Medicine 10

Question 1

List some causes of a fixed dilated pupil.

Answer 1

3rd nerve palsy
Mydriatics (e.g. tropicamide)
Iris trauma
Acute glaucoma

Question 2

List some causes of optic atrophy.

Answer 2

MS
Glaucoma
Congenital (LHON, CMT, Friedreich ataxia)
Toxins (ethambutol, B12 deficiency)

Question 3

How can acute glaucoma be distinguished from anterior uveitis?

Answer 3

Cloudy cornea
Large pupil
Increased IOP

NOTE: both are painful

Question 4

How can episcleritis and scleritis be distinguished?

Answer 4

Scleritis: vasculitis of the sclera, PAINFUL, worse on eye movement
Episcleritis: painless, acuity preserved, redness can be moved over sclera

Question 5

Which imaging tool is used to give a 3D representation of the retina?

Answer 5

Optical coherence tomography

Question 6

Outline the management options for wet ARMD.

Answer 6

Photodynamic therapy
Intravitreal VEGF injections (bevacizumab)
Anti-oxidants and zinc may help early ARMD

Question 7

List some classes of medications that are used to reduced IOP in open angle glaucoma.

Answer 7

Beta-blockers (reduce production) - timolol
Prostaglandin analogue (increase uveoscleral outflow) - latanoprost
Alpha-agonists (reduce product and increase outflow) - brimonidine
Carbonic anhydrase inhibitors - acetazolamide
Miotics - pilocarpine

Question 8

List some causes of cataracts.

Answer 8

Age
DM
Steroids
Congenital (Rubella, Wilson’s, myotonic dystrophy)

Question 9

What is the normal duration of the following parts of an ECG?
PR interval
QRS complex
QTc

Answer 9

PR interval: 120-200 ms (3-5 small squares)
QRS complex: < 120 ms (3 small squares)
QTc: 380-420 ms (~2 big squares)

NOTE: normal ECG calibration is 25 mm/s

Question 10

What is the difference between bifascicular and trifascicular block?

Answer 10

Bifascicular: RBBB + left anterior or posterior fascicular block
Trifascicular: RBBB + left anterior or posterior fascicular block + prolonged PR (1st degree)

Question 11

What are escape rhythms?

Answer 11

Appear after an anticipated beat
Atrial Escape: SAN fails to depolarise leading to failed sinus beat, followed by atrial escape (narrow complex)
Ventricular Escape: atrial wave fails to conduct due to AV block, followed by ventricular escape (broad complex - weird and wide)

Question 12

List some differentials for broad complex tachycardia.

Answer 12

VT
VF
Torsades de pointes
SVT with BBB

Question 13

List some causes of VT.

Answer 13

Infarction
Myocarditis 
Long QT syndrome 
Cardiomyopathy 
Iatrogenic (antiarrhythmics)

Question 14

List some contraindications for thrombolysis.

Answer 14

GI bleeding
Recent haemorrhagic stroke
Severe hypertension
Trauma

Question 15

List some differentials for chest pain.

Answer 15

ACS 
Angina
Aortic dissection 
Aortic aneurysm 
GORD 
Oesophageal spasm 
Musculoskeletal

Question 16

List some causes of heart failure.

Answer 16

SYSTOLIC: ischaemia, DCM, hypertension, myocarditis
DIASTOLIC: pericardial effusion, restrictive cardiomyopathy
ARRHYTHMIA: brady/tachy
Valve disease
HIGH OUTPUT: anaemia, thyrotoxicosis, pregnancy, Paget’s disease

Question 17

List the main CXR features of heart failure.

Answer 17

Alveolar shaddowing 
Kerley B lines 
Cardiomegaly 
Upper lobe diversion 
Effusions

Question 18

What are the main indications for pharmacological management of hypertension?

Answer 18

< 80 yrs, stage 1 hypertension (140/90-160/100) and one of:
- target organ damage (retinopathy, LVH)
- 10 yr CVD > 10% (QRISK)
- established CVD
- diabetes mellitus
- renal disease
Anyone with stage 2 hypertension and above

NOTE: statin should also be offered if QRISK > 10%

Question 19

List some echocardiography features of severe mitral stenosis.

Answer 19

Valve orifice < 1 cm^2
Pressure gradient > 10 mm Hg
Pulmonary artery systolic pressure > 50 mm Hg

Question 20

Which investigations should be requested insuspected infective endocarditis?

Answer 20

Bloods: ESR, blood cultures (3 x 12 hours apart), serology for unusual organisms
Urine: microscopic haematuria
ECG: AV block
Echo: vegetations

Question 21

Which investigations should you request in a patient with suspected rheumatic fever?

Answer 21

Bloods: ASO titre, streptococcal antigen, FBC, ESR
Throat swab (if strep throat)
ECG
Echocardiogram (MR/AR)

Question 22

List some causes of restrictive cardiomyopathy.

Answer 22

Amyloidosis
Haemochromatosis
Sarcoidosis
Primary endomyocardial fibrosis

Question 23

List some causes of dilated cardiomyopathy.

Answer 23

Muscular dystrophy 
Myocarditis 
Alcoholism
SLE 
Drugs (doxorubicin)
Thyrotoxicosis

Question 24

List some complications of congenital heart disease.

Answer 24

Infective endocarditis
Pulmonary hypertension
Paradoxical emboli
Eisenmenger syndrome

Question 25

List some features of Marfan syndrome.

Answer 25

``` Cardiac: aortic aneurysm, aortic dissection, aortic regurgitation, mitral valve prolapse Lens dislocation High-arched palate Arm span > height Pectus excavatum Scoliosis Hypermobility ```

Question 26

List some features of Ehlers-Danlos syndrome.

Answer 26

Hyperelastic skin Hypermobility (Beighton) Cardiac (mitral prolapse, MR, AR, aneurysms) Easy bruising (fragile blood vessels) NOTE: cutis laxa is loose skin and hypermobile joints

Question 27

List some complications of pneumonia.

Answer 27

``` Respiratory failure Sepsis AF Pleural effusion Empyema ```

Question 28

List the different diseases that can be caused by aspergillosis.

Answer 28

``` Asthma ABPA Aspergilloma Invasive aspergillosis Extrinsic allergic alveolitis ```

Question 29

List some causes of ARDS.

Answer 29

Pulmonary: pneumonia, aspiration, inhalational, contusion Systemic: sepsis, pancreatitis, DIC, acute liver failure

Question 30

List some causes of pulmonary oedema.

Answer 30

``` Heart failure Renal failure Liver failure Iatrogenic fluid overload Nephrotic syndrome Lymphatic obstruction ARDS (exudative) ```

Question 31

What concentration of oxygen should be used in acutely unwell COPD patients?

Answer 31

80-90% 15 L/min through non-rebreathe mask initially and perform ABG If PCO2 < 6 kPa: aim for target SaO2 94-98% If PCO2 > 6 kPa: maintain target SaO2 88-92%

Question 32

Outline the management of primary and secondary pneumothorax.

Answer 32

PRIMARY - < 2 cm rim and not SOB - consider discharge - otherwise: aspiration --> chest drain SECONDARY - > 2 cm rim OR SOB OR > 55 years --> chest drain - otherwise: aspiration --> chest drain - ALL patents should be admitted for at least 24 hours

Question 33

List some features of sarcoidosis.

Answer 33

``` Constitutional upset Respiratory (fibrosis, bilateral hilar lymphadenopathy) Arthralgia Peripheral/cranial neuropathy (e.g. Bell's palsy) Uveitis/keratoconjunctivitis Restrictive cardiomyopathy Hepatosplenomegaly Lupus pernio Erythema nodosum ```

Question 34

What pulmonary artery pressure counts as pulmonary hypertension?

Answer 34

> 25 mm Hg NOTE: normal is 8-20 mm Hg

Question 35

Outline the management of pulmonary hypertension.

Answer 35

``` Treat underlying condition LTOT CCB Sildenafil Prostacyclin analogues Heart failure treatment Heart-lung transplant ```

Question 36

List some secondary causes of diabetes mellitus.

Answer 36

Drugs (steroids, tacrolimus, ciclosporin) Pancreatic (chronic pancreatitis, cystic fibrosis, hereditary haemochromatosis) Endocrinology (phaeo, Cushing's, phaeo)

Question 37

What is usually checked at a routine diabetes check up?

Answer 37

Control (glycaemic) - HbA1c, BP, lipids, capillary blood glucose Complications - BP, cardiac auscultation, fundoscopy, ACR, sensory testing Competency - with treatment regime Coping - psychosocial

Question 38

What are the two main types of insulin regime in diabetes?

Answer 38

Biphasic - 30 mins before breakfast and dinner, good for patients with regular lifestyle (e.g. children, elderly) Basal-Bolus - bedtime long-acting insulin + short-acting insulin before meals, good for patients with flexible lifestyle NOTE: once-daily long-acting before bed is initially used in patients switching from tablets in T2DM

Question 39

List some side-effects of insulin therapy.

Answer 39

Hypoglycamia (careful with alcohol and beta-blockers) Lipohypertrophy Weight gain

Question 40

What should patients with diabetes be informed about regarding diabetes management when they are ill?

Answer 40

Insulin requirements usually increase Check BMs more frequently than every 4 hours (and check urine for ketonuria) Increase insulin dose if glucose is rising Maintain calories as much as possible

Question 41

Which investigation is used to check for proliferative diabetic nephropathy and wet ARMD?

Answer 41

Fluorescein angiography

Question 42

List some complications of DKA.

Answer 42

Cerebral oedema (excess fluid administration) Aspiration Hypokalaemia Hypophosphataemia (resp and skeletal muscle weakness) VTE

Question 43

List some causes of hypoglycaemia.

Answer 43

``` Inappropriate insulin Drugs (sulphonylureas) Pituitary insufficiency Addison's disease Liver failure Insulinoma ```

Question 44

List some causes of hypothyroidism.

Answer 44

``` Atrophic hypothyroidism Hashimoto's hypothyroidism Iodine deficiency De Quervain's thyroiditis Drugs (thionamides, lithium) Thyroidectomy ```

Question 45

What are the main features of multiple endocrine neoplasia (MEN)?

Answer 45

MEN1: pituitary adenoma (prolactin, GH) + parathyroid adenoma/hyperplasia + pancreatic islet cell (gastrinoma, insulinoma) MEN2: medullary thyroid cancer + phaeochromocytoma + parathyroid hyperplasia (2B - marfanoid body habitus)

Question 46

Which diseases fall under the autoimmune polyendocrine syndromes?

Answer 46

``` Type 1 (recessive): Addison's, candidiasis, hypoparathyroidism Type 2 (polygenic): Addison's, thyroid disease, T1DM ```

Question 47

List some clinical features of acromegaly.

Answer 47

``` Prominent supraorbital ridges Coarse facial features Prognathism Macroglossia Wide-spaced teeth Thenar wasting (and CTS symptoms) Sweaty spade-like hands ```

Question 48

What are the initial steps in the management of a patient with suspected coeliac disease and a high TTG?

Answer 48

Refer for gastroscopy and duodenal biopsies Referral for bone density scan Screening of first-degree relatives Referral to dieticians for gluten-free diet advice

Question 49

Which extra-GI manifestations of UC are related to the activity of colitis?

Answer 49

``` Erythema nodosum Aphthous ulcers Episcleritis Acute arthropathy Pyoderma gangrenosum Anterior uveitis ```

Question 50

List some medical treaments used for multiple sclerosis.

Answer 50

Steroids (IV methylprednisolone for optic neuritis) 1st line: Beta-interferon, glatiramer acetate 2nd line: natalizumab Symptomatic: baclofen (spasticity)