16/10/2024

Question 1

Antibiotic choice for bacterial meningitis?

Answer 1

IV cefotaxime
If <3 months or >50 then amoxillicin should be given too

Question 2

Antibiotic choice for managing bacterial meningitis contacts?

Answer 2

Oral ciprofloxacin
(Or rifampicin)

Question 3

Interpretation of AAA screening?

Answer 3

<3.0 Cm is normal
3-4.4 = rescan every 12 months
4.5-5.4 = rescan every 3 months
>=5.5cm OR expanding >1cm a year = 2 week referral to vascular surgery for EVAR or open repair

Question 4

pathophysiology of acoustic neuroma

Answer 4

Benign, slow growing tumours that form along the branches of the vestibulocichlear nerve

Question 5

Features of acoustic neuroma and relate them to the cranial nerve?

Answer 5

CN 5 - absent corneal reflex
CN 7 - facial palsy (palsy of forehead too as LMN lesion)
CN 8 - vertigo, U/L sensorineural hearing loss, U/L tinnitus

Question 6

Investigations for acoustic neuroma?

Answer 6

Audiometry to show sensorineural hearing loss
MRI with gadolinium contrast

Question 7

Features of neurofibromatoiss type 2?

Answer 7

B/L acoustic neuromas
Multiple intracranial schwannomas, meningiomas and ependymomas

Question 8

Management of eclampsia?

Answer 8

Once a decision to deliver baby has been made give IV bolus of 4g magnesium sulphate over 5-10 minutes followed by an infusion of 1g/hour
Continue Tx for 24 hours after last seizure or after delivery

Remember if considering delivery <34/40 give corticosteroids

Question 9

Causes of gingival hyperplasia

Answer 9

Drugs - phenytoin, Ciclosporin, CCB
AML

Question 10

When should you consider medical/surgical management of miscarriage rather than expectatnt management?

Answer 10

1. If increased risk of haemorrhage e.g. late first trimester or coagulopathy
2. Previous adverse/traumatic experience associated with pregnancy
3. Infection

Question 11

Management of missed miscarriage?

Answer 11

Oral mifepristone -> 48 hours give misoprostol (oral, vaginal, sublingual)

If bleeding has not started within 48 hours of misoprostol advise pt to contact HCP
Offer antiemetics and analgesia

Question 12

Tx of incomplete miscarriage?

Answer 12

Single dose of misoprostol (vaginal, oral, sublingual)

Question 13

When should a pregnancy test be performed after medical miscarriage?

Answer 13

3 weeks

Question 14

Tx of thyrotoxicosis?

Answer 14

Propanolol to control Sx
Carbimazole - high doses for 6 weeks until pt is euthyroid and then reduced
Radioiodine Tx

Question 15

Why is Carbimazole used first line for thyrotoxicosis ahead of propothyluracil?

Answer 15

Due to its risk of liver damage

Question 16

MOA of Carbimazole?

Answer 16

blocks thyroid peroxidase from coupling and iodinating the tyrosine residues on thyroglobulin → reducing thyroid hormone production

Question 17

Rules for breastfeeding with HIV?

Answer 17

Never advised

Question 18

Which antibodies should you test for in suspected T1DM?

Answer 18

Anti-glutamic acid decarboxylase (anti-GAD)
Insulin autoantibodies (IAA)
Islet cell antibodies (ICA)

Note they are present in up to 70% of people at time of diagnosis but titre declines with time!

Question 19

When should you test c-peptide and autoantibodies in suspected diabetes?

Answer 19

Not routinely to confirm T1DM but if some atypical features e.g. high GMI, >=50
Basically when you are unsure between T1 and T2

Question 20

Why can mitral stenosis cause haemoptysis?

Answer 20

Mitral valve will become thicker, obstructing blood flow across the mitral valve from the left atrium to the left ventricle, leading to an increase in pressure within the left atrium, pulmonary vasculature and right side of the heart.
This might cause increased pressure in the pulmonary circulation causing rupture of pulmonary vessels, leading to haemoptysis.

Question 21

Outline acute asthma Tx?

Answer 21

Stepwise progression:

Oxygen 15L NRB
Inhaled salbutamol
Nebulised Salbutamol (if severe or life threatening)
40-50mg prednisolone orally (at least 5 days)
Add nebulised ipratropium bromide 0.5mg 4-6 hourly
Consider IV magnesium sulphate 1.2-2g over 20 minutes

Consult with senior medical start -> consider IV aminophylline
Treat in ITU/HDU - consider intubation & ventilation or ECMO

Question 22

When should you give further Tx after metformin monotherapy in T2DM?

Answer 22

If already on 1 drug and HbA1c has risen to 58mmol/mol\

(Note SGLT2 inhibitors may be added on at any point if any risk of or established CVD/heart failure)

Question 23

HbA1c target if T2DM treated with metformin?

Answer 23

48

Question 24

HbA1c target if T2DM treated with any diabetic drug which can cause hypoglycaemia?

Answer 24

53

Question 25

HbA1c target if T2DM is already being treated with 1 drug but HbA1c previously rose to 58?

Answer 25

53

Question 26

What are typical carboxyhaemoglobin levels in smokers and non-smokers?

Answer 26

Non-smoker = <3% Smoker = <10%

Question 27

What should you think if a pt has cabroxyhaemoglobin levels of >10%?

Answer 27

CO poisoning

Question 28

Features of carbon monoxide toxicity?

Answer 28

headache: 90% of cases nausea and vomiting: 50% vertigo: 50% confusion: 30% subjective weakness: 20% severe toxicity: 'pink' skin and mucosae, hyperpyrexia, arrhythmias, extrapyramidal features, coma, death

Question 29

How long do cephalohaematomas take to resolve?

Answer 29

Up to 3 months

Question 30

What type of murmur does tricuspid regurgitation produce?

Answer 30

Pan-systolic

Question 31

Which antibiotics are used as prophylaxis in oesophageal variceal haemorrhage?

Answer 31

Quinolones

Question 32

What should you do if you have an uncontrolled varicella haemorrhage?

Answer 32

Insert a Sengstaken-Blakemore tube If this fails then consider TIPSS

Question 33

Prophylaxis of variceal haemorrhage?

Answer 33

Propanolol Endoscopic variceal band ligation at 2-weekly intervals until all varices have been eradicated. Use PPI cover If not successful in preventing further episodes consider TIPSS

Question 34

What is Pseudocholinesterase deficiency?

Answer 34

Autosomal dominant condition Causes a defective form of the enzyme which is unable to metabolize succinylcholine leading to prolonged neuromuscular paralysis

Question 35

Peripheral blood smear findings in AML?

Answer 35

Myeloblast cells Auer rods

Question 36

Peripheral blood smear findings in ALL?

Answer 36

Lymphoblast cells

Question 37

Peripheral blood smear findings in CML?

Answer 37

Immature granulocytes Eosinophilia and basophilia Usually few blast cells

Question 38

Peripheral blood smear findings in CLL?

Answer 38

Small lymphocytes with scant cytoplasm Smudge cells

Question 39

Management of a breast abscess as a complication of mastitis?

Answer 39

Incision and drainage

Question 40

What are precipitating factors for hyperosmolar hyperglycaemic states?

Answer 40

Inter current illnes Dementia Sedative drugs

Question 41

BG level in HHS?

Answer 41

>30mmol/L

Question 42

Management of HHS?

Answer 42

IV 0.9% sodium chloride 0.5-1L (Monitor K+ levels!!) Insulin should only be given if BG stops falling whilst giving IV fluids VTE prophylaxis Catheter to monitor urine output Tx underlying cause

Question 43

Complications of HHS?

Answer 43

Usually hyperviscocity -> MI or stroke

Question 44

What are metabolic consequences of refeeding syndrome?

Answer 44

Low phosphate - hallmark feature! Low K+ Low magnesium Abnormal fluid balance

Question 45

Pathophysiology of low phosphate in refeeding syndrome?

Answer 45

Reintroduction of carbs causes a shift from fat to carbohydrate metabolism which activates insulin secretion = increases cellular uptake of glucose This also stimulates intracellular movement of phosphate as its used in synthesis of ATP and 2,3-diphosphoglycerate levels in erythrocytes = reduces serum phosphate levels So chronic malnutrition = depleted phosphate stores and when refeeding starts the sudden demands for phosphate in anabolic processes exceeds supplies = hypophosphataemia

Question 46

Clinical consequences of hypophosphataemia seen in refeeding syndrome?

Answer 46

Cardiac Dysfunction: Hypophosphatemia can impair myocardial contractility, leading to heart failure. It may also cause arrhythmias due to its role in maintaining normal cellular electrophysiology. Respiratory Failure: Phosphate is essential for ATP production, necessary for respiratory muscle function. Severe hypophosphatemia can lead to muscle weakness, including the diaphragm and intercostal muscles, potentially resulting in acute respiratory failure. Neurological Complications: These can range from confusion and seizures to coma, attributable to disturbed ATP metabolism in the central nervous system. Haematological Effects: Reduced 2,3-diphosphoglycerate levels in erythrocytes affect oxygen release from haemoglobin, leading to tissue hypoxia. Hypophosphatemia can also result in hemolysis. Rhabdomyolysis: Phosphate depletion impairs ATP production in muscles, which can lead to muscle breakdown and rhabdomyolysis.

Question 47

How to prevent refeeding syndrome?

Answer 47

Try to correct electrolytes before starting nutrition support if a patient hasn't eaten for > 5 days or is at risk, aim to re-feed at no more than 50% of requirements for the first 2 days.

Question 48

Investigation for phaeochromocytoma?

Answer 48

24 hour urinary collection of metanphrines Tumour localisation with MRI or CT abdo

Question 49

Management of phaeochromocytoma?

Answer 49

Surgery is definitive But pt must be stabilised with medical Tx first. Give alpha blockers before beta blockers

Question 50

Sx of trichomonas vaginalis?

Answer 50

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

Question 51

Investigation of trichomonas vaginalis?

Answer 51

microscopy of a wet mount shows motile trophozoites

Question 52

Tx of trichomonas?

Answer 52

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

Question 53

Differences between BV and trochomonas?

Answer 53

BV has thin white discharge. Trichomonas has frothy, yellow-green Trichomonas causes vulvovaginitis and strawberr crevices BV on microscopy: clue cells Trochomonas wet mount: motile trophozoites Both cause pH >4.5 and you treat both with metronidazole

Question 54

Tx of hypercalcaemia?

Answer 54

Rehydration with normal saline - usually 3-4L a day Following rehydration - bisphosphanates

Question 55

Most common type of breast cancer?

Answer 55

Invasive ductal carcinoma

Question 56

What scoring tool is used to estimate prognosis in breast cancer?

Answer 56

Nottingham prognostic index

Question 57

Breast cancer referral guidelines

Answer 57

2WW: >=30 and any new breast lump >=50 and any symptoms in 1 nipple e.g. discharge or retraction Consider If any skin Sx suggestive of breast cancer If >=30 and unexplained lump in axilla Non-urgent referral for unexplained breast lump in women <30

Question 58

Pathophysiology of haemochromatoiss?

Answer 58

Autosomal recessive - inheritance of both mutations on copies of HFE gene on chromosome 6 Causes a disorder or iron absorption and metabolism = iron accumulation

Question 59

Symptoms of haemochromatoiss?

Answer 59

Early = fatigue, ED and arthralgia often in hands Later = bronzing of skin, hypogonadism e.g. amenorrhoea, diabetes, chronic liver disease, cardiac failure and arthritis

Question 60

Investigations for haemochromatoiss?

Answer 60

Liver studies - transferrin saturation >55% in men and >50% in women, raised ferritin, raised iron, low TIBC LFTs for liver accumulation (can consider a liver biopsy for cirrhosis) MRI to quantify liver and cardiac iron Test family members using genetic testing for HFE mutation

Question 61

Investigations for haemochromatoiss?

Answer 61

Liver studies - transferrin saturation >55% in men and >50% in women, raised ferritin, raised iron, low TIBC LFTs for liver accumulation (can consider a liver biopsy for cirrhosis) MRI to quantify liver and cardiac iron Test family members using genetic testing for HFE mutation

Question 62

Tx of haemochromatoiss?

Answer 62

Venesections - aim to keep transferrin saturation <50% and ferritin concentration <50 Second line - desferioxamine (iron chelation)

Question 63

Complications of haemochromatoiss?

Answer 63

Diabetes Liver disease or cirrhosis or hepatocellular carcinoma Sexual and endocrine dysfunction Seconday cardiomyopathy Hypothyroidism - iron can cause oxidative damage to the thyroid Pseudogout due to chondrocalcinosis

Question 64

Interpretations ABPI?

Answer 64

>1.4 suggests calcification e.g, in diabetes 1-1.4 normal 0.6-0.9 - claudication Anything <0.5 suggests chronic limb-threatening ischaemia (used to be called critical limb ischaemia) 0.3-0.6 indicates rest pain <0.3 is impending

Question 65

Statin and antiplatelet for peripheral arterial disease?

Answer 65

Atorvastatin 80mg ON Clopidogrel 75mg OD

Question 66

What drug can sometimes be used for PAD when pts are not responding to exercise therapy and lifestyle modifications?

Answer 66

naftidrofuryl oxalate: vasodilator, sometimes used for patients with a poor quality of life

Question 67

What classification is used to grade chronic limb ischaemia?

Answer 67

Rutherford classification

Question 68

First line investigations for peripheral arterial disease?

Answer 68

Duplex USS CT angiogram can guide revascularisation treatment

Question 69

Management of intermittent claudication?

Answer 69

offer a supervised exercise programme (~2 hours a week for 3 months - should be exercising to the point of maximal pain) if not available consider suggesting unsupervised exercise. Offer referral for consideration of angioplasty or bypass surgery if this has not lef to Sx improvement alongside modifying RF Consider offering naftidrofuryl oxalate only when exercise hasn’t helped and pt does not want referral. Review at 3-6 months. This is a vasodilator! Offer information of cause, risk of limb loss and CVD risk, key modifiable risk factors, how to manage pain. Offer advice on foot care e.g. daily checking of feet, good shoes, not walking bare feet etc.

Question 70

Management of acute limb ischaemia?

Answer 70

emergency assessment by vascular specialist -> endovascular therapies or surgical interventions e.g. bypass surgery, amputation, percutaneous mechanical thrombus extraction etc Pts are usually given IV opioids and IV UFH to prevent thrombus propagation. All these pts need follow up with managing CVD risk… smoking cessation, diet, weight management, exercise, statin therapy with 80mg atorvastatin, prevention/Tx of diabetes, Tx of hypertension and clopidogrel 75mg daily.

Question 71

Management of chronic limb-threatening ischaemia?

Answer 71

refer urgently to a vascular MDT. Anage pain with paracetamol or opioids (+/- laxative) All these pts need follow up with managing CVD risk… smoking cessation, diet, weight management, exercise, statin therapy with 80mg atorvastatin, prevention/Tx of diabetes, Tx of hypertension and clopidogrel 75mg daily. Counsel them on risk of limb loss or cardiovascular events associated with PAD

Question 72

Chronic limb-threatening ischaemia vs acute limb ischaemia?

Answer 72

Chronic limb-threatening ischaemia — characterised by chronic, inadequate tissue perfusion in combination with ischaemic rest pain, with or without tissue loss (for example ulcers, gangrene) or infection. It represents the end stage of peripheral arterial disease cute limb ischaemia is a sudden decrease in limb perfusion that threatens limb viability — decreased perfusion and symptoms and signs develop over less than 2 weeks. It is a medical emergency.

Question 73

Most common cause of death in diffuse cutaneous systemic sclerosis?

Answer 73

the most common cause of death is now respiratory involvement, which is seen in around 80%: interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH)