September

Question 1

Which of these is a contraindication for using epidural anaesthesia during labour?

Answer 1

Coagulopathy is the only answer which contraindicates using epidural anaesthesia in labour - all other answers make using epidural anaesthesia more likely.

Question 2

A 74-year-old woman is reviewed. She recently had ambulatory blood pressure monitoring that showed an average reading of 142/90 mmHg. There is no significant past medical history of note other than hypothyroidism. Her 10-year cardiovascular risk score is 23%. What is the most appropriate management?
Newly diagnosed patient with hypertension (> 55 years) - add a calcium channel blocker
Importance: 57
This patient has stage 1 hypertension and is below 80 years of age. However, as she has a raised cardiovascular risk score treatment should be offered. In this age group, —- are first-line.

Answer 2

Newly diagnosed patient with hypertension (> 55 years) - add a calcium channel blocker

This patient has stage 1 hypertension and is below 80 years of age. However, as she has a raised cardiovascular risk score treatment should be offered. In this age group, calcium channel blockers are first-line.

Question 3

– for patients who are going to take long-term steroids should start immediately
Start oral — + ensure calcium and vitamin – replete

Answer 3

Bone protection
alendronate
D

Question 4

The low calcium and phosphate combined with the raised alkaline phosphatase point towards—-.

Answer 4

osteomalacia

Question 5

Progressive multifocal leukoencephalopathy is caused by the —-virus or – virus

Answer 5

JC virus or BK virus

Question 6

When prescribing fluids, the potassium requirement per day is —-
NICE also recommends that patients have —ml/kg/day of water.
As this patient weighs 62kg that means the patient should receive approximately –L of fluid in a 24 hour period.
If the patient is receiving 1-litre bags of fluid then one should contain – mmol and the other – mmol potassium to ensure an adequate potassium intake

Answer 6

1 mmol/kg/day

25-30

1.5 - 2

40—20

Question 7

A known sequela of pancreatitis is hypo—.
Lipase from pancreatic cells breaks down mesenteric and peripancreatic fat.
This results in the liberation of free fatty acids that bind —, decreasing the circulating concentration.

Answer 7

calcemia

calcium

Question 8

It is important to remember that A—) antibody is positive in approximately 40% of patients who test negative for Rheumatoid Factor.
Therefore— is an important diagnostic test for RA.

Answer 8

Anti-CCP (cyclic citrullinated peptide) antibody is positive in approximately 40% of patients who test negative for Rheumatoid Factor.
Therefore Anti-CCP is an important diagnostic test for RA.

Question 9

The bacteria responsible for Acne is — which is an anaerobic rod. This is important because it means traditional beta-lactam antibiotics are ineffective in treating infections caused by this and so –+—+— must be used in managing acne.

Answer 9

Propionibacterium acnes

tetracyclines, macrolides or trimethoprim

Question 10

— is a condition characterised by seizures in a pregnant woman with –.
Early signs of — include hypertension and proteinuria. Other symptoms of — include abdominal pain, nausea, vomiting and visual disturbance.

Prolonged hyperemesis gravidarum can result in —- and — abnormalities, which could result in seizures.

Answer 10

Eclampsia
pre-eclampsia

dehydration and metabolic abnormalities

Question 11

Acute —- is a complication of myocardial infarction

Intravenous — such as— is the best pharmacological treatment for this patient as this method of administration has better bioavailability since the patient is severely dyspnoeic with very poor vital signs.
IV —- are also recommended by NICE guidelines for the treatment of acute heart failure.
Nitrates are not routinely offered.
Oral antibiotics are not required as there are no signs of infection and the clinical presentation is in keeping with —-.

Answer 11

pulmonary oedema

The most likely diagnosis in this patient is acute pulmonary oedema or heart failure due to past history of myocardial infarction. Intravenous diuretics such as furosemide is the best pharmacological treatment for this patient as this method of administration has better bioavailability since the patient is severely dyspnoeic with very poor vital signs. IV diuretics are also recommended by NICE guidelines for the treatment of acute heart failure. Nitrates are not routinely offered. Oral antibiotics are not required as there are no signs of infection and the clinical presentation is in keeping with acute pulmonary oedema.

Question 12

The Royal College of Obstetrics and Gynaecology suggest that — pressure should be used to improve the effectiveness of the — manoeuvre’ in their shoulder dystocia guidelines.

Answer 12

suprapubic

McRoberts

Question 13

Women who have migraine with — should stop the pill immediately - this is because the — component of the COCP can increase the risk of the women having an —.
A — contraceptive pill is therefore the only alternative contraceptive medication that can be prescribed

Answer 13

aura
oestrogen
ischaemic stroke
progesterone only

Question 14

—- is a common cause of haemolysis in patients with glucose-6-phoshate dehydrogenase deficiency (antibiotic)

Answer 14

Ciprofloxacin

Question 15

Patients with —- often get relief from shaking their hands and this may be an important clue in exam questions

Answer 15

carpal tunnel syndrome

Question 16

An ambulatory blood pressure reading of greater than or equal to — mmHg confirms a diagnosis of stage 1 hypertension.
However, the National Institute for Clinical Excellence (NICE) suggest that antihypertensive treatment should be offered only if the person is:
aged — with stage 1 hypertension with one or more of, —x5

If stage 2 hypertension is diagnosed then —
Lifestyle advice should be reinforced in all patients

Answer 16

135/85

less than 80 years

1. target organ damage,
2. established cardiovascular disease,
3. renal disease,
4. diabetes, and/or a
5. 10 year cardiovascular risk of 10% or more.

antihypertensive medication should be started regardless of age.

Question 17

The primary mode of action of the contraceptive implant is to prevent ovulation.

Implants may also prevent sperm penetration by altering the — and possibly prevent implantation by thinning the —, but this is not their primary mode of action.

Answer 17

to prevent ovulation

cervical mucus, endometrium

Question 18

– is a risk factor for shoulder dystocia

Answer 18

Diabetes mellitus

Question 19

— is first line in children suspected of Mycoplasma pneumonia.
Otherwise, amoxicillin is first line, with —- indicated if the child presents with pneumonia associated with —.

—- is used for suspected meningitis, and — is an antiviral.

Answer 19

Erythromycin

co-amoxiclav -influenza

Benzylpenicillin

aciclovir

Question 20

Dysphagia equally to both solids and liquids from the outset is suggestive of —-.
A — which shows a grossly expanded oesophagus that tapers at the lower oesophageal sphincter (—’ appearance) confirms the diagnosis.

Answer 20

achalasia
barium swallow

‘bird’s beak

Question 21

Drug treatment of essential hypertension can be summarised as follows, but for a more detailed explanation see the link below;
Step 1; Age <55 -
. Age >55 or of — origin - –
Step 2; – + —
Step 3; – + – + —
Step 4; consider further —– and seeking expert advice

Answer 21

Step 1; Age <55 - ACE inhibitor. Age >55 or of black African or Caribbean origin - calcium channel blocker
Step 2; ACE inhibitor + calcium channel blocker
Step 3; ACE inhibitor + calcium channel blocker + thiazide-like diuretic
Step 4; consider further diuretic or beta-blockade or alpha blocker and seeking expert advice

Question 22

— in Grave’s disease indicates severe eye pathology

The severity of Grave’s eye disease can be graded using the mnemonic NOSPECS

Answer 22

Corneal involvement

No signs / symptoms
Only signs (e.g: upper lid retraction)
Signs & symptoms (including soft-tissue involvement)
Proptosis- is protrusion of the eyeball. Exophthalmos means the same thing, and this term is usually used when describing proptosis due to Graves disease.
Extra-ocular muscle involvement
Corneal involvement
Sight loss due to optic nerve involvement

Question 23

For — in acute ischaemic stroke, an extended target time of 6-24 hours may be considered if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing –

Answer 23

thrombectomy

limited infarct core volume

Question 24

Women with hypothyroidism may need to —- their thyroid hormone replacement dose by up to 50% as early as —-weeks of pregnancy

Answer 24

Women with hypothyroidism may need to increase their thyroid hormone replacement dose by up to 50% as early as 4-6 weeks of pregnancy

Question 25

– levels are now the first-line test for acromegaly

Answer 25

Serum IGF-1

Question 26

Key information for the different types of thyroid cancers:

1) Papillary - 65%, generally --- ----. 
Metastasis to --- lymph nodes. 
--- can be used as a tumour marker. 
Characteristic --- eyes on light microscopy. 
--- prognosis

2) Follicular - 20%, generally —-.
Metastasis to — and –.
—- can be used as a tumour marker.
—- prognosis

3) Medullary - 5%, sporadic or part of — syndrome. It originates from the — cells which produce — - can be used as a tumour marker.
4) Anaplastic - very rare. —- patient. — prognosis
5) Lymphoma - 5%, might present with dysphagia or stridor

MEN SYNDROME

MEN ? - Mucosal neuroma, marfanoid appearance, medullary thyroid carcinoma, phaeochromocytoma

MEN ? - Parathyroid hyperplasia, medullary thyroid carcinoma, phaeochromocytoma

MEN ? - Pituitary adenoma, parathyroid hyperplasia, pancreatic tumours

Answer 26

Key information for the different types of thyroid cancers:

1) Papillary - 65%, generally young females. Metastasis to cervical lymph nodes. Thyroglobulin can be used as a tumour marker. Characteristic Orphan Annie eyes on light microscopy. Good prognosis
2) Follicular - 20%, generally women >50 years old. Metastasis to lung and bones. Thyroglobulin can be used as a tumour marker. Moderate prognosis
3) Medullary - 5%, sporadic or part of MEN2 syndrome. It originates from the parafollicular cells which produce calcitonin - can be used as a tumour marker.
4) Anaplastic - very rare. Elderly patient. Very poor prognosis
5) Lymphoma - 5%, might present with dysphagia or stridor

MEN SYNDROME

MEN 1 - Pituitary adenoma, parathyroid hyperplasia, pancreatic tumours

MEN 2A - Parathyroid hyperplasia, medullary thyroid carcinoma, phaeochromocytoma

MEN 2B - Mucosal neuroma, marfanoid appearance, medullary thyroid carcinoma, phaeochromocytoma

Question 27

This patient has subclinical hypothyroidism (very mildly raised — but normal — and –)

management of patients with subclinical hypothyroidism and recommend a ‘—’ approach in patients over the age of 80 years old.

If the patient here were below 65 years of age and was symptomatic then she may have been offered a trial of –. Moreover, it may well be worth rechecking her TFTs but NICE recommend doing so in – months time.

A very severe rise in — (>10 mU/L) in a younger patient (<70 years old) would prompt treatment with — replacement.

Answer 27

This patient has subclinical hypothyroidism (very mildly raised TSH but normal T3 and T4)

NICE CKS have published guidance on the management of patients with subclinical hypothyroidism and recommend a ‘watch and wait’ approach in patients over the age of 80 years old.

If the patient here were below 65 years of age and was symptomatic then she may have been offered a trial of levothyroxine. Moreover, it may well be worth rechecking her TFTs but NICE recommend doing so in 6 months time.

A very severe rise in TSH (>10 mU/L) in a younger patient (<70 years old) would prompt treatment with levothyroxine replacement

Question 28

– are associated with an increased risk of urinary tract infections

Answer 28

Sodium-glucose co-transporter 2 inhibitors

Question 29

Human papilloma viruses –and– are non-carcinogenic and associated with genital warts

Answer 29

6 and 11

Question 30

Woman with – metastases- most likely to originate in the breast

Answer 30

bone

Question 31

— is the most specific tumour markers from the options in cases of pancreatic cancer.

Answer 31

CA19-9

Question 32

Neoplastic spinal cord compression
Investigation
Management

Answer 32

investigation
urgent MRI: the 2019 NICE guidelines recommend a whole MRI spine within 24 hours of presentation

Management
high-dose oral dexamethasone
urgent oncological assessment for consideration of radiotherapy or surgery

Question 33

Lung Cancer type:?
most common type in non-smokers
peripheral lesion

Answer 33

adenocarcinoma

Question 34

— is the most common cause of SVCO

Answer 34

Small cell lung cancer

Question 35

Nasogastric tubes are safe to use if pH

Answer 35

5.5

Question 36

Ascites: a high SAAG gradient (> 11g/L) indicates portal —
SAAG = serum-ascites albumin gradient

SAAG = (– albumin concentration) - (– albumin concentration)

A high SAAG (>11 g/L) is an indication of —-.
This is because increased hydrostatic pressure forces fluid out of the vascular spaces, concentrating – albumin.

Answer 36

hypertension

SAAG = serum-ascites albumin gradient

SAAG = (serum albumin concentration) - (ascitic albumin concentration)

A high SAAG (>11 g/L) is an indication of portal hypertension. This is because increased hydrostatic pressure forces fluid out of the vascular spaces, concentrating serum albumin.

Question 37

Common peroneal nerve lesion can cause weakness of foot — and foot —

Answer 37

dorsiflexion

eversion

Question 38

PHaeochromocytoma - give P–before beta-blockers

Answer 38

Phenoxybenzamine is a preferred α-blocker; however, prazosin, terazosin, doxazosin can also be used.