Final

Question 1

If an enteric organism (e.g. E.coli), or UTI is the most likely cause of epididymo-orchitis treat with [] (10 days) or [] (14 days).

Answer 1

If an enteric organism (e.g. E.coli), or UTI is the most likely cause - treat with levofloxacin (10 days) or ofloxacin (14 days).

Question 2

How can PDR lead to blindness? [4]

Answer 2

• New blood vessels are very fragile; easily break and leak
• Retinal haemorrhage can lead to acute blindness
• If repeated; leads to fibrosis & scarring
• Can lead to: tractional retinal detachment: when scar tissue or other tissue grows on your retina and pulls it away from the layer underneath

Question 3

What is the management of diabetic retinopathy? [5]

Answer 3

Laser photocoagulation

Anti-VEGF medications such as ranibizumab, bevacizumab & Aflibercept

Vitreoretinal surgery (keyhole surgery on the eye) may be required in severe disease or a vitrectomy may be necessary to clear severe vitreous hemorrhage or to relieve tractional retinal detachment.

Corticosteroids: (triamcinolone, dexamethasone implant) can also be used, particularly in refractory DME.

Pan-retinal photocoagulation (PRP): laser used to make small burns evenly across the peripheral retina - should make blood vessels shrink and dissapear

Question 4

What is the most common cause of visual loss in patients with diabetes? [1]

Describe this [1]

Answer 4

Diabetic macular oedema (DMO)

DMO is the commonest cause of visual loss in patients with diabetes

DMO is characterised by oedematous changes in or around the macula. As the macula is responsible for central vision, affected patients tend to complain of blurred vision when reading or difficulty recognising faces in front of them. DMO is the commonest cause of visual loss in patients with diabetes.9

Question 5

Treatment of mild [2], moderate [2] and severe [4] hypoglycaemia?

Answer 5

Mild:
 Sugary drink, e.g. lucozade, ordinary coke, orange juice
 5-7 glucose tablets, or 3-4 heaped teaspoons of sugar in water

Moderate:
 Glucogel® – 1-2 tubes buccally (into cheek), or jam, honey, treacle massaged into the cheek.
 Intramuscular glucagon if needed

Severe (unconscious)
 Do not put anything in the mouth
 Place the person in the recovery position Administer 0.5-1mg glucagon IM
 If carer is unable to administer glucagon, call 999
 In hospital, administer iv glucose:
- Ideally 75mls of 20% glucose or 150mls 10% glucose over 15 mins
- 50mls 50% glucose can be given, but take care with veins – extravasation can cause chemical burns

Question 6

A patient with DMT2 is presenting with symptoms of gastroparesis.

What drug could you rec. to resolve this? [1]

Answer 6

First line treatment for this condition as recommended by NICE is with Domperidone, a dopamine receptor antagonist

Question 7

Diagnosis of prediabetes involves specific criteria:

Impaired Fasting Glucose (IFG): Fasting blood glucose levels between [] mmol/L

Impaired Glucose Tolerance (IGT): Two-hour oral glucose tolerance test (OGTT) values between [] mmol/L

Answer 7

Diagnosis of prediabetes involves specific criteria:

Impaired Fasting Glucose (IFG): Fasting blood glucose levels between 6.1-6.9 mmol/L

Impaired Glucose Tolerance (IGT): Two-hour oral glucose tolerance test (OGTT) values between 7.8-11.1 mmol/L

Question 8

One or more of which parameters would warrant referral to a high-dependency unit (level 2 care)? [7]

Answer 8

• Blood ketone > 6 mmol/L
• Bicarbonate level < 5 mmol/L
• pH < 7.0
• GCS ≤ 12
• Systolic BP < 90 mmHg
• Hypokalaemia on admission < 3.5 mmol/L

Question 9

State 5 causes of drug induced diabetes [5]

Answer 9

 Glucocorticoids

 b-blockers

 Thiazide diuretics

 Tacrolimus (used in transplantation – may cause “New Onset Diabetes after Transplantation” [NODAT])

 Atypical anti-psychotics – eg. olanzapine, risperidone, clozapine

Question 10

Which drugs are contraindicated for patients with DMT2 who might also be suffering from:

Heart Failure [2]
CKD [1]
Frail / elderly [3]
Obesity [2]

Answer 10

Heart Failure:
- Pioglitazone: causes oedema as an AE
- Saxagliptin: increase risk of HF

CKD [2]
- Caution with SUs

Frail / elderly [3]
- SGLT2i (hypoglycaemia risk)
- GLPs (hypoglycaemia risk)
- Caution with SUs (hypoglycaemia risk)

Obesity
- SUs (weight gain)
- Pioglitzaone (weight gain)

Question 11

Name three anti-VEGF medications used to treat diabetic retinopathy [3]

Answer 11

ranibizumab, bevacizumab & Aflibercept

Question 12

What is the arrow pointing to? [1]

Answer 12

Cotton wool spot

Cotton wool spots appear as grayish/whitish spots with soft, fuzzy edges, giving them a resemblance to a ball of cotton wool. They do not usually appear in clusters like hard exudate.

Question 13

Name this complication of diabetic retinopathy [1]

Answer 13

Diabetic retinopathy is one of several causes of neovascular glaucoma: a type of secondary glaucoma.

Neovascularization can occur within the iris and its trabecular meshwork (rubeosis) causing a narrowing and closure of the drainage angle and therefore increased intraocular pressure.

Question 14

Describe basic overview on how you determine AF tx? [+]

Answer 14

First question: is patient haemodinamically stable?
* if no then DC

If yes, Two questions to ask:
* i. is patient >65 y/o?
* ii. Does patient has history of ischaemic heart disease?

If yes to ANY of the two questions then:
* first line Beta Blockers, second line digoxin

If no to BOTH then
* First line is fleccanide, second line ameodarone

Question 15

Congenital adrenal hyperplasia is caused by a congenital deficiency of the which enzyme? (In most cases) [1]

Answer 15

21-hydroxylase
- In a small number of cases it is caused by a deficiency of 11-beta-hydroxylase rather than 21-hydroxylase.

Question 16

What is the role of 21-hydroxylase? [1]

Answer 16

21-hydroxylase is the enzyme responsible for converting progesterone into aldosterone and cortisol.

Question 17

Autoantibodies directed at the adrenal cortex to the autoantigens [] and [] can be seen in 70% of patients with idiopathic or primary Addison’s disease

Answer 17

Autoantibodies directed at the adrenal cortex to the autoantigens 21-hydroxylase and 17 alpha hydroxylase can be seen in 70% of patients with idiopathic or primary Addison’s disease

Question 18

Which enzyme being suppressed / mutated causes syndrome of apparent mineralocorticoid excess? [1]

Why does that create symptoms of hyperaldosternism? [1]

Answer 18

When 11BHSD-2 enzyme is supressed/mutated - cortisol is NOT deactivated and will binds to MR.
symptoms of hyperaldosteronism

Question 19

Name three causes of adrenal insufficiency caused infections [3]

Answer 19

Pseudomonas aeruginosa
Meningococcal infection
TB

Question 20

A patient has recently started a new medication that has caused them to have decreased free T3/4 levels.

What medication could it be?

• Interaction with calcium carbonate
• Interaction with amlodipine
• Iodine deficiency
• Interaction with aspirin
• Poor adherence to levothyroxine

Answer 20

A patient has recently started a new medication that has caused them to have decreased free T3/4 levels.

What medication could it be?

Interaction with calcium carbonate

• Interaction with amlodipine
• Iodine deficiency
• Interaction with aspirin
• Poor adherence to levothyroxine

Question 21

What is the most common endogenous cause of this Cushings?

Adrenal adenoma

Adrenal carcinoma

Glucocorticoid therapy

Micronodular adrenal dysplasia

Pituitary adenoma

Answer 21

What is the most common endogenous cause of this Cushings?

Adrenal adenoma
- adrenal adenoma (5-10%)

Adrenal carcinoma

Glucocorticoid therapy

Micronodular adrenal dysplasia

Pituitary adenoma

Question 22

Describe the results from high-dose dexomethasone testing for Cushings syndrome, Cushing disease and ectopic ACTH [3]

Answer 22

Question 23

State which pathologies MEN1 [3], MEN2A [3] AND MEN2B [3] relate to

Answer 23

MEN1: 3Ps-
* Pituitary
* Pancreas
* Parathyroid

MEN2a- 3Cs
* Calcitonin- medullary thyroid
* Calcium- parathyroid
* Catecholamines- phaeochromocytoma

MEN2b- big and belly (the big ones and in the tummy)
* Medullary thyroid
* Phaeochromocytoma
* Mucosal tumours- eg GI tract

Question 24

How can you figure out if a patient has bilateral adrenal hyperplasia or renal artery stenosis causing Na++++ and K —-? [1]

Answer 24

Renal artery stenosis will have a raised renin

Question 25

Give differential diagnosis of primary hyperparathyroidism [3]

Answer 25

Thiazide like diuretics [1] Lithium [1] Tertiary hyperparathyroidism [1]

Question 26

How do you treat hyperparathyroidism? - Surgically? [1] - Therapeutically? [1]

Answer 26

 **Parathyroidectomy**  **Cinacalcet** directly lowers parathyroid hormone levels by increasing the sensitivity of the calcium sensing receptors to activation by extracellular calcium, resulting in the inhibition of PTH secretion. Indicated in patients with: - **Chronic renal failure** - **Tertiary hyperparathyroidism**

Question 27

How do you treat ptx with hypocalcaemia: With < 1.9 Ca2+, no symptoms? [2] With < 1.9 Ca2+, symptoms? [2]

Answer 27

 < 1.9 with no symptoms -  **Oral calcium supplements** -  If due to severe vitamin D def, treat with **high dose vit D** (Calcitriol)  < 1.9 with symptoms -  **IV calcium gluconate**

Question 28

How does renal artery stenosis cause HTN? [2]

Answer 28

- **Atherosclerosis** or fibromuscular dysplasia most causes narrowing of the renal arteries - The chronic ischemia produced by the obstruction of renal blood flow leads to adaptive changes in the kidney which include the **formation of collateral blood vessels and secretion of renin by juxtaglomerular apparatus**

Question 29

*TOM TIP:* The MHRA issued a warning in 2019 about the risk of [] in patients taking **carbimazole**. In your exams, look out for a patient on carbimazole presenting with symptoms of [] | NB - not agranulocytosis

Answer 29

TOM TIP: The MHRA issued a warning in 2019 about the risk of **acute** **pancreatitis** in patients taking **carbimazole**. In your exams, look out for a patient on **carbimazole** presenting with **symptoms of pancreatitis** (e.g., severe epigastric pain radiating to the back).

Question 30

Describe the treatment for HBV [3]

Answer 30

Nucleoside analogues: - **Entecavir** - **Tenofovir** AND **PEG-IFN** (peginterferon alfa 2a) If cirrhosis - just E & T

Question 31

Describe HCV treatment: - Length? [1] - Therapies? [3]

Answer 31

**8-12 weeks** **Therapies**: - ARVs: aim sustained virological response (SVR; undetectable serum HCV RNA six months after the end of therapy) - Combination dependent on genotype and stage of fibrosis - currently a combination of **protease** **inhibitors** (e.g. **daclatasvir + sofosbuvir or sofosbuvir + simeprevir**) with or without **ribavirin** are used

Question 32

Which drugs are used if seizures [1] and pyschotic symptoms [1] develop from AWS?

Answer 32

Seizures: **IV Lorazepam** Pyschotic symptoms: **Haloperidol** (blocks D2 receptors)

Question 33

Describe and explain treatment plan for hepatic encephalopathy [3]

Answer 33

**1. Lactulose**: - Increases faecal bulk & peristalsis - Also reduces colonic pH: reduces absorption of NH3 - dose varies from 15-50ml TDS **2. Phosphate enemas:** - fast acting osmotic laxative - STAT if Ptx encephalopathic; after passing stools PRN BD **3. Rifaximin** - antibiotic: diminishes deaminating enteric bacteria to decrease production of nitrogenous compounds - 550mg BD

Question 34

Describe IV NAC infusion regime in paracetamol OD [3]

Answer 34

**First infusion:** - 150mg/kg: one hour **Second infusion:** - 50mg/kg: 4 hours **Third infusion** (can repeat if need) - 100mg/kg: 16 hours

Question 35

Tx for Hep B? [2] Which is safe in pregnancy? [1]

Answer 35

**Tenofocir** - competitive inhibition: replaces the deoxyribonucleitde substrate in HBV DNA - faster acting than entecavir - safe in pregancy **Entecavir** - inhibits RT of Hep B DNA - toxicity in pregnancy

Question 36

Explain specific change in blood flow from portal hypertension contributes to hepatic encephalopathy [1]

Answer 36

**Collaterals** between s**plenic and renal veins**: **spleno-renal shunts**: allow blood from bowel to bypass the liver and leak into systemic circulation, ammonia included (instead of being converted to urea and excreted). Goes to brain

Question 37

How does portal hypertension lead to ascites? [5]

Answer 37

- Increased pressure in portal system causes fluid to leak out of the capillaries in the liver and into peritoneal cavity. Increase in pressure also causes release of splachnic vasodilators. - Drop in circulating volume due to vasodilators on splachnic vessels and fluid forced out causes reduced pressure in kidneys - Renin is released - Aldosterone is secreted via RAAS - Increased aldosterone increase Na+ and therefore fluid reabsorption - Cirrhosis is causes low albumin levels, which decreases oncotic pressure

Question 38

How is spontaneous bacterial peritonitis diagnosed? [2]

Answer 38

**Ascitic** **tap**: - **WCC** > **250** mm3 (neutrophils 80%) - Gram -ve often

Question 39

Tx of SBP? [2]

Answer 39

IV antibiotics: **IV** **cefotaxime** **Human albumin solution**

Question 40

Which immunoglobulins are specifically screened for in a liver screen? [3] Which diseases do they indicate may be more likely?

Answer 40

**IgA**: **ALD** **IgM**: **Primary biliary cholangitis (PBC)** **IgG**: **Autoimmune** **hepatitis**

Question 41

Describe the process of TIPS [2]

Answer 41

- **shunt inserted into portal vein & into hepatic circulation** - reduces portal pressure

Question 42

How do you manage Ptx with ALF? [6]

Answer 42

* **Monitor** for **encephalopathy** and conscious state. * Administer **N-acetylcysteine** in **all patients with acute liver failure,** regardless of aetiology * Insert a urinary catheter and monitor **urine output hourly** * **Blood glucose** should be monitored by nursing staff **every 2 hours for hypoglycaemia.** * Baseline tests depend on the history ie **paracetamol levels following an overdose** * Arrange **USS abdomen with Doppler of hepatic veins**

Question 43

What is dialysis dysequilibrium syndrome? [1]

Answer 43

As urea doesn't leave the BBB as quick so you have excess urea in the brain but lower in circulation so there is a shift of water into the brain **causing cerebral oedema**

Question 44

What MCV results are seen in SCA? [1]

Answer 44

Sickle cell disease causes a **normocytic anaemia with raised reticulocyte count** - due to haemolysis

Question 45

What is the treatment of nephrogenic DI? [1]

Answer 45

**Thiazide like diuretic**: - In simple terms DI leads to the production of vast amounts of dilute urine which is dehydrating and raises the plasma osmolarity, stimulating thirst. The effect of the thiazide causes more sodium to be released into the urine. This lowers the serum osmolarity which helps to break the polyuria-polydipsia cycl

Question 46

Which pathologies make up Men1, 2a & 3a [+]

Answer 46

Question 47

WPW is associated with which cardiac disease? [1]

Answer 47

HOCM

Question 48

? abscess of colon should be investigated by..

Answer 48

Acutely unwell surgical patients should be investigated in a systematic way. Plain abdominal films and an erect chest x-ray will identify perforation. **An abdominal CT scan** (not a CT cologram) with oral and intravenous contrast will help to identify whether acute inflammation is present but also the presence of local complications such as abscess formation.

Question 49

Coagulase-negative, Gram-positive bacteria such as **[]** are the most common cause of neutropenic sepsis

Answer 49

Coagulase-negative, Gram-positive bacteria such as **Staphylococcus epidermidis** are the most common cause of neutropenic sepsis

Question 50

What change is seen in this kidney biopsy? [1]

Answer 50

**Glomeruli are full of crescents.**

Question 51

What does this CT show? [1] Background of XS alcohol

Answer 51

**Pancreatic pseudocyst** A mild jaundice, raised WCC and dense fluid-filled mass on CT are classic findings. Note fluid is less dense than the surrounding tissues and will therefore appear darker on CT

Question 52

If symptomatic, one of the following results is sufficient for diagnosis for DMT2 Random blood glucose ≥ **[]** mmol/l Fasting plasma glucose ≥ **[]** mmol/l 2-hour glucose tolerance ≥ **[]** mmol/l HbA1C ≥ **[]** mmol/mol (6.5%)

Answer 52

If symptomatic, one of the following results is sufficient for diagnosis: Random blood glucose **≥ 11.1mmol/l** Fasting plasma glucose **≥ 7mmol/l** 2-hour glucose tolerance **≥ 11.1mmol/l** HbA1C **≥ 48mmol/mol (6.5%)**

Question 53

In life-threatening bleeds what should you give a haemophiliac A patient? [1]

Answer 53

Haemophilia A affects factor VIII levels, and in major or life-threatening bleeds, **recombinant factor VIII is the most appropriate treatment.** Desmopressin raises factor VIII levels and is used in minor bleeding in haemophilia A; it is not used in major bleeds.

Question 54

How do you differentiate between a sickle cell patient having a splenic sequestration crisis and an aplastic crisis? [1]

Answer 54

Sequestration crisis and aplastic crisis can present similarly, **however the reticulocyte count will typically be high in a sequestration crisis and low in an aplastic crisis.**

Question 55

How can you distinguish between a fibroadenoma and phyllodes tumour? [2]

Answer 55

They can be difficult to distinguish from a fibro-adenoma, as both present as a firm, non-tender, mobile lump in the breast. However, **phyllodes** **tumours** are typically much faster growing and most commonly affect **women in their 40s and 50s**

Question 56

A patient has A 65 year old man presents to the district nurse clinic with acute urinary retention secondary to an enlarged prostate. An immediate urinary catheterisation is attempted and the volume post-catheterisation is recorded as 1200ml. Explain what the next appropriate management is [1]

Answer 56

This patient has a large retention volume of >1000ml. **He should be admitted to monitor for post-obstructive diuresis** - Patients will be at risk for dehydration and **should be monitored closely for their urine output in the hospital and if >200ml/hr urine is being produced**, they should be replaced with intravenous fluids to **avoid acute kidney injury.**

Question 57

How do you differentiate between ASD and VSD based off their murmurs? [2]

Answer 57

**Atrial septal defect** - ejection systolic murmur louder on inspiration **VSD** - would give a pansystolic murmur and is therefore incorrect.

Question 58

Which conditions are DOACs contraindicated in? [1]

Answer 58

In renal failure: if **egfr < 15**

Question 59

If a patient has AF and structural heart disease - what do you give them? [1]

Answer 59

**Amiodarone**

Question 60

What are the 4 stages to testicular tumour spreaD? [4

Answer 60

Question 61

A patient is fat and presents with this symptom. What does it specifically suggest? [1]

Answer 61

**eruptive xanthomas** - **hypertriglyceridemia**

Question 62

What are the rules about anticoagulating post-stroke / or TIA for a patient with AF? [2]

Answer 62

AF post stroke: - following **TIA** - start **immediately** and after excluding haemorrhage - following **stroke** - after **2 weeks**. give **antiplatelet** in **intervening** **period**

Question 63

What are two rules need to consider with regards to AF treatment and DOACs [1] and Amiodarone treatment? [2]

Answer 63

**DOACs** are **contraindicated** in **valvular AF** If **structural heart disease** - **amiodarone** for rhythm control

Question 64

Describe the murmur heard in coarctation of the aorta [1]

Answer 64

Systolic machinery murmur

Question 65

Describe the (very) general management of umbilical and inguinal hernias [2]

Answer 65

remember it using the mnemonic: **Inguinal** **hernia** - get then **IN** for surgery **Umbilical** **hernia** - **um** don't need to operate

Question 66

How much ml of blood is determined as life-threatening haemoptysis? [1]

Answer 66

**more than 120mls of frank blood in 24 hrs**

Question 67

Which drug should be avoided when giving levothyroxine as it reduces the effectiveness? [1] How do you alter dosing timing to alleviate this? [1]

Answer 67

**Ferrous sulphate** should not be taken at the same time as Levothyroxine as the **iron interferes with levothyroxine absorption.** The two medications should be taken **about 2-4 hours** **apart** with the Levothyroxine taken first.

Question 68

Explain the change in JVP waveform you see in tricuspid regurgitation

Answer 68

**Big v waves** - Tricuspid regurg happens during ATRIAL DIASTOLE, and means some blood moves from the ventricle to the atria filling it even more, and sending more of an equal and opposite force upwards to the internal jugular vein hence why we see prominent v waves.

Question 69

Describe these changes seen in CXR [1] What disease does this indicate? [1]

Answer 69

**Ring shadows** in the left lower zone are consistent with **bronchiectasis**.

Question 70

A 25-year-old female presents with a 2-week history of bloating, abdominal cramps, and foul-smelling diarrhoea. Stool studies reveal Giardia lamblia. What is the first-line treatment for this patient's infection?

Answer 70

**metronidazole**

Question 71

How do you treat sigmoid volvulus [1] How

Answer 71

* **sigmoid volvulus**: **rigid** **sigmoidoscopy** with rectal tube insertion * **caecal volvulus**: management is usually **operative**. **Right** **hemicolectomy** is often needed

Question 72

Sputum for TB? [3]

Answer 72

One straight away One morning after One morning after

Question 73

Which type of polyp is associated with colorectal caner? [1] What electrolyte change would this cause? [1]

Answer 73

**Villous polyp** - causes **hypokalaemia**

Question 74

How do you calculate absolute risk? E.g. The study recruited 3000 patients. 1700 received the new drug of which 170 patients developed carpal tunnel syndrome. The remaining patients received a placebo of which 300 developed carpal tunnel syndrome. What is the absolute risk reduction of developing carpal tunnel syndrome by taking the new drug?

Answer 74

The absolute risk of the exposure group is **10% (170/1700)**. The absolute risk of the control group is **23% (300/1300).** Therefore, the absolute risk reduction is **13% (23-10).**

Question 75

The presence of PR prolongation in infective endocarditis is suspicious for **[]**

Answer 75

The presence of PR prolongation in infective endocarditis is suspicious for **aortic root abscess**

Question 76

What can you give to **prevent** calcium stones? [3]

Answer 76

Ask patients to add **lemon juice to water** **Potassium citrate** should be considered for the prevention of calcium stones **limit salt** **avoid carbonated drinkd**

Question 77

Name two things can give to reduce the chance of oxalate stones [2]

Answer 77

**cholestyramine** reduces urinary oxalate secretion **pyridoxine** reduces urinary oxalate secretion

Question 78

What is BCG vaccine good at protecting agaisnt? [1]

Answer 78

**TB meningitis in children**

Question 79

**[]** is the most common complication of **mumps** in **post-pubertal males.** ## Footnote NB: symptoms of mumps - bilateral pain and swelling at the angle of the jaw, which is made worse by talking or chewing. On examination his pulse is 90/min, temperature 38.4ºC and bilateral palpable, tender parotid glands are noted.

Answer 79

**Orchitis** is the most common complication of mumps in post-pubertal males.

Question 80

Name what the arrow is pointing at [1] What drug class might you expect to see them in? [1]

Answer 80

**Hyaline casts may be seen in the urine of patients taking loop diuretics**

Question 81

What is the difference in murmur between pulmonary and tricuspid stenosis? [2]

Answer 81

**Pulmonary stenosis:** ejection systolic **tricuspid stenosis**: diastolic

Question 82

Desribe the early presentation [2] and late presentation [5]of TURP syndrome [2

Answer 82

TURP syndrome typically presents with **CNS, respiratory and systemic symptoms**: **Early features** * mild cases may go **unrecognised** * **restlessness**, **headache**, and **tachypnoea**, or a **burning sensation in the face and hands** **Features of greater severity** * **respiratory** **distress**, **hypoxia**, **pulmonary** **oedema** * **nausea**, **vomiting** * **visual** **disturbance** (e.g. blindness, fixed pupils) * **confusion**, **convulsions**, **and** coma * **haemolysis** * **acute renal failure** * reflex **bradycardia** from fluid absorption

Question 83

Which of the following treatments for prostate cancer works as an non-steroidal anti-androgen? Cytoproterone acetate Degarelix Goserelin Bicalutamide Abiraterone

Answer 83

Which of the following treatments for prostate cancer works as an non-steroidal anti-androgen? Cytoproterone acetate Degarelix Goserelin **Bicalutamide** Abiraterone

Question 84

Which of the following treatments for prostate cancer works is an steroidal anti-androgen? Cytoproterone acetate Degarelix Goserelin Bicalutamide Abiraterone

Answer 84

Which of the following treatments for prostate cancer works is an steroidal anti-androgen? **Cytoproterone acetate** Degarelix Goserelin Bicalutamide Abiraterone

Question 85

Which of the following treatments for prostate cancer works is an androgen synthesis inhibitor? Cytoproterone acetate Degarelix Goserelin Bicalutamide Abiraterone

Answer 85

Which of the following treatments for prostate cancer works is an androgen synthesis inhibitor? Cytoproterone acetate Degarelix Goserelin Bicalutamide **Abiraterone**

Question 86

Which of the following treatments for prostate cancer works is an GnRH antagonist? Cytoproterone acetate Degarelix Goserelin Bicalutamide Abiraterone

Answer 86

Which of the following treatments for prostate cancer works is an GnRH antagonist? Cytoproterone acetate **Degarelix** Goserelin Bicalutamide Abiraterone

Question 87

Which of the following treatments for prostate cancer works is an GnRH agonist? Cytoproterone acetate Degarelix Goserelin Bicalutamide Abiraterone

Answer 87

Which of the following treatments for prostate cancer works is an GnRH agonist? Cytoproterone acetate Degarelix **Goserelin** Bicalutamide Abiraterone

Question 88

Name this form of taking prostate biopsies [1] Why is it better than trans rectal biopsy? [1]

Answer 88

**Template / transperineal biopsy (BP)** Less infections; more biopsies can be taken

Question 89

A guided biopsy is offered to patients with a Likert score of [] or greater

Answer 89

A guided biopsy is offered to patients with a Likert score of **3 or greater** 3 = Chance of clinically significant cancer is equivocal 4 = Clinically significant cancer is likely to be present 5 = Clinically significant cancer is highly likely to be present

Question 90

Describe the treatment types for **localised prostate cancer** [4]

Answer 90

**Radical prostatectomy** (if < 75 and fit): can be **open, laparoscopic or robotic surgery** **Focal therapy:** - **Brachytherapy** (radioactive seeds) - **Cryotherapy** - **HIFU** (High frequency focused ultrasound) **Radiotherapy** **Radiotherapy & androgen deprivation** (stops stimulating the cancer to grow): - **Androgen-receptor blocker**s such as **bicalutamide** - **GnRH** **agonists** such as **goserelin** (Zoladex) or **leuprorelin** (Prostap)

Question 91

A 70-year-old patient with prostate cancer is commenced on goserelin therapy. A week after starting treatment, he attends a local emergency department complaining of worsened lower urinary tract symptoms and new onset back pain. Which treatment may have helped avoid this deterioration? [1]

Answer 91

**Flutamide**, a synthetic antiandrogen, can be used **preemptively to attenuate the tumour flare** through its antagonistic effects at androgen receptors.

Question 92

Which of the following treatments for prostate cancer works by preventing DHT binding from intracytoplasmic protein complexes? Cytoproterone acetate Degarelix Goserelin Bicalutamide Abiraterone

Answer 92

Which of the following treatments for prostate cancer works by preventing DHT binding from intracytoplasmic protein complexes? **Cytoproterone acetate** - steroidal anti-androgen Degarelix Goserelin Bicalutamide Abiraterone

Question 93

Which of the following treatments for prostate cancer is normally the option for the treatment of hormone-relapsed metastatic prostate cancer in patients who have no or mild symptoms after androgen deprivation therapy has failed, and before chemotherapy is indicated? Cytoproterone acetate Degarelix Goserelin Bicalutamide Abiraterone

Answer 93

Which of the following treatments for prostate cancer is normally the option for the treatment of hormone-relapsed metastatic prostate cancer in patients who have no or mild symptoms after androgen deprivation therapy has failed, and before chemotherapy is indicated? Cytoproterone acetate Degarelix Goserelin Bicalutamide **Abiraterone**

Question 94

How do you decide when to use mirabegron or oxybutynin? [2]

Answer 94

**Oxybutynin** - is an immediate-release antimuscarinic drug, often used for urge incontinence. - However it can **lead worsening of dementia** and **postural hypotension** in older patients **Mirabegron** - beta-3 receptor agonist - it is used in **frail** **elderly** **patients** as it has **fewer anticholinergic side-effects** so will **not** worsen **dementia**.

Question 95

How do you treat unilateral and bilateral undescended testes in newborns? [2]

Answer 95

**unilateral undescended testis**: - Arrange a review at 6-8 weeks **bilateral undescended testes**: - Refer to a senior paediatrician for endocrine or genetic investigation - the presence of bilateral undescended testes should prompt the clinician to consider the possibility of an underlying pathology **(commonly congenital adrenal hyperplasia (CAH).**

Question 96

A patient has BPH and concurrent DMT2 peripheral neuropathy. Which treatment for the peripheral neuropathy is CI because of his BPH? [1]

Answer 96

**Amitriptyline** due to the risk of **urinary retention.** ***amyDRIPtyline** - don't prescribe to BPH patients with terminal dribbling*

Question 97

Describe the GI side effects of bisphosphonates like alendronic acid [3] How do you instruct patients to take this medication to reduced the risks? [1]

Answer 97

Alendronic acid, a bisphosphonate used in the treatment of osteoporosis, can cause gastrointestinal side effects, including **dyspepsia, oesophagitis and gastric ulcers**. It is important for patients to take alendronic acid correctly (**with a full glass of water, without lying down for 30 minutes afterwards**) to reduce these risks.

Question 98

Name some CI for sildenafil use for ED? [5]

Answer 98

Individuals taking **nitrates** **Hypertension/hypotension** **Arrhythmias** **Unstable angina** **Stroke** Recent **myocardial infarction.**

Question 99

What is the difference in renal cancer staging between 1-4? [4]

Answer 99

Stage 1: < 7cm; no spread Stage 2: > 7cm; no spread Stage 3: > 7cm; spread locally Stage 4: Spread to abdomen; adrenal glands; lymph nodes

Question 100

Treatment for localised renal cancer?: T1 [2] & T2 [1]

Answer 100

T1 tumours: - < 3 cm: **ablative therapies** - up to 7 cm: **partial nephrectomy** T2: **Radical nephrectomy** (open, laporoscopic, open)

Question 101

Name 4 differential diagnosises of cannonball metastasis

Answer 101

- **renal** - **choriocarcinoma** less commonly, with **prostate**, **bladder** and **endometrial** cancer.

Question 102

Describe what is meant by Stauffer syndrome

Answer 102

**Stauffer syndrome: RCC paraneoplastic syndrome** **Hepatosplenomegaly** + **Cholestatic LFTs** (elevated bilirubin; ALP and GGT)

Question 103

Describe NICE guidelines regarding haematuria that determines investigating for bladder cancer [2]

Answer 103

**Painless haematuria:** **Aged over 45 with unexplained visible haematuria**, either **without a UTI** or **persisting after treatment** for a UTI. 2/3 samples positive for blood require investigation **Aged over 60 with microscopic haematuria** (not visible but positive on a urine dipstick) PLUS: **Dysuria** or; **Raised white blood cells** on a full blood count

Question 104

Describe the treatment for Mild [2], Intermediate [2] & High [3] risk patients of Non-Muscle Invasive Bladder Cancer (NMIBC)

Answer 104

**Mild**: - **Transurethral resection of bladder tumor (TURBT)**: provides diagnosis, staging, and initial treatment of **diathermy** - **Post TURBT** - Intravesical chemotherapy (**mitomycin** or **gemcitabine**) given using a catheter: reduces risk of relapse **Moderate**: - **Transurethral resection of bladder tumor (TURBT):** provides diagnosis, staging, and initial treatment - Post TURBT - Intravesical chemotherapy (**mitomycin**) given using a **catheter; 6 doses** - liquid place directly in bladder **High**: - Transurethral resection of bladder tumor (**TURBT**): **X2** - **BCG vaccine** - **Cystectomy** – totally remove the bladder

Question 105

Describe treatment for Muscle Invasive Bladder Cancer (MIBC) [3]

Answer 105

**Radical cystectomy:** - gold standatd - Complete surgical removal of the bladder, prostate or uterus, and regional lymph nodes - Requires urinary diversion **Radiotherapy:** - organ sparing (Adjuvant &/OR) **Chemotherapy**: - Cisplatin before radical cystectomy

Question 106

Describe the treatment for metastatic bladder cancer [3]

Answer 106

**First-line therapy**: - platinum-based combination chemotherapy, such as **gemcitabine-cisplatin** or dose-dense **methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC).** **Immune checkpoint inhibitors:** - For patients ineligible for cisplatin or after progression on first-line chemotherapy, **pembrolizumab, atezolizumab, or nivolumab** are options. **Targeted therapy:** - For patients with specific molecular alterations (e.g., FGFR3), targeted therapies like **erdafitinib** may be considered.

Question 107

Describe the therapy options provided post-radical cystectomy [4]

Answer 107

**Ileal conduit:** - A section of the ileum (15 – 20cm) is removed, and end-to-end anastomosis is created so that the bowel is continuous. - The ends of the ureters are anastomosed to the separated section of the ileum. - The other end of this section of the ileum forms a stoma on the skin, draining urine into a urostomy bag **Continent urinary diversion:** - Create a pouch inside the abdomen from a section of the ileum, with the ureters connected and fills with urine - A thin tube is connected between a stoma on the skin and the internal pouch - Urine does not drain from the stoma (unlike a urostomy), and the patient needs to intermittently insert a catheter into the stoma to drain urine from the pouch. **Neobladder formation:** - Formed from ileum; connected to both ureters and urethra - Functions as normal bladder **Ureterosigmoidostomy (rare)** - Attaching the ureters directly to the sigmoid colon. - The rectum may be expanded to create a recto sigmoid pouch (called a Mainz II procedure) to create a larger space for urine to collect. - The patient can then drain the urine by relaxing the anal sphincter in the same way they open their bowels.

Question 108

What is the name for this operation? [1]

Answer 108

**Continent urinary diversion**

Question 109

Name this operation [1]

Answer 109

**Ileal conduit**

Question 110

Describe the treatment for metastatic testicular cancer [3]

Answer 110

Chemotherapy: - **Cisplatin** & **Etoposide** (cornerstone) - **Bleomycin** (added)

Question 111

Describe which parameters of varicoceles determine if treatment is given [2]

Answer 111

**Grade II or III varicocoele Management**: * **Asymptomatic** AND **normal** **semen** parameters **Semen analysis every 1-2yrs** * **Symptomatic** OR **abnormal** **semen** parameters: **Surgery**

Question 112

Label the tumour marker for each type of testicular cancer [4]

Answer 112

A: **hCG & AFP** B: **AFP** C: **hCG** D: **no rise**

Question 113

Describe the difference in percutaneous nephrostomy and percutaneous nephrolithotomy [1]

Answer 113

**nephrostomy** - focuses on draining urine to relieve obstruction - e.g *A 23-year-old male is admitted with left sided loin pain and fever. His investigations demonstrate a left sided ureteric calculi that measures 0.7cm in diameter and associated hydronephrosis.* **nephrolithotomy** - focuses on removing kidney stones - e.g. *A 30-year-old male presents with left sided loin pain. His investigations demonstrate a large left sided staghorn calculus that measures 2.3cm in diameter.*

Question 114

What is the management of lower UTIs causing **uncomplicated cystitis**: (include length of time) First line? [2] Second line? [3] Length of treatment? [1]

Answer 114

**3-5 day** course of standard antibiotics to local guidance: First line: * **Nitrofurantoin** * **Trimethoprim** Second line: * **co-amoxiclav** * **cephalosporin** * **ciprofloxacin**

Question 115

NICE guidelines (2018) recommend the which first-line antibiotics for 7-10 days when treating **pyelonephritis** in the community? [5]

Answer 115

**Cefalexin** **Co-amoxiclav** (oral or IV if more serious; if culture results are available) **Trimethoprim** (if culture results are available) **Ciprofloxacin** (keep tendon damage and lower seizure threshold in mind) **IV Gentamicin** (if severe)

Question 116

How do you manage UTIs in men: - If lower UTI [2] - If suspected prostatic involvement [1]

Answer 116

If lower UTI: * **7 day course** of **trimethoprim or nitrofurantoin** If suspected prostatic involvement: - **Ciprofloxacin** - **Cefalexin** (the typical choice)

Question 117

# he d NICE guidelines (2018) recommend which first-line antibiotics for 7-10 days when treating pyelonephritis in the community? [4]

Answer 117

**Cefalexin** **Co-amoxiclav** (if culture results are available) **Trimethoprim** (if culture results are available) **Ciprofloxacin** (keep tendon damage and lower seizure threshold in mind)

Question 118

What's a pneumonic for remembering the causes of small bowel obstruction?

Answer 118

“**HANG IVs”** **H**ernias 2% **A**dhesions (from previous surgery with formation of intra abdominal adhesions, commonly colorectal and gynaecological surgery) **N**eoplasms (malignant, benign, primary or secondary) (5%) **G**allstone ileus **I**ntussusception **V**olvulus **S**trictures (eg Crohn’s disease (6%), ischaemia)

Question 119

Describe the treatment algorithm for acute fissures

Answer 119

1st line: soften stool - **high fibre intak** - **Bulk forming laxatives** - **lubricants like petroleum jelly** 2nd line: - **Glyceryl trinitrate** 3rd line: - **topical diltiazem** (if headaches from glyceryl trinitrate are too much)

Question 120

Describe the treatment algorithm for chronic anal fissures [3]

Answer 120

**topical glyceryl trinitrate (GTN**) is first-line treatment for a chronic anal fissure **Botulinum toxin** or **sphincterotomy** is used after failure of topical treatment for **8 weeks** *sphincterotomy*: *The operation usually takes about 15 minutes. Your surgeon will make a small cut on the skin near your back passage. They will cut the lower part of the internal sphincter muscle. This will relieve the spasm in the sphincter, allowing a better blood supply to heal the fissure.*

Question 121

Describe the adjuvant chemotherapy given for colorectal cancer: [2] Describe the biologicals used [3]

Answer 121

Dukes B if poor prognositic factors Dukes C: - **Fluorouracil (5-FU)** - **Capecitabine** (first line) Biologicals: - **Cetuximab** (anti-EGFR) - **Panitumubab** (anti-EGFR) - **Bevacizumab** (anti-VEGF)

Question 122

What is the FOLFOX regime of treating colorectal cancer? [3]

Answer 122

Chemotherapy regime of: * 5-FU * Folinic acid * Oxaliplatin

Question 123

Describe the topical treatments used for haemorrhoids? [3]

Answer 123

**Anusol**: - Chemicals used to shrink **Anusol HC** - As above but with hydrocortisone **Germoloids**: - Lidocaine

Question 124

23. A 45-year-old man presents with a carcinoma 10cm from the anal verge, he has completed a long course of chemoradiotherapy and has achieved downstaging with no evidence of threatened circumferential margin on MRI scanning. What is the most appropriate colonic resction for this patient?

Answer 124

**Anterior resection with covering loop ileostomy** - 'carcinoma 10cm from the anal verge' implies that the anus is unaffected by the cancer. **Abdominal-perineal excision of rectum is only used when the anus is involved.** Low rectal cancer is usually treated with a low anterior resection. Contraindications to this include involvement of the sphincters (unlikely here) and poor sphincter function that would lead to unsatisfactory function post resection. Most colorectal surgeons defunction resections below the peritoneal reflection as they have an intrinsically high risk of anastomotic leak. A loop ileostomy provides a safe an satisfactory method of defunctioning these patients. A contrast enema should be performed prior to stoma reversal.

Question 125

Describe how you treat fistulae if: - No IBD or distal obstruction? [1] - High-output is excessive? [2] - Secondary to Crohns? [1]

Answer 125

No IBD or distal obstruction: **Conservative management** - High-output is excessive: **octreotide (reduces pancreatic secretions); TPN** - Secondary to Crohns: **drain acute sepsis; seton placement**

Question 126

Low rectal cancer is usually treated with **[]** surgery. How do you adapt ^ to avoid the high risk of anastomotic leak? [1] What is the contraindication to this? [1]

Answer 126

Low rectal cancer is usually treated with a **low anterior resection** - Contraindications to this **include involvement of the sphincters** - Most colorectal surgeons **defunction resections** below the peritoneal reflection as they have an intrinsically high risk of anastomotic leak. **A loop ileostomy** provides a safe an satisfactory method of defunctioning these patients

Question 127

Treatment for high output stomas? [5]

Answer 127

● **Hydrate** (fluid and high salt replacement) ○ Glucose-electrolyte solution aids sodium absorption ○ Restrict low sodium (Hypotonic) fluid (500-1000ml/day) ● Anti-diarrhoeal medication, eg **loperamide** ● Anti-secretory drugs ○ PPI (**omeprazole**) ○ **Octreotride** (rarely) ● Correct Hypomagnesaemia ● Opiates (**codeine phosphate**)

Question 128

What are the NICE guidelines on what makes patients with colorectals adenomas low, intermediate and high risk? [3] How often should low, intermediate and high risk colorectal adenoma patients be offered colonoscopies? [3]

Answer 128

Classification of risk and advised management in patients with colorectal adenomas are as follows: **Low risk** - **one** or **two** **adenomas** **smaller** than **10** **mm** - should be considered for **colonoscopy at five years** **Intermediate risk** - **three/four adenomas smaller than 10 mm** or - **one/two adenomas if one is 10 mm or larger** - should be offered a **colonoscopy at three years** **High risk** - **five** or **more** **adenomas** **smaller** than **10** **mm** or - **three or more adenomas if one is 10 mm** or **larger** - offered a **colonoscopy at one year**.

Question 129

Describe the management of uncomplicated hernia [4]

Answer 129

**Surgery**: **Open mesh repair:** - **Direct hernia**: plication - **Indirect**: sac excision - **Both**: add mesh which produces fibrosis **Laporoscopic mesh repair:** - As above, but reduced injury of nerves & post-op chronic pain - Reinforces wall to elimiante reoccurence **Laporoscopic pre-peritoneal mesh repair** **Suture repair** (high chance of reoccurance PassMed: **Primary unilateral/ bilateral hernia:** * **Mesh repair**(Lichtenstein’s or endoscopic repair), the mesh repair uses polypropylene mesh to reinforce the posterior wall. A recurrence rate of 2-10% for both procedures. **Recurrent inguinal hernia:** * **If previous anterior hernia repair**: **open** **preperitoneal** mesh or endoscopic approach * **If previous posterior hernia repair:** **Lichtenstein’s totally extraperitoneal (TEP).** A minimally invasive procedure where the mesh is used to seal the hernia from outside the peritoneum.

Question 130

Describe the method used to test for indirect inguinal hernia c.f. direct [2]

Answer 130

**To test for indirect inguinal hernias:** - finger **pressure** should be applied over the **deep inguinal ring**. The finger pressure will control the hernia when the patient coughs. **To test for direct hernias:** - instruct the patient to **cough**, and a bulge should **appear** **medial** to **point of finger pressure.** - If a hernia reappears it is more likely to be a direct inguinal hernia whereas if it does not, it is more likely to be an indirect inguinal hernia.

Question 131

What is the surgical procedure for recurrent inguinal hernia: - If previous anterior hernia repair? [1] - If previous posterior hernia repair? [1]

Answer 131

**If previous anterior hernia repair**: - **open preperitoneal mesh** or **endoscopic** approach **If previous posterior hernia repair:** - **Lichtenstein’s totally extraperitoneal (TEP)**. A minimally invasive procedure where the mesh is used to seal the hernia from outside the peritoneum.

Question 132

Which type of repair is best suited for unilateral [1] and bilateral or recurrent inguinal hernias [1]?

Answer 132

**unilateral inguinal hernias** are generally repaired with an **open approach** **bilateral and recurrent inguinal hernias** are generally repaired **laparoscopically**

Question 133

Name [1] and describe the classification used for PAD [4]

Answer 133

**Fontaine classification**

Question 134

Which drug is often prescribed post Milligan Morgan style conventional haemorroidectomy to reduce pain? [1]

Answer 134

**metronidazole**

Question 135

how would you treat haemorrhoids if there are more marked symptoms of bleeding and occasional prolapse, where the haemorroidal complex is largely internal? [1]

Answer 135

**stapled haemorroidopexy** - excises rectal tissue above the dentate line and disrupts the haemorroidal blood supply - At the same time the excisional component of the procedure means that the haemorroids are less prone to prolapse

Question 136

Name and describe the treatment for Large haemorroids with a substantial external component? [1]

Answer 136

Large haemorroids with a substantial external component may be best managed with a **Milligan Morgan style conventional haemorroidectomy.** - three haemorroidal cushions are excised, together with their vascular pedicle.

Question 137

What is the scar called? [1] Whats the indication? [1]

Answer 137

**Rutherford Morison**

Question 138

What part of the QRS does a 4th heart sound correlat with? [1]

Answer 138

A fourth heart sound is always pathological and indicates forceful atrial contraction against a stiff, hypertrophic left ventricle. As it is atrial contraction, it **corresponds to the P wave of the ECG.**

Question 139

[] is the single best predictor of a patient's risk for cardiovascular disease (when measuring cholesterol levels)

Answer 139

**Total Cholesterol/HDL ratio**

Question 140

**[]** access is preferred to femoral access for primary PCI

Answer 140

Radial access is preferred to femoral access for primary PCI

Question 141

Describe the treatment used for rhythm control for AF (electrical and pharmological) [3]

Answer 141

**DC Cardioversion** - electrical stimulation to restore sinus rhythm **Amiodarone** - antiarrhythmic drug which can restore sinus rhythm on its own. It is suitable in most patients **Flecainide** - an antiarrhythmic drug that can be used in some patients to restore sinus rhythm, but is contraindicated in those with possible structural or ischaemic heart disease

Question 142

NICE guidelines (2021) suggest all patients with AF should have rate control as first-line, except in which four instances? [4]

Answer 142

NICE guidelines (2021) suggest all patients with AF should have rate control as first-line, except with: * A **reversible** **cause** for their AF * **New onset** atrial fibrillation (within the last 48 hours) * **Heart failure** caused by atrial fibrillation * **Symptoms** **despite** being **effectively rate controlled**

Question 143

Long-term AF rhythm control is with which drugs? [3]

Answer 143

**Beta blockers** first-line **Dronedarone** second-line for maintaining normal rhythm where patients have had successful cardioversion **Amiodarone** is useful in patients with heart failure or left ventricular dysfunction

Question 144

Describe the process of AVN ablation to treat AF [3]

Answer 144

Atrioventricular node ablation involves **destroying the connection between the atria and ventricles** (the atrioventricular node) After the procedure, the **irregular electrical activity** in the atria **cannot pass through to the ventricles** A **permanent pacemaker** is required to **control ventricular contraction** **Anticoagulation** is still needed to prevent strokes.

Question 145

Name five side effect of amiodarone use [5]

Answer 145

- Pneumonitis - Bradycardia and Heart Block - Hepatitis - Photosensitivty and grey discolouration - Thyroid abnormalties (hyper & hypo): *amIODarone - iodine in the drug*

Question 146

State 4 side effects of digoxin use [4]

Answer 146

Bradycardia GI upset Rash Dizziness Visual disturbance

Question 147

Digoxin is contraindicated in which conditions [2]

Answer 147

- **Second degree heart block** - **Ventricular arrhythmias**

Question 148

Why is assessment of the cardiac function with echocardiography is required when cardioversion is being considered? [1]

Answer 148

Assessment of the cardiac function with echocardiography is required because **flecainide** (type I antiarrhythmic) **is dangerous in structural heart disease (pro-arrhythmic and increased risk of sudden cardiac death)**

Question 149

What is the mechanism of action of alteplase? ADP-receptor blocker Activates plasminogen to form plasmin Inhibits plasmin Inhibits the conversion of fibrinogen to fibrin Activates thrombin to form thromboplastin

Answer 149

What is the mechanism of action of alteplase? ADP-receptor blocker **Activates plasminogen to form plasmin** Inhibits plasmin Inhibits the conversion of fibrinogen to fibrin Activates thrombin to form thromboplastin

Question 150

Which drugs are contra-indicated in a patient with known atrial fibrillation (or atrial flutter) and Wolff-Parkinson-White? [4] Why? [1]

Answer 150

- **Beta blockers** - **CCBs** - **digoxin** - **adenosine** These medications may **trigger ventricular fibrillation.**

Question 151

Usually, long-term management of SVT is only indicated if the frequency and severity of SVT episodes significantly impacts on the patients quality of life and functioning. What is the stepwise treatment options for long term management? [3]

Answer 151

1st line: - **radio-frequency ablation** 2nd line (if decline RAB) - **BB or CCB** 3rd line: - **flecainide** and **sotalol**

Question 152

Name an electrolyte abnormality that could trigger sick sinus syndrome [1]

Answer 152

**Hyperkalaemia**

Question 153

Name an endocrine pathology that could trigger sick sinus syndrome [1]

Answer 153

Hypothyroidism.

Question 154

Aortic regurgitation may be associated with an Austin-Flint murmur. Which of the following best describes the classical Austin-Flint murmur? A Early diastolic murmur B Ejection systolic murmur C Pansystolic murmur D Mid-diastolic murmur E Gallop rhythm

Answer 154

Aortic regurgitation may be associated with an Austin-Flint murmur. Which of the following best describes the classical Austin-Flint murmur? A Early diastolic murmur B Ejection systolic murmur C Pansystolic murmur **D Mid-diastolic murmur** E Gallop rhythm

Question 155

Mechanical valves - target INR: aortic: [] mitral: []

Answer 155

Mechanical valves - target INR: **aortic: 3.0** **mitral: 3.5**

Question 156

When is treatment indicated in Mobitz type I? [1] What is first line? [1]

Answer 156

However, in cases such as this where the patient is symptomatic (typically pre-syncope/syncope, hypotension, bradycardia) and particularly in elderly patients, treatment might be considered, which would primarily consist of **transcutaneous pacing.**

Question 157

A patient has been admitted last week for infective endocarditis. They have an ECG performed which shows new onset PR prolongation. What is the likely diagnosis [1] and treatment? [1]

Answer 157

The newly lengthened PR interval (1st degree heart block) **suggests peri-valvular abscess** as a **complication of infective endocarditis**. Abscess is an **indication for valve replacement.**

Question 158

A 44 year old presents to the emergency department with a four week history of malaise, fevers and recent concerns over painful purple spots on his fingertips. He has been treated by his GP for a lower respiratory tract infection with a short course of doxycycline but this has done little to abate his symptoms. He is otherwise fit and well and takes no regular medications. On examination he has raised, red and painful lesions on his fingertips and an ejection systolic murmur on auscultation of his chest. His lung fields are clear and he has non-swollen calves bilaterally. His blood tests show a raised white cell count and a high C-reactive protein An ECG shows normal sinus rhythm Blood cultures have grown gram positive cocci in two different bottles What would be the most appropriate antibiotic regimen for this gentleman? Gentamicin 360mg once daily 1 Ciprofloxacin 500mg twice daily 2 Temocillin 2g twice daily 3 Nitrofurantoin 100mg three times daily 4 Flucloxacillin 2g 4-6 hourly

Answer 158

**Flucloxacillin 2g 4-6 hourly** Flucloxacillin at high dose, sometimes with the addition of gentamicin at twice daily dosing, is the initial optimal management out of the options given. The high dose flucloxacillin will provide good gram positive cover against the suspected pathogen. Treatment course would be discussed with a microbiologist but often runs to between 6 and 8 weeks with re-imaging at this point

Question 159

A single positive blood culture of [3] meets a major criterion for infective endocarditis, for a total of two major criteria. Note that this differs from other organisms such as** viridans streptococci, Staphylococcus aureus, Streptococcus bovis** and the **HACEK** **group** **TWO** separate blood cultures are required

Answer 159

Coxiella burnetii, Bartonella species or Chlamydia psittaci

Question 160

How do you treat Dresslers? [1]

Answer 160

Post infarction pericarditis or Dressler's syndrome can occur in 5-10% of patients after an acute MI Treat with **high dose aspirin**

Question 161

Which antiplatelets alongside aspirin do you give a STEMI patient depending on their current anticoagulation? [2]

Answer 161

NO medication - **pragusel** Anticoagulation: **Clopidogrel**

Question 162

Which antiplatelets alongside aspirin do you give an NSTEMI patient depending on their risk of bleeding? [2]

Answer 162

**Low risk of bleeding:** - Aspirin; Ticagrelor; Fondaparinoux **High risk of bleeding**: - Aspirin; Clopidogrel; Fondaparinoux

Question 163

A 47 year old woman presents to her GP with a history of breathlessness of 6 months duration. On examination she has a large a wave of her jugular venous pressure. Which condition is likely to be the cause of the large a wave? Heart failure Mitral valve prolapse Mitral regurgitation Pulmonary hypertension Tricuspid regurgitation

Answer 163

**Pulmonary hypertension**

Question 164

What is the name for the criteria used for IE? [1] Describe how a diagnosis is made from Dukes criteria [1]

Answer 164

**Modified Duke criteria** A diagnosis requires either: * **One major plus three minor criteria** * **Five minor criteria**

Question 165

What are the major criteria in Dukes classification of IE? [2] What are the minor criteria in Dukes classification of IE? [5]

Answer 165

**Major criteria:** * **Persistently positive blood cultures** (typical bacteria on multiple cultures) - persistent bacteraemia with **2x blood cultures >12 hours apart or =>3 positive blood cultures with less specific microorganisms (S.aureus or S. epidermidis)**. * **Specific imaging findings** (e.g., a vegetation seen on the echocardiogram) * **Single positive blood culture** for **Coxiella** **burnetti** or positive antibody titre **Minor criteria are:** * **Predisposition** (e.g., IV drug use or heart valve pathology) * **Fever above 38°C** * **Vascular phenomena** (e.g., **splenic** **infarction**, **intracranial** **haemorrhage** and **Janeway** **lesions**) * **Immunological phenomena** (e.g., Osler’s nodes, Roth spots and glomerulonephritis) * **Microbiological phenomena** (e.g., positive cultures not qualifying as a major criterion)

Question 166

Which Abx are the mainstay treatment for IE? [1]

Answer 166

Intravenous broad-spectrum antibiotics (e.g., **amoxicillin** and optional **gentamicin**) are the mainstay of treatment The choice of antibiotic may be more specific once the causative organism is identified on cultures.

Question 167

HOCM is associated with which pulse changes? [2]

Answer 167

Jerky pulse bisferiens pulse

Question 168

Which electrolyte imbalances are a risk factor for digoxin toxicity? [3]

Answer 168

hypokalaemia, hypomagnesaemia or hypercalcaemia.

Question 169

Describe the pathophysiology, triggers and diagnosis of Brugada syndrome [3]

Answer 169

**Automsomal dominant** **Na** **channelopathy** associated with **arrythmias** such as **VF or VT** - Triggers typically are **heavy alcohol use, fever, heavy meal, dehydration, certain medications** - Diagnosis is via **ECG**

Question 170

A 24-year-old lady from Western India presents with symptoms of lethargy and dizziness, worse on turning her head. On examination her systolic blood pressure is 176/128. Her pulses are impalpable at all peripheral sites. Auscultation of her chest reveals a systolic heart murmur. Subclavian steal syndrome Takayasu's arteritis Cervical rib Aortic coarctation Patent ductus arteriosus

Answer 170

A 24-year-old lady from Western India presents with symptoms of lethargy and dizziness, worse on turning her head. On examination her systolic blood pressure is 176/128. Her pulses are impalpable at all peripheral sites. Auscultation of her chest reveals a systolic heart murmur. **Takayasu's arteritis** - Takayasu's arteritis most commonly affects young Asian females. **Pulseless peripheries are a classical finding**. The CNS symptoms may be variable.

Question 171

A 25-year-old junior doctor has a chest x-ray performed as part of a routine insurance medical examination. The x-ray shows evidence of rib notching. Auscultation of his chest reveals a systolic murmur which is loudest at the posterior aspect of the fourth intercostal space. Subclavian steal syndrome Takayasu's arteritis Cervical rib Aortic coarctation Patent ductus arteriosus

Answer 171

A 25-year-old junior doctor has a chest x-ray performed as part of a routine insurance medical examination. The x-ray shows evidence of rib notching. Auscultation of his chest reveals a systolic murmur which is loudest at the posterior aspect of the fourth intercostal space. Subclavian steal syndrome Takayasu's arteritis Cervical rib Aortic coarctation **Patent ductus arteriosus** - Untreated patients develop symptoms of congestive cardiac failure

Question 172

What is meant by Prinzmetal's or variant angina? [1]

Answer 172

When you get transient ST elevation due to coronary vasopasm (artery isn't blocked, but muscle is in spasm)

Question 173

What is meant by cardiac syndrome X? [1]

Answer 173

St depression on excerise ECG but normal angiogram Sign of microvascular angina

Question 174

Describe the treatment algorithm for stable angina patients [5]

Answer 174

**Sublingual glyceryl trinitrate** to abort angina attacks **All patients:** - **Aspirin** **75** **mg** - **Statin** **1st line:** - **Beta blocker**: e.g. **metoprolol** - **CCB**: e.g. **Amlodopine** - If there is a **poor** **response** to **initial** **treatment** then **medication** should be **increased** to the **maximum** **tolerated** **dose** (e.g. for atenolol 100mg od) - If a patient is **still** **symptomatic** **after** **monotherapy** with a **beta**-**blocker** **add** a **calcium** **channel** **blocker** and **vice** **versa** **2nd line:** - a long-acting nitrate: **Isosorbide mononitrate** - **ivabradine** - **nicorandil** - **ranolazine** **3rd line:** - **CABG** - **PCI**

Question 175

Describe the MoA of ivabradine [1]

Answer 175

**pacemaker current inhibitor**: slows the HR down (not a Beta blocker)

Question 176

Describe the treatment regimes for difference IE valves / pathogens

Answer 176

Question 177

How can you tell from a murmur in AS if it is mild-moderate c.f severe murmur? [2]

Answer 177

**Early peaking** is more consistent with **mild or moderate** AS and **late** **peaking** is consistent with **severe AS** **Murmur** becomes **softer** the more **severe the stenosis**

Question 178

When is dobutamine stress echo indicated in AS patients? [1] By what mmHg does AS gr

Answer 178

**Dobutamine stress echocardiogram:** - useful for patients who have **low-gradient AS** - patients may be symptomatic but have seemingly low pressures due to a low ejection fraction - **gradient will increase > 40 mmHg after administration of low dose dobutamine**

Question 179

How do you classify AS as being severe? [3]

Answer 179

Severe AS classified as: - **aortic jet velocity ≥4 m/s** (direct measurement of the highest antegrade systolic velocity signal across the aortic valve) - **mean trans-valvular pressure gradient ≥ 40 mmHg** - **aortic valve area ≤1 cm2.**

Question 180

What indicates surgery for AS? [3]

Answer 180

If **symptomatic** If asymptomatic but have: - **LVEF < 50%** - **Undergoing other cardiac surgery** - **low surgical risk factors**

Question 181

Describe the managment of acute AR [what are the two causes of acute AR]

Answer 181

**Acute AR is a surgical emergency**: Aortic valve replacement or repair should be performed as soon as possible. It **primarily occurs secondary to infective endocarditis or aortic dissection**, both of which carry very high morbidity and mortality: **Aortic dissection (Stanford type A):** - management depends on the patients pre-morbid state and severity of presentation. If not already there, patients are transferred to the local on-call dissection centre. Emergency open surgery is typically required, management depends on the exact pattern of findings but may consist of root replacement and valve repair or replacement. **Infective endocarditis**: - management depends upon pattern of valvular involvement (multiple valves may be affected) and complications (e.g. annular/aortic abscess, septic emboli). Coronary angiogram may be performed in selected stable patients prior to operative management. AR is generally an indication for early surgery. -

Question 182

The normal size of the aortic valve area is more than **[]** cm2, in mild AS it is more than **[]** cm2, in moderate AS it is from **[]** to **[]**cm2, and in severe AS < **[]** cm2.

Answer 182

The normal size of the aortic valve area is more than **2 cm2**, in mild AS it is more than **1.5 cm2,** in moderate AS it is from **1.0 to 1.5 cm2**, and in severe AS **< 1 cm2.**

Question 183

When is surgery indicated for chronic MR patients?

Answer 183

Chronic MR: - **asymptomatic** & **LVEF < 60%** OR - **asymptomatic & LV end systolic diameter >40mm** - **All symptomatic if fit for surgery** | BMJ BP

Question 184

What signs would indicate that MS has become more severe? [2]

Answer 184

**length** of **murmur** increases **opening snap** becomes **closer to S2**

Question 185

Which form of ECHO is best for investigating mitral valve? [1]

Answer 185

**transthoracic echocardiography**

Question 186

patent ductus arteriosus is associated with Early diastolic murmur, high pitched and blowing Holosystolic murmur, harsh in character Continous machinery murmur Ejection systolic murmur Mid-late diastolic murmur, rumbling Late systolic murmur

Answer 186

**Continous machinery murmur**

Question 187

**Decompensated heart failure** accounts for most cases of **AHF**. What are the most common precipitating causes of acute AHF? [4]

Answer 187

* **Acute coronary syndrome** * **Hypertensive** **crisis**: e.g. bilateral renal artery stenosis * **Acute** **arrhythmia** * **Valvular** **disease** *There is generally a history of pre-existing cardiomyopathy. It usually presents with signs of fluid congestion, weight gain, orthopnoea and breathlessness.* ## Footnote **CHAMP** **A**cute coronary syndrome (ACS) **H**ypertensive crisis **A**rrhythmias, e.g. atrial fibrillation, ventricular tachycardia, bradyarrhythmia **M**echanical problems, e.g. myocardial rupture as a complication of ACS, valve dysfunction **P**ulmonary embolism

Question 188

Describe why right sided heart failure may occur [4]

Answer 188

Right-sided heart failure commonly occurs as a result of **advanced left-sided failure.** Primary right-sided heart failure is uncommon and broadly related to three categories: * **Pulmonary hypertension** * **Pulmonary/Tricuspid valve disease** * **Pericardial disease** Also: * **Pneumonia** * **Pulmonary embolism (PE)** * **Mechanical ventilation** * **Acute respiratory distress syndrome (ARDS)** ## Footnote *Pulmonary hypertension may occur secondary to left-sided heart disease, primary pulmonary hypertension or significant pulmonary disease (e.g. COPD).*

Question 189

A **[]** is the main investigation for the confirmation of heart failure.

Answer 189

A **transthoracic echocardiography (TTE)** is the main investigation for the confirmation of heart failure.

Question 190

If a patient remains symptomatic despite optimal treatment what interventions using a device can be used in selected patients? [4]

Answer 190

**Implantable cardiac defibrillator (ICD):** * important for primary and secondary prevention of sudden cardiac death (specific indications) . **Cardiac resynchronisation therapy (CRT)**: * biventricular pacing, which is indicated in certain patients with HFrEF (i.e. ≤ 35%) & prolonged QRS (i.e. ≥ 130 ms). Usually receive combined device with defibrillator. **Percutaneous coronary intervention (PCI):** * patients with ischaemic heart disease may be offered revascularisation therapy if indicated.| **Cardiac transplant**: * highly specialised procedure for certain patient groups with heart failure.

Question 191

Explan your answer [1]

Answer 191

**Left ventricular aneurysm** The **ischaemic damage sustained may weaken the myocardium** resulting in **aneurysm formation**. This is typically associated with **persistent ST elevation and left ventricular failure**. Thrombus may form within the aneurysm increasing the risk of stroke. Patients are therefore anticoagulated.

Question 192

Name the four causes of diastolic HF [4]

Answer 192

* cardiac tamponade * hypertrophic obstructive cardiomyopathy * constrictive pericarditis * restrictive cardiomyopathy

Question 193

Name the four causes of systolic HF [4]

Answer 193

* ischaemic heart disease * arrhythmias * myocarditis * dilated cardiomyopathy

Question 194

A patient has chronic heart failure. You trial and ACEI but the patient is intolerant. You then trial an ARB, but the patient is still intolerant. What treatment should you consider nexr? [1]

Answer 194

**Hydralazine and nitrate**

Question 195

Describe how you were determine if you give each of the following for third line chronic HF tx? **Ivabradine** **sacubitril-valsartan** **hydralazine in combination with nitrate** **cardiac resynchronisation therapy**

Answer 195

**Ivabradine** - sinus rhythm > 75/min and a left ventricular fraction < 35% **sacubitril-valsartan**: - criteria: left ventricular fraction < 35% - is considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs **digoxin** **hydralazine in combination with nitrate** - this may be particularly indicated in Afro-Caribbean patients **cardiac resynchronisation therapy** - indications include a widened QRS (e.g. left bundle branch block) complex on ECG

Question 196

A patient has chronic heart failure. You iniate an ACEin and a BB as first line treatment. This does not resolve their EF. You next trial and aldosterone antagonist. This does also not help. They are Afro-Carribean. What is the appropriate third line treatment? * Ivabradine * sacubitril-valsartan * digoxin * hydralazine in combination with nitrate * cardiac resynchronisation therapy

Answer 196

* **hydralazine in combination with nitrate**

Question 197

When are nitrates considered in the treatment of acute heart failure patients? [3]

Answer 197

Acute HF + - **concomitant myocardial ischaemia** - **severe hypertension** - **regurgitant aortic or mitral valve disease**

Question 198

Describe the medical managment plan for a patient with HOCM used to reduce symptoms and LVOT obstruction [5]

Answer 198

A. **Beta blockers** - 1st line: **atenolol** or **propranolol** B. **CCBs**: - **Verapamil** C. **antiarrhythmic agents**: - **Disopyramide** D. **Diuretics**: - **furosemide** - Caution is warranted due to the potential for hypovolemia and exacerbation of LVOT obstruction. E. **Anticoagulation**: - Indicated in patients with atrial fibrillation or a history of thromboembolic events.

Question 199

Which drug classes should be avoided in HOCM patients? [3]

Answer 199

**nitrates** **ACE-inhibitors** **inotropes**

Question 200

How do you manage arrhythmogenic right ventricular cardiomyopathy? [3]

Answer 200

Management * drugs: **sotalol** is the most widely used antiarrhythmic * **catheter** **ablation** to prevent ventricular tachycardia * **implantable cardioverter-defibrillator**

Question 201

Describe the different classifications of Necrotising soft tissue infections (NSTIs) with regards to their infective organisms

Answer 201

**Type I:** - **polymicrobial**: typically mixed anaerobes & aerobes, on average four or more organisms **Type II:** - **group A streptococcus (Strep. pyogenes +/- Staph. aureus)** **Type III:** - **Gram-negative monomicrobial infection.** - Typically associated with **Vibrio** species infection **Type IV**: - **Fungal infection** (typically Candida species, zygomycetes).

Question 202

Which of the following is usually caused by trauma, such as a bite? Type 1 Type 2 Type 3 Type 4

Answer 202

Which of the following is usually caused by trauma, such as a bite? Type 1 **Type 2** Type 3 Type 4

Question 203

What are the potential complications of myocarditis? [2]

Answer 203

**Complications** * **heart failure** * **arrhythmia**; frequent premature ventricular complexes, irregular and polymorphic VT, or ventricular fibrillation possibly leading to sudden death * **dilated cardiomyopathy**: usually a late complication

Question 204

How do you determine which drugs to give if during to PCI based on their access? [2]

Answer 204

**patients** with **radial** **access**: - **unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI)** **Patients** with **femoral** **access**: - **bivalirudin with bailout GPI**

Question 205

What is the medication used following NSTEMI as seconary prevention? [6]

Answer 205

**6 As** **AAAAAA** * **Aspirin** 75mg once daily indefinitely * **Another** Antiplatelet (e.g., ticagrelor or clopidogrel) for 12 months * **Atorvastatin** 80mg once daily * **ACE** **inhibitors** (e.g. ramipril) titrated as high as tolerated * **Atenolol** (or another beta blocker – usually bisoprolol) titrated as high as tolerated * **Aldosterone** **antagonist** for those with clinical heart failure (i.e. **eplerenone** titrated to 50mg once daily)

Question 206

State the different risk stratifications based of GRACE scores [5]

Answer 206

Question 207

# MI complications: What would cause persistent ST elevation without chest pain? [1]

Answer 207

Ventricular aneurysm

Question 208

Answer 208

**Left ventricular free wall rupture** This is seen in around 3% of MIs and occurs around 1-2 weeks afterwards. Patients present with acute heart failure secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds). Urgent pericardiocentesis and thoracotomy are required.

Question 209

How do you differentiate between a posterior and anterior MI on an ECG?

Answer 209

**Anterior MI** - **ST-segment elevation** in the precordial leads **V1-V4** **Posterior MI** - **tall R waves V1-3** *PosteRioR contains 2 tall Rs* - **Horizontal ST depression** in **V1-3**

Question 210

You believe he has Balanitis Xerotica Obliterans. What can be associated with this condition? Protection from cancer Phimosis Protection from infection Prostate hyperplasia Basal cell carcinoma

Answer 210

You believe he has Balanitis Xerotica Obliterans. What can be associated with this condition? Protection from cancer **Phimosis** Protection from infection Prostate hyperplasia Basal cell carcinoma

Question 211

his patient has several signs of chronic (high-pressure) retention: >1L retention volume, abnormal renal profile and possibly postobstructive diuresis (>200 mL/h). How do you manage this patient? [1]

Answer 211

**Leave the catheter in situ** - These patients should not have a trial without catheter (TWOC) as it can further exacerbate renal impairment. Instead, they should have a long term catheter until further specialist review with regards to the underlying cause

Question 212

How do you treat WPW? [1]

Answer 212

definitive treatment: **radiofrequency ablation of the accessory pathway** medical therapy: **sotalol, amiodarone, flecainide** *sotalol should be avoided if there is coexistent atrial fibrillation as prolonging the refractory period at the AV node may increase the rate of transmission through the accessory pathway, increasing the ventricular rate and potentially deteriorating into ventricular fibrillation*

Question 213

What are the symptoms of digoxin toxicity? [+]

Answer 213

dizziness, nausea and vomiting, palpitations, bradycardia, visual disturbances, confusion, and hyperkalaemia.

Question 214

What is the MoA of digoxin? [1]

Answer 214

**Inhibiting the Na+ K+ ATPase enzyme**, also known as the sodium-potassium pump. This causes **sodium** to build up **inside the heart cells**, **decreasing the ability of the sodium-calcium exchanger** to **push calcium** out of the cells, consequently **causing calcium to build up in the sarcoplasmic reticulum**. **Increased** **intracellular** **calcium** results in a **positive inotropic effect**, which in turn has the effect of **increasing the force of the heart’s contractions.**

Question 215

Cholera can present with diarrhoea and []

Answer 215

Cholera can present with **diarrhoea** and **hypoglycaemia**

Question 216

What is amyloidosis: - pathophysiology? - difference between primary and secondary?

Answer 216

**Pathophysiology:** - extracellular and or intracellular tissue deposition of insoluble amyloid fibrils that prevent the normal functioning of tissues and organs affected **Primary**: - deposits of monoclonal light chains in tissue **Secondary**: - Due to malignancy or chronical microbrial infection

Question 217

Describe the clinical features of amyloidosis

Answer 217

Question 218

Describe how you diagnose and treat amyloidosis

Answer 218

**Dx**: - The diagnosis of Amyloidosis requires a **tissue** biopsy that shows apple-green birefringence when stained with **Congo red and viewed under polarised light** **Tx:** - In amyloid AA, management of chronic infection and inflammation is important - In amyloid AL, strategies similar to myeloma therapy can be used (eg. dexamethasone and bortezomib as a first line) with measurements of serum-free light chains to assess response

Question 219

How would warfarin poisoning present on a clotting screen? [3]

Answer 219

Rasied APTT; PT and INR Normal platelet count

Question 220

What is the first line treatment for TTP? [3] What's the aim for this? ^ [1]

Answer 220

1. **Plasma exchange** 2. **IV methylprednisolone** 3. **Rituximab** Aim is to get rid of **ADAMST13 antibodies**

Question 221

Burkitt lymphoma is associated with which chromosome swap? [2]

Answer 221

**8-14**

Question 222

What effect does haemodialysis have on HbA1C levels? [1]

Answer 222

Falsely low

Question 223

Give 5 causes of falsely increased HbA1C [5]. Describe why this occurs [1]

Answer 223

B12 deficiency IDA deficiency Chronic alcoholism Splenectomy Pregnancy All increase the lifespan of Hb

Question 224

Give 5 causes of falsely decreased HbA1C [5]. Describe why this occurs [1]

Answer 224

SCA Haemodialysis Splenomegaly Thal. Decreases the lifespan of Hb

Question 225

Describe how you would investigate if you suspect patient has diabetic kidney disease [1]

Answer 225

Peform an **A:Cr screen**: 1. Spot sample 2. Repeat if abnormal

Question 226

How do you manage AIHA? [4]

Answer 226

Blood transfusions Prednisolone Rituximab (a monoclonal antibody against B cells) Splenectomy

Question 227

If patient has COPD and undergo rapid oxygen desaturation - what is the likely cause? [1]

Answer 227

**Mucus plugging**

Question 228

A patient has warm AIHA - where does the haemolysis usually occur? [1]

Answer 228

In extravascular sites like the spleen

Question 229

What is the usual surgery that patients with FAP undergo? [1]

Answer 229

**Total proctocolectomy with end ileal anastomosis**

Question 230

Describe the first line management for sigmoid volvulus [2]

Answer 230

* **endoscopic decompression is first-line**, using either flexible or rigid sigmoidoscopy - corrects the volvulus; can leave in and later remove * If there is evidence of **ischaemia**, **perforation** or **mucosal** **gangrene**, **surgical management is still required in the first instance**; might be **laporoscopic** or a **Hartmans**

Question 231

When is an S3 considered normal? [1]

Answer 231

Under 30

Question 232

S4 can be heard in which cardiac conditions? [2]

Answer 232

HOCM AS

Question 233

How do you treat acute [1] and chronic [1] hydronephrosis?

Answer 233

Acute: **nephrostomy** Chronic: **ureteric stent**

Question 234

First and second line tx for acute constipation? [2] how do you treat opiod induced constipation? [1]

Answer 234

1. **Ipsaghula husk** 2. **macrogol** opoid induced: **senna**

Question 235

Symptomatic perianal fistuala tx: - simple? [1] - complex? [1]

Answer 235

SImple: oral metronizadole Complex: seton placement

Question 236

Overdosing on which substances would indicate the following reversal agents? [4] formepizone desferrioxamine flumazenil bicarb

Answer 236

**anti freeze** - formepizone **heavy metals**- desferrioxamine **benzos**- flumazenil **salicylate/ tricyclics**- bicarb

Question 237

A patient presents with lipomas, supernumerary teeth, osteomas, and epidermoid cysts. A 25 year old male patient presents to the general practitioner with a 1 month history of constipation, PR bleeding, and weight loss. He reports a family history of gastrointestinal problems. What is the most likely diagnosis? [1]

Answer 237

**Gardner's variant of familial adenomatous polyposis (FAP):** lipomas, supernumerary teeth, osteomas, and epidermoid cysts. FAP is caused by mutation of 1 allele in the APC gene A tumour suppressor gene)

Question 238

When is the use of morphine CI? [1] Name two alternatives that can be used [2]

Answer 238

Renal impairment / dialysis Can use **oxycodone** or **tramadol**

Question 239

A patient presents with the following, alongside respiratory symptoms. Which infective organism is most likely to have caused this?

Answer 239

**Mycoplasma pneumonia**

Question 240

A patient presents with the following, alongside respiratory symptoms. Which infective organism is most likely to have caused this?

Answer 240

Streptococcus pneumonia | Herpes labialis

Question 241

What are the four criteria that determines if something is ARDS? [4]

Answer 241

The four criteria: - **acute onset** (within 1 week of a known risk factor) - **pulmonary oedema**: bilateral infiltrates on chest x-ray ('not fully explained by effusions, lobar/lung collapse or nodules) - **non-cardiogenic** (pulmonary artery wedge pressure needed if doubt) - **pO2/FiO2 < 40kPa (200 mmHg)**

Question 242

What do you give patients prior to bronchoscopy? [2]

Answer 242

Benzodiazepam - for sedation Fentanyl - for pain

Question 243

What platelet levels indicate a transfusion in a normal patient? [no ongoing bleeding]? [1]

Answer 243

A threshold of **10 x 109** except where platelet transfusion is contradindicated or there are alternative treatments for their condition

Question 244

What are the platelet levels that would indicate a transfusion for patients with: - a clinically significant bleeding risk - severe bleeding from critical sites, such as CNS

Answer 244

Offer platelet transfusions to patients with a platelet count of **< 30 x 10 9** with **clinically significant bleeding** (World Health organisation bleeding grade 2- e.g. haematemesis, melaena, prolonged epistaxis) Platelet thresholds for transfusion are higher (maximum **< 100 x 10 9**) for patients with severe bleeding (World Health organisation bleeding grades 3&4), or **bleeding at critical sites, such as the CNS.**

Question 245

What causes this change? [1] What FBC would you expect to see with this? [2]

Answer 245

**Sideroblastic anaemia** is a condition where red cells fail to completely form haem, whose biosynthesis takes place partly in the mitochondrion: - **hypochromic microcytic anaemia** - **high ferritin iron & transferrin saturation**

Question 246

When do you use CMV serenegative components? [2]

Answer 246

Patients at risk of severe CMV disease: - **Pregnant** - **Neonates**

Question 247

When do you give irradiated components? [4]

Answer 247

Question 248

When plalelet concentrates indicated for transfusion? [4]

Answer 248

Question 249

When are fresh frozen plasma transfusions indicated? [4]

Answer 249

Question 250

Which extra-intestinal manifestation occurs independently of the disease activity of IBD? Episcleritis 1 Scleritis 2 Erythema nodosum 3 Primary sclerosing cholangitis 4 Large joint arthritis

Answer 250

Which extra-intestinal manifestation occurs independently of the disease activity of IBD? Episcleritis 1 Scleritis 2 Erythema nodosum 3 **Primary sclerosing cholangitis** 4 Large joint arthritis

Question 251

Label the side effects

Answer 251

Question 252

How d you treat a thrombotic and embolic acute limb ischaemia? [2]

Answer 252

**For thrombotic causes:** - **Angiography** for incomplete ischaemia. This helps map the occlusion site and plan for intervention. Potential endovascular procedures include **angioplasty, thrombectomy, or intra-arterial thrombolysis**. - **Urgent bypass surgery** for complete ischaemia. **For embolic causes**: - the leg is typically threatened, and **immediate** **embolectomy** is required. If embolectomy fails, on-table thrombolysis may be considered.

Question 253

What are contraindications to thrombolysis for PCI? [+]

Answer 253

Aortic Dissection GI bleed Allergic reaction Iatrogenic: recent surgery Neurological disease: recent stroke (within 3 months), malignancy Severe HTN (>200/120) Trauma, including recent CPR

Question 254

A mammogram typically shows a star or rosette-shaped lesion with a translucent centre AND asymptomatic with no evidence of lumps = ?

Answer 254

**Radial scar** - A radial scar is a benign breast condition which can mimic a breast carcinoma. It describes idiopathic sclerosing hyperplasia of the breast ducts

Question 255

Infective endocarditis infection with Strep bovis indicates which further investigations? [1] Why? [1]

Answer 255

**Colonoscopy** - important link with colorectal cancer. Need to consider colonoscopy and biopsy in these patients.

Question 256

Describe what is meant by **Immune Thrombocytopenic Purpura** [3]

Answer 256

*(AKA autoimmune thrombocytopenic purpura, idiopathic thrombocytopenic purpura and primary thrombocytopenic purpura)* - **antibodies** are created against **platelets**, leading to their **destruction** - antibodies are produced of **IgG** and target the **platelet membrane glycoproteins GPIIb/IIIa** - the bone marrow compensates by making more **megakaryocytes**

Question 257

Desribe the treatment plan for ITP

Answer 257

**First line treatment:** - **Oral prednisone** at **1mg/kg daily** with **proton pump inhibitors** - Over **2 - 4 weeks** and weaned off a few weeks after AND - **Pooled normal human immunoglobulin (IVIG)** **Second line:** - **Mycophenolate mofetil**- mmunosuppressive agent AND - **thrombopoietin receptor agonist** (e.g romiplostim) AND - **Rituximab** AND - **Fostamatinib** spleen tyrosine kinase (Syk) inhibitor AND - **Splenectomy**

Question 258

What is meant by Evans syndrome? [1]

Answer 258

Evan's syndrome **ITP** in **association** with **autoimmune haemolytic anaemia (AIHA)**

Question 259

Describe the phenomona of Heparin-Induced Thrombocytopenia [2]

Answer 259

Development of **antibodies** against **platelets** in response to **heparin** (usually unfractionated heparin, but it can occur with low-molecular-weight heparin). **Heparin-induced antibodies** target a protein on platelets called **platelet factor 4** (**PF4**). The **HIT antibodies activate the clotting system**, causing a **hypercoagulable** **state** and **thrombosis** (e.g., deep vein thrombosis) They also break down platelets and cause **thrombocytopenia**

Question 260

State the proliferating cell line in each of the following [3] * **Primary myelofibrosis** * **Polycythaemia vera** * **Essential thrombocythaemia**

Answer 260

Primary myelofibrosis: - **Haematopoietic stem cells** Polycythaemia vera: - **Erythroid cells** Essential thrombocythaemia: - **Megakaryocyte**

Question 261

**[]** is a complication of polycythaemia

Answer 261

**Gout** is a complication of polycythaemia

Question 262

What are the symptomatic or palliative treatment options for myelofibrosis? [4]

Answer 262

**Ruxolitinib**: - a JAK2 inhibitor - effective regardless of JAK2 mutation status. **Hydroxyurea** / (**hydroxycarbamide**) **interferon-alpha**

Question 263

How do you manage PV? [5]

Answer 263

**Venesection** - *first line treatment* - to keep the haemoglobin in the normal range **Aspirin** **75mg** **daily** - to reduce the risk of thrombus formation **Chemotherapy** - (typically **hydroxycarbamide**: reduces the number of RBC **Phosphorus-32 therapy**

Question 264

Cytoreductive therapy (Hydroxycarbamide / hydroxyurea) is considered in high-risk patients, defined by BSH as? [2]

Answer 264

**Age ≥ 65 years** and/or **Prior PV-associated arterial** or **venous thrombosis**

Question 265

Describe how you would investigate for CLL [4]

Answer 265

**FBC**: - **Presence of excess lymphocytes** on full blood count that are found to be clonal **PBS**: - indicated to confirm lymphocytosis - presence of **smudge cells** *artefacts from lymphocytes damaged during the slide preparation because of the fragile nature of these cells.* **Immunophenotyping**: - shows the characteristic clonal B lymphocytes expressing **CD5 and CD23 antigens.** - detect **deletion of TP53 gene**

Question 266

Describe the staging criteria for CLL (there are two)

Answer 266

**Binet staging** - used more in the UK * **Stage A**: < 3 lymphoid sites * **Stage B**: ≥ 3 lymphoid sites * **Stage C**: presence of anaemia ( < 100 g/L) and/or thrombocytopaenia (< 100 x10^9/L) **Rai staging** * **Stage 0 (lymphocytosis)**: 25% at initial diagnosis * **Stage I-II** (lymphocytosis + lymphadenopathy + organomegaly): 50% at initial diagnosis * **Stage III-IV** (lymphocytosis + anaemia or thrombocytopaenia +/- lymphadenopathy/ organomegaly): 25% at initial diagnosis

Question 267

What does NICE recomennd for CLL patients who are **previously untreated and without TP53 mutations** [3]

Answer 267

**Fludarabine, cyclophosphamide and rituximab (FCR)**

Question 268

What is the treatment advised by NICE for the first-line treatment of CLL (Binet stage B or C) in patients for whom FCR chemotherapy is not appropriate? [1]

Answer 268

Chemotherapy with **bendamustine** is advised by NICE as an option for the first-line treatment of CLL (Binet stage B or C) in patients for whom FCR chemotherapy is not appropriate.

Question 269

For patients with FCR or bendamustine-based therapy unsuitable, what treatment does NICE recommend? [2]

Answer 269

For adults with FCR or bendamustine-based therapy unsuitable, NICE recommends **obinutuzumab** in combination with **chlorambucil** as an option.

Question 270

What is the treatment NICE rec. for patients with TP53 deletion/mutation have a poor prognosis even after first line FCR combined chemotherapy? [1]

Answer 270

Patients with TP53 deletion/mutation have a poor prognosis even after first line FCR combined chemotherapy. In such cases, chemo agents like **ibrutinib** can be used.

Question 271

**[]** is a monoclonal antibody which has also been shown to be effective in TP53 mutations.

Answer 271

**Alemtuzumab** is a monoclonal antibody which has also been shown to be effective in TP53 mutations.

Question 272

**[]** is the dominant clinical feature among the complication in CLL, which should be treated with **[]**.

Answer 272

**Auto‐immune cytopenia** is the dominant clinical feature among the complication in CLL, which should be treated with **corticosteroids**.

Question 273

What is the most common cytogenetic feature seen in ALL? t(4;11) t(12;21) t(9;22) Hypodiploid karyotype Hypodiploid karyotype

Answer 273

What is the most common cytogenetic feature seen in ALL? t(4;11) **t(12;21)** t(9;22) Hypodiploid karyotype Hypodiploid karyotype

Question 274

Desribe how the **pre-treatment & supportive therapy phase** of ALL is performed [4]

Answer 274

For roughly 5-7 daysL * **Corticosteroids** with or without another drug * **Hydration** * **Allopurinol** * **CNS** **prophylaxis** is given intrathecally *This pre-phase helps reduce the risk of TLS*

Question 275

Describe the regime usually used for maintenance therapy fr ALL

Answer 275

**daily 6-mercaptopurine** and **weekly methotrexate** *though there is considerable variation.*

Question 276

Describe the genetic pathophysiology of CML [3]

Answer 276

presence of the **BCR-ABL fusion gene:** - results from a reciprocal translocation between **chromosomes 9 and 22** - known as the **Philadelphia (Ph) chromosome** - BCR-ABL fusion protein drives **uncontrolled cell growth and proliferation, leading to CML.**

Question 277

Which of the following is most associated with smudge cells Acute myeloid leukaemia Acute lymphoblastic leukaemia Chronic myeloid leukaemia Chronic lymphocytic leukaemia

Answer 277

**Chronic lymphocytic leukaemia**

Question 278

Describe the general management prinicples for AML [2]

Answer 278

Treatment is set up in cycles and organised into **induction** and **consolidation** (and occasionally maintenance) stages. **Induction**: - **7+3 GO** - An induction regime consisting of **cytarabine, daunorubicin and gemtuzumab ozogamicin (GO)** (combination therapy) **Consolidation**: - **IDAC +/- GO** - A consolidation regime consisting of **intermediate-dose cytarabine (IDAC) +/- gemtuzumab ozogamicin.** **allogenic haematopoietic stem cell transplantation** - for patients with unfavourable prognostic factors (unfavourable cytogenetics) or patients who do not achieve remission through chemotherapy

Question 279

How would you differentiate between AML & ALL? [2]

Answer 279

**terminal deoxynucleotidyl transferase (TdT) positive** in ALL No Auer rods in ALL

Question 280

How would the following change in AML? [5] - Prothrombin time - activated partial thromboplastin time (APTT) - platelet count - D-dimer concentration - fibrinogen concentration

Answer 280

How would the following change in AML? - Prothrombin time: **raised** - activated partial thromboplastin time (APTT): **raised** - platelet count: **reduced** - D-dimer concentration: **elevated** - fibrinogen concentration: **reduced**

Question 281

Which cytogenetic abnomarlities in AML have a really poor prognsosis (3% to 10yrs)? [1]

Answer 281

**inversion 3**

Question 282

How do you treat a breast cyst? [2]

Answer 282

* Cysts should be **aspirated** * Those which are **blood stained or persistently refill** should be **biopsied or excised**

Question 283

How do you treat a phyllodes tumour? [1]

Answer 283

Treatment involves surgical removal of the tumour and the surrounding tissue **(“wide excision”)**. They can reoccur after removal

Question 284

Which of the following is a selective oestrogen receptor downregulato Tamoxifen Fulvestrant Anastrozole Leuprorelin Trastuzumab Pertuzumab

Answer 284

Which of the following is a selective oestrogen receptor downregulato Tamoxifen **Fulvestrant** Anastrozole Leuprorelin Trastuzumab Pertuzumab

Question 285

Non-lactational breast abscesses may be caused by **[]**

Answer 285

Non-lactational breast abscesses may be caused by **duct ectasia,** which is a thickening and widening of the mild duct generally seen in women aged 45-55, and that can cause mastitis and subsequent infection.

Question 286

Prior to breast surgery for cancer, what do you investigate for as it determines management?

Answer 286

**presence/absence of axillary lymphadenopathy determines management**: women with **no palpable axillary lymphadenopathy** at presentation: - should have a **pre-operative axillary ultrasound** before their **primary surgery** - if **negative** then they should have a **sentinel node biopsy to assess the nodal burden** in patients **with breast cancer who present with clinically palpable lymphadenopathy**: - **axillary node clearance is indicated at primary surgery** -

Question 287

Describe what causes inflammatory breast cancer [1] Describe the presentation of inflammatory breast cancer [1]

Answer 287

**IBC** is a rare but rapidly progressive form of breast cancer caused by **obstruction of lymph drainage causing erythema and oedema** **progressive** **erythema** and **oedema of the breast** in the **absence** **signs** of **infection** such as **fever, discharge or elevated WCC and CRP)** and an **elevated CA 15-3.**

Question 288

How do you treat inflammatory breast cancer? [3]

Answer 288

neo-adjuvant chemotherapy first-line, followed by total mastectomy +/- radiotherapy.

Question 289

A 58-year-old undergoes a triple assessment after finding a lump in the right upper lateral quadrant of her breast. Her last menstrual period was 8 years ago, she has never used any hormonal contraceptives or hormone replacement therapy and has no other past medical history. A biopsy shows the presence of ductal carcinoma in situ that is progesterone receptor-negative, HER2-negative, and oestrogen receptor-positive. She is offered a lumpectomy with adjuvant radiotherapy and endocrine therapy. What is the mechanism of action of the most likely drug she will be given? Complete oestrogen receptor antagonism GnRH receptor agonism GnRH receptor antagonism Inhibition of peripheral oestrogen synthesis Partial oestrogen receptor antagonism tamoxifen

Answer 289

**Inhibition of peripheral oestrogen synthesis**

Question 290

**Periductal mastitis** is common in smokers and may present with recurrent infections. Treatment is with **[]**.

Answer 290

Periductal mastitis is common in smokers and may present with recurrent infections. **Treatment is with co-amoxiclav**

Question 291

**Comedo necrosis** is a feature of high nuclear grade ductal carcinoma in situ. It is has a high risk of being associated with foci of invasion. What causes comedo necrosis? Ductal carcinoma in situ Invasive ductal carcinoma Invasive lobular carcinoma Paget's disease of the nipple Lobular carcinoma in situ.

Answer 291

**Comedo necrosis** is a feature of high nuclear grade ductal carcinoma in situ. It is has a high risk of being associated with foci of invasion. What causes comedo necrosis? **Ductal carcinoma in situ** Invasive ductal carcinoma Invasive lobular carcinoma Paget's disease of the nipple Lobular carcinoma in situ.