Friday [08/10/2021] Flashcards

Question

Long-term SE of ECT [1]

Answer 1

some patients report impaired memory

Answer 2

Band ligation

Answer 3

ABC: patients should ideally be resuscitated prior to endoscopy correct clotting: FFP, vitamin K vasoactive agents: terlipressin is currently the only licensed vasoactive agent and is supported by NICE guidelines. It has been shown to be of benefit in initial haemostasis and preventing rebleeding octreotide may also be used although there is some evidence that terlipressin has a greater effect on reducing mortality prophylactic IV antibiotics have been shown to reduce mortality in patients with liver cirrhosis. Quinolones are typically used. NICE support this in their 2016 guidelines: 'Offer prophylactic intravenous antibiotics for people with cirrhosis who have upper gastrointestinal bleeding.' both terlipressin and antibiotics should be given before endoscopy in patients with suspected variceal haemorrhage endoscopy: endoscopic variceal band ligation is superior to endoscopic sclerotherapy. NICE recommend band ligation Sengstaken-Blakemore tube if uncontrolled haemorrhage Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail connects the hepatic vein to the portal vein exacerbation of hepatic encephalopathy is a common complication

Answer 4

both terlipressin and antibiotics should be given before endoscopy in patients with suspected variceal haemorrhage [Abx given those with liver cirrhosis]

Answer 5

Sengstaken-Blakemore tube if uncontrolled haemorrhage Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail connects the hepatic vein to the portal vein exacerbation of hepatic encephalopathy is a common complication

Answer 6

propranolol: reduced rebleeding and mortality compared to placebo endoscopic variceal band ligation (EVL) is superior to endoscopic sclerotherapy. It should be performed at two-weekly intervals until all varices have been eradicated. Proton pump inhibitor cover is given to prevent EVL-induced ulceration. This is supported by NICE who recommend: 'Offer endoscopic variceal band ligation for the primary prevention of bleeding for people with cirrhosis who have medium to large oesophageal varices.'

Answer 7

1 - SABA 2 - SABA + paediatric low-dose inhaled ICS 3 - SABA + paediatric low-dose inhaled ICS + LTRA

Answer 8

NICE advise either topiramate or propranolol 'according to the person's preference, comorbidities and risk of adverse events'. Propranolol should be used in preference to topiramate in women of child bearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives

Answer 9

first-line: offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol

Answer 10

Patients who have received an organ transplant are at risk of skin cancer (particularly squamous cell carcinoma) due to long-term use of immunosuppressants

Answer 11

Cardiovascular disease - tacrolimus and ciclosporin can cause hypertension and hyperglycaemia. Tacrolimus can also cause hyperlipidaemia. Patients must be monitored for accelerated cardiovascular disease.

Answer 12

Renal failure - due to nephrotoxic effects of tacrolimus and ciclosporin/graft rejection/recurrence of original disease in transplanted kidney

Answer 13

SoB: - Inpatient treatment for erythroderma must be monitored for complications like dehydration, infection and high-output heart failure

Answer 14

When more than 95% of the skin is involved in a rash of any kind

Answer 15

eczema psoriasis drugs e.g. gold lymphomas, leukaemias idiopathic

Answer 16

may result from progression of chronic disease to an exfoliative phase with plaques covering most of the body. Associated with mild systemic upset more serious form is an acute deterioration. This may be triggered by a variety of factors such as withdrawal of systemic steroids. Patients need to be admitted to hospital for management

Answer 17

Raised inflammatory markers, RUQ pain and fever

Answer 18

Combination of antibiotics and drainage

Answer 19

The most common organisms found in pyogenic liver abscesses are Staphylococcus aureus in children and Escherichia coli in adults.

Answer 20

drainage (typically percutaneous) and antibiotics amoxicillin + ciprofloxacin + metronidazole if penicillin allergic: ciprofloxacin + clindamycin

Answer 21

Pregnant women with GDM should be advised to maintain their CBGs below the following target levels: fasting: 5.3mmol/L AND 1 hour postprandial: 7.8 mmol/L or 2 hours postprandial: 6.4 mmol/L

Answer 22

If these targets are not met with diet, exercise and metformin, then insulin should be offered as add-on therapy.

Answer 23

Between 6-12 hours

Answer 24

Alcohol withdrawal symptoms: 6-12 hours seizures: 36 hours delirium tremens: 72 hours

Answer 25

first-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol

Answer 26

tremor, sweating, tachycardia, anxiety

Answer 27

amiodarone indomethacin

Answer 28

ethambutol amiodarone metronidazole

Answer 29

chloroquine, quinine

Answer 30

Genital herpes is most often caused by the herpes simplex virus (HSV) type 2 (cold sores are usually due to HSV type 1)

Answer 31

Primary attacks are often severe and associated with fever whilst subsequent attacks are generally less severe and localised to one site. There is typically multiple painful ulcers.

Answer 32

Syphilis is a sexually transmitted infection caused by the spirochaete Treponema pallidum. Infection is characterised by primary, secondary and tertiary stages. A painless ulcer (chancre) is seen in the primary stage. The incubation period= 9-90 days.

Answer 33

Chancroid is a tropical disease caused by Haemophilus ducreyi. It causes painful genital ulcers associated with unilateral, painful inguinal lymph node enlargement. The ulcers typically have a sharply defined, ragged, undermined border.

Answer 34

Lymphogranuloma venereum (LGV) is caused by Chlamydia trachomatis. Typically infection comprises of three stages stage 1: small painless pustule which later forms an ulcer stage 2: painful inguinal lymphadenopathy stage 3: proctocolitis

Answer 35

Doxycycline

Answer 36

airway, breathing, circulation burns caused by heat: remove the person from the source. Within 20 minutes of the injury irrigate the burn with cool (not iced) water for between 10 and 30 minutes. Cover the burn using cling film, layered, rather than wrapped around a limb electrical burns: switch off power supply, remove the person from the source chemical burns: brush any powder off then irrigate with water. Attempts to neutralise the chemical are not recommended

Answer 37

Wallace's Rule of Nines: head + neck = 9%, each arm = 9%, each anterior part of leg = 9%, each posterior part of leg = 9%, anterior chest = 9%, posterior chest = 9%, anterior abdomen = 9%, posterior abdomen = 9% Lund and Browder chart: the most accurate method the palmar surface is roughly equivalent to 1% of total body surface area (TBSA). Not accurate for burns \> 15% TBSA

Answer 38

all deep dermal and full-thickness burns. superficial dermal burns of more than 3% TBSA in adults, or more than 2% TBSA in children superficial dermal burns involving the face, hands, feet, perineum, genitalia, or any flexure, or circumferential burns of the limbs, torso, or neck any inhalation injury any electrical or chemical burn injury suspicion of non-accidental injury

Answer 39

Following the burn, there is a local response with progressive tissue loss and release of inflammatory cytokines. Systemically, there are cardiovascular effects resulting from fluid loss and sequestration of fluid into the third space. There is a marked catabolic response. Immunosupression is common with large burns and bacterial translocation from the gut lumen is a recognised event. Sepsis is a common cause of death following major burns.

Answer 40

The initial aim is to stop the burning process and resuscitate the patient. Intravenous fluids will be required for children with burns greater than 10% of total body surface area. Adults with burns greater than 15% of total body surface area will also require IV fluids. The fluids are calculated using the Parkland formula which is; volume of fluid= total body surface area of the burn % x weight (Kg) x4. Half of the fluid is administered in the first 8 hours. A urinary catheter should be inserted. Analgesia should be given. Complex burns, burns involving the hand perineum and face and burns \>10% in adults and \>5% in children should be transferred to a burns unit.

Answer 41

Conservative management is appropriate for superficial burns and mixed superficial burns that will heal in 2 weeks. More complex burns may require excision and skin grafting. Excision and primary closure is not generally practised as there is a high risk of infection.

Answer 42

Indicated in circumferential full thickness burns to the torso or limbs. Careful division of the encasing band of burn tissue will potentially improve ventilation (if the burn involves the torso), or relieve compartment syndrome and oedema (where a limb is involved)

Answer 43

Treating the affected person and all household members, close contacts, and sexual contacts with a topical insecticide (e.g. permethrin 5% cream or malathion 0.5% liquid), even in the absence of symptoms.

Answer 44

avoid close physical contact with others until treatment is complete all household and close physical contacts should be treated at the same time, even if asymptomatic launder, iron or tumble dry clothing, bedding, towels, etc., on the first day of treatment to kill off mites.

Answer 45

widespread pruritus linear burrows on the side of fingers, interdigital webs and flexor aspects of the wrist in infants, the face and scalp may also be affected secondary features are seen due to scratching: excoriation, infection

Answer 46

Overweight is 25-30, obese class 1 is 30-35

Answer 47

conservative: diet, exercise medical surgical

Answer 48

Orlistat is a pancreatic lipase inhibitor used in the management of obesity. Adverse effects include faecal urgency/incontinence and flatulence

Answer 49

A lower dose version is now available without prescription ('Alli').

Answer 50

BMI of 28 kg/m^2 or more with associated risk factors, or BMI of 30 kg/m^2 or more continued weight loss e.g. 5% at 3 months orlistat is normally used for \< 1 year

Answer 51

She is having unprotected intercourse and will not be covered by the lactational amenorrhea method (LAM) as the baby is getting less than 85% of its feeds as breast milk (NICE CKS: Contraception - natural family planning)

Answer 52

If not covered by the LAM, women are at risk of pregnancy from unprotected intercourse from day 21 postpartum

Answer 53

The COCP is absolutely contraindicated (UKMEC 4) for women who are breastfeeding less than 6 weeks post-partum

Answer 54

However, this lady is seven weeks postpartum meaning she falls into the 6 weeks - 6 months postpartum guidance, in which the COCP is categorised as UKMEC2 for breastfeeding women. This means that advantages of prescribing the COCP would generally outweigh the disadvantages and based on the FRSH advice regarding the COCP, NICE clinical knowledge summaries recommend

Answer 55

the FSRH advise 'postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.' after day 21 additional contraception should be used for the first 2 days a small amount of progestogen enters breast milk but this is not harmful to the infant

Answer 56

absolutely contraindicated - UKMEC 4 - if breast feeding \< 6 weeks post-partum UKMEC 2 - if breast feeding 6 weeks - 6 months postpartum\* the COC may reduce breast milk production in lactating mothers may be started from day 21 - this will provide immediate contraception after day 21 additional contraception should be used for the first 7 days

Answer 57

The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks.

Answer 58

is 98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and \< 6 months post-partum

Answer 59

An inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birthweight and small for gestational age babies.

Answer 60

Pre-eclampsia is defined as new-onset BP ≥ 140/90 mmHg after 20 weeks AND ≥ 1 of proteinuria or organ dysfunction

Answer 61

eclampsia other neurological complications include altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata fetal complications intrauterine growth retardation prematurity liver involvement (elevated transaminases) haemorrhage: placental abruption, intra-abdominal, intra-cerebral cardiac failure

Answer 62

hypertension: typically \> 160/110 mmHg and proteinuria as above proteinuria: dipstick ++/+++ headache visual disturbance papilloedema RUQ/epigastric pain hyperreflexia platelet count \< 100 \* 106/l, abnormal liver enzymes or HELLP syndrome

Answer 63

hypertensive disease in a previous pregnancy chronic kidney disease autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome type 1 or type 2 diabetes chronic hypertension

Answer 64

first pregnancy age 40 years or older pregnancy interval of more than 10 years body mass index (BMI) of 35 kg/m² or more at first visit family history of pre-eclampsia multiple pregnancy

Answer 65

Reducing the risk of hypertensive disorders in pregnancy women with the following should take aspirin 75-150mg daily from 12 weeks gestation until the birth ≥ 1 high risk factors ≥ 2 moderate factors

Answer 66

Initial assessment NICE recommend arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed

Answer 67

oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine (e.g. if asthmatic) and hydralazine may also be used delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario

Answer 68

Nifedipine

Answer 69

There are two strains of the herpes simplex virus (HSV) in humans: HSV-1 and HSV-2. Whilst it was previously thought HSV-1 accounted for oral lesions (cold sores) and HSV-2 for genital herpes it is now known there is considerable overlap

Answer 70

primary infection: may present with a severe gingivostomatitis cold sores painful genital ulceration

Answer 71

gingivostomatitis: oral aciclovir, chlorhexidine mouthwash cold sores: topical aciclovir although the evidence base for this is modest genital herpes: oral aciclovir. Some patients with frequent exacerbations may benefit from longer term aciclovir

Answer 72

elective caesarean section at term is advised if a primary attack of herpes occurs during pregnancy at greater than 28 weeks gestation women with recurrent herpes who are pregnant should be treated with suppressive therapy and be advised that the risk of transmission to their baby is low

Answer 73

Patients who have Addison's disease are usually given both glucocorticoid and mineralocorticoid replacement therapy.

Answer 74

hydrocortisone: usually given in 2 or 3 divided doses. Patients typically require 20-30 mg per day, with the majority given in the first half of the day fludrocortisone

Answer 75

emphasise the importance of not missing glucocorticoid doses consider MedicAlert bracelets and steroid cards patients should be provided with hydrocortisone for injection with needles and syringes to treat an adrenal crisis discuss how to adjust the glucocorticoid dose during an intercurrent illness (see below)

Answer 76

in simple terms the glucocorticoid dose should be doubled, with the fludrocortisone dose staying the same the Addison's Clinical Advisory Panel have produced guidelines detailing particular scenarios - please see the CKS link for more details

Answer 77

diabetes mellitus: up to 20% of diabetics may have an episode of frozen shoulder

Answer 78

external rotation is affected more than internal rotation or abduction both active and passive movement are affected patients typically have a painful freezing phase, an adhesive phase and a recovery phase bilateral in up to 20% of patients the episode typically lasts between 6 months and 2 years

Answer 79

no single intervention has been shown to improve outcome in the long-term treatment options include NSAIDs, physiotherapy, oral corticosteroids and intra-articular corticosteroids

Answer 80

Trichomonas vaginalis is a highly motile, flagellated protozoan parasite. Trichomoniasis is a sexually transmitted infection (STI).

Answer 81

vaginal discharge: offensive, yellow/green, frothy vulvovaginitis strawberry cervix pH \> 4.5 in men is usually asymptomatic but may cause urethritis

Answer 82

microscopy of a wet mount shows motile trophozoites

Answer 83

oral metronidazole for 5-7 days, although the BNF also supports the use of a one-off dose of 2g metronidazole

Answer 84

Myasthenia gravis is an autoimmune condition whereby the patient's immune system attacks the acetylcholine receptors at the neuromuscular junction. Symptoms include weakness, especially in the evening. Treatment is focused on increasing the concentration of acetylcholine in the synaptic cleft using acetylcholinesterase inhibitors.

Answer 85

Guillan-barre syndrome is an autoimmune condition. It has no known causes but often occurs after an episode of infection or immunization. Both conditions are associated with slowed motor conduction on nerve conduction studies.

Answer 86

Motor neuron disease is a neurological condition of unknown cause which can present with both upper and lower motor neuron signs. It rarely presents before 40 years and various patterns of disease are recognised including amyotrophic lateral sclerosis, progressive muscular atrophy and bulbar palsy.

Answer 87

fasciculations the absence of sensory signs/symptoms\* the mixture of lower motor neuron and upper motor neuron signs wasting of the small hand muscles/tibialis anterior is common

Answer 88

doesn't affect external ocular muscles no cerebellar signs abdominal reflexes are usually preserved and sphincter dysfunction if present is a late feature

Answer 89

The diagnosis of motor neuron disease is clinical, but nerve conduction studies will show normal motor conduction and can help exclude a neuropathy. Electromyography shows a reduced number of action potentials with increased amplitude. MRI is usually performed to exclude the differential diagnosis of cervical cord compression and myelopathy

Answer 90

affects both upper (corticospinal tracts) and lower motor neurons results in a combination of upper and lower motor neuron signs

Answer 91

affects anterior horns resulting in lower motor neuron signs

Answer 92

1. Lateral corticospinal tract 2. Dorsal columns 3. Lateral spinothalamic tract

Answer 93

1. Ipsilateral spastic paresis below lesion 2. Ipsilateral loss of proprioception and vibration sensation 3. Contralateral loss of pain and temperature sensation

Answer 94

Same as subacute combined degeneration of the spinal cord (see above)

Answer 95

Same as subacute combined degeneration of the spinal cord (see above) In addition cerebellar ataxia → other features e.g. intention tremor

Answer 96

Asymmetrical, varying spinal tracts involved

Answer 97

Combination of motor, sensory and ataxia symptoms

Answer 98

Disorder Tracts affected Clinical notes Neurosyphilis (tabes dorsalis) 1. Dorsal columns 1. Loss of proprioception and vibration sensation

Answer 99

The sensation of fine touch, proprioception and vibration are all conveyed in the dorsal column

Answer 100

It is primarily responsible for transmitting pain and temperature as well as coarse touch.

Answer 101

The primary responsibility of the lateral corticospinal tract is to control the voluntary movement of contralateral limbs

Answer 102

The spinocerebellar tracts carry unconscious proprioceptive information gleaned from muscle spindles, Golgi tendon organs, and joint capsules to the cerebellum

Answer 103

No Tx as not recommedned by NICE. Not proven to be beneficial.Lifestyle changes (less red meat, alcohol and sugar) can reduce uric acid levels without drug treatment and so can be advised.

Answer 104

Hyperuricaemia may be associated with hyperlipidaemia and hypertension. It may also be seen in conjunction with the metabolic syndrome

Answer 105

Lesch-Nyhan disease myeloproliferative disorders diet rich in purines exercise psoriasis cytotoxics

Answer 106

drugs: low-dose aspirin, diuretics, pyrazinamide pre-eclampsia alcohol renal failure lead

Answer 107

Idiopathic pulmonary fibrosis (IPF, previously termed cryptogenic fibrosing alveolitis) is a chronic lung condition characterised by progressive fibrosis of the interstitium of the lungs. Whilst there are many causes of lung fibrosis (e.g. medications, connective tissue disease, asbestos) the term IPF is reserved when no underlying cause exists.

Answer 108

IPF is typically seen in patients aged 50-70 years and is twice as common in men.

Answer 109

progressive exertional dyspnoea bibasal fine end-inspiratory crepitations on auscultation dry cough clubbing

Answer 110

spirometry: classically a restrictive picture (FEV1 normal/decreased, FVC decreased, FEV1/FVC increased) impaired gas exchange: reduced transfer factor (TLCO) imaging: bilateral interstitial shadowing (typically small, irregular, peripheral opacities - 'ground-glass' - later progressing to 'honeycombing') may be seen on a chest x-ray but high-resolution CT scanning is the investigation of choice and required to make a diagnosis of IPF ANA positive in 30%, rheumatoid factor positive in 10% but this does not necessarily mean that the fibrosis is secondary to a connective tissue disease. Titres are usually low

Answer 111

imaging: bilateral interstitial shadowing (typically small, irregular, peripheral opacities - 'ground-glass' - later progressing to 'honeycombing') may be seen on a chest x-ray but high-resolution CT scanning is the investigation of choice and required to make a diagnosis of IPF

Answer 112

pulmonary rehabilitation very few medications have been shown to give any benefit in IPF. There is some evidence that pirfenidone (an antifibrotic agent) may be useful in selected patients (see NICE guidelines) many patients will require supplementary oxygen and eventually a lung transplant

Answer 113

poor, average life expectancy is around 3-4 years

Answer 114

classically a restrictive picture (FEV1 normal/decreased, FVC decreased, FEV1/FVC increased)

Answer 115

A chest x-ray will show interstitial shadowing, and a high resolution CT will show 'honeycomb' lungs.

Answer 116

Lynch syndrome (HNPCC) is characterised by development of bowel cancer (among other cancers) with little formation of adenomatous polyps

Answer 117

Typically over 100 colonic adenomas Cancer risk of 100% 20% are new mutations

Answer 118

Multiple colonic polyps Later onset right sided cancers more common than in FAP 100% cancer risk by age 60

Answer 119

Multiple benign intestinal hamartomas Episodic obstruction and intussusception Increased risk of GI cancers (colorectal cancer 20%, gastric 5%) Increased risk of breast, ovarian, cervical pancreatic and testicular cancers

Answer 120

Macrocephaly Multiple intestinal hamartomas Multiple trichilemmomas 89% risk of cancer at any site 16% risk of colorectal cancer

Answer 121

Colo rectal cancer 30-70% Endometrial cancer 30-70% Gastric cancer 5-10% Scanty colonic polyps may be present Colonic tumours likely to be right sided and mucinous

Answer 122

In sick euthyroid syndrome (now referred to as non-thyroidal illness) it is often said that everything (TSH, thyroxine and T3) is low. In the majority of cases however the TSH level is within the \>normal range (inappropriately normal given the low thyroxine and T3).

Answer 123

In sick euthyroid syndrome (now referred to as non-thyroidal illness) it is often said that everything (TSH, thyroxine and T3) is low. In the majority of cases however the TSH level is within the \>normal range (inappropriately normal given the low thyroxine and T3). Changes are reversible upon recovery from the systemic illness and hence no treatment is usually needed.

Answer 124

The correct answer is: CT c-spine40% This man needs a CT scan of his c-spine. A CT scan will give the best resolution of any bony injury.

Answer 125

CT head within 1h72% This lady has a head injury and vomiting \> 1, therefore an urgent CT head is indicated.

Answer 126

Urgent neurosurgical review (even before CT head performed)86% A penetrating injury needs urgent neurosurgical review.

Answer 127

GCS \< 13 on initial assessment GCS \< 15 at 2 hours post-injury suspected open or depressed skull fracture. any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign). post-traumatic seizure. focal neurological deficit. more than 1 episode of vomiting

Answer 128

CT head scan within 8 hours of the head injury - for adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury: age 65 years or older any history of bleeding or clotting disorders dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs) more than 30 minutes' retrograde amnesia of events immediately before the head injury

Answer 129

Perform CT head within 8h

Answer 130

Red flag if presneting with this, should be rederred to hospital immediately

Answer 131

age \< 20 years or \> 50 years history of previous malignancy night pain history of trauma systemically unwell e.g. weight loss, fever

Answer 132

Usually gradual onset Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as 'aching', 'crawling'. Relieved by sitting down, leaning forwards and crouching down Clinical examination is often normal Requires MRI to confirm diagnosis

Answer 133

Typically a young man who presents with lower back pain and stiffness Stiffness is usually worse in morning and improves with activity Peripheral arthritis (25%, more common if female)

Answer 134

Pain on walking, relieved by rest Absent or weak foot pulses and other signs of limb ischaemia Past history may include smoking and other vascular diseases

Answer 135

Klinefelter's syndrome is associated with karyotype 47, XXY

Answer 136

often taller than average lack of secondary sexual characteristics small, firm testes infertile gynaecomastia - increased incidence of breast cancer elevated gonadotrophin levels

Answer 137

Diagnosis is by chromosomal analysis

Answer 138

Kallman's syndrome is a recognised cause of delayed puberty secondary to hypogonadotrophic hypogonadism. It is usually inherited as an X-linked recessive trait. Kallman's syndrome is thought to be caused by failure of GnRH-secreting neurons to migrate to the hypothalamus.

Answer 139

Features 'delayed puberty' hypogonadism, cryptorchidism anosmia sex hormone levels are low LH, FSH levels are inappropriately low/normal patients are typically of normal or above average height Cleft lip/palate and visual/hearing defects are also seen in some patients

Answer 140

The clue given in many questions is lack of smell (anosmia) in a boy with delayed puberty

Answer 141

Androgen insensitivity syndrome is an X-linked recessive condition due to end-organ resistance to testosterone causing genotypically male children (46XY) to have a female phenotype. Complete androgen insensitivity syndrome is the new term for testicular feminisation syndrome

Answer 142

'primary amenorrhoea' undescended testes causing groin swellings breast development may occur as a result of conversion of testosterone to oestradiol

Answer 143

buccal smear or chromosomal analysis to reveal 46XY genotype

Answer 144

``` counselling - raise child as female bilateral orchidectomy (increased risk of testicular cancer due to undescended testes) oestrogen therapy ```

Answer 145

Klinefelter's syndrome - high LH - low testerone

Answer 146

Kallman's - low LH - low testerone

Answer 147

AIS - high LH - normal/high testerone

Answer 148

Malignant hyperthermia Hyperkalaemia [normally transient] May cause fasciculations

Answer 149

Binds to nicotinic acetylcholine receptors resulting in persistent depolarization of the motor end plate

Answer 150

Suxamethonium is contraindicated for patients with penetrating eye injuries or acute narrow angle glaucoma, as suxamethonium increases intra-ocular pressure

Answer 151

Competitive antagonist of nicotinic acetylcholine receptors Tubcurarine, atracurium, vecuronium, pancuronium Hypotension Reversal by Acetylcholinesterase inhibitors (e.g. neostigmine)

Answer 152

In aortic dissection, a pulse deficit may be seen: weak or absent carotid, brachial, or femoral pulse variation in arm BP

Answer 153

infective endocarditis

Answer 154

RVH such as in cor pulmomale

Answer 155

tear in the tunica intima of the wall of the aorta

Answer 156

hypertension: the most important risk factor trauma bicuspid aortic valve collagens: Marfan's syndrome, Ehlers-Danlos syndrome Turner's and Noonan's syndrome pregnancy syphilis

Answer 157

chest pain: typically severe, radiates through to the back and 'tearing' in nature pulse deficit weak or absent carotid, brachial, or femoral pulse variation (\>20 mmHg) in systolic blood pressure between the arms aortic regurgitation hypertension other features may result from the involvement of specific arteries. For example coronary arteries → angina, spinal arteries → paraplegia, distal aorta → limb ischaemia the majority of patients have no or non-specific ECG changes. In a minority of patients, ST-segment elevation may be seen in the inferior leads

Answer 158

type A - ascending aorta, 2/3 of cases type B - descending aorta, distal to left subclavian origin, 1/3 of cases

Answer 159

type I - originates in ascending aorta, propagates to at least the aortic arch and possibly beyond it distally type II - originates in and is confined to the ascending aorta type III - originates in descending aorta, rarely extends proximally but will extend distally

Answer 160

Anaphylaxis may be defined as a severe, life-threatening, generalised or systemic hypersensitivity reaction.

Answer 161

food (e.g. nuts) - the most common cause in children drugs venom (e.g. wasp sting)

Answer 162

The Resus Council UK define anaphylaxis as: the sudden onset and rapid progression of symptoms Airway and/or Breathing and/or Circulation problems Airway problems may include: swelling of the throat and tongue →hoarse voice and stridor Breathing problems may include: respiratory wheeze dyspnoea Circulation problems may include: hypotension tachycardia

Answer 163

generalised pruritus widespread erythematous or urticarial rash

Answer 164

\<6m then 100-150mcg Adult then 500mcg

Answer 165

Adrenaline can be repeated every 5 minutes if necessary

Answer 166

The best site for IM injection is the anterolateral aspect of the middle third of the thigh.

Answer 167

defined as respiratory and/or cardiovascular problems persist despite 2 doses of IM adrenaline IV fluids should be given for shock expert help should be sought for consideration of an IV adrenaline infusion

Answer 168

non-sedating oral antihistamines, in preference to chlorphenamine, may be given following initial stabilisation especially in patients with persisting skin symptoms (urticaria and/or angioedema) sometimes it can be difficult to establish whether a patient had a true episode of anaphylaxis. Serum tryptase levels are sometimes taken in such patients as they remain elevated for up to 12 hours following an acute episode of anaphylaxis all patients with a new diagnosis of anaphylaxis should be referred to a specialist allergy clinic an adrenaline injector should be givens an interim measure before the specialist allergy assessment (unless the reaction was drug-induced) patients should be prescribed 2 adrenaline auto-injectors training should be provided on how to use it

Answer 169

- a risk-stratified approach to discharge should be taken as biphasic reactions can occur in up to 20% of patients

Answer 170

fast-track discharge (after 2 hours of symptom resolution): good response to a single dose of adrenaline complete resolution of symptoms has been given an adrenaline auto-injector and trained how to use it adequate supervision following discharge minimum 6 hours after symptom resolution: 2 doses of IM adrenaline needed, or previous biphasic reaction minimum 12 hours after symptom resolution: severe reaction requiring \> 2 doses of IM adrenaline patient has severe asthma possibility of an ongoing reaction (e.g. slow-release medication) patient presents late at night patient in areas where access to emergency access care may be difficult observation for at 12 hours following symptom resolution

Answer 171

pelvic thrusting family member with epilepsy much more common in females crying after seizure don't occur when alone gradual onset

Answer 172

Ongue biting Raised serum prolactin [why is not fully understood]

Answer 173

Video telemetry

Answer 174

Hand, foot and mouth disease is a self-limiting condition affecting children. It is caused by the intestinal viruses of the Picornaviridae family (most commonly coxsackie A16 and enterovirus 71)

Answer 175

It is very contagious and typically occurs in outbreaks at nursery

Answer 176

mild systemic upset: sore throat, fever oral ulcers followed later by vesicles on the palms and soles of the feet

Answer 177

symptomatic treatment only: general advice about hydration and analgesia reassurance no link to disease in cattle children do not need to be excluded from school the HPA recommends that children who are unwell should be kept off school until they feel better they also advise that you contact them if you suspect that there may be a large outbreak.

Answer 178

cervical rib is a common cause of thoracic outlet syndrome [about 10% will develop cervical rib syndrome]

Answer 179

Hangman's fracture is another incorrect answer. This is a fracture to the C2 vertebrae commonly as a result of hanging. It is unlikely that this 16-year-old boy has a hangman's fracture, especially as there is no history of neck pain or suicide attempts.

Answer 180

Thoracic outlet syndrome (TOS) is a disorder involving compression of brachial plexus, subclavian artery or vein at the site of the thoracic outlet. TOS can be neurogenic or vascular; the former accounts for 90% of the cases.

Answer 181

given the lack of widely agreed diagnostic criteria, the epidemiology of TOS is not well documented patients are typically young thin women possessing long neck and drooping shoulders peak onset occurs in the 4th decade

Answer 182

TOS develops when neck trauma occurs to individuals with anatomical predispositions neck trauma can either be a single acute incident or repeated stresses anatomical anomalies can either be in the form of soft tissue (70%) or osseous structures (30%) a well-known osseous anomaly is the presence of cervical rib examples of soft tissue causes are scalene muscle hypertrophy and anomalous bands there is usually a history of neck trauma preceding TOS

Answer 183

painless muscle wasting of hand muscles, with patients complaining of hand weakness e.g. grasping sensory symptoms such as numbness and tingling may be present if autonomic nerves are involved, the patient may experience cold hands, blanching or swelling

Answer 184

subclavian vein compression leads to painful diffuse arm swelling with distended veins subclavian artery compression leads to painful arm claudication and in severe cases, ulceration and gangrene

Answer 185

chest and cervical spine plain radiographs to check for any obvious osseous abnormalities e.g. cervical ribs, exclude malignant tumours or other differentials e.g. cervical spine degenerative changes other imaging modalities may be helpful e.g. CT or MRI to rule out cervical root lesions venography or angiography may be helpful in vascular TOS an anterior scalene block may be used to confirm neurogenic TOS and check the likelihood of successful surgical treatment

Answer 186

there is a limited evidence base conservative management with education, rehabilitation, physiotherapy, or taping is typically the first-line management for neurogenic TOS surgical decompression is warranted where conservative management has failed especially if there is a physical anomaly. Early intervention may prevent brachial plexus degeneration in vascular TOS, surgical treatment may be preferred other therapies being investigated include botox injection

Answer 187

``` bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding) bladder stabilising drugs: antimuscarinics are first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in 'frail older women' mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients ```

Answer 188

pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months surgical procedures: e.g. retropubic mid-urethral tape procedures duloxetine may be offered to women if they decline surgical procedures a combined noradrenaline and serotonin reuptake inhibitor mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction

Answer 189

Hodgkin's lymphoma is a malignant proliferation of lymphocytes characterised by the presence of the Reed-Sternberg cell. It has a bimodal age distributions being most common in the third and seventh decades

Answer 190

I: single lymph node II: 2 or more lymph nodes/regions on same side of diaphragm III: nodes on both sides of diaphragm IV: spread beyond lymph nodes

Answer 191

``` A = no systemic symptoms other than pruritus B = weight loss \> 10% in last 6 months, fever \> 38c, night sweats (poor prognosis ```

Answer 192

Takotsubo cardiomyopathy is associated with apical ballooning of myocardium (resembling an octopus pot)

Answer 193

Takotsubo cardiomyopathy is a type of non-ischaemic cardiomyopathy associated with a transient, apical ballooning of the myocardium. It may be triggered by stress.

Answer 194

Takotsubo is a Japanese word that describes an octopus trap the apical ballooning appearance occurs due to severe hypokinesis of the mid and apical segments with preservation of activity of the basal segments. In simple terms, the bottom of the heart (the apex) does not contract and therefore appears to balloon out. However, the area closer to the top (the base) continues to contract (creating the neck of the octopus trap)

Answer 195

chest pain features of heart failure ECG: ST-elevation normal coronary angiogram

Answer 196

Treatment is supportive. Prognosis the majority of patients improve with supportive treatment

Answer 197

The most likely diagnosis in this case is metastatic prostate cancer. This disease is the most common cancer to metastasise to bone and patients often present with pathological fractures or bone pain as the first sign of disease. Prostate cancer metastases typically have a sclerotic appearance on x-ray.

Answer 198

Multiple myeloma and Paget's disease are typically associated with osteolytic lesions rather than sclerotic, however.

Answer 199

Osteosarcoma is a rare cancer most commonly affecting the long bones of children/young adults. It would be highly unusual to be present in the spine of man of this age. It often presents with pathological fractures of long bones such as the femur.

Answer 200

Most common tumour causing bone metastases (in descending order) prostate breast lung

Answer 201

Most common site (in descending order) spine pelvis ribs skull long bones

Answer 202

pathological fractures -\> sclerotic appearnace, not osteolytic lesions hypercalcaemia raised ALP

Answer 203

Colonoscopy Deep ulceration affecting terminal ileum and colon, with skip lesions Biopsy sample from terminal ileum Granulomatous inflammation extending from serosa to mucosa [transmural]

Answer 204

GLucocorticoids [oral, topical or IV] -\> e.g. 300mg of predninsolone

Answer 205

Crohn's disease is a form of inflammatory bowel disease. It commonly affects the terminal ileum and colon but may be seen anywhere from the mouth to anus. NICE published guidelines on the management of Crohn's disease in 2012.

Answer 206

``` First-line = glucocorticoids (oral, topical or intravenous) are generally used to induce remission. Budesonide is an alternative in a subgroup of patients Second-line = 5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective ```

Answer 207

enteral feeding with an elemental diet may be used in addition to or instead of other measures to induce remission, particularly if there is concern regarding the side-effects of steroids (for example in young children)

Answer 208

azathioprine or mercaptopurine\* may be used as an add-on medication to induce remission but is not used as monotherapy. Methotrexate is an alternative to azathioprine

Answer 209

infliximab is useful in refractory disease and fistulating Crohn's. Patients typically continue on azathioprine or methotrexate metronidazole is often used for isolated peri-anal disease

Answer 210

as above, stopping smoking is a priority (remember: smoking makes Crohn's worse, but may help ulcerative colitis) azathioprine or mercaptopurine is used first-line to maintain remission methotrexate is used second-line 5-ASA drugs (e.g. mesalazine) should be considered if a patient has had previous surgery

Answer 211

+TMPT activity should be assessed before starting

Answer 212

around 80% of patients with Crohn's disease will eventually have surgery see below for further detail

Answer 213

Azathioprine or mercaptopurine

Answer 214

The commonest disease pattern in Crohn's is stricturing terminal ileal disease and this often culminates in an ileocaecal resection

Answer 215

Other procedures performed include segmental small bowel resections and stricturoplasty. Colonic involvement in patients with Crohn's is not common and, where found, distribution is often segmental. However, despite this distribution segmental resections of the colon in patients with Crohn's disease are generally not advocated because the recurrence rate in the remaining colon is extremely high, as a result, the standard options of colonic surgery in Crohn's patients are generally; sub total colectomy, panproctocolectomy and staged sub total colectomy and proctectomy. Restorative procedures such as ileoanal pouch have no role in therapy.

Answer 216

Crohn's disease is notorious for the developmental of intestinal fistulae; these may form between the rectum and skin (perianal) or the small bowel and skin. Fistulation between loops of bowel may also occur and result in bacterial overgrowth and malabsorption. Management of enterocutaneous fistulae involves controlling sepsis, optimising nutrition, imaging the disease and planning definitive surgical management.

Answer 217

``` As well as the well-documented complications described above, patients are also at risk of: small bowel cancer (standard incidence ratio = 40) colorectal cancer (standard incidence ration = 2, i.e. less than the risk associated with ulcerative colitis) osteoporosis ```

Answer 218

87.5% have gestational diabetes 7.5% have type 1 diabetes 5% have type 2 diabetes

Answer 219

Gestational diabetes is the second most common medical disorder complicating pregnancy (after hypertension), affecting around 4% of pregnancies.

Answer 220

Pregnant patients with type 1 diabetes should monitor their blood glucose levels closely. They should test their levels multiple times during the day. NICE NG3 Daily fasting, pre-meal, 1-hour post meal and bedtime tests.

Answer 221

weight loss for women with BMI of \> 27 kg/m^2 stop oral hypoglycaemic agents, apart from metformin, and commence insulin folic acid 5 mg/day from pre-conception to 12 weeks gestation detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts tight glycaemic control reduces complication rates treat retinopathy as can worsen during pregnancy

Answer 222

Clarithromycin -This patient was likely sent away initially due to the high probability he had a self-limiting viral illness. Due to the persistence of his symptoms the GP would be justified in treating the child for a bacterial lower respiratory tract infection. Without penicillin allergy then amoxicillin is the first choice treatment, however in this case this must be avoided, clarithromycin is the antibiotic of choice instead.

Answer 223

Essential tremor (previously called benign essential tremor) is an autosomal dominant condition which usually affects both upper limbs

Answer 224

postural tremor: worse if arms outstretched [6-8Hz] improved by alcohol and rest most common cause of titubation (head tremor)

Answer 225

Management propranolol is first-line primidone is sometimes used

Answer 226

history of glucocorticoid use rheumatoid arthritis alcohol excess history of parental hip fracture low body mass index current smoking

Answer 227

sedentary lifestyle premature menopause Caucasians and Asians endocrine disorders: hyperthyroidism, hypogonadism (e.g. Turner's, testosterone deficiency), growth hormone deficiency, hyperparathyroidism, diabetes mellitus multiple myeloma, lymphoma gastrointestinal disorders: inflammatory bowel disease, malabsorption (e.g. Coeliac's), gastrectomy, liver disease chronic kidney disease osteogenesis imperfecta, homocystinuria

Answer 228

SSRIs antiepileptics proton pump inhibitors glitazones long term heparin therapy aromatase inhibitors e.g. anastrozole

Answer 229

If a patient is diagnosed with osteoporosis or has a fragility fracture further investigations may be warranted. NOGG recommend testing for the following reasons: exclude diseases that mimic osteoporosis (e.g. osteomalacia, myeloma); identify the cause of osteoporosis and contributory factors; assess the risk of subsequent fractures; select the most appropriate form of treatment

Answer 230

History and physical examination Blood cell count, sedimentation rate or C-reactive protein, serum calcium, albumin, creatinine, phosphate, alkaline phosphatase and liver transaminases Thyroid function tests Bone densitometry ( DXA)

Answer 231

Lateral radiographs of lumbar and thoracic spine/DXA-based vertebral imaging Protein immunoelectrophoresis and urinary Bence-Jones proteins 25OHD PTH Serum testosterone, SHBG, FSH, LH (in men), Serum prolactin 24 hour urinary cortisol/dexamethasone suppression test Endomysial and/or tissue transglutaminase antibodies (coeliac disease) Isotope bone scan Markers of bone turnover, when available Urinary calcium excretion

Answer 232

full blood count urea and electrolytes liver function tests bone profile CRP thyroid function tests

Answer 233

Small cell lung cancer

Answer 234

The syndrome of inappropriate ADH secretion (SIADH) is characterised by hyponatraemia secondary to the dilutional effects of excessive water retention.

Answer 235

correction must be done slowly to avoid precipitating central pontine myelinolysis fluid restriction demeclocycline: reduces the responsiveness of the collecting tubule cells to ADH ADH (vasopressin) receptor antagonists have been developed

Answer 236

Squamous cell carcinoma of the skin [also cervical and lymphoma cancer risk increased] Research shows that 25% of patients who live for 20 years after a transplant develop some type of cancer. This occurs due to the immunosuppressive effects of the medication given to prevent transplant rejection. The risk of all skin cancers increases following kidney transplantation, evidence has shown that in particular the risk of squamous cell carcinoma is increased. The risks of lymphoma and cervical cancer are also increased.

Answer 237

CVD, renal disease and malignany monitoring

Answer 238

Cardiovascular disease - tacrolimus and ciclosporin can cause hypertension and hyperglycaemia. Tacrolimus can also cause hyperlipidaemia. Patients must be monitored for accelerated cardiovascular disease.

Answer 239

Renal failure - due to nephrotoxic effects of tacrolimus and ciclosporin/graft rejection/recurrence of original disease in transplanted kidney

Answer 240

Malignancy - patients should be educated about minimising sun exposure to reduce the risk of squamous cell carcinomas and basal cell carcinomas

Answer 241

IUS [Mirena]

Answer 242

Previously defined as over 80ml blood loss per menses, now has become whatever the women feels is heavy

Answer 243

a full blood count should be performed in all women NICE recommend arranging a routine transvaginal ultrasound scan if symptoms (for example, intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms) suggest a structural or histological abnormality. Other indications include abnormal pelvic exam findings.

Answer 244

either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period if no improvement then try other drug whilst awaiting referral

Answer 245

``` intrauterine system (Mirena) should be considered first-line combined oral contraceptive pill long-acting progestogens ```

Answer 246

Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding.

Answer 247

Slipped upper femoral epiphysis is the commonest adolescent hip disorder. It occurs most commonly in obese males. It may often present as knee pain which is usually referred from the ipsilateral hip. The knee itself is normal. The hip often limits internal rotation. The diagnosis is easily missed. X-rays will show displacement of the femoral epiphysis and the degree of its displacement may be calculated using the Southwick angle. Treatment is directed at preventing further slippage which may result in avascular necrosis of the femoral head.

Answer 248

Perthes disease78% This is a typical presentation for Perthes disease. X-ray may show flattening of the femoral head or fragmentation in more advanced cases.

Answer 249

Developmental dysplasia of the hip63% Developmental dysplasia of the hip. Usually diagnosed by Barlow and Ortolani tests in early childhood. Most Breech deliveries are also routinely subjected to USS of the hip joint. At this young age an arthrodesis may be preferable to hip replacement.

Answer 250

Mild = no organ failure, no local complications M. severe = no or transient organ failure [\<48h], possible local Cx Severe = persistent [\>48h] organ failure, possible local Cx

Answer 251

1. Fluid resus 2. Analgesia 3. Nutrition 4. Abx 5. Surgery

Answer 252

aggressive early hydration with crystalloids. In severe cases 3-6 litres of third space fluid loss may occur aim for a urine output of \> 0.5mls/kg/hr may also help relieve pain by reducing lactic acidosis

Answer 253

pain may be severe so this is a key priority of care intravenous opioids are normally required to adequately control the pain

Answer 254

patients should not routinely be made 'nil-by-mouth' unless there is a clear reason e.g. the patient is vomiting enteral nutrition should be offered to anyone with moderately severe or severe acute pancreatitis within 72 hours of presentation parental nutrition should only be used if enteral nurition has failed or is contraindicated

Answer 255

NICE state the following: 'Do not offer prophylactic antimicrobials to people with acute pancreatitis' potential indications include infected pancreatic necrosis

Answer 256

Patients with acute pancreatitis due to gallstones should undergo early cholecystectomy Patients with obstructed biliary system due to stones should undergo early ERCP Patients who fail to settle with necrosis and have worsening organ dysfunction may require debridement, fine needle aspiration is still used by some Patients with infected necrosis should undergo either radiological drainage or surgical necrosectomy. The choice of procedure depends upon local expertise

Answer 257

usually occur early in a viral infection as the temperature rises rapidly seizures are usually brief, lasting less than 5 minutes are most commonly tonic-clonic

Answer 258

\<15m, generalised seizure, typically no recurrence within 24h, should be complete recovery within an hour

Answer 259

15-30m, focal seziure, may have repeated seizures

Answer 260

Time seizure lasts over 30m

Answer 261

children who have had a first seizure OR any features of a complex seizure should be admitted to paediatrics

Answer 262

regular antipyretics have not been shown to reduce the chance of a febrile seizure occurring

Answer 263

if recurrences, try teaching parents how to use rectal diazepam or buccal midazolam. Parents should be advised to phone for an ambulance if the seizure lasts \> 5 minutes

Answer 264

the overall risk of further febrile convulsion = 1 in 3. However, this varies widely depending on risk factors for further seizure. These include: age of onset \< 18 months, fever \< 39ºC, shorter duration of fever before seizure and a family history of febrile convulsions if recurrences, try teaching parents how to use rectal diazepam or buccal midazolam. Parents should be advised to phone for an ambulance if the seizure lasts \> 5 minutes regular antipyretics have not been shown to reduce the chance of a febrile seizure occurring

Answer 265

risk factors for developing epilepsy include a family history of epilepsy, having complex febrile seizures and a background of neurodevelopmental disorder children with no risk factors have 2.5% risk of developing epilepsy if children have all 3 features the risk of developing epilepsy is much higher (e.g. 50%)

Answer 266

Group B Streptococcus (most common cause in neonates) E. coli Listeria monocytogenes

Answer 267

Neisseria meningitidis Streptococcus pneumoniae Haemophilus influenzae

Answer 268

Neisseria meningitidis Streptococcus pneumoniae

Answer 269

Streptococcus pneumoniae Neisseria meningitidis Listeria monocytogenes

Answer 270

Listera monocytogenes

Answer 271

Neisseria meningitis and Streptococcus pneumoniae would be most common in this age group but it is N.meningitis that is a gram negative diplococci. S. pneumoniae is a gram positive diplococci/chain E. coli is a gram negative bacilli H. influenzae is a gram negative coccobacilli L. monocytogenes is a gram positive rod

Answer 272

Management of patients with cervical myelopathy should be by specialist spinal services (neurosurgery or orthopaedic spinal surgery). Decompressive surgery is the mainstay of treatment and has been shown to stop disease progression

Answer 273

Pain (affecting the neck, upper or lower limbs) Loss of motor function (loss of digital dexterity, preventing simple tasks such as holding a fork or doing up their shirt buttons, arm or leg weakness/stiffness leading to impaired gait and imbalance Loss of sensory function causing numbness Loss of autonomic function (urinary or faecal incontinence and/or impotence) - these can occur and do not necessarily suggest cauda equina syndrome in the absence of other hallmarks of that condition Hoffman's sign: is a reflex test to assess for cervical myelopathy. It is performed by gently flicking one finger on a patient's hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick.

Answer 274

Carpal tunnel syndrome

Answer 275

An MRI of the cervical spine is the gold standard test where cervical myelopathy is suspected. It may reveal disc degeneration and ligament hypertrophy, with accompanying cord signal change.

Answer 276

All patients with degenerative cervical myelopathy should be urgently referred for assessment by specialist spinal services (neurosurgery or orthopaedic spinal surgery). This is due to the importance of early treatment. The timing of surgery is important, as any existing spinal cord damage can be permanent. Early treatment (within 6 months of diagnosis) offers the best chance of a full recovery but at present, most patients are presenting too late. In one study, patients averaged over 5 appointments before diagnosis, representing \>2 years.

Answer 277

Currently, decompressive surgery is the only effective treatment. It has been shown to prevent disease progression. Close observation is an option for mild stable disease, but anything progressive or more severe requires surgery to prevent further deterioration. Physiotherapy should only be initiated by specialist services, as manipulation can cause more spinal cord damage.

Answer 278

Pharyngeal puch

Answer 279

Goitre47% Patients with a goitre are often euthyroid or have minor symptoms. A thyroglossal cyst would be unusual at this age - they typically present in patients \< 20 years old.

Answer 280

Cystic hygroma

Answer 281

Reactive lyphmadenopathy

Answer 282

Thyroid swelling

Answer 283

Thyroglossal cyst

Answer 284

Pharyngeal pouch

Answer 285

Cystic hygroma

Answer 286

Brnachial cyst

Answer 287

Cervical rub

Answer 288

Carotid aneurysm

Answer 289

primary: defined as the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics secondary: cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea

Answer 290

gonadal dysgenesis (e.g. Turner's syndrome) - the most common causes testicular feminisation congenital malformations of the genital tract functional hypothalamic amenorrhoea (e.g. secondary to anorexia) congenital adrenal hyperplasia imperforate hymen

Answer 291

hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise) polycystic ovarian syndrome (PCOS) hyperprolactinaemia premature ovarian failure thyrotoxicosis\* Sheehan's syndrome Asherman's syndrome (intrauterine adhesions)

Answer 292

exclude pregnancy with urinary or serum bHCG full blood count, urea & electrolytes, coeliac screen, thyroid function tests gonadotrophins raised if gonadal dysgenesis (e.g. Turner's syndrome) prolactin androgen levels oestradiol

Answer 293

raised if gonadal dysgenesis (e.g. Turner's syndrome)

Answer 294

low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)

Answer 295

May be seen in PCOS

Answer 296

investigate and treat any underlying cause with primary ovarian insufficiency due to gonadal dysgenesis (e.g. Turner's syndrome) are likely to benefit from hormone replacement therapy (e.g. to prevent osteoporosis etC)

Answer 297

exclude pregnancy, lactation, and menopause (in women 40 years of age or older) treat the underlying cause

Answer 298

Hypothyroidism

Answer 299

Reducing the sertraline dose is the correct answer. With antidepressants and ECT, you do not suddenly stop them when the patient commences ECT treatment. The recommended regime is to safely reduce them to the minimum dose. You may actually add an increased dose of antidepressant towards the end of the ECT course.

Answer 300

Electroconvulsive therapy is a useful treatment option for patients with severe depression refractory to medication (e.g. catatonia) those with psychotic symptoms.

Answer 301

The only absolute contraindications is raised intracranial pressure.

Answer 302

headache nausea short term memory impairment memory loss of events prior to ECT cardiac arrhythmia

Answer 303

Some patients report impaired memory

Answer 304

IV adenosine is incorrect. It is used as a rate lowering drug used to slow supraventricular tachycardias. Since there are QRS abnormalities here, there is an indication of ventricular or conducting system pathology. Adenosine is not always appropriate in these circumstances - and expert help should be sought first.

Answer 305

shock: hypotension (systolic blood pressure \< 90 mmHg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness syncope myocardial ischaemia heart failure

Answer 306

If any of the above adverse signs are present then synchronised DC shocks should be given. Up to 3 shocks can be given; after this expert help should be sought.

Answer 307

assume ventricular tachycardia (unless previously confirmed SVT with bundle branch block) loading dose of amiodarone followed by 24 hour infusion

Answer 308

Seek expert help

Answer 309

atrial fibrillation with bundle branch block - the most likely cause in a stable patient atrial fibrillation with ventricular pre-excitation torsade de pointes

Answer 310

vagal manoeuvres followed by IV adenosine if above unsuccessful consider diagnosis of atrial flutter and control rate (e.g. beta-blockers)

Answer 311

probable atrial fibrillation if onset \< 48 hr consider electrical or chemical cardioversion rate control: beta-blockers are usually first-line unless there is a contraindication

Answer 312

Acute interstitial nephritis is not the correct answer. This is an interrenal AKI due to inflammation of the nephron interstitium, usually in response to drugs such as penicillin, rifampicin, NSAIDs, allopurinol or furosemide. More systemic symptoms such as joint pain, fever, rashes would be present if this were the case. Investigations will show mild renal impairment but importantly there will be white cell casts and sterile pyuria.

Answer 313

White cell clasts and sterile pyuria

Answer 314

Acute tubular necrosis is not the correct answer. This is an example of intrarenal AKI, in which the kidney tubules are damaged leading to an inability to reabsorb sodium. This leads to dilute urine (low osmolality) with high amounts of sodium. Acute tubular necrosis is usually due to nephrotoxins such as aminoglycosides and light chains in myeloma- neither of which are indicated in this patient.

Answer 315

This is an example of intrarenal AKI, in which the kidney tubules are damaged leading to an inability to reabsorb sodium. This leads to dilute urine (low osmolality) with high amounts of sodium

Answer 316

Haemolytic uraemic syndrome is not the correct answer. This is a glomerular intrarenal cause of AKI caused by an infection that is most common in childhood. This would present with the core symptoms of AKI, anaemia and thrombocytopenia. The patient here has normal red blood cell and platelet counts.

Answer 317

Hypovolaemia is the correct answer. This is an example of prerenal uraemia, a cause of acute kidney injury (AKI) due to renal hypoperfusion, usually caused by shock, haemorrhage or volume depletion

Answer 318

Prerenal uraemia can also be differentiated from other causes of AKI by the results of the urine analysis in which the kidneys reabsorb water in order to increase circulatory volume. This leads to the production of concentrated urine (high osmolality) urine with low amounts of sodium. Urine osmolality of more than 500 mOsm/kg, with an urine sodium inferior to 20 mol/l is landmark for the diagnosis os pre-renal disease.

Answer 319

Pre-renal uraemia ('azotemia') ATN Urine sodium \< 20 mmol/L \> 40 mmol/L Urine osmolality \> 500 mOsm/kg \< 350 mOsm/kg

Answer 320

Basal cell carcinoma (BCC) is one of the three main types of skin cancer. Lesions are also known as rodent ulcers and are characterised by slow-growth and local invasion.

Answer 321

many types of BCC are described. The most common type is nodular BCC, which is described here sun-exposed sites, especially the head and neck account for the majority of lesions initially a pearly, flesh-coloured papule with telangiectasia may later ulcerate leaving a central 'crater'

Answer 322

Basal cell carcinoma, squamous cell carcinoma, malignant meloma

Answer 323

generally, if a BCC is suspected, a routine referral should be made

Answer 324

surgical removal curettage cryotherapy topical cream: imiquimod, fluorouracil radiotherapy

Answer 325

5d before surgery

Answer 326

Usually resumed at the normal dose on the evning of the surgery or the next day if haemostasis is adequet

Answer 327

Warfarin is an oral anticoagulant which inhibits epoxide reductase preventing the reduction of vitamin K to its active hydroquinone form, which in turn acts as a cofactor in the carboxylation of clotting factor II, VII, IX and X (mnemonic = 1972) and protein C.

Answer 328

venous thromboembolism: target INR = 2.5, if recurrent 3.5 atrial fibrillation, target INR = 2.5 mechanical heart valves, target INR depends on the valve type and location. Mitral valves generally require a higher INR than aortic valves.

Answer 329

Patients on warfarin are monitored using the INR (international normalised ration), the ratio of the prothrombin time for the patient over the normal prothrombin time

Answer 330

Warfarin has a long half-life and achieving a stable INR may take several days. There a variety of loading regimes and computer software is now often used to alter the dose.

Answer 331

liver disease P450 enzyme inhibitors, e.g.: amiodarone, ciprofloxacin cranberry juice drugs which displace warfarin from plasma albumin, e.g. NSAIDs inhibit platelet function: NSAIDs

Answer 332

haemorrhage teratogenic, although can be used in breastfeeding mothers skin necrosis: when warfarin is first started biosynthesis of protein C is reduced. This results in a temporary procoagulant state after initially starting warfarin, normally avoided by concurrent heparin administration. Thrombosis may occur in venules leading to skin necrosis purple toes

Answer 333

Should be taken from the vulvo-vaginal area [introitus]

Answer 334

Nucleic acid amplification tests (NAATs) are currently the most sensitive and specific test for the diagnosis of Chlamydia in females. An endocervical swab can be performed, but it is not as sensitive as a vulvovaginal swab. Vulvovaginal swabs for NAAT is the specimen of choice in females, as recommended by BASHH.

Answer 335

NAAT with - for men: the urine test is first-line

Answer 336

Chlamydiatesting should be carried out two weeks after a possible exposure

Answer 337

Approximately 1 in 10 young women in the UK have Chlamydia

Answer 338

The incubation period is around 7-21 days, although it should be remembered a large percentage of cases are asymptomatic

Answer 339

asymptomatic in around 70% of women and 50% of men women: cervicitis (discharge, bleeding), dysuria men: urethral discharge, dysuria

Answer 340

epididymitis pelvic inflammatory disease endometritis increased incidence of ectopic pregnancies infertility reactive arthritis perihepatitis (Fitz-Hugh-Curtis syndrome)

Answer 341

in England the National Chlamydia Screening Programme is open to all men and women aged 15-24 years the 2009 SIGN guidelines support this approach, suggesting screening all sexually active patients aged 15-24 years relies heavily on opportunistic testing

Answer 342

doxycycline (7 day course) if first-line this is now preferred to azithromycin due to concerns about Mycoplasma genitalium. This infection is often coexistant in patients with Chlamydia and there is evidence of rising levels of macrolide resistance, hence why doxycycline is preferred if doxycycline is contraindicated / not tolerated then either azithromycin (1g od for one day, then 500mg od for two days) should be used

Answer 343

if pregnant then azithromycin, erythromycin or amoxicillin may be used. The SIGN guidelines suggest azithromycin 1g stat is the drug of choice 'following discussion of the balance of benefits and risks with the patient'

Answer 344

patients diagnosed with Chlamydia should be offered a choice of provider for initial partner notification - either trained practice nurses with support from GUM, or referral to GUM for men with urethral symptoms: all contacts since, and in the four weeks prior to, the onset of symptoms for women and asymptomatic men all partners from the last six months or the most recent sexual partner should be contacted contacts of confirmed Chlamydia cases should be offered treatment prior to the results of their investigations being known (treat then test)

Answer 345

Acute urinary retention is when a person suddenly (over a period of hours or less) becomes unable to voluntarily pass urine. It is the most common urological emergency and there are several potential causes that must be investigated for.

Answer 346

Whilst acute urinary retention is common in men, it rarely occurs in women (incidence ratio of 13:1). It occurs most frequently in men over 60 years of age and incidence increases with age. It has been estimated that around a third of men in their 80s will develop acute urinary retention over a five year period.

Answer 347

In men, acute urinary retention most commonly occurs secondary to benign prostatic hyperplasia; a condition where the prostate becomes enlarged but non-cancerous. The enlarged prostate presses on the urethra which can make the bladder wall thicker and less able to empty.

Answer 348

In men, acute urinary retention most commonly occurs secondary to benign prostatic hyperplasia; a condition where the prostate becomes enlarged but non-cancerous. The enlarged prostate presses on the urethra which can make the bladder wall thicker and less able to empty. Other urethral obstructions; including urethral strictures, calculi, cystocele, constipation or masses. Some medications can cause acute urinary retention by affecting nerve signals to the bladder: these include anticholinergics, tricyclic antidepressants, antihistamines, opioids and benzodiazepines. Less commonly, there may be a neurological cause for the acute urinary retention. In patients with predisposing causes, a simple urinary tract infection can be enough to cause acute urinary retention Acute urinary retention often occurs postoperatively and in women postpartum: usually secondary to a combination of the above risk factors.

Answer 349

Inability to pass urine Lower abdominal discomfort Considerable pain or distress an acute confusional state may also be present in elderly patients

Answer 350

This differs from chronic urinary retention which is typically painless. In a patient with a background of chronic urinary retention, acute urinary retention may present instead with overflow incontinence.

Answer 351

Palpable distended urinary bladder either on an abdominal or rectal exam Lower abdominal tenderness All men and women should have a rectal and neurological examination to assess for the likely causes above. Women should also have a pelvic examination.

Answer 352

Patients should all be investigated with a urine sample which should be sent for urinalysis and culture. This might only be possible after urinary catheterisation. Serum U&Es and creatinine should also be checked to assess for any kidney injury. A FBC and CRP should also be performed to look for infection PSA is not appropriate in acute urinary retention as it is typically elevated

Answer 353

To confirm the diagnosis of acute urinary retention a bladder ultrasound should be performed. A volume of \>300 cc confirms the diagnosis, but if the history and examination are consistent, with an inconsistent bladder scan, there are causes of bladder scan inaccuracies and hence the patient can still have acute urinary retention.

Answer 354

Acute urinary retention is managed by decompressing the bladder via catheterisation Urinary catheterisation can be performed in patients with suspected acute urinary retention, and the volume of urine drained in 15 minutes measured. A volume of \<200 confirms that a patient does not have acute urinary retention, and a volume over 400 cc means the catheter should be left in place. In between these volumes, it depends on the case. Further investigation should be targeted by the likely cause. In reversible causes such as UTI, resolution with treatment is sufficient and further investigation is not necessary. Men not diagnosed by BPH should be further evaluated by a urologist, Patients with neurological symptoms should be evaluated by a neurologist and women with gynaecological symptoms by a gynaecologist. Where no likely cause is identified, patients should be evaluated by a urologist for anatomical and urodynamic causes.

Answer 355

post-obstructive diuresis the kidneys may increase diuresis due to the loss of their medullary concentration gradient. This can take time re-equilibrate this can lead to volume depletion and worsening of any acute kidney injury some patients may therefore require IV fluids to correct this temporary over-diuresis

Answer 356

100% ST elevation in the LAD Widepread ST elevation in this territory implies a complete occlusion of the left anterior descending artery.

Answer 357

myocardial infarction pericarditis/myocarditis normal variant - 'high take-off' left ventricular aneurysm Prinzmetal's angina (coronary artery spasm) Takotsubo cardiomyopathy rare: subarachnoid haemorrhage

Answer 358

Uhthoff ’s phenomenon where neurological symptoms are exacerbated by increases in body temperature is typically associated with multiple sclerosis

Answer 359

Patient's with multiple sclerosis (MS) may present with non-specific features, for example around 75% of patients have significant lethargy.

Answer 360

Diagnosis can be made on the basis of two or more relapses and either objective clinical evidence of two or more lesions or objective clinical evidence of one lesion together with reasonable historical evidence of a previous relapse

Answer 361

optic neuritis: common presenting feature optic atrophy Uhthoff's phenomenon: worsening of vision following rise in body temperature internuclear ophthalmoplegia

Answer 362

pins/needles numbness trigeminal neuralgia paraesthesiae in limbs on neck flexion

Answer 363

Paraesthesiae in limbs on neck flexion

Answer 364

ataxia: more often seen during an acute relapse than as a presenting symptom tremor

Answer 365

urinary incontinence sexual dysfunction intellectual deterioration

Answer 366

Mucinous cystadenoma

Answer 367

Serous cystadenoma

Answer 368

Dermoid cyst [teratoma]

Answer 369

Benign ovarian cysts are extremely common. They may be divided into physiological cysts, benign germ cell tumours, benign epithelial tumours and benign sex cord stromal tumours.

Answer 370

Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy.

Answer 371

1. Follicular cysts 2. Corpus luteum cysts

Answer 372

Follicular cysts commonest type of ovarian cyst due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle commonly regress after several menstrual cycles

Answer 373

during the menstrual cycle if pregnancy doesn't occur the corpus luteum usually breaks down and disappears. If this doesn't occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst more likely to present with intraperitoneal bleeding than follicular cysts

Answer 374

Dermoid cyst

Answer 375

also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth

Answer 376

most common benign ovarian tumour in woman under the age of 30 years median age of diagnosis is 30 years old bilateral in 10-20% usually asymptomatic. Torsion is more likely than with other ovarian tumours

Answer 377

Arise from the ovarian surface epithelium

Answer 378

Serous cystadenoma Mucinous cystadenoma

Answer 379

Serous cystadenoma the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma) bilateral in around 20%

Answer 380

Mucinous cystadenoma second most common benign epithelial tumour they are typically large and may become massive if ruptures may cause pseudomyxoma peritonei

Answer 381

Prophylactic IV Abx

Answer 382

Acute appendicitis is the most common acute abdominal condition requiring surgery. It can occur at any age but is most common in young people aged 10-20 years.

Answer 383

lymphoid hyperplasia or a faecolith → obstruction of appendiceal lumen → gut organisms invading the appendix wall → oedema, ischaemia +/- perforation

Answer 384

Abdominal pain is seen in the vast majority of patients: peri-umbilical abdominal pain (visceral stretching of appendix lumen and appendix is midgut structure) radiating to the right iliac fossa (RIF) due to localised parietal peritoneal inflammation. the migration of the pain from the centre to the RIF has been shown to be one of the strongest indicators of appendicitis patients often report the pain being worse on coughing or going over speed bumps. Children typically can't hop on the right leg due to the pain.

Answer 385

vomit once or twice but marked and persistent vomiting is unusual diarrhoea is rare. However, pelvic appendicitis may cause localised rectal irritation of some loose stools. A pelvic abscess may also cause diarrhoea mild pyrexia is common - temperature is usually 37.5-38oC. Higher temperatures are more typical of conditions like mesenteric adenitis anorexia is very common. It is very unusual for patients with appendicitis to be hungry around 50% of patients have the typical symptoms of anorexia, peri-umbilical pain and nausea followed by more localised right lower quadrant pain Vomiting, diarrhoea, pyrexia, anorexia

Answer 386

generalised peritonitis if perforation has occurred or localised peritonism rebound and percussion tenderness, guarding and rigidity retrocaecal appendicitis may have relatively few signs digital rectal examination may reveal boggy sensation if pelvic abscess is present, or even right-sided tenderness with a pelvic appendix classical signs: Rovsing's and psoas

Answer 387

Rovsing's sign (palpation in the LIF causes pain in the RIF) is now thought to be of limited value psoas sign: pain on extending hip if retrocaecal appendix

Answer 388

typically raised inflammatory markers coupled with compatible history and examination findings should be enough to justify appendicectomy a neutrophil-predominant leucocytosis is seen in 80-90% urine analysis: useful to exclude pregnancy in women, renal colic and urinary tract infection. In patients with appendicitis, urinalysis may show mild leucocytosis but no nitrites there are no definite rules on the use of imaging and its use is often determined by the patient's gender, age, body habitus and the likelihood of appendicitis: - thin, male patients with a high likelihood of appendicitis may be diagnosed clinically - ultrasound is useful in females where pelvic organ pathology is suspected. Although it is not always possible to visualise the appendix on ultrasound, the presence of free fluid (always pathological in males) should raise suspicion - CT scans are widely used in patients with suspected appendicitis in the US but this practice has not currently reached the UK, due to the concerns regarding excessive ionising radiation and resource limitations

Answer 389

Tpyically raised inflammatory markers; neutrophil-predominnnat leucocytosis seen in 80-90%

Answer 390

thin, male patients with a high likelihood of appendicitis may be diagnosed clinically ultrasound is useful in females where pelvic organ pathology is suspected. Although it is not always possible to visualise the appendix on ultrasound, the presence of free fluid (always pathological in males) should raise suspicion

Answer 391

appendicectomy can be performed via either an open or laparoscopic approach laparoscopic appendicectomy is now the treatment of choice

Answer 392

appendicectomy - can be performed via either an open or laparoscopic approach - laparoscopic appendicectomy is now the treatment of choice administration of prophylactic intravenous antibiotics reduces wound infection rates patients with perforated appendicitis (typical around 15-20%) require copious abdominal lavage. patients without peritonitis who have an appendix mass should receive broad-spectrum antibiotics and consideration given to performing an interval appendicectomy be wary in the older patients who may have either an underlying caecal malignancy or perforated sigmoid diverticular disease. trials have looked at the use of intravenous antibiotics alone in the treatment of appendicitis. The evidence currently suggests that whilst this is successful in the majority of patients, it is associated with a longer hospital stay and up to 20% of patients go on to have an appendicectomy within 12 months.

Answer 393

Chronic plaque psoriasis

Answer 394

This patient is presenting with a history suggestive of chronic plaque psoriasis. The Koebner phenomenon describes the tendency for new skin lesions to form at sites of cutaneous injury. It is not clear why this occurs, but it is observed in chronic plaque psoriasis and vitiligo.

Answer 395

Photosensitive rash is primarily associated with SLE and other connective tissue diseases including dermatomyositis. It may rarely be seen in psoriasis, but the majority of psoriasis patients actually experience an improvement in symptoms when exposed to UV light, and so this is not the most likely feature.

Answer 396

Aspirin sensitivity and nasal polyps are two aspects of Samter's triad, the third being chronic asthma, not psoriasis. Samter's triad is seen in aspirin-exacerbated respiratory disease, where hypersensitivity to aspirin results in asthmatic symptoms.

Answer 397

Aphthous ulceration is the formation of ulcers on the oral and genital mucous membranes. It may be idiopathic but is also associated with connective tissue diseases including Behcet's and systemic lupus erythematosus (SLE). It is not a feature associated with psoriasis.

Answer 398

The Koebner phenomenon describes skin lesions that appear at the site of injury. It is seen in: psoriasis vitiligo warts lichen planus lichen sclerosus molluscum contagiosum

Answer 399

chest pain: may be pleuritic. Is often relieved by sitting forwards other symptoms include non-productive cough, dyspnoea and flu-like symptoms pericardial rub tachypnoea tachycardia

Answer 400

Sitting forwards

Answer 401

Pericardial rub

Answer 402

viral infections (Coxsackie) tuberculosis uraemia (causes 'fibrinous' pericarditis) trauma post-myocardial infarction, Dressler's syndrome connective tissue disease hypothyroidism malignancy

Answer 403

malignancy!

Answer 404

the changes in pericarditis are often global/widespread, as opposed to the 'territories' seen in ischaemic events 'saddle-shaped' ST elevation PR depression: most specific ECG marker for pericarditis

Answer 405

all patients with suspected acute pericarditis should have transthoracic echocardiography

Answer 406

treat the underlying cause a combination of NSAIDs and colchicine is now generally used for first-line for patients with acute idiopathic or viral pericarditis

Answer 407

Colchicine is an adjuvant therapy which improves the response to medical therapy and reduces the rate of recurrence in acute pericarditis. Also used for gout, Behcets disease and FMF.

Answer 408

De Quervain's thyroiditis [subacute thyoiriditis] Whilst Grave's disease is the most common cause of thyrotoxicosis it would not cause a tender goitre. In the context of thyrotoxicosis this finding is only really seen in De Quervain's thyroiditis. Hashimoto's thyroiditis is an autoimmune disorder of the thyroid gland. It is typically associated with hypothyroidism although there may be a transient thyrotoxicosis in the acute phase. The goitre is non-tender in Hashimoto's.

Answer 409

Subacute thyroiditis (also known as De Quervain's thyroiditis and subacute granulomatous thyroiditis) is thought to occur following viral infection and typically presents with hyperthyroidism.

Answer 410

``` There are typically 4 phases; phase 1 (lasts 3-6 weeks): hyperthyroidism, painful goitre, raised ESR phase 2 (1-3 weeks): euthyroid phase 3 (weeks - months): hypothyroidism phase 4: thyroid structure and function goes back to normal ```

Answer 411

thyroid scintigraphy: globally reduced uptake of iodine-131

Answer 412

usually self-limiting - most patients do not require treatment thyroid pain may respond to aspirin or other NSAIDs in more severe cases steroids are used, particularly if hypothyroidism develops

Answer 413

``` Hypo = Hashimotos, Riedel's thyroiditis, Iodine def., lithium Hyper = Graves', toxic multinodular goitre ```

Answer 414

Subacute thyroiditis, postpartum thyroiditis

Answer 415

Amiodarone

Answer 416

Autosomal recessive disorder

Answer 417

Wilson's disease is an autosomal recessive disorder characterised by excessive copper deposition in the tissues.

Answer 418

Metabolic abnormalities include increased copper absorption from the small intestine and decreased hepatic copper excretion. Wilson's disease is caused by a defect in the ATP7B gene located on chromosome 13.

Answer 419

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

Answer 420

Liver hepatitis Neurological Sx like basal ganglia degeneration, speech/psychiatric problems, dementia Kayser-Fleischer rings Renal tubular acidosis Haemolysis Blue nails

Answer 421

speech, behavioural and psychiatric problems are often the first manifestations

Answer 422

green-brown rings in the periphery of the iris due to copper accumulation in Descemet membrane present in around 50% of patients with isolated hepatic Wilson's disease and 90% who have neurological involvemen

Answer 423

Features result from excessive copper deposition in the tissues, especially the brain, liver and cornea: liver: hepatitis, cirrhosis neurological: - basal ganglia degeneration: in the brain, most copper is deposited in the basal ganglia, particularly in the putamen and globus pallidus - speech, behavioural and psychiatric problems are often the first manifestations - also: asterixis, chorea, dementia, parkinsonism Kayser-Fleischer rings - green-brown rings in the periphery of the iris - due to copper accumulation in Descemet membrane - present in around 50% of patients with isolated hepatic Wilson's disease and 90% who have neurological involvement renal tubular acidosis (esp. Fanconi syndrome) haemolysis blue nails

Answer 424

slit lamp examination for Kayser-Fleischer rings reduced serum caeruloplasmin reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin) - free (non-ceruloplasmin-bound) serum copper is increased increased 24hr urinary copper excretion

Answer 425

reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin)

Answer 426

penicillamine (chelates copper) has been the traditional first-line treatment

Answer 427

penicillamine (chelates copper) has been the traditional first-line treatment trientine hydrochloride is an alternative chelating agent which may become first-line treatment in the future tetrathiomolybdate is a newer agent that is currently under investigation

Answer 428

Calcium resonium results in removal of potassium from the body, rather than shifting potassium between fluid compartments in the short-term

Answer 429

Untreated hyperkalaemia may cause life-threatening arrhythmias. Precipitating factors should be addressed (e.g. acute kidney injury) and aggravating drugs stopped (e.g. ACE inhibitors). Management may be categorised by the aims of treatment

Answer 430

The European Resuscitation Council classifies hyperkalaemia as: mild: 5.5 - 5.9 mmol/L moderate: 6.0 - 6.4 mmol/L severe: ≥ 6.5 mmol/L

Answer 431

Remember that the presence of ECG changes is important in determining the management - it should be done in all patients with new hyperkalaemia. The following changes are associated with hyperkalaemia: peaked or 'tall-tented' T waves (occurs first) loss of P waves broad QRS complexes sinusoidal wave pattern

Answer 432

Short-term shift in potassium from extracellular (ECF) to intracellular fluid (ICF) compartment - combined insulin/dextrose infusion - nebulised salbutamol

Answer 433

Removal of potassium from the body - calcium resonium (orally or enema) - enemas are more effective than oral as potassium is secreted by the rectum - loop diuretics - dialysis - haemofiltration/haemodialysis should be considered for patients with AKI with persistent hyperkalaemia

Answer 434

Stabilisation of the cardiac membrane - IV calcium gluconate - does NOT lower serum potassium levels

Answer 435

Stabilise cardiac membrane, shift potassium from ECF to ICF, remove potassium from the body

Answer 436

All patients with severe hyperkalaemia (≥ 6.5 mmol/L) or with ECG changes should have emergency treatment IV calcium gluconate: to stabilise the myocardium insulin/dextrose infusion: short-term shift in potassium from ECF to ICF other treatments such as nebulised salbutamol may be given to temporarily lower the serum potassium

Answer 437

Further management stop exacerbating drugs e.g. ACE inhibitors treat any underlying cause lower total body potassium calcium resonium loop diuretics dialysis

Answer 438

Management Principles of treatment modalities Stabilisation of the cardiac membrane IV calcium gluconate does NOT lower serum potassium levels Short-term shift in potassium from extracellular (ECF) to intracellular fluid (ICF) compartment combined insulin/dextrose infusion nebulised salbutamol Removal of potassium from the body calcium resonium (orally or enema) enemas are more effective than oral as potassium is secreted by the rectum loop diuretics dialysis haemofiltration/haemodialysis should be considered for patients with AKI with persistent hyperkalaemia Outline of practical treatment All patients with severe hyperkalaemia (≥ 6.5 mmol/L) or with ECG changes should have emergency treatment IV calcium gluconate: to stabilise the myocardium insulin/dextrose infusion: short-term shift in potassium from ECF to ICF other treatments such as nebulised salbutamol may be given to temporarily lower the serum potassium Further management stop exacerbating drugs e.g. ACE inhibitors treat any underlying cause lower total body potassium calcium resonium loop diuretics dialysis

Answer 439

SABA or LAMA

Answer 440

+ LAMA or ICS

Answer 441

Erythroderma

Answer 442

Extensive exfoliation on patient with erythroderma

Answer 443

Pulmonary fibrosis I think

Answer 444

Hand foot mouth disease

Answer 445

ECG showing pericarditis -\> note widespread ST elevation anf PR depression

Answer 446

ECG showing hyperkalaemia -\> widening QRS complexes and peaked T waves

Friday [08/10/2021] Flashcards

(502 cards)