Thursday 30th Flashcards
1
Q
This patient is presenting with a progressive, subacute vision loss with features such as loss of central vision and difficulty in seeing in the dark/with a change from light to darkness
Dx? [1]
A
Drusen:
- Drusen = dry macular degeneration. These are small yellowish deposits of lipids that accumulate under the retina
2
Q
When is AV nicking seen on fundoscopy? [1]
A
Hypertensive patients -> article crosses over the path of a venule
3
Q
Would patients have changes in vision with hypertensive retinopathy? [1]
A
No
4
Q
When are cotton wool spots associated with? [2]
A
Hypertensive and diabetic retinopathy
5
Q
When is cupping of the optic disc seen? [1]
A
Glaucoma due to damage of the optic nerve
6
Q
How does glaucoma present? [3]
A
Blurred vision [often in the peripheries], haloes around lights, poor vision in the dark
7
Q
When are flame haemorrhages seen? Are they associated with loss of vision? [2]
A
Seen in hypertensive retinopathy, not associated with loss of central vision or poor vision at night
8
Q
What is the most common cause of blindness in the UK? [1]
A
Age-related macular degeneration
9
Q
What can be seen on fundoscopy in ARMD? [1]
A
Drusen!
10
Q
Groups more at risk of ARMD? [2]
A
Women, advancing age
11
Q
Other RFs of ARMD [3]
A
- Smokers have slightly higher risk
- FH strong RF
- increased CVD risk
12
Q
Traditionally, what are the two forms of ARMD? [2]
A
Dry macular degeneration: 90% cases
Wet macular degneration: 10%
13
Q
Differentiate between dry and wet degeneration [3]
A
Dry:
- characterised by Drusen [yellow spots in Bruch’s membrane]
Wet:
- choroidal neovascularisation
- leakage of serous fluid and blood can subsequently result in rapid loss of vision
- carries worst prognosis
14
Q
Ix for ARMD [3]
A
- slit-lamp microscopy firs tline Ix
- fluorescein angiography also
- ocular coherence tomography
15
Q
First line dry ARMD [2]
A
Zinc with anti-oxidant vitamins ACE with mild ARMD
16
Q
Next line Tx ARMD, give an example drug [2]
A
Vascular endothelial growth factor [VEGF]
- examples include ranizumba, bevacizumab and pegaptanib
17
Q
Axillary node clearance, which is the biggest Cx should be aware? [1]
A
Axillary node clearance is associated with arm lymphedema and functional arm impairment [in around 14% patients]
18
Q
Which tumours should have a mastectomy procedure? [4]
A
Multifocal tumour
Central tumour
Large lesion in small breast
DCIS > 4cm
19
Q
Which tumours should have a wide local excision procedure? [4]
A
Solitary lesion
Peripheral tumour
Small lesion in large breast
DCIS > 4cm
20
Q
What is recommended after women has had wide-local excision? [1]
A
Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds.
21
Q
When is hormone therapy used for breast cancer patients? Which drug is used premenopausal women? [2]
A
Adjuvant hormonal therapy is offered if tumours are positive for hormone receptors. For many years this was done using tamoxifen for 5 years after diagnosis. Tamoxifen is still used in pre- and peri-menopausal women
22
Q
Which hormonal drug used post-menopausal women? [1]
A
In post-menopausal women, aromatase inhibitors such as anastrozole are used for this purpose*.
23
Q
Important SE of tamoxifen [3]
A
Important side-effects of tamoxifen include an increased risk of endometrial cancer, venous thromboembolism and menopausal symptoms.
24
Q
When is Herceptin used for breast cancer patients? [1]
A
The most common type of biological therapy used for breast cancer is trastuzumab (Herceptin). It is only useful in the 20-25% of tumours that are HER2 positive.
25
When is chemotherapy used in breast cancer? [2]
Cytotoxic therapy may be used either prior to surgery ('neoadjuvanant' chemotherapy) to downstage a primary lesion or after surgery depending on the stage of the tumour, for example, if there is axillary node disease - FEC-D is used in this situation.
26
A 4 year boy presents with an abnormal gait. He has a history of recent viral illness. His WCC is 11 and ESR is 30.
Dx and why [2]
The correct answer is: Transient synovitis 83%
Viral illnesses can be associated with transient synovitis. The WCC should ideally be > 12 and the ESR > 40 to suggest septic arthritis.
27
A 6-year-old boy presents with an groin pain. He is known to be disruptive in class. He reports that he is bullied for being short. On examination he has an antalgic gait and pain on internal rotation of the right hip. Dx and why [2]
Perthes disease 62%
This child is short, has hyperactivity (disruptive behaviour) and is within the age range for Perthes disease. Hyperactivity and short stature are associated with Perthes disease.
28
An obese 12-year-old boy is referred with pain in the left knee and hip. On examination he has an antaglic gait and limitation of internal rotation. His knee has normal range of passive and active movement. Dx and why? [2]
Musculoskeletal pain
The correct answer is: Slipped upper femoral epiphysis 86%
Slipped upper femoral epiphysis is commonest in obese adolescent males. The x-ray will show displacement of the femoral epiphysis inferolaterally. Treatment is usually with rest and non weight bearing crutches.
29
Presentation of DDH [2]
Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies.
30
Tx of DDH [2]
Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision.
31
Presentation of Perthes disease [2]
Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%.
32
Tx of Perthes disease [2]
Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly.
33
Slipped upper femoral epiphysis presentation [2]
Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%.
34
Tx of slipper upper femoral epiphysis [2]
Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required.
35
Which drug is indicated for pain relief in palliative patients with severe renal impairment? [2]
Buprenorphine or fentanyl are the opioids of choice for pain relief in palliative care patients with severe renal impairment, as they are not renally excreted and therefore are less likely to cause toxicity than morphine
36
Which drug is indicated for moderate renal impairment in palliative care patients? [1]
Oxycodone (oral and IV) can be used in mild to moderate renal impairment (GFR 10-50mL/min/1.73²) but it is avoided in severe renal impairment. This is because, despite being mainly metabolised in the liver, some is still renally excreted and so may lead to toxicity in severe renal impairment.
37
What should be given to all patients starting strong opioids? [1]
laxatives should be prescribed for all patients initiating strong opioids
38
In addition to opioids, what can be given treat metastatic bone pain? [4]
In addition to strong opioids, bisphosphonates and radiotherapy, denosumab may be used to treat metastatic bone pain.
39
What are the transient and persistent SE of opioids? [3]
Transient:
- nausea and drowsiness
Persistent:
- constipation
40
Codeine strength compared to oral morphine? [1]
Divide morphine by 10
41
Tramadol strength compared to oral morphine? [1]
Divide by 10 also
42
oxycodone SE compared to morphine [1]
Oxycodone generally causes less sedation, vomiting and pruritis than morphine but more constipation.
43
From oral morphine to oral oxycodone [1]
Divide by 1.5-2
44
When starting Tx for pallaitive pain, what should be offered? [2]
when starting treatment, offer patients with advanced and progressive disease regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain
45
Should oral MR morphine or transdermal patches be preferred at the start of palliative Tx? [1]
Oral MR
46
Dose of morphine to begin with for palliative pain? [2]
if no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain. For example, 15mg modified-release morphine tablets twice a day with 5mg of oral morphine solution as required
47
patient presenting with chaotic deflections on his ECG and no identifiable P/QRS/T waves after car crash, what should be the first step? [1]
Electrical cardio version
| - VF/pulselessness should be treated with 1 shock ASAP
48
Which patients would be treated with adenosine IV? [3]
Adenosine IV bolus is incorrect. This is more likely to be used in the management of regular rhythm, narrow complex tachycardia, following failed vagal manoeuvres.
49
When can adrenaline IV be considered for ALS? [1]
Amiodarone IV bolus is incorrect. This may be used in the management of VF after a third failed attempt at electrical cardioversion.
50
When are vagal manoeuvres considered? [2]
Vagal manoeuvres is incorrect. This is commonly used as first-line management of regular rhythm, narrow complex tachycardia.
51
What are the stages in CPR with cardio version? [2]
a single shock for VF/pulseless VT followed by 2 minutes of CPR
52
Following successfully resuscitations, what should be titrated up in the patient and what is this to? [2]
following successful resuscitation oxygen should be titrated to achieve saturations of 94-98%. This is to address the potential harm caused by hyperoxaemia
53
What are the 8 reversible cases of cardiac arrest? [8]
The Hs
- Hypoxia
- Hypovolaemia
- Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders
- Hypothermia
The 4Ts
- Thrombosis (coronary or pulmonary)
- Tension pneumothorax
- Tamponade – cardiac
- Toxins
54
Splenomegaly, increased number of mature myeloid cells, presence of 10% blast cells and Philadelphia chromosome all suggest what? [1]
CML
55
What is recommended first-line Tx for newly diagnosed chronic phase, Philadelphia chromosome-positive CML? What type of drug is this? [2]
Imatinib is a type of tyrosine kinase inhibitor,
56
Which drug is used to Tx CLL? [1]
Venetoclax
57
What are the classical features of MM? [4]
hypercalcaemia, poor renal function, anaemia and bone involvement
CRAB features
58
Which drug used in the Tx for MM? [1]
Bortezomib is a drug used in the treatment of multiple myeloma (MM).
59
How common is the Philadelphia chromosome is CML? [1]
The Philadelphia chromosome is present in more than 95% of patients
60
Simple PP of CML [3]
It is due to a translocation between the long arm of chromosome 9 and 22 - t(9:22)(q34; q11). This results in part of the ABL proto-oncogene from chromosome 9 being fused with the BCR gene from chromosome 22. The resulting BCR-ABL gene codes for a fusion protein that has tyrosine kinase activity in excess of normal.
61
Presentation of CML [6]
Presentation (60-70 years)
anaemia: lethargy
weight loss and sweating are common
splenomegaly may be marked → abdo discomfort
an increase in granulocytes at different stages of maturation +/- thrombocytosis
decreased leukocyte alkaline phosphatase
may undergo blast transformation (AML in 80%, ALL in 20%)
62
Other Tx for CML [3]
Management
imatinib is now considered first-line treatment
inhibitor of the tyrosine kinase associated with the BCR-ABL defect
very high response rate in chronic phase CML
hydroxyurea
interferon-alpha
allogenic bone marrow transplant
63
Which single blood test is the most important for patients that have had subarachnoid haemorrhages and why? [2]
Urea and electrolytes because hyponatraemia is a common Cx of subarachnoid
64
Most common cause of SaH? [1]
Trauma
65
What is it called in the absence of trauma SaH? [1]
Spontaneous SaH
66
Causes of spontaneous SaH [6]
Intracranial aneurysm* (saccular ‘berry’ aneurysms): this accounts for around 85% of cases. Conditions associated with berry aneurysms include adult polycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta
Arteriovenous malformation
Pituitary apoplexy
Arterial dissection
Mycotic (infective) aneurysms
Perimesencephalic (an idiopathic venous bleed)
67
Classic presenting features of SaH [7]
Headache: typically sudden-onset (‘thunderclap’ or ‘baseball bat’), severe (‘worst of my life’) and occipital
Nausea and vomiting
Meningism (photophobia, neck stiffness)
Coma
Seizures
Sudden death
ECG changes including ST elevation may be seen
68
Two ways of confirming a SaH [2]
CT head and LP
69
Why is an LP performed at least 12 hours after the SAH? [2]
LP is performed at least 12 hours following the onset of symptoms to allow the development of xanthochromia (the result of red blood cell breakdown).
Xanthochromia helps to distinguish true SAH from a ‘traumatic tap’ (blood introduced by the LP procedure).
70
As well as xanthochromia, what else can be seen in CSF findings? [1]
As well as xanthochromia, CSF findings consistent with subarachnoid haemorrhage include a normal or raised opening pressure
71
What should happen as soon as SAH confirmed? [1]
Refer to neurosurgery
72
After SAH confirmed, what is the next step? [3]
After spontaneous SAH is confirmed, the aim of investigation is to identify a causative pathology that needs urgent treatment:
- CT intracranial angiogram (to identify a vascular lesion e.g. aneurysm or AVM)
- +/- digital subtraction angiogram (catheter angiogram)
73
How are most intracranila aneurysms now Tx? [1]
Most intracranial aneurysms are now treated with a coil by interventional neuroradiologists, but a minority require a craniotomy and clipping by a neurosurgeon
74
Until aneurysm treated, how should the patient be looked after? [3]
Until the aneurysm is treated, the patient should be kept on strict bed rest, well-controlled blood pressure and should avoid straining in order to prevent a re-bleed of the aneurysm
75
How are vasospasm prevented in SAH? [2]
Vasospasm is prevented using a 21-day course of nimodipine (a calcium channel inhibitor targeting the brain vasculature) and treated with hypervolaemia, induced-hypertension and haemodilution**
76
How is hydrocephalus temporarily treated? [2]
Hydrocephalus is temporarily treated with an external ventricular drain (CSF diverted into a bag at the bedside) or, if required, a long-term ventriculo-peritoneal shunt
77
Cx of SaH [6]
Re-bleeding
- happens in around 10% of cases and most common in the first 12 hours
- if rebleeding is suspected (e.g. sudden worsening of neurological symptoms) then a repeat CT should be arranged
- associated with a high mortality (up to 70%)
Vasospasm (also termed delayed cerebral ischaemia), typically 7-14 days after onset
Hyponatraemia (most typically due to syndrome inappropriate anti-diuretic hormone (SIADH))
Seizures
Hydrocephalus
Death
78
Which lung condition causes upper zone fibrosis? [1]
Coal workers' pneumoconiosis typically causes upper zone fibrosis
79
Which other conditions can cause upper zone fibrosis? [6]
The causes of upper lobe fibrosis can be remembered with the mnemonic 'CHARTS'
Coal workers’ pneumoconiosis
Histiocytosis
Ankylosing spondylitis/Allergic bronchopulmonary aspergillosis
Radiation
Tuberculosis
Silicosis (progressive massive fibrosis), sarcoidosis
80
What does asbestosis cause? [1]
Lower zone fibrosis
81
Epidemiology of coal worker's pneumoconiosis [4]
Prevalence is higher in populations with higher levels of exposure – e.g. areas with large coal mining industries.
Most individuals are male due to their prevalence in the coal mining industry.
Coal worker’s pneumoconiosis makes up around 7% of all Pneumoconiosis.
Diagnosis is usually 15-20 years after initial exposure to the coal dust.
82
14-year-old boy jumps off a 10 foot wall and lands on both feet. An x-ray shows a bimalleolar fracture of the right ankle. Dx [1]
Pott's
83
A 22-year-old drunk man is involved in a fight. He hurts his thumb when he punches his opponent [1]
Bennett's
84
A 73-year-old woman presents with pain in her wrist after falling on to an outstretched hand. On examination there is dorsal displacement and angulation. An x-ray shows a transverse fracture of the radius around 2 cm proximal to the radio-carpal joint [1]
Colles'
85
3 features of Colles' fractures [3]
1. Transverse fracture of the radius
2. 1 inch proximal to the radio-carpal joint
3. Dorsal displacement and angulation
86
When do Smith's fractures occur? [1]
Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed
87
How do Smith's fractures occur? [1]
Volar angulation of distal radius fragment (Garden spade deformity)
88
What are Bennett's fractures? How do they look on an XR? [2]
Intra-articular fracture of the first carpometacarpal jointX-ray: triangular fragment at ulnar base of metacarpal
89
What is, how is it caused, and why is it important to check a Monteggia's fracture? [3]
Dislocation of the proximal radioulnar joint in association with an ulna fracture
Fall on outstretched hand with forced pronation
Needs prompt diagnosis to avoid disability
90
What is Goleazzi fracture and how is it caused? [2]
Radial shaft fracture with associated dislocation of the distal radioulnar joint
Direct blow
91
What is Pott's fracture? [1]
Bimalleolar ankle fracture
| Forced foot eversion
92
What is a Barton's fracture and when does it happen? [2]
Distal radius fracture (Colles'/Smith's) with associated radiocarpal dislocation
Fall onto extended and pronated wrist
93
Erythematous rash of the nipple with associated thickening what should you be concerned about? [1]
Reddening and thickening of nipple and areola → think Paget's disease of the breast
94
Key difference between Paget's disease and nipple eczema [1]
key differentiating feature is nipple eczema starts in the areola and spreads to the nipple, whereas Paget's disease starts at the nipple and spreads to the areola only in the later stage
95
How common is Paget's disease? [1]
Paget's disease is an eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer
96
Typical presentation of Paget's disease [2]
In half of these patients, it is associated with an underlying mass lesion and 90% of such patients will have an invasive carcinoma. 30% of patients without a mass lesion will still be found to have an underlying carcinoma. The remainder will have carcinoma in situ.
97
Weight loss, salt cravings, hyper-pigmentation of the palmar creases, likely Dx? [1]
Addison's disease
98
What is Addison's disease the commonest type of? [1]
Primary hypoaldosternoism
99
What is hypercortisolism also known as? [1]
Cushing's disease
100
What is Conn's syndrome also known as? [1]
Primary hyperadldosteronism
101
Features of Conn's syndrome [3]
While this may cause weakness, it is also likely to produce increased urination and thirst, neither of which are seen in this patient. This diagnosis is also likely to produce hypertension and not hyperpigmentation of the palms.
102
What is Conn's syndrome?
Autoimmune destruction of the adrenal glands
103
Features of Addison's disease [3]
Features
lethargy, weakness, anorexia, nausea & vomiting, weight loss, 'salt-craving'
hyperpigmentation (especially palmar creases)*, vitiligo, loss of pubic hair in women, hypotension, hypoglycaemia
hyponatraemia and hyperkalaemia may be seen
104
What happens in a Addison crisis? [1]
Collapse, shock, pyrexia
105
Primary causes of hypoadrenalism [5]
```
tuberculosis
metastases (e.g. bronchial carcinoma)
meningococcal septicaemia (Waterhouse-Friderichsen syndrome)
HIV
antiphospholipid syndrome
```
106
Secondary causes of hypoadrenalism
```
Secondary causes
pituitary disorders (e.g. tumours, irradiation, infiltration)
```
Exogenous glucocorticoid therapy
107
How to differentiate between primary Addisons and secondary adrenal insufficiency? [1]
*Primary Addison's is associated with hyperpigmentation whereas secondary adrenal insufficiency is not
108
Which Ix will offer a definitive Dx for possible stroke? [1]
CT head
109
Signs of autonomic dysreflexia? [2]
She has marked hypertension and bradycardia, alongside signs of sympathetic activation (sweating, headache and facial erythema).
110
What is autonomic dysreflexia? [1]
This is where the body loses the ability to properly control sympathetic and parasympathetic activation and is due to an insult to the central nervous system.
111
What can cause autonomic dysreflexia? [2]
This could be caused by this woman's urinary retention following a trial without a catheter compressing the spinal cord.
Facial impaction another common cause.
112
What may autonomic dysreflexia lead to? [1]
A stroke
113
Where does insult to spinal cord have to occur for autonomic dysreflexia? [1]
Above T6 level
114
Mx of autonomic dysreflexia [2]
Management of autonomic dysreflexia involves removal/control of the stimulus and treatment of any life-threatening hypertension and/or bradycardia.
115
What are cherry haemangiomas? [2]
Cherry haemangiomas (Campbell de Morgan spots) are benign skin lesions which contain an abnormal proliferation of capillaries.
116
Who are Cherry haemangiomas common in? [1]
They are more common with advancing age and affect men and women equally
117
Features of cherry hamangiomas [4]
erythematous, papular lesions
typically 1-3 mm in size
non-blanching
not found on the mucous membranes
118
Tx of cherry haemangiomas [1]
As they are benign no treatment is usually required
119
What is the single most important prognostic factor for melanoma? [1]
the invasion depth of the tumour is the single most important prognostic factor
120
What is another poor prognostic factor for melanoma? [1]
High mitotic rate
121
less than 0.75mm 5 year survival rate compared to over 4mm survival rate according to Breslow thickness
95-100% to 50%
122
What is an indication for emergency valve replacement surgery? [1]
Infective endocarditis causing congestive cardiac failure is an indication for emergency valve replacement surgery
123
How can endocarditis be diagnosed? [2]
Endocarditis was positively diagnosed by 2 major Duke's criteria being fulfilled (2 separate blood cultures + echocardiographic evidence of endocardial lesions)
124
What are the criteria for urgent valve replacement? [4]
Severe congestive cardiac failure
Overwhelming sepsis despite antibiotic therapy (+/- perivalvular abscess, fistulae, perforation)
Recurrent embolic episodes despite antibiotic therapy
Pregnancy
125
Poor prognostic factors for infective endocarditis [4]
Staphylococcus aureus infection (see below)
prosthetic valve (especially 'early', acquired during surgery)
culture negative endocarditis
low complement levels
126
Indications for surgery endocarditis [5]
severe valvular incompetence
aortic abscess (often indicated by a lengthening PR interval)
infections resistant to antibiotics/fungal infections
cardiac failure refractory to standard medical treatment
recurrent emboli after antibiotic therapy
