General Flashcards
(336 cards)
1
Q
Symptoms of urethral stricture?
A
A 24 year old man has poor urine flow and takes a very long time to empty his bladder. He has no other urinary symptoms. He has been well previously apart from one episode of non-gonococcal urethritis 1 year ago.
Urethral stricture is a condition that occurs when the urethra narrows, which can cause difficulty in passing urine and a slow urinary stream. This can lead to a feeling of incomplete emptying of the bladder and a need to strain to empty the bladder completely. Urethral stricture follows previous urethral inflammation due to infection.
2
Q
When should AVR be considered in aortic stenosis
A
The aortic valve gradient of 50mmHg is considered the level where aortic valve replacement should be considered.
3
Q
A 46 year old man has pain in his left leg and tingling in his left big toe. He developed severe lower back pain 1 week ago and he is unable to walk on his left heel. There is loss of pinprick perception over the left great toe. Which nerve root is the most likely to have been affected?
A
L5
L5 is the most likely nerve root to have been affected. The patient has a combination of lower back pain, pain in the left leg, and tingling in the left big toe, which are consistent with the dermatomal distribution of the L5 nerve root. The inability to walk on the left heel suggests a left-sided foot drop, and so is also consistent with L5 nerve root dysfunction. The loss of pinprick perception over the left great toe also suggests involvement of the L5 dermatome.
4
Q
A 52 year old man has three days of severe epigastric pain, radiating to his back, but no chest pain. He has vomited several times. He was previously well. He drinks approximately 60 units of alcohol a week and smokes 20 cigarettes per day. There is epigastric tenderness but his abdomen is not distended, and bowel sounds are present.
Diagnosis?
A
Pancreatitis
5
Q
Cryptosporidium
A
Cryptosporidium is a protozoan parasite that can cause diarrhoea in immunocompromised patients, including those with HIV. It is commonly found in contaminated water sources and is a significant cause of diarrhoeal disease in developing countries.
Cryptosporidium parvum is the most likely causative organism for diarrhoea in an HIV positive patient working in Namibia.
6
Q
hypoglossal nerve functions?
A
The hypoglossal nerve is responsible for motor function of the tongue, including protrusion and side-to-side movements, speaking etc. Damage to the hypoglossal nerve on one side will cause the tongue to deviate towards the affected side (the stronger left side will push it to the right). In this case, the patient had carotid surgery on the left side, so the right hypoglossal nerve is likely to have been damaged.
7
Q
Treatment for migraine?
A
Acute = triptans
Chronic = propanolol/topiramate
8
Q
A 75 year old man has had 3 days of intermittent headaches, blurred vision and vomiting. For the past 24 hours he has had a severe left sided headache and eye pain, accompanied by blurred vision and vomiting. His left eye is red and the left pupil is dilated.
Condition?
A
acute angle-closure glaucoma
9
Q
subacute combined degeneration of the cord
A
Mixture of upper motor neurone (extensor plantars) and lower motor neurone (absent ankle jerks) features. The sensory ataxia (positive Romberg test and absent position sense in the ankles) is most likely due to dorsal column dysfunction from vitamin B12 deficiency, and this can be confirmed by serum vitamin B12 measurement.
10
Q
urticarial weals tx?
A
Initial treatment for this should be a non-sedating H1-antihistamine.
11
Q
Ocular varicella-zoster virus complications?
A
Ocular involvement occurs in approximately 50% of patients and some of these can experience a range of complications. However, in the majority of cases there is complete resolution with no sequelae.
12
Q
The most appropriate topical treatment for Bowen’s disease?
A
situ 5-fluorouracil (Efudix) cream. This is a form of topical cytotoxic chemotherapy which is used to treat both Bowen’s disease and actinic keratosis. It is typically applied to the affected area once or twice a day for 2-4 weeks. An inflammatory reaction, which can be severe, should be expected
13
Q
A 50 year old man has a 3 month history of right loin pain and weight loss. For the past 20 years, he has smoked ten cigarettes per day. His temperature is 37.4°C, pulse rate is 72 bpm and BP is 142/74 mmHg. Investigations: Haemoglobin 11.2 g/L (130–175) Platelets 340 × 109/L (150–400) White cell count 10.1 × 109/L (4.0–11.0) Urinalysis blood 3+ Which is the most likely diagnosis?
A
Renal cancer
14
Q
Serum osmolality calcu;ation?
A
Serum osmolality is 2 x(Na) + Urea + glucose
15
Q
Treatment for trigeminal neuralgia?
A
Carbamazepine
16
Q
most appropriate initial antibiotic treatment in this case of MRSA cellulitis.
A
Vancomycin
17
Q
A 70 year old man is an inpatient on the cardiology ward. He has worsening breathlessness that woke him up last night. His pulse rate is 99 bpm, BP 160/100 mmHg and respiratory rate 20 breaths per minute. Auscultation of the chest reveals bibasal crepitations, and there is dullness to percussion of both bases. Chest X-ray shows small bilateral pleural effusions with upper lobe blood vessel diversion. Which is the most appropriate diagnostic investigation?
A
Echocardiogram
18
Q
A 72 year old woman has had inability to sleep well for the past 3 years. She gets to sleep by 23:00 but wakes up two or three times in the night and gets up by 07:00. Her husband says that she doesn’t snore. Her BMI is 23 kg/m2. She carries out her normal daytime activities with no daytime somnolence. She is otherwise well. Her MMSE (Mini Mental State Examination) score is 27/30.
Which is the most likely cause of her insomnia?
A
Normal age related sleep pattern
19
Q
A 35 year old man visits his GP with 3 days of a red, painful left eye with no discharge. There is a diffuse area of redness in the medial aspect of his left sclera. His pupils and visual acuity are normal. Which is the most appropriate management?
A
Arrange assessment in emergency eye clinic
20
Q
A 35 year old man with type 1 diabetes mellitus has burning pain in his feet and difficulty sleeping. He has retinopathy and nephropathy. Investigation:eGFR 28 mL/min/1.73m2(> 60) Which is the most appropriate management?
A. Acupuncture B. Amitriptyline C. Duloxetine D. Physiotherapy E. Sodium valproate
A
The most appropriate management for this patient with type 1 diabetes mellitus, burning pain in his feet, difficulty sleeping, and decreased eGFR would be amitriptyline. Although duloxetine can be used in this condition it is not recommended with an eGFR <30 mL/min.
21
Q
O/e bronchiectasis?
A
Often there are coarse crackles on examination and there may be wheeze if there is an exacerbation
Can be clubbing if CF
22
Q
Ix for biliary colic?
A
USS abdomen
23
Q
Mesothelioma affects which part of the lung?
A
Pleura
24
Q
A 65 year old woman has severe left-sided abdominal pain. Yesterday, she noticed blood mixed in with her stools. There is no history of weight loss. Her temperature is 37.7°C. She is very tender on palpation in the left lower quadrant. No masses are felt on rectal examination, but there is blood on the glove. Which is the most likely cause of her symptoms?
A
Diverticulitis
25
A 67 year old woman has an ulcer with a raised white margin on her left ear; it has been present for 3 years, growing slowly and never completely healing. She spent 20 years living in Australia before returning to the UK recently. On examination, she has a small ulcerated area, 4 mm × 6 mm, on her left pinna. Which is the most likely diagnosis?
Basal cell carcinoma
26
Basal cell carcinoma features?
The history of an ulcerated lesion on the ear in an individual likely to have had a high level of ultraviolet light exposure from living in Australia should raise the possibility of a keratinocyte cancer. Given the long history yet small size of the lesion, together with the description of a raised, pale border make basal cell carcinoma (BCC) the most likely diagnosis. Other characteristic features would be a shiny or pearly surface, a rolled edge or overlying telangiectasia.
27
A 48 year old man has visible haematuria and right loin pain. His temperature is 37.3°C, pulse rate 72 bpm and BP 170/97 mmHg. Masses are palpable in both flanks. Investigations: Creatinine 220 µmol/L (60-120) Urinalysis: blood 4+ Which is the most appropriate next investigation?
A. CT scan of kidneys, ureters and bladder B. Cystoscopy C. MR scan of renal tract D. Ultrasound scan of renal tract
E. Urine cytology
The most appropriate next investigation is an ultrasound of the renal tract. The patient likely has undiagnosed polycystic kidney disease with bilateral renal masses, reduced renal function and haematuria. A renal ultrasound will rapidly confirm the presence of cysts. MR scan may be done later to assess renal sizes ahead of possible therapy with vasopressin antagonists.
28
Branches of the trigeminal nerve
V1, known as the ophthalmic branch, innervates the eyes, the skin of the upper face, and the skin of the anterior scalp. V2, the maxillary branch, innervates the upper lip, teeth, gingiva, anterior soft palate, cheeks, and maxillary sinus. V3, or the mandibular branch, innervates parts of the lower jaw, tongue, lower lip, and chin.
29
Causes of trigeminal neuralgia?
- Vascular compression of nerve
Compression with tumour/cyst
30
Signs of aortic stenosis?
Ejection systolic murmur, radiating to the carotids.
Sustained apex
Slow rising pulse
Narrow pulse pressure
Others:
Soft S2 - a marker of severity, the aortic component of the second heart sound may become quieter in more severe disease as the valve leaflets fail to oppose each other forcefully.
Fourth heart sound (S4) - caused by the atria contracting against stiff, hypertrophied ventricles.
Reversed splitting
Easy bruising/epistaxis
31
Midline sternotomy? what to do?
Look for vein harvesting in the legs and arms?
32
o ET tube placement:
Clinically
equal and symmetrical chest expansion and air entry, fogging mask
Observations SpO2 maintained, CO2 reading
Radiological CXR shows ET tube just above carina
33
Food and drink prior to surgery?
No food <6 hours before surgery
No drink <2 hours before surgery
Same rules for diabetics & pregnant women
34
Treatment of malignant hyperthermia?
dantrolene
35
o Suxamethonium CI?
Contraindications: hyperkalaemia in burns/trauma patients
36
Ketamine - anaesthetics
* May be used for induction of anaesthesia
* Has moderate to strong analgesic properties
* Produces little myocardial depression making it a suitable agent for anaesthesia in those who are haemodynamically unstable
* May induce state of dissociative anaesthesia resulting in nightmares
* No respiratory depression used in OOH trauma
37
atelectasis, S/S:
Pyrexia
Reduced O2 saturations
Reduced breath sounds at lung bases
Mx: reposition upright, chest physiotherapy
38
Veins harvested for CABG?
leg (saphenous vein), inside your chest (internal mammary artery), or your arm (radial artery).
39
Trichophyton rubrum = tinea corporis treatment?
Clotrimazole
40
Indications for dialysis?
Refractory hyperkalaemia, acidosis, uraemic symptoms, treatment resistant fluid overload, CKD stage 5
41
Hernia complications:
Early
- haemorrhage
- ischaemia
- high output (K+, mx: loperamide)
- parastomal abscess
- stoma retraction
Delayed
- parastomal hernia
- obstruction (adhesion, herniation)
- dermatitis
- stoma prolapse
- stenosis, stricture
- fistula
- psychosexual dysfunction
42
Lower limb reflexes?
o S1-S2 buckle my shoe Achilles reflex
o L3-L4 kick the door patella reflex
43
Nerve damaged in shoulder dislocation?
Axillary nerve
44
Nerve damaged by humoral shaft fractures?
Radial nerve
45
Nerve damaged in fractures and dislocations of the elbow joint?
Ulnar nerve
46
* Erb’s palsy
(C5/C6 damage); S/S: adducted, medially rotated, pronated, flexed wrist
47
* Klumpke’s palsy
C8/T1 damage); S/S: claw hand
o Test for location of lesion:
Good prognosis = elevate scapulae (N. to levator scapulae and rhomboids)
Bad prognosis = Horner’s syndrome (loss of SNS outflow due to T1 damage)
48
Tibial N. injury
loss of plantarflexion (inability to stand on tiptoes)
49
Common peroneal N. injury
loss of dorsiflexion (foot drop)
50
LOAF muscles innervation?
Median nerve
51
NON-LOAF intrinsic hand muscles?
Ulnar nerve
52
Axillary innervation?
Teres minor, deltoid
53
o Hip joint ligaments:
Intracapsular:
* Ligament of the head of the femur
o Contains branch of obturator artery
Extracapsular:
* Iliofemoral ligament
o Y-shaped from AIIS to intertrochanteric line of femur
o Strongest of the ligaments
o Prevents hyperextension
* Pubofemoral ligament
o Superior pubic rami to intertrochanteric line of femur
o Reinforces capsule ant./inf.
* Ischiofemoral ligament
o Between ischial body and greater trochanter
o Reinforces capsule post. / prevents hyperextension (holding head in acetabulum)
54
Knee joint ligaments?
There are 4
ACL:
* Path: arises from intercondylar area of tibial plateau and passes superiorly and posteriorly to attach to posteromedial aspect of lateral femoral condyle
* Action: prevent post. translation of femur on tibia (or ant. displacement of tibia)
PCL:
* Path: arises from post. intercondylar area of tibial plateau and passes superiorly and posteriorly to attach to lateral aspect of medial femoral condyle
* Action: two bands (anterolateral band tightens in flexion; posteromedial tightens in extension) to prevent ant. translation of femur on tibia (or post. displacement of tibia)
MCL:
* Path: arises from medial femoral epicondyle, inserts to upper medial surface of tibia and tibial periosteum deep to pes anserine attachment
* Blends with joint capsule and medial meniscus (increased risk of injury compared to LCL)
LCL:
* Path: arises from lateral femoral epicondyle, joins biceps femoris tendon to form conjoint tendon inserting into the fibula
55
Staging for colorectal cancer?
Dukes' A-D
A = tumour confined to the mucosa
C = Lymph node metastases
D = distant mestastes
56
Ix for obstruction?
1st: AXR/erect CXR; definitive: CT abdomen (CT)
57
Ix for colorectal cancer?
o Sigmoidoscopy colonoscopy
o Screening:
55yo flexi-sig colonoscopy (if +ve)
* Once
* Male and Female
60-74yo (UK) faecal immunochemical test / FIT (a FOB that recognises antibodies against human Hb)
* Every 2 years
* Male and Female
* If +ve, a colonoscopy is offered
58
Multiple benign intestinal hamartomas
Peutz-Jegher's syndrome
59
FAP
Mutation of APC gene
AD
>100 colonic adenomas
Cancer risk of 100%
20% are new mutations
60
HNPCC (Lynch syndrome)
CRC 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
Germline mutations of DNA mismatch repair genes
61
Mx of bowel obstruction?
o 1st line “drip & suck” + conservative (successful in 65-85% cases)
o 2nd line adhesiolysis (creates raw surfaces upon which more adhesions form)
62
Inguinal hernia
Inguinal hernias account for 75% of abdominal wall hernias. 95% M; M = 25% lifetime risk
Above and medial to pubic tubercle
Strangulation is rare
63
Femoral hernia
Below and lateral to the pubic tubercle
More common in women, particularly multiparous ones
High risk of obstruction and strangulation
Mx: surgical repair required
64
Paraumbilical hernia
Asymmetrical bulge - half the sac is covered by skin of the abdomen directly above or below the umbilicus
Mx: Mayo repair (high risk of strangulation)
65
Hernia repair surgery?
* Inguinal repair (even if asymptomatic; can be routine)
* Femoral repair (urgent repair; Lockwood Low or McEvedy high)
66
elective femoral hernia repair
ELECTIVE Lockwood Low approach (low incision over hernia with herniotomy/herniorrhaphy)
67
Emergency femoral hernia repair
EMERGENCY McEvedy High approach (via inguinal region to inspect and resect non-viable bowel)
68
Audiogram interpretation?
Above 20dB line = normal
SNHL = both air and bone conduction are impaired
* I.E. Presbycusis = bilateral high-freq. HL, air > bone conduction
Conductive HL = only air conduction is impaired
Mixed HL = both air and bone conduction are impaired (AC worse than BC)
69
* TMJ dysfunction mx?
1st line: NSAIDs (short-term), warm compress, reduce stress, soft food diet
2nd line (≥3m, referral to ENT): botox, steroid injections, surgery (i.e. arthroscopy)
70
Necrotising otitis externa
* Mainly due to P. aeruginosa or S. aureus; mainly in elderly
* Criteria – pain, oedema, exudate, micro abscess, granulation tissue, pseudomonas culture
* If suspected requires urgent ENT referral; ix: CT head; mx: IV ciprofloxacin
71
Acute otitis media with perforation
* Oral amoxicillin, 5 days
* Review in 6 weeks (should heal in 6-8 weeks – if not, refer to ENT myringoplasty)
72
Ix for glue ear?
* Otoscopy (eardrum dull and retracted, fluid level visible)
* Tympanometry (flat tympanogram)
* Audiometry
73
s/s cholesteatoma?
98% = ear discharge OR conductive hearing loss:
10-20 yo
Mx = refer for surgery
74
Mx of Menières disease?
Medical (vertigo) cyclizine, betahistine
* Anti-vertigo (prevent future attacks) betahistine
* Anti-emetic (treat emesis) cyclizine
Surgical gentamicin instillation (via grommets); saccus decompression
75
Viral labyrinthisis s/s?
Recent viral infection
Sudden onset
N&V, hearing may be affected
76
Vestibular neuronitis?
Recent firal infection, recurrent vertigo attacks lasting hours/days, no hearing loss
77
Acoustic neuroma s/s?
Hearing loss, vertigo, tinnitus, absent corneal reflex is important sign
Neurofibromatosis type 2
78
Management of vestibular neuronitis?
o Management:
Acute phase:
* Severe buccal / IM prochlorperazine
* Less severe PO cyclizine or prochlorperazine (stopped after few days – can delay recovery)
Chronic vestibular rehabilitation exercises [referral to balance specialist – 2ww]
79
Conductive hearing loss?
Osteosclerosis, infection, wax, trauma, infection
80
Sensorineural hearing loss? (defect of cochlea, nerve or brain)
Drugs, meningitism measles, mumps, Meniere's, trauma, MS, low B12
81
o Mx sudden SNHL
refer to ENT in <24 hours, high-dose PO prednisolone (continued for 7 days)
82
Mx of quinsy?
Mx: IV ABx + drainage tonsillectomy in 6 weeks
83
o Surgical tonsillectomy if…
If it's significantly impairing functioning
2 bouts of Quinsy (or 1 bout of Quinsy with a significant history of tonsillitis)
7 bouts in 1 year
5 bouts/year for 2 years
3 bouts/year for 3 years
84
Scarlet fever
Fever, coryza (fever, headache, vomiting, myalgia)
Rash (12-48 hours later) ± erythroderma:
* Neck + chest spread to trunk + legs
* Characteristic ‘sandpaper’ texture
85
Mx of Ramsay-Hunt syndrome?
o Mx: valaciclovir PO (7 days) + steroids PO (5 days)
86
* Ludwig’s angina?
o Aetiology: a rare infection of the floor of the mouth and soft tissue of the neck
RFs: dental surgery
o S/S: neck swelling, dysphagia, fever
o Ix: clinical
o Mx: urgent admission + airway management + IV ABx
87
* Pharyngeal pouch (outpouching into Zenker’s diverticulum):?
o S/S: halitosis, food getting stuck
o Mx: Dohlman’s procedure (minimally invasive stapling)
88
Green nipple discharge + tender lump around areola?
Duct ectasia
89
Fat necrosis?
S/S: firm, round hard, irregular lump
History of trauma
Fat women
90
When to excise fibroadenoma?
>3cm = surgical excision
91
- middle-aged women, very common
- no increased risk of breast cancer
- S/S: 'lumpy' breasts which may be painful, bilateral
-- symptoms may worsen prior to menstruation
Fibrocystic disease /fibroadenosis
92
S/S: clear / blood-stained discharge
Intraductal papilloma
93
x: stellate mass on XR
Radical scar - S/s breast lump/pain
94
Name the types of breast cancer?
o Invasive ductal carcinoma / ‘No Special Type’ (NST) ------- 1st most common type of breast cancer
o Invasive lobular carcinoma ------- 2nd most common type of breast cancer
o Ductal carcinoma-in-situ (DCIS) ------- “Comedo necrosis”
o Lobular carcinoma-in-situ (LCIS) / ‘Special Type’ (ST) – ST also includes many other rarer breast cancers
95
Breast lymph drainage
75% to lateral axillary nodes
25% to parasternal nodes or opposite breast
96
* LOW grade breast ca?
ER/PR positive Her2 negative
97
* HIGH grade breast ca?
ER/PR negative Her2 positive
98
Clinical axillary lymphadenopathy? How should this be treated?
* YES = axillary node clearance (possible lymphoedema)
* NO = USS and SLNB ± axillary node clearance
99
Mx (if HER2 +ve)?
Trastuzumab (Herceptin)
100
Prognosis scale in breast ca?
Nottingham Prognostic Index:
101
Struvite (MgNH4PO4; triple) stones?
Staghorn calculi
102
o Hydronephrosis / infection (febrile) mx?
Percutaneous neprhostomy + Abx
103
Mx of BPH?
1st: alpha-1 antagonists; 2nd: 5 alpha-reductase inhibitors
104
3rd line for prostate cancer ix?
o 3rd TRUS-guided biopsy (Trans-Rectal US = TRUS)
105
Ix for renal cell carcinoma
Ix: 1st cystoscopy, renal tract USS
Gold-standard (definitive diagnosis) CT urogram
106
o Papillary renal cell carcinoma 15%
Associations?
Long-term dialysis
107
o Bulbar rupture (most common): urethral injury
Straddle type injury e.g. bicycles
Triad S/S: urinary retention, perineal haematoma, blood at the meatus
108
Membranous rupture: Urethral injury
Pelvic fracture
S/S: penile or perineal oedema/ hematoma, PR (prostate displaced upwards)
109
Investigations for urethral injury
* Ix: ascending urethrogram
* Mx: suprapubic catheter
110
Seminomas tumour marker?
* AFP normal
* hCG 10-20% elevated
* LDH 10-20% elevated
*can have essentially normal markers*
111
Non-seminomas tumour marker?
* AFP 70% elevated
* hCG 40% elevated
* LDH normal
*AFP and b-hCG often raised*
112
S/s of testicular tumour?
o 1st = USS
o 2nd = AFP, hCG, LDH
o CT TAP
113
Ix for testicular cancer?
* Ix: cremasteric reflex -ve (inner leg stroke raise), Prehn’s test -ve (elevation)
114
Treatment for prostatitis?
* Mx: quinolone (14/7), screening for STIs
115
Associations with variocele?
Renal cell carcinoma
116
HPV is associated with what head and neck cancer?
Oropharyngeal cancer
117
EBV is associated with what head and neck cancer?
Nasopharyngeal cancer
118
Derm referral for acne
Nodulocystic acne / scarring
Severe form (acne conglobata, acne fulminans)
Severe psychological distress
Diagnostic uncertainty
Failing to respond to medications
119
Mx of acne rosacea?
o Mild, moderate = topical metronidazole
Flushing, limited telangiectasia topical brimonidine gel
o Severe oral tetracycline (oxytetracycline)
o Adjuncts: high-factor sunscreen, camouflage creams, laser therapy (telangiectasia)
120
S/s of acne rosacea?
o 1st flushing
o 2nd symmetrical rash of nose, cheeks, forehead ± telangiectasia
o 3rd persistent pustulopapular erythema
Rhinophyma (nose has thickened skin and more sebaceous glands)
Ocular involvement (blepharitis)
Photosensitivity
121
What is TEN?
>30% involvement
Nikolsky's sign = never press skin as it can peel
122
Mx of SJS/TEN
stop precipitating factor, ITU
1st IVIG
2nd immunosuppression (ciclosporin, cyclophosphamide), plasmapheresis
123
Moderate acne tx?
* Oral ABx (max 3m) + BPO / retinoid
* 1st line = tetracyclines Lymecycline, doxycycline
* 2nd line = macro
124
Tx of pityriasis vesicolor?
topical ketoconazole
125
What is Pityriasis Rosea?
Caused by HHV-7
* Signs & symptoms:
o 1st: Recent viral infection herald patch (usually on trunk)
o 2nd: erythematous, oval, scaly patches
Running parallel to the line of Langer = 'fir-tree' appearance
* Mx: self-limiting (6-12w)
126
o Guttate psoriasis?
streptococcal infection multiple, transient, red, teardrop lesions no mx required
127
Drugs that exacerbate psoriasis?
o Drugs (beta blockers, lithium, antimalarials (chloroquine, hydroxychloroquine), NSAIDs, ACEi, infliximab)
128
Treatment of tinea?
o Tinea Faciei, Tinea Corporis, Tinea Cruris or Tinea Pedis
Mild topical antifungals (e.g. topical terbinafine, clotrimazole, miconazole)
Moderate hydrocortisone 1% cream
Severe oral antifungals (1st line: oral terbinafine; 2nd line: oral itraconazole)
o Tinea Capitis oral antifungal (e.g. griseofulvin or terbinafine)
129
Dermatophyte infection tx?
1st: PO terbinafine; 2nd: PO itraconazole (finger = 6w-3m; toe = 3m-6m)
* Check LFTs before prescribing
130
Wickham’s striae in which condition?
Lichen planus
131
Mx of lichen sclerosis?
o Mx: 1st (3m): clobetasol propionate (strong steroid ointment) 2nd: tacrolimus + biopsy
132
* Bullous pemphigoid:
o Antibodies against BM (dermoepidermal junction)
o S/S: itchy tense blisters, no oral involvement
o Mx: oral corticosteroids
133
* Pemphigus vulgaris:
o Antibodies against desmosomes
o S/S: flaccid blisters, oral involvement
134
Erythema nodosum causes?
S Streptococci, mycoplasma, EBV S Sulphonamides, penicillin
O OCP H Hansen’s disease (leprosy)
R Rickettsia I IBD, Idiopathic
E Eponymous (Behçet’s) N Non-Hodgkin’s lymphoma
S Sarcoidosis, TB
135
* Hereditary haemorrhagic telangiectasia (HHT)
o (1) Epistaxis
o (2) Telangiectasia (characteristic sites: lips, oral cavity, fingers, nose)
o (3) Visceral lesions (GI ± anaemia, AVM pulmonary/hepatic/spinal/cerebral)
o (4) FHx (1st degree)
136
Athlete's foot mx?
o Management:
1st: topical antifungals (i.e. clotrimazole, imidazole)
2nd: oral antifungals (i.e. PO terbinafine)
137
Tx of ankylosing spondylitis?
Conservative - physical activity and exercise
Medical - 1st NSAIDs
138
Treatment for Raynaud's syndrome?
o Mx: gloves/avoid cold, CCBs (nifedipine), PDE V inhibitors (sildenafil) IV prostacyclin (iloprost)
139
CREST syndrome/limited systemic sclerosis?
CREST = Calcinosis, Raynaud’s, Oesophageal dysmotility, Sclerodactyly, Telangiectasia
Skin involvement (beak nose, microstomia, pul. HTN) limited to face, hands and feet
140
o Diffuse Systemic Sclerosis (30%) s/s?
Diffuse skin involvement extends past the wrists and up the arms
Organ fibrosis:
* GI: GOR, aspiration, dysphagia, anal incontinence
* Lung (80% get these symptoms): fibrosis, pul. HTN
* Cardiac: arrhythmias, conduction defects
* Renal: acute HTN crisis (most common cause of death)
141
Antibodies in systemic sclerosis?
* Limited CREST = anti-centromere
* Diffuse = anti-SCL70, anti-RNA polymerase 1, 2, 3
142
Dermatomyositis = myositis + skin signs:
143
s/s of polymyositis?
o Progressive symmetrical proximal muscle weakness (associated myalgia & arthralgia)
o Wasting of shoulder and pelvic girdle
o Dysphagia, dysphonia, respiratory weakness
144
S/s of dermatomyositis?
Periorbital heliotrope rash on eyelids ± oedema
Gottron’s papules: knuckles, elbows, knees
Mechanics hands: painful, rough skin cracking of fingertips
Macular rash (shawl sign +ve: over back and shoulders)
Nailfold erythema
Retinopathy: haemorrhages and cotton wool spots
Subcutaneous calcifications
o Extra-Muscular features:
Fever
Arthritis
Bibasal pulmonary fibrosis
Raynaud’s phenomenon
Myocardial involvement: myocarditis, arrhythmias
145
Ix for dermatomyositis?
o Muscle enzymes (↑CK (1,000s), ↑AST, ↑ALT, ↑LDH)
o EMG
o Biopsy (definitive)
o Antibodies (“myositis panel”):
Anti-Jo1 (anti-aminoacyl transfer RNA synthetase antibody)
Anti-Mi2 DM > PM
Anti-SRP (signal recognition peptide) PM
o Malignancy screen (tumour markers, CXR, mammogram, USS, CT)
146
Breakdown of vasculitdes?
* Large vessel:
o GCA / temporal arteritis
o Takayasu’s arteritis
* Medium vessel:
o Polyarteritis nodosa
o Kawasaki’s disease Chapel-Hill criteria [2012]
* Small vessel:
o pANCA Churg-Strauss (eGPA), microscopic polyangiitis
o cANCA Wegener’s Granulomatosis (GPA)
o ANCA –ve HSP, Goodpasture’s, cryoglobulinaemia
147
What is amaurosis fugax?
ant. ischaemic optic neuropathy)
148
Tx for CGS with visual symptoms?
Visual symptoms = IV methylprednisolone
149
S/s of takaysu's arteritis
s./S: weak/unequal upper limb pulses, HTN, large vessel blockage (HF, CRF)
150
* Polyarteritis nodosa:
o Epidemiology: young, male adults (less common in the UK)
o S/S: systemic symptoms, skin (rash), GIT (melaena, abdominal pain), renal (HTN), liver dysfunction (HBV)
o Ix: HBV serology, ‘rosary bead sign’ on renal angiogram
o Mx: prednisolone + cyclophosphamide
151
GPA?
Signs & symptoms:
* URT – rhinitis, epistaxis, saddle-nose
* LRT – haemoptysis, cough
* Renal – RPGN, nephritic syndrome
Ix: cANCA (PR3), dipstick (p +, h +), CXR (nodules)
Mx: prednisolone + cyclophosphamide OR rituximab
152
Eosinophilic granulomatosis + polyangitis (Churg-Strauss)
Signs & symptoms:
* Eosinophilia
* Asthma (late-onset)
* Vasculitis (incl. RPGN)
Ix: pANCA (MPO; n.b. also +ve in UC and TB)
153
Antibodies in GPA?
cANCA
154
Antibodies in eGPA?
pANCA
155
Goodpasture's syndrome
S/S: RPGN, haemoptysis
glomerulonephritis and pulmonary haemorrhage.
Ix: anti-glomerular BM antibody, CXR (bilateral lower zone infiltrates)
Mx: immunosuppression + plasmapheresis
156
Antibodies in goodpasture's syndrome?
anti-GBM antibodies
157
Neuropathic pain treatment?
o 1st line neuropathic pain amytriptyline, pregabalin
o 1st line diabetic neuropathy duloxetine
o 1st line trigeminal neuralgia carbamazepine
Don't give duloxetine in low eGFR
158
Mx of Still's disease?
o Management:
1st line: NSAIDs for fever, joint pain, serositis
2nd line (after 1 week of NSAIDs): + steroids
3rd line: methotrexate, IL-1, anti-TNF
159
o Signs & symptoms of SLE?
Serositis Blood (all counts low) Malar rash
Oral ulcers, hair loss Renal (proteinuria, haematuria) Discoid rash
Arthritis ANA (≥95%)
Photosensitive Immunological (anti-dsDNA, AIHA)
Neurological (psych, seizures)
160
Severe SLE flare tx?
Severe flares (AIHA, nephritis, pericarditis, CNS disease) prednisolone + IV cyclophosphamide
161
Maintenance of SLE?
hydroxychloroquine ± DMARDS (MMF, azathioprine) ± low-dose steroids
* Severe disease maintenance (biologicals – anti-B-cell) belimumab, rituximab
* Sun protection sun cream, low-dose steroids
162
A 29-year-old pregnant female is recovering from cavernous venous sinus thrombosis. All nerves passing through the wall of the sinus have been affected.
What cranial nerve is most likely affected?
Ophthalmic division of the trigeminal nerve
163
An 87-year-old male falls while walking in the garden of his nursing home. He is unable to bear weight on his left leg. On arrival in the Emergency Department, he has a shortened and externally rotated left leg. His foot is warm and well-perfused. He can move his toes. Capillary refill time is normal bilaterally.
What is the most likely diagnosis?
Fractured neck of femur
164
What is Beçhet's disease?
o S/S: recurrent oral and/or genital ulceration, uveitis, erythema nodosum, VTE
o Ix: skin pathergy test (pinprick papule formation)
o Mx: immunosuppression
165
Ix and mx of Sjorgren's syndrome
o Ix: Schirmer’s test, ABs (anti-Ro [70%], anti-La [30%], RhF [50%]), hypergammaglobulinaemia, parotid biopsy
o Mx: artificial tears, saliva replacement + NSAIDs/hydroxychloroquine immunosuppression
N.B. ABs can cross placenta and cause heart block in the baby so need specialist O&G management
166
Anti-Jo antibodies are seen in which condition more?
Polymyositis
167
Psoriatic disease XR signs?
"Pencil in cup deformity"
168
RF of pseudogout?
RFs: ↑age, OA, DM, hypothyroidism, hyperparathyroidism, hereditary haemochromatosis, Wilson’s
169
Acute mx of gout?
* 1st line = colchicine, NSAIDs (not aspirin) Do not stop allopurinol if already established
* Renal impairment = PO steroids Do not stop aspirin 75mg if for cardioprotection
* Follow-up in 4-6 weeks and check BP, HbA1c, serum urate, U&Es, lipids consider ULT
170
Urate lowering therapy in renal impariment?
febuxostat (i.e. renal impairment)
171
Rheumatoid arthritis X-ray signs?
Loss of joint space
Erosions (periarticular)
Soft tissue swelling
Subluxation & deformity
172
When to increase RA treatment?
If DAS-28 >5.1, consider stepping up management
If d pain/CRP/DAS, offer simple analgesics (paracetamol)
173
Felty's syndrome - signs+symptoms
* Splenomegaly
* Anaemia
* Neutropenia
* Thrombocytopenia
* Arthritis
Associated with RA
174
Monitoring required for methotrexate?
Regular FBC and LFTs required (risk of myelosuppression & liver cirrhosis)
175
A 28 year old man has an insurance medical. His pulse rate is 72 bpm and BP 210/110 mmHg. There is radiofemoral delay. A systolic murmur is audible on auscultation. Chest X-ray reveals notching of the ribs in the mid-clavicular line. Which is the most likely diagnosis?
Coarctation of the aorta
176
A 28 year old man has an insurance medical. His pulse rate is 72 bpm and BP 210/110 mmHg. There is radiofemoral delay. A systolic murmur is audible on auscultation. Chest X-ray reveals notching of the ribs in the mid-clavicular line. Which is the most likely diagnosis?
Ethambutol
Can cause optic neuritis
177
Elevated calcium and perihilar lymphadenopathy?
Sarcoidosis
178
A 56 year old man has had a single episode of painless visible haematuria. He has no other urinary symptoms and is otherwise fit and well. He has smoked ten cigarettes per day for the past 35 years. He has a BP of 140/85 mmHg. Urinalysis performed after this episode shows blood 2+, no protein and no nitrites. Investigations: Urea 6.5 mmol/L (2.5–7.8) Creatinine 95 µmol/L (60–120) Urine culture: no growth Which investigation is most likely to confirm the diagnosis?
Flexible cystoscopy
179
IE in IVDU causative organism?
Staph aureus
180
Vitamin C deficiency?
This is typical of vitamin C deficiency which presents with a petechial rash and gum changes. It is still seen in the UK in people with poor diets.
181
A 45 year old man has had 6 months of tiredness, reduced libido and erectile dysfunction. Investigations: Testosterone 1.8 nmol/L (9.9–27.8) LH 1.2 U/L (1–8) FSH 1.0 U/L (1–12) Which is the most likely cause of his presentation?
Pituitary adenoma
182
A 22 year old soldier steps off a cramped military aircraft following a long flight from the United Kingdom. She suddenly collapses and hits her head on the ground. While unconscious, she has asynchronous jerking of her limbs for less than 15 seconds. Witnesses say that she looked pale. She regains consciousness within 1 minute. What is the most likely cause of her collapse?
Vasovagal syncope
183
A 62 year old man has 2 months of increasing shortness of breath and chest pain. He is now unable to lie flat. For the past 2 weeks, he has also had a productive cough which was flecked with blood on two occasions. He had a myocardial infarction 6 months ago, at which point he stopped smoking. His temperature is 37.1°C, BP 126/66 mmHg, respiratory rate 24 breaths per minute and oxygen saturation 93% breathing air. Investigations: Chest X-ray: moderate right-sided pleural effusion. Pleural aspirate protein content 56 g/L. Which is the most likely underlying diagnosis?
The high protein content (56 g/L) in the pleural aspirate indicates an exudative effusion, which more indicative of malignancies like lung cancer.
184
A 55 year old man is referred to the vascular outpatient clinic with bilateral claudication, limiting his walking distance to 10 metres. He is a smoker. Imaging shows chronic distal aortic and bilateral common iliac occlusive disease. Which is the most appropriate surgical intervention? A. Aortic endarterectomy B. Aorto-bifemoral bypass graft C. Aorto-iliac embolectomy D. Bilateral iliac angioplasty E. Femoral-to-femoral crossover graft
B
Chronic distal aortic and bilateral common iliac occlusive disease would make aorto-bifemoral bypass graft the most appropriate surgical intervention. This involves bypassing the occluded aortic and iliac vessels with a synthetic graft to restore blood flow to the legs.
Other surgical options like aortic endarterectomy or aorto-iliac embolectomy may not be suitable for chronic occlusive disease, while bilateral iliac angioplasty and femoral-to-femoral crossover graft may not be adequate for restoring blood flow to the entire leg.
185
A 28 year old man has a headache, intermittent fever, sore throat and diarrhoea. His temperature is 37.7°C. His fauces are red and there are two small aphthous ulcers on his left buccal mucosa. He also has a maculopapular erythematous rash on his upper trunk, red hands and folliculitis on his chest. His liver and spleen are just palpable and he has mild neck stiffness. Investigations: Haemoglobin 135 g/L (130–175) White cell count 3.3 x 109/L (3.0–10.0) Platelets 84 x 109/L (150–400) Which investigation is most likely to lead to a diagnosis?
HIV Serology
The presentation suggests an infection, which is affecting a number of different body regions and systems. The most specific information is the presence of a rash with folliculitis on the chest, which is a prominent feature in late stage HIV infection. Additionally, HIV can explain all of the symptoms, hence the correct answer is HIV serology.
186
A 78 year old woman is found dead at home. At autopsy, the pathologist finds bilateral pneumonia and meningitis. Microscopy of a meningeal swab shows Gram-positive cocci arranged in pairs. Which is the most likely causative organism?
Streptococcus pneumoniae
187
A 52 year old woman reports increased urinary frequency, urgency and urge incontinence. She has multiple sclerosis, which affects her walking. A midstream urine sample shows no cells and is sterile on culture. A bladder scan shows a residual volume of 300 mL. Urodynamic assessment shows that she has a neuropathic bladder. Which is the most appropriate management?
Intermittent self-catheterisation
188
An 84 year old man develops profuse diarrhoea whilst in hospital. An outbreak of Clostridioides (Clostridium) difficile has occurred in his ward. Which feature of this organism makes it particularly difficult to destroy?
Spore formation
189
Where is the bifurcation of the trachea?
T4–T5 intervertebral disc
This is the level of the manubriosternal angle of Louis, the bifurcation of the trachea and also the level of the carina. Other structures which lie at this level include the undersurface of the arch of the aorta, the ligamentum arteriosum, the left recurrent laryngeal nerve, the division of the pulmonary trunk and the entrance of the azygos vein into the superior vena cava. However, when the subject stands erect and inspires fully, the carina can descend as low as the sixth thoracic vertebra.
190
Chlamydia s/s and culture findings?
Symptoms in women include intermenstrual bleeding, cervical discharge, pain on urination and abdominal pain. Those infected may frequently be asymptomatic, and chronic infection may lead to infertility in women. Cell culture and/or antibody testing should always be considered, as cytology alone has a low yield for Chlamydia.
Gram negative rod
191
Gonorrhoea culture results?
Gram-negative diplococci
192
Actinic Keratosis
This describes a classic squamous cell carcinoma (SCC) of the skin, the second most common skin cancer after basal cell carcinoma. It typically affects older men with a history of sun exposure. SCC can also arise in areas of chronic inflammation or pre-existing actinic keratosis. It is a slow-growing malignancy that locally invades, while spread to nearby lymph nodes is uncommon but not very rare. Examination reveals small, red, ulcerating nodules with scaling, commonly found on sun-exposed areas. Biopsy shows characteristic features, including keratin pearls. Treatment options include topical creams or excision. Basal cell carcinoma is the most common skin cancer, presenting as a pearly nodule with rolled telangiectatic edges, usually on the face. It is locally aggressive and best managed with excision or radiotherapy if large, with metastases being very rare.
193
A 32-year-old former air hostess attends a general medical outpatient clinic with numerous constitutional symptoms. She has been extensively investigated previously, but no diagnosis was found. The patient reports that she has recently read about polymyositis and feels that this condition seems to fit with her symptoms; she would like to know if she has had any tests for this condition.
Which of the following autoantibodies is most specific for polymyositis?
Anti-Jo
194
A 53-year-old male with a 30-pack-year history of smoking presents to his General Practitioner with a 2-month history of epigastric pain. He has been unable to weed his garden since the pain began and is often woken up at night. He finds that the pain is relieved by drinking a glass of milk. He has also had to give up his frequent visits to the pub.
What is the most likely cause of this patient's epigastric pain?
Duodenal ulcer
195
A 25 year old man has had penile pain for two days. His most recent sexual intercourse was one week ago. There are multiple tender ulcers on his preputial skin. His penile and scrotal skin does not have any other abnormality. Which is the most likely diagnosis?
Herpes simplex virus
196
The links between deprivation and health inequalities are well evidenced and widely accepted, but there are a number of explanations for that association. One explanation proposes that ill health determines people's social class. Which type of explanation of health inequality is this? A. Artefact B. Cultural/behavioural C. Idealist D. Materialist E. Social selection/mobility
E
197
What is artefact bias?
Artefact would be proposing that the observed differences are due to differences in measurement (and so not actually present).
198
Types of health bias?
Cultural/behavioural is proposing that differences in behaviour cause differences in health. Idealist would be suggesting that individual construction of health is different in different groups, so they might define health differently, and Materialist, emphasises the role of economic and social factors, such as income, education, and employment, in shaping health outcomes
199
Spondylolisthesis
Spondylolisthesis is a condition where one vertebra slips out of line with the one above it, most commonly in the lumbar spine. The exaggerated lumbar lordosis and the palpable depression above L5 can be clinical findings of spondylolisthesis. Symptoms include lower back pain that worsens with activity and improves with rest. Neurological examination is typically normal.
200
Bechet's syndrome
Patients with Behcet’s syndrome experience ulceration and joint pain but renal involvement and haematological changes are less likely.
201
A 29 year old woman has pain and morning stiffness in her finger and wrist joints. This improves during the day and after active movement. She has had recurrent mouth ulcers for the last 2 years. She had an episode of pleuritic chest pain 6 months ago which resolved without seeking help. Her BP is 128/85 mmHg. She has no warmth or tenderness in her hands. Urinalysis: protein 1+, blood 1+ Investigations: Haemoglobin 109 g/L (115–150) White cell count 3.8 × 109/L (4.0–11.0) Lymphocytes 0.9 × 109/L (1.1–3.3) Platelets 160 × 109/L (150–400) Creatinine 90 µmol/L (60–120) CRP 21 mg/L (< 5) Which is the most likely diagnosis?
SLE
202
How do adenocarcinomas spread?
Adenocarcinomas of the lung often metastasise to the liver through the bloodstream, making haematogenous spread the most likely route.
203
A 68 year old woman has noticed a lump in her neck for 2 months, but otherwise feels well. There are small lymph nodes palpable in the cervical, axillary and inguinal regions. Investigations: Haemoglobin 124 g/L (115–150) White cell count 27.2 × 109/L (3.8–10.0) Neutrophils 2.5 × 109/L (2.0–7.5) Lymphocytes 21.6 × 109/L (1.1–3.3) Monocytes 0.9 × 109/L (0.2–1.0) Eosinophils 0.4 × 109/L (0–0.4) Basophils 0.1 × 109/L (0–0.1) Platelets 137 × 109/L (150–400) Blood film: increased lymphocytes with sparse cytoplasm Which is the most likely diagnosis? A. Acute lymphoblastic leukaemia B. Chronic lymphocytic leukaemia C. Infectious mononucleosis D. Myeloma E. Non Hodgkin's lymphoma
B
204
Treatment for hepatic encephalopathy?
Lactulose
205
A 45 year old man has a 5 month history of chronic sinusitis and unresolving headaches. When he bends forward, purulent fluid pours from his nose. Which anatomical structure is most likely to be the source of this fluid?
Maxillary sinus
206
A 42 year old woman has 6 months of a painful right shoulder. Her pain keeps her awake at night and is worsened by movement. She is otherwise well. There is no history of trauma. She has pain on shoulder abduction between 80° and 120°. Her shoulder movements are otherwise normal. There is no joint effusion. X-ray of right shoulder is normal. Which is the most likely diagnosis?
Subacromial bursitis
207
A 74 year old woman has had left sided headache and discomfort when chewing food for 3 months. She experiences a sensation of pressure and pain in her jaw, even when talking. She has lost 8 kg in weight over the same time period. Investigations: CRP 45 mg/L (<5) Which investigation is most likely to establish the diagnosis?
Temporal artery biopsy
208
GCA?
The typical symptoms of headache, jaw claudication, and unintentional weight loss, along with elevated CRP levels, raise a strong suspicion of giant cell arteritis. Temporal artery biopsy is the gold standard test for diagnosis, as it shows characteristic histopathological changes of giant cell arteritis such as mononuclear cell infiltration and granulomatous inflammation
209
A group of 75 men and a group of 75 women performed a standardised exercise test and had their pulse rate measured at the end. The data from the two groups were compared. The data is normally distributed with equal variance. Which is the most appropriate statistical test to compare these groups?
Unpaired student t test
210
. A 18 year old man is worried about his cancer risk. His paternal grandfather died of colorectal cancer at 42 years of age and his 36 year old father has just been diagnosed with colorectal cancer. The son's colonoscopy shows hundreds of colonic polyps, and biopsies from several of the polyps show adenomatous change with low grade dysplasia. Which is the most appropriate strategy to prevent colon cancer in this situation?
Panproctocolectomy
211
A 62 year old man is brought to the operating theatre recovery room after a laryngoscopy and vocal cord biopsy. He appears to be conscious, but his breathing is shallow and respiratory rate 28 breaths per minute. His voice is weak and, when the recovery nurse asks him to squeeze her fingers with his hand, the grip is not sustained. Which drug will reverse these signs?
Neostigmine
The weak grip, cough and shallow breathing suggest residual effects of neuromuscular blockade that has been administered to facilitate laryngoscopy and vocal chord biopsy under general anaesthetic.
212
A 72 year old man has had difficulty swallowing solids. He has cancer of the middle third of the oesophagus and hepatic metastases. Which is the most appropriate initial management of his dysphagia?
Oesophageal stent
213
A consultant is looking to find published evidence on reducing the incidence of deep venous thrombosis. Which type of study would provide the highest quality evidence?
Meta-analysis of trials
214
Hepatocellular carcinoma marker?
alpha-fetoprotein
215
A 23 year old woman commenced chemotherapy for Burkitt's lymphoma yesterday. Since then she has been feeling increasingly nauseated. Urine output has been 40 mL in the last 12 hours. Her temperature is 36.8°C, pulse rate 96 bpm and BP 112/80 mmHg. Investigations on admission were normal. Investigations today: Potassium 6.2 mmol/L (3.5–5.3) Urea 9 mmol/L (2.5–7.8) Creatinine 410 µmol/L (60–120) Which investigation is most likely to identify the cause of her acute deterioration?
Urate
216
Tumour lysis syndrome?
Tumour lysis syndrome, which is a potentially life threatening complication of chemotherapy that can cause electrolyte imbalances and kidney damage. The most appropriate investigation to identify the cause of her acute deterioration would be urate, as elevated uric acid levels are a hallmark of tumour lysis syndrome.
However, all of the other options may also be useful in helping to manage her condition. Blood cultures may be taken to rule out a bacterial infection, C-reactive protein can indicate inflammation or infection, creatine kinase may be elevated in rhabdomyolysis (another potential complication of chemotherapy), and phosphate levels may also be elevated in tumour lysis syndrome.
217
What is elevated in tumour lysis syndrome?
Urate
218
histological description of duct-like structures lined by regular, low columnar cells separated by loose fibrous tissue, with welldefined margins
Fibroadenoma
219
A 22 year old woman has intense itching and pain in her right ear that has gradually worsened over several days. She says that her hearing appears to be affected. She is a surfer. She has debris in the right ear canal, and the tympanic membrane is not visible. There is pain on pulling the pinna. Which is the most likely diagnosis?
Otitis externa
220
A 39 year old woman has had worsening tiredness for 2 weeks. She was previously well.She is mildly jaundiced. Her pulse rate is 96 bpm and BP 112/76 mmHg. Investigations: Haemoglobin 48 g/L (115–150) White cell count 6.2 × 109/L (4.0–11.0) Platelets 165 × 109/L (150–400) Mean cell volume (MCV) 98 fL (80–96) Alkaline phosphatase 100 IU/L (25–115) Aspartate aminotransferase (AST) 27 IU/L (10–40) Bilirubin (total) 41 µmol/L (< 21) Lactate dehydrogenase 560 IU/L (70–250) Blood film: red cell polychromasia, occasional spherocytes, no red cell fragments Which is the most appropriate diagnostic investigation?
Direct antiglobulin test
The patient has anaemia with raised bilirubin and LDH but otherwise normal liver function tests. The polychromasia on the film is due to an increase in reticulocytes and together these laboratory results are consistent with haemolytic anaemia (evidence of both increased RBC production and destruction).
221
Treatment of sickle cell crisis?
Treatment of an acute painful sickle cell crisis needs to be considered an acute medical emergency. Pain must be assessed immediately and treated with an acute bolus of a strong opioid such as morphine. The patient is afebrile with a normal white cell count and thus no evidence of infection, and hence antibiotics such as co-amoxiclav are not indicated at this stage.
222
Antibodies against desmosomes?
Pemphigus vulgaris
223
Antibodies against hemidesmosomes
Bullous pemphigoid
224
Toxic megacolon?
The above presentation of unstable observations, a tender abdomen in a patient with a history of ulcerative colitis, is concerning for toxic megacolon. Toxic megacolon is a complication of inflammatory bowel disease characterised by a non-obstruction dilation of the large bowel with systemic manifestations. Plain abdominal films should be ordered urgently to assess for this life-threatening condition. The transverse colon will typically be dilated > 6 cm on plain abdominal films, diagnostic of toxic megacolon.
225
Erythaema ab igne - what is this skin condition?
Caused by hot water bottle use,
People who sit near fires
226
Goodpasture syndrome
Refers to clinically evident glomerulonephritis and pulmonary haemorrhage.
Anti-GBM antibodies directed against type IV collagen.
Anti-GBM disease is characterised by a rapidly progressive crescentic glomerulonephritis.
227
Nephritic syndrome?
Haematuria, oliguria, proteinuria, fluid retention
228
Causes of nephrotic syndrome?
Membranous nephropathy
Focal segmental glomerulosclerosis
Membranoproliferative glomerulonephritis
Henoch-Schönlein purpura (HSP)
Diabetes
Infection (e.g., HIV)
229
Rapidly progressive glomerulonephritis histology?
Glomerular crescents
230
p-ANCA (or MPO antibodies): which condition?
Microscopic polyangitis
231
Chronic aortic regurg?
In chronic aortic regurgitation, patients may remain asymptomatic for many decades. Valvular incompetence develops slowly. Regurgitation of blood during diastole causes an increase in the left ventricular end-diastolic volume (essentially the preload). This leads to systolic and diastolic dysfunction, left ventricular dilatation develops with eccentric hypertrophy.
Can see cardiomegaly on CXR. It may show a dilated ascending aorta in those with aortic root pathology though the sensitivity is poor.
Gold standard is ECHO
232
O/E aortic regurg?
Chronic AR
Palpitations
Angina
Dyspnoea
Water hammer pulse
Wide pulse pressure
Chest signs:
Displaced apex
Ejection diastolic murmur
Soft S1 and S2
233
Mx of aortic regurg?
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:
Chronic AR
According to the 2017 ESC guidelines, surgical management is indicated (depending on individual operative risk) in chronic AR in patients with:
Significant enlargement of the ascending aorta or
Symptomatic severe AR or
Severe AR with LVEF ≤ 50% or LVEDD > 70mm or LVESD > 50mm (may be adjusted for body size)
Marfan's with aortic root disease with a maximal ascending aorta diameter ≥ 50mm
234
Spinothalamic tracts:
Carries crude touch information, pain and temperature info
Thus, fibres cross at the spinal cord level.
235
Dorsal columns:
Light touch, vibration, proprioception
Thus, fibres cross at the level of the brainstem.
236
Corticospinal tracts:
Voluntary movement
Thus, fibres predominantly cross at the level of the brainstem.
237
Posterior cord syndrome:
Gait ataxia, abnormal vibration sense, paraesthesia below the level of injury
Inflammatory (e.g. multiple sclerosis)
Syphilis
Ischaemia (e.g. posterior spinal artery syndrome)
Malignancy
Metabolic (e.g. subacute degeneration of the cord due to vitamin B12 deficiency)
Hereditary (e.g. Friedreich ataxia)
238
Anterior cord syndrome:
Clinical features
The syndrome is characterised by a broad range of clinical features:
Bilateral weakness (paraplegia or quadriplegia): depends on the level of the lesion
Bilateral loss of pain and temperature
Autonomic dysfunction: abnormal blood pressure
Bladder dysfunction: Urinary incontinence
Caused by trauma, thromboembolism, hypotension, aortic disease
Disc herniation, trauma
239
Brown-sequard syndrome: What is it?
Hemisection of the cord
240
Ipsilateral weakness: the corticospinal tracts cross at the brainstem. Upper motor neuron signs below the lesion (i.e. high tone, hyperreflexia, weakness). There is usually flaccid paralysis (i.e. lower motor neuron weakness) at the level of the lesion
Ipsilateral proprioception/vibration loss: the dorsal columns cross at the medulla
Contralateral pain/temperature loss: cross at the level of the spinal cord
Horner’s syndrome (Triad: miosis, ptosis, anhidrosis): if the lesion is above T1, hemisection of the cord affects the first order sympathetic neuron
Often due to trauma - gun shot wound, stabbing, road-traffic collision
241
Central cord syndrome
A clinical syndrome commonly due to a hyperextension injury of the neck.
Weakness: upper extremity weakness > lower extremity weakness. Neurons to the upper extremities are more densely represented within the medial part of the lateral corticospinal tract
Pain and temperature loss: usually located at the level of the lesion in a ‘cape-like’ distribution affecting the upper back and upper extremities. This is known as a ‘suspended sensory level’.
Neck pain: commonly due to the mechanism of injury (hyperextension injury in trauma).
Normal vibration and proprioception (dorsal columns unaffected)
Urinary retention may occur
242
TACS bamford classification criteria?
- Unilateral weakness +/- sensory deficit within the face and/or arm and/or leg.
- Homonymous hemianopia
- Higher cerebral dysfunction
243
‘Wallenberg syndrome’?
(posterior inferior cerebellar artery occlusion)
Nystagmus
Vertigo
Ipsilateral Horner’s syndrome
Ipsilateral facial sensory loss
Dysarthria & dysphagia
Diplopia
Contralateral pain and temperature loss
244
PACS? (part of bamford classification)
Two of the following need to be present for a diagnosis of a PACS:
Unilateral weakness (and/or sensory deficit) of the face, arm and leg
Homonymous hemianopia
Higher cerebral dysfunction (dysphasia, visuospatial disorder)*
245
Posterior circulation syndrome (POCS)
A posterior circulation syndrome (POCS) involves damage to the area of the brain supplied by the posterior circulation (e.g. cerebellum and brainstem).
One of the following need to be present for a diagnosis of a POCS:
Cranial nerve palsy and a contralateral motor/sensory deficit
Bilateral motor/sensory deficit
Conjugate eye movement disorder (e.g. horizontal gaze palsy)
Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia)
Isolated homonymous hemianopia
246
Lacunar stroke?
One of the following needs to be present for a diagnosis of a LACS:
Pure sensory stroke
Pure motor stroke
Sensori-motor stroke
Ataxic hemiparesis
247
Erythrema multiforme?
Target lesions, allergic reaction to certain medications
immune-mediated, typically self-limiting, mucocutaneous condition
Often precipitated by HSV
248
Criteria for AKI diagnosis?
Rise in creatinine of more than 25 micromol/L in 48 hours
Rise in creatinine of more than 50% in 7 days
Urine output of less than 0.5 ml/kg/hour over at least 6 hours
249
Renal causes of AKI?
Acute tubular necrosis
Glomerulonephritis
Acute interstitial nephritis
Haemolytic uraemic syndrome
Rhabdomyolysis
250
Muddy brown casts on urinanalysis?
Acute tubular necrosis
251
Causes of CKD?
Diabetes, HTN, obesity, heart disease, history of AKI, glomerulonephritis, PKD, lupusm sepsis, hydronephrosis
252
Which medications slow progression of CKD?
ACE inhibitors (or angiotensin II receptor blockers)
SGLT-2 inhibitors (specifically dapagliflozin)
253
Acute dialsysis indications?
A – Acidosis (severe and not responding to treatment)
E – Electrolyte abnormalities (particularly treatment-resistant hyperkalaemia)
I – Intoxication (overdose of certain medications)
O – Oedema (severe and unresponsive pulmonary oedema)
U – Uraemia symptoms such as seizures or reduced consciousness
254
Extra-renal manifestations of PKD include:
Cerebral aneurysms (berry)
Hepatic, splenic, pancreatic, ovarian and prostatic cysts
Mitral regurgitation
Colonic diverticula
255
Diagnosing PKD?
USS and genetic testing
256
Mx of PKD?
Antihypertensives for hypertension (e.g., ACE inhibitors)
Analgesia for acute pain
Antibiotics for infections (e.g., UTIs or cyst infections)
Drainage of symptomatic can be performed by aspiration or surgery
Dialysis for end-stage renal failure
Renal transplant for end-stage renal failure
257
Which cancer's are associated with immunosuppression?
Skin cancer (particularly SCC)
Non-Hodgkin lymphoma
258
Type 1 renal tubular acidosis
Type 1
Distal tubule cannot excrete hydrogen ions
Urinary pH = High
Serum potassium = Low
259
Type 4 renal tubular acidosis
Type 4
Low aldosterone or impaired aldosterone function
Urinary pH = Low
Serum potassium = High
260
HUS triad
Microangiopathic haemolytic anaemia
Acute kidney injury
Thrombocytopenia (low platelets)
261
Hydronephrosis?
Hydronephrosis is a condition that occurs when a kidney swells and can't get rid of pee (urine) like it should. This swelling typically happens when urine cannot drain out from the kidney to the bladder due to a blockage or obstruction.
Can be cauased by kidney stones, blood clots, UTI
262
Cluster headache tx?
Treatment involves high-flow oxygen and sumatriptan for acute attacks, while verapamil or topiramate are used for prevention.
263
Case-Control Study
Start with outcome and look back to determine what factors made this more likely (demographic-matched control)
264
Cross-sectional study?
prevalence at a certain point
265
o Specificity calculations?
= true negatives / total number without the disease
266
* Positive Predictive Value
= true positives as measured with screening/ total number positive =
o Positive predictive value dependent on disease prevalence
266
Toxic megacolon?
Toxic megacolon
A major complication of UC is toxic mega colon (TMC).
TMC is a medical emergency, which refers to toxic, non-obstructive, dilatation of the colon (> 6cm). Patients with UC who present with abdominal distension and tenderness should be admitted for suspected TMC.
266
* Negative Predictive Value
=true negatives as measured with screening/ total number negative
o PPV and NPV determine the accuracy of the test to get the diagnosis right or wrong
266
Oesophageal varices
Terlipressin
Broad spectrum antibiotics
267
discharge (white), STI?
Chlamydia
268
discharge (mucopurulent)?
Gonorrhoea
Azithromycin stat + ceftriaxone IM stat♀️
269
Syphilis
Treponema pallidum
1o - painless ulcer
2o - rash, general lymphadenopathy, constitutional sx, condylomata lata, tingling
270
Most common cause of SBP?
E coli
271
Ventricular ectopics on ECG?
isolated, random, abnormal, broad QRS complexes on an otherwise normal ECG.
272
First degree heart block?
On an ECG, first-degree heart block presents as a PR interval greater than 0.2 seconds (5 small or 1 big square).
273
Mobitz Type 1
On an ECG, there is an increasing PR interval until a P wave is not followed by a QRS complex. The PR interval then returns to normal, and the cycle repeats itself.
274
Mobitz Type 2
There is usually a set ratio of P waves to QRS complexes, for example, three P waves for each QRS complex (3:1 block). The PR interval remains normal. There is a risk of asystole with Mobitz type 2.
275
Third degree heart block
Also called complete heart block. There is no observable relationship between the P waves and QRS complexes.
276
Causes of AF?
S – Sepsis
M – Mitral valve pathology (stenosis or regurgitation)
I – Ischaemic heart disease
T – Thyrotoxicosis
H – Hypertension
Alcohol and caffeine are lifestyle causes worth remembering.
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pharmacological cardioversion,
Flecainide
Amiodarone (the drug of choice in patients with structural heart disease)
278
When to do ascitic tap?
Spontaneous bacterial peritonitis (SBP) should be suspected in patients with ascites due to cirrhosis who develop symptoms such as fever, abdominal pain or tenderness, and confusion. The signs and symptoms are more subtle compared with those seen in patients with standard bacterial peritonitis. It is important not to miss SBP as delayed recognition is associated with a high mortality
279
13. A 27 year old woman has had abdominal pain for 48 hours. She also reports recurrent mouth ulcers and altered bowel habit for a few weeks. Her temperature is 37.5°C. She has central abdominal tenderness. Investigations: CT colonoscopy shows a normal appendix with distal small bowel thickening. There are enlarged nodes in the small bowel mesentery.
Which is the most likely diagnosis?
Crohn's ileitis
280
Duodenal ulcers
Duodenal ulcers tend to be made worse with stress and the pain is often worse at night radiating into the back - it is relieved by eating and patients tend to put weight on - in contrast to a gastric ulcer which is made worse with eating and people often lose weight.
281
screening test for haemachromatosis
Transferrin saturation is the screening test for haemochromatosis
282
18. A 72 year old man has had difficulty swallowing solids. He has cancer of the middle third of the oesophagus and hepatic metastases.
Which is the most appropriate initial management of his dysphagia?
Oesophageal stent
283
First Ix in suspected PE?
CXR (to rule out other pathologies)
284
IE investigations?
Transoesophageal echocardiogram and blood cultures
285
Ix for subarachnoid haemorrhage?
LP
286
18 year old woman has 6 hours of severe dizziness and nausea. She says that the room is constantly spinning round and she has vomited several times. The dizziness is worse when she opens her eyes. She reports that her hearing has not changed.
She has nystagmus with the fast phase to the left, which does not fatigue.
Which is the most likely diagnosis?
Vestibular neuronitis
287
6. A 35-year-old woman gets pale, blue and painful fingers and toes on exposure to cold. Recently, she has had some difficulty swallowing solid food. She has tight skin over her face and fingers.
Which is the most likely diagnosis?
Systemic sclerosis
288
11. A 31 year old man visits his GP with a painless lump in his scrotum.
There is a well-defined, non-tender spherical 1 cm mass on the right side of the scrotum. It is superior to the testis and transilluminates.
Which is the most likely diagnosis?
Epidydimal cyst
289
20. The association between maternal smoking during pregnancy and low birthweight can be studied by obtaining smoking histories from pregnant women at the time of first prenatal visit, then assessing birthweight at delivery and analysing the data according to the smoking histories: what type of study?
c. Prospective cohort
290
Fibrocystic disease
Fibrocystic disease characteristically causes pain associated with the menstrual cycle. The fine needle aspiration supports this with no malignant cells seen. A fibroadenoma is a solid lump. Pain if present would be localised with fat necrosis. Breast abscess would be a more acute history and again would not be expected to cause bilateral breast pain.
291
13. A 65 year old man has sudden pain and redness in his right eye. He also has a headache and nausea. Visual acuity is 6/60 in the right eye. The eye is congested, with a hazy cornea and mid-dilated pupil.
Which is the most likely diagnosis?
Acute glaucoma
292
15. A 65 year old man reports sudden onset of visual disturbance with flashing lights, floaters and loss of vision in the upper outer quadrant of his right eye. He has a history of hypertension.
Which is the most likely diagnosis?
Retinal detachment
293
17. A 64 year old man has right-sided hearing loss. There has been slow deterioration over the previous year, and he is now also troubled by non-pulsatile, left-sided tinnitus that prevents him from sleeping. A pure-tone audiogram shows right-sided high-frequency hearing loss. He has normal tympanometry bilaterally.
Which is the most appropriate diagnostic investigation?
D. MR imaging of internal acoustic meatus
294
Squamous cell lung cancer
Causes PTHrP paraneoplastic syndrome.
295
Small cell lung cancer paraneoplastic effects?
SIADH, ACTH and Lambert-Eaton syndrome
296
Adjuvant?
After surgery
297
Treatment for breathlessness in palliative care?
Morphine
298
Purulent discharge with red eye - STI?
Gonorrhoea
299
Gram positive cocci?
Streptococcus pneumoniae
300
Ix for sarcoid?
ACE
301
Prophylaxis for SBP?
Ciprofloxacin
302
Short PR interval and slurred QRS?
WPW
303
Stroke lady has been treated medically but struggling with ADLS. What scoring tool is commonly used to assess if she needs help?
Barthel index
304
Causes of epidydmo-orchitis?
Chalmydia/E. coli
305
Young adult in car crash, GCS on scene 8 and intubated (?). GCS at 60 minutes was 12. Had memory loss of 18 hours after event. Has basal skull fracture on imaging. What is the best prognostic indicator of cognitive function?
GCS at 60 minutes
306
CXR showing bilateral diffuse alveolar space disease.
ARDS
307
Which marker first rises in acute myocardial infarction?
Myoglobin
308
Patient with hepatic hypoperfusion in lactic acidosis needs maintenance fluids. Which fluid is most important to avoid giving to prevent worsening of the acidosis?
Hartmann's solution
309
Football player, sudden change in direction. Could weight bear and walk off pitch (limped off the pitch) but in pain ?heard a popping sound. Able to leg raise and extend leg fully. What is damaged?
Meniscus
310
Prostatitis?
Ciprofloxacin
311
Middle aged man with cough, green sputum, for 2 weeks and generally unwell for 3 weeks. Smoker 25 years. Obs showed high temp. May have had blood results showing WCC?
Examination had reduced breath sounds, reduced vocal resonance, dullness to percussion all on one side. No CXR results.
What is the diagnosis?
Empyema
312
Gold standard diagnosis of SVCO?
CT chest
313
Erythrema multiforme cause?
HSV type 2
Cytomegalovirus
Epstein-Barr virus
Influenza virus
Vulvovaginal candidiasis
SARS-CoV-2
Mycoplasma pneumoniae
Antibiotics (including erythromycin, nitrofurantoin, penicillins, sulfonamides, and tetracyclines)
Anti-epileptics
Non-steroidal anti-inflammatory drugs
Vaccinations (most common cause in infants).
314
Sudden onset crushing chest pain radiating to back. Blood pressure asymmetry. Father had MI at age 45. Mid diastolic murmur auscultated. ECG shows ST elevation in leads 2, 3 and AVF. Big difference between BP in right and left arm.
What is the most likely diagnosis?
Aortic dissection
315
Patient has ongoing Hypertension.
CT Urinary Tract shows one kidney measured to be 7cm whilst the other one is 11cm.
Which is the most likely?
Fibrodysplasia of renal artery
316
Pyrazinimide?
Hepatotoxic
317
Heart failure diagnosis?
A transthoracic echocardiography (TTE) is the main investigation for the confirmation of heart failure
318
Heart failure treatment?
-Ramipril
-Beta blockers
-Eplerenone 25 mg OD
May be added to ACE and beta-blocker if symptoms persist.
Contra-indicated in hyperkalaemia, hyponatraemia, acute kidney injury.
Entresto (Sacubitril/valsartan) =
319
Heart failure with preserved ejection fraction tx?
SGL2 inhibitor
320
High-resolution CT scan (HRCT) of the thorax (showing a typical “ground glass” appearance)
ILD
321
When should insulin be given in HHS?
Insulin should only be commenced if there is evidence of significant ketonaemia (> 1 mmol/L) or ketonuria (2+ or more). If so, insulin should be commenced as a fixed rate intravenous insulin infusion (FRIII) at 0.05 units/kg/hr (half the dose used in DKA).
322
Menisceal tears mechanism?
Meniscal tears often occur during twisting movements in the knee. In young patients, this often happens when playing sports. With increasing age, the meniscus becomes more prone to injury. Tears can occur with minor twisting movements in older patients (e.g., standing from seated with an awkward twist in the knee).
323
Causes of SIADH?
Post-operative after major surgery
Lung infection, particularly atypical pneumonia and lung abscesses
Brain pathologies, such as a head injury, stroke, intracranial haemorrhage or meningitis
Medications (e.g., SSRIs and carbamazepine)
Malignancy, particularly small cell lung cancer
Human immunodeficiency virus (HIV)
324
Treatment of SIADH?
Fluid restrict
325
Results in SIADH?
Hyponatraemia
Therefore patients with SIADH have high urine osmolality and high urine sodium.
326
Subcutaneous emphysema
Crackles like snow
Air pockets under the skin after surgery
327
Jones Criteria for Rheumatic Fever?
(hx of recent strep infection and 2 major or 1 major + 2 minor)
Major criteria - ‘JONES’
Joints (arthritis)
♡ Heart (carditis)
Nodules
Erythema marginatum
Sydenham’s chorea
Minor criteria - ‘PEACE’
Previous rheumatic fever
ECG with PR prolongation
Arthralgia
CRP and ESR high
Elevated temperature (pyrexia)
328
Menisceal tears?
Meniscal tears often occur during twisting movements in the knee. In young patients, this often happens when playing sports.
With increasing age, the meniscus becomes more prone to injury. Tears can occur with minor twisting movements in older patients (e.g., standing from seated with an awkward twist in the knee).
The initial injury can be accompanied by a “pop” sound or sensation.
Symptoms include:
Pain
Swelling
Stiffness
Restricted range of motion
Locking of the knee
Instability or the knee “giving way”
329
ACL tear
Symptom suggestive of an acute anterior cruciate ligament tear include:
A “pop”
Rapid onset swelling
Instability or giving way
330
De Querveain's tenosynovitis
Presentation
Patients present with symptoms at the radial aspect of the wrist near the base of the thumb. Typical symptoms include:
Pain, often radiating to the forearm
Aching
Burning
Weakness
Numbness
Tenderness
331
How to diagnose carpal tunnel syndrome
Nerve conduction studies are the primary investigation for establishing the diagnosis.
332
Patient with typical SLE features, 3 year history of Raynauds, photosensitivity, positive ANA, clear chest and heart sounds normal, which investigation would you do next?
Urine dipstick
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