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surgery/rheum Flashcards

1
Q

investigations (blood tests) for erectile dysfunction

A

lipids
cholesterol
free testosterone (9am-11am)
- if testosterone high, then do FSH, LH and prolactin

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2
Q

FIT screening programme is offered to who

A

Ages 60-74 years
Every 2 years
(in England)

(Age 50-74 in Scotland)

Over 74 can request screening

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3
Q

colchicine main side effect

A

diarrhoea

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4
Q

if NSAIDs and colchicine are contraindicated in gout, what can be given

A

oral steroids
e.g. prednisolone 15mg/day

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5
Q

When should you offer urate-lowering therapy (e.g. allopurinol) to patients with gout?

A

After their first attack of gout

ULT especially recommended if:
>2 attacks in 1 year
Tophi
Renal disease
Uric acid renal stones
Prophylaxis if on diuretics or cytotoxics

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6
Q

Breast screening programme (mammogram) is offered to women from which age and is how often

A

Age 50-70 years
Every 3 years

after 70 can self-refer

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7
Q

What is first line for back pain

A

NSAIDs
+ PPIs

if there is sciatica then follow neuropathic pain guidelines

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8
Q

investigation of choice for non-specific back pain

A

MRI

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9
Q

semen analysis usually needs to be performed twice following a vasectomy at what time frame

A

at 12 weeks after

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10
Q

X-ray findings:
Bone destruction and formation
Soft tissue calcification
Codman triangle (from periosteal elevation)
Sunburst appearance

What is the diagnosis

A

Osteosarcoma

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11
Q

In children and young people with unexplained bone swelling and pain, what should be arranged

A

Urgent direct access x-ray (within 48 hours)

if this suggests bone sarcoma then urgent referral (48 hrs) for specialist assessment

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12
Q

What are 3 benign bone tumours

A
  1. Osteoma
  2. Osteochondroma (exotosis) - most common
  3. Giant cell tumour
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13
Q

Xray shows double bubble or soap bubble appearance

What is the diagnosis

A

Giant cell tumour
(benign)

  • tumour of multinucleated giant cells within a fibrous stroma
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14
Q

What are 3 malignant bone tumours?

A
  1. Osteosarcoma
  2. Ewing’s sarcoma
  3. Chrondrosarcoma
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15
Q

Osterosarcoma is associated with mutation of which gene

A

Rb gene

association with retinoblastoma

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16
Q

X-ray of bones shows onion skin appearance - what bone tumour is this

A

Ewing’s sarcoma

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17
Q

osteoma tends to be associated with what syndrome

A

Gardner’s syndrome
(variant of familial adenomatous polyposis - FAP)

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18
Q

cartilage-capped bony projection on the external surface of a bone is typically seen with which benign bone tumour?

A

osteochondroma (exotosis)

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19
Q

what is the benign bone tumour that is multinucleated giant cells within a fibrous stroma?

A

giant cell tumour

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20
Q

what malignant bone tumour is a small round blue cell tumour?

A

Ewing’s sarcoma

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21
Q

What bone tumour is associated with a t(11;22) translocation?

A

Ewing’s sarcoma

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22
Q

What bone tumour is a malignant tumour of the cartilage?

A

Chondrosarcoma

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23
Q

What four groups should be advised to take vitamin D supplementation?

A
  1. All pregnant + breastfeeding women - 10ug daily
  2. Children aged 6 months to 5 years (unless if having formula milk)
  3. Adults >65 years
  4. People who are not exposed to much sun i.e. housebound
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24
Q

When to avoid colchicine in renal impairment

A

Reduce dose if eGFR 10-50
Avoid if eGFR <10

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25
Q

what is initial dose of allopurinol and target serum uric acid level

A

100mg OD
Titrate every few weeks
Aim for serum uric acid <360
(or <300 if tophi, chronic)

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26
Q

What is the second line agent for urate-lowering prophylaxis in gout if allopurinol is not tolerated or ineffective

A

Febuxostat

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27
Q

For patients taking leflunomide, effective contraception is required for at least how long in women and men after stopping?

A

2 years - women
3 months - men

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28
Q

Stopping leflunomide (DMARD) has a very long wash out period of up to 1 year. This requires the administration of…?

A

Cholestyramine

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29
Q

For SLE, which test has the highest positive predictive value (most SPECIFIC)?

A

anti-dsDNA

Highly specific (>99%)
Less sensitive (70%) - i.e. not present in everyone!

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30
Q

For SLE, which test is the best to rule it out i.e. most sensitive but low specifity

A

ANA

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31
Q

T scores in DEXA scans are based on bone mass of young reference population. Z scores are adjusted for what 3 factors?

A
  1. Age
  2. Gender
  3. Ethnic factors
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32
Q

T score ranges for normal, osteopenia and osteoporosis

A

> -1.0 = normal
-1.0 to -2.5 = osteopenia
< -2.5 = osteoporosis

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33
Q

Patients with gout who already take allopurinol - should allopurinol continue during the attack or not?

A

Continue with acute attack treatment

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34
Q

greater trochanteric pain syndrome is also called

A

trochanteric bursitis

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35
Q

Meralgia paraesthetica - compression of lateral cutaneous nerve of thigh; causes a burning sensation over which part of the thigh?

A

Antero-lateral

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36
Q

Meralgia paraesthetica = burning sensation over antero-lateral aspect of thigh.

What nerve is compressed?

A

Lateral cutaneous nerve of thigh

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37
Q

what hip pain cause is common in pregnancy due to hormonal changes leading to ligament laxity?

A

pubic symphysis dysfunction

pain over pubic symphysis radiating to groin + medial thigh.

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38
Q

what is an uncommon hip pain condition sometimes seen in third trimester of pregnancy with raised ESR?

A

transient idiopathic osteoporosis

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39
Q

Low calcium
Low phosphate
Low vitamin D
Raised ALP
Bone pain

What is the likely cause?

A

Osteomalacia

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40
Q

What does x-ray show in osteomalacia?

A

Translucent bands
Looser’s zones
Pseudofractures

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41
Q

Treatment of osteomalacia

A

Vitamin D supplementation (with loading dose)
+/- Calcium supplementation

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42
Q

Treatment of polymyalgia rheumatica

A

Prednisolone
e.g. 15mg/OD

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43
Q

treatment of giant cell arteritis (temporal)

A

High dose glucocorticoids

If no visual loss - high dose prednisolone
If visual loss - same-day opthalmology review, IV methylprednisolone first then pred

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44
Q

Women and men on methotrexate need to avoid pregnancy and use effective contraception for how long

A

At least 6 months after treatment has stopped

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45
Q

What blood tests are regularly monitored on methotrexate

A

FBC
U+Es
LFT

Before treatment and repeated weekly until stabilised, then every 2-3 months

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46
Q

What should be co-prescribed with methotrexate

A

Folic acid 5mg once weekly
Taken >24 hours after methotrexate dose

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47
Q

Avoid prescribing what 3 drugs with methotrexate

A

Trimethoprim
Co-trimoxazole
High-dose aspirin

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48
Q

Treatment for methotrexate toxicity

A

Folinic acid (Calcium folinate)

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49
Q

Patients who are on long term steroids (>7.5mg daily prednisolone for 3 months or longer) should be prescribed what without the need for a DEXA scan

A

Bisphosphonate

alendronate 10mg OD or 70mg weekly

or risedronate 5mg OD or 35mg weekly

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50
Q

What patients should be offered bone protection with bisphosphonates (+/- vit D/calcium if also low)?

A

Over 65 with fragility fracture

Under 65 with DEXA T score less than -1.5

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51
Q

If there is a T score between 0 and -1.5 with no history of fracture and no history of steroid use, what should be management

A

Repeat DEXA scan in 1-3 years
Restore calcium, vit D levels

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52
Q

Differences between:
(a) external haemorrhoids
(b) internal haemorrhoids

A

(a) external haemorrhoids - below dentate line, painful, thrombose
(b) internal haemorrhoids - above dentate line, painless

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53
Q

What are the features of internal haemorrhoids:
Grade 1-4

A

Grade 1: do not prolapse
Grade 2: prolapse but reduce spontaneously
Grade 3: manually reduce
Grade 4: cannot be reduced

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54
Q

Treatment of haemorrhoids

A
  1. Soften stools - increase fibre and fluid
  2. Topical local anesthetics + steroids
  3. Outpatient rubber band ligation > injection sclerotherapy
  4. Surgery for large symptomatic haemorrhoids that do not respond
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55
Q

If a patient presents with acutely thrombosed external haemorrhoids (purple, oedematous tender subcut perianal mass) within 72 hours, what is the treatment

A

Refer for excision

Otherwise with stool softeners, ice packs, analgesia

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56
Q

Achilles tendinitis is classically associated with which inflammatory disease?

A

Ankylosing spondylitis

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57
Q

Dactylitis (inflammation of digits) is seen with which 2 kinds of disease

A
  1. Arthritis - psoriasis and reactive
  2. Sickle cell disease
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58
Q

management of people with secondary Raynaud’s phenomenon

A
  • referral to secondary card
  • 1st line = CCBs e.g. nifedipine
  • IV prostacyclin (epoprostenol) infusions
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59
Q

4 medical indications for circumcision

A
  1. phimosis
  2. recurrent balantitis
  3. balanitis xerotica obliterans
  4. paraphimosis
  • it is important to exclude hypospadias
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60
Q

what does circumcision reduce the risk of three things

A
  1. penile cancer
  2. UTIs
  3. STIs
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61
Q

A newborn baby is noted to have bilateral clubfoot (Talipes equinovarus). What is the treatment?

A
  1. Ponseti method - manipulation and progressive casting starting soon after birth, usually corrected after 6-10 weeks
  2. Achilles tenotomy may be needed
  3. Night time braces until child is 4 years
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62
Q

BNF advises to treat mastitis with antibiotics (fluclox) if what four criteria

A
  • if systemically unwell
  • nipple fissure present
  • if symptoms do not improve after 12-24hours of effective milk removal
  • if culture is +ve
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63
Q

what medication increases risk of cataracts

A

steroids!
prednisolone

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64
Q

risk factors for osteoporosis

A

age
female sex
steroids
alcohol + smoking
low BMI
rheumatoid arthritis

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65
Q

medications that can worsen osteoporosis

A

steroids
SSRIs
antiepileptics
PPIs
long term heparin

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66
Q

Abdominal aortic aneurysm screening by ultrasound scan occurs for who

A

Men >65
Men and women with strong FHx of triple A

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67
Q

What diameter of aorta is considered aneurysmal in triple A screening

A

> 3cm

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68
Q

Risk factors for the development of aneurysms

A

Smoking
Hypertension
Syphilis
Connective tissue diseases

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69
Q

management of erectile dysfunction

A
  1. PDE-5 inhibitors - e.g viagra (sildenafil), alprostadil
  2. Vacuum erection devices
  3. Young man - refer to urology
  4. Advise to stop cycling
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70
Q

Women going for surgery who take the COCP - how early before surgery should this be stopped

A

4 weeks before

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71
Q

4 risk factors for varicose veins

A
  1. age
  2. female
  3. pregnancy
  4. obesity
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72
Q

investigation for varicose veins and what will this demonstrate

A

venous duplex ultrasound

shows retrograde venous flow

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73
Q

Management of varicose veins

A
  1. Conservation - leg elevation, weight loss, exercise, TED stockings (only AFTER ABPI is done!)
  2. Referral to secondary care if significant symptoms (pain, swelling), previous bleeding from the veins, skin changes, thrombophlebitis, venous leg ulcer
  3. Endothermal ablation
  4. Foam sclerotherapy
  5. Surgery - ligation or stripping
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74
Q

First line for cyclical mastalgia

A

supportive bra and simple analgesia (paracetamol, NSAIDs)

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75
Q

When is referral considered for cyclical mastalgia

A

If not responded to conservative measures after 3 months
Or affecting QoL or sleep

Hormonal agents such as bromocriptine and danazol may be used/ effective

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76
Q

first line for osteoarthritis

A

topical NSAIDs

especially in knee or hand

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77
Q

Livedo reticularis is seen with which condition

A

SLE

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78
Q

Carpal tunnel syndrome shows weakness and wasting where /in which muscles?

A

Weakness of thumb abduction - abductor pollicis brevis
Wasting of THENAR eminence (thumb + index finger)

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79
Q

What condition do patients get relief from shaking their hands?

A

Carpal tunnel syndrome

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80
Q

Compression of what nerve in carpal tunnel syndrome

A

Median nerve

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81
Q

What is the treatment for carpal tunnel syndrome

A

6 week trial of corticosteroid injection, and wrist splints at night

If fails or severe symptoms - surgical decompression

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82
Q

What are the four seronegative arthritis - negative RhF but positive for HLA-B27?

A

Psoriatic arthropathy
Ankylosing spondylitis
Reactive arthritis
Enteropathic (IBD) arthritis

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83
Q

What nail changes are seen in psoriatic arthritis

A

pitting
onycholysis

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84
Q

X-ray - erosive changes
new bone formation
periostitis
pencil-in-cup appearance

what bone disorder causes this?

A

psoriatic arthritis

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85
Q

management of psoriatic arthritis

A

managed by rheumatologist
- mild - NSAIDs
- moderate/severe - DMARDs like methotrexate, or monoclonal antibodies, apremilase (PDE4 inhibitor)

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86
Q

causes of acute pancreatitis
- get smashed

A

Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune (e.g. PAN)
Scorpion venom
Hypertriglyceride, hyperCa, hypothermia
ERCP
Drugs - azathioprine, thiazides, steroids

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87
Q

Surgical joint replacement for hips - most common type of operation

A

cemented hip replacement

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88
Q

post-operative recovery for hip replacement advice

A

physiotherapy
walking sticks/crutched for up to 6 weeks

avoid flexing hip >90 degees
avoid low chairs
do not cross legs
sleep on your back for 6 weeks

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89
Q

Baker’s cysts are a distension of the bursa. What is the difference between primary and secondary Baker’s cysts?

A

Primary - no cause. Usually in children.
Secondary - usually caused by OA. Usually in adults.

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90
Q

If alendronate, risedronate or etidronate cannot be taken then strontium ranelate or raloxifene may be given based on what

A

Strict T-scores

i.e. less than -3.5

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91
Q

Triad of reactive arthritis

A

Urethritis
Arthritis
Conjunctivitis

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92
Q

At what age do NICE recommend that we start to assess women regarding their risk suffering a fragility fracture?

A

65

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93
Q

What is the most important investigation to monitor Marfan’s syndrome ?

A

Echocardiogram

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94
Q

What inheritance is marfans syndrome

A

autosomal dominant

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95
Q

what cardiovascular conditions are seen with Marfan’s syndrome

A

dilation of aortic sinuses (90%)
aortic aneurysm
aortic dissection
mitral valve prolapse (75%)

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96
Q

Abdominal aortic aneurysm screening is done for men >65. What is classed as normal and no further scanning/action is needed

A

Aorta < 3cm

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97
Q

Abdominal aortic aneurysm screening is done for men >65. When do you rescan?

A

3-4.4cm = small aneurysm, rescan every 1 year

4.5-5.4cm = medium aneurysm, rescan every 3 months

> 5.5cm = large aneurysm - refer within 2weeks to vascular

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98
Q

Elective endovascular repair (EVAR) can be done to treat abdominal aortic aneurysm. What is the complication of this?

A

Endo-leak
Stent fails to exclude blood from aneurysm

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99
Q

What is classed as high rupture risk for abdominal aortia aneurysm?

A

Large aneurysm = >5.5cm
OR
Rapidly enlarging >1cm per year

refer to vascular surgery within 2 weeks for EVAR or open repair

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100
Q

when starting allopurinol, what should be used too as ‘cover’?

A

colchicine

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101
Q

A child with a suspected Baker’s cyst requires what to confirm the diagnosis

A

ultrasound

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102
Q

Sciatica symptoms usually settle within

A

4-6 weeks

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103
Q

Rheumatoid arthritis 1st line treatment

A

DMARD monotherapy e.g. methotrexate!
+/- short course of bridging prednisolone

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104
Q

NICE recommends using a combination of what to monitor response to treatment of rheumatoid arthritis

A

CRP and disease activity (DAS28 score)

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105
Q

Flares of rheumatoid arthritis are usually managed with

A

corticosteroids
oral or intramuscular

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106
Q

The current indication for TNF-inhibitor in rheumatoid arthritis is what..?

A

Poor response to at least 2 DMARDs

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107
Q

What are 3 examples of TNF-inhibitors that can be used in rheumatoid arthritis (if poor response to 2 or more DMARDs)

A

etanercept
infliximab
adalimumab

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108
Q

Rituximab mechanism of action

A

anti-CD20

Two 1g IV infusions are given two weeks apart

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109
Q

Two risk factors for Achilles tendon disorders

A
  1. quinolone use e.g. ciprofloxacin
  2. hypercholesteraemia
110
Q
  • audible ‘pop’ in ankle while running
  • sudden onset pain in calf or ankle
  • inability to walk

what is the diagnosis?

A

Achilles tendon rupture

111
Q

Achilles tendinopathy (tendinitis) presents with gradual back heel pain worse after activity with morning pain + stiffness.

What is the treatment?

A
  1. Analgesia
  2. Calf muscle eccentric exercises - physio or self directed
112
Q

For Achilles tendon RUPTURE (pop in ankle), examination should be conducted using what…?

A

Simmond’s triad

looking for abnormal angle of declination (more dorsiflexion)

113
Q

what is the imaging modality of choice for suspected achilles tendon rupture

A

ultrasound

114
Q

management of suspected achilles tendon rupture

A

acute referral to ortho

115
Q

Morton’s neuroma is a benign neuroma affecting what nerve

A

intermetatarsal plantar nerve

  • pain in 3rd inter-metatarsophalangeal space
116
Q

Loss of sensation distally in toes, and Mulder’s click is seen in what condition

A

Morton’s neuroma

  • try to hold neuroma between finger and thumb and squeeze, causes a click
117
Q

Management of Morton’s neuroma

A
  1. avoid high heels
  2. metatarsal pad
  3. refer if symtoms >3 months
    - specialists can give metatarsal dome orthotic
    - or corticosteroid injection and neurectomy
118
Q

Ottawa rules for ankle injury and doing ankle x-ray

A
  1. Pain in the malleolar zone and any of:
    - bony tenderness at lateral malleolar zone
    - bony tenderness at medial malleolar zone
  2. Inability to walk 4 weight bearing steps immediately after the injury and in ED
119
Q

Pain following hip resurfacing (metal-on-metal bearing) should be referred for investigations such as

A

MRI

to exclude pseudotumour

120
Q

What should patients taking etanercept (i.e. for rheumatoid arthritis) do when they get an infection

A

Stop etanercept until infection is cleared

121
Q

Pain on the radial side of the wrist/tenderness over the radial styloid process

Pain on ulnar deviation of the wrist

What is the diagnosis

A

De Quervain’s tenosynovitis

122
Q

De Quervain’s tenosynovitis is where there is inflammation of the sheath containing what two tendons

A

extensor pollicis brevis
abductor pollicis longus

123
Q

what is the test done for diagnosis of De Quervain’s tenosynovitis

A

Finkelstein’s test

pulls thumb of patient in ulnar deviation
causes pain over radial styloid

124
Q

management of De Quervain’s tenosynovitis

A
  1. analgesia
  2. steroid injection
  3. immobilisation with thumb splint (spica)
  4. surgery sometimes neededc
125
Q

3 features of antiphospholipid syndrome

A
  1. thrombosis
  2. recurrent miscarriages
  3. livedo reticularis
126
Q

what antibodies are seen in antiphospholipid syndrome

A

anti-cardiolipin
anti-beta 2 GP I
lupus anticoagulant

127
Q

what blood results for platelets and APTT are in antiphospholipid syndrome

A

low platelets
high APTT

128
Q

management of anti-phospholipid syndrome

A
  1. primary thromboprophylaxis - low dose aspirin
  2. secondary thromboprophylaxis:
    - first VTE: lifelong warfarin, target INR 2-3
    - recurrent VTE: lifelong warfarin, consider adding aspirin, target INR 3-4
    - arterial thrombosis - lifelong warfarin, target INR 2-3
129
Q

Calcium supplementation has been linked to an increased risk of

A

myocardial infarction

130
Q

roughened red papules over the extensor surfaces and are seen in dermatomyositis are called…?

A

Gottron’s papules

131
Q

Heliotrope rash in periorbital region
Photosensitive
Gottron’s papules
Proximal symmetrical muscle weakness

What is the diagnosis

A

Dermatomyositis

132
Q

What are gottron’s papules

A

red papules
over extensor surfaces of fingers

seen in dermatomyositis

133
Q

What antibody is seen in dermatomyositis

A

ANA +ve (80%)
Aminoacyl-tRNA (30%)

134
Q

Patients with long saphenous vein superficial thrombophlebitis should have what investigation

A

USS

to exclude underlying DVT

135
Q

What does NICE recommends for the management of hot flushes in men undergoing hormonal treatment (gonadorelin analogue injections) for prostate cancer?

A

cyproterone acetate

136
Q

FRAX may be used for patients aged…

A

40-90

137
Q

What underlying conditions are screened for with dermatomyositis diagnosis?

A

Underlying malignancy

138
Q

What is the chance of siblings and children of a patient (who is BRCA1 positive) also having the gene?

A

50%

139
Q

age adjusted upper limits for PSA:
(a) 50-59 years
(b) 60-69 years
(c) >70 years

A

(a) 50-59 years - 3
(b) 60-69 years - 4
(c) >70 years - 5

140
Q

acute versus chronic anal fissure time frame

A

acute < 6 weeks
chronic >6 weeks

141
Q

management of acute anal fissure (<1 week)

A
  1. soften stool - high fibre diet with fluids. bulk-forming laxatives are 1st line. if not tolerated then lactulose
  2. lubricants before defecation
  3. topical anaesthetic
  4. analgesia
142
Q

management of chronic anal fissure (>6 weeks)

A
  1. topical GTN
  2. if not effective after 8 weeks then referral to secondary care for surgery - sphincterotomy or botulinum toxin
143
Q

trigger finger is associated with abnormal flexion of digits. what 2 diseases is it associated with?

A

rheumatoid arthritis
diabetes

144
Q

management of trigger finger

A
  1. steroid injection
  2. finger splint afterwards
  3. surgery for those who have not responded to steroid injections
145
Q

What side-effect of diclofenac is it most important to warn patients about?

A

Diarrhoea

146
Q

male sterilisation failure rate

A

1 in 2000

147
Q

In osteoporosis, 10 year fracture risk/DEXA scan should be reassessed after how many years of treatment with alendronate

A

after 5 years

148
Q

hip/groin pain
snapping sensation at hip
sensation of locking

what is the diagnosis

A

acetabular labral tear

149
Q

what is a contraindication to circumcision in infancy

A

hypospadias

150
Q

chronic prostatitis treatment

A

prolonged course of quinolone

151
Q

Brown-green nipple discharge is most commonly associated with

A

duct ectasia

152
Q

Sulfasalazine is a DMARD used in rheumatoid arthritis and IBD. What 2 instances should you avoid using it?

A
  1. G6PD deficiency
  2. Allergic to aspirin or sulphonamides
153
Q

What are adverse effects of sulfasalazine on:
(a) fertility
(b) lungs
(c) haem
(d) eyes

A

(a) fertility - oligospermia
(b) lungs - pneumonitis, lung fibrosis
(c) haem - myelosuppression, Heinz body or megaloblastic anaemia
(d) eyes - coloured tears, stained contact lenses

154
Q

What are two common medication causes of drug induced lupus

A
  1. procainamide
  2. hydralazine
155
Q

How can testicular cancer be categorised

A

Germ cell tumours (95%)
- Seminomas
- Non-seminomas = embryonal, yolk sac, teratoma, choriocarcinoma

Non-germ cell tumours
- Leydig cell tumours

156
Q

hCG is elevated in what type of testicular cancers

A

Germ cell tumours:
seminomas - in 20%
non-seminomas - in 80%

157
Q

AFP is elevated in what type of testicular cancers

A

Germ cell tumour:
Non-seminomas

158
Q

LDH is elevated in which type of testicular cancers

A

40% of germ cell tumours

159
Q

What are tumour markers in testicular cancers and for which types

A

Germ cell tumours
- LDH in 40%
- hCG 20% of seminomas
- AFP and/or beta-hCG in 80% of non-seminomas

160
Q

Is prognosis good or bad for testicular cancers

A

Generally excellent
If stage 1, the 5 year survival rates are:
- seminomas = 95%
- teratomas = 85%

161
Q

Lump separate from body of testicle
Posterior to testicle
Non-tender

What is the diagnosis

A

Epididymal cyst

162
Q

3 associated conditions with epididymal cysts

A
  1. polycystic kidney disease
  2. cystic fibrosis
  3. von Hippel-Lindau syndrome
163
Q

management for epididymal cysts is usually supportive. if they are larger or symptomatic what are the options?

A

surgical removal or sclerotherapy

164
Q

hydrocele can be divided into:
1. communicating
2. non-communicating

what are the differences

A
  1. communicating - patent processus vaginalis so fluid drains into scrotum
  2. non-communicating - excess fluid production within tunica vaginalis
165
Q

hydroceles can develop secondary to what 3 things

A
  1. epididymo-orchitis
  2. testicular torsion
  3. testicular tumours
166
Q

Soft non-tender swelling of hemi-scrotum
Anterior and below the testicle
Can get above the mass
Transilluminates

What is the diagnosis

A

Hydrocele

167
Q

What is the management of infantile hydroceles

A

If they do not resolve spontaneously by the age of 1-2 years, infantile hydroceles are repaired

168
Q

Management of hydroceles in adults

A

Ultrasound is done to exclude underlying cause e.g. tumour

Conservation approach generally

169
Q

Varicocele is usually associated with what complication

A

infertility

170
Q

varicoceles are more common on what side

A

left side

171
Q

what is management of varicocele

A
  1. usually conservation
  2. surgery if very painful
172
Q

what investigation is done for varicocele

A

ultrasound with doppler studies

173
Q

All patients with peripheral arterial disease should take what 2 medications

A

clopidogrel and statins

174
Q

severe peripheral artery disease or critical limb ischaemia may be treated by what 3 techniques

A
  1. EVAR - endovascular revascularisation
    - percutaneous transluminal angioplasty +/- stent
    - for short segment stenosis and high risk patients
  2. surgical revascularisation
    - for long segment lesions or multifocal
    - surgical bypass, endarterectomy or open techqnieues
  3. amputation if not appropriate for above
175
Q

what two drugs (after clopidogrel + Statins) are licensed for use in peripheral arterial disease

A
  1. naftidrofuryl oxalate - vasodilator
  2. cilostazol - phosphodiesterase III inhibitor, antiplatelet + vasodilator. not recommended by NICE
176
Q

What is the limit to the number of generic sildenafil that can be prescribed to NHS patients with erectile dysfunction?

A

No limit!

177
Q

Patients on DMARDs should not receive what type of vaccines

A

Live vaccines

178
Q

Shingles vaccine is available on NHS for people aged over what

A

over 70 years

179
Q

hydroxychlorquine is only considered for initial DMARD rheumatoid monotherapy if what type of disease

A

if mild or palindromic disease

180
Q

All children aged between what ages should be given vitamin D supplementation

A

6 months and 5 years

181
Q

What two types of anti-oestrogen drugs exist and can be used for treatment of breast cancer (ER +ve)

A
  1. Selective Oestrogen Receptor Modulators (SERMs) - e.g. tamoxifen
  2. Aromatase inhibitors - e.g. anastrozole
182
Q

Tamoxifen is a selective oestrogen receptor modulator (SERM). How does this act for management of ER+ve positive breast cancer?

A

Oestrogen receptor antagonist
Partial agonist

SEs: hot flushes, VTE, endometrial cancer

183
Q

What cancer risk does tamoxifen increase

A

endometrial cancer

184
Q

Aromatase inhibitors (e.g. anastrozole, letrozole) mechanism of action in ER+ve breast cancer

A

Reduces peripheral oestrogen synthesis

185
Q

What is the main adverse effect of aromatase inhibitors (anastrozole and letrozole) for ER+ve breast cancer, and what investigation is done before starting patients on them due to this side effect

A

Osteoporosis

recommends a DEXA scan when starting patients on it

186
Q

What is the analgesia of choice for renal colic

A

NSAIDs

if contraindicated, then IV paracetamol

187
Q

For patients who require admission for renal stones and colic, first line is NSAIDs for analgesia. What other analgesia can be given in these groups?

A
  1. IV paracetamol
  2. Parenteral analgesia - e.g. IM diclofenac
  3. Alpha-blockers! e.g. tamsulosin
188
Q

Investigation of choice for renal stones/colic

A

Non-contrast CT KUB

USS in pregnant women and children

189
Q

Management of renal stones <5mm

A

These will pass spontaneously within 4 weeks of symptoms onset

190
Q

Renal stones are not managed conservatively if …?

A
  1. Greater than 5mm
  2. Ureteric obstruction due to stones with infection
  3. Renal developmental abnormality e.g. horseshoe kidney and previous renal transplant
191
Q

What are the 3 options in non-emergency setting for treatment of renal stone removal

A
  1. Shockwave lithotripsy
  2. Percutaneous nephrolithotomy
  3. Ureteroscopy
192
Q

What method of renal stone removal is most suitable in pregnancy

A

Ureteroscopy

193
Q

What method of renal stone removal treatment is suitable for:
Stone burden of less than 2cm in aggregate

A

Lithotripsy

194
Q

What method of renal stone removal treatment is suitable for:
Stone burden of less than 2cm in pregnant females

A

Ureteroscopy

195
Q

What method of renal stone removal treatment is suitable for:
Complex renal calculi and staghorn calculi

A

Percutaneous nephrolithotomy

196
Q

What method of renal stone removal treatment is suitable for:
Ureteric calculi less than 5mm

A

Manage expectantly

197
Q

Caclium stones - what can be done to prevent this
(a) dietary
(b) medications

A

(a) high fluid intake, low protein, low salt diet
(b) thiazide diuretics

198
Q

What 2 medications are useful for preventing oxalate stones

A

cholestyramine
pyridoxine

199
Q

what two medications are useful for preventing uric acid stones

A
  1. allopurinol
  2. oral bicarbonate - i.e. urinary alkalinisation
200
Q

Discoid lupus erythematosus is characterised by

A

follicular keratin plugs

201
Q

management of discoid lupus erythematosus

A
  1. topical steroid cream
  2. oral anti-malarials e.g. hydroxychloroquine
  3. avoid sun exposure
202
Q

Well-demarcated erythematous plaque with a ragged white border on his penis

Present with Reiter’s syndrome: urethritis, arthritis, and conjunctivitis

What is the cause of this penile rash?

A

Circinate balanitis

203
Q

myxoid (mucous) cysts are benign ganglion cysts usually found on distal, dorsal aspects of fingers. what condition usually affects the surrounding joint?

A

osteoarthritis

204
Q

A solitary right-sided varicocele requires what kind of referral

A

urgent referral to urology

205
Q

Sitting is better than standing and patients may find it easier to walk uphill rather than downhill

what is the likely diagnosis

A

lumbar stenosis

206
Q

investigation for lumbar stenosis

A

MRI

207
Q

treatment for lumbar stenosis

A

laminectomy

208
Q

Osteoarthritis: x-ray changes
LOSS

A

Loss of joint space
Osteophytes at joint margins
Subchondral sclerosis
Subchondral cysts

209
Q

first-line investigation in suspected prostate cancer

A

MRI multiparametric

results are reported on a 5-point Likert scale
If >3 = biopsy is done

210
Q

Management for:
(a) Grade I (mild) varicoele
(b) Grade II or III - asymptomatic and normal semen
(c) Grade II or III - symptomatic or abnormal semen

A

(a) Grade I = observe
(b) Grade II or III - asymptomatic and normal semen = semen analysis every 1-2 years
(c) Grade II or III - symptomatic or abnormal semen = surgery

211
Q

Patients with new synovitis - where should they be referred

A

Urgent referral to rheumatology

212
Q

Patients with Sjogren’s syndrome have an increased risk of which malignancies

A

lymphoid

213
Q

What antibodies are seen in Sjorens syndrome

A

Rheumatoid factor
ANA +ve
Anti-Ro
Anti-La

214
Q

Schirmer’s test is useful for diagnosis of what

A

sjorens syndrome

filter paper near eye to measure tear formation

215
Q

management of sjorens syndrome

A
  1. artificial tears and saliva
  2. pilocarpine - to stimulate saliva formation
216
Q

ankylosing spondylitis gene association

A

HLA-B27

217
Q

What is the pain pattern in a patient with ankylosing spondylitis

A

Stiffness worse in morning
Improves with exercise
Pain at night
Improves on getting up

218
Q

Clinical examination of ankylosing spondylitis shows reduction in which back/chest movements

A

REDUCED
lateral flexion
forward flexion - Schober’s test
chest expansion

219
Q

Following a complete prostatectomy, the PSA level should be

A

undetectable
i.e. <0.2ng/ml

220
Q

Ganglion cyst management

A
  • often disappear spontaneously after a few months
  • surgical excision if severe symptoms or neurovascular manifestations
221
Q

what should be corrected before giving bisphosphonates

A

hypocalcaemia
low vitamin D

222
Q

adverse effects of bisphosphonates

A
  • oesophageal reactions
  • osteonecrosis of jaw
  • atypical stress fractures of proximal femoral shaft
223
Q

Frozen shoulder (adhesive capsulitis) affects external rotation > internal rotation.

How long does the episode typically last for?

A

6 months to 2 years

n.b. it is bilateral in 20%

224
Q

rheumatoid factor can be detected by what 2 tests

A

rose-waaler test
latex agglutination test

225
Q

NICE recommend xrays of what in all patients with suspected rheumatoid arthritis

A

hands and feet

226
Q

cauda equina syndrome causes

A
  1. commonest = central disc prolapse, usually at L4/5 or L5/S1
  2. tumours
  3. infection
  4. trauma
227
Q

Low back pain
Bilateral sciatica
Reduced sensation in peri-anal area
Decreased anal tone

what is the diagnosis + investigation of choice

A

cauda equina syndrome
urgent MRI

Rx = urgent decompression

228
Q

Lateral epicondylitis: pain is worse on what wrist movement

A

worse on resisted wrist extension/suppination whilst elbow extended

229
Q

Finasteride treatment of BPH may take how long before results are seen

A

6 months

230
Q

The maximum dose of 1% lidocaine for a 66kg person is

A

20ml

231
Q

hydroxychloroquine monitoring

A

ask patient about visual symptoms and monitor visual acuity annually using the standard reading chart

232
Q

Management of mortons neuroma

A

avoid high heels
metatarsal pad

233
Q

ocular complications with rheumatoid arthritis

A

keratoconjunctivitis sicca
episcleritis
scleritis
cataracts (from steroids)
keratitis

234
Q

charcot (neuropathic) joint describes a joint that has become badly disrupted and damaged secondary to a loss of…

A

sensation

caused by diabetes/ syphilis

235
Q

CREST syndrome refers to which type of systemic sclerosis

A

limited systemic sclerosis

236
Q

what does CREST stand for in limited systemic sclerosis

A

Calcinosis
Raynaud’s phenomenon
oEsophageal dysmotility
Sclerodactylyl
Telangiectasia

237
Q

What antibodies are associated with limited cutaneous systemic sclerosis (CREST)

A

anti-centromere

238
Q

What antibodies are associated with diffuse cutaneous systemic sclerosis (CREST)

A

anti scl-70

239
Q

where does diffuse cutaneous systemic sclerosis versus CREST limited cutaneous systemic sclerosis affect in the body?

A

Limited/CREST - face + distal limbs
Diffuse - trunk + proximal limbs

240
Q

Which of the systemic sclerosis (diffuse or limited/CREST) leads to respiratory involvement too?

A

Diffuse

Interstitial lung disease and pulmonary arterial hypertension

241
Q

what is the most common type of breast cancer

A

invasive ductal carcinoma

242
Q

NICE recommend offering a PR and PSA test to men with any of the following five unexplained symptoms:

A
  1. erectile dysfunction
  2. haematuria
  3. lower back pain
  4. bone pain
  5. weight loss, especially in the elderly.
243
Q

Ehler danlos syndrome is autosomal dominant. what is a useful tool to assess hypermobility

A

beighton score

244
Q

Sensory loss of posterolateral aspect of leg and lateral aspect of foot, weakness in plantar flexion of foot, reduced ankle reflex, positive sciatic nerve stretch test

what nerve lesion

A

S1

245
Q

what score is used to predict prostate cancer prognosis

A

gleason score

higher the score = worse the prognosis

246
Q

What antibodies and enzyme are raised in polymyositis (inflammatory disease with proximal muscle weakness)

A

Anti-Jo 1
Raised CK

247
Q

Polymyositis (anti-Jo antibodies and raised CK) is treated with… ?

A

High dose corticosteroids
Azathioprine as a steroid-sparing agent

248
Q

meralgia parasthetica symptoms are motor or sensory?

A

only sensory
there is no motor weakness

249
Q

how are symptoms of meralgia parasthetica in the upper lateral aspect of the thigh reproduced and therefore diagnosed?

A
  • deep palpation below the ASIS (pelvic compression) - this is for diagnosis
  • and by extension of the hip
250
Q

treatment of meralgia parasthetica

A

injection of the nerve with local anaesthetic

251
Q

Felty’s syndrome triad

A

Rheumatoid arthritis
Splenomegaly
Low white cell count

252
Q

What is the maximum safe dose of lidocaine

A

Maximum safe 3mg/kg

253
Q

What are the removal times for non-absorbable sutures in:
(a) face
(b) scalp, limbs, chest
(c) hand, foot, back

A

(a) face - 3-5
(b) scalp, limbs, chest - 7-10
(c) hand, foot, back - 10-14

254
Q

Venous ulcers are often treated with …

A

compression bandaging

this is acceptable if ABPI >0.8 (i.e. there is no PAD) - so remember to check ABPI first as peripheral arterial disease (<0.8) is a contraindication for this

255
Q

ankle brachial pressure index - what are the values for:
(a) calcified, stiff arteries
(b) normal
(c) acceptable
(d) peripheral artery disease

A

(a) calcified, stiff arteries >1.2
(b) normal 1.0-1.2
(c) acceptable 0.9-1.0
(d) peripheral artery disease <0.9

<0.5 = severe PAD that needs urgent referral

256
Q

what nerve is compressed in cubital tunnel syndrome

A

ulnar nerve

257
Q

where is there tingling/numbness in cubital tunnel syndrome

A

tingling and numbness of 4th and 5th finger

pain is worse when leaning on elbow

258
Q

what investigations should be done for BPH

A
  1. urine dipstick
  2. U+Es
  3. PSA
  4. Urinary frequency-volume chart - for at least 3 days
  5. IPSS score for LUTS
259
Q

treatment of BPH

A
  1. alpha-1 antagonists e.g. tamsulosin
  2. 5 alpha-reductase inhibitors e.g. finasteride
  3. combination of above
  4. or add antimuscarinic (anti-ACh) e.g. tolterodine can be tried with alpha-1 antagonist
  5. surgery - TURP
260
Q

what medications are first line for BPH

A

ALPHA-1 ANTAGONISTS

e.g. tamsulosin, alfuzosin

2nd line = 5-alpha reductase inhibitors

261
Q

inguinal hernia - 75% of abdominal wall hernias

what is their anatomy

A

superior and medial to pubic tubercle

262
Q

what are definitions of direct and indirect inguinal hernias and how is it relevant to management

A

direct - through posterior wall of inguinal canal
indirect - through inguinal canal

not relevant!

263
Q

management of inguinal hernias

A
  1. treat all
  2. mesh repair
  3. hernia truss if not fit for surgery
264
Q

When should patients return to work after:
(a) open repair of inguinal hernia
(b) laparoscopic repair of inguinal hernia

A

(a) open = 2-3 weeks
(b) laparoscopic = 1-2 weeks

265
Q

what is the anatomy of femoral hernia

A

Below and lateral to the pubic tubercle

266
Q

treatment of femoral hernia

A

URGENT surgical repair
risk of strangulation and obstruction

267
Q

what test is done to assess meniscal tear

A

Thessaly’s test

268
Q

acute bacterial prostatitis

A

14 day course of quinolone (e.g. ciprofloxacin)

269
Q

Rheumatoid arthritis 1st line treatment initially is a DMARD and short-term bridging prednisolone. What are some examples of DMARDs

A

Methotrexate
Sulfasalazine
Leflunomide
Hydroxychloquine - only used in mild or palindromic disease

270
Q

What needs to be monitored with leflunomide (DMARD)?

A

FBC
LFTs
Blood pressure

271
Q

Which of the three DMARDs (methotrexate, leflunomide, sulfasalazine) is safe in pregnancy and breastfeeding?

A

SULFASALAZINE

Methotrexate - avoid pregnancy for 6 months after stopping
Leflunomide - avoid for 2 years in women, 3 months in men

AKT (25 decks)

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