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Surgical Specialties Flashcards

1
Q

Pelvic floor exercises better for which type of incontinence?

A

Stress incontinence

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2
Q

First line medication for urge incontinence

A

Oxybutynin
Tolteridone

Mirabegron

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3
Q

Which type of incontinence is due to overactive detrusor muscle?

A

Urge incontinence

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4
Q

Which medication can be used in stress incontinence?

A

Duloxetine

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5
Q

If conservative management for removal of kidney stone fails, which surgery is most likely?

A

Shock wave lithotripsy

- breaks stones into smaller pieces so that they can be passed

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6
Q

Detrusor overactivity is diagnosed by which investigation?

A

Urodynamics

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7
Q

Which type of incontinence is due to damage to the pelvic floor or urethral function?

A

Stress incontinence

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8
Q

Stress / urge incontinence has a better role for pharmacotherapy?

A

Urge incontinence

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9
Q

Mainstay of treatment for stress incontinence?

A

Pelvic floor exercises

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10
Q

First line treatment for urge incontinence

A

Bladder retraining (6 weeks)

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11
Q

First line treatment for stress incontinence

A

Pelvic floor exercises (3 months)

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12
Q

Who should not get oxybutynin?

A

Frail elderly women

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13
Q

Ring pessaries are used as non surgical management for?

A

Pelvic organ prolapse

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14
Q

Anti-muscarinic drugs and side effects

A

Oxybutynin, tolteridone

SE: anti-cholinergic (dry mouth, constipation)

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15
Q

When are urodynamics needed?

A

When there is diagnostic uncertainty

When there are plans for surgery

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16
Q

Sympathetics dilate/constrict the pupil

A

Dilate

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17
Q

Parasympathetics dilate/constrict the pupil

A

Constrict

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18
Q

Fixed pin point pupil makes you think

A

Opioid toxicity

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19
Q

Fixed dilated pupil makes you think pathology of which CN?

A

CN III

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20
Q

Blink reflex

  • afferent arm
  • efferent arm
A

Afferent arm : CNV1

Efferent arm : CNVII

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21
Q

Pupillary light reflex

  • afferent arm
  • efferent arm
A

Afferent arm : CN II

Efferent arm : CN III (constriction bilaterally)

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22
Q

Lacrimal gland is under sympathetic/parasympathetic control and is supplied by which CN ?

A

Parasympathetic

CN VII

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23
Q

Eye in “down and out” position. Which CN is most likely to be affected?

A

CN III

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24
Q

Blurred vision when going down stairs (looking down) and double vision. Which CN is most likely to be affected?

A

CN IV

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25
How do you measure intra ocular pressure?
Tanometry - measures how much force is required to indent into a patients eye? - patient given LA
26
What produces aqueous humour?
Cilliary body
27
if you hear "arcuate scotoma" where is the pathology?
Retina
28
If you have a process where you're losing ganglion cells in the eye, you will notice the effects in the periphery/middle first?
Periphery
29
An enlarging cup:disc ratio is a buzzword for which ophthalmology condition? What does it actually mean?
Glaucoma | - raised IOP causes ganglion cells around the optic nerve to die --> as they die, see fewer of them -> get a larger cup
30
Increased risk of open angle glaucoma if you are short / long sighted?
Short sighted
31
Name 5 types of medication for glaucoma
``` Prostaglandin analogues Beta blockers Carbonic anhydrase inhibitors (acetazolomide) Parasympathomimetics (pilocarpine) sympathomimetics (adrenaline, alphagan) ```
32
Name the 2 types of medication for glaucoma which 'turn off the tap' i.e. reduce aqueous humour production
Beta blockers | carbonic anhydrase inhibitors
33
Carbonic anhydrase inhibitors - which preparation is better: oral tablet or topical drops?
Oral tablet more effective
34
First line medication type for glaucoma
Prostaglandin analogues
35
Usual order of treatment for glaucoma
1) prostaglandin analogues 2) + B-blocker / carbonic anhydrase inhibitor 3) + B-blocker + carbonic anhydrase inhibitor 4) laser surgery? 5) sympathomimetic or parasympathomimetic 6) surgery (trabeculectomy)
36
Increased risk of ACUTE closed angle glaucoma if you are short sighted / long sighted?
Long sighted
37
What presents more in the emergency setting - open angle glaucoma - closed angle glaucoma
Closed angle glaucoma
38
Thumping headache, sick, really unwell, visual loss, often red eye. Gets CT scan everything normal. Someone looks in eye - find abnormality. What is likely diagnosis
Acute angle closure glaucoma
39
Management of acute angle closure glaucoma
1) decrease IOP medically with IV acetazolomide (carbonic anhydrase inhibitor) 2) peripheral iridotomy (stop it from happening again)
40
What is the most worrying acute cause of raised intra ocular pressure
Acute angle closure glaucoma
41
treatment of bacterial conjunctivitis
Topical chloramphenicol
42
Bacterial / viral conjunctivitis is associated with tender pre-auricular lymph nodes?
Viral
43
Unilateral folicular conjunctivitis in a young patient. What do you need to consider?
Chlamydial conjunctivitis
44
Bacterial corneal ulcer (keratitis) investigation of choice
Corneal scrape
45
First line management of bacterial kertatitis
Ofloxacin (hourly drops)
46
Why should you be cautious of using steroids in patient with red eye?
If the cause is herpetic keratitis and the patient has a dendritic ulcer, steroids will cause geographical ulcer making it much harder to treat
47
Which is more common: episcleritis or scleritis
Episcleritis
48
Which is more serious: episcleritis or scleritis
Scleritis
49
``` Red eye (limbus) Acute onset Dull achey pain Vision may be reduced Photophobia Hypopyon What do these symptoms make you think of? ```
Anterior uveitis
50
``` Cloudy cornea Red eye Fixed mid dilated pupil Significantly reduced visual acuity. Makes you think? ```
Acute angle closure glaucoma
51
How does aqueous humour normally drain away?
Through the trabecular meshwork
52
Emergency first line management of acute angle closure glaucoma
IV acetazolamide - to reduce the IOP
53
What does pilocarpine do to the pupil?
Shrinks the pupil
54
Surgical treatment for closed angle glaucoma
Peripheral iridotomy
55
Myopia - short sighted or long sighted
Short sighted
56
High myopia can increase risk of what condition?
Retinal detachment
57
High hypermetropia can increase risk of what condition?
Acute angle closure glaucoma
58
What carries 2/3rds of the ability to focus in the eye?
Lens
59
What is the commonest cause of blindness in the elderly population?
ARMD
60
Patient with gradual decrease in central visual acuity and then one day wakes up with sudden dramatic decrease in visual acuity. What is the likely diagnosis?
Dry ARMD --> wet ARMD
61
Describe the pathogenesis of wet ARMD
New blood vessels created to 'repair' the damage made by dry ARMD. These blood vessels leak fluid / blood into the retinal tissue Cause sudden sharp decrease in central visual acuity
62
What is the best way to diagnose or monitor ARMD
OCT scan
63
Tenting of the retinal pigment epithelium on OCT suggests
wet ARMD
64
What is the best investigation to confirm the diagnosis of wet ARMD
fluorescene angiography
65
Management of wet ARMD
Anti VEGF injection | - inhibits the growth of new vessels -> decreased leakage
66
Name 4 causes of gradual visual loss
Cataracts ARMD Diabetic retinopathy Open angle glaucoma
67
Name 5 causes of PAINLESS sudden visual loss
``` Central retinal artery occlusion Central retinal vein occlusion Amaurosis fugax Retinal detachment Vitreous haemorrhage ```
68
Name 3 causes of PAINFUL sudden visual loss
Acute angle closure glaucoma Optic neuritis Giant cell arteritis
69
TIA in the eye
Amaurosis fugax
70
Pale swollen retina with cherry red spot at macula
Central retinal artery occlusion
71
Sudden profound visual loss + temporal headache, scalp tenderness, jaw claudication what do you think?
Giant cell arteritis
72
Treatment of GCA
Long term steroids
73
Paper bag breathing causes increased/decreased pCO2 and therefore vasodilation/vasoconstriction of the arteries
Increased pCO2 | Vasodilation
74
Management of CRAO
If presents within 12-24 hours - occular massage (push to a branch) - paper bag breathing - IV acetazolamide
75
Which visual loss is more severe? CRAO or CRVO ?
CRAO
76
Stormy sunset Cotton wool spots Dilated torturous veins What do you think
CRVO
77
What is a cotton wool spot
Ischaemia of the retinal nerve fibre layer
78
Sudden onset of flashing lights in the periphery Burst of new floaters Dark shadow in peripheral vision, increasing in size makes you think
Retinal detachment
79
Which features of examination do you focus on when assessing optic nerve function
Visual acuity Visual fields Colour vision Pupil responses - RAPD (swinging light reflex)
80
Unilateral optic disc swelling - what condition are you thinking about
OPtic neuritis
81
Bilateral optic disc swelling - what condition are you thinking about
Papilloedema
82
MS and which ophthalmic condition go hand in hand
Optic neuritis
83
Patient with optic neuritis, female, young. What investigation should you consider?
MRI
84
Sudden unilateral loss in vision over period of a few days, dull ache pain on eye movements, decreased colour vision in affected eye
optic neuritis
85
Bilateral optic disc swelling and raised ICP. What is first investigation and what are you looking for
MRI / CT scan to identify if there is a space occupying lesion
86
Bilateral optic disc swelling and raised ICP. Ix done but no space occupying lesion found...what could be the diagnosis now and what Ix should you do?
Idiopathic intracranial hypertension | Ix - Lumbar puncture
87
Lesion at optic nerve would do what to vision?
Unilateral visual loss (on same side as optic nerve damage)
88
Lesion at optic chiasm would do what to vision?
Bitemporal hemianopia
89
Lesion at optic tract / radiation would do what to vision?
Homonymous hemianopia
90
Lesion at visual cortex would do what to vision?
Cortical blindness, macula sparing
91
``` Mild ptosis (eyelid droop) Constricted pupil which does not dilate Reduced ipsilateral sweating ```
Horners Syndrome
92
Patient with double vision -> cover one eye and double vision disappears. This is monocular/binocular diplopia?
Binocular
93
Patient with double vision -> cover one eye and double vision remains indicates
Problem with that eye | - ie corneal problem or cataract
94
Monocular/binocular diplopia is seen with problems with eye movement (ie CN pathology)
Binocular diplopia
95
CN III palsy clinical findings (3)
Dilated pupil Ptosis (eyelid droop) Eye looks down and out
96
Patient with sudden loss of vision. What is it important to exclude?
GCA
97
Goinoscopy is used for
Glaucoma
98
What is the leading cause of blindness in working age people?
Diabetic retinopathy
99
What is the management of proliferative retinopathy
``` Later treatment (pan-retino-photocoagulation) ablate peripheral retina to preserve the central ```
100
A child's visual system is constantly developing from birth until the age of
6
101
What is amblyopia?
Reduced vision usually in one eye due to a degraded retinal period so the brain doesn't develop the binocular visual pathways essentially a lazy eye
102
Causes of amblyopia?
Squint Unequal refractive errors Obstruction to visual axis: cataract, ptosis
103
How do you treat amblyopia?
Cover the good eye | Patch
104
Long sighted (hypermetropic) people have a tendency for eyes to point inwards/outwards?
Inwards
105
4 year old boy presents with 1 week Hx convergent squint and vomiting ++. What are you worried about?
Raised intra cranial pressure
106
Which CN palsy (3,4, or 6) makes you most worried about raised intra cranial pressure?
CN 6 palsy (esp if bilateral)
107
``` Patient with ?papilloedema - bilateral CN VI palsy - vomiting - swollen optic discs What is your investigation of choice? ```
Urgent CT | - look for dilated ventricles
108
Why should infant with no red reflex be referred urgently?
?retinoblastoma
109
Retinoblastoma is most common eye cancer in childhood. True or false?
True
110
What would an iris coloboma look like?
Think madelline mccann Area of iris is missing Key hole defect
111
Absent red reflex but instead a yellow reflex completely filling the pupil. What does this make you think of?
Retinoblastoma
112
14 month toddler, normal visual development up until 12 months, then stopped walking and was becoming more distressed, couldn't see food on plate. What does this make you think?
Congenital cataract
113
What are the 2 main causes of sticky eyes in infancy?
Ophthalmia neonatorum (conjunctivitis occurring in first 28 days from birth) Blocked nasolacrimal duct
114
Commonest cause of ophthalmia neonatorum
Picked up from maternal STI when passing through the birth canal - gonococcal cause presents quickest - chlamydial cause presents 2 weeks post birth
115
Management of ophthalmia neonatorum
Swabs Azithromycin Contact tracing for mother
116
Sticky + watery + white uninflammed eye from 2 months. What is likely diagnosis?
Blocked nasolacrimal duct
117
What investigation is done if ?blocked nasolacrimal duct?
Fluorescene dye - should be seen in nostrils - confirms diagnosis if the dye is picked up around the eye
118
Management of blocked nasolacrimal duct
DO nothing | - resist prescribing topical antibiotics
119
How are most convergent squints treated
Glasses
120
What is the likely diagnosis in a 21 year old male, with a longstanding female partner who presents with conjunctivitis and urethritis? How would you treat this patient?
Reiters syndrome likely | antibiotics
121
How do you treat amblyopia if patient doesn't tolerate patch?
Atropine 1% in good eye
122
Latent squint always affects both eyes. True or false?
True
123
Management of paediatric squint
Maximise visual acuity - correct refractive error - treat amblyopia THEN surgery if required
124
flexible/rigid uteroscope is used to get stones from the kidney?
Flexible - so it can move into the calyces
125
Flexible/rigid uteroscope is used to get stones from the ureter?
Rigid
126
What is cystoscopy used for?
Follow up bladder cancer | Investigate ?bladder cancer
127
Name some LUTS | Voiding AND Storage
Voiding - difficulty initiating - poor stream - post micturation dribble Storage - frequency - urgency - nocturia
128
Patient with white patches where foreskin usually contracts and bleeding. What is the likely diagnosis and management?
Diagnosis: balantitis xerotica obliterans Management: Circumcision
129
BPH usually occurs in which zone of prostate?
Transitional zone (central)
130
Elderly male patient with LUTS. What examination do you do?
PR exam
131
Name 2 medications used to manage BPH (and their MOA)
Tamsulosin (alpha blocker - better flow) Finasteride (5-alpha reductase inhibitor - shrinks prostate)
132
Which surgical procedure is carried out for BPH
TURP
133
Name 2 possible complications of BPH
Acute urinary retention | UTI
134
Name 2 risk factors for bladder cancer
Dye/chemical exposure, smoking
135
Painless frank haematuria. No other symptoms. What are you worried about?
Bladder cancer
136
In which region of the bladder does bladder cancer usually occur?
Trigone
137
Patient with painless haematuria. Which investigations do you want to carry out?
Urinalysis Bloods Flexible cystoscopy CT urogram
138
Patient with painless haematuria. Flexible cystoscopy reveals an area which is potentially malignant. What do you do?
Rigid cystoscopy + biopsy
139
Management of bladder cancer (including follow up) in LOW risk patients
Transurethral bladder resection | Follow up with cystoscopy for ?3 years
140
Management of bladder cancer (including follow up) in HIGH risk patients
Transurethral bladder resection Follow up with cystoscopy for 10 years BCG injection
141
Which Vaccination helps reduce the recurrence of bladder cancer?
BCG
142
Management of bladder cancer if patient is not fit for surgery
external beam radiotherapy
143
Bladder cancer has a HIGH/LOW recurrence rate?
High
144
Which zone of prostate is it most common to get prostate cancer?
Peripheral zone
145
LUTS, haematospermia, weight loss, bone pain makes you think
Prostate cancer (advanced)
146
Suspect prostate cancer, which examination is done?
PR exam | - hard, craggy, irregular mass
147
Patient with ?prostate cancer, which investigations are valuable?
PSA | Trans rectal US guided prostate biopsy
148
PSA is a good diagnostic test. True or false?
False | - but it is good for monitoring
149
Scoring system used for prostate cancer (and breakdown)
Gleason score - score < 6 - low risk - score 6-7 - intermediate risk - score 8-10 - high risk
150
Treatment of low risk prostate cancer
radical prostatectomy + radical radiotherapy
151
Treatment of intermediate risk prostate cancer
Radical prostatectomy + external beam radiotherapy + hormone therapy (LHRH agonist)
152
Penile cancer - common in young/elderly males?
Elderly
153
Elderly male with phimosis, raised red area of penis, red velvety patches on glans of penis. What is the likely diagnosis?
Penile cancer (SCC)
154
What is the investigation of choice for penile cancer
US
155
Testicular cancer - common in young/elderly male?
Young
156
What are the 2 broad categories of testicular tumours
Seminoma | Non-seminoma (yolk sac, teratoma)
157
Testicular tumour with solid homogenous pale macroscopic appearance
Seminoma
158
Which is more likely to spread: seminoma / non-seminoma?
Non-seminoma
159
Investigation of choice for ?testicular cancer?
US
160
``` Which tumour marker is raised in non-seminoma but NOT seminoma? PLAP B-HCG AFP LDH ```
AFP
161
``` Which tumour marker is raised in yolk sac tumours (non-seminoma) ? PLAP B-HCG AFP LDH ```
AFP
162
Which lymph nodes to testicular tumours typically spread to
Para aortic / aortocaval
163
Which is more RADIOsensitive: seminoma / non-seminoma
Seminoma
164
Which is more CHEMOsensitive: seminoma / non-seminoma
Non-seminoma
165
Define hydronephrosis
Back pressure of urine into the kidneys due to dilatation of ureters - urine back pressure into the calyces compresses the nephrons within the medullary pyramids resulting in renal failure
166
Management of hydronephrosis?
Nephrostomy
167
Patient develops AKI after treatment of hypertension. What is the most likely diagnosis?
Renal artery stenosis
168
What is the management of acute urinary retention?
Catheterise
169
Foetus with small break in nose, low lying ears, regressing jaw. What is the likely diagnosis?
Potter's syndrome
170
Name 5 causes of frank haematuria
``` Tumours (Bladder cancer, renal cell cancer, prostate cancer) Infection Stones Trauma Polycystic kidneys ```
171
What are the 2 best investigations to investigate frank haematuria
Flexible cystoscopy | CT urogram
172
Which medications (3) can look like patient is having haematuria
Nitrofurantoin Anticoagulation Rifampicin
173
Blood clots in urine | - long and worm like VS shapeless
Long and worm like - think upper urinary tract | shapeless - think lower urinary tract
174
What is the first line investigation if there is frank haematuria in over 50 year olds?
CT urogram
175
Best imaging Ix to look for stones
Plain CT scan
176
If you have a blocked nose you tend to have more problems in the lungs. True or false?
True | - nose is a protector of the respiratory tract so if blocked, more likely to have infections
177
What are the 2 top investigations for allergic rhinitis ?
RAST (specific IgE levels) | Skin prick testing
178
Which 2 immune things cause allergic rhinitis?
Histamine | Leukotrienes
179
Name 2 antihistamines used in the treatment of allergic rhinitis
Certirizine | Loratidine
180
Name 1 leukotriene receptor antagonist used in allergic rhinitis
Montelukast
181
Steroids are used in the treatment of allergic rhinitis. True or false?
True | - they are very effective
182
In which part of the cell do steroids work?
Nucleus
183
If a patient has an allergic rhinitis, GP has a look and refers to ENT because they see a 'polyp'. What is is most likely to be?
Inferior turbinate, not a polyp
184
What is first line analgesia indicated for severe renal colic?
IM NSAIDs
185
FIrst line investigation of choice for patients presenting with suspected renal colic?
Non contrast CT KUB
186
28 y/o male presents with swelling within left scrotum., which aches when he stands. O/E: swelling is not tender and feels like a bag of worms. What is the likely diagnosis?
Varicocele | - more common in left
187
Painless scrotal swelling which transilluminates. Does this make your suspicion of testicular cancer increase or decrease?
Decrease | - more likely to be fluid (eg hydrocele or epididymal cyst)
188
Bladder US requires a full / empty bladder?
Full | - easier to assess outline
189
What is the gold standard investigation for local staging of bladder wall tumours?
MRI scan
190
Which investigation is good for detecting renal artery stenosis?
MR angiogram
191
Initial imaging of choice for ?prostate tancer
US | - Trans rectal US + biopsy
192
Imaging for staging of prostate cancer
MRI
193
What are the 3 anatomical sites of ureteric constriction (ie where are you most likely to get renal calculi)
Pelviureteric junction Pelvic brim - Where ureter crosses over anterior aspect of common iliac artery Ureteric orifice
194
``` Colicky loin -> groin pain Can't lie still Frank haematuria may have co-existing UTI What does this make you think of? ```
Renal colic
195
What is the investigation of choice for urinary tract calculi?
CT non contrast | - so this is safe in patients with renal impairment
196
Initial management of urinary tract calculi?
IM/IV diclofenac (NSAID) for analgesia fluids antibiotics if UTI present
197
Patient has a stone over 5mm with pain not resolving with analgesics. What do you do?
Tamsulosin Nifedipine These tablets promote expulsion
198
Management of patient with a large stone they are unable to pass using medical therapies / if stone not passed in 1 month (2)
Shockwave lithotripsy | Uteroscopy with basket
199
Severe suprapubic pain | O/E: distended, palpable bladder, dull to percussion
Acute urinary retention
200
2 options for management of upper urinary tract obstruction
Ureteric stent | Nephrostomy
201
Name 4 causes of acute urinary retention
Prostatic obstruction Urethral stricture infection carcinoma
202
Immedicate management of acute urinary retention (2)
``` Suprapubic catheter Alpha blocker (tamsulosin) ```
203
Schistasomiasis inreases your risk of which type of tumour?
Bladder cancer - SCC
204
More likely to pass small volumes of urine in stress/urge incontinence ?
Stress - small
205
Young man wakes up in the middle of the night with extreme pain in one testis, N&V. O/E: testis is high in scrotum, very tender hot and swollen. What does this make you think of?
torsion of the spermatic cord
206
Which testicular pathology is an emergency
Torsion of the spermatic cord
207
Blue dot sign on mobile testis
Torsion of appendix testis
208
Which testicular problem is commonly associated with STI
Epidiymo orchitis
209
Varicocele usually affects left or right side
Left
210
Scrotum feels like a 'bag of worms'. What does this suggest?
Varicocele
211
Diagnosis of torsion of spermatic cord is required before surgery. True or false?
False | - if suspected, urgent surgery required
212
A patient with primary open angle glaucoma is started on latanoprost eye drops to reduce her intraocular pressure. What is its main mode of action? Increased aqueous absorption Constriction of the pupil and opening the trabecular meshwork Reduction in aqueous production at the ciliary body Flattening of the lens by the ciliary muscle
Increased aqueous absorption
213
Which type of glaucoma medication causes growth of eyelashes
Prostaglandin analogues (latanoprost)
214
Which 2 classes of glaucoma medication reduce aqueous production at the ciliary body
``` Beta blocker (timolol) Carbonic anhydrase inhibitor (acetazolamide) ```
215
Which glaucoma medication causes constriction of the pupil and opening of the trabecular meshwork?
Pilocarpine
216
what is the most common sight threatening complication of branch retinal vein occulusion?
Macular oedema
217
``` A 70 year old woman is admitted headache and scalp tenderness and reports 1 stone in weight loss over the last 2 months. On examination, she has a non-pulsatile and tender super fical temporal artery on the right side. Bloods are taken which reveal a raised erythrocyte sedimentation rate (ESR). She has no signi ficant past medical history. What should be done next as a matter of priority? Temporal artery biopsy Arrange urgent CT Commence oral steroids Commence oral NSAIDs Commence IV NSAIDs ```
Commence oral steroids - If ESR and CRP positive then given the clinical Hx it is most likely to be GCA. - Confirmed GCA is treated with high dose oral steroids - only where there is diagnostic uncertainty, temporal artery biopsy is required
218
In cataract surgery there is a corneal / scleral incision ?
Corneal
219
Name 2 complications of cataract surgery ?
Endophthalmitis | Unexpected refractive error
220
A young child is brought to the opticians with bilateral gritty red eyes. There is a watery discharge. He had recently been o ff school with a cold. On examination, he has some palpable lymphadenopathy in the preauricular area. What is the appropriate course of action? - prescribe oral aciclovir - prescribe topical chloramphenicol - prescribe topical aciclovir - cold compress / lubricants - chloramphenicol ointment
Cold compress / lubricants | - this child has viral conjunctivitis
221
WHat drug is commonly used to treat viral herpetic keratitis?
Topical aciclovir
222
Sudden onset of ashes and oaters and a "curtain-like" shadow or veil across the vision are highly suggestive of
retinal detachment
223
A 87 year old man visits his GP with his daughter who has noticed he is increasingly bumping into things on his left side and has fallen at home on two occasions. His visual acuity is 6/9 in both eyes. On visual fi eld examination, he appears to be missing the temporal hemi field in the left eye and the nasal hemi field in the right eye. His pupils are reactive to light and accommodation and there is no RAPD. Where in the visual pathway is the problem likely to be located? - right optic radiation - left optic radiation - optic chiasm - right optic tract - left optic tract
Right optic tract
224
What is the surgical treatmnt when medication fails in primary open angle glaucoma ?
Trabeculectomy
225
What is the treatment of low grade bladder cancer
Transurethral resection of bladder tumour (TURBT) | Local diathermy
226
What is the treatment of bladder cancer that has invaded into the detrusor muscle?
Radical cystectomy
227
Which is more likely to spread beyond testes: seminoma or non seminoma?
Non seminoma
228
Nasal polyps in children are common/uncommon
Uncommon
229
If you see child with nasal polyps think?
?Cystic fibrosis
230
What is more alarming: unilateral / bilateral polyps?
Unilateral
231
Most common location of epistaxis
Little's area (anterior part of septum)
232
Name 4 potential causes of epistaxis
Trauma Tumour Anticoagulants Bleeding disorders
233
Treatment of epistaxis (3 options)
1. External digital compression / pressure 2. Cautery (with silver nitrate) 3. Nasal packing
234
Treatment of chronic sinusitis?
Surgical enlargement of sinus drainage opening when maximal medical therapy (antibiotics / nasal vasoconstrictors) has failed
235
How to classify rhinitis
``` Infective - viral usually (rhinosinusitis) Non-infective - allergic - non-allergic (polyps) ```
236
What are the most common allergens of allergic rhinitis
Grass and tree pollen
237
How to classify intermittent vs persistent rhinitis?
Intermittent = less than 4 days per week or less than 4 weeks Persistent = more than 4 days per week AND more than 4 weeks
238
Name 2 investigations for allergic rhinitis
Skin prick testing | RAST
239
Medical management of nasal polyps
topical +/- oral steroids
240
What is the most common bacterial cause of sore throat?
Streptococcus pyogenes (group A strep)
241
Name 4 potential complications that can occur with bacterial sore throat?
Peritonsilar abscess (quinsy) Rheumatic fever Glomerulonephritis
242
Severe sore throat with grey-white membrane across the pharynx
Diphtheria
243
Which virus causes infectious mononucleosis?
EBV
244
Sore throat, fever, enlarged cervical lymph nodes, malaise, lethargy, rash. On examination white exudate coats tonsils. What does this make you think
Infectious mononucleosis
245
Investigations for infectious mononucleosis
``` Bloods - atypical lymphocytes (B lymphocytes) - low CRP (surprising) EBV IgM - Monospot test - Paul Bunnel test Maybe have raised LFT ```
246
Management of infectious mononucleosis
Self limiting | If severe, oral corticosteroids
247
What happens if you give a patient with sore throat antibiotics? (presumed to be bacterial but its actually infecious mononucleosis)
Generalised macular rash
248
Chromafin positive gangliomas are usually above/below the diaphragm and produce ____?
Below | Produce adrenaline
249
Which is more likely to present with lymphadenopathy: viral or bacterial tonsilitis?
Bacterial
250
Throat swab is recommended in tonsilitis. True or false?
False | - core species do not always correlate with commensal surface bacteria
251
Which antibiotic is used to treat bacterial tonsilitis?
Phenoxymethylpenicillin
252
Surgery (tonsilectomy) is only considered if patient has X or more episodes of tonsilitis per year?
7 or more
253
Criteria used to differentiate between bacterial and viral sore throat
CENTOR criteria - absence of cough - tonsilar Exudates - tender cervical lymphadenopathy - temperature - age under 15 - add 1 point - age over 44 - subtract 1 point
254
CENTOR criteria score 0-1 management
Self limiting, viral cause
255
CENTOR criteria 2-3 management
Antibiotics if symptoms persist, possible bacterial infection
256
CENTOR criteria 4-5 management
Treat empirically with antibiotis
257
Hx of preceding tonsilitis then unilateral throat pain, odynophagia, lock jaw
Peritonsilar abscess
258
What is the management of a peritonsilar abscess
Aspiration
259
What is the most common cause of noisy breathing in infancy?
Laryngomalacia
260
What are the 2 types of benign HPV
6 and 11
261
What are the 2 types of malignanct HPV
16 and 18
262
What condition causes subglottic stenosis ?
Small vessel vasculitis
263
Cancer of the vocal cords is very likely / unlikely to metastasise?
Very unlikely
264
Supra glottis tumours spread to which lymph nodes
Deep cervical lymph nodes
265
Infra glottis tumours spread to which lymph nodes
Paratracheal lymph nodes
266
Salivary gland tumours - which gland is most often affected?
Parotid gland
267
Where does a pleomorphic adenoma commonly occur?
Parotid gland
268
Name 4 risk factors for head and neck cancer
Smoking (elderly) Alcohol (elderly) Viruses (HPV and EBV) - younger onset Betel nut chewing
269
Red flag symptoms suggestive of throat cancer
``` Persisting sore throat Hoarse voice Change in voice (recurrent laryngeal nerve) Stridor Dysphagia Odynophagia Neck lump ```
270
Head and neck cancer: small tumour, big lymph nodes
HPV
271
What is the first line investigation in suspicious neck mass?
US + FNA
272
Examining cervical lymph nodes
Zig zag - medial to lateral using finger prints - down anterior triangle using pincer grip - along clavicle area using flat hands - pre auricular, post auricular - occipital
273
39 year old overweight female with soft supraclavicular swelling. US normal, bloods normal. What is the likley diagnosis?
Supraclavicular fat pad
274
Neck swelling + dilated veins
?SVC obstruction
275
Swollen lymph glands + young patient ...
Think ?lymphoma
276
2 common locations for HPV cancer
Base of tongue | Tonsils
277
Treatment of non severe nasal polyps
Topical steroids
278
Treatment of severe nasal polyps
Oral steroids
279
What is a pleomorphic adenoma?
Benign salivary gland tumour
280
Which salivary gland is most affected by tumour (benign or malignant) ?
Parotid gland
281
Which muscle is good for distinguishing between anterior and posterior triangle of neck?
Sternocleidomastoid
282
B-symptoms (?lymphoma) in neck lump
Night sweats | Weight loss
283
When feeling for neck lump what should you report (4)
Where is it located Is there only one lump? Is it mobile or fixed?
284
What imaging investigation is good for staging head and neck cancer
CT scan
285
What imaging investigation is good for salivary glands
MRI sca n
286
Rule of 80's for cervical lymph nodes
80% cancerous 80% metastasis, only 20% lymphoid (ie lymphoma) 80% of primary sites are above level of clavicle
287
Rule of 80's for salivary gland tumour
80% parotid gland 80% benign 80% pleomorphic adenoma
288
Name 2 benign salivary gland tumours?
Pleomorphic adenoma | Warthins tumour
289
Features of malignant salivary gland tumour
Facial nerve palsy Pain Lymphadenopathy
290
Thyroid lumps move on swallowing. True or false?
True
291
2 most important things to ask in thyroid pathology Hx?
Hx of radiation exposure | FHx thyroid cancer
292
Thyroid cyst - what are the TFTs like
Normal
293
Investigation of thyroid cyst
US | CT scan
294
Multinodular goitre investigation
US - benign
295
Multinodular goitre TFTs
Normal
296
Hashimotos thyroiditis TFTs
Hypothyroid (T3/T4 low, TSH high) | TPO elevated
297
Graves disease TFTs
Hyperthyroid (T3/T4 high, TSH low)
298
Most common type of thyroid cancer
Papillary
299
Rapid onset neck mass, midline, airway issues and hoarseness. Which type of cancer is this
Anaplastic
300
Mainstay of management for thyroid papillary cancer
Surgery and radioactive iodine
301
Most common cause of lymph nodes in children?
Reactive lymphadenopathy (infectious cause)
302
Congenital neck lumps: dermoid - location - treatment
location: midline, can have a hair in it Treatment: surgery
303
Congenital neck lumps: thyroglossal cyst | - location
Location: midline, moves on swallowing, over larynx and below hyoid usually
304
Congenital neck lumps: cystic hygroma - location - treatment
Location: posterior triangle Treatment: surgery or sclerotherapy
305
Branchial cyst location
Anterior triangle
306
Cystic hygroma is common in elderly / young?
Young - present at birth
307
Name top 3 head and neck malignancies in children?
Lymphoma Rhabdomyosarcoma Neuroblastoma
308
MEN is associated with which type of thyroid cancer?
medullary
309
Which type of thyroid cancer is most common in children?
Medullary
310
A patient will be diagnosed to have recurrent Urinary tract infections (UTIs), if the frequency of UTIs episode is at least:
3 in one year or twice in 6 months
311
Which 1 of the following findings on urine dipstick would suggest a patient is likely to have UTI? - presence of leukocytes - presence of nitrites - presence of blood - pH >7.5
Presence of nitrites
312
Name 3 classes of antibiotics effective in the treatment of prostatitis?
Ciprofloxacin Doxycycline Co-trimoxazole
313
Young patient, age 30, with multiple recurrent UTIs. US urinary tract shows no abnormalities. What is the next best investigation? - CT urogram - CT stone search - flexible cystoscopy - KUB X-ray
FLexible cystoscopy
314
? bladder cancer. Flexible cystoscopy done and did not show any abnormality. What is next investigation? - CT urogram - Urine culture and sensitivities - US urinary tract - PSA level
CT urogram
315
Staghorn calculi are associated with what types of urinary stone?
magnesium ammonium phosphate stone | Proteus?
316
A male patient is admitted with history of left ureteric colic. CT stone search showed, radiolucent 5 mm left distal ureteric stone. His observations are stable and afebrile but pain is persisting and blood tests showed worsening renal function. What is next step in management and WHY? - ureteric stent insertion - ESWL (lithroplasty)
Ureteric stent insertion - over 5mm in size so must be removed - worsening renal function
317
When do you use ureteric stent insertion over ESWL for ureteric stone removal
If infection or obstruction present, use stent insertion
318
A 60-year-old diabetic male, has bothersome mild to moderate lower urinary tract symptoms, along with erectile dysfunction. Which of following medications will be the best choice to alleviate his symptoms? - phosphodiesterase-5 inhibitors (tadalafil) - 5-alpha reductase inhibitor (finasteride) - alpha blocker (tamsulosin) - muscarinic receptor inhibitor (tolteridine)
phosphodiesterase-5 inhibitors (tadalafil)
319
patient with sudden visual blurring bilaterally and light sensitivity. BP 191/127. On dilated fundoscopy both optic discs re swollen, cotton wool spots and flame haemorhages. What is likely diagnosis and what is first line Tx?
Hypertensive retinopathy | IV labetolol
320
Only way air can get into the middle ear is through
Eustachian tube
321
What is Jacobson's nerve
Branch of CN IX
322
What is Arnold's nerve
Branch of CN X
323
Name 5 areas that the CN V3 supplies
``` Anterior 2/3rd of tongue Inferior oral cavity Floor of mouth Lower teeth Salivary glands ```
324
What supplies posterior 1/3rd tongue
CN IX
325
Otalgia + hearing loss makes you think
?obstruction
326
Otalgia + tinnitus or vertigo? where is the problem likely to be?
In the inner ear
327
TMJ problems tend to affect women/men ?
Women
328
Which is a red flag in ENT: unilateral or bilateral neck mass?
Unilateral
329
Patient with otalgia + unusual looking tonsil ?malignancy what imaging investigation is done?
CT scan
330
Management of CN IX neuralgia | - unilateral tingling / throbbing type of pain ?
Carbamazepine Gabapentin Amitryptiline
331
What is necrotising otitis externa? What is the common causative organism? What is the treatment?
When otitis externa extends into the temporal bone Pseudomonas aerguinosa Hospitalisation for 6 weeks IV antibiotics
332
Patient with chronic earache - normal ENT exam - normal dental exam What do you do?
MRI
333
Which 2 things to do when examining TMJ
1. look at patient straight on and assess symmetry | 2. feel TMJ for crepitus whilst patient opens and shuts mouth
334
Which nerves can cause referred otalgia (4)
C2 and C3 CN V3 CN IX CN X
335
How can C2 and C3 spinal nerves cause otalgia?
Through arthritis / cervical spondylosis
336
Name 3 ways which CN V3 can cause otalgia (3)
``` Dental disease (eg tooth impaction, abscess) TMJ dysfunction Nasopharyngeal disease ```
337
Name 2 ways which CN IX can cause otalgia
tongue base tumor | Almost any oropharyngeal infective process (tonsilitis, pharyngitis, quinsy)
338
Name 1 way in which CN X can cause otalgia ?
Malignancy or larync and hypopharynx
339
Stertor is caused by obstruction of airway above/below the larynx?
Above
340
Low pitched snoring or snuffly sound
Stertor
341
In which condition do you get stertor
Obstructive sleep apnoea
342
Stridor is due to air flow changes within the larnynx, trachea or main bronchi. True or false?
True
343
Continuous noise, whistling in nature
Wheeze
344
Wheeze is common by conditions affecting upper/lower respiratory tract?
Lower
345
What does normal voice production require
Vocal cords need to come together, dring the closure they vibrate
346
laryngectomy vs tracheostomy
laryngectomy - complete removal of the larynx, trachea brought to the skin as a stoma, person can only breathe through stoma tracheostomy - hole made in the trachea, person can breathe through nose and mouth
347
Speech through speaking valve can be done in laryngectomy / tracheostomy?
Tracheostomy
348
Airway emergency (eg stridor) management
OXYGEN Heliox (helium and oxygen) nebulised adrenaline
349
How to secure an airway obstruction - get in above/below cause of obstrution?
Below
350
3 options for securing an airway if patient has an airway obstruction
Intubation Cricothyroidotomy Tracheostomy
351
When may you use a nasopharyngeal airway instead of oropharyngeal airway?
Severe anaphylaxis so tongue is swollen and there is no way of getting tube down the mouth Severe fractures of the jaw so can't open mouth
352
Cricothyroidotomy is usually temporary measure / permentent?
Temporary measure
353
What is used to treat cancer of the larynx? tracheostomy / laryngectomy?
Laryngectomy
354
Causes of nose bleeds
``` Trauma Tumour Medication - warfarin Patient's with low platelets GPA HHT - hereditary haemorrhagic telangectasia ```
355
Pubertal boy with recurrent epistaxis
juvenile nasal angiofibroma
356
Which autoimmune condition causes epistaxis
GPA
357
Name 2 principle parts of the body that GPA affects
Renal | Lungs
358
If GPA in the nose is not treated, what happens to the nose?
Saddle deformity | nasal septum gone.
359
First line management of epistaxis in any situation
Apply external compression Lean forward - so that you don't swallow the blood Suck on ice
360
Treating of epistaxis in A+E
Adrenaline + lidocane gauze up nose to stop bleeding (constricts vessels and numbs nose) + tranexamic acid then cauterisation Then packs
361
85 y/o patient with epistaxis, tried everything including packing but nothing helping. Not fit to go under GA. What do you do?
Interventional radiology - embolize
362
Unmasked bone conduction,
Hear it in the ear that hears best
363
Sensorineural hearing loss at high frequency
Presbycusis
364
4K dip on audiogram, sensorineural, what is the likely cause
Noise exposure
365
low frequency sensorineural hearing loss is classically what you get in which condition?
Menieres disease
366
How can you tell if you're looking at T1 or T2 MRI
Fat is bright on T1 and T2, bone is black on T1 and T2 Water is bright in T2 Water is dark in T1
367
Unilateral sensorineural hearing loss, What do you do?
MRI scan to check for vestibular schwanoma
368
Name 6 treament options (in order) for epistaxis
1. external compression + ice 2. Cauterisation with silver nitrate 3. Nasal packing 4. Endoscopic ligation of sphenopalatine artery 5. ligation of the external carotid artery 6. embolisation
369
Name the 5 vessels which supply the nasal cavity
``` Greater palatine artery Sphenopalatine artery Anterior ethmoidal artery Posterior ethmoidal artery Superior labial branch of the facial artery ```
370
The sphenopalatine artery mainly supplies which area of the nose?
Lateral wall
371
Antihistamines used in allergy are more specifically antagonists of which histamine receptors? H1/H2/H3/H4
H1
372
Which symptoms might be caused by chronic ottitis media with effusion? - recurrent otalgia - recurrent ear discharge - hearing loss - none - all of the above
All of the above
373
What would tympanic membrane look like in chronic ottitis media with effusion? - name 2 features
Retracted and dull
374
HPV head and neck cancer usually responds well/poorly to treatment?
Well
375
``` Patient with vertigo episodes - last up to 4 hours - preceding aural fullness - tinnitus what is likely diagnosis? ```
Meniere's disease
376
Which 2 of the following features make quinsy more likely than tonsilitis - voice change - history of previous tonsilitis - change in sense of taste - loss of appetite - headache - laterality of sore throat
Laterality of sore throat | Voice change
377
``` Which feature in the full blood count might be helpful in demonstrating infectious mononucleosis? Microcytic anaemia Neutropenia Lymphocytosis Thrombocytopenia Neutrophilia ```
Lymphocytosis
378
Sudden unilateral hearing loss (sensorineural) then vertigo later. What is likely?
Vestibular schwannoma
379
Prolonged vertigo for a number of days (can last for 3 weeks) Patient may feel nauseous and vomit No associated tinnitus No associated hearing loss
Vestibular neuronitis
380
What investigation do you do to confirm if a patient has middle ear effusion? and what will it show?
Tympanogram - flat line
381
What is the main complication to be aware of of acute otitis media?
Acute mastoiditis
382
gradual onset conductive hearing loss with normal examination findings
Otosclerosis
383
Which treatment is contraindicated in patients with otosclerosis?
HRT
384
B cells / T cells produce IgE ?
B cells
385
Name 2 things which mast cells produce
Histamine | Leukotrienes
386
Patient presents to GP with nose blockage. Fixed and always present in Right side. Name 2 possibilities
Septal deviation | Nasal polyps in right
387
Patient with allergic rhinitis in GP. How long should they be treated for and what are examples of treatment
Treat for 3 months Avoidance of trigger Anti-histamines - certirazine, loratidine Topical steroids - fluticasone, beclometasone LTRA
388
Patient with hoarseness should be referred from GP -> secondary care if the hoarseness persists beyond ???
3 weeks
389
``` Patient with the following symptoms - persistent dysphonia - stridor / airway obstruction - dysphagia - otalgia - neck nodes What is likely diagnosis? ```
Laryngeal cancer
390
Majority of people with laryngeal cancer will need a laryngectomy. True or false?
False | - most treated with radiotherapy / chemoradiotherapy / laser surgery
391
Cricoid cartilage is above/below thyroid cartilage
Below
392
All laryngeal muscles are supplied by which nerve? | Apart from which muscle?
All laryngeal muscles are supplied by RLN apart from cricothyroid muscle.
393
What would happen if the patient had a bilateral vocal cord palsy ? What would they need?
Wouldn't be able to speak or difficulty swallowing | - needs tracheotomy
394
Which nerve is involved in vocal cord paralysis?
Vagus nerve
395
What is the most common cause of renkie's oedema?
Smoking
396
Which nerve supplies the middle ear? | And what specifically is it called?
CN IX | Jacob's nerve
397
Management of TMJ dysfunction
NSAIDs Soft diet Dental guard Refer to dentist
398
What is hairy leukoplakia associated with?
EBV
399
? suspicious lesion in salivary gland. What is best investigation? CT or MRI?
MRI
400
Causes of congenital sensorineural hearing loss non-genetic (2)
Maternal infection | Alcohol/drug misuse during pregnancy
401
Causes of acquired sensorineural hearing loss (7)
Presbyacusis (age related) Noise induced Inflammatory (meningitis, mumps, measles, syphilis) Autoimmune (GPA, sarcoidosis, rheumatoid arthritis) Vestibular schwannoma Meniere's disease Ototoxic drugs
402
Rapidly progressing, fluctuating, unilateral sensorineural hearing loss. What is likely cause and how would you treat
Autoimmune - GPA / sarcoidosis / rheumatoid arthritis - Tx: steroids +/- immunosuppression
403
Patients presenting with unilateral sensorineural hearing loss should have what investigation and why
MRI | Check for vestibular schwannoma
404
menieres disease is typically low/high frequency hearing loss
Low
405
Name 2 drugs which are ototoxic
Gentamicin | Platinum based chemotherapy agents
406
Newborn undergoes hearing assessment on the ward and fails. What is next step?
Re-test
407
Newborn undergoes hearing assessment and fails, then fails the re-test. What is next step?
Brainstem evoked response audiometry
408
Sensorineural hearing loss present at birth / develops in childhood Retinitis pigmentosa (gradual onset visual impairment) balance problems Autosomal recessive
Usher's syndrome
409
Sensorineural hearing loss presetn at birth Different coloured iris White patch of hair What is this syndrome called and what is mode of inheritance?
Waardenburg's syndrome | Autosomal Dominant
410
Sensorineural hearing loss Goitre (with normal or reduced thyroid function) What is the syndrome and what is mode of inheritance?
Pendred's syndrome | Autosomal recessive
411
Where in the nose are nasal packs inserted in epistaxis?
Along the hard palate
412
Patient has ongoing epistaxis despite first aid cauterisation and nasal packing, what is the most common operation?
Sphenopalatine artery ligation
413
Patient has ongoing epistaxis despite first aid cauterisation and nasal packing, what is the last line operation?
Embolisation with IR
414
Whats the treatment of Bell's palsy
Early high dose steroids
415
What is ramsay hunt syndrome
Shingles affecting the facial nerve
416
Parotid swelling + facial nerve palsy suggests
Parotid malignancy
417
Which systemic disease can cause a facial palsy
Lymes disease
418
What is the treatment of ramsay hunt syndrome
Oral steroids (5 days) + oral antiviral (aciclovir - 7 days)
419
Name 3 complications of obstructive sleep apnoea
Pulmonary hypertension - cor pulmonale - cardiac dysrhythmias Daytime solemnence
420
OSA and DVLA
Must tell DVLA you have OSA
421
OSA and DVLA and HGV
Can't drive HGV until OSA treated
422
Management of OSA in children
Adenotonsillectomy
423
Hypermetropia is a risk factor for open/closed angle glaucoma?
Closed angle
424
Visual field defect in the macula will be
Central scotoma
425
Which of the following fundoscopy findings is a key feature of grade 4 hypertensive retinopathy? - AV nipping - cotton wool spots - papilloedema - flame haemorrhages
Pappiloedema
426
Myopia is a risk factor for which condition?
Retinal detachment
427
26 year old seeks medical attention for red eye. He wears contact lenses, and apart from redness is entirely asymptomatic. What is likely cause?
Episcleritis
428
Risks for subconjunctival haemorrahge
Straining - cough - sneeze
429
Treatment of choice for CMV retinitis
Gancyclovir
430
Temporal lobe lesions cause a homonymous SUPERIOR/INFERIOR quadrantopia
Superior | - PITS
431
AV nipping is an early/late change seen in hypertensive retinopathy
Early
432
Branchial cydt Cystic hygroma Which is more common in children?
Cystic hygroma
433
What is the investigation of choice for acoustic neuroma?
MRI scan
434
Patient over 45 with visible haematuria that persists or recurs following UTI. What should you suspect?
Bladder cancer
435
Patient with BPH and urinary retention. Has TWOC but fails. What should you do?
TURP procedure
436
What does the lingual nerve supply?
Taste for the anterior 2/3rds of the tongue
437
What is the treatment of ottitis externa?
Topical antibiotics +/- steroids 7 days

Y4 (23 decks)

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