BIG THREE

Question 1

Non-urgent endoscopy referral criteria

Answer 1

-Patients with haematemesis
-Patients aged >= 55 years who’ve got:
treatment-resistant dyspepsia or
-upper abdominal pain with low haemoglobin levels or
raised platelet count with any of the following: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain
nausea or vomiting with any of the following: weight loss, reflux, dyspepsia, upper abdominal pain

Question 2

Urgent endoscopy referral criteria

Answer 2

-All patients who’ve got dysphagia
-All patients who’ve got an upper abdominal mass consistent with stomach cancer
-Patients aged >= 55 years who’ve got weight loss, AND any of the following:
upper abdominal pain
reflux
dyspepsia

Question 3

Managing patients who do not meet referral criteria (‘undiagnosed dyspepsia’)

Answer 3

This can be summarised at a step-wise approach
1. Review medications for possible causes of dyspepsia
2. Lifestyle advice
3. Trial of full-dose proton pump inhibitor for one month OR a ‘test and treat’ approach for H. pylori
if symptoms persist after either of the above approaches then the alternative approach should be tried

Testing for H. pylori infection
initial diagnosis: NICE recommend using a carbon-13 urea breath test or a stool antigen test, or laboratory-based serology ‘where its performance has been locally validated’
test of cure:
there is no need to check for H. pylori eradication if symptoms have resolved following test and treat
however, if repeat testing is required then a carbon-13 urea breath test should be used

Question 4

Atrial fibrillation: rate control

Answer 4

Rate control should be offered as the first‑line treatment strategy for atrial fibrillation except in people:
whose atrial fibrillation has a reversible cause
who have heart failure thought to be primarily caused by atrial fibrillation
with new‑onset atrial fibrillation (< 48 hours)
with atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm
for whom a rhythm‑control strategy would be more suitable based on clinical judgement

Medications

Agents used to control rate in patients with atrial fibrillation
beta-blockers
a common contraindication for beta-blockers is asthma
calcium channel blockers
digoxin
Digoxin is not considered first-line anymore as they are less effective at controlling the heart rate during exercise
should only be considered if the person does no or very little physical exercise or other rate‑limiting drug options are ruled out because of comorbidities
may have a role if there is coexistent heart failure

Question 5

Atrial fibrillation: rhythm control

Answer 5

Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation

• beta-blockers
• dronedarone: second-line in patients following cardioversion
• amiodarone: particularly if coexisting heart failure

Question 6

Atrial fibrillation: catheter ablation

Answer 6

NICE recommends the use of catheter ablation for those with AF who have not responded to or wish to avoid, antiarrhythmic medication.

Technical aspects
the aim is to ablate the faulty electrical pathways that are resulting in atrial fibrillation. This is typically due to aberrant electrical activity between the pulmonary veins and left atrium
the procedure is performed percutaneously, typically via the groin
both radiofrequency (uses heat generated from medium frequency alternating current) and cryotherapy can be used to ablate the tissue

Anticoagulation
should be used 4 weeks before and during the procedure
it should be remember that catheter ablation controls the rhythm but does not reduce the stroke risk, even if patients remain in sinus rhythm. Therefore, patients still require anticoagulation as per their CHA2DS2-VASc score
if score = 0: 2 months anticoagulation recommended
if score > 1: longterm anticoagulation recommended

Outcome
-notable complications include
cardiac tamponade
stroke
pulmonary vein stenosis
-success rate
around 50% of patients experience an early recurrence (within 3 months) of AF that often resolves spontaneously
longer term, after 3 years, around 55% of patients who've had a single procedure remain in sinus rhythm. Of patients who've undergone multiple procedures around 80% are in sinus rhythm

Question 7

Patient on Mesalazine (Ulcerative colitis) feeling unwell. Most important 1st test and why

Answer 7

FBC - as mesalazine (an aminosalicylate) causes many haematological adverse effects, including agranulocytosis

Question 8

1st line treatment of C difficile

Answer 8

Oral vancomycin

Question 9

1st line treatment of life-threatening C.difficile

Answer 9

Oral vancomycin + IV metronidazole

Question 10

Treatment of recurrent C. difficile

Answer 10

Prescribe oral fidaxomicin - recommended if the patient presents with a recurrent episode of C.difficile within 12 weeks of symptoms resolution. Recurrence of C.difficile infection within 12 weeks may indicate that the organism is resistant and thus requires fidaxomicin.
Should this fail provide oral vancomycin + IV metronidazole

Question 11

Pulses: pulsus paradoxus

Answer 11

greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration
severe asthma, cardiac tamponade

Question 12

Pulses: slow rising/plateau

Answer 12

aortic stenosis

Question 13

Pulses: collapsing

Answer 13

aortic regurgitation
patent ductus arteriosus
hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)

Question 14

Pulses: Pulsus arternans

Answer 14

regular alternation of the force of the arterial pulse

severe LVF

Question 15

Pulses: bisferiens pulse

Answer 15

‘double pulse’ - two systolic peaks

mixed aortic valve disease, HOCM

Question 16

Aortic dissection - investigation of choice

Answer 16

CT angiography: pelvis/chest/abdomen (depending on stability of patient) 
Transoesophageal echocardiography (TOE)
more suitable for unstable patients who are too risky to take to CT scanner

Question 17

Budd-chiari syndrome classic triad

Answer 17

The features are classically a triad of:
abdominal pain: sudden onset, severe
ascites → abdominal distension
tender hepatomegaly

Budd-Chiari syndrome is a condition characterized by obstruction to hepatic venous outflow. It usually occurs in a patient with a hypercoagulative state (e.g. antiphospholipid syndrome) but can also occur as a result of physical obstruction (e.g. tumour). The venous congestion can cause hepatomegaly and portal hypertension which can can also result in splenomegaly and ascites.

Question 18

Severe exacerbation of asthma

Answer 18

The features of acute severe asthma are: PEFR 33-50% best or predicted, inability to complete full sentences, RR >25/min and pulse >110 bpm

Question 19

Moderate exacerbation of asthma

Answer 19

PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm

Question 20

Life-threatening asthma

Answer 20

PEFR < 33% best or predicted
Oxygen sats < 92%
'Normal' pC02 (4.6-6.0 kPa)
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma

Question 21

Indicator of HOCM

Answer 21

Ventricle thickening
Tall R waves in V4-6
Deep q waves common

Question 22

HOCM management (ABCDE)

Answer 22

A- Amioderone
B- Beta-blockers or verapamil for symptoms
C- Cardiac defibrillation 
D- Dual chamber pacemaker
E- Endocarditis prophylaxis

Question 23

HOCM - Drugs to avoid

Answer 23

Nitrates
Ace-inhibitors
Inotropes

Question 24

Why transferrin saturation, total ferritin is high but total iron-binding capacity is low in Haemochromatosis

Answer 24

Haemochromatosis is an iron storage disorder therefore binding capacity in the blood is unaffected

Question 25

HOCM ECG findings

Answer 25

T wave inversion LVH - tall r waves Deep ST depression

Question 26

VIT C deficiency signs/symptoms

Answer 26

involved in connective tissue (collagen) synthesis thus associated with poor wound healing involved with iron absorption thus can have iron deficiency anaemia (pale, pale conjunctiva,bleeding gums,fatigued)

Question 27

Klebsiella pneumonia A's

Answer 27

Alcoholism, Aspiration pneumonia (affects upper lungs) and Abscesses (empyema) Also presents with red jelly-like sputum also more common with diabetics

Question 28

Asbestos & Asbestosis

Answer 28

- Commonly affects lower lobes (typically) - Length of exposure can relate to the severity - Crocidolite (blue) asbestos is the most dangerous form. - Causes pleural thickening - Causes pleural plaques (benign and do not undergo malignant change). - Can cause mesothelioma.

Question 29

New onset Atrial fibrillation: Pharmacological conversion

Answer 29

Agents with proven efficacy in the pharmacological cardioversion of atrial fibrillation: amiodarone flecainide (if no structural heart disease) others (less commonly used in the UK): quinidine, dofetilide, ibutilide, propafenone ``` Less effective agents beta-blockers (including sotalol) calcium channel blockers digoxin (used in non-paroxysmal AF only if sedimentary) disopyramide procainamide ```

Question 30

STEMI ECG CRITERIA

Answer 30

``` ≥ 2 contiguous leads of: 2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men < 40 years, or ≥ 2.0 mm ST elevation in leads V2-3 in men > 40 years 1.5 mm ST elevation in V2-3 in women 1 mm ST elevation in other leads new LBBB ```

Question 31

COPD: stable management - First line problems

Answer 31

Bronchodilator therapy a short-acting beta2-agonist (SABA) or short-acting muscarinic antagonist (SAMA) is the first-line treatment for patients who remain breathless or have exacerbations despite using short-acting bronchodilators the next step is determined by whether the patient has 'asthmatic features/features suggesting steroid responsiveness'

Question 32

COPD: stable management - second-line therapy (non-asthmatic features/ features suggesting steroid responsiveness)

Answer 32

add a long-acting beta2-agonist (LABA) + long-acting muscarinic antagonist (LAMA) if already taking a SAMA, discontinue and switch to a SABA

Question 33

COPD: stable management - second-line therapy (asthmatic symptoms/features suggesting steroid responsiveness)

Answer 33

Asthmatic features/features suggesting steroid responsiveness LABA + inhaled corticosteroid (ICS) if patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS if already taking a SAMA, discontinue and switch to a SABA NICE recommend the use of combined inhalers where possible

Question 34

main ECG findings with hypercalcaemia

Answer 34

Shortened QT interval

Question 35

Features of hypercalcaemia

Answer 35

- 'bones, stones, groans and psychic moans' - corneal calcification - shortened QT interval on ECG - hypertension

Question 36

Prevention of acute mountain syndrome (altitude-related disorders)

Answer 36

- the risk of AMS may actually be positively correlated to physical fitness -gain altitude at no more than 500 m per day -acetazolamide (a carbonic anhydrase inhibitor) is widely used to prevent AMS and has a supporting evidence base it causes a primary metabolic acidosis and compensatory respiratory alkalosis which increases respiratory rate and improves oxygenation -treatment: descent

Question 37

Management of high altitude cerebral oedema (HACE/O)

Answer 37

descent | dexamethasone

Question 38

Presentation of high altitude cerebral oedema (HACE/O)

Answer 38

papilloedema headache ataxia

Question 39

Presentations of high altitude pulmonary oedema (HAPE)

Answer 39

-Dyspnoea (SOB particularly on exertion) -coughing (may produce pink frothy sputum) -Feeling of choking/drowning when horizontal. -Wheezing ETC.

Question 40

Management of HAPE

Answer 40

- Descent - Nifedipine, dexamethasone, acetazolamide, phosphodiesterase type V inhibitors* - Oxygen if available

Question 41

Treatment of Wilson's Disease

Answer 41

- Penicillamine - chelates copper | - Trientine hydrochloride is an alternative chelating agent

Question 42

Torsades de pointes - Treatment

Answer 42

IV magnesium sulphate

Question 43

DUKE criteria for bacterial endocarditis (either pathological criteria positive, or 2 major criteria, or 1 major and 3 minor criteria, or 5 minor criteria)

Answer 43

-Presence of pathological findings: Positive histology or microbiology of pathological material - Major criteria: 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, or ~positive serology for Coxiella burnetii, Bartonella species or Chlamydia psittaci, or 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), or ~new valvular regurgitation Minor: predisposing heart condition or intravenous drug use microbiological evidence 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

Question 44

Signs of wilsons disease

Answer 44

``` Copper ring deposits (green/brown) around iris (Kayser-fleisher) Jaundice / liver cirrhosis Arthritis Blue nails Cardiomyopathy renal tubule dysfunction Neurological/cognitive impairment ```

Question 45

-gatran drug suffix

Answer 45

``` Thrombin inhibitors (argatroban type) e.g efegatran Can be used in AF ```

Question 46

-pine drug suffix

Answer 46

Calcium channel blockers - e.g amilodipine | Lowers BP

Question 47

What drug to use if bleeding on antithrombin dabigatran

Answer 47

Idracizumab - is a humanised monoclonal antibody fragment that binds specifically to dabigatran and its metabolites, thereby reversing the anticoagulant effect.

Question 48

Drugs to reverse Heparin

Answer 48

Protamine sulphate

Question 49

Drug to reverse warfarin

Answer 49

Phytomenadione (vitamin K)

Question 50

2nd line warfarin reversal treatment if Vit K insufficient

Answer 50

Prothrombin complex - This is used to treat major bleeding on warfarin despite treatment with phytomenadione.

Question 51

ECG territories and arteries

Answer 51

Anteroseptal - V1->V4 - LAD Inferior - II, III and aVF - Right coronary/RCA Anterolateral - V4-V6, I and aVL - LAD or Left Circumflex Lateral - I, aVL, +/- V5-V6 - Left circumflex Posterior - Tall R waves V1-V2 - Usually left circumflex, also right coronary

Question 52

Adverse effects of Adenosine

Answer 52

``` chest pain bronchospasm transient flushing can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome) Heart-block ```

Question 53

Adverse effects Beta-blockers

Answer 53

``` Side-effects bronchospasm cold peripheries fatigue sleep disturbances, including nightmares erectile dysfunction ```

Question 54

Contraindications of Beta blockers

Answer 54

- uncontrolled heart failure - asthma - sick sinus syndrome - concurrent verapamil use: may precipitate severe bradycardia

Question 55

Side/Adverse effects of ACEi

Answer 55

~cough - occurs in around 15% of patients and may occur up to a year after starting treatment, thought to be due to increased bradykinin levels ~angioedema: may occur up to a year after starting treatment ~hyperkalaemia ~first-dose hypotension: more common in patients taking diuretics

Question 56

Contraindications of ACEi

Answer 56

~Pregnancy and breastfeeding - avoid ~renovascular disease - may result in renal impairment ~aortic stenosis - may result in hypotension ~hereditary of idiopathic angioedema ~specialist advice should be sought before starting ACE inhibitors in patients with a potassium >= 5.0 mmol/L

Question 57

Causes of ST depression

Answer 57

``` secondary to abnormal QRS (LVH, LBBB, RBBB) ischaemia digoxin hypokalaemia syndrome X ```

Question 58

Adverse effects of amioderone

Answer 58

``` thyroid dysfunction: both hypothyroidism and hyper-thyroidism corneal deposits pulmonary fibrosis/pneumonitis liver fibrosis/hepatitis peripheral neuropathy, myopathy photosensitivity 'slate-grey' appearance thrombophlebitis and injection site reactions bradycardia lengths QT interval ```

Question 59

Wolf-parkinson- white syndrome ECG findings

Answer 59

Wolff-Parkinson-White syndrome (left-sided accessory pathway) a short PR interval delta waves right axis deviation

Question 60

What is Dressler's Syndrome

Answer 60

Dressler's syndrome tends to occur around 2-6 weeks following a MI. The underlying pathophysiology is thought to be an autoimmune reaction against antigenic proteins formed as the myocardium recovers. It is characterised by a combination of fever, pleuritic pain, pericardial effusion and a raised ESR. It is treated with NSAIDs.

Question 61

Causes of LBBB

Answer 61

myocardial infarction diagnosing a myocardial infarction for patients with existing LBBB is difficult rhe Sgarbossa criteria can help with this hypertension aortic stenosis cardiomyopathy rare: idiopathic fibrosis, digoxin toxicity, hyperkalaemia

Question 62

Loop-diuretics adverse effects

Answer 62

``` hypotension hyponatraemia hypokalaemia, hypomagnesaemia hypochloraemic alkalosis ototoxicity hypocalcaemia renal impairment (from dehydration + direct toxic effect) hyperglycaemia (less common than with thiazides) gout ```

Question 63

PE ECG changes

Answer 63

Pulmonary embolism inverted T waves right bundle branch block right axis deviation

Question 64

Wolff-Parkinson-White syndrome (left-sided accessory pathway) ECG Changes

Answer 64

a short PR interval delta waves right axis deviation

Question 65

T Wave inversion causes

Answer 65

``` myocardial ischaemia digoxin toxicity subarachnoid haemorrhage arrhythmogenic right ventricular cardiomyopathy pulmonary embolism ('S1Q3T3') Brugada syndrome ```

Question 66

Peaked T wave ECG causes

Answer 66

hyperkalaemia | myocardial ischaemia

Question 67

Causes of RBBB

Answer 67

normal variant - more common with increasing age right ventricular hypertrophy chronically increased right ventricular pressure - e.g. cor pulmonale pulmonary embolism myocardial infarction/ischaemia atrial septal defect (ostium secundum) cardiomyopathy or myocarditis

Question 68

Aortic dissection Features

Answer 68

severe tearing chest pain, unequal BP in arms widened mediastinum on chest x-ray false lumen on CT angiography

Question 69

Pneumonia : caused by legionella pneumphillia

Answer 69

dry cough and atypical chest signs, hyponatraemia and lymphopenia

Question 70

Pneumonia: Pneumocystis jiroveci

Answer 70

a history of HIV, dry cough, exercise-induced desaturations and the absence of chest signs