Tuesday [05/10/2021]

Question 1

A 36-year-old woman presents with progressive tingling and numbness of the 4th and 5th fingers of her right hand. Initially, this was intermittent but recently has become constant. She notices that the symptoms are worse when leaning on her right elbow. She recalls hitting her elbow against a door some time ago. Dx? [2]

Answer 1

Cubital tunnel syndrome is caused by compression of the ulnar nerve and can present with tingling/numbness of the 4th and 5th finger

Question 2

How would De Quervain’s tenosynovitis present? [2]

Answer 2

De Quervain’s tenosynovitis would present differently, with pain on movement of the thumb/wrist. The radial styloid may be hardened and thickened.

Question 3

How would medial epicondylitis present? [1]

Answer 3

Medial epicondylitis, or golfer’s elbow, would present with pain along the medial elbow, close to the cubital tunnel - but localised to the area as it is a tendinopathy, and not compression of the nerve.

Question 4

How would radial tunnel syndrome present? [2]

Answer 4

Radial tunnel syndrome, as the name suggests, is due to compression of the radial nerve and may lead to tingling/numbness/pain along the back of the hand and forearm.

Question 5

Clinical features of cubital tunnel syndrome [4]

Answer 5

Tingling and numbness of the 4th and 5th finger which starts off intermittent and then becomes constant.
Over time patients may also develop weakness and muscle wasting
Pain worse on leaning on the affected elbow
Often a history of osteoarthritis or prior trauma to the area.

Question 6

Dx of cubital tunnel syndrome [2]

Answer 6

the diagnosis is usually clinical
however, in selected cases nerve conduction studies may be used

Question 7

Mx of cubital tunnel syndrome [4]

Answer 7

Avoid aggravating activity
Physiotherapy
Steroid injections
Surgery in resistant cases

Question 8

What is the initial definitive management for cord prolapse leading to CTG decelerations? [1]

Answer 8

Place hand into vagina to elevate presenting part

Question 9

What can be considered whilst preparing for C-section if persistent mechincal methods of prevneting compression fail? [1]

Answer 9

Tocolysis [i.e. terbutaline]

Question 10

What is cord prolapse? [2]

Answer 10

Cord prolapse involves the umbilical cord descending ahead of the presenting part of the fetus. This occurs in 1/500 deliveries. Left untreated, this can lead to compression of the cord or cord spasm, which can cause fetal hypoxia and eventually irreversible damage or death.

Question 11

RFs for cord prolapse [5]

Answer 11

prematurity
multiparity
polyhydramnios
twin pregnancy
cephalopelvic disproportion
abnormal presentations e.g. Breech, transverse lie
placenta praevia
long umbilical cord
high fetal station

Question 12

When do the majority of cord prolapses occur? [2]

Answer 12

The majority of cord prolapses occur at artificial rupture of the membranes. The diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally, or if the cord is visible beyond the level of the introitus.

Question 13

Mx of cord prolapse [4]

Answer 13

For management of cord prolapse, the presenting part of the fetus may be pushed back into the uterus to avoid compression. Tocolytics may be used. If the cord is past the level of the introitus, it should be kept warm and moist but should not be pushed back inside. The patient is asked to go on ‘all fours’ until preparations for an immediate caesarian section have been carried out. Although this is the usual first-line method of delivery, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low. If treated early, fetal mortality in cord prolapse is low. Incidence has been reduced by the increase in caesarian sections being used in breech presentations.

Question 14

Principle for migraine Mx [1]

Answer 14

It should be noted that as a general rule 5-HT receptor agonists are used in the acute treatment of migraine whilst 5-HT receptor antagonists are used in prophylaxis

Question 15

First-line acute Tx of migraine [2]

Answer 15

first-line: offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol

Question 16

Second-line acute Mx of migraine [2]

Answer 16

for young people aged 12-17 years consider a nasal triptan in preference to an oral triptan
if the above measures are not effective or not tolerated offer a non-oral preparation of metoclopramide* or prochlorperazine and consider adding a non-oral NSAID or triptan

Question 17

When should prophylaxis of migraine be offered? [1]

Answer 17

prophylaxis should be given if patients are experiencing 2 or more attacks per month. Modern treatment is effective in about 60% of patients.

Question 18

What drugs should be given for prophylaxis of migraine? [3]

Answer 18

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
if these measures fail NICE recommend ‘a course of up to 10 sessions of acupuncture over 5-8 weeks’
NICE recommend: ‘Advise people with migraine that riboflavin (400 mg once a day) may be effective in reducing migraine frequency and intensity for some people’

Question 19

Mx for women with menstrual migraine

Answer 19

for women with predictable menstrual migraine treatment NICE recommend either frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) as a type of ‘mini-prophylaxis’

Question 20

A 52-year-old female has very bad sunburn after only being outside for a very short period of time. What antibiotic is most likely to have caused this? [1]

Answer 20

Doxycycline

Question 21

What type of drug is doxycycline? [1]

Answer 21

Tetracycline

Question 22

MoA and indications for doxycycline [5]

Answer 22

Mechanism of action
protein synthesis inhibitors
binds to 30S subunit blocking binding of aminoacyl-tRNA

Mechanism of resistance
increased efflux of the bacteria by plasmid-encoded transport pumps, ribosomal protection

Indications
acne vulgaris
Lyme disease
Chlamydia
Mycoplasma pneumoniae

Question 23

Notable adverse effects of doxycycline [4]

Answer 23

discolouration of teeth: therefore should not be used in children < 12 years of age
photosensitivity
angioedema
black hairy tongue

Question 24

Why should tetracyclines not be given to pregnant/breastfeeding women? [1]

Answer 24

Tetracyclines should not be given to women who are pregnant or breastfeeding due to the risk of discolouration of the infant’s teeth.

Question 25

If PE is likely as patient has Well’s score above 4 Mx [2]

Answer 25

• arrange an immediate computed tomography pulmonary angiogram (CTPA)
• If there is a delay in getting the CTPA then interim therapeutic anticoagulation should be given until the scan is performed.
  
  • interim therapeutic anticoagulation used to mean giving low-molecular-weight heparin
  • NICE updated their guidance in 2020. They now recommend using an anticoagulant that can be continued if the result is positive.
  • this means normally a direct oral anticoagulant (DOAC) such as apixaban or rivaroxaban

Question 26

If PE is unlikely as 4 points or less Well’s score Mx? [2]

Answer 26

• arranged a D-dimer test
  
  • if positive arrange an immediate computed tomography pulmonary angiogram (CTPA). If there is a delay in getting the CTPA then give interim therapeutic anticoagulation until the scan is performed
  • if negative then PE is unlikely - stop anticoagulation and consider an alternative diagnosis

Question 27

Sx of peptic ulcer perforation [2]

Answer 27

• epigastric pain, later becoming more generalised
• patients may describe syncope

Question 28

Sx of peptic ulcer perforation [2]

Answer 28

• epigastric pain, later becoming more generalised
• patients may describe syncope

Question 29

Ix for peptic ulcer disease perforation

Answer 29

• Although the diagnosis is largely clinical, UptoDate recommend that plain x-rays are the first form of imaging to obtain
• An upright (‘erect’) chest x-ray is usually required when a patient presents with acute upper abdominal pain
• This is a useful test, as approximately 75% of patients with a perforated peptic ulcer will have free air under the diaphragm

Question 30

What is CAH? [4]

Answer 30

• group of autosomal recessive disorders
• affect adrenal steroid biosynthesis
• in response to resultant low cortisol levels the anterior pituitary secretes high levels of ACTH
• ACTH stimulates the production of adrenal androgens that may virilize a female infant

Question 31

Cause of CAH [3]

Answer 31

• 21-hydroxylase deficiency (90%)
• 11-beta hydroxylase deficiency (5%)
• 17-hydroxylase deficiency (very rare)

Question 32

What can uncal herniation cause? [1]

Answer 32

Uncal herniation causes a dilated pupil due to compression of the third cranial nerve

Question 33

What is hernation? [1]

Answer 33

As intracranial pressure rises to pathological levels, normal brain structures are forcefully displaced. This is called herniation.

Question 34

What is brainstem compression also known as? [1]

Answer 34

Herniation is a decompensation of normal brain anatomy and physiology. Displacement of brain causes compression of important structures, the most important of which is the brain stem. Brainstem compression is called ‘coning’.

Question 35

Subfalcine herniation [1]

Answer 35

Displacement of the cingulate gyrus under the falx cerebri

Question 36

Central hernation [1]

Answer 36

Downwards displacement of the brain

Question 37

Transtentorial/uncal hernation [2]

Answer 37

Displacement of the uncus of the temporal lobe under the tentorium cerebelli. Clinical consequences include an ipsilateral fixed, dilated pupil (due to parasympathetic compression of the third cranial nerve) and contralateral paralysis (due to compression of the cerebral peduncle)

Question 38

Tonsillar hernation [2]

Answer 38

Displacement of the cerebellar tonsils through the foramen magnum. This is called ‘coning’. In raised ICP this causes compression of the cardiorespiratory centre. In Chiari 1 malformation, tonsillar herniation is seen without raised ICP

Question 39

Transcalvarial hernation [1]

Answer 39

Occurs when brain is displaced through a defect in the skull (e.g. a fracture or craniotomy site)

Question 40

Where can occupational exposure to asbestos be related to? [1]

Answer 40

Occupational exposure to asbestos occurs by working in factories related to insulation, flooring, and roofing.

Question 41

What is asbestosis and what are the clinical features? [2]

Answer 41

Asbestosis is a lung condition (inflammation and diffuse interstitial fibrosis) caused by long-term exposure to asbestos. It causes shortness of breath, coughing, and wheezing. Bibasilar crackle is an important finding during auscultation.

Question 42

What type of pulmonary function results would asbestosis show? [2]

Answer 42

Asbestosis shows a restrictive deficit (FEV1 – reduced, FVC - significantly reduced, FEV1/FVC - normal or increased) on pulmonary function testing. FEV1 is reduced and FEV1/FVC ratio can be increased or normal.

Question 43

Pulmonary function tests of obstructive lung disease [L] as compared to restrictive lung disease [R] [4]

Answer 43

FEV1 - significantly reduced
FVC - reduced or normal
FEV1% (FEV1/FVC) - reducedFEV1 - reduced
FVC - significantly reduced
FEV1% (FEV1/FVC) - normal or increasedAsthma
COPD
Bronchiectasis
Bronchiolitis obliteransPulmonary fibrosis
Asbestosis
Sarcoidosis
Acute respiratory distress syndrome
Infant respiratory distress syndrome
Kyphoscoliosis e.g. ankylosing spondylitis
Neuromuscular disorders
Severe obesity

Question 44

Which causative organism is associated with a vaginal pH of 4.5? [1]

Answer 44

Trichomonas vaginalis

Question 45

How does candida albicans usually present? [2]

Answer 45

Candida albicans is the bacteria responsible for candidiasis. This would present as ‘cottage cheese’, non-offensive discharge, whilst here the patient is complaining of foul-smelling vaginal discharge.

Question 46

How does chlamydia trachomatis usually present? [1]

Answer 46

Chlamydia trachomatis is the organism responsible for Chlamydia. This condition is symptomatic in 70% of women and 50% of men. When symptomatic in women it causes cervicitis and dysuria, none of which are seen above.

Question 47

How does N. gonorrhoea usually present? [1]

Answer 47

Neisseria gonorrhoeae is the causative organism of gonorrhoea. The classic symptom of this disease in women is cervicitis. This patient has pain but the discharge and vaginal pH point more towards a diagnosis of Trichomonas vaginalis.

Question 48

What is the causative organism of syphilis? [1]

Answer 48

Treponema pallidum

Question 49

Common Sx of syphilis [1]

Answer 49

Treponema pallidum is the causative organism of syphilis. The most common symptom of this disease is a chancre, a painless ulcer at the site of sexual contact. This patient has no lesions.

Question 50

Features of trichomans vaginalis [5]

Answer 50

• vaginal discharge: offensive, yellow/green, frothy
• vulvovaginitis
• strawberry cervix
• pH > 4.5
• in men is usually asymptomatic but may cause urethritis

Question 51

Ix for trichomans vaginalis [1]

Answer 51

• microscopy of a wet mount shows motile trophozoites

Question 52

Mx of trichomans vaginalis [1]

Answer 52

• oral metronidazole for 5-7 days, although the BNF also supports the use of a one-off dose of 2g metronidazole

Question 53

What is the most appropriate first-line Mx of sigmoid volvulus? [1]

Answer 53

Decompression via rigid sigmoidoscopy and flatus tube insertion

Question 54

What is volvulus? [1]

Answer 54

Volvulus may be defined as torsion of the colon around it’s mesenteric axis resulting in compromised blood flow and closed loop obstruction.

Question 55

What is the more common type of volvulus? [3]

Answer 55

Sigmoid volvulus (around 80% of cases) describes large bowel obstruction caused by the sigmoid colon twisting on the sigmoid mesocolon. A similar problem may also occur at the caecum (20% of cases). In most people (around 80%) the caecum is a retroperitoneal structure so not at risk of twisting. In the remaining minority there is however developmental failure of peritoneal fixation of the proximal bowel putting these patients at risk of caecal volvulus

Question 56

Sigmoid volvulus associations [3]

Answer 56

• older patients
• chronic constipation
• Chagas disease
• neurological conditions e.g. Parkinson’s disease, Duchenne muscular dystrophy
• psychiatric conditions e.g. schizophrenia

Question 57

Caecal volvulus associations

Answer 57

All ages, adhesions, pregnancy

Question 58

Features of volvulus [4]

Answer 58

• constipation
• abdominal bloating
• abdominal pain
• nausea/vomiting

Question 59

Dx of volvulus [3]

Answer 59

• usually diagnosed on the abdominal film
• sigmoid volvulus: large bowel obstruction (large, dilated loop of colon, often with air-fluid levels) + coffee bean sign
• caecal volvulus: small bowel obstruction may be seen

Question 60

Mx of volvulus

Answer 60

• sigmoid volvulus: rigid sigmoidoscopy with rectal tube insertion
• caecal volvulus: management is usually operative. Right hemicolectomy is often needed

Question 61

Differentiate between atopic dermatitis, pityriasis rosea, acne rosacea and lupus

Answer 61

This a classic presentation of rosacea, an erythematous pustular rash appearing in a 30 to 50 year old woman which can also affect the eyes. Sunlight is a key feature which can exacerbate the symptoms. Atopic dermatitis usually presents as a dry itchy rash, it is uncommon for pityriasis rosea to present only on the face. Acne vulgaris is not exacerbated by sunlight. Lupus commonly presents differently as a malar butterfly rash although that does not commonly affect the forehead, it too can also be exacerbated by sunlight.

Question 62

features of rosacea [5]

Answer 62

• typically affects nose, cheeks and forehead
• flushing is often first symptom
• telangiectasia are common
• later develops into persistent erythema with papules and pustules
• rhinophyma
• ocular involvement: blepharitis
• sunlight may exacerbate symptoms/

Question 63

Mx of mild rosacea [1]

Answer 63

• topical metronidazole may be used for mild symptoms (i.e. Limited number of papules and pustules, no plaques)

Question 64

Mx of more severe rosacea [1]

Answer 64

• more severe disease is treated with systemic antibiotics e.g. Oxytetracycline

Question 65

Summarise Tx of rosacea [5]

Answer 65

• topical metronidazole may be used for mild symptoms (i.e. Limited number of papules and pustules, no plaques)
• topical brimonidine gel may be considered for patients with predominant flushing but limited telangiectasia
• more severe disease is treated with systemic antibiotics e.g. Oxytetracycline
• recommend daily application of a high-factor sunscreen
• camouflage creams may help conceal redness
• laser therapy may be appropriate for patients with prominent telangiectasia
• patients with a rhinophyma should be referred to dermatology

Question 66

A 24-year-old female is due to undergo urgent surgery after sustaining traumatic injuries to her left leg in a car crash. She has a family history of malignant hyperpyrexia and last ate solid food 90 minutes ago.

Which of the following would be unsafe to use in this patient?

Answer 66

Laryngeal mask airway provides poor control against reflux of gastric contents therefore is unsuitable in non fasted patients

Question 67

List 3 simple positional manoeuvres which can open the airway [3]

Answer 67

• head tilt
• chin lift
• jaw thrust

Question 68

When is oropharyngeal airway used? [4]

Answer 68

• Easy to insert and use
• No paralysis required
• Ideal for very short procedures
• Most often used as bridge to more definitive airway

Question 69

When is a laryngeal mask used to manage an airway? [5]

Answer 69

• Widely used
• Very easy to insert
• Device sits in pharynx and aligns to cover the airway
• Poor control against reflux of gastric contents
• Paralysis not usually required
• Commonly used for wide range of anaesthetic uses, especially in day surgery
• Not suitable for high pressure ventilation (small amount of PEEP often possible

Question 70

When is a laryngeal mask CI? [2]

Answer 70

Poor control against reflux of gastric contents

Not suitable fro high pressure ventilation

Question 71

When is a tracheostomy used? [4]

Answer 71

• Reduces the work of breathing (and dead space)
• May be useful in slow weaning
• Percutaneous tracheostomy widely used in ITU
• Dries secretions, humidified air usually required

Question 72

When is an endotracheal tube used? [5]

Answer 72

• Provides optimal control of the airway once cuff inflated
• May be used for long or short term ventilation
• Errors in insertion may result in oesophageal intubation (therefore end tidal CO₂ usually measured)
• Paralysis often required
• Higher ventilation pressures can be used

Question 73

First-line Mx for secretions in palliative care setting that cause rattling noise [1]

Answer 73

Hyoscine hydrobromide or hyoscine butylbromide [muscarinic receptor antagonists] is generally used first-line to manage secretions in a palliative care setting

Question 74

What type of turbulent secretions can cause rattling sound end of life? [1]

Answer 74

This woman is experiencing excessive bronchial and hypopharyngeal secretions which can occur in the terminal phase of life

Question 75

Conservative Mx of secretions palliative care [2]

Answer 75

• Avoiding fluid overload - particularly stopping IV or subcutaneous fluids
• Educating the family that the patient is likely not troubled by secretions

Question 76

Compare moderate, severe and life-threatening asthma attacks [3]

Answer 76

ModerateSevereLife-threateningPEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpmPEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpmPEFR < 33% best or predicted
Oxygen sats < 92%
‘Normal’ pC0₂ (4.6-6.0 kPa)
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma

Question 77

Asthmatic patient can’t complete sentences, what type of asthma? [1]

Answer 77

Severe

Question 78

Oxygen sats below 92% asthma attack severity [1]

Answer 78

Life-threatening

Question 79

Define ‘near-fatal asthma’ [1]

Answer 79

A fourth category, ‘Near-fatal asthma’, is also recognised characterised by a raised pC0₂ and/or requiring mechanical ventilation with raised inflation pressures.

Question 80

What further assessment should patients have with an asthma attack? [2]

Answer 80

• the BTS guidelines recommend arterial blood gases for patients with oxygen sats < 92%
• a chest x-ray is not routinely recommended, unless:
  
  • life-threatening asthma
  • suspected pneumothorax
  • failure to respond to treatment

Question 81

Admission for asthmatic attack patient [3]

Answer 81

• • all patients with life-threatening should be admitted in hospital
    
    • patients with features of severe acute asthma should also be admitted if they fail to respond to initial treatment.
    • other admission criteria include a previous near-fatal asthma attack, pregnancy, an attack occurring despite already using oral corticosteroid and presentation at night

Question 82

Oxygen for asthma attack pts [2]

Answer 82

• if patients are hypoxaemic, it is important to start them on supplemental oxygen therapy
• if patients are acutely unwell they should be started on 15L of supplemental via a non-rebreathe mask, which can then be titrated down to a flow rate where they are able to maintain a SpO₂ 94-98%.

Question 83

Bronchodilation for asthma patients [3]

Answer 83

• high-dose inhaled SABA e.g. salbutamol, terbutaline
• in patients without features of life-threatening or near-fatal asthma, this can be given by a standard pressurised metered-dose inhaler (pMDI) or by an oxygen-driven nebulizer
• in patients with features of a life-threatening exacerbation of asthma, nebulised SABA is recommended

Question 84

COC for asthmatic patients [2]

Answer 84

• all patients should be given 40-50mg of prednisolone orally (PO) daily, which should be continued for at least five days or until the patient recovers from the attack
• during this time, patients should continue their normal medication routine including inhaled corticosteroids.

Question 85

What is commonly given with severe/life-treatening asthma? [2]

Answer 85

• ipratropium bromide: in patients with severe or life-threatening asthma, or in patients who have not responded to beta₂-agonist and corticosteroid treatment, nebulised ipratropium bromide, a short-acting muscarinic antagonist

Question 86

Is IV magnesium sulphate or aminophylline routinely offered asthma attacks? [2]

Answer 86

• IV magnesium sulphate
  
  • the BTS notes that the evidence base is mixed for this treatment that is now commonly given for severe/life-threatening asthma
• IV aminophylline may be considered following consultation with senior medical staff

Question 87

Mx of patient that fail to respond to medical Tx [2]

Answer 87

• patients who fail to respond require senior critical care support and should be treated in an appropriate ITU/HDU setting. Treatment options include:
  
  • intubation and ventilation
  • extracorporeal membrane oxygenation (ECMO)

Question 88

Criteria for discharge of asthma attacks pt [3]

Answer 88

• been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours
• inhaler technique checked and recorded
• PEF >75% of best or predicted

Question 89

Summarise Mx of asthma attack [9]

Answer 89

Management

• admission
  
  • all patients with life-threatening should be admitted in hospital
  • patients with features of severe acute asthma should also be admitted if they fail to respond to initial treatment.
  • other admission criteria include a previous near-fatal asthma attack, pregnancy, an attack occurring despite already using oral corticosteroid and presentation at night
• oxygen
  
  • if patients are hypoxaemic, it is important to start them on supplemental oxygen therapy
  • if patients are acutely unwell they should be started on 15L of supplemental via a non-rebreathe mask, which can then be titrated down to a flow rate where they are able to maintain a SpO₂ 94-98%.
• bronchodilation with short-acting beta₂-agonists (SABA)
  
  • high-dose inhaled SABA e.g. salbutamol, terbutaline
  • in patients without features of life-threatening or near-fatal asthma, this can be given by a standard pressurised metered-dose inhaler (pMDI) or by an oxygen-driven nebulizer
  • in patients with features of a life-threatening exacerbation of asthma, nebulised SABA is recommended
• corticosteroid
  
  • all patients should be given 40-50mg of prednisolone orally (PO) daily, which should be continued for at least five days or until the patient recovers from the attack
  • during this time, patients should continue their normal medication routine including inhaled corticosteroids.
• ipratropium bromide: in patients with severe or life-threatening asthma, or in patients who have not responded to beta₂-agonist and corticosteroid treatment, nebulised ipratropium bromide, a short-acting muscarinic antagonist
• IV magnesium sulphate
  
  • the BTS notes that the evidence base is mixed for this treatment that is now commonly given for severe/life-threatening asthma
• IV aminophylline may be considered following consultation with senior medical staff
• patients who fail to respond require senior critical care support and should be treated in an appropriate ITU/HDU setting. Treatment options include:
  
  • intubation and ventilation
  • extracorporeal membrane oxygenation (ECMO)

Criteria for discharge

• been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours
• inhaler technique checked and recorded
• PEF >75% of best or predicted

Question 90

Fine needle aspiration is performed and shows a benign pleomorphic adenoma, which is confirmed by histology.

What is the most appropriate management and why? [1]

Answer 90

Routine surgical resection → malignant transformation may occur in pts with a pleomorphic adenoma, therefore should be surgically removed

Question 91

What is the most common parotid neoplasm? [1]

Answer 91

Benign pleomorphic adenoma or benign mixed tumour

• Most common parotid neoplasm (80%)

Question 92

How common is malignant transformation of pleomorphic adenoma? [1]

Answer 92

• Malignant transformation occurrs in 2-10% of adenomas observed for long periods, with carcinoma ex-pleomorphic adenoma occurring most frequently as adenocarcinoma

Question 93

Summarise features of pleomorphic adenoma [6]

Answer 93

• Most common parotid neoplasm (80%)
• Proliferation of epithelial and myoepithelial cells of the ducts and an increase in stromal components
• Slow growing, lobular, and not well encapsulated
• Recurrence rate of 1-5% with appropriate excision (parotidectomy)
• Recurrence possibly secondary to capsular disruption during surgery
• Malignant transformation occurrs in 2-10% of adenomas observed for long periods, with carcinoma ex-pleomorphic adenoma occurring most frequently as adenocarcinoma

Question 94

During his annual diabetic review you notice that whilst his foot pulses are easy to palpate there is a loss of sensation in 4 of the 10 points tested on the right foot and 2 of the 10 points tested on the left foot. What is the most appropriate management? [1]

Answer 94

Refer to local diabetic foot centre → Diabetic patients who have any foot problems other than simple calluses should be followed up regularly by the local diabetic foot centre

Question 95

What does diabetic foot disease occur secondary to? [2]

Answer 95

• neuropathy: resulting in loss of protective sensation (e.g. not noticing a stone in the shoe), Charcot’s arthropathy, dry skin
• peripheral arterial disease: diabetes is a risk factor for both macro and microvascular ischaemia

Question 96

Presentation of diabetic foot disease [3]

Answer 96

• neuropathy: loss of sensation
• ischaemia: absent foot pulses, reduced ankle-brachial pressure index (ABPI), intermittent claudication
• complications: calluses, ulceration, Charcot’s arthropathy, cellulitis, osteomyelitis, gangrene

Question 97

How often should diabetic patients be screened for diabetic foot disease? [2]

Answer 97

All patients with diabetes should be screened for diabetic foot disease on at least an annual basis

• screening for ischaemia: done by palpating for both the dorsalis pedis pulse and posterial tibial artery pulse
• screening for neuropathy: a 10 g monofilament is used on various parts of the sole of the foot

Question 98

Compare low to moderate to high risk diabetic foot patients [3]

Answer 98

Low riskModerate riskHigh risk• no risk factors except callus alone• deformity or
• neuropathy or
• non-critical limb ischaemia.• previous ulceration or
• previous amputation or
• on renal replacement therapy or
• neuropathy and non-critical limb ischaemia together or
• neuropathy in combination with callus and/or deformity or
• non-critical limb ischaemia in combination with callus and/or deformity.

Question 99

Which hormonal condition can excess steroids cause? [1]

Answer 99

This patient has symptoms suggestive of Cushing’s syndrome caused by prolonged exposure to exogenous corticosteroids such as Prednisolone for his medical conditions.

Question 100

What would Cushing’s syndrome look like on a VBG? [3]

Answer 100

Cushing’s syndrome - hypokalaemic metabolic alkalosis. The metabolic alkalosis is due to excess aldosterone which increases acid and potassium excretion in the kidney.

Question 101

What would Addison’s disease look like on an VBG? [3]

Answer 101

Addison’s disease - hyperkalaemic metabolic acidosis. The metabolic acidosis is due to insufficiency of aldosterone which decreases acid secretion in the kidney and leads to the retention of potassium

Question 102

Possible causes of Cushing’s syndrome [3]

Answer 102

• iatrogenic: corticosteroid therapy
• ACTH-dependent causes
  
  • Cushing’s disease (a pituitary adenoma → ACTH secretion)
  • ectopic ACTH secretion secondary to a malignancy
• ACTH-independent causes
  
  • adrenal adenoma

Question 103

General findings conssitent with Cushing’s syndrome [2]

Answer 103

A hypokalaemic metabolic alkalosis may be seen, along with impaired glucose tolerance.

Ectopic ACTH secretion (e.g. secondary to small cell lung cancer) is characteristically associated with very low potassium levels.

Question 104

Two commonly used tests for Cushing’s syndrome [2]

Answer 104

• overnight dexamethasone suppression test
  
  • this is the most sensitive test and is now used first-line to test for Cushing’s syndrome
  • patients with Cushing’s syndrome do not have their morning cortisol spike suppressed
• 24 hr urinary free cortisol

Question 105

What are the localisation tests? [2]

Answer 105

The first-line localisation is 9am and midnight plasma ACTH (and cortisol) levels. If ACTH is suppressed then a non-ACTH dependent cause is likely such as an adrenal adenoma.

High0dose dexamethsone is used to located the pathology of Cushing’s.

Question 106

How to interpret high-dose dexamethasone suppresion tests [9]

Answer 106

CortisolACTHInterpretationNot suppressedSuppressedCushing’s syndrome due to other causes (e.g. adrenal adenomas)SuppressedSuppressedCushing’s disease (i.e. pituitary adenoma → ACTH secretion)Not suppressedNot suppressedEctopic ACTH syndrome

Question 107

What other tests can be used Cushing’s? [3]

Answer 107

CRH stimulation

• if pituitary source then cortisol rises
• if ectopic/adrenal then no change in cortisol

Petrosal sinus sampling of ACTH may be needed to differentiate between pituitary and ectopic ACTH secretion.

An insulin stress test is used to differentiate between true Cushing’s and pseudo-Cushing’s.

Question 108

Compare presentations of acute dystonic reaction, malignant hyperthermia, pelvic abscess, epilepsy and SS [5]

Answer 108

Anaesthetic agents, such as suxamethonium, can cause malignant hyperthermia in patients with a genetic defect. Acute dystonic reaction normally is associated with antipsychotics (haloperidol) and metoclopramide. These lead to marked extrapyramidal effects. Serotonin syndrome is associated with the antidepressants selective serotonin reuptake inhibitors (SSRIs) and selective serotonin/norepinephrine reuptake inhibitors (SSNRIs). This causes a syndrome of agitation, tachycardia, hallucinations and hyper-reflexia.

Question 109

When is malignant hyperthermia commonly seen? [1]

Answer 109

• condition often seen following administration of anaesthetic agents

Question 110

What is malignant hyperthermia characterised by? [1]

Answer 110

• characterised by hyperpyrexia and muscle rigidity

Question 111

Cause of malignant hyperthermia [3]

Answer 111

• cause by excessive release of Ca2+ from the sarcoplasmic reticulum of skeletal muscle
• associated with defects in a gene on chromosome 19 encoding the ryanodine receptor, which controls Ca2+ release from the sarcoplasmic reticulum
• susceptibility to malignant hyperthermia is inherited in an autosomal dominant fashion

Question 112

Causative agents of malignant hyperthermia [3]

Answer 112

• halothane
• suxamethonium
• other drugs: antipsychotics (neuroleptic malignant syndrome)

Question 113

Ix and Mx of malignant hyperthermia [3]

Answer 113

Investigations

• CK raised
• contracture tests with halothane and caffeine

Management

• dantrolene - prevents Ca2+ release from the sarcoplasmic reticulum

Question 114

What is the commonest cause of wound infection in the UK? [2]

Answer 114

In this setting Staphylococcus aureus Infection is the most likely cause. In the UK between 2010 and 2011 the commonest cause of wound infection was enterobacter infections (usually following cardiac or colonic surgery). 23% of infections were due to Staph aureus, which fits the scenario above

Question 115

Measures that inceease risk of SSI [4]

Answer 115

• Shaving the wound using a razor (disposable clipper preferred)
• Using a non iodine impregnated incise drape if one is deemed to be necessary
• Tissue hypoxia
• Delayed administration of prophylactic antibiotics in tourniquet surgery

Question 116

Preop, intraop, postop measures to reduce risk of SSI [3]

Answer 116

Preoperatively

• Don’t remove body hair routinely
• If hair needs removal, use electrical clippers with single use head (razors increase infection risk)
• Antibiotic prophylaxis if:
• placement of prosthesis or valve
• clean-contaminated surgery
• contaminated surgery
• Use local formulary
• Aim to give single dose IV antibiotic on anaesthesia
• If a tourniquet is to be used, give prophylactic antibiotics earlier

Intraoperatively

• Prepare the skin with alcoholic chlorhexidine (Lowest incidence of SSI)
• Cover surgical site with dressing
• A recent meta analysis has confirmed that administration of supplementary oxygen does not reduce the risk of wound infection. In contrast to previous individual RCT’s(1)
• Wound edge protectors do not appear to confer benefit (2)

Post operatively
Tissue viability advice for management of surgical wounds healing by secondary intention

Question 117

Inheritance pattern of maturity onset diabetes of the young [MODY] [1]

Answer 117

Autosomal dominant

Question 118

Features of MODY [4]

Answer 118

• typically develops in patients < 25 years
• a family history of early onset diabetes is often present
• ketosis is not a feature at presentation
• patients with the most common form are very sensitive to sulfonylureas, insulin is not usually necessary

Question 119

HIV patient with multifocal non-enhancing lesions [1]

Answer 119

John Cunningham virus

Question 120

What is JC virus? [1]

Answer 120

A patient who is known to have HIV presents gradually worsening speech and behavioural problems associated with coordination difficulties. A MRI shows multifocal non-enhancing lesions - JC virus

Question 121

What accounts for around 50% of cerebral lesions in pts with HIV? [1]

Answer 121

Txoxplasmosis

Question 122

Sx, CT and Mx of toxoplasmosis with HIV [3]

Answer 122

• accounts for around 50% of cerebral lesions in patients with HIV
• constitutional symptoms, headache, confusion, drowsiness
• CT: usually single or multiple ring enhancing lesions, mass effect may be seen
• management: sulfadiazine and pyrimethamine

Question 123

Which pathogen is associated with primary CNS lymphoma? [1]

Answer 123

Epstein-Barr virus

Question 124

Prevalence, CT and Tx for primary CNS lymphoma in HIV [3]

Answer 124

• accounts for around 30% of cerebral lesions
• associated with the Epstein-Barr virus
• CT: single or multiple homogenous enhancing lesions
• treatment generally involves steroids (may significantly reduce tumour size), chemotherapy (e.g. methotrexate) + with or without whole brain irradiation. Surgical may be considered for lower grade tumours

Question 125

How to differentiate between toxoplasmosis and lymphoma in HIV [2]

Answer 125

ToxoplasmosisLymphomaMultiple lesions
Ring or nodular enhancement
Thallium SPECT negativeSingle lesion
Solid (homogenous) enhancement
Thallium SPECT positive

Question 126

What would TB look like in HIV? [1]

Answer 126

• much less common than toxoplasmosis or primary CNS lymphoma
• CT: single enhancing lesion

Question 127

Summarise focal neurological deficit in HIV causes [3]

Answer 127

Toxoplasmosis, lymphoma, TB

Question 128

Causes of generalised neurological disease in HIV [4]

Answer 128

Encephalitis, crytococcus, progressive multifocal leurkocephalopathy [PML], AIDS dementia complex

Question 129

Features of encephalitis in HIV [3]

Answer 129

• may be due to CMV or HIV itself
• HSV encephalitis but is relatively rare in the context of HIV
• CT: oedematous brain

Question 130

Features of crytococcus in HIV [5]

Answer 130

• most common fungal infection of CNS
• headache, fever, malaise, nausea/vomiting, seizures, focal neurological deficit
• CSF: high opening pressure, India ink test positive
• CT: meningeal enhancement, cerebral oedema
• meningitis is typical presentation but may occasionally cause a space occupying lesion

Question 131

Features of PML in HIV [4]

Answer 131

• widespread demyelination
• due to infection of oligodendrocytes by JC virus (a polyoma DNA virus)
• symptoms, subacute onset : behavioural changes, speech, motor, visual impairment
• CT: single or multiple lesions, no mass effect, don’t usually enhance. MRI is better - high-signal demyelinating white matter lesions are seen

Question 132

Features of AIDS dementia complex in HIV [3]

Answer 132

• caused by HIV virus itself
• symptoms: behavioural changes, motor impairment
• CT: cortical and subcortical atrophy

Question 133

What does subacute thyroiditis typically present after? [2]

Answer 133

Subacute thyroiditis (also known as De Quervain’s thyroiditis and subacute granulomatous thyroiditis) is thought to occur following viral infection and typically presents with hyperthyroidism.

Question 134

The 4 phases of subacute thyroiditis [4]

Answer 134

• phase 1 (lasts 3-6 weeks): hyperthyroidism, painful goitre, raised ESR
• phase 2 (1-3 weeks): euthyroid
• phase 3 (weeks - months): hypothyroidism
• phase 4: thyroid structure and function goes back to normal

Question 135

Ix for subacute thyroiditis [1]

Answer 135

• thyroid scintigraphy: globally reduced uptake of iodine-131

Question 136

Mx of subacute thyroiditis [3]

Answer 136

• usually self-limiting - most patients do not require treatment
• thyroid pain may respond to aspirin or other NSAIDs
• in more severe cases steroids are used, particularly if hypothyroidism develops

Question 137

Common presentation of delirium tremens [1]

Answer 137

Visual and auditory hallucinations

Question 138

First-line Mx of alcohol withdrawal [1]

Answer 138

• first-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol

Question 139

Factors suggesting Dx of depression over dementia

Answer 139

• short history, rapid onset
• biological symptoms e.g. weight loss, sleep disturbance
• patient worried about poor memory
• reluctant to take tests, disappointed with results
• mini-mental test score: variable
• global memory loss (dementia characteristically causes recent memory loss

Question 140

What must pts have before cardioversion of AF? [1]

Answer 140

For cardioversion of AF: patients must either be anticoagulated or have had symptoms for < 48 hours to reduce the risk of stroke.

Question 141

Classification of AF [3]

Answer 141

• first detected episode (irrespective of whether it is symptomatic or self-terminating)
• recurrent episodes, when a patient has 2 or more episodes of AF. If episodes of AF terminate spontaneously then the term paroxysmal AF is used. Such episodes last less than 7 days (typically < 24 hours). If the arrhythmia is not self-terminating then the term persistent AF is used. Such episodes usually last greater than 7 days
• in permanent AF there is continuous atrial fibrillation which cannot be cardioverted or if attempts to do so are deemed inappropriate. Treatment goals are therefore rated control and anticoagulation if appropriate

Question 142

What are the two key ways of managing AF? [1]

Answer 142

Rate and rhythm control

Question 143

How rate and rhythm control work? [2]

Answer 143

• rate control: accept that the pulse will be irregular, but slow the rate down to avoid negative effects on cardiac function
• rhythm control: try to get the patient back into, and maintain, normal sinus rhythm. This is termed cardioversion. Drugs (pharmacological cardioversion) and synchronised DC electrical shocks (electrical cardioversion) may be used for this purpose

Question 144

Which type of contorl in AF is usually preferred now? Exception to this? [2]

Answer 144

For many years the predominant approach was to try and maintain a patient in sinus rhythm. This approach changed in the early 2000’s and now the majority of patients are managed with a rate control strategy. NICE advocate using a rate control strategy except in a number of specific situations such as coexistent heart failure, first onset AF or where there is an obvious reversible cause.

Question 145

First-line for rate control [2]

Answer 145

A beta-blocker or a rate-limiting calcium channel blocker (e.g. diltiazem) is used first-line to control the rate in AF.

If one drug does not control the rate adequately NICE recommend combination therapy with any 2 of the following:

• a betablocker
• diltiazem
• digoxin

Question 146

Why is it important to either be anticoagulated/short duration of Sx before attempting cardioversion? [2]

Answer 146

When considering cardioversion it is very important to remember that the moment a patient switches from AF to sinus rhythm presents the highest risk for embolism leading to stroke. Imagine the thrombus formed in the fibrillating atrium suddenly being pushed out when sinus rhythm is restored. For this reason patients must either have had a short duration of symptoms (less than 48 hours) or be anticoagulated for a period of time prior to attempting cardioversion.

Question 147

What is the risk strasifying score for stroke in AF? [1]

Answer 147

Some patients with AF are at a very low risk of stroke whilst others are at a very significant risk. Clinicians use risk stratifying tools such as the CHA₂DS₂-VASc score to determine the most appropriate anticoagulation strategy.

Question 148

Most common infectious agents seen acute sinusitis [1]

Answer 148

Streptococcus pneumoniae, Haemophilus influenzae and rhinoviruses.

Question 149

Predisposing factors for acute sinusitis [4]

Answer 149

• nasal obstruction e.g. septal deviation or nasal polyps
• recent local infection e.g. rhinitis or dental extraction
• swimming/diving
• smoking

Question 150

Features acute sinusitis [3]

Answer 150

• facial pain
  
  • typically frontal pressure pain which is worse on bending forward
• nasal discharge: usually thick and purulent
• nasal obstruction

Question 151

Mx of acute sinusitis [4]

Answer 151

• analgesia
• intranasal decongestants or nasal saline may be considered but the evidence supporting these is limited
• NICE CKS recommend that intranasal corticosteroids may be considered if the symptoms have been present for more than 10 days
• oral antibiotics are not normally required but may be given for severe presentations.
  
  • The BNF recommends phenoxymethylpenicillin first-line, co-amoxiclav if ‘systemically very unwell, signs and symptoms of a more serious illness, or at high-risk of complications’
  • ‘double-sickening’ may sometimes be seen, where an initial viral sinusitis worsens due to secondary bacterial infection

Question 152

A 56-year-old man who drinks heavily is found collapsed by friends at his house. He was out drinking the previous night and following this was noted to have vomited repeatedly so his friends brought him home [2]

Answer 152

The correct answer is: Oesophageal rupture76%

Spontaneous rupture of the oesophagus may occur following an episode of vomiting. The subsequent mediastinitis can produce severe sepsis and death if not treated promptly. Adequate drainage of sepsis and early surgery are the cornerstones of management.

Question 153

A 43-year-old man has been troubled with dysphagia for many years. He is known to have achalasia and has had numerous dilatations. Over the past 6 weeks his dysphagia has worsened. At endoscopy a friable mass is noted in the oesophagus

Answer 153

Squamous cell carcinoma36%

The risk of squamous cell carcinoma of the oesophagus is increased in people with achalasia. The condition often presents late and has a poor prognosis.

Question 154

A 73-year-old lady is troubled by episodic swallowing difficulty and halitosis. An upper GI endoscopy is attempted and abandoned due to difficulty in achieving intubation.

Answer 154

The correct answer is: Pharyngeal pouch76%

Pharyngeal pouches occur when a defect occurs in killians dehiscence. Difficulty in intubation is a well recognised consequence and care must be taken to take the correct track during OGD to avoid perforation. Most cases are now treated with endoscopic stapling.

Question 155

Usually history of antecedent vomiting. This is then followed by the vomiting of a small amount of blood. There is usually little in the way of systemic disturbance or prior symptoms.

Answer 155

Mallory-Weiss tear

Question 156

Often longstanding history of dyspepsia, patients are often overweight. Uncomplicated hiatus hernias should not be associated with dysphagia or haematemesis.

Answer 156

Hiatus hernia of gastric cardia

Question 157

Complete disruption of the oesophageal wall in absence of per-existing pathology. Left postero-lateral oesophageal is commonest site (2-3cm from OG junction). Suspect in patients with severe chest pain without cardiac diagnosis and signs suggestive of pneumonia without convincing history, where there is history of vomiting. Erect CXR shows infiltrate or effusion in 90% of cases(1).

Answer 157

Oeosphageal rupture

Question 158

History of progressive dysphagia. Often signs of weight loss. Usually little or no history of previous GORD type symptoms.

Answer 158

Sqaumous cell carcinoma of the oesophagus

Question 159

Progressive dysphagia, may have previous symptoms of GORD or Barretts oesophagus.

Answer 159

Adenocarcinoma of the oesphagus

Question 160

Longer history of dysphagia, often not progressive. Usually symptoms of GORD. Often lack systemic features seen with malignancy

Answer 160

Peptic stricture

Question 161

May have dysphagia that is episodic and non progressive. Retrosternal pain may accompany the episodes.

Answer 161

Dysmotility disorder

Question 162

A 2-month-old previously healthy girl is brought into the GP by her mother who reports a change in her demeanour. She suspects her child has a fever. On examination the baby is feverish with temperature of 38.5 ºC but no other significant findings.

What is the appropriate next step?

Answer 162

A child aged < 3 months with a fever > 38ºC should be assessed as high risk of serious illness

Question 163

What should be recorded in all febrile children? [4]

Answer 163

• temperature
• heart rate
• respiratory rate
• capillary refill time

Signs of dehydration (reduced skin turgor, cool extremities etc) should also be looked for

Question 164

How to measure temperature in child is under 4w? [1]

Answer 164

Measuring temperature should be done with an electronic thermometer in the axilla if the child is < 4 weeks or with an electronic/chemical dot thermometer in the axilla or an infra-red tympanic thermometer.

Question 165

RR 65, chest indrawing, reduced skin turgor, 2m old with temp of 38.2, how should child be Mx? [1]

Answer 165

Red flag patient, refer to specialist immediately

Question 166

How to manage green vs amber vs red child [3]

Answer 166

If green:

• Child can be managed at home with appropriate care advice, including when to seek further help

If amber:

• provide parents with a safety net or refer to a paediatric specialist for further assessment
• a safety net includes verbal or written information on warning symptoms and how further healthcare can be accessed, a follow-up appointment, liaison with other healthcare professionals, e.g. out-of-hours providers, for further follow-up

If red:

• refer child urgently to a paediatric specialist

Question 167

Should orla Abx be Rx to an unwell child? [1]

Answer 167

• oral antibiotics should not be prescribed to children with fever without apparent source

Question 168

When does endometrial Ca commonly occur? [1]

Answer 168

Endometrial cancer is classically seen in post-menopausal women but around 25% of cases occur before the menopause.

Question 169

RFs for endometrial cancer [important] [9]

Answer 169

• obesity
• nulliparity
• early menarche
• late menopause
• unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
• diabetes mellitus
• tamoxifen
• polycystic ovarian syndrome
• hereditary non-polyposis colorectal carcinoma

Question 170

Features of endometrial Ca [3]

Answer 170

• postmenopausal bleeding is the classic symptom
• premenopausal women may have a change intermenstrual bleeding
• pain and discharge are unusual features

Question 171

Ix of endometrial Ca [3]

Answer 171

• women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
• first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
• hysteroscopy with endometrial biopsy

Question 172

Mx of endometrial Ca [2]

Answer 172

• localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Patients with high-risk disease may have post-operative radiotherapy
• progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery

Question 173

What, counterintuitively, are protective for endometial Ca? [2]

Answer 173

Smoking and COCP

Question 174

A 22-year-old man presents with symptoms of lethargy and bilateral facial nerve palsy. On examination he has bilateral parotid gland enlargement.

Answer 174

Sarcoidosis49%

Facial nerve palsy is the commonest neurological manifestation of sarcoid. It usually resolves. The absence of ear discharge or discrete lesion on palpation is against the other causes.

Question 175

A 21-year-old man presents with a unilateral facial nerve palsy after being hit in the head. On examination he has a right sided facial nerve palsy and a watery discharge from his nose.

Answer 175

Petrous temporal fracture91%

Nasal discharge of clear fluid and recent head injury makes a basal skull fracture the most likely underlying diagnosis.

Question 176

A 43-year-old lady presents with symptoms of chronic ear discharge and a right sided facial nerve palsy. On examination she has foul smelling fluid draining from her right ear and a complete right sided facial nerve palsy

Answer 176

Warthins tumour
The correct answer is: Cholesteatoma87%

Foul smelling ear discharge and facial nerve weakness is likely to be due to cholesteatoma. The presence of a neurological deficit is a sinister feature.

Question 177

Function of the facial nerve [4]

Answer 177

Supply - ‘face, ear, taste, tear’

• face: muscles of facial expression
• ear: nerve to stapedius
• taste: supplies anterior two-thirds of tongue
• tear: parasympathetic fibres to lacrimal glands, also salivary glands

Question 178

Causes bilateral facial nerve palsy [5]

Answer 178

• sarcoidosis
• Guillain-Barre syndrome
• Lyme disease
• bilateral acoustic neuromas (as in neurofibromatosis type 2)
• as Bell’s palsy is relatively common it accounts for up to 25% of cases f bilateral palsy, but this represents only 1% of total Bell’s palsy cases

Question 179

Unilaterla LMN facial nerve palsy causes

Answer 179

• Bell’s palsy
• Ramsay-Hunt syndrome (due to herpes zoster)
• acoustic neuroma
• parotid tumours
• HIV
• multiple sclerosis*
• diabetes mellitus

Question 180

UMN unilateral facial palsy [1]

Answer 180

Stroke

Question 181

LMN vs UMN facial palsy [1]

Answer 181

• upper motor neuron lesion ‘spares’ upper face i.e. forehead
• lower motor neuron lesion affects all facial muscles

Question 182

subarchnoid, facial canal and stylomastoid formaen path. Also, what are the branches of the faicl nerve [4]

Answer 182

Subarachnoid path

• Origin: motor- pons, sensory- nervus intermedius
• Pass through the petrous temporal bone into the internal auditory meatus with the vestibulocochlear nerve. Here they combine to become the facial nerve.

Facial canal path

• The canal passes superior to the vestibule of the inner ear
• At the medial aspect of the middle ear, it becomes wider and contains the geniculate ganglion.
• 3 branches:
• 1. greater petrosal nerve
• 2. nerve to stapedius
• 3. chorda tympani

Stylomastoid foramen

• Passes through the stylomastoid foramen (tympanic cavity anterior and mastoid antrum posteriorly)
• Posterior auricular nerve and branch to posterior belly of digastric and stylohyoid muscle

Question 183

A 32-year-old woman presents with recurrent deep vein thromboses and pulmonary embolisms. She has a past medical history of recurrent miscarriages. Blood results reveal a prolonged APTT.

What is the most appropriate test from the options below?

Answer 183

Anti-cardiolipin antibody → features suggestive of antiphospholipid syndrome

Question 184

Characteristics of antiphospholipid syndrome [2]

Answer 184

Antiphospholipid syndrome is an acquired disorder characterised by a predisposition to both venous and arterial thromboses, recurrent fetal loss and thrombocytopenia. It may occur as a primary disorder or secondary to other conditions, most commonly systemic lupus erythematosus (SLE)

Question 185

Features of antiphospholipid syndrome [5]

Answer 185

• venous/arterial thrombosis
• recurrent fetal loss
• livedo reticularis
• thrombocytopenia
• prolonged APTT
• other features: pre-eclampsia, pulmonary hypertension

Question 186

Mx of APS [2]

Answer 186

• primary thromboprophylaxis
  
  • low-dose aspirin
• secondary thromboprophylaxis
  
  • initial venous thromboembolic events: lifelong warfarin with a target INR of 2-3
  • recurrent venous thromboembolic events: lifelong warfarin; if occurred whilst taking warfarin then consider adding low-dose aspirin, increase target INR to 3-4
  • arterial thrombosis should be treated with lifelong warfarin with target INR 2-3

Question 187

Can levonorgestrel be used as emergency contraception? [1]

Answer 187

Levonorgestrel must be taken within 72 hours of UPSI, can be used though

Question 188

What are the two methods of emergency hormonal contraception? [2]

Answer 188

There are now two methods of emergency hormonal contraception (‘emergency pill’, ‘morning-after pill’); levonorgestrel and ulipristal, a progesterone receptor modulator.

Question 189

MoA Levonorgestrel [2]

Answer 189

• mode of action not fully understood - acts both to stop ovulation and inhibit implantation
• should be taken as soon as possible - efficacy decreases with time

Question 190

Dose of Levonorgestrel [1]

Answer 190

• single dose of levonorgestrel 1.5mg (a progesterone)
  
  • the dose should be doubled for those with a BMI >26 or weight over 70kg

Question 191

If vomiting occurs within 3h of leonorgestrel, what should be done? [1]

Answer 191

• if vomiting occurs within 3 hours then the dose should be repeated

Question 192

Can levonorgestrel be used more than once within a menstrual cycle? [1]

Answer 192

• can be used more than once in a menstrual cycle if clinically indicated

Question 193

What cnabe started immediately after levnoogestrel? [1]

Answer 193

• hormonal contraception can be started immediately after using levornogestrel (Levonelle) for emergency contraception

Question 194

MoA of ulipristal [1]

Answer 194

• a selective progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation

Question 195

Dose of unipristal [1]

Answer 195

• 30mg oral dose taken as soon as possible, no later than 120 hours after intercourse

Question 196

Can unipristal be used more than once in the same cycle? [1]

Answer 196

Yes

Question 197

When can IUD be inserted as emergency contraception? [2]

Answer 197

• must be inserted within 5 days of UPSI, or
• if a women presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date

Question 198

How do IUD work? [1]

Answer 198

• may inhibit fertilisation or implantation

Question 199

What should be given alongside IUD in pts high-risk for an STI [1]

Answer 199

• prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection

Question 200

Effectivity and advantage of IUD [2]

Answer 200

• is 99% effective regardless of where it is used in the cycle
• may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period

Question 201

What is bullous pemphigoid? [2]

Answer 201

Bullous pemphigoid is an autoimmune condition causing sub-epidermal blistering of the skin. It is common in elderly patients and is usually itchy. Given that this patient has no blisters and itchiness the diagnosis is unlikely.

Question 202

What is erythema marginatum? [2]

Answer 202

Erythema marginatum is a form of reactive inflammatory erythema seen in around 10% of the cases of rheumatic fever and it is rare in adults. It involves pink rings on the torso and inner surfaces of the limbs that are barely raised and are non-itchy. In this case, the lesions are not itchy, but they are clearly raised. This patient does not complain of other symptoms, making this diagnosis unlikely.

Question 203

What is eryhtema nodosum? [2]

Answer 203

Erythema nodosum is an inflammation of subcutaneous fat that typically causes tender, erythematous, nodular lesions. It typically occurs on the shins. It can be caused by an infection or a systemic disease such as sarcoidosis. This patient’s lesions are targeted lesions, whilst in erythema nodosum, you would expect a more of a ‘bulging’ lesion.

Question 204

What is SJS? [2]

Answer 204

Stevens-Johnson syndrome is a severe systemic reaction affecting the skin and mucosa, almost always caused by a drug reaction. The characteristic rash is typically maculopapular with target lesions. This patient has this type of lesion, however, this patient is systematically well, whilst in Stevens-Johnson syndrome, fever and arthralgia extremely are common. The condition causes epidermolysis (blistering and peeling) which causes severe fluid loss, causing the patient to feel extremely unwell. This is not seen in this patient.