MISC

Question 1

Write out (from memory) the GCS scale

Answer 1

Eye opening 
4 - Spontaneous 
3 - To speech
2 - To pain 
1 - No response 

Verbal response 
5 - Oriented
4 - Confused sentences 
3 - Inappropriate words 
2 - Sounds that are incomprehensible 
1 - No response 

Motor response 
6 - Obeys commands 
5 - Localises pain 
4 - Withdraws to pain 
3 - Flexion to pain 
2 - Extension to pain 
1 - No response

Question 2

A man attends A&E via paramedics due to a fall. He has a decreased GCS of 6, and has a history of alcohol access. What is your initial first step and why?

Answer 2

Initial first step - Urgent CT scan of the head
Why - could have a bleed in the brain, specifically a subdural heamatoma as a fall, reduced GCS and alcohol excess are all risk factors

Question 3

A woman with a BMI of 35 attends your breast clinic due to a lump in her left breast. On examination, it is irregular and hard. She mentions it was initially firm, round and painful after trauma to the breast last week. She has a PMH of T2DM, IHD, OA and Hyperlipidaemia.

1. What is your diagnosis?
2. What investigations would you like to do and why?

Answer 3

1. Diagnosis is fat necrosis of the breast. This is a classic history.
2. Investigations - Mammogram and biopsy - to rule out malignancy as presentation of breast cancer is similar.

Question 4

Name features of biliary colic

Answer 4

Colicky RUQ pain
Worse after eating
No fever
Murphy sign -ve

Question 5

What is the complication of biliary colic?

Answer 5

Obstructive jaundice = jaundice, dark urine and pale stools

Question 6

What can ascending cholangitis be caused by?

Answer 6

Biliary calculi, benign biliary stricture, malignancy

Question 7

Name three risk factors of cholangiocarcinoma

Answer 7

Hx of gallstones, smoking, obesity, porcelain gallbladder, primary sclerosing cholangitis, UC, Chrons, Oestrogens, Occupational exposure

Question 8

A man had a radical prostatectomy 5 months ago due to prostate cancer. He now returns to you as he has a week stream and post micturition dribble. Why might he have these symptoms now?

Answer 8

Developed a urethral stricture

Question 9

A patient attends ED as she has anxiety. She has SOB and feels her heart is beating too quickly. You carry out an ABG.What would this show?

Answer 9

Respiratory alkalosis.
WHY? Pt has anxiety —> panic attacks due to hyperventilation —> breathing off too much CO2 so reduces pp of CO2 —> = resp alkalosis

Question 10

When do we invite women to breast screening?

Answer 10

ages 50-70yrs, every 3 years

Question 11

How is an active seizure treated in the hospital setting?

Answer 11

IV 4mg lorazepam

Question 12

Which organism causes Staghorn calculus in abdominal XR

Answer 12

Proteus species infection- causes alkalisation of urine leading to staghorn calculus e.g Proteus mirabilis. Note: E.coli causes UTIs but does not cause stones to form

Question 13

What does having a glucose-6-phosphate dehydrogenase (G6PD) deficiency mean for red blood cells?

Answer 13

G6pd keep red blood cells working properly and live a normal ~ 120 day cycle. Without this, red cells lyse early (haemolysis) - get haemolytic anaemia

Question 14

In achalasia, how is pain/discomfort described clinically?

Answer 14

Retrosternal discomfort.

Question 15

How does Pharyngeal pouch present?

Answer 15

Dysphagia, regurgitation of undigested food, aspiration, chronic cough, weight loss

Question 16

A history of dysphagia, regurgitation of food and aspiration can bring about what differentials?

Answer 16

Achalasia
GORD
Pharyngeal pouch

Question 17

Name treatment used for HER2 receptor positive breast cancer

Answer 17

Trastuzumab aka Herceptin

Question 18

Which hormone receptor must a breast lesion be positive for to be treated with Tamoxifen?

Answer 18

ER (oestrogen receptor) positive

Question 19

Which antibiotic would be an appropriate choice for the treatment of a food borne enteric infection acquired in the UK?

Answer 19

Ciprofloxacin - good activity against many salmonellae and campylobacter.

Question 20

What particular food borne infection is metronidazole effective in treating?

Answer 20

Giardia

Question 21

Quinolone antibiotics need to be used with caution in the following groups:
Patients with e\_\_\_\_\_\_
Patients over \_\_ years old 
C\_\_\_\_\_\_
Patients who are p\_\_\_\_

Answer 21

Patients with epilepsy
Patients over 60 years old
Children
Patients who are pregnant

Question 22

Name three contraindications to using loperamide

Hints - medication causing gut problem, stool abnormality, hot hot hot!

Answer 22

Antibiotic associated colitis, bloody diarrhoea, high temperature

Question 23

What should you advise a patient about before taking metronidazole?

Answer 23

Metronidazole has a disulfram-like effect web drinking alcohol along side metronidazole. Symptoms of this include flushing, abdominal pain and hypotension.

Question 24

If the colon is dilated more than 10cm on an abdominal x ray, what is your top differential?

Answer 24

Toxic megacolon

Question 25

Amlodipine, Ramipril, Atorvastatin, Beclometasone and Salbutamol inhaler all have side effects. Which two from this list cause GI symptoms such as heartburn/dyspepsia, belching, occasional vomiting?

Answer 25

Amlodipine - causes dyspepsia. Atorvastatin - cause upper GI symptoms

Question 26

A 30 year old woman attends ED as she has an acutely red swollen leg. You confirm a DVT. Bloods are significant for thrombocytopenia and a prolonged activated partial thromboplastin time (APTT). These findings prompt an antibody screen, and the patient is subsequently diagnosed with antiphospholipid syndrome.
What should her long term treatment be (i.e. once discharged)?

Answer 26

Lifelong warfarin - After the first VTE, patients with antiphospholipid syndrome should be on lifelong warfarin

Question 27

Which lung cancer can present with moon face and purple striae on the abdomen?

Answer 27

Small cell lung cancer - secretes ACTH - leads to Cushing’s syndrome

Question 28

What is mesothelioma

Answer 28

Mesothelioma is a cancer of the pleura due to asbestos exposure.

Question 29

What is the lymphatic drainage of the bladder?

Answer 29

External and internal iliac nodes, so if cancer in bladder, these will be the first nodes affected

Question 30

What metabolic disturbance are you most worried about when prescribing salbutamol?

Answer 30

Hypokalaemia

Question 31

How does hyperkalaemia show on ECG?

Answer 31

Tall tented T waved

Question 32

What do you give if you see tall tented t waves on ECG and why?

Answer 32

IV calcium gluconate, to stabilise the myocardium and prevent cardiac arrest

Question 33

Characteristics of hypodelirum?

Answer 33

Withdrawal and sleepiness

Question 34

How does levy body dementia commonly present?

Answer 34

Dementia w Parkinsonism

Fluctuating cognition - compared to other dementia

Question 35

What are the 5D’s of charcot’s foot found on Xray? (Capsule clinical investigation case 142)

Answer 35

Density change (areas of lucency and sclerosis)

Destruction

Debris (loose bodies and bone fragments)

Distension (joint effusion)

Dislocation (e.g. metacarpophalangeal joints).

Question 36

What to do with warfarin if a pt has an IC haemorrhage?

Answer 36

give IV vitamin K 5mg + prothrombin complex concentrate