy Women at higher risk of child with NTD should take 5mg folic acid from before conception until 12th week Women higher risk if- Either partner has NTD, previous NTD pregnancy, FH NTD Antiepileptic drugs, coeliac, diabetes or thalassemia BMI>30

Question 126

COCP UKMEC 4?

Answer 126

more than 35 years old and smoking more than 15 cigarettes/day migraine with aura history of thromboembolic disease or thrombogenic mutation history of stroke or ischaemic heart disease breast feeding < 6 weeks post-partum uncontrolled hypertension current breast cancer major surgery with prolonged immobilisation positive antiphospholipid antibodies (e.g. in SLE)

Question 127

VEAL CHOP for cardiotopography?

Answer 127

VEAL CHOP Variable decelerations --> Cord compression Early decelerations --> Head compression Accelerations --> Okay Late decelerations --> placental insufficiency

Question 128

Two key worrying things from a foetal CTG?

Answer 128

Terminal bradycardia- Baseline fetal heart rate drops below 100 BPM for more than 10 minutes. Terminal deceleration- when the heart rate drops and does not recover for more than 3 minutes These are indicatiors for an emergency caesarean section

Question 129

What urine rate is classed as oliguria?

Answer 129

A urine output less than 0.5 ml/kg/hour

Question 130

Key ways of identifying AKI?

Answer 130

Reduced urine output- less than 0.5ml/kg/hour Fluid overload A rise in molecules that the kidney normally excretes/maintains a careful balance of- examples- potassium, urea, creatinine Can lead to symptoms/signs: Reduced urine otput Pulmonary/peripheral oedema Arrhythmias- secondary to changes in potassium and acid-base balance Features of uraemia- pericarditis or encephalopathy

Question 131

Drugs safe to continue in AKI?

Answer 131

Paracetamol Warfarain Statins Aspirin Clopidogrel Beta-blockers

Question 132

Drugs to be stopped in AKI as worsen renal function?

Answer 132

NSAIDs Aminoglycosides ACEi ARB Diuretics

Question 133

Drugs to be stopped in AKI as increased risk of toxicity?

Answer 133

Metformin Lithium Digoxin

Question 134

Urea:Creatinine ratio in AKI?

Answer 134

urea / (creatine divided by 1000) - do the divide by 1000 so its same units >100 - pre renal cause <100 - ATN

Question 135

Causes of hyperkalaemia?

Answer 135

AKI Drugs: potassium sparing diuretics, ACEi, ARB, Spironolactone, Ciclosporin, heparin Metabolic acidosis Addison's disease Rhabdomyolysis Massive blood transfusion

Question 136

Hyperkalaemia stages?

Answer 136

Mild- 5.5-5.9 Moderate- 6-6.4 Severe- >6.5

Question 137

Hyperkalaemia ECG?

Answer 137

Peaked or tall tented t waves Loss of P waves Broad QRS complexes Sinusoidal wave pattern

Question 138

Management of hyperkalaemia?

Answer 138

Stabilisation of the cardiac membrane- IV calcium gluconate (does not lower serum potassium levels) Combined insulin/dextrose infusion, nebulised salbutamol (causes a short term shift in potassium from ECF compartment to ICF compartment) Removal of potassium from the body- Calcium resonium (orally or enema)- enemas more effective as potassium secreted by the rectum Loop diuretics Dialysis- haemofiltration/haemodyalysis considered for AKI patients with persistent hyperkalaemia Practically of >6.5 emergency treatment of: IV Calcium gluconate Insulin/dextrose infusion Stop exacerbating drugs ACEi Treat underlying cause Lower total body posassium- calcium resonium, loop diuretics, dialysis

Question 139

Nephrogenic diabetes insipidus treatment?

Answer 139

Thiazides Low salt/protein diet

Question 140

Central (cranial) diabetes insipidus treatment?

Answer 140

Desmopressin

Question 141

Paediatric fluids calculation (non-neonates)?

Answer 141

100ml for first 10 kg 50ml for next 10kg (11-20) 20ml for every extra kilo Up to a max of around 2L

Question 142

Adult maintenance fluids calculation?

Answer 142

25-30ml/kg/day of water 1mmol/kg/day of potassium, sodium and chloride 50-100g/day of glucose to limit starvation ketosis

Question 143

Risk of using 0.9% saline if large volumes of fluid required?

Answer 143

Hyperchoraemic metabolic acidosis

Question 144

Which common drug can cause rhabdomyolysis?

Answer 144

Statins (especially if co-prescribed with clarithromycin)

Question 145

Most common renal cause of AKI?

Answer 145

Acute tubular necrosis (ATN)

Question 146

Two causes of ATN?

Answer 146

Ischaemia- shock, sepsis Nephrotoxins- aminoglycosides, myoglobin secondary to rhabdomyolysis, radioconstrast agents, lead Muddy-brown casts in urine

Question 147

Type 1 vs Type 2 respiratory failure?

Answer 147

Type 1- just one gas is effected (eg just the oxygen or CO2 out of range) Type 2 - two gasses effected (both oxygen and CO2 out of range) Could be wrong- correct is- Type 1- Low oxygen with normal or low CO2 Type 2- Low oxygen with High CO2

Question 148

If renin high but aldosterone high, unlikely to be primary hyperaldostronism what else is most likely?

Answer 148

Renal artery stenosis

Question 149

Things in urine and their meaning?

Answer 149

Hyaline casts- normal- paticularly in patients taking loop diuretics Brown granlar casts- acute tubular necrosis Bland urinary sediment- prerenal uraemia Red cell casts- nephritic syndrome

Question 150

Haematuria referral?

Answer 150

In younger- usually renal referral In older- usually urology referral

Question 151

Kidney condition associated with berry aneurysms?

Answer 151

ADPKD

Question 152

Why is nephrotic syndrome associated with an increased risk of thromboembolism?

Answer 152

Nephrotic syndrome leads to a loss of antithrombin III and plasminogen in the urine

Question 153

How are diabetics screened for diabetic nephropathy?

Answer 153

Annually using albumin:creatinine ratio (ACR) Early morning specimen

Question 154

Anaemia signs- paticularly due to CKD?

Answer 154

Usually caused by iron deficiency or erythropoitein deficiency in CKD Tachycardia, fatigue, pallor and an aortic flow murmur

Question 155

Example regime/ drugs for immunosuppression?

Answer 155

Initial: Ciclosporin/ tacrolimus Maintenance- Ciclosporin/tacrolimus with Mycophenolate mofetil (MMF) or Sirolimus (rapamycin) Add steroids if more than one steroid responsive acute rejection episode Immunosuppression means more likely to get malignancy such as skin cancer Some of the drugs can cause cardiovascular issues

Question 156

Difference between somatisation and hypochondriasis (illness anxiety disorder)?

Answer 156

Somatisation- multiple physical SYMPTOMS present for at least 2 years patient refuses to accept reassurance or negative test results Hypochondriasis- persistent belief in the presence of an underlying serious DISEASE, e.g. cancer patient again refuses to accept reassurance or negative test results

Question 157

How long should a PPI be stopped before upper endoscopy?

Answer 157

2 weeks

Question 158

Gold standard investigation for GORD (after endoscopy)?

Answer 158

24 hour oesophageal pH monitoring

Question 159

Group B step presentation neonates?

Answer 159

Most common cause of early onset neonatal sepsis Classically- fever, tachycardia and respiratory distress within hours of birth

Question 160

Risk factors for GBS transmission?

Answer 160

Prematurity Prolonged rupture of the membranes Previous sibling GBS infection Maternal pyrexia (secondary to chorioamnionitis)

Question 161

Conditions associated with MALT lymphoma?

Answer 161

H.pylori infections- 95% Hashimoto's thyroiditis

Question 162

Most common causes of hypercalcaemia?

Answer 162

Primary hyperparathyroidism- in non-hospitalised Malignancy- in hospitalised patients- can be PTHrP from tumour in SCLC, bone metasteses or myeloma For this reason measuring PTH levels is the key investigation for patients with hypercalcaemia Other causes- Sarcoidosis Vit D intoxication Acromegaly Thyrotoxicosis Drugs- thiazides, calcium-containing antacids Dehydration Addison's disease Paget's disease of the bone

Question 163

First investigation for heart failure?

Answer 163

NT-proBNP If levels high (>2000) then specialist assessment (including transthoracic ECHO) within 2 weeks If levels raised (400-2000) then specialist assessment (including transthoracic ECHO) within 6 weeks

Question 164

When is the majority of hydrocortisone treatment given for Addison's?

Answer 164

Majority given in the first half of the day

Question 165

Addison's during illness?

Answer 165

Hydrocortisone doubled, fludrocortisone stay the same

Question 166

Manouvre for shoulder dystocia?

Answer 166

McRobert's manoeuvre

Question 167

Features of life-threatening asthma?

Answer 167

33 92 CHEST: PEFR <33 Sats < 92% Confusion/Cyanosis Hypotension Exhaustion Silent chest Transiently normal CO2

Question 168

Urge or stress incontinence management?

Answer 168

Bladder retraining exercises- minimum of 6 weeks 1st line- oxybutinin, darifenacin, tolterodine If old, frail avoid oxybutinin and give mirabegron due to risk of anticholinergic side effects

Question 169

Way to screen for postnatal depression?

Answer 169

Edinburgh Postnatal Depression Scale

Question 170

SSRIs that can be used in postnatal depression?

Answer 170

Sertraline and paroxetine

Question 171

Up to when can the COCP not be used after pregnancy due to VTE risk?

Answer 171

Up to day 21

Question 172

What causes roseola infantum (sixth disease)?

Answer 172

Human herpes virus 6

Question 173

When should levonorgestrel dose be doubled?

Answer 173

Those with a BMI >26 or weight over 70kg Also if taking enzyme inducing drugs but copper IUD preferable in this situation

Question 174

Levonorgestrel extra bits?

Answer 174

If vomiting occurs within 3 hours then dose should be repeated Can be used more than once in a menstrual cycle if clinically indicated Hormonal contraception can be started immediately after using

Question 175

SSRI that causes QT prolongation/ torsades de pointes?

Answer 175

Citalopram

Question 176

Clinical features of Down's syndrome?

Answer 176

Face: upslanting palpebral fissures, epicanthic folds, Brushfield spots in iris, protruding tongue, small low-set ears, round/flat face Flat occiput Single palmar crease, pronounced 'sandal gap' between big and first toe Hypotonia Congenital heart defects (40-50%, see below) Duodenal atresia Hirschsprung's disease

Question 177

Later complications of Down's syndrome?

Answer 177

Subfertility: males are almost always infertile due to impaired spermatogenesis. Females are usually subfertile, and have an increased incidence of problems with pregnancy and labour Learning difficulties Short stature Repeated respiratory infections (+hearing impairment from glue ear) Acute lymphoblastic leukaemia Hypothyroidism Alzheimer's disease Atlantoaxial instability

Question 178

When are pregnant women screened for anaemia

Answer 178

The booking visit (often at 8-10 weeks) 28 weeks

Question 179

Anaemia cut offs in pregnancy?

Answer 179

Cut offs for is a woman should recieve iron therapy: First trimester- <110g/L Second trimester- <105g/L Postpartum- <100g/L

Question 180

What is the most important thing to do for someone who presents with an infection that is taking clozapine?

Answer 180

Arrange a full blood count to check for agranulocytosis/neutropenia- life threatening side effect of clozapine

Question 181

Hypercalcaemia symptoms?

Answer 181

Stones- kidney or biliary stones Bones- bony pain Groans- Abdominal pains Thrones- constipation or frequent urination Tones- Muscle weakness and hypotrefelxia Psychiatric moans- depression, anxiety, confusion (Bendroflumethiazide (thiazide like diuretics) cuse hypercalcaemia, hyponatraemia, hypokalaemia and hypomagnesaemia)

Question 182

How do thiazide like diuretics work?

Answer 182

Inhibit sodium reabsorption at the begininning of the distal convoluted tubule

Question 183

Thiazide like diuretics side effects?

Answer 183

Common adverse effects dehydration postural hypotension hypokalaemia due to increased delivery of sodium to the distal part of the distal convoluted tubule → increased sodium reabsorption in exchange for potassium and hydrogen ions hyponatraemia hypercalcaemia the flip side of this is hypocalciuria, which may be useful in reducing the incidence of renal stones gout impaired glucose tolerance impotence Rare adverse effects thrombocytopaenia agranulocytosis photosensitivity rash pancreatitis

Question 184

Are statins contraindicated in pregnancy?

Answer 184

Yes Also contraindicated with macrolides (erythromycin, clarithromycin)

Question 185

Alcohol units for men and women?

Answer 185

14 units per week for both 1 unit= 10ml of alcohol

Question 186

When should beta blockers be stopped in acute heart failure?

Answer 186

If the patient has a heart rate <50, second or third degree AV block or shock

Question 187

Does SIADH lead to signs of fluid overload?

Answer 187

No because the fluid is equally distributed throughout the body The blood does become diluted through leading to a hyponatremia

Question 188

Furosemide side effects?

Answer 188

OH DANG O-otoxicity H-hypokalaemia D-Dehydration A-allergy N-nephritis G-GOut Hyponatremia as well

Question 189

How to know if DKA has resolved ?

Answer 189

pH over 7.3 Blood ketones <0.6 Bicard >15 If not like this 24 hours after admission they need review from a senior endocrinologist Both ketonemia and acidosis should resolve within 24 hours If the criteria are met and patient is eating and drinking switch to subcut insulin Patient reviewed by diabetes specialist nurse prior to discharge

Question 190

If CHADSVASC suggests no need for anticoagulation (0) what needs to be done?

Answer 190

Do a transthoracic echocardiogram to exclude valvular heart disease, which is requires anticoagulation in combination with AF

Question 191

C.difficile management?

Answer 191

Current antibiotic therapy reviewed and antibiotics stopped if possible 1st- Oral vancomycin- 10 days 2nd- Oral fidaxomicin 3rd- Oral vancomycin +/- IV metronidazole If life threatening stragiht to 3rd Isolation in a side room

Question 192

Insulinoma triad?

Answer 192

Whipple's triad Symptoms and signs of hypoglycemia Plasma glucose <2.5mmol/L Reversibility of symptoms on the administation of glucose Most importantly C-peptide levels do not fall on the administation of insulin if the patient has an insulinoma as endogenous levels are not reduced through negative feedback

Question 193

What should a UC patient who had 2 or more severe exacerabtions in the past year be given to maintain remission?

Answer 193

Either oral azathioprine or oral mercaptopurine

Question 194

Metabolic alkalosis + hypokalaemia?

Answer 194

?prolonged vomiting

Question 195

Management of h.pylori?

Answer 195

PPI+ Amoxicillin + Clarithromyin OR Metronidazole If pen allergic PPI+Clarithromycin+metronidazole

Question 196

When shoud urea breath test not be performed?

Answer 196

Within 4 weeks of treatment with an antibacterial or within 2 weeks of an antisecretory drug (PPI)

Question 197

Which test should be used to check for H.pylori eradication?

Answer 197

Urea breath test

Question 198

CRP and infection?

Answer 198

CRP can lag behind other blood results such as WCC

Question 199

Multiple endocrine neoplasia?

Answer 199

MEN Type 1- 3Ps- Parathyroid (hyper), Pituitary, Pancreas (insulinoma, gastrinoma- causing peptic ulcer) (Also adrenal and thyroid)- most common presentation hypercalcemia MEN Type IIa- 2Ps- Parathyroid, Phaeochromocytoma MEN type IIb- 1P- Phaeochromocytoma. Also neuromas and marfanoid body habitus

Question 200

Zollinger-Ellison Syndrome?

Answer 200

Excessive levels of gastrin secondary to gastrin-secreting tumour. Can be part of MEN 1 syndrome Features: multiple gastroduodenal ulcers, diarrhoea, malabsorpiton

Question 201

Afro-carribean + HF?

Answer 201

Hydralazine + Nitrates

Question 202

HF treatment?

Answer 202

ACEi and BB- start one drug at a time 2nd- Add an aldosterone antagonist- spironolactone/eplerenone- remember to monitor potassium if also on ACEi as both cause hyperkalaemia 3rd- Ivabradine- sinus rhythm >75/min and left ventricular fraction <35% Sacubitril-valsartan- left ventricular fraction <35%- symptomatic on ACEi/ARB- initiated following ACEi/ARB washout period Digoxin- Indicated in coexistant atrial fibrillation Hydralazine + nitrate- afro-carribean Cardiac resynchronisation therapy- widened QRS (LBBB) on ECG Also a role for SGLT-2 inhibitors Annual influenza vaccine Offer one-off pneumococcal vaccine

Question 203

Drug to slow heart rate contraindicated in asthmatics?

Answer 203

IV adenosine Verapamil prederable

Question 204

Statin interactions?

Answer 204

Macrolides (erythromycin, lcarithromycin) Pregnancy

Question 205

Oesophageal cancer types?

Answer 205

UK/US- adenocarcinoma- GORD, Barrett's Developing- squamous cell cancer- smoking, alcohol

Question 206

Postpartum contraception from when?

Answer 206

Day 21

Question 207

How to define menhorrhagia?

Answer 207

Used to be over 80ml per menses but now is defined as an amount that the woman considers to be excessive

Question 208

Extrapyramidal side-effects (EPSEs)?

Answer 208

Parkinsonism Acute dystonia- torticollis, oculogyric crisis- managed with procyclidine Akathisia Tardive dyskinesia- occurs after longer term use

Question 208

Side effects antipsychotics?

Answer 208

Typical- Extrapyramidal side-effects and hyperprolactinaemia common Haloperidol, Chlorpromazine Atypical- Above less common. Metabolic effects. Clozapine, Risperidone, Olanzapine

Question 209

What causes epiglottitis?

Answer 209

Haemophilus influenzae type B

Question 210

Features of epiglottitis?

Answer 210

Features: Rapid onset High temp, generally unwell Stridor Drooling of saliva Tripod position- easier to breath if leaning forward and extending their neck in a seated position Diagnosis made by direct visualisation by senior/airway trained staff X-ray signs- Lateral view- thumb sign Posterior-anterior view- steeple sign

Question 211

Can you breastfeed on antiepileptic drugs?

Answer 211

Yes on nearly all of them

Question 212

Constipation management in children?

Answer 212

MSO Movicol paediatric plain Stimulant- Senna Osmotic- lactulose

Question 213

Less severe vs more severe depression PHQ-9?

Answer 213

Less severe is a PHQ-9 score of <16 More severe is a PHQ-9 score of >16 Less severe depression- not routine for antidepressant first line unless patient preference Guided self help Group CBT Individual CBT SSRI More severe- SSRI and Individual CBT combination

Question 214

Do stage 1 hypertension get treated?

Answer 214

Only if <80 and 1 of: target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 10% or greater

Question 215

What does sudden deterioration with ventilation suggest?

Answer 215

Tension pneumothroax

Question 216

What reverses the effect of dabigatran?

Answer 216

Idarucizumab

Question 217

Which scoring system to use after endoscopy for upper GI bleed?

Answer 217

Rockall score- gives a percentage risk of rebleeding and mortality

Question 218

When to use the Glasgow-Blatchford score?

Answer 218

At the first assessment of a GI bleed to decide if managed as outpatient or inpatient- patients with a score of 0 can be considered for early discharge

Question 219

Risks of HRT?

Answer 219

Increased VTE risk with oral- none with transdermal Stroke- slight increase with oral CHD Breast cancer- increased risk Ovarian cancer- increased risk

Question 220

Non-HRT menopause management?

Answer 220

Vasomotor symptoms- fluoxetine, citalopram or venlafaxine Vaginal dryness- vaginal lubricant Psychological symptoms- self-help, CBT or antidepressants Urogenital atrophy- vaginal oestrogens

Question 221

Things wrong with pulses?

Answer 221

Pulsus paradoxus- greater than 10mmHg fall in systolic BP during inspiration- faint or absent pulse on inspiration- severe asthma, cardiac tamponade Slow rising pulse- aortic stenosis Collapsing pulse- aortic regurgitation, patent ductus arteriosus, hyperkinetic states Pulsus alternans- regular alternation of the force of arterial pulse- severe LVF Bisderiens pulse- mixed aortic valve disease- both stenosis and regurgitation- causes two systolic peaks Jerky puse- HOCM

Question 222

Subacute thyroiditis (De Quervain's)?

Answer 222

De QuerPains Vains- viral post viral There are typically 4 phases; phase 1 (lasts 3-6 weeks): hyperthyroidism, painful goitre, raised ESR phase 2 (1-3 weeks): euthyroid phase 3 (weeks - months): hypothyroidism phase 4: thyroid structure and function goes back to normal globally reduced uptake of iodine-131 Self limiting

Question 223

Obesity management?

Answer 223

Conservative- diet, exercise Medical- orlistat, liraglutide Surgical Orlistat for over BMI 28 with risk facors or over BMI30 Liraglutide criteria- BMI 35 or over and in the prediabetic range- HbA1c 42-47 mmol/mol

Question 224

Murmurs?

Answer 224

Ejection systolic- Louder on expiration- aortic stenosis, HOCM Louder on inspration- pulmonary stenosis, atrial septal defect Tetralogy of Fallot Pansystolic- Mitral/tricuspid regurgitation- tricuspid louder on inspiration, mitral isn't Ventricular septal defect Late systolic- Mitral valve prolapse Coarctation of the aorta Early diastolic- Aortic regurgitation Graham-Steel murmur Mid-late diastolic- mitral stenosis Austin-Flint mrmur Continuous machinary like murmur- Patent ductus arteriosus Right sided murmur- inspiration Left sided murmur- expiration

Question 225

Best markers for acute liver monitoring/acute liver failure?

Answer 225

Prothrombin time Albumin level Prothrombin has shorter half life so it is a better marker Liver enzymes not reliable as take time to change

Question 226

Features and causes of acute liver failure?

Answer 226

Causes- paracetamol overdose Alcohol viral hepatitis (usually A or B) acute fatty liver of pregnancy Features jaundice coagulopathy: raised prothrombin time hypoalbuminaemia hepatic encephalopathy renal failure is common ('hepatorenal syndrome')

Question 227

First line non-hormonal treatment for menorrhagia?

Answer 227

Tranexamic acid Mefenamic acid (paticularly if dysmenorrhoea as well) If require contraception: Mirena COCP Long acting progestogens

Question 228

Who is adenomyosis more common in?

Answer 228

Older, multiparous women towards the end of their reproductive years

Question 229

ECG changes associated with hypothermia?

Answer 229

Bradycardia- <60bpm J waves First degree heart block Long QT Atrial and ventricular arrythmias Jeez it's bloody freezing J waves, irregular rhythms, bradycardia, first degree heart block

Question 230

Prophylaxis of variceal haemorrhage?

Answer 230

Propanolol Endoscopic variceal band ligation Transjugular intrahepatic portosystemic shunt

Question 231

Which drug is contrainidcated in VT?

Answer 231

Verapamil

Question 232

What is the safe triangle for insertion of a chest drain?

Answer 232

Anterior edge of latissius dorsi Lateral border of the pectoralis major A line superior to the horizontal level of the nipple (5th intercostal space)

Question 233

CRB65 score + interpretation?

Answer 233

Confusion Resp rate >=30/min BP <90/<60 Age over 65 0- low risk- treatment at home 1 or 2- intermediate risk- hospital assessment considered 3 or 4- urgent admission to hospital CURB65- Urea >7 0-1- consider home 2 or more hospital based 3 or more intensive care assessment

Question 234

Pneumonia treatment

Answer 234

Low severity: Amoxicillin Macrolide or tetracycline if pen allergic Moderate/high-severity Dual therapy- amoxicillin and a macrolide

Question 235

Follow up for pneumonia?

Answer 235

All pneumonia should have a repeat chest x-ray at 6 weeks after clinical resolution to ensure no underlying secondary abnormalities such as a lung tumour

Question 236

Added benefits to mirtazapine?

Answer 236

Increased appetite and sedation effects

Question 237

Ketones over what for DKA?

Answer 237

>3mmol/l

Question 238

What is pseudomembranous colitis?

Answer 238

C.difficle colitis- another name for it

Question 239

What do you need to check before treatment with azathioprine?

Answer 239

Thiopurine methyltransferase deficiency (TMPT)

Question 240

Extra azathioprine bits?

Answer 240

Generally considered safe in pregnancy Adverse effects- Bone marrow depression N+V Pancreatitis Increased risk of non-melanoma skin cancer Significant interaction may occur with allopurinol- potentially use lower doses

Question 241

Are chemotherapy patients at an increased risk of gout?

Answer 241

Yes- due to increased urate production Chemotherapy causes rapid cell death leading to the release of purines that are metabolised into uric acid

Question 242

Sulfasalazine extra bits?

Answer 242

Considered safe to use in both pregnancy and breastfeeding unlike other DMARDs Caution- G6PD deficiency, allergy to aspirin or sulphonamides Adverse effects Oligospermia Stevens-Johnson syndrome

Question 243

Antiphospholipid syndrome features?

Answer 243

Venous/arterial thrombosis Recurrent miscarridges Livedo reticularis (Pre-eclampsia, pulmonary hypertension) Investigations- Antibodies- anticardiolopin antibodies anti-beta2 glycoprotein antibodies lupus anticoagulan Thrombocytopenia Prolonged APTT Management: Primary thtromboprophylaxis- low-dose aspirin Secondary thromboprohylaxis- initial venous thrmboemloic events- lifelong warfarin with a target INR of 2-3 Reccurent VTE events- add aspiring INR to 3-4 Arterial thrombosis- lifelong warfarin with target INR 2-3

Question 244

Which conditions is closely related to temporal arteritis?

Answer 244

Polymyalgia rheumatica

Question 245

What is a raised anti-CCP associated with?

Answer 245

Rheumatoid arthritis

Question 246

Which blood result is notably normal in polymyalgia rheumatica?

Answer 246

Creatine kinase

Question 247

Methotrexate indications?

Answer 247

Inflammatory arthritis- especially rheumatoid Psoriasis Some chemotherapy- ALL

Question 248

Adverse effects of methotrexate?

Answer 248

Mucositis Myelosuppression Pneumonitis- most commonn pulmonary manifestation- non-productive cough, dyspnoea, malaise, fever Pulmonary fibrosis Liver fibrosis Avoid pregnancy for at least 6 months after treatment stopped BNF also advises men using methotrexate need to use effective contraception for at least 6 months after treatment

Question 249

Prescribing methotrexate general advice?

Answer 249

Methotrexate had high potential for patient harm Methotrexate is taken weekly, rather than daily FBC, U&E, LFT regularly monitored- FBC, renal and LFTs before strting treatment and weekly until therapy stable, then every 2-3 months Folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after methotrexate dose

Question 250

Interactions of methotrexate?

Answer 250

Trimethoprim or co-trimoxazole- increases the risk of marrow aplasia High dose aspirin- reduced methotrxate excretion

Question 251

Mechanism of action for bisphosphonates?

Answer 251

They inhibit osteoclasts by reducing recruitment and promoting apoptosis

Question 251

Methotrexate toxicity treatment?

Answer 251

Folinic acid

Question 252

Adverse effects of bisphosphonates?

Answer 252

Oesophageal reacions Osteonecrosis of he jaw- substationally greater risk for patients receiving IV bisphosphonates in the treatment of cancer than for patients receiving oral bisphosphonates for osteoporosis or Paget's disease increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate acute phase response: fever, myalgia and arthralgia may occur following administration Hypocalcaemia- usually clinically unimportant

Question 253

Counselling for taking oral bisphosphonates?

Answer 253

'Tablets should be swallowed whole with plenty of water while sitting or standing; to be given on an empty stomach at least 30 minutes before breakfast (or another oral medication); patient should stand or sit upright for at least 30 minutes after taking tablet'

Question 254

Bispohosphonates and prexisting deficiency?

Answer 254

Hypocalcemia/vitamin D deficiency should be corrected before giving bisphosphonates. However, when starting bisphosphonate treatment for osteoporosis, calcium should only be prescribed if dietary intake is inadequate. Vitamin D supplements are normally given.

Question 255

Duration of bisphosphonate treatment?

Answer 255

The duration of bisphosphonate treatment varies according to the level of risk. Some authorities recommend stopping bisphosphonates at 5 years if the following apply: patient is < 75-years-old femoral neck T-score of > -2.5 low risk according to FRAX/NOGG

Question 256

Most common site for metatarsal stress fracture?

Answer 256

2nd metatarsal shaft

Question 257

Reactive arthritis triad?

Answer 257

Arthralgia, urethritis and uveitits (Arthritis, urethritis, conjunctivitis) Develops following an infection where the organism cannot be recovered from the joint Can't see, can't pee can't climb a tree

Question 258

Organisms for reactive arthritis?

Answer 258

Shigella, salmonella, campylobacter- post-dysenteric Post-STI- chlamydia trachomatis

Question 259

Management reactive arthritis?

Answer 259

Analgesia, NSAIDs, intra-articular steroids Sulfasalazine and methotrexate for persistent disease Symptoms rarely last more than 12 months

Question 260

Do ganglion cysts transilluminate?

Answer 260

Yes

Question 261

Most common organism in osteomyelitis?

Answer 261

Staph. aureus In patients with sickle-cell it is salmonella

Question 262

Difference between Raynaud's disease and Raynaud's phenomenon?

Answer 262

Raynaud's disease is primary- typically women under 30 years old Raynaud's phenomenon is secondary

Question 263

Secondary causes of Raynaud's phenomenon?

Answer 263

Connective tissue disorders- scleroderma (most common), RA, SLE Leukaemia Use of vibrating drugs COCP

Question 264

Cardiac condition associated with discitis?

Answer 264

IE- assess patients with transthoracic echo Discitis usually due to bacteraemia and seeding that could also have occured elsewhere

Question 265

Complication of discitis?

Answer 265

Epidural abscess- can cause lower limb neurology

Question 266

What to do if a patient is deemed high risk on a QFracture or FRAX scre?

Answer 266

They should have a DEXA scan to assess bone mineral density

Question 267

A mutation in which protein causes Marfan's syndrome?

Answer 267

Fibrillin-1 Autosomal dominant

Question 268

Features of Marfan's syndrome?

Answer 268

all stature with arm span to height ratio > 1.05 high-arched palate arachnodactyly pectus excavatum pes planus scoliosis of > 20 degrees heart: dilation of the aortic sinuses (seen in 90%) which may lead to aortic aneurysm, aortic dissection, aortic regurgitation mitral valve prolapse (75%), lungs: repeated pneumothoraces eyes: upwards lens dislocation (superotemporal ectopia lentis) blue sclera myopia dural ectasia (ballooning of the dural sac at the lumbosacral level)

Question 269

Sjogren's syndrome malignancy association?

Answer 269

Marked increased risk of lymphoid malignancy 40-60 fold

Question 270

What are the 4 As of ankylosing spondylitis?

Answer 270

Apical fibrosis Anterior uveitis Aortic valve incompetence Achilles tendonitis Other features - the 'A's Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis and cauda equina syndrome peripheral arthritis (25%, more common if female)

Question 271

Ankylosing spondylitis X-Ray?

Answer 271

Sacroiliitis: subchondral erosions, sclerosis Squaring of lumbar vertebrae Bamboo spine (late and uncommon) Syndesmophytes CXR- apical fibrosis

Question 272

Is measles a notifiable disease?

Answer 272

Yes

Question 273

Is HIV a notifiable disease?

Answer 273

No

Question 274

Only absolute contraindication for ECT?

Answer 274

Raised ICP

Question 275

How long before surgery should oestrogen contraceptives be stopped?

Answer 275

4 weeks before Can switch to the POP

Question 276

Nerve problems?

Answer 276

C1, 2 - Look at your shoe- Neck flexion/extension C3 - A fallen tree - Neck lateral flexion C4 - I'm not sure - Shoulder elevation C5 - Arms out wide - Shoulder flexion, abduction, & lateral rotation C6, 7, 8 - Close the gate - Shoulder extension, adduction & medial rotation C5, 6 - Pick up sticks - Elbow flexion C7, 8 - Lay them straight - Elbow extension C5, 6 - Flick my wrists - Forearm supination C7, 8 - The time is late - Forearm pronation C6, 7 - Fly up to heaven - Wrist flexion & extension C7 - Paper - Finger extension C8 - Rock - Finger flexion (though some sources say C7, 8 does both finger extension and flexion) T1 - Scissors - Finger abduction & adduction (T1-12 - Supplies chest wall and abdominal muscles) (L1 - Contributes to hip flexion & adduction) Kicking a ball: L2, 3 - Lift my knee - Hip flexion L3, 4 - Kick the door - Knee extension (& knee-jerk reaction) L4, 5 - Foot points to the sky - Ankle dorsiflexion Bringing foot back to the floor: L4, 5 - Extend my thigh - Hip extension L5, S1, (S2) - Kick my bum (Run to poo) - Knee flexion S1, 2 - Stand on my shoes - Ankle plantarflexion (& ankle jerk) (Babinski plantar reflex/extensor response in UMN lesion is L5, S1, S2) L2, 3, 4 - Modestly close the door - Hip adduction & internal/medial rotation L4 - S2 - The opposite is true - Hip abduction & external/lateral rotation [ SUPPLIES ] C3, 4, 5 - Keeps the diaphragm alive â→ Innervates the diaphragm S2, 3, 4 - Keeps s*** off the floor â→ Innervates bowel, bladder, sex organs, anal sphincter, pelvic muscles. (& anal wink reflex)

Question 277

Two main fractures at risk of compartment syndrome?

Answer 277

Supracondylar fractures and tibial shaft fractures

Question 278

Chromosome present in CML?

Answer 278

Philadelphia chromosome- translocation 9 and 22

Question 279

Most common cause of AIN and examples of them?

Answer 279

Drugs: Penicillins NSAIDs Furosemide Rifampicin Allopurinol

Question 280

What to do in DVT if US scan negative but d-dimer positive?

Answer 280

Stop anticiagulation and re-scan in 1 week

Question 281

Which must be replaced first B12 or Folate?

Answer 281

BeFore Replace B12 before Folate to avoid subacute degeneration of the spinal cord

Question 282

Treatment B12 deficiency?

Answer 282

If no neurological involvement 1 mg of IM hydroxocobalamin 3 times each week for 2 weeks, then once every 3 months

Question 283

Extra factors in a Z socre DEXA?

Answer 283

AGE Age Gender Ethnicity

Question 284

What suggests achillies tendon rupture?

Answer 284

Playing sport Audible pop Sudden onset significant pain in cal or ankle/ inability to walk/continue Positive Simmond's sign

Question 285

Risk factors for achilles tendon disorders?

Answer 285

Quinolone use (ciprofloxacin) Hypercholesterolaemia

Question 286

Indications for dialysis?

Answer 286

AEIOU A- acidosis <7.1 E- electrolyte derangement (refractory hyperkalaemia) I- Intoxication/ingestion (alcohol/salicylates/lithium) O- overload of fluid (cogestive cardiac failure) U- uraemia (uraemic pericarditis or encephalopathy)

Question 287

Can testosterone deficiency cause osteoporosis?

Answer 287

Yes

Question 288

Which bones are most likely to be affected in Paget's disease of the bone?

Answer 288

Skull, spine/pelvis and long bones of the lower extremities are most commonly affected

Question 289

What is the most common optic compilcation of temporal arteritis?

Answer 289

Anterior ischemic optic neuropathy- results from occlusion of the posterior ciliary artery. Swollen pale disc and blurred margins.

Question 290

Which is the strange indication for dialysis in AKI?

Answer 290

Pulmonary oedema Also: Hyperkalaemia Uraemia Metabolic acidosis

Question 291

Most common anaemia worldwide?

Answer 291

Iron deficiency anaemia

Question 292

Stages if hyperkalaemia?

Answer 292

mild: 5.5 - 5.9 mmol/L moderate: 6.0 - 6.4 mmol/L severe: ≥ 6.5 mmol/L Treat as severe if moderate/mild with ECG changes

Question 293

Red flags for cancer- back pain?

Answer 293

Trauma/Thoracic back pain Unexplained weight loss Neuro sx Age <20>50 Fever (night sweats) IVDU Steroid use Hx of cancer Back pain at night

Question 294

Monteggia fracture/ Galeazzi fracture?

Answer 294

Monteggia Ulnar (Manchester United), Galeazzi radius (Glasgow Rangers) Fractures of proximal ulnar/radius wih an associated dislocation of the proximal radioulnar joint (Manchester), distal radioulnar joint (Glasgow) Galeazzi distal- Glasgow further away than Manchester- Monteggia proximal

Question 295

Pre renal uraemia vs acute tubular necrosis?

Answer 295

Check diagram on passmed

Question 296

Straight leg raise pain cause?

Answer 296

Sciatic nerve pain

Question 297

Abdominal pain and neurological signs condition to consider?

Answer 297

Lead poisoning Features abdominal pain peripheral neuropathy (mainly motor) neuropsychiatric features fatigue constipation blue lines on gum margin (only 20% of adult patients, very rare in children)

Question 298

Antibiotic of choice for neutropenic sepsis?

Answer 298

Piperacillin with tazobactam (Tazocin)

Question 299

What can cause thrombotic crises in sickle cell?

Answer 299

Precipitated by infection, dehydration or deoxygenation

Question 300

Post menopausal women taking high dose steroids?

Answer 300

Steroids over 7.5 or equivalent for the next 3 months Need bisphosphonates/ calcium/vit D- don't wait for the results of a DEXA scan

Question 301

Most common causative organism for neuropenic sepsis?

Answer 301

Staph epidermidis- associated with central line infections

Question 302

Normal blood result in PMR?

Answer 302

Creatine kinase is normal

Question 303

ADPKD treatment?

Answer 303

Tolvaptan

Question 304

Constipation management overview?

Answer 304

1st- Bulk forming- Isphaghula Husk 2nd line- hard stools- osmotic- macrogol 2nd line- soft stools with tenesmus- stimulant= senna Opioid induced- osmotic- macrogol + stimulant- senna Faecal impaction- high dose macrogol +/- disimpaction/ enema/ suppositry

Question 305

Best test to diagnose Addison's disease?

Answer 305

Short synacthen test

Question 306

Trousseau's sign?

Answer 306

Carpal spasm on inflation of BP cuff to pressure above systolic Hypocalcaemia causes it

Question 307

Coeliac disease which vaccine every 5 years?

Answer 307

Pneumococcal due to hyposplenism

Question 308

Cotard syndrome?

Answer 308

Person thinking they are dead or non-existent

Question 309

Treatment for threatworm?

Answer 309

Mebendazole Me got bendy worm in my azole

Question 310

Schneider's first rank symptoms?

Answer 310

Auditory hallucinations of a specific type: two or more voices discussing the patient in the third person thought echo voices commenting on the patient's behaviour Thought disorders thought insertion thought withdrawal thought broadcasting Passivity phenomena: bodily sensations being controlled by external influence actions/impulses/feelings - experiences which are imposed on the individual or influenced by others Delusional perceptions a two stage process) where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. 'The traffic light is green therefore I am the King'.

Question 311

Platelets transfusion problem?

Answer 311

Stored at room temperature- if given can introduce infection as more risk of bacterial contamination

Question 312

Common cause of reactive thrombocytosis?

Answer 312

Iron deficiency anaemia- results in high platelets in IDA. Also bleeding, hyposplenism (can happen in coeliac), infections and malignancies Also, potential for low retuculocytes

Question 313

Key random investigation for IDA?

Answer 313

Anti-transglutaminase antibodies- rule out coeliac

Question 314

Abdominal pain + Neurological signs?

Answer 314

Consider lead poisoning Also consider acute intermittent porphyria

Question 315

DKA treatment?

Answer 315

FIGPICK F- Fluids I- Insulin G- Glucose P- Potassium I- Infection C- Chart fluid balance K- Ketones

Question 316

In hyperparathyroidism PTH result?

Answer 316

In primary hyperparathyroidism the PTH level can be inappropriately normal as apposed to raised when a high calcium is also taken into account

Question 317

Management of diabetic neuropathy?

Answer 317

First line- amitriptyline, duloxetine, gabapentin or pregabalin Tramadol can be used as a rescue therapy for exacebations Pain management clinics useful for patients with resistant problems

Question 318

Differentiate between the different causes of Cushing's disease?

Answer 318

On the high dose test- If it is low ACTH low Cortisol- Cushings disease from pituitary- pituitary even though tumour retains some negative deefback if it is low ACTH high cortisol- cushing's syndrome- adrenal adenomas if it is high ACTH high cortisol- ectopic ACTH syndrome

Question 319

Hashimoto's thyroiditis?

Answer 319

Hypothyroidism + Goitre + anti-TPO

Question 320

Test use to identify pheochromocytoma?

Answer 320

24-hour urinary metanephrine

Question 321

What to do if scaphoid fracture suspected and initial imaging inconclusive?

Answer 321

Arrange further imaging for 7-10 days time as scaphoid fracture can take time to show up radiologically

Question 322

Normal anion gap vs raised anion gap conditions?

Answer 322

Normal anion gap (hyperchloraemic metabolic acidosis): - GI bicarbonate loss- prolonged diarrhoea (can cause hypokalaemia as well), fistula - Renal tubular acidosis -Drugs- acetazolamide - Ammonium chloride injection -Addison's disease Raised anion gap: - Lactate- shock, sepsis, hypoxia - Ketones- DKA, alcohol - Urate- renal failure - Acid poisoning- salicylates, methanol

Question 323

What metabolic disturbance is renal tubular acidosis associated with?

Answer 323

Hyperchloraemic metabolic acidosis (normal anion gap) Type 1 RTA- inability to generate acid urine (secrete H+) in distal tubule- causes hypokalaemia type 2 RTA- ecreaed HCO3- reabsorption on proximal tubule- causes hypokalaemia RTA 3- very rare RTA 4 (hyperkalaemic)- reduction in aldosterone leads to a reduction in proximal tubular ammonium excretion- hyperkalaemia

Question 324

Age range for toxic multinodular goitre?

Answer 324

Older women over 50, on the back of a long standing goitre, develops gradally

Question 325

Amiodarone therapy and thyroid?

Answer 325

Causes hyperthyroidism

Question 326

Gastroparesis diabetes complication?

Answer 326

Bloating, early satiety, chronic nausea, vomiting Caused by poor glucose control leading to autonomic neuropathy Leads to erratic blood glucose control due to slow emptying of the stomach Management options- metocopramide, domperidone or erythromycin

Question 327

Two drugs particularly linked with ED?

Answer 327

SSRIs, beta-blockers

Question 328

When to refer to endocrinology with ED?

Answer 328

If testosterone low and one of FSH, LH or prolactin levels are also abnormal Check testosterone levels in all men presenting with ED

Question 329

Proctitis?

Answer 329

Rectal inflammation particularly seen after radiotherapy for prostate cancer Similar to symptoms of UC, bloody diarrhoea, tenesmus, painful diarrhoea

Question 330

Difference between primary and secondary hyperparathyroidism?

Answer 330

Primary- solitary adenoma prodrucing too much PTH leading to icnreased calcium, decreased phosphate and elevated PTH Secondary- Parathyroid gland hyperplasia (must often with a background of chronic renal failure). The kidneys cannot get rif of the phosphate and fail to activate vit D meaning less calcium absorption and low calcium meaning PTH is raised as calcium is low and phosphate is high because it cannot be excreted

Question 331

Lab results for osteomalacia?

Answer 331

Calcium- decreased phosphate- decreased ALP-increased PTH- increased In primary hyperparathyroidism, CKD (secondary hyperparathyroidism)- ALP increased and PTH increased Paget's only ALP increased

Question 332

What is osteomalacia in children?

Answer 332

Rickets Caused by low vit D levels Or CKD/drug induced/liver disease

Question 333

Antiphospholipid syndrome?

Answer 333

Characterised by a predisposition to both venous and arterial thromboses, recurrent fetal loss and thrombocytopenia Linked wiht SLE Causes a paradoxical rise in APTT Investigations- antibodies- anticardiolipin, anti-beta2 glycoprotein, lupus anticoagulant Thrombocytopenia Prolonged APTT Management- Primary thromboprohylaxis- low dose aspirin Secodary- intial VTE events- lifelong warfarin with target of 2-3

Question 334

Tumour lysis syndrome electroytes?

Answer 334

High potassium, high phosphate, low calcium Suspect in any patient presenting with an AKI in the presence of a high phosphate and high uric acid level

Question 335

Preventative drugs for tumour lysis syndrome?

Answer 335

Allopurinol/ Rasburicase Do not give together Give IV fluids as well

Question 336

What must you look for along with TTG antibodies when investigating coeliac disease?

Answer 336

Total IgA- check for IgA deficiency Also perform an endoscpic intestinal biospy- Findings supportive of coeliac- Villious atrophy Crypt hyperplasia Increase in intraepithelial lymphocytes Lamina propria infiltration with lymphocytes

Question 337

CXR finding in aortic dissection?

Answer 337

Widened mediastinum

Question 338

Is a third heart sound normal under 30?

Answer 338

Yes HOCM- 4 letters, 4th heart sound

Question 339

Which condition has a 4th heart sound?

Answer 339

HOCM- 4 letters, 4th heart sound

Question 340

POP how late can pill be?

Answer 340

Most are a 3 hour window Cerazette/Cerelle (desogestrel containing) are 12 hours

Question 341

Paeds resus fluids?

Answer 341

10ml/kg over less than 10 minutes

Question 342

Why is Coomb-positive in aquired haemolytic anaemias?

Answer 342

Positive in immune causes Negative in non immune causes

Question 343

Haemophilia blood test results?

Answer 343

Haemophilia A- deficiency in factor VIII Haemophilia B- deficiency in factor IX Features: haemoarthroses, haematomas, prolonged bleeding after surgery/trauma Blood tests- Key- Prolonged APTT Bleeding time, thrombin time, prothrombin time a normal

Question 344

Typical findings in hyposplenism?

Answer 344

Howell-Jolly bodies Siderocytes

Question 345

Post splenectomy sepsis reccomendations?

Answer 345

Vaccinations- administered 2 weeks before or after splenectomy- pneumococcal, haemophilius type b, meningococcal type C Antibiotic prophylaxis Travel- pharmacological and mechanical protection if going to malaria-endemic areas

Question 346

Heparin-induced thrombocytopenia (HIT)?

Answer 346

Immune mediated- antibodies form against complexes of platelet factor 4 (PF4) and heparin Develops 5-10 days after treatment Low platelets Despite low platelets, it is a prothrombotic condition- DVT etc can be a sign

Question 347

What does heparin act on?

Answer 347

All heparins generally act by activating atithrombin III Unfractionated heparin forms a complex which inhibits thrombin and factors Xa, IXa, XIa and XIIa. LMWH however only increases the action of antithrombin II on factor Xa

Question 348

What is the mechanism of action of aspirin for the antiplatelet effect?

Answer 348

Inhibits the production of thromboane A2

Question 349

Difference between dabigatran and other DOACs?

Answer 349

Dabigatran a direct thrombin (Factor IIa) inhibitor Other DOACs- direct factor Xa inhibitors- rivaroxaban, apixaban and edoxaban Dabigatran reversal- idarucizumab Other DOACs- andexanet alfa

Question 350

Reversal agents for anticoagulants?

Answer 350

Dabigatran-> idarucizumab Factor Xa (rivaroxaban)-> Andexanet alfa Heparins-> Protamine sulphate Warfarin -> Vit K

Question 351

Neutropenia causes?

Answer 351

Viral- HIV, EBV, Hepatitis Drugs- cytotoxics, carbimaxole, cozapine benign ethnic neutropaenia common in people of black African and Afro-Caribbean ethnicity requires no treatment haematological malignancy myelodysplastic malignancies aplastic anemia rheumatological conditions systemic lupus erythematosus: mechanisms include circulating antineutrophil antibodies rheumatoid arthritis: e.g. hypersplenism as in Felty's syndrome severe sepsis haemodialysis

Question 352

In addition to repeated transfusions, which other therapy is important in beta thalassaemia-major?

Answer 352

Iron chelation therapy- desferrioxamine The repeat transfusions cause iron overload

Question 353

What is first line treatment for warm autoimmune haemolytic anaemia?

Answer 353

Steroids +/- rituximab

Question 354

Warm vs cold autoimmune haemolytic anaemia?

Answer 354

Cold weather is MMMiserable= cold AIHA -> IgM + caused by mycoplasma or infectious mononucleosis Warm wrather is Great= warm AIHI -> IgG + caused by CLL or SLE

Question 355

Difference between aplastic crises and sequestration crises in sickle cell anaemia?

Answer 355

Aplastic- infection with parvovirus- sudden fall in haemoglobin Reduced reticulocyte count due to bone marrow suppression Sequestration crises- sickling within organs such as spleen causes a pooling of blood and worsening of anaemia Associated with an increased reticulocyte count

Question 356

Urine output AKI?

Answer 356

<0.5ml/kg/hour for 6 consecutive hours

Question 357

At what level of hyperkalaemia do you give treatment straight away?

Answer 357

≥6.5 mmol/L (severe) or symptomatic If below that and asymptomatic do an ECG Peaked/tall tented T waves Loss of P waves Broad QRS complexes Sinusoidal pattern

Question 358

What is BP target for diabetes and CKD?

Answer 358

Less than 130/80 ACEi is the medication of choice

Question 359

Copper coil and PID?

Answer 359

Contraindicated

Question 360

Strange ACEi side effect?

Answer 360

Rare- angiodema Tongue and facial swelling Can occur anytime after starting treatment- potentially weeks-months

Question 361

ACEi side effects?

Answer 361

A- Angiodema C- Cough E- Elevated potassium i- First dose hypertension U+E checked before treatment started and after increasing the dose Acceptable is a rise in creatinine 30% and increase in potassium to 5.5

Question 362

ACEi contraindictions/cautions?

Answer 362

Pregnancy and breastfeeding- avoid Renovascular diseae- may result in renal impairment Aortic stenosis- may result in hypotension

Question 363

Depth of malignant melanoma scoring system name?

Answer 363

Breslow depth

Question 364

Treatment for venous ulcer?

Answer 364

Compression bandaging

Question 365

Allergen testing?

Answer 365

If it goes in you, do a prick test If it goes on you, do a patch test

Question 366

How does a tension pneumothorax cause cardiac arrest?

Answer 366

Cardiac outflow obstruction

Question 367

Cause of epiglottitis?

Answer 367

H.Influenzae type B

Question 368

Triad for RCC?

Answer 368

Haematuria Loin pain Abdo mass

Question 369

Atypical UTI features (children)

Answer 369

Seriously ill Poor urine flow Abdominal or bladder mass Raised creatinine Septicaemia Failure to respond to antibiotics within 48 hours Infection with non-e.coli organisms

Question 370

When do women get their doses of anti-D?

Answer 370

28 and 34 weeks

Question 371

Four A's of extra skeletal features in ankylosing spondylitis?

Answer 371

Anterior uveitis Amyloidosis Apical lung fibrosis Aortitits/ aortic valve insufficiency

Question 372

Best X-ray for ankylosing spondylitis?

Answer 372

Pelvic x-ray to identify sacro-ilitis

Question 373

Psoriatic arthritis?

Answer 373

Pencil and cup, plantar spur- both begin with P Nail changes- pitting, onycholysis, soft tissue inflammation

Question 374

Rosacea treatment?

Answer 374

Simple measure- high factor sunscreen Predominant erythema/flushing limited telangiectasia- topical brimonidine Mild to moderate papules/pustules- topical ivermectin Moderate to severe papules/pustules- topical ivermectin + oral doxycycline Refer if symptoms not improved with primary care management- laser therapy may be appropriate for patient with telangiectasia Patients with a rhinophyma

Question 375

Topical steroids?

Answer 375

Mild- hydrocortisone Moderate- Eumovate (clobetasone butyrate 0.05%) Potent- Betnovate (betamethasone valerate 0.1%) Very potent- Dermovate (Clobetasol propionate 0.05%) Helps- hydrocortisone Every- Eumovate Budding- Betnovate Dermatologist- Dermovate

Question 376

Adverse effects topical steroids?

Answer 376

Skin thinning Hypopigmentation Excessive hair growth

Question 377

Retinoid treatment contraindication?

Answer 377

Retinoid therapy

Question 378

Erythema nodosum causes?

Answer 378

NO DOSUM NO- Idiopathic D- Drugs (penicillin, sulphonamides) O- Oral contraceptive/pregnancy S- Sarcoidosis/TB U- Ulcerative colitis/Crohn's/ Behcet's M- Microbiology (streptococcus, mycoplasma, EBV etc)

Question 379

Urticaria treatment?

Answer 379

1st- on-sedating antihistamines (loratidine or cetirizine) 2nd- sedating, can be considered for night-time use if trouble sleeping- chlorphenamine If severe or resistant- prednisolone

Question 380

Acanthosis nigricans causes?

Answer 380

Mainly caused by insulin resistance/hyperinsulinemia T2DM GI cancer Obesity PCOS Acromegaly Cushing's disease Hpothyroidism Familial Prader-Willi syndrome Drugs- COCP, nicotinic acid

Question 381

What would you find in a peripheral blood film of myeloma?

Answer 381

Rouleaux formation

Question 382

Difference between aplastic crisis and sequestration crisis in SCA?

Answer 382

Aplastic crisis- reduced reticulocytes- often precipitated by exposure to parvovirus B19 Sequestration crisis- increased reticulocytes

Question 383

CLL transforms to what?

Answer 383

Non-hodgkin's lymphoma- Richter's transformation

Question 384

Beta-thalassemia major features?

Answer 384

Presents in first year of life with failure to thrive and hepatosplenomegaly Microcytic anaemia HbA2 & HbF raised HbA absent Treatment- repeated transfusion that can ead to iron overload- use iron chelation- desferrioxamine

Question 385

Dabigatran reveral agent?

Answer 385

Idarucizumab

Question 386

IgA blood transfusion reactions?

Answer 386

Think anaphylaxis Low IgA

Question 387

Erythema nodosum causes?

Answer 387

NODOSUM Normal (idiopathic) Oncology Drugs Oral Contraceptives Sarcoidosis Ulcerative colitis/Crohns Microbiology - Tb, Viral, Bacterial, Fungal +Pregnancy

Question 388

In which type of patient does TACO usually present?

Answer 388

On a background of heart failure -> causes fluid overload -> give loop diuretics There will be a high BP

Question 389

Difference in treatment for scalp psoriasis vs normal psoriasis?

Answer 389

Scalp psoriasis- 1st line is potent topical steroid only If no improvement after 4 weeks then either use a different formulation of the potent corticosteroid (shampoo/mousse)

Question 390

Burkitt's lymphoma genetic changes?

Answer 390

C-myc gene translocation EBV heavily associated

Question 391

Triad for reactive arhritis?

Answer 391

Urethritis, conjunctivitis, arthritis- mainly large joints Following an initial infection- typically develops after 4 weeks with symptoms lasting 4-6 months

Question 392

Foot sign for reactive arthritis?

Answer 392

Keratoderma blenorrhagica- waxy yellow/brown papules on palms and soles

Question 393

Pontine haemorrhage?

Answer 393

Pin point pupils point to pons Pontine haemorrhage? Peduced GCS Pinpoint pupils Paralysis

Question 394

Idiopathic vs drug induced Parkinson's differentiator?

Answer 394

Idiopathic asymmetrical Drug induced more likely bilateral symptoms + history of dopamiergic drugs

Question 395

Parkinson's triad?

Answer 395

Bradykinesia, tremor and rigidity

Question 396

How to differentiate between essential tremor and Parkinson's disease if difficult?

Answer 396

123I-FP-CIT single photon emission computed tomography (SPECT)

Question 397

Drug to improve motor symptoms in Parkinson's?

Answer 397

Levodopa

Question 398

What to do if a Parkinson's patient cannot take levodopa orally?

Answer 398

Prescribe a dopamine agonist patch as a rescue medication to prevent acute dystonia

Question 399

Bacterial white cell appearance on LP in meningitis?

Answer 399

Polymorphs- also cloudy, low glucose (less than 0.5plasma) and high protein white cells 10-5000

Question 400

Which antiemetic is more likely to cause extrapyramidal side effects?

Answer 400

Metoclopramide

Question 401

Why are bibasal crackles more common in left sided heart failure than right sided heart failure?

Answer 401

Left sided- backs up into lungs Right sided backs up into liver area and body- raised JVP, ankle oedema and hepatomegaly

Question 402

What differentiate acne rosacea from seborrhoeic dermatitis?

Answer 402

In SD the nasolabial folds are involved, they are not in rosaccea

Question 403

Treatment for seborrhoeic dermatitis?

Answer 403

Ketonazole

Question 404

What is present in about 80-90% of patients with psoriatic arthropathy?

Answer 404

Nail changes- also in psoriasis Pitting Onycholysis Subungual hyperkeratosis Loss of the nail

Question 405

What is HHS characteristed by?

Answer 405

1. Severe hyperglycaemia 2. Dehydration/ renal faiilure 3. Mild/absent ketonuria Can remember as: HHS Hypovolaemia Hyperglycaemis Significantly raised serum osmolality Absence of ketoacidosis Patients at risk of VTE- give prophylaxis- vascular complications due to hyperviscosity

Question 406

Causes of cranial DI?

Answer 406

Idiopathic Post head injury Pituitary surgery Craniopharyngiomas Haemochromatosis Causes of nephrogenic: Genetic Electrolytes Lithium

Question 407

Treatment for vestibular neuronitis?

Answer 407

Buccal/ IM prochlorperazine if severe Short course of prochorperazine, or an antihistamine may alleviate less severe cases Vestibular rehabilitation exercises are preffered for patients who experience chronic symptoms

Question 408

When should urine culture be sent in UTI?

Answer 408

Women aged over 65 years Recurrent UTI (2 episodes in 6 months or 3 in 12 months) Pregnant women Men Visible or non-visible haematuria

Question 409

Palliative care treatment for acute agitation/ confusion/ delirium/ hallucinations?

Answer 409

Oral haloperidol

Question 410

Infectious mononucleosis triad?

Answer 410

Fever, sore throat, lymphadenopathy Other features include: malaise, anorexia, headache palatal petechiae splenomegaly - occurs in around 50% of patients and may rarely predispose to splenic rupture hepatitis, transient rise in ALT lymphocytosis: presence of 50% lymphocytes with at least 10% atypical lymphocytes haemolytic anaemia secondary to cold agglutins (IgM) a maculopapular, pruritic rash develops in around 99% of patients who take ampicillin/amoxicillin whilst they have infectious mononucleosis Avoid playing contact sports for 4 weeks after having gladnular fever to reduce the risk of splenic rupture

Question 411

Investigation for pulsatile tinnitus?

Answer 411

Magnetic resonance angiography (MRA)

Question 412

Antivirals for influenza?

Answer 412

1st- Oseltamivir 2nd- Zanamivir Indications: > 65 years old pregnant women chronic disease of respiratory, cardiac, renal, hepatic or neurological nature diabetes immunosuppression morbid obesity

Question 413

Diagnostic manouvre for BPPV?

Answer 413

Dix-Hallpike- provokees a rotatry nystagmus

Question 414

Erythromycin vs clarythromycin in pregnancy?

Answer 414

Erythromycin is safe Clarythromycin is contraindicated

Question 415

Managment of cellulitis?

Answer 415

Eron Class I- 1st- flucloxacillin Penicillin allergic- clarithromycin, erythromycin in pregnancy Eron class III-IV- Admit Oral/IV co-amoxiclav

Question 416

Proper name for hayfever?

Answer 416

Allergic rhinitis

Question 417

Grittiness in eye/ bits in eye?

Answer 417

Blepharitis Symptom usually bilateral

Question 418

Drugs that make psoriasis worse?

Answer 418

BLANQ- Beta blocker Lithium Alcohol NSAIDs Quinines

Question 419

How does herpes simplex keratitis commonly present?

Answer 419

A dendritic corneal ulcer Red, painful eye Photophobia Epiphora Visual acuity decrease Immediate referral to an opthalmologist Topical aciclovir

Question 420

What is keratitis?

Answer 420

Inflammation of the cornea

Question 421

What are adapalene and tretinoin?

Answer 421

Retinoids Contraindicated in pregnancy

Question 422

Distribution for hand, foot and mouth?

Answer 422

Hands, feet, mouth and buttocks

Question 423

Viruses that causes hand, foot and mouth disease?

Answer 423

Coxsackie A16 and Enterovirus 71 Mild systemic upset- fever, sore throat Oral ulcers Later followed by vesicles on the palms and soles of the feet

Question 424

Treatment for IIH?

Answer 424

Weight loss- potentially add on drugs to help Acetazolamide Topiramate

Question 425

Presenting features of cystic fibrosis?

Answer 425

Neonatal period: meconium ileus, prolonged jaundice Recurrent chest infections Malabsorption: steatorrhoea, failure to thrive Liver disease Other features: Short stature Diabetes mellitus Delayed puberty Rectal prolapse Nasal polyps Male infertility, female subfertility

Question 426

What do CF patient's lungs get colonised with?

Answer 426

Burkholderia cepacia- it is a CI to lung transplantation in CF patients

Question 427

Drug treatment for CF?

Answer 427

Lumacaftor/ Ivacaftor

Question 428

Most common complication post ERCP?

Answer 428

Pancreatitis

Question 429

Adrenaline doses?

Answer 429

Anaphylaxis- 0.5mg 1:1000 1:10000 for cardiac arrests

Question 430

5 P's acronym for delirium in the elderly?

Answer 430

Pee Poo Pus Pills/poison Pain

Question 431

Inguinal vs Fermoral hernia?

Answer 431

In relation to the pubic tubercle: MILF- Medial inguinal, lateral femoral

Question 432

Side effects of heparins?

Answer 432

Bleeding Thrombocytopenia- heparin induced thrombocytopenia is a prothrombotic condition so requires anticoagulation Osteoporosis and increased fracture risk Hyperkalaemia

Question 433

Reversal of heparin?

Answer 433

Protamine sulphate

Question 434

Management of renal stones?

Answer 434

Renal stoenes Watchful waiting if <5mm and asymptomatic 5-10mm shockwave lithotripsy 10-20mm shockwavev lithotripsy or ureteroscopy >20mm percutaneous nephrolithotomy Uretic stones Shockwave lithotripsy +/- alpha blockers 10-20mm ureteroscopy

Question 435

When oral vancomycin and IV metronidazole in C.diff?

Answer 435

Only if life threatening- Hypotension Massive systemic upset Paritial or complete ileus Toxic megacolon Oral vancomycin 1st Oral fidaxomicin 2nd Thirs- Vanc+met

Question 436

Features of clostridium difficle?

Answer 436

Diarrhoea Abdo pain Raised WCC is characteristic If severe- toxic megacolon

Question 437

Small Cell Lung Cancer paraneoplastic syndromes?

Answer 437

S- SiADH C- Cushing's syndrome L- Lambert-Eaton syndrome C- Cerebellar syndrome

Question 438

Lung cancer + Gynae?

Answer 438

Adenocarcinoma

Question 439

What does the pneumococcal vaccine prevent?

Answer 439

Streptococcus pneumoniae- due to the risk of hyposplenism

Question 440

Upper or lower lobe fibrosis?

Answer 440

Upper lobe- Coal miners pneumoconiosis, sarcoidosis, silicosis, TB, Ank Spon Lower lobe- Asbestosis, rheumatoid, idiopathic pulmonary fibrosis

Question 441

CT head showing temporal lobe changes?

Answer 441

Think herpes simplex encephalitis

Question 442

Which circulation should be occluded for thrombectomy to be appropriate?

Answer 442

The proximal anterior circulation Also proximal posterior circulation- but consider instead of offer

Question 443

Extrapyramidal side effects treatments?

Answer 443

Tardive dyskinesia- Tetrabenazine Akathesia- propanalol Acute dystonia- procyclidine

Question 444

Which extrapyramidal side effect comes on after being on antipsychotics for a while?

Answer 444

Tardive dyskinesia- involuntary movements- chewing and pouting of the jaw, sticking tongue out Treat with tetrabenazine

Question 445

Stepping down asthma treatment?

Answer 445

Aim for a 25-50% reduction in the dose of inhaled corticosteroid

Question 446

Which are the rate limiting CCBs for use in angina?

Answer 446

Verapamil, Diltiazem- use these if doing a CCB monotherapy If used in combination with a BB then use a longer-acting dihydropyridine CCB- amlodipine/modified release nifedipine No BB+verpamil for risk of complete heart block

Question 447

What to do about adding third drugs in angina?

Answer 447

Add the nitrate stuff if on monotherapy and can't tolerate a CCB/BB Only add it as the third drug if waiting for an assessment for PCI or CABG

Question 448

Investigation for thyroid lumps?

Answer 448

Initial investigation- TSH + USS If TSH normal/elevated -> consider fine needle aspiration depending on USS If TSH low- nuclear medicine scan. Cold nodule -> Consider fine needle aspiration, hot nodule -> treat hyperthyroidism

Question 449

What should be avoided in Lewy body dementia?

Answer 449

Neuroleoptics- haloperidol- may cause irreversible parkinsonism Antisphychotics to be avoided in patients with dementia HARM drugs should be avoided H- Haloperidol A- Antipsychotics R- pRochlorperazine M- Metoclopramide

Question 450

How to differentiate between Lewy body dementia and Parkinson's

Answer 450

Cognitive impairment before parkinsonism- lewy body dementia- usually both within a year from each other Motor symptoms present at least one year before cognitive symptoms- Parkison's disease There are characteristic hallucinations in Lewy body dementia

Question 451

Kidney disease + eosinophillia?

Answer 451

Acute interstital nephritis Raised urinary WCC and eosinophils alongside impaired renal function

Question 452

What is xanthochromia?

Answer 452

The result of red blood cell breakdown In diagnosis of SAH, if CT head is done more than 6 hours after onset and normal, do an LP at least 12 hours after symptom onset and look for xanthochromia RBCs not indicative as can result from a traumatic tap Normal or raised opening pressure also a sign

Question 453

Most common signs of Sheehan's syndrome?

Answer 453

Lack of postpartum milk production and amenorrhoea following delivery

Question 454

Anorexia features?

Answer 454

Most things low G's and C's raised- growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia

Question 455

In what demographic is Bell's palsy more common?

Answer 455

Pregnant women

Question 456

Which part of the tongue is affected in Bell's palsy?

Answer 456

Anterior 2/3

Question 457

What gene do you test for in haemochromatosis?

Answer 457

HFE mutation Typical iron profile: Transferrin saturation- high Raised ferritin Low TIBC Treatment: Venesection Desferrioxamine

Question 458

Investigation for varicose veins?

Answer 458

Venous duplex ultrasound will demonstrate retrograde venous flow

Question 459

Which childhood disease is associated with febrile convulsions?

Answer 459

Roseola infantum- caused by human herpes virus 6 (HHV6)- affecfts children aged 6 months to 2 years High fever- lasting a few days followed by- Maculopapular rash Nagayama spots Diarrhoea and cough commonly seen

Question 460

Felty's syndrome?

Answer 460

Complication of RA: SANTA Splenomegaly Anaemia Neutropenia Thrombocytopenia Arthritis Rheumatoid arthritis, Splenomegaly and a low WCC

Question 461

What is paralytic ileus?

Answer 461

Inability to pass stool, abdo pain, nausea and vomiting after surgery

Question 462

Differentiator between small bowel obstruction and large bowel obstruction?

Answer 462

In small bowel obstruction, significant nausea and vomiting- then constipation In large bowel obstruction, constipation first then nausea and vomiting occuring later Small bowel obstruction also associated with an increase in amylase In acute pancreatitis should be over 3x the normal limit

Question 463

Most common cause of large bowel obstruction?

Answer 463

Colorectal cancer- often constitutional symptoms are present such as weihgt loss, night sweats, changes in bowel habits, rectal bleeding

Question 464

Most common cause of small bowel obstruction?

Answer 464

Adhesions (following previous surgery), 2nd is hernias

Question 465

Hypercalcaemia management?

Answer 465

Rehydration with normal saline Following rehydration bisphosphonates may be used- take 2-3 days to work Other options- calcitonin- quicker effect than bisphosphonates steroids in sarcoidosis

Question 466

What are the presenting features for cardiac tamponade?

Answer 466

Persistent hypotension, raised JVP and tachycardia despite fluid resuscitation Beck's triad- hypotension, raised JVP and muffled heart sounds

Question 467

First line treatment for trigeminal neuralgia?

Answer 467

Carbamazepine

Question 468

Mechanism of action for fondaparinux?

Answer 468

Activates antithrombin III which inhibits factor Xa

Question 469

When to use CPAP vs BiPAP?

Answer 469

Type 1 respiratory failure- CPAP Type 2 respiratory failure- BiPAP

Question 470

Does Hodgkin's lymphoma cause deragned blood tests?

Answer 470

Lymphocytes can be normal Findings on blood tests: Eosinophilia Normocytic anaemia LDH raised On lymph node biopsy the presence of Reed-Sternberg cells are diagnostic Hodgkin lymphom is the one with the classic alcohol pain

Question 471

How to distinguish biliary colic from cholecystitis or cholangitis?

Answer 471

There is an absence of deranged LFTs or raised inflammatory markers (CRP)

Question 472

Treatment for biliary colic?

Answer 472

Elective laparocopic cholecystectomy

Question 473

Mycoplasma pneumoniae?

Answer 473

A cause of atypical pneumonia that typically affects younger patients- associated with characteristic complications of erythema multiforme and cold autoimmune haemolytic anaemia. Prolonged and gradual onset- flu like symptoms precede a dry cough, bilateral consolidationon x-ray Complications- Cold agglutins (IgM)- may cause haemolytic anameia, Erythema multiforme Immune mediated neurological disease Diagnosis- mycoplasma serology Positive cold agglutination test- peripheral blood smear may show RBC agglutination Management- doxycycline or a macrolide

Question 474

Legionella pneumophilia?

Answer 474

Typically colonises water tanks and hence questions may contain air-conditioning systems or foreign holidays- no person-person transmission Flu like symptoms including fever Dry cough Relative bradycardia Confusion Lymphopaenia Hyponatremia Deranged LFTs Pleural effusion Investigations- Diagnostic test of choice- urinary antigen Chest x-ray findings are non specific may include- mid to lower zone predominance of patchy consolidation Treat with erythromycin/ clarithromycin

Question 475

Standard preparation for pregnancy advice?

Answer 475

Folic acid 400 micrograms starting 3 months before conception up to 12 weeks gestation Those with epilepsy, diabetes, BMI over 30 or a history of NTD require 5mg

Question 476

Pre-eclampsia prevention?

Answer 476

Women with 1 or more high risk/ 2 or more moderate risk should takte 75-150mg of aspirin daily from 12 weeks gestation until the birth

Question 477

Associations with pseudogout?

Answer 477

Increasing age Haemochromatosis Hyparathyroidism Low magnesium, low phosphate Acromegaly, Wilson's disease

Question 478

Tests for SLE?

Answer 478

ANA 99%- very sensitive, low specificity Anti-dsDNA- highly specific, but less sensitive

Question 479

Treatment of choice for SLE?

Answer 479

Hydroxychloroquine

Question 480

Cardiac manifestation of SLE?

Answer 480

Pericarditis

Question 481

Most likely causes for acute otitis media?

Answer 481

Inside of ear lined by similar epithelium to lungs- same bacteria as COPD, bronchectasis and epiglottis Streptococcus pneumoniae, haemophilius influenzae and moraxella cartarrhalis

Question 482

Main complication of a Colles fracture?

Answer 482

Median nerve injury- acute carpal tunnel syndrome presenting with weakness or loss of thumb/index finger flexion

Question 483

Features of a Colles fractures?

Answer 483

Fall on outstretched hand Dorsally displaced distal radius- dinner fork deformity

Question 484

Which condition is Finkelstein's test positive?

Answer 484

De Quervain's tenosynovitis- examinar pulls thumb of the patient in ulnardeviation longitudinal traction causes pain

Question 485

Prophylaxis of variceal haemorrhage?

Answer 485

Propanolol

Question 486

What are patients with perianal fistulae given in Crohn's?

Answer 486

Metronidazole

Question 487

Caseous granuloma vs non-caseating granuloma?

Answer 487

Caseous granuloma- TB Non-caseating granuloma- sarcoidosis

Question 488

Tuberculosis investigations?

Answer 488

CXR- upper lobe cavitation classical finding of reactivated bilateral hilar lymphadenopathy Sputum smear- 3 specimens needed- rapid/inexpensive- all mycobacteria will stain positive Ziehl-Neelsen- sensitiveity decresed from 50-80 to 20-30 in those with HIV Sputum culture- gold standard- more sensitive than a sputum smear can assess drug sensitivities

Question 489

Diagnosis of latent TB?

Answer 489

Positive tuberculin skin test or Interferon-Gamma release assay (IGRA) combined with a normal chest c-ray 2 choices for treating latent TB: 3 months of isoniazid (with pyridoxine) and rifampicin 6 months of isoniazid (with pyridoxine)

Question 490

Tuburculosis management?

Answer 490

Initial phase- first 2 months (RIPE) Rifampicin Isoniazid Pyrazinamide Ethambutol Continuation phase- next 4 months Rifampicin Isoniazid Meningeal tuberculosis- prolonged to at least 12 months with the addition of steroids

Question 491

Adverse effects TB drugs?

Answer 491

Rifampicin- potent liver enzyme inducer hepatitis, orange secretions flu-like symptoms Isoniazid- peripheral neuropathy- prevent with Vit B6 Hepatitis, agranulocytosis Liver enzyme inhibitior Pyrazinamide- Hyperuricaemia causing gout Arthralgia, myalgia Hepatitis Ethambutol Optic neuritis- check visual acuity before starting treatment

Question 492

Name for vitamin B6?

Answer 492

Pyridoxine

Question 493

What is malaria caused by?

Answer 493

Different types of plasmodium protozoa- spread by the female Anopheles mosquito: Plasmodium falciparum- nearly all severe cases of malaria Plasmodium vivax Plasmodium ovale Plasmodium malariae

Question 494

Clinical features of falciparum malaria?

Answer 494

Paroxysms of fever, chills and sweating- symptoms occur every 48 hours corresponding to the erythrocyctic cycle of the plasmodium falciparum Fever- cyclical, sweating, rigors GI- anorexia, nausea, vomiting Resp- cough, mild tachy MSK- body aches and pains Neuro- headache Cardio- tachy Haem- thrombocytopenia Shizonts on a blood film Uncomplicated- artemisinin-based combination therapies Severe- IV artesunate

Question 495

Non-falciparum malaria treatment?

Answer 495

Artemisinin-based combination therapy (ACT) or chloroquine If given chloroquine- should be followed with primaquine

Question 496

S.aureus pneumonia?

Answer 496

Commonly occurs after influenzae type infection

Question 497

SAH investigation?

Answer 497

Non-contrast CT- if done within 6 hours of symptom onset and normal- consider an alternative diagnosis- no LP If done more than 6 hours after symptom onset and is normal- do an LP, do it at least 12 hours following onset of symptoms to allow xanthochromia to develop

Question 498

How to prevent vasospasm in SAH?

Answer 498

Oral nimodipine

Question 499

What is the double duct sign seen in?

Answer 499

Pancreatic cancer

Question 500

Which CA is associated with pancreatic cancer?

Answer 500

CA 19-9

Question 501

ACEi electrolyte disturbance?

Answer 501

Hyperkalaemia

Question 502

ACEi side effects?

Answer 502

Cough Angioedema- may occur up to a year after starting treatment Hyperkalaemia First dose hypertension- more common in patients taking diuretics

Question 503

Occupational asthma causes?

Answer 503

Isocyanates are the most common cause- spray painting Flour Serial measurements of peeak expiratory flow are reccomended at work and away from work

Question 504

Which two drugs are highest risk for medication overuse headache?

Answer 504

Opioids and triptans Simple analgesics and triptans should be withdrawn abruptly Opioid analgesics should be gradually withdrawn

Question 505

Test to distinguish between unilateral adenoma and bilateral hyperplasia (hyperaldrostronism)?

Answer 505

Adrenal venous sampling (AVS) Treatment for bilateral adrenocortical hyperplasia- aldosterone antagonist- spironolactone

Question 506

Gynaecomastia most common drugs?

Answer 506

Spironolactone makes you Sexy Metoclopromide makes you Milky

Question 507

Actinic keratoses treatment?

Answer 507

Avoid sun, sun cream Fluorouracil cream- 2-3 week course

Question 508

Rheumatoid arthritis scoring system for disease activity?

Answer 508

DAS28

Question 509

Methotrexate monitoring?

Answer 509

FBC and LFTs- due to the risk of myelosuppression and liver cirrhosis Other side effects- pneumonitis

Question 510

How to manage flare of rheumatoid arthritis?

Answer 510

Corticosteroids- oral or intramuscular

Question 511

DMARD examples?

Answer 511

Methotrexate Sulfasalazine Leflunomide Hydroxychloroquine

Question 512

Indication for TNF-inhibitors in RA?

Answer 512

Inadequate response to at least two DMARDs including methotrexate Etanercept- can cause demyelination- risks include reactivation of TB Infliximab

Question 513

X-ray A-E approach

Answer 513

Lines/Devices ABCDE- Airway Breathing spaces (lungs) Diaphragm Evil areas (ABCDE again)- (apices bones/tissue cardiac-look behind it Devices/below diaphragm Everything - take the whole image in again)

Question 514

Two main fractures associated with compartment syndrome?

Answer 514

Supracondylar fractures and tibial shaft injuries

Question 515

How often is methotrexate taken?

Answer 515

Weekly

Question 516

What should be co-prescribed with methotrexate?

Answer 516

Folic acid 5mg once weekly taken more than 24 hours after methotrexate dose

Question 517

Methotrexate interactions?

Answer 517

Trimethoprim Co-trimoxazole High dose aspirin

Question 518

Methotrexate toxicity treatment?

Answer 518

Folinic acid

Question 519

NYHA heart failure classification?

Answer 519

Stage I - No limitation on ordinary physical activity Stage II - Normal at rest. Ordinary physical activity causes breathlessness Stage III - Normal at rest. Less-than-ordinary activity causes breathlessness Stage IV - Symptoms at rest

Question 520

Cure for aspirin overdose

Answer 520

IV sodium bicarbonate if big overdose and requiring alkalinisation If recent give activated charcoal

Question 521

Aspirin overdose presentation?

Answer 521

Nausea, vomiting, tinnitus and headache

Question 522

Way to remember reflex routes?

Answer 522

C5+C6 I grab some sticks (biceps reflex), C7+C8 I lay them straight (triceps reflex) L3+L4 I kick the door (knee jerk reflex), S1+S2 I tie my shoe (ankle reflex),

Question 523

C3, 4, 5

Answer 523

Keeps the diaphragm alive

Question 524

S2, 3, 4

Answer 524

Keeps shit off the floor

Question 525

Nerve responsible for the ankle reflex?

Answer 525

S1, 2

Question 526

Rosacea with predominant erythema/flushing treatment?

Answer 526

Topical brimonidine gel

Question 527

Rosacea with mild/moderate pustules and severe oustules>

Answer 527

Mild to moderate- topical ivermectin Moderate to severe- topical ivermectin + oral doxycycline

Question 528

Hepatitis B serology?

Answer 528

HBs antigen (HBsAg)- have you got it now HBs- are you immune HBc- have you had it before (negative if immunised)

Question 529

How to see if someone is a retainer (hypoxic drive in COPD)?

Answer 529

Raised bicarbonate

Question 530

ROME for blood gas interpretation?

Answer 530

Respiratory = Opposite low pH + high PaCO2 i.e. acidosis, or high pH + low PaCO2 i.e. alkalosis Metabolic = Equal low pH + low bicarbonate i.e. acidosis, or high pH + high bicarbonate i.e. akalosis

Question 531

How is legionella pneumophillia best diagnosed?

Answer 531

Urinary antigen test Wee-gionella Treat with erythromycin/ clarithromycin

Question 532

How does sigmoid volvulus present?

Answer 532

Constipation Abdominal bloating Abdominal pain N+V Diangosed on abdo film- sigmoid volvulus- coffee bean sign

Question 533

Sigmoid volvulus management?

Answer 533

Rigid sigmoidoscopy with rectal tube insertion

Question 534

Refferal criteria for N+V in pregnancy?

Answer 534

Continued N+V and unable to keep down liquids or oral antiemetics Continued N+V with ketonuria and/or weight loss (greater than 5% body weight despite treatment with oral antiemetics Confirmed or suspected comorbidity

Question 535

Diagnosis of hyperemesis gravidarum?

Answer 535

5% pre-pregnancy weight loss Dehydration Electrolyte imbalance

Question 536

Why can metocopramide/domperidone not be used for more than 5 days in hyperemesis gravidarum?

Answer 536

Risk of extrapyramidal side effects

Question 537

Antinatal testing- Down's, Edward's, Patau

Answer 537

Stuff that goes up in Down's- HIT- hCG, Inhibin A, Translucency If low hCG then it is Edwards or Patau PIES- Pataus increase, Edward's decrease

Question 538

Which type of pneumonia is associated with Guillain-Barre and other immune-mediated neurological diseases?

Answer 538

Mycoplasma pneumoniae

Question 539

Some important interactions to know?

Answer 539

Adverse effects of CCBs- ankle swelling Quinolones- eg ciprofloxacin- risk of tendon rupture- further increased if also using steroids Quinolones prolong the QT interval/ reduce seizure threshold

Question 540

Influenze before pneumonia- pneumonia causative organism?

Answer 540

S.Aureus

Question 541

Adverse effects of alpha 1 antagonists?

Answer 541

Tamsulosin, alfuzosin Dizziness, postural hypotension, dry mouth, depression

Question 542

Which drugs increase the risk of idiopathic intracranial hypertension?

Answer 542

COCP Steroids Tetracyclines Retinoids (iso/tretinoin)/ Vit A Lithium

Question 543

Centor/FeverPain criteria?

Answer 543

The Centor criteria are: score 1 point for each (maximum score of 4) presence of tonsillar exudate tender anterior cervical lymphadenopathy or lymphadenitis history of fever absence of cough The FeverPAIN criteria are: score 1 point for each (maximum score of 5) Fever over 38°C. Purulence (pharyngeal/tonsillar exudate). Attend rapidly (3 days or less) Severely Inflamed tonsils No cough or coryza

Question 544

Treatment for tonsillitis?

Answer 544

If antibiotics are indicated then either phenoxymethylpenicillin or clarithromycin (if the patient is penicillin-allergic) should be given

Question 545

ACE inhibitors in CKD indication?

Answer 545

They should be used first-line in patients with coexistent hypertension and CKD, if the ACR is > 30 mg/mmol If the ACR > 70 mg/mmol they are indicated regardless of the patient's blood pressure

Question 546

Important marker for CKD?

Answer 546

Albumin:creatinine ratio (ACR)

Question 547

Paget's disease of the bone presentation?

Answer 547

Bone pain + isolated raise in ALP First line treatment- oral bisphosphonates Skull, spine/pelvis and long bones of the lower extremities most commonly affected Bowing of tibia, bossing of skull

Question 548

When to perform an immediate electrical cardioversion in AF?

Answer 548

In unstable, decompensated cases of AF

Question 549

What is given at the same time as amiodarone for cardioversion?

Answer 549

Heparin

Question 550

Salter-Harris classification memory aid?

Answer 550

SALTEr Type 1- S- Straight 2- A- Above 3- L- Lower 4- T- Through (above and below) 5- Er- Everything (Crush)

Question 551

DVLA and diabetes driving?

Answer 551

Notify the DVLA if using insulin- can potentially still drive If on tablets that may induce hypo + one or more episodes of hypo in previous 12 months- notify the DVLA If on insulin, no more than one hypo for cat 1 (cars), no hypos at all for cat 2 (lorries)

Question 552

CA for breast?

Answer 552

CA15-3 CA19-9 for pancratic cancer

Question 553

Testicular cancer tumour markers?

Answer 553

Seminomas- hCG Non-seminomas- AFP and/or beta-hCG

Question 554

Extrapyramidal side effects treatments?

Answer 554

Akathisia- propanolol Acute dystonia- procyclidine Tardive dyskinesia- tetrabenezine NMS- dantrolene, bromocriptine SS- cyprohepatadine

Question 555

Investigations for aortic dissection?

Answer 555

CT angiography of chest, abdomen and pelvis- a false lumen is a key finding CXR- widened mediastinum Transoesophageal echocardiography (TOE)- more suitable for unstable patients too risky for the CT scanner

Question 556

Placental abruption management?

Answer 556

Fetus alive and < 36 weeks fetal distress: immediate caesarean no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation Fetus alive and > 36 weeks fetal distress: immediate caesarean no fetal distress: deliver vaginally Fetus dead induce vaginal delivery

Question 557

SAH associated cardiac problem?

Answer 557

Torsades de pointes- long QT interval- polymorphic ventricular tachycardia

Question 558

When to use contrast in CT?

Answer 558

If needed quick- non contrast- stroke If detailed info -contrast Contrast paticularly for blood suppy- cancers etc If what you are trying to visualise has no blood supply- more likely to be non-contrast

Question 559

How long to continue SSRIs after resolution of symptoms?

Answer 559

Depression- 6 months OCD- 12 months

Question 560

SSRI contraindications?

Answer 560

NSAIDs Warfarin/heparin Aspirin Triptans- increased risk of serotonin syndrome MAOIs- increased risk of serotonin syndrome

Question 561

How much glucose to prescribe with fluids?

Answer 561

50-100g per day

Question 562

Does hypercalcaemia cause polyuria and polydipsia?

Answer 562

Yes- can be due to diabetes insipidus

Question 563

Pain and rash?

Answer 563

?shingles

Question 564

Shingles treatment?

Answer 564

Infectious until vesicles have crusted over- avoid pregnant women and the immunosuppressed Analgesia- paracetamil and NSAIDs Oral corticosteroids may be considered in immunocompetent adults with localized shingles if the pain is severe and not responding to above Antivirals within 72 hours for majority of patients unless <50 with mild rash Antivirals reduce the incidence of post-herpetic neuralgia

Question 565

Reasons to delay a lumbar puncture in suspected meningitis?

Answer 565

Signs of severe sepsis or a rapidly evolving rash Severe respiratory/cardiac compromise Significant bleeding risk Signs of raised intracranial pressure: focal neurological signs papilloedema continuous or uncontrolled seizures GCS ≤ 12

Question 566

Prostate cancer first line investigation?

Answer 566

Multiparametric MRI is the first line now Results are reported on a 5 point Likert scare- if 3 or more then a multiparametric MRI-influenced prostate biopsy is offered 1-2 discuss pros/cons of having the biopsy

Question 567

Kidney problem with raised eosinophils?

Answer 567

Acute interstitial nephritis

Question 568

Most common cause of viral hepatitis in adults?

Answer 568

Enteroviruses

Question 569

Contraindications for sildenafil?

Answer 569

Nicorandil and nitrates- can cause excessive hypotension Hypotension Recent stroke or MI

Question 570

Side effects of sildenafil (PDE5 inhibitors)?

Answer 570

Visual disturbances- blue discolouration Nasal congestion Flushing GI side effects Headache Priapism

Question 571

First line treatment for opioid detoxification?

Answer 571

Methadone or buprenorphine

Question 572

Treatment for proliferative diabetic retinoathy?

Answer 572

Panretinal laser photocoagulation- reduction in visual field and decrease in night vision are side effects Intravitreal VEGF inhbitiors If severe or vitreous haemorrhage- vitreoretinal surgery

Question 573

Medication of choice for suppressing lactation?

Answer 573

Cabergoline

Question 574

Causes of keratitis (inflammation of the cornea)?

Answer 574

Bacterial- typically s.aureus, pseudomonas aeruginosa see in contact lens wearers Fungal Amoebic- Acanthamoebic keratitis- incrased incidence if eye exposure to soil or contaminated water

Question 575

Is aspirin an anticoagulant or an antiplatelet?

Answer 575

Antiplatelet

Question 576

TIA mimics that require exclusion?

Answer 576

Hypoglycaemia Intracranial haemorrhage- all patients on anticoagulants r with similar risk factors should be admitted for urgent imaging to exclude haemorrhage

Question 577

TIA management?

Answer 577

Resolved TIA, awaiting specialist review within 24 hours- aspirin Reviewed by specialist, initial 21 days when at high risk of further events- aspirin + clopidogrel Long-term secondary prevention after 21 days- clopidogrel If patient has AF anicoagulate as soon as intracranial haemorrhage has been excluded Statins

Question 578

Further investigation in TIA?

Answer 578

Atheroslerosis in the carotid may be a source of emboli in some patients- if a patient considered a candidate for carotid intervention they should have carotid imagine performed within 24 hours of assessment- carotid duplex ultrasound or either CT angiography or MR angiography Carotid endarterectomy is recommended if the patient has suffered a stroke or TIA in the carotid territory and is not severely disabled- should only be considered if the stenosis >50%

Question 579

What is most likely to infect a staghorn calculus of the left kidney?

Answer 579

Proteus mirabilis Protein Stag

Question 580

What is it important to give before replacing potassium?

Answer 580

Magnesium if it is low- a lack of magnesium impedes the absorption of potassium

Question 581

Main five symptoms that suggest a more sinister cause for a headache?

Answer 581

Vomiting more than once with no other cause New neurological deficit (motor or sensory) Reduction in conscious score (GCS score) Valsalva (associated with coughing or sneezing) or positional changes Progressive headache with a fever

Question 582

TCA overdose?

Answer 582

Early features: dry mouth, dilated pupils, agitation, sinus tachycardia, blurred vision Features of severe: arrhythmias, seizures, metabolic acidosis, coma ECG changes include- sinus tachycardia, widening of QRS, prolongation of QT interval Management- IV bicarbonate- first line for hypotension or arrythmias

Question 583

Benzodiazepine overdose treatment?

Answer 583

Flumazenil The majority of overdoses are managed with supportive care only due to the risk of seizures with flumazenil. It is generally only used with severe or iatrogenic overdoses

Question 584

Heparin reveral agent?

Answer 584

Protamine sulphate

Question 585

Beta blockers overdose management?

Answer 585

If bradycardic- atropine In resistant cases- glucagon

Question 586

What is ethylene glycol known as?

Answer 586

Antifreeze

Question 587

Antifreeze overdose treatment?

Answer 587

Ethanol Fomepizole is now preferred first line to ethanol

Question 588

Carbon dioxide poisoning management?

Answer 588

100% oxygen Hyperbaric oxygen

Question 589

Lead poisoning treatment?

Answer 589

Dimercaprol, calcium edetate

Question 590

Iron overdose treatment?

Answer 590

Desferrioxamine, a chelating agent

Question 591

Cyanide treatment?

Answer 591

Hydroxocobalamin; also combination of amyl nitrite, sodium nitrite, and sodium thiosulfate

Question 592

Treatment for UTI in pregnant women?

Answer 592

1st- Nitrofurantoin (should be avoided near term) 2nd- Amoxicillin or cefalexin 7 days of treatment Trimethoprim should be avoided in pregnancy as it is teratogenic If asymptomatic treat then a further urine culture should be send as a test of cure

Question 593

Opiates key conversion?

Answer 593

Morphine PO to IV- 2:1 Codeine to morphine PO- 10:1

Question 594

Opiate in palliative care for patients with mild-moderate renal impairment?

Answer 594

Oxycodone

Question 595

Urticaria treatment?

Answer 595

Management non-sedating antihistamines (e.g. loratadine or cetirizine) are first-line this should be continued for up to 6 weeks following an episode of acute urticaria a sedating antihistamine (e.g. chlorphenamine) may be considered for night-time use (in addition to day-time non-sedating antihistamine) for troublesome sleep symptoms prednisolone is used for severe or resistant episodes

Question 596

Which cancer develops in around 10% of PSC patients?

Answer 596

Cholangiocarcinoma

Question 597

Key features of optic neuritis?

Answer 597

CRAP Central scotoma Relative afferent pupillary defect (RAPD) Affected colour vision Painful eye movements

Question 598

Optic neuritis?

Answer 598

Causes- MS, diabetes, syphilis Features: Unilateral decrease in visual acuity over hours or days Poor discrimination of colours, red desaturation Pain worse on eye movement Relative afferent pupillary defect Central scotoma Investigation- MRI brain and orbits with gadolinium contrast Management- high dose steroids

Question 599

Cyclical fever + systemic upset?

Answer 599

Malaria

Question 600

Treatment of malaria?

Answer 600

IV Artesunate

Question 601

COCP UKMEC 3?

Answer 601

Examples of UKMEC 3 conditions include more than 35 years old and smoking less than 15 cigarettes/day BMI > 35 kg/m^2* family history of thromboembolic disease in first degree relatives < 45 years controlled hypertension immobility e.g. wheel chair use carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2) current gallbladder disease

Question 602

COCP UKMEC 4?

Answer 602

Examples of UKMEC 4 conditions include more than 35 years old and smoking more than 15 cigarettes/day migraine with aura history of thromboembolic disease or thrombogenic mutation history of stroke or ischaemic heart disease breast feeding < 6 weeks post-partum uncontrolled hypertension current breast cancer major surgery with prolonged immobilisation positive antiphospholipid antibodies (e.g. in SLE)

Question 603

When should a trial of diet and exercise be done for gestational diabetes?

Answer 603

If the fasting plasma glucose is <7 mmol/l 6-6.9 with evidence of complications- macrosomia or hydramnios

Question 604

Long term oxygen therapy in COPD?

Answer 604

If 2 measurements of pO2 <7.3

Question 605

Pleural effusion transudate vs ecudate memory aid?

Answer 605

Way to remember causes of exudate and transudates: Exudate >30g/L - all the I's Infiltration (malignancy) Ischaemia Infection Exudate <30g/L - all the F's heart Failure liver Failure nePHrotic syndrome

Question 606

Indications for chest drain in pleural infection?

Answer 606

If the fluid is purulent or turbid/cloudy a chest tube should be placed to allow drainage If the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection a chest tube should be placed

Question 607

Which two blood results are lowered in legionella pneumonia?

Answer 607

Lymphopenia Hyponatremia

Question 608

Diagnostic test for legionella?

Answer 608

Urinary antigen Treat with erythromycin/clarithromycin

Question 609

Trousseau's sign?

Answer 609

Carpal spasm if the brachial artery occluded by inflating the blood pressure cuff and maintaining pressure above systolic Seen in patients wit hypocalcaemia

Question 610

Endocarditis causes?

Answer 610

S.aureus- now most common cause of infective endocarditis, paticularly common in acute presentation and IVDUs Streptococcus viridans Staph epidermidis- indwelling ines and patients following prosthetic valve surgery

Question 611

Markers present in primary biliary cholangitis?

Answer 611

IgM Anti-mitochondrial antibodies Middle aged females First line treatment is ursodeoxycholic acid Pruritus- cholestyramine

Question 612

NICE guidelines for induction of labour- Bishop score?

Answer 612

If the Bishop score is ≤ 6 vaginal prostaglandins or oral misoprostol mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean If the Bishop score is > 6 amniotomy and an intravenous oxytocin infusion

Question 613

What should all patients with TB be offered?

Answer 613

HIV test

Question 614

Stopping of voluntary movement or staying still in an unusual position?

Answer 614

Catatonia

Question 615

Schneider's first rank symptoms?

Answer 615

Passivity phenomena Thought disorders Delusional perceptions Auditory hallucination

Question 616

Criteria for diagnosing AKI?

Answer 616

Rise in creatinine of 26µmol/L or more in 48 hours OR >= 50% rise in creatinine over 7 days OR Fall in urine output to < 0.5ml/kg/hour for more than 6 hours in adults (8 hours in children) OR >= 25% fall in eGFR in children / young adults in 7 days.

Question 617

Staging criteria for AKI?

Answer 617

Stage 1- Increase in creatinine to 1.5-1.9 times baseline, or Increase in creatinine by ≥26.5 µmol/L, or Reduction in urine output to <0.5 mL/kg/hour for ≥ 6 hours Stage 2- Increase in creatinine to 2.0 to 2.9 times baseline, or Reduction in urine output to <0.5 mL/kg/hour for ≥12 hours Stage 3- Increase in creatinine to ≥ 3.0 times baseline, or Increase in creatinine to ≥353.6 µmol/L or Reduction in urine output to <0.3 mL/kg/hour for ≥24 hours, or The initiation of kidney replacement therapy, or, In patients <18 years, decrease in eGFR to <35 mL/min/1.73 m2

Question 618

Mangement of periarrest tahcycardia (VT)?

Answer 618

Classify as stable or unstable If unstable- then synchronised DC shocks- up to 3 given Then broad complex or narrow complex tachycardia- Broad complex- Regular- assume VT- loading dose of amiodarone followed by 24 hour infusion Irregular- seek expert help. Could be AF with BBB or torsades de pointes Narrow complex- Regular- vagal manoeuvres followed by IV adenosine- if unsuccessful consider disgnosis of artial flutter and control rate Irregular- probable atrial fibrillation- if onset <48hours consider electrical or chemical cardioversion- beta-blockers are usually first-line unless there is a contraindication

Question 619

Colorectal cancer referral guidelines?

Answer 619

Updated so faecal immunichemical test (FIT) testing is used in preferance to doing a colonoscopy first line FIT positive- refer on the suspected cancer pathway FIT negative- safety netting refer if ongoing significant concern

Question 620

Criteria for doing a FIT test?

Answer 620

An abdominal mass Change in bowl habit Iron-deficiency anaemia 40 or over with unexplained weight loss and abdo pain Aged under 50 with rectal bleeding and either of the following unexplained symptoms- abdo pain, weight loss Aged 50 and over with any of the following uexplained symptoms- rectal bleeding, abdo pain, weight loss or Aged 60 and over with anaemia even in the absence of iron deficiency Rectal mass, anal mass or anal ulceration can be referred without a FIT test

Question 621

NHS bowel cancer screening test?

Answer 621

National screening programme offering screening every 2 years to all men and women aged 60 to 74 years in England, 50 to 74 in Scotland. Patients over 74 may still request screening Can detect and quantify blood in stool, patients with abnormal results offered a colonoscopy The FIT test is also recommended for patients with new symptoms who do not meet the 2-week criteria listed above, for example: patients >= 50 years with unexplained abdominal pain OR weight loss patients < 60 years with changes in their bowel habit OR iron deficiency anaemia patients >= 60 years who have anaemia even in the absence of iron deficiency

Question 622

First line management for a chronic anal fissure?

Answer 622

Topical glyceryl trinitrate (GTN) If GTN not effective after 6 weeks then secondary care referral should be considered for sugery (sphincterotomy)

Question 623

What is the screening for AAA?

Answer 623

A single abdominal ultrasound for men aged 65 years old

Question 624

GCS?

Answer 624

Motor response 6. Obeys commands 5. Localises to pain 4. Withdraws from pain 3. Abnormal flexion to pain (decorticate posture) 2. Extending to pain 1. None Verbal response 5. Orientated 4. Confused 3. Words 2. Sounds 1. None Eye opening 4. Spontaneous 3. To speech 2. To pain 1. None

Question 625

Fungal nail infections?

Answer 625

Causative organisms- most likely dermatophytes- Trichophyton rubrum Ix- nail clippings/scraping of the affected nail- done in all patients if antifungal treatment is being considered Management- no treatment if asymptomatic and patient not bothered by the appearance If dermatophyte or candida confirmed- Limited involvement- topical amorolfine nail lacquer- 6 months for fingernails, 9-12 for toenails If more extensive- oral terbinafine for dermatophtes is first line- 6 weeks- 3 months fingernail, 3-6 months for toes If candida and extensive- oral itraconazole is reccomended first line

Question 626

Erythema nodosum causes?

Answer 626

NO : idiopathic D : drugs → penicillin sulphonamides O : oral contraceptives / pregnancy S : sarcoidosis / TB U : ulcerative colitis / Crohn's disease / Behçet's disease M : micro → strep, mycoplasma, EBV and more

Question 627

Thiazides electrolyte disturbances?

Answer 627

HyperGLUC Glycaemia Lactate Uraemia Calcemia And hyponatremia, hypokalaemia, hypomagnesium

Question 628

Campylobacter jejuni?

Answer 628

Fever, abdo tenderness and bloody diarrhoea- commonest facterial cause of infectious intestinal disease in the UK tranmitted by the faecal oral route Doesn't require treatment unless severe- first line clarithromycin GB can follow

Question 629

What bacteria causes travellers diarrhoea?

Answer 629

Enterotocigenic e.coli

Question 630

Aspirin (salicylate overdose)?

Answer 630

Causes resp acidosis eary as hyperventilation- stimuates respiration, tinnitus, lethargy, sweating N+V

Question 631

Asthma?

Answer 631

Oh S***, I Hate My Asthma 1) Oxygen 2) Salbutamol nebulisers 3) Ipratropium bromide nebulisers 4) Hydrocortisone IV or Oral Prednisolone 5) Magnesium Sulfate IV 6) Aminophylline / IV salbutamol

Question 632

Treatment of eclampsia?

Answer 632

Magnesium sulphate Given once decision to deliver has been made Urine output, reflexes, resp rate, and O2 sats should be monitored Resp depression can occur- calcium gluconate is the first line treatment for magnesium sulphate induced resp depression Treatment should continue for 24 hours after last seizure or delivery

Question 633

In hypercalcaemia due to malignancy, what is low?

Answer 633

PTH

Question 634

Water deprivation test in nephrogenic DI?

Answer 634

Water deprivation test: nephrogenic DI urine osmolality after fluid deprivation: low urine osmolality after desmopressin: low

Question 635

Burkitt's lymphoma appearance on biopsy?

Answer 635

Starry sky appearance

Question 636

Hodgkin's vs non-hodgkin's differentiators?

Answer 636

Alcohol pain in Hodgkin's B symptoms earlier in Hodgkins than non-Hodgkins Extra nodal disease more common in non-Hodgkins lymphoma than Hodgkin's

Question 637

Treatment for non-Hodgkin's lymphoma?

Answer 637

Rituximab is used in combination with conventional chemotherapy regimes (CHOP) Patients should be screened for hep B before treatment with rituximab as it can cause reactivation of hep B in patients with prior exposure

Question 638

Syphilis tests?

Answer 638

A way to remember tests if it helps anyone: If the syphilis test has an 'A' in it, it will Always be raised (in infected and those with resolved infection) If the syphilis test has an 'R' in it, it will be raised in Recent (i.e. current infection)

Question 639

Ramadan and DM type 2?

Answer 639

Long acting carb for meal before sunrise Blood glucose monitor to check Metformin- one third before sunrise, 2/3 after sunset

Question 640

CN 3 palsy?

Answer 640

Ptosis + dilated pupil

Question 641

Horner's presentation?

Answer 641

Ptosis + constricted pupil

Question 642

Most useful prognostic marker in paracetamol overdose?

Answer 642

An elevated prothrombin time- liver creates clotting factors so elevated prothrombin time indicates it is failing

Question 643

Paracetamol overdose treatment?

Answer 643

If presenting within 1 hour may benefit from activated charcoal- reduces absorption of the drug Acetylcysteine- staggered overdose, presenting 8-24 hours after ingestion, >24 ours if they are clearly jaundiced If paracetamol concentration or ALT remains elevated acetylcysteine should be continued Acetylcysteine now given over 1 hour rather than 15 mins

Question 644

King's college hospital criteria for liver transplantation?

Answer 644

Arterial pH < 7.3, 24 hours after ingestion or all of the following: prothrombin time > 100 seconds creatinine > 300 µmol/l grade III or IV encephalopathy

Question 645

If loads of random S.aureus in the blood?

Answer 645

Echocardiogram to look for endocarditis

Question 646

Most common cause of discitis?

Answer 646

S.aureus Imaging: MRI

Question 647

Key features seen in Graves but not other causes of thyrotoxicosis?

Answer 647

EYE SIGNS- Exopthalmos Opthalmoplegia Pretibial myxoedema Thyroid acropachy: Digital clubbing Soft tissue swelling of hands and feet Periosteal new bone formation

Question 648

RA poor prognostic factors?

Answer 648

Rheumatoid factor positive Anti-CCP antibodies Functional status poor at presentation X-ray- early erosions Extra articular features- nodules HLA DR4 Insidious onset

Question 649

Kidney transplant in a dermatology question?

Answer 649

Squamous cell carcinoma Growing, bleeding, firm, indurated plaque or nodule

Question 650

Bone protection for people taking steroids?

Answer 650

Bisphosphonate + ensure calcium and vitamin D replete

Question 651

Gatroparesis?

Answer 651

Can be a complication of diabetes- due to neuropathy Leads to poor gastric emptying and poor glucose control Metoclopramide is a pro kinetic drug so best to give- it improves gastric emptying- also domperidone and erythromycin- both prokinetic agents

Question 652

Drusen on fundoscopy?

Answer 652

Dry age related macular degeneration

Question 653

Bitemporal hemianopia?

Answer 653

Bitemporal hemianopia lesion of optic chiasm upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma

Question 654

Teratomas vs seminomas age group?

Answer 654

Teratomas in the troops (under 30), seminomas in the sergeants (over 30)

Question 655

Common features of frontotemporal dementia?

Answer 655

Onset before the age of 65 Insidious onset Relatively preserved memory and visuospatial skills Personality change and social conduct problems

Question 656

Is CKD a risk factor for osteoporosis?

Answer 656

Yes

Question 657

Antibiotic causing ototoxicity?

Answer 657

Gentimicin

Question 658

Important equipment to know if you are in the airway- intubation?

Answer 658

Capnography- CO2 monitor

Question 659

Adverse effects of lithium?

Answer 659

Adverse effects nausea/vomiting, diarrhoea fine tremor nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus thyroid enlargement, may lead to hypothyroidism ECG: T wave flattening/inversion weight gain idiopathic intracranial hypertension leucocytosis hyperparathyroidism and resultant hypercalcaemia

Question 660

Pulmonary embolism most common ECG finding?

Answer 660

Sinus tachycardia Less commonly is S1Q3T3

Question 661

Score used to identify severe cases of pancreatitis?

Answer 661

The Glasgow score Some features indicating severe pancreatitis: age > 55 years hypocalcaemia hyperglycaemia hypoxia neutrophilia elevated LDH and AST

Question 662

Carpal tunnel syndrome in pregnancy?

Answer 662

Wrist splint

Question 663

Insecticide poisoning?

Answer 663

DUMBELS D: defaecation & diaphoresis U: urinary incontinence M: miosis (pupil constriction) B: bradycardia E: emesis L: lacrimation S: salivation

Question 664

When should antivirals be given in chicken pox exposure in pregnancy?

Answer 664

Check maternal varicella antibodies first Give antivirals 7-14 days after exposure, not immediatley

Question 665

Treatment for myasthenia gravis?

Answer 665

Pyridostigmine

Question 666

Which condition is a thymoma associated with?

Answer 666

Myasthenia gravis

Question 667

Management of hiccups in palliative care?

Answer 667

Chlorpromazie Haloperidol, gabapenin also used

Question 668

Upper limit for feeling first foetal movement?

Answer 668

24 weeks gestation Foetal movements usually start at 18-20 weeks gestation

Question 669

Osteomyelitis organism in sickle cell?

Answer 669

Salmonella Most common cause normally s.aureus MRI normally imaging of choice in osteomyelitis

Question 670

CT head/MRI showing temporal changes?

Answer 670

Think herpes simplex encephalitis

Question 671

COCP, POP and emergency contraceptives are reduced in efficacy by which type of drugs?

Answer 671

Drugs that induce enzyme activity- Carbamazepine, phenytoin, rifampicin etc

Question 672

Most common causative organism for cellulitis?

Answer 672

Streptococcus pyogenes Less common- staph aureus

Question 673

Criteria for managing cellulitis?

Answer 673

Eron classification

Question 674

Management of cellulitis?

Answer 674

1st- Oral flucloxaclillin 2nd- Oral clarithromycin/ erythromycin in pregnancy- in patients allergic to penicillin

Question 675

Management if mineral bone disease in CKD?

Answer 675

Reduce dietary intake of phosphate is the first line Give vit D Calcoum based binders- problems include hypercalcemia and vascular calcification Sevelamer- non-calcium based binder- binds to dietary phosphate to prevent its absorption

Question 676

Definitive management of variceal haemorrhage?

Answer 676

Endoscopic band ligation

Question 677

Aortic vs mitral valves target INR?

Answer 677

Aortic- 3.0- lower as better blood flow across the valve Mitral- 3.5- higher

Question 678

Classic triad of nephritic syndrome?

Answer 678

Haematuria, oliguria and hypertension

Question 679

Congenital inguinal hernia?

Answer 679

Repair soon after diagnosis as at risk of incarceration

Question 680

Infantile umbilical hernia?

Answer 680

Vast majority resolve without intervention before the age of 4-5 years old

Question 681

Vitamin D analogue example?

Answer 681

Calcipotriol, calcitriol Can be used long term unlike steroids (for psoriasis etc)

Question 682

Goodpastures?

Answer 682

Rapidly progressive glomerulonephritis- proteinuria + haematuria With pulmonary haemorrhages Anti-glomerular basement membrane antibodies against type IV collagen

Question 683

AIN vs ATN?

Answer 683

Both causes of intrinsic AKI- not nephritic or nephrotic as that is for the glomerulus- these don't affect that ATN- most common AKI cause- ischaemia or nephrotoins- aminoglycosides or rhabdomyolysis- raised urea, creatinine, potassium, muddy brown casts AIN- fever, rash, arthralgia- drugs- NSAIDs, penicilllins, SLE etc- eosinophilia, sterile pyuria, white cell casts

Question 684

What should be corrected before giving bisphosphonates?

Answer 684

Vitamin D and calcium if they are low

Question 685

IV acetylcysteine complication?

Answer 685

Anaphylactoid reaction (bronchospasm, urticaria, hypotension). Stop infusion- treat reaction- start infusion again at slower rate

Question 686

When would you not give dexamethasone in meningitis?

Answer 686

Use it for bacterial meningitis Do not use it in- viral, systemic infection (sepsis) and meningiococcal disease (non-blanching rash)

Question 687

What is a hernia that cannot be reduced called?

Answer 687

An incarcerated hernia- they are at risk of strangulation

Question 688

Do you shock in regular bradycardia with signs of shock?

Answer 688

No, atropine up to 3mg then transcutaneous pacing if required Bradycardia is ok unless symptomatic

Question 689

Falciparum malaria?

Answer 689

Triad of fever, chills and sweating Thrombocytopenia Treat with artesunate

Question 690

Definitive diagnostic test for sickle cell?

Answer 690

Haemoglobin electrophoresis

Question 691

What is the use of the mantoux test?

Answer 691

Screen for latent TB Gamma interferon blood test may also be used

Question 692

Gold standard for diagnosing active TB?

Answer 692

Sputum culture

Question 693

How is a sputum smear stained when looking for TB?

Answer 693

Ziehl-Neelsen stain for acid fast bacilli- all mycobacteria stain positive Sensitivity decreased in those with HIV

Question 694

Osgood-Schlatter's disease?

Answer 694

Osgood-SchlaTTer Pain over the tibial tubercle

Question 695

Life threatening C.Diff?

Answer 695

ORAL vancomycin + IV metronidazole Trying to kill bacteria in the gut so has to be oral stuff- metronidazole is IV

Question 696

First line investigation for prostate cancer?

Answer 696

Multiparametric MRI- it has replacecd the TRUS biopsy Results reported using the 5-point Likert scale- If the Likert scale is >=3 a multiparametric MRI-influenced prostate biopsy is offered If the Likert scale is 1-2 then NICE recommend discussing with the patient the pros and cons of having a biopsy

Question 697

Test to distinguish between vestibular neuronitis and a posterior circulation stroke?

Answer 697

The HiNTs exam

Question 698

TNF-inhibitors for RA?

Answer 698

If inadequate response to two DMARDs- etanercept, infliximab, adalimumab Risk of reactivation of TB- do chest x-ray before you give them

Question 699

Blood disturbances for acute pancreatitis?

Answer 699

Hypocalcaemia Raised WBC and CRP

Question 700

What to do for DVT if d-dimer positive but leg ultrasound negative?

Answer 700

Stop anticoagulation and arrange an ultrasound scan in 1 week

Question 701

MORTAR for carpal tunnel?

Answer 701

MORTAR Myxoedema (hypothyroid) Oedematous states (eg. pregnancy, HF)/Obesity Rheumatoid arthritis Trauma Acromegaly Repetitive stress jobs & idiopathic as well

Question 702

What is the surgical intervention for carpal tunnel syndrome called?

Answer 702

Surgical decompression (flexor retinaculum division)

Question 703

Test that must be offered for patients with TB?

Answer 703

HIV test

Question 704

Acetylcholinesterase inhibitors?

Answer 704

River in Donegal Rivastigmine, Donepezil, Galantamine

Question 705

Alzheimer's drugs?

Answer 705

1st- acrtylchonesterase inhibitors (rivastigmine, donepezil, galantamine) 2nd- Memantine