Miscellaneous Flashcards
(317 cards)
1
Q
What are the biochemical features of Tumour Lysis Syndrome?
A
Treatment of cancer results in lysis which releases components into bloodstream: raised phosphate raised potassium raised uric acid lowered calcium (chelated by elevated phosphate) raised creatinine (renal failure)
2
Q
What is the MOA of Rasbirucase?
A
rh-Urate oxidase which converts uric acid into allantoin. Allantoin is water soluble thus more easily excreted by the kidneys
3
Q
What is the most common form of Malaria?
A
M falciparum
4
Q
What are the features of Malaria falciparum?
A
Fever >39C
Hypoglycaemia
Acidosis
Severe anaemia: TATT
Schizonts on blood film
5
Q
What are the complications to be concerned of regarding malaria falciparum?
A
Cerebral spread: seizures/coma
Acute renal failure: blackwater fever (haemorrhaging of RBCs releasing Hb into urine)
ARDS
Hypoglycaemia
DIC
6
Q
What is the most common non-falciparum malaria cause?
A. P falciparum
B. P malariae
C. P ovarle
D. P vivax
A
D
7
Q
Which forms of malaria is associated with nephrotic syndrome?
A. P vivax
B. P malariae
C. P falciparum only
D. P malariae and P falciparum
A
D
8
Q
A 55-year-old man presents with fever, fatigue, and chest pain. The patient was discharged after a successful mitral valve replacement 6 weeks ago. An urgent echo showed the presence of a new valvular lesion. Three sets of blood cultures are taken, and a diagnosis of infective endocarditis is confirmed.
Given the background, what is the most likely causative organism?
A
S epidermis
9
Q
A 12-hour old baby girl is noted to have dysmorphic features, including webbing of the neck and wide-spaced nipples. She is also noted to have ‘puffy’ hands and feet. She is in the 10th percentile for length and weight.
There is no family medical history and, other than being small for gestational age, there were no abnormalities noted during pregnancy.
What cardiac condition is commonly associated with the likely underlying diagnosis?
A
CoA
10
Q
You review a patient in the respiratory clinic who has a history of recurrent pulmonary embolism despite anticoagulation with warfarin.
What lung-specific, physiological change may be expected?
A
TLCO reduced
11
Q
What drugs should be stopped in an AKI as they are nephrotoxic?
A
Mnemonic: NADA
NSAIDs ACEi Diuretics Aminoglycosides ARBs
12
Q
A 23-year-old woman presents with dysuria, malaise, vaginal pain, fever, and myalgia. She consents to a vaginal examination which reveals multiple painful ulcerations around the vagina and perineum. Urinalysis reveals trace leukocytes, no nitrites, and microscopic haematuria. Swabs are taken and sent and a urine MCS is also sent.
Given the most likely diagnosis, what is the most appropriate treatment?
A
This woman has genital herpes. The painful nature rules out lymphogranuloma venereum.
Therefore it is a Genital Herpes caused by HSV-1 which requires an antiviral for 10 days.
Valaciclovir for BDS 10/7
13
Q
A 27-year-old man presents to his GP feeling generally unwell complaining of joint pain and swelling. He returned from a walking trip in Thailand one month ago and one day after his return he developed severe watery diarrhoea and abdominal cramps that lasted for one week.
On examination he appears unwell and looks fatigued. He has large effusions of the left knee and right ankle along with tender planter fascia bilaterally. He also has tender metatarsophalangeal joints on both feet. On closer inspection of the feet he has a papular rash on the soles of both feet.
For the last week he has been taking regular paracetamol and ibuprofen with minimal improvement in symptoms.
Given the most likely diagnosis what is the most appropriate next step in this patients management?
A
This man has Reactive Arthritis
Therefore oral steroids required for 4/6/52
14
Q
A 38-year-old woman presents with a litany of symptoms that have been ongoing for the past four months. These include weight gain, which particularly bothers her around the abdomen, with troubling purplish stretch marks, thin skin and easy bruising. She has been noticing increased swelling in her ankles and poor mood. In the diagnostic work-up, a range of laboratory tests is taken.
What is the expected electrolyte abnormality in this patient?
A
This woman has Cushing’s Syndrome.
The elevated cortisol is due to ectopic production or exogenous sources.
Cortisol may simulate aldosterone thus increased sodium reabsorption, potassium excretion. At high levels of potassium excretion, bicarbonate is absorbed.
This results in a metabolic alkalosis that is hypokalaemic thus Hypokalaemic metabolic alkalosis.
15
Q
What are the features of severe acute asthma?
A
RR >25
HR >110bpm
PEF 33-50% of normal
Cannot complete sentences in one breath
16
Q
A 68-year-old male presents to the Emergency Department with a two-hour history of crushing left-sided chest pain radiating to the jaw. He has a past medical history of dyslipidaemia and hypertension. You perform an electrocardiogram and serum troponin which confirm an anterior ST-elevated myocardial infarction (STEMI). The nearest primary percutaneous coronary intervention (PCI) centre is three hours away by ambulance and urgent fibrinolysis is therefore given in preference to PCI.
What is the most appropriate management plan regarding myocardial revascularisation of this patient?
A
Take ECG 60-90 minutes later and if no correction, transfer for PCI
17
Q
What are the clinical features of Port wine stains?
Do they require treatment?
A
Unilateral
Deep red/purple (vascular birthmark)
Darken and raise over time
Not symptomatically, but potentially if Sturge-Weber Syndrome or psychosocial implications
Cosmetic camouflage
Laser therapy
18
Q
What are the clinical features of a dermatofibroma?
A
Solitary firm papule resulting from trauma
5-10mm in size
Skin dimples on pinching skin
19
Q
What are the clinical features of Mongolian blue spots?
A
Flat blue/grey skin markings occurring at birth/after
Base of spine/back
Dermal melanosis with melanocytes remain deep in dermis (red wavelengths of light absorbed and blue wavelengths reflected back from brown melanin pigment deep in dermis) - “Tyndall Effect”
20
Q
What is Eisenmenger Syndrome?
Give the clinical features.
A
Reversal of L-to-R shunt in CHD due to pulmonary hypertension.
Murmur may not be heard Cyanosis Clubbing RV failure Haemoptysis/Embolism
21
Q
What is Transposition of the Great Arteries?
Give the clinical features.
What is the management of this?
A
Congenital heart defect with failure in embryonic development.
Aorta leaves from RV
Pulmonary artery leaves LV
Cyanosis Tachypnoea Found S2 (ejection systolic murmur) RV impulse prominent CXR: Egg-on-side appearance
Must surgically correct.
Maintain patency of any shunt with PGEs
Surgically correct
22
Q
Outline what a Stokes-Adams attack is?
A
Syncopal episodes occurring from cardiac arrhythmia - heart block or sick sinus syndrome
23
Q
How may Syncope be classified?
A
Cardiac
- Arrhythmia
- Structural
- Others: e.g. PE; Myocarditis
Neural
- Vasovagal
- Situational
- Carotid sinus
Orthostatic syncope
- Autonomic failure
- Drug-induced
- Volume depletion
24
Q
What is a femoral aneurysm?
How may it present?
A
Bulging weakness in wall of femoral artery
Pulsation in groin
Pain in leg/abdomen/back
Claudication symptom
Nerve compression (femoral nerve/obturator nerve)
25
What is Short Bowel Syndrome?
Give the clinical features.
Absence of functional SI
```
Fatigue
Vomiting
Thirst/Dry skin
Bloating/Cramping
Foul-smelling stool
Weakness
```
26
When prescribing anti-emetics in palliative care, what should be considered?
Consider the cause of the N/V to be treated
```
Reduced motility (e.g. secondary to opioids)
- Use metoclopramide / domperidone
```
Chemically mediated (e.g. secondary to hypercalcemia; opioids or chemotherapy)
- Ondansetron
- Levomepromazine
Visceral/serosal (secondary to constipation/oral candidiasis)
- Cyclizine
- Levopromazine
Raised ICP
- Cyclizine
- Dexamethasone (if metastases)
Vestibular (opioid related)
- Cyclizine
Cortical (e.g. anxiety/pain/fear)
- Benzodiazepines
- Cyclizine
27
When would you avoid oral anti-emetics in palliative care?
```
NBM
Poor swallow
Vomiting
Malabsorption
Gastric stasis
```
Therefore use IV route
28
How do you calculate the breakthrough dose of morphine?
1/6 of daily dose
29
What should be prescribed with opioids?
Laxatives
30
What opioid should be given in patients with renal impairment?
Moderate impairment: Oxycodone
Severe impairment: Buprenorphine; Fentanyl
31
What can be used to manage metastatic bone pain?
Opioid analgesia
Bisphosphonates
Radiotherapy
32
What are the side effects of opioids?
Respiratory depression
Nausea
Drowsiness
Constipation
33
How do you convert between oral codeine and oral morphine?
Divide by 10
34
How do you convert between oral tramadol and oral morphine?
Divide by 10
35
What are the differences in side effects between oxycodone and morphine?
Cf Morphine...
More constipation
Less sedation
Less vomiting
Less pruritus
36
How do you convert between oral morphine and oral oxycodone?
Divide by 2
37
How do you convert from oral morphine to subcutaneous morphine?
Divide by 2
38
How do you convert from oral morphine to subcutaneous diamorphine?
Divide by 3
39
What is the management for intractable hiccups?
Chlorpromazine
Dexamethasone (if hepatic lesions)
40
How is confusion managed in palliative care?
Sedatives
Haloperidol
Chlorpromazine
Levomepromazine
41
How are secretions managed in palliative care?
Hyoscine hydrobromide/Hyoscine butylbromide
Glycopyrronium bromide
42
When is neutropenic sepsis most likely to occur?
7-14 days following chemotherapy
Neutrophil count <0.5 x 10^9
Fever >38 C
Sepsis features
43
What is the management of neutropenic sepsis?
ABX: Pip/Taz
+
Specialist assessment
If still unwell after 48 hours - use alternative ABX e.g. Meropenum ± Vancomycin
44
A patient who is fully active is which WHO performance status?
A. 1
B. 0
C. 2
D. 3
B
45
A patient who is restricted in physical activity but ambulatory and able to carry out work is which WHO performance status?
A. 1
B. 0
C. 2
D. 3
A
46
A patient who is able to self care but unable to work, out of bed for 50% of the day is which WHO performance status?
A. 1
B. 0
C. 2
D. 3
C
47
A patient who is bedridden for >50% of the day is?
A. 1
B. 0
C. 2
D. 3
D
48
A patient who is completely disabled, unable to carry on self-care or leave chair is given which WHO performance status?
A. 1
B. 4
C. 2
D. 3
B
49
Which cancers are most commonly associated with hypercalcaemia?
Breast
Kidney
Multiple myeloma
50
Why might a magnet be placed over an ICD?
In the event that you are unclear whether an ICD has been deactivated, placing a large magnet over the device will temporarily deactivate the defibrillation function for the duration of time the magnet is in place. The magnet should therefore be securely taped over the ICD to prevent it slipping off the patient’s chest. If it turns out the ICD has been deactivated, the magnet will do no harm and can simply be removed once it is confirmed deactivation has taken place.
51
What are the criteria to certify a patient's death?
```
Absence of pupillary response
Failed response to pain
Absence of central pulse
Absence of heart sounds
Absence of bowel sounds
Check and confirm again at 5 minutes
```
52
Give the two predictors of mortality in the palliative patient group?
Deteriorating function
Surprise Question: Would you be surprised if this patient were to die in the next days/weeks/months?
53
Give two examples of deprivation of liberty.
Restraint being used to admit a patient to a hospital / care home when the patient has resisted admission
Medication being given by force against a patient’s will
Staff taking complete control over a person’s care and movements over a long period
Patients being prevented from seeing family or friends because the care home / hospital had restricted their access to them.
54
What does the DOLS Mental Capacity Act 2005 aim to do?
Aims to ensure patients in care settings are cared for in accordance to their wishes without restricting their freedom
55
Why may Glycopyrronium be preferred to Hyoscine hydrobromide?
Hyoscine hydrobromide is an antimuscarinic drug which will also dry secretions, it can cross the blood-brain barrier and cause agitation, so glycopyrronium might be preferable.
56
A 40-year-old with known rheumatoid arthritis, established on sulfasalazine and regular paracetamol and ibuprofen, is seen by her GP with ongoing low mood. Non-pharmaceutical interventions have been trialled with limited improvement and now the patient reports they feel their depressive symptoms are worsening.
As such the GP decided to commence the patient on an antidepressant.
What agent would increase this patient’s risk of a GI bleed the most, therefore, warranting a protein pump inhibitor as cover?
SSRI in combination with NSAID = increased risk
PPI should be prescribed
57
A 52-year-old man is admitted to hospital with acute pancreatitis. He drinks 90 units of alcohol per week. When is the peak incidence of delirium tremens following alcohol withdrawal?
72 hours
6-12 hours = symptoms (tremor, tachycardia, anxiety)
36 hours = seizures
72 hours = Fever, confusion, delusions, tremor and hallucinations
58
A 36-year-old man with a history of asthma and schizophrenia presents to his local GP surgery. He complains of 'tonsillitis' and requests an antibiotic. On examination he has bilateral inflammed tonsils, temperature is 37.8ºC and the pulse is 90/min. His current medications include salbutamol inhaler prn, Clenil inhaler 2 puffs bd, co-codamol 30/500 2 tabs qds and clozapine 100mg bd. You decide to prescribe penicillin.
What is the most appropriate further action?
FBC - Clozapine can cause agranolocytosis/neutropenia
59
A 23-year-old male has been on antipsychotics for the past few months. He has been suffering from a side-effect of this drug, that you grade as severe, which causes repetitive involuntary movements including grimacing and sticking out the tongue. This side-effect is known to arise only in individuals who have been on antipsychotic for a while.
Which medication is therefore most suitable to treat this side-effect?
Tetrabenzene - treats tardive dyskinesia
60
A 24-year-old woman is brought to the Emergency Department by her friend. The friend states she has been acting differently and can't seem to concentrate on one thing at a time. He has noticed over the past few days that she hasn't been sleeping as he can hear her walking around in the early hours of the morning. His main concern is that she has been coming home with multiple bags of very expensive looking shopping every day for the past 3 days.
The patient denies any hallucinations but states she feels great and wants to eat all the time. She has no past medical history and takes no medications.
What is the most likely cause of this patient's presentation?
Hypomania
61
What are the clinical features of SSRI discontinuation syndrome?
```
increased mood change
restlessness
difficulty sleeping
unsteadiness
sweating
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia
```
62
A 36-year-old with a long standing history of schizophrenia presents to the emergency department in status epilepticus. Once he is treated, he tells the doctor he has been having a lot of seizures recently.
Which of the following medications is most likely to be causing the seizures?
A. Sertraline
B. Lithium
C. Clozapine
D. Onlazapine
C - Clozapine reduces the seizure threshold
63
Which factors give a poor prognosis of Schizophrenia?
```
strong family history
gradual onset
low IQ
prodromal phase of social withdrawal
lack of obvious precipitant
```
64
Joseph, a 55-year-old man, goes to his GP describing a lack of energy, low mood and lack of pleasure doing activities he normally enjoys for the past 10 days. According to ICD-10 criteria, how long must Joseph's symptoms last to be classified as a depressive episode?
2 weeks
65
A 60-year-old man with chronic schizophrenia presented with nausea and vomiting. He receives metoclopramide for his symptoms. Twenty minutes later he becomes agitated and develops marked oculogyric crises and oromandibular dystonia.
What is the most appropriate drug to prescribe?
Procyclidine
66
A 27-year-old man presents to his GP with ongoing issues with sleep and admits that he has not been sleeping because of tension in his relationship with his girlfriend. He feels she is somewhat distant with him and is concerned that she is spending time with her former boyfriend who works in the same office as her.
On further questioning, he explains he has had several relationships in the past during which he felt as though they were not interested in him. He feels as though he will never be able to find the perfect partner therefore suffers from mood swings as a result. During the consultation, he reveals that he feels 'alone in the world' and that even his friends are 'out to get him', risk assessment reveals he does not have any suicidal thoughts but self-harms from time to time. A referral to psychiatry is made and subsequently he is diagnosed with borderline personality disorder.
What is the most appropriate treatment?
DBT
67
You are on a psychiatric liaison rotation, and have been asked to talk to an admitted patient with known bipolar disorder. Upon trying to take a history from him, you struggle to follow his stream of consciousness, as he keeps saying things like: 'I went home to feed my cat -- so fat I am, I really need to lose weight -- I hate the postman, he always speeds in his red van, Dan is my best friend at work -'. You suspect that his flight of ideas is linked only by rhyme or similar sounding words.
What is the medical term for this psychiatric symptom?
Clang associations
68
Outline the difference between Somatisation, Hypochondriasis, Conversion disorder, Fatitious disorder and Malingering.
Somatisation = 2+ Sx for 2+ years
Hypochondriasis = belief of disease without accepting medical tests e.g. Cancer
Conversion disorder = motor/sensory loss without consciously knowing
- No malingering
- No factitious
Factitious disorder = Munchausen's with intentional production (insight)
Malingering = fraudulent simulation of symptoms to gain financially or in another way
69
A 75-year-old male presents to the acute medical unit with dyspnoea. He has a past medical history of chronic obstructive pulmonary disorder (COPD). On examination the patient has an SpO2 = 85%, blood pressure 100/65 mmHg, temperature = 38.6 C and widespread bilateral expiratory wheeze on auscultation. An arterial blood gas (ABG) sample reveals:
```
pO2 = 6.8 kPa
pCO2 = 7.8 kPa
pH = 7.31
HCO3- = 44 mmol/l
```
Acute on chronic Respiratory Acidosis
70
A 26-year-old male presents via ambulance to the emergency department of your local hospital following a motor vehicle accident. He was a restrained passenger. The paramedics have secured his c-spine before transporting him. He is complaining of chest pain and shortness of breath. A primary and secondary survey are undertaken and the following pertinent findings are reported:
Young, otherwise healthy looking male in clear pain and respiratory distress.
Glasgow coma scale (GCS) of 14.
Heart rate of 104/min.
Blood pressure of 94/50mmHg.
Respiratory rate of 24/min.
Oxygen saturation: 99% on 15L non-rebreather.
Temperature: 36.8 degrees.
There is a tender contusion on the anterior chest. No abnormal chest movements. JVP can been seen at the level of the earlobe. Auscultation reveals soft heart sounds and bibasal crepitations. There is air entry throughout both lung fields.
An ECG is performed.
Which of the following ECG findings is most likely to be reported in this patient?
Electrical Alternans
71
A 26-year-old male presents via ambulance to the emergency department of your local hospital following a motor vehicle accident. He was a restrained passenger. The paramedics have secured his c-spine before transporting him. He is complaining of chest pain and shortness of breath. A primary and secondary survey are undertaken and the following pertinent findings are reported:
Young, otherwise healthy looking male in clear pain and respiratory distress.
Glasgow coma scale (GCS) of 14.
Heart rate of 104/min.
Blood pressure of 94/50mmHg.
Respiratory rate of 24/min.
Oxygen saturation: 99% on 15L non-rebreather.
Temperature: 36.8 degrees.
There is a tender contusion on the anterior chest. No abnormal chest movements. JVP can been seen at the level of the earlobe. Auscultation reveals soft heart sounds and bibasal crepitations. There is air entry throughout both lung fields.
An ECG is performed.
Which triad is demonstrated here?
Beck's Triad = hypotension + raised JVP + muffled heart sounds
72
A thirty-four-year-old man with ulcerative colitis is recovering on the ward 6 days following a proctocolectomy. During the morning ward round he complains to the team looking after him that he has developed pain in his abdomen. The pain started in the left iliac fossa but is now diffuse. It came on suddenly, overnight, and has gradually been getting worse since. He ranks it an 9/10. He has not opened his bowels or passed flatus since the procedure. He has had no analgesia for this.
On examination:
Blood pressure: 105/68 mmHg; Heart rate: 118/minute, regular; Respiratory rate: 12/minute; Temperature: 38.2 ºC; Oxygen saturations: 98%.
Abdominal exam: abdomen is distended and diffusely tender upon palpation and widespread guarding, indicating peritonism. No organomegaly or palpable abdominal aortic aneurysm. Kidneys are non ballotable. No shifting dullness. Bowel sounds are absent.
There is 250 mL of feculent matter in the abdominal wound drain.
The registrar requests an abdominal CT which demonstrates an anastomotic leak. What is the most appropriate initial management of this patient?
Take to theatre immediately
73
Jenna is an 18-year-old woman who was initially admitted with a fever and disseminated rash. She had not been previously vaccinated and was in contact with her 2-year-old cousin who had developed a fever and disseminated blisters and vesicles containing clear fluid. She began to have a fever and flu-like symptoms 2 weeks after seeing her cousin. Similar clear-fluid filled vesicles and blisters developed 3 days later and she was admitted for further observation.
After 3 days, she noticed that while most of her skin lesions are healing, one of the lesions on the thigh appears to be red and becoming hot to touch. An area of skin approximately 3x3cm was erythematous. The skin was marked and she was commenced on IV flucloxacillin. Over the coming 12 hours, the erythema around this lesion continued to spread. The pain around her leg increased in intensity, requiring morphine to take the edge off the pain. A blueish discolouration begins to develop around the rash.
Given the likely complication that has developed, what is the likely organism that has caused the complication?
GAS
74
Jenna is an 18-year-old woman who was initially admitted with a fever and disseminated rash. She had not been previously vaccinated and was in contact with her 2-year-old cousin who had developed a fever and disseminated blisters and vesicles containing clear fluid. She began to have a fever and flu-like symptoms 2 weeks after seeing her cousin. Similar clear-fluid filled vesicles and blisters developed 3 days later and she was admitted for further observation.
After 3 days, she noticed that while most of her skin lesions are healing, one of the lesions on the thigh appears to be red and becoming hot to touch. An area of skin approximately 3x3cm was erythematous. The skin was marked and she was commenced on IV flucloxacillin. Over the coming 12 hours, the erythema around this lesion continued to spread. The pain around her leg increased in intensity, requiring morphine to take the edge off the pain. A blueish discolouration begins to develop around the rash.
Given the likely complication that has developed, what is the likely diagnosis?
Necrotising Fasciitis
Chickenpox can predispose you to Nec Fasc
75
What is target blood pressure for a 56-year-old man with type 2 diabetes mellitus who has no end-organ damage, if using a clinic blood pressure reading?
<140/90 mmHg
76
A 32-year-old woman comes to surgery for her blood results. She is 25 weeks pregnant and has had her glucose tolerance test.
The results are as follows:
Fasting glucose = 7.3 mmol/L
2-hour glucose 8.5 mmol/L
What would be the most appropriate next step?
Fasting glucose > 7 thus insulin immediately
If fasting glucose < 7 then 1 week trial of diet and exercise may be given
77
A 43-year-old man is attending today following a referral from his GP. He has a history of poorly controlled hypertension and has come in today to have his aldosterone: renin ratio performed. The results showed high aldosterone and low renin levels. The patient also has a CT scan which shows bilateral hyperplasia of the adrenal glands.
How should this patient be managed?
This patient has a high aldosterone : renin ratio therefore there is elevated levels of aldosterone which feeds back to suppress renin.
Aldosterone levels increase sodium retention and potassium secretion thus hypertension occurs.
The cause is bilateral thus surgery not indicated, but something to antagonise the effects of aldosterone hence Spironolactone
78
A 29-year-old woman presents to the GP with her mother. She has been experiencing fatigue for 2 weeks which she says is unusual for her. She has multiple petechiae on her arms and legs and hepatomegaly on examination. Her vital signs are all normal, and she is not aware of having any long-term medical conditions.
Which of the following is the most appropriate management?
Refer to specialist urgently - suspected leukaemia
79
What are the clinical features of an atrial myxoma?
systemic: dyspnoea, fatigue, weight loss, pyrexia of unknown origin, clubbing
emboli
atrial fibrillation
mid-diastolic murmur, 'tumour plop'
echo: pedunculated heterogeneous mass typically attached to the fossa ovalis region of the interatrial septum
80
An 85-year-old man is bought into hospital after developing severe abdominal pain at home. His family report that he has also seemed more confused today and is 'off his legs'.
On examination, his abdomen is full with a large palpable bladder. A PR examination reveals a smooth, mildly enlarged prostate with an empty rectum. A bladder scan shows 1L of urine in his bladder.
His most recent prescription shows that he takes aspirin, fexofenadine, ramipril, paracetamol, prazosin and insulin.
What medication is most likely to have contributed to this presentation?
Fexofenadine - may cause urinary retention
81
A 16-year-old girl with cystic fibrosis is being reviewed for her annual check-up. She was diagnosed with cystic fibrosis 15 years ago.
She has a good exercise tolerance, minimal gastrointestinal symptoms and has not been hospitalised in the past year.
Her recent investigations show an iron-deficient anaemia on her blood work, and multiple positive sputum cultures for Burkholderia species. Her latest FEV1 is 650% of her predicted.
What feature of her history confers the greatest increase in mortality?
Chronic Burkholderia infection
82
A 23-year-old female with severe learning difficulties is brought into the emergency department by her parents following an accidental paracetamol overdose. She was found 40 minutes ago to have mistakenly ingested 16 grams of paracetamol after having been briefly unsupervised.
What is the best initial management of this patient?
Within 1 hour, can give Charcoal
Check serum Paracetamol levels to determine if above treatment line then give n-acetylcysteine
83
A 77-year-old male presents to the Emergency Department after waking in the morning with lower back pain and an inability to stand unassisted. He has a past medical history of metastatic lung cancer and is currently receiving palliative care for this. Examination of the lower limbs reveals severe neurological deficits of both legs.
Given the likely diagnosis, which of the following would be a late sign in this patient?
Urinary incontinence
84
A 47-year-old man is admitted to the hospital with severe knee pain, swelling and stiffness which began last night. He is unable to weight bear and is systemically unwell with a temperature of 39.3ºC. He undergoes joint aspiration to confirm the diagnosis.
How long of a course of antibiotics should be prescribed?
4-6 weeks for Septic Arthritis
85
What are the side effects of glucocorticoids?
Immunosuppression/Neutrophilia
Growth suppression
Psychiatric: Mania/Insomnia/Depression/Psychosis
Ophthalmic: Glaucoma/Cataracts
GI: peptic ulceration/pancreatitis
Dermatological: Acne
Endocrine: IGT/ Increased appetite/ Weight gain/ Hirsutism/ Hyperlipidaemia
Cushing syndorme: moon face; striae; buffalo hump
86
Why are steroids gradually tapered?
Long-term corticosteroids suppress the glucocorticoid axis therefore sudden withdrawal may lead to an Addisonian crisis
87
How long does steroid withdrawal symptoms last for?
Up to 2 weeks
88
What may be a protective factor in a paracetamol overdose?
Acute alcohol intake
89
Which patients are at increased risk of hepatotoxicity following a paracetamol overdose?
Patients taking enzyme inducing drugs (rifampicin, phenytoin, carbamazepine, chronic alcohol excess, St. John's Wart)
Malnourished patients
90
When may charcoal be of benefit in a paracetamol overdose?
<1 hour
91
When should acetylcysteine be given in a paracetamol OD?
Staggered overdose
Plasma concentration above treatment line
92
How is acetylcysteine given?
Infuse over 1 hour - reduce risk of anaphylactoid reaction
93
What are the criteria for a liver transplant following paracetamol overdose?
Arterial pH <7.3 after 24 hours of ingestion
PT >100 seconds
sCr > 300umol/L
Grade III or IV encephalopathy
94
How may encephalopathy be graded?
I = irritable
II = confusion
III = incoherent/restless
IV = coma
95
What is the first line management of hepatic encephalopathy?
Lactulose first line ± Rifaximim for secondary prophylaxis
96
What is the underlying cause of hepatic encephalopathy?
Any liver pathology with excess levels of ammonia and glutamine which cause confusion, asterixis, constructional apraxia and raised ammonia levels with triphasic slow waves on EEG.
97
What is the first line treatment of Scleroderma associated renal injury?
ACEi
98
What are the clinical features of Ankylosing Spondylitis?
Back stiffness: morning, improves with activity
Reduced movement
Reduced chest expansion
```
"The A's..."
Amyloidosis
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Peripheral arthritis
Achilles tendonitis
```
99
Give an example of a cluster A personality disorder?
Paranoid
Schizoid
Schizotypal
100
Give an example of a Cluster B personality type?
Antisocial
Borderline
Histrionic
Narcissistic
101
Give an example of a cluster C personality type?
Obsessive-Compulsive
Dependent
Avoidant
102
What are the clinical features of a paranoid personality disorder?
```
Hypersensitivity
Questions loyalty
Perceives attacks on character
Does not trust
Preoccupied with alt beliefs
```
103
Give the clinical features of a Schizoid personality disorder.
```
Indifferent to praise
Solo activities
Emotional coldness
Few interest
Few friends or confidants other than family
Lack of desire for companionship
Lack of interest in sexual interactions
```
104
What are the clinical features of Schizotypal personality disorder?
Schizophrenic features BUT insight
Odd beliefs and magical thinking
Ideas of reference
Unusual perceptual disturbances (pseudohallucinations)
Odd, eccentric behaviour
Lack of close friends other than family members
Inappropriate affect
105
What are the clinical features of antisocial behaviour?
```
No social norms
Deception
Impulsiveness
Irritable
Aggressive
Disregard for patient safety
```
106
What are the clinical features of Borderline personality disorder?
```
Unstable interpersonal relationships - alternate between idolisation and devaluation
Unstable self image
Impulsivity
Affective instability
Chronic feelings of emptiness
Difficulty controlling temper
```
107
What are the clinical features of histrionic personality disorder?
Inappropriate sexual seductiveness
Need to be centre of attention
Shallow expression of emotion
Relationships considered to be more intimate than they are
108
What are the clinical features of narcissistic personality disorder?
```
Grandiose self importance
Preoccupation with unlimited success
Sense of entitlement
Opportunistic - takes advantage of others
Lack of empathy
Craves admiration
Chronic envy
```
109
What are the clinical features of Obsessive-Compulsive personality disorder?
```
Occupied with details
Perfectionism
Must act on obsessions
Not capable of disposing of worn out possessions
Unwilling to pass on tasks
Stingy with money and spending
```
110
What are the clinical features of avoidant personality disorder?
Avoidance of activity out of fear of rejection
Preoccuied with ideas they are being criticised
Restraint in relationship due to fear of ridicule
Views self a inept and inferior to others
Social isolation whilst craving social contact
111
What are the clinical features of dependent personality disorder?
Requires assurance from others
Lack of initiative
Efforts to gain support for others
Unrealistic feelings that they cannot care for themselves
Unrealistic fears of being left to care for themselves
112
When is a phimosis considered treatable?
2 years old
113
Give 3 RFs for Vulval carcinoma.
HPV
Immunosuppression
Lichen sclerosus
VIN
114
A 27-year-old woman presents to her general practitioner with a one month history of abdominal pain, bloody diarrhoea and weight loss. She is referred for colonoscopy and biopsy which shows a continuous area on inflammation confined to the mucosa and the presence of crypt abscesses.
Given her likely diagnosis, which of the following antibodies is most specific?
This lady has UC
pANCA may be raised in UC, but not in CD
115
A 65-year-old man is seen in the rheumatology clinic following an acute monoarthropathy that affected the metatarsophalangeal joint of his left big toe. Analysis of synovial fluid aspirated from the joint showed the presence of negatively birefringent crystals under polarised light. Following acute treatment to settle the inflammation, the rheumatologist decides to initiate prophylactic treatment with allopurinol to prevent recurrence.
What is the most appropriate medication to initiate alongside allopurinol?
Colchicine / NSAID cover for up to 6/12
116
Which of the following is not a poor prognostic marker for ALL?
A. Age <2 years
B. WBC >20 x 10^9/L at diagnosis
C. T or B cell surface markers
D. Female sex
D - Male sex is a poor prognostic marker
117
A 32-year-old sewage worker presents with a 3 days history of lower back pain, fever, myalgia, fatigue, jaundice and a subconjunctival haemorrhage. He has no past medical history and has not been abroad in the last 6 months.
Na+ 136 mmol/l
K+ 5.2 mmol/l
Urea 10 mmol/l
Creatinine 180 µmol/l
What is the most likely diagnosis?
Leptospirosis
118
What distinguishes labyrinthitis from vestibular neuritis?
Hearing - in vestibular neuronitis the patient may have a preceding URTI but no hearing changes
119
If the D-dimer is positive but nothing is found on US, what should be done?
Stop the DOAC and repeat US in 1 week
120
How is a Jarisch-Herxheimer reaction different to anaphylaxis?
Fever, rash, tachycardia following ABX due to endotoxin release following bacterial death
However, no wheeze or hypotension
121
What are cannonball metastases secondary to?
Renal cell cancer
122
In a premature baby, how do you calculate the corrected age for which a development milestone should be reached?
The corrected age of a premature baby is the age minus the number of weeks he/she was born early from 40 weeks
123
Which intracranial venous thrombosis is characterised by an empty delta sign seen on venography?
Sagittal sinus thrombosis
124
What are the clinical features of normal pressure hydrocephalus?
Dementia
Ataxia
Urinary incontinence
125
What are the complications of M pneumoniae infection?
Cold agglutins (IgM): haemolytic anaemia/thrombocytopenia
Erythema multiforme
Erythema nodosum
Neurological diseases: meningoencephalitis; GBS
Bullous myringitis
Hepatitis
Pancreatitis
Acute glomerulonephritis
126
What is the recommended dose of adrenaline in ALS in a patient with an arrest?
1mL of 1:1000 IV Adrenaline
127
What are the features of life-threatening asthma?
PEFR <33%
Normal pCO2
Silent chest
Cyanosis
Bradycardia/Hypotension
Exhaustion, confusion, coma
128
What are the causes of increased nuchal translucency?
Down's syndrome
CHD
Abdominal wall defects
129
A 52-year-old Nigerian woman presents with a 3 month history of menorrhagia and pelvic pain. On examination there is a palpable, firm, non-tender abdominal mass arising from the pelvis. Pelvic ultrasound confirms the presence of a large uterine fibroid. A decision is taken to perform a hysterectomy. Which medication would be most appropriate in preparation for her surgery?
GnRH agonist e.g. Leuprolide as it will shrink the size of the fibroid
130
what are the clinical features of sick euthyroid syndrome?
Following recent infection in vulnerable e.g. elderly
TSH is low/normal but T3/T4 low
Usually requires no treatment
131
What is the pterion?
Joining of the temporal, parietal frontal and sphenoid bones
132
A 13-year-old girl is brought by her mother for a widespread skin eruption. She began itching 2 days ago and has since developed fevers and a skin rash. On examination, there are various stages of lesions including macules, papules, crusted lesions, and vesicles which cover a majority of her body. Her mother has been giving her ibuprofen for the fever and discomfort.
Given the likely diagnosis, why would ibuprofen not be recommended in this scenario?
Risk of necrotising fasciitis
133
What are the dermatological features of Pernicious Anaemia?
Jaundice = 'lemon tinge'
134
What is the threshold to mange subclinical hypothyroidism?
If TSH >10 = treat
If TSH 4-10 = watch and wait
Mnemonic: Ten is treat in hypoT
135
How is maintenance fluid calculated in children?
Calculated serially by weight
100mL/kg for first 10kg
50mL/kg for next 10kg
20mL/kg for every other kg
136
Which medications may decrease the quantity of a drug as they are enzyme inducers?
```
Carbamazepine
Phenytoin
Phenobarbitone
Rifampicin
St Johns Wart
Chronic alcohol intake
Griseofulvin
Smoking
```
137
Which medications may increase the quantity of a drug as they are enzyme inhibitors?
```
Ciprofloxacin
Erythromycin
Isoniazid
Cimetidine
Omeprazole
Amiodarone
Allopurinol
Ketoconazole
Fluconazole
SSRs
Sodium valproate
Acute alcohol intake
Quinupristin
```
138
A 72-year-old lady with metastatic gastric adenocarcinoma presented with recurrent vomiting and abdominal pain. On examination, she was found to have a painful palpable umbilical node. This metastatic nodule representing advanced malignancy is eponymously referred to as?
Sister Mary Joseph's Node
Palpable nodule in umbilicus due to metastasis of malignant cancer within pelvis or abdomen
139
What is the most common infective exacerbation of COPD?
H influenza
140
When should you initiate treatment for hyperkalaemia?
Severe thus >6.5mmol/L requires IV Calcium Gluconate and Insulin/Dextrose infusion
141
How are thromboses haemorrhoids managed?
Within 3 days = excision
Outwith 3 days = supportive measures
142
What are the features of an Argyll-Robertson Pupil?
Mnemonic: ARP, PRA
Accommodation reflex present; Pupil reflex absent
143
In which conditions may you see an Argyll-Robertson pupil?
Diabetes Mellitus
Syphilis
144
What are the clinical features of a Holmes-Adie pupil?
Dilated pupil
Slow reactive to accommodation
Association with ankle/knee reflex absence in Holmes-Adie Syndrome
145
Outline the key differences between Legionella pneumonia and Mycoplasma pneumonia.
```
Both:
Atypical pneumonia
Flu-like symptoms
Dry cough
LFT deranged
```
Rx with macrolide
Legionella:
Lymphopenia
Hyponatremia
Ix Urinary Antigen
```
Mycoplasma:
Haemolytic anaemia/ITP
Erythema multiforme
Encephalitis
Myocarditis
```
Ix Serology
146
What are the clinical features of Dengue fever?
```
Fever
Retro-orbital headache
Facial flushing
Rash
Thrombocytopenia
```
147
What are the clinical features of Klebsiella pneumonia?
Prevalence in Diabetics and Alcoholics
Occurs following aspiration
Red currnant jelly
Affects upper lobes
148
A 7 year-old boy from Sierra Leone presents with a 1 week history of painful left arm. He is homozygous for sickle cell disease. On examination the child is pyrexial at 40.2ºC and there is bony tenderness over the left humeral shaft. Investigations are:
Hb = 7.1 g/dL
Blood culture = Gram negative rods
X-ray left humerus: Osteomyelitis - destruction of bony cortex with periosteal reaction.
What is the most likely responsible pathogen?
Non-typhi Salmonella
149
Tell me everything you know about malignant hyperthermia
Chromosome 19, gene encoding RyR which controls Ca++ release from SR
Susceptibility following anaesthetic
Hyperthermia
Hypertonicity
Ix shows CK raised
Tx Dantrolene
150
What are the clinical features of Osler nodes?
Tender
Purple papules
Pale centre
Result of immune complex deposition
151
Give examples of live vaccines.
```
Rotavirus
MMR
Influenza
Oral polio
Yellow fever
BCG
```
152
Which vaccines are derived from inactivated toxins?
DTP
153
What are the clinical features of Behcets Syndrome?
```
Ulceration: Oral + Genital
Anterior uveitis
DVT
Arthritis
Neurological involvement
GI: Abdo pain, diarrhoea, colitis
Erythema nodosum
```
154
Which drugs may exacerbate digoxin toxicity?
```
Amiodarone
Verapamil/Diltiazem
Quinidine
Spironolactone
Diuretics
Ciclosporin
```
Note: Heart meds; Kidney meds
155
What is contrast media nephropathy?
What can be done to limit this?
25% increase in sCr within 5 days of IV contrast
Give IV NaCl 0.9% at 1mL/kg/hour
156
Describe ischaemic hepatitis.
Diffuse hepatic injury from acute hypoperfusion following an inciting event e.g. cardiac arrest
Ix shows raise ALT
AKI may be shown
157
What are the clinical features of antisynthetase syndrome?
Myositis
ILD
Mechanic's hands
Raynaud's
This is Abs to anti-Jo1 but also affects other anti-synthetases
158
In a DEXA score, how do the z and T scores differ?
Z score adjusted for age, gender and ethnicity
T score cf to healthy 30 year old
159
Why do Azathioprine and allopurinol interact to cause bone marrow suppression?
Allopurine is a XOi thus results in elevated 6-mercaptopurine which is incorporated in the DNA in bone marrow precursors which reduces platelet cell lines and RBC/WBC line productions
160
Which is the most likely pathogen to cause osteomyelitis in a Sickle Cell disease patient?
S enteritidis
161
What are Kanavel's signs of flexor tendon sheath infection?
Fixed flexion
Painful passive extension
Fusiform swelling
162
What scoring test can be used to assess hypermobility?
Beighton score
Used to assess for Ehler-Danlos Syndrome
163
Which malignancies is dermatomyositis associated with?
Ovarian
Breast
Lung
164
Which antibodies are most associated with drug-induced lupus?
Antihistone antibodies
165
What are the clinical features of Hand, Foot and Mouth disease?
Mnemonic: CRASH and burn
```
Conjunctivitis
Rash
Adenopathy
Strawberry tongue
Hand swelling
```
Burn: fever > 5 days and high
166
What is the management of Kawasaki disease?
Aspirin + IVIG
167
What are the complications of Kawasaki disease?
Coronary artery aneurysm
168
What are 'innocent murmurs'?
These are murmurs heard in children which are benign, with no worrisome pathology
Venous Hum = turbulent flow in vein with blowing noise at the infraclavicular region
Still's murmur = low-pitched sound heard at left sternal edge
Mnemonic: Still = sternal edge
169
What are the clinical features of an innocent murmur?
```
Soft blowing noise
Asymptomatic
Varies with position
No added sounds
No thrill
No heave
No other abnormalities
```
170
How does the management of sepsis in a child <3 months differ to a standard sepsis case?
Use IV Amoxicillin in conjunction to IV Cephalosporin
171
What are the clinical features of Fragile X Syndrome?
Mnemonic: Nothing but an L
```
Low set ears
Long thin face
Large head
Learning difficulties
Low tone
Low mitral valve (mitral valve prolapse)
```
172
What are the causes of cerebral palsy?
Congenital infection
Cerebral malformation
Asphyxia
Trauma
Intraventricular haemorrhage
Meningitis
Head-trauma
173
What is the MOA of Baclofen?
GABA agonist, therefore encourages relaxation of skeletal muscle
174
What is the criterion for pauciarticular JIA?
What Abs may be present in JIA?
<4 joints
ANA in an under 16
175
What pathogen causes roseola infantum?
HHV-6
176
In what condition would you see Nagayama spots?
Describe these.
Roseola infantolum
Papular enanthem (eruption of mucous membrane) on the uvula and soft palate
177
If a patient with Addison's disease falls ill, what should their medications be?
Double the corticosteroids
Keep mineralocorticoids the same
178
What are the side effects of Thiazolidinediones?
Mnemonic: ELBOW
```
Elevated Liver enzymes
Liquid retained
Bladder cancer
Osteoporosis
Weight gain
```
179
What are the clinical features of Noonan Syndrome?
Webbed neck
Pes excavatum
Short
Pulmonary stenosis
180
What are the clinical features of Pierre-Robin syndrome?
Micrognathia
Posterior displacement of tongue
Cleft palate
181
What are the clinical features of PWS?
Hypogonadism
Obese
Hypotonia
182
What are the clinical features of Patau syndrome?
Microcephaly
Cleft palate
Polydactyly
Scalp lesions
183
What are the clinical features of Edward's syndrome?
Micrognathia
Low-set ears
Rocker bottom feet
Overlapping fingers
184
What are the clinical features of Fragile X syndrome?
```
Learning difficulties
Macrocephaly
Long face
Large ears
Macro-orchidism
```
185
What are the clinical features of William's syndrome?
Short stature
Learning difficulties
Friendly/extroverted
Supravalvular aortic stenosis
186
What are the clinical conditions in MEN 1?
3 Ps
Pituitary
Pancreatic
Parathyroid
187
What are the clinical features of MEN Type 2a?
Parathyroid
| Phaeochromocytoma
188
What are the clinical features of MEN Type 2b?
Phaeochromocytoma
Marfanoid body habitus (Marfinoid body)
Neuroma
189
What are the types of shock?
Septic: SIRS + hypotension
Hypovolaemic: Loss of fluid e.g. haemorrhage
Cardiogenic: Reduced CO following cardiac compromise
Neurogenic: SCI causing PSNS > SNS thus reduced TPR with reduced blood pressure
Anaphylactic: trigger results in vasodilation following mast cell and IgE and histamine release with vasodilation and third compartment losses
190
What is the Cushing's triad?
Raided ICP causing hypertension, bradycardia and irregular respiration
191
What common examination findings may suggest Downs Syndrome in a neonate?
Floppy
Poor feed
Epicanthic fold
Sandlewedge gap
Single palmar crease
Brushfield spots of the iris
192
Outline the VTE prophylaxis in a pregnant woman.
Two forms exist: Mechanical or Pharmacological
Assess at antenatal assessment into high risk, intermediate risk or low risk
3 or more low RFs or 1 high risk = LMWH
```
Low risk:
BMI >30
Age > 35 years
Smoker
Immobility
Pre-eclampsia
Parity > 3
Dehydration
Multiple pregnancy/ART
```
Postnatal RFs (different to above): Operation/AVD/PPH >1L
If a suspicion of VTE or diagnosis of VTE - Treat with LMWH
193
State 5 causes of a low GCS.
```
Trauma
SOL
Infection
Lupus
Toxicity
Stroke
Seizure
Hypoxia
Haemorrhage
```
194
What is Boas sign?
Tender on palpation of R inferior angle of scapula due to cholecystitis
195
A patient's bloods show:
HbsAg - negative
anti-HBc - negative
anti-HBs - negative
IgM anti-HBc - negative
What is their hepatitis B status?
A. Natural immunity
B. Susceptible
C. Acute infection
D. Immune due to vaccination
E. Chronically infected
B
Absence of any Abs
196
A patient's bloods show:
HbsAg - negative
anti-HBc - positive
anti-HBs - positive
IgM anti-HBc - negative
What is their hepatitis B status?
A. Natural immunity
B. Susceptible
C. Acute infection
D. Immune due to vaccination
E. Chronically infected
A
197
A patient's bloods show:
HbsAg - negative
anti-HBc - negative
anti-HBs - positive
IgM anti-HBc - negative
What is their hepatitis B status?
A. Natural immunity
B. Susceptible
C. Acute infection
D. Immune due to vaccination
E. Chronically infected
D
198
A patient's bloods show:
HbsAg - positive
anti-HBc - positive
anti-HBs - negative
IgM anti-HBc - positive
What is their hepatitis B status?
A. Natural immunity
B. Susceptible
C. Acute infection
D. Immune due to vaccination
E. Chronically infected
C
199
A patient's bloods show:
HbsAg - positive
anti-HBc - positive
anti-HBs - negative
IgM anti-HBc - negative
What is their hepatitis B status?
A. Natural immunity
B. Susceptible
C. Acute infection
D. Immune due to vaccination
E. Chronically infected
E
200
What is the definition of priapism?
>4 hours of an erection not associated with sexual stimulation
201
Give 5 causes of priapism.
Idiopathic
Hb-opathy
Anticoagulants; blue pills; ecstasy; sildenafil
Trauma
202
What are the features of Still's disease?
```
Arthralgia
Maculopapular salmon pink rash
Pyrexia
Lymphadenopathy
RF
```
Elevated serum ferritin
203
How is the anion gap calculated?
all cations - all anions
(Na+ + K+) - (Cl- + HCO3-)
Should be between 8-14mmol/L
204
Give the causes of a normal anion gap.
This would be anything which does not increase anions...
Renal tubular acidosis
Acetazolamide
Addison's disease
GI bicarb loss - diarrhoea
205
Give the causes of a raised anion gap metabolic acidosis.
Mnemonic: MUD PILES
Methanol
Uraemia
DKA
```
Paraldehyde
Isoniazid/Iron
Lactic acid
Ethylene Glycol
Salicylate
```
206
Which of the following is an intravenous anaesthetic?
A. Isoflurane
B. Desflurane
C. Propofol
D. NO
Propofol
207
What is the MOA of Propofol?
Potentiates GABAa
208
Why does propofol cause pain on injection?
Activation of a pain receptor TRPA1
209
How does desflurane work?
Unsure - speculated to be GABAa, glycine and NMDA receptors
210
What are the side effects of isoflurane?
Myocardial depression
| Malignant hyperthermia
211
What are the potential side effects of NO?
Diffuse into other gas occupied compartments causing increased pressure - avoid in pneumothorax
212
When might you consider avoiding NO in a patient?
If gas disequilibrium in other compartments such as Pneumothorax
213
Which of the following IV anaesthetics works by blocking NMDA receptors?
A. Propofol
B. Thiopental
C. Etomidate
D. Ketamine
D - blocks NMDA receptors
214
Which of the following IV anaesthetics may cause Laryngospasm?
A. Propofol
B. Thiopental
C. Etomidate
D. Ketamine
B - Thiopental = throat
215
Which of the following IV anaesthetics would be most useful in trauma?
A. Propofol
B. Thiopental
C. Etomidate
D. Ketamine
D - Ketamine
No BP drop caused and acts as a dissociative anaesthetic
216
Which of the following drugs has anti-emetic effects?
A. Propofol
B. Thiopental
C. Etomidate
D. Ketamine
A. Propofol
Pain and Prevent sickness
217
How is pleural aspiration conducted?
21G needle and 50mL syringe
Fluid sent for: pH, lactate, protein and microbiology
Evaluate using Light's criteria
218
Outline Light's Criteria.
Always focus on the pleural fluid
If pleural protein between 25-35g/L... one of the following qualifies for exudative
Protein: Pleural / serum = >0.5
LDH: Pleural / serum = >0.6
LDH: 1.66x upper limit of serum LDH
219
In what condition might you see cannonball metastases?
Renal cell carcinoma
| Prostate cancer
220
How should you manage wound dehiscence?
```
Cover with gauze
IV ABX
IV Fluids
Analgesia
Arrange to go to surgery
```
221
What imaging should you request if suspicious of a SAH?
CT non-contrast
Blood is radio-opaque thus contrast not required
222
How do you manage severe colitis in UC?
IV Corticosteroids
223
What are the clinical features of early vs late shock?
```
Early shock:
Normotensive
Tachycardia
Tachypnoea
Oliguria
Mottled/pale
```
```
Late shock:
Hypotensive
Tachycardia
Kussmaul breathing
Anuria
Blue
```
224
What is the INR if in AF?
2.5
225
What is the target INR in VTE?
2. 5 prevention
| 3. 5 recurrent §
226
Which diuretics may cause hypercalcemia and hypocalcuria?
Thiazide diuretics
227
Outline the Levine scale for a heart murmur.
Grade 1 - Very faint murmur, frequently overlooked
Grade 2 - Slight murmur
Grade 3 - Moderate murmur without palpable thrill
Grade 4 - Loud murmur with palpable thrill
Grade 5 - Very loud murmur with extremely palpable thrill. Can be heard with stethoscope edge
Grade 6 - Extremely loud murmur - can be heard without stethoscope touching the chest wall
228
What are the features of life-threatening asthma?
```
Confusion
Sats <92%
Normal pCO2 (4.6-6kPa)
Silent chest
Bradycardia, hypotension
```
229
What are the cardiac complications of Carcinoid syndrome?
Mnemonic: TIPS
Tricuspid insufficiency
Pulmonary stenosis
230
How may Hypothyroidism cause hyponatraemia?
Reduced CO causes reduced BP thus baroreceptors trigger increased ADH resulting in SIADH and euvolaemic hyponatraemia
231
What is the name of the sign when the anterior chest wall demonstrates surgical emphysema, outlining the pec major muscle?
Gingkgo leaf sign
232
What is the drug of choice for reversing respiratory depression caused by magnesium sulphate?
Calcium gluconate
233
State 3 p450 enzyme inducers.
Mnemonic: R ABCDS
```
Rifampicin
Anti-epileptics: Carbamazepine, Phenytoin
Barbiturates
Chronic alcohol use
Demon chaser (St Johns Wart)
Smoking
```
234
When should you consider a liver transplant in a paracetamol OD?
pH <7.3 24 hours post-OD
or ALL of these:
PT >100
sCr > 300
Grade 3/4 hepatic encephalopathy
235
What is the treatment for Non-Falciparum Malaria?
P vivax malaria treat with ACT or Chloroquine THEN Primaquine
236
Which cause of gastroenteritis features a short onset and vomiting?
S aureus
237
With a QRISK of 11% and cholesterol levels of 5.1, what is your management?
Need primary prevention dose of Atorvastatin 20mg
238
What investigations are required to diagnose postpartum thyroiditis?
TFTs alone
239
What may precipitate digoxin toxicity?
```
Renal failure
Hypokalemia
Hypoalbuminaemia
Hypothermia
Hypothyroidism
Drugs: TZDs; Loop diuretics; Spironolactone; Ciclosporin; Amiodarone; CCBs
```
240
What is Corrigan's sign?
Rapid upstroke and collapse of carotid pulse, seen in Aortic Regurgitation
241
Which valve is commonly affected in IVDUs?
Tricuspid valve
242
What is the most common cause of exudative pleural effusion?
Pneumonia
243
Give 5 causes of low SAAG.
```
Hypoalbuminaemia
Malignancy
Infection
Pancreatitisis
Bowel obstruction
Biliary ascites
Postoperative lymphatic leak
Serositis in connective tissue diseases
```
244
What are the clinical features of Ebola?
Fever, Fatigue, Myalgia, Headache, Rash, Sore throat
Liver failure
Kidney failure
Haemorrhagic (potentially)
Infectious once symptomatic
2-21 day incubation
245
How is diabetic retinopathy classified?
```
Background (HOME):
Haemorrhages
Oedema
Microaneurysms
Exudate
```
Pre-proliferative:
Cotton wool spots
Venous abnormalities
Proliferative:
New vessel growth on retina, optic disc, iris
246
What is the classification of Hypertensive Retinopathy?
Keith-Wagener-Barker classification
Grade I: Arteriolar nipping
Grade II: AV nipping
Grade III: Flame haemorrhages
Grade IV: Optic disc swelling and macular oedema
247
What is the difference between phacoemulsification and extracapsular lens extraction?
Phacoemulsification divides cataract into portions by US cutter and removes diseased lens with intraocular lens implanted in.
Extracapsular extraction involves a large corneal incision, lens removed in one piece and the wound is stitched into the eye
248
Give 3 causes of a Third Nerve Palsy.
```
Raised ICP
Vasculitis
Demyelination
Diabetes
Dyslipidaemia
Hypertension
Smoking
```
249
What do you see in a Third Nerve palsy?
Why do you see this?
Eye is down and out and ptotic
Weakened elevation (superior rectus and inferior oblique)
WITH
unopposed abduction of lateral recuts and superior oblique
The eye is ptotic as the CN III innervates levator palpebrae superioris which elevates the eyelid.
250
What is Uhthoff's phenomenon?
Worsening of vision following rise in body temperature in MS
251
How would you explore the treatment options in a Cancer patient, broadly-speaking?
Look at intention - is it curative or palliative?
Look at the modes of treatment:
Radio/Chemo
Medical
Surgery
Discuss this at the MDT depending on factors such as age, co-morbidities, functionality, patient wishes.
252
What is the MOA of a DNA alkylating agent? Give an example.
Forms a DNA cross-link between DNA base pairs thus prevents mitosis
Platinum-based drugs
Busulfan
253
What is the MOA of antimetabolites?
Give an example.
Inhibits RNA/DNA synthesis thus stops formation of nucleic acids
Fluorouracil
Methotrexate
254
What is the MOA of plant-derived chemotherapeutics?
Inhibit microtubule formation by binding to tubulin
Vincristine
Vinblastine
255
What is the MOA of anti-tumour antibiotics?
Intercalates between DNA base pairs thus DNA damage
Bleomycin
Doxorubicin
Epirubicin
256
Why are bloods monitored prior to and during Radiotherapy?
Keep Hb >100g/L as Oxygen-dependent process which DNA damage generates toxic free radicals.
O2 is determining factor in cell killing
257
Give 5 complications of radiotherapy.
```
Alopecia
Mucositis
Telangiectasia
Skin rash
N/V
Diarrhoea
Strictures
Secondary cancer
Immunosuppression
```
258
Why is there a link between Acromegaly and Colon cancer?
GH released binds to liver to produce IGF-1 which can bind to IGF-R or IR on colonic tissue with downstream signalling to increase CRC risk
259
What is the first-line antidepressant in a post-MI patient?
Sertraline
260
What are the causes of Erythema Nodosum?
Mnemonic: NODOSUM
```
NO (idiopathic)
Drugs (sulphonamides; penicillin)
OCP
Sarcoidosis/TB
Ulcerative colitis/CD
Microbiology (Strep/EBV/Mycoplasma)
```
261
What are the additional consequences of Ankylosing Spondylitis?
```
Amyloidosis and acute cauda equina
Anterior uveitis
AV node block
Aortic regurgitation
Achilles tendonitis
Arthritis (peripheral)
```
262
Following confirmation of S Bovis infection, what investigation/screening should occur? Explain why.
S Boris increases risk of colonic metaplasia thus colonoscopy advised
263
Give 10 causes of endocarditis.
S viridans
S aureus
S epidermidis
C burnetti
HACEK bacteria
Chlamydia
Candida
SLE (Libman-Sacks endocarditis)
Malignancy
264
Why do statins and clarithromycin react?
Clarithromycin Is an enzyme inhibitor of P450 enzymes thus increased levels of atorvastatin and reduced metabolism. Leads to increased chance of rhabdomyolysis. Risk is increased if CKD
265
What are the contraindications to statins?
Macrolides
Pregnancy
266
What are the indications for primary prevention dose of statins?
Atorvastatin 20mg
10 year risk >10%
eGFR <60ml/min/m2
DM
267
Which of the following is a P450 enzyme inducer?
A. Isoniazid
B. Sertraline
C. Acute alcohol
D. Chronic alcohol
D
268
Which of the following is a P450 enzyme inducer?
A. Isoniazid
B. Sertraline
C. Acute alcohol
D. Amiodarone
D
269
Which of the following is a P450 enzyme inducer?
A. Isoniazid
B. Sertraline
C. Rifampicin
D. Acute alcohol
C
270
Which of the following is an enzyme inhibitor?
A. St Johns Wort
B. Carbamazepine
C. Sodium valproate
D. Phenytoin
C
271
Which of the following is an enzyme inhibitor?
A. St Johns Wort
B. Carbamazepine
C. Ritonavir
D. Phenytoin
C
272
Which of the following is an enzyme inhibitor?
A. St Johns Wort
B. Carbamazepine
C. Omeprazole
D. Phenytoin
C
273
What is Trade's sign?
Pistol shot femoral pulses in Aortic regurgitation
274
What is Quincke's sign?
Capillary pulses in the nailbed
275
What murmur is heard in Aortic Regurgitation?
Austin-Flint murmur (mid-diastolic murmur at the apex)
276
Give 5 causes of clubbing
Cyanotic heart disease
Bacterial endocarditis
Atrial myxoma
Lung Ca
Pyogenic conditions
Asbesosis/Mesothelioma
Alveolitis
CD
Cirrhosis; PBC
Grave's disease
Whipple's disease
277
What type of chemotherapy is Cyclophosphamide?
A. Alkylating agent
B. Cytotoxic antibiotic
C. Antimetabolite
D. Acts on Mt
A
278
What type of chemotherapy is Bleomycin?
A. Alkylating agent
B. Cytotoxic antibiotic
C. Antimetabolite
D. Acts on Mt
B
279
What type of chemotherapy is Doxorubicin?
A. Alkylating agent
B. Cytotoxic antibiotic
C. Antimetabolite
D. Acts on Mt
B
280
What type of chemotherapy is Fluorouracil?
A. Alkylating agent
B. Cytotoxic antibiotic
C. Antimetabolite
D. Acts on Mt
C
281
What type of chemotherapy is Vincristine?
A. Alkylating agent
B. Cytotoxic antibiotic
C. Antimetabolite
D. Acts on Mt
D
282
What type of chemotherapy is Methotrexate?
A. Alkylating agent
B. Cytotoxic antibiotic
C. Antimetabolite
D. Acts on Mt
C
283
What investigation should be undertaken prior to Hydroxychloroquine?
Eye test - can cause retinal damage
284
What are the risk factors for SIDS?
```
Sleep in same bed
Smoking
Prone sleeping
Hyperthermia and head covering
Prematurity
```
285
What are the potential side effects of Loop diuretics?
```
Headaches
Postural hypotension
Hypocalcaemia
Metabolic alkalosis
Hypokalaemia
```
Ototoxicity
Gout
ATN
285
What are the potential side effects of Loop diuretics?
```
Headaches
Postural hypotension
Hypocalcaemia
Metabolic alkalosis
Hypokalaemia
```
Ototoxicity
Gout
ATN
286
Successful treatment with BenPen for Syphilis would be shown as?
Positive treponema test
Negative non-treponema test
Note: Non-treponemal test detects biomarkers released in cellular damage thus should be negative when no longer present
287
What is the gold standard for diagnosing schistosomiasis?
Stool and urine microscopy
287
What is the gold standard for diagnosing schistosomiasis?
Stool and urine microscopy
288
Name 3 medications which give erectile dysfunction
Beta blockers
| SSRIs
289
What is the main difference between investigations to diagnose asthma in children vs adults?
In those under 17:
BPT
Spirometry
In those above 18:
BPT
Spirometry
FeNO test
290
A 73-year-old woman is admitted to hospital. After being treated with a broad-spectrum antibiotic for sepsis secondary to a lower respiratory tract infection. After a period of improvement, the patient deteriorates and is discovered to have an MRSA bacteraemia. The patient is documented as having previously had an allergic reaction to vancomycin. With which antibiotic would it be appropriate to treat the patient?
Linezolid
291
A 67-year-old diabetic patient has been on a surgical ward for one week, for treatment of a necrotic toe. His current medications include metformin and gliclazide. Since admission, he has received paracetamol, morphine, and daily enoxaparin.
His initial bloods showed:
K+ 4.0 mmol/L (3.5 - 5.0)
One week later, his blood results showed:
K+ 5.4 mmol/L (3.5 - 5.0)
Which medication is most likely to have caused the rise in serum potassium?
LMWH can cause hyperkalaemia
292
Which medications may worsen Myasthenia Gravis?
```
Beta blockers
ABX
Penicillamine
Procainamide
Phenytoin
```
293
Why are Loop diuretics not first choice in the management of secondary ascites in liver cirrhosis?
Furosemide causes hypokalaemia and alkalosis which promotes formation of NH3+ compounds which may precipitate a hepatic encephalopathy.
Spironolactone is the first line
294
What is the most likely pathogen to cause Infective Endocarditis in a patient 3 months post-operation?
S aureus
295
What is the most common cause of infective endocarditis within the first 2 weeks of a valve replacement?
S epidermidis
296
Give 5 causes of ST elevation.
```
Normal variation (take-off)
Printzmetals angina
Pericarditis
Myocarditis
LV aneurysm
Takutsubo's
SAH
```
297
What is the upper limit of LFT derangement permissible when starting Statins?
Allowed x3 of the derangement
298
When should you notify the consultant for communicable disease upon a meningococcal septicaemia patient?
Clinical suspicion
299
Calculate the osmolarity of blood.
2Na + 2K+ + Glucose + Urea
300
When should you refer a patient with varicose veins to a vascular surgeon?
Symptoms
Skin changes
Superficial venous thrombosis
Ulceration
301
Following a sickle cell crisis, how long should a patient wait to travel?
10 days
302
What are the 3 Ps of Vasovagal syncope?
Posture (upright)
Provocation (warm/cold/stress etc)
Prodromal symptoms (dizziness)
303
Which cancers are BRCA1 and BRCA2 associated with?
Breast
Ovarian
Prostate
Pancreas
Melanoma
304
Where do the majority of gastric cancers arise from?
Cardia
305
What is Lemierre's syndrome?
Thrombophlebitis of IJV secondary to anaerobic oropharyngeal infection.
Spread via carotid sheath which contains the IJV; thrombus of septic emboli forms
306
Give 5 examples when a chest drain should be done immediately.
Pneumothorax of >2cm in 50 y/o + COPD or other secondary cause
Failed aspiration in pneumothorax
```
Pleural fluid pH <7.2
Pleural fluid glucose <2.2mmol/L
LDH >1000 IU/L
Positive gram culture
Empyema (gross pus upon pleural aspirate)
```
307
Give 3 examples of pulmonary fibrosis of the upper zones.
Mnemonic: CHARTS
```
Coal miner's lung
Hypersensitivity pneumonitis/Histiocytosis
AS
Radiation
TB
Sarcoidosis/Silicosis
```
308
What might cause fibrosis of the lower zones?
Drugs: Amiodarone/Nitrofurantoin/Bleomycin/Cyclophosphomide/Methotrexate
Systemic disorders: Wegener's/Churg-Strauss
CT disorders: SLE/RA/Sjogrens/ Scleroderma/ Polymyositis
EEA
Radiotherapy
309
Give 3 types of extrinsic allergic alveolitis.
Farmer's lung (Thermoactinomyces)
Mushroom worker's lung (Thermoactinomyces)
Malt worker's lung (A clavatus)
Wine maker's lung (Botrytis)
310
List 3 complications of liver cirrhosis.
Malnutrition: Catabolic state/Reduced glycogenolysis/IGT/Increased gluconeogenesis
Vitamin deficiencies: B vitamins
Coagulopathy
Impaired immune system
Varices (portal hypertension >12mmHg)
Oedema/Ascites
Hepatic encephalopathy
Hepatorenal syndrome (hepatic failure results in vasoactive splanchnic mediators which drops systemic vascular resistance causing renal failure)
311
Why does ascites occur in liver cirrhosis?
Shrunken, cirrhotic liver results in portal hypertension with reduced protein production thus hypoalbuminaemia.
Hypoalbuminaemia with portal hypertension results in increased capillary permeability with transudate into peritoneal cavity resulting in abdominal distension and peripheral oedema.
312
Give 5 causes of hepatic failure.
```
Alcoholic
Infective (viral, bacteria, parasitic)
Drugs
Toxins
Ischaemic
Pregnancy
Infiltration (PCKD/VHL/Haemochromatosis/Wilson's disease)
```
313
Which drugs may be used in neuropathic pain?
Amitryptiline
Duloxetine
Gabapentin/Pregabalin
314
Which viruses are associated with Polyarteritis nodosa?
HBV
Hep C
CMV
HIV
315
What type of ovarian cancer may cause thyrotoxicosis?
Struma ovarii
