Flashcards in High yield Deck (541):
What ages is cervical screening offered to women in the UK?
How often is cervical screening offered to the different age groups?
Age 25-49 - every 3 years
Aged 50-64 - every 5 years
What are the 3 components of cervical screening?
High risk HPV testing
Sampling with cytobrush for liquid cytology
Patient presents with bilateral wheeze and RR of 27/min. Diagnosed with asthma attack, what category of attack is patient suffering?
Acute severe asthma
Requires one of:
PEF 33-50% of predicted
RR above or equal to 25
HR above or equal to 110
Inability to complete sentences in one breath
What name given to the type of technique used to remove skin cancer and assess the cell types
What are the benefits of Mohs surgery over other types of excision?
During the surgery, after each removal of tissue and while the patient waits, the tissue is examined for cancer cells. That examination informs the decision for additional tissue removal.
This allows complete margin control
What is the name of the skin type scale?
Fitzpatrick scale (1-6 white to black)
Gentleman drinks 4 cans of 440ml 7% strength lager a week. Work out the units he drinks in a week
What is the transformation zone of the cervix
Junction between the squamous cells of the exocervix, and the columnar cells of the endocervix
Name 3 enablers of self-management
- preparing in advance
- identifying issues and problems
Collabarative goal setting
- SMART goals
- Soon - within 14 days
Give 4 barriers to self management
Poor family support
What is the most common type of skin cancer?
Basal Cell Carcinoma (BCC)
What is the A-E approach for pigmented skin lesions
Diameter greater than 6mm
Evolution - has it changed over time
What are the 4 domains of childhood development
3 Causes of cerebral palsy
Congenital infection (CMV)
No conception after 1 year of unprotected vaginal sexual intercourse
What key biochemical changes underlie polycystic ovarian syndrome (PCOS)
Primary defect - insulin resistance (acquired / inherited)
Hyperinsulinaemia → amplification of LH production
LH↑ - imbalance of steroidogenesis in ovary → androgens ↑
What cancer are PCOS sufferes more likely to get?
Give 4 contraindications for prescribing the COCP
Smokers aged 35 or more
History of venous thromboembolism
Migraine with aura
Give 4 skin disorders that occur with SLE
What associated condition could cause repeated miscarriages in a woman with SLE?
MOA of warfarin
Decreased synthesis of clotting factors X, IX, VII and II
- via the inhibition of vitamin K epoxide reductase
What is a normal INR range?
Give 2 ECG features of Aortic Stenosis
Taller R waves
Classic triad of symptoms for Aortic Stenosis?
Shortness of breath
What are the negative symptoms of schizophrenia (4)
- Affective blunting
Give the first rank symptoms of schizophrenia
2 Somatic Hallucinations
3 Delusions of Perception
4 Thought insertation, broadcasting, withdrawal
5 Third Party Auditory Hallucinations
6 Thought Echo
If you felt that a patient needed to be sectioned, how could you do this and how long could you keep them for?
Sectioned under section 2 of the MHA. (for assessment)
Can be held for 28 days
What scoring system is used to assess upper GI bleeds?
What test is used to confirm diabetes insipidus?
Water deprivation test
- No water intake for prolonged (4-18hrs) period, Measure body wt, urine output, + composition, No change in water loss after water deprivation indicates DI
Most common cause of breast lump?
Why use Anastrozole in post-menopausal women for treatment of ER+ve breast cancer?
Anastrozole is an aromatase inhibitor.
Post-menopausal woman produce the majority of their oestrogen through aromatase.
4 other differentials to consider with a patient with suspected gout
What common medication can predispose someone to gout?
After what times are Troponin T samples usually taken to identify biochemical evidence of cardiac ischaemia?
At presentation and 6 then 12 hours after onset of chest pain
2 causes of Left Ventricular Failure
What abnormality might be detected on auscultation in a patient with LVF
What are the A-E signs of heart failure on CXR?
Alveolar oedema (bat wings)
Kerley B lines (interstitial oedema)
Dilated upper lobe vessels (Pulmonary venous HTN)
Pleural Effusion (blunting of costophrenic angles)
Give the CENTOR criteria
Absence of cough
Score of 3 or more is suggestive of group b strep infection
Offer penicillin V if that is case
Clinical features of hepatic encephalopathy
Reversal of sleep pattern
Asterixis (Liver flap)
Loss of concentration
6 causes of abdominal distension (6 Fs)
Causes of mitral stenosis
Most common murmur in pregnancy
Mitral stenosis (Mid diastolic murmur)
What ecg signs are seen in right bundle branch block?
M shape in early V leads
W in later V leads
Opposite for LBBB
Triad of nephrotic syndrome
Triad of pre eclampsia
What ejection fraction is suggestive of LVF?
>55 is normal
45-54 is mild LVSD
35-44 is moderate LVSD
What are the 3 types of AF?
Paroxysmal - up to 7 days
Persistent - 7 days - 1 year
Permanent - 1 year+ and resistant to rhythm control
3 main function of liver
Filter: absorbs venous blood via portal vein from GI tract
Excretion: eliminates unnecessary metabolites via bike duct
Metabolism: secretes useful nutrients into circulation via hepatic vein
Underlying pathology of Crohns
Involving whole GI Tracy
A 6 month old child is dehydrated and unconscious due to an accident resulting in burns over their head and upper body. They need urgent fluid replacement, what is your preferred route of access?
A "cut-down" 1.5 cm anterior and superior to the medial malleolus
What is a hydrocoele?
An accumulation of fluid in the tunica vaginalis
What is the likely histological assessment of a biopsied TB lesion?
Wellformed granulomas with caseous necrosis
What blood test would be diagnostic for Haemophilia A
Low plasma levels Factor VIII
Define hallucination, illusion and delusion
Hallucination -A perception experienced in the absence of an external stimulus, in any modality
Illusion - A misperception of a real object/external stimulus
Delusion - A delusion is a belief that is firmly held on inadequate grounds, is not affected by rational argument or evidence to the contrary
How does a second order auditory hallucinations differ from third order auditory hallucinations?
Second person ‐ you are being talked to by the voices
Third person ‐ patient hears voices taling about them and talking about them in the 3rd person
What are the 2 types social of stigma?
Enacted stigma - real experience of -ve attitudes
Felt stigma - Fear that prejudice or discrimination may occur
Define discrediting and discreditable stigma
Discreditable stigma: attribute, condition or impairment not immediate obvious or known by many e.g. mastectomy
Discrediting stigma: obvious and visible attribute, condition or impairment
Describe THREE ways in which dementia can impair decision making capacity, with reference to the capacity criteria specified in the Mental Capacity Act.
1. Dementia can affect short term memory, so the patient may not be able to retain the relevant information.
2. Dementia can affect reasoning processes or judgment and so may affect the ability to understand the relevant information or to weigh the information to make a choice.
(May have a mark for impaired understanding and ability to weigh up, if linked to cognitive impairment/impaired reasoning process).
3. In more advanced dementia, patients may not be able to communicate and so fail the communication criteria in the assessment.
Describe mechanism underlying HbA1C formation
Haemoglobin undergoes glycation in vivo, at a rate proportional to blood glucose concentration
List TWO ways in which diabetes mellitus is atherogenic
Increased oxidative stress
Definition of concordance
A negotiated, shared agreement between clinician and patient concerning treatment regime(s), outcomes and behaviours
Give 3 routine postnatal checks that will be carried out on the mother within 6 hours of birth
Assess volume of blood loss
Contraction of Uterus
What 2 markers are screened for in a HIV test?
What is the time limit for offering Post-exposure prophylaxis
72 hours after exposure
Signs of PE
Low O2 sats
RIsk factors for PE
What is meant by enacted and felt stigma?
Enacted stigma = real experience of negative attitudes or discrimination as a result of having a particular condition
Felt stigma = fear that prejudice or discrimination may occur as a result of having a particular condition
Define terms discrediting and discreditable stigma
Discrediting stigma = obvious & visible attribute, condition or impairment
Discreditable stigma = attribute, condition or impairment not immediately obvious or known e.g. mastectomy
II. Sexual identity/orientation
i. Sexuality = umbrella term relating to private dimension in which people live out their sexual, intimate or emotional desires
ii. Sexual identity/orientation = describes the focus of a person’s sexual attractions & desires
Which area of the brain degenerates in Parkinson's?
Substansia Nigra pars compacta
Three dysmorphic features associated with Trisomy 21
Flat facial profile
Single deep transverse palmar crease
Most common heart defect in Trisomy 21 patients?
Atrioventricular septal defect
Two common conditions associated with Trisomy 21
Obstructive sleep apnoea
What conditions are screend for in the heel prick test?
Inherited metabolic conditions
- Medium-chain acyl-CoA dehydrogenase deficiency (MCADD)
- Homocystinuria (HCU)
- Maple syrup urine disease (MSUD)
- Glutaric Acidemia Type 1 (GA1)
- Isovaleric Acidemia (IV
- Phenylketonuria (PKU)
What do efficacy expectations predict?
- Likelihood of individual’s engagement in activity or behaviour
- Degree to which they will overcome obstacles
- Likelihood of success in achieving and maintaining behaviour change
How can efficacy expectations be enhanced?
o Positive mastery experiences
o Positive vicarious experiences
o Positive verbal persuasion
o Positive emotional readjustment
Define - equitable access
- equal access
Equitable access - is having access to the care that people need
Equal access - is having the same access to healthcare as everyone else
Which organisation should food poisoning be reported to?
Notification of Infectious Diseases
Give 4 signs of derlirium
Euphoric, fearful, angry or depressed (Labile mood)
Illusions, hallucinations, delusions
Reversal of sleep pattern
Explain the breastfeeding method of contraception
To use this method, women must breastfeed exclusively, nursing at least every 4 hours during the day, and at least every 6 hours during the night.
It can be used until one of the following happens: first menstrual period, 6 months postnatal, infants nurse less often
What contraception would you offer to a new mother who is breastfeeding?
Barrier methods (condoms)
Implant can be used 21 day after
Oestrogen containing contraception can interfere with milk production
What is the minimum number of weeks post-delivery at which a cervical smear could be performed and why?
Reschedule cervical screening (unless you think the woman will not re-attend), if the woman:
- Is menstruating.
- Is less than 12 weeks postnatal.
- Has a vaginal discharge or pelvic infection — treat the infection and take the sample on another occasion.
This is because of inflammatory changes during pregnancy making a smear test difficult to interpret
Describe the characteristic appearance of Neisseria gonorrhoea when it is Gram stained and viewed under the microscope
gram-negative intracellular diplococci on microscopy
Give two features to identify small bowel on AXR
Valvulae conniventes - mucosal folds that cross the full width of the bowel
Describe the FRAMES model of alcohol interventions
Feedback: Give patient honest and feedback on their subtance misuse, including risks and negative consequences
Responsibility: Make it known they need to take responsibility for the use of alcohol
Advice: Honest straightforward advice on how to cut down
Menu: Options availble to help cut down
Empathy: Be empathetic and non- judgemental
Self-Efficacy: Express optimism that the individual can do this
What is the most common motor disorder in childhood?
Give some examples of developemental milestones in each domain a 12 month old should have reached
Gross motor: Straight back sitting (9 months)
Fine motor/vision: Mature pincer grip
Speech/language: Understands common words
Uses one or two words
Social: Seperation anxiety
Dependence on parental figure
Definition of anxiety
A state of apprehension, uncertainty or fear, resulting from the anticipation of a realistic or imaginary threatening event or situation
Definiton of mental health
A state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.
What are the 6 primary emotions?
What diagnostic criteria should be used in suspected IBS?
Rome IV criteria
What biomarker should be checked in suspected IBS to rule out other organic causes to symptoms?
Anti TTG (rule out coeliacs)
Anti endomysial Ab (rule out coeliacs)
Faecal calprotectin (can help rule out IBD)
Faecal elastase (rules out pancreatic exocrine insufficiency)
Abnormal passage of loose of liquid stools
More than 3 times daily
A volume of stool >200g/day
What type of diarrhoea does cholera infection cause?
Secretory diarrhoea caused by toxins
Gastroenteritis e.g. any 2 of …
2. abdominal pain / colic
3. nausea / vomiting
4. fever / myalgia / headache
Give 3 causes of viral gastroenteritis
Give 3 causes of bacterial gastroenteritis
Describe Xray appearance of RA
Loss of joint space
Soft tissue swelling
Soft bones (osteopenia)
Describe Xray appearance of OA
Loss of joint space
Give 4 extra-articular features of RA
Eyes: episcleritis, scleritis,
Heart & lungs: effusions, fibrosis, nodules
Skin & soft tissues: Rheumatoid nodules, vasculitis, rashes
Systemic: Weight loss, fever, fatigue
What biochemical markers would you check in a patient with suspected RA and why?
Rheumatoid factor as it is present in 70% of RA patients
Anti -CCP antibodies(most specific test for RA)
Give 3 broad management options for RA
How can you differentiate between inflammatory and non-inflammatory causes of joint pain?
Inflammatory causes of joint pain present with:
- Morning stiffness that should relieve with activity due to natural increases in cortisol levels through day
- Warmth over affected joint
Non-inflammatory causes of joint pain present with:
- Worse at end of day due to wear and tear aspect
- Relieved by not using structures involved
- Restriction of movement
• Premalignant condition
• Increased cell growth
• Cellular atypia
• Altered differentiation
What is clonality?
Tumours develop from a single cell – they form a monoclonal population arising from a single cell.
If clonality can be proved, this is strong evidence for neoplasia
New abnormal growth of cells which persists after initiating stimulus has been removed
What is the key feature distinguishing between cancer and in-situ malignancy?
No invasion through basement membrane
Does have all other features of malignancy
- Epithelial neoplasm with features of malignancy
- Altered cell growth
- Cytological atypia
- Altered differentiation
Abrupt loss of kidney function over a period of hours to days
Creatinine >120micromols/L (normal 60-120)
What is the RIFLE criteria?
It is a classification of AKI
Risk Creatinine 1.5-2x baselines
Loss (>4 weeks)
ESRD (>3 months)
Give the 3 causes of anuria
Severe acute glomerulonephritis
What complications may occur from an AKI?
Short-term treatment for hyperkalaemia
10% Calcium gluconate (10mL) to stabilise cardiac membrane
Drive K+ into cells with 10 units insulin (Actrapid) in 50mL 20% glucose
Give 4 causes of hyperkalaemia
Drugs (ACEi, NSAIDs, ARBs)
Iatrogenic (over replacement in fluids)
Haemolysis of sample
Describe ECG changes seen in hyperkalaemia
Tall tented T waves
Flattened P waves
Broad QRS complexes
What are the 3 types of AKI and give a cause of each
Pre renal - Inadequate renal perfusion due to NSAIDs
Intrinsic - Glomerulonephritis
Post-renal - Stones
The extent to which a person's behaviour corresponds with agreed recommendations from a health care provider
The fulfilment by the patient of the healthcare professional’s recommended course of treatment
Describe 2 effects of poor concordance
Poor treatment outcomes for patients
Increased financial burden with excess urgent care visits
What 5 patient centred factors influence concordance?
Demographics - Adolescents have poor concordance
A variable period between childhood and adulthood between 10-20 years of age characterised by rapid development in psychosocial domain
Describe how risk taking is linked to brain development in adolescence
Risk taking is normal part of adolescence
Disparity in maturation of limbic system and prefrontal cortex
Early development of limbic system leads to pleasure seeking, reward processing, sleep regulation
Protracted development of prefrontal cortex leads to redcued ability to control impulses and plan for future
Why is self management challenging in adolescents?
They are working towards independence and autonomy
Developing new relationships with peers, family and clinicians
New environments and activities
Define a rough sleeper
People sleeping, about to bed down (sitting on/in or standing next to their bedding) or bedded down in the open air.
People in buildings or other places not designed for habitation
Define statutory homeless
Someone who is eligible for public funds/has a local connection/unintentionally homeless AND have a priority need:
• A household with dependent children
• A household with a pregnant woman
• Vulnerable because of physical or mental health
• Aged 16 or 17 or aged 18-20 and previously in care
What is a sofa surfer?
Someone staying with family or on a friends sofa
What are the routes into homelessness?
Welfare changes - reducing access to private rented sector. Cuts to legal aid, social housing etc.
Lack of affordable housing
Lack of new builds
Closure of longterm psych hospitals
Which antipsyhotic is associated with agranulocytosis?
What is the bishops score? What is it used for?
The Bishop Score assessing cervical favourability and it is the most commonly used method to rate the readiness of the cervix for induction of labor.
Score of abover 8 is good for induction and a score below 6 is an unripe cervix for induction
What is normal range of variability on a CTG?
5-25 bpm is seen as reassuring
How to read a CTG (acronym)
DR C BRAVADO
DR – Define Risk
C – Contractions
BRa – Baseline Rate
V – Variability
A – Accelerations
D – Decelerations
O – Overall impression
Give some reasons to classify a pregnancy as high risk
Normal foetal heartrate?
When are foetal decelerations normal?
Decelerations start with uterine contractions and quickly resolve after
Theses are normal and are known as early decelerations caused by increased vagal tone due to increased pressure on the head
What is the sepsis 6?
Give high flow oxygen
Take blood cultures
Give empirical antibiotics in line with trust guidelines
Measure serum lactate
Monitor urine output
Which types of HPV are associated with cervical cancer?
HPV 16 and 18
Who is the HPV vaccine offered to?
12-13 year old girls
What part of the cervix do most cervical cancers arise from?
Transformation zone at region between endo and ecto cervix
What period in days (ha) does the secretory phase of menstruation occur?
Define primary amenorrhoea
- No menstruation by age 14 with failure of development of secondary sexual characteristics
- No menstruation by age 16 with normal development of secondary sexual characteristics
Define primary and secondary dysmenorrhoea
1o - Pain in absense of pelvic pathology, occuring during menses
2o - Pain associated with pelvic pathology, typically starting before menstruation
Menorrhagia is excessive menstrual bleeding over several consecutive cycles that interferes with the woman's physical, emotional, social, and material quality of life.
What is the treatment for fibroids called?
Give 4 common effects of housing on health
Cold - results in excess winter deaths
Overcrowding - Leads to communicable diseases, stress and poor educational attainment
Damp & mould - Resp. infections, allergies, asthma
Structural - lighting, stairs, rails - leads to accidents
Ongoing collection, collation and analysis of data in preparation for action
Why is surveillance needed?
Monitor trends, early warning for outbreaks, can plan and monitor interventions better
Who does what in communicable disease control?
Public health england - Legal obligation to take notifications and manage outbreaks
NHS - Lead and coordiante NHS response
CCGs - Support NHS england and trusts
PCTs - Support ix and management through taking samples and organising treatment
Hospital trusts - Provide microbiological advice regarding single cases of outbreaks
Local Authorities - Environmental health officers support ix of certain outbreaks which may have an environmental source. They can prosecute
Define the concepts Agent:Host factors:Environment in relation to spread of infectious diseases
Agent = the thing causing disease (virus/bacteria/fungi)
Host factors = factors that control whether you become infected and how you respond to infection. e.g. sexual behaviours, diet, age, gender
Environment = Crowding, surroundings, sanitation, availability of health services
Give 3 direct and 3 indirect modes of transmission
Direct - touching, sex, faeco-oral
Indirect - Vehicle, vector e.g. malaria, airbourne
What are the stages in managing an outbreak?
1) Confirm (verify diagnosis)
2) Immediate control
3) Convene an outbreak control team
4) Review epidemiological and microbiological info.
5) Case finding
6) Descriptive epidemiology
7) Analytical study (case control or cohort)
8) Declare outbreak over
9) Communication throughout
With regards to communicable disease define sporadic
Occasional cases at irregular levels
With regards to communicable disease define endemic
Persistent low or moderate levels
With regards to communicable disease define hyper endemic
A higher persistent level
With regards to communicable disease define cluster
Occurance exceeds expected level: may be a possible link
With regards to communicable disease define outbreak
Localised epidemic: 2+ cases or a single case of rare disease
With regards to communicable disease define Pandemic
Epidemic occuring worldwide affecting large amounts of people
With regards to communicable disease define Epidemic
Occurance exceeds expected level: high probable or confirmed link
What are the different types of epidemic curve?
Point - suggests cases may be from a single event
Propagated - Begins like an infection from an index case but develops into a epidemic which propagates larger and larger
Continuous - Here exposure continues over a longer time so outbreak persists for longer
Name the top 3 mental health disorders that account for the most DALYS globally
Depression and anxiety
Alcohol and drug use disorders
SCZ and BPD
What is the most common mental health problem among men and women in europe?
M: Alcohol use
Give 4 factors that influence physical health of people with mental illness
Lifestyle - more likely to smoke, drink, have HTN/DM
Poor access to healthcare - Less compliance, difficulty understanding
How do you work out Mean Arterial Pressure (MAP)?
MAP = 1/3 * SBP + 2/3 * DBP
Give the equation for ejection fraction
EF = (SV / EDV) ⋅ 100
Describe the phases of cardiac conduction
Phase 0 (Depolarisation) - Rapid Na+ influx
Phase 1 (Early repolarisation) - Transient efflux of K+
Phase 2 (Plateau phase) - Slow influx of Ca 2+ and continues efflux of K+
Phase 3 (Repolarisation) - Ca2+ channels close but continued K + efflux returns TMP to -90mV
Eventually normal ionic concentrations are restored via Na+/K+ ATPase, Na+-Ca2+ exchanger and Ca2+-ATPase
Phase 4 (Resting phase) - Constant slow leak of K+ out of cell but Na+ and Ca2+ channels are closed
Give some causes of anaemia of chronic disease (4)
Aetiology of aplastic anaemia
Pancytopaenia (deficiency of all cellular blood elements)
Aplasia (hypocellularity of bone marrow)
Aplastic refers to inability of the stem cells to generate mature blood cells
Give 4 causes of haemolytic anaemia
Haemoglobin abnormalities - Thalassaemia/sickle cell
Metabolic defects e.g. Glucose-6-phosphate dehydrogenase deficiency
Immune e.g. Autoimmune haemolytic anaemia, Haemolytic transfusion reactions
Paroxysmal nocturnal haemoglobinuria
Clinical features of aplastic anaemia
Increased infections due to low WCC (esp oral infections)
Bleeding (e.g. gums, epistaxis) / bruising as low platelets
How does CKD lead to anaemia?
CKD leads to a reduction in production of EPO which gives as a result normocytic normochromic anaemia
What is a direct coombs test?
Direct Coombs’ test: identifies RBCs coated with antibody/complement and a positive result ususally indicates an immune cause to anaemias
What is an indirect coombs test?
The indirect Coombs test is used to detect in-vitro antibody-antigen reactions. It is used to detect very low concentrations of antibodies present in a patient's plasma/serum prior to a blood transfusion.
3 causes of iron deficiency anaemia
What Ix would you do for suspected iron deficiency anaemia?
FBC: Hb↓ MCV↓
Blood smear: microcytic, hypochromic RBCs
Iron studies: Serum ferritin ↓ Serum Iron↓
A 62 year old gentlemen presents with new onset anaemia and weight loss, what is your management?
As he is over 60 and has some cancer symptoms he should be referred via 2ww
Also consider 2ww referral if aged under 50 with rectal bleeding
AND Iron deficiency Anaemia symptoms
Pathophysiology of pernicious anaemia
Autoimmune condition where there is atrophy of the gastric mucosa, with failure of Intrinsic Factor (and acid production) → B12↓ absorption.
What would the LFTs show in a pre-hepatic cause of jaundice?
Unconjugated bilirubin - Increased
AST/ALT - Normal
ALP/GGT - Normal
What would LFTs show in a post-hepatic cause of jaundice?
Conjugated bilirubin - Increased
AST/ALT - Slight increase
ALP/GGT - Large increase
Describe pathophysiology of cirrhosis
- Entire liver architecture disrupted
- Portal portal & portal-central bridging fibrosis
- Nodules of proliferating hepatocytes surrounded by fibrosis
- Vascular relationships lost abnormal communication resulting in portal and arterial blood bypassing hepatocytes
Clinical features of anterior uveitis
Dull pain in orbital region
↓ visual acuity
Synechiae (iris adherence to cornea or lens)
Give 4 causes of anterior uveitis
Seronegative arthropathies e.g. IBD, sarcoidosis
How could you differentiate between bacterial, viral and allergic conjunctivitis?
Eye discharge is more watery in viral conjunctivitis
Purulent discharge is more likely bacterial
Allergic often has ropy mucoid discharge with itching as the main symptom
What is angle-closure glaucoma?
Angle-closure glaucoma (ACG) is a group of diseases in which there is reversible or adhesional closure of the anterior-chamber angle resulting in elevation of the intra-ocular pressure (IOP).
In the acute form, the IOP rises rapidly as a result of relatively sudden blockage of the trabecular meshwork by the iris, via the pupillary block mechanism.
Management of PCOS
COCP if not wishing to conceive
• Dianette if hirsutism
Clomiphene citrate to induce ovulation if wishing to conceive
Metformin to control insulin resistance
Give 4 causes of menorrhagia
Management of menorrhagia
Correct iron deficiency
NSAIDs - mefanamic acid for pain
Antifibrinolytics - tranexamic acid
Surgical ablation/removal of fibroids (myomectomy)
Define cerebral palsy
A primary abnormality of movement and posture secondary to a non-progressive lesion of developing brain.
What is autistic spectrum disorder?
A developmental disorder characterized by difficulties in social interaction and communication and by restricted or repetitive patterns of thought and behaviour.
Experiencing events that are perceived as endangering one’s physical or psychological well-being. The events are known as stressors and the result as the stress response
What are the 4 broad manifestations of anxiety?
Physical e.g. chest tightness
Affective e.g. panic, terror
Cognitive e.g. worry, apprehension
Behavioural e.g. avoiding triggers
MOA of copper coil
Prevention of fertilisation (cu effect on ova and sperm)
Cu effect on cervical mucus reduces sperm penetration
Endometrial inflammatory reaction prevents implantation
What happens to LH and FSH levels after menopause?
Increase due to less -ve feedback from oestrogen
What are the signs of menopause? (low oestrogen)
Loss of keratin
What is the indication for prescribing HRT?
Reducing vasomotor symptoms is the only correct indication
Can you start HRT while still having periods?
Yes it will regulate them
What are the risks of HRT
- Increases with age and duration of use
- Most in year 1. May be less for patches
- Very low risk
Coronary heart disease
- Only combined HRT
Benefits of HRT
May reduce risk of CHD
Reduce colorectal cancer risk
Biological stage in a woman’s life when menstruation ceases permanently due to the loss of ovarian follicular activity.
- Mean age in UK 51 years
What is premature ovarian failure?
Menopause before the age of 40 years
Why do women get hot flushes?
Narrowing of the thermoneutral zone
Contraindication for oestrogen only HRT?
Women with a uterus unless used in conjunction with a mirena coil (Alone it can increase risk of endometrial cancer)
What type of HRT should be offered if women have had a period in the last year?
Cyclical HRT (combined progesterone and oestrogen)
When can you offer continuous HRT?
If a woman hasn't had a period in a year post menopause
CI for HRT
History of Pulmonary Embolism
Abnormal liver function tests
Blood pressure of 180/98
Give 4 causes for male LUTS
What are 3 red flag symptoms for LUTS
Recent severe symptoms
Palpable bladder and nocturnal incontinence – high pressure chronic retention
Abnormal U&Es and PSA
3 types of LUTS
Voiding - poor flow, hesitancy
Storage - frequency, urgency, incontinence, nocturia
Post-micturition - dribbling
Treatments for LUTS
Voiding - Alpha-blockers (tamsulosin)
Storage - Beta agonist (mirabegron)
Post-mict - Urethral milking, pelvic floor exercises
Treatment for acute urinary retention
Catheter (via urethra or suprapubic)
Give 3 differentials for a painless/minimally painful scrotal swelling
Investigations for suspected testcular tumour
USS of testes
Tumour markers - beta-HCG and alpha fetoprotein (AFP)
Staging CT of chest, abdomen and pelvis
Management of testicular cancer
Radical orchidectomy with or without prosthesis
Differentials for acute painful scrotum
Testicular torsion until proven otherwise.
Torsion of hydatid of Morgagni
Idiopathic scrotal oedema
Management of epididymorchitis
Give 4 causes of haematuria
What investigations would you carry out for a patient with haematuria?
- Urine analysis (dipstix, culture, cytology)
- FBC, U&Es, PSA, clotting
- CT urogram (US)
- Flexible cystoscopy
Risk factors for TCC of bladder
Benzene compounds exposure
Drugs (cyclophosphamide, phenacetin)
Management of TCC
Transurethral resection of bladder tumour (TURBT)
Installation of mytomycin C
Staging for muscle invasive tumours
Radiotherapy or cystectomy for muscle invasive
Pallative chemo if metastasised
What are the age related cut offs for PSA
70 and over >5.0
When should you refer for suspected prostate cancer?
If PSA is markedly raised
DRE shows irregular, hard prostate (arrange PSA so he can take results with him to referral)
What grading system is used for prostate cancers?
The Gleason score is used to classify the pattern of tumour growths found in prostate specimens.
The Gleason score is the sum of the two most common patterns of tumour growth. It ranges between 6 and 10 — that is, between (3 + 3) and (5 + 5).
Differentials for chronic headache
Tenion headache - bilateral non-pulsatile headache without vomiting
Raised ICP - Worse on waking, lying or bending forwards
Medication overuse - Common culprits are paracetamol and codeine
Differentials for acute headache
Meningitis - if meningism is present
Subarachnoid haemorrhage - worst ever headache, stiff neck, focal neuro signs
Head injury - pain at site of trauma
Sinusitis - Dull ache over sinuses with tenderness an post nasal drip
Acute glaucoma - Typically in elderly long sighted people, constant aching pain develops around one eye
If suspicious, refer for head CT to rule out severe causes.
Symptoms of migraine
Visual or other aura lasting 15-30 mins followed by severe unilateral throbbing headache or isolated aura with no headache
Triggers for migraine
Chocolate, cheese, wine, alcohol, lie-ins
Treatment for migraine
NSAIDs, Triptans, prevention with B2 blockers or tricyclis
What must be excluded in anyone >50 with subacute onset headache?
Giant cell arteritis
- Tender, thickened, pulseless temporal arteries, jaw claudiation with raised ESR.
Requires prompt steroids to avoid blindness
What is sensitivity and how do you calculate it?
Sensitivity is the probability that a test will indicate disease among those with the disease
What is specificity and how do you calculate it?
Specificity is the proportion of people who do not have the disease that the test correctly identifies as not having the disease
TN/(TN + FP)
What is PPV and how do you calculate it?
The probability that a person has the disease given that they have had a positive test result
TP/(TP + FP)
What is NPV and how do you calculate it?
The probability that a person does not have the disease given that they have a negative test result
TN/(TN + FN)
Give the Wilson and Junger criteria for screening
1. Condition important health problem
2. Treatment available
3. Facilities for diagnosis and treatment should be available
4. Should be latent stage of the disease
5. Should be a test/examination for the condition
6. Treatment acceptable to the population
7. Natural history of disease should be adequately understood
8. Agreed policy on who to treat
9. Should be cost effective
10. Case-finding should be a continuous process
What are the main services offered by Coventry MIND?
Support at home to address mental health and daily living needs
Recovery and development groups
What is social stigma?
Attributes, behaviours or pathological states that in some way sets a person apart from others and marks them as less acceptable or inferior
What are the top 3 infectious disease categories?
1. Respiratory infetions
2. Diarrhoeal diseases
Give 4 risk factors for HIV (many)
Sex after alcohol/drugs
Having another STI
Blood transfusion before 1985
Living in a country with high HIV prevalence
Males who have sex with males
Mother with HIV before birth
Global risk factors for infectious disease
Under-resourced healthcare services
Access to clean water
What piece of legislaton prevents discrimination in the workplace for LGBTQI persons
Equalities act (Sexual orientation) 2007
Teen pregnancy is associated with - ?
Describe trends in common STIs
Chlamydia is most common
Syphillis and Gonorrhoea are on the rise
Large STI diagnosis increase in MSM
Explain the increase in STIs
Increase young people having sex
Easier service access
Why should you notify partners of patients with STI?
Protect partner from reinfection
Offer partner STI tests
Inhibit further spread
What important factors from a Hx do you want to ask a patient presenting with jaundice?
GI symptoms - stool and urine colour, weight loss
Hepatitis risk factors - tattoos, travel, sexual hx
What is the most sensitive blood test of synthetic liver function?
Why might PT/INR increase in a jaundiced patient?
– Failure of synthetic function
– Failure of absorption of Vitamin K due impaired bile salt
excretion into gut by biliary obstruction
What is the key investigation for jaundice?
What is Courvoirsier's law?
This states that in the presence of a palpably enlarged gallbladder which is nontender and accompanied with mild painless jaundice, the cause is unlikely to be gallstones.
What is weight loss?
Weight loss of at least 5% of the patient’s usual body
weight that occurs within the preceding 6-12 months
A patient presents with weight loss, give 4 questions you would ask to narrow differentials
Quantify the weight loss
Intentional or unintentional
Change in bowel habits
What tool is used for patients at risk of malnutrition?
Malnutrition Universal Screening Tool (MUST)
Give 4 differentials for weight loss with poor appetite
GI inflamation e.g. IBD
Systemic infection e.g. HIV
Give 4 differentials for weight loss with normal appetite
Malabsorption e.g. Coeliacs
Endocrine e.g. Diabetes
Give 4 causes of malabsorption in the small intestines
What are the complications of Coeliac's?
Enteropathy-associated lymphoma (intestines)
Osteoporosis the leading to fractures
Small bowel and oesophageal carcinoma
Oesophageal carcinoma risk factors
What investigations would you perform in suspected oesopheageal cancer?
0 FBC, U&Es, LFTs
Imaging and special tests
0 OGD ± biopsy / barium swallow
0 Staging CT / staging MRI/PET scan
When should you refer patients for suspected colon cancer using 2ww?
40 or over with unexplained weight loss and abdo pain
50 or over with unexplained rectal bleeding
60 or over with
- Iron-deficiency anaemia or
- Changes in bowel habit
What is pernicious anaemia?
Common haematological condition characteriseby
autoimmune destruction of the parietal cell and intrinsic
factor resulting in severe VITAMIN B12 deficiency.
Treatment of pernicious anaemia
Treatment is with IM injections of hydroxycobalamin 3x weekly for 2 weeks then every 3 months
What PMH do you want to find out in a sexual history?
LMP if female
Last smear if >25 and female
Definition of dysuria
Painful voiding of the urinary bladder
Potential causes of dysuria
What is the most common causative organism in a UTI
What Ix would you like to do for a patient with dysuria?
Management of UTI
Uncomplicated - Trimethoprim or Nitrofurantoin
Complicated - Co-amoxiclav
If a patient has an indwelling catheter can you diagnose a UTI from dipstick?
No as all catheters become colonised with bacteria so urine samples are always +ve for bacteria
Differentials for genital discharge
- Thrush (Candidiasis)
- Retained foreign body
What is the Amsel criteria?
A criteria for diagnosisng BV wth 3 indicating BV
White adherent discharge
+ve whiff test
Vaginal pH >4.5
Treatment for Chlamydia
Treatment for Gonorrhoea
Treatment for BV
Differentials for genital ulcers
Herpes simplex 2 HSV2
What are some AIDS defining illnesses
Chronic HSV infection
Lymphoma due to EBV
What is melana?
Dark black, tarry feces that are associated with upper gastrointestinal bleeding.
The black color and characteristic strong odor are caused by hemoglobin in the blood being altered by digestive enzymes and intestinal bacteria
Management of H. Pylori
Triple therapy advised
Omeprazole, metronidazole, clarithromycin
Advise patient to stop smoking
Re-endoscope at 6 weeks to check for resolution of ulcer
3 causes of an oesophageal bleed
3 causes of a bleed from the stomach
Management of piles
Cons - High fibre diet, laxatives, analgesia, avoid strain
Medical - Injecton sclerotherapy
Surgical - Haemorrhoidectomy, arterial ligation
What is diverticular disease?
Colonic diverticulosis refers to herniation of mucosa and submucosa through the muscular layer of the colonic wall (outpouching).
What important factors would you like to gather in a history of a patient with dysphagia?
Pain on swallowing (odynophagia)
Regurgitation of food
Any weight loss
What are the 3 phases of swallowing?
Buccal - voluntary
Pharyngeal phase - involuntary
Oesophogeal phase - involuntary
Give 4 causes of dysphagia
What ix would you do for dysphagia?
Bloods - FBC U+Es
Staging CT scan
What are ALARM features for patients with GORD?
Evidence of GI blood loss
Unexplained weight loss
Upper abdo mass
Any of these means patients need to be referred to hospital specialists
Management of GORD
Cons - MDT, stop smoking, reduce alcohol, reduce weight
Medical - Antacids, PPIs, H2 receptor antagonists, ?H. Pylori eradication
Surgical - Nissen fundoplication
How would you explain an OGD to a patient
- Fasting for at least 4 hours
- Procedure will take 5-15 mins
- If you need to be sedated you will need someone to accompany you home
Risks and benefits
- Diagnosis of your condition
- Helps us guide treatment
What is Barrett's Oesophagus?
Occurs as a result of acid reflux
Causes metaplasia of squamous cells to columnar cells
Associated with increased risk of malignancy
What is Achalasia?
• Impaired relaxation of LOS
Leads to intermittent dysphagia to both solids and liquids.
Management of achalasia
Endoscopic balloon dilatation
What are the treatments for asthma (ladder) in adults
Step 1: Inhaled short-acting B2 agonist
Step 2: Add inhaled corticosteroid
Step 3: Add long-acting B2 agonist
Step 4: Increase inhaled steroid or add a 4th drug e.g. leukotriene receptor antagonist
Step 5: Daily steroid tablet but consider treatments to avoid steroid use
What defines moderate asthma?
PEF >50-75% best or predicted
No features of acute severe asthma
Features of acute severe asthma
Any one of:
PEF 33-50% best or predicted
Respiratory rate >/=25/min
Heart rate >/=110/min
Inability to complete sentences in one breath
Features of life-threatening asthma
In a patient with severe asthma any one of:
PEF <33% best or predicted
Poor respiratory effort
How would you initially assess an critically unwell or deteriorating patient?
2 gross motor milestones that should be reached by age 6 months
Any 2 from:
Little or no head lag on being pulled to sit
Lying on abdomen, good head control
Held sitting, lumbar curve
Lying on abdomen, arms extended
Lying on back, lifts and grasps feet
Pulls self to sitting
Held sitting, back straight
Rolls front to back
What is stridor?
Stridor is a high-pitched breath sound resulting from turbulent air flow in the larynx or lower in the bronchial tree. It is caused by a narrow or obstructed airway.
What criteria are used to diagnose PCOS?
Give one complication of pregnancy that PCOS sufferers are more likely to develop
What blood test can be used to identify Antiphospholipid syndrome
Anti cardiolipin antibodies OR lupus anticoagulant
Name 2 causes of aortic stenosis
Rheumatic heart disease
Bicuspid valves (genetic defect)
Define a TIA
A TIA is a sudden, focal, neurological deficit of vascular origin that lasts less than 24 hours
Where is folic acid absorbed?
What can cause folate deficiency?
How are bacteria classified?
Classified on gram stain and shape
Gram = +ve or -ve
Shape = coccus or bacillus/rod
What scoring system do you use for a patient with community accquired pneumonia?
Resp. rate >30/min
BP <90 systolic or <60 diastolic
Age 65 or over
Score of >1 admit
>2 then IV treatment
Give 3 mechanisms or antimicrobial resistance
Alternative metabolic pathways
What is horizontal gene transfer?
Horizontal gene transfer is the process of exchanging mobile non-chromosomal genetic material such as plasmids between ‘unrelated’ individual bacterial cells
What is vertical gene transfer?
Vertical gene transfer is the passing on of genetic information as part of the process of reproduction – in bacteria, the chromosomal genetic information is replicated prior to cell division
What are the 3 ways in which horizontal gene transfer can occur?
Transformation: the uptake of short DNA fragments from the surrounding medium without direct cell-cell contact
Transduction: where DNA is transferred from one bacterial cell to another by bacteriophage, viruses that infect bacteria
Conjugation: which involves transfer of DNA from one bacterium to another by direct cell-cell contact
What is antimicrobial stewardship?
Using the minimal possible antibiotics in a hospital
Using the cheapest antibiotic that will be effective
Not giving antibiotics to someone with a viral illness
Making antibiotic decisions based on the best evidence
Restricting antibiotic prescribing to “antibiotic stewards”
Stopping antibiotics being available over the counter
Finishing the course of an antibiotic
Top 3 leading risk factors of death by sex
F: Stroke, IHD, LRTI
M: IHD, Stroke, COPD
Top 3 risk factors globally
HTN, tobacco, high cholesterol
How has the demographic transition affected the population pyramid?
Less of a pyramid and more of a diamond shape with a shrinking base and a growing top
What are the differences between population and high risk strategy for reducing cardiovascular disease? (Think upstream downstream from 1st year)
- Attempts to control determinants of incidence rather than cases
- Population based
- More radical
- More permanent
High risk strategy
- Extension of traditional clinical approach
- No lasting change
- Repeated from generation to generation
Give the 3 main drivers of increasing cardiovascular disease in developing countries
- Shift from simple to processed foods
- Increase in fat production and consumption
- Rise of cards
- Rise of obesity
What are the different approaches to reducing salt intake? Which is most effective?
Regulation and market control (most effective)
Primary care (least effective)
Define inequity in healthcare
When people with the same needs do not have the same level of access to the services they require
Define inequality in healthcare
It is the systematic differences in health and illness across social groups
Why should inequity in healthcare be addressed?
Principles of justice and fairness
Determinant of health inequalities
Duty under equalities act 2010
Give 4 causes of inequitable access
Cultural - lack of interpreters, preferring same sex HCP
Clinician beliefs and attitude
Navigating through health and social care system
How can barriers to access be reduced? (4 of many)
Driven from health needs assessment
Reducing physical and geographical barriers
Clinician shift to shared decision making
Reduce cost to individual
Reduce varition in service quality
5 main function of the kidney
Filtration - remove urea/creatinine
Regulation of ECF components
Electrolyte balance - Na+/K+
Endocrine function- RAAS
Give 3 causes of primary nephrotic syndrome
Minimal change glomerulonephritis
Focal segmental glomerulosclerosis
Give 3 causes of secondary nephrotic syndrome
Hep B and C
Give 2 causes of nephritic syndrome
Give 5 common nephrotoxic drugs
NSAIDs - Inhibit vasodilatory PGs in afferent arteriole
ACEi - reduce BP and dilate efferent arteriole
Gentamicin - Directly cytotoxic
What is oliguria?
<0.5 mls/Kg/hr of urine
What is anuria?
0ml/day - <100mls/day
What needs to be excluded before a diagnosis of anuria can be made?
General management of AKI
Stop nephrotoxic drugs where possible
Monitor creatinine, sodium, potassium, calcium, phosphate, glucose
Identify and treat infection
Optimise fluid balance
Urgent relief of urinary tract obstruction
Refer to a nephrologist
Identify and treat acute complications
Referral to a nephrologist where indicated
What is CKD?
Gradual loss of kidney function that occurs over months to years
What can be found in urine that can help confirm multiple myeloma?
Describe the path of the common iliac down to the foot
Common iliac splits into external and internal iliac vessels
External iliac becomes common femoral at the inguinal ligament
The common femoral splits into profunda femoris and superficial femoral artery
Superfical femoral artery becomes popliteal artery as it passes the adductor hiatus
This gives off the anterior tibial artery in the popliteal fossa and then continues as the tibioperonial trunk
This then bifurcates into posterior tibial and peronial (fibular) arteries
If a patient present with claudication in the gluteal muscles what level is the blockage present at?
What medications may indicate patient is at risk of peripheral vascular disease?
DDx of an acute cold leg
Thrombosis of aneurysm
DDx of an acute warm leg
Give 4 signs of PVD
Reduced muscle bulk
Describe the characterisitics of an arterial ulcer
Often found at toes, feet or ankles
Punched out well defined edge
Describe characteristics of a venous ulcer
Commonly found at medial gaiter region
Edges poorly defined
Haemosiderin deposits around wound
Can be large
What would an ABPI value of >1.3 suggest?
Calcification of vessel
Give the 6 Ps of ischaemia
Give the 5 initial steps to halt bleeding after an injury
vWF binds to surrounding collagen
Adhesion and aggregation of platelets
Platelets release ADP and TxA2
Activation of clotting cascade to create a fibrin clot
What is haemophilia A?
A hereditary clotting disorder caused by deficiency in factor VIII
Most common haemophilia
X linked recessive so affects boys more than girls
What blood tests results would you see in a patient with haemophilia A?
Elevated APTT with normal PT & vWF levels
What is the treatment for haemophilia A?
Factor VIII infusion either prophylactically or at time of bleeding
What is haemophilia B?
A herediatary clotting disorder caused by a deficiency in factor IX
X linked recessive
Also known as Christmas disease
What is Disseminated Intravascular Coagulation (DIC)?
Mixture of initial thrombosis due to
– Generation of fibrin in vessel walls
– Activation of coagulation
Then bleeding tendency due to consumption of coagulation factors and fibrinolytic activation
3 causes of DIC
– Haemolytic transfusion reactions
– Liver disease
Rx for DIC
No treatment unless bleeding
Treat underlying cause
Can use packed RBCs, Plt transfusion and FFP/cryo if bleeding
What is the Well's criteria for PE?
Objectifies risk of PE
Clinical signs and symptoms of DVT (+3)
PE is #1 diagnosis or equally likely (+3)
HR >100 (+1.5)
Immobilisation for at least 3 days or surgery in past 4 weeks (+1.5)
Previous objectively diagnosed PE or DVT (+1.5)
Malignancy w/ treatment within 6 months (+1)
<2 points consider D-dimer to rule out PE
2-6 consider D dimer
>6 consider CTPA D-dimer not needed
Diagnostic criteria for Antiphospholipid syndrome
• Lupus anticoagulant or;
• Anticardiolipin antibody or;
• Anti-b2-glycoprotein I antibody
On two or more occasions at least 12 weeks
When would you use thrombolytics?
• STEMI, if PCI not available within 90- 120mins
• Massive PE
• Ischaemic stroke
• Streptokinase (derived from bacteria, risk of allergic reaction)
• Alteplase, reteplase (recombinant tissue plasminogen activators)
When would you use anti-platelet drugs?
• Aspirin – COX inhibitor
• Clopidogrel – targets platelet ADP receptor
• Abciximab - GpIIb/IIIa inhibitor
• Ticagrelor (STEMI) – platelet aggregation inhibitor (P2Y 12 receptor antag)
When would you use anticoagulants and give some examples
• Warfarin – coumarin (PO)
• LMWH (+MI) (SC) e.g. enoxaparin, tinzaparin, dalteparin
• Unfractionated heparin (IV) – risk of heparin-induced thrombocytopenia
• Dabigatran – direct thrombin inhibitor
• Rivaroxaban, apixiban – DOAC (direct factor Xa inhibitor)
What complications can arise from obesity?
Metabolic complications – type II diabetes, with insulin resistance, hyperlipdaemia, ischaemic heart disease
Physical complications – increased osteoarthritis, particularly hips and knees, varicose veins, hermias, obstructive sleep apnoea
Hepatic complications – fatty infiltration of the liver with cirrhosis
Increased cancer risk – breast, ovary, endometrium, cervix, prostate, bowel
Main general causes of obesity
Environment – By far the commonest cause.
Causes of a fixed dilated pupil
If unconscious then herniation
Oculomotor nerve palsy
Acute closed-angle glaucoma
Symptoms of SIADH
Caused by the hyponatraemia
Mild – Nausea/Vomiting/Headache/Anorexia /Lethargy
Moderate – Muscle cramps/Weakness/Confusion/Ataxia
Severe – Drowsiness / Seizures / Coma
Signs of SIADH
Decreased level of consciousness
Focal or generalised seizures
Brain stem herniation – severe acute hyponatraemia (coma / respiratory arrest)
Hypervolaemia –pulmonary oedema / peripheral oedema / raised JVP / ascites
What Ix would you do for suspected SIADH?
What is the biochemical triad of DKA?
Ketonaemia, hyperglycaemia and acidaemia
What is the clinical presentaiton of a patient with DKA?
Polyuria with polydipsia – commonest presenting symptom
Preceding febrile illness
Define term immigrant
Anyone who moves to another country for 1 year+
Define term asylum seeker
Person who claims asylum in the UK due to persecution in country of origin
Give 3 common migrant health issues
No access to healthcare (illegal immigrants)
What are the criteria for bariatric surgery?
All appropriate non-surgical measure have been tried
The person has been receiving or will receive intensive management in a tier 3 service
The person is generally fit for anaesthesia and surgery
The person commits to the need for long-term follow up
Have to have BMI of at least 40 without co-morbidity
OR 35 with recent onset T2DM
What are BMI thresholds for action to prevent T2DM in Asian and African/Afro-carribbean populations?
23 is increased risk
27.5 is high risk
MoA of Orlistat
Inhibits action of lipase in GI tract so 30% less dietary fat is absorbed
What 2 school years is the national child measurement programme carried out in england?
Year 6 (10-11)
A 48 year old gentlemen with T2DM is diagnosed with stage 1 HTN (BP ≥140/90) what is your management for him?
Assess cardiovascular risk and end-organ damage via:
- plasma glucose, GFR, cholesterol
Offer lifestyle advice
- Reduce salt, alcohol, smoking
- Exercise regularly
Offer ACEi initially then review
Who should be offered antihypertensives?
NICE says to offer antihypertensives to people aged <80 with stage 1 if they have:
- Target organ damage
- Established CVD
- Renal disease
- 10 year risk of =/>20%
If stage 2 they should all be offered antihypertensives
Why should ACEi not be used in pregnancy?
Reported to cause congenital malformations, stillbirths and neonatal deaths
Give 4 causes of ascites
DDx of acute diarrhoea (3 of many)
IBD flare up
What is hypospadias?
Opening of urethra on ventral surface of penis
How does lichen planus present clinically?
Pruritic, purple, polygonal, planar papules and plaques
Remember the 6 P's of lichen planus
What condition is associated with this presentation? – A pink pearly nodule with telangiectasias, ulceration and rolled borders on the upper lip.
Basal cell carcinoma
How does impetigo present?
Golden honey coloured crust over an erythematous base
What is the pathogenesis of pemphigus vulgaris?
IgG antibody against desmoglein resulting in painful flaccid bullae or blisters that rupture easily on both skin and oral mucosa.
What skin condition is caused by the pox virus and what is its presentation?
Presents as an umbilicated papule.
What are the signs of cardiac tamponade?
Hypotension, muffled heart sounds and increased JVP.
At which point in the menstrual cycle is a women most fertile?
The most fertile period of the menstrual cycle is from 5 days before ovulation to 1-2 days after.
So day 9-16 of menstrual cycle
What does symmetrical intrauterine growth restriction (both the head circumference and abdominal circumference are lower than normal) suggest?
Chromosomal abnormality rather than placental insufficiency which would more likely present as asymmetrical
Describe the first stage of labour
Starts when the effaced cervix is 3cm dilated and ends when the cervix is fully dilated at 10cm.
What is the correct way to calculate the estimated date of delivery (EDD)?
First day of LMP + 9 months and 1 week
At 28 weeks gestation where would you expect to feel the uterine fundus?
Halfway between umbilicus and xiphisternum
Which period of gestation does the 2nd trimester represent?
When will a pregnant patient expect to feel foetal movements?
Definition of post-partum haemorrhage
Loss of >500ml of blood from the vagina within 24 hours of delivery
Describe the underlying pathology of Grave's disease
An autoimmune disease directed against thyroid stimulating hormone (TSH) receptors.
The autoantibodies stimulate the TSH receptors causing increased T3 and T4 production.
What is gold standard Ix for diagnosing acromegaly?
Oral glucose tolerance test + Growth hormone measurement
What is the cut-off for an acceptable weight loss in the first 7 days of life?
Any more requires follow up/referral
Which vaccinations are given as "Pre-school boosters" at around 3 years?
At around 3 years 4 months the 4-in-1 DTaP/IPV is given, along with the second dose of MMR.
What two systems are used to predict prognosis and guide treatment for malignant melanoma?
Clark index- measures how deeply the melanoma has grown into the skin and which levels of the skin are affected.
I: confined to epidermis, in situ
II: invasion of the papillary dermis
III: filling of the papillary dermis, but no extension into the reticular dermis
IV: invasion of the reticular dermis
V: invasion of the subcutaneous tissue
Breslow thickness- measure thickness in millimitres from the overlying granular layer of the epidermis to the deepest easily identifiable tumour cells with an ocular micrometer.
What is erythema multiforme and give its common causes
Erythema multiforme is a hypersensitivity reaction usually triggered by infections, most commonly herpes simplex virus (HSV).
It presents with a skin eruption characterised by a typical target lesion.
What is dermatitis herpetiformis and what GI condition is it associated with?
Dermatitis herpetiformis (DH) is a rare but persistent immunobullous disease that has been linked to coeliac disease
How does acute pancreatitis present clinically?
Epigastric/central abdominal pain
• Pain radiates to the back
• Helped by sitting forward
– Tachycardia, hypotension, pyrexia, ↑RR, ↓O2
sats, abdo pain, Cullens/Grey Turner’s sign,
Signs of ascending cholangitis
2. Fever, usually with rigors
3. Right upper quadrant abdominal pain.
Pathophysiology of asthma
Bronchial muscle constriction
Increased mucus production and plugging of bronchi
Definition of stroke
Stroke is the sudden onset of focal neurological deficit
lasting more than 24 hours (or leading to death)
caused by a vascular problem.
Rx for hypovolaemic hyponatraemia
Slow rehydration with normal Na+
What Ix would you do for a patient with hyponatraemia?
Serum osmolality (often low)
Urinary sodium (can help differentiate between SIADH and a reducition in circulating volume/addison's)
Give 3 causes of hypokalaemia
Definition of a Health Needs Assessment
A systematic method of identifying unmet health and healthcare needs of a population and making changes to meet these unmet demands
What is the aim of a HNA?
To provide information to plan and change services for the better and to improve health
What are the 3 components of a HNA?
Epidemiological - epidemiology of current health condtion and risk factors
Comparative - compare service and care between diff. population
Corporate - views of stakeholders
Define self management support
Techniques that help patients choose healthy behaviours. Transforms care-giver relationship into partnership
Define self efficacy
Ability to monitor ones condition and effect cognitive, behavioural and emotional responses necessary to manintain satisfactory QoL
What bedside investigations would you undertake in someone with a supected TIA?
Blood glucose - rule out hypoglycaemia as a cause of neuro signs
What the is range of gestational age for the foetus to be classified as preterm baby?
24-37 weeks (before 24 weeks it is classed as spontaneous abortiong/miscarriage even though some babies can survive earlier than this point)
Explain what elements are required for successful claim of clinical negligence against a doctor
The doctor or other healthcare professional owed a duty to take care of the claimant and not cause injury;
There was a breach of that duty to take care;
That breach of duty has caused harm to the claimant; and
Damage or other losses have resulted from that harm.
What age do women commence breast screening?
50 years of age
Give 3 clinical features of a breast lump that would warrant a 2WW referral
aged 30 and over and have an unexplained breast lump with or without pain or
aged 50 and over with any of the following symptoms in one nipple only:
other changes of concern - 'peau d’orange’, tethering, bony pain(mets)
Two indications for use of an NG tube
Unable to swallow
Unable to maintain adequate nutritional intake
Drainage of stomach contents
Describe management of pressure ulcers
Dressing that promotes a warm, moist healing environment to treat grade 2, 3 and 4 pressure ulcers.
Topical antimicrobial dressings to treat a pressure ulcer where clinically indicated,
Repositioning, air mattresses, air cushions
Nutritional supplements and hydration
Give 3 examination findings in RA
Symmetric swelling of wrist, metacarpophalangeal, or proximal interphalangeal joints
Ulnar deviation of MCP joints and phalanges
Z-deformity of the thumb
Swan-neck & Boutonniere deformity of interphalangeal joints
Volar (anterior) subluxation of digits
Rheumatoid nodules under skin
Give 3 examination findings in OA
Affects distal interphalangeal joints & 1st carpometacarpal joints.
Heberden’s nodes present = enlargement of base of distal phalanx
Bouchard’s nodes = enlargement of the PIP
Bunions may present on the feet
Limited movement, grinding (crepitation)
What are the broad areas assessed in the MSE? (8)
Appearance and behaviour
What 3 types of embryonic tissue is the eye derived from?
Mesoderm of the head region
The neural tube (neuro-ectoderm)
- Corneoscleral and uveal tunics
What are the macula and fovea?
Macula is the area between the two temporal arcades
Fovea is small central area of the macular containing high density of cones
- Area concerned with fine detailed vision
Physiological relevance of choroid
Nourishes the outer layers of the retina
Regulates retinal heat
Assists in the control of intraocular pressure
Pigment absorbs excess light decreasing reflection.
What is the underlying cause of cataract in older people?
Lens cells grow throughout life and there become more densely packed with time
Densely packed cells stiffen the lens leading to loss of accommodation = presbyopia
Densely packed cells become opaque=cataract
What 3 muscles control the eyelids
Orbicularis oculi = closes (CN VII)
Levator palpebrae superioris = opens (CN III)
Superior tarsal muscle = opens (Sympathetic)
What veins can be accessed in the cubital fossa?
Cephalic, basilic or median cubital veins
Borders of cubital fossa
Superior – Epicondylar line
Lateral – Brachioradialis
Medial – Pronator teres
What nerves are at risk with cannulation into cubital fossa?
Medical and lateral cutaneous nerves of forearm
What structures are at risk when cannulating the cephalic vein in the anatomical snuffbox?
Superficial branch of radial nerve
Describe the path of the great saphenous vein
Passes up medial aspect of lower limb
Anterior to medial malleolus
Along posterior region of medial tibial border (alongside saphenous cutaneous nerve)
Posterior to patella
Then through saphenous opening ~3cm inferior and lateral to the pubic tubercle
Describe path of short saphenous vein
Passes from lateral foot up posterior leg into popliteal fossa
Posterior to lateral malleolus
Ascends midline leg (posterior) alongside sural cutaneous nerve
Into popliteal fossa via crural fascia and into popliteal vein
What two positions can the IJV be accessed from for central venous cannulation?
Lesser supraclavicular fossa
Posterior border of SCM
What nerves are at risk when attempting to cannulation the EJV
Accessory nerve (CNXI)
Cutaneous branches of cervical plexus
Borders of femoral triangle
Superior border - Inguinal ligament
Lateral border - Medial border of sartorius
Medial border - Medial border of the adductor longus muscle
Roof - Fascia lata
Floor - Pectineus, iliopsoas and adductor longus
What are Langer's lines?
Lines of tension/cleavage (Langer’s) which help guide the orientation of surgical incisions
Determined by direction of collagen fibres
Incisions along lines heal better
What type of incision allows adequate exposure while aligining with tension lines?
What surgical approach would you take to access the mediastinum and why?
Avoids intercostal muscles and neurovascular bundle, internal thoracic artery & vein and provides good mediastinal access
Borders of the triangle of safety and its use
Posterior axillary fold (lat. dorsi and teres minor)
Anterior axillary fold (Pec. major and minor)
Nipple line (4/5th ics)
Used for chest tube insertion
What incision is used to access the anterior and posterior compartments of thigh?
Lateral fasciotomy incision
Describe surgical approach to ankle
Incision made midway between tibia & fibula heading towards 4th metatarsal base
Intermediate dorsal cutaneous nerve id
Extensor tendons retracted
Describe surgical approach to shoulder
Anterolateral approach made
ID coracobrachialis and work at lateral side
Medial side is the suicide
What is the gold standard investigation for diagnosis of TB?
Discharged pus or biopsy material for direct staining and culture
Describe the legal positon regarding a 16 year old refusing treatment
A child deemed competent can consent to treatment and this cannot be overridden.
A refusal of treatment can be overrideen by someone with authority to consent e.g. parent
If there is parental disagreement then the court can be asked to make the decision on what is in the best interests of the patient.
What is a vesicle?
A raised lesion filled with serous fluid that is <5mm diameter
What type of epithelium lines the labia minora?
Non-keratinised stratified squamous
What is the major determinant of the clinical manifestations of a virus?
Tropism of the virus for specific tissues and cell types
Give 2 direct cytopathic effects of viruses once they have entered cells
Induction of apoptosis
Production of toxic proteins
Production of degradative enzymes
Give 2 reasons why a combo of chemotherapy agents are used to treat patients
More effective due to different MoA
Reduces chance of resistance
What cell types would be increased if a patient is give G-CSF
How do you calculate relative risk reduction?
Risk of disease in control group is 5% and 3% in treatment group what is RRR
Absoulte risk reduction by control event rate
2/5 x 100 = 40%
What are the 4 classes of anti-arrhythmic drugs and where do they act?
Class 1 : Sodium channel blockers (membrane stablising)
Class 2: Beta blockers (reduce adrenergic input)
Class 3: Potassium channel blockers
Class 4: Calcium channel blockers
Pathways involving which neurotransmitter are involved in the pathogenesis of confusion?
What is beta oxidation?
Process in which fatty acids are broken down in mitochondria to generate acetyl-coA
How do class 1c antiarrhythmics stabilise heart rhythm?
By slowing conduction in all parts of the heart
Give 3 reasons it is possible to detain someone under the Mental Health Act 2007
Hold to allow a formal psychiatric assessment
Psychiatric assessment with a view to treat
Treatment for a psychiatric disorder
Why is AF a risk factor for vascular dementia?
AF causes turbulent flow in the atrium leading to thrombus formation and emboli can end up in cerebral vasculature
What timescale does HbA1c reflect glycaemic control over?
The preceding 2-3 months
How do sulphonylureas increase the secretion of insulin?
Inhibition of the ATP sensitive K+ channels in the plasma membrane meaning K+ cannot efflux causing influx of Ca2+ and activation of normal machinery that releases insulin.
What would you see on fundoscopy in a patient with age related macular degeneration
Dry AMD will show drusen (yellow/white accumulations of extracellular material in the macula)
Wet AMD will show choroidal neovascularisation
3 questions you would want to ask a patient who presents with TIA about their presenting complaint
Any sensory losses
3 risk factors for TIA
3 common causative organisms for otitis media
3 serious complications of progressive middle ear infection
3 complications of pneumonia
Two factors that increase risk of developmental hip dysplasia
4 layers of epidermis
Granular cell layer
Spinous cell layer
Basal cell layer
3 Cells found in epidermis
Keritanocytes - produce proteins
Melanocytes - secrete melanin
Merkel cells - light touch
Functions of skin
Protection against infection/ UV
Prevent water loss
Vit. D synthesis
How can you describe a lesion? (Pneumonic)
Features of nodular BCC
Small, shiny, skin-coloured swelling
Telangiectasia at edge
Rolled edge and central ulcer
NICE advice for sun protection
Seek shade between 11-3
Wear covering clothing e.g. hats
Suncream with minimum spf 15 and 4* UVA
Keep kids under 6 months out of direct sunlight
Grades of pressure ulcers
Grade 1: Redess of intact skin
Grade 2: Partial thickness skin loss involving epidermis, dermis or both.
Grade 3: Full thickness skin loss involving damage to subcutaneous tissue.
Grade 4: Extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures
Give 3 differentials for superficial neck lumps
2 differentials for midline neck lump
Thyroglossal duct cyst
4 differentials for anterior triangle neck lumps
Salivary gland swelling
2 differentials for posterior triangle neck lumps
Subclavian artery aneurysm
NHYA classification of HF
Class 1 - symptoms only when exerting self to levels that would limit a healthy individual
Class 2 - symptoms on normal exertion
Class 3 - symptoms with less than normal exertion
Class 4 - symptoms of HF at rest
4 causes of T1 respiratory failure
4 causes of T2 respiratory failure
MRC dyspnoea scale
1 - Not troubled by breathlessness except during strenuous exercise
2 - Short of breath when hurrying or walking up a slight hill
3 - Walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace
4 - Stops for breath after walking about 100 m or after a few minutes on the level
5 - Too breathless to leave the house, or breathless when dressing or undressing
How do you confirm diagnoses of COPD
Spirometry - FEV1 and FVC
The ratio will be <70% showing an obstructive pattern
What criteria are used to determine if a patient needs home oxygen?
Must NOT be smoking
Describe the appearance of acute guttate psoriasis
Salmon pink papules +/- scales
Scattered discrete lesions mainly on trunk
Can evolve into chronic plaque form
Describe appearance of chronic plaque psoriasis
Well defined dull red plaques with loosely adherent whitish scale
Bilateral and often symmetrical
Nails commonly involved
Can have single lesion or lesions localised to site - mainly elbow, knees, sacral region, scalp, palms and soles
Nails changes in psoriasis
Causative agent of acne vulgaris
Pathology underlying acne
Follicular plugging prevents drainage of sebum
Androgens stimulate sebaceous glands
Intense inflammation leads to scarring
Features of acne skin lesions
Papules and pustules
Features of rosacea
What is the most common primary immunodeficiency?
Common variable immunodeficiency
4 types of primary immunodeficiency
Severe combined immuno-deficiencies
Predominantly antibody deficiencies
Gold standard Ix for CGD
Nitro-tetrazolium blue (NBT) - Normal phagocytes reduce this to a dark blue pigment
Treatment for CGD and CVID
CGD - Prophylactic abx, recombinant IFN gamma , bone marrow/ stem cell transplant (curative)
CVID - Prophylactic immunoglobuin transfusions every 3-4 weeks
What test can be done to confirm diagnosis of anaphylaxis?
What are the requirements for an ADRT to be considered valid?
Be an adult (over 18) when decision made
Capacity to make decision
Freedom from coercion
ADRT must also state precisely the treatment to be refused and the circumstances in which it applies
State 3 things you need to do ensure a patient has sufficient information to consent to being screened
Give clear and accurate information about benefits and risks
Tailor the information to individual patient
Take into account patient's views, preferences and concerns about adverse outcomes.
Provide supplementary material to facilitate discussion
Describe legal concepts of battery and negligence
Uninvited invasion of bodily integrity (physical contact against patient’s valid consent), or the “unlawful application of force
Negligence is harm caused by a doctor’s failing to correctly discharge their duty of care.
Explain what is meant by the Bolam test
The Bolam test is a legal mechanism for determining a doctor’s liability in the context of a negligence claim.
3 elements that are required in order to bring a successful negligence claim
Duty of care: whenever one can reasonably foresee that one’s conduct may cause harm to another
Breach of duty: the claimant must show that the defendant fell below the required standard of care
Causation: the claimant must establish that (s)he would not have come to harm but for the actions of the doctor
What are the two definitions of death that are relevant to organ donation
Brain stem death: irreversible cessation of brain stem function
Circulatory death: irreversible cessation of cardiorespiratory function
What is the acid test?
How to decide whether someone is being deprived of liberties (by lady hale)
Objective - Person must be under continuous supervision and control and not free to leave
Subjective - Person lacks capacity to consent to their living arrangements
Describe and explain an ethical consideration that might be relevant when considering implementing a screening programme.
Respecting patient autonomy.
This may require that patients are given the freedom to decide whether to participate in a screening programme, given enough information to make an informed choice, and in an environment where they are free from coercion (e.g. pressure from the treating clinician).
Define a schema
A cohesive, repeatable action sequence possessing component actions that are tightly interconnected and governed by a core meaning.
2 ways that child builds up knowledge
Assimilation - An existing schema works well for a new situation so new knowledge is assimilated into existing schema
Accomodation - No exisiting schema fits the new situation, so schema must be altered to accommodate new informtion.
Factors affecting concordance
Social and economic
Define attribution bias
We attribute our errors to situational factors but others errors to character flaws
What's meant by discounting of disconfirmatory evidence?
Tendency to stick with a diagnosis once it's been chosen even when conflicting information comes in
What is availability bias?
Tending to come up with a solution that happens to be on your mind
What is affective bias?
Basing your decisions on emotional reaction to a patient
What is meant by the danger space in the neck?
What is its significance?
Potential space between the alar fascia and prevertebral fascia that communicates with the posterior mediastinum to diaphragm level
What do the carotid sinus and carotid body sense?
Carotid sinus senses pressure
Carotid body senses mainly PO2 and PCO2
What are the B symptoms of lymphoma
3 signs which would be relevant to lymphoma
Other palpable lymph nodes
Systemic features (fever, anorexia)
3 features of a breast lump that could be indicative of breast cancer
Firmness or hard irregularity
Ulceration of breast
Give a medical treatment for ectopic pregnancy
Avoid pregnancy because of persisting teratogenic effect on foetus
Two predisposing causes for ectopic pregnancy
What hormone is measured in early pregnancy and what is its function
Acts on corpus luteum to secrete oestrogen and progesterone
What scoring system is used for acute pancreatitis?
Renal: Urea >16
Enzymes: LDH >600
Sugar: Glucose >10mmol/L
Two systemic manifestations of gonorrhoea
Skin rash - erythema nodosum
Eye problems - keratoconjunctivitis
Joint problems - Reactive Arthritis
Symptoms of hyponatraemia
Concentration and cognitive deficits
Which murmur is most associated with AF
Boundaries of the neck
- Inferior mandible and base of skull
- Manubrium, clavicle and actinium to spinous process of C7
Three clinical signs on abdominal examination that would be elicited in a patient with ascites
Fullness in flanks
Dilated superficial abdominal veins
Boundaries of carotid triangle
Ant - omohyoid (sup. belly)
Sup - Digastric (pos. belly)
Post - SCM
Submandibular triangle borders
Sup - Inferior border of mandible
Inf - Digastric (ant. and post. bellies)
Where is the lower back
Area in between base of 12th ribs, buttock creases and mid axillary line
What is the mental capacity act 2005?
Sets out legal framework for making decisions for people who lack capacity to make decisions for themselves
5 key principles of MCA
Assume capacity unless proven otherwise
Unwise decision doesn't mean lack of capacity
All practicable help given
Features of subcortical dementia
Forgetful and slow
Impaired visuospatial abilities
Depression of mood
Features of cortical dementia
Higher cortical abnormalities
2 examples of subcortical dementia and 2 examples of cortical
- Normal pressure hydrocephalus
- Creutzfeld-Jakob disease
- Frontotemporal dementia
What is the most common infectious organism responsible for bronchiolitis?
Respiratory syncytial virus (RSV)
What test should be used to confirm a diagnosis of gestational diabetes?
2 hour OGTT - value of 7.8mmol/L or above is diagnostic
Give 3 risk factors for a woman developing gestational diabetes
BMI > 30
Previous gestational diabetes
FHx of diabetes mellitus
3 complications of gestational diabetes in mother/baby/foetus
Higher risk of preeclampsia and later diabetes
What is the target range of fasting blood glucose for women with gestational diabetes?
What foetal investigations should be offered to mothers with gestational diabetes?
USS for foetal growth and amniotic fluid volume - every 4 weeks from 28 to 36 weeks
USS for congenital malformations should be offered at 20 weeks
What does NICE recommend post partum for women who had gestational diabetes?
Women should be offered lifestyle advice and offered a fasting plasma glucose measurement but not a OGTT
4 causes of azoospermia
Give 2 further investigations to help assess cause of azoospermia
Two options for a couple who are infertile due to azoospermia
Give 2 risk factors for developing psoriasis
Drugs e.g. Lithium, beta blockers, alcohol
Genetic link - first degree relative suffering from it