PASS MEDICINE Flashcards

1
Q

What are the red flags for back pain?

A
Age  50 years
History of previous malignancy
Night pain
History of trauma
Systemically unwell e.g. weight loss, fever
Thoracic spine affected
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2
Q

A 35-year-old female presents with abdominal pain associated with bloating for the past 6 months, Which one of the following symptoms is least associated with a diagnosis of irritable bowel syndrome?

Feeling of incomplete stool evacuation
Weight loss
Back pain
Lethargy
Nausea
A

Weight loss

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3
Q

What are the Ottawa rules surrounding whether or not an ankle injury needs x-ray?

A

An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:

Bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)

Bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)

Inability to walk four weight bearing steps immediately after the injury and in the emergency department

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4
Q

A 22-year-old man presents with a three week history of diarrhoea. He says his bowels have not been right for the past few months and he frequently has to run to the toilet. These symptoms had seemed to be improving up until three weeks ago. For the past week he has also been passing some blood in the stool and reports the feeling of incomplete evacuation after going. He has lost no weight and has a good appetite. Examination of his abdomen demonstrates mild tenderness in the left lower quadrant but no guarding. What is the most likely diagnosis?

Diverticulitis
Colorectal cancer
Crohn's disease
Ulcerative colitis
Infective diarrhoea
A

Ulcerative colitis

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5
Q

Which one of the following is the most effective screening tool for harmful alcohol drinking and alcohol dependence?

Liver ultrasound
CAGE questionnaire
FAST questionnaire
Combination of MCV and gamma GT blood test
AUDIT questionnaire
A

AUDIT
10 item questionnaire, takes about 2-3 minutes to complete
Has been shown to be superior to CAGE and biochemical markers for predicting alcohol problems

Minimum score = 0, maximum score = 40: a score of 8 or more in men, and 7 or more in women, indicates a strong likelihood of hazardous or harmful alcohol consumption. A score of 15 or more in men, and 13 or more in women, is likely to indicate alcohol dependence.

AUDIT-C is an abbreviated form consisting of 3 questions

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6
Q

A 30-year-old woman is admitted to hospital with abdominal pain and diarrhoea. She has no past medical history other than depression for which she takes citalopram. She smokes 20 cigarettes/day and drinks 20 units of alcohol per week. Ileocolonoscopy shows features consistent with Crohn’s disease and she is treated successfully with glucocorticoid therapy. Which one of the following is the most important intervention to reduce the chance of further episodes?

Infliximab
Stop drinking
Stop smoking
Mesalazine
Budesonide
A

Stop smoking

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7
Q

Which drug used in the treatment of rheumatoid arthritis has proteinuria as a possible side effect?

A

Gold

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8
Q

Which drug used in the treatment of rheumatoid arthritis has oligospermia as a possible side effect?

A

Sulfasalazine

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9
Q

Which drug used in the treatment of rheumatoid arthritis has reactivation of tuberculosis as a possible effect?

A

Infliximab

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10
Q

What is the name of the syndrome characterised by epigastric pain and diarrhoea?

A

Zollinger-Ellison syndrome

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11
Q

What endocrine condition do a third of Zollinger-Ellison syndrome patients also have?

A

Multiple endocrine neoplasia type I (MEN-I)

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12
Q

What is Zollinger-Ellison syndrome?

A

A condition characterised by excessive levels of gastrin, usually from a gastrin secreting tumour usually of the duodenum or pancreas. The excessive gastrin leads to multiple gastroduodenal ulcers, diarrhoea and malabsorption.
Around 30% occur as part of MEN type I syndrome.

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13
Q

A 49-year-old female is referred to the gastroenterology out-patient clinic with a 3 month history of epigastric pain and diarrhoea. Her GP initially prescribed lansoprazole 30mg od but this didn’t alleviate her symptoms. The only past medical history of note is hyperparathyroidism.

Endoscopy revealed multiple duodenal ulcerations. What is the likely diagnosis?

Multiple endocrine neoplasia type II a
Coeliac disease
Multiple endocrine neoplasia type I
Autoimmune polyendocrinopathy syndrome
Crohn's disease
A

MEN-I as part of a Zollinger-Ellison diagnosis. The lansoprazole would need to be a much higher dose.

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14
Q

A 38-year-old woman develops lower back pain radiating down her right leg whilst performing DIY. She describes a severe, sharp, stabbing pain which is worse on movement. Clinical examination reveals a positive straight leg raise test on the right side but otherwise the examination is unremarkable. Appropriate analgesia is prescribed. Of the following, what is the most suitable next-step in management?

Check ESR
Arrange physiotherapy
Refer for MRI
Perform a vaginal examination
Lumbar spine x-ray
A

Arrange for physiotherapy - This patient has symptoms consistent with a prolapsed disc. Even if this is proven by a MRI scan it would not change the initial management as the vast majority of patients improve with conservative treatment such as physiotherapy.

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15
Q

Which one of the following features is more common in Crohn’s disease than ulcerative colitis?

Abdominal mass palpable in the right iliac fossa
Tenesmus
Bloody diarrhoea
Faecal incontinence
Abdominal pain in the left lower quadrant

A

Abdominal mass palpable in the right iliac fossa

Look at table in University College London/Year 4/Gastrointestinal folder for differences between UC and CD

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16
Q

A 14-year-old presents with left knee pain for the past 4 weeks. There is no history of trauma. The pain is felt in the anterior aspect of the joint and is worse when walking up and down stairs. Examination is unremarkable. What is the most likely diagnosis?

Chondromalacia patellae
Osteoarthritis
Osgood-Schlatter disease
Osteogenesis imperfecta
Osteochondritis dissecans
A

Chondromalacia patellae

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17
Q

What is Chondromalacia patellae?

A

Softening of the cartilage of the patella
Common in teenage girls
Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting
Usually responds to physiotherapy

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18
Q

What are the features of Chondromalacia patellae?

A

Softening of the cartilage of the patella
Common in teenage girls
Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting
Usually responds to physiotherapy

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19
Q

What are the features of Osgood-Schlatter disease (tibial apophysitis)?

A

Seen in sporty teenagers

Pain, tenderness and swelling over the tibial tubercle

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20
Q

What are the features of Osteochondritis dissecans?

A

Pain after exercise

Intermittent swelling and locking

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21
Q

What are the features of Patellar subluxation?

A

Medial knee pain due to lateral subluxation of the patella

Knee may give way

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22
Q

What are the features of Patellar tendonitis?

A

More common in athletic teenage boys
Chronic anterior knee pain that worsens after running
Tender below the patella on examination

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23
Q

A 59-year-old man with a history of gout presents with a swollen and painful first metatarsophalangeal joint. He currently takes allopurinol 400mg od as gout prophylaxis. What should happen to his allopurinol therapy?

Stop and recommence 4 weeks after acute inflammation has settled
Reduce allopurinol to 100mg od until acute attack has settled
Stop and switch to colchicine prophylaxis
Stop and recommence 2 weeks after acute inflammation has settled
Continue allopurinol in current dose

A

Continue allopurinol in current dose - Patients already prescribed allopurinol should continue to take it at the same dose during acute episodes. This is of course in contrast to the advice that patients should not be started on allopurinol until an acute attack has settled.

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24
Q

A 45-year-old man presents with palpitations that began around 40 minutes ago. Other than having a stressful day at work there appears to have been no obvious trigger. He denies any chest pain or dyspnoea. An ECG shows a regular tachycardia of 180 bpm with a QRS duration of 0.10ms. Blood pressure is 106/70 mmHg and oxygen saturations are 98% on room air. You ask him to perform the Valsava manoeuvre but this has no attempt on the rhythm. What is the most appropriate next course of action?

Electrical cardioversion
Intravenous labetalol
Intravenous adenosine
Intravenous amiodarone
Re-attempt Valsava manoeuvre in 5 minutes
A

Intravenous adenosine - This patient has a supraventricular tachycardia with no adverse signs (e.g. shock, myocardial ischaemia etc). If vagal manoeuvres fail intravenous adenosine should be given.

Acute management:

  1. Vagal manoeuvres (e.g. Valsalva manoeuvre)
  2. Intravenous adenosine 6mg → 12mg → 12mg. (Contraindicated in asthmatics - verapamil is a preferable option)
  3. Electrical cardioversion

Prevention of future episodes:
Beta-blockers
Radio-frequency ablation

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25
Q

A 46-year-old man is being investigated for indigestion. Jejunal biopsy shows deposition of macrophages containing PAS-positive granules. What is the most likely diagnosis?

Bacterial overgrowth
Coeliac disease
Tropical sprue
Whipple's disease
Small bowel lymphoma
A

Whipple’s disease

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26
Q

What is Whipple’s disease?

A

Whipple’s disease is a rare multi-system disorder caused by Tropheryma whippelii infection. It is more common in those who are HLA-B27 positive and in middle-aged men.

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27
Q

Of the following, which one is the most useful prognostic marker in paracetamol overdose?

ALT
Prothrombin time
Paracetamol levels at presentation
Paracetamol levels at 12 hours
Paracetamol levels at 24 hours
A

Prothrombin time - An elevated prothrombin time signifies liver failure in paracetamol overdose and is a marker of poor prognosis. However, arterial pH, creatinine and encephalopathy are also markers of a need for liver transplantation

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28
Q

What is the drug that can be used in acute presentation of paracetamol overdose?

A

Acetylcysteine

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29
Q

What class of drug is amlodipine?

A

Dihydropyridine receptor antagonist

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30
Q

What are some of the drugs that classically have ankle swelling as one of their side effects?

A

Amlodipine
Diltiazem
Pioglitazone

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31
Q

What are some of the drugs that classically have pulmonary fibrosis as one of their side effects?

A

Amiodarone
Methotrexate
Bromocriptine

32
Q

What is the most appropriate next step in the following scenario: poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a thiazide diuretic. K+ > 4.5mmol/l?

Add a calcium channel blocker
Increase dose of thiazide diuretic
Add a thiazide diuretic
Add a ACE inhibitor
Add a beta blocker
Add spironolactone
A

Add a thiazide diuretic. You would add spironolactone if their K was low.

33
Q

A patient is noted to have a new early-to-mid systolic murmur 10 days after being admitted for a myocardial infarction is a stereotypical history of?

First degree heart block
Left ventricular aneurysm
HOCM
Dressler's syndrome
Ischaemia of the papillary muscles
Atrial myxoma
A

Ischaemia of the papillary muscle

34
Q

What is Kussmaul’s sign?

A

Kussmaul’s sign describes a paradoxical rise in JVP during inspiration seen in constrictive pericarditis.

35
Q

What wave form in the JVP would indicate tricuspid regurgitation?

A

Giant V waves

36
Q

What wave form in the JVP would indicate complete heart block?

A

Cannon A waves

37
Q

A patient complains of pins/needles and pain on the lateral aspect of the hand is a stereotypical history for an injury to which nerve?

Upper trunk of the brachial plexus (C5, C6)
Ulnar nerve
Long thoracic nerve
Lower trunk of the brachial plexus (C7, C8)
Radial nerve
Median nerve

A

Median nerve

38
Q

Which one of the following is most likely to cause a pulsus parodoxus?

HOCM
Mixed aortic disease
Aortic regurgitation
Severe asthma
Patent ductus arteriosus
Severe LVF
A

Severe asthma - pulsus parodoxus is an abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mm Hg. When the drop is more than 10 mm Hg, it is referred to as pulsus paradoxus.

The paradox in pulsus paradoxus is that, on clinical examination, one can detect beats on cardiac auscultation during inspiration that cannot be palpated at the radial pulse.

39
Q

What type of blood gas abnormality does pulmonary embolism most commonly cause?

Respiratory alkalosis
Respiratory acidosis

A

Alkalosis - PE reduces oxygen, hence increasing ventilation rate and reducing CO2 leading to alkalosis.

40
Q

Which cardiac drugs can cause flushing?

A
Amlodipine
Nicorandil
Isosorbide mononitrate
Sildenafil
Nicotinic acid
Verapamil
Tamoxifen
Diltiazem
Hydralazine
41
Q

Apart from flushing and erections, what is one of the strange side effects of sildenafil (viagra)?

A

Blue discolouration of vision

42
Q

When reviewing an ECG, which one of the following is most associated with ST elevation?

Left anterior hemiblock
Left posterior hemiblock
Cor pulmonale
Hypertension
Hypothermia
Pericarditis
A

Pericarditis

43
Q

What is the most likely diagnosis in the following case? A 57-year-old woman with a history of gallstones presents with progressive right upper quadrant pain, rigors and jaundice.

A

Ascending cholangitis

44
Q

What is ascending cholangitis?

A

Ascending cholangitis is an infection of the bile duct, usually caused by bacteria ascending from its junction with the duodenum. It tends to occur if the bile duct is already partially obstructed by gallstones.

45
Q

What is step 1 in the treatment of patients diagnosed with hypertension?

A

Patients 55-years-old or of Afro-Caribbean origin: calcium channel blocker

46
Q

What is step 2 in the treatment of patients diagnosed with hypertension?

A

ACE inhibitor + calcium channel blocker (A + C)

47
Q

What is step 3 in the treatment of patients diagnosed with hypertension?

A

Add a thiazide diuretic to the ACE inhibitor and the calcium channel blocker.

NICE now advocate using either chlorthalidone (12.5-25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide

48
Q

What is step 4 in the treatment of patients diagnosed with hypertension?

A

Consider further diuretic treatment:
if potassium 4.5 mmol/l add higher-dose thiazide-like diuretic treatment

If further diuretic therapy is not tolerated, or is contraindicated or ineffective, consider an alpha- or beta-blocker

49
Q

Which antibiotics are most associated with C. difficile infections?

A

Fluoroquinolones
Cephalosporins
Carbapenems
Clindamycin

50
Q

A 65-year-old man presents with bilateral leg pain that is brought on by walking. His past medical history includes peptic ulcer disease and osteoarthritis. He can typically walk for around 5 minutes before it develops. The pain subsides when he sits down. He has also noticed that leaning forwards or crouching improves the pain. Musculoskeletal and vascular examination of his lower limbs is unremarkable. What is the most likely diagnosis?

Inflammatory arachnoiditis
Peripheral arterial disease
Raised intracranial pressure
Spinal stenosis
Lumbar vertebral crush fracture
A

Peripheral artery disease

51
Q

What is the most likely diagnosis of the following case? A 28-year-old who is 10 weeks pregnant is noted to be hypertensive on her booking visit. Blood show a potassium of 3.1 mmol/l. Clinical examination is unremarkable.

Adult polycystic kidney disease
Cushing's syndrome
Congenital adrenal hyperplasia
Primary hyperaldosteronism
Phaeochromocytoma
Acromegaly
Bartter's syndrome
Medication-induced
Renal artery stenosis
Pregnancy-induced hypertension
A

Primary hyperaldosteronism - At 10 weeks gestation pregnancy-induced hypertension is not a possibility. The booking visit may represent the first time this patient has had her blood pressure checked, revealing an long-standing disorder. The low potassium points to a diagnosis of primary hyperaldosteronism (of which Conn’s syndrome is a subtype).

52
Q

What is the difference between Cushing’s syndrome and Cushing’s disease?

A

Cushing’s disease is Cushing’s syndrome caused by a pituitary adenoma. Cushing’s syndrome can be caused by a number of things, most commonly steroid medication.

53
Q

What is Wilson’s disease?

A

Wilson’s disease is an autosomal recessive disorder characterised by excessive copper deposition in the tissues. Metabolic abnormalities include increased copper absorption from the small intestine and decreased hepatic copper excretion. Wilson’s disease is caused by a defect in the ATP7B gene located on chromosome 13.

The onset of symptoms is usually between 10 - 25 years. Children usually present with liver disease whereas the first sign of disease in young adults is often neurological disease.

54
Q

What are some of the signs, symptoms and complications that may be expressed by a patient with Wilson’s disease?

A

Liver: hepatitis, cirrhosis
Neurological: basal ganglia degeneration, speech and behavioural problems are often the first manifestations. Also: asterixis, chorea, dementia
Kayser-Fleischer rings
Renal tubular acidosis (esp. Fanconi syndrome)
Haemolysis
Blue nails

55
Q

How is the diagnosis of Wilson’s disease made?

A

Reduced serum caeruloplasmin

Increased 24hr urinary copper excretion

56
Q

What are the ECG changes with pericarditis?

A

Widespread ‘saddle shaped’ ST-elevation

PR segment depression (most specific sign)

57
Q

What are the causes of pericarditis?

A

Viral infections (Coxsackie)
Tuberculosis
Uraemia (causes ‘fibrinous’ pericarditis)
Trauma
Post-myocardial infarction, Dressler’s syndrome
Connective tissue disease
Hypothyroidism

58
Q

What are the signs and symptoms of pericarditis?

A

Chest pain: may be pleuritic. Is often relieved by sitting forwards
Non-productive cough, dyspnoea and flu-like symptoms
Pericardial rub
Tachypnoea
Tachycardia

59
Q

You are reviewing a 50-year-old woman who is complaining of exertional chest pain for the past six months. The pain typically eases when she rests and she has had no episodes of pain lasting more than three minutes. Clinical examination and resting ECG are normal. You arrange fasting blood tests. Following NICE guidelines, what is the most appropriate next step?

Give a trial of GTN spray
Arrange no further diagnostic tests and treat her as having angina
Calculate her estimated risk of having coronary artery disease
Refer for an exercise tolerance test
Refer for a coronary angiograph

A

Calculate her estimated risk of having coronary artery disease - With all due respect to NICE the guidelines for assessment of patients with stable chest pain are rather complicated. They suggest an approach where the risk of a patient having coronary artery disease (CAD) is calculated based on their symptoms (whether they have typical angina, atypical angina or non-anginal chest pain), age, gender and risk factors.

60
Q

What are the major features in the modified Duke criteria of infective endocarditis?

A

Positive blood cultures:

Two positive blood cultures showing typical organisms consistent with infective endocarditis, such as Streptococcus viridans and the HACEK group, or
persistent bacteraemia from two blood cultures taken > 12 hours apart or three or more positive blood cultures where the pathogen is less specific such as Staph aureus and Staph epidermidis.
Positive serology for Coxiella burnetii, Bartonella species or Chlamydia psittaci.
Positive molecular assays for specific gene targets

Evidence of endocardial involvement:

Positive echocardiogram (oscillating structures, abscess formation, new valvular regurgitation or dehiscence of prosthetic valves)
New valvular regurgitation
61
Q

What are the minor features in the modified Duke criteria of infective endocarditis?

A

Predisposing heart condition or intravenous drug use
Microbiological evidence which does not meet major criteria
Fever > 38ºC
Vascular phenomena: major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions, petechiae or purpura
Immunological phenomena: glomerulonephritis, Osler’s nodes, Roth spots

62
Q

Which one of the following features is not part of the modified Duke criteria used in the diagnosis of infective endocarditis?

Fever > 38ºC
Positive molecular assays for specific gene targets
Indwelling central line
Intravenous drug use
Janeway lesions
A

Indwelling central line

63
Q

Which one of the following adverse effects is most characteristically associated with levodopa?

Hyperprolactinaemia
Peripheral neuropathy
Hypotension
Hirsutism
Blurred vision
Akathisia (severe restlessness)
A

Hypotension

64
Q

A 60-year-old man is transferred from the local psychiatric unit to the Emergency Department. An ECG taken following admission shows a broad complex tachycardia consistent with torsardes de pointes, rate 120/min. His blood pressure is 122/80 mmHg and there are no signs of heart failure. What is the most appropriate management?

Intravenous naloxone
Intravenous magnesium sulphate
DC cardioversion
Intravenous amiodarone
Intravenous verapamil
A

IV magnesium sulphate

65
Q

A 71-year-old woman presents with palpitations and ‘lightheadedness’. An ECG shows that she is in atrial fibrillation with a rate of 130 / min. Her blood pressure is normal and examination of her cardiorespiratory system is otherwise unremarkable. Her past medical history includes well controlled asthma (salbutamol & beclomethasone) and depression (citalopram). Her symptoms have been present for around three days. What is the most appropriate medication to use for rate control?

Diltiazem
Sotalol
Digoxin
Atenolol
Amiodarone
A

Diltiazem - Her history of asthma is a contraindication to the prescription of a beta-blocker. NICE therefore recommend a rate-limiting calcium channel blocker.

66
Q

You refer a 24-year-old female to rheumatology with intermittent pain and swelling of the metacarpal phalangeal joints for the past 3 months. An x-ray shows loss of joint space and soft-tissue swelling. Rheumatoid factor is positive and a diagnosis of rheumatoid arthritis is made. What initial management is she most likely to be given to help slow disease progression?

Infliximab
Methotrexate
Sulfasalazine
Methotrexate + sulfasalazine + short-course of prednisolone
Diclofenac
A

Methotrexate + sulfasalazine + short-course of prednisolone

The 2009 NICE guidelines recommend that patients with newly diagnosed active RA start a combination of DMARDs (including methotrexate and at least one other DMARD, plus short-term glucocorticoids).

67
Q

You review a 67-year-old man with a past history of hypertension. He complains of gradually increasing shortness-of-breath on exertion and orthopnoea over the past few months. Clinical examination is unremarkable. Blood tests including full blood count are normal. Spirometry and a chest x-ray are also normal. You suspect the patient may have heart failure. What is the most appropriate next test to perform?

Troponin I
B-type natriuretic peptide
Myocardial perfusion scan
Echocardiogram
Coronary angiography
A

B-type natriuretic peptide

NICE issued updated guidelines on diagnosis and management in 2010. The choice of investigation is determined by whether the patient has previously had a myocardial infarction or not.

Previous myocardial infarction:
Arrange echocardiogram within 2 weeks

No previous myocardial infarction:
Measure serum natriuretic peptides (BNP)
if levels are ‘high’ arrange echocardiogram within 2 weeks
if levels are ‘raised’ arrange echocardiogram within 6 weeks

68
Q

One of your patients who has a family history of Marfan’s syndrome has recently been diagnosed with the condition. What is the most important investigation to monitor their condition?

Urea and electrolytes
Echocardiography
Spirometry
Electrocardiogram
DEXA scan
A

Echocardiogram

69
Q

A 60 year old man with a history of hypercholesterolemia, hypertension and type 2 diabetes mellitus reports an episode of right sided facial weakness and dysphasia lasting thirty minutes earlier that same day. His symptoms have since resolved. His blood pressure is recorded at 130/85 mmHg and there is a carotid bruit present on the left side. What is his ABCD2 score?

3

4

5

6

7

A

5

Age more than or equal to 60 years = 1

Blood pressure more than or equal to 140/90 mmHg = 1

Clinical features:

  • Unilateral weakness = 2
  • Speech disturbance, no weakness = 1

Duration of symptoms:

  • > 60 minutes = 2
  • 10-59 minutes = 1

Patient has diabetes = 1

70
Q

What is the drug used in the treatment of angina that patients may develop tolerance to necessitating a change in dosing regime?

A

Isosorbide mononitrate

71
Q

What drug is the most appropriate first-line anti-anginal for stable angina in a patient with known heart failure, if there are no contraindications?

Verapamil

Amlodipine

Nifedipine

Atenolol

Isosorbide mononitrate

A

Atenolol

72
Q

A 21 year old gentleman is under the cardiologists for investigation of prolonged QT-syndrome. He presents to your surgery with a 5 day history of cough productive of thick, green sputum, fevers and lethargy. Examination reveals a temperature of 39ºC, oxygen saturations of 96% on air and crackles at the right lung base. Which of the following drugs should be avoided in the management of his condition?

Co-amoxiclav

Metronidazole

Doxycycline

Erythromycin

Amoxicillin

A

Erythromycin

Drugs that cause prolonged QT include:

  • Amiodarone, sotalol, class 1a antiarrhythmic drugs (quinidine, procainamide, disopyramide)
  • Tricyclic antidepressants and SSRIs (especially citalopram)
  • Methadone
  • Chloroquine
  • Erythromycin
  • Haloperidol
73
Q

A 62-year-old female with a 40 pack year history of smoking is investigated for a chronic cough associated with haemoptysis. Bronchoscopy reveals a 4 cm tumour confined to the right main bronchus. A biopsy taken shows small cell lung cancer (SCLC). Extensive staging investigations only show evidence of nodal involvement in the ipsilateral peribronchial nodes, giving a TNM grading of T2, N1, M0. What is the most appropriate management?

Laser therapy

Chemotherapy + radiotherapy

Surgery

Radiotherapy

Interferon-alpha

A

Chemotherapy + radiotherapy

Surgery plays little role in the management of small cell lung cancer, with chemotherapy being the mainstay of treatment. Adjuvant radiotherapy is also now given in patients with limited disease.

74
Q

A 27-year-old woman comes for review. She is having problems with increasingly frequent migraine attacks. She has tried a combination of paracetamol and ibuprofen to try and control the attacks but this seems to have had a limited effect. Her current medication includes paracetamol and ibuprofen as required and Cerazette (a progestogen-only pill).

What is the most appropriate medication to try and reduce the frequency of her migraine attacks?

Propranolol

Zolmitriptan

Topiramate

Amitriptyline

Switch Cerazette to a combined oral contraceptive pill

A

Propranolol

Propranolol is preferable to topiramate in women of childbearing age (i.e. the majority of women with migraine)

NICE recommend either propranolol or topiramate for migraine prophylaxis.

The combined oral contraceptive pill is contraindicated given her history of migraine.

Zolmitriptan is useful to abort attacks but is not used for prophylaxis.

75
Q

A 56 year old gentleman is being treated as an inpatient for a duodenal ulcer. He notices that his first metatarsophalangeal joint is severely inflamed on waking this morning. There is swelling and tenderness of the joint, and fluid is sent for microscopy. He has a past medical history of hypertension. What is the best initial medication to prescribe?

Diclofenac

Allopurinol

Cyclizine

Colchicine

Indomethacin

A

Colchicine

Diclofenac and indomethacin are contraindicated because of his duodenal ulcer. Colchicine is a suitable alternative. Allopurinol should not be given in the acute phase, but is good for preventing recurrent attacks.

76
Q

A 65-year-old woman presents with new, ongoing speech disturbance. She is worried that she may have had a stroke. Which one of the following scoring systems is it most appropriate to use to evaluate whether she has had a stroke?

CHADS2 score

ABCD2 score

RCP-RSE score

ROSIER score

CHADS2-VASC score

A

ROSIER score

77
Q

A 30-year-old woman is admitted to hospital with abdominal pain and diarrhoea. She has no past medical history other than depression for which she takes citalopram. She smokes 20 cigarettes/day and drinks 20 units of alcohol per week. Ileocolonoscopy shows features consistent with Crohn’s disease and she is treated successfully with glucocorticoid therapy. Which one of the following is the most important intervention to reduce the chance of further episodes?

Infliximab

Stop drinking

Stop smoking

Mesalazine

Budesonide

A

Stop smoking