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Make a Medic Recap Decks (COPY) > Medicine > Flashcards

Medicine Flashcards

1
Q

What is the first-line treatment option for patients with newly-diagnosed rheumatoid arthritis?

A

DMARD Monotherapy (Methotrexate, Sulfasalazine or Leflunomide)

https://cks.nice.org.uk/topics/rheumatoid-arthritis/management/confirmed-ra/

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2
Q

Which autoantibody is most specific for rheumatoid arthritis?

A

Anti-CCP Antibody

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3
Q

What are the main clinical features of reactive arthritis?

A

Mono- or oligoarthritis
Urethritis
Uveitis
Other features include keratoderma blenorrhagicum and circinate balanitis

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4
Q

Which markers of disease activity are useful in a patient with a suspected flare of systemic lupus erythematosus?

A

C3 and C4 (usually low)
Anti-dsDNA Titre (usually high)

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5
Q

What is the main treatment used for Familial Mediterranean Fever?

A

Colchicine

https://patient.info/doctor/familial-mediterranean-fever#nav-4

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6
Q

What are the main features of limited cutaneous systemic sclerosis?

A

Calcinosis
Raynaud’s Phenomenon
Esophageal Dysmotility
Sclerodactyly
Telangiectasia

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7
Q

List some clinical features of pseudogout.

A

Acute-onset joint pain and swelling
X-ray will reveal chondrocalcinosis (calcification of the cartilage)

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8
Q

How does asthma tend to present?

A

Chronic cough (worst at night)
Shortness of breath (reduced exercise tolerance)
Wheezing
Screen for symptoms of other atopic diseases (e.g. eczema)

Resources:
OSMOSIS: https://www.osmosis.org/learn/Asthma

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9
Q

What is the first step in managing mild asthma?

A

PRN Salbutamol Inhaler

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10
Q

Which clinical features are associated with tuberculosis?

A

Productive cough
Haemoptysis
Shortness of breath
Fever
Weight loss
Night sweats

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11
Q

How may cystic fibrosis present in children who were not identified during routine neonatal screening?

A

Recurrent chest infections
Shortness of breath
Chronic cough
Failure to thrive
Chronic diarrhoea
Rectal prolapse
Nasal polyps

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12
Q

Which parameter is measured during the heel-prick test to determine whether a newborn is at risk of having cystic fibrosis?

A

Immunoreactive Trypsinogen

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13
Q

What is the most common type of lung cancer in smokers?

A

Squamous cell carcinoma

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14
Q

What is the gold-standard treatment option for patients with stage 1-2 non-small cell lung cancer?

A

Lobectomy

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15
Q

What is the most common bacterial cause of pneumonia?

A

Streptococcus pneumoniae

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16
Q

Outline the components of the CURB-65 score.

A

C – Confusion
U – Urea > 7mmol/L
R – Respiratory Rate >30
B – Systolic BP <90, Diastolic BP <60
65 – Age >65

Score 0 = Mild and home management with oral antibiotics should be considered.
Score 1-2 = Moderate, consider admission and PO/IV antibiotics.
Score >3 = Severe and requires admission and prompt IV antibiotics.

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17
Q

How should a mild CAP be treated?

A

Oral Amoxicillin 500 mg TDS

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18
Q

How should a primary spontaneous pneumothorax that is > 2 cm or associated with shortness of breath be treated?

A

Initially → Needle Aspiration
If fails → Chest Drain Insertion

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19
Q

Which paraneoplastic syndrome, associated with small cell lung cancer, presents with weakness due to damage to integral components of the neuromuscular junction?

A

Lambert-Eaton Syndrome
Characterised by the production of anti-voltage gated calcium channel antibodies
Results in muscle weakness that improves with repetition (in contrast to myasthenia gravis that fatigues with repetition)

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20
Q

Which ECG finding is seen most commonly in patients with pulmonary embolism?

A

Sinus tachycardia

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21
Q

What is the first-line anticoagulant in the management of a confirmed PE?

A

Apixaban or Rivaroxaban

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22
Q

Outline the interpretation of the CURB-65 score.

A

0-1 (mild) = oral antibiotics as outpatient
2 (moderate) = admit to hospital for antibiotics
3+ (severe) = admit to hospital and consider ITU admission if the patient is very unwell

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23
Q

What is the first pharmacological agent used in the management of an acute exacerbation of asthma?

A

Nebulised Salbutamol

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24
Q

What are the four aspects of treating an infective exacerbation of COPD?

A

Oxygen
Bronchodilators (e.g. salbutamol and ipratropium bromide)
Steroids (e.g. oral prednisolone)
Antibiotics (e.g. co-amoxiclav, doxycycline)

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25
Q

Define Light’s criteria for pleural effusions.

A

Used when the pleural fluid protein concentration is 25-35 g/L

It is considered exudative if:
- Effusion protein: serum protein ratio > 0.5
- Effusion LDH: serum LDH ratio > 0.6
- Effusion LDH level > two-thirds the upper limit of the laboratory’s reference range of serum LDH

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26
Q

Outline the management of a primary spontaneous pneumothorax.

A

< 2 cm and no SOB: discharge with outpatient review in 2-4 weeks
> 2 cm and/or SOB: aspirate with 16-18G cannula, if unsuccessful, insert chest drain

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27
Q

How is a tension pneumothorax managed?

A

Urgent needle decompression

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28
Q

Which tuberculosis treatment causes red secretions?

A

Rifampin

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29
Q

Describe the presenting features of sarcoidosis.

A

Dry cough
Shortness of breath
Painless, enlarged lymph nodes
Erythema nodosum
Weight loss

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30
Q

List some causes of tracheal deviation towards the side of the lesion.

A

Unilateral fibrosis
Lung collapse
Lobectomy or pneumonectomy

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31
Q

What is the best way of determining whether a blood gas sample is arterial or venous?

A

Compare the SaO2 on the blood gas to the patient’s non-invasive SaO2 at the time the sample was taken. It should match.

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32
Q

Which organism most commonly causes respiratory tract infections in adult patients with cystic fibrosis?

A

Pseudomonas aeruginosa

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33
Q

List some of the absolute contraindications for lung transplantation in cystic fibrosis patients.

A

Recent malignancy
Multi-organ dysfunction
Unstable medical condition (e.g. sepsis)
Uncorrectable bleeding disorder
Poorly controlled infection
Evidence of active tuberculosis
Obesity
Poor compliance
Unable to participate in rehabilitation programme

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34
Q

Which questionnaire is used to facilitate the diagnosis of obstructive sleep apnoea?

A

Epworth Sleepiness Score

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35
Q

What is the probability that two carriers of a cystic fibrosis allele will have a child affected by the condition?

A

25% (0.5 x 0.5 = 0.25)

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36
Q

What are the chest X-ray features commonly seen in congestive heart failure?

A

Alveolar shadowing
Kerley B lines
Cardiomegaly
Upper lobe Diversion
Effusions

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37
Q

How is oral thrush treated?

A

Nystatin
Alternative: Fluconazole

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38
Q

What is the first-line antibiotic in patients with suspected streptococcal pharyngitis?

A

Phenoxymethylpenicillin
If penicillin allergy: Clarithromycin

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39
Q

What classical CT scan finding is seen in invasive aspergillosis?

A

Halo Sign

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40
Q

Which criteria are commonly applied to stage acute kidney injury?

A

RIFLE Criteria

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41
Q

Outline the NICE guidelines advice about ultrasound KUB in patients with AKI.

A

When pyonephrosis (infected and obstructed kidney(s)) is suspected, offer immediate ultrasound of the urinary tract to be performed within 6 hours of assessment.
When patients have no identified cause of their AKI or are at risk of urinary tract obstruction, offer urgent ultrasound within 24 hours of assessment

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42
Q

List some risk factors for developing gout.

A

Male
Obese
CKD
Diabetes mellitus
Hypertension
Diuretics
Alcohol Excess
High Red Meat or Seafood Intake

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43
Q

Which lymph nodes does transitional cell carcinoma of the kidneys tend to drain to?

A

Para-aortic lymph nodes

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44
Q

How long after having a renal transplant does acute graft rejection tend to happen?

A

Within days to weeks
Caused by cell-mediated damage to the graft (usually lymphocytes)

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45
Q

List some clinical features associated with renal cell carcinoma.

A

Haematuria
Fever
Hypertension
Secondary polycythaemia

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46
Q

Describe the typical presenting features of post-streptococcal glomerulonephritis.

A

Haematuria
Hypertension
Deteriorating renal function
Usually arises 2-6 weeks after a streptococcal infection (e.g. throat or skin)

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47
Q

What form of screening should be offered to immediate family members of a person with autosomal dominant polycystic kidney disease?

A

Ultrasound KUB

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48
Q

Which long-term treatment option should be considered in patients with anaemia secondary to CKD?

A

Erythropoietin Injections

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49
Q

Which components of a diet do dieticians primarily focus on in a patient with CKD?

A

Potassium
Phosphate
Protein

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50
Q

What is the mechanism of action of tacrolimus?

A

Calcineurin Inhibitor

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51
Q

What is acute tubular necrosis?

A

Damage to the renal tubular epithelium caused by hypoperfusion or exposure to toxins
Damage to the tubules impairs the ability of the kidneys to concentrate urine and retain sodium appropriately. This can lead to hyponatraemia with low urine osmolality and raised urinary sodium concentrations.

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52
Q

Which imaging modality is used first in the investigation of Wilm’s tumours?

A

Abdominal Ultrasound

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53
Q

What is cardiorenal syndrome?

A

Complex condition in which impaired renal function develops in a patient with heart failure
The mechanism is complex but is thought to be related to elevated intra-abdominal pressures resulting from ascites and abdominal wall oedema. There are also several hormonal mediators that are associated with cardiorenal syndrome.

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54
Q

Why is an ultrasound scan of the urinary tract recommended in patients who are being investigated for secondary causes of hypertension?

A

To assess renal size as this can provide some useful information about the possibly underlying cause (e.g. in renal artery stenosis, one kidney will likely be bigger than the other, polycystic kidney appear large and bulky)

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55
Q

What is the mechanism of action of acetazolamide?

A

Carbonic anhydrase inhibitor
It increases urinary bicarbonate and sodium excretion, thereby causing a diuretic effect

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56
Q

Which organism most commonly causes lower urinary tract infections?

A

Escherichia coli

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57
Q

How does acute angle closure glaucoma classically present?

A

Headache
Reduced visual acuity
Conjunctival injection
Dilated pupil

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58
Q

What is the first-line investigation for a patient with a suspected angle closure glaucoma?

A

Slit-Lamp Gonioscopy

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59
Q

How do cataracts tend to present?

A

Gradual worsening of vision (usually bilateral)
Washed-out colour vision
Absent red reflex or straw-coloured lens on examination

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60
Q

Which surgical management option is often used to treat cataracts?

A

Phacoemulsification

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61
Q

What is the first-line medical treatment option for chronic angle closure glaucoma?

A

Topical Prostaglandin Analogues (e.g. latanoprost)

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62
Q

What is the most common cause of TIAs?

A

Carotid Atherosclerosis

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63
Q

Which investigation is required to confirm a diagnosis of cataracts?

A

Slit-Lamp Examination

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64
Q

How does episcleritis present?

A

Acute-onset redness of the eye associated with mild pain
May also cause photophobia and watering of the eye

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65
Q

What are the fundoscopic appearances of central retinal artery occlusion?

A

Pale retina
Cherry red spot in the macula

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66
Q

How do cataracts tend to present?

A

Painless and gradual loss of vision
Vision may be worse in bright light
Examination may reveal a loss of the red reflex in the affected eye(s)

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67
Q

Which blood or bone marrow film feature is highly specific for acute myeloid leukaemia?

A

Auer Rods

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68
Q

What is the first-line treatment option for acute promyelocytic leukaemia?

A

All-Trans-Retinoic Acid (ATRA)

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69
Q

Which chromosomal abnormality is associated with acute promyelocytic leukaemia?

A

t(15;17)

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70
Q

Which fusion gene is responsible for acute promyelocytic leukaemia?

A

PML-RARA (caused by t(15;17))

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71
Q

How does acute lymphoblastic leukaemia tend to manifest?

A

Features of bone marrow failure
Anaemia (shortness of breath, fatigue, pallor)
Thrombocytopaenia (easy bruising)
Low white cell counts (recurrent infections)

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72
Q

Outline the Ann Arbor staging system for Hodgkin lymphoma.

A

Stage I: Single lymph node region
Stage II: Two or more lymph node regions on the same side of the diaphragm
Stage III: Two or more lymph node regions on both sides of the diaphragm
Stage IV: Extranodal spread

‘b’ refers to the presence of B symptoms (fever, weight loss, night sweats)

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73
Q

What is the classical histological appearance of Burkitt’s lymphoma?

A

Starry Sky Appearance

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74
Q

What rare but classical examination finding is commonly associated with Hodgkin lymphoma?

A

Pain after alcohol consumption

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75
Q

Which point mutation causes sickle cell disease?

A

Point mutation on codon 6 of chromosome 11 which leads to the encoded amino acid changing from glutamine to valine

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76
Q

Which common infection can precipitate an aplastic crisis in patients with sickle cell disease?

A

Parvovirus B19

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77
Q

How does haemophilia tend to present?

A

Usually within the first 3 years of life
Deep bleeding into muscles and joints (haemarthrosis) with minimal trauma

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78
Q

How is haemophilia diagnosed?

A

Factor VIII and IX Assay

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79
Q

How does multiple myeloma present?

A

Features of hypercalcaemia (joint pain, constipation, psychiatric changes, polyuria, nausea and vomiting)

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80
Q

What bone marrow biopsy results would you expect to see in multiple myeloma?

A

Over 10% monoclonal plasma cells

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81
Q

What haemolysis screen results would you expect to see in autoimmune haemolytic anaemia?

A

Macrocytic Anaemia
High Unconjugated Bilirubin
Low Haptoglobin
High LDH

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82
Q

How does polycythaemia vera classically present?

A

Headaches
Facial Flushing
Pruritus after exposure to hot baths or showers

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83
Q

Which gene mutation is most closely associated with polycythaemia vera?

A

JAK2 V617F

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84
Q

What type of blood test results do you expect to see in beta thalassemia trait?

A

Mild microcytic anaemia that is usually asymptomatic
The microcytosis is often out of proportion with the degree of anaemia

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85
Q

Which features are considered by the Centor criteria?

A

Age
Fever
Tonsillar Exudate
Cervical Lymphadenopathy
Absence of Cough

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86
Q

Which investigation should patients with suspected colorectal cancer urgently undergo?

A

Colonoscopy

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87
Q

What is the best imaging modality of suspected prostate cancer?

A

Multiparametric MRI Scan

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88
Q

What differential should be considered in a post-menopausal woman with breast swelling and tenderness that fails to respond to antibiotic treatment?

A

Inflammatory Breast Cancer

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89
Q

What is a vestibular schwannoma?

A

Benign slow-growing primary brain tumour that usually presents with unilateral sensorineural hearing loss associated with dizziness and facial numbness. Larger tumours may cause headaches, ataxia, papilloedema and obstructive hydrocephalus, which can be life threatening.

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90
Q

How does cholangiocarcinoma present?

A

Painless jaundice
Abdominal discomfort/fullness
Change in stool appearance and frequency (looser and paler)
Constitutional upset (e.g. weight loss)

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91
Q

Which organisms are most commonly implicated in neutropenic sepsis?

A

Gram-positive organisms (e.g. S. aureus, S. epidermidis)

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92
Q

Which blood test parameters are important to check in a patient with suspected tumour lysis syndrome?

A

Potassium (High)
Phosphate (High)
Calcium (Low)
Uric Acid (High)

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93
Q

How does radial nerve palsy due to a defect at the axilla manifest?

A

Weakness of forearm, wrist and finger extension (resulting in wrist drop)

Sensory impairment over the lateral and posterior arm, posterior forearm and dorsal surface of the lateral three fingers h

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94
Q

How can a spinal cord lesion be distinguished from cauda equina syndrome?

A

Spinal cord lesions will likely cause a sensory level and cause upper motor neurone signs whereas cauda equina syndrome is characterised by lower motor neurone signs, perianal numbness and bladder and bowel dysfunction

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95
Q

Describe the clinical features of acute inflammatory demyelinating polyneuropathy.

A

Ascending symmetrical limb weakness and numbness
It can progress to involve the respiratory muscles resulting in respiratory failure

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96
Q

What CSF finding is often seen in Guillain-Barré syndrome?

A

High CSF Protein
Normal CSF White Cell Count
This is known as albuminocytologic dissociation

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97
Q

Which part of the brain does herpes simplex encephalitis tend to affect?

A

Temporal Lobes

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98
Q

Which preventative treatment should be offered to close contacts of a case of meningococcal meningitis?

A

Single dose of ciprofloxacin
Rifampicin is an alternative

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99
Q

What is the first-line pharmacological management option for idiopathic intracranial hypertension?

A

Acetazolamide

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100
Q

What is Lhermitte sign?

A

Paraesthesia that is felt in the upper limbs and trunk, often down the spine, when a patient flexes their neck. Commonly associated with multiple sclerosis

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101
Q

What is the gold-standard imaging modality for multiple sclerosis?

A

MRI Brain and Spinal Cord

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102
Q

What is Horner syndrome?

A

Triad of ptosis, miosis and anhidrosis that occurs as a result of disruption to the sympathetic chain supplying the head and neck.

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103
Q

List some causes of Horner syndrome.

A

Syringomyelia
Multiple Sclerosis
Thyroid Cancer
Apical (Pancoast) Lung Tumour
Carotid Artery Dissection
Cavernous Sinus Thrombosis

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104
Q

Outline the difference in aetiology between upper and lower motor neurone facial nerve palsies.

A

The fibres providing motor innervation to the forehead receives descending inputs from primary neurones arising in both cerebral hemispheres.

Therefore, if there is a defect in the right primary motor cortex resulting in left-sided facial weakness, the forehead will be spared because the lower motor neurones of the facial nerve will still receive descending inputs from the left primary motor cortex.

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105
Q

Aside from a neurological examination, which other examinations should be conducted in a patient with unilateral subacute facial weakness?

A

Otoscopy - look for evidence of Ramsay-Hunt Syndrome (it will feature a vesicular rash in the outer ear)

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106
Q

What are the main presenting features of Huntington’s disease?

A

Cognitive decline
Motor dysfunction (chorea, dystonia, dyskinesia)

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107
Q

Which genetic defect causes Huntington’s disease?

A

CAG Triplet Repeat

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108
Q

Which medications are recommended for the acute treatment of migraines?

A

Aspirin
Paracetamol
Ibuprofen
Sumatriptan

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109
Q

Describe the classical presentation of a subarachnoid haemorrhage.

A

Sudden-onset worst headache ever. Often starting occipitally and spreading. Associated with meningism and may present unconscious.

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110
Q

What dose of phenytoin is administered in status epilepticus?

A

20 mg/kg (maximum 2 g)
Cardiac Monitoring

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111
Q

What are the main symptoms of Parkinson’s disease?

A

Resting tremor (usually unilateral)
Rigidity
Bradykinesia
Gait instability (stooped and shuffling)
Hypomimic face
Low mood
Insomnia

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112
Q

How is Parkinson’s disease diagnosed?

A

Clinical diagnosis (sometimes a DaT scan may be used if there is any diagnostic uncertainty)

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113
Q

Which class of medications is useful in reducing the on-off motor fluctuations in patients with Parkinson’s disease that is treated with levodopa/carbidopa?

A

COMT Inhibitors (e.g. entacapone)

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114
Q

What are the main clinical features that are seen in neurofibromatosis type 1?

A

At least 2 or more of:

  • 5 or more cafe-au-lait macules that are over 15 mm in diameter if post-pubertal (may be fewer in children under 5 years)
  • 2 or more neurofibromas of any type or 1 plexiform neurofibroma
  • Multiple freckles in the axillary or inguinal regions
  • Optic nerve glioma
  • 2 or more iris Lisch nodules on slit lamp examination
  • Sphenoid wing dysplasia or congenital boeing or thinning of long bone cortex with or without pseudoarthrosis
  • A first degree relative with NF1 by the above criteria
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115
Q

How does normal pressure hydrocephalus present?

A

Dementia
Urinary Incontinence
Gait Instability (broad-based)

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116
Q

What can be used to treat neuropathic pain associated with multiple sclerosis?

A

Gabapentin
Pregabalin
Duloxetine
Carbamazepine

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117
Q

A stroke involving which artery results in lateral medullary syndrome?

A

Posterior Inferior Cerebellar Artery

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118
Q

What are some key features of vascular dementia that help distinguish it from other forms of dementia?

A

Stepwise decline in cognitive function
Background of vascular risk factors (e.g. hypertension, diabetes mellitus)

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119
Q

How does a cluster headache tend to manifest?

A

Intense unilateral headaches that tend to occur at a specific time every day for a period of weeks or months
Associated with ipsilateral lacrimation, rhinorrhoea, nasal congestion and eyelid swelling.

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120
Q

What is the first-line medical treatment in the acute management of cluster headaches?

A

SC Sumatriptan

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121
Q

Which antibodies are associated with myasthenia gravis?

A

Nicotinic Acetylcholine Receptor Antibodies

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122
Q

What is the main priority in managing a patient with suspected meningitis?

A

IV Antibiotics

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123
Q

How should suspected giant cell arteritis be managed?

A

Check ESR
High-Dose Steroids (e.g. prednisolone)

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124
Q

Describe how tension headaches usually present.

A

Relatively mild pain in a band-like distribution across the front of the head . Often related to stress and usually responsive to simple analgesia (e.g. paracetamol)

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125
Q

Define spondylolysis.

A

A stress fracture of the pars interarticularis.

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126
Q

Describe the classical presenting symptoms of ankylosing spondylitis.

A

Chronic lower back pain (worse in the morning and improves with exercise or NSAIDs)
Reduced range of lumbar spinal movement
Extra-articular manifestations (aortic regurgitation, apical lung fibrosis, achilles tendinitis)

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127
Q

How is Schober’s test carried out?

A

Mark a point on the skin overlying the L5 spinous process.

Mark a second point about 10 cm superior to the first point.

Ask the patient to bend over and touch their toes

If the distance between the point increases by less than 5 cm, that is a positive result (reduced range of motion in the lumbar spine.

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128
Q

What is the first-line management option for ankylosing spondylitis?

A

NSAIDs

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129
Q

What are the main manifestations of carpal tunnel syndrome?

A

Pain (often worse at night and relieved by shaking the affected hand)
Impaired sensation in the median nerve distribution (palmar aspect of thumb, index finger and middle finger)
Weak grip and loss of dexterity
Wasting of the thenar eminence

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130
Q

Which investigation may be used in the investigation of a patient with suspected carpal tunnel syndrome?

A

Electromyography

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131
Q

How should severe carpal tunnel syndrome be managed?

A

Carpal Tunnel Release Surgery

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132
Q

What are the contents of the carpal tunnel?

A

Flexor Pollicis Longus
Flexor Digitorum Profundus (4 tendons)
Flexor Digitorum Superficialis (4 tendons)

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133
Q

How does giant cell arteritis manifest?

A

Unilateral headache
Scalp tenderness
Jaw claudication
Visual changes
Constitutional upset (e.g. fever, fatigue)

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134
Q

What definitive investigation is used in suspected giant cell arteritis?

A

Temporal Artery Biopsy

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135
Q

Which branch of the external carotid artery is implicated in giant cell arteritis?

A

Superficial Temporal Artery

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136
Q

Which clinical test is used for Sjogren syndrome?

A

Schirmer’s Test
Involves placing a strip of filter paper under the patient’s eyelid and monitoring the progress that the tears make through the paper. Progression of less than 10 mm after 5 mins is considered a positive result.

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137
Q

What are the main sources of Gram-negative sepsis?

A

Urinary tract
Biliary tree

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138
Q

What is human herpes virus 3?

A

Varicella Zoster Virus

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139
Q

How does non-alcoholic fatty liver disease usually present?

A

Incidental finding of deranged liver function test results in a patient without a background of excessive alcohol intake
Common associated features include obesity and type 2 diabetes mellitus

https://www.nice.org.uk/guidance/ng49/chapter/context#:~:text=The%20prevalence%20of%20NAFLD%20in,2%20diabetes%20or%20metabolic%20syndrome.

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140
Q

What is the gold standard imaging modality for primary sclerosing cholangitis?

A

MRCP

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141
Q

Which scoring system is used to determine the severity of an upper gastrointestinal score before endoscopy?

A

Glasgow-Blatchford Score

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142
Q

What is the first-line treatment option for hepatic encephalopathy?

A

Lactulose (aiming for 2 or more bowel movements per day)
Rifaximin may be used as an adjunct

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143
Q

Which classification system is used to classify the endoscopic findings of a patient with Barrett’s oesophagus?

A

Paris and Prague Classification

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144
Q

How should a patient with Barrett’s oesophagus with low grade dysplasia be managed?

A

Repeat endoscopy in 6 months

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145
Q

How does gastroenteritis caused by Campylobacter jejuni infection tend to present?

A

Diarrhoea (may be bloody)
Fever
Abdominal Cramps
Usually contracted by eating under-cooked poultry

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146
Q

How does gastro-oesophageal reflux disease tend to present?

A

Retrosternal chest discomfort that is usually worst after a large meal and when lying down

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147
Q

Describe the clinical features associated with Whipple’s disease.

A

Diarrhoea
Abdominal pain
Joint pain
Jejunal biopsy reveals vacuolated macrophages that appear purple with periodic acid-Schiff stain

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148
Q

Which stool test is useful in cases of suspected inflammatory bowel disease?

A

Faecal Calprotectin

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149
Q

Which blood test is important to conduct before starting a patient on azathioprine?

A

TPMT Level

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150
Q

Which investigation should be urgently performed in patients with suspected colorectal cancer?

A

Which investigation should be urgently performed in patients with suspected colorectal cancer?

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151
Q

Which medical treatment can reduce the risk of complication from oesophageal varices in patients with chronic liver disease?

A

Non-selective beta-blockers (e.g. carvedilol)

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152
Q

Describe the appearance of simple liver cysts on a contrast CT scan.

A

Thin-walled, round, homogenous lesions that demonstrate hypoattenuation

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153
Q

Which scoring system is used to assess whether treatment with steroids has been effective in a patient with alcoholic hepatitis?

A

Lille Score

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154
Q

What Maddrey’s score would warrant treatment with steroids?

A

Over 32

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155
Q

List some common causes of drug-induced liver injury.

A

Amiodarone
NSAIDs
Steroids
COCP
Erythromycin
Isoniazid
Statins
Tetracyclines

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156
Q

What is the first-line medical management option for ascites due to chronic liver failure?

A

Spironolactone

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157
Q

What essential medication will patients undergoing large-volume paracentesis need to reduce the risk of post-paracentesis circulatory dysfunction?

A

20% Humans Albumin Solution (HAS)

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158
Q

How is the serum ascites albumin gradient (SAAG) interpreted?

A

< 11 g/L = exudative (and nephrotic syndrome)
> 11 g/L = transudative

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159
Q

What non-invasive test is useful in the investigation of suspected chronic pancreatitis?

A

Faecal Elastase (low in chronic pancreatitis)

160
Q

What investigation is most appropriate to confirm a diagnosis of ulcerative colitis?

A

Flexible Sigmoidoscopy and Biopsy

161
Q

What endoscopic findings are classically associated with Crohn’s disease?

A

Longitudinal and circumferential fissures and ulcers separating islands of mucosa

162
Q

How does hereditary haemochromatosis present?

A

Impaired liver function test results
Hepatomegaly
Type 2 diabetes mellitus
Hyperpigmentation of the skin
Loss of libido
Erectile dysfunction

163
Q

Which investigation is most important for prognostication in a patient with hereditary haemochromatosis?

A

Liver Biopsy

164
Q

What are the different stages of haemochromatosis?

A

Stage 1: C282Y homozygosity and increased transferrin saturation with a normal ferritin and no symptoms

Stage 2: C282Y homozygosity with increased transferrin and ferritin levels with no symptoms.

Stage 3: C282Y homozygosity with increased transferrin and ferritin levels with clinical symptoms affecting the quality of life (asthenia, impotence, arthropathy).

Stage 4: C282Y homozygosity with increased transferrin and ferritin levels with evidence of end-organ damage (e.g. cirrhosis, insulin-dependent diabetes mellitus).

165
Q

Describe the barium swallow appearance that you would classically see in a patient with achalasia.

A

Bird’s beak appearance with dilated proximal oesophagus

166
Q

How might coeliac disease present in adults?

A

Chronic diarrhoea
Pale stools
Weight loss
Consequences of vitamin and mineral malabsorption (e.g. anaemia)

167
Q

How does Wilson’s disease tend to present?

A

Liver dysfunction
Neuropsychiatric symptoms (e.g. tremor, dystonia, dyskinesia, change in personality)

168
Q

What is the first-line management option for Wilson’s disease?

A

Zinc and Dietary Modification

169
Q

What liver function test results would you expect to see in viral hepatitis?

A

Very High ALT, Very High AST, High Bilirubin, Normal GGT, Normal ALP

170
Q

What is the classical pattern of liver function test results that you would expect to see in alcoholic liver disease?

A

High ALT and AST (with an AST: ALT ratio of over 2)
High Bilirubin
Normal GGT and ALP

171
Q

What patterns of liver function test results would you expect to see in a patient with primary biliary cholangitis?

A

High ALT, High AST, High Bilirubin, High GGT, High ALP

172
Q

What hepatitis B serology results would you expect to see in a patient with acute hepatitis B infection?

A

HBsAg +, HBeAg +, HBsAb -, HBcAb IgM +

173
Q

Which investigations are used in the diagnosis of achalasia?

A

Oesophageal Manometry
Also barium swallow and OGD (to check for other differentials)

174
Q

How is vitamin B12 deficiency treated?

A

Hydroxocobalamin or Cyanocobalamin

175
Q

What is the best investigation for confirming a diagnosis of autoimmune hepatitis?

A

Liver Biopsy

176
Q

What ascitic fluid analysis results would you expect to see in a patient with spontaneous bacterial peritonitis?

A

Cloudy Appearance
High Protein
Low Glucose
High WCC (Predominantly Neutrophils)

177
Q

How is alcohol withdrawal managed in hospital inpatients?

A

CIWA score and chlordiazepoxide

178
Q

Which medications can be used to reduce cravings for alcohol

A

Acamprosate
Naltrexone

179
Q

How is delirium tremens treated?

A

Benzodiazepines (e.g. lorazepam)

180
Q

What electrolyte abnormalities would you expect to see in a patient with refeeding syndrome?

A

Hypophosphataemia
Hypokalaemia
Hypomagnesaemia
Hypercalcaemia

181
Q

How do anal fissures tend to present?

A

Pain upon defecation
Small amount of blood on the toilet paper noted upon wiping
Often occurs on a background of constipation

182
Q

What ascitic fluid finding is diagnostic of spontaneous bacterial peritonitis?

A

Polymorphonuclear cell count of >250 cells/mm3

183
Q

What type of molecule is alpha-1 antitrypsin?

A

Neutrophil elastase inhibitor

184
Q

Describe the mechanism of action of sulfonylureas.

A

Act on SUR1 receptors which close the ATP-dependent potassium channel on pancreatic beta cells.

This leads to an increase in intracellular potassium concentration, membrane depolarisation and, consequently, opening of the voltage-gated calcium channels. Influx of calcium triggers the exocytosis of insulin.

185
Q

Outline the immediate management of an Addisonian crisis.

A

IV Hydrocortisone
IV Fluid Resuscitation

186
Q

Which antithyroid medications are often used in the management of Graves disease?

A

Carbimazole
Propylthyiouracil

187
Q

What are the presenting symptoms of acromegaly?

A

Change in appearance (coarse facies)
Large hands
Carpal tunnel syndrome
Visual field defect

188
Q

Describe the clinical features of tertiary hyperparathyroidism.

A

Usually occurs in the context of vitamin D deficiency in CKD
After a prolonged period of secondary hyperparathyroidism, the parathyroid gland eventually becomes autonomous resulting in tertiary hyperparathyroidism.
Bloods will reveal a normal or raised PTH and a high serum calcium concentration.

189
Q

For which type of thyroid cancer is calcitonin used as a tumour marker?

A

Medullary Thyroid Cancer

190
Q

What is the first-line treatment option for prolactinoma?

A

Dopamine agonists (e.g. bromocriptine)

191
Q

What TFT results would you expect to see in a patient with primary hypothyroidism?

A

High TSH
Low T4

192
Q

Describe the presenting symptoms of phaeochromocytoma.

A

Hypertension
Episodic palpitations, sweating and anxiety

193
Q

What blood test results would you expect to see in hypercalcaemia of malignancy?

A

High Calcium
Low PTH

194
Q

What initial diagnostic test is used in the diagnosis of suspected hyperaldosteronism?

A

Plasma Renin: Aldosterone Ratio

195
Q

How is a high-dose dexamethasone test interpreted?

A

It is done to distinguish Cushing disease from other causes of Cushing syndrome.
A reduction in serum cortisol of > 50% the morning after administration of dexamethasone is suggestive of Cushing disease
A reduction of < 50% is suggestive of ectopic ACTH secretion or a hypersecreting adrenal tumour.

196
Q

What is the maximum rate of correction of serum sodium concentration in patients with hyponatraemia?

A

10 mmol/L over 24 hours

197
Q

Why is it important to monitor urine output in patients receiving treatment for severe hyponatraemia?

A

Patients with hypovolaemic hyponatraemia will have a significant ADH response that reduces their urine output. As they become intravascularly replete with IV fluids, the stimulus for ADH secretion will diminish and the patient will start producing increasing volumes of urine. The relative loss of fluid in the urine is greater than the loss of sodium meaning that this diuresis can lead to a rapidly increasing serum sodium concentration. This, in turn, can lead to osmotic demyelination syndrome.

198
Q

How long after overcorrection of hyponatraemia would you expect osmotic demyelination syndrome to manifest?

A

3-5 days

199
Q

What are the criteria that are often quoted in the diagnosis of hyperosmolar hyperglycaemic state?

A

Marked Hyperglycaemia (> 30 mmol/L) without significant ketonaemia
Raised Serum Osmolality (> 320 mOsmol/kg)
Hypovolaemia

200
Q

What is the best diagnostic test for suspected primary adrenal insufficiency?

A

Short synacthen test

201
Q

What water deprivation test results would you expect to see in a patient with nephrogenic diabetes insipidus?

A

High Plasma Osmolality
Low Urine Osmolality (that does not become more concentrated with water deprivation or following the administration of desmopressin)

202
Q

What is the strongest prognostic factor for the development of Graves’ eye disease?

A

Smoking

203
Q

Which biochemical test results would you expect to see in a patient with Paget’s disease?

A

Normal Calcium, Normal Phosphate, Normal PTH, High ALP

204
Q

What is the first-line treatment option for Paget’s disease of the bone?

A

Bisphosphonates

205
Q

List some euvolaemic causes of hyponatraemia.

A

SIADH
Hypothyroidism
Adrenal Insufficiency

206
Q

What is the main investigation that is used to diagnose familial hypocalciuric hypercalcaemia?

A

24-hour Urinary Calcium Collection

207
Q

What is the first-line medical treatment option for hypercalcaemia of malignancy?

A

Bisphosphonates

208
Q

By what mechanism does lymphoma cause hypercalcaemia?

A

Activity of ectopic 25(OH)D-1-hydroxylase expressed by macrophages or tumour cells leads to the formation of excessive amounts of 1,25(OH)₂D (i.e. active vitamin D)

209
Q

How should a the long- and short-acting insulin doses of a patient with well-controlled type 1 diabetes mellitus be managed ahead of a short operation in which they are only expected to miss one meal?

A

Reduce long-acting insulin dose (usually to around 80%)
Omit short-acting insulin dose whilst fasting

210
Q

List some signs and symptoms of Cushing syndrome.

A

Weight gain
Low mood
Thin skin
Easy bruising
Hypertension
Proximal myopathy

211
Q

What screening test is sometimes used to rule out Cushing syndrome?

A

Late night salivary cortisol level

212
Q

What 11 pm cortisol and low-dose dexamethasone suppression test results would you expect to see in a patient with Cushing syndrome?

A

High 11 pm Cortisol
High LDDST Cortisol

213
Q

How is Cushing disease definitively treated?

A

Trans-sphenoidal Hypophysectomy

214
Q

List some features that are specific to Graves disease (compared to other forms of hyperthyroidism).

A

Exophthalmos
Pretibial Myxoedema

215
Q

Which autoantibody causes Graves’ disease?

A

TSH-Receptor Stimulating Antibody

216
Q

What is a rare but important side-effect of carbimazole that patients should be counselled about?

A

Agranulocytosis (they should be advised to seek medical attention if they ever develop any symptoms of an infection)

217
Q

What serum and urine osmolality results would you expect to see in SIADH?

A

Low Serum Osmolality, High Urine Osmolality, High Urine Sodium

218
Q

What are the usual presenting features of polycystic ovarian syndrome?

A

Diagnosed using the Rotterdam criteria
Oligo- or anovulation (irregular periods)
Clinical or biochemical evidence of hyperandrogenism (e.g. acne, weight gain, raised serum androgen levels)
Presence of polycystic ovaries on ultrasound (> 12 follicles measuring 2-9 mm in diameter and/or an ovarian volume > 10 mL in at least one ovary)

219
Q

Which criteria are used to make a diagnosis of polycystic ovarian syndrome?

A

The Rotterdam criteria states that 2 or more of the following must be fulfilled to make a diagnosis of PCOS:
- Oligo- or anovulation (irregular periods)
Clinical or biochemical evidence of hyperandrogenism (e.g. acne, weight gain, raised serum androgen levels)
- Presence of polycystic ovaries on ultrasound (> 12 follicles measuring 2-9 mm in diameter and/or an ovarian volume > 10 mL in at least one ovary)

220
Q

Which contraceptive option is best for a patient with polycystic ovarian syndrome who would like to have predictable periods?

A

Cyclical Progestogens

221
Q

Which type of cancer are people with polycystic ovarian syndrome at particularly increased risk of developing?

A

Endometrial Cancer

222
Q

How does Conn syndrome present?

A

Hypertension in a young person
Hypokalaemia (may cause arrhythmias and muscle cramps)

223
Q

What blood test abnormalities would you expect to see in a patient with primary hyperaldosteronism?

A

Hypokalaemia
High Aldosterone: Renin Ratio

224
Q

What is the main medical treatment option for primary hyperaldosteronism?

A

Aldosterone antagonist (e.g. spironolactone)

225
Q

What thyroid function test results would you expect to see in a patient with central hypothyroidism?

A

Low TSH
Low T3 and T4

226
Q

What is the most common cause of hypothyroidism worldwide?

A

Iodine Deficiency

227
Q

How does carcinoid syndrome manifest?

A

Facial flushing
Diarrhoea
Palpitations
Shortness of breath (due to bronchospasm)

228
Q

How does prolactinoma manifest?

A

Secondary amenorrhoea
Headaches
Breast pain and tenderness
Lactation

229
Q

Which metric is used to assess whether a child is obese?

A

BMI Centiles (above the 98th centile is considered obese)

230
Q

List some drugs that reduce bone mineral density.

A

Steroids
PPIs
Heparin
Warfarin

231
Q

How is osteoporosis defined based on the DEXA scan results?

A

Score of less than -2.5 is suggestive of osteoporosis

232
Q

How does phaeochromocytoma manifest?

A

Episodes of anxiety, sweating, palpitations and tremor. During these episodes, the patient will likely be tachycardic and hypertensive.

233
Q

List some features of hypogonadism in males.

A

Erectile dysfunction
Low libido
Reduced energy
Muscle weakness

234
Q

How is idiopathic hypogonadotropic hypogonadism initially managed?

A

Testosterone Gel

235
Q

What is the initial imaging modality that is used in the work-up of suspected thyroid cancer?

A

Ultrasound

236
Q

Which gene mutation is associated with multiple endocrine neoplasia type 2?

A

RET Oncogene Mutation

237
Q

What is starvation ketosis?

A

Depletion of carbohydrates within the body triggers the compensatory generation of ketones by the liver
It is associated with poor oral intake and dehydration

238
Q

How would poor compliance with thyroid hormone replacement manifest in the thyroid function test results?

A

Low Free T4 and High TSH

NOTE: if the patient erratically takes their medications in the short-term before an appointment, the free T4 may be normal or high but the TSH will remain high

239
Q

What TFT results would suggest under-treated hypothyroidism?

A

Low T4
High TSH

240
Q

Which classical X-ray feature is associated with osteomalacia?

A

Looser’s zones (transverse lucencies with sclerotic borders that traverse part of the way through a bone and is perpendicular to the cortex)

241
Q

What is the most common side-effect of oral bisphosphonates?

A

Dyspepsia due to oesophagitis/gastritis

242
Q

What is the initial investigation of choice for patients with suspected primary hyperaldosteronism?

A

Serum Aldosterone: Renin Ratio

243
Q

What electrolyte abnormalities are caused by hypoparathyroidism?

A

Hypocalcaemia
Hyperphosphataemia

244
Q

Outline the anatomy of the adrenal gland and the hormones produced.

A

Zona Glomerulosa (outermost) → Aldosterone
Zona Fasciculata (middle) → Cortisol
Zona Reticularis (innermost) → Androgens
Adrenal Medulla → Catecholamines

245
Q

How is osteoporosis initially managed?

A

Bisphosphonates with vitamin D and calcium supplementation

246
Q

What visual field defect would be caused by a pituitary macroadenoma that invades the cavernous sinus?

A

Oculomotor nerve palsy
Abducens nerve palsy
Bitemporal hemianopia

247
Q

Describe the clinical features of acromegaly.

A

Prognathism
Widening of the nose
Coarse facial features
Carpal tunnel syndrome
Skin/hair changes
Goitre (due to increased vascularity of the thyroid gland)
Insulin resistance (and, hence, type 2 diabetes mellitus)

248
Q

What is the first-line management option for acromegaly?

A

Surgery (trans-sphenoidal hypophysectomy)

249
Q

What urine and plasma osmolality would you expect to see in a patient with diabetes insipidus?

A

High Plasma Osmolality
Low Urine Osmolality

NOTE: if it is nephrogenic DI, the urine will fail to concentrate after administration of desmopressin

250
Q

What is the best investigation for suspected diabetes insipidus?

A

Water Deprivation Test

251
Q

What is the most important initial management step in the management of pituitary apoplexy with some evidence of haemodynamic instability?

A

Administer Steroids

252
Q

What is the gold-standard investigation for diagnosing Cushing’s disease (i.e. ACTH secreting pituitary adenoma)?

A

Inferior Petrosal Sinus Sampling

253
Q

What is the first-line management option for a non-functioning pituitary adenoma that is causing a mass effect (e.g. visual field defect)?

A

Trans-sphenoidal Hypophysectomy

254
Q

How does Conn syndrome manifest?

A

Refractory hypertension
Hypokalaemia

255
Q

After an aldosterone: renin ratio confirms a diagnosis of primary hyperaldosteronism, which investigation should be requested next?

A

CT Adrenal Glands

256
Q

Which investigation is useful for pyrexia of unknown origin?

A

PET-CT Scan

257
Q

What is the first-line investigation for diagnosing a DVT?

A

Duplex ultrasonography

258
Q

What are some clinical features of life-threatening asthma?

A

PEFR < 33% of Predicted
SpO2 < 92%
Cyanosis
Hypotension
Exhaustion, confusion
Silent chest, poor respiratory effort
Tacy/brady/arrhythmias

259
Q

What can cause a paradoxical embolism?

A

Patent foramen ovale
Atrial septal defect
Ventricular septal defect

260
Q

Describe the classical features of vasovagal syncope.

A

Dizziness, nausea, sweating and visual disturbances followed by transient loss of consciousness that resolves.

261
Q

What treatment is used for opioid toxicity?

A

Naloxone

262
Q

What is the antidote used for paracetamol overdose?

A

N-Acetylcysteine

263
Q

What blood gas result would you expect to see in a patient in the early stages of an aspirin overdose?

A

Respiratory Alkalosis
Occurs because aspirin stimulates the respiratory centre and causes an increase in minute ventilation

264
Q

Which peripheral vasopressor is often used to support blood pressure in critically unwell patients?

A

Metaraminol (alpha-1 agonist)

265
Q

What is the first-line management option for mild-to-moderate acne?

A

Topical adapalene with topical benzoyl peroxide
or
Topical tretinoin with topical clindamycin
or
Topical benzoyl peroxide with topical clindamycin

266
Q

What would be the most appropriate next step in the management of a patient whose acne has worsened despite 12 weeks of topical therapy with adapalene and benzoyl peroxide?

A

Add in oral antibiotic (lymecycline or doxycycline)

267
Q

Outline the monitoring requirements of isotretinoin.

A

Measure liver function and lipid profile before treatment and at 1 month after commencing treatment and then every 3 months thereafter.

268
Q

List the main topical steroids in order of potency.

A

> Mildly Potent – hydrocortisone 0.1%, 0.5% and 1.0%.
Moderately Potent – betamethasone valerate 0.025% and clobetasone butyrate 0.05% (Eumovate)
Potent – betamethasone valerate 0.1% (Betnovate) and betamethasone dipropionate 0.05%.
Very Potent – clobetasol propionate 0.05% (Dermovate)

269
Q

Describe the appearance of eczema herpeticum.

A

Predominantly affects the face and neck
Lesions spread over 7-10 days
Rash consists of monomorphic blisters that are filled with yellow fluid or blood and have a central umbilication
They have a tendency to weep or bleed and crust over
Secondary bacterial infection is common

270
Q

Describe the options that can be used by patients with frequent relapses of eczema requiring steroid therapy.

A

Step Down Treatment (use the lowest potency steroid that controls the eczema indefinitely)
Intermittent Therapy (steroid is used on two consecutive days per week or every 3-4 days.

271
Q

Describe the appearance of erythema multiforme.

A

Polymorphous, well demarcated, round, red macules
Become raised and form papules
The centre of the lesion darkens and becomes blistered or crusted (resulting in the target appearance)

272
Q

Describe the classical presentation of guttate psoriasis.

A

Acute-onset, widespread raindrop-like rash after having a throat infection (streptococcal)

273
Q

What is the first-line treatment option for chronic plaque psoriasis?

A

Potent topical steroid with a topical vitamin D preparation

274
Q

How is molluscum contagiosum managed?

A

No treatment required as it is self-limiting

275
Q

What are the most common drug causes of toxic epidermal necrolysis?

A

Allopurinol
Sulphonamides
Penicillins
Anticonvulsants
NSAIDs.

276
Q

Briefly describe the advice that should be given to a patient that is starting treatment with topical steroids.

A

One finger tip unit is equivalent to an area about half the size of the flat of the hand.
Steroids should be applied 15 minutes after emollient

277
Q

Describe the appearance of seborrhoeic keratosis.

A

Raised and flat papules that have a warty appearance and may vary in colour
They have a distinctive ‘stuck on’ appearance

278
Q

Describe the appearance of progression of a keratoacanthoma.

A

Single, well demarcated nodule with a central hyperkeratotic plug
Grows rapidly within a few weeks, then remains stable for several weeks before regressing

279
Q

How is a keratoacanthoma usually treated?

A

Surgical excision

280
Q

Describe the different types of basal cell carcinoma.

A

Nodular BCC: the classic pearly lesion and the most common type as demonstrated in this case.
Superficial BCC: scaly, irregular plaque with a very thin rolled border.
Morphoeic BCC: waxy appearance resembling a scar.
Basosquamous carcinoma: mixed BCC and squamous cell carcinoma.

281
Q

Describe the main types of malignant melanoma.

A

Superficial Spreading: As the name suggests, these spread outwards first. It is the most common type of melanoma.
Nodular: Proliferate downwards into the skin and can form a nodule at the surface.
Lentigo Maligna Melanoma: A discoloured patch that grows outwards over 5-20 years from the precursor, lentigo maligna.
Amelanotic: Non-melanin producing lesions often appearing as pink- or skin-coloured nodules. There may be a thin rim of melanin.
Acral Lentiginous: Rare type of melanoma that arises from the palms and soles.

282
Q

What is Hutchinson’s sign of the thumb?

A

Pigmentation of the cuticle that extends to the nail fold
Associated with acral lentiginous melanoma

283
Q

Describe the appearance of the rash in pityriasis rosea.

A

The appearance of multiple, small oval-shaped macules along lines of skin tension (Christmas tree distribution)
This is usually preceded by the appearance of a large macule or patch (Herald patch)

284
Q

Describe the appearance of bullous pemphigoid.

A

Tense bullae that spare the mucosal membranes

285
Q

What is allergic contact dermatitis?

A

Delayed type lV hypersensitivity reaction to an allergen, commonly adhesives, topical antibiotics, perfumes, nickel, clothing and rubber.
This occurs in two stages - the first is sensitisation in which allergens activate Langerhans cells that travel to lymph nodes and activate naïve T cells. Re-exposure then triggers elicitation in which sensitised T cells travel to the sites of the allergen and trigger an inflammatory reaction, occurring 1-2 days after exposure.

286
Q

Outline the management of urticaria.

A

Oral non-sedating antihistamine (e.g. cetirizine)
A short course of oral prednisolone may be considered if symptoms are severe

287
Q

Define papule.

A

Elevated skin lesion with an elevation of less than 1 cm

288
Q

Describe the appearance of the rash in lichen planus.

A

Violaceous polygonal lesions usually found on the wrists and legs
Involvement of the oral mucosa is common, and may appear as lace-like white streaks (known as Wickham’s striae)

289
Q

Outline the management of severe acne rosacea with prominent papules and pustules.

A

Topical Ivermectin with an Oral Antibiotic (e.g. doxycycline)

290
Q

Which features of a cutaneous horn would be suggestive of malignancy?

A

Painful
Large size
Indurated, wide or erythematous base

291
Q

What is an epidermoid cyst?

A

Arise from hair follicles due to obstruction of the pilosebaceous unit
Commonly found on the chest and shoulder
appear as skin-coloured papules or nodules with a central punctum that may express cheesy debris

292
Q

What is hidradenitis suppurativa?

A

Chronic inflammatory skin condition affecting areas that are rich in sweat glands (e.g. groin, axilla)
It is characterised by the development of inflammatory lesions (papules, pustules, nodules and abscesses) and can be complicated by draining sinuses and scarring

293
Q

What is onycholysis?

A

Separation of the nail from the underlying nail bed
May occur secondary to trauma, skin diseases (e.g. psoriasis), infections, systemic diseases (e.g. hypothyroidism) or medications (e.g. tetracyclines).

294
Q

What is acute generalised exanthematous pustulosis?

A

Severe adverse cutaneous reaction that is characterised by rapid-onset erythema that is studded with tiny sterile pustules
These have a predilection towards skin folds and the rash often starts on the face before becoming widespread
The majority of cases are triggered by medications (in particular, beta-lactam antibiotics)

295
Q

What is erythema multiforme?

A

A hypersensitivity reaction associated with particular infections, most commonly the Herpes Simplex Virus (HSV). It can also be associated with mycoplasma infection or, less commonly, certain medications or vaccines. It is characterised by target lesions which have 3 concentric colour regions; a dark red centre which may be blistered or crusted, a paler pink ring which is raised due to oedema, and a deep red outermost ring.

296
Q

How is erythema multiforme diagnosed?

A

Clinical diagnosis

297
Q

How is erythema multiforme associated with HSV infection managed?

A

Topical Emollient and Steroid with Oral Antihistamine

298
Q

Which rash is strongly associated with inflammatory bowel disease?

A

Erythema Nodosum

299
Q

What histological findings would you expect to see in erythema nodosum?

A

Inflammation of the septa between subcutaneous fat lobules, without vasculitis

300
Q

What is the treatment of choice for patients with severe, symptomatic erythema nodosum?

A

Oral potassium iodide

301
Q

What are pressure sores?

A

Localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or of pressure in combination with shear force.

They are typically found on the sacrum, heels of the feet, over the greater trochanters of the hips, and the shoulders.

302
Q

Describe the appearance of chronic plaque psoriasis.

A

Symmetrical, well-demarcated, erythematous plaques covered by adherent silvery-white scale
It commonly appears on the scalp and extensor surfaces

303
Q

Which tool is used to assess the severity and extent of psoriasis?

A

Psoriasis Area Severity Index (PASI)

304
Q

What is the third-line management option for chronic plaque psoriasis after emollients and preparations containing steroids and vitamin D?

A

PUVA (Psoralen and UVA therapy)

305
Q

Describe the appearance of molluscum contagiosum.

A

Pearly umbilicated papules

306
Q

Which commonly used cardiac medications are contraindicated in severe aortic stenosis?

A

Vasodilators such as nitrates

307
Q

What are the two main causes of an ejection systolic murmur heard loudest over the aortic area?

A

Aortic Stenosis (e.g. bicuspid aortic valve)
Aortic Sclerosis

308
Q

What is Dressler syndrome?

A

Pericarditis that develops around 2-10 weeks after a myocardial infarction
Patients tend to present with pleuritic chest pain and may have a low-grade fever

309
Q

What murmur is associated with tricuspid regurgitation?

A

Pansystolic murmur heard loudest at the lower left sternal edge during inspiration

310
Q

What is Takotsubo cardiomyopathy?

A

Sudden dysfunction of the ventricular myocardium in response to stress
An echocardiogram classically reveals apical ballooning of the ventricles

311
Q

What ECG features are associated with digoxin toxicity?

A

Sinus bradycardia
Down-sloping ST segment (‘reverse tick’ sign)
Supraventricular tachycardia
Atrioventricular block
Slow atrial fibrillation
Premature ventricular complexes

312
Q

Define trifascicular block.

A

Commonly used definition: bifascicular block (right bundle branch block and left or right axis deviation) with a 1st degree heart block
True trifascicular block: 3rd degree heart block with right bundle branch block and left anterior or posterior fascicular block

313
Q

Which investigation should be arranged in a patient who is noted to have high blood pressure during a GP appointment?

A

Ambulatory blood pressure monitoring

314
Q

What is the most appropriate initial investigation to request in a patient with suspected peripheral artery disease?

A

Ankle Brachial Pressure Index (ABPI)

315
Q

What is the mainstay of managing mild peripheral vascular disease in the community?

A

Aggressive risk factor modification (e.g. statin therapy, smoking cessation) and enrolment in a supervised exercise programme

316
Q

Which investigation should be requested urgently in a patient with a suspected leaking abdominal aortic aneurysm?

A

CT Aortogram

317
Q

How is viral pericarditis managed?

A

NSAIDs and Colchicine

318
Q

Describe the ECG appearance of Third-Degree heart block.

A

Complete dissociation between the P waves and the QRS complexes.

319
Q

Which medication should be administered as soon as possible once a non-shockable rhythm is identified in cardiac arrest?

A

IV Adrenaline 1 mg (1:1000)

320
Q

What is the gold standard investigation for diagnosing deep vein thrombosis?

A

Doppler Ultrasound Scan

321
Q

What is the first-line interventional option in a patient who has failed a trial of conservative management for symptomatic varicose veins?

A

Endothermal radiofrequency ablation

322
Q

Outline the management of AAA based on the diameter.

A

3.0-4.4 cm: Annual Ultrasound
4.5-5.4 cm: 3-Monthly Ultrasound
> 5.5 cm: Referral for Consideration of Surgical Intervention

323
Q

Which arrest rhythm is most commonly seen in someone who is having a myocardial infarction?

A

Polymorphic ventricular tachycardia descending into ventricular fibrillation.

324
Q

Which medication should be administered as soon as possible once a non-shockable rhythm is identified in cardiac arrest?

A

IV Adrenaline 1 mg (1:1000)

325
Q

What are the clinical and diagnostic features of myocardial infarction?

A
  • Rise in serum troponin concentration
  • Symptoms of ischaemia
  • ECG changes indicative of new ischaemia (new ST-T changes or new left bundle branch block)
  • ECG changes showing development of pathological Q waves
  • Imaging evidence of new loss of viable myocardium or a new regional wall motion abnormality
  • Identification of an intracoronary thrombus during angiography or autopsy.
326
Q

What are the presenting symptoms of pericarditis?

A

Sharp chest pain that is worse on inspiration

Improved by leaning forward

Often preceded by a viral infection (e.g. upper respiratory tract infection or gastroenteritis)

327
Q

Which combination of antiplatelets is recommended in patients who have had a myocardial infarction requiring stent insertion?

A

Aspirin and Ticagrelor (for 1 year, followed by aspirin alone for life).

Clopidogrel is an alternative to ticagrelor. Ticagrelor is associated with a lower rate of future adverse cardiac events, but it is also associated with a higher risk of bleeding.

328
Q

What kind of murmur is caused by aortic regurgitation?

A

Early diastolic decrescendo murmur

329
Q

What ECG features do you expect to see in a posterior wall myocardial infarction?

A

ST depression in V1-V4
If V4-6 are moved to the patient’s back (and, hence, renamed V7-9), ST elevation will be seen in these leads.
Q waves may also be seen in V7-9.

330
Q

What is the first-line antihypertensive for a 60-year-old Caucasian patient with newly-diagnosed hypertension?

A

Calcium channel blocker

331
Q

What are the ECG features of hypokalaemia?

A

Flattened T waves
U waves
Prolonged PR interval
Long QT interval

332
Q

What are the first steps in the management of acute heart failure?

A

Sit Up
High-Flow Oxygen
IV Furosemide
+/- IV Morphine and Nitrates

333
Q

Which factors favour the use of rhythm control instead of rate control for the management of atrial fibrillation?

A

There is a clear reversible cause for the AF (e.g. pneumonia, PE)
The patient has no underlying heart disease (e.g. valvular disease)
The patient has presented within 48 hours of the onset of symptoms

334
Q

Which condition is associated with Roth spots?

A

Infective endocarditis
They are white-centred retinal haemorrhages

335
Q

What are the clinical features of cardiac tamponade?

A

Beck’s Triad: Hypotension, Raised JVP and Muffled Heart Sounds

336
Q

Aside from ECG, troponins and coronary angiograms, which other investigation should all patients with an acute coronary syndrome have performed before discharge?

A

Echocardiogram

337
Q

Which type of medication that is commonly used in the context of ACS should be generally avoided in patients with severe aortic stenosis?

A

Nitrates (it can cause a sudden reduction in preload which can cause a sudden drop in coronary perfusion in patients with severe aortic stenosis)

338
Q

Why should amiodarone be generally run through a central vein?

A

Achieves greater haemodilution and hence reduces the risk of phlebitis

339
Q

Why is it important to carry out a chest X-ray after a pacemaker is inserted?

A

To check for a pneumothorax (from pleural damage caused by insertion) and to ensure the leads are in the correct position.

340
Q

Which medical treatment option is most appropriate for the treatment of bigeminy?

A

Beta-blockers (e.g. bisoprolol)

341
Q

What is the mechanism of action of tirofiban?

A

GPIIb/IIIa inhibitor (prevents platelet aggregation)

342
Q

Which PPI is preferred in patients on clopidogrel?

A

Lansoprazole

NOTE: omeprazole interacts with clopidogrel and reduces its effectiveness

343
Q

Why does metformin need to be withheld in a patient who is undergoing a percutaneous coronary intervention?

A

There is a risk of contrast-induced nephropathy in patients who are undergoing a coronary angiogram.
Metformin is associated with an increased risk of lactic acidosis in patients with renal impairment so it should be held for 48 hours before undergoing an elective angiogram.

344
Q

In the context of acute coronary syndrome, what can cause non-sustained ventricular tachycardia?

A

Ischaemia
Reperfusion after PCI
Electrolyte imbalances (e.g. hypomagnesemia or hypokalaemia)
Underlying myocardial scar
Increased automaticity (ability of heart cells to spontaneously depolarise) in the myocardium adjacent to the infarcted area

345
Q

Why does metformin need to be withheld in a patient who is undergoing a percutaneous coronary intervention?

A

There is a risk of contrast-induced nephropathy in patients who are undergoing a coronary angiogram.
Metformin is associated with an increased risk of lactic acidosis in patients with renal impairment so it should be held for 48 hours before undergoing an elective angiogram.

346
Q

Which medication has a positive inotropic and negative chronotropic effect?

A

Digoxin (it is, therefore, useful in patients with fast AF and a background of heart failure)

347
Q

What is the most common cause of mitral stenosis?

A

Rheumatic Heart Disease

348
Q

Describe the ECG appearance of complete heart block.

A

Regular P waves and regular QRS complexes but shows no relationship between them (loss of connection between the atria and the ventricles)

349
Q

In which leads would you expect to see ECG changes when the right coronary artery is occluded?

A

II, III and aVF

350
Q

Describe the ECG appearance of Wolff-Parkinson-White syndrome.

A

Short PR interval, a broad QRS complex and a slurred upstroke of the QRS complex (delta wave)

351
Q

What murmur is associated with aortic regurgitation?

A

Early diastolic murmur that is high-pitched and blowing in character, and usually heard best over the left sternal edge on expiration

352
Q

What is the initial intervention of choice in a haemodynamically unstable patient with ventricular tachycardia?

A

DC Cardioversion

353
Q

Which type of malignancy is Streptococcus bovis endocarditis associated with?

A

Colorectal Cancer

354
Q

What is the risk of giving rate-limiting calcium channel blockers with beta-blockers?

A

Complete Heart Block

355
Q

Which ECG features would you expect to see due to the left atrial hypertrophy that develops as a result of mitral stenosis?

A

Bifid P Waves

356
Q

What is the most common cardiac complication in patients with hyperthyroidism?

A

Atrial Fibrillation

357
Q

Which murmur would you expect to hear in a patient with heart failure secondary to dilated cardiomyopathy?

A

An S3 heart sound and a holosystolic murmur in the left fifth intercostal space at the midclavicular line

358
Q

Why should beta-blockers be used with caution in patients with acute heart failure?

A

It can diminish the sympathetic drive to the heart and worsen cardiogenic shock.

359
Q

List the indications for ICD insertion.

A
  • If medical treatment of the underlying cause of VT/VF fails (e.g. electrolyte imbalances)
  • Patients who have survived cardiac arrest due to VT/VF
  • Idiopathic and prolonged VT/VF with either syncope, haemodynamic instability or a reduced ejection fraction < 35%
  • Inherited conditions that increase risk of developing VT/VF such as long QT syndrome, hypertrophic cardiomyopathy and Nrugada syndrome.
  • Patients who have developed heart failure with a reduced ejection fraction < 35% secondary to myocardial infarction
360
Q

What are the main indications for pacemaker insertion?

A

Complete atrioventricular block or third degree heart block.
Mortbitz type II atrioventricular block. There is a risk of progressing to third degree heart block, and therefore a pacemaker is needed.
Persistent symptomatic bradycardia.
Medication resistant tachyarrhythmias (e.g. SVT, AF).

361
Q

What echocardiogram findings do you expect to see in mitral regurgitation?

A

Dilated left atrium with poor ventricular ejection fraction

362
Q

List some clinical features of infective endocarditis.

A

New Murmur
Fever
Janeway Lesions
Osler’s Nodes
Roth Spots on Retina
Microscopic Haematuria

363
Q

Which investigation should be requested for a patient with symptoms suggestive of stable angina?

A

CT Coronary Angiogram

364
Q

Why are regular VBGs important in the ongoing management of a patient who has undergone an embolectomy for acute limb ischaemia?

A

Reperfusion can lead to drainage of the potassium and acids released by damaged myocytes into the systemic circulation.

365
Q

What is the most appropriate imaging modality to request in a patient with a suspected leaking abdominal aortic aneurysm?

A

CT Angiogram

366
Q

Outline the frequency with which patients should have an ultrasound scan if a AAA is identified.

A

< 3 cm = No Follow-Up
3 - 4.4 cm = 1 Year
4.5-5.4 cm = 3 Months
> 5.5 cm = Refer to Vascular Surgery

367
Q

What are the indications for surgical intervention in infective endocarditis?

A

Heart failure
Fistula formation
Perforation
Recurrent emboli despite antibiotic treatment
Abscess formation

368
Q

Which ECG findings are associated with pericarditis?

A

PR Depression
Widespread, saddle-shaped ST elevation

369
Q

What is the most accurate way of diagnosing pulmonary hypertension?

A

Right Heart Catheterisation

370
Q

Which medication is usually prescribed in patients with a new diagnosis of peripheral vascular disease?

A

Antiplatelets (e.g. clopidogrel)

371
Q

Outline the initial management of crescendo angina.

A

Dual antiplatelet therapy
Discuss with on-call cardiology registrar and/or nearest PCI centre

372
Q

Which class of medications should be avoided in patients with Prinzmetal angina?

A

Beta blockers (can worsen vasospasm)

373
Q

What is Prinzmetal angina?

A

Also known as variant angina
Form of angina that is caused by coronary artery vasospasm (unclear aetiology)
Patients complain of chest pain that can occur at rest and with exercise (ischaemic ECG changes may be noted during an episode)

374
Q

Outline the initial management of STEMI.

A

Loading dose of dual antiplatelet therapy (aspirin 300 mg AND ticagrelor 180 mg OR clopidogrel 300 mg OR prasugrel 60 mg)
Urgent PCI within 120 mins
If PCI is not available within 120 mins, fibrinolysis should be considered

375
Q

Outline the acute management of NSTEMI.

A

Loading dose of dual antiplatelet therapy (aspirin 300 mg AND ticagrelor 180 mg OR clopidogrel 300 mg OR prasugrel 60 mg)
Fondaparinux 2.5 mg SC OD
Risk stratify to determine when coronary angiogram should be performed

376
Q

How is asymptomatic first degree heart block managed?

A

No intervention required

377
Q

How is symptomatic third degree heart block treated?

A

If the patient is haemodynamically unstable, an isoprenaline infusion can be used in the short term or temporary pacing could be trialled.
If the patient is stable, they should be admitted to a cardiac monitor bed and arrangements should be made to have a permanent pacemaker fitted.

378
Q

Outline the management of hypoplastic left heart syndrome.

A

Prostaglandin E1 infusion
Staged surgical management

379
Q

What are the echocardiographic features that you may see in patients with a pulmonary embolism?

A

Right heart strain

380
Q

Which intervention is considered in patients with critical aortic stenosis who are not suitable for surgical valve replacement?

A

Transcatheter Aortic Valve Implantation (TAVI)

381
Q

What is often the first step in decompensated heart failure?

A

IV Furosemide

382
Q

What should muffled heart sounds and hypotension soon after PCI raise suspicion of?

A

Haemopericardium causing cardiac tamponade

383
Q

What are the ECG findings in bifascicular block?

A

Right bundle branch block and left or right axis deviation

384
Q

How is Torsades de Pointes treated?

A

IV Magnesium Sulphate

385
Q

Describe the ECG appearance of monomorphic ventricular tachycardia.

A

Broad and uniform QRS complexes with a regular rhythm throughout all leads

386
Q

Which risk assessment tool is used for DVTs?

A

Wells’ Score

387
Q

Describe the ECG changes seen in bifascicular block.

A

Left or Right Axis Deviation and Right Bundle Branch Block

388
Q

What are the ECG features of hypokalaemia?

A

Widespread ST Depression
T wave inversion
Prominent U waves
Long QT interval

389
Q

Describe the ECG changes seen in bifascicular block.

A

Left or Right Axis Deviation and Right Bundle Branch Block

390
Q

What are the ECG features of hypokalaemia?

A

Widespread ST Depression
T wave inversion
Prominent U waves
Long QT interval

391
Q

What murmur is associated with mitral regurgitation?

A

Pansystolic murmur heard at the left 5th ICS in the midclavicular line and radiates to the axilla

392
Q

Describe the ECG features of AVNRT.

A

GAP DECK BACK
Regular narrow complex tachycardia with no p waves
Pseudo R waves

393
Q

What is a normal cardiac axis?

A

-30° to 90°

394
Q

How does aortic dissection classically present?

A

Sudden-onset, central, tearing chest pain that radiates to the back (between the shoulder blades)

395
Q

What is Quincke’s sign?

A

Visible pulsation of the nail bed associated with aortic regurgitation.

396
Q

Describe the appearance of 1st degree heart block on an ECG.

A

Fixed prolonged PR interval (over 200 ms)

397
Q

Which autoantibody is most specific for SLE?

A

Anti-dsDNA antibody

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