Wednesday [06/10/2021]

Question 1

Features of erythema multiforme [4]

Answer 1

Target lesions

initially seen on the back of the hands/feet before spreading to the torso

upper limbs are more commonly affected than the lower limbs

Question 2

Causes of erythema multiforme [4]

Answer 2

• viruses: herpes simplex virus (the most common cause), Orf*
• idiopathic
• bacteria: Mycoplasma, Streptococcus
• drugs: penicillin, sulphonamides, carbamazepine, allopurinol, NSAIDs, oral contraceptive pill, nevirapine
• connective tissue disease e.g. Systemic lupus erythematosus
• sarcoidosis
• malignancy

Question 3

What is erythema multiforme major? [1]

Answer 3

The more severe form, erythema multiforme major is associated with mucosal involvement.

Question 4

What is vitrreous haemorrhage? [3]

Answer 4

Vitreous haemorrhage is bleeding into the vitreous humour. It is one of the most common causes of sudden painless loss of vision. It causes disruption to vision to a variable degree, ranging from floaters to complete visual loss. The source of bleeding can be from disruption of any vessel in the retina as well as the extension through the retina from other areas. Once the bleeding stops, the blood is typically cleared from the retina at an approximate rate of 1% per day¹.

Question 5

Common causes of vitreous haemorrhage in 90% cases? [3]

Answer 5

• proliferative diabetic retinopathy (over 50%)
• posterior vitreous detachment
• ocular trauma: the most common cause in children and young adults

Question 6

Presentation of vietreous haemorrhage [3]

Answer 6

• painless visual loss or haze (commonest)
• red hue in the vision
• floaters or shadows/dark spots in the vision

Question 7

Signs of vitreous haemorrhage [2]

Answer 7

• decreased visual acuity: variable depending on the location, size and degree of vitreous haemorrhage
• visual field defect if severe haemorrhage

Question 8

Ix for vitreous haemorrhage [5]

Answer 8

• dilated fundoscopy: may show haemorrhage in the vitreous cavity
• slit-lamp examination: red blood cells in the anterior vitreous
• ultrasound: useful to rule out retinal tear/detachment and if haemorrhage obscures the retina
• fluorescein angiography: to identify neovascularization
• orbital CT: used if open globe injury

Question 9

Common symptoms include:

• nausea and vomiting, anorexia
• myalgia
• lethargy
• right upper quadrant (RUQ) pain

Questions may point to risk factors such as foreign travel or intravenous drug use [1]

Answer 9

Viral hepatitis

Question 10

The liver only usually causes pain if stretched. One common way this can occur is as a consequence of congestive heart failure. In severe cases cirrhosis may occur.

Answer 10

Congestive hepatomegaly

Question 11

RUQ pain, intermittent, usually begins abruptly and subsides gradually. Attacks often occur after eating. Nausea is common.

It is sometimes taught that patients are female, forties, fat and fair although this is obviously a generalisation. [1]

Answer 11

Biliary colic

Question 12

Pain similar to biliary colic but more severe and persistent. The pain may radiate to the back or right shoulder.

The patient may be pyrexial and Murphy’s sign positive (arrest of inspiration on palpation of the RUQ)

Answer 12

Acute cholecystitis

Question 13

An infection of the bile ducts commonly secondary to gallstones. Classically presents with a triad of:

• fever (rigors are common)
• RUQ pain
• jaundice

Answer 13

Ascending cholagnitis

Question 14

This describes small bowel obstruction secondary to an impacted gallstone. It may develop if a fistula forms between a gangrenous gallbladder and the duodenum.

Abdominal pain, distension and vomiting are seen.

Answer 14

Gallstone ileus [2]

Question 15

Persistent biliary colic symptoms, associated with anorexia, jaundice and weight loss. A palpable mass in the right upper quadrant (Courvoisier sign), periumbilical lymphadenopathy (Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node) may be seen

Answer 15

Cholangiocarcinoma

Question 16

Usually due to alcohol or gallstones
Severe epigastric pain
Vomiting is common
Examination may reveal tenderness, ileus and low-grade fever
Periumbilical discolouration (Cullen’s sign) and flank discolouration (Grey-Turner’s sign) is described but rare

Answer 16

Acute pancreatitis

Question 17

Painless jaundice is the classical presentation of pancreatic cancer. However pain is actually a relatively common presenting symptom of pancreatic cancer. Anorexia and weight loss are common

Answer 17

Pancreatic cancer

Question 18

Typical symptoms are malaise, anorexia and weight loss. The associated RUQ pain tends to be mild and jaundice is uncommon.

Answer 18

Amoebic liver disease

Question 19

Whom is G6PD deficiency common in? [1]

Answer 19

People from Mediterranean and Africa

Question 20

How is G6PD inherited? [1]

Answer 20

X-linked inheritance pattern

Question 21

signs of haemolytic anaemia [3]

Answer 21

Dark urine, reduced exercise tolerance, yellow sclerae, sinus tachycardia, raised Heinz bodies [as seen in G6PD deficiency]

Question 22

Examples of quinolones [2]

Answer 22

Quinolones are a group of antibiotics which work by inhibiting DNA synthesis and are bactericidal in nature. Examples include:

• ciprofloxacin
• levofloxacin

Question 23

MoA and mechanism of resistance of quinolones [2]

Answer 23

Mechanism of action

• inhibit topoisomerase II (DNA gyrase) and topoisomerase IV

Mechanism of resistance

• mutations to DNA gyrase, efflux pumps which reduce intracellular quinolone concentration

Question 24

Adverse effects of quinolones [4]

Answer 24

• lower seizure threshold in patients with epilepsy
• tendon damage (including rupture) - the risk is increased in patients also taking steroids
• cartilage damage has been demonstrated in animal models and for this reason quinolones are generally avoided (but not necessarily contraindicated) in children
• lengthens QT interval

Question 25

CI of quinolones [2]

Answer 25

• Quinolones should generally be avoided in women who are pregnant or breastfeeding
• avoid in G6PD

Question 26

What EECG sign is in cardiac tamponade? [1]

Answer 26

Electric alternanas

Question 27

What is Beck’s triad? [2]

Answer 27

Cardiac tamponade signs:

• hypotension
• raised JVP
• soft heart sounds

Question 28

What is electric alternans? [2]

Answer 28

Electrical alternans is a relatively specific but non-sensitive ECG sign of cardiac tamponade. Electrical alternans is characterised by beat to beat variation in QRS amplitude and morphology. This variability is due to the heart ‘swinging’ in the pericardial fluid.

Question 29

What is a short PR interval indicative of? [1]

Answer 29

WPW

Question 30

What is QT prolongation seen in? [2]

Answer 30

QT prolongation is usually caused by electrolyte abnormalities (hypokalemia, hypocalcemia) or medications (antipsychotics). QT prolongation is not associated with cardiac tamponade.

Question 31

T wave inversion in leads II, III, AVF [1]

Answer 31

T wave inversion in leads II, III and AVF is highly suggestive of inferior myocardial ischaemia. It is important to remember that cardiac tamponade is a potential complication of a myocardial infarction

Question 32

Other features of cardiac tamponade? [6]

Answer 32

• dyspnoea
• tachycardia
• an absent Y descent on the JVP - this is due to the limited right ventricular filling
• pulsus paradoxus - an abnormally large drop in BP during inspiration
• Kussmaul’s sign - much debate about this
• ECG: electrical alternans

Question 33

Compare constrictive pericarditis and cardaic tamponade [4]

Answer 33

Cardiac tamponadeConstrictive pericarditisJVPAbsent Y descentPulsus paradoxusPresentKussmaul’s signRareCharacteristic features

Question 34

Mx of cardiac tamponade? [1]

Answer 34

Urgent pericardiocentesis

Question 35

What can phenytoin cause? [1]

Answer 35

Folic acid defiency and macroscytic anaemia

Question 36

What is a good source of folic acid? [1]

Answer 36

Folic acid is converted to tetrahydrofolate (THF). Green, leafy vegetables are a good source of folic acid.

Question 37

Fucntions of folic acid? [1]

Answer 37

• THF plays a key role in the transfer of 1-carbon units (e.g. methyl, methylene, and formyl groups) to the essential substrates involved in the synthesis of DNA & RNA

Question 38

Causes of folic acid defieincy [4]

Answer 38

• phenytoin
• methotrexate
• pregnancy
• alcohol excess

Question 39

Consequences of folic acid defiency

Answer 39

Macrocytic, megaloblastic anaemia

Neural tube defects

Question 40

Prevention of neural tube defects during pregnancy [3]

Answer 40

• all women should take 400mcg of folic acid until the 12th week of pregnancy
• women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy
• women are considered higher risk if any of the following apply:
  
  • either partner has a NTD, 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 41

Which heart sound does pulmonary hypertension cause? [1]

Answer 41

Pulmonary hypertension is a cause of a loud S2 (due to a loud P2)

Question 42

Dx of firbomyaglia [2]

Answer 42

Diagnosis is clinical and sometimes refers to the American College of Rheumatology
classification criteria which lists 9 pairs of tender points on the body. If a patient is tender in at least 11 of these 18 points it makes a diagnosis of fibromyalgia more likely

Question 43

Mx of firbomyalgia [4]

Answer 43

• explanation
• aerobic exercise: has the strongest evidence base
• cognitive behavioural therapy
• medication: pregabalin, duloxetine, amitriptyline

Question 44

NSTEMI [managed with PCI] antiplatelet choice [2]

Answer 44

• if the patient is not taking an oral anticoagulant: prasugrel or ticagrelor
• if taking an oral anticoagulant: clopidogrel

Question 45

Features of pernicious anaemia [3]

Answer 45

• anaemia features
  
  • lethargy
  • pallor
  • dyspnoea
• neurological features
  
  • peripheral neuropathy: ‘pins and needles’, numbness. Typically symmetrical and affects the legs more than the arms
  • subacute combined degeneration of the spinal cord: progressive weakness, ataxia and paresthesias that may progress to spasticity and paraplegia
  • neuropsychiatric features: memory loss, poor concentration, confusion, depression, irritabiltiy
• other features
  
  • mild jaundice: combined with pallor results in a ‘lemon tinge’
  • glossitis → sore tongue

Question 46

Ix of pernicious anaemia [4]

Answer 46

• full blood count
  
  • macrocytic anaemia: macrocytosis may be absent in around of 30% of patients
  • hypersegmented polymorphs on blood film
  • low WCC and platelets may also be seen
• vitamin B12 and folate levels
  
  • a vitamin B12 level of >= 200 nh/L is generally considered to be normal
• antibodies
  
  • anti intrinsic factor antibodies: sensivity is only 50% but highly specific for pernicious anaemia (95-100%)
  • anti gastric parietal cell antibodies in 90% but low specificity so often not useful clinically
• Schilling test is no longer routinely done
  
  • radiolabelled B12 given on two occasions, firstly on its own, secondly with oral IF. Urine B12 levels are then measured

Question 47

Mx of pernicious anaemia [2]

Answer 47

• vitamin B12 replacement
  
  • usually given intramuscularly
  • no neurological features: 3 injections per week for 2 weeks followed by 3 monthly treatment of vitamin B12 injections
  • more frequent doses are given for patients with neurological features
  • there is some evidence that oral vitamin B12 may be effective for providing maintenance levels of vitamin B12 but it is not yet common practice
• folic acid supplementation may also be required

Question 48

Why is amtriptyline CI in a patient with T2DM and diabetic neuropathy that has bening prostatic hyperplasia? [1]

Answer 48

Risk of urinary retention

Question 49

Mx of diabetic neuroapthy [5]

Answer 49

• first-line treatment: amitriptyline, duloxetine, gabapentin or pregabalin
• if the first-line drug treatment does not work try one of the other 3 drugs
• tramadol may be used as ‘rescue therapy’ for exacerbations of neuropathic pain
• topical capsaicin may be used for localised neuropathic pain (e.g. post-herpetic neuralgia)
• pain management clinics may be useful in patients with resistant problems

Question 50

Steroid dose children with asthma attack? [2]

Answer 50

• Use a dose of 10 mg prednisolone for children under 2 years of age, 20 mg for children aged 2-5 years and 30-40 mg for children >5 years. Those already receiving maintenance steroid tablets
• should receive 2 mg/kg prednisolone up to a maximum dose of 60 mg.*
• Repeat the dose of prednisolone in children who vomit and consider intravenous steroids in those who are unable to retain orally ingested medication.
• Treatment for up to three days is usually sufficient, but the length of course should be tailored to the number of days necessary to bring about recovery. Tapering is unnecessary unless the course of steroids exceeds 14 days.

Question 51

Mx of children with mild to moderate acute asthma [2]

Answer 51

Bronchodilator therapy

• give a beta-2 agonist via a spacer (for a child < 3 years use a close-fitting mask)
• give 1 puff every 30-60 seconds up to a maximum of 10 puffs
• if symptoms are not controlled repeat beta-2 agonist and refer to hospital

Steroid therapy

• should be given to all children with an asthma exacerbation
• treatment should be given for 3-5 days

Question 52

Which antidaiebtic drug has had an increase risk of bladder cancer? [2]

Answer 52

Recent studies have identified that thiazolidinediones, in particular, pioglitazone, are associated with an increased risk of bladder cancer. This is a rare, but important, adverse effect to consider in a patient on thiazolidinediones.

Question 53

Adverse effects of SLGT-2 inhibitors, biguinines like metoformin, GLP-1 mimetics and insulin [4]

Answer 53

1 - SGLT-2 inhibitors - genital infections, diabetic ketoacidosis
2 - Biguanides e.g. metformin - GI upset, lactic acidosis
4 - GLP-1 mimetics - nausea, vomiting, pancreatitis
5 - Insulin - weight gain, hypoglycaemia, lipodystrophy

Question 54

How do thiazlidinediones work? [2]

Answer 54

Thiazolidinediones are a class of agents used in the treatment of type 2 diabetes mellitus. They are agonists to the PPAR-gamma receptor and reduce peripheral insulin resistance. Rosiglitazone was withdrawn in 2010 following concerns about the cardiovascular side-effect profile.

Question 55

Adverse effects of thiazolidinediones [5]

Answer 55

• weight gain
• liver impairment: monitor LFTs
• fluid retention - therefore contraindicated in heart failure. The risk of fluid retention is increased if the patient also takes insulin
• recent studies have indicated an increased risk of fractures
• bladder cancer: recent studies have shown an increased risk of bladder cancer in patients taking pioglitazone (hazard ratio 2.64)

Question 56

Features of intraheptaic cholestasis of pregnancy [3]

Answer 56

• pruritus - may be intense - typical worse palms, soles and abdomen
• clinically detectable jaundice occurs in around 20% of patients
• raised bilirubin is seen in > 90% of cases

Question 57

What is first-line Tx for pregnant women with UTI? [1]

Answer 57

Nitrofurantoin 7 days course [though should be avoided near term]

Question 58

Tx of UTI for non-pregnancy women [1]

Answer 58

• NICE Clinical Knowledge Summaries recommend trimethoprim or nitrofurantoin for 3 days

Question 59

When to send for a urine culture in non-pregnant women with LUTI [2]

Answer 59

Aged over 65, visible or non-visible haematuria

Question 60

Summarise Mx for lower UTI in non-pregnnat women

Answer 60

• local antibiotic guidelines should be followed if available
• NICE Clinical Knowledge Summaries recommend trimethoprim or nitrofurantoin for 3 days
• send a urine culture if:
  
  • aged > 65 years
  • visible or non-visible haematuria

Question 61

Mx of prengnact women if symptomatic [5]

Answer 61

• a urine culture should be sent in all cases
• should be treated with an antibiotic for
• first-line: nitrofurantoin (should be avoided near term)
• second-line: amoxicillin or cefalexin
• trimethoprim is teratogenic in the first trimester and should be avoided during pregnancy

Question 62

Which Abx for UTI is teratogenic during the firs ttrimester? [1]

Answer 62

Trimethoprim

Question 63

Asymptomatic bacteriuria in pregnant women Mx [4]

Answer 63

• a urine culture should be performed routinely at the first antenatal visit
• Clinical Knowledge Summaries recommend an immediate antibiotic prescription of either nitrofurantoin (should be avoided near term), amoxicillin or cefalexin. This should be a 7-day course
• the rationale of treating asymptomatic bacteriuria is the significant risk of progression to acute pyelonephritis
• a further urine culture should be sent following completion of treatment as a test of cure

Question 64

Mx of men with lower UTI [3]

Answer 64

• an immediate antibiotic prescription should be offered for 7 days
• as with non-pregnant women, trimethoprim or nitrofurantoin should be offered first-line unless prostatitis is suspected
• NICE Clinical Knowledge Summaries state: ‘Referral to urology is not routinely required for men who have had one uncomplicated lower urinary tract infection (UTI).’

Question 65

How to Tx catheterised pts with lower UTI [2]

Answer 65

• do not treat asymptomatic bacteria in catheterised patients
• if the patient is symptomatic they should be treated with an antibiotic
  
  • a 7-day, rather than a 3-day course should be given

Question 66

How to manage acute pyelonephritis [2]

Answer 66

For patients with sign of acute pyelonephritis hospital admission should be considered

• local antibiotic guidelines should be followed if available
• the BNF currently recommends a broad-spectrum cephalosporin or a quinolone (for non-pregnant women) for 10-14 days

Question 67

What are early signs of haemochromatosis? [3]

Answer 67

Featifue, erectile dysfunction and arthralgia

Question 68

Addison;s disease acute presentation [3]

Answer 68

Abdominal pain, weight loss, N and V

Question 69

Wilson’s disease presentation [2]

Answer 69

Wilson’s disease normally presents in children and adolescents as neuropsychiatric symptoms as well as the symptoms of liver failure. As said above the fact it typically presents in much younger patients helps to rule this out.

Question 70

Presentation of SLE in men [3]

Answer 70

Systemic lupus erythematosus can present with a variety of symptoms such as fatigue, arthralgia and weight loss. While these symptoms could account for his arthralgia and fatigue, erectile dysfunction is not typical. Even if it was, the fact that both his dad and grandfather died of liver conditions points towards another diagnosis.

Question 71

How would Budd-Chiari syndrome present? [2]

Answer 71

Budd-Chiari syndrome is due to obstruction of the hepatic vein. It typically presents with right upper quadrant pain and painful ascites. You could also note hepatomegaly, jaundice and it may be associated with an acute kidney injury and so this does not fit his presentation.

Question 72

INheritance pattern of haemachromatosis [1]

Answer 72

Haemochromatosis is an autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation

Question 73

What is haemoachromatosis caused by? [2]

Answer 73

It is caused by inheritance of mutations in the HFE gene on both copies of chromosome 6*. It is often asymptomatic in early disease and initial symptoms often non-specific e.g. lethargy and arthralgia

Question 74

Epidemiology of haemachromatosis [2]

Answer 74

• 1 in 10 people of European descent carry a mutation in the genes affecting iron metabolism, mainly HFE
• prevalence in people of European descent = 1 in 200, making it more common than cystic fibrosis

Question 75

Presenting feratures of haemachromatosis [7]

Answer 75

• early symptoms include fatigue, erectile dysfunction and arthralgia (often of the hands)
• ‘bronze’ skin pigmentation
• diabetes mellitus
• liver: stigmata of chronic liver disease, hepatomegaly, cirrhosis, hepatocellular deposition)
• cardiac failure (2nd to dilated cardiomyopathy)
• hypogonadism (2nd to cirrhosis and pituitary dysfunction - hypogonadotrophic hypogonadism)
• arthritis (especially of the hands)

Question 76

Which complications of haemachromatosis are reverisble, and whoch are irreversible? [6]

Answer 76

• Reversible complications*Irreversible complications
• Cardiomyopathy
• Skin pigmentation
• Liver cirrhosis**
• Diabetes mellitus
• Hypogonadotrophic hypogonadism
• Arthropathy

Question 77

A 64-year-old Bangladeshi man presents to the GP with blood-stained sputum and breathlessness. On further questioning, he notes fatigue, weight loss and some sweating in the night. The GP takes sputum samples and sends the man for a chest X-ray. Possible Dx likely? [1]

Answer 77

TB

Question 78

What is primary tuberculosis? [2]

Answer 78

A non-immune host who is exposed to M. tuberculosis may develop a primary infection of the lungs. A small lung lesion known as a Ghon focus develops. The Ghon focus is composed of tubercle-laden macrophages. The combination of a Ghon focus and hilar lymph nodes is known as a Ghon complex

In immunocompetent people, the initial lesion usually heals by fibrosis. Those who are immunocompromised may develop disseminated disease (miliary tuberculosis).

Question 79

When can secondary [post-primary] TB occur? [3]

Answer 79

If the host becomes immunocompromised the initial infection may become reactivated. Reactivation generally occurs in the apex of the lungs and may spread locally or to more distant sites. Possible causes of immunocompromise include:

• immunosuppressive drugs including steroids
• HIV
• malnutrition

Question 80

Where may extra-pulmonary inefction occur in TB? [5]

Answer 80

The lungs remain the most common site for secondary tuberculosis. Extra-pulmonary infection may occur in the following areas:

• central nervous system (tuberculous meningitis - the most serious complication)
• vertebral bodies (Pott’s disease)
• cervical lymph nodes (scrofuloderma)
• renal
• gastrointestinal tract

Question 81

Which test is important to do for TB? [1]

Answer 81

HIV test

Question 82

What does head and neck cancer refer to? [3]

Answer 82

• Oral cavity cancers
• Cancers of the pharynx (including the oropharynx, hypopharynx and nasopharynx)
• Cancers of the larynx

Question 83

Features of head and neck cancers [4]

Answer 83

• neck lump
• hoarseness
• persistent sore throat
• persistent mouth ulcer

Question 84

2w wait layrngeal cancer suspected [2]

Answer 84

• Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for laryngeal cancer in people aged 45 and over with:
  
  • persistent unexplained hoarseness or
  • an unexplained lump in the neck

Question 85

2w wait oral cancer suspected [4]

Answer 85

• Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with either:
  
  • unexplained ulceration in the oral cavity lasting for more than 3 weeks or
  • a persistent and unexplained lump in the neck.
• Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either:
  
  • a lump on the lip or in the oral cavity or
  • a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.

Question 86

2w wait thyroid cancer suspected

Answer 86

Thyroid cancer

• Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for thyroid cancer in people with an unexplained thyroid lump.

Question 87

A 54-year-old man of Asian heritage presents with a slowly enlarging neck lump in the posterior triangle. A biopsy is performed and the histological report is ‘metastatic SCC in a lymph node.’ On inspection, there are no obvious skin lesions present. Primary site Ca and why? [1]

Answer 87

Nasopharyngeal carcinoma may present as a painless lymphadenopathy because of its tendency for early spread. Nasopharyngeal carcinoma is more common in people of Asian origin, and typically presents with epistaxis, headaches, lymph node metastasis or unilateral hearing loss.

Question 88

Where would larynx, buccal and tonsillar fossa cancers spread into? [1]

Answer 88

The other remaining options (larynx, buccal mucosa, and tonsillar fossa) would drain to the anterior triangle.

Question 89

Epistaxis where bleeding site difficult to manage and pinching soft area nose for 20m doesn;t work [1]

Answer 89

Anterior packing

Question 90

When should epistaxis be referred to ENT? [1]

Answer 90

If anterior packing doesn;t work, then refer for posterior packing

Question 91

What is epistaxis split up into? []

Answer 91

Anterior and posterior bleeds

Question 92

Most common cause of epistaxis [1]

Answer 92

Trauma

Question 93

Uncommon causes of epistaxis [5]

Answer 93

Bleeding can also indicate platelet function disorders such as thrombocytopenia, splenomegaly, leukaemia, Waldenstrom’s macroglobulinaemia and ITP. In adolescent males, juvenile angiofibroma is a benign tumour that may bleed as it is highly vascularised. If the nasal septum looks abraded or atrophied, inquire about drug use. This is because inhaled cocaine is a powerful vasoconstrictor and repeated use may result in obliteration of the septum. In the elderly, hereditary haemorrhagic telangiectasia may cause prolonged nasal bleeding. Granulomatosis with polyangiitis and pyogenic granuloma may also present with nosebleeds.

Question 94

First aid measures of haemodynamically stable patients with epistaxis [2]

Answer 94

• Asking the patient to sit with their torso forward and their mouth open- avoid lying down unless they feel faint. This decreases blood flow to the nasopharynx and allows the patient to spit out any blood in their mouth. It also reduces the risk of aspirating blood.
• Pinch the cartilaginous (soft) area of the nose firmly and consistently for at least 20 minutes and ask the patient to breathe through their mouth.

Question 95

What to do next if first-aid meaures are successful? [1]

Answer 95

If first aid measures are successful, consider using a topical antiseptic such as Naseptin (chlorhexidine and neomycin) to reduce crusting and the risk of vestibulitis. Cautions to this include patients that have peanut, soy or neomycin allergies, and Mupirocin is a viable alternative.

Question 96

What should be used initially if first aid measures are unsuccessful for visible bleed epistaxis? [1]

Answer 96

If bleeding does not stop after 10-15 minutes of continuous pressure on the nose, consider cautery or packing. Cautery should be used initially if the source of the bleed is visible and cautery is tolerated- it is not so well-tolerated in younger children! Packing may be used if cautery is not viable or the bleeding point cannot be visualised. If the nose is packed in primary care, the patient should be admitted to hospital for review.

Question 97

How is cautery done for epistaxis? [3]

Answer 97

• Ask the patient to blow their nose in order to remove any clots. Be wary that bleeding may resume.
• Use a topical local anaesthetic spray (e.g. Co-phenylcaine) and wait 3-4 minutes for it to take effect
• Identify the bleeding point and apply the silver nitrate stick for 3-10 seconds until it becomes grey-white. Avoid touching areas which do not require treatment, and only cauterise one side of the septum as there is a risk of perforation.
• Dab the area clean with a cotton bud and apply Naseptin or Muciprocin

Question 98

How is packing done for epistaxis? [4]

Answer 98

• Anaesthetise with topical local anaesthetic spray (e.g. Co-phenylcaine) and wait for 3-4 minutes
• Pack the patient’s nose while they are sitting with their head forward, following the manufacturer’s instructions
• Pressure on the cartilage around the nostril can cause cosmetic changes and this should be reviewed after inserting the pack.
• Examine the patient’s mouth and throat for any continuing bleeding, and consider packing the other nostril as this increases pressure on the septum and offending vessel.
• Patients should be admitted to hospital for observation and review, and to ENT if available

Question 99

Epistaxis that has failed all emergency maanged should be amanged how? [1]

Answer 99

Epistaxis that has failed all emergency management may require sphenopalatine ligation in theatre

Question 100

Features of LB dementia [3]

Answer 100

• progressive cognitive impairment
  
  • in contrast to Alzheimer’s, early impairments in attention and executive function rather than just memory loss
  • cognition may be fluctuating, in contrast to other forms of dementia
  • usually develops before parkinsonism
• parkinsonism
• visual hallucinations (other features such as delusions and non-visual hallucinations may also be seen)

Question 101

Dx of LB dementia [2]

Answer 101

• usually clinical
• single-photon emission computed tomography (SPECT) is increasingly used. It is currently commercially known as a DaTscan. Dopaminergic iodine-123-radiolabelled 2-carbomethoxy-3-(4-iodophenyl)-N-(3-fluoropropyl) nortropane (123-I FP-CIT) is used as the radioisotope. The sensitivity of SPECT in diagnosing Lewy body dementia is around 90% with a specificity of 100%

Question 102

Mx of LB dementia [2]

Answer 102

• both acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine can be used as they are in Alzheimer’s. NICE have made detailed recommendations about what drugs to use at what stages. Please see the link for more details
• neuroleptics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism. Questions may give a history of a patient who has deteriorated following the introduction of an antipsychotic agent

Question 103

What is Argyll-Robertson pupil? [2]

Answer 103

Argyll-Robertson pupil is one of the classic pupillary syndrome. It is sometimes seen in neurosyphilis. A mnemonic used for the Argyll-Robertson Pupil (ARP) is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA)

Question 104

Features of ARP [2]

Answer 104

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

Question 105

Causes of ARP [2]

Answer 105

• diabetes mellitus
• syphilis

Question 106

RFs for endometrial Ca [9]

Answer 106

• 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 107

How often does endometrial Ca happen before menopause? [1]

Answer 107

Endometrial cancer is classically seen in post-menopausal women but around 25% of cases occur before the menopause. It usually carries a good prognosis due to early detection

Question 108

Features of endometrial Ca [3]

Answer 108

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

Question 109

Ix for endometrial Ca [3]

Answer 109

• 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 110

When do febrile seizures commonly occur? [1]

Answer 110

Febrile convulsions are seizures provoked by fever in otherwise normal children. They typically occur between the ages of 6 months and 5 years and are seen in 3% of children.

Question 111

Clinical features of febrile convulsions [3]

Answer 111

• usually occur early in a viral infection as the temperature rises rapidly
• seizures are usually brief, lasting less than 5 minutes
• are most commonly tonic-clonic

Question 112

What does a sandpaper rash and strawberry tongue indicate in a child? [1]

Answer 112

Scarlet fever

Question 113

WHen should you call an ambulance for febrile convulsions? [1]

Answer 113

If the febrile convulsion lasts longer than 5m

Question 114

COmpare simple, to complex to febrile status elipticus [3]

Answer 114

SimpleComplexFebrile status epilepticus< 15 minutes15 - 30 minutes> 30 minutesGeneralised seizureFocal seizure Typically no recurrence within 24 hoursMay have repeat seizures within 24 hours Should be complete recovery within an hour

Question 115

Mx following a seizure [1]

Answer 115

• children who have had a first seizure OR any features of a complex seizure should be admitted to paediatrics

Question 116

Prognosis of febrile seizures [3]

Answer 116

• the overall risk of further febrile convulsion = 1 in 3. However, this varies widely depending on risk factors for further seizure. These include: age of onset < 18 months, fever < 39ºC, shorter duration of fever before seizure and a family history of febrile convulsions
• if recurrences, try teaching parents how to use rectal diazepam or buccal midazolam. Parents should be advised to phone for an ambulance if the seizure lasts > 5 minutes
• regular antipyretics have not been shown to reduce the chance of a febrile seizure occurring

Question 117

Link to elilepsy for febrile seizures [3]

Answer 117

• risk factors for developing epilepsy include a family history of epilepsy, having complex febrile seizures and a background of neurodevelopmental disorder
• children with no risk factors have 2.5% risk of developing epilepsy
• if children have all 3 features the risk of developing epilepsy is much higher (e.g. 50%)

Question 118

inheritance of tuberous sclerosis [1]

Answer 118

Tuberous sclerosis (TS) is a genetic condition of autosomal dominant inheritance. Like neurofibromatosis, the majority of features seen in TS are neurocutaneous.

Question 119

Cutaneous , nuerological and other features of tuberous sclerosis [3]

Answer 119

• depigmented ‘ash-leaf’ spots which fluoresce under UV light
• roughened patches of skin over lumbar spine (Shagreen patches)
• adenoma sebaceum (angiofibromas): butterfly distribution over nose
• fibromata beneath nails (subungual fibromata)
• café-au-lait spots* may be seen

Question 119

Cutaneous , nuerological and other features of tuberous sclerosis [3]

Answer 119

Cutaneous features

• depigmented ‘ash-leaf’ spots which fluoresce under UV light
• roughened patches of skin over lumbar spine (Shagreen patches)
• adenoma sebaceum (angiofibromas): butterfly distribution over nose
• fibromata beneath nails (subungual fibromata)
• café-au-lait spots* may be seen

Neurological features

• developmental delay
• epilepsy (infantile spasms or partial)
• intellectual impairment

Also

• retinal hamartomas: dense white areas on retina (phakomata)
• rhabdomyomas of the heart
• gliomatous changes can occur in the brain lesions
• polycystic kidneys, renal angiomyolipomata
• lymphangioleiomyomatosis: multiple lung cysts
  *

Question 120

Where is the most common site for epistaxis? [1]

Answer 120

Little’s area in the anterior nasal septum is the site of Kiesselbach’s plexus, supplied by 4 arteries. Epistaxis therefore most commonly originates from the anterior of the nose

Question 121

Second-line Tx for neuropathic pain [1]

Answer 121

First-line treatment for neuropathic pain is amitriptyline, duloxetine, gabapentin or pregabalin. If one of these agents don’t work next line is to try one of the other remaining three drugs

Question 122

Examples of neuropathic pain [4]

Answer 122

• diabetic neuropathy
• post-herpetic neuralgia
• trigeminal neuralgia
• prolapsed intervertebral disc

Question 123

Summary of Mx of neuropathic pain [4]

Answer 123

• first-line treatment*: amitriptyline, duloxetine, gabapentin or pregabalin
  
  • if the first-line drug treatment does not work try one of the other 3 drugs
  • in contrast to standard analgesics, drugs for neuropathic pain are typically used as monotherapy, i.e. if not working then drugs should be switched, not added
• tramadol may be used as ‘rescue therapy’ for exacerbations of neuropathic pain
• topical capsaicin may be used for localised neuropathic pain (e.g. post-herpetic neuralgia)
• pain management clinics may be useful in patients with resistant problems

Question 124

Patient presenting wioth flu-like Sx, RUQ pain, tender hepatomegaly and cholestatic LFTs [1]

Answer 124

Hepatitis A

Question 125

What are cholestatic LFTs [3]

Answer 125

• Raised bilirubin
• Raised ALT/ AST
• Normal or slightly raised ALP

Question 126

Overveiw and features of hepatitis A [2]

Answer 126

Overview

• incubation period: 2-4 weeks
• RNA picornavirus
• transmission is by faecal-oral spread, often in institutions
• doesn’t cause chronic disease

Features

• flu-like prodrome
• abdominal pain: typically right upper quadrant
• tender hepatomegaly
• jaundice
• cholestatic liver function tests

Question 127

Cx of hepatitis A [1]

Answer 127

• complications are rare and there is no increased risk of hepatocellular cancer

Question 128

Immunisation of hepatitis A [5]

Answer 128

Immunisation

• an effective vaccine is available
• after the initial dose a booster dose should be given 6-12 months later

Who should be vaccinated? (Based on the Green book guidelines)

• people travelling to or going to reside in areas of high or intermediate prevalence, if aged > 1 year old
• people with chronic liver disease
• patients with haemophilia
• men who have sex with men
• injecting drug users
• individuals at occupational risk: laboratory worker; staff of large residential institutions; sewage workers; people who work with primates

Question 129

Heart failure Mx for all patients [1]

Answer 129

IV loop diuretics e.g. furosemide or bumetanide

Question 130

What to give patient with heart failure if not improving on oxygen and diuretifs in acute setting? [1]

Answer 130

CPAP

Question 131

When is Ropinirole used? [1]

Answer 131

Mx of restless leg syndrome

Question 132

What are varicose veins? [2]

Answer 132

Varicose veins are dilated, tortuous, superficial veins that occur secondary to incompetent venous valves, allowing blood to flow back, away from the heart. They most commonly occur in the legs due to reflux in the great saphenous vein and small saphenous vein. Whilst extremely common, the vast majority of patients do not require any intervention.

Question 133

RF for varicose veins [4]

Answer 133

• increasing age
• female gender
• pregnancy
  
  • the uterus causes compression of the pelvic veins
• obesity

Question 134

Sx of varicose veins [3]

Answer 134

For many patients, the cosmetic appearance may prompt presentation. However other patients may complain of symptoms:

• aching, throbbing
• itching

Question 135

Cx of varicose veins [4]

Answer 135

• a variety of skin changes may be seen:
  
  • varicose eczema (also known as venous stasis)
  • haemosiderin deposition → hyperpigmentation
  • lipodermatosclerosis → hard/tight skin
  • atrophie blanche → hypopigmentation
• bleeding
• superficial thrombophlebitis
• venous ulceration
• deep vein thrombosis

Question 136

Mx of varicose veins [3]

Answer 136

• the majority of patients with varicose veins do not require surgery. Conservative treatments include:
  
  • leg elevation
  • weight loss
  • regular exercise
  • graduated compression stockings
• reasons for referral to secondary care include:
  
  • significant/troublesome lower limb symptoms e.g. pain, discomfort or swelling
  • previous bleeding from varicose veins
  • skin changes secondary to chronic venous insufficiency (e.g. pigmentation and eczema)
  • superficial thrombophlebitis
  • an active or healed venous leg ulcer
• possible treatments:
  
  • endothermal ablation: using either radiofrequency ablation or endovenous laser treatment
  • foam sclerotherapy: irritant foam → inflammatory response → closure of the vein
  • surgery: either ligation or stripping

Question 137

RFs for development of N and V [4]

Answer 137

• anxiety
• age less than 50 years old
• concurrent use of opioids
• the type of chemotherapy used

Question 138

Low-risk Sx whihc drugs can be used 1st line, whihc drugs 2nd line for N and V with chemotherapy [2]

Answer 138

For patients at low-risk of symptoms then drugs such as metoclopramide may be used first-line. For high-risk patients then 5HT3 receptor antagonists such as ondansetron are often effective, especially if combined with dexamethasone

Question 139

What do nearly all atypical antopsychotics cause? [2]

Answer 139

Nearly all typical and some atypical antipsychotics like risperidone & amisulpride cause hyperprolactinaemia. Effects of hyperprolactinemia can involve breast tenderness, breast enlargement and lactation.

Question 140

Which antipsychotic has a tolerable SE profile in terms of hyperprolacitnoaa? [1]

Answer 140

Aripiprazole is known for its having fewer side effects especially with respect to prolactin elevation.

Question 141

Which type of drugs are now used 1st line in schizophrenia and why? [2]

Answer 141

Atypical antipsychotics should now be used first-line in patients with schizophrenia, according to 2005 NICE guidelines. The main advantage of the atypical agents is a significant reduction in extrapyramidal side-effects.

Question 142

Adverse effects of atypical antipsychotics [3]

Answer 142

• weight gain
• clozapine is associated with agranulocytosis (see below)
• hyperprolactinaemia

Question 143

Increased risk of antispychotics in the elderly? [2]

Answer 143

• increased risk of stroke
• increased risk of venous thromboembolism

Question 144

Examples of atpyical antipsychotics [3]

Answer 144

• clozapine
• olanzapine: higher risk of dyslipidemia and obesity
• risperidone
• quetiapine
• amisulpride
• aripiprazole: generally good side-effect profile, particularly for prolactin elevation

Question 145

Why does Clozapine require FBC monitoring? [1]

Answer 145

Clozapine, one of the first atypical agents to be developed, carries a significant risk of agranulocytosis and full blood count monitoring is therefore essential during treatment. For this reason, clozapine should only be used in patients resistant to other antipsychotic medication. The BNF states:

Clozapine should be introduced if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each for at least 6–8 weeks.

Question 146

Adverse effects of clozapine [5]

Answer 146

• agranulocytosis (1%), neutropaenia (3%)
• reduced seizure threshold - can induce seizures in up to 3% of patients
• constipation
• myocarditis: a baseline ECG should be taken before starting treatment
• hypersalivation

Question 147

When might dose adjustment be neccessary for clozapine? [1]

Answer 147

Dose adjustment of clozapine might be necessary if smoking is started or stopped during treatment.

Question 148

What can erythema nodosum be caused by? [1]

Answer 148

Streptococcal infection

Question 149

What is polymorphic eruption of pregnancy? [2]

Answer 149

Polymorphic eruption of pregnancy is a relatively common skin disorder that can occur in women during pregnancy. It usually presents within the first pregnancy. It appears as an itchy, bumpy rash that starts in the stretch marks of the abdomen in the last 3 months of pregnancy then clears with delivery. This is unlikely to be the case here.

Question 150

What is erythema gyratum? [2]

Answer 150

Erythema gyratum repens is a rare paraneoplastic type of annular erythema with a distinctive figurate wood-grain appearance which has a strong association with malignancy.

Question 151

What is erythema nodosum? [3]

Answer 151

• inflammation of subcutaneous fat
• typically causes tender, erythematous, nodular lesions
• usually occurs over shins, may also occur elsewhere (e.g. forearms, thighs)
• usually resolves within 6 weeks
• lesions heal without scarring

Question 152

Causes of erythema nodosum? [5]

Answer 152

Causes

• infection
  
  • streptococci
  • tuberculosis
  • brucellosis
• systemic disease
  
  • sarcoidosis
  • inflammatory bowel disease
  • Behcet’s
• malignancy/lymphoma
• drugs
  
  • penicillins
  • sulphonamides
  • combined oral contraceptive pill
• pregnancy

Question 153

Infectious causes if erythema nodosum [3]

Answer 153

• streptococci
• tuberculosis
• brucellosis

Question 154

What is the most commoncause of liver disease in the developed world? [1]

Answer 154

NAFLD

Question 155

Types of NAFLD [3]

Answer 155

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

Question 156

What is the key MoA leading to steatosis in NAFLD? [1]

Answer 156

NAFLD is thought to represent the hepatic manifestation of the metabolic syndrome and hence insulin resistance is thought to be the key mechanism leading to steatosis.

Question 157

How common is NASH? [1]

Answer 157

Non-alcoholic steatohepatitis (NASH) is a term used to describe liver changes similar to those seen in alcoholic hepatitis in the absence of a history of alcohol abuse. It is relatively common and thought to affect around 3-4% of the general population.

Question 158

Associated factors with NAFLD? Which are the most important ones? [2]

Answer 158

• obesity
• type 2 diabetes mellitus
• hyperlipidaemia
• jejunoileal bypass
• sudden weight loss/starvation

Question 159

Features of NAFLD [4]

Answer 159

• usually asymptomatic
• hepatomegaly
• ALT is typically greater than AST
• increased echogenicity on ultrasound

Question 160

Key points for the Ix and Mx of NAFLD [4]

Answer 160

• there is no evidence to support screening for NAFLD in adults, even in at risk groups (e.g. type 2 diabetes)
• the guidelines are therefore based on the management of the incidental finding of NAFLD - typically asymptomatic fatty changes on liver ultrasound
• in these patients, 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. An algorithm based on these values results in an ELF blood test score, similar to triple testing for Down’s syndrome

Question 161

Mx of NAFLD [2]

Answer 161

• the mainstay of treatment is lifestyle changes (particularly weight loss) and monitoring
• there is ongoing research into the role of gastric banding and insulin-sensitising drugs (e.g. metformin, pioglitazone)

Question 162

How does IgA nephropathy classically present? [1]

Answer 162

IgA nephropathy classically presents as visible haematuria following a recent URTI

Question 163

How to post-streptococcal glomuerulonephritis typically present? How is this different to IgA nephropathy? [2]

Answer 163

It is important to not confuse it with post-streptococcal glomerulonephritis, which is caused by immune complex (IgG, IgM, and C3) deposition in the glomeruli. This happens more slowly, typically 7-14 days following a group A beta-hemolytic Streptococcus infection and causes proteinuria.

IgA is a shorter word, fewer days, post-strep longer word so more days

Question 164

Characteristics of Alport’s syndrome [3]

Answer 164

Alport’s syndrome is an X-linked dominant disease. It presents with microscopic haematuria, bilateral sensorineural deafness, and lenticonus. This patient does not have any of these characteristics.

Question 165

Characteristics of membranoproliferastive glomerulonephritis [2]

Answer 165

Membranoproliferative glomerulonephritis can present as nephrotic syndrome, haematuria, or proteinuria. It rarely affects children and it can be caused by multiple factors such as cryoglobulinaemia, hepatitis B or C, and partial lipodystrophy. This patient does not have any of these comorbidities.

Question 166

How will minimal change disease present in children [2]

Answer 166

Minimal change disease is very common in children, but nearly always presents as nephrotic syndrome. This child’s dipstick is negative for proteins but highly positive for blood, indicating a nephritic syndrome.

Question 167

Classical presentation of IgA nephropathy [4]

Answer 167

• young male, recurrent episodes of macroscopic haematuria
• typically associated with a recent respiratory tract infection
• nephrotic range proteinuria is rare
• renal failure is unusual and seen in a minority of patients

Question 168

Associated conditions with IgA nephopathy [3]

Answer 168

• alcoholic cirrhosis
• coeliac disease/dermatitis herpetiformis
• Henoch-Schonlein purpura

Question 169

PP of IgA nephropathy [3]

Answer 169

• thought to be caused by mesangial deposition of IgA immune complexes
• there is considerable pathological overlap with Henoch-Schonlein purpura (HSP)
• histology: mesangial hypercellularity, positive immunofluorescence for IgA & C3

Question 170

Differentiating between IgA nephropathy and post-strep glomerulonephritis [3]

Answer 170

• post-streptococcal glomerulonephritis is associated with low complement levels
• main symptom in post-streptococcal glomerulonephritis is proteinuria (although haematuria can occur)
• there is typically an interval between URTI and the onset of renal problems in post-streptococcal glomerulonephritis

Question 171

Mx of IgA nephorpathy

Answer 171

• isolated hematuria, no or minimal proteinuria (less than 500 to 1000 mg/day), and a normal glomerular filtration rate (GFR)
  
  • no treatment needed, other than follow-up to check renal function
• persistent proteinuria (above 500 to 1000 mg/day), a normal or only slightly reduced GFR
  
  • initial treatment is with ACE inhibitors
• if there is active disease (e.g. falling GFR) or failure to respond to ACE inhibitors
  
  • immunosuppression with corticosteroids

Question 172

Prognosis of IgA nephropathy [3]

Answer 172

• 25% of patients develop ESRF
• markers of good prognosis: frank haematuria
• markers of poor prognosis: male gender, proteinuria (especially > 2 g/day), hypertension, smoking, hyperlipidaemia, ACE genotype DD

Question 173

Red flags for back pain [12]

Answer 173

• Thoracic pain
• Age <20 or >55 years
• Non-mechanical pain
• Pain worse when supine
• Night pain
• Weight loss
• Pain associated with systemic illness
• Presence of neurological signs
• Past medical history of cancer or HIV
• Immunosuppression or steroid use
• IV drug use
• Structural deformity

Question 174

What Ix should pts with back pain have? [3]

Answer 174

Patients with red flags should have blood tests for FBC, ESR, Calcium, Phosphate, Alkaline phosphatase and PSA if appropriate. X-ray imaging should also be arranged.

Question 175

Sx of LBP [3]

Answer 175

• *May be acute or chronic**
• *Pain worse in the morning and on standing**
• *On examination there may be pain over the facets. The pain is typically worse on extension of the back**

Question 176

Compare spinal stenosis, to AS, to peripheral arterial disease presentation for LBP [3]

Answer 176

Spinal stenosisUsually gradual onset
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as ‘aching’, ‘crawling’.
Relieved by sitting down, leaning forwards and crouching down
Clinical examination is often normal
Requires MRI to confirm diagnosisAnkylosing spondylitisTypically a young man who presents with lower back pain and stiffness
Stiffness is usually worse in morning and improves with activity
Peripheral arthritis (25%, more common if female)Peripheral arterial diseasePain on walking, relieved by rest
Absent or weak foot pulses and other signs of limb ischaemia
Past history may include smoking and other vascular diseases

Question 177

Why is suxamethonium CI in patients with eye injuries? [1]

Answer 177

Suxamethonium is contraindicated for patients with penetrating eye injuries or acute narrow angle glaucoma, as suxamethonium increases intra-ocular pressure

Question 178

Compare depolarizing to non-depolarizing neuromusuclar drugs [10]

Answer 178

Mechanism of actionBinds to nicotinic acetylcholine receptors resulting in persistent depolarization of the motor end plateCompetitive antagonist of nicotinic acetylcholine receptorsExamplesSuccinylcholine (also known as suxamethonium)Tubcurarine, atracurium, vecuronium, pancuroniumAdverse effectsMalignant hyperthermia
Hyperkalaemia (normally transient)HypotensionReversal Acetylcholinesterase inhibitors (e.g. neostigmine)NotesThe muscle relaxant of choice for rapid sequence induction for intubation

May cause fasciculationsContraindicationsSuxamethonium is contraindicated for patients with penetrating eye injuries or acute narrow angle glaucoma, as suxamethonium increases intra-ocular pressure

Question 179

Drugs to give in TB [1

Answer 179

RIPE!

Question 180

MoA and SE of Rifampicin [4]

Answer 180

• mechanism of action: inhibits bacterial DNA dependent RNA polymerase preventing transcription of DNA into mRNA
• potent liver enzyme inducer
• hepatitis, orange secretions
• flu-like symptoms

Question 181

MoA and SE of Isoniazid [4]

Answer 181

• mechanism of action: inhibits mycolic acid synthesis
• peripheral neuropathy: prevent with pyridoxine (Vitamin B6)
• hepatitis, agranulocytosis
• liver enzyme inhibitor

Question 182

MoA and SE of Pyrazinamide [4]

Answer 182

• mechanism of action: converted by pyrazinamidase into pyrazinoic acid which in turn inhibits fatty acid synthase (FAS) I
• hyperuricaemia causing gout
• arthralgia, myalgia
• hepatitis

Question 183

MoA and Se of Ethambutol [3]

Answer 183

• mechanism of action: inhibits the enzyme arabinosyl transferase which polymerizes arabinose into arabinan
• optic neuritis: check visual acuity before and during treatment
• dose needs adjusting in patients with renal impairment

Question 184

When should patietns recieve activated charcoal? [1]

Answer 184

The minority of patients who present within 1 hour may benefit from activated charcoal to reduce absorption of the drug.

Question 185

When should acetylcysteine be given for OD? [2]

Answer 185

• there is a staggered overdose* or there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration; or
• the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity

Question 186

How is acetylcysteine given? [1]

Answer 186

Acetylcysteine is now infused over 1 hour (rather than the previous 15 minutes) to reduce the number of adverse effects

Question 187

SE of acetylcysteine and how is this generally managed? [2]

Answer 187

Acetylcysteine commonly causes an anaphylactoid reaction (non-IgE mediated mast cell release). Anaphylactoid reactions to IV acetylcysteine are generally treated by stopping the infusion, then restarting at a slower rate.

Question 188

What is the King’s College hospital critera for liver transplantation? [4]

Answer 188

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

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 189

What is the King’s College hospital critera for liver transplantation? [4]

Answer 189

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

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 190

What is considered an OD of paracetamol? [1]

Answer 190

If all the tablets are not taken within 1 hour

Question 191

Which anti-anginal medications do patients commonly develop tolerance to? [1]

Answer 191

Standard release isosorbide mononitrate

Question 192

Summarise Mx for angina pectoris [8]

Answer 192

• all patients should receive aspirin and a statin in the absence of any contraindication
• sublingual glyceryl trinitrate to abort angina attacks
• NICE recommend using either a beta-blocker or a calcium channel blocker first-line based on ‘comorbidities, contraindications and the person’s preference’
• 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). Remember that beta-blockers should not be prescribed concurrently with verapamil (risk of complete heart block)
• if there is a poor response to initial treatment then medication should be increased to the maximum tolerated dose (e.g. for atenolol 100mg od)
• 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 193

How should patients who develop nitrate toleracne be amanged? [1]

Answer 193

• many patients who take nitrates develop tolerance and experience reduced efficacy
• NICE advises that patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimise the development of nitrate tolerance
• this effect is not seen in patients who take once-daily modified-release isosorbide mononitrate

Question 194

What is autoimmune hepatitis? [2]

Answer 194

Autoimmune hepatitis is condition of unknown aetiology which is most commonly seen in young females. Recognised associations include other autoimmune disorders, hypergammaglobulinaemia and HLA B8, DR3. Three types of autoimmune hepatitis have been characterised according to the types of circulating antibodies present

Question 195

Compare the three types of autoimmune hepatitis [3]

Answer 195

Type IType IIType IIIAnti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA)

Affects both adults and children
Anti-liver/kidney microsomal type 1 antibodies (LKM1)

Affects children only
Soluble liver-kidney antigen

Affects adults in middle-age

Question 196

Features of autoimmune hepatitis [5]

Answer 196

• may present with signs of chronic liver disease
• acute hepatitis: fever, jaundice etc (only 25% present in this way)
• amenorrhoea (common)
• ANA/SMA/LKM1 antibodies, raised IgG levels
• liver biopsy: inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis

Question 197

Mx of autoimmmune hepatitis [2]

Answer 197

• steroids, other immunosuppressants e.g. azathioprine
• liver transplantation

Question 198

Which medicaiton should be given in patients not responding to benzos in status elipsticus? [1]

Answer 198

Phenytoin infusion

Question 199

When is carbamazepine used for seizures? [1]

Answer 199

Carbamazepine is the drug of choice for simple and complex focal seizures and can be used for generalised tonic clinic seizures, but it is not used in the treatment of status epilepticus.

Question 200

When can propofol be used in seizures? [1]

Answer 200

Propofol can be used in intensive care if phenytoin fails to control the seizure at 45minutes.

Question 201

When can sodium valproate be used in seizures? [1]

Answer 201

Sodium valproate is the first-line treatment for newly diagnosed generalised tonic-clonic seizures, but it isn’t used in the acute treatment of status epilepticus.

Question 202

When can thimaine be used in seizures? [1]

Answer 202

Thiamine should be considered if a seizure is believed to be related to underlying alcohol abuse.

Question 203

Define status elipticus [2]

Answer 203

• a single seizure lasting >5 minutes, or
• >= 2 seizures within a 5-minute period without the person returning to normal between them

Question 204

Why is status elepticus a medical emergency? [1]

Answer 204

Can lead to irreversible brain damage

Question 205

Mx of status eliepticus [4]

Answer 205

• ABC
  
  • airway adjunct
  • oxygen
  • check blood glucose
• First-line drugs are benzodiazepines such as diazepam or lorazepam
  
  • in the prehospital setting diazepam may be given rectally
  • in hospital IV lorazepam is generally used. This may be repeated once after 10-20 minutes
• If ongoing (or ‘established’) status it is appropriate to start a second-line agent such as phenytoin or phenobarbital infusion
• If no response (‘refractory status’) within 45 minutes from onset, then the best way to achieve rapid control of seizure activity is induction of general anaesthesia.

Question 206

What is the most common cause of traveller’s diarrhoea? [1]

Answer 206

E.coli

Question 207

Define traveller’s diarrhoea [1]

Answer 207

Travellers’ diarrhoea may be defined as at least 3 loose to watery stools in 24 hours with or without one of more of abdominal cramps, fever, nausea, vomiting or blood in the stool. The most common cause is Escherichia coli.

Question 208

Common amongst travellers
Watery stools
Abdominal cramps and nausea

Answer 208

E coli

Question 209

Prolonged, non-bloody diarrhoea

Answer 209

Giardasis

Question 210

Profuse, watery diarrhoea
Severe dehydration resulting in weight loss
Not common amongst travellers

Answer 210

Cholera

Question 211

Bloody diarrhoea
Vomiting and abdominal pain

Answer 211

Shigella

Question 212

Severe vomiting
Short incubation period

Answer 212

Staphylococcus aureus

Question 213

A flu-like prodrome is usually followed by crampy abdominal pains, fever and diarrhoea which may be bloody
May mimic appendicitis
Complications include Guillain-Barre syndrome

Answer 213

Campylobacter

Question 214

Two types of illness are seen

• vomiting within 6 hours, stereotypically due to rice
• diarrhoeal illness occurring after 6 hours

Answer 214

bacillus cereus

Question 215

Gradual onset bloody diarrhoea, abdominal pain and tenderness which may last for several weeks

Answer 215

Amoebiasis

Question 216

How long does SHigella take to incubate? [1]

Answer 216

Incubation period

• 1-6 hrs: Staphylococcus aureus, Bacillus cereus*
• 12-48 hrs: Salmonella, Escherichia coli
• 48-72 hrs: Shigella, Campylobacter
• > 7 days: Giardiasis, Amoebiasis

Question 217

Compare adenocarcinoma to SCC of the oesophagus [3]

Answer 217

AdenocarcinomaSquamous cell cancerEpidemiologyMost common type in the UK/USLocationLower third - near the gastroesophageal junctionRisk factors

• GORD
• Barrett’s oesophagus
• smoking
• achalasia
• obesity

Question 218

Dx of adenocarcinoma [4]

Answer 218

• Upper GI endoscopy is the first line test
• Contrast swallow may be of benefit in classifying benign motility disorders but has no place in the assessment of tumours
• Staging is initially undertaken with CT scanning of the chest, abdomen and pelvis. If overt metastatic disease is identified using this modality then further complex imaging is unnecessary
• If CT does not show metastatic disease, then local stage may be more accurately assessed by use of endoscopic ultrasound
• Staging laparoscopy is performed to detect occult peritoneal disease. PET CT is performed in those with negative laparoscopy. Thoracoscopy is not routinely performed.

Question 219

Tx of adenocarincoma [3]

Answer 219

• Operable disease is best managed by surgical resection - the most common procedure is an Ivor-Lewis type oesophagectomy
• The biggest surgical challenge is that of anastomotic leak, with an intrathoracic anastomosis resulting in mediastinitis
• In addition to surgical resection many patients will be treated with adjuvant chemotherapy

Question 220

For each of the following procedures select the most appropriate preparation with respect to ordering blood products:

16.Cystectomy

Answer 220

Cross-match 4-6 units depending on local protocols

Question 221

Appendectomy ordering blood products [1]

Answer 221

Group and save

Question 222

Elective AAA repair [1]

Answer 222

Cross-match 4-6 units depending on local protocols

Question 223

Total replacement ordering blood products

Answer 223

Chance of transfusionExample of actionExample of operationsUnlikelyGroup and saveHysterectomy (simple), appendicectomy, thyroidectomy, elective lower segment caesarean section, laparoscopic cholecystectomyLikelyCross-match 2 unitsSalpingectomy for ruptured ectopic pregnancy, total hip replacementDefiniteCross-match 4-6 unitsTotal gastrectomy, oophorectomy, oesophagectomy
Elective AAA repair, cystectomy, hepatectomy

Question 224

thyroidectomy orering blood products [1]

Answer 224

Chance of transfusionExample of actionExample of operationsUnlikelyGroup and saveHysterectomy (simple), appendicectomy, thyroidectomy, elective lower segment caesarean section, laparoscopic cholecystectomyLikelyCross-match 2 unitsSalpingectomy for ruptured ectopic pregnancy, total hip replacementDefiniteCross-match 4-6 unitsTotal gastrectomy, oophorectomy, oesophagectomy
Elective AAA repair, cystectomy, hepatectomy

Question 225

which operation definitvely needs blood products ordered? [1]

Answer 225

Chance of transfusionExample of actionExample of operationsUnlikelyGroup and saveHysterectomy (simple), appendicectomy, thyroidectomy, elective lower segment caesarean section, laparoscopic cholecystectomyLikelyCross-match 2 unitsSalpingectomy for ruptured ectopic pregnancy, total hip replacementDefiniteCross-match 4-6 unitsTotal gastrectomy, oophorectomy, oesophagectomy
Elective AAA repair, cystectomy, hepatectomy

Question 226

A 50-year-old man presents with red-eye associated with slight watering and mild photophobia. He reports no pain or tenderness and vision is not affected

What is the most likely diagnosis? [1]

Answer 226

The correct answer here is episcleritis. All the other causes of a red eye listed present with pain and either blurring of vision or decreased visual acuity. Episcleritis is classically not painful despite diffuse inflammation although mild tenderness may sometimes be reported. It can be treated with non-steroidal anti-inflammatories or steroids in resistant cases.

Question 227

Features of episcleritis

Answer 227

• red eye
• classically not painful (in comparison to scleritis), but mild pain may be present
• watering and mild photophobia may be present
• in episcleritis, the injected vessels are mobile when gentle pressure is applied on the sclera. In scleritis, vessels are deeper, hence do not move
• phenylephrine drops may be used to differentiate between episcleritis and scleritis. Phenylephrine blanches the conjunctival and episcleral vessels but not the scleral vessels. If the eye redness improves after phenylephrine a diagnosis of episcleritis can be made

Question 228

A way of differentiating between episcleritis and scleritis? [1]

Answer 228

• phenylephrine drops may be used to differentiate between episcleritis and scleritis. Phenylephrine blanches the conjunctival and episcleral vessels but not the scleral vessels. If the eye redness improves after phenylephrine a diagnosis of episcleritis can be made

Question 229

Mx of episcleritis [1]

Answer 229

• conservative
• artificial tears may sometimes be used

Question 230

When should you be concerned if there are no foetal movements? [1]

Answer 230

If no foetal movements by 24w, referrral to maternal fetal unit

Question 231

what can reduced fetal movements represent? [1]

Answer 231

Reduced fetal movements can represent fetal distress, as a method of fetal compensation to reduce oxygen consumption as a response to chronic hypoxia in utero. This is concerning, as it reflects risk of stillbirth and fetal growth restriction. It is believed that there may also be a link between reduced fetal movements and placental insufficiency.

Question 232

What is the first onset of fetal movements known as? [2]

Answer 232

The first onset of recognised fetal movements is known as quickening. This usually occurs between 18-20 weeks gestation, and increase until 32 weeks gestation at which point the frequency of movement tends to plateau. Multiparous women will usually experience fetal movements sooner, from 16-18 weeks gestation. Towards the end of pregnancy, fetal movements should not reduce.

Question 233

What constitutes RFM? [1]

Answer 233

Expectant mothers will usually quickly recognise a pattern to these movements. The nature of the movements themselves can be very variable. There is no established definition for what constitutes reduced fetal movements (RFM), but the RCOG considers less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) an indication for further assessment.

Question 234

How common is RFM? [1]

Answer 234

Fetal movements should be established by 24 weeks gestation.

Reduced fetal movements is a fairly common presentation, affecting up to 15% of pregnancies. 3-5% of pregnant women will have recurrent presentations with RFM.

Question 235

RFs for RFM [7]

Answer 235

• Posture
  
  • There can be positional changes in fetal movement awareness, generally being more prominent during lying down and less when sitting and standing
• Distraction
  
  • Awareness of fetal movements can be distractable, and if a woman is busy or concentrating on something else, these can be less prominent
• Placental position
  
  • Patient with anterior placentas prior to 28 weeks gestation may have lesser awareness of fetal movements
• Medication
  
  • Both alcohol and sedative medications like opiates or benzodiazepines can temporarily cause reduced fetal movements
• Fetal position
  
  • Anterior fetal position means movements are less noticeable
• Body habitus
  
  • Obese patients are less likely to feel prominent fetal movements
• Amniotic fluid volume
  
  • Both oligohydramnios and polyhydramnios can cause reduction in fetal movements
• Fetal size
  
  • Up to 29% of women presenting with RFM have a SGA fetus

Question 236

Ix for RFM [4]

Answer 236

As per RCOG Green-top guidelines, investigations are dependent of gestation at onset of RFM.

• If past 28 weeks gestation:
  
  • Initially, handheld Doppler should be used to confirm fetal heartbeat.
  • If no fetal heartbeat detectable, immediate ultrasound should be offered.
  • If fetal heartbeat present, CTG should be used for at least 20 minutes to monitor fetal heart rate which can assist in excluding fetal compromise.
  • If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used. Ultrasound assessment should include abdominal circumference or estimated fetal weight (to exclude SGA), and amniotic fluid volume measurement
• If between 24 and 28 weeks gestation, a handheld Doppler should be used to confirm presence of fetal heartbeat.
• If below 24 weeks gestation, and fetal movements have previously been felt, a handheld Doppler should be used.
• If fetal movements have not yet been felt by 24 weeks, onward referral should be made to a maternal fetal medicine unit.

Question 237

How are RFM commonly assessed? [2]

Answer 237

Fetal movements are usually based solely on maternal perception, though it can also be objectively assessed using handheld Doppler or ultrasonography.

Question 238

Prognosis for RFM [1]

Answer 238

Concern regarding absent or reduced fetal movements stems for the potential for this presentation to represent fetal distress or impending demise. Between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis.

However, in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication.

Question 239

Compare lichen planus to lichen sclerosus [2]

Answer 239

Lichen

• planus: purple, pruritic, papular, polygonal rash on flexor surfaces. Wickham’s striae over surface. Oral involvement common
• sclerosus: itchy white spots typically seen on the vulva of elderly women

Question 240

Features of lichen planus

Answer 240

• itchy, papular rash most common on the palms, soles, genitalia and flexor surfaces of arms
• rash often polygonal in shape, with a ‘white-lines’ pattern on the surface (Wickham’s striae)
• Koebner phenomenon may be seen (new skin lesions appearing at the site of trauma)
• oral involvement in around 50% of patients: typically a white-lace pattern on the buccal mucosa
• nails: thinning of nail plate, longitudinal ridging

Question 241

Which drugs can cause lichenoid drug eruptions? [3]

Answer 241

• gold
• quinine
• thiazides

Question 242

Mx of lichen planus [3]

Answer 242

• potent topical steroids are the mainstay of treatment
• benzydamine mouthwash or spray is recommended for oral lichen planus
• extensive lichen planus may require oral steroids or immunosuppression

Question 243

A 55-year-old man presents with intermittent leg pain which is exacerbated by movement and relieved by rest. He denies recent injury or illness. ABPI is 0.8. Which Tx should he be on? [2]

Answer 243

Atorvastatin 80mg OD and Clopidogrel → all patietns with PAD should take these two drugs [he’s experiencing intermittent claudication]

Question 244

Commonest cause of intermittent claudication? [1]

Answer 244

Athersclerosis

Question 245

ABPI that suggests PAD [1]

Answer 245

Below 0.9

Question 246

ABPI that suggests CLI [1]

Answer 246

below 0.5

Question 247

What type of Mx has shwons significant beenfits for PAD? [1]

Answer 247

Exercise training

Question 248

How is PAD Mx? [4]

Answer 248

Peripheral arterial disease (PAD) is strongly linked to smoking. Patients who still smoke should be given help to quit smoking.

Comorbidities should be treated, including

• hypertension
• diabetes mellitus
• obesity

As with any patient who has established cardiovascular disease, all patients should be taking a statin. Atorvastatin 80 mg is currently recommended. In 2010 NICE published guidance suggesting that clopidogrel should be used first-line in patients with peripheral arterial disease in preference to aspirin.

Exercise training has been shown to have significant benefits. NICE recommend a supervised exercise programme for all patients with peripheral arterial disease prior to other interventions.

Question 249

How is severe PAD or CLI Mx? [3]

Answer 249

• angioplasty
• stenting
• bypass surgery

Question 250

When should amputation be consdiered for CLI? [1]

Answer 250

Amputation should be reserved for patients with critical limb ischaemia who are not suitable for other interventions such as angioplasty of bypass surgery.

Question 251

Other drugs licensed for PAD? [2]

Answer 251

• naftidrofuryl oxalate: vasodilator, sometimes used for patients with a poor quality of life
• cilostazol: phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects - not recommended by NICE

Question 252

What is high temperature generally considered in an adult?

Answer 252

Over 38

Question 253

Other than findings resp exam, which observations will make Dx of tension pnueothorax more likely than simple pneuothorax [1]

Answer 253

Hypotension will occur in tension pneumothoraces as a result of cardiac outflow obstruction

Question 254

When can tension pneuothorax occur? [1]

Answer 254

• May occur following thoracic trauma when a lung parenchymal flap is created.

Question 255

What does a parenchymal flap create? [1]

Answer 255

• This acts as a one way valve and allows pressure to rise.

Question 256

Resp examination findings of tension pneuothorax [1]

Answer 256

• The trachea shifts and hyper-resonance is apparent on the affected side.

Question 257

How is tension pneuothorax Mx? [1]

Answer 257

• Treatment is with needle decompression and chest tube insertion.

Question 258

What is codeine to morphine equivalent dose? [1]

Answer 258

Codeine to morphine divide by 10

Question 259

Codeine to morphine

Answer 259

divide by 10

Question 260

tramadol to morhpine

Answer 260

divide by 10 [same as codeine]

Question 261

morphine to oxycodone

Answer 261

divide by 1.5-2

Question 262

What are the conversion factors for transdermal patches? [2]

Answer 262

• a transdermal fentanyl 12 microgram patch equates to approximately 30 mg oral morphine daily
• a transdermal buprenorphine 10 microgram patch equates to approximately 24 mg oral morphine daily.

Question 263

Oral morphine to subcut morphine

Answer 263

divide by 2

Question 264

oral morphine to subcut diamorphine

Answer 264

FromToConversion factorOral morphineSubcutaneous morphineDivide by 2Oral morphineSubcutaneous diamorphineDivide by 3Oral oxycodoneSubcutaneous diamorphineDivide by 1.5

Question 265

orla oxycodone to subcut diamorphine

Answer 265

FromToConversion factorOral morphineSubcutaneous morphineDivide by 2Oral morphineSubcutaneous diamorphineDivide by 3Oral oxycodoneSubcutaneous diamorphineDivide by 1.5

Question 266

Migraine during pregnancy Mx [3]

Answer 266

• paracetamol 1g is first-line
• NSAIDs can be used second-line in the first and second trimester
• avoid aspirin and opioids such as codeine during pregnancy

Question 267

Migraine and the COCP [1]

Answer 267

• if patients have migraine with aura then the COC is absolutely contraindicated due to an increased risk of stroke (relative risk 8.72)

Question 268

Migraine and menstruation [2]

Answer 268

• many women find that the frequency and severity of migraines increase around the time of menstruation
• SIGN recommends that women are treated with mefanamic acid or a combination of aspirin, paracetamol and caffeine. Triptans are also recommended in the acute situation

Question 269

Migraine and HRT [1]

Answer 269

• safe to prescribe HRT for patients with a history of migraine but it may make migraines worse

Question 270

Which organism is responsible for Scarlet fever? [1]

Answer 270

Scarlet fever is a reaction to erythrogenic toxins produced by Group A haemolytic streptococci (usually Streptococcus pyogenes)

Question 271

A 65-year-old man calls an ambulance as he has central crushing chest pain that radiates to his left arm and jaw. As he arrives at the emergency department his heart rate is found to be 50/min. An ECG is performed which shows ST elevation and bradycardia with a 1st-degree heart block.

Given the history, which of the following are the leads will most likely show the ST elevation? [2]

Answer 271

This question is asking about the presentation of an ST-elevated myocardial infarction. The patient has presented 1st-degree heart block following his MI and so we can work out that his MI has most likely affected the inferior leads (right coronary arteries also provide blood supply to the AV node). Therefore the question requires you to know that leads II, III and aVF represent the inferior heart and the right coronary artery.

Question 272

What ECG changes correspond to the LAD? [1]

Answer 272

ECG changesCoronary arteryAnteroseptalV1-V4InferiorII, III, aVFAnterolateralV4-6, I, aVLLateralI, aVL +/- V5-6PosteriorTall R waves V1-2

Question 273

What ECG changes correspond to the left circumflex artery? [1]

Answer 273

ECG changesCoronary arteryAnteroseptalV1-V4InferiorII, III, aVFAnterolateralV4-6, I, aVLLateralI, aVL +/- V5-6PosteriorTall R waves V1-2

Question 274

Summarise inferior, aterolateral, laterla, posterior, inferior ECG changes [5]

Answer 274

ECG changesCoronary arteryAnteroseptalV1-V4InferiorII, III, aVFAnterolateralV4-6, I, aVLLateralI, aVL +/- V5-6PosteriorTall R waves V1-2

Question 275

Why may a new LBBB point towards? [1]

Answer 275

ACS

Question 276

Which territories on an ECG does the lateral, inferior, anterior and lateral leads correspond to? [4]

Question 277

What are the requirements for maintenance fluids? [3]

Answer 277

• 25-30 ml/kg/day of water and
• approximately 1 mmol/kg/day of potassium, sodium and chloride and
• approximately 50-100 g/day of glucose to limit starvation ketosis

Question 278

So, what would an 80kg man recieve maintenance fluids over 24h? [2]

Answer 278

• 2 litres of water
• 80mmol potassium

Question 279

Electrolytes in plasma [4]

Answer 279

Na⁺Cl^-K⁺HCO3^-GlucosePlasma135-14598-1053.5-522-280.9% saline154154–5% glucose—-0.18% saline with 4% glucose3030–Hartmann’s solution131111529

Question 280

Electrolytes in 0.9% saline

Answer 280

Na⁺Cl^-K⁺HCO3^-GlucosePlasma135-14598-1053.5-522-280.9% saline154154–5% glucose—-0.18% saline with 4% glucose3030–Hartmann’s solution131111529

Question 281

What does Hartmann’s solution contain? [4]

Answer 281

Na⁺Cl^-K⁺HCO3^-GlucosePlasma135-14598-1053.5-522-280.9% saline154154–5% glucose—-0.18% saline with 4% glucose3030–Hartmann’s solution131111529

Question 282

what is there is a risk of in patients if lrge volumes of 0.9% are used? [1]

Answer 282

• if large volumes are used there is an increased risk of hyperchloraemic metabolic acidosis

Question 283

What type of patients should Hartmann’s solution not be used for? [1]

Answer 283

• contains potassium and therefore should not be used in patients with hyperkalaemia

Question 284

What does seborrhoeic keratosis look like? [2]

Answer 284

This lesion is characteristic of a seborrhoeic keratosis. Seborrhoeic keratoses are benign skin lesions that are common in people over 50. Note the brown nodule with a fissured greasy surface that is well demarcated against the skin. It has the classic ‘stuck on’ appearance of seborrhoeic keratoses. Most seborrhoeic keratosis lesions are asymptomatic and therefore no treatment is required.

Question 285

What does actinic keratosis look like? [2]

Answer 285

Actinic keratosis (AK) is incorrect. AK is associated with chronic UV exposure and are typically flesh-coloured, irregularly shaped, small macules or plaques. Actinic keratoses have the potential to progress to squamous cell carcinoma. The lesions are small (typically 1-5mm) and do not have a ‘stuck on’ appearance as in this case.

Question 286

Features of Bowen’s disease [2]

Answer 286

Bowen’s disease is also known as squamous cell carcinoma (SCC) in situ. Typically these lesions are slow-growing, red, scaly patches.

Question 287

Features of malignant melanoma [2]

Answer 287

Malignant melanoma is an important differential to consider. However, a malignant melanoma typically varies more in colour, such as brown/blue/black and red. Furthermore, melanomas do not have a ‘stuck on’ and greasy appearance as in this case.

Question 288

Naevus features [2]

Answer 288

Naevus is not the correct answer in this case. Naevi typically develop within the first 20 years of life, whereas seborrhoeic keratosis is more common with advancing age

Question 289

Features seborrhoeic keratoses [3]

Answer 289

Seborrhoeic keratoses are benign epidermal skin lesions seen in older people.

Features

• large variation in colour from flesh to light-brown to black
• have a ‘stuck-on’ appearance
• keratotic plugs may be seen on the surface

Question 290

Seborrhoiec keratoses Mx

Answer 290

reassurance about benign nature of the lesion is an option

options for removal include crettage, cryosurgery, shave biopsy

Question 291

What does osteomylitis describe? [1]

Answer 291

Infeciton of the bone

Question 292

Subclassificaitons of osteomyelitis [2]

Answer 292

• haematogenous osteomyelitis
  
  • results from bacteraemia
  • is usually monomicrobial
  • most common form in children
  • vertebral osteomyelitis is the most common form of haematogenous osteomyelitis in adults
  • risk factors include: sickle cell anaemia, intravenous drug user, immunosuppression due to either medication or HIV, infective endocarditis
• non-haematogenous osteomyelitis:
  
  • results from the contiguous spread of infection from adjacent soft tissues to the bone or from direct injury/trauma to bone
  • is often polymicrobial
  • most common form in adults
  • risk factors include: diabetic foot ulcers/pressure sores, diabetes mellitus, peripheral arterial disease

Question 293

Microbiology of OM

Answer 293

• Staph. aureus is the most common cause except in patients with sickle-cell anaemia where Salmonella species predominate

Question 294

Ix for OM [1]

Answer 294

MRI imaging of choice mdality, sensitivty of 90-100%

Question 295

Mx of OM [2]

Answer 295

• flucloxacillin for 6 weeks
• clindamycin if penicillin-allergic

Question 296

Gluten containing foods

Answer 296

• wheat: bread, pasta, pastry
• barley: beer
  
  • whisky is made using malted barley. Proteins such as gluten are however removed during the distillation process making it safe to drink for patients with coeliac disease
• rye
• oats
  
  • some patients with coeliac disease appear able to tolerate oats

Question 297

Notable foods that are gluten free

Answer 297

rice, potatoes, corn

Question 298

What can be checked to check compliance to gluten free diet? [1]

Answer 298

Tissue transglutaminase

Question 299

What vaccine are all coeliac patients offered? [2]

Answer 299

• Patients with coeliac disease often have a degree of functional hyposplenism
• For this reason, all patients with coeliac disease are offered the pneumococcal vaccine
  
  • Coeliac UK recommends that everyone with coeliac disease is vaccinated against pneumococcal infection and has a booster every 5 years
• Currrent guidelines suggest giving the influenza vaccine on an individual basis.

Question 300

Which index used to assess severity of UC in adults? [1]

Answer 300

The Truelove and Witts’ severity index is recommended by NICE when assessing the severity of ulcerative colitis in adults.

Question 301

How should patients with severe UC be Mx? [1]

Answer 301

Any patient with features of severe ulcerative colitis should be admitted to hospital as an emergency. They should be treated with intravenous corticosteroids to induce remission.

Question 302

Flare ups for UC [3]

Answer 302

• stress
• medications
  
  • NSAIDs
  • antibiotics
• cessation of smoking

Question 303

Mild vs moderate vs severe flare ups of UC [according tot eh Truelove and Witts’ severity index]

Answer 303

MildModerateSevereFewer than four stools daily, with or without blood

No systemic disturbance

Normal erythrocyte sedimentation rate and C-reactive protein valuesFour to six stools a day, with minimal systemic disturbance

More than six stools a day, containing blood

Evidence of systemic disturbance, e.g.

• fever
• tachycardia
• abdominal tenderness, distension or reduced bowel sounds
• anaemia
• hypoalbuminaemia

Question 304

A 65-year-old woman with COPD attends surgery with a 2-day history of worsening dyspnoea, productive cough, and fever. On examination, she has basal crackles on the right side. Organism?

Answer 304

Haemophilus influenzae75%

This is an infective exacerbation of COPD, with the fever and basal crackles indicating a bacterial cause. The most common cause in COPD is Haemophilus influenzae.

Question 305

An 8-year-old boy is brought in by his mother with a history of shortness of breath and fever over the last few hours. On examination, he has a toxic appearance, has inspiratory stridor, and is drooling.

Answer 305

Haemophilus influenzae type B64%

The history indicates acute epiglottitis, and this child would obviously need an ambulance to transfer him to the emergency department urgently. The most common cause of acute epiglottitis in children is Haemophilus influenzae type B, and the incidence of acute epiglottitis has fallen since the introduction of the Hib vaccine.

Question 306

A 27-year-old man attends with a 2-day history of right-sided otalgia and discharge. He is a keen swimmer. On examination, the external auditory canal is swollen and erythematous, with purulent material on the walls.

Answer 306

Pseudomonas aeruginosa34%

Bacterial causes of otitis externa are most common, with Pseudomonas aeruginosa being most prevalent. Other causes include Staphylococcus aureus.

Question 307

What are the two types of bacteria? [2]

Answer 307

• Gram-positive cocci = staphylococci + streptococci (including enterococci)
• Gram-negative cocci = Neisseria meningitidis + Neisseria gonorrhoeae, also Moraxella catarrhalis

Question 308

Name all the gram-positive rods? [5]

Answer 308

Therefore, only a small list of Gram-positive rods (bacilli) need to be memorised to categorise all bacteria - mnemonic = ABCD L

• Actinomyces
• Bacillus anthracis (anthrax)
• Clostridium
• Diphtheria: Corynebacterium diphtheriae
• Listeria monocytogenes

Question 309

Name gram-negative rods

Answer 309

Remaining organisms are Gram-negative rods, e.g.:

• Escherichia coli
• Haemophilus influenzae
• Pseudomonas aeruginosa
• Salmonella sp.
• Shigella sp.
• Campylobacter jejuni

Question 310

What is Pharyngeal pouch? [2]

Answer 310

Phayngeal pouch: During swallowing an outpouching of the posterior hypopharyngeal wall is visualised at the level C5-C6, right above the upper oesophageal sphincter.

A pharyngeal pouch is a posteromedial diverticulum through Killian’s dehiscence. Killian’s dehiscence is a triangular area in the wall of the pharynx between the thyropharyngeus and cricopharyngeus muscles. It is more common in older patients and is 5 times more common in men

Question 311

Features of pharyngeal pouch [5]

Answer 311

• dysphagia
• regurgitation
• aspiration
• neck swelling which gurgles on palpation
• halitosis

Question 312

Mx of pharyngeal pouch

Answer 312

Surgery

Question 313

A 62-year-old woman presents with a one day history of pain around her right eye. She feels nauseated and has vomited once. On examination her right eye is red

Answer 313

Acute glaucoma

Question 314

A 42-year-old man presents with pain in the posterior and left side of his head. This came on over one minute and is now severe. The pain is worse when he bends his neck. His temperature is 37.3ºC

Answer 314

SaH

Question 315

A 22-year-old woman presents with recurrent headaches around the time of her periods. These are typically on the left-side and severe. When she gets a headache it lasts several hours and she usually goes to bed.

Answer 315

Migraine

Question 316

Pain typical occurs once or twice a day, each episode lasting 15 mins - 2 hours with clusters typically lasting 4-12 weeks
Intense pain around one eye (recurrent attacks ‘always’ affect same side)
Patient is restless during an attack
Accompanied by redness, lacrimation, lid swelling
More common in men and smokers

Answer 316

Cluster headache

Question 317

Typically patient > 60 years old
Usually rapid onset (e.g. < 1 month) of unilateral headache
Jaw claudication (65%)
Tender, palpable temporal artery
Raised ESR

Answer 317

Temporal artery

Question 318

Present for 15 days or more per month
Developed or worsened whilst taking regular symptomatic medication
Patients using opioids and triptans are at most risk
May be psychiatric co-morbidity

Answer 318

Medicaiton overuse headache

Question 319

Suggest other causes of an acute headache

Answer 319

• meningitis
• encephalitis
• subarachnoid haemorrhage
• head injury
• sinusitis
• glaucoma (acute closed-angle)
• tropical illness e.g. Malaria

Question 320

Suggest causes of a chronic headache

Answer 320

• chronically raised ICP
• Paget’s disease
• psychological

Question 321

A 77-year-old man presents to his GP with a painful rash around his ear. He first noticed pain in his left ear 3 days ago and is now also complaining of vertigo and tinnitus. On examination, you note a vesicular rash around his left ear.

Given the most likely diagnosis, what is the most appropriate treatment for this patient?

Answer 321

Ramsey Hunt syndreom: Oral aciclovir and oral prednisolone for 5d

Question 322

What is Ramsey Hunt syndrome? [2]

Answer 322

Ramsay Hunt syndrome (herpes zoster oticus) is caused by the reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve.

Question 323

Features of Ramsey Hunt syndrome [4]

Answer 323

• auricular pain is often the first feature
• facial nerve palsy
• vesicular rash around the ear
• other features include vertigo and tinnitus

Question 324

A 11-year-old boy with severe lower abdominal pain is rushed to the Emergency Department by his mother. On examination, you note that the left testicle is swollen, higher than the right and it is exquisitely tender to touch. He is apyrexial. The cremasteric reflex is absent. He denies any urinary symptoms. The pain started approximately 120 minutes ago. What is the most appropriate next step in his management?

Answer 324

Emergency surgical exploration as this is presentation of testicular torsion!

Question 325

When is testicular cacner most common? p[1]

Answer 325

Men aged 20-30 y/o

Question 326

Where do the testicular tumours derive from? [1]

Answer 326

Around 95% are germ-cell tumours

Question 327

Features, tumour markers and pathology of seminoma

Answer 327

• Tumour typeKey featuresTumour markers*PathologySeminoma
• Commonest subtype (50%)
• Average age at diagnosis = 40
• Even advanced disease associated with 5 year survival of 73%
• AFP usually normal
• HCG elevated in 10% seminomas
• Lactate dehydrogenase; elevated in 10-20% seminomas (but also in many other conditions)
  Sheet like lobular patterns of cells with substantial fibrous component. Fibrous septa contain lymphocytic inclusions and granulomas may be seen.

Question 328

Features, tumour markers and pathology of non-seminomatous tumours [4]

Answer 328

Non seminomatous germ cell tumours (42%)

• Teratoma
• Yolk sac tumour
• Choriocarcinoma
• Mixed germ cell tumours (10%)
• Younger age at presentation =20-30 years
• Advanced disease carries worse prognosis (48% at 5 years)
• Retroperitoneal lymph node dissection may be needed for residual disease after chemotherapy
• AFP elevated in up to 70% of cases
• HCG elevated in up to 40% of cases
• Other markers rarely helpful
  Heterogenous texture with occasional ectopic tissue such as hair

Question 329

RFs for testicular Ca

Answer 329

• Cryptorchidism
• Infertility
• Family history
• Klinefelter’s syndrome
• Mumps orchitis

Question 330

Features of testicular Ca

Answer 330

• A painless lump is the most common presenting symptom
• Pain may also be present in a minority of men
• Other possible features include hydrocele, gynaecomastia

Question 331

Dx of testicular Ca [3]

Answer 331

• Ultrasound is first-line
• CT scanning of the chest/ abdomen and pelvis is used for staging
• Tumour markers (see above) should be measured

Question 332

Mx of testicular Ca [3]

Answer 332

• Orchidectomy (Inguinal approach)
• Chemotherapy and radiotherapy may be given depending on staging
• Abdominal lesions >1cm following chemotherapy may require retroperitoneal lymph node dissection.

Question 333

Prognosis of testicualr tumours [2]

Answer 333

• 5 year survival for seminomas is around 95% if Stage I
• 5 year survival for teratomas is around 85% if Stage I

Question 334

Feeatures of epididymo-orchitis

Answer 334

Acute epididymitis is an acute inflammation of the epididymis, often involving the testis and usually caused by bacterial infection.

• Infection spreads from the urethra or bladder. In men <35 years, gonorrhoea or chlamydia are the usual infections.
• Amiodarone is a recognised non infective cause of epididymitis, which resolves on stopping the drug.
• Tenderness is usually confined to the epididymis, which may facilitate differentiating it from torsion where pain usually affects the entire testis.

Question 335

Features of testicular torsion [5]

Answer 335

• Twist of the spermatic cord resulting in testicular ischaemia and necrosis.
• Most common in males aged between 10 and 30 (peak incidence 13-15 years)
• Pain is usually severe and of sudden onset.
• Cremasteric reflex is lost and elevation of the testis does not ease the pain.
• Treatment is with surgical exploration. If a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral.

Question 336

Features of a hydrocele [5]

Answer 336

• Presents as a mass that transilluminates, usually possible to ‘get above’ it on examination.
• In younger men it should be investigated with USS to exclude tumour.
• In children it may occur as a result of a patent processus vaginalis.
• Treatment in adults is with a Lords or Jabouley procedure.
• Treatment in children is with trans inguinal ligation of PPV.

Question 337

A 32-year-old woman presents with a tender breast lump. She has a 2 month old child. Clinically there is a tender, fluctuant mass of the breast.

Answer 337

The correct answer is: Breast abscess70%

This lady is likely to be breast feeding and is at risk of mastitis. This may lead to an abscess if not treated. Staphylococcus aureus is usually the causative organism.

Question 338

A 53-year-old lady presents with a creamy nipple discharge. On examination she has discharge originating from multiple ducts and associated nipple inversion.

Answer 338

Duct ectasia55%

Duct ectasia is common during the period of breast involution that occurs during the menopausal period. As the ducts shorten they may contain insipiated material. The discharge will often discharge from several ducts

Question 339

A 52-year-old lady presents with an episode of nipple discharge. It is usually clear in nature. On examination the discharge is seen to originate from a single duct and although it appears clear, when the discharge is tested with a labstix it is shown to contain blood. Imaging and examination shows no obvious mass lesion.

Answer 339

Intraductal papilloma65%

Intraductal papilloma usually cause single duct discharge. The fluid is often clear, although it may be blood stained. If the fluid is tested with a labstix (little point in routine practice) then it will usually contain small amounts of blood. A microdocechtomy may be performed.

Question 340

• Present at younger age than duct ectasia
• May present with features of inflammation, abscess or mammary duct fistula
• Stongly associated with smoking
• Usually treated with antibiotics, abscess will require drainage

Answer 340

Periductal mastitis

Question 341

• Growth of papilloma in a single duct
• Usually presents with clear or blood stained discharge originating from a single duct
• No increase in risk of malignancy

Answer 341

Intraductal papilloma

Question 342

Duct ectasia features [4]

Answer 342

• Mammary duct ectasia may be seen in up to 25% of normal female breasts
• Patients usually present with nipple discharge, which may be from single or multiple ducts (usually present age >50 years)
• The discharge is often thick and green
• Duct ectasia is a normal varient of breast involution and is not the same condition as periductal mastitis

Question 343

Breast abscess features [5]

Answer 343

• Lactational mastitis is common
• Infection is usually with Staphylococcus aureus
• On examination there is usually a tender fluctuant mass
• Treatment is with antibiotics and ultrasound guided aspiration
• Overlying skin necrosis is an indication for surgical debridement, which may be complicated by the development of a subsequent mammary duct fistula.

Question 344

TB in breasts features [4]

Answer 344

• Rare in western countries, usually secondary TB
• Affects women later in child bearing period
• Chronic breast or axillary sinus is present in up to 50% cases
• Diagnosis is by biopsy culture and histology

Question 345

. Which of the following is the most likely location of the ectopic pregnancy?

Answer 345

Ampulla fallopian tube

Question 346

Chance of having a tubal ecoptic

Answer 346

tubal ectopic: 93-97%

• ampullary ectopic: most common ~70% of tubal ectopics and ~65% of all ectopics
• isthmal ectopic: ~12% of tubal ectopics and ~11% of all ectopics
• fimbrial ectopic: ~11% of tubal ectopics and ~10% of all ectopics

Question 347

What is an ectopic pregnancy? [1]

Answer 347

Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy

Question 348

How common are ecotpics? [1]

Answer 348

• incidence = c. 0.5% of all pregnancies

Question 349

RFs for ecoptics [5]

Answer 349

• damage to tubes (pelvic inflammatory disease, surgery)
• previous ectopic
• endometriosis
• IUCD
• progesterone only pill
• IVF (3% of pregnancies are ectopic)

Question 350

What is Kartagener’s syndrome? [2]

Answer 350

Kartagener’s syndrome (also known as primary ciliary dyskinesia) was first described in 1933 and most frequently occurs in examinations due to its association with dextrocardia (e.g. ‘quiet heart sounds’, ‘small volume complexes in lateral leads’)

Question 351

Pathogenesis and features of Kartagener’s syndrome [5]

Answer 351

Pathogenesis

• dynein arm defect results in immotile cilia

Features

• dextrocardia or complete situs inversus
• bronchiectasis
• recurrent sinusitis
• subfertility (secondary to diminished sperm motility and defective ciliary action in the fallopian tubes)

Question 352

How would minimal change disease present? [1]

Answer 352

Minimal change disease would have been the most likely differential of nephrotic syndrome were the patient a child.

Question 353

How would mesangiocapillary glomerulonephritis present? [2]

Answer 353

Mesangiocapillary glomerulonephritis causes a nephritic syndrome with at least a small amount of blood being present in the urine, which is absent in this patient.

Question 354

How would granulomatosis present? [1]

Answer 354

Granulomatosis with polyangiitis is associated with a more nephritic picture.

Question 355

How would Goodpasture’s present? [2]

Answer 355

Goodpasture’s is associated with haematuria and concurrent pulmonary disease in which haemoptysis is a feature, neither of which this patient has.

Question 356

What is FSGS a cause of? WHome does it present in? [2]

Answer 356

Focal segmental glomerulosclerosis (FSGS) is a cause of nephrotic syndrome and chronic kidney disease. It generally presents in young adults.

Question 357

Causes of FSGS [5]

Answer 357

• idiopathic
• secondary to other renal pathology e.g. IgA nephropathy, reflux nephropathy
• HIV
• heroin
• Alport’s syndrome
• sickle-cell

Question 358

Ix for FSGC [2]

Answer 358

• renal biopsy
  
  • focal and segmental sclerosis and hyalinosis on light microscopy
  • effacement of foot processes on electron microscopy

Question 359

Mx and prognosis of FSGS

Answer 359

Management

• steroids +/- immunosuppressants

Prognosis

• untreated FSGS has a < 10% chance of spontaneous remission

Question 360

Which drugs are known to improve long term survival for congestive HF? [3]

Answer 360

This patient has features of congestive heart failure. While loop diuretics (furosemide, bumetanide) and nitrates are important in the management of acute or decompensated cardiac failure, they have no effect on long-term survival.

The following drugs have all been shown to reduce mortality in patients with left ventricular failure:

• ACE-inhibitors
• Beta-blockers
• Angiotensin receptor blockers
• Aldosterone antagonists
• Hydralazine and nitrates

Question 361

Does digoxin improve mortality for CHF? [1]

Answer 361

Digoxin has been shown to reduce hospital admissions but not mortality. It is generally used in patients with worsening heart failure despite first or second line treatments, or in patients with co-existant atrial fibrillation

Question 362

1st line Tx for all patients with heart failure [3]

Answer 362

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

• generally, one drug should be started at a time. NICE advise that clinical judgement is used when determining which one to start first
• beta-blockers licensed to treat heart failure in the UK include bisoprolol, carvedilol, and nebivolol.
• ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction

Question 363

2nd line Tx for heart failure [2]

Answer 363

Second-line treatment is an aldosterone antagonist

• these are sometimes referred to as mineralocorticoid receptor antagonists. Examples include spironolactone and eplerenone
• it should be remembered that both ACE inhibitors (which the patient is likely to already be on) and aldosterone antagonists both cause hyperkalaemia - therefore potassium should be monitored

Question 364

Third-line Tx for heart failure [5]

Answer 364

Third-line treatment should be initiated by a specialist. Options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy

• 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 365

What immunisations should CHF pts also recieve? [2]

Answer 365

• offer annual influenza vaccine
• offer one-off pneumococcal vaccine
  
  • adults usually require just one dose but those with asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years

Question 366

What is allergic bronchoplumonary aspergillosis? [2]

Answer 366

Allergic bronchopulmonary aspergillosis results from an allergy to Aspergillus spores. In the exam questions often give a history of bronchiectasis and eosinophilia.

Question 367

Features of ABA [2]

Answer 367

• bronchoconstriction: wheeze, cough, dyspnoea. Patients may have a previous label of asthma
• bronchiectasis (proximal)

Question 368

Ix for ABA [5]

Answer 368

• eosinophilia
• flitting CXR changes
• positive radioallergosorbent (RAST) test to Aspergillus
• positive IgG precipitins (not as positive as in aspergilloma)
• raised IgE

Question 369

Mx of ABA [2]

Answer 369

• oral glucocorticoids
• itraconazole is sometimes introduced as a second-line agent

Question 370

How can a patient be diagnosed with DM? [1]

Answer 370

The diagnosis of type 2 diabetes mellitus can be made by either a plasma glucose or a HbA1c sample. Diagnostic criteria vary according to whether the patient is symptomatic (polyuria, polydipsia etc) or not.

Question 371

How to Dx DM [3]

Answer 371

If the patient is symptomatic:

• fasting glucose greater than or equal to 7.0 mmol/l
• random glucose greater than or equal to 11.1 mmol/l (or after 75g oral glucose tolerance test)

If the patient is asymptomatic the above criteria apply but must be demonstrated on two separate occasions.

Question 372

Diagnosis of DM for HbA1c [4]

Answer 372

• a HbA1c of greater than or equal to 48 mmol/mol (6.5%) is diagnostic of diabetes mellitus
• a HbAlc value of less than 48 mmol/mol (6.5%) does not exclude diabetes (i.e. it is not as sensitive as fasting samples for detecting diabetes)
• in patients without symptoms, the test must be repeated to confirm the diagnosis
• it should be remembered that misleading HbA1c results can be caused by increased red cell turnover (see below)

Question 373

Conditions where HbA1c may not be used for diagnosis [5]

Answer 373

• haemoglobinopathies
• haemolytic anaemia
• untreated iron deficiency anaemia
• suspected gestational diabetes
• children
• HIV
• chronic kidney disease
• people taking medication that may cause hyperglycaemia (for example corticosteroids)

Question 374

What is the definition of impaired fasting lgucose and impaired glucose tolerance? [3]

Answer 374

A fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l implies impaired fasting glucose (IFG)

Impaired glucose tolerance (IGT) is defined as fasting plasma glucose less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l

Diabetes UK suggests:

• ‘People with IFG should then be offered an oral glucose tolerance test to rule out a diagnosis of diabetes. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person doesn’t have diabetes but does have IGT.’

Question 375

What should be offered to women who’ve had wide-local excision procedure [1]

Answer 375

Whole breast radiotherapy

Question 376

Features of chronic plaque psoriasis

Answer 376

• erythematous plaques covered with a silvery-white scale
• typically on the extensor surfaces such as the elbows and knees. Also common on the scalp, trunk, buttocks and periumbilical area
• clear delineation between normal and affected skin
• plaques typically range from 1 to 10 cm in size
• if the scale is removed, a red membrane with pinpoint bleeding points may be seen (Auspitz’s sign)

Question 377

How common is chronic plaque psoriasis? [1]

Answer 377

Chronic plaque psoriasis is the most common form of psoriasis seen in clinical practice, accounting for around 80% of presentations.

Question 378

Which antibiotics are used in the respriatory system for excerbations of chronic bronchitis, CAP, pneuomnia, HAP [4]

Answer 378

Exacerbations of chronic bronchitisAmoxicillin or tetracycline or clarithromycinUncomplicated community-acquired pneumoniaAmoxicillin (Doxycycline or clarithromycin in penicillin allergic, add flucloxacillin if staphylococci suspected e.g. In influenza)Pneumonia possibly caused by atypical pathogensClarithromycinHospital-acquired pneumoniaWithin 5 days of admission: co-amoxiclav or cefuroxime
More than 5 days after admission: piperacillin with tazobactam OR a broad-spectrum cephalosporin (e.g. ceftazidime) OR a quinolone (e.g. ciprofloxacin)

Question 379

Abx for LUTI, pyelonephritis, acute prostitis

Answer 379

Lower urinary tract infectionTrimethoprim or nitrofurantoin. Alternative: amoxicillin or cephalosporinAcute pyelonephritisBroad-spectrum cephalosporin or quinoloneAcute prostatitisQuinolone or trimethoprim

Question 380

Abx for skin conditions: impetigo, cellulitis, erysipelas, animal bite, mastitis [6]

Answer 380

ConditionRecommended treatmentImpetigoTopical hydrogen peroxide, oral flucloxacillin or erythromycin if widespreadCellulitisFlucloxacillin (clarithromycin, erythromycin or doxycycline if penicillin-allergic)Cellulitis (near the eyes or nose)Co-amoxiclav (clarithromycin, + metronidazole if penicillin-allergic)ErysipelasFlucloxacillin* (clarithromycin, erythromycin or doxycycline if penicillin-allergic)Animal or human biteCo-amoxiclav (doxycycline + metronidazole if penicillin-allergic)Mastitis during breast-feedingFlucloxacillin

Question 381

Abx for throat infections, sinusitis, otitis media, otitis externa, periapical or periodontal abscess, ginigitivits [6]

Answer 381

Throat infectionsPhenoxymethylpenicillin (erythromycin alone if penicillin-allergic)SinusitisPhenoxymethylpenicillinOtitis mediaAmoxicillin (erythromycin if penicillin-allergic)Otitis externa**Flucloxacillin (erythromycin if penicillin-allergic)Periapical or periodontal abscessAmoxicillinGingivitis: acute necrotising ulcerativeMetronidazole

Question 382

Abx for gonorrhoea, chlamydia, PID, syphilis, bacterial vaginosis

Answer 382

ConditionRecommended treatmentGonorrhoeaIntramuscular ceftriaxoneChlamydiaDoxycycline or azithromycinPelvic inflammatory diseaseOral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazoleSyphilisBenzathine benzylpenicillin or doxycycline or erythromycinBacterial vaginosisOral or topical metronidazole or topical clindamycin

Question 383

Abx for C.diff, campylobacter enteritis, salmonella [4]

Answer 383

Clostridium difficileFirst episode: metronidazole
Second or subsequent episode of infection: vancomycinCampylobacter enteritisClarithromycinSalmonella (non-typhoid)CiprofloxacinShigellosisCiprofloxacin

Question 384

A 23-year-old man presents to his GP. He describes episodes of leg weakness following bouts of laughing whilst out with friends. The following weekend his friends described a brief collapse following a similar episode. What is the most likely diagnosis?

Answer 384

Laughter → fall/collapse ? cataplexy

Question 384

A 23-year-old man presents to his GP. He describes episodes of leg weakness following bouts of laughing whilst out with friends. The following weekend his friends described a brief collapse following a similar episode. What is the most likely diagnosis?

Answer 384

Laughter → fall/collapse ? cataplexy

Question 385

What is cataplexy? What is it closely related? [2]

Answer 385

Cataplexy describes the sudden and transient loss of muscular tone caused by strong emotion (e.g. laughter, being frightened). Around two-thirds of patients with narcolepsy have cataplexy.

Features range from buckling knees to collapse.

Question 386

What is one of the biggest cuases of heptaitis E? [1]

Answer 386

Undercooked pork

Question 387

Which types of hepatitis are spread through the faecal-oral route? [1]

Answer 387

Hepatitis E and A

Question 388

What hepatitis requires co-infection with hepatitis B? [1]

Answer 388

Hepatitis D requires co-infection with hepatitis B.

Question 389

Features of hepatitis E

Answer 389

• RNA hepevirus
• spread by the faecal-oral route
• incubation period: 3-8 weeks
• common in Central and South-East Asia, North and West Africa, and in Mexico
• causes a similar disease to hepatitis A, but carries a significant mortality (about 20%) during pregnancy
• does not cause chronic disease or an increased risk of hepatocellular cancer
• a vaccine is currently in development, but is not yet in widespread use

Question 390

Which hepatitis type is commonly vaccinated against when young? [1]

Answer 390

Hep B I think

Question 391

WHat can cause ground-glass opacities in the lower zones and how much generally needed to cause this? [1]

Answer 391

This patient has developed pulmonary fibrosis secondary to long term amiodarone use. It typically occurs with doses that exceed 400mg daily after two or more months of therapy. Estimates range from 1 to 5% in the patients who are on long term amiodarone. The mechanism is not entirely understood however, current hypotheses include direct toxic injury to the lung or an indirect immunological reaction.

Question 392

Fibrosis predominantly affecting the upper zones

Answer 392

Acronym for causes of upper zone fibrosis:

CHARTS

• C - Coal worker’s pneumoconiosis
• H - Histiocytosis/ hypersensitivity pneumonitis
• A - Ankylosing spondylitis
• R - Radiation
• T - Tuberculosis
• S - Silicosis/sarcoidosis

Question 393

Fibrosis preodminantly affecting the lower zones [4]

Answer 393

• diopathic pulmonary fibrosis
• most connective tissue disorders (except ankylosing spondylitis) e.g. SLE
• drug-induced: amiodarone, bleomycin, methotrexate
• asbestosis

Question 394

History of alcohol excess
Stigmata of chronic liver disease: spider naevi, bruising, palmar erythema, gynaecomastia etc
Evidence of decompensation: ascites, jaundice, encephalopathy

Answer 394

Liver disease

Question 395

Pallor
Other signs: koilonychia, atrophic glossitis, post-cricoid webs, angular stomatitis, pruritis

Answer 395

iron defieincy anaemia

Question 396

Pruritus particularly after warm bath
‘Ruddy complexion’
Gout
Peptic ulcer disease

Answer 396

PCV

Question 397

Lethargy & pallor
Oedema & weight gain
Hypertension

Pruritis

Answer 397

CKD

Question 398

Night sweats
Lymphadenopathy
Splenomegaly, hepatomegaly
Fatigue

Pruritis

Answer 398

Lymhpoma

Question 399

Signs of iron defieicny anaemia in a man over 60 what should be done? [1]

Answer 399

Colonscopy to r/o colorectal Ca

Question 400

What is ringworm caused by?

Answer 400

Fungal infection

Question 401

3 types of ringworm? [3]

Answer 401

• tinea capitis - scalp
• tinea corporis - trunk, legs or arms
• tinea pedis - feet