25/04

Question 1

tb meds

Answer 1

I eat perfect rice

Isoniazid.
Rifampin
Ethambutol
Pyrazinamide.

Question 2

tertiary hyperparathyroidism signs

Answer 2

Raised alkaline phosphatase levels
This is due to increased bone turnover (osteoblastic activity in particular) as a result of raised parathyroid levels. It is likely this patient has progressed from secondary to tertiary hyperparathyroidism, as persistent secondary hyperparathyroidism leads to autonomous production of parathyroid hormone, regardless of negative feedback from calcium levels.

Question 3

prolonged PR interval

Answer 3

1st-degree heart block is caused by a delay in conduction from the SA node into the ventricles. As the AV node is supplied by the right coronary artery in 85% of individuals, disease in this artery may lead to first-degree heart block.

Question 4

Acute Kidney Injury(AKI) and treatment

Answer 4

increase in serum creatinine of 26 μmol/L within 48 hours or an increase in serum creatinine ≥1.5 times above baseline value within 1 week or urine output of <0.5 ml/kg/hr for > 6 consecutive hours.

dialysis

Question 5

signs of asthma

Answer 5

Tachypnoea- fast breathing
Hyperinflated chest
Hyper-resonance on chest percussion

Question 6

Investigations in chronic asthma

Answer 6

Spirometry: FEV1/FVC <0.7 (obstructive spirometry)

Bronchodilator reversibility tests: Improvement of FEV1 >12% after bronchodilator therapy is diagnostic

Question 7

Investigations in acute asthma

Answer 7

ABG: type 2 respiratory failure (low PaO2 and high PaCO2) is a sign of a life-threatening attack.
Routine blood tests (including FBC, CRP): to look for precipitating causes of an asthma attack, such as an infection.
Chest x-ray: to exclude differentials and possibly identify a precipitating infection.

Question 8

asthma drugs

Answer 8

SABA

+ICS- beclometasone, Prednisolone, hydrocortisone
+LABA- salmeterol
+ Trial oral leukotriene receptor antagonist,/monelukast high-dose steroid, oral B2-agonist

Question 9

tumours of the caecum and ascending colon

Answer 9

right hemicolectomy

Question 10

tumours of the distal transverse colon and descending colon

Answer 10

left hemicolectomy

Question 11

tumours of the sigmoid colon.

Answer 11

sigmoid colectomy

Question 12

tumours >8 cm from the anal canal or involving the proximal 2/3 of the rectum

Answer 12

Anterior resection

Question 13

tumours <8 cm from the anal canal or involving the distal 1/3 of the rectum.

Answer 13

Abdomino-perineal (AP) resection

Question 14

Hepatic Adenoma surgery

Answer 14

<5cm or reducing in size - annual MRI

>5cm or increase in size - for surgical excision

Question 15

HCC surgery

Answer 15

<2cm

Question 16

peripheral lesions adenocarcinoma of the lung diagnosis

Answer 16

CT chest abdomen pelvis

then

biopsy would be the next investigation to carry out after a CT CAP to provide a definitive diagnosis. As this is a peripheral lesion it will most likely be obtained via transthoracic needle aspiration.

Question 17

falls and elderly

Answer 17

Use the Fracture Risk Assessment Tool (FRAX)

This patient is elderly and clearly has a high falls risk, making her liable to have an osteoporotic fracture in the future. The FRAX score offers a formal way to quantify this risk, and if it is above a certain threshold, bisphosphonates should be given. If the risk is low, bisphosphonates do not need to be given, but if the risk is between the two extremes, a DEXA scan should be carried out to guide the need for bisphosphonates.

Question 18

ramipril side effects

Answer 18

Ramipril causes hyperkalaemia by blocking the aldosterone pathway thereby leading to a retention of potassium.

Question 19

2 week worsening SoB, stiffness and pain in wrists and fingers, particularly in the morning

dullness to percussion at the right lung base with associated reduced breath sounds
tenderness and boggy swelling at the metacarpo-phalangeal joints bilaterally.

Answer 19

Pleural fluid glucose <3.3 mmol/L

This is the correct answer. The patient presents with a pleural effusion, most likely an extra-articular manifestation of underlying rheumatoid arthritis. Almost 100% of effusions due to rheumatoid arthritis have low glucose levels.

Question 20

absolute contraindication for diagnostic laparoscopy?

Answer 20

On warfarin with an INR of 2.8

An abdominal aortic aneurysm risks vascular rupture if not directly visualized. However, it is a relative contraindication rather than absolute.

Question 21

MI and can’t get PCI till 2h and intracranial haemorrhage history
treatment

Answer 21

However, they have a previous intracranial haemorrhage which is an absolute contra-indication for fibrinolysis so PCI is the best option even if outside of the typical window.

Question 22

diarrhoea after Bangladesh . He describes it as rice water looking and has also been vomiting.

and treatment

Answer 22

lassical description of a cholera infection. It is a Gram-negative aerobic bacterium. It is very rare or extinct in the western world, however in developing nations still exists. It is found in faecally contaminated water. It causes profuse watery diarrhoea and is treated with oral rehydration salts and fluids. Antibiotics can be given if the infection is severe, which lessens the severity and shortens the disease lifespan.- Doxycycline or co-trimoxazole)

Question 23

Salmonella enterocolitis symptoms

Answer 23

t presents with diarrhoea, fever and cramps (usually within 12-36 hours of exposure). It can cause sepsis or meningitis, as well as septic arthritis.

Question 24

fatigue, easy bruising, and tooth loss

multiple ecchmoses at non-traumatic sites, perifollicular haemorrhages, coiled hairs, and gingival swelling.

Answer 24

vitamin C deficiency. Refugee populations are at particular risk. There is a risk of intracerebral and endocardial haemorrhage,

Question 25

5kg weight loss over the last 5 weeks and malaise He also reports dark-coloured urine. He has a past medical history of familial adenomatous polyposis, for which he had a proctocolectomy 8 years ago. On physical examination he is cachectic and there is scleral icterus.

Answer 25

Duodenal cancer This is the correct answer. Patients with familial adenomatous polyposis (FAP) not only have a high risk of colorectal cancer, but are also at increased risk of duodenal cancer. Duodenal cancer is the 2nd highest cause of cancer death in FAP. Duodenal cancer can present with weight loss, nausea/vomiting, abdominal pain, and obstructive jaundice.

Question 26

Mitral regurgitation

Answer 26

produces a pansystolic murmur that is heard best over the apex.

Question 27

aortic stenosis

Answer 27

presents with syncope, shortness of breath and angina. It also produces an ejection systolic murmur heard best over the upper right sternal edge.

Question 28

how to calc units

Answer 28

Units = strength % x volume (ml) ÷ 1000

Question 29

Plummer Vinson Syndrome

Answer 29

triad of dysphagia, iron deficiency anaemia and glossitis/ inflamed tongue

Question 30

Peutz-Jeghers syndrome

Answer 30

autosomal dominant hamartomatous polyps in the GIT pigmented lesions on the lips, face, palms and soles. GI bleeding secondary to these polyps, and have an increased risk of developing gastric cancer. Management tends to be conservative, unless complications arise.

Question 31

Hypothermia ecg sign

Answer 31

J waves

Question 32

Hyperkalaemia ecg sign

Answer 32

tall tented T waves and flattened P waves.

Question 33

Ventricular fibrillation ecg

Answer 33

chaotic with no discernible P waves or QRS complexes.

Question 34

one week history of fevers, myalgia and cough productive of white sputum. recently abroad in Crete and returned home a week before his symptoms began. A chest X-ray shows diffuse bilateral infiltrates.

Answer 34

Legionella pneumophila inhalation or aspiration of unsanitary water such as in showers supplied by poorly maintained water tanks. It causes atypical pneumonia, sometimes with bilateral signs of infection on a chest X-ray. It can also cause deranged liver function tests and electrolytes

Question 35

Congestive cardiac failure

Answer 35

no chest pain

Question 36

ascities causes

Answer 36

liver disease, however in most cases it results from a combination of portal hypertension and hypoalbuminaemia. It is not related to hyperbilirubinaemia.

Question 37

raised serum bilirubin, fatigue, weakness and loss of appetite for the past year as well as abdominal swelling which he says started around a month ago. He is known to abuse alcohol and has been drinking around 70 units a week for the last 10 years. palmar erythema, Dupuytren's contracture, multiple spider naevi, and a distended abdomen with shifting dullness on percussion. He also has leuconychia and excoriations on his arms and stomach.

Answer 37

Raised serum bilirubin as seen in chronic liver disease is associated with pruritus and this often results in excoriations where patients scratch themselves with their nails. Itching frequently precedes jaundice in these patients. Although there is some debate in the literature as to the precise cause of pruritus associated with raised serum bilirubin, colestyramine (a bile acid sequestrant) is effective at reducing it.

Question 38

Barrett's oesophagus

Answer 38

oesophagal epithelium from squamous to columnar owing to long term acid reflux. Typical symptoms of oesophageal reflux would be heartburn-like pain worsened on lying flat or eating acidic foods. Patients can, however, be asymptomatic

Question 39

Functional dyspepsia

Answer 39

This is the cause of 60% of dyspepsia cases. It may be caused by gut hypersensitivity, non-erosive reflux disease, motility problems, post infectious bowel upset or psychological factors. abdominal discomfort, nausea and belching

Question 40

Peptic ulcer disease

Answer 40

abnormal upper GI endoscopy Epigastric tenderness would also be likely on examination duodenal and gastric ulcers; duodenal ulcers most common. The stomach lining protects itself with mucin and bicarbonate secretion and mucosal blood flow; however, damage can occur if these barriers are not sufficient, or if external factors such as Helicobacter pylori (H. Pylori) are present. mostly due to H. pylori can be due to NSAIDS - ibuprofen, aspirin

Question 41

aortic stenosis treatment and symptoms

Answer 41

worsening dyspnoea and an ejection systolic murmur radiating to carotids. transcatheter aortic valve implantation (TAVI) or open valve replacement, depending on the patient's fitness. Medical therapy only as a treatment option should be reserved for patients unsuitable for the above.

Question 42

63 year old man is admitted to hospital having been found collapsed. His past medical history includes type 2 diabetes and hypertension partially compensated metabolic acidosis and a high lactate.

Answer 42

lactic acidosis. Sepsis is a well known cause of this and comes about via local tissue hypoxia (secondary to increased metabolic requirement and poor perfusion because of vasodilation).

Question 43

which hernias are surgically treated

Answer 43

symptomatic ones

Question 44

CSF predominantly polymorphs, with a cell count of 90-1000+; CSF glucose is less than half of plasma glucose; over 1.5g/L of protein is present

Answer 44

bacterial meningitis

Question 45

severe UC flare up

Answer 45

>6 bloody stools per day, a temperature > 37.8, Hb < 108, CRP > 30

Question 46

Gastro-oesophageal reflux disease (GORD)

Answer 46

retrosternal pain that is associated with meals, belching and regurgitation. Chronic untreated GORD may develop into Barrett's oesophagus, with potential to transform into oesophageal adenocarcinoma.

Question 47

Cachexia

Answer 47

a “wasting” disorder that causes extreme weight loss and muscle wasting, and can include loss of body fat

Question 48

Ecchymosis

Answer 48

bruise

Question 49

diffuse consolidation

Answer 49

spread out

Question 50

Pruritus

Answer 50

itchy skin

Question 51

Leukonychia

Answer 51

white discoloration appearing on nails | mostly at base of nails

Question 52

excoriations

Answer 52

skin picking | red parts on skin

Question 53

Aortic regurgitation

Answer 53

left parasternal edge murmur

Question 54

sudden onset crushing chest pain and diaphoresis/ excess sweating The pain has persisted for around 25 minutes and an ECG reveals ST depression in the inferior leads. blood pressure is noted to be 210/90. medication for lowering BP

Answer 54

Hypertensive emergencies should be treated with IV medication. Oral amlodipine can be used in the management of hypertensive urgencies Amlodipine takes longer to work than nifedipine due to a larger volume of distribution. Therefore, both can be given initially and nifedipine discontinued after 3 days by which time amlodipine should start to work.

Question 55

step 1 hypertension management

Answer 55

ACE-inhibitor (e.g. Ramipril) if <=55 years old CCB (e.g. Nefedipine) if >55 y OR African or Caribbean ethnicity If unable to tolerate ACE-inhibitor then switch to Angiotensin Receptor Blocker (e.g. Candesartan)

Question 56

Step 2 of hypertension management

Answer 56

(If maximal dose of Step 1 has failed or not tolerated) Combine CCB and ACE-I/ARB

Question 57

Step 3 of hypertension management

Answer 57

(If maximal doses of Step 2 has failed or not tolerated): Add thiazide-like diuretic (e.g. Indapamide)

Question 58

Step 4 of hypertention management

Answer 58

if blood potassium <4.5mmol/L then add Spironolactone If >4.5mmol/L increase thiazide-like diuretic dose/ Alpha blocker (e.g. Doxacosin) Beta blocker (e.g. Atenolol) Referral to cardiology for further advice

Question 59

sudden onset shortness of breath and pleuritic chest pain. She is currently receiving chemotherapy for metastatic ovarian cancer and is bedbound. Vital signs are: temperature 36.5'C, heart rate 90 beats per minute, respiratory rate 24/minute, oxygen saturation 92% on room air, blood pressure 100/75 mmHg. Chest x-ray and ECG are normal what sign will be expected

Answer 59

PE!! | In a sub-massive PE there may be signs of right heart strain (such as a raised JVP, parasternal heave, and loud P2).

Question 60

STEMI diagnosis criteria

Answer 60

men under 40-years-old (≥ 2.5 mm in leads V2-3) and for women (≥ 2.5 mm in leads V2-3). apart from ST-segment elevation, a new-onset LBBB or hyperacute T-waves are also indicative of a STEMI.

Question 61

most important direct consequence of refeeding syndrome?

Answer 61

Hypophosphataemia is caused by an increase in insulin production when carbohydrates are re-introduced to the body. This then leads to many of the complications of tumour lysis syndrome such as rhabdomyolysis, fluids shifts, other electrolyte imbalances and arrhythmias.

Question 62

tension pneumothorax

Answer 62

2nd intercostal space, mid clavicular line!!! not mid axillary !! needle decompression with a 14-16 gauge cannula into the right second intercostal space, mid-clavicular line THEN chest drain

Question 63

Type 1 Diabetes is found collapsed on the floor at a bus stop treatment

Answer 63

100ml of 20% glucose IV

Question 64

past medical history of Wolff-Parkinson-White syndrome and waiting for definitive treatment, develops sudden-onset palpitations. She also reported chest pain and momentarily lost consciousness and was brought to A&E by ambulance. regular rhythm with narrow QRS complexes with a heart rate of 140 beats per minute. P-waves are not seen. blood pressure is 125/85 mmHg, her JVP is not raised and no pedal oedema was noted. first step for management

Answer 64

urgent Synchronised electrical cardioversion This patient has supraventricular tachycardia with adverse features such as syncope and chest pain.

Question 65

fever. Her symptoms began three weeks ago with a swollen red tongue and a fine rash across her trunk. Her rash has now resolved, but her fever is persistent. On examination, there is an audible pan-systolic murmur, loudest at the apex. Her blood tests reveal a C-reactive protein (CRP) of 124 mg/L. first step management

Answer 65

IV Benzylpenicillin . Rheumatic fever is precipitated by Group A beta-haemolytic streptococcal infection,

Question 66

Rheumatic fever symtoms

Answer 66

recent streptococcal infection Arthritis Pancarditis Affects all layers of the myocardium, endocardial inflammation may predominate causing valvulitis. tachycardia, new murmur or new conduction defect. Sydenham's chorea abrupt, non-rhythmic, involuntary movements along with muscular weakness and emotional disturbance. They are most frequently marked on one side and cease during sleep. Arthralgia- joint stiffness Raised acute phase proteins (ESR and CRP) Prolonged PR interval on ECG fever Erythema marginatum pink/red, nonpruritic rash involving mainly the trunk, thighs and arms. Subcutaneous nodules- Firm, mobile painless lesions

Question 67

rheumatic fever management

Answer 67

Eradication of group-A beta-haemolytic streptococcal infection IV Benzylpenicillin, with a ten day course of Phenoxymethylpenicillin to follow Analgesia/painkillerts for arthritic symptoms Aspirin/ (NSAIDs) such as ibuprofen or naproxen. Aspirin should be used with caution in young children If carditis is complicated by heart failure Glucocorticoids (e.g. Prednisolone) can provide benefit (NSAIDs should be stopped concurrently). Diuretic treatment may also be necessary, and valve surgery if severe. Sydenham's chorea for distressing symptoms or risk of harm. Erythema marginatum is associated with rheumatic fever is temporary and doesn't require treatment, although antihistamines can help with pruritus.

Question 68

Management of a Simple Primary Pneumothorax

Answer 68

short of breath OR the pneumothorax is >2 cm the pneumothorax should be aspirated with a 16-18G cannula under local anaesthetic. If this is successful the patient can be discharged. If this fails an intercostal drain is necessary (and the patient must be admitted).

Question 69

2 month history of constipation, blood in the stool, weight loss

Answer 69

colorectal cancer so colonoscopy first line not CT!! CT for staging

Question 70

sarcoidosis symptoms

Answer 70

Pulmonary (most common manifestation): dry cough, dyspnoea, reduced exercise tolerance, crepitations. Constitutional: fatigue, weight loss, arthralgia/joint stiffness, and low-grade fever. General signs include lymphadenopathy and ENLARGED PAROTID GLANDS Neurological: meningitis, peripheral neuropathy, bilateral Bell's palsy. Ocular: uveitis, keratoconjunctivitis sicca. Cardiac: arrhythmias, restrictive cardiomyopathy. Abdominal: hepatomegaly, splenomegaly, renal stones. Dermatological: erythema nodosum, lupus pernio.

Question 71

10-month old baby boy rapid onset abdominal pain. off his food and not his usual temperament for 3 days prior regular wet nappies and there are no rashes or vomit redcurrent jelly stools pale and his abdomen there is a sausage shaped mass in the right upper quadrant and the boy draws ups his legs and screams uncontrollably on palpation.

Answer 71

Intussusception most common in 3 months - 12-month-old children and 75% are ileocaecal in location. If the child is relatively well, pneumatic reduction under fluoroscopic guidance can be attempted. If the child is unwell or perforation is suspected laparotomy

Question 72

Viral gastroenteritis cause, symptoms and treatment

Answer 72

diarrhoea/ vomiting + fever Rotavirus Norovirus: common cause of viral Adenoviruses: resp system and children management- fluid replacement severe- Salmonella and shigella- ciprofloxacin. Campylobacter - macrolide, erythromycin. Cholera - tetracycline

Question 73

long PR interval and infective endocarditis

Answer 73

Perivavlular or aortic root abscesses are a potential complication of infective endocarditis. They manifest through prolongation of the PR interval on the ECG, which can be followed by higher degrees of heart block. Patients with infective endocarditis are monitored for this complication through daily ECGs.

Question 74

Risedronate side effect

Answer 74

dyspepsia and acid reflux. Patients should be advised to take the tablet half an hour before breakfast with plenty of water and to remain upright to reduce the risk of mucosal irritation.

Question 75

dyspepsia

Answer 75

indigestion, refers to discomfort or pain that occurs in the upper abdomen, often after eating or drinking symptom

Question 76

Wolff-Parkinson-White syndrome symptoms and management

Answer 76

``` supraventricular tachycardias. often asymptomatic Palpitations Dizziness Syncope short PR interval Broad QRS ``` ``` Radiofrequency ablation of the accessory pathway Drug treatment (such as amiodarone or sotalol) to avoid further tachyarrhthmias. These are contraindicate din structural heart disease. ```

Question 77

CXR sign for pulmonary oedema

Answer 77

patchy perihilar shadowing

Question 78

squamous cell carcinoma of tongue

Answer 78

smoking side of tongue and floor of mouth >2 week, should be biopsied

Question 79

linchen planus

Answer 79

itchy rash affecting wrists and shins and sore mouth | white striae and buccul mucosa

Question 80

smooth, sore, red tongue, cracking at corners

Answer 80

iron deficiency

Question 81

sore mouth, inflamed palette with white patches that rub off

Answer 81

oral candidiasis associated with corticosteroids so like people with asthma treatment- topical miconazole gel oral fluconazole for severe

Question 82

pancreatic carcinoma related to

Answer 82

diabetes

Question 83

acute pancreatitis, worsening SoB, resp acidosis so resp failure , cyanosis around lips, bilateral crackles

Answer 83

acute resp distress syndrome