Key Learning Points (1 OF 2)

Question 1

Outline the key features of benign essential tremor? (4)

Answer 1

• Postural tremor; worse when arms are outstretched - Improved with alcohol - Improved with rest - Bilateral

Question 2

Outline how the ankle-brachial pressure index (ABPI) can be used to inform diagnosis of peripheral vascular disease?

Answer 2

• ABPI < 0.9; likely peripheral arterial disease (PAD)
• ABPI 0.9 - 1.2; normal/acceptable
• ABPI > 1.2; arterial calcification (stiff arteries) seen in advanced age and diabetes

Question 3

Outline the classical examination signs that can be positive in patients with meningitis? (2)

Answer 3

• Brudzinski’s sign; inability to fully extend at the knee when the hip is flexed at 90¬∫ due to pain - Kernig’s sign; spontaneous flexion of the knees and hips on active flexion of the neck due to pain

Question 4

Which disease should all patients with type 1 diabetes or autoimmune thyroid disease be screened for?

Answer 4

Coeliac disease

Question 5

Outline the management approach used in granulomatosis with polyangitis (GPA)? (2)

Answer 5

• Induce remisssion; IV methlyprednisolone and cyclophosphamide or rituximab
• Maintenance of remission; wean the steroids in favour of azathioprine, mycophenylate or rituximab

Question 6

Which conditions are patients who have received radiotherapy treatment for prostate cancer, at increased risk of developing? (2)

Answer 6

• Bladder cancer
• Colorectal cancer

Question 7

Which single tumour type is the most likely to metastasise to the brain?

Answer 7

Lung tumours

Question 8

Which scoring system can be used to risk stratify and guide the treatment of neutropenic sepsis?

Answer 8

Multinational Association for Supportive Care in Cancer (MASCC)

Question 9

What is the most common cause of cholecystitis?

Answer 9

Impacted gallstone in the cystic duct or the neck of the gallbladder

Question 10

Outline the most common insertion site for an intraosseous line?

Answer 10

Proximal tibia

Question 11

Outline the NICE Guidelines for when to make an urgent 2-week wait referral for haematuria? (3)

Answer 11

• Age ‚â• 45 and unexplained visible haematuria without urinary tract infection - Age ‚â• 45 and visible haematuria that persists or recurs after successful treatment of urinary tract infection - Aged ‚â• 60 and unexplained non-visible haematuria and eith

Question 12

Outline the immediate managament of a witnessed cardiac arrest occuring whilst the patient is on cardiac monitoring?

Answer 12

Up to 3 successive shocks before CPR is commenced

Question 13

Outline the key ECG changes associated with hypokalaemia? (5)

Answer 13

• P waves; increased amplitude and width - PR interval; prolonged (can cause 1st degree heart block) - ST segment; depression - T waves; low amplitude - Additional ‘U; waves

Question 14

What is the most common cause of thyrotoxicosis?

Answer 14

Grave’s Disease

Question 15

Outline the diagnostic criteria for medication overuse headaches (MOH)? (3)

Answer 15

• Headache ‚â•15 days/month in context of pre-existing headache disorder - Regular overuse (>3 months) of ‚â•1 drug taken for acute treatment of headache - No better ICHD-3 diagnosis

Question 16

Outline the criteria used for a diagnosis of epilepsy? (3)

Answer 16

• Criteria 1; ≥ 2 unprovoked (or reflex) seizures occurring > 24 hours apart
• Criteria 2; ≥ 1 unprovoked (or reflex) seizure with a similar risk of recurrence
• Criteria 3; a known diagnosis of an underlying epilepsy syndrome

Question 17

Which organisms are most commonly associated with infective endocarditis? (3)

Answer 17

• Streptococcus viridans (Œ±-haemolytic); in most patients - Staphylococcus aureus; in IVDU or prosthetic valves - Staphylococcus epidermidis; in prosthetic valves

Question 18

What is the conversion factor for oral to subcutaneous morphine administration?

Answer 18

Divide oral dose by two

Question 19

What is the first-step investigation in a patient who has been exposed to chickenpox during pregnancy?

Answer 19

Perform blood test for varicella-zoster antibodies and await the result

Question 20

What is Bowen’s disease?

Answer 20

Bowen’s disease is a type of precancerous dermatosis that is a precursor to squamous cell carcinoma (SCC) and is more commonly seen in elderly patients

Question 21

Outline the major risk factors for the development of a pulmonary embolism? (7)

Answer 21

• Current/recent DVT - Previous VTE - Active cancer - Recent surgery - Significant immobility; hospitalisation, bed-rest - Lower limb trauma/fracture - Pregnancy; and upto six weeks postpartum

Question 22

Outline the advice given to patients who are to undergo a colonoscopy? (2)

Answer 22

• Laxatives the day before
• No food within 24 hours

Question 23

How long does it take for an arteriovenous fistula to mature and become fully functioning?

Answer 23

6 to 8 weeks

Question 24

Outline the main clinical signs associated with a negative fluid balance? (5)

Answer 24

• Tachycardia
• Hypotension
• Oliguria
• Sunken eyes
• Reduced skin turgor

Question 25

What is the most common cause of lytic boney lesions seen on imaging?

Answer 25

Multiple myeloma

Question 26

Outline the causative organism in syphalis?

Answer 26

Treponema pallidum

Question 27

Outline the clinical features associated with Kartagener's syndrome (primary ciliary dyskinesia)? (4)

Answer 27

- Dextrocardia/situs invertus - Bronchiectasis - Recurrent sinusitis - Subfertility

Question 28

Which point in the GI tract is most commonly affected by ulcerative colitis?

Answer 28

Rectum

Question 29

Which antibiotic is known to lower the seizure threshold and thus may preciptate seizures following its use?

Answer 29

Ciprofloxacin

Question 30

Which region of the bowel is the most common site of diverticula?

Answer 30

Sigmoid colon

Question 31

Which autoantibodies are associated with primary sclerosing cholangitis? (3)

Answer 31

- Anti-neutrophil cytoplasmic antibodies (ANCA)- Anti-nuclear antibodies (ANA) - Anti-cardiolipin antibodies (anti-CL)

Question 32

Outline the most likely causitive organism in a patient presenting with pneumonia following a recent bout of influenza?

Answer 32

*Staphylococcus aureus*

Question 33

What clinical features indicate a severe Clostridium difficile infection? (5)

Answer 33

- WCC > 15 x 109/L - Rising creatinine (>133μmol/L) - Fevers >38.5° - Evidence of severe colitis on imaging - Development of complications; perforation, peritonitis, ileus, toxic mega colon

Question 34

Outline the triad of features associated with Wernicke's encephalopathy? (3)

Answer 34

CAN; - Confusion/altered GCS - Ataxia - Nystagmus

Question 35

What sign seen during fundoscopy is associated with infective endocarditis?

Answer 35

**Roth Spots**; non-specific red spots with white or pale centres, seen on the retina that indicate immune complex deposition

Question 36

Which antibiotics are most commonly associated with causing pseudomembranous colitis due to *Clostridium difficile* infection?

Answer 36

Cephalosporins

Question 37

Which antibiotics can be used in the treatment of a methicillin-resistant Staphylococcus aureus (MRSA) infection? (3)

Answer 37

- Vancomycin - Teicoplanin - Linezolid

Question 38

Outline the clinical features associated with anti-phospholipid syndrome? (4)

Answer 38

- Recurrent miscarriages - Previous venous thromboembolic event(s) (VTEs) - Prolonged APTT - Anti-cardiolipin antibodies

Question 39

Which drug is the most appropriate first-line anti-anginal for stable angina in a patient with known heart failure, if there are no contraindications?

Answer 39

Atenolol; cardioselective β1-antagonist

Question 40

Outline the management of severe hypokalaemia? (3)

Answer 40

- Transfer patient to area with cardiac monitoring - IV fluid replacement (if not contraindicated by heart failure/fluid overload) - K+ infusion; rate should not exceed 20 mmol/hr

Question 41

Which autoantibodies are associated with dermatomyositis?

Answer 41

Anti-MI-2 antibodies

Question 42

Outline the symptoms that can be associated with severe hypomagnesaemia? (3)

Answer 42

- Tonic-clonic Seizures - tetany - Cardiac arrhythmias

Question 43

Outline the triad of histological findings consistent with membranous glomerulonephritis? (3)

Answer 43

- Basement membrane thickening on light microscopy - Subepithelial spikes on sliver staining - Positive immunohistochemistry for PLA2R

Question 44

Which type of vasculitides most commonly present with a rapidly progressing renal impairment?

Answer 44

ANCA-associated small vessel vasculitides

Question 45

Outline the main types of laxatives and give examples? (4)

Answer 45

- Stimulants; senna, bisacodyl (dulcolax) - Osmotics; lactulose, magnesium sulphate - Bulk-forming; macrogol (movicol) - Softeners; docusate

Question 46

Outline the anticoagulation regimen used in the treatment of a pulmonary embolus? (2)

Answer 46

- Provoked; 3 months DOAC - Unprovoked; 6 months DOAC

Question 47

Which treatment is used in the management of carbon monoxide poisoning?

Answer 47

Hyperbaric 100% oxygen

Question 48

Which acid-base disorder is associated with renal tubular acidosis?

Answer 48

Renal tubular acidosis is a cause of normal anion gap metabolic acidosis

Question 49

Outline symptoms stated in the NICE Guidelines for severe hypertension that require referral for same-day specialist assessment? (6)

Answer 49

- **Blood pressure > 180/120 mmHg** plus ≥ 1 of; * New-onset confusion * Chest pain * Signs of heart failure * Acute kidney injury (AKI) * Papilloedema

Question 50

Outline the investigations used to diagnose an aortic dissection? (2)

Answer 50

- Stable patients; CT angiogram - Unstable patients; transoesophageal echocardiography (TOE)

Question 51

Which investigation is used in the diagnosis of acromegaly?

Answer 51

**Oral Glucose Tolerance Test (OGTT)**; Glucose administration should suppress GH levels, in acromegaly, this suppression is lost. Failure to suppress GH levels to less than 0.6 μg/L after a bolus of glucose, alongside a raised IGF-1 level, is usually diagnostic of the condition.

Question 52

Outline the continutation phase of management used in the treament of an active tuberculosis infection? (2)

Answer 52

From 2-6 months continue; - Riampicin - Isoniazid

Question 53

Which classes of drugs make up the anticipatory medications prescribed to patients in palliative care? (4)

Answer 53

- **Analgesic**; morphine, oxycodone, alfentanil - **Sedative**; midazolam, haloperidol - **Anti-muscarinic**; hyoscine butylbromide, glycopyrronium - **Anti-emetic**; levochlorpromezine, cyclizine

Question 54

Outline the main pulse abnormalities that are commonly associated with aortic dissection? (2)

Answer 54

- Weak or absent carotid, brachial or femoral pulses - Variation in arm blood pressures

Question 55

What are the main classes of macrocytic anaemia? (2)

Answer 55

- Megaloblastic anaemia - Normoblastic macrocytic anaemia

Question 56

Outline the most common causes of normoblastic macrocytic anaemia? (4)

Answer 56

**HARD**; - **H**ypothyroidism - **A**lcohol - **R**ecticulocytosis; secondary to haemolytic anaemia or acute blood loss - **D**rugs; azathioprine

Question 57

What is the most common cause of a falsely negative Mantoux test for Mycobacterium tuberculosis infection/immunity?

Answer 57

Immunosuppression; sarcoidosis, steroid use, AIDS and lymphoma

Question 58

Outline how the pattern of AST and ALT elevation can be used to inform on the likelihood of an alcohol-related liver disease (ArLD)?

Answer 58

An AST/ALT ratio > 1.5:1 is classically thought to be associated with alcohol-related liver disease (ArLD)

Question 59

What is the definition of a transient ischaemic attack (TIA)?

Answer 59

A transient neurological dysfunction that occurs secondary to ischaemia but without infarction

Question 60

What is the most appropriate starting rate for a fixed-rate intravenous insulin infusion (FRIII) in the treatment of diabetic ketoacidosis (DKA)?

Answer 60

0.1 units kg^-1 hr^-1

Question 61

What key features are commonly associated with Clostridium botulinum infection? (4)

Answer 61

- history of intravenous drug usage - Descending paralysis - Diplopia - Bulbar palsy

Question 62

Why may acute pancreatitis cause hypocalcaemia?

Answer 62

- Lipase from the pancreatic Cells breaks down mesenteric and peripancreatic fat - This results in the liberation of free fatty acids that bind calcium, decreasing the circulating concentration

Question 63

What is the gold-standard investigation used to diagnose cholangitis?

Answer 63

Magnetic resonance cholangiopancreatography (MRCP)

Question 64

In which situations is rhythm control used as first-line management in the treatment of atrial fibrillation? (4)

Answer 64

- Age < 65 years- Established reversible cause (infection etc.) - New onset < 48 hrs - Signs of heart failure

Question 65

Outline the pathognomonic features associated with nephritic and nephrotic syndrome? (2)

Answer 65

- Nephritic syndrome; haematuria, hypertension, uraemia and renal failure - Nephrotic syndrome; proteinuria, hypoalbuminaemia, oedema and hyperlipidaemia

Question 66

Outline the common features of renal cell carcinoma (RCC)? (6)

Answer 66

- Haematuria - Loin pain - Abdominal mass - Pyrexia of unknown origin (PUO) - Left varicocele in men; due to occlusion of left testicular vein - Endocrine effects; may secrete erythropoietin (polycythaemia), parathyroid hormone (hypercalcaemia), renin, AC

Question 67

Which triad of features are associated with chronic mesenteric ischaemia/intestinal angina? (3)

Answer 67

- Colicky post-prandial abdominal pain - Weight Loss - An abdominal bruit

Question 68

Which additional class of medication is used in the treatment of meningeal tuberculosis alongside isoniazid, pyridoxine and rifampicin?

Answer 68

Steroids; continued for 12 months alongisde the other agents

Question 69

What is the gold-standard investigation used in the diagnosis of gout?

Answer 69

Joint aspiration; needle-shaped monosodium urate crystals that are negatively birefringent

Question 70

Outline the implications of the Glasgow-Blatchford Score (GBS) in the investigation and management of upper gastrointestinal bleeding (UGIB)?

Answer 70

- **Score = 0**; low risk, consider for discharge with outpatient endoscopy - **Score ≥ 1**; high risk, inpatient admission and urgent endoscopy within 24 hours

Question 71

What is the most common cause of primary hyperaldosteronism (Conn's syndrome)?

Answer 71

Bilateral idiopathic adrenal hyperplasia

Question 72

Outline the criteria needed to issue anti-hypertensive therapy in patients with stage 1 hypertension?

Answer 72

- < 80 years of age with one or more of, target organ damage, established cardiovascular disease, renal disease, diabetes, and/or - QRISK Score ‚â•10%

Question 73

Outline the broad classification of arthritis? (2)

Answer 73

- Non-inflammatory arthritis; osteoarthritis (OA) - Inflammatory arthritis; rheumatoid arthritis (RA), reactive arthritis, gout

Question 74

Oultine the management of a severe flare-up of ulcerative colitis?

Answer 74

Admit the patient for IV hydrocortisone

Question 75

What severe side effect is associated with the use of SGLT2 inhibitors?

Answer 75

**Fournier's Gangrene**; necrotising fasciitis of the genitalia and/or perineum

Question 76

Outline the management of necrotising fasciitis? (2)

Answer 76

- IV antibiotics - Surgical debridement

Question 77

What is the definition of a significant bacteriuria?

Answer 77

> 100,000 colony forming units (CFU) mL-1

Question 78

Which investigations can be used to diagnose Guillain-Barré Syndrome (GBS)? (2)

Answer 78

- **Nerve conduction studies**; show decreased motor nerve conduction velocity - **Lumbar puncture**; CSF shows a raised protein with normal cell counts and glucose levels

Question 79

What is the biochemical threshold value that warrants a diagnosis of severe hypokalaemia?

Answer 79

Serum postassium concentration < 2.5 mmol L-1

Question 80

Which criteria can be used to aid in the diagnosis of bacterial vaginosis (BV)?

Answer 80

**Amstel's Criteria** (3/4 Required); - Thin, white, homogeneous discharge - Vaginal fluid pH >4.5 - Clue cells on microscopy of wet mount - Release of a fishy odour on adding alkali (potassium hydroxide)

Question 81

Which antibiotics are most commonly used in the treatment of a low severity community acquired pneumonia? (2)

Answer 81

- Majority of patients; **amoxicillin** 500mg TDS - Penicillin allergy; macrolide (**clarithromycin**) or tetracycline

Question 82

What is the most common cause of atrial fibrillation (AF)?

Answer 82

Ischaemic heart disease (IHD)

Question 83

When referring to lymphomas, what is meant by 'B' symptoms? (3)

Answer 83

- Fever - Night sweats - Weight Loss

Question 84

What is the other name for Factor V Leiden mutations?

Answer 84

Activated protein C resistance; this is because the mutation in Factor V Leiden renders it more resistant to inactivation by activated protein C

Question 85

Outline the different classifications of acute liver failure (ALF)? (3)

Answer 85

- Hyperacute liver failure; symptoms of hepatic encephalopathy within 7 days of noticing jaundice - Acute liver failure; symptoms of hepatic encephalopathy within 8-28 days of noticing jaundice - Subacute liver failure; symptoms of hepatic encephalopathy

Question 86

Outline the indications for an immediate CT head in patients presenting with a head injury? (6)

Answer 86

- Vomiting > 1 - Focal neurological deficit - Reduced GCS; < 13 on initial assessment or < 15 at 2 hours post-injury - Suspected open or depressed skull fracture - Signs of basal skull fracture; Panda eyes, CSF leakage etc. - Post-traumatic seizure

Question 87

Outline the components of the Pulmonary Embolism Rule-Out Criteria (PERC) score that is used to guide whether to investigate a patients for a pulmonary embolus (PE)?

Answer 87

PERC Score - Age ‚â• 50 +1 - HR ‚â• 100 +1 - SpO2 (RA) <95% +1 - Unilateral leg swelling +1 - Haemoptysis +1 - Recent surgery/trauma +1 - Previous DVT/PE +1 - Hormone usage +1

Question 88

What is the first-line test used in suspected hyperaldosteronism?

Answer 88

Aldosterone-renin ratio (ARR)

Question 89

Which clinical features are associated with infective endocarditis? (4)

Answer 89

- Splinter haemorrhages; linear points of bleeding underneath the nails - Janeway’s lesions; irregular, erythematous, flat, painless macules on the palms and soles - Osler’s nodes; painful, red, raised lesions found on the hands and feet - Roth spots;

Question 90

Which diagnostic imaging modality can be used at the bedside to rapidly assess a patient for fluid within the abdomen?

Answer 90

FAST Scan

Question 91

Outline the mechanism of action of lactulose in hepatic encephalopathy? (4)

Answer 91

- Lactulose is broken down into lactate and protons - These H⁺ ions decrease the luminal pH in the GI tract - This shifts the ammonia-ammonium equilibrium towards generating ammonium - This ammonium cannot be absorbed and is therefore excreted

Question 92

Outline the target oxygen saturation level in an acute exacerbation of asthma?

Answer 92

94-98%

Question 93

Which opioid pain relief is preferred to morphine in palliative patients with mild-moderate renal impairment?

Answer 93

Oxycodone as alfentanil has too short of a half-life

Question 94

Outline the MRC grading of power score that is used to assess for muscle weakness? (6)

Answer 94

- **Grade 0**; no movement - **Grade 1**; trace of contraction (twitching) - **Grade 2**; movement with gravity eliminated - **Grade 3**; movement against gravity but without resistance - **Grade 4**; movement against an external resistance with reduced strength - **Grade 5**; normal movement and strength

Question 95

Outline the treatment options used in the suppression of methicillin-resistant *Staphylococcus aureus* (MRSA)? (2)

Answer 95

- **Nose**; mupirocin 2% in white soft paraffin, TDS for 5 days - **Skin**; chlorhexidine gluconate, OD for 5 days

Question 96

Outline the conditions associated with ankylosing spondylitis? (6)

Answer 96

**The 6 A's** - **A**pical pulmonary fibrosis - **A**nterior uveitis - **A**ortic regurgitation - **A**chilles tendonitis - **A**trioventricular (AV) nodal block - **A**myloidosis

Question 97

Outline the most common causes of megaloblastic anaemia? (2)

Answer 97

- B12 deficiency - Folate deficiency

Question 98

Why are patients with nephrotic syndrome at increased risk of thrombus formation?

Answer 98

Patients with nephrotic syndrome can lose antithrombin III and plasminogen proteins in the urine as a result of damage to the filtration barrier in the kidneys

Question 99

Which investigation can be used to diagnose contact dermititis?

Answer 99

Skin patch test

Question 100

Outline the management of anti-phospholipid syndrome during pregnancy? (2)

Answer 100

- Low-dose aspirin; commenced once the pregnancy is confirmed on urine testing - Low molecular weight heparin (LMWH); once a fetal heart is seen on ultrasound

Question 101

What is meant by bridging therapy used in the treatment of DVT/PE?

Answer 101

Patients who have been anticoagulated on LMWH who are due to start warfarin/DOAC as long-term anticoagulation in the treatment of DVT/PE must have two consecutive INRs >2.0 before stopping the LMWH

Question 102

Which investigation can be performed to confirm a diagnosis of a subarachnoid haemorrhage (SAH) in patients with normal imaging?

Answer 102

Lumbar puncture 12 hours after the onset of symptoms

Question 103

Outline the main indications for an emergency thoracotomy in patients with a haemothorax? (2)

Answer 103

- > 1.5 L of blood loss initially - > 200 mL hr-1 of blood loss for >2 hours

Question 104

Which vessel is most often used to administer total parenteral nutrition (TPN)?

Answer 104

Subclavian vein; TPN should be administered via a central vein as it is strongly phlebitic

Question 105

Outline the criteria needed for a diagnosis of systemic inflammatory response syndrome (SIRS)? (4)

Answer 105

‚â• 2 of the following - Tachycardia - Tachypnoea - Hypothermia/pyrexia - WBC > 12.0 or < 4.0 x 109 L-1

Question 106

Outline the most common causes of aortic stenosis? (5)

Answer 106

- Degenerative valvular disease - Rheumatic heart disease - Age-related calcification - Congenitally bicuspid valve - Fabry's disease; rare genetic lysosomal storage disease, which leads to accumulation of certain glycolipids

Question 107

Outline the management of (acne) rosacea? (2)

Answer 107

- Mild-to-moderate; topical metronidazole - Severe/resistant; oral tetracyclines (doxycycline)

Question 108

Outline the typical presentation associated with myeloma? (4)

Answer 108

Myeloma Presentation; CRAB - Calcium elevated - Renal failure - Anaemia - Bone pain

Question 109

Outline the immediate management for a patient with a pulmonary embolus (PE) who is also hypotensive?

Answer 109

Thrombolysis; alteplase or tenecteplase

Question 110

Outline the triad of features that indicate acute rejection in patients who have received a kidney transplant? (3)

Answer 110

- Rising creatinine - Pyuria; presence of leukocytes in urine - Proteinuria

Question 111

Which Parkinson's disease medications are most associated with impulse control disorders?

Answer 111

Dopamine agonists

Question 112

What is the most appropriate starting rate for a fixed-rate intravenous insulin infusion (FRIII) in the treatment of hyperosmolar hyperglycaemia state (HHS)?

Answer 112

0.05 units kg^-1 hr^-1

Question 113

What is the most common type of diabetic neuropathy?

Answer 113

Distal symmetrical polyneuropathy; so-called '**glove and stocking**' distribution **sensory neuropathy** affecting the distal limbs

Question 114

Outline the most common causes of hypoglycaemia? (6)

Answer 114

ExPLAIN; - Exogenous agents (drugs); insulin/sulfonylureas - Pituitary insuficiency - Liver failure - Addison's Disease - Insulinomas; pancreatic β-cell tumours - Non-pancreatic neoplasms

Question 115

Which vaccines should be avoided in patients who are HIV positive?

Answer 115

Any live attenuated vaccines

Question 116

What ECG abnormality is commonly associated with hypercalcaemia?

Answer 116

Short QT interval

Question 117

What abnormal serum biochemistry is likely to be seen in haemochromatosis? (2)

Answer 117

- Raised transferrin saturation - Raised serum ferritin

Question 118

Which imaging modailty is used for the investigation and staging of lymphoma?

Answer 118

CT positron emission tomography (CT-PET)

Question 119

Outline the two potential treatment options used in the management of temporal arteritis/giant cell ateritis (GCA)? (2)

Answer 119

- GCA with visual symptoms and/or abnormal fundoscopy; intravenous methylprednisolone - GCA without visual symptoms and with no abnormal fundoscopy findings; high-dose oral prednisolone

Question 120

Which features, either alone or in combination, meet the surgical referral criteria for excision biopsy of a breast fibroadenoma? (2)

Answer 120

- **Size**; > 3cm - **Pain**; causing moderate discomfort

Question 121

Which class of antibiotics are most commonly associated with causing an intrinsic (renal) acute kidney injury (AKI)?

Answer 121

Aminoglycosides (gentamycin)

Question 122

How do β2 adrenoceptor agonists reduce extracellular (serum) potassium (K+) concentrations? (2)

Answer 122

- Directly; activation of β2ARs triggers a rise in cAMP via the Gαs subunit which stimulates the activity of the Na+/K+ATPase to pump K+ into the cells - Indirectly; activation of β2ARs triggers insulin release which results in increased glucose uptake

Question 123

Give example of specific laboratory tests that form part of a myeloma screen? (3)

Answer 123

- Protein electrophoresis - Serum free light chains - Bence Jones urine protein assay

Question 124

Which arrest rhythm is likely to be seen in a patient with a tension pneumothorax following recent trauma?

Answer 124

Pulseless electrical activity (PEA)

Question 125

Which two conditions are associated with an Argyll-Robertson Pupil? (2)

Answer 125

- Tertiary neurosyphilis - Poorly-controlled Diabetes mellitus

Question 126

What is the most common type of renal cell carcinoma (RCC)?

Answer 126

Adenocarcinoma (~75% of RCCs)

Question 127

What is the reversal agent used for patients who are anticoagulated on dabigatran?

Answer 127

Idarucizumab

Question 128

Outline the signs and symptoms of syringomyelia? (5)

Answer 128

- Loss of pain and temperature sensation; indicating spinothalamic tract involvment - Spastic weakness; predominantly affecting the upper limbs - Paresthesia - Neuropathic pain - Upgoing plantar reflexes

Question 129

Outline the first line investigations for patients with a suspected diagnosis of vestibular schwannoma (acoustic neuroma)? (2)

Answer 129

- Audiogram - Gadolinium-enhanced MRI of the internal auditory meatus (IAM)

Question 130

What is the dose conversion factor between oral codeine and oral morphine?

Answer 130

When converting dosages of oral codeine to oral morphine you divide the codeine dose by 10 For example; - 2 x 30mg codeine tablets taken QDS - 2 x 30 x 4 240mg - Divide dose by 10 24mg - Hence 24mg oral morphine per day

Question 131

Outline the most common causes of normocytic anaemia? (5)

Answer 131

AHAHA! - Acute blood loss - Haemolytic anaemia - Anaemia of chronic disease - Hypothyroidism - Aplastic anaemia

Question 132

Outline the management of thyrotoxic storm? (3)

Answer 132

- **Beta blocker**; treat subsequent tachycardia - **Propylthiouracil**; TPO inhibitor - **Hydrocortisone**; prevent peripheral conversion of T₄ to T₃

Question 133

Outline the volumes and dose of adrenaline that can be given during adult advanced life support (ALS)? (2)

Answer 133

- Intravenous (IV) infusion of **10 mL of 1:10000 adrenaline** for a total dose of 1 mg (1000 μg) OR - Intravenous (IV) infusion of **1 mL of 1:1000 adrenaline** for a total dose of 1 mg (1000 μg)

Question 134

Which classification system can be used to guide the need for surgical intervention in diverticulitis?

Answer 134

Modified Hinchey Classification; - IA; confined pericolic inflammation/phlegmon - IB; confined pericolic abscess - II; pelvic, retroperitoneal or distant intraabdominal abscess - III; generalised purulent peritonitis - IV; generalised faecal peritonitis

Question 135

Outline the criteria for urgent valvular replacement in infective endocarditis? (4)

Answer 135

- Severe congestive cardiac failure - Overwhelming sepsis despite antibiotic therapy (+/- perivalvular abscess, fistulae, perforation) - Recurrent embolic episodes despite antibiotic therapy - Pregnancy

Question 136

Outline the signs and symptoms associated with autosomal dominant polycystic kidney disease (ADPKD)? (6)

Answer 136

- HTN - Recurrent UTI - abdominal pain - Renal stones - Haematuria - CKD causing anaemia

Question 137

What are the most common causes of lower lobe fibrosis? (5)

Answer 137

CRABS; - Cryptogenic fibrosing alveolitis (idiopathic pulmonary fibrosis) - Rheumatoid arthritis - Asbestosis - Bleomycin - SLE/scleroderma

Question 138

Which is the most common type of haemophilia?

Answer 138

Haemophilia A; accounts for 90% of cases

Question 139

Prior to transfer to hospital, which antibiotic should patients with suspected meningitis and a non-blanching rash be given?

Answer 139

IM or IV benzylpenicillin

Question 140

When should N-acetylcysteine (NAC) be commenced immediately in patients admitted with a paracetamol overdose?

Answer 140

If they have ingested >150 mg/kg within 8-24 hours of admission

Question 141

Outline the first-line medical management used in thyroid/thyrotoxic storm?

Answer 141

Intravenous β-blockers (propranolol)

Question 142

Outline the post-void urine volume present following catherisation that indicates an acute-on-chronic urinary retention?

Answer 142

> 800mL is considered pathological for an episode of acute-on-chronic urinary retention

Question 143

Outline the acute management of an exacerbation of COPD? (4)

Answer 143

Oh! ABC; - Oxygen; controlled so as to not cause respiratory depression in CO2 retainers - Antibiotics; if infective, typically doxycycline, but follow local guidelines - Bronchodilators; salbutamol and ipratropium nebulisers - Corticosteroids; prednisolone 30 mg for 5 days

Question 144

Which viruses are most commonly assocaited with causing viral meningitis?

Answer 144

Enteroviruses; such as coxsackie B virus and echovirus

Question 145

Outline the key clinical features associated with Goodpasture Syndrome (anti-glomerular basement membrane disease)? (3)

Answer 145

- Pulmonary haemorrhage; haemoptysis - Rapidly progressive glomerulonephritis - Rapid onset AKI

Question 146

Outline the NICE guidelines for when a prostate-specific antigen (PSA) test can be carried out accurately? (5)

Answer 146

- ≥ 6 weeks after a prostate biopsy - ≥ 4 weeks following a proven urinary tract infection (UTI) - ≥ 1 week after a digital rectal examination (DRE) - ≥ 48 hours after vigorous exercise - ≥ 48 hours after ejaculation

Question 147

Infections caused by which class of organism are classically seen in alcoholics?

Answer 147

*Klebsiella spp.*; causing pneumonia and empyema

Question 148

Outline the difference between the first-line management of inflammatory (RA) and non-inflammatory arthropathies (OA)? (2)

Answer 148

- Osteoarthritis; paracetamol and topical NSAID - Inflammatory arthritis; oral NSAID and proton pump inhibitor (PPI)

Question 149

What is the normal range for the anion gap?

Answer 149

10-18mmol/L

Question 150

Which medication can be used first line in the treatment of stress incontinence?

Answer 150

Duloxetine

Question 151

Which additional medication should every person with insulin-dependent diabetes mellitus (IDDM) be supplied with in case of emergencies?

Answer 151

Glucagon

Question 152

Outline the acute management options used in patients with a migraine? (2)

Answer 152

- Most patients; oral triptan + paracetamol/non-steroidal anti-inflammatory (NSAID) - Aged 12-17 years; nasal triptan + paracetamol/non-steroidal anti-inflammatory (NSAID)

Question 153

Outline the main contraindication for the use of IV adenosine in supraventricular tachycardia (SVT)?

Answer 153

Asthma; adenosine is a potent bronchoconstrictor that mimics the effects of β2AR stimulation, therefore it should be avoided in asthmatics

Question 154

Which class of medications has been shown to reduce the risk of a scleroderma renal crisis in patients with systemic sclerosis?

Answer 154

Angiotensin-converting enzyme inhibitors (ACE-inhibitors) such as ramipril may reduce 1-year mortality and risk of further renal crises

Question 155

Outline the first-line management of osteoporosis? (3)

Answer 155

- Bisphosphonates - calcium supplementation if deficient - Vitamin D supplementation if deficient

Question 156

What is the most useful test in diagnosing chlamydia infections in females?

Answer 156

Vuvlovaginal swab for nucleic acid amplification testing (NAAT)

Question 157

Outline the immidiate management of amaurosis fugax (temporary visual loss)?

Answer 157

Treat as a transient ischaemic attack (TIA); **aspirin 300 mg STAT** and refer for **specialist review within 24 hours**

Question 158

What is the single most useful test for determining the cause of hypercalcaemia?

Answer 158

Parathyroid hormone (PTH) levels

Question 159

Which vessel is most likely to be affected in an myocardial infarction (MI) causing a complete heart block?

Answer 159

**Right cononary artery (RCA)**; the right coronary artery perfuses the atrioventricular node (AVN), so inferior myocardial infarctions are associated with bradycardias, heart blocks and arrhythmias

Question 160

What radiological feature is associated with multiple myeloma?

Answer 160

Raindrop skull; the presence of multiple, well-defined lytic lesions (punched out lesions) of various size scattered throughout the skull

Question 161

Which variables are used to calculate eGFR using the Modification of Diet in Renal Disease (MDRD) equation? (4)

Answer 161

**CAGE**; - **C**reatinine - **A**ge - **G**ender - **E**thnicity

Question 162

Outline all possible investigation findings that are sufficient, in isolation, for a diagnosis of diabetes mellitus type 2 (T2DM) to be made in an asymptomatic patient? (4)

Answer 162

- Two separate HbA1c > 48 mmol mol-1 - Two separate fasting glucose ‚â• 7.0 mmol L-1 - Two separate random glucose ‚â• 11.1 mmol L-1 - Two separate serum glucose 2 hours post-75g oral glucose tolerance test (OGTT) ‚â• 11.1 mmol L-1

Question 163

Outline the grading of hepatic encephalopathy?

Answer 163

- Grade I; irritability - Grade II; confusion and/or innappropriate behaviour - Grade III; incoherent restlessness - Grade IV; coma

Question 164

Outline the main indication for cardiac resynchronisation therapy (CRT) with a biventricular (triple chamber) pacemaker?

Answer 164

Severe heart failure

Question 165

Outline the main indication for an implantable cardioverter defibrillator (ICD)?

Answer 165

Hypertrophic obstructive cardiomyopathy (HOCM)

Question 166

Outline the main indications for a standard pacemaker? (3)

Answer 166

- Symptomatic bradycardia - Mobitz type II 2^nd degree heart block - 3^rd degree heart block

Question 167

Which medications can be used to treat hyperphosphataemia often associated with chronic kidney disease (CKD)?

Answer 167

Calcium-based phosphate binders such as calcium acetate or sevelamer

Question 168

Outline the treatment of Rabies post-exposure in a patients who have not been vaccinated against the disease? (2)

Answer 168

- Human rabies immunoglobulin (HRIG) - Full course of vaccination

Question 169

According to the 2010 British Thoracic Society (BTS) guidelines, where is the best place to measure the size of a pneumothorax on a chest radiograph?

Answer 169

Inter-pleural distance at the level of the hilum

Question 170

Why is it that the central visual field may be preserved in posterior cerebral artery (PCA) strokes? (3)

Answer 170

- Posterior cerebral artery (PCA) strokes affect the optic radiation, thus causing a homonymous hemianopia affecting the contralateral visual field - However, the occipital pole, where the macula (central vision) is represented, receives a dual blood supply from the middle cerebral artery (MCA) as well as the PCA - Thus central vision is maintained in PCA strokes due to the supply from the MCA

Question 171

Outline the pharmacological management of prostatitis?

Answer 171

Fluoroquinolone (ciprofloxacin) for 14 days

Question 172

Which tumours are associated with Multiple Endocrine Tumours Type 1 (MEN1)? (3)

Answer 172

MEN I; the 3 P's - Parathyroid hyperplasia - Pituitary adenoma - Pancreatic tumours; gastrinoma or insulinoma

Question 173

Which investigation should be carried out in all patients presenting with a first episode of atrial fibrillation, regardless of their CHA₂DS₂-VASc score?

Answer 173

**Transthoracic echocardiogram (TTE)**; to exclude valvular heart disease or the presence of a left atrial appendage thrombus

Question 174

Which class of antibiotics are commonly associated with torsades de pointes?

Answer 174

**Macrolides** such as clarithromycin can cause QT prolongation and predispose to torsades de pointes

Question 175

Outline the components of the CHA2DS2VASc score which can be used to inform whether to anticoagulate a patient with atrial fibrillation (AF)?

Answer 175

- Congestive heart failure +1 - Hypertension +1 - Age ‚â• 75 +2 - Diabetes +1 - Stroke/TIA/VTE +2 - Vascular disease +1 - Age 65-74 +1 - Sex category female +1

Question 176

Outline the four main mechanisms that contribute to the intracellular-to-extracellular shift in K+ seen in diabetic ketoacidosis (DKA)? (4)

Answer 176

- Decreased ATP levels results in decreased K+ influx via Na+/K+ATPases - Decreased sensitivity to catecholamine-mediated insulin release decreases ATP availability and in-turn Na+/K+ATPase activity - Metabolic acidosis resulting in acidaemia leads to inc

Question 177

What is the most likely location of a lesion causing a bitemporal upper quadrantanopia?

Answer 177

**Optic chiasm**; specifically inferior chiasmal compression, commonly due to a pituitary tumour

Question 178

Pathology affecting which nerve pathways can cause secondary referred otalgia? (5)

Answer 178

- Trigeminal nerve (**CN V**) - Facial nerve (**CN VII**) - Glossopharyngeal nerve (**CN IX**) - Vagus nerve (**CN X**) - **C2/C3** spinal nerves

Question 179

What complication may arise as a result of rapid correction of a hypernatraemia?

Answer 179

Cerebral oedema

Question 180

Which staging system can be used to classify the stages of Hodgkin and Non-Hodgkin lymphoma?

Answer 180

Lugano Staging System; - A; absence of 'B' symptoms - B; presence of 'B' symptoms - E; denotes extranodal involvement - X; denotes bulky disease (>10cm) - S; denotes splenomegaly

Question 181

Outline the threshold values of protein quantification that can be used to distinguish nephrotic syndrome from nephritic syndrome? (3)

Answer 181

Nephrotic Range; - 24 hour urinary protein > 3.5 g - Albumin creatinine ratio (ACR) > 220 - Protein creatinine ratio (PCR) > 300

Question 182

What advice is given to patients diagnosed with glandular fever?

Answer 182

Must avoid contact sports for 8 weeks due to the potential for splenic rupture

Question 183

Which scoring system can be used to grade the severity of a patient presenting with a flare-up of their ulcerative colitis?

Answer 183

Truelove & Witts Score

Question 184

Which organism is most commonly associated with haemolytic uraemic syndrome (HUS)?

Answer 184

*Escherichia coli* strain O157:H7

Question 185

Outline the key radiological signs that may be seen on a chest X-ray in a patient with heart failure? (5)

Answer 185

ABCDE; - Alveolar oedema; bat’s wings - Kerley B lines; interstitial oedema - Cardiomegaly - Dilated prominent upper lobe vessels - Effusion (pleural)

Question 186

Which glomerulonephritides commonly present with nephrotic syndrome? (4)

Answer 186

- Minimal change disease (MCD) - Focal segmental glomerulosclerosis (FSGS) - Membranous nephropathy - Renal amyloidosis

Question 187

Outline the management of a patient on warfarin who's INR has been found to be between 5.0-8.0 but with no associated bleeding? (2)

Answer 187

- Withhold 1 or 2 doses - Reduce subsequent maintenance dose

Question 188

What is the most common cause of a 'snowstorm' appearance seen on an ultrasound scan of the axillary lymph nodes in females?

Answer 188

Extracapsular breast implant rupture

Question 189

What condition are mirror image or Reen-Sternberg cells associated with?

Answer 189

Hodgkin's Lymphoma

Question 190

Which viruses are most often responsible for causing progressive multifocal leukoencephalopathy (PML) in HIV positive patients? (2)

Answer 190

- JC virus - BK virus

Question 191

Outline the tetrad of signs seen in neuroleptic malignant syndrome? (4)

Answer 191

- Hyperthermia - Muscle rigidity - Autonomic instability - Altered mental status

Question 192

What additional monitoring is required when giving IV phenytoin during staus epilepticus?

Answer 192

Cardiac monitoring; phenytoin can have pro-arrhythmogenic effects due to voltage-gated Na+ channel inhibition as well as upredictable pharmacokinetics

Question 193

Which haemoglobin variant is raised in patients with beta thalassaemia major?

Answer 193

**HbA2**; hemoglobin A that consists of two alpha and two delta chains (α₂δ₂)

Question 194

What recent infection is classically associated with Guillain-Barré Syndrome (GBS)?

Answer 194

Gastrointestinal infections; classically *Campylobacter jejuni*

Question 195

Which drugs can be given prophylactically to prevent tumour lysis syndrome (TLS) in patients undergoing chemotherapy? (2)

Answer 195

- IV allopurinol; immediately prior to and during the first days of chemotherapy OR - IV rasburicase; immediately prior to and during the first days of chemotherapy

Question 196

Outline the main indications for endovascular aneurysm repair (EVAR) in patients with an abdominal aortic aneurysm (AAA)? (2)

Answer 196

- Symptomatic AAA - Aneurysm > 5.5 cm in diameter

Question 197

What are stage-horn calculi normally composed of?

Answer 197

Struvite (magnesium ammonium phosphate)

Question 198

Which medication needs to be co-prescribed alongside goserelin in the first three weeks of treatment for prostate cancer?

Answer 198

Cyproterone acetate; anti-androgen that helps to prevent the tumour flare phenomen caused by the initial GnRH angonism mediated by goserelin

Question 199

What is the first-line pharmacological agent used to relieve the symptoms of irritable bowel syndrome (IBS)?

Answer 199

**Loperamide**; anti-motility agent that functions as a μ opioid receptor (μOR) agonist but that cannot cross the blood-brain-barrier (BBB) in the same way that other opioid agonists such as morphine can

Question 200

What is the main side effect associated with oral magnesium replacement?

Answer 200

Diarrhoea

Question 201

Outline the criteria needed for a diagnosis of status epilepticus? (2)

Answer 201

One or more of the following; - A **single seizure** lasting **> 5 minutes** - **≥ 2 seizures** within a **5-minute** period **without returning to normal** inbetween

Question 202

Outline the SIGN guidelines used in the management of acute severe asthma? (3)

Answer 202

**First-line**; - Oxygen - Salbutamol nebulisers - Ipratropium bromide nebulisers - Hydrocortisone IV OR Oral Prednisolone **Second-line**; - Magnesium sulfate IV **Third-line**; - Senior review - Aminophylline/IV salbutamol

Question 203

Outline the management of a pressure ulcer? (4)

Answer 203

- Wound dressing - Analgesia - Nutritional assessment - Antibiotics; only if clear signs of infection

Question 204

Which drug can be given to patients presenting with symptoms of bile-acid malabsorption?

Answer 204

Cholestyramine

Question 205

Outline the triad of biochemical features associated with alcoholic hepatitis? (3)

Answer 205

- Raised transaminases (AST & ALT) - AST/ALT ratio > 1.5:1 - Raised γ-GT

Question 206

Outline the pathophysiology of heparin-induced thrombocytopaenia (HIT)? (3)

Answer 206

- Body generates antibodies against heparin bound to platelet factor 4 (PF-4) - These trigger platelet activation giving rise to a prothrombotic state - Subsequent platelet consumption results in thrombocytopaenia

Question 207

How can you differentiate between an iron-deficiency anaemia (IDA) and an anaemia of chronic disease (ACD) also causing a normocytic anaemia?

Answer 207

**Iron Studies**; - **Iron deficiency anaemia** (IDA); ferritin, serum iron and transferrin saturations are all reduced - **Anaemia of chronic disease** (ACD); serum iron and transferrin saturations are reduced but ferritin levels are normal or increased

Question 208

Outline the most common causes of bilhilar lymphadenopathy seen on a chest X-ray? (4)

Answer 208

- Sarcoidosis - Tuberculosis - Lymphoma - Lung carcinoma

Question 209

Which organism is most classically associated with early prosthetic valve endocarditis (PVE)?

Answer 209

Staphylococcus aureus

Question 210

Which adjuvant therapy to antbiotics can be used to improve outcomes in patients who have bacterial meningitis?

Answer 210

Dexamethasone

Question 211

Outline the first-line medications used in the treatment of newly diagnosed focal siezures? (2)

Answer 211

Carbamazepine OR Lamotrigine

Question 212

Lesions above which level of the spinal cord are associated with autonomic dysreflexia?

Answer 212

Above the level of the T6 vertebra

Question 213

Which screening blood tests should be carried out in all patients newly diagnosed with chronic pancreatitis?

Answer 213

Annual HbA1c due to the increased risk of developing type 3c diabetes mellitus (pancreatogenic diabetes)

Question 214

Which investigation if prefered in the definitive diagnosis of an aortic dissection?

Answer 214

CT angiography of the chest, abdomen and pelvis (CTA-CAP)

Question 215

Which blood test can be used to differentiate between polymyalgia rheumatica (PMR) and other inflammatory myopathies?

Answer 215

Creatine kinase (CK); normal; in polymyalgia rheumatica (PMR) but raised in other inflammatory myopathies

Question 216

Outline the main biochemical markers that indicate acute interstitial nephritis (AIN)? (4)

Answer 216

- Pyuria; raised urinary WCC - Raised serum IgE - Eosinophilia - Raised creatinine

Question 217

When should a patient with HIV be commenced on anti-retroviral therapy?

Answer 217

At the time of diagnosis

Question 218

How can one differentiate between inguinal and femoral hernias based on their location?

Answer 218

- Inguinal hernias and superior and medial to the pubic tubercle - femoral hernias are found inferior and lateral to the pubic tubercle

Question 219

Outline the biochemical abnormalities associated with Wilson's disease? (4)

Answer 219

- Reduced serum caeruloplasmin - Reduced total serum copper - Reduced free serum copper - Increased 24 hour urinary copper excretion

Question 220

How can you quickly assess whether fluid dripping from the nose or ear is CSF?

Answer 220

Check for glucose

Question 221

Outline the indications for primary prevention of cardiovascular disease (CVD) in patients with diabetes? (4)

Answer 221

- > 40 years of age - Diabetic for > 10 years - Established diabetic nephropathy - Additional risk factors; obesity, hypertension, smoking etc.

Question 222

Outline the triad of symptoms associated with a presentation of phaeochromocytoma? (3)

Answer 222

- Sweating - Headaches - Palpitations

Question 223

Outline the 'sick day' advice given to patients with T1DM? (5)

Answer 223

- Aim to drink 3L of fluid per day - Continue normal insulin regimen - Monitor blood glucose more regularly - Monitor urinary ketones more regularly - If unable to eat then drink sugary drinks

Question 224

Which organism is the most common cause of peritonitis secondary to peritoneal dialysis?

Answer 224

Staphylococcus epidermidis

Question 225

Which antidiabetic medication is contraindicated in heart failure?

Answer 225

Pioglitazone

Question 226

Which first-line investigation is most usefult in suspected testicular cancer?

Answer 226

Testicular ultrasound scan

Question 227

Outline the main causes of erythema nodosum? (7)

Answer 227

SPOTTED; - Sarcoidosis - Pregnancy - Oral contraceptive (COCP) - Tuberculosis - Throat infections (Streptococcal) - Everything else (e.g. IBD, NHL) - Drugs (e.g. sulphonamides)

Question 228

Which drug is used in the management of benzodiazepine overdose?

Answer 228

Flumazenil

Question 229

Outline the management of an symptomatic bacteriuria in a catherised patient?

Answer 229

No treatment required; this is a common finding in catherised patients

Question 230

Outline the clinical features associated with refeeding syndrome? (4)

Answer 230

- Hypophosphataemia - Hypokalaemia - Hypomagnesaemia - Abnormal fluid balance

Question 231

Outline the main clinical signs associated with fluid overload? (5)

Answer 231

- Ascites - Chest crackles on auscultation - Tachypnoea - elevated JVP - Pitting oedema

Question 232

What is ascending cholangitis?

Answer 232

Bacterial infection (typically *E.coli*) of the biliary tree that is commonly associated with gallstones

Question 233

Outline the red flag symptoms that warrant urgent gastroscopy in patients presenting with dyspepsia? (6)

Answer 233

ALARMS - Anaemia - Loss of weight - Appetite loss, nausea and vomiting - Reflux; new onset or worsening - Malaena; and other features of GI bleeding - Swallowing difficulties (dysphagia)

Question 234

What is the classical acid-base disturbance seen in primary aldosteronism?

Answer 234

Metabolic alkalosis

Question 235

Outline the reversible causes of cardiac arrest? (8)

Answer 235

**The 4 H’s**; - **H**ypoxia - **H**ypovolaemia - **H**yperkalaemia - **H**ypothermia **The 4 T’s**; - **T**hrombosis - **T**ension pneumothorax - **T**amponade - **T**oxins

Question 236

Which clotting factors are deficient in haemophilia A and haemophilia B?

Answer 236

- **Haemophilia A**; factor **VIII** deficiency - **Haemophilia B**; factor **IX** deficiency

Question 237

What important additional management is required when treating a patient for diabetic ketoacidosis where they capillary blood glucose drops below 14.0mmol/L?

Answer 237

Start a 10% dextrose IV infusion at 125mL/hr alongside the normal saline and fixed rate insulin infusion

Question 238

Outline the chemoprophylaxis given to patients exposed to bacterial meningitis?

Answer 238

Ciprofloxacin 500mg single dose

Question 239

Which imaging modality is most appropriate for the diagnosis of meniscal tears?

Answer 239

MRI knee

Question 240

Outline the management of ankylosing spondylitis? (2)

Answer 240

- First-line; oral non-steroidal anti-inflammatory drugs (NSAIDs) - Second-line; anti-TNFα biologics (infliximab, etanercept)

Question 241

Which medications are known to cause neuroleptic malignant syndrome?

Answer 241

Antipsychotics

Question 242

Which blood tests are ordered as part of a haemolytic anaemia screen? (5)

Answer 242

- FBCs - Lactate Dehydrogenase (LDH) - blood Film - LFTs - serum Haptoglobin

Question 243

Which type of antibodies are involved in autoimmune haemolytic anaemia (AIHA)?

Answer 243

IgM

Question 244

Outline the management of Bell's palsy?

Answer 244

Oral prednisolone within 72 hours of onset plus artificial tears for eye care

Question 245

Which criteria is used in the definitive diagnosis of infective endocarditis?

Answer 245

Duke Criteria

Question 246

Outline the management of severe hypomagnesaemia?

Answer 246

IV magnesium sulphate can be given to correct hypomagnesaemia < 0.4 mmol/L or that is associated with tetany, arrhythmias, or seizures

Question 247

Which antibiotic should be used as prophylaxis following an animal bite?

Answer 247

- Majority of patients; co-amoxiclav - Penicillin-allergy; doxycycline plus metronidazole

Question 248

Which investigation is used to diagnose an anastomotic leak?

Answer 248

Abdominal CT

Question 249

Outline the triad of symptoms seen in acute cholangitis? (3)

Answer 249

Charcot's Triad - Fever - Jaundice - RUQ pain

Question 250

Outline the first-line investigation in patients with examination/biochemical findings suspicious of prostate cancer?

Answer 250

Multiparametric MRI is the first-line investigation in suspected prostate cancer

Question 251

Which scoring system can be used to risk assess patients with confirmed pulmonary embolism (PE) in order to guide management?

Answer 251

Pulmonary embolism severity index (PESI) score is a prognostic scoring system that is useful to determine the appropriateness of outpatient versus inpatient management.

Question 252

Which imaging modality should be used in a patient with suspected pancreatic cancer?

Answer 252

High-resolution CT abdomen

Question 253

Which drug can be used in palliative care to treat excess secretions and/or noisy breathing?

Answer 253

Hyoscine is the most appropriate drug management for respiratory secretions in palliative care

Question 254

Which scoring system can be used to classify the severity of an acute stroke?

Answer 254

National Institute of Health Stroke Score (NIHSS)

Question 255

Which organism is most commonly responsible for causing cholangitis?

Answer 255

Escherichia coli

Question 256

Which autoantibodies are primarily associated with autoimmune hepatitis? (5)

Answer 256

- Anti-nuclear antibodies (ANA) - Anti-smooth mucle antibodies (anti-SMA) - Anti-soluble liver/kidney microsomal antibodies (anti-LKM1) - Anti-soluble liver antigen (anti-SLA/LP) - Anti-liver cytosol antigen type 1 (anti-LC1)

Question 257

Outline the potential complications of tumour lysis syndrome (TLS)? (4)

Answer 257

- Seizures - Arrhythmias - Acute kidney injury (AKI) - Sudden death

Question 258

Outline the causes of acute pancreatitis? (11)

Answer 258

I GET SMASHED; - Idiopathic/Ischaemic - Gallstones - Ethanol - Trauma - Steroids - Mumps/Malignancy - Autoimmune - Scorpion Sting - Hypercalcaemia/Hypertriglyceridaemia - ECRP - Drugs (sulfonamides, azathiprine, NSAIDs or diuretics)

Question 259

When should patients who have undergone a total hip replacement be started on low-molecular weight heparin (LMWH) post-operatively?

Answer 259

6-12 hours following the operation

Question 260

Which primary tumours often metastasise to the brain? (5)

Answer 260

- Breast - Bowel - Renal - Lung - Melanoma

Question 261

Why is hypokalaemia often seen in end-stage alcohol-related liver disease?

Answer 261

Because in liver failure, hyperaldosteronism is common and this leads to excess potassium excretion in the urine

Question 262

Which tumours are associated with Multiple Endocrine Tumours Type IIb (MEN IIb)? (3)

Answer 262

MEN IIb; - Medullary thyroid cancer - Phaeochromocytoma - Neuroma

Question 263

Which cardiac defect is commonly associated with acromegaly?

Answer 263

Cardiomyopathy

Question 264

Which additional medication should be prescribed to patients taking the equivalent to 10 mg or more of prednisolone per day who are due to undergo surgery and why is this?

Answer 264

Hydrocortisone supplementation is required prior to surgery to prevent an Addisonian crisis

Question 265

Which combination chemotherapy is used in the treatment of node positive breast cancer? (4)

Answer 265

FEC-D; - 5-Fluorouracil - Epirubicin - Cyclophosphamide - Docetaxel

Question 266

Outline the pharmacological management of acute pulmonary oedema? (4)

Answer 266

FOND; - Furosemide 40mg IV - Oxygen (high-flow) - Nitrates (sublingual or infusion) - Diamorphine IV

Question 267

Outline the most common organisms that cause an atypical community acquired pneumonia (CAP)? (5)

Answer 267

Legions of Shitty MCQs;- Legionella pneumophilia (legionnaire's disease) - Chlamydia psittaci - Myoplasma pneumoniae - Chlamydydophilia pneumoniae - Coxiella burnetii (Q-fever)

Question 268

Which biochemical marker is more useful in diagnosing a late presentation of acute pancreatitis?

Answer 268

Serum lipase; has a longer half-life than amylase when investigating suspected acute pancreatitis and may be useful for late presentations > 24 hours

Question 269

Outline the serum potassium (K+) concentration that is preferred in patients in diabetic ketoacidosis (DKA)?

Answer 269

4.0 - 5.5 mmol L-1

Question 270

Outline the management options in aortic stenosis? (3)

Answer 270

- **Symptomatic**; open aortic valve replacement (AVR) or transcatheter aortic valve insertion (TAVI) - **Asymptomatic** with aortic valve **pressure gradient of > 40 mmHg**; aortic valve replacement (AVR) or TAVI - **Asymptomatic** with **normal** aortic valve **pressure gradient**; regular cardiology outpatient follow-up

Question 271

Outline the main features of haemolytic uraemic syndrome? (4)

Answer 271

- Normocytic anaemia - Raised urea - Thrombocytopenia - Acute kidney injury (AKI) - Recent diarrhoeal illness

Question 272

Outline the three main levels of seizure classification? (3)

Answer 272

- Area of onset; generalised vs focal (partial) - Awareness; aware vs impaired awarness - Associated features; motor vs non-motor

Question 273

Outline the anticoagulant options for patients with a confirmed pulmonary embolus? (6)

Answer 273

- Haemodynamically unstable; thrombolysis (**alteplase**) - Stable with no significant co-morbidities; **DOAC** (apixaban/rivaroxaban) or **LMWH** for **5 days** followed by **edoxaban/warfarin** - Active cancer; DOAC (**edoxaban**) or **LMWH** - Pregnant; **LMWH** or warfarin (rarely) - Renal impairment; **LMWH** OR **UFH** - Significnat bleeding risk; **UFH**

Question 274

Oultine the classical triggers associated with the development of migraines? (9)

Answer 274

Migraine Triggers; CHOCOLATE - Chocolate - Hangover/hormonal - Orgasm - Cheese/Caffiene - Oral Contraceptive Pill - Lie-ins - Alcohol - Travel - Exercise

Question 275

Which pharmacological agent should be prescribed as secondary prevention of cardiovascular disease in patients with peripheral arterial disease?

Answer 275

- Lifelong clopidogrel 75mg OD - If contraindicated/not tolerated then 75mg aspirin OD can be used

Question 276

What is the haemoglobin threshold level for transfusion in patients with ACS?

Answer 276

Hb < 80 g/L indicates transfusion

Question 277

Outline the long-term antiplatelet therapy used in patients following an acute ischaemic stroke?

Answer 277

- Aspirin 300 mg (OD) 2 weeks after the event - Clopidogrel 75 mg (OD) lifelong after 2-weeks

Question 278

Which imaging modality is used in the diagnosis of multiple sclerosis (MS)?

Answer 278

Gadolinium-enhanced magnetic resonance imaging (MRI)

Question 279

Outline the indications for circumcision? (4)

Answer 279

- Phimosis - Paraphimosis - Recurrent balanitis - Balanitis xerotica obliterans

Question 280

Outline the indications for cardioversion in patients with atrial fibrillation? (2)

Answer 280

Patients must either be; - Anticoagulated - Have had symptoms for < 48 hours This is to reduce the risk of stroke which is likely to occur after prolonged AF due to pooling of the blood in the atria

Question 281

Outline the management of a brain abscess?

Answer 281

IV ceftriaxone plus metronidazole

Question 282

Which drugs can be used for symptomatic relief in patients with ascites secondary to liver cirrhosis?

Answer 282

Aldosterone antagonists; spironolactone

Question 283

Outline the triad of symptoms associated with acute tubulointerstitial nephritis (TIN)? (3)

Answer 283

- Fever - Eosinophilia - rash

Question 284

What is the most likely diagnosis in a patient with a raised alkaline phosphatase (ALP) in the presence of otherwise normal liver function tests?

Answer 284

Primary bone malignancy or boney metastases

Question 285

When does hyperacute transplant rejection occur?

Answer 285

Within minutes to hours

Question 286

What dietary advice is it important to give to patients taking warfarin?

Answer 286

Avoid foods high in vitamin K (leafy greens); sprouts, spinach, kale and broccoli

Question 287

What investigations must be carried out in all men presenting with erectile dysfunction?

Answer 287

All men presenting with erectile dysfunction should have their morning testosterone levels checked

Question 288

What are the key principles in inflammatory bowel disease management? (4)

Answer 288

- Induce remission - Maintain remission - Surgical management; as and when required - Surveillance colonoscopy; screening for dysplasia

Question 289

What feature is likely to be seen on renal ultrasound in a patient with diabetic nephropathy?

Answer 289

Bilaterally enlarged kidneys

Question 290

What kind of anaemia is associated with alcoholism and why?

Answer 290

Macrocytic anaemia; as alcoholic patients lose folate and hence it is a folate-deficient macrocytic anaemia

Question 291

Outline the cause of Cushing's syndrome (hypercortisolism) in patients where a low-dose dexamethasone suppression test fails to suppress cortisol levels but a high-dose dexamethasone suppression test does suppress cortisol levels?

Answer 291

Pituitary adenoma (Cushing's disease); failure of a low-dose dexamethasone suppression test to suppress cortisol levels indicates an ACTH-dependent Cushing's syndrome which when combined with successful suppression of cortisol with a high-dose dexamethasone suppression test rules out an ectopic source of ACTH such as a small cell lung cancer (SCLC) and suggests that the Cushing's syndrome is due to excess secretion of ACTH from the pituitary gland

Question 292

What symptoms are associated with testicular cancer? (2)

Answer 292

- Painless testicular lump - Gynaecomastia

Question 293

Which criteria can be used to indicate a bacterial (Group A β-haemolytic Streptococcus pyogenes) cause of a sore throat?

Answer 293

Centor Criteria (FACT) - Fever (> 38°C) +1 - Absence of cough +1 - Cervical lymphadenopathy +1- Tonsillar exudate +1

Question 294

Which tumours are associated with Multiple Endocrine Tumours Type IIa (MEN IIa)? (3)

Answer 294

2 P’s; - Medullary thyroid cancer - Parathyroid hyperplasia - Phaeochromocytoma

Question 295

What is the most suitable first-line investigation in a patient suspected of having a phaeochromocytoma?

Answer 295

24 hour urinary metanephrines

Question 296

Outline the most common causes of a substantially raised (> 1000 U L^-1) alanine aminotransferase (ALT)? (3)

Answer 296

- Viral hepatitis - Paracetamol overdose - Anoxic liver injury

Question 297

Outline the aspects of the WHO Surgical Safety Checklist that must be chcked before the induction of anaesthesia? (7)

Answer 297

- Confirmed patient identity, procedure, site and consent - Site is marked - Anaesthesia safety check completed - Pulse oximeter is on patient and functioning - Allergies - Airway/aspiration risk - Blood loss risk; > 500ml in adults or 7ml/kg in children

Question 298

Why is it that thiazide diuretics can cause lithium toxicity in patients being treated for bipolar disorder? (3)

Answer 298

- Thiazide diuretics inhibit the sodium/chloride cotransporter (NCC) in the distal convoluted tubule (DCT) - As a result, there is a compensatory increase in the reabsorption of sodium in the proximal tubule (PCT) - Lithium reabsorption is subsequently increased alongside this sodium reabsorption thus resulting in an increase in serum Lithium levels

Question 299

Outline the cardinal features of Waldenström macroglobulinaemia? (4)

Answer 299

- Hyperviscosity symptoms; headache, nosebleeds, vertigo, nystagmus, dizziness, tinnitus, and ataxia - Hepatosplenomegaly - IgM monoclonal antibodies - Normocytic anaemia

Question 300

Which organism is most likely to cause necrotising fasciitis following a recent chickenpox infection?

Answer 300

Group A β-haemolytic *Streptococcus spp.* (*Streptococcus pyogenes*)

Question 301

Outline the major contraindications for the use of nitrates in acute coronary syndromes (ACS)? (3)

Answer 301

- Hypotension; **SBP < 90 mmHg** - Bradycardia **HR < 50 bpm** - **PDE-5 inhibitor use* within **24-48 hours**

Question 302

What is the difference between systemic inflammatory response syndrome (SIRS) and sepsis? (2)

Answer 302

- Systemic inflammatory response syndrome (SIRS); is an inflammatory state affecting the whole body - Sepsis; is the specific case of a systemic inflammatory response syndrome (SIRS) caused by infection

Question 303

Outline the pharmacological cardioversion options for a patient in atrial fibrillation (AF)? (2)

Answer 303

- **Flecanide**; in the majority of patients - **Amiodarone**; if patients have structural heart disease

Question 304

Outline the clinical signs can be associated with aortic regurgitation? (4)

Answer 304

- Quincke’s sign; pulsation of nail beds - Müller’s sign; pulsation of uvula - Early diastolic murmur; heard loudest at the left sternal edge - Collapsing (waterhammer) pulse; bounding, forceful pulse with a rapid upstroke and descent

Question 305

Outline the preferred imaging modality use in the investigation of superior vena cava obstruction (SVCO)?

Answer 305

Contrast-enhanced CT chest

Question 306

Which scoring system can be used to assess the severity of an upper GI bleed and inform whether the patient can be management safely as an outpation?

Answer 306

Glasgow-Blatchford Score (GBS)

Question 307

Outline the normal range for the base excess (BE)?

Answer 307

-2 to +2 mmol L^-1

Question 308

Which pH range is suitable for non-invasive ventilation (NIV) in patients with an exacerbation of their COPD?

Answer 308

pH 7.25 to 7.35

Question 309

Outline the management of alcoholic ketoacidosis? (2)

Answer 309

- IV thiamine - 0.9% saline

Question 310

Which biochemical markers are commonly associated with upper GI bleeding?

Answer 310

Microcytic anaemia with a raised urea

Question 311

Outline the features that indicate steroid responsivness in patients with COPD? (4)

Answer 311

- Previous diagnosis of asthma or of atopy - Raised serum eosinophils - FEV₁ variation ≥ 400mL - Diurnal PEFR varation ≥ 20%

Question 312

Which organism is most often associated with an aspiration pneumonia?

Answer 312

Klebsiella pneumonia

Question 313

Outline the first-line treatment used in the management of acromegaly?

Answer 313

Trans-sphenoidal surgery to remove the pituitary adenoma

Question 314

Outline the most common causes of status epilepticus? (6)

Answer 314

- Subdural haemorrhage - Hypoxia - Hypoglycaemia - Alcohol withdrawal - Mengitis - Uncontrolled epilepsy

Question 315

What key clinical feature is key in distinguishing myasthenia gravis from Lambert-Eaton Myasthenic Syndrome (LEMS)?

Answer 315

- **Myasthenia Gravis** (MG); muscle weakness worsens with use - **Lambert-Eaton Myasthenic Syndrome** (LEMS); muscle weakness improves with use

Question 316

Outline the cardinal clinical signs associated with primary hyperaldosteronism? (3)

Answer 316

- Hypertension - Hypokalaemia - Metabolic alkalosis

Question 317

Outline the most appropriate choices of antibiotic to be prescribed for the treatment of cellulits? (3)

Answer 317

- Majority of patients; flucloxacillin - Penicillin allergy; clarithromycin - Pregnancy; erythromycin

Question 318

How often can you repeat IM adrenaline injections in patients in anaphylaxis?

Answer 318

Every 5 minutes

Question 319

What is meant by the deprivation of liberty safeguards (DoLS) and what does it allow?

Answer 319

The deprivation of liberty safeguards (DoLS) allows you to detain a patient under the Mental Capacity Act (2005) with the caveat that it is the least restrictive option and in the best interests of the patient

Question 320

Which organism is most commonly associated with gastroenteritis following ingestion of reheated rice?

Answer 320

*Bacillus cereus*

Question 321

Which classes of drugs are known to cause acute interstitial nephritis? (5)

Answer 321

NSAIDs- Non-steroidal anti-inflammatory drugs (NSAIDs) - Salicylates - Antimicrobials; penicillin and rifampicin - Angiotensin converting enzyme inhibitors (ACE-Is) - Diuretics; furosemide

Question 322

Outline the hospital management of status epilepticus? (3)

Answer 322

- First-line; IV lorazepam - Second-line; IV lorazepam repeated ONCE after 10-20minutes - Third-line; IV phenytoin - Refractory status; general anaesthesia

Question 323

Outline the management options in ventricular tachycardia (VT)? (2)

Answer 323

- Systolic blood pressure (**SPB**) **> 90 mmHg**; loading dose of **amiodarone** followed by a 24hr amiodarone infusion - Systolic blood pressure (**SPB**) **< 90 mmHg**; proceed to **DC cardioversion**

Question 324

ST-elevation myocardial infarctions in which heart region are most heavily associated with bradyarrhythmias?

Answer 324

Inferior STEMIs (II, III and aVF) most commonly lead to bradyarrhythmias due to occlusion of the right coronary artery (RCA) which supplies the SAN, AVN and BoH

Question 325

Which autoantibodies are associated with Lambert-Eaton Myasthenic Syndrome (LEMS)?

Answer 325

Anti-voltage-gated calcium channel (VGCA) antibodies

Question 326

Which abnormal RBC appearances may be seen in the blood films of patients with coeliac disease? (2)

Answer 326

- Target Cells; due to the iron-deficiency anaemia that occurs in coeliac disease - Howell-Jolly Bodies; due to hyposplenism that occurs in 1/3 of coeliac patients

Question 327

During which phases of the respiratory cycle are right and left-sided murmurs loudest?

Answer 327

- Right-sided murmurs; loudest with inspiration - Left-sided murmurs; loudest with expiration

Question 328

Which organism is most commonly associated with pyelonephritis?

Answer 328

Escherichia coli

Question 329

Broadly speaking, outline the main problem associated with potassium handling in patients in diabetic ketoacidosis (DKA)?

Answer 329

There is an overall intracellular-to-extracellular shift in potassium in diabetic ketoacidosis (DKA)

Question 330

Outline all possible investigation findings that are sufficient, in isolation, for a diagnosis of diabetes mellitus type 2 (T2DM) to be made in an symptomatic patient? (4)

Answer 330

- A single HbA1c > 48 mmol mol-1 - A single fasting glucose ‚â• 7.0 mmol L-1 - A single random glucose ‚â• 11.1 mmol L-1 - A single serum glucose 2 hours post-75g oral glucose tolerance test (OGTT) ‚â• 11.1 mmol L-1

Question 331

Outline the immediate management of a symptomatic bradycardia? (3)

Answer 331

- First-line; atropine 500μg IV - Second-line; increase atropine up to maximum of 3mg - Third-line; transcutaneous pacing

Question 332

Outline the features associated with Staphylococcal toxic shock syndrome (STSS)? (3)

Answer 332

- Fever - Hypotension - rash causing desquamation

Question 333

Which autoantibodies are associated with anti-phospholipid syndrome?

Answer 333

Anti-cardiolipin antibodies

Question 334

Outline the key indications for CT head in a patient presenting with headache? (5)

Answer 334

- Vomiting more than once with No other cause - New neurological deficit (motor or Sensory) - Reduction in conscious level (reduced GCS) - Associated with coughing or sneezing (valsalva) or positional - Progressive with Fever

Question 335

What is meant by Murphy's sign?

Answer 335

Inspiration during deep palpation of the right upper quadrant elicits significant pain due to depression of the gallbladder onto the palpating hand by the contraction of the diaphragm

Question 336

Which antibiotic should be used prophylactically against *Pneumocystis jiroveci* pneumonia (PJP) in patients with HIV patients and a CD4⁺ count lower than 200/mm³?

Answer 336

**Co-trimoxazole** (trimethoprim and suxamethoxazole)

Question 337

What is the threshold Glasgow Coma Score (GCS) that indicates urgent airway considerationintubation?

Answer 337

GCS < 8

Question 338

Outline the normal post-void urine volumes for patients who have been catherised? (2)

Answer 338

- < 65 years old; <50 mL is considered physiological - > 65 years old; < 100ml is considered physiological

Question 339

Which malignancies are patients with sjögren's syndrome at increased risk of developing?

Answer 339

Lymphoid malignancies such as lymphoma

Question 340

Outline the location that should be used to administer an adrenaline autoinjector (EpiPen)?

Answer 340

Anterolateral aspect of the middle third of the thigh

Question 341

Outline the definition of severe hypomagnesaemia? (2)

Answer 341

- Biochemical hypomagnesaemia of 0.3 mmol/L or below - Clinically associated with tonic-clonic seizures, tetany or arrhythmias

Question 342

Outline the management of patients with stable angina? (4)

Answer 342

- Step 1; GTN PRN - Step 2; Add β-blocker OR CCB - Step 3; Switch β-blocker for CCB OR vice versa - Step 4; Revert to β-blocker OR CCB monotherapy and ADD any one of; a long-acting nitate, ivabridine, nicorandil or ranolazine

Question 343

What is Waterhouse-Friderichsen syndrome (WFS)?

Answer 343

Waterhouse-Friderichsen syndrome (WFS) refers to **acute adrenal insufficiency** caused by **adrenal haemorrhage** due to rupture of blood vessels in the adrenal gland often in the context of **severe bacterial infection**

Question 344

Which test carries the highest sensitivity and specificity in differentiating between sepsis and systemic inflammatory response syndrome (SIRS)?

Answer 344

**Procalcitonin**; will be **elevated in sepsis** but characteristically normal in systemic inflammatory response syndrome (SIRS)

Question 345

Which medication can be used in the prophylaxis of oesophageal bleeding?

Answer 345

Non-selective β-blockers (propranolol)

Question 346

Outline the first-line investigation used in suspected prostate cancer?

Answer 346

Transrectal ultrasound (TRUS) guided biospy of the prostate gland

Question 347

What further investigation should be carried out in a patient presenting with sudden-onset severe headache but whose CT scan appears normal?

Answer 347

**Lumbar puncture** 12 hours following the onset of symptoms to confirm or exclude a diagnosis of a subarachnoid haemorrhage (SAH)

Question 348

Outline the measures that can be used to prevent contrast-induced nephropathy in patients with renal impairment?

Answer 348

Intravenous 0.9% sodium chloride at a rate of 1 mL kg-1 hour-1 for 12 hours pre- and post-procedure

Question 349

What is the most common type of renal stone?

Answer 349

Calcium oxalate

Question 350

Outline the red flag symptoms to screen for in patients with back pain? (9)

Answer 350

- Age; under 20 OR over 55 - Night pain; remains when supine - Thoracic pain - Fever, chills - Unexplained weight loss - History of malignancy - Recent infection - IV drug use - Immunocompromised

Question 351

What is the definitive management for primary hyperparathyroidism?

Answer 351

Surgical; total parathyroidectomy

Question 352

Outline the clinical definition of a resolution of DKA? (3)

Answer 352

- pH > 7.3 - Blood ketones < 0.6 mmol/L - Bicarbonate > 15.0 mmol/L

Question 353

Which blood tests should be carried out first-line in suspected coeliac disease? (2)

Answer 353

- Total IgA - IgA tissue transglutaminase (tTG)

Question 354

Outline the main subtypes of hypertonia? (2)

Answer 354

- Rigidity; velocity independant hypertonia - Spasticity; velocity dependant hypertonia

Question 355

What is the target blood pressure for patients with hypertension and type 1 diabetes mellitus and albuminaemia?

Answer 355

< 130/80 mmHg

Question 356

Outline the triad of features seen in Budd-Chiari Syndrome? (3)

Answer 356

- abdominal pain - Ascites - Tender hepatomegaly

Question 357

Outline the main types of medications that can cause hypokalaemia? (3)

Answer 357

- Diuretics; particularly loop and thiazide diuretics - Insulin; due to increased in ATP and Na+/K+ATPase activity - β2 agonists; salbutamol, adrenaline

Question 358

Which antibiotic is given prophylactically to prevent recurrance of spontaneous bacterial peritonitis (SPB) in patients who have had a previous episode?

Answer 358

Ciprofloxacin

Question 359

Which antibiotics should be used to treat a urinary tract infection during pregnancy? (2)

Answer 359

- **Nitrofurantoin**; avoided near term due to increased risk of neonatal haemolysis - **Amoxicillin** or **cefalexin**; used where nitrofurantoin contraindicated

Question 360

Which artery is particularly at risk following a posterior ruptured duodenal ulcer?

Answer 360

Gastroduodenal artery

Question 361

Which anti-emetic(s) is/are preferred in nausea and vomiting that is associated with chemotherapy or radiotherapy?

Answer 361

**5-HT₃-receptor antagonists** such as odansetron in combination with **dexamethasone**

Question 362

What is the clinical definition of chronic tension-type headaches?

Answer 362

Headaches occurring on average **≥ 15 days/month** for **> 3 months**

Question 363

Which medications must be stopped temporarily whilst a patient is on macrolide (clarithromycin, erythromycin) antiobiotic therapy?

Answer 363

Statins; due to the increased risk of rhabdomyolysis as a result of CYP3A4 inhibition which results in a decreased breakdown of statins

Question 364

Which antibiotic is first-line in the treatment of methicillin-resistant Staphylococcus aureus (MRSA) in patients that are allergic to vancomycin?

Answer 364

Linezolid

Question 365

Which spirometric measurements are sufficient for a diagnosis of asthma? (4)

Answer 365

- An increase in FEV₁ of ≥ 12% post bronchodilator - A post-bronchodilator improvement in lung volume of ≥ 200 mL - A PEFR variability of ≥ 20% - An FEV₁/FVC ratio < 70%

Question 366

Which blood test abnormality is a relative contraindication for chest drain insertion?

Answer 366

INR > 1.3

Question 367

What is the daily potassium requirement used in prescribing of maintainance fluids?

Answer 367

1mmol/kg/day

Question 368

Outline the most common organisms that cause a typical hopsital acquired pneumonia (HAP)? (3)

Answer 368

- Gram-negative bacilli; Pseudomonas aeruginosa - Staphylococcus aureus - Legionella pneumophila

Question 369

Which blistering skin condition is associated with coeliac disease?

Answer 369

**Dermatitis herpetiformis**; caused by anti-TTG IgA antibodies binding to epidermal transglutaminase present in dermal papillae causing chronic, intensely itchy, blistering skin lesions

Question 370

Which patients are particularly at risk of invasive aspergillosis?

Answer 370

Immunocompromised patients

Question 371

Outline the ECG changes that may be associated with dextrocardia? (3)

Answer 371

- Inverted P wave in lead I - Right axis deviation - Loss of R wave progression

Question 372

Which autoantibodies are associated with primary billary cirrhosis/cholangitis? (2)

Answer 372

- Anti-mitochondrial antibodies (AMA) - Anti-nuclear antibodies (ANA)

Question 373

Outline the adjustments to the metformin administration regime in patients with type 2 diabetes who are due to undergo same day surgery? (2)

Answer 373

- **OD or BD**; take as normal - **TDS**; miss lunchtime dose (Assumes only one meal will be missed during surgery, a eGFR > 60 and no contrast used during procedure )

Question 374

Outline the complications associated with transurethral resection of the prostate (TURP) procedures? (4)

Answer 374

TURP; - TURP Syndrome - Urethral Strictures/UTIs - Retrograde Ejaculation - Prostate Perforation

Question 375

Which joints are most commonly affected in rheumatoid arthritis (RA)?

Answer 375

Metacarpophalangeal joints (MCPs)

Question 376

When is adrenaline given during a cardiac arrest? (2)

Answer 376

- **Shockable rhythm**; after the 3rd shock if no return of spontaneous circulation (ROSC) - **Non-shockable rhythm**; immediately, before commencing cardiopulmonary resuscitation (CPR)

Question 377

Outline the indications for rhythm control as first-line in patients with atrial fibrillation? (6)

Answer 377

- Age < 65 years - New-onset/first episode - Identifiable reversible cause - Heart failure - Associated with atrial flutter - Rhythm control felt to be more suitable (clinical judgement)

Question 378

Why are patients receiving chemotherapy at increased risk of developing gout?

Answer 378

Because cytotoxic chemotherapy agents cause an increase in the breakdown of cells which release products that are degraded into uric acid

Question 379

Outline the pharmacological management of osteoporosis? (2)

Answer 379

- Bisphosphonates - Vitamin D supplementation

Question 380

According to NICE guidelines, under what circumstances should patients with an excerbation of COPD be given antibiotics? (2)

Answer 380

- Purulent sputum - Clinical signs of pneumonia; neutrophilia, radiological evidence of consolidation/effusion

Question 381

Outline the features of acute limb ischaemia? (6)

Answer 381

**6 P's**; - **P**ain - **P**ulseless - **P**allor - **P**erishingly cold - **P**aralysis (late) - **P**araesthesia (late)

Question 382

Which procedure is used to diagnose and treat an infected, obstructed biliary system?

Answer 382

Endoscopic retrograde cholangiopancreatography (ERCP)

Question 383

Outline some of the key features of hypocalcaemia? (4)

Answer 383

- Perioral paresthesia - Muscle cramps/tetany - Convulsions - LongQT

Question 384

Why do patients who have had a 'long lie' after falling develope AKI?

Answer 384

Prolonged lies following a fall can result in rhabdomyolysis which causes acute tubular necrosis (ATN) which in turn results in an acute kidney injury (AKI)

Question 385

What is the most likely location of a lesion causing an incongruous homonymous hemianopia?

Answer 385

Contralateral optic tract

Question 386

What triad of signs can be used to indicated brain herniation in patients with a head injury? (3)

Answer 386

Cushing's triad; - Hypertension - Bradycardia - Tachypnoeic with irregular respirations (Cheyne-Stokes breathing)

Question 387

Outline the specific ECG changes needed to indicate thrombolysis or percutaneous coronary intervention (PCI) in patients presenting with an acute coronary syndrome (ACS)? (3)

Answer 387

- ST elevation of > 2mm (2 small squares) in ‚â• 2 consecutive anterior leads (V1-V6) OR - ST elevation of > 1mm (1 small square) in > 2 consecutive inferior leads (II, III, avF, avL) OR - New left bundle branch block (LBBB)

Question 388

Which class of mediciations are used first-line in the managment of reactive arthritis?

Answer 388

Non-steroidal anti-inflammatory drugs (NSAIDs)

Question 389

Which acid-base disturbance is commonly associated with diarrhoea?

Answer 389

Normal anion gap metabolic acidosis

Question 390

Why is it important to request a chest X-ray (CXR) prior to commencing a biologic of the anti-TNFα class?

Answer 390

Biologics such as adalimumab can cause reactivation of tuberculosis (TB)

Question 391

Which medication can be used in the treatment of dermatitis herpetiformis?

Answer 391

**Dapsone**; a sulfonamide antibiotic

Question 392

What is akathisia and which medications is it commonly associated with?

Answer 392

**Akathisia**; severe restlessness commonly associated with anti-psychotics

Question 393

What complication may arise as a result of rapid correction of a hyponatraemia?

Answer 393

Central pontine myelinolysis/osmotic demylination syndrome

Question 394

Which main groups of patients are screened for abdominal aortic aneurysms (AAA)? (2)

Answer 394

- Males > 65 years - Women > 70 years with risk factors

Question 395

Outline the triad of features are associated with gastric volvulus? (3)

Answer 395

- Vomiting - Pain - Failed attempts to pass a nasogastric tube (NGT)

Question 396

Outline the components of Reynold's pentad that may be seen in severe cases of ascending cholangits? (5)

Answer 396

- Fever - RUQ pain - Jaundice - Hypotension/shock - Confusion

Question 397

Which key clinical features indicate acute mesenteric ischaemia in a patient presenting with bloody diarrhoea? (2)

Answer 397

- Very acute history (12 hours) - Pain out of proportion to signs

Question 398

What conditions need to be met before administering benzylpenicillin pre-hospital in patients with suspected meningitis? (2)

Answer 398

- No know penicillin allegeries - Must have the presence of A non-blanching rash

Question 399

Outline the most common causes of nephrotic syndrome in adults and children? (2)

Answer 399

- **Adults**; focal segmental glomerulosclerosis (FSGS) - **Children**; minimal change disease (MCD)

Question 400

What are the charactersitic features of acute liver failure (ALF)? (3)

Answer 400

- Coagulopathy of hepatic origin - Altered levels of consciousness due to hepatic encephalopathy (HE) - No underlying chronic liver disease

Question 401

Which investigation can be used to differentiate between unilateral and bilateral structural causes of primary hyperaldosteronism?

Answer 401

Adrenal venous sampling (AVS) can be used to distinguish between unilateral adenoma and bilateral hyperplasia in primary hyperaldosteronism

Question 402

Which regions of the large bowel are most commonly affected by cancer? (2)

Answer 402

- Rectum - Sigmoid colon

Question 403

Which area of the colon is most often affected by ischaemic colitis?

Answer 403

Splenic flexure

Question 404

Under what circumstance, should intravenous corticosteroids (hydrocortisone) be administered to patients with hypothyroidism? (2)

Answer 404

- if they are presenting with features of myxoedema coma such as Confusion, bradycardia, Hypothermia and profoundly hypothyroidism - Administering intravenous thyroid hormone replacement can precipitate An Addisonian crisis if there is co-existing adrenal insufficiency

Question 405

Abdominal pain with blood and leukocytes on urine dipstick is indicative of what diagnosis?

Answer 405

Renal tract stones

Question 406

What is Budd-Chiari syndrome?

Answer 406

Budd-Chiari syndrome refers to a triad of features (abdominal pain, ascites, tender hepatomegaly) that occur due to thrombus formation in the hepatic vein

Question 407

What are the key indications for emergency dialysis? (4)

Answer 407

- Refractory pulmonary oedema - Refractory hyperkalaemia - Severe metabolic acidosis - Severe uraemia

Question 408

Outline the acute management of a cluster headache? (2)

Answer 408

- Subcutaneous sumitriptan - 100% oxygen therapy

Question 409

Outline the triad of features associated with transurethral resection of the prostate syndrome? (3)

Answer 409

- Hyponatraemia (dilutional) - fluid overload - Glycine toxicity

Question 410

Which investigation would be most useful in diagnosing non-convulsive status epilepticus?

Answer 410

Electroencephalogram (EEG)

Question 411

Outline the indications for a CT head within 8 hours in patients presenting with a head injury? (4)

Answer 411

**DRAB**; - **D**angerous mechanism of injury - **R**etrograde amnesia > 30 mins - **A**ge > 65 - **B**leeding/clotting disorders

Question 412

When should warfarin be stopped prior to surgery?

Answer 412

**5 days before** the operation and/or until **INR < 1.5**

Question 413

What radiological feature is associated with hyperparathyroidism?

Answer 413

Pepperpot skull is a characteristic X-ray finding of hyperparathyroidism

Question 414

Outline the features that indicate long-term oxygen therapy in chronic obstructive pulmonary disease (COPD)? (2)

Answer 414

- pO2 < 7.3 kPa on ‚â• 2 arterial blood gases (ABGs) - Must have stopped smoking

Question 415

Which class(es) of drugs are contraindicated in patients with angina who are already taking β-blockers? (2)

Answer 415

Non-dihydropyridine calcium channel blockers (CCBs) due to the risk of complete heart block; - Phenylalkylamine CCBs (verapamil) - Benzothiazepine CCBs (diltiazem)

Question 416

Which antibiotics should be used in the treatment of bacterial vaginosis?

Answer 416

Metronidazole 400mg BD for 7 days

Question 417

What is the target blood pressure for patients with hypertension and type 1 diabetes mellitus but no albuminaemia?

Answer 417

<135/85 mmHg

Question 418

Oultine the management of degenerative cervical myelopathy (DCM)?

Answer 418

Neurosurgery/orthopaedic spinal decompression

Question 419

Outline the most common causes of iron-deficiency anaemia (IDA) in the western world? (5)

Answer 419

GM3C; - Gastrointestinal blood loss - Malnutrition - Menorrhagia - Malignancy - Coeliac disease

Question 420

What are Stokes-Adams attacks?

Answer 420

Transient losses of consciousness caused by episodes of complete heart block or asystole that occur in patients with self-limiting rapid tachyarrhythmias

Question 421

What is the mechanism by which controlled hyperventillation can be used to treat raised intracranial pressure (ICP)?

Answer 421

Reduces blood CO2 which induces cerebral vasoconstriction and a reduction in intracerebral pressure

Question 422

Outline the agents used to reverse warfarin-mediated anticoagulation in a patient with severe bleeding or a head injury following trauma? (2)

Answer 422

- Vitamin K - Prothrombin complex concentrate

Question 423

Outline the first-line management of heart failure? (4)

Answer 423

Heart Failure Management; ABAL - ACE inhibitor; usually ramipril 1.25mg OD - β blocker; usually bisoprolol 1.25mg OD - Aldosterone/Mineralocorticoid antagonist; usually eplerenone 25mg OD - Loop diuretic; 40mg OD for sympomatic relief

Question 424

Which induction anaesthetic is preferred in patients who are haemodynamically unstable?

Answer 424

Ketamine

Question 425

What is the most common location of an abdominal aortic aneurysm?

Answer 425

Infrarenal; around 95% of cases

Question 426

Outline the features consistent with a posterior cerebral artery (PCA) stroke? (2)

Answer 426

- Homonymous hemianopia with macular sparing - Visual agnosia; impaired recognition of visually presented objects

Question 427

What is the most appropriate revascularisation approach in patients who have suffered an ST-elevation myocardial infarction (STEMI) where percutaneous coronary intervention (PCI) is not available within 2 hours?

Answer 427

Fibrinolysis within 12 hours of onset of symptoms

Question 428

Outline the antibiotics used for inpatient management of diverticulitis?

Answer 428

Intravenous ceftriaxone and metronidazole

Question 429

Outline the third stage interventional management of heart failure? (4)

Answer 429

Consider; - Implantable cardiac defibrillator (ICD) - Cardiac resynchronisation therapy/biventricular pacing (CRT) - Percutaneous coronary intervention (PCI) - Cardiac transplantation

Question 430

Outline the initial phase of management used in the treament of an active tuberculosis infection? (4)

Answer 430

Initial Phase; first 2 months - Rifampicin - Isoniazid - Pyrazinamide - Ethambutol

Question 431

What investigation should be carried out following bloods and ECG in a patient presenting with intermittent palpitations?

Answer 431

**Holter monitoring**; 24 hour cardiac tape that attempts to try to catch an episode of the arrhythmia

Question 432

What is the most common generalised epilepsy syndrome?

Answer 432

Juvenile Myoclonic Epilepsy (JME)

Question 433

Which antibiotic is first-line in the treatment of methicillin-resistant *Staphylococcus aureus* (MRSA)?

Answer 433

Vancomycin

Question 434

How soon should a patient with a suspected transient ischaemic attack (TIA) be seen by a specialist?

Answer 434

Within 24 hours of the original onset of symptoms

Question 435

What is the purpose of irradiating blood products for use in patients with haematological malignancies?

Answer 435

Irraditation prevents transfusion-associated graft versus host (GvH) disease by rendering donor T-lymphocytes inactive

Question 436

What are the indications for commencing statin therapy as primary prevention in patients at risk of cardiovascular disease? (3)

Answer 436

- QRISK > 10% - Diabetes mellitus for > 10 years - eGFR < 60 mL min^-1 m^-2

Question 437

Which antibiotics can be used to treat Clostridium difficile infections? (3)

Answer 437

- Mild to moderate; oral metronidazole 400 mg TDS for 10-14 days - Severe (or no response to previous within 7 days); switch to oral vancomycin 125-250 mg QDS for 10-14 days - Life-threatening; oral vancomycin and IV metronidazole

Question 438

How many units of insulin are present in 1 mL of a standard preparation?

Answer 438

100 units per 1 mL (**100 U mL^-1**)

Question 439

Outline the two main types of neuropathy associated with type 2 diabetes mellitus? (2)

Answer 439

- **Sensory neuropathy**; diabetic foot ulcers, silent MI, peripheral neuropathy - **Autonomic neuropathy**; erectile dysfunction, postural hypotension, loss of respiratory arrhythmia

Question 440

Which imaging modality is first-line in suspected small bowel obstruction?

Answer 440

Abdominal X-ray

Question 441

Outline the most common causes of acute pulmonary oedema? (2)

Answer 441

- acute left ventricular dysfunction - Renal artery stenosis

Question 442

Which conditions are associated with the Malassezia furfur organism? (2)

Answer 442

- Pityriasis (tinea) versicolor; superficial cutaneous skin infection causing appearance of flaky discoloured patches on the chest and back - Seborrhoeic dermatitis; a chronic dermatitis causing a proliferation of normal skin in response to an inflammator

Question 443

Outline the treatment options used in latent tuberculosis infection? (2)

Answer 443

- 3 months of isoniazid, pyridoxine and rifampicin OR - 6 months of isoniazid with pyridoxine

Question 444

Outline the most common causes of microcytic anaemia? (5)

Answer 444

TAILS; - Thalassaemia - Anaemia of chronic disease (CKD) - Iron-deficiency anaemia - Lead poisoning - Sideroblastic anaemia

Question 445

Outline the most common causes of cholestatic liver function tests (LFTs)? (5)

Answer 445

- Malignancy; cholangiocarcinoma, hepatocellular carcinoma, pancreatic adenocarcinoma - Strictures; bile duct strictures - Stone; cholelithiasis - Intrinsic liver disease; primary sclerosing cholangitis (PSC), primary biliary cirrhosis/cholangitis (PBC) -

Question 446

Outline the specialist blood test that can be used to indicate portal hypertension in a patient with ascites?

Answer 446

**Serum-ascites albumin gradient (SAAG)**; - Calculated by subtracting the ascitic fluid albumin concentration from the serum albumin concentration - A high SAAG (>11 g/L) is an indication of portal hypertension

Question 447

Outline the two features needed for acute pancreatitis to be diagnosed clinically without any imaging? (2)

Answer 447

- Pain is characteristic; i.e. epigastric pain radiating to the back - Serum amylase > 3 times normal level

Question 448

Which antibiotics are most commonly used in the treatment of a high severity community acquired pneumonia? (2)

Answer 448

- Clarithromycin 500 mg BD (PO) - Amoxicillin 1 g TDS (PO)

Question 449

Outline the significance of a Blatchford and/or Rockall Score of zero (0) when investigating the cause of upper GI bleeding?

Answer 449

A score of 0 on the Blatchford/Rockall score is associated with a **low risk of mortality** and patients can be considered for **early discharge and/or non-admission**

Question 450

Which key feature is important to acertain during a respiratory history that make a diagnosis of asthma less likely?

Answer 450

Presence of peripheral tingling during episodes of dyspnoea

Question 451

Which thyroid condition is associated with a painful goitre?

Answer 451

Subacute (De Quervain's) thyroiditis

Question 452

What intervention is vital in the long-term prevention and/or management of ascites?

Answer 452

Restriction of dietary sodium intake

Question 453

Outline the triad of features commonly associated with irritable bowel syndrome (IBS)? (3)

Answer 453

**ABC**; - **A**bdominal pain - **B**loating - **C**hange in bowel habit

Question 454

What features indicate a tertiary hyperparathyroidism over primary/secondary hyperparathyroidism? (3)

Answer 454

- presence of chronic kidney disease - Extremely elevated PTH levels - Moderately Raised serum calcium

Question 455

What is the gold-standard investigation used to diagnose a renal calculus?

Answer 455

Non-contrast CT kidneys, ureter and bladder (CT-KUB)

Question 456

What feature may be seen on the chest X-ray of a patient with an aortic dissection?

Answer 456

Widened mediastinum; due to the extra blood filling the aortic wall through the defect.

Question 457

Outline how the serum ascitic albumin gradient (SAAG) can be used to establish the likely cause of an ascites? (2)

Answer 457

- SAAG > 11 g L-1 indicates a transudative cause, most often portal hypertension - SAAG < 11 g L-1 indicates an exudative cause, most often infection or malignancy

Question 458

Which biochemical marker can be used as an indication of carcinoid syndrome?

Answer 458

Urinary 5-Hydroxyindoleacetic acid (5-HIAA); carcinoid tumours release serotonin, so will cause a raised urinary 5-HIAA

Question 459

Which investigation can be used to differentiate between a true seizure and a pseudoseizure?

Answer 459

Prolactin levels; these will be raised in a true seizure

Question 460

Which organism is most commonly responsible for pneumonia in patients who are HIV positive?

Answer 460

*Pneumocystis jirovecii*

Question 461

Outline the most common causes of upper lobe lung fibrosis? (6)

Answer 461

BREAST; - Bronchopulmonary aspergillosis - Radiotherapy - Extrinsic allergic alveolitis - Ankylosing spondylitis - Sarcoidosis - Tuberculosis

Question 462

Outline the common findings seen in a patient with acute tubular necrosis (ATN)? (4)

Answer 462

- Acute kidney injury (AKI) - Hyperkalaemia - Oligouria; possibly with muddy-brown casts - Reduced urine osmolarity; < 350 mOsm/kg

Question 463

Outline the add-on medical therapies that can be used in the management of heart failure? (4)

Answer 463

- Hydralazine - Ivabridine - Sacubitril/valsartan (Entresto) - Digoxin

Question 464

Outline the triad of clinical signs associated with cardiac tamponade? (3)

Answer 464

Beck’s Triad; - Worsening hypotension - Rising jugular venous pulse (JVP) - Muffled heart sounds

Question 465

Which surgical treatment can be offered to patients with achalasia?

Answer 465

Heller cardiomyotomy; involves cutting of the thick muscle around the lower oesophagus and upper stomach to allow for passage of food and drink.

Question 466

Which acid-base balance disorder is associated with Addison's disease?

Answer 466

Hyperkalaemic metabolic acidosis; due to insufficiency of aldosterone which decreases acid secretion in the kidney and leads to the retention of potassium.

Question 467

Which single laboratory finding should prompt an immediate consideration of liver cirrhosis and urgent review by hepatology in those with chronic liver disease?

Answer 467

Thrombocytopenia (platelet count <150,000 mm-3) is the most sensitive and specific lab finding for diagnosis of liver cirrhosis in those with chronic liver disease

Question 468

What is the most common cause of nephrotic syndrome in children?

Answer 468

Minimal change disease (MCD)

Question 469

Which investigation finding is considered most sensitive and specific for idiopathic intracranial hypertension (IIH)?

Answer 469

**Magnetic resonance (MR) venogram**; classically shows evidence of transverse venous stenosis

Question 470

Which medications are commonly associated with the presence of hyaline casts upon urinalysis?

Answer 470

Loop duiretics (furosemide)

Question 471

Which antibiotic should be used to treat a urinary tract infection in mothers who are breast feeding?

Answer 471

Trimethoprim

Question 472

Which condition, other than pancreatitis, can be associated with a raised serum amylase?

Answer 472

Small bowel obstruction

Question 473

Which drug is used in the management of paracetamol overdose?

Answer 473

N-acetylcysteine (NAC)

Question 474

What is the most appropriate initial management in an adult patient suffering an anaphylactic reaction?

Answer 474

Intramuscular (IM) injection of **0.5 mL of 1:1000 adrenaline** corresponding to a dose of 0.5 mg (500 μg)

Question 475

Outline the pharacological agent used in the management of male patient's presenting with lower urinary tract symptoms (LUTS) but a normal digital rectal examination (DRE) and a normal prostate-specific antigen (PSA) level?

Answer 475

Tamsulosin; an α1AR antagonist

Question 476

Briefly outline how packages of care are funded following patient discharge from hospital? (2)

Answer 476

- Socially-funded care; means tested - Healthcare-funded care; NHS-funded

Question 477

How soon after treatment of diabetic ketoacidosis (DKA) should it take for the ketonaemia and acidosis to resolve?

Answer 477

Within 24 hours; if there is no resolution of ketonaemia and acidosis within 24 hours then a review by a senior endocrinologist is required

Question 478

Which scoring system can be used to stratify the severity of alcoholic hepatitis and guide whether to give steroids?

Answer 478

Maddrey Discriminant Function (MDF); a score > 32 indicates severe hepatitis and potential benefit from corticosteroids

Question 479

What is melanosis coli and what is it a sign of? (3)

Answer 479

- A disorder of pigmentation of the bowel wall - Characterised by pigment-laden macrophages present upon histological analysis of biopsy samples - Associated with laxative abuse, especially anthraquinone compounds such as senna

Question 480

How can one differentiate between constrictive pericarditis and cardiac tamponade?

Answer 480

**Kussmaul's Sign**; - **Negative**; **JVP** that **falls with inspiration** indicates cardiac **tamponade** - **Positive**; **JVP** that does **not fall** or, **rises further, with inspiration**, indicates constrictive **pericarditis**

Question 481

Which organism is most commonly associated with epididymo-orchitis?

Answer 481

*Chlamydia trachomatis*

Question 482

Outline the mainstay of treatment in rhabdomyolyisis?

Answer 482

IV fluid replacement 0.9% (normal) saline

Question 483

Outline the management of a liver abscess? (2)

Answer 483

- **Drainage**; typically percutaneous - **Antibiotics**; * **Most patients**; amoxicillin + ciprofloxacin + metronidazole * **Penicillin allergic**; ciprofloxacin + clindamycin

Question 484

What is the most appropriate investigation to used in the diagnosis of intussusception?

Answer 484

Abdominal ultrasound

Question 485

Which medication can be used in the initial management of a patient presenting with signs of raised intracranial pressure (ICP)?

Answer 485

IV mannitol

Question 486

What symptom/sign can be indicative of osmotic demylination syndrome/central pontine myelinolysis?

Answer 486

New onset spastic quadriparesis

Question 487

Outline the main features of Kartagener's syndrome? (4)

Answer 487

Primary Ciliary Dyskinesia (Kartagener's Syndrome); - Dextrocardia/Situs Invertus - Bronchiectasis - Recurrent Sinusitis - Subfertility; diminised sperm motility/defective Fallopian tubes

Question 488

Which acid-base balance disorder is associated with Cushing's syndrome?

Answer 488

Hypokalaemic metabolic alkalosis; due to excess aldosterone which increases acid and potassium excretion in the kidney

Question 489

Outline the management of acute pulmonary oedema? (4)

Answer 489

**Pour SOD**; - Fluid restrict/**stop IV fluids** - **S**it the patient up - **O**xygen if desaturating - **D**iuretics

Question 490

Which types of organisms are most commonly associated with cholecystitis?

Answer 490

Gram negatives and anaerobes

Question 491

Which region of the bowel is most likely to be affected by ischaemic colitis?

Answer 491

Splenic flexure; this marks the point where the majority of blood supply changes from the superior mesenteric artery (SMA) to the inferior mesenteric artery (IMA) making it most vulnerable to reduced blood supply

Question 492

Outline the British Thoracic Society (BTS) Guidelines on good inhaler technique? (5)

Answer 492

- Remove cap and shake - Breathe out gently - Put mouthpiece in mouth and breathe in slowly and deeply as you press canister down and continue to inhale steadily and deeply - Hold breath for 10 seconds, or as long as is comfortable - For a second dose wait for approximately 30 seconds before repeating steps

Question 493

Outline the sick day rules for patients with Addison's disease who develop an infection? (2)

Answer 493

- Double the dose of glucocorticoids (hydrocortisone) - Keep same dose of mineralocorticoids (fludrocortisone)

Question 494

Outline the main indication for

Question 495

Which medications are used first-line in the treamtent of cocaine toxicity?

Answer 495

Benzodiazepines (diazepam)

Question 496

Which antidiabetic medications can be continued on the day of surgery? (3)

Answer 496

- Metformin - DPP-4 inhibitors (glitpins) - GLP-1 agonists (incretins)

Question 497

Outline the indications for assessment of long-term oxygen therapy (LTOT) in patients with chronic obstructive pulmonary disease (COPD)? (4)

Answer 497

The 4 B's; - Blue; cyanosis, SpO2 < 92% - Breathing; severe airway obstruction, FEV1 < 30% - Blood; secondary polycythaemia - Ballooning; peripheral oedema, raised JVP, hepatomegaly

Question 498

Outline the dose adjustment needed for patients on once daily long-acting insulin injections who are due to undergo surgery scheduled for the same day/next day?

Answer 498

Reduce the number of units by 20%

Question 499

Outline the first-line investigation used in patients with a suspected diagnosis of Budd-Chiari syndrome?

Answer 499

Ultrasound with Doppler flow studies

Question 500

Which antibiotic is used first-line in the treatment of acute pyelonephritis?

Answer 500

IV ceftriaxone