Year 4 PassMed Incorrect Qs 2

Question 1

Management of placental abrubtion

Fetus < 36 weeks
- fetal distress:
- no fetal distress:

Fetus > 36 weeks
- fetal distress:
- no fetal distress:

Fetus dead

Answer 1

Fetus < 36 weeks
- fetal distress: immediate caesarean
- no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation

Fetus alive and > 36 weeks
- fetal distress: immediate caesarean
- no fetal distress: deliver vaginally

Fetus dead
- induce vaginal delivery

Question 2

Perineal tears- degrees and managment

Answer 2

First degree
- superficial damage with no muscle involvement
do not require any repair

Second degree
- injury to anything beyond the vaginal mucosa including the perineal muscle, submucosa or subcutaneous tissue- but not involving the anal sphincter
- require suturing on the ward by a suitably experienced midwife or clinician

Third degree
- injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS)
3a: less than 50% of EAS thickness torn
3b: more than 50% of EAS thickness torn
3c: IAS torn
- require repair in theatre by a suitably trained clinician

Fourth degree
injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa
require repair in theatre by a suitably trained clinician

Question 3

What are the boundaries of the ‘safe triangle’ for chest drain insertion?

Which intercostal space and what line?

Answer 3

mid axillary line of the 5th intercostal space.

It is bordered by:
- Anterior edge latissimus dorsi
- lateral border of pectoralis major
- a line superior to the horizontal level of the nipple, and the apex below the axilla.

Question 4

Minimum amount of time for PTSD diagnosis?

Answer 4

4 Weeks

Question 5

Paediatric Constipation steps in management

Answer 5

1) Osmotic = Movicol Paediatric plain aka polyethylene glycol 3350 + electrolytes
2) Add stimulant = Senna
3) Substitute stim for lactulose (osmotic)

Question 6

When should surgery for Hypospadias typically be performed at?

Answer 6

at around 12 months of age

Question 7

Characteristics of an innocent
ejection murmur include (8)

Answer 7

• soft-blowing murmur in the pulmonary area or short buzzing murmur in the aortic area
• may vary with posture
• localised with no radiation
• no diastolic component
• no thrill
• no added sounds (e.g. clicks)
• asymptomatic child
• no other abnormality

Question 8

What is Conversion disorder

Answer 8

Typically involves loss of motor or sensory function. May be caused by stress.

Question information for context:
Functional paralysis, as she has no capability for voluntary movement, but involuntary movements are possible due to present reflexes and positive Hoover’s sign. Hoover’s sign is a compensatory movement of the other leg, due to synergistic contraction - when the unaffected leg is flexed against resistance, the affected leg involuntarily extends.

Question 9

Alcohol withdrawal Times
- symptoms:
- seizures:
- delirium tremens:

Answer 9

symptoms: 6-12 hours
seizures: 36 hours
delirium tremens: 72 hours

Question 10

Resp- Atypical Pneumonia Pathogen which causes red and jelly-like sputum. Associated with aspiration pneumonia.

Answer 10

Klebsiella pneumonia

Question 11

Management of chronic venous insufficiency

Conservative (4)
Reasons for secondary care referral (4)
Possible treatments (3)

Answer 11

Management
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 secondary care referral:
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 12

How many days penecillin V for Scarlet fever? When can they return to school?

Answer 12

10 days
After 24 hrs of starting antibiotics

Question 13

Diagnostic investigation for obstructive sleep apnoea?

Answer 13

Polysomnography

patient is recorded using wires measuring various parameters including rapid eye movements, oxygen saturations and the electrical activity of the brain.

Question 14

When can bariatric surgery be a first-line option for adults?

Answer 14

Consider bariatric surgery as a first-line option for adults with a BMI >50

If comorbidities affected by weight can be considered BMI > 35

Question 15

Clozapine SE

Answer 15

C-
Lo- Lower seizure threhold
Z- zzz sedating?
A- Agranulocytosis
P-
I- increase saliver
N-
E-

Question 16

Rare complication of chicken pox in children (4)

Answer 16

• pneumonia
• encephalitis (cerebellar involvement may be seen)
• disseminated haemorrhagic chickenpox
• arthritis, nephritis and pancreatitis may very rarely be seen

Question 17

Pschy- what is clang association?

Answer 17

Clang associations - ideas related only by rhyme or being similar sounding

Seen in psychosis

Question 18

Psych- Management for
mild OCD
mod OCD
severe OCD

Answer 18

mild
- low-intensity psychological treatments: cognitive behavioural therapy (CBT) including exposure and response prevention (ERP)
If this is insufficient or can’t engage in psychological therapy, then offer a choice of either a course of an SSRI or more intensive CBT (including ERP)

moderate functional impairment
- offer a choice of either a course of an SSRI (any SSRI for OCD but fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP)
consider clomipramine (as an alternative first-line drug treatment to an SSRI) if the person prefers clomipramine or has had a previous good response to it, or if an SSRI is contraindicated

If severe functional impairment
refer to the secondary care mental health team for assessment
whilst awaiting assessment - offer combined treatment with an SSRI and CBT (including ERP) or consider clomipramine as an alternative as above

Question 19

What drug classes cause gingival hyperplasia?

3 drugs and 1 condition

Answer 19

• phenytoin (anticonvulsant last line status epilepticus)
• ciclosporin ( class of immunosupressant used in preventing organ rejection in transplant)
• calcium channel blockers

Also AML Acute myeloid Leukamia causes it

Question 20

What is Ramsey Hunt syndrome? + Pathogen?

Presentation (4)

Management (2)

Answer 20

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 (facial nerve)

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

Management
oral aciclovir and corticosteroids are usually given (can sometimes give monotherapy aciclovir)

Question 21

Rubella characteristic features
Rash- looks like and location?
STEM feature

Answer 21

Rash: pink maculopapular, initially on face before spreading to whole body, usually fades by the 3-5 day

Lymphadenopathy: suboccipital and postauricular

Question 22

Pathological fractures STEM

• Giant cell tumours on x-ray
• Ewing’s sarcoma

Answer 22

Giant cell tumours- soap bubble’ appearance

Ewing’s sarcoma- onion type periosteal reaction and most common in males between 10-20 years.

Question 23

What difference urinary and bood results would you see in osteomalcia vs osteoperosis?

Answer 23

osteomalacia- Hypocalcemia and low urinary calcium are biochemical features

osteoperosis- has normal calcium

Question 24

WHat is considered a prmiary haemorrhage after tenosillectomy and what is the managment?

Answer 24

occurs within 24 hours post-tonsillectomy (most often within the first 6-8 hours)

Management
tonsils are highly vascularised, and if the surrounding tissues don’t compress upon themselves, bleeding can result.
This should be managed by: - immediate return to theatre while
- ensuring the airway remains patent in the meantime
- ENT and anaesthetics should be called immediately.

Question 25

Difference between Acute otitis media with effusion and Otitis media with effusion

Answer 25

AOM with eff- Current infection with otalgia, fever, and features suggesting a middle ear effusion (such as a bulging tympanic membrane which causes the loss of the light reflex on otoscopy)

OM with eff- Also known as glue ear, this describes an effusion in the middle ear without features suggesting an acute infection (e.g. NO fever OR erythema of the ear canal and tympanic membrane).

Question 26

What ECG changes can you see with a paraneoplastic syndrome of squamous cell lung carcinoma and why?

Answer 26

Squamous cell lung cancer is associated with hypercalcaemia of malignancy due to parathyroid hormone-related peptide (PTHrP) secretion.

A common ECG finding in hypercalcaemia is a shortened QT interval. This patient’s symptoms of polyuria and dry mucous membranes also can be explained by hypercalcemia.

Question 27

Inheritance pattern of Haemophilia A?

Answer 27

X-linked recessive

Question 28

On spirometry, what type of picture does Alpha-1 antitrypsin show?

Answer 28

Alpha-1 antitrypsin deficiency shows an OBSTRUCTIVE picture on spirometry

Question 29

Prostate cancer- Patient is prescrbied Gosrelin (Zoladex) a GnRH analogue, what should be prescribed for the first 3 weeks and why?

MOA of gosrelin
When should it be prescribed?

Answer 29

Anti-androgen treatment such as cyproterone acetate should be co-prescribed when starting gonadorelin analogues due to the risk of tumour flare.

This phenomenon is secondary to initial stimulation of luteinising hormone release by the pituitary gland resulting in increased testosterone levels.

The BNF advises starting cyproterone acetate 3 days before the gonadorelin analogue.

MOA- GnRH agonist, inc. LH inc. Tesosterone. However at high doses for long periods of time the GnRH Rec become desensitized and therefore dec. LH therefore dec. Testosterone

Question 30

Management of Primary and Secondary pneumothorax

Answer 30

Primary pneumothorax

Recommendations include:
if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered.

otherwise, aspiration should be attempted
if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted

Tip: Aspiration first, Chest drain second because ‘A’ is before ‘C’ in the alphabet

Secondary pneumothorax

Recommendations include:
if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.

otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours
if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours

Question 31

Management of recurrent or persistent PTX?

Answer 31

If a patient has a persistent air leak or insufficient lung reexpansion despite chest drain insertion, or the patient has recurrent pneumothoraces, then video-assisted thoracoscopic surgery (VATS) should be considered to allow for mechanical/chemical pleurodesis +/- bullectomy.