Core Content

Question 1

Acute DKA management

Answer 1

A-E, senior, admit

1. Fluids resuscitation (0.9% saline)
2. Insulin (0.1 unit/kg/hour)
3. Potassium and glucose replacement

Monitor - VBG (pH and electrolytes), capillary glucose, capillary ketones

Question 2

DKA diagnostic criteria

Answer 2

PH < 7.3
Glucose > 11
Ketones > 3 serum, ++ urine

Question 3

Acute stroke (ischaemic)

Answer 3

1. A-E, alert stroke team (stroke call)
2. CT Head, BP, ECG, bloods (esp. clotting)
3. Aspirin 300mg
4. Thrombolysis if within 4.5 hours +/- thrombectomy

If > 4.5 hours supportive treatment on specialist stroke ward

Question 4

Acute stroke (haemorrhagic)

Answer 4

1. A-E, stroke call/senior
2. CT head, ECG, BP, bloods (esp. clotting)
3. BP control if HTN, aim 130-140
4. Reverse coagulation if patient on
5. Surgical decompression if severe, else supportive care

Question 5

Acute ACS management - STEMI

Answer 5

1. A-E, cardio bleep
2. ECG, trop, BP, bloods incl. VBG, CXR
3. MONA - morphine + anti-emeric , oxygen, nitrate, aspirin 300mg
4. Ticareglol 180mg
5. PCI or thrombolysis (alteplase, if no PCI)

Question 6

Acute ACS management - NSTEMI

Answer 6

1. A-E, cardio bleep
2. ECG, trop, BP, bloods incl. VBG, CXR
3. MONA - morphine + anti-emeric , oxygen, nitrate, aspirin 300mg
4. Fondaparinux (LMWH)
5. Calculate GRACE score (6 month mortality)

Question 7

How does GRACE score change treatment of NSTEMI patients?

Answer 7

GRACE - 6 month mortality score, considered high if > 3%

HIGH - second anti-platelet (ticagrelol), PCI within 72 hours

LOW - can be d/c once stable, likely elective OP PCI

Question 8

Long term post MI management

Answer 8

Conservative

1. Lifestyle - smoking, diet, activity
2. Cardiac rehabilitation programme

Medicine - BADS
Beta blocker
ACEi
Dual antiplatelet - aspirin 75mg (lifelong) + ticagrelol 90mg (1 year)
Statin - high dose

Question 9

Complications of MI

Answer 9

DARTH VADAR

Death
Arrythmia
Rupture - V wall, papillary muscle (MR)
Tamponade
Heart failure

Valve disease
Aneurysm of ventricle
Dressler’s syndrome (pericarditis)
thromboEmbolism
Recurrence

Question 10

Acute management of heart failure

Answer 10

POD MAN

Position - sit up
Oxygen
Diuretics - furosemide 50mg IV

Morphine
Anti-emetic
Nitrates

Question 11

Long term management of heart failure

Answer 11

CONSERVATIVE

1. Cardiology MDT
2. Lifestyle - smoking, execise

MEDICAL
Treat the underlying cause if possible

1. ACEi + beta blocker + loop diuretic if oedema
2. Add spironolactone
3. Specialist Tx such as ibravadine, sacubitral-valsartan

SURGICAL

1. Cardiac resynchronisation
2. ICD

Question 12

Interpreting NT pro BNP

Answer 12

> 2000 ng/L - 2 week referral to cardio

400-2000 - 6 week referral to cardio

< 400 - unlikely heart failure

Question 13

Acute management of PE

Answer 13

A-E assessment, breif history for RF, alert seniors

Calculate wells score

• low - D.Dimer
• high - CTPA

CXR, ECG, BP, bloods incl. clotting

Unstable - thrombolysis with alteplase
Stable - anti-coagulation with apixaban

Question 14

Acute management of asthma

Answer 14

A-E

O SHIT ME

Oxygen

Salbutamol nebs
Hydrocortisone
Ipratropium nebs
Theophylline IV

Magnesium sulphate IV
Escalation - intubation and ventilation

Question 15

Acute management of COPD

Answer 15

O SHIT

Oxygen - titrate with venturi

Salbutamol nebs
Hydrocortison
Ipratropium nebs
Theophylline

If infection + antibiotics e.g. doxy
If not responding - NIV (BiPaP)

Question 16

When do you use BiPap vs CPAP?

Answer 16

Type 1 RF - 1 thing wrong (hypoxic) - CPAP

Type 2 RF - 2 things wrong (hypoxic, hypercapnic) - BiPaP

Question 17

Acute management of pneumothorax

Answer 17

A-E assessment
CXR, sats, RR, tracheal deviation, BP
Stop NIV if running and high suspicion of pneumo

Tension - needle decompression 2nd ICS MCL then chest drain

Non tension - assess size of rim of air on CXR, if patient is symptomatic and if primary/secondary

Question 18

Management of a non tension pneumothorax (after A-E)

Answer 18

Primary

• < 2cm and no SOB - d/c, repeat CXR in 2-3 weeks
• > 2cm or Sx - needle aspirate
• failure of aspiration - chest drain

Secondary - always admit

• <1cm + no SOB - 24 hours oxygeb
• 1-2cm + no SOB - needle aspiration
• > 2cm, SOB or failed aspiration - chest drain

Question 19

Management of sepsis

Answer 19

A-E, senior input

Sepsis 6
Urine output, IV fluids
Blood cultures, IV antibiotics
Lactate (Blood gas), Oxygen

Assess for source - CXR, urine dip, cultures, assess neuro/CNS

Question 20

Management of meningitis and/encephalitis

Answer 20

1. A-E approach, senior input
2. CT head, lumbar puncture
3. IV antibiotics (ceftriaxone +/- amoxicillin)
4. Anti-viral if ?encephalitis/viral → IV aciclovir
5. Sepsis 6 if unstable/septic

Question 21

Long term stroke management (ischaemic specific?

Answer 21

Reducing recurrence risk

• CVD RF modification
• look for emboli - ECG and ECHO
• look for carotid stenosis (doppler)

Conservative

• SALT, OT/PT
• lifestyle - smoking, alcohol, etc

Medical

• aspirin 300mg for 2 weeks then life long clopidogrel
• BP control
• high dose statin
• glycaemic control if DM

Question 22

Acute management of upper GI bleed

Answer 22

1. A-E, if shocked major haemorrhage call
2. Fluid resusciation +/- blood
3. Fastbleep gastro for endoscopy consideration
4. NBM
5. IV Abx
6. Analgesia + anti-emetic
7. Terlipressin if likely/known varicela bleed
8. Stengstaken-blakemore if life-threatening

Question 23

Acute management of anaphylaxis

Answer 23

1. A-E, if stridor - anaesthetics, stop ?offending drugs, IV access
2. IM Adrenaline 0.5ml 1 in 1000 (500mcg)
3. IV fluids - manage hypotension
4. Repeat IM adrenaline if 5 minutes if no change

After 2 doses = refractory - set up IV infusion adrenaline via central line, goes to ITU

Question 24

Acute management of status epilepticus

Answer 24

1. A-E, start timing, follow status protocol, alert seniors
2. Reversible causes - VBG, glucose, blood panel
3. 5 minutes - IV lorazepam or buccal midazolam
4. After 10 minutes - repeat benzo, ensure ITU/anaesthetics attending
5. After another 10 minutes - IV phenytoin + cardiac monitoring
6. After another 10 minutes - RSI with propofol, ITU + EEG

Question 25

components of A in A-E ## Footnote **airway**

Answer 25

* assessment * talking = patent * stridor * sounds of upper airway obstruction * interventions * head tilt + chin lift * jaw thrust * oro/nasopharyngeal airway * LMA * ET/tracheostomy

Question 26

components of B in A-E ## Footnote **breathing**

Answer 26

* assessment * RR + sats * Auscultate, percuss, expansion, trachea * CXR * ABG * interventions * 15L non-rebreathe mask * ventilation in severe

Question 27

components of C in A-E ## Footnote **circulation**

Answer 27

* assessment * BP, HR * heart sounds * fluid status - JVP, mucus membranes, CRT, UO * ECG * bloods - VBG + specific for scenario * interventions * 2 x large bore IV cannula * fluid challenge if hypotensive * blood transfusion if major bleed

Question 28

components of D in A-E ## Footnote **disability**

Answer 28

* assessment * capillary blood glucose * GCS calculation * Pupils - equal/reactive to light * CT head if reduced GCS * intervention * glucose replacement * head up, neuro _+_ mannitol for raised ICP

Question 29

components of E in A-E ## Footnote **exposure/everything else**

Answer 29

* assessment * limbs - neurovascular status * skin - rash * abdo - SNT? * orifices for other sites of bleeding

Question 30

Acute management of hypoglycaemia

Answer 30

* conscious + moderate - glucogel * unconscious/severe + IV access - 75ml 10% glucose * unconscious, no access - IM glucagon

Question 31

acute management of bradycardia with life-threatening signs

Answer 31

1. A-E with IV access, seniors 2. monitor BP, sats + cardiac monitoring, ECG 3. Atropine 500mcg IV - repeat up to 6 doses 4. Transcutaneous pacing or IV adrenaline or IV isoprenaline 5. Transvenous pacing

Question 32

what are the life-threatening signs in arrhythmias?

Answer 32

HISS * heart failure * ischaemia (MI) * shock * syncope

Question 33

acute management of bradycardia without life-threatening signs

Answer 33

1. A-E approach 2. monitor BP, ECG, sats, cardiac monitoring 3. observe and urgent cardio review

Question 34

what are the shockable rhythms of arrest?

Answer 34

ventricular fibrillation pulseless ventricular tachycardia

Question 35

what are the non-shockable rhythms of arrest?

Answer 35

PEA asystole

Question 36

management of **regular narrow complex tachycardia** no life-threatening features

Answer 36

1. A-E, cardiac monitoring, sats, BP 2. Vagal manoeuvres 3. IV adenosine - up to 3 doses 1. verapamil if asthmatic 4. beta-blocker or verapamil 5. synchronised DC cardioversion

Question 37

management of **regular narrow complex tachycardia** _with_ life-threatening features

Answer 37

1. A-E, senior support 2. synchronised DC cardioversion

Question 38

management of **narrow complex, irregular tachycardia** no life-threatening features

Answer 38

1. A-E, senior input, likely AF 2. beta-blocker 1. if evidence of HF - digoxin or amiodarone 3. anticoagulation if \> 48 hours, consider DC if \< 48 for rhythm control

Question 39

management of **polymorphic broad complex tachycardia** no life-threatening features

Answer 39

1. A-E, senior 2. IV magnesium sulphate 3. assess for reversible causes - drug review, electrolytes

Question 40

management of **broad complex tachycardia** _with_ life threatening features

Answer 40

* synchronised DC cardioversion

Question 41

management of **regular broad complex tachycardia** no life-threatening signs

Answer 41

1. A-E, senior input, monitoring 2. 300mg IV amiodarone over 10-20 minutes, then 900mg over 24 hours 3. consider DC cardioversion if no response via central line

Question 42

ALS algorithm for shockable rhythms

Answer 42

1. Defibrillation shock 2. CPR - 30:2 3. Reassess rhythm 4. Repeat steps 1-3 provided rhythm remains shockable _Drugs_ * after 3rd shock * 1mg adrenaline IV/IM * 300mg IV amiodarone bolus * after * continue adrenaline every 3-5 mins * another 150mg amiodarone after 5th shock

Question 43

ALS algorithm for non-shockable rhythms

Answer 43

1. Start CPR - 30:2 2. Adrenaline 1mg IM - give every other cycle of CPR 3. Atropine 3mg IV if rate \< 60bpm

Question 44

what type of hypersensitivity reaction is asthma?

Answer 44

type 1

Question 45

Ix for diagnosing asthma

Answer 45

* bedside * Peak flow diary * sats + RR + resp examination * bloods - FBC, IgE * imaging - CXR * special * spirometry + bronchodilator - improvement of FEV1 \> 12% or volume \> 200 * FeNO \> 40 parts per billion

Question 46

aims of asthma treatment?

Answer 46

* no daytime symptoms * no night time waking due to symptoms * no need for rescue medications * no attacks * no limitations on daily activities * normal lung function

Question 47

CXR features of bronchiectasis

Answer 47

* tram lines * ring shadows

Question 48

describe the CURB-65 score

Answer 48

* confusion (AMTS \< 8) * urea ( \> 7) * respiratory rate (\>30) * blood pressure (low, SBP \< 90 or DBP \< 60) * age ( \>65)

Question 49

what are the drugs used to treat TB?

Answer 49

RIPE rifampicin, isoniazid, pyrazinamide, ethambutol

Question 50

SE of rifampicin

Answer 50

orange secretions e.g. urine hepatitis induces liver enzymes

Question 51

SE of isoniazid?

Answer 51

hepatitis peripheral neuropathy

Question 52

SE of pyrazinamide

Answer 52

hepatitis photo sensitivity gout

Question 53

SE of ethambutol

Answer 53

optic neuritis

Question 54

causes of upper lobe fibrosis?

Answer 54

A TEA SHOP * A - allergic bronchopulmonary aspergillosis * T - TB * E - extrinsic allergic alveolitis * A - ankylosing spondylitis * S - sarcoidosis * H - histiocytes * O - occupation (silicosis, berylliosis) * P - pneumoconiosis (coal worker's)

Question 55

causes of lower lobe fibrosis

Answer 55

IPAS - BM * IP - infection, interstitial pneumonia * A - alpha-1 anti-trypsin deficiency, asbestosis * S - systemic sclerosis, CTD e.g. RA * B - bronchiectasis * M - medications

Question 56

causes of exudative pleural effusion

Answer 56

* Infection * Malignancy * Inflammation e.g. RA, SLE, acute pancreatitis * Pulmonary infarct e.g. secondary to PE

Question 57

causes of transudative pleural effusion

Answer 57

* ↑ capillary hydrostatic pressure * Heart failure * ↓ capillary oncotic pressure * Cirrhosis * Nephrotic syndrome * CKD * GI malabsorption or malnutrition e.g. Crohn's

Question 58

medications that cause fibrosis

Answer 58

BANS ME * Bleomycin * Amiodarone * Nitrofurantoin * Sulfasalazine * MEthotrexate

Question 59

PEF criteria for grading asthma attack

Answer 59

* 50-70 = moderate * 33-49 - severe * \< 33 - life-threatening

Question 60

who does ABPA tend to effect? what does it lead to?

Answer 60

asthmatics poor control

Question 61

Allergic bronchopulmonary aspergillosis management

Answer 61

1. oral glucocorticoids 2. itraconazole

Question 62

NICE treatment ladder for asthma (long-term)

Answer 62

1. **SABA**, salbutamol 2. **SABA +** ***_ICS_*** e.g. budesonide 3. **SABA + ICS +** ***_LTRA_*** e.g. Montelukast, PO 4. **SABA + ICS +** ***_LABA_*** (salmeterol) **_+_ LTRA** * Continue LTRA if responsive 5. Switch LABA/ICS → **maintenance and reliever** **herapy** with low-dose ICS * **SABA + MART _+_ LRTA** 6. Increase ICS to medium dose - **SABA + MART with medium dose ICS _+_ LRTA** 7. Referral to specialist - biologic, high dose ICS

Question 63

drugs contraindicated in asthma

Answer 63

beta-blockers NSAIDs ACEi adenosine

Question 64

conservative management of COPD

Answer 64

* smoking cessation * flu + pneumococcal vaccines * pulmonary rehabilitation/chest physio

Question 65

long term medical management of COPD

Answer 65

* **1st - SABA or SAMA** * **2nd - _Asthmatic features_ → add** **LABA + ICS** * **2nd - _No asthmatic features_ → add** **LABA and LAMA** * if on SAMA → SABA * **3rd line -** **LAMA + LABA + ICS**

Question 66

what are the asthmatic features of COPD?

Answer 66

PEDS * PMHx atopy/asthma * Eosinophils high * Diurnal variation PEFR * Steroid responsive before

Question 67

what are the specialist medical interventions for COPD?

Answer 67

* prophylactic antibiotics (azithromycin) - multiple exacerbations/year * LTOT

Question 68

what is the criteria for LTOT in all resp conditions (COPD, fibrosis)

Answer 68

* non smoker * PaO2 \< 7.3 kPa on 2 ABG 3 weeks apart * PaO2 7.3 - 8 kPa with 1 of: * polycythaemia * peripheral oedema * pulmonary HTN

Question 69

what are the surgical options for COPD?

Answer 69

bullectomy lung volume reduction surgery

Question 70

diagnostic test for pulmonary fibrosis?

Answer 70

high resolution CT honeycombing

Question 71

management of idiopathic pulmonary fibrosis

Answer 71

**best supportive care pathway,** **respiratory MDT**. * **Conservative** * Chest physiotherapy * Pulmonary rehabilitation * Smoking cessation * **Medical** * Anti-fibrotic - Pirfenidone, * LTOT * **Surgical** * Transplant

Question 72

features of small cell lung cancer

Answer 72

* central * associated with smoking * paraneoplastic syndromes - ACTH, lambert-eaton

Question 73

features of squamous cell lung cancer

Answer 73

* associated with smoking * central tumours * cavitating lesions * paraneoplastic - high calcium, PTHrP secreting

Question 74

features of adenocarcinoma of the lung

Answer 74

* non-smokers * peripherally located

Question 75

investigations for suspected lung cancer

Answer 75

CXR CT chest then if confirmed- imaging to stage

Question 76

common pneumonia CAP organisms

Answer 76

* **Streptococcus pneumoniae** (70% of CAP) * Haemophilus influenzae (2nd most common) * Morexalla catarrhalis * Group A streptococci * Klebsiella pneumoniae * Staphylococcus Aureus

Question 77

what are the common atypical pathogens of CAP?

Answer 77

* Chlamydia pneumonia * Mycoplasma pneumoniae * Legionella * Chlamydia psittaci

Question 78

what pathogen of pneumonia: * rusty coloured sputum * lobar on CXR * +ve diplococci

Answer 78

s. pneumoniae

Question 79

what pathogen of pneumonia: * smoking + COPD * gram -ve cocco-baccili

Answer 79

haemophilus influenzae

Question 80

what pathogen of pneumonia * following recent viral infection/flu * cavitation on CXR * +ve cocci

Answer 80

s. aureus

Question 81

who gets klebsiella pneumonia?

Answer 81

alcoholics and elderly

Question 82

treatment of pneumonia

Answer 82

admit if high CURB * **medical treatment** * **Typical CAP** * Mild → (**_amoxicillin_**_)_ * Moderate-severe → penicillin + macrolide * **Atypical CAPs** * generally = clarithromycin or doxycycline * **supportive treatment** * Oxygen, IV fluids, Analgesics * NIV/ventilation * Drainage of abscess or empyema

Question 83

acute abdomen core principles

Answer 83

NBM IV fluids analgesia antiemetic Abx (cef + met)

Question 84

investigations for the surgeon

Answer 84

* CT abdo * FBC + CRP * U&E, LFTs * clotting + G&S * amylase * calcium

Question 85

definition of AAA?

Answer 85

Abdominal aorta develops a permanent localised dilation of \> 50% of expected artery diameter (\>3cm)

Question 86

cardiovascular RF

Answer 86

* HTN * Hyperlipidaemia * Smoking * Previous CVD disease * DM * Male * Older

Question 87

what conditions in which to screen/consider for CVD RF?

Answer 87

* stroke * ACS * AAA/aneurysms * peripheral vascular disease * CKD * DM

Question 88

describe screening for AAA

Answer 88

* **men one off USS at 65** * women at high risk USS at 70 * (RF - vascular disease, FHx AAA, high risk of CVD)

Question 89

describe the monitoring of AAA

Answer 89

* 3-4.4cm - yearly USS * 4.4 - 5.4cm - USS every 3 months

Question 90

indications for elective repair of AAA

Answer 90

* symptomatic * asymptomatic + _\>_ 5.5 cm * asymptomatic + growing \> 1cm/year

Question 91

acute management of ruptured AAA

Answer 91

1. A-E assessment, major haemorrhage call, vascular 2. CT with contrast, G&S + X-match, IV access + resuscitate 3. permissive hypotension (\< 100mmHg) 4. surgery - open repair usually

Question 92

management of unruptured AAA

Answer 92

* active monitoring * conservative - stop smoking * medical - HTN Tx, statin, aspirin * surgery - EVAR or open procedure * EVAR for older/frail * open for younger

Question 93

6 P's of acute limb ischaemia

Answer 93

* Pain - constant, persistent * Pulseless - ankle pulses absent * Pallor (or cyanosis or mottling) * Perishingly cold * *Paraesthesia* or ↓ sensation or numbness * *Paralysis* or power loss

Question 94

key vascular investigations

Answer 94

* **bedside** * vascular examination * BP, HR * ECG * ABPI * handheld doppler USS * **bloods** * FBC, lipids, HbA1c * clotting * **imaging** * doppler USS * CT angiogram * digital subtraction angiography * **special** * carotid dopplers

Question 95

acute management of acute limb ischaemia

Answer 95

1. A-E, vascular review urgent 2. Limb down (promote blood flow) 3. Heparin IV 4. Assess if salvageable → if yes revascularisation (embolectomy, thrombolysis or bypass)

Question 96

what are the revascularisation options for acute limb ischaemia?

Answer 96

* emboli * embolectomy (balloon, Fogarty catheter) * thrombus * bypass grafting (usually if incomplete occlusion) * thrombolysis _+_ stent

Question 97

how to assess limb viability in acute ischaemia?

Answer 97

* neurosensory deficit → time critical, late stage ischamia * paraesthesia + paralysis * skin appearance * mottling → suggests non-salvageable

Question 98

options for non-salvageable limbs

Answer 98

* amputation * palliation - supportive measures until auto-amputation

Question 99

what are the risks of revascularisation?

Answer 99

* reperfusion injury → hyperkalaemia, acidosis, rhabdomyolysis, acute renal failure, sepsis * compartment syndrome

Question 100

describe IV maintenance fluid guidance

Answer 100

* daily requirements * water - 30ml/kg/day if fit; 25ml/kg/day if old, kidney or heart failure * 1 mmol/kg per day of K+, Na+, Cl- * 50g-100g of glucose each day

Question 101

how you could estimate surface area of burns?

Answer 101

rule of 9s

Question 102

acute management of burns (A-E)

Answer 102

* severe → Burns centre * **A** - assess for inhalation injury, consider pre-emptive intubation if high risk * **B** - 100% O2, ABG, check carboxyhaemoglobin levels * **C -** 2 large bore IV * routine bloods, G&S, clotting, CK * aggressive fluid therapy - Parkland's formula, 0.9% NaCl warmed * IV analgesia (morphine) * **D** - GCS, temperature (risk of hypothermia), PEARL * **E** - estimate % burns + wound care

Question 103

describe Parkland's formula for burns fluid resuscitation in adults

Answer 103

* Parklands = fluid volume for 1st 24 hrs after major burns * Adults - **4mL (Hartmann's) x weight (kg) x % TBSA burned** * Give 50% calculated in 8 hours post burn and 50% in remaining 16 hours

Question 104

differentials for life-threatening chest injuries

Answer 104

ATOMIC * airway obstruction * tension pneumothorax * open pneumothorax (sucking) * massive haemothorax * intercostal disruption + pulmonary contusion * cardiac tamponade

Question 105

what is the management of variceal bleeding?

Answer 105

* acute upper GI management * acute specific * Terlipressin + IV Abx pre-op * endoscopy - variceal banding, endoscopy ligation, endoscopic injection * long term * beta-blocker (propanolol) * TIPSS procedure * address chronic liver disease

Question 106

causes of cauda equina syndrome

Answer 106

* disc prolapse (most common, L4/5, L5/S1) * trauma - # * malignancy * infection - discitis, Pott's * iatrogenic - haematoma after spinal anaesthetic

Question 107

red flags for cauda equina syndrome?

Answer 107

* Bilateral sciatica * Progressive evolving neurology, rapid * Saddle anaesthesia * Urinary symptoms - incontinence, loss of urge or retention * Bowel symptoms - unable to open bowels, incontinence

Question 108

acute management of spinal compression/CES

Answer 108

1. Urgent **MRI** and urgent referral to **neurosurgery** 2. Pre-op measures → Analgesia + NBM + G&S 3. Catheterisation - prevent post-renal AKI 4. *Metastatic spinal cord compression* * Dexamethasone 16mg in divided doses PO (high dose corticosteroids) + PPI

Question 109

definitive management of spinal compression/cauda equina syndrome

Answer 109

* **surgical** * *Surgical decompression* - within 48 hours, laminectomy, posterior decompression * Radiotherapy _+_ chemotherapy if cancer * Steroids - if cancer, some inflammation e.g. AS * **post-operative** * PT/OT * treat any underlying/contributive cause

Question 110

causes of encephalitis?

Answer 110

* **infection** * **viruses** → **herpes simplex virus 1** (most common) * bacteria - N. meningitides * fungal * autoimmune encephalitis

Question 111

cord compression vs cauda equina differentiating by: tone, power, reflex, clonus, plantars, bowel, bladder and sensation

Answer 111

Question 112

what are the CSF findings in **bacterial** infection? _variables_: appearance; WCC, protein, glucose

Answer 112

Question 113

what are the CSF findings in **virus** infection? _variables_: appearance; WCC, protein, glucose

Answer 113

Question 114

what are the CSF findings in **GBS** infection? _variables_: appearance; WCC, protein, glucose

Answer 114

Question 115

what are the CSF findings in **SAH** infection? _variables_: appearance; WCC, protein, glucose

Answer 115

Question 116

what are the CSF findings in **TB** infection? _variables_: appearance; WCC, protein, glucose

Answer 116

Question 117

describe the components of GCS (broad categories + total score) ?

Answer 117

eye - 4 verbal - 5 motor - 6

Question 118

detailed GCS score

Answer 118

Question 119

what are the signs of basal skull #?

Answer 119

* haemotympanum * "panda" eyes * CSF leak from ear or nose * Battle's sign

Question 120

what are the indications for **CT head within _1 hour_ ADULT?**

Answer 120

* consciousness related * Initial A&E GCS \< 13 * GCS \< 15 at 2 hours after the injury * injury related * Suspected open or depressed skull fracture * Any sign of basal skull # * concerning neurology * Focal neurological deficit * Post-traumatic seizure * _\>_ 1 episode of vomiting

Question 121

what are the indications for **CT head within _8_ hours in ADULTS?**

Answer 121

* over 65 years * Hx of bleeding or clotting disorder * On anti-coagulants * Dangerous mechanism of injury * \> 30 minutes retrograde amnesia of events immediately prior to head injury

Question 122

acute management of raised ICP

Answer 122

1. A-E 2. Urgent neurosurgical referral 3. Head up 40 degrees 4. If intubated → hyperventilate (↓ PaCO2 → cerebral vasoconstriction → ↓ ICP) 5. Osmotic agents e.g. mannitol 6. Steroids - if ↑ ICP due to malignancy

Question 123

what are the common organisms of meningitis in **neonates?**

Answer 123

* group B streptococci * *listeria monocytogenes* * *Escherichia coli*

Question 124

what are the common organisms of meningitis **overall?**

Answer 124

NHS * *N. meningitides* * *H. influenza B* * *S. pneumoniae,*

Question 125

what are encapsulated bacteria that are clinically important after splenectomy?

Answer 125

NHS * *N. meningitides* * *H. influenza B* * *S. pneumoniae*

Question 126

what are the common organisms of meningitis **older and immunocompromised?**

Answer 126

* *s. pneumoniae* * *L. monocytogenes* * *TB* * gram negative organisms

Question 127

what is the prophylaxis for meningococcal meningitis?

Answer 127

ciprofloxacin to close household contacts

Question 128

what are the causes of spinal cord compression?

Answer 128

* metastatic cord compression (most common) * lung, breast, prostate * traumatic * infective - abscess, TB, discitis * disc prolapse (rare in upper spine)

Question 129

what # are most commonly associated with compartment syndrome?

Answer 129

supracondylar tibial

Question 130

key features of compartment syndrome

Answer 130

* pain out of proportion to injury * sensation of pressure * paraesthesia * paralysis of muscle group

Question 131

management of compartment syndrome

Answer 131

1. **Dressing release** 2. Analgesia + urgent T&O/surgery review 3. **Fasciotomy** 4. Monitor for rhabdomyolysis and renal impairment 5. **Surgical intervention** - if frankly necrotic muscle is seen on fasciotomy → debridement _+_ amputation

Question 132

what is the diagnostic criteria of creatine kinase?

Answer 132

5 x the upper limit of normal

Question 133

what are some causes of rhabdomyolysis?

Answer 133

* _Trauma_ * _long lie_ - elderly after falls * _Ischaemia_ - compartment syndrome, reperfusion * _Medical causes_ - seizure, infections, metabolic abnormalities * _Drug induced_ - cocaine, diuretics (severe K+ depletion), statin, anti-psychotics, DDP-4 inhibitors (e.g. sitagliptin) * _Toxins_ - cyanide, copper, CO

Question 134

management of rhabdomyolysis

Answer 134

1. **IV fluids** + correct electrolyte abnormalities 2. **Urine alkalinisation -** IV sodium bicarbonate 3. **Haemodialysis** - refractory raised K+ or acidosis * **Helps with ↑ K+ and acidosis** * **Indicated if anuric with severe acidosis and hyperkalaemia**

Question 135

management of acute alcohol withdrawal?

Answer 135

1. seizure prevention - reducing dose of chlordiazepoxide 2. Wernicke-Korsakoff prevention - IV thiamine 3. screen for liver disease 4. involve alcohol services

Question 136

features of salicyclate/aspirin OD?

Answer 136

* flushed * fever * hyperventilation * _tinnitus_, dizziness * Respiratory alkalosis → lactic acidosis (mixed pH disturbance)

Question 137

management of salicyclate OD?

Answer 137

* IV sodium bicarbonate * emergency haemodialysis if life-threatening OD or coma due to OD

Question 138

treatment of opiate OD?

Answer 138

naloxone 400mcg IM/IV can repeat if unresponsive

Question 139

risks of hepatotoxicity after paracetamol OD?

Answer 139

* enzyme inducing medication (PC BRASS) * malnourish - anorexia, chronic ETOH * staggered OD * delayed presentation

Question 140

what is the management of paracetamol OD?

Answer 140

* N-acetylcysteine * anti-emetic + fluids, monitor electrolytes + LFTS * liver transplant - acute liver failure

Question 141

who should get an immediate NAC infusion? what is usually done?

Answer 141

* single OD → bloods at 4 hours, nomogram to see if needs NAC * immediate NAC at presentation if: * staggered, unsure of time of ingestion * high risk of toxicity e.g. alcoholic

Question 142

benzodiazepine antidote

Answer 142

flumazenil

Question 143

management of beta blocker OD

Answer 143

* atropine for bradycardia * anti-dote = glucagon

Question 144

antidote to digoxin

Answer 144

digifab

Question 145

antidote for ethylene glycol poisoning

Answer 145

fomepizole

Question 146

antidote for local anaesthetic overdose

Answer 146

intralipid

Question 147

management of TCA overdose

Answer 147

* cardiac monitoring - risk of QTc prolongation and ventricular arrhythmias * sodium bicarbonate *

Question 148

features + treatment of duct ectasia

Answer 148

* older woman * characterised by dilation of ducts * nipple discharge - green/brown * management * conservative - reassurance * surgical - if persistent Sx - duct excision

Question 149

most common type of breast cancer

Answer 149

ductal carcinoma (either in situ or invasive)

Question 150

RF for breast cancer

Answer 150

* genetic - BRCA 1 or 2 * high oestrogen exposure * nulliparity * early menarche, late menopause * COCP/HRT * PMHx breast, ovarian, endometrial, colorectal cancer * obesity

Question 151

what is the triple assessment for breast cancer?

Answer 151

1. clinical examination 2. imaging - USS \< 35; mammogram if \> 35 3. histology - FNA or core biopsy

Question 152

what is the screening program for breast cancer?

Answer 152

mammogram every 3 years (2 views) from 50-70

Question 153

general description of cancer treatment

Answer 153

* MDT * treatment combination based on patient factors, tumour staging and patient wishes * curative or palliative intent * conservative - psychological support * medical - chemotherapy, radiotherapy, immunotherapy * surgical - resection

Question 154

management of breast cancer

Answer 154

* **general** * MDT * **surgical resection** * wide local excision - if small, localised * mastectomy * _+_ axillary LN clearance * **adjunct treatment** * radiotherapy * chemotherapy * hormonal treatment * tamoxifen (SERM) if pre-menopausal * anastrozole (aromatase inhibitor) if post-menopausal * **reconstruction** - prosthetic or flap

Question 155

complications of mastectomy

Answer 155

* Pain * Infection * Bleeding * Lymphoedema of the arm if axillary clearance conducted * Phantom breast pain * Seroma

Question 156

common cause of mastitis/breast abscess?

Answer 156

flucloxacillin

Question 157

management of mastitis

Answer 157

1. anti-pyretic 2. antibiotics - flucloxacillin PO, if severe IV Abx

Question 158

management of breast abscess

Answer 158

1. anti-pyretic 2. antibiotics - flucloxacillin PO, if severe IV Abx 3. needle aspiration - LA, USS, send for MC&S 4. Incision and drainage - if failed multiple aspiration, very large or multi-loculated

Question 159

classification of aortic dissection (stanford)

Answer 159

* **Type A** - dissection of the ascending aorta or arch of the aorta * Most common * **Type B** - dissection of aorta distal to the left subclavian aorta (descending)

Question 160

diagnostic test for aortic dissection

Answer 160

CT angiogram

Question 161

acute management of aortic dissection

Answer 161

* A-E assessment, major haemorrhage protocol, vascular referral * haemodynamically unstable * theatre - graft or repair * haemodynamically stable * type A - surgery, graft repair * type B - strict BP control (IV labetalol), bed rest, EVAR/open if develop end organ damage

Question 162

RF for aortic dissection

Answer 162

* _HTN_ * _CTD_ (EDS, SLE, Marfan's) * aortitis * trauma/iatrogenic * _cocaine/amphetamines_ * _valvular heart disease_

Question 163

common secondary causes of AF

Answer 163

* ischaemic heart disease * rheumatic heart disease * thyrotoxicosis * pneumonia * PE * sepsis * alcohol * mitral valve disease

Question 164

investigations for AF

Answer 164

* **Bedside** * **ECG** - _diagnostic_. Irregularly irregular rhythm, No P waves * **Bloods** * Exclude contributing cause - FBC + CRP, TFTs, U&Es * **Imaging** * Echocardiogram - structure heart disease * **Specialist or scoring** * CHA₂DS₂-VASc stroke risk score * ORBIT bleeding risk score

Question 165

what is the CHADsVASc and how to interpret?

Answer 165

* \> 2 F - should be anticoagulated * \> 1 M - should be * C - congestive cardiac failure (1) * H - HTN (1) * A2 - \> 75 (2) * D - DM (1) * S2 - Stroke/TIA (2) * V- Vascular disease (1) * A - 65-74 (1) * Sc - female (1)

Question 166

new-onset AF - guidance for DC cardioversion?

Answer 166

\< 48 hours - can cardiovert 48+ hours - TOE to exclude thrombus + DC _or_ anti-coagulate for 3/52 then elective cardiovert

Question 167

management of AF

Answer 167

* **conservative** * cardiovascular RF modification * education about AF + stroke signs * **medical** * rate control * rhythm control * stroke prevention * **surgical** * atrial ablation - refractory, identifiable originating loci

Question 168

detailed medical management of AF?

Answer 168

* **rate control** * beta-blocker (bisoprolol) * rate-limiting CCB (verapamil) * digoxin - if hypotension, heart failure * **rhythm control** * elective electrical cardioversion * pharmacological - flecainide (pill in pocket), amiodarone * **stroke prevention** - DOAC (apixiban), warfarin + LMWH bridging (always if valvular AF)

Question 169

what is atrial flutter?

Answer 169

* re-entrant atrial tachycardia * atrial rate 250-320 bpm * fixed or variable AV condition, narrow QRS * saw-tooth pattern on ECG

Question 170

management of atrial flutter

Answer 170

* haemodynamically unstable → DC cardioversion * stable * rate control - beta-blocker, CCB * rhythm control - elective cardioversion * VTE prophylaxis e.g. apixiban * catheter radiofrequency ablation - 1st line if normal/mild enlarged LA * pacemaker (atrial if refractory to Tx)

Question 171

causes of high output failure?

Answer 171

anaemia sepsis pregnancy Paget's hyperthyroidism

Question 172

what is a reduced EF?

Answer 172

\< 45%

Question 173

features of LV heart failure

Answer 173

* pulmonary congestion - SOB, PND, orthopnoea * hypotension/syncope - low CO * S3 gallop * functional MR

Question 174

CXR features of heart failure

Answer 174

* A - alveolar oedema ("batwing" perihilar shadowing) * B - Kerley B lines, interstitial oedema * C - Cardiomegaly (\> 0.5) * D - upper lobe blood diversion * E - pleural effusions (usually bilateral, transudates) * F - fluid in the horizontal fissure

Question 175

types of cardiomyopathy

Answer 175

* dilated * hypertrophic * restrictive

Question 176

Dilated cardiomyopathy summary * **description** * **causes** * **management**

Answer 176

Dilated cardiomyopathy summary * **description**- systolic dysfunction, dilation of heart * **causes** - idiopathy (majority), post-viral, alcoholism, post-partum * **management** * symptomatic support + HF management * ICD if arrhythmias * heart transplant

Question 177

Ix for cardiomyopathy

Answer 177

* **bedside** - ECG * **bloods** - NT pro-BNP, lipids, HBA1c, U&Es, FBC * **imaging** - CXR, echo * **specialist** * endomyocardial biopsy * genetic analysis * cardiac catheterisation

Question 178

Hypertrophic cardiomyopathy summary * **description** * **causes** * **management**

Answer 178

Hypertrophic cardiomyopathy summary * **description** - thickened heart tissue, diastolic dysfunction, preserved EF till end * **causes** - genetic, AD * **management** * ICD - high risk of sudden cardiac death * exercise restriction * reducing outflow obstruction * beta-blocker, verapamil * surgical myomectomy * alcohol septal ablation * screening of relatives

Question 179

Restrictive cardiomyopathy summary * **description** * **causes** * **management**

Answer 179

Restrictive cardiomyopathy summary * **description** - diastolic dysfunction, reduced compliance of heart tissue, RARE * **causes** - familial, infiltrative (sarcoid, amyloid), storage (haemochromatosis), radiation induced fibrosis * **management** * symptomatic + HF * ICD if arrhythmia * heart transplant

Question 180

DVT well's score

Answer 180

* 2+ - likely, 1 or less - unlikely. * Criteria are: * Active cancer 1 * Paralysis, paresis or recent plaster immobilisation of lower extremities 1 * Recently bedridden for _\>_ 3 days, or major surgery within 3/12 = 1 * Tenderness along deep vein system = 1 * Entire leg swollen = 1 * Calf swelling at least 3 cm = 1 * Pitting oedema = 1 * Collateral superficial veins (non-varicose) = 1 * Previously documented DVT = 1 * An alternative diagnosis is at least as likely as DVT = -2

Question 181

management if high DVT Well's score (\> 2)

Answer 181

* USS to confirm diagnosis within 4 hours * anticoagulation if +ve USS → DOAC (apixiban), LMWH * mechanical intervention - thrombectomy _+_ IVC filter only if can't anticoagulate

Question 182

how long to anti-coagulate for in VTE?

Answer 182

3 months if provoked 6 months if unprovoked

Question 183

management if low DVT Well's score

Answer 183

D-dimer test within 4 hours * If cannot get result within 4 hr → offer interim anticoagulation * If negative - consider alternative diagnosis * If positive - offer USS (if within 4 hours) + interim anticoagulation

Question 184

what to do if D-dimer +ve and USS negative in DVT?

Answer 184

stop anti-coagulation repeat USS in 1 week

Question 185

what is the primary prevention statin choice?

Answer 185

20mg atorvastatin

Question 186

what is the secondary prevention statin of choice?

Answer 186

80mg of atorvastatin

Question 187

indications for amputation

Answer 187

* Death → tissue death most commonly due PAD * Dangerous → infected or malignancy in limb * Damage → trauma, burns, frostbite * Damn annoying → pain, etc, refractory to other treatment

Question 188

what are the types of heart block?

Answer 188

* **first degree** - consistent PR prolongation, no loss of QRS * **Second degree** - prolonged PR with loss of QRS complexes in a predictable manner * **Mobitz type 1 -** progressive lengthening of the PR interval until P wave with failed conduction of QRS * **Mobitz type 2** - intermittent non-conduction of P to QRS with a fixed constant PR interval * **Third degree** - *complete heart block*, atrial impulses fail to be conducted to ventricles

Question 189

causes of 1st degree heart block?

Answer 189

* athletes - high vagal tone (not pathological) * acute inferior MI * electrolyte abnormalities * meds

Question 190

what medications can cause heart block?

Answer 190

* beta-blockers * CCB * digoxin * amiodarone

Question 191

what is a major cause of second and third degree heart block?

Answer 191

myocardial infarction

Question 192

management of 1st degree heart block?

Answer 192

benign, doesn't require treatment screen for any underlying cause, if found treat

Question 193

management of second degree heart block

Answer 193

* **Mobitz type 1** * asymptomatic - no Tx * symptomatic - most no Tx, ECG monitoring, review medication, consider pacemaker * **Mobitz type 2** * pace maker as high risk of complete high block

Question 194

management of third degree heart block

Answer 194

permanent pacemaker

Question 195

what is malignant HTN

Answer 195

> *over 180/120*

Question 196

secondary causes of HTN

Answer 196

* *Renal:* renal artery stenosis, PCKD, CKD * *Endocrine:* hyperthyroidism, Cushing’s, Conn’s syndrome, pheochromocytoma, acromegaly * *Cardiovascular:* coarctation of aorta * *Drugs:* sympathomimetics, corticosteroids, COCP

Question 197

investigations of HTN

Answer 197

* diagnosis * clinic + confirmed with ambulatory (1st line) or home BP readings * assess for complications * urine dipstick - protein * ECG * bloods - U&E (renal function), HbA1c (CVD risk), lipids (CVD risk) * fundoscopy

Question 198

medical management of HTN

Answer 198

Question 199

management of severe HTN (\> 180/120)

Answer 199

* asymptomatic * urgent assessment for end organ damage - headache, eyes, renal, heart * initiate oral HTN treatment * symptomatic * hospital assessment + admission * IV labetalol

Question 200

what are the HTN retinopathy stages

Answer 200

1. Silver wiring 2. Silver wiring + **arteriovenous nipping** 3. Silver wiring, arteriovenous nipping, **flame haemorrhages and cotton wool exudates** 4. Silver wiring, arteriovenous nipping, flame haemorrhages, cotton wool exudates + **papilloedema**

Question 201

complications of HTN

Answer 201

* cardiac - HF, coronary artery disease, PVD * neuro - CVA, HTN encephalopathy * renal - HTN nephropathy, CKD * eyes - hypertensive retinopathy

Question 202

Duke's criteria for infective endocarditis

Answer 202

* **major** * +ve blood cultures (2 +ve, 12 hours apart, different site) * echocardiogram findings - vegetations * **minor** * RF e.g. IVDU * fever \> 38 * immune complex - haematuria/glomerulonephritis, osler's, roth spots * embolic phenomena - stroke/PE, splinter, janeway * +ve echo not meeting criteria

Question 203

pathogens seen in IE

Answer 203

* subacute - Strep. viridans * acute - S. Aureus, S. epidermis

Question 204

what valves are most common affected in IE?

Answer 204

mitral and aortic, unless IVDU then RH valves

Question 205

management of infective endocarditis

Answer 205

1. **Admit** 2. **A-E** 3. **IV antibiotics -** 4-6 week course, should respond within 48 hours of initiation treatment 4. **Surgical intervention** - severe cases, uncontrolled infection

Question 206

management of stable angina

Answer 206

* **conservative** * education * lifestyle and RF modification * **medical** * short term nitrate PRN * anti-anginal medication * 1st - beta blocker or CCB * 2nd - ivabradine * secondary prevention - 75mg aspirin, 80mg statin, HTN management * **surgical** * CT angiography 1st line to assess suitability for surgery * PCI _+_ stenting * CABG

Question 207

management of intermittent claudication

Answer 207

* **conservative** * RF - smoking, lifestyle * **supervised exercise program** * **medical** * secondary prevention - 75mg clopidogrel * vasodilator * **surgical** * revascularisation - angioplasty + stenting; bypass

Question 208

what does ABPI tell you?

Answer 208

* high - calcification, seen in DM * \< 0.9 = PAD * 0.9-0.8 - mild; 0.8-0.5 - moderate; \< 0.5 - severe/critical

Question 209

what is the management of critical limb ischaemia?

Answer 209

* **urgent referral vascular** * **medical** * analgesia * secondary prevention - clopidogrel * **surgical** * revascularisation - bypass * amputation if gangrene

Question 210

what is rheumatic fever?

Answer 210

Rheumatic fever is a systemic inflammatory condition following group A beta-haemolytic streptococcal infection

Question 211

what is the Jones criteria

Answer 211

Infection + 2 major _or_ 1 major + 2 minor * Evidence of recent streptococcal infection * Major criteria * Arthritis * Pancarditis * Sydenham's chorea * Erythema marginatum * Subcutaneous nodules * Minor criteria * Fever * Arthralgia - unless arthritis met as major * ↑ acute phase proteins (ESR, CRP) * Prolonged PR interval on ECG

Question 212

which valves are most commonly affected in rheumatic fever?

Answer 212

most common = mitral 2nd most common = aortic

Question 213

treatment of rheumatic fever

Answer 213

* eradicate group A beta-haemolytic strep - IV benzypenicillin * bed rest * analgesia * cardiac assessment - may require valve replacement

Question 214

general ulcer management

Answer 214

* treat any underlying contributing cause * wound care * treat any complicating infection * severe wounds - assessment by plastics for ?debridement _+_ grafting

Question 215

features of arterial ulcers

Answer 215

* lower legs, areas of trauma or pressure * small, deep lesions * painful * clear edges * features of peripheral arterial disease - cold peripheries, thick nails, hair loss, long CRT

Question 216

features of venous ulcers

Answer 216

* gaiter region * large and shallow * sloped edges * sloughing ulcer * painful * features of venous insufficiency e.g. varicose veins

Question 217

4 main types of ulcers

Answer 217

* arterial * venous * neuropathic * pressure

Question 218

features of neuropathic ulcers

Answer 218

* bony areas e.g. heel, plantar aspect * deep, clear edges * painless * surrounding features - dry, cracked, insensate, calluses, charcot joint * associated with peripheral neuropathies (DM, B12)

Question 219

treatment of arterial ulcers

Answer 219

* general ulcer principles * refer to vascular as sign of critical limb ischaemia * CVD risk factor modification * surgery - revascularisation (stenting or bypass)

Question 220

treatment of venous ulcers

Answer 220

* **conservative** * leg elevation, increased exercise, weight reduction * **medical** * general ulcer principles * compression bandaging - check ABPI first * **surgical** * treat concurrent venous insufficiency

Question 221

management of neuropathic ulcers

Answer 221

* wound care * optimise factors affecting peripheral neuropathy - e.g. glycaemic control in DM

Question 222

causes of aortic regurgitation

Answer 222

* acute * IE * aortic dissection * trauma * chronic * rheumatic heart disease * bicuspid valve * IE * CTD

Question 223

key clinical features of AR

Answer 223

* early diastolic murmur, LLSE, expiration * wide pulse pressure * collapsing pulse * LH failure - SOB

Question 224

eponymous signs of aortic regurgitation

Answer 224

* Corrigans - exaggerated carotid * Quinke's - nailbed pulsation * De Musset's - head nodding * Traube's sign - “pistol shot” at femoral

Question 225

investigating valve disease

Answer 225

* **bedside** * cardio examination, ECG * **bloods** - FBC, U&E, lipids, glucose * **imaging** - echo, CXR * **special** - angiogram if for open repair

Question 226

management of aortic regurgitation

Answer 226

* **conservative** * RF modification * regular review by cardio * **medical** * reducing afterload → beta-blocker, ACEi, diuretics * treat underlying cause * **surgical** * open aortic valve replacement _+_ aortic root graft

Question 227

general indications for valve replacement (R heart)

Answer 227

* symptomatic * features of heart failure * severe valve disease on echo

Question 228

causes of aortic stenosis

Answer 228

* bicuspid valve * senile calcification * rheumatic heart disease

Question 229

clinical features of aortic stenosis

Answer 229

* ejection systolic murmur, aortic region, 2nd ICS * S4 * heaving, non-displaced apex beat * slow rising pulse, narrow pulse pressure * quiet S2 (severe)

Question 230

what are the key symptoms of aortic stenosis?

Answer 230

syncope angina dyspnoea

Question 231

management of aortic stenosis

Answer 231

* **conservative** * monitoring, severe 6-12 monthly * RF modification * **medical** * symptomatic treatment if features of HF * **surgical** * open aortic valve repair * TAVI (preferred in older/frail)

Question 232

causes of mitral regurgitation

Answer 232

* acute * ischaemic - papillary muscle rupture * IE * rheumatic heart disease * chronic * degeneration of valve (age) * CTD * dilated cardiomyopathy

Question 233

clinical features of mitral regurgitation

Answer 233

* pansystolic murmur at the apex, radiate to axilla, expiration * quiet/soft S1 * parasternal heave * irregularly irregular pulse * prolapse - mid-systolic click

Question 234

management of mitral regurgitation

Answer 234

* **conservative**- monitoring and RF * **medical** * AF management * HF management if present * **surgery** * valve repair (1st) * valve repalcement (2nd)

Question 235

causes of mitral stenosis

Answer 235

* rheumatic heart disease (most common) * mitral calcification * carcinoid syndrome

Question 236

clinical features of mitral stenosis

Answer 236

* rumbling mid-diastolic murmur over apex, bell, expiration, left lateral * tapping + non-displaced apex * parasternal heave * loud S1 * malar flush * AF

Question 237

management of mitral stenosis

Answer 237

* **conservative** - monitoring and RF * **medical** * manage AF * consider diuretics (reduce pre-load) * **surgical** * transcatheter valvotomy (rheumatic MS) * mitral valve replacement

Question 238

complications of varicose veins

Answer 238

* bleeding * superficial vein thrombosis * skin ulceration * depression * reduced QOL

Question 239

RF for varicose veins

Answer 239

* older age * FHx * female * pregnancy * obesity * prolonged sitting/standing * Hx of DVT

Question 240

management of varicose veins

Answer 240

* **conservative** * reduce standing, elevate stocking, weight loss * **medical** * compression stocking * **interventional** * radiofrequency ablation * injection sclerotherapy * **surgery** * ligation * stripping

Question 241

what are the indications for interventional or surgical treatment of varicose veins?

Answer 241

bleeding, symptomatic, venous insufficiency chronic changes, venous ulcers

Question 242

pathology of vasovagal syncope

Answer 242

* neural mediated reflex syncope * **excessive vagal discharge** causing **reflex bradycardia _+_ peripheral vasodilation**.

Question 243

management of vagal attack

Answer 243

* education about triggers * if impending syncope → lie down, legs up, volume expansion (more fluids, salt) * severe/unpredictable → tilt training, isometric counterpressure manoeuvres

Question 244

what is wolff-Parkinson white?

Answer 244

WPW is a syndrome characterised by a congenital abnormality which predisposes to _supraventricular tachycardia_ secondary to an accessory pathway

Question 245

clinical features of WPW

Answer 245

* bundle of kent (congenital) * syncope, palpitation, dizzy * short PR * delta wave on ECG

Question 246

management of WPW

Answer 246

* **acute** * unstable - cardiovert * stable - IV adenosine, if feature of flutter amiodarone * **chronic** * medication review * ablation of accessory pathway - radiofrequency or surgical

Question 247

indications for carotid endarterectomy

Answer 247

* Carotid artery disease - in prevention of ischaemia stroke * Symptomatic carotid stenosis of 50-99% * \> 50% stenosis and \> 1 TIA in last six months provided stenosis on side accounting for TIA

Question 248

clinical features of cluster headache

Answer 248

* _trigger_ - ETOH, smoking, exercise * severe, unilateral headache, rapid, clustered, night * _associated_ - red, teary eye, rhinorrhoea, lacrimation, facial vasodilation

Question 249

management of cluster headache

Answer 249

* **conservative** * avoid trigger, good sleep hygiene * **acute** * high flow O2 * sumatriptan SC * **long term** * verapamil

Question 250

what are the types of seizure?

Answer 250

* focal * simple * complex - impaired consciousness * generalised * absence * tonic * myoclonic * tonic-clonic * atonic

Question 251

features of temporal lobe seizure

Answer 251

* automatism e.g. lip smacking * deja vu * emotional disturbance * hallucination (sensory e.g. olfactory)

Question 252

features of frontal lobe seizure

Answer 252

motor jacksonian march, Todd's paresis

Question 253

features of parietal lobe seizures

Answer 253

sensory - tingling, numbness can develop into motor as electrical activity spreads into frontal lobe

Question 254

management of alzheimer's dementia

Answer 254

* bio * acetylcholinesterase inhibitor (donepezil) * NMDA antagonist (memantine) * psycho * managing psychological symptoms e.g. mood disturbance * social * support at home + carers * home safety

Question 255

features of Miller Fisher syndrome

Answer 255

ataxia + opthalmoplegia + areflexia subtype of GBS

Question 256

key features of Guillain-Barre syndrome

Answer 256

* ascending symmetrical paralysis (LMN) * risk of T2RF * anti-ganglioside antibodies * LP - raised protein, normal cell count + glucose * reduced nerve conduction studies

Question 257

what are the main triggers for GBS?

Answer 257

respiratory or GI infection (Campylobacter, mycoplasma, EBV)

Question 258

management of GBS?

Answer 258

* serial ABG + spirometry for resp. function * IVIG + plasmapheresis * ventilation of required

Question 259

causes of horner's syndrome

Answer 259

* central * stroke, MS, tumour * pre-ganglionic * Pancoast, trauma, cervical rib * post-ganglionic * carotid dissection, endartectomy, cavernous sinus thrombosis

Question 260

triad of Horner's

Answer 260

* ptosis * miosis * anhidrosis

Question 261

what is the genetics of Huntingtons?

Answer 261

trinucleotid repeat (CAG, Chr 4, huntingtin protein) AD condition

Question 262

what are the clinical features of Huntington?

Answer 262

* choreoathetosis (chorea) * dementia * familial condition

Question 263

what are the types of hydrocephalus?

Answer 263

1. **Non-communicating/obstructive** where the flow of CSF is blocked 2. **Communicating** - is an issue with reduced absorption or blockage of the venous drainage system

Question 264

causes of obstructive hydrocephalus

Answer 264

* obstructing tumour or cyst * congenital

Question 265

causes of communicating hydrocephalus

Answer 265

* infective meningitis * SAH * normal pressure hydrocephalus

Question 266

management of hydrocephalus

Answer 266

* medical - acetazolamide (limited use) * surgical - ventriculo-peritoneal shunt

Question 267

What bleeds in an extradural?

Answer 267

Middle meningeal artery (most common)

Question 268

Key features of extradural

Answer 268

- blood collects between bone and dura - lucid period then reduced GCS - features of raised ICP

Question 269

What is the appearance of an extradural on CT?

Answer 269

Hyperdense biconvex/lentiform haematoma

Question 270

Management of extradural

Answer 270

General principles - A-E - neurosurgery - raised ICP management Definitive - surgery (burr holes, craniotomy) if GCS \< 8, large, midline shift, focal neuro deficits - conservative - everyone else - neurorehab

Question 271

What bleeds in a subarachnoid haemorrhage?

Answer 271

Aneurysm - e.g Berry AV malformations

Question 272

Key features of SAH

Answer 272

- blood accumulating in subarachnoid space - sudden onset thunderclap headache - associated with PCKD

Question 273

Diagnosing SAH

Answer 273

- CT head - blood in SA space often around circle Willis - CT angiogram/DSA - LP 12 hours after Sx onset - xanthochromia

Question 274

Management of SAH

Answer 274

1. A-E, neurosurgical review 2. Nimodipine 4hrl to prevent vasospasm 3. BP control \< 180 systolic 4. Surgical - coiling or clipping of aneurysm 5. Neuro-obs + rehab

Question 275

What is bleeding in a subdural?

Answer 275

Briding veins between cortex and venous sinuses

Question 276

Types of subdural haemorrhage

Answer 276

Acute - \<72hrs, associated with trauma Subacute - 3-20 days Chronic - \> 3 weeks

Question 277

Key features of subdural

Answer 277

* bleeding between dura mater and brain surface * fluctuating consciousness * may have long hx * gait deterioration * psych symptoms / CI

Question 278

appearance of a subdural haemorrhage on CT?

Answer 278

* crescent shaped * acute - homogenous hyperdensity * subacute/chronic - varying density

Question 279

management of subdural haemorrhage

Answer 279

* A-E, neurosurgical review * anti-convulsant for 1 week (seizure prophylaxis) * surgical intervention - large, midline shift, neurological deficit * trauma craniotomy * burr hole _+_ drain * conservative otherwise

Question 280

classical migraine features

Answer 280

* unilateral throbbing headache, hours * aura * N&V * photophobia * phonophobia * still/reduction in function

Question 281

acute management of migraine

Answer 281

* oral triptan e.g. sumitriptan * analgesia - OTC * anti-emetic e.g. metoclopramide

Question 282

long term management of migraine

Answer 282

* **conservative** * trigger avoidance * OCP CI (meds r/v) * **medical** * indicated - multiple episodes in month * 1st line - propranolol (F), topiramate * 2nd - amitriptyline

Question 283

what is motor neurone disease

Answer 283

Motor neurone disease refers to a spectrum of heredodegenerative disease of the peripheral and central motor neurones has UMN and LMN features

Question 284

what are the 4 types of MND?

Answer 284

* amyotrophic lateral sclerosis * bulbar amyotrophic lateral sclerosis * progressive muscular atrophy * progressive lateral sclerosis

Question 285

what is the most common form of MND?

Answer 285

amyotrophic lateral sclerosis

Question 286

key features of bulbar amyotrophic lateral sclerosis

Answer 286

* early bulbar involvement * dysarthria, dysphagia, wasted fasciculation tongue * poor prognosis

Question 287

investigations for MND

Answer 287

* **bedside** - neuro examination * **bloods** - CK, ESR, anti-ganglioside AB (Exclude GBS) * **imaging** - MRI head and spine * **special** * nerve conduction studies * spirometry

Question 288

management of MND

Answer 288

* neurology MDT * **conservative** * PT/OT * education * psych * **medical** * _riluzole_ * respiratory support e.g. NIV * symptom management * cramps → quinine * spasticity → baclofen * pain Tx

Question 289

what is the medication used to treat/prolong life in MND?

Answer 289

riluzole

Question 290

what is MS?

Answer 290

MS is an autoimmune condition whereby T cell mediated immune response leads to discrete areas of demyelination within the CNS.

Question 291

what are the types of MS?

Answer 291

* Relapsing-remitting - 80% at PC * Primary progressive * Progressive-relapsing disease * Secondary progressive

Question 292

what criteria is used to diagnose MS?

Answer 292

McDonald

Question 293

what investigations for MS?

Answer 293

* **bedside** - neuro + eye exam * **blood** - exclude other causes * **imaging** * MRI brain + spine with contrast (plaques of demyelination) * **special** * LP - IgG oligoclonal bands, electrophoresis

Question 294

management of acute MS relapse?

Answer 294

1. high dose glucocorticoids 2. plasma exchange if no response to steroids

Question 295

long term management of MS

Answer 295

* MDT neuro * **conservative** * PT/OT, psych, education * **medical - disease modifying** * beta-interferon (glatiramir) - 1st line * biologic - natalizumab * **medical - symptoms** * spasticity - baclofen * clonazepam - tremor * anti-cholinergic/catheter = bladder dysfunction

Question 296

what is the 1st line disease modifying drug for MS?

Answer 296

beta-interferon (glatiramir)

Question 297

what is a biologic used in MS?

Answer 297

natalizumab prevents migration of leucocytes over BBB by blocking receptor

Question 298

what are the key Ab in myasthenia gravis?

Answer 298

anti-acetylcholine receptor Ab

Question 299

what is myasthenia gravis associated with? how to assess?

Answer 299

thymoma CT chest

Question 300

what are complications of myasthenia gravis?

Answer 300

* myasthenic crisis (respiratory failure) * reduced QOL

Question 301

how to differentiate myasthenia gravis from lambert eaton?

Answer 301

MG - worse with repetition LE - better with repetition

Question 302

management of acute myasthenia gravis crisis

Answer 302

1. A-E 2. serial FVC monitoring _+_ ventilatory support 3. steroids 4. IVIG or plasmapheresis if severe/steroid unresponsive

Question 303

long term management of myasthenia gravis

Answer 303

* thymectomy if thymoma + * anti-cholinesterase inhibitor - **pyridostigmine**

Question 304

core features of parkinson's

Answer 304

rest tremor rigidity bradykinesia postural instability

Question 305

what are the parkinson plus syndromes?

Answer 305

* progressive supranuclear palsy - impaired downgaze * multiple system atrophy - autonomic + cerebellar signs * corticobasal degeneratoin * lewy-body - fluctuating consciousness, hallucination

Question 306

what is the underlying issue in parkinsons (pathology)

Answer 306

loss of DA neurons in substantia nigra

Question 307

medical management of parkinson's disease

Answer 307

* Levodopa + COMT inhibitor * inhibitor - prevent peripheral metabolism * Levodopa - boost DA levels

Question 308

key features of tension headache

Answer 308

* mild * bilateral, non pulsatile headache * tight band * often end of day/associated with stress

Question 309

management of tension headache

Answer 309

* OTC pain relief - advice r.e. overuse * stress management * reassure benign condition

Question 310

TIA vs stroke?

Answer 310

TIA refers to focal neurology which resolves with no evidence of infarct on scans (MRI)

Question 311

what are the Ix for TIA

Answer 311

* **bedside** * neuro exam + cardio * BP * ECG * **bloods** * FBC, U&E, LFTs, lipids, glucose * **imaging** * CT head (acute, current neurology) * diffusion weight MRI - assess for ischemia * carotid USS

Question 312

what is the initial management of TIA?

Answer 312

* 300mg aspirin * referral * ongoing neuro Sx → A&E * TIA in last 7 days → TIA clinic within 24 hours * TIA \> 7 days → TIA clinic within a week

Question 313

long term management of TIA

Answer 313

* CVD risk reduction * anti-platelet - clopidogrel * treat AF if present * consider carotid endarterectomy

Question 314

key features of trigeminal neuralgia

Answer 314

* severe sharp pain in trigeminal distribution * unilateral * triggers - light touch, wind, shaving

Question 315

what is the treatment for trigeminal neuralgia?

Answer 315

* **medical** * 1st line - carbamazepine * **surgical** * microvascular decompression

Question 316

what is Wernicke's encephalopathy?

Answer 316

triad of: mental status change + ophthalmoplegia + gait dysfunction

Question 317

what causes Wernicke's encephalopathy?

Answer 317

B12 deficiency

Question 318

what is the management of Wernicke's encephalopathy

Answer 318

* acute * IV pabrinex (thiamine) * long term * reduce drinking if alcoholic * manage liver disease if present

Question 319

definition of achalasia

Answer 319

oesophageal motility disorder of impaired muscle activity leading to failure/incomplete relaxation of the lower oesophageal sphincter

Question 320

gold standard test for achalasia

Answer 320

oesophageal manometry * shows: * Absence of oesophageal peristalsis * Failure of relaxation of lower oesophageal sphincter * High resting lower oesophageal sphincter tone

Question 321

management of achalasia

Answer 321

* **conservative** * reflux management strategies * nutritional support if required * **medical** * botulinum toxin injection * CCB/nitrates - short lasting effect * **surgical** * oesophageal endoscopic balloon dilatation * Heller's myotomy - division of lower oesophageal sphincter

Question 322

stages of alcoholic liver disease

Answer 322

fatty liver → alcoholic hepatitis → alcoholic cirrhosis

Question 323

what LFT would suggest alcoholic liver disease?

Answer 323

* **LFTs** - ↑ AST + ALT, **_AST:ALT \> 2_** → indicative of alcoholic liver disease; ↓ albumin * **GGT** - ↑↑

Question 324

what is seen on biopsy of alcoholic liver disease?

Answer 324

* centrilobar hepatocyte balooning * Mallory-Denk bodies (mallory-hyaline inclusion) * evidence of inflammation and fibrosis

Question 325

management of alcoholic liver disease

Answer 325

* **acute** * acute withdrawal - chlordiazepoxide + pabrinex * manage liver decompensation as appropriate * **conservative** * reduce ETOH * **medical** * *prednisolone* * **surgical** * liver transplant - abstinent for 3/12

Question 326

causes of anal fissure

Answer 326

* primary * secondary * constipation * IBD * STI * rectal malignancy * birth

Question 327

management of anal fissure

Answer 327

* **conservative** * high fibre diet + good hydration * **medical** * laxatives - bulk forming (ispaghula husk) * local anaesthetic ointment * GTN ointment if \> 1 week + no improvement * Topical 2% diltiazem, specialist guidance * **surgical** * lateral sphincterotomy - unresponsive to medical Tx

Question 328

management of anal fissure

Answer 328

* **conservative** * high fibre diet + good hydration * **medical** * laxatives - bulk forming (ispaghula husk) * local anaesthetic ointment * GTN ointment if \> 1 week + no improvement * Topical 2% diltiazem, specialist guidance * **surgical** * lateral sphincterotomy - unresponsive to medical Tx

Question 329

what are the signs associated with appendicitis?

Answer 329

* periumbilical pain → RIF * **Rovsing's sign** - palpation of LIF produces pain in RIF * **Psoas sign** - RIF pain with extension of right hip * **Cope sign** - pain on flexion + internal rotation of hip (occurs if appendix near obturator internus)

Question 330

differentials for appendicitis?

Answer 330

* Gynae - ovarian cyst accident, ectopic, PID * Renal - ureteric stone, UTI * GI - obstruction, strangulated hernia, IBD * Urological - testicular torsion, epididymo-orchitis * Other - DKA, pneumonia, porphyria

Question 331

what score is used for appedicitis?

Answer 331

Alvarado

Question 332

what is the management of appendicitis?

Answer 332

* **Medical** * Septic 6 - if required * IV antibiotics - cefuroxime, metronidazole * NBM + IVF + analgesia + anti-emetic * **Surgery** * Laparoscopic appendicectomy (1st line)

Question 333

antibodies associated with autoimmune hepatitis

Answer 333

* type 1 - anti-smooth muscle Ab, ANA * type 2 - anti liver/kidney microsomal Ab type 1

Question 334

what are the nerves for the ankle reflex?

Answer 334

**S1**/S2

Question 335

nerves for patella reflex?

Answer 335

L3/L4

Question 336

nerve for triceps reflex?

Answer 336

**C7**-C8

Question 337

nerve for biceps reflex?

Answer 337

C5/**C6**

Question 338

supinator reflex (brachioradialis) nerve root

Answer 338

C5/**C6**

Question 339

management of autoimmune hepatitis

Answer 339

* **Medical** * Induction → _steroids_ * Maintenance therapy → _azathioprine_ * _Vaccinate_ against hepatitis A and B, test prior to vaccination * surveillance for HCC → USS + serum AFP * **Surgical** * _Liver transplant_ - terminal stages, recurrence after transplant occurs in some

Question 340

what is Barret's oesophagus?

Answer 340

Barrett's oesophagus refers metaplasia of squamous epithelium to columnar epithelium following chronic acid exposure

Question 341

Ix for Barret's

Answer 341

* Gi examination * H. pylori testing * endoscopy + biopsy - _histological diagnosis_

Question 342

complications of Barret's oesophagus

Answer 342

Oesophageal adenocarcinoma, oesophageal stricture

Question 343

management of Barret's oesophagus

Answer 343

* **Conservative -** all * ↓ ETOH intake, normal weight * meds r/v - ↓ gastric protection or affecting oesophageal motility * Reflux prevention * **No dysplasia** * Endoscopy every 2-5 years * **Low grade dysplasia** * High dose PPI (BD) * Endoscopic surveillance every 6/12, quandrantic biopsies every 1cm * **High grade dysplasia** * Endoscopy every 3/12 * Treat any visible lesions → resection (photodynamic, radiofrequency or laser)

Question 344

what is cholangiocarcinoma?

Answer 344

* cancer of biliary tree - usually extrahepatic * most common at bifurcation of hepatic duct * 95% adenocarcinoma

Question 345

what is the tumour marker for cholangiocarinoma?

Answer 345

CA19-9

Question 346

management of cholangiocarcinoma

Answer 346

* **Management under MDT** * **_Curative treatment_** * **Surgical** * **Complete surgical resection** - gives definitive treatment * Intrahepatic and tumours at hepatic bifurcation → *partial hepatectomy and reconstruction of biliary tree* * Distal common duct tumours - *pancreaticoduodenectomy* (Whipple's procedure) * **Radiotherapy** * **_Palliative treatment_** * ERCP stenting - dilate bile duct to relieve obstruction * Surgical bypass procedures * Chemotherapy

Question 347

what is cirrhosis?

Answer 347

Cirrhosis refers to the diffuse fibrosis and structural abnormality of liver characteristic of chronic liver disease * impairment of Liver function

Question 348

major causes of cirrhosis

Answer 348

Alcoholic liver disease * Non-alcoholic fatty liver disease * Chronic viral hepatitis * Autoimmune hepatitis * Biliary causes - PBC, PSC * Genetic causes - haemochromatosis, Wilson's disease, alpha-1 antitrypsin deficiency, * Medications * Budd-Chiari syndrome

Question 349

liver panel bloods

Answer 349

* LFTs * bone profile + albumin * FBC + clotting * U&E - hepatorenal * cause: * viral hepatitis serology * iron studies * auto-antibodies - smooth muscle, anti-mitochondrial, etc * aceruloplasmin * alpha-1 anti-trypsin

Question 350

what are the components of the Child Pugh score?

Answer 350

* Albumin * Bilirubin * Clotting - PT/INR * Distended abdomen - Ascites * Encephalopathy graded A-C with C most severe, high risk for variceal bleed if B/C

Question 351

what is coeliac disease?

Answer 351

T cell mediated inflammation AI disease due to sensitivity to gluten components (prolamin) resulting in villous atrophy + malabsorption

Question 352

investigations for coeliac disease

Answer 352

* **bedside** * stool MC&S - exclude infection * **bloods** * total IgA * IgA anti-TTG, and IgA anti-endomysial * FBC, U&E/bone profile, LFT, iron, B12, folate * **imaging** * **specialist** * jejunal/duodenal biopsy - villous atrophy, crypt:villous ratio \< 2:1

Question 353

what are the biopsy features of coeliac?

Answer 353

* villous atrophy, ↑ intraepithelial lymphocytes, crypt hyperplasia * ↓ crypt: villous ratio ( \< 2:1)

Question 354

what do patients going for endoscopy for coeliacs need to do?

Answer 354

eat gluten for 6 weeks

Question 355

management of coeliac

Answer 355

* **conservative** * **gluten exclusion** * **medical** * screening for other AI disease * management malnutrition complications e.g. Fe2+ supplements

Question 356

what cancer is coeliac a RF for?

Answer 356

T cell lymphoma (enteropathy associated T cell lymphoma)

Question 357

what are the familial syndrome associated with colorectal cancer?

Answer 357

* familial adenomatosis polyposis - APC gene * Gardner's * Peutz-Jegher's * hereditary non-polyposis colorectal cancer (NPCC/Lynch syndrome)

Question 358

what runs through the cavernous sinus?

Answer 358

* Abducens nerve (CN VI) * Carotid plexus (post-ganglionic sympathetic nerve fibres) * Internal carotid artery (cavernous portion)

Question 359

what runs lateral to the cavernous sinus?

Answer 359

* Oculomotor nerve (CN III) * Trochlear nerve (CN IV) * Ophthalmic (V1) and maxillary (V2) branches of the trigeminal nerve

Question 360

investigations for colon cancer?

Answer 360

* **bedside** * GI examination + DRE * faecal immunohistochemistry test * **bloods** * CEA - tumour marker * routine * **imaging** * barium enema - apple core stricture * CT colonoscopy - if unable to do actual * Staging CT (CAP) * **specialist** * colonoscopy + biopsy = gold standard for diagnosis

Question 361

what is the tumour marker for colon cancer?

Answer 361

carcinoembryonic antigen (CEA)

Question 362

describe the 2WW for colorectal cancer

Answer 362

* _\>_ 40 + unexplained weight loss + abdominal pain * _\>_ 50 + unexplained PR bleeding * _\>_ 60 with IDA or changes in bowel habit * +ve occult blood in faeces

Question 363

describe the screening for colorectal cancer

Answer 363

* Kit sent at: 56 years, then every 2 years from 60-74 * Colonoscopy if +ve * ↓ risk of dying from bowel cancer by 16% * Offer another FIT to those with PR bleeding, IDA, CIBH who don't meet 2WW

Question 364

describe the Duke's criteria for colorectal cancer

Answer 364

Question 365

what is the management of colorectal cancer?

Answer 365

* **Management under MDT** * **curative** * **surgery → Resection** * Type of surgery is depending on region affected by malignancy * **_+_ chemotherapy** (before or after depends on staging) * **_+_ neoadjuvant radiotherapy** - _rectal_ cancers * **Non-surgical treatments** * FOLFOX or FOLRIR chemotherapy regime - unsuitable for surgery * Stenting - palliative procedure for symptomatic relief

Question 366

what are the surgeries for colorectal cancer?

Answer 366

* _No rectal-disease_ * Right hemicolectomy - caecum + ascending colon * Left hemicolectomy - distal transverse colon descending colon * Sigmoid colectomy - sigmoid colon * _Rectal disease_ * Anterior resection - tumour \> 8cm from anal canal or involving proximal 2/3 of rectum * Abdomino-perineal resection - tumour \< 8cm from anal canal or involves distal 1/3 of rectum

Question 367

key histological features of Crohn's

Answer 367

* transmural inflammation * goblet cells * non-caseating granulomas

Question 368

features of crohn's

Answer 368

* mouth → anus * skip lesions * bowel obstruction * fistula * usually non bloody diarrhoea * arthritis * erythema nodosum * pyoderma gangrenosum

Question 369

features of UC

Answer 369

* continuous disease * no inflammation beyond submucosa * crypt abscess * bloody diarrhoea * PSC * uveitis * colorectal cancer * erythema nodosum * pyoderma gangrenosum

Question 370

what is the genetic link with crohn'?

Answer 370

CARD15

Question 371

Ix for Crohn's

Answer 371

* **bedside** * GI examination + PR * faecal calprotectin * **bloods** * FBC, CRP, ER, LFT, bone, TPMT * **imaging** * CT abdomen * **specialist** * ileocolonoscopy + biopsy - gold standard Dx

Question 372

management of Crohn's

Answer 372

* **conservative** * smoking cessation * education + IBD nurse, nutrition * **medical** * remission - corticosteroids * maintenance (\>2/yr) - azathioprine, methotrexate * biologic - TNF-alpa (infliximab) * symptomatic Mx * **surgical** * resection _+_ stoma as required

Question 373

treatment of pyoderma gangrenosum?

Answer 373

topical or systemic steroids ciclosporin if resistant

Question 374

types of diverticular disease

Answer 374

* diverticula - outpouching of gut wall * diverticulosis - asymptomatic * diverticular disease - symptomatic * diverticulitis - inflammation _+_ bleeding

Question 375

RF for diverticulitis

Answer 375

older age, low dietary fibre, obesity

Question 376

complications of diverticulitis

Answer 376

* recurrence * perforation * haemorrhage * abscess * stricture/obstruction * fistula

Question 377

management of diverticulosis?

Answer 377

high fibre diet + fluid intake laxatives if ongoing constipation

Question 378

management of diverticular disease

Answer 378

* high fibre diet * bulk forming laxatives * analgesia * anti-spasmodic - relief cramping if required

Question 379

management of diverticulitis

Answer 379

* admission if severe * antibiotics * co-amoxiclav (IV or PO) * cef + met IV (2nd) * transfusion if required * angiography + embolectomy for haemorrhage if distal branch * surgical * Hartmann's - emergency * resection _+_ stoma elective

Question 380

what are the types of gallstone?

Answer 380

* **cholesterol** (90%) * **pigment** - associated with haemolysis * **mixed stones**

Question 381

RF for gallstone disease

Answer 381

fat, fair (Caucasian), fertile, forties, female, FHx

Question 382

management of biliary colic

Answer 382

1. Analgesia 2. Lifestyle advice - Low fat diet, maintain normal weight, ↑ exercise 3. Elective laparoscopic cholecystectomy - within 6 weeks of 1st PC

Question 383

acute cholecystitis vs ascending cholangitis

Answer 383

* acute cholecystitis - no jaundice * ascending cholangitis - jaundice, transaminases deranged, CBD obstruction

Question 384

what is mirizzi syndrome?

Answer 384

stone in Hartmann's pouch of gallbladder or in cystic duct → can compressed adjacent common hepatic duct causing an obstructive jaundice despite no stone in the CBD

Question 385

what is gallstone ileus?

Answer 385

after formation of a cholecystoduodenal fistula → gallstone passes into bowel and impacts terminal ileum → small bowel obstruciton

Question 386

what are features of mild vs moderate vs severe cholecystitis

Answer 386

* **mild** - stable, short Hx * **moderate** - majority, raised WCC, palpable mass in RUQ, \> 72hrs, localised inflammation * **severe** - resistant hypotension, lowered GCS, oliguria, hepatic dysfunction, hypoxia

Question 387

management of mild cholecystitis

Answer 387

* oral antibiotics * analgesia (OTC) * early laparoscopic cholecystectomy - 1 week within 1st PC

Question 388

management of moderate cholecystitis

Answer 388

* A-E + admit + general surg. pt Tx * IV antibiotics * laparoscopic cholecystectomy - within 1 week (NICE) * percutaneous cholecystostomy - IR, unfit for surgery + not responding to Abx, drain insertion + delayed cholecystectomy (6 weeks)

Question 389

management of severe cholecystitis

Answer 389

* as moderate _+_ ICU * more likely for drain + delayed cholecystectomy * open cholecystectomy if: mass, sig. inflammation or bleeding, pregnant

Question 390

major organisms of ascending cholangitis?

Answer 390

E. coli, klebsiella, enterococcus

Question 391

what is Charcot's triad? what for?

Answer 391

RUQ pain + fever + jaundice ascending cholangitis

Question 392

management of ascending cholangitis

Answer 392

* A-E, resuscitation * IV antibiotics * ERCP (1st line) * percutaneous transhepatic cholangiography - T-tube for drainage (2nd) * cholecystectomy - definitive

Question 393

indications for ERCP

Answer 393

* Choledocholithiasis * Acute pancreatitis * Chronic pancreatitis (dilatation or stent placement) * Lesion within biliary system that requires biopsy * Dilatation of benign stricture * Manometry reading for sphincter of Oddi dysfunction

Question 394

types of gastric cancer

Answer 394

* adenocarcinoma (95%) * intestinal type - smoking, chronic gastritis, lesser curve * diffuse type - signet cell CA, leather bottle stomach * SCC * lymphoma/MALT - H.pylori

Question 395

what are some associated conditions with gastric cancer

Answer 395

* GI - pernicious anaemia, H. pylori, atrophic gastritis, adenomatous polyps * blood group A * smoking * diet - high nitrates, high salt, low Vit C * nitrosamine exposure

Question 396

where does gastric cancer usually affect?

Answer 396

antrum

Question 397

investigations for gastric cancer

Answer 397

* **bedside** * GI examination * **bloods** * FBC, LFTs * **imaging** * endoscopic USS - assess depth * CT CAP * **specialist** * gastroscopy + biopsy

Question 398

2WW for gastric cancer

Answer 398

2WW appointment: * Upper abdominal mass Urgent upper GI endoscopy with 2/52 if: * Dysphagia * _\>_ 55 + weight loss + one of: upper abdominal pain, reflux, dyspepsia

Question 399

management of gastric cancer

Answer 399

* MDT * surgical * early T1a - endoscopic mucosal resection * locally invasive - partial/total gastrectomy + reconstruction _+_ neoadjuvant chemo * medical - nutritional * palliative - majority by time diagnosed

Question 400

causes of GORD

Answer 400

* Lower oesophageal sphincter incompetence * Hiatus hernia * Loss of oesophageal peristaltic function * obesity * _Gastric factors_ - gastric acid hypersecretion, slow gastric emptying * _Patient factors_ - smoking, alcohol, pregnancy * medications (TCA, anti-cholinergic, nitrates) * _Associated conditions_ - systemic sclerosis, H. pylori infection

Question 401

Ix for GORD

Answer 401

* **bedside**- GI exam * **bloods** - FBC * **imaging** * **specialist** * endoscopy (OGD) + biopsy * H. pylori (urea breath, stool antigen) * barium swallow - if ? hernia * 24 hour pH monitoring - gold standard, uncommon

Question 402

management of GORD

Answer 402

* **conservative** * medication r/v * raise bed * smoking cessation, low fat, smaller meals * avoid triggers * **medical** * acute - anti-acid, alginate * PPI

Question 403

management of dyspepsi

Answer 403

* dyspepsia = reflux, no OGD, clinically diagnosed * review meds * trial full dose PPI 4 weeks or “test and treat” H. pylori * treatment resistant → non urgent OGD

Question 404

what should be done after H. pylori eradication treatment in ulcer patients?

Answer 404

test of cure 6-8 weeks after treatment

Question 405

what is the treatment of H. pylori

Answer 405

* PPI + amoxicillin + clarithromycin/metronidazole BD 7 days * pen allergic = PPI + clarithromycin + metronidazole BD 7 days

Question 406

management of GORD

Answer 406

* reflux + histological Dx after OGD * full dose PPI 4-8 weeks * recurrent → high dose PPI * refractory + sever → Nissen fundoplication

Question 407

treatment of C. Diff

Answer 407

* 1st line - oral vancomycin 10/7 or oral fidaxomicin * 2nd line - oral vancomycin _+_ IV metronidazole (1st if severe, life-threatening)

Question 408

key facts of haemochromatosis including issue

Answer 408

* hereditary, AR * increased intestinal iron absorption → iron overload * HFE C282Y Chr 6

Question 409

key Ix for haemochromatosis

Answer 409

* FBC * iron studies - raised ferritin, transferrin saturation, low transferrin, low TIBC * LFTs - deranged * CRP - exclude acute ferritin * HbA1c, hormone levels

Question 410

complications of haemachromatosis

Answer 410

* Liver fibrosis, cirrhosis, hepatocellular carcinoma * Severe myocardial siderosis, cardiac dysfunction * DM * Skin hyperpigmentation * Arthropathy

Question 411

management of haemochromatosis

Answer 411

* venesection - 500mg (450mg iron) 1-2 x week; aim ferritin \< 50 ug/L * desferrioxamine * liver transplant * screening for HCC, monitor ferritin levels

Question 412

what are the types of haemorrhoid?

Answer 412

internal - above dentate external - below dentate line

Question 413

what are the grades of haemorrhoids?

Answer 413

1. Project into lumen of canal but don't prolapse 2. Prolapse on straining but spontaneously reduce 3. Prolapse on straining, require manual reduction 4. Prolapsed and incarcerated, cannot be reduced

Question 414

what is the management of haemorrhoids?

Answer 414

* **conservative** - minimise straining, fibre + fluid * **medical** * laxative * analgesia - LA + steroid * **minor procedure** * rubber band ligation * injection sclerotherapy * photocoagulation * **surgical** * haemorrhoidectomy

Question 415

RF for hepatocellular carcinoma

Answer 415

* hep B and hep C - chronic * alcoholism * haemochromatosis * PBC * aflatoxins * cirrhosis

Question 416

Ix for hepatocellular carcinoma

Answer 416

* LFT * clotting * liver screen * AFP * abdominal USS + biopsy

Question 417

tumour marker for hepatocellular carcinoma

Answer 417

alfa-fetoprotein

Question 418

how to differentiate groin hernia using pubic tubercle?

Answer 418

superior + medial → inguinal inferior and lateral → femoral

Question 419

hernia superior + medial to pubic tubercle

Answer 419

inguinal

Question 420

hernia inferior and lateral to pubic tubercle

Answer 420

femoral hernia

Question 421

differentiating inguinal hernias related to inferior epigastric vessels

Answer 421

direct = medial indirect = lateral

Question 422

differentiating indirect vs direct clinically

Answer 422

pressure on deep inguinal ring and assess cough impulse * direct = protrudes * indirect - no protrusion

Question 423

descriptions of hernia

Answer 423

* **Reducible hernia -** uncomplicated * **Irreducible or incarcerated** - contents of hernia cannot be returned to their original cavity * **Obstruction** - bowel lumen becomes obstructed * **Strangulated** - compression of hernia which cannot be reduced leads to blood supply compromise, leading to the bowel becoming ischaemia

Question 424

RF for femoral hernia

Answer 424

female, pregnancy, raised intra-abdominal pressure, older age

Question 425

RF for inguinal hernia

Answer 425

male, increasing age, raised intra-abdominal pressure, obesity

Question 426

management of inguinal hernia

Answer 426

* **non-surgical/conservative** * small + no sx → watchful wait * RF modification * **surgical** * open mesh repair - primary unilateral * laparoscopic repair - bilateral, recurrent, primary unilateral, female

Question 427

management of femoral hernia

Answer 427

* **surgical** - urgent, within 2 weeks * low or high approach repair relative to inguinal ligament * repair defect with suture or mesh * high approach preferred for emergencies

Question 428

types of hiatus hernia

Answer 428

* **sliding** * 80%, gastro-oesophageal junction moves up into chest * **rolling** * 20%, stomach herniates into chest (upward movement of fundus)

Question 429

management of hiatus hernia

Answer 429

* **conservative** * elevate head at night, small meals, avoid alcohol, smoking cessation * **medical** * PPI * **surgical** * Nissen fundoplication

Question 430

what is acute mesenteric ischaemia?

Answer 430

* acute compromise to blood flow, usually emboli in arteries, usually small bowel * Life-threatening, surgical emergency * Sudden onset intestinal hypoperfusion * Most common site → superior mesenteric artery

Question 431

what is chronic mesenteric ischaemia

Answer 431

* "intestinal angina", ↓ blood supply which gradually deteriorates over time, usually due to atherosclerosis * Common sites - coeliac trunk, SMA, IMA

Question 432

what is ischaemic colitis?

Answer 432

acute but transient compromise in blood flow to _large bowel_. Can result in _inflammation_, ulceration and haemorrhage

Question 433

causes of acute mesenteric ischaemia

Answer 433

* thrombus due to atherosclerotic plaque * emboli - AF, aneurysm * non-occlusive e.g. cardiogenic shock * venous occlusion + congestion

Question 434

definitive diagnostic test for acute mesenteric ischaemia\>

Answer 434

**CT abdomen with IV contrast (CT angiogram)** - triple phase scan with thin slices in arterial phase → definitive diagnosis of acute mesenteric

Question 435

management of acute mesenteric ischaemia

Answer 435

* A-E, admit, surgical Tx + referral * surgical * necrotic bowel resection * re-vascularisation - IR + angioplasty 1st line

Question 436

management of chronic mesenteric ischaemia

Answer 436

* **conservative** - cardio RF modification * **medical** * anti-platelet + statin * nutritional optimisation * **surgical** * EVAR - angioplasty and stenting of mesenteric vessels * open re-vascularisation (endartectomy or bypass)

Question 437

management of ischaemic colitis

Answer 437

* supportive care incl. transfusion * broad spec IV Abx * surgery - if generalised peritonitis, perforation, ongoing bleeding, failed conservative Tx

Question 438

causes of small bowel obstruction?

Answer 438

**HAT** Hernia Adhesions Tumour

Question 439

causes of large bowel obstruction?

Answer 439

**CVS** cancer volvulus strictures (diverticular \> IBD)

Question 440

pathophysiology in SBO

Answer 440

The blockage → proximal dilation → perforation. In acute cases hyperperistalsis distal to obstruction occurs leading to diarrhoea.

Question 441

pathophysiology of LBO

Answer 441

Colon proximal to obstruction dilates → increased colonic pressure → mesenteric blood flow reduced → mucosal oedema. If arterial supply is compromised → ulceration and necrosis. Perforation eventually occurs

Question 442

management of sigmoid volvulus

Answer 442

* decompression with flexible sigmoidoscope * open/laparoscopic repair if fails

Question 443

management of SBO

Answer 443

* conservative * dip + suck * water soluble contrast study - if no contrast in colon after 6 hrs → surgery * surgery * adhesionlysis, resection, hernia repair

Question 444

what are the functional bowel obstructions?

Answer 444

paralytic ileus pseudo-obstruction (large bowel)

Question 445

what is the criteria for IBS?

Answer 445

**Manning criteria for IBS - NICE recommended** * At least 6/12 * Abdominal discomfort of pain relieved by defecation or associated with altered bowel habit or stool form * At least 2 of: * Altered stool passage e.g. straining or urgency * Abdominal bloating * Symptoms made worse by eating * Passage of mucus

Question 446

how to diagnose IBS?

Answer 446

* diagnosis of exclusion * conservative * diet, review fibre, low FODMAP * medical - symptomatic * anti-spasmodic - buscopan * prokinetic (metoclopramide) * anti-diarrhoea - loperamide * laxative * psych - CBT, relaxation

Question 447

what is the most common cause of amoebic liver abscess? + treatment

Answer 447

Entamoeba histolytica metronidazole _+_ drainage/resection

Question 448

what scores are used to assess for liver transplant?

Answer 448

MELD score - chronic liver disease King's college hospital criteria - acute liver failure

Question 449

factors in Child Pugh score

Answer 449

Albumin Bilirubin Clotting (INR) Distended abdomen (ascites) Encephalopathy (present, grade) A-C, associated with life expectancy

Question 450

complications of liver failure

Answer 450

* infection - usually bacterial * cerebral oedema + high ICP * bleeding * hypoglycaemia * SBP * portal HTN * variceal bleeding * hepatorenal syndrome

Question 451

management of ascites?

Answer 451

* dietary salt + fluid restrict * spironolactone _+_ furosemide * therapeutic paracentesis * IV albumin * \< 15 g/L prophylactic Abx (ciprofloxacin) * TIPSS procedure

Question 452

when to give ABx in ascites? and which?

Answer 452

\< 15 g/L protein in ascitic fluid or previous SBP ciprofloxacin

Question 453

management of SBP

Answer 453

broad spectrum IV Abx

Question 454

describe serum-ascites albumin gradient

Answer 454

> over 11g/L = transudate \< 11 g/L = exudate

Question 455

causes of ascitic transudate

Answer 455

* \> 11g/L SAAG * portal HTN * cirrhosis, acute liver failure, liver met/cancer * RH failure * constrictive pericarditis * budd-chiari * portal vein thrombosis

Question 456

causes of ascitic exudate

Answer 456

* SAAG \< 11g/L * low albumin - nephrotic, malnutrition * peritoneal cancers * TB peritonitis * pancreatitis * biliary ascites * post-op lymphatic leak

Question 457

management of hepatic encephalopathy

Answer 457

* conservative * avoid sedatives * 30 degree head tilt * medical * lactulose * rifaximin (secondary prophylaxis) * IV mannitol

Question 458

management of variceal bleeding

Answer 458

* A-E resuscitation * Blood transfusion * Vitamin K, FFP and platelet transfusions as required * **Terlipressin** - splanchnic vasoconstriction, ↓ portal pressure and bleeding * **Broad spectrum Abx** * **Sengstaken-Blakemore tube** - * **Urgent OGD** ideally within 24 hrs (band, sclerotheraoy)

Question 459

long term prophylaxis of variceal bleeding

Answer 459

propranolol (beta blocker)

Question 460

stages of non-alcoholic liver disease

Answer 460

steatosis → steatohepatitis (NASH) → liver fibrosis → cirrhosis

Question 461

what test is used to assess for liver fibrosis?

Answer 461

enhanced liver fibrosis blood test hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1

Question 462

gold standard for diagnosis of NASH

Answer 462

USS guided liver biopsy (histological diagnosis)

Question 463

management of NASH

Answer 463

* refer to HBP team if fibrosis/end stage liver disease * healthy weight (weight loss) * healthy diet * avoid ETOH and hepatotoxic drugs * CVD risk factor modification

Question 464

types of oesophageal cancer?

Answer 464

* **squamous cell** - upper oesophagus, aggressive * **adenocarcinoma** - most common UK, lower ⅓, reflux

Question 465

1st line for focal seizures

Answer 465

carbamazepine or lamotrigine

Question 466

1st line for absence seizure

Answer 466

sodium valproate or ethiosuximide

Question 467

1st line for tonic clonic seizures

Answer 467

sodium valproate or lamotrigine

Question 468

1st line for myoclonic seizures

Answer 468

sodium valproate

Question 469

1st line for atonic seizures

Answer 469

sodium valproate or lamotrigine

Question 470

what is oesophageal adenocarcinoma associated with?

Answer 470

barrett's oesophagus, GORD, smoking, high fat intake

Question 471

Ix for oesphageal cancer

Answer 471

* **bedside** * **blood** - baseline bloods * **imaging** * endoscopic USS - assess depth of invasion * staging CT CAP + neck * **specialist** * OGD + biopsy - gold standard, diagnostic * staging laparoscopy - junctional tumor for intra-peritoneal metastases

Question 472

2WW rules for urgent OGD for oesophageal cancer

Answer 472

* Dysphagia * _\>_ 55 years + weight loss + 1 of: abdominal pain, reflux, dyspepsia

Question 473

management of oesophageal cancer

Answer 473

* MDT * **curative** * adenocarcinoma - surgery _+_ chemo/radiotherapy * oesophagectomy with reconstruction * SCC - chemoradiotherapy * intense nutritional support - jejunostomy * **palliative** - majority * stent * chemo/radiotherapy * nutritional support including RIG

Question 474

types of pancreatic cancer

Answer 474

* ductal adenocarcinoma = 90%, from exocrine region * exocrine tumours * endocrine tumours - derived from islet cell, better prognosis

Question 475

where is the most common site for pancreatic cancer?

Answer 475

head

Question 476

Rf for pancreatic cancer

Answer 476

* smoking * chronic pancreatitis * diet - high red meat * FHx - MEN, HNPCC, FAP, VHL * late onset DM

Question 477

Ix for pancreatic cancer

Answer 477

* **bedside** * **bloods** - baseline * CA19-9 (tumour marker), clotting * **imaging** * abdominal USS * CT imaging with panreatic protocol (HR) - _gold standard for prelim diagnosis_ * endoscopic USS _+_ biopsy

Question 478

2WW for pancreatic cancer

Answer 478

_\>_ 40 + jaundice

Question 479

management of pancreatic cancer

Answer 479

* MDT * **curative** * radial resection * adjuvant chemotherapy * **palliative** - majority * chemotherapy * symptom control - biliary stenting, Creon, pain management (coeliac plexus block)

Question 480

what are the radical resections for pancreatic cancer?

Answer 480

* **Pancreaticoduodenectomy (Whipple's)** + **regional lymphadenectomy** → if _head_ of pancreas cancer * Remove head of pancreas, antrum of stomach, 1st + 2nd part of duodenum, CBD, gallbladder * **Distal pancreatectomy _+_ splenectomy + regional lymphadenectomy** → if _body/tail_ of pancreas cancer * High morbidity associated

Question 481

causes of acute pancreatitis

Answer 481

**GET SMASHED** (mnemonic) * ***Gallstones*** * ***Ethanol*** * Trauma * Steroids * Mumps * Autoimmune (PAN, SLE) * Scorpion bite * Hyperlipidaemia, hypothermia, **hypercalcaemia** * **ERCP** and emboli * Drugs - azathioprine, NSAIDs, diuretics

Question 482

ix for pancreatitis (acute)

Answer 482

* **bedside** - exam * **blood** * VBG * bone profile - Calcium * LFT + albumin * clotting * serum amylase/lipase * lipase - more sensitive * **imaging** * abdominal USS - ?gallstones * **specialist** * calculate glasgow score

Question 483

when should a contrast enhanced CT be done in pancreatitis and why?

Answer 483

6-10 days after PC assess for severity - indicated if persistent inflammatory response or organ failure e.g. detect pseudocyst

Question 484

describe the glasgow criteria for pancreatitis

Answer 484

* **P**aO2 \< 8kPa on ABG * **A**ge _\>_ 55 years * **N**eutrophilia – WBC \> 15x 10⁹/L * **C**alcium \<2mmol/L * **R**enal function – urea \>16mmol/L * **E**nzymes – LDH \>600iu/L or AST \> 200 iu/L * **A**lbumin \< 32 g/L (serum) * **S**ugar – blood glucose \> 10mmol/L

Question 485

complications of acute pancreatitis

Answer 485

* Chronic pancreatitis * DIC, ARDs, hypocalcaemia, hyperglycaemia * Pancreatic necrosis, pancreatic pseudocyst, pancreatic abscess, haemorrhage

Question 486

management of acute pancreatitis

Answer 486

* A-E, admit, glasgow \> 3 ITU * conservative * UO * medical * treat underlying e.g. ERCP * aggressive IV fluid resuscitation * NG if sig. vomit else oral intake as tolerated * opioid analgesia * broad spec Abx if confirmed necrosis * surgical * pancreatic debridement

Question 487

management of pancreatic pseudocyst

Answer 487

* 50% spontaneously resolve, give up to 12 weeks to resolve * If there after 6/52 unlikely to resolve → surgical debridement or endoscopic drainage often into stomach

Question 488

causes of chronic pancreatitis

Answer 488

* Chronic alcohol excess (80%) * Idiopathic (15-20%) * Cystic fibrosis * Obstruction - pancreatic cancer * Recurrent acute pancreatitis * Metabolic - ↑ triglycerides, hypercalcaemia * Autoimmune - autoimmune pancreatitis, SLE

Question 489

what is chronic pancreatitis?

Answer 489

caused by chronic inflammation and fibrosis of both the exocrine and endocrine components of the pancreas

Question 490

Ix for chronic pancreatitis

Answer 490

* baseline bloods * glucose/HbA1c * faecal elastase * AXR/CT - pancreatic calcification * secretin stimulation test - only if dx uncertain

Question 491

management of chronic pancreatitis

Answer 491

* **conservative** * reduce alcohol * **medical** * analgesia _+_ coeliac plexus block * insulin * Creon - exocrine enzyme replacement * A, D, E, K vitamin supplement * **surgical** * pancreatectomy

Question 492

duodenal vs gastric ulcer

Answer 492

* duodenal more common 4:1 * worse after eating - gastric * better with food, worse with fast/night → duodenal

Question 493

tests for peptic ulcer disease

Answer 493

* **bedside** * H. pylori carbon 13 urea breath test * H. pylori stool antigen * **blood** - FBC, CRP * **imaging** * erect CXR in acute * **specialist** * upper GI endoscopy

Question 494

prep urea breath test for h. pylori what can't patients do?

Answer 494

No Abx or bismuth products for 4 weeks and no PPI for 2 weeks before H. Pylori diagnosis

Question 495

complications of peptic ulcer disease

Answer 495

gastric outlet obstruction, upper GI bleed, perforation

Question 496

acute management of peptic ulcer disease

Answer 496

* A-E approach * Urgent endoscopy * PPI after endoscopy * Urgent intervention angiography with trans-arterial embolization or surgery * If endoscopic procedures fail or too unstable for endoscopy

Question 497

management of peptic ulcer disease

Answer 497

* **conservative** * stop smoking, less ETOH * diet - avoid trigger, healthy, weight loss * medication r/v * stress management * **medical** * 4-8 weeks full dose PPI * H. pylori eradication if +ve * **surgical** * partial gastrectomy in severe/emergencies

Question 498

what drugs are associated with peptic ulcer disease

Answer 498

NSAIDS, steroids, bisphosphonates, potassium supplements, SSRIs, cocaine

Question 499

management of peri-anal fistula

Answer 499

* asymptomatic - watch and wait * surgical * drainage seton (1st line if trans-sphinteric) * fistulotomy (1st line if low, submucosal fistula)

Question 500

definition of portal hypertension

Answer 500

portal HTN is abnormally high pressure in hepatic portal vein \> 10 mmHg

Question 501

causes of portal HTN

Answer 501

* **pre-hepatic** * thrombosis (splenic vein) * extrinsic compression * **intra-hepatic** * cirrhosis * idiopathic portal HTN * **post-hepatic** * Budd-chiari * right heart failure * constrictive pericarditis

Question 502

management of portal HTN

Answer 502

* **conservative** * salt restriction _ fluid * **medical** * spiro _+_ furo * non-selective beta blocker - propranolol * terlipressin - acute * **surgical** * transjugular intrahepatic portosystemic shunt (TIPSS) * liver transplant

Question 503

definition of primary biliary cirrhosis

Answer 503

Autoimmune inflammatory destruction of the **intrahepatic bile ducts** which results in cholestasis and progressive development of cirrhosis over many years.

Question 504

antibody for primary biliary cirrhosis

Answer 504

anti-mitochondrial

Question 505

treatment of PBC

Answer 505

* conservative * avoid systemic oestrogen * medical * **ursodeoxycholic acid** - can induce remission * cholestyramine - itch tx * surgical - transplant (liver)

Question 506

what is primary sclerosing cholangitis?

Answer 506

chronic cholestatic disorder characterised by inflammation and fibrosis of _intrahepatic and extrahepatic_ bile ducts, resulting in multifocal biliary strictures

Question 507

what is PSC associated with?

Answer 507

IBD esp. UC

Question 508

antibodies associated with PSC

Answer 508

pANCA anti-smooth muscle

Question 509

Ix for PSC

Answer 509

* LFT * anti-smooth muscle, pANCA * biliary tree USS - duct dilation * ERCP/MRCP - beading of bile ducts * biopsy - onion skinning fibrosis

Question 510

management of PSC

Answer 510

* yearly screening for malignancy * cholestyramine - manage pruritus * stricture dilation via ERCP * liver transplant

Question 511

what is ulcerative colitis?

Answer 511

Ulcerative colitis is the most common form of inflammatory granulomatous bowel disease * Characterised by diffuse continual mucosal inflammation of the large bowel, beginning in rectum and spreading proximally

Question 512

investigations of UC

Answer 512

* **bedside -** faecal calprotectin * **bloods** - FBC, CRP, U&Es, LFTs, clotting * **imaging** * AXR - lead pipe colon, thumbprinting, toxic megacolon * barium - lead-pipe * **specialist** * colonoscopy + biopsy = diagnostic

Question 513

how is UC severity graded in acute?

Answer 513

truelove and witt score

Question 514

management of UC

Answer 514

* **Medical** * ***Inducing remission - severe disease*** * IV fluid resuscitation * Nutritional support * Prophylactic heparin - VTE prevention * *IV corticosteroids + immunosuppression (ciclosporin or 5-ASA suppositories)* * ***Inducing remission - mild-moderate*** * topical/oral 5-ASA (aminosalicylates) * _+_ oral prednisolone * Oral tacrolimus * ***Maintaining remission*** * 1st line - 5-ASA's e.g. mesalazine or sulfasalazine * 2nd line - azathioprine * ***Colonoscopic surveillance*** - if \> 10 yrs with \> 1 segment of bowel affected * **Surgical** * Segmental bowel resection _+_ stome * *_Total proctocolectomy_* - curative, forms end-ileostomy

Question 515

what is the most common renal stone?

Answer 515

calcium oxalate

Question 516

what stone is associated with haemolysis?

Answer 516

uric acid renal stone

Question 517

what bacteria is associated with staghorn calculus

Answer 517

proteus made of struvite