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MSRA > Things I didn't know > Flashcards

Things I didn't know Flashcards

1
Q

Treatment for latent TB? (2)

A

The treatment for latent tuberculosis is 3 months of isoniazid (with pyridoxine) and rifampicin OR 6 months of isoniazid (with pyridoxine)

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2
Q

Treatment for meningeal TB? (1)

A

Patients with meningeal tuberculosis are treated for a prolonged period (at least 12 months) with the addition of steroids

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3
Q

Complication of TB treatment - enlarging lymph nodes at 3-6 weeks?

A

Immune reconstitution disease

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4
Q

TB drug which causes gout?

A

Pyrazinamide

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5
Q

TB drug which cause agranulocytosis?

A

Isoniazid

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6
Q

Most common inherited kidney disease?

A

Autosomal dominant polycystic kidney disease (ADPKD) 1 in 1000 caucasians

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7
Q

Autosomal dominant polycystic kidney disease (ADPKD) types? Chromosomes involved? Which has earlier renal failure?

A

ADPKD Type 1 - 85% cases - PKD1 on Ch 16. Presents with early renal failure. ADPKD Type 2 - 15% cases - PKD2 on Ch4.

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8
Q

Treatment for polycystic kidney disease in selected patients?

A

Tolvaptan (V2 receptor antagonist) - They must have CKD 2-3 with evidence of rapid progressoin.

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9
Q

Treatment for otitis media with perforation?

A

Amoxicillin then review in 2 weeks (may need myringoplasty if not healing).

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10
Q

Most common ankle ligament sprained in inversion injuries?

A

The anterior talofibular ligament is the most commonly sprained ligament in inversion injuries of the ankle (>90%).

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11
Q

Components of the syndesmosis binding the distal tibia and fibula?

A

Composed of the: - anterior inferior tibiofibular ligament (AITFL) - posterior inferior tibiofibular ligament (PITFL) - interosseous ligament (IOL) -the interosseous membrane

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12
Q

Lateral collateral ligaments of the ankle (3)?

A

The distal fibular is secured to the to the talus by the anterior and posterior talofibular ligaments (ATFL and PTFL) and to the calcaneus by the calcaneofibular ligament

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13
Q

What is a high ankle sprain? Usual mechanism?

A

Sprain involving syndesmosis. Usually external rotation of the foot causing the talus to push the fibula laterally.

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14
Q

What is a Maisonneuve fracture?

A

The Maisonneuve fracture is a spiral fracture of the proximal third of the fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane.

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15
Q

What is a loop ileostomy used for?

A

Defunctioning of colon e.g. following rectal cancer surgery

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16
Q

When is an end ileostomy used for?

A

Where a colon is diverted or resected and anastomosis is not primarily achievable or desirable

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17
Q

Section 2 of MHA?

A

Admission for assessment for up to 28 days, not renewable. Treatment can be given against patient’s wishes.

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18
Q

Section 3 of MHA?

A

Admission for treatment for up to 6 months, can be renewed. Treatment can be given against patient’s wishes.

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19
Q

Section 4 of MHA?

A

72 hour assessment order used as an emergency, when a section 2 would involve an unacceptable delay

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20
Q

Section 5(2) of MHA?

A

A patient who is a voluntary patient in hospital can be legally detained by a doctor for 72 hours

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21
Q

Section 135 of MHA?

A

a court order can be obtained to allow the police to break into a property to remove a person to a Place of Safety

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22
Q

Section 136 of MHA?

A

Someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety. Can only be used for up to 24 hours, whilst a Mental Health Act assessment is arranged

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23
Q

Peutz-Jegher syndrome - Inheritance pattern? - Genes ? (2)

A

autosomal dominant responsible gene encodes serine threonine kinase LKB1 or STK11

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24
Q

Tumour marker CA 15-3 associated with?

A

Breast cancer

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25
Q

Tumour marker Bombesin associated with?

A

Small cell lung carcinoma, gastric cancer, neuroblastoma

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26
Q

Tumour marker S-100 associated with?

A

Melanoma, schwannomas

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27
Q

Most common cause of renal artery stenosis in young women?

A

fibromuscular dysplasia

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28
Q

Second-line urate-lowering agent?

A

Febuxostat (also a xanthine oxidase inhibitor)

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29
Q

What should be added when starting urate-lowering therapy?

A

The initiation or up-titration of urate-lowering therapy may precipitate an acute attack, and therefore colchicine should be considered as prophylaxis and continued for up to 6 months. A low-dose NSAID with gastro-protection is an alternative in patients who have contra-indications to colchicine

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30
Q

Live attenuated vaccines (57

A
  • BCG
  • measles, mumps, rubella (MMR)
  • influenza (intranasal)
  • oral rotavirus
  • oral polio
  • yellow fever
  • oral typhoid
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31
Q

95% of cases of testicular cancer are? They can be divided into 2 categories (2)

A

Germ cell tumours Germ cell tumours may essentially be divided into: seminomas & non-seminomas: including embryonal, yolk sac, teratoma and choriocarcinoma

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32
Q

Peak age of incidence for testicular teratomas? And seminomas? Risk factors (5)

A

The peak incidence for teratomas is 25 years and seminomas is 35 years. Risk factors include: infertility (increases risk by a factor of 3) cryptorchidism family history Klinefelter’s syndrome mumps orchitis

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33
Q

Beta thalassaemia trait: Blood film? Which blood marker is characteristically raised?

A

Beta-thalassaemia trait is an autosomal recessive condition characterised by a mild hypochromic, microcytic anaemia. It is usually asymptomatic Features mild hypochromic, microcytic anaemia - microcytosis is characteristically disproportionate to the anaemia HbA2 raised (> 3.5%)

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34
Q

Psoriasis plaque management: Primary care: First line? Duration? Second line? Third line? Secondary care: First line? First line systemic therapy?

A

regular emollients may help to reduce scale loss and reduce pruritus first-line: a potent corticosteroid applied OD plus vitamin D analogue applied OD (should be applied separately) 4 weeks as initial treatment second-line: if no improvement after 8 weeks then offer: a vitamin D analogue twice daily third-line: if no improvement after 8-12 weeks then offer either: a potent corticosteroid applied twice daily for up to 4 weeks, or a coal tar preparation applied once or twice daily Secondary care management Phototherapy narrowband ultraviolet B light is now the treatment of choice. If possible this should be given 3 times a week Systemic therapy oral methotrexate is used first-line. It is particularly useful if there is associated joint disease

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35
Q

Management of scalp psoriasis?

A

NICE recommend the use of potent topical corticosteroids used once daily for 4 weeks

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36
Q

Management of face, flexural and genital psoriasis?

A

NICE recommend offering a mild or moderate potency corticosteroid applied once or twice daily for a maximum of 2 weeks

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37
Q

Examples of vit D analogues? Should be avoided in?

A

Vitamin D analogues examples of vitamin D analogues include calcipotriol (Dovonex), calcitriol and tacalcitol they work by ↓ cell division and differentiation → ↓ epidermal proliferation they should be avoided in pregnancy

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38
Q

Vitiligo Tend to affect which areas of body? What can precipitate new lesions?

A

the peripheries tend to be most affected trauma may precipitate new lesions (Koebner phenomenon)

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39
Q

Management of vitiligo:

A

Management sunblock for affected areas of skin camouflage make-up topical corticosteroids may reverse the changes if applied early there may also be a role for topical tacrolimus and phototherapy, although caution needs to be exercised with light-skinned patients

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40
Q

When should fibrinolysis be used in STEMI? What drug should be given prior to fibrinolysis? How does it work?

A

Fibrinolysis is the indicated treatment for ST-elevation myocardial infarctions when percutaneous coronary intervention (PCI) cannot be given within 120 minutes Fondaparinux is an antithrombin medication. It works by activating antithrombin 3 which causes the inactivation of factor Xa. In patients undergoing fibrinolysis. Its role in STEMI is to prevent the clot from getting bigger. It should be given before fibrinolysis.

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41
Q
A
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42
Q

What is bailout in PCI? Which drug is used?

A

bailout is the action of using a GPI during the procedure when it was not intended from the outset, e.g. because of worsening or persistent thrombus

glycoprotein IIb/IIIa inhibitor (GPI)

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43
Q
A
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44
Q

Conservative management for patients with NSTEMI/unstable angina?

A

‘dual antiplatelet therapy’, i.e. aspirin + another drug)

if the patient is not at a high risk of bleeding: ticagrelor

if the patient is at a high risk of bleeding: clopidogrel

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45
Q

SSRI interacts with what to cause bleeding?

A

SSRI + NSAID = GI bleeding risk - give a PPI

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46
Q

How do azathioprine and allopurinol interact?

A

Azathioprine is a prodrug, meaning it is metabolised to its active form, 6-mercaptopurine, which causes immunosuppression (preventing kidney rejection in this patient). The active 6-mercaptopurine is subsequently metabolised by xanthine oxidase to inactive this uric acid which is excreted. As allopurinol inhibits xanthine oxidase, the combination of the two drugs can lead to excessive myelosuppression and therefore increase the risk of neutropenic sepsis.

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47
Q
A
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48
Q

Inactivated preparation vaccines (3)

A

Inactivated preparations

rabies

hepatitis A

influenza (intramuscular)

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49
Q

Toxoid vaccines (3)

A

Toxoid (inactivated toxin)

tetanus

diphtheria

pertussis

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50
Q

Conjugate vaccines (5)

A

pneumococcus (conjugate)

haemophilus (conjugate)

meningococcus (conjugate)

hepatitis B

human papillomavirus

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51
Q

Causes of raised ALP (7)

A

Causes of raised alkaline phosphatase (ALP)

  • liver: cholestasis, hepatitis, fatty liver, neoplasia
  • Paget’s
  • osteomalacia
  • bone metastases
  • hyperparathyroidism
  • renal failure
  • physiological: pregnancy, growing children, healing fractures
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52
Q

Diagnosis of gestational diabetes:

Fasting?

2 hour?

A

fasting glucose is >= 5.6 mmol/L

2-hour glucose is >= 7.8 mmol/L

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53
Q

If gestational diabetes is diagnosed and fasting glucose is <7, what are the three management steps?

And if fasting glucose is >7?

A
  1. if the fasting plasma glucose level is < 7 mmol/l a trial of diet and exercise should be offered
  2. if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started
  3. if glucose targets are still not met insulin should be added to diet/exercise/metformin

gestational diabetes is treated with short-acting, not long-acting, insulin

  • if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started
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54
Q

Management of lichen planus?

A

potent topical steroids are the mainstay of treatment

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55
Q

Features of toxic epidermal necrolysis (TEN)? (2)

Drugs known to induce TEN (6)

Management (3)

A

Features

  • systemically unwell e.g. pyrexia, tachycardic
  • positive Nikolsky’s sign: the epidermis separates with mild lateral pressure

Drugs known to induce TEN

  • phenytoin
  • sulphonamides
  • allopurinol
  • penicillins
  • carbamazepine
  • NSAIDs

Management

  • stop precipitating factor
  • supportive care - often in an intensive care unit
  • intravenous immunoglobulin has been shown to be effective and is now commonly used first-line
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56
Q
A
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57
Q

How often is Depo Provera given?

How long can you wait?

What is the main mechanism of action?

A

It is given via in intramuscular injection every 12 weeks. It can however be given up to 14 weeks after the last dose without the need for extra precautions**

The main method of action is by inhibiting ovulation.

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58
Q

When should visible haematuria be referred under a 2 week wait (2)?

When should a non-urgent referral be made?

A

2WW

Aged >= 45 years AND:

  • unexplained visible haematuria without urinary tract infection, or
  • visible haematuria that persists or recurs after successful treatment of urinary tract infection

Aged >= 60 years AND have unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test

Non-urgent

Aged >=60 years with recurrent or persistent unexplained urinary tract infection

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59
Q

When can non-visible haematuria be safely managed in primary care?

A

Patients under the age of 40 years with normal renal function, no proteinuria and who are normotensive do not need to be referred and may be managed in primary care

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60
Q

When is carotid end arterectomy recommended?

A

Carotid artery endarterectomy is recommend if the patient has suffered a stroke or TIA in the carotid territory and is not severely disabled. It should only be considered if the carotid stenosis is greater than 70% or 50%.

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61
Q

Antiplatelet for TIA/ischaemic stroke?

If it can’t be tolerated?

A

Antiplatelets

TIA: clopidogrel

ischaemic stroke: clopidogrel

Aspirin 75 mg daily with modified-release dipyridamole 200 mg twice daily may be used if clopidogrel cannot be tolerated.

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62
Q

Lateral epicodylitis AKA?

A

tennis elbow

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63
Q

Management of Parkinson’s - how is first line treatment determined?

A

For first-line treatment:

  • if the motor symptoms are affecting the patient’s quality of life: levodopa
  • if the motor symptoms are not affecting the patient’s quality of life: dopamine agonist (non-ergot derived), levodopa or monoamine oxidase B (MAO‑B) inhibitor
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64
Q

2WW criteria for breast lumps? (2)

A

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:

  • aged 30 and over and have an unexplained breast lump with or without pain or
  • aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern
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65
Q

Causes of scarring alopecia (5)

A
  • trauma, burns
  • radiotherapy
  • lichen planus
  • discoid lupus
  • tinea capitis*
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66
Q

Causes of non-scarring alopecia (7)

A

Non-scarring alopecia

  • male-pattern baldness
  • drugs: cytotoxic drugs, carbimazole, heparin, oral contraceptive pill, colchicine
  • nutritional: iron and zinc deficiency
  • autoimmune: alopecia areata
  • telogen effluvium
  • hair loss following stressful period e.g. surgery
  • trichotillomania
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67
Q

Which trinucleotide repeat disorder does not show anticipation?

A

Friedreich’s ataxia is unusual in not demonstrating anticipation

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68
Q

Management of acne

First step?

Second step?

Oral antibiotics? Alternative in women? And in pregnancy?

Final step?

A
  1. single topical therapy (topical retinoids, benzoyl peroxide)
  2. topical combination therapy (topical antibiotic, benzoyl peroxide, topical retinoid)
  3. oral antibiotics: (tetracyclines: lymecycline, oxytetracycline, doxycycline)
    • Erythromycin in pregnancy
    • COCP/Dianette for women
  4. Oral isotretinoin
    • Pregnancy is a contraindication to topical and oral retinoids
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69
Q

COCP increases risk of which cancers (2)?

Protective against which cancers (2)?

A

Combined oral contraceptive pill

  • increased risk of breast and cervical cancer
  • protective against ovarian and endometrial cancer
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70
Q

Menopause management

  • Vasomotor symptoms?
  • Vaginal dryness
  • Psychological self help
  • Urogenital symptoms
A

Vasomotor symptoms

  • fluoxetine, citalopram or venlafaxine

Vaginal dryness

  • vaginal lubricant or moisturiser

Psychological symptoms

  • self-help groups, cognitive behaviour therapy or antidepressants

Urogenital symptoms

  • if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not
  • vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required.
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71
Q

UKMEC4 conditions for COCP (8)

A

Examples of UKMEC 4 conditions include

  1. more than 35 years old and smoking more than 15 cigarettes/day
  2. migraine with aura
  3. history of thromboembolic disease or thrombogenic mutation
  4. history of stroke or ischaemic heart disease
  5. breast feeding < 6 weeks post-partum
  6. uncontrolled hypertension
  7. current breast cancer
  8. major surgery with prolonged immobilisation
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72
Q

What medications confound a urea breath test and with what timings?

A

Urea breath test - no antibiotics in past 4 weeks, no antisecretory drugs (e.g. PPI) in past 2 weeks

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73
Q

Ulcerative colitis management

  • First line for mild to moderate ? When is oral treatment needed?
  • How long before adding second line?
A

First line for mild to moderate - topical (rectal) aminosalicylate.

If disease is extensive (past left sided colon), then add oral amiosalicylate (as enema won’t reach).

If remission not achieved within 4 weeks, add oral aminosalicylate or switch to PO + steroid.

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74
Q

Ulcerative colitis maintenance

  • Following mild flare?
  • Following severe relapse or >2 exacerbation per year?
A

Following a mild-to-moderate ulcerative colitis flare

proctitis and proctosigmoiditis

  • topical (rectal) aminosalicylate alone (daily or intermittent) or
  • an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or
  • an oral aminosalicylate by itself: this may not be effective as the other two options

left-sided and extensive ulcerative colitis

  • low maintenance dose of an oral aminosalicylate

Following a severe relapse or >=2 exacerbations in the past year

  • oral azathioprine or oral mercaptopurine
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75
Q

Treatment of TIA if presenting to GP within 7 days?

A

A patient who presents to their GP within 7 days of a clinically suspected TIA should have 300mg aspirin immediately (and be referred for specialist review within 24h)

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76
Q

How to withdraw long term benzos?

And if this doesn’t work?

A
  • The dose should be withdrawn in steps of about 1/8 (range 1/10 to 1/4) of the daily dose every fortnight.

If difficulties:

  • switch patients to the equivalent dose of diazepam
  • reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg
  • time needed for withdrawal can vary from 4 weeks to a year or more
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77
Q

How do benzodiazipines and barbiturates differ in their effect on chloride channel opening?

A

GABAA drugs

benzodiazipines increase the frequency of chloride channels

barbiturates increase the duration of chloride channel opening

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78
Q

In which patients should FRAX be used (3)?

How are FRAX results ultiilsed?

A
  1. all women aged >= 65 years
  2. all men aged >= 75 years
  3. Younger patients should be assessed in the presence of risk factor

If the FRAX assessment was done without a bone mineral density (BMD) measurement the results (10-year risk of a fragility fracture) will be given and categorised automatically into one of the following:

  • low risk: reassure and give lifestyle advice
  • intermediate risk: offer BMD test
  • high risk: offer bone protection treatment
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79
Q

How should breast cysts be managed?

A

Breast cysts should be aspirated as there is a small risk of breast cancer, especially in younger women.

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80
Q

Contraceptives - time until effective (if not first day period):

  • IUD?
  • POP?
  • COC, injection, implant, IUS?
A

Contraceptives - time until effective (if not first day period):

  • instant: IUD
  • 2 days: POP
  • 7 days: COC, injection, implant, IUS
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81
Q

Management of cradle cap

  • Mild
  • Severe
A

Management depends on severity

mild-moderate: baby shampoo and baby oils

severe: mild topical steroids e.g. 1% hydrocortisone

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82
Q

How does mania differ from hypomania (4)?

A
  • Lasts for at least 7 days
  • Causes severe functional impairment in social and work setting
  • May require hospitalization due to risk of harm to self or others
  • May present with psychotic symptoms (e.g. delusions of grandeur, auditory hallucinations)
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83
Q

How should MRSA carriers be treated?

A

Suppression of MRSA from a carrier once identified

  • nose: mupirocin 2% in white soft paraffin, tds for 5 days
  • skin: chlorhexidine gluconate, od for 5 days. Apply all over but particularly to the axilla, groin and perineum
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84
Q

Varenicline & buproprion

Mechanisms?

Side effects?

Contraindication?

A

Varenicline

  • a nicotinic receptor partial agonist
  • nausea is the most common adverse effect.
  • varenicline should be used with caution in patients with a history of depression. Contraindicated in pregnancy and breast feeding.

Buproprion

  • a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
  • should be started 1 to 2 weeks before the patients target date to stop
  • small risk of seizures (1 in 1,000)
  • contraindicated in epilepsy, pregnancy and breast feeding. Having an eating disorder is a relative contraindication
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85
Q

Ottowa rules for ankle injury (1+3)

A

An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:

  • bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)
  • bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)
  • inability to walk four weight bearing steps immediately after the injury and in the emergency department
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86
Q

Which medication is contraindicated in VT?

A

Verapamil

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87
Q

From which age can pure tone audiometry be performed?

A

>3 years

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88
Q

2nd line antihypertensive in AfroCarribean pts?

A

For patients of black African or African–Caribbean origin taking a calcium channel blocker for hypertension, if they require a second agent consider an angiotensin receptor blocker in preference to an ACE inhibitor

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89
Q

Factors suggesting faecal impaction in children (3)?

Treatment?

A

Factors which suggest faecal impaction include:

  • symptoms of severe constipation
  • overflow soiling
  • faecal mass palpable in the abdomen (digital rectal examination should only be carried out by a specialist)

If faecal impaction is present

  • polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment
  • add a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks
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90
Q

How should labour be managed in a woman with grade III/IV placenta previa?

A

If a woman with known placenta praevia goes into labour (with or without bleeding), an emergency caesarean section should be performed

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91
Q

When should anti-D routinely be given to non-sensitised Rh-ve mothers?

Which other situations require anti-D (8)?

A

NICE (2008) advise giving anti-D to non-sensitised Rh -ve mothers at 28 and 34 weeks

Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) in the following situations:

  1. delivery of a Rh +ve infant, whether live or stillborn
  2. any termination of pregnancy
  3. miscarriage if gestation is > 12 weeks
  4. ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)
  5. external cephalic version
  6. antepartum haemorrhage
  7. amniocentesis, chorionic villus sampling, fetal blood sampling
  8. abdominal trauma
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92
Q

First line for urge incontinence?

First meds?

Second line med?

A
  • bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
  • bladder stabilising drugs: antimuscarinics are first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in ‘frail older women’
  • mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
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93
Q

Argyll Robinson pupil?

A

Argyll-Robertson Pupil (ARP) is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA)

Features

  • small, irregular pupils
  • no response to light but there is a response to accommodate
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94
Q

Which NSAID is contraindicated in cardiac disease?

A

Diclofenac is now contraindicated with any form of cardiovascular disease

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95
Q

Meds causing pancreatitis (8)?

A
  1. azathioprine
  2. mesalazine
  3. didanosine
  4. bendroflumethiazide
  5. furosemide
  6. pentamidine
  7. steroids
  8. sodium valproate
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96
Q

What must be performed before treating venous ulcers with compression bandaging?

A

An ABPI must be performed before initiating compression treatment to rule out arterial disease (normal result 0.9-1.2).

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97
Q

Which oral medication may improve healing of venous ulcers?

A

Oral pentoxifylline, a peripheral vasodilator, improves healing rate

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98
Q

How are AAA screened in the UK?

Above what diameter is considered an aneurysm?

A

In the UK, all men aged 65 years are offered aneurysm screening with a single abdominal ultrasound

Diameters of 3cm and greater, are considered aneurysmal

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99
Q

What is secondary dysmenorrhoea?

Causes (5)?

Management?

A

Secondary dysmenorrhoea typically develops many years after the menarche and is the result of an underlying pathology. In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period. Causes include:

  • endometriosis
  • adenomyosis
  • pelvic inflammatory disease
  • intrauterine devices*
  • fibroids

All patients with secondary dysmenorrhoea need to be referred to gynaecology for investigation.

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100
Q

Which blood tests may return elevated in anorexia(6)?

A

G’s and C’s raised:

  • growth hormone
  • Glucose
  • Salivary glands
  • Cortisol,
  • Cholesterol
  • Carotinaemia
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101
Q

90% of genital warts caused by which HPV strains (2)?

Management (first line (2), second line(1))

Which HPV strains cause cervical cancer (3)?

A

Types 6 and 11 are responsible for 90% of genital warts cases

  • Topical podophyllum or cryotherapy are commonly used as first-line
  • Multiple, non-keratinised warts are generally best treated with topical agents whereas solitary, keratinised warts respond better to cryotherapy.
  • Imiquimod is a topical cream which is generally used second line

It is now well established that HPV (primarily types 16,18 & 33) predisposes to cervical cancer.

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102
Q

IUS vs IUD

  • Mechanism of action?
  • Time until effective?
A

IUD: primary mode of action is prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions)

IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening

IUD - can be relied upon immediately following insertion

IUS - can be relied upon after 7 days

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103
Q

Chickenpox exposure in pregnancy

How is it managed differently at different gestations?

If a woman develops symptoms?

A

If there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies.

  • If the pregnant woman <= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible.
  • if the pregnant woman > 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure

If develops symptoms - specialist advice + PO aciclovir

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104
Q

The A’s of ankylosing spondylitis(6)?

A

Ankylosing spondylitis features - the ‘A’s

  1. Apical fibrosis
  2. Anterior uveitis
  3. Aortic regurgitation
  4. Achilles tendonitis
  5. AV node block
  6. Amyloidosis
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105
Q

What is Fitz-Hugh-Curtis syndrome?

Cause?

A

Fitz-Hugh–Curtis syndrome is a rare complication of pelvic inflammatory disease (PID) involving liver capsule inflammation leading to the creation of adhesions.

It is usually caused by Chlamydia trachomatis (Chlamydia) or Neisseria gonorrhoeae (Gonorrhea)

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106
Q

Diagnosis of hereditary haemorrhagic telangiectasia(4)?

Inheritance?

A

There are 4 main diagnostic criteria. If the patient has 2 then they are said to have a possible diagnosis of HHT. If they meet 3 or more of the criteria they are said to have a definite diagnosis of HHT:

  • epistaxis : spontaneous, recurrent nosebleeds
  • telangiectases: multiple at characteristic sites (lips, oral cavity, fingers, nose)
  • visceral lesions: for example gastrointestinal telangiectasia (with or without bleeding), pulmonary arteriovenous malformations (AVM), hepatic AVM, cerebral AVM, spinal AVM
  • family history: a first-degree relative with HHT

Autosomal dominant

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107
Q

Most common cause of HCC worldwide? And in Europe?

A

Hepatocellular carcinoma

hepatitis B most common cause worldwide

hepatitis C most common cause in Europe

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108
Q

Factors that increase BNP(11)?

A

Increase BNP levelsDecrease BNP levels

  1. Left ventricular hypertrophy
  2. Ischaemia
  3. Tachycardia
  4. Right ventricular overload
  5. Hypoxaemia (including pulmonary embolism)
  6. GFR < 60 ml/min
  7. Sepsis
  8. COPD
  9. Diabetes
  10. Age > 70
  11. Liver cirrhosis
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109
Q

Factors that decrease BNP levels(6)?

A

Decrease BNP levels

  1. Obesity
  2. Diuretics
  3. ACE inhibitors
  4. Beta-blockers
  5. Angiotensin 2 receptor blockers
  6. Aldosterone antagonists
110
Q

Classic triad of glandular fever?

Other features (8)

A

Classic triad of sore throat, pyrexia and lymphadenopathy

Other features

  • malaise, anorexia, headache
  • palatal petechiae
  • splenomegaly - occurs in around 50% of patients and may rarely predispose to splenic rupture
  • hepatitis, transient rise in ALT
  • lymphocytosis: presence of 50% lymphocytes with at least 10% atypical lymphocytes
  • haemolytic anaemia secondary to cold agglutins (IgM)
  • a maculopapular, pruritic rash develops in around 99% of patients who take ampicillin/amoxicillin whilst they have infectious mononucleosis
111
Q

Why can domperidone be safely used in PD?

A

Domperidone does not cross the blood-brain barrier and therefore does not cause extra-pyramidal side-effects.

112
Q

Diagnostic investigation for pancreatic cancer?

A

High-resolution CT scanning is the diagnostic investigation of choice for pancreatic cancer

113
Q

Treatment for bacterial vaginosis in pregnancy?

A

Metronidazole 400mg BD for 7 days

114
Q

Appearance of vulval carcinoma vs VIN?

A

Vulval carcinomas are commonly ulcerated and can present on the labium majora. Melanomas are usually pigmented. Vulval intraepithelial neoplasia tend to be white or plaque like and don’t tend to ulcerate.

115
Q

Nerve roots for following reflexes:

  • Ankle
  • Knee
  • Biceps
  • Triceps
A

Reflex Root

  • Ankle S1-S2
  • Knee L3-L4
  • Biceps C5-C6
  • Triceps C7-C8
116
Q

When should Abx prophylaxis be given in ascites(2)?

A

Antibiotic prophylaxis should be given to patients with ascites if:

  • patients who have had an episode of SBP
  • patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome
117
Q
A
118
Q

Glaucoma drug causing brown pigmentation of iris?

A

Latanoprost

119
Q

Drugs that may cause urinary retention (5)

A

The following drugs may cause urinary retention:

tricyclic antidepressants e.g. amitriptyline

anticholinergics

opioids

NSAIDs

disopyramide

120
Q

How are deaths of patients with previous asbestos exposure handled (regardless of cause)?

A

If a person with an asbestos-related condition dies, regardless of the cause of their death, the coroner should be notified

121
Q

Ages covered by NHS breast screening programme?

When should younger women be referred for assessment(2)?

A

The NHS Breast Screening Programme is being expanded to include women aged 47-73 years from the previous parameter of 50-70 years. Women are offered a mammogram every 3 years.

Referral to breast clinic at a younger age is warranted if:

  • one first-degree or second-degree relative diagnosed with breast cancer at any age and one first-degree or second-degree relative diagnosed with ovarian cancer at any age (one of these should be a first-degree relative).
  • Paternal family history of breast cancer
122
Q

When are tetanus vaccinations required following an injury (2)?

When is tetanus immunoglobulin required (2)?

A

Patient has had a full course of tetanus vaccines, with the last dose < 10 years ago

  • no vaccine nor tetanus immunoglobulin is required, regardless of the wound severity

Patient has had a full course of tetanus vaccines, with the last dose > 10 years ago

  • if tetanus prone wound: reinforcing dose of vaccine
  • high-risk wounds (e.g. compound fractures, delayed surgical intervention, significant degree of devitalised tissue): reinforcing dose of vaccine + tetanus immunoglobulin

If vaccination history is incomplete or unknown

  • reinforcing dose of vaccine, regardless of the wound severity
  • for tetanus prone and high-risk wounds: reinforcing dose of vaccine + tetanus immunoglobulin
123
Q

Vitamin D supplementation in pregnancy?

A

All pregnant and breastfeeding women should take a daily supplement containing 10micrograms of vitamin D

124
Q

Which class of drug is tamoxifen? Which cancer is it used for?

Adverse effects (4)

A

Tamoxifen is a Selective oEstrogen Receptor Modulators (SERM) that acts as an oestrogen receptor antagonist and partial agonist. It is used in the management of oestrogen receptor-positive breast cancer.

Adverse effects

  • menstrual disturbance: vaginal bleeding, amenorrhoea
  • hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects
  • venous thromboembolism
  • endometrial cancer
125
Q

Two examples of aromatase inhibitors?

Which patients are they used in?

Adverse effects (4)

A

Anastrozole and letrozole are aromatase inhibitors that reduce peripheral oestrogen synthesis. This is important as aromatisation accounts for the majority of oestrogen production in postmenopausal women and therefore anastrozole is used for ER +ve breast cancer in this group.

Adverse effects

  • osteoporosis
    • NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer
  • hot flushes
  • arthralgia, myalgia
  • insomnia
126
Q

When should a COCP be stopped before surgery?

A

Oestrogen-containing contraceptives should preferably be discontinued 4 weeks before major elective surgery and all surgery to the legs or surgery which involves prolonged immobilisation of a lower limb.

127
Q

Most common extra-intestinal feature in both Crohn’s and UC?

A

Arthritis is the most common extra-intestinal feature in both Crohn’s and UC

128
Q

Management of first trimester bleeding?

  • Less than 6 weeks?
  • More than 6 weeks?

Symptoms suggestive of ectopic pregnancy(3)?

A

If the pregnancy is < 6 weeks gestation and women have bleeding, but NO pain or risk factors for ectopic pregnancy, then they can be managed expectantly. These women should be advised:

  • to return if bleeding continues or pain develops
  • to repeat a urine pregnancy test after 7–10 days and to return if it is positive
  • a negative pregnancy test means that the pregnancy has miscarried

If the pregnancy is > 6 weeks gestation (or of uncertain gestation) and the woman has bleeding she should be referred to an early pregnancy assessment service.

Symptoms suggestive of ectopic pregnancy:

  1. pain and abdominal tenderness
  2. pelvic tenderness
  3. cervical motion tenderness
129
Q

Cervical cancer screening:

Ages?

Frequency?

A

Cervical cancer screening

25-49 years: 3-yearly

50-64 years: 5-yearly

130
Q

Management of cluster headaches:

Acute (2)

Prophylaxis (1)

A

Management

  • acute: 100% oxygen (80% response rate within 15 minutes), subcutaneous triptan (75% response rate within 15 minutes)
  • prophylaxis: verapamil is the drug of choice. There is also some evidence to support a tapering dose of prednisolone
131
Q

Who needs a test of cure following chlamydia treatment and when?

A

A TOC should be performed 6 weeks post infection in pregnant women as recommended by the BASHH guidelines.

A TOC is not routinely required in uncomplicated chlamydia infection in men and non- pregnant women.

132
Q

LARC of choice in under 20’s?

A

The progesterone-only implant (Nexplanon) is therefore the LARC of choice is young people.

133
Q

First sign of puberty in males? And in females?

A

Males

  • first sign is testicular growth at around 12 years of age (range = 10-15 years)

Females

  • first sign is breast development at around 11.5 years of age (range = 9-13 years)
134
Q

Mechanism of Nexplanon?

A

Nexplanon - main mechanism of action is inhibition of ovulation

135
Q

Reasons that high dose folate is needed in pregnancy (6)

A
  • either partner has a neural tube defect they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
  • the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
  • the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).
136
Q

What are the following operations used for:

  • Right hemicolectomy?
  • Left hemicolectomy?
  • High anterior resection?
  • Low anterior resection? Difference from high?
  • Hartmann’s procedure?
A

Cancers of the cecum, ascending or a proximal third of the transverse colon are resected using a right hemicolectomy.

A left hemicolectomy is used to excise tumours of the distal two-thirds of the transverse colon and descending colon.

A high anterior resection is used to excise upper rectal tumours. Resection of the proximal rectum and sigmoid colon

A low anterior resection is used to approach low rectal tumours (less than 5cm from the anus). It involves excision of the distal colon, rectum and anal sphincters, resulting in a permanent end colostomy.

Hartmann’s procedure is executed in emergencies, such as bowel obstruction or perforation. This involves complete resection of the rectum and sigmoid colon with the formation of an end colostomy and the closure of the rectal stump.

137
Q

Describe the following signs:

Tinel’s

Phalen’s

Reverse Phalen’s

Froments

Westphal

A

The symptoms of a median nerve palsy in this context can be reproduced by tapping the area of the flexor retinaculum (Tinel’s sign), or by holding the wrist in flexion (Phalen’s sign) or extension (reverse Phalen’s), both of which increase the pressure within the carpal tunnel.

Froment’s sign: The patient is asked to hold an object, usually a flat object such as a piece of paper, between the thumb and index finger (pinch grip) associated with ulnar nerve palsy.

Westphal’s sign is the absence of a patellar jerk.

138
Q

Foods to avoid in gout(5)?

A

Foods to avoid include those high in purines e.g. Liver, kidneys, seafood, oily fish (mackerel, sardines) and yeast products

139
Q

Causes of massive splenomegaly(5)

A

The causes of massive splenomegaly are as follows:

  1. myelofibrosis
  2. chronic myeloid leukaemia
  3. visceral leishmaniasis (kala-azar)
  4. malaria
  5. Gaucher’s syndrome
140
Q

When can medical management of fibroids be trialled?

A

If a uterine fibroid is less than 3cm in size, and not distorting the uterine cavity, medical treatment can be tried (e.g. IUS, tranexamic acid, COCP etc)

141
Q

Classification of ovarian hyperstimulation syndrome

Criteria for each category:

Mild (2)

Moderate (3)

Severe (4)

Critical (4)

A
142
Q

Piyriasis versicolor

Caused by?

Commonly affects?

More noticeable when?

Treatment (2)?

A

Pityriasis versicolor, also called tinea versicolor, is a superficial cutaneous fungal infection

  • caused by Malassezia furfur (formerly termed Pityrosporum ovale)
  • most commonly affects trunk
  • patches may be hypopigmented, pink or brown (hence versicolor). May be more noticeable following a suntan

Management

  • topical antifungal. NICE Clinical Knowledge Summaries advise ketoconazole shampoo as this is more cost effective for large areas
  • if failure to respond to topical treatment then consider alternative diagnoses (e.g. send scrapings to confirm the diagnosis) + oral itraconazole
143
Q

X-ray changes in OA(4)?

A

X-ray changes of osteoarthritis

  • decrease of joint space
  • subchondral sclerosis
  • subchondral cysts
  • osteophytes forming at joint margins
144
Q

Salivary gland tumours

Most common presentation?

What is a Warthin’s tumour?

A

80% affect parotid and are

Pleomorphic adenomas (benign, ‘mixed parotid tumour’, 80%)

  • middle age
  • slow growing, painless lump
  • superficial parotidectomy; risk = CN VII damage

Warthin’s tumour (benign, ‘adenolymphomas’, 10%)

  • males, middle age
  • softer, more mobile and fluctuant (although difficult to differentiate)
145
Q

Salivary gland stones

Most common site?

A

Stones

  • recurrent unilateral pain & swelling on eating
  • may become infected → Ludwig’s angina
  • 80% are submandibular
146
Q

Where are the 3 pairs of salivary glands?

A

parotid (serous) - most tumours

submandibular (mixed) - most stones

sublingual (mucous)

147
Q

Holmes-Adie pupil?

Accommodation vs light reflex?

Holmes-Adie syndrome?

A

Holmes-Adie pupil is a benign condition most commonly seen in women. It is one of the differentials of a dilated pupil.

Overview

  • unilateral in 80% of cases
  • dilated pupil
  • once the pupil has constricted it remains small for an abnormally long time
  • slowly reactive to accommodation but very poorly (if at all) to light

Holmes-Adie syndrome

association of Holmes-Adie pupil with absent ankle/knee reflexes

148
Q

HOCM

Most common defects in HOCM (2)?

Echo findings (3)

Associations (2)

A

The most common defects involve a mutation in the gene encoding β-myosin heavy chain protein or myosin-binding protein C

Echo findings - mnemonic - MR SAM ASH

  • mitral regurgitation (MR)
  • systolic anterior motion (SAM) of the anterior mitral valve leaflet
  • asymmetric hypertrophy (ASH)

Associations

  • Friedreich’s ataxia
  • Wolff-Parkinson White
149
Q

Drug induced thrombocytopenia (7)

A

Drug-induced thrombocytopenia (probable immune-mediated)

  • quinine
  • abciximab
  • NSAIDs
  • diuretics: furosemide
  • antibiotics: penicillins, sulphonamides, rifampicin
  • anticonvulsants: carbamazepine, valproate
  • heparin
150
Q

Morphine conversions

Oral to oxycodone

Oral to Subcut morphine

Oral to subcut diamorphine

A

Oral morphine to oxycodone - divide by 1.5

151
Q

Risk factors for DDH(7)?

A

Risk factors

  • female sex: 6 times greater risk
  • breech presentation
  • positive family history
  • firstborn children
  • oligohydramnios
  • birth weight > 5 kg
  • congenital calcaneovalgus foot deformity
152
Q

When should IV dexamethasone not be given in meningitis (4)?

A

Intravenous dexamethasone should also be given to reduce the risk of neurological sequelae, but the BNF advise to withhold if:

  • septic shock
  • meningococcal septicaemia
  • immunocompromised
  • meningitis following surgery
153
Q

Cautions in use of sulfasalazine (2)

Adverse effects (5)

A

Cautions

  • G6PD deficiency
  • allergy to aspirin or sulphonamides (cross-sensitivity)

Adverse effects

  • oligospermia
  • Stevens-Johnson syndrome
  • pneumonitis / lung fibrosis
  • myelosuppression, Heinz body anaemia, megaloblastic anaemia
  • may colour tears → stained contact lenses
154
Q

Most common cause of liver disease in the developed world?

A

Non-alcoholic fatty liver disease (NAFLD) is now the most common cause of liver disease in the developed world.

155
Q

Stages of NAFLD (3)

What test should be done is NAFLD is found incidentally?

A

spectrum of disease ranging from:

  • steatosis - fat in the liver
  • steatohepatitis - fat with inflammation, non-alcoholic steatohepatitis (NASH), see below
  • progressive disease may cause fibrosis and liver cirrhosis

NICE recommends the use of the enhanced liver fibrosis (ELF) blood test to check for advanced fibrosis

the ELF blood test is a combination of hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1.

156
Q

Stroke management

Thrombolysis - time frame?

A

Thrombolysis with alteplase should only be given if:

  • it is administered within 4.5 hours of onset of stroke symptoms (unless as part of a clinical trial)
  • haemorrhage has been definitively excluded (i.e. Imaging has been performed)
157
Q

Thrombectomy

Situations for use plus time frames for each (3)

A

Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)

Offer to patients who were last well between 6 hours and 24 hours previously (including wake-up strokes) with confirmed anterior circulation stroke and if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume.

Consider thrombectomy(+/- thrombolysis) in patients last known to be well up to 24 hours previously (including wake-up strokes) who have acute ischaemic stroke and confirmed occlusion of the proximal posterior circulation if there is the potential to salvage brain tissue.

158
Q

Secondary prevention stroke (2)

A
  • clopidogrel is now recommended by NICE ahead of combination use of aspirin plus modified-release (MR) dipyridamole in people who have had an ischaemic stroke
  • aspirin plus MR dipyridamole is now recommended after an ischaemic stroke only if clopidogrel is contraindicated or not tolerated, but treatment is no longer limited to 2 years’ duration
  • MR dipyridamole alone is recommended after an ischaemic stroke only if aspirin or clopidogrel are contraindicated or not tolerated, again with no limit on duration of treatment

With regards to carotid artery endarterectomy:

  • recommend if patient has suffered stroke or TIA in the carotid territory and are not severely disabled
  • should only be considered if carotid stenosis > 70% according ECST** criteria or > 50% according to NASCET*** criteria
159
Q

Diagnostic thresholds for gestational diabetes

  • fasting glucose
  • 2-hour glucose
A

Diagnostic thresholds for gestational diabetes

these have recently been updated by NICE, gestational diabetes is diagnosed if either:

fasting glucose is >= 5.6 mmol/l

2-hour glucose is >= 7.8 mmol/l

160
Q

Breast cancer risk factors (11)

A

Predisposing factors

  • BRCA1, BRCA2 genes - 40% lifetime risk of breast/ovarian cancer
  • 1st degree relative premenopausal relative with breast cancer (e.g. mother)
  • nulliparity, 1st pregnancy > 30 yrs (twice risk of women having 1st child < 25 yrs)
  • early menarche, late menopause
  • combined hormone replacement therapy (relative risk increase * 1.023/year of use), combined oral contraceptive use
  • past breast cancer
  • not breastfeeding
  • ionising radiation
  • p53 gene mutations
  • obesity
  • previous surgery for benign disease
161
Q

Head injury in adults

Immediate CT head (7)

Within 8 hours (4)

A

CT head immediately

  • GCS < 13 on initial assessment
  • GCS < 15 at 2 hours post-injury
  • suspected open or depressed skull fracture.
  • any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
  • post-traumatic seizure.
  • focal neurological deficit.
  • more than 1 episode of vomiting

CT head scan within 8 hours of the head injury - for adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury:

  • age 65 years or older
  • any history of bleeding or clotting disorders
  • dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)
  • more than 30 minutes’ retrograde amnesia of events immediately before the head injury

If a patient is on warfarin who have sustained a head injury with no other indications for a CT head scan, perform a CT head scan within 8 hours of the injury.

162
Q

How to decide between cyclical vs continuous HRT?

A

Cyclical HRT is recommended in perimenopausal women because it produces predictable withdrawal bleeding, whereas continuous regimens often cause unpredictable bleeding.

163
Q

Management of boxer’s fracture?

A

Metacarpal fracture may require surgical repair, and so should normally be discussed with plastic or hand surgery. A volar slab is an appropriate technique to immobilise the hand in the meantime.

164
Q

Most common type of breast cancer?

A

Invasive ductal carcinoma (no special type) is the most common type of breast cancer

165
Q

Drug monitoring for the following:

  • Amiodarone
  • Methotrexate
  • Azathioprine
  • Lithium
  • Sodium valproate
  • Glitazones
A

Amiodarone

  • TFT, LFT, U&E, CXR prior to treatment
  • TFT, LFT every 6 months

Methotrexate

  • FBC and renal and LFTs before starting treatment and repeated weekly until therapy stabilised, thereafter patients should be monitored every 2-3 months

Azathioprine

  • FBC, LFT before treatment
  • FBC weekly for the first 4 weeks
  • FBC, LFT every 3 months

Lithium

  • TFT, U&E prior to treatment
  • Lithium levels weekly until stabilised then every 3 months
  • TFT, U&E every 6 months

Sodium valproate

  • LFT, FBC before treatment
  • LFT ‘periodically’ during first 6 months

Glitazones

  • LFT before treatment
  • LFT ‘regularly’ during treatment
166
Q

Above what ABPM/HBPM is treatment required(2)?

A

ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension)

treat if < 80 years of age AND any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 10% or greater

ABPM/HBPM >= 150/95 mmHg (i.e. stage 2 hypertension)

offer drug treatment regardless of age

167
Q

BP targets

Clinic and ABPM/HBPM targets by age

A

Clinic BP

Age < 80 years

  • 140/90 mmHg

Age > 80 years

  • 150/90 mmHg

ABPM / HBPM

Age < 80 years

  • 135/85 mmHg

Age > 80 years

  • 145/85 mmHg
168
Q

First line for trigeminal neuralgia?

A

Carbamazepine is first-line

169
Q

Causes of artificially raised HbA1c (3)

A

Vitamin B12/folic acid deficiency
Iron-deficiency anaemia
Splenectomy

170
Q

Emergency contraception

Levonorgestrel (Levonelle)

  • Must be taken within?
  • Dosing considerations (2)
  • If vomiting?
  • How many times per menstrual cycle can it be used?
  • When can hormonal contraception be restarted?

Ulipristal (EllaOne)

  • Mechanism
  • Must be taken within?
  • Interaction with hormonal contraception?
  • Caution in which patients?
  • How many times per menstrual cycle?

IUD

  • Must be inserted within (2)
  • If patient wishes it removed?
A

Levonorgestrel (Levonelle)

  • Must be taken within 72 hours
  • Dosing considerations - double if BMI>26 or wt >70kg
  • If vomiting within 3 hours, repeat dose
  • Can be used more than once per menstrual cycle
  • Hormonal contraception be restarted immediately

Ulipristal (EllaOne)

  • Inhibits ovulation
  • Must be taken within 120 hours
  • Reduced effectiveness of hormonal contraception - 5 days
  • Caution in patients with severe asthma
  • Can be used more than once per cycle

IUD

  • Must be inserted within 5 days of UPSI or up to 5 days after likely ovulation date.
  • May be left in-situ to provide long-term contraception. If the patient wishes for the IUD to be removed it should be at least kept in until the next period
171
Q

Benign ganglion cysts usually found on the distal, dorsal aspect of the finger are known as?

Association?

A

Myxoid cysts (also known as mucous cysts) are benign ganglion cysts usually found on the distal, dorsal aspect of the finger. There is usually osteoarthritis in the surrounding joint. They are more common in middle-aged women.

172
Q

Management of anterior uveitis(2)?

A

Anterior uveitis is most likely to be treated with a steroid + cycloplegic (mydriatic) drops

173
Q
A
174
Q

Management of keloid scars?

A

Treatment

  • early keloids may be treated with intra-lesional steroids e.g. triamcinolone
  • excision is sometimes required
175
Q

Features of compression of L3 (4)

A

Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test

176
Q

Features of compression of L4 (4)

A

Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test

177
Q

Features of compression of L5 (4)

A

Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test

178
Q

Features of S1 nerve root compression (4)

A

Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test

179
Q

First-line management of primary open angle glaucoma?

A

first line: prostaglandin analogue (PGA) eyedrop

180
Q

First line for generalised seizures?

First line for focal seizures?

A

Sodium valproate is considered the first line treatment for patients with generalised seizures

Carbamazepine used for focal seizures.

181
Q

Which seizures can carbemazepine exacerbate?

A

Carbamazepine may exacerbate absence seizures and myoclonic seizures

182
Q

How should suspected age-related macular degeneration be managed?

A

Referral to ophthalmology urgently within 1 week if suspecting AMD

183
Q

Definition of maternal mortality?

A

Maternal mortality includes any death in pregnancy and labour as well as up to six weeks post partum

184
Q

Drugs causing raised prolactin (galactorrhoea) (4)

A

Drug causes of raised prolactin

metoclopramide

Domperidone

phenothiazines (chlorpromazine)

haloperidol

185
Q

Normal ICP (mmHg)?

A

<15mmgHg

186
Q

Which common antihypertensives should be avoided in HOCM? Why?

A

ACE-inhibitors should be avoided in patients with HOCM.

ACE inhibitors can reduce afterload which may worsen the LVOT gradient.

187
Q

Drugs causes of gynaecomastia (7)?

A

Drug causes of gynaecomastia

  • spironolactone (most common drug cause)
  • cimetidine
  • digoxin
  • cannabis
  • finasteride
  • GnRH agonists e.g. goserelin, buserelin
  • oestrogens, anabolic steroids
188
Q

Urinary osmolality in ATN? And urinary Na?

A

Kidneys can no longer concentrate urine or retain sodium - urine osmolality low, urine sodium high.

189
Q

Difference between circumstantiality and tangentiality?

A

Circumstantiality is the inability to answer a question without giving excessive, unnecessary detail. However, this differs from tangentiality in that the person does eventually return the original point.

Tangentiality refers to wandering from a topic without returning to it.

190
Q

Most common cause of erythema multiforme?

Drug causes (6)

A

Herpes simplex virus (the most common cause)

Penicillin, sulphonamides, carbamazepine, allopurinol, NSAIDs, oral contraceptive pill.

191
Q

Extra-intestinal features of Crohn’s/UC that are related to disease activity(4)?

And those unrelated to disease activity(5)?

A

Related to disease activity

  • Arthritis: pauciarticular, asymmetric
  • Erythema nodosum
  • Episcleritis
  • Osteoporosis

Unrelated to disease activity

  • Arthritis: polyarticular, symmetric
  • Uveitis
  • Pyoderma gangrenosum
  • Clubbing
  • Primary sclerosing cholangitis
192
Q

Treatment of thrush in pregnancy?

A

Clotrimazole pessary

193
Q

Reasons for early referral for infertility in women (5)

Reasons for early referral for infertility in men (5)

A

Female

  • Age above 35
  • Amenorrhoea
  • Previous pelvic surgery
  • Previous STI
  • Abnormal genital examination

Male

  • Previous surgery on genitalia
  • Previous STI
  • Varicocele
  • Significant systemic illness
  • Abnormal genital examination
194
Q
A
195
Q

Drugs that can exacerbate psoriasis (6)

A

The following factors may exacerbate psoriasis:

  • trauma
  • alcohol
  • drugs: beta blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors, infliximab
  • withdrawal of systemic steroids
196
Q

Which ages are covered by the NHS screening programme for bowel cancer? How frequently are they tested?

Which test is used?

How does it work?

A

the NHS now has a national screening programme offering screening every 2 years to all men and women aged 60 to 74 years in England, 50 to 74 years in Scotland. Patients aged over 74 years may request screening

Eligible patients are sent Faecal Immunochemical Test (FIT) tests through the post.a Atype of faecal occult blood (FOB) test which uses antibodies that specifically recognise human haemoglobin (Hb).

197
Q

Risk assessment score for bleeding with anticoagulation?

A
198
Q

Relationship of hernias to pubic tubercle:

  • Inguinal
  • Femoral
A

Inguinal hernias and superior and medial to the pubic tubercle

A femoral hernia is located laterally and inferiorly to the pubic tubercle.

199
Q

King’s College Hospital criteria for liver transplantation (paracetamol liver failure) (1 or 3)

A

Arterial pH < 7.3, 24 hours after ingestion

or all of the following:

  • prothrombin time > 100 seconds
  • creatinine > 300 µmol/l
  • grade III or IV encephalopathy
200
Q

When should T1DM patients without cardiovascular disease be offered statins (4)?

A

Individuals with type 1 diabetes who do not have established cardiovascular disease (CVD) risk factors should be offered atorvastatin 20 mg for primary prevention of CVD if they are:

  • Older than 40 years of age
  • Have had diabetes for more than 10 years
  • Have established nephropathy
  • Have other CVD risk factors (such as obesity and hypertension)
201
Q

Drugs causing erythema nodosum (3)?

A

drugs

  • penicillins
  • sulphonamides
  • combined oral contraceptive pill
202
Q

Empirical Abx for suspected epididymo-orchitis?

A

Suspected epididymo-orchitis: If unknown organism: ceftriaxone 500mg intramuscularly single dose, plus oral doxycycline 100mg twice daily for 10-14 days

203
Q

With respect to pregnancy, when can the MMR vaccine be safely given?

A

Non-immune mothers should be offered the MMR vaccination in the post-natal period

MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant

204
Q

Risk of rubella causing fetal injury in first trimester?

Features of congenital rubella(9)?

A

In first 8-10 weeks, risk of damage to fetus is as high as 90%

Features of congenital rubella syndrome

  1. sensorineural deafness
  2. congenital cataracts
  3. congenital heart disease (e.g. patent ductus arteriosus)
  4. growth retardation
  5. hepatosplenomegaly
  6. purpuric skin lesions
  7. ‘salt and pepper’ chorioretinitis
  8. microphthalmia
  9. cerebral palsy
205
Q

When should migraine prophylaxis be given?

What are the first line meds? And if pregnant?

A

Prophylaxis should be given if patients are experiencing 2 or more attacks per month.

NICE advise either topiramate or propranolol ‘according to the person’s preference, comorbidities and risk of adverse events’. Propranolol should be used in preference to topiramate in women of child bearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives.

206
Q

Blurring of vision after cataract surgery?

A

Blurring of vision again years after cataract surgery can occur due to posterior capsule opacification

207
Q

Mechanism of Nexplanon(2)?

Active ingredient?

Duration of action?

A

The main mechanism of action is preventing ovulation. They also work by thickening the cervical mucus.

Slowly releases the progestogen hormone etonogestrel

Lasts 3 years.

208
Q

Drugs contraindicated in breastfeeding (8)§?

A

The following drugs should be avoided:

  1. antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
  2. psychiatric drugs: lithium, benzodiazepines
  3. aspirin
  4. carbimazole
  5. methotrexate
  6. sulfonylureas
  7. cytotoxic drugs
  8. amiodarone
209
Q
A
210
Q

Doses of emergency IM benpen in suspected meningitis?

A

Dose

  • < 1 year - 300 mg
  • 1 - 10 years - 600 mg
  • > 10 years - 1200 mg
211
Q

Score for assessing likelihood of stroke?

First line investigation?

A

A non-contrast CT head scan is the first line radiological investigation for suspected stroke

212
Q

Distinguishing between episcleritis and scleritis

Pain?

Medication?

A

Episcleritis is classically not painful.

Phenylephrine 10% eye drops can be used to distinguish between episcleritis and scleritis. Blanches with episcleritis.

213
Q

Risk factors for Barret’s oesophagus (4)

Which is strongest?

A

Risk factors

  • gastro-oesophageal reflux disease (GORD) is the single strongest risk factor
  • male gender (7:1 ratio)
  • smoking
  • central obesity

Interestingly alcohol does not seem to be an independent risk factor for Barrett’s although it is associated with both GORD and oesophageal cancer.

214
Q

Formula to work out Down syndrome risk above 30?

A

Down’s syndrome risk - 1/1,000 at 30 years then divide by 3 for every 5 years

215
Q

Criteria for assessing the probability of septic arthritis (4)?

A

Kocher’s criteria is used to assess the probability of septic arthritis in children using 4 parameters:

  • Non-weight bearing - 1 point
  • Fever >38.5ºC - 1 point
  • WCC >12 * 109/L - 1 point
  • ESR >40mm/hr
216
Q

Drugs that can precipitate lithium toxicity (4)?

Non-drug causes(2)?

A

Toxicity may be precipitated by:

  • dehydration
  • renal failure
  • drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.
217
Q

Features of lithium toxicity (6)?

A

Features of toxicity

  • coarse tremor (a fine tremor is seen in therapeutic levels)
  • hyperreflexia
  • acute confusion
  • polyuria
  • seizure
  • coma
218
Q

NICE advise that, as PSA levels may be increased, testing should not be done within at least? (5 situation)

A

NICE advise that, as PSA levels may be increased, testing should not be done within at least:

  • 6 weeks of a prostate biopsy
  • 4 weeks following a proven urinary infection
  • 1 week of digital rectal examination
  • 48 hours of vigorous exercise
  • 48 hours of ejaculation
219
Q

Management of patients at risk of corticosteroid-induced osteoporosis

Two groups?

Management of each?

A
  1. Patients over the age of 65 years or those who’ve previously had a fragility fracture should be offered bone protection.
  2. Patients under the age of 65 years should be offered a bone density scan, with further management dependent:

T score

0 - Greater than Reassure

Between 0 and -1.5. - Repeat bone density scan in 1-3 years

Less than -1.5 - Offer bone protection

The first-line treatment is alendronate. Patients should also be calcium and vitamin D replete.

220
Q

Usual timing of MMR?

What if the dose interval if vaccinating at a later time?

A

12-15 months and 3-4 years as part of the routine immunisation schedule

The Green Book recommends allowing 3 months between doses to maximise the response rate. A period of 1 month is considered adequate if the child is greater than 10 years of age. In an urgent situation (e.g. an outbreak at the child’s school) then a shorter period of 1 month can be used in younger children.

221
Q

Red flags for lower back pain (5)

A

Red flags for lower back pain

  • age < 20 years or > 50 years
  • history of previous malignancy
  • night pain
  • history of trauma
  • systemically unwell e.g. weight loss, fever
222
Q

Definition of puerperal pyrexia

Causes (5)

Management of most common cause?

A

Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery.

Causes:

  • endometritis: most common cause
  • urinary tract infection
  • wound infections (perineal tears + caesarean section)
  • mastitis
  • venous thromboembolism

If endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)

223
Q

Drug causes of gingival hyperplasia (3)

Other causes (1)

A

Drug causes of gingival hyperplasia

  • phenytoin
  • ciclosporin
  • calcium channel blockers (especially nifedipine)

Other causes of gingival hyperplasia include

  • acute myeloid leukaemia (myelomonocytic and monocytic types)
224
Q

First-line treatment for LV systolic dysfunction (2)

Second line (1)

A

The first-line treatment for all patients is both an ACE-inhibitor and a beta-blocker

Second-line treatment is an aldosterone antagonist

225
Q

Third line treatments for heart failure secondary to LV systolic dysfunction

Criteria for each:

  • Ivabradine
  • Sacubitril-valsartan
  • Digoxin
  • Hydralizine + nitrate
  • CRT
A

ivabradine

  • criteria: sinus rhythm > 75/min and a left ventricular fraction < 35%

sacubitril-valsartan

  • criteria: left ventricular fraction < 35%
  • is considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs
  • should be initiated following ACEi or ARB wash-out period

digoxin

  • digoxin has also not been proven to reduce mortality in patients with heart failure. It may however improve symptoms due to its inotropic properties
  • it is strongly indicated if there is coexistent atrial fibrillation

hydralazine in combination with nitrate

  • this may be particularly indicated in Afro-Caribbean patients

cardiac resynchronisation therapy

  • indications include a widened QRS (e.g. left bundle branch block) complex on ECG
226
Q

Antibiotics to avoid in pregnancy (4)

A

Antibiotics

  • tetracyclines
  • aminoglycosides
  • sulphonamides and trimethoprim
  • quinolones: the BNF advises to avoid due to arthropathy in some animal studies
227
Q

Anaemia associated with which antiepileptic?

A

Phenytoin may cause a megaloblastic anaemia by altering folate metabolism

228
Q

What are eruptive xanthoma?

Causes of eruptive xanthoma (2)?

Causes of xanthelasma(2)?

A

Eruptive xanthoma are due to high triglyceride levels and present as multiple red/yellow vesicles on the extensor surfaces (e.g. elbows, knees)

Causes of eruptive xanthoma

  • familial hypertriglyceridaemia
  • lipoprotein lipase deficiency

Tendon xanthoma, tuberous xanthoma, xanthelasma

  • familial hypercholesterolaemia
  • remnant hyperlipidaemia
229
Q

Neuroleptic malignant syndrome

Typical features (4)

Management (2)

A

Typical features are:

  • pyrexia
  • muscle rigidity
  • autonomic lability: typical features include hypertension, tachycardia and tachypnoea
  • agitated delirium with confusion

Management

  • IV fluids to prevent renal failure
  • dantrolene may be useful in selected cases
230
Q

Differences between serotonin syndrome and neuroleptic malignant syndrome

  • Causes
  • Onset
  • Reflexes
  • Pupils
  • Management of severe cases
A

Differences from serotonin syndrome

  • SS caused by SSRIs, MAOIs, ecstasy. NMS - antipsychotics.
  • SS has faster onset (hours) vs NMS (hours to days)
  • SS has hyperreflexia and clonus vs hyporeflexia and rigidity in NMS
  • SS pupils dilated. NMS normal pupils.

Mx of severe cases:

  • SS - IV cyproheptadine, NMS - IV dantrolene
231
Q

Hyperacute rejection

Time scale?

Cause? Type of hypersensitivity?

Risk factors (3)

Management?

A

Hyperacute rejection occurs minutes to hours after re-vascularisation of the transplanted kidney. It is due to pre-existing antibodies in the recipient’s blood, such as ABO antibodies (Type II hypersensitivity). This type of rejection is very rare now due to the sensitivity of cross-matching but risk factors include:

  • Previous blood transfusions
  • Previous transplants
  • Multiple pregnancies

No treatment is possible and the graft must be removed

232
Q

When is a CT head within 8 hours indicated after head injury(4)?

A

CT head scan within 8 hours of the head injury - for adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury:

  • age 65 years or older
  • any history of bleeding or clotting disorders
  • dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)
  • more than 30 minutes’ retrograde amnesia of events immediately before the head injury
233
Q

What happens to total iron-binding capacity in iron deficiency anaemia? And transferrin levels? And transferrin saturation?

A

Total iron-binding capacity (TIBC) + transferrin levels are typically raised in iron-deficiency anaemia.

Please note that whilst the transferrin level is typically raised in iron-deficiency anaemia, the transferrin saturation level is reduced.

234
Q

Recurrent vaginal candidiasis

Definition

Actions on diagnosis (5)

Management (2)

A
  • BASHH define recurrent vaginal candidiasis as 4 or more episodes per year

Actions

  • compliance with previous treatment should be checked
  • confirm the diagnosis of candidiasis
  • high vaginal swab for microscopy and culture
  • consider a blood glucose test to exclude diabetes
  • exclude differential diagnoses such as lichen sclerosus

Consider the use of an induction-maintenance regime

  • induction: oral fluconazole every 3 days for 3 doses
  • maintenance: oral fluconazole weekly for 6 months
235
Q

Management of corneal abrasion (1)

A

Treatment with a topical antibiotic is recommended for these patients in order to prevent bacterial superinfection.

236
Q

Definition of primary post partum haemorrhage? Most common cause?

Management (4)

A

Primary PPH

  • occurs within 24 hours
  • affects around 5-7% of deliveries
  • most common cause of PPH is uterine atony (90% of cases). Other causes include genital trauma and clotting factors
  • ABC including two peripheral cannulae, 14 gauge
  • IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms
  • IM carboprost
  • if medical options failure to control the bleeding then surgical options will need to be urgently considered
  • the RCOG state that the intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage
237
Q

If a patient is taking metformin, what is their target HbA1C?

At which HbA1C should a second agent be added?

A

Target - 48mmol/mol (6.5%)

Add second agent - above 58mmol/mol (7.5%)

238
Q
A
239
Q

Acute rejection reactions

2 types?

Time scales?

Which is most common?

A

Acute antibody-mediated rejection occurs weeks to months after transplantation. It is mediated by host antibody recognition of graft antigens as foreign and results in complement activation and immune complex deposition.

Acute T-cell mediated rejection occurs weeks to months after the transplantation. It is mediated by lymphocytic infiltration of the graft. This is the most common type of rejection.

240
Q

Class 1 HLA antigens (3)?

Class 2 (3)?

Relative importance of HLA antigens for HLA matching of organs?

A

Class 1 antigens include A, B and C.

Class 2 antigens include DP,DQ and DR

When HLA matching for a renal transplant the relative importance of the HLA antigens are as follows DR > B > A

241
Q

Methods of termination of pregnancy (3)

  • Less than 9 weeks?
  • Less than 13 weeks?
  • More than 15 weeks?
A

The method used to terminate pregnancy depends upon gestation

  • less than 9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions
  • less than 13 weeks: surgical dilation and suction of uterine contents
  • more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)
242
Q

Immune cells that mediate psoriasis?

A

Psoriasis is mediated by type 1 helper T cells

243
Q

Benign Rolandic epilepsy

Ages affected?

Characteristics of seizures (2)

EEG?

Prognosis?

A

Benign rolandic epilepsy is a form of childhood epilepsy which typically occurs between the age of 4 and 12 years.

Features

  • seizures characteristically occur at night
  • seizures are typically partial (e.g. paraesthesia affecting face) but secondary generalisation may occur (i.e. parents may only report tonic-clonic movements)
  • child is otherwise normal

EEG characteristically shows Benign rolandic epilepsy is a form of childhood epilepsy which typically occurs between the age of 4 and 12 years.

Features

seizures characteristically occur at night

seizures are typically partial (e.g. paraesthesia affecting face) but secondary generalisation may occur (i.e. parents may only report tonic-clonic movements)

child is otherwise normal

EEG characteristically shows centro-temporal spikes

Prognosis is excellent, with seizures stopping by adolescence

Prognosis is excellent, with seizures stopping by adolescence

244
Q

Antidepressants to avoid co-prescribing with warfarin and heparin?

A

NICE guidance suggests avoiding selective serotonin reuptake inhibitors in patients taking warfarin or heparin due to their antiplatelet effect and subsequent increased risk of bleeding.

245
Q

Diagnosis of chronic fatigue syndrome (3 criteria)

A

Diagnosed after at least 4 months of disabling fatigue affecting mental and physical function more than 50% of the time in the absence of another disease which may explain symptoms

246
Q

Malaria prophylaxis for pregnant women (2)?

A

chloroquine can be taken

proguanil: folate supplementation (5mg od) should be given

247
Q

Meniere’s disease

Driving limitations?

Management of acute attacks (2)

Prevention of attacks?

A

ENT assessment is required to confirm the diagnosis

  • patients should inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is achieved
  • acute attacks: buccal or intramuscular prochlorperazine. Admission is sometimes required
  • prevention: betahistine and vestibular rehabilitation exercises may be of benefit
248
Q

Definition of hypertension in pregnancy?

Features of the following?

  • Pre-existing hypertension
  • Pregnancy induced/gestational
  • Pre-eclampsia
A

Hypertension in pregnancy in usually defined as:

  • systolic > 140 mmHg or diastolic > 90 mmHg
  • or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

Pre-existing hypertension

A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation. No proteinuria, no oedema.

Pregnancy-induced hypertension

Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks). No proteinuria, no oedema.

Pre-eclampsia

Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours). Oedema may occur.

249
Q

Causes of raised CA125 besides cancer (3)?

A

CA125 is a tumour marker - although it can be raised by endometriosis, menstruation and benign ovarian cysts

250
Q

First-line analgesia for lower back pain?

A

NSAIDs include ibuprofen or naproxen and consideration should be given to co-administration of PPI.

Paracetamol alone is not recommended for lower back pain and for patients unable to tolerate NSAIDs, co-codamol should be considered.

251
Q

Alternative to valproate for the treatment of tonic-clonic seizures in women of childbearing age?

A

Offer lamotrigine if sodium valproate is unsuitable

252
Q

Cut-offs for diagnosing diabetes (2)

And if they’re asymptomatic?

A

Diabetes diagnosis: fasting > 7.0, random > 11.1

If asymptomatic need two readings

253
Q

Treatment of stable angina

First line? Caveats?

Second line?

Third line? Caveat?

A

First line - beta-blocker or a calcium channel blocker

  • If a calcium channel blocker is used as monotherapy a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker then use a long-acting dihydropyridine calcium-channel blocker (e.g. modified-release nifedipine).

if a patient is still symptomatic after monotherapy with a beta-blocker add a calcium channel blocker and vice versa

if a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then consider one of the following drugs: a long-acting nitrate, ivabradine, nicorandil or ranolazine

if a patient is taking both a beta-blocker and a calcium-channel blocker then only add a third drug whilst a patient is awaiting assessment for PCI or CABG

254
Q

Conditions associated with seborrhoeic dermatitis(2)?

A

Associated conditions include

HIV

Parkinson’s disease

255
Q

Test to diagnose De Quervain’s tenosynovitis?

A

Finkelstein’s test: the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus

256
Q

Examination finding of iliotibial band syndrome?

A

Iliotibial band syndrome is a common cause of lateral knee pain in runners, occurring in around 1 in 10 people who run regularly.

Features

  • tenderness 2-3cm above the lateral joint line
257
Q

Basic advice post-hip replacement(4)?

A

Patients who have had a hip replacement operation should receive basic advice to minimise the risk of dislocation:

  • avoiding flexing the hip > 90 degrees
  • avoid low chairs
  • do not cross your legs
  • sleep on your back for the first 6 weeks
258
Q

Drugs that can precipitate digoxin toxicity?

A

The calcium channel blockers diltiazem and verapamil both increase serum digoxin levels.

259
Q

Congenital inguinal hernia

Mechanism/cause?

Frequency? More common in (2)?

Laterality?

Management?

A

Indirect hernias resulting from a patent processus vaginalis

Occur in around 1% of term babies. More common in premature babies and boys

60% are right sided, 10% are bilaterally

Should be surgically repaired soon after diagnosis as at risk of incarceration

260
Q

Duration of contraception post-menopause:

If >50years old?

If <50 years old?

A

Need for contraception after the menopause

12 months after the last period in women > 50 years

24 months after the last period in women < 50 years

261
Q

Most useful early marker of haemochromatosis?

Stain used on liver biopsy?

Typical iron studies (transferrin sats, ferritin, TIBC)?

How is treatment monitored? Targets (2)

A

Transferrin saturation is considered the most useful marker.

Perl’s stain is used on liver biopsy.

Typical iron study profile in patient with haemochromatosis

  • transferrin saturation > 55% in men or > 50% in women
  • raised ferritin (e.g. > 500 ug/l) and iron
  • low TIBC

Ferritin and transferrin saturation are used to monitor treatment in haemochromatosis

  • transferrin saturation should be kept below 50% and the serum ferritin concentration below 50 ug/l
262
Q

Define intracapsular and extracapsular hip fracture?

Treatment of following hip fractures:

  • Undisplaced intertrochanteric (extracapsular) proximal femoral fracture
  • Undisplaced subtrochanteric/transverse femoral fracture.
  • Undisplaced intracapsular neck of femur fracture in unfit patients.
  • Undisplaced intracapsular neck of femur fracture in fit patients.
  • Displaced and fit
  • Displaced and unfit
A

Location

  • intracapsular (subcapital): from the edge of the femoral head to the insertion of the capsule of the hip joint
  • extracapsular: these can either be trochanteric or subtrochanteric (the lesser trochanter is the dividing line)

Undisplaced intertrochanteric (extracapsular) proximal femoral fracture

  • Dynamic hip screw

Undisplaced subtrochanteric femoral fracture.

  • Intramedullary nail

Undisplaced intracapsular neck of femur fracture in unfit patients.

  • Hemiarthroplasty

Undisplaced intracapsular neck of femur fracture in fit patients.

  • Internal fixation

Displaced and fit

  • THR

Displaced and unfit

  • Hemiarthoplasty
263
Q

Bile acid malabsorption

Presentation

Primary cause (1)

Secondary causes (3)

Investigation of choice?

Management?

A

Presentation

  • steatorrhoea and vitamin A, D, E, K malabsorption.

Primary cause

  • Excessive production of bile acid

Secondary causes (3)

  • cholecystectomy
  • coeliac disease
  • small intestinal bacterial overgrowth

Investigation of choice

  • SeHCAT

Management

  • bile acid sequestrants e.g. cholestyramine
264
Q

Combined test for Down’s screening (3)

Timing

High risk of Down’s suggested by (3)

T13/T18 detection?

A

nuchal translucency measurement + serum B-HCG + pregnancy-associated plasma protein A (PAPP-A)

these tests should be done between 11 - 13+6 weeks

Down’s syndrome is suggested by ↑ HCG, ↓ PAPP-A, thickened nuchal translucency

trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the PAPP-A tends to be lower

265
Q

If late booking, how is T21 screened (2)?

Results suggestive of T21 (3,4)

A

if women book later in pregnancy either the triple or quadruple test should be offered between 15 - 20 weeks

  • triple test: alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin
  • quadruple test: alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin and inhibin-A

Triple test - AFP is low, oestriol is low, bHCG is high.

Quadruple test - AFP is low, oestriol is low, bHCG is high, inhibin A is high

266
Q

Vaccines at:

  • 2 months (3)
  • 3 months (3)
  • 4 months (2)
  • 12-13 months (4)
  • 2-8 years (1)
  • 3-4 years (2)
  • 12-13 years (1)
  • 13-18 years (2)
A

2 months

  • ‘6-1 vaccine’ (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B)
  • Oral rotavirus vaccine
  • Men B

3 months

  • ‘6-1 vaccine’ (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B)
  • Oral rotavirus vaccine
  • PCV

4 months

  • ‘6-1 vaccine’ (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B)
  • Men B

12-13 months

  • Hib/Men C
  • MMR
  • PCV
  • Men B

2-8 years

  • Flu vaccine (annual)

3-4 years

  • ‘4-in-1 pre-school booster’ (diphtheria, tetanus, whooping cough and polio)
  • MMR

12-13 years

  • HPV vaccination

13-18 years

  • ‘3-in-1 teenage booster’ (tetanus, diphtheria and polio)
  • Men ACWY
267
Q

Which medication should patients with a history of pre-eclampsia be started on at 12-14 weeks gestation to reduce the risk of intrauterine growth retardation?

A

Low dose aspirin

268
Q

Most common type of ovarian cyst?

Most common benign ovarian tumour?

Most common ovarian cancer?

A

Most common type of ovarian cyst?

  • Follicular cyst (non-rupture of dominant follicle)

Most common benign ovarian tumour?

  • Serous cystadenoma

Most common ovarian cancer

  • Serous carcinoma
269
Q

Commonest cause of hypothyroidism in children in the UK?

And in the developing world?

A

The most common cause of hypothyroidism in children (juvenile hypothyroidism) is autoimmune thyroiditis.

Other causes include

  • post total-body irradiation (e.g. in a child previous treated for acute lymphoblastic leukaemia)
  • iodine deficiency (the most common cause in the developing world)
270
Q

Management of pregnant women with pre-existing diabetes ($)

A
  • stop oral hypoglycaemic agents, apart from metformin, and commence insulin
  • folic acid 5 mg/day from pre-conception to 12 weeks gestation
  • aspirin 75mg/day from 12 weeks until the birth of the baby, to reduce the risk of pre-eclampsia
  • detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
271
Q
A
272
Q
A

MSRA (1 decks)

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