Monday [11/10/2021]

Question 1

What is a FAST scan used for? [1]

Answer 1

To investigate the presence of free fluid

Question 2

What is the trimodal death distribution? []3

Answer 2

Following trauma there is a trimodal death distribution:
Immediately following injury. Typically as result of brain or high spinal injuries, cardiac or great vessel damage. Salvage rate is low.
In early hours following injury. In this group deaths are due to phenomena such as splenic rupture, sub dural haematomas and haemopneumothoraces
In the days following injury. Usually due to sepsis or multi organ failure.

Question 3

Example thoracic injuries [4]

Answer 3

Simple pneumothorax
Mediastinal traversing wounds
Tracheobronchial tree injury
Haemothorax
Blunt cardiac injury
Diaphragmatic injury
Aortic disruption
Pulmonary contusion

Question 4

Mx of simple pneumothorax [2]

Answer 4

Simple pneumothorax insert chest drain. Aspiration is risky in trauma as pneumothorax may be from lung laceration and convert to tension pneumothorax.

Question 5

Mx of mediastinal traversing wounds [2]

Answer 5

These result from situations like stabbings. Exit and entry wounds in separate hemithoraces. The presence of a mediastinal haematoma indicates the likelihood of a great vessel injury. All patients should undergo CT angiogram and oesophageal contrast swallow. Indications for thoracotomy are largely related to blood loss and will be addressed below.

Question 6

Mx of tracheobronchial tree injuries [2]

Answer 6

Unusual injuries. In blunt trauma most injuries occur within 4cm of the carina. Features suggesting this injury include haemoptysis and surgical emphysema. These injuries have a very large air leak and may have tension pneumothorax.

Question 7

Mx of cardiac contusions

Answer 7

Usually caused by laceration of lung vessel or internal mammary artery by rib fracture. Patients should all have a wide bore 36F chest drain. Indications for thoracotomy include loss of more than 1.5L blood initially or ongoing losses of >200ml per hour for >2 hours.

Question 8

Mx of diaphragmatic injuries

Answer 8

Usually cardiac arrhythmias, often overlying sternal fracture. Perform echocardiography to exclude pericardial effusions and tamponade. Risk of arrhythmias falls after 24 hours.

Question 9

Mx of truamatic aortic disruptions

Answer 9

Commonest cause of death after RTA or falls. Usually incomplete laceration near ligamentum arteriosum. All survivors will have contained haematoma. Only 1-2% of patients with this injury will have a normal chest x-ray.

Question 10

Mx of pulmonary contusions

Answer 10

Common and lethal. Insidious onset. Early intubation and ventilation.

Question 11

Mx of diaphragmatic injuries [1]

Answer 11

Usually left sided. Direct surgical repair is performed.

Question 12

Which injuries are common in abdominla trauma? [1]

Answer 12

Deceleration injuries are common.

Question 13

How to manage abdominal trauma [5]

Answer 13

Deceleration injuries are common.
In blunt trauma requiring laparotomy the spleen is most commonly injured (40%)
Stab wounds traverse structures most commonly liver (40%)
Gunshot wounds have variable effects depending upon bullet type. Small bowel is most commonly injured (50%)
Patients with stab wounds and no peritoneal signs up to 25% will not enter the peritoneal cavity
Blood at urethral meatus suggests a urethral tear
High riding prostate on PR = urethral disruption
Mechanical testing for pelvic stability should only be performed once

Question 14

Advantage of a CT scan for abdiominla trauma

Answer 14

Most specific for localising injury; 92 to 98% accurate

Question 15

Disadvantage of CT abdomen for trauma

Answer 15

Location of scanner away from facilities, time taken for reporting, need for contrast

Question 16

Adv and dis for USS for abdominal trauma [2]

Answer 16

Early diagnosis, non invasive and repeatable; 86 to 95% accurate

Operator dependent and may miss retroperitoneal injury

Question 17

Se of digoxin [1]

Answer 17

Loss of appetite and anorexia

Question 18

What type of drug is digoxin? [2]

Answer 18

Digoxin is a cardiac glycoside now mainly used for rate control in the management of atrial fibrillation

Question 19

How does digoxin work? [2]

Answer 19

As it has positive inotropic properties it is sometimes used for improving symptoms (but not mortality) in patients with heart failure.

Question 20

MoA of digoxin [3]

Answer 20

decreases conduction through the atrioventricular node which slows the ventricular rate in atrial fibrillation and flutter
increases the force of cardiac muscle contraction due to inhibition of the Na+/K+ ATPase pump. Also stimulates vagus nerve
digoxin has a narrow therapeutic index

Question 21

Monitoring of digoxin [2]

Answer 21

digoxin level is not monitored routinely, except in suspected toxicity
if toxicity is suspected, digoxin concentrations should be measured within 8 to 12 hours of the last dose

Question 22

Features of digoxin toxicity [3]

Answer 22

generally unwell, lethargy, nausea & vomiting, anorexia, confusion, yellow-green vision
arrhythmias (e.g. AV block, bradycardia)
gynaecomastia

Question 23

Precipitating factors for digoxin toxicity [5]

Answer 23

classically: hypokalaemia
increasing age
renal failure
myocardial ischaemia
hypomagnesaemia, hypercalcaemia, hypernatraemia, acidosis
hypoalbuminaemia
hypothermia
hypothyroidism
drugs: amiodarone, quinidine, verapamil, diltiazem, spironolactone (competes for secretion in distal convoluted tubule therefore reduce excretion), ciclosporin. Also drugs which cause hypokalaemia e.g. thiazides and loop diuretics

Question 24

Mx of digoxin toxicity [3]

Answer 24

Digibind
correct arrhythmias
monitor potassium

Question 25

How does hypokalaemia cause digoxin toxicity? [2] -\> important

Answer 25

digoxin normally binds to the ATPase pump on the same site as potassium. Hypokalaemia → digoxin more easily bind to the ATPase pump → increased inhibitory effects

Question 26

can Digoxin toxicity occur within the therapeutic range? [2]

Answer 26

Toxicity may occur even when the concentration is within the therapeutic range. The BNF advises that the likelihood of toxicity increases progressively from 1.5 to 3 mcg/l.

Question 27

. A 72-year-old man presents with a large nodule on his face. It is friable. There is no regional lymphadenopathy. He is lost to follow up and re-attends several months later. On this occasion the lesion has been noted to resolve with scarring.

Answer 27

Keratoacanthoma71% Keratoacanthomas may reach a considerable size prior to sloughing off and scarring.

Question 28

2. A 22-year-old woman is troubled by intensely itchy crops of blisters on her arms and legs. On examination she is malnourished and she has papulovesicular eruptions over her elbows and knees.

Answer 28

Dermatitis herpetiformis79% Dermatitis herpetiformis is seen in association with coeliac disease.

Question 29

A 30-year-old man cuts the corner of his lip whilst shaving. Over the next few days a large purplish lesion appears at the site which bleeds on contact.

Answer 29

Pyogenic granuloma76% Pyogenic granulomas often appear at sites of trauma.

Question 30

Features of BCC [5]

Answer 30

Most common form of skin cancer. Commonly occur on sun exposed sites apart from the ear. Sub types include nodular, morphoeic, superficial and pigmented. Typically slow growing with low metastatic potential. Standard surgical excision, topical chemotherapy and radiotherapy are all successful. As a minimum a diagnostic punch biopsy should be taken if treatment other than standard surgical excision is planned.

Question 31

Features of SCC

Answer 31

Again related to sun exposure. May arise in pre - existing solar keratoses. May metastasize if left. Immunosupression (e.g. following transplant), increases risk. Wide local excision is the treatment of choice and where a diagnostic excision biopsy has demonstrated SCC, repeat surgery to gain adequate margins may be required.

Question 32

Main diagnostic criteria for malignant vs minor criteria for MM [4]

Answer 32

The main diagnostic features (major criteria): Change in size Change in shape Change in colour Secondary features (minor criteria) Diameter \>6mm Inflammation Oozing or bleeding Altered sensation

Question 33

Tx of malignant carcinomas [2]

Answer 33

Suspicious lesions should undergo excision biopsy. The lesion should be removed in completely as incision biopsy can make subsequent histopathological assessment difficult. Once the diagnosis is confirmed the pathology report should be reviewed to determine whether further re-excision of margins is required (see below):

Question 34

What is Kaposi Sarcoma? [4]

Answer 34

Tumour of vascular and lymphatic endothelium. Purple cutaneous nodules. Associated with immuno supression. Classical form affects elderly males and is slow growing. Immunosupression form is much more aggressive and tends to affect those with HIV related disease.

Question 35

Features of Dermatitis Herpetiformis

Answer 35

Chronic itchy clusters of blisters. Linked to underlying gluten enteropathy (coeliac disease).

Question 36

Features of dermatofibroma

Answer 36

Benign lesion. Firm elevated nodules. Usually history of trauma. Lesion consists of histiocytes, blood vessels and fibrotic changes

Question 37

Features of pyogenic granuloma

Answer 37

Overgrowth of blood vessels. Red nodules. Usually follow trauma. May mimic amelanotic melanoma

Question 38

Features of acanothsis nigricans

Answer 38

Brown to black, poorly defined, velvety hyperpigmentation of the skin. Usually found in body folds such as the posterior and lateral folds of the neck, the axilla, groin, umbilicus, forehead, and other areas. The most common cause of acanthosis nigricans is insulin resistance, which leads to increased circulating insulin levels. Insulin spillover into the skin results in its abnormal increase in growth (hyperplasia of the skin). In the context of a malignant disease, acanthosis nigricans is a paraneoplastic syndrome and is then commonly referred to as acanthosis nigricans maligna. Involvement of mucous membranes is rare and suggests a coexisting malignant conditio

Question 39

A 55-years-old man presents to the emergency department with severe epigastric pain and fever. He looks unkempt and affirms to be drinking 40 units of alcohol per week. He presented to the emergency department after suffering from the symptoms for two days, due to a phobia of hospitals. Given the most likely diagnosis, which of the following is the single best investigation to order?

Answer 39

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

Question 40

PP of acute pancreatitis [2]

Answer 40

- autodigestion of pancreatic tissue by the pancreatic enzymes, leading to necrosis

Question 41

Features of acute pancreatitis [4]

Answer 41

severe epigastric pain that may radiate through to the back vomiting is common examination may reveal epigastric tenderness, ileus and low-grade fever periumbilical discolouration (Cullen's sign) and flank discolouration (Grey-Turner's sign) is described but rare

Question 42

Ix for pancreatitis [6]

Answer 42

serum amylase - raised in 75% of patients - typically \> 3 times the upper limit of normal - levels do not correlate with disease severity - specificity for pancreatitis is around 90%. Other causes of raised amylase include: pancreatic pseudocyst, mesenteric infarct, perforated viscus, acute cholecystitis, diabetic ketoacidosis serum lipase - more sensitive and specific than serum amylase - it also has a longer half-life than amylase and may be useful for late presentations \> 24 hours imaging a diagnosis of acute pancreatits can be made without imaging if characteristic pain + amylase/lipase \> 3 times normal level however, early ultrasound imaging is important to assess the aetiology as this may affect management - e.g. patients with gallstones/biliary obstruction other options include contrast-enhanced CT

Question 43

When can diagnosis of acute pancreatitis be made w/o imaging? [2]

Answer 43

a diagnosis of acute pancreatits can be made without imaging if characteristic pain + amylase/lipase \> 3 times normal level

Question 44

Why is early USS important in a patient with acute pancreatitis? [2]

Answer 44

however, early ultrasound imaging is important to assess the aetiology as this may affect management - e.g. patients with gallstones/biliary obstruction

Question 45

Common factors indicating severe pancreatitis [5]

Answer 45

The specifics of each scoring system will not be repeated here. However, some common factors indicating severe pancreatitis include: age \> 55 years hypocalcaemia hyperglycaemia hypoxia neutrophilia elevated LDH and AST

Question 46

What are the hypersensitivty reaction types? [1]

Answer 46

Gell and Coombs classification

Question 47

T1 hypersensitivity reaction

Answer 47

Antigen reacts with IgE bound to mast cells Seen in: • Anaphylaxis • Atopy (e.g. asthma, eczema and hayfever)

Question 48

T2 hypersensitivity reaction

Answer 48

Cell bound: IgG or IgM binds to antigen on cell surface * Autoimmune haemolytic anaemia * ITP * Goodpasture's syndrome * Pernicious anaemia * Acute haemolytic transfusion reactions * Rheumatic fever * Pemphigus vulgaris / bullous pemphigoid

Question 49

T3 hypersensitivity reaction

Answer 49

Immune complex Free antigen and antibody (IgG, IgA) combine • Serum sickness * Systemic lupus erythematosus * Post-streptococcal glomerulonephritis * Extrinsic allergic alveolitis (especially acute phase)

Question 50

T4 hypersensitivity reaction

Answer 50

Delayed hypersensitivity T-cell mediated * Tuberculosis / tuberculin skin reaction * Graft versus host disease * Allergic contact dermatitis * Scabies * Extrinsic allergic alveolitis (especially chronic phase) * Multiple sclerosis * Guillain-Barre syndrome

Question 51

T5 hypersensitivity reaction

Answer 51

Antibodies that recognise and bind to the cell surface receptors. This either stimulating them or blocking ligand binding • Graves' disease • Myasthenia gravis

Question 52

A 27-year-old farmer has been brought to the emergency department after being found unconscious in a barn. On initial examination he is agitated and combative with hypersalivation with excessive production of respiratory secretions. There is evidence of diaphoresis, urinary and faecal incontinence and miosis along with muscle fasciculations. Given the likely diagnosis, which of the following are you most likely to find in the observations?

Answer 52

Organophosphate insecticide poisoning -\> bardycardia [along with other Sx in SLUD]

Question 53

What is organophosphate inseciticide poisoning? [2]

Answer 53

One of the effects of organophosphate poisoning is inhibition of acetylcholinesterase leading to upregulation of nicotinic and muscarinic cholinergic neurotransmission. In warfare, sarin gas is a highly toxic synthetic organophosphorus compound that has similar effects.

Question 54

Features of organophosphate insecticide poisoning [5]

Answer 54

Features can be predicted by the accumulation of acetylcholine (mnemonic = SLUD) Salivation Lacrimation Urination Defecation/diarrhoea cardiovascular: hypotension, bradycardia also: small pupils, muscle fasciculation

Question 55

Mx or organophosphate insecticide poisoning [2]

Answer 55

atropine the role of pralidoxime is still unclear - meta-analyses to date have failed to show any clear benefit

Question 56

Which is best way of Ix B12 deficiency? [2]

Answer 56

Intrinsic factor antibodies are more useful than gastric parietal cell antibodies when investigating vitamin B12 deficiency, given low specificity of gastric parietal cell antibodies

Question 57

Type of anaemia is B12 deficiency? [2]

Answer 57

Pernicious anaemia (PA) is a disease of the stomach that results in vitamin B12 deficiency and macrocytic anaemia

Question 58

PP of pernicious anaemia [2]

Answer 58

antibodies to intrinsic factor +/- gastric parietal cells - intrinsic factor antibodies → bind to intrinsic factor blocking the vitamin B12 binding site - gastric parietal cell antibodies → reduced acid production and atrophic gastritis. Reduced intrinsic factor production → reduced vitamin B12 absorption vitamin B12 is important in both the production of blood cells and the myelination of nerves → megaloblastic anaemia and neuropathy

Question 59

Ix for pernicious anaemia [4]

Answer 59

full blood count macrocytic anaemia: macrocytosis may be absent in around of 30% of patients hypersegmented polymorphs on blood film low WCC and platelets may also be seen vitamin B12 and folate levels a vitamin B12 level of \>= 200 nh/L is generally considered to be normal antibodies anti intrinsic factor antibodies: sensivity is only 50% but highly specific for pernicious anaemia (95-100%) anti gastric parietal cell antibodies in 90% but low specificity so often not useful clinically Schilling test is no longer routinely done radiolabelled B12 given on two occasions, firstly on its own, secondly with oral IF. Urine B12 levels are then measured

Question 60

A 6-year-old boy is brought to the GP by his mother. He has been experiencing coryza accompanied by a fever of 37.8C for the last 3 days. This morning his mother noticed a red rash on both cheeks and pallor surrounding his mouth. Which one of the following is the most likely causative organism?

Answer 60

Slapped cheek -\> Parvovirus B19

Question 61

Chickenpox presentation [3]

Answer 61

Fever initially Itchy, rash starting on head/trunk before spreading. Initially macular then papular then vesicular Systemic upset is usually mild

Question 62

Measles presentation [4]

Answer 62

Prodrome: irritable, conjunctivitis, fever Koplik spots: white spots ('grain of salt') on buccal mucosa Rash: starts behind ears then to whole body, discrete maculopapular rash becoming blotchy & confluent

Question 63

Mumps presentation [2]

Answer 63

Fever, malaise, muscular pain Parotitis ('earache', 'pain on eating'): unilateral initially then becomes bilateral in 70%

Question 64

Rubella presentatino [3]

Answer 64

Rash: pink maculopapular, initially on face before spreading to whole body, usually fades by the 3-5 day Lymphadenopathy: suboccipital and postauricular

Question 65

Erythema infectiosum presentation [3]

Answer 65

Also known as fifth disease or 'slapped-cheek syndrome' Caused by parvovirus B19 Lethargy, fever, headache 'Slapped-cheek' rash spreading to proximal arms and extensor surfaces

Question 66

Scarlet fever presentation [5]

Answer 66

Reaction to erythrogenic toxins produced by Group A haemolytic streptococci Fever, malaise, tonsillitis 'Strawberry' tongue Rash - fine punctate erythema sparing the area around the mouth (circumoral pallor)

Question 67

HFM presentation [3]

Answer 67

Caused by the coxsackie A16 virus Mild systemic upset: sore throat, fever Vesicles in the mouth and on the palms and soles of the feet

Question 68

Abx for BV [1]

Answer 68

Metronidazole

Question 69

Abx for human bite [1]

Answer 69

Co-amoxiclav

Question 70

Abx for campylobacter [1]

Answer 70

Clarithromycin

Question 71

Most appropriate Ix of an anastomic leak from bowel surgery [1]

Answer 71

CT abdo

Question 72

When is IPF typically seen? [1]

Answer 72

IPF is typically seen in patients aged 50-70 years and is twice as common in men.

Question 73

Features of IPF [4]

Answer 73

- progressive exertional dyspnoea - bibasal fine end-inspiratory crepitations on auscultation - dry cough - clubbing

Question 74

Dx of IPF [4]

Answer 74

spirometry: classically a restrictive picture (FEV1 normal/decreased, FVC decreased, FEV1/FVC increased) impaired gas exchange: reduced transfer factor (TLCO) imaging: bilateral interstitial shadowing (typically small, irregular, peripheral opacities - 'ground-glass' - later progressing to 'honeycombing') may be seen on a chest x-ray but high-resolution CT scanning is the investigation of choice and required to make a diagnosis of IPF ANA positive in 30%, rheumatoid factor positive in 10% but this does not necessarily mean that the fibrosis is secondary to a connective tissue disease. Titres are usually low

Question 75

Mx of IPF [3]

Answer 75

pulmonary rehabilitation very few medications have been shown to give any benefit in IPF. There is some evidence that pirfenidone (an antifibrotic agent) may be useful in selected patients (see NICE guidelines) many patients will require supplementary oxygen and eventually a lung transplant

Question 76

Prognosis of IPF [3]

Answer 76

Poor, average life expectnact is around 3-4y

Question 77

What is RF for IPF? [1]

Answer 77

Working with wood

Question 78

What is lateral epiconylitis? When is it most likely to occur? [2]

Answer 78

Lateral epicondylitis typically follows unaccustomed activity such as house painting or playing tennis ('tennis elbow'). It is most common in people aged 45-55 years and typically affects the dominant arm.

Question 79

Features of lateral epicondylitis [4]

Answer 79

- pain and tenderness localised to the lateral epicondyle - pain worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended - episodes typically last between 6 months and 2 years. Patients tend to have acute pain for 6-12 weeks

Question 80

Mx of lateral epiconylitis [4]

Answer 80

advice on avoiding muscle overload simple analgesia steroid injection physiotherapy

Question 81

When should propanolol be avoided as prophylaxis for migraines? [1]

Answer 81

Avoided in ashtmatics

Question 82

Define neutropenic sepsis [2]

Answer 82

Neutropenic sepsis is a relatively common complication of cancer therapy, usually as a consequence of chemotherapy. It most commonly occurs 7-14 days after chemotherapy. It may be defined as a neutrophil count of \< 0.5 \* 109 in a patient who is having anticancer treatment and has one of the following: - a temperature higher than 38ºC or - other signs or symptoms consistent with clinically significant sepsis

Question 83

Prophylaxis of neutropenic sepsis

Answer 83

Prophylaxis if it is anticipated that patients are likely to have a neutrophil count of \< 0.5 \* 109 as a consequence of their treatment they should be offered a fluoroquinolone

Question 84

mx of neutropenic sepsis []

Answer 84

antibiotics must be started immediately, do not wait for the WBC NICE recommends starting empirical antibiotic therapy with piperacillin with tazobactam (Tazocin) immediately many units add vancomycin if the patient has central venous access but NICE do not support this approach following this initial treatment patients are usually assessed by a specialist and risk-stratified to see if they may be able to have outpatient treatment if patients are still febrile and unwell after 48 hours an alternative antibiotic such as meropenem is often prescribed +/- vancomycin if patients are not responding after 4-6 days the Christie guidelines suggest ordering investigations for fungal infections (e.g. HRCT), rather than just starting therapy antifungal therapy blindly there may be a role for G-CSF in selected patients

Question 85

A 23-year-old woman has a telephone appointment with her GP after missing her oral contraceptive pill. She reports that she has started her new packet 6 days ago but forgot her past 2 doses. She takes the combined oral contraceptive pill and has previously never missed a dose. On further questioning, she reports having sex with her boyfriend 4 days ago but has not had unprotected sexual intercourse since. What is the most appropriate advice to give this patient?

Answer 85

COCP: If 2 pills are missed in week 1, consider emergency contraception if she had unprotected sex during the pill-free interval or week 1

Question 86

What is an acceptable increase in creatinine when starting a ACE-inhibitor? [1]

Answer 86

An increase in serum creatinine up to 30% from baseline is acceptable when initiating ACE inhibitor treatment

Question 87

SE of ACE-inhibitors [4]

Answer 87

cough occurs in around 15% of patients and may occur up to a year after starting treatment thought to be due to increased bradykinin levels angioedema: may occur up to a year after starting treatment hyperkalaemia first-dose hypotension: more common in patients taking diuretics

Question 88

A 54-year-old man with a history of hypertension comes for review. He currently takes lisinopril 10mg od, simvastatin 40mg on and aspirin 75mg od. His blood pressure is well controlled at 124/76 mmHg but he also mentions that he is due to have a tooth extraction next week. What advice should be given with regards to his aspirin use?

Answer 88

In the BNF section 'Prescribing in dental practice' it advises that patients in this situation should continue taking anti-platelets as normal

Question 89

MoA of aspirin [2]

Answer 89

Aspirin works by blocking the action of both cyclooxygenase-1 and 2. Cyclooxygenase is responsible for prostaglandin, prostacyclin and thromboxane synthesis.

Question 90

Answer 90

Erythema mulitforme [target lesions]

Question 91

Answer 91

Erythema nodosum

Question 92

Answer 92

Erythema gryatum

Question 93

Answer 93

Plymorphic eruption of pregnancy

Question 94

Answer 94

Tuberous sclerosis

Question 95

Answer 95

Cafe au lait spots [seen in TS and NF]

Question 96

Answer 96

Lichen planus

Question 97

Answer 97

Lichen slceorsis

Question 98

Answer 98

Lichen sclerosis

Question 99

Answer 99

Actinic keratosis

Question 100

Answer 100

Multiple myeloma

Question 101

Answer 101

SCC

Question 102

Answer 102

BCC

Question 103

Answer 103

Chronic plaque psoriasis

Question 104

Answer 104

Naevus

Question 105

Answer 105

Lung collpase

Question 106

Answer 106

Malar rash in SLE

Question 107

Compare NMS to SS

Answer 107

Question 108

Grade 3 VUR

Answer 108

Question 109

Answer 109

Pityriasis rosea

Question 110

Answer 110

pityriasis rosea

Question 111

Answer 111

Guttate psoriasis

Question 112

Differentiating between gutttate psoriasis and pityriasis rosea

Answer 112

Question 113

Answer 113

Seen in reactive arthritis