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Flashcards in High yield Deck (541):
1

What ages is cervical screening offered to women in the UK?

25-64

2

How often is cervical screening offered to the different age groups?

Age 25-49 - every 3 years
Aged 50-64 - every 5 years

3

What are the 3 components of cervical screening?

Colposcopy
High risk HPV testing
Sampling with cytobrush for liquid cytology

4

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

5

What name given to the type of technique used to remove skin cancer and assess the cell types

Mohs surgery

6

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

7

What is the name of the skin type scale?

Fitzpatrick scale (1-6 white to black)

8

Gentleman drinks 4 cans of 440ml 7% strength lager a week. Work out the units he drinks in a week

12.32 units

9

What is the transformation zone of the cervix

Junction between the squamous cells of the exocervix, and the columnar cells of the endocervix

10

Name 3 enablers of self-management

Agenda setting
- preparing in advance
- identifying issues and problems
Collabarative goal setting
- SMART goals
Follow up
- Proactive
- Soon - within 14 days

11

Give 4 barriers to self management

Control beleifs
Self efficacy
Depression
Poor family support
Weight problems
Behavioural beliefs

12

What is the most common type of skin cancer?

Basal Cell Carcinoma (BCC)

13

What is the A-E approach for pigmented skin lesions

Asymmetry
Borders
Colour
Diameter greater than 6mm
Evolution - has it changed over time

14

What are the 4 domains of childhood development

Gross motor
Fine motor/vision
Speech/language
Social

15

3 Causes of cerebral palsy

Congenital infection (CMV)
Birth asphyxia/trauma
Head-trauma

16

Define infertility

No conception after 1 year of unprotected vaginal sexual intercourse

17

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 ↑

18

What cancer are PCOS sufferes more likely to get?

Endometrial cancer

19

Give 4 contraindications for prescribing the COCP

Smokers aged 35 or more
Hypertension
History of venous thromboembolism
Migraine with aura

20

Give 4 skin disorders that occur with SLE

Photosensitive rash
Alopecia
Vasculitic rash
Malar rash

21

What associated condition could cause repeated miscarriages in a woman with SLE?

Anti-phospholid syndrome

22

MOA of warfarin

Decreased synthesis of clotting factors X, IX, VII and II
- via the inhibition of vitamin K epoxide reductase
Remember 1972

23

What is a normal INR range?

0.8-1.2

24

Give 2 ECG features of Aortic Stenosis

LV hypertrophy
Taller R waves

25

Classic triad of symptoms for Aortic Stenosis?

Angina/chest pain
Shortness of breath
Syncope

26

What are the negative symptoms of schizophrenia (4)

4 A's
- Alogia
- Anhedonia
- Apathy
- Affective blunting

27

Give the first rank symptoms of schizophrenia

1 Passivity
2 Somatic Hallucinations
3 Delusions of Perception
4 Thought insertation, broadcasting, withdrawal
5 Third Party Auditory Hallucinations
6 Thought Echo

28

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

29

What scoring system is used to assess upper GI bleeds?

Rockall score

30

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

31

Most common cause of breast lump?

Fibroadenoma

32

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.

33

4 other differentials to consider with a patient with suspected gout

Pseudogout
Septic arthritis
Reactive arthritis
Fracture

34

What common medication can predispose someone to gout?

Thiazide-like diuretics

35

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

36

2 causes of Left Ventricular Failure

MI
IHD

37

What abnormality might be detected on auscultation in a patient with LVF

S3 gallop

38

What are the A-E signs of heart failure on CXR?

Alveolar oedema (bat wings)
Kerley B lines (interstitial oedema)
Cardiomegaly
Dilated upper lobe vessels (Pulmonary venous HTN)
Pleural Effusion (blunting of costophrenic angles)

39

Give the CENTOR criteria

Absence of cough
Temperature >38
Cervical lymphadenopathy
Tonsillar exudate

Score of 3 or more is suggestive of group b strep infection

Offer penicillin V if that is case

40

Clinical features of hepatic encephalopathy

Reversal of sleep pattern
Asterixis (Liver flap)
Loss of concentration
Constructional dyspraxia

41

6 causes of abdominal distension (6 Fs)

Fat
Faeces
Flatus
Foetus
Fluid
Fibroids/Tumour

42

Causes of mitral stenosis

Rheumatic fever
SLE
Endocarditis

43

Most common murmur in pregnancy

Mitral stenosis (Mid diastolic murmur)

44

What ecg signs are seen in right bundle branch block?

MarroW

M shape in early V leads
W in later V leads

Opposite for LBBB

45

Triad of nephrotic syndrome

Proteinuria
Oedema
Hypoalbuminaemia

46

Triad of pre eclampsia

Oedema
Proteinuria
Hypertension

47

What ejection fraction is suggestive of LVF?

<35

>55 is normal
45-54 is mild LVSD
35-44 is moderate LVSD

48

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

49

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

50

Underlying pathology of Crohns

Transmural inflammation
Involving whole GI Tracy
Discontinuous

51

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

52

What is a hydrocoele?

An accumulation of fluid in the tunica vaginalis

53

What is the likely histological assessment of a biopsied TB lesion?

Well­formed granulomas with caseous necrosis

54

What blood test would be diagnostic for Haemophilia A

Low plasma levels Factor VIII

55

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

56

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

57

What are the 2 types social of stigma?

Enacted stigma - real experience of -ve attitudes
Felt stigma - Fear that prejudice or discrimination may occur

58

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

59

 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.

60

Describe mechanism underlying HbA1C formation

Haemoglobin undergoes glycation in vivo, at a rate proportional to blood glucose concentration

61

 List TWO ways in which diabetes mellitus is atherogenic

Endothelial dysfunction
Increased oxidative stress

62

Definition of concordance

A negotiated, shared agreement between clinician and patient concerning treatment regime(s), outcomes and behaviours 

63

Give 3 routine postnatal checks that will be carried out on the mother within 6 hours of birth

Assess volume of blood loss
Blood pressure
Contraction of Uterus

64

What 2 markers are screened for in a HIV test?

p24
IgG

65

What is the time limit for offering Post-exposure prophylaxis

72 hours after exposure

66

Signs of PE

Raised JVP
Tachycardia
Tachypnoae
Low O2 sats

67

RIsk factors for PE

COCP
Malignancy
Pregnancy
Recent VTE
Immobility

68

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

69

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

70

Define:
I. Sexuality
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

71

Which area of the brain degenerates in Parkinson's?

Substansia Nigra pars compacta

72

Three dysmorphic features associated with Trisomy 21

Flat facial profile
Single deep transverse palmar crease
Short neck

73

Most common heart defect in Trisomy 21 patients?

Atrioventricular septal defect

74

Two common conditions associated with Trisomy 21

Duodenal atresia
Obstructive sleep apnoea
CHD

75

What conditions are screend for in the heel prick test?

Sickle cell
Cystic fibrosis
Congenital hypothyroidism
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)

76

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

77

How can efficacy expectations be enhanced?

o Positive mastery experiences
o Positive vicarious experiences
o Positive verbal persuasion
o Positive emotional readjustment

78

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

79

Which organisation should food poisoning be reported to?

Notification of Infectious Diseases

80

Give 4 signs of derlirium

Disordered thinking
Euphoric, fearful, angry or depressed (Labile mood)
Language impaired
Illusions, hallucinations, delusions
Reversal of sleep pattern
Inattention
Unaware/disorientated
Memory deficits

81

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

82

What contraception would you offer to a new mother who is breastfeeding?

Barrier methods (condoms)
POP (mini-pill)
Implant can be used 21 day after
Oestrogen containing contraception can interfere with milk production

83

What is the minimum number of weeks post-delivery at which a cervical smear could be performed and why?

12 weeks.

NICE says:
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

84

Describe the characteristic appearance of Neisseria gonorrhoea when it is Gram stained and viewed under the microscope

gram-negative intracellular diplococci on microscopy

85

Give two features to identify small bowel on AXR

Central position
Valvulae conniventes - mucosal folds that cross the full width of the bowel

86

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

87

What is the most common motor disorder in childhood?

Cerebral palsy

88

Give some examples of developemental milestones in each domain a 12 month old should have reached

Gross motor: Straight back sitting (9 months)
Walks alone
Fine motor/vision: Mature pincer grip
Speech/language: Understands common words
Uses one or two words
Social: Seperation anxiety
Dependence on parental figure

89

Definition of anxiety

A state of apprehension, uncertainty or fear, resulting from the anticipation of a realistic or imaginary threatening event or situation

90

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.

91

What are the 6 primary emotions?

Happiness
Fear
Sadness
Anger
Suprise
Disgust

92

What diagnostic criteria should be used in suspected IBS?

Rome IV criteria

93

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)

94

Define diarrhoea

Abnormal passage of loose of liquid stools
More than 3 times daily
and/or
A volume of stool >200g/day

95

What type of diarrhoea does cholera infection cause?

Secretory diarrhoea caused by toxins

96

Define gastroenteritis

Gastroenteritis e.g. any 2 of …
1. diarrhoea
2. abdominal pain / colic
3. nausea / vomiting
4. fever / myalgia / headache

97

Give 3 causes of viral gastroenteritis

Rotavirus
Norovirus
Astrovirus

98

Give 3 causes of bacterial gastroenteritis

Campylobacter
E. Coli
Cholera

99

Describe Xray appearance of RA

Loss of joint space
Erosions
Soft tissue swelling
Soft bones (osteopenia)

100

Describe Xray appearance of OA

Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis

101

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

102

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)

103

Give 3 broad management options for RA

Exercise/physio
NSAIDs
DMARDs

104

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
- Redness
- Swelling/bogginess

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
- Crepitus
- Restriction of movement

105

Describe dysplasia

• Premalignant condition
• Increased cell growth
• Cellular atypia
• Altered differentiation

106

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

107

Define neoplasm

New abnormal growth of cells which persists after initiating stimulus has been removed

108

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

109

Define AKI

Abrupt loss of kidney function over a period of hours to days
Creatinine >120micromols/L (normal 60-120)

110

What is the RIFLE criteria?

It is a classification of AKI
Risk Creatinine 1.5-2x baselines
Injury 2-3x
Failure >3x
Loss (>4 weeks)
ESRD (>3 months)

111

Give the 3 causes of anuria

Obstruction
Vascular catastrophe
Severe acute glomerulonephritis

112

What complications may occur from an AKI?

Hyperkalaemia
Pulmonary oedema
Ureamia
Acidaemia

113

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
Salbutamol

114

Give 4 causes of hyperkalaemia

Drugs (ACEi, NSAIDs, ARBs)
Renal impairment
Iatrogenic (over replacement in fluids)
Haemolysis of sample

115

Describe ECG changes seen in hyperkalaemia

Tall tented T waves
Flattened P waves
Broad QRS complexes

116

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

117

Define adherence

The extent to which a person's behaviour corresponds with agreed recommendations from a health care provider

118

Define compliance

The fulfilment by the patient of the healthcare professional’s recommended course of treatment

119

Describe 2 effects of poor concordance

Poor treatment outcomes for patients
Increased financial burden with excess urgent care visits

120

What 5 patient centred factors influence concordance?

Demographics - Adolescents have poor concordance
Psychological
Health literacy
Patient-prescriber relationship
Patient knowledge

121

Define adolescence

A variable period between childhood and adulthood between 10-20 years of age characterised by rapid development in psychosocial domain

122

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

123

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
Risk taking

124

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

125

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

126

What is a sofa surfer?

Someone staying with family or on a friends sofa

127

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
Unemployment
Closure of longterm psych hospitals

128

Which antipsyhotic is associated with agranulocytosis?

Clozapine

129

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

130

What is normal range of variability on a CTG?

5-25 bpm is seen as reassuring

131

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

132

Give some reasons to classify a pregnancy as high risk

Gestational diabetes
HTN
Asthma
PROM
Pre-eclampsia

133

Normal foetal heartrate?

100-160bpm

134

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

135

What is the sepsis 6?

Give high flow oxygen
Take blood cultures
Give empirical antibiotics in line with trust guidelines
Measure serum lactate
Fluid resuscitation
Monitor urine output

136

Which types of HPV are associated with cervical cancer?

HPV 16 and 18

137

Who is the HPV vaccine offered to?

12-13 year old girls

138

What part of the cervix do most cervical cancers arise from?

Transformation zone at region between endo and ecto cervix

139

What period in days (ha) does the secretory phase of menstruation occur?

Day 13-28

140

Define primary amenorrhoea

- No menstruation by age 14 with failure of development of secondary sexual characteristics
OR
- No menstruation by age 16 with normal development of secondary sexual characteristics

141

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

142

Define menorrhagia

Menorrhagia is excessive menstrual bleeding over several consecutive cycles that interferes with the woman's physical, emotional, social, and material quality of life.

143

What is the treatment for fibroids called?

Myomectomy

144

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

145

Define surveillance

Ongoing collection, collation and analysis of data in preparation for action

146

Why is surveillance needed?

Monitor trends, early warning for outbreaks, can plan and monitor interventions better

147

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

148

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

149

Give 3 direct and 3 indirect modes of transmission

Direct - touching, sex, faeco-oral
Indirect - Vehicle, vector e.g. malaria, airbourne

150

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

151

With regards to communicable disease define sporadic

Occasional cases at irregular levels

152

With regards to communicable disease define endemic

Persistent low or moderate levels

153

With regards to communicable disease define hyper endemic

A higher persistent level

154

With regards to communicable disease define cluster

Occurance exceeds expected level: may be a possible link

155

With regards to communicable disease define outbreak

Localised epidemic: 2+ cases or a single case of rare disease

156

With regards to communicable disease define Pandemic

Epidemic occuring worldwide affecting large amounts of people

157

With regards to communicable disease define Epidemic

Occurance exceeds expected level: high probable or confirmed link

158

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

159

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

160

What is the most common mental health problem among men and women in europe?

F: Depression
M: Alcohol use

161

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
Treatment SEs
Suicide

162

How do you work out Mean Arterial Pressure (MAP)?

MAP = 1/3 * SBP + 2/3 * DBP

163

Give the equation for ejection fraction

EF = (SV / EDV) ⋅ 100

164

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

165

Give some causes of anaemia of chronic disease (4)

Infection
RA
Crohn's
TB
Endocarditis

166

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

167

Give 4 causes of haemolytic anaemia

Hereditary spherocytosis
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
Malaria
Drugs
Hypersplenism

168

Clinical features of aplastic anaemia

Anaemic symptoms
Increased infections due to low WCC (esp oral infections)
Bleeding (e.g. gums, epistaxis) / bruising as low platelets

169

How does CKD lead to anaemia?

CKD leads to a reduction in production of EPO which gives as a result normocytic normochromic anaemia

170

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

171

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.

172

3 causes of iron deficiency anaemia

Malabsorption
Poor diet
Blood loss

173

What Ix would you do for suspected iron deficiency anaemia?

FBC: Hb↓ MCV↓
Blood smear: microcytic, hypochromic RBCs
Iron studies: Serum ferritin ↓ Serum Iron↓

174

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

175

Pathophysiology of pernicious anaemia

Autoimmune condition where there is atrophy of the gastric mucosa, with failure of Intrinsic Factor (and acid production) → B12↓ absorption.

176

What would the LFTs show in a pre-hepatic cause of jaundice?

Unconjugated bilirubin - Increased
AST/ALT - Normal
ALP/GGT - Normal

177

What would LFTs show in a post-hepatic cause of jaundice?

Conjugated bilirubin - Increased
AST/ALT - Slight increase
ALP/GGT - Large increase

178

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

179

Clinical features of anterior uveitis

Unilateral
Dull pain in orbital region
Blurred vision
↓ visual acuity
Synechiae (iris adherence to cornea or lens)

180

Give 4 causes of anterior uveitis

HSV
CMV
Seronegative arthropathies e.g. IBD, sarcoidosis
Eye trauma
TB
Syphillis

181

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

182

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.

183

Management of PCOS

Weight loss!
COCP if not wishing to conceive
• Dianette if hirsutism
Clomiphene citrate to induce ovulation if wishing to conceive
Metformin to control insulin resistance

184

Give 4 causes of menorrhagia

Fibroids
Adenomyosis
Pelvic infection
Endometrial cancer

185

Management of menorrhagia

Correct iron deficiency
NSAIDs - mefanamic acid for pain
Antifibrinolytics - tranexamic acid
Surgical ablation/removal of fibroids (myomectomy)

186

Define cerebral palsy

A primary abnormality of movement and posture secondary to a non-progressive lesion of developing brain.

187

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.

188

Define stress

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

189

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

190

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

191

What happens to LH and FSH levels after menopause?

Increase due to less -ve feedback from oestrogen

192

What are the signs of menopause? (low oestrogen)

Atrophic vaginitis
Endometrial atrophy
Loss of keratin
CVD, CVA
Bone depletion

193

What is the indication for prescribing HRT?

Reducing vasomotor symptoms is the only correct indication

194

Can you start HRT while still having periods?

Yes it will regulate them

195

What are the risks of HRT

Breast cancer
- Increases with age and duration of use
Venous thromboembolism
- Most in year 1. May be less for patches
Stroke
- Very low risk
Coronary heart disease
- Only combined HRT

196

Benefits of HRT

Symptom control
Osteoporosis prevention
May reduce risk of CHD
Reduce colorectal cancer risk

197

Define menopause

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

198

What is premature ovarian failure?

Menopause before the age of 40 years

199

Why do women get hot flushes?

Narrowing of the thermoneutral zone

200

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)

201

What type of HRT should be offered if women have had a period in the last year?

Cyclical HRT (combined progesterone and oestrogen)

202

When can you offer continuous HRT?

If a woman hasn't had a period in a year post menopause

203

CI for HRT

History of Pulmonary Embolism
Abnormal liver function tests
Angina
Blood pressure of 180/98
Intermenstrual bleeding

204

Give 4 causes for male LUTS

BPH
Prostate cancer
Overactive bladder
Bladder cancer
Urethral stricture
Neuropathic bladder

205

What are 3 red flag symptoms for LUTS

Haematuria
Recent severe symptoms
Pain
Palpable bladder and nocturnal incontinence – high pressure chronic retention
Abnormal DRE
Abnormal U&Es and PSA

206

3 types of LUTS

Voiding - poor flow, hesitancy
Storage - frequency, urgency, incontinence, nocturia
Post-micturition - dribbling

207

Treatments for LUTS

Voiding - Alpha-blockers (tamsulosin)
Storage - Beta agonist (mirabegron)
Post-mict - Urethral milking, pelvic floor exercises

208

Treatment for acute urinary retention

Catheter (via urethra or suprapubic)

209

Give 3 differentials for a painless/minimally painful scrotal swelling

Hydrocoele
Testicular tumour
Hernia
Spermatocoele
Varicocoele

210

Investigations for suspected testcular tumour

USS of testes
Tumour markers - beta-HCG and alpha fetoprotein (AFP)
Staging CT of chest, abdomen and pelvis

211

Management of testicular cancer

Radical orchidectomy with or without prosthesis
Chemotherapy
Sperm storage

212

Differentials for acute painful scrotum

Testicular torsion until proven otherwise.
Torsion of hydatid of Morgagni
Idiopathic scrotal oedema
Epididymorchitis
Trauma

213

Management of epididymorchitis

Analgesia
Doxycycline, ciprofloxacin

214

Give 4 causes of haematuria

BPH
UTI
Malignancy
Stones
Trauma
Glomerulonephritis

215

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

216

Risk factors for TCC of bladder

Smoking
Benzene compounds exposure
Drugs (cyclophosphamide, phenacetin)

217

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

218

What are the age related cut offs for PSA

40-49 >2.0
50–59 >3.0
60–6 >4.0
70 and over >5.0

219

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)

220

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).

221

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

222

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.

223

Symptoms of migraine

Visual or other aura lasting 15-30 mins followed by severe unilateral throbbing headache or isolated aura with no headache

224

Triggers for migraine

Chocolate, cheese, wine, alcohol, lie-ins

225

Treatment for migraine

NSAIDs, Triptans, prevention with B2 blockers or tricyclis

226

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

227

What is sensitivity and how do you calculate it?

Sensitivity is the probability that a test will indicate disease among those with the disease

TP/(TP+FN)

228

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)

229

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)

230

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)

231

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

232

What are the main services offered by Coventry MIND?

Support at home to address mental health and daily living needs
Accomodation support
Recovery and development groups
Befriending
Counselling
Gardening
Wellbeing hub

233

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

234

What are the top 3 infectious disease categories?

1. Respiratory infetions
2. Diarrhoeal diseases
3. HIV/AIDS

235

Give 4 risk factors for HIV (many)

Unprocted sex
Multiple partners
Sharing needles
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

236

Global risk factors for infectious disease

Poverty
War
Under-resourced healthcare services
Access to clean water
Environment

237

What piece of legislaton prevents discrimination in the workplace for LGBTQI persons

Equalities act (Sexual orientation) 2007

238

Teen pregnancy is associated with - ?

Social disadvantage
Poor education
Low aspiration

239

Describe trends in common STIs

Chlamydia is most common
Syphillis and Gonorrhoea are on the rise
Large STI diagnosis increase in MSM

240

Explain the increase in STIs

Increase young people having sex
STI awareness
Easier service access
Better diagnosis
Artefact

241

Why should you notify partners of patients with STI?

Protect partner from reinfection
Offer partner STI tests
Treatment
Inhibit further spread

242

What important factors from a Hx do you want to ask a patient presenting with jaundice?

Demographic
GI symptoms - stool and urine colour, weight loss
Alcohol
Hepatitis risk factors - tattoos, travel, sexual hx

243

What is the most sensitive blood test of synthetic liver function?

PT/INR

244

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

245

What is the key investigation for jaundice?

Abdominal ultrasound

246

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.

247

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

248

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
Appetite change

249

What tool is used for patients at risk of malnutrition?

Malnutrition Universal Screening Tool (MUST)

250

Give 4 differentials for weight loss with poor appetite

GI inflamation e.g. IBD
Cancer
Psychiatric disorders
Systemic infection e.g. HIV

251

Give 4 differentials for weight loss with normal appetite

Malabsorption e.g. Coeliacs
Endocrine e.g. Diabetes
Drugs
Alcoholism

252

Give 4 causes of malabsorption in the small intestines

Coeliac's
Crohn's
Lactose intolerance
Intestinal resection

253

What are the complications of Coeliac's?

Enteropathy-associated lymphoma (intestines)
Anaemia
Osteoporosis the leading to fractures
Small bowel and oesophageal carcinoma

254

Oesophageal carcinoma risk factors

Smoking
Alchohol
FHx
Hiatus hernia

255

What investigations would you perform in suspected oesopheageal cancer?

Bloods
0 FBC, U&Es, LFTs
Imaging and special tests
0 OGD ± biopsy / barium swallow
0 Staging CT / staging MRI/PET scan

256

When should you refer patients for suspected colon cancer using 2ww?

40 or over with unexplained weight loss and abdo pain
OR
50 or over with unexplained rectal bleeding
OR
60 or over with
- Iron-deficiency anaemia or
- Changes in bowel habit

257

What is pernicious anaemia?

Common haematological condition characteriseby
autoimmune destruction of the parietal cell and intrinsic
factor resulting in severe VITAMIN B12 deficiency.

258

Treatment of pernicious anaemia

Treatment is with IM injections of hydroxycobalamin 3x weekly for 2 weeks then every 3 months

259

What PMH do you want to find out in a sexual history?

Previous STIs/UTIs
HIV status
LMP if female
Last smear if >25 and female

260

Definition of dysuria

Painful voiding of the urinary bladder

261

Potential causes of dysuria

UTI
Stones
Urethritis (STIs)
Bladder tumour
Prostatitis

262

What is the most common causative organism in a UTI

E. coli

263

What Ix would you like to do for a patient with dysuria?

Urine dip
Urine MCS

264

Management of UTI

Uncomplicated - Trimethoprim or Nitrofurantoin
Complicated - Co-amoxiclav

265

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

266

Differentials for genital discharge

Infective
- Chlamydia
- Gonnorhoea
- Trichomonas
- BV
- Thrush (Candidiasis)

Non-infective
- Polyp
- Retained foreign body
- Malignancy

267

What is the Amsel criteria?

A criteria for diagnosisng BV wth 3 indicating BV
White adherent discharge
Clue cells
+ve whiff test
Vaginal pH >4.5

268

Treatment for Chlamydia

Doxycycline/Azithromycin

269

Treatment for Gonorrhoea

IM cephalosporin

270

Treatment for BV

Metronidazole

271

Differentials for genital ulcers

Herpes simplex 2 HSV2
Syphillis
HIV

272

What are some AIDS defining illnesses

Chronic HSV infection
Kaposi's sarcoma
Oesophaegal candidiasis
Pneumocystis pneumonia
CMV retinitis
Lymphoma due to EBV

273

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

274

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

275

3 causes of an oesophageal bleed

Mallory-Weiss tear
Malignancy
Varices

276

3 causes of a bleed from the stomach

Gastric ulcers
Gastric varices
Cancer

277

Management of piles

Cons - High fibre diet, laxatives, analgesia, avoid strain
Medical - Injecton sclerotherapy
Surgical - Haemorrhoidectomy, arterial ligation

278

What is diverticular disease?

Colonic diverticulosis refers to herniation of mucosa and submucosa through the muscular layer of the colonic wall (outpouching).

279

What important factors would you like to gather in a history of a patient with dysphagia?

Duration
Progression
Pain on swallowing (odynophagia)
Solids/Liquids/Both?
Regurgitation of food
Any weight loss
Smoking/alcohol hx

280

What are the 3 phases of swallowing?

Buccal - voluntary
Pharyngeal phase - involuntary
Oesophogeal phase - involuntary

281

Give 4 causes of dysphagia

Myasthenia Gravis
Achalasia
Goitre
Stricture
Oesophageal spasm
Cancer

282

What ix would you do for dysphagia?

Bloods - FBC U+Es
CXR
Barium swallow
OGD
Staging CT scan
PET scan

283

What are ALARM features for patients with GORD?

Dysphagia
Evidence of GI blood loss
Persistent vomiting
Unexplained weight loss
Upper abdo mass

Any of these means patients need to be referred to hospital specialists

284

Management of GORD

Cons - MDT, stop smoking, reduce alcohol, reduce weight
Medical - Antacids, PPIs, H2 receptor antagonists, ?H. Pylori eradication
Surgical - Nissen fundoplication

285

How would you explain an OGD to a patient

Procedure:
- 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
- Perforation
- Aspiration

Obtain consent

286

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

287

What is Achalasia?

Oesophageal aperistalsis
• Impaired relaxation of LOS

Leads to intermittent dysphagia to both solids and liquids.

288

Management of achalasia

Symptomatic relief
Endoscopic balloon dilatation
Botox injection
Surgery

289

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

290

What defines moderate asthma?

Increasing symptoms
PEF >50-75% best or predicted
No features of acute severe asthma

291

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

292

Features of life-threatening asthma

In a patient with severe asthma any one of:
PEF <33% best or predicted
SpO2 <92%
PaO2 <8kPa
Normal PaCO2
Silent chest
Cyanosis
Poor respiratory effort
Arrhythmia
Exhaustion
Hypotension

293

How would you initially assess an critically unwell or deteriorating patient?

ABCDE approach

294

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

295

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.

296

What criteria are used to diagnose PCOS?

Rotterdam criteria

297

Give one complication of pregnancy that PCOS sufferers are more likely to develop

Gestational diabetes
Pre-eclampsia
Preterm labour

298

What blood test can be used to identify Antiphospholipid syndrome

Anti cardiolipin antibodies OR lupus anticoagulant

299

Name 2 causes of aortic stenosis

Senile calcification
Rheumatic heart disease
Bicuspid valves (genetic defect)

300

Define a TIA

A TIA is a sudden, focal, neurological deficit of vascular origin that lasts less than 24 hours

301

Where is folic acid absorbed?

Jejunum

302

What can cause folate deficiency?

Poor diet
Alcoholics
Coeliac disease
Crohn's disease

303

How are bacteria classified?

Classified on gram stain and shape
Gram = +ve or -ve
Shape = coccus or bacillus/rod

304

What scoring system do you use for a patient with community accquired pneumonia?

CURB-65

Confusion
Urea >7mmol/L
Resp. rate >30/min
BP <90 systolic or <60 diastolic
Age 65 or over

Score of >1 admit
>2 then IV treatment

305

Give 3 mechanisms or antimicrobial resistance

Antibiotic efflux
Enzymatic degredation
Target mutation
Reduced permeability
Alternative metabolic pathways

306

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

307

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

308

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

309

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

310

Top 3 leading risk factors of death by sex

F: Stroke, IHD, LRTI
M: IHD, Stroke, COPD

311

Top 3 risk factors globally

HTN, tobacco, high cholesterol

312

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

313

What are the differences between population and high risk strategy for reducing cardiovascular disease? (Think upstream downstream from 1st year)

Population strategy:
- 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

314

Give the 3 main drivers of increasing cardiovascular disease in developing countries

Diet
- Shift from simple to processed foods
- Increase in fat production and consumption

Physical inactivity
- Rise of cards
- Rise of obesity

Cultural change
- Supermarketisation
- Lifestyle

315

What are the different approaches to reducing salt intake? Which is most effective?

Regulation and market control (most effective)
Taxation
Primary care (least effective)

316

Define inequity in healthcare

When people with the same needs do not have the same level of access to the services they require

317

Define inequality in healthcare

It is the systematic differences in health and illness across social groups

318

Why should inequity in healthcare be addressed?

Principles of justice and fairness
Determinant of health inequalities
Duty under equalities act 2010

319

Give 4 causes of inequitable access

Physical access
Geographical
Financial
Cultural - lack of interpreters, preferring same sex HCP
Clinician beliefs and attitude
Navigating through health and social care system

320

How can barriers to access be reduced? (4 of many)

Multi-disciplinary approach
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

321

5 main function of the kidney

Filtration - remove urea/creatinine
Regulation of ECF components
Electrolyte balance - Na+/K+
Acid-base balance
Endocrine function- RAAS

322

Give 3 causes of primary nephrotic syndrome

Minimal change glomerulonephritis
Focal segmental glomerulosclerosis
Membranous glomerulonephritis

323

Give 3 causes of secondary nephrotic syndrome

SLE
Hep B and C
HIV
Diabetes mellitus
Malignancy

324

Give 2 causes of nephritic syndrome

IgA nephropathy
Post-streptococcal glomerulonephritis
Goodpastures syndrome

325

Give 5 common nephrotoxic drugs

NSAIDs - Inhibit vasodilatory PGs in afferent arteriole
ACEi - reduce BP and dilate efferent arteriole
Gentamicin - Directly cytotoxic
Furosemide
Penicillins
Cephalosporins

326

What is oliguria?

<0.5 mls/Kg/hr of urine
OR
<400mls/day

327

What is anuria?

0ml/day - <100mls/day

328

What needs to be excluded before a diagnosis of anuria can be made?

Mechanical obstruction

329

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

330

What is CKD?

Gradual loss of kidney function that occurs over months to years

331

What can be found in urine that can help confirm multiple myeloma?

Bence-Jones proteins

332

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

333

If a patient present with claudication in the gluteal muscles what level is the blockage present at?

Aorto/Iliac

334

What medications may indicate patient is at risk of peripheral vascular disease?

Beta-blockers

335

DDx of an acute cold leg

Embolus
Pressure/compression
Trauma
Thrombosis of aneurysm

336

DDx of an acute warm leg

DVT
Cellulitis
Osteomyelitis
Sciatica
Gout
OA
#

337

Give 4 signs of PVD

Hair loss
Shiny
Cyanosed
Dry skin
Ulcers
Reduced muscle bulk

338

Describe the characterisitics of an arterial ulcer

Often found at toes, feet or ankles
Punched out well defined edge
Necrotic base
Painful
Often small

339

Describe characteristics of a venous ulcer

Commonly found at medial gaiter region
Edges poorly defined
Haemosiderin deposits around wound
Can be large
Minimal pain

340

What would an ABPI value of >1.3 suggest?

Calcification of vessel

341

Give the 6 Ps of ischaemia

Pain
Pallor
Pulseless
Perishingly cold
Paralysis
Paraesthesia

342

Give the 5 initial steps to halt bleeding after an injury

Local vasoconstriction
vWF binds to surrounding collagen
Adhesion and aggregation of platelets
Platelets release ADP and TxA2
Activation of clotting cascade to create a fibrin clot

343

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

344

What blood tests results would you see in a patient with haemophilia A?

Elevated APTT with normal PT & vWF levels

345

What is the treatment for haemophilia A?

Factor VIII infusion either prophylactically or at time of bleeding

346

What is haemophilia B?

A herediatary clotting disorder caused by a deficiency in factor IX
X linked recessive
Also known as Christmas disease

347

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

348

3 causes of DIC

– Malignancy
– Sepsis
– Haemolytic transfusion reactions
– trauma/burns/surgery
– Liver disease

349

Rx for DIC

No treatment unless bleeding
Treat underlying cause
Can use packed RBCs, Plt transfusion and FFP/cryo if bleeding

350

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)
Haemoptysis (+1)
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

351

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
apart

352

When would you use thrombolytics?

• STEMI, if PCI not available within 90- 120mins
• Massive PE
• Ischaemic stroke
Options are
• Streptokinase (derived from bacteria, risk of allergic reaction)
• Alteplase, reteplase (recombinant tissue plasminogen activators)

353

When would you use anti-platelet drugs?

• MI
Options are:
• Aspirin – COX inhibitor
• Clopidogrel – targets platelet ADP receptor
• Abciximab - GpIIb/IIIa inhibitor
• Ticagrelor (STEMI) – platelet aggregation inhibitor (P2Y 12 receptor antag)

354

When would you use anticoagulants and give some examples

DVT, PE
Options are:
• 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)

355

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

356

Main general causes of obesity

Environment – By far the commonest cause.
Genetic factors
Endocrine (<1%)
Drugs

357

Causes of a fixed dilated pupil

If unconscious then herniation
Oculomotor nerve palsy
Acute closed-angle glaucoma

358

Symptoms of SIADH

Caused by the hyponatraemia
Mild – Nausea/Vomiting/Headache/Anorexia /Lethargy
Moderate – Muscle cramps/Weakness/Confusion/Ataxia
Severe – Drowsiness / Seizures / Coma

359

Signs of SIADH

Decreased level of consciousness
Cognitive impairment
Focal or generalised seizures
Brain stem herniation – severe acute hyponatraemia (coma / respiratory arrest)
Hypervolaemia –pulmonary oedema / peripheral oedema / raised JVP / ascites

360

What Ix would you do for suspected SIADH?

Fluid status
Serum sodium
Serum potassium
Urinary sodium
TFTs

361

What is the biochemical triad of DKA?

Ketonaemia, hyperglycaemia and acidaemia

362

What is the clinical presentaiton of a patient with DKA?

Polyuria with polydipsia – commonest presenting symptom
Weight loss
Fatigue
Dyspnoea
Vomiting
Preceding febrile illness
Abdominal pain
Polyphagia
Ketotic breath

363

Define term immigrant

Anyone who moves to another country for 1 year+

364

Define term asylum seeker

Person who claims asylum in the UK due to persecution in country of origin

365

Give 3 common migrant health issues

FGM
Infectious diseases
No access to healthcare (illegal immigrants)

366

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

367

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

368

MoA of Orlistat

Inhibits action of lipase in GI tract so 30% less dietary fat is absorbed

369

What 2 school years is the national child measurement programme carried out in england?

Reception (4-5)
Year 6 (10-11)

370

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:
- fundoscopy
- QRISK2
- ECG
- Proteinuria/haematuria
- plasma glucose, GFR, cholesterol

Offer lifestyle advice
- Reduce salt, alcohol, smoking
- Exercise regularly

Offer ACEi initially then review

371

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
- Diabetes
- 10 year risk of =/>20%

If stage 2 they should all be offered antihypertensives

372

Why should ACEi not be used in pregnancy?

Reported to cause congenital malformations, stillbirths and neonatal deaths

373

Give 4 causes of ascites

Cirrhosis
HF
Bacterial peritonitis
Acute pancreatitis
Renal failure
Pseudomembranous colitis

374

DDx of acute diarrhoea (3 of many)

Infection (Norovirus)
Drugs
Ischaemic colitis
IBD flare up
Diverticular disease

375

What is hypospadias?

Opening of urethra on ventral surface of penis

376

How does lichen planus present clinically?

Pruritic, purple, polygonal, planar papules and plaques

Remember the 6 P's of lichen planus

377

What condition is associated with this presentation? – A pink pearly nodule with telangiectasias, ulceration and rolled borders on the upper lip.

Basal cell carcinoma

378

How does impetigo present?

Golden honey coloured crust over an erythematous base

379

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.

380

What skin condition is caused by the pox virus and what is its presentation?

Molluscum contagiosum
Presents as an umbilicated papule.

381

What are the signs of cardiac tamponade?

Beck's Triad
Hypotension, muffled heart sounds and increased JVP.

382

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

383

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

384

Describe the first stage of labour

Starts when the effaced cervix is 3cm dilated and ends when the cervix is fully dilated at 10cm.

385

What is the correct way to calculate the estimated date of delivery (EDD)?

First day of LMP + 9 months and 1 week

386

At 28 weeks gestation where would you expect to feel the uterine fundus?

Halfway between umbilicus and xiphisternum

387

Which period of gestation does the 2nd trimester represent?

13-28 weeks

388

When will a pregnant patient expect to feel foetal movements?

18-20 weeks

389

Definition of post-partum haemorrhage

Loss of >500ml of blood from the vagina within 24 hours of delivery

390

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.

391

What is gold standard Ix for diagnosing acromegaly?

Oral glucose tolerance test + Growth hormone measurement

392

What is the cut-off for an acceptable weight loss in the first 7 days of life?

10%

Any more requires follow up/referral

393

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.

394

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.

395

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.

396

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

397

How does acute pancreatitis present clinically?

Epigastric/central abdominal pain
• Pain radiates to the back
• Helped by sitting forward
• Vomiting

Signs;
– Tachycardia, hypotension, pyrexia, ↑RR, ↓O2
sats, abdo pain, Cullens/Grey Turner’s sign,
peritonitic

398

Signs of ascending cholangitis

Charcot's triad
1. Jaundice
2. Fever, usually with rigors
3. Right upper quadrant abdominal pain.

399

Pathophysiology of asthma

Bronchial muscle constriction
Mucosal swelling/inflammation
Increased mucus production and plugging of bronchi

400

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.

401

Rx for hypovolaemic hyponatraemia

Slow rehydration with normal Na+

402

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)

403

Give 3 causes of hypokalaemia

Extra-renal:
- Vomiting
- Diarrhoea
Renal:
- Diuretics
- Conn's
- Cushing's
- Steroids

404

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

405

What is the aim of a HNA?

To provide information to plan and change services for the better and to improve health

406

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

407

Define self management support

Techniques that help patients choose healthy behaviours. Transforms care-giver relationship into partnership

408

Define self efficacy

Ability to monitor ones condition and effect cognitive, behavioural and emotional responses necessary to manintain satisfactory QoL

409

What bedside investigations would you undertake in someone with a supected TIA?

ECG
Blood glucose - rule out hypoglycaemia as a cause of neuro signs

410

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)

411

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.

412

What age do women commence breast screening?

50 years of age

413

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:
discharge
retraction
other changes of concern - 'peau d’orange’, tethering, bony pain(mets)

414

Two indications for use of an NG tube

Unsafe swallow
Unable to swallow
Unable to maintain adequate nutritional intake
Drainage of stomach contents

415

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

416

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

417

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)

418

What are the broad areas assessed in the MSE? (8)

Appearance and behaviour
Speech
Thought
Mood
Perception
Insight
Cognition

419

What 3 types of embryonic tissue is the eye derived from?

Mesoderm of the head region
- Lens
The neural tube (neuro-ectoderm)
- Retina
Surface ectoderm
- Corneoscleral and uveal tunics

420

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

421

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.

422

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

423

What 3 muscles control the eyelids

Orbicularis oculi = closes (CN VII)

Levator palpebrae superioris = opens (CN III)

Superior tarsal muscle = opens (Sympathetic)

424

What veins can be accessed in the cubital fossa?

Cephalic, basilic or median cubital veins

425

Borders of cubital fossa

Superior – Epicondylar line

Lateral – Brachioradialis

Medial – Pronator teres

426

What nerves are at risk with cannulation into cubital fossa?

Medical and lateral cutaneous nerves of forearm

427

What structures are at risk when cannulating the cephalic vein in the anatomical snuffbox?

Superficial branch of radial nerve
Radial artery

428

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

429

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

430

What two positions can the IJV be accessed from for central venous cannulation?

Lesser supraclavicular fossa
Posterior border of SCM

431

What nerves are at risk when attempting to cannulation the EJV

Accessory nerve (CNXI)
Cutaneous branches of cervical plexus

432

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

433

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

434

What type of incision allows adequate exposure while aligining with tension lines?

Z-plasty

435

What surgical approach would you take to access the mediastinum and why?

Median sternotomy
Avoids intercostal muscles and neurovascular bundle, internal thoracic artery & vein and provides good mediastinal access

436

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

437

What incision is used to access the anterior and posterior compartments of thigh?

Lateral fasciotomy incision

438

Describe surgical approach to ankle

Incision made midway between tibia & fibula heading towards 4th metatarsal base
Intermediate dorsal cutaneous nerve id
Extensor tendons retracted

439

Describe surgical approach to shoulder

Anterolateral approach made
ID coracobrachialis and work at lateral side
Medial side is the suicide

440

What is the gold standard investigation for diagnosis of TB?

Discharged pus or biopsy material for direct staining and culture

441

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.

442

What is a vesicle?

A raised lesion filled with serous fluid that is <5mm diameter

443

What type of epithelium lines the labia minora?

Non-keratinised stratified squamous

444

What is the major determinant of the clinical manifestations of a virus?

Tropism of the virus for specific tissues and cell types

445

Give 2 direct cytopathic effects of viruses once they have entered cells

Induction of apoptosis
Production of toxic proteins
Production of degradative enzymes

446

Give 2 reasons why a combo of chemotherapy agents are used to treat patients

More effective due to different MoA
Reduces chance of resistance
Different toxicities

447

What cell types would be increased if a patient is give G-CSF

Neutrophils
Eosinophils
Basophils

448

How do you calculate relative risk reduction?

Example:
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%

449

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

450

Pathways involving which neurotransmitter are involved in the pathogenesis of confusion?

Acetylcholine

451

What is beta oxidation?

Process in which fatty acids are broken down in mitochondria to generate acetyl-coA

452

How do class 1c antiarrhythmics stabilise heart rhythm?

By slowing conduction in all parts of the heart

453

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

454

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

455

What timescale does HbA1c reflect glycaemic control over?

The preceding 2-3 months

456

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.

457

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

458

3 questions you would want to ask a patient who presents with TIA about their presenting complaint

Any sensory losses
Dysphagia
Dysphasia
Visual disturbance

459

3 risk factors for TIA

HTN
Smoking
AF
Diabetes
Previous TIA/Stroke

460

3 common causative organisms for otitis media

H. Influenzae
Strep. pneumonia
Staph. Aureus

461

3 serious complications of progressive middle ear infection

Mastoiditis
Labyrinthitis
Brain abscess
Epidural abscess

462

3 complications of pneumonia

Empyema
Pleural effusion
Sepsis
Pneumothorax
Lung abscess

463

Two factors that increase risk of developmental hip dysplasia

Breech presentation
Female
FHx
Oligohydramnios
1st born

464

4 layers of epidermis

Stratum corneum
Granular cell layer
Spinous cell layer
Basal cell layer

465

3 Cells found in epidermis

Keritanocytes - produce proteins
Melanocytes - secrete melanin
Merkel cells - light touch

466

Functions of skin

Physical barrier
Protection against infection/ UV
Prevent water loss
Vit. D synthesis
Wound healing
Sensation
Temp. regulation
Psychosocial

467

How can you describe a lesion? (Pneumonic)

Size
Shape
Colour
Associated change
Margins
Morphology

SSCAMM

468

Features of nodular BCC

Small, shiny, skin-coloured swelling
Telangiectasia at edge
Rolled edge and central ulcer
Bleed spontaneously
Slow growing

469

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

470

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

471

Give 3 differentials for superficial neck lumps

Sebaceous cyst
Lipoma
Abscess

472

2 differentials for midline neck lump

Thyroglossal duct cyst
Goitre
Cyst
Thyroid malignancy

473

4 differentials for anterior triangle neck lumps

Lymph nodes
Branchial cyst
Salivary gland swelling
Carotid aneurysm

474

2 differentials for posterior triangle neck lumps

Lymph nodes
Subclavian artery aneurysm

475

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

476

4 causes of T1 respiratory failure

Pneumonia
PE
Pulmonary oedema
Asthma
Fibrosis
ARDS

477

4 causes of T2 respiratory failure

COPD
Opiates
Fibrosis
Asthma
Myasthaenia Gravis

478

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

479

How do you confirm diagnoses of COPD

Spirometry - FEV1 and FVC
The ratio will be <70% showing an obstructive pattern

480

What criteria are used to determine if a patient needs home oxygen?

PaO2 <7.3

Must NOT be smoking

481

Describe the appearance of acute guttate psoriasis

Salmon pink papules +/- scales
Scattered discrete lesions mainly on trunk
Can evolve into chronic plaque form

482

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

483

Nails changes in psoriasis

Pitting
Oncholysis
Oil spots
Transverse ridging
Subungal hyperkeratosis

484

Causative agent of acne vulgaris

Propionibacterium acnes

485

Pathology underlying acne

Follicular plugging prevents drainage of sebum
Androgens stimulate sebaceous glands
Inflammatory response
Intense inflammation leads to scarring

486

Features of acne skin lesions

Comedones
Papules and pustules
Nodules
Scars

487

Features of rosacea

Erythema
Papules
Nodules
No comedones
Symmetrical

488

What is the most common primary immunodeficiency?

Common variable immunodeficiency

489

4 types of primary immunodeficiency

Phagocytes deficiency
Complement deficiencies
Severe combined immuno-deficiencies
Predominantly antibody deficiencies

490

Gold standard Ix for CGD

Nitro-tetrazolium blue (NBT) - Normal phagocytes reduce this to a dark blue pigment

491

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

492

What test can be done to confirm diagnosis of anaphylaxis?

Serum tryptase

493

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
Informed decision
ADRT must also state precisely the treatment to be refused and the circumstances in which it applies

494

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

495

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.

496

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.

497

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

498

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

499

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

500

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).

501

Define a schema

A cohesive, repeatable action sequence possessing component actions that are tightly interconnected and governed by a core meaning.

502

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.

503

Factors affecting concordance

Patient centred
Therapy related
Social and economic
Healthcare system
Disease

504

Define attribution bias

We attribute our errors to situational factors but others errors to character flaws

505

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

506

What is availability bias?

Tending to come up with a solution that happens to be on your mind

507

What is affective bias?

Basing your decisions on emotional reaction to a patient

508

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

509

What do the carotid sinus and carotid body sense?

Carotid sinus senses pressure

Carotid body senses mainly PO2 and PCO2

510

What are the B symptoms of lymphoma

Night sweats
Fever
Weight loss
Persistent tiredness
N+V

511

3 signs which would be relevant to lymphoma

Hepatomegaly
Splenomegaly
Anaemia
Other palpable lymph nodes
Systemic features (fever, anorexia)

512

3 features of a breast lump that could be indicative of breast cancer

Firmness or hard irregularity
Tethering
Lymphadenopathy
Nipple changes
Ulceration of breast
Peau d'orange

513

Give a medical treatment for ectopic pregnancy

Methotrexate
Avoid pregnancy because of persisting teratogenic effect on foetus

514

Two predisposing causes for ectopic pregnancy

PID
IUD
Tubal/gynaecological surgery

515

What hormone is measured in early pregnancy and what is its function

hCG
Acts on corpus luteum to secrete oestrogen and progesterone

516

What scoring system is used for acute pancreatitis?

Glasgow-Imrie
PaO2 <8kPa
Age >55
Neutrophils >15
Ca2+ <2
Renal: Urea >16
Enzymes: LDH >600
Albumin <32g/L
Sugar: Glucose >10mmol/L

517

Two systemic manifestations of gonorrhoea

Skin rash - erythema nodosum
Eye problems - keratoconjunctivitis
Joint problems - Reactive Arthritis

518

Symptoms of hyponatraemia

Gait instability
Concentration and cognitive deficits
Headache
Vomiting
Drowsiness
Seizures

519

Which murmur is most associated with AF

Mitral Stenosis

520

Boundaries of the neck

Superior boundary
- Inferior mandible and base of skull

Inferior boundary
- Manubrium, clavicle and actinium to spinous process of C7

521

Three clinical signs on abdominal examination that would be elicited in a patient with ascites

Shifting dullness
Fullness in flanks
Fluid thrill
Herniae
Dilated superficial abdominal veins

522

Boundaries of carotid triangle

Ant - omohyoid (sup. belly)
Sup - Digastric (pos. belly)
Post - SCM

523

Submandibular triangle borders

Sup - Inferior border of mandible
Inf - Digastric (ant. and post. bellies)

524

Where is the lower back

Area in between base of 12th ribs, buttock creases and mid axillary line

525

What is the mental capacity act 2005?

Sets out legal framework for making decisions for people who lack capacity to make decisions for themselves

526

5 key principles of MCA

Assume capacity unless proven otherwise
Unwise decision doesn't mean lack of capacity
Best interests
All practicable help given
Least restrictive

527

Features of subcortical dementia

Apathetic
Forgetful and slow
Impaired visuospatial abilities
Depression of mood

528

Features of cortical dementia

Higher cortical abnormalities
Dysphasia
Agnosia
Apraxia

529

2 examples of subcortical dementia and 2 examples of cortical

Subcortical
- HD
- Parkinson's
- Normal pressure hydrocephalus

Cortical
- Alzheimers
- Creutzfeld-Jakob disease
- Frontotemporal dementia

530

What is the most common infectious organism responsible for bronchiolitis?

Respiratory syncytial virus (RSV)

531

What test should be used to confirm a diagnosis of gestational diabetes?

2 hour OGTT - value of 7.8mmol/L or above is diagnostic

532

Give 3 risk factors for a woman developing gestational diabetes

BMI > 30
Previous gestational diabetes
FHx of diabetes mellitus

533

3 complications of gestational diabetes in mother/baby/foetus

Shoulder dystocia
Macrosomia
Higher risk of preeclampsia and later diabetes

534

What is the target range of fasting blood glucose for women with gestational diabetes?

5.3mmol/L

535

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

536

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

537

4 causes of azoospermia

Vasectomy
Hypogonadism
Undescended testes
Anti-sperm antibodies

538

Give 2 further investigations to help assess cause of azoospermia

Serum LH
Serum FSH

539

Two options for a couple who are infertile due to azoospermia

Adoption
Donor insemination

540

Give 2 risk factors for developing psoriasis

Drugs e.g. Lithium, beta blockers, alcohol
Genetic link - first degree relative suffering from it
Stress

541

What is the Koebner phenomenon?
What conditions is it associated with?

It is the development of a skin lesion at the site of an injury

Occurs in psoriasis, vitiligo, lichen plants, viral warts