Things I didn't know

Question 1

Treatment for latent TB? (2)

Answer 1

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

Question 2

Treatment for meningeal TB? (1)

Answer 2

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

Question 3

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

Answer 3

Immune reconstitution disease

Question 4

TB drug which causes gout?

Answer 4

Pyrazinamide

Question 5

TB drug which cause agranulocytosis?

Answer 5

Isoniazid

Question 6

Most common inherited kidney disease?

Answer 6

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

Question 7

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

Answer 7

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

Question 8

Treatment for polycystic kidney disease in selected patients?

Answer 8

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

Question 9

Treatment for otitis media with perforation?

Answer 9

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

Question 10

Most common ankle ligament sprained in inversion injuries?

Answer 10

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

Question 11

Components of the syndesmosis binding the distal tibia and fibula?

Answer 11

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

Question 12

Lateral collateral ligaments of the ankle (3)?

Answer 12

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

Question 13

What is a high ankle sprain? Usual mechanism?

Answer 13

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

Question 14

What is a Maisonneuve fracture?

Answer 14

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.

Question 15

What is a loop ileostomy used for?

Answer 15

Defunctioning of colon e.g. following rectal cancer surgery

Question 16

When is an end ileostomy used for?

Answer 16

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

Question 17

Section 2 of MHA?

Answer 17

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

Question 18

Section 3 of MHA?

Answer 18

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

Question 19

Section 4 of MHA?

Answer 19

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

Question 20

Section 5(2) of MHA?

Answer 20

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

Question 21

Section 135 of MHA?

Answer 21

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

Question 22

Section 136 of MHA?

Answer 22

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

Question 23

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

Answer 23

autosomal dominant responsible gene encodes serine threonine kinase LKB1 or STK11

Question 24

Tumour marker CA 15-3 associated with?

Answer 24

Breast cancer

Question 25

Tumour marker Bombesin associated with?

Answer 25

Small cell lung carcinoma, gastric cancer, neuroblastoma

Question 26

Tumour marker S-100 associated with?

Answer 26

Melanoma, schwannomas

Question 27

Most common cause of renal artery stenosis in young women?

Answer 27

fibromuscular dysplasia

Question 28

Second-line urate-lowering agent?

Answer 28

Febuxostat (also a xanthine oxidase inhibitor)

Question 29

What should be added when starting urate-lowering therapy?

Answer 29

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

Question 30

Live attenuated vaccines (57

Answer 30

* BCG * measles, mumps, rubella (MMR) * influenza (intranasal) * oral rotavirus * oral polio * yellow fever * oral typhoid

Question 31

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

Answer 31

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

Question 32

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

Answer 32

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

Question 33

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

Answer 33

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%)

Question 34

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

Answer 34

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

Question 35

Management of scalp psoriasis?

Answer 35

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

Question 36

Management of face, flexural and genital psoriasis?

Answer 36

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

Question 37

Examples of vit D analogues? Should be avoided in?

Answer 37

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

Question 38

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

Answer 38

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

Question 39

Management of vitiligo:

Answer 39

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

Question 40

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

Answer 40

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.

Question 41

Answer 41

Question 42

What is bailout in PCI? Which drug is used?

Answer 42

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)

Question 43

Answer 43

Question 44

Conservative management for patients with NSTEMI/unstable angina?

Answer 44

'dual antiplatelet therapy', i.e. aspirin + another drug) ## Footnote if the patient is not at a high risk of bleeding: ticagrelor if the patient is at a high risk of bleeding: clopidogrel

Question 45

SSRI interacts with what to cause bleeding?

Answer 45

SSRI + NSAID = GI bleeding risk - give a PPI

Question 46

How do azathioprine and allopurinol interact?

Answer 46

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.

Question 48

Inactivated preparation vaccines (3)

Answer 48

Inactivated preparations ## Footnote rabies hepatitis A influenza (intramuscular)

Question 49

Toxoid vaccines (3)

Answer 49

Toxoid (inactivated toxin) ## Footnote tetanus diphtheria pertussis

Question 50

Conjugate vaccines (5)

Answer 50

pneumococcus (conjugate) haemophilus (conjugate) meningococcus (conjugate) hepatitis B human papillomavirus

Question 51

Causes of raised ALP (7)

Answer 51

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

Question 52

Diagnosis of gestational diabetes: Fasting? 2 hour?

Answer 52

fasting glucose is \>= 5.6 mmol/L 2-hour glucose is \>= 7.8 mmol/L

Question 53

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

Answer 53

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

Question 54

Management of lichen planus?

Answer 54

potent topical steroids are the mainstay of treatment

Question 55

Features of toxic epidermal necrolysis (TEN)? (2) Drugs known to induce TEN (6) Management (3)

Answer 55

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

Question 57

How often is Depo Provera given? How long can you wait? What is the main mechanism of action?

Answer 57

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.

Question 58

When should visible haematuria be referred under a 2 week wait (2)? When should a non-urgent referral be made?

Answer 58

_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

Question 59

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

Answer 59

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

Question 60

When is carotid end arterectomy recommended?

Answer 60

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%.**

Question 61

Antiplatelet for TIA/ischaemic stroke? If it can't be tolerated?

Answer 61

Antiplatelets ## Footnote 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.

Question 62

Lateral epicodylitis AKA?

Answer 62

tennis elbow

Question 63

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

Answer 63

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

Question 64

2WW criteria for breast lumps? (2)

Answer 64

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

Question 65

Causes of scarring alopecia (5)

Answer 65

* trauma, burns * radiotherapy * lichen planus * discoid lupus * tinea capitis\*

Question 66

Causes of non-scarring alopecia (7)

Answer 66

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

Question 67

Which trinucleotide repeat disorder does not show anticipation?

Answer 67

Friedreich's ataxia is unusual in not demonstrating anticipation

Question 68

_Management of acne_ First step? Second step? Oral antibiotics? Alternative in women? And in pregnancy? Final step?

Answer 68

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

Question 69

COCP increases risk of which cancers (2)? Protective against which cancers (2)?

Answer 69

Combined oral contraceptive pill * increased risk of breast and cervical cancer * protective against ovarian and endometrial cancer

Question 70

Menopause management ## Footnote - Vasomotor symptoms? - Vaginal dryness - Psychological self help - Urogenital symptoms

Answer 70

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.

Question 71

UKMEC4 conditions for COCP (8)

Answer 71

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

Question 72

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

Answer 72

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

Question 73

Ulcerative colitis management * First line for mild to moderate ? When is oral treatment needed? * How long before adding second line?

Answer 73

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.

Question 74

Ulcerative colitis maintenance * Following mild flare? * Following severe relapse or \>2 exacerbation per year?

Answer 74

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

Question 75

Treatment of TIA if presenting to GP within 7 days?

Answer 75

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)

Question 76

How to withdraw long term benzos? And if this doesn't work?

Answer 76

* 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

Question 77

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

Answer 77

GABAA drugs ## Footnote benzodiazipines increase the frequency of chloride channels barbiturates increase the duration of chloride channel opening

Question 78

In which patients should FRAX be used (3)? How are FRAX results ultiilsed?

Answer 78

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

Question 79

How should breast cysts be managed?

Answer 79

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

Question 80

_Contraceptives - time until effective (if not first day period):_ * IUD? * POP? * COC, injection, implant, IUS?

Answer 80

Contraceptives - time until effective (if not first day period): * instant: IUD * 2 days: POP * 7 days: COC, injection, implant, IUS

Question 81

_Management of cradle cap_ * Mild * Severe

Answer 81

Management depends on severity ## Footnote mild-moderate: baby shampoo and baby oils severe: mild topical steroids e.g. 1% hydrocortisone

Question 82

How does mania differ from hypomania (4)?

Answer 82

* 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)

Question 83

How should MRSA carriers be treated?

Answer 83

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

Question 84

Varenicline & buproprion Mechanisms? Side effects? Contraindication?

Answer 84

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

Question 85

Ottowa rules for ankle injury (1+3)

Answer 85

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

Question 86

Which medication is contraindicated in VT?

Answer 86

Verapamil

Question 87

From which age can pure tone audiometry be performed?

Answer 87

\>3 years

Question 88

2nd line antihypertensive in AfroCarribean pts?

Answer 88

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

Question 89

Factors suggesting faecal impaction in children (3)? Treatment?

Answer 89

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

Question 90

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

Answer 90

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

Question 91

When should anti-D routinely be given to non-sensitised Rh-ve mothers? Which other situations require anti-D (8)?

Answer 91

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

Question 92

First line for urge incontinence? First meds? Second line med?

Answer 92

* 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 o**xybutynin (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

Question 93

Argyll Robinson pupil?

Answer 93

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

Question 94

Which NSAID is contraindicated in cardiac disease?

Answer 94

Diclofenac is now contraindicated with any form of cardiovascular disease

Question 95

Meds causing pancreatitis (8)?

Answer 95

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

Question 96

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

Answer 96

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

Question 97

Which oral medication may improve healing of venous ulcers?

Answer 97

Oral pentoxifylline, a peripheral vasodilator, improves healing rate

Question 98

How are AAA screened in the UK? Above what diameter is considered an aneurysm?

Answer 98

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

Question 99

What is secondary dysmenorrhoea? Causes (5)? Management?

Answer 99

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.

Question 100

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

Answer 100

G's and C's raised: * growth hormone * Glucose * Salivary glands * Cortisol, * Cholesterol * Carotinaemia

Question 101

90% of genital warts caused by which HPV strains (2)? Management (first line (2), second line(1)) Which HPV strains cause cervical cancer (3)?

Answer 101

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.

Question 102

IUS vs IUD * Mechanism of action? * Time until effective?

Answer 102

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

Question 103

Chickenpox exposure in pregnancy How is it managed differently at different gestations? If a woman develops symptoms?

Answer 103

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

Question 104

The A's of ankylosing spondylitis(6)?

Answer 104

Ankylosing spondylitis features - the 'A's 1. Apical fibrosis 2. Anterior uveitis 3. Aortic regurgitation 4. Achilles tendonitis 5. AV node block 6. Amyloidosis

Question 105

What is Fitz-Hugh-Curtis syndrome? Cause?

Answer 105

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)

Question 106

Diagnosis of hereditary haemorrhagic telangiectasia(4)? Inheritance?

Answer 106

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

Question 107

Most common cause of HCC worldwide? And in Europe?

Answer 107

Hepatocellular carcinoma ## Footnote hepatitis B most common cause worldwide hepatitis C most common cause in Europe

Question 108

Factors that increase BNP(11)?

Answer 108

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

Question 109

Factors that decrease BNP levels(6)?

Answer 109

Decrease BNP levels 1. Obesity 2. Diuretics 3. ACE inhibitors 4. Beta-blockers 5. Angiotensin 2 receptor blockers 6. Aldosterone antagonists

Question 110

Classic triad of glandular fever? Other features (8)

Answer 110

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

Question 111

Why can domperidone be safely used in PD?

Answer 111

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

Question 112

Diagnostic investigation for pancreatic cancer?

Answer 112

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

Question 113

Treatment for bacterial vaginosis in pregnancy?

Answer 113

Metronidazole 400mg BD for 7 days

Question 114

Appearance of vulval carcinoma vs VIN?

Answer 114

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.

Question 115

Nerve roots for following reflexes: * Ankle * Knee * Biceps * Triceps

Answer 115

Reflex Root * Ankle S1-S2 * Knee L3-L4 * Biceps C5-C6 * Triceps C7-C8

Question 116

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

Answer 116

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

Question 117

Answer 117

Question 118

Glaucoma drug causing brown pigmentation of iris?

Answer 118

Latanoprost

Question 119

Drugs that may cause urinary retention (5)

Answer 119

The following drugs may cause urinary retention: ## Footnote tricyclic antidepressants e.g. amitriptyline anticholinergics opioids NSAIDs disopyramide

Question 120

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

Answer 120

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

Question 121

Ages covered by NHS breast screening programme? When should younger women be referred for assessment(2)?

Answer 121

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

Question 122

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

Answer 122

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

Question 123

Vitamin D supplementation in pregnancy?

Answer 123

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

Question 124

Which class of drug is tamoxifen? Which cancer is it used for? Adverse effects (4)

Answer 124

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

Question 125

Two examples of aromatase inhibitors? Which patients are they used in? Adverse effects (4)

Answer 125

**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

Question 126

When should a COCP be stopped before surgery?

Answer 126

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.

Question 127

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

Answer 127

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

Question 128

Management of first trimester bleeding? * Less than 6 weeks? * More than 6 weeks? Symptoms suggestive of ectopic pregnancy(3)?

Answer 128

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 gestati**on (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

Question 129

Cervical cancer screening: Ages? Frequency?

Answer 129

Cervical cancer screening ## Footnote 25-49 years: 3-yearly 50-64 years: 5-yearly

Question 130

Management of cluster headaches: Acute (2) Prophylaxis (1)

Answer 130

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

Question 131

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

Answer 131

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.

Question 132

LARC of choice in under 20's?

Answer 132

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

Question 133

First sign of puberty in males? And in females?

Answer 133

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)

Question 134

Mechanism of Nexplanon?

Answer 134

Nexplanon - main mechanism of action is inhibition of ovulation

Question 135

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

Answer 135

* 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).

Question 136

What are the following operations used for: * Right hemicolectomy? * Left hemicolectomy? * High anterior resection? * Low anterior resection? Difference from high? * Hartmann's procedure?

Answer 136

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.

Question 137

Describe the following signs: Tinel's Phalen's Reverse Phalen's Froments Westphal

Answer 137

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.

Question 138

Foods to avoid in gout(5)?

Answer 138

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

Question 139

Causes of massive splenomegaly(5)

Answer 139

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

Question 140

When can medical management of fibroids be trialled?

Answer 140

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)

Question 141

_Classification of ovarian hyperstimulation syndrome_ Criteria for each category: Mild (2) Moderate (3) Severe (4) Critical (4)

Answer 141

Question 142

Piyriasis versicolor Caused by? Commonly affects? More noticeable when? Treatment (2)?

Answer 142

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

Question 143

X-ray changes in OA(4)?

Answer 143

X-ray changes of osteoarthritis * decrease of joint space * subchondral sclerosis * subchondral cysts * osteophytes forming at joint margins

Question 144

_Salivary gland tumours_ Most common presentation? What is a Warthin's tumour?

Answer 144

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)

Question 145

_Salivary gland stones_ Most common site?

Answer 145

Stones * recurrent unilateral pain & swelling on eating * may become infected → Ludwig's angina * 80% are submandibular

Question 146

Where are the 3 pairs of salivary glands?

Answer 146

## Footnote parotid (serous) - most tumours submandibular (mixed) - most stones sublingual (mucous)

Question 147

Holmes-Adie pupil? Accommodation vs light reflex? Holmes-Adie syndrome?

Answer 147

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

Question 148

_HOCM_ Most common defects in HOCM (2)? Echo findings (3) Associations (2)

Answer 148

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

Question 149

Drug induced thrombocytopenia (7)

Answer 149

Drug-induced thrombocytopenia (probable immune-mediated) * quinine * abciximab * NSAIDs * diuretics: furosemide * antibiotics: penicillins, sulphonamides, rifampicin * anticonvulsants: carbamazepine, valproate * heparin

Question 150

_Morphine conversions_ Oral to oxycodone Oral to Subcut morphine Oral to subcut diamorphine

Answer 150

Oral morphine to oxycodone - divide by 1.5

Question 151

Risk factors for DDH(7)?

Answer 151

Risk factors * female sex: 6 times greater risk * breech presentation * positive family history * firstborn children * oligohydramnios * birth weight \> 5 kg * congenital calcaneovalgus foot deformity

Question 152

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

Answer 152

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

Question 153

Cautions in use of sulfasalazine (2) Adverse effects (5)

Answer 153

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

Question 154

Most common cause of liver disease in the developed world?

Answer 154

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

Question 155

Stages of NAFLD (3) What test should be done is NAFLD is found incidentally?

Answer 155

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.

Question 156

_Stroke management_ Thrombolysis - time frame?

Answer 156

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)

Question 157

_Thrombectomy_ Situations for use plus time frames for each (3)

Answer 157

**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.

Question 158

Secondary prevention stroke (2)

Answer 158

* 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

Question 159

_Diagnostic thresholds for gestational diabetes_ * fasting glucose * 2-hour glucose

Answer 159

Diagnostic thresholds for gestational diabetes ## Footnote 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

Question 160

Breast cancer risk factors (11)

Answer 160

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

Question 161

Head injury in adults Immediate CT head (7) Within 8 hours (4)

Answer 161

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.

Question 162

How to decide between cyclical vs continuous HRT?

Answer 162

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

Question 163

Management of boxer's fracture?

Answer 163

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.

Question 164

Most common type of breast cancer?

Answer 164

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

Question 165

Drug monitoring for the following: * Amiodarone * Methotrexate * Azathioprine * Lithium * Sodium valproate * Glitazones

Answer 165

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

Question 166

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

Answer 166

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

Question 167

_BP targets_ Clinic and ABPM/HBPM targets by age

Answer 167

**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

Question 168

First line for trigeminal neuralgia?

Answer 168

Carbamazepine is first-line

Question 169

Causes of artificially raised HbA1c (3)

Answer 169

Vitamin B12/folic acid deficiency Iron-deficiency anaemia Splenectomy

Question 170

_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?

Answer 170

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

Question 171

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

Answer 171

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.

Question 172

Management of anterior uveitis(2)?

Answer 172

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

Question 174

Management of keloid scars?

Answer 174

Treatment * early keloids may be treated with intra-lesional steroids e.g. triamcinolone * excision is sometimes required

Question 175

Features of compression of L3 (4)

Answer 175

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

Question 176

Features of compression of L4 (4)

Answer 176

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

Question 177

Features of compression of L5 (4)

Answer 177

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

Question 178

Features of S1 nerve root compression (4)

Answer 178

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

Question 179

First-line management of primary open angle glaucoma?

Answer 179

first line: prostaglandin analogue (PGA) eyedrop

Question 180

First line for generalised seizures? First line for focal seizures?

Answer 180

Sodium valproate is considered the first line treatment for patients with generalised seizures Carbamazepine used for focal seizures.

Question 181

Which seizures can carbemazepine exacerbate?

Answer 181

Carbamazepine may exacerbate absence seizures and myoclonic seizures

Question 182

How should suspected age-related macular degeneration be managed?

Answer 182

Referral to ophthalmology urgently within 1 week if suspecting AMD

Question 183

Definition of maternal mortality?

Answer 183

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

Question 184

Drugs causing raised prolactin (galactorrhoea) (4)

Answer 184

Drug causes of raised prolactin ## Footnote metoclopramide Domperidone phenothiazines (chlorpromazine) haloperidol

Question 185

Normal ICP (mmHg)?

Answer 185

\<15mmgHg

Question 186

Which common antihypertensives should be avoided in HOCM? Why?

Answer 186

ACE-inhibitors should be avoided in patients with HOCM. ACE inhibitors can reduce afterload which may worsen the LVOT gradient.

Question 187

Drugs causes of gynaecomastia (7)?

Answer 187

Drug causes of gynaecomastia * spironolactone (most common drug cause) * cimetidine * digoxin * cannabis * finasteride * GnRH agonists e.g. goserelin, buserelin * oestrogens, anabolic steroids

Question 188

Urinary osmolality in ATN? And urinary Na?

Answer 188

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

Question 189

Difference between circumstantiality and tangentiality?

Answer 189

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.

Question 190

Most common cause of erythema multiforme? Drug causes (6)

Answer 190

Herpes simplex virus (the most common cause) Penicillin, sulphonamides, carbamazepine, allopurinol, NSAIDs, oral contraceptive pill.

Question 191

Extra-intestinal features of Crohn's/UC that are related to disease activity(4)? And those unrelated to disease activity(5)?

Answer 191

_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

Question 192

Treatment of thrush in pregnancy?

Answer 192

Clotrimazole pessary

Question 193

Reasons for early referral for infertility in women (5) Reasons for early referral for infertility in men (5)

Answer 193

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

Question 195

Drugs that can exacerbate psoriasis (6)

Answer 195

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

Question 196

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?

Answer 196

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).

Question 197

Risk assessment score for bleeding with anticoagulation?

Answer 197

Question 198

Relationship of hernias to pubic tubercle: * Inguinal * Femoral

Answer 198

Inguinal hernias and superior and medial to the pubic tubercle A femoral hernia is located laterally and inferiorly to the pubic tubercle.

Question 199

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

Answer 199

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

Question 200

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

Answer 200

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)

Question 201

Drugs causing erythema nodosum (3)?

Answer 201

drugs * penicillins * sulphonamides * combined oral contraceptive pill

Question 202

Empirical Abx for suspected epididymo-orchitis?

Answer 202

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

Question 203

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

Answer 203

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

Question 204

Risk of rubella causing fetal injury in first trimester? Features of congenital rubella(9)?

Answer 204

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

Question 205

When should migraine prophylaxis be given? What are the first line meds? And if pregnant?

Answer 205

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.

Question 206

Blurring of vision after cataract surgery?

Answer 206

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

Question 207

Mechanism of Nexplanon(2)? Active ingredient? Duration of action?

Answer 207

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.

Question 208

Drugs contraindicated in breastfeeding (8)§?

Answer 208

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

Question 210

Doses of emergency IM benpen in suspected meningitis?

Answer 210

Dose * \< 1 year - 300 mg * 1 - 10 years - 600 mg * \> 10 years - 1200 mg

Question 211

Score for assessing likelihood of stroke? First line investigation?

Answer 211

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

Question 212

Distinguishing between episcleritis and scleritis Pain? Medication?

Answer 212

Episcleritis is classically not painful. Phenylephrine 10% eye drops can be used to distinguish between episcleritis and scleritis. Blanches with episcleritis.

Question 213

Risk factors for Barret's oesophagus (4) Which is strongest?

Answer 213

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.

Question 214

Formula to work out Down syndrome risk above 30?

Answer 214

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

Question 215

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

Answer 215

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

Question 216

Drugs that can precipitate lithium toxicity (4)? Non-drug causes(2)?

Answer 216

Toxicity may be precipitated by: * dehydration * renal failure * drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.

Question 217

Features of lithium toxicity (6)?

Answer 217

Features of toxicity * coarse tremor (a fine tremor is seen in therapeutic levels) * hyperreflexia * acute confusion * polyuria * seizure * coma

Question 218

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

Answer 218

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

Question 219

_Management of patients at risk of corticosteroid-induced osteoporosis_ Two groups? Management of each?

Answer 219

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.

Question 220

Usual timing of MMR? What if the dose interval if vaccinating at a later time?

Answer 220

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.

Question 221

Red flags for lower back pain (5)

Answer 221

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

Question 222

Definition of puerperal pyrexia Causes (5) Management of most common cause?

Answer 222

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)

Question 223

Drug causes of gingival hyperplasia (3) Other causes (1)

Answer 223

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)

Question 224

First-line treatment for LV systolic dysfunction (2) Second line (1)

Answer 224

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

Question 225

_Third line treatments for heart failure secondary to LV systolic dysfunction_ Criteria for each: * Ivabradine * Sacubitril-valsartan * Digoxin * Hydralizine + nitrate * CRT

Answer 225

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

Question 226

Antibiotics to avoid in pregnancy (4)

Answer 226

Antibiotics * tetracyclines * aminoglycosides * sulphonamides and trimethoprim * quinolones: the BNF advises to avoid due to arthropathy in some animal studies

Question 227

Anaemia associated with which antiepileptic?

Answer 227

Phenytoin may cause a megaloblastic anaemia by altering folate metabolism

Question 228

What are eruptive xanthoma? Causes of eruptive xanthoma (2)? Causes of xanthelasma(2)?

Answer 228

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

Question 229

Neuroleptic malignant syndrome Typical features (4) Management (2)

Answer 229

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

Question 230

Differences between serotonin syndrome and neuroleptic malignant syndrome * Causes * Onset * Reflexes * Pupils * Management of severe cases

Answer 230

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

Question 231

_Hyperacute rejection_ Time scale? Cause? Type of hypersensitivity? Risk factors (3) Management?

Answer 231

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

Question 232

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

Answer 232

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

Question 233

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

Answer 233

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.

Question 234

_Recurrent vaginal candidiasis_ Definition Actions on diagnosis (5) Management (2)

Answer 234

* 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

Question 235

Management of corneal abrasion (1)

Answer 235

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

Question 236

Definition of primary post partum haemorrhage? Most common cause? Management (4)

Answer 236

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

Question 237

If a patient is taking metformin, what is their target HbA1C? At which HbA1C should a second agent be added?

Answer 237

Target - 48mmol/mol (6.5%) Add second agent - above 58mmol/mol (7.5%)

Question 239

Acute rejection reactions 2 types? Time scales? Which is most common?

Answer 239

**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.**

Question 240

Class 1 HLA antigens (3)? Class 2 (3)? Relative importance of HLA antigens for HLA matching of organs?

Answer 240

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

Question 241

Methods of termination of pregnancy (3) * Less than 9 weeks? * Less than 13 weeks? * More than 15 weeks?

Answer 241

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')

Question 242

Immune cells that mediate psoriasis?

Answer 242

Psoriasis is mediated by type 1 helper T cells

Question 243

_Benign Rolandic epilepsy_ Ages affected? Characteristics of seizures (2) EEG? Prognosis?

Answer 243

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

Question 244

Antidepressants to avoid co-prescribing with warfarin and heparin?

Answer 244

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.

Question 245

Diagnosis of chronic fatigue syndrome (3 criteria)

Answer 245

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

Question 246

Malaria prophylaxis for pregnant women (2)?

Answer 246

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

Question 247

Meniere's disease Driving limitations? Management of acute attacks (2) Prevention of attacks?

Answer 247

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

Question 248

Definition of hypertension in pregnancy? Features of the following? * Pre-existing hypertension * Pregnancy induced/gestational * Pre-eclampsia

Answer 248

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.

Question 249

Causes of raised CA125 besides cancer (3)?

Answer 249

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

Question 250

First-line analgesia for lower back pain?

Answer 250

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.

Question 251

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

Answer 251

Offer lamotrigine if sodium valproate is unsuitable

Question 252

Cut-offs for diagnosing diabetes (2) And if they're asymptomatic?

Answer 252

Diabetes diagnosis: fasting \> 7.0, random \> 11.1 If asymptomatic need two readings

Question 253

Treatment of stable angina First line? Caveats? Second line? Third line? Caveat?

Answer 253

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**

Question 254

Conditions associated with seborrhoeic dermatitis(2)?

Answer 254

Associated conditions include ## Footnote HIV Parkinson's disease

Question 255

Test to diagnose De Quervain's tenosynovitis?

Answer 255

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

Question 256

Examination finding of iliotibial band syndrome?

Answer 256

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

Question 257

Basic advice post-hip replacement(4)?

Answer 257

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

Question 258

Drugs that can precipitate digoxin toxicity?

Answer 258

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

Question 259

Congenital inguinal hernia Mechanism/cause? Frequency? More common in (2)? Laterality? Management?

Answer 259

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

Question 260

Duration of contraception post-menopause: If \>50years old? If \<50 years old?

Answer 260

Need for contraception after the menopause ## Footnote 12 months after the last period in women \> 50 years 24 months after the last period in women \< 50 years

Question 261

Most useful early marker of haemochromatosis? Stain used on liver biopsy? Typical iron studies (transferrin sats, ferritin, TIBC)? How is treatment monitored? Targets (2)

Answer 261

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

Question 262

# 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

Answer 262

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

Question 263

_Bile acid malabsorption_ ## Footnote Presentation Primary cause (1) Secondary causes (3) Investigation of choice? Management?

Answer 263

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

Question 264

Combined test for Down's screening (3) Timing High risk of Down's suggested by (3) T13/T18 detection?

Answer 264

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

Question 265

If late booking, how is T21 screened (2)? Results suggestive of T21 (3,4)

Answer 265

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

Question 266

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)

Answer 266

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

Question 267

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?

Answer 267

Low dose aspirin

Question 268

Most common type of ovarian cyst? Most common benign ovarian tumour? Most common ovarian cancer?

Answer 268

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

Question 269

Commonest cause of hypothyroidism in children in the UK? And in the developing world?

Answer 269

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)

Question 270

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

Answer 270

* 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